Physicians' perspectives of prognosis and goals of care discussions after hip fracture

BACKGROUND

Hip fracture often represents a major transition in patients' health, with a 1-year mortality rate between 25% and 30% and a challenging recovery course. Caring for hip fracture patients presents opportunities for goals of care discussions that include prognostic information and guidance about functional dependence.

METHODS

We conducted qualitative, semi-structured interviews with 23 attending physicians involved with the care of hip fracture patients, including orthopedic surgeons, anesthesiologists, internists, and geriatricians, across 13 health systems in the United States and Canada. Questions addressed knowledge and interpretation of prognosis, discussing prognosis and goals of care, and timing and prioritization of surgery. Interviews were analyzed using a constructivist grounded theory approach to identify themes and develop a coding taxonomy.

RESULTS

Physicians agreed that hip fracture had a considerable 1-year mortality, felt that it was important to discuss prognostic outcomes and the recovery process, wanted to elucidate patients' priorities, and often promoted timely surgery. Physicians perceived challenges when discussing mortality data with new patients in an acute setting. They more easily discussed outcomes related to functional dependence and quality of life. Some physicians used iterative communication as a strategy to have in-depth conversations in a busy perioperative setting.

CONCLUSION

Providing timely, compassionate care for hip fracture patients is challenging. There are opportunities to study iterative communication to encourage dialogue at key points of patient care to better discuss prognosis and recovery and bolster coordinated multidisciplinary care that focuses on patients' goals and values.

Imagining the 'structural' in medical education and practice in the United States: A curricular investigation

A number of conceptual frameworks have emerged with the goal of helping clinicians understand and navigate the intersections of the health system and broader political, economic, and cultural processes when they care for patients. In this study, we analyze the impact that one emerging framework, "structural competency," had on medical students' and physicians' understanding of societal problems affecting patient health and the practices of health systems. In this sub-analysis of a longitudinal qualitative study conducted between August and December 2020, we analyzed 19 semi-structured interviews with 7 first-year medical students, 7 upper-level medical students, and 5 physician course facilitators who participated in a course called Introduction to Medicine and Society at an medical school in the United States affiliated with a large urban academic medical center. This paper focuses on three main findings: how medical students and faculty describe "structures" and their effects on patients and patient care; how they use or imagine using structural competency to improve patient-physician communication and work interprofessionally to address social needs; and the emotional and personal reactions that confronting societal challenges provokes. We conclude that structural competency enhances existing efforts to improve patient-physician communication and to address patients' social needs. However, we highlight how structural competency efforts might fall short of their goal to shift physicians' perspectives "upstream" to the determinants of health due to both critical ambiguities in the concept and inattention to the emotional and personal impacts of addressing societal problems in the clinic. These findings have practical implications for how clinicians are trained to act on societal issues from within the health system and conceptual implications for refining how existing frameworks and curricula conceive of the intersection between healthcare and broader processes.

Understanding Debriefing: A Qualitative Study of Event Reconstruction at an Academic Medical Center

PURPOSE

This qualitative study sought to characterize the role of debriefing after real critical events among anesthesia residents at the Hospital of the University of Pennsylvania.

METHOD

From October 2016 to June 2017 and February to April 2018, the authors conducted 25 semistructured interviews with 24 anesthesia residents after they were involved in 25 unique critical events. Interviews focused on the experience of the event and the interactions that occurred thereafter. A codebook was generated through annotation, then used by 3 researchers in an iterative process to code interview transcripts. An explanatory model was developed using an abductive approach.

RESULTS

In the aftermath of events, residents underwent a multistage process by which the nature of critical events and the role of residents in them were continuously reconstructed. Debriefing-if it occurred-was 1 stage in this process, which also included stages of internal dialogue, event documentation, and lessons learned. Negotiated in each stage were residents' culpability, reputation, and the appropriateness of their affective response to events.

CONCLUSIONS

Debriefing is one of several stages of interaction that occur after a critical event; all stages play a role in shaping how the event is interpreted and remembered. Because of its dynamic role in constituting the nature of events and residents' role in them, debriefing can be a high-stakes interaction for residents, which can contribute to their reluctance to engage in it. The function and quality of debriefing can be assessed in more insightful fashion by understanding its relation to the other stages of event reconstruction.

Community pharmacies as sites of adult vaccination: A systematic review

Vaccine-preventable deaths among adults remain a major public health concern, despite continued efforts to increase vaccination rates in this population. Alternative approaches to immunization delivery may help address under-vaccination among adults. This systematic review assesses the feasibility, acceptability, and effectiveness of community pharmacies as sites for adult vaccination. We searched 5 electronic databases (PubMed, EMBASE, Scopus, Cochrane, LILACS) for studies published prior to June 2016 and identified 47 relevant articles. We found that pharmacy-based immunization services (PBIS) have been facilitated by state regulatory changes and training programs that allow pharmacists to directly provide vaccinations. These services are widely accepted by both patients and pharmacy staff, and are capable of improving access and increasing vaccination rates. However, political and organizational barriers limit the feasibility and effectiveness of vaccine delivery in pharmacies. These studies provide evidence to inform policy and organizational efforts that promote the efficacy and sustainability of PBIS.