Systems-based Practice Research Articles

Compliance rate of anti-rabies vaccination in patients presenting with an animal bite

Introduction: To prevent rabies in animal bite victims, complete postexposure prophylaxis (PEP) with an anti-rabies vaccination (ARV) is essential. This study was done to determine the compliance rate of ARV in patients with animal bites who presented to the emergency department (ED) during the COVID-19 pandemic. Materials and Methods: This was a prospective observational study done on patients presenting to the ED with a history of animal bites over 1 year (May 2020–June 2021). Categorical variables were presented as percentages, and quantitative variables were summarized using mean and standard deviation (SD). Results: A total of 122 animal bite (World Health Organization [WHO] Category II and III) victims presented to the ED during the study. The mean age of the cohort was 38.12 (SD: 16.4) years with a male (n = 67: 54.9%) preponderance. Based on the physiological stability, a majority were triaged as priority III (n = 119; 97.5%). Most patients presented with dog bites (n = 88; 72.1%), followed by cat (n = 14; 11.5%) and rat bites (n = 13; 10.7%). Two-thirds were unprovoked (n = 82; 67.2%) and were caused by stray animals (n = 62; 50.8%). More than half (n = 65; 53.3%) of the bites were WHO Category III bites. All Category II and III patients had received the first dose of ARV at our center and category III patients received immunoglobulin local injection as well. Noncompliance to ARV was seen in almost a quarter (n = 32; 26.2%) of patients of which forgotten dates (n = 11; 34.4%) were the most common cause. There was no significant statistical variable to determine the cause of noncompliance. Conclusion: Unprovoked bites by stray dogs were the cause of a majority of the animal bites. Compliance with PEP remains low at two-thirds of the total. The most common cause of noncompliance to ARV was due to forgotten dates. The following core competencies are addressed in this article: Medical knowledge, Systems-based practice, Practice-based learning and improvement.

A 5-year analysis of admissions, seasonal variation, and patient outcomes in rural Nigeria

Introduction: In low- and middle-income countries like Nigeria, there is an observed paucity of data on the admission pattern and patient outcomes in health facilities. Few related studies were conducted in the urban centers, but none from the rural areas where the majority of the populace resides. This study is to ascertain the demographic profile, seasonal variations, yearly distribution, admission pattern, and treatment outcomes at the accident and emergency department (AED). Materials and Methods: A retrospective survey was used to review the data of patients admitted to the AED of the institution between January 2015 and December 2019. The data obtained were analyzed using SPSS Version 20.0. The results were presented in descriptive and tabular formats. Results: Five thousand nine hundred and forty-four patients were studied with a mean age of 49.8 ± 19 years. There were 53.9% males and 46.1% females. Many (60.1%) were admitted from April to October. There were 58.9% medical and 41.1% surgical cases. Among the medical cases were 18.6% noncommunicable and 18.5% communicable diseases. Out of 5944 patients, 9435 disease patterns were diagnosed with infectious diseases 15.5%, and orthopedic 14.4% being the most frequently diagnosed medical and surgical cases, respectively. The treatment outcome revealed that the mortality rate was 3.7%. Conclusions: The number of admissions increased over 5 years. Although most patients were treated and discharged successfully, the number discharged against medical advice was high. Therefore, appropriate hospital and community interventions should be implemented to improve admission outcomes. The following core competencies are addressed in this article: Patient care and procedural skills, Medical knowledge, and Systems-based practice.

How Should Health Systems Science Promote Health Systems' Sustainability?

An expanded sustainability framework for health systems science (HSS) could promote health systems' capacity to deliver efficient, effective care for patients and to care for the planet by decreasing emissions and solid waste while cutting costs. This framework aligns well with the HSS mission to reform curricula and practice and has direct implications for patient care and systems-based practice competency development. Training clinicians to think critically about health system function, resilience, and sustainability will help prepare trainees to lead, innovate, and transform current health systems to prioritize planetary health, resource stewardship, and patient outcomes in a circular supply chain with low emissions.

Competency-Based Education: Will This be the New Training Paradigm in Plastic Surgery?

The Accreditation Council for Graduate Medical Education created the "Next Accreditation System" in 2013 requiring residents to meet educational milestones based on core competencies over the course of their training. The 6 core competencies include patient care and technical skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Since the traditional time-based model requires a predetermined length of training irrespective of learning style, pace, or activity, a competency-based model is appealing because it refocuses education on deliberate and relevant skills acquisition and retention. Plastic surgery has been slowly transitioning to competency-based education (CBE), thereby permitting residents to learn at their own pace to master each competency. We performed a nonsystematic literature review of the efficacy of CBE and implementation efforts, particularly within plastic surgery. The literature revealed perceived barriers to implementation, as well as the nuts and bolts of implementation. We highlighted possible solutions and training tools with practical applications in plastic surgery. Success of CBE in plastic surgery requires instituting a transparent process that involves continuously piloting multiple assessment tools and a discussion of related costs. CBE may be particularly appealing for trainees focused on further training in craniofacial or pediatric plastic surgery after completion of an integrated or independent training program in plastic surgery to allow them to focus on their career interests once competence is achieved in the core skills required of a plastic surgeon.

Professional Behavior and Value Erosion: A Qualitative Study of Physicians and the Electronic Health Record.

Goal:Occurrences of physician burnout have reached epidemic numbers, and the electronic health record (EHR) is a commonly cited cause of the distress. To enhance current understanding of the relationship between burnout and the EHR, we explored the connections between physicians' distress and the EHR.Methods:In this qualitative study, physicians and graduate medical trainees from two healthcare organizations in California were interviewed about EHR-related distressing events and the impact on their emotions and actions. We analyzed physician responses to identify themes regarding the negative impact of the EHR on physician experience and actions. EHR “distressing events” were categorized using the Accreditation Council for Graduate Medical Education (ACGME) Physician Professional Competencies.Principal Findings:Every participating physician reported EHR-related distress affecting professional activities. Five main themes emerged from our analysis: system blocks to patient care; poor implementation, design, and functionality of the EHR; billing priorities conflicting with ideal workflow and best-practice care; lack of efficiency; and poor teamwork function. When mapped to the ACGME competencies, physician distress frequently stemmed from situations where physicians prioritized systems-based practice above other desired professional actions and behaviors. Physicians also reported a climate of silence in which physicians would not share problems due to fear of retribution or lack of confidence that the problems would be addressed.Practical Applications:Physicians and administrators need to address the hierarchy of values that prioritizes system requirements such as those required by the EHR above physicians' other desired professional actions and behaviors. Balancing the importance of competing competencies may help to address rising burnout. We also recommend that administrators consider qualitative anonymous interviews as an effective method to uncover and understand physician distress in light of physicians' reported climate of silence.

Developing and sustaining advanced practice provider services: A decade of lessons learned.

Developing and sustaining advanced practice provider services: A decade of lessons learned.

Assessing Well-Being in Milestones 2.0: A Case for Flourishing-Focused Advising.

Assessing Well-Being in Milestones 2.0: A Case for Flourishing-Focused Advising.

The Disparity Morbidity and Mortality Conference: A Mechanism to Identify and Remedy Health Care Inequity.

The Disparity Morbidity and Mortality Conference: A Mechanism to Identify and Remedy Health Care Inequity.

Viewpoint on Milestones for Fellowship Training in Movement Disorders.

Viewpoint on Milestones for Fellowship Training in Movement Disorders.

Developing Medical Student Competencies, Clinical Skills, and Self-Efficacy With an Emergency Medical Responder Certification Course

IntroductionPrevious studies have claimed gap year clinical experiences before medical school matriculation increase student self-efficacy and clinical confidence. At the University of Central Florida College of Medicine, 41 first-year medical students participated in a new certification course to become emergency medical responders before beginning their coursework. This study describes the results of a follow-up study that aims to investigate the impact the course had on student competency, self-efficacy, and clinical efficacy and if the course would prepare students similarly to previous clinical experience.MethodsFirst-year medical students completed a 30-question survey consisting of a Likert scale and free-response questions. Questions were based on the Accreditation Council for Graduate Medical Education core competencies: medical knowledge, practice-based learning and improvement, systems-based practice, patient care, professionalism, and interpersonal and communication skills. Questions on the perceived benefit of the emergency medical responder course and previous clinical experiences were also included. Responses were separated based on participation in the emergency medical responder course and prior clinical experience. Two-tail Welch’s t-tests were performed on the data to determine significance.ResultsOf 98 responses: 20.4% (20/98) of participants of the emergency medical responder course had previous clinical experience, 21.5% (21/98) of participants of the course had no clinical experience, 26.5% (26/98) did not participate in the course but had previous clinical experience, and 31.6% (31/98) did not participate in the course nor had previous clinical experience. Students with previous clinical experience reported the emergency medical responder course improved both their patient care skills and performance in courses that emphasized patient interviewing and physical exams. Students with clinical experience had significantly higher medical knowledge (p < 0.1) and professionalism (p < 0.1) Likert scores. Eighty-seven percent of students agreed the course had a positive impact on their patient care skills.ConclusionLarger sample size is needed to make stronger conclusions; however, the responses show the emergency medical responder course had a positive subjective impact on students with previous medical experience. Previous clinical experience leads to the most positive subjective reporting of competencies such as medical knowledge and professionalism. Early clinical exposure, such as an emergency medical responder certification course, may improve self-efficacy and patient care skills for medical students with no previous clinical experience.

The level of knowledge about rheumatic diseases in Saudi Arabia

Introduction: Joint inflammation, which causes pain and swelling, is common in rheumatic diseases. In Saudi Arabia, large multicenter studies on the prevalence of rheumatic diseases and the common beliefs about these diseases are lacking. Our study aimed to investigate the false beliefs about rheumatic diseases in Saudi Arabia. Materials and Methods: A cross-sectional questionnaire-based study was carried out in Riyadh, Saudi Arabia, from December 2019 to January 2020, to assess the understanding and misconceptions of rheumatic disorders in the study population. The statistical analysis was performed using the Fisher's exact test and the Chi-squared test, and binary logistic regression was employed for dichotomous variables. Results: Five hundred and eleven respondents were recruited in the study, with a mean age of 26.9 years; 76.9% of respondents were female. 89.4% of the respondents were Saudi nationals; 75.2%, 20.3%, and 4.5% of respondents had bachelor's, prebachelor's, and master's degrees, respectively. The most frequently reported rheumatic disease was rheumatoid arthritis (66%), followed by myositis (13.3%). Most of the respondents (77%) in this study were aware of rheumatic diseases. Conclusion: Most of the respondents were aware of rheumatic diseases. However, a more exhaustive multicentric survey with a wider population-based survey is needed to provide substantial data and help rheumatologists overcome patients' misconceptions and improve outcomes. The following core competencies are addressed in this article: Medical knowledge, Patient care, Systems-based practice, Practice-based learning and improvement.

Comparison of undergraduate dental students' academic performance using structured and unstructured oral examinations

Introduction: Assessment plays a central role in formal education. Unstructured oral examinations are the status quo in dental education in India but have some drawbacks, including a lack of inter-rater reliability. It is not known whether structured oral examinations provide different scores nor how they will be accepted by students or examiners. Materials and Methods: A sample of 20 students were randomly selected from a group of third-year BDS students who had scored 65% and above in the 2nd year university examination in Bapuji Dental College and Hospital. They were exposed to a total of 4 h of lecture and problem-solving sessions on dental ethics. Four raters (teaching faculty), having similar academic experience and designation, were selected and they were trained to conduct structured oral examinations according to a format, especially designed for the same purpose. Half the students underwent structured examination followed by unstructured examination while half the students underwent unstructured examination followed by structured examination. Paired t-test was applied to find out the statistical difference between structured and unstructured oral examination formats. Results: The students obtained a mean score of 13.35 ± 3.8 out of a total score of 20 in the unstructured oral examination when compared to a mean score of 14 ± 3.76 in the structured oral examination. The difference was not statistically significant (P = 0.69). The acceptance trended favorable for structure examination but was not statistically significant. The structured examination had higher inter-rater reliability than the unstructured examination. Conclusion: The results showed good reliability and repeatability of the structured oral examination format with an inter-rater reliability of 0.82. Structured viva voce was not found to improve the performance of students when compared to unstructured viva voce. The following core competencies are addressed in this article: Practice-based learning and improvement, Patient care and procedural skills, Systems-based practice, Medical knowledge, Interpersonal and communication skills, and Professionalism.

Flipped journal club

After its origin during the 18th century, the journal club has come a long way as an effective method of pedagogy in postgraduate medical education. As the traditional format of the journal club is becoming less attractive for residents, the newer concept of blended learning and flipped classrooms is now being incorporated slowly into the traditional format of the journal club. This newer format of journal club is called flipped journal club, where all materials regarding the article are shared among residents and faculty well before the day of presentation. On the presentation day, there is a small group discussion regarding the summary, critical appraisal, and its implication on the concerned subject. The following core competencies are addressed in this article: Practice-based learning and improvement, Systems-based practice, Medical knowledge, Professionalism.

Cyanide Poisoning.

Cyanide Poisoning.

Evaluation of detection of severe acute respiratory syndrome coronavirus-2 by chip-based real-time polymerase chain reaction test (truenat™ beta CoV) in multi-sample pools

Introduction: Systematic testing for Severe Acute Respiratory Syndrome CoronaVirus-2 (SARS-CoV-2) using molecular diagnostic tools to identify individuals with coronavirus disease 2019 (COVID-19) infection, and tracing their primary and secondary contacts is important to curb its spread. With resource limitations on testing individual samples, testing of pooled samples provides alternative approach to increase testing capacity. Present aimed at assessing the detection of SARS-CoV-2 RNA in pooled samples using chip-based real-time polymerase chain reaction Test (Truenat™ Beta CoV). Materials and Methods: Pooled sample size of five was used from laboratory confirmed COVID-19 positive and negative samples. SARS-CoV-2 positive nasopharyngeal specimens of known samples from high, medium, low, and very low viral load were mixed with SARS-CoV-2 negative nasopharyngeal specimens of known samples in 1:4 ratio, followed by analysis using Truenat. Furthermore, each sample in that pool was tested individually. Pooled sample testing was also done on the samples of unknown status. Results: The results of the present study showed cycle threshold (Ct) values of pooled sample with SARS-CoV-2 positive RNA of high, medium, low, and very low viral load were 16.8, 24.22, 28.2, and 33.43, compared to Ct values of individual samples of 16.43, 22.0, 28.00, and 33.00, respectively. Conclusion: These results suggest that the Ct values of pooled samples were in agreement with Ct values of individual samples indicating the validity of pooled sample testing for screening SARS-CoV-2 using Truenat. The following core competencies are addressed in this article: Medical knowledge, Patient care and procedural skills systems-based practice, Practice-based learning and improvement.

Standardized Medical Coding Curriculum in Surgical Graduate Medical Education.

Despite the increasing importance of coding and billing in healthcare as a whole and calls from the Accreditation Council for Graduate Medical Education (ACGME) to emphasize systems-based practice, many surgical training programs have not prioritized coding and billing within their curricula. We aim to evaluate the performance of surgical residents and early career surgeons in coding and billing and to appraise interventions to improve coding and billing abilities within this group. A literature search from conception to March 15th, 2022 utilizing PubMed, Google Scholar, and EMBASE was conducted to search for studies that evaluate surgical resident coding practices and interventions to improve practice management and financial competency. Discrepancies in coding and billing ability are prominent between residents, surgeons, and professional coders. One study demonstrated coding accuracy of 76.5% for professional coders, 62.1% for surgical attendings, and 54.1% for surgical residents, whereas another study reported a 52.82% coding accuracy and residents. Resident performance in coding and billing was inferior to their more experienced surgical attending counterparts and professional coders. Surgical residents and fellows demonstrated significantly improved knowledge and confidence in coding following the administration of either individual or longitudinal educational interventions. Coding and billing discrepancies among students, residents, and surgeons persist due to a lack of formalized training. Integration of standardized and mandated medical coding curricula and interventions within residency programs has great potential to improve surgical coding practices and should be a mandatory component of graduate medical education.

16. Reliability of a Case-Based Oral Examination by Case and Competency for Evaluation of Plastic Surgery Residents

Background: An oral examination was developed for administration to integrated and independent residents in their final three years of training at multiple Plastic Surgery residency programs. Questions were designed to assess specific skills as outlined in the ACGME six core competencies. Using the combined scores for each case, residents were able to be given feedback on their performance. Our aim is to assess the reliability of our examination by case and by competency. Methods: A unique 8-case oral examination was administered yearly from 2013 to 2019 at multiple Plastic Surgery residency programs. We evaluated one specific examination that was administered in Spring 2019 in 3 states to 38 Plastic Surgery residents from 8 programs. Each item in each case was labeled to target a specific core competency. There was a total of 48 patient care items, 10 medical knowledge items, 5 professionalism items, 4 practice-based learning and improvement items, 4 systems-based practice items, and 1 communication skills item. Reliability was assessed by cronbach’s alpha coefficient calculated for the entire exam, for each unique case, and for each competency. Results: The entire 72-item examination was highly reliable (cronbach’s alpha = 0.91). The cronbach’s alpha coefficients were higher by case than by competency. 7 of the 8 cases were reliable (cronbach’s alpha > 0.70, range 0.45 - 0.82). The competency with the highest reliability was patient care (cronbach’s alpha = 0.87) and the lowest reliability was systems-based practice (cronbach’s alpha = 0.14). Communication skills could not be assessed as there was only one item. Conclusion: The reliability of the examination in total is excellent and it shows promise to be used on a broader scale in a standardized fashion. The reliability of the cases is good and may be used to assess resident knowledge of specific case content. While patient care and medical knowledge are reliably assessed in this exam, further work needs to be done to adequately evaluate for the other 4 core competencies.

Hospital-Based Health Technology Assessment of Machine Perfusion Systems for Human Liver Transplantation

Based on published data, we have carried out a hospital-based health technology assessment of machine perfusion in adult liver transplantation using cold storage as a comparator, and within the perspective of a national health system-based hospital practice and disease-related group reimbursement policy. A systematic literature review on machine perfusion for adult liver transplantation was conducted exploring the Pubmed, CINAHL, Scopus, Embase, and Cochrane databases. The literature was analyzed with the intent to provide information on 6 dimensions and 19 items of the hospital-based health technology assessment framework derived from previous studies. Out of 705 references, 47 (6.7%) were retained for current analysis. Use of machine perfusion was associated with advantages over cold storage, i.e., a 10%–50% reduced risk for early allograft dysfunction, 7%–15% less ischemia reperfusion injury; 7%–50% fewer ischemic biliary complications, comparable or improved 1-year graft and patient survival, and up to a 50% lower graft discard rate. Hospital stay was not longer, and technical failures were anecdotal. Information on costs of machine perfusion is limited, but this technology is projected to increase hospital costs while cost-effectiveness analysis requires data over the transplant patient lifetime. No hospital-based health technology assessment study on machine perfusion in liver transplantation was previously conducted. From the hospital perspective, there is evidence of the clinical advantages of this novel technology, but strategies to counterbalance the increased costs of liver transplantation are urgently needed. Further studies should focus on the ethical, social, and organizational issues related to machine perfusion.

Association Between Resident Race and Ethnicity and Clinical Performance Assessment Scores in Graduate Medical Education.

To assess the association between internal medicine (IM) residents' race/ethnicity and clinical performance assessments. The authors conducted a cross-sectional analysis of clinical performance assessment scores at 6 U.S. IM residency programs from 2016 to 2017. Residents underrepresented in medicine (URiM) were identified using self-reported race/ethnicity. Standardized scores were calculated for Accreditation Council for Graduate Medical Education core competencies. Cross-classified mixed-effects regression assessed the association between race/ethnicity and competency scores, adjusting for rotation time of year and setting; resident gender, postgraduate year, and IM In-Training Examination percentile rank; and faculty gender, rank, and specialty. Data included 3,600 evaluations by 605 faculty of 703 residents, including 94 (13.4%) URiM residents. Resident race/ethnicity was associated with competency scores, with lower scores for URiM residents (difference in adjusted standardized scores between URiM and non-URiM residents, mean [standard error]) in medical knowledge (-0.123 [0.05], P = .021), systems-based practice (-0.179 [0.05], P = .005), practice-based learning and improvement (-0.112 [0.05], P = .032), professionalism (-0.116 [0.06], P = .036), and interpersonal and communication skills (-0.113 [0.06], P = .044). Translating this to a 1 to 5 scale in 0.5 increments, URiM resident ratings were 0.07 to 0.12 points lower than non-URiM resident ratings in these 5 competencies. The interaction with faculty gender was notable in professionalism (difference between URiM and non-URiM for men faculty -0.199 [0.06] vs women faculty -0.014 [0.07], P = .01) with men more than women faculty rating URiM residents lower than non-URiM residents. Using the 1 to 5 scale, men faculty rated URiM residents 0.13 points lower than non-URiM residents in professionalism. Resident race/ethnicity was associated with assessment scores to the disadvantage of URiM residents. This may reflect bias in faculty assessment, effects of a noninclusive learning environment, or structural inequities in assessment.

Commentary: Countering the Growing Problem of Radiologist Burnout.

This is an invited editorial on radiologist burnout, its presenting manifestations, toll on patient care and systems-based practice, and suggested remedies to mitigate stress and exhaustion.