Physician Training Level Research Articles

TCT-494 Impact of Level of Physician Training on Transfer of ST Segment Elevation Myocardial Infarction

Patients (pts) presenting with STEMI to facilities that do not perform PCI receive lytics and/or are transferred. AHA's Mission: Lifeline “Strategies for the Ideal STEMI-Referral Hospital” recommends Door In Door Out (DIDO) time within 30 minutes for the referring hospital (1). The Omaha

Study on Physician Ordering Behavior on Hypercoaguable Screening Tests

AbstractAbstract 4745 Background:We can now identify hereditary and acquired risk factors in patients with a venous thrombotic event. Hereditary factors include factor V Leiden; prothrombin G 20210A mutation; or deficiencies of antithrombin, protein C, or protein S. But considerable uncertainty exists in hypercoagulable testing. Clinical criteria (Bauer, 2002) guidelines are available and laboratory evaluation can confirm the diagnosis. But we know of anecdotal stories where physicians ignored the testing pathways. Even when correctly utilized, testing was inappropriately timed after the thrombotic event. There are many scenarios for thrombosis with no single test to identify these risk factors. We need to re-examine the use of these screening tests for inherited and acquired thrombosis syndromes. Materials and Methods:Retrospectively, 200 patient charts were reviewed on the use of hypercoagulable screening panels, patient characteristics, and physician characteristics. The hypercoaguable screening tests contain prothrombin time, partial thromboplastin time, thrombin time, fibrinogen, antithrombin, plasminogen, activated protein C resistance, protein C, protein S, and lupus anticoagulant. Factor V Leiden and prothrombin G 20210A mutation results were reviewed if available. Data reviewed included age, gender, location of thrombosis (arterial vs. venous), malignancy, connective tissue disorder, diabetes, hypertension, nephrotic syndrome, liver disease, active infections, recent surgery, trauma, anticoagulation medications, obstetric history, family history, hypercoaguable screening test results, physician specialty, training level, and indications for the tests. Results:Patient age range was 18–91; 79 males and 12 females. Among 200 cases, 23 were positive from the hypercoaguable screening tests but only 4 were true positive for hereditary thrombophilia (Factor V Leiden, prothrombin G 20210A, antithrombin deficiency and protein C and S deficiency, respectively). False positive results (low levels of antithrombin, protein C, protein S) were due to coumadin. Ordering physicians were diverse (internal medicine, general medicine, family medicine, hematology/oncology, cardiology, pulmonary, rheumatology, nephrology, neurology, general surgery, vascular surgery, and pediatrics). Reason for ordering tests were varied: family history of thrombosis, recurrent deep vein thrombosis, myocardial infarction, pulmonary embolus, stroke, malignancy, myeloproliferative disorders, connective tissue disorders, inflammatory bowel disease, liver disease, diabetes, nephrotic syndrome, arteriovenous shunt operation, and fetal loss. Few cases fit the clinical criteria. Ordering tests were inconsistent with the indications for hereditary thrombophilia, with no relation to the clinical history, physician training level, or specialty. Discussion and Conclusion:Why these irregularities in behavior exist, we are not sure. From our literature review, there were few papers available on discrepancies in physician reasoning for utilizing laboratory tests. Wertman (1980) identified no single reason for test ordering behavior of physicians. Axt-Adams (1993) suggested that motivators, other than physician education, had a higher correlation of influencing physician ordering behavior when over-utilizing laboratory tests. These motivators included 1) fear of failure to diagnose, 2) fear of criticism, 3) inability to cope with diagnostic uncertainty, 4) eagerness to complete the screening evaluation while in the hospital, 5) desire to be complete in evaluation, 6) hope that additional follow-up testing provides the correct diagnosis, 7) provide reassurance for patient, 8) collective ordering, and 9) ignorance of costs and diagnostic significance of tests and their sensitivity, specificity, and predictability. In many cases, the diagnostic criteria for ordering hypercoagulable screenings were not followed. We did not have the opportunity to interview the ordering physicians about their rationale which may have provided more insight. More education is necessary on hereditary thrombophilia, limitations of coagulation tests, acquired conditions for thrombosis, and the costs of these specialized tests. More studies are necessary to understand physician behaviors in ordering these expensive tests. Disclosures:No relevant conflicts of interest to declare.

Assessment of knowledge of physicians about trauma/emergency care in public and private sectors in four districts of Sindh, pakistan

BackgroundIn Pakistan, currently there is only one institution, which offers postgraduate residency training program. Doctors from other specialties manage emergencies. Pakistan is vulnerable to natural and manmade emergencies. Therefore, our...

Chronic kidney disease management in an academic internal medicine clinic

We sought to evaluate the current state of chronic kidney disease (CKD) management in our academic internal medicine clinic. A retrospective review was carried out involving all patients with laboratory evidence of CKD enrolled in our clinic. We evaluated the rate of CKD recognition as well as compliance with standard guidelines. We further subdivided our results based on physician training level, presence of diabetes, recognition of CKD, age, and race. Factors that significantly improved recognition and treatment of CKD in our study included presence of diabetes (p < 0.001), black race (p = 0.013), younger age (p = 0.004), and treatment by a resident physician (p = 0.009). Recognition of stage 3 CKD was associated with significant increases in urine protein analysis (p < 0.001) and nephrology consultation (p < 0.001). Chronic kidney disease remains under-recognized and undertreated despite well-publicized guidelines and widespread use of routine eGFR reporting.

Comparative Clinical Practice of Residents and Attending Physicians Who Care for Pediatric Patients in the Emergency Department

The purpose of our study was to explore the effect of the physician's training level on the emergency management of common illnesses in the pediatric emergency department (ED). Our hypothesis was that physicians in training used more resources than attending physicians did in caring for pediatric patients in the ED. We retrospectively reviewed all records of patients younger than 18 years who presented to the pediatric section in ED of Taipei Veterans General Hospital between January 1, 2004, and December 31, 2005. The cohort study was composed of patients treated by a pediatric attending physician (group 1) or treated by a resident (group 2). We collected their demographic data, diagnoses, admission and revisiting rates, direct costs (including radiographic, laboratory, and medication costs per visit), and utilization data. Admission and 72-hour revisiting rates did not differ between groups. Lengths of ED stay and total, radiographic, and medication costs significantly increased with the residents (all P < 0.001). Residents ordered more radiographic (30.7% vs 23.8%, P < 0.001) and laboratory (37.2% vs 34.6%, P = 0.13) studies than attending physicians did, notably when patients had acute bronchitis and bronchiolitis or noninfectious gastroenteritis and colitis. Residents also ordered more laboratory studies in cases of pneumonia. Residents treating pediatric patients in the ED spent more time and used more medical resources than attending physicians did. An important educational objective is to improve physicians' diagnostic skills to reduce resource utilization and to improve outcomes.

Open access colonoscopy in the training setting: which factors affect patient satisfaction and pain?

Patient satisfaction with colonoscopy is important for quality assurance; it may be affected by various factors, including patient characteristics, physician training level, and procedural or organizational features. We aimed to analyze how these factors influenced patient satisfaction and pain in an outpatient training setting. Consecutive patients for open access colonoscopy (OAC) were enrolled in a prospective, single-blinded, controlled study. Primary and secondary outcomes were satisfaction and pain scores with and without trainee participation. A multivariate analysis was designed to achieve an 80 % power with an alpha value of 0.05. 368 patients were enrolled. Satisfaction with the procedure was high (mean score 1.36; 1 = best to 5 = worst). In the multivariate analysis only waiting time in the endoscopy suite was significantly associated with lower satisfaction scores ( P = 0.024). Satisfaction was unaffected by patient factors (gender, American Society of Anesthesiologists' [ASA] score, anxiety, etc). Higher pain scores were associated with higher anxiety levels ( P = 0.02), female gender ( P = 0.02), longer procedure ( P< 0.001), and lower sedation levels ( P = 0.001); trainee involvement (49 % of procedures) did not adversely affect satisfaction or pain scores. Patient satisfaction with OAC using sedation appears to depend primarily on organizational factors (waiting time beforehand). In contrast, pain is associated with patient characteristics (female gender, anxiety) and procedural factors (lower sedation, longer procedure). Trainee participation did not affect satisfaction or pain scores, a finding which may help to reassure patients undergoing OAC with trainee participation.

What Are You Waiting For? A Study of Resident Physician-Parent Communication in a Pediatric Emergency Department

This study measures the degree to which parents of patients, in the course of evaluation and treatment in a pediatric emergency department (ED), could report what they were waiting for. Brief in-person interviews were conducted with parents of nonemergency patients during an ED visit. After the patient had been seen by a resident physician and evaluation and treatment were in progress, parents were asked to report what they were waiting for. The patient's physician was also asked to report what the patient was waiting for. These answers were compared and coded as complete agreement, partial agreement, or disagreement. Association between lack of agreement and patient factors (age, sex), parent factors (sex, education, age), physician factors (sex, postgraduate year), and system factors (wait time, time of day, number of patients in the department) was examined. Logistic regression was used to calculate adjusted odds ratios. A total of 200 paired surveys were included in the data analysis. Two thirds of parental reports completely agreed with physician reports, 11.5% partially agreed, and 21.5% completely disagreed. Multivariate analysis revealed that disagreement between resident physician and parents was associated with parental educational level and physician training level. Parents with less than a high school education were more than 9 times more likely to disagree than those with at least some college education (odds ratio 9.3; 95% confidence interval [CI] 2.4 to 35.7). As the postgraduate level of the physician decreased, disagreement was more common; disagreement for patients of postgraduate level 1 residents was 5 times more likely (95% CI 1.8 to 14.5) than that of postgraduate level 3 and higher residents. As measured by asking the question "what are you waiting for," significant communication gaps were identified between physicians and the parents of their patients in this emergency department. One in five parents could not report what they were waiting for. Factors such as lower parental education and less physician experience increase the risk of such a gap. Further work in defining the source of the ineffective communication and interventions to remediate the problem is needed.

Opioid contract use is associated with physician training level and practice specialty

Opioid contracts are widely used to manage opioid prescribing in the treatment of pain conditions, but they are not well studied. A notable gap in our knowledge of opioid contracts involves the factors that determine their use. As an initial inquiry, this study evaluated the responses of a Web-based survey of trainees and faculty in an academic medical training context to determine correlates of opioid contract use. All paid faculty, third- and fourth-year medical students, and residents in The University of Oklahoma College of Medicine were invited via email to participate in a Web-based survey of their attitudes and prescribing practices related to controlled prescription drugs. Respondents composing a subgroup of those who replied to the survey were identified by their prescription of opioids and by their designation that pain was the most likely diagnosis for which they would prescribe a controlled drug. Chi-square analysis was used to determine any correlation between contract use and respondents' demographic variables and categorical survey responses. Analysis of variance was used to determine any correlation between contract use and survey responses that involved continuous variables. Our results showed that opioid contract use was significantly associated with resident status, primary care specialty, participant estimation of alcohol and illicit drug abuse by patients, and the participant's assessment of the risks in general of prescribing controlled drugs. A majority of contract users reported that the use of this tool increased their sense of mastery and comfort with prescribing controlled drugs. The factors associated with opioid contract use found in this study suggest there are significant prescriber-specific determinants of the use of the tool, including training level, medical specialty, and risk appraisals. Opioid contracts' effects on mastery and comfort of the physician with prescribing opioids suggest that they may play an important role in facilitating appropriate pain management with opioids. Further study is needed to elucidate environmental and patient-specific factors that may influence opioid contract use.

Measuring the Quality of Physician Practice by Using Clinical Vignettes: A Prospective Validation Study

Worldwide efforts are under way to improve the quality of clinical practice. Most quality measurements, however, are poorly validated, expensive, and difficult to compare among sites. To validate whether vignettes accurately measure the quality of clinical practice by using a comparison with standardized patients (the gold standard method), and to determine whether vignettes are a more or less accurate method than medical record abstraction. Prospective, multisite study. Outpatient primary care clinics in 2 Veterans Affairs medical centers and 2 large, private medical centers. 144 of 163 eligible physicians agreed to participate, and, of these, 116 were randomly selected to see standardized patients, to complete vignettes, or both. Scores, expressed as the percentage of explicit quality criteria correctly completed, were obtained by using 3 methods. Among all physicians, the quality of clinical practice as measured by the standardized patients was 73% correct (95% CI, 72.1% to 73.4%). By using exactly the same criteria, physicians scored 68% (CI, 67.9% to 68.9%) when measured by the vignettes but only 63% (CI, 62.7% to 64.0%) when assessed by medical record abstraction. These findings were consistent across all diseases and were independent of case complexity or physician training level. Vignettes also accurately measured unnecessary care. Finally, vignettes seem to capture the range in the quality of clinical practice among physicians within a site. Despite finding variation in the quality of clinical practice, we did not determine whether poorer quality translated into worse health status for patients. In addition, the quality scores are based on measurements from 1 patient-provider interaction. As with all other scoring criteria, vignette criteria must be regularly updated. Vignettes are a valid tool for measuring the quality of clinical practice. They can be used for diverse clinical settings, diseases, physician types, and situations in which case-mix variation is a concern. They are inexpensive and easy to use. Vignettes are particularly useful for comparing quality among and within sites and may be useful for longitudinal evaluations of interventions intended to change clinical practice.

Volume 20 (2004) Index

Adamiak, Grazyna Teresa, and Ingvar Karlberg. The Impact of Physician Training Level on Emergency Readmission within Internal Medicine, 516

Impact of physician training level on emergency readmission within internal medicine

The research question was whether training level of admitting physicians and referrals from practitioners in primary health care (PHC) are risk factors for emergency readmission within 30 days to internal medicine. This report is a prospective multicenter study carried out during 1 month in 1997 in seven departments of internal medicine in the County of Stockholm, Sweden. Two of the units were at university hospitals, three at county hospitals and two in district hospitals. The study area is metropolitan-suburban with 1,762,924 residents. Data were analyzed by multiple logistic regression. A total of 5,131 admissions, thereby 408 unplanned readmissions (8 percent) were registered (69.8 percent of 7348 true inpatient episodes). The risk of emergency readmission increased with patient's age and independently 1.40 times (95 percent confidence interval [CI], 1.13-1.74) when residents decided on hospitalization. Congestive heart failure as primary or comorbid condition was the main reason for unplanned readmission. Referrals from PHC were associated with risk decrease (odds ratio, 0.53; 95 percent CI, 0.38-0.73). The causes of unplanned hospital readmissions are mixed. Patient contact with primary health care appears to reduce the recurrence. In addition to the diagnoses of cardiac failure, training level of admitting physicians in emergency departments was an independent risk factor for early readmission. Our conclusion is that it is cost-effective to have all decisions on admission to hospital care confirmed by senior doctors. Inappropriate selection of patients to inpatient care contributes to poor patient outcomes and reduces cost-effectiveness and quality of care.

Competent patient care is dependent upon attending to empathic opportunities presented during interview sessions

Objective Core competencies in surgical education and clinical care rely on effective patient-physician communication. We aim to develop quantitative and empirical tools for understanding critical communication tasks during patient interviews. Methods Residents in surgical training and attending physicians were separately video recorded during stressful, first visit oncology patient interview sessions. Taped sessions (n = 16) were analyzed in detail to identify and label patient-initiated actions (PIAs), or “empathic opportunities,” that call for recognition or action from the caregiver. Doctor-responsive actions (DRAs) were labeled as matching to, or missing from, each empathic opportunity. Missed empathic opportunities occurred when a PIA did not have an associated DRA. Presession and postsession surveys queried the patient's perception of how well their health-care needs were met. Results Resident trainees and attending physicians missed 70% of 160 clearly identified empathic opportunities. There was no clear association with the level of physician training. This pilot study did not have enough power to discern differences in patient satisfaction. Conclusions Physicians are often not very attentive to empathic opportunities offered by patients. Individual feedback and training regarding empathic opportunities in recorded patient communication encounters may improve resident and physician core competencies. These improvements may affect patient satisfaction related to these encounters.

Why do some women refuse to allow male residents to perform pelvic exams?

Many women who receive medical care in residency training clinics refuse to allow male residents to perform their pelvic exams. This study was conducted to identify which women were most likely to refuse and to learn their reasons for refusing. From January to March 1997, a questionnaire was given to all women entering a Tri-County Health office and a Planned Parenthood clinic, both in the Denver, Colorado, metropolitan area, who consented to participate in the study. Data from the questionnaire were analyzed using a statistical software package. A total of 1,437 women entered the clinics during the study period. Of these patients, 1,078 consented to complete the questionnaire. Seven of these 1,078 women did not complete the questionnaire. Women who did not know the training level of the resident performing the pelvic exam were more likely to refuse than were women who knew the training level of the resident (p =.001), but many women preferred a female physician regardless of the physician's training level. Fifty-eight percent said they would allow a male resident to observe a female attending physician perform the exam, compared with 36% who said they would allow a male resident to observe if the attending physician was a man. Common statements from those who would refuse were: "I am just more comfortable with a female," "Women do not want men to examine their private body parts," and "Women explain things better." A woman's knowledge of the resident's training level correlates with her willingness to have a pelvic exam performed by a male resident. Women who said they would refuse a pelvic exam performed by a male resident gave specific reasons for their decision.

Language barriers and resource utilization in a pediatric emergency department.

Although an inability to speak English is recognized as an obstacle to health care in the United States, it is unclear how clinicians alter their diagnostic approach when confronted with a language barrier (LB). To determine if a LB between families and their emergency department (ED) physician was associated with a difference in diagnostic testing and length of stay in the ED. Prospective cohort study. This study prospectively assessed clinical status and care provided to patients who presented to a pediatric ED from September 1997 through December 1997. Patients included were 2 months to 10 years of age, not chronically ill, and had a presenting temperature >/=38.5 degrees C or complained of vomiting, diarrhea, or decreased oral intake. Examining physicians determined study eligibility and recorded the Yale Observation Score if the patient was <3 years old, and whether there was a LB between the physician and the family. Standard hospital charges were applied for each visit to any of the 22 commonly ordered tests. Comparisons of total charges were made among groups using Mann-Whitney U tests. Analysis of covariance was used to evaluate predictors of total charges and length of ED stay. Data were obtained about 2467 patients. A total of 286 families (12%) did not speak English, resulting in a LB for the physician in 209 cases (8.5%). LB patients were much more likely to be Hispanic (88% vs 49%), and less likely to be commercially insured (19% vs 30%). These patients were slightly younger (mean 31 months vs 36 months), but had similar acuity, triage vital signs, and Yale Observation Score (when applicable). In cases in which a LB existed, mean test charges were significantly higher: $145 versus $104, and ED stays were significantly longer: 165 minutes versus 137 minutes. In an analysis of covariance model including race/ethnicity, insurance status, physician training level, attending physician, urgent care setting, triage category, age, and vital signs, the presence of a LB accounted for a $38 increase in charges for testing and a 20 minute longer ED stay. Despite controlling for multiple factors, the presence of a physician-family LB was associated with a higher rate of resource utilization for diagnostic studies and increased ED visit times. Additional study is recommended to explore the reasons for these differences and ways to provide care more efficiently to non-English-speaking patients.

Patients' understanding of the roles of interns, residents, and attending physicians in the emergency department.

To assess patients' knowledge of the responsibilities and roles of physician training in the ED. This was a prospective survey of a convenience sample of 345 adult patients and family members in an academic county ED. Thirty questions addressed the different roles, responsibilities, and hierarchies of physician levels of training. Four opinion-based questions assessed patients' willingness to have physicians-in-training care for them. 96.5% of the surveys were returned. Of the participants responding, 68% were Hispanic, 23% were non-Hispanic white, and 55% were women. Forty percent of the participants indicated that they had education greater than a high school diploma. Most participants answered fewer than 50% of the questions correctly, indicating that they did not understand the levels of physician training. Participants with higher education were more likely to know the correct answer. Seventy-nine percent of the participants believed that it is very important to know the level of training of their physicians. However, only 34% of the participants actually thought they knew the training level of their physicians when they were being treated. Twenty-nine percent of the participants did not want learning to take place on themselves by physicians-in-training. Participants believe that it is important to know their physicians' level of training, but they do not understand the roles and responsibilities of physicians-intraining in the medical training system in which they receive care. In particular, patients who have less than a high school education seem to know least about this system.

Complications and risks of central venous catheter placement in children

Background: Since Aubaniac's first description in 1952, the use of central venous catheters has increased dramatically; they are now considered commonplace. Placement of these catheters, however, has an associated risk of morbidity and mortality. In most cases, this risk is outweighed by the benefit gained, especially when long-term access to the central venous system is needed for multiple transfusions, chemotherapy, antibiotics, or parenteral nutrition. A large number of central venous catheters are placed in children at our institution, usually by interns and residents. Methods: To identify associated risks and complications, we reviewed the records of 1435 consecutive catheterizations in children over a 10-year period. Data collected included age, sex, site of catheterization, type of catheter, primary disease, prior catheterizations, indication for placement, failed attempts, number of attempts, catheter misplacement, level of physician training, new needle punctures, and complications. We then used logistic regression analysis to identify independent risk factors for complications. Results: We noted 39 (3.1%) perioperative complications, including 19 (1.5%) arterial punctures, 10 (0.8%) pneumothoraces, 6 (0.5%) hemothoraces, 2 (0.2%) cases of superior vena cava syndrome, 1 (0.1%) episode of ventricular fibrillation that required cardioversion, and 1 episode of bleeding that required a cutaneous suture. Univariate analysis revealed that catheters placed in a subclavian vein (vs all other sites combined, P < .01) were less likely to have an associated complication. In addition, multiple attempts (vs success on first attempt, P < .0001), failed attempt (vs success at initial site, P < .0001), catheter misplacement (vs proper initial position, P < .01), and prior catheterizations (vs no prior catheterization, P < .0005) were associated with complications. Logistic regression revealed multiple attempts (vs success on first attempt, odds ratio (OR) = 5.4), failed attempt (vs success at initial site, OR = 5.2), and catheter misplacement (vs proper initial position, OR = 6.9) to be independent risk factors for complications. Age, sex, type of catheter, primary disease, indication for placement, and level of physician training (intern or resident vs staff) were not associated with complications. Conclusions: Central venous catheterization in children is relatively safe, with only a 3.2% complication rate and no mortality in our series. (Surgery 1998;124:911-6.)

Open Thoracotomy Procedural Competency: Validity Study of Teaching and Assessment Modalities

Study objectives: To determine (1) reliability and validity estimates of three modalities used to assess open thoracotomy procedural competency and (2) the effect of computer practice on procedural performance as measured by the three assessment modalities. Methods: An experimental, sequential assessment design with volunteer examinees completing all three assessment modalities (paper, computer, pig model) was implemented at the animal support facilities of a university medical school with an affiliated emergency medicine residency program. Level of physician training (student, resident, faculty) and type of computer practice (thoracotomy, cricothyrotomy) were independent variables. Procedural competency scores were determined for each modality; scores were defined in terms of performance time and performance accuracy for three thoracotomy procedures (opening the chest, pericardiotomy, and aortic cross-clamping). Results: Thoracotomy performance on the pig reliably discriminated among examinees known to differ in level of training. However, computer simulation performance did not significantly differ among examinees with different levels of training. Computer simulation practice significantly improved later performance on the computer assessment ( P<.05) but not on the pig assessment. The greatest predictor of procedural competency (time and accuracy) on the pig assessment was the ability to sequentially order procedural steps. Conclusion: This study establishes the pig model as superior to the paper and computer models as the criterion standard for open thoracotomy assessment. Psychometric properties support the pig model as the most reliable and valid model yet described for assessing thoracotomy procedural competency. Computer simulation practice using visual images (complex anatomy) and the sequential ordering of procedural steps through paper modeling show promise for teaching and assessment of prerequisite skills required to develop psychomotor procedural competency. [Chapman DM, Rhee KJ, Marx JA, Honigman B, Panacek EA, Martinez D, Brofeldt BT, Cavanaugh SH: Open thoracotomy procedural competency: A validity study of teaching and assessment modalities. Ann Emerg Med December 1996;28:641-647.]

Accuracy of Death Certificate Completion

To assess the extent to which accuracy of death certificate completion varies with level of physician training and experience. In a classroom setting, subjects were presented with six written cases of hospital deaths adapted from materials from the National Center for Health Statistics and were asked to complete the cause-of-death section of the New York City death certificate. A total of 12 practicing general internists, 21 internal medicine residents, and 35 senior medical students. The underlying cause of death recorded by each participant was compared with the correct cause determined by a nosologist. Agreement and disagreement were classified as major or minor depending on concordance within the 17 International Classification of Diseases categories. Only one internist and five residents had received formal training in death certificate completion. The overall level of agreement between underlying cause of death reported by the three groups of participants and the correct cause was 56.9% for internists, 56.0% for residents, and 55.7% for medical students, although agreement varied with the type of case, ranging from 15% to 99%. If the misclassification observed in this pilot study were widespread, it would imply a substantial underreporting of mortality from both circulatory diseases and diabetes. These data strongly support the need to include training in death certificate completion as part of physician education.

Emergency thoracotomy: comparison of medical student, resident, and faculty performances on written, computer, and animal-model assessments.

In clinical practice, thoracotomy and other critical emergency procedures are rarely required. Consequently, medical students and residents have difficulty acquiring procedural competency in these critical procedures. The authors developed objective written, computer, and animal-model assessments of thoracotomy procedural competency to permit comparison of the reliability and validity of these three procedural assessment modalities. Thoracotomy procedural competency was evaluated for 18 persons at three levels of training (medical student, resident, faculty), using written, computer, and animal-model assessments. A prospective, sequential assessment design was used, with the examinees serving as their own controls. Procedural competency was defined in terms of performance time (animal time scale) and performance accuracy (written accuracy, computer accuracy, and animal accuracy scales) for three thoracotomy procedures (opening the chest, pericardiotomy, and aortic cross-clamping). Level of training was the independent variable, and procedural competency scores were the outcome measures. Confounding variables included previous thoracotomy and computer experience. Computer and animal-model assessments produced reliable results (Chronbach's alpha > 0.50). The animal time scale and computer accuracy scale best reflected the expected skill differences among levels of physician training, providing support for construct validity. In contrast, written and animal accuracy scale scores did not significantly differ by level of physician training. Moreover, previous thoracotomy experience (i.e., number of procedures previously performed) was not a significant predictor of procedural competency. This study demonstrates that critical emergency medicine procedures can be evaluated reliably and validly using computer simulation and animal-model assessments. Neither previous thoracotomy experience nor knowledge of procedure content adequately predicts thoracotomy competency.

Physician response to a prediction rule for the triage of emergency department patients with chest pain

To determine the response of physicians to a noncoercive prediction rule for the triage of emergency department patients with chest pain. Prospective time-series intervention study. A university hospital emergency department. 68 physicians, all of whom were responsible for the triage of at least one of 252 patients presenting to the emergency department with a chief complaint of acute chest pain. A previously validated algorithmic prediction rule that was attached to the back of patient data forms in the emergency department. Patients' clinical data were recorded by the examining physician in the emergency department or by a research nurse blinded to patient outcome. The physicians recorded their own estimates of the risk of acute myocardial infarction and their reactions to the prediction rule in a self-administered questionnaire completed at the time of triage. The physicians reported that they looked at the prediction rule during the triage of 115 (46%) of the 252 patients. The likelihood of using the prediction rule decreased significantly with increasing level of physician training. The most common reasons given for disregarding the prediction rule were confidence in unaided decision making and lack of time. The physicians reported that of the 115 cases for which the prediction rule was used, only one triage decision (1%) was changed by it. Future research should explore how prediction rules can be designed and implemented to surmount the barriers highlighted by these data.