Rurality and Atrial Fibrillation: Patient Perceptions of Barriers and Facilitators to Care.

Background Patients experience atrial fibrillation (AF) as a complex disease given its adversity, chronicity, and necessity for long-term treatments. Few studies have examined the experience of rural individuals with AF. We conducted qualitative assessments of patients with AF residing in rural, western Pennsylvania to identify barriers and facilitators to care. Methods and Results We conducted 8 semistructured virtual focus groups with 42 individuals living in rural western Pennsylvania using contextually tailored questions to assess participant perspectives. We inductively analyzed focus group transcripts using paragraph-by-paragraph and focused coding to identify themes with the qualitative description approach. We used Krippendorff α scoring to determine interreviewer reliability. We harnessed investigator triangulation to augment the reliability of our findings. We reached thematic saturation after coding 8 focus groups. Participants were 52.4% women, with a median age of 70.9 years (range, 54.5-82.0 years), and most were White race (92.9%). Participants identified medication costliness, invisibility of AF to others, and lack of emergent transportation as barriers to care. Participants described interpersonal support and use of technology as important for AF self-care, and expressed ambivalence about how relationships with health care providers affected AF care. Conclusions Focus group participants described multiple social and structural barriers to care for AF. Our findings highlight the complexity of the experience of individuals with AF residing in rural western Pennsylvania. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04076020.

Prudence in end-of-life decision making: A virtue-based analysis of physician communication with patients and surrogates.

Despite significant improvements in end-of-life care over several decades, belated hospice referrals and hospital staffing patterns make challenging end-of-life conversations between strangers unsurprising, especially when the interaction is time-sensitive. Understanding how physicians perform under these circumstances is relevant to patient quality and medical education. This study is a secondary analysis of transcripts from a simulation that placed 88 intensivists, hospitalists, and ED physicians in the setting of responding to a nurse's call to evaluate a floor patient for impending respiratory collapse. A philosophical account of prudence guided the analytical approach and was operationalized through behavior-based and exemplar-based qualitative coding strategies. Exemplary performances and specific behaviors were then compared with preferred outcomes. Results indicate that exemplary performance correlated with a cluster of 3 behaviors that predicted the desired outcomes, but did not determine them: (1) directly affirming the likelihood that the patient will die in the near term; (2) explicitly soliciting the patient's preferences for care; and (3) asking what other family and friends should be involved. The current study implies that educational initiatives aimed at improving end-of-life conversations should expose clinicians both to technical competencies and to the virtues required to employ these competencies well.

Cultures of Practice: Specialty-Specific Differences in End-of-Life Conversations.

Importance: Goals of care discussions at the end of life give opportunity to affirm the autonomy and humanity of dying patients. Best practices exist for communication around goals of care, but there is no research on differences in approach taken by different specialties engaging these conversations. Objective: To describe the communication practices of internal medicine (IM), emergency medicine (EM), and critical care (CC) physicians in a high-fidelity simulation of a terminally ill patient with stable and defined end-of-life preferences. Design, Setting, and Participants: Mixed-methods secondary analysis of transcripts obtained from a multicenter study simulating high stakes, time-limited end-of-life decision making in a cohort of 88 volunteer physicians (27 IM, 22 EM, and 39 CC) who were called to evaluate a standardized patient in extremis. The patient had clear comfort-oriented goals of care that the physician needed to elicit and use to inform treatment decisions. Discussions were coded at the level of the sentence for semantic content. Exposures: Data were analyzed by physician specialty. Main Outcome Measure: Occurrence of content codes indicative of prudent (right outcome by the right means) goals of care conversations. Data were analyzed both for number of occurrences of the code in a simulated conversation and for presence or absence of the code within a conversation. Results: There was no difference between physician types in intubation rates or intensive care unit admissions. Codes for "comfort as a goal of care," "noncurative goals of care," and "oblique references to death" emerged as significantly different between physician types. Conclusions and Relevance: This experiment shows demonstrable differences in practice patterns between physician specialties when addressing end-of-life decision making. Some of the variation likely arose from differences in setting, but these data suggest that training in goals of care conversations may benefit if it is adapted to the distinct needs and culture of each specialty.

Outpatient precepting of international medical graduates in family medicine.

BACKGROUND: The purpose of this study was to examine outpatient precepting for international medical graduates (IMGs) in family medicine residencies. The education of IMGs in residency programs has been a subject of concern. Multiple obstacles in acculturation may negatively influence IMGs' thoughts/feelings and subsequently affect their learning in teacher-learner interaction especially during a time-constrained environment like outpatient precepting. However, there is no research on IMGs' thoughts and feelings during outpatient precepting. METHODS: We used qualitative research using multiple methods, primarily semi-structured individual interview during Interpersonal Process Recall (IPR). We purposefully sampled IMGs from three family medicine residency programs and videotaped their outpatient precepting. As a standard for comparison, we also videotaped US medical graduates (USMGs). We used multiple methods to explore their thoughts/feelings during precepting: brief interview, preceptor questionnaire, video review, and IPR debriefing of the precepting encounter. For analysis, we developed thematic codes from IPR transcripts and explored their consistency with data from the three other sources. RESULTS: Seven themes emerged: cultural differences, language barriers, clinical performance, relationship, preceptor's teaching behaviors/attitudes, internalized process, and external factors. IMGs experienced various negative thoughts and feelings related to language barriers and cultural differences. These internalized processes adversely influenced their learning attitudes, precepting behaviors, and clinical performance. CONCLUSIONS: Precepting is more stressful for IMGs than for USMGs. IMGs need more specific orientation for outpatient precepting, and preceptors need further opportunity to reflect on their precepting skills for IMGs. Residency programs may do well to develop and test a curriculum and learning environment to meet IMGs' special needs.