US Teaching Research Articles

Perceptions of managerial support after workplace violence.

Workplace violence against nurses perpetrated by patients is a global problem, and healthcare organisations must take steps to ensure that staff feel safe at work and supported when incidents occur. A study was undertaken in a US teaching hospital to determine nurses' perceptions of management support following violent workplace incidents. This article describes the study and reports the results, which suggest that nurses want better implementation and enforcement of anti-violence policies, as well as more visible and immediate support from managers.

Designing for the Future: Quality and Safety Education at US Teaching Hospitals.

Teaching hospitals in the United States are under unprecedented pressure to demonstrate value.1,2 Coupled with national policy trends and demand from consumers, there has been an increased focus on systems-based quality improvement and patient safety. Alongside this increased scrutiny, in 2012 the Accreditation Council for Graduate Medical Education (ACGME) outlined its new accreditation system, urging enhanced competence in systems-based practice for the next generation of physicians.3 One component of the new system is the Clinical Learning Environment Review (CLER) program, which includes institutional site visits to assess resident participation in 6 focus areas: patient safety, quality improvement, care transitions, supervision, duty hours, and professionalism. Early findings from the first year4 of the CLER site visits “indicate a generalized lack of resident engagement in a ‘systems-based practice’ of medicine in the clinical environments in which they learn and provide clinical care.”5 During the development of the CLER program, the Institute for Healthcare Improvement, in collaboration with the ACGME, identified opportunities for improvement in quality and safety and systems-based education within graduate medical education (GME) programs using literature reviews, key informant interviews, reviews of GME curricula, and site visits. Based on that experience, we offer a perspective on current challenges and several principles to guide institutions toward achieving ACGME's evolving standards for systems-based practice.

Sustaining Social Justice Learning: What Teacher Educators Can Do

As public schools become more diverse in terms of student population, the US teaching force remains relatively stable. For this reason, teacher education programs need to provide and sustain social justice learning to ensure pre-service teachers enter classrooms prepared to teach <em>all </em>students. This article examines how pre-service teachers took up identities as social justice educators and sustained social justice learning during lapses in teacher education curricula. Analysis reveals that teacher educators can incorporate methods into course curriculum to ensure social justice learning is sustained in teacher education. Implications for teacher educators include strategies to provide social justice pedagogy scaffolding and offer plausible suggestions to incorporate and sustain social justice education for pre-service teachers when absent in future teacher education curricula.

Effective Teacher Qualities from International Mathematics, Science, and Computer Teachers' Perspectives

The purpose of this study is to investigate how international teachers, who were from overseas but taught in the United States, rate effective teacher qualities in three domains; personal, professional, and classroom management skills. The study includes 130 international mathematics, science, and computer teachers who taught in a multi-school charter school system in south-central America. It was found that international teachers perception of effective teachers was similar to findings of other research regardless of nationality as long as teachers enjoys teaching, explain the materials clearly, and grade student work fairly. Univariate ANOVA analysis revealed that international teachers‟ US teaching experience had statistically significant effect on teachers‟ ratings of professional skills. Findings were discussed in light of developing more general effective teacher qualities regardless of subject matter.

Abstract W P304: Variation in Use of Carotid Revascularization Procedures and In-Hospital Mortality Among Large, Urban Teaching Hospitals in the United States

Background: Guidelines and quality improvement efforts seek to minimize variation in care and outcomes across hospitals. We assessed hospital-level variation in procedure rates and in-hospital mortality for patients hospitalized with ischemic stroke at similar hospitals in the US. The use of procedures and in-hospital mortality were not expected to vary significantly among comparable, high-volume facilities after adjusting for patient case-mix. Methods: We selected urban teaching hospitals with ≥100 annual ischemic stroke discharges (ICD-9 433, 434, 436) from the Nationwide Inpatient Sample 2010-2011. Generalized linear mixed models were used to quantify between-hospital variation in the use of carotid artery stenting (CAS) and endarterectomy (CEA), as well as in-hospital mortality, adjusting for patient characteristics. Adjusted odds ratios were calculated to reflect the odds that patients would have the procedure/outcome when treated at hospitals 1 SD above relative to hospitals 1 SD below the overall rate for that procedure/outcome (an odds ratio of 1.0 would reflect no hospital variation in the procedure/outcome). Results: A total of 105 urban teaching hospitals were selected, with a median annual volume of 453 ischemic stroke discharges (IQR 351-600). Among a total of 52,090 ischemic stroke discharges (mean age 68±14.8 yrs), the overall rates were 3.7% (SD 3.1) for CAS and 15.6% (SD 8.0) for CEA; in-hospital mortality was 4.3% (SD 1.7). The odds of receiving CAS and CEA were almost 7 and 4 times as high, respectively, for a patient treated at a hospital 1 SD above versus 1 SD below the overall rate for that procedure (CAS: 6.68, 95% CI 4.97-8.98; CEA: 3.62, 95% CI 3.17-4.13). The odds of dying for those treated at a hospital 1 SD above relative to 1 SD below the overall mortality rate were 2.09 (95% CI 1.98-2.21). Conclusions: There was marked between-hospital heterogeneity in the use of carotid revascularization procedures and in-hospital mortality among large, urban US teaching hospitals. Future research needs to identify system-level factors contributing to these variations in care and outcomes.

A US perspective on the implementation of inquiry-based learning in mathematics

This paper discusses issues related to the potential adoption of inquiry-based learning (IBL) projects in mathematics in the United States. To explain the chal- lenges faced in making a place for IBL in the mathematics curriculum, we describe the historical demands of working with a diverse, highly distributed educational system (that is, a system that does not have a central educational deci- sion-making agency with the authority to mandate nation- wide changes), the impact of high-stakes tests to either open or limit the potential for curricular changes, and the changing context in the United States owing to the emer- gence of the Common Core State Standards in Mathe- matics (CCSS-M) and nationwide high-stakes assessments designed to be consistent with the CCSS-M. We identify a number of dimensions along which there would be chal- lenges for the implementation of IBL in US school math- ematics, including: perceived societal needs; schooling traditions; the specific framing of CCSS-M goals pertaining to problem solving, communicating and reasoning, and modeling and data analysis; and the readiness of the US teaching force to implement IBL. We then consider the issue of scaling up interventions such as IBL, and the politics involved therein.

Prostate cancer management: Racial disparities in the United States.

e16012 Background: Racial disparities in prostate cancer management have been reported. Black patients with well–differentiated disease were less likely to receive definitive therapy than whites with similar disease according to Underwood et. al., who included 142,340 patients from the Surveillance, Epidemiology and End Result (SEER) registry (J Urol, Vol. 171, 1504 – 1507, April 2004). Our objective was to identify racial disparities in the management of prostate cancer patients from the National Cancer Database. Methods: Prostate cancer treatment according to race in the USA, obtained from the National Cancer Database, was retrospectively reviewed. 1,497,540 patients with prostate cancer in 1397 US teaching and community hospitals between 2000 and 2010 were included. Chi square and Fisher tests were used for statistical analysis. Results: Black patients with stage II disease underwent radical prostatectomy significantly less than white patients (34.3% versus 43%, p&lt;0.05). 10.9% of blacks with stage II disease did not receive any therapy, versus 6.7% of whites (p&lt;0.05). 0.9% of whites with stage III disease didn’t receive any therapy versus 2% of blacks (p&lt;0.05). The disparity was even more accentuated for stage IV disease, where 13.4% of blacks did not receive any form of treatment versus 10.3% of whites (p&lt;0.05). 44% of blacks with localized disease (stage I and II) received radiation therapy, 34% received surgery. Blacks were less likely to receive radical prostatectomy for stage I and II disease compared to whites (34% versus 43%, p&lt;0.05). Stage IV disease at presentation was more common in blacks (7.2%) than in whites (4.7%, p&lt;0.05). Conclusions: This is the largest study which has analyzed ethnicity and prostate cancer management. Significant racial disparities exist in prostate cancer management between whites and blacks in the USA. Our study reveals that blacks are more likely to receive radiation therapy and less likely to get radical prostatectomy for stage I and II disease. A higher percentage of black patients with stage II, III or IV disease do not undergo any treatment as compared to whites. Blacks are also more likely to present with stage IV disease.

The Clinical Learning Environment

MORE THAN A DECADE AFTER THE INSTITUTE OF Medicine reported problems with the quality and safety of US health care, formal training of the health care workforce in quality and patient safety is still inadequate. A recently released survey of hospital leaders from the American Hospital Association (AHA) highlighted the need to educate US physicians and trainees regarding quality improvement. The AHA report identified deficiencies in newly trained physicians in systems-based practice, communication skills, and the ability to work within teams. The Accreditation Council for Graduate Medical Education (ACGME) recognizes the public’s need for a physician workforce capable of meeting the requirements of the rapidly evolving health care environment. This effort dates to the late 1990s, when the ACGME, collaborating with the American Board of Medical Specialties, established 6 core competencies creating a framework for attaining the skills needed for the modern practice of medicine. This framework drives both curriculum design and evaluation of educational outcomes for resident physicians. The next step in the evolution of resident physician training is the Next Accreditation System (NAS), which is now being implemented by the ACGME. The NAS emphasizes outcomes instead of processes for resident learning. These outcomes are assessed by achievement of performance measures, including milestones as residents progress toward independent practice. Examples of these outcomes include clinical experience as evidenced by case logs, milestones progression, scholarly activity, and specialty certification pass rates. The Clinical Learning Environment Review (CLER) program is the first component of the NAS to be operationalized nationally. The CLER program identifies US teaching hospitals’ efforts to engage residents in 6 focus areas: patient safety; health care quality, including reduction in health care disparities; transitions in care; supervision; duty hours and fatigue management and mitigation; and professionalism. CLER site visits have started at all ACGME-accredited sponsoring institutions having more than 1 training program. The CLER site visits are being conducted by a team including ACGME staff and volunteer site visitors from other sponsoring institutions and involve discussions and observations with hospital executive leadership (including the chief executive officer), resident physicians, faculty, graduate medical education leadership, nursing, and other hospital staff. These visits are designed to stimulate improvement in residents’ engagement in the 6 focus areas and, as such, are intentionally not directly linked to accreditation. Site visitors gain knowledge about residents’ engagement in the 6 focus areas through group meetings and visits in clinical service areas. Group meetings involve structured interviews with residents, faculty, and program directors. Walking rounds entail unplanned visits to various clinical sites at random times of the day and evening to meet with physicians, nursing, and other staff and discuss resident engagement. From these 2 sources of information, the site visit team assesses how the institution is performing in each of the 6 focus areas. At the end of the visit, the site visit team provides the institution with feedback and a written report soon thereafter. The ACGME is currently planning on repeating the CLER visits every 18 months to assess institutional progress in improving resident involvement in the 6 focus areas. A newly established evaluation committee is developing a set of performance expectations for teaching hospitals and medical centers. Institutional performance will be evaluated in light of these expectations. With time, the aggregated experience regarding institutional performance in these areas will shape future ACGME accreditation requirements. Early experience with CLER visits revealed numerous interesting improvement projects and some efforts in the education and training of residents and fellows in the 6 focus areas. Site visitors have also encountered hospitals and medical centers where the role of the residents in organizational efforts to improve health care quality and patient safety was, at best, uncertain. These visits revealed significant opportunities to enhance graduate medical education as well as institutional performance to better meet the needs of pa-

The Availability of Clinical Protocols in US Teaching Intensive Care Units

Survey of Anesthesiology: October 2011 - Volume 55 - Issue 5 - p 209-210 doi: 10.1097/01.SA.0000399988.71384.5e

The Effect of Imaging Capacity on the Imaging Workup of Patients With Stroke: A Preliminary Case for a Cross-Country Comparison

Medical imaging is a large and growing component of health care expenditures. To better understand some of the determinants of imaging ordering behavior, the authors analyzed the effect of differential capacity on the imaging workup of patients with acute nonhemorrhagic stroke. All patients at a US teaching hospital and a two-campus Canadian teaching hospital between 2001 and 2005 discharged with diagnoses of acute nonhemorrhagic stroke were identified. Billing data were linked with clinical information systems to identify all imaging studies performed, comorbidities, and patient disposition. Nine hundred eighteen patients at the US hospital and 1,759 patients at the Canadian hospital were included. Patients were similar in age and distribution of comorbid illnesses. The rate of MRI scans at the US hospital was more than twice that at either of the Canadian hospitals (95.75 scans per 100 patients vs 41.39 scans per 100 patients). The length of stay was significantly shorter and the inpatient mortality rate significantly lower at the US hospital compared with the Canadian hospital. A multivariate regression analysis demonstrated that only patient age and site (US vs Canada) were significant predictors of MRI use, controlling for patient gender, comorbidities, and use of anticoagulants. Scanning utilization varied at hospitals with differential access to scanning technologies. There was less frequent use of MRI scanning at hospitals with limited access to this modality. Patient and health system factors are important considerations when interpreting the mechanisms for this variation, its importance, and the potential relationship of imaging use with patient outcomes.

Supervision in Medical Education: Logical Fallacies and Clear Choices

Editor's Note: The ACGME News and Views section of JGME includes data reports, updates, and perspectives from the ACGME and its review committees. The decision to publish the article is made by the ACGME. Underlying the clamor for reform of health care insurance, financing, and delivery is a demand for accountability in medical education. Academic medicine must overcome complexity and inertia to accommodate unprecedented societal expectations for safety, quality, and reliability. To achieve this shift, the academic community must rethink and transform learner supervision, autonomy, observation, and feedback. Deep-rooted logical fallacies impede this transformation. Several key items are discussed in the following sections.

Metabolic Abnormalities in Human Immunodeficiency Virus-Infected Children: Two-Year Follow-up

HIV-associated lipodystrophy (LD) manifests with fat maldistribution, dyslipidemia, and insulin resistance in some HIV-infected children on antiretroviral therapy. To assess whether lipid abnormalities in patients with HIV are stable over time. The perinatally HIV-infected cohort at a medium-sized urban US teaching hospital. This prospective, observational study consisted of five visits (at entry and 3, 6, 24, and 30 months after entry) during which fasting venous blood samples were drawn for HIV-1 RNA, CD4 lymphocytes, lipid profile, free fatty acids (FFA), glucose, insulin, and adiponectin. IGF-I/IGFBP-3 levels were measured at the first and fifth visits. Of 36 study participants, seven were lipodystrophic, and 30 patients completed all five study visits. LDL-cholesterol, total cholesterol (TC), triglycerides (TG), and FFA levels were significantly higher in patients taking protease inhibitors (PIs). Patients with LD had higher TC and TG levels (both p < 0.05), and higher FFA (p = 0.0532). Adiponectin levels did not differ between PI/non-PI and LD/non-LD groups. HDL-cholesterol seemed to decrease, and FFA to increase over time. All IGF-I and all but one IGFBP-3 level were within normal range for age and Tanner stage. Dyslipidemia remained relatively constant over our study period. Adiponectin was not useful as a marker of LD in our population.

Molecular Diagnostics Clinical Laboratory Science Course Design: Making It Real

The ability of a clinical laboratory scientist (CLS) to perform molecular diagnostic testing has become critical to the profession. Knowledge of methodology associated with detection of pathogens and inherited genetic disorders is imperative for the current and future CLS. CLS programs in the US teach human genetics and molecular diagnostics in various components and formats. Integrating these sometimes expensive methods into the curriculum can be challenging. This article provides a commentary with specific details associated with our experience in designing a dedicated CLS molecular diagnostics course. It offers a flexible template for incorporating a lecture and laboratory course to address theoretical and practical knowledge in this dynamic area of the laboratory.

Evaluation of intraoperative medication error reporting and tracking in major US teaching hospitals

Department of Anesthesiology, UM/JMH Center for Patient Safety, University of Miami Miller School of Medicine

Screening Colonoscopy in Very Elderly Patients

Current guidelines do not include an upper age cutoff for colorectal cancer screening with colonoscopy. Although the prevalence of colonic neoplasia increases with age, life expectancy decreases. Thus, the benefit of screening colonoscopy in very elderly patients may be limited. To compare estimated life-years saved with screening colonoscopy in very elderly vs younger persons. Cross-sectional study conducted among 1244 asymptomatic individuals in 3 age groups (50-54 years [n = 1034], 75-79 years [n = 147], and > or =80 years [n = 63]) who underwent screening colonoscopy at a US teaching hospital and clinic. Prevalence of various types of colon neoplasia; estimated gain in life expectancy, calculated as life expectancy--(life expectancy during polyp lag time + life expectancy after colorectal cancer diagnosis); and comparison of mean gain in life expectancy across the 3 groups. Life expectancy and mortality data were derived from life tables, previous studies, and national databases. The prevalence of neoplasia was 13.8% in the 50- to 54-year-old group, 26.5% in the 75- to 79-year-old group, and 28.6% in the group aged 80 years or older. Despite higher prevalence of neoplasia in elderly patients, mean extension in life expectancy was much lower in the group aged 80 years or older than in the 50- to 54-year-old group (0.13 vs 0.85 years). In sensitivity analysis, with longer polyp lag times the mean extension in life expectancy decreased more in the elderly than in the younger patients; alternatively, if it was assumed that a smaller proportion of adenomas progress to colorectal cancer, the mean extension in life expectancy decreased less in the elderly than in the younger patients. Even though prevalence of neoplasia increases with age, screening colonoscopy in very elderly persons (aged > or =80 years) results in only 15% of the expected gain in life expectancy in younger patients. Screening colonoscopy in very elderly patients should be performed only after careful consideration of potential benefits, risks, and patient preferences.

Copyright in the networked world: copies in courses

PurposeThis column looks at questions from teaching faculty about the use of copyright protected materials in an online course.Design/methodology/approachCopyright guidelines are considered. The US TEACH Act and Fair Use statutes are examined, as well as how to make a risk assessment for the institution.FindingsUS universities have a reasonable freedom to use protected materials in the virtual equivalent of face‐to‐face teaching, as long as it costs the rights holders no loss of expected income and as long as it takes into account the litigiousness of certain firms and associations.Originality/valueEach copyright use assessment has unique circumstances, but a discussion of the reasoning behind an actual case helps to build a community of good practice that strengthens similar assessments.

Pediatric Residency Education: Is Sports Medicine Getting Its Fair Share?

Sports are the leading injury-related cause for pediatric primary care visits. Pediatric residency education guidelines suggest incorporating sports medicine (SM) education into curricula; however, research is lacking regarding effective teaching methods. To assess reported US pediatric residency SM curricula, teaching methods, and resident evaluation of SM education. Chief residents (CRs) and third-year residents (PL3s) from 100 randomly selected US Accreditation Council for Graduate Medical Education-accredited residency programs, stratified by size and geographic location, received surveys regarding programs' SM curriculum and teaching methods and individuals' methods for learning SM. Response rates were 63% and 39% for CRs and PL3s, respectively. According to CRs, 34% of programs had no one in charge of their SM curriculum. Lecture (77%) was the primary method used for teaching SM. Hands-on teaching (37%) was used less frequently. CRs stated that 29% of programs did not include musculoskeletal examination teaching in their curriculums; 24% did not include formal teaching of concussion management, and 29% did not include reasons for medical disqualification. PL3s rated teaching of joint examinations and the preparticipation physical as the most poorly taught components of the physical examination. PL3s rated hands-on teaching and patient experience as the best methods for improving SM education. CRs reported that only 36% of programs have discussed incorporating more SM into their curriculum. SM education is deficient in US pediatric residency programs. Standardized curricula should be developed with a focus on hands-on training as a means for teaching SM to pediatric residents.

Impact of a critical pathway on inpatient management of diabetic ketoacidosis

To assess the management of diabetic ketoacidosis (DKA) and evaluate if introduction of a critical pathway improves management, we studied adults admitted with DKA to the Medicine and Critical Care Services in a US teaching hospital. Patients admitted with DKA in 1997 before implementation of the critical pathway were the control group ( n=72). In 1998, housestaff and nurses in the emergency department (ED) and on the General Medicine and Critical Care Services were instructed in the use of the critical pathway. Patients admitted with DKA during 1998 ( n=77) were the intervention group. Length of stay (LOS), hospital cost, adherence to guidelines, and medical outcomes to be avoided were compared, and regression analyses were performed to correlate processes and outcomes of care. Mean LOS and variability in LOS decreased during the intervention period, especially in patients treated without endocrinology consultation (EC) (5.2±10.6 vs. 2.4±2.1 days, P=0.01), and hospital cost and variability in cost tended to decrease ($6441±15,204 vs. $3625±3478, P=0.24). More intervention subjects received the recommended intravenous fluid volume (88 vs. 71%, P=0.013), education in sick-day management (77 vs. 54%, P=0.006), and EC (38 vs. 21%, P=0.03). Insulin management was not changed. We conclude that implementation of a DKA critical pathway reduced practice variation and was associated with shorter LOS and a trend toward decreased cost. Some processes of care were improved but many require additional interventions.

Anesthetic-related cardiac arrest and its mortality: a report covering 72,959 anesthetics over 10 years from a US teaching hospital.

A prospective and retrospective case analysis study of all perioperative cardiac arrests occurring during a 10-yr period from 1989 to 1999 was done to determine the incidence, cause, and outcome of cardiac arrests attributable to anesthesia. One hundred forty-four cases of cardiac arrest within 24 h of surgery were identified over a 10-yr period from an anesthesia database of 72,959 anesthetics. Case abstracts were reviewed by a Study Commission composed of external and internal members in order to judge which cardiac arrests were anesthesia-attributable and which were anesthesia-contributory. The rates of anesthesia-attributable and anesthesia-contributory cardiac arrest were estimated. Fifteen cardiac arrests out of a total number of 144 were judged to be related to anesthesia. Five cardiac arrests were anesthesia-attributable, resulting in an anesthesia-attributable cardiac arrest rate of 0.69 per 10,000 anesthetics (95% confidence interval, 0.085-1.29). Ten cardiac arrests were found to be anesthesia-contributory, resulting in an anesthesia-contributory rate of 1.37 per 10,000 anesthetics (95% confidence interval, 0.52-2.22). Causes of the cardiac arrests included medication-related events (40%), complications associated with central venous access (20%), problems in airway management (20%), unknown or possible vagal reaction in (13%), and one perioperative myocardial infarction. The risk of death related to anesthesia-attributable perioperative cardiac arrest was 0.55 per 10,000 anesthetics (95% confidence interval, 0.011-1.09). Most perioperative cardiac arrests were related to medication administration, airway management, and technical problems of central venous access. Improvements focused on these three areas may result in better outcomes.

Mutation in the gene responsible for cystic fibrosis and predisposition to chronic rhinosinusitis in the general population.

Chronic rhinosinusitis (CRS) is a common condition in the US general population, yet little is known about its underlying molecular cause. Chronic rhinosinusitis is a consistent feature of the autosomal recessive disorder cystic fibrosis (CF). To determine whether mutations in the cystic fibrosis transmembrane regulator (CFTR) gene, which is responsible for CF, predispose to CRS. Case-control study conducted from 1996 to 1999 in which the DNA of CRS patients and controls was typed for 16 mutations that account for 85% of CF alleles in the general population. Chronic rhinosinusitis patients with 1 CF mutation were evaluated for a CF diagnosis by sweat chloride testing, nasal potential difference measurement, and DNA analysis for additional mutations. Otolaryngology-head and neck clinic of a US teaching hospital. One hundred forty-seven consecutive adult white patients who met stringent diagnostic criteria for CRS and 123 CRS-free white control volunteers of similar age range, geographic region, and socioeconomic status. Presence of CF mutations by DNA analysis among CRS patients vs controls. Eleven CRS patients were found to have a CF mutation (DeltaF508, n = 9; G542X, n = 1; and N1303K, n = 1). Diagnostic testing excluded CF in 10 of these patients and led to CF diagnosis in 1. Excluding this patient from the analyses, the proportion of CRS patients who were found to have a CF mutation (7%) was significantly higher than in the control group (n = 2 [2%]; P =.04, both having DeltaF508 mutations). Furthermore, 9 of the 10 CF carriers had the polymorphism M470V, and M470V homozygotes were overrepresented in the remaining 136 CRS patients (P =.03). These data indicate that mutations in the gene responsible for CF may be associated with the development of CRS in the general population. JAMA. 2000;284:1814-1819.