Factors Affecting Resident Satisfaction in Continuity Clinic-a Systematic Review.

PURPOSE: In recent years, with an increasing emphasis on time spent in ambulatory training, educators have focused attention on improving the residents' experience in continuity clinic. The authors sought to review the factors associated with physician trainee satisfaction with outpatient ambulatory training. METHODS: A systematic literature review was conducted for all English language articles published between January 1980 and December 2016 in relevant databases, including Medline (medicine), CINAHL (nursing), PSYCHinfo (psychology), and the Cochrane Central Register of Controlled Clinical Trials. Search terms included internship and residency, satisfaction, quality of life, continuity of care, ambulatory care, and medical education. We included studies that directly addressed resident satisfaction in the ambulatory setting through interventions that we considered reproducible. RESULTS: Three hundred fifty-seven studies were reviewed; 346 studies were removed based on exclusion criteria with 11 papers included in the final review. Seven studies emphasized aspects of organizational structure such as block schedules, working in teams, and impact on resident-patient continuity (continuity between resident provider and patient as viewed from the provider's perspective). Four studies emphasized the importance of a dedicated faculty for satisfaction. The heterogeneity of the studies precluded aggregate analysis. CONCLUSIONS: Clinic structures that limit inpatient and outpatient conflict and enhance continuity, along with a dedicated outpatient faculty, are associated with greater resident satisfaction. Implications for further research are discussed.

A new index of prognostic severity for chronic asthma.

OBJECTIVE: To develop a prognostic clinical index for adults with chronic stable asthma. DESIGN: Analysis of data from a 48-week randomized, crossover trial of regular vs as-needed inhaled beta-agonist therapy. PATIENTS: Eligible patients included 70 men and women between the ages of 15 and 64 years with asthma for > 1 year. OUTCOME MEASURE: Asthma deterioration within 20 weeks, defined as either a marked decline in FEV1 (> or = 1.0 L or > or = 30% from baseline) or initiation of systemic corticosteroid therapy for asthma exacerbation. RESULTS: Three baseline factors independently predicted asthma deterioration: frequent symptoms on waking in the 4 weeks before baseline, past hospitalization for asthma, and age 35 years or older. Based on cross-stratification and consolidation of these prognostic factors, an index was developed that stratified subjects into four risk groups with distinctive deterioration rates of 9%, 21%, 39%, and 67% (p<0.001). CONCLUSION: For adults with chronic stable asthma, three simple clinical factors can be combined to stratify effectively for risk of subsequent asthma deterioration.

Clinical reasoning and the new "non-" nosology.

Although seemingly odd, the designations prefixed with "non-" have become a familiar feature of clinical terminology. A common structure of these designations is the partition of a single clinical category into two contrasting ones. Despite the similar "non-" designations, the partitions can have four different functions: dividing one disease into two, aggregating multiple diseases, distinguishing etiologic uncertainty, and negating "legitimate" disease. The "non-" terminology may seem peculiar, but it is based on clinically pertinent distinctions and similarities in disease, reflecting prudent clinical reasoning.