Through the Looking Glass: Comparing Hospitalists' and Internal Medicine Residents' Perceptions of Feedback.

INTRODUCTION: Feedback is critical for resident growth and is most effective when the relationship between residents and attendings is collaborative, with shared expectations for the purpose, timing, and manner of communication for feedback. Within internal medicine, there is limited work exploring the resident and hospitalist perspectives on whether key elements are included in feedback sessions. METHODS: We surveyed internal medicine residents and supervising hospitalists at a large urban training program about their perspectives on four components of effective feedback: specificity,timeliness, respectful communication, and actionability. RESULTS: We received surveys from 130/184 internal medicine residents and 74/129 hospitalists (71% and 57% response rate, respectively). Residents and hospitalists differed in their perspectives about specificity and timeliness: 54% (70/129) of residents reported they did not receive specific feedback while 90% (65/72) of hospitalists reported they delivered specific feedback (p<0.01), and 33% (43/129) of residents compared with 82% (59/72) of hospitalists perceived feedback as timely (p<0.01). Internal medicine residents and hospitalists reported concordant rates of feedback sessions consisting of a two-way conversation (84%, 109/129; 89%, 64/72, respectively, p=0.82) and that communication was delivered in a respectful manner (95%, 122/129; 97%, 70/72, respectively, p=0.57). CONCLUSIONS: We observed discordance between internal medicine residents and supervising hospitalist perspectives on the inclusion of two critical components of feedback: specificity and timing. The hospitalist cohort reported delivering more components of effective feedback than the resident cohort reported receiving. The etiology of this discordance is likely multifactorial and requires further investigation.

Checklists and consistency of care after resuscitation from in-hospital cardiac arrest: A pilot study.

BACKGROUND: In-hospital cardiac arrest (IHCA) with the return of spontaneous circulation (ROSC) is a clinical scenario associated with potentially devastating outcomes. OBJECTIVE: Inconsistencies in post-ROSC care exist and we sought to find a low cost way to decrease this variability. DESIGNS, SETTINGS, AND PARTICIPANTS: We obtained pre and post intervention metrics including percentage of IHCA with a timely electrocardiogram (ECG), arterial blood gas (ABG), physician documentation, and documentation of patient surrogate communication after ROSC. INTERVENTION: We developed and implemented a post-ROSC checklist for IHCA and measured post-ROSC clinical care delivery metrics at our hospital during a 1-year pilot period. MAIN OUTCOME AND RESULTS: After the introduction of the checklist, 83.7% of IHCA had an ECG within 1 h of ROSC, compared to a baseline of 62.8% (p = 0.01). The rate of physician documentation within 6 h of ROSC was 74.4% after introduction of the checklist, compared to a baseline of 49.5% (p < 0.01). The percentage of IHCA with ROSC that completed all four of the critical post-ROSC tasks after the introduction of the post-ROSC checklist was 51.1% as compared to 19.4% before implementation (p < 0.01). CONCLUSIONS: Our study demonstrated improved consistency in completing post-ROSC clinical tasks after the introduction of a post-ROSC checklist to our hospital. This work suggests that the implementation of a checklist can have meaningful impacts on task completion in the post-ROSC setting. Despite this, considerable inconsistencies in post-ROSC care persisted after the intervention indicating the limits of checklists in this setting. Future work is needed to identify interventions that can further improve post-ROSC processes of care.

An Interactive COVID-19 Vaccine Hesitancy Workshop for Internal Medicine Residents and Medical Students.

Introduction Since being first identified in December 2019, SARS-CoV-2 has resulted in millions of illnesses and deaths worldwide. Despite the safety and availability of effective vaccines that offer protection from severe COVID-19 disease, a sizable minority of the United States population has reported COVID-19 vaccine hesitancy and remains unvaccinated. Methods We developed an interactive workshop for internal medicine residents and medical students in which a framework is utilized to aid the subtyping of COVID-19 vaccine hesitancy. Learners then interactively apply this framework through vaccine counseling in a role-playing exercise. Results The workshop increased confidence in the learner's ability to determine the COVID-19 vaccine hesitancy subtype after participation in the workshop (53% preworkshop, 81% postworkshop, p=0.01). The workshop also increased reported confidence in tailoring COVID-19 vaccine counseling after participation in the workshop (60% preworkshop, 90% postworkshop, p=0.005). These gains were also seen when participant learners were compared with nonparticipant learners for both subtyping confidence (81% postworkshop, 26% nonparticipant, p<0.0001) and confidence in providing tailored counseling (90% postworkshop, 60% nonparticipant, p=0.004). Conclusion The implementation of our workshop correlated with an increase in the reported trainee confidence related to COVID-19 vaccine counseling. This offers a promising early step in developing educational programs that build trainee skills in this domain. More work is needed to establish robust curricula to support learners in reaching patients who express COVID-19 vaccine hesitancy.

Thinking Critically About Classifying Adverse Events: Incidence of Pancreatitis in Patients Treated With Nivolumab + Ipilimumab.

The Common Terminology Criteria for Adverse Events (CTCAE) were developed to document the adverse effects of chemotherapy but are now also used to document immune-related adverse events (irAE). Characterization of irAE by the CTCAE has implications for determining dose-limiting toxicity (DLT) and, consequently, the recommended phase II dose (RP2D) of investigational agents. In the phase I trial of nivolumab + ipilimumab, an asymptomatic increase in lipase was the primary DLT that informed the RP2D. We performed a retrospective study of 119 patients with melanoma who were treated at Memorial Sloan Kettering Cancer Center with the combination of nivolumab + ipilimumab to investigate the relationship between asymptomatic grade 3 or higher increases in amylase and/or lipase and pancreatitis, a known irAE. Of the 119 patients, there were only two cases of pancreatitis, representing 20% of patients with grade 3 or higher amylase, 6.3% of patients with grade 3 or higher lipase, and 20% of patients with grade 3 or higher elevations of both enzymes. The application of the CTCAE, especially in grading independent lab values, should be considered carefully in clinical trials of novel immunotherapeutic agents.