Recent Publications by CFE Educators

Patient engagement through shared decision-making (SDM) is increasingly seen as a key component for patient safety, patient satisfaction, and quality of care. Current SDM models do not adequately account for medical and environmental contexts, which may influence medical decisions in the hospital. We identified leading SDM models and reviews to inductively construct a novel SDM model appropriate for the inpatient setting. A team of medicine and pediatric hospitalists reviewed the literature to integrate core SDM concepts and processes and iteratively constructed a synthesized draft model. We then solicited broad SDM expert feedback on the draft model for validation and further refinement. The SDM 3 Circle Model identifies 3 core categories of variables that dynamically interact within an "environmental frame." The resulting Venn diagram includes overlapping circles for (1) patient/family, (2) provider/team, and (3) medical context. The environmental frame includes all external, contextual factors that may influence any of the 3 circles. Existing multistep SDM process models were then rearticulated and contextualized to illustrate how a shared decision might be made. The SDM 3 Circle Model accounts for important environmental and contextual characteristics that vary across settings. The visual emphasis generated by each "circle" and by the environmental frame direct attention to often overlooked interactive forces and has the potential to more precisely define, promote, and improve SDM. This model provides a framework to develop interventions to improve quality and patient safety through SDM and patient engagement for hospitalists.

BACKGROUND

In-training evaluation reports are a commonly used assessment method for clinical learners that can characterise the development of competence in essential domains of practice. Strategies to increase the usefulness and specificity of written narrative comments about learner performance in these reports are needed to guide their learning. Soliciting narrative comments by competency domain from supervising doctors on in-training evaluation reports could improve the quality of written feedback to students.

METHODS

This is a pre-post study examining narrative comments derived from assessments of core clerkship students by faculty members and resident supervisors in seven clerkships using two assessment forms in academic years 2013/14 (pre; two comments fields - summative, constructive) and 2014/15 (post; seven comments fields - six competency domains, constructive comments). Using a purposive sample of 60 students based on overall clerkship performance, we conducted content analysis of written comments to compare comment quality based on word count, competencies addressed and reinforcing or constructive content. Differences between the two forms across these three components of quality were compared using Student's t-tests.

RESULTS

The revised form elicited more narrative comments in all seven clerkships, with more competencies addressed. The revised form led to a decrease in the proportion of constructive comments about the students' performances. In-training evaluation reports are a commonly used assessment method for clinical learners DISCUSSION: Structural changes to a medical student assessment form to elicit narrative comments by competency improved some measures of the quality of narrative comments provided by faculty members and residents. Additional study is needed to determine how learners use this information to improve their clinical practice.

UNLABELLED

Patients with T1 hepatocellular carcinoma (HCC) are not eligible for Model for End Stage Liver Disease (MELD) exception for liver transplant (LT) in part due to a high rate of misdiagnosis (no HCC on explant). The likelihood of misdiagnosis for T2 HCC and factors associated with misdiagnosis are unknown. We analyzed the Organ Procurement and Transplantation Network database including 5664 adults who underwent LT from 2012 to 2015 with MELD exception for T2 HCC, and searched for no evidence of HCC in the explant pathology file. We focused on those (n = 324) receiving no local-regional therapy (LRT) to evaluate the probability of no HCC found in explant. Median waiting time was short at 1.7 months, and 35 (11%) had no HCC on explant. On multivariable logistic regression, factors associated with no HCC on explant were age 50 (OR: 17.3, P  .001), non-HCV (OR: 5.4, P = .001), and alpha-fetoprotein 10 (OR: 2.9, P = .04). Tumor size and number were not different between groups. The proportion of misdiagnosis did not change significantly after implementation of Liver Imaging Reporting and Data System (LI-RADS) for HCC diagnosis.

CONCLUSION

The rate of misdiagnosis was 11% among T2 HCC patients who underwent LT without receiving LRT prior to LT and did not change significantly after implementation of LI-RADS. More efforts are needed to eliminate unnecessary LT for patients without HCC.

PURPOSE

We explored the relation of cycling to urinary and sexual function in a large multinational sample of men.

MATERIALS AND METHODS

Cyclists were recruited to complete a survey through Facebook® advertisements and outreach to sporting clubs. Swimmers and runners were recruited as a comparison group. Cyclists were categorized into low and high intensity cyclists. Participants were queried using validated questionnaires, including SHIM (Sexual Health Inventory for Men), I-PSS (International Prostate Symptom Score) and NIH-CPSI (National Institutes of Health Chronic Prostatitis Symptom Index), in addition to questions about urinary tract infections, urethral stricture, genital numbness and saddle sores.

RESULTS

Of 5,488 complete survey responses 3,932 (72%) were included in our analysis. On multivariate analysis swimmers/runners had a lower mean SHIM score than low and high intensity cyclists (19.5 vs 19.9 and 20.7, p = 0.02 and 0.001, respectively). No significant differences were found in I-PSS or NIH-CPSI scores, or urinary tract infection history. Cyclists had statistically higher odds of urethral stricture compared to swimmers/runners (OR 2.5, p = 0.042). Standing more than 20% of the time while cycling significantly reduced the odds of genital numbness (OR 0.4, p = 0.006). Adjusting the handlebar higher or even with the saddle had lower odds of genital numbness and saddle sores (OR 0.8, p = 0.005 and 0.6, p 0.001, respectively).

CONCLUSIONS

Cyclists had no worse sexual or urinary functions than swimmers or runners but cyclists were more prone to urethral stricture. Increased time standing while cycling and a higher handlebar height were associated with lower odds of genital sores and numbness.

OBJECTIVE

To describe clinical and imaging responses in neurosarcoidosis to infliximab, a monoclonal antibody against tumor necrosis factor-α.

METHODS

Investigators at 6 US centers retrospectively identified patients with CNS sarcoidosis treated with infliximab, including only patients with definite or probable neurosarcoidosis following rigorous exclusion of other causes.

RESULTS

Of 66 patients with CNS sarcoidosis (27 definite, 39 probable) treated with infliximab for a median of 1.5 years, the mean age was 47.5 years at infliximab initiation (SD 11.7, range 24-71 years); 56.1% were female; 62.1% were white, 37.0% African American, and 3% Hispanic. Sarcoidosis was isolated to the CNS in 19.7%. Using infliximab doses ranging from 3 to 7 mg/kg every 4-8 weeks, MRI evidence of a favorable treatment response was observed in 82.1% of patients with imaging follow-up (n = 56), with complete remission of active disease in 51.8% and partial MRI improvement in 30.1%; MRI worsened in 1 patient (1.8%). There was clinical improvement in 77.3% of patients, with complete neurologic recovery in 28.8%, partial improvement in 48.5%, clinical stability in 18.2%, worsening in 3%, and 1 lost to follow-up. In 16 patients in remission when infliximab was discontinued, the disease recurred in 9 (56%), typically in the same neuroanatomic location.

CONCLUSIONS

Most patients with CNS sarcoidosis treated with infliximab exhibit favorable imaging and clinical treatment responses, including some previously refractory to other immunosuppressive treatments.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that for patients with CNS sarcoidosis infliximab is associated with favorable imaging and clinical responses.

PURPOSE

Studies of surgical complications of penile inversion vaginoplasty are limited due to small sample sizes. We describe postoperative complications after penile inversion vaginoplasty and evaluated age, body mass index and years on hormone replacement therapy as risk factors for complications.

MATERIALS AND METHODS

We retrospectively reviewed the records of male-to-female patients who presented for primary penile inversion vaginoplasty to a high volume surgeon (MLB) from 2011 to 2015. Complications included granulation tissue, vaginal pain, wound separation, labial asymmetry, vaginal stenosis, fistula formation, urinary symptoms including spraying stream or dribbling, infection, vaginal fissure or vaginal bleeding. We classified complications by Clavien-Dindo grade. Multivariable logistic regression was performed to determine the independent effects of age, body mass index and hormone replacement therapy on postoperative surgical complications.

RESULTS

A total of 330 patients presented for primary penile inversion vaginoplasty. Median age at surgery was 35 years (range 18 to 76). Median followup in all patients was 3 months (range 3 to 73). Of the patients 95 (28.7%) presented with a postoperative complication. Median time to a complication was 4.4 months (IQR 1-11.5). Rectoneovaginal fistulas developed in 3 patients (0.9%). A total of 30 patients (9.0%) required a second operation. There were no complications greater than Clavien-Dindo grade IIIB. Age, body mass index and hormone replacement therapy were not associated with complications.

CONCLUSIONS

Penile inversion vaginoplasty is a relatively safe procedure. Most complications due to this surgery develop within the first 4 months postoperatively. Age, body mass index and hormone replacement therapy are not associated with complications and, thus, they should not dictate the timing of surgery.

INTRODUCTION

Objective standardized teaching exercises (OSTEs) are widely used to develop professional competencies, especially in the health care professions. An OSTE involves exposing different providers to the same, time-limited scenario that is concurrently observed and/or recorded for either formative or summative evaluation. As there are limited resources available for creating a resident-specific OSTE, especially those applicable to family and community medicine residents, we created and evaluated a resident OSTE (R-OSTE) for second- and third-year family and community medicine residents.

METHODS

This R-OSTE involved two cases. The first featured Taylor, a third-year medical student resistant to feedback. The second featured Kris, a first-year resident nervous about approaching the attending on duty. Our R-OSTE had residents teaching interpersonal skills to trained actors in a standardized learner role.

RESULTS

Residents in the teaching role were formatively evaluated by peer observers (fellow residents) and standardized learners on interpersonal domains such as communication and professionalism. Learners gave residents an average performance rating of 4.9 on a 1 to 6 scale with 1 = and 6 = . Residents also evaluated the OSTE itself, rating their experience on multiple teaching-related statements. Eighty-six percent of residents agreed this exercise was an appropriate development activity for family medicine residents. Overall, our R-OSTE was rated highly for relevance to teaching by the residents.

DISCUSSION

The residents were rated highly by both peer observers and standardized learners. However, there was little variability in peer observer scores, indicating the need for an alternative method of measurement.