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Simulation Resident‐as‐Teacher Program
Residency training, in addition to developing clinical competence among trainees, is charged with improving resident teaching skills. The Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education require that residents be provided with training or resources to develop their teaching skills.[1, 2] A variety of resident‐as‐teacher (RaT) programs have been described; however, the optimal format of such programs remains in question.[3] High‐fidelity medical simulation using mannequins has been shown to be an effective teaching tool in various medical specialties[4, 5, 6, 7] and may prove to be useful in teacher training.[8] Teaching in a simulation‐based environment can give participants the opportunity to apply their teaching skills in a clinical environment, as they would on the wards, but in a more controlled, predictable setting and without compromising patient safety. In addition, simulation offers the opportunity to engage in deliberate practice by allowing teachers to facilitate the same case on multiple occasions with different learners. Deliberate practice, which involves task repetition with feedback aimed at improving performance, has been shown to be important in developing expertise.[9]
We previously described the first use of a high‐fidelity simulation curriculum for internal medicine (IM) interns focused on clinical decision‐making skills, in which second‐ and third‐year residents served as facilitators.[10, 11] Herein, we describe a RaT program in which residents participated in a workshop, then served as facilitators in the intern curriculum and received feedback from faculty. We hypothesized that such a program would improve residents' teaching and feedback skills, both in the simulation environment and on the wards.
METHODS
We conducted a single‐group study evaluating teaching and feedback skills among upper‐level resident facilitators before and after participation in the RaT program. We measured residents' teaching skills using pre‐ and post‐program self‐assessments as well as evaluations completed by the intern learners after each session and at the completion of the curriculum.
Setting and Participants
We embedded the RaT program within a simulation curriculum administered July to October of 2013 for all IM interns at Massachusetts General Hospital (interns in the preliminary program who planned to pursue another field after the completion of the intern year were excluded) (n = 52). We invited postgraduate year (PGY) II and III residents (n = 102) to participate in the IM simulation program as facilitators via email. The curriculum consisted of 8 cases focusing on acute clinical scenarios encountered on the general medicine wards. The cases were administered during 1‐hour sessions 4 mornings per week from 7 AM to 8 AM prior to clinical duties. Interns completed the curriculum over 4 sessions during their outpatient rotation. The case topics were (1) hypertensive emergency, (2) post‐procedure bleed, (3) congestive heart failure, (4) atrial fibrillation with rapid ventricular response, (5) altered mental status/alcohol withdrawal, (6) nonsustained ventricular tachycardia heralding acute coronary syndrome, (7) cardiac tamponade, and (8) anaphylaxis. During each session, groups of 2 to 3 interns worked through 2 cases using a high‐fidelity mannequin (Laerdal 3G, Wappingers Falls, NY) with 2 resident facilitators. One facilitator operated the mannequin, while the other served as a nurse. Each case was followed by a structured debriefing led by 1 of the resident facilitators (facilitators switched roles for the second case). The number of sessions facilitated varied for each resident based on individual schedules and preferences.
Four senior residents who were appointed as simulation leaders (G.A.A., J.K.H., R.K., Z.S.) and 2 faculty advisors (P.F.C., E.M.M.) administered the program. Simulation resident leaders scheduled facilitators and interns and participated in a portion of simulation sessions as facilitators, but they were not analyzed as participants for the purposes of this study. The curriculum was administered without interfering with clinical duties, and no additional time was protected for interns or residents participating in the curriculum.
Resident‐as‐Teacher Program Structure
We invited participating resident facilitators to attend a 1‐hour interactive workshop prior to serving as facilitators. The workshop focused on building learner‐centered and small‐group teaching skills, as well as introducing residents to a 5‐stage debriefing framework developed by the authors and based on simulation debriefing best practices (Table 1).[12, 13, 14]
| Stage of Debriefing | Action | Rationale |
|---|---|---|
| ||
| Emotional response | Elicit learners' emotions about the case | It is important to acknowledge and address both positive and negative emotions that arise during the case before debriefing the specific medical and communications aspects of the case. Unaddressed emotional responses may hinder subsequent debriefing. |
| Objectives* | Elicit learners' objectives and combine them with the stated learning objectives of the case to determine debriefing objectives | The limited amount of time allocated for debriefing (1520 minutes) does not allow the facilitator to cover all aspects of medical management and communication skills in a particular case. Focusing on the most salient objectives, including those identified by the learners, allows the facilitator to engage in learner‐centered debriefing. |
| Analysis | Analyze the learners' approach to the case | Analyzing the learners' approach to the case using the advocacy‐inquiry method[11] seeks to uncover the learner's assumptions/frameworks behind the decision made during the case. This approach allows the facilitator to understand the learners' thought process and target teaching points to more precisely address the learners' needs. |
| Teaching | Address knowledge gaps and incorrect assumptions | Learner‐centered debriefing within a limited timeframe requires teaching to be brief and targeted toward the defined objectives. It should also address the knowledge gaps and incorrect assumptions uncovered during the analysis phase. |
| Summary | Summarize key takeaways | Summarizing highlights the key points of the debriefing and can be used to suggest further exploration of topics through self‐study (if necessary). |
Resident facilitators were observed by simulation faculty and simulation resident leaders throughout the intern curriculum and given structured feedback either in‐person immediately after completion of the simulation session or via a detailed same‐day e‐mail if the time allotted for feedback was not sufficient. Feedback was structured by the 5 stages of debriefing described in Table 1, and included soliciting residents' observations on the teaching experience and specific behaviors observed by faculty during the scenarios. E‐mail feedback (also structured by stages of debriefing and including observed behaviors) was typically followed by verbal feedback during the next simulation session.
The RaT program was composed of 3 elements: the workshop, case facilitation, and direct observation with feedback. Because we felt that the opportunity for directly observed teaching and feedback in a ward‐like controlled environment was a unique advantage offered by the simulation setting, we included all residents who served as facilitators in the analysis, regardless of whether or not they had attended the workshop.
Evaluation Instruments
Survey instruments were developed by the investigators, reviewed by several experts in simulation, pilot tested among residents not participating in the simulation program, and revised by the investigators.
Pre‐program Facilitator Survey
Prior to the RaT workshop, resident facilitators completed a baseline survey evaluating their preparedness to teach and give feedback on the wards and in a simulation‐based setting on a 5‐point scale (see Supporting Information, Appendix I, in the online version of this article).
Post‐program Facilitator Survey
Approximately 3 weeks after completion of the intern simulation curriculum, resident facilitators were asked to complete an online post‐program survey, which remained open for 1 month (residents completed this survey anywhere from 3 weeks to 4 months after their participation in the RaT program depending on the timing of their facilitation). The survey asked residents to evaluate their comfort with their current post‐program teaching skills as well as their pre‐program skills in retrospect, as previous research demonstrated that learners may overestimate their skills prior to training programs.[15] Resident facilitators could complete the surveys nonanonymously to allow for matched‐pairs analysis of the change in teaching skills over the course of the program (see Supporting Information, Appendix II, in the online version of this article).
Intern Evaluation of Facilitator Debriefing Skills
After each case, intern learners were asked to anonymously evaluate the teaching effectiveness of the lead resident facilitator using the adapted Debriefing Assessment for Simulation in Healthcare (DASH) instrument.[16] The DASH instrument evaluated the following domains: (1) instructor maintained an engaging context for learning, (2) instructor structured the debriefing in an organized way, (3) instructor provoked in‐depth discussions that led me to reflect on my performance, (4) instructor identified what I did well or poorly and why, (5) instructor helped me see how to improve or how to sustain good performance, (6) overall effectiveness of the simulation session (see Supporting Information, Appendix III, in the online version of this article).
Post‐program Intern Survey
Two months following the completion of the simulation curriculum, intern learners received an anonymous online post‐program evaluation assessing program efficacy and resident facilitator teaching (see Supporting Information, Appendix IV, in the online version of this article).
Statistical Analysis
Teaching skills and learners' DASH ratings were compared using the Student t test, Pearson 2 test, and Fisher exact test as appropriate. Pre‐ and post‐program rating of teaching skills was undertaken in aggregate and as a matched‐pairs analysis.
The study was approved by the Partners Institutional Review Board.
RESULTS
Forty‐one resident facilitators participated in 118 individual simulation sessions encompassing 236 case scenarios. Thirty‐four residents completed the post‐program facilitator survey and were included in the analysis. Of these, 26 (76%) participated in the workshop and completed the pre‐program survey. Twenty‐three of the 34 residents (68%) completed the post‐program evaluation nonanonymously (13 PGY‐II, 10 PGY‐III). Of these, 16 completed the pre‐program survey nonanonymously. The average number of sessions facilitated by each resident was 3.9 (range, 112).
Pre‐ and Post‐program Self‐Assessment of Residents' Teaching Skills
Participation in the simulation RaT program led to improvements in resident facilitators' self‐reported teaching skills across multiple domains (Table 2). These results were consistent when using the retrospective pre‐program assessment in matched‐pairs analysis (n=34) and when performing the analysis using the true pre‐program preparedness compared to post‐program comfort with teaching skills in a non‐matched‐pairs fashion (n = 26) and matched‐pairs fashion (n = 16). We report P values for the more conservative estimates using the retrospective pre‐program assessment matched‐pairs analysis. The most significant improvements occurred in residents' ability to teach in a simulated environment (2.81 to 4.16, P < 0.001 [5‐point scale]) and give feedback (3.35 to 3.77, P < 0.001).
| Pre‐program Rating (n = 34) | Post‐program Rating (n = 34) | P Value | |
|---|---|---|---|
| |||
| Teaching on rounds | 3.75 | 4.03 | 0.005 |
| Teaching on wards outside rounds | 3.83 | 4.07 | 0.007 |
| Teaching in simulation | 2.81 | 4.16 | <0.001 |
| Giving feedback | 3.35 | 3.77 | <0.001 |
Resident facilitators reported that participation in the RaT program had a significant impact on their teaching skills both within and outside of the simulation environment (Table 3). However, the greatest gains were seen in the domain of teaching in simulation. It was also noted that participation in the program improved resident facilitators' medical knowledge.
| Category | Not at All | Slightly Improved | Moderately Improved | Greatly Improved | Not Sure |
|---|---|---|---|---|---|
| Teaching on rounds, n = 34 | 4 (12%) | 12 (35%) | 13 (38%) | 4 (12%) | 1 (3%) |
| Teaching on wards outside rounds, n = 34 | 3 (9%) | 13 (38%) | 12 (35%) | 5 (15%) | 1 (3%) |
| Teaching in simulation, n = 34 | 0 (0%) | 4 (12%) | 7 (21%) | 23 (68%) | 0 (0%) |
| Giving feedback, n = 34 | 4 (12%) | 10 (29%) | 12 (35%) | 6 (18%) | 2 (6%) |
| Medical knowledge, n = 34 | 2 (6%) | 11 (32%) | 18 (53%) | 3 (9%) | 0 (0%) |
Subgroup analyses were performed comparing the perceived improvement in teaching and feedback skills among those who did or did not attend the facilitator workshop, those who facilitated 5 or more versus less than 5 sessions, and those who received or did not receive direct observation and feedback from faculty. Although numerically greater gains were seen across all 4 domains among those who attended the workshop, facilitated 5 or more sessions, or received feedback from faculty, only teaching on rounds and on the wards outside rounds reached statistical significance (Table 4). It should be noted that all residents who facilitated 5 or more sessions also attended the workshop and received feedback from faculty. We also compared perceived improvement among PGY‐II and PGY‐III residents. In contrast to PGY‐II residents, who demonstrated an improvement in all 4 domains, PGY‐III residents only demonstrated improvement in simulation‐based teaching.
| Pre‐program | Post‐program | P Value | Pre‐program | Post‐program | P Value | |
|---|---|---|---|---|---|---|
| Facilitated Less Than 5 Sessions (n = 18) | Facilitated 5 or More Sessions (n = 11) | |||||
| Did Not Attend Workshop (n = 10) | Attended Workshop (n = 22) | |||||
| Received Feedback From Resident Leaders Only (n = 11) | Received Faculty Feedback (n = 21) | |||||
| PGY‐II (n = 13) | PGY‐III (n = 9) | |||||
| ||||||
| Teaching on rounds | 3.68 | 3.79 | 0.16 | 3.85 | 4.38 | 0.01 |
| Teaching on wards outside rounds | 3.82 | 4 | 0.08 | 3.85 | 4.15 | 0.04 |
| Teaching in simulation | 2.89 | 4.06 | <0.01 | 2.69 | 4.31 | <0.01 |
| Giving feedback | 3.33 | 3.67 | 0.01 | 3.38 | 3.92 | 0.01 |
| Teaching on rounds | 4 | 4.1 | 0.34 | 3.64 | 4 | <0.01 |
| Teaching on wards outside rounds | 4 | 4 | 1.00 | 3.76 | 4.1 | <0.01 |
| Teaching in simulation | 2.89 | 4.11 | <0.01 | 2.77 | 4.18 | <0.01 |
| Giving feedback | 3.56 | 3.78 | 0.17 | 3.27 | 3.77 | <0.01 |
| Teaching on rounds | 3.55 | 3.82 | 0.19 | 3.86 | 4.14 | 0.01 |
| Teaching on wards outside rounds | 4 | 4 | 1.00 | 3.75 | 4.1 | <0.01 |
| Teaching in simulation | 2.7 | 3.8 | <0.01 | 2.86 | 4.33 | <0.01 |
| Giving feedback | 3.2 | 3.6 | 0.04 | 3.43 | 3.86 | <0.01 |
| Teaching on rounds | 3.38 | 3.85 | 0.03 | 4.22 | 4.22 | 1 |
| Teaching on wards outside rounds | 3.54 | 3.85 | 0.04 | 4.14 | 4.14 | 1 |
| Teaching in simulation | 2.46 | 4.15 | <0.01 | 3.13 | 4.13 | <0.01 |
| Giving feedback | 3.23 | 3.62 | 0.02 | 3.5 | 3.88 | 0.08 |
Intern Learners' Assessment of Resident Facilitators and the Program Overall
During the course of the program, intern learners completed 166 DASH ratings evaluating 34 resident facilitators (see Supporting Information, Appendix V, in the online version of this article). Ratings for the 6 DASH items ranged from 6.49 to 6.73 (7‐point scale), demonstrating a high level of facilitator efficacy across multiple domains. No differences in DASH scores were noted among subgroups of resident facilitators described in the previous paragraph.
Thirty‐eight of 52 intern learners (73%) completed the post‐program survey.
| Facilitator Behaviors | Very Often, >75% | Often, >50% | Sometimes, 25%50% | Rarely, <25% | Never |
|---|---|---|---|---|---|
| Elicited emotional reactions, n = 38 | 18 (47%) | 16 (42%) | 4 (11%) | 0 (0%) | 0 (0%) |
| Elicited objectives from learner, n = 37 | 26 (69%) | 8 (22%) | 2 (6%) | 1 (3%) | 0 (0%) |
| Asked to share clinical reasoning, n = 38 | 21 (56%) | 13 (33%) | 4 (11%) | 0 (0%) | 0 (0%) |
| Summarized learning points, n = 38 | 31 (81%) | 7 (19%) | 0 (0%) | 0 (0%) | 0 (0%) |
| Spoke for less than half of the session, n = 38 | 8 (22%) | 17 (44%) | 11 (28%) | 2 (6%) | 0 (0%) |
All intern learners rated the overall simulation experience as either excellent (81%) or good (19%) on the post‐program evaluation (4 or 5 on a 5‐point Likert scale, respectively). All interns strongly agreed (72%) or agreed (28%) that the simulation sessions improved their ability to manage acute clinical scenarios. Interns reported that resident facilitators frequently utilized specific debriefing techniques covered in the RaT curriculum during the debriefing sessions (Table 5).
DISCUSSION
We describe a unique RaT program embedded within a high‐fidelity medical simulation curriculum for IM interns. Our study demonstrates that resident facilitators noted an improvement in their teaching and feedback skills, both in the simulation setting and on the wards. Intern learners rated residents' teaching skills and the overall simulation curriculum highly, suggesting that residents were effective teachers.
The use of simulation in trainee‐as‐teacher curricula holds promise because it can provide an opportunity to teach in an environment closely approximating the wards, where trainees have the most opportunities to teach. However, in contrast to true ward‐based teaching, simulation can provide predictable scenarios in a controlled environment, which eliminates the distractions and unpredictability that exist on the wards, without compromising patient safety. Recently, Tofil et al. described the first use of simulation in a trainee‐as‐teacher program.[17] The investigators utilized a 1‐time simulation‐based teaching session, during which pediatric fellows completed a teacher‐training workshop, developed and served as facilitators in a simulated case, and received feedback. The use of simulation allowed fellows an opportunity to apply newly acquired skills in a controlled environment and receive feedback, which has been shown to improve teaching skills.[18]
The experience from our program expands on that of Tofil et al., as well as previously described trainee‐as‐teacher curricula, by introducing a component of deliberate practice that is unique to the simulation setting and has been absent from most previously described RaT programs.[3] Most residents had the opportunity to facilitate the same case on multiple occasions, allowing them to receive feedback and make adjustments. Residents who facilitated 5 or more sessions demonstrated more improvement, particularly in teaching outside of simulation, than residents who facilitated fewer sessions. It is notable that PGY‐II resident facilitators reported an improvement in their teaching skills on the wards, though less pronounced as compared to teaching in the simulation‐based environment, suggesting that benefits of the program may extend to nonsimulation‐based settings. Additional studies focusing on objective evaluation of ward‐based teaching are needed to further explore this phenomenon. Finally, the self‐reported improvements in medical knowledge by resident facilitators may serve as another benefit of our program.
Analysis of learner‐level data collected in the postcurriculum intern survey and DASH ratings provides additional support for the effectiveness of the RaT program. The majority of intern learners reported that resident facilitators used the techniques covered in our program frequently during debriefings. In addition, DASH scores clustered around maximum efficacy for all facilitators, suggesting that residents were effective teachers. Although we cannot directly assess whether the differences demonstrated in resident facilitators' self‐assessments translated to their teaching or were significant from the learners' perspective, these results support the hypothesis that self‐assessed improvements in teaching and feedback skills were significant.
In addition to improving resident teaching skills, our program had a positive impact on intern learners as evidenced by intern evaluations of the simulation curriculum. While utilizing relatively few faculty resources, our program was able to deliver an extensive and well‐received simulation curriculum to over 50 interns. The fact that 40% of second‐ and third‐year residents volunteered to teach in the program despite the early morning timing of the sessions speaks to the interest that trainees have in teaching in this setting. This model can serve as an important and efficient learning platform in residency training programs. It may be particularly salient to IM training programs where implementation of simulation curricula is challenging due to large numbers of residents and limited faculty resources. The barriers to and lessons learned from our experience with implementing the simulation curriculum have been previously described.[10, 11]
Our study has several limitations. Changes in residents' teaching skills were self‐assessed, which may be inaccurate as learners may overestimate their abilities.[19] Although we collected data on the experiences of intern learners that supported residents' self‐assessment, further studies using more objective measures (such as the Objective Structured Teaching Exercise[20]) should be undertaken. We did not objectively assess improvement of residents' teaching skills on the wards, with the exception of the residents' self assessment. Due to the timing of survey administration, some residents had as little as 1 month between completion of the curriculum and responding to the post‐curriculum survey, limiting their ability to evaluate their teaching skills on the wards. The transferability of the skills gained in simulation‐based teaching to teaching on the wards deserves further study. We cannot definitively attribute perceived improvement of teaching skills to the RaT program without a control group. However, the frequent use of recommended techniques during debriefing, which are not typically taught in other settings, supports the efficacy of the RaT program.
Our study did not allow us to determine which of the 3 components of the RaT program (workshop, facilitation practice, or direct observation and feedback) had the greatest impact on teaching skills or DASH ratings, as those who facilitated more sessions also completed the other components of the program. Furthermore, there may have been a selection bias among facilitators who facilitated more sessions. Because only 16 of 34 participants completed both the pre‐program and post‐program self‐assessments in a non‐anonymous fashion, we were not able to analyze the effect of pre‐program factors, such as prior teaching experience, on program outcomes. It should also be noted that allowing resident facilitators the option to complete the survey non‐anonymously could have biased our results. The simulation curriculum was conducted in a single center, and resident facilitators were self‐selecting; therefore, our results may not be generalizable. Finally, the DASH instrument was only administered after the RaT workshop and was likely limited further by the ceiling effect created by the learners' high satisfaction with the simulation program overall.
In summary, our simulation‐based RaT program improved resident facilitators' self‐reported teaching and feedback skills. Simulation‐based training provided an opportunity for deliberate practice of teaching skills in a controlled environment, which was a unique component of the program. The impact of deliberate practice on resident teaching skills and optimal methods to incorporate deliberate practice in RaT programs deserves further study. Our curriculum design may serve as a model for the development of simulation programs that can be employed to improve both intern learning and resident teaching skills.
Acknowledgements
The authors acknowledge Deborah Navedo, PhD, Assistant Professor, Massachusetts General Hospital Institute of Health Professions, and Emily M. Hayden, MD, Assistant Professor, Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, for their assistance with development of the RaT curriculum. The authors thank Dr. Jenny Rudolph, Senior Director, Institute for Medical Simulation at the Center for Medical Simulation, for her help in teaching us to use the DASH instrument. The authors also thank Dr. Daniel Hunt, MD, Associate Professor, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, for his thoughtful review of this manuscript.
Disclosure: Nothing to report.
- Liaison Committee on Medical Education. Functions and structure of a medical school: standards for accreditation of medical education programs leading to the M.D. degree. Washington, DC, and Chicago, IL: Association of American Medical Colleges and American Medical Association; 2000.
- Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in pediatrics. Available at: http://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQ-PIF/320_pediatrics_07012013.pdf. Accessed June 18, 2014.
- , , , . A systematic review of resident‐as‐teacher programmes. Med Educ. 2009;43(12):1129–1140.
- , , , et al. The utility of simulation in medical education: what is the evidence? Mt Sinai J Med. 2009;76:330–343.
- , , , et al. National growth in simulation training within emergency medicine residency programs, 2003–2008. Acad Emerg Med. 2008;15:1113–1116.
- , , , et al. Simulation center accreditation and programmatic benchmarks: a review for emergency medicine. Acad Emerg Med. 2010;17(10):1093–1103.
- . How much evidence does it take? A cumulative meta‐analysis of outcomes of simulation‐based education. Med Educ. 2014;48(8):750–760.
- , , , et al.. Resident‐as‐teacher: a suggested curriculum for emergency medicine. Acad Emerg Med. 2006;13(6):677–679.
- . Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004;79(10 suppl):S70–S81.
- , , , , , . Pilot program utilizing medical simulation in clinical decision making training for internal medicine interns. J Grad Med Educ. 2012;4:490–495.
- , , , et al. How we implemented a resident‐led medical simulation curriculum in a large internal medicine residency program. Med Teach. 2014;36(4):279–283.
- , , , . There's no such thing as “nonjudgmental” debriefing: a theory and method for debriefing with good judgment. Simul Healthc. 2006;1:49–55.
- , , , . Improving faculty feedback to resident trainees during a simulated case: a randomized, controlled trial of an educational intervention. Anesthesiology. 2014;120(1):160–171.
- . Introduction to debriefing. Semin Perinatol. 2013:37(3)166–174.
- , . Response‐shift bias: a source of contamination of self‐report measures. J Appl Psychol. 1979;4:93–106.
- Center for Medical Simulation. Debriefing assessment for simulation in healthcare. Available at: http://www.harvardmedsim.org/debriefing‐assesment‐simulation‐healthcare.php. Accessed June 18, 2014.
- , , , et al. A novel iterative‐learner simulation model: fellows as teachers. J Grad Med Educ. 2014;6(1):127–132.
- , , . Direct observation of faculty with feedback: an effective means of improving patient‐centered and learner‐centered teaching skills. Teach Learn Med. 2007;19(3):278–286.
- , . Unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self assessments. J Pers Soc Psychol. 1999;77:1121–1134.
- , , , et al. Reliability and validity of an objective structured teaching examination for generalist resident teachers. Acad Med. 2002;77(10 suppl):S29–S32.
Residency training, in addition to developing clinical competence among trainees, is charged with improving resident teaching skills. The Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education require that residents be provided with training or resources to develop their teaching skills.[1, 2] A variety of resident‐as‐teacher (RaT) programs have been described; however, the optimal format of such programs remains in question.[3] High‐fidelity medical simulation using mannequins has been shown to be an effective teaching tool in various medical specialties[4, 5, 6, 7] and may prove to be useful in teacher training.[8] Teaching in a simulation‐based environment can give participants the opportunity to apply their teaching skills in a clinical environment, as they would on the wards, but in a more controlled, predictable setting and without compromising patient safety. In addition, simulation offers the opportunity to engage in deliberate practice by allowing teachers to facilitate the same case on multiple occasions with different learners. Deliberate practice, which involves task repetition with feedback aimed at improving performance, has been shown to be important in developing expertise.[9]
We previously described the first use of a high‐fidelity simulation curriculum for internal medicine (IM) interns focused on clinical decision‐making skills, in which second‐ and third‐year residents served as facilitators.[10, 11] Herein, we describe a RaT program in which residents participated in a workshop, then served as facilitators in the intern curriculum and received feedback from faculty. We hypothesized that such a program would improve residents' teaching and feedback skills, both in the simulation environment and on the wards.
METHODS
We conducted a single‐group study evaluating teaching and feedback skills among upper‐level resident facilitators before and after participation in the RaT program. We measured residents' teaching skills using pre‐ and post‐program self‐assessments as well as evaluations completed by the intern learners after each session and at the completion of the curriculum.
Setting and Participants
We embedded the RaT program within a simulation curriculum administered July to October of 2013 for all IM interns at Massachusetts General Hospital (interns in the preliminary program who planned to pursue another field after the completion of the intern year were excluded) (n = 52). We invited postgraduate year (PGY) II and III residents (n = 102) to participate in the IM simulation program as facilitators via email. The curriculum consisted of 8 cases focusing on acute clinical scenarios encountered on the general medicine wards. The cases were administered during 1‐hour sessions 4 mornings per week from 7 AM to 8 AM prior to clinical duties. Interns completed the curriculum over 4 sessions during their outpatient rotation. The case topics were (1) hypertensive emergency, (2) post‐procedure bleed, (3) congestive heart failure, (4) atrial fibrillation with rapid ventricular response, (5) altered mental status/alcohol withdrawal, (6) nonsustained ventricular tachycardia heralding acute coronary syndrome, (7) cardiac tamponade, and (8) anaphylaxis. During each session, groups of 2 to 3 interns worked through 2 cases using a high‐fidelity mannequin (Laerdal 3G, Wappingers Falls, NY) with 2 resident facilitators. One facilitator operated the mannequin, while the other served as a nurse. Each case was followed by a structured debriefing led by 1 of the resident facilitators (facilitators switched roles for the second case). The number of sessions facilitated varied for each resident based on individual schedules and preferences.
Four senior residents who were appointed as simulation leaders (G.A.A., J.K.H., R.K., Z.S.) and 2 faculty advisors (P.F.C., E.M.M.) administered the program. Simulation resident leaders scheduled facilitators and interns and participated in a portion of simulation sessions as facilitators, but they were not analyzed as participants for the purposes of this study. The curriculum was administered without interfering with clinical duties, and no additional time was protected for interns or residents participating in the curriculum.
Resident‐as‐Teacher Program Structure
We invited participating resident facilitators to attend a 1‐hour interactive workshop prior to serving as facilitators. The workshop focused on building learner‐centered and small‐group teaching skills, as well as introducing residents to a 5‐stage debriefing framework developed by the authors and based on simulation debriefing best practices (Table 1).[12, 13, 14]
| Stage of Debriefing | Action | Rationale |
|---|---|---|
| ||
| Emotional response | Elicit learners' emotions about the case | It is important to acknowledge and address both positive and negative emotions that arise during the case before debriefing the specific medical and communications aspects of the case. Unaddressed emotional responses may hinder subsequent debriefing. |
| Objectives* | Elicit learners' objectives and combine them with the stated learning objectives of the case to determine debriefing objectives | The limited amount of time allocated for debriefing (1520 minutes) does not allow the facilitator to cover all aspects of medical management and communication skills in a particular case. Focusing on the most salient objectives, including those identified by the learners, allows the facilitator to engage in learner‐centered debriefing. |
| Analysis | Analyze the learners' approach to the case | Analyzing the learners' approach to the case using the advocacy‐inquiry method[11] seeks to uncover the learner's assumptions/frameworks behind the decision made during the case. This approach allows the facilitator to understand the learners' thought process and target teaching points to more precisely address the learners' needs. |
| Teaching | Address knowledge gaps and incorrect assumptions | Learner‐centered debriefing within a limited timeframe requires teaching to be brief and targeted toward the defined objectives. It should also address the knowledge gaps and incorrect assumptions uncovered during the analysis phase. |
| Summary | Summarize key takeaways | Summarizing highlights the key points of the debriefing and can be used to suggest further exploration of topics through self‐study (if necessary). |
Resident facilitators were observed by simulation faculty and simulation resident leaders throughout the intern curriculum and given structured feedback either in‐person immediately after completion of the simulation session or via a detailed same‐day e‐mail if the time allotted for feedback was not sufficient. Feedback was structured by the 5 stages of debriefing described in Table 1, and included soliciting residents' observations on the teaching experience and specific behaviors observed by faculty during the scenarios. E‐mail feedback (also structured by stages of debriefing and including observed behaviors) was typically followed by verbal feedback during the next simulation session.
The RaT program was composed of 3 elements: the workshop, case facilitation, and direct observation with feedback. Because we felt that the opportunity for directly observed teaching and feedback in a ward‐like controlled environment was a unique advantage offered by the simulation setting, we included all residents who served as facilitators in the analysis, regardless of whether or not they had attended the workshop.
Evaluation Instruments
Survey instruments were developed by the investigators, reviewed by several experts in simulation, pilot tested among residents not participating in the simulation program, and revised by the investigators.
Pre‐program Facilitator Survey
Prior to the RaT workshop, resident facilitators completed a baseline survey evaluating their preparedness to teach and give feedback on the wards and in a simulation‐based setting on a 5‐point scale (see Supporting Information, Appendix I, in the online version of this article).
Post‐program Facilitator Survey
Approximately 3 weeks after completion of the intern simulation curriculum, resident facilitators were asked to complete an online post‐program survey, which remained open for 1 month (residents completed this survey anywhere from 3 weeks to 4 months after their participation in the RaT program depending on the timing of their facilitation). The survey asked residents to evaluate their comfort with their current post‐program teaching skills as well as their pre‐program skills in retrospect, as previous research demonstrated that learners may overestimate their skills prior to training programs.[15] Resident facilitators could complete the surveys nonanonymously to allow for matched‐pairs analysis of the change in teaching skills over the course of the program (see Supporting Information, Appendix II, in the online version of this article).
Intern Evaluation of Facilitator Debriefing Skills
After each case, intern learners were asked to anonymously evaluate the teaching effectiveness of the lead resident facilitator using the adapted Debriefing Assessment for Simulation in Healthcare (DASH) instrument.[16] The DASH instrument evaluated the following domains: (1) instructor maintained an engaging context for learning, (2) instructor structured the debriefing in an organized way, (3) instructor provoked in‐depth discussions that led me to reflect on my performance, (4) instructor identified what I did well or poorly and why, (5) instructor helped me see how to improve or how to sustain good performance, (6) overall effectiveness of the simulation session (see Supporting Information, Appendix III, in the online version of this article).
Post‐program Intern Survey
Two months following the completion of the simulation curriculum, intern learners received an anonymous online post‐program evaluation assessing program efficacy and resident facilitator teaching (see Supporting Information, Appendix IV, in the online version of this article).
Statistical Analysis
Teaching skills and learners' DASH ratings were compared using the Student t test, Pearson 2 test, and Fisher exact test as appropriate. Pre‐ and post‐program rating of teaching skills was undertaken in aggregate and as a matched‐pairs analysis.
The study was approved by the Partners Institutional Review Board.
RESULTS
Forty‐one resident facilitators participated in 118 individual simulation sessions encompassing 236 case scenarios. Thirty‐four residents completed the post‐program facilitator survey and were included in the analysis. Of these, 26 (76%) participated in the workshop and completed the pre‐program survey. Twenty‐three of the 34 residents (68%) completed the post‐program evaluation nonanonymously (13 PGY‐II, 10 PGY‐III). Of these, 16 completed the pre‐program survey nonanonymously. The average number of sessions facilitated by each resident was 3.9 (range, 112).
Pre‐ and Post‐program Self‐Assessment of Residents' Teaching Skills
Participation in the simulation RaT program led to improvements in resident facilitators' self‐reported teaching skills across multiple domains (Table 2). These results were consistent when using the retrospective pre‐program assessment in matched‐pairs analysis (n=34) and when performing the analysis using the true pre‐program preparedness compared to post‐program comfort with teaching skills in a non‐matched‐pairs fashion (n = 26) and matched‐pairs fashion (n = 16). We report P values for the more conservative estimates using the retrospective pre‐program assessment matched‐pairs analysis. The most significant improvements occurred in residents' ability to teach in a simulated environment (2.81 to 4.16, P < 0.001 [5‐point scale]) and give feedback (3.35 to 3.77, P < 0.001).
| Pre‐program Rating (n = 34) | Post‐program Rating (n = 34) | P Value | |
|---|---|---|---|
| |||
| Teaching on rounds | 3.75 | 4.03 | 0.005 |
| Teaching on wards outside rounds | 3.83 | 4.07 | 0.007 |
| Teaching in simulation | 2.81 | 4.16 | <0.001 |
| Giving feedback | 3.35 | 3.77 | <0.001 |
Resident facilitators reported that participation in the RaT program had a significant impact on their teaching skills both within and outside of the simulation environment (Table 3). However, the greatest gains were seen in the domain of teaching in simulation. It was also noted that participation in the program improved resident facilitators' medical knowledge.
| Category | Not at All | Slightly Improved | Moderately Improved | Greatly Improved | Not Sure |
|---|---|---|---|---|---|
| Teaching on rounds, n = 34 | 4 (12%) | 12 (35%) | 13 (38%) | 4 (12%) | 1 (3%) |
| Teaching on wards outside rounds, n = 34 | 3 (9%) | 13 (38%) | 12 (35%) | 5 (15%) | 1 (3%) |
| Teaching in simulation, n = 34 | 0 (0%) | 4 (12%) | 7 (21%) | 23 (68%) | 0 (0%) |
| Giving feedback, n = 34 | 4 (12%) | 10 (29%) | 12 (35%) | 6 (18%) | 2 (6%) |
| Medical knowledge, n = 34 | 2 (6%) | 11 (32%) | 18 (53%) | 3 (9%) | 0 (0%) |
Subgroup analyses were performed comparing the perceived improvement in teaching and feedback skills among those who did or did not attend the facilitator workshop, those who facilitated 5 or more versus less than 5 sessions, and those who received or did not receive direct observation and feedback from faculty. Although numerically greater gains were seen across all 4 domains among those who attended the workshop, facilitated 5 or more sessions, or received feedback from faculty, only teaching on rounds and on the wards outside rounds reached statistical significance (Table 4). It should be noted that all residents who facilitated 5 or more sessions also attended the workshop and received feedback from faculty. We also compared perceived improvement among PGY‐II and PGY‐III residents. In contrast to PGY‐II residents, who demonstrated an improvement in all 4 domains, PGY‐III residents only demonstrated improvement in simulation‐based teaching.
| Pre‐program | Post‐program | P Value | Pre‐program | Post‐program | P Value | |
|---|---|---|---|---|---|---|
| Facilitated Less Than 5 Sessions (n = 18) | Facilitated 5 or More Sessions (n = 11) | |||||
| Did Not Attend Workshop (n = 10) | Attended Workshop (n = 22) | |||||
| Received Feedback From Resident Leaders Only (n = 11) | Received Faculty Feedback (n = 21) | |||||
| PGY‐II (n = 13) | PGY‐III (n = 9) | |||||
| ||||||
| Teaching on rounds | 3.68 | 3.79 | 0.16 | 3.85 | 4.38 | 0.01 |
| Teaching on wards outside rounds | 3.82 | 4 | 0.08 | 3.85 | 4.15 | 0.04 |
| Teaching in simulation | 2.89 | 4.06 | <0.01 | 2.69 | 4.31 | <0.01 |
| Giving feedback | 3.33 | 3.67 | 0.01 | 3.38 | 3.92 | 0.01 |
| Teaching on rounds | 4 | 4.1 | 0.34 | 3.64 | 4 | <0.01 |
| Teaching on wards outside rounds | 4 | 4 | 1.00 | 3.76 | 4.1 | <0.01 |
| Teaching in simulation | 2.89 | 4.11 | <0.01 | 2.77 | 4.18 | <0.01 |
| Giving feedback | 3.56 | 3.78 | 0.17 | 3.27 | 3.77 | <0.01 |
| Teaching on rounds | 3.55 | 3.82 | 0.19 | 3.86 | 4.14 | 0.01 |
| Teaching on wards outside rounds | 4 | 4 | 1.00 | 3.75 | 4.1 | <0.01 |
| Teaching in simulation | 2.7 | 3.8 | <0.01 | 2.86 | 4.33 | <0.01 |
| Giving feedback | 3.2 | 3.6 | 0.04 | 3.43 | 3.86 | <0.01 |
| Teaching on rounds | 3.38 | 3.85 | 0.03 | 4.22 | 4.22 | 1 |
| Teaching on wards outside rounds | 3.54 | 3.85 | 0.04 | 4.14 | 4.14 | 1 |
| Teaching in simulation | 2.46 | 4.15 | <0.01 | 3.13 | 4.13 | <0.01 |
| Giving feedback | 3.23 | 3.62 | 0.02 | 3.5 | 3.88 | 0.08 |
Intern Learners' Assessment of Resident Facilitators and the Program Overall
During the course of the program, intern learners completed 166 DASH ratings evaluating 34 resident facilitators (see Supporting Information, Appendix V, in the online version of this article). Ratings for the 6 DASH items ranged from 6.49 to 6.73 (7‐point scale), demonstrating a high level of facilitator efficacy across multiple domains. No differences in DASH scores were noted among subgroups of resident facilitators described in the previous paragraph.
Thirty‐eight of 52 intern learners (73%) completed the post‐program survey.
| Facilitator Behaviors | Very Often, >75% | Often, >50% | Sometimes, 25%50% | Rarely, <25% | Never |
|---|---|---|---|---|---|
| Elicited emotional reactions, n = 38 | 18 (47%) | 16 (42%) | 4 (11%) | 0 (0%) | 0 (0%) |
| Elicited objectives from learner, n = 37 | 26 (69%) | 8 (22%) | 2 (6%) | 1 (3%) | 0 (0%) |
| Asked to share clinical reasoning, n = 38 | 21 (56%) | 13 (33%) | 4 (11%) | 0 (0%) | 0 (0%) |
| Summarized learning points, n = 38 | 31 (81%) | 7 (19%) | 0 (0%) | 0 (0%) | 0 (0%) |
| Spoke for less than half of the session, n = 38 | 8 (22%) | 17 (44%) | 11 (28%) | 2 (6%) | 0 (0%) |
All intern learners rated the overall simulation experience as either excellent (81%) or good (19%) on the post‐program evaluation (4 or 5 on a 5‐point Likert scale, respectively). All interns strongly agreed (72%) or agreed (28%) that the simulation sessions improved their ability to manage acute clinical scenarios. Interns reported that resident facilitators frequently utilized specific debriefing techniques covered in the RaT curriculum during the debriefing sessions (Table 5).
DISCUSSION
We describe a unique RaT program embedded within a high‐fidelity medical simulation curriculum for IM interns. Our study demonstrates that resident facilitators noted an improvement in their teaching and feedback skills, both in the simulation setting and on the wards. Intern learners rated residents' teaching skills and the overall simulation curriculum highly, suggesting that residents were effective teachers.
The use of simulation in trainee‐as‐teacher curricula holds promise because it can provide an opportunity to teach in an environment closely approximating the wards, where trainees have the most opportunities to teach. However, in contrast to true ward‐based teaching, simulation can provide predictable scenarios in a controlled environment, which eliminates the distractions and unpredictability that exist on the wards, without compromising patient safety. Recently, Tofil et al. described the first use of simulation in a trainee‐as‐teacher program.[17] The investigators utilized a 1‐time simulation‐based teaching session, during which pediatric fellows completed a teacher‐training workshop, developed and served as facilitators in a simulated case, and received feedback. The use of simulation allowed fellows an opportunity to apply newly acquired skills in a controlled environment and receive feedback, which has been shown to improve teaching skills.[18]
The experience from our program expands on that of Tofil et al., as well as previously described trainee‐as‐teacher curricula, by introducing a component of deliberate practice that is unique to the simulation setting and has been absent from most previously described RaT programs.[3] Most residents had the opportunity to facilitate the same case on multiple occasions, allowing them to receive feedback and make adjustments. Residents who facilitated 5 or more sessions demonstrated more improvement, particularly in teaching outside of simulation, than residents who facilitated fewer sessions. It is notable that PGY‐II resident facilitators reported an improvement in their teaching skills on the wards, though less pronounced as compared to teaching in the simulation‐based environment, suggesting that benefits of the program may extend to nonsimulation‐based settings. Additional studies focusing on objective evaluation of ward‐based teaching are needed to further explore this phenomenon. Finally, the self‐reported improvements in medical knowledge by resident facilitators may serve as another benefit of our program.
Analysis of learner‐level data collected in the postcurriculum intern survey and DASH ratings provides additional support for the effectiveness of the RaT program. The majority of intern learners reported that resident facilitators used the techniques covered in our program frequently during debriefings. In addition, DASH scores clustered around maximum efficacy for all facilitators, suggesting that residents were effective teachers. Although we cannot directly assess whether the differences demonstrated in resident facilitators' self‐assessments translated to their teaching or were significant from the learners' perspective, these results support the hypothesis that self‐assessed improvements in teaching and feedback skills were significant.
In addition to improving resident teaching skills, our program had a positive impact on intern learners as evidenced by intern evaluations of the simulation curriculum. While utilizing relatively few faculty resources, our program was able to deliver an extensive and well‐received simulation curriculum to over 50 interns. The fact that 40% of second‐ and third‐year residents volunteered to teach in the program despite the early morning timing of the sessions speaks to the interest that trainees have in teaching in this setting. This model can serve as an important and efficient learning platform in residency training programs. It may be particularly salient to IM training programs where implementation of simulation curricula is challenging due to large numbers of residents and limited faculty resources. The barriers to and lessons learned from our experience with implementing the simulation curriculum have been previously described.[10, 11]
Our study has several limitations. Changes in residents' teaching skills were self‐assessed, which may be inaccurate as learners may overestimate their abilities.[19] Although we collected data on the experiences of intern learners that supported residents' self‐assessment, further studies using more objective measures (such as the Objective Structured Teaching Exercise[20]) should be undertaken. We did not objectively assess improvement of residents' teaching skills on the wards, with the exception of the residents' self assessment. Due to the timing of survey administration, some residents had as little as 1 month between completion of the curriculum and responding to the post‐curriculum survey, limiting their ability to evaluate their teaching skills on the wards. The transferability of the skills gained in simulation‐based teaching to teaching on the wards deserves further study. We cannot definitively attribute perceived improvement of teaching skills to the RaT program without a control group. However, the frequent use of recommended techniques during debriefing, which are not typically taught in other settings, supports the efficacy of the RaT program.
Our study did not allow us to determine which of the 3 components of the RaT program (workshop, facilitation practice, or direct observation and feedback) had the greatest impact on teaching skills or DASH ratings, as those who facilitated more sessions also completed the other components of the program. Furthermore, there may have been a selection bias among facilitators who facilitated more sessions. Because only 16 of 34 participants completed both the pre‐program and post‐program self‐assessments in a non‐anonymous fashion, we were not able to analyze the effect of pre‐program factors, such as prior teaching experience, on program outcomes. It should also be noted that allowing resident facilitators the option to complete the survey non‐anonymously could have biased our results. The simulation curriculum was conducted in a single center, and resident facilitators were self‐selecting; therefore, our results may not be generalizable. Finally, the DASH instrument was only administered after the RaT workshop and was likely limited further by the ceiling effect created by the learners' high satisfaction with the simulation program overall.
In summary, our simulation‐based RaT program improved resident facilitators' self‐reported teaching and feedback skills. Simulation‐based training provided an opportunity for deliberate practice of teaching skills in a controlled environment, which was a unique component of the program. The impact of deliberate practice on resident teaching skills and optimal methods to incorporate deliberate practice in RaT programs deserves further study. Our curriculum design may serve as a model for the development of simulation programs that can be employed to improve both intern learning and resident teaching skills.
Acknowledgements
The authors acknowledge Deborah Navedo, PhD, Assistant Professor, Massachusetts General Hospital Institute of Health Professions, and Emily M. Hayden, MD, Assistant Professor, Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, for their assistance with development of the RaT curriculum. The authors thank Dr. Jenny Rudolph, Senior Director, Institute for Medical Simulation at the Center for Medical Simulation, for her help in teaching us to use the DASH instrument. The authors also thank Dr. Daniel Hunt, MD, Associate Professor, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, for his thoughtful review of this manuscript.
Disclosure: Nothing to report.
Residency training, in addition to developing clinical competence among trainees, is charged with improving resident teaching skills. The Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education require that residents be provided with training or resources to develop their teaching skills.[1, 2] A variety of resident‐as‐teacher (RaT) programs have been described; however, the optimal format of such programs remains in question.[3] High‐fidelity medical simulation using mannequins has been shown to be an effective teaching tool in various medical specialties[4, 5, 6, 7] and may prove to be useful in teacher training.[8] Teaching in a simulation‐based environment can give participants the opportunity to apply their teaching skills in a clinical environment, as they would on the wards, but in a more controlled, predictable setting and without compromising patient safety. In addition, simulation offers the opportunity to engage in deliberate practice by allowing teachers to facilitate the same case on multiple occasions with different learners. Deliberate practice, which involves task repetition with feedback aimed at improving performance, has been shown to be important in developing expertise.[9]
We previously described the first use of a high‐fidelity simulation curriculum for internal medicine (IM) interns focused on clinical decision‐making skills, in which second‐ and third‐year residents served as facilitators.[10, 11] Herein, we describe a RaT program in which residents participated in a workshop, then served as facilitators in the intern curriculum and received feedback from faculty. We hypothesized that such a program would improve residents' teaching and feedback skills, both in the simulation environment and on the wards.
METHODS
We conducted a single‐group study evaluating teaching and feedback skills among upper‐level resident facilitators before and after participation in the RaT program. We measured residents' teaching skills using pre‐ and post‐program self‐assessments as well as evaluations completed by the intern learners after each session and at the completion of the curriculum.
Setting and Participants
We embedded the RaT program within a simulation curriculum administered July to October of 2013 for all IM interns at Massachusetts General Hospital (interns in the preliminary program who planned to pursue another field after the completion of the intern year were excluded) (n = 52). We invited postgraduate year (PGY) II and III residents (n = 102) to participate in the IM simulation program as facilitators via email. The curriculum consisted of 8 cases focusing on acute clinical scenarios encountered on the general medicine wards. The cases were administered during 1‐hour sessions 4 mornings per week from 7 AM to 8 AM prior to clinical duties. Interns completed the curriculum over 4 sessions during their outpatient rotation. The case topics were (1) hypertensive emergency, (2) post‐procedure bleed, (3) congestive heart failure, (4) atrial fibrillation with rapid ventricular response, (5) altered mental status/alcohol withdrawal, (6) nonsustained ventricular tachycardia heralding acute coronary syndrome, (7) cardiac tamponade, and (8) anaphylaxis. During each session, groups of 2 to 3 interns worked through 2 cases using a high‐fidelity mannequin (Laerdal 3G, Wappingers Falls, NY) with 2 resident facilitators. One facilitator operated the mannequin, while the other served as a nurse. Each case was followed by a structured debriefing led by 1 of the resident facilitators (facilitators switched roles for the second case). The number of sessions facilitated varied for each resident based on individual schedules and preferences.
Four senior residents who were appointed as simulation leaders (G.A.A., J.K.H., R.K., Z.S.) and 2 faculty advisors (P.F.C., E.M.M.) administered the program. Simulation resident leaders scheduled facilitators and interns and participated in a portion of simulation sessions as facilitators, but they were not analyzed as participants for the purposes of this study. The curriculum was administered without interfering with clinical duties, and no additional time was protected for interns or residents participating in the curriculum.
Resident‐as‐Teacher Program Structure
We invited participating resident facilitators to attend a 1‐hour interactive workshop prior to serving as facilitators. The workshop focused on building learner‐centered and small‐group teaching skills, as well as introducing residents to a 5‐stage debriefing framework developed by the authors and based on simulation debriefing best practices (Table 1).[12, 13, 14]
| Stage of Debriefing | Action | Rationale |
|---|---|---|
| ||
| Emotional response | Elicit learners' emotions about the case | It is important to acknowledge and address both positive and negative emotions that arise during the case before debriefing the specific medical and communications aspects of the case. Unaddressed emotional responses may hinder subsequent debriefing. |
| Objectives* | Elicit learners' objectives and combine them with the stated learning objectives of the case to determine debriefing objectives | The limited amount of time allocated for debriefing (1520 minutes) does not allow the facilitator to cover all aspects of medical management and communication skills in a particular case. Focusing on the most salient objectives, including those identified by the learners, allows the facilitator to engage in learner‐centered debriefing. |
| Analysis | Analyze the learners' approach to the case | Analyzing the learners' approach to the case using the advocacy‐inquiry method[11] seeks to uncover the learner's assumptions/frameworks behind the decision made during the case. This approach allows the facilitator to understand the learners' thought process and target teaching points to more precisely address the learners' needs. |
| Teaching | Address knowledge gaps and incorrect assumptions | Learner‐centered debriefing within a limited timeframe requires teaching to be brief and targeted toward the defined objectives. It should also address the knowledge gaps and incorrect assumptions uncovered during the analysis phase. |
| Summary | Summarize key takeaways | Summarizing highlights the key points of the debriefing and can be used to suggest further exploration of topics through self‐study (if necessary). |
Resident facilitators were observed by simulation faculty and simulation resident leaders throughout the intern curriculum and given structured feedback either in‐person immediately after completion of the simulation session or via a detailed same‐day e‐mail if the time allotted for feedback was not sufficient. Feedback was structured by the 5 stages of debriefing described in Table 1, and included soliciting residents' observations on the teaching experience and specific behaviors observed by faculty during the scenarios. E‐mail feedback (also structured by stages of debriefing and including observed behaviors) was typically followed by verbal feedback during the next simulation session.
The RaT program was composed of 3 elements: the workshop, case facilitation, and direct observation with feedback. Because we felt that the opportunity for directly observed teaching and feedback in a ward‐like controlled environment was a unique advantage offered by the simulation setting, we included all residents who served as facilitators in the analysis, regardless of whether or not they had attended the workshop.
Evaluation Instruments
Survey instruments were developed by the investigators, reviewed by several experts in simulation, pilot tested among residents not participating in the simulation program, and revised by the investigators.
Pre‐program Facilitator Survey
Prior to the RaT workshop, resident facilitators completed a baseline survey evaluating their preparedness to teach and give feedback on the wards and in a simulation‐based setting on a 5‐point scale (see Supporting Information, Appendix I, in the online version of this article).
Post‐program Facilitator Survey
Approximately 3 weeks after completion of the intern simulation curriculum, resident facilitators were asked to complete an online post‐program survey, which remained open for 1 month (residents completed this survey anywhere from 3 weeks to 4 months after their participation in the RaT program depending on the timing of their facilitation). The survey asked residents to evaluate their comfort with their current post‐program teaching skills as well as their pre‐program skills in retrospect, as previous research demonstrated that learners may overestimate their skills prior to training programs.[15] Resident facilitators could complete the surveys nonanonymously to allow for matched‐pairs analysis of the change in teaching skills over the course of the program (see Supporting Information, Appendix II, in the online version of this article).
Intern Evaluation of Facilitator Debriefing Skills
After each case, intern learners were asked to anonymously evaluate the teaching effectiveness of the lead resident facilitator using the adapted Debriefing Assessment for Simulation in Healthcare (DASH) instrument.[16] The DASH instrument evaluated the following domains: (1) instructor maintained an engaging context for learning, (2) instructor structured the debriefing in an organized way, (3) instructor provoked in‐depth discussions that led me to reflect on my performance, (4) instructor identified what I did well or poorly and why, (5) instructor helped me see how to improve or how to sustain good performance, (6) overall effectiveness of the simulation session (see Supporting Information, Appendix III, in the online version of this article).
Post‐program Intern Survey
Two months following the completion of the simulation curriculum, intern learners received an anonymous online post‐program evaluation assessing program efficacy and resident facilitator teaching (see Supporting Information, Appendix IV, in the online version of this article).
Statistical Analysis
Teaching skills and learners' DASH ratings were compared using the Student t test, Pearson 2 test, and Fisher exact test as appropriate. Pre‐ and post‐program rating of teaching skills was undertaken in aggregate and as a matched‐pairs analysis.
The study was approved by the Partners Institutional Review Board.
RESULTS
Forty‐one resident facilitators participated in 118 individual simulation sessions encompassing 236 case scenarios. Thirty‐four residents completed the post‐program facilitator survey and were included in the analysis. Of these, 26 (76%) participated in the workshop and completed the pre‐program survey. Twenty‐three of the 34 residents (68%) completed the post‐program evaluation nonanonymously (13 PGY‐II, 10 PGY‐III). Of these, 16 completed the pre‐program survey nonanonymously. The average number of sessions facilitated by each resident was 3.9 (range, 112).
Pre‐ and Post‐program Self‐Assessment of Residents' Teaching Skills
Participation in the simulation RaT program led to improvements in resident facilitators' self‐reported teaching skills across multiple domains (Table 2). These results were consistent when using the retrospective pre‐program assessment in matched‐pairs analysis (n=34) and when performing the analysis using the true pre‐program preparedness compared to post‐program comfort with teaching skills in a non‐matched‐pairs fashion (n = 26) and matched‐pairs fashion (n = 16). We report P values for the more conservative estimates using the retrospective pre‐program assessment matched‐pairs analysis. The most significant improvements occurred in residents' ability to teach in a simulated environment (2.81 to 4.16, P < 0.001 [5‐point scale]) and give feedback (3.35 to 3.77, P < 0.001).
| Pre‐program Rating (n = 34) | Post‐program Rating (n = 34) | P Value | |
|---|---|---|---|
| |||
| Teaching on rounds | 3.75 | 4.03 | 0.005 |
| Teaching on wards outside rounds | 3.83 | 4.07 | 0.007 |
| Teaching in simulation | 2.81 | 4.16 | <0.001 |
| Giving feedback | 3.35 | 3.77 | <0.001 |
Resident facilitators reported that participation in the RaT program had a significant impact on their teaching skills both within and outside of the simulation environment (Table 3). However, the greatest gains were seen in the domain of teaching in simulation. It was also noted that participation in the program improved resident facilitators' medical knowledge.
| Category | Not at All | Slightly Improved | Moderately Improved | Greatly Improved | Not Sure |
|---|---|---|---|---|---|
| Teaching on rounds, n = 34 | 4 (12%) | 12 (35%) | 13 (38%) | 4 (12%) | 1 (3%) |
| Teaching on wards outside rounds, n = 34 | 3 (9%) | 13 (38%) | 12 (35%) | 5 (15%) | 1 (3%) |
| Teaching in simulation, n = 34 | 0 (0%) | 4 (12%) | 7 (21%) | 23 (68%) | 0 (0%) |
| Giving feedback, n = 34 | 4 (12%) | 10 (29%) | 12 (35%) | 6 (18%) | 2 (6%) |
| Medical knowledge, n = 34 | 2 (6%) | 11 (32%) | 18 (53%) | 3 (9%) | 0 (0%) |
Subgroup analyses were performed comparing the perceived improvement in teaching and feedback skills among those who did or did not attend the facilitator workshop, those who facilitated 5 or more versus less than 5 sessions, and those who received or did not receive direct observation and feedback from faculty. Although numerically greater gains were seen across all 4 domains among those who attended the workshop, facilitated 5 or more sessions, or received feedback from faculty, only teaching on rounds and on the wards outside rounds reached statistical significance (Table 4). It should be noted that all residents who facilitated 5 or more sessions also attended the workshop and received feedback from faculty. We also compared perceived improvement among PGY‐II and PGY‐III residents. In contrast to PGY‐II residents, who demonstrated an improvement in all 4 domains, PGY‐III residents only demonstrated improvement in simulation‐based teaching.
| Pre‐program | Post‐program | P Value | Pre‐program | Post‐program | P Value | |
|---|---|---|---|---|---|---|
| Facilitated Less Than 5 Sessions (n = 18) | Facilitated 5 or More Sessions (n = 11) | |||||
| Did Not Attend Workshop (n = 10) | Attended Workshop (n = 22) | |||||
| Received Feedback From Resident Leaders Only (n = 11) | Received Faculty Feedback (n = 21) | |||||
| PGY‐II (n = 13) | PGY‐III (n = 9) | |||||
| ||||||
| Teaching on rounds | 3.68 | 3.79 | 0.16 | 3.85 | 4.38 | 0.01 |
| Teaching on wards outside rounds | 3.82 | 4 | 0.08 | 3.85 | 4.15 | 0.04 |
| Teaching in simulation | 2.89 | 4.06 | <0.01 | 2.69 | 4.31 | <0.01 |
| Giving feedback | 3.33 | 3.67 | 0.01 | 3.38 | 3.92 | 0.01 |
| Teaching on rounds | 4 | 4.1 | 0.34 | 3.64 | 4 | <0.01 |
| Teaching on wards outside rounds | 4 | 4 | 1.00 | 3.76 | 4.1 | <0.01 |
| Teaching in simulation | 2.89 | 4.11 | <0.01 | 2.77 | 4.18 | <0.01 |
| Giving feedback | 3.56 | 3.78 | 0.17 | 3.27 | 3.77 | <0.01 |
| Teaching on rounds | 3.55 | 3.82 | 0.19 | 3.86 | 4.14 | 0.01 |
| Teaching on wards outside rounds | 4 | 4 | 1.00 | 3.75 | 4.1 | <0.01 |
| Teaching in simulation | 2.7 | 3.8 | <0.01 | 2.86 | 4.33 | <0.01 |
| Giving feedback | 3.2 | 3.6 | 0.04 | 3.43 | 3.86 | <0.01 |
| Teaching on rounds | 3.38 | 3.85 | 0.03 | 4.22 | 4.22 | 1 |
| Teaching on wards outside rounds | 3.54 | 3.85 | 0.04 | 4.14 | 4.14 | 1 |
| Teaching in simulation | 2.46 | 4.15 | <0.01 | 3.13 | 4.13 | <0.01 |
| Giving feedback | 3.23 | 3.62 | 0.02 | 3.5 | 3.88 | 0.08 |
Intern Learners' Assessment of Resident Facilitators and the Program Overall
During the course of the program, intern learners completed 166 DASH ratings evaluating 34 resident facilitators (see Supporting Information, Appendix V, in the online version of this article). Ratings for the 6 DASH items ranged from 6.49 to 6.73 (7‐point scale), demonstrating a high level of facilitator efficacy across multiple domains. No differences in DASH scores were noted among subgroups of resident facilitators described in the previous paragraph.
Thirty‐eight of 52 intern learners (73%) completed the post‐program survey.
| Facilitator Behaviors | Very Often, >75% | Often, >50% | Sometimes, 25%50% | Rarely, <25% | Never |
|---|---|---|---|---|---|
| Elicited emotional reactions, n = 38 | 18 (47%) | 16 (42%) | 4 (11%) | 0 (0%) | 0 (0%) |
| Elicited objectives from learner, n = 37 | 26 (69%) | 8 (22%) | 2 (6%) | 1 (3%) | 0 (0%) |
| Asked to share clinical reasoning, n = 38 | 21 (56%) | 13 (33%) | 4 (11%) | 0 (0%) | 0 (0%) |
| Summarized learning points, n = 38 | 31 (81%) | 7 (19%) | 0 (0%) | 0 (0%) | 0 (0%) |
| Spoke for less than half of the session, n = 38 | 8 (22%) | 17 (44%) | 11 (28%) | 2 (6%) | 0 (0%) |
All intern learners rated the overall simulation experience as either excellent (81%) or good (19%) on the post‐program evaluation (4 or 5 on a 5‐point Likert scale, respectively). All interns strongly agreed (72%) or agreed (28%) that the simulation sessions improved their ability to manage acute clinical scenarios. Interns reported that resident facilitators frequently utilized specific debriefing techniques covered in the RaT curriculum during the debriefing sessions (Table 5).
DISCUSSION
We describe a unique RaT program embedded within a high‐fidelity medical simulation curriculum for IM interns. Our study demonstrates that resident facilitators noted an improvement in their teaching and feedback skills, both in the simulation setting and on the wards. Intern learners rated residents' teaching skills and the overall simulation curriculum highly, suggesting that residents were effective teachers.
The use of simulation in trainee‐as‐teacher curricula holds promise because it can provide an opportunity to teach in an environment closely approximating the wards, where trainees have the most opportunities to teach. However, in contrast to true ward‐based teaching, simulation can provide predictable scenarios in a controlled environment, which eliminates the distractions and unpredictability that exist on the wards, without compromising patient safety. Recently, Tofil et al. described the first use of simulation in a trainee‐as‐teacher program.[17] The investigators utilized a 1‐time simulation‐based teaching session, during which pediatric fellows completed a teacher‐training workshop, developed and served as facilitators in a simulated case, and received feedback. The use of simulation allowed fellows an opportunity to apply newly acquired skills in a controlled environment and receive feedback, which has been shown to improve teaching skills.[18]
The experience from our program expands on that of Tofil et al., as well as previously described trainee‐as‐teacher curricula, by introducing a component of deliberate practice that is unique to the simulation setting and has been absent from most previously described RaT programs.[3] Most residents had the opportunity to facilitate the same case on multiple occasions, allowing them to receive feedback and make adjustments. Residents who facilitated 5 or more sessions demonstrated more improvement, particularly in teaching outside of simulation, than residents who facilitated fewer sessions. It is notable that PGY‐II resident facilitators reported an improvement in their teaching skills on the wards, though less pronounced as compared to teaching in the simulation‐based environment, suggesting that benefits of the program may extend to nonsimulation‐based settings. Additional studies focusing on objective evaluation of ward‐based teaching are needed to further explore this phenomenon. Finally, the self‐reported improvements in medical knowledge by resident facilitators may serve as another benefit of our program.
Analysis of learner‐level data collected in the postcurriculum intern survey and DASH ratings provides additional support for the effectiveness of the RaT program. The majority of intern learners reported that resident facilitators used the techniques covered in our program frequently during debriefings. In addition, DASH scores clustered around maximum efficacy for all facilitators, suggesting that residents were effective teachers. Although we cannot directly assess whether the differences demonstrated in resident facilitators' self‐assessments translated to their teaching or were significant from the learners' perspective, these results support the hypothesis that self‐assessed improvements in teaching and feedback skills were significant.
In addition to improving resident teaching skills, our program had a positive impact on intern learners as evidenced by intern evaluations of the simulation curriculum. While utilizing relatively few faculty resources, our program was able to deliver an extensive and well‐received simulation curriculum to over 50 interns. The fact that 40% of second‐ and third‐year residents volunteered to teach in the program despite the early morning timing of the sessions speaks to the interest that trainees have in teaching in this setting. This model can serve as an important and efficient learning platform in residency training programs. It may be particularly salient to IM training programs where implementation of simulation curricula is challenging due to large numbers of residents and limited faculty resources. The barriers to and lessons learned from our experience with implementing the simulation curriculum have been previously described.[10, 11]
Our study has several limitations. Changes in residents' teaching skills were self‐assessed, which may be inaccurate as learners may overestimate their abilities.[19] Although we collected data on the experiences of intern learners that supported residents' self‐assessment, further studies using more objective measures (such as the Objective Structured Teaching Exercise[20]) should be undertaken. We did not objectively assess improvement of residents' teaching skills on the wards, with the exception of the residents' self assessment. Due to the timing of survey administration, some residents had as little as 1 month between completion of the curriculum and responding to the post‐curriculum survey, limiting their ability to evaluate their teaching skills on the wards. The transferability of the skills gained in simulation‐based teaching to teaching on the wards deserves further study. We cannot definitively attribute perceived improvement of teaching skills to the RaT program without a control group. However, the frequent use of recommended techniques during debriefing, which are not typically taught in other settings, supports the efficacy of the RaT program.
Our study did not allow us to determine which of the 3 components of the RaT program (workshop, facilitation practice, or direct observation and feedback) had the greatest impact on teaching skills or DASH ratings, as those who facilitated more sessions also completed the other components of the program. Furthermore, there may have been a selection bias among facilitators who facilitated more sessions. Because only 16 of 34 participants completed both the pre‐program and post‐program self‐assessments in a non‐anonymous fashion, we were not able to analyze the effect of pre‐program factors, such as prior teaching experience, on program outcomes. It should also be noted that allowing resident facilitators the option to complete the survey non‐anonymously could have biased our results. The simulation curriculum was conducted in a single center, and resident facilitators were self‐selecting; therefore, our results may not be generalizable. Finally, the DASH instrument was only administered after the RaT workshop and was likely limited further by the ceiling effect created by the learners' high satisfaction with the simulation program overall.
In summary, our simulation‐based RaT program improved resident facilitators' self‐reported teaching and feedback skills. Simulation‐based training provided an opportunity for deliberate practice of teaching skills in a controlled environment, which was a unique component of the program. The impact of deliberate practice on resident teaching skills and optimal methods to incorporate deliberate practice in RaT programs deserves further study. Our curriculum design may serve as a model for the development of simulation programs that can be employed to improve both intern learning and resident teaching skills.
Acknowledgements
The authors acknowledge Deborah Navedo, PhD, Assistant Professor, Massachusetts General Hospital Institute of Health Professions, and Emily M. Hayden, MD, Assistant Professor, Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, for their assistance with development of the RaT curriculum. The authors thank Dr. Jenny Rudolph, Senior Director, Institute for Medical Simulation at the Center for Medical Simulation, for her help in teaching us to use the DASH instrument. The authors also thank Dr. Daniel Hunt, MD, Associate Professor, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, for his thoughtful review of this manuscript.
Disclosure: Nothing to report.
- Liaison Committee on Medical Education. Functions and structure of a medical school: standards for accreditation of medical education programs leading to the M.D. degree. Washington, DC, and Chicago, IL: Association of American Medical Colleges and American Medical Association; 2000.
- Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in pediatrics. Available at: http://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQ-PIF/320_pediatrics_07012013.pdf. Accessed June 18, 2014.
- , , , . A systematic review of resident‐as‐teacher programmes. Med Educ. 2009;43(12):1129–1140.
- , , , et al. The utility of simulation in medical education: what is the evidence? Mt Sinai J Med. 2009;76:330–343.
- , , , et al. National growth in simulation training within emergency medicine residency programs, 2003–2008. Acad Emerg Med. 2008;15:1113–1116.
- , , , et al. Simulation center accreditation and programmatic benchmarks: a review for emergency medicine. Acad Emerg Med. 2010;17(10):1093–1103.
- . How much evidence does it take? A cumulative meta‐analysis of outcomes of simulation‐based education. Med Educ. 2014;48(8):750–760.
- , , , et al.. Resident‐as‐teacher: a suggested curriculum for emergency medicine. Acad Emerg Med. 2006;13(6):677–679.
- . Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004;79(10 suppl):S70–S81.
- , , , , , . Pilot program utilizing medical simulation in clinical decision making training for internal medicine interns. J Grad Med Educ. 2012;4:490–495.
- , , , et al. How we implemented a resident‐led medical simulation curriculum in a large internal medicine residency program. Med Teach. 2014;36(4):279–283.
- , , , . There's no such thing as “nonjudgmental” debriefing: a theory and method for debriefing with good judgment. Simul Healthc. 2006;1:49–55.
- , , , . Improving faculty feedback to resident trainees during a simulated case: a randomized, controlled trial of an educational intervention. Anesthesiology. 2014;120(1):160–171.
- . Introduction to debriefing. Semin Perinatol. 2013:37(3)166–174.
- , . Response‐shift bias: a source of contamination of self‐report measures. J Appl Psychol. 1979;4:93–106.
- Center for Medical Simulation. Debriefing assessment for simulation in healthcare. Available at: http://www.harvardmedsim.org/debriefing‐assesment‐simulation‐healthcare.php. Accessed June 18, 2014.
- , , , et al. A novel iterative‐learner simulation model: fellows as teachers. J Grad Med Educ. 2014;6(1):127–132.
- , , . Direct observation of faculty with feedback: an effective means of improving patient‐centered and learner‐centered teaching skills. Teach Learn Med. 2007;19(3):278–286.
- , . Unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self assessments. J Pers Soc Psychol. 1999;77:1121–1134.
- , , , et al. Reliability and validity of an objective structured teaching examination for generalist resident teachers. Acad Med. 2002;77(10 suppl):S29–S32.
- Liaison Committee on Medical Education. Functions and structure of a medical school: standards for accreditation of medical education programs leading to the M.D. degree. Washington, DC, and Chicago, IL: Association of American Medical Colleges and American Medical Association; 2000.
- Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in pediatrics. Available at: http://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQ-PIF/320_pediatrics_07012013.pdf. Accessed June 18, 2014.
- , , , . A systematic review of resident‐as‐teacher programmes. Med Educ. 2009;43(12):1129–1140.
- , , , et al. The utility of simulation in medical education: what is the evidence? Mt Sinai J Med. 2009;76:330–343.
- , , , et al. National growth in simulation training within emergency medicine residency programs, 2003–2008. Acad Emerg Med. 2008;15:1113–1116.
- , , , et al. Simulation center accreditation and programmatic benchmarks: a review for emergency medicine. Acad Emerg Med. 2010;17(10):1093–1103.
- . How much evidence does it take? A cumulative meta‐analysis of outcomes of simulation‐based education. Med Educ. 2014;48(8):750–760.
- , , , et al.. Resident‐as‐teacher: a suggested curriculum for emergency medicine. Acad Emerg Med. 2006;13(6):677–679.
- . Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004;79(10 suppl):S70–S81.
- , , , , , . Pilot program utilizing medical simulation in clinical decision making training for internal medicine interns. J Grad Med Educ. 2012;4:490–495.
- , , , et al. How we implemented a resident‐led medical simulation curriculum in a large internal medicine residency program. Med Teach. 2014;36(4):279–283.
- , , , . There's no such thing as “nonjudgmental” debriefing: a theory and method for debriefing with good judgment. Simul Healthc. 2006;1:49–55.
- , , , . Improving faculty feedback to resident trainees during a simulated case: a randomized, controlled trial of an educational intervention. Anesthesiology. 2014;120(1):160–171.
- . Introduction to debriefing. Semin Perinatol. 2013:37(3)166–174.
- , . Response‐shift bias: a source of contamination of self‐report measures. J Appl Psychol. 1979;4:93–106.
- Center for Medical Simulation. Debriefing assessment for simulation in healthcare. Available at: http://www.harvardmedsim.org/debriefing‐assesment‐simulation‐healthcare.php. Accessed June 18, 2014.
- , , , et al. A novel iterative‐learner simulation model: fellows as teachers. J Grad Med Educ. 2014;6(1):127–132.
- , , . Direct observation of faculty with feedback: an effective means of improving patient‐centered and learner‐centered teaching skills. Teach Learn Med. 2007;19(3):278–286.
- , . Unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self assessments. J Pers Soc Psychol. 1999;77:1121–1134.
- , , , et al. Reliability and validity of an objective structured teaching examination for generalist resident teachers. Acad Med. 2002;77(10 suppl):S29–S32.
© 2015 Society of Hospital Medicine
Undiagnosed Psoriatic Arthritis
Of all the comorbidities associated with psoriasis, psoriatic arthritis (PsA) is the most common and one of the most problematic. Early recognition, diagnosis, and treatment of PsA can help prevent or limit extensive joint damage that occurs in later stages of the disease. Because cutaneous psoriasis precedes the onset of PsA in 84% of patients with psoriasis, it is incumbent upon dermatologists to be the first line of defense in the screening for joint problems. However, the efficacy of PsA screening remains unknown.
In a recent article published online on June 5 in the Journal of the American Academy of Dermatology, Villani et al performed an analysis to determine the point prevalence of undiagnosed PsA in patients with psoriasis, utilizing a systematic search of the literature and meta-analysis. Searching PubMed, Cochrane, and Embase databases, the authors identified 394 studies for review. None of the studies sought to determine the prevalence of undiagnosed PsA in patients with psoriasis.
The investigators made the assumption that the prevalence of newly diagnosed PsA in patients with psoriasis at the time they sought medical care could be a reasonable estimate of this value. Seven epidemiological studies and 5 studies on PsA screening questionnaires were selected for review and were used to clearly identify patients with newly diagnosed PsA.
The authors found that the prevalence of undiagnosed PsA was 15.5% when all studies were analyzed and 10.1% when only epidemiological studies were included. The high prevalence of undiagnosed PsA in patients with psoriasis reinforces the recommendation that dermatologists need to screen all patients with psoriasis for PsA.
What’s the issue?
The findings of this study are not surprising. Therefore, it is important that we double our efforts to screen patients for PsA to address this comorbidity as early as possible. Improved algorithms for screening of patients for PsA would be a welcome advancement. How will you improve your screening methods for PsA?
Of all the comorbidities associated with psoriasis, psoriatic arthritis (PsA) is the most common and one of the most problematic. Early recognition, diagnosis, and treatment of PsA can help prevent or limit extensive joint damage that occurs in later stages of the disease. Because cutaneous psoriasis precedes the onset of PsA in 84% of patients with psoriasis, it is incumbent upon dermatologists to be the first line of defense in the screening for joint problems. However, the efficacy of PsA screening remains unknown.
In a recent article published online on June 5 in the Journal of the American Academy of Dermatology, Villani et al performed an analysis to determine the point prevalence of undiagnosed PsA in patients with psoriasis, utilizing a systematic search of the literature and meta-analysis. Searching PubMed, Cochrane, and Embase databases, the authors identified 394 studies for review. None of the studies sought to determine the prevalence of undiagnosed PsA in patients with psoriasis.
The investigators made the assumption that the prevalence of newly diagnosed PsA in patients with psoriasis at the time they sought medical care could be a reasonable estimate of this value. Seven epidemiological studies and 5 studies on PsA screening questionnaires were selected for review and were used to clearly identify patients with newly diagnosed PsA.
The authors found that the prevalence of undiagnosed PsA was 15.5% when all studies were analyzed and 10.1% when only epidemiological studies were included. The high prevalence of undiagnosed PsA in patients with psoriasis reinforces the recommendation that dermatologists need to screen all patients with psoriasis for PsA.
What’s the issue?
The findings of this study are not surprising. Therefore, it is important that we double our efforts to screen patients for PsA to address this comorbidity as early as possible. Improved algorithms for screening of patients for PsA would be a welcome advancement. How will you improve your screening methods for PsA?
Of all the comorbidities associated with psoriasis, psoriatic arthritis (PsA) is the most common and one of the most problematic. Early recognition, diagnosis, and treatment of PsA can help prevent or limit extensive joint damage that occurs in later stages of the disease. Because cutaneous psoriasis precedes the onset of PsA in 84% of patients with psoriasis, it is incumbent upon dermatologists to be the first line of defense in the screening for joint problems. However, the efficacy of PsA screening remains unknown.
In a recent article published online on June 5 in the Journal of the American Academy of Dermatology, Villani et al performed an analysis to determine the point prevalence of undiagnosed PsA in patients with psoriasis, utilizing a systematic search of the literature and meta-analysis. Searching PubMed, Cochrane, and Embase databases, the authors identified 394 studies for review. None of the studies sought to determine the prevalence of undiagnosed PsA in patients with psoriasis.
The investigators made the assumption that the prevalence of newly diagnosed PsA in patients with psoriasis at the time they sought medical care could be a reasonable estimate of this value. Seven epidemiological studies and 5 studies on PsA screening questionnaires were selected for review and were used to clearly identify patients with newly diagnosed PsA.
The authors found that the prevalence of undiagnosed PsA was 15.5% when all studies were analyzed and 10.1% when only epidemiological studies were included. The high prevalence of undiagnosed PsA in patients with psoriasis reinforces the recommendation that dermatologists need to screen all patients with psoriasis for PsA.
What’s the issue?
The findings of this study are not surprising. Therefore, it is important that we double our efforts to screen patients for PsA to address this comorbidity as early as possible. Improved algorithms for screening of patients for PsA would be a welcome advancement. How will you improve your screening methods for PsA?
Deoxycholic acid (Kybella) for treatment of submental fullness
We are so lucky to be part of a field of medicine where advances in patient treatment options continue to occur. Having been involved in the Kybella clinical trials, it is exciting and satisfactory to see a new successful aesthetic treatment come to fruition. Kybella is the first and only Food and Drug Administration–approved injectable drug to reduce the appearance of “double chin” (submental fullness associated with submental fat) in adult patients. It is a synthetic form of naturally occurring deoxycholic acid (DCA), which lyses adipocytes when properly injected into subcutaneous fat. The safe and effective use of Kybella for the treatment of subcutaneous fat outside of the submental region has not been established and is not recommended.
The drug received unanimous support from an FDA advisory panel in March based on two placebo-controlled phase III trials involving more than 1,000 adults. In over 1,600 patients treated, 79% saw great improvement. In the studies, safety and efficacy were demonstrated with treatment of up to 50 injections of 0.2 mL each of the 1% DCA solution administered in a single treatment. Up to six treatments were administered at least 1 month apart.
Serious side effects associated with injection of DCA may include injury to the marginal mandibular nerve and dysphagia, but the most common side effects are swelling, bruising, pain, numbness, redness, and areas of hardness in the treatment area. Other potential side effects include: tingling, nodule, itching, skin tightness, headache, alopecia, and skin ulceration. In the studies, all cases of marginal mandibular nerve injury, manifesting as an asymmetric smile or facial muscle weakness, resolved spontaneously (range 1-298 days, median 44 days). Dysphagia occurred in the clinical trials as a result of administration site reactions (for example, pain, swelling, and induration in the submental area). Cases of dysphagia resolved spontaneously (range 1-81 days, median 3 days).
Caution should be taken in patients with a history of medical conditions in the neck area, difficulty swallowing, bleeding problems, or who take blood thinners. Likewise, caution should be used in patients who are or plan to become pregnant or breastfeed as Kybella has not been studied in pregnant or breastfeeding patients. Injection is contraindicated in the presence of infection at injection sites. Kybella only should be administered by a trained health care professional.
In addition to assessing whether not the patient is an ideal candidate, setting realistic expectations, and counseling about potential side effects, consultation also should include preprocedure photographs in the Frankfurt plane. Patients with moderate to severe convexity or fullness of the submental area are ideal candidates for the procedure. Those with little submental fat and excessive skin laxity may not be good candidates for this procedure and should consider a neck lift surgery as an alternative. Patients with prominent platysmal bands prior to procedure still may notice these bands after the procedure and may consider botulinum toxin injections or platysmal banding to treat these. While the active ingredient targets fat, some beneficial skin tightening may occur as a result of inflammation and fibrosis.
After photographs are taken, it is highly recommended to mark out specific anatomic landmarks on the patient, to avoid injury to the marginal mandibular nerve, salivary glands, lymph nodes, and the subhyoid region.
The procedure takes about 15-20 minutes with a short preparation time involved. Antihistamines and anti-inflammatory medications such as loratadine and ibuprofen may be given before the procedure to help reduce risk of discomfort and edema often experienced after injection. Preprocedure injection with local anesthetic also is recommended.
Once the treatment area is demarcated with a grid placed on the patient’s skin, injections of 0.2 mL of DCA are performed with a 30-gauge ½ inch needle. The product is supplied in a box with four 2-mL vials (10 mg/mL). No refrigeration is required. Once a vial is opened, it should only be used on one patient. A maximum of up to 10 mL may be injected in one patient in one session. Ice may applied after treatment. Postprocedure swelling and throbbing can be expected for several days and may rarely last up to 1 month. Patients may require two to six treatments spaced at least 1 month apart.
Dr. Wesley and Dr. Talakoub are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley. Dr. Wesley was an investigator in the phase III Kybella clinical trials. E-mail her at [email protected].
We are so lucky to be part of a field of medicine where advances in patient treatment options continue to occur. Having been involved in the Kybella clinical trials, it is exciting and satisfactory to see a new successful aesthetic treatment come to fruition. Kybella is the first and only Food and Drug Administration–approved injectable drug to reduce the appearance of “double chin” (submental fullness associated with submental fat) in adult patients. It is a synthetic form of naturally occurring deoxycholic acid (DCA), which lyses adipocytes when properly injected into subcutaneous fat. The safe and effective use of Kybella for the treatment of subcutaneous fat outside of the submental region has not been established and is not recommended.
The drug received unanimous support from an FDA advisory panel in March based on two placebo-controlled phase III trials involving more than 1,000 adults. In over 1,600 patients treated, 79% saw great improvement. In the studies, safety and efficacy were demonstrated with treatment of up to 50 injections of 0.2 mL each of the 1% DCA solution administered in a single treatment. Up to six treatments were administered at least 1 month apart.
Serious side effects associated with injection of DCA may include injury to the marginal mandibular nerve and dysphagia, but the most common side effects are swelling, bruising, pain, numbness, redness, and areas of hardness in the treatment area. Other potential side effects include: tingling, nodule, itching, skin tightness, headache, alopecia, and skin ulceration. In the studies, all cases of marginal mandibular nerve injury, manifesting as an asymmetric smile or facial muscle weakness, resolved spontaneously (range 1-298 days, median 44 days). Dysphagia occurred in the clinical trials as a result of administration site reactions (for example, pain, swelling, and induration in the submental area). Cases of dysphagia resolved spontaneously (range 1-81 days, median 3 days).
Caution should be taken in patients with a history of medical conditions in the neck area, difficulty swallowing, bleeding problems, or who take blood thinners. Likewise, caution should be used in patients who are or plan to become pregnant or breastfeed as Kybella has not been studied in pregnant or breastfeeding patients. Injection is contraindicated in the presence of infection at injection sites. Kybella only should be administered by a trained health care professional.
In addition to assessing whether not the patient is an ideal candidate, setting realistic expectations, and counseling about potential side effects, consultation also should include preprocedure photographs in the Frankfurt plane. Patients with moderate to severe convexity or fullness of the submental area are ideal candidates for the procedure. Those with little submental fat and excessive skin laxity may not be good candidates for this procedure and should consider a neck lift surgery as an alternative. Patients with prominent platysmal bands prior to procedure still may notice these bands after the procedure and may consider botulinum toxin injections or platysmal banding to treat these. While the active ingredient targets fat, some beneficial skin tightening may occur as a result of inflammation and fibrosis.
After photographs are taken, it is highly recommended to mark out specific anatomic landmarks on the patient, to avoid injury to the marginal mandibular nerve, salivary glands, lymph nodes, and the subhyoid region.
The procedure takes about 15-20 minutes with a short preparation time involved. Antihistamines and anti-inflammatory medications such as loratadine and ibuprofen may be given before the procedure to help reduce risk of discomfort and edema often experienced after injection. Preprocedure injection with local anesthetic also is recommended.
Once the treatment area is demarcated with a grid placed on the patient’s skin, injections of 0.2 mL of DCA are performed with a 30-gauge ½ inch needle. The product is supplied in a box with four 2-mL vials (10 mg/mL). No refrigeration is required. Once a vial is opened, it should only be used on one patient. A maximum of up to 10 mL may be injected in one patient in one session. Ice may applied after treatment. Postprocedure swelling and throbbing can be expected for several days and may rarely last up to 1 month. Patients may require two to six treatments spaced at least 1 month apart.
Dr. Wesley and Dr. Talakoub are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley. Dr. Wesley was an investigator in the phase III Kybella clinical trials. E-mail her at [email protected].
We are so lucky to be part of a field of medicine where advances in patient treatment options continue to occur. Having been involved in the Kybella clinical trials, it is exciting and satisfactory to see a new successful aesthetic treatment come to fruition. Kybella is the first and only Food and Drug Administration–approved injectable drug to reduce the appearance of “double chin” (submental fullness associated with submental fat) in adult patients. It is a synthetic form of naturally occurring deoxycholic acid (DCA), which lyses adipocytes when properly injected into subcutaneous fat. The safe and effective use of Kybella for the treatment of subcutaneous fat outside of the submental region has not been established and is not recommended.
The drug received unanimous support from an FDA advisory panel in March based on two placebo-controlled phase III trials involving more than 1,000 adults. In over 1,600 patients treated, 79% saw great improvement. In the studies, safety and efficacy were demonstrated with treatment of up to 50 injections of 0.2 mL each of the 1% DCA solution administered in a single treatment. Up to six treatments were administered at least 1 month apart.
Serious side effects associated with injection of DCA may include injury to the marginal mandibular nerve and dysphagia, but the most common side effects are swelling, bruising, pain, numbness, redness, and areas of hardness in the treatment area. Other potential side effects include: tingling, nodule, itching, skin tightness, headache, alopecia, and skin ulceration. In the studies, all cases of marginal mandibular nerve injury, manifesting as an asymmetric smile or facial muscle weakness, resolved spontaneously (range 1-298 days, median 44 days). Dysphagia occurred in the clinical trials as a result of administration site reactions (for example, pain, swelling, and induration in the submental area). Cases of dysphagia resolved spontaneously (range 1-81 days, median 3 days).
Caution should be taken in patients with a history of medical conditions in the neck area, difficulty swallowing, bleeding problems, or who take blood thinners. Likewise, caution should be used in patients who are or plan to become pregnant or breastfeed as Kybella has not been studied in pregnant or breastfeeding patients. Injection is contraindicated in the presence of infection at injection sites. Kybella only should be administered by a trained health care professional.
In addition to assessing whether not the patient is an ideal candidate, setting realistic expectations, and counseling about potential side effects, consultation also should include preprocedure photographs in the Frankfurt plane. Patients with moderate to severe convexity or fullness of the submental area are ideal candidates for the procedure. Those with little submental fat and excessive skin laxity may not be good candidates for this procedure and should consider a neck lift surgery as an alternative. Patients with prominent platysmal bands prior to procedure still may notice these bands after the procedure and may consider botulinum toxin injections or platysmal banding to treat these. While the active ingredient targets fat, some beneficial skin tightening may occur as a result of inflammation and fibrosis.
After photographs are taken, it is highly recommended to mark out specific anatomic landmarks on the patient, to avoid injury to the marginal mandibular nerve, salivary glands, lymph nodes, and the subhyoid region.
The procedure takes about 15-20 minutes with a short preparation time involved. Antihistamines and anti-inflammatory medications such as loratadine and ibuprofen may be given before the procedure to help reduce risk of discomfort and edema often experienced after injection. Preprocedure injection with local anesthetic also is recommended.
Once the treatment area is demarcated with a grid placed on the patient’s skin, injections of 0.2 mL of DCA are performed with a 30-gauge ½ inch needle. The product is supplied in a box with four 2-mL vials (10 mg/mL). No refrigeration is required. Once a vial is opened, it should only be used on one patient. A maximum of up to 10 mL may be injected in one patient in one session. Ice may applied after treatment. Postprocedure swelling and throbbing can be expected for several days and may rarely last up to 1 month. Patients may require two to six treatments spaced at least 1 month apart.
Dr. Wesley and Dr. Talakoub are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley. Dr. Wesley was an investigator in the phase III Kybella clinical trials. E-mail her at [email protected].
‘Zebra’ hunting getting harder in general practice
I’m not a zebra hunter by nature. I see them here and there, but in a general practice the odds of finding them are pretty low. If I can’t solve the case, I refer to the more accomplished zebrologists at the tertiary centers.
That’s not to say I don’t look for them as best I can. Sometimes you get the vaguest hint you’re dealing with the unusual. Maybe because you’ve seen it before, or something the patient said triggered a distant memory from training.
One problem (among many) in diagnosing a zebra is time. It takes time to draw out a complex history and do an exam. There’s also time needed for the first, second, third … and later rounds of tests to come back, as well as time at appointments to note new symptoms, ask further questions, and discuss a diagnosis and plan. And, sometimes, you need time just to follow patients and see how their symptoms change.
Unfortunately, in medicine these days time is usually what you don’t have. Doctors are always under pressure to see a lot of patients and don’t have time to sort through the complex ones. This gets even worse for those employed by a health care system, when they may be working under quota requirements. After all, you can see four to five horses in the time needed for one zebra. And they pay about the same.
In solo practice, I don’t have quite the time constraints of an employed doctor meeting set numbers, but I still have the financial ones. I get the luxury of setting the schedule to give me more minutes when I know they’ll be needed, but at the back end it still comes with a financial penalty.
All of this makes it harder to find the zebras. They’re difficult enough to see as it is, and the financial pressure to shorten visits can keep even thorough docs from getting the whole story or turning over the case mentally. As one of my residency teachers (not Yogi Berra) said of differential diagnoses, “If you don’t think of it, you don’t think of it.”
Sadly, the nature of modern medicine is that it limits your ability to think of it, making it harder than ever to find the zebras in the herd.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I’m not a zebra hunter by nature. I see them here and there, but in a general practice the odds of finding them are pretty low. If I can’t solve the case, I refer to the more accomplished zebrologists at the tertiary centers.
That’s not to say I don’t look for them as best I can. Sometimes you get the vaguest hint you’re dealing with the unusual. Maybe because you’ve seen it before, or something the patient said triggered a distant memory from training.
One problem (among many) in diagnosing a zebra is time. It takes time to draw out a complex history and do an exam. There’s also time needed for the first, second, third … and later rounds of tests to come back, as well as time at appointments to note new symptoms, ask further questions, and discuss a diagnosis and plan. And, sometimes, you need time just to follow patients and see how their symptoms change.
Unfortunately, in medicine these days time is usually what you don’t have. Doctors are always under pressure to see a lot of patients and don’t have time to sort through the complex ones. This gets even worse for those employed by a health care system, when they may be working under quota requirements. After all, you can see four to five horses in the time needed for one zebra. And they pay about the same.
In solo practice, I don’t have quite the time constraints of an employed doctor meeting set numbers, but I still have the financial ones. I get the luxury of setting the schedule to give me more minutes when I know they’ll be needed, but at the back end it still comes with a financial penalty.
All of this makes it harder to find the zebras. They’re difficult enough to see as it is, and the financial pressure to shorten visits can keep even thorough docs from getting the whole story or turning over the case mentally. As one of my residency teachers (not Yogi Berra) said of differential diagnoses, “If you don’t think of it, you don’t think of it.”
Sadly, the nature of modern medicine is that it limits your ability to think of it, making it harder than ever to find the zebras in the herd.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
I’m not a zebra hunter by nature. I see them here and there, but in a general practice the odds of finding them are pretty low. If I can’t solve the case, I refer to the more accomplished zebrologists at the tertiary centers.
That’s not to say I don’t look for them as best I can. Sometimes you get the vaguest hint you’re dealing with the unusual. Maybe because you’ve seen it before, or something the patient said triggered a distant memory from training.
One problem (among many) in diagnosing a zebra is time. It takes time to draw out a complex history and do an exam. There’s also time needed for the first, second, third … and later rounds of tests to come back, as well as time at appointments to note new symptoms, ask further questions, and discuss a diagnosis and plan. And, sometimes, you need time just to follow patients and see how their symptoms change.
Unfortunately, in medicine these days time is usually what you don’t have. Doctors are always under pressure to see a lot of patients and don’t have time to sort through the complex ones. This gets even worse for those employed by a health care system, when they may be working under quota requirements. After all, you can see four to five horses in the time needed for one zebra. And they pay about the same.
In solo practice, I don’t have quite the time constraints of an employed doctor meeting set numbers, but I still have the financial ones. I get the luxury of setting the schedule to give me more minutes when I know they’ll be needed, but at the back end it still comes with a financial penalty.
All of this makes it harder to find the zebras. They’re difficult enough to see as it is, and the financial pressure to shorten visits can keep even thorough docs from getting the whole story or turning over the case mentally. As one of my residency teachers (not Yogi Berra) said of differential diagnoses, “If you don’t think of it, you don’t think of it.”
Sadly, the nature of modern medicine is that it limits your ability to think of it, making it harder than ever to find the zebras in the herd.
Dr. Block has a solo neurology practice in Scottsdale, Ariz.
Naringenin
The flavanone naringenin (5,7,4-trihydroxyflavanone) is known to exhibit anticarcinogenic, antioxidative, antiatherogenic, estrogenic, and immunomodulatory activity (Nutr. Cancer. 2012;64:714-24; J. Nutr. 2001;131:235-41; Life Sci. 2013;93:516-24). Naringenin can be found in high concentrations in grapefruits, oranges, and other citrus fruits as well as tomatoes (skin), with grapefruit juice found to yield much higher levels in plasma than orange juice (J. Nutr. 2001;131:235-41; Am. J. Physiol. Gastrointest. Liver Physiol. 2000;279:G1148-54; Nutr. Cancer 2012;64:714-24). Naringenin has been shown, along with other flavanones such as hesperetin and ponciretin, to strongly inhibit IgE-induced beta-hexosaminidase release from RBL-2H3 cells. Sung-Hwan Park and associates have suggested that the glycosides of these substances have potential as agents for treating IgE-induced atopic allergies (Planta Med. 2005;71:24-7).
In 2012, Kushi Anand and associates also showed that the combination of curcumin and naringenin exerted antiangiogenic and antitumor effects in Swiss albino mice, adding that neither compound has been associated with reports of toxicity in animals or humans (Nutr. Cancer 2012;64:714-24).
Potential cutaneous benefits
Tae-Ho Kim and colleagues studied the effects of naringenin on 2,4-dinitrofluorobenzene (DNFB)-induced atomic dermatitis in NC/Nga mice in 2013. After repetitive skin contact with DNFB, mice received intraperitoneal injections of naringenin for 1 week, with the treatment with the fruit flavonoid significantly diminishing ear swelling and back skin lesions. The flavonoid also significantly inhibited interferon (IFN)-alpha production by activated CD4+ T cells and lowered serum IgE levels as well as DNFB-induced infiltration of eosinophils, mast cells, CD4+ T cells, and CD8+ T cells in skin lesions (Life Sci. 2013;93:516-24).
Also that year, a naringenin glucoside (naringenin-7-O-glucoside) was found in an industrial blanch water extract, a byproduct of almond processing, and believed to play a role in exerting or contributing to a photoprotective effect in a small in vivo study with 12 volunteers (Molecules 2013;18:12426-40).
In 2014, K. Murata and associates screened several Prunus species in a search for skin-whitening compounds. Using an antityrosinase assay, the investigators determined that P. persica exhibited the greatest inhibitory activity and, in additional evaluation, it was found to hinder melanogenesis in B16 rat melanoma cells. Further, they identified afzelin (3-O-alpha-L-rhamnosylkaempferol) and the flavanone naringenin as the active ingredients responsible for inhibition of tyrosinase and melanogenesis and concluded that these substances warrant attention as potential skin-whitening agents (Nat. Prod. Commun. 2014;9:185-8).
A 2014 study in the ophthalmologic literature may also shed light on the photoprotective properties of naringenin. Jun-Li Lin and colleagues, studying the effects of the flavanone in eye drops used to treat N-methyl-N-nitrosourea (MNU)-induced photoreceptor cell death in rats, found that topical naringenin dose-dependently shielded the outer nuclear layer, outer retina, and whole retina, and prevented structural and functional damages to retinal neurons (Int. J. Ophthalmol. 2014;7:391-6).
Conclusion
The antioxidative, antiatherogenic, anticarcinogenic, antiproliferative, antimutagenic, estrogenic, and immunomodulatory properties of naringenin have been established in the laboratory. It remains to be seen whether such activity can be harnessed for medical applications, particularly in the dermatologic arena. Nevertheless, this flavanone warrants watching as research into its potential cutaneous applications proceeds. Currently, there is a dearth of research, though, regarding the use of naringenin in topical products.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.
The flavanone naringenin (5,7,4-trihydroxyflavanone) is known to exhibit anticarcinogenic, antioxidative, antiatherogenic, estrogenic, and immunomodulatory activity (Nutr. Cancer. 2012;64:714-24; J. Nutr. 2001;131:235-41; Life Sci. 2013;93:516-24). Naringenin can be found in high concentrations in grapefruits, oranges, and other citrus fruits as well as tomatoes (skin), with grapefruit juice found to yield much higher levels in plasma than orange juice (J. Nutr. 2001;131:235-41; Am. J. Physiol. Gastrointest. Liver Physiol. 2000;279:G1148-54; Nutr. Cancer 2012;64:714-24). Naringenin has been shown, along with other flavanones such as hesperetin and ponciretin, to strongly inhibit IgE-induced beta-hexosaminidase release from RBL-2H3 cells. Sung-Hwan Park and associates have suggested that the glycosides of these substances have potential as agents for treating IgE-induced atopic allergies (Planta Med. 2005;71:24-7).
In 2012, Kushi Anand and associates also showed that the combination of curcumin and naringenin exerted antiangiogenic and antitumor effects in Swiss albino mice, adding that neither compound has been associated with reports of toxicity in animals or humans (Nutr. Cancer 2012;64:714-24).
Potential cutaneous benefits
Tae-Ho Kim and colleagues studied the effects of naringenin on 2,4-dinitrofluorobenzene (DNFB)-induced atomic dermatitis in NC/Nga mice in 2013. After repetitive skin contact with DNFB, mice received intraperitoneal injections of naringenin for 1 week, with the treatment with the fruit flavonoid significantly diminishing ear swelling and back skin lesions. The flavonoid also significantly inhibited interferon (IFN)-alpha production by activated CD4+ T cells and lowered serum IgE levels as well as DNFB-induced infiltration of eosinophils, mast cells, CD4+ T cells, and CD8+ T cells in skin lesions (Life Sci. 2013;93:516-24).
Also that year, a naringenin glucoside (naringenin-7-O-glucoside) was found in an industrial blanch water extract, a byproduct of almond processing, and believed to play a role in exerting or contributing to a photoprotective effect in a small in vivo study with 12 volunteers (Molecules 2013;18:12426-40).
In 2014, K. Murata and associates screened several Prunus species in a search for skin-whitening compounds. Using an antityrosinase assay, the investigators determined that P. persica exhibited the greatest inhibitory activity and, in additional evaluation, it was found to hinder melanogenesis in B16 rat melanoma cells. Further, they identified afzelin (3-O-alpha-L-rhamnosylkaempferol) and the flavanone naringenin as the active ingredients responsible for inhibition of tyrosinase and melanogenesis and concluded that these substances warrant attention as potential skin-whitening agents (Nat. Prod. Commun. 2014;9:185-8).
A 2014 study in the ophthalmologic literature may also shed light on the photoprotective properties of naringenin. Jun-Li Lin and colleagues, studying the effects of the flavanone in eye drops used to treat N-methyl-N-nitrosourea (MNU)-induced photoreceptor cell death in rats, found that topical naringenin dose-dependently shielded the outer nuclear layer, outer retina, and whole retina, and prevented structural and functional damages to retinal neurons (Int. J. Ophthalmol. 2014;7:391-6).
Conclusion
The antioxidative, antiatherogenic, anticarcinogenic, antiproliferative, antimutagenic, estrogenic, and immunomodulatory properties of naringenin have been established in the laboratory. It remains to be seen whether such activity can be harnessed for medical applications, particularly in the dermatologic arena. Nevertheless, this flavanone warrants watching as research into its potential cutaneous applications proceeds. Currently, there is a dearth of research, though, regarding the use of naringenin in topical products.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.
The flavanone naringenin (5,7,4-trihydroxyflavanone) is known to exhibit anticarcinogenic, antioxidative, antiatherogenic, estrogenic, and immunomodulatory activity (Nutr. Cancer. 2012;64:714-24; J. Nutr. 2001;131:235-41; Life Sci. 2013;93:516-24). Naringenin can be found in high concentrations in grapefruits, oranges, and other citrus fruits as well as tomatoes (skin), with grapefruit juice found to yield much higher levels in plasma than orange juice (J. Nutr. 2001;131:235-41; Am. J. Physiol. Gastrointest. Liver Physiol. 2000;279:G1148-54; Nutr. Cancer 2012;64:714-24). Naringenin has been shown, along with other flavanones such as hesperetin and ponciretin, to strongly inhibit IgE-induced beta-hexosaminidase release from RBL-2H3 cells. Sung-Hwan Park and associates have suggested that the glycosides of these substances have potential as agents for treating IgE-induced atopic allergies (Planta Med. 2005;71:24-7).
In 2012, Kushi Anand and associates also showed that the combination of curcumin and naringenin exerted antiangiogenic and antitumor effects in Swiss albino mice, adding that neither compound has been associated with reports of toxicity in animals or humans (Nutr. Cancer 2012;64:714-24).
Potential cutaneous benefits
Tae-Ho Kim and colleagues studied the effects of naringenin on 2,4-dinitrofluorobenzene (DNFB)-induced atomic dermatitis in NC/Nga mice in 2013. After repetitive skin contact with DNFB, mice received intraperitoneal injections of naringenin for 1 week, with the treatment with the fruit flavonoid significantly diminishing ear swelling and back skin lesions. The flavonoid also significantly inhibited interferon (IFN)-alpha production by activated CD4+ T cells and lowered serum IgE levels as well as DNFB-induced infiltration of eosinophils, mast cells, CD4+ T cells, and CD8+ T cells in skin lesions (Life Sci. 2013;93:516-24).
Also that year, a naringenin glucoside (naringenin-7-O-glucoside) was found in an industrial blanch water extract, a byproduct of almond processing, and believed to play a role in exerting or contributing to a photoprotective effect in a small in vivo study with 12 volunteers (Molecules 2013;18:12426-40).
In 2014, K. Murata and associates screened several Prunus species in a search for skin-whitening compounds. Using an antityrosinase assay, the investigators determined that P. persica exhibited the greatest inhibitory activity and, in additional evaluation, it was found to hinder melanogenesis in B16 rat melanoma cells. Further, they identified afzelin (3-O-alpha-L-rhamnosylkaempferol) and the flavanone naringenin as the active ingredients responsible for inhibition of tyrosinase and melanogenesis and concluded that these substances warrant attention as potential skin-whitening agents (Nat. Prod. Commun. 2014;9:185-8).
A 2014 study in the ophthalmologic literature may also shed light on the photoprotective properties of naringenin. Jun-Li Lin and colleagues, studying the effects of the flavanone in eye drops used to treat N-methyl-N-nitrosourea (MNU)-induced photoreceptor cell death in rats, found that topical naringenin dose-dependently shielded the outer nuclear layer, outer retina, and whole retina, and prevented structural and functional damages to retinal neurons (Int. J. Ophthalmol. 2014;7:391-6).
Conclusion
The antioxidative, antiatherogenic, anticarcinogenic, antiproliferative, antimutagenic, estrogenic, and immunomodulatory properties of naringenin have been established in the laboratory. It remains to be seen whether such activity can be harnessed for medical applications, particularly in the dermatologic arena. Nevertheless, this flavanone warrants watching as research into its potential cutaneous applications proceeds. Currently, there is a dearth of research, though, regarding the use of naringenin in topical products.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.
Fecal Microbiotia Transplantation in Treatment of Recurrent Clostridium difficile Infection
Clinical question: Does fecal microbiotia transplantation (FMT) effectively treat patients with recurrent Clostridium difficile infection (CDI)?
Background: Patients with initial CDI have increased rates of recurrence (15%–30%), with variable success noted in treatment of recurrent disease. Increased interest in the use of FMT as a treatment strategy for CDI has led to various studies evaluating its efficacy.
Study design: Systematic review.
Setting: Multiple settings from studies obtained from MEDLINE, Cochrane Library, and ClinicalTrials.gov.
Synopsis: Literature search and review yielded a total of 35 included articles for analysis, mostly case-series studies (28), with only two randomized controlled trials (RCTs). Primary outcome was defined as symptom resolution, with a secondary outcome of recurrence. Although studies included assessed FMT as treatment for initial, recurrent, and refractory CDI, the majority of the evidence was focused on recurrent CDI. Among the studies analyzed, FMT was found to have a substantial effect on primary outcome of symptom resolution (85% of cases) among all pooled studies for recurrent CDI.
Although this review provided evidence suggestive of the efficacy of FMT in recurrent CDI, the paucity of RCT data was well documented and noted as a limitation in providing high-quality recommendations on FMT as a treatment option. Further high-quality research is recommended, and hospitalists caring for patients with recurrent CDI should be wary of treatment with FMT based on these data alone.
Bottom line: Studies evaluating FMT as a treatment option for recurrent CDI demonstrate significant benefit in symptom resolution, but further high-quality research is needed.
Citation: Drekonja D, Reich J, Gezahegn S, et al. Fecal microbiota transplantation for Clostridium difficile infection: a systematic review of the evidence. Ann Intern Med. 2015;162:630-638. doi:10.7326/M14-2693.
Visit our website for more hospitalist-focused literature reviews.
Clinical question: Does fecal microbiotia transplantation (FMT) effectively treat patients with recurrent Clostridium difficile infection (CDI)?
Background: Patients with initial CDI have increased rates of recurrence (15%–30%), with variable success noted in treatment of recurrent disease. Increased interest in the use of FMT as a treatment strategy for CDI has led to various studies evaluating its efficacy.
Study design: Systematic review.
Setting: Multiple settings from studies obtained from MEDLINE, Cochrane Library, and ClinicalTrials.gov.
Synopsis: Literature search and review yielded a total of 35 included articles for analysis, mostly case-series studies (28), with only two randomized controlled trials (RCTs). Primary outcome was defined as symptom resolution, with a secondary outcome of recurrence. Although studies included assessed FMT as treatment for initial, recurrent, and refractory CDI, the majority of the evidence was focused on recurrent CDI. Among the studies analyzed, FMT was found to have a substantial effect on primary outcome of symptom resolution (85% of cases) among all pooled studies for recurrent CDI.
Although this review provided evidence suggestive of the efficacy of FMT in recurrent CDI, the paucity of RCT data was well documented and noted as a limitation in providing high-quality recommendations on FMT as a treatment option. Further high-quality research is recommended, and hospitalists caring for patients with recurrent CDI should be wary of treatment with FMT based on these data alone.
Bottom line: Studies evaluating FMT as a treatment option for recurrent CDI demonstrate significant benefit in symptom resolution, but further high-quality research is needed.
Citation: Drekonja D, Reich J, Gezahegn S, et al. Fecal microbiota transplantation for Clostridium difficile infection: a systematic review of the evidence. Ann Intern Med. 2015;162:630-638. doi:10.7326/M14-2693.
Visit our website for more hospitalist-focused literature reviews.
Clinical question: Does fecal microbiotia transplantation (FMT) effectively treat patients with recurrent Clostridium difficile infection (CDI)?
Background: Patients with initial CDI have increased rates of recurrence (15%–30%), with variable success noted in treatment of recurrent disease. Increased interest in the use of FMT as a treatment strategy for CDI has led to various studies evaluating its efficacy.
Study design: Systematic review.
Setting: Multiple settings from studies obtained from MEDLINE, Cochrane Library, and ClinicalTrials.gov.
Synopsis: Literature search and review yielded a total of 35 included articles for analysis, mostly case-series studies (28), with only two randomized controlled trials (RCTs). Primary outcome was defined as symptom resolution, with a secondary outcome of recurrence. Although studies included assessed FMT as treatment for initial, recurrent, and refractory CDI, the majority of the evidence was focused on recurrent CDI. Among the studies analyzed, FMT was found to have a substantial effect on primary outcome of symptom resolution (85% of cases) among all pooled studies for recurrent CDI.
Although this review provided evidence suggestive of the efficacy of FMT in recurrent CDI, the paucity of RCT data was well documented and noted as a limitation in providing high-quality recommendations on FMT as a treatment option. Further high-quality research is recommended, and hospitalists caring for patients with recurrent CDI should be wary of treatment with FMT based on these data alone.
Bottom line: Studies evaluating FMT as a treatment option for recurrent CDI demonstrate significant benefit in symptom resolution, but further high-quality research is needed.
Citation: Drekonja D, Reich J, Gezahegn S, et al. Fecal microbiota transplantation for Clostridium difficile infection: a systematic review of the evidence. Ann Intern Med. 2015;162:630-638. doi:10.7326/M14-2693.
Visit our website for more hospitalist-focused literature reviews.
Hospitalists Can Help Reduce "July Spike" in Hospital-Acquired Complications
The number of inpatient hospital-acquired complications (HACs) typically spikes in July, but hospitalists can be instrumental in reducing this annual uptick, according to the lead author of a study on the "July effect" in hospital admissions.
Researcher Timothy Wen, MPH, a medical student at the Keck School of Medicine of University of Southern California in Los Angeles, examined patient discharge data collected nationally from 2008 to 2011 and found that July admissions had a 6% increase in the likelihood of HAC occurrence compared with admissions during all other months.
Wen, whose research findings were published in the Journal of Hospital Medicine, links the increase with the arrival of new residents, medical students, and hospital faculty in July. He says the annual staff changes can challenge the efficiency of hospital systems and processes.
Fortunately, hospitalists can help to reduce complications during and beyond this time of transition, Wen says.
“Because of their role,” Wen says, “hospitalists have a unique opportunity to not only utilize their institutional knowledge of the system and their patients but also to train residents in navigating the system with improved communication skills and working with ancillary staff. We believe that an initial step in resolving the outcomes associated with the 'July effect' is to have improved communication between ancillary, trainee, and attending staff. Furthermore, we believe that burden of surveillance during this transition period may require additional support from more senior ancillary and attending staff as the new trainees and faculty become more acquainted with the processes of a new hospital and service.”
HACs are a chronic issue for inpatients, contributing to longer lengths of stay and higher hospital costs. Wen says his study is among the first to “address the disparities in HACs between these time periods” and suggests more research on the impact of HACs is needed.
"HACs represent not only egregious complications of high cost and burden to hospitals and patients, but they are also a surrogate marker of adverse events that are preventable through systemic changes," he says. "We need future studies to continue to identify this disparity and its impacts, as well as research into novel initiatives and training protocols to work on reducing these HACs."
Visit our website for more information on reducing HACs.
The number of inpatient hospital-acquired complications (HACs) typically spikes in July, but hospitalists can be instrumental in reducing this annual uptick, according to the lead author of a study on the "July effect" in hospital admissions.
Researcher Timothy Wen, MPH, a medical student at the Keck School of Medicine of University of Southern California in Los Angeles, examined patient discharge data collected nationally from 2008 to 2011 and found that July admissions had a 6% increase in the likelihood of HAC occurrence compared with admissions during all other months.
Wen, whose research findings were published in the Journal of Hospital Medicine, links the increase with the arrival of new residents, medical students, and hospital faculty in July. He says the annual staff changes can challenge the efficiency of hospital systems and processes.
Fortunately, hospitalists can help to reduce complications during and beyond this time of transition, Wen says.
“Because of their role,” Wen says, “hospitalists have a unique opportunity to not only utilize their institutional knowledge of the system and their patients but also to train residents in navigating the system with improved communication skills and working with ancillary staff. We believe that an initial step in resolving the outcomes associated with the 'July effect' is to have improved communication between ancillary, trainee, and attending staff. Furthermore, we believe that burden of surveillance during this transition period may require additional support from more senior ancillary and attending staff as the new trainees and faculty become more acquainted with the processes of a new hospital and service.”
HACs are a chronic issue for inpatients, contributing to longer lengths of stay and higher hospital costs. Wen says his study is among the first to “address the disparities in HACs between these time periods” and suggests more research on the impact of HACs is needed.
"HACs represent not only egregious complications of high cost and burden to hospitals and patients, but they are also a surrogate marker of adverse events that are preventable through systemic changes," he says. "We need future studies to continue to identify this disparity and its impacts, as well as research into novel initiatives and training protocols to work on reducing these HACs."
Visit our website for more information on reducing HACs.
The number of inpatient hospital-acquired complications (HACs) typically spikes in July, but hospitalists can be instrumental in reducing this annual uptick, according to the lead author of a study on the "July effect" in hospital admissions.
Researcher Timothy Wen, MPH, a medical student at the Keck School of Medicine of University of Southern California in Los Angeles, examined patient discharge data collected nationally from 2008 to 2011 and found that July admissions had a 6% increase in the likelihood of HAC occurrence compared with admissions during all other months.
Wen, whose research findings were published in the Journal of Hospital Medicine, links the increase with the arrival of new residents, medical students, and hospital faculty in July. He says the annual staff changes can challenge the efficiency of hospital systems and processes.
Fortunately, hospitalists can help to reduce complications during and beyond this time of transition, Wen says.
“Because of their role,” Wen says, “hospitalists have a unique opportunity to not only utilize their institutional knowledge of the system and their patients but also to train residents in navigating the system with improved communication skills and working with ancillary staff. We believe that an initial step in resolving the outcomes associated with the 'July effect' is to have improved communication between ancillary, trainee, and attending staff. Furthermore, we believe that burden of surveillance during this transition period may require additional support from more senior ancillary and attending staff as the new trainees and faculty become more acquainted with the processes of a new hospital and service.”
HACs are a chronic issue for inpatients, contributing to longer lengths of stay and higher hospital costs. Wen says his study is among the first to “address the disparities in HACs between these time periods” and suggests more research on the impact of HACs is needed.
"HACs represent not only egregious complications of high cost and burden to hospitals and patients, but they are also a surrogate marker of adverse events that are preventable through systemic changes," he says. "We need future studies to continue to identify this disparity and its impacts, as well as research into novel initiatives and training protocols to work on reducing these HACs."
Visit our website for more information on reducing HACs.
SVS: Opt for early repair of PDA/GDA splanchnic aneurysms
CHICAGO – Pancreaticoduodenal and gastroduodenal artery aneurysms should be repaired at diagnosis, according to Dr. Michael Corey, a vascular surgeon at Massachusetts General Hospital in Boston.
The reason is “they rupture at small sizes. Most other small splanchnic artery aneurysms” – below 25 mm – “do not grow or rupture over time and can safely undergo surveillance imaging every 3 years,” he said at a meeting hosted by the Society for Vascular Surgery.
The insights come from Dr. Corey’s review of 264 splanchnic artery aneurysms (SAAs) treated at Massachusetts General Hospital from 1994 to 2014 .
Pancreaticoduodenal (PDA) and gastroduodenal (GDA) artery aneurysms were the most likely to cause trouble. Almost all of the 36 in the study were associated with high-grade celiac axis stenosis, and 12 (33%) were symptomatic at presentation, including 7 (19%) that had ruptured at a mean size of 27.4 mm, range 15-48 mm.
Those 7 accounted for more than half of the 13 ruptures in the study. There were also five ruptures among 95 splenic artery aneurysms – the most common aneurysm type in the study – at a mean of 42 mm, and one among 34 hepatic artery aneurysms at 40 mm. Thirty-day morbidity after rupture repair was 54% and mortality 8%.
Pancreaticoduodenal (odds ratio, 14.41; 95% confidence interval, 3.5-59.9; P = .0002) and gastroduodenal artery aneurysms (OR, 6.95; 95% CI, 1.1-45.1; P = .042) were far more predictive of rupture than aneurysm size (OR, 1.04; 95% CI, 1.01-1.08; P = .0042). The strongest predictor was type 4 Ehlers-Danlos syndrome (OR, 34.09; 95% CI, 2.4-479.8; P = .0089). Calcification, meanwhile, did not predict rupture, growth, or thrombus burden.
Dr. Corey and his colleagues reviewed Massachusetts General’s experience with SAAs because “no strong consensus exists in the literature concerning the indications for treatment; 2 cm is currently the indication for surgical treatment of asymptomatic lesions,” he said.
Two centimeters might be too aggressive in some cases. Among 176 aneurysms put under surveillance for a mean of 36.1 months, the mean aneurysm size was 16.3 mm but ranged up to 40 mm. Even so, none of them ruptured. Just 12 aneurysms grew during surveillance, and only 8 eventually needed intervention. Perhaps most “small asymptomatic lesions do not affect longevity,” Dr. Corey said. The mean aneurysm size was 31.1 mm in the 88 patients repaired within 6 months of diagnosis. Splenic, pancreaticoduodenal, gastroduodenal, and hepatic aneurysms were the most likely to be repaired early, the majority by coil embolization and other endovascular techniques. Thirty-day morbidity for intact repair was 13% and mortality 3%.
Most of the splenic artery aneurysms were asymptomatic at presentation. In the half that were watched, just six grew.
Similarly, 78 celiac artery aneurysms – the second most common in the study – all presented without symptoms. Just 3 of the 60 under surveillance grew over a mean of 43.6 months. “These aneurysms rarely change,” Dr. Corey said.
Most of the 34 hepatic artery aneurysms and 17 superior mesenteric artery (SMA) aneurysms were asymptomatic. Between both groups, 20 aneurysms were put under surveillance; growth was noted in 1, an SMA lesion.
Although there was a shift from open to endovascular repair during the study period, there were no statistically significant differences in morbidity or mortality between the two approaches.
Dr. Corey has no disclosures.
CHICAGO – Pancreaticoduodenal and gastroduodenal artery aneurysms should be repaired at diagnosis, according to Dr. Michael Corey, a vascular surgeon at Massachusetts General Hospital in Boston.
The reason is “they rupture at small sizes. Most other small splanchnic artery aneurysms” – below 25 mm – “do not grow or rupture over time and can safely undergo surveillance imaging every 3 years,” he said at a meeting hosted by the Society for Vascular Surgery.
The insights come from Dr. Corey’s review of 264 splanchnic artery aneurysms (SAAs) treated at Massachusetts General Hospital from 1994 to 2014 .
Pancreaticoduodenal (PDA) and gastroduodenal (GDA) artery aneurysms were the most likely to cause trouble. Almost all of the 36 in the study were associated with high-grade celiac axis stenosis, and 12 (33%) were symptomatic at presentation, including 7 (19%) that had ruptured at a mean size of 27.4 mm, range 15-48 mm.
Those 7 accounted for more than half of the 13 ruptures in the study. There were also five ruptures among 95 splenic artery aneurysms – the most common aneurysm type in the study – at a mean of 42 mm, and one among 34 hepatic artery aneurysms at 40 mm. Thirty-day morbidity after rupture repair was 54% and mortality 8%.
Pancreaticoduodenal (odds ratio, 14.41; 95% confidence interval, 3.5-59.9; P = .0002) and gastroduodenal artery aneurysms (OR, 6.95; 95% CI, 1.1-45.1; P = .042) were far more predictive of rupture than aneurysm size (OR, 1.04; 95% CI, 1.01-1.08; P = .0042). The strongest predictor was type 4 Ehlers-Danlos syndrome (OR, 34.09; 95% CI, 2.4-479.8; P = .0089). Calcification, meanwhile, did not predict rupture, growth, or thrombus burden.
Dr. Corey and his colleagues reviewed Massachusetts General’s experience with SAAs because “no strong consensus exists in the literature concerning the indications for treatment; 2 cm is currently the indication for surgical treatment of asymptomatic lesions,” he said.
Two centimeters might be too aggressive in some cases. Among 176 aneurysms put under surveillance for a mean of 36.1 months, the mean aneurysm size was 16.3 mm but ranged up to 40 mm. Even so, none of them ruptured. Just 12 aneurysms grew during surveillance, and only 8 eventually needed intervention. Perhaps most “small asymptomatic lesions do not affect longevity,” Dr. Corey said. The mean aneurysm size was 31.1 mm in the 88 patients repaired within 6 months of diagnosis. Splenic, pancreaticoduodenal, gastroduodenal, and hepatic aneurysms were the most likely to be repaired early, the majority by coil embolization and other endovascular techniques. Thirty-day morbidity for intact repair was 13% and mortality 3%.
Most of the splenic artery aneurysms were asymptomatic at presentation. In the half that were watched, just six grew.
Similarly, 78 celiac artery aneurysms – the second most common in the study – all presented without symptoms. Just 3 of the 60 under surveillance grew over a mean of 43.6 months. “These aneurysms rarely change,” Dr. Corey said.
Most of the 34 hepatic artery aneurysms and 17 superior mesenteric artery (SMA) aneurysms were asymptomatic. Between both groups, 20 aneurysms were put under surveillance; growth was noted in 1, an SMA lesion.
Although there was a shift from open to endovascular repair during the study period, there were no statistically significant differences in morbidity or mortality between the two approaches.
Dr. Corey has no disclosures.
CHICAGO – Pancreaticoduodenal and gastroduodenal artery aneurysms should be repaired at diagnosis, according to Dr. Michael Corey, a vascular surgeon at Massachusetts General Hospital in Boston.
The reason is “they rupture at small sizes. Most other small splanchnic artery aneurysms” – below 25 mm – “do not grow or rupture over time and can safely undergo surveillance imaging every 3 years,” he said at a meeting hosted by the Society for Vascular Surgery.
The insights come from Dr. Corey’s review of 264 splanchnic artery aneurysms (SAAs) treated at Massachusetts General Hospital from 1994 to 2014 .
Pancreaticoduodenal (PDA) and gastroduodenal (GDA) artery aneurysms were the most likely to cause trouble. Almost all of the 36 in the study were associated with high-grade celiac axis stenosis, and 12 (33%) were symptomatic at presentation, including 7 (19%) that had ruptured at a mean size of 27.4 mm, range 15-48 mm.
Those 7 accounted for more than half of the 13 ruptures in the study. There were also five ruptures among 95 splenic artery aneurysms – the most common aneurysm type in the study – at a mean of 42 mm, and one among 34 hepatic artery aneurysms at 40 mm. Thirty-day morbidity after rupture repair was 54% and mortality 8%.
Pancreaticoduodenal (odds ratio, 14.41; 95% confidence interval, 3.5-59.9; P = .0002) and gastroduodenal artery aneurysms (OR, 6.95; 95% CI, 1.1-45.1; P = .042) were far more predictive of rupture than aneurysm size (OR, 1.04; 95% CI, 1.01-1.08; P = .0042). The strongest predictor was type 4 Ehlers-Danlos syndrome (OR, 34.09; 95% CI, 2.4-479.8; P = .0089). Calcification, meanwhile, did not predict rupture, growth, or thrombus burden.
Dr. Corey and his colleagues reviewed Massachusetts General’s experience with SAAs because “no strong consensus exists in the literature concerning the indications for treatment; 2 cm is currently the indication for surgical treatment of asymptomatic lesions,” he said.
Two centimeters might be too aggressive in some cases. Among 176 aneurysms put under surveillance for a mean of 36.1 months, the mean aneurysm size was 16.3 mm but ranged up to 40 mm. Even so, none of them ruptured. Just 12 aneurysms grew during surveillance, and only 8 eventually needed intervention. Perhaps most “small asymptomatic lesions do not affect longevity,” Dr. Corey said. The mean aneurysm size was 31.1 mm in the 88 patients repaired within 6 months of diagnosis. Splenic, pancreaticoduodenal, gastroduodenal, and hepatic aneurysms were the most likely to be repaired early, the majority by coil embolization and other endovascular techniques. Thirty-day morbidity for intact repair was 13% and mortality 3%.
Most of the splenic artery aneurysms were asymptomatic at presentation. In the half that were watched, just six grew.
Similarly, 78 celiac artery aneurysms – the second most common in the study – all presented without symptoms. Just 3 of the 60 under surveillance grew over a mean of 43.6 months. “These aneurysms rarely change,” Dr. Corey said.
Most of the 34 hepatic artery aneurysms and 17 superior mesenteric artery (SMA) aneurysms were asymptomatic. Between both groups, 20 aneurysms were put under surveillance; growth was noted in 1, an SMA lesion.
Although there was a shift from open to endovascular repair during the study period, there were no statistically significant differences in morbidity or mortality between the two approaches.
Dr. Corey has no disclosures.
AT THE 2015 VASCULAR ANNUAL MEETING
Key clinical point: Pancreaticoduodenal and gastroduodenal artery aneurysms rupture at smaller sizes than do other visceral aneurysms.
Major finding: Almost all of the 36 aneurysms in the study were associated with high-grade celiac axis stenosis, and 12 (33%) were symptomatic at presentation, including 7 (19%) that had ruptured at a mean size of 27.4 mm (range, 15-48 mm).
Data source: Review of 264 splanchnic artery aneurysms treated at Massachusetts General Hospital from 1994 to 2014.
Disclosures: The lead investigator has no relevant disclosures.
Intensive Glucose Control in Type 2 Diabetes Mellitus Reduces CV Events, but Not Mortality, After 10 Years
Clinical question: Are there long-term benefits to more intensive glycemic control in patients with type 2 diabetes mellitus?
Bottom line: After approximately 10 years of follow-up, this study found 1 fewer cardiovascular event per 116 person-years among a group of patients (97% men) randomized to receive tight glycemic control, but found no reduction in mortality. This result must be balanced against the results from other trials, which saw a mixed bag of benefits and harms with long-term follow-up. It is important to note that even the intensive glycemic control group had a mean hemoglobin A1c of 6.9%, not 6% or 6.5% as some guidelines advocate.
Reference: Hayward RA, Reaven PD, Wiitala WL, et al, for the VADT Investigators. Follow-up of glycemic control and cardiovascular outcomes in type 2 diabetes. N Engl J Med 2015;372(23):2197-2206.
Study design: Cohort (prospective); (LOE: 2b)
Setting: Outpatient (any)
Synopsis: The Veteran's Affairs Diabetes Trial (VADT) originally randomized 1791 veterans with type 2 diabetes mellitus to receive intensive or usual glycemic control, and achieved mean hemoglobin A1C levels of 6.9% and 8.4%, respectively, after a median of 5.6 years. The original trial found a nonsignificant trend toward fewer cardiovascular events in the intensive therapy group, but no change in mortality. Two other large, similar trials reported similar findings, although one found increased mortality in the intensive glycemic control group. Follow-up studies for these 2 other trials have had mixed results, one finding increased mortality and no change in events, with the other finding fewer events but no change in mortality.
The current study linked patients in the original VADT to national disease registries (92% of participants) and also to regular record reviews and surveys (77% agreed to participte). The median follow-up was 9.8 years for cardiovascular events and 11.8 years for assessment of total mortality. They found a small but statistically significant reduction in the primary combined outcome of myocardial infarction , stroke, new or worsening heart failure, cardiovascular death, or amputation (44.1 vs 52.7 per 1000 person-years; P = .04). There was no significant difference between groups in the likelihood of cardiovascular death or all-cause mortality. The greatest contribution to the reduction in cardiovascular events was fewer nonfatal myocardial infarctions.
Mark H. Ebell, MD, MS, is an associate professor at the University of Georgia in Athens, editor-in-chief of Essential Evidence, and deputy editor of the American Family Physician journal.
Clinical question: Are there long-term benefits to more intensive glycemic control in patients with type 2 diabetes mellitus?
Bottom line: After approximately 10 years of follow-up, this study found 1 fewer cardiovascular event per 116 person-years among a group of patients (97% men) randomized to receive tight glycemic control, but found no reduction in mortality. This result must be balanced against the results from other trials, which saw a mixed bag of benefits and harms with long-term follow-up. It is important to note that even the intensive glycemic control group had a mean hemoglobin A1c of 6.9%, not 6% or 6.5% as some guidelines advocate.
Reference: Hayward RA, Reaven PD, Wiitala WL, et al, for the VADT Investigators. Follow-up of glycemic control and cardiovascular outcomes in type 2 diabetes. N Engl J Med 2015;372(23):2197-2206.
Study design: Cohort (prospective); (LOE: 2b)
Setting: Outpatient (any)
Synopsis: The Veteran's Affairs Diabetes Trial (VADT) originally randomized 1791 veterans with type 2 diabetes mellitus to receive intensive or usual glycemic control, and achieved mean hemoglobin A1C levels of 6.9% and 8.4%, respectively, after a median of 5.6 years. The original trial found a nonsignificant trend toward fewer cardiovascular events in the intensive therapy group, but no change in mortality. Two other large, similar trials reported similar findings, although one found increased mortality in the intensive glycemic control group. Follow-up studies for these 2 other trials have had mixed results, one finding increased mortality and no change in events, with the other finding fewer events but no change in mortality.
The current study linked patients in the original VADT to national disease registries (92% of participants) and also to regular record reviews and surveys (77% agreed to participte). The median follow-up was 9.8 years for cardiovascular events and 11.8 years for assessment of total mortality. They found a small but statistically significant reduction in the primary combined outcome of myocardial infarction , stroke, new or worsening heart failure, cardiovascular death, or amputation (44.1 vs 52.7 per 1000 person-years; P = .04). There was no significant difference between groups in the likelihood of cardiovascular death or all-cause mortality. The greatest contribution to the reduction in cardiovascular events was fewer nonfatal myocardial infarctions.
Mark H. Ebell, MD, MS, is an associate professor at the University of Georgia in Athens, editor-in-chief of Essential Evidence, and deputy editor of the American Family Physician journal.
Clinical question: Are there long-term benefits to more intensive glycemic control in patients with type 2 diabetes mellitus?
Bottom line: After approximately 10 years of follow-up, this study found 1 fewer cardiovascular event per 116 person-years among a group of patients (97% men) randomized to receive tight glycemic control, but found no reduction in mortality. This result must be balanced against the results from other trials, which saw a mixed bag of benefits and harms with long-term follow-up. It is important to note that even the intensive glycemic control group had a mean hemoglobin A1c of 6.9%, not 6% or 6.5% as some guidelines advocate.
Reference: Hayward RA, Reaven PD, Wiitala WL, et al, for the VADT Investigators. Follow-up of glycemic control and cardiovascular outcomes in type 2 diabetes. N Engl J Med 2015;372(23):2197-2206.
Study design: Cohort (prospective); (LOE: 2b)
Setting: Outpatient (any)
Synopsis: The Veteran's Affairs Diabetes Trial (VADT) originally randomized 1791 veterans with type 2 diabetes mellitus to receive intensive or usual glycemic control, and achieved mean hemoglobin A1C levels of 6.9% and 8.4%, respectively, after a median of 5.6 years. The original trial found a nonsignificant trend toward fewer cardiovascular events in the intensive therapy group, but no change in mortality. Two other large, similar trials reported similar findings, although one found increased mortality in the intensive glycemic control group. Follow-up studies for these 2 other trials have had mixed results, one finding increased mortality and no change in events, with the other finding fewer events but no change in mortality.
The current study linked patients in the original VADT to national disease registries (92% of participants) and also to regular record reviews and surveys (77% agreed to participte). The median follow-up was 9.8 years for cardiovascular events and 11.8 years for assessment of total mortality. They found a small but statistically significant reduction in the primary combined outcome of myocardial infarction , stroke, new or worsening heart failure, cardiovascular death, or amputation (44.1 vs 52.7 per 1000 person-years; P = .04). There was no significant difference between groups in the likelihood of cardiovascular death or all-cause mortality. The greatest contribution to the reduction in cardiovascular events was fewer nonfatal myocardial infarctions.
Mark H. Ebell, MD, MS, is an associate professor at the University of Georgia in Athens, editor-in-chief of Essential Evidence, and deputy editor of the American Family Physician journal.
Nipping buds, kicking butts, being safer than sorry
Brad came in with his mother for me to treat a small wart on the sole of his left foot. “It doesn’t bother me,” he said.
“I had one of those when I was Brad’s age,” said his mother, Mary Lou. “We neglected it and it really grew! With a thing like that, you have to nip it in the bud.”
We all learn little maxims about how the world works and what to do about it. One of these is that to avoid trouble, you should nip things in the bud.
This sounds like it makes sense. Sometimes it’s actually true. But there are other times when what you’re trying to nip doesn’t have a bud.
If you have a plantar wart on the bottom of your foot and you don’t treat it, here are some things that can happen:
• It can grow and become painful.
• It can stay the same for years, never bother you, and go away.
• New ones can appear elsewhere on the sole.
• It can disappear tomorrow afternoon.
Which will happen? For the individual case, I have no idea. Like you, I’ve seen ‘em all.
There are reasons other than functional disability to treat plantar warts. For instance, they’re ugly and embarrassing. So if treatment is not too painful or expensive, why not? But sometimes we freeze it – a standard treatment – and it takes forever, visit after visit, and the wart is still there, grinning complacently. Some insurance plans don’t cover treatments unless the wart hurts, so therapy gets too expensive.
That’s when it might make sense to explain to the patient that you can nip some buds off plants to help them grow better, but you really can’t nip the buds off warts, which have neither roots nor buds.
Another maxim we all pick up is that it’s better to be safe than sorry. That sounds like plain common sense. “Can’t you take off that mole?” asks Annie. “I’m sure it’s bigger that it used to be.”
It’s just an ordinary mole, though, and it doesn’t look worrisome. All moles grow – they start out small and get a bit bigger before they stop. Plus, Annie is a young woman, and her mole is on her face. Even if a plastic surgeon takes it off, she’ll have a scar with no wrinkles to hide it in.
I explain this to Annie. “But isn’t it better to be safe than sorry?” she asks.
Well, sometimes maybe. Just not this time.
Ankur has eczema. He is really frustrated. “Doctors keep giving me creams,” he says. “The rash gets a little better,” but then it comes back. “I’d like you to give me a treatment that will kick it in the butt.”
What Ankur wants, of course, is for me to do something that will shove eczema out the door and then lock the door behind it so it can’t come back.
I would love to do that. Only I can’t. Like the many other recurring conditions we treat every day, nothing specific causes eczema, so nothing definitive gets rid of it once and for all.
In other words, eczema has no butt. So you can’t kick it.
The examples I’ve given are common and homely. There are bigger issues, in medicine and in life, to which common-sense maxims seem to apply but sometimes don’t.
The well-known public debates over prostate-specific antigen (PSA) screening for prostate cancer in older men and routine mammography in younger women attest to how tricky it is to decide whether catching things early is necessarily a good idea. It also shows how the public reacts when data contradict common sense. Of course you should catch cancer early, says the outraged public. Isn’t it always better to be safe than sorry?
No, actually it sometimes isn’t.
We all pick up maxims to live by. We hear them as children without realizing we’re learning them. That makes it hard to accept that not everything is a plant with a bud to be nipped. Or that there are situations when trying to be safe can make you sorrier.
Or that there are indeed butts, big and small. But not everything has one to kick.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.
Brad came in with his mother for me to treat a small wart on the sole of his left foot. “It doesn’t bother me,” he said.
“I had one of those when I was Brad’s age,” said his mother, Mary Lou. “We neglected it and it really grew! With a thing like that, you have to nip it in the bud.”
We all learn little maxims about how the world works and what to do about it. One of these is that to avoid trouble, you should nip things in the bud.
This sounds like it makes sense. Sometimes it’s actually true. But there are other times when what you’re trying to nip doesn’t have a bud.
If you have a plantar wart on the bottom of your foot and you don’t treat it, here are some things that can happen:
• It can grow and become painful.
• It can stay the same for years, never bother you, and go away.
• New ones can appear elsewhere on the sole.
• It can disappear tomorrow afternoon.
Which will happen? For the individual case, I have no idea. Like you, I’ve seen ‘em all.
There are reasons other than functional disability to treat plantar warts. For instance, they’re ugly and embarrassing. So if treatment is not too painful or expensive, why not? But sometimes we freeze it – a standard treatment – and it takes forever, visit after visit, and the wart is still there, grinning complacently. Some insurance plans don’t cover treatments unless the wart hurts, so therapy gets too expensive.
That’s when it might make sense to explain to the patient that you can nip some buds off plants to help them grow better, but you really can’t nip the buds off warts, which have neither roots nor buds.
Another maxim we all pick up is that it’s better to be safe than sorry. That sounds like plain common sense. “Can’t you take off that mole?” asks Annie. “I’m sure it’s bigger that it used to be.”
It’s just an ordinary mole, though, and it doesn’t look worrisome. All moles grow – they start out small and get a bit bigger before they stop. Plus, Annie is a young woman, and her mole is on her face. Even if a plastic surgeon takes it off, she’ll have a scar with no wrinkles to hide it in.
I explain this to Annie. “But isn’t it better to be safe than sorry?” she asks.
Well, sometimes maybe. Just not this time.
Ankur has eczema. He is really frustrated. “Doctors keep giving me creams,” he says. “The rash gets a little better,” but then it comes back. “I’d like you to give me a treatment that will kick it in the butt.”
What Ankur wants, of course, is for me to do something that will shove eczema out the door and then lock the door behind it so it can’t come back.
I would love to do that. Only I can’t. Like the many other recurring conditions we treat every day, nothing specific causes eczema, so nothing definitive gets rid of it once and for all.
In other words, eczema has no butt. So you can’t kick it.
The examples I’ve given are common and homely. There are bigger issues, in medicine and in life, to which common-sense maxims seem to apply but sometimes don’t.
The well-known public debates over prostate-specific antigen (PSA) screening for prostate cancer in older men and routine mammography in younger women attest to how tricky it is to decide whether catching things early is necessarily a good idea. It also shows how the public reacts when data contradict common sense. Of course you should catch cancer early, says the outraged public. Isn’t it always better to be safe than sorry?
No, actually it sometimes isn’t.
We all pick up maxims to live by. We hear them as children without realizing we’re learning them. That makes it hard to accept that not everything is a plant with a bud to be nipped. Or that there are situations when trying to be safe can make you sorrier.
Or that there are indeed butts, big and small. But not everything has one to kick.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.
Brad came in with his mother for me to treat a small wart on the sole of his left foot. “It doesn’t bother me,” he said.
“I had one of those when I was Brad’s age,” said his mother, Mary Lou. “We neglected it and it really grew! With a thing like that, you have to nip it in the bud.”
We all learn little maxims about how the world works and what to do about it. One of these is that to avoid trouble, you should nip things in the bud.
This sounds like it makes sense. Sometimes it’s actually true. But there are other times when what you’re trying to nip doesn’t have a bud.
If you have a plantar wart on the bottom of your foot and you don’t treat it, here are some things that can happen:
• It can grow and become painful.
• It can stay the same for years, never bother you, and go away.
• New ones can appear elsewhere on the sole.
• It can disappear tomorrow afternoon.
Which will happen? For the individual case, I have no idea. Like you, I’ve seen ‘em all.
There are reasons other than functional disability to treat plantar warts. For instance, they’re ugly and embarrassing. So if treatment is not too painful or expensive, why not? But sometimes we freeze it – a standard treatment – and it takes forever, visit after visit, and the wart is still there, grinning complacently. Some insurance plans don’t cover treatments unless the wart hurts, so therapy gets too expensive.
That’s when it might make sense to explain to the patient that you can nip some buds off plants to help them grow better, but you really can’t nip the buds off warts, which have neither roots nor buds.
Another maxim we all pick up is that it’s better to be safe than sorry. That sounds like plain common sense. “Can’t you take off that mole?” asks Annie. “I’m sure it’s bigger that it used to be.”
It’s just an ordinary mole, though, and it doesn’t look worrisome. All moles grow – they start out small and get a bit bigger before they stop. Plus, Annie is a young woman, and her mole is on her face. Even if a plastic surgeon takes it off, she’ll have a scar with no wrinkles to hide it in.
I explain this to Annie. “But isn’t it better to be safe than sorry?” she asks.
Well, sometimes maybe. Just not this time.
Ankur has eczema. He is really frustrated. “Doctors keep giving me creams,” he says. “The rash gets a little better,” but then it comes back. “I’d like you to give me a treatment that will kick it in the butt.”
What Ankur wants, of course, is for me to do something that will shove eczema out the door and then lock the door behind it so it can’t come back.
I would love to do that. Only I can’t. Like the many other recurring conditions we treat every day, nothing specific causes eczema, so nothing definitive gets rid of it once and for all.
In other words, eczema has no butt. So you can’t kick it.
The examples I’ve given are common and homely. There are bigger issues, in medicine and in life, to which common-sense maxims seem to apply but sometimes don’t.
The well-known public debates over prostate-specific antigen (PSA) screening for prostate cancer in older men and routine mammography in younger women attest to how tricky it is to decide whether catching things early is necessarily a good idea. It also shows how the public reacts when data contradict common sense. Of course you should catch cancer early, says the outraged public. Isn’t it always better to be safe than sorry?
No, actually it sometimes isn’t.
We all pick up maxims to live by. We hear them as children without realizing we’re learning them. That makes it hard to accept that not everything is a plant with a bud to be nipped. Or that there are situations when trying to be safe can make you sorrier.
Or that there are indeed butts, big and small. But not everything has one to kick.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.
