Teaching Sideways: Implementing a Peer-Led Medical Student Orientation Bootcamp and Survival Guide for Internal Medicine Clerkship.

OBJECTIVES: Transitioning from classroom learning to clerkships presents a challenge for medical students because there is often sparse preparation material on how to effectively contribute to the medical team as a clerkship student. Although some medical schools have implemented transition-to-clerkship sessions, they often are led by faculty and lack the practical and contemporary guidance from students who have recently completed clerkships themselves. METHODS: Using a sideways mentorship approach, we implemented a 1-hour near-peer Internal Medicine (IM) clerkship orientation bootcamp at our medical school and wrote an accompanying survival guide to teach students how to function as part of a medical team and to increase the transparency of student expectations and evaluations during the clerkship. The 1-hour session covered the following core topics: clerkship logistics, how to gather/present clinical information, a resident/student question-and-answer panel, and how to contribute to the medical team. A postclerkship medical student and second-year IM resident conducted the bootcamp for four student cohorts (105 students total) during the January to December 2022 clerkship year before the IM rotation of each cohort. After the bootcamp, students received a copy of the survival guide to solidify concepts covered in the session. RESULTS: A preclerkship survey included questions to assess student confidence in 10 core IM clerkship domains pre- and postbootcamp. Both pre- and postclerkship surveys asked students to provide feedback on bootcamp strengths and weaknesses. Wilcoxon signed rank tests revealed a significant increase in postbootcamp student confidence rating for all 10 clerkship domains in the early clerkship cohort and in the late clerkship cohort for all of the domains, except finding clinical reference resources (P = 0.15). The bootcamp had the largest effect size (r) on student confidence in both early and late clerkship cohorts for the following clerkship domains: familiarity with IM clerkship evaluation (early: r = 0.61, P < 0.001; late: r = 0.56, P = 0.002), identification of ways to contribute to the medical team (early: r = 0.58, P < 0.001; late: r = 0.63, P < 0.001), and prerounding/chart checking (early r = 0.52, P < 0.001; late: r = 0.55, P = 0.001). The percentage of students rating the helpfulness of both the bootcamp and survival guide as a 3 to 5 on a 5-point Likert scale in the postclerkship survey was highest for the following domains: being familiar with the structure of a subjective, objective, assessment, and plan presentation (88% and 97%), prerounding/chart checking (82% and 95%), writing progress notes (82% and 92%), and identifying ways to contribute to the medical team (82% and 95%). Students commented that the main strengths of the bootcamp included its specific tips on synthesizing and presenting clinical information and its transparency about student expectations and experiences. CONCLUSIONS: A structured student-led bootcamp can increase clerkship preparation in core domains. The bootcamp is now part of mandatory clerkship didactics at our medical school, given its success during the 2022 clerkship year, and its content is continuing to be expanded upon by postclerkship students and residents. In addition, the format of the bootcamp also is being adapted to other clerkships, including surgery and obstetrics/gynecology.

Addressing Cognitive Biases in Interpreting an Elevated Lactate in a Patient with Type 1 Diabetes and Thiamine Deficiency.

We present the case of a young woman admitted for diabetic ketoacidosis with persistent, asymptomatic lactic acid (LA) elevation during the evolving COVID-19 pandemic. Cognitive biases in interpreting an elevated LA in this patient's care resulted in an extensive infectious workup instead of the low-cost and potentially diagnostic provision of empiric thiamine. We discuss clinical patterns and etiologies of LA elevation and the role of thiamine deficiency. We also address cognitive biases potentially affecting the interpretation of elevated lactate levels and provide guidance for clinicians to determine appropriate patients for empiric thiamine administration.

Screening, Diagnosis, and Staging of Non-Alcoholic Fatty Liver Disease (NAFLD): Application of Society Guidelines to Clinical Practice.

PURPOSE OF REVIEW: Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly nonalcoholic fatty liver disease (NAFLD), is the most common chronic liver disease affecting 30% of the global population. In this article, we summarize current expert guidelines, review clinical practice implications, and provide insight into the utility of non-invasive tests (NITs). RECENT FINDINGS: The burden of MASLD is growing with the obesity epidemic, yet disease awareness and diagnosis is low. Patients can progress to metabolic dysfunction-associated steatohepatitis (MASH, formerly NASH), which can advance to liver fibrosis, cirrhosis, hepatic decompensation, and liver cancer. NITs help identify high-risk patients who may benefit from specialty referral and MASH-directed therapy. Global societies offer various recommendations for the screening and diagnosis of MASLD utilizing evidence-based, widely accessible methods such as serum indices, NITs, and liver biopsy. Several targeted steatotic liver disease (SLD) screening tools and novel therapies are under development.

Holistic management of hepatocellular carcinoma: The hepatologist's comprehensive playbook.

Hepatocellular carcinoma (HCC) is a common complication in patients with chronic liver disease and leads to significant morbidity and mortality. Liver disease and liver cancer are preventable by mitigating and managing common risk factors, including chronic hepatitis B and C infection, alcohol use, diabetes, obesity and other components of the metabolic syndrome. The management of patients with HCC requires treatment of the malignancy and adequate control of the underlying liver disease, as preserving liver function is critical for successful cancer treatment and may have a relevant prognostic role independent of HCC management. Hepatologists are the ideal providers to guide the care of patients with HCC as they are trained to identify patients at risk, apply appropriate surveillance strategies, assess and improve residual liver function, evaluate candidacy for transplant, provide longitudinal care to optimize and preserve liver function during and after HCC treatment, survey for cancer recurrence and manage its risk factors, and prevent and treat decompensating events. We highlight the need for a team-based holistic approach to the patient with liver disease and HCC and identify necessary gaps in current care and knowledge.

Increased Mortality in Patients Undergoing Inpatient Endoscopy During the Early COVID-19 Pandemic.

BACKGROUND AND AIMS: The Coronavirus disease 2019 (COVID-19) pandemic led to the restructuring of most healthcare systems, but the impact on patients undergoing inpatient endoscopic procedures is unknown. We sought to identify factors associated with 30-day mortality among patients undergoing inpatient endoscopy before and during the first wave of the pandemic within an academic tertiary care center. METHODS: We studied patients who underwent inpatient endoscopic procedures from March 1-May 31 in 2020 (COVID-19 era), the peak of the pandemic's first wave across the care center studied, and in March 1-May 31, 2018 and 2019 (control). Patient demographics and hospitalization/procedure data were compared between groups. Cox regression analyses were conducted to identify factors associated with 30-day mortality. RESULTS: Inpatient endoscopy volume decreased in 2020 with a higher proportion of urgent procedures, increased proportion of patients receiving blood transfusions, and a 10.1% mortality rate. In 2020, male gender, further distance from hospital, need for intensive care unit (ICU) admission, and procedures conducted outside the endoscopy suite were associated with increased risk of 30-day mortality. CONCLUSIONS: Patients undergoing endoscopy during the pandemic had higher proportions of ICU admission, more urgent indications, and higher rates of 30-day mortality. Greater proportions of urgent endoscopy cases may be due to hospital restructuring or patient reluctance to seek hospital care during a pandemic. Demographic and procedural characteristics associated with higher mortality risk may be potential areas to improve outcomes during future pandemic hospital restructuring efforts.

Open management of complex infrarenal aortic occlusive disease.

Open aortic reconstruction for complex aortoiliac occlusive disease is a time-honored and durable solution. Symptoms manifest as disabling claudication or chronic limb threatening ischemia in patients with multilevel disease. Advanced endovascular techniques have supplanted a large volume of aortic surgery. Nonetheless, it is essential for surgeons-in-training to learn and hone their skills in open aortic surgery. Comprehensive literature review over the past 50 years was conducted on the topics of "aortic occlusive disease," "aortic bypass," and "iliofemoral bypass." Pertinent articles were selected for inclusion as references. The technical aspects of the various aortoiliac exposures are described and selected case images were chosen from the senior author's experience. This review paper details the various operative approaches to open aortoiliac revascularization with emphasis on "tips and tricks" for the learner.

The Development of an Innovative Crowdsourced Resident Procedure Team Model to Improve Bedside Procedural Proficiency in the Inpatient Setting.

Background Bedside procedures are a necessary skill for many residents. Practice changes, including the discontinuation of a minimum number of procedures required by the American Board of Internal Medicine, may have resulted in decreased incentive for residents to seek procedural opportunities. Objective To improve residents' procedural output and confidence in abdominal paracentesis, arterial and central venous line placement, nasogastric intubation, and ultrasound-guided peripheral intravenous catheter insertions (USPIV). Methods A novel Resident Procedure Team (RPT) model was created using crowdsourced proficient (having completed ≥5 procedures) near-peers in combination with peer-led USPIV simulation workshops to increase the number of supervising residents available. Procedure logs and the number of residents who became qualified to perform and supervise procedures were tracked from July 2018 to June 2022 and compared before and after the implementation of the RPT in July 2020. Results Implementing the novel RPT model significantly increased the number of procedures performed (1875 procedures post-RPT vs 1292 pre-RPT; P=.02). Abdominal paracentesis increased from 411 to 482 (17.3%), central venous line placement increased from 344 to 401 (16.6%), USPIV increased from 318 to 389 (22.3%), arterial line placement increased from 189 to 360 (90.5%), and nasogastric intubation increased from 30 to 243 (710.0%). Resident confidence levels increased significantly after RPT-led USPIV workshops (P<.05 for all). Conclusions Implementation of a novel, crowdsourced, resident-led procedure team and peer-led USPIV workshops helped increase the number of procedures performed by residents.

Inpatient teaching with a clinical review game.

BACKGROUND: Shortened preclinical curricula, social distancing policies and the fast-paced nature of inpatient medicine make clinical education challenging. Crowdsourced learning and a review game derived from real-time patient cases can offer an engaging solution for inpatient teaching. APPROACH: We implemented a clinical review game with 67 participants (10 physician instructors, 40 residents and 17 medical students) rotating through the adult inpatient medicine service at an academic medical centre from July 2018 through July 2020. During 2-week rotations, participants identified shareable teaching points about their patients on rounds. Teaching points were compiled by an instructor into a 30-minute end-of-rotation review game formatted from a free gameshow-based PowerPoint template. After the review game was completed, learners were then asked to complete end-of-rotation evaluations. EVALUATION: Learners were surveyed on their educational experience, and teaching point submissions were studied. After eight rotations, 39 participants (39/67 = 58.2% response rate) submitted a total of 268 teaching points, and nearly half of which were from learners (n = 131 [48.9%]). In the review game, 35 residents and 17 medical students participated and correctly answered 80% of questions. Learner evaluations highlighted the activity strengths including self-directed learning, peer teaching from primary literature and a warm, collaborative educational environment. IMPLICATIONS: Our crowdsourced clinical review game approach helped to highlight clinically relevant content for teaching rounds, build a collaborative culture across trainee levels and encourage self-study for trainees to stay informed with current evidence-based practice, even during pandemic restrictions.

Low real-world eligibility rates for nonalcoholic steatohepatitis patients for phase 3 clinical trial criteria application in a large academic health system.

OBJECTIVE: Nonalcoholic steatohepatitis (NASH) is the most common liver disease in the USA. Clinical trials have stringent study criteria which may limit real-world generalizability. Thus, we studied whether a real-world, university-based cohort of patients could be eligible for a pivotal phase 3 NASH clinical trial. METHODS: We queried Yale-New Haven Health System electronic medical records for patients with a diagnosis of NASH from 2013 to 2017. Of those who received liver biopsy, we extracted demographic, clinical, laboratory, and biopsy data. We compared patient characteristics to enrollment criteria of the Randomized Global Phase 3 Study to Evaluate the Impact on NASH with Fibrosis of Obeticholic Acid Treatment. RESULTS: Of 14 403 patients with NASH, 478 (3.3%) completed liver biopsy, of whom 237 (49.6%) had histological confirmation by a gastrointestinal pathologist. Histologically-confirmed NASH patients were 51.1 ± 13.2 years old, 56.5% female, 69.6% white race, and 24.6% had cirrhosis. In this group, 68 (28.7%) patients met all inclusion criteria, 87 (36.7%) had no exclusions, and 34 (14.4%) met all enrollment criteria. Other than cirrhosis, common reasons for ineligibility were presence of medical comorbidity (n = 83) or laboratory abnormalities (n = 47). Multiple logistic regression did not reveal significant predictors of eligibility. CONCLUSION: Within a university-based cohort of NASH patients, few met phase 3 clinical trial enrollment criteria, mostly due to low rates of liver biopsy. Of those with histologic confirmation, 14.4% met enrollment criteria. Validation of generalizability for safety and efficacy of NASH investigational agents in real-world populations is needed.

Drug development of nonalcoholic fatty liver disease: challenges in research, regulatory pathways, and study endpoints.

INTRODUCTION: The growing prevalence of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH), and its association with obesity as a metabolic disease contributes to harmful outcomes and healthcare resource burden worldwide. For this reason, there is an urgent need to develop new therapies. Identification of treatment targets, research design, endpoints definitions and assessments, and supportive regulatory pathways for drug approval all play prominent roles in shaping efforts in drug discovery, investigation, and approval. AREAS COVERED: In this perspective, the authors enumerate key challenges of NAFLD clinical research and offer a conceptual framework to address these issues which arise during clinical trials. EXPERT OPINION: With the anticipated significant healthcare and costs burden that NAFLD will impose throughout the world, the diagnostics and drug development processes need to be accelerated. Important measures to improve clinical trial research include standardization of case definitions, comprehensive and granular covariate data collection, quality study development incorporating novel trial designs, and quality data reporting. The authors believe that these actions will accelerate understanding, development, and ultimately approval of efficacious treatments.

Analysis of weekend effect in severe acute liver injury: A nationwide database study.

BACKGROUND AND AIMS: Severe acute liver injury (ALI) can lead to poor outcomes without timely management. Comparatively worse outcomes in various severe, emergent conditions have been attributed to reduced hospital resources experienced by patient weekend admissions, a phenomenon termed "weekend effect." To date, a weekend effect has not been studied in severe ALI, an emergency also necessitating timely management. We aimed to evaluate such an effect in this condition by analyzing a large national inpatient database in the United States. METHODS: We analyzed the Nationwide/National Inpatient Sample (NIS) 2000 to 2014, the largest inpatient, all-payer database in the United States (US), containing sociodemographic, clinical, patient-, and hospital-level data. We identified severe ALI using International Classification of Disease, 9th Revision diagnosis codes for acute/subacute hepatic necrosis (570) with encephalopathy (572.2). Our primary outcome was in-hospital mortality. Using a full-model approach for covariate selection, we performed multiple logistic regression modeling to assess for weekend effect and identify predictors of in-hospital mortality. RESULTS: We identified 15 762 eligible hospitalizations, with 12 182 (77.3%) having complete covariate data. This sample comprised 53.3% males, 69.3% White race, and had an average (± SD) age of 55.0 ± 14.1 years. We utilized a full-model approach for covariate inclusion but did not include patient transfer data due to limited availability. We observed no significant mortality differences in weekend admissions (OR = 1.06, 95% CI: 0.97-1.15, P = 0.02). However, significantly higher mortality was associated with male sex, older age, Black or Hispanic race, Northeast US hospitalization, urban teaching status, and larger hospital size. Sensitivity analyses using multiple imputation datasets and transfer covariates did not change our results. CONCLUSION: We did not observe a weekend effect of in-hospital mortality for weekend admissions for severe ALI, but our overall diagnosis ascertainment yield was low-indicating that lack of accurate documentation for the etiology of severe ALI may be masking an effect. Additionally, our findings suggest that racial differences and hospital-level characteristics in the context of severe ALI may be associated with varying outcomes, regardless of admission day, which warrants further research.