Faculty Bibliography

There is limited data on which hospitalist switch day is optimal for hospital operations and throughput. A quality improvement intervention was implemented, changing the hospitalist switch day from Monday to Tuesday. Retrospective observational analysis revealed an increase in Monday discharges (1.3%, p = .01), a decrease in Tuesday discharges (-1.6%, p < .005), and a significant reduction in 30-day unplanned readmission rates (-1.5%, p = .003), with no significant changes in the average length of stay. Additional studies are needed to further verify these findings in different hospital settings and to consider other switch day patterns.

IMPORTANCE/UNASSIGNED:Hospital course (HC) summarization represents an increasingly onerous discharge summary component for physicians. Literature supports large language models (LLMs) for HC summarization, but whether physicians can effectively partner with electronic health record-embedded LLMs to draft HCs is unknown. OBJECTIVES/UNASSIGNED:To compare the editing effort required by time-constrained resident physicians to improve LLM- vs physician-generated HCs toward a novel 4Cs (complete, concise, cohesive, and confabulation-free) HC. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:Quality improvement study using a convenience sample of 10 internal medicine resident editors, 8 hospitalist evaluators, and randomly selected general medicine admissions in December 2023 lasting 4 to 8 days at New York University Langone Health. EXPOSURES/UNASSIGNED:Residents and hospitalists reviewed randomly assigned patient medical records for 10 minutes. Residents blinded to author type who edited each HC pair (physician and LLM) for quality in 3 minutes, followed by comparative ratings by attending hospitalists. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Editing effort was quantified by analyzing the edits that occurred on the HC pairs after controlling for length (percentage edited) and the degree to which the original HCs' meaning was altered (semantic change). Hospitalists compared edited HC pairs with A/B testing on the 4Cs (5-point Likert scales converted to 10-point bidirectional scales). RESULTS/UNASSIGNED:Among 100 admissions, compared with physician HCs, residents edited a smaller percentage of LLM HCs (LLM mean [SD], 31.5% [16.6%] vs physicians, 44.8% [20.0%]; P < .001). Additionally, LLM HCs required less semantic change (LLM mean [SD], 2.4% [1.6%] vs physicians, 4.9% [3.5%]; P < .001). Attending physicians deemed LLM HCs to be more complete (mean [SD] difference LLM vs physicians on 10-point bidirectional scale, 3.00 [5.28]; P < .001), similarly concise (mean [SD], -1.02 [6.08]; P = .20), and cohesive (mean [SD], 0.70 [6.14]; P = .60), but with more confabulations (mean [SD], -0.98 [3.53]; P = .002). The composite scores were similar (mean [SD] difference LLM vs physician on 40-point bidirectional scale, 1.70 [14.24]; P = .46). CONCLUSIONS AND RELEVANCE/UNASSIGNED:Electronic health record-embedded LLM HCs required less editing than physician-generated HCs to approach a quality standard, resulting in HCs that were comparably or more complete, concise, and cohesive, but contained more confabulations. Despite the potential influence of artificial time constraints, this study supports the feasibility of a physician-LLM partnership for writing HCs and provides a basis for monitoring LLM HCs in clinical practice.

Learning Objective #1: Recognize protein malnutrition and cirrhosis as potential complications of biliopancreatic diversion with duodenal switch (BPD-DS). CASE: A 37-year-old man with a history of severe obesity status post laparoscopic BPD-DS presented with diffuse swelling. The patient was admitted six months previously for severe protein-calorie malnutrition requiring initiation of total parental nutrition (TPN). During that admission, he was found to have elevated liver enzymes and ascites. Workup for autoimmune, infectious, and hereditary etiologies of cirrhosis was unremarkable; a liver biopsy showed steatosis without evidence of alcoholic hepatitis or cirrhosis. He now complained of abdominal distension and lower extremity edema that had progressed over several weeks, requiring multiple large-volume paracenteses. He endorsed past heavy alcohol use, but denied recent exposure. On physical examination, he was grossly anasarcic with a distended abdomen and appreciable fluid wave, 3+ pitting edema to the hips, and scrotal edema. His admission Model for End-Stage Liver Disease (MELD) score was 14. Repeat biopsy demonstrated prominent portal fibrosis and focal nodularity indicative of advanced-stage cirrhosis, with an interval decrease in steatosis from his previous biopsy. The rapidity of fibrosis and reversal of fatty change suggested the etiology was his bariatric surgery. He was treated with intravenous diuretics with improvement in his anasarca. At one-month follow-up, he had a stable MELD and diuretic-responsive ascites. He has been approved for liver transplant evaluation, with plans to reverse his bypass prior to transplant. IMPACT/DISCUSSION: BPD-DS is classically associated with improvement in hepatic function due to reversal of nonalcoholic steatohepatitis (NASH). However, case reports of hepatic failure following BPD-DS do exist. Clinicians should be alert to this complication and monitor post-surgical patients closely for signs of hepatic decompensation.
Conclusion(s): BPD-DS is the most effective bariatric surgery technique for sustained weight loss in the super-obese (BMI > 50 kg/m, ²). Nevertheless its widespread adoption has been limited by technical complexity and concerns over vitamin deficiencies and malnutrition. Loss of hepatotrophic factors due to protein malnutrition has been advanced as a mechanism to explain its contribution to the development of cirrhosis. With the increasing prevalence of obesity and the documented effectiveness of BPD-DS for sustained weight loss this surgery will likely become more commonplace. Awareness of this potential complication and vigilance to ensure adequate protein intake, with aggressive intervention-including the initiation of TPN-to preserve nutritional status is paramount to effective management of BPD-DS patients post-operatively