Better Together: Development and Implementation of Fellow Group Evaluations of Faculty.

Background: High-quality trainee evaluations of faculty are essential for meaningful faculty development and for improving the clinical learning environment. However, concerns about anonymity can limit usefulness of trainee evaluations, particularly in smaller programs, such as subspecialty fellowships. Objective: To develop and implement a fellow-driven group evaluation process to enhance trainee confidentiality and generate high-quality feedback for pulmonary and critical care medicine faculty. Methods: A novel process was developed for faculty evaluation and feedback consisting of quarterly, structured, fellow-led group evaluation sessions focused on collecting confidential, behaviorally oriented, actionable feedback for faculty. Upper-year fellow moderators utilized a standard format to structure discussion, generating strengths and areas for growth for each faculty member while explicitly asking for input from fellows with divergent perspectives. Moderators compiled anonymized session notes for the program director, who delivered feedback to individual faculty. After the first six sessions, an electronic survey was distributed to assess fellow perceptions of the group evaluation model. Results: Thirty-seven faculty members were evaluated in 11 group sessions over 42 months. Fellows rated group-generated feedback as more confidential, more specific, more accurate, more efficient, more actionable, and less biased when compared with individual written evaluations (P < 0.01 for all categories). Conclusion: The authors successfully developed and implemented a process for fellow-led group evaluation of faculty, designed to facilitate fellow confidentiality and enrich the quality of feedback. Fellows preferred the group evaluation process and perceived group-generated feedback more favorably compared with individual written evaluations.

Pertuzumab Plus Trastuzumab in Patients With Endometrial Cancer With ERBB2/3 Amplification, Overexpression, or Mutation: Results From the TAPUR Study.

PURPOSE: The TAPUR Study is a pragmatic basket trial evaluating antitumor activity of commercially available targeted agents in patients with advanced cancers harboring potentially actionable genomic alterations. Data from a cohort of patients with endometrial cancer (EC) with ERBB2 or ERBB3 (ERBB2/3) amplification, overexpression, or mutation treated with pertuzumab plus trastuzumab (P + T) are reported. METHODS: Eligible patients had advanced EC, no standard treatment options, measurable disease (RECIST v1.1), Eastern Cooperative Oncology Group performance status 0-2, adequate organ function, and tumors with ERBB2/3 amplification, overexpression, or mutation. Simon's two-stage design was used with a primary end point of disease control (DC), defined as objective response (OR) or stable disease (SD) of at least 16 weeks (SD16+) duration. Secondary end points include safety, duration of response, duration of SD, progression-free survival (PFS), and overall survival (OS). RESULTS: Twenty-eight patients were enrolled from March 2017 to November 2019; all patients were evaluable for efficacy and toxicity. Seventeen patients had tumors with ERBB2/3 amplification and/or overexpression, eight with both ERBB2 amplification and ERBB2/3 mutations, and three with only ERBB2 mutations. Ten patients had DC (two partial response and eight SD16+); all 10 had ERBB2 amplification, and 6 of the 10 patients with DC had >1 ERBB2/3 alteration. DC and OR rates were 37% (95% CI, 21 to 50) and 7% (95% CI, 1 to 24), respectively; the median PFS and median OS were 16 weeks (95% CI, 10-28) and 61 weeks (95% CI, 24-105), respectively. One patient experienced a grade 3 serious adverse event (muscle weakness) at least possibly related to P + T. CONCLUSION: P + T has antitumor activity in heavily pretreated patients with EC with ERBB2 amplification and warrants additional study.

Are Text Pages an Effective Nudge to Increase Attendance at Internal Medicine Morning Report Conferences? A Cluster Randomized Controlled Trial.

Background: Despite the importance of medical educational conferences, low attendance remains an issue. The utility of reminder text pages as a behavioral nudge to increase attendance is unknown. Our objective was to determine whether reminder text pages increase daily morning report attendance. Methods: We conducted a multiple-crossover cluster randomized controlled trial among medical students and internal medicine interns and residents (learners) at the Veteran Affairs Boston Healthcare System during the 2019 to 2020 academic year. During intervention periods, all residents and interns received a text page reminder 5 minutes before the upcoming 8:00 am morning report conference; no page was sent during control periods. The primary outcome was conference attendance 10 minutes after the start of the conference. Results: The study period included 85 morning report conferences, which 211 unique learners were eligible to attend; outcome data were available for 100% of eligible learners. On days when no page was sent, 44.4% of eligible learners attended the conference by 8:10 am ; on days when a reminder page was sent, 49.5% of eligible learners attended (P = .007). Accounting for clustering within individuals and controlling for date and team, the adjusted risk difference in morning report attendance associated with a reminder page was 4.0% (95% CI, 0.5%-7.6%) compared with no reminder page. No effect modification by overnight admissions was detected. Conclusions: Our results suggest that daily reminder pages may result in a small increase in conference attendance. Whether this small increase is educationally significant will vary across training programs that apply this strategy.

Education for Tobacco Use Disorder Treatment: Current State, Evidence, and Unmet Needs.

Background: Tobacco use is undertreated in the medical setting. One driver may be inadequate tobacco use disorder treatment (TUDT) training for clinicians in specialties treating tobacco-dependent patients. Objective: We sought to evaluate the current state of TUDT training for diverse professionals and how these skills are assessed in credentialing exams. Methods: We performed a focused review of current educational practices, evidence-based strategies, and accreditation exam contents focused on TUDT. Results: Among medical students, participants in reviewed studies reported anywhere from 45 minutes to 3 hours of TUDT training throughout their 4-year programs, most often in the form of didactic sessions. Similarly, little TUDT training was reported at the post-graduate (residency, fellowship, continuing medical education) levels, and reported training was typically delivered as time-based (expected hours of instruction) rather than competency-based (demonstration of mastery) learning. Multiple studies evaluated effective TUDT curricula at varied stages of training. More effective curricula incorporated longitudinal sessions and active learning, such as standardized patient encounters or proctored patient visits. Knowledge of TUDT is minimally evaluated on certification exams. For example, the American Board of Internal Medicine blueprint lists TUDT as <2% of one subtopic on both the internal medicine and pulmonary exams. Conclusion: TUDT training for most clinicians is minimal, does not assess competency, and is minimally evaluated on certification exams. Effective, evidence-based TUDT training incorporating active learning should be integrated into medical education at all levels, with attention paid to inclusion on subsequent certifying exams.

Closeness-inducing discussions with a romantic partner increase cortisol and testosterone.

Despite progress in understanding the social neuroendocrinology of close relationship processes, most work has focused on negative experiences, such as relationship conflict or stress. As a result, much less is known about the neuroendocrine implications of positive, emotionally intimate relationship experiences. In the current study, we randomly assigned 105 dating or married couples to a 30-minute semi-structured discussion task that was designed to elicit either high or low levels of closeness. Participants provided pre- and post-task saliva samples (to assess cortisol and testosterone) and post-task reports of self-disclosure, closeness, attraction, positive and negative affect, and stress. Participants found the discussion conditions comparably positive and enjoyable, but those in the high-closeness condition reported that they disclosed marginally more and felt marginally closer to their partners than those in the low-closeness condition. Participants also showed larger increases in cortisol and testosterone during the high (versus low) closeness discussion, and self-reported disclosure mediated these increases in cortisol and testosterone. Self-reported closeness and other theoretically plausible mediators, such as sexual attraction and excitement, did not mediate changes in either hormone. Taken together, the current findings contribute to our understanding of neuroendocrine changes associated with emotionally intimate relationship experiences. We consider possible explanations for the hormone changes we observed and offer directions for future research on the neuroendocrine implications of close relationship experiences.

Better to brag: Underestimating the risks of avoiding positive self-disclosures in close relationships.

OBJECTIVE: Capitalization, or disclosing positive news in close relationships, is interpersonally and intrapersonally beneficial and expected by relational partners. Why do some individuals avoid capitalizing? How do close relational partners react when they later discover that positive news was not directly disclosed to them? METHOD: We conducted nine correlational and experimental studies using vignettes and recalled events (N = 2,177). RESULTS: We find that individuals who are concerned about being seen as braggarts tend to avoid capitalizing with their close relationships even when it is likely their partner would ultimately learn of the news. Yet this concern may be relatively unwarranted and these individuals show a forecasting error: They overestimate how negatively their partner would react to disclosure and predict that their partner would react more positively if they discovered the news through external means. However,they neglect to predict that partners who later learn of the news and realize they were not disclosed toward in fact feel devalued. We discuss how this concern with bragging is linked to decreased extraversion, perspective taking, and empathy. CONCLUSIONS: Uniquely in close relationships, being concerned about bragging may elicit negative relational outcomes, by hindering the positive self-disclosures that one's partners expect.

National trends in the use of PSA, urinalysis, and digital rectal exam for evaluation of lower urinary tract symptoms in men.

PURPOSE: The purpose of this study was to describe the practices of primary care physicians (PCPs) and urologists in their implementation of the 2010 American Urological Association (AUA) recommendations for the management of benign prostatic hyperplasia (BPH) in a nationally representative sample. METHODS: Data collected from 2008 to 2015 in the National Ambulatory Medical Care Survey (NAMCS) were used. Men aged 45 and older who presented with either a new complaint or exacerbation of lower urinary tract symptoms (LUTS) were included. Primary outcomes were the prevalence and determinants of prostate-specific antigen (PSA) testing, urinalysis (UA), and digital rectal exam (DRE), as all three were included in the AUA guidelines during the time period studied. In logistic regression analyses weighted to reflect national estimates, potential determinants of adherence for each testing modality were examined. RESULTS: Between 2008 and 2015, 878 visits met inclusion criteria, corresponding to 14,399,121 ambulatory visits for new or exacerbated LUTS. Weighted prevalence estimates were 24% for PSA testing (95% CI: 19-29%), 61% for urinalysis (95% CI: 56-66%), and 18% for DRE (95% CI: 15-23%). Age ≥ 75 years was associated with lower prevalence of testing for all three tests, and region was associated with different testing estimates for PSA and UA. Patients referred to urologists were more likely to receive a DRE, although overall rates of DRE decreased per additional year of data. CONCLUSIONS: Adherence to AUA guidelines for evaluation of LUTS in ambulatory visits was low in a nationally representative sample of Americans, particularly for PSA testing and DRE, suggesting substantial discordance between guidelines at the time and practice patterns. Practice patterns also differed by age and region. These discrepancies encourage increased education of providers in the implementation of the guidelines, particularly since they have been updated recently.

Patient and Care Delivery Characteristics Associated With Harm From Neuromuscular Blockade.

OBJECTIVES: To identify the prevalence of and evaluate factors associated with down-titration of sedation in patients receiving neuromuscular blockade. DESIGN: Retrospective cohort study. SETTING: Tertiary care teaching hospital in Boston, MA. PATIENTS: All patients over 18 years old admitted to the medical, surgical, or cardiac ICUs from 2013 to 2016, and who received cisatracurium for at least 24 hours. INTERVENTIONS: We examined patients for whom sedation was decreased despite accompanying ongoing neuromuscular blockade administration. MEASUREMENTS AND MAIN RESULTS: Of the 300 patients who met inclusion criteria (39% female, mean age of 57 yr old), 168 (56%) had sedation down-titrated while receiving neuromuscular blockade with a mean decrease in sedation dose of 18.7%. Factors associated with down-titration of sedation were bispectral index usage (90/168 [53.6%] vs 50/168 [29.8%] patients; p < 0.01; odds ratio, 1.82; 1.12-2.94), and bolus dose of neuromuscular blockade prior to continuous infusion (138/168 [82.1%] vs 79/168 [47.0%] patients; p < 0.0001). CONCLUSIONS: Down-titration of sedation among mechanically ventilated patients receiving neuromuscular blockade was common and was correlated with bispectral index monitor usage. Clinicians should be aware of the limitations of quantitative electroencephalography monitoring devices and recognize their potential to cause inappropriate down-titration of sedation. Substantial opportunity exists to improve the quality of care of patients receiving neuromuscular blockade through development of guidelines and standardized care pathways.

Five Questions for Residency Leadership in the Time of COVID-19: Reflections of Chief Medical Residents From an Internal Medicine Program.

The COVID-19 pandemic has drastically affected the traditional methods residency programs use to train their residents. Chief residents serve a unique role as part of the residency leadership to foster the education and development of the residents. Given the rapid shift in demands on physicians in the face of the pandemic, the responsibilities of the chief residents have also shifted to help prepare the residents to meet these demands as frontline providers. There is not a precedent for how residency programs respond to this crisis while maintaining their primary role to develop and train physicians. The authors have identified 5 questions chief residents can ask to guide their program's response to the demands of COVID-19 during this uncertain time in health care.

Ipilimumab in the treatment of prostate cancer.

Ipilimumab (Yervoy(®); Bristol-Myers Squibb, NY, USA) is a fully human monoclonal antibody targeting CTLA-4 and is approved for the treatment of metastatic melanoma. Preclinical and clinical studies have shown its activity in a number of different cancer types, including prostate cancer. Recently, the results from a Phase III study of ipilimumab in prostate cancer patients with prior docetaxel therapy were reported. Although the study did not meet the primary end point of improved overall survival, prespecified subset analyses suggested that ipilimumab may be more active in men with lower disease burden, which suggests that immunotherapy should be tested early in men with castration-refractory prostate cancer. Immune-related adverse events are common and most can be well managed with standard immunosuppressive algorithms.