Background

Safely and effectively discharging a patient from the hospital requires working within a multidisciplinary team. However, little is known about how perceptions of responsibility among the team impact discharge communication practices.

Objective

Our study attempts to understand residents' perceptions of who is primarily responsible for discharge education, how these perceptions affect their own reported communication with patients, and how residents envision improving multidisciplinary communication around discharges.

Design

A multi-institutional cross-sectional survey.

Participants

Internal medicine (IM) residents from seven US residency programs at academic medical centers were invited to participate between March and May 2019, via email of an electronic link to the survey.

Main measures

Data collected included resident perception of who on the multidisciplinary team is primarily responsible for discharge communication, their own reported discharge communication practices, and open-ended comments on ways discharge multidisciplinary team communication could be improved.

Key results

Of the 613 resident responses (63% response rate), 35% reported they were unsure which member of the multidisciplinary team is primarily responsible for discharge education. Residents who believed it was either the intern's or the resident's primary responsibility had 4.28 (95% CI, 2.51-7.30) and 3.01 (95% CI, 1.66-5.71) times the odds, respectively, of reporting doing discharge communication practices frequently compared to those who were not sure who was primarily responsible. To improve multidisciplinary discharge communication, residents called for the following among team members: (1) clarifying roles and responsibilities for communication with patients, (2) setting expectations for communication among multidisciplinary team members, and (3) redefining culture around discharges.

Conclusions

Residents report a lack of understanding of who is responsible for discharge education. This diffusion of ownership impacts how much residents invest in patient education, with more perceived responsibility associated with more frequent discharge communication.

Purpose

To characterize residents' practices around hospital discharge communication and their exposure to transitions-of-care instruction in graduate medical education (GME).

Method

In 2019, internal medicine residents at 7 academic medical centers completed a cross-sectional survey reporting the types of transitions-of-care instruction they experienced during GME training and the frequency with which they performed 6 key discharge communication practices. The authors calculated a mean discharge communication score for each resident, and, using multiple logistic regression, they analyzed the relationship between exposure to types of educational experiences and discharge communication practices residents reported they performed frequently (> 60% of time). The authors used content analysis to explore factors that motivated residents to change their discharge practices.

Results

The response rate was 63.5% (613/966). Resident discharge communication practices varied. Notably, only 17.0% (n = 104) reported routinely asking patients to "teach-back" or explain their understanding of the discharge plans. The odds of frequently performing key discharge communication practices were greater if residents received instruction based on observation of and feedback regarding their communication (adjusted odds ratio 1.73; 95% confidence interval [CI], 1.07-2.81) or if they received explicit on-rounds teaching (adjusted OR 1.46; 95% CI, 1.04-2.23). In open-ended comments, residents reported that experiencing adverse patient events at some point in the postdischarge continuum was a major impetus for practice change.

Conclusions

This study exposes gaps in hospital discharge communication with patients, highlights the benefits of workplace-based instruction on discharge communication skills, and reveals the influence of adverse events as a source of hidden curricula. The results suggest that developing faculty to incorporate transitions-of-care instruction in their rounds teaching and integrating experiences across the postdischarge continuum into residents' education may foster physicians-in-training who are champions of effective transitions of care within the fragmented health care system.

Background

Advance care planning allows patients to share their preferences for medical care with the aim of ensuring goal-concordant care in times of serious illness. The morbidity and mortality of the COVID-19 pandemic has increased the importance and public visibility of advance care planning. However, little is known about the frequency and quality of advance care planning documentation during the pandemic.

Aim

This study examined the frequency, quality, and predictors of advance care planning documentation among hospitalized medical patients with and without COVID-19.

Design

This retrospective cohort analysis used multivariate logistic regression to identify factors associated with advance care planning documentation.

Setting/participants

This study included all adult patients tested for COVID-19 and admitted to a tertiary medical center in San Francisco, CA during March 2020.

Results

Among 262 patients, 31 (11.8%) tested positive and 231 (88.2%) tested negative for SARS-CoV-2. The rate of advance care planning documentation was 38.7% in patients with COVID-19 and 46.8% in patients without COVID-19 (p = 0.45). Documentation consistently addressed code status (100% and 94.4% for COVID-positive and COVID-negative, respectively), but less often named a surrogate decision maker, discussed prognosis, or elaborated on other wishes for care. Palliative care consultation was associated with increased advance care planning documentation (OR: 6.93, p = 0.004).

Conclusion

This study found low rates of advance care planning documentation for patients both with and without COVID-19 during an evolving global pandemic. Advance care planning documentation was associated with palliative care consultation, highlighting the importance of such consultation to ensure timely, patient-centered advance care planning.

PURPOSE:Although medical students will influence the future U.S. health care system, their opinions on the Patient Protection and Affordable Care Act (ACA) have not been assessed since the 2016 presidential election and elimination of key ACA provisions. Understanding medical students' views on health care policy and professional obligations can provide insight into issues that will be shaped by the next generation of physicians. METHOD:From October 2017 to November 2017, the authors conducted an electronic survey of medical students from seven U.S. institutions to elicit opinions regarding the ACA and their professional responsibility to address health policy. Participant demographics and responses were tabulated, and multiple logistic regression models were used to assess the associations of demographic characteristics with student opinions. RESULTS:Completed surveys were returned by 1,660/4,503 (36.9%) eligible medical students. Respondent demographics were similar to national estimates. In total, 89.1% (1,475/1,660) supported the ACA, and 82.0% (1,362/1,660) reported they understood the health care law. Knowledge of the law's provisions was positively associated with support for the ACA (P < .001). Most students (85.8%; 1,423/1,660) reported addressing health policy to be a professional responsibility. Political affiliation was consistently associated with student opinions. CONCLUSIONS:Most medical students support the ACA, with greater levels of support among medical students who demonstrated higher levels of objective knowledge about the law. Furthermore, students indicated a professional responsibility to engage in health policy, suggesting tomorrow's physicians are likely to participate in future health care reform efforts.