Implementation, Reach, and Effectiveness of the Direct Observation of Residents in Clinic Program.

BACKGROUND: Direct observation is important, yet medical residents are rarely observed. We implemented and evaluated a direct observation program in resident clinics to increase the frequency of observation and feedback and improve perceptions about direct observation. METHODS: We assigned faculty as observers in our resident clinics between June 2019 and February 2020. We surveyed residents and faculty before and after the program. Faculty completed a form for each observation performed. We analyzed surveys to examine changes in barriers, frequency and type of observations and feedback, and attitudes toward observation. The analytical sample included 38 and 37 pre- and postresident surveys, respectively, and 20 and 25 pre- and postfaculty surveys, respectively. RESULTS: Resident survey response rates were 32.3% (40/124) pre- and 30.7% (39/127) postintervention. Most residents (76% [pre], 86% [post], P = 0.258) reported being observed in at least one of the four areas: history, examination, counseling, or wrap-up. We received observation tracking forms on 68% of eligible residents. Observed history taking increased from 30% to 79% after the program (P = 0.0010). Survey response rates for faculty were 64.7% (22/34) pre- and 67.5% (25/37) postintervention. Fewer faculty reported time (80% [pre], 52% [post], P = 0.051) and competing demands (65% [pre], 52% [post], P = 0.380) as barriers postintervention. Fewer faculty postintervention viewed observation as a valuable teaching tool (100% [pre], 79% [post], P = 0.0534). All faculty who did not view observation as valuable were the least experienced. DISCUSSION: Assigning faculty as observers can increase observation, especially in history taking, though data suggest an increase in negative perceptions of observation by faculty.

Postpartum Maternal Hypothermia in an Adolescent Patient Following Spontaneous Vaginal Delivery.

Postpartum hypothermia, though rare after spontaneous vaginal delivery, can be life-threatening, warranting efficient workup and intervention. A 14-year-old primigravida developed postpartum hypothermia following spontaneous vaginal delivery. No clear etiology was identified despite extensive workup. Intervention with warmed fluids and application of forced air warming system resolved the hypothermia in less than 24 hours without relapse. Following negative workup, the most likely etiology was administration of chilled intravenous fluids in the setting of acute blood loss of delivery and physiologic vasodilation of pregnancy. This case demonstrates the importance of considering common and unusual causes of postpartum hypothermia and leads to a recommendation for routine postpartum temperature checks and hypothermia protocols that include warmed fluid replacement and a forced air warming system.

Relationships Between English Language Proficiency, Health Literacy, and Health Outcomes in Somali Refugees.

Little is known about the impacts of health literacy and English proficiency on the health status of Somali refugees. Data came from interviews in 2009-2011 of 411 adult Somali refugees recently resettled in Massachusetts. English proficiency, health literacy, and physical and mental health were measured using the Basic English Skills Test Plus, the Short Test of Health Literacy in Adults, and the Physical and Mental Component Summaries of the Short Form-12. Associations were analyzed using multiple linear regression. In adjusted analyses, higher English proficiency was associated with worse mental health in males. English proficiency was not associated with physical health. Health literacy was associated with neither physical nor mental health. Language proficiency may adversely affect the mental health of male Somali refugees, contrary to findings in other immigrant groups. Research on underlying mechanisms and opportunities to understand this relationship are needed.

Identifying and Addressing Language Needs in Primary Care: a Pilot Implementation Study.

BACKGROUND: Medical interpreters improve care for patients with Limited English Proficiency but are underused. Protocols to improve interpreter use in primary care are needed. METHODS: Medical Assistants (MAs) screened patients for language needs and arranged for telephone interpreters during rooming in two pilot clinics (PCs). We interviewed MAs and providers and analyzed interviews using modified grounded theory, linking themes to the Promoting Action on Research Implementation in Health Services (PARiHS) framework categories of Context, Evidence, and Facilitation. Providers in PCs and four comparison clinics were surveyed. RESULTS: Context themes included issues with the telephone interpreter vendor; having established teams, roles and workflows; and difficulty incorporating time-sensitive tasks. Evidence themes included engagement in language screening; preferring in-person interpreters; improving the patient experience; and having mixed responses to the protocol. Facilitation themes included MAs needing more support. PC providers were more satisfied with care (OR = 12.7) and communication (OR = 7.6) than comparison clinic providers. CONCLUSIONS: The protocol may improve patient care and communication, but implementation was inconsistent. Language screening is a complex process and further research is needed to improve screening questions and procedures. Future interventions should capitalize on team members' drives to improve patient care and control costs but also need to consider the impacts of health system changes, and to consider the culture, training needs, roles, and relationships of team members.

Feasibility and Patient Perceptions of Video Declarations Regarding End-of-Life Decisions by Hospitalized Patients.

BACKGROUND: A videotaped declaration by patients of their advance care planning preferences could be an opportunity to supplement advance directive forms and be a source of information for family, caregivers, and clinicians, yet research is needed to examine the content and acceptability of making declarations among patients. OBJECTIVE: To evaluate the content and acceptability of 'video declarations': the process of patients videotaping themselves describing their advance care planning preferences. DESIGN: We showed a brief video describing three approaches to end-of-life care and then invited participants to use an iPad to videotape themselves making a declaration about their wishes. SETTING/SUBJECTS: Hospitalized patients from a large urban U.S. safety net hospital. MEASUREMENTS: We interviewed participants about the acceptability of the declaration process. Declarations were transcribed and coded by a team, with multiple stakeholder input. RESULTS: There were 16 participants; mean age was 60 (SD = 14) years. One participant declined. Out of 15 declarations, most were able to express their wishes for CPR (n = 12) and intubation (n = 13). Participants frequently discussed their family structure (n = 11), religious/spiritual well-being (n = 8), legacy/dignity issues (n = 6), and physical symptoms (n = 6). Nine declarations had directives judged to be unclear. The majority (66%) thought that this process was quite a bit or extremely helpful. CONCLUSIONS: Findings show that asking hospitalized patients to make videos describing their advance care planning preferences was feasible and acceptable. While the majority described their wishes around CPR and intubation, a fair amount of uncertainty remained. Further research is needed to support patients in describing their wishes clearly and test the effectiveness of video declarations to promote care concordant with preferences.

Persistent pneumocystis colonization leads to the development of chronic obstructive pulmonary disease in a nonhuman primate model of AIDS.

Human immunodeficiency virus (HIV)-infected patients are at increased risk for development of pulmonary complications, including chronic obstructive pulmonary disease (COPD). Inflammation associated with subclinical infection has been postulated to promote COPD. Persistence of Pneumocystis is associated with HIV infection and COPD, although a causal relationship has not been established. We used a simian/human immunodeficiency virus model of HIV infection to study pulmonary effects of Pneumocystis colonization. Simian/human immunodeficiency virus-infected/Pneumocystis-colonized monkeys developed progressive obstructive pulmonary disease characterized by increased emphysematous tissue and bronchial-associated lymphoid tissue. Increased levels of T helper type 2 cytokines and proinflammatory mediators in bronchoalveolar lavage fluid coincided with Pneumocystis colonization and a decline in pulmonary function. These results support the concept that an infectious agent contributes to the development of HIV-associated lung disease and suggest that Pneumocystis colonization may be a risk factor for the development of HIV-associated COPD. Furthermore, this model allows examination of early host responses important to disease progression, thus identifying potential therapeutic targets for COPD.