Bridging the Gap from Student to Doctor: Developing Coaches for the Transition to Residency
BACKGROUND/UNASSIGNED:A lack of educational continuity creates disorienting friction at the onset of residency. Few programs have harnessed the benefits of coaching, which can facilitate self-directed learning, competency development, and professional identity formation, to help ease this transition. OBJECTIVE/UNASSIGNED:To describe the process of training faculty Bridge Coaches for the Transition to Residency Advantage (TRA) program for interns. METHODS/UNASSIGNED:Nineteen graduate faculty educators participated in a coaching training course with formative skills assessment as part of a faculty development program starting in January 2020. Surveys (nÂ =Â 15; 79%) and a focus group (nÂ =Â 7; 37%) were conducted to explore the perceived impact of the training course on coaching skills, perceptions of coaching, and further program needs during the pilot year of the TRA program. RESULTS/UNASSIGNED:Faculty had strong skills around establishing trust, authentic listening, and supporting goal-setting. They required more practice around guiding self-discovery and following a coachee-led agenda. Faculty found the training course to be helpful for developing coaching skills. Faculty embraced their new roles as coaches and appreciated having a community of practice with other coaches. Suggestions for improvement included more opportunities to practice and receive feedback on skills and additional structures to further support TRA program encounters with coaches. CONCLUSIONS/UNASSIGNED:The faculty development program was feasible and had good acceptance among participants. Faculty were well-suited to serve as coaches and valued the coaching mindset. Adequate skills reinforcement and program structure were identified as needs to facilitate a coaching program in graduate medical education.
Efficacy and Safety of Sofosbuvir-based Regimens in Hepatitis C Patients With Decompensated Cirrhosis: A Systematic Review and Meta-analysis
BACKGROUND AND AIMS/UNASSIGNED:Decompensated cirrhotic patients with hepatitis C (HCV) are often under-represented in clinical trials. We aimed to evaluate pooled data on the efficacy and safety of sofosbuvir (SOF)-based regimens in these patients. METHODS/UNASSIGNED:We conducted a systemic review and meta-analysis by searching multiple databases for studies published from October 2010 to October 2020. Outcomes of interest were sustained virologic response (SVR) and safety of SOF-based regimens in decompensated HCV patients. Two reviewers independently performed the study selection and data extraction. RESULTS/UNASSIGNED:=0.76)] in decompensated patients, which was also true in subgroup analyses for each regimen within the same treatment duration. However, adding ribavirin significantly increased the frequency of adverse events from 52.9% (95% CI: 28.0-77.1) to 89.2% (95% CI: 68.1-99.9) and frequency of severe events. The pooled incidence of hepatocellular carcinoma and case-fatality of decompensated patients were 3.1% (95% CI: 1.5-5.0) and 4.6% (95% CI: 3.1-6.3), respectively. The overall heterogeneity was high. There was no publication bias. CONCLUSIONS/UNASSIGNED:The analysis found that 12 weeks of SOF/velpatasvir without ribavirin is the preferred therapy, with a significantly higher SVR compared with other SOF-based regimens in decompensated HCV patients.
Nationwide Clinical Practice Patterns of Anesthesiology Critical Care Physicians-A Survey to Members of the Society of Critical Care Anesthesiologists
BACKGROUND:Despite the growing contributions of critical care anesthesiologists to clinical practice, research, and administrative leadership of intensive care units (ICUs), relatively little is known about the subspecialty-specific clinical practice environment. An understanding of contemporary clinical practice is essential to recognize the opportunities and challenges facing critical care anesthesia, optimize staffing patterns, assess sustainability and satisfaction, and strategically plan for future activity, scope, and training. This study surveyed intensivists who are members of the Society of Critical Care Anesthesiologists (SOCCA) to evaluate practice patterns of critical care anesthesiologists, including compensation, types of ICUs covered, models of overnight ICU coverage, and relationships between these factors. We hypothesized that variability in compensation and practice patterns would be observed between individuals. METHODS:Board-certified critical care anesthesiologists practicing in the United States were identified using the SOCCA membership distribution list and invited to take a voluntary online survey between May and June 2021. Multiple-choice questions with both single- and multiple-select options were used for answers with categorical data, and adaptive questioning was used to clarify stem-based responses. Respondents were asked to describe practice patterns at their respective institutions and provide information about their demographics, salaries, effort in ICUs, as well as other activities. RESULTS:A total of 490 participants were invited to take this survey, and 157 (response rate 32%) surveys were completed and analyzed. The majority of respondents were White (73%), male (69%), and younger than 50 years of age (82%). The cardiothoracic/cardiovascular ICU was the most common practice setting, with 69.5% of respondents reporting time working in this unit. Significant variability was observed in ICU practice patterns. Respondents reported spending an equal proportion of their time in clinical practice in the operating rooms and ICUs (median, 40%; interquartile range [IQR], 20%-50%), whereas a smaller proportion-primarily those who completed their training before 2009-reported administrative or research activities. Female respondents reported salaries that were $36,739 less than male respondents; however, this difference was not statistically different, and after adjusting for age and practice type, these differences were less pronounced (-$27,479.79; 95% confidence interval [CI], -$57,232.61 to $2273.03; P = .07). CONCLUSIONS:These survey data provide a current snapshot of anesthesiology critical care clinical practice patterns in the United States. Our findings may inform decision-making around the initiation and expansion of critical care services and optimal staffing patterns, as well as provide a basis for further work that focuses on intensivist satisfaction and burnout.
Practice patterns of the medical evaluation of living liver donors in the United States
Living donor liver transplantation (LDLT) can help address the growing organ shortage in the United States, yet little is known about the current practice patterns in the medical evaluation of living liver donors. We conducted a 131-question survey of all 53 active LDLT transplant programs in the United States to assess current LDLT practices. The response rate was 100%. Donor acceptance rate was 0.33 with an interquartile range of 0.33-0.54 across all centers. Areas of high intercenter agreement included minimum age cutoff of 18â€‰years (73.6%) and the exclusion of those with greater than Class 1 obesity (body mass index, 30.0-34.9â€‰m/kg2 ) (88.4%). Diabetes mellitus was not an absolute exclusion at most centers (61.5%). Selective liver biopsies were performed for steatosis or iron overload on imaging (67.9% and 62.3%, respectively) or for elevated liver enzymes (60.4%). Steatohepatitis is considered an exclusion at most centers (84.9%). The most common hypercoagulable tests performed were factor V Leiden (FVL) (88.5%), protein C (73.1%), protein S (71.2%), antithrombin III (71.2%) and prothrombin gene mutation (65.4%). At 41.5% of centers, donors were allowed to proceed with donation with FVL heterozygote status. Most programs discontinue oral contraceptive pills at least 28â€‰days prior to surgery. At most centers, the need for cardiovascular ischemic risk testing is based on age (73.6%) and the presence of one or more cardiac risk factors (68.0%). Defining areas of practice consensus and variation underscores the need for data generation to develop evidence-based guidance for the evaluation and risk assessment of living liver donors.
Developing a Model to Predict High Health Care Utilization Among Patients in a New York City Safety Net System
BACKGROUND:Health care facilities use predictive models to identify patients at risk of high future health care utilization who may benefit from tailored interventions. Previous predictive models that have focused solely on inpatient readmission risk, relied on commercial insurance claims data, or failed to incorporate social determinants of health may not be generalizable to safety net hospital populations. To address these limitations, we developed a payer-agnostic risk model for patients receiving care at the largest US safety net hospital system. METHODS:We transformed electronic health record and administrative data from 833,969 adult patients who received care during July 2016-July 2017 into demographic, utilization, diagnosis, medication, and social determinant variables (including homelessness and incarceration history) to predict health care utilization during the following year.We selected the final model by developing and validating multiple classification and regression models predicting 10+ acute days, 5+ acute days, or continuous acute days. We compared a portfolio of performance metrics while prioritizing positive predictive value for patients whose predicted utilization was among the top 1% to maximize clinical utility. RESULTS:The final model predicted continuous number of acute days and included 17 variables. For the top 1% of high acute care utilizers, the model had a positive predictive value of 47.6% and sensitivity of 17.3%. Previous health care utilization and psychosocial factors were the strongest predictors of future high acute care utilization. CONCLUSIONS:We demonstrated a feasible approach to predictive high acute care utilization in a safety net hospital using electronic health record data while incorporating social risk factors.
Methods and Impact for Using Federated Learning to Collaborate on Clinical Research
BACKGROUND:The development of accurate machine learning algorithms requires sufficient quantities of diverse data. This poses a challenge in health care because of the sensitive and siloed nature of biomedical information. Decentralized algorithms through federated learning (FL) avoid data aggregation by instead distributing algorithms to the data before centrally updating one global model. OBJECTIVE:To establish a multicenter collaboration and assess the feasibility of using FL to train machine learning models for intracranial hemorrhage (ICH) detection without sharing data between sites. METHODS:Five neurosurgery departments across the United States collaborated to establish a federated network and train a convolutional neural network to detect ICH on computed tomography scans. The global FL model was benchmarked against a standard, centrally trained model using a held-out data set and was compared against locally trained models using site data. RESULTS:A federated network of practicing neurosurgeon scientists was successfully initiated to train a model for predicting ICH. The FL model achieved an area under the ROC curve of 0.9487 (95% CI 0.9471-0.9503) when predicting all subtypes of ICH compared with a benchmark (non-FL) area under the ROC curve of 0.9753 (95% CI 0.9742-0.9764), although performance varied by subtype. The FL model consistently achieved top three performance when validated on any site's data, suggesting improved generalizability. A qualitative survey described the experience of participants in the federated network. CONCLUSION/CONCLUSIONS:This study demonstrates the feasibility of implementing a federated network for multi-institutional collaboration among clinicians and using FL to conduct machine learning research, thereby opening a new paradigm for neurosurgical collaboration.
Assessing donor organ quality according to recipient characteristics in lung transplantation
OBJECTIVE:There is a shortage of donor lungs relative to need, but overall donor organ utilization remains low. The most common reason for refusal is organ quality, but the standards applied to selection vary. In this study we sought to characterize differences in lung utilization according to quality across several clinically distinct recipient pools. METHODS:Data on donor lungs recovered (April 2006 to September 2019) were extracted from the Scientific Registry of Transplant Recipients database. Organs were classified as ideal, standard, or extended quality according to their poorest metric among selected parameters. Subanalyses were performed on the basis of procedure type, age, lung allocation score, era, and alternative definitions of extended quality. Recipient traits and survival according to organ quality were assessed. RESULTS:Of 156,022 lungs analyzed during the study period, 25,777 (16.5%) were transplanted. There was no difference in quality distribution for single and bilateral transplants. Young candidates were more likely to receive ideal (14.7% vs 12.3%) or standard (9.5% vs 8.2%) lungs, but not extended lungs (75.9% vs 79.5%; all PÂ <Â .01). Absolute differences in distribution according to lung allocation score quartile were small (<2%). Extended quality donor utilization increased over time. Survival according to donor category was similar at 1 and 3Â years post transplant in unadjusted and Cox regression analyses. CONCLUSIONS:Extended quality lungs comprise an increasing share of transplants in a national sample. Organ selection varies according to recipient age and lung allocation score. However, absolute differences in quality distribution are small, and adverse effects on outcomes are limited to organs with multiple extended qualifying characteristics.
Desirable Difficulty: Theory and application of intentionally-challenging learning
CONTEXT/BACKGROUND:Health professions trainees must acquire a vast amount of clinical knowledge and skills, and a deliberate instructional design approach is needed to provide trainees with effective learning strategies. One powerful yet counterintuitive strategy that facilitates long-term learning is incorporating intentional difficulties during the learning process. Difficulties that require more effort from learners may impede short-term learning but are ultimately beneficial for long-term learning and are therefore termed, Desirable Difficulties. OBJECTIVES/OBJECTIVE:In this cross-cutting edge paper, we describe the Desirable Difficulty effect from three theoretical perspectives originating in different fields, discuss common evidence-based Desirable Difficulty strategies used in Health Professions Education, and explore emerging research that could further optimize Desirable Difficulty-enhanced learning for health professions trainees. METHODS:We synthesize theory and research from psychology, cognitive science, and health professions education literatures to further the understanding and application of Desirable Difficulties. We introduce three theoretical perspectives that provide a comprehensive overview of the theoretical underpinnings of the Desirable Difficulty effect: New Theory of Disuse, Challenge Point Framework, and Cognitive Load Theory. We then illustrate how three common Desirable Difficulty strategies in medical education research -- retrieval practice, spaced practice, and interleaved practice -- can be understood through these theoretical lenses. Finally, we provide relevant examples from the literature and explore emerging research in this area. CONCLUSIONS:This paper summarizes the theory and empirical research on Desirable Difficulties during the learning process, from explaining what they are and why they may be effective to how they have been applied in different contexts. We argue that providing educators and trainees with a comprehensive theoretical and applied understanding of Desirable Difficulty will promote deliberate instructional design decisions and lead to more effective learning.
Plasma Soluble Tumor Necrosis Factor Receptor Concentrations and Clinical Events After Hospitalization: Findings From the ASSESS-AKI and ARID Studies
RATIONALE & OBJECTIVE/OBJECTIVE:The role of plasma soluble tumor necrosis factor receptor (sTNFR)1 and sTNFR2 in the prognosis of clinical events after hospitalization with or without acute kidney injury (AKI) is unknown. STUDY DESIGN/METHODS:Prospective cohort. SETTING & PARTICIPANTS/METHODS:Hospital survivors from the Assessment, Serial Evaluation, and Subsequent Sequelae of Acute Kidney Injury (ASSESS-AKI) and AKI Risk in Derby (ARID) with and without AKI during the index hospitalization who had baseline serum samples for biomarker measurements. PREDICTORS/METHODS:We measured sTNFR1 and sTNFR2 obtained 3 months post-discharge. OUTCOMES/RESULTS:The associations between biomarkers with longitudinal kidney disease incidence and progression, heart failure and death were evaluated. ANALYTICAL APPROACH/METHODS:Cox proportional hazard models. RESULTS:Among 1474 participants with plasma biomarker measurements, 19% developed kidney disease progression, 14% had later heart failure, and 21% died over a median follow-up of 4.4 years. For the kidney outcome, the adjusted HRs per doubling in concentration were 2.9 (2.2-3.9) for sTNFR1 and 1.9 (1.5-2.5) for sTNFR2. AKI during the index hospitalization did not modify the association between biomarkers and kidney events. For heart failure, the adjusted HRs per doubling in concentration were 1.9 (1.4-2.5) for sTNFR1 and 1.5 (1.2-2.0) for sTNFR2. For mortality, the adjusted HRs were 3.3 (2.5-4.3) for sTNFR1 and 2.5 (2.0-3.1) for sTNFR2. The findings in ARID were qualitatively similar for the magnitude of association between biomarkers and outcomes. LIMITATIONS/CONCLUSIONS:Different biomarker platforms, AKI definitions, limited generalizability to other ethnic groups. CONCLUSION/CONCLUSIONS:Plasma sTNFR1 and sTNFR2 measured 3 months after discharge were independently associated with clinical events, regardless of AKI status during the index admission. sTNFR1 and sTNFR2 may assist with the risk stratification of patients during follow-up.
A Longitudinal View of Disparities in Insulin Pump Use Among Youth with Type 1 Diabetes: The SEARCH for Diabetes in Youth Study