Focused Ethnography of Diagnosis in Academic Medical Centers.

Abstract:

BACKGROUND:Approaches of trainees to diagnosis in teaching hospitals are poorly understood. Identifying cognitive and system-based barriers and facilitators to diagnosis may improve diagnosis in these settings. METHODS:We conducted a focused ethnography of trainees at 2 academic medical centers to understand the barriers and facilitators to diagnosis. Field notes regarding the diagnostic process (eg, information gathering, integration and interpretation, working diagnosis) and the work system (eg, team members, organization, technology and tools, physical environment, tasks) were recorded. Following observations, focus groups and interviews were conducted to understand the viewpoints, problems, and solutions to improve diagnosis. RESULTS:Between January 2016 and May 2016, 4 teaching teams (4 attendings, 4 senior residents, 9 interns, and 12 medical students) were observed for 168 h. Observations of diagnosis during care led to identification of the following 4 key themes: (a) diagnosis is a social phenomenon; (b) data necessary to make diagnoses are fragmented; (c) distractions interfere with the diagnostic process; and (d) time pressures impede diagnostic decision-making. These themes suggest that specific interventions tailored to the academic setting such as team-based discussions of diagnostic workups, scheduling diagnostic time-outs during the day, and strategies to "protect" learners from interruptions might prove to be useful in improving the process of diagnosis. Future studies that implement these ideas (either alone or within a multimodal intervention) appear to be necessary. CONCLUSIONS:Diagnosis in teaching hospitals is a unique process that requires improvement. Contextual insights gained from this ethnography may be used to inform future interventions.

journal_name

J Hosp Med

authors

Chopra V,Harrod M,Winter S,Forman J,Quinn M,Krein S,Fowler KE,Singh H,Saint S

doi

10.12788/jhm.2966

subject

Has Abstract

pub_date

2018-10-01 00:00:00

pages

668-672

issue

10

eissn

1553-5592

issn

1553-5606

journal_volume

13

pub_type

杂志文章
  • Changes in patient satisfaction related to hospital renovation: experience with a new clinical building.

    abstract:IMPORTANCE:There is an increasing trend toward designing hospitals with patient-centered features like reduced noise, improved natural light, visitor friendly facilities, well-decorated rooms, and hotel-like amenities. It has also been suggested that because patients cannot reliably distinguish positive experiences wit...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章

    doi:10.1002/jhm.2297

    authors: Siddiqui ZK,Zuccarelli R,Durkin N,Wu AW,Brotman DJ

    更新日期:2015-03-01 00:00:00

  • Evaluation of an innovative pediatric clerkship structure using multiple outcome variables including career choice.

    abstract:BACKGROUND:Few studies have examined alternative structures for inpatient clerkships. OBJECTIVE:Compare 2 inpatient clerkship structures using multiple outcome variables. DESIGN:Prospective, randomized controlled trial. SETTING:Tertiary-care, freestanding children's hospital. SUBJECTS:All medical students enrolled ...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章,随机对照试验

    doi:10.1002/jhm.250

    authors: Antommaria AH,Firth SD,Maloney CG

    更新日期:2007-11-01 00:00:00

  • Hospitalist time usage and cyclicality: opportunities to improve efficiency.

    abstract:BACKGROUND:Academic medical centers (AMCs) have a constrained resident work force. Many AMCs have increased the use of nonresident service hospitalists to manage continued growth in clinical volume. To optimize their time in the hospital, it is important to understand hospitalists' work flow. DESIGN:We performed a tim...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章

    doi:10.1002/jhm.613

    authors: Kim CS,Lovejoy W,Paulsen M,Chang R,Flanders SA

    更新日期:2010-07-01 00:00:00

  • Beyond warfarin: a patient-centered approach to selecting novel oral anticoagulants for stroke prevention in atrial fibrillation.

    abstract:BACKGROUND:Warfarin reduces stroke in patients with atrial fibrillation. However, its narrow therapeutic index and need for chronic monitoring are barriers to its optimal utilization in many patients. The recent introduction of 3 novel oral anticoagulants (NOACs), as alternatives to warfarin, may change the eligibility...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章,评审

    doi:10.1002/jhm.2201

    authors: Patel KK,Mehdirad AA,Lim MJ,Ferreira SW,Mikolajczak PC,Stolker JM

    更新日期:2014-06-01 00:00:00

  • A Protean Protein.

    abstract:BACKGROUND: OBJECTIVE: DESIGN, SETTING, PATIENTS: INTERVENTION: MEASUREMENTS: CONCLUSIONS: ...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章

    doi:10.12788/jhm.3102

    authors: Nawas MT,Walker EJ,Richie MB,White AA,Hsu G

    更新日期:2019-02-01 00:00:00

  • Hospital Privileging Practices for Bedside Procedures: A Survey of Hospitalist Experts.

    abstract::Many hospitalists are routinely granted hospital privileges to perform invasive bedside procedures, but criteria for privileging are not well described. We conducted a survey of 21 hospitalist procedure experts from the Society of Hospital Medicine Point-of-Care Ultrasound Task Force to better understand current privi...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章

    doi:10.12788/jhm.2837

    authors: Jensen TP,Soni NJ,Tierney DM,Lucas BP

    更新日期:2017-10-01 00:00:00

  • All Together Now: Impact of a Regionalization and Bedside Rounding Initiative on the Efficiency and Inclusiveness of Clinical Rounds.

    abstract:BACKGROUND:Attending rounds at academic medical centers are often disconnected from patients and team members who are not physicians. Regionalization of care teams may facilitate bedside rounding and more frequent interactions among doctors, nurses, and patients. OBJECTIVE:We used time-motion analysis to investigate h...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章

    doi:10.12788/jhm.2696

    authors: Huang KT,Minahan J,Brita-Rossi P,Aylward P,Katz JT,Roy C,Schnipper JL,Boxer R

    更新日期:2017-03-01 00:00:00

  • The TEND (Tomorrow's Expected Number of Discharges) Model Accurately Predicted the Number of Patients Who Were Discharged from the Hospital the Next Day.

    abstract:BACKGROUND:Knowing the number of discharges that will occur is important for administrators when hospital occupancy is close to or exceeds 100%. This information will facilitate decision making such as whether to bring in extra staff, cancel planned surgery, or implement measures to increase the number of discharges. W...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章

    doi:10.12788/jhm.2802

    authors: van Walraven C,Forster AJ

    更新日期:2018-03-01 00:00:00

  • The Hospitalized Patient with Interstitial Lung Disease: A Hospitalist Primer.

    abstract::Interstitial lung disease (ILD) is a diverse group of disorders typically with insidious onset. Diagnosis and management largely occur in the outpatient setting; however, ILD can present acutely necessitating hospitalization. Effective inpatient management requires the clinician to establish an accurate diagnosis and ...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章,评审

    doi:10.12788/jhm.2774

    authors: Farrand E,Shah R,Collard H

    更新日期:2017-07-01 00:00:00

  • Dismantling Rube Goldberg: cutting through chaos to achieve coordinated care.

    abstract::Dr. Pham, a practicing general internist and health policy researcher, recalls her experience, as a granddaughter, of how patients, families, and physicians are often complicit in foiling the good coordination of care. ...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章

    doi:10.1002/jhm.410

    authors: Pham HH

    更新日期:2009-04-01 00:00:00

  • Do physicians clean their hands? Insights from a covert observational study.

    abstract::Physicians are notorious for poor hand hygiene (HH) compliance. We wondered if lower performance by physicians compared with other health professionals might reflect differences in the Hawthorne effect. We introduced covert HH observers to see if performance differences between physicians and nurses decreased and to g...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章

    doi:10.1002/jhm.2632

    authors: Kovacs-Litman A,Wong K,Shojania KG,Callery S,Vearncombe M,Leis JA

    更新日期:2016-12-01 00:00:00

  • Routine rapid HIV testing in hospitals: another opportunity for hospitalists to improve care.

    abstract:BACKGROUND:The Centers for Disease Control and Prevention recommends routinely offering HIV testing to inpatients at hospitals with an HIV seroprevalence rate of greater than 1% or an AIDS diagnosis rate of greater than 1.0 per 1000 discharges. This recommendation has not been widely adopted, perhaps because of one of ...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章,评审

    doi:10.1002/jhm.66

    authors: Greenwald JL

    更新日期:2006-03-01 00:00:00

  • Effects of provider characteristics on care coordination under comanagement.

    abstract:BACKGROUND:Care coordination is critical in settings characterized by high levels of uncertainty, time constraints, and interdependent work processes. The effects of provider characteristics on coordination in comanaged teams has never been examined. OBJECTIVE:To characterize individual providers based on their contri...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章

    doi:10.1002/jhm.797

    authors: Hinami K,Whelan CT,Konetzka RT,Edelson DP,Casalino LP,Meltzer DO

    更新日期:2010-11-01 00:00:00

  • Association of hospital admission service structure with early transfer to critical care, hospital readmission, and length of stay.

    abstract:BACKGROUND:Hospital medical groups use various staffing models that may systematically affect care continuity during the admission process. OBJECTIVE:To compare the effect of 2 hospitalist admission service models ("general" and "admitter-rounder") on patient disposition and length of stay. DESIGN:Retrospective obser...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章

    doi:10.1002/jhm.2592

    authors: Smith GR Jr,Ma M,Hansen LO,Christensen N,O'Leary KJ

    更新日期:2016-10-01 00:00:00

  • Job characteristics, satisfaction, and burnout across hospitalist practice models.

    abstract:BACKGROUND:Nearly two-thirds of hospitals in the United States are served by hospitalist physicians. How hospitalist work patterns and job satisfaction vary across various practice models is unknown. METHODS:We administered the Hospitalist Worklife Survey to a randomized stratified sample of 3105 potential hospitalist...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章,多中心研究,随机对照试验

    doi:10.1002/jhm.1907

    authors: Hinami K,Whelan CT,Miller JA,Wolosin RJ,Wetterneck TB,Society of Hospital Medicine Career Satisfaction Task Force.

    更新日期:2012-05-01 00:00:00

  • Opportunities and Challenges for Improving the Patient Experience in the Acute and Postacute Care Setting Using Patient Portals: The Patient's Perspective.

    abstract::Efforts to improve the patient experience are increasingly focusing on engaging patients and their "care partners" by using patient portals. The Acute Care Patient Portal Task Force was supported by the Gordon and Betty Moore Foundation to convene a national meeting of an interdisciplinary group of stakeholders, inclu...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章

    doi:10.12788/jhm.2860

    authors: Dalal AK,Bates DW,Collins S

    更新日期:2017-12-01 00:00:00

  • Teaching Physical Examination to Medical Students on Inpatient Medicine Teams: A Prospective, Mixed-Methods Descriptive Study.

    abstract::Physical examination (PE) is a core clinical competency, and the internal medicine clerkship is a premiere venue for students to develop PE skills. However, clinical rotations often lack opportunities for real-time instruction. We sought to measure the frequency, content, and factors affecting PE instruction during th...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章

    doi:10.12788/jhm.2972

    authors: Bergl PA,Taylor AC,Klumb J,Quirk K,Muntz MD,Fletcher KE

    更新日期:2018-06-01 00:00:00

  • Preventing another event: role of the hospitalist in discharge stroke prevention.

    abstract::Only 1 of 8 stroke patients is managed exclusively by a neurologist. Furthermore, many stroke patients harbor other vascular comorbidities and are also at risk for developing general medical complications that can lead to death following stroke. With the growing hospitalist system, it is quite clear that hospitalists ...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章,评审

    doi:10.1002/jhm.147

    authors: Ovbiagele B,Sachdeva S

    更新日期:2007-01-01 00:00:00

  • Hospitalized Medical Patients With Posttraumatic Stress Disorder (PTSD): Review of the Literature and a Roadmap for Improved Care.

    abstract::Posttraumatic stress disorder (PTSD) is common in the United States, with a prevalence of nearly 8% in the general population and between 10% and 30% in veterans. Despite how common PTSD is, inpatient providers may not be familiar with its manifestations or feel comfortable taking care of patients who may exhibit symp...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章,评审

    doi:10.12788/jhm.3409

    authors: Fletcher KE,Steinbach S,Lewis F,Hendricks M,Kwan B

    更新日期:2021-01-01 00:00:00

  • Association Between Radiologic Incidental Findings and Resource Utilization in Patients Admitted With Chest Pain in an Urban Medical Center.

    abstract:BACKGROUND:Increasing use of testing among hospitalized patients has resulted in an increase in radiologic incidental findings (IFs), which challenge the provision of high-value care in the hospital setting. OBJECTIVE:To understand impact of radiologic incidental findings on resource utilization in patients hospitaliz...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章

    doi:10.12788/jhm.2722

    authors: Gundareddy VP,Maruthur NM,Chibungu A,Bollampally P,Landis R,Eid SM

    更新日期:2017-05-01 00:00:00

  • Assess Before Rx: Reducing the Overtreatment of Asymptomatic Blood Pressure Elevation in the Inpatient Setting.

    abstract:BACKGROUND:Asymptomatic blood pressure elevation is common in the inpatient setting. National guidelines recommend treating with oral agents to slowly decrease blood pressure; however, many clinicians use intravenous antihypertensive medications, which can lead to unpredictable changes in blood pressure. OBJECTIVE:To ...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章

    doi:10.12788/jhm.3190

    authors: Pasik SD,Chiu S,Yang J,Sinfield C,Zubizarreta N,Ramkeesoon R,Cho HJ,Krouss M

    更新日期:2019-03-01 00:00:00

  • Things We Do for No Reason: Intermittent Pneumatic Compression for Medical Ward Patients?

    abstract:: ...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章

    doi:10.12788/jhm.3114

    authors: Holleck JL,Gunderson CG

    更新日期:2019-01-01 00:00:00

  • Unplanned transfers to the intensive care unit: the role of the shock index.

    abstract:BACKGROUND:Unplanned (unexpected) transfers to the intensive care unit (ICU) are typically preceded by physiologic instability. However, trends toward instability may be subtle and not accurately reflected by changes in vital signs. The shock index (SI) (heart rate/systolic blood pressure as an indicator of left ventri...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章

    doi:10.1002/jhm.779

    authors: Keller AS,Kirkland LL,Rajasekaran SY,Cha S,Rady MY,Huddleston JM

    更新日期:2010-10-01 00:00:00

  • Pediatric hospitalist preoperative evaluation of children with neuromuscular scoliosis.

    abstract:WHAT'S NEW:This is the first study of a pediatric hospitalist preoperative clinic. Pediatric hospitalists frequently make significant recommendations for patients with neuromuscular scoliosis prior to spinal surgery, especially those with medical complexity. Certain clinical criteria are statistically significantly ass...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章

    doi:10.1002/jhm.2101

    authors: Rappaport DI,Cerra S,Hossain J,Sharif I,Pressel DM

    更新日期:2013-12-01 00:00:00

  • Use of provider-level dashboards and pay-for-performance in venous thromboembolism prophylaxis.

    abstract:BACKGROUND:Despite safe and cost-effective venous thromboembolism (VTE) prevention measures, VTE prophylaxis rates are often suboptimal. Healthcare reform efforts emphasize transparency through programs to report performance and payment incentives through pay-for-performance programs. OBJECTIVE:To sequentially examine...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章

    doi:10.1002/jhm.2303

    authors: Michtalik HJ,Carolan HT,Haut ER,Lau BD,Streiff MB,Finkelstein J,Pronovost PJ,Durkin N,Brotman DJ

    更新日期:2015-03-01 00:00:00

  • Pediatric weekend admission and increased unplanned readmission rates.

    abstract::Outcomes for patients hospitalized on weekends are often worse for adults-the so-called "weekend effect." Less is known about the weekend effect for children. We examined 55,383 hospitalizations at a tertiary care children's hospital. We used logistic regression to examine the associations of weekend admission and wee...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章

    doi:10.1002/jhm.2426

    authors: Auger KA,Davis MM

    更新日期:2015-11-01 00:00:00

  • Comparative effectiveness of macrolides and quinolones for patients hospitalized with acute exacerbations of chronic obstructive pulmonary disease (AECOPD).

    abstract:BACKGROUND:Meta-analyses of randomized trials have found that antibiotics are effective in acute exacerbations of chronic obstructive pulmonary disease (AECOPD), but there is insufficient evidence to guide antibiotic selection. Current guidelines offer conflicting recommendations. OBJECTIVE:To compare the effectivenes...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章,多中心研究

    doi:10.1002/jhm.628

    authors: Rothberg MB,Pekow PS,Lahti M,Brody O,Skiest DJ,Lindenauer PK

    更新日期:2010-05-01 00:00:00

  • Health information exchange systems and length of stay in readmissions to a different hospital.

    abstract:BACKGROUND:Readmission to a different hospital than the original discharge hospital may result in breakdowns in continuity of care. In different-hospital readmissions (DHRs), continuity can be maintained when hospitals are connected through health information exchange (HIE) systems. OBJECTIVE:To examine whether length...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章

    doi:10.1002/jhm.2535

    authors: Flaks-Manov N,Shadmi E,Hoshen M,Balicer RD

    更新日期:2016-06-01 00:00:00

  • Development of a pediatric hospitalist sedation service: training and implementation.

    abstract:OBJECTIVE:There is growing demand for safe and effective procedural sedation in pediatric facilities nationally. Currently, these needs are being met by a variety of providers and sedation techniques, including anesthesiologists, pediatric intensivists, emergency medicine physicians, and pediatric hospitalists. There i...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章

    doi:10.1002/jhm.979

    authors: Turmelle M,Moscoso LM,Hamlin KP,Daud YN,Carlson DW

    更新日期:2012-04-01 00:00:00

  • Can the identification of an idle line facilitate its removal? A comparison between a proposed guideline and clinical practice.

    abstract:BACKGROUND:There are 250,000 cases of central line-associated blood stream infections in the United States annually, some of which may be prevented by the removal of lines that are no longer needed. OBJECTIVE:To test the performance of criteria to identify an idle line as a guideline to facilitate its removal. METHOD...

    journal_title:Journal of hospital medicine

    pub_type: 杂志文章

    doi:10.1002/jhm.2573

    authors: Kara A,Johnson CS,Murray M,Dillon J,Hui SL

    更新日期:2016-07-01 00:00:00