A novel approach to supporting relationship-centered care through electronic health record ergonomic training in preclerkship medical education.

PROBLEM: How can physicians incorporate the electronic health record (EHR) into clinical practice in a relationship-enhancing fashion ("EHR ergonomics")? APPROACH: Three convenience samples of 40 second-year medical students with varying levels of EHR ergonomic training were compared in the 2012 spring semester. All participants first received basic EHR training and completed a presurvey. Two study groups were then instructed to use the EHR during the standardized patient (SP) encounter in each of four regularly scheduled Doctoring (clinical skills) course sessions. One group received additional ergonomic training in each session. Ergonomic assessment data were collected from students, faculty, and SPs in each session. A postsurvey was administered to all students, and data were compared across all three groups to assess the impact of EHR use and ergonomic training. OUTCOMES: There was a significant positive effect of EHR ergonomics skills training on students' relationship-centered EHR use (P<.005). Students who received training reported that they were able to use the EHR to engage with patients more effectively, better articulate the benefits of using the EHR, better address patient concerns, more appropriately position the EHR device, and more effectively integrate the EHR into patient encounters. Additionally, students' self-assessments were strongly corroborated by SP and faculty assessments. A minimum of three ergonomic training sessions were needed to see an overall improvement in EHR use. NEXT STEPS: In addition to replication of these results, further effectiveness studies of this educational intervention need to be carried out in GME, practice, and other environments.

Patient factors associated with failure to diagnose tuberculosis in the emergency department.

BACKGROUND: Emergency department (ED) presentation of pulmonary tuberculosis (TB) can be highly atypical and an ED visit might be the only health care interaction for high-risk patients. OBJECTIVE: Our objective was to identify patient factors associated with discharge without a diagnosis of TB during an infectious ED visit. METHODS: The study population consisted of 150 patients from 2000 to 2009 with 190 infectious ED visits. Patients were initially identified from the state registry of confirmed TB cases and epidemiological characteristics were identified prospectively during case investigation. A retrospective review was performed for clinical characteristics of visits dichotomized according to whether the diagnosis of TB was made during the ED visit. RESULTS: Analysis revealed that 77% of all infectious-patient visits ended with a diagnosis of TB. A TB diagnosis was more likely when patients presented with pulmonary or infectious chief complaints, endorsed cough, subjective fever, chills, dyspnea, previous TB infection, or had an abnormal lung examination or chest x-ray study. Patients were significantly less likely to be diagnosed with TB when they were unresponsive during clinical evaluation or when they reported a history of both homelessness and any substance abuse during the last year. In addition, these characteristics were independent predictors of nondiagnosis when traditional TB risk factors or abnormal vital signs were considered. CONCLUSIONS: Patients with atypical presentations, as well as those who were unresponsive or reported a history of homelessness and substance abuse, were at greater risk for nondiagnosis of TB during an infectious ED visit.

Medical student training in domestic violence: a comparison of students entering residency training in 1995 and 2001.

BACKGROUND: As domestic violence (DV) is frequently unrecognized by physicians, efforts to improve education on the topic have been undertaken. PURPOSE: To assess changes in medical education about DV. METHODS: Incoming residents from 1995 (N = 52) and 2001 (N = 43) were surveyed regarding education and attitudes about DV. RESULTS: The resident-reported emphasis on DV education increased significantly from 1995 to 2001. Hours devoted to the subject experienced no significant change. The likelihood they would ask female patients about DV and their competence in dealing with DV-specific situations experienced no significant improvement-both were rated below average. CONCLUSIONS: Although emphasis on medical education about DV has improved from 1995 to 2001, likelihood of screening and competence at dealing with DV has not improved. The content of undergraduate medical education about DV should be strengthened, and the educational process should continue during residency training.