ABSTRACT: Ward attending rounds are an integral part of internal medicine education. Being a good teacher is necessary, but not sufficient for successful rounds. Understanding perceptions of successful attending rounds (AR) may help define key areas of focus for enhancing learning, teaching and patient care.
We sought to expand the conceptual framework of 30 previously identified attributes contributing to successful AR by: 1) identifying the most important attributes, 2) grouping similar attributes, and 3) creating a cognitive map to define dimensions and domains contributing to successful rounds.
Multi-institutional, cross-sectional study design.
We recruited residents and medical students from a university-based internal medicine residency program and a community-based family medicine residency program. Faculty attending a regional general medicine conference, affiliated with multiple institutions, also participated.
Participants performed an unforced card-sorting exercise, grouping attributes based on perceived similarity, then rated the importance of attributes on a 5-point Likert scale. We translated our data into a cognitive map through multi-dimensional scaling and hierarchical cluster analysis.
Thirty-six faculty, 49 residents and 40 students participated. The highest rated attributes (mean rating) were "Teach by example (bedside manner)" (4.50), "Sharing of attending's thought processes" (4.46), "Be approachable-not intimidating" (4.45), "Insist on respect for all team members" (4.43), "Conduct rounds in an organized, efficient & timely fashion" (4.39), and "State expectations for residents/students" (4.37). Attributes were plotted on a two-dimensional cognitive map, and adequate convergence was achieved. We identified five distinct domains of related attributes: 1) Learning Atmosphere, 2) Clinical Teaching, 3) Teaching Style, 4) Communicating Expectations, and 5) Team Management.
We identified five domains of related attributes essential to the success of ward attending rounds.
Journal of General Internal Medicine 06/2012; 27(11):1492-8. · 2.83 Impact Factor
ABSTRACT: IntroductionPublishing a case report demonstrates scholarly productivity for trainees and clinician-educators.
AimTo assess the learning outcomes from a case report writing workshop.
SettingMedical students, residents, fellows and clinician-educators attending a workshop.
Program DescriptionCase report writing workshop conducted nine times at different venues.
Program EvaluationBefore and after each workshop, participants self-rated their perceived competence to write a case report, likelihood of submitting
a case report to a meeting or for publication in the next 6–12months, and perceived career benefit of writing a case report
(on a five-point Likert scale). The 214 participants were from 3 countries and 27 states or provinces; most participants were
trainees (64.5 %). Self-rated competence for writing a case report improved from a mean of 2.5 to 3.5 (a 0.99 increase; 95%
CI, 0.88–1.12, p < 0.001). The perceived likelihood of submitting a case report, and the perceived career benefit of writing
one, also showed statistically significant improvements (p = 0.002, p = 0.001; respectively). Nine of 98 participants published
a case report 16–41months after workshop completion.
DiscussionThe workshop increased participants’ perception that they could present or publish a case report.
Journal of General Internal Medicine 04/2012; 24(3):398-401. · 2.83 Impact Factor
ABSTRACT: Efforts to implement evidence-based medicine (EBM) training in developing countries are limited. We describe the results of an international effort to improve research capacity in a developing country; we conducted a course aimed at improving basic EBM attitudes and identified challenges.
Between 2005 and 2009, we conducted an annual 3-day course in Perú consisting of interactive lectures and case-based workshops. We assessed self-reported competence and importance in EBM using a Likert scale (1 = low, 5 = high).
Totally 220 clinicians participated. For phase I (2005-2007), self-reported EBM competence increased from a median of 2 to 3 (P < 0.001) and the perceived importance of EBM did not change (median = 5). For phase II (2008-2009), before the course, 8-72% graded their competence very low (score of 1-2). After the course, 67-92% of subjects graded their increase in knowledge very high (score of 4-5). The challenges included limited availability of studies relevant to the local reality written in Spanish, participants' limited time and lack of long-term follow-up on practice change. Informal discussion and written evaluation from participants were universally in agreement that more training in EBM is needed.
In an EBM course in a resource-poor country, the baseline self-reported competence and experience on EBM were low, and the course had measurable improvements of self-reported competence, perceived utility and readiness to incorporate EBM into their practices. Similar to developed countries, translational research and building the research capacity in developing countries is critical for translating best available evidence into practice.
Journal of Evaluation in Clinical Practice 01/2011; 17(4):644-50. · 1.23 Impact Factor
ABSTRACT: Multidrug-resistant tuberculosis (MDR-TB), resistance to at least isoniazid and rifampin, is a worldwide problem.
To develop a clinical prediction rule to stratify risk for MDR-TB among patients with pulmonary tuberculosis.
Derivation and internal validation of the rule among adult patients prospectively recruited from 37 health centers (Perú), either a) presenting with a positive acid-fast bacillus smear, or b) had failed therapy or had a relapse within the first 12 months.
Among 964 patients, 82 had MDR-TB (prevalence, 8.5%). Variables included were MDR-TB contact within the family, previous tuberculosis, cavitary radiologic pattern, and abnormal lung exam. The area under the receiver-operating curve (AUROC) was 0.76. Selecting a cut-off score of one or greater resulted in a sensitivity of 72.6%, specificity of 62.8%, likelihood ratio (LR) positive of 1.95, and LR negative of 0.44. Similarly, selecting a cut-off score of two or greater resulted in a sensitivity of 60.8%, specificity of 87.5%, LR positive of 4.85, and LR negative of 0.45. Finally, selecting a cut-off score of three or greater resulted in a sensitivity of 45.1%, specificity of 95.3%, LR positive of 9.56, and LR negative of 0.58.
A simple clinical prediction rule at presentation can stratify risk for MDR-TB. If further validated, the rule could be used for management decisions in resource-limited areas.
PLoS ONE 01/2010; 5(8):e12082. · 4.09 Impact Factor
ABSTRACT: We examined diffusion of troponin testing in Medicare patients with unstable angina before the release of year 2000 American College of Cardiology/American Heart Association guidelines recommending measurement in all patients with acute coronary syndromes.
We identified unstable angina admissions from Medicare administrative files for 22 Alabama hospitals over two time periods: 03/1997-02/1998 and 01/99-12/1999. Data were obtained from chart abstraction. Patients not confirmed for unstable angina by a clinical algorithm were eliminated.
For 1997-1998, 1116 (87.7%) of all identified cases were clinically confirmed for unstable angina, and 1176 (90.3%) were confirmed for 1999. In 1997-1998, 235 (21%) of unstable angina patients had troponin measured, compared to 822 (70%) in 1999. From 1999, patients with troponin measurement, vs. those without, more likely had typical angina (50.9%, 37.4%), chest pain on arrival (72.8%, 57.1%), and chest pain at rest (45.4%, 37.2%) and more often received EKG within 20 min of presentation (46.3%, 27.9%) (P<.0005 for all). Patients with abnormal troponin levels more often received angiotensin converting enzyme inhibitors (54.6%, 18.3%), cardiac catheterization (45.4%, 31.2%), and percutaneous coronary intervention (18.6%, 4.8%) (P<.05 for all). These associations remained significant after multivariable adjustment for patient and hospital characteristics.
This study demonstrates increasing and appropriate use of troponin before guideline release. Our findings suggest that guidelines may codify currently accepted practice rather than always disseminate new knowledge. The same forces that lead to guideline development and release may also lead to changes in clinical practice before guideline release.
Journal of Clinical Epidemiology 12/2003; 56(12):1236-43. · 4.27 Impact Factor