Faculty Bibliography

OBJECTIVES: Gastroenterology (GI) training programs are mandated to teach fellows interpersonal communication and professionalism as basic competencies. We sought to assess important skill sets used by our fellows but not formally observed or measured: handoffs, telephone management, and note writing. We designed an Observed Standardized Clinical Examination (OSCE) form and provided the faculty with checklists to rate fellows' performance on specific criteria. METHODS: We created two new scenarios: a handoff between a tired overnight senior fellow on call and a more junior fellow, and a telephone management case of an ulcerative colitis flare. Fellows wrote a progress notes documenting the encounters. To add educational value, we gave the participants references about handoff communication. Four OSCE stations-handoff communication, telephone management, informed consent, and delivering bad news-were completed by fellows and observed by faculty. RESULTS: Eight faculty members and eight fellows from four GI training programs participated. All the fellows agreed that handoffs can be important learning opportunities and can be improved if they are structured, and that handoff skills can improve with practice. CONCLUSIONS: OSCEs can serve as practicums for assessing complex skill sets such as handoff communication and telephone management.

OBJECTIVES: The American Gastroenterological Association fellowship curriculum identifies geriatric components for gastroenterology (GI) training; however, few tools are available for this purpose. Using an objective structured clinical examination (OSCE), we aimed to assess ACGME competencies of communication, professionalism, and geriatric-specific patient care among GI fellows. METHODS: We developed an informed-consent case involving a geriatric patient who needs surveillance colonoscopy. We used a validated faculty skills checklist to rate fellows across three competency domains. Fifteen fellows from four GI training programs participated. RESULTS: Although the fellows excelled at communication and professionalism, only 51% excelled at geriatric-specific patient-care skills. Fellows were least likely to demonstrate collaboration with the patient, to assess patient understanding, and to explain the limits of the test. Communication and geriatric-specific skills were correlated. CONCLUSIONS: OSCEs are a feasible method for assessing geriatric-related ACGME competencies for fellows. The results highlight the need for curriculum development.

Recent health care improvement initiatives have linked financial payments to compliance with predetermined performance measures. This article reports the effect of a unique prophylactic antibiotic use program on compliance rates and costs. The Departments of Surgery, Infection Control, and Anesthesiology collaborated on a prophylactic preoperative antibiotic protocol, whereby Anesthesiology assumed responsibility for timely antibiotic prophylaxis (TAP) before surgical incision. Data from January 1, 2008, to December 31, 2008, were compared (z test) with the 12-month period before this change. chi(2) Analysis identified factors associated with TAP. Return on investment (ROI) was calculated. TAP compliance rates increased from 75.1% to 89.3% (P < .001) following program implementation. Factors associated with TAP failure included >60 minutes from anesthesia induction to surgical incision (P < .001), surgical procedure (P < .001), specific antibiotic administered (P < .001), and individual anesthesia provider (P < .001). The ROI was 2.2. TAP compliance rates increased after Anesthesiology assumed responsibility, with anesthesia providers being a significant factor

Autoregulation of cholesterol synthesis focuses on the 19 metabolic steps from lanosterol to cholesterol. Although synchronization of their rates of synthesis in all tissues was the paradigm, a known exception occurs in the ovary where a local increase in a sterol intermediate, FF-MAS (follicular fluid meiosis activating sterol), activates meiosis during oocyte maturation. Mutations in the genes that govern synchronization cause an increase in sterol intermediates that follow an alternate, oxysterol, pathway of metabolism. Experimental models in animals imply that oxysterol metabolites are determinants of the dysmorphism that occurs during fetal development in these genetic diseases. These few examples may portend a much broader role for sterol intermediates and their novel oxysterol metabolites in physiologic and pathophysiologic processes

In the fourth part in a four-part series, Ofri talks about his book Medicine in Translation: Journeys with My Patients. He writes here about freedom from fear and how the Americans she knows strive for it every day of their lives

When Mr. S. was doing time at Rikers Island in the early 1990s, he was given a standard battery of tests for the medical ailments that run rampant behind bars -- AIDS, hepatitis, tuberculosis. Despite the other medical assaults on his body -- diabetes, hypertension, hepatitis C, stubborn leg ulcers -- his immune system remained intact.

Mr. Cheney, as he did at several holiday receptions in Washington, chatted about his new pump. At one cocktail party, he even opened his coat jacket to show off the pump. While Mr. Cheney is noticeably thinner -- his stiff, one-sided grin now shows up on a markedly leaner face -- he is returning, associates say, to his old life, including hunting and socializing. With former President George W. Bush having decided to stay largely silent during Mr. [Barack Obama]'s tenure, Mr. Cheney had embraced the role of public critic, accusing the new, young president of rolling back Bush-era policies and undermining the security of the United States. In 2009, Mr. Cheney and Mr. Obama gave dueling speeches on the same day. Mr. Cheney's friends and family say that he is making plans to get out in 2011 and do more speeches. On Jan. 20, he is to fly to Texas for the 20th anniversary of the Gulf War with former President George H.W. Bush, the emir of Kuwait, and a host of alumni of that administration, including the former national security adviser Brent Scowcroft and Colin L. Powell, who was the chairman of the Joint Chiefs of Staff at the time, when Mr. Cheney was defense secretary

While the long-term goal is to develop highly effective AIDS vaccines, first generation vaccines may be only partially effective. Other HIV prevention modalities such as preexposure prophylaxis with antiretrovirals (PrEP) may have limited efficacy as well. The combined administration of vaccine and PrEP (VAXPREP), however, may have a synergistic effect leading to an overall benefit that is greater than the sum of the individual effects. We propose two test-of-concept trial designs for an AIDS vaccine plus oral or topical ARV. In one design, evidence that PrEP reduces the risk of HIV acquisition is assumed to justify offering it to all participants. A two-arm study comparing PrEP alone to VAXPREP is proposed in which 30 to 60 incident infections are observed to assess the additional benefit of vaccination on risk of infection and setpoint viral load. The demonstrated superiority of VAXPREP does not imply vaccine alone is efficacious. Similarly, the lack of superiority does not imply vaccine alone is ineffective, as antagonism could exist between vaccine and PrEP. In the other design, PrEP is assumed not to be in general use. A 2 x 2 factorial design is proposed in which high-risk individuals are randomized to one of four arms: placebo vaccine given with placebo PrEP, placebo vaccine given with PrEP, vaccine given with placebo PrEP, or VAXPREP. Between 60 and 210 infections are required to detect a benefit of vaccination with or without PrEP on risk of HIV acquisition or setpoint viral load, with fewer infections needed when synergy is present