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JAMA Jul 2024
PubMed: 38949836
DOI: 10.1001/jama.2024.11126 -
JAMA Network Open Jul 2024Serious illness conversations (SICs) that elicit patients' values, goals, and care preferences reduce anxiety and depression and improve quality of life, but occur... (Randomized Controlled Trial)
Randomized Controlled Trial
IMPORTANCE
Serious illness conversations (SICs) that elicit patients' values, goals, and care preferences reduce anxiety and depression and improve quality of life, but occur infrequently for patients with cancer. Behavioral economic implementation strategies (nudges) directed at clinicians and/or patients may increase SIC completion.
OBJECTIVE
To test the independent and combined effects of clinician and patient nudges on SIC completion.
DESIGN, SETTING, AND PARTICIPANTS
A 2 × 2 factorial, cluster randomized trial was conducted from September 7, 2021, to March 11, 2022, at oncology clinics across 4 hospitals and 6 community sites within a large academic health system in Pennsylvania and New Jersey among 163 medical and gynecologic oncology clinicians and 4450 patients with cancer at high risk of mortality (≥10% risk of 180-day mortality).
INTERVENTIONS
Clinician clusters and patients were independently randomized to receive usual care vs nudges, resulting in 4 arms: (1) active control, operating for 2 years prior to trial start, consisting of clinician text message reminders to complete SICs for patients at high mortality risk; (2) clinician nudge only, consisting of active control plus weekly peer comparisons of clinician-level SIC completion rates; (3) patient nudge only, consisting of active control plus a preclinic electronic communication designed to prime patients for SICs; and (4) combined clinician and patient nudges.
MAIN OUTCOMES AND MEASURES
The primary outcome was a documented SIC in the electronic health record within 6 months of a participant's first clinic visit after randomization. Analysis was performed on an intent-to-treat basis at the patient level.
RESULTS
The study accrued 4450 patients (median age, 67 years [IQR, 59-75 years]; 2352 women [52.9%]) seen by 163 clinicians, randomized to active control (n = 1004), clinician nudge (n = 1179), patient nudge (n = 997), or combined nudges (n = 1270). Overall patient-level rates of 6-month SIC completion were 11.2% for the active control arm (112 of 1004), 11.5% for the clinician nudge arm (136 of 1179), 11.5% for the patient nudge arm (115 of 997), and 14.1% for the combined nudge arm (179 of 1270). Compared with active control, the combined nudges were associated with an increase in SIC rates (ratio of hazard ratios [rHR], 1.55 [95% CI, 1.00-2.40]; P = .049), whereas the clinician nudge (HR, 0.95 [95% CI, 0.64-1.41; P = .79) and patient nudge (HR, 0.99 [95% CI, 0.73-1.33]; P = .93) were not.
CONCLUSIONS AND RELEVANCE
In this cluster randomized trial, nudges combining clinician peer comparisons with patient priming questionnaires were associated with a marginal increase in documented SICs compared with an active control. Combining clinician- and patient-directed nudges may help to promote SICs in routine cancer care.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT04867850.
Topics: Humans; Female; Male; Middle Aged; Neoplasms; Aged; Physician-Patient Relations; Communication; Adult; Cluster Analysis; Pennsylvania
PubMed: 38949813
DOI: 10.1001/jamanetworkopen.2024.18639 -
JAMA Network Open Jul 2024Discrimination, bullying, and harassment in medicine have been reported internationally, but exposures for Indigenous medical students and physicians, and for racism...
IMPORTANCE
Discrimination, bullying, and harassment in medicine have been reported internationally, but exposures for Indigenous medical students and physicians, and for racism specifically, remain less examined.
OBJECTIVE
To examine the prevalence of racism, discrimination, bullying, and harassment for Māori medical students and physicians in New Zealand and associations with demographic and clinical characteristics.
DESIGN, SETTING, AND PARTICIPANTS
This cross-sectional study used data from an anonymous national survey of Māori medical students and physicians in New Zealand in late 2021 and early 2022. Data were analyzed from March 2022 to April 2024.
EXPOSURES
Age, gender, marginalized status (ie, in addition to being Māori, belonging to other groups traditionally marginalized or underrepresented in medicine), year of medical school, year of graduation, and main work role.
MAIN OUTCOMES AND MEASURES
Direct and witnessed racism, discrimination, bullying, and harassment were measured as any experience in the last year and ever. Any exposure to negative comments about social groups and witnessing discriminatory treatment toward Māori patients or whānau (extended family). Considering leaving medicine, including because of mistreatment, was measured.
RESULTS
Overall, 205 Māori medical students (median [IQR] age, 23.1 [21.6-24.3] years; 137 [67.2%] women) and 200 physicians (median [IQR] age, 36.6 [30.1-45.3] years; 123 [62.8%] women) responded. Direct and witnessed exposure to racism (184 students [91.5%]; 176 physicians [90.7%]) and discrimination (176 students [85.9%]; 179 physicians [89.5%]) ever in medical education, training, or work environments was common. Ever exposure to witnessed and direct bullying (123 students [66.5%]; 150 physicians [89.3%]) and harassment (73 students [39.5%]; 112 physicians [66.7%]) was also common. Most respondents reported witnessing Māori patients or their whānau being treated badly in clinical settings, in direct interactions (67 students [57.8%]; 112 physicians [58.9%]) or behind their backs (87 students [75.0%]; 138 physicians [72.6%]). One-quarter of Māori medical students (45 students), and 37.0% of physicians (61 physicians) had considered leaving or taken a break from medicine because of these experiences. Additional marginalized statuses were significantly associated with any direct experience of mistreatment in the last year for students and physicians. Exposure to some forms of mistreatment were also significantly associated with higher likelihood of thinking about leaving or taking a break from medicine for physicians.
CONCLUSIONS AND RELEVANCE
In this study, Māori medical students and physicians reported high exposure to multiple forms of racism, discrimination, bullying, and harassment in medical education, training, and work environments, requiring an urgent response from medical institutions.
Topics: Humans; Students, Medical; Racism; Male; Bullying; Female; New Zealand; Cross-Sectional Studies; Adult; Physicians; Native Hawaiian or Other Pacific Islander; Young Adult; Surveys and Questionnaires; Middle Aged; Maori People
PubMed: 38949810
DOI: 10.1001/jamanetworkopen.2024.19373 -
Nephrology Nursing Journal : Journal of... 2024Nurse managers and medical directors play integral roles in ensuring the delivery of high-quality care. Nurse managers oversee day-to-day operations, coordinating...
Nurse managers and medical directors play integral roles in ensuring the delivery of high-quality care. Nurse managers oversee day-to-day operations, coordinating staffing, patient care, and resource allocation. They are responsible for fostering a supportive environment for nursing staff while upholding standards of excellence in patient care. Medical directors bring their clinical expertise and leadership, guiding treatment protocols and ensuring adherence to best practices. Together, nurse managers and medical directors form a dynamic partnership in which collaboration is paramount. By synergizing their respective strengths, nurse managers and medical directors can optimize patient outcomes, streamline processes, and drive continuous improvement initiatives. Effective communication and mutual respect are foundational to this collaboration because they work hand-in-hand to navigate complex medical challenges and uphold standards of excellence. In this symbiotic relationship, the ultimate goal is to produce quality care that enhances patient well-being and satisfaction.
Topics: Nurse Administrators; Humans; Physician Executives; Nephrology Nursing; Nurse's Role; Quality of Health Care; Interprofessional Relations; Leadership
PubMed: 38949796
DOI: No ID Found -
Obstetrics and Gynecology Jul 2024To evaluate maternal and neonatal outcomes by type of antihypertensive used in participants of the CHAP (Chronic Hypertension in Pregnancy) trial. (Randomized Controlled Trial)
Randomized Controlled Trial Comparative Study
OBJECTIVE
To evaluate maternal and neonatal outcomes by type of antihypertensive used in participants of the CHAP (Chronic Hypertension in Pregnancy) trial.
METHODS
We conducted a planned secondary analysis of CHAP, an open-label, multicenter, randomized trial of antihypertensive treatment compared with standard care (no treatment unless severe hypertension developed) in pregnant patients with mild chronic hypertension (blood pressure 140-159/90-104 mm Hg before 20 weeks of gestation) and singleton pregnancies. We performed three comparisons based on medications prescribed at enrollment: labetalol compared with standard care, nifedipine compared with standard care, and labetalol compared with nifedipine. Although active compared with standard care groups were randomized, medication assignment within the active treatment group was not random but based on clinician or patient preference. The primary outcome was the occurrence of superimposed preeclampsia with severe features, preterm birth before 35 weeks of gestation, placental abruption, or fetal or neonatal death. The key secondary outcome was small for gestational age (SGA) neonates. We also compared medication adverse effects between groups. Relative risks (RRs) and 95% CIs were estimated with log binomial regression to adjust for confounding.
RESULTS
Of 2,292 participants analyzed, 720 (31.4%) received labetalol, 417 (18.2%) received nifedipine, and 1,155 (50.4%) received no treatment. The mean gestational age at enrollment was 10.5±3.7 weeks; nearly half of participants (47.5%) identified as non-Hispanic Black; and 44.5% used aspirin. The primary outcome occurred in 217 (30.1%), 130 (31.2%), and 427 (37.0%) in the labetalol, nifedipine, and standard care groups, respectively. Risk of the primary outcome was lower among those receiving treatment (labetalol use vs standard adjusted RR 0.82, 95% CI, 0.72-0.94; nifedipine use vs standard adjusted RR 0.84, 95% CI, 0.71-0.99), but there was no significant difference in risk when labetalol was compared with nifedipine (adjusted RR 0.98, 95% CI, 0.82-1.18). There were no significant differences in SGA or serious adverse events between participants receiving labetalol and those receiving nifedipine.
CONCLUSION
No significant differences in predetermined maternal or neonatal outcomes were detected on the basis of the use of labetalol or nifedipine for treatment of chronic hypertension in pregnancy.
CLINICAL TRIAL REGISTRATION
ClinicalTrials.gov, NCT02299414.
Topics: Humans; Pregnancy; Female; Labetalol; Nifedipine; Antihypertensive Agents; Adult; Pregnancy Outcome; Hypertension; Infant, Newborn; Pregnancy Complications, Cardiovascular; Hypertension, Pregnancy-Induced; Administration, Oral; Infant, Small for Gestational Age; Pre-Eclampsia; Chronic Disease
PubMed: 38949541
DOI: 10.1097/AOG.0000000000005613 -
Internal Medicine Journal Jul 2024This study surveyed South Australian medical oncologists to capture their perceptions, willingness to participate and perceived barriers and motivations to participation...
This study surveyed South Australian medical oncologists to capture their perceptions, willingness to participate and perceived barriers and motivations to participation in voluntary assisted dying (VAD) activities. Approximately 70% of surveyed medical oncologists reported familiarity with VAD legislation. Less than half of physicians (39.1%) reported willingness to participate in any VAD activities, and the rate of conscientious objection was 22%. The top barriers to participation were lack of time and uncertainty given no prior experience. These results demonstrate both a low rate of conscientious objection and a low rate of willingness to participate at the point of VAD implementation in South Australia, and identify barriers to participation that are largely logistical.
PubMed: 38949456
DOI: 10.1111/imj.16448 -
South African Family Practice :... Jun 2024Pain is a common reason that patients seek care in the emergency department (ED). Regional anaesthesia in the form of nerve blocks provides an excellent alternative to...
Pain is a common reason that patients seek care in the emergency department (ED). Regional anaesthesia in the form of nerve blocks provides an excellent alternative to traditional forms of analgesia, and may be superior in managing musculoskeletal pain compared to opioids. Adequate pain management improves patient satisfaction, facilitates examination and minor procedures, and allows for earlier and safe discharge. In low resource settings this modality is underutilised due to lack of trained providers and/or support from specialised services, shortages of equipment, and lack of context-sensitive guidelines. Advances in ultrasound guided regional anaesthesia has the potential to improve access to safe and reliable anaesthesia. It is often not accessible or an active part of training even for emergency physicians. There are, however, a number of nerve blocks that are easy to learn, don't require specialised equipment, and can be readily applied in EDs for minor procedures and longer acting forms of analgesia. Nerve blocks more applicable in the operating theatre or best done under ultrasound guidance are mentioned but not discussed in this article. This continuous professional development (CPD) article aims to provide guidance with respect to several key areas related to more commonly used types of regional anaesthesia in district level services. We discuss the importance of good clinical practice including thorough preparation of equipment and the patient to avoid common complications, clinical indications for regional blocks in the ED, local anaesthetic agents, different techniques for some common regional blocks, potential complications, and the need for a trained interprofessional team.
Topics: Humans; Anesthesia, Conduction; Nerve Block; Hospitals, District; Pain Management; Ultrasonography, Interventional; Anesthetics, Local; Emergency Service, Hospital
PubMed: 38949453
DOI: 10.4102/safp.v66i1.5872 -
African Journal of Primary Health Care... Jun 2024Workplace-based assessment has become increasingly crucial in the postgraduate training of specialists in South Africa, particularly for family physicians. The...
Workplace-based assessment has become increasingly crucial in the postgraduate training of specialists in South Africa, particularly for family physicians. The development of a Portfolio of Learning (PoL) has been a central focus within the discipline of family medicine for over a decade. Initially, a paper-based portfolio was adopted to collect evidence of learning for 50 out of 85 agreed exit-level outcomes. Stellenbosch University led the conversion of this portfolio into an electronic format, known as e-PoL, utilising Scorion software. The e-PoL was successfully implemented in the Western and Eastern Cape regions and was subsequently adopted nationally under the coordination of the South African Academy of Family Physicians. In 2023, the e-PoL underwent a redesign to gather evidence of learning for 22 entrustable professional activities (EPAs). Key insights from this development process underscore the importance of the PoL in supporting assessment-for-learning rather than merely assessment-of-learning. This necessitates features for feedback and interaction, ensuring that the PoL functions beyond a mere repository of forms. Additionally, the e-PoL should facilitate triangulation, aggregation, and saturation of data points to effectively measure EPAs. Furthermore, the PoL has not only documented learning but has also played a pivotal role in guiding the development of clinical training by explicitly outlining expectations for both registrars and supervisors. While the initial design and development costs are significant, operational costs become affordable when shared across all training programmes.
Topics: South Africa; Humans; Family Practice; Education, Medical, Graduate; Educational Measurement; Clinical Competence; Learning
PubMed: 38949444
DOI: 10.4102/phcfm.v16i1.4525 -
The South African Journal of... Jun 2024Healthcare professionals are required to work effectively together to deliver the best healthcare services. Without awareness of other healthcare professionals' roles...
BACKGROUND
Healthcare professionals are required to work effectively together to deliver the best healthcare services. Without awareness of other healthcare professionals' roles and responsibilities, interprofessional practice (IPP) cannot be optimally achieved.
OBJECTIVES
This study aimed to investigate healthcare professionals' awareness of audiology and speech-language pathology (SLP) services in Saudi Arabia.
METHOD
This cross-sectional descriptive study consisted of two parts. The content of a 20-item paper questionnaire was firstly validated. The full-scale study addressed the aim through distributing questionnaire items among potential participants. Descriptive statistics and chi-square test were used.
RESULTS
A total of 403 participants completed the questionnaires for the main study. Most of the participants were Saudi citizens (84.1%), aged 18 years - 40 years (84.8%) years, and lived in Riyadh region (76.2%). Allied health professionals (40.2%), physicians (22.6%), nursing (15.4%) and dentistry (11.2%) were the main group of participants working mainly at governmental hospitals (69.2%). Of the total participants, 92.6% and 95.3% reported being fully aware of the services provided by audiologists and SLPs, respectively. No statistically significant association between the specialty of participants and their familiarity with the scope of practice for SLPs and audiologists was determined.
CONCLUSION
Our study examined healthcare professionals' awareness of audiology and SLP services and revealed a high level of awareness.Contribution: The existed level of awareness is expected to facilitate IPP and enhance the quality of care. Still, awareness campaigns about audiology and SLP services are needed to address the existing lack of knowledge among some healthcare professionals.
Topics: Humans; Saudi Arabia; Audiology; Speech-Language Pathology; Cross-Sectional Studies; Adult; Male; Female; Young Adult; Surveys and Questionnaires; Adolescent; Health Personnel; Middle Aged; Health Knowledge, Attitudes, Practice; Attitude of Health Personnel; Allied Health Personnel
PubMed: 38949430
DOI: 10.4102/sajcd.v71i1.1043 -
Journal of the History of the... Jul 2024The establishment of neurology schools in Latin America during the late-nineteenth and early-twentieth centuries profoundly influenced the French neurology school. In...
The establishment of neurology schools in Latin America during the late-nineteenth and early-twentieth centuries profoundly influenced the French neurology school. In the latter half of the nineteenth century, the neurology department at the Salpêtrière Hospital in Paris held a preeminent position as the global hub of neurology. Professor Jean-Martin Charcot, widely acclaimed as the father of modern neurology, was the most revered neurology professor of the nineteenth century. Many physicians from diverse countries across South America (notably Argentina, Uruguay, Peru, Brazil, and Colombia), the Caribbean (Cuba), and Mexico pursued specialized training in neurology under Charcot's tutelage, and even after his passing in 1893, they continued their training with his numerous disciples. As a result, nearly two centuries after the birth of Charcot, his enduring contributions to the field of neurology remain vibrantly influential, particularly in Latin America.
PubMed: 38949401
DOI: 10.1080/0964704X.2024.2368446