Patient Case Discussions Research Articles

Behavioral Health in Pediatrics (BeHiP) Improving Behavioral Health for Children in Tennessee Foster Care

Introduction The Tennessee Chapter of the AAP secured financial support from BlueCross and BlueShield of Tennessee to fund Behavioral Health in Pediatrics (BeHiP)--a pilot foster care learning collaborative in northeast Tennessee. Pediatricians were recruited to participate in an intensive one-day behavioral health training and monthly video learning collaborative sessions. Sessions focused on discussion of challenging foster care patient cases submitted by the pediatricians and discussed with representatives from the regional behavioral system of care, including a child and adolescent psychiatrist and psychologist, the health nurse and patient advocate from the …

Cases in Psychiatry: A description of a multi-campus elective course for pharmacy students.

Cases in Psychiatry was a multi-campus elective course aimed to expand psychiatry knowledge beyond the required course curriculum. The format of the class included didactic course work, small group discussion of patient cases and article evaluation, submission of written notes, debates, and script concordance test questions delivered via a live online platform. Based on student assessment and feedback at the end of the course, the elective course was determined to meet the prespecified course objectives.

A naloxone and harm reduction educational program across four years of a doctor of pharmacy program

Background and purposeNaloxone distribution is an increasing service provided by pharmacists as more states enact laws enabling pharmacists to dispense naloxone without a prescription or per protocol to individuals in the wake of an opioid overdose epidemic. Education and training programs are necessary to ensure students and practicing pharmacists are able to effectively provide the service. Educational activity and settingAll first, second, and third year students in the doctor of pharmacy (PharmD) program at The Ohio State University College of Pharmacy (OSUCOP) participated in a pilot naloxone and harm reduction educational program. The program consisted of a three-part recorded lecture and a hands-on interactive workshop. Fourth-year students had the opportunity to participate. Students completed a ten-question assessment based on the content of the recorded lecture. Following the workshop, self-reflection and feedback were solicited. FindingsQualitative data indicated students felt the naloxone educational program was beneficial. Inclusion of harm reduction strategies, a mock counseling session, hands-on practice with naloxone delivery devices, and patient case discussions were valued. Discussion and summaryOSUCOP was able to develop and deliver a naloxone and harm reduction educational program across all four years of the PharmD curriculum within one year of passage of laws increasing pharmacist dispensing of naloxone.

Teaching and Implementing Evidence-Based Practice in a Hospital Unit With Secondary Vocational Trained Nurses: Lessons Learned.

Evidence-based practice (EBP) was systematically implemented using the implementation model by Grol et al. Barriers and facilitators for change were diagnostically analyzed. Implementation strategies were directed at the barriers. The two main implementation interventions were (a) a tailored interactive outreach training course about EBP and (b) a patient case discussion based on EBP principles. The authors learned that it is important to simplify the five EBP steps to suit the level of education of the nurses by formulating PICO questions around major patient care topics such as pain, and having a search strategy focusing on (Dutch) clinical practice guidelines and other summarized evidence, such as systematic reviews and critically appraised topics. The authors advised the hospital management to appoint nurse practitioners or other nurses with a master's degree to help the nurses on the ward with the EBP process steps, especially regarding efficiently searching the research literature and critically appraising the evidence. J Contin Educ Nurs. 2017;48(9):407-412.

“Three-Level, Four-Integration” Internet-Based Smart Medical Platform

To decrease the difficulty of patients in visiting the doctor and receiving quality health care, to enhance the service capacity of community primary health care institutes, and to implement the grading treatment strategies, Ji'nan Central Hospital has worked with Ping’yin County Hospital for the construction of “Three-Level, Four-Integration” Internet-Based Smart Medical Platform. The platform connects with the hospitals’ LIS and PACS systems, explores the mechanisms and models of three-grading health care in four aspects: medical treatment, teaching, research and administration. Its functions include long-distance (1) medical consultation, (2) multidisciplinary consultation, (3) clinical patient case discussion, (4) health education, (5) academic conference, (6) laboratory samples inspection and results reviewing, and (7) medical image diagnosis. As a result, an internet-based smart medical platform has been initially constructed, connecting city, county, and town hospitals, and providing quality and efficient health care services for urban and rural residents in Ji'nan area.

Implementation and impact of a chronic kidney disease elective for second-year pharmacy students

Background and purposePharmacists can make a great impact on the management of chronic kidney disease (CKD), which is a highly prevalent and costly disorder. This article describes the implementation and impact of a CKD elective course for second-year pharmacy students, which aimed to expose students to CKD and enhance their ability to care for these patients. Educational activity and settingTopics associated with CKD were covered in a fifteen-week, three credit hour course. Various active-learning techniques were utilized, including student presentations of pharmacotherapy and primary literature, team-based learning though patient case discussions, and interactions with standardized and actual patients. Surveys designed to assess students’ career goals and level of confidence with assessing primary literature, delivering presentations to peers, working as members of a team, and communicating with patients were administered at the beginning and end of the course. FindingsTwenty-three students (100%) participated in the initial survey, and nineteen (86.4%) participated in the final survey. Students gave more positive responses on the final survey that they were considering a career in ambulatory care (P=0.03), planning to pursue a career in ambulatory care (P=0.02), considering a career in kidney disease management (P=0.02), and planning to pursue a career in kidney disease management (P=0.0498). Students also felt more confident in their ability to assess primary literature (P=0.005) and deliver presentations to their peers (P=0.02). SummaryCourses such as this can expose students to new and unique career paths and help them develop key skills to promote a successful and fulfilling pharmacy career.

Impact of Flipped Classroom Design on Student Performance and Perceptions in a Pharmacotherapy Course

Objective. To determine whether a flipped classroom design would improve student performance and perceptions of the learning experience compared to traditional lecture course design in a required pharmacotherapy course for second-year pharmacy students. Design. Students viewed short online videos about the foundational concepts and answered self-assessment questions prior to face-to-face sessions involving patient case discussions. Assessment. Pretest/posttest and precourse/postcourse surveys evaluated students' short-term knowledge retention and perceptions before and after the redesigned course. The final grades improved after the redesign. Mean scores on the posttest improved from the pretest. Postcourse survey showed 88% of students were satisfied with the redesign. Students reported that they appreciated the flexibility of video viewing and knowledge application during case discussions but some also struggled with time requirements of the course. Conclusion. The redesigned course improved student test performance and perceptions of the learning experience during the first year of implementation.

Design, implementation, and assessment of an Integrated Pharmacy Applications course series

The McWhorter School of Pharmacy implemented a new curriculum in 2009 that sought to integrate information horizontally and vertically throughout the entire curriculum. A six-semester Integrated Pharmacy Applications (IPA) course series was designed to accomplish this. The objective of this article is to describe the design, implementation, and assessment of the integrated applications course sequence. Each semester of the didactic curriculum contains a one-credit-hour IPA course. The course has a weekly laboratory component and a two-hour time block on Fridays for discussion sessions. A framework for developing and facilitating sessions was created and provided to faculty. Example sessions include increasingly complex patient case discussion, technique demonstration, and simulations. Friday discussion sessions are designed to illustrate application of didactic course content to direct patient care. Students are charged a laboratory fee each semester to provide funds necessary to purchase supplies and equipment. The course series was implemented over a period of three years. An administrative position was created to oversee the series and ensure assessment of curricular integration efforts. Course topics are selected by this person in collaboration with faculty. Assessment of student performance in the course is formative and includes rubrics for direct observations, case notes, care plans, group work, and reflections. Course evaluations and student focus groups are used to obtain student feedback about the course. Deliberate planning and coordination of the IPA course series has fostered maximization of student learning, achievement of curricular integration, and compliance with accreditation standards.

Development and implementation of a telehealth-enhanced intervention for pain and symptom management

Managing chronic pain effectively is often challenging for health care providers and patients. Telehealth technologies can bridge geographic distance and improve patients' quality of care in communities where access to pain specialists has previously been unavailable. This paper describes the development and evaluation of a telehealth intervention (TelePain) designed to address the need for pain specialist consultation regarding pain and symptom management issues in non-academic medical centers. We describe the theoretical foundation and development of a multifaceted intervention using a cluster randomized clinical trial design. Health care providers and their patients with chronic pain are enrolled in the study. Patient participants receive the intervention (report of symptoms and receipt of a pain graph) weekly for 8weeks and are contacted at 12weeks for completion of post-intervention follow-up measures. Their providers attend TelePain sessions which involve a didactic presentation on an evidence-based topic related to pain management followed by patient case presentations and discussion by community clinicians. Symptom management recommendations for each patient case are made by a panel of pain specialists representing internal medicine, addiction medicine, rehabilitation medicine, anesthesiology, psychiatry, and nursing. The outcomes assessed in this randomized trial focus on pain intensity, pain's interference on function and sleep, and anxiety, depression, and cost-effectiveness. Some of the challenges and lessons that we have learned early in implementing the TelePain intervention are also reported.

Adult and Pediatric Perspectives on Heart Retransplant

At the Ethics of the Heart II: Ethical and Policy Challenges in Congenital Heart Disease Conference, March 16-17, 2012 in Philadelphia, Pennsylvania, one of the sessions focused on the issues related to end-stage heart failure in patients with congenital heart disease including utilizing the therapy of heart transplantation. This article will summarize the session related to repeat heart transplant that was based on discussion of actual patient cases, two adults and one pediatric, presented, respectively, by an adult and a pediatric heart transplant specialist. Outcome data related to retransplant for both adult and pediatric heart transplant populations are reviewed. The complicated ethical issues related to considerations of beneficence versus nonmalfeasance by a medical care team for an individual patient, patient autonomy related to adherence, and obligations to society to fairly allocate the scarce precious resource of donor organs are discussed.

Effect of a Resident Physician Educational Program on Pediatric Emergency Department Pharmacy Interventions and Medication Errors

To determine the effects of a resident physician educational program in a pediatric emergency department (ED) on pharmacy interventions and medication errors, particularly dose adjustments, order clarifications, and adverse drug events (ADE). The ED pharmacist recorded all interventions and medication errors on weekdays from 3 to 11 pm during a 9-month period, consisting of a preobservational (Quarter 1), observational (Quarter 2), and interventional (Quarter 3) phases. Program implementation occurred in Quarter 3, with an initial 3-hour lecture during the ED orientation, followed by daily patient case discussions. Weekly interventions and errors were analyzed using statistical process control u-chart analyses. Chi-square analyses of independence were also performed. Resident and ED staff feedback on the program was obtained through anonymous internet-based surveys. A total of 3507 interventions were recorded during the 9-month period. Chi-square approximation and interval estimation of odds ratio showed a statistically significant decrease between Quarters 1 and 3 in the number of dose adjustments (95% confidence interval [CI], 0.324-0.689) and order clarifications (95% CI, 0.137 to 0.382) after initiation of the program. The decline in ADE, while not as substantial (95% CI, 0.003 to 1.078), still achieved a level of significance (90% CI, 0.006 to 0.674). Survey results were positive toward the program. The implementation of a resident physician educational program in our pediatric ED significantly decreased the number of medication errors, increased resident physician awareness of the potential for errors, and increased ED pharmacist utilization.

The nonverbal structure of patient case discussions in multidisciplinary medical team meetings

Meeting analysis has a long theoretical tradition in social psychology, with established practical ramifications in computer science, especially in computer supported cooperative work. More recently, a good deal of research has focused on the issues of indexing and browsing multimedia records of meetings. Most research in this area, however, is still based on data collected in laboratories, under somewhat artificial conditions. This article presents an analysis of the discourse structure and spontaneous interactions at real-life multidisciplinary medical team meetings held as part of the work routine in a major hospital. It is hypothesized that the conversational structure of these meetings, as indicated by sequencing and duration of vocalizations, enables segmentation into individual patient case discussions. The task of segmenting audio-visual records of multidisciplinary medical team meetings is described as a topic segmentation task, and a method for automatic segmentation is proposed. An empirical evaluation based on hand labelled data is presented, which determines the optimal length of vocalization sequences for segmentation, and establishes the competitiveness of the method with approaches based on more complex knowledge sources. The effectiveness of Bayesian classification as a segmentation method, and its applicability to meeting segmentation in other domains are discussed.

Effects of the Restriction of Working Time for Residents: A Dutch Perspective

A main objective of restricting working time for residents, whether it is the Accreditation Council for Graduate Medical Education (ACGME) regulation or the European Working Time Directive (EWTD), is to protect patients from exhausted doctors. However, in the Netherlands, legislation enacted in 1993 to reduce working hours for junior doctors, as residents are termed, and midwives was prompted by trainees in a teaching hospital who complained to members of parliament about long working hours and miserable personal lives. At the time, public working hours were mandated to no more than 38 h/wk. An arbitrary 10 hours was added for education and training: thus, trainees were allowed to work 48 hours a week. In the first years, the Dutch Department of Labor took a more or less lenient position but, in 1997, started to enforce the law. Site visits to hospitals are made routinely, resident schedules are inspected, and hospitals are fined if they do not comply with the rules. Initially the surgical community fiercely opposed the new regulation and argued that a work week of 48 hours would not suffice to adequately train young surgeons. However, their plea for a 60-hour work week was politically unacceptable to the Dutch government, which had already accepted the limits of the European Working Time Directive. In 1995, the yearly survey of the Dutch Association of Surgical Trainees reported a work week of 57 hours. This number decreased to 55 hours in 2005 and has remained unchanged since.1

The Consultation Conference: A New Model of Collaboration for Child Psychiatry and Primary Care

Because of the relative shortage of available child psychiatrists, primary-care providers are increasingly expanding their role in the provision of mental health care. Accordingly, there is an increased need to develop a standardized approach to teaching specialized skills to these providers. One method of doing so is to expand the child psychiatrist’s consultative role to include the structured discussion of patient cases. By emphasizing the reasoning behind treatment recommendations, the psychiatrist can assist the primary-care provider in applying this knowledge to other patients in his or her practice. A group setting, or “consultation conference,” can be used to involve more providers—who, in turn, become resources for each other. This model of a group conference adapts principles of adult learning (1–5) to facilitate the dual consultative and educational goals. Providers who care for patients in the same (or similar) setting come together as a group to share their experience and knowledge. The psychiatrist assists in that group setting, functioning both as expert resource and facilitator. Participants discuss problem cases, thus learning in their own context while receiving assistance in the understanding and management of actual patients (indirect consultation).

PACS: Do clinical users benefit from it as a training adjunct?

Background. Over the past four years, Steve Biko Academic Hospital has been in the process of implementing and refining the use of a picture archiving and communications system (PACS). As part of a post-implementation refining process, it is necessary to evaluate user-perceptions in order to improve on good system qualities and correct flaws.
 Aim. The aim of this study was to assess whether medical clinicians perceived PACS as a positive adjunct to training and teaching opportunities – specifically those opportunities related to radiological image viewing and interpretation as part of patient case discussions.
 Method. Standardised questionnaires with ‘free text’ and ‘option selection’ questions were distributed to clinicians who, as part of their training, rotated at Steve Biko Academic Hospital (where a PACS is in place) as well as other teaching hospitals without a PACS. Between February 2009 and May 2009, approximately 400 questionnaires were distributed. As a result of constant academic rotations, leave schedules of medical staff and posts vacated, questionnaires could not be distributed to the entire target population that was estimated to be in the region of 550 medical clinicians (comprising senior medical students, interns, medical officers, registrars and consultants). Of the 400 questionnaires distributed, 189 completed questionnaires were returned. Completion of the questionnaires was voluntary and anonymous.
 Results and conclusion. Although a PACS relates specifically to the archiving and retrieval of radiological images and reports, it became clear from the feedback received from medical clinicians (who are ward-based, theatre-based or clinic-based users of a digital system) that many other factors, such as lack of adequate hardware and sub-optimal personal IT proficiency, contributed to some of the negative PACS-related perceptions and ‘lost teaching opportunities’ reported. Negative comments specifically related to PACS as a training adjunct included the frustrations associated with PACS downtime (especially during the period in 2009 when many electrical power cuts were experienced nationwide, resulting in network interruptions) and slow image retrieval during peak work-flow times. The advantages of PACS as a positive training adjunct were highlighted in the areas of multi-site viewing and consultation, the possibility of image manipulation and measurement tools, and better overall image quality. Clinicians felt that their training experience was also enhanced because of better patient follow-up made possible by access to all previous radiological imaging of a particular patient. Of the clinicians who completed the questionnaires, 63.5% felt that the PACS at Steve Biko Academic Hospital contributed positively to their training by creating more overall learning opportunities than other training environments without a PACS.

Measuring progressive independence with the resident supervision index: empirical approach.

A Resident Supervision Index (RSI) developed by our research team quantifies the intensity of resident supervision in graduate medical education, with the goal of testing for progressive independence. The 4-part RSI method includes a survey instrument for staff and residents (RSI Inventory), a strategy to score survey responses, a theoretical framework (patient centered optimal supervision), and a statistical model that accounts for the presence or absence of supervision and the intensity of patient care. The RSI Inventory data came from 140 outpatient encounters involving 57 residents and 37 attending physicians during a 3-month period at a Department of Veterans Affairs outpatient clinic. Responses are scored to quantitatively measure the intensity of resident supervision across 10 levels of patient services (staff is absent, is present, participated, or provided care with or without a resident), case discussion (resident-staff interaction), and oversight (staff reviewed case, reviewed medical chart, consulted with staff, or assessed patient). Scores are analyzed by level and for patient care using a 2-part model (supervision initiated [yes or no] versus intensity once supervision was initiated). All resident encounters had patient care supervision, resident oversight, or both. Consistent with the progressive independence hypothesis, residents were 1.72 (P = .019) times more likely to be fully responsible for patient care with each additional postgraduate year. Decreasing case complexity, increasing clinic workload, and advanced nonmedical degrees among attending staff were negatively associated with supervision intensity, although associations varied by supervision level. These data are consistent with the progressive independence hypothesis in graduate medical education and offer empirical support for the 4-part RSI method to quantify the intensity of resident supervision for research, program evaluation, and resident assessment purposes. Before informing policy, however, more scientific research in actual teaching settings is needed to better understand the relationships among patient outcomes, clinic workload, case complexity, and graduate medical education experience in resident supervision and professional development.

Physiotherapy students’ and clinical teachers’ perspectives on best clinical teaching and learning practices: A qualitative study.

Background: Clinical education forms a core component of the training of physiotherapy students. Little research on the efficacy of commonly used physiotherapy clinical learning and teaching opportunities are available. Objective: This paper sought to identify the clinical teaching and learning opportunities that undergraduate physiotherapy students and clinical teachers viewed as effective in enhancing learning, as well as the reasoning behind their views.Design: A qualitative research design was used. Data was analyzed using content analysis. Data was coded, cate gorized and conceptualized into key themes and patterns. Participants: All third year (n=40) and fourth year (n=40) physiotherapy students as well as their clinical teachers (n=37) were eligible to participate. Semi-structured individual interviews were conducted with a purposive sample consisting of six third-year students, six fourth-year students and six clinical teachers. Results: The results indicated that learning is best facilitated in open, relaxed environments.Demonstrations of patient management by teachers and students, discussion of patient cases, feedback and formative assessment were identified to be effective strategies to enhance development of clinical competence. Conclusion: Clinical education, using focused and structured processes, could ensure that students are exposed to a range of learning opportunities for development of clinical competence.

Webinar : An Initial Experience with Web-based Real Time Interactive Clinical Seminars for Japanese Medical Students

OBJECTIVE To demonstrate the feasibility of webinars, web-based real time interactive seminars, for geographically distant medical students and their tutors. METHODS Six participants from 5 medical schools in Japan were self-selected 3rd to 6th year medical students. A North American medical educator served as their webinar tutor. The students and tutor used home computers to participate in the webinar. RESULTS AND CONCLUSIONS A total of twelve webinars were held, 4 with a tutor and 8 without the tutor. Unstructured tutoring formats included symptom-related differential diagnoses, role-play and patient case discussions. We suggest webinar is a feasible technology to supplement the clinical training of medical students at medical universities.

Viewpoint: The Importance of Worldviews for Medical Education

The culture of academic medicine holds implicit and explicit assumptions about what is important in life, including assumptions about health and the practice of medicine. This philosophy of life constitutes a worldview from which medicine is practiced. Medical educators should introduce medical students to the benefits and limitations of this worldview, and to important alternative worldviews, early in medical school. The authors describe the concept of worldview, discuss the biomedical worldview that is dominant in Western medicine, compare it with other life philosophies (including non-Western and spiritual perspectives), and propose teaching about biomedical and other worldviews within the existing structure of preclinical medical education. The authors propose beginning medical school with a Foundations of Healing course that would introduce students to the concept of worldviews, place the biomedical worldview in a larger context with other worldviews, and explore the beneficial and adverse elements of the biomedical worldview. To maintain the awareness of worldviews after the course described above, the authors propose humanistic "horizontal strands." These would be structural elements of a longitudinal curriculum that intentionally interweave patient vignettes and case discussions into basic science lectures to highlight the variety of worldviews operating in healthcare contexts. By exposing students to the concept of worldview early in their training, educators can better meet professionalism mandates related to bias and self-awareness, immunize students against the adverse effects of the hidden curriculum, and bolster the status of the social and behavioral sciences in medical education.

Evolution Towards A Clinical Pharmacy Degree Program: A U.S. Perspective

Pharmacy practice is progressing toward the future with the addition of 2 years to the Japanese pharmacy school curriculum by the year 2006. With a 6-year pharmacy degree, graduating pharmacists can provide more pharmaceutical care to patients in hospitals and community pharmacies than ever before. In the United States, the clinical pharmacy movement began to evolve during the 1960's. Several key philosophical changes and structural modifications to the pharmacy curriculum prepared graduates for new roles in patient education, communication with physicians, independent learning, and problem-solving. Patient case discussions through the small group, problem-based learning (PBL) approach are essential courses for the development of analytical thinking skills. Students are required to justify their choices with evidence-based primary literature. The curriculum is also strengthened by including participatory experiences, such as clinical rotations, within the curriculum structure prior to graduation. The clinical pharmacy movement was successful and now pharmacists in the United States perform a broad scope of patient-oriented clinical practice activities, such as preventative healthcare screening and monitoring of cholesterol, blood glucose, and hemoglobin Alc blood levels, taking blood pressure measurements, administering immunizations and providing more patient education than ever before.