Improving the Management of Hepatorenal Syndrome-Acute Kidney Injury Using an Updated Guidance and a New Treatment Paradigm.

Cirrhosis, or advanced scarring of the liver, represents the end stage of chronic liver disease and is associated with high morbidity and mortality. Hepatorenal syndrome-acute kidney injury (HRS -AKI), a condition causing functional and progressive kidney failure, is a complication of cirrhosis that contributes to its high mortality rate. In the United States, the standard-of-care treatments for HRS -AKI have historically been suboptimal. Recently, terlipressin became the first drug approved for HRS -AKI in the United States, and the American Association for the Study of Liver Diseases updated its guidance document on HRS diagnosis and management. Clinical practice guidelines and guidance documents have a variable effect on physician behavior owing to a lack of awareness, familiarity, and education. The imple mentation of standardized order sets can improve guidance adherence and the quality of care delivered by encouraging data-driven treatment administration, especially for new therapies. This review seeks to facilitate improvements in the management of HRS -AKI by discussing early HRS -AKI interventions, which will streamline diagnosis and treatment in a practical way for clinical use, and how to incorporate new treatments into patient care to improve survival in this subset of patients. Finally, these recommendations are integrated into a sample order set developed by members of the Chronic Liver Disease Foundation and experts in the management of HRS-AKI.

Enhancing existing medical school curricula with an innovative healthcare disparities curriculum.

BACKGROUND: Effective healthcare disparities curricula seek to train physicians who are well equipped to address the health needs of an increasingly diverse society. Current literature on healthcare disparities curricula and implementation focuses on courses created independent of existing educational materials. Our aim was to develop and implement a novel resource-conserving healthcare disparities curriculum to enhance existing medical school lectures without the need for additional lectures. METHODS: This non-randomized intervention was conducted at the University of California Los Angeles. The curriculum was offered to all first-year medical students in the class of 2021 (n=188). With institutional approval, a new healthcare disparities curriculum was created based on the Society of General Internal Medicine's core learning objectives for effective healthcare disparities curricula (J General Internal Med 25:S160-163, 2010). Implementation of the curriculum made use of "teachable moments" within existing medical school lectures. Teachable moments were broad lecture topics identified by the research team as suitable for introducing relevant healthcare disparities content. The new lecture-enhancing healthcare disparities curriculum was delivered with the related lecture via integrated PDF documents uploaded to an online learning management system. Students were encouraged to complete pre- and post- course assessments to examine changes in disparities knowledge and self-rated confidence in addressing disparities. Matched χ2 tests were used for statistical analysis. RESULTS: Participating students (n=92) completed both pre- and post-course assessments and were retrospectively stratified, based on self-reported use of the new lecture enhancing curriculum, into the "high utilizer" group (use of materials "sometimes" or "very often," n=52) and the comparison "low utilizer" group (use of the materials "rarely" or "very rarely," n=40). Students who self-identified as underrepresented racial and ethnic minorities in medicine were more likely to utilize the material (41% of the high utilizers vs. 17% of the low utilizer group, p<.01). Post-course knowledge assessment scores and self-reported confidence in addressing healthcare disparities improved only in the high utilizer group. CONCLUSIONS: Integrating new guideline based curricula content simultaneously into pre-existing lectures by identifying and harnessing teachable moments may be an effective and resource-conserving strategy for enhancing healthcare disparities education among first year medical students.

Resident Physician Experiences With and Responses to Biased Patients.

Importance: Biased patient behavior negatively impacts resident well-being. Data on the prevalence and frequency of these encounters are lacking and are needed to guide the creation of institutional trainings and policies to support trainees. Objective: To evaluate the frequency of resident experiences with and responses to a range of biased patient behaviors. Design, Setting, and Participants: A retrospective survey was sent via email to 331 second- and third-year internal medicine residents from 3 academic medical centers in California and North Carolina. First-year residents were excluded owing to their limited interactions with patients at the time of participant recruitment. Data were collected from August 21 to November 25, 2019. Main Outcomes and Measures: Descriptive statistics were used to report the frequency of experience of various types of biased patient behavior, residents' responses, the factors impeding residents' responses, and residents' experiences and beliefs regarding training and policies. Results: Overall, 232 of 331 residents (70%) participated; 116 (50%) were women; 116 of 247 (47%) were White (participants had the option of selecting >1 race/ethnicity); and 23 (10%) identified as lesbian, gay, bisexual, transgender, or queer. The frequency of resident-reported experience of types of biased patient behaviors varied. The most common behaviors-belittling comments and assumption of nonphysician status-were reported to be experienced 1 or more times per week by 14% of residents (32 of 231) and 17% of residents (38 of 230), respectively. Women, Black or Latinx, and Asian residents reported experiencing biased behavior more frequently. Forty-five percent of Black or Latinx residents (17 of 38) encountered instances of explicit epithets or rejection of care. All 70 Asian residents reported experiencing inquiries into their ethnic origins. Most women residents (110 of 115 [96%]) experienced role questioning behaviors, and 87% (100 of 115) experienced sexual harassment. The need to prioritize clinical care and a sense of futility in responding were the most common factors (cited by 34% of residents [76 of 227] and 25% of residents [56 of 227], respectively) significantly impeding responses to biased behaviors. Eighty-five percent of residents (191 of 226) never reported incidents to their institution. Eighty-nine percent of residents (206 of 232) identified training and policies as necessary or very necessary. Conclusions and Relevance: This survey study suggests that biased patient behavior is experienced frequently by internal medicine residents. Non-White and women residents reported experiencing a disproportionate burden of these incidents. Residents' responses rarely included institutional involvement. Residency programs and health care systems should prioritize training and policies to address biased patient behavior and support affected residents.

A Prescription for Note Bloat: An Effective Progress Note Template.

BACKGROUND: United States hospitals have widely adopted electronic health records (EHRs). Despite the potential for EHRs to increase efficiency, there is concern that documentation quality has suffered. OBJECTIVE: To examine the impact of an educational session bundled with a progress note template on note quality, length, and timeliness. DESIGN: A multicenter, nonrandomized prospective trial. SETTING: Four academic hospitals across the United States. PARTICIPANTS: Intern physicians on inpatient internal medicine rotations at participating hospitals. INTERVENTION: A task force delivered a lecture on current issues with documentation and suggested that interns use a newly designed best practice progress note template when writing daily progress notes. MEASUREMENTS: Note quality was rated using a tool designed by the task force comprising a general impression score, the validated Physician Documentation Quality Instrument, 9-item version (PDQI-9), and a competency questionnaire. Reviewers documented number of lines per note and time signed. RESULTS: Two hundred preintervention and 199 postintervention notes were collected. Seventy percent of postintervention notes used the template. Significant improvements were seen in the general impression score, all domains of the PDQI-9, and multiple competency items, including documentation of only relevant data, discussion of a discharge plan, and being concise while adequately complete. Notes had approximately 25% fewer lines and were signed on average 1.3 hours earlier in the day. CONCLUSIONS: The bundled intervention for progress notes significantly improved the quality, decreased the length, and resulted in earlier note completion across 4 academic medical centers.

Internal medicine progress note writing attitudes and practices in an electronic health record.

BACKGROUND: The electronic health record (EHR) has been viewed with both praise and skepticism. Multiple editorials have expressed concerns that EHR implementation and "efficiency tools" such as copy forward and auto population have resulted in a decrement in note accuracy, relevance, and critical thinking. OBJECTIVE: To evaluate the perceptions of internal medicine housestaff and attendings on inpatient progress note quality at 4 academic institutions after the implementation of an EHR. DESIGN: Cross-sectional survey. MEASUREMENTS: We developed surveys that assessed housestaff and attendings opinion of current progress note quality, the impact of the EHR on quality, and the purposes of a progress note. RESULTS: We received 99 completed surveys from interns (66%), 155 from residents (49%), and 153 from attendings (70%) across 4 institutions. The majority of housestaff responded that the quality of notes was "unchanged" or "better" following the implementation of an EHR, whereas attendings believed note quality was "unchanged" or "worse." Attendings' perceptions of housestaff notes were significantly lower than housestaff perceptions of their own notes across all domains. With regard to the effect of copy forward and autopopulation, the majority of housestaff viewed these to be "neutral" or "somewhat positive," whereas attendings viewed these as "neutral" or "somewhat negative." Housestaff and attendings had nearly perfect agreement regarding the purpose of the progress note. CONCLUSIONS: Attendings and housestaff disagree on the current quality of progress notes and the impact of an EHR on note quality, but agree on the purpose of a progress note.