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Madrazo L, Zhang G, Bishop KA, Appleton A, Joneja M, Goldszmidt M. "It's What We Can Do Right Now": Professional Identity Formation Among Internal Medicine Residents During the COVID-19 Pandemic. Acad Med 2023; 98:1428-1433. [PMID: 37683270 DOI: 10.1097/acm.0000000000005452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
PURPOSE The COVID-19 pandemic represents a consequential moment of disruption for medical training that has far-reaching implications for professional identity formation (PIF). To date, this has not been studied. As medical education grapples with a postpandemic era, it is essential to gain insight into how the pandemic has influenced PIF to better support its positive influences and mitigate its more detrimental effects. This study examined how PIF occurred during the COVID-19 pandemic to better adapt future medical training. METHOD Constructivist grounded theory guided the iterative data collection and analyses. The authors conducted semistructured group interviews with 24 Ontario internal medicine residents in postgraduate years (PGYs) 1 to 3 between November 2020 and July 2021. Participants were asked to reflect on their day-to-day clinical and learning experiences during the pandemic. RESULTS Twenty-four internal medicine residents were interviewed (12 PGY-1 [50.0%], 9 PGY-2 [37.5%], and 3 PGY-3 [12.5%]). Participants described how navigating patient care and residency training through the pandemic consistently drew their attention to various system problems. How participants responded to these problems was shaped by an interplay among their personal values, their level of personal wellness or burnout, self-efficacy, institutional values, and the values of their supervisors and work community. As they were influenced by these factors, some were led toward acting on the problem(s) they identified, whereas others had a sense of resignation and deferred action. These interactions were evident in participants' experiences with communication, advocacy, and learning. CONCLUSIONS Residents' professional identities are continuously shaped by how they perceive, reconcile, and address various challenges. As residents navigate tensions between personally held values and apparent system values, individuals in supervisory positions should be mindful of their influence as role models who empower values and practices that are recognized by participants to be important aspects of physician identity.
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Welk B, Killin L, Reid JN, Anderson KK, Shariff SZ, Appleton A, Kearns G, Garg AX. Effect of electronic medication reconciliation at the time of hospital discharge on inappropriate medication use in the community: an interrupted time-series analysis. CMAJ Open 2021; 9:E1105-E1113. [PMID: 34848551 PMCID: PMC8648355 DOI: 10.9778/cmajo.20210071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND It is unclear if enhanced electronic medication reconciliation systems can reduce inappropriate medication use and improve patient care. We evaluated trends in potentially inappropriate medication use after hospital discharge before and after adoption of an electronic medication reconciliation system. METHODS We conducted an interrupted time-series analysis in 3 tertiary care hospitals in London, Ontario, using linked health care data (2011-2019). We included patients aged 66 years and older who were discharged from hospital. Starting between Apr. 13 and May 21, 2014, physicians were required to complete an electronic medication reconciliation module for each discharged patient. As a process outcome, we evaluated the proportion of patients who continued to receive a benzodiazepine, antipsychotic or gastric acid suppressant as an outpatient when these medications were first started during the hospital stay. The clinical outcome was a return to hospital within 90 days of discharge with a fall or fracture among patients who received a new benzodiazepine or antipsychotic during their hospital stay. We used segmented linear regression for the analysis. RESULTS We identified 15 932 patients with a total of 18 405 hospital discharge episodes. Before the implementation of the electronic medication reconciliation system, 16.3% of patients received a prescription for a benzodiazepine, antipsychotic or gastric acid suppressant after their hospital stay. After implementation, there was a significant and immediate 7.0% absolute decline in this proportion (95% confidence interval [CI] 4.5% to 9.5%). Before implementation, 4.1% of discharged patients who newly received a benzodiazepine or antipsychotic returned to hospital with a fracture or fall within 90 days. After implementation, there was a significant and immediate 2.3% absolute decline in this outcome (95% CI 0.3% to 4.3%). INTERPRETATION Implementation of an electronic medication reconciliation system in 3 tertiary care hospitals reduced potentially inappropriate medication use and associated adverse events when patients transitioned back to the community. Enhanced electronic medication reconciliation systems may allow other hospitals to improve patient safety.
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Affiliation(s)
- Blayne Welk
- Departments of Surgery (Welk), and Epidemiology and Biostatistics (Welk, Killin, Anderson, Garg), Western University; ICES Western (Welk, Killin, Reid, Anderson, Shariff, Garg); Arthur Labatt Family School of Nursing (Shariff) Western University; Department of Medicine (Appleton, Garg), Western University; St. Joseph's Healthcare and London Health Sciences Centre (Kearns), London, Ont.
| | - Lauren Killin
- Departments of Surgery (Welk), and Epidemiology and Biostatistics (Welk, Killin, Anderson, Garg), Western University; ICES Western (Welk, Killin, Reid, Anderson, Shariff, Garg); Arthur Labatt Family School of Nursing (Shariff) Western University; Department of Medicine (Appleton, Garg), Western University; St. Joseph's Healthcare and London Health Sciences Centre (Kearns), London, Ont
| | - Jennifer N Reid
- Departments of Surgery (Welk), and Epidemiology and Biostatistics (Welk, Killin, Anderson, Garg), Western University; ICES Western (Welk, Killin, Reid, Anderson, Shariff, Garg); Arthur Labatt Family School of Nursing (Shariff) Western University; Department of Medicine (Appleton, Garg), Western University; St. Joseph's Healthcare and London Health Sciences Centre (Kearns), London, Ont
| | - Kelly K Anderson
- Departments of Surgery (Welk), and Epidemiology and Biostatistics (Welk, Killin, Anderson, Garg), Western University; ICES Western (Welk, Killin, Reid, Anderson, Shariff, Garg); Arthur Labatt Family School of Nursing (Shariff) Western University; Department of Medicine (Appleton, Garg), Western University; St. Joseph's Healthcare and London Health Sciences Centre (Kearns), London, Ont
| | - Salimah Z Shariff
- Departments of Surgery (Welk), and Epidemiology and Biostatistics (Welk, Killin, Anderson, Garg), Western University; ICES Western (Welk, Killin, Reid, Anderson, Shariff, Garg); Arthur Labatt Family School of Nursing (Shariff) Western University; Department of Medicine (Appleton, Garg), Western University; St. Joseph's Healthcare and London Health Sciences Centre (Kearns), London, Ont
| | - Andrew Appleton
- Departments of Surgery (Welk), and Epidemiology and Biostatistics (Welk, Killin, Anderson, Garg), Western University; ICES Western (Welk, Killin, Reid, Anderson, Shariff, Garg); Arthur Labatt Family School of Nursing (Shariff) Western University; Department of Medicine (Appleton, Garg), Western University; St. Joseph's Healthcare and London Health Sciences Centre (Kearns), London, Ont
| | - Glen Kearns
- Departments of Surgery (Welk), and Epidemiology and Biostatistics (Welk, Killin, Anderson, Garg), Western University; ICES Western (Welk, Killin, Reid, Anderson, Shariff, Garg); Arthur Labatt Family School of Nursing (Shariff) Western University; Department of Medicine (Appleton, Garg), Western University; St. Joseph's Healthcare and London Health Sciences Centre (Kearns), London, Ont
| | - Amit X Garg
- Departments of Surgery (Welk), and Epidemiology and Biostatistics (Welk, Killin, Anderson, Garg), Western University; ICES Western (Welk, Killin, Reid, Anderson, Shariff, Garg); Arthur Labatt Family School of Nursing (Shariff) Western University; Department of Medicine (Appleton, Garg), Western University; St. Joseph's Healthcare and London Health Sciences Centre (Kearns), London, Ont
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Perrault-Sequeira L, Torti J, Appleton A, Mathews M, Goldszmidt M. Discharging the complex patient - changing our focus to patients' networks of care providers. BMC Health Serv Res 2021; 21:950. [PMID: 34507571 PMCID: PMC8431846 DOI: 10.1186/s12913-021-06841-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 07/30/2021] [Indexed: 11/18/2022] Open
Abstract
Background A disconnect exists between the idealized model of every patient having a family physician (FP) who acts as the central hub for care, and the reality of health care where patients must navigate a network of different providers. This disconnect is particularly evident when hospitalized multimorbid patients transition back into the community. These discharges are identified as high-risk due to lapses in care continuity. The aim of this study was to identify and explore the networks of care providers in a sample of hospitalized, complex patients, and better understand the nature of their attachments to these providers as a means of discovering novel approaches for improving discharge planning. Methods This was a constructivist grounded theory study. Data included interviews from 30 patients admitted to an inpatient internal medicine service of a midsized academic hospital in Ontario, Canada. Analysis and data collection proceeded iteratively with sampling progressing from purposive to theoretical. Results We identified network of care configurations commonly found in patients with multiple medical comorbidities receiving care from multiple different providers admitted to an internal medicine service. FPs and specialists form the network’s scaffold. The involvement of physicians in the network dictated not only how patients experienced transitions in care but the degree of reliance on social supports and personal capacities. The ideal for the multimorbid patient is an optimally involved FP that remains at the centre, even when patients require more subspecialized care. However, in cases where a rostered FP is non-existent or inadequate, increased involvement and advocacy from specialists is crucial. Conclusions Our results have implications for transition planning in hospitalized complex patients. Recognizing salient network features can help identify patients who would benefit from enhanced discharge support. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06841-2.
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Affiliation(s)
| | - Jacqueline Torti
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,Centre for Education Research & Innovation - Western University, London, ON, Canada
| | - Andrew Appleton
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Maria Mathews
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Mark Goldszmidt
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,Centre for Education Research & Innovation - Western University, London, ON, Canada
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Appleton A, Lam M, Le B, Shariff S, Gershon A. Effects of removing a fee-for-service incentive on specialist chronic disease services: a time-series analysis. Health Promot Chronic Dis Prev Can 2021; 41:57-64. [PMID: 33599445 DOI: 10.24095/hpcdp.41.2.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Physician payment models are known to affect the nature and volume of services provided. Our objective was to study the effects of removing a financial incentive, the fee-for-service premium, on the provision of chronic disease follow-up services by internal medicine, cardiology, nephrology and gastroenterology specialists. METHODS We collected linked administrative health care data for the period 1 April 2013 to 31 March 2017 from databases held at the Institute for Clinical Evaluative Sciences (ICES) in Ontario, Canada. We conducted a time-series analysis before and after the removal of the fee-for-service premium on 1 April 2015. The primary outcome was total monthly visits for chronic disease follow-up services. Secondary outcomes were monthly visits for total follow-up services and new patient consultations. We compared internal medicine, cardiology, nephrology and gastroenterology specialists practising during the study timeframe with respirology, hematology, endocrinology, rheumatology and infectious diseases specialists who remained eligible to claim the premium. We chose this comparison group as these are all subspecialties of internal medicine, providing similar services. RESULTS The number of chronic disease follow-up visits decreased significantly after removal of the premium, but there was no decrease in total follow-up visits. There was also a significant downward trend in new patient consultations. No changes were observed in the comparison group. CONCLUSION The decrease in volume of chronic disease follow-up visits can be explained by diagnostic criteria being met less often, rather than an actual reduction in services provided. Potential effects on patient outcomes require further exploration.
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Affiliation(s)
- Andrew Appleton
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,ICES Western, London, Ontario, Canada
| | | | | | | | - Andrea Gershon
- Faculty of Medicine, Department of Medicine, University of Toronto, Ontario, Canada.,ICES Central, Toronto, Ontario, Canada
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Smaggus A, Mrkobrada M, Marson A, Appleton A. Effects of efforts to optimise morbidity and mortality rounds to serve contemporary quality improvement and educational goals: a systematic review. BMJ Qual Saf 2017; 27:74-84. [DOI: 10.1136/bmjqs-2017-006632] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 08/23/2017] [Accepted: 09/03/2017] [Indexed: 12/13/2022]
Abstract
BackgroundThe quality and safety movement has reinvigorated interest in optimising morbidity and mortality (M&M) rounds. We performed a systematic review to identify effective means of updating M&M rounds to (1) identify and address quality and safety issues, and (2) address contemporary educational goals.MethodsRelevant databases (Medline, Embase, PubMed, Education Resource Information Centre, Cumulative Index to Nursing and Allied Health Literature, Healthstar, and Global Health) were searched to identify primary sources. Studies were included if they (1) investigated an intervention applied to M&M rounds, (2) reported outcomes relevant to the identification of quality and safety issues, or educational outcomes relevant to quality improvement (QI), patient safety or general medical education and (3) included a control group. Study quality was assessed using the Medical Education Research Study Quality Instrument and Newcastle-Ottawa Scale-Education instruments. Given the heterogeneity of interventions and outcome measures, results were analysed thematically.ResultsThe final analysis included 19 studies. We identified multiple effective strategies (updating objectives, standardising elements of rounds and attaching rounds to a formal quality committee) to optimise M&M rounds for a QI/safety purpose. These efforts were associated with successful integration of quality and safety content into rounds, and increased implementation of QI interventions. Consistent effects on educational outcomes were difficult to identify, likely due to the use of methodologies ill-fitted for educational research.ConclusionsThese results are encouraging for those seeking to optimise the quality and safety mission of M&M rounds. However, the inability to identify consistent educational effects suggests the investigation of M&M rounds could benefit from additional methodologies (qualitative, mixed methods) in order to understand the complex mechanisms driving learning at M&M rounds.
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Appleton A, Singh S, Eady N, Buszewicz M. Why did you choose psychiatry? a qualitative study of psychiatry trainees investigating the impact of psychiatry teaching at medical school on career choice. BMC Psychiatry 2017; 17:276. [PMID: 28754157 PMCID: PMC5534074 DOI: 10.1186/s12888-017-1445-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 07/25/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There is no consensus regarding the optimal content of the undergraduate psychiatry curriculum as well as factors contributing to young doctors choosing a career in psychiatry. Our aim was to explore factors which had influenced psychiatry trainees' attitudes towards mental health and career choice. METHOD Qualitative in-depth interviews with 21 purposively sampled London psychiatry trainees analysed using the Framework method. RESULTS Early exposure and sufficient time in undergraduate psychiatry placements were important in influencing psychiatry as a career choice and positive role models were often very influential. Integration of psychiatry with teaching about physical health was viewed positively, although concerns were raised about the potential dilution of psychiatry teaching. Foundation posts in psychiatry were very valuable in positively impacting career choice. Other suggestions included raising awareness at secondary school level, challenging negative attitudes amongst all medical educators, and promoting integration within medical specialties. CONCLUSIONS Improvements in teaching psychiatry could improve medical attitudes and promote recruitment into psychiatry.
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Affiliation(s)
- A. Appleton
- 0000000121901201grid.83440.3bResearch Department of Primary Care and Population Health, University College London, London, NW3 2PF UK
| | - S. Singh
- 0000000121901201grid.83440.3bResearch Department of Primary Care and Population Health, University College London, London, NW3 2PF UK
| | - N. Eady
- 0000 0004 0426 7183grid.450709.fEast London NHS Foundation Trust, 9 Alie Street, London, E1 8DE UK
| | - M. Buszewicz
- 0000000121901201grid.83440.3bResearch Department of Primary Care and Population Health, University College London, London, NW3 2PF UK
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Bartz B, Collins M, Stoddard G, Appleton A, Livingood R, Sobcynski H, Vogel KD. Assessment of nonpenetrating captive bolt stunning followed by electrical induction of cardiac arrest in veal calves. J Anim Sci 2016; 93:4557-63. [PMID: 26440354 DOI: 10.2527/jas.2015-9332] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The purpose of this study was to evaluate the impact of nonpenetrating captive bolt stunning followed by electrical induction of cardiac arrest on veal calf welfare, veal quality, and blood yield. Ninety calves from the same farm were randomly assigned to 1 of 2 treatment groups in a balanced unpaired comparison design. The first treatment group (the "head-only" method-application of the pneumatic nonpenetrating stun to the frontal plate of the skull at the intersection of 2 imaginary lines extending from the lateral canthus to the opposite poll [CONTROL]) was stunned with a nonpenetrating captive bolt gun ( = 45). The second group ( = 45) was stunned with a nonpenetrating captive bolt gun followed by secondary electrical induction of cardiac arrest (the "head/heart" method-initial application of the pneumatic nonpenetrating captive bolt stun followed by 1 s application of an electrical stun to the ventral region of the ribcage directly caudal to the junction of the humerus and scapula while the stunned calf was in lateral recumbence [HEAD/HEART]). Stunning efficacy was the indicator of animal welfare used in this study. All calves were instantly rendered insensible by the initial stun and did not display common indicators of return to consciousness. For meat quality evaluation, all samples were collected from the 12th rib region of the longissimus thoracis. Meat samples were evaluated for color, drip loss, ultimate pH, cook loss, and Warner-Bratzler shear force. The L* values (measure of meat color lightness) were darker ( < 0.05) in the HEAD/HEART group (45.08 ± 0.72) than the CONTROL group (47.10 ± 0.72). There were no differences ( > 0.05) observed in a* (redness) and b* (yellowness) values between treatments. No differences ( > 0.05) were observed in drip loss, ultimate pH, cook loss, and Warner-Bratzler shear force. The blood yield from the CONTROL group (7,217.9 ± 143.5 g) was greater ( < 0.05) than that from the HEAD/HEART group (6,656.4 ± 143.5 g). Overall, the data indicated no difference between the CONTROL and HEAD/HEART groups with regard to animal welfare because the initial stun was effective in all calves. However, longissimus thoracis L* and blood yield were negatively impacted by the HEAD/HEART method. The data in this study suggest that secondary induction of cardiac arrest is not necessary with effective nonpenetrating captive bolt stunning in veal calves.
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Abstract
Re-expansion pulmonary oedema is a recognised but rare complication following the rapid drainage of a large pleural effusion or pneumothorax [1,2], usually occurring on the side of re-inflation. The pathogenesis of the pulmonary oedema is poorly understood but is thought to be due to micro-vascular shearing resulting in neutrophil activation and adhesion to the vascular endothelium resulting in increased micro-vascular permeability [3-7]. Few reports appear in the literature of invasive haemodynamic monitoring following this catastrophe. We describe a patient who sustained fatal pulmonary oedema arising in the contralateral lung, with pulmonary flow catheter data documenting the initial circulatory collapse following the aspiration of a massive pulmonary effusion.
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Affiliation(s)
- A Gascoigne
- Intensive Therapy Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
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Appleton A. Medicaid fraud & abuse control. Caring 1985; 4:53-4. [PMID: 10300234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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