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Factors determining medical students’ and residents’ satisfaction during VA-based training: findings from the VA Learners’ Perceptions Survey.

Acad Med. 2008 Jun;83(6):611-20

Authors: Cannon GW, Keitz SA, Holland GJ, Chang BK, Byrne JM, Tomolo A, Aron DC, Wicker AB, Kashner TM

PURPOSE: To compare medical students' and physician residents' satisfaction with Veterans Affairs (VA) training to determine the factors that were most strongly associated with trainee satisfaction ratings. METHOD: Each year from 2001 to 2006, all medical students and residents in VA teaching facilities were invited to complete the Learners' Perceptions Survey. Participants rated their overall training satisfaction on a 100-point scale and ranked specific satisfaction in four separate educational domains (learning environment, clinical faculty, working environment, and physical environment) on a five-point Likert scale. Each domain was composed of unique items. RESULTS: A total of 6,527 medical students and 16,583 physician residents responded to the survey. The overall training satisfaction scores for medical students and physician residents were 84 and 79, respectively (P < .001), with significant differences in satisfaction reported across the training continuum. For both medical students and residents, the rating of each of the four educational domains was statistically significantly associated with the overall training satisfaction score (P < .001). The learning environment domain had the strongest association with overall training satisfaction score, followed by the clinical preceptor, working environment, and physical environment domains; no significant differences were found between medical students and physician residents in the rank order. Satisfaction with quality of care and faculty teaching contributed significantly to training satisfaction. CONCLUSIONS: Factors that influence training satisfaction were similar for residents and medical students. The domain with the highest association was the learning environment; quality of care was a key item within this domain.

PMID: 18520472 [PubMed - indexed for MEDLINE]

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Recommendations for the management of individuals with acquired valvular heart diseases who are involved in leisure-time physical activities or competitive sports.

Eur J Cardiovasc Prev Rehabil. 2008 Feb;15(1):95-103

Authors: Mellwig KP, van Buuren F, Gohlke-Baerwolf C, Bjørnstad HH

Physical check-ups among athletes with valvular heart disease are of significant relevance. In athletes with mitral valve stenosis the extent of allowed physical activity is dependant on the size of the left atrium and the severity of the valve defect. Patients with mild-to-moderate mitral valve regurgitation can participate in all types of sport associated with low and moderate isometric stress and moderate dynamic stress. Patients under anticoagulation should not participate in any type of contact sport. Asymptomatic athletes with mild aortic valve stenosis can take part in all types of sport, as long as left ventricular function and size are normal, a normal response to exercise at the level performed during athletic activities is present and there are no arrhythmias. Asymptomatic athletes with moderate aortic valve stenosis should only take part in sports with low dynamic and static stress. Aortic valve regurgitation is often present due to connective tissue disease of a bicuspid valve. Athletes with mild aortic valve regurgitation, with normal end diastolic left ventricular size and systolic function can participate in all types of sport. A mitral valve prolapse is often associated with structural diseases of the myocardium and endocardium. In patients with mitral valve prolapse Holter-ECG monitoring should also be performed to detect significant arrhythmias. All athletes with known valvular heart disease, a previous history of infective endocarditis and valve surgery should receive endocarditis prophylaxis before dental, oral, respiratory, intestinal and genitourinary procedures associated with bacteraemia. Sport activities have to be avoided during active infection with fever.

PMID: 18277193 [PubMed - indexed for MEDLINE]

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Frequency of medication errors with intravenous acetylcysteine for acetaminophen overdose.

Ann Pharmacother. 2008 Jun;42(6):766-70

Authors: Hayes BD, Klein-Schwartz W, Doyon S

BACKGROUND: Acetadote, an intravenous preparation of acetylcysteine, became commercially available in the US in June 2004 for the treatment of acetaminophen poisoning. The dosing regimen is complex, consisting of a loading dose followed by 2 maintenance doses, each with different infusion rates. OBJECTIVE: To analyze the frequency of medication errors related to the complex dosing regimen for intravenous acetylcysteine. METHODS: A retrospective chart review of a regional poison center’s records was performed for all patients treated with intravenous acetylcysteine from August 1, 2006, to August 31, 2007. Data collected included acetylcysteine dose, infusion rate, interruptions in therapy, unnecessary administration, and medical outcome. Records that revealed medication errors were further examined for the time and location of the errors. RESULTS: There were 221 acetaminophen overdose cases treated with intravenous acetylcysteine that met inclusion criteria. Of these, 84 medication errors occurred in 74 (33%) patients. The frequency and types of errors were 1.4% incorrect dose, 5% incorrect infusion rate, 18.6% more than 1 hour of interruption in therapy, and 13.1% unnecessary administration. The frequency and types of medication errors in pediatric patients were similar to those in the total patient population. Errors occurred most frequently in the emergency department compared with intensive care units or general medical floors. In addition, errors occurred most frequently on third shift, compared with first or second shift. Evaluation of medical outcomes in cases involving acetaminophen only found that medication errors did not have an impact on coded outcomes. CONCLUSIONS: Medication administration errors occur frequently with intravenous acetylcysteine. Awareness of this problem, coupled with increased vigilance in identifying factors associated with errors, should decrease medication errors with intravenous acetylcysteine therapy for acetaminophen poisoning.

PMID: 18445707 [PubMed - indexed for MEDLINE]

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Ampicillin/sulbactam compared with polymyxins for the treatment of infections caused by carbapenem-resistant Acinetobacter spp.

J Antimicrob Chemother. 2008 Jun;61(6):1369-75

Authors: Oliveira MS, Prado GV, Costa SF, Grinbaum RS, Levin AS

BACKGROUND: There has been an increase in worldwide infections caused by carbapenem-resistant Acinetobacter. This poses a therapeutic challenge as few treatment options are available. OBJECTIVES: The aim of this study was to evaluate the efficacy and safety of polymyxins and ampicillin/sulbactam for treating infections caused by carbapenem-resistant Acinetobacter spp. and to evaluate prognostic factors. METHODS: This was a retrospective review of patients from two teaching hospitals who had nosocomial infections caused by carbapenem-resistant Acinetobacter spp. from 1996 to 2004. Diagnosis of infection was based on CDC criteria plus the isolation of Acinetobacter from a usually sterile site or from bronchoalveolar lavage. Urinary tract infections were not included. Data on demographic and clinical features and treatment were collected from medical records. Prognostic factors associated with two outcomes (mortality during treatment and in-hospital mortality) were evaluated. RESULTS: Eighty-two patients received polymyxins and 85 were treated with ampicillin/sulbactam. Multiple logistic regression analysis revealed that independent predictors of mortality during treatment were treatment with polymyxins, higher Acute Physiological and Chronic Health Evaluation II (APACHE II) score, septic shock, delay in starting treatment and renal failure. On multivariate analysis, prognostic factors for in-hospital mortality were older age, septic shock and higher APACHE II score. CONCLUSIONS: This is the first study comparing current therapeutic options for infections due to carbapenem-resistant Acinetobacter. The most important finding of the present study is that ampicillin/sulbactam appears to be more efficacious than polymyxins, which was an independent factor associated with mortality during treatment.

PMID: 18367459 [PubMed - indexed for MEDLINE]

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Daily cost of antimicrobial therapy in patients with Intensive Care Unit-acquired, laboratory-confirmed bloodstream infection.

Int J Antimicrob Agents. 2008 Feb;31(2):161-5

Authors: Vandijck DM, Depaemelaere M, Labeau SO, Depuydt PO, Annemans L, Buyle FM, Oeyen S, Colpaert KE, Peleman RP, Blot SI, Decruyenaere JM

This study analysed daily antimicrobial costs of Intensive Care Unit (ICU)-acquired, laboratory-confirmed bloodstream infection (BSI) per patient admitted to the ICU of a university hospital, based on prospectively collected data over a 4-year period (2003-2006). Costs were calculated based on the price of the agent(s) initiated on the first day of appropriate treatment and according to: (i) focus of infection; (ii) pathogen; and (iii) antimicrobial agent. The study included 310 adult patients who developed 446 BSI episodes. Mean overall daily antimicrobial cost was euro114.25. Daily antimicrobial cost was most expensive for BSIs with unknown focus (euro137.70), followed by catheter-related (euro122.73), pulmonary (euro112.80), abdominal (euro98.00), wound (euro89.21), urinary (euro87.85) and other inciting focuses (euro81.59). Coagulase-negative staphylococci were the most prevalent pathogens isolated. Treatment of BSIs caused by Candida spp. was the most costly. The daily antimicrobial costs per infected patient with multidrug-resistant BSI was ca. 50% higher compared with those without (euro165.09 vs. euro82.67; P<0.001). Among the total of 852 prescriptions, beta-lactam antibiotics accounted for approximately one-third of the overall daily cost of antimicrobial agents. The antibiotic cost associated with ICU-acquired, laboratory-confirmed BSI is significant and should be reduced by implementing infection control measures and preventive strategies.

PMID: 18164599 [PubMed - indexed for MEDLINE]

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Effects of reflective practice on the accuracy of medical diagnoses.

Med Educ. 2008 May;42(5):468-75

Authors: Mamede S, Schmidt HG, Penaforte JC

CONTEXT: Reflective practice has been suggested to be an important instrument in improving clinical judgement and developing medical expertise. Empirical evidence supporting this suggestion, however, is absent. This paper reports on an experiment conducted to study the effects of reflective practice on diagnostic accuracy. METHODS: Participants were 42 internal medicine residents in hospitals in 2 states in the northeast of Brazil. They diagnosed 16 clinical cases. The experiment employed a repeated measures design, with 2 independent variables: the complexity of clinical cases (simple or complex), and the reasoning approach induced to diagnose the case (participants were instructed to diagnose each case either through pattern recognition or reflective reasoning). The dependent variable was the accuracy of the diagnosis provided for each case. All participants participated in each of the 2 levels of both independent variables. RESULTS: A main effect of case complexity emerged. There was no statistically significant main effect of reflective practice. However, a significant interaction effect was found between case complexity and mode of processing (F[1,41] = 4.48, P < 0.05), indicating that although reflective practice did not make a difference to accuracy of diagnosis in simple cases, it had a positive effect when diagnosing complex cases. CONCLUSIONS: Reflective practice had a positive effect on diagnosis of complex, unusual cases. Non-analytical reasoning was shown to be as effective as reflective reasoning for diagnosing routine clinical cases. Findings support the idea that reflective practice may particularly improve diagnoses in situations of uncertainty and uniqueness, reducing diagnostic errors.

PMID: 18412886 [PubMed - indexed for MEDLINE]

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Performance during internal medicine residency training and subsequent disciplinary action by state licensing boards.

Ann Intern Med. 2008 Jun 3;148(11):869-76

Authors: Papadakis MA, Arnold GK, Blank LL, Holmboe ES, Lipner RS

BACKGROUND: Physicians who are disciplined by state licensing boards are more likely to have demonstrated unprofessional behavior in medical school. Information is limited on whether similar performance measures taken during residency can predict performance as practicing physicians. OBJECTIVE: To determine whether performance measures during residency predict the likelihood of future disciplinary actions against practicing internists. DESIGN: Retrospective cohort study. SETTING: State licensing board disciplinary actions against physicians from 1990 to 2006. PARTICIPANTS: 66,171 physicians who entered internal medicine residency training in the United States from 1990 to 2000 and became diplomates. MEASUREMENTS: Predictor variables included components of the Residents’ Annual Evaluation Summary ratings and American Board of Internal Medicine (ABIM) certification examination scores. RESULTS: 2 performance measures independently predicted disciplinary action. A low professionalism rating on the Residents’ Annual Evaluation Summary predicted increased risk for disciplinary action (hazard ratio, 1.7 [95% CI, 1.3 to 2.2]), and high performance on the ABIM certification examination predicted decreased risk for disciplinary action (hazard ratio, 0.7 [CI, 0.60 to 0.70] for American or Canadian medical school graduates and 0.9 [CI, 0.80 to 1.0] for international medical school graduates). Progressively better professionalism ratings and ABIM certification examination scores were associated with less risk for subsequent disciplinary actions; the risk ranged from 4.0% for the lowest professionalism rating to 0.5% for the highest and from 2.5% for the lowest examination scores to 0.0% for the highest. LIMITATIONS: The study was retrospective. Some diplomates may have practiced outside of the United States. Nondiplomates were excluded. CONCLUSION: Poor performance on behavioral and cognitive measures during residency are associated with greater risk for state licensing board actions against practicing physicians at every point on a performance continuum. These findings support the Accreditation Council for Graduate Medical Education standards for professionalism and cognitive performance and the development of best practices to remediate these deficiencies.

PMID: 18519932 [PubMed - indexed for MEDLINE]

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The role of chemotherapy at the end of life: “when is enough, enough?”.

JAMA. 2008 Jun 11;299(22):2667-78

Authors: Harrington SE, Smith TJ

Patients face difficult decisions about chemotherapy near the end of life. Such treatment might prolong survival or reduce symptoms but cause adverse effects, prevent the patient from engaging in meaningful life review and preparing for death, and preclude entry into hospice. Palliative care and oncology clinicians should be logical partners in caring for patients with serious cancers for which symptom control, medically appropriate goal setting, and communication are paramount, but some studies have shown limited cooperation. We illustrate how clinicians involved in palliative care and oncology can more effectively work together with the story of Mr L, a previously healthy 56-year-old man, who wanted to survive his lung cancer at all costs. He lived 14 months with 3 types of chemotherapy, received chemotherapy just 6 days before his death, and resisted entering hospice until his prognosis and options were explicitly communicated. Approaches to communication about prognosis and treatment options and questions that patients may want to ask are discussed.

PMID: 18544726 [PubMed - indexed for MEDLINE]

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Cardiovascular risk factors among internal medicine residents.

Prev Cardiol. 2008;11(2):76-81

Authors: Mihalopoulos NL, Berenson GS

Modification of risk factors can reduce the number of deaths due to cardiovascular disease (CVD). Internal medicine (IM) residents devote significant clinical time to help patients modify CVD risk factors but may fail to recognize the presence of such factors in their own lives. The prevalence of major modifiable risk factors was assessed in IM residents. Of 101 eligible residents, 56 completed at least 1 component of the study. None had symptoms or history of CVD, and 11 (20%) had > or = 2 CVD risk factors. Of 39 subjects who had physical assessment, 3 had systolic hypertension and 13 had a body mass index > or = 25. Of 38 patients with fasting lipid measurements, 13 had total cholesterol >200 mg/dL; 28 had low-density lipoprotein > or = 100 mg/dL, with 7 >160 mg/dL; and 7 had high-density lipoprotein <40 mg/dL. Three residents smoked 10 cigarettes per day and 15 were sedentary. Training in IM should include strategies to increase awareness of modifiable personal risk factors for CVD, as well as strategies to reduce or eliminate them.

PMID: 18401234 [PubMed - indexed for MEDLINE]

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Effects of call on sleep and mood in internal medicine residents.

Behav Sleep Med. 2008 Apr;6(2):75-88

Authors: Rose M, Manser T, Ware JC

Residents on call experience decreased total sleep time (TST) and increased dysphoria. This study monitored changes in mood and sleepiness for 3 post-call days. Fifty-two internal medicine residents participated in the study. The residents wore actigraphs for the 4 to 9 days of the study. Each morning resident completed mood scales, a sleepiness scale, and estimated their prior night TST. The residents were on a 1-in-4 schedule. Call decreased subjective- and actigraphy-derived TST to less than 4 hr. During the 3 days post call, mood measures improved. Tension, depression, and anxiety stabilized on the first post-call day following the first night of off-call sleep during which the residents obtained about 7 hr of sleep. Vigor, fatigue, and confusion stabilized on the second post-call day. The Epworth Sleepiness Scale dropped to less than 11 after 1 post-call night and continued to decrease up to 3 post-call days. The effects of call linger past the first recovery night. For these residents, recovery sleep appeared inadequate, and the negative effects of call persisted across succeeding off-call days. Thus, for these residents on a 1-in-4 schedule, call affects their mood for much of the time when off call and potentially their personal and professional interactions during this period as well.

PMID: 18443947 [PubMed - indexed for MEDLINE]

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Effect of a hospitalist-care coordinator team on a nonteaching hospitalist service.

J Hosp Med. 2008 Mar;3(2):103-9

Authors: O’Leary KJ, Lindquist LA, Colone MA, Haviley C, Thompson JA, Baker DW

BACKGROUND: Although many hospitalists work with clinical coordinators, few studies have evaluated their impact. OBJECTIVE: The purpose of the study was to evaluate the impact of a hospitalist-care coordinator team on hospitalist work experience, patient satisfaction, and hospital efficiency. DESIGN AND PARTICIPANTS: During each of 12 weeks, hospitalists on a nonteaching hospitalist service were randomly assigned to work with a hospitalist care coordinator (HCC) or to work independently. MEASUREMENTS: Each week hospitalists completed a survey to assess their satisfaction and perceived work efficiency. Patient satisfaction with hospital discharge was assessed by telephone interviews. Hospital efficiency was analyzed with multivariate linear regression using log-transformed length of stay (LOS) and cost as dependent variables. RESULTS: The 356 patients cared for by hospitalist-HCC teams were similar to 337 patients cared for by control hospitalists. Twenty-eight of 31 hospitalists (90%) who worked with an HCC responded that the HCC improved their efficiency and job satisfaction. Seventy-one of 196 eligible patients (36%) completed the postdischarge interview. The mean ratings of overall satisfaction with hospital discharge on a scale of 10 were similarly high in both groups (8.57 vs. 8.37; P = .94). In multivariate regression analyses, LOS was 0.28 days shorter and cost was $585.62 lower for patients cared for by hospitalist-HCC teams; however, these results were not statistically significant (P = .17 and .15, respectively). CONCLUSIONS: Hospitalists working in a team approach with an HCC reported improved efficiency and job satisfaction compared with hospitalists working independently. These findings are important in light of growing concerns about hospitalist workload and job satisfaction.

PMID: 18438806 [PubMed - indexed for MEDLINE]

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Should patients with venous thromboembolism be screened for thrombophilia?

Am J Med. 2008 Jun;121(6):458-63

Authors: Dalen JE

In the mid-19th century, Virchow identified hypercoagulability as part of the triad leading to venous thrombosis, but the specific causes of hypercoagulability remained a mystery for another century. The first specific cause to be identified was antithrombin III deficiency. Many other causes of thrombophilia, both genetic and acquired, have been discovered since then. The 2 most common genetic causes of thrombophilia are the Leiden mutation of factor V and the G20210A mutation of prothrombin. The most common acquired cause is antiphospholipid syndrome. These factors increase the relative risk of an initial episode of venous thromboembolism (VTE) by a factor of 2 to 10, but the actual risk remains relatively modest. Therefore, thrombophilia screening to prevent initial episodes of VTE is not indicated, except possibly in women with a family history of idiopathic VTE who are considering oral contraceptive therapy. Some physicians screen for thrombophilia to aid decision making concerning the duration of anticoagulant therapy. However, several studies have demonstrated that, with the exception of antiphospholipid syndrome, thrombophilia does not significantly increase the risk of recurrent VTE. On the other hand, idiopathic VTE significantly increases the risk of recurrence in patients with or without thrombophilia.

PMID: 18501222 [PubMed - indexed for MEDLINE]

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Factors associated with osteonecrosis of the jaw among bisphosphonate users.

Am J Med. 2008 Jun;121(6):475-483.e3

Authors: Hess LM, Jeter JM, Benham-Hutchins M, Alberts DS

BACKGROUND: Bisphosphonates are medications that impact bone reformation by inhibiting osteoclast function. Osteonecrosis of the jaw has been reported among patients receiving these medications. It is unclear if the risk factors associated with osteonecrosis of the jaw among cancer patients taking bisphosphonates also are possible risk factors among patients receiving these medications for other indications. METHODS: A systematic review search strategy was used to identify cases of osteonecrosis of the jaw among patients taking bisphosphonates for an indication other than cancer to identify potential contributing factors. Data were analyzed according to previous models to develop a more expanded model that may explain possible mechanisms for the development of osteonecrosis of the jaw among patients without cancer. RESULTS: Ninety-nine cases of osteonecrosis of the jaw were identified among patients who were prescribed a bisphosphonate for an indication other than cancer. These cases included 85 osteoporosis patients, 10 patients with Paget’s disease, 2 patients with rheumatoid arthritis, 1 patient with diabetes, and 1 patient with maxillary fibrous dysplasia. The mean age was 69.4 years, 87.3% were female, and 83.3% were receiving oral, but not intravenous, bisphosphonates. Of the 63 patients reporting dental care information, 88.9% had a dental procedure before the onset of osteonecrosis of the jaw. Of all cases providing medical information, 71% were taking at least one medication that affects bone turnover in addition to the bisphosphonate, and 81.3% reported additional underlying health conditions. CONCLUSIONS: The case details suggest a multiplicity of factors associated with this condition and provide the foundation for a model outlining the potential mechanism for the development of osteonecrosis of the jaw among patients taking bisphosphonates for an indication other than cancer.

PMID: 18501224 [PubMed - indexed for MEDLINE]

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Infective endocarditis prevention: update on 2007 guidelines.

Am J Med. 2008 Jun;121(6):484-6

Authors: Burton MJ, Geraci SA

Antibiotic prophylaxis for preventing infective endocarditis is unproven. The recently issued American Heart Association guidelines for endocarditis prevention call for restricting the use of preprocedure antibiotics. We discuss how these revisions apply to clinical practice in patients undergoing elective medical and dental procedures.

PMID: 18501225 [PubMed - indexed for MEDLINE]

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Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy.

Med Clin North Am. 2008 May;92(3):491-509, xi

Authors: Cappell MS, Friedel D

Acute upper gastrointestinal bleeding is a relatively common, potentially life-threatening medical emergency responsible for more than 300,000 hospital admissions and about 30,000 deaths per annum in America. The initial assessment focuses on bleeding activity, bleeding severity, hemodynamic compromise from the bleeding, and differentiating upper from lower gastrointestinal bleeding. The initial supportive therapy includes fluid resuscitation to reverse the hypovolemia, blood transfusions to replete the lost blood, respiratory support as necessary, and proton pump inhibitor therapy to stabilize mucosal blood clots and promote hemostasis. Esophagogastroduodenoscopy is the best test to determine the bleeding site and cause.

PMID: 18387374 [PubMed - indexed for MEDLINE]

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