Making decisions "in the dark": Learning through uncertainty in clinical practice during Covid-19.

Purpose: The purpose of this study was to explore how decision making and informal and incidental learning (IIL) emerged in the clinical learning environment (CLE) during the height of the Covid-19 pandemic. The authors' specific interest was to better understand the IIL that took place among frontline physicians who had to navigate a CLE replete with uncertainty and complexity with the future goal of creating experiences for medical students that would simulate IIL and use uncertainty as a catalyst for learning. Method: Using a modified constructivist, grounded theory approach, we describe physicians' IIL while working during times of heightened uncertainty. Using the critical incident technique, we conducted 45-min virtual interviews with seven emergency department (ED) and five intensive care unit (ICU) physicians, who worked during the height of the pandemic. The authors transcribed and restoried each interview before applying inductive, comparative analysis to identify patterns, assertions, and organizing themes. Results: Findings showed that the burden of decision making for physicians was influenced by the physical, emotional, relational, and situational context of the CLE. The themes that emerged for decision making and IIL were interdependent. Prominent among the patterns for decision making were ways to simplify the problem by applying prior knowledge, using pattern recognition, and cross-checking with team members. Patterns for IIL emerged through trial and error, which included thoughtful experimentation, consulting alternative sources of information, accumulating knowledge, and "poking at the periphery" of clinical practice. Conclusions: Complexity and uncertainty are rife in clinical practice and this study made visible decision-making patterns and IIL approaches that can be built into formal curricula. Making implicit uncertainty explicit by recognizing it, naming it, and practicing navigating it may better prepare learners for the uncertainty posed by the clinical practice environment.

Practical tips for moving your patient panel online.

Patient panels are an inspiring, highly rated educational tool to complement course goals and objectives for students in medical education programs. The COVID-19 pandemic brought challenges on the ability to successfully host in-person patient panels. These challenges resulted in the need to pivot in-person patient panels to online platforms, while still ensuring the quality and intimacy of patient narratives. In this 12 tips article, we share lessons learned in transitioning patient panels in our health systems science curriculum to an online experience for students enrolled in a pre-clinical medical education program.

The Impact of Chronic Medical Conditions on Mortality in Acute Respiratory Distress Syndrome.

PURPOSE: To examine the impact of chronic comorbidities on mortality in Acute Respiratory Distress Syndrome (ARDS). MATERIALS AND METHODS: Retrospective cohort study of adults with ARDS (ICD-10-CM code J80) from the National Inpatient Sample between January, 2016 and December, 2018. For the primary outcome of mortality, we conducted weighted logistic regression adjusting for factors identified on univariate analysis as potentially significant or differing between the two groups at baseline. We used negative binomial regression adjusting for the same comorbidities to identify risk factors for longer length of stay (LOS) among ARDS survivors. RESULTS: After exclusions, 1046 records were analyzed (3355 ARDS survivors and 1875 non-survivors.) The comorbidities examined included hypertension, diabetes mellitus, obesity, hypothyroidism, alcohol and drug use, chronic kidney disease (CKD), cardiovascular disease, chronic liver disease, chronic pulmonary disease and malignancy. In multivariate analysis, we found that malignancy (OR 2.26, 95% CI 1.84-2.78, p < 0.001), cardiovascular disease (OR 1.54, 95% CI 1.23-1.92, p < 0.001), and CKD (OR 1.75, 95% CI 1.22-2.50, p = 0.002) increased the risk of death. In interaction analyses, cardiovascular disease combined with either malignancy or CKD conferred higher odds of death compared to either risk factor alone. CONCLUSIONS: The comorbidity of malignancy confers the most reliable risk of poor outcomes in ARDS with higher odds of hospital death and a simultaneous association with longer hospital LOS among survivors.

A Cautionary Tale: Exploring Stakeholder Emotions During Curricular Change Using Group Concept Mapping.

PhenomenonCurricular change is essential but challenging. Change efforts often struggle and some fail due to well-articulated challenges as well as other barriers less understood. The curricular change literature characterizes the organizational and operational features of successful change yet virtually ignores stakeholder emotions. A deeper understanding of these emotional responses during the change process could enhance participant and organizational well-being and support change success. Approach In 2019, data were collected at one large North American medical school using group concept mapping methodology, an asynchronous mixed methods approach. We sought to generate themes characterizing the emotional responses of faculty, administrative staff, and students across multiple stakeholder groups participating in the new and traditional (legacy) curricula 27 months after curricular change initiation. Participants brainstormed, sorted, and rated statements on emotional responses. Rating participants rated each statement using a Likert scale from 1 (does not resonate) to 4 (very strongly resonates) according to this prompt: "This emotional response resonates with my emotional experience during the curricular change." Multidimensional scaling and hierarchical cluster analyses were used to generate emotional profiles and compare them across stakeholders. Findings Of 335 stakeholders invited, 123 contributed to brainstorming (36.7%), 153 completed rating (45.7%) and 33 completed sorting (9.9%). Participants generated six themes of emotional responses to curricular change: enthusiastic, apprehensive, overwhelmed, missed opportunities, uncertain, and abandoned. The enthusiastic theme overall had the highest mean statement ratings while the abandoned theme had the lowest. Demographic subgroup analysis revealed new curriculum students (Class of 2021) were most enthusiastic while legacy curriculum students (Class of 2020) were more likely to feel abandoned. Overall, faculty and administrative staff were more enthusiastic than students whereas students rated the five other themes higher than faculty and administrative staff. InsightsCurricular change is emotionally taxing. Students in both curricula experienced greater uncertainty, apprehension, sense of missed opportunities, and feeling overwhelmed than did faculty and administrative staff. Legacy curriculum students rated statements in the abandoned cluster highest while new curriculum students rated statements in the enthusiastic cluster highest. Given the ubiquity of curricular change which often includes a legacy cohort, medical schools embarking on this journey must carefully attend to the varied emotional responses of their different stakeholder groups. The very activities recommended by organizational change models used in medical education, such as communicating wins early and often, could alienate legacy students, creating emotional polarization. These findings suggest that tailored communication strategies are necessary during change implementation to optimize success.

Differences in Utilization of Life Support and End-of-Life Care for Medical ICU Patients With Versus Without Cancer.

OBJECTIVES: To explore differences in the utilization of life support and end-of-life care between patients dying in the medical ICU with cancer compared with those without cancer. DESIGN: Retrospective review of 403 deaths or hospice transfers in the medical ICU from January 1, 2012, to June 30, 2013. SETTING: Urban tertiary care university hospital. PATIENTS: Consecutive medical ICU deaths or hospice transfers over an 18-month period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred eighty-two patients (45%) had a diagnosis of active cancer and 221 (55%) did not. Despite similar severity of illness, there were significant differences in the use of life support and end-of-life care. Patients without cancer had longer medical ICU length of stay (median, 5 vs 4 d; p = 0.0495), used mechanical ventilation more often and for longer (83.7% vs 70.9%, p = 0.002; 4 vs 3 d, p = 0.017), and initiated dialysis more frequently (26.7% vs 14.8%; p = 0.0038). Patients without active cancer had family meetings later (median, 3 vs 2 d; p = 0.001), less frequent palliative care consultation (17.6% vs 32.4%; p = 0.0006), and took longer to transition to do not resuscitate or comfort care (median, 4 vs 3 d; p = 0.048). CONCLUSIONS: Among patients dying in the medical ICU, the diagnosis of active cancer influences the intensity of life support utilization and the quality of end-of-life care. Patients with active cancer use less life support and may receive better end-of-life care than similar patients without cancer. These differences are likely due to biases or misunderstandings about the trajectory of advanced nonmalignant disease among patients, families, and perhaps providers.

Tuberculous Peritonitis.

Tuberculous peritonitis is rare in the United States but continues to be reported to occur in certain high-risk populations, which include patients with AIDS or cirrhosis, patients on continuous ambulatory peritoneal dialysis, recent immigrants from areas of high endemicity, and those who are immunosuppressed. The diagnosis of this disease requires a high clinical index of suspicion and should be considered in the differential of ascites with a lymphocyte predominance and serum-ascitic albumin gradient of <1.1 mg/dl. Microbiological or pathological confirmation remains the gold standard for diagnosis. Ascitic fluid cultures have low yield, but peritoneoscopy with biopsy or cultures frequently confirms the diagnosis. Newer techniques with future application include determination of adenosine deaminase and interferon gamma levels in ascitic fluid. Ultrasound and computed tomography are frequently used to guide fluid aspiration and biopsies. Six months of treatment with antituberculosis therapy is adequate except in cases of drug-resistant tuberculosis. The role of steroids remains controversial. Surgical approaches may be required to deal with complications including bowel perforation, intestinal obstruction from adhesions, fistula formation, or bleeding.

Readmissions after hospital discharge with acute exacerbation of COPD: are we missing something?

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is an important part of the disease's morbidity, mortality, and progression, and is associated with increasing utilization of health care resources. The concept of integrated care based on a chronic care model is relatively new to chronic obstructive pulmonary disease, but has proved successful in improving clinical outcomes and probably in decreasing health care utilization in other chronic conditions. A comprehensive approach is needed to target a change in behavioral patterns in patients, increase physician's awareness and adherence to evidence-based recommendations, and address system related issues. This article discusses the evidence for various facets of nonpharmacological management of AECOPD and proposes a model of care that might be the missing link for reducing hospital readmissions for AECOPD. This model may decrease the morbidity, slow disease progression, and curb the increasing health care resource utilization without compromising patient care.

Chemo killed the small-talk gene.

Urvashi Vaid is a community organizer and writer active in the lesbian, gay, bisexual, and transgender (LGBT) and social justice movements for over three decades. She is currently Director of the Engaging Tradition Project at the Center for Gender and Sexuality Law at Columbia University Law School. She is founder of LPAC, the first lesbian political action committee, and sits on the Board of Directors of the Gill Foundation. Vaid's past positions include Executive Director of the Arcus Foundation, Deputy Director of Governance and Civil Society Unit for the Ford Foundation, Executive Director of the National Gay and Lesbian Task Force, and staff attorney for the ACLU National Prison Project. She is author of the books Irresistible Revolution: Confronting Race, Class and The Assumptions of Lesbian, Gay, Bisexual, and Transgender Politics, and Virtual Equality: The Mainstreaming of Gay & Lesbian Liberation, and co-editor of the book Creating Change: Public Policy, Sexuality and Civil Rights. Urvashi has had thyroid cancer and stage III breast cancer.

Poor positive predictive value of McConnell's sign on transthoracic echocardiography for the diagnosis of acute pulmonary embolism.

BACKGROUND: Acute pulmonary embolism (PE) is a life-threatening condition. Making a definitive diagnosis with radiologic studies may delay therapy or be unsafe for the patient. Echocardiography is readily available and can suggest PE by demonstrating right ventricular (RV) dysfunction. McConnell's sign on echocardiogram (ECHO-CG) (RV dysfunction with characteristic sparing of the apex) has been reported to have high sensitivity and specificity for the diagnosis of acute PE. It is hypothesized that McConnell's sign on ECHO-CG in patients hospitalized with suspected acute PE would have a high positive predictive value (PPV). METHODS: Data, from 2005 to 2010, were retrospectively collected on all patients with an ECHO-CG interpreted as revealing McConnell's sign, who had undergone another diagnostic study (computed tomography pulmonary angiography, ventilation-perfusion scan, upper or lower extremity Doppler ultrasound, or autopsy) for venous thromboembolic disease (VTE). The PPV on transthoracic ECHO-CG was calculated for the diagnostic accuracy of McConnell's sign in all patients. To minimize the potential for ECHO-CG reader bias of patients already confirmed to have had a PE by another modality, the PPV was then recalculated only on the patients in whom the ECHO-GM was the first diagnostic study. RESULTS: Seventy-three patients had findings of McConnell's sign on ECHO-CG. The PPV of McConnell's sign on ECHO-CG was 57% (CI, 45%-67%). Of the 37 patients who underwent an ECHO-CG in the first study for suspected acute PE, 15 patients had VTE confirmed; the PPV in this subset was only 40% (CI, 24%-56%). There were 20 patient deaths overall; of these, only 9 of the patients were confirmed to have VTE. CONCLUSION: We concluded that the presence of McConnell's sign has a relatively poor PPV for the diagnosis of acute PE and should not be used in isolation when making a diagnosis of PE in patients.

Model for End-Stage Liver Disease score for predicting outcome in critically ill medical patients with liver cirrhosis.

PURPOSE: We hypothesized that the Model for End-Stage Liver Disease (MELD) score at admission to the intensive care unit (ICU) can predict in-hospital mortality for patients with liver cirrhosis. We also tested the MELD-natremia (Na) score and compared the predictive value of the 2 models. MATERIALS AND METHODS: This is a retrospective cohort study. A total of 441 consecutive patients with liver cirrhosis admitted to the ICU were included. The MELD and MELD-Na scores and other variables were obtained upon patients' admission to the ICU. RESULTS: The area under the receiver operating characteristic curve to predict in-hospital mortality was 0.77 (95% confidence interval, 0.73-0.82) for the MELD score and 0.77 (95% confidence interval, 0.73-0.81) for the MELD-Na score. CONCLUSION: The MELD scoring system provides useful prognostic information for critically ill patients with liver cirrhosis admitted to an ICU. The MELD and MELD-Na scores had similar predictive value.

Thrombolytic therapy in a patient with suspected pulmonary embolism despite a negative computed tomography pulmonary angiogram.

We report a case of a 62-year-old male who presented to our intensive care unit with hypoxemia 6 hours after retinal surgery. He had a negative computed tomography (CT) pulmonary angiogram, but an emergency echocardiogram revealed the McConnell sign. He was thrombolysed and had rapid improvement in oxygenation and hemodynamics. Thrombolysis in hemodynamically unstable pulmonary embolism is not controversial, but most algorithms require confirmation of the diagnosis. Our patient had a negative CT pulmonary angiogram but was thrombolysed based on the clinical picture. Autopsy confirmed the diagnosis of multiple pulmonary emboli and unexpectedly discovered a patent foramen ovale that explained paradoxical embolism to the brain.