Do Decision Support Tools Decrease the Prevalence of Hospital-Acquired Venous Thromboembolisms When Compared to Clinical Judgement? A Single-Center Pre-Post Study.

Introduction: Hospital-acquired venous thromboembolisms (HA-VTEs) carry a significant health burden on patients and a financial burden on hospitals due to reimbursement penalties. VTE prophylaxis at our institute was performed through utilizing an order set based on healthcare professionals' perceived level of risk. However, the use of standardized risk assessment models is recommended by multiple professional societies. Furthermore, integrating decision support tools (DST) based on the standardized risk assessment models has been shown to increase the administration of appropriate deep vein thrombosis (DVT) prophylaxis. Nonetheless, such scoring systems are not inherently flawless and their integration into EMR as a mandatory step can come at the risk of healthcare professional fatigue and burnout. We conducted a study to evaluate the incidence of HA-VTE and length of stay pre- and post implementation of a DST. Methods: We conducted a retrospective, pre-post-implementation observational study at a tertiary medical center after implementing a mandatory DST. The DST used Padua scores for medical patients and Caprini scores for surgical patients. Patients were identified through ICD-10 codes and outcomes were collected from electronic charts. Healthcare professionals were surveyed through an anonymous survey and stored securely. Statistical analysis was conducted by using R (version 3.4.3). Results: A total of 343 patients developed HA-VTE during the study period. Of these, 170 patients developed HA-VTE in the 9 months following the implementation of the DST, while 173 patients were identified in the 9 months preceding the implementation. There was no statistically significant difference in mean HA-VTE/1000 discharge/month pre- and post implementation (4.4 (SD 1.6) compared to 4.6 (SD 1.2), confidence interval [CI] -1.6 to 1.2, p = 0.8). The DST was used in 73% of all HA-VTE cases over the first 6 months of implementation. The hospital length of stay (LOS) was 14.2 (SD 1.9) days prior to implementation and 14.1 (SD 1.6) days afterwards. No statistically significant change in readmission rates was noted (8.8% (SD 2.6) prior to implementation and 15.53% (SD 9.6) afterwards, CI -14.27 to 0.74, p = 0.07). Of the 56 healthcare professionals who answered the survey, 84% (n = 47) reported to be dissatisfied or extremely dissatisfied with the DST, while 91% (n = 51) reported that it slowed them down. Conclusions: There were no apparent changes in the prevalence of HA-VTE, length of stay, or readmission rates when VTE prophylaxis was mandated through DST compared to a prior model which used order sets based on perceived risk. Further studies are needed to further evaluate the current risk assessment models and improve healthcare professionals' satisfaction with DST.

Getting to know you: implementing an interprofessional education program for medical and respiratory therapy students in mechanical ventilation - challenges and lessons learned.

The physician and respiratory therapist function as an interprofessional team caring for patients on mechanical ventilation. There is a paucity of research devoted to interprofessional education (IPE) of students from different professions in mechanical ventilation during clinical rotations in the medical intensive care unit (MICU). Student interprofessional education could develop team communication and shared decision-making skills early in training. The uniqueness of this introductory IPE programme is that it occurs during a clinical rotation in a real MICU, as opposed to a pre-clinical simulated campus setting, and it blends students from various educational backgrounds. Medical students and respiratory therapy students from different academic institutions participated in traditional lectures, small interprofessional group case-based problem-solving sessions, MICU bedside teaching sessions, written assessments, and focus groups. Quantitative responses were analyzed using descriptive statistics. Qualitative responses were categorised using the core competencies for Interprofessional Collaborative Practice. The purpose of this introductory IPE programme was to foster opportunities for interprofessional interaction during the student clinical experience while improving knowledge about mechanical ventilation. Qualitative expectations and feedback were predominantly positive. Quantitative responses suggest that students from both disciplines gained knowledge about mechanical ventilation in an IPE setting.

Community Perspectives on the Creation of a Hospital-Based Doula Program.

Objective: Racial and ethnic inequities in perinatal health outcomes are pervasive. Doula support is an evidence-based practice for improving maternal outcomes. However, women in lower-income populations often do not have access to doulas. This study explored community perspectives on doula care to inform the development of a hospital-based doula program to serve primarily low-income women of color. Methods: Four focus groups and four individual interviews were conducted with: (1) women who were pregnant or parenting a child under age 2 (n=20); (2) people who had provided support during a birth in the previous 2 years (n=5); and (3) women who had received doula training (n=4). Results: Participants had generally positive perceptions of doula services. Many aspects of doula support desired by participants are core to birth doula services. Participants identified ways that doulas could potentially address critical gaps in health care services known to impact outcomes (e.g., continuity of care and advocacy), and provide much-needed support in the postpartum period. Responses also suggested that doula training and hospital-based doula programs may need to be adapted to address population-specific needs (e.g., women with substance use disorder and younger mothers). Novel program suggestions included "on call" informational doulas. Conclusions: Findings suggested that women in racial/ethnic minority and lower income groups may be likely to utilize a hospital-based doula program and identified adaptations to traditional doula care that may be required to best meet the needs of women in groups with higher risk of poor maternal health and birth outcomes.

The Impact of an Institutional Grant Program on the Economic, Social, and Cultural Capital of Women Researchers.

Introduction: Early funding can have significant impact on a researcher's career. However, funding is not equal for men and women. Not only do female researchers apply for fewer grants than men, but they also experience a lower success rate when they do. The Zucker Grant Program (ZGP) was established in 2000 to promote the early success of women researchers. The purpose of this evaluation is to support other institutions hoping to grow the research careers of women scientists. Methods: This program evaluation reviewed the first 16 years of the program's history. Our mixed-methods, outcomes-based evaluation had four phases: (I) interviews with key stakeholders, (II) development and distribution of a survey to ZGP recipients, (III) focus groups and interviews with ZGP recipients, (IV) document analysis from the ZGP Center and the Tufts University School of Medicine (TUSM) Development Office. This article reports on the qualitative data collection and analysis. Results: Between 2000 and 2016, US$377,050 was awarded for 142 recipients. Qualitative data revealed how grant funding was critical to support pilot data in awardees' research to inform extramural grant applications. However, the program evaluation also identified effects on awardees' confidence as researchers and connection to a community. Conclusion: Outcomes are interpreted through the framework of Bourdieu's three forms of capital, including economic, social, and cultural capital. Viewed through this framework, they provide a critical infrastructure to the development and success of early career female investigators. This work offers other institutions a framework to consider when establishing intramural funding and support programs for their early career investigators.

Characteristics of Successful Internal Medicine Resident Research Projects: Predictors of Journal Publication Versus Abstract Presentation.

PURPOSE: To identify the characteristics of successful research projects at an internal medicine residency program with an established research curriculum. METHOD: The authors collected data about all research projects initiated by or involving medicine residents from 2006 to 2013 at Baystate Medical Center, using departmental files and institutional review board applications. Resident and mentor characteristics were determined using personnel files and Medline searches. Using multivariable models, the authors identified predictors of successful completion of projects using adjusted prevalence ratios (PRs). The primary outcome was manuscript publication, and secondary outcome was publication or regional/national presentation. Finally, residents were surveyed to identify barriers and/or factors contributing to project completion. RESULTS: Ninety-four research projects were identified: 52 (55.3%) projects achieved the primary outcome and 72 (76.5%) met the secondary outcome, with overlap between categories. Most study designs were cross-sectional (41; 43.6%) or retrospective cohort (30; 31.9%). After adjustment, utilization of the epidemiology/biostatistical core (PR = 2.09; 95% CI: 1.36, 3.21), established publication record of resident (PR = 1.54; 95% CI: 1.14, 2.07), and resident with U.S. medical education (PR = 1.39; 95% CI: 1.02, 1.90) were associated with successful project completion. Mentor publication record (PR = 3.13) did not retain significance because of small sample size. Most respondents (65%) cited "lack of time" as a major project barrier. CONCLUSIONS: Programs seeking to increase resident publications should consider an institutional epidemiology/biostatistical core, made available to all residency research projects, and residents should choose experienced mentors with a track record of publications.

'No Pink Ribbons': How Women's Lived Experiences With Breast Atypia Inform Decisions Involving Risk-Reducing Medications.

PURPOSE: Atypical hyperplasia (AH) is associated with a nearly 4-fold elevation of lifetime risk for breast cancer, and lobular carcinoma in situ (LCIS) is associated with a 7- to 8-fold risk. Women with AH/LCIS make numerous decisions in the course of treatment, including whether to take a risk-reducing medication, an option relatively few women pursue. We explored women's decision-making processes through patient narratives in an effort to inform decision supports for AH/LCIS. METHODS: We conducted in-depth interviews with 20 English-speaking women with AH/LCIS and no subsequent diagnosis of invasive breast cancer who had enrolled in the Rays of Hope Center for Breast Cancer Research patient registry between April 5, 2012, and March 31, 2016. Interviews were audiotaped, professionally transcribed, and qualitatively analyzed using thematic qualitative content analysis. RESULTS: We identified three major narrative themes: 1) experiences with medical care; 2) decision-making; and 3) making sense of AH/LCIS. Each major theme had several subthemes, many of which map onto existing decisional theories and heuristics. Subthemes included the impact of life context on diagnosis meaning, emotional responses, changes in self-concept and body image, and understanding of the risk-benefit of risk-reducing medications. CONCLUSIONS: This narrative analysis offers important insights into how lived experience may influence decision-making for women with AH/LCIS. Decision supports that focus not only on analytic decisional processes, but also patients' subjectivities and decisional heuristics, could prove useful for women and their health care providers.

Geographical assignment of hospitalists in an urban teaching hospital: feasibility and impact on efficiency and provider satisfaction.

OBJECTIVE: To evaluate whether implementation of a geographic model of assigning hospitalists is feasible and sustainable in a large hospitalist program and assess its impact on provider satisfaction, perceived efficiency and patient outcomes. METHODS: Pre (3 months) - post (12 months) intervention study conducted from June 2014 through September 2015 at a tertiary care medical center with a large hospitalist program caring for patients scattered in 4 buildings and 16 floors. Hospitalists were assigned to a particular nursing unit (geographic assignment) with a goal of having over 80% of their assigned patients located on their assigned unit. Satisfaction and perceived efficiency were assessed through a survey administered before and after the intervention. RESULTS: Geographic assignment percentage increased from an average of 60% in the pre-intervention period to 93% post-intervention. The number of hospitalists covering a 32 bed unit decreased from 8-10 pre to 2-3 post-intervention. A majority of physicians (87%) thought that geography had a positive impact on the overall quality of care. Respondents reported that they felt that geography increased time spent with patient/caregivers to discuss plan of care (p < 0.001); improved communication with nurses (p = 0.0009); and increased sense of teamwork with nurses/case managers (p < 0.001). Mean length of stay (4.54 vs 4.62 days), 30-day readmission rates (16.0% vs 16.6%) and patient satisfaction (79.9 vs 77.3) did not change significantly between the pre- and post-implementation period. The discharge before noon rate improved slightly (47.5% - 54.1%). CONCLUSIONS: Implementation of a unit-based model in a large hospitalist program is feasible and sustainable with appropriate planning and support. The geographical model of care increased provider satisfaction and perceived efficiency; it also facilitated the implementation of other key interventions such as interdisciplinary rounds.

Ambulatory Morning Report: A Case-Based Method of Teaching EBM Through Experiential Learning.

OBJECTIVES: Evidence-based medicine (EBM) skills are important to daily practice, but residents generally feel unskilled incorporating EBM into practice. The Kolb experiential learning theory, as applied to curricular planning, offers a unique methodology to help learners build an EBM skill set based on clinical experiences. We sought to blend the learner-centered, case-based merits of the morning report with an experientially based EBM curriculum. We describe and evaluate a patient-centered ambulatory morning report combining the User's Guides to the Medical Literature approach to EBM and experiential learning theory in the internal medicine department at Baystate Medical Center. METHODS: The Kolb experiential learning theory postulates that experience transforms knowledge; within that premise we designed a curriculum to build EBM skills incorporating residents' patient encounters. By developing structured clinical questions based on recent clinical problems, residents activate prior knowledge. Residents acquire new knowledge through selection and evaluation of an article that addresses the structured clinical questions. Residents then apply and use new knowledge in future patient encounters. RESULTS: To assess the curriculum, we designed an 18-question EBM test, which addressed applied knowledge and EBM skills based on the User's Guides approach. Of the 66 residents who could participate in the curriculum, 61 (92%) completed the test. There was a modest improvement in EBM knowledge, primarily during the first year of training. CONCLUSIONS: Our experiential curriculum teaches EBM skills essential to clinical practice. The curriculum differs from traditional EBM curricula in that ours blends experiential learning with an EBM skill set; learners use new knowledge in real time.

Healthcare Providers' Knowledge of Diets and Dietary Advice.

OBJECTIVES: Little is known about healthcare providers' knowledge of dietary evidence or about what dietary advice providers offer to patients. The objective of our study was to determine which diets providers recommended to patients and providers' beliefs about the evidence behind those recommendations. METHODS: This was a 22-question cross-sectional survey conducted between February 2013 and September 2013, in 45 ambulatory practices within two health systems. Attending physicians, housestaff, and advanced practitioners in internal medicine, medicine-pediatrics, family medicine, cardiology, and endocrinology practices were audited. Providers' attitudes, perceptions, and beliefs about diet modification were collected. Knowledge scores were constructed based on the number of correct responses to specific questions. RESULTS: Of 343 provider responses, largely from primary care specialties (n = 3027, 90%), the top dietary recommendations were low-salt diet (71%) for hypertension, low-carbohydrate diet (64%) for uncontrolled diabetes mellitus, low saturated fat diet (73%) for dyslipidemia, low-calorie diet (72%) for obesity, and low saturated fat diet (63%) for coronary heart disease. Providers believed that 51% of diet recommendations were supported by randomized trial evidence when they were not. Respondents' overall knowledge of randomized trial evidence for dietary interventions was low (mean [standard deviation] knowledge score 44.3% [22.4%], range 0.0%-100.0%). The survey study from two health systems, using a nonvalidated survey tool limits external and internal validity. CONCLUSIONS: Providers report recommending different diets depending on specific risk factors and generally believe that their recommendations are evidence based. Substantial gaps between their knowledge and the randomized trial evidence regarding diet for disease prevention remain.

Healthcare Professionals' Perceptions and Knowledge of the USPSTF Guidelines on Breast Self-Examination.

OBJECTIVES: In 2009, the US Preventive Services Task Force (USPSTF) published revised guidelines for breast cancer screening, which recommended against teaching breast self-examination (BSE). The objective of this study was to assess providers' perceptions and knowledge regarding these updated guidelines. METHODS: A cross-sectional survey study was administered to 205 attending and resident physicians, nurse practitioners, physician's assistants, and registered nurses working in five medical and gynecological practices affiliated with a large academic teaching hospital in western Massachusetts. The survey solicited demographic data and inquired about practitioners' perceptions and knowledge of the revised guidelines. RESULTS: Fewer than half (41.1%) of respondents correctly identified the new USPSTF guidelines for BSE. Among those who stated they were aware of guidelines, only 37.1% adhered to them. Overall, 70% report that they teach patients to perform BSE. Teaching BSE was associated with female sex (odds ratio [OR] 2.64, 95% confidence interval [CI] 1.11-6.29), a belief that BSE reduces morbidity and mortality (OR 2.91, 95% CI 1.08-7.81), and internal medicine residency (OR 0.18, 95% CI 0.06-0.59). CONCLUSIONS: Knowledge of the 2009 USPSTF guidelines is suboptimal and greater efforts should be made to educate healthcare professionals about them.

Procedural sedation for MRI in children with ADHD.

BACKGROUND: Attention-deficit hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood, affecting 5-8% of children. It has been observed that these children have poor sedation experiences; however, to date there is minimal research on procedural sedation in this population. AIM: To examine whether children with ADHD required larger doses of propofol for magnetic resonance imaging (MRI) sedation. METHODS: The hospital's administrative billing database was used to identify all billing codes for MRI brain scans (with and without contrast) in children aged between 5 and 12 years over the preceding 5.5 years. The hospital's electronic medical record database provided baseline demographics. The sedation record was reviewed for propofol dose, psychostimulant use, and prescribed dose. All children received a standard weight-based dose of midazolam prior to receiving the necessary amount of propofol. Primary outcome was the dose of propofol administered (mg·kg(-1) ) to achieve adequate sedation. RESULTS: A total of 258 procedures met the inclusion criteria. The sample was 52% male, 74% White, 7.8% Black, 7.8% Hispanic, 4.3% Asian, and 6.2% other. ADHD was documented for 49 procedures with a prevalence of 18.5%. Patients with ADHD were older, more likely to be male, Hispanic, or to report race as 'Refused/Unknown'. Indications for MRI for patients with ADHD varied significantly, with 'Behavioral' and 'Neurocutaneous' being significantly overrepresented in the ADHD group. The average sedative dose for all patients was 2.8 mg·kg(-1) (95% CI 2.62-2.94). Sedative dose was similar among children with and without ADHD diagnosis. CONCLUSIONS: Our study illustrates that children with ADHD do not have higher sedative requirements to achieve a successful brain MRI.

Informed Decision Making for Percutaneous Coronary Intervention for Stable Coronary Disease.

IMPORTANCE: Patients with stable coronary disease undergoing percutaneous coronary intervention (PCI) are frequently misinformed about the benefits of PCI. Little is known about the quality of decision making before angiography and possible PCI. OBJECTIVE: To assess the quality of informed decision making and its association with patient decisions. DESIGN, SETTING, AND PARTICIPANTS: We performed a cross-sectional analysis of recorded conversations between August 1, 2008, and August 31, 2012, among adults with known or suspected stable coronary disease at outpatient cardiology practices. MAIN OUTCOMES AND MEASURES: Presence of 7 elements of informed decision making and the decision to undergo angiography and possible PCI. RESULTS: Of 59 conversations conducted by 23 cardiologists, 2 (3%) included all 7 elements of informed decision making; 8 (14%) met a more limited definition of procedure, alternatives, and risks. Specific elements significantly associated with not choosing angiography and possible PCI included discussion of uncertainty (odds ratio [OR], 20.5; 95% CI, 2.3-204.9), patient's role (OR, 5.3; 95% CI, 1.3-21.3), exploration of alternatives (OR, 9.5; 95% CI, 2.5-36.5), and exploration of patient preference (OR, 4.8; 95% CI, 1.2-19.4). Neither the presence of angina nor severity of symptoms was associated with choosing angiography and possible PCI. In a multivariable analysis using the total number of elements as a predictor, better informed patients were less likely to choose angiography and possible PCI (OR per additional element, 3.2; 95% CI, 1.4-7.1; P = .005). CONCLUSIONS AND RELEVANCE: In conversations between cardiologists and patients with stable angina, informed decision making is often incomplete. More complete discussions are associated with patients choosing not to undergo angiography and possible PCI.

Factors associated with emergency department visits in asthma exacerbation.

OBJECTIVES: Despite quality improvement initiatives to prevent asthma-related emergency department (ED) visits, rates have not declined. We sought to determine factors associated with ED visits in an underserved population. METHODS: We performed a case-control analysis of asthma patients at three ambulatory care centers serving low-income populations. Cases consisted of asthmatic patients aged 18 to 45 years with ≥1 ED visit for an asthma exacerbation between August 1, 2008 and July 31, 2010. Controls were patients with asthma aged 18 to 45 years with ≥1 outpatient visit during the same period but with no asthma-related ED visit. Data were collected by chart review and included demographics, past referral for asthma education or to a pulmonologist, recent tobacco use, influenza vaccination, and asthma medication prescriptions in the year before the index visit. RESULTS: Among 244 cases and 475 controls, there were no significant differences in age, sex, or ethnicity. Cases were more likely than controls to have ever been referred for asthma education (odds ratio [OR] 4.09, 95% confidence interval [CI] 2.57-6.50) or to a pulmonologist (OR 2.31, 95% CI 1.15-4.66). In the year before the index visit, cases were more likely than controls to receive other medications in addition to inhaled corticosteroids (ICS; OR 1.74, 95% CI 1.14-2.66) but less likely to receive influenza vaccination (OR 0.49, 95% CI 0.34-0.71), a short-acting ß-agonist (OR 0.43, 95% CI 0.24-0.78), or ICS alone (OR 0.53, 95% CI 0.34-0.84). CONCLUSIONS: Markers of severe disease were associated with ED visits, as well as a lack of an influenza vaccination and failure to prescribe either ICS or short-acting ß-agonists.

TRACER: an 'eye-opener' to the patient experience across the transition of care in an internal medicine resident program.

BACKGROUND: A safe patient transition requires a complex set of physician skills within the interprofessional practice. OBJECTIVE: To evaluate a rotation which applies self-reflection and workplace learning in a TRAnsition of CarE Rotation (TRACER) for internal medicine (IM) residents. TRACER is a 2-week required IM resident rotation where trainees join a ward team as a quality officer and follow patients into postacute care. METHODS: In 2010, residents participated in semistructured, one-on-one interviews as part of ongoing program evaluation. They were asked what they had learned on TRACER, the year prior, and how they used those skills in their practice. Using transcripts, the authors reviewed and coded each transcript to develop themes. RESULTS: Five themes emerged from a qualitative, grounded theory analysis: seeing things from the other side, the 'ah ha' moment of fragmented care, team collaboration including understanding nursing scope of practice in different settings, patient understanding, and passing the learning on. TRACER gives residents a moment to breathe and open their eyes to the interprofessional practice setting and the patient's experience of care in transition. CONCLUSIONS: Residents learn about transitions of care through self-reflection. This learning is sustained over time and is valued enough to teach to their junior colleagues.

How cardiologists present the benefits of percutaneous coronary interventions to patients with stable angina: a qualitative analysis.

IMPORTANCE: Patients with stable coronary artery disease (CAD) attribute greater benefit to percutaneous coronary interventions (PCI) than indicated in clinical trials. Little is known about how cardiologists' presentation of the benefits and risks may influence patients' perceptions. OBJECTIVES: To broadly describe the content of discussions between patients and cardiologists regarding angiogram and PCI for stable CAD, and to describe elements that may affect patients' understanding. DESIGN, SETTING, AND PARTICIPANTS: Qualitative content analysis of encounters between cardiologists and patients with stable CAD who participated in the Verilogue Point-of-Practice Database between March 1, 2008, and August 31, 2012. Transcripts in which angiogram and PCI were discussed were retrieved from the database. Patients were aged 44 to 88 years (median, 64 years); 25% were women; 50% reported symptoms of angina; and 6% were taking more than 1 medication to treat angina. MAIN OUTCOMES AND MEASURES: Results of conventional and directed qualitative content analysis. RESULTS: Forty encounters were analyzed. Five major categories and subcategories of factors that may affect patients' understanding of benefit were identified: (1) rationale for recommending angiogram and PCI (eg, stress test results, symptoms, and cardiologist's preferences); (2) discussion of benefits (eg, accurate discussion of benefit [5%], explicitly overstated benefit [13%], and implicitly overstated benefit [35%]); (3) discussion of risks (eg, minimization of risk); (4) cardiologist's communication style (eg, humor, teach-back, message framing, and failure to respond to patient questions); and (5) patient and family member contributions to the discussion. CONCLUSIONS AND RELEVANCE: Few cardiologists discussed the evidence-based benefits of angiogram and PCI for stable CAD, and some implicitly or explicitly overstated the benefits. The etiology of patient misunderstanding is likely multifactorial, but if future quantitative studies support the findings of this hypothesis-generating analysis, modifications to cardiologists' approach to describing the risks and benefits of the procedure may improve patient understanding.

Do physicians underrecognize obesity?

OBJECTIVES: A physician's advice is among the strongest predictors of efforts toward weight management made by obese patients, yet only a minority receives such advice. One contributor could be the physician's failure to recognize true obesity. The objectives of this study were to assess physicians' ability to recognize obesity and to identify factors associated with recognition and documentation of obesity. METHODS: Internal medicine residents and attending physicians at three academic urban primary care clinics and their adult patients participated in a study using recognition and documentation of patient obesity as the main measures. RESULTS: A total of 52 physicians completed weight assessments for 400 patients. The mean patient age was 51 years, 56% were women, 77% were Hispanic, and 67% had one or more obesity-related comorbidity. There were 192 (48%) patients, of whom 66% were correctly identified by physicians as being obese, 86% of those with a body mass index (BMI) ≥ 35, but only 49% of those with a BMI of 30 to 34.9 (P < 0.0001). Fewer obese Hispanic patients were identified than were non-Hispanic patients (62% vs 76%; P = 0.03). No physician characteristics were significantly associated with recognition of obesity. Physicians documented obesity as a problem for 51% of patients. Attending physicians documented obesity more frequently than did residents (64% vs 43%, odds ratio 2.5, 95% confidence interval 1.3-4.6) and normal-weight physicians documented obesity more frequently than overweight physicians (58% vs 41%, odds ratio 2.0, 95% confidence interval 1.0-4.0). Documentation was more common for patients with a BMI ≥ 35 and for non-Hispanics. Documentation was not more common for patients with obesity-related comorbidities. CONCLUSIONS: Physicians have difficulty recognizing obesity unless patients' BMI is ≥ 35. Training physicians to recognize true obesity may increase rates of documentation, a first step toward treatment.

Implementing a resident research program to overcome barriers to resident research.

Internal medicine residents are required to participate in scholarly activity, but conducting original research during residency is challenging. Following a poor Match at Baystate Medical Center, the authors implemented a resident research program to overcome known barriers to resident research. The multifaceted program addressed the following barriers: lack of interest, lack of time, insufficient technical support, and paucity of mentors. The program consisted of evidence-based medicine training to stimulate residents' interest in research and structural changes to support their conduct of research, including protected time for research during ambulatory blocks, a research assistant to help with tasks such as institutional review board applications and data entry, a research nurse to help with data collection, easily accessible biostatistical support, and a resident research director to provide mentorship. Following implementation in the fall of 2005, there was a steady rise in the number of resident presentations at national meetings, then in the number of resident publications. From 2001 to 2006, the department saw 3 resident publications. From 2006 to 2012, that number increased to 39 (P< .001). The department also saw more original research (29 publications) and resident first authors (12 publications) after program implementation. The percentage of residents accepted into fellowships rose from 33% before program implementation to 49% after (P = .04). This comprehensive resident research program, which focused on evidence-based medicine and was tailored to overcome specific barriers, led to a significant increase in the number of resident Medline publications and improved the reputation of the residency program.

Hospital workers' perceptions of waste: a qualitative study involving photo-elicitation.

OBJECTIVES: To elicit sources of waste as viewed by hospital workers. DESIGN: Qualitative study using photo-elicitation, an ethnographic technique for prompting in-depth discussion. SETTING: U.S. academic tertiary care hospital. PARTICIPANTS: Physicians, nurses, pharmacists, administrative support personnel, administrators and respiratory therapists. METHODS: A purposive sample of personnel at an academic tertiary care hospital was invited to take up to 10 photos of waste. Participants discussed their selections using photos as prompts during in-depth interviews. Transcripts were analysed in an iterative process using grounded theory; open and axial coding was performed, followed by selective and thematic coding to develop major themes and subthemes. RESULTS: Twenty-one participants (nine women, average number of years in field=19.3) took 159 photos. Major themes included types of waste and recommendations to reduce waste. Types of waste comprised four major categories: Time, Materials, Energy and Talent. Participants emphasised time wastage (50% of photos) over other types of waste such as excess utilisation (2.5%). Energy and Talent were novel categories of waste. Recommendations to reduce waste included interventions at the micro-level (eg, individual/ward), meso-level (eg, institution) and macro-level (eg, payor/public policy). CONCLUSIONS: The waste hospital workers identified differed from previously described waste both in the types of waste described and the emphasis placed on wasted time. The findings of this study represent a possible need for education of hospital workers about known types of waste, an opportunity to assess the impact of novel types of waste described and an opportunity to intervene to reduce the waste identified.