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1.  Interns' Experiences of Disruptive Behavior in an Academic Medical Center 
Background
The first year of graduate medical education is an important period in the professional development of physicians. Disruptive behavior interferes with safe and effective clinical practice.
Objective
To determine the frequency and nature of disruptive behavior perceived by interns and attending physicians in a teaching hospital environment.
Method
All 516 interns at Partners HealthCare (Boston, MA) during the 2010 and 2011 academic years were eligible to complete an anonymous questionnaire. A convenience nonrandom sample of 40 attending physicians also participated.
Results
A total of 394 of 516 eligible interns (76.4%) participated. Attendings and interns each reported that their team members generally behaved professionally (87.5% versus 80.4%, respectively). A significantly greater proportion of attendings than interns felt respected at work (90.0% versus 71.5% respectively; P  =  .01). Disruptive behavior was experienced by 93% of interns; 54% reported that they experienced it once a month or more. Interns reported disruptive behavior significantly more frequently than attending physicians, including increased reports of condescending behavior (odds ratio [OR], 5.46 for interns compared with attendings; P < .001), exclusion from decision making (OR, 6.97; P < .001), and berating (OR, 4.84; P  =  .02). Inappropriate jokes, abusive language, and gender bias were also reported, and they were not significantly more frequent among interns than attending physicians. Interns most frequently identified nurses as the source of disruption, and were significantly more likely than faculty to identify nurses as the source of disruptive behavior (OR, 10.40; P < .001). Attendings reported other physicians as the most frequent source of disruption.
Conclusions
Although interns generally feel respected at work, they frequently experience disruptive behavior. Interns described more disruptive behaviors than a convenience sample of attending physicians at our institution.
doi:10.4300/JGME-D-12-00025.1
PMCID: PMC3613313  PMID: 24404222
2.  A Randomized Comparison of Online- and Telephone-Based Care Management with Internet Training Alone in Adult Patients with Poorly Controlled Type 2 Diabetes 
Diabetes Technology & Therapeutics  2012;14(11):1060-1067.
Abstract
Aims
Care management may improve the quality of diabetes care by enhancing contact between high-risk patients and their providers. This prospective, longitudinal, randomized trial sought to investigate whether telephone or online care management improves diabetes-related outcomes over time compared with usual care supplemented with Internet access and training.
Subjects and Methods
One hundred fifty-one adult subjects with type 2 diabetes mellitus and an elevated hemoglobin A1c (A1c) level (≥8.5%) were randomly assigned to online care management (n=51), telephone-based care management (n=51), or Web training (n=49) groups. Online and telephone participants interacted with a care manager through a diabetes education and care management Web site and by telephone, respectively. The Web training group was provided with online diabetes self-management resources but no care management support. The primary outcome measure was A1c measured every 3 months for a year.
Results
A1c declined significantly and substantially in all groups over 12 months. A1c declined linearly at a rate of 0.32% (P<0.0001) per quarter for the online group, 0.36% (P<0.0001) for the telephone group, and 0.41% for the Web training group (P<0.0001). The rate of change over time did not differ significantly among groups. The groups converged at 12 months with average absolute A1c difference of −1.5%. The number of interactions with care providers was not significantly associated with the change in A1c. Blood pressure, weight, lipid levels, and diabetes distress did not differ among groups over time.
Conclusions
Online, telephone-based care management, and Web training for diabetes patients with elevated A1c were each associated with a substantial improvement in A1c over a 1-year period. Internet access and training alone may be as effective as care management in patients with poorly controlled diabetes.
doi:10.1089/dia.2012.0137
PMCID: PMC3482842  PMID: 22953754
3.  Development of a Test of Residents' Ethics Knowledge for Pediatrics (TREK-P) 
Background
Professionalism is one of the Accreditation Council for Graduate Medical Education's core competencies. Residency programs must teach residents about ethical principles, which is an essential component of professionalism.
Objectives
We aimed to formally develop a valid and reliable test of ethics knowledge that effectively discriminated among learners in pediatric residency training and to improve methods for measuring outcomes of resident education in medical ethics.
Methods
We created an instrument with 36 true/false questions that tested knowledge in several domains of pediatric ethics: professionalism, adolescent medicine, genetic testing and diagnosis, neonatology, end-of-life decisions, and decision making for minors. All questions and their correct answers were derived from published statements from the American Academy of Pediatrics Committee on Bioethics. We invited a range of participants from novices to experts to complete the test. We evaluated the instrument's reliability and explored item discrimination, omitting 13 items with the least discriminatory power. Score differences between the 3 categories of examinees were evaluated.
Results
The 23-item test, completed by 54 participants, demonstrated good internal reliability (Kuder-Richardson 20 statistic  =  0.73). The test was moderately difficult and had a mean overall score of 17.3 (±3.3 standard deviation). Performance appropriately improved with degree of expertise: median scores for medical students, postgraduate year-3 residents, and ethicists were 15 (65%, range, 11–19), 19 (83%, range, 14–23), and 22 (96%, range, 20–23), respectively. Ethicists' scores were significantly higher than those of medical students (P < .001) and residents (P  =  .007). Moreover, residents performed significantly better than medical students (P  =  .001).
Conclusions
We developed a standardized instrument, entitled Test of Residents' Ethics Knowledge for Pediatrics (TREK-P), to evaluate residents' knowledge of pediatric ethics. The TREK-P is easy to administer, reliably discriminates among learners, and highlights content areas in which knowledge may be deficient.
doi:10.4300/JGME-D-11-00280.1
PMCID: PMC3399620  PMID: 23730449
4.  Medical students’ attitudes toward gay men 
BMC Medical Education  2012;12:71.
Background
Healthcare providers’ attitudes toward sexual minorities influence patient comfort and outcomes. This study characterized medical student attitudes toward gay men, focusing on behavior, personhood, gay civil rights, and male toughness.
Methods
A cross-sectional web-based anonymous survey was sent to medical students enrolled at the University of California, Davis (N = 371) with a response rate of 68%.
Results
Few respondents expressed negative attitudes toward gay men or would deny them civil rights. More negative responses were seen with respect to aspects of intimate behavior and homosexuality as a natural form of sexual expression. Men and students younger than 25 years old were more likely to endorse negative attitudes toward behavior as well as more traditional views on male toughness.
Conclusions
We show that an important minority of students express discomfort with the behavior of gay men and hold to a narrow construction of male identity. These findings suggest that competency training must move beyond conceptual discussions and address attitudes toward behaviors through new pedagogical approaches.
doi:10.1186/1472-6920-12-71
PMCID: PMC3460746  PMID: 22873668
Homosexuality; Medical students; Bias
5.  The Effect of Workload Reduction on the Quality of Residents’ Discharge Summaries 
Background
The completeness of hospital discharge summaries may reflect the overall quality of inter-professional communications. The effect of reducing resident workload on clinical performance is largely unknown.
Objective
We examined the impact of reducing housestaff workload on the quality of discharge summaries, an indicator of clinical performance, as compared to discharge summaries created by trainees on a team with a more typical workload.
Design
Patients admitted to a medicine service at a community teaching hospital affiliated with an academic medical center were alternately allocated between a control and intervention care team of residents. First-year residents on the intervention team carried an average census of 3.5 patients compared with 6.6 patients for peers on the control team. A random selection of 142 discharge summaries from a 3-month period were blindly evaluated using a structured tool based on professional documentation standards.
Participants
61 internal medicine residents.
Main Results
Inter-rater reliability of discharge summary quality was 0.9. Discharge summaries produced by residents on the intervention team with a reduced workload had significantly more of the required elements (74 vs 65%, p < 0.001). Intervention team summaries were more frequently complete and contained significantly more of the required elements describing the patient history (65.7% vs 36.1%, p = 0.0005), the inpatient narrative (47.1% vs 22.2%, p = 0.003), discharge planning (20.0% vs 5.5%, p = 0.012), and continuity of care (24.3% vs 6.9%, p = 0.005). Fewer than a quarter of the summaries reviewed included discharge instructions, information on follow-up care, or a discharge medication list.
Conclusions
Reducing resident workload can significantly improve discharge summary quality, a measure of resident performance.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-010-1465-z) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-010-1465-z
PMCID: PMC3024111  PMID: 20697967
discharge summary; residency design; work hours
6.  Improving Residents' Knowledge of Arterial and Central Line Placement With a Web-Based Curriculum 
Background
Procedural skill is predicated on knowledge. We used a previously validated test to evaluate the impact of a web-based education program on medical residents' knowledge of 2 advanced medical procedures.
Methods
We enrolled 210 internal medicine residents at 3 residency programs in a randomized, controlled, educational trial. Study participants completed a 20-item, validated online test of their knowledge of central venous and arterial line (CVL and AL, respectively) placement at baseline and after performing their next 2 procedures (test 1 and test 2). Between test 1 and test 2, participants were randomized to online educational material for CVL insertion, AL insertion, both, or neither. The primary outcome of the study was the difference in test scores between test 1 and test 2 by randomization group.
Results
Though residents in the baseline cohort were confident about their knowledge of procedural technique, their mean test scores were low (62% and 58% in the CVL and AL tests, respectively). Baseline test score correlated with the number of prior procedures performed. Sixty-five residents completed all 3 CVL tests, and 85 residents completed all 3 AL tests. Access to the web-based procedure education was associated with a significant improvement in scores for both the CVL test (effect size, d  =  0.25, P  =  .01) and AL test (d  =  0.52, P < .001).
Conclusions
Web-based procedure training improves knowledge of procedures to a significantly greater extent than performing the procedure alone. Web-based curricula can effectively supplement other methods of skill development.
doi:10.4300/JGME-D-10-00029.1
PMCID: PMC3010938  PMID: 22132276
7.  Changes in Diabetes Distress Related to Participation in an Internet-Based Diabetes Care Management Program and Glycemic Control 
Background
This article investigated how changes in diabetes distress relate to receiving care management through an Internet-based care management (IBCM) program for diabetes and level of participation in this program. Further, it examined the relationship between diabetes distress and changes in glycemic control.
Methods
We enrolled patients of the Veterans Affairs Boston Healthcare System with diabetes who had hemoglobin A1c (HbA1c) levels of ≥9.0%. Subjects were randomized to usual care (n = 52) or IBCM (n = 52) for 1 year. We measured diabetes distress at baseline and quarterly thereafter using the Problem Areas in Diabetes (PAID) questionnaire. Glycemic control was determined by baseline and quarterly HbA1c. For subjects randomized to IBCM, we measured participation by observing frequency and consistency of their usage of the IBCM patient portal over 12 months. Linear mixed models were used to analyze THE data.
Results
PAID scores declined over time for both treatment groups. Among subjects randomized to IBCM, the decline in PAID scores over time was significant for sustained users of the IBCM patient portal but not for nonusers. Moreover, subjects whose usage of the patient portal was sustained throughout the study had lower PAID scores at baseline. With respect to changes in glycemic control, HbA1c reduced individual differences in PAID scores by 44%; a lower baseline HbA1c was associated with lower baseline PAID scores, and over time, the decrease in HbA1c was associated with further decreases in the PAID score.
Conclusions
Participation in IBCM varies by initial diabetes distress, with people with less distress participating more. For people who participate, IBCM further mitigates diabetes distress. There is also a relationship between achievements in glycemic control and subsequent lowering of diabetes distress. Future research should identify how to maximize fit between patient needs and the provisions of IBCM, with the aim of increasing patient engagement in the active management of their health using this care modality. A key to maximizing fit might be first addressing metabolic control aggressively and then using IBCM for sustainment of health.
PMCID: PMC2769854  PMID: 20046656
diabetes distress; disease management; Internet; PAID scale; patient care management; psychosocial
8.  Patient Safety Knowledge and Its Determinants in Medical Trainees 
Journal of General Internal Medicine  2007;22(8):1150-1154.
Background
Patient safety is a core educational topic for medical trainees.
Objectives
To determine the current level and determinants of patient safety knowledge in medical trainees.
Design
Multi-institutional cross-sectional assessment of patient safety knowledge.
Participants
Residents and medical students from seven Harvard-affiliated residencies and two Harvard Medical School courses.
Measurements
Participants were administered a 14-item validated test instrument developed based on the patient safety curriculum of the Risk Management Foundation (Cambridge, MA). The primary outcome measure was the amount of patient safety knowledge demonstrated by trainees on the validated test instrument. The secondary outcome measure was their subjective perceptions as to their baseline knowledge level in this domain.
Results
Ninety-two percent (640/693) of residents and medical students completed the patient safety test. Participants correctly answered a mean 58.4% of test items (SD 15.5%). Univariate analyses show that patient safety knowledge levels varied significantly by year of training (p = 0.001), degree program (p < 0.001), specialty (p < 0.001), country of medical school (p = 0.006), age (p < 0.001), and gender (p = 0.050); all but the latter two determinants remained statistically significant in multivariate models. In addition, trainees were unable to assess their own knowledge deficiencies in this domain.
Conclusions
Patient safety knowledge is limited among medical trainees across a broad range of training levels, degrees, and specialties. Effective educational interventions that target deficiencies in patient safety knowledge are greatly needed.
doi:10.1007/s11606-007-0247-8
PMCID: PMC2305739  PMID: 17551796
safety; medical errors; medical education
9.  Web-based Care Management in Patients with Poorly Controlled Diabetes Mellitus 
Diabetes care  2005;28(7):1624-1629.
Objective
To assess the effects of web-based care management on glucose and blood pressure control over 12 months in patients with poorly controlled diabetes mellitus.
Research Design and Methods
104 patients with diabetes mellitus and hemoglobin A1c ≥ 9.0% who received their care at a VA medical center were recruited. All participants completed a diabetes education class and were randomized to continue with usual care (n = 52) or receive web-based care management (n = 52). The care management group received a notebook computer, glucose and blood pressure monitoring devices and access to a care management website. The website provided educational modules, accepted uploads from monitoring devices, and had an internal messaging system for patients to communicate with the care manager.
Results
Participants receiving web-based care management had lower hemoglobin A1c over 12 months (P<0.05) when compared to education and usual care. Persistent website users had greater improvement in hemoglobin A1c when compared to intermittent users (−1.9% vs. −1.2%, P=0.051) or education and usual care (−1.4%, P<0.05). Greater numbers of website data uploads were associated with larger declines in hemoglobin A1c (highest tertile −2.1%, lowest tertile: −1.0%, P<0.02). Hypertensive participants in the web-based care management group had a greater reduction in systolic blood pressure (P<0.01). HDL cholesterol rose and triglycerides fell in the web-based care management group (P<0.05).
Conclusions
Web-based care management may be a useful adjunct in the care of patients with poorly controlled diabetes mellitus.
PMCID: PMC1262644  PMID: 15983311
10.  Effect of a Physical Examination Teaching Program on the Behavior of Medical Residents 
Context
The reliance on physical examination as a diagnostic aid is in decline.
Objective
To determine whether an educational program can increase the use of physical examination by medical residents.
Design and Participants
A series of educational workshops were provided to 47 second- and third-year medical residents at a large academic teaching hospital.
Measurements
Interns and students reported the frequency and depth of clinical examination performance on morning rounds by their residents before and up to six months after the workshops. Behavior before and after the workshops was compared using a mixed model.
Results
A total of 374 reports were returned (77% response). After adjusting for the type of service and observer, there was a statistically significant 23% increase (P=.02) in the performance of physical examination among residents who attended the course. Residents significantly increased the fraction of patients they examined on rounds (absolute increase 11%, P=.002) but did not increase the depth of their examination. The change was greatest on general medical teams, among whom the performance of physical examination had been least frequent. Teaching and feedback events on medicine teams by residents to their interns (2.8 and 1.1 events per 2 weeks, respectively) and medical students (5.9 and 2.8 events per 2 weeks, respectively) remained infrequent.
Conclusions
A skills improvement program can significantly increase the frequency of physical examination, but teaching and feedback events remain sporadic and infrequent.
doi:10.1111/j.1525-1497.2005.0159.x
PMCID: PMC1490175  PMID: 16050879
medical education; physical examination; clinical skills

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