Jakob I. McSparron

Osseous sarcoidosis: Clinical characteristics, treatment, and outcomes—Experience from a large, academic hospital

OBJECTIVE Osseous sarcoidosis has been infrequently reported. We aimed to characterize the distribution of lesions, clinical presentation, treatment, and outcomes for osseous sarcoidosis. METHODS Cases of osseous sarcoidosis were identified by directed inquiry to clinicians and electronic query. Cases were defined as having pathologic evidence of non-caseating granulomas on bone biopsy or evidence of osseous lesions on imaging attributable to sarcoidosis in patients with known sarcoidosis. Detailed characteristics were obtained by medical record review. RESULTS We identified a total of 20 cases of osseous sarcoidosis. Osseous lesions were detected by imaging during the initial sarcoidosis presentation in 60% of cases. In those who had a prior diagnosis of sarcoidosis, the median duration of sarcoidosis before detection of osseous involvement was 4.3 years. Symptoms were present in 50% of cases. All cases had more than one bone involved. The axial skeleton was involved in the majority of cases (90%), primarily the pelvis and the lumbar spine. Most cases required no treatment (55%); a minority of cases (45%) were treated, most often with prednisone, methotrexate, or hydroxychloroquine. Two cases required multiple immunosuppressants, including tumor necrosis factor inhibitors, for refractory symptomatic osseous sarcoidosis. Treated cases were younger than those who were untreated. At last follow-up, most cases (85%) were asymptomatic from osseous lesions. CONCLUSIONS In this case series of osseous sarcoidosis from a single center, most patients had multiple bones affected and had other systemic manifestations of sarcoidosis. A minority required treatment for relief of symptoms, and most cases were asymptomatic at last follow-up.

Procedural instruction in invasive bedside procedures: a systematic review and meta-analysis of effective teaching approaches

Importance Optimal approaches to teaching bedside procedures are unknown. Objective To identify effective instructional approaches in procedural training. Data sources We searched PubMed, EMBASE, Web of Science and Cochrane Library through December 2014. Study selection We included research articles that addressed procedural training among physicians or physician trainees for 12 bedside procedures. Two independent reviewers screened 9312 citations and identified 344 articles for full-text review. Data extraction and synthesis Two independent reviewers extracted data from full-text articles. Main outcomes and measures We included measurements as classified by translational science outcomes T1 (testing settings), T2 (patient care practices) and T3 (patient/public health outcomes). Due to incomplete reporting, we post hoc classified study outcomes as ‘negative’ or ‘positive’ based on statistical significance. We performed meta-analyses of outcomes on the subset of studies sharing similar outcomes. Results We found 161 eligible studies (44 randomised controlled trials (RCTs), 34 non-RCTs and 83 uncontrolled trials). Simulation was the most frequently published educational mode (78%). Our post hoc classification showed that studies involving simulation, competency-based approaches and RCTs had higher frequencies of T2/T3 outcomes. Meta-analyses showed that simulation (risk ratio (RR) 1.54 vs 0.55 for studies with vs without simulation, p=0.013) and competency-based approaches (RR 3.17 vs 0.89, p<0.001) were effective forms of training. Conclusions and relevance This systematic review of bedside procedural skills demonstrates that the current literature is heterogeneous and of varying quality and rigour. Evidence is strongest for the use of simulation and competency-based paradigms in teaching procedures, and these approaches should be the mainstay of programmes that train physicians to perform procedures. Further research should clarify differences among instructional methods (eg, forms of hands-on training) rather than among educational modes (eg, lecture vs simulation).

Teaching during consultation: factors affecting the resident-fellow teaching interaction.

The subspecialty consultation represents a potentially powerful opportunity for resident learning, but barriers may limit the educational exchanges between fellows (subspecialty registrars) and residents (house officers). We conducted a focus group study of internal medicine (IM) residents and subspecialty fellows to determine barriers against and factors facilitating resident–fellow teaching interactions on the wards, and to identify opportunities for maximising teaching and learning.

Simulation for Skills-based Education in Pulmonary and Critical Care Medicine

The clinical practice of pulmonary and critical care medicine requires procedural competence in many technical domains, including vascular access, airway management, basic and advanced bronchoscopy, pleural procedures, and critical care ultrasonography. Simulation provides opportunities for standardized training and assessment in procedures without placing patients at undue risk. A growing body of literature supports the use and effectiveness of low-fidelity and high-fidelity simulators for procedural training and assessment. In this manuscript by the Skills-based Working Group of the American Thoracic Society Education Committee, we describe the background, available technology, and current evidence related to simulation-based skills training within pulmonary and critical care medicine. We outline working group recommendations for key procedural domains.

The Fellow as Clinical Teacher Curriculum: Improving Rheumatology Fellows' Teaching Skills During Inpatient Consultation

Enhancing rheumatology fellows’ teaching skills in the setting of inpatient consultation may have a broad positive impact. Such efforts may improve fellows’ clinical skills and overall patient care. Most importantly, effective resident‐fellow teaching interactions may not only increase residents’ knowledge of rheumatology but may influence their career choice. However, a number of barriers to the resident‐fellow teaching interaction have been identified, including fellows’ teaching skills. We developed the Fellow As Clinical Teacher (FACT) curriculum in order to enhance fellows’ teaching skills during inpatient consultation.

Fellow As Teacher Curriculum: Improving Rheumatology Fellows' Teaching Skills During Inpatient Consultation.

Enhancing rheumatology fellows’ teaching skills in the setting of inpatient consultation may have a broad positive impact. Such efforts may improve fellows’ clinical skills and overall patient care. Most importantly, effective resident‐fellow teaching interactions may not only increase residents’ knowledge of rheumatology but may influence their career choice. However, a number of barriers to the resident‐fellow teaching interaction have been identified, including fellows’ teaching skills. We developed the Fellow As Clinical Teacher (FACT) curriculum in order to enhance fellows’ teaching skills during inpatient consultation.

Improving Resident Communication in the Intensive Care Unit. The Proceduralization of Physician Communication with Patients and Their Surrogates

Effective communication between providers and patients and their surrogates in the intensive care unit (ICU) is crucial for delivery of high-quality care. Despite the identification of communication as a key education focus by the American Board of Internal Medicine, little emphasis is placed on teaching trainees how to effectively communicate in the ICU. Data are conflicting on the best way to teach residents, and institutions vary on their emphasis of communication as a key skill. There needs to be a cultural shift surrounding the education of medical residents in the ICU: communication must be treated with the same emphasis, precision, and importance as placing a central venous catheter in the ICU. We propose that high-stakes communications between physicians and patients or their surrogates must be viewed as a medical procedure that can be taught, assessed, and quality controlled. Medical residents require training, observation, and feedback in specific communication skill sets with the goal of achieving mastery. It is only through supervised training, practice in real time, observation, and feedback that medical residents can become skillful practitioners of communication in the ICU.

Cognitive learning theory for clinical teaching

Editor’s note: Cognition is the act of knowing, perceiving and processing information specifically in relation to brain functioning and mental processes. Thus cognitive learning is about using thinking to learn, where such thinking may be affected by external and internal factors. As the authors of this toolbox article describe, cognitive learning theory may be applied to explain and facilitate retention and translation of clinical knowledge. The theory and its application are presented through a series of six concepts relevant to clinical teaching practices: retrieval practice; spaced learning; interleaving; self-practice; reflection; and elaboration. Each of these is discussed in ways that clinical teachers may apply easily in practice. In particular I feel that the table of strategies to integrate cognitive learning theory into clinical education will be of great practical benefit.

More than Meets the Eye. A 23-Year-Old Woman with Rapidly Progressive Respiratory Failure, Mucositis, and Rash.

A previously healthy young adult woman presented with acute respiratory failure and rash. Her clinical condition rapidly deteriorated, with development of surface tissue sloughing, primarily involving mucocutaneous areas and conjunctiva. A thorough medical history, interpretation of a rapidly evolving physical examination, and aggressive diagnostic testing lead to a diagnosis and successful treatment.

Fellow as Clinical Teacher (FACT) Curriculum: Improving Fellows’ Teaching Skills During Inpatient Consultation

Introduction Multiple barriers, including time constraints, a demanding teaching environment, and lack of longitudinal relationships with residents, make it challenging for fellows and learners to engage in effective teaching during consultation. Methods The Fellow as Clinical Teacher (FACT) curriculum was developed to overcome such barriers and improve fellow teaching in the setting of inpatient consultation. The FACT curriculum consists of two 45- to 60-minute small-group sessions designed for subspecialty fellows. The first session focuses on overcoming barriers to teaching and application of the principles of adult learning theory. The second introduces the PARTNER (partner with resident, assess the learner, reinforce positives, teaching objectives, new knowledge, execute recommendations, review) framework for teaching during consultation and uses video examples to model the application of this framework, allowing fellows to practice its implementation through role-play. Results Previously, the FACT curriculum was shown to improve teaching skills of rheumatology and pulmonary/critical care fellows as evaluated by objective structured teaching exercises. Here, the curriculum has been expanded to 51 internal medicine and pediatrics fellows in 15 different training programs. The curriculum improved fellow teaching skills as assessed by self-assessment surveys. It was highly rated by participants, and fellows reported being more likely to teach during consultation following this educational intervention. Discussion The FACT curriculum can be integrated into subspecialty training programs to improve the teaching skills of internal medicine and pediatrics fellows in the setting of inpatient consultation. Ultimately, improved teaching from fellows may have broad-reaching effects for residents, patients, and the fellows themselves.