Você está pensando, refletindo, analisando o que você vê e o que você faz o tempo todo: percepção de residentes de Medicina de Família e Comunidade sobre vídeo feedback / You are thinking, reflecting, analysing what you see and what you do all the time: perception of General Practice trainees about video feedback / Estás pensando, reflexionando, analizando lo que ves y lo que haces todo el tiempo: percepción de los residentes de Medicina Familiar y Comunitaria sobre vídeo feedback

Introdução: A comunicação é reconhecida como uma habilidade central por vários órgãos reguladores internacionais da educação médica. O ensino específico de habilidades de comunicação é fundamental para melhorar a comunicação dos médicos. As técnicas experienciais mostraram superioridade em comparação com os modelos tradicionais. A utilização de consultas reais ajuda os estudantes a visualizar melhor as suas competências de entrevista e a refletir sobre elas. Com os avanços da tecnologia, o uso de consultas médicas gravadas em vídeo tornou-se a abordagem padrão para o ensino da comunicação. No entanto, a eficácia dessa técnica depende do envolvimento ativo dos estudantes. As suas contribuições e comentários dos pares sobre a consulta gravada são essenciais para a aprendizagem. Contudo, a perspectiva do estudante sobre a utilidade dessa abordagem educativa recebeu pouca atenção. Objetivos: Compreender a percepção da aprendizagem dos residentes de medicina de família e comunidade resultante da atividade de vídeo feedback na sua formação profissional. Métodos: Estudo exploratório, qualitativo, realizado com residentes do primeiro ano de medicina de família e comunidade de um programa de residência estabelecido em São Paulo, Brasil. Os participantes foram entrevistados após as sessões educativas, que foram analisadas por meio de análise temática reflexiva. Resultados: A autopercepção de sua prática, o aprendizado de habilidades de comunicação e os ganhos afetivos foram identificados pelos participantes como pontos de aprendizado derivados da atividade de vídeo feedback. Além disso, sobre o aprendizado de habilidades específicas de comunicação, eles mencionaram comunicação não-verbal e verbal, conexões entre teoria e prática, estrutura de consulta e oportunidades para cristalizar conhecimentos. Os ganhos afetivos incluíram sentir-se parte de um grupo, melhora da autoestima, superação de inseguranças, percepção de consultas mais efetivas, reforço do gosto pelo trabalho e reconhecer a necessidade de mais aprendizado. Conclusões: Os ganhos de aprendizagem identificados em nosso estudo levaram a uma experiência de humanidade compartilhada, que permite aos participantes serem mais efetivos técnica e afetivamente com seus pacientes. Além disso, identificamos que a atividade educativa de vídeo feedback pode ser utilizada para outros possíveis fins educacionais além do ensino da comunicação.

Introduction: Communication is recognized as a central skill by various international medical education regulatory bodies. Specific teaching on communication skills is important to enhance doctors' communication. Experiential techniques appear to be superior compared to traditional models. Real-life consultation helps trainees visualize their interview skills and reflect on them. Upgraded by technology, the use of video-recorded medical visits became the standard approach for communication teaching. However, the effectiveness pf this technique relies on trainees' active involvement. Their inputs and peer feedback on the recorded consultation are essential to learning. Despite its importance, their perspective on the usefulness of video feedback in medical education has received limited attention. Objective: To understand the perception of learning among general practice trainees as a result of the video feedback activity in their vocational training. Methods: An exploratory, qualitative study, conducted with first-year general practice trainees from an established training program in São Paulo, Brazil. Participants were interviewed after educational session, which were analyzed using reflexive thematic analysis. Results: Self-perception of their practice, communication skills learning, and affective gains were identified by participants as learning points derived from the video feedback activity. Furthermore, for specific communication skills learning, they mentioned nonverbal and verbal communication, theory and practice connections, consultation structure and opportunities for crystallizing knowledge. Affective gains included feeling part of a group, improving self-esteem, overcoming insecurities, perception of more effective consultations, reinforcing fondness for their work, and need for more learning. Conclusions: The learning gains identified in our study led to an experience of common humanity, which allowed participants to be more technically and affectively effective with their patients. Also, we identified that the video feedback educational activity can be used for other possible educational purposes, beyond the teaching of communication.

Introducción: La comunicación es reconocida como una habilidad fundamental por varios organismos reguladores internacionales de educación médica. La enseñanza específica de habilidades de comunicación es importante para mejorar la comunicación de los médicos. Las técnicas experienciales parecen ser superiores a los modelos tradicionales. El uso de consultas reales ayuda a los estudiantes a visualizar y reflexionar mejor sobre sus habilidades de entrevista. Actualizado por la tecnología, el uso de consultas médicas grabadas en video se ha convertido en el enfoque estándar para la enseñanza de la comunicación. Sin embargo, para que la técnica funcione, la participación de los estudiantes es crucial. Sus contribuciones y comentarios de los compañeros sobre la consulta grabada son esenciales para el aprendizaje. Sin embargo, la perspectiva de los estudiantes sobre la utilidad de este enfoque educativo ha recibido poca atención. Objetivos: Comprender la percepción del aprendizaje por parte de los residentes de medicina de familia y comunitaria como resultado de la actividad de vídeo feedback en su formación profesional. Métodos: Estudio cualitativo exploratorio realizado con residentes de primer año de medicina familiar y comunitaria de un programa de residencia establecido en São Paulo, Brasil. Los participantes fueron entrevistados después de una sesión educativa, que fueron analizados mediante análisis temático reflexivo. Resultados: La autopercepción de su práctica, el aprendizaje de habilidades comunicativas y las ganancias afectivas fueron identificadas por los participantes como puntos de aprendizaje derivados de la actividad de vídeo feedback. Además, sobre el aprendizaje de habilidades comunicativas específicas, mencionaron la comunicación verbal y no verbal, las conexiones entre la teoría y la práctica, la estructura de consulta y las oportunidades para cristalizar conocimientos. En cuanto a las ganancias afectivas, relataron sentirse parte de un grupo, mejora de la autoestima, superación de las inseguridades, percepción de consultas más efectivas, refuerzo del gusto por el trabajo y necesidad de más aprendizaje. Conclusión: Los logros de aprendizaje identificados en nuestro estudio llevaron a una experiencia de humanidad compartida, que permite a los participantes ser técnica y afectivamente más efectivos con sus pacientes. Además, identificamos que la actividad educativa de vídeo feedback puede ser utilizada para otros posibles fines educativos, además de la enseñanza de la comunicación.

Japanese General Clinical Oncologists' Knowledge and Real-world Experiences of Cancer Genomic Medicine: A Nationwide Web-based Survey Study.

Introduction: In Japan, insurance began covering two cancer gene panel tests in 2019. However, the availability of these tests remains limited to 247 facilities (as of October 2023). This survey-based study assessed the knowledge and recognition of cancer genomic medicine by physicians involved in cancer treatment. Methods: Written requests for participation in a web-based questionnaire survey were sent to 14,579 affiliated general clinical oncologists certified by the Japanese Board of Cancer Therapy. The survey was conducted from July 1 to 31st, 2021. Data between physicians affiliated with cancer genome hospitals and noncancer genome hospitals and between regions of Japan were compared. Results: In total, 2,402 valid responses were analyzed. Of the respondents, 1,296 and 1,106 were physicians working at cancer and noncancer genome hospitals, respectively. Physicians working at cancer genome hospitals showed significantly higher results for both knowledge of cancer genomic medicine and experience in cancer gene panel test performance compared with those working at noncancer genome hospitals. There were no significant regional differences in the percentage of physicians who reported having performed cancer gene panel tests. Conclusions: The survey results suggest a disparity in the knowledge of cancer genomic medicine between physicians working at cancer genome hospitals and those working at noncancer genome hospitals; this disparity should be addressed by stakeholders. Closer collaboration between these facilities may be necessary to achieve national dissemination of cancer genomic medicine.

Endovascular Salvage of Type Ia and Ib Endoleaks Using a Physician-Modified Fenestrated/Branched Endograft and an Iliac Branch Device Via Unilateral Transfemoral Arterial Access.

PURPOSE: This study aims to explore the feasibility and effectiveness of a unilateral transfemoral access endovascular salvage technique for complex abdominal aortic aneurysms with concurrent type Ia and Ib endoleaks following previous endovascular repair. CASE REPORT: A 69-year-old female with multiple comorbidities presented with an extent IV thoracoabdominal aortic aneurysm complicated by type Ia and Ib endoleaks and chronically occluded left iliac endoprosthesis after prior endovascular repair. Given the patient's medical complexities, open explant repair was deemed high risk. The case was successfully managed using a physician-modified fenestrated/branched endograft (PM-F/BEVAR) and an iliac branch device (IBD) deployed through a single percutaneous transfemoral access. CONCLUSION: The presented case demonstrates the safety and efficacy of PM-F/BEVAR with concomitant IBD deployment via unilateral transfemoral access. This innovative approach allows endovascular salvage in cases with restricted iliofemoral access and avoids the complexities associated with upper extremity or aortic arch manipulation. While acknowledging the technical challenges, this technique offers a viable alternative for salvaging failed endovascular repairs, emphasizing the importance of real-time modifications in achieving successful outcomes. Further studies and long-term follow-up are warranted to validate the broader applicability and durability of this approach in the management of complex abdominal aortic aneurysms with multiple endoleaks. CLINICAL IMPACT: Although not the conventional approach, unilateral transfemoral access can be utilized to implant either a physician-modified fenestrated aortic endograft or an iliac branch device. Such an approach avoids complicating issues related to upper extremity access. This innovative technique may be necessary when there is a failed prior EVAR in the setting of significant contralateral iliofemoral occlusive disease. Doing both procedures in the same setting to resolve a type Ia and Ib endoleak is feasible as demonstrated in this case report. Expanding the endovascular armamentarium to address EVAR failure will be increasingly useful in the future, especially given the morbidity profile of EVAR explantation.

Association between physician age and patterns of end-of-life care among older Americans.

BACKGROUND: End-of-life (EOL) care patterns may differ by physician age given differences in how physicians are trained or changes associated with aging. We sought to compare patterns of EOL care delivered to older Americans according to physician age. METHODS: We conducted a cross-sectional study of a 20% sample of Medicare fee-for-service beneficiaries aged ≥66 years who died in 2016-2019 (n = 487,293). We attributed beneficiaries to the physician who had >50% of primary care visits during the last 6 months of life. We compared beneficiary-level outcomes by physician age (<40, 40-49, 50-59, or ≥60) in two areas: (1) advance care planning (ACP) and palliative care; and (2) high-intensity care at the EOL. RESULTS: Beneficiaries attributed to younger physicians had slightly higher proportions of billed ACP (adjusted proportions, 17.1%, 16.1%, 15.5%, and 14.0% for physicians aged <40, 40-49, 50-59, and ≥60, respectively; p-for-trend adjusted for multiple comparisons <0.001) and palliative care counseling or hospice use in the last 180 days of life (64.5%, 63.6%, 61.9%, and 60.8%; p-for-trend <0.001). Similarly, physicians' younger age was associated with slightly lower proportions of emergency department visits (57.4%, 57.0%, 57.4%, and 58.1%; p-for-trend <0.001), hospital admissions (51.2%, 51.1%, 51.4%, and 52.1%; p-for-trend <0.001), intensive care unit admissions (27.8%, 27.9%, 28.2%, and 28.3%; p-for-trend = 0.03), or mechanical ventilation or cardiopulmonary resuscitation (14.2, 14.9%, 15.2%, and 15.3%; p-for-trend <0.001) in the last 30 days of life, and in-hospital death (20.2%, 20.6%, 21.3%, and 21.5%; p-for-trend <0.001). CONCLUSIONS: We found that differences in patterns of EOL care between beneficiaries cared for by younger and older physicians were small, and thus, not clinically meaningful. Future research is warranted to understand the factors that can influence patterns of EOL care provided by physicians, including initial and continuing medical education.

Factors Influencing Referral for Bariatric Surgery by Primary Care Physicians in Northern Israel.

PURPOSE: Obesity is a chronic metabolic disease with global distribution among adults and children which affects daily functioning and ultimately quality of life. Primary care physicians (PCPs) provide an important role for the treatment of severe obesity. Better understanding of obesity and its treatment options may increase patients' referral rates to the various treatment modalities, including metabolic/bariatric surgery (MBS). MATERIALS AND METHODS: A quantitative cross-sectional study used a self-reported questionnaire among PCPs of Clalit Health Services (CHS) in Northern Israel. The quantitative questionnaire examined the PCP's knowledge, opinions, attitude, and approaches to managing severe obesity. RESULTS: A total of 246 PCPs from Northern Israel filled the questionnaire (42.9%), the majority were Muslim Arabs (54.5%), who gained their medical degree outside of Israel (73.8%) and practicing for over 10 years (58.8%). 64.3% of PCPs had a high workload (over 100 appointments per week), 77.1% did not know the definition of severe obesity, and 69.17% did not attend educational meetings regarding obesity during the previous year. The referral rate for MBS was 50.4% ± 23.3. Two prognostic factors that had a statistically significant effect on the referral rate for bariatric surgery were the total appointments per week, and the number of practice years. Both had a negative association. CONCLUSION: The knowledge and referral rates for bariatric surgery are higher among PCPs with lower workload and relatively fewer practice years. Workshops and annual training courses may fortify knowledge and awareness for the treatment of obesity, which in turn could increase the referral rate for MBS.

Clinical Physician Assistant Students' Perceptions of Evidence-Based Medicine Resources: A Cross-Sectional Examination.

Evidence-based medicine (EBM) instruction is required for physician assistant (PA) students. As a follow-up to an initial didactic year survey, this study seeks to understand which attributes of EBM resources clinical PA students find most and least useful, their self-efficacy utilizing medical literature, and their usage of EBM tools in the clinic. Results indicate that students preferred UpToDate and PubMed. PA students valued ease of use, which can inform instructors and librarians. Respondents utilized EBM tools daily or a few days a week, underscoring the importance of EBM tools in real-world scenarios. After their clinical year, students felt moderately confident utilizing the medical literature, emphasizing EBM training.

Impact of Incentives on Physician Participation in Research Surveys: Randomized Experiment.

BACKGROUND: Web-based surveys can be effective data collection instruments; however, participation is notoriously low, particularly among professionals such as physicians. Few studies have explored the impact of varying amounts of monetary incentives on survey completion. OBJECTIVE: This study aims to conduct a randomized study to assess how different incentive amounts influenced survey participation among neurologists in the United States. METHODS: We distributed a web-based survey using standardized email text to 21,753 individuals randomly divided into 5 equal groups (≈4351 per group). In phase 1, each group was assigned to receive either nothing or a gift card for US $10, $20, $50, or $75, which was noted in the email subject and text. After 4 reminders, phase 2 began and each remaining individual was offered a US $75 gift card to complete the survey. We calculated and compared the proportions who completed the survey by phase 1 arm, both before and after the incentive change, using a chi-square test. As a secondary outcome, we also looked at survey participation as opposed to completion. RESULTS: For the 20,820 emails delivered, 879 (4.2%) recipients completed the survey; of the 879 recipients, 622 (70.8%) were neurologists. Among the neurologists, most were male (412/622, 66.2%), White (430/622, 69.1%), non-Hispanic (592/622, 95.2%), graduates of American medical schools (465/622, 74.8%), and board certified (598/622, 96.1%). A total of 39.7% (247/622) completed their neurology residency more than 20 years ago, and 62.4% (388/622) practiced in an urban setting. For phase 1, the proportions of respondents completing the survey increased as the incentive amount increased (46/4185, 1.1%; 76/4165, 1.8%; 86/4160, 2.1%; 104/4162, 2.5%; and 119/4148, 2.9%, for US $0, $10, $20, $50, and $75, respectively; P<.001). In phase 2, the survey completion rate for the former US $0 arm increased to 3% (116/3928). Those originally offered US $10, $20, $50, and $75 who had not yet participated were less likely to participate compared with the former US $0 arm (116/3928, 3%; 90/3936, 2.3%; 80/3902, 2.1%; 88/3845, 2.3%; and 74/3878, 1.9%, for US $0, $10, $20, $50, and $75, respectively; P=.03). For our secondary outcome of survey participation, a trend similar to that of survey completion was observed in phase 1 (55/4185, 1.3%; 85/4165, 2%; 96/4160, 2.3%; 118/4162, 2.8%; and 135/4148, 3.3%, for US $0, $10, $20, $50, and $75, respectively; P<.001) and phase 2 (116/3928, 3%; 90/3936, 2.3%; 80/3902, 2.1%; 88/3845, 2.3%; and 86/3845, 2.2%, for US $0, $10, $20, $50, and $75, respectively; P=.10). CONCLUSIONS: As expected, monetary incentives can boost physician survey participation and completion, with a positive correlation between the amount offered and participation.

Patient-Physician Sex Discordance and "Before Medically Advised" Discharge from Hospital: A Population-Based Retrospective Cohort Study.

BACKGROUND: Patient-physician sex discordance (when patient sex does not match physician sex) has been associated with reduced clinical rapport and adverse outcomes including post-operative mortality and unplanned hospital readmission. It remains unknown whether patient-physician sex discordance is associated with "before medically advised" hospital discharge (BMA discharge; commonly known as discharge "against medical advice"). OBJECTIVE: To evaluate whether patient-physician sex discordance is associated with BMA discharge. DESIGN: Retrospective cohort study using 15 years (2002-2017) of linked population-based administrative health data for all non-elective, non-obstetrical acute care hospitalizations from British Columbia, Canada. PARTICIPANTS: All individuals with eligible hospitalizations during study interval. MAIN MEASURES: Exposure: patient-physician sex discordance. OUTCOMES: BMA discharge (primary), 30-day hospital readmission or death (secondary). RESULTS: We identified 1,926,118 eligible index hospitalizations, 2.6% of which ended in BMA discharge. Among male patients, sex discordance was associated with BMA discharge (crude rate, 4.0% vs 2.9%; adjusted odds ratio [aOR] 1.08; 95%CI 1.03-1.14; p = 0.003). Among female patients, sex discordance was not associated with BMA discharge (crude rate, 2.0% vs 2.3%; aOR 1.02; 95%CI 0.96-1.08; p = 0.557). Compared to patient-physician sex discordance, younger patient age, prior substance use, and prior BMA discharge all had stronger associations with BMA discharge. CONCLUSIONS: Patient-physician sex discordance was associated with a small increase in BMA discharge among male patients. This finding may reflect communication gaps, differences in the care provided by male and female physicians, discriminatory attitudes among male patients, or residual confounding. Improved communication and better treatment of pain and opioid withdrawal may reduce BMA discharge.

Using Reflective Practice to Enhance Student Professionalism.

Reflective practice, critically reflecting on one's actions or attitudes to engage in the process of continuous adaptation and learning, has proven to be an effective strategy for improved patient care. Additionally, literature supports applying reflective practice for professional growth in medical providers. When contemplating professionalism training in physician assistant (PA) education, it is important to consider how to obtain buy-in from students. One way to do this is to link professionalism to the students' future career as a PA. The School of Physician Assistant Studies at Pacific University (the Program) created an Online Orientation Reflective Practice Assignment that was implemented during online orientation. Students were prompted to use reflective practice to create detailed "plans for success." The goal of this assignment was to reduce common professionalism missteps students often experienced. Data regarding the number of professionalism encounters per cohort, broken down into occurrences by curricular phase (didactic vs clinical), was tracked and collated using Microsoft® Excel®. The data was analyzed to determine trends. Implementation of the Online Reflective Practice Assignment for all PA students at the beginning of their education has increased student awareness of the Program's, and the profession's, expectations regarding professionalism and accountability. Thus far, the resulting number of professionalism missteps have not decreased year-over-year. We hypothesize that this is due to the difficulty meeting increased administrative expectations and burdens put on students during the pandemic. Students' use of reflective practice to review what went wrong and to create plans to avoid missteps in the future allows them to focus on productive next steps in building their professional identity. Implementation of the Online Orientation Reflective Practice Assignment has better prepared students for the expectations of the PA profession and provided them with a solid foundation to build their professional identity throughout their education and into their careers.

Mapping Proximity to Infectious Disease Physicians Across the United States.

Enduring shortages of infectious disease physicians across the United States continue despite efforts to mitigate the problem. The recent fellowship match results underscore the difficulty in rectifying that shortage. Our report sheds light on the current geographic distribution of US infectious disease physicians and highlights the challenges faced by rural communities.

Report of similar placebo response in one internet versus onsite randomised controlled trials from the literature.

Objective: The aim of this study was to compare the magnitude and the predictors of the placebo response in an internet versus onsite randomised controlled trials (RCTs) in people with hand osteoarthritis (HOA). Method: This study is a post-hoc analysis based on one internet RCT (RADIANT) and previously published onsite RCTs for HOA identified through a rigorous searching and selection strategy. The magnitude of the placebo response in the two different types of RCTs were compared using heterogeneity statistics and forest plots visualisation. Classic placebo predictors as well as a combined model, defined with data from onsite RCTs, were tested to predict the placebo response. Results: We analysed the dataset from RADIANT and fourteen previously published onsite RCTs. None of the analyses showed a significant difference between the placebo response for the internet versus onsite RCTs. The "classic" placebo predictors combined in a multivariate predictive model correlated significantly with the placebo response measured in RADIANT study. Conclusion: Despite the absence of face-to-face interactions with the study personnel, there is no evidence that either the magnitude or the predictors of the placebo response of this internet RCT differ from those of onsite RCTs. This analysis is considered as a first step towards evaluating the difference between these designs and strengthens the argument that internet RCTs remain an acceptable alternative way to assess the efficacy of an active treatment in comparison to a placebo.

Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study.

Background and aim: While intensive care unit (ICU) mortality rates in India are higher when compared to countries with more resources, fewer patients with clinically futile conditions are subjected to limitation of life-sustaining treatments or given access to palliative care. Although a few surveys and audits have been conducted exploring this phenomenon, the qualitative perspectives of ICU physicians regarding end-of-life care (EOLC) and the quality of dying are yet to be explored. Methods: There are 22 eligible consultant-level ICU physicians working in multidisciplinary ICUs were purposively recruited and interviewed. The study data was analyzed using reflexive thematic analysis (RTA) with a critical realist perspective, and the study findings were interpreted using the lens of the semiotic theory that facilitated the development of themes. Results: About four themes were generated. Intensive care unit physicians perceived the quality of dying as respecting patients' and families' choices, fulfilling their needs, providing continued care beyond death, and ensuring family satisfaction. To achieve this, the EOLC process must encompass timely decision-making, communication, treatment guidelines, visitation rights, and trust-building. The contextual challenges were legal concerns, decision-making complexities, cost-related issues, and managing expectations. To improve care, ICU physicians suggested amplifying patient and family voices, building therapeutic relationships, mitigating conflicts, enhancing palliative care services, and training ICU providers in EOLC. Conclusion: Effective management of critically ill patients with life-limiting illnesses in ICUs requires a holistic approach that considers the complex interplay between the EOLC process, its desired outcome, the quality of dying, care context, and the process of meaning-making by ICU physicians. How to cite this article: Iyer S, Sonawane RN, Shah J, Salins N. Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study. Indian J Crit Care Med 2024;28(5):424-435.

Evaluating the Diagnostic Performance of Large Language Models on Complex Multimodal Medical Cases.

Large language models showed interpretative reasoning in solving diagnostically challenging medical cases.

Trends in Medicare utilization and reimbursement for hematology/oncology procedures from 2012 to 2023: A geriatric oncology perspective.

Objectives: Given the scarcity of data exploring reimbursement trends in the field of hematology/oncology, we sought to characterize these trends for common procedures in this field from 2012 to 2023. Methods: Using the Centers for Medicare and Medicaid Services' Physician Fee Schedule Look-Up Tool we collected reimbursement data for 40 hematology/oncology procedure codes from 2012 to 2023. Data was adjusted to 2023 United States (US) dollars using the Consumer Price Index (CPI). Results: From 2012 to 2023 gross reimbursement for the facility price decreased 4.4% and increased 9.2% for the non-facility price. When adjusted for inflation, compensation decreased 96.1% and 96.6%, respectively. None of the 40 examined Current Procedural Terminology (CPT) codes increased in net reimbursement over the study period. Conclusions: Medicare reimbursement for common hematology/oncology procedures decreased from 2012 to 2023. Further research is necessary to explore the implications of these trends on the delivery of patient care.

The Role of Large Language Models in Transforming Emergency Medicine: Scoping Review.

BACKGROUND: Artificial intelligence (AI), more specifically large language models (LLMs), holds significant potential in revolutionizing emergency care delivery by optimizing clinical workflows and enhancing the quality of decision-making. Although enthusiasm for integrating LLMs into emergency medicine (EM) is growing, the existing literature is characterized by a disparate collection of individual studies, conceptual analyses, and preliminary implementations. Given these complexities and gaps in understanding, a cohesive framework is needed to comprehend the existing body of knowledge on the application of LLMs in EM. OBJECTIVE: Given the absence of a comprehensive framework for exploring the roles of LLMs in EM, this scoping review aims to systematically map the existing literature on LLMs' potential applications within EM and identify directions for future research. Addressing this gap will allow for informed advancements in the field. METHODS: Using PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) criteria, we searched Ovid MEDLINE, Embase, Web of Science, and Google Scholar for papers published between January 2018 and August 2023 that discussed LLMs' use in EM. We excluded other forms of AI. A total of 1994 unique titles and abstracts were screened, and each full-text paper was independently reviewed by 2 authors. Data were abstracted independently, and 5 authors performed a collaborative quantitative and qualitative synthesis of the data. RESULTS: A total of 43 papers were included. Studies were predominantly from 2022 to 2023 and conducted in the United States and China. We uncovered four major themes: (1) clinical decision-making and support was highlighted as a pivotal area, with LLMs playing a substantial role in enhancing patient care, notably through their application in real-time triage, allowing early recognition of patient urgency; (2) efficiency, workflow, and information management demonstrated the capacity of LLMs to significantly boost operational efficiency, particularly through the automation of patient record synthesis, which could reduce administrative burden and enhance patient-centric care; (3) risks, ethics, and transparency were identified as areas of concern, especially regarding the reliability of LLMs' outputs, and specific studies highlighted the challenges of ensuring unbiased decision-making amidst potentially flawed training data sets, stressing the importance of thorough validation and ethical oversight; and (4) education and communication possibilities included LLMs' capacity to enrich medical training, such as through using simulated patient interactions that enhance communication skills. CONCLUSIONS: LLMs have the potential to fundamentally transform EM, enhancing clinical decision-making, optimizing workflows, and improving patient outcomes. This review sets the stage for future advancements by identifying key research areas: prospective validation of LLM applications, establishing standards for responsible use, understanding provider and patient perceptions, and improving physicians' AI literacy. Effective integration of LLMs into EM will require collaborative efforts and thorough evaluation to ensure these technologies can be safely and effectively applied.

Exploring the Severity Strata of Disease Activity and Repigmentation in Vitiligo Based on Validated Physician Global Assessment (PGA) Scores.

Background/Objectives: There is currently no guidance on how to interpret the global degrees of activity (worsening) and repigmentation (improvement) in vitiligo. Stratification into global degrees can be completed for static evaluations (e.g., visible disease activity signs) and dynamic assessments (e.g., evolution over time). For the latter, the Vitiligo Disease Activity Score (VDAS15&60) and Vitiligo Disease Improvement Score (VDIS15&60) were recently validated. Methods: In the current study, a Physician Global Assessment (PGA) for disease activity (worsening) and repigmentation (improvement) was evaluated for validity (construct) and reliability (inter- and intrarater) based on a photo set of 66 patients. Subsequently, the PGA activity (worsening) and repigmentation (improvement) were used to stratify the Vitiligo Extent Score plus (VESplus), VDAS15&60 or VDIS15&60 into three global categories (slightly, moderately and much worse/improved), based on ROC analysis. Results: For the VESplus, cut-off values for the categories 'slightly, moderately and much worse' were >0.3%, >27.71% and >128.75% BSA (relative changes in the affected total BSA), respectively. For the categories 'slightly, moderately and much improved', they were >0%, >4.87% and >36.88% BSA (relative changes in the affected total BSA), respectively. The optimal cut-off values of the number of active (VDAS15) body areas were >0 areas for slightly worse, >2 areas for moderately worse and >7 for much worse. For VDIS15, the cut-off values for slightly improved and moderately improved were >0 and >1. For VDAS60 and VDIS60, the cut-off points were >0.5, >3, >9.5 and >0.5 and >1.5, respectively. The results should be interpreted with caution in patients with extensive vitiligo due to the rather limited disease extent of the included patient population (VESplus (median: 3.2%)). Conclusions: This research will aid in the development of more detailed international definitions.

Clinician Barriers to Ordering Pulmonary Function Tests for Adults with Suspected Asthma.

BACKGROUND: Primary care clinicians do not adhere to national and international guidelines recommending pulmonary function testing (PFTs) in patients with suspected asthma. Little is known about why that occurs. Our objective was to assess clinician focused barriers to ordering PFTs. METHODS: An internet-based 11-item survey of primary care clinicians at a large safety-net institution was conducted between August 2021 and November 2021. This survey assessed barriers and possible electronic health record (EHR) solutions to ordering PFTs. One of the survey questions contained an open-ended question about barriers which was analyzed qualitatively. RESULTS: The survey response rate was 59% (117/200). The top 3 reported barriers included beliefs that testing will not change management, distance to testing site, and the physical effort it takes to complete testing. Clinicians were in favor of an EHR intervention to prompt them to order PFTs. Responses to the open-ended question also conveyed that objective testing does not change management. DISCUSSION: PFTs improve diagnostic accuracy and reduce inappropriate therapies. Of the barriers we identified, the most modifiable is to educate clinicians about how PFTs can change management. That in conjunction with an EHR prompt, which clinicians approved of, may lead to guideline congruent and improved quality in asthma care.

ACTION Teens Saudi Arabia: Perceptions, attitudes, motivators, and barriers among adolescents living with obesity, caregivers, and healthcare professionals in Saudi Arabia.

Obesity is predicted to affect approximately one-quarter of children/adolescents in Saudi Arabia by 2030, but there is limited evidence regarding the perceptions, attitudes, behaviours, and barriers to effective obesity care for adolescents living with obesity (ALwO), caregivers of ALwO, and healthcare professionals (HCPs). We report data from 500 ALwO (aged 12-<18 years), 500 caregivers, and 200 HCPs surveyed in Saudi Arabia as part of the global, cross-sectional ACTION Teens study (NCT05013359). Nearly all respondents recognized that obesity has a strong impact on overall health (ALwO 88%; caregivers 85%; HCPs 90%). Most ALwO and caregivers were aware of the ALwO's obesity status (95% and 99%, respectively) and worried about weight impacting the ALwO's future health (both ≥99%), and social media was their most commonly used source of weight-management information (60% and 53%, respectively). Among ALwO and caregivers who had discussed weight with an HCP in the past year, most experienced ≥1 negative feeling following their most recent discussion (61% and 59%, respectively). Although 81% of HCPs felt motivated to help their ALwO patients lose weight, 57% believed weight loss was completely the ALwO's responsibility (compared with only 37% of ALwO and 35% of caregivers). This may reflect the finding that only 24% of HCPs had received advanced training in obesity/weight management after medical school. Overall, while respondents had similar perceptions of the impact of obesity, we found HCPs' attitudes towards weight loss were not aligned with those of ALwO and caregivers, suggesting a need for improved communication and obesity education.

Effect of patient death on referrals to cardiac specialists.

In this paper, I examine how patient death affects referrals from referring physicians to cardiac surgeons. I use Medicare data to identify pairs of referring physicians and cardiac surgeons who experience a patient death after a major surgical procedure to examine how these events affect referrals. I construct counterfactuals for affected pairs using pairs that experience a patient death but five quarters in the future. I find that there is a significant decline in the number of referrals and probability of a referral from the referring physician to the cardiac surgeon after the patient's death.