User-created content and communications on Web-based applications, such as networking sites, media sharing sites, or blog platforms, have dramatically increased in popularity over the past several years, but there has been little policy or guidance on the best practices to inform standards for the professional conduct of physicians in the digital environment. Areas of specific concern include the use of such media for nonclinical purposes, implications for confidentiality, the use of social media in patient education, and how all of this affects the public's trust in physicians as patient-physician interactions extend into the digital environment. Opportunities afforded by online applications represent a new frontier in medicine as physicians and patients become more connected. This position paper from the American College of Physicians and the Federation of State Medical Boards examines and provides recommendations about the influence of social media on the patient-physician relationship, the role of these media in public perception of physician behaviors, and strategies for physician-physician communication that preserve confidentiality while best using these technologies.

Background: Little is known regarding how internal medicine residents manage uncertainty during decision making and subsequent effects on patient care. The aims of this study were to describe types of uncertainty faced by residents, strategies employed to manage uncertainty and effects on patient care. Methods: Using critical incident technique, residents were asked to recall important clinical decisions during a recent call night, with probes to identify decisions made during uncertainty. They were also asked to report who they approached for advice. Three authors independently coded transcripts using the constant comparative method.

Background Communication and coordination with primary care physicians (PCPs) is recommended to ensure safe care transitions for hospitalized older patients. Understanding patient experiences of problems after discharge can help clinical teams design more patient-centered care transitions. Objective To report older patients’ experiences with problems after hospital discharge and investigate whether PCPs were aware of their hospitalization Design Prospective mixed methods study Setting Single academic medical center Patients Hospitalized patients and PCPs Measurements Telephone interviews of older frail general medical patients conducted two weeks after discharge to elicit patient problems after discharge, such as obtaining medications, or follow-up appointments; and 2) perceptions of hospital physician communication with their PCP. For each patient interviewed, their PCP was faxed a survey two weeks after discharge to assess awareness of hospitalization. Results Forty-two percent (27) of patients reported 42 different post-discharge problems. The most frequently reported problems were difficulty with follow-up appointments or tests (12). Other reported problems included readmission and return to the Emergency Department (10), problems with medications (8), not-prepared for discharge (8), and hospital complications or questions (4). Thirty percent of PCPs were unaware of patient hospitalization. Patients were twice as likely to report a problem if their PCP was unaware of the hospitalization (31% PCP aware, vs. 67% PCP not aware; p<0.05). Conclusion This study suggests that many frail older patients reported problems after discharge and were twice as likely to do so when the patient’s PCP was not aware of the hospitalization. Systematic interventions to improve communication with PCPs during patient hospitalization are needed.

AIM:The Observed Simulated Hand-off Experience (OSHE) was created to evaluate medical students' sign-out skills using a real-time assessment tool, the Hand-off CEX.SETTING: Thirty-two 4th year medical students participated as part of an elective course.PROGRAM DESCRIPTION: One week following an interactive workshop where students learned effective hand-off strategies, students participated in an experience in which they performed a hand-off of a mock patient using simulated history and physical examination data and a brief video. PROGRAM EVALUATION:Internal medicine residents served as standardized hand-off receivers and were trained on expectations. Students were provided feedback using a newly developed Hand-off CEX, based on the "Mini-CEX," which rates overall hand-off performance and its components on a 9-point Likert-type scale. Outcomes included performance ratings and pre-and poststudent self-assessments of hand-off preparedness. Data were analyzed using Wilcoxon signed-rank tests and descriptive statistics. Resident receivers rated overall student performance with a mean score of 6.75 (range 4-9, maximum 9). Statistically significant improvement was observed in self-perceived preparedness for performing an effective hand-off (67% post-vs. 27% prereporting 'well-prepared,' p<0.009).DISCUSSION: This brief, standardized hand-off training exercise improved students' confidence and was rated highly by trained observers. Future work focuses on formal validation of the Hand-off CEX instrument. 129 SETTINGThe OSHE was a module in a month-long skills-based "Transitions to Internship" elective course offered to graduating students in April of their final year of medical school. Thirty-four students who had matched into nine different specialties participated in the course. This elective focuses specifically on "orphan" topics not addressed elsewhere in the curriculum. Topics include procedural skills, preparedness for life as a resident, advanced communication skills (e.g., obtaining informed consent and disclosing medical error) and personal life preparedness (e.g., debt management and maintaining work/life balance). PROGRAM DESCRIPTIONStudents participated in a 90-min interactive workshop on communication skills necessary to perform effective handoffs (see online Appendix A). This module, delivered by one of the authors (VA), discussed communication theory as it relates to effective hand-off communication. Key points communicated during this workshop included: the importance of face-to-face communication, encouraging questions from the hand-off receiver, providing detailed "to-do" lists with rationale and anticipatory guidance. The instructor included case-based examples on the importance of effective hand-offs both in medicine and other industries 20 .The components of a written hand-off were discussed during the 90-min hand-off training, and students were given a representative example of a high-quality written sign-out 21 .Finally, students were provided with electronic access to the workshop materials and a...

BACKGROUND: Medical supervisors struggle to find meaningful ways to evaluate the preparedness of trainees to independently perform patient care tasks. The aim of this study was to describe the factors that influence how attending and resident physician perceptions of trust impact decision making.

Student observation and participation in unprofessional behaviors increased during clerkships. Participation in unprofessional behaviors is associated with perceiving these behaviors as acceptable.

BACKGROUND: New supervisory regulations highlight the challenge of balancing housestaff supervision and autonomy. To better understand the impact of increased supervision on residency training, we investigated housestaff perceptions of education, autonomy, and clinical decisionmaking before and after implementation of an in-hospital, overnight attending physician (nocturnist).

Background: Safe patient transitions depend on effective communication and a functioning care coordination process. Evidence suggests that primary care physicians are not satisfied with communication at transition points between inpatient and ambulatory care, and that communication often is not provided in a timely manner, omits essential information, or contains ambiguities that put patients at risk. Objective: Our aim was to demonstrate how process mapping can illustrate current handover practices between ambulatory and inpatient care settings, identify existing barriers and facilitators to effective transitions of care, and highlight potential areas for quality improvement. Methods: We conducted focus group interviews to facilitate a process mapping exercise with clinical teams in six academic health centres in the USA, Poland, Sweden, Italy, Spain and the Netherlands. Findings: At a high level, the process of patient admission to the hospital through the emergency department, inpatient care, and discharge back in the community were comparable across sites. In addition, the process maps highlighted similar barriers to providing information to primary care physicians, inaccurate or incomplete information on referral and discharge, a lack of time and priority to collaborate with counterpart colleagues, and a lack of feedback to clinicians involved in the handovers. Conclusions: Process mapping is effective in bringing together key stakeholders and makes explicit the mental models that frame their understanding of the clinical process. Exploring the barriers and facilitators to safe and reliable patient transitions highlights opportunities for further improvement work and illustrates ideas for best practices that might be transferrable to other settings.