Recent Publications by CFE Educators

OBJECTIVES

Cognitive load theory (CLT) focuses on the limited bandwidth of working memory. Core to CLT is the concept of cognitive overload, which occurs when working memory demands exceed working memory capacity, and learning and performance suffer. Within health professions education (HPE), workplace learning settings are very complex, placing learners at high risk of cognitive overload. Although continuous monitoring of physiologic parameters can indicate states of high cognitive load, how to practically identify cognitively overloaded learners within everyday workplace settings is not well understood. We sought to characterise how attending physicians described their perceiving of cognitive overload among learners in two different workplace settings: the gastrointestinal endoscopy suite and the intensive care unit.

METHODS

We performed a secondary qualitative analysis of transcripts of interviews with workplace teachers that had been carried out during two previous studies. These studies had addressed different objectives but both were informed by CLT. Each included questions that prompted participants to reflect on how they perceived cognitive overload to manifest among learners in the workplace. To investigate the phenomenon of cognitive overload, we developed a new codebook and performed content analysis.

RESULTS

We analysed 42 interview transcripts (22 endoscopists, 12 hospitalists, eight intensivists). Participants described four behaviours they had witnessed among learners they thought were cognitively overloaded: poor performance on workplace tasks; non-verbal physical manifestations (including posture, eye and body movements and autonomic functions); verbal utterances (words and sounds), and interpersonal interactions with team members. Endoscopists often described individually oriented examples, whereas intensivists and hospitalists tended to frame examples within an interpersonal context.

CONCLUSIONS

We identified four overarching ways in which HPE workplace teachers perceived learners as appearing to be cognitively overloaded. Workplace teachers and learners should be mindful of and watch for these signs, which may signal states of cognitive overload. Earlier recognition of cognitive overload may facilitate timely action to reduce cognitive overload and promote learning.

OBJECTIVE

Telehealth offers a solution to many challenges in health care, including the shortage of psychiatric providers. Recently the need to limit patient and provider exposure to coronavirus disease 2019 (COVID-19) has escalated implementation of telehealth across the globe. As telehealth utilization expands, its role in nursing education and training requires systematic evaluation. Since publication of the National Organization of Nurse Practitioner Faculty white paper supporting telehealth in health care delivery and nurse practitioner education, several studies have demonstrated successful didactic instruction and training in telehealth. However, a recent literature review found no studies evaluating the use of telehealth technology as a means of precepting in clinical training.

METHODS

This small-scale qualitative study investigates the readiness of one behavioral health clinic to provide teleprecepting to psychiatric mental health nurse practitioner students. Two preceptors and one student were interviewed using a peer-reviewed semistructured interview guide using video chat. Responses were reviewed, coded, and categorized into themes.

RESULTS

Thematic analysis of the interviews revealed three categories for consideration in establishing teleprecepting. Clinical factors, logistics, and comparison with traditional precepting are discussed. Interviewees viewed teleprecepting as a viable method of increasing access to clinical training.

CONCLUSIONS

This project supports teleprecepting as a feasible strategy for improving access to clinical training and as a technological resource that merits systematic evaluation. Practice guidelines are needed for teleprecepting of advanced practice registered nurse students, and both preceptors and students may benefit from training to support best practices prior to implementation.

OBJECTIVE

To determine the degree of contemporary practice variation for the treatment of urethral stricture disease (USD) given repeated endoscopic management yields poor long-term success.

MATERIALS AND METHODS

The AUA Quality (AQUA) Registry collects data from participating urologists across practice settings by direct interface with local electronic health record systems. We identified procedures used for USD using Current Procedural Terminology (CPT) and International Statistical Classification of Diseases (ICD-9/-10) codes. We assessed the association between patient and provider factors and repeated endoscopic treatment using generalized linear models. Provider details were derived from AUA Census.

RESULTS

We identified 20,640 male patients with USD treated surgically in AQUA from 2014-2018. The patients were cared for by 1343 providers at 171 practices, 95% of these community-based. Among patients with USD who had treatment, 20,101(97.9%) underwent endoscopic management. 6218(31%) underwent repeated endoscopic treatment during the study period. Urethroplasty was performed in 539(2.6%) patients.  Median patient age at first procedure for endoscopic surgery vs. urethroplasty was 73 vs. 39 years old, respectively (p0.001). At the practice level, significant variation in rates of repeated endoscopic management was noted. Patients of older age (OR=1.08, 95%CI: 1.06-1.11 for ages ≥80) and patients with a bladder cancer diagnosis (OR=1.17, 95%CI: 1.15-1.20) had higher odds of receiving repeated endoscopic management. Increasing practitioner age was also associated with increased odds of repeated endoscopic management. (OR=1.13, 95%CI: 1.11- 1.16, for practitioners ≥64).

CONCLUSIONS

Repeated endoscopic management for USD is overused. The utilization of endoscopic management is variable across practices and frequently guideline-discordant, presenting an opportunity for quality improvement.

BACKGROUND

SARS-CoV-2 enters cells by binding of its spike protein to angiotensin-converting enzyme 2 (ACE2). Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) have been reported to increase ACE2 expression in animal models, and worse outcomes are reported in patients with co-morbidities commonly treated with these agents, leading to controversy during the COVID-19 pandemic over whether these drugs might be helpful or harmful.

METHODS

Animal, in vitro and clinical data relevant to the biology of the renin-angiotensin system (RAS), its interaction with the kallikrein-kinin system (KKS) and SARS-CoV-2, and clinical studies were reviewed.

FINDINGS AND INTERPRETATION

SARS-CoV-2 hijacks ACE2to invade and damage cells, downregulating ACE2, reducing its protective effects and exacerbating injurious Ang II effects. However, retrospective observational studies do not show higher risk of infection with ACEI or ARB use. Nevertheless, study of the RAS and KKS in the setting of coronaviral infection may yield therapeutic targets.

INTRODUCTION

In the USA, African American men bear a disproportionate burden of prostate cancer (PCa) compared with all other groups, having a higher incidence and mortality, poorer quality of life and higher dissatisfaction with care. They are also less likely to receive guideline-concordant treatment (eg, undertreatment of aggressive disease). Inadequate patient-provider communication contributes to suboptimal care, which can be exacerbated by patients' limited health literacy, providers' lack of communication skills and time constraints in low-resource, safety net settings. This study is designed to examine the communication experiences of African American patients with PCa as they undertake treatment decision-making.

METHODS AND ANALYSIS

Using an ethnographic approach, we will follow 25 African American men newly diagnosed with PCa at two public hospitals, from diagnosis through treatment decision. Data sources include: (1) audio-recorded clinic observations during urology, radiation oncology, medical oncology and primary care visits, (2) field notes from clinic observations, (3) patient surveys after clinic visits, (4) two in-depth patient interviews, (5) a provider survey, and (6) in-depth interviews with providers. We will explore patients' understanding of their diagnoses and treatment options, sources of support in decision-making, patient-provider communication and treatment decision-making processes. Audio-recorded observations and interviews will be transcribed verbatim. An iterative process of coding and team discussions will be used to thematically analyse patients' experiences and providers' perspectives, and to refine codes and identify key themes. Descriptive statistics will summarise survey data.

ETHICS AND DISSEMINATION

To our knowledge, this is the first study to examine in-depth patient-provider communication among African American patients with PCa. For a population as marginalised as African American men, an ethnographic approach allows for explication of complex sociocultural and contextual influences on healthcare processes and outcomes. Study findings will inform the development of interventions and initiatives that promote patient-centred communication, shared decision-making and guideline-concordant care. This study was approved by the University of California San Francisco and the Alameda Health System Institutional Review Boards.

OBJECTIVE

Understanding transgender voice is in nascent stages. This study describes voice characteristics in treatment-seeking trans women by comparing two validated questionnaires-Voice Handicap Index-10 (VHI-10) and Transsexual Voice Questionnaire (TVQ )-and reports incidence of abnormal stroboscopy findings and acoustic characteristics.

METHODS

Retrospective review of transgender patients presenting to tertiary-care laryngology center between February 2018-February 2019. Mean VHI-10, TVQ, and Singing VHI-10 (SVHI-10) scores; audio-perceptual grade; acoustic measures; and stroboscopy findings were analyzed. VHI-10 and SVHI-10 vs TVQ were compared.

RESULTS

Sixty-one trans female patients (mean age: 32 ± 11 years) were analyzed. Mean duration since start of transition was 41.5 ± 61 months. Sixty-nine percent presented full-time female in all contexts. Pathologic stroboscopy findings were found in 5%. Mean questionnaire scores were 16 ± 10 (VHI-10), 19 ± 13 (SVHI-10), and 81 ± 22 (TVQ ). Correlation between VHI-10 and SVHI-10 versus TVQ was weak, R = 0.47 (P = .053) and R = 0.35 (P = .17), respectively. Mean audio-perceptual grade was 0.27 ± 0.15. Mean Cepstral Spectral Index of Dysphonia (CSID, sustained vowel) was 8.5 ± 21.9. Mean Cepstral Peak Prominence (CPP) Fo and CPP Fo SD in rainbow passage were 157.3 ± 16 and 59.4 ± 15.9, respectively.

CONCLUSION

Trans women report perceived voice handicap in speaking and singing, which appears separate from gender-related voice/communication concerns. This study is the first to report stroboscopy findings in transgender individuals, with 5% being abnormal. Stroboscopy is encouraged before initiating voice intervention in transgender patients. Preliminary evaluation suggests weak correlation between VHI-10 or SVHI-10 and TVQ but requires further investigation. TVQ may provide information which more specifically reflects voice concerns of trans women as compared to VHI-10 and SVHI-10.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1071-1077, 2021.

OBJECTIVE

To demonstrate our hypothesis that the presence of extravasation on postoperative urethrogram is inconsequential for disease recurrence in urethroplasty postoperative follow-up.

MATERIALS AND METHODS

We utilized the Trauma and Urologic Reconstructive Network of Surgeons database to assess 1691 patients who underwent urethroplasty and post-operative urethrogram. Anatomic and functional recurrence were defined as 17 Fr stricture documented at 12-month cystoscopy and need for a secondary procedure during 1 year of follow-up, respectively. Our primary outcomes were the sensitivity and positive predictive value of post-operative urethrogram for predicting anatomic and functional recurrence of urethral stricture disease.

RESULTS

Among 1101 patients with cystoscopy follow-up, 54 (4.9%) had extravasation on initial postoperative urethrogram. Among those 54, 74.1% developed an anatomic recurrence vs 13% without extravasation (P .001). Similarly, functional recurrence was 9.3% with extravasation vs 3.2 % without extravasation (P = .04). Patients with extravasation more often reported a postoperative urinary tract infection (12.9% vs 2.7%; P .01) or wound infection (7.4% vs 2.6%; P = .04). Sensitivity of postoperative urethrogram in predicting any recurrence was 27.3%, specificity 98.7%, positive predictive value 77.8%, and negative predictive value 89.3%. Fourty-five of 54 patients with extravasation had a recurrence of some kind, equating to a 22.2% urethroplasty success rate at 1 year.

CONCLUSION

Postoperative urethrogram has a high specificity but low sensitivity for anatomic and functional recurrence during short term follow-up. The positive predictive value of urinary extravasation is high: patients with extravasation incur a high risk of anatomic recurrence within 1 year and such patients may warrant increased monitoring.