Introduction Clinical reasoning is a core skill for physicians; most doctors do not attain the level of expertise associated with that of an expert clinician (EC). The purpose of this study is to identify the clinical reasoning strategies ECs prioritize when reasoning through complex cases. Methods We interviewed 14 ECs and performed a thematic analysis to identify strategies ECs prioritize when reasoning through complex clinical cases.
View Article and Find Full Text PDFPoint-of care-ultrasound (POCUS) is becoming a core clinical skill in many medical specialties. Teaching POCUS at the bedside allows for observation of learners during actual patient encounters, provides a medium for role modeling skills and behaviors, and incorporates all core POCUS competencies. Nonetheless, bedside teaching can be time consuming and intimidating for learners and teachers, and the full benefits of teaching at the bedside can be difficult to attain.
View Article and Find Full Text PDFBackground: At some US Academic Health Centers (AHCs), patients with predominantly Medicaid insurance are seen in one clinic and patients with other insurance are seen in another. The extent of this practice and implications are unknown.
Objective: To estimate the proportion of AHCs that have at least two primary care internal medicine clinics that differ substantially in proportion of patients with Medicaid and to compare patient demographic, staffing, and operational features.
Background: Residents lack exposure to chronic hepatitis C (HCV) infection management, limiting the pipeline of providers able to alleviate the treatment bottleneck.
Activity: We surveyed 34 residents rotating through a new HCV curriculum comprised of a clinic primer, didactics, and supervised patient care. Outcome measures were knowledge and self-efficacy regarding HCV management.
Reflective practice is essential for the ongoing maturation of clinicians and requires regular self-evaluation in association with ongoing mentoring and feedback. Currently, most resident physicians do not have access to educational experiences that fulfill these needs. We present a novel model for structured one-on-one longitudinal coaching using the principles of deliberate practice to improve diagnostic skills.
View Article and Find Full Text PDFStructured Interdisciplinary Bedside Rounds (SIBR) is a standardized, team-based intervention for hospitals to deliver high quality interprofessional care. Despite its potential for improving IPC and the workplace environment, relatively little is known about SIBR's effect on these outcomes. Our study aimed to assess the fidelity of SIBR implementation on an inpatient medicine teaching unit and its effects on perceived IPC and workplace efficiency.
View Article and Find Full Text PDFObjectives: Concerns regarding lack of privacy, poor patient understanding, and physician discomfort have led to a decline in rounding at the bedside. Our project explored patient perceptions of the implementation and value of bedside rounding.
Methods: This mixed-methods study used semi-structured qualitative interviews and a five-item Likert survey, which included questions about patients' experiences with rounds, their comfort level with the rounding process, and their understanding of care after rounds.
Background: The year-long position of chief medical resident is a time-honored tradition in the United States that serves to provide the trainee with an opportunity to gain further skills as a clinician, leader, teacher, liaison, and administrator. However, in most training programs in the developing world, this role does not exist.
Objectives: We sought to develop a collaborative program to train the first medical chief residents for the University of Rwanda and to assess the impact of the new chief residency on residency training, using questionnaires and qualitative interviews with Rwandan faculty, chief residents, and residents.
Objectives: Chart-stimulated recall (CSR) is a case-based interviewing technique advocated by the Accreditation Council for Graduate Medical Education as an assessment tool across a variety of clinical competencies, yet resident and faculty perceptions of this exercise have not been reported previously. The authors incorporated a CSR exercise into an internal medicine residency program and sought to assess the perceptions of residents and faculty participants.
Methods: Faculty met weekly with night float residents at the end of their shift.
Objectives: Patient throughput and early discharges are important for decreasing emergency department wait times and creating available beds for new hospital admissions. The educational schedule of internal medicine trainees can interfere with timely discharges, but targeted interventions can help residents meet the hospital's patient flow needs. Our training program instituted daily morning discharge rounds on the inpatient service, requiring each team to prepare potential discharges 1 day ahead and prioritizing these discharges the next day.
View Article and Find Full Text PDFBackground: Medicaid is the federal program, administered by states, for health care for the poor. The Affordable Care Act (ACA) has added a large number of new recipients to this program.
Hypothesis: Medicaid programs in some, if not many, states do not provide patients uniform access to subspecialty care guaranteed by the federal statutes.
Background: The Accreditation Council for Graduate Medical Education and American Board of Internal Medicine have identified cost-awareness as an important component to residency training. Cost-awareness is generally not emphasized in current, traditional residency curricula despite the recognized importance of this topic.
Description: Using a traditional Morning Report structure and actual charge data from our institution, the charges associated with trainee-directed workup of clinical cases are compared in a friendly competition among medical students, interns, residents, and faculty.
Hepatitis C (HCV) is a leading cause of chronic liver disease in the United States. Connecticut has a registry of laboratory reported cases of HCV. These reports include limited patient-level information.
View Article and Find Full Text PDFGoals: To examine a wide range of sociodemographic and clinical characteristics as potential predictors of complementary and alternative medicine (CAM) use among chronic liver disease (CLD) patients, with a focus on CAM therapies with the greatest potential for hepatotoxicity and interactions with conventional treatments.
Background: There is some evidence that patients with CLD commonly use CAM to address general and CLD-specific health concerns.
Study: Patients enrolled in a population-based surveillance study of persons newly diagnosed with CLD between 1999 and 2001 were asked about current use of CAM specifically for CLD.
Goals: We describe the epidemiology of outpatients newly diagnosed with chronic alcoholic liver disease and describe predictors of cirrhosis and referral for specialty care.
Background: Alcohol is a major cause of liver disease in the United States. Most previous work has described hospitalized patients.
Obesity appears to be a risk factor for hepatic steatosis, which has been implicated in the development of hepatic fibrosis in patients with hepatitis C virus infection. We conducted the current study to examine whether obesity is associated with hepatic steatosis among patients with chronic hepatitis C identified from a population-based cohort. Study participants were persons with chronic hepatitis C who had had a liver biopsy, identified from a population-based study of persons with newly identified chronic liver disease conducted in gastroenterology practices.
View Article and Find Full Text PDFBackground & Aims: Assessment of liver histology has an important role in the management of chronic liver disease. It is not clear whether there are interobserver variabilities between hepatopathologists and general community pathologists. We evaluated the effect of type of pathologist and biopsy specimen size on interobserver agreement for hepatic fibrosis.
View Article and Find Full Text PDFChronic viral hepatitis can cause cirrhosis. Viral hepatitis-related cirrhosis may be causing an increasing health burden since exposure to hepatitis B virus and hepatitis C virus in the United States increased starting in the 1960s. Using hospital discharge data, we estimated the number of adult New Haven County residents hospitalized for cirrhosis and examined the proportion caused by chronic viral hepatitis.
View Article and Find Full Text PDFPurpose: The United States National Center for Health Statistics (NCHS) uses death certificate data to estimate the burden of serious disease. This study aimed to determine the accuracy of the NCHS method for estimating the burden of chronic liver disease (CLD).
Method: The authors identified death certificates of New Haven County residents who died from October 1999-September 2000 that were assigned one of 115 ICD-10 codes that might indicate CLD.
Objectives: Chronic liver disease (CLD) is an important cause of morbidity and mortality, but the epidemiology is not well described. We conducted prospective population-based surveillance to estimate newly diagnosed CLD incidence, characterize etiology distribution, and determine disease stage.
Methods: We identified cases of CLD newly diagnosed during 1999-2001 among adult county residents seen in any gastroenterology practice in New Haven County, Connecticut; Multnomah County, Oregon; and Northern California Kaiser Permanente Medical Care Program (KPMCP, Oakland, California [total population 1.