Sylvia Bereknyei Merrell

All Publications

• Language-discordant care in pediatric neurosurgery: parent and provider perspectives on challenges and multilevel solutions to reduce disparities. Journal of neurosurgery. Pediatrics Ruiz Colon, G. D., Bereknyei Merrell, S., Poon, D. C., Mahaney, K. B., Maher, C. O., Prolo, L. M. 2024: 1-7

  Abstract

  OBJECTIVE: In the United States, Spanish is the second most spoken language, with nearly 42 million individuals speaking Spanish at home. Spanish speakers have been noted to have higher rates of unfavorable neurosurgical outcomes; however, to the authors' knowledge, no study has explored the experiences of patients, caregivers, and providers receiving or delivering neurosurgical care in language-discordant settings. In this study, the authors sought to identify challenges faced by pediatric neurosurgery providers and Spanish-speaking parents communicating with a language barrier and propose solutions to address those challenges.METHODS: Spanish-speaking parents and pediatric neurosurgery providers were invited to participate in semistructured interviews. Purposeful sampling was used to recruit Spanish-speaking parents whose child had recently undergone neurological surgery at the authors' institution and to identify pediatric neurosurgery clinical team members to interview, including physicians, advanced practice providers, and interpreters. Codes were inductively developed and applied to transcripts by two researchers. Thematic analysis was conducted to identify challenges faced by parents and providers.RESULTS: Twenty individuals were interviewed, including parents (n = 8), advanced practice providers (n = 5), physicians (n = 3), interpreters (n = 2), a social worker (n = 1), and a nurse (n = 1). Three challenges were identified. 1) Compared with English-speaking parents, providers noted that Spanish-speaking parents were less likely to ask questions or raise new concerns. Concurrently, Spanish-speaking parents expressed a desire to better understand their child's future medical needs, care, and development. 2) There is a dearth of high-quality resources available in the Spanish language to supplement patient and parent neurosurgical education. 3) Both parents and providers invariably prefer in-person interpreters; however, their availability is limited.CONCLUSIONS: Three challenges were identified by Spanish-speaking parents of pediatric neurosurgery patients and providers when receiving or delivering care through a language barrier. The authors discuss multilevel solutions that, if deployed, could directly address these shared challenges. Furthermore, optimizing communication may help mitigate the disparities experienced by non-English-speaking Hispanic/Latino individuals when receiving neurosurgical care.

  View details for DOI 10.3171/2024.1.PEDS23435

  View details for PubMedID 38518279

• Perceptions of US-Based Muslim Patients of Their Dermatology Care. JAMA dermatology El-Banna, G., Rezaei, S. J., Chang, M., Merrell, S. B., Bailey, E. E., Kibbi, N. 2023

  Abstract

  Cultural humility training is of growing interest, yet the religious and cultural accommodations of Muslim patients in dermatology have not been studied.To explore the perceptions of Muslim patients of their dermatology care.This qualitative mixed-methods study, consisting of surveys and semistructured interviews, recruited participants from 2 clinical sites within a large academic health care system in California. Participants were adult, English-speaking, Muslim patients who were evaluated at least once by a medical or surgical dermatologist between January 2022 and January 2023.A survey obtained the following data: demographics, religious practices pertinent to dermatology care, and experiences of bias outside and inside the dermatology clinic. Semistructured interviews covered topics related to positive and negative experiences in the dermatology clinic, accommodation of cultural and religious needs in dermatology, and future interventions.A total of 21 patients (mean [SD] age, 36.4 [11.6] years; range, 26-71 years) participated in the study: 5 male individuals (24%) and 16 female individuals (76%), including 10 female individuals who wore hijab. Eleven participants identified as Middle Eastern (52%), 8 as South Asian (38%), 1 as North African (5%), and 1 as Pacific Islander (5%). Survey results showed variations in the impact of Islamic practices on dermatology care. Interviews showed that Muslim participants did not perceive dermatology care as a priority and expressed interest in community events focused on general dermatology education. They also experienced stigmatization of their skin disease and cosmetic care. Prior experiences with Islamophobia and colorism hindered the Muslim patient-dermatologist relationship and disclosure of the need for accommodations. There were instances when participants experienced bias and poor cultural humility from dermatologists. Finally, Muslim participants had unique religious and cultural needs pertinent to their care, including clinician gender concordance, medication timing adjustment while fasting, and halal medication ingredients.This qualitative mixed-methods study explored the experiences of Muslim patients in dermatology in the US. Recommendations supported by this study include incorporating religion into cultural humility training, increasing diversity in the dermatology workforce, implementing policies for clearer medication labeling, supporting dermatology research in subpopulations of Muslim individuals in the US, and partnering with community organizations for dermatology education.

  View details for DOI 10.1001/jamadermatol.2023.4439

  View details for PubMedID 37966806

  View details for PubMedCentralID PMC10652213

• Usability of ENTRUST as an Assessment Tool for Entrustable Professional Activities (EPAs): A Mixed Methods Analysis. Journal of surgical education Lee, M. C., Melcer, E. F., Merrell, S. B., Wong, L. Y., Shields, S., Eddington, H., Trickey, A. W., Tsai, J., Korndorffer, J. R., Lin, D. T., Liebert, C. A. 2023

  Abstract

  As the American Board of Surgery transitions to a competency-based model of surgical education centered upon entrustable professional activities (EPAs), there is a growing need for objective tools to determine readiness for entrustment. This study evaluates the usability of ENTRUST, an innovative virtual patient simulation platform to assess surgical trainees' decision-making skills in preoperative, intra-operative, and post-operative settings.This is a mixed-methods analysis of the usability of the ENTRUST platform. Quantitative data was collected using the system usability scale (SUS) and Likert responses. Analysis was performed with descriptive statistics, bivariate analysis, and multivariable linear regression. Qualitative analysis of open-ended responses was performed using the Nielsen-Shneiderman Heuristics framework.This study was conducted at an academic institution in a proctored exam setting.The analysis includes n = 47 (PGY 1-5) surgical residents who completed an online usability survey following the ENTRUST Inguinal Hernia EPA Assessment.The ENTRUST platform had a median SUS score of 82.5. On bivariate and multivariate analyses, there were no significant differences between usability based on demographic characteristics (all p > 0.05), and SUS score was independent of ENTRUST performance (r = 0.198, p = 0.18). Most participants agreed that the clinical workup of the patient was engaging (91.5%) and felt realistic (85.1%). The most frequent heuristics represented in the qualitative analysis included feedback, visibility, match, and control. Additional themes of educational value, enjoyment, and ease-of-use highlighted participants' perspectives on the usability of ENTRUST.ENTRUST demonstrates high usability in this population. Usability was independent of ENTRUST score performance and there were no differences in usability identified in this analysis based on demographic subgroups. Qualitative analysis highlighted the acceptability of ENTRUST and will inform ongoing development of the platform. The ENTRUST platform holds potential as a tool for the assessment of EPAs in surgical residency programs.

  View details for DOI 10.1016/j.jsurg.2023.09.001

  View details for PubMedID 37821350

• ENTRUST: A Serious Game-Based Virtual Patient Platform to Assess Entrustable Professional Activities in Graduate Medical Education. Journal of graduate medical education Lin, D. T., Melcer, E. F., Keehl, O., Eddington, H., Trickey, A. W., Tsai, J., Camacho, F., Merrell, S. B., Korndorffer, J., Liebert, C. A. 2023; 15 (2): 228-236

  Abstract

  As entrustable professional activities (EPAs) are implemented in graduate medical education, there is a great need for tools to efficiently and objectively evaluate clinical competence. Readiness for entrustment in surgery requires not only assessment of technical ability, but also the critical skill of clinical decision-making.We report the development of ENTRUST, a serious game-based, virtual patient case creation and simulation platform to assess trainees' decision-making competence. A case scenario and corresponding scoring algorithm for the Inguinal Hernia EPA was iteratively developed and aligned with the description and essential functions outlined by the American Board of Surgery. In this study we report preliminary feasibility data and validity evidence.In January 2021, the case scenario was deployed and piloted on ENTRUST with 19 participants of varying surgical expertise levels to demonstrate proof of concept and initial validity evidence. Total score, preoperative sub-score, and intraoperative sub-score were analyzed by training level and years of medical experience using Spearman rank correlations. Participants completed a Likert scale user acceptance survey (1=strongly agree to 7=strongly disagree).Median total score and intraoperative mode sub-score were higher with each progressive level of training (rho=0.79, P<.001 and rho=0.69, P=.001, respectively). There were significant correlations between performance and years of medical experience for total score (rho=0.82, P<.001) and intraoperative sub-scores (rho=0.70, P<.001). Participants reported high levels of platform engagement (mean 2.06) and ease of use (mean 1.88).Our study demonstrates feasibility and early validity evidence for ENTRUST as an assessment platform for clinical decision-making.

  View details for DOI 10.4300/JGME-D-22-00518.1

  View details for PubMedID 37139206

  View details for PubMedCentralID PMC10150817

• A Novel Serious Illness Communication Curriculum Improves Neurology Residents' Confidence and Skills. Journal of palliative medicine Goyal, T., Merrell, S. B., Weimer-Elder, B., Kline, M., Rassbach, C. E., Gold, C. A. 2023

  Abstract

  Background and Purpose: Competency in serious illness communication is mandated by the Accreditation Council of Graduate Medical Education. Previous efforts to teach communication skills have been hampered by intensive time requirements. In this study, we developed and evaluated a brief goals-of-care communication curriculum for neurology residents. Methods: We developed and implemented a two-part curriculum based on themes identified from a needs assessment: (1) fundamental physician-patient communication skills; and (2) counseling surrogate decision makers and providing neuroprognostication. We used a three-pronged pre-post study design to evaluate the impact of the curriculum: resident self-assessment surveys, direct observations of resident-patient interactions, and patient perception surveys using the Communication Assessment Tool. Results: Residents reported a significant increase in mean scores [standard deviation] of confidence practicing fundamental communication skills, such as offering opportunities for emotion (3.84 [0.9] vs. 4.54 [0.6], p=0.002), and goals-of-care communication skills, such as using triggers for serious conversations (2.65 [0.7] vs. 3.29 [0.5], p=0.004). Observed resident-patient interactions showed significant improvement in fundamental communication skills, such as involving the patient in decision making (1.89 [0.6] vs. 4.0 [0.9], p<0.001). There was no significant impact on patient perception of resident communication skills in the three months following the intervention. Conclusions: A brief, learner-centered curricular intervention improved neurology residents' confidence in serious illness communication and improved their skills as judged by trained observers.

  View details for DOI 10.1089/jpm.2022.0371

  View details for PubMedID 36952327

• Pulse oximeter provision and training of non-physician anesthetists in Zambia: a qualitative study exploring perioperative care after training. BMC health services research Peterson, M. E., Mattingly, A. S., Merrell, S. B., Asnake, B. M., Ahmed, I., Weiser, T. G. 2022; 22 (1): 1395

  Abstract

  BACKGROUND: Pulse oximetry monitoring is included in the WHO Safe Surgery Checklist and recognized as an essential perioperative safety monitoring device. However, many low resource countries do not have adequate numbers of pulse oximeters available or healthcare workers trained in their use. Lifebox, a nonprofit organization focused on improving anesthetic and surgical safety, has procured and distributed pulse oximeters and relevant educational training in over 100 countries. We aimed to understand qualitatively how pulse oximetry provision and training affected a group of Zambian non-physician anesthetists' perioperative care and what, if any, capacity gaps remain.METHODS: We identified and approached non-physician anesthetists (NPAPs) in Zambia who attended a 2019 Lifebox pulse oximetry training course to participate in a semi-structured interview. Interviews were audio recorded and transcribed. Codes were iteratively derived; the codebook was tested for inter-rater reliability (pooled kappa>0.70). Team-based thematic analysis identified emergent themes on pulse oximetry training and perioperative patient care.RESULTS: Ten of the 35 attendees were interviewed. Two themes emerged concerning pulse oximetry provision and training in discussion with non-physician anesthetists about their experience after training: (1) Impact on Non-Physician Anesthetists and the Healthcare Team and (2) Impact on Perioperative Patient Monitoring. These broad themes were further explored through subthemes. Increased knowledge brought confidence in monitoring and facilitated quick interventions. NPAPs reported improved preoperative assessments and reaffirmed the necessity of having pulse oximetry intraoperatively. However, lack of device availability led to case delays or cancellations. A portable device travelling with the patient to the recovery ward was noted as a major improvement in postoperative care. Pulse oximeters also improved communication between nurses and NPAPs, giving NPAPs confidence in the recovery process. However, this was not always possible, as lack of pulse oximeters and ward staff unfamiliarity with oximetry was commonly reported. NPAPs expressed that wider pulse oximetry availability and training would be beneficial.CONCLUSION: Among a cohort of non-physician anesthetists in Zambia, the provision of pulse oximeters and training was perceived to improve patient care throughout the perioperative timeline. However, capacity and resource gaps remain in their practice settings, especially during transfers of care. NPAPs identified a number of areas where patient care and safety could be improved, including expanding access to pulse oximetry training and provision to ward and nursing staff to ensure the entire healthcare team is aware of the benefits and importance of its use.

  View details for DOI 10.1186/s12913-022-08698-5

  View details for PubMedID 36419106

• The Student Guidance Program: Applying an Executive Coaching Model to Medical Student Remediation. Academic medicine : journal of the Association of American Medical Colleges Ariel, D., Lau, J., Osterberg, L., Gesundheit, N., Brar, K., Merrell, S. B. 2022; 97 (11S): S117

  View details for DOI 10.1097/ACM.0000000000004886

  View details for PubMedID 36287648

• The Student Guidance Program: Applying an Executive Coaching Model to Medical Student Remediation. Academic medicine : journal of the Association of American Medical Colleges Ariel, D., Lau, J., Osterberg, L., Gesundheit, N., Brar, K., Merrell, S. B. 2022; 97 (11S): S117

  View details for DOI 10.1097/ACM.0000000000004886

  View details for PubMedID 37838851

• The Student Guidance Program: Applying an Executive Coaching Model to Medical Student Remediation. Academic medicine : journal of the Association of American Medical Colleges Ariel, D., Lau, J., Osterberg, L., Gesundheit, N., Brar, K., Merrell, S. B. 2022; 97 (11S): S117

  View details for DOI 10.1097/ACM.0000000000004886

  View details for PubMedID 36734742

• Examination of an Intergenerational Summer Meal Program for Children and Older Adults. Journal of community health Bruce, J. S., Lien, T. N., George, E., Puri, V., Ramirez, M., Merrell, S. B. 2022

  Abstract

  Unreliable access to a sufficient quantity of affordable, nutritious food in the U.S. is a persistent public health threat significantly impacting households with children (15%) and older adults (20%). Well-established nutrition assistance programs serve children and seniors independently, yet few programs utilize an intergenerational meal program model. The aim of this mixed methods study is to examine the impact of an intergenerational meal program administered through a partnership between a local school district and a county Senior Nutrition Program. Participating older adults completed surveys to assess food security and program attendance, and examine their understanding and utilization of community-based food resources. Interviews with a subsample of participants explored perceptions of the intergenerational meal program and community-level food security. Older adults (n=83) completed surveys in English (59%), Spanish (25%), and Mandarin (16%). They identified primarily as Asian (44%), Latinx (30%), White (21%), and multi-racial (5%). Forty-eight percent of participants indicated low or very low food security at some time in the last 12months. The subsample of interviewparticipants (n=24; Spanish 46% and English 54%) revealed key insights: 1) perceived benefits of an intergenerational meal program; 2) community-level food insecurity and struggles of older adults to make ends meet; and 3) importance and challenge of obtaining nutritious foods for those with limited budgets and medical comorbidities. Implementation of this intergenerational meal program highlights the opportunity to support the nutritional needs of children and older adults while leveraging a new interdisciplinary partnership and existing organizational capacity.

  View details for DOI 10.1007/s10900-022-01125-0

  View details for PubMedID 35915322

• Validity Evidence for ENTRUST as an Assessment of Surgical Decision-Making for the Inguinal Hernia Entrustable Professional Activity (EPA). Journal of surgical education Liebert, C. A., Melcer, E. F., Keehl, O., Eddington, H., Trickey, A. W., Lee, M., Tsai, J., Camacho, F., Merrell, S. B., Korndorffer, J. R., Lin, D. T. 2022

  Abstract

  OBJECTIVE: As the American Board of Surgery (ABS) moves toward implementation of Entrustable Professional Activities (EPAs), there is a growing need for objective evaluation of readiness for entrustment of residents. This requires not only assessment of technical skills and knowledge, but also surgical decision-making in preoperative, intraoperative, and postoperative settings. We developed and piloted an Inguinal Hernia EPA Assessment on ENTRUST, a serious game-based online virtual patient simulation platform to assess trainees' decision-making competence.DESIGN: This is a prospective analysis of resident performance on the ENTRUST Inguinal Hernia EPA Assessment using bivariate analyses.SETTING: This study was conducted at an academic institution in a proctored exam setting.PARTICIPANTS: Forty-three surgical residents completed the ENTRUST Inguinal Hernia EPA Assessment.RESULTS: Four case scenarios for the Inguinal Hernia EPA and corresponding scoring algorithms were iteratively developed by expert consensus aligned with ABS EPA descriptions and functions. ENTRUST Inguinal Hernia Grand Total Score was positively correlated with PGY-level (p < 0.0001). Preoperative, Intraoperative, and Postoperative Total Scores were also positively correlated with PGY-level (p = 0.001, p = 0.006, and p = 0.038, respectively). Total Case Scores were positively correlated with PGY-level for cases representing elective unilateral inguinal hernia (p = 0.0004), strangulated inguinal hernia (p < 0.0001), and elective bilateral inguinal hernia (p = 0.0003). Preoperative Sub-Scores were positively correlated with PGY-level for all cases (p < 0.01). Intraoperative Sub-Scores were positively correlated with PGY-level for strangulated inguinal hernia and bilateral inguinal hernia (p = 0.0007 and p = 0.0002, respectively). Grand Total Score and Intraoperative Sub-Score were correlated with prior operative experience (p < 0.0001). Prior video game experience did not correlate with performance on ENTRUST (p = 0.56).CONCLUSIONS: Performance on the ENTRUST Inguinal Hernia EPA Assessment was positively correlated to PGY-level and prior inguinal hernia operative performance, providing initial validity evidence for its use as an objective assessment for surgical decision-making. The ENTRUST platform holds potential as tool for assessment of ABS EPAs in surgical residency programs.

  View details for DOI 10.1016/j.jsurg.2022.07.008

  View details for PubMedID 35909070

• BEHAVIORAL RESPONSES TO A SEASONAL ENVIRONMENT REDUCE FREQUENCY BUT INCREASE EXTENT OF WATER CONTACT IN A SCHISTOSOMIASIS-ENDEMIC REGION OF WEST AFRICA Lund, A., Sam, M., Sy, A., Sow, O., Sokolow, S., Merrell, S., Bruce, J., Jouanard, N., Senghor, S., Riveau, G., De Leo, G., Lopez-Carr, D. AMER SOC TROP MED & HYGIENE. 2021: 405

  View details for Web of Science ID 000778105603359

• ENTRUST: A Serious Game-Based Virtual Patient Platform to Assess Entrustable Professional Activities in Surgical Education Liebert, C. A., Lin, D. T., Melcer, E. F., Keehl, O. G., Trickey, A., Eddington, H., Merrell, S., Korndorffer, J. R. ELSEVIER SCIENCE INC. 2021: S224

  View details for Web of Science ID 000718303100423

• MOTIVATIONS AND BARRIERS TOWARD IMPLEMENTATION OF A RECTAL CANCER SYNOPTIC OPERATIVE REPORT: A PROCESS EVALUATION. Diseases of the colon and rectum Bidwell, S., Poles, G., Shelton, A., Staudenmayer, K., Bereknyei Merrell, S., Morris, A. M. 2021

  Abstract

  BACKGROUND: Use of synoptic reporting has been shown to improve documentation of critical information and provide added value related to data access and extraction, data reliability, relevant detail, and completeness of information. Surgeon acceptance and adoption of synoptic reports has lagged behind other specialties.OBJECTIVE: To evaluate the process of implementing a synoptic operative report.DESIGN: Mixed methods process evaluation including surveys and qualitative interviews.SETTINGS: Colorectal Surgery practices across the United States.PATIENTS: Twenty-eight board-certified colorectal surgeons.INTERVENTIONS: Implementation of the synoptic operative report for rectal cancer.MAIN OUTCOME MEASURES: Acceptability, feasibility, and usability measured by Likert-type survey questions and followed up with individual interviews to elicit experiences with implementation as well as motivations and barriers to use.RESULTS: Among all study participants, 28 surgeons completed the electronic survey (76% response rate) and 21 (57%) completed the telephone interview. Mean usability was 4.14 (range=1-5, standard error (SE)=0.15), mean feasibility was 3.90 (SE=0.15), and acceptability was 3.98 (SE=0.18). Participants indicated substantial administrative and technical support were necessary but not always available for implementation and many were frustrated by the need to change their workflow.LIMITATIONS: Most surgeon participants were male, white, had >12 years in practice, and used Epic electronic medical record systems. Therefore, they may not represent the perspectives of all U.S. colon and rectal surgeons. Additionally, as the synoptic operative report is implemented more broadly across the U.S., it will be important to consider variations in the process by EMR system.CONCLUSIONS: The synoptic operative report for rectal cancer was generally easy to implement and incorporate into workflow but surgeons remained concerned about additional burden without immediate and tangible value. In spite of recognizing benefits, many participants indicated they only implemented the synoptic operative report because it was mandated by the National Accreditation Program for Rectal Cancer. See Video Abstract at http://links.lww.com/DCR/B735.

  View details for DOI 10.1097/DCR.0000000000002202

  View details for PubMedID 34711713

• Self-efficacy Toward a Healthcare Career Among Minority High School Students in a Surgical Pipeline Program: A Mixed Methods Study. Journal of surgical education Yelorda, K., Bidwell, S., Fu, S., Miller, M. O., Merrell, S. B., Koshy, S., Morris, A. M. 2021

  Abstract

  OBJECTIVE: While many barriers to healthcare careers exist for URM students, a strong sense of self-efficacy may help mitigate these obstacles. This study explores how URM high school students describe their academic challenges and compares their descriptions across self-efficacy scores.DESIGN: We conducted a convergent mixed methods study of URM high school students. Students completed a validated self-efficacy questionnaire and participated in semi-structured focus group interviews to discuss their approach to academic challenges, goal setting, and achievement. The primary outcome was academic, social, and emotional self-efficacy, measured using the Self-Efficacy Questionnaire for Children. We separated participants into high and low self-efficacy groups based on scores in each domain. Using thematic analysis, we identified and compared common themes associated with academic challenges and goal setting.SETTING: Surgical exposure pipeline program sponsored by Stanford University Department of Surgery PARTICIPANTS: Low-income, high academic achieving URM high school students interested in science, technology, engineering and mathematics, and/or healthcare careers.RESULTS: Thirty-one high school students completed the focus groups and self-efficacy questionnaire. Most students scored in the high self-efficacy group for at least one domain: 65% for academic self-efficacy, 56% for social self-efficacy, and 19% for emotional self-efficacy. Four emergent themes highlighted participants' perspectives toward educational success: fulfillment in academic challenges, focus on future goals, failing forward, and asking for help. Compared to students with low self-efficacy scores, students in the high-scoring self-efficacy groups more often discussed strategies and concrete behaviors such as the importance of seeking support from teachers and peers and learning from failure.CONCLUSIONS: Students in high self-efficacy groups were more comfortable utilizing approaches that helped them succeed academically. Additional efforts are needed to bolster student self-efficacy, particularly in students from URM backgrounds, to increase diversity in medical schools.

  View details for DOI 10.1016/j.jsurg.2021.04.010

  View details for PubMedID 34011476

• ACQUISITION OF MEDICAID AT THE TIME OF INJURY: AN OPPORTUNITY FOR SUSTAINABLE INSURANCE COVERAGE. The journal of trauma and acute care surgery Jaramillo, J. D., Arnow, K., Trickey, A. W., Dickerson, K., Wagner, T. H., Harris, A. H., Tran, L. D., Bereknyei, S., Morris, A. M., Spain, D. A., Knowlton, L. M. 2021

  Abstract

  INTRODUCTION: Uninsured trauma patients are at higher risk of mortality, limited access to postdischarge resources and catastrophic health expenditure. Hospital Presumptive Eligibility (HPE), enacted with the 2014 Affordable Care Act, enables uninsured patients to be screened and acquired emergency Medicaid at the time of hospitalization. We sought to identify factors associated with successful acquisition of HPE insurance at the time of injury, hypothesizing that patients with higher injury severity (ISS>15) would be more likely to be approved for HPE.METHODS: We identified Medicaid and uninsured patients aged 18-64 years old with a primary trauma diagnosis (ICD-10) in a large level I trauma center between 2015-2019. We combined trauma registry data with review of electronic medical records, to determine our primary outcome, HPE acquisition. Descriptive and multivariate analyses were performed.RESULTS: Among 2,320 trauma patients, 1,374 (59%) were already enrolled in Medicaid at the time of hospitalization. Among those uninsured at arrival, 386 (40.8%) acquired HPE before discharge, and 560 (59.2%) remained uninsured. HPE patients had higher injury severity score (ISS > 15: 14.8% vs. 5.7%, p < .001), longer median length of stay (LOS) (2 [IQR: 0,5] vs. 0 [0,1] days, p < .001), were more frequently admitted as inpatients (64.5% vs. 33.6%, p < .001) and discharged to post-acute services (11.9% vs. 0.9%, p < .001). Patient, hospital and policy factors contributed to HPE non-approval. In adjusted analyses, Hispanic ethnicity (vs. non-Hispanic whites: aOR 1.58, p = .02) and increasing ISS (p ≤ .001) were associated with increased likelihood of HPE approval.CONCLUSION: The time of hospitalization due to injury is an underutilized opportunity for intervention, whereby uninsured patients can acquire sustainable insurance coverage. Opportunities to increase HPE acquisition merit further study nationally across trauma centers. As administrative and trauma registries do not capture information to compare HPE and traditional Medicaid patients, prospective insurance data collection would help to identify targets for intervention.LEVEL OF EVIDENCE: Epidemiologic, level III.

  View details for DOI 10.1097/TA.0000000000003195

  View details for PubMedID 33783416

• In situ interprofessional operating room simulations: Empowering learners in crisis resource management principles. Surgery Gros, E., Shi, R., Hasty, B., Anderson, T., Schmiederer, I., Roman-Micek, T., Merrell, S. B., Lau, J. 2021

  Abstract

  BACKGROUND: Given the multifaceted nature of operating room teams, miscommunication at various perioperative stages leads to lapses in teamwork and communication, which potentiates adverse events. In situ interprofessional operating room simulations are a valuable tool in identifying the possible threats to patient safety in the operating room. Participant confidence may also increase; however, perceived confidence in specific areas of team communication in the clinical environment remains unclear. This research aims to study how in situ interprofessional operating room simulations increase participants' individual confidence in 4 team principles derived from crisis resource management: using effective communication, utilizing resources, establishing role clarity, and using effective situational awareness.METHODS: Over a 2-year period, interdisciplinary operating room team members were assigned to participate in 13 simulated surgical case scenarios, which were chosen based on the volunteer surgeon's specialty. These cases were designed to engage all team members and included a crisis scenario (ie, hemorrhage, airway emergency, arrhythmia, or cardiac arrest). All statistical analyses were performed using RStudio version 1.2.1335 software. We analyzed matched pre- and postsimulation self-assessment of individual confidence using the Wilcoxon signed-rank test for each of the 4 aforementioned constructs of interest derived from crisis resource management training principles. Significance was set at P < .0038, using Bonferroni correction, for all comparisons to account for the multiple comparisons problem.RESULTS: There was a statistically significant shift in the 4-point scale toward greater self-reported confidence from presimulation to postsimulation for each of the 4 team principles: using effective communication (P= .0019, r= 0.18), utilizing resources well (P= .0014, r= 0.18), establishing role clarity (P < .0010, r= 0.22), and using effective situational awareness (P < .0010, r= 0.27).CONCLUSION: In this pilot study, we describe how teaching crisis resource management principles in an in situ operative simulation is an effective way to increase the confidence of communication skills among the members of an interdisciplinary procedure/operative team during crisis scenarios. In situ simulation can be used to evaluate system competence and interdisciplinary dynamics, and to identify latent conditions that predispose to medical error. As we continue to conduct these sessions, we aim to evaluate their impact on individual confidence and the advancement of interdisciplinary efforts to improve patient care.

  View details for DOI 10.1016/j.surg.2021.02.011

  View details for PubMedID 33771356

• Local and Visiting Physician Perspectives on Short Term Surgical Missions in Guatemala A Qualitative Study ANNALS OF SURGERY Coughran, A. J., Merrell, S., Pineda, C., Sceats, L. A., Yang, G. P., Morris, A. M. 2021; 273 (3): 606–12

  View details for DOI 10.1097/SLA.0000000000003292

  View details for Web of Science ID 000613888300047

• Puerto Rico Health System Resilience After Hurricane Maria: Implications for Disaster Preparedness in the COVID-19 Era FRONTIERS IN COMMUNICATION Rios, C. C., Ling, E. J., Rivera-Gutierrez, R., Sanchez, J., Merrell, S., Bruce, J., Barry, M., Perez, V. 2021; 5

  View details for DOI 10.3389/fcomm.2020.593939

  View details for Web of Science ID 000677962900001

• COVID-19 Impact on Surgical Resident Education and Coping. The Journal of surgical research Wise, C. E., Bereknyei Merrell, S. n., Sasnal, M. n., Forrester, J. D., Hawn, M. T., Lau, J. N., Lin, D. T., Schmiederer, I. S., Spain, D. A., Nassar, A. K., Knowlton, L. M. 2021; 264: 534–43

  Abstract

  Healthcare systems and surgical residency training programs have been significantly affected by the novel coronavirus disease 2019 (COVID-19) pandemic. A shelter-in-place and social distancing mandate went into effect in our county on March 16, 2020, considerably altering clinical and educational operations. Along with the suspension of elective procedures, resident academic curricula transitioned to an entirely virtual platform. We aimed to evaluate the impact of these modifications on surgical training and resident concerns about COVID-19.We surveyed residents and fellows from all eight surgical specialties at our institution regarding their COVID-19 experiences from March to May 2020. Residents completed the survey via a secure Qualtrics link. A total of 38 questions addressed demographic information and perspectives regarding the impact of the COVID-19 pandemic on surgical training, education, and general coping during the pandemic.Of 256 eligible participants across surgical specialties, 146 completed the survey (57.0%). Junior residents comprised 43.6% (n = 61), compared to seniors 37.1% (n = 52) and fellows 19.3% (n = 27). Most participants, 97.9% (n = 138), anticipated being able to complete their academic year on time, and 75.2% (n = 100) perceived virtual learning to be the same as or better than in-person didactic sessions. Participants were most concerned about their ability to have sufficient knowledge and skills to care for patients with COVID-19, and the possibility of exposure to COVID-19.Although COVID-19 impacted residents' overall teaching and clinical volume, residency programs may identify novel virtual opportunities to meet their educational and research milestones during these challenging times.

  View details for DOI 10.1016/j.jss.2021.01.017

  View details for PubMedID 33862581

• Feasibility and acceptability of virtually coaching residents on communication skills: a pilot study. BMC medical education Sasnal, M., Miller-Kuhlmann, R., Merrell, S. B., Beres, S., Kipp, L., Lee, S., Threlkeld, Z., Nassar, A. K., Gold, C. A. 2021; 21 (1): 513

  Abstract

  Developing communication skills is a key competency for residents. Coaching, broadly accepted as a training modality in medical education, has been proven a successful tool for teaching communication skills. Little research is available thus far to investigate virtual coaching on communication skills for telemedicine encounters. The purpose of the study was to test the hypothesis that virtually coaching residents on communication skills is feasible and acceptable. We surveyed 21 resident-faculty pairs participating in a "fully virtual" coaching session (patient, coach, and resident were virtual).We asked 50 neurology resident-faculty coach pairs to complete one "fully virtual" coaching session between May 20 and August 31, 2020. After each session, the resident and coach completed a 15-item survey, including Likert-style scale and open-ended questions, assessing feasibility and acceptability. Descriptive statistics and qualitative content and thematic analyses were performed.Forty-two percent (21/50) of all eligible residents completed "fully virtual" coaching sessions. The overall survey response rate was 91 % (38/42). The majority of respondents agreed that the direct observation and debriefing conversation were easy to schedule and occurred without technical difficulties and that debriefing elements (self-reflection, feedback, takeaways) were useful for residents. Ninety-five percent of respondents rated the coach's virtual presence to be not at all disruptive to the resident-patient interaction. Virtual coaching alleviated resident stress associated with observation and was perceived as an opportunity for immediate feedback and a unique approach for resident education that will persist into the future.In this pilot study, residents and faculty coaches found virtual coaching on communication skills feasible and acceptable for telemedicine encounters. Many elements of our intervention may be adoptable by other residency programs. For example, residents may share their communication goals with clinic faculty supervisors and then invite them to directly observe virtual encounters what could facilitate targeted feedback related to the resident's goals. Moreover, virtual coaching on communication skills in both the in-person and telemedicine settings may particularly benefit residents in challenging encounters such as those with cognitively impaired patients or with surrogate decision-makers.

  View details for DOI 10.1186/s12909-021-02936-w

  View details for PubMedID 34583691

• Clinical Uses and Impacts of Emergency Manuals During Perioperative Crises. Anesthesia and analgesia Goldhaber-Fiebert, S. N., Bereknyei Merrell, S., Agarwala, A. V., De La Cruz, M. M., Cooper, J. B., Howard, S. K., Asch, S. M., Gaba, D. M. 2020; 131 (6): 1815–26

  Abstract

  BACKGROUND: Performing key actions efficiently during crises can determine clinical outcomes, yet even expert clinicians omit key actions. Simulation-based studies of crises show that correct performance of key actions dramatically increases when emergency manuals (EMs) are used. Despite widespread dissemination of EMs, there is a need to understand in clinical contexts, when, how, and how often EMs are used and not used, along with perceived impacts.METHODS: We conducted interviews with the anesthesia professionals involved in perioperative crises, identified with criterion-based sampling, occurring between October 2014 and May 2016 at 2 large academic medical centers with a history of EM training and implementation. Our convergent, mixed-methods study of the interview data extracted quantitative counts and qualitative themes of EM use and nonuse during clinical crises.RESULTS: Interviews with 53 anesthesia professionals yielded 80 descriptions of applicable clinical crises, with varying durations and event types. Of 69 unique patients whose cases involved crises, the EM was used during 37 (54%; 95% confidence interval [CI], 41-66). Impacts on clinician team members included decreased stress for individual anesthesia professionals (95%), enabled teamwork (73%), and calmed atmosphere (46%). Impacts on delivery of patient care included specific action improvements, including catching errors of omission, for example, turning off anesthetic during cardiac arrest, only after EM use (59%); process improvements, for example, double-checking all actions were completed (41%); and impediments (0%). In 8% of crises, EM use was associated with potential distractions, although none were perceived to harm delivery of patient care. For 32 EM nonuses (46%; 95% CI, 34-59), participants self-identified errors of omission or delays in key actions (56%), all key actions performed (13%), and crisis too brief for EM to be used (31%).CONCLUSIONS: This study provides evidence that EMs in operating rooms are being used during many applicable crises and that clinicians perceive EM use to add value. The reported negative effects were minimal and potentially offset by positive effects.

  View details for DOI 10.1213/ANE.0000000000005012

  View details for PubMedID 33197160

• A comparison of provider perspectives on cultural competency training: A mixed methods study. American journal of surgery Liu, M. M., Miller, M. O., Merrell, S. B., Bruce, J. S., Kin, C., Morris, A. M. 2020

  Abstract

  BACKGROUND: We aimed to identify differences in training among colorectal cancer physicians and advanced practice providers with high and low cultural competency METHODS: Using explanatory sequential mixed methods, we surveyed providers and dichotomized into high and low cultural competency (CC) groups, conducted qualitative interviews, and analyzed verbatim transcripts using deductive and inductive codes to compared findings across groups using a joint display.RESULTS: Fifty-four of 92 providers (59%) responded; 10 respondents from each group (20/36 invited) completed semi-structured interviews about previous CC trainings. Low CC providers' training included explanations of cultural differences that, in practice, improved awareness and utilization of communication tools, but they also desired decision-making tools and cultural exposure. High CC providers' training included action-oriented toolkits. In practice, they admitted failures, improved communication, and attributed patient behaviors to external factors. High CC providers desired performance evaluations.CONCLUSIONS: Behaviorally-oriented CC training offered a robust foundation for culturally competent care.

  View details for DOI 10.1016/j.amjsurg.2020.11.003

  View details for PubMedID 33220937

• "Making It Work": A Preliminary Mixed Methods Study of Rural Trauma Care Access and Resources in New Mexico. Cureus Carroll, A. L., Garcia, D., Cassells, S. J., Bruce, J. S., Bereknyei Merrell, S., Schillinger, E. 2020; 12 (10): e11143

  Abstract

  Introduction Patients in the rural western United States face challenges accessing trauma and surgical services and are more likely to succumb to their injuries. New Mexico, a rural and medically underresourced state, is a salient space to study these disparities. We examine how travel distance from trauma centers impacts injured patient outcomes and describe care delivery obstacles. Materials and Methods We conducted an explanatory mixed methods study by creating geospatial maps of New Mexico's trauma data, incorporating linear regression analyses on patient outcomes as a function of estimated travel distance from trauma centers. We also conducted qualitative semi-structured interviews with trauma providers to illuminate and provide context for the geospatial findings utilizing a systematic, collaborative, iterative transcript analysis process. We constructed a conceptual framework describing rural trauma care delivery obstacles. Results Geospatial analyses revealed that most New Mexicans face long travel times to trauma centers. Comparing regression analyses using different data sources suggests that solely hospital-derived data may undercount rural trauma deaths. Interviews with 10 providers suggest that elements that may contribute to these findings include on-the-ground resource-based challenges and those related to broader healthcare systems-based issues. Our conceptual framework denotes how these elements collectively may impact rural trauma outcomes and proposes potential solutions. Conclusions In addressing rural patients' needs, healthcare policy decision-makers should ensure that their datasets are comprehensive and inclusive. They must also take into account the particular challenges of underserved rural patients and providers who care for them by eliciting their perspectives, as presented in our conceptual framework.

  View details for DOI 10.7759/cureus.11143

  View details for PubMedID 33251053

  View details for PubMedCentralID PMC7685818

• "Making It Work": A Preliminary Mixed Methods Study of Rural Trauma Care Access and Resources in New Mexico CUREUS Carroll, A. L., Garcia, D., Cassells, S. J., Bruce, J. S., Merrell, S., Schillinger, E. 2020; 12 (10)

  View details for DOI 10.7759/cureus.11143

  View details for Web of Science ID 000582230400024

• Implementation and Evaluation of an Educational Program for Increasing Diversity and Inclusion in Surgery for Preclinical Students. JAMA network open Bryant, T. S., Carroll, A. L., Steinberg, J. R., Marin-Nevarez, P., Anderson, T. N., Merrell, S. B., Lau, J. N. 2020; 3 (9): e2015675

  View details for DOI 10.1001/jamanetworkopen.2020.15675

  View details for PubMedID 32870310

• A Mixed Methods Approach to Understanding Curricular Impact of a Capstone Course on the Self-Efficacy of Fourth-Year Medical Students CUREUS Jacobs, K. G., Kugler, J., Chi, J., Stuart, E., Merrell, S., Rassbach, C. 2020; 12 (8)

  View details for DOI 10.7759/cureus.9537

  View details for Web of Science ID 000554830700009

• A Mixed Methods Approach to Understanding Curricular Impact of a Capstone Course on the Self-Efficacy of Fourth-Year Medical Students. Cureus Jacobs, K. G., Kugler, J., Chi, J., Stuart, E., Bereknyei Merrell, S., Rassbach, C. 2020; 12 (8): e9537

  Abstract

  Background Capstone, or bootcamp, courses have been shown to increase the knowledge, skills, and self-efficacy of students prior to starting intern year and have been recommended by the Alliance for Clinical Education (ACE) to be incorporated into the fourth-year medical school curricula. However, a paucity of research exists regarding the exploration of the student perspective on critical curricular content and teaching strategies in a capstone course. Self-efficacy, one's subjective task-specific judgment of capability, has served in the literature as a framework for capstone outcomes and is derived from four sources of experiences: practice, observation of others, feedback, and one's emotional reaction to difficult situations. Utilizing this framework, we aimed to evaluate the impact of our capstone curriculum on students' self-efficacy and to identify critical curricular content and teaching strategies that affected students' self-efficacy and their transition into residency. Methods We designed a mixed methods study of our institution's capstone course in May 2019. Students were invited to participate in the retrospective pre- and post- self-efficacy survey and focus group immediately after the capstone and in semi-structured interviews four months after they began the intern year. Themes were identified via qualitative analysis using inductive coding to allow participants' voices to guide code development and deductive analysis using codes derived from the self-efficacy framework. Results  Nine enrolled students participated in the study (surveys n=8, focus group n=7, follow-up interview n=6). Students reported the capstone was a very valuable educational experience (median 4.5 [interquartile range, or IQR 4-5]), increased their preparedness for intern year (median 5 [IQR 4.25-5]) and increased self-efficacy in multiple domains. Qualitative analysis revealed the critical curricular elements that most impacted students' self-efficacy were practical and communication skills to which students previously had limited exposure, in particular managing acute clinical needs, overnight cross-cover pages, inpatient pharmacology, daily intern communication (handoffs, consults, consenting), and end-of-life communication (goals of care, code status, pronouncing death). While all four sources contributed to self-efficacy, students reported that instructor and peer feedback were fundamental to providing context and substance to their performance. Students preferred practice-based learning via high-fidelity simulation and small groups for familiar tasks (daily intern communication, overnight pages, pharmacology) and observation of peers for new tasks (end-of-life communication and acute clinical deterioration). Conclusions This is the first study describing students' perspectives on critical curricular content and teaching strategies for a capstone course derived from qualitative analysis. Practical and communication skills with previously limited clerkship exposure and task-specific learning strategies increased the students' self-efficacy. Constructive feedback provided an important source of self-efficacy for all tasks, augmenting the benefits of practice and observation. This data provides preliminary groundwork for future research as multi-institutional studies are necessary to better understand students' needs around the curriculum to address residency transition.

  View details for DOI 10.7759/cureus.9537

  View details for PubMedID 32905172

  View details for PubMedCentralID PMC7465827

• A Novel Goals of Care Communication Curriculum for Neurology Residents Improves Confidence and Skills Goyal, T., Merrell, S., Weimer-Elder, B., Kline, M., Gold, C. LIPPINCOTT WILLIAMS & WILKINS. 2020

  View details for Web of Science ID 000536058006035

• Medical Student Values Inform Career Plans in Service & Surgery-A Qualitative Focus Group Analysis. The Journal of surgical research Carroll, A. L., Chan, A. n., Steinberg, J. R., Bryant, T. S., Marin-Nevarez, P. n., Anderson, T. N., Bereknyei Merrell, S. n., Lau, J. N. 2020; 256: 636–44

  Abstract

  Diversifying the surgical workforce is a critical component of improving care for underserved patients. To recruit surgeons from diverse backgrounds, we must understand how medical students choose their specialty. We investigate how preclinical students contemplate entering a surgical field.We conducted semistructured focus groups during two iterations of a seminar class called Service Through Surgery. Discussion goals included identifying student values and assessing how they inform early career decisions. We used a systematic, collaborative, and iterative process for transcript analysis, including developing a codebook, assessing inter-rater reliability, and analyzing themes.Twenty-four preclinical medical students from diverse backgrounds participated in seven focus groups; most were women (16; 67%), in their first year of medical school (19; 79%), and interested in surgery (17; 71%). Participants ranked professional fulfillment, spending time with family, and serving their communities and/or underserved populations among their most important values and agreed that conducting groundbreaking research, working long hours, and finding time for leisure activities were the least important. We constructed a framework to describe student responses surrounding their diverse visions for service in future surgical careers through individual doctoring interactions, roles in academia, and broader public service.Our framework provides a basis for greater understanding and study of the ways in which preclinical medical students think about their personal values and visions for service in potential future surgical careers. This research can guide early interventions in medical education to promote diversity and care for the underserved in surgery.

  View details for DOI 10.1016/j.jss.2020.07.030

  View details for PubMedID 32810664

• Implementation of a Synoptic Operative Report for Rectal Cancer: A Mixed-Methods Study. Diseases of the colon and rectum Bidwell, S. S., Merrell, S. B., Poles, G. n., Morris, A. M. 2020; 63 (2): 190–99

  Abstract

  The National Accreditation Program for Rectal Cancer is a collaborative effort to improve the quality of rectal cancer care, including multidisciplinary assessment, treatment planning, and documentation using synoptic radiology, pathology, and operative reports.The purpose of this study was to examine the implementation and use of a synoptic operative report for rectal cancer.This was a convergent mixed-methods implementation study of electronic medical record data, surveys, and qualitative interviews.The study was conducted at US medical centers.Colorectal surgeons were included.After development, the synoptic operative report was iteratively revised and ultimately approved by the American Society of Colon and Rectal Surgeons Executive Council and the National Accreditation Program for Rectal Cancer and then implemented into participants' institutional electronic medical record systems.Change in fidelity to documentation of 19 critical items after implementation of synoptic reports and in-depth details and perspectives about the synoptic operative report were measured.Thirty-seven surgeons from 14 institutions submitted preimplementation operative reports (n = 180); 32 of 37 surgeons submitted postimplementation reports (n = 118). The operation type, approach, and formation of a stoma were present in >70% of preimplementation reports; however, the location of the tumor, the type of reconstruction, and the distal margin were reported in <50%. Each item was present in ≥89% of postimplementation reports. Twenty eight of 37 participants completed the survey, and 21 of 37 participants completed qualitative interviews. Emergent themes included concerns for additional burden and time constraints using the synoptic report themselves, as well as errors or absent information in traditional narrative operative reports of other surgeons.The study was limited by its sample size, cross-sectional nature, specialized centers, and inclusion of colorectal surgeons only.Although fidelity to the 19 items substantially increased after implementation of the synoptic report, reactions to the synoptic report varied among surgeons. Many indicated concerns that it would hinder workflow or add extra time burden. Others felt the synoptic report could indirectly improve rectal cancer quality of care and provide useful data for quality improvement and research. More work is needed to update and improve the synoptic operative report and streamline the workflow. See Video Abstract at http://links.lww.com/DCR/B100. IMPLEMENTACIÓN DE UN INFORME OPERATIVO SINÓPTICO PARA EL CÁNCER DE RECTO: UN ESTUDIO UTILIZANDO MÉTODOS MIXTOS: El Programa Nacional de Acreditación para el Cáncer Rectal es una iniciativa de colaboración para mejorar la calidad de la atención del cáncer rectal, utilizando evaluación multidisciplinaria, planificación del tratamiento y documentación mediante radiología sinóptica, patología e informes quirúrgicos.Examinar la implementación y el uso de un informe operativo sinóptico para el cáncer de recto.Estudio de implementación de métodos mixtos convergentes de datos de registros médicos electrónicos, encuestas y entrevistas cualitativas.Centros médicos de los Estados Unidos.Cirujanos colorrectales.Después de su formulación, el informe operativo sinóptico fue revisado de forma iterativa y finalmente aprobado por el Consejo Ejecutivo de la Sociedad Americana de Cirujanos de Colon y Rectal y el Programa Nacional de Acreditación para el Cáncer Rectal. Posteriormente, se implementó en los sistemas de registros médicos electrónicos institucionales de los participantes.Cambios en la precisión de documentación de 19 ítems críticos después de la implementación de informes sinópticos; Revisión de detalles y perspectivas en a profundidad sobre el informe operativo sinóptico.Treinta y siete cirujanos de 14 instituciones presentaron informes operativos previos a la implementación (n = 180); 32/37 cirujanos presentaron informes posteriores a la implementación (n = 118). El tipo de operación, el enfoque y la formación de un estoma estuvieron presentes en > 70% de los informes previos a la implementación; sin embargo, la ubicación del tumor, el tipo de reconstrucción y el margen distal se informaron en <50%. Cada ítem estuvo presente en > 89% de los informes posteriores a la implementación. 28/37 participantes completaron la encuesta y 21/37 participantes completaron entrevistas cualitativas. Los temas emergentes incluyeron preocupaciones por la carga adicional y las limitaciones de tiempo usando el informe sinóptico en sí, y errores o información ausente en los informes operativos narrativos tradicionales de otros cirujanos.Tamaño de la muestra, estudio transversal, centros especializados, cirujanos colorrectales solamente.Aunque la fidelidad a los 19 ítems aumentó sustancialmente después de la implementación del informe sinóptico, las reacciones al informe sinóptico variaron entre los cirujanos. Muchos indicaron preocupaciones de que obstaculizaría el flujo de trabajo o agregaría una carga de tiempo adicional. Otros consideraron que el informe sinóptico podría mejorar indirectamente la calidad de la atención del cáncer de recto y proporcionar datos útiles para la mejora de la calidad y la investigación. Se necesita más trabajo para actualizar y mejorar el informe operativo sinóptico y agilizar el flujo de trabajo. Consulte Video Resumen en http://links.lww.com/DCR/B100. (Traducción-Dr. Adrian E. Ortega).

  View details for DOI 10.1097/DCR.0000000000001518

  View details for PubMedID 31914112

• "It's Like Learning by the Seat of Your Pants": Surgeons Lack Formal Training in Opioid Prescribing. Journal of surgical education Ayakta, N. n., Sceats, L. A., Merrell, S. B., Kin, C. n. 2020

  Abstract

  To determine the training surgical residents and faculty receive on opioid prescribing, and to identify opportunities for curricula development to fill training gaps.We conducted qualitative semi-structured interviews and surveys. After applying an overarching organizational framework, we used an iterative, team-based process to develop relevant inductive codes. We then performed thematic analyses to identify and catalogue critical domains related to surgeons' education about opioid prescribing.Tertiary care academic medical center.Maximum variation purposive sampling was used to recruit general surgery residents and surgical faculty members.We interviewed 21 attending surgeons and 20 surgical residents. Surgeons reported minimal formal training on pain management and prescribing opioids. A minority of individuals described receiving opioid training in the form of continuing medical education, intern boot camp sessions, and medical school classes. Participants compensated for the lack of formal training during residency by informally learning from senior residents, consulting pain specialists, and seeking external learning resources. Increased surgical experience was correlated with increased comfort with pain management. A majority of surgeons desired formal training. The most commonly requested educational resources were opioid prescribing guidelines for common operations and recommendations for treating chronic pain patients. Residents requested that training occur early in residency to maximize the benefits received. Based on these findings, we developed a conceptual framework to explain how surgeons learn to prescribe opioids and to highlight opportunities for improvement.Although surgeons routinely prescribe opioids and desire education on opioids, a majority of them do not receive any training. Instituting formal educational programs is critical for improving opioid prescribing practices among surgeons.These programs should include standard prescribing guidelines and address management of acute postoperative pain in patients with chronic pain.

  View details for DOI 10.1016/j.jsurg.2020.07.003

  View details for PubMedID 32917541

• What constitutes a 'successful' recovery? Patient perceptions of the recovery process after a traumatic injury. Trauma surgery & acute care open Rosenberg, G., Zion, S. R., Shearer, E., Bereknyei Merrell, S., Abadilla, N., Spain, D. A., Crum, A. J., Weiser, T. G. 2020; 5 (1): e000427

  Abstract

  Background: As the number of patients surviving traumatic injuries has grown, understanding the factors that shape the recovery process has become increasingly important. However, the psychosocial factors affecting recovery from trauma have received limited attention. We conducted an exploratory qualitative study to better understand how patients view recovery after traumatic injury.Methods: This qualitative, descriptive study was conducted at a Level One university trauma center. Participants 1-3years postinjury were purposefully sampled to include common blunt-force mechanisms of injuries and a range of ages, socioeconomic backgrounds and injury severities. Semi-structured interviews explored participants' perceptions of self and the recovery process after traumatic injury. Interviews were transcribed verbatim; the data were inductively coded and thematically analyzed.Results: We conducted 15 interviews, 13 of which were with male participants (87%); average hospital length of stay was 8.9 days and mean injury severity score was 18.3. An essential aspect of the patient experience centered around the recovery of both the body and the 'self', a composite of one's roles, values, identities and beliefs. The process of regaining a sound sense of self was essential to achieving favorable subjective outcomes. Participants expressed varying levels of engagement in their recovery process, with those on the high end of the engagement spectrum tending to speak more positively about their outcomes. Participants described their own subjective interpretations of their recovery as most important, which was primarily influenced by their engagement in the recovery process and ability to recover their sense of self.Discussion: Patients who are able to maintain or regain a cohesive sense of self after injury and who are highly engaged in the recovery process have more positive assessments of their outcomes. Our findings offer a novel framework for healthcare providers and researchers to use as they approach the issue of recovery after injury with patients.Level of evidence: III-descriptive, exploratory study.

  View details for DOI 10.1136/tsaco-2019-000427

  View details for PubMedID 32154383

• Are EMS bypass policies effective implementation strategies for intravenous alteplase for stroke? Implementation science communications Harris, A. H., Barreto, N. B., Trickey, A. W., Bereknyei, S. n., Meng, T. n., Wagner, T. H., Govindarajan, P. n. 2020; 1: 50

  Abstract

  Stroke is a leading cause of disability and the fifth leading cause of death in the USA. Intravenous alteplase is a highly effective clot-dissolving stroke treatment that must be given in a hospital setting within a time-sensitive window. To increase the use of intravenous alteplase in stroke patients, many US counties enacted policies mandating emergency medical service (EMS) paramedics to bypass local emergency departments and instead directly transport patients to specially equipped stroke centers. The objective of this mixed-methods study is to evaluate the effectiveness of policy enactment as an implementation strategy, how differences in policy structures and processes impact effectiveness, and to explore how the county, hospital, and policy factors explain variation in implementation and clinical outcomes. This paper provides a detailed description of an Agency for Healthcare Quality and Research (AHRQ)-funded protocol, including the use of the Consolidated Framework for Implementation Research (CFIR) in the qualitative design.We will construct the largest-ever national stroke database of Medicare enrollees (~ 1.5 million stroke patients) representing 896 policy counties paired with 1792 non-policy counties, then integrate patient-, hospital-, county-, and state-level covariates from eight different data sources. We will use a difference-in-differences analysis to estimate the overall effect of the policy enactment on intravenous alteplase use (implementation outcome) as well as key patient outcomes. We will also quantitatively examine if variation in the context (urban/rural status) and variation in policy features affect outcomes. Finally, a CFIR-informed multiple case study design will be used to interview informants in 72 stakeholders in 24 counties to identify and validate factors that enable policy effects.Policies can be potent implementation strategies. However, the effects of EMS bypass policies to increase intravenous alteplase use have not been rigorously evaluated. By learning how context and policy structures impact alteplase implementation, as well as the barriers and facilitators experienced by stakeholders responsible for policy enactment, the results of this study will inform decisions regarding if and how EMS bypass policies should spread to non-policy counties, and if indicated, creation of a "best practices" toolkit.

  View details for DOI 10.1186/s43058-020-00041-5

  View details for PubMedID 32885206

  View details for PubMedCentralID PMC7427915

• Creation and implementation of a novel clinical workflow based on the AAST uniform anatomic severity grading system for emergency general surgery conditions. Trauma surgery & acute care open Bessoff, K. E., Choi, J. n., Bereknyei Merrell, S. n., Nassar, A. K., Spain, D. n., Knowlton, L. M. 2020; 5 (1): e000552

  Abstract

  Emergency general surgery (EGS) conditions encompass a variety of diseases treated by acute care surgeons. The heterogeneity of these diseases limits infrastructure to facilitate EGS-specific quality improvement (QI) and research. A uniform anatomic severity grading system for EGS conditions was recently developed to fill this need. We integrated this system into our clinical workflow and examined its impact on research, surgical training, communication, and patient care.The grading system was integrated into our clinical workflow in a phased fashion through formal education and a written handbook. A documentation template was also deployed in our electronic medical record to prospectively assign severity scores at the time of patient evaluation. Mixed methods including a quantitative survey and qualitative interviews of trainees and attending surgeons were used to evaluate the impact of the new workflow and to identify obstacles to its adoption.We identified 2291 patients presenting with EGS conditions during our study period. The most common diagnoses were small bowel obstruction (n=470, 20.5%), acute cholecystitis (n=384, 16.8%), and appendicitis (n=370, 16.1%). A total of 21 qualitative interviews were conducted. Twenty interviewees (95.2%) had a positive impression of the clinical workflow, citing enhanced patient care and research opportunities. Fifteen interviewees (75.0%) reported the severity grading system was a useful framework for clinical management, with five participants (25.0%) indicating the system was useful to facilitate clinical communication. Participants identified solutions to overcome barriers to adoption of the clinical workflow.The uniform anatomic severity grading system can be readily integrated into a clinical workflow to facilitate prospective data collection for QI and research. The system is perceived as valuable by users. Educational initiatives that focus on increasing familiarity with the system and its benefits will likely improve adoption of the classification system and the clinical workflow that uses it.Level III.

  View details for DOI 10.1136/tsaco-2020-000552

  View details for PubMedID 32953998

  View details for PubMedCentralID PMC7481073

• Drivers, Beliefs, and Barriers Surrounding Surgical Opioid Prescribing: A Qualitative Study of Surgeons' Opioid Prescribing Habits. The Journal of surgical research Sceats, L. A., Ayakta, N., Merrell, S. B., Kin, C. 2019

  Abstract

  BACKGROUND: Recent data demonstrate that surgeons overprescribe opioids and vary considerably in the amount of opioids prescribed for common procedures. Limited data exist about why and how surgeons develop certain opioid prescribing habits. We sought to identify surgeons' knowledge, attitudes, and beliefs about opioid prescribing and elicit barriers to guideline-based prescribing.METHODS: We conducted qualitative semistructured interviews accompanied by demographic surveys at an academic medical center. Surgical residents and faculty members were selected by maximum variation purposive sampling. We used thematic analysis to identify themes associated with opioid prescribing.RESULTS: Twenty surgical residents and twenty-one surgical faculty members were interviewed. Characteristics of individual surgeons, patients, health care teams, practice environments, and the complex interplay between these domains drove prescribing habits. Attending-resident communication about opioid prescribing was extremely limited. Surgeons received little training and feedback about opioid prescribing and were rarely aware of negative long-term consequences, limiting motivation to change prescribing habits. Although surgeons frequently interacted with pain management physicians to comanage patients postoperatively, few involved pain management physicians in preoperative planning. Perceived barriers to guideline-based prescribing included the following: limitations to electronic prescribing, cross-coverage problems, inadequate time for patient education, and impediments to use of nonopioid alternatives.CONCLUSIONS: Interventions to improve compliance with opioid prescribing guidelines should include surgeon education and personal feedback. Future interventions should aim to improve attending-resident communication about opioid prescribing, reduce hurdles to electronic prescribing, provide clear pain management plans for cross-covering physicians, assess alternative methods for efficient patient education, and maximize use of nonnarcotic pain medications.

  View details for DOI 10.1016/j.jss.2019.10.039

  View details for PubMedID 31767277

• Flipping the Boot Camp: A Multidisciplinary Curriculum for Incoming Interns Lee, E. W., Sapp, R. W., Mazer, L. M., Merrell, S., Lau, J. N., Lin, D. T. ELSEVIER SCIENCE INC. 2019: E184

  View details for Web of Science ID 000492749600437

• Unavoidable Risks: Local Perspectives on Water Contact Behavior and Implications for Schistosomiasis Control in an Agricultural Region of Northern Senegal. The American journal of tropical medicine and hygiene Lund, A. J., Sam, M. M., Sy, A. B., Sow, O. W., Ali, S., Sokolow, S. H., Merrell, S. B., Bruce, J., Jouanard, N., Senghor, S., Riveau, G., Lopez-Carr, D., De Leo, G. A. 2019

  Abstract

  Human schistosomiasis is a snail-borne parasitic disease affecting more than 200 million people worldwide. Direct contact with snail-infested freshwater is the primary route of exposure. Water management infrastructure, including dams and irrigation schemes, expands snail habitat, increasing the risk across the landscape. The Diama Dam, built on the lower basin of the Senegal River to prevent saltwater intrusion and promote year-round agriculture in the drought-prone Sahel, is a paradigmatic case. Since dam completion in 1986, the rural population-whose livelihoods rely mostly on agriculture-has suffered high rates of schistosome infection. The region remains one of the most hyperendemic regions in the world. Because of the convergence between livelihoods and environmental conditions favorable to transmission, schistosomiasis is considered an illustrative case of a disease-driven poverty trap (DDPT). The literature to date on the topic, however, remains largely theoretical. With qualitative data generated from 12 focus groups in four villages, we conducted team-based theme analysis to investigate how perception of schistosomiasis risk and reported preventive behaviors may suggest the presence of a DDPT. Our analysis reveals three key findings: 1) rural villagers understand schistosomiasis risk (i.e., where and when infections occur), 2) accordingly, they adopt some preventive behaviors, but ultimately, 3) exposure persists, because of circumstances characteristic of rural livelihoods. These findings highlight the capacity of local populations to participate actively in schistosomiasis control programs and the limitations of widespread drug treatment campaigns. Interventions that target the environmental reservoir of disease may provide opportunities to reduce exposure while maintaining resource-dependent livelihoods.

  View details for DOI 10.4269/ajtmh.19-0099

  View details for PubMedID 31452497

• Qualitative outcomes of Clean Cut: implementation lessons from reducing surgical infections in Ethiopia. BMC health services research Mattingly, A. S., Starr, N., Bitew, S., Forrester, J. A., Negussie, T., Bereknyei Merrell, S., Weiser, T. G. 2019; 19 (1): 579

  Abstract

  BACKGROUND: Clean Cut is a six month, multi-modal, adaptive intervention aimed at reducing surgical infections through improving six critical perioperative processes: 1) handwashing/skin preparation, 2) surgical gown/drape integrity, 3) antibiotic administration, 4) instrument sterility, 5) gauze counts, and 6) WHO Surgical Safety Checklist use. The aim of this study was to elucidate themes across Clean Cut implementation sites in Ethiopia to improve implementation at future hospitals.METHODS: We conducted semi-structured interviews of 20 clinicians involved in Clean Cut at four hospitals. Participation was limited to Clean Cut team members and included surgeons, anesthetists, operating room (OR) nurses, ward nurses, OR managers, quality improvement personnel, and hospital administrators. Audio recordings were transcribed and coded using qualitative software. A codebook was inductively and iteratively derived between two researchers, tested for inter-rater reliability, and applied to all transcripts. We conducted thematic analysis to derive our final qualitative results.RESULTS: The interviews revealed barriers and facilitators to the implementation of Clean Cut, as well as strategies for future implementation sites. Key barriers included material resource limitations, feelings of job burden, existing gaps in infection prevention education, and communication errors during data collection. Common facilitators included strong hospital leadership support, commitment to improved patient outcomes, and organized Clean Cut training sessions. Future strategies include resource assessments, creating a sense of responsibility among staff, targeted training sessions, and incorporating new standards into daily routine.CONCLUSIONS: The findings of this study highlight the importance of engaging hospital leadership, providers and staff in quality improvement programs, and understanding their work contexts. The identified barriers and facilitators will inform future initiatives in the field of perioperative infection prevention.

  View details for DOI 10.1186/s12913-019-4383-8

  View details for PubMedID 31419972

• Tracking Surgical Education Survey Research Through the APDS Listserv. Journal of surgical education Anderson, T. N., Lee, E. W., Merrell, S. B., Korndorffer, J. R. 2019

  Abstract

  OBJECTIVE: Survey-based studies are cornerstones in medical education research. The Association of Program Directors in Surgery (APDS) listserv offers a method to contact program directors (PD) and residents for such research. To facilitate research beneficial to the APDS, improve the quality of survey-based research and minimize survey fatigue, the APDS research committee (ARC) developed a survey review process to grant access to the listserv for research. This study was conducted to determine the impact of the review process on the quality of survey-based research and eventual publication.DESIGN: This log was systematically reviewed identifying publications resulting from accepted surveys. Publications were categorically analyzed to determine the components of their survey tool methodology, response rate (RR), and medical education research study quality instrument (MERSQI) score.SETTING: The ARC used a 2-reviewer peer-review process for survey distribution requests. The request was either accepted, rejected, or returned for revision. Accepted surveys were distributed through the listserv with an ARC attestation of approval.PARTICIPANTS: A log of all survey requests maintained from 2014 to 2017 and subsequent publications.RESULTS: Thirty-five requests were accepted (40%), 30 were reviewed discovering 10 surveys that led to 12 publications (publication rate of 33%). The average RR was 60% (SD = 29%). Detailed explanations of survey development strategies were reported in 5 (42%), consisting of methods building validity evidence such as expert consensus, modified Delphi method, and pilot group sampling. Half of study participants were PD (50%). MERSQI scores averaged 10 (SD = 1.6).CONCLUSION: Based on those survey research published to date, the ARC survey peer-review process has enabled most accepted surveys to achieve adequate RR. Although the pool of accepted requests is small, it does highlight areas of improvement. With further refinement of the process, including questioning the survey development methods, the process and listserv can be a powerful tool for further research.

  View details for DOI 10.1016/j.jsurg.2019.07.006

  View details for PubMedID 31383613

• Challenges of infertility genetic counseling: Impact on counselors' personal and professional lives JOURNAL OF GENETIC COUNSELING Liker, K., Black, L., Weil, J., Bruce, J., Merrell, S., Bivona, S., Ormond, K. E. 2019; 28 (3): 626–40

  View details for DOI 10.1002/jgc4.1106

  View details for Web of Science ID 000472673100012

• IMPLEMENTATION OF THE ACS NAPRC SYNOPTIC OPERATIVE REPORT: A MIXED METHODS STUDY. Morris, A. M., Bidwell, S., Poles, G., Merrell, S., T Report Comm LIPPINCOTT WILLIAMS & WILKINS. 2019: E94-E95

  View details for Web of Science ID 000467974300113

• STRATEGIES OF CULTURALLY COMPETENT PROVIDERS TO MITIGATE INEQUITIES IN CARE FOR DIVERSE COLORECTAL CANCER PATIENTS: A MIXED METHODS COMPARISON STUDY Miller, M., Liu, M., Merrell, S., Kin, C., Morris, A. M. LIPPINCOTT WILLIAMS & WILKINS. 2019: E82-E83

  View details for Web of Science ID 000467974300092

• Combating Child Summer Food Insecurity: Examination of a Community-Based Mobile Meal Program. Journal of community health Bruce, J. S., De La Cruz, M. M., Lundberg, K., Vesom, N., Aguayo, J., Merrell, S. B. 2019

  Abstract

  Low-income children's access to meals decreases during the summer months due to losing the benefit of the free and reduced-price lunches they normally receive during the school year. Few studies critically examine community-based approaches to providing summer meals. This mixed methods study examined a mobile meal program implemented in a community with large economic disparities. Parents and caregivers who attended the mobile meal program with a child at one of three sites completed surveys that screened for risk of food insecurity and examined access and utilization of community food resources. Interviews with a representative subsample of English- and Spanish-speaking participants elicited an in-depth understanding of food insecurity in the community and perspectives on the mobile meal program. Surveys (n=284) were completed in English (78%) and Spanish (22%). Participants identified primarily as Asian (32%), Latino/Hispanic (29%), and White (27%), with 26% screening positive for risk of food insecurity within the past 12months. Qualitative interviews (n=36) revealed widespread support for meals served in public settings as they were perceived to be welcoming, fostered social interactions, and helped the community at large. Participants described the high cost of living as a key motivation for participating and cited immigration fears as a barrier to accessing public resources. Findings from this study suggest the importance of innovative community-based approaches to serving hard-to-reach children during the summer.

  View details for DOI 10.1007/s10900-019-00675-0

  View details for PubMedID 31073855

• BEHAVIORAL SKILLS OF CULTURALLY COMPETENT PROVIDERS AND PATIENT REPORTED OUTCOMES Miller, M., Liu, M., Kin, C., Merrell, S., Morris, A. W B SAUNDERS CO-ELSEVIER INC. 2019: S1374

  View details for Web of Science ID 000467106005351

• Local and Visiting Physician Perspectives on Short Term Surgical Missions in Guatemala: A Qualitative Study. Annals of surgery Coughran, A. J., Merrell, S. B., Pineda, C., Sceats, L. A., Yang, G. P., Morris, A. M. 2019

  Abstract

  OBJECTIVE: To explore the impact of short-term surgical missions (STMs) on medical practice in Guatemala as perceived by Guatemalan and foreign physicians.SUMMARY BACKGROUND DATA: STMs send physicians from high-income countries to low and middle-income countries to address unmet surgical needs. Although participation among foreign surgeons has grown, little is known of the impact on the practice of foreign or local physicians.METHODS: Using snowball sampling, we interviewed 22 local Guatemalan and 13 visiting foreign physicians regarding their perceptions of the impact of Guatemalan STMs. Interviews were transcribed verbatim, iteratively coded, and analyzed to identify emergent themes. Findings were validated through triangulation and searching for disconfirming evidence.RESULTS: We identified 2 overarching domains. First, the delivery of surgical care by both Guatemalan and foreign physicians was affected by practice in the STM setting. Differences from usual practice manifested as occasionally inappropriate utilization of skills, management of postoperative complications, the practice of perioperative care versus "pure surgery," and the effect on patient-physician communication and trust. Second, both groups noted professional and financial implications of participation in the STM.CONCLUSIONS: While Guatemalan physicians reported a net benefit of STMs on their careers, they perceived STMs as an imperfect solution to unmet surgical needs. They described missed opportunities for developing local capacity, for example through education and optimal resource planning. Foreign physicians described costs that were manageable and high personal satisfaction with STM work. STMs could enhance their impact by strengthening working relationships with local physicians and prioritizing sustainable educational efforts.This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0.

  View details for PubMedID 31009390

• Attending Surgeons Differ From Other Team Members in Their Perceptions of Operating Room Communication. The Journal of surgical research Grade, M. M., Tamboli, M. K., Bereknyei Merrell, S., Mueller, C., Girod, S. 2019; 235: 105–12

  Abstract

  BACKGROUND: The Joint Commission has repeatedly recognized inadequate communication as a top contributing factor to medical error in the operating room (OR). The goal of this qualitative study was to develop a deeper and more nuanced understanding of OR communication dynamics, specifically across different interdisciplinary roles and to recommend specific interventions based on these findings.METHODS: We performed a two-phase qualitative study at one academic institution to explore contributors and barriers to optimal OR communication. The first phase consisted of interviews with OR team members, including surgery and anesthesiology attending faculty and residents, medical students, and OR staff. We qualitatively analyzed the transcripts of these interviews using a deductive approach. We additionally verified the findings through subsequent focus groups.RESULTS: Most OR team members, independent of role, noted that team familiarity, clear role expectations, and formal communication are vital for effective OR communication. There was a disconnect between attending surgeons and the rest of the OR team: Whereas the majority of team members noted the importance of procedural-focused discussions, team hierarchy, and the attending surgeon's mood as major contributors to successful OR communication, the attending surgeons did not recognize their own ability to contribute to optimal OR communication in these regards.CONCLUSIONS: Although team familiarity was important to all participants in the OR, we noted that attending surgeons differed in their perceptions of OR communications from other members of the team, including attending anesthesiologists, residents, medical students, and nurses. Our findings support the need for (1) improved awareness of the impact of a team members's content and character of communication, particularly by attending surgeons; and (2) targeted initiatives to prioritize team familiarity in OR scheduling.

  View details for PubMedID 30691783

• Challenges of infertility genetic counseling: Impact on counselors' personal and professional lives. Journal of genetic counseling Liker, K., Black, L., Weil, J., Bruce, J., Bereknyei Merrell, S., Bivona, S., Ormond, K. E. 2019

  Abstract

  Infertility genetic counselors (GCs) work with patients struggling to become pregnant who desire genetic testing of embryos and preconception genetic testing or carrier screening. Because personal and professional challenges have not been examined in this relatively new genetic counseling specialty, we investigated the difficulties infertility GCs face in their professional roles. Past and present infertility GCs in patient-facing roles were recruited through the National Society of Genetic Counselors. Purposive sampling ensured participants were diverse in clinical setting, reproductive history, and other demographics. Nineteen participants completed a semi-structured interview, at which time data saturation occurred. Thematic analysis revealed infertility GCs consider their patients more emotionally stressed than patients in other specialties. Infertility GCs relate easily to patients, build long-term patient relationships, and feel invested in the reproductive successes of patients. Participants reported heightened concern for their own fertility, leading to high personal uptake of preconception genetic and fertility tests. Participants described discomfort when counseling while visibly pregnant and reluctance to disclose their own reproductive histories. Further research is needed on the complex interactions of GCs' personal and professional lives. Peer support groups and professional dialogue about the personal effects of the role may be beneficial for infertility GCs.

  View details for PubMedID 30821877

• Attending Surgeons Differ From Other Team Members in Their Perceptions of Operating Room Communication JOURNAL OF SURGICAL RESEARCH Grade, M. M., Tamboli, M. K., Merrell, S., Mueller, C., Girod, S. 2019; 235: 105–12

  View details for DOI 10.1016/j.jss.2018.09.030

  View details for Web of Science ID 000456777000015

• Preclinical curriculum of prospective case-based teaching with faculty- and student-blinded approach BMC MEDICAL EDUCATION Waliany, S., Caceres, W., Merrell, S., Thadaney, S., Johnstone, N., Osterberg, L. 2019; 19

  View details for DOI 10.1186/s12909-019-1453-x

  View details for Web of Science ID 000456530600001

• Preclinical curriculum of prospective case-based teaching with faculty- and student-blinded approach. BMC medical education Waliany, S., Caceres, W., Merrell, S. B., Thadaney, S., Johnstone, N., Osterberg, L. 2019; 19 (1): 31

  Abstract

  BACKGROUND: Case-based teaching with real patient cases provides benefit of simulating real-world cognition. However, while clinical practice involves a prospective approach to cases, preclinical instruction typically involves full disclosure of case content to faculty, introducing hindsight bias into faculty teaching in medical curricula.METHODS: During 2015-2018, we piloted an optional medical school curriculum involving 6-7 one-hour sessions over a 3-month period each year. New groups enrolled each year from first- and second-year classes. A facilitator provided a blinded physician discussant and blinded students with case information during and not in advance of each session, allowing prospective case-based discussions. Cases were based on real patients treated in the Department of Medicine. Clinical material was presented in the chronologic sequence encountered by treating physicians. Content covered a median of 5 patient visits/case (range: 2-10) spanning over months. A 14-item survey addressing components of the reporter-interpreter-manager-educator (RIME) scheme was developed and used to compare self-reported clinical skills between course participants and non-participant controls during the 2016 course iteration.RESULTS: This elective curriculum at Stanford School of Medicine involved 170 preclinical students (22.7% of 750 eligible). During the 2016 course iteration, a quasi-experimental study compared self-reported clinical skills between 29 course participants (response rate: 29/49 [59.2%]) and 35 non-participant controls (response rate: 35/132 [26.5%]); students self-assessed clinical skills via the RIME-based survey developed for the course. Two-sample t-tests compared the change in pre- and post-course skills between course participants and non-participants. Of 15 Department of Medicine faculty members invited as discussants, 12 (80%) consented to participate. Compared with controls, first-year participants self-assessed significantly greater improvement in understanding how clinicians reason through cases step-by-step to arrive at diagnoses (P=0.049), work through cases in longitudinal settings (P=0.049), and share information with patients (P=0.047). Compared with controls, second-year participants self-assessed significantly greater improvement (P=0.040) in understanding how clinicians reason through cases step-by-step to arrive at diagnoses.CONCLUSIONS: Prospective case-based discussions with blinding offaculty and students to clinical content circumvents hindsight bias and may impart real-world cognitive skills as determined by student self-report.

  View details for PubMedID 30674302

• Service through surgery: A quasi-experimental comparison study on the impact of a preclinical seminar course on diverse mentorship and attitudes towards the underserved. American journal of surgery Steinberg, J. R., Bryant, T. S., Carroll, A. L., Marin-Nevarez, P. n., Lee, E. W., Anderson, T. N., Merrell, S. B., Lau, J. N. 2019

  Abstract

  Increased surgical workforce diversity diminishes health disparities.Researchers recruited and nonrandomly enrolled participants into intervention and comparison groups for a quasi-experimental study of the impact of a seminar course on student exposure to diverse mentorship and service through surgery. All metrics were analyzed with chi-squared and paired t-tests.109 students participated (34 intervention, 75 comparison). There were significant differences in the percentage of participants that newly met a surgeon of their race (intervention, comparison: 100%, 25%), their race and gender (80%, 21%), their religion (23%, 9%), and who completed health disparities research (90%, 45%, p-value for all <0.05). There was a nonsignificant change in participants' attitudes towards underserved populations in intervention and comparison groups.This preclinical surgery seminar course increased exposure of underrepresented students to surgeons from diverse backgrounds and may impact student attitudes towards the underserved. This class represents a replicable model for increasing mentorship.

  View details for DOI 10.1016/j.amjsurg.2019.07.031

  View details for PubMedID 31376950

• Perception and confidence of medical students in informed consent: A core EPA. Surgery Anderson, T. N., Aalami, L. R., Lee, E. W., Merrell, S. B., Sgroi, M. D., Lin, D. T., Lau, J. N. 2019

  Abstract

  Informed consent discussions have been identified as a core entrustable professional activity for medical students by the Association of American Medical Colleges. Medical students, however, rarely receive formal instruction on how to appropriately conduct informed consent discussions before residency, resulting in inconsistent levels of experience and deficiencies in performance. This study explores medical students' understanding of the elements of informed consent discussions and their readiness to perform a comprehensive informed consent discussion.Using expert consensus, cognitive interviews, and piloting, we iteratively developed a 15-item survey aligned with entrustable professional activity guidelines concerning informed consent discussions consisting of multiple choice, free text, and 5-point Likert-type questions. The instrument covered domains of experience, confidence, medical-legal knowledge, and recall of informed consent discussion elements. The full survey was distributed anonymously to undergraduate medical students at our institution. An abbreviated survey was administered to postgraduate students who were new interns at our institution. Responses were analyzed quantitatively using descriptive statistics. The free text data were coded for inclusion in this analysis.A total of 75 undergraduate medical students across all years responded (response rate [RR] = 86%), and 34 (RR = 77%) of the postgraduate students who were new interns participated. A total of 45 (75%) undergraduate medical students reported no training on informed consent discussions, and 9 (15%) undergraduate medical students had never witnessed an informed consent discussion. The undergraduate medical students agreed that informed consent discussions could be legally performed by residents and advance practice providers but were unsure whether the same applied to medical students. On a 5-point scale (anchored to "Not at all," "Somewhat," and "Extremely"), they were "somewhat confident" in their ability to perform an informed consent discussion. When asked to list the 7 elements of an informed consent discussion, 2 undergraduate medical students (3%) were able to identify all the elements. Although 3 undergraduate medical students (9%) had experience leading an informed consent discussion and 11 (32%) reported formal instruction in informed consent, the ability (3.7 ± 0.9 standard deviation [SD]) of the postgraduate students who were new interns to recall the 7 elements was similar to that of the undergraduate medical students (3.4 ± 1.2 SD); P = .31.These findings suggest that undergraduate medical students and postgraduate students who are new interns are not confident or competent in their ability to perform an appropriate informed consent discussion. Our study findings support the creation of a needs-based, entrustable professional activity-aligned informed consent discussion teaching program and the need for an ongoing evaluation of the success of such a program.

  View details for DOI 10.1016/j.surg.2019.11.012

  View details for PubMedID 31879088

• Education Research: Understanding barriers to goals of care communication for neurology trainees. Neurology Goyal, T. n., Hasty, B. N., Bereknyei Merrell, S. n., Gold, C. A. 2019; 93 (8): 362–66

  Abstract

  To describe the perspectives of neurology residents regarding barriers to effective goals of care discussions and to identify residents' current and desired educational strategies to improve goals of care communication.All neurology residents at our institution were invited to voluntarily participate in focus groups. Residents were organized into 3 focus groups by year of training. Moderators asked residents open-ended questions about current goals of care communication practice and ideas for improving the frequency and effectiveness of goals of care discussions. All responses were audiorecorded, transcribed, and de-identified. Transcripts of the focus groups were independently read and coded by members of the research team. We performed thematic analysis to identify and systematize relationships across coded data.Twenty out of 29 neurology residents participated in the focus groups. We identified 3 overarching domains impeding goals of care communication: patient factors, resident factors, and systems factors. Residents proposed specific desired strategies to address these 3 domains with the goal of improving the frequency and efficacy of goals of care communication. The desired strategies included receiving feedback from patients and families, developing resident-focused educational opportunities through direct observation and coaching, and systems changes by documenting goals of care discussions.Neurology residents identify multiple barriers to effective goals of care communication and propose specific desired strategies for improvement. This detailed input from residents will be incorporated into future curricular interventions to improve confidence and skill in leading goals of care discussions.

  View details for DOI 10.1212/WNL.0000000000007975

  View details for PubMedID 31427487

• Validity Evidence for a Knowledge Assessment Tool for a Mastery Learning Scrub Training Curriculum. Academic medicine : journal of the Association of American Medical Colleges Hasty, B. N., Lau, J. N., Tekian, A. n., Miller, S. E., Shipper, E. S., Bereknyei Merrell, S. n., Lee, E. W., Park, Y. S. 2019

  Abstract

  To examine the validity evidence for a scrub training knowledge assessment tool to demonstrate the utility and robustness of a multimodal, entrustable professional activity (EPA)-aligned, mastery learning scrub training curriculum.Validity evidence was collected for the knowledge assessment used in the scrub training curriculum at Stanford University School of Medicine from April 2017-June 2018. The knowledge assessment had 25 selected response items that mapped to curricular objectives, EPAs, and operating room policies. A mastery passing standard was established using the Mastery Angoff and Patient-Safety approaches. Learners were assessed pre-curriculum, post-curriculum, and 6 months after the curriculum.From April 2017-June 2018, 220 medical and physician assistant students participated in the scrub training curriculum. The mean pre- and post-curriculum knowledge scores were 74.4% (SD = 15.6) and 90.1% (SD = 8.3), respectively, yielding a Cohen's d = 1.10, P <.001. The internal reliability of the assessment was 0.71. Students with previous scrub training performed significantly better on the pre-curriculum knowledge assessment than those without previous training (81.9% [SD = 12.6] vs. 67.0% [SD = 14.9]; P <.001). The mean item difficulty was 0.74, and the mean item discrimination index was 0.35. The Mastery Angoff overall cut score was 92.0%.This study describes the administration of and provides validity evidence for a knowledge assessment tool for a multimodal, EPA-aligned, mastery-based curriculum for scrub training. The authors support the use of scores derived from this test for assessing scrub training knowledge among medical and physician assistant students.

  View details for DOI 10.1097/ACM.0000000000003007

  View details for PubMedID 31577588

• Introductory Surgical Skills Course: Technical Training and Preparation for the Surgical Environment. MedEdPORTAL : the journal of teaching and learning resources Miller, S., Shipper, E., Hasty, B., Bereknyei Merrell, S., Lee, E. W., Lin, D., Lau, J. N. 2018; 14: 10775

  Abstract

  Introduction: Early exposure to surgery in a positive learning environment can contribute to increased student interest. The primary objectives of this study included developing increased comfort in the operating room (OR) environment, confidence in surgical skills, and mentorship for students interested in surgery.Methods: The course comprised seven 2-hour sessions covering both nontechnical and technical skills facilitated by attending and resident surgeons. Sessions included nontechnical skills training, basic knot tying and suturing, laparoscopic surgical skills, and high-fidelity operative simulations on animal and cadaver models. The curriculum also matched students with faculty mentors in order to scrub into operative cases. Surveys assessing self-reported comfort in the OR, confidence levels in surgical skills, and whether students had mentors in surgery were distributed before and after the course.Results: Thirty preclinical medical students were enrolled in the course in 2016 and an additional 41 students in 2017. Results showed increased confidence in all skills and in comfort in the OR, as well as increased surgeon mentorship. Thirty-two students who completed the course entered clinical rotations in 2018 and, when surveyed, reported increased confidence in the aforementioned domains and in their preparedness for their surgery clerkship, compared to 49 peers who had not completed the course.Discussion: The course successfully increased comfort in the OR, increased confidence in performing surgical skills, and provided students with mentors in surgery, all of which will hopefully foster positive experiences during their surgery clerkship and ultimately increase their consideration of surgery as a career.

  View details for PubMedID 30800975

• Exploring the Medical and Psychosocial Concerns of Adolescents and Young Adults With Craniofacial Microsomia: A Qualitative Study CLEFT PALATE-CRANIOFACIAL JOURNAL Hamilton, K. V., Ormond, K. E., Moscarello, T., Bruce, J. S., Merrell, S., Chang, K. W., Bernstein, J. A. 2018; 55 (10): 1430–39

  View details for DOI 10.1177/1055665618768542

  View details for Web of Science ID 000446871400011

• Psychologist-Facilitated Group Sessions for Residents: A Worthwhile Investment? Lin, D. T., Qiu, W., Lai, C., Post, L. I., Merrell, S., Lau, J. N., Salles, A., Mueller, C. M. ELSEVIER SCIENCE INC. 2018: E53–E54

  View details for DOI 10.1016/j.jamcollsurg.2018.08.138

  View details for Web of Science ID 000447772500120

• Medical Student Mistreatment: Coping Strategies and Resilience on the Surgery Clerkship Hasty, B. N., Merrell, S., Brandford, E. C., Lee, E. W., Lau, J. N. ELSEVIER SCIENCE INC. 2018: E207–E208

  View details for DOI 10.1016/j.jamcollsurg.2018.08.561

  View details for Web of Science ID 000447772500499

• Emotional Intelligence as a Possible Safeguard to Surgeon Wellness Lee, E. W., Hasty, B. N., Lau, J. N., Merrell, S., Hawn, M. T., Shanafelt, T., Salles, A., Lin, D. T. ELSEVIER SCIENCE INC. 2018: S145

  View details for DOI 10.1016/j.jamcollsurg.2018.07.307

  View details for Web of Science ID 000447760600278

• Surgeon Emotional Intelligence Is Strongly Correlated with Patient Satisfaction Lee, E. W., Hasty, B. N., Lau, J. N., Merrell, S., Hawn, M. T., Shanafelt, T., Salles, A., Lin, D. T. ELSEVIER SCIENCE INC. 2018: S164–S165

  View details for DOI 10.1016/j.jamcollsurg.2018.07.350

  View details for Web of Science ID 000447760600321

• The long-term impact of a comprehensive scholarly concentration program in biomedical ethics and medical humanities BMC MEDICAL EDUCATION Liu, E., Batten, J., Merrell, S., Shafer, A. 2018; 18: 204

  Abstract

  There is a strong and growing interest in biomedical ethics and medical humanities (BEMH) within medical education for facilitating key components of medical professionalism and ethics, clinical communication and observational skills, and self-care and reflective practices. Consequently, United States (US) medical institutions have begun to incorporate BEMH through formal Scholarly Concentrations (SCs). This is the first study to examine the impact of a US BEMH SC, from student experience in medical school to post-graduate development, as perceived by graduate physicians.Graduated students who participated in the BEMH SC or did extensive BEMH research prior to the BEMH SC's establishment (n = 57) were sampled for maximum variation across graduating years. In telephone surveys and interviews, participants discussed the perceived impact of the BEMH SC on (a.) student experience during medical school and (b.) post-graduate development. Interviews were audiotaped, transcribed, and de-identified. The authors iteratively generated a codebook; two raters coded independently, adjudicated codes, and completed inter-rater reliability (IRR) tests. The authors subsequently conducted a team-based thematic analysis, identifying emergent themes.Nineteen BEMH graduates were interviewed. Results were analyzed according to (a.) student experience and (b.) post-graduate development. Overall, respondents perceived impacts in reinforcing knowledge and skills in clinical ethics; solidifying self-care and reflective practices; refining a sense of professional identity and integrity for ethically challenging situations; and promoting student skills, productivity, and later careers involving BEMH.A comprehensive US BEMH SC achieved the purported aims of BEMH in medical education, with graduate physicians perceiving persisting effects into clinical practice. Furthermore, the structure and format of a SC may offer additional advantages in promoting student scholarly skill and productivity, career development, and professional identity formation-core competencies identified across clinical training and ethics programs. Our findings indicate that a BEMH SC is effective in achieving a range of desired immediate and post-graduate effects and represent a particularly promising venue for BEMH in medical education. We believe these findings to be of critical significance to medical educators and administrators when considering how best to incorporate BEMH into SCs and medical curricula.

  View details for DOI 10.1186/s12909-018-1311-2

  View details for Web of Science ID 000442961400002

  View details for PubMedID 30153822

  View details for PubMedCentralID PMC6114241

• Use of an Emergency Manual During an Intraoperative Cardiac Arrest by an Interprofessional Team: A Positive-Exemplar Case Study of a New Patient Safety Tool JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Merrell, S., Gaba, D. M., Agarwala, A., Cooper, J. B., Nevedal, A. L., Asch, S. M., Howard, S. K., Goldhaber-Fiebert, S. N. 2018; 44 (8): 477–84

  Abstract

  An emergency manual (EM) is a set of evidence-based crisis checklists, or cognitive aids, that can improve team performance. EMs are used in other safety-critical industries, and health care simulation studies have shown their efficacy, but use in clinical settings is nascent. A case study was conducted on the use of an EM during one intraoperative crisis, which entailed the assessment of the impact of the EM's use on teamwork and patient care and the identification of lessons for effectively using EMs during future clinical crises.In a case study of a single crisis, an EM was used during a cardiac arrest at a tertiary care hospital that had systematically implemented perioperative EMs. Semistructured interviews were conducted with all six clinicians present, interview transcripts were iteratively coded, and thematic analysis was performed.All clinician participants stated that EM use enabled effective team functioning via reducing stress of individual clinicians, fostering a calm work environment, and improving teamwork and communication. These impacts in turn improved the delivery of patient care during a clinical crisis and influenced participants' intended EM use during future appropriate crises.In this positive-exemplar case study, an EM was used to improve delivery of evidence-based patient care through effective clinical team functioning. EM use must complement rather than replace good clinician education, judgment, and teamwork. More broadly, understanding why and how things go well via analyzing positive-exemplar case studies, as a converse of root cause analyses for negative events, can be used to identify effective applications of safety innovations.

  View details for PubMedID 30071967

• Assessment of Programs Aimed to Decrease or Prevent Mistreatment of Medical Trainees. JAMA network open Mazer, L. M., Bereknyei Merrell, S., Hasty, B. N., Stave, C., Lau, J. N. 2018; 1 (3): e180870

  Abstract

  Mistreatment of medical students is pervasive and has negative effects on performance, well-being, and patient care.To document the published programmatic and curricular attempts to decrease the incidence of mistreatment.PubMed, Scopus, ERIC, the Cochrane Library, PsycINFO, and MedEdPORTAL were searched. Comprehensive searches were run on "mistreatment" and "abuse of medical trainees" on all peer-reviewed publications until November 1, 2017.Citations were reviewed for descriptions of programs to decrease the incidence of mistreatment in a medical school or hospital with program evaluation data. A mistreatment program was defined as an educational effort to reduce the abuse, mistreatment, harassment, or discrimination of trainees. Studies of the incidence of mistreatment without description of a program, references to a mistreatment program without outcome data, or a program that has never been implemented were excluded.Authors independently reviewed all retrieved citations. Articles that any author found to meet inclusion criteria were included in a full-text review. The data extraction form was developed based on the guidelines for Best Evidence in Medical Education. An assessment of the study quality was conducted using a conceptual framework of 6 elements essential to the reporting of experimental studies in medical education.A descriptive review of the interventions and outcomes is presented along with an analysis of the methodological quality of the studies. A separate review of the MedEdPORTAL mistreatment curricula was conducted.Of 3347 citations identified, 10 studies met inclusion criteria. Of the programs included in the 10 studies, all were implemented in academic medical centers. Seven programs were in the United States, 1 in Canada, 1 in the United Kingdom, and 1 in Australia. The most common format was a combination of lectures, workshops, and seminars over a variable time period. Overall, quality of included studies was low and only 1 study included a conceptual framework. Outcomes were most often limited to participant survey data. The program outcome evaluations consisted primarily of surveys and reports of mistreatment. All of the included studies evaluated participant satisfaction, which was mostly qualitative. Seven studies also included the frequency of mistreatment reports; either surveys to assess perception of the frequency of mistreatment or the frequency of reports via official reporting channels. Five mistreatment program curricula from MedEdPORTAL were also identified; of these, only 2 presented outcome data.There are very few published programs attempting to address mistreatment of medical trainees. This review identifies a gap in the literature and provides advice for reporting on mistreatment programs.

  View details for DOI 10.1001/jamanetworkopen.2018.0870

  View details for PubMedID 30646041

  View details for PubMedCentralID PMC6324298

• Assessment of Programs Aimed to Decrease or Prevent Mistreatment of Medical Trainees JAMA NETWORK OPEN Mazer, L. M., Merrell, S., Hasty, B. N., Stave, C., Lau, J. N. 2018; 1 (3)

  View details for DOI 10.1001/jamanetworkopen.2018.0870

  View details for Web of Science ID 000452641400015

• Early Childhood Learning and the Pediatrician: A Qualitative Study Among Diverse, Low-Income Caregivers JOURNAL OF DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS Steinberg, J., Bruce, J. S., Marin-Nevarez, P., Phan, K., Merrell, S., Chamberlain, L. J. 2018; 39 (5): 376–86

  View details for DOI 10.1097/DBP.0000000000000564

  View details for Web of Science ID 000441393000004

• Promoting student case creation to enhance instruction of clinical reasoning skills: a pilot feasibility study. Advances in medical education and practice Chandrasekar, H., Gesundheit, N., Nevins, A. B., Pompei, P., Bruce, J., Merrell, S. B. 2018; 9: 249-257

  Abstract

  It is a common educational practice for medical students to engage in case-based learning (CBL) exercises by working through clinical cases that have been developed by faculty. While such faculty-developed exercises have educational strengths, there are at least two major drawbacks to learning by this method: the number and diversity of cases is often limited; and students decrease their engagement with CBL cases as they grow accustomed to the teaching method. We sought to explore whether student case creation can address both of these limitations. We also compared student case creation to traditional clinical reasoning sessions in regard to tutorial group effectiveness, perceived gains in clinical reasoning, and quality of student-faculty interaction.Ten first-year medical students participated in a feasibility study wherein they worked in small groups to develop their own patient case around a preassigned diagnosis. Faculty provided feedback on case quality afterwards. Students completed pre- and post-self-assessment surveys. Students and faculty also participated in separate focus groups to compare their case creation experience to traditional CBL sessions.Students reported high levels of team engagement and peer learning, as well as increased ownership over case content and understanding of clinical reasoning nuances. However, students also reported decreases in student-faculty interaction and the use of visual aids (P < 0.05).The results of our feasibility study suggest that student-generated cases can be a valuable adjunct to traditional clinical reasoning instruction by increasing content ownership, encouraging student-directed learning, and providing opportunities to explore clinical nuances. However, these gains may reduce student-faculty interaction. Future studies may be able to identify an improved model of faculty participation, the ideal timing for incorporation of this method in a medical curriculum, and a more rigorous assessment of the impact of student case creation on the development of clinical reasoning skills.

  View details for DOI 10.2147/AMEP.S155481

  View details for PubMedID 29692641

  View details for PubMedCentralID PMC5903478

• Interprofessional Collaboration: A Qualitative Study of Non-Physician Perspectives on Resident Competency JOURNAL OF GENERAL INTERNAL MEDICINE Garth, M., Millet, A., Shearer, E., Stafford, S., Merrell, S., Bruce, J., Schillinger, E., Aaronson, A., Svec, D. 2018; 33 (4): 487–92

  Abstract

  The Association of American Medical Colleges (AAMC) includes the ability to collaborate in an interprofessional team as a core professional activity that trainees should be able to complete on day 1 of residency (Med Sci Educ. 26:797-800, 2016). The training that medical students require in order to achieve this competency, however, is not well established (Med Sci Educ. 26:457-61, 2016), and few studies have examined non-physician healthcare professionals' perspectives regarding resident physicians' interprofessional skills.This study aims to describe non-physicians' views on barriers to collaboration with physicians, as well as factors that contribute to good collaborative relationships.Nurses, social workers, case managers, dietitians, rehabilitation therapists, and pharmacists at one academic medical center, largely working in the inpatient setting.A qualitative study design was employed. Data were collected from individual interviews and focus groups comprising non-physician healthcare professionals.Knowledge gaps identified as impeding interprofessional collaboration included inadequate understanding of current roles, potential roles, and processes for non-physician healthcare professionals. Specific physician behaviors that were identified as contributing to good collaborative relationships included mutual support such as backing up other team members and prioritizing multidisciplinary rounds, and communication including keeping team members informed, asking for their input, physicians explaining their rationale, and practicing joint problem-solving with non-physicians.Discussion of how physician trainees can best learn to collaborate as members of an interprofessional team must include non-physician perspectives. Training designed to provide medical students and residents with a better understanding of non-physician roles and to enhance mutual support and communication skills may be critical in achieving the AAMC's goals of making physicians effective members of interprofessional teams, and thus improving patient-centered care. We hope that medical educators will include these areas identified as important by non-physicians in targeted team training for their learners.

  View details for PubMedID 29204972

  View details for PubMedCentralID PMC5880757

• Early Childhood Learning and the Pediatrician: A Qualitative Study Among Diverse, Low-Income Caregivers. Journal of developmental and behavioral pediatrics : JDBP Steinberg, J. R., Bruce, J. S., Marin-Nevarez, P., Phan, K., Merrell, S. B., Chamberlain, L. J. 2018

  Abstract

  OBJECTIVE: School readiness by kindergarten entry is associated with increased high school graduation, decreased juvenile arrest, and better long-term health. Inadequate early childhood learning (ECL) disproportionately affects low-income children. Pediatricians have near-universal access to children younger than 5 years but remain an underused ECL resource. This study examined caregivers' perceptions of ECL, the role of the pediatrician and pediatric office, and the use of community-based ECL resources among diverse, low-income caregivers whose children were not enrolled in preschool.METHODS: Using community-engaged strategies, caregivers were recruited to participate in in-depth focus groups (FGs). Demographic and FG data were collected in English, Spanish, and Vietnamese. Qualitative data were analyzed with iterative transcript-based coding and theme analysis.RESULTS: From June 2015 to August 2015, 69 low-income mothers (n = 46), fathers (n = 8), and grandparents (n = 15) from African-American (33%), Latino (32%), and Vietnamese (35%) communities participated in 12 FGs. Caregivers across groups wanted pediatricians to act as ECL experts and to provide ECL services. Caregivers valued ECL, especially when delivered by trusted sources. Utilization and perception of community ECL resources varied among groups. The greatest variation included different preferences for resource setting, accessibility, and acceptability, especially cultural acceptability. Each individual and groups' unique, and occasionally adverse, experiences and financial and logistical considerations informed ECL preferences.CONCLUSION: This exploratory study brings forth diverse caregivers' perspectives regarding the role of pediatricians in ECL and their desire for pediatricians to be an access point for high-quality, affordable ECL services. Caregivers' preferences regarding ECL programming may inform clinic-based pediatric ECL programming.

  View details for PubMedID 29538187

• Determining the educational value of a technical and nontechnical skills medical student curriculum. The Journal of surgical research Shipper, E. S., Miller, S. E., Hasty, B. N., De La Cruz, M. M., Merrell, S. B., Lin, D. T., Lau, J. N. 2018; 225: 157–65

  Abstract

  Residency application rates to general surgery remain low. The purpose of this study is to describe the educational value of a curriculum designed to increase preclinical medical student interest in surgical careers to better understand the process by which medical students decide to pursue a career in surgery.We used qualitative methodology to describe the educational value of a technical and nontechnical skills curriculum offered to preclinical medical students at our institution. We conducted semistructured interviews of students and instructors who completed the curriculum in 2016. The interviews were recorded, transcribed, and inductively coded. The data were analyzed for emergent themes.A total of eight students and five instructors were interviewed. After analysis of 13 transcripts, four themes emerged: (1) The course provides a safe environment for learning, (2) acquisition and synthesis of basic technical skills increases preclinical student comfort in the operating room, (3) developing relationships with surgeons creates opportunities for extracurricular learning and scholarship, and (4) operative experiences can inspire students to explore a future career in surgery.These factors can help inform the design of future interventions to increase student interest, with the ultimate goal of increasing the number of students who apply to surgical residency programs.

  View details for PubMedID 29605027

• Information-Seeking about Anxiety and Perceptions about Technology to Teach Coping Skills in Older Veterans CLINICAL GERONTOLOGIST Zapata, A. L., Beaudreau, S. A., O'Hara, R., Merrell, S., Bruce, J., Garrison-Diehn, C., Gould, C. E. 2018; 41 (4): 346–56

  Abstract

  We sought to learn where older veterans seek information about anxiety and coping. Due to increasing use of technology in health care, we also explored benefits and barriers of using technology to teach coping skills.Twenty veterans (mean age = 69.5 years, SD = 7.3) participated in semi-structured interviews in which we inquired about where they seek information about anxiety. We explored quantitative and qualitative differences for veterans with high versus low anxiety. In follow-up focus groups, we examined opinions about learning coping skills using technology.Though veterans primarily named health care professionals as sources of information about anxiety, online searches and reading books were frequently mentioned. Reported benefits of using technology were convenience and standardized instruction of coping skills. Barriers included lack of interaction and frustration with technology usability.Older veterans use multiple sources, heavily rely on interpersonal sources (e.g., professionals, friends), and employ varied search strategies regarding how to cope with anxiety. Using technology to teach coping skills was generally acceptable to older veterans.Health care professionals could guide patients towards credible online and book sources. Providing instruction about using technology may help older adults use technology to learn coping skills.

  View details for PubMedID 28967837

• Exploring the Medical and Psychosocial Concerns of Adolescents and Young Adults With Craniofacial Microsomia: A Qualitative Study. The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association Hamilton, K. V., Ormond, K. E., Moscarello, T. n., Bruce, J. S., Bereknyei Merrell, S. n., Chang, K. W., Bernstein, J. A. 2018: 1055665618768542

  Abstract

  This study explores the experiences of adolescents and young adults with craniofacial microsomia, including the impact of growing up with this craniofacial condition on daily life and sense of self. The results may guide future research on optimally supporting individuals with craniofacial microsomia during this critical life phase.Participants were recruited through a craniofacial center, online patient support groups, and social media sites. Eleven individual semistructured interviews with participants between 12 and 22 years old were conducted by a single interviewer, transcribed, iteratively coded, and thematically analyzed.Five themes were evident in the data: (1) impact on personal growth and character development, (2) negative psychosocial impact, (3) deciding to hide or reveal the condition, (4) desire to make personal surgical decisions, and (5) struggles with hearing loss.We identified both medical and psychosocial concerns prevalent among adolescents with craniofacial microsomia. Although adolescents with craniofacial microsomia exhibit considerable resilience, the challenges they face impact their sense of self and should be addressed through psychosocial support and counseling. Further research should investigate the potential benefit of the wider use of hearing aids, as well as the involvement of patients in decision-making about reconstructive ear surgery.

  View details for PubMedID 29634364

• Promoting student case creation to enhance instruction of clinical reasoning skills: a pilot feasibility study Advances in Medical Education and Practice Chandrasekar, H., Gesundheit, N., Nevins, A. B., Pompei, P., Bruce, J., Bereknyei Merrell, S. 2018; 2018 (9): 249-257

  Abstract

  It is a common educational practice for medical students to engage in case-based learning (CBL) exercises by working through clinical cases that have been developed by faculty. While such faculty-developed exercises have educational strengths, there are at least two major drawbacks to learning by this method: the number and diversity of cases is often limited; and students decrease their engagement with CBL cases as they grow accustomed to the teaching method. We sought to explore whether student case creation can address both of these limitations. We also compared student case creation to traditional clinical reasoning sessions in regard to tutorial group effectiveness, perceived gains in clinical reasoning, and quality of student-faculty interaction.Ten first-year medical students participated in a feasibility study wherein they worked in small groups to develop their own patient case around a preassigned diagnosis. Faculty provided feedback on case quality afterwards. Students completed pre- and post-self-assessment surveys. Students and faculty also participated in separate focus groups to compare their case creation experience to traditional CBL sessions.Students reported high levels of team engagement and peer learning, as well as increased ownership over case content and understanding of clinical reasoning nuances. However, students also reported decreases in student-faculty interaction and the use of visual aids (P < 0.05).The results of our feasibility study suggest that student-generated cases can be a valuable adjunct to traditional clinical reasoning instruction by increasing content ownership, encouraging student-directed learning, and providing opportunities to explore clinical nuances. However, these gains may reduce student-faculty interaction. Future studies may be able to identify an improved model of faculty participation, the ideal timing for incorporation of this method in a medical curriculum, and a more rigorous assessment of the impact of student case creation on the development of clinical reasoning skills.

  View details for DOI 10.2147/AMEP.S155481

  View details for PubMedCentralID PMC5903478

• Medical student perceptions of a mistreatment program during the surgery clerkship. American journal of surgery Hasty, B. N., Miller, S. E., Bereknyei Merrell, S. n., Lin, D. T., Shipper, E. S., Lau, J. N. 2018

  Abstract

  Medical student mistreatment remains a concern, particularly in the surgery clerkship. This is a single academic institution's report of medical student perceptions of a mistreatment program embedded in the surgery clerkship.Students who completed the surgery clerkship and the mistreatment program volunteered to be interviewed individually or in focus groups. The interviews were transcribed and qualitatively analyzed.Twenty-four medical students were interviewed and nine transcripts were obtained. Codes were identified independently then nested into four codes: Student Growth, Faculty Champion and Team, Student Perspectives on Surgical Culture, and Program Methods. Rank orders were then calculated for each major code.Our mistreatment program has shown that providing students with an opportunity to define mistreatment, a safe environment for them to debrief, and staff to support and advocate for them empowers them with the knowledge and skillset to confront what is too often considered part of the hidden curriculum.

  View details for PubMedID 29395030

• Education in consultation: A comparative survey-based assessment of perceived educational effectiveness within a university and community-based internal medicine residency. MedEdPublish (2016) Rope, R., Merrell, S. B., Stedman, M., Young, B. 2017; 6: 153

  Abstract

  This article was migrated. The article was marked as recommended. Background: Education in consultation is a potentially valuable, but understudied, element of medical education. Inpatient consultation is an opportunity for significant subspecialist contact for resident trainees and an avenue for improving their knowledge and patient care across content areas. We evaluated the perceived educational effectiveness of education in consultation among internal medicine residents, within a university and a community-based program, as well as the role of barriers in medical training that may limit education. Methods: We used a web-based survey expanded from a previously published survey consisting of 12 questions, including one free-response, on education in consultation. Data were analyzed descriptively and qualitatively. We surveyed residents from two internal medicine programs in 2016. One within a large university-based hospital and the second within a smaller community-based safety-net hospital. Results: 91/198 (46%) of residents responded. Overall results from both programs were similar despite their structural differences. Residents viewed education in consultation as a priority and the majority felt it was at least moderately effective but underutilized. Importantly, educational interactions are largely dependent on outreach from residents. While in-person teaching interactions were the most effective, key barriers to these interactions include a lack of time, difficulty locating residents, and the perception of residents as being too busy. Conclusions: Inpatient consultation offers a unique opportunity for specialist-led education for internal medicine residents. It is potentially effective but constrained extensively in modern training environments. Interventions aimed at emphasizing education in consultation within fellowships and residencies, increasing in-person resident-specialist interactions, and addressing structural barriers, may improve resident knowledge across specialties and strengthen patient care.

  View details for DOI 10.15694/mep.2017.000153

  View details for PubMedID 38406436

  View details for PubMedCentralID PMC10885288

• Development of a video-delivered relaxation treatment of late-life anxiety for veterans. International psychogeriatrics Gould, C. E., Zapata, A. M., Bruce, J., Bereknyei Merrell, S., Wetherell, J. L., O'Hara, R., Kuhn, E., Goldstein, M. K., Beaudreau, S. A. 2017: 1-13

  Abstract

  Behavioral treatments reduce anxiety, yet many older adults may not have access to these efficacious treatments. To address this need, we developed and evaluated the feasibility and acceptability of a video-delivered anxiety treatment for older Veterans. This treatment program, BREATHE (Breathing, Relaxation, and Education for Anxiety Treatment in the Home Environment), combines psychoeducation, diaphragmatic breathing, and progressive muscle relaxation training with engagement in activities.A mixed methods concurrent study design was used to examine the clarity of the treatment videos. We conducted semi-structured interviews with 20 Veterans (M age = 69.5, SD = 7.3 years; 55% White, Non-Hispanic) and collected ratings of video clarity.Quantitative ratings revealed that 100% of participants generally or definitely could follow breathing and relaxation video instructions. Qualitative findings, however, demonstrated more variability in the extent to which each video segment was clear. Participants identified both immediate benefits and motivation challenges associated with a video-delivered treatment. Participants suggested that some patients may need encouragement, whereas others need face-to-face therapy.Quantitative ratings of video clarity and qualitative findings highlight the feasibility of a video-delivered treatment for older Veterans with anxiety. Our findings demonstrate the importance of ensuring patients can follow instructions provided in self-directed treatments and the role that an iterative testing process has in addressing these issues. Next steps include testing the treatment videos with older Veterans with anxiety disorders.

  View details for DOI 10.1017/S1041610217000928

  View details for PubMedID 28592349

• The Patient Voice in Cultural Diversity Training for Patient Centered Outcomes Researchers Carter-Pokras, O., Huang, D., Towle, A., Leyland, C., Christopher, M., Dogra, N., Suurmond, J., Merrell, S., Disney, L. CHURCHILL LIVINGSTONE. 2017: S51

  View details for DOI 10.1016/j.jpain.2017.02.196

  View details for Web of Science ID 000398755400208

• Implementation of a Needs-Based, Online Feedback Tool for Anesthesia Residents With Subsequent Mapping of the Feedback to the ACGME Milestones ANESTHESIA AND ANALGESIA Tanaka, P., Merrell, S. B., Walker, K., Zocca, J., Scotto, L., Bogetz, A. L., Macario, A. 2017; 124 (2): 627-635

  Abstract

  Optimizing feedback that residents receive from faculty is important for learning. The goals of this study were to (1) conduct focus groups of anesthesia residents to define what constitutes optimal feedback; (2) develop, test, and implement a web-based feedback tool; and (3) then map the contents of the written comments collected on the feedback tool to the Accreditation Council for Graduate Medical Education (ACGME) anesthesiology milestones.All 72 anesthesia residents in the program were invited to participate in 1 of 5 focus groups scheduled over a 2-month period. Thirty-seven (51%) participated in the focus groups and completed a written survey on previous feedback experiences. On the basis of the focus group input, an initial online feedback tool was pilot-tested with 20 residents and 62 feedback sessions, and then a final feedback tool was deployed to the entire residency to facilitate the feedback process. The completed feedback written entries were mapped onto the 25 ACGME anesthesiology milestones.Focus groups revealed 3 major barriers to good feedback: (1) too late such as, for example, at the end of month-long clinical rotations, which was not useful because the feedback was delayed; (2) too general and not specific enough to immediately remedy behavior; and (3) too many in that the large number of evaluations that existed that were unhelpful such as those with unclear behavioral anchors compromised the overall feedback culture. Thirty residents (42% of 72 residents in the program) used the final online feedback tool with 121 feedback sessions with 61 attendings on 15 rotations at 3 hospital sites. The number of feedback tool uses per resident averaged 4.03 (standard deviation 5.08, median 2, range 1-21, 25th-75th % quartile 1-4). Feedback tool uses per faculty averaged 1.98 (standard deviation 3.2, median 1, range 1-25, 25th-75th % quartile 1-2). For the feedback question item "specific learning objective demonstrated well by the resident," this yielded 296 milestone-specific responses. The majority (71.3%) were related to the patient care competency, most commonly the anesthetic plan and conduct (35.8%) and airway management (11.1%) milestones; 10.5% were related to the interpersonal and communication skills competency, most commonly the milestones communication with other professionals (4.4%) or with patients and families (4.4%); and 8.4% were related to the practice-based learning and improvement competency, most commonly self-directed learning (6.1%). For the feedback tool item "specific learning objective that resident may improve," 67.0% were related to patient care, most commonly anesthetic plan and conduct (33.5%) followed by use/interpretation of monitoring and equipment (8.5%) and airway management (8.5%); 10.2% were related to practice-based learning and improvement, most commonly self-directed learning (6.8%); and 9.7% were related to the systems-based practice competency.Resident focus groups recommended that feedback be timely and specific and be structured around a tool. A customized online feedback tool was developed and implemented. Mapping of the free-text feedback comments may assist in assessing milestones. Use of the feedback tool was lower than expected, which may indicate that it is just 1 of many implementation steps required for behavioral and culture change to support a learning environment with frequent and useful feedback.

  View details for DOI 10.1213/ANE.0000000000001647

  View details for Web of Science ID 000392366200035

• A Pilot Study of the Chronology of Present Illness: Restructuring the HPI to Improve Physician Cognition and Communication. Journal of general internal medicine Mazer, L. M., Storage, T., Bereknyei, S., Chi, J., Skeff, K. 2017; 32 (2): 182-188

  Abstract

  Patient history-taking is an essential clinical skill, with effects on diagnostic reasoning, patient-physician relationships, and more. We evaluated the impact of using a structured, timeline-based format, the Chronology of Present Illness (CPI), to guide the initial patient interaction.To determine the feasibility and impact of the CPI on the patient interview, written notes, and communication with other providers.Internal medicine residents used the CPI during a 2-week night-float rotation. For the first week, residents interviewed, documented, and presented patient histories according to their normal practices. They then attended a brief educational session describing the CPI, and were asked to use this method for new patient interviews, notes, and handoffs during the second week. Night and day teams evaluated the method using retrospective pre-post comparisons.Twenty-two internal medicine residents in their second or third postgraduate year.An educational dinner describing the format and potential benefits of using the CPI.Retrospective pre-post surveys on the efficiency, quality, and clarity of the patient interaction, written note, and verbal handoff, as well as open-ended comments. Respondents included night-float residents, day team residents, and attending physicians.All night-float residents responded, reporting significant improvements in written note, verbal sign-out, assessment and plan, patient interaction, and overall efficiency (p < 0.05). Day team residents (n = 76) also reported increased clarity in verbal sign-out and written note, improved efficiency, and improved preparedness for presenting the patient (p < 0.05). Attending physician ratings did not differ between groups.Resident ratings indicate that the CPI can improve key aspects of patient care, including the patient interview, note, and physician-physician communication. These results suggest that the method should be taught and implemented more frequently.

  View details for DOI 10.1007/s11606-016-3928-3

  View details for PubMedID 27896691

• Implementation of a Needs-Based, Online Feedback Tool for Anesthesia Residents With Subsequent Mapping of the Feedback to the ACGME Milestones. Anesthesia and analgesia Tanaka, P., Bereknyei Merrell, S., Walker, K., Zocca, J., Scotto, L., Bogetz, A. L., Macario, A. 2017; 124 (2): 627-635

  Abstract

  Optimizing feedback that residents receive from faculty is important for learning. The goals of this study were to (1) conduct focus groups of anesthesia residents to define what constitutes optimal feedback; (2) develop, test, and implement a web-based feedback tool; and (3) then map the contents of the written comments collected on the feedback tool to the Accreditation Council for Graduate Medical Education (ACGME) anesthesiology milestones.All 72 anesthesia residents in the program were invited to participate in 1 of 5 focus groups scheduled over a 2-month period. Thirty-seven (51%) participated in the focus groups and completed a written survey on previous feedback experiences. On the basis of the focus group input, an initial online feedback tool was pilot-tested with 20 residents and 62 feedback sessions, and then a final feedback tool was deployed to the entire residency to facilitate the feedback process. The completed feedback written entries were mapped onto the 25 ACGME anesthesiology milestones.Focus groups revealed 3 major barriers to good feedback: (1) too late such as, for example, at the end of month-long clinical rotations, which was not useful because the feedback was delayed; (2) too general and not specific enough to immediately remedy behavior; and (3) too many in that the large number of evaluations that existed that were unhelpful such as those with unclear behavioral anchors compromised the overall feedback culture. Thirty residents (42% of 72 residents in the program) used the final online feedback tool with 121 feedback sessions with 61 attendings on 15 rotations at 3 hospital sites. The number of feedback tool uses per resident averaged 4.03 (standard deviation 5.08, median 2, range 1-21, 25th-75th % quartile 1-4). Feedback tool uses per faculty averaged 1.98 (standard deviation 3.2, median 1, range 1-25, 25th-75th % quartile 1-2). For the feedback question item "specific learning objective demonstrated well by the resident," this yielded 296 milestone-specific responses. The majority (71.3%) were related to the patient care competency, most commonly the anesthetic plan and conduct (35.8%) and airway management (11.1%) milestones; 10.5% were related to the interpersonal and communication skills competency, most commonly the milestones communication with other professionals (4.4%) or with patients and families (4.4%); and 8.4% were related to the practice-based learning and improvement competency, most commonly self-directed learning (6.1%). For the feedback tool item "specific learning objective that resident may improve," 67.0% were related to patient care, most commonly anesthetic plan and conduct (33.5%) followed by use/interpretation of monitoring and equipment (8.5%) and airway management (8.5%); 10.2% were related to practice-based learning and improvement, most commonly self-directed learning (6.8%); and 9.7% were related to the systems-based practice competency.Resident focus groups recommended that feedback be timely and specific and be structured around a tool. A customized online feedback tool was developed and implemented. Mapping of the free-text feedback comments may assist in assessing milestones. Use of the feedback tool was lower than expected, which may indicate that it is just 1 of many implementation steps required for behavioral and culture change to support a learning environment with frequent and useful feedback.

  View details for DOI 10.1213/ANE.0000000000001647

  View details for PubMedID 28099326

• A Mixed-Methods Analysis of a Novel Mistreatment Program for the Surgery Core Clerkship. Academic medicine Lau, J. N., Mazer, L. M., Liebert, C. A., Merrell, S. B., Lin, D. T., Harris, I. 2017

  Abstract

  To review mistreatment reports from before and after implementation of a mistreatment program, and student ratings of and qualitative responses to the program to evaluate the short-term impact on students.In January 2014, a video- and discussion-based mistreatment program was implemented for the surgery clerkship at the Stanford University School of Medicine. The program aims to help students establish expectations for the learning environment; create a shared and personal definition of mistreatment; and promote advocacy and empowerment to address mistreatment. Counts and types of mistreatment were compared from a year before (January-December 2013) and two years after (January 2014-December 2015) implementation. Students' end-of-clerkship ratings and responses to open-ended questions were analyzed.From March 2014-December 2015, 141/164 (86%) students completed ratings, and all 47 (100%) students enrolled from January-August 2014 provided qualitative program evaluations. Most students rated the initial (108/141 [77%]) and final (120/141 [85%]) sessions as excellent or outstanding. In the qualitative analysis, students valued that the program helped establish expectations; allowed for sharing experiences; provided formal resources; and provided a supportive environment. Students felt the learning environment and culture were improved and reported increased interest in surgery. There were 14 mistreatment reports the year before the program, 9 in the program's first year, and 4 in the second year.The authors found a rotation-specific mistreatment program, focused on creating shared understanding about mistreatment, was well received among surgery clerkship students, and the number of mistreatment reports decreased each year following implementation.

  View details for DOI 10.1097/ACM.0000000000001575

  View details for PubMedID 28121657

• Patient-Centered Care Challenges and Surprises: Through the Clerkship Students' Eyes. Family medicine Boggiano, V. L., Wu, Y., Bruce, J. S., Merrell, S. B., Schillinger, E. 2017; 49 (1): 57-61

  Abstract

  The patient-centered care model for health care delivery encourages medical providers to respect patients' preferences and give patients more autonomy over their health care decisions. This approach has gained importance within US medical school curricula. Yet, little is known about student perspectives on both patient-centered care and the benefits and challenges that lie therein. This manuscript explores the greatest impediments to, as well as the benefits from, student engagement in patient-centered care from the perspectives of students participating in their family medicine outpatient clerkship.Clerkship students on their core family medicine clerkship at Stanford University School of Medicine were provided the following open-ended prompt: "Describe a patient-centered care challenge or surprise in the family medicine core clerkship." Free-text responses were collected and analyzed using content and thematic analysis.A total of 326 responses from 216 students were analyzed for frequency and patient-centered themes. Nine final themes emerged and were grouped into three domains: student definitions of patient-centered care, patient-centered care impact on patients, and patient-centered care impact on medical professionals.Our study suggests that students find the patient-centered care model for health care delivery to be challenging but worthwhile. We highlight that students find communication with patients in a patient-centered manner challenging and discuss the need for improved medical education about patient-centered care in order to better prepare students to implement the model in a variety of psychosocial and medical contexts.

  View details for PubMedID 28166582

• Pilot evaluation of the Computer-Based Assessment for Sampling Personal Characteristics test. The Journal of surgical research Shipper, E. S., Mazer, L. M., Merrell, S. B., Lin, D. T., Lau, J. N., Melcher, M. L. 2017; 215: 211–18

  Abstract

  High attrition rates hint at deficiencies in the resident selection process. The evaluation of personal characteristics representative of success is difficult. Here, we evaluate a novel tool for assessing personal characteristics.To evaluate feasibility, we used an anonymous voluntary survey questionnaire offered to study participants before and after contact with the CASPer test. To evaluate the CASPer test as a predictor of success, we compared CASPer test assessments of personal characteristics versus traditional faculty assessment of personal characteristics with applicant rank list position.All applicants (n = 77) attending an in-person interview for general surgery residency, and all faculty interviewers (n = 34) who reviewed these applications were invited to participate. Among applicants, 84.4% of respondents (65 of 77) reported that a requirement to complete the CASPer test would have no bearing or would make them more likely to apply to the program (mean = 3.30, standard deviation = 0.96). Among the faculty, 62.5% respondents (10 of 16) reported that the same condition would have no bearing or would make applicants more likely to apply to the program (mean = 3.19, standard deviation = 1.33). The Spearman's rank-order correlation coefficients for the relationships between traditional faculty assessment of personal characteristics and applicant rank list position, and novel CASPer assessment of personal characteristics and applicant rank list position, were -0.45 (P = 0.033) and -0.41 (P = 0.055), respectively.The CASPer test may be feasibly implemented as component of the resident selection process, with the potential to predict applicant rank list position and improve the general surgery resident selection process.

  View details for PubMedID 28688650

• Actual and Standardized Patient Evaluations of Medical Students' Skills. Family medicine Sattler, A. L., Merrell, S. B., Lin, S. Y., Schillinger, E. n. 2017; 49 (7): 548–52

  Abstract

  Physicians must communicate effectively with patients. Actual patients (APs) rarely evaluate medical students' clinical skills; instead, standardized patients (SPs) provide proxy ratings. It is unclear how well SP ratings mirror AP experiences. The aim of this study was to compare AP and SP assessments of medical students' communication skills and professionalism. We hypothesized that their perspectives would be similar, but distinct, and offer insight about how to more reliably include the patient's voice in medical education.Using a mixed methods design, data were gathered from both APs and SPs using a modified SEGUE (Set the stage, Elicit information, Give information, Understand the patient's perspective, End the encounter) framework. Authors analyzed Likert-scale surveys using Spearman's rho (ρ) correlations, and qualitatively analyzed open-ended comments about students' interpersonal skills and professionalism.For APs, the domains of "trusted the student," "discussed treatment," and "reviewed next steps" were positively correlated with whether they would recommend the student to others (ρ.89, ρ.89, ρ.88, respectively, all P<.001). For SPs, feeling like they "trusted the student," "student appeared professionally competent," and "made personal connection" were most highly correlated with recommending the student to others (ρ.86, ρ.86, ρ.76, respectively, all P<.001).Feedback from APs provides unique perspectives, complementing those of SPs, and prompts insights into incorporating patients' voices and values into training. Students may benefit from learning experiences focused on sharing and clarifying information. Providing opportunities for deliberate practice and feedback during both AP and SP encounters may enhance mastery of these skills.

  View details for PubMedID 28724153

• Underlying mechanisms of mistreatment in the surgical learning environment: A thematic analysis of medical student perceptions. American journal of surgery Brandford, E. n., Hasty, B. n., Bruce, J. S., Bereknyei Merrell, S. n., Shipper, E. S., Lin, D. T., Lau, J. N. 2017

  Abstract

  Medical students experience more psychological distress than the general population. One contributing factor is mistreatment. This study aims to understand the mechanisms of mistreatment as perceived by medical students.Students completed anonymous surveys during the first and last didactic session of their surgery clerkship in which they defined and gave examples of mistreatment. Team-based thematic analysis was performed on responses.Between January 2014 and June 2016, 240 students participated in the surgery clerkship. Eighty-nine percent of students completed a survey. Themes observed included (1) Obstruction of Students' Learning, (2) Exploitation of Student Vulnerability, (3) Exclusion from the Medical Team, and (4) Contextual Amplifiers of Mistreatment Severity.The themes observed in this study improve our understanding of the students' perspective on mistreatment as it relates to their role in the clinical learning context, which can serve as a starting point for interventions that ultimately improve students' experiences in the clinical setting.

  View details for PubMedID 29167023

• Evaluation of a technical and nontechnical skills curriculum for students entering surgery. The Journal of surgical research Shipper, E. S., Miller, S. E., Hasty, B. N., Merrell, S. B., Lin, D. T., Lau, J. N. 2017; 219: 92–97

  Abstract

  Prior interventions to address declining interest in surgical careers have focused on creating early exposure and fostering mentorship at the preclinical medical student level. Navigating the surgical environment can be challenging, however, and preclinical students may be more likely to pursue a surgical career if they are given the tools to function optimally.We designed a 10-wk technical and nontechnical skills curriculum to provide preclinical students with knowledge and skills necessary to successfully navigate the surgical learning environment, followed by placement in high-fidelity surgical simulations and scrubbing in on operative cases with attending surgeons. We administered pre-post surveys to assess student confidence levels in operative skills, self-perceptions of having a mentor, overall course efficacy, and interest in a career in surgery.The overall response rates presurvey and postsurvey were 100% (30 of 30) and 93.3% (28 of 30), respectively. Confidence levels across all operative skills increased significantly after completing the course. Faculty mentorship increased significantly from 30.0% before to 61.5% after the course. Overall effectiveness of the course was 4.00 of 5 (4 = "very effective"), and although insignificant, overall interest in a career in surgery increased at the completion of the course from 3.77 (standard deviation = 1.01) to 4.17 (standard deviation = 0.94).Our curriculum was effective in teaching the skills necessary to enjoy positive experiences in planned early exposure and mentorship activities. Further study is warranted to determine if this intervention leads to an increase in students who formally commit to a career in surgery.

  View details for PubMedID 29078916

• Patient-Centered Care Challenges and Surprises FAMILY MEDICINE Boggiano, V. L., Wu, Y., Bruce, J. S., Merrell, S. B., Schillinger, E. 2017; 49 (1): 57-61

  Abstract

  The patient-centered care model for health care delivery encourages medical providers to respect patients' preferences and give patients more autonomy over their health care decisions. This approach has gained importance within US medical school curricula. Yet, little is known about student perspectives on both patient-centered care and the benefits and challenges that lie therein. This manuscript explores the greatest impediments to, as well as the benefits from, student engagement in patient-centered care from the perspectives of students participating in their family medicine outpatient clerkship.Clerkship students on their core family medicine clerkship at Stanford University School of Medicine were provided the following open-ended prompt: "Describe a patient-centered care challenge or surprise in the family medicine core clerkship." Free-text responses were collected and analyzed using content and thematic analysis.A total of 326 responses from 216 students were analyzed for frequency and patient-centered themes. Nine final themes emerged and were grouped into three domains: student definitions of patient-centered care, patient-centered care impact on patients, and patient-centered care impact on medical professionals.Our study suggests that students find the patient-centered care model for health care delivery to be challenging but worthwhile. We highlight that students find communication with patients in a patient-centered manner challenging and discuss the need for improved medical education about patient-centered care in order to better prepare students to implement the model in a variety of psychosocial and medical contexts.

  View details for Web of Science ID 000397087700010

• The socioeconomic impact of international aid: a qualitative study of healthcare recovery in post-earthquake Haiti and implications for future disaster relief GLOBAL PUBLIC HEALTH Kligerman, M., Walmer, D., Merrell, S. B. 2017; 12 (5): 531-544

  Abstract

  We assessed healthcare provider perspectives of international aid four years after the Haiti Earthquake to better understand the impact of aid on the Haitian healthcare system and learn best practices for recovery in future disaster contexts. We conducted 22 semi-structured interviews with the directors of local, collaborative, and aid-funded healthcare facilities in Leogane, Haiti. We coded and analysed the interviews using an iterative method based on a grounded theory approach of data analysis. Healthcare providers identified positive aspects of aid, including acute emergency relief, long-term improved healthcare access, and increased ease of referrals for low-income patients. However, they also identified negative impacts of international aid, including episodes of poor quality care, internal brain drain, competition across facilities, decrease in patient flow to local facilities, and emigration of Haitian doctors to abroad. As Haiti continues to recover, it is imperative for aid institutions and local healthcare facilities to develop a more collaborative relationship to transition acute relief to sustainable capacity building. In future disaster contexts, aid institutions should specifically utilise quality of care metrics, NGO Codes of Conduct, Master Health Facility Lists, and sliding scale payment systems to improve disaster response.

  View details for DOI 10.1080/17441692.2015.1094111

  View details for Web of Science ID 000396840900003

• Finding the Words: Medical Students' Reflections on Communication Challenges in Clinic FAMILY MEDICINE Braverman, G., Merrell, S. B., Bruce, J. S., Makoul, G., Schillinger, E. 2016; 48 (10): 775-783

  Abstract

  Interpersonal communication is essential to providing excellent patient care and requires ongoing development. Although aspects of medical student interpersonal communication may degrade throughout career progression, it is unknown what specific elements pose challenges. We aimed to characterize clerkship students' perspectives on communication challenges in the outpatient setting to help inform curricular development.Third-year medical students in a required family medicine clerkship were asked to describe a communication challenge they encountered. Open-ended written responses were collected through a mandatory post-clerkship survey. Responses were qualitatively coded using an a priori framework for teaching and assessing communication skills (The SEGUE Framework for Teaching and Assessing Communication Skills) with data-derived additions to the framework, followed by a team-based thematic analysis.We collected 799 reflections written by 518 students from 2007-2014. Three dominant themes emerged from the analysis: challenges with (1) effectively exchanging information with patients, (2) managing emotional aspects of the patient encounter, and (3) negotiating terms of the encounter.Communication curricula focus on content and process of the medical interview, but insufficient time and energy are devoted to psychosocial factors, including aspects of the encounter that are emotionally charged or conflicting. While gaps in students' communication skillsets may be anticipated or observed by educators, this study offers an analysis of students' own perceptions of the challenges they face.

  View details for Web of Science ID 000387121300004

  View details for PubMedID 27875600

• TESTING THE USABILITY OF A PORTABLE DVD PLAYER AND PHOTO INSTRUCTIONS GUIDE WITH OLDER VETERANS Gould, C. E., Zapata, A., Merrell, S., Bruce, J., Beaudreau, S. A., Goldstein, M., Wetherell, J., O'Hara, R. OXFORD UNIV PRESS INC. 2016: 568

  View details for Web of Science ID 000388585002588

• A MIXED-METHODS EVALUATION OF A VIDEO-DELIVERED RELAXATION TREATMENT OF ANXIETY IN OLDER VETERANS Gould, C. E., O'Hara, R., Zapata, A., Bruce, J., Merrell, S., Wetherell, J., Goldstein, M., Beaudreau, S. A. OXFORD UNIV PRESS INC. 2016: 448

  View details for Web of Science ID 000388585002119

• Student perceptions of a simulation-based flipped classroom for the surgery clerkship: A mixed-methods study. Surgery Liebert, C. A., Mazer, L., Bereknyei Merrell, S., Lin, D. T., Lau, J. N. 2016; 160 (3): 591-598

  Abstract

  The flipped classroom, a blended learning paradigm that uses pre-session online videos reinforced with interactive sessions, has been proposed as an alternative to traditional lectures. This article investigates medical students' perceptions of a simulation-based, flipped classroom for the surgery clerkship and suggests best practices for implementation in this setting.A prospective cohort of students (n = 89), who were enrolled in the surgery clerkship during a 1-year period, was taught via a simulation-based, flipped classroom approach. Students completed an anonymous, end-of-clerkship survey regarding their perceptions of the curriculum. Quantitative analysis of Likert responses and qualitative analysis of narrative responses were performed.Students' perceptions of the curriculum were positive, with 90% rating it excellent or outstanding. The majority reported the curriculum should be continued (95%) and applied to other clerkships (84%). The component received most favorably by the students was the simulation-based skill sessions. Students rated the effectiveness of the Khan Academy-style videos the highest compared with other video formats (P < .001). Qualitative analysis identified 21 subthemes in 4 domains: general positive feedback, educational content, learning environment, and specific benefits to medical students. The students reported that the learning environment fostered accountability and self-directed learning. Specific perceived benefits included preparation for the clinical rotation and the National Board of Medical Examiners shelf exam, decreased class time, socialization with peers, and faculty interaction.Medical students' perceptions of a simulation-based, flipped classroom in the surgery clerkship were overwhelmingly positive. The flipped classroom approach can be applied successfully in a surgery clerkship setting and may offer additional benefits compared with traditional lecture-based curricula.

  View details for DOI 10.1016/j.surg.2016.03.034

  View details for PubMedID 27262534

• Emergency Manual Uses During Actual Critical Events and Changes in Safety Culture From the Perspective of Anesthesia Residents: A Pilot Study. Anesthesia and analgesia Goldhaber-Fiebert, S. N., Pollock, J., Howard, S. K., Bereknyei Merrell, S. 2016; 123 (3): 641-649

  Abstract

  Emergency manuals (EMs), context-relevant sets of cognitive aids or crisis checklists, have been used in high-hazard industries for decades, although this is a nascent field in health care. In the fall of 2012, Stanford clinically implemented EMs, including hanging physical copies in all Stanford operating rooms (ORs) and training OR clinicians on the use of, and rationale for, EMs. Although simulation studies have shown the effectiveness of EMs and similar tools when used by OR teams during crises, there are little data on clinical implementations and uses. In a subset of clinical users (ie, anesthesia residents), the objectives of this pilot study were to (1) assess perspectives on local OR safety culture regarding cognitive aid use before and after a systematic clinical implementation of EMs, although in the context of long-standing resident simulation trainings; and (2) to describe early clinical uses of EMs during critical events.Surveys collecting both quantitative and qualitative data were used to assess clinical adoption of EMs in the OR. A pre-implementation survey was e-mailed to Stanford anesthesia residents in mid-2011, followed by a post-implementation survey to a new cohort of residents in early 2014. The post-implementation survey included pre-implementation survey questions for exploratory comparison and additional questions for mixed-methods descriptive analyses regarding EM implementation, training, and clinical use during critical events since implementation.Response rates were similar for the pre- and post-implementation surveys, 52% and 57%, respectively. Comparing post- versus pre-implementation surveys in this pilot study, more residents: agreed or strongly agreed "the culture in the ORs where I work supports consulting a cognitive aid when appropriate" (73.8%, n = 31 vs 52.9%, n = 18, P = .0017) and chose more types of anesthesia professionals that "should use cognitive aids in some way," including fully trained anesthesiologists (z = -2.151, P = .0315). Fifteen months after clinical implementation of EMs, 19 respondents (45%) had used an EM during an actual critical event and 15 (78.9% of these) agreed or strongly agreed "the EM helped the team deliver better care to the patient" during that event, with the rest neutral. We present qualitative data for 16 of the 19 EM clinical use reports from free-text responses within the following domains: (1) triggering EM use, (2) reader role, (3) diagnosis and treatment, (4) patient care impact, and (5) barriers to EM use.Since Stanford's clinical implementation of EMs in 2012, many residents' self-report successful use of EMs during clinical critical events. Although these reports all come from a pilot study at a single institution, they serve as an early proof of concept for feasibility of clinical EM implementation and use. Larger, mixed-methods studies will be needed to better understand emerging facilitators and barriers and to determine generalizability.

  View details for DOI 10.1213/ANE.0000000000001445

  View details for PubMedID 27541721

• ONE PATIENT'S CARDIAC ARREST IN THE OPERATING ROOM: SIX PERSPECTIVES ON EMERGENCY MANUAL USE, READER ROLE, AND TEAMWORK Goldhaber-Fiebert, S. N., Merrell, S., Agarwala, A. V., McCarty, K., Cooper, J., Nevedal, A., Asch, S. LIPPINCOTT WILLIAMS & WILKINS. 2016

  View details for Web of Science ID 000403582200203

• Effectiveness of the Surgery Core Clerkship Flipped Classroom: a prospective cohort trial AMERICAN JOURNAL OF SURGERY Liebert, C. A., Lin, D. T., Mazer, L. M., Bereknyei, S., Lau, J. N. 2016; 211 (2): 451-U214

  Abstract

  The flipped classroom has been proposed as an alternative curricular approach to traditional didactic lectures but has not been previously applied to a surgery clerkship.A 1-year prospective cohort of students (n = 89) enrolled in the surgery clerkship was taught using a flipped classroom approach. A historical cohort of students (n = 92) taught with a traditional lecture curriculum was used for comparison. Pretest and post-test performance, end-of-clerkship surveys, and National Board of Medical Examiners (NBME) scores were analyzed to assess effectiveness.Mean pretest and post-test scores increased across all modules (P < .001). There was no difference between mean NBME examination score in the prospective and historical cohorts (74.75 vs 75.74, P = .28). Mean ratings of career interest in surgery increased after curriculum completion (4.75 to 6.50, P < .001), with 90% reporting that the flipped classroom contributed to this increase.Implementation of a flipped classroom in the surgery clerkship is feasible and results in high learner satisfaction, effective knowledge acquisition, and increased career interest in surgery with noninferior NBME performance.

  View details for DOI 10.1016/j.amjsurg.2015.10.004

  View details for Web of Science ID 000368344800023

• Impact of an Innovative Classroom-Based Lecture Series on Residents' Evaluations of an Anesthesiology Rotation. Anesthesiology research and practice Tanaka, P., Yanez, D., Lemmens, H., Djurdjulov, A., Scotto, L., Borg, L., Walker, K., Bereknyei Merrell, S., Macario, A. 2016; 2016: 8543809-?

  Abstract

  Introduction. Millennial resident learners may benefit from innovative instructional methods. The goal of this study is to assess the impact of a new daily, 15 minutes on one anesthesia keyword, lecture series given by faculty member each weekday on resident postrotation evaluation scores. Methods. A quasi-experimental study design was implemented with the residents' rotation evaluations for the 24-month period ending by 7/30/2013 before the new lecture series was implemented which was compared to the 14-month period after the lecture series began on 8/1/2013. The primary endpoint was "overall teaching quality of this rotation." We also collected survey data from residents at clinical rotations at two other different institutions during the same two evaluation periods that did not have the education intervention. Results. One hundred and thirty-one residents were eligible to participate in the study. Completed surveys ranged from 77 to 87% for the eight-question evaluation instrument. On a 5-point Likert-type scale the mean score on "overall teaching quality of this rotation" increased significantly from 3.9 (SD 0.8) to 4.2 (SD 0.7) after addition of the lecture series, whereas the scores decreased slightly at the comparison sites. Conclusion. Rotation evaluation scores for overall teaching quality improved with implementation of a new structured slide daily lectures series.

  View details for DOI 10.1155/2016/8543809

  View details for PubMedID 26989407

  View details for PubMedCentralID PMC4773520

• Behavioral and Social Sciences for Personalized Medicine: Teaching with Novel Methods. Academic psychiatry Louie, A. K., Merrell, S. B., Beresin, E. V., Balon, R., Coverdale, J. H., Roberts, L. W. 2015; 39 (6): 609-612

  View details for DOI 10.1007/s40596-015-0435-5

  View details for PubMedID 26423677

• The socioeconomic impact of international aid: a qualitative study of healthcare recovery in post-earthquake Haiti and implications for future disaster relief. Global public health Kligerman, M., Walmer, D., Merrell, S. B. 2015: 1-14

  Abstract

  We assessed healthcare provider perspectives of international aid four years after the Haiti Earthquake to better understand the impact of aid on the Haitian healthcare system and learn best practices for recovery in future disaster contexts. We conducted 22 semi-structured interviews with the directors of local, collaborative, and aid-funded healthcare facilities in Leogane, Haiti. We coded and analysed the interviews using an iterative method based on a grounded theory approach of data analysis. Healthcare providers identified positive aspects of aid, including acute emergency relief, long-term improved healthcare access, and increased ease of referrals for low-income patients. However, they also identified negative impacts of international aid, including episodes of poor quality care, internal brain drain, competition across facilities, decrease in patient flow to local facilities, and emigration of Haitian doctors to abroad. As Haiti continues to recover, it is imperative for aid institutions and local healthcare facilities to develop a more collaborative relationship to transition acute relief to sustainable capacity building. In future disaster contexts, aid institutions should specifically utilise quality of care metrics, NGO Codes of Conduct, Master Health Facility Lists, and sliding scale payment systems to improve disaster response.

  View details for PubMedID 26565063

• Service-Based Learning for Residents: A Success for Communities and Medical Education. Family medicine Gefter, L., Merrell, S. B., Rosas, L. G., Morioka-Douglas, N., Rodriguez, E. 2015; 47 (10): 803-806

  Abstract

  Community-based service-learning opportunities could support residents' acquisition of Accreditation Council for Graduate Medical Education (ACGME) competencies, but this concept has not been tested, and such programs are difficult to find. The objective of this work was to assess the value and the ACGME competency relevance of a service-learning program for residents that could be easily replicated nationally.Forty-one family medicine residents from three training programs participated in the Stanford Youth Diabetes Coaches Program at six high schools in California and Georgia serving minority students of low socioeconomic status. Residents completed online surveys to provide qualitative feedback and assess the program's impact on their acquisition of residency program competencies and self-management support proficiencies, including prior use and planned use of action plans-a key self-management support strategy.Ninety-five percent of residents indicated that the program was a valuable experience that contributed to acquisition of residency program competencies, including interpersonal and communication skills and communication with teens. Compared with baseline, significantly more residents reported intention to use action plans with patients following participation. Themes from qualitative feedback included: valuing the overall experience, increasing opportunities to practice teaching, enhancing their ability to communicate with adolescents, contributing to the health of the community, recognizing the potential of action plans, and increasing intent to use action plans.This pilot demonstrated that a brief service-learning program can enhance standard residency curriculum by encouraging acquisition of ACGME competencies and promoting utilization of self-management support in clinical practice.

  View details for PubMedID 26545059

• Training Health Care Professionals for 21st-Century Practice: A Systematic Review of Educational Interventions on Chronic Care ACADEMIC MEDICINE Bogetz, J. F., Rassbach, C. E., Bereknyei, S., Mendoza, F. S., Sanders, L. M., Braddock, C. H. 2015; 90 (11): 1561-1572

  Abstract

  To systematically review the evidence for high-quality and effective educational strategies to train health care professionals across the education continuum on chronic disease care.A search of English-language publications and conference proceedings was performed in November 2013 and updated in April 2014. Studies that evaluated a newly developed curriculum targeting chronic disease care with learner outcomes were included. Two primary reviewers and one adjudicating reviewer evaluated the studies and assessed their quality using the validated Medical Education Research Study Quality Instrument (MERSQI). Studies were also mapped onto elements of Wagner's chronic care model (CCM) to evaluate their use of established evidence-based models for chronic care delivery. Miller's classification of clinical competence was used to assess the quality of learner achievements for each educational intervention.A total of 672 articles were found for this review. Twenty-two met criteria for data extraction. The majority of studies were of moderate quality according to MERSQI scoring. Only three studies reported both learner and patient outcomes. The highest-quality studies incorporated more elements of Wagner's CCM and showed high-level learner competence according to Miller's classification. Successful interventions redesigned health care delivery systems to include team-based care, emphasized training of health care professionals on patient self-management, and included learner-based quality improvement initiatives.The growing number of children and adults with chronic disease necessitates improved educational interventions for health care professionals that involve evidence-based models for restructuring chronic care delivery, aim for high-level learner behavioral outcomes, and evolve through quality improvement initiatives.

  View details for DOI 10.1097/ACM.0000000000000773

  View details for PubMedID 26039140

• Elevating the Behavioral and Social Sciences in Premedical Training: MCAT2015 ACADEMIC PSYCHIATRY Roberts, L. W., Louie, A. K., Goldsmith, M., Tait, G. R., Balon, R., Beresin, E. V., Bereknyei, S., Coverdale, J. H. 2015; 39 (2): 127-131

  View details for DOI 10.1007/s40596-015-0289-x

  View details for PubMedID 25700671

• Emergency manual implementation: can brief simulation-based or staff trainings increase familiarity and planned clinical use? Joint Commission journal on quality and patient safety / Joint Commission Resources Goldhaber-Fiebert, S. N., Lei, V., Nandagopal, K., Bereknyei, S. 2015; 41 (5): 212-217

  Abstract

  Emergency manuals (EMs)-context-relevant sets of cognitive aids such as crisis checklists-are useful tools to enhance perioperative patient care. Studies in high-hazard industries demonstrate that humans, regardless of expertise, do not optimally retrieve or deploy key knowledge under stress. EM use has been shown in both health care simulation studies and other industries to help expert teams effectively manage critical events. However, clinical adoption and use are still nascent in health care. Recognizing that training with, access to, and cultural acceptance of EMs can be vital elements for successful implementation, this study assessed the impact of a brief in situ operating room (OR) staff training program on familiarity with EMs and intention to use them during critical events.Nine 50-minute training sessions were held with OR staff as part of a broader perioperative EM implementation. Participants primarily included OR nurses and surgical technologists. The simulation-based in situ trainings included why and how to use EMs, familiarization with format, simulated scenarios of critical events, and debriefings. A retrospective pre-post survey was conducted to determine participants' levels of EM familiarity and intentions to use EMs clinically.The 126 trained OR staff self-reported increases in awareness of the EM (p < .01), familiarity with EM (p < .01), willingness to use for educational review (p < .01), and intention to use during critical events (p < .01). Participants rated the sessions highly and expressed interest in more opportunities to practice using EMs.Implementing institutions should not only provide EMs in accessible places in ORs but also incorporate training mechanisms to increase clinicians' familiarity, cultural acceptance, and planned clinical use.

  View details for PubMedID 25977248

• The Impact of a Faculty Development Program in Health Literacy and Ethnogeriatrics ACADEMIC MEDICINE Evans, K. H., Bereknyei, S., Yeo, G., Hikoyeda, N., Tzuang, M., Braddock, C. H. 2014; 89 (12): 1640-1644

  Abstract

  A faculty development curriculum aimed at increasing health literacy and awareness of patient care issues in ethnogeriatrics is essential to address serious deficiencies in faculty and health professionals' training and to prepare future health care professionals to care for older adults.Authors from the Stanford Geriatric Education Center developed and implemented a faculty development program in Health Literacy and Ethnogeriatrics (HLE). The goal was to enhance faculty and health professionals' knowledge, skills, and attitudes in HLE-related areas (e.g., health disparities, low health literacy, quality of care for ethnically diverse elders, patient/provider communication). The curriculum was implemented during an intensive weeklong program over a three-year period (2008-2010). The eight-module core curriculum was presented in a train-the-trainer format, supplemented by daily resource sessions.Thirty-four faculty participants from 11 disciplines, including medicine, came from 19 institutions in 12 states. The curriculum positively affected participants' knowledge, skills, and attitudes related to topics in HLE. Participants rated the curriculum's usefulness highly, and they reported that over 57% of the content was new. The HLE curriculum provided a mechanism to increase the self-assessed knowledge, skills, and attitudes of participants. It also fostered local curricular change: Over 91% of the participants have either disseminated the HLE curriculum through seminars conducted at their home sites or implemented HLE-related projects in their local communities, reaching diverse patient populations.Next steps include measuring the impact on the participants' teaching skills and at their home sites through their trainees and patients.

  View details for DOI 10.1097/ACM.0000000000000411

  View details for Web of Science ID 000345919500024

  View details for PubMedID 25006703

• The Prevalence of Social and Behavioral Topics and Related Educational Opportunities During Attending Rounds ACADEMIC MEDICINE Satterfield, J. M., Bereknyei, S., Hilton, J. F., Bogetz, A. L., Blankenburg, R., Buckelew, S. M., Chen, H. C., Monash, B., Ramos, J. S., Rennke, S., Braddock, C. H. 2014; 89 (11): 1548-1557

  Abstract

  To quantify the prevalence of social and behavioral sciences (SBS) topics during patient care and to rate team response to these topics once introduced.This cross-sectional study used five independent raters to observe 80 inpatient ward teams on internal medicine and pediatric services during attending rounds at two academic hospitals over a five-month period. Patient-level primary outcomes-prevalence of SBS topic discussions and rate of positive responses to discussions-were captured using an observational tool and summarized at the team level using hierarchical models. Teams were scored on patient- and learner-centered behaviors.Observations were made of 80 attendings, 83 residents, 75 interns, 78 medical students, and 113 allied health providers. Teams saw a median of 8.0 patients per round (collectively, 622 patients), and 97.1% had at least one SBS topic arise (mean = 5.3 topics per patient). Common topics were pain (62%), nutrition (53%), social support (52%), and resources (39%). After adjusting for team characteristics, the number of discussion topics raised varied significantly among the four services and was associated with greater patient-centeredness. When topics were raised, 38% of teams' responses were positive. Services varied with respect to learner- and patient-centeredness, with most services above average for learner-centered, and below average for patient-centered behaviors.Of 30 SBS topics tracked, some were addressed commonly and others rarely. Multivariable analyses suggest that medium-sized teams can address SBS concerns by increasing time per patient and consistently adopting patient-centered behaviors.

  View details for DOI 10.1097/ACM.0000000000000483

  View details for Web of Science ID 000343897500032

  View details for PubMedCentralID PMC4213280

• The prevalence of social and behavioral topics and related educational opportunities during attending rounds. Academic medicine Satterfield, J. M., Bereknyei, S., Hilton, J. F., Bogetz, A. L., Blankenburg, R., Buckelew, S. M., Chen, H. C., Monash, B., Ramos, J. S., Rennke, S., Braddock, C. H. 2014; 89 (11): 1548-1557

  Abstract

  To quantify the prevalence of social and behavioral sciences (SBS) topics during patient care and to rate team response to these topics once introduced.This cross-sectional study used five independent raters to observe 80 inpatient ward teams on internal medicine and pediatric services during attending rounds at two academic hospitals over a five-month period. Patient-level primary outcomes-prevalence of SBS topic discussions and rate of positive responses to discussions-were captured using an observational tool and summarized at the team level using hierarchical models. Teams were scored on patient- and learner-centered behaviors.Observations were made of 80 attendings, 83 residents, 75 interns, 78 medical students, and 113 allied health providers. Teams saw a median of 8.0 patients per round (collectively, 622 patients), and 97.1% had at least one SBS topic arise (mean = 5.3 topics per patient). Common topics were pain (62%), nutrition (53%), social support (52%), and resources (39%). After adjusting for team characteristics, the number of discussion topics raised varied significantly among the four services and was associated with greater patient-centeredness. When topics were raised, 38% of teams' responses were positive. Services varied with respect to learner- and patient-centeredness, with most services above average for learner-centered, and below average for patient-centered behaviors.Of 30 SBS topics tracked, some were addressed commonly and others rarely. Multivariable analyses suggest that medium-sized teams can address SBS concerns by increasing time per patient and consistently adopting patient-centered behaviors.

  View details for DOI 10.1097/ACM.0000000000000483

  View details for PubMedID 25250747

• Estimating population size, HIV prevalence and HIV incidence among men who have sex with men: a case example of synthesising multiple empirical data sources and methods in San Francisco SEXUALLY TRANSMITTED INFECTIONS Raymond, H., Bereknyei, S., Berglas, N., Hunter, J., Ojeda, N., McFarland, W. 2013; 89 (5): 383-387

  Abstract

  The number of persons living with HIV/AIDS, the number of new infections and the number of persons at risk for HIV infection are the foundations of evidence-based prevention, treatment and care planning. However, few jurisdictions have complete and accurate estimates of these indicators. HIV/AIDS case reporting, which includes only persons diagnosed with infection and reported to health departments, does not reflect all HIV/AIDS cases, thus underestimating the true size of the epidemic. Obtaining direct measures of HIV incidence is methodologically challenging. Moreover, no censuses exist for the number of persons at highest risk for infection, including men who have sex with men (MSM).We present an approach of triangulation that draws upon multiple empirical and overlapping sources of information through different methods to synthesise data-based estimates of the prevalence, incidence and denominator of MSM at risk for infection in San Francisco. We further use existing data to establish plausible upper and lower bounds for each estimate.We arrived at an overall population size of 66 487 of MSM in San Francisco as of 31 December 2010. The number of MSM living with HIV/AIDS was 15 873, corresponding to an HIV prevalence of 23.9%. We projected 806 new cases in 2010, translating to an incidence rate of 1.59% per year.While not without limitations, our estimates provide useful information for the purpose of HIV/AIDS prevention and care planning, drawing from diverse sources that may be available in local health jurisdictions. We believe that our approach enhances the credibility of such estimates by mitigating bias from only one source of data or one methodological approach.

  View details for DOI 10.1136/sextrans-2012-050675

  View details for Web of Science ID 000322116900015

  View details for PubMedID 23620133

• INTERDISCIPLINARY HEALTH CARE FACULTY DEVELOPMENT IN HEALTH LITERACY AND ETHNOGERIATRICS Yeo, G., GRUDZEN, M., Hikoyeda, N., Tzuang, M., Braddock, C., Bereknyei, S., Hooper, K. OXFORD UNIV PRESS INC. 2012: 387–387

  View details for Web of Science ID 000312888203094

• New elements for informed decision making: A qualitative study of older adults' views PATIENT EDUCATION AND COUNSELING Price, E. L., Bereknyei, S., Kuby, A., Levinson, W., Braddock, C. H. 2012; 86 (3): 335-341

  Abstract

  To explore older adults' views of existing informed decision making (IDM) elements and investigate the need for additional elements.We recruited persons 65 and older to participate in six focus groups. Participants completed questionnaires about IDM preferences, and discussed videotapes of idealized patient-physician interactions in light of seven IDM elements: (1) discussion of the patient's role in decision making; (2) discussion of the clinical issue; (3) discussion of alternatives; (4) discussion of benefits/risks; (5) discussion of uncertainties; (6) assessment of patient understanding; and (7) exploration of patient preference. We used a modified grounded theory approach to assess agreement with existing IDM elements and identify new elements.In questionnaires, 97-100% of 59 participants rated each IDM element as "somewhat" or "very" important. Qualitative analysis supported existing elements and suggested two more: opportunity for input from trusted others, and discussion of decisions' impacts on patients' daily lives. Elements overlapped with global communication themes.Focus groups affirmed existing IDM elements and suggested two more with particular relevance for older patients.Incorporation of additional IDM elements into clinical practice can enhance informed participation of older adults in decision making.

  View details for DOI 10.1016/j.pec.2011.06.006

  View details for Web of Science ID 000302672700010

  View details for PubMedID 21757315

  View details for PubMedCentralID PMC3276685

• Measuring Informed Decision Making about Prostate Cancer Screening in Primary Care MEDICAL DECISION MAKING Leader, A., Daskalakis, C., Braddock, C. H., Kunkel, E. J., Cocroft, J. R., Bereknyei, S., Riggio, J. M., Capkin, M., Myers, R. E. 2012; 32 (2): 327-336

  Abstract

  To measure the extent of informed decision making (IDM) about prostate cancer screening in physician-patient encounters, describe the coding process, and assess the reliability of the IDM measure.Audiorecoded encounters of 146 older adult men and their primary care physicians were obtained in a randomized controlled trial of mediated decision support related to prostate cancer screening. Each encounter was dual coded for the presence or absence of 9 elements that reflect several important dimensions of IDM, such as information sharing, patient empowerment, and engaging patients in preference clarification. An IDM-9 score (range = 0-9) was determined for each encounter by summing the number of elements that were coded as present. Estimates of coding reliability and internal consistency were calculated.Male patients tended to be white (59%), married (70%), and between the ages of 50 and 59 (70%). Physicians tended to be white (90%), male (74%), and have more than 10 years of practice experience (74%). IDM-9 scores ranged from 0 to 7.5 (mean [SD], 2.7 [2.1]). Reliability (0.90) and internal consistency (0.81) of the IDM-9 were both high. The IDM dimension observed most frequently was information sharing (74%), whereas the dimension least frequently observed was engagement in preference clarification (3.4%).In physician-patient encounters, the level of IDM concerning prostate cancer screening was low. The use of a dual-coding approach with audiorecorded encounters produced a measure of IDM that was reliable and internally consistent.

  View details for DOI 10.1177/0272989X11410064

  View details for Web of Science ID 000328315800014

• Measuring informed decision making about prostate cancer screening in primary care. Medical decision making : an international journal of the Society for Medical Decision Making Leader, A., Daskalakis, C., Braddock, C. H., Kunkel, E. J., Cocroft, J. R., Bereknyei, S., Riggio, J. M., Capkin, M., Myers, R. E. 2011; 32 (2): 327-36

  Abstract

  To measure the extent of informed decision making (IDM) about prostate cancer screening in physician-patient encounters, describe the coding process, and assess the reliability of the IDM measure.Audiorecoded encounters of 146 older adult men and their primary care physicians were obtained in a randomized controlled trial of mediated decision support related to prostate cancer screening. Each encounter was dual coded for the presence or absence of 9 elements that reflect several important dimensions of IDM, such as information sharing, patient empowerment, and engaging patients in preference clarification. An IDM-9 score (range = 0-9) was determined for each encounter by summing the number of elements that were coded as present. Estimates of coding reliability and internal consistency were calculated.Male patients tended to be white (59%), married (70%), and between the ages of 50 and 59 (70%). Physicians tended to be white (90%), male (74%), and have more than 10 years of practice experience (74%). IDM-9 scores ranged from 0 to 7.5 (mean [SD], 2.7 [2.1]). Reliability (0.90) and internal consistency (0.81) of the IDM-9 were both high. The IDM dimension observed most frequently was information sharing (74%), whereas the dimension least frequently observed was engagement in preference clarification (3.4%).In physician-patient encounters, the level of IDM concerning prostate cancer screening was low. The use of a dual-coding approach with audiorecorded encounters produced a measure of IDM that was reliable and internally consistent.

  View details for DOI 10.1177/0272989X11410064

  View details for PubMedID 21685377

• MEASURING INFORMED DECISION MAKING RELATED TO PROSTATE CANCER SCREENING IN PRIMARY CARE Leader, A., Daskalakis, C., Braddock, C., Kunkel, E., Cocroft, J., Bereknyei, S., Riggio, J., Capkin, M., Myers, R. SPRINGER. 2011: S38

  View details for Web of Science ID 000289297700149

• Does Cultural Competency Training of Health Professionals Improve Patient Outcomes? A Systematic Review and Proposed Algorithm for Future Research JOURNAL OF GENERAL INTERNAL MEDICINE Lie, D. A., Lee-Rey, E., Gomez, A., Bereknyei, S., Braddock, C. H. 2011; 26 (3): 317-325

  Abstract

  Cultural competency training has been proposed as a way to improve patient outcomes. There is a need for evidence showing that these interventions reduce health disparities.The objective was to conduct a systematic review addressing the effects of cultural competency training on patient-centered outcomes; assess quality of studies and strength of effect; and propose a framework for future research.The authors performed electronic searches in the MEDLINE/PubMed, ERIC, PsycINFO, CINAHL and Web of Science databases for original articles published in English between 1990 and 2010, and a bibliographic hand search. Studies that reported cultural competence educational interventions for health professionals and measured impact on patients and/or health care utilization as primary or secondary outcomes were included.Four authors independently rated studies for quality using validated criteria and assessed the training effect on patient outcomes. Due to study heterogeneity, data were not pooled; instead, qualitative synthesis and analysis were conducted.Seven studies met inclusion criteria. Three involved physicians, two involved mental health professionals and two involved multiple health professionals and students. Two were quasi-randomized, two were cluster randomized, and three were pre/post field studies. Study quality was low to moderate with none of high quality; most studies did not adequately control for potentially confounding variables. Effect size ranged from no effect to moderately beneficial (unable to assess in two studies). Three studies reported positive (beneficial) effects; none demonstrated a negative (harmful) effect.There is limited research showing a positive relationship between cultural competency training and improved patient outcomes, but there remains a paucity of high quality research. Future work should address challenges limiting quality. We propose an algorithm to guide educators in designing and evaluating curricula, to rigorously demonstrate the impact on patient outcomes and health disparities.

  View details for DOI 10.1007/s11606-010-1529-0

  View details for Web of Science ID 000287661800020

  View details for PubMedID 20953728

  View details for PubMedCentralID PMC3043186

• Longitudinal development of medical students' communication skills in interpreted encounters. Education for health (Abingdon, England) Lie, D. A., Bereknyei, S., Vega, C. P. 2010; 23 (3): 466-?

  Abstract

  Describe longitudinal skill development of medical students for the interpreted encounter.Two successive classes of students (n=92 and 100) participated in standardized clinical stations testing general communication skills and skills for working with interpreters at the end of their second year and after completing clinical clerkships during their third year. Performance was rated by standardized patients, interpreters and students using validated scales.Analysis of individual matched paired data was performed for each scale item using the Wilcoxon signed-rank test. Pairwise correlation was used to compare global scores of the standardized patient and standardized interpreter with student self-ratings.Over one year students' (n=124-168) performance worsened in behaviors for 'managing the encounter' (per interpreters' ratings) or remained unchanged (per patients' ratings). By patients' ratings, performance scores in general communication remained high. Students rated themselves as significantly improved in five of eight skills for working with interpreters despite a lack of external evidence of improvement from patient or interpreter. Students showed a trend toward underestimating their own global skills at baseline and overestimating them in comparison with the interpreters' global ratings.Students' general communication skills remained excellent over one year of training but some skills for working with interpreters worsened. Over time students showed a pattern of overrating their own skills compared with trained observers. Faculty who teach students should focus on specific behaviors that are most likely to decay without reinforcement and practice.

  View details for PubMedID 21290365

• Longitudinal Development of Medical Students' Communication Skills in Interpreted Encounters EDUCATION FOR HEALTH Lie, D. A., Bereknyei, S., Vega, C. P. 2010; 23 (3)

  View details for Web of Science ID 000441083300013

• Relationships of the Location and Content of Rounds to Specialty, Institution, Patient-Census, and Team Size PLOS ONE Priest, J. R., Bereknyei, S., Hooper, K., Braddock, C. H. 2010; 5 (6)

  Abstract

  Existing observational data describing rounds in teaching hospitals are 15 years old, predate duty-hour regulations, are limited to one institution, and do not include pediatrics. We sought to evaluate the effect of medical specialty, institution, patient-census, and team participants upon time at the bedside and education occurring on rounds.Between December of 2007 and October of 2008 we performed 51 observations at Lucile Packard Children's Hospital, Seattle Children's Hospital, Stanford University Hospital, and the University of Washington Medical Center of 35 attending physicians. We recorded minutes spent on rounds in three location and seven activity categories, members of the care team, and patient-census.Results presented are means. Pediatric rounds had more participants (8.2 vs. 4.1 physicians, p<.001; 11.9 vs. 2.4 non-physicians, p<.001) who spent more minutes in hallways (96.9 min vs. 35.2 min, p<.001), fewer minutes at the bedside (14.6 vs. 38.2 min, p = .01) than internal medicine rounds. Multivariate regression modeling revealed that minutes at the bedside per patient was negatively associated with pediatrics (-2.77 adjusted bedside minutes; 95% CI -4.61 to -0.93; p<.001) but positively associated with the number of non-physician participants (0.12 adjusted bedside minutes per non physician participant; 95% CI 0.07 to 0.17; p = <.001). Education minutes on rounds was positively associated with the presence of an attending physician (2.70 adjusted education minutes; 95% CI 1.27 to 4.12; p<.001) and with one institution (1.39 adjusted education minutes; 95% CI 0.26 to 2.53; p = .02).Pediatricians spent less time at the bedside on rounds than internal medicine physicians due to reasons other than patient-census or the number of participants in rounds. Compared to historical data, internal medicine rounds were spent more at the bedside engaged in patient care and communication, and less upon educational activities.

  View details for DOI 10.1371/journal.pone.0011246

  View details for Web of Science ID 000279058300029

  View details for PubMedID 20574534

  View details for PubMedCentralID PMC2888591

• Beyond Knowledge, Toward Linguistic Competency: An Experiential Curriculum JOURNAL OF GENERAL INTERNAL MEDICINE Bereknyei, S., Nevins, A., Schillinger, E., Garcia, R. D., Stuart, A. E., Braddock, C. H. 2010; 25: S155-S159

  Abstract

  Training is essential for future health care providers to effectively communicate with limited English proficient (LEP) patients during interpreted encounters. Our aim is to describe an innovative skill-based medical school linguistic competency curriculum and its impact on knowledge and skills.At Stanford University School of Medicine, we incorporated a linguistic competency curriculum into a 2-year Practice of Medicine preclinical doctoring course and pediatrics clerkship over three cohorts.First year students participated in extensive interpreter-related training including: a knowledge-based online module, interactive role-play exercises, and didactic skill-building sessions. Students in the pediatrics clerkship participated in interpreted training exercises with facilitated feedback.Knowledge and skills were evaluated in the first and fourth years. First year students' knowledge scores increased (pre-test = 0.62, post-test = 0.89, P < 0.001), and they demonstrated good skill attainment during an end-year performance assessment. One cohort of students participated in the entire curriculum and maintained performance into the fourth year.Our curriculum increased knowledge and led to skill attainment, each of which showed good durability for a cohort of students evaluated 3 years later. With a growing LEP population, these skills are essential to foster in future health care providers to effectively communicate with LEP patients and reduce health disparities.

  View details for DOI 10.1007/s11606-010-1271-7

  View details for Web of Science ID 000277270300016

  View details for PubMedID 20352511

  View details for PubMedCentralID PMC2847115

• Surmounting the Unique Challenges in Health Disparities Education: A Multi-Institution Qualitative Study JOURNAL OF GENERAL INTERNAL MEDICINE Carter-Pokras, O., Bereknyei, S., Lie, D., Braddock, C. H. 2010; 25: S108-S114

  Abstract

  The National Consortium for Multicultural Education for Health Professionals (Consortium) comprises educators representing 18 US medical schools, funded by the National Institutes of Health. Collective lessons learned from curriculum implementation by principal investigators (PIs) have the potential to guide similar educational endeavors.Describe Consortium PI's self-reported challenges with curricular development, solutions and their new curricular products.Information was collected from PIs over 2 months using a 53-question structured three-part questionnaire. The questionnaire addressed PI demographics, curriculum implementation challenges and solutions, and newly created curricular products. Study participants were 18 Consortium PIs. Descriptive analysis was used for quantitative data. Narrative responses were analyzed and interpreted using qualitative thematic coding.Response rate was 100%. Common barriers and challenges identified by PIs were: finding administrative and leadership support, sustaining the momentum, continued funding, finding curricular space, accessing and engaging communities, and lack of education research methodology skills. Solutions identified included engaging stakeholders, project-sharing across schools, advocacy and active participation in committees and community, and seeking sustainable funding. All Consortium PIs reported new curricular products and extensive dissemination efforts outside their own institutions.The Consortium model has added benefits for curricular innovation and dissemination for cultural competence education to address health disparities. Lessons learned may be applicable to other educational innovation efforts.

  View details for DOI 10.1007/s11606-010-1269-1

  View details for Web of Science ID 000277270300008

  View details for PubMedID 20352503

  View details for PubMedCentralID PMC2847111

• Assessing Medical Students' Skills in Working With Interpreters During Patient Encounters: A Validation Study of the Interpreter Scale ACADEMIC MEDICINE Lie, D., Bereknyei, S., Braddock, C. H., Encinas, J., Ahearn, S., Boker, J. R. 2009; 84 (5): 643-650

  Abstract

  Interpreted patient encounters require distinct communication skills. The absence of available reliable, valid, and practical measures hinders the assessment of these skills; therefore, the authors aimed to construct and validate the Interpreter Scale (IS).The authors constructed the IS based on expert consensus and prior studies. They administered the IS to two classes (n = 182) in an interpreted standardized patient (SP) case setting. Standardized interpreters in the examination room assessed, using the IS, students' communication skills. Concurrently, SPs, using the validated Patient-Physician Interaction scale (PPI) and the Interpreter Impact Rating Scale (IIRS), also assessed students' skills. Trained observers watched DVDs and used the Faculty Observer Rating Scale (FORS) to assess student performance. A prior study documented the qualities of the IIRS and FORS. The authors determined the internal consistency reliability and examined construct validity of IS scores through factor analysis and concordance with other measures' scores.IS reliability analysis yielded Cronbach alpha = 0.77. Factor analysis demonstrated two IS dimensions. Nine items, "managing the encounter," and four items, "setting the stage," explained 76% and 15% of score variance, respectively. IS and FORS scores significantly correlated (r = 0.385; P < .0001). IS factor 1 scores significantly correlated (all P < .0001) with FORS (r = 0.402), IIRS (r = 0.277), and PPI (r = 0.332) scores.The IS has reasonable internal consistency reliability and construct validity to warrant use for formatively measuring student communication skills in interpreted SP encounters, and it needs testing in actual patient encounters.

  View details for Web of Science ID 000267655300020

  View details for PubMedID 19704202

• Learning Outcomes of a Web Module for Teaching Interpreter Interaction Skills to Pre-clerkship Students FAMILY MEDICINE Lie, D., Bereknyei, S., Kalet, A., Braddock, C. 2009; 41 (4): 234-235

  View details for Web of Science ID 000270118300001

  View details for PubMedID 19343546

• Letters to the Editor JOURNAL OF PAEDIATRICS AND CHILD HEALTH Soler-Palacin, P., Clemente, S., Martin, A., Cabanas, M., Hidalgo, E., Figueras, C. 2009; 45 (4): 234-235

  View details for DOI 10.1111/j.1440-1754.2009.01480.x

  View details for Web of Science ID 000265410200015

  View details for PubMedID 19426382

• "Surgery is certainly one good option": quality and time-efficiency of informed decision-making in surgery. journal of bone and joint surgery. American volume Braddock, C., Hudak, P. L., Feldman, J. J., Bereknyei, S., Frankel, R. M., Levinson, W. 2008; 90 (9): 1830-1838

  Abstract

  Informed decision-making has been widely promoted in several medical settings, but little is known about the actual practice in orthopaedic surgery and there are no clear guidelines on how to improve the process in this setting. This study was designed to explore the quality of informed decision-making in orthopaedic practice and to identify excellent time-efficient examples with older patients.We recruited orthopaedic surgeons, and patients sixty years of age or older, in a Midwestern metropolitan area for a descriptive study performed through the analysis of audiotaped physician-patient interviews. We used a valid and reliable measure to assess the elements of informed decision-making. These included discussions of the nature of the decision, the patient's role, alternatives, pros and cons, and uncertainties; assessment of the patient's understanding and his or her desire to receive input from others; and exploration of the patient's preferences and the impact on the patient's daily life. The audiotapes were scored with regard to whether there was a complete discussion of each informed-decision-making element (an IDM-18 score of 2) or a partial discussion of each element (an IDM-18 score of 1) as well as with a more pragmatic metric (the IDM-Min score), reflecting whether there was any discussion of the patient's role or preference and of the nature of the decision. The visit duration was studied in relation to the extent of the informed decision-making, and excellent time-efficient examples were sought.There were 141 informed-decision-making discussions about surgery, including knee and hip replacement as well as wrist/hand, shoulder, and arthroscopic surgery. Surgeons frequently discussed the nature of the decision (92% of the time), alternatives (62%), and risks and benefits (59%); they rarely discussed the patient's role (14%) or assessed the patient's understanding (12%). The IDM-18 scores of the 141 discussions averaged 5.9 (range, 0 to 15; 95% confidence interval, 5.4 to 6.5). Fifty-seven percent of the discussions met the IDM-Min criteria. The median duration of the visits was sixteen minutes; the extent of informed decision-making had only a modest relationship with the visit duration. Time-efficient strategies that were identified included use of scenarios to illustrate distinct choices, encouraging patient input, and addressing primary concerns rather than lengthy recitations of pros and cons.In this study, which we believe is the first to focus on informed decision-making in orthopaedic surgical practice, we found opportunities for improvement but we also found that excellent informed decision-making is feasible and can be accomplished in a time-efficient manner.

  View details for DOI 10.2106/JBJS.G.00840

  View details for PubMedID 18762641

  View details for PubMedCentralID PMC2657309

• "Surgery Is Certainly One Good Option": Quality and time-efficiency of informed decision-making in surgery JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Braddock, C., Hudak, P. L., Feldman, J. J., Bereknyei, S., Frankel, R. M., Levinson, W. 2008; 90A (9): 1830-1838

  Abstract

  Informed decision-making has been widely promoted in several medical settings, but little is known about the actual practice in orthopaedic surgery and there are no clear guidelines on how to improve the process in this setting. This study was designed to explore the quality of informed decision-making in orthopaedic practice and to identify excellent time-efficient examples with older patients.We recruited orthopaedic surgeons, and patients sixty years of age or older, in a Midwestern metropolitan area for a descriptive study performed through the analysis of audiotaped physician-patient interviews. We used a valid and reliable measure to assess the elements of informed decision-making. These included discussions of the nature of the decision, the patient's role, alternatives, pros and cons, and uncertainties; assessment of the patient's understanding and his or her desire to receive input from others; and exploration of the patient's preferences and the impact on the patient's daily life. The audiotapes were scored with regard to whether there was a complete discussion of each informed-decision-making element (an IDM-18 score of 2) or a partial discussion of each element (an IDM-18 score of 1) as well as with a more pragmatic metric (the IDM-Min score), reflecting whether there was any discussion of the patient's role or preference and of the nature of the decision. The visit duration was studied in relation to the extent of the informed decision-making, and excellent time-efficient examples were sought.There were 141 informed-decision-making discussions about surgery, including knee and hip replacement as well as wrist/hand, shoulder, and arthroscopic surgery. Surgeons frequently discussed the nature of the decision (92% of the time), alternatives (62%), and risks and benefits (59%); they rarely discussed the patient's role (14%) or assessed the patient's understanding (12%). The IDM-18 scores of the 141 discussions averaged 5.9 (range, 0 to 15; 95% confidence interval, 5.4 to 6.5). Fifty-seven percent of the discussions met the IDM-Min criteria. The median duration of the visits was sixteen minutes; the extent of informed decision-making had only a modest relationship with the visit duration. Time-efficient strategies that were identified included use of scenarios to illustrate distinct choices, encouraging patient input, and addressing primary concerns rather than lengthy recitations of pros and cons.In this study, which we believe is the first to focus on informed decision-making in orthopaedic surgical practice, we found opportunities for improvement but we also found that excellent informed decision-making is feasible and can be accomplished in a time-efficient manner.

  View details for DOI 10.2106/JBJS.G.00840

  View details for Web of Science ID 000259049300003

  View details for PubMedCentralID PMC2657309

• Informed decision-making and colorectal cancer screening - Is it occurring in primary care? 30th Annual Meeting of the Society-of-General-Internal-Medicine Ling, B. S., Trauth, J. M., Fine, M. J., Mor, M. K., Resnick, A., Braddock, C. H., Bereknyei, S., Weissfeld, J. L., Schoen, R. E., Ricci, E. M., Whittle, J. LIPPINCOTT WILLIAMS & WILKINS. 2008: S23–S29

  Abstract

  Current recommendations advise patients to participate in the decision-making for selecting a colorectal cancer (CRC) screening option. The degree to which providers communicate the information necessary to prepare patients for participation in this process is not known.To assess the level of informed decision-making occurring during actual patient-provider communications on CRC screening and test for the association between informed decision-making and screening behavior.Observational study of audiotaped clinic visits between patients and their providers in the primary care clinic at a Veterans Administration Medical Center.Male patients, age 50-74 years, presenting to a primary care visit at the study site.The Informed Decision-Making (IDM) Model was used to code the audiotapes for 9 elements of communication that should occur to prepare patients for participation in decision-making. The primary outcome is completion of CRC screening during the study period.The analytic cohort consisted of 91 patients due for CRC screening who had a test ordered at the visit. Six of the 9 IDM elements occurred in < or =20% of the visits with none addressed in > or =50%. CRC screening occurred less frequently for those discussing "pros and cons" (12% vs. 46%, P = 0.01) and "patient preferences" (6% vs. 47%, P = 0.001) compared with those who did not.We found that a lack of informed decision-making occurred during CRC screening discussions and that particular elements of the process were negatively associated with screening. Further research is needed to better understand the effects of informed decision-making on screening behavior.

  View details for Web of Science ID 000258945500005

  View details for PubMedID 18725829

• "It's Not What You Say..." - Racial disparities in communication between orthopedic surgeons and patients MEDICAL CARE Levinson, W., Hudak, P. L., Feldman, J. J., Frankel, R. M., Kuby, A., Bereknyei, S., Braddock, C. 2008; 46 (4): 410-416

  Abstract

  Excellent communication between surgeons and patients is critical to helping patients to make informed decisions and is a key component of both high quality of care and patient satisfaction. Understanding racial disparities in communication is essential to provide quality care to all patients.To examine the content and process of informed decision-making (IDM) between orthopedic surgeons and elderly white versus African American patients. To assess the association of race and patient satisfaction with surgeon communication.Analysis of audiotape recordings of office visits between orthopedic surgeons and patients.Eighty-nine orthopedic surgeons and 886 patients age 60 years or older in Chicago, Illinois.Tapes were analyzed by coders for content using 9 elements of IDM and for process using 4 global ratings of the relationship-building component of communication (responsiveness, respect, listening, and sharing). Ratings by race were compared using chi analysis. Patients completed a questionnaire rating satisfaction with surgeon communication and the visit overall. Logistic analysis was used to assess the effect of race on satisfaction.Overall there were practically no significant differences in the content of the 9 IDM elements based on race. However, coder ratings of relationship were higher on 3 of 4 global ratings (responsiveness, respect, and listening) in visits with white patients compared with African American patients (P < 0.01). Patient ratings of communication and overall satisfaction with the visit were significantly higher for white patients.The content of IDM conversations does not differ by race. Yet differences in the process of relationship building and in patient satisfaction ratings were clearly present. Efforts to enhance cultural communication competence of surgeons should emphasize the skills of building relationships with patients in addition to the content of IDM.

  View details for Web of Science ID 000254571100011

  View details for PubMedID 18362821

  View details for PubMedCentralID PMC3593347

• Communications on colorectal and prostate cancer screening: Are patient perceptions consistent with actual information exchanged 31st Annual Meeting of the Society-of-General-Internal-Medicine Ling, B., Trauth, J. M., Fine, M. J., Mor, M. K., Braddock, C. H., Bereknyei, S., Weissfeld, J., Schoen, R., Whittle, J. SPRINGER. 2008: 269–269

  View details for Web of Science ID 000254237100492

• Validating measures of third year medical students' use of interpreters by standardized patients and faculty observers JOURNAL OF GENERAL INTERNAL MEDICINE Lie, D., Boker, J., Bereknyei, S., Ahearn, S., Fesko, C., Lenahan, P. 2007; 22: 336-340

  Abstract

  Increasing prevalence of limited English proficiency patient encounters demands effective use of interpreters. Validated measures for this skill are needed.We describe the process of creating and validating two new measures for rating student skills for interpreter use.Encounters using standardized patients (SPs) and interpreters within a clinical practice examination (CPX) at one medical school.Students were assessed by SPs using the interpreter impact rating scale (IIRS) and the physician patient interaction (PPI) scale. A subset of 23 encounters was assessed by 4 faculty raters using the faculty observer rating scale (FORS). Internal consistency reliability was assessed by Cronbach's coefficient alpha (alpha). Interrater reliability of the FORS was examined by the intraclass correlation coefficient (ICC). The FORS and IIRS were compared and each was correlated with the PPI.Cronbach's alpha was 0.90 for the 7-item IIRS and 0.88 for the 11-item FORS. ICC among 4 faculty observers had a mean of 0.61 and median of 0.65 (0.20, 0.86). Skill measured by the IIRS did not significantly correlate with FORS but correlated with the PPI.We developed two measures with good internal reliability for use by SPs and faculty observers. More research is needed to clarify the reasons for the lack of concordance between these measures and which may be more valid for use as a summative assessment measure.

  View details for DOI 10.1007/s11606-007-0349-3

  View details for Web of Science ID 000250866700013

  View details for PubMedID 17957421

  View details for PubMedCentralID PMC2078539

• Informed decision making and colorectal cancer screening: Is it occurring in primary care and what is the impact on screening rates? 30th Annual Meeting of the Society-of-General-Internal-Medicine Ling, B., Trauth, J. M., Fine, M. J., Mor, M. K., Abby, R., Braddock, C. H., Bereknyei, S., Weissfeld, J., Schoen, R., Whittle, J. SPRINGER. 2007: 40–40

  View details for Web of Science ID 000251610700135

• Impact of a multifaceted curriculum in multi-cultural practice on medical student attitudes Braddock, C. H., Bereknyei, S., Medrano, M. SPRINGER. 2007: 85-86

  View details for Web of Science ID 000251610700289

• Focus groups to explore older patients' views of an informed decision making model Leemann, E. L., Bereknyei, S., Kuby, A., Braddock, C. SPRINGER. 2007: 114

  View details for Web of Science ID 000251610700387

• Toward shared decision making at the end of life in intensive care units - Opportunities for improvement ARCHIVES OF INTERNAL MEDICINE White, D. B., Braddock, C. H., Bereknyei, S., Curtis, J. R. 2007; 167 (5): 461-467

  Abstract

  In North America, families generally wish to be involved in end-of-life decisions when the patient cannot participate, yet little is known about the extent to which shared decision making occurs in intensive care units.We audiotaped 51 physician-family conferences about major end-of-life treatment decisions at 4 hospitals from August 1, 2000, to July 31, 2002. We measured shared decision making using a previously validated instrument to assess the following 10 elements: discussing the nature of the decision, describing treatment alternatives, discussing the pros and cons of the choices, discussing uncertainty, assessing family understanding, eliciting patient values and preferences, discussing the family's role in decision making, assessing the need for input from others, exploring the context of the decision, and eliciting the family's opinion about the treatment decision. We used a mixed-effects regression model to determine predictors of shared decision making and to evaluate whether higher levels of shared decision making were associated with greater family satisfaction.Only 2% (1/51) of decisions met all 10 criteria for shared decision making. The most frequently addressed elements were the nature of the decision (100%) and the context of the decision to be made (92%). The least frequently addressed elements were the family's role in decision making (31%) and an assessment of the family's understanding of the decision (25%). In multivariate analysis, lower family educational level was associated with less shared decision making (partial correlation coefficient, 0.34; standardized beta, .3; P = .02). Higher levels of shared decision making were associated with greater family satisfaction with communication (partial correlation coefficient, 0.15; standardized beta, .09; P = .03).Shared decision making about end-of-life treatment choices was often incomplete, especially among less educated families. Higher levels of shared decision making were associated with greater family satisfaction. Shared decision making may be an important area for quality improvement in intensive care units.

  View details for Web of Science ID 000244854400009

  View details for PubMedID 17353493