Mazzuca S A, Brandt K D, Katz B P
Arthritis Care Res. 1993 Jun;6(2):59-63. doi: 10.1002/art.1790060203.
This study examined whether the clinical environment could be used to increase internal medicine house officers' adoption of care recommendations taught in a didactic conference. Subjects were 11 internal medicine house officers who served 6-week rheumatology elective rotations. At the start of each of four rotation periods, house officers attended a 1-hour conference in which periarticular rheumatic disorders associated with knee pain (anserine bursitis, pseudothrombophlebitis) and shoulder pain (bicipital tendinitis) were discussed. All house officers also practiced physical examination techniques on anatomic models simulating the disorders. During alternate rotation periods, reminder sheets were appended to the records of arthritis patients with histories of chronic knee or shoulder pain. The frequency with which house officers followed conference recommendations was documented by direct observation (6 house officers in 17 encounters with reminders, 5 house officers in 30 encounters without reminders). Specific questioning about a recent history of knee or shoulder pain and the performance of four of five recommended physical examination maneuvers were increased significantly by reminder sheets in patients' charts (P < 0.05 for all). Although rheumatology faculty often have limited options available to increase the number of house officer trainees or to intensify clinical activity, qualitative improvements within existing logistic parameters are feasible by assuring that the clinical environment (e.g., patient records) contains salient cues that will prompt desired actions.
本研究探讨了临床环境是否可用于提高内科住院医师对在教学会议中讲授的护理建议的采纳率。研究对象为11名在内科进行为期6周风湿科选修轮转的住院医师。在四个轮转期的每个轮转期开始时，住院医师参加了一次为时1小时的会议，会上讨论了与膝关节疼痛相关的关节周围风湿性疾病（鹅足滑囊炎、假性血栓性静脉炎）和与肩部疼痛相关的疾病（肱二头肌肌腱炎）。所有住院医师还在模拟这些疾病的解剖模型上练习了体格检查技术。在交替的轮转期，在有慢性膝关节或肩部疼痛病史的关节炎患者的病历中附上提醒单。通过直接观察记录住院医师遵循会议建议的频率（有提醒单的17次诊疗中有6名住院医师，无提醒单的30次诊疗中有5名住院医师）。病历中的提醒单显著增加了关于近期膝关节或肩部疼痛病史的具体询问以及五项推荐体格检查动作中四项动作的执行情况（所有P值均<0.05）。尽管风湿科教员增加住院医师培训学员数量或加强临床活动的选择往往有限，但通过确保临床环境（如患者病历）包含能促使采取期望行动的显著线索，在现有后勤参数范围内实现质量改进是可行的。
