How preceptors develop trust in continuity clinic residents and how trust influences supervision: A qualitative study

Introduction To advance in their clinical roles, residents must earn supervisors’ trust. Research on supervisor trust in the inpatient setting has identified learner, supervisor, relationship, context, and task factors that influence trust. However, trust in the continuity clinic setting, where resident roles, relationships, and context differ, is not well understood. We aimed to explore how preceptors in the continuity clinic setting develop trust in internal medicine residents and how trust influences supervision. Methods In this qualitative study, we conducted semi-structured interviews with faculty preceptors from two continuity clinic sites in an internal medicine residency program at an urban academic medical center in the United States from August 2018–June 2020. We analyzed transcripts using thematic analysis with sensitizing concepts related to the theoretical framework of the five factors of trust. Results Sixteen preceptors participated. We identified four key drivers of trust and supervision in the continuity clinic setting: 1) longitudinal resident-preceptor-patient relationships, 2) direct observations of continuity clinic skills, 3) resident attitude towards their primary care physician role, and 4) challenging context and task factors influencing supervision. Preceptors shared challenges to determining trust stemming from incomplete knowledge about patients and limited opportunities to directly observe and supervise between-visit care. Discussion The continuity clinic setting offers unique supports and challenges to trust development and trust-supervision alignment. Maximizing resident-preceptor-patient continuity, promoting direct observation, and improving preceptor supervision of residents’ provision of between-visit care may improve resident continuity clinic learning and patient care.

Added diagnostic accuracy after [18F]flutemetamol PET scanning in young patients with dementia in an academic memory clinic setting

ABSTRACTIntroductionA timely diagnosis of Alzheimer’s Disease (AD) in an early stage of dementia is important to support timely access to treatment, advice, and care. The aim of this study was to estimate the diagnostic accuracy of [18F]flutemetamol PET in addition to the usual diagnostic workup for the diagnosis of AD in a memory clinic population with young onset dementia by means of a panel reference-based etiology diagnosis.Methodsin an academic memory clinic early onset dementia cohort (n=211) the nosological diagnosis was set by usual diagnostic workup and after including [18F]flutemetamol amyloid PET in a stepwise approach. To assess the change in proportion correctly diagnosed, the diagnosis with and without [18F]flutemetamol PET was related to a panel-based reference standard, serving as gold standard, consisting of 3 neurologists who relied on available clinical information over 2-year follow-up (n=152; blinded for PET).ResultsThe panel majority nosology was set as a reference diagnosis in 122 participants, leaving 30 (20%) participants with no majority reached. In 107 (88%) cases post-PET was in line with the reference, and in 103 (84%) the pre-PET diagnosis was in line with the reference. The difference was 3.3% (95% CI -3.5% to 10.1%; p=0.424).Discussion[18F]flutemetamol PET did not significantly improve the diagnostic accuracy in young patients with dementia in an academic memory clinic setting. The secondary analyses provided several indications for future research in a narrower subsample of persons with (very) high diagnostic uncertainty and to assess patient relevant health outcomes.

Feasibility of a Health Utility Assessment Platform in a Hemodialysis Outpatient Setting (Preprint)

BACKGROUND Background: Patients with End-Stage Kidney Disease (ESKD) wait roughly 4 years for a kidney transplant. A potential way to reduce wait times is through the use of Hepatitis-C Viremic (HCV) kidneys. OBJECTIVE Objective: As preparation for developing a shared decision-making tool to assist ESKD patients with the decision whether to accept an HCV-viremic kidney transplant, we first wanted to assess the feasibility of using the Gambler II, a health utility assessment tool, in an ambulatory dialysis clinic setting. Secondary goals were to collect ESKD patients’ utilities and to explore whether use of race-matched vs race-mismatched exemplars impacted knowledge gained during the assessment process. METHODS Methods: We used the Gambler II to elicit utilities for ESKD-related health states: hemodialysis, kidney transplant with HCV-unexposed kidney, and transplantation with HCV-viremic kidney. We created race exemplar video clips describing these health states and randomly assigned patients into the race-matched or race-mismatched video arms. We obtained utilities for these 3 health states from each patient, and we evaluated knowledge about ESKD and HCV-associated health conditions with pre- and post-intervention knowledge assessments. RESULTS Results: 63 hemodialysis patients from 4 outpatient Dialysis Center Inc. sites completed the study. Mean adjusted standard gamble utilities for hemodialysis, transplant with HCV-unexposed kidney, and transplantation with HCV-viremic kidney were 82.5, 89, and 75.5 respectively. General group knowledge assessment scores improved by 10 points (p < 0.05) following utility assessment process. CONCLUSIONS Conclusion: Using The Gambler II to collect ESKD patients’ utilities in an ambulatory dialysis clinic setting proved feasible. In addition, educational information about health states provided as part of the utility assessment process tool improved patients’ knowledge and understanding about ESKD-related health states and implications of organ transplantation with HCV-viremic kidneys. Wide variation in patient health state utilities reinforces the importance of incorporating patients’ preferences into decisions regarding use of HCV-viremic kidneys for transplantation

Patient Perceptions of Dermatologic Photography: A Scoping Review (Preprint)

BACKGROUND Medical photography is used extensively in dermatology to record disease progression, measure treatment response, and help teach patients about skin disease; such photos are also commonly utilized in teledermatology, medical education, research, and medical reference websites. Understanding patient perceptions of medical photographs obtained during dermatologic care in the clinic- or hospital- setting is critical to enable the delivery of high-quality, patient-centered medical care. OBJECTIVE The aim of this study was to elucidate patient perceptions of skin photos in dermatology, and to explore possible next steps in improving the patient experience of medical photography in the hospital- or clinic- setting. METHODS A scoping review of the literature was performed using the PubMed database, with clinic- or hospital- based full-text publications in English spanning the last ten years considered for inclusion. RESULTS The majority of included studies (n=10/11, 91%) found positive patient attitudes toward medical photographs. The majority of patients (n=1197/1511, 79.2%) felt that medical photographs could improve medical care in the clinic setting. Written consent detailing all photo uses, including secondary uses (such as research or teaching), was preferred apart from one study. Patients preferred or found it acceptable for the photographer of their medical photos to be a physician (n=1301/1444, 90.1%). Clinic-owned cameras with departmental record storage were the preferred modality. Latinx and African-American patients expressed less trust in the utility of medical photographs to improve care, compared to Asian and White patients. Study limitations include the minimal number of available publications on this topic and the inclusion of articles older than five years are limitations, since patient perceptions of medical photography may have rapidly changed during this time span, particularly in light of the COVID-19 pandemic and the subsequent increase in teledermatology visits. CONCLUSIONS Patients reported positive perceptions of dermatologic photography for improving their medical care. Ethnic disparities in patient perceptions require further exploration to better elucidate nuances and develop interventions to improve the experience of marginalized patients. Building patient trust in nonphysician photographers may enhance clinic efficiency. While clinic-owned cameras are well-accepted by patients, improved patient education surrounding the safety of EMR phone applications is needed. CLINICALTRIAL