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BACKGROUND:Patients with low socioeconomic status (low-SES) are at risk for poor outcomes during the posthospital transition. Few prior studies explore perceived reasons for poor outcomes from the perspectives of these high-risk patients. OBJECTIVE: We explored low-SES patients' perceptions of hospitalization, discharge and post-hospital transition in order to generate hypotheses and identify common experiences during this transition. DESIGN: We conducted a qualitative study using indepth semi-structured interviewing. PARTICIPANTS: We interviewed 65 patients who were: 1) uninsured, insured by Medicaid or dually eligible for Medicaid and Medicare; 2) residents of five low-income ZIP codes; 3) had capacity or a caregiver who could be interviewed as a proxy; and 4) hospitalized on the general medicine or cardiology services of two academically affiliated urban hospitals. APPROACH: Our interview guide investigated patients' perceptions of hospitalization, discharge and the posthospital transition, and their performance of recommended post-hospital health behaviors related to: 1) experience of hospitalization and discharge; 2) external constraints on patients' ability to execute discharge instructions; 3) salience of health behaviors; and 4) self-efficacy to execute discharge instructions. We used a modified grounded theory approach to analysis. KEY RESULTS: We identified six themes that low-SES patients shared in their narratives of hospitalization, discharge and post-hospital transition. These were: 1) powerlessness during hospitalization due to illness and socioeconomic factors; 2) misalignment of patient and care team goals; 3) lack of saliency of health behaviors due to competing issues; 4) socioeconomic constraints on patients' ability to perform recommended behaviors; 5) abandonment after discharge; and 6) loss of self-efficacy resulting from failure to perform recommended behaviors.CONCLUSIONS: Low-SES patients describe discharge goals that are confusing, unrealistic in the face of significant socioeconomic constraints, and in conflict with their own immediate goals. We hypothesize that this goal misalignment leads to a cycle of low achievement and loss of self-efficacy that may underlie poor post-hospital outcomes among low-SES patients.

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Strategies that address socioeconomic stressors of hospitalization and provide empathic support may improve the post-hospital transition for these high-risk individuals.

2020) The 'July Effect' in supervisory residents: assessing the emotions of rising internal medicine PGY2 residents and the impact of an orientation retreat, Medical Education Online, 25:1, 1728168, ABSTRACT Background: The arrival of new residents brings challenges for residency programs and residents. Many residency programs conduct orientation sessions to help transition rising supervisory residents into their new roles, but no evaluation of their impact on residents' emotional well-being has been performed.Objective: This study assesses the impact of a half-day orientation retreat on rising internal medicine post-graduate year (PGY) 2 residents' emotions toward PGY2 year and their selfconfidence in fulfilling the supervisory resident role. Design: A survey was administered to a class of rising supervisory residents immediately before and after an orientation retreat in May 2017. The survey provided participants an open-ended prompt to describe their emotions toward PGY2 year and a 5-point Likert scale to rate their confidence in fulfilling supervisory resident roles. Differences were assessed using McNemar's exact and Wilcoxon signed-rank tests, respectively. Results: Forty-four of 50 (88%) eligible participants completed pre-and post-intervention Likert scales and 40 of 50 (80%) eligible participants completed corresponding emotion sections. Pre-intervention the most common emotions were anxiety (n = 33, 82.5%) and excitement (n = 32, 80.0%). Post-intervention, participants' fear was reduced (45.0% vs 12.0%; p < 0.001). Participants reported greater confidence that internship prepared them for PGY2 year and understanding of triaging and admitting principles (agree or strongly agree from 65.9% to 84.0% and from 25.0% to 68.2%, respectively; p < 0.005 for improvement by Wilcoxon signed-rank for both). Conclusions: Orientation retreats may be an effective way to reduce fear and demystify the supervisory resident role. ARTICLE HISTORY