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OBJECTIVE The number of unsolicited patient complaints (UPCs) about surgeons correlates with surgical complications and malpractice claims. Using a large, national patient complaint database, the authors sought to do the following: 1) compare the rates of UPCs for neurosurgeons to those for other physicians, 2) analyze the risk of UPCs with individual neurosurgeon characteristics, and 3) describe the types of UPCs made about neurosurgeons. METHODS Patient and family complaint reports among 36,265 physicians, including 423 neurosurgeons, 8292 other surgeons, and 27,550 nonsurgeons who practiced at 33 medical centers (22 academic and 11 regional) from January 1, 2014, to December 31, 2017, were coded with a previously validated Patient Advocacy Reporting System (PARS) algorithm. RESULTS Among 423 neurosurgeons, 93% were male, and most (71%) practiced in academic medical centers. Neurosurgical subspecialties included general practice (25%), spine (25%), tumor (16%), vascular (13%), functional (10%), and pediatrics (10%). Neurosurgeons had more average total UPCs per physician (8.68; 95% CI 7.68–9.67) than nonsurgeons (3.40; 95% CI 3.33–3.47) and other surgeons (5.01; 95% CI 4.85–5.17; p < 0.001). In addition, a significantly higher percentage of neurosurgeons received at least one UPC (71.6%; 95% CI 67.3%–75.9%) than did nonsurgeons (50.2%; 95% CI 49.6%–50.8%) and other surgeons (58.2%; 95% CI 57.1%–59.3%; p < 0.001). Factors most associated with increased average UPCs were younger age, measured as median medical school graduation year (1990.5 in the 0-UPC group vs 1993 in the 14+-UPC group, p = 0.009) and spine subspecialty (13.4 mean UPCs in spine vs 7.9 mean UPCs in other specialties, 95% CI 2.3–8.5, p < 0.001). No difference in complaints was seen in those who graduated from non-US versus US medical schools (p = 0.605). The most common complaint types were related to issues surrounding care and treatment, communication, and accessibility, each of which was significantly more common for neurosurgeons than other surgical specialties (p < 0.001). CONCLUSIONS Neurosurgeons were more likely to generate UPCs than other surgical specialties, and almost 3 out of 4 neurosurgeons (71.6%) had at least one UPC during the study period. Prior studies have shown that feedback to physicians about behavior can result in fewer UPCs. These results suggest that neurosurgeons have opportunities to reduce complaints and potentially improve the overall quality of care delivered.

Dedicated leadership, effective planning and teamwork, and reliable implementation are essential elements of successful healthcare initiatives, clinical outcomes and research endeavors. Lapses in professional conduct at any level may undermine the teamwork necessary to achieve goals in safety and outcomes. Therefore, Academic Medical Center (AMC) leaders need means for identifying lapses and addressing unnecessary variation in professional performance. This chapter discusses application of self- and group-regulation—hallmarks of professionalism—to a hypothetical AMC faculty member, “Dr. A,” recruited to create a Coordinated Clinical Care Center, an important programmatic need for the department. Despite his department Chair’s expectations that Dr. A will implement a multidisciplinary approach to patient care, evidence accumulates that Dr. A’s performance is undermining attainment of the Center’s goals. The chapter describes an evidence-based plan and process by which AMCs may promote professionalism and restore full and effective functioning (“redeem”) physicians—both leaders like Dr. A and non-leader colleagues—who model conduct inconsistent with AMC values and a culture of safety.

Objectives Determine whether words contained in unsolicited patient complaints differentiate physicians with and without neurocognitive disorders (NCD). Methods We conducted a nested case-control study using data from 144 healthcare organizations that participate in the Patient Advocacy Reporting System (PARS ® ) program. Cases (physicians with probable or possible NCD) and two comparison groups of 60 physicians each (matched for age/sex and site/number of unsolicited patient complaints) were identified from 33,814 physicians practicing at study sites. We compared the frequency of words in patient complaints related to an NCD diagnostic domain between cases and our two comparison groups. Results Individual words were all statistically more likely to appear in patient complaints for cases (73% of cases had at least one such word) compared to age/sex matched (8%, p 2 = 30.21, d.f. = 1) and site/complaint matched comparisons (18%, p 2 = 17.51, d.f. = 1). Cases were significantly more likely to have at least one complaint with any word describing NCD than the two comparison groups combined (conditional logistic model adjusted odds ratio 20.0 (95% confidence interval 4.9-81.7)). Conclusions Analysis of words in unsolicited patient complaints found that descriptions of interactions with physicians with NCD were significantly more likely to include words from one of the diagnostic domains for NCD than were two different comparison groups. Further research is needed to understand whether patients might provide information for healthcare organizations interested in identifying professionals with evidence of cognitive impairment.

Introduction Previous research reveals associations between patient complaints and urological subspecialty, but relationships between complaints and practice environments have gone untested. In this study we explored whether associations exist between the types and rates of patient complaints filed against urological surgeons and their practice environments, defined as academic (medical school faculty) or community (independent medical group members). Complaints are a surrogate for malpractice litigation risk, so understanding the variables that drive complaints may suggest risk reduction interventions. Methods In this retrospective, exploratory study we examined 2,883 unsolicited patient complaints about 357 urologists affiliated with organizations partnering with the Vanderbilt Center for Patient and Professional Advocacy. Overall 222 (62%) urologists were practicing in 16 academic medical center systems and 135 (38%) in 11 community systems that recorded complaints from January 1, 2011 through December 31, 2014. Specific concerns about urologists were counted. Complaint type profiles were generated using a standardized coding system. Statistical analyses tested associations among practice environment (academic vs community), complaint counts and distribution of complaints by type. Results Academic urologists had more complaints per physician than their community colleagues (Z = 2.53, p Conclusions Academic urologists are associated with more patient complaints than community urologists, suggesting greater exposure to medical malpractice claims. Concerns regarding access, communication and the care that patients received appear to drive this discrepancy. Personal practice and clinical management solutions designed to improve these elements of patient experiences, especially access, may help reduce medical malpractice claims related activity.

To analyze unsolicited patient complaints (UPCs) among otolaryngologists, identify risk factors for UPCs, and determine the impact of physician feedback on subsequent UPCs.This retrospective study reviewed UPCs associated with US otolaryngologists from 140 medical practices from 2014 to 2017. A subset of otolaryngologists with high UPCs received peer-comparative feedback and was monitored for changes.The study included 29,778 physicians, of whom 548 were otolaryngologists. UPCs described concerns with treatment (45%), communication (19%), accessibility (18%), concern for patients and families (10%), and billing (8%). Twenty-nine (5.3%) otolaryngologists were associated with 848 of 3659 (23.2%) total UPCs. Male sex and graduation from a US medical school were statistically significantly associated with an increased number of UPCs ( P = .0070 and P = .0036, respectively). Twenty-nine otolaryngologists with UPCs at or above the 95th percentile received peer-comparative feedback. The intervention led to an overall decrease in the number of UPCs following intervention ( P = .049). Twenty otolaryngologists (69%) categorized as "responders" reduced the number of complaints an average of 45% in the first 2 years following intervention.Physician demographic data can be used to identify otolaryngologists with a greater number of UPCs. Most commonly, UPCs expressed concern regarding treatment. Peer-delivered, comparative feedback can be effective in reducing UPCs in high-risk otolaryngologists.Systematic monitoring and respectful sharing of peer-comparative patient complaint data offers an intervention associated with UPCs and concomitant malpractice risk reduction. Collegial feedback over time increases the response rate, but a small proportion of physicians will require directive interventions.

Purpose The number of unsolicited patient complaints about a physician has been shown to correlate with increased malpractice risk. Using a large national patient complaint database, we evaluated the number and content of unsolicited patient complaints about ophthalmologists to identify significant risk factors for receiving a complaint. Design Retrospective cohort study. Participants Ophthalmologists, nonophthalmic surgeons, nonophthalmic nonsurgeons. Methods We analyzed 2087 unsolicited or spontaneous complaints reported about 815 ophthalmologists practicing in 24 academic and nonacademic organizations using the Patient Advocacy Reporting System (PARS). Complaints against 5273 nonophthalmic surgeons and 19487 nonophthalmic nonsurgeons during the same period were used for comparison. Complaint type profiles were assigned using a previously validated standardized coding system. We (1) described the distribution of complaints against ophthalmologists; (2) compared the distribution and rates of patient complaints about ophthalmologists with those of nonophthalmic surgeons and nonophthalmic nonsurgeons in the database; (3) analyzed differences in complaint type profiles and quantity of complaints by ophthalmic subspecialty, practice setting, physician gender, medical school type, and graduation date; and (4) identified significant risk factors for high numbers of unsolicited patient complaints after adjusting for other covariates. Main Outcome Measures Unsolicited patient complaints. Results Ophthalmologists had significantly fewer complaints per physician than other nonophthalmic surgeons and nonsurgeons. Sixty-three percent of ophthalmologists had 0 complaints, whereas 10% of ophthalmologists accounted for 61% of all complaints. Ophthalmologists from academic centers, female ophthalmologists, and younger ophthalmologists had significantly more complaints ( P P P Conclusions Ophthalmologists had significantly fewer complaints than nonophthalmic surgeons and nonophthalmic nonsurgeons, and by implication may have a lower malpractice risk as a group. Nevertheless, a small number of ophthalmologists generated a disproportionate number of complaints. Working at an academic center was a significant independent risk factor for having more patient complaints. Further research is needed to clarify the underlying reasons for this association and to identify interventions that may decrease this risk.

Objectives The aims of the study were to develop a valid and reliable taxonomy of coworker reports of alleged unprofessional behavior by physicians and advanced practice professionals and determine the prevalence of reports describing particular types of unprofessional conduct. Methods We conducted qualitative content analysis of coworker reports of alleged unprofessional behavior by physicians and advanced practice professionals to create a standardized taxonomy. We conducted a focus group of experts in medical professionalism to assess the taxonomy's face validity. We randomly selected 120 reports (20%) of the 590 total reports submitted through the medical center's safety event reporting system between June 2015 and September 2016 to measure interrater reliability of taxonomy codes and estimate the prevalence of reports describing particular types of conduct. Results The initial taxonomy contained 22 codes organized into the following four domains: competent medical care, clear and respectful communication, integrity, and responsibility. All 10 experts agreed that the four domains reflected essential elements of medical professionalism. Interrater reliabilities for all codes and domains had a κ value greater than the 0.60 threshold for good reliability. Most reports (60%, 95% confidence interval = 51%-69%) described disrespectful or offensive communication. Nine codes had a prevalence of less than 1% and were folded into their respective domains resulting in a final taxonomy composed of 13 codes. Conclusions The final taxonomy represents a useful tool with demonstrated validity and reliability, opening the door for reliable analysis and systems to promote accountability and behavior change. Given the safety implications of unprofessional behavior, understanding the typology of coworker observations of unprofessional behavior may inform organization strategies to address this threat to patient safety.

Introduction Unsolicited patient complaints (UPCs) serve as a powerful predictor of increased risk of malpractice claims, and reductions in UPCs, through targeted physician interventions, lower incidence of lawsuits and decrease cost of risk management. We analyzed UPCs, verified by trained counselors in patient relations, to determine the malpractice risk of plastic surgeons, compared to dermatologists, all surgeons, and all physicians, from a national patient complaint registry. Methods We examined the patient complaint profiles and risk scores of 31,077 physicians (3935 surgeons, 338 plastic and reconstructive surgeons, and 519 dermatologists), who participated in the Patient Advocacy Reporting System, a national registry of UPCs. Patient complaint data were collected from 70 community and academic hospitals across 29 states, from 2009 to 2012. In addition to determining the specific complaint mix for plastic surgery compared to all physicians, each physician was assigned a patient complaint risk score, based on a proprietary weighted-sum algorithm, with a score higher than 70, indicative of high risk for malpractice claims. Patient complaint profiles and risk scores were compared between all groups, using Wilcoxon rank and χ analysis. P values less than 0.05 were assigned statistical significance. Results Over this 4-year period, the majority of plastic surgeons (50.8%) did not generate any patient complaints, but those who did received an average of 9.8 complaints from 4.8 patients. The percentage of physicians at high risk for malpractice claims, based upon the Patient Advocacy Reporting System index score of patient complaints, was as follows: all physicians, 2.0%; all surgeons, 4.1%; plastic and reconstructive surgeons, 2.4%; dermatologists, 1.4%. Physicians (from 2012 only) who were identified by their sponsoring institutions as "reconstructive" plastic surgeons (n = 41) were 5 times as likely to have a high risk score, compared to physicians who were identified as "plastic" surgeons (n = 233), and were more likely to practice within an academic health care system that had a level 1 trauma center and a plastic surgery residency program. The overall mix of patient complaints from plastic and reconstructive surgeons was nearly the same as the national cohort of all physicians: care and treatment, 49%; communication, 19%; accessibility and availability, 14%; money or payment issues, 9%; and concern for patient/family, 9%. Conclusions "Reconstructive" plastic surgeons are at increased risk for UPCs, compared to most physicians, especially dermatologists. Because UPCs are a robust proxy for malpractice risk, targeted interventions to decrease patient complaints may improve patient satisfaction and reduce malpractice claims and risk management activity. Monitoring UPCs may permit early identification of high-risk surgeons before malpractice claims accumulate.

Importance Understanding the distribution of patient complaints by physician age may provide insight into common patient concerns characteristic of early, middle, and late stages of careers in ophthalmology. Most previous studies of patient dissatisfaction have not addressed the association with physician age or controlled for other characteristics (eg, practice setting, subspecialty) that may contribute to the likelihood of patient complaints, unsafe care, and lawsuits. Objective To assess the association between ophthalmologist age and the likelihood of generating unsolicited patient complaints (UPCs) among a cohort of ophthalmologists. Design, Setting, and Participants Retrospective cohort study with variable duration of follow-up. The study assessed time to first complaint between 2002 and 2015 in 1342 attending ophthalmologists or neuro-ophthalmologists who had graduated from medical school before 2010 and were affiliated with an organization that participates in Vanderbilt University Medical Center’s Patient Advocacy Reporting System. Participants were stratified into 5 age bands and were followed up from the time of their employment to receipt of their first complaint. Trained coders categorized UPCs into 34 specific types under 6 major categories. Main Outcomes and Measures Time to first recorded complaint. Multivariable Cox proportional hazards model was used to measure the association between time to first complaint and ophthalmologist age after adjustment for predetermined covariates. Results The median physician age was 47 years, with 9% who were 71 years or older. The cohort was 74% male, 90% held MD degrees, and 73% practiced in academic medical centers. The mean follow-up period was 9.8 years. Ophthalmologists older than 70 years had the lowest complaint rate (0.71 per 1000 follow-up days vs 1.41, 1.84, 2.02, and 1.88 in descending order of age band). By 2000 days of follow-up (or within 5.5 years), the youngest group had an estimated UPC risk of 0.523. By 4000 days (>10 years), participants in the older than 70 years age band had an estimated risk of UPC of only 0.364. The 2 youngest age bands were associated with a statistically significant shorter time to first complaint. Compared with those aged 71 years or older, the risk of incurring a UPC for those aged 41 to 50 years was 1.73-fold higher (hazard ratio [HR], 1.73; 95% CI, 1.21-2.46;P = .002). Similarly, participants aged 31 to 40 years had a 2.36 times higher risk of incurring a UPC (HR, 2.36; 95% CI, 1.64-3.40;P Conclusions and Relevance This study suggests that older ophthalmologists are less likely to receive UPCs than younger ones. Although limitations in the study design could affect the interpretation of these conclusions, the findings may have practical implications for patient safety, clinical education, and clinical practice management.

For surgical teams, high reliability and optimal performance depend on effective communication, mutual respect, and continuous situational awareness. Surgeons who model unprofessional behaviors may undermine a culture of safety, threaten teamwork, and thereby increase the risk for medical errors and surgical complications.To test the hypothesis that patients of surgeons with higher numbers of reports from coworkers about unprofessional behaviors are at greater risk for postoperative complications than patients whose surgeons generate fewer coworker reports.This retrospective cohort study assessed data from 2 geographically diverse academic medical centers that participated in the National Surgical Quality Improvement Program (NSQIP) and recorded and acted on electronic reports of safety events from coworkers describing unprofessional behavior by surgeons. Patients included in the NSQIP database who underwent inpatient or outpatient operations at 1 of the 2 participating sites from January 1, 2012, through December 31, 2016, were eligible. Patients were excluded if they were younger than 18 years on the date of the operation or if the attending surgeon had less than 36 months of monitoring for coworker reports preceding the date of the operation. Data were analyzed from August 8, 2018, through April 9, 2019.Coworker reports about unprofessional behavior by the surgeon in the 36 months preceding the date of the operation.Postoperative surgical or medical complications, as defined by the NSQIP, within 30 days of the operation.Among 13 653 patients in the cohort (54.0% [7368 ] female; mean [SD] age, 57 [16] years) who underwent operations performed by 202 surgeons (70.8% [143] male), 1583 (11.6%) experienced a complication, including 825 surgical (6.0%) and 1070 medical (7.8%) complications. Patients whose surgeons had more coworker reports were significantly more likely to experience any complication (0 reports, 954 of 8916 [10.7%]; ≥4 reports, 294 of 2087 [14.1%]; P .001), any surgical complication (0 reports, 516 of 8916 [5.8%]; ≥4 reports, 159 of 2087 [7.6%]; P .01), or any medical complication (0 reports, 634 of 8916 [7.1%]; ≥4 reports, 196 of 2087 [9.4%]; P .001). The adjusted complication rate was 14.3% higher for patients whose surgeons had 1 to 3 reports and 11.9% higher for patients whose surgeons had 4 or more reports compared with patients whose surgeons had no coworker reports (P = .05).Patients whose surgeons had higher numbers of coworker reports about unprofessional behavior in the 36 months before the patient's operation appeared to be at increased risk of surgical and medical complications. These findings suggest that organizations interested in ensuring optimal patient outcomes should focus on addressing surgeons whose behavior toward other medical professionals may increase patients' risk for adverse outcomes.

A Case of a Retained Sponge: “JS” is a 25 year old male brought to the emergency department with multiple gunshot wounds to his abdomen and pelvis. X-rays reveal an extensive injury pattern. He requires bowel resection and liver repair, after which he is transferred to the trauma unit. A chest x-ray taken to confirm chest tube placement reveals a retained sponge. JS needs surgery to remove the sponge. Dr. ABC has asked you for advice on whether JS should be informed about the need to go back to the operating room; after all, he has not yet awakened from the initial surgery. Dr. ABC reports that JS’s family has arrived and asks whether they need to be told about the need for the second surgery. If disclosure of the retained sponge is to be discussed, Dr. ABC will want your advice about how best to explain to JS his need for a second surgery. What guidance is available?

Disruptive (“non-teamwork-promoting”) behavior by medical professionals undermines healthcare quality and a culture of safety, decreases staff morale, increases healthcare expense and increases litigation risk. Despite these untoward outcomes, disruptive behavior, defined as any performance that impacts the team's ability to achieve intended outcomes, often goes unacknowledged and unaddressed. Aggressive outbursts and other unprofessional behaviors frequently arise in high stress arenas, such as operating rooms, medical–surgical units, and intensive care units. Passive–aggressive and passive actions also interfere with individual performance, team cohesion, and system reliability. Given these observations, it's no surprise that pediatric cardio-thoracic surgeons, cardiologists, and their leaders – in fact all healthcare professionals – must sometimes deal with issues of personal behavior that impair healthcare team performance, cross-discipline relationships, and patient safety. This article begins with a problematic clinical event, then identifies key concepts for dealing effectively with colleagues whose behavior is not consistent with professional standards, group policies or practices. Five principles, reinforced by several action oriented tips and practical tools, are offered as guides to promoting professionalism and professional accountability in support of quality team-oriented care, patient safety and, if necessary, legal defense if disruptive colleagues challenge disciplinary interventions. The principles and tips revolve around issues of justice, assembling data that permit reasonable certainty that action is appropriate, minimizing or eliminating conflicts of interest between reviewers and those reviewed, aiming to help those whose performance is reviewed achieve insight about their disruptive behavior's impacts, and, ultimately, restoration to the norms of professional practice. Readers are challenged to consider how to increase the reliability of their processes; maximize colleagues' opportunities for receiving performance- and professionalism-related feedback; serve patients, families, and colleagues well; and reduce concomitant litigation risk.

Effective teamwork is critical to successful outcomes in pediatric cardiac surgery. Unfortunately, lapses in professional performance and conduct by those who treat pediatric cardiac patients pose threats to quality and safety. One hallmark of a profession is self regulation. Therefore, healthcare leaders need specific means for identifying and addressing those lapses and indicators of unsafe systems or individuals. This article describes an initial "near miss" event involving a pediatric cardiac surgeon. While fictional, the case represents a composite of events involving several pediatric cardiac surgeons who practice at different medical centers throughout the U.S. Research shows that patient complaints are significantly associated with physicians' risk management activity and lawsuits. Research also demonstrates that a small subset of physicians and surgeons in various areas of practice are associated with disproportionate shares of patient complaints. Coded and aggregated patient complaint data therefore offer a metric for identifying and promoting behavior change. Analysis of the distribution of patient complaints associated with 41 pediatric cardiac surgeons is presented as a means for helping leaders show one surgeon how her/his risk status compares with peers'. The paper describes a specific plan and reliable process by which medical group/center colleagues and leaders may: 1) address lapses in professionalism and performance; 2) follow-up to promote professionalism, professional accountability, quality, and a safety culture; and 3) reduce risk.

Trauma surgery is perceived to have high malpractice risk. Unsolicited patient complaints (UPCs) can predict increased malpractice risk. An ex ante analysis of UPCs was performed to determine the risk profile for trauma surgeons compared with nontrauma surgeons.UPCs from 14 health systems over 4 years were retrospectively studied. Surgeons were divided into nontrauma surgeons (NTS) and trauma surgeons (TS). Inclusion criteria for TS were practice at a Level I or geographically isolated Level II adult trauma center and either surgical critical care certification or American Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma, or Western Trauma Association membership. Standardized risk scores were generated using a weighted sum algorithm from UPC data. Mann-Whitney U test, Kolvogorov-Smirnov two-sample test for distribution, χ for linear trend, and relative risk analysis were performed.A total of 16,518 UPCs were filed against 4,244 surgeons, including 55 TS. 18% of TS and 57% of NTS had 0 UPCs. Mean risk score was higher for TS (29.2 ± 29.0 vs. 10.2 ± 19.5, p0.001), and more TS (20.0% vs. 3.15%) were at moderate (score 50-69) or at high risk (score70) (7.27% vs. 2.57%; p0.001), reflecting a shifted risk distribution (p0.001) compared with NTS. TS have a relative risk of 6.17 (95% CI: 3.36-11.33) for score50.TS are at increased risk of UPCs compared with NTS, but this risk is still largely borne by a minority of TS. UPCs seem to be a reasonable proxy for malpractice risk, so targeted interventions for TS associated with disproportionate shares of UPCs may reduce patient dissatisfaction and, perhaps, malpractice claims.

Vanderbilt University School of Medicine (VUSM) employs several strategies for teaching professionalism. This article, however, reviews VUSM’s alternative, complementary approach: identifying, measuring, and addressing unprofessional behaviors. The key to this alternative approach is a supportive infrastructure that includes VUSM leadership’s commitment to addressing unprofessional/disruptive behaviors, a model to guide intervention, supportive institutional policies, surveillance tools for capturing patients’ and staff members’ allegations, review processes, multilevel training, and resources for addressing disruptive behavior. Our model for addressing disruptive behavior focuses on four graduated interventions: informal conversations for single incidents, nonpunitive “awareness” interventions when data reveal patterns, leader-developed action plans if patterns persist, and imposition of disciplinary processes if the plans fail. Every physician needs skills for conducting informal interventions with peers; therefore, these are taught throughout VUSM’s curriculum. Physician leaders receive skills training for conducting higher-level interventions. No single strategy fits every situation, so we teach a balance beam approach to understanding and weighing the pros and cons of alternative interventionrelated communications. Understanding common excuses, rationalizations, denials, and barriers to change prepares physicians to appropriately, consistently, and professionally address the real issues. Failing to address unprofessional behavior simply promotes more of it. Besides being the right thing to do, addressing unprofessional behavior can yield improved staff satisfaction and retention, enhanced reputation, professionals who model the curriculum as taught, improved patient safety and risk-management experience, and better, more productive work environments. Acad Med. 2007; 82:1040–1048.

Nurses increasingly use telephonic assessment and counseling to manage clients with a variety of chronic illnesses. This article describes a study designed to assess a group of telephonic nurse disease managers' teaching and adherence promotion skills during actual patient interactions. Nurse care managers showed improvements after training in four main counseling skills categories, with a decrease in time spent.

Objective To study the association between physicians' complaint records and their risk management experiences in a regional healthcare center. Data sources Patient complaints about physicians in a large border state medical center's hospital and outpatient clinics were recorded and coded. The study period was from January 2001 through December 2003. These records were linked to the counterpart physicians' data covered by the institutions' risk management plan through June 2004. Study design and data collection All physicians at the institution who had contact with patients during the study period were identified as surgeons or non-surgeons. Complaints for these physicians were recorded by the institution's Office of Patient Relations (OPR) and independently coded using a standardized protocol to characterize the nature of the problem and to uniquely identify the person complained about. The complaint records were then linked to the risk management files (RMFs) for the defined physician cohort. In addition, these data were supplemented with clinical service values (RVUs) which were available for 338 members (76%) of the 445 member cohort. Principal findings Both patient complaints and risk management events were higher for surgeons than for non-surgeons. This was true for the number of RMFs, those involving expenditures, and for lawsuits. Logistic regression was used to assess the effects of complaint counts, practice type and volume of clinical activity. All were statistically significant in predicting the number of RMF openings, RMF openings with expenditures and lawsuits. Predictive concordance was 75% or greater for each of the three risk management outcomes. Conclusions Expressions of patient dissatisfaction and practice type are significantly related to risk management experiences in a regional medical center. Associations of risk management experiences with volume of clinical activity (RVUs) for surgeons in the regional medical center environment were not as strong as those found in a similar study reported from an academic medical center.

Disparities in depression care remain an important problem in the United States. Action inquiry technologies may assist individuals and communities in their attempts to reduce or eliminate these disparities--and the multiple factors contributing to them--through a recurring cycle of planning, action, evaluation, and new actions based on reflections about what occurred during previous actions. This article will briefly review different action inquiry methods--specifically, participatory action research (PAR) in communities and action research in physicians' practices and offices of continuing medical education (CME). The authors develop a conceptual model in which those involved in providing, receiving, and improving depression care can use action inquiry strategies that are coordinated using the domains-based outcomes assessment model. This conceptual model may help CME planners collaborate with others to address disparities in depression care.

The number of unsolicited patient complaints about a physician has been shown to correlate with increased malpractice risk. Using a large national patient complaint database, we evaluated the number and content of unsolicited patient complaints about ophthalmologists to identify significant risk factors for receiving a complaint.Retrospective cohort study.Ophthalmologists, nonophthalmic surgeons, nonophthalmic nonsurgeons.We analyzed 2087 unsolicited or spontaneous complaints reported about 815 ophthalmologists practicing in 24 academic and nonacademic organizations using the Patient Advocacy Reporting System (PARS). Complaints against 5273 nonophthalmic surgeons and 19487 nonophthalmic nonsurgeons during the same period were used for comparison. Complaint type profiles were assigned using a previously validated standardized coding system. We (1) described the distribution of complaints against ophthalmologists; (2) compared the distribution and rates of patient complaints about ophthalmologists with those of nonophthalmic surgeons and nonophthalmic nonsurgeons in the database; (3) analyzed differences in complaint type profiles and quantity of complaints by ophthalmic subspecialty, practice setting, physician gender, medical school type, and graduation date; and (4) identified significant risk factors for high numbers of unsolicited patient complaints after adjusting for other covariates.Unsolicited patient complaints.Ophthalmologists had significantly fewer complaints per physician than other nonophthalmic surgeons and nonsurgeons. Sixty-three percent of ophthalmologists had 0 complaints, whereas 10% of ophthalmologists accounted for 61% of all complaints. Ophthalmologists from academic centers, female ophthalmologists, and younger ophthalmologists had significantly more complaints (P 0.01), and general ophthalmologists had significantly fewer complaints than subspecialists (P0.05). After adjusting for covariates using multivariable analysis, working at an academic center was a statistically significant risk factor (adjusted relative risk, 1.82; 95% confidence interval, 1.36-2.43; P0.001).Ophthalmologists had significantly fewer complaints than nonophthalmic surgeons and nonophthalmic nonsurgeons, and by implication may have a lower malpractice risk as a group. Nevertheless, a small number of ophthalmologists generated a disproportionate number of complaints. Working at an academic center was a significant independent risk factor for having more patient complaints. Further research is needed to clarify the underlying reasons for this association and to identify interventions that may decrease this risk.

One factor that affects surgical team performance is unprofessional behavior exhibited by the surgeon, which may be observed by patients and families and reported to health care organizations in the form of spontaneous complaints. The objective of this study was to assess the relationship between patient complaints and adverse surgical outcomes. A retrospective cohort study used American College of Surgeons National Surgical Quality Improvement Program data from an academic medical center and included 10 536 patients with surgical procedures performed by 66 general and vascular surgeons. The number of complaints for a surgeon was correlated with surgical occurrences (P < .01). Surgeons with more patient complaints had a greater rate of surgical occurrences if the surgeon’s aggregate preoperative risk was higher (β = .25, P < .05), whereas there was no statistically significant relationship between patient complaints and surgical occurrences for surgeons with lower aggregate perioperative risk (β = −.20, P...

Research supports the potential effectiveness of health programs offered through African American churches, but pastors are often unprepared to assess the value of and help their congregations adopt such programs. This article summarizes how Nashville REACH 2010 addressed these issues via a "Faith and Health" course offered by the American Baptist College, a 4-year coeducational, liberal arts Bible college serving a predominantly African American student body. Participants became change agents by planning health-related programs for their congregations. Content analysis of student projects revealed 5 themes deemed important for program implementation and instituting systems change.

Diabetes education has largely been accepted in diabetes care. The effect of diabetes education on glycemic control and the components of education responsible for such an effect are uncertain. We performed a meta-analysis of randomized controlled trials of diabetes patient education published between 1990 and December 2000 to quantitatively assess and characterize the effect of patient education on glycated hemoglobin (HbA(1c)). Additionally, we used meta-regression to analyze which variables within an education intervention that best explained variance in glycemic control. Twenty-eight educational interventions (n=2439) were included in the analysis. The net glycemic change was 0.320% lower in the intervention group than in the control group. Meta-regression revealed that interventions which included a face-to-face delivery, cognitive reframing teaching method, and exercise content were more likely to improve glycemic control. Those three areas collectively explained 44% of the variance in glycemic control. Current patient education interventions modestly improve glycemic control in adults with diabetes. We highlight three potential components of educational interventions that may predict an increased likelihood of success in ameliorating glycemic control.

Purpose To systematically identify and describe common obstacles to medication adherence (i.e., compliance) for patients with glaucoma. Methods A prospective case series of structured interviews were conducted with 48 patients with glaucoma. The subjects' responses were recorded verbatim on interview forms as well as recorded on audiotapes. Situational obstacles to medication adherence were elicited. Using hierarchical cluster analysis, the situational descriptions were stratified, grouped, and analyzed by frequency distribution. Results Seventy-one unique situational obstacles were reported. These were then grouped into 4 defined and separate categories: situational/environmental factors (35 of 71 situations; 49%), medication regimen (23 of 71; 32%), patient factors (11 of 71; 16%), and provider factors (2 of 71; 3%). Conclusion Significant barriers to compliance exist for patients with glaucoma in addition to those cited by previous ophthalmic studies. A systematic classification (i.e., taxonomy) of these barriers was formulated to assist in optimizing patient education and problem-solving regarding prescribed therapeutic regimens.

Dietitians who work with hospitalized elderly persons need specialized training to assess nutritional needs and develop appropriate, cost-effective interventions for their patients. We evaluated “Nutrition and Aging: Implications for Hospital-Based Care,” a five-contact-hour continuing education program designed to help participants make plans to implement and adhere to selected evidence-based nutritional recommendations for the elderly hospitalized population. Seventynine out of 85 registered dietitians participating in two course offerings made “Commitments to Change.” Evaluation of the commitments assessed whether participants' plans were reasonable and were implemented, and what barriers interfered. Three months post-course, they estimated actual implementation of intended changes and identified obstacles to success. Of 170 commitments, 0% and 100% progress were reported on 48 (28%) and 46 (27%) commitments, respectively. Mean implementation rate was 52%. After removing responses reporting 0%...

In Brief Among the many efforts to reduce the burden of diabetes in the United States, one involves focusing on communities. Evidence from cardiovascular disease and cancer-related community intervention projects indicate that such efforts show promise in reducing behavioral risk factors, many of which are the same for diabetes. Such projects, therefore, may provide insight for diabetes educators, researchers, and others who are interested in designing and implementing diabetes interventions within communities.

Introduction Physicians must understand regulatory changes in long-term care (LTC) and adhere to prospective payment system (PPS) guidelines for minimum data set (MDS), resource utilization groups (RUG) and resident assessment instrument (RAI) processes, documentation, and evaluation. We pilot-tested “Prospective Payment System in LTC,” a 7.5 hour continuing medical education (CME) program designed to help participants make plans to implement and adhere to PPS guidelines and regulatory requirements. Methods Twelve medical directors or attending physicians participated. A “commitment to change” evaluation assessed whether participants’ plans were reasonable and were implemented, and what barriers interfered. Participants identified 3–5 changes they intended to make. Three months later, participants estimated actual implementation of intended changes, identified obstacles to success, and rated PPS's impacts on patient care. Results Respondents “committed” to an average of 3.4 changes ranging from “better monitor transfers from LTC to acute care” to “train nurses re MDS and RUGs.” Of 40 commitments, 0% and 100% progress were reported on 9 (23%) each. Mean implementation rate was 41%. Removing responses reporting 0% implementation, the rate was 53%. Common barriers were “lack of time,” and “can't get attending MDs to meetings.” MDs’ ratings of PPSs’ impacts were neutral (2.9 on a scale where 1 = “PPS causes great deterioration in quality of care,” 3 = “…no change…” and 5 = “…great improvement…”) both immediately and 3 months post-course. Conclusions Participants made reasonable plans consistent with course objectives and made progress implementing most intentions. LTC physicians who attended the CME course intended to alter their behaviors, but significant obstacles interfered, at least in the short term. Most thought PPS would not change the quality of care provided in their institutions. Future courses should address implementation barriers.

Importance Unsolicited patient observations are associated with risk of medical malpractice claims. Because lawsuits may be triggered by an unexpected adverse outcome superimposed on a strained patient-physician relationship, a question remains as to whether behaviors that generate patient dissatisfaction might also contribute to the genesis of adverse outcomes themselves. Objective To examine whether patients of surgeons with a history of higher numbers of unsolicited patient observations are at greater risk for postoperative complications than patients whose surgeons generate fewer such unsolicited patient observations. Design, Setting, and Participants This retrospective cohort study used data from 7 academic medical centers participating in the National Surgical Quality Improvement Program and the Vanderbilt Patient Advocacy Reporting System from January 1, 2011, to December 31, 2013. Patients older than 18 years included in the National Surgical Quality Improvement Program who underwent inpatient or outpatient operations at 1 of the participating sites during the study period were included. Patients were excluded if the attending surgeon had less than 24 months of data in the Vanderbilt Patient Advocacy Reporting System preceding the date of the operation. Data analysis was conducted from June 1, 2015, to October 20, 2016. Exposures Unsolicited patient observations for the patient’s surgeon in the 24 months preceding the date of the operation. Main Outcomes and Measures Postoperative surgical or medical complications as defined by the National Surgical Quality Improvement Program within 30 days of the operation of interest. Results Among the 32 125 patients in the cohort (13 230 men, 18 895 women; mean [SD] age, 55.8 [15.8] years), 3501 (10.9%) experienced a complication, including 1754 (5.5%) surgical and 2422 (7.5%) medical complications. Prior unsolicited patient observations for a surgeon were significantly associated with the risk of a patient having any complication (odds ratio, 1.0063; 95% CI, 1.0004-1.0123; P = .03), any surgical complication (odds ratio, 1.0104; 95% CI, 1.0022-1.0186; P = .01), any medical complication (odds ratio, 1.0079; 95% CI, 1.0009-1.0148; P = .03), and being readmitted (odds ratio, 1.0088, 95% CI, 1.0024-1.0151; P = .007). The adjusted rate of complications was 13.9% higher for patients whose surgeon was in the highest quartile of unsolicited patient observations compared with patients whose surgeon was in the lowest quartile. Conclusions and Relevance Patients whose surgeons have large numbers of unsolicited patient observations in the 24 months prior to the patient’s operation are at increased risk of surgical and medical complications. Efforts to promote patient safety and address risk of malpractice claims should continue to focus on surgeons’ ability to communicate respectfully and effectively with patients and other medical professionals.

When patients and families observe and report their healthcare experiences, they can play important roles in promoting safety and improving quality. This chapter begins with the case of a busy, well regarded medical professional associated with a patient complaint. The complaint is a means by which patients and families can be “safety promoters”. While barriers to this role exist, they may be reduced or eliminated when organizations commit to assessing their readiness to invite and address patient concerns, and build a robust infrastructure to support the effort. This chapter discusses our experience using unsolicited (voluntary) patient complaints to address unsafe systems and behaviors. We use the physician and the physician’s practice group to illustrate implementation and outcomes of interventions designed to reduce unnecessary variation in healthcare professionals’ behavior and performance that undermine a healthcare organization’s culture of safety. The chapter concludes with guidance to hospital and healthcare systems on how best to develop, implement and sustain a patient and family experience program.

Content. The risk for serious gastrointestinal complications due to nonsteroidal anti-inflammatory drugs (NSAIDs) is high in the elderly. Acetaminophen-based regimens are safer and may be as effective as NSAIDs for the treatment of osteoarthritis in many patients. Objective. To determine the effects of an educational program on NSAID use and clinical outcomes in nursing homes. Design and Setting. Randomized controlled study. Ten pairs of Tennessee nursing homes with ≥8% of residents receiving NSAIDs were randomized to intervention or control. Subjects. Nursing home residents (intervention n = 76 and control n = 71) aged 65 years and older taking NSAIDs regularly. Interventions. An educational program for physicians and nursing home staff that included the risks and benefits of NSAIDs in the elderly and an algorithm that substituted acetaminophen, topical agents, and nonpharmacologic measures for the treatment of noninflammatory musculoskeletal pain. Intervention and control subjects were assessed at baseline and 3 months later. Main Outcome Measures. Differences in NSAID and acetaminophen use, and pain, function, and disability scores in intervention and control nursing home subjects. Results. The intervention was effective resulting in markedly decreased NSAID use and increased acetaminophen use. Mean number of days of NSAID use in the 7 day periods before the baseline and 3 month assessments decreased from 7.0 to 1.9 days in intervention home subjects compared with a decrease from 7.0 to 6.2 days in control homes (P = 0.0001). Acetaminophen use in the 7 days immediately before the 3 month assessment increased by 3.1 days in intervention home subjects compared with 0.31 days in control homes (P = 0.0001). A similar proportion of subjects in control (32.5%) and intervention (35.4%) groups had worsening of their arthritis pain score (P = 0.81). Conclusions. An educational intervention effectively reduced NSAID use in nursing homes without worsening of arthritis pain.

PURPOSE this article reports the results of a symposium in which diabetes educators considered and discussed issues that are likely to arise when continuous glucose monitoring (CGM) becomes available and readily accessible. METHODS Fifteen certified diabetes educators and 5 others with complementary expertise participated in a discussion based on their responses to 11 questions designed to elicit perspectives on issues related to CGM. Issues for discussion and debate include those related to patient acceptance and lifestyle, implications for professional practice and reimbursement, concerns about professional liability, use of CGM data by insurers and payers, and CGM data transfer. RESULTS Educators offered varied and sometimes conflicting responses to CGM-related issues. CONCLUSIONS Awareness of CGM-related issues will likely become an important part of diabetes professional development and perspectives in practice. Identifying and framing the issues before the new technologies become available allow diabetes educators to participate proactively in structuring the emerging policies, procedures, and standards of care.

Article-at-a-Glance Background A pilot study was conducted to learn whether an academic medical center's database of patient complaints would reveal particular service units (or clinics) with disproportionate shares of patient complaints, the types of complaints patients have about those units, and the types of personnel about whom the complaints were made. Results During the seven-year (December 1991–November 1998) study period, Office of Patient Affairs staff recorded 6,419 reports containing 15,631 individual complaints. More than 40% of the reports contained a single complaint. One-third of the reports contained three or more complaints. Complaints were associated with negative perceptions of care and treatment (29%), communication (22%), billing and payment (20%), humaneness of staff (13%), access to staff (9%), and cleanliness or safety of the environment (7%). Complaints were not evenly distributed across the medical center's various units, even when the data were corrected for numbers of patient visits to clinics or bed days in the hospital. The greatest proportion of complaints were associated with physicians. Discussion Complaint-based report cards may be used in interventions in which peers share the data with unit managers and seek to learn the nature of the problems, if any, that underlie the complaints. Such interventions should influence behavioral and systems changes in some units. Summary and conclusions Further experience should indicate how different types of complaints lead to different kinds of interventions and improvements in care. Tests of the system are also currently under way in several nonacademic community medical centers.

A 2-week summer school program, combining problem-based learning with behavior therapy, was developed to help adolescents with insulin-dependent diabetes improve their ability to cope with obstacles to dietary management. Ten students participated in a first session, and 9 participated in a second session, serving as a waiting list control group. Outcomes were evaluated preand postsession and at a 4-month follow-up using 3-day food diaries, blood glucose data, and paper-and-pencil tests of diabetes-related knowledge, self-efficacy, coping strategies, and general problem solving. Improvements were observed in self-efficacy, problem-solving skills, and self-reported coping strategies. No significant changes were observed in daily intake of fat, cholesterol, calories, mean blood glucose levels or blood glucose variability, and diabetes knowledge. Comparisons between the first group and the waiting list control group do not allow the significant pre-post changes to be clearly attributed to the summer school program.

BACKGROUND Anesthesiology groups continually seek data sources and evaluation metrics for ongoing professional practice evaluation, credentialing, and other quality initiatives. The analysis of patient complaints associated with physicians has been previously shown to be a marker for patient dissatisfaction and a predictor of malpractice claims. Additionally, previous studies in other specialties have revealed a nonuniform distribution of complaints among professionals. In this study, we describe the distribution of complaints among anesthesia providers and identify factors associated with complaint risk in pediatric and adult populations. METHODS We performed an analysis of a complaint database for an academic medical center. Complaints were recorded as comments during postoperative telephone calls to ambulatory surgery patients regarding the quality of their anesthesiology care. Calls between July 1, 2006 and June 30, 2010 were included. Risk factors were grouped into 3 categories: patient demographics, procedural, and provider characteristics. RESULTS A total of 22,871 calls placed on behalf of 120 anesthesiologists were evaluated, of which 307 yielded a complaint. There was no evidence of provider-to-provider heterogeneity in complaint risk in the pediatric population. In the adult population, an unadjusted test for the random intercept variance component in the mixed effects model pointed toward significant heterogeneity (P = 0.01); however, after adjusting for a prespecified set of risk factors, provider-to-provider heterogeneity was no longer observed (P = 0.20). Several risk factors exhibited evidence for complaint risk. In the pediatric patient model, risk factors associated with complaint risk included a 10-year change in age, the use of general anesthesia (versus not), and a 1-hour change in the actual minus scheduled start times. Odds ratios were 1.47 (95% confidence interval (CI), 1.04-2.08), 0.22 (95% CI, 0.07-0.62), and 1.27 (95% CI, 1.10-1.47), respectively. In the adult patient model, risk factors associated with complaint risk included male gender, general anesthesia, a 10-year change in provider experience, and speaking with the patient (rather than a family member). Odd ratios were 0.66 (95% CI, 0.47-0.92), 0.67 (95% CI, 0.47-0.95), 1.18 (95% CI, 1.01-1.38), and 1.96 (95% CI, 1.17-3.29), respectively. CONCLUSIONS There was apparent evidence in adult patients to suggest heterogeneity in provider risk for a patient complaint. However, once patient, procedural, and provider factors were acknowledged in analyses, such evidence for heterogeneity is diminished substantially. Further study into how and why these factors are associated with greater complaint risk may reveal potential interventions to decrease complaints.

Purpose: To develop and evaluate a tool for assessing selected aspects of dietary adherence in adolescents with diabetes mellitus (IDDM). Methods: The Situational Obstacles to Dietary Adherence Questionnaire (SODA) is a 30-item inventory that yields a total self-efficacy score and scales that measure cognitive and behavioral coping strategies. Alternative forms of the SODA were administered at the beginning and end of a summer camp for youngsters with IDDM in order to obtain evidence for its reliability and validity, and to evaluate the impact of an educational intervention. The program consisted of two 50-minute small group sessions intended to help adolescents with IDDM improve their ability to cope with challenging dietary situations. Using the method of anchored instruction, the campers first viewed a video about a teenager with diabetes who faces common situations that make diabetes self-management difficult. Group problem-solving sessions led by a registered dietitian were used to help campers learn more effective ways to solve dietary problems. Results and conclusions: Results suggested that the SODA has reasonable reliability and validity. In addition, anchored instruction improved dietary self-efficacy and changed young adolescents' estimates of how often they would use selected cognitive and behavioral strategies to solve dietary problems.

Effective Patient Teaching (EPT), a course designed to improve health professionals' and health professions students' teaching skills, reliably produces gains in participants' skills when presented by its developers. The objective of this dissemination research study was to investigate whether, using a 'training of trainers' approach, seven nurses with staff development responsibilities in five different sites could teach EPT with similar effectiveness. The evaluation included pre- and post-course analysis of audiotaped patient education sessions conducted by 48 health professional participants who took EPT from one of the trainers in their home institutions. Post-course participant satisfaction surveys were also administered. EPT resulted in teaching skill improvements in four of five sites, and overall teaching skills scores improved significantly (P < 0.01). EPT can improve participants' teaching skills when taught by health professional trainers with staff development responsibilities who have recently received EPT training.

Article-at-a-Glance Background Health care team members are well positioned to observe disrespectful and unsafe conduct—behaviors known to undermine team function. Based on experience in sharing patient complaints with physicians who subsequently achieved decreased complaints and malpractice risk, Vanderbilt University Medical Center developed and assessed the feasibility of the Co-Worker Observation Reporting System SM (CORS SM ) for addressing coworkers' reported concerns. Methods VUMC leaders used a "Project Bundle" readiness assessment, which entailed identification and development of key people, organizational supports, and systems. Methods involved gaining leadership buy-in, recruiting and training key individuals, aligning the project with organizational values and policies, promoting reporting, monitoring reports, and employing a tiered intervention process to address reported coworker concerns. Results Peer messengers shared coworker reports with the physicians and advanced practice professionals associated with at least one report 84% of the time. Since CORS inception, 3% of the medical staff was associated with a pattern of CORS reports, and 71% of recipients of pattern-related interventions were not named in any subsequent reports in a one-year follow-up period. Conclusions Systematic monitoring of documented coworker observations about unprofessional conduct and sharing that information with involved professionals are feasible. Feasibility requires organizationwide implementation; coworkers willing and able to share respectful, nonjudgmental, timely feedback designed initially to encourage self-reflection; and leadership committed to be more directive if needed. Follow-up surveillance indicates that the majority of professionals "self-regulate" after receiving CORS data.

Objective To develop a taxonomy of everyday situations that create obstacles for adherence to dietary management in patients with diabetes. Subjects Twenty-six adults with diabetes (12 with insulin-dependent diabetes mellitus and 14 with non-insulin-dependent diabetes mellitus) were recruited from an outpatient diabetes clinic. Main outcome measures Subjects were interviewed to identify problem situations that create obstacles for dietary adherence. The resulting 69 situations were judged for the presence of absence of 32 environmental features using a reliable coding system. Statistical analysis A hierarchical cluster analysis was used to identify homogeneous groups of dietary adherence obstacles. Results Twelve types of problem situations were identified: negative emotions, resisting temptation, eating out, feeling deprived, time pressure, tempted to relapse, planning, competing priorities, social events, family support, food refusal, and friends' support. Conclusions The resulting taxonomy provides an outline for the detailed assessment of obstacles to dietary adherence. An individual's ability to cope with this array of obstacles to dietary adherence should be assessed so treatment can be individualized.

Twenty adolescents with insulin -dependent diabetes mellitus were interviewed to obtain samples of problem situations that create obstacles to dietary adherence. The resulting 57 situations were analyzed using a reliable coding system to determine the presence or absence of 28 stimulus features. A hierarchical cluster analysis was used to identify 10 relatively homogeneous categories of obstacles to dietary adherence: being tempted to stop trying; negative emotional eating; facing forbidden foods; peer interpersonal conflict; competing priorities; eating at school; social events and holidays; food cravings; snacking when home, alone, or bored; and social pressure to eat. Diabetes educators should consider an individual's ability to cope with this array of obstacles to adherence when individualizing treatment. Dietary intervention then can be personalized to address specific situational obstacles.

This study's hypotheses were that both shortly after instruction and after an 8-month follow-up, diabetic children taught via anchored instruction (AI), a format for problem solving, would outperform controls. Subjects were 8 1 9–15-year-old campers with insulin dependent diabetes who were randomly assigned to AI or control groups for two 45-min small group teaching sessions. AIs viewed a video about a girl who mismanages her diabetes during intercurrent illness, and they were challenged to identify, define and solve her errors. Controls learned sick-day management via conventional direct instruction. At the end of the 2-week camp, AI and control groups' scores on factual knowledge were equal. AIs were more likely than controls at the end of the camp (0.75 vs. 0.54, P < 0.05) and 8 months later (0.59 vs. 0.38, P < 0.02) to provide a rationale for the use of remembered guidelines. Across all campers, this ability to link guidelines and their rationales was significantly correlated (r = 0.55, P < 0.01) with the number of self-management practices employed by campers who suffered an illness between the end of camp and the 8-month follow-up. Only one long-term behavioral difference between groups emerged: AIs' parents shared in making most diabetes decisions on sick days, while controls' parents left more decision making to their children. AI appears at least as good as conventional teaching, and may better 'link' rules and reasons, perhaps aiding daily real-life problem solving.

Nutrition counseling is often not effective, I and one obstacle may be the quality of the patient education being offered. Specifically, many dietitians have not had formal instruction in teaching, and many do not routinely employ teaching skills known to enhance instructional effectiveness.3•4 There have been calls for teaching skills training for nutritionists, and many health professionals desire such instruction.4.5 Unfortunately, it has not been widely available or accessible. This article reports an evaluation of a course on skills for teaching patients when it was translated from the institution where it was developed to another academic setting. The course "Effective Patient Teaching" (EPT) has been offered both as an elective to health professions students and as a continuing education course for health professionals.79 Course time (30 hours) is equally divided between facultyled lecture-discussions and four to five videotaped "microteaching"IO exercises in which classmates serve as surrogate patients, and participants are able to practice 20 selected teaching skills (Table 1) and receive feedback on their effectiveness. The individual items form four subgroups. For example, Interpersonal Skills help build trust and rapport. Essential Teaching Functions are general strategies that should form a framework for most teaching. Presentation Skills help make instruction memorable (i.e., they improve efficiency). Finally, Adherence Promotion Skills are used to improve the likelihood that patients will apply what they learn. Evaluations show that EPT improves the patient teaching skills of undergraduate medical and nursing students8• and practicing health professionals. II •12 EPT may prove a helpful response to the need for teaching skills instruction for undergraduate nutrition stu

We developed a home study version of an established and successful workshop program called Effective Patient Teaching (EPT), making use of suggested guidelines for developing home study courses. The self-study modules we produced consisted of workbook materials, videotaped illustrations, and practice exercises, all of which focused on patient teaching and counseling skills. During a period of 2 years and 3 months, 28 participants enrolled in the home study course. Only one participant completed the entire course. Another participant completed the portion purchased. The barrier most commonly cited as preventing completion of the home study course was other work-related deadlines. We suspect that our requirement for a feedback procedure (either an audio- or n videotape of an instruction interview) may also have prevented submission of a completed course. The low, completion rate made quantitative evaluations impossible. Although the literature includes reported successes in the use of self-learning courses, few formal evaluations have been conducted and reported. The efficacy of home study courses, particularly when enhanced skill is the desired outcome rather than knowledge gain, is yet to be e published, and merits close examination and rigorous evaluations.