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.

Evaluation of the UCLA department of medicine Malawi global health clinical elective: lessons from the first five years.

In 2008, the UCLA Department of Medicine established a three-week clinical elective in Malawi, Africa, for Medicine and Medicine/Pediatrics residents. We sought to determine whether the elective resulted in improved medical knowledge, alterations in career trajectory, and whether the opportunity for the elective influenced selection of UCLA for residency. A 29-question survey was distributed to all graduates of the elective from 2009-2013. Surveys were distributed to 40 individuals, with 33 responses (82.5%). Thirty-one participants (93.9%) reported increased medical knowledge and 24 participants (72.7%) reported the rotation altered their career trajectory. Among the 23 residents who came to UCLA after the elective was established, 13 (56.5%) stated it had an influential role in their selection of UCLA for residency. The Malawi elective resulted in self-reported increases in medical knowledge, alterations in career trajectory, and has played an important role in attracting individuals to UCLA for residency.

Addressing delays in medication administration for patients transferred from the hospital to the nursing home: a pilot quality improvement project.

BACKGROUND: Patients being transferred to a nursing home (NH) after an acute hospitalization are subject to adverse effects, including medication errors, related to poor coordination of care across settings. OBJECTIVE: The goal of this study was to develop, implement, and evaluate the impact of a pilot intervention to improve patient safety by reducing delays in administration and omission of medications among patients discharged from the hospital to the NH. METHODS: An expedited discharge protocol was developed in collaboration with hospital physician residents, hospital discharge planners, and NH staff (administrators, directors of nursing services, and licensed nurses). The intervention included education of the involved health care professionals and implementation of the expedited protocol to ensure that medication orders were transmitted to the NH-contracted pharmacy before patients' arrival at the NH. The intervention protocol was compared with a standard discharge protocol among patients aged > or =65 years being discharged from 2 university-affiliated hospitals to a single proprietary NH. The primary outcomes were the time between arrival at the NH and administration of first dose of an ordered medication; the number of omitted medications; the proportion of patients experiencing medication omissions; and the proportion of patients with omitted medications that had a low, medium, and high potential for negative consequences. RESULTS: The study involved 10 patients discharged from each of the 2 hospitals and transferred to the NH. Although several components of the intervention were successfully implemented, none of the medication orders were transmitted to the NH-ccontracted pharmacy before patients' arrival at the NH. All 17 patients with medications ordered to be administered in the evening had > or =1 dose of a medication omitted after their arrival at the NH. The mean (SD) delay from arrival at the NH to administration of the first dose of an ordered medication was 12.55 (7.45) hours. The mean number of doses of different medications omitted per patient was 3.4 (2.60). Sixty-seven doses of medications were omitted; 53 of these omissions involved only 1 dose of a medication. Thirty-three percent of omitted doses involved medications with the highest potential for resulting in a negative consequence. CONCLUSIONS: The intervention to improve patient safety by reducing medication delays for patients making the transition from the hospital to the NH was not successfully implemented, as medication orders were not transmitted to the NH-contracted pharmacies before patients' arrival at the NH. All patients making the transition from hospital to NH experienced a >12-hour delay in medication administration, and the mean number of missed doses of medications was >3. There is a need for further exploration of the reasons for and possible solutions to delays in medication administration during the transition to the NH, as well as of the impact of such delays on patient outcomes, including adverse drug events, emergency department visits, and rehospitalizations.