Faculty Bibliography

Background Clinical reasoning (CR) is a core competency in medical education. Few studies have examined efforts to train faculty to teach CR and lead CR curricula in medical schools and residencies. In this report, we describe the development and preliminary evaluation of a faculty development workshop to teach CR grounded in CR theory. Methods Twenty-six medicine faculty (nine hospitalists and 17 subspecialists) participated in a workshop that introduced a framework to teach CR using an interactive, case-based didactic followed by role-play exercises. Faculty participated in pre- and post-Group Observed Structured Teaching Exercises (GOSTE), completed retrospective pre-post assessments (RPPs), and made commitment to change statements (CTCs). Results In the post-GOSTE, participants significantly improved in their use of problem representation and illness scripts to teach CR. RPPs revealed that faculty were more confident in their ability and more likely to teach CR using educational strategies grounded in CR educational theory. At 2-month follow-up, 81% of participants reported partially implementing these teaching techniques. Conclusions After participating in this 3-h workshop, faculty demonstrated increased ability to use these teaching techniques and expressed greater confidence and an increased likelihood to teach CR. The majority of faculty reported implementing these newly learned educational strategies into practice.

Background: Faculty development programs (FDP) in medical education can increase clinician educators' (CE) confidence in teaching and improve their teaching skills. The impact of FDP on faculty's role as educators and sense of an educator community is less well understood. Identification with a community of educators (COE) can enhance teaching in the workplace along with personal and professional growth. We evaluated the impact of participation in the Education for Educators program (E4E) on these issues. E4E is a yearlong FDP designed to enhance teaching confidence and skill in a variety of venues; improve ability to assess learners; promote an environment of academic inquiry with trainees at different levels; and create a COE.
Method(s): An annual needs assessment of key stakeholders including medical school deans, program directors, and participants forms the basis for the E4E curriculum. The program begins with a Group Observed Structured Teaching Experience (GOSTE) followed by three 3-hour workshops which pair a clinical and teaching topic. After each workshop, participants complete " commitment to change" statements and take part in peer-to-peer (P2P) observations wherein participants observe each other teaching in their usual teaching environment. The program concludes with structured debriefs and an assessment of participants' perception of their role as educators and their sense of an educator community. Participants reported how participation in E4E impacted their teaching and what new skills they implemented. Structured phone conversations assessed the same information one-year after completing the program.
Result(s): Fifty-one CEs completed the program in two cohorts (2016-17 and 2017-18), 60% of whom were women. Participants included 20 hospitalists and 31 subspecialists, averaging 8 years in practice (range 1-28) and spending an average of 63% of their time in patient care (range 10-100%). Thirty-eight participants (75%) completed the immediate post-program debrief sessions. Participants reported a renewed identification with their role as an educator. They cited a change in perspective to become more reflective and focused on teaching and recognized that their teaching skills can in fact be improved. Many reported time constraints as a barrier to teaching. They noted an increased identification with their COE, stating that they now had peers and mentors with whom to discuss teaching challenges. To date, phone interviews have been completed with three participants at one-year of follow-up. The preliminary Results show a sustained impact on educators' roles and belonging to a COE. They also reported ongoing use of specific skills including resilience strategies, and planning teaching sessions.
Conclusion(s): Longitudinal FDP in medical education for CE can lead to a greater appreciation for the role of an educator, and identification with a COE. Investment in longitudinal FDP may have lasting impact on the clinical learning environment and the identity of faculty as an educator

LEARNING OBJECTIVE #1: Discuss the clinical utility and mechanism of action of a widely used novel immunotherapeutic agents. LEARNING OBJECTIVE #2: Highlight the incidence of endocrinopathies associated with Ipilimumab and Nivolumab. CASE: A 70 year old female with metastatic melanoma presented to the emergency department with fatigue and lethargy for one month. She had recently completed 6 cycles of Nivolumab and Ipilimumab and was currently receiving Nivolumab monotherapy. Over the past month she had worsening fatigue associated with nausea and decreased appetite. Lab work one week prior to admission was significant for newly elevated TSH and low T4, and thyroid replacement therapy was initiated. On the day of admission, she had a syncopal episode at home prompting presentation. On arrival, she was hypotensive to 89/57. Lab work was significant for hyponatremia, hypokalemia, and hypochloremia. Due to concern for adrenal insufficiency, she was started on stress dose hydrocortisone. An AM serum cortisol was 1.5 and ACTH level was undetectable. FSH and LH levels were also low. An MRI of the brain was notable for enhancement of the pituitary gland suggestive of hypophysitis, which was likely a side effect of her immunotherapy. IMPACT: Ipilimumab and Nivolumab are novel immunotherapeutic agents used in the treatment of melanoma, with research investigating their use into other malignancies as well. Endocrinopathies are relatively common side effects of these agents, especially when given as combination therapy. Nonspecific complaints, such as fatigue and nausea in our patient, should warrant a thorough investigation for endocrinopathies in patients with treatment exposure to ipilimumab and/or nivolumab. DISCUSSION: Nivolumab and Ipilimumab are novel immunotherapeutic agents that are currently used for metastatic melanoma and squamous lung carcinoma. Nivolumab antagonizes the binding of Programmed Cell Death Ligand 1 to the programmed cell death 1 receptor (PD-1), activation of which would normally promote T-cell apoptosis. Ipilimumab antagonizes the cytotoxic T lymphocyte-associated antigen 4 (CTLA-4), preventing down regulation cytotoxic T lymphocytes. Endocrinopathies are relatively common side effects of checkpoint inhibitors and are thought to be result of auto-immune inflammation. They can manifest as primary hyper/hypothyroidism, primary adrenal insufficiency and/or hypophysitis thereby affecting the multiple hormonal systems. A retrospective review from Memorial Sloan Kettering showed an incidence of hypophysitis of 8 and thyroiditis of 6% following treatment with ipilimumab. The incidence of hypophysitis and thyroiditis increased to 9 and 22% respectively in patients who received combination therapy with ipilimumab and nivolumab. Our patient seemingly developed primary hypothyroidism and hypophysitis causing a secondary adrenal insufficiency secondary to her combination therapy. The initiation of levothyroxine therapy likely precipitated her adrenal insufficiency leading to her syncopal event

LEARNING OBJECTIVE #1: Recognize the clinical features and complications of Lemierre's syndrome. CASE: A healthy 25-year-old male presented with 8 days of progressively worsening sore throat, fever and neck swelling which were unresponsive to 2 outpatient courses of clarithromycin. On presentation, he was febrile, tachycardic, hypotensive, tachypneic and hypoxic. Physical examination was significant for a palpable left-sided neck mass, trismus, and muffled voice. Initial labs revealed a white blood cell count of 26k, creatinine of 1.9mg/dL, and serum lactate of 4.5mg/dL. The patient was intubated for airway protection, and started on antibiotics and vasopressors. Ultrasound and CT imaging revealed left tonsillar, peritonsillar, and sublingual abscesses, pulmonary septic emboli, bilateral parapneumonic effusions and left internal jugular (IJ) thrombus. Wound cultures of left tonsillar abscess grew Fusobacterium necrophorum and antibiotics were narrowed to piperacillin-tazobactam. He underwent left IJ ligation and left lower lobe lobectomy, and gradually improved and was discharged home on a prolonged course of antibiotics. IMPACT: Lemierre's syndrome is a potentially fatal disease that can cause rapid decompensation if untreated. When a young adult presents with worsening symptoms of acute pharyngitis, one must have a high suspicion for this disease in order to diagnose and treat it early. DISCUSSION: Lemierre's syndrome is a rare and serious disease entity that primarily affects healthy young adults with an incidence of 1 in 1 million and a mortality rate of 4-12%. It involves oropharyngeal fusobacteriuminfection that can form abscesses and internal jugular thrombophlebitis. IJ thrombophlebitis results in bacteremia with septic emboli, commonly to the lungs and joints. The prevalence of Lemierre's syndrome has been rising in recent years due to more judicious use of antibiotics for acute pharyngitis.2 This is also attributed to rising resistance of fusobacterium to macrolides that are often prescribed for pharyngitis, as illustrated by our patient who was initially treated with clarithromycin