Understanding suboptimal e-consult requests: lessons from the VA.

OBJECTIVES: Electronic consultations, or e-consults, which are requests for specialist advice without direct patient interaction, are becoming increasingly common across health systems. We sought to identify clinicians' perspectives on the quality of e-consult requests that they send and receive. STUDY DESIGN: A qualitative research study at the US Department of Veterans Affairs (VA) New England Healthcare System. METHODS: We interviewed a total of 73 clinicians, including 38 specialists across 3 specialties (cardiology, neurology, pulmonology) and 35 primary care clinicians (PCCs), between March and June 2019. The interviews were analyzed using thematic analysis. RESULTS: VA specialists and PCCs generally agreed that e-consult requests should be focused and precise, not require lengthy chart review, and include adequate preliminary workup results. At the same time, specialists expressed frustration with what they perceived as suboptimal e-consult requests. Interviewees attributed this gap to 3 factors: limitations of the electronic health record user interface, divergence between PCCs and specialists in the areas of expertise, and organizational pressures on the 2 groups. CONCLUSIONS: VA clinicians' perspectives on suboptimal requests contain lessons that are broadly applicable to other health systems that seek to maximize the potential of e-consults to facilitate clinician collaboration and care coordination.

Electronic consultations and economies of scale: a qualitative study of clinician perspectives on scaling up e-consult delivery.

OBJECTIVE: To explore Veterans Health Administration clinicians' perspectives on the idea of redesigning electronic consultation (e-consult) delivery in line with a hub-and-spoke (centralized) model. MATERIALS AND METHODS: We conducted a qualitative study in VA New England Healthcare System (VISN 1). Semi-structured phone interviews were conducted with 35 primary care providers and 38 specialty care providers, including 13 clinical leaders, at 6 VISN 1 sites varying in size, specialist availability, and e-consult volume. Interviews included exploration of the hub-and-spoke (centralized) e-consult model as a system redesign option. Qualitative content analysis procedures were applied to identify and describe salient categories. RESULTS: Participants saw several potential benefits to scaling up e-consult delivery from a decentralized model to a hub-and-spoke model, including expanded access to specialist expertise and increased timeliness of e-consult responses. Concerns included differences in resource availability and management styles between sites, anticipated disruption to working relationships, lack of incentives for central e-consultants, dedicated staff's burnout and fatigue, technological challenges, and lack of motivation for change. DISCUSSION: Based on a case study from one of the largest integrated healthcare systems in the United States, our work identifies novel concerns and offers insights for healthcare organizations contemplating a scale-up of their e-consult systems. CONCLUSIONS: Scaling up e-consults in line with the hub-and-spoke model may help pave the way for a centralized and efficient approach to care delivery, but the success of this transformation will depend on healthcare systems' ability to evaluate and address barriers to leveraging economies of scale for e-consults.

Implications of Electronic Consultations for Clinician Communication and Relationships: A Qualitative Study.

BACKGROUND: Strong relationships and effective communication between clinicians support care coordination and contribute to care quality. As a new mechanism of clinician communication, electronic consultations (e-consults) may have downstream effects on care provision and coordination. OBJECTIVE: The objective of this study was to understand primary care providers' and specialists' perspectives on how e-consults affect communication and relationships between clinicians. RESEARCH DESIGN: Qualitative study using thematic analysis of semistructured interviews. SUBJECTS: Six of 8 sites in the VISN 1 (Veterans Integrated Service Network) in New England were chosen, based on variation in organization and received e-consult volume. Seventy-three respondents, including 60 clinicians in primary care and 3 high-volume specialties (cardiology, pulmonology, and neurology) and 13 clinical leaders at the site and VISN level, were recruited. MEASURES: Participants' perspectives on the role and impact of e-consults on communication and relationships between clinicians. RESULTS: Clinicians identified 3 types of e-consults' social affordances: (1) e-consults were praised for allowing specialist advice to be more grounded in patient data and well-documented, but concerns about potential legal liability and increased transparency of communication to patients and others were also noted; (2) e-consults were perceived as an imperfect modality for iterative communication, especially for complex conversations requiring shared deliberation; (3) e-consults were understood as a factor influencing clinician relationships, but clinicians disagreed on whether e-consults promote or undermine relationship building. CONCLUSIONS: Clinicians have diverse concerns about the implications of e-consults for communication and relationships. Our findings may inform efforts to expand and improve the use of e-consults in diverse health care settings.

Electronic consultations (E-consults) and their outcomes: a systematic review.

OBJECTIVE: Electronic consultations (e-consults) are clinician-to-clinician communications that may obviate face-to-face specialist visits. E-consult programs have spread within the US and internationally despite limited data on outcomes. We conducted a systematic review of the recent peer-reviewed literature on the effect of e-consults on access, cost, quality, and patient and clinician experience and identified the gaps in existing research on these outcomes. MATERIALS AND METHODS: We searched 4 databases for empirical studies published between 1/1/2015 and 2/28/2019 that reported on one or more outcomes of interest. Two investigators reviewed titles and abstracts. One investigator abstracted information from each relevant article, and another confirmed the abstraction. We applied the GRADE criteria for the strength of evidence for each outcome. RESULTS: We found only modest empirical evidence for effectiveness of e-consults on important outcomes. Most studies are observational and within a single health care system, and comprehensive assessments are lacking. For those outcomes that have been reported, findings are generally positive, with mixed results for clinician experience. These findings reassure but also raise concern for publication bias. CONCLUSION: Despite stakeholder enthusiasm and encouraging results in the literature to date, more rigorous study designs applied across all outcomes are needed. Policy makers need to know what benefits may be expected in what contexts, so they can define appropriate measures of success and determine how to achieve them.

Cardiology electronic consultation (e-consult) use by primary care providers at VA medical centres in New England.

INTRODUCTION: E-consultations (e-consults) were implemented at VA medical centers to improve access to specialty care. Cardiology e-consults are among the most commonly requested, but little is known about how primary care providers (PCPs) use cardiology e-consults to access specialty care. METHODS: This is a retrospective analysis of 750 patients' medical charts with cardiology e-consults requested by medical providers (October 2013-September 2015) in the VA New England Healthcare System. We described the patients and referring provider characteristics, and e-consult questions. We reviewed cardiologists' responses and examined their recommendations. RESULTS: Among the 424 e-consults requested from PCPs, 92.7% were used to request answers to clinical questions, while 7.3% were used for administrative purposes. Among the 393 e-consults with clinical questions, 60 e-consults were regarding preoperative management; these questions most commonly addressed general risk assessment (n = 44), anti-coagulation/anti-platelet management (n = 33), and EKG interpretation (n = 20). Cardiologists provided answers for the majority (89.6%) of clinical questions. Among the e-consults in which cardiologists did not provide answers or clinical guidance (n = 41), the reasons included missing or insufficient clinical information (n = 18), medical complexity (n = 6), and deferment to the patient's non-VA primary cardiologist (n = 7). Cardiologists recommended that the patients be seen as face-to-face consults for 7.9% of e-consults. DISCUSSION: Primary care providers are the most frequent requesters of cardiology e-consults, using them primarily to obtain input on clinical questions. Cardiologists did not provide answers for one in ten, owing principally to insufficient available clinical information. Educating PCPs and standardizing the template for requesting e-consultation may help to reduce the number of unanswered e-consults.

Evaluating diverse electronic consultation programs with a common framework.

BACKGROUND: Electronic consultation is an emerging mode of specialty care delivery that allows primary care providers and their patients to obtain specialist expertise without an in-person visit. While studies of individual programs have demonstrated benefits related to timely access to specialty care, electronic consultation programs have not achieved widespread use in the United States. The lack of common evaluation metrics across health systems and concerns related to the generalizability of existing evaluation efforts may be hampering further growth. We sought to identify gaps in knowledge related to the implementation of electronic consultation programs and develop a set of shared evaluation measures to promote further diffusion. METHODS: Using a case study approach, we apply the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) and the Quadruple Aim frameworks of evaluation to examine electronic consultation implementation across diverse delivery systems. Data are from 4 early adopter healthcare delivery systems (San Francisco Health Network, Mayo Clinic, Veterans Administration, Champlain Local Health Integration Network) that represent varied organizational structures, care for different patient populations, and have well-established multi-specialty electronic consultation programs. Data sources include published and unpublished quantitative data from each electronic consultation database and qualitative data from systems' end-users. RESULTS: Organizational drivers of electronic consultation implementation were similar across the systems (challenges with timely and/or efficient access to specialty care), though unique system-level facilitators and barriers influenced reach, adoption and design. Effectiveness of implementation was consistent, with improved patient access to timely, perceived high-quality specialty expertise with few negative consequences, garnering high satisfaction among end-users. Data about patient-specific clinical outcomes are lacking, as are policies that provide guidance on the legal implications of electronic consultation and ideal remuneration strategies. CONCLUSION: A core set of effectiveness and implementation metrics rooted in the Quadruple Aim may promote data-driven improvements and further diffusion of successful electronic consultation programs.

Innovative Use Of Electronic Consultations In Preoperative Anesthesiology Evaluation At VA Medical Centers In New England.

Electronic consultations (e-consults) improve access to specialty care without requiring face-to-face patient visits. We conducted a mixed-methods descriptive study to understand the variability in e-consult use across anesthesiology departments in the Veterans Affairs New England Healthcare System (VANEHS). In the period 2012-15, the system experienced a rapid increase in the use of anesthesiology e-consults: 5,023 were sent in 2015, compared with 103 in 2012. Uptake across sites varied from near-universal use of e-consults for preoperative assessment to use for only selected low-risk patients or no use. Interviews with stakeholders revealed considerable differences in the perceived impact of e-consults on workflow and patient-centeredness. Clinicians at sites with high use of e-consults noted that they improved workflow efficiency. In comparison, clinicians at sites with low use preferentially valued face-to-face visits for some or all patients. The adoption of a health information technology innovation can alter the process of care delivery, depending on perceptions of its value by key stakeholders.

Improving Communication With Surrogate Decision-Makers: A Pilot Initiative.

BACKGROUND: Difficult conversations in medical care often occur between physicians and patients' surrogates, individuals entrusted with medical decisions for patients who lack the capacity to make them. Poor communication between patients' surrogates and physicians may exacerbate anxiety and guilt for surrogates, and may contribute to physician stress and burnout. OBJECTIVE: This pilot study assesses the effectiveness of an experiential learning workshop that was conducted in a clinical setting, and aimed at improving resident physician communication skills with a focus on surrogate decision-making. METHODS: From April through June 2016, we assessed internal medicine residents' baseline communication skills through an objective structured clinical examination (OSCE) with actors representing standardized surrogates. After an intensive, 6-hour communication skills workshop, residents were reassessed via an OSCE on the same day. A faculty facilitator and the surrogate evaluated participants' communication skills via the expanded Gap Kalamazoo Consensus Statement Assessment Form. Wilcoxon signed rank tests (α of .05) compared mean pre- and postworkshop scores. RESULTS: Of 44 residents, 33 (75%) participated. Participants' average preworkshop OSCE scores (M = 3.3, SD = 0.9) were significantly lower than postworkshop scores (M = 4.3; SD = 0.8; Z = 4.193; P < .001; effect size r = 0.52). After the workshop, the majority of participants self-reported feeling "more confident." CONCLUSIONS: Residents' communication skills specific to surrogate decision-making benefit from focused interventions. Our pilot assessment of a workshop showed promise, and additionally demonstrated the feasibility of bringing OSCEs and simulated encounters into a busy clinical practice.

A Team-Based Online Game Improves Blood Glucose Control in Veterans With Type 2 Diabetes: A Randomized Controlled Trial.

OBJECTIVE: Rigorous evidence is lacking whether online games can improve patients' longer-term health outcomes. We investigated whether an online team-based game delivering diabetes self-management education (DSME) to patients via e-mail or mobile application (app) can generate longer-term improvements in hemoglobin A1c (HbA1c). RESEARCH DESIGN AND METHODS: Patients (n = 456) on oral diabetes medications with HbA1c ≥58 mmol/mol were randomly assigned between a DSME game (with a civics booklet) and a civics game (with a DSME booklet). The 6-month games sent two questions twice weekly via e-mail or mobile app. Participants accrued points based on performance, with scores posted on leaderboards. Winning teams and individuals received modest financial rewards. Our primary outcome measure was HbA1c change over 12 months. RESULTS: DSME game patients had significantly greater HbA1c reductions over 12 months than civics game patients (-8 mmol/mol [95% CI -10 to -7] and -5 mmol/mol [95% CI -7 to -3], respectively; P = 0.048). HbA1c reductions were greater among patients with baseline HbA1c >75 mmol/mol: -16 mmol/mol [95% CI -21 to -12] and -9 mmol/mol [95% CI -14 to -5] for DSME and civics game patients, respectively; P = 0.031. CONCLUSIONS: Patients with diabetes who were randomized to an online game delivering DSME demonstrated sustained and meaningful HbA1c improvements. Among patients with poorly controlled diabetes, the DSME game reduced HbA1c by a magnitude comparable to starting a new diabetes medication. Online games may be a scalable approach to improve outcomes among geographically dispersed patients with diabetes and other chronic diseases.

Electronic Consultations (E-consults): Advancing Infectious Disease Care in a Large Veterans Affairs Healthcare System.

The impact of e-consults on total consultative services was evaluated. After implementing infectious diseases e-consults within an electronically integrated healthcare system, consultation volume increased. As compared with face-to-face consultations, e-consults were more often related to antimicrobial guidance and were requested by off-site providers. E-consults increased the breadth and volume of total consults.

Bringing mini-chalk talks to the bedside to enhance clinical teaching.

Chalk talks - where the teacher is equipped solely with a writing utensil and a writing surface - have been used for centuries, yet little has been written about strategies for their use in medical education. Structured education proximal to patient encounters (during rounds, at the bedside, or in between patients in clinic) maximizes the opportunities for clinical learning. This paper presents a strategy to bring mini-chalk talks (MCTs) to the bedside as a practical way to provide relevant clinical teaching by visually framing teachable moments. Grounded in adult learning theory, MCTs leverage teaching scripts to facilitate discussion, involve learners at multiple levels, and embrace the increased retention associated with visual aids. These authors provide specific recommendations for the design and implementation of MCT sessions including what topics work well, how to prepare, and how to involve and engage the learners. ABBREVIATIONS: ADHD: Attention Deficit Hyperactivity Disorder; MCT: Mini-chalk talks.

The Ambulatory Diagnostic and Treatment Center: A Unique Model for Educating Medical Trainees and Providing Expedited Care.

In this article, the authors reexamine the Ambulatory Diagnostic and Treatment Center (ADTC) model, which uniquely combines the education of trainees with the care of referred patients at one Veterans Affairs medical center. As an ambulatory clinic with an inpatient mind-set, the ADTC uses a series of closely spaced outpatient appointments that are longer than typical ambulatory visits, offering a VIP-level of evaluation with the patient-centered goal of expedited diagnosis and treatment. Faculty triage patients by weighing factors such as urgency, educational value, complexity, and instability of diseases in conjunction with the resources, availability, and appropriateness of other services within the medical center.The ADTC's unique focus on the education of trainees in comparison with other clinical rotations is evident in the ratio of learning to patient care. This intensive training environment expects postgraduate year 2 and 3 internal medicine residents and fourth-year medical students to read, reflect, and review literature daily. This mix of education and care delivery is ripe for reexploration in light of recent calls for curriculum reform amidst headlines exposing delays in veterans' access to care.A low-volume, high-intensity clinic like the ADTC can augment the clinical services provided by a busy primary care and subspecialty workforce without losing its emphasis on education. Other academic health centers can learn from this model and adapt its structure in settings where accountable care organizations and education meet.

Disruptive Innovation: Implementation of Electronic Consultations in a Veterans Affairs Health Care System.

BACKGROUND: Electronic consultations (e-consults) offer rapid access to specialist input without the need for a patient visit. E-consult implementation began in 2011 at VA Boston Healthcare System (VABHS). By early 2013, e-consults were available for all clinical services. In this implementation, the requesting clinician selects the desired consultation within the electronic health record (EHR) ordering menu, which creates an electronic form that is pre-populated with patient demographic information and allows free-text entry of the reason for consult. This triggers a message to the requesting clinician and requested specialty, thereby enabling bidirectional clinician-clinician communication. OBJECTIVE: The aim of this study is to examine the utilization of e-consults in a large Veterans Affairs (VA) health care system. METHODS: Data from the electronic health record was used to measure frequency of e-consult use by provider type (physician or nurse practitioner (NP) and/or physician assistant), and by the requesting and responding specialty from January 2012 to December 2013. We conducted chart reviews for a purposive sample of e-consults and semi-structured interviews with a purposive sample of clinicians and hospital leaders to better characterize the process, challenges, and usability of e-consults. RESULTS: A total of 7097 e-consults were identified, 1998 from 2012 and 5099 from 2013. More than one quarter (27.56%, 1956/7097) of the e-consult requests originated from VA facilities in New England other than VABHS and were excluded from subsequent analysis. Within the VABHS e-consults (72.44%, 5141/7097), variability in frequency and use of e-consults across provider types and specialties was found. A total of 64 NPs requested 2407 e-consults (median 12.5, range 1-415). In contrast, 448 physicians (including residents and fellows) requested 2349 e-consults (median 2, range 1-116). More than one third (37.35%, 1920/5141) of e-consults were sent from primary care to specialists. While most e-consults reflected a request for specialist input to a generalist's question in diagnosis or management in the ambulatory setting, we identified creative uses of e-consults, including requests for face-to-face appointments and documentation of pre-operative chart reviews; moreover, 7.00% (360/5141) of the e-consults originated from our sub-acute and chronic care inpatient units. In interviews, requesting providers reported high utility and usability. Specialists recognized the value of e-consults but expressed concerns about additional workload. CONCLUSIONS: The e-consult mechanism is frequently utilized for its initial intended purpose. It has also been adopted for unexpected clinical and administrative uses, developing into a "disruptive innovation" and highlighting existing gaps in mechanisms for provider communication. Further investigation is needed to characterize optimal utilization of e-consults within specialty and the medical center, and what features of the e-consult program, other than volume, represent valid measures of access and quality care.

Limited adoption of current guidelines for clinical breast examination by primary care physician educators.

BACKGROUND: In 2004, the CDC and the American Cancer Society (ACS) published performance guidelines recommending a validated method of clinical breast exams (CBE) using the vertical strips method (VSM) along with other key exam components. We examined the use of the VSM by academic medicine physicians and identified predictor variables for its adoption. METHODS: Clinician educators in the Society of General Internal Medicine (SGIM) and physicians in the Society of Teachers of Family Medicine (STFM) were administered web-based surveys on CBE practices in 2009. RESULTS: A total of 1,772 (42%) physicians responded. Only 40% of respondents reported using the VSM, compared with 53% using the circular search method. Variables and their odds ratios (ORs) associated with an increase adoption of the VSM were having a primary teaching hospital affiliation (OR 1.4 [1.1, 1.9]), having taken a course on breast health or breast cancer in the past 5 years (OR 1.5 [1.1, 2.0]), and having completed residency in the past 5 years (OR 2.3 [1.6, 3.4]) and/or 10-15 years (OR 1.6 [1.2, 2.2]) compared to more than 15 years. The extent of teaching responsibilities was not associated with adoption of the VSM. CONCLUSIONS: A majority of physician responders highly involved in education of students and residents continue to practice methods of CBE that do not reflect the current guidelines. Faculty development and training on updated CBE practices may accelerate adoption of guideline-recommended care.

Human dimensions in bedside teaching: focus group discussions of teachers and learners.

BACKGROUND: Clinical teaching has moved from the bedside to conference rooms; many reasons are described for this shift. Yet, essential clinical skills, professionalism, and humanistic patient interactions are best taught at the bedside. PURPOSE: Clinical teaching has moved from the bedside to conference rooms; many reasons are described for this decline. This study explored perceptions of teachers and learners on the value of bedside teaching and the humanistic dimensions of bedside interactions that make it imperative to shift clinical teaching back to the bedside. METHOD: Focus group methodology was used to explore teacher and learner opinions. Four teacher groups consisted of (a) Chief Residents, (b) Residency Program Directors, (c) skilled bedside teachers, and (d) a convenience group of other Department of Medicine faculty at Boston University School of Medicine. Six learner groups consisted 2 each of 3rd-year students, PGY1 medicine residents, and PGY2 medicine residents. Each discussion lasted 60 to 90 minutes. Sessions were audiotaped, transcribed, and analyzed using qualitative methods. RESULTS: Teachers and learners shared several opinions on bedside teaching, particularly around humanistic aspects of bedside interactions. The key themes that emerged included (a) patient involvement in discussions, (b) teachers as role models of humanism, (c) preserving learner autonomy, (d) direct observation and feedback of learners at the bedside, (e) interactions with challenging patients, and (e) admitting limitations. Within these themes, participants noted some behaviors best avoided at the bedside. CONCLUSIONS: Teachers and learners regard the bedside as a valuable venue in which to learn core values of medicine. They proposed many strategies to preserve these humanistic values and improve bedside teaching. These strategies are essential for true patient-centered care.

Factors associated with disclosure of medical errors by housestaff.

PURPOSE: Attributes of the organisational culture of residency training programmes may impact patient safety. Training environments are complex, composed of clinical teams, residency programmes, and clinical units. We examined the relationship between residents' perceptions of their training environment and disclosure of or apology for their worst error. METHOD: Anonymous, self-administered surveys were distributed to Medicine and Surgery residents at Boston Medical Center in 2005. Surveys asked residents to describe their worst medical error, and to answer selected questions from validated surveys measuring elements of working environments that promote learning from error. Subscales measured the microenvironments of the clinical team, residency programme, and clinical unit. Univariate and bivariate statistical analyses examined relationships between trainee characteristics, their perceived learning environment(s), and their responses to the error. RESULTS: Out of 109 surveys distributed to residents, 99 surveys were returned (91% overall response rate), two incomplete surveys were excluded, leaving 97: 61% internal medicine, 39% surgery, 59% male residents. While 31% reported apologising for the situation associated with the error, only 17% reported disclosing the error to patients and/or family. More male residents disclosed the error than female residents (p=0.04). Surgery residents scored higher on the subscales of safety culture pertaining to the residency programme (p=0.02) and managerial commitment to safety (p=0.05). Our Medical Culture Summary score was positively associated with disclosure (p=0.04) and apology (p=0.05). CONCLUSION: Factors in the learning environments of residents are associated with responses to medical errors. Organisational safety culture can be measured, and used to evaluate environmental attributes of clinical training that are associated with disclosure of, and apology for, medical error.

The path to physician leadership in community health centers: implications for training.

BACKGROUND AND OBJECTIVES: Community health centers are facing a shortage of primary care physicians at a time when government plans have called for an expansion of community health center programs. To succeed with this expansion, community health centers require additional well-trained physician leadership. Our objective was to ascertain how medical directors obtain leadership skills in an attempt to identify the best methods and venues for providing future leadership training programs. METHODS: Using recorded interviews and focus group data with community health center medical directors, we identified patterns and themes through cross-case content analysis to determine leadership training needs in underserved settings. RESULTS: Medical directors often enter positions unprepared and can quickly become frustrated by an inability to make system improvements. Medical directors seek multiple ways to obtain the leadership skills necessary, including conferences, peer networking, mentorship, and formal degree training. Many directors express a desire for additional training, preferring flexibility in curriculum and hands-on components. CONCLUSIONS: Additional leadership training opportunities for active and future medical directors are needed. Academic medical centers and other training sponsors should consider innovative ways to develop effective physician leadership to provide quality care to underserved communities.

Comparing a self-administered measure of empathy with observed behavior among medical students.

PURPOSE: Studies show that measures of physician and medical students' empathy decline with clinical training. Presently, there are limited data relating self-reported measures to observed behavior. This study explores a self-reported measure and observed empathy in medical students. METHOD: Students in the Class of 2009, at a university-based medical school, were surveyed at the end of their 2nd and 3rd year. Students completed the Jefferson Scale of Physician Empathy-Student Version (JSPE-S), a self-administered scale, and were evaluated for demonstrated empathic behavior during Objective Structured Clinical Examinations (OSCEs). RESULTS: 97.6% and 98.1% of eligible students participated in their 2nd and 3rd year, respectively. The overall correlation between the JSPE-S and OSCE empathy scores was 0.22, p < 0.0001. Students had higher self-reported JSPE-S scores in their 2nd year compared to their 3rd year (118.63 vs. 116.08, p < 0.0001), but had lower observed empathy scores (3.96 vs. 4.15, p < 0.0001). CONCLUSIONS: Empathy measured by a self-administered scale decreased, whereas observed empathy increased among medical students with more medical training.

Improving bedside teaching: findings from a focus group study of learners.

PURPOSE: Literature reviews indicate that the proportion of clinical educational time devoted to bedside teaching ranges from 8% to 19%. Previous studies regarding this paucity have not adequately examined the perspectives of learners. The authors explored learners' attitudes toward bedside teaching, perceptions of barriers, and strategies to increase its frequency and effectiveness, as well as whether learners' stages of training influenced their perspectives. METHOD: Six focus group discussions with fourth-year medical students and first- or second-year internal medicine residents recruited from the Boston University School of Medicine and Residency Program in Internal Medicine were conducted between June 2004 and February 2005. Each 60- to 90-minute discussion was audiotaped, transcribed, and analyzed using qualitative methods. RESULTS: Learners believed that bedside teaching is valuable for learning essential clinical skills. They believed it is underutilized and described many barriers to its use: lack of respect for the patient; time constraints; learner autonomy; faculty attitude, knowledge, and skill; and overreliance on technology. Learners suggested a variety of strategies to mitigate barriers: orienting and including the patient; addressing time constraints through flexibility, selectivity, and integration with work; providing learners with reassurance, reinforcing their autonomy, and incorporating them into the teaching process; faculty development; and advocating evidence-based physical diagnosis. Students focused on the physical diagnosis aspects of bedside teaching, whereas views of residents reflected their multifaceted roles as learners, teachers, and managers. CONCLUSIONS: Bedside teaching is valuable but underutilized. Including the patient, collaborating with learners, faculty development, and promoting a supportive institutional culture can redress several barriers to bedside teaching.

Prolonged cerebellar ataxia: an unusual complication of hypoglycemia.

A 51-year-old male with a history of insulin-dependent diabetes and polysubstance abuse presented after overdose on insulin. Soon after resuscitation, he displayed a severe ataxia in all 4 limbs and was unable to walk; all of which persisted for at least 5 days. Laboratory testing was unrevealing, including relatively normal brain magnetic resonance imaging. He had recovered full neurologic function 3 months after the event. This report describes a case of reversible cerebellar ataxia as a rare complication of severe hypoglycemia that may occur in patients with abnormal cerebellar glucose metabolism. Thus, this phenomenon should be included in the differential diagnosis of patients with a history of hypoglycemia who present with ataxia. In this context, the differential diagnosis of cerebellar ataxia is discussed, as is the proposed mechanism for hypoglycemia-induced cerebellar dysfunction.