Physician Advocacy: Identifying Motivations for Work Beyond Clinical Practice.

Introduction: Advocacy is a perceived social and professional obligation of physicians. However, many feel their training and practice environment do not support increased engagement in advocacy. The aim of this qualitative project was to delineate the role that advocacy plays in physicians' careers and the factors driving physician engagement in advocacy. Methods: Physicians engaged in health advocacy in Kansas were identified by personal contacts and referrals through snowball sampling. They received a standardized email invitation to participate in a short interview. These interviews were recorded and transcribed using Apple Voice Memos and Google Dictation. Two team members independently identified themes from interview transcripts, while a third member served as a moderator if themes identified were dyssynchronous. Results: Of the 19 physicians invited to participate, 13 were interviewed. The most common reasons for engaging in advocacy included the desire to change policy, obligation to go beyond regular clinic duties, giving patients a voice, and avoiding burnout. Physicians reported passion for patients and past experiences with disparities as the most common inspiration. Most physicians did not receive formal advocacy training, but identified professional societies and peers as informal guides. Common supports for advocacy were professional organizations, community partners, and employers. Time was the most common barrier to conducting advocacy work. Conclusions: Physicians have a broad number of reasons for the importance of doing advocacy work, but identify key professional barriers to further engagement. Providing accessible opportunities through professional organizations and community partnerships may increase advocacy participation.

Factors Associated with Musculoskeletal Injuries While Hiking with a Backpack at Philmont Scout Ranch.

INTRODUCTION: Participants at Philmont Scout Ranch embark on 12-d treks with pre-trek physical conditioning and medical clearance by their primary care physician. In this study, we investigated potential contributing factors to self-reported musculoskeletal injuries during a backpack trek. METHODS: This study was a prospective cohort study that used a 3-part survey administered to participants before, during, and after their trek from June through August 2019. Health history and demographic information were retrieved from each hiker's medical record. A logistic regression model was used to assess factors associated with injuries, and odds ratios and 95% confidence intervals were reported. RESULTS: There were 1206 individuals enrolled in this study, and none withdrew from participation. The median age of the participants was 17 y (interquartile range 15-47); 1130 were male, 75 were female, and 1 was of unknown sex. Injuries were reported by 7% (n=88) of participants while in the backcountry, with injuries occurring in various anatomic locations (knee, ankle, leg, foot, hand, arm). Participants without missing data (74%; n=897) were included in the logistical regression analysis to describe factors significantly associated with injury. Factors significantly associated with injury included greater backpack weight to body weight ratio, body mass index greater than 30 kg·m-2, and past injuries that required a doctor visit. CONCLUSIONS: Self-reported injuries while hiking at Philmont Scout Ranch are infrequent and do not often require evacuation or advanced medical care. Camp policies to maintain appropriate backpack weight and counseling of obese and previously injured individuals may mitigate injury occurrence.

Health Advocacy and Training Perceptions: a Comparison of Medical Student Opinions.

BACKGROUND: The American Medical Association considers health advocacy to be a core aspect of a physician's responsibility, which has sparked medical schools to institutionalize training. However, there is little information regarding student perspectives on advocacy education. PURPOSE: To evaluate medical student opinions on advocacy education and to determine similarities and differences across classes. METHODS: In this qualitative study, four focus groups were conducted with five to eight students from each medical school class. Students were randomly selected from rosters and received an email to participate. Sessions were audiotaped and transcribed, and demographic data was obtained. Investigators reviewed transcripts independently and identified important items in each transcript then consolidated common themes into groups. These themes were integrated into concept map representations. RESULTS: Of those contacted, 25 (16%) students chose to participate in focus group sessions. All participants who responded to questionnaires (n = 24) identified advocacy in medicine as very important. Definitions of advocacy varied among students and classes. Common themes in all focus groups included feeling overwhelmed by advocacy due to lack of time, lack of perceived prioritization in medical education, feelings of imposter syndrome, and inability to align individual views with healthcare systems. Another common theme was frustration that students learned of advocacy through didactic sessions rather than engagement in advocacy work. CONCLUSIONS: All participating students identified advocacy as an important aspect of medicine, yet students felt inadequately prepared to participate in advocacy work. This reveals an opportunity to improve upon the formal education needed to engage in advocacy.

Blood Pressure Changes While Hiking at Moderate Altitudes: A Prospective Cohort Study.

Recreational hiking in the mountains is a common activity, whether for a single day or for several days in a row. We sought to measure blood pressure (BP) response during a 10-day trek at moderate-altitude elevation (6500-13,000 feet) and observe for uncontrolled hypertension and/or adverse cardiovascular outcomes. A total of 1279 adult participants completed an observational study of resting BP during a 10-day trek in the Sangre de Cristo mountains. Following initial recruitment, participants were issued a trail data card to record BP measurements at day 0 (basecamp), day 3, day 6 and day 9. BP was measured using a sphygmomanometer and auscultation. Demographic data, height, weight, home altitude, daily water and sports drink intake, existence of pre-arrival hypertension and BP medication class were also recorded. We observed a rise in mean blood pressure for the cohort during all exposures to moderate altitudes. The increases were greatest for individuals with pre-existing hypertension and/or obesity. There were no observed life-threatening cardiovascular events for participants. We conclude that for individuals with a modestly controlled blood pressure of 160/95 mmHg, hiking at a moderate altitude is a safe activity.

Population Health in the Medical School Curriculum: a Look Across the Country.

INTRODUCTION: Population health (PH) is an important component of medical school education and is required for physicians to practice effectively. Identifying the number of medical schools teaching population health and the individual curricular components could lead to a better understanding of the current status of population health implementation into medical education. MATERIALS AND METHODS: Between February and March 2019, medical schools in the USA were surveyed about the structure and content of their population health curriculum. Differences were analyzed by school funding and class size. RESULTS: Respondents were gathered from 28 (68%) public and 13 (32%) private schools; 27 (66%) schools having fewer than 150 students and 14 (34%) having greater than or equal to 150. Thirty-two schools (78%) had a structured PH curriculum. Seven (22%) only had a dedicated preclinical module and 33 (83%) had a longitudinal curriculum throughout multiple years of school. Many programs utilized flipped classroom models (n = 19, 46%); however, only 8 (20%) utilized standardized patients. Health disparities (100%), community health initiatives (88%), and preventative health guidelines (88%) are among the most commonly taught subjects. Quality improvement was taught by 34 of 41 programs (83%), but only sixteen (39%) schools required students to complete a quality improvement project. DISCUSSION: Differences in population health curricula were found between school size and funding. As evidenced by this study, most medical schools recognize the importance of population health by including it in their curriculum and a majority are incorporating the subject longitudinally into multiple years of school.

Incidence and Characteristics Associated with Hospital Readmission after Discharge to Home Hospice.

Background: Home hospice is designed to provide comfort to patients at the end of their life and hospital readmission is incongruent with this goal. Objective: The purpose of this study was to investigate the incidence of and characteristics associated with hospital readmissions from home hospice over a two-year period. Design/Subjects: This was a retrospective cohort study of 705 inpatients discharged from a quaternary academic medical center to home hospice from January 1, 2016 to December 31, 2017. Measures: The primary outcome was incidence of hospital readmission after discharge to home hospice. Multivariate regression with stepwise forward selection was used to identify characteristics associated with readmission. Results: The incidence of readmission was found to be 10.50% (n = 74), and the median days from discharge to readmission were 32.50 days (interquartile range = 14.00, 75.00). Reasons for readmission were: unanticipated new medical issue (n = 33, 44.59%), uncontrolled symptoms (n = 25, 33.78%), misunderstanding of hospice status (n = 12, 16.22%), and caregiver distress (n = 4, 5.41%). The following characteristics were associated with readmission: female versus male (odds ratio [OR] = 1.96; 95% confidence interval [CI]: 1.16-3.32), non-white versus white (OR = 2.40; 95% CI: 1.36-4.24), and hospice diagnosis of cardiac disease versus all other diagnoses (OR = 4.40; 95% CI: 2.06-9.37). Conclusions: Compared with prior studies, our findings showed a lower incidence of readmission, 10.50%, from home hospice. In addition, those who are female, non-white, or have a hospice diagnosis of cardiac disease are more likely to be readmitted.

Appropriate utilisation of cardiac telemetry monitoring: a quality improvement project.

For hospitals located in the United States, appropriate use of cardiac telemetry monitoring can be achieved resulting in cost savings to healthcare systems. Our institution has a limited number of telemetry beds, increasing the need for appropriate use of telemetry monitoring to minimise delays in patient care, reduce alarm fatigue, and decrease interruptions in patient care. This quality improvement project was conducted in a single academic medical centre in Kansas City, Kansas. The aim of the project was to reduce inappropriate cardiac telemetry monitoring on intermediate care units. Using the 2004 American Heart Association guidelines to guide appropriate telemetry utilisation, this project team sought to investigate the effects of two distinct interventions to reduce inappropriate telemetry monitoring, huddle intervention and mandatory order entry. Telemetry utilisation was followed prospectively for 2 years. During our initial intervention, we achieved a sharp decline in the number of patients on telemetry monitoring. However, over time the efficacy of the huddle intervention subsided, resulting in a need for a more sustained approach. By requiring physicians to input indication for telemetry monitoring, the second intervention increased adherence to practice guidelines and sustained reductions in inappropriate telemetry use.