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Hemenway AN, Meyer-Junco L, Ahmed Khan MI, Affinati M. Creation of a Didactic Clinical Pharmacology Lecture Series for Internal Medicine Residents. Cureus 2023; 15:e42090. [PMID: 37469577 PMCID: PMC10353880 DOI: 10.7759/cureus.42090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2023] [Indexed: 07/21/2023] Open
Abstract
INTRODUCTION One of the noted areas of weakness for internal medicine residents is pharmacology. However, there is little data documenting the creation and effect of a comprehensive pharmacology didactic program. Our goal was to create a two-year clinical pharmacology didactic program focused on areas of stated weakness and to evaluate this program for an increase in knowledge and prescribing confidence of the participants. METHODS From August 2020 to June 2022, a two-year pharmacology program was developed, which included 20 didactic lectures on a variety of topics. Pre- and post-tests were given for 15 of the lectures, and four surveys were given, two during each year of the program. Four questions on each survey were the same and asked about confidence in choosing an appropriate medication based on current guidelines, patient-specific factors, primary literature, and pharmacokinetics. RESULTS Over the two years, participation in the pharmacology sessions ranged from 17 to 29 residents (65-74% of the residency class). The average pre- and post-test scores increased by an average of 25.1%, which was a statistically significant increase (p<0.001, 95% CI [17.5, 32.8]). A Kruskal-Wallis H test showed a statistically significant difference in resident-reported confidence adjusting medications based on primary literature between the different survey groups, χ2 = 9.871, p = 0.02. CONCLUSION A two-year, didactic pharmacology program improved the knowledge of resident participants and confidence in their ability to choose an appropriate medication based on primary literature.
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Affiliation(s)
- Alice N Hemenway
- Department of Pharmacy Practice, University of Illinois at Chicago, Rockford, USA
| | - Laura Meyer-Junco
- Department of Pharmacy Practice, University of Illinois at Chicago, Rockford, USA
| | | | - Mario Affinati
- Department of Medicine, University of Illinois at Chicago, Rockford, USA
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Design and Implementation of an Interactive Curriculum on Telemetry Use and Interpretation for Medicine Interns: a Survey Study. J Gen Intern Med 2021; 36:827-829. [PMID: 32096077 PMCID: PMC7947130 DOI: 10.1007/s11606-020-05742-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 02/11/2020] [Indexed: 10/24/2022]
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Wintermark M, Willis MH, Hom J, Franceschi AM, Fotos JS, Mosher T, Cruciata G, Reuss T, Horton R, Fredericks N, Burleson J, Haines B, Bruno M. Everything Every Radiologist Always Wanted (and Needs) to Know About Clinical Decision Support. J Am Coll Radiol 2020; 17:568-573. [DOI: 10.1016/j.jacr.2020.03.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/26/2019] [Accepted: 03/19/2020] [Indexed: 12/18/2022]
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Tseng EK, Mukerji G, Weinerman A, Fuller J, McLeod A, Wong BM, Kuper A, Stroud LS. Choosing Words Wisely: Residents' Use of Rhetorical Appeals in Conversations About Unnecessary Tests. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:275-282. [PMID: 31517680 DOI: 10.1097/acm.0000000000002980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE To characterize how residents employ rhetorical appeals (i.e., the strategic use of communication to achieve specifiable goals) when discussing unnecessary diagnostic tests with patients. METHOD In 2015, senior hematology residents from 10 Canadian universities participating in a national formative objective structured clinical examination (OSCE) completed a resource stewardship communication station. In this communication scenario, a standardized patient (SP) portrayed a patient requesting unnecessary thrombophilia testing following early pregnancy loss. The authors performed a thematic analysis of audio transcripts using a qualitative description approach to identify residents' rhetorical appeals to logic (rational appeals), credibility, and emotion. RESULTS For persuasive communication, residents (n = 27) relied primarily on rational appeals that fit into 3 categories (with themes) focused on medical evidence (poor utility, professional guidelines and recommendations), avoidance of harm (insurance implications, unnecessary or potentially harmful interventions, patient anxiety), and reassurance to patient (normalizing, clinical pretest probability, criteria for reconsidering testing). Appeals to credibility and emotion were rarely used. CONCLUSIONS In an OSCE setting, residents relied predominantly on rational appeals when engaging SPs in conversations about unnecessary tests. These observations yield insights into how recent emphasis within residency education on appropriate test utilization may manifest when residents put recommendations into practice in conversations with patients. This study's framework of rational appeals may be helpful in designing communication curricula about unnecessary testing. Future studies should explore rhetoric about unnecessary testing in the clinical environment, strategies to teach and coach residents leading these conversations, and patients' preferences and responses to different appeals.
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Affiliation(s)
- Eric K Tseng
- E.K. Tseng is assistant professor, Department of Medicine, University of Toronto, and staff physician, Division of Hematology/Oncology, St. Michael's Hospital, Toronto, Ontario, Canada. G. Mukerji is assistant professor, Department of Medicine, University of Toronto, and staff physician, Division of Endocrinology, Women's College Hospital, Toronto, Ontario, Canada. A. Weinerman is assistant professor, Department of Medicine, University of Toronto, and staff physician, Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. J. Fuller is assistant professor, Department of History and Philosophy of Science, University of Pittsburgh, Pittsburgh, Pennsylvania, and research associate, African Centre for Epistemology and Philosophy of Science, University of Johannesburg, Johannesburg, South Africa. A. McLeod is assistant professor, Department of Medicine, University of Toronto, and staff physician, Division of Hematology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. B.M. Wong is associate professor, Department of Medicine, and associate director, Centre for Quality Improvement and Patient Safety, University of Toronto, and staff physician, Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. A. Kuper is associate professor, Department of Medicine, and education scientist, Wilson Centre for Education, University of Toronto, and staff physician, Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. L.S. Stroud is associate professor, Department of Medicine, and centre researcher, Wilson Centre for Education, University of Toronto, and staff physician, Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Xu S, Hom J, Balasubramanian S, Schroeder LF, Najafi N, Roy S, Chen JH. Prevalence and Predictability of Low-Yield Inpatient Laboratory Diagnostic Tests. JAMA Netw Open 2019; 2:e1910967. [PMID: 31509205 PMCID: PMC6739729 DOI: 10.1001/jamanetworkopen.2019.10967] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
IMPORTANCE Laboratory testing is an important target for high-value care initiatives, constituting the highest volume of medical procedures. Prior studies have found that up to half of all inpatient laboratory tests may be medically unnecessary, but a systematic method to identify these unnecessary tests in individual cases is lacking. OBJECTIVE To systematically identify low-yield inpatient laboratory testing through personalized predictions. DESIGN, SETTING, AND PARTICIPANTS In this retrospective diagnostic study with multivariable prediction models, 116 637 inpatients treated at Stanford University Hospital from January 1, 2008, to December 31, 2017, a total of 60 929 inpatients treated at University of Michigan from January 1, 2015, to December 31, 2018, and 13 940 inpatients treated at the University of California, San Francisco from January 1 to December 31, 2018, were assessed. MAIN OUTCOMES AND MEASURES Diagnostic accuracy measures, including sensitivity, specificity, negative predictive values (NPVs), positive predictive values (PPVs), and area under the receiver operating characteristic curve (AUROC), of machine learning models when predicting whether inpatient laboratory tests yield a normal result as defined by local laboratory reference ranges. RESULTS In the recent data sets (July 1, 2014, to June 30, 2017) from Stanford University Hospital (including 22 664 female inpatients with a mean [SD] age of 58.8 [19.0] years and 22 016 male inpatients with a mean [SD] age of 59.0 [18.1] years), among the top 20 highest-volume tests, 792 397 were repeats of orders within 24 hours, including tests that are physiologically unlikely to yield new information that quickly (eg, white blood cell differential, glycated hemoglobin, and serum albumin level). The best-performing machine learning models predicted normal results with an AUROC of 0.90 or greater for 12 stand-alone laboratory tests (eg, sodium AUROC, 0.92 [95% CI, 0.91-0.93]; sensitivity, 98%; specificity, 35%; PPV, 66%; NPV, 93%; lactate dehydrogenase AUROC, 0.93 [95% CI, 0.93-0.94]; sensitivity, 96%; specificity, 65%; PPV, 71%; NPV, 95%; and troponin I AUROC, 0.92 [95% CI, 0.91-0.93]; sensitivity, 88%; specificity, 79%; PPV, 67%; NPV, 93%) and 10 common laboratory test components (eg, hemoglobin AUROC, 0.94 [95% CI, 0.92-0.95]; sensitivity, 99%; specificity, 17%; PPV, 90%; NPV, 81%; creatinine AUROC, 0.96 [95% CI, 0.96-0.97]; sensitivity, 93%; specificity, 83%; PPV, 79%; NPV, 94%; and urea nitrogen AUROC, 0.95 [95% CI, 0.94, 0.96]; sensitivity, 87%; specificity, 89%; PPV, 77%; NPV 94%). CONCLUSIONS AND RELEVANCE The findings suggest that low-yield diagnostic testing is common and can be systematically identified through data-driven methods and patient context-aware predictions. Implementing machine learning models appear to be able to quantify the level of uncertainty and expected information gained from diagnostic tests explicitly, with the potential to encourage useful testing and discourage low-value testing that incurs direct costs and indirect harms.
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Affiliation(s)
- Song Xu
- Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California
| | - Jason Hom
- Division of Hospital Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Santhosh Balasubramanian
- Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California
| | - Lee F. Schroeder
- Department of Pathology, University of Michigan School of Medicine, Ann Arbor
| | - Nader Najafi
- Department of Medicine, University of California, San Francisco
| | - Shivaal Roy
- Department of Computer Science, Stanford University, Stanford, California
| | - Jonathan H. Chen
- Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California
- Division of Hospital Medicine, Department of Medicine, Stanford University, Stanford, California
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Kwang H, Mou E, Richman I, Kumar A, Berube C, Kaimal R, Ahuja N, Harman S, Johnson T, Shah N, Witteles R, Harrington R, Shieh L, Hom J. Thrombophilia testing in the inpatient setting: impact of an educational intervention. BMC Med Inform Decis Mak 2019; 19:167. [PMID: 31429747 PMCID: PMC6701078 DOI: 10.1186/s12911-019-0889-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 08/06/2019] [Indexed: 11/26/2022] Open
Abstract
Background Thrombophilia testing is frequently ordered in the inpatient setting despite its limited impact on clinical decision-making and unreliable results in the setting of acute thrombosis or ongoing anticoagulation. We sought to determine the effect of an educational intervention in reducing inappropriate thrombophilia testing for hospitalized patients. Methods During the 2014 academic year, we implemented an educational intervention with a phase implementation design for Internal Medicine interns at Stanford University Hospital. The educational session covering epidemiology, appropriate thrombophilia evaluation and clinical rationale behind these recommendations. Their ordering behavior was compared with a contemporaneous control (non-medicine and private services) and a historical control (interns from prior academic year). From the analyzed data, we determined the proportion of inappropriate thrombophilia testing of each group. Logistic generalized estimating equations were used to estimate odds ratios for inappropriate thrombophilia testing associated with the intervention. Results Of 2151 orders included, 934 were deemed inappropriate (43.4%). The two intervention groups placed 147 orders. A pooled analysis of ordering practices by intervention groups revealed a trend toward reduction of inappropriate ordering (p = 0.053). By the end of the study, the intervention groups had significantly lower rates of inappropriate testing compared to historical or contemporaneous controls. Conclusion A brief educational intervention was associated with a trend toward reduction in inappropriate thrombophilia testing. These findings suggest that focused education on thrombophilia testing can positively impact inpatient ordering practices. Electronic supplementary material The online version of this article (10.1186/s12911-019-0889-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Henry Kwang
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Eric Mou
- Division of Hematology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Ilana Richman
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Andre Kumar
- Division of Hospital Medicine, Department of Medicine, Stanford University, 300 Pasteur Drive, HC007, Stanford, CA, 94305, USA
| | - Caroline Berube
- Division of Hematology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Rajani Kaimal
- Department of Medicine, Quantitative Sciences Unit, Stanford University, Stanford, CA, USA
| | - Neera Ahuja
- Division of Hospital Medicine, Department of Medicine, Stanford University, 300 Pasteur Drive, HC007, Stanford, CA, 94305, USA
| | - Stephanie Harman
- Division of Palliative Care, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Tyler Johnson
- Division of Oncology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Neil Shah
- Department of Pathology, Stanford University, Stanford, CA, USA
| | - Ronald Witteles
- Division of Cardiology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Robert Harrington
- Division of Cardiology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Lisa Shieh
- Division of Hospital Medicine, Department of Medicine, Stanford University, 300 Pasteur Drive, HC007, Stanford, CA, 94305, USA.
| | - Jason Hom
- Division of Hospital Medicine, Department of Medicine, Stanford University, 300 Pasteur Drive, HC007, Stanford, CA, 94305, USA.
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Marshall AL, Jenkins S, Oxentenko AS, Lee AI, Siegel MD, Katz JT, Vyas JM, Del Valle J, Mikhael JR. Internal medicine trainees' knowledge and confidence in using the American Society of Hematology Choosing Wisely guidelines in hemostasis, thrombosis, and non-malignant hematology. PLoS One 2018; 13:e0197414. [PMID: 29768480 PMCID: PMC5955511 DOI: 10.1371/journal.pone.0197414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 05/01/2018] [Indexed: 11/29/2022] Open
Abstract
Background Several specialty societies participate in the Choosing Wisely (CW) campaign in an attempt to reduce waste in health care spending. We surveyed internal medicine (IM) residents with an objective of classifying knowledge of and confidence in using the American Society of Hematology (ASH) CW principles in hemostasis, thrombosis, and non-malignant hematology. Methods Multi-institutional study of IM residents at 5 academic training programs in the United States. A 10-question, case-based multiple choice test, with each question accompanied by a 5-point Likert-scale confidence assessment, was distributed electronically. Responses were summarized with frequencies and percentages or medians and ranges, as appropriate. Two sample t-tests or Wilcoxon rank-sum tests were used to compare confidence and knowledge scores. Results Of 892 IM residents, 174 (19.5%) responded to all questions. Overall, residents answered a median of 7 of 10 questions correctly (range 2–10) and median resident confidence in their responses was 3.1 (on a 5-point scale). Correct responses were significantly associated with higher confidence for all but one question. Having a hematology rotation experience was significantly associated with more correct responses and with higher confidence (p = 0.001 and p<0.001, respectively). Conclusions IM residents at several academic hospitals have variable knowledge of ASH-CW guidelines in thrombosis and hemostasis/non-malignant hematology. Residents who have done hematology rotations, particularly a hematology consult rotation, were more likely to answer questions correctly and to be more confident that their answers were correct. Adequate clinical exposure and training in cost-effective care is essential to train clinicians who are cost-conscious in any specialty.
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Affiliation(s)
- Ariela L. Marshall
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, United States of America
- * E-mail:
| | - Sarah Jenkins
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Amy S. Oxentenko
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Alfred I. Lee
- Division of Hematology, Yale School of Medicine, New Haven, CT, United States of America
| | - Mark D. Siegel
- Division of Hematology, Yale School of Medicine, New Haven, CT, United States of America
| | - Joel T. Katz
- Department of Internal Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Jatin M. Vyas
- Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - John Del Valle
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Joseph R. Mikhael
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix, Arizona, United States of America
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