The effect of health care working conditions on patient safety.
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Evidence-Based Medicine↗
Biomedical subjects
D H Hickam
Publications and source records attributed to D H Hickam.
Factors associated with successful answering of clinical questions using an information retrieval system.
OBJECTIVES: Despite the growing use of online databases by clinicians, there has been very little research documenting how effectively they are used. This study assessed the ability of medical and nurse-practitioner students to answer clinical questions using an information retrieval system. It also attempted to identify the demographic, experience, cognitive, personality, search mechanics, and user-satisfaction factors associated with successful use of a retrieval system. METHODS: Twenty-nine students completed questionnaires of clinical and computer experience as well as tests of cognitive abilities and personality type. They were then administered three clinical questions to answer in a medical library setting using the MEDLINE database and electronic and print full-text resources. RESULTS: Medical students were able to answer more questions correctly than nurse-practitioner students before and after searching, but both had comparable improvements in the number of correct questions before and after searching. Successful ability to answer questions was also associated with having experience in literature searching and higher standardized test-score percentiles. CONCLUSIONS: Medical and nurse-practitioner students obtained comparable benefits in the ability to answer clinical questions from use of the information retrieval system. Future research must examine strategies that improve successful search and retrieval of clinical questions posed by clinicians in practice.
Adult↗
Changing physician practice of physical activity counseling.
We conducted a prospective controlled trial to determine whether an educational intervention could improve resident physician self-efficacy and counseling behaviors for physical activity and increase their patients' reported activity levels. Forty-eight internal medicine residents who practiced at a Department of Veterans Affairs hospital received either two workshops on physical activity counseling or no intervention. All residents completed questionnaires before and 3 months after the workshops. The 21 intervention physicians reported increased self-efficacy for counseling and increased frequency of counseling compared with the 27 control physicians. Approximately 10 patients of each resident were included in the study and surveyed before and 6 months after the intervention. Of 560 patients, 465 (83%) returned both questionnaires. Following the intervention, there were no significant differences between patients of intervention and control physicians on any outcome measures. We conclude that educational interventions can improve physicians' reported self-efficacy of physical activity counseling but may not increase patient physical activity levels. Alternative approaches that emphasize overcoming the substantial barriers to exercise in chronically ill outpatients clearly will be important for facilitating changes in physical activity.
Counseling↗
How well do physicians use electronic information retrieval systems? A framework for investigation and systematic review.
OBJECTIVE: Despite the proliferation of electronic information retrieval (IR) systems for physicians, their effectiveness has not been well assessed. The purpose of this review is to provide a conceptual framework and to apply the results of previous studies to this framework. DATA SOURCES: All sources of medical informatics and information science literature, including MEDLINE, along with bibliographies of textbooks in these areas, were searched from 1966 to January 1998. STUDY SELECTION: All articles presenting either classifications of evaluation studies or their results, with an emphasis on those studying use by physicians. DATA EXTRACTION: A framework for evaluation was developed, consisting of frequency of use, purpose of use, user satisfaction, searching utility, search failure, and outcomes. All studies were then assessed based on the framework. DATA SYNTHESIS: Due to the heterogeneity and simplistic study designs, no meta-analysis of studies could be done. General conclusions were drawn from data where appropriate. A total of 47 articles were found to include an evaluation component and were used to develop the framework. Of these, 21 articles met the inclusion criteria for 1 or more of the categories in the framework. Most use of IR systems by physicians still occurs with bibliographic rather than full-text databases. Overall use of IR systems occurs just 0.3 to 9 times per physician per month, whereas physicians have 2 unanswered questions for every 3 patients. CONCLUSIONS: Studies comparing IR systems with different searching features have not shown that advanced searching methods are significantly more effective than simple text word methods. Most searches retrieve only one fourth to one half of the relevant articles on a given topic and, once retrieved, little is known about how these articles are interpreted or applied. These studies imply that further research and development are needed to improve system utility and performance.
Evaluation Studies as Topic↗
Patients' preferences for risk disclosure and role in decision making for invasive medical procedures.
OBJECTIVE: To assess the level of involvement patients want in decision making related to the acceptance or rejection of an invasive medical intervention and whether their preference for decision making is related to their preference for qualitative (verbal) or quantitative (numeric) information about the risks of the procedure. SETTING: A university-based Department of Veterans Affairs Medical Center. DESIGN: Cross-sectional study using structured interviews of consecutive patients seen for continuity care visits in a general medicine clinic. PATIENTS: Four hundred and sixty-seven consecutive patients with a mean age of 65.2 years (SD 10.70 years, range 31-88 years) and with a mean of 12.6 years (SD 2.96 years, range 0-24 years) of formal education. MEASUREMENTS AND MAIN RESULTS: In the context of an invasive diagnostic or therapeutic intervention, patients were asked whether they preferred patient-based, physician-based, or shared patient-physician decision making. Patients were asked to give the ratio of patient-to-physician decision making they preferred, and whether they preferred discussions using words, numbers, or both. Of 467 subjects, 318 (68%) preferred shared decision making; 100 (21.4%) preferred physician-based decision making; and 49 (10.5%) preferred patient-based decision making. In terms of risk disclosure, 436 (93.4%) preferred that their physician disclose risk information to them. Of these 436 patients, 42.7% preferred disclosure of information about the probability of adverse outcomes using qualitative (verbal) expressions of probability; 35.7% preferred disclosure in terms of quantitative (numeric) expressions of probability; and 9.8% preferred disclosure in both qualitative and quantitative terms. Younger patients (odds ratio [OR] 0.96; confidence interval [CI] 0.93, 0.99), patients who had at least one stroke (OR 3.03; CI 1.03, 8.90), and patients who preferred to discuss risk information with their physicians in terms of numbers (OR 2.39; CI 1.40, 4.06) tended to prefer patient-based or shared decision making. CONCLUSIONS: Male veterans consistently preferred shared patient-physician decision making in the context of invasive medical interventions.
Adult↗
How do faculty evaluate students' case presentations?
BACKGROUND: Although the case presentation is a frequent activity, little is known about the attributes that faculty members use when assessing case presentation ability. PURPOSE: Define the dimensions used by faculty when assessing students' case presentation abilities. METHODS: Eleven internal medicine faculty members independently assessed the same 17 videotaped student case presentations. Raters used an evaluation form assembled with 4 descriptors of content and 6 attributes of communication style. For each evaluator, correlation analyses were used to examine associations among the individual descriptors and a student's overall evaluation. RESULTS: Despite efforts toward uniform scoring, faculty evaluators varied in their application of rating criteria. The majority of raters had significant (p < .01) correlation between 4 of the 10 dimensions and the overall score. These 4 were history of present illness and three communication skills: economy, fluency, and precision of language. CONCLUSIONS: Faculty members' assessment of case presentations is based on both the facts presented and communication style. These identified performance dimensions can facilitate teaching students to present cases and allow more informative feedback on their abilities.
Journal Article↗
Effects of a physician communication intervention on patient care outcomes.
OBJECTIVE: To determine whether an intervention designed to improve patient-physician communication increases the frequency with which physicians elicit patients' concerns, changes other communication behaviors, and improves health care outcomes. DESIGN: Pretest-posttest design with random assignment of physicians to intervention or control groups. SETTING: General medicine clinics of a university-affiliated Veterans Affairs Hospital. PATIENTS/PARTICIPANTS: Forty-two physicians and 348 continuity care patients taking prescription medications for chronic medical conditions. INTERVENTIONS: Intervention group physicians received 4.5 hours of training on eliciting and responding to patients' concerns and requests, and their patients filled out the Patient Requests for Services Questionnaire prior to a subsequent clinic visit. Control group physicians received 4.5 hours of training in medical decision-making. MEASUREMENTS AND MAIN RESULTS: The frequency with which physicians elicited all of a patient's concerns increased in the intervention group as compared with the control group (p = .032). Patients perceptions of the amount of information received from the physician did increase significantly (p < .05), but the actual magnitude of change was small. A measure of patient satisfaction with the physicians was high at baseline and also showed no significant change after the intervention. Likewise, the intervention was not associated with changes in patient compliance with medications or appointments, nor were there any effects on outpatient utilization. CONCLUSIONS: A low-intensity intervention changed physician behavior but had no effect on patient outcomes such as satisfaction, compliance, or utilization. Interventions may need to focus on physicians and patients to have the greatest effect.
Communication↗
Five-year survival curves: how much data are enough for patient-physician decision making in general surgery?
OBJECTIVE: To find out whether patients' preferences for a particular type of treatment are changed by the way in which the information is presented (point estimates-year 0 and year 5 data points-or two five-year survival curves). DESIGN: Prospective study. SETTING: University-based Department of Veterans Affairs Medical Center, USA. SUBJECTS: 236 Consecutive patients seen in a general medical outpatient clinic. INTERVENTIONS: Patients were asked to choose between two treatments, one with a 10% immediate mortality and 37% five-year survival (treatment A) and one with no immediate mortality and 22% five-year survival (treatment B). They were randomised to be given the survival data either as point estimates or as two five-year survival curves. MAIN OUTCOME MEASURES: Number of patients who chose each treatment. RESULTS: The mean age was 67 years (range 40-84) and mean duration of education was 13 years (range 0-22). Significantly fewer patients chose the treatment with better immediate survival when they were given the data as survival curves (47/140, 34% compared with 93/140, 66% p < 0.0001) than when they were given data as point estimates (57/96, 59%, compared with 39/96, 41%). CONCLUSION: Patients are significantly more likely to make different decisions when given more data (in the form of five-year survival curves which show short, medium, and long term results) than when they are presented with only point estimates.
Adult↗
Towards new measures of information retrieval evaluation.
All of the methods currently used to assess information retrieval (IR) systems have limitations in their ability to measure how well users are able to acquire information. We utilized a new approach to assessing information obtained, based on a short-answer test given to senior medical students. Students took the ten-question test and then searched one of two IR systems on the five questions for which they were least certain of their answer Our results showed that pre-searching scores on the test were low but that searching yielded a high proportion of answers with both systems. These methods are able to measure information obtained, and will be used in subsequent studies to assess differences among IR systems.
Evaluation Studies as Topic↗
The effect of house officer rotation on inpatient satisfaction and ward atmosphere: preliminary findings.
Continual rotation of house officers builds discontinuity into the physician-patient relationship in teaching hospitals. This has led to speculation about the problem of residents and interns leaving their patients in the midst of hospital treatment. This article uses prospective data to assess the effect of house officer turnover on levels of patient satisfaction with hospital care and on patient perception of the hospital environment. Two inpatient cohorts defined by whether or not they had undergone a house officer change were matched by age and diagnostic category. Although survey instruments were significantly correlated, there was no significant difference between the two inpatient cohorts overall or on any of the survey subscales. The survey showed good satisfaction with the hospital, doctors, and nurses in both test groups. The authors draw a preliminary conclusion that patient satisfaction with medical care and with the hospital atmosphere remains constant, independent of termination of the doctor-patient relationship. Results from other reports linking patient satisfaction with continuity of care have been mixed. In discussing the limitations of their study, the authors point out that their findings are based on single-site data.
Hospitals, Teaching↗
Outpatients' attitudes and understanding regarding living wills.
OBJECTIVE: To assess outpatients' attitudes toward and understanding of a standard living will. DESIGN: Survey using a self-administered questionnaire that patients completed after they had read a sample living will. SETTING: General medicine clinic of a Department of Veterans Affairs medical center. PATIENTS: Two hundred fourteen patients (85% of those approached) attending a continuity care clinic appointment. Eighty-seven percent were men; mean age was 60 years. MEASUREMENTS AND MAIN RESULTS: Patients' attitudes toward living wills, understanding of the terminology contained in living wills, desire to discuss living wills with their doctors, and desire to prepare a living will. RESULTS: Seventy-two percent of the patients had prior knowledge of living wills, though only 53% had discussed the topic with family members and only 14% with physicians. Half felt that the living will terminology should be simplified, and 55% were unable to identify the correct definition for at least one commonly used term. Desire to prepare a living will was positively associated with better understanding of the sample document and previous knowledge of and exposure to living wills, and was negatively associated with concern about its use and revocability (all p < 0.001). Patients who reported poor understanding of the living will were more likely to want to discuss the topic with a physician (p < 0.01). CONCLUSIONS: In this ambulatory patient population attitudes toward living wills were influenced by knowledge and understanding of these documents. Primary care physicians and institutions should develop patient education strategies that enhance understanding of advance directives.
Attitude to Death↗
Attending rounds on in-patient units: differences between medical and non-medical services.
The objective of this cross-sectional observational study was to quantify communication patterns between teachers and trainees on in-patient attending ward rounds and assess trainees' perceptions of the effectiveness of teaching interactions. Sixty-nine in-patient ward rounds on medical and non-medical teaching services at a university hospital and its affiliated VA Medical Center were studied. Teaching rounds were observed and audiotaped, and trained raters coded verbal interchange for its location, speaker identity and topic of the exchange. One to three days following the teaching rounds, residents and students were interviewed and completed a questionnaire concerning recollections of the content of the session. Medical rounds lasted a mean of 90 minutes, while non-medical rounds averaged 38 minutes. Medical teams spent more time than non-medical teams on case presentations and discussions of diseases not directly related to patient care. Both groups averaged approximately 10 minutes directly interacting with patients, and equal times were spent speaking by the teacher and trainees. The role of postgraduate year 1 residents and medical students primarily was to recite details of patients' clinical condition. Twenty-nine per cent of trainees were unable to recall a specific teaching point from rounds when interviewed 1-3 days later. Duration and content of in-patient rounds differed on medical and non-medical services. For both, discourse tended to be hierarchical, with those at different training levels adhering to specific roles. Bedside patient interactions were limited. The content recalled by students and house staff suggests that new, more effective educational paradigms are needed.
Clinical Competence↗
Patient interpretations of terms connoting low probabilities when communicating about surgical risk.
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Cognition↗
A comparison of retrieval effectiveness for three methods of indexing medical literature.
Conventional approaches to indexing medical literature include the human assignment of terms from a controlled vocabulary, such as MeSH, or the computer assignment of all words in the title and abstract as indexing terms. Human indexing suffers from inconsistency, while word-based indexing suffers from the multiple meanings of words. SAPHIRE is a computer program designed to provide indexing using controlled terms that are assigned by computer, based on their occurrence in the title and abstract. In this first evaluation of SAPHIRE, the authors compared the retrieval performance of the three indexing approaches--human-based MEDLINE with text words; machine-based SAPHIRE with text words; and text words only--for searches by measuring recall and precision for each search using a test collection of 200 abstracts. The abstracts were judged by human reviewers for relevance as applied to 12 literature queries. The results suggest that text word indexing is more effective than indexing with MeSH terms. SAPHIRE's indexing performance was slightly inferior but the program has other advantageous features.
Abstracting and Indexing↗
Words, concepts, or both: optimal indexing units for automated information retrieval.
What is the best way to represent the content of documents in an information retrieval system? This study compares the retrieval effectiveness of five different methods for automated (machine-assigned) indexing using three test collections. The consistently best methods are those that use indexing based on the words that occur in the available text of each document. Methods used to map text into concepts from a controlled vocabulary showed no advantage over the word-based methods. This study also looked at an approach to relevance feedback which showed benefit for both word-based and concept-based methods.
Abstracting and Indexing↗
Previous visits to emergency departments by patients with chest discomfort.
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Chest Pain↗
Assessing predictive accuracy: how to compare Brier scores.
Several investigators have used the Brier index to measure the predictive accuracy of a set of medical judgments; the Brier scores of different raters who have evaluated the same patients provides a measure of relative accuracy. However, such comparisons may be difficult to interpret because of the lack of a statistical test for differentiating between two Brier scores. To demonstrate a method for addressing this issue we analyzed the judgments of five medical students, each of whom independently evaluated the same 25 patients with recurrent chest pain. Using the method we determined that two of the students gave judgments that were incompatible with the actual observed outcomes (p less than 0.05); of the three remaining students we detected a significant difference between two (p less than 0.05). These results differed from receiver operating characteristic curve area analysis, another technique used to evaluate predictive accuracy. We suggest that the proposed method can provide a useful tool for investigators using the Brier index to compare how well clinicians express uncertainty using probability judgments.
Chest Pain↗
A prospective study of internal medicine residents' emotions and attitudes throughout their training.
To evaluate whether the negative emotions and attitudes that residents develop during internship continue throughout the remaining years of their residency, the authors undertook a four-year prospective study of two classes of internal medicine residents who completed their training in 1985 and 1986 in a residency program based at the Oregon Health Sciences University. Every two to three months over all three years of training, the residents indicated on Likert-type scales their levels of agreement with questions about their career satisfaction and emotional states, and the satisfying and dissatisfying aspects of their residency experiences. Between the internship and the end of their residencies, the physicians indicated significant improvements in their emotions and attitudes. Those experiences identified as satisfying continued to be so, whereas those considered dissatisfying became less so. Although more research of other classes of residents is needed, the findings suggest that while internal medicine internships may be dysphoric, the residents' emotional states and attitudes tend to normalize during the remainder of the residency.
Adult↗