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Biomedical subjects

Kathlyn E Fletcher

Publications and source records attributed to Kathlyn E Fletcher.

11 recordsLinked to original sources
PubMed2006

Graduate medical education and patient safety: a busy--and occasionally hazardous--intersection.

A patient admitted to a teaching hospital with a mild episode of acute pancreatitis initially improved, but then her condition deteriorated and she subsequently died. The initial deterioration probably reflected bowel obstruction, as shown on an abdominal radiograph that an on-call intern forgot to review. This diagnostic delay was compounded by poor communication that resulted in a medical student inserting a feeding tube--rather than a nasogastric tube--to decompress the bowel, followed by failure to recognize how ill the patient had become. The case highlights the hazards of patient handoffs as well as the importance of clear communication techniques and knowing when to ask for help. The discussion also shows the vicious circle that results when attending physicians fail to provide effective supervision: Not only is safety compromised but trainees lose the experience of being supervised. Consequently, trainees have no models of effective supervision on which to draw when they become supervisors. They then fall into the same trap as those who taught them, busying themselves with direct patient care and providing supervision only as time allows.

Aged, 80 and over↗
PubMed2006

Defining, navigating, and negotiating success: the experiences of mid-career Robert Wood Johnson Clinical Scholar women.

BACKGROUND: We studied female graduates of the Robert Wood Johnson Clinical Scholars Program (CSP, Class of 1984 to 1989) to explore and describe the complexity of creating balance in the life of mid-career academic woman physicians. METHODS: We conducted and qualitatively analyzed (kappa 0.35 to 1.0 for theme identification among rater pairs) data from a semi-structured survey of 21 women and obtained their curricula vitae to quantify publications and grant support, measures of academic productivity. RESULTS: Sixteen of 21 (76%) women completed the survey. Mean age was 48 (range: 45 to 56). Three were full professors, 10 were associate professors, and 3 had left academic medicine. Eleven women had had children (mean 2.4; range: 1 to 3) and 3 worked part-time. From these data, the conceptual model expands on 3 key themes: (1) defining, navigating, and negotiating success, (2) making life work, and (3) making work work. The women who described themselves as satisfied with their careers (10/16) had clarity of values and goals and a sense of control over their time. Those less satisfied with their careers (6/16) emphasized the personal and professional costs of the struggle to balance their lives and described explicit institutional barriers to fulfillment of their potential. CONCLUSION: For this group of fellowship-prepared academic women physicians satisfaction is achieving professional and personal balance.

Achievement↗
PubMed2005

Effects of work hour reduction on residents' lives: a systematic review.

CONTEXT: The Accreditation Council for Graduate Medical Education implemented mandatory work hour limitations in July 2003, partly out of concern for residents' well-being in the setting of sleep deprivation. These limitations are likely to also have an impact on other aspects of the lives of residents. OBJECTIVE: To summarize the literature regarding the effect of interventions to reduce resident work hours on residents' education and quality of life. DATA SOURCES: We searched the English-language literature about resident work hours from 1966 through April 2005 using MEDLINE, EMBASE, and Current Contents, supplemented with hand-search of additional journals, reference list review, and review of abstracts from national meetings. STUDY SELECTION: Studies were included that assessed a system change designed to counteract the effects of resident work hours, fatigue, or sleep deprivation; included an outcome directly related to residents; and were conducted in the United States. DATA EXTRACTION: For each included study, 2 investigators independently abstracted data related to study quality, subjects, interventions, and findings using a standard data abstraction form. DATA SYNTHESIS: Fifty-four articles met inclusion criteria. The interventions used to decrease resident work hours varied but included night and day float teams, extra cross-coverage, and physician extenders. Outcomes included measures of resident education (operative experience, test scores, satisfaction) and quality of residents' lives (amount of sleep, well-being). Interventions to reduce resident work hours resulted in mixed effects on both operative experience and on perceived educational quality but generally improved residents' quality of life. Many studies had major limitations in their design or conduct. CONCLUSIONS: Past interventions suggest that residents' quality of life may improve with work hour limitations, but interpretation of the outcomes of these studies is hampered by suboptimal study design and the use of nonvalidated instruments. The long-term impact of reducing resident work hours on education remains unknown. Current and future interventions should be evaluated with more rigorous methods and should investigate links between residents' quality of life and quality of patient care.

Education, Medical↗
PubMed2005

Balancing continuity of care with residents' limited work hours: defining the implications.

The impact of the new resident work-hours rules on all aspects of patient care and education must be considered. While physician fatigue has taken center stage as the primary motivation behind this movement, the effect of these rules on the continuity of care for hospitalized patients needs to be critically analyzed from the perspectives of patients, physicians, and the health care system. The authors describe a conceptual framework that places continuity at the center and then considers the benefits and drawbacks of preserving continuity from the perspectives of the major stakeholders. They describe the categories of outcomes related to residents' fatigue and sleep deprivation that have been studied. Only a few studies have addressed patient outcomes, while most address resident outcomes. The authors discuss some of the possible solutions, including night float and the British system of shift work, and suggest that these solutions have different effects on each group of stakeholders, including both intended and unintended benefits and harms. Finally, the research agenda that arises from this framework is described. It includes taking into account multiple perspectives, identifying important outcomes, and considering unintended consequences. Using this framework, medical educators may better evaluate previous studies and consider remaining questions.

Continuity of Patient Care↗
PubMed2005

Bedside interactions from the other side of the bedrail.

OBJECTIVE: To assess the importance to patients of various aspects of bedside interactions with physician teams. DESIGN: Cross-sectional survey. SETTING: VA hospital. PATIENTS: Ninety-seven medical inpatients. INTERVENTION: Survey of 44 questions including short answer, multiple choice, and Likert-type questions. MEASUREMENTS AND MAIN RESULTS: Data analysis included descriptive statistics. The sample was predominantly male, with a mean age of 62. Overall satisfaction with the hospital experience and with the team of doctors were both high (95% and 96% reported being very or mostly satisfied, respectively). Patients reported learning about several issues during their interactions with the teams; the 3 most highly rated areas were new problems, tests that will be done, and treatments that will be done. Most patients (76%) felt that their teams cared about them very much. Patients were made comfortable when the team showed that they cared, listened, and appeared relaxed (reported by 63%, 57%, and 54%, respectively). Patients were made uncomfortable by the team using language they did not understand (22%) and when several people examined them at once (13%). Many (58%) patients felt personally involved in teaching. The majority of patients liked having medical students and residents involved in their care (69% and 64%, respectively). CONCLUSIONS: Patients have much to teach about what is important about interacting with physician teams. Although patients' reactions to team interactions are generally positive, patients are different with respect to what makes them comfortable and uncomfortable. Taking their preferences into account could improve the experience of being in a teaching hospital.

Cross-Sectional Studies↗
PubMed2004

Systematic review: effects of resident work hours on patient safety.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) mandated new work hours rules for all residency programs in July 2003. PURPOSE: To critically evaluate the evidence that adhering to the ACGME standards will improve patient safety. DATA SOURCES: Searches of electronic databases (MEDLINE, EMBASE, PREMEDLINE, and Current Contents) and other methods to identify the English-language literature for studies on resident work hours for the years 1966 to 2004. STUDY SELECTION: Studies that assessed a system change designed to counteract the effects of work hours, fatigue, or sleep deprivation and that included an outcome related to patient safety were included. Seven studies met these criteria. DATA EXTRACTION: Two investigators abstracted data from all included studies by using a standard data abstraction form; each study was rated according to established criteria to assess study design quality. DATA SYNTHESIS: Interventions used were float systems, other cross-coverage systems, or unspecified schedule changes. Outcomes included mortality, adverse events, and medication errors. The results suggest that introducing such interventions has an unclear effect on selected patient safety indicators. Specifically, some indicators (such as mortality) may not change after interventions, while other indicators may improve or worsen. LIMITATIONS: This analysis is limited by the study designs of the included studies, the diversity of interventions in the studies, and the possibility of publication bias favoring studies that demonstrated statistically significant differences. CONCLUSION: Evidence on patient safety is insufficient to inform the process of reducing resident work hours.

Continuity of Patient Care↗
PubMed2004

Viewpoints from generation X: a survey of candidate and associate viewpoints on resident duty-hour regulations.

BACKGROUND: The American Medical Student Association, the Committee of Interns and Residents, and Public Citizen petitioned the Occupational Safety and Health Administration for national resident duty-hour limitations. Subsequently, federal legislation was introduced to limit resident duty hours. To preempt the federal government, the Accreditation of Graduate Medical Education implemented resident duty-hour guidelines. STUDY DESIGN: To evaluate the viewpoints and attitudes of surgical resident and staff physicians as they pertain to the national resident duty-hour guidelines, we asked attendees of the American College of Surgeons' Candidate Associate Society Forum during the American College of Surgeons Clinical Congress meeting in 2001 to complete a self-administered questionnaire. Analyses were performed to determine the frequency of response for each survey item. RESULTS: Eighty-six of the 102 (84%) surgeons who attended the American College of Surgeons Forum completed the survey. Most disagreed with the federal government involvement in regulating duty hours. Although most agreed that residents should not be on call more than every third night, viewpoints varied on the other duty-hour guidelines. Most (63.4%) reported that residents should work 81 to 100 hours per week, but 11% reported that residents should work > 101 hours per week and 25.6% reported that <or= 80 hours per week was optimal. CONCLUSIONS: As future guidelines are considered, further studies must be done to determine the viewpoints and attitudes of surgical resident and staff physicians with regard to resident duty-hour reform. These "front line" individuals may have unique insights into the benefits and barriers of duty-hour regulations.

Attitude of Health Personnel↗
PubMed2004

The physical examination of patients with abdominal pain: the long-term effect of adding standardized patients and small-group feedback to a lecture presentation.

BACKGROUND: One of the most effective methods for teaching physical diagnosis may be standardized patient instructors. PURPOSE: To determine if a lecture plus standardized patient instructors with small-group sessions is more effective than a lecture alone for teaching the evaluation of patients with abdominal pain. METHODS: Control (class of 2001) and intervention (class of 2002) groups both attended a lecture on the abdominal examination. The intervention group then underwent an exercise with standardized patient instructors and a review session with surgical faculty. An evaluation 18 months later used standardized patient instructors to complete evaluations assessing history-taking and physical examination skills. RESULTS: The intervention group performed significantly better than the control group on both the history and the physical examination subscales. CONCLUSION: It is possible to have an important, measurable, and lasting effect on physical examination skills by adding standardized patient instructors and small-group discussion to a lecture presentation.

Abdominal Pain↗
PubMed2003

Teaching at the bedside: a new model.

The patient is at the center of clinical medicine. In order to effectively teach clinical skills a teacher must learn to involve patients in the educational process. It is through this process that learners acquire the skills of observation, communication, examination and professionalism. Despite the importance of teaching with the patient present, many clinical teachers are hesitant to teach at the bedside. This paper describes a workshop on bedside teaching. The authors present barriers and advantages discussed during the workshop as well as a 'Model of Best Bedside Teaching Practices', which emerged after conducting the workshop for over 135 medical educators. The model includes suggested skills for effective bedside teaching that are arranged into three domains: attending to patient comfort, focused teaching and group dynamics.

Attitude of Health Personnel↗