Procedure training, decision making, and more

Research summaries from ACP Hospitalist Weekly.

Study finds early skill decay after paracentesis training in residency

Residents trained in paracentesis may see procedural performance decays as soon as three months after initial training, a recent study found.

From September 2016 to June 2017, 118 participating internal medicine and medicine-pediatrics residents at one program underwent paracentesis simulation training. Researchers looked at differences in resident competence in paracentesis over time using the Paracentesis Competency Assessment Tool (PCAT), which combines a checklist, global scale, and entrustment score. The tool also delineates two categorical cut-point scores: the Minimum Passing Standard (MPS) and the Unsupervised Practice Standard (UPS). The researchers randomized residents to return to the simulation lab at three and six months (group A, n=60) or at six months only (group B, n=58). Faculty raters assessed resident performance at each session, and the researchers analyzed data to compare scores at each session and between groups at six months. Results were published online on Sept. 23, 2020, by the Journal of General Internal Medicine.

Image by Getty Images
Image by Getty Images

After initial training, all residents met the MPS. The number of residents who achieved UPS did not differ between groups (group A, n=24 [40%] vs. group B, n=20 [34.5%]; P=0.67). Overall, six residents were lost to follow-up due to scheduling conflicts, illness, or early graduation. When group A was retested at three months, performance on each PCAT component significantly declined, as did the proportion of residents meeting the MPS and UPS. Although the proportion of residents in group A who achieved the MPS at six months improved compared with the three-month test (89.7% vs. 52.5%), it was still significantly less than after initial training (P=0.03). In contrast, the proportion of residents who achieved the UPS at six months was not different compared with after initial training (P=0.67). At the six-month test, residents in group A performed significantly better than residents in group B, with 52 (89.7%) and 20 (34.5%) achieving the MPS and UPS, respectively, in group A compared with 25 (46.3%) and two (3.70%) in group B (P<0.001 for both comparisons).

Limitations of the study included that all procedure assessments occurred in simulation rather than with live patients, the authors noted. They added that assessments from a minimal number of simulated or live procedures are unlikely to be enough to make summative decisions about procedural competence.

The observed performance decays at three months may be clinically significant, given that the proportion of residents who achieved either the MPS or UPS also significantly declined, the authors noted. “This is alarming, given the interruption of consecutive procedural opportunities for residents, which often extends beyond 3 or 6 months. . . . Procedural competence requires frequent retraining, and programs need to determine how best to implement such training with potentially limited resources,” they wrote.

Decision-making preferences of hospitalized patients linked to care satisfaction, trust

Hospitalized patients' willingness to leave medical decisions to their physicians was associated with care satisfaction and trust in their physicians in a recent study.

Researchers conducted a survey study in an academic research setting to investigate the association of hospitalized patients' desire to delegate decisions to their physician with care dissatisfaction. As part of the University of Chicago Hospitalist Study, they collected data on hospitalized patients admitted to the general internal medicine service of the University of Chicago Medical Center between July 1, 2004, and Sept. 30, 2012, who answered surveys soon after admission and at 30-day follow-up. The survey measured patients' preferences to leave medical decisions to their physician (definitely agree or somewhat agree vs. somewhat disagree or definitely disagree). The main outcomes were patient-reported dissatisfaction with overall service, dissatisfaction with physician care, and lack of confidence and trust in the physicians providing treatment, which were obtained from the 30-day follow-up survey. Results were published on Oct. 2, 2020, by JAMA Network Open.

The sample population included 13,902 patients (mean age, 56.7 years; 60.4% women; 74.2% African American) who completed both surveys. Overall, 53.2% had no higher educational attainment, 22.7% were insured by Medicaid, and 51.1% self-assessed their health status as fair or poor. When asked whether they preferred to delegate decisions to their physician, 71.1% agreed and 28.9% disagreed. A higher proportion of those who agreed rated their overall care as excellent or very good compared with those who disagreed (68.0% vs. 62.5%; P<0.001). In addition, a higher proportion of those who agreed were extremely satisfied with the physician care received (67.8% vs. 62.5%; P<0.001). Compared with those patients who definitely agreed with delegation, patients who definitely disagreed were more likely to be dissatisfied with overall service (odds ratio [OR], 1.86; 95% CI, 1.54 to 2.24) and the physician care received (OR, 1.78; 95% CI, 1.42 to 2.22) and to lack confidence and trust in the physicians providing treatment (OR, 2.05; 95% CI, 1.62 to 2.59).

Limitations of the study include the fact that the results may not be generalizable outside of its urban, largely African American population, the authors noted. They added that about 29% of admitted patients did not participate in the survey.

“Within certain patient populations, expectations of care and communication that accompany a desire to participate in health care decisions may deleteriously alter satisfaction,” they concluded. “Clinicians should individualize their encouragement of patient participation, which can have consequences on satisfaction and trust.”