Medicine Teaching Unit Research Articles

Making assessment a team sport: a qualitative study of facilitated group feedback in internal medicine residency.

Competency-based medical education relies on feedback from workplace-based assessment (WBA) to direct learning. Unfortunately, WBAs often lack rich narrative feedback and show bias towards Medical Expert aspects of care. Building on research examining interactive assessment approaches, the Queen's University Internal Medicine residency program introduced a facilitated, team-based assessment initiative ("Feedback Fridays") in July 2017, aimed at improving holistic assessment of resident performance on the inpatient medicine teaching units. In this study, we aim to explore how Feedback Fridays contributed to formative assessment of Internal Medicine residents within our current model of competency-based training. A total of 53 residents participated in facilitated, biweekly group assessment sessions during the 2017 and 2018 academic year. Each session was a 30-minute facilitated assessment discussion done with one inpatient team, which included medical students, residents, and their supervising attending. Feedback from the discussion was collected, summarized, and documented in narrative form in electronic WBA forms by the program's assessment officer for the residents. For research purposes, verbatim transcripts of feedback sessions were analyzed thematically. The researchers identified four major themes for feedback: communication, intra- and inter-personal awareness, leadership and teamwork, and learning opportunities. Although feedback related to a broad range of activities, it showed strong emphasis on competencies within the intrinsic CanMEDS roles. Additionally, a clear formative focus in the feedback was another important finding. The introduction of facilitated team-based assessment in the Queen's Internal Medicine program filled an important gap in WBA by providing learners with detailed feedback across all CanMEDS roles and by providing constructive recommendations for identified areas for improvement.

Prioritizing Quality over Quantity: Defining Optimal Pharmacist-to-Patient Ratios to Ensure Comprehensive Direct Patient Care in a Medical or Surgical Unit.

The expanding scope of practice of hospital pharmacists has contributed to improvements in patient care; however, workload remains a barrier to the provision of optimal pharmaceutical care. Established ratios to guide clinical pharmacy staffing on medical and surgical units are lacking in Canada. To determine the pharmacist-to-patient ratio that allows for provision of comprehensive pharmaceutical care to each patient on a medical or surgical unit and to determine which comprehensive care tasks can be delivered in settings where staffing is limited. A multiphase study was conducted in 6 hospitals. First, a modified Delphi study was conducted to define and prioritize the elements of comprehensive pharmaceutical care. Next, a work sampling study was conducted to establish the frequency of each task and the time required for completion. Finally, a workforce calculator was used to determine pharmacy staffing ratios. Ten pharmacists participated in the modified Delphi study, and 31 participated in the work sampling study. A total of 15 comprehensive care tasks were identified, 7 of which were categorized as tasks to prioritize in settings where staffing is limited. The optimal staffing ratios were 1 pharmacist to 13 patients in internal medicine teaching units, 1 pharmacist to 26 patients in hospitalist or internal medicine nonteaching units, and 1 pharmacist to 14 patients in surgical units. The optimal staffing ratios determined in this study should enable pharmacists to provide comprehensive care to each patient. Implementing these staffing ratios could increase the consistency of clinical pharmacy services, improve patient outcomes, and improve pharmacists' work satisfaction. Further research is required to validate these ratios in a variety of settings.

Baseline monitoring of atypical antipsychotics at a Family Medicine Teaching Unit (FMTU) in Ontario, Canada

Baseline monitoring of atypical antipsychotics at a Family Medicine Teaching Unit (FMTU) in Ontario, Canada

Importance of the vaporization margin during CO2 laser treatment of oral leukoplakia: A survival study.

The main purpose of this study was to assess the response of oral leukoplakia to CO2 laser vaporization treatment, as well as determining possible factors that may affect recurrence of lesions. A retrospective study was conducted, in which the medical records of patients who had been clinically and histologically diagnosed with oral leukoplakia and treated with CO2 laser between 1996 and 2019 at the Oral Medicine Teaching Unit of the Faculty of Dentistry of the University of Santiago de Compostela were reviewed. Fifty-eight patients were included: 36 female and 22 male subjects, with a mean age of 63.7 years old (SD ±13.1). The average follow-up time was 57.5 months (SD ±57.9). A relapse rate of 52.6% was determined. Of all the studied variables, the margin was the only one for which a statistically significant association with recurrence of lesions was demonstrated (p < 0.05). The vaporization of lesions using CO2 laser with a safety margin of at least 3 mm from the clinical limits of OL is a key factor in preventing recurrence.

Opioid Prescribing on an Internal Medicine Teaching Unit

ObjectiveTo investigate the rationale and timing of opioid prescriptions for Internal Medicine inpatients in an academic center in Saskatoon, Canada.MethodsWe performed a cross-sectional study of Internal Medicine inpatients that were prescribed opioids in Saskatoon. We examined documentation of clinical rationale and timing of opioid initiation or first escalation.ResultsOf 57 patients, 34 (60%) were opioid naive prior to admission and 48 (84%) had opioid doses either initiated or escalated. Of these 48 patients, 27 (56%) occurred during on-call hours. Rationale for escalation was documented in 31 cases (65%), with reasons including terminal care (17%), musculoskeletal pain (15%), and skin and soft tissue infections (13%).ConclusionRationale for opioid use was frequently not documented. Initial decision to change opioid dose occurred equally between daytime and on-call hours. RÉSUMÉObjectifÉtudier la justification et le moment choisi pour prescrire des opioïdes chez les patients hospitalisés en médecine interne dans un centre universitaire de Saskatoon (Canada).MéthodologieNous avons mené une étude de prévalence sur des patients hospitalisés en médecine interne chez qui on a prescrit des opioïdes à Saskatoon. Nous avons examiné la documentation concernant la justification clinique et le moment choisi pour entreprendre le traitement par les opioïdes ou effectuer la première augmentation de dose. RésultatsDes 57 patients, 34 (60 %) n’avaient jamais pris d’opioïdes avant leur hospitalisation et 48 (84 %) ont reçu leur première dose d’opioïdes ou une augmentation de dose. De ces 48 patients, 27 (56 %) ont reçu leur dose durant les heures de garde. La justification de l’augmentation de dose est documentée dans 31 cas (65 %), les raisons étant les soins de fin de vie (17 %), la douleur musculosquelettique (15 %) et les infections de la peau et des tissus mous (13 %).ConclusionSouvent, la justification de l’utilisation des opioïdes n’est pas documentée. Le moment où la décision initiale de modifier la dose d’opioïde est prise est réparti de façon égale entre le jour et durant les heures de garde.

Optimizing handover for family medicine outpatients using an electronic medical record-integrated tool.

In many family medicine teaching units (FMTUs), patients are regularly transferred between resident providers. Often, incoming first-year residents inherit patients from outgoing second-year residents, with no formal handover process in place. This is deeply concerning, as transition of care from

Structured interdisciplinary bedside rounds improve interprofessional communication and workplace efficiency among residents and nurses on an inpatient internal medicine unit

ABSTRACT Structured Interdisciplinary Bedside Rounds (SIBR) is a standardized, team-based intervention for hospitals to deliver high quality interprofessional care. Despite its potential for improving IPC and the workplace environment, relatively little is known about SIBR’s effect on these outcomes. Our study aimed to assess the fidelity of SIBR implementation on an inpatient medicine teaching unit and its effects on perceived IPC and workplace efficiency. We conducted a quasi-experimental study with 88 residents and 44 nurses at a large academic medical center and observed 1308 SIBR encounters over 24 weeks. Of these 1308 encounters, the bedside nurse was present for 96.7%, physician for 97.6%, and care manager for 94.7, and 64.7% occurred at the bedside. Following SIBR implementation, perceived IPC improved significantly among residents (93.3% versus 67.9%, p < .024) and nurses (73.7% versus 36.0%, p < .008) compared to before implementation. Moreover, residents perceived greater workplace efficiency operationalized as being paged less frequently with questions by nurses (20.0% versus 49.1%, p = .01). No statistically significant improvements were reported regarding burnout, meaning at work, and workplace satisfaction. Our implementation of SIBR significantly improved perceived IPC and workplace efficiency, which are two important domains of healthcare quality. Future work should examine the impact of SIBR on patient-centered outcomes such as patient experience.

Explicit Dialogue About the Purpose of Hospital Admission Is Essential: How Different Perspectives Affect Teamwork, Trust, and Patient Care.

The authors previously found that attending physicians conceptualize hospital admission purpose according to 3 perspectives: one focused dominantly on discharge, one on monitoring and managing chronic conditions, and one on optimizing overall patient health. Given implications of varying perspectives for patient care and team collaboration, this study explored how purpose of admission is negotiated and enacted within clinical teaching teams. Direct observations and field interviews took place in 2 internal medicine teaching units at 2 teaching hospitals in Ontario, Canada, in summer 2017. A constructivist grounded theory approach was used to inform data collection and analysis. The 54 participants included attendings, residents, and medical students. Management decisions were identified across 185 patients. Attendings and senior medical residents (second- and third-year residents) were each observed to enact one dominant perspective, while junior trainees (first-year residents and students) appeared less fixed in their perspectives. Teams were not observed discussing purpose of admission explicitly; however, differing perspectives were present and enacted. These differences became most noticeable when at the extremes (discharge focused vs optimization focused) or between senior medical residents and attendings. Attendings implicitly signaled and enforced their perspectives, using authority to shut down and redirect discussion. Trainees' maneuvers for enacting their perspectives ranged from direct advocacy to covert manipulation (passive avoidance/forgetting and delaying until attending changeover). Failing to negotiate and explicitly label perspectives on purpose of admission may lead to attendings and senior medical residents working at cross-purposes and to trainees participating in covert maneuvers, potentially affecting trust and professional identify development.

Simulated co-location of patients admitted to an inpatient internal medicine teaching unit: potential impacts on efficiency and physician-nurse collaboration

Effective communication between nurses and physician teams on the internal medicine unit is crucial for high quality, safe, and efficient patient care. In our hospital of interest, a large academic health sciences centre, the physical layout of the unit, current admission process, and the presence of three separate physician teams contribute to uneven workload and communication barriers. We address this by physically co-locating each physician teams’ patients so as to facilitate physician-nurse collaboration, and more evenly distribute workload across all three teams. Based upon one year of real-world data, we developed a simulation model of inpatient flow through the internal medicine unit and determined the impact of two proposed changes: co-locating each team’s patients, and new admission rules for how patients are assigned to those teams. Under the new arrangement, each physician team would interact with roughly half the number of nurses, and nurses in turn would have fewer individual team members with whom to communicate, thereby improving effective communication and increasing time for direct patient care for both physicians and nurses.

Effectiveness of an educational intervention to improve the safety culture in primary care: a randomized trial

BackgroundFostering a culture of safety is an essential step in ensuring patient safety and quality in primary care. We aimed to evaluate the effectiveness of an educational intervention to improve the safety culture in the family and community medicine teaching units in an Atlantic European Region.MethodsRandomized study conducted in family and community medicine teaching units in Galicia (Spain). Participants were all fourth-year residents and their tutors (N = 138). Those who agreed to participate were randomized into one of two groups (27 tutors/26 residents in the intervention group, 23 tutors/ 23 residents in the control one).All were sent the Survey on Patient Safety Culture. After that, the intervention group received specific training in safety; they also recorded incidents over 15 days, documented them following a structured approach, and had feedback on their performance. The control group did not receive any action. All participants completed the same survey four months later. Outcome measures were the changes in safety culture as quantified by the results variables of the Survey: Patient Safety Grade and Number of events reported.We conducted bivariate and adjusted analyses for the outcome measures. To explore the influence of participants’ demographic characteristics and their evaluation of the 12 dimensions of the safety culture, we fitted a multivariate model for each outcome.ResultsTrial followed published protocol. There were 19 drop outs. The groups were comparable in outcome and independent variables at start. The experiment did not have any effect on Patient safety grade (− 0.040) in bivariate analysis. The odds of reporting one to two events increased by 1.14 (0.39–3.35), and by 13.75 (2.41–354.37) the odds of reporting 3 or more events. Different dimensions had significant independent effects on each outcome variable.ConclusionA educational intervention in family and community medicine teaching units may improve the incidents reported. The associations observed among organizational dimensions and outcomes evidence the complexity of patient safety culture measurement and, also, show the paths for improvement. In the future, it would be worthwhile to replicate this study in teaching units from different settings and with different health professionals engaged.Trial registrationIt was retrospectively registered with (ISRCTN41911128, 31/12/2010).

Using a sociomaterial approach to generate new insights into the nature of interprofessional collaboration: Findings from an inpatient medicine teaching unit

ABSTRACTToday’s hospitals are burdened with patients who have complex health needs. This is readily apparent in an inpatient internal medicine setting. While important elements of effective interprofessional collaboration have been identified and trialled across clinical settings, their promise continues to be elusive. One reason may be that caring for patients requires understanding the size and complexity of healthcare networks. For example, the non-human ‘things’ that healthcare providers work with and take for granted in their professional practice—patient beds, diagnostic imaging, accreditation standards, work schedules, hospital policies, team rounds—also play a role in how care is shaped. To date, how the human and non-human act together to exclude, invite, and regulate particular enactments of interprofessional collaboration has been subject to limited scrutiny. Our paper addresses this gap by attending specifically to the sociomaterial. Drawing on empirical data collected from an Academic Health Sciences Centre’s inpatient medicine teaching unit setting in Ontario, Canada, we explore the influence of the sociomaterial on the achievement of progressive collaborative refinement, an ideal of how teams should work to support safe and effective patient care as patients move through the system. Foregrounding the sociomaterial, we were able to trace how assemblies of the human and the non-human are performed into existence to produce particular enactments of interprofessional collaboration that, in many instances, undermined the quality of care provided. Our research findings reveal the “messiness” of interprofessional collaboration, making visible how things presently assemble within the inpatient setting, albeit not always in the ways intended. These findings can be used to guide future innovation work in this and other similar settings.

Sikanjalo district hospital Procedural medicine teaching unit

No abstract available.

Interdisciplinary teaching in family medicine teaching units: the residents’ points of view

Interdisciplinary teaching (IDT) is the norm in Canadian family medicine residency programs. Literature on IDT reports many academic, collaborative and organizational benefits, but little is known about family medicine residents' own perspectives of IDT. The purpose of this study was to explore family medicine residents' points of view on IDT in family medicine teaching units (FMTU). A mixed methods design combined interviews and self-completed online questionnaires to explore participants' perceptions of IDT during residency. Content analysis was conducted on the qualitative data and univariate analysis statistical tests on means and proportions were conducted on the quantitative survey questions. A total of 125 family medicine residents from 12 FMTU affiliated with Université Laval (Quebec City) participated in the study (11 interviews and 114 online questionnaires). Participants perceived significant benefits of IDT, including clinical knowledge, complementary perspectives and interprofessional collaboration skills. However, they believe that IDT works best when the educators adapt their teaching to the specific needs of residents in family medicine. These findings support those of previous IDT research and highlight the positive impacts of interdisciplinary education in family medicine residency, especially on interprofessional collaboration. IDT should remain an essential component of the family medicine curricula.

Developing and testing an electronic medication administration monitoring device for community dwelling seniors: a feasibility study

BackgroundMedication non-adherence, polypharmacy, and adverse drug events are major healthcare issues leading to significant morbidity, mortality, and healthcare expenditures. Currently, there are no methods to systematically track medication usage in community-dwelling seniors. The eDosette prototype was created to make medication use patterns visible via the Internet. This study aims to demonstrate feasibility, usability, and acceptability of the eDosette in community-dwelling seniors in primary care.MethodsA 2-week feasibility study involving a convenience sample of 10 patients from an academic family medicine teaching unit in Hamilton, Ontario, Canada, was conducted over a 6-month period between April and October 2015. The eDosette transmitted hourly electronic data via the Internet on each participant’s pattern of medication use; this data was converted into an individualized medication administration record (MAR). Based on the MARs from the 10 participants, the frequency of missed medication doses, the time of dose administration, and each participant’s adherence rate for their prescribed medications could be determined. A medication adherence survey and a patient usability and acceptability survey were administered to all the participants of the study.ResultsThe eDosette was able to record a participant’s medication use and transmit this data electronically via the Internet with sufficient quality to create participant-specific MARs. A total of 418 doses were captured by the eDosette throughout the study; only 5% (n = 22 doses) were missing information or had poor image quality. Analysis of the MARs revealed that 19% (n = 79 doses) were taken outside a 2-h window of the average dose administration time, and two doses were completely missed by all participants during this feasibility study. Participant feedback found the eDosette easy and acceptable to use. Participant feedback also identified hardware and software issues that require attention prior to a larger study.ConclusionsThe eDosette is a feasible and novel technology that can be successfully installed into the homes of community-dwelling seniors to help in monitoring actual medication use patterns. This study provided details for further device development and evidence to support the need for a larger pilot study on the eDosette’s impact on medication adherence.

Effectiveness of a strategy that uses educational games to implement clinical practice guidelines among Spanish residents of family and community medicine (e-EDUCAGUIA project): a clinical trial by clusters.

BackgroundClinical practice guidelines (CPGs) have been developed with the aim of helping health professionals, patients, and caregivers make decisions about their health care, using the best available evidence. In many cases, incorporation of these recommendations into clinical practice also implies a need for changes in routine clinical practice. Using educational games as a strategy for implementing recommendations among health professionals has been demonstrated to be effective in some studies; however, evidence is still scarce. The primary objective of this study is to assess the effectiveness of a teaching strategy for the implementation of CPGs using educational games (e-learning EDUCAGUIA) to improve knowledge and skills related to clinical decision-making by residents in family medicine. The primary objective will be evaluated at 1 and 6 months after the intervention. The secondary objectives are to identify barriers and facilitators for the use of guidelines by residents of family medicine and to describe the educational strategies used by Spanish teaching units of family and community medicine to encourage implementation of CPGs.Methods/designWe propose a multicenter clinical trial with randomized allocation by clusters of family and community medicine teaching units in Spain. The sample size will be 394 residents (197 in each group), with the teaching units as the randomization unit and the residents comprising the analysis unit. For the intervention, both groups will receive an initial 1-h session on clinical practice guideline use and the usual dissemination strategy by e-mail. The intervention group (e-learning EDUCAGUIA) strategy will consist of educational games with hypothetical clinical scenarios in a virtual environment.The primary outcome will be the score obtained by the residents on evaluation questionnaires for each clinical practice guideline. Other included variables will be the sociodemographic and training variables of the residents and the teaching unit characteristics. The statistical analysis will consist of a descriptive analysis of variables and a baseline comparison of both groups. For the primary outcome analysis, an average score comparison of hypothetical scenario questionnaires between the EDUCAGUIA intervention group and the control group will be performed at 1 and 6 months post-intervention, using 95 % confidence intervals. A linear multilevel regression will be used to adjust the model.DiscussionThe identification of effective teaching strategies will facilitate the incorporation of available knowledge into clinical practice that could eventually improve patient outcomes. The inclusion of information technologies as teaching tools permits greater learning autonomy and allows deeper instructor participation in the monitoring and supervision of residents. The long-term impact of this strategy is unknown; however, because it is aimed at professionals undergoing training and it addresses prevalent health problems, a small effect can be of great relevance.Trial registrationClinicalTrials.gov: NCT02210442.

Coexistence of exocrine and endocrine pancreatic insufficiency in chronic pancreatitis. Our experience 2001-2014

s / Pancreatology 2 Family and Community Medicine Teaching Unit, EVES, Valencia, Spain Background: Acute pancreatitis (AP) is a common cause of hospital admissionwith increasing incidence inwestern countries. Clinical course is usually unpredictable at the onset of symptoms and hence, early detection of severe cases is critical in order to encourage strict monitoring and aggressive treatment strategies, as well as referral to an intensive care unit. Objectives: To identify factors predicting moderately-severe and severe AP (MSAP, SAP) on admission, according to the 2012 Atlanta classification. Methods: Prospective study including 97 patients diagnosed with AP that were admitted into our hospital during a 12 month period (January 2014 e December 2014). Clinical, laboratory and imaging variables were recorded, in addition to parameters such as: onset of organ failure (OF), presence of pancreatic necrosis (PN) or infected pancreatic necrosis (IPN), and requirement of either percutaneous drainage or surgery. A logistic regression model was employed, using odds ratio (OR) as a measure of association and the area under the ROC curve (AUC) to determine discrimination. 95% confidence intervals (CI) were calculated for each test. Results: 54 patients were male (55.7%) and mean age was 64.6 years. 77 cases of APwere interstitial (79.4%) and 20were necrotizing (20.6%), ofwhich 6 developed IPN (6.2%), 11 developed OF (11.3%) and 7 deceased (7.2%). 23 cases were classified as a MSAP or SAP, both of which were found to be independently associatedwith the following: hypotension [(SBP 90mg/L (OR 4.8; 95%IC 1.4e17.3; p1⁄40.01), WBC count>17000/mL (OR 5.0; 95%IC 1.5 e 15.5; p1⁄40.008) and hematocrit >45% (OR 5.8; 95%IC 1.7 e 19.6; p1⁄40.004). Multivariate analysis revealed adequate discriminatory power (AUC 0.85; 95%IC 0.78 e 0.93). Conclusions: The presence on admission of hypotension, increased CRP, WBC count or hematocrit are all independent predictors of poor clinical outcome and should therefore prompt strict monitoring of these patients.

Supervised near-peer clinical teaching in the ambulatory clinic: an exploratory study of family medicine residents' perspectives.

Near-peer teaching is used extensively in hospital-based rotations but its use in ambulatory care is less well studied. The objective of this study was to verify the benefits of near-peer teaching found in other contexts and to explore the benefits and challenges of near-peer clinical supervision unique to primary care. A qualitative descriptive design using semi-structured interviews was chosen to accomplish this. A faculty preceptor supervised senior family medicine residents as they supervised a junior resident. We then elicited residents’ perceptions of the experience. The study took place at a family medicine teaching unit in Canada. Six first-year and three second-year family medicine residents participated. Both junior and senior residents agreed that near-peer clinical supervision should be an option during family medicine residency training. The senior resident was perceived to benefit the most. Near-peer teaching was found to promote self-reflection and confidence in the supervising resident. Residents felt that observation by a faculty preceptor was required. In conclusion, the benefits of near-peer teaching previously described in hospital settings can be extended to ambulatory care training programmes. However, the perceived need for direct observation in a primary care context may make it more challenging to implement.

OP26.09: Comparison of first trimester to second trimester fetal heart examination in detection of cardiac anomalies in a tertiary fetal medicine teaching unit

<scp>OP</scp>26.09: Comparison of first trimester to second trimester fetal heart examination in detection of cardiac anomalies in a tertiary fetal medicine teaching unit

Cultura de seguridad del paciente en residentes de medicina familiar y comunitaria de Aragón

Introductionhaving an appropriate patient safety culture is the first recommendation to improve it. The aim of this article is to determine the safety culture in family medicine residents and then to identify improvement strategies. Methodsan online cross-sectional survey of residents in family medicine teaching units of Aragon using the translated, validated and adapted to Spanish, Medical Office Survey on Patient Safety Culture (MOSPS) questionnaire. The results were grouped in 12-dimensional responses for analysis, and the mean value of each dimension was calculated. Perceptions were described by Percentages of Positive (PRP) and Negative Responses (PRN) to each dimension. Resultspositive results were seen in «the Patient Care Tracking/Follow-up». There were significant differences in the «Information Exchange With Other Settings», «Staff Training» and «Overall Perceptions of Patient Safety and Quality». Study participants viewed «Work Pressure and Pace» negatively. Conclusionsthe institutions providing health services, as well as their staff, are increasingly aware of the importance of improving Patient Safety, and the results of this study allowed us to present information that helps identify weaknesses, and to design initiatives and strategies to improve care practices.

Postgraduate internal medicine residents’ roles at patient discharge – do their perceived roles and perceptions by other health care providers correlate?

Knowing one’s own role is a key collaboration competency for postgraduate trainees in the Canadian competency framework (CanMEDS®). To explore methods to teach collaborative competency to internal medicine postgraduate trainees, baseline role knowledge of the trainees was explored. The perceptions of roles (self and others) at patient discharge from an acute care internal medicine teaching unit amongst 69 participants, 34 physicians (25 internal medicine postgraduate trainees and 9 faculty physicians) and 35 health care professionals from different professions were assessed using an adapted previously validated survey (Jenkins et al., 2001). Internal medicine postgraduate trainees agreed on 8/13 (62%) discharge roles, but for 5/13 (38%), there was a substantial disagreement. Other professions had similar lack of clarity about the postgraduate internal medicine residents’ roles at discharge. The lack of interprofessional and intraprofessional clarity about roles needs to be explored to develop methods to enhance collaborative competence in internal medicine postgraduate trainees.