Language Matters: Is There Gender Bias in Internal Medicine Grand Rounds Introductions?

PURPOSE:  We performed an exploratory evaluation of gender-specific differences in speakers and their introductions at internal medicine grand rounds. METHOD:  Internal medicine grand rounds video archives from three sites between December 2013 and September 2020 were manually transcribed and analyzed using natural language processing techniques. Differences in word usage by gender were compared. RESULTS:  Four hundred and sixty-two grand rounds held at three institutions were examined. There were 167 (34.6%) speakers who were women and 316 (65.4%) who were men. The proportion of women speakers was significantly lower than that of women in the internal medicine workforce (34.6% vs. 39.2%, p = 0.04). Among 191 external speakers, only 57 (29.8%) were women. The use of professional titles was equivalent between genders. Despite equal mention of specific achievements in both male and female speaker introductions, there was a trend toward casting female speakers as being less established. CONCLUSION:  There is a need to adopt processes that will decrease inequities in the representation of women in grand rounds and in their introductions.

Identifying and Measuring Administrative Harms Experienced by Hospitalists and Administrative Leaders.

Importance: Administrative harm (AH), defined as the adverse consequences of administrative decisions within health care that impact work structure, processes, and programs, is pervasive in medicine, yet poorly understood and described. Objective: To explore common AHs experienced by hospitalist clinicians and administrative leaders, understand the challenges that exist in identifying and measuring AH, and identify potential approaches to mitigate AH. Design, Setting, and Participants: A qualitative study using a mixed-methods approach with a 12-question survey and semistructured virtual focus groups was held on June 13 and August 11, 2023. Rapid qualitative methods including templated summaries and matrix analysis were applied. The participants included 2 consortiums comprising hospitalist clinicians, researchers, administrative leaders, and members of a patient and family advisory council. Main Outcomes and Measures: Quantitative data from the survey on specific aspects of experiences related to AH were collected. Focus groups were conducted using a semistructured focus group guide. Themes and subthemes were identified. Results: Forty-one individuals from 32 different organizations participated in the focus groups, with 32 participants (78%) responding to a brief survey. Survey participants included physicians (91%), administrative professionals (6%), an advanced practice clinician (3%), and those in leadership roles (44%), with participants able to select more than one role. Only 6% of participants were familiar with the term administrative harm to a great extent, 100% felt that collaboration between administrators and clinicians is crucial for reducing AH, and 81% had personally participated in a decision that led to AH to some degree. Three main themes were identified: (1) AH is pervasive and comes from all levels of leadership, and the phenomenon was felt to be widespread and arose from multiple sources within health care systems; (2) organizations lack mechanisms for identification, measurement, and feedback, and these challenges stem from a lack of psychological safety, workplace cultures, and ambiguity in who owns a decision; and (3) organizational pressures were recognized as contributors to AHs. Many ideas were proposed as solutions. Conclusions and Relevance: The findings of this study suggest that AH is widespread with wide-reaching impact, yet organizations do not have mechanisms to identify or address it.

Attention Among Health Care Professionals : A Scoping Review.

BACKGROUND: The concept of attention can provide insight into the needs of clinicians and how health systems design can impact patient care quality and medical errors. PURPOSE: To conduct a scoping review to 1) identify and characterize literature relevant to clinician attention; 2) compile metrics used to measure attention; and 3) create a framework of key concepts. DATA SOURCES: Cumulated Index to Nursing and Allied Health Literature (CINAHL), Medline (PubMed), and Embase (Ovid) from 2001 to 26 February 2024. STUDY SELECTION: English-language studies addressing health care worker attention in patient care. At least dual review and data abstraction. DATA EXTRACTION: Article information, health care professional studied, practice environment, study design and intent, factor type related to attention, and metrics of attention used. DATA SYNTHESIS: Of 6448 screened articles, 585 met inclusion criteria. Most studies were descriptive (n = 469) versus investigational (n = 116). More studies focused on barriers to attention (n = 387; 342 descriptive and 45 investigational) versus facilitators to improving attention (n = 198; 112 descriptive and 86 investigational). We developed a framework, grouping studies into 6 categories: 1) definitions of attention, 2) the clinical environment and its effect on attention, 3) personal factors affecting attention, 4) relationships between interventions or factors that affect attention and patient outcomes, 5) the effect of clinical alarms and alarm fatigue on attention, and 6) health information technology's effect on attention. Eighty-two metrics were used to measure attention. LIMITATIONS: Does not synthesize answers to specific questions. Quality of studies was not assessed. CONCLUSION: This overview may be a resource for researchers, quality improvement experts, and health system leaders to improve clinical environments. Future systematic reviews may synthesize evidence on metrics to measure attention and on the effectiveness of barriers or facilitators related to attention. PRIMARY FUNDING SOURCE: None.

Virtual hospital care development and deployment: A rapid qualitative study of frontline clinicians and leaders.

BACKGROUND: Virtual hospitalist programs are rapidly growing in popularity due to worsening clinician shortages and increased pressure for flexible work options. These programs also have the potential to establish sustainable staffing models across multiple hospitals optimizing cost. We aimed to explore the current state of virtual hospitalist services at various health systems, challenges and opportunities that exist in providing virtual care, and future opportunities for these types of services. OBJECTIVES: To identify perspectives on design and implementation of virtual hospitalist programs from academic hospitalist leaders. METHODS: We conducted focus groups with United States academic hospitalist leaders. Semistructured interviews explored experiences with virtual hospitalist programs. Using rapid qualitative methods including templated summaries and matrix analysis, focus group recordings were analyzed to identify key themes. RESULTS: We conducted four focus groups with 13 participants representing nine hospital systems across six geographic regions and range of experience with virtual hospital medicine care. Thematic analysis identified three themes: (1) a broad spectrum of virtual care delivery; (2) adoption and acceptance of virtual care models followed the stages of diffusion of innovation; and (3) sustainability and scalability of programs were affected by unclear finances. CONCLUSIONS: Hospitalist leader perspectives revealed complex factors influencing virtual care adoption and implementation. Addressing concerns about care quality, financing, and training may accelerate adoption. Further research should clarify the best practices for sustainable models optimized for access, hospitalist experience, patient safety, and financial viability.

Impact of billing reforms on academic hospitalist physician and advanced practice provider collaboration: A qualitative study.

BACKGROUND: Medicare previously announced plans for new billing reforms for inpatient visits that are shared by physicians and advanced practice providers (APPs) whereby the clinician spending the most time on the patient visit would bill for the visit. OBJECTIVE: To understand how inpatient hospital medicine teams utilize APPs in patient care and how the proposed billing policies might impact future APP utilization. DESIGN, SETTING AND PARTICIPANTS: We conducted focus groups with hospitalist physicians, APPs, and other leaders from 21 academic hospitals across the United States. Utilizing rapid qualitative methods, focus groups were analyzed using a mixed inductive and deductive method at the semantic level with templated summaries and matrix analysis. Thirty-three individuals (physicians [n = 21], APPs [n = 10], practice manager [n = 1], and patient representative [n = 1]) participated in six focus groups. RESULTS: Four themes emerged from the analysis of the focus groups, including: (1) staffing models with APPs are rapidly evolving, (2) these changes were felt to be driven by staffing shortages, financial models, and governance with minimal consideration to teamwork and relationships, (3) time-based billing was perceived to value tasks over cognitive workload, and (4) that the proposed billing changes may create unintended consequences impacting collaboration and professional satisfaction. CONCLUSIONS: Physician and APP collaborative care models are increasingly evolving to independent visits often driven by workloads, financial drivers, and local regulations such as medical staff rules and hospital bylaws. Understanding which staffing models produce optimal patient, clinician, and organizational outcomes should inform billing policies rather than the reverse.

The development and pilot of a novel mobile application to assess clinician perception of workload and work environment.

BACKGROUND: Traditional measures of workload such as wRVUs may not be adequate to understand the impact of workload on key outcomes. OBJECTIVE: The objective of this study was to develop a mobile application to assess, in near real time, clinicians' perception of workload and work environment. DESIGNS, SETTINGS AND PARTICIPANTS: We developed the GrittyWork™ application (GW App) using the Chokshi and Mann process model for user-centered digital development. Study occured at a single academic medical center with hospitalist clinicians. MAIN OUTCOME MEASURES AND MEASURES: Measures included the System Usability Scale (SUS), use measures from GW App, electronic health record (EHR) event log data and note counts, and qualitative interviews. RESULTS: From October 28, 2022 to November 3, 2022, six hospitalist clinicians provided feedback on the early prototype of the GW App, and from February 28, 2023 to June 8, 2023, 30 hospitalist clinicians participated in the pilot while on clinical service. All 30 clinicians (100%) participated in the pilot submitting data for a total of 122 shifts. Participants reported working 10 ± 1 h per day (mean ± SD) and were responsible for an average of 11 ± 3 patients per day. The postpilot evaluation of the GW App showed a SUS score of 86 ± 11 and a participant preference toward mobile application-based surveys (73% of participants). Regarding workload measures, EHR event log data and notes data correlated with physician-reported workloads. Applying user-centered design techniques, we successfully developed a mobile application with high usability. These data can be paired with EHR event log data and outcomes to provide insights into the impact of workloads and work environments on outcomes.

A patient follow-up intervention to improve medical decision making at an internal medicine residency program.

OBJECTIVES: Practice-based learning and improvement (PBLI) is an ACGME (Accreditation Council for Graduate Medical Education) core competency. Learning and reflecting on patients through follow-up is one method to help achieve this competency. We therefore designed a study evaluating a structured patient follow-up intervention for senior internal medicine (IM) residents at the University of Colorado Hospital (UCH). METHODS: Trainees completed structured reflections after performing chart review of prior patients during protected educational time. Two-month follow-up surveys evaluated the exercise's potential influence on clinical and reflective practices. RESULTS: Forty out of 108 (37 %) eligible residents participated in the exercise. Despite 62.5 % of participants lacking specific questions about patient outcomes before chart review, 81.2 % found the exercise at least moderately helpful. 48.4 % of participants believed that the review would change their practice, and 60.9 % felt it reinforced their existing clinical practices. In our qualitative data, residents learned lessons related to challenging clinical decisions, improving transitions of care, the significance of early goals of care conversations, and diagnostic errors/strategies. CONCLUSIONS: Our results indicate that IM residents found a structured patient follow-up intervention educational, even when they lacked specific patient outcomes questions. Our results underscore the importance of structured self-reflection in the continuous learning process of trainees and suggest the benefit of dedicated educational time for this process.

Hospitalist Shared Leadership for Safety, Health, and Well-Being at Work: United States, 2022‒2023.

We assessed how hospitalists frame workplace safety, health, and well-being (SHW); their perception of hospital supports for SHW; and whether and how they are sharing leadership responsibility for each other's SHW. Our findings highlight the important role of local support for hospitalist SHW and reveal the systemic, hospital-wide problems that may impede their SHW. We believe that positioning hospitalists as leaders for SHW will result in systems-wide changes in practices to support the SHW of all care team members. (Am J Public Health. 2024;114(S2):S162-S166. https://doi.org/10.2105/AJPH.2024.307573).

The Impact of Completing X-Waiver Training and Clinical Addiction Exposure on Internal Medicine Residents Treating Patients With Opioid Use Disorder.

BACKGROUND: Treating opioid use disorder (OUD) with buprenorphine or methadone significantly reduces overdose and all-cause mortality. Prior studies demonstrate that clinicians and residents reported a lack of preparedness to diagnose or treat OUD. Little is known about how clinical exposure or buprenorphine X-waiver training impacts OUD care delivery by resident physicians. OBJECTIVE: Distinguish the effects of X-waiver training and clinical exposure with OUD on resident's knowledge, attitudes, feelings of preparedness, and practices related to OUD treatment provision. METHODS: From August 2021 to April 2022, we distributed a cross-sectional survey to internal medicine residents at a large academic training program. We analyzed associations between self-reported clinical exposure and X-waiver training across 4 domains: knowledge about best practices for OUD treatment, attitudes about patients with OUD, preparedness to treat OUD, and clinical experience with OUD. RESULTS: Of the 188 residents surveyed, 91 responded (48%). A majority of respondents had not completed X-waiver training (60%, n = 55) while many had provided clinical care to patients with OUD (65%, n = 59). Most residents had favorable attitudes about OUD treatment (97%). Both residents with clinical exposure to treating OUD and X-waiver training, and residents with clinical exposure without X-waiver training, felt more prepared to treat OUD (P < .0008) compared to residents with neither clinical exposure or X-waiver training or only X-waiver training. CONCLUSIONS: Residents with clinical exposure to treating OUD are more prepared to treat patients with OUD than those without clinical exposure. Greater efforts to incorporate clinical exposure to the treatment of OUD and education in internal medicine residency programs is imperative to address the opioid epidemic.

Evaluation of a Guided Nature and Forest Therapy Walk for Internal Medical Residents - A Brief Report.

Background: Medical residents commonly face compassion fatigue, burnout, anxiety, and depression. Studies of nature-based interventions show improved mental and physical health; few focus on healthcare providers. Objective: To explore potential benefits of forest bathing for medical residents' wellbeing. Methods: Using the Association of Nature and Forest Therapy's framework, we piloted a forest bathing intervention among medical residents with pre/post-participation surveys assessing perceptions of mindfulness and psychological wellbeing. Responses were analyzed using a Fisher's exact test and Student's t-test for independent samples. Results: Fourteen of fifteen participants completed both surveys. We observed significantly improved mindfulness scores and expressions of feeling calm, vital, or creative, as well as a decreased sense of anxiety and depression. Nonsignificant trends towards decreased burnout and irritability were seen. Conclusion: This quality improvement pilot demonstrates trends that forest bathing can improve medical residents' psychological wellbeing and mindfulness. Further exploration of this intervention for healthcare providers is warranted.

In-Hospital Methadone Enrollment: a Novel Program to Facilitate Linkage from the Hospital to the Opioid Treatment Program for Vulnerable Patients with Opioid Use Disorder.

INTRODUCTION: Methadone ameliorates opioid withdrawal among hospitalized patients with opioid use disorder (OUD). To continue methadone after hospital discharge, patients must enroll in an opioid treatment program (OTP) per federal regulations. Uncontrolled opioid withdrawal is a barrier to linkage from hospital to OTP. AIM: Describe a federally compliant In-Hospital Methadone Enrollment Team (IN-MEET) that enrolls hospitalized patients with OUD into an OTP with facilitated hospital to OTP linkage. SETTING: Seven hundred-bed university hospital in Aurora, CO. PROGRAM DESCRIPTION: A physician dually affiliated with a hospital's addiction consultation service and a community OTP completes an in-hospital, face-to-face medical assessment required by federal law and titrates methadone to comfort. An OTP-affiliated nurse with hospital privileges completes a psychosocial evaluation and provides case management by arranging transportation and providing weekly telephone check-ins. PROGRAM EVALUATION METRICS: IN-MEET enrollments completed, hospital to OTP linkage, and descriptive characteristics of patients who completed IN-MEET enrollments compared to patients who completed community OTP enrollments. RESULTS: Between April 2019 and April 2023, our team completed 165 IN-MEET enrollments. Among a subset of 73 IN-MEET patients, 56 (76.7%) presented to the OTP following hospital discharge. Compared to community OTP enrolled patients (n = 1687), a higher percentage of IN-MEET patients were older (39.7 years, standard deviation [SD] 11.2 years vs. 36.1 years, SD 10.6 years) and were unhoused (n = 43, 58.9% vs. n = 199, 11.8%). Compared to community OTP enrolled patients, a higher percentage of IN-MEET patients reported heroin or fentanyl as their primary substance (n = 53, 72.6% vs. n = 677, 40.1%), reported methamphetamine as their secondary substance (n = 27, 37.0% vs. n = 380, 22.5%), and reported they injected their primary substance (n = 46, 63.0% vs. n = 478, 28.3%). CONCLUSION: IN-MEET facilitates hospital to OTP linkage among a vulnerable population. This model has the potential to improve methadone access for hospitalized patients who may not otherwise seek out treatment.

Communicating Patient Discharge Readiness: An Implementation Evaluation in an Inpatient Hospital Medicine Setting.

BACKGROUND: The progression of patients through a hospital from admission to discharge can be slowed by delays in patient discharge, increasing pressure on health care staff. We designed and piloted the Discharge Today tool, with the goal of improving the efficiency of patient discharge; however, adoption remained low. PURPOSE: To close this implementation gap, we deployed and evaluated a 4-part implementation strategy bundle. METHODS: We measured the success of implementation by evaluating validated implementation outcomes using both quantitative and qualitative methods, grounded in Normalization Process Theory. RESULTS: The implementation strategies used were effective for increasing use of the Discharge Today tool by hospital medicine physicians and advanced practice providers during both the active and passive implementation periods. CONCLUSIONS: While the implementation strategies used were effective, qualitative findings indicate that limitations in the functionality of the tool, alongside inconsistent use of the tool across clinical staff, continued to inhibit adoption.

Impact of Clinical Demands on the Educational Mission in Hospital Medicine at 17 Academic Medical Centers : A Qualitative Analysis.

BACKGROUND: Clinical growth is outpacing the growth of traditional educational opportunities at academic medical centers (AMCs). OBJECTIVE: To understand the impact of clinical growth on the educational mission for academic hospitalists. DESIGN: Qualitative study using semistructured interviews that were analyzed using a mixed inductive and deductive method at the semantic level. SETTING: Large AMCs across the United States that experienced clinical growth in the past 5 years. PARTICIPANTS: Division heads, section heads, and other hospital medicine (HM) leaders who oversaw and guided academic and clinical efforts of HM programs. MEASUREMENTS: Themes and subthemes. RESULTS: From September 2021 to January 2022, HM leaders from 17 AMCs participated in the interviews, and 3 key themes emerged. First, AMCs' disproportionate clinical growth highlighted the tension between clinical and educational missions. This included a mismatch in supply and demand for traditional teaching time, competing priorities, and clinical growth being seen as both an opportunity and a threat. Second, amid the shifting landscape of high clinical demands and evolving educational opportunities, hospitalists still strongly prefer traditional teaching. To address this mismatch, HM groups have had to alter recruitment strategies and create innovative solutions to help build academic careers. Third, participants noted a need to reimagine the role and identity of an academic hospitalist, emphasizing tailored career pathways and educational roles spanning well beyond traditional house staff teaching teams. LIMITATION: The study focused on large AMCs. CONCLUSION: Although HM groups have implemented many creative strategies to address clinical growth and keep education front and center, challenges remain, particularly heavy clinical workloads and a continued dilution of traditional teaching opportunities. PRIMARY FUNDING SOURCE: Society of Hospital Medicine Student Scholar Grant.

Interventions to Reduce Inappropriate Physical Therapy Consultation in the Inpatient Setting: A Quality Improvement Initiative.

ABSTRACT: Physical therapy (PT) in inpatient settings is a limited and valuable resource. Inappropriate PT consultation is costly and can lead to delays in care and discharge planning. Baseline data at an academic hospital revealed that approximately one in four PT consults were inappropriate (n = 29,230) across all services, as defined by an activity measure post-acute care "6-Clicks" basic mobility score of >22. Our interdisciplinary quality improvement team used the Six Sigma methodology to address this problem. We performed a root-cause analysis that identified high-impact root causes and implemented two targeted interventions: (1) A modified electronic health record PT order with clinical-decision support, and (2) nursing role change to assume PT-ordering responsibility. The rate of inappropriate PT consults decreased from 23.9% to <10% postintervention across all inpatient units, with the nursing role change reaching statistical significance (p < .0019). Our multifaceted intervention contributed to a significant reduction in unnecessary PT consults, expediting evaluation of patients qualifying for skilled inpatient therapy.

Achieving diagnostic excellence through prevention and teamwork (ADEPT) study protocol: A multicenter, prospective quality and safety program to improve diagnostic processes in medical inpatients.

BACKGROUND: Few hospitals have built surveillance for diagnostic errors into usual care or used comparative quantitative and qualitative data to understand their diagnostic processes and implement interventions designed to reduce these errors. OBJECTIVES: To build surveillance for diagnostic errors into usual care, benchmark diagnostic performance across sites, pilot test interventions, and evaluate the program's impact on diagnostic error rates. METHODS AND ANALYSIS: Achieving diagnostic excellence through prevention and teamwork (ADEPT) is a multicenter, real-world quality and safety program utilizing interrupted time-series techniques to evaluate outcomes. Study subjects will be a randomly sampled population of medical patients hospitalized at 16 US hospitals who died, were transferred to intensive care, or had a rapid response during the hospitalization. Surveillance for diagnostic errors will occur on 10 events per month per site using a previously established two-person adjudication process. Concurrent reviews of patients who had a qualifying event in the previous week will allow for surveys of clinicians to better understand contributors to diagnostic error, or conversely, examples of diagnostic excellence, which cannot be gleaned from medical record review alone. With guidance from national experts in quality and safety, sites will report and benchmark diagnostic error rates, share lessons regarding underlying causes, and design, implement, and pilot test interventions using both Safety I and Safety II approaches aimed at patients, providers, and health systems. Safety II approaches will focus on cases where diagnostic error did not occur, applying theories of how people and systems are able to succeed under varying conditions. The primary outcome will be the number of diagnostic errors per patient, using segmented multivariable regression to evaluate change in y-intercept and change in slope after initiation of the program. ETHICS AND DISSEMINATION: The study has been approved by the University of California, San Francisco Institutional Review Board (IRB), which is serving as the single IRB. Intervention toolkits and study findings will be disseminated through partners including Vizient, The Joint Commission, and Press-Ganey, and through national meetings, scientific journals, and publications aimed at the general public.

Sigh Ventilation in Patients With Trauma: The SiVent Randomized Clinical Trial.

Importance: Among patients receiving mechanical ventilation, tidal volumes with each breath are often constant or similar. This may lead to ventilator-induced lung injury by altering or depleting surfactant. The role of sigh breaths in reducing ventilator-induced lung injury among trauma patients at risk of poor outcomes is unknown. Objective: To determine whether adding sigh breaths improves clinical outcomes. Design, Setting, and Participants: A pragmatic, randomized trial of sigh breaths plus usual care conducted from 2016 to 2022 with 28-day follow-up in 15 academic trauma centers in the US. Inclusion criteria were age older than 18 years, mechanical ventilation because of trauma for less than 24 hours, 1 or more of 5 risk factors for developing acute respiratory distress syndrome, expected duration of ventilation longer than 24 hours, and predicted survival longer than 48 hours. Interventions: Sigh volumes producing plateau pressures of 35 cm H2O (or 40 cm H2O for inpatients with body mass indexes >35) delivered once every 6 minutes. Usual care was defined as the patient's physician(s) treating the patient as they wished. Main Outcomes and Measures: The primary outcome was ventilator-free days. Prespecified secondary outcomes included all-cause 28-day mortality. Results: Of 5753 patients screened, 524 were enrolled (mean [SD] age, 43.9 [19.2] years; 394 [75.2%] were male). The median ventilator-free days was 18.4 (IQR, 7.0-25.2) in patients randomized to sighs and 16.1 (IQR, 1.1-24.4) in those receiving usual care alone (P = .08). The unadjusted mean difference in ventilator-free days between groups was 1.9 days (95% CI, 0.1 to 3.6) and the prespecified adjusted mean difference was 1.4 days (95% CI, -0.2 to 3.0). For the prespecified secondary outcome, patients randomized to sighs had 28-day mortality of 11.6% (30/259) vs 17.6% (46/261) in those receiving usual care (P = .05). No differences were observed in nonfatal adverse events comparing patients with sighs (80/259 [30.9%]) vs those without (80/261 [30.7%]). Conclusions and Relevance: In a pragmatic, randomized trial among trauma patients receiving mechanical ventilation with risk factors for developing acute respiratory distress syndrome, the addition of sigh breaths did not significantly increase ventilator-free days. Prespecified secondary outcome data suggest that sighs are well-tolerated and may improve clinical outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT02582957.