"What's My Line?": Pseudo-Improvised Teaching When the Clinical Teaching Script Is Blank

ABSTRACT

Commitment to clinical education often requires significant forethought and attention to provide a comprehensive learning experience for trainees. In these settings, teaching is typically time-limited, prompted by a clinical scenario, and requires preparation. However, it is not uncommon for teachers to have insufficient time to prepare or to encounter a clinical scenario in which they have not yet developed a teaching script.In this article, the authors share 5 categories of teaching techniques that instructors can pull from regardless of the prompt or busyness of the clinical setting and that are ideal for using when the teaching script is "blank." They call this approach of having scenario-independent teaching techniques ready to be applied with minimal preparation, "pseudo-improvised teaching."Drawing from the literature, their own experience, and borrowing from improvisational theater, the authors share a toolkit of pseudo-improvised teaching techniques spanning from pathophysiology to clinical skills to work-life integration. In addition to highlighting several techniques, they describe models of meta-structure for teaching in which the use of themes for the day (i.e., longitudinal themes) and routines can ease some of the cognitive load felt by both learners and educators.

Laypeople's (Mis)Understanding of Common Medical Acronyms

OBJECTIVES

Abbreviations are often used in medicine yet may be a source of confusion for patients and their families. We aimed to determine the general public's understanding of commonly used medical acronyms.

METHODS

For this cross-sectional study, we surveyed state fair visitors regarding their understanding of 5 common medical acronyms. An electronic survey was administered to a volunteer sample of adults who spoke and read English and who had never trained to work in medicine or nursing. Free-text responses were coded as correct, partially correct, or incorrect by 2 independent researchers, adding a third researcher if consensus was not reached. Analysis methods included descriptive statistics, Fisher exact tests, and multivariable logistic regression models.

RESULTS

We recruited 204 volunteers (55% female; mean age 43 years; 67% had a bachelor's degree or higher). ED (emergency department) was correctly defined by 32%, PCP (primary care provider/physician) by 18%, CBC (complete blood count) by 14%, and PRN (as needed) and NPO (nothing by mouth) by 13% each. Female gender was associated with higher odds of correctly understanding NPO (odds ratio, 3.11; 95% confidence interval, 1.18-8.21; P = .02); older age was associated with higher odds of understanding PRN (odds ratio, 1.03; 95% confidence interval, 1.00-1.05; P = .04). Education level was not found to correlate significantly with successful explanation of any tested acronym.

CONCLUSIONS

Medical acronyms are a predictable source of miscommunication. In this large cross-sectional study, none of the acronyms evaluated was understood correctly by more than one-third of adults. Clinicians should avoid using acronyms with patients and families to minimize confusion.

Prolonged Elevations of Factor VIII and von Willebrand Factor Antigen After Multisystem Inflammatory Syndrome in Children

Multisystem Inflammatory Syndrome in Children (MIS-C) is a late systemic inflammatory response to a recent mild or asymptomatic coronavirus disease of 2019 infection. The pathophysiology is incompletely understood but it often features significant coagulopathy along with cardiac and endothelial dysfunction. Endothelial inflammation has been primarily described in acute coronavirus disease of 2019 infection, with less characterization in MIS-C. Here we describe novel findings of nearly universal severe and prolonged factor VIII (FVIII) and von Willebrand factor antigen elevations in an institutional cohort of patients with MIS-C ages younger than or 21 years old (N=31). All patients had elevated acute phase reactants and D-dimer at presentation and met published criteria for MIS-C. FVIII was high at presentation in 97% of patients but continued to rise during the ensuing weeks of treatment to a mean 429%, peaking on median day 17 of illness as an outpatient. FVIII levels were >600% in multiple patients. von Willebrand factor antigen was measured less frequently but showed similar trends. These escalations occurred amidst resolving cardiac dysfunction and acute phase reactant normalization and despite patients receiving multimodal anti-inflammatory treatments and aspirin and enoxaparin thromboprophylaxis. No thrombotic events occurred. Endothelial dysfunction represented by very elevated FVIII levels may persist longer than other acute phase reactants may reflect.

Jargon Be Gone - Patient Preference in Doctor Communication

While it has been shown that healthcare providers often use medical jargon, less is known about how patients prefer their clinicians communicate. This mixed-methods study aimed to better understand the general public's preference in healthcare communication. A volunteer cohort of 205 adult attendees at the 2021 Minnesota State Fair was presented a survey with two scenarios at a doctor's office sharing the same information: one using medical terminology and one using simpler, jargon-free language. Survey participants were asked which doctor they preferred, to describe each doctor, and to explain why they believe that doctors may use medical terminology. Common descriptive themes for the jargon-using doctor included that this doctor caused confusion, was too technical, and was uncaring, while the doctor who spoke without jargon was perceived as a good communicator, caring/empathetic, and approachable. Respondents perceived a range of reasons why doctors use jargon, from not recognizing they are using words that are not understood to trying to make themselves feel more important. Overall, 91% of survey respondents preferred the doctor who communicated without medical jargon.

What's in a name? Laypeople's understanding of medical roles and titles

BACKGROUND

Physicians regularly use jargon in patient communication, which can lead to confusion and misunderstanding.

OBJECTIVE

To assess the general public's understanding of names and roles of medical specialties and job seniority titles.

DESIGNS

Volunteer participants completed an electronic survey, filling-in-the-blanks for 14 medical specialties (e.g., "pediatricians are doctors who take care of _____"), and ranked physician titles in order of experience (medical student, intern, senior resident, fellow, attending).

SETTING

The 2021 Minnesota State Fair.

PARTICIPANTS

Volunteers >18 years old without medical or nursing training.

MAIN OUTCOME AND MEASURES

We summarized responses with descriptive statistics. Two researchers coded open-ended answers as correct, partially correct, or incorrect, with a third researcher for coding discrepancies.

RESULTS

Two hundred and four participants completed the survey (55% female; mean age 43; 67% of respondents with a bachelor's degree or higher). Of 14 medical specialties listed on the survey, respondents most accurately identified dermatologists (94%) and cardiologists (93%). Six specialties were understood by less than half of the respondents: neonatologists (48%), pulmonologists (43%), hospitalists (31%), intensivists (29%), internists (21%), and nephrologists (20%). Twelve percent of participants correctly identified medical roles in rank order. Most participants (74%) correctly identified medical students as the least experienced. Senior residents were most often identified as the most experienced (44%), with just 27% of respondents correctly placing the attending there. We conclude that medical professionals should recognize that titles are a common source of misunderstanding among the general public and should describe their role when introducing themselves to minimize confusion.

Accuracy in Patient Understanding of Common Medical Phrases

IMPORTANCE

Despite acknowledging that medical jargon should be avoided, health care practitioners frequently use it when communicating with patients.

OBJECTIVE

To characterize the understanding of common medical jargon terms by surveying a cross section of the general public and studying phrases that have established meanings in regular usage but different meanings in a medical context (eg, negative and positive test results).

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, participants indicated their understanding of phrases that may have different meanings in medicine than in colloquial English via a mix of short answer and multiple choice questions. Several questions included paired phrases to assess for differences in understanding with or without jargon. Volunteers were recruited at the 2021 Minnesota State Fair near St Paul, Minnesota. An electronic survey was given to a volunteer sample of 215 adults (>18 years) who did not work or train to work in the medical field and spoke and read English.

EXPOSURES

Completing a written or verbal survey.

MAIN OUTCOMES AND MEASURES

The main outcome was an accurate understanding of the medical terminology. Free-text responses were coded by 2 researchers for comprehension. Secondary outcomes looked for associations between volunteer demographics and understanding.

RESULTS

The 215 respondents (135 [63%] female; mean [SD] age, 42 [17] years) demonstrated a varied ability to interpret medical jargon phrases. For example, most participants (207 [96%]) knew that negative cancer screening results meant they did not have cancer, but fewer participants (143 [79%]) knew that the phrase "your tumor is progressing" was bad news, or that positive lymph nodes meant the cancer had spread (170 [67%]). While most (171 [80%]) recognized that an unremarkable chest radiography was good news, only 44 participants (21%) correctly understood that a clinician saying their radiography was impressive was generally bad news. In each of the paired phrases comparing jargon vs nonjargon approaches, the nonjargon phrase was understood significantly better (P < .001).

CONCLUSIONS AND RELEVANCE

These findings suggest that several common phrases are misunderstood when used in a medical setting, with the interpreted meaning frequently the exact opposite of what is intended.

Improving Communication by Standardizing Pediatric Rapid Response Team Documentation

BACKGROUND

Rapid response teams (RRTs) have been used by multiple hospital systems to enhance patient care and safety. However, processes to document rapid response events (RRE) are often varied among providers and teams, which can lead to suboptimal communication of recommendations to both the primary medical team and family.

METHODS

A preintervention chart review was conducted from January-March 2018 and revealed suboptimal baseline documentation following RREs. A literature review and survey of RRT team members led to the creation of a standardized document with an Epic SmartPhrase which included six key elements of RRE documentation: physical examination, intervention performed, response to intervention, plan of care, communication with care team, and communication with family. A postintervention chart review was completed from April-June 2019 to assess improvements in documentation with the use of this SmartPhrase.

RESULTS

There were 23 RRE activations in the postintervention period, of which 60.8% were due to respiratory distress. The documentation of the six key elements improved (p < .05) after SmartPhrase creation and serial educational interventions.

CONCLUSIONS

Standardized RRE documentation of six key elements significantly improved with the implementation of an Epic SmartPhrase. Improved quality of documentation enhances communication between team members and can contribute to safer patient care.

Say What? Quantifying and Classifying Jargon Use During Inpatient Rounds

BACKGROUND

Although plain language is recognized as essential for effective communication, research reveals that medical providers regularly use jargon terminology that may be misunderstood by patients. Little is known, however, about the types and frequency of jargon used in the pediatric inpatient setting. We aimed to quantify jargon use by medical team members during inpatient family-centered rounds (FCRs) and to identify the most common categories of jargon used.

METHODS

One of 3 trained medical students audited FCRs on a general pediatric service once weekly for 12 weeks, recording and categorizing jargon used with a published classification framework. Jargon usage was classified by category and quantified by using descriptive statistics. Rates were calculated by patient encounter and per minute. Feedback was provided to rounding teams after each observation.

RESULTS

During 70 observed FCR patient encounters, there were a total of 443 jargon words or phrases spoken, of which 309 (70%) were not explicitly defined to the patient or family by the health care provider team. The mean number of undefined jargon words or phrases used per patient was 4.3 (±1.7), with a mean of 0.4 (±0.1) uses of undefined jargon per minute. The most common categories of undefined jargon used include technical terminology (eg, bronchiolitis), medical vernacular (eg, cultures), and abbreviations and acronyms (eg, NPO for "nothing by mouth") at 34%, 30%, and 17%, respectively.

CONCLUSIONS

Undefined medical jargon was used frequently by health care providers during pediatric FCRs. We found it was feasible to measure provider jargon use and to use a jargon classification scheme to provide real-time, concrete feedback.

Prescribing Video-Based Patient Education in the Hospital Setting: Can Bedside Breastfeeding Videos Affect Exclusive Breastfeeding at Postpartum Discharge?

BACKGROUND AND OBJECTIVES

Evaluate the impact of a standardized bundle of educational videos delivered via the bedside television to postpartum mothers on exclusive breastfeeding rates. Despite the growing use of videos for hospital discharge education, there is a paucity of literature evaluating their effectiveness.

METHODS

In November 2015, we began ordering 4 externally produced, peer-reviewed breastfeeding education videos for all postpartum mothers to view via their bedside televisions. Mothers could choose whether to watch the videos, and if they did, this was automatically documented in the electronic health record. We then performed a retrospective chart review generating a data set focusing on newborns who were healthy, term, and appropriate for gestational age, born in the year pre- and postintervention, and compared exclusive breastfeeding rates at the time of discharge among both groups.

RESULTS

Our data set included 3115 newborns (1467 pre- and 1648 postintervention). In the postintervention year, the exclusive breastfeeding rate at discharge was 69.5% vs 68.4% preintervention (P value: .80). Most mothers (81.3%; 1339) watched all 4 videos, and 308 mothers (18.7%) watched none. The mothers who watched all 4 videos were more likely to breastfeed exclusively (72.7% vs 55.3%) and less likely to exclusively formula feed than the mothers who watched none (1.1% vs 19.8%; P < .0001).

CONCLUSIONS

There was no change in exclusive breastfeeding rates pre- versus post-video education intervention. However, most mothers watched all 4 videos, and those who did were significantly more likely to engage in any breastfeeding (98.9%) compared with those who watched none (80.2%) during the postpartum hospitalization.

ED RAPID: A Novel Children's Hospital Direct Admission Process Utilizing the Emergency Department

INTRODUCTION

Direct hospital admission of children without evaluation in the emergency department (ED) is common, but few guidelines exist to maximize safety by assessing patient stability. This report describes a novel approach to support patient safety.

METHODS

An interdisciplinary children's hospital team developed a brief ED-based evaluation process called the ED Rapid Assessment of Patients Intended for Inpatient Disposition (ED RAPID). It entails a brief evaluation of vital signs and clinical stability by the ED attending physician and nurse. Children deemed stable are admitted to inpatient wards, whereas those requiring immediate intervention undergo full ED evaluation and disposition. We assessed outcomes for all children evaluated through this process from March 2013 through February 2015.

RESULTS

During the study period, we identified 715 patients undergoing ED RAPID evaluation. Of these, we directly admitted 691 (96.4%) to the hospital ward after ED RAPID evaluation; median ED treatment time was 4.0 minutes. We transitioned 24 (3.4%) to full ED evaluation, 14 (2.0%) because a ward bed was unavailable, and 10 (1.4%) for clinical reasons identified in the evaluation. We admitted four of the 10 stopped (40% of stops, 0.6% of total) to an intensive care unit, and 6 (60% of stops, 0.8% of total) to the hospital ward after ED care. Eight children (1.1%) admitted to the hospital ward after ED RAPID evaluation required a transfer to an intensive care unit within 12 hours.

CONCLUSION

The ED RAPID evaluation process for children directly admitted to the hospital was feasible and effective in this setting.

The Admission Conference Call: A Novel Approach to Optimizing Pediatric Emergency Department to Admitting Floor Communication

Optimizing information sharing at transfer of care between teams is an important target for the improvement of patient safety. Traditional emergency department (ED)-to-floor handoffs do not support a shared mental model between physicians, residents, and nurses. This report describes and evaluates acceptance of a novel process for coordinating physician and nursing handoff calls for patients being admitted to an inpatient floor from a children's hospital ED.

METHODS

The Admission Conference Call (ACC) is a single conference call including attendings, residents, and nurses from the ED and inpatient teams, currently used for 29.8% of admissions from one ED. Physicians and nurses were surveyed to assess perception of its effects on patient care.

RESULTS

A total of 653 ACCs were conducted during 2017. The survey was completed by 43 nurses and 89 physicians. Mean Likert scale findings were in favor of the process supporting safe patient care (4.5/5; standard deviation [SD], 0.6); none said it increased risk. Ratings favored the process improving interdisciplinary alignment (4.0/5; SD, 0.8) and the benefits outweighing the inconvenience (3.9/5; SD, 0.9). Respondents were neutral on the effect of the ACC on throughput time (3.0/5; SD, 1.0). Logistical concerns were expressed; mean satisfaction was 6.8/10 (SD, 2.1). Free text comments varied widely, from pride to frustration.

CONCLUSION

The Admission Conference Call is a well-accepted alternative to a traditional multiple call process. Most participants believe it supports safe patient care. Further research is necessary to confirm measurable effects on patient outcomes, but this project provides encouragement to institutions considering innovative approaches.

Hospital-Based Quality Measures for Pediatric Mental Health Care

BACKGROUND AND OBJECTIVES

Patients with a primary mental health condition account for nearly 10% of pediatric hospitalizations nationally, but little is known about the quality of care provided for them in hospital settings. Our objective was to develop and test medical record-based measures used to assess quality of pediatric mental health care in the emergency department (ED) and inpatient settings.

METHODS

We drafted an evidence-based set of pediatric mental health care quality measures for the ED and inpatient settings. We used the modified Delphi method to prioritize measures; 2 ED and 6 inpatient measures were operationalized and field-tested in 2 community and 3 children's hospitals. Eligible patients were 5 to 19 years old and diagnosed with psychosis, suicidality, or substance use from January 2012 to December 2013. We used bivariate and multivariate models to examine measure performance by patient characteristics and by hospital.

RESULTS

Eight hundred and seventeen records were abstracted with primary diagnoses of suicidality (n = 446), psychosis (n = 321), and substance use (n = 50). Performance varied across measures. Among patients with suicidality, male patients (adjusted odds ratio: 0.27, P < .001) and African American patients (adjusted odds ratio: 0.31, P = .02) were less likely to have documentation of caregiver counseling on lethal means restriction. Among admitted suicidal patients, 27% had documentation of communication with an outside provider, with variation across hospitals (0%-38%; P < .001). There was low overall performance on screening for comorbid substance abuse in ED patients with psychosis (mean: 30.3).

CONCLUSIONS

These new pediatric mental health care quality measures were used to identify sex and race disparities and substantial hospital variation. These measures may be useful for assessing and improving hospital-based pediatric mental health care quality.

Quality Measures to Assess Care Transitions for Hospitalized Children

BACKGROUND

Transitions between sites of care are inherent to all hospitalizations, yet we lack pediatric-specific transitions-of-care quality measures. We describe the development and validation of new transitions-of-care quality measures obtained from medical record data.

METHODS

After an evidence review, a multistakeholder panel prioritized quality measures by using the RAND/University of California, Los Angeles modified Delphi method. Three measures were endorsed, operationalized, and field-tested at 3 children's hospitals and 2 community hospitals: quality of hospital-to-home transition record content, timeliness of discharge communication between inpatient and outpatient providers, and ICU-to-floor transition note quality. Summary scores were calculated on a scale from 0 to 100; higher scores indicated better quality. We examined between-hospital variation in scores, associations of hospital-to-home transition quality scores with readmission and emergency department return visit rates, and associations of ICU-to-floor transition quality scores with ICU readmission and length of stay.

RESULTS

A total of 927 charts from 5 hospitals were reviewed. Mean quality scores were 65.5 (SD 18.1) for the hospital-to-home transition record measure, 33.3 (SD 47.1) for the discharge communication measure, and 64.9 (SD 47.1) for the ICU-to-floor transition measure. The mean adjusted hospital-to-home transition summary score was 61.2 (SD 17.1), with significant variation in scores between hospitals (P < .001). Hospital-to-home transition quality scores were not associated with readmissions or emergency department return visits. ICU-to-floor transition note quality scores were not associated with ICU readmissions or hospital length of stay.

CONCLUSIONS

These quality measures were feasible to implement in diverse settings and varied across hospitals. The development of these measures is an important step toward standardized evaluation of the quality of pediatric transitional care.

Introduced Siberian chipmunks are more heavily infested by ixodid ticks than are native bank voles in a suburban forest in France

By serving as hosts for native vectors, introduced species can surpass native hosts in their role as major reservoirs of local pathogens. During a 4-year longitudinal study, we investigated factors that affected infestation by ixodid ticks on both introduced Siberian chipmunks Tamias sibiricus barberi and native bank voles Myodes glareolus in a suburban forest (Forêt de Sénart, Ile-de-France). Ticks were counted on adult bank voles and on adult and young chipmunks using regular monthly trapping sessions, and questing ticks were quantified by dragging. At the summer peak of questing Ixodes ricinus availability, the average tick load was 27-69 times greater on adult chipmunks than on adult voles, while average biomass per hectare of chipmunks and voles were similar. In adult chipmunks, individual effects significantly explained 31% and 24% of the total variance of tick larvae and nymph burdens, respectively. Male adult chipmunks harboured significantly more larvae and nymphs than adult females, and than juveniles born in spring and in summer. The higher tick loads, and more specifically the ratio of nymphs over larvae, observed in chipmunks may be caused by a higher predisposition--both in terms of susceptibility and exposure--to questing ticks. Tick burdens were also related to habitat and seasonal variation in age- and sex-related space use by both rodents. Introduced chipmunks may thus have an important role in the dynamics of local vector-borne pathogens compared with native reservoir hosts such as bank voles.

[Fleas community in introduced Siberian chipmunks (Tamias sibiricus Laxmann) in Forest of Sénart, France]

We examined the fleas community in an introduced population of Siberian chipmunks, Tamias sibiricus, between 2005 and 2007, in the Forest of Sénart (Essonne, France). We collected and identified 383 fleas on 463 chipmunks (total: 1,891 captures on 471 chipmunks). In 2005, 120 fleas were also collected on 65 bank voles, Clethrionomys glareolus, and on 25 wood mice, Apodemus sylvaticus, trapped within the same area. Ceratophyllus sciurorum sciurorum formed 73.6% of the chipmunks' flea community, with an annual prevalence (P) ranging between 8 and 13% and a mean intensity (I) ranging between 1.1 and 1.6 fleas per individual. Among the six other species infecting this Sciurid, Ctenophthalmus agyrtes impavidus constituted 17.2% (P: 1.6-2.2%; I: 1.1-2.6), and Megabothris turbidus 8.1% (P: 0.8-1.9%; I: 1.0-1.4) of the flea community, respectively. These last two species represented respectively 60.8% and 36.6% of the flea community on the bank vole and the wood mouse. Originated from Asia, chipmunks did not import any flea species to Sénart, probably because they were used as pets before their release in the wild. Abundance in C. s. sciurorum increased with adult chipmunk density and with juvenile density in summer. On adult chipmunks C. s. sciurorum tented to decrease with increasing abundance of red squirrels (Sciurus vulgaris]. Moreover, the two other flea species mainly infected young chipmunks during the fall, and their number was not related to chipmunk density. However, the distribution of species within the flea community became more balanced with increase juvenile chipmunk density. Overall, these results indicate that the close phyletic relationship between chipmunks and red squirrels contributed in the acquisition and the spread of fleas by chipmunks. Primary and secondary hosts densities, their habitat use, and more specifically burrowing activities and tree canopy use, also played a role in the spread of fleas on chipmunks.