Impact of a Medical Scribe Program on the Educational Trajectory of Prehealth and Underrepresented in Medicine Students.

BACKGROUND AND OBJECTIVES: Sparse research exists on evaluating the effects of medical scribing programs on the educational trajectory of prehealth students. This study assesses the impact of the Stanford Medical Scribe Fellowship (COMET) on its prehealth participants' educational goals, preparation for graduate training, and acceptance into health professional schools. METHODS: We distributed a 31-question survey with both closed- and open-ended questions to 96 alumni. The survey collected participant demographics, self-reported underrepresented in medicine (URM) status, pre-COMET clinical experiences and educational goals, application to and acceptance at health professional schools, and perceived impact of COMET on their educational trajectory. SPSS was used to complete the analyses. RESULTS: The survey had a 97% (93/96) completion rate. Among all respondents, 69% (64/93) applied to a health professional school and 70% (45/64) were accepted. Among URM respondents, 68% (23/34) applied to a health professional school and 70% (16/23) were accepted. Overall acceptance rates for MD/DO and PA/NP programs were 51% (24/47) and 61% (11/18), respectively. URM acceptance rates for MD/DO and PA/NP programs were 43% (3/7) and 58% (7/12), respectively. For current or recently graduated health professional school respondents, 97% (37/38) "strongly agreed" or "agreed" that COMET helped them succeed in their training. CONCLUSIONS: COMET is associated with a positive impact on the educational trajectory of its prehealth participants and a higher acceptance rate into health professional schools than the national rates for both overall and URM applicants. Scribing programs may serve as pipeline development and help increase the diversity of the future health care workforce.

Five Years' Experience With a Medical Scribe Fellowship: Shaping Future Health Professions Students While Addressing Provider Burnout.

Professional burnout has reached epidemic levels among U.S. medical providers. One key driver is the burden of clinical documentation in the electronic health record, which has given rise to medical scribes. Despite the demonstrated benefits of scribes, many providers-especially those in academic health systems-have been unable to make an economic case for them. With the aim of creating a cost-effective scribe program in which premedical students gain skills that better position them for professional schooling, while providers at risk of burnout obtain documentation support, the authors launched the Clinical Observation and Medical Transcription (COMET) Program in June 2015 at Stanford University School of Medicine. COMET is a new type of postbaccalaureate premedical program that combines an apprenticeship-like scribing experience and a package of teaching, advising, application support, and mentored scholarship that is supported by student tuition. Driven by strong demand from both participants and faculty, the program grew rapidly during its first 5 years (2015-2020). Program evaluations indicated high levels of satisfaction among participants and faculty with their mentors and mentees, respectively; that participants felt the experience better positioned them for professional schooling; and that faculty reported improved joy of practice. In summary, tuition-supported medical scribe programs, like COMET, appear to be feasible and cost-effective. The COMET model may have the potential to help shape future health professions students, while simultaneously combating provider burnout. While scalability and generalizability remain uncertain, this model may be worth exploring at other institutions.

Identifying Opportunities to Improve Intimate Partner Violence Screening in a Primary Care System.

BACKGROUND AND OBJECTIVES: Intimate partner violence (IPV) is a silent epidemic affecting one in three women. The US Preventive Services Task Force recommends routine IPV screening for women of childbearing age, but actual rates of screening in primary care settings are low. Our objectives were to determine how often IPV screening was being done in our system and whether screening initiated by medical assistants or physicians resulted in more screens. METHODS: We conducted a retrospective chart review to investigate IPV screening practices in five primary care clinics within a university-based network in Northern California. We reviewed 100 charts from each clinic for a total of 500 charts. Each chart was reviewed to determine if an IPV screen was documented, and if so, whether it was done by the medical assistant or the physician. RESULTS: The overall frequency of IPV screening was 22% (111/500). We found a wide variation in screening practices among the clinics. Screening initiated by medical assistants resulted in significantly more documented screens than screening delivered by physicians (74% vs 9%, P<0.001). CONCLUSIONS: IPV screening is an important, but underdelivered service. Using medical assistants to deliver IPV screening may be more effective than relying on physicians alone.

Residents' Perspectives on Careers in Academic Medicine: Obstacles and Opportunities.

BACKGROUND AND OBJECTIVES: Worsening faculty shortages in medical schools and residency programs are threatening the US medical education infrastructure. Little is known about the factors that influence the decision of family medicine residents to choose or not choose academic careers. Our study objective was to answer the following question among family medicine residents: "What is your greatest concern or fear about pursuing a career in academic family medicine?" METHODS: Participants were family medicine residents who attended the Faculty for Tomorrow Workshop at the Society of Teachers of Family Medicine Annual Spring Conference in 2016 and 2017. Free responses to the aforementioned prompt were analyzed using a constant comparative method and grounded theory approach. RESULTS: A total of 156 participants registered for the workshops and 95 (61%) answered the free response question. Eight distinct themes emerged from the analysis. The most frequently recurring theme was "lack of readiness or mentorship," which accounted for nearly one-third (31%) of the codes. Other themes included work-life balance and burnout (17%), job availability and logistics (15%), lack of autonomy or flexibility (11%), competing pressures/roles (10%), lower financial rewards (4%), politics and bureaucracy (4%), and research (3%). CONCLUSIONS: To our knowledge, this is the first study to identify barriers and disincentives to pursuing a career in academic medicine from the perspective of family medicine residents. There may be at least eight major obstacles, for which we summarize and consider potential interventions. More research is needed to understand why residents choose, or don't choose, academic careers.

One Year of Family Physicians' Observations on Working with Medical Scribes.

PURPOSE: The immense clerical burden felt by physicians is one of the leading causes of burnout. Scribes are increasingly being used to help alleviate this burden, yet few published studies investigate how scribes affect physicians' daily work, attitudes and behaviors, and relationships with patients and the workplace. METHODS: Using a longitudinal observational design, data were collected, over 1 year, from 4 physicians working with 2 scribes at a single academic family medicine practice. Physician experience was measured by open-ended written reflections requested after each 4-hour clinic session. A data-driven codebook was generated using a constant comparative method with grounded theory approach. RESULTS: A total of 361 physician reflections were completed, yielding 150 distinct excerpts; 289 codes were assigned. The 11 themes that emerged were further categorized under 4 domains. The most frequently recurring domain was clinic operations, which comprised 51.6% of the codes. Joy of practice, quality of care, and patient experience comprised 22.1%, 16.3%, and 10.0% of the codes, respectively. CONCLUSIONS: Our study suggests that integrating scribes into a primary care clinic can produce positive outcomes that go beyond reducing clerical burden for physicians. Scribes may benefit patient experience, quality of care, clinic operations, and joy of practice.

Asthma in Children of Mothers With Systemic Lupus Erythematosus and the Role of Preterm Birth.

OBJECTIVE: Systemic lupus erythematosus (SLE) and asthma share inheritable IgE-related pathophysiology, but the association between maternal SLE and asthma in the offspring has not been explored. Our aim was to investigate the association between maternal SLE during pregnancy and childhood asthma and examine the role of preterm birth as a mediator of the association using Swedish register data. METHODS: Information on 12,000 singleton live births (2001-2013) was collected from the Medical Birth Register. Childhood asthma was defined as at least 1 International Classification of Diseases-coded visit in the National Patient Register. Prevalent maternal SLE at delivery was identified from the Medical Birth Register and the National Patient Register. Risk ratios for asthma were estimated while controlling for confounders. Mediation analysis was used to estimate what percentage of the total effect can be explained by preterm birth (defined as either <34 or <37 weeks of gestation). RESULTS: We compared 775 children born to mothers with SLE with 11,225 born to mothers without SLE. Ninety seven children of mothers with SLE (13%) were diagnosed with asthma, compared to 1,211 in the unexposed group (11%). The risk ratio for childhood asthma was 1.46 (95% confidence interval 1.16-1.84). In mediation analysis, 20-29% of the total effect of SLE was explained by preterm birth. CONCLUSION: Prevalent maternal SLE during pregnancy is associated with an increased risk of asthma in the offspring. While preterm birth can explain a fair proportion of this association, additional unidentified mechanisms also likely play a role.

Impact of Scribes on Physician Satisfaction, Patient Satisfaction, and Charting Efficiency: A Randomized Controlled Trial.

PURPOSE: Scribes are increasingly being used in clinical practice despite a lack of high-quality evidence regarding their effects. Our objective was to evaluate the effect of medical scribes on physician satisfaction, patient satisfaction, and charting efficiency. METHODS: We conducted a randomized controlled trial in which physicians in an academic family medicine clinic were randomized to 1 week with a scribe then 1 week without a scribe for the course of 1 year. Scribes drafted all relevant documentation, which was reviewed by the physician before attestation and signing. In encounters without a scribe, the physician performed all charting duties. Our outcomes were physician satisfaction, measured by a 5-item instrument that included physicians' perceptions of chart quality and chart accuracy; patient satisfaction, measured by a 6-item instrument; and charting efficiency, measured by time to chart close. RESULTS: Scribes improved all aspects of physician satisfaction, including overall satisfaction with clinic (OR = 10.75), having enough face time with patients (OR = 3.71), time spent charting (OR = 86.09), chart quality (OR = 7.25), and chart accuracy (OR = 4.61) (all P values <.001). Scribes had no effect on patient satisfaction. Scribes increased the proportion of charts that were closed within 48 hours (OR =1.18, P =.028). CONCLUSIONS: To our knowledge, we have conducted the first randomized controlled trial of scribes. We found that scribes produced significant improvements in overall physician satisfaction, satisfaction with chart quality and accuracy, and charting efficiency without detracting from patient satisfaction. Scribes appear to be a promising strategy to improve health care efficiency and reduce physician burnout.

Rethinking empathy decline: results from an OSCE.

BACKGROUND: The phenomenon of empathy decline among medical students during training is widely accepted, with evidence based largely on studies using self-administered instruments. Recently, researchers have called into question this phenomenon, in light of new findings that suggest a discrepancy between self-administered empathy scores and observed empathic behaviours: for example, during objective structured clinical examinations (OSCEs). Our objective was to compare observed empathy among medical students in different clerkship years using an OSCE. METHODS: Participants were medical students in their first or second year of clinical clerkships, enrolled in a required family medicine clerkship at Stanford University. Participants completed an OSCE that was directly observed by trained faculty staff, who used the Measure of Patient-Centered Communication (MPCC) instrument to measure empathic behaviours. Statistics were used to determine correlations between observed empathy and the students' year of clerkship, gender, and specialty preference. RESULTS: A total of 129 medical students, evenly divided by gender and clerkship year, participated. There was a possible trend towards higher MPCC scores among students in their second clerkship year compared with students in their first year (p = 0.09), which became more significant when adjusted for outlier effects (p = 0.05). There was no difference in performance by gender. Students interested in a 'people-oriented' specialty scored higher in 'handling the patient's frustration' compared with those who are interested in a 'technology-oriented' specialty. DISCUSSION: In our study, observed empathic behaviours were not lower in the second compared with the first year of clerkship training. More research is warranted to investigate the apparent discrepancy between self-administered empathy scores and observed empathic behaviours. New findings suggest a discrepancy between self-administered empathy scores and observed empathic behaviours.

Early-onset Preeclampsia in Lupus Pregnancy.

BACKGROUND: Systemic lupus erythematosus (SLE) is a chronic systemic autoimmune disease that occurs during childbearing years and has been associated with preeclampsia. However, little is known about preeclampsia of early onset, which is associated with severe adverse maternal and perinatal outcomes. METHODS: Using national population-based Swedish registers we identified women with SLE (≥2 visits with corresponding ICD codes) and a sample without SLE who gave birth to singleton infants 2001-12. Risk ratios (RR) and 95% confidence intervals (CI) for early-onset preeclampsia (defined by ICD codes corresponding to preeclampsia registered at <34 weeks) in SLE women were calculated based on adjusted modified Poisson models for first, subsequent, and all pregnancies. RESULT: Among 742 births to women with SLE and 10 484 births to non-SLE women, there were 32 (4.3%) and 55 (0.5%) diagnoses of early-onset preeclampsia respectively. SLE was associated with an increased risk of early-onset preeclampsia (RR 7.8, 95% CI 4.8, 12.9, all pregnancies). The association remained similar upon restriction to women without pregestational hypertension. Adjustment for antiphospholipid syndrome (APS)-proxy attenuated the association. RRs for early-onset preeclampsia were smaller for subsequent pregnancies (RR 4.7, 95% CI 2.0, 11.2) compared to first and all (see above). CONCLUSION: Women with SLE are at increased risk of early-onset preeclampsia and this increased risk may be independent of the traditional risk factors such as pregestational hypertension, APS, BMI, or smoking. Women with SLE during pregnancy should be closely monitored for early-onset preeclampsia and future research needs to identify the non-traditional preeclampsia factors that might cause this serious outcome.

Sociodemographic Disparities in Intervention Service Utilization in Families of Children with Autism Spectrum Disorder.

This study investigates whether sociodemographic factors are associated with utilization of intervention services for children with autism spectrum disorder (ASD) enrolled in the Childhood Autism Risks from Genetics and the Environment Study. Maternal ethnicity, insurance status, and education for 696 families of children with ASD were available. Children of Black mothers entered intervention earlier compared to White mothers (2 vs. 2.6 years; p = 0.001). Having public insurance was associated with receiving <15 h/week of individual services, while having a Bachelor degree was associated with receiving <15 h/week of classroom-based services. These differences suggest that SES may be a factor in utilization of services. Efforts should be made to ensure that interventions offered are culturally and linguistically accessible.

Impact of a scholarly track on quality of residency program applicants.

INTRODUCTION: It is generally believed that residency programs offering scholarly tracks attract higher quality applicants, although there is little evidence of this in the literature. We explored the impact of a clinician-educator track on the quality of applicants to our residency program by comparing the volume and characteristics of applicants before (2008-2011) and after (2012-2015) the track was introduced. METHODS: The total number of applications received was compared between the pre-track and post-track years. Among interviewees, data on United States Medical Licensing Examination (USMLE) Step 1 scores, Step 2 Clinical Knowledge (CK) scores, Medical Student Performance Evaluation (MSPE) scores, and proportion of candidates with an advanced degree (e.g. MPH, PhD) were compared. An online survey was administered to all interviewees in 2014-2015 to measure interest in the track. RESULTS: The total number of applications to the residency program increased significantly from the pre-track to the post-track years. Compared to the pre-track years, interviewees during the post-track years had statistically higher USMLE Step 1 and Step 2 CK scores, better MSPE scores, and were more likely to have an advanced degree. Two-thirds of survey respondents reported that the track increased their interest in the residency program. DISCUSSION: A residency clinician-educator track may be associated with increased overall interest from applicants, higher application volume, and better measures of applicant quality based on USMLE scores, MSPE scores, and proportion of candidates with an advanced degree. Residency programs may consider a potential increase in the quality of their applicants as an added benefit of offering a scholarly track.

Problem-solving skills training for mothers of children recently diagnosed with autism spectrum disorder: A pilot feasibility study.

Problem-solving skills training is an intervention designed to teach coping skills that has shown to decrease negative affectivity (depressive symptoms, negative mood, and post-traumatic stress symptoms) in mothers of children with cancer. The objective of this study was to see whether mothers of children recently diagnosed with autism spectrum disorder would be receptive to receiving problem-solving skills training (feasibility trial). Participants were recruited from a local outpatient developmental clinic that is part of a university department of pediatrics. Participants were to receive eight 1-h sessions of problem-solving skills training and were asked to complete assessments prior to beginning problem-solving skills training (T1), immediately after intervention (T2), and 3 months after T2 (T3). Outcome measures assessed problem-solving skills and negative affectivity (i.e. distress). In total, 30 mothers were approached and 24 agreed to participate (80.0%). Of them, 17 mothers completed problem-solving skills training (retention rate: 70.8%). Mothers of children with autism spectrum disorder who completed problem-solving skills training had significant decreases in negative affectivity and increases in problem-solving skills. A comparison to mothers of children with cancer shows that mothers of children with autism spectrum disorder displayed similar levels of depressive symptoms but less negative mood and fewer symptoms of post-traumatic stress. Data suggest that problem-solving skills training may be an effective way to alleviate distress in mothers of children recently diagnosed with autism spectrum disorder. Data also suggest that mothers of children with autism spectrum disorder were moderately receptive to receiving problem-solving skills training. Implications are that problem-solving skills training may be beneficial to parents of children with autism spectrum disorder; modifications to improve retention rates are suggested.

Hepatitis B Screening in Asian and Pacific Islanders: New Guidelines, Old Barriers.

Chronic hepatitis B virus (HBV) infection is a serious liver disease that disproportionately affects Asian and Pacific Islander immigrants. In May 2014, the U.S. Preventive Services Task Force released new HBV screening guidelines that expanded screening to non-pregnant adolescents and adults who were born in Asia and the Pacific Islands, and U.S.-born persons not vaccinated as infants whose parents were born in Central or Southeast Asia. Although the guidelines empower health care providers and community health workers to expand their screening efforts, old barriers to screening remain deeply rooted in this population. These barriers include cultural beliefs about wellness, myths and misconceptions about HBV, and lack of access to appropriate, culturally sensitive care. Through a combination of strategies--retooling the current health care workforce to be more culturally sensitive providers, involving oriental medicine practitioners in patient education, and engaging grassroots organizations--we can overcome barriers and take full advantage of the new HBV screening guidelines.

Effectiveness of a smartphone app for guiding antidepressant drug selection.

BACKGROUND AND OBJECTIVES: Major depression is a prevalent chronic disease in the United States. However, many physicians lack access to decision support tools at point of care to help choose antidepressants in a rational, evidence-based manner. A patient-centered treatment model that uses a symptom-based approach to selecting antidepressants was developed into a smartphone application to provide instant, evidence-based recommendations and drug monographs. The purpose of this study was to assess the impact of this mobile application on the confidence level of family physicians in treating depression. METHODS: The smartphone application was provided to 14 family medicine residents and attending physicians from the O'Connor Family Medicine Residency Program in San Jose, CA. Participants were asked to use the software as drug reference and clinical decision support during patient care activities. Three surveys were administered over a 12-week period to assess provider characteristics, outcome measures (ie, confidence in managing depression and choosing an initial antidepressant based on patient symptoms, medical comorbidities, potential side effects, and drug interactions), and fund of antidepressant knowledge. RESULTS: The average confidence levels in managing depression, starting an antidepressant on a patient with depression, and choosing an initial antidepressant based on patient symptoms increased significantly within the period of smartphone application usage. The average scores on the antidepressant knowledge tests also improved. CONCLUSIONS: The smartphone application was an effective tool for both increasing confidence in depression treatment and educating physicians. Future studies to evaluate the effectiveness and impact of smartphone applications on medical education and postgraduate training are warranted.