2012 May 26

Preparedness for practice: the perceptions of medical graduates and clinical teams.

May 262012

Preparedness for practice: the perceptions of medical graduates and clinical teams.

Med Teach. 2012;34(2):123-35

Authors: Morrow G, Johnson N, Burford B, Rothwell C, Spencer J, Peile E, Davies C, Allen M, Baldauf B, Morrison J, Illing J

Abstract
BACKGROUND: Earlier research indicated that medical graduates feel unprepared to start work, and that this varies with medical school.
AIMS: To examine the extent to which graduates from different UK medical schools differed in their perceptions of preparedness for practice, and compare their perceptions with those of clinical team members.
METHOD: An anonymous questionnaire assessing perceptions of 53 aspects of preparedness was devised, and administered to the graduating cohorts of three medical schools: Newcastle (systems-based, integrated curriculum); Warwick (graduate-entry) and Glasgow (problem-based learning). In addition, a triangulating questionnaire was cascaded via ward managers to doctors, nurses and pharmacists who worked with new graduates in their first posts.
RESULTS: The response rate for the cohort questionnaire was 69% (479/698). The overall mean preparedness score was 3.5 (on a five-point scale), with no significant difference between schools. On individual items, there were large differences within each site, but smaller differences between sites. Graduates felt most prepared for aspects of working with patients and colleagues, history taking and examination. They felt least prepared for completing a cremation form, some aspects of prescribing, complex practical procedures and for applying knowledge of alternative and complementary therapies, and of the NHS. A total of 80 clinical team questionnaires were completed, similarly showing substantial variation within each site, but smaller differences between sites.
CONCLUSIONS: New doctors feel relatively unprepared for a number of aspects of practice, a perception shared by their colleagues. Although medical school has some effect on preparedness, greater differences are common across sites. Differences may reflect hidden influences common to all the schools, unintended consequences of national curriculum guidance or common traits in the graduate populations sampled. Further research is needed to identify the causes.

PMID: 22288990 [PubMed - indexed for MEDLINE]

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Determining whether a patient is feeling better: pitfalls from the science of human perception.

J Gen Intern Med Start a Discussion »

May 262012

Determining whether a patient is feeling better: pitfalls from the science of human perception.

J Gen Intern Med. 2011 Aug;26(8):900-6

Authors: Redelmeier DA, Dickinson VM

Abstract
Human perception is fallible and may lead patients to be inaccurate when judging whether their symptoms are improving with treatment. This article provides a narrative review of studies in psychology that describe misconceptions related to a patient's comprehension, recall, evaluation and expression. The specific misconceptions include the power of suggestion (placebo effects), desire for peace-of-mind (cognitive dissonance reduction), inconsistent standards (loss aversion), a flawed sense of time (duration neglect), limited perception (measurement error), declining sensitivity (Weber's law), an eagerness to please (social desirability bias), and subtle affirmation (personal control). An awareness of specific pitfalls might help clinicians avoid some mistakes when providing follow-up and interpreting changes in patient symptoms.

PMID: 21336670 [PubMed - indexed for MEDLINE]

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Specialty-specific admission: a cost-effective intervention?

Ir J Med Sci Start a Discussion »

May 262012

Specialty-specific admission: a cost-effective intervention?

Ir J Med Sci. 2012 Mar;181(1):87-91

Authors: Slattery E, Harewood GC

Abstract
INTRODUCTION: Cost effectiveness of healthcare has become an important component in its delivery. Current practices need to be assessed and measured for variations that may lead to financial savings. Speciality specific admission is known not only to lead improved clinical outcomes but also to lead important cost reductions.
METHODS: All patients admitted to an Irish teaching hospital via the emergency department over a 2-year period with a gastroenterology (GI) related illness were included in this analysis.GI illness was classified using the Disease related grouping (DRG) system. Mean length of stay (LOS) and patient level costing (PLC) were calculated. Differences between DRGs with respect to speciality (i.e. specialist vs. non-specialist) were calculated for the five commonest DRGs.
RESULTS: Significant variations in LOS and PLC were demonstrated in the DRGs. Mean LOS varied with increasing complexity, from 3.2 days for non-complex GI haemorrhage to 14.4 days for complex alcohol related cirrhosis as expected. A substantial difference in LOS within DRG groups was demonstrated by large standard deviations in the mean (up to 8.1 days in some groups) and was independent of complexity of cases. PLC also varied widely in both complex and non-complex cases with standard deviations of up to <euro>17,342 noted. Specialty-specific admission was associated with shorter LOS for most GI admissions.
CONCLUSION: Significant disparity exists for both LOS and PLC for most GI diagnoses. Specialty-specific admissions are associated with reduced LOS. Specialty-specific admission would appear to be cost-effective which may also lead to improved clinical outcomes.

PMID: 21938442 [PubMed - indexed for MEDLINE]

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Temporal trends in infective endocarditis in the context of prophylaxis guideline modifications: three successive population-based surveys.

J Am Coll Cardiol Start a Discussion »

May 262012

Temporal trends in infective endocarditis in the context of prophylaxis guideline modifications: three successive population-based surveys.

J Am Coll Cardiol. 2012 May 29;59(22):1968-76

Authors: Duval X, Delahaye F, Alla F, Tattevin P, Obadia JF, Le Moing V, Doco-Lecompte T, Celard M, Poyart C, Strady C, Chirouze C, Bes M, Cambau E, Iung B, Selton-Suty C, Hoen B,

Abstract
OBJECTIVES: The goal of this study was to evaluate temporal trends in infective endocarditis (IE) incidence and clinical characteristics after 2002 French IE prophylaxis guideline modifications.
BACKGROUND: There are limited data on changes in the epidemiology of IE since recent guidelines recommended restricting the indications of antibiotic prophylaxis of IE.
METHODS: Three 1-year population-based surveys were conducted in 1991, 1999, and 2008 in 3 French regions totaling 11 million inhabitants age ?20 years. We prospectively collected IE cases from all medical centers and analyzed age- and sex-standardized IE annual incidence trends.
RESULTS: Overall, 993 expert-validated IE cases were analyzed (323 in 1991; 331 in 1999; and 339 in 2008). IE incidence remained stable over time (95% confidence intervals given in parentheses/brackets): 35 (31 to 39), 33 (30 to 37), and 32 (28 to 35) cases per million in 1991, 1999, and 2008, respectively. Oral streptococci IE incidence did not increase either in the whole patient population (8.1 [6.4 to 10.1], 6.3 [4.8 to 8.1], and 6.3 [4.9 to 8.0] in 1991, 1999, and 2008, respectively) or in patients with pre-existing native valve disease. The increased incidence of Staphylococcus aureus IE (5.2 [3.9 to 6.8], 6.8 [5.3 to 8.6], and 8.2 [6.6 to 10.2]) was not significant in the whole patient population (p = 0.228) but was significant in the subgroup of patients without previously known native valve disease (1.6 [0.9 to 2.7], 3.7 [2.6 to 5.1], and 4.1 [3.0 to 5.6]; p = 0.012).
CONCLUSIONS: Scaling down antibiotic prophylaxis indications was not associated with an increased incidence of oral streptococcal IE. A focus on avoidance of S. aureus bacteremia in all patients, including those with no previously known valve disease, will be required to improve IE prevention.

PMID: 22624837 [PubMed - in process]

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Safe placement of central venous catheters: a measured approach.

J Intensive Care Med Start a Discussion »

May 262012

Safe placement of central venous catheters: a measured approach.

J Intensive Care Med. 2011 Nov-Dec;26(6):392-6

Authors: McGee WT, Mailloux PT, Martin RT

Abstract
INTRODUCTION: To develop a simple method for safely placing central venous catheters (CVCs) outside the heart from the subclavian or internal jugular vein in compliance with Food and Drug Administration (FDA) and manufacturer guidelines.
METHODS: Patients requiring CVCs were enrolled into this prospective trial. Central venous catheters were inserted into the subclavian or internal jugular vein from either the right or left side to a depth of 15 cm. Chest radiographs were obtained immediately after insertion of the catheter to check tip placement and to evaluate for mechanical complications.
RESULTS: Operators successfully placed 201 of 210 (96%) CVCs outside the heart. Six of these required repositioning. Nine catheter tips were located in an intracardiac position. No cases of pneumothorax, hemothorax, or pericardial tamponade occurred. One case of delayed hydrothorax due to superior vena cava injury occurred.
CONCLUSIONS: Using a 15-cm insertion depth via the internal jugular or subclavian vein results in safe catheter tip location in the majority of procedures consistent with FDA and manufacturer guidelines.

PMID: 21436169 [PubMed - indexed for MEDLINE]

Link to Article at PubMed