Knowledge and Perceptions of Hepatitis B and Hepatocellular Carcinoma Screening Guidelines Among Trainees: A Tale of Three Centers.

BACKGROUND: Hepatitis B (HBV), the leading cause of hepatocellular carcinoma (HCC) worldwide, disproportionately affects minorities in the USA. Undiagnosed HBV precludes HCC screening and contributes to late-stage cancer presentation and decreased survival. Barriers to HBV and HCC screening include lack of insurance and limited diffusion of guidelines. We aimed to assess knowledge about HBV and HCC screening indications and explore barriers to screening. METHODS: We surveyed trainees from the University of Miami/Jackson Memorial Hospitals, Palmetto General Hospital, and Mount Sinai Medical Center. We assessed knowledge using clinical vignettes. We performed bivariate and Chi-squared analyses. RESULTS: There were 183 respondents; median age was 31 and 52% were male. The sample was 35% Hispanic, 29% White, 18% Asian, and 9% Black. Training department was Internal Medicine, 71%; Family Medicine, 11%; Infectious Diseases, 6%; or Gastroenterology, 7%. Only 59% correctly estimated national HBV prevalence; 25% correctly estimated global prevalence. In vignettes with behavioral risk factors, trainees correctly advised screening, 63-96%. However, when the risk factor was the birthplace, correct responses ranged from 33 to 53%. Overall, 45% chose an incorrect combination of HBV screening tests. Perceived barriers to screening included limited expertise in screening of immigrants and limited patient education. Respondents were more likely to recommend HCC screening in cirrhotic patients versus non-cirrhotic HBV patients. Key barriers to HCC screening included uncertainty about HCC guidelines and patient financial barriers. CONCLUSIONS: Knowledge of HBV and HCC screening recommendations is suboptimal among trainees. Efforts to broadly disseminate HBV and HCC guidelines through targeted educational interventions are needed.

'Wargaming with the chiefs': A novel pre-mortem exercise to enhance communication and well-being among 'top gun' chief residents.

Pilots who complete the 'TOPGUN' program return to their squadrons as elite leaders and instructors. Physicians from all specialties who are selected to become Chief residents can also be viewed as 'Top Guns', as they are the 'cream of the crop'; having been chosen to be the leaders and role-models for all the other residents in their programs. Yet, unlike Top Gun pilots, Chief residents are arguably only minimally prepared for this new role. Wargaming involves generating every possible bad outcome and brainstorming contingencies for these possible outcomes. We developed an exercise for the incoming Chiefs (ICs) and outgoing Chiefs (OCs) in four specialties: Family Medicine, Internal Medicine, Neurosurgery, and Neurology. Following this exercise, 100% of the Chiefs in all four programs indicated that this activity was beneficial and the majority agreed that wargaming improved communication and their own feelings of well-being. Based on our trainees' feedback, it appears that wargaming is a simple, fun, and highly-interactive exercise which increases perceived control among ICs and allows OCs the chance to reflect and share their knowledge and experience with the new Chiefs. This activity also seems to enhance communication and feelings of well-being among both incoming and outgoing Chief residents.