All Content

Clinical Question: Does improving hand hygiene compliance from a high level (>80%) to a very high level (>95%) reduce healthcare-associated infections?

Background: Hand hygiene compliance remains an elusive infection prevention parameter to master. Studies show a correlation in reduction of healthcare-associated infections with improved hand hygiene compliance from a low to medium level, but little data exist on very high rates of hand hygiene compliance.

Study Design: Prospective observational.

Setting: University of North Carolina Hospitals.

Synopsis: Researchers recruited all hospital staff to be hand hygiene monitors, thereby using the Hawthorne effect to drive hand hygiene compliance rates. Over a 17-month period, >4,000 unique observers made >140,000 observations. Data showed a significant increase in hand hygiene compliance rates of about 10% (P<0.001) and a significant decrease in overall healthcare-associated infection rates of about 6% (P=0.0066). A reduction in healthcare-associated Clostridium difficile infection of 14% was observed in association with the improved hand hygiene compliance. No association with multidrug-resistant organisms was found.

Bottom Line: There is continued correlation between improved hand hygiene compliance and reduced healthcare-associated infection rates even at very high levels (>95%) of hand hygiene compliance.

Citation: Sickbert-Bennett EE, DiBiase LM, Willis TM, Wolak ES, Weber DJ, Rutala WA. Reduction of healthcare-associated infections by exceeding high compliance with hand hygiene practices. Emerg Infect Dis. 2016;22(9):1628-1630.

Short Take

Avoid Fluoroquinolones in Acute Sinusitis, Acute Exacerbations of Bronchitis, and Uncomplicated Urinary Tract Infections If Other Treatment Options Exist

Because fluoroquinolones have been associated with potentially permanent side effects involving tendons, muscles, joints, and nerves, the FDA recently updated the boxed warning to state that the risk of use likely outweighs the benefit for uncomplicated infections.

Citation: Fluoroquinolone Antibacterial Drugs for Systemic Use: Drug Safety Communication - Warnings Updated Due to Disabling Side Effects. FDA website. Accessed September 9, 2016.

Clinical Question: Does improving hand hygiene compliance from a high level (>80%) to a very high level (>95%) reduce healthcare-associated infections?

Background: Hand hygiene compliance remains an elusive infection prevention parameter to master. Studies show a correlation in reduction of healthcare-associated infections with improved hand hygiene compliance from a low to medium level, but little data exist on very high rates of hand hygiene compliance.

Study Design: Prospective observational.

Setting: University of North Carolina Hospitals.

Synopsis: Researchers recruited all hospital staff to be hand hygiene monitors, thereby using the Hawthorne effect to drive hand hygiene compliance rates. Over a 17-month period, >4,000 unique observers made >140,000 observations. Data showed a significant increase in hand hygiene compliance rates of about 10% (P<0.001) and a significant decrease in overall healthcare-associated infection rates of about 6% (P=0.0066). A reduction in healthcare-associated Clostridium difficile infection of 14% was observed in association with the improved hand hygiene compliance. No association with multidrug-resistant organisms was found.

Bottom Line: There is continued correlation between improved hand hygiene compliance and reduced healthcare-associated infection rates even at very high levels (>95%) of hand hygiene compliance.

Citation: Sickbert-Bennett EE, DiBiase LM, Willis TM, Wolak ES, Weber DJ, Rutala WA. Reduction of healthcare-associated infections by exceeding high compliance with hand hygiene practices. Emerg Infect Dis. 2016;22(9):1628-1630.

Short Take

Avoid Fluoroquinolones in Acute Sinusitis, Acute Exacerbations of Bronchitis, and Uncomplicated Urinary Tract Infections If Other Treatment Options Exist

Because fluoroquinolones have been associated with potentially permanent side effects involving tendons, muscles, joints, and nerves, the FDA recently updated the boxed warning to state that the risk of use likely outweighs the benefit for uncomplicated infections.

Citation: Fluoroquinolone Antibacterial Drugs for Systemic Use: Drug Safety Communication - Warnings Updated Due to Disabling Side Effects. FDA website. Accessed September 9, 2016.

Clinical Question: Does improving hand hygiene compliance from a high level (>80%) to a very high level (>95%) reduce healthcare-associated infections?

Background: Hand hygiene compliance remains an elusive infection prevention parameter to master. Studies show a correlation in reduction of healthcare-associated infections with improved hand hygiene compliance from a low to medium level, but little data exist on very high rates of hand hygiene compliance.

Study Design: Prospective observational.

Setting: University of North Carolina Hospitals.

Synopsis: Researchers recruited all hospital staff to be hand hygiene monitors, thereby using the Hawthorne effect to drive hand hygiene compliance rates. Over a 17-month period, >4,000 unique observers made >140,000 observations. Data showed a significant increase in hand hygiene compliance rates of about 10% (P<0.001) and a significant decrease in overall healthcare-associated infection rates of about 6% (P=0.0066). A reduction in healthcare-associated Clostridium difficile infection of 14% was observed in association with the improved hand hygiene compliance. No association with multidrug-resistant organisms was found.

Bottom Line: There is continued correlation between improved hand hygiene compliance and reduced healthcare-associated infection rates even at very high levels (>95%) of hand hygiene compliance.

Citation: Sickbert-Bennett EE, DiBiase LM, Willis TM, Wolak ES, Weber DJ, Rutala WA. Reduction of healthcare-associated infections by exceeding high compliance with hand hygiene practices. Emerg Infect Dis. 2016;22(9):1628-1630.

Short Take

Avoid Fluoroquinolones in Acute Sinusitis, Acute Exacerbations of Bronchitis, and Uncomplicated Urinary Tract Infections If Other Treatment Options Exist

Because fluoroquinolones have been associated with potentially permanent side effects involving tendons, muscles, joints, and nerves, the FDA recently updated the boxed warning to state that the risk of use likely outweighs the benefit for uncomplicated infections.

Citation: Fluoroquinolone Antibacterial Drugs for Systemic Use: Drug Safety Communication - Warnings Updated Due to Disabling Side Effects. FDA website. Accessed September 9, 2016.

Clinical Question: Does direct observation underestimate physician compliance with hand hygiene (HH) compared to other professional groups due to the Hawthorne effect?

Background: Although it is well-known that HH is imperative to infection control, physician compliance remains suboptimal and is often reported to be below that of nurses. The Hawthorne effect may be contributing to this perceived difference because nurses, who work on the same unit consistently, may more readily recognize hospital auditors.

Study Design: Observational.

Setting: 800-bed acute-care academic hospital in Canada.

Synopsis: Two students were trained to covertly observe physician and nursing HH compliance on inpatient units. For two months, students rotated units every week to minimize risk of discovery. Their findings were compared with data gathered by hospital auditors over the same time period.

Covertly observed HH compliance was 50% (799/1,597 opportunities) compared with 83.7% (2,769/3,309) reported by hospital auditors (P<0.0002). The difference in physician compliance was 19% (73.2% compliance with overt observation versus 54.2% with covert observation). The difference was much higher for nurses at 40.7% (85.8% compliance with overt observation versus 45.1% with covert observation). Attending physician behaviors heavily influenced team behaviors—79.5% of trainees were compliant if their attending was compliant compared with 18.9% if attending was not (P<0.0002).

Bottom Line: Traditional HH audit findings that physicians are less compliant than nurses may be at least partially due to the Hawthorne effect. Nonetheless, all healthcare providers have substantial room for improvement, and attending physicians are powerful role models to effect this change.

Citation: Kovacs-Litman A, Wong K, Shojania KJ, Callery S, Vearncombe M, Leis J. Do physicians clean their hands? Insights from a covert observational study [published online ahead of print July 5, 2016]. J Hosp Med.

Clinical Question: Does direct observation underestimate physician compliance with hand hygiene (HH) compared to other professional groups due to the Hawthorne effect?

Background: Although it is well-known that HH is imperative to infection control, physician compliance remains suboptimal and is often reported to be below that of nurses. The Hawthorne effect may be contributing to this perceived difference because nurses, who work on the same unit consistently, may more readily recognize hospital auditors.

Study Design: Observational.

Setting: 800-bed acute-care academic hospital in Canada.

Synopsis: Two students were trained to covertly observe physician and nursing HH compliance on inpatient units. For two months, students rotated units every week to minimize risk of discovery. Their findings were compared with data gathered by hospital auditors over the same time period.

Covertly observed HH compliance was 50% (799/1,597 opportunities) compared with 83.7% (2,769/3,309) reported by hospital auditors (P<0.0002). The difference in physician compliance was 19% (73.2% compliance with overt observation versus 54.2% with covert observation). The difference was much higher for nurses at 40.7% (85.8% compliance with overt observation versus 45.1% with covert observation). Attending physician behaviors heavily influenced team behaviors—79.5% of trainees were compliant if their attending was compliant compared with 18.9% if attending was not (P<0.0002).

Bottom Line: Traditional HH audit findings that physicians are less compliant than nurses may be at least partially due to the Hawthorne effect. Nonetheless, all healthcare providers have substantial room for improvement, and attending physicians are powerful role models to effect this change.

Citation: Kovacs-Litman A, Wong K, Shojania KJ, Callery S, Vearncombe M, Leis J. Do physicians clean their hands? Insights from a covert observational study [published online ahead of print July 5, 2016]. J Hosp Med.

Clinical Question: Does direct observation underestimate physician compliance with hand hygiene (HH) compared to other professional groups due to the Hawthorne effect?

Background: Although it is well-known that HH is imperative to infection control, physician compliance remains suboptimal and is often reported to be below that of nurses. The Hawthorne effect may be contributing to this perceived difference because nurses, who work on the same unit consistently, may more readily recognize hospital auditors.

Study Design: Observational.

Setting: 800-bed acute-care academic hospital in Canada.

Synopsis: Two students were trained to covertly observe physician and nursing HH compliance on inpatient units. For two months, students rotated units every week to minimize risk of discovery. Their findings were compared with data gathered by hospital auditors over the same time period.

Covertly observed HH compliance was 50% (799/1,597 opportunities) compared with 83.7% (2,769/3,309) reported by hospital auditors (P<0.0002). The difference in physician compliance was 19% (73.2% compliance with overt observation versus 54.2% with covert observation). The difference was much higher for nurses at 40.7% (85.8% compliance with overt observation versus 45.1% with covert observation). Attending physician behaviors heavily influenced team behaviors—79.5% of trainees were compliant if their attending was compliant compared with 18.9% if attending was not (P<0.0002).

Bottom Line: Traditional HH audit findings that physicians are less compliant than nurses may be at least partially due to the Hawthorne effect. Nonetheless, all healthcare providers have substantial room for improvement, and attending physicians are powerful role models to effect this change.

Citation: Kovacs-Litman A, Wong K, Shojania KJ, Callery S, Vearncombe M, Leis J. Do physicians clean their hands? Insights from a covert observational study [published online ahead of print July 5, 2016]. J Hosp Med.

In recognition of Chronic Obstructive Pulmonary Disease (COPD) Month, check out SHM’s free guide and toolkit to improve the care of patients hospitalized for an exacerbation of COPD. The toolkit can also help you make changes to COPD care at both the individual patient and institutional level.

Download the guide or view the toolkit today at www.hospitalmedicine.org/copd.

In recognition of Chronic Obstructive Pulmonary Disease (COPD) Month, check out SHM’s free guide and toolkit to improve the care of patients hospitalized for an exacerbation of COPD. The toolkit can also help you make changes to COPD care at both the individual patient and institutional level.

Download the guide or view the toolkit today at www.hospitalmedicine.org/copd.

In recognition of Chronic Obstructive Pulmonary Disease (COPD) Month, check out SHM’s free guide and toolkit to improve the care of patients hospitalized for an exacerbation of COPD. The toolkit can also help you make changes to COPD care at both the individual patient and institutional level.

Download the guide or view the toolkit today at www.hospitalmedicine.org/copd.

Delivering feedback is a fundamental skill in medicine. Feedback ensures trainees remain on track to meet expected goals and standards. At some point in our careers, all of us have been on the receiving end of feedback. Many of us have likely had the opportunity to provide feedback to students or junior residents during our training. Moving from the role of trainee to supervisor presents a unique set of challenges and responsibilities to the young hospitalist.

Despite an extensive amount published on feedback, translation from theory to practice remains challenging.1 When surveyed, medical students and residents commonly perceive they do not receive enough feedback.2 Conversely, attendees of faculty development courses frequently indicate their greatest need is learning how to give feedback more effectively.3 Why does this performance gap exist?

The Issues

Careful exploration of our current training model reveals several systemic barriers to effective feedback. For one, many faculty members who supervise trainees are not formally trained educators. As such, they may lack the proper skills set to deliver feedback.1 Additionally, lack of time is often cited in the pressure to complete both clinical and academic duties within a packed workday. If learners aren’t directly observed by their supervisors, the impact and quality of feedback substantially diminishes.4 Likewise, if feedback is not embedded in the local culture and expected by both educator and learner, it can be perceived as a burden rather than a valuable exercise.

Feedback can evoke deep, sometimes subconscious emotional responses in both supervisor and recipient. During verbal interactions with trainees, dialogue tends to assume positive or neutral tones regardless of content.5 To avoid bruising a young learner’s ego, a well-intentioned educator may talk around the actual problem, using indirect statements in an attempt to “soften the blow.” Fearing a negative evaluation, the student may support and reinforce the teacher’s avoidance, further obscuring the message being sent. This concept is known as “vanishing feedback” and is a common barrier to the delivery of effective feedback.4 Educators additionally may shy away from giving constructive feedback because they fear reprisal on teaching evaluations.

Mounting evidence shows physicians, as a whole, tend to overestimate their abilities, and many are not skilled at self-assessment.6 When physician-learners receive feedback incongruent with their own self-perceptions, it may trigger feelings of anger, sadness, guilt, or self-doubt, which may block the receipt of any useful information. The so-called “millennial generation effect,” describing current medical school graduates, may further compound this issue. Millennials are “raised with an emphasis on being special; a previous absence of a balanced focus on weakness may present a barrier to accepting the validity of negative feedback.”1,5 As such, certain learners may intentionally avoid feedback as a method of self-preservation.

A New Approach

Many of us were taught to use the “feedback sandwich,” in which two positive statements surround a single negative corrective comment. This model, however, has some notable weaknesses. Given the ratio of positive to negative statements, educators may concentrate too heavily on the positive, diluting any constructive criticism and leaving learners with a false impression. Alternatively, trainees may learn to ignore positive comments while waiting for the other shoe to drop. As such, any initial positivity may feel insincere and artificial.7

Instead, we advocate using the “reflective feedback conversation,” a model that begins with self-assessment and places the onus on learners to identify their strengths and weaknesses.7 For example, a trainee might remark, “I struggle with controlling my temper when I am stressed.” The educator might reinforce that comment by stating, “I noticed you raised your voice last week when talking with the nurse because she forgot to administer Lasix.” To conclude the conversation, the teacher and student discuss shared goal setting and mutually agree on future improvements. Notably, this model does not facilitate conversation about problems a learner fails to detect. Hence, the educator must be prepared to deliver feedback outside of the learner’s own assessment.

 

Here are our favorite tips and tricks for delivering effective feedback:

1. Establish a positive learning climate. Educators must partner with learners to generate an atmosphere of mutual trust and respect.1,3,4,8 An example of how to ally with learners is to announce early on, “As a teacher, I really value feedback. As such, I plan on giving feedback throughout the rotation because I want you to be the best doctor you can possibly be.”
2. Require reflection. Effective feedback hinges on learners’ ability to self-assess.2,5,7 One approach is starting each feedback session with a simple open-ended question, such as, “How do you think you are doing?” Alternatively, you could be more specific, such as, “How do you think you did in managing the patient’s electrolytes when he went into diabetic ketoacidosis?”
3. Be prompt. Feedback should be timely.1,4,7,8 An important distinction between feedback and evaluation is that feedback is formative, enabling learners to make needed changes before the end of a course, whereas evaluation is summative and presents a distinct judgment.1,4 If feedback is withheld until the end of the rotation, learners will not have an opportunity to remediate behaviors.
4. Take advantage of different formats. Try a brief, concrete suggestion on the fly. A statement that might occur on bedside rounds is, “Allow me to show you a better technique to measure the liver span.” Or use a teachable event, such as a medical error or a particularly challenging case. Pulling interns aside after they deliver sobering news is a great opportunity to provide feedback in a semiformal fashion. Finally, formal sit-down feedback should be scheduled halfway through each rotation to ensure learners are on track and to address any major issues, such as professionalism or an inadequate clinical performance.2
5. Be specific. Focus on behaviors and examples rather than judgments.1,2,4,7,8 For example, we have all experienced the inattentive student. Instead of framing feedback as, “It seems like you don’t care about medicine because you weren’t paying attention on rounds,” one could say, “I noticed you were fidgeting and looking at your phone during Aaron’s presentation.” Feedback should be based on firsthand observations and should be descriptive, utilizing neutral language.
6. Avoid information overload. Feedback is best consumed in small snacks rather than an all-you-can-eat buffet.1,7 Your goal should not be to completely overhaul a learner but rather to focus on a few observable, correctable behaviors.
7. Be empathetic. To make negative feedback less threatening, take yourself off the pedestal. An example of this could be saying, “As a third-year medical student, I struggled to remember all the right questions to ask, so performing a thorough review of systems helped me to catch the things I would miss.”
8. Confirm understanding. It is important to know the learner has heard the feedback and to conclude the session with an action plan.

Just as hospitals engage in continuous quality improvement, as professionals, we should all strive for continuous self-improvement. Giving and receiving feedback is critical to personal growth. It is our hope that by using these tips, all of us will improve, creating a new generation of providers who give effective and useful feedback.

References

1. Anderson PA. Giving feedback on clinical skills: are we starving our young? J Grad Med Educ. 2012;4(2):154-158. doi:10.4300/JGME-D-11-000295.1.
2. Branch WT, Paranjape A. Feedback and reflection: teaching methods for clinical settings. Acad Med. 2002;77(12 Pt 1):1185-1188.
3. Hewson MG, Little ML. Giving feedback in medical education: verification of recommended techniques. J Gen Intern Med. 1998;13(2):111-116.
4. Ende J. Feedback in clinical medical education. JAMA. 1983;250(6):777-781.
5. Bing-You RG, Trowbridge RL. Why medical educators may be failing at feedback. JAMA. 2009;302(12):1330-1331.
6. Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA. 2006;296(9):1094-1102.
7. Cantillon P, Sargeant J. Giving feedback in clinical settings. BMJ. 2008;337:a1961.
8. Ramani S, Krackov SK. Twelve tips for giving feedback effectively in the clinical environment. Med Teach. 2012;34(10):787-791.

Delivering feedback is a fundamental skill in medicine. Feedback ensures trainees remain on track to meet expected goals and standards. At some point in our careers, all of us have been on the receiving end of feedback. Many of us have likely had the opportunity to provide feedback to students or junior residents during our training. Moving from the role of trainee to supervisor presents a unique set of challenges and responsibilities to the young hospitalist.

Despite an extensive amount published on feedback, translation from theory to practice remains challenging.1 When surveyed, medical students and residents commonly perceive they do not receive enough feedback.2 Conversely, attendees of faculty development courses frequently indicate their greatest need is learning how to give feedback more effectively.3 Why does this performance gap exist?

The Issues

Careful exploration of our current training model reveals several systemic barriers to effective feedback. For one, many faculty members who supervise trainees are not formally trained educators. As such, they may lack the proper skills set to deliver feedback.1 Additionally, lack of time is often cited in the pressure to complete both clinical and academic duties within a packed workday. If learners aren’t directly observed by their supervisors, the impact and quality of feedback substantially diminishes.4 Likewise, if feedback is not embedded in the local culture and expected by both educator and learner, it can be perceived as a burden rather than a valuable exercise.

Feedback can evoke deep, sometimes subconscious emotional responses in both supervisor and recipient. During verbal interactions with trainees, dialogue tends to assume positive or neutral tones regardless of content.5 To avoid bruising a young learner’s ego, a well-intentioned educator may talk around the actual problem, using indirect statements in an attempt to “soften the blow.” Fearing a negative evaluation, the student may support and reinforce the teacher’s avoidance, further obscuring the message being sent. This concept is known as “vanishing feedback” and is a common barrier to the delivery of effective feedback.4 Educators additionally may shy away from giving constructive feedback because they fear reprisal on teaching evaluations.

Mounting evidence shows physicians, as a whole, tend to overestimate their abilities, and many are not skilled at self-assessment.6 When physician-learners receive feedback incongruent with their own self-perceptions, it may trigger feelings of anger, sadness, guilt, or self-doubt, which may block the receipt of any useful information. The so-called “millennial generation effect,” describing current medical school graduates, may further compound this issue. Millennials are “raised with an emphasis on being special; a previous absence of a balanced focus on weakness may present a barrier to accepting the validity of negative feedback.”1,5 As such, certain learners may intentionally avoid feedback as a method of self-preservation.

A New Approach

Many of us were taught to use the “feedback sandwich,” in which two positive statements surround a single negative corrective comment. This model, however, has some notable weaknesses. Given the ratio of positive to negative statements, educators may concentrate too heavily on the positive, diluting any constructive criticism and leaving learners with a false impression. Alternatively, trainees may learn to ignore positive comments while waiting for the other shoe to drop. As such, any initial positivity may feel insincere and artificial.7

Instead, we advocate using the “reflective feedback conversation,” a model that begins with self-assessment and places the onus on learners to identify their strengths and weaknesses.7 For example, a trainee might remark, “I struggle with controlling my temper when I am stressed.” The educator might reinforce that comment by stating, “I noticed you raised your voice last week when talking with the nurse because she forgot to administer Lasix.” To conclude the conversation, the teacher and student discuss shared goal setting and mutually agree on future improvements. Notably, this model does not facilitate conversation about problems a learner fails to detect. Hence, the educator must be prepared to deliver feedback outside of the learner’s own assessment.

 

Here are our favorite tips and tricks for delivering effective feedback:

1. Establish a positive learning climate. Educators must partner with learners to generate an atmosphere of mutual trust and respect.1,3,4,8 An example of how to ally with learners is to announce early on, “As a teacher, I really value feedback. As such, I plan on giving feedback throughout the rotation because I want you to be the best doctor you can possibly be.”
2. Require reflection. Effective feedback hinges on learners’ ability to self-assess.2,5,7 One approach is starting each feedback session with a simple open-ended question, such as, “How do you think you are doing?” Alternatively, you could be more specific, such as, “How do you think you did in managing the patient’s electrolytes when he went into diabetic ketoacidosis?”
3. Be prompt. Feedback should be timely.1,4,7,8 An important distinction between feedback and evaluation is that feedback is formative, enabling learners to make needed changes before the end of a course, whereas evaluation is summative and presents a distinct judgment.1,4 If feedback is withheld until the end of the rotation, learners will not have an opportunity to remediate behaviors.
4. Take advantage of different formats. Try a brief, concrete suggestion on the fly. A statement that might occur on bedside rounds is, “Allow me to show you a better technique to measure the liver span.” Or use a teachable event, such as a medical error or a particularly challenging case. Pulling interns aside after they deliver sobering news is a great opportunity to provide feedback in a semiformal fashion. Finally, formal sit-down feedback should be scheduled halfway through each rotation to ensure learners are on track and to address any major issues, such as professionalism or an inadequate clinical performance.2
5. Be specific. Focus on behaviors and examples rather than judgments.1,2,4,7,8 For example, we have all experienced the inattentive student. Instead of framing feedback as, “It seems like you don’t care about medicine because you weren’t paying attention on rounds,” one could say, “I noticed you were fidgeting and looking at your phone during Aaron’s presentation.” Feedback should be based on firsthand observations and should be descriptive, utilizing neutral language.
6. Avoid information overload. Feedback is best consumed in small snacks rather than an all-you-can-eat buffet.1,7 Your goal should not be to completely overhaul a learner but rather to focus on a few observable, correctable behaviors.
7. Be empathetic. To make negative feedback less threatening, take yourself off the pedestal. An example of this could be saying, “As a third-year medical student, I struggled to remember all the right questions to ask, so performing a thorough review of systems helped me to catch the things I would miss.”
8. Confirm understanding. It is important to know the learner has heard the feedback and to conclude the session with an action plan.

Just as hospitals engage in continuous quality improvement, as professionals, we should all strive for continuous self-improvement. Giving and receiving feedback is critical to personal growth. It is our hope that by using these tips, all of us will improve, creating a new generation of providers who give effective and useful feedback.

References

1. Anderson PA. Giving feedback on clinical skills: are we starving our young? J Grad Med Educ. 2012;4(2):154-158. doi:10.4300/JGME-D-11-000295.1.
2. Branch WT, Paranjape A. Feedback and reflection: teaching methods for clinical settings. Acad Med. 2002;77(12 Pt 1):1185-1188.
3. Hewson MG, Little ML. Giving feedback in medical education: verification of recommended techniques. J Gen Intern Med. 1998;13(2):111-116.
4. Ende J. Feedback in clinical medical education. JAMA. 1983;250(6):777-781.
5. Bing-You RG, Trowbridge RL. Why medical educators may be failing at feedback. JAMA. 2009;302(12):1330-1331.
6. Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA. 2006;296(9):1094-1102.
7. Cantillon P, Sargeant J. Giving feedback in clinical settings. BMJ. 2008;337:a1961.
8. Ramani S, Krackov SK. Twelve tips for giving feedback effectively in the clinical environment. Med Teach. 2012;34(10):787-791.

Delivering feedback is a fundamental skill in medicine. Feedback ensures trainees remain on track to meet expected goals and standards. At some point in our careers, all of us have been on the receiving end of feedback. Many of us have likely had the opportunity to provide feedback to students or junior residents during our training. Moving from the role of trainee to supervisor presents a unique set of challenges and responsibilities to the young hospitalist.

Despite an extensive amount published on feedback, translation from theory to practice remains challenging.1 When surveyed, medical students and residents commonly perceive they do not receive enough feedback.2 Conversely, attendees of faculty development courses frequently indicate their greatest need is learning how to give feedback more effectively.3 Why does this performance gap exist?

The Issues

Careful exploration of our current training model reveals several systemic barriers to effective feedback. For one, many faculty members who supervise trainees are not formally trained educators. As such, they may lack the proper skills set to deliver feedback.1 Additionally, lack of time is often cited in the pressure to complete both clinical and academic duties within a packed workday. If learners aren’t directly observed by their supervisors, the impact and quality of feedback substantially diminishes.4 Likewise, if feedback is not embedded in the local culture and expected by both educator and learner, it can be perceived as a burden rather than a valuable exercise.

Feedback can evoke deep, sometimes subconscious emotional responses in both supervisor and recipient. During verbal interactions with trainees, dialogue tends to assume positive or neutral tones regardless of content.5 To avoid bruising a young learner’s ego, a well-intentioned educator may talk around the actual problem, using indirect statements in an attempt to “soften the blow.” Fearing a negative evaluation, the student may support and reinforce the teacher’s avoidance, further obscuring the message being sent. This concept is known as “vanishing feedback” and is a common barrier to the delivery of effective feedback.4 Educators additionally may shy away from giving constructive feedback because they fear reprisal on teaching evaluations.

Mounting evidence shows physicians, as a whole, tend to overestimate their abilities, and many are not skilled at self-assessment.6 When physician-learners receive feedback incongruent with their own self-perceptions, it may trigger feelings of anger, sadness, guilt, or self-doubt, which may block the receipt of any useful information. The so-called “millennial generation effect,” describing current medical school graduates, may further compound this issue. Millennials are “raised with an emphasis on being special; a previous absence of a balanced focus on weakness may present a barrier to accepting the validity of negative feedback.”1,5 As such, certain learners may intentionally avoid feedback as a method of self-preservation.

A New Approach

Many of us were taught to use the “feedback sandwich,” in which two positive statements surround a single negative corrective comment. This model, however, has some notable weaknesses. Given the ratio of positive to negative statements, educators may concentrate too heavily on the positive, diluting any constructive criticism and leaving learners with a false impression. Alternatively, trainees may learn to ignore positive comments while waiting for the other shoe to drop. As such, any initial positivity may feel insincere and artificial.7

Instead, we advocate using the “reflective feedback conversation,” a model that begins with self-assessment and places the onus on learners to identify their strengths and weaknesses.7 For example, a trainee might remark, “I struggle with controlling my temper when I am stressed.” The educator might reinforce that comment by stating, “I noticed you raised your voice last week when talking with the nurse because she forgot to administer Lasix.” To conclude the conversation, the teacher and student discuss shared goal setting and mutually agree on future improvements. Notably, this model does not facilitate conversation about problems a learner fails to detect. Hence, the educator must be prepared to deliver feedback outside of the learner’s own assessment.

 

Here are our favorite tips and tricks for delivering effective feedback:

1. Establish a positive learning climate. Educators must partner with learners to generate an atmosphere of mutual trust and respect.1,3,4,8 An example of how to ally with learners is to announce early on, “As a teacher, I really value feedback. As such, I plan on giving feedback throughout the rotation because I want you to be the best doctor you can possibly be.”
2. Require reflection. Effective feedback hinges on learners’ ability to self-assess.2,5,7 One approach is starting each feedback session with a simple open-ended question, such as, “How do you think you are doing?” Alternatively, you could be more specific, such as, “How do you think you did in managing the patient’s electrolytes when he went into diabetic ketoacidosis?”
3. Be prompt. Feedback should be timely.1,4,7,8 An important distinction between feedback and evaluation is that feedback is formative, enabling learners to make needed changes before the end of a course, whereas evaluation is summative and presents a distinct judgment.1,4 If feedback is withheld until the end of the rotation, learners will not have an opportunity to remediate behaviors.
4. Take advantage of different formats. Try a brief, concrete suggestion on the fly. A statement that might occur on bedside rounds is, “Allow me to show you a better technique to measure the liver span.” Or use a teachable event, such as a medical error or a particularly challenging case. Pulling interns aside after they deliver sobering news is a great opportunity to provide feedback in a semiformal fashion. Finally, formal sit-down feedback should be scheduled halfway through each rotation to ensure learners are on track and to address any major issues, such as professionalism or an inadequate clinical performance.2
5. Be specific. Focus on behaviors and examples rather than judgments.1,2,4,7,8 For example, we have all experienced the inattentive student. Instead of framing feedback as, “It seems like you don’t care about medicine because you weren’t paying attention on rounds,” one could say, “I noticed you were fidgeting and looking at your phone during Aaron’s presentation.” Feedback should be based on firsthand observations and should be descriptive, utilizing neutral language.
6. Avoid information overload. Feedback is best consumed in small snacks rather than an all-you-can-eat buffet.1,7 Your goal should not be to completely overhaul a learner but rather to focus on a few observable, correctable behaviors.
7. Be empathetic. To make negative feedback less threatening, take yourself off the pedestal. An example of this could be saying, “As a third-year medical student, I struggled to remember all the right questions to ask, so performing a thorough review of systems helped me to catch the things I would miss.”
8. Confirm understanding. It is important to know the learner has heard the feedback and to conclude the session with an action plan.

Just as hospitals engage in continuous quality improvement, as professionals, we should all strive for continuous self-improvement. Giving and receiving feedback is critical to personal growth. It is our hope that by using these tips, all of us will improve, creating a new generation of providers who give effective and useful feedback.

References

1. Anderson PA. Giving feedback on clinical skills: are we starving our young? J Grad Med Educ. 2012;4(2):154-158. doi:10.4300/JGME-D-11-000295.1.
2. Branch WT, Paranjape A. Feedback and reflection: teaching methods for clinical settings. Acad Med. 2002;77(12 Pt 1):1185-1188.
3. Hewson MG, Little ML. Giving feedback in medical education: verification of recommended techniques. J Gen Intern Med. 1998;13(2):111-116.
4. Ende J. Feedback in clinical medical education. JAMA. 1983;250(6):777-781.
5. Bing-You RG, Trowbridge RL. Why medical educators may be failing at feedback. JAMA. 2009;302(12):1330-1331.
6. Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA. 2006;296(9):1094-1102.
7. Cantillon P, Sargeant J. Giving feedback in clinical settings. BMJ. 2008;337:a1961.
8. Ramani S, Krackov SK. Twelve tips for giving feedback effectively in the clinical environment. Med Teach. 2012;34(10):787-791.

Clinical Question: Is there a mortality difference in nondiabetic patients with multivessel coronary artery disease (CAD) treated with coronary artery bypass graft (CABG) versus percutaneous coronary intervention (PCI)?

Background: Randomized clinical trials have shown a mortality benefit of CABG over PCI with drug-eluting stents (DES) for diabetic patients. The best strategy for nondiabetics, however, has not been well established.

Study Design: Pooled individual patient data from two large randomized clinical trials.

Setting: Multicenter, multinational (Europe, United States, Asia).

Synopsis: Excluding patients with left main disease, a total of 1,275 nondiabetic patients with two- or three-vessel CAD were analyzed. After median follow-up of 61 months, the CABG group had significantly fewer deaths from any cause (hazard ratio [HR], 0.65; 95% CI, 0.43–0.98; P=0.039) as well as fewer deaths from cardiac causes (HR, 0.41; 95% CI, 0.25–0.78; P=0.005) when compared to PCI with DES. The benefit was primarily seen at five-year follow-up in patients with intermediate to severe disease, with a nonsignificant difference detected in patients with less severe disease.

Despite the increasing popularity of DES, this study suggests that for nondiabetic patients with CAD, there is a mortality benefit at five years favoring CABG over PCI with DES. However, in this study stents used for PCI included both older and newer generation DES; a study using only newer DES may reduce the differences in outcomes between the groups.

Bottom Line: Five-year mortality is lower in nondiabetic patients with multivessel CAD treated with CABG compared with PCI with DES.

Citation: Chang M, Ahn JM, Lee CW, et al. Long-term mortality after coronary revascularization in nondiabetic patients with multivessel disease. J Am Coll Cardiol. 2016;68(1):29-36.

Clinical Question: Is there a mortality difference in nondiabetic patients with multivessel coronary artery disease (CAD) treated with coronary artery bypass graft (CABG) versus percutaneous coronary intervention (PCI)?

Background: Randomized clinical trials have shown a mortality benefit of CABG over PCI with drug-eluting stents (DES) for diabetic patients. The best strategy for nondiabetics, however, has not been well established.

Study Design: Pooled individual patient data from two large randomized clinical trials.

Setting: Multicenter, multinational (Europe, United States, Asia).

Synopsis: Excluding patients with left main disease, a total of 1,275 nondiabetic patients with two- or three-vessel CAD were analyzed. After median follow-up of 61 months, the CABG group had significantly fewer deaths from any cause (hazard ratio [HR], 0.65; 95% CI, 0.43–0.98; P=0.039) as well as fewer deaths from cardiac causes (HR, 0.41; 95% CI, 0.25–0.78; P=0.005) when compared to PCI with DES. The benefit was primarily seen at five-year follow-up in patients with intermediate to severe disease, with a nonsignificant difference detected in patients with less severe disease.

Despite the increasing popularity of DES, this study suggests that for nondiabetic patients with CAD, there is a mortality benefit at five years favoring CABG over PCI with DES. However, in this study stents used for PCI included both older and newer generation DES; a study using only newer DES may reduce the differences in outcomes between the groups.

Bottom Line: Five-year mortality is lower in nondiabetic patients with multivessel CAD treated with CABG compared with PCI with DES.

Citation: Chang M, Ahn JM, Lee CW, et al. Long-term mortality after coronary revascularization in nondiabetic patients with multivessel disease. J Am Coll Cardiol. 2016;68(1):29-36.

Clinical Question: Is there a mortality difference in nondiabetic patients with multivessel coronary artery disease (CAD) treated with coronary artery bypass graft (CABG) versus percutaneous coronary intervention (PCI)?

Background: Randomized clinical trials have shown a mortality benefit of CABG over PCI with drug-eluting stents (DES) for diabetic patients. The best strategy for nondiabetics, however, has not been well established.

Study Design: Pooled individual patient data from two large randomized clinical trials.

Setting: Multicenter, multinational (Europe, United States, Asia).

Synopsis: Excluding patients with left main disease, a total of 1,275 nondiabetic patients with two- or three-vessel CAD were analyzed. After median follow-up of 61 months, the CABG group had significantly fewer deaths from any cause (hazard ratio [HR], 0.65; 95% CI, 0.43–0.98; P=0.039) as well as fewer deaths from cardiac causes (HR, 0.41; 95% CI, 0.25–0.78; P=0.005) when compared to PCI with DES. The benefit was primarily seen at five-year follow-up in patients with intermediate to severe disease, with a nonsignificant difference detected in patients with less severe disease.

Despite the increasing popularity of DES, this study suggests that for nondiabetic patients with CAD, there is a mortality benefit at five years favoring CABG over PCI with DES. However, in this study stents used for PCI included both older and newer generation DES; a study using only newer DES may reduce the differences in outcomes between the groups.

Bottom Line: Five-year mortality is lower in nondiabetic patients with multivessel CAD treated with CABG compared with PCI with DES.

Citation: Chang M, Ahn JM, Lee CW, et al. Long-term mortality after coronary revascularization in nondiabetic patients with multivessel disease. J Am Coll Cardiol. 2016;68(1):29-36.

Clinical Question: What is the incidence of neutropenia in patients treated with prolonged courses of ceftaroline?

Background: Ceftaroline, a new broad-spectrum cephalosporin antibiotic, is FDA approved for the treatment of skin and soft-tissue infections and community-acquired pneumonia (CAP). Other than a few case reports, previous studies have not assessed the incidence of neutropenia in patients receiving ceftaroline for off-label indications or for prolonged courses.

Study Design: Retrospective chart review.

Setting: Brigham and Women’s Hospital and Massachusetts General Hospital in Boston.

Synopsis: The authors identified 67 patients who received ceftaroline for seven or more consecutive days. Overall, ceftaroline exposure for two or more weeks was associated with a 10%–14% incidence of neutropenia (absolute neutrophil count less than 1,800 cells/mm3), and ceftaroline exposure for three or more weeks was associated with a 21% incidence of neutropenia. Both the mean duration of ceftaroline exposure and the total number of ceftaroline doses were associated with incident neutropenia.

This is the first study to systematically assess the incidence of ceftaroline-associated neutropenia. The data support a correlation between cumulative ceftaroline exposure and neutropenia. Hospitalists managing patients with prolonged courses of ceftaroline should carefully monitor hematologic studies during treatment.

Bottom Line: The overall rate of neutropenia in patients receiving prolonged courses of ceftaroline is significant, and it is associated with duration of ceftaroline exposure and total number of doses received.

Citation: Furtek KJ, Kubiak DW, Barra M, Varughese C, Ashbaugh CD, Koo S. High incidence of neutropenia in patients with prolonged ceftaroline exposure. J Antimicrob Chemother. 2016;71(7):2010-2013.

Short Take

New Guidelines from IDSA/ATS for Patients with Community-Acquired Pneumonia Can Safely Be Implemented for Hospitalized Patients

A multicenter, non-inferiority randomized clinical trial of 312 patients with community-acquired pneumonia (CAP) found that stopping antibiotics after five days was not associated with worse outcomes and may reduce readmissions.

Citation: Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016;176(9):1257-1265.

Clinical Question: What is the incidence of neutropenia in patients treated with prolonged courses of ceftaroline?

Background: Ceftaroline, a new broad-spectrum cephalosporin antibiotic, is FDA approved for the treatment of skin and soft-tissue infections and community-acquired pneumonia (CAP). Other than a few case reports, previous studies have not assessed the incidence of neutropenia in patients receiving ceftaroline for off-label indications or for prolonged courses.

Study Design: Retrospective chart review.

Setting: Brigham and Women’s Hospital and Massachusetts General Hospital in Boston.

Synopsis: The authors identified 67 patients who received ceftaroline for seven or more consecutive days. Overall, ceftaroline exposure for two or more weeks was associated with a 10%–14% incidence of neutropenia (absolute neutrophil count less than 1,800 cells/mm3), and ceftaroline exposure for three or more weeks was associated with a 21% incidence of neutropenia. Both the mean duration of ceftaroline exposure and the total number of ceftaroline doses were associated with incident neutropenia.

This is the first study to systematically assess the incidence of ceftaroline-associated neutropenia. The data support a correlation between cumulative ceftaroline exposure and neutropenia. Hospitalists managing patients with prolonged courses of ceftaroline should carefully monitor hematologic studies during treatment.

Bottom Line: The overall rate of neutropenia in patients receiving prolonged courses of ceftaroline is significant, and it is associated with duration of ceftaroline exposure and total number of doses received.

Citation: Furtek KJ, Kubiak DW, Barra M, Varughese C, Ashbaugh CD, Koo S. High incidence of neutropenia in patients with prolonged ceftaroline exposure. J Antimicrob Chemother. 2016;71(7):2010-2013.

Short Take

New Guidelines from IDSA/ATS for Patients with Community-Acquired Pneumonia Can Safely Be Implemented for Hospitalized Patients

A multicenter, non-inferiority randomized clinical trial of 312 patients with community-acquired pneumonia (CAP) found that stopping antibiotics after five days was not associated with worse outcomes and may reduce readmissions.

Citation: Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016;176(9):1257-1265.

Clinical Question: What is the incidence of neutropenia in patients treated with prolonged courses of ceftaroline?

Background: Ceftaroline, a new broad-spectrum cephalosporin antibiotic, is FDA approved for the treatment of skin and soft-tissue infections and community-acquired pneumonia (CAP). Other than a few case reports, previous studies have not assessed the incidence of neutropenia in patients receiving ceftaroline for off-label indications or for prolonged courses.

Study Design: Retrospective chart review.

Setting: Brigham and Women’s Hospital and Massachusetts General Hospital in Boston.

Synopsis: The authors identified 67 patients who received ceftaroline for seven or more consecutive days. Overall, ceftaroline exposure for two or more weeks was associated with a 10%–14% incidence of neutropenia (absolute neutrophil count less than 1,800 cells/mm3), and ceftaroline exposure for three or more weeks was associated with a 21% incidence of neutropenia. Both the mean duration of ceftaroline exposure and the total number of ceftaroline doses were associated with incident neutropenia.

This is the first study to systematically assess the incidence of ceftaroline-associated neutropenia. The data support a correlation between cumulative ceftaroline exposure and neutropenia. Hospitalists managing patients with prolonged courses of ceftaroline should carefully monitor hematologic studies during treatment.

Bottom Line: The overall rate of neutropenia in patients receiving prolonged courses of ceftaroline is significant, and it is associated with duration of ceftaroline exposure and total number of doses received.

Citation: Furtek KJ, Kubiak DW, Barra M, Varughese C, Ashbaugh CD, Koo S. High incidence of neutropenia in patients with prolonged ceftaroline exposure. J Antimicrob Chemother. 2016;71(7):2010-2013.

Short Take

New Guidelines from IDSA/ATS for Patients with Community-Acquired Pneumonia Can Safely Be Implemented for Hospitalized Patients

A multicenter, non-inferiority randomized clinical trial of 312 patients with community-acquired pneumonia (CAP) found that stopping antibiotics after five days was not associated with worse outcomes and may reduce readmissions.

Citation: Uranga A, España PP, Bilbao A, et al. Duration of antibiotic treatment in community-acquired pneumonia: a multicenter randomized clinical trial. JAMA Intern Med. 2016;176(9):1257-1265.

Hospitalists often rely on inpatient telemetry monitoring to identify arrhythmias, ischemia, and QT prolongation, but research has shown that its inappropriate usage increases costs to the healthcare system. An abstract presented at the 2016 meeting of the Society of Hospital Medicine looked at one hospital’s telemetry usage and how it might be improved.

The study revolved around a progress note template the authors developed, which incorporated documentation for telemetry use indications and need for telemetry continuation on non-ICU internal medicine services. The authors also provided an educational session describing American College of Cardiology and American Heart Association (ACC/AHA) telemetry use guidelines for internal medicine residents with a pretest and posttest.

Application of ACA/AHA guidelines was assessed with five scenarios before and after instruction on the guidelines. On pretest, only 29% of trainees answered all five questions correctly; on posttest, 63% did. A comparison between charts of admitted patients with telemetry orders from 2015 with charts from 2013 indicated that the appropriate initiation of telemetry improved significantly as did telemetry documentation. Inappropriate continuation rates were cut in half.

The success of the study suggests further work.

“We plan expansion of telemetry utilization education to internal medicine faculty and nursing to encourage daily review of telemetry usage,” the authors write. “We are also working to develop telemetry orders that end during standard work hours to prevent inadvertent continuation by overnight providers.”

Reference

1. Kuehn C, Steyers CM III, Glenn K, Fang M. Resident-based telemetry utilization innovations lead to improved outcomes [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed October 17, 2016.

Hospitalists often rely on inpatient telemetry monitoring to identify arrhythmias, ischemia, and QT prolongation, but research has shown that its inappropriate usage increases costs to the healthcare system. An abstract presented at the 2016 meeting of the Society of Hospital Medicine looked at one hospital’s telemetry usage and how it might be improved.

The study revolved around a progress note template the authors developed, which incorporated documentation for telemetry use indications and need for telemetry continuation on non-ICU internal medicine services. The authors also provided an educational session describing American College of Cardiology and American Heart Association (ACC/AHA) telemetry use guidelines for internal medicine residents with a pretest and posttest.

Application of ACA/AHA guidelines was assessed with five scenarios before and after instruction on the guidelines. On pretest, only 29% of trainees answered all five questions correctly; on posttest, 63% did. A comparison between charts of admitted patients with telemetry orders from 2015 with charts from 2013 indicated that the appropriate initiation of telemetry improved significantly as did telemetry documentation. Inappropriate continuation rates were cut in half.

The success of the study suggests further work.

“We plan expansion of telemetry utilization education to internal medicine faculty and nursing to encourage daily review of telemetry usage,” the authors write. “We are also working to develop telemetry orders that end during standard work hours to prevent inadvertent continuation by overnight providers.”

Reference

1. Kuehn C, Steyers CM III, Glenn K, Fang M. Resident-based telemetry utilization innovations lead to improved outcomes [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed October 17, 2016.

Hospitalists often rely on inpatient telemetry monitoring to identify arrhythmias, ischemia, and QT prolongation, but research has shown that its inappropriate usage increases costs to the healthcare system. An abstract presented at the 2016 meeting of the Society of Hospital Medicine looked at one hospital’s telemetry usage and how it might be improved.

The study revolved around a progress note template the authors developed, which incorporated documentation for telemetry use indications and need for telemetry continuation on non-ICU internal medicine services. The authors also provided an educational session describing American College of Cardiology and American Heart Association (ACC/AHA) telemetry use guidelines for internal medicine residents with a pretest and posttest.

Application of ACA/AHA guidelines was assessed with five scenarios before and after instruction on the guidelines. On pretest, only 29% of trainees answered all five questions correctly; on posttest, 63% did. A comparison between charts of admitted patients with telemetry orders from 2015 with charts from 2013 indicated that the appropriate initiation of telemetry improved significantly as did telemetry documentation. Inappropriate continuation rates were cut in half.

The success of the study suggests further work.

“We plan expansion of telemetry utilization education to internal medicine faculty and nursing to encourage daily review of telemetry usage,” the authors write. “We are also working to develop telemetry orders that end during standard work hours to prevent inadvertent continuation by overnight providers.”

Reference

1. Kuehn C, Steyers CM III, Glenn K, Fang M. Resident-based telemetry utilization innovations lead to improved outcomes [abstract]. J Hosp Med. 2016;11(suppl 1). Accessed October 17, 2016.

The hospitalist’s performance is among the major determinants of a patient’s hospital experience. But what are the elements of a successful interaction? The authors of an article published in the Journal of Hospital Medicine set out to establish metrics to answer—and measure the answer—to that question, to assess hospitalists’ behaviors, and to establish norms and expectations.

“This study represents a first step to specifically characterize comportment and communication in hospital medicine,” the authors write.

Patient satisfaction surveys, they state, have some shortcomings in providing useful answers to that question.

“First, the attribution to specific providers is questionable,” the authors write. “Second, recall about the provider by the patients may be poor because surveys are sent to patients days after they return home. Third, the patients’ recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time.”

Researchers asked the chiefs of hospital medicine divisions at five hospitals to identify their “most clinically excellent” hospitalists. Each hospitalist was observed during a routine clinical shift, and behaviors were recorded that were believed to be associated with excellent comportment and communication using the hospital medicine comportment and communication tool (HMCCOT), the final version of which has 23 variables. The physicians’ HMCCOT scores were associated with their patient satisfaction survey scores, suggesting that improved comportment might translate into enhanced patient satisfaction.

The results showed extensive variability in comportment and communication at the bedside. One variable that stood out to the researchers was that teach-back was employed in only 13% of the encounters.

“Previous studies have shown that teach-back corroborates patient comprehension and can be used to engage patients (and caregivers) in realistic goal setting and optimal health service utilization,” the researchers write. “Further, patients who clearly understand their post-discharge plan are 30% less likely to be readmitted or visit the emergency department. The data for our group have helped us to see areas of strengths, such as hand washing, where we are above compliance rates across hospitals in the United States, as well as those matters that represent opportunities for improvement such as connecting more deeply with our patients.”

The researchers call for future studies to determine whether hospitalists can improve feedback from this tool and whether enhancing comportment and communication can improve both patient satisfaction and clinical outcomes.

Reference

1. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine [published online ahead of print August 13, 2016]. J Hosp Med. doi:10.1002/jhm.2647.

The hospitalist’s performance is among the major determinants of a patient’s hospital experience. But what are the elements of a successful interaction? The authors of an article published in the Journal of Hospital Medicine set out to establish metrics to answer—and measure the answer—to that question, to assess hospitalists’ behaviors, and to establish norms and expectations.

“This study represents a first step to specifically characterize comportment and communication in hospital medicine,” the authors write.

Patient satisfaction surveys, they state, have some shortcomings in providing useful answers to that question.

“First, the attribution to specific providers is questionable,” the authors write. “Second, recall about the provider by the patients may be poor because surveys are sent to patients days after they return home. Third, the patients’ recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time.”

Researchers asked the chiefs of hospital medicine divisions at five hospitals to identify their “most clinically excellent” hospitalists. Each hospitalist was observed during a routine clinical shift, and behaviors were recorded that were believed to be associated with excellent comportment and communication using the hospital medicine comportment and communication tool (HMCCOT), the final version of which has 23 variables. The physicians’ HMCCOT scores were associated with their patient satisfaction survey scores, suggesting that improved comportment might translate into enhanced patient satisfaction.

The results showed extensive variability in comportment and communication at the bedside. One variable that stood out to the researchers was that teach-back was employed in only 13% of the encounters.

“Previous studies have shown that teach-back corroborates patient comprehension and can be used to engage patients (and caregivers) in realistic goal setting and optimal health service utilization,” the researchers write. “Further, patients who clearly understand their post-discharge plan are 30% less likely to be readmitted or visit the emergency department. The data for our group have helped us to see areas of strengths, such as hand washing, where we are above compliance rates across hospitals in the United States, as well as those matters that represent opportunities for improvement such as connecting more deeply with our patients.”

The researchers call for future studies to determine whether hospitalists can improve feedback from this tool and whether enhancing comportment and communication can improve both patient satisfaction and clinical outcomes.

Reference

1. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine [published online ahead of print August 13, 2016]. J Hosp Med. doi:10.1002/jhm.2647.

The hospitalist’s performance is among the major determinants of a patient’s hospital experience. But what are the elements of a successful interaction? The authors of an article published in the Journal of Hospital Medicine set out to establish metrics to answer—and measure the answer—to that question, to assess hospitalists’ behaviors, and to establish norms and expectations.

“This study represents a first step to specifically characterize comportment and communication in hospital medicine,” the authors write.

Patient satisfaction surveys, they state, have some shortcomings in providing useful answers to that question.

“First, the attribution to specific providers is questionable,” the authors write. “Second, recall about the provider by the patients may be poor because surveys are sent to patients days after they return home. Third, the patients’ recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time.”

Researchers asked the chiefs of hospital medicine divisions at five hospitals to identify their “most clinically excellent” hospitalists. Each hospitalist was observed during a routine clinical shift, and behaviors were recorded that were believed to be associated with excellent comportment and communication using the hospital medicine comportment and communication tool (HMCCOT), the final version of which has 23 variables. The physicians’ HMCCOT scores were associated with their patient satisfaction survey scores, suggesting that improved comportment might translate into enhanced patient satisfaction.

The results showed extensive variability in comportment and communication at the bedside. One variable that stood out to the researchers was that teach-back was employed in only 13% of the encounters.

“Previous studies have shown that teach-back corroborates patient comprehension and can be used to engage patients (and caregivers) in realistic goal setting and optimal health service utilization,” the researchers write. “Further, patients who clearly understand their post-discharge plan are 30% less likely to be readmitted or visit the emergency department. The data for our group have helped us to see areas of strengths, such as hand washing, where we are above compliance rates across hospitals in the United States, as well as those matters that represent opportunities for improvement such as connecting more deeply with our patients.”

The researchers call for future studies to determine whether hospitalists can improve feedback from this tool and whether enhancing comportment and communication can improve both patient satisfaction and clinical outcomes.

Reference

1. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine [published online ahead of print August 13, 2016]. J Hosp Med. doi:10.1002/jhm.2647.

Dear Dr. Hospitalist:

I completed my residency approximately a year ago and was hired by a large academic hospital medicine program with an H-1B visa. After six to eight months in what I thought was the “application process” for permanent residency, I discovered that the people responsible for filing the necessary paperwork had not done anything. During this delayed application period, it is too risky to travel internationally. While I’m still gracious for the opportunity to train and work in the U.S., I am depressed and angry because I haven’t seen my family for almost two years. Should I escalate and complain about my situation beyond the director of my division or just sit back and wait it out?

Dr. Angry and in Limbo

 

Dr. Hospitalist responds:

I can appreciate your angst related to your inability to travel and see family and friends for an extended period of time. Like most of us, you never really appreciate how precious free reign is until you lose it.

There were 2,576 H-1B petitions approved for physicians and surgeons in FY 2012.1 Even though the Society of Hospital Medicine does not currently track the number of international medical graduates (IMGs) in the U.S. practicing hospital medicine, most authorities believe it’s between 20 and 25 percent of the current workforce. 2 Undoubtedly, many of these docs are already U.S. citizens, but most work in the U.S. on employer-sponsored programs (H1-B), with a few taking the J-1 visa tract. Both programs are often used as a catalyst to permanent residency, but the J-1 requires the individual to work in an underserved area for three years before being eligible.

Because the H-1B visa individual can only maintain this status for three years at a time for a maximum of six years, I’m assuming you used three years of the program to complete your residency and will either need to obtain permanent residency (a green card) very soon or will have to leave the country for at least a year before you can apply again. The law does grant extensions beyond this six-year period but only when certain parts of the green card process have been pending for one year prior to the requested H1-B start date.

Assuming you have no culpability for the delay in processing the application (e.g., you turned in necessary paperwork on time, responded timely to correspondence from processors), you have every right to be angry. The application process is tedious and very complex, with very rigid time constraints. Many organizations have used physicians with H-1B visas to fill the gaps in their recruiting without the necessary infrastructure to support the needs of this group. While I recognize it would be difficult for small groups or hospitals to afford knowledgeable and skilled support staff, the days of having part-time administrative support to manage this task are long gone. There are web-based organizations that are skilled and affordable for the smaller groups, and larger groups should invest in administrative staff to support their physicians with visas. After all, in this era of “we’re all part of the team,” it’s difficult to feel valued when your ability to borrow money or travel internationally is limited or even worse: You could be deported.

As an ex-military guy, following the chain of command is in my blood. However, if after given reasonable opportunity to assist and rectify your issues, the division director is unresponsive or unable to assist, I would escalate to the department chair and beyond if necessary.

Good luck! TH

References

 

1. U.S. Department of Homeland Security, U.S. Citizenship and Immigration Services. Characteristics of H1B Specialty Occupation Workers: Fiscal Year 21012 Annual Report to Congress. U.S. Citizenship and Immigration Services website. Accessed October 17, 2016
2. Educational Commission for Foreign Medical Graduates [10-06-2012];Annual Report.

   Accessed October 17, 2016

Dear Dr. Hospitalist:

I completed my residency approximately a year ago and was hired by a large academic hospital medicine program with an H-1B visa. After six to eight months in what I thought was the “application process” for permanent residency, I discovered that the people responsible for filing the necessary paperwork had not done anything. During this delayed application period, it is too risky to travel internationally. While I’m still gracious for the opportunity to train and work in the U.S., I am depressed and angry because I haven’t seen my family for almost two years. Should I escalate and complain about my situation beyond the director of my division or just sit back and wait it out?

Dr. Angry and in Limbo

 

Dr. Hospitalist responds:

I can appreciate your angst related to your inability to travel and see family and friends for an extended period of time. Like most of us, you never really appreciate how precious free reign is until you lose it.

There were 2,576 H-1B petitions approved for physicians and surgeons in FY 2012.1 Even though the Society of Hospital Medicine does not currently track the number of international medical graduates (IMGs) in the U.S. practicing hospital medicine, most authorities believe it’s between 20 and 25 percent of the current workforce. 2 Undoubtedly, many of these docs are already U.S. citizens, but most work in the U.S. on employer-sponsored programs (H1-B), with a few taking the J-1 visa tract. Both programs are often used as a catalyst to permanent residency, but the J-1 requires the individual to work in an underserved area for three years before being eligible.

Because the H-1B visa individual can only maintain this status for three years at a time for a maximum of six years, I’m assuming you used three years of the program to complete your residency and will either need to obtain permanent residency (a green card) very soon or will have to leave the country for at least a year before you can apply again. The law does grant extensions beyond this six-year period but only when certain parts of the green card process have been pending for one year prior to the requested H1-B start date.

Assuming you have no culpability for the delay in processing the application (e.g., you turned in necessary paperwork on time, responded timely to correspondence from processors), you have every right to be angry. The application process is tedious and very complex, with very rigid time constraints. Many organizations have used physicians with H-1B visas to fill the gaps in their recruiting without the necessary infrastructure to support the needs of this group. While I recognize it would be difficult for small groups or hospitals to afford knowledgeable and skilled support staff, the days of having part-time administrative support to manage this task are long gone. There are web-based organizations that are skilled and affordable for the smaller groups, and larger groups should invest in administrative staff to support their physicians with visas. After all, in this era of “we’re all part of the team,” it’s difficult to feel valued when your ability to borrow money or travel internationally is limited or even worse: You could be deported.

As an ex-military guy, following the chain of command is in my blood. However, if after given reasonable opportunity to assist and rectify your issues, the division director is unresponsive or unable to assist, I would escalate to the department chair and beyond if necessary.

Good luck! TH

References

 

1. U.S. Department of Homeland Security, U.S. Citizenship and Immigration Services. Characteristics of H1B Specialty Occupation Workers: Fiscal Year 21012 Annual Report to Congress. U.S. Citizenship and Immigration Services website. Accessed October 17, 2016
2. Educational Commission for Foreign Medical Graduates [10-06-2012];Annual Report.

   Accessed October 17, 2016

Dear Dr. Hospitalist:

I completed my residency approximately a year ago and was hired by a large academic hospital medicine program with an H-1B visa. After six to eight months in what I thought was the “application process” for permanent residency, I discovered that the people responsible for filing the necessary paperwork had not done anything. During this delayed application period, it is too risky to travel internationally. While I’m still gracious for the opportunity to train and work in the U.S., I am depressed and angry because I haven’t seen my family for almost two years. Should I escalate and complain about my situation beyond the director of my division or just sit back and wait it out?

Dr. Angry and in Limbo

 

Dr. Hospitalist responds:

I can appreciate your angst related to your inability to travel and see family and friends for an extended period of time. Like most of us, you never really appreciate how precious free reign is until you lose it.

There were 2,576 H-1B petitions approved for physicians and surgeons in FY 2012.1 Even though the Society of Hospital Medicine does not currently track the number of international medical graduates (IMGs) in the U.S. practicing hospital medicine, most authorities believe it’s between 20 and 25 percent of the current workforce. 2 Undoubtedly, many of these docs are already U.S. citizens, but most work in the U.S. on employer-sponsored programs (H1-B), with a few taking the J-1 visa tract. Both programs are often used as a catalyst to permanent residency, but the J-1 requires the individual to work in an underserved area for three years before being eligible.

Because the H-1B visa individual can only maintain this status for three years at a time for a maximum of six years, I’m assuming you used three years of the program to complete your residency and will either need to obtain permanent residency (a green card) very soon or will have to leave the country for at least a year before you can apply again. The law does grant extensions beyond this six-year period but only when certain parts of the green card process have been pending for one year prior to the requested H1-B start date.

Assuming you have no culpability for the delay in processing the application (e.g., you turned in necessary paperwork on time, responded timely to correspondence from processors), you have every right to be angry. The application process is tedious and very complex, with very rigid time constraints. Many organizations have used physicians with H-1B visas to fill the gaps in their recruiting without the necessary infrastructure to support the needs of this group. While I recognize it would be difficult for small groups or hospitals to afford knowledgeable and skilled support staff, the days of having part-time administrative support to manage this task are long gone. There are web-based organizations that are skilled and affordable for the smaller groups, and larger groups should invest in administrative staff to support their physicians with visas. After all, in this era of “we’re all part of the team,” it’s difficult to feel valued when your ability to borrow money or travel internationally is limited or even worse: You could be deported.

As an ex-military guy, following the chain of command is in my blood. However, if after given reasonable opportunity to assist and rectify your issues, the division director is unresponsive or unable to assist, I would escalate to the department chair and beyond if necessary.

Good luck! TH

References

 

1. U.S. Department of Homeland Security, U.S. Citizenship and Immigration Services. Characteristics of H1B Specialty Occupation Workers: Fiscal Year 21012 Annual Report to Congress. U.S. Citizenship and Immigration Services website. Accessed October 17, 2016
2. Educational Commission for Foreign Medical Graduates [10-06-2012];Annual Report.

   Accessed October 17, 2016