Assessing Nephrology Fellows' Skills in Communicating About Kidney Replacement Therapy and Kidney Biopsy: A Multicenter Clinical Simulation Study on Breaking Bad News.

RATIONALE & OBJECTIVE: Interpersonal communication skills and professionalism competencies are difficult to assess among nephrology trainees. We developed a formative "Breaking Bad News" simulation and implemented a study in which nephrology fellows were assessed with regard to their skills in providing counseling to simulated patients confronting the need for kidney replacement therapy (KRT) or kidney biopsy. STUDY DESIGN: Observational study of communication competency in the setting of preparing for KRT for kidney failure, for KRT for acute kidney injury (AKI), or for kidney biopsy. SETTING & PARTICIPANTS: 58 first- and second-year nephrology fellows assessed during 71 clinical evaluation sessions at 8 training programs who participated in an objective structured clinical examination of simulated patients in 2017 and 2018. PREDICTORS: Fellowship training year and clinical scenario. OUTCOME: Primary outcome was the composite score for the "overall rating" item on the Essential Elements of Communication-Global Rating Scale 2005 (EEC-GRS), as assessed by simulated patients. Secondary outcomes were the score for EEC-GRS "overall rating" item for each scenario, score < 3 for any EEC-GRS item, Mini-Clinical Examination Exercise (Mini-CEX) score < 3 on at least 1 item (as assessed by faculty), and faculty and fellow satisfaction with simulation exercise (via a survey they completed). ANALYTICAL APPROACH: Nonparametric tests of hypothesis comparing performance by fellowship year (primary goal) and scenario. RESULTS: Composite scores for EEC-GRS overall rating item were not significantly different between fellowship years (P = 0.2). Only 4 of 71 fellow evaluations had an unsatisfactory score for the EEC-GRS overall rating item on any scenario. On Mini-CEX, 17% scored < 3 on at least 1 item in the kidney failure scenario; 37% and 53% scored < 3 on at least 1 item in the AKI and kidney biopsy scenarios, respectively. In the survey, 96% of fellows and 100% of faculty reported the learning objectives were met and rated the experience good or better in 3 survey rating questions. LIMITATIONS: Relatively brief time for interactions; limited familiarity with and training of simulated patients in use of EEC-GRS. CONCLUSIONS: The fellows scored highly on the EEC-GRS regardless of their training year, suggesting interpersonal communication competency is achieved early in training. The fellows did better with the kidney failure scenario than with the AKI and kidney biopsy scenarios. Structured simulated clinical examinations may be useful to inform curricular choices and may be a valuable assessment tool for communication and professionalism.

Impact of Novel Multiinstitutional Curriculum on Critical Care Fellow Ventilator Knowledge.

Background: Management of mechanical ventilation (MV) is a curricular milestone for trainees in pulmonary critical care medicine (PCCM) and critical care medicine (CCM) fellowships. Though recognition of ventilator waveform abnormalities that could result in patient complications is an important part of management, it is unclear how well fellows recognize these abnormalities.Objective: To study proficiency of ventilator waveform analysis among first-year fellows enrolled in a MV course compared with that of traditionally trained fellows.Methods: The study took place from July 2016 to January 2019, with 93 fellows from 10 fellowship programs completing the waveform examination. Seventy-three fellows participated in a course during their first year of fellowship, with part I occurring at the beginning of fellowship in July and part II occurring after 6 months of clinical work. These fellows were given a five-question ventilator waveform examination at multiple time points throughout the two-part course. Twenty fellows from three other fellowship programs who were in their first, second, or third year of fellowship and who did not participate in this course served as the control group. These fellows took the waveform examination a single time, at a median of 23 months into their training.Results: Before the course, scores were low but improved after 3 days of education at the beginning of the fellowship (18.0 ± 1.6 vs. 45.6 ± 3.0; P < 0.0001). Scores decreased after 6 months of clinical rotations but increased to their highest levels after part II of the course (33.7 ± 3.1 for part II pretest vs. 77.4 ± 2.4 for part II posttest; P < 0.0001). After completing part I at the beginning of fellowship, fellows participating in the course outperformed control fellows, who received a median of 23 months of traditional fellowship training at the time of testing (45.6 ± 3.0 vs. 25.3 ± 2.7; P < 0.0001). There was no difference in scores between PCCM and CCM fellows. In anonymous surveys, the fellows also rated the mechanical ventilator lectures highly.Conclusion: PCCM and CCM fellows do not recognize common waveform abnormalities at the beginning of fellowship but can be trained to do so. Traditional fellowship training may be insufficient to master ventilator waveform analysis, and a more intentional, structured course for MV may help fellowship programs meet the curricular milestones for MV.

Not Just Hocus POCUS: Implementation of a Point of Care Ultrasound Curriculum for Internal Medicine Trainees at a Large Residency Program.

INTRODUCTION: In 2018, the American College of Physicians formally acknowledged the importance of Point of Care Ultrasound (POCUS) to the practice of internal medicine (IM). For the military internist, POCUS training is critical for care of the trauma patient in austere environments, mass casualty events and natural disasters. While emergency medicine and critical care training programs have adopted POCUS education, few IM programs have integrated POCUS into their core curricula. We designed and implemented an iterative POCUS curriculum for trainees at a large military IM residency program over a two-year period. METHODS: In collaboration with our critical care and simulation departments, we developed a pilot curriculum consisting of five, 60-minute courses offered on a voluntary basis at monthly intervals throughout 2017. Based on the pilot's success we incorporated a POCUS curriculum into the core academics received by all IM trainees during the 2017-2018 academic year. Trainees attended seven, 3-hour sessions during their scheduled academic time taught by subspecialists with POCUS expertise in an on-site simulation center. Baseline surveys and knowledge assessment examinations were administered during orientation and repeated at the end of the academic year. Comparison of results before and after the POCUS curriculum was the primary outcome evaluated. RESULTS: Intervention #1: Pilot, 2016-2017 Academic Year45 trainees attended at least one course with an average of 1.8 sessions per trainee. Baseline survey data showed 91% of trainees believe POCUS is quite or extremely beneficial for their patients, but 73% feel slightly or not at all confident in POCUS knowledge. The pre-test mean and median scores were 71% and 77% respectively, which both increased to a post-test mean and median of 81%. Post-test mean percentage correct for trainees attending 1, 2, or 3 courses was 74%, 82%, and 91% respectively. Intervention #2: Incorporation of POCUS into Core Academics, 2017-2018 Academic YearAll 75 trainees participated in training with an average of 3.77 sessions attended per trainee. Survey analysis revealed significant improvement in confidence of performing ultrasound-guided procedures (p = 0.0139), and a 37% absolute increase in respondents who anticipate using ultrasound in their clinical practice (p = 0.0003). The mean pre-test score was 67.8% with median of 63.6% while mean and median post-test scores were 82.1% and 81.8%, with an absolute improvement of 14.3% and 18.2% respectively (p = 0.0004). CONCLUSION: A structured POCUS curriculum was successfully incorporated at a large multiservice military IM residency program, with demonstrated retention of knowledge, improved confidence in performance of ultrasound guided invasive procedures, and increased interest in the use of POCUS in future clinical practice. Similar programs should be implemented across all IM programs in military graduate medical education to enhance operational readiness and battlefield care.

Clinical Reasoning in the Primary Care Setting: Two Scenario-Based Simulations for Residents and Attendings.

Introduction: We describe the development and implementation of tools medical educators or researchers can use for developing or analyzing residents' through attending physicians' clinical reasoning in an outpatient clinic setting. The resource includes two scenario-based simulations (i.e., diabetes, angina), implementation support materials, an open-ended postencounter form, and a think-aloud reflection protocol. Method: We designed two scenarios with potential case ambiguity and contextual factors to add complexity for studying clinical reasoning. The scenarios are designed to be used prior to an open-ended written exercise and a think-aloud reflection to elicit reasoning and reflection. We report on their implementation in a research context but developed them to be used in both educational and research settings. Results: Twelve physicians (five interns, three residents, and four attendings) considered between three and six differential diagnoses (M = 4.0) for the diabetes scenario and between three and nine differentials (M = 4.3) for angina. In think-aloud reflections, participants reconsidered their thinking between zero and 14 times (M = 3.5) for diabetes and zero and 11 times (M = 3.3) for angina. Cognitive load scores ranged from 4 to 8 (out of 10; M = 6.2) for diabetes and 5 to 8 (M = 6.6) for angina. Participants rated scenario authenticity between 4 and 5 (out of 5). Discussion: The potential case content ambiguity, along with the contextual factors (e.g., patient suggesting alternative diagnoses), provides a complex environment in which to explore or teach clinical reasoning.

The Impact of Deployment on the Practice of the Military Internist: A Needs Assessment for Post-Deployment Refresher Training.

INTRODUCTION: U.S. Army internists serve in a variety of provider roles during deployment, many of which vary from the traditional responsibilities of a general internist or internal medicine subspecialist. There is significant interest in defining specific clinical and procedural skills in which Army internists may require refresher training after deployment, but information to quantify and clarify these needs is lacking. MATERIALS AND METHODS: An online, anonymous survey was created to assess Army internists' experience and comfort level with specialty-specific problems and procedures before and after deployment. This survey was distributed via the Army Central Simulation Committee to all U.S. Army internists eligible for deployment. The survey was available online from January 11, 2012, to March 9, 2012. RESULTS: Ninety-seven of all 115 (84%) U.S. Army internists eligible for deployment responded. The reported comfort level with core clinical problems in general internal medicine before and after deployment did not change, with the exception of decreased comfort with the performance of advanced cardiac life support (87% versus 76% comfortable, p = 0.035), evaluation and management of anemia (92% versus 83% comfortable, p = 0.039), and comfort with preoperative risk stratification and mitigation (81% versus 65% comfortable, p = 0.017). Providers' reported comfort level performing core internal medicine procedures decreased, including significant decreases with lumbar puncture (p < 0.001), arterial line placement (p = 0.02), ultrasound-guided central line placement (p = 0.01), ultrasound-guided thoracentesis (p = 0.004), and arthrocentesis (p = 0.01). Despite a reported deceased comfort with certain core clinical problems and procedural skills, only 10 of 68 (13%) respondents reported being offered refresher skills training following deployment. CONCLUSION: Although Army internists' comfort with core general internal medicine clinical problems remains largely unaffected by deployment, confidence in core internal medicine procedures suffers because of limited opportunities to practice these skills in the deployed setting. Skills training and assessment in procedures required for individual provider practice should be a primary focus of reintegration after deployment.

The Central Simulation Committee (CSC): a model for centralization and standardization of simulation-based medical education in the U.S. Army healthcare system.

In this report, we describe the organizational framework, operations and current status of the Central Simulation Committee (CSC). The CSC was established in 2007 with the goals of standardizing simulation-based training in Army graduate medical education programs, assisting in redeployment training of physicians returning from war, and improving patient safety within the Army Medical Department. Presently, the CSC oversees 10 Simulation Centers, controls over 21,000 sq ft of simulation center space, and provides specialty-specific training in 14 medical specialties. In the past 2 years, CSC Simulation Centers have trained over 50,000 Army medical students, residents, physician assistants, nurses, Soldiers and DoD civilian medical personnel. We hope this report provides simulation educators within the military, and our civilian simulation colleagues, with insight into the workings of our organization and provides an example of centralized support and oversight of simulation-based medical education.

Does difficult mask ventilation predict obstructive sleep apnea? A prospective pilot study to identify the prevalence of osa in patients with difficult mask ventilation under general anesthesia.

BACKGROUND: Given the pathogenesis of obstructive sleep apnea (OSA), anesthesiologists may be in a unique position to rapidly identify patients who are at risk for undiagnosed OSA in the perioperative period. Identification is the first step in prompt diagnosis and potential prevention of OSA related comorbidities. Patients who exhibit unanticipated difficult mask ventilation (DMV) during induction of general anesthesia may be at risk of having undiagnosed OSA. OBJECTIVE: To determine the association of OSA in patients with difficult mask ventilation under general anesthesia. METHODS: Ten patients were identified over a 2-year period at the time of anesthetic induction as being difficult to mask ventilate and were then enrolled in this prospective pilot study. After enrollment and informed consent, the patients were referred to the sleep study center for full overnight polysomnography to evaluate for the presence and severity of OSA. RESULTS: Of our cohort, 9/10 patients exhibited polysomnographic evidence of OSA, while the last subject tested positive for sleep disordered breathing. Eighty percent (8/10) of subjects espoused snoring, but only 10% (1/10) reported witnessed apneas. Average DMV was 2.5, and higher grades of DMV were associated with more severe OSA. CONCLUSION: In this study, difficult mask ventilation was predictive of undiagnosed OSA. Anesthesiologists may be in a unique position to identify patients at risk for OSA and prevention of related comorbidities.

An uncommon cause of chest pain in the deployed soldier.

Chest pain is a common complaint at medical treatment facilities during combat operations. The initial evaluation focuses on potentially life-threatening conditions (acute coronary syndrome, aortic dissection, pulmonary embolus), in addition to pericarditis and benign musculoskeletal conditions such as costochondritis. Pulmonary arteriovenous malformation is a rare condition, but an important diagnostic consideration in soldiers who present with chest pain and/or hypoxia and in whom other life-threatening conditions, such as cardiovascular disasters and pulmonary embolus, are excluded. We present the case of a male soldier deployed to Operation Iraqi Freedom, who was air-evacuated back to Washington, DC, for definitive care. We present his case and a review of the relevant literatures on the diagnosis and treatment of patients with pulmonary arteriovenous malformations.

Clinical and lung-function variables associated with vocal cord dysfunction.

BACKGROUND: Vocal cord dysfunction (VCD) is difficult to diagnose. Laryngoscopy while the patient is symptomatic is the accepted standard method to establish a diagnosis of VCD, but patient characteristics and spirometry values are thought to be useful for predicting VCD. We sought to identify clinical and spirometric variables that suggest VCD. METHODS: We performed 2 parallel studies. First, 3 staff pulmonologists (who were blinded to the laryngoscopy results), scored 3 flow-volume loops from each PFT session on the likelihood that the inspiratory curve indicated VCD. We also performed a cross-sectional study of clinical characteristics and spirometric data from all patients who underwent laryngoscopy for any indication, including suspected VCD, over a 3-year period. We compared the laryngoscopy findings to the clinical characteristics, spirometry results, and the pulmonologists' assessments of the flow-volume loops. We used multivariate logistic regression to identify independent predictors of VCD. RESULTS: The pulmonologists agreed about which flow-volume loops predicted VCD (quadratic kappa range 0.55-0.76), but those ratings were not predictive of laryngoscopic diagnosis of VCD. During the study period, 226 patients underwent laryngoscopy. One hundred (44%) were diagnosed with VCD. Independent predictors of VCD included female sex (odds ratio 2.72, 95% confidence interval 1.55-4.75) and obesity (body mass index > 30 kg/m(2)) (odds ratio 2.06, 95% confidence interval 1.12-3.80). With spirometric data from the effort that had the best forced-vital-capacity, multivariate analysis found the ratio of the forced inspiratory flow at 25% of the inspired volume to forced inspiratory flow at 75% of the inspired volume (FIF(25%/75%)) predictive of VCD (odds ratio 1.97, 95% confidence interval 1.12-3.44). The diagnostic performance of these characteristics was poor; the area under the receiver-operating-characteristic curve was 0.68. With the spirometric data from the effort that had the subjectively determined best inspiratory curve, and after controlling for the reproducibility of the inspiratory curves, multivariate analysis found none of the spirometric variables predictive of VCD. CONCLUSIONS: VCD remains difficult to predict with spirometry or flow-volume loops. If VCD is suspected, normal flow-volume loop patterns should not influence the decision to perform laryngoscopy.

Vocal cord dysfunction.

A case of vocal cord dysfunction (VCD) is presented, followed by a discussion of the clinical characteristics, pathogenesis, diagnosis, and management of this disorder. Special emphasis is given to clinical pearls and pitfalls for the practicing allergist. VCD is a common condition that mimics asthma. Dyspnea, cough, and chest tightness are frequent manifestations of the disease. A high degree of clinical suspicion is required to recognize VCD and diagnosis is made most confidently by laryngoscopy. The mainstay of treatment for VCD is reassurance, speech therapy, and treatment of associated comorbidities including gastroesophageal reflux disease, postnasal drip syndrome, and psychiatric conditions.

Allergic bronchopulmonary aspergillosis.

A case of allergic bronchopulmonary aspergillosis (ABPA) is presented, followed by a discussion of the clinical characteristics, pathogenesis, diagnosis, and management of this disease. Special emphasis is given to clinical pearls and pitfalls for the practicing allergist. ABPA is a hypersensitivity response to Aspergillus antigens in the lung and is distinct from other forms of Aspergillus pulmonary disease. Episodic bronchospasm, expectoration of mucous plugs, and fleeting pulmonary infiltrates are common manifestations of the disease. Several diagnostic schemes for ABPA have been described with varying criteria, which uniformly includes asthma and positive immediate skin-prick test to Aspergillus fumigatus. The mainstay of treatment for ABPA is corticosteroids, which are normally effective.

High levels of medical utilization by ambulatory patients with vocal cord dysfunction as compared to age- and gender-matched asthmatics.

STUDY OBJECTIVES: To evaluate medical utilization by ambulatory patients with vocal cord dysfunction (VCD). DESIGN: Retrospective, case-control study. SETTING: Pulmonary disease clinic at an army tertiary-care center. PATIENTS: Twenty-five ambulatory patients with VCD (mean age, 41 years; range, 27 to 69 years) who were age- (+/- 3 years) and gender-matched to 25 control patients with moderate persistent asthma. MEASUREMENTS AND RESULTS: Medical utilization for the year preceding the diagnosis of VCD or asthma was obtained from a computerized medical record. End points included total outpatient visits, evaluations by subspecialty physicians, presentations for urgent care, hospitalizations, and number of prescriptions. Total physician visits (477 visits vs 267 visits, respectively; p < 0.004) and subspecialty care visits (277 visits vs 118 visits; p < 0.007) were significantly greater among the VCD cohort as compared with the asthmatic cohort. The groups were also found to have comparable utilization of prescriptions (448 prescriptions vs 394 prescriptions, respectively; p < 0.63), frequency of hospitalizations (seven hospitalizations vs five hospitalizations; p < 0.59), and urgent care visits (45 visits vs 20 visits; p < 0.14). CONCLUSIONS: Ambulatory VCD patients use significantly more medical provider resources and similar pharmaceutical assets as compared to patients with moderate persistent asthma.