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To establish whether items included in instruments published in the last decade assessing risk of bias of randomized controlled trials (RCTs) are indeed addressing risk of bias.We searched Medline, Embase, Web of Science, and Scopus from 2010 to October 2021 for instruments assessing risk of bias of RCTs. By extracting items and summarizing their essential content, we generated an item list. Items that two reviewers agreed clearly did not address risk of bias were excluded. We included the remaining items in a survey in which 13 experts judged the issue each item is addressing: risk of bias, applicability, random error, reporting quality, or none of the above.Seventeen eligible instruments included 127 unique items. After excluding 61 items deemed as clearly not addressing risk of bias, the item classification survey included 66 items, of which the majority of respondents deemed 20 items (30.3%) as addressing risk of bias; the majority deemed 11 (16.7%) as not addressing risk of bias; and there proved substantial disagreement for 35 (53.0%) items.Existing risk of bias instruments frequently include items that do not address risk of bias. For many items, experts disagree on whether or not they are addressing risk of bias.

In the spring of 2020, our hospital faced a surge of critically ill coronavirus disease 2019 patients, with intensive care unit (ICU) occupancy peaking at 204% of the baseline maximum capacity. In anticipation of this surge, we developed a remote communication liaison program to help the ICU and palliative care teams support families of critically ill patients. In just nine days from inception until implementation, we recruited and prepared ambulatory specialty providers to serve in this role effectively, despite minimal prior critical care experience. We report here the primary elements needed to reproduce and scale this program in other hospitals facing similar ICU surges, including a checklist for replication (Appendix I). Keys to success include strong logistical support, clinical reference material designed for rapid evolution, and a liaison team structure with peer coaching.

For its clinical, epidemiologic, educational, and health services research, evaluation, administrative, regulatory, and accreditation purposes, the perceptions survey is a data collection tool that...

Recruiting professional staff is an important business reason for hospitals allowing health trainees to engage in supervised patient care. Whereas prior studies have focused on educational institutions, this study focuses on teaching hospitals and whether trainees' clinical experiences affect their willingness to work (ie, recruitability) for the type of healthcare center where they trained.A pre-post, observational study based on Learners' Perceptions Survey data in which respondents served as their own controls.Convenience sample of 15,207 physician, 11,844 nursing, and 13,012 associated health trainees who rotated through 1 of 169 US Department of Veterans Affairs (VA) medical centers between July 1, 2014, and June 30, 2017. Generalized estimating equations computed how clinical, learning, working, and cultural experiences influenced pre-post differences in willingness to consider VA for future employment.VA recruitability increased dramatically from 55% pretraining to 75% post training (adjusted odds ratio [OR], 2.1; 95% CI, 2.0-2.1; P.001) in all 3 cohorts: physician (from 39% to 59%; OR, 1.6; 95% CI, 1.5-1.6; P.001), nursing (from 61% to 84%; OR, 2.5; 95% CI, 2.4-2.6; P.001), and associated health trainees (from 68% to 87%; OR, 2.7; 95% CI, 2.6-2.9; P.001). For all trainees, changes in recruitability (P.001) were associated with how trainees rated their clinical learning environment, personal experiences, and culture of psychological safety. Satisfaction ratings with faculty and preceptors (P.001) were associated with positive changes in recruitability among nursing and associated health students but not physician residents, whereas nursing students who gave higher ratings for interprofessional team culture became less recruitable.Academic medical centers can attract their health trainees for future employment if they provide positive clinical, working, learning, and cultural experiences.

Background Psychological safety (PS) is the perception that it is safe to take interpersonal risks in the work environment. In teaching hospitals, PS may influence the clinical learning environment for trainees. Objective We assessed whether resident physicians believe they are psychologically safe, and if PS is associated with how they rate satisfaction with their clinical learning experience. Methods Data were extracted from the Learners' Perceptions Survey (LPS) of residents who rotated through a Department of Veterans Affairs health care facility for academic years 2011–2014. Predictors of PS and its association with resident satisfaction were adjusted to account for confounding and response rate biases using generalized linear models. Results The 13 044 respondents who completed the LPS (30% response rate) were comparable to nonpediatric, non–obstetrics-gynecology residents enrolled in US residency programs. Among respondents, 11 599 (89%) agreed that “. . . members of the clinical team of which I was part are able to bring up problems and tough issues.” Residents were more likely to report PS if they were male, were in a less complex clinical facility, in an other medicine or psychiatry specialty, or cared for patients who were aged, had multiple illnesses, or had social supports. Nonpsychiatric residents felt safer when treating patients with no concurrent mental health diagnoses. PS was strongly associated with how residents rated their satisfaction across 4 domains of their clinical learning experience (P Conclusions PS appears to be an important factor in resident satisfaction across 4 domains that evaluators of graduate medical education programs should consider when assessing clinical learning experiences.

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Background In 2010, the Department of Veterans Affairs (VA) implemented a national patient-centered care initiative that organized primary care into interdisciplinary teams of health care professionals to provide patient-centered, continuous, and coordinated care. Objective We assessed the discriminate validity of the Learners' Perceptions Survey—Primary Care (LPS-PC), a tool designed to measure residents' perceptions about their primary and patient-centered care experiences. Methods Between October 2010 and June 2011, the LPS-PC was administered to Loma Linda University Medical Center internal medicine residents assigned to continuity clinics at the VA Loma Linda Healthcare System (VALLHCS), a university setting, or the county hospital. Adjusted differences in satisfaction ratings across settings and over domains (patient- and family-centered care, faculty and preceptors, learning, clinical, work and physical environments, and personal experience) were computed using a generalized linear model. Results Our response rate was 86% (77 of 90). Residents were more satisfied with patient- and family-centered care at the VALLHCS than at either the university or county (P < .001). However, faculty and preceptors (odds ratio [OR] = 1.53), physical (OR = 1.29), and learning (OR = 1.28) environments had more impact on overall resident satisfaction than patient- and family-centered care (OR = 1.08). Conclusions The LPS-PC demonstrated discriminate validity to assess residents' perceptions of their patient-centered clinical training experience across outpatient primary care settings at an internal medicine residency program. The largest difference in scores was the patient- and family-centered care domain, in which residents rated the VALLHCS much higher than the university or county sites.

The current diabetes epidemic threatens to overwhelm the healthcare system unless we redesign how diabetes care is delivered. The number of endocrinologists is grossly inadequate to provide care for all individuals with diabetes, but with the appropriate utilization of the primary care workforce and alternative healthcare providers working together in teams, effective diabetes care can be provided to all. We propose a patient-centered, goal-based approach with resources devoted to care coordination, measurement of outcomes, appropriate use of technology, and measurement of patient satisfaction. Financial incentives to healthcare systems and providers need to be based on defined outcome measures and reducing long-term total medical expenditures, rather than reimbursement based on number of visits and lengthy documentation. Endocrinologists have a responsibility in setting up effective diabetes care delivery systems within their organizations, in addition to delivering diabetes care and serving as a resource for the educational needs for other medical professionals in the community. There are major challenges to implementing such systems, both at the financial and organizational levels. We suggest a stepwise implementation of discrete components based on the local priorities and resources and provide some examples of steps we have taken at our institution.

Misbehavior and disruption in the operating room are an all too common problem. Disruptive behaviors have been observed and experienced by all members of the operating room team, and these behaviors need to be addressed in a timely and appropriate fashion. Sometimes, hospital administrators and hospital leadership know about these problems but do not act, and thus they may be complicit in allowing these problems to continue. This chapter reviews the potential reasons for disruptive behavior among nurses and physicians and provides explanations for organizational reluctance to deal with disruptive behaviors, as well as recommendations to address these issues effectively.

Objective To assess how changes in curriculum, accreditation standards, and certification and licensure competencies impacted how medical students and physician residents value interprofessional team and patient-centered care. Primary Data Source The Department of Veterans Affairs Learners’ Perceptions Survey (2003–2013). The nationally administered survey asked a representative sample of 56,569 U.S. medical students and physician residents, with a comparison group of 78,038 nonphysician trainees, to rate satisfaction with 28 elements, in two overall domains, describing their clinical learning experiences at VA medical centers. Study Design Value preferences were scored as independent adjusted associations between an element (interprofessional team, patient-centered preceptor) and the respective overall domain (clinical learning environment, faculty, and preceptors) relative to a referent element (quality of clinical care, quality of preceptor). Principal Findings Physician trainees valued interprofessional (14 percent vs. 37 percent, p

To compare medical students' and physician residents' satisfaction with Veterans Affairs (VA) training to determine the factors that were most strongly associated with trainee satisfaction ratings.Each year from 2001 to 2006, all medical students and residents in VA teaching facilities were invited to complete the Learners' Perceptions Survey. Participants rated their overall training satisfaction on a 100-point scale and ranked specific satisfaction in four separate educational domains (learning environment, clinical faculty, working environment, and physical environment) on a five-point Likert scale. Each domain was composed of unique items.A total of 6,527 medical students and 16,583 physician residents responded to the survey. The overall training satisfaction scores for medical students and physician residents were 84 and 79, respectively (P.001), with significant differences in satisfaction reported across the training continuum. For both medical students and residents, the rating of each of the four educational domains was statistically significantly associated with the overall training satisfaction score (P.001). The learning environment domain had the strongest association with overall training satisfaction score, followed by the clinical preceptor, working environment, and physical environment domains; no significant differences were found between medical students and physician residents in the rank order. Satisfaction with quality of care and faculty teaching contributed significantly to training satisfaction.Factors that influence training satisfaction were similar for residents and medical students. The domain with the highest association was the learning environment; quality of care was a key item within this domain.

Now is an exciting time to be or become a diagnostician. More diagnostic tests, including portions of the medical interview and physical examination, are being studied rigorously for their accuracy, precision, and usefulness in practice,1,2 and this research is increasingly being systematically reviewed and synthesized.3,4 Diagnosticians are gaining increasing access to this research evidence, raising hope that this knowledge will inform their diagnostic decisions and improve their patients’ clinical outcomes.5 For patients to benefit fully from this accumulating knowledge, the diagnosticians serving them must be able to reason probabilistically, to understand how test results can revise disease probability to confirm or exclude disorders, and to integrate this reasoning with other types of knowledge and diagnostic thinking.6–8 Yet, clinicians encounter several barriers when trying to integrate research evidence into clinical diagnosis.9 Some barriers involve difficulties in understanding and using the quantitative measures of tests’ accuracy and discriminatory power, including sensitivity, specificity, and likelihood ratios (LRs).9,10 We have noticed that LRs are particularly troubling to many learners at first, and we have wondered if this is because of the way they have been taught. Stumbling blocks can arise in several places when learning LRs: the names and formulae themselves can be intimidating; the arithmetic functions can be mystifying when attempted all at once; if two levels of test results are taught first, learners can have difficulty ‘stretching’ to multiple levels; and if disease probability is framed in odds terms (to directly multiply the odds by the likelihood ratio), learners can misunderstand why and how this conversion is done. Other stumbling blocks may occur as well. Other authors have described various approaches to helping clinicians understand LRs.11–16 In this article, we describe two additional approaches to help clinical learners understand how LRs describe the discriminatory power of test results. Whereas we mention other concepts such as pretest and posttest probability, full treatment of those subjects is beyond the scope of this article. These approaches were developed by experienced teachers of evidence-based medicine (EBM) and were refined over years of teaching practice. These tips have also been field-tested to double-check the clarity and practicality of these descriptions, as explained in the introductory article of this series.17 To help the reader envision these teaching approaches, we present sequenced advice for teachers in plain text, coupled with sample words to speak, in italics. These scripts are meant to be interactive, which means that teachers should periodically check in with the learners for their understanding and that teachers should try other ways to explain the ideas if the words we have suggested do not “click.” We present them in order from shorter to longer; however, because these 2 scripts cover the same general content, we encourage teachers to use either or both in an order that best fits their setting and learners.

Evidence based clinical practice has been defined as the conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients. It refers to a broad set of principles and methods intended to ensure that medical decisions, guidelines and health policy are based on well designed studies of therapeutic effectiveness and benefit.We review the principles and practice of evidence based clinical practice using examples from the urology literature. We further provide a guide to currently available web based evidence based clinical practice resources and guidelines for urologists.Evidence based clinical practice integrates a hierarchy of evidence and patient values with practitioner judgment to guide decision making for the individual patient. Important steps in the evidence based clinical practice process include the formulation of an answerable question and a systematic search of the literature. In the absence of pre-appraised evidence or disease specific guidelines, the practice of evidence based clinical practice relies heavily on the evaluation of the primary literature by the individual urologist. Depending on the question domain (therapy/prevention, etiology/cause/harm, diagnosis or prognosis) and study design, a given study is critically appraised for validity, impact and applicability. Evidence is then integrated with clinical judgment, and patient circumstances and preferences. Finally, the practice of evidence based clinical practice includes a self-assessment of provider performance.Knowledge, practice and documentation of evidence based clinical practice are of increasing importance to every urologist. Urologists should embrace evidence based clinical practice principles by acquiring the necessary skills to critically appraise the literature for the best evidence applicable to patient care.

Incorporating evidence-based medicine (EBM) into clinical practice is an important competency that residency training must address. Residency program directors, and the clinical educators who work with them, should develop curricula to enhance residents' capacity for independent evidence-based practice. In this article, the authors argue that residency programs must move beyond journal club formats to promote the practice of EBM by trainees. The authors highlight the limitations of journal club, and suggest additional curricular approaches for an integrated EBM curriculum. Helping residents become effective evidence users will require a sustained effort on the part of residents, faculty, and their educational institutions.

Clinicians wishing to quickly answer a clinical question may seek a systematic review, rather than searching for primary articles. Such a review is also called a meta-analysis when the investigators have used statistical techniques to combine results across studies. Databases useful for this purpose

In the first article in this series,[1][1] we presented an approach to understanding how to estimate a treatment's effectiveness that covered relative risk reduction, absolute risk reduction and number needed to treat. But how precise are these estimates of treatment effect? ![Figure][2]

The U.S. Department of Veterans Affairs (VA) supports 8,700 resident positions nationally to enhance quality of care for veterans and to educate physicians. This study sought to establish a yearly quality indicator to identify and follow strengths and opportunities for improvement in VA clinical training programs.In March 2001, the VA Learners' Perceptions Survey, a validated 57-item questionnaire, was mailed to 3,338 residents registered at 130 VA facilities. They were asked to rate their overall satisfaction with the VA clinical training experience and their satisfaction in four domains: faculty/preceptor, learning, working, and physical environments using a five-point Likert scale. Questionnaires were received from 1,775 residents (53.2%). A full analysis was conducted using 1,436 of these questionnaires, whose respondents were categorized in four training programs: medicine (n = 706), surgery (n = 291), subspecialty (n = 266), and psychiatry (n = 173).On a scale of 0 to 100, residents gave their clinical training experience an average score of 79. Eighty-four percent would have recommended VA training to peers, and 81% would have chosen VA training again. Overall, 87% were satisfied with their faculty/preceptors, 78% with the learning environment, and 67% with the working and physical environments. The survey was sensitive to differences in satisfaction among the trainee groups, with residents in internal medicine (IM) the least satisfied.The VA Learners' Perceptions Survey is the first validated survey to address comprehensive satisfaction issues in clinical training. The survey highlights strengths and opportunities for improvement in VA clinical training and is the first step toward improving education.

To examine access to and utilization of primary healthcare services with respect to gender. Greater family and child-rearing responsibilities are possible barriers to healthcare access and utilization for women with HIV infection.This study was part of a prospective, randomized, controlled trial evaluating primary care for HIV-infected patients at Duke University Medical Center (DUMC), a tertiary care medical center. Subjects were 214 HIV-infected, uninsured or publicly insured participants. Ambulatory care visits, emergency room utilization, hospitalization rates, length of stay, preventive and screening measures, and antiretroviral use were the outcome measures.Women (n = 83) and men (n = 131) enrolled in the study were similar with respect to race, educational level, marital status, and employment status. Women with HIV were more likely than men to have children (80% vs. 25%, p = 0.001) and spend their time as primary caregivers for their children (22% vs. 0.8%, p = 0.001). Women had higher CD4(+) cell counts (378 +/- 287 vs. 243 +/- 252 cells/microl, p = 0.0002), and a smaller proportion of women than men had AIDS at baseline (41% vs. 62%, p = 0.002). Women and men had similar numbers of primary care visits, emergency room visits, annual admission rates, and lengths of stay for hospitalizations. Pneumocystis carinii pneumonia prophylaxis, pneumococcal vaccination, and tuberculosis screening were also similar between women and men. Women were more likely than men to have ever been prescribed an antiretroviral agent (88.0% vs. 71.8%, p = 0.005).Women had greater familial responsibilities than men, but this was not a barrier to access or utilization of healthcare services. Despite less advanced HIV disease, women received similar care and had similar utilization of health services.

The authors designed an electronic database of clinical questions (CQs) and medical evidence and implemented it in 2001-02 at Duke University Medical Center and the Veterans Administration Medical Center in Durham, North Carolina. This Web-based data collection system is called the Critical Appraisal Resource (CAR) and is still in operation. This report is of ten months of the system's operation. During their medicine ward rotations, residents entered CQs into the CAR; they also entered Medline reference links and validated article summaries. Residents' utilization of the CAR database, Medline, and other electronic resources was prospectively measured. In addition, residents were prospectively surveyed regarding the impact of each question and associated reference on medical decision making for individual patients. Over ten months, residents entered 625 patient-based CQs into the CAR and were able to obtain useful information from the medical literature on 82% of the CQs they searched. The two most prevalent CQ types were therapy and diagnosis questions (53% and 22%). Sixty percent of the therapy articles considered useful were reports of randomized controlled trials. Residents obtained 77% of their useful data from Medline. They reported that obtaining useful data altered patient management 47% of the time. Residents used the CAR as a resource, searching the database for information 1,035 times over the study period. In summary, the use of an evidence-based critical appraisal resource led residents to engage the medical literature on behalf of their patients and influenced approximately half of their patient-care decisions. Residents benefited from questions previously searched by other residents, allowing them to address a wider spectrum of CQs during ward rotations.

To determine if a simple educational intervention can increase resident physician literature search activity.Randomized controlled trial.University hospital-based internal medicine training program.Forty-eight medical residents rotating on the general internal medicine service.One-hour didactic session, the use of well-built clinical question cards, and practical sessions in clinical question building.Objective data from the library information system that included the number of log-ons to medline, searching volume, abstracts viewed, full-text articles viewed, and time spent searching. Median search activity as measured per person per week (control vs intervention): number of log-ons to medline (2.1 vs 4.4, P.001); total number of search sets (24.0 vs 74.2, P.001); abstracts viewed (5.8 vs 17.7, P=.001); articles viewed (1.0 vs 2.6, P=.005); and hours spent searching (0.8 vs 2.4, P.001).A simple educational intervention can markedly increase resident searching activity.

Rationale, aims and objectives To summarize 20-year experience of conducting a workshop designed for educators who wish to improve their teaching skills of evidence based medicine (EBM). The goal is to provide tips for educators interested in replicating this educational model. Methods Qualitative description of factors associated with the success of the workshop. Results The factors considered by instructors to be most helpful are: the small group interactive design, role-play and simulation of real world learning environments, a mentorship model and high educator to learner ratio. Conclusions Although this experience is observational and does not represent high quality evidence, certain attributes in the design of EBM workshops may lead to better dissemination of EBM concepts. Educators may consider empirically applying some of these attributes and testing their efficacy in comparative studies.

Compared with younger patients, patients aged 50 years or older were less likely to have acquired HIV via intravenous drug use or homosexual contact (p = .0001). Older patients were more likely to have comorbid diseases (12% vs 4%; p = .0001), had more frequent neurologic findings on admission (19% vs 9%; p = .0001), and scored higher on a PCP-specific severity-of-illness scale indicating more severe disease (p = .0001). Older patients had more intensive care unit admissions and intubations (p = .0001). Patients aged 50 years or older were less likely to have a diagnosis of HIV mentioned in their progress notes during the first 2 days of admission (75% vs 85%; p = .0001), less likely to receive PCP-specific therapy within the first 2 hospital days (58% vs 76%; p = .0001), and more likely to receive steroids (32% vs 22%; p = .0001). Older patients had a greater in-hospital mortality (32% vs 18%; p = .0001). However, in logistic regression analysis with mortality as the outcome, the effect of older age was diminished when adjustments were made for insurance status, severity of illness, comorbidity, timely PCP therapy, and inpatient use of steroids.Age differences in mortality for AIDS-related PCP may be explained by increased severity of presenting illness, underrecognition of HIV, and delay in initiation of PCP-specific therapy. Physicians may need to consider HIV-related infections for persons aged 50 years or older at risk of HIV infection.

Background As the Accreditation Council on Graduate Medical Education (ACGME) deliberates over further limiting duty hours of graduate medical education (GME) trainees, few large-scale studies have shown residents to be satisfied with the effect the 2003 standards have had on clinical care, education outcomes, or working environments. This study measures the effect of the 2003 duty hours limits on resident-reported satisfaction with GME training during their rotations through the Department of Veterans Affairs (VA) medical centers from 2001 through 2007. Method Self-reported satisfaction with clinical care and education environments were assessed by comparing responses to VA's annual Learners' Perceptions Survey administered before 2003 with responses administered after 2003. To measure duty hours effects on satisfaction, before-after differences were adjusted for covariate biases modeled after an exhaustive covariate search with 10-fold cross-validation. Because nonteaching controls are not available in satisfaction studies, we used a robust differencing variable technique to control before-after differences for trend biases in the simultaneous presence of missing data and possible model misspecification. Results There were 19,605 responders. Adjusting for covariate and trend biases, after the 2003 ACGME standards, 25% more residents in medicine specialties reported satisfaction with VA clinical environment and 11% more with VA preceptors and faculty. For surgery, 33% more residents reported satisfaction with VA clinical environment and 12% more with VA preceptors and faculty. Satisfaction with working environment was mixed. Conclusions The 2003 ACGME duty hours standards were associated with improved satisfaction for resident clinical training and learning environments.

To summarize 20-year experience of conducting a workshop designed for educators who wish to improve their teaching skills of evidence based medicine (EBM). The goal is to provide tips for educators interested in replicating this educational model.Qualitative description of factors associated with the success of the workshop.The factors considered by instructors to be most helpful are: the small group interactive design, role-play and simulation of real world learning environments, a mentorship model and high educator to learner ratio.Although this experience is observational and does not represent high quality evidence, certain attributes in the design of EBM workshops may lead to better dissemination of EBM concepts. Educators may consider empirically applying some of these attributes and testing their efficacy in comparative studies.

To develop a survey instrument designed to quantify supervision by attending physicians in nonprocedural care and to assess the instrument's feasibility and reliability.In 2008, the Department of Veterans Affairs (VA) Office of Academic Affiliations convened an expert panel to adopt a working definition of attending supervision in nonprocedural patient care and to construct a survey to quantify it. Feasibility was field-tested on residents and their supervising attending physicians at primary care internal medicine clinics at the VA Loma Linda Healthcare System in their encounters with randomly selected outpatients diagnosed with either major depressive disorder or diabetes. The authors assessed both interrater concurrent reliability and test-retest reliability.The expert panel adopted the VA's definition of resident supervision and developed the Resident Supervision Index (RSI) to measure supervision in terms of residents' case understanding, attending physicians' contributions to patient care through feedback to the resident, and attending physicians' time (minutes). The RSI was field-tested on 60 residents and 37 attending physicians for 148 supervision episodes from 143 patient encounters. Consent rates were 94% for residents and 97% for attending physicians; test-retest reliability intraclass correlations (ICCs) were 0.93 and 0.88, respectively. Concurrent reliability between residents' and attending physicians' reported time was an ICC of 0.69.The RSI is a feasible and reliable measure of resident supervision that is intended for research studies in graduate medical education focusing on education outcomes, as well as studies assessing quality of care, patient health outcomes, care costs, and clinical workload.

BackgroundGraduate medical education is based on an on-the-job training model in which residents provide clinical care under supervision. The traditional method is to offer residents graduated levels of responsibility that will prepare them for independent practice. However, if progressive independence from supervision exceeds residents' progressive professional development, patient outcomes may be at risk. Leaders in graduate medical education have called for “optimal” supervision, yet few studies have conceptually defined what optimal supervision means and whether optimal care is theoretically compatible with progressive independence, nor have they developed a test for progressive independence.ObjectiveThis research develops theory and analytic models as part of the Resident Supervision Index to quantify the intensity of supervision.MethodsWe introduce an explicit set of assumptions for an ideal patient-centered theory of optimal supervision of resident-provided care. A critical assumption is that informed attending staff will use available resources to optimize patient outcomes first and foremost, with residents gaining clinical competencies by contributing to optimal care. Next, we derive mathematically the consequences of these assumptions as theoretical results.ResultsUnder optimal supervision, (1) patient outcome is expected to be no worse than if residents were not involved, (2) supervisors will avoid undersupervising residents (when patients are at increased risk for poor outcomes) or oversupervising residents (when residents miss clinical opportunities to practice care), (3) optimal patient outcomes will be compatible with progressive independence, (4) progressive development can be inferred from progressive independence whenever residents contribute to patient care, and (5) analytic models that test for progressive independence will emphasize adjusting the association between length of graduate medical education training and supervision for case complexity and clinic workload, but not patient health outcomes.ConclusionAn explicit theoretical framework is critical to measure scientifically progressive independence from supervision using graduate medical education data.

BackgroundA Resident Supervision Index (RSI) developed by our research team quantifies the intensity of resident supervision in graduate medical education, with the goal of testing for progressive independence. The 4-part RSI method includes a survey instrument for staff and residents (RSI Inventory), a strategy to score survey responses, a theoretical framework (patient centered optimal supervision), and a statistical model that accounts for the presence or absence of supervision and the intensity of patient care.MethodsThe RSI Inventory data came from 140 outpatient encounters involving 57 residents and 37 attending physicians during a 3-month period at a Department of Veterans Affairs outpatient clinic. Responses are scored to quantitatively measure the intensity of resident supervision across 10 levels of patient services (staff is absent, is present, participated, or provided care with or without a resident), case discussion (resident-staff interaction), and oversight (staff reviewed case, reviewed medical chart, consulted with staff, or assessed patient). Scores are analyzed by level and for patient care using a 2-part model (supervision initiated [yes or no] versus intensity once supervision was initiated).ResultsAll resident encounters had patient care supervision, resident oversight, or both. Consistent with the progressive independence hypothesis, residents were 1.72 (P = .019) times more likely to be fully responsible for patient care with each additional postgraduate year. Decreasing case complexity, increasing clinic workload, and advanced nonmedical degrees among attending staff were negatively associated with supervision intensity, although associations varied by supervision level.ConclusionsThese data are consistent with the progressive independence hypothesis in graduate medical education and offer empirical support for the 4-part RSI method to quantify the intensity of resident supervision for research, program evaluation, and resident assessment purposes. Before informing policy, however, more scientific research in actual teaching settings is needed to better understand the relationships among patient outcomes, clinic workload, case complexity, and graduate medical education experience in resident supervision and professional development.

Background Supporting 21st century health care and the practice of evidence-based medicine (EBM) requires ubiquitous access to clinical information and to knowledge-based resources to answer clinical questions. Many questions go unanswered, however, due to lack of skills in formulating questions, crafting effective search strategies, and accessing databases to identify best levels of evidence. Methods This randomized trial was designed as a pilot study to measure the relevancy of search results using three different interfaces for the PubMed search system. Two of the search interfaces utilized a specific framework called PICO, which was designed to focus clinical questions and to prompt for publication type or type of question asked. The third interface was the standard PubMed interface readily available on the Web. Study subjects were recruited from interns and residents on an inpatient general medicine rotation at an academic medical center in the US. Thirty-one subjects were randomized to one of the three interfaces, given 3 clinical questions, and asked to search PubMed for a set of relevant articles that would provide an answer for each question. The success of the search results was determined by a precision score, which compared the number of relevant or gold standard articles retrieved in a result set to the total number of articles retrieved in that set. Results Participants using the PICO templates (Protocol A or Protocol B) had higher precision scores for each question than the participants who used Protocol C, the standard PubMed Web interface. (Question 1: A = 35%, B = 28%, C = 20%; Question 2: A = 5%, B = 6%, C = 4%; Question 3: A = 1%, B = 0%, C = 0%) 95% confidence intervals were calculated for the precision for each question using a lower boundary of zero. However, the 95% confidence limits were overlapping, suggesting no statistical difference between the groups. Conclusion Due to the small number of searches for each arm, this pilot study could not demonstrate a statistically significant difference between the search protocols. However there was a trend towards higher precision that needs to be investigated in a larger study to determine if PICO can improve the relevancy of search results.

The paper compares the speed, validity, and applicability of two different protocols for searching the primary medical literature.A randomized trial involving medicine residents was performed.An inpatient general medicine rotation was used.Thirty-two internal medicine residents were block randomized into four groups of eight.Success rate of each search protocol was measured by perceived search time, number of questions answered, and proportion of articles that were applicable and valid.Residents randomized to the MEDLINE-first (protocol A) group searched 120 questions, and residents randomized to the MEDLINE-last (protocol B) searched 133 questions. In protocol A, 104 answers (86.7%) and, in protocol B, 117 answers (88%) were found to clinical questions. In protocol A, residents reported that 26 (25.2%) of the answers were obtained quickly or rated as "fast" (5 minutes) as opposed to 55 (51.9%) in protocol B, (P = 0.0004). A subset of questions and articles (n = 79) were reviewed by faculty who found that both protocols identified similar numbers of answer articles that addressed the questions and were felt to be valid using critical appraisal criteria.For resident-generated clinical questions, both protocols produced a similarly high percentage of applicable and valid articles. The MEDLINE-last search protocol was perceived to be faster. However, in the MEDLINE-last protocol, a significant portion of questions (23%) still required searching MEDLINE to find an answer.

High-quality palliative care requires physicians who communicate effectively, yet many do not receive adequate training. Leading efforts to demonstrate the effectiveness of such training have involved time-intensive programs that included primarily attending physicians, which have been conducted outside of the United States. The goal was to evaluate the effect of a short course to improve residents' communication skills delivering bad news and eliciting patients' preferences for end-of-life care.This prospective trial enrolled internal medicine residents at Duke University Medical Center from 1999 to 2001. The course consisted of small-group teaching with lecture, discussion, and role-play. The outcome measure was observed communication skills delivering bad news and eliciting patients' preferences for end-of-life treatment, assessed via audio-recorded standardized patient encounters before and after receiving the intervention.Thirty-seven residents received the intervention and 19 were in the control group. Residents attending the course demonstrated statistically significant increases in their overall skill ratings in the delivery of bad news, with improvement in the specific areas of information giving and responding to emotional cues. Although cumulative scores for discussions about patient preferences for treatment did not increase, residents demonstrated enhanced specific skills including discussing probability, presenting clinical scenarios, and asking about prior experience with end-of-life decision making.A relatively short, intensive course can improve the end-of-life communication skills of U.S. medical residents.

Randomized, controlled trials are the gold standard for evidence based assessment of therapeutic interventions. In 1996 the Consolidated Standards of Reporting Trials statement was published in an effort to standardize the reporting of clinical trials. To our knowledge we report the first systematic assessment of randomized, controlled trial quality in the urology literature by Consolidated Standards of Reporting Trials standards.All human subject randomized, controlled trials published in 4 leading urology journals in 1996 and 2004 were identified for formal review. A standardized evaluation form was developed based on the Consolidated Standards of Reporting Trials statement. Each article was evaluated by 2 independent reviewers and discrepancies were settled by consensus. A Consolidated Standards of Reporting Trials criteria summary score was calculated on a scale of 0 to 22.A total of 152 randomized, controlled trials met inclusion criteria. The mean+/-SEM Consolidated Standards of Reporting Trials summary score was 10.2+/-0.3 (median 10.3) and 12.0+/-0.3 (median 12.2) in 1996 and 2004, respectively, with a mean difference of 1.8 (95% CI 1.0, 2.6; p=0.001). Reporting of important methodological criteria, eg sample size justification and randomization implementation, improved from 1996 to 2004. Improvement notwithstanding, reporting of key methodological criteria remained consistently below 50% in 2004.This formal review suggests that randomized, controlled trial reporting in the urology literature has improved since the publication of the Consolidated Standards of Reporting Trials statement in 1996. Certain areas, such as reporting of trial methods, continue to meet Consolidated Standards of Reporting Trials criteria in fewer than half of publications. Ongoing graduate and postgraduate education in trial design and evidence based practice may result in further improvement in randomized, controlled trial reporting.

For clinicians to use a diagnostic test in clinical practice, they need to know how well the test distinguishes between those who have the suspected disease or condition and those who do not. If investigators choose clinically inappropriate populations for their study of a diagnostic test and

Imagine that you're a busy family physician and that you've found a rare free moment to scan the recent literature. Reviewing your preferred digest of abstracts, you notice a study comparing emergency physicians' interpretation of chest radiographs with radiologists' interpretations.[1][1] The

Physicians, patients and policy-makers are influenced not only by the results of studies but also by how authors present the results.[1][1],[2][2],[3][3],[4][4] Depending on which measures of effect authors choose, the impact of an intervention may appear very large or quite small, even though the

To measure the impact of a teaching intervention and to compare process and outcomes of care for HIV-infected patients randomly assigned to a general medicine clinic (GMC) or an infectious disease clinic (IDC) for primary care.Prospective, randomized, controlled trial.University hospital in Durham, NC.Two hundred fourteen consecutive HIV-infected patients presenting for primary care.Physicians at the GMC received HIV-related training and evidence-based practice guidelines.Utilization of services, health-related quality of life, preventive and screening measures, and antiretroviral use for one year.At baseline GMC patients were more likely to be African American (85% vs 71%; P =.03) and had lower baseline CD4+ cell counts than IDC patients (262 +/- 269 vs 329 +/- 275; P =.05). A similar and high proportion of patients in both groups received appropriate preventive care services including Pneumocystis carinii pneumonia (PCP) prophylaxis, pneumococcal vaccination, and antiretroviral therapy. Screening for TB was more frequent in GMC (89% vs 68%; P =.001). In the year following randomization, GMC patients made more visits to the emergency department than IDC patients (1.6 +/- 3.0 vs 0.7 +/- 1.5; P =.05). Hospital use was higher for GMC patients with average length of stay 7.8 +/- 6.3 days compared to 5.7 +/- 3.8 days for IDC patients (P =.01). In analyses, which adjust for potential baseline imbalances, these differences remained.Targeted education in GMC achieved similar provision of primary care for GMC patients, yet use of health care services was higher for this group. The delivery of adequate primary care is necessary but not sufficient to produce changes in health care utilization.

At the June 2005 McMaster Evidence-Based Practice Workshop, our group, led by librarian Jan Figurski and tutor trainee Rakesh Patel, developed a very useful teaching tool for our tutorials. We called it the 4Ts Teaching Tips. After such initial success, the rest of us further developed the tool into the 6Ts Teaching Tips at the June 2006 Workshop. The overall objective of this tool is to provide a touchstone to both plan and evaluate a teaching session. (1) The first T stands for Time management. A critical appraisal exercise or any teaching session requires careful planning about topics to be covered in a specified period of time. The first T also reminds teachers about leaving time for evaluation …

Background Managed care restrictions on resource use may affect communication between patients and health care professionals. Methods To characterize negotiations between primary care physicians and patients with expectations for new medications, tests, or referrals, this observational study combined survey data with audiotape recordings of clinical encounters. Fifty-five physicians from 20 randomly selected primary care practices in a managed care network and 211 patients who voiced specific expectations in a previsit survey were included. From the recorded clinic visits we determined modes of negotiation of patient expectations and requests. From the surveys we determined patient previsit expectations, postvisit fulfillment of expectations, satisfaction, and trust. Results Two-hundred fifty-six self-reported expectations were captured in 200 audiotape-recorded encounters. Of the previsit expectations, 97.3% were discussed during the encounter. Expectations were expressed by direct patient request (40.6%), mentioning of symptoms related to request (29.7%), or physician-initiated discussion (27.0%). Most expectations were met (66.8%); physicians suggested an alternative 21.6% of the time. Expectations for medications and tests were met more frequently than expectations for referrals (75.6% and 71.4% vs 40.8%). Patient satisfaction and trust remained high regardless of whether expectations were met. Physicians reported that they would not have ordered 62 (44.9%) of 138 requests had the patients not directly asked, and they were uncomfortable filling 8 requests (12.9%). Conclusions Previsit expectations for medications, tests, or referrals were discussed at the visit, and physicians met or offered alternatives for nearly 90%. Patients generally received what they asked for and altered physician behavior nearly half of the time.

The notion that prognostic differences between treatment groups might explain apparent differences in outcomes lies at the heart of clinical investigation. If clinicians are to understand the research studies that guide their clinical practice, they must grasp this concept. Further, clinicians should understand statistical adjustment for differences in prognostic variables. This tip describes approaches to conveying these concepts to learners. As with other articles in this series, educators experienced in teaching evidence-based medicine developed these tips and used them extensively to clarify statistical concepts to learners solving clinical problems or critically appraising studies and reviews. An article from the Canadian Medical Association Journal described the development of this series and pertinent background information.1 For each of the tips we provide guidance on when to use them, a teaching script, a “bottom line,” and a summary card. For each tip we identify the appropriate target audience and provide time estimates for the exercise. We present qualitative introductions to the concepts of confounding variables and adjusted analysis, followed by quantitative examples illustrating the potential impact of adjustment. These demonstrations are characteristically interpolated into clinically centered discussions with clinical learners. We do not in the course of using them routinely attempt to address performing or analyzing multivariable or multivariate analyses with such learners. We consider learner mastery of the concept of relative risk to be prerequisite for understanding the tips, particularly for tip 3. A previously published manuscript addressed teaching relative risk.2

Background Clinical prediction rules (CPR) are tools that clinicians can use to predict the most likely diagnosis, prognosis, or response to treatment in a patient based on individual characteristics. CPRs attempt to standardize, simplify, and increase the accuracy of clinicians’ diagnostic and prognostic assessments. The teaching tips series is designed to give teachers advice and materials they can use to attain specific educational objectives. Educational Objectives In this article, we present 3 teaching tips aimed at helping clinical learners use clinical prediction rules and to more accurately assess pretest probability in every day practice. The first tip is designed to demonstrate variability in physician estimation of pretest probability. The second tip demonstrates how the estimate of pretest probability influences the interpretation of diagnostic tests and patient management. The third tip exposes learners to various examples and different types of Clinical Prediction Rules (CPR) and how to apply them in practice. Pilot Testing We field tested all 3 tips with 16 learners, a mix of interns and senior residents. Teacher preparatory time was approximately 2 hours. The field test utilized a board and a data projector; 3 handouts were prepared. The tips were felt to be clear and the educational objectives reached. Potential teaching pitfalls were identified. Conclusion Teaching with these tips will help physicians appreciate the importance of applying evidence to their every day decisions. In 2 or 3 short teaching sessions, clinicians can also become familiar with the use of CPRs in applying evidence consistently in everyday practice.

Background Learner satisfaction assessment is critical in the design and improvement of training programs. However, little is known about what influences satisfaction and whether trainee specialty is correlated. A national comparison of satisfaction among internal medicine subspecialty fellows in the Department of Veterans Affairs (VA) provides a unique opportunity to examine educational factors associated with learner satisfaction. We compared satisfaction across internal medicine fellows by subspecialty and compared factors associated with satisfaction between procedural versus non-procedural subspecialty fellows, using data from the Learners' Perceptions Survey (LPS), a validated survey tool. Methods We surveyed 2,221 internal medicine subspecialty fellows rotating through VA between 2001 and 2008. Learners rated their overall training satisfaction on a 100-point scale, and on a five-point Likert scale ranked satisfaction with items within six educational domains: learning, clinical, working and physical environments; personal experience; and clinical faculty/preceptor. Results Procedural and non-procedural fellows reported similar overall satisfaction scores (81.2 and 81.6). Non-procedural fellows reported higher satisfaction with 79 of 81 items within the 6 domains and with the domain of physical environment (4.06 vs. 3.85, p Conclusions Internal medicine fellows are highly satisfied with their VA training. Nonprocedural fellows reported higher satisfaction with most items. For both procedural and non-procedural fellows, clinical faculty/preceptor and personal experience have the strongest impact on overall satisfaction.