A novel hospitalist peer observation program to improve educational and operational rounding practices.

Academic hospitalists must balance trainee education with operational demands to round efficiently and optimize hospital throughput. Peer observation has been shown to support educator development, however, few hospitalists have formal training to optimize both skill sets. We sought to extend and adapt peer observation programs to equally focus on education and operations-based outcomes. During the 2-year study period, 76 of 98 (78%) eligible faculty participated in a structured, real-time peer observation program. Immediately after observing a peer, 42% of respondents planned to adopt an operations-related rounding behavior. Following program completion, 77% of respondents endorsed the implementation of a new rounding behavior learned from a peer, with a third of these behaviors related to clinical operations. Ninety-five percent of respondents endorsed at least a moderate degree of program satisfaction. High levels of engagement and sustained behavior change following program participation suggest clinical operations are an important addition to peer observation programs and faculty development initiatives.

A peer-to-peer handoff tool to ease clerkship transitions.

EDUCATIONAL CHALLENGE: Frequent transitions between core clinical rotations in medical school increase anxiety and cognitive load. Few formalized programs exist to ease these transitions. Our institutional needs-assessment found that approximately 85% of students believed that additional rotation-specific information prior to starting a new rotation would reduce anxiety and increase success. PROPOSED SOLUTION AND IMPLEMENTATION OF SOLUTION: We developed a novel web-based peer-to-peer handoff tool available to all clerkship students at a single, large academic institution. The tool contains the names and contact information of students who most recently completed rotations on each service for all clerkships. A handoff checklist was also created with suggested discussion points for handoffs. Students were encouraged to schedule a handoff 1-2 weeks before starting a new rotation. LESSONS LEARNED: Overall, 83 students (66%) utilized the handoff tool, with use and efficacy decreasing with time during the clinical year. Of tool users, 65% expressed that having access to the tool prior to starting a new rotation helped to reduce anxiety, and 74% felt that the information gained helped to ease transitions. Our peer-to-peer handoff tool may help students feel more prepared to start a new rotation, decrease anxiety during clerkship year, and ease transitions. NEXT STEPS: This low-resource intervention may be implemented at other institutions to provide students with equal opportunities to receive valuable information prior to starting new rotations, regardless of pre-existing peer connections. An automated update system, which we are implementing at our institution, could greatly decrease the time required to maintain a handoff tool and improve sustainability.

Twelve tips for excelling as an introvert in academic medicine (at all levels).

BACKGROUND: Introverted individuals comprise up to half of the population, but are often overlooked in a culture that privileges extraversion. This misunderstanding of introversion has downstream effects for introverts in academic medicine, including lower grades on clinical rotations, increased stress, and under-representation in leadership positions. AIMS: To increase support for and awareness of the unique strengths of introverted individuals at all stages of a career in academic medicine. DESCRIPTION: This article offers twelve tips, based in the educational, business, and personality literature, to empower introverted students, residents, and faculty members for success in academic medicine. While many of the tips apply broadly, certain tips may be more relevant to those in a particular career stage. CONCLUSION: Increased understanding of the natural tendencies and strengths of introversion will promote a more inclusive working environment for all personality types in medicine and allow introverts at all levels of training and practice to thrive.

Into the Unknown: Characterizing Fellow Uncertainty During the Transition to Unsupervised Practice.

Background: Helping fellows confront and manage uncertainty in the course of diagnosis and treatment of patients has been a growing focus of medical education. How these same fellows confront uncertainty as they make a transition in their professional development is less commonly a focus of training programs. Better understanding of how fellows experience these transitions will allow fellows, training programs, and hiring institutions to navigate transitions more easily. Objective: This study aimed to explore how fellows in the United States experience uncertainty during the transition to unsupervised practice. Methods: Using constructivist grounded theory, we invited participants to engage in semi-structured interviews exploring experiences with uncertainty as they navigate the transition to unsupervised practice. Between September 2020 and March 2021, we interviewed 18 physicians in their final year of fellowship training from 2 large academic institutions. Participants were recruited from adult and pediatric subspecialties. Data analysis was conducted using an inductive coding approach. Results: Experiences with uncertainty during the transition process were individualized and dynamic. Primary sources of uncertainty identified included clinical competence, employment prospects, and career vision. Participants discussed multiple strategies for mitigating uncertainty, including structured graduated autonomy, leveraging professional networks locally and non-locally, and utilizing established program and institutional supports. Conclusions: Fellows' experiences with uncertainty during their transitions to unsupervised practice are individualized, contextual, and dynamic with several shared overarching themes.

Conflicting Goals Influence Physicians' Expressed Beliefs to Patients and Colleagues.

BACKGROUND: Physicians who communicate their prognostic beliefs to patients must balance candor against other competing goals, such as preserving hope, acknowledging the uncertainty of medicine, or motivating patients to follow their treatment regimes. OBJECTIVE: To explore possible differences between the beliefs physicians report as their own and those they express to patients and colleagues. DESIGN: An online panel of 398 specialists in internal medicine who completed their medical degrees and practiced in the United States provided their estimated diagnostic accuracy and prognostic assessments for a randomly assigned case. In addition, they reported the diagnostic and prognostic assessments they would report to patients and colleagues more generally. Physicians answered questions about how and why their own beliefs differed from their expressed beliefs to patients and colleagues in the specific case and more generally in their practice. RESULTS: When discussing beliefs about prognoses to patients and colleagues, most physicians expressed beliefs that differed from their own beliefs. Physicians were more likely to express greater optimism when talking to patients about poor prognoses than good prognoses. Physicians were also more likely to express greater uncertainty to patients when prognoses were poor than when they were good. The most common reasons for the differences between physicians' own beliefs and their expressed beliefs were preserving hope and acknowledging the inherent uncertainty of medicine. CONCLUSION: To balance candor against other communicative goals, physicians tended to express beliefs that were more optimistic and contained greater uncertainty than the beliefs they said were their own, especially in discussions with patients whose prognoses were poor.

Enteric tube placement in patients with esophageal varices: Risks and predictors of postinsertion gastrointestinal bleeding.

BACKGROUND AND AIM: Enteric tube (ET) placement is approached with caution in patients with esophageal varices (EV) due to concern of causing variceal bleeding. Data are limited on rates and predictors of gastrointestinal bleeding (GIB) in these patients. This study aims to assess the rate and predictors of bleeding from EV after ET placement. METHODS: We performed a retrospective chart review on patients requiring ET access with known EV. Inclusion criteria were age >18 with endoscopically proven EV who required ET placement. Patients who were admitted with, or developed a GIB prior to placement of ET were excluded, as were patients admitted for liver transplantation. Primary outcome was incidence of GIB within 48 h of tube placement. Secondary outcome was a >2 g/dL drop in hemoglobin within 48 h of placement without evidence of bleed. Statistical analysis was performed using Fischer's exact test, Mann-Whitney U test, and univariate logistic regression model. RESULTS: A total of 75 patients were included in the analysis. The most common etiology of cirrhosis was alcohol (44%). The most common location of EV was in the lower third of the esophagus (61%). The primary outcome was observed in 11 (14.6%) patients. The secondary outcome was found in eight (10.6%) patients. On univariate analysis, GIB was associated with higher MELD-Na (P = 0.026) and EV located in the lower third of the esophagus (P = 0.048). CONCLUSION: ET placement in patients with EV is associated with low risk of bleeding. Elevated MELD-Na and lower EV location conferred a higher risk of bleeding after ET placement.

Pathogen colonization of the gastrointestinal microbiome at intensive care unit admission and risk for subsequent death or infection.

PURPOSE: Loss of colonization resistance within the gastrointestinal microbiome facilitates the expansion of pathogens and has been associated with death and infection in select populations. We tested whether gut microbiome features at the time of intensive care unit (ICU) admission predict death or infection. METHODS: This was a prospective cohort study of medical ICU adults. Rectal surveillance swabs were performed at admission, selectively cultured for vancomycin-resistant Enterococcus (VRE), and assessed using 16S rRNA gene sequencing. Patients were followed for 30 days for death or culture-proven bacterial infection. RESULTS: Of 301 patients, 123 (41%) developed culture-proven infections and 76 (25%) died. Fecal biodiversity (Shannon index) did not differ based on death or infection (p = 0.49). The presence of specific pathogens at ICU admission was associated with subsequent infection with the same organism for Escherichia coli, Pseudomonas spp., Klebsiella spp., and Clostridium difficile, and VRE at admission was associated with subsequent Enterococcus infection. In a multivariable model adjusting for severity of illness, VRE colonization and Enterococcus domination (≥ 30% 16S reads) were both associated with death or all-cause infection (aHR 1.46, 95% CI 1.06-2.00 and aHR 1.47, 95% CI 1.00-2.19, respectively); among patients without VRE colonization, Enterococcus domination was associated with excess risk of death or infection (aHR 2.13, 95% CI 1.06-4.29). CONCLUSIONS: Enterococcus status at ICU admission was associated with risk for death or all-cause infection, and rectal carriage of common ICU pathogens predicted specific infections. The gastrointestinal microbiome may have a role in risk stratification and early diagnosis of ICU infections.

Determinants of Follow-up Care for Patients With Celiac Disease.

GOALS: This study aimed to investigate follow-up patterns among celiac disease (CD) patients. BACKGROUND: Gender factors are important in CD with women diagnosed more frequently than men despite equal seropositivity in screening studies. To determine if gender influences postdiagnosis care, we performed a retrospective cohort study investigating the impact of gender and mode of presentation on follow-up patterns after diagnosis. STUDY: The study included adults with biopsy-proven CD presenting to a single tertiary care center between 2005 and 2014. The primary exposure was at least 1 visit with a CD specialist. The primary outcome was ≥2 follow-up visits, including office visits and endoscopic procedures. Data extracted included whether patients had tissue transglutaminase antibodies performed by our laboratory. RESULTS: We analyzed 708 patients of which 70.5% were female. Follow-up was good with a majority of patients (69%) having at least 1 follow-up visit. On bivariate analysis, patients least likely to follow-up were ages 18 to 29 (P=0.03) and women with atypical presentations (P=0.003). After adjusting for potential confounders, individuals over age 65 were significantly more likely to attend at least 2 follow-up visits (odds ratio, 2.07; 95% confidence interval, 1.21-3.55; P=0.0079). Individuals with an abnormal baseline tissue transglutaminase antibody value in our laboratory were significantly more likely to follow-up (odds ratio, 1.99; 95% confidence interval, 1.39-2.85; P=0.0002). CONCLUSIONS: Gender had no impact on follow-up patterns despite prior studies demonstrating an impact on diagnosis rates. Future attention should focus on retaining young patients and those with atypical modes of presentation.

Surgical Antibiotic Prophylaxis and Risk for Postoperative Antibiotic-Resistant Infections.

BACKGROUND: Antibiotic-resistant infections have high rates of morbidity and mortality, and exposure to antibiotics is the crucial risk factor for development of antibiotic resistance. If surgical antibiotic prophylaxis (SAP) increases risk for antibiotic-resistant infections, prophylaxis may cause net harm, even if it decreases overall infection rates. STUDY DESIGN: This retrospective cohort study included adults who underwent elective surgical procedures and developed infections within 30 postoperative days. Procedures from multiple disciplines were included if SAP was considered discretionary by current guidelines. Postoperative antibiotic-resistant infections were defined as positive culture results from any site within 30 postoperative days, showing intermediate or nonsusceptibility across 1 or more antibiotic classes. Surgical antibiotic prophylaxis included use of antibiotics within any class and at any dose from 1 hour before first incision until the end of the operation. RESULTS: Among 689 adults with postoperative infections, 338 (49%) had postoperative resistant infections. Use of SAP was not associated with postoperative antibiotic-resistant infections (odds ratio [OR] 0.99; 95% CI 0.67 to 1.46). This result remained robust when the SAP definition was extended to antibiotics given within 4 hours before first incision (OR 0.94; 95% CI 0.63 to 1.40) and when the follow-up window was narrowed to 14 days (OR 0.82; 95% CI 0.50 to 1.34). Previous antibiotic-resistant infections were associated with risk for postoperative antibiotic-resistant infections (OR 1.81; 95% CI 1.16 to 2.83). CONCLUSIONS: Use of SAP was not associated with risk for postoperative antibiotic-resistant infections in a large cohort of patients with postoperative infections. This provides important reassurance regarding use of surgical antibiotic prophylaxis.

Prophylaxis for Stress Ulcers With Proton Pump Inhibitors Is Not Associated With Increased Risk of Bloodstream Infections in the Intensive Care Unit.

BACKGROUND & AIMS: Proton pump inhibitors (PPIs) have been associated with increased risk of infection, likely because of changes in intestinal epithelial permeability and the gastrointestinal microbiome. PPIs are frequently given to patients in the intensive care unit (ICU) to prevent stress ulcers. These patients are at risk for bloodstream infections (BSIs), so we investigated the relationship between PPI use and BSIs among patients in the ICU. METHODS: We performed a retrospective cohort study of adults (≥18 years) admitted to 1 of 14 ICUs within a hospital network of 3 large hospitals from 2008 through 2014. The primary exposure was PPI use for stress ulcer prophylaxis in the ICU. The primary outcome was BSI, confirmed by culture analysis, arising 48 hours or more after admission to the ICU. Subjects were followed for 30 days after ICU admission or until death, discharge, or BSI. Multivariable Cox proportional hazards modeling was used to test the association between PPIs and BSI after controlling for patient comorbidities and other clinical factors. RESULTS: We analyzed data from 24,774 patients in the ICU, including 756 patients (3.1%) who developed BSIs while in the ICU. The cumulative incidence of BSI was 3.7% in patients with PPI exposure compared with 2.2% in patients without PPI exposure (log-rank test, P < .01). After adjusting for potential confounders, PPI exposure was not associated with increased risk of BSI while in the ICU (adjusted hazard ratio, 1.08; 95% confidence interval, 0.91-1.29). Comorbidities, antibiotic use, and mechanical ventilation were all independently associated with increased risk for BSIs. CONCLUSIONS: In a retrospective study of patients in the ICU, administration of PPIs to prevent bleeding was not associated with increased risk of BSI. These findings indicate that concern for BSI should not affect decisions regarding use of PPIs in the ICU.

Renal dysfunction as an independent predictor of outcome after aneurysmal subarachnoid hemorrhage: a single-center cohort study.

BACKGROUND AND PURPOSE: Acute kidney injury occurs in 1% to 25% of critically ill patients with small increases in creatinine adversely affecting outcome. We sought to determine the burden of acute kidney injury in patients with aneurysmal subarachnoid hemorrhage and whether this dysfunction affects outcome. METHODS: Between 1996 and 2008, 787 consecutive patients with aneurysmal subarachnoid hemorrhage were enrolled in our prospective database. Demographics, serum creatinine levels, and discharge modified Rankin scores were recorded, and changes in creatinine clearance were calculated. A multiple logistic regression was performed using known predictors for poor outcome after aneurysmal subarachnoid hemorrhage in addition to burden of contrast-enhanced imaging and change in creatinine clearance. RESULTS: One hundred seventy-nine (23.1%) patients were at risk for renal failure during their hospitalization. In a multivariate model, those patients who developed risk for renal failure were twice as likely to have a poor 3-month outcome (OR, 2.01; P=0.021). Survival curves comparing those not at risk, those at risk (increasing severity classes Risk, Injury, and Failure, and the 2 outcome classes Loss and End-Stage Kidney Disease [RIFLE] R), and those with renal injury or failure (RIFLE I and F) demonstrated that risk of death increases significantly as one progresses through the RIFLE classes (log rank, P<0.0001). CONCLUSIONS: In a large, consecutive series of prospectively enrolled patients with aneurysmal subarachnoid hemorrhage, we demonstrate, using the newly defined RIFLE classification for risk of renal failure, that even seemingly insignificant decreases in creatinine clearance are associated with significantly worse 3-month outcomes. This study highlights the importance of close surveillance of renal function and stresses the value of renal hygiene in the aneurysmal subarachnoid hemorrhage population.