Evaluating the SPIKES Model for Improving Peer-to-Peer Feedback Among Internal Medicine Residents: a Randomized Controlled Trial.

BACKGROUND: Feedback improves trainee clinical performance, but the optimal way to provide it remains unclear. Peer feedback offers unique advantages but comes with significant challenges including a lack of rigorously studied methods. The SPIKES framework is a communication tool adapted from the oncology and palliative care literature for teaching trainees how to lead difficult conversations. OBJECTIVE: To determine if a brief educational intervention focused on the SPIKES framework improves peer feedback between internal medicine trainees on inpatient medicine services as compared to usual practice. DESIGN: Randomized, controlled trial at an academic medical center during academic year 2017-2018. PARTICIPANTS: Seventy-five PGY1 and 49 PGY2 internal medicine trainees were enrolled. PGY2s were randomized 1:1 to the intervention or control group. INTERVENTION: The intervention entailed a 30-min, case-based didactic on the SPIKES framework followed by a refresher email on SPIKES sent to PGY2s before each inpatient medicine rotation. PGY1s were blinded as to which PGY2s underwent the training. MAIN MEASURES: The primary outcome was PGY1 evaluation of the extent of feedback provided by PGY2s. Secondary outcomes included PGY1 report of feedback quality and PGY2 self-report of feedback quantity and quality. Outcomes were obtained via anonymous online survey and reported using a Likert scale with a range of one to four. KEY RESULTS: PGY1s completed 207 surveys (51% response rate) and PGY2s completed 61 surveys (42% response rate). PGY1s reported a higher extent of feedback (2.5 vs 2.2; p = 0.02; Cohen's d = 0.31), more specific feedback (2.3 vs 2.0; p < 0.01; d = 0.33), and higher satisfaction with feedback (2.6 vs 2.2; p < 0.01; d = 0.47) from intervention PGY2s. There were no significant differences in PGY2 self-reported outcomes. CONCLUSIONS: With modest implementation requirements and notable limitations, a brief educational intervention focused on SPIKES increased PGY1 perception of the extent, specificity, and satisfaction with feedback from PGY2s.

How to become a better clinical teacher: a collaborative peer observation process.

BACKGROUND: Peer observation of teaching (PoT) is most commonly done as a way of evaluating educators in lecture or small group teaching. Teaching in the clinical environment is a complex and hectic endeavor that requires nimble and innovative teaching on a daily basis. Most junior faculty start their careers with little formal training in education and with limited opportunity to be observed or to observe more experienced faculty. AIM: Formal PoT would potentially ameliorate these challenges. METHODS: This article describes a collaborative peer observation process that a group of 11 clinician educators is using as a longitudinal faculty development program. RESULTS: The process described in this article provides detailed and specific teaching feedback for the observed teaching attending while prompting the observing faculty to reflect on their own teaching style and to borrow effective teaching techniques from the observation. CONCLUSION: This article provides detailed examples from written feedback obtained during collaborative peer observation to emphasize the richness of this combined experience.

Serial Procalcitonin as a Predictor of Bacteremia and Need for Intensive Care Unit Care in Adults With Pneumonia, Including Those With Highest Severity: A Prospective Cohort Study.

BACKGROUND: Procalcitonin (PCT) is a prohormone that rises in bacterial pneumonia and has promise in reducing antibiotic use. Despite these attributes, there are inconclusive data on its use for clinical prognostication. We hypothesize that serial PCT measurements can predict mortality, intensive care unit (ICU) admission, and bacteremia. METHODS: A prospective cohort study of inpatients diagnosed with pneumonia was performed at a large tertiary care center in Boston, Massachusetts. Procalcitonin was measured on days 1 through 4. The primary endpoint was a composite adverse outcome defined as all-cause mortality, ICU admission, and bacteremia. Regression models were calculated with area under the receiver operating characteristic curve (AUC) as a measure of discrimination. RESULTS: Of 505 patients, 317 patients had a final diagnosis of community-acquired pneumonia (CAP) or healthcare-associated pneumonia (HCAP). Procalcitonin was significantly higher for CAP and HCAP patients meeting the composite primary endpoint, bacteremia, and ICU admission, but not mortality. Incorporation of serial PCT levels into a statistical model including the Pneumonia Severity Index (PSI) improved the prognostic performance of the PSI with respect to the primary composite endpoint (AUC from 0.61 to 0.66), bacteremia (AUC from 0.67 to 0.85), and need for ICU-level care (AUC from 0.58 to 0.64). For patients in the highest risk class PSI >130, PCT was capable of further risk stratification for prediction of adverse outcomes. CONCLUSION: Serial PCT measurement in patients with pneumonia shows promise for predicting adverse clinical outcomes, including in those at highest mortality risk.

Acute on chronic liver failure in a patient with sickle cell anaemia (HbSS).

A man in his late 40s with sickle cell anaemia (HbSS) presented to the emergency department with 2 weeks of diffuse oedema, increased abdominal girth and dyspnoea. His anasarca was thought to be indicative of an acute decompensation of his known liver cirrhosis with transfusion-induced haemosiderosis. While his anasarca improved with diuresis, his direct hyperbilirubinaemia suddenly worsened without any signs of haemolysis, biliary disease or obstruction. He also developed an acute worsening in serum creatinine (1.17-7.0 mg/dL in 7 days) despite subsequent treatment for presumed hepatorenal syndrome (HRS). Given his clinical decline, the patient's goals of care were transitioned to comfort measures only. His clinical presentation and rapid liver and renal deterioration were most typical of sickle cell intrahepatic cholestasis (SCIC). SCIC can lead to rapid deterioration in renal function and can be mistaken for HRS. When SCIC is suspected, consideration of exchange transfusions should be made early.

Procalcitonin algorithms for antibiotic therapy decisions: a systematic review of randomized controlled trials and recommendations for clinical algorithms.

Previous randomized controlled trials suggest that using clinical algorithms based on procalcitonin levels, a marker of bacterial infections, results in reduced antibiotic use without a deleterious effect on clinical outcomes. However, algorithms differed among trials and were embedded primarily within the European health care setting. Herein, we summarize the design, efficacy, and safety of previous randomized controlled trials and propose adapted algorithms for US settings. We performed a systematic search and included all 14 randomized controlled trials (N = 4467 patients) that investigated procalcitonin algorithms for antibiotic treatment decisions in adult patients with respiratory tract infections and sepsis from primary care, emergency department (ED), and intensive care unit settings. We found no significant difference in mortality between procalcitonin-treated and control patients overall (odds ratio, 0.91; 95% confidence interval, 0.73-1.14) or in primary care (0.13; 0-6.64), ED (0.95; 0.67-1.36), and intensive care unit (0.89; 0.66-1.20) settings individually. A consistent reduction was observed in antibiotic prescription and/or duration of therapy, mainly owing to lower prescribing rates in low-acuity primary care and ED patients, and shorter duration of therapy in moderate- and high-acuity ED and intensive care unit patients. Measurement of procalcitonin levels for antibiotic decisions in patients with respiratory tract infections and sepsis appears to reduce antibiotic exposure without worsening the mortality rate. We propose specific procalcitonin algorithms for low-, moderate-, and high-acuity patients as a basis for future trials aiming at reducing antibiotic overconsumption.