How the Hospital Works: An Interdisciplinary, Systems-Based Practice Medical Student Elective.

OBJECTIVES: Although proficient systems-based practice is a foundational skill for physicians, how best to teach it has not been well established. An elective course for fourth-year medical students wherein participants had an immersive experience with multiple interprofessional staff was created and analyzed. The authors hypothesized that participating students and interprofessional staff would show gains in systems-based knowledge and interprofessional communication. METHODS: The course was a 2-week elective experience for fourth-year medical students at the Larner College of Medicine at the University of Vermont, Burlington, VT, USA. Participants integrated into a variety of interprofessional, non-physician, and administrative roles within the hospital system. Pre- and post-elective systems-based knowledge and interprofessional communication were assessed. Participating interprofessional staff were also surveyed on their experiences. RESULTS: From 2019 through 2022, 14 students participated in the elective, all of whom provided data. All participating students showed a quantitative improvement in systems-based knowledge and qualitatively commented on the high value of the elective in furthering their understanding of interdisciplinary care and communication. Of the 22 participating interprofessional staff surveyed, 17 responded (response rate 77%), and data showed high satisfaction with the experience and that having students learn more about their jobs improved their own job satisfaction. CONCLUSIONS: An immersive, hands-on experience with interprofessional colleagues showed dual benefits for both students and staff alike. Such an elective experience is scalable to other institutions nationally and should become a standard part of medical student curricula.

What the "Nonteaching" Service Can Teach Us.

"Teaching" services usually incorporate a cadre of learners such as resident physicians and medical students as part of the care team, led by a faculty physician. "Nonteaching" services, in contrast, are usually defined by the absence of resident physicians on the care team. The care for patients on a nonteaching service is frequently managed directly by a faculty or nonfaculty physician. Nonteaching services have grown in number and size at academic medical centers (AMCs) in response to regulatory requirements, operational demands, and efforts to improve clinical education. The allocation of patients to teaching and nonteaching services is frequently based on perceived teaching value of hospitalized patients, which can potentially lead to a number of unintended consequences for medical education, professional satisfaction, and patient care. Through a series of four lessons, the authors describe how the structure of nonteaching services can result in curricular gaps, devalue attending physicians, and undermine the educational and clinical missions of AMCs. Anticipating the continued expansion and evolution of nonteaching services, the authors propose seven design principles for nonteaching services to ensure robust education for students and resident physicians, advance quality of care, and enhance attending physician and patient experience.

Quality of Interhospital Transfer Communication Practices and Association With Adverse Events on an Internal Medicine Hospitalist Service.

Communication practices around interhospital transfer have not been rigorously assessed in adult medicine patients. Furthermore, the clinical implications of such practices have not been reported. This case-control study was designed to assess the quality of communication between clinicians during interhospital transfer and to determine if posttransfer adverse events (PTAEs) are associated with suboptimal communication. Cases included patients transferred to a Medicine Hospitalist Service from an outside hospital who subsequently experienced a PTAE, defined as unplanned transfer to an intensive care unit or death within 24 hours of transfer. Control patients also underwent interhospital transfer but did not experience a PTAE. A blinded investigator retrospectively reviewed the recorded pretransfer phone conversations between sending and receiving clinicians for adherence to a set of 13 empiric best practice communication elements. The primary outcome was the mean communication score, on a scale of 0-13. Mean scores between PTAE (8.3; 95% confidence interval [CI], 7.6-8.9) and control groups (7.9; 95% CI, 7.1-8.8) did not differ significantly (p = .50), although suboptimal communication on a subset of these elements was associated with increased PTAEs. Communication around interhospital transfer appears suboptimal compared with an empiric set of standard communication elements. Posttransfer adverse events were not associated with aggregate adherence to these standards.

A swine model of pseudo-pulseless electrical activity induced by partial asphyxiation.

BACKGROUND: The incidence of pulseless electrical activity (PEA) as a presenting rhythm during cardiac arrest is increasing. The current animal models of PEA arrest, post-countershock or total asphyxiation, unreliably generate PEA for a specific time period. Neither of these models predictably generate pseudo-PEA. The purpose of this study was to create an animal model of pseudo-PEA that will allow for a prolonged time period in this arrest state for future research. METHODS: In a laboratory setting, five ventilated swine on inhaled anesthesia and 100% oxygen with continuous EKG recordings were instrumented with central aortic and venous pressure-transducing catheters. Animals were then switched to intravenous anesthesia while being ventilated with a 16% oxygen/84% nitrogen mix. Continuous EKG, aortic and venous pressures were recorded to a computerized data collection program. Arterial blood gas samples were taken every 10min. Time until onset of pseudo-PEA, duration of pseudo-PEA, and cardiac rhythm during pseudo-PEA were recorded. RESULTS: Mean time to onset of pseudo-PEA was 80.6+/-47.3min. Mean duration of pseudo-PEA was 18.6+/-6.2min. Mean arterial pH at pseudo-PEA onset was 7.20+/-0.05 with a mean associated base excess of -11.4+/--5.94. No significant differences were noted in other recorded variables. CONCLUSIONS: Partial asphyxiation using a 16% oxygen/84% nitrogen mix is a reliable laboratory method to create a prolonged state of pseudo-PEA in a swine model. The mechanism generating pseudo-PEA is hypoxemia-induced systemic acidosis. This model will allow sufficient time in this low-flow cardiac state for future research to be conducted.