Professionalism in residency training: is there a generation gap?

Teach Learn Med. 2008 Jan-Mar;20(1):11-7

Authors: Borrero S, McGinnis KA, McNeil M, Frank J, Conigliaro RL

BACKGROUND: Teaching and evaluating professionalism is part of the Accreditation Council for Graduate Medical Education’s training requirements for postgraduate education. Defining what constitutes professional behavior is the first step in this endeavor. Difficulty in teaching and evaluating professionalism may stem from generational differences between teachers and trainees in their definition of professional behavior. PURPOSE: We sought to explore the magnitude of generational differences by asking faculty and residents to evaluate behaviors along a continuum of professionalism. METHODS: A questionnaire composed of 16 vignettes describing unprofessional behaviors was distributed to a sample of internal medicine trainees and faculty. For each specific behavior described, participants were asked to rate the severity of the infraction on a 4-point scale. RESULTS: Within each group, responses were distributed across severity categories for most vignettes. There were no significant differences in the responses of trainees versus faculty for any of the vignettes except two. CONCLUSION: There is little consensus for determining the severity of unprofessional behaviors among faculty and trainees at one urban university training program. However, this lack of consensus does not appear to have a generational basis. Attributing difficulties in teaching and assessing professionalism cannot be blamed on differences between the generations.

PMID: 18444179 [PubMed - indexed for MEDLINE]

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Shared by Robert Mahoney

http://www.ncbi.nlm.nih.gov/entrez/utils/fref.fcgi?PrId=4487&itool=Abstract-def&uid=18444180&db=pubmed&url=http://dx.doi.org/10.1080/10401330701797974
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Medical subinternship: student e…

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Medical subinternship: student experience on a resident uncovered hospitalist service.

Teach Learn Med. 2008 Jan-Mar;20(1):18-21

Authors: O’Leary KJ, Chadha V, Fleming VM, Martin GJ, Baker DW

BACKGROUND: Studies demonstrating the value of hospitalists to medical student education have been performed in traditional resident covered ward service settings (RCWS). PURPOSE: To compare medical subinterns’ experiences on an RCWS to that on a resident uncovered hospitalist service (RUHS). METHODS: We assessed students’ overall experience and knowledge learned on the two services using a 5-point Likert scale. We also assessed learning environment characteristics, workload, and time spent at the hospital on each service. RESULTS: The mean rating for knowledge learned was higher on the RCWS. Subinterns rated the two services equivalent on measures of educational value of patient problems, faculty assessment, supervision, and number and value of teaching sessions. The RCWS received higher ratings on variety of patient problems and frequency of intellectual discussion. CONCLUSIONS: The RCWS provided a superior learning experience for subinterns. Academic medical centers should take these findings into consideration before placing medical students on an RUHS.

PMID: 18444180 [PubMed - indexed for MEDLINE]

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Use of the 24-lead “standard” electrocardiogram to identify the site of acute coronary occlusion. A review paper.

J Electrocardiol. 2008 May-Jun;41(3):238-44

Authors: Wagner GS, Pahlm-Webb U, Pahlm O

This review presents the added value for diagnosis of acute ischemia/infarction of considering ST elevation in the 12 inverted leads (-I, -II, -II, -aVR, etc) of the standard electrocardiogram in addition to ST elevation in 12 positive leads. A small number of studies have been published showing substantial increases in sensitivity at the “cost of” slight decreases in specificity. One recent study indicated that only 7 of the inverted leads should be considered, yielding a “19-lead electrocardiogram” encompassing the following leads (presented here in the logical sequences): -III, aVL, I, -aVR, II, aVF, III, -aVL, -I, aVR; and V1, V2, V3, V4, V5, V6, -V1, -V2, -V3. Studies have to be performed to establish the thresholds that should be applied to these leads for achievement of sensitivity/specificity.

PMID: 18433615 [PubMed - indexed for MEDLINE]

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Making straight suture needles a little safer: a technique to keep fingers from harm’s way.

J Emerg Med. 2008 Feb;34(2):195-7

Authors: Nelson BP

Straight suture needles are commonly employed to secure arterial and venous catheters to the skin. These needles have been demonstrated to be more dangerous than curved or blunt suture needles, with a higher rate of injury for health care workers. This article describes a technique for using the straight needle that may reduce the chances of injury. By utilizing the plastic needle sheath present in most central venous line kits as a “thimble,” counter pressure and skin puncture may be achieved without bringing the fingers near the sharp end of the suture.

PMID: 18282537 [PubMed - indexed for MEDLINE]

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Randomized controlled trial of an implantable continuous hemodynamic monitor in patients with advanced heart failure: the COMPASS-HF study.

J Am Coll Cardiol. 2008 Mar 18;51(11):1073-9

Authors: Bourge RC, Abraham WT, Adamson PB, Aaron MF, Aranda JM, Magalski A, Zile MR, Smith AL, Smart FW, O’Shaughnessy MA, Jessup ML, Sparks B, Naftel DL, Stevenson LW,

OBJECTIVES: The purpose of this study was to determine whether a heart failure (HF) management strategy using continuous intracardiac pressure monitoring could decrease HF morbidity. BACKGROUND: Patients with HF may experience frequent decompensations that require hospitalization despite intensive treatment and follow-up. METHODS: The COMPASS-HF (Chronicle Offers Management to Patients with Advanced Signs and Symptoms of Heart Failure) study was a prospective, multicenter, randomized, single-blind, parallel-controlled trial of 274 New York Heart Association functional class III or IV HF patients who received an implantable continuous hemodynamic monitor. Patients were randomized to a Chronicle (Medtronic Inc., Minneapolis, Minnesota) (n = 134) or control (n = 140) group. All patients received optimal medical therapy, but the hemodynamic information from the monitor was used to guide patient management only in the Chronicle group. Primary end points included freedom from system-related complications, freedom from pressure-sensor failure, and reduction in the rate of HF-related events (hospitalizations and emergency or urgent care visits requiring intravenous therapy). RESULTS: The 2 safety end points were met with no pressure-sensor failures and system-related complications in only 8% of the 277 patients who underwent implantation (all but 4 complications were successfully resolved). The primary efficacy end point was not met because the Chronicle group had a nonsignificant 21% lower rate of all HF-related events compared with the control group (p = 0.33). A retrospective analysis of the time to first HF hospitalization showed a 36% reduction (p = 0.03) in the relative risk of a HF-related hospitalization in the Chronicle group. CONCLUSIONS: The implantable continuous hemodynamic monitor-guided care did not significantly reduce total HF-related events compared with optimal medical management. Additional trials will be necessary to establish the clinical benefit of implantable continuous hemodynamic monitor-guided care in patients with advanced HF.

PMID: 18342224 [PubMed - indexed for MEDLINE]

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Transient ST-elevation myocardial infarction: clinical course with intense medical therapy and early invasive approach, and comparison with persistent ST-elevation myocardial infarction.

Am Heart J. 2008 May;155(5):848-54

Authors: Meisel SR, Dagan Y, Blondheim DS, Dacca S, Shochat M, Kazatsker M, Asif A, Frimerman A, Shotan A

Patients presenting with ST-elevation myocardial infarction (STEMI), whose symptoms and electrocardiographic changes completely resolve upon admission and before the administration of reperfusion therapy, pose a therapeutic dilemma. The optimal management of this syndrome, termed here as transient STEMI (TSTEMI), has not yet been fully determined. We describe 69 prospectively recorded patients with TSTEMI, of which 63 patients (56.7 +/- 11 years, 48 men) were available for long-term follow-up out of 1244 consecutive patients with acute myocardial infarction (5%). Patients with TSTEMI treated with intravenous isosorbide dinitrate, aspirin, and clopidogrel, and/or with glycoprotein IIb/IIIa inhibitors were compared with a control group of matched patients with STEMI without resolution, who were treated conventionally. The time interval from symptom onset to presentation at the emergency department of patients with TSTEMI was 1.7 +/- 1.3 hours, and to first recording of ST elevations, 1.5 +/- 1.4 hours. Symptoms and electrocardiographic changes fully resolved 1.2 +/- 0.8 hours later, 1 hour after aspirin and nitrate administration. Coronary angiography, performed 36 +/- 39 hours (median, 24 hours) from admission, demonstrated no obstructive lesion or single-vessel obstructive disease in 43 patients (70%). Primary coronary intervention was performed in 48 patients (77%), and 8 patients (13%) were referred to surgery. Left ventricular ejection fraction was within normal limits, and peak creatine kinase was mildly elevated. Patients with TSTEMI had less extensive coronary artery disease (P < .038), better thrombolysis in myocardial infarction flow on angiography (P < .01), lower peak creatine kinase level (P < .001), higher left ventricular ejection fraction (P < .0001), and lower likelihood to sustain a second additional coronary event after index admission (P = .024) than patients with STEMI. Transient STEMI was associated with less myocardial damage, less extensive coronary artery disease, higher thrombolysis in myocardial infarction flow grade in culprit artery, and better cardiac function. These data suggest that immediate intense medical therapy with an early invasive approach is an appropriate therapy in patients with TSTEMI.

PMID: 18440331 [PubMed - indexed for MEDLINE]

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Optimal heart failure therapy and successful cardioversion in heart failure patients with atrial fibrillation.

Am Heart J. 2008 May;155(5):890-5

Authors: Boldt LH, Rolf S, Huemer M, Parwani AS, Luft FC, Dietz R, Haverkamp W

BACKGROUND: Effectiveness, safety, and other factors associated with success of cardioversion (CV) of atrial fibrillation (AF) have not yet been evaluated in patients with reduced left ventricular ejection fraction. We studied 148 consecutive patients with left ventricular dysfunction (ejection fraction < or = 45%), who underwent electrical CV for AF in our department. The patients had New York Heart Association heart failure ranging from class II to IV. The overall CV success rate was 71%. We relied on univariate and multivariate regression and sought variables influencing success rate. Conversion success did not correlate with New York Heart Association class. Instead, we found that the greatest predictor was the degree of heart failure treatment. Patients receiving beta-blockers, angiotensin-converting enzyme inhibitors or angiotension receptor blockers, plus mineralocorticoid receptor blockers had the greatest chance for conversion success. Success was more likely in patients with coronary artery disease (91%) than in patients with nonischemic cardiomyopathy. CONCLUSIONS: Cardioversion is a safe and effective method for the restoration of sinus rhythm in patients with AF and reduced left ventricular ejection fraction. Our findings underscore the value of aggressive heart failure treatment before CV in patients with AF.

PMID: 18440338 [PubMed - indexed for MEDLINE]

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Shared by Robert Mahoney

Link to full text: http://thorax.bmj.com/cgi/content/full/63/5/415
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…

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Cell-free hemoglobin-based blood substitutes and risk of myocardial infarction and death: a meta-analysis.

JAMA. 2008 May 21;299(19):2304-12

Authors: Natanson C, Kern SJ, Lurie P, Banks SM, Wolfe SM

CONTEXT: Hemoglobin-based blood substitutes (HBBSs) are infusible oxygen-carrying liquids that have long shelf lives, have no need for refrigeration or cross-matching, and are ideal for treating hemorrhagic shock in remote settings. Some trials of HBBSs during the last decade have reported increased risks without clinical benefit. OBJECTIVE: To assess the safety of HBBSs in surgical, stroke, and trauma patients. DATA SOURCES: PubMed, EMBASE, and Cochrane Library searches for articles using hemoglobin and blood substitutes from 1980 through March 25, 2008; reviews of Food and Drug Administration (FDA) advisory committee meeting materials; and Internet searches for company press releases. STUDY SELECTION: Randomized controlled trials including patients aged 19 years and older receiving HBBSs therapeutically. The database searches yielded 70 trials of which 13 met these criteria; in addition, data from 2 other trials were reported in 2 press releases, and additional data were included in 1 relevant FDA review. DATA EXTRACTION: Data on death and myocardial infarction (MI) as outcome variables. RESULTS: Sixteen trials involving 5 different products and 3711 patients in varied patient populations were identified. A test for heterogeneity of the results of these trials was not significant for either mortality or MI (for both, I2 = 0%, P > or = .60), and data were combined using a fixed-effects model. Overall, there was a statistically significant increase in the risk of death (164 deaths in the HBBS-treated groups and 123 deaths in the control groups; relative risk [RR], 1.30; 95% confidence interval [CI], 1.05-1.61) and risk of MI (59 MIs in the HBBS-treated groups and 16 MIs in the control groups; RR, 2.71; 95% CI, 1.67-4.40) with these HBBSs. Subgroup analysis of these trials indicated the increased risk was not restricted to a particular HBBS or clinical indication. CONCLUSION: Based on the available data, use of HBBSs is associated with a significantly increased risk of death and MI.

PMID: 18443023 [PubMed - indexed for MEDLINE]

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Selecting medical students: Beware of self selection and self fulfilling prophecy.

BMJ. 2008 May 10;336(7652):1034

Authors: Singleton PD

PMID: 18467390 [PubMed - indexed for MEDLINE]

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US medical schools should say no to pharma support.

BMJ. 2008 May 10;336(7652):1035

Authors: Tanne JH

PMID: 18467393 [PubMed - indexed for MEDLINE]

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Patients would prefer ward to emergency department boarding while awaiting an inpatient bed.

J Emerg Med. 2008 Feb;34(2):221-6

Authors: Walsh P, Cortez V, Bhakta H

Boarding of admitted patients in the Emergency Department (ED), rather than in inpatient care areas, is widespread. We surveyed boarded patients, patients without a disposition, and visitors at a county hospital ED serving a mixed urban and rural population. Subjects were asked “If you needed to be admitted to the hospital but no inpatient bed is available, would you prefer to be kept in an ER hallway or a hallway on an inpatient ward?” Boarded patients said they would prefer ward to ED boarding, 117/213 (54.9%; 95% confidence interval [CI] 48.0%-61.7%). Patients without a disposition 314/477 (65.8%; 95% CI 61.4%-70.0%) and visitors 370/532 (69.5%; 95% CI 65.4%-73.4%) stated a preference for ward boarding in 314/477 (65.8%; 95% CI 61.4%-70.0%) and in 370/532 (69.5%; 95% CI 65.4%-73.4%), respectively. Common reasons for preferring inpatient ward boarding were privacy concerns and reduced noise levels. Those preferring ED boarding valued easy access to a doctor.

PMID: 17976825 [PubMed - indexed for MEDLINE]

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Antimicrobial activity of tigecycline against community-acquired methicillin-resistant Staphylococcus aureus isolates recovered from North American medical centers.

Diagn Microbiol Infect Dis. 2008 Apr;60(4):433-6

Authors: Mendes RE, Sader HS, Deshpande L, Jones RN

A total of 1989 community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) were susceptibility tested by broth microdilution. Pulsed-field gel electrophoresis, SCCmec type, and polymerase chain reaction for Panton-Valentine leukocidin (PVL) genes were also performed. The overall tigecycline susceptibility rate was 98.2%. Glycopeptides, quinupristin/dalfopristin, linezolid, and chloramphenicol were also active against this collection (< or =0.7% resistant). The vast majority (70.8%) of the CA-MRSA was SCCmec type IV, from which 88.4% belonged to the USA300-0114 clone and 94.7% were PVL positive. Tigecycline showed in vitro activity comparable with other highly active parenteral agents and represents an option for treating complicated infections caused by CA-MRSA.

PMID: 18068326 [PubMed - indexed for MEDLINE]

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Review of intern preparedness and education experiences in General Medicine.

Intern Med J. 2008 Apr;38(4):249-53

Authors: Gome JJ, Paltridge D, Inder WJ

BACKGROUND: Few studies assess the transition from medical student to intern and there is limited understanding of what measures are required to assist intern development. The aim of the study was to assess interns’ perception of their preparedness before commencing and on completion of their rotation in General Medicine, and their attitudes towards educational experiences at a tertiary metropolitan teaching hospital. METHODS: Self-assessed preparedness for the General Medical internship and educational experiences were evaluated using a quantitative 5-point scale (1 = low score and 5 = high score) and qualitatively through interview, on interns based at St Vincent’s Hospital (Melbourne). Data were collected at the beginning and at the end of each 10-week rotation (n = 25). RESULTS: Before commencement of the rotation, the interns identified areas where they felt inadequately prepared, particularly resuscitation skills and medico-legal aspects. When resurveyed at the completion of their 10-week rotation, the interns felt they had been better prepared for their role than they initially perceived, both generally and in specific aspects. Nine out of 16 parameters showed a significant increase in preparedness score at week 10 compared to week 1. The educational experiences most valued were peer driven education sessions and informal registrar teaching. Formal consultant teaching and online learning were perceived as being the least useful. CONCLUSION: Interns at St Vincent’s Hospital have been adequately prepared for their role in General Medicine, although many realize this only in retrospect. Deficiencies in educational opportunities for interns have been uncovered that emphasize areas of attention for medical educators.

PMID: 18298561 [PubMed - indexed for MEDLINE]

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