Andrew Austin White

Background: High‐quality clinician‐patient communication is associated with improved patient understanding, trust, and healthcare outcomes. However, the hospital environment poses unique challenges to effective communication, and research documents that many hospitalized patients report poor communication with clinicians. Objective: Characterize current efforts and barriers to improving clinician‐patient communication across hospital medicine. Methods: We conducted a multi‐methods study using virtual focus groups with an online survey. Focus groups were held with hospital medicine clinicians and members of the Hospital Medicine ReEngineering Network (HOMERuN) Patient and Family Advisory Council (PFAC). We analyzed focus groups using rapid qualitative analysis. Results: Across 8 total focus groups, 37 clinicians and 4 PFAC members participated. We received 26 survey responses (63% response rate); the majority (19, 73%) reported their institution had initiatives in place to improve clinician‐patient communication. Our qualitative analysis revealed four primary themes: (1) hospital medicine communication initiatives vary widely in approaches and objectives; (2) trainees are taught foundational communication skills through formal and informal mechanisms, but these efforts may be siloed from other initiatives; (3) hospital medicine clinicians perceive multiple barriers to improving individual communication behaviors; and (4) systems‐level factors make it challenging to effectively develop, evaluate, and sustain communication initiatives. Conclusions: Hospital medicine groups are actively engaged in diverse communication initiatives, but these efforts are undermined by fragmentation, inadequate feedback mechanisms, and competing priorities. Our findings highlight a need for coordinated strategies that align communication projects with real‐world clinical workflows, provide clinicians with actionable feedback, and incorporate genuine partnership with patients and caregivers.

Guidelines recommend measuring glycated hemoglobin (HgbA1c) levels on all inpatients with diabetes mellitus, if untested in the prior 3 months. In response, our health system applies default HgbA1c orders in the electronic insulin orders for qualifying patients. However, recent red blood cell transfusions may cause falsely low HgbA1c values, leading to inappropriate management. Clinicians often forget to deselect default HgbA1c orders after transfusion, leading to erroneous results. We evaluated a non-interruptive clinical decision support (CDS) intervention to discourage automatic HgbA1c testing in patients with recent transfusions. A retrospective, observational analysis of the number and percentage of HgbA1c tests performed on inpatients within 7 days of a red blood cell transfusion over a 40-month period. Preintervention, clinicians ordered an average of 827 HgbA1c tests/month on inpatients. Of these, 11.7% (97 tests/month) were on patients who received a red blood cell transfusion within the preceding 7 days. Postintervention, clinicians ordered an average of 832 HgbA1c tests per month on inpatients, of which 5.8% (48 tests/month) were performed within 7 days of red blood cell transfusions. A non-interruptive CDS intervention can significantly decrease the number of HgbA1c tests performed in hospitalized patients who received a red blood cell transfusion, a common cause of erroneous HgbA1c values. This approach reduced waste without restricting clinician autonomy or requiring interruptive alerts that generate alert fatigue.

Late career physicians (LCPs; physicians working beyond age 65 to 75 years) may be at higher risk for delivering unsafe care. To oversee LCPs, some health care organizations (HCOs) have adopted LCP policies requiring cognitive, physical, and practice performance screening assessments. Despite recent controversies, little is known about the content and implementation of such policies. To characterize key features of LCP policies and the perspectives of medical leaders responsible for policy development and implementation. Mixed-methods study using content analysis and key informant interviews. 29 U.S. HCOs with LCP policies active in 2020. 21 purposively sampled interviewees in physician leadership roles at 18 HCOs. Descriptive statistics of policy features and content analysis of interviews. Although policies had many commonalities-mandatory universal screening at a trigger age around 70 years, a strategy of screening followed by in-depth assessment of positive results, and commitment to patient safety as the key motive-they varied substantially in the testing required, funding, processes after a positive screening result, and decision making around concerning results. Policies prioritized institutional discretion in interpreting and responding to test results; many lacked clear language about appeals or other procedural protections for physicians. Leaders were generally satisfied with policies but reported preemptive retirements as physicians approached the screening age and cautioned that substantial investment in cultivating physicians' buy-in was required for successful rollout. Sampled policies and interviews may not be representative of all HCOs. The analysis excluded the experiences of HCOs that tried and failed to implement LCP screening. Policies about LCPs are considered successful by institutional leaders. Policy variations and early adopters' implementation experiences highlight opportunities to improve physician acceptance and program rigor. The Greenwall Foundation.

Introduction Annual influenza vaccination reduces disease burden but vaccination rates are suboptimal, with persistent disparities among subpopulations. The purpose of this trial is to evaluate multicomponent behavioural economic nudge interventions to clinicians and patients to increase influenza vaccination. This trial also includes an intensification nudge to reduce disparities in vaccination among older adult, primary care patients. Methods This is a two-part, multisite cluster randomised, pragmatic clinical trial. In the first part, a multicomponent nudge intervention will be tested over approximately 6 months (September 2023–February 2024). The second part consists of a replication trial conducted at an additional site during the following influenza season (September 2024–February 2025). Primary care clinics will be randomised to the nudge intervention or usual care. Eligible clinicians and patients at intervention clinics will receive the intervention, and patients deemed high risk for not receiving a vaccine will be further randomised to receive an intensification nudge. The primary outcome is vaccine completion during the eligible visit and the secondary outcome is vaccine completion within 3 months of the eligible visit. Analysis The effect of the clinic-level nudge intervention on the primary and secondary outcomes will be evaluated using generalised estimating equations (GEEs) with a clinic-level exchangeable working correlation to account for clustering of observations within the clinic. GEE models with an independent working correlation will be used to evaluate the impact of the additional intensification nudge on the primary and secondary outcomes. Ethics and dissemination The University of Pennsylvania Institutional Review Board (IRB) approved this trial and serves as the single IRB of record (IRB #851838). Results will be disseminated via peer-reviewed publication and conference presentations. Trial registration number NCT06057727.

Importance: Residents must prepare for effective communication with patients after medical errors. The video-based communication assessment (VCA) is software that plays video of a patient scenario, asks the physician to record what they would say, engages crowdsourced laypeople to rate audio recordings of physician responses, and presents feedback to physicians.Objective: To evaluate the effectiveness of VCA feedback in resident error disclosure skill training.Design, Setting, and Participants: This single-blinded, randomized clinical trial was conducted from July 2022 to May 2023 at 7 US internal medicine and family medicine residencies (10 total sites). Participants were second-year residents attending required teaching conferences. Data analysis was performed from July to December 2023.Intervention: Residents completed 2 VCA cases at time 1 and were randomized to the intervention, an individual feedback report provided in the VCA application after 2 weeks, or to control, in which feedback was not provided until after time 2. Residents completed 2 additional VCA cases after 4 weeks (time 2).Main Outcomes and Measures: Panels of crowdsourced laypeople rated recordings of residents disclosing simulated medical errors to create scores on a 5-point scale. Reports included learning points derived from layperson comments. Mean time 2 ratings were compared to test the hypothesis that residents who had access to feedback on their time 1 performance would score higher at time 2 than those without feedback access. Residents were surveyed about demographic characteristics, disclosure experience, and feedback use. The intervention’s effect was examined using analysis of covariance.Results: A total of 146 residents (87 [60.0%] aged 25-29 years; 60 female [41.0%]) completed the time 1 VCA, and 103 (70.5%) completed the time 2 VCA (53 randomized to intervention and 50 randomized to control); of those, 28 (54.9%) reported reviewing their feedback. Analysis of covariance found a significant main effect of feedback between intervention and control groups at time 2 (mean [SD] score, 3.26 [0.45] vs 3.14 [0.39]; difference, 0.12; 95% CI, 0.08-0.48; P = .01). In post hoc comparisons restricted to residents without prior disclosure experience, intervention residents scored higher than those in the control group at time 2 (mean [SD] score, 3.33 [0.43] vs 3.09 [0.44]; difference, 0.24; 95% CI, 0.01-0.48; P = .007). Worse performance at time 1 was associated with increased likelihood of dropping out before time 2 (odds ratio, 2.89; 95% CI, 1.06-7.84; P = .04).Conclusions and Relevance: In this randomized clinical trial, self-directed review of crowdsourced feedback was associated with higher ratings of internal medicine and family medicine residents’ error disclosure skill, particularly for those without real-life error disclosure experience, suggesting that such feedback may be an effective way for residency programs to address their requirement to prepare trainees for communicating with patients after medical harm.Trial Registration: ClinicalTrials.gov Identifier: NCT06234085

Background: US residents require practice and feedback to meet Accreditation Council for Graduate Medical Education mandates and patient expectations for effective communication after harmful errors. Current instructional approaches rely heavily on lectures, rarely provide individualized feedback to residents about communication skills, and may not assure that residents acquire the skills desired by patients. The Video-based Communication Assessment (VCA) app is a novel tool for simulating communication scenarios for practice and obtaining crowdsourced assessments and feedback on physicians’ communication skills. We previously established that crowdsourced laypeople can reliably assess residents’ error disclosure skills with the VCA app. However, its efficacy for error disclosure training has not been tested. Objective: We aimed to evaluate the efficacy of using VCA practice and feedback as a stand-alone intervention for the development of residents’ error disclosure skills. Methods: We conducted a pre-post study in 2020 with pathology, obstetrics and gynecology, and internal medicine residents at an academic medical center in the United States. At baseline, residents each completed 2 specialty-specific VCA cases depicting medical errors. Audio responses were rated by at least 8 crowdsourced laypeople using 6 items on a 5-point scale. At 4 weeks, residents received numerical and written feedback derived from layperson ratings and then completed 2 additional cases. Residents were randomly assigned cases at baseline and after feedback assessments to avoid ordinal effects. Ratings were aggregated to create overall assessment scores for each resident at baseline and after feedback. Residents completed a survey of demographic characteristics. We used a 2×3 split-plot ANOVA to test the effects of time (pre-post) and specialty on communication ratings. Results: In total, 48 residents completed 2 cases at time 1, received a feedback report at 4 weeks, and completed 2 more cases. The mean ratings of residents’ communication were higher at time 2 versus time 1 (3.75 vs 3.53; P<.001). Residents with prior error disclosure experience performed better at time 1 compared to those without such experience (ratings: mean 3.63 vs mean 3.46; P=.02). No differences in communication ratings based on specialty or years in training were detected. Residents’ communication was rated higher for angry cases versus sad cases (mean 3.69 vs mean 3.58; P=.01). Less than half of all residents (27/62, 44%) reported prior experience with disclosing medical harm to patients; experience differed significantly among specialties (P<.001) and was lowest for pathology (1/17, 6%). Conclusions: Residents at all training levels can potentially improve error disclosure skills with VCA practice and feedback. Error disclosure curricula should prepare residents for responding to various patient affects. Simulated error disclosure may particularly benefit trainees in diagnostic specialties, such as pathology, with infrequent real-life error disclosure practice opportunities. Future research should examine the effectiveness, feasibility, and acceptability of VCA within a longitudinal error disclosure curriculum.