Initial Clinical Encounter Research Articles

Creating a Residency Application Personal Statement Writers Workshop: Fostering Narrative, Teamwork, and Insight at a Time of Stress.

Every graduating medical student must write a personal statement for the Electronic Residency Application Service (ERAS), yet there are no widely available resources designed to aid the writing process, causing stress among applicants. The authors offered every Medical College of Wisconsin senior student in the Classes of 2014 and 2015 a voluntary self-contained two-hour Residency Application Personal Statement Writers Workshop. The session included the selection of writing prompts, speedwriting, and a peer-edit critique. Data were gathered before and after each workshop and at the time of ERAS submission. One hundred nine students elected to participate. Of the 96 participants completing a preworkshop questionnaire, only 28 (29%) were comfortable with creative and reflective writing. Fifty-four students completed a follow-up survey after submitting their ERAS application. Fifty-one (94%) found the session effective in getting their personal statement started, and 65 (70%) were surprised by the quality of their writing. Almost all could trace some of their final statement to the workshop. Forty-six (85%) found working with other students helpful, and 49 (91%) would recommend the session to future students; 47 (87%) agreed that the workshop was "fun." The full workshop will be repeated yearly. Workshops will also be offered to residents preparing fellowship applications. A shorter version (without the peer-edit critique) was used successfully with the entire Class of 2016 to help them reflect on their initial clinical encounters. The authors will seek further opportunities to enhance reflection for students, residents, and faculty with these techniques.

Population‐based comparative analysis of risk of death in children and adolescents with epilepsy and migraine

Follow-up studies of children and adolescents with epilepsy (CAW-E) have revealed higher risk of mortality than children in the general population. The mortality experience of CAW-E relative to patients with other common neurologic disorders in the pediatric age group is yet undetermined. The objectives of this study are the following: (1) to compare the causes and the adjusted risk of death in CAW-E with that of children and adolescents with migraine (CAW-M) in reference to children and adolescents with lower extremity fracture (CAW-LEF), and children and adolescents in the general population; (2) to evaluate if disparate mortality risks exist by demographic characteristics. This retrospective cohort study included 56,781 children and adolescents 0-18 years of age hospitalized or treated in an emergency or outpatient department from 2000 to 2011 for epilepsy, migraine, or lower extremity fracture from all nonfederal health care facilities. Data on deaths were acquired from linked multiple causes of death data file using person-specific unique identifiers. Time of follow-up was from initial clinical encounter to time of death or censoring date of December 31, 2011. The association of risk characteristics with mortality was examined with Cox proportional hazard model after adjusting for potential confounders. Four hundred forty-seven CAW-E and 125 CAW-M died yielding mortality rates of 8.71 and 1.36 per 1,000 person-years, respectively. The 5-year risk of death was 4.38% for CAW-E, 0.68% for CAW-M, and 0.71% for CAW-LEF. Adjusted hazard ratios (HRs) were 3.81 (95% confidence interval [CI] 3.08-3.72) in CAW-E and 1.14 (95% CI 0.94-1.34) in CAW-M relative to CAW-LEF. Risk of death from neurodevelopmental comorbidities was 5.86 (95% CI 4.24-8.08) times greater than those without in the model that compared epilepsy with LEF. There is an elevated risk of death in CAW-E with neurodevelopmental comorbidities that remains to be proven.

Establishing a clinic-based pancreatic cancer and periampullary tumour research registry in Quebec.

Enrolling patients in studies of pancreatic ductal adenocarcinoma (pdac) is challenging because of the high fatality of the disease. We hypothesized that a prospective clinic-based study with rapid ascertainment would result in high participation rates. Using that strategy, we established the Quebec Pancreas Cancer Study (qpcs) to investigate the genetics and causes of pdac and other periampullary tumours (pats) that are also rare and underrepresented in research studies. Patients diagnosed with pdac or pat were introduced to the study at their initial clinical encounter, with a strategy to enrol participants within 2 weeks of diagnosis. Patient self-referrals and referrals of unaffected individuals with an increased risk of pdac were also accepted. Family histories, epidemiologic and clinical data, and biospecimens were collected. Additional relatives were enrolled in families at increased genetic risk. The first 346 completed referrals led to 306 probands being enrolled, including 190 probands affected with pdac, who represent the population focus of the qpcs. Participation rates were 88.4% for all referrals and 89.2% for pdac referrals. Family history, epidemiologic and clinical data, and biospecimens were ascertained from 91.9%, 54.6%, and 97.5% respectively of patients with pdac. Although demographics and trends in risk factors in our patients were consistent with published statistics for patients with pdac, the qpcs is enriched for families with French-Canadian ancestry (37.4%), a population with recurrent germ-line mutations in hereditary diseases. Using rapid ascertainment, a pdac and pat research registry with high participation rates can be established. The qpcs is a valuable research resource and its enrichment with patients of French-Canadian ancestry provides a unique opportunity for studies of heredity in these diseases.

A clinical approach to inherited premature coronary artery disease.

Family history of premature coronary artery disease or myocardial infarction is often sought during the initial clinical encounter, but a definitive genetic diagnosis is rarely made. We review potential monogenic causes of coronary artery disease and explore the clinical genetics that might initiate molecular testing or specialist referral. Coronary artery disease (CAD) and myocardial infarction (MI) are often viewed as prototypical complex genetic disorders. However, when the presentation occurs early in life or when the disease appears to segregate in families, it may be related to one of several Mendelian disorders with CAD or MI as part of the phenotypic expression. The most useful evaluation tool at present is a definitive, carefully curated family history focused on the identification of the limited number of testable genetic causes while avoiding additional testing for conditions with low pretest probability. Here we review the potential genetic causes to consider when assessing a patient with premature MI or CAD and outline recommendations for genetic testing or consideration of referral to a center specializing in cardiovascular genetics. A 35-year-old man presents with crescendo angina culminating in rest pain with ECG changes in the precordial leads and associated biomarker abnormalities. He has no past medical history and has no risk factors for vascular or metabolic disease. His most recent fasting lipid panel was completely normal. An initial family history is notable for “heart” problems in his mother’s side of the family. At coronary angiography he is found to have a 95% stenosis of his proximal left anterior descending artery which is successfully treated by percutaneous coronary intervention including a drug-eluting stent. A subsequent detailed family history with objective confirmation reveals that his mother presented with an acute left anterior descending syndrome at the age of 42 and two of her male siblings underwent coronary revascularization before …

Pain Beliefs and Readiness to Change Among Adolescents With Chronic Musculoskeletal Pain and Their Parents Before an Initial Pain Clinic Evaluation

To understand relationships between pain-related beliefs and readiness to change among treatment-seeking adolescents with chronic musculoskeletal pain and their parents. A total of 102 adolescent-parent dyads were recruited at the time of initial evaluation at a multidisciplinary pain management clinic. Dyads completed self-report measures to assess pain, catastrophizing, endorsement of a biopsychosocial perspective of pain, and readiness to change/motivation to adopt a self-management approach to pain coping. Agreement between adolescent-parent dyad reports of pain catastrophizing and readiness to change was found; however, adolescents were less likely to view pain as "affected by feelings and emotions" than parents. The hypothesis that greater pain catastrophizing would be correlated with less readiness to change was partially supported. Adolescent and parents who reported lower levels of endorsement of a biopsychosocial perspective were less willing to adopt a self-management approach to pain coping. Endorsement of a biopsychosocial perspective of pain aligned with readiness to change stages more consistently for parents. This study documents initial relationships among pain catastrophizing, biopsychosocial perspectives of pain, and readiness to engage in a self-management approach to pain coping for adolescents with chronic pain and their parents. Although agreement exists between dyads regarding catastrophizing and readiness to change, differences were noted in biopsychosocial perspective and dominant readiness to change stage before an initial pain clinic encounter. Findings are considered in terms of future research to advance knowledge regarding the role these factors may play in treatment adherence and outcomes.

Familial clustering of hepatocellular carcinoma in HBsAg-positive patients in the United States.

The impact of familial clustering of hepatocellular carcinoma (HCC) in hepatitis B virus (HBV)-infected persons in a low HBV endemic area was investigated. Four hundred thirteen HBsAg-positive patients, 173 with HCC and 240 without HCC, were subgrouped into those with or without a family history of HCC and analyzed for risk factors associated with HCC development. In families with HCC clustering, the ages of HCC onset in parents and siblings were compared. Forty-four of 173 (25.4%) HCC patients, all of Asian descent, had 82 other blood relatives with HCC. Of these, 69 (84.1%) were first-degree relatives. Compared to HCC patients without HCC family history, male HCC patients with family history developed HCC at a younger age than either their mothers or fathers with HCC (45.2±10.3years vs. 63.0±6.8years, p<0.001 and 41.2±14.8years vs. 60.5±5.5years, p=0.001, respectively); however, this was not observed in female HCC patients. In mothers of index HCC cases, 22/26 (84.6%) tested were HBsAg positive and 14 (63.6%) had HCC; in fathers, 11/21 (52.4%) tested were HBsAg positive and 10 (90.9%) had HCC. By multivariate analysis, independent risk factors for HCC development included family history (OR=2.58, p=0.05), male gender (OR=3.23, p=0.03), cirrhosis (OR=2.4, p=0.04), Child-Pugh classification (OR=7.62, p=0.004), AFP per log10 increase (OR=1.68, p=0.01), precore mutation (OR=3.77, p=0.003), and basal core promoter mutation (OR=8.33, p<0.001). HBsAg-positive male HCC patients presented at a younger age than their parents with HCC. In adult patients with an HCC family history, HCC surveillance should begin at the time of the initial clinic encounter.

Tailoring Chronic Pain Care by Brief Assessment of Impact and Prognosis Comment on “Point-of-Care Prognosis for Common Musculoskeletal Pain in Older Adults”

In 2011, an Institute of Medicine report, Relieving Pain in America, called for a cultural transformation of pain care.1 The report concluded that “healthcare providers should increasingly aim at tailoring pain care to each person's experience, and self-management of pain should be promoted.”1(p1) Medical treatments are often less than adequate for patients with chronic musculoskeletal pain. Ordering more diagnostic tests of uncertain value, prescribing more prescription analgesics with poorly understood risks and benefits, and providing more surgical procedures, nerve blocks, and epidural injections will not achieve the aims of improved patient outcomes, increased patient satisfaction, and more prudent use of finite health care resources.2,3 Rather, we need to help patients with chronic pain resume valued life activities by placing more emphasis on improving quality of life and less on interventions that afford only short-term pain relief with appreciable risks and costs.

The Clinical Differentiation of Bacterial and Fungal Keratitis: A Photographic Survey

The purpose of this study was to determine whether clinical signs of infectious keratitis can be used to identify the causative organism. Eighty photographs of eyes with culture-proven bacterial keratitis or smear-proven fungal keratitis were randomly selected from 2 clinical trials. Fifteen cornea specialists from the F. I. Proctor Foundation and the Aravind Eye Care System assessed the photographs for prespecified clinical signs of keratitis, and they identified the most likely causative organism. Clinicians were able to correctly distinguish bacterial from fungal etiology 66% of the time (P < 0.001). The Gram stain, genus, and species were accurately predicted 46%, 25%, and 10% of the time, respectively. The presence of an irregular/feathery border was associated with fungal keratitis, whereas a wreath infiltrate or an epithelial plaque was associated with bacterial keratitis. Cornea specialists correctly differentiated bacterial from fungal keratitis more often than chance, but in fewer than 70% of cases. More specific categorization led to less successful clinical distinction. Although certain clinical signs of infectious keratitis may be associated with a bacterial or fungal etiology, this study highlights the importance of obtaining appropriate microbiological testing during the initial clinical encounter.

What do medical trainees think is so difficult about communicating with patients?

ObjectiveTo identify the communication skills medical trainees perceive themselves to avoid or use during initial clinical encounters and the areas of communication learning need they identify. Methods446 2nd year undergraduate medical students were invited to take part in the study. Details of four encounters with patients were entered into a web-based electronic logbook by the student. Details included perception of use, success and requests for further training from a list of communication process skills. Results395 (89%) students took part. Factor analysis yielded three types of skills: those used to manage the flow of interaction; the emotional content of the interaction; and structuring the interaction. Skills perceived as being used least often and least successfully and identified by the students as requiring further training were primarily those that involved managing the emotional aspects of interactions with patients rather than managing the flow of information. ConclusionCommunication training should focus further on the emotional aspects of patient interactions in order to support students during early clinical encounters. Practice implicationsSkills required to manage emotional encounters need to be made more explicit to students. Opportunities to obtain feedback and develop competency should be offered as part of the core curriculum.

Cigarette smoking shortens the survival of patients with low-risk myelodysplastic syndromes.

Myelodysplastic syndromes (MDS) are a group of hematological malignancies with poor survival. Although previous studies have identified the prognostic role of multiple demographic and clinical characteristics, the potential role of lifestyle factors has not been evaluated. In this study, we conducted an extensive assessment of the predictors of MDS survival, with a special focus on lifestyle factors. A total of 616 patients (median survival = 4.1 years) were included in the analysis, and multivariate Cox proportional hazard models were utilized to estimate hazard ratios. Compared with non-smokers, MDS patients who smoked at the initial clinical encounter had a significantly increased risk of death [hazard ratio (HR) = 1.46, 95% confidence intervals (CI): 1.07-2.00]. The elevated risk was restricted to men (HR = 1.76, 95% CI: 1.21-2.56) and not observed among women (HR = 0.98, 95% CI: 0.51-1.85). When patients were stratified by the IPSS categorization, a near three fold increased risk of death was associated with smoking among patients with low-risk MDS (HR = 2.83, 95% CI: 1.48-5.39), whereas smoking did not appear to influence the survival of patients with intermediate- or high-risk MDS. This study was the first to identify smoking as a significant and independent predictor of MDS survival, particularly among low-risk patients.

Evaluation and Treatment of the Patient with Chronic Cough Referred to the Otolaryngologist

Methods: Patients were identified as being referred for cough between 2005 and 2010. Initial consultation and clinical encounters were reviewed and diagnostic studies/therapies recorded. Findings on diagnostic studies were noted if they aided in treatment. Response to therapies was determined by reviewing clinical encounter documentation and therapies were rated: no response, partial response, or complete response.

How missing information in diagnosis can lead to disparities in the clinical encounter.

Previous studies have documented diagnostic bias and noted that its reduction could eliminate misdiagnosis and improve mental health service delivery. Few studies have investigated clinicians' methods of obtaining and using information during the initial clinical encounter. We describe a study examining contributions to clinician bias during diagnostic assessment of ethnic/racial minority patients. A total of 129 mental health intakes were videotaped, involving 47 mental health clinicians from 8 primarily safety-net clinics. Videos were coded by another clinician using an information checklist, blind to the diagnoses provided by the original clinician. We found high levels of concordance between clinicians for substance-related disorders, low levels for depressive disorders, and anxiety disorders except panic. Most clinicians rely on patients' mention of depression, anxiety, or substance use to identify disorders, without assessing specific criteria. With limited diagnostic information, clinicians can optimize the clinical intake time to establish rapport with patients. We found Latino ethnicity to be a modifying factor of the association between symptom reports and likelihood of a depression diagnosis. Differential discussion of symptom areas, depending on patient ethnicity, may lead to differential diagnosis and increased likelihood of diagnostic bias.

Clinical presentation of a traumatic cervical spine disc rupture in alpine sports: a case report

Isolated non-skeletal injuries of the cervical spine are rare and frequently missed. Different evaluation algorithms for C-spine injuries, such as the Canadian C-spine Rule have been proposed, however with strong emphasis on excluding osseous lesions. Discoligamentary injuries may be masked by unique clinical situations presenting to the emergency physician. We report on the case of a 28-year-old patient being admitted to our emergency department after a snowboarding accident, with an assumed hyperflexion injury of the cervical spine. During the initial clinical encounter the only clinical finding the patient demonstrated, was a burning sensation in the palms bilaterally. No neck pain could be elicited and the patient was not intoxicated and did not have distracting injuries. Since the patient described a fall prevention attempt with both arms, a peripheral nerve contusion was considered as a differential diagnosis. However, a high level of suspicion and the use of sophisticated imaging (MRI and CT) of the cervical spine, ultimately led to the diagnosis of a traumatic disc rupture at the C5/6 level. The patient was subsequently treated with a ventral microdiscectomy with cage interposition and ventral plate stabilization at the C5/C6 level and could be discharged home with clearly improving symptoms and without further complications.This case underlines how clinical presentation and extent of injury can differ and it furthermore points out, that injuries contracted during alpine snow sports need to be considered high velocity injuries, thus putting the patient at risk for cervical spine trauma. In these patients, especially when presenting with an unclear neurologic pattern, the emergency doctor needs to be alert and may have to interpret rigid guidelines according to the situation. The importance of correctly using CT and MRI according to both – standardized protocols and the patient's clinical presentation – is crucial for exclusion of C-spine trauma.

Diagnostic Performance of Pyogenic Vertebral Osteomyelitis

Early diagnosis of pyogenic vertebral osteomyelitis (PVO) is frequently difficult. There are, however, few studies that have investigated the diagnostic performance of PVO in Japan. Our aim was to analyze the diagnostic performance and identify clinical factors associated with the diagnostic delay of PVO. We performed hospital-based retrospective case analysis. All patients with PVO were identified from the computerized medical database at Okinawa Chubu Hospital in Okinawa, Japan, from January 1985 to December 2004. We collected the following data; baseline information; laboratory tests; clinical and microbiologic outcomes; and diagnostic process. We used multivariable-adjusted linear regression to identify significant factors associated with patient and hospital delay to the diagnosis of PVO. We reviewed total of 209,428 patients hospitalized during the 20-year study period. Of those, we identified 51 patients with PVO. Eighty percent of these patients were misdiagnosed at their initial clinical encounters. Median duration from the symptom onset to the diagnosis was 19 days. Median durations of patient factor and hospital factor that contributed to the total delay were 1 and 8 days, respectively. Significant patient factor that contributed to delay was cognitive dysfunction. Cognitive dysfunction is a risk factor for patient delay for visiting physicians in patients with PVO. Diagnosis of PVO is difficult at the initial clinical encounter. High index of suspicion is needed for more rapid diagnosis of PVO.

Moral professional personhood: ethical reflections during initial clinical encounters in nursing education.

Moral agency is an important constituent of the nursing role. We explored issues of ethical development in Greek nursing students during clinical practice at the beginning of their studies. Specifically, we aimed to explore students' lived experience of ethics, and their perceptions and understanding of encountered ethical conflicts through phenomenological analysis of written narratives. The process of developing an awareness of personal values through empathizing with patients was identified as the core theme of the students' experience. Six more common themes were identified. Development of the students' moral awareness was conceptualized as a set of stages, commencing with empathizing with patients and nurses, moving on to taking a moral stand and, finally, concluding by becoming aware of their personal values and showing evidence of an emerging professional moral personhood. The notions of empathy, caring and emotion were in evidence throughout the students' experience. Implications for practice and nurse education are discussed.

Etiology and diagnosis of bilateral leg edema in primary care

Purpose: To identify the causes of bilateral leg edema in a primary care setting, and to determine the ability of primary care providers to arrive at the correct diagnosis using the information available at the initial clinical encounter. Patients and Methods: Fifty-eight ambulatory adult patients with bilateral leg edema were enrolled at an inner city family practice during a 3-year period. Historical information, physical examination findings, and clinical impressions of primary care providers were compared with the results of laboratory evaluations consisting of echocardiograms, venous duplex ultrasound leg scans, serum albumin levels, and when appropriate, 24-hour urinalyses. Results: Forty-five patients (78%) completed the study. The initial clinical impression was venous insufficiency in 32 (71%) patients and congestive heart failure in 8 (18%) patients. In actuality, 15 (33%) patients had a cardiac condition as a cause of their leg edema, and 19 (42%) had pulmonary hypertension. All of the patients with heart disease, and almost all of those with pulmonary hypertension, were age 45 years or older. Only 10 (22%) of the subjects had venous insufficiency. Renal conditions, medication use, and hypoalbuminemia were less common. Conclusions: Utilizing clinical information only, many patients with cardiopulmonary pathology were incorrectly diagnosed as having more benign conditions, most commonly venous insufficiency. Echocardiographic evaluation, including an estimation of pulmonary artery pressure, may be advisable in many patients with bilateral leg edema, especially if they are at least 45 years old.

Validity of the Creasy Risk Appraisal Instrument For Prediction of Preterm Labor

The study objectives were twofold: (a) retrospective evaluation of the predictive validity of the Creasy in a cross-cultural urban and rural population based on the outcome data of publicly served prenatal patients, and (b) examination of the universality of the Creasy through comparison of the predictive validity found in the study population with other published results. Subjects were 433 white and African American women who entered prenatal services through 1 urban and 12 rural health department sites and received care in a regionalized system in East Central Georgia. The Creasy instrument was administered once to all prenatal women in their initial clinical encounters. The instrument identified 30.47% of the women who experienced preterm deliveries. Only 44.3% of the time did a score indicating high risk for preterm delivery accurately predict preterm delivery. Predictive validity for rural and urban subjects was not significantly different. As predictive validity for the Creasy was low, it was determined that it has limited clinical usefulness with a single administration. Usefulness may be improved with further risk-factor specification and frequent measurement throughout pregnancy.

Validity of the Creasy Risk Appraisal Instrument for Prediction of Preterm Labor

The study objectives were twofold: (a) retrospective evaluation of the predictive validity of the Creasy in a cross-cultural urban and rural population based on the outcome data of publicly served prenatal patients, and (b) examination of the universality of the Creasy through comparison of the predictive validity found in the study population with other published results. Subjects were 433 white and African American women who entered prenatal services through 1 urban and 12 rural health department sites and received care in a regionalized system in East Central Georgia. The Creasy instrument was administered once to all prenatal women in their initial clinical encounters. The instrument identified 30.47% of the women who experienced preterm deliveries. Only 44.3% of the time did a score indicating high risk for preterm delivery accurately predict preterm delivery. Predictive validity for rural and urban subjects was not significantly different. As predictive validity for the Creasy was low, it was determined that it has limited clinical usefulness with a single administration. Usefulness may be improved with further risk-factor specification and frequent measurement throughout pregnancy.