The Relation of Surgical Volume to Competence: When Is Enough, Enough?

ABSTRACT Given the inherent risk in surgical intervention and the need for the optimal utilization of health care resources, achieving high-quality surgical care is a priority for the American health care system, and competent surgeons are critical to reaching this goal. Despite the multifactorial nature of patient safety and satisfaction, surgeon competence is often oversimplified to an assessment of volume because of the ease of collection and comparison. In any practice model, the analysis of competence is complex, but the components of clinical skill for military surgeons further include multiple areas of expertise, which, although superficially unrelated to surgical currency, augment the overall care delivered by these clinicians. Thus, volume as a solitary indicator of skill excludes the unique circumstances encompassed in military service. In this paper, the factors comprising volume and competence are explained, as well as the additional factors unique to military medicine. Furthermore, process improvements are proposed for assessing and optimizing surgical competence in the Military Health System.

“We’re a Little Biased”: Medicine and the Management of Bias through the Case of Contraception

There is a wealth of literature demonstrating the presence of bias throughout the American health care system. Despite acknowledging such presence, however, little is known about how bias functions within medical encounters, particularly how providers grapple with bias in their patient counseling and decision-making. We explore such processes through the case of contraceptive counseling, a highly raced, classed, and gendered context. In-depth interviews with 51 health care providers reveal that providers use four primary strategies to navigate and minimize bias in their care—using scientific rationale, employing “safe” biases, standardizing counseling, and implementing patient-centered care. Paradoxically, using these strategies can exacerbate rather than resolve bias. Understanding these bias management strategies reveals provider-held biases, how they manifest within appointments, and the potential consequences for patients’ health autonomy. Such knowledge informs interventions that promote contraceptive use among women in the United States, addresses bias in health care broadly, and thus ultimately helps combat health disparities.

Patients Viewing Their Radiology Images Online: Post-Intervention Results (Preprint)

BACKGROUND The ability for patients to directly view their radiology images through secure electronic portals is rare in the American health care system. We previously surveyed patients within our health system and found that a large majority wanted to view their own radiology images online, and have since implemented this new feature. OBJECTIVE We aim to understand patient experiences, opinions and actions taken after viewing their own radiology images online. METHODS We emailed an online survey to patients who recently viewed their radiology images via our electronic patient portal. RESULTS We sent a total of 1,825 surveys to patients and received 299 responses (response rate=16.4%). Patients reported a favorable experience (86% agree) viewing their radiology images online. Patients found value in reading their radiology reports (96% agree) and viewing their images (89% agree). Overall, patients felt that accessing and viewing their radiology images online increased their understanding of their medical condition (83%), made them feel more in control and reassured (79% and 74%, respectively), and increased levels of trust (72%). Only 6% of participants indicated concerns with finding errors, 6% felt that viewing their images online made them worry more, and 7% felt confused when viewing their images online. Of patients who viewed their images online, 45% took no action with their images, 33% saved a copy for their records, 25% shared them with their doctor, and 15% shared them with another doctor for a second opinion. A total of 9 patients (3%) shared their radiology images on Facebook and/or Instagram, primarily to inform family and friends. Ten percent of patients had questions about their radiology images after viewing them online, with the majority (65%) seeking out a doctor and far fewer (16%) choosing to ask a family member about their images. Finally, respondents viewed their images online using one or more devices including computers, smartphones, and/or tablets. Twenty-seven percent (n=103/385) of responses noted technical difficulties in total, with the highest incidence rate occurring with smartphones. CONCLUSIONS We report the first known survey results from patients who have viewed their own radiology images through an online portal. Patients reported high levels of satisfaction and increased levels of trust, autonomy, reassurance, and medical understanding. Only a small minority of patients expressed anxiety or confusion. We suggest that patient access to radiology images, like patient access to radiology reports, is highly desired by patients and operationally practical. Other health care institutions should consider offering patients access to their radiology images online in the pursuit of information transparency.

Considering Needle Phobia among Adult Patients During Mass COVID-19 Vaccinations

As mass vaccination is underway to combat the COVID-19 pandemic and achieve herd immunity, healthcare professionals need to recognize the fear and phobia of needles among their patients. Approximately 11.5 to 66 million U.S. adults may suffer from this condition. This population often avoids seeking medical care including vaccinations. The exact number of people suffering from this phobia is unknown, and the potential years of life lost in the American health care system cannot be estimated accurately. The resistance to vaccinations among this population may delay achieving herd immunity to end this current pandemic. An overview of needle phobia, vaccinations, and current treatments are explored. The use of telemedicine could prove critical for reaching this population as well as those who are hesitant about vaccinations. Providing education to healthcare providers to identify and manage these patients during the pandemic is necessary.

Athletic Trainers' Knowledge Regarding Health Care Delivery Systems and Administration in the American Health Care System

Context The American health care system is dynamic and ever evolving. As athletic training continues to advance, our understanding of and the ability to integrate best practices in policy construction and implementation, documentation, and basic business practices is critical to promoting optimal patient care. Objective To identify and compare knowledge gaps of clinicians and educators regarding health care delivery systems and administration. Design and Setting Cross-sectional, Web-based survey. Patients or Other Participants Athletic trainers (N = 485), representative of the national demographic of the profession (age = 37 ± 12 years, experience = 14 ± 11 years). Intervention(s) We used a multi-part assessment including a perceived knowledge questionnaire, validated knowledge assessment (21 items: knowledge retrieval [11 items], knowledge utilization [10 items]), and self-efficacy scales. Main Outcome Measure(s) We calculated the knowledge assessment total score and compared educators (n = 41) and clinicians (n = 444). We calculated the knowledge gap with a Spearman ρ correlation to determine the relationship between perceived knowledge mean and the knowledge retrieval subscore. We calculated the practice gap with a Spearman ρ correlation to determine the relationship between self-efficacy mean and the knowledge utilization subscore. Results Athletic trainers scored less than 50% on a knowledge assessment (mean = 10.27 ± 2.41 of 21) about health care delivery systems and administration. We identified that educators scored approximately 1 point higher (11.65 ± 0.4) than clinicians (10.14 ± 0.11), equivalent to 7% to 10% higher on the knowledge assessment. We identified, relative to health care delivery systems and administration, a knowledge gap (Spearman ρ = .161, P < .001) between perceived knowledge and knowledge retrieval and a practice gap (Spearman ρ = .095, P = .037) between self-efficacy and knowledge utilization. Conclusions Athletic trainers demonstrated knowledge and practice gaps related to health care delivery systems and administration. To meet the expectations of the practice analysis and the needs of patients in today's American health care system, we must engage in professional development in this domain of practice.

Book Reviews

Christian Pardo of Saint Joseph’s University reviews “Sick to Debt: How Smarter Markets Lead to Better Care,” by Peter A. Ubel. The Econlit abstract of this book begins: “Explores the current state of the American health-care system, with a particular focus on health-care consumerism and strategies for improving the functioning of health-care markets.”