Jeffrey Chi

The Road Back to the Bedside

According to that old story, a local giving directions to a lost traveler says, “If I wanted to get there, I wouldn’t start from here.” Medicine finds itself far from the bedside,1,2 seeking a way back, unsure where to begin. That we have wandered far afield is plain to see. Core bedside skills of history taking and physical examination—still vital to comprehensive assessment, diagnostic accuracy,3 and truly patient-focused care—are taught and assessed in the first two years of medical school but largely ignored once the student reaches the clinical years.4 During residency, development of these skills is assumed when in fact they wither further.5 The physical examination of newly admitted patients is often cursory and, what is worse, perverted by drop-down boxes into an exaggerated and invented form that reads better than the truth. Technology drives diagnosis, but it often merely substitutes our fears of uncertainty with delusions of certainty. We seem increasingly chained to the computer, providing perfect care to our virtual patient, the iPatient.2 More has seemed better than less for so long that we now need a national campaign6 to alert our patients to “Just Say No” and save themselves from the hazards and costs of diagnostic misadventure. While we all agonize over the spiraling costs of a “Hi-Tech, Lo-Think” approach, many stand to gain from its persistence. But we have to start somewhere. The way physicians are taught is fundamental to the type of health care they deliver. The road back to the bedside will, we believe, start at the bedside, in the way that clinical skills are taught and assessed. We in the United States stand out among other major Western health care professionals in having a summative postgraduate medical certification process that is entirely dependent on the assessment of knowledge. Elsewhere, for example, the United Kingdom, internal medicine trainees must additionally pass a clinical skills assessment in which independent facultylevel examiners directly observe resident-level trainees assessing real patients.7 In the States, no high-stakes clinical skills assessment for the purpose of certification in internal medicine has survived. The USMLE Step 2 CS is for many trainees the last time that their clinical skills are objectively assessed, and it ensures that a basic level of competence is attained. But given its current content and standard, it cannot equip internal medicine trainees for future practice and appears to mark an end, not a beginning. Meanwhile, high scores on tests of knowledge directly translate into better career prospects. If “assessment does indeed drive learning,”8 we should not be surprised if our trainees prefer books to the bedside. In the absence of a high-stakes assessment of postgraduate clinical skills, we have myriad formative workplace-based tools, but we use them infrequently and inconsistently,9 perhaps because we doubt their veracity or perhaps because it is difficult enough to find faculty willing and confident in their own clinical skills sufficient to teach or assess residents. Escalating constraints of work hour rules, rapid turnover, and the need for documentation add to the problem. Direct observation is the key to the development of competence10; in its absence a resident’s expertise in interpreting information gathered is taken to mean that he or she has similar expertise in gathering the information. As matters stand, assessment of residents’ clinical skills often appears to be based on little more than the general impression of attending physicians, whose own clinical skills were never directly observed. Can it really be that an internal medicine trainee passes through his or her entire residency without ever assessing a patient under the direct observation of a faculty-level assessor? What would our patients say if they knew? Much the same, we suspect, if they were told that their pilot had never been vetted in the cockpit. At Stanford, our interest in bedside medicine and the presence of a visitor (A.E.) on sabbatical from a system where high-stakes postgraduate clinical skills assessment remains the norm, led us to four principles to guide our own efforts to enhance residents’ bedside skills and begin on the path back: 1. Involve Real Patients. As valuable as “simulated patients”—of humankind or mannequin-kind—can be, the term is only 50% correct: “simulated,” yes; “patient,” no. Teaching and assessing higher-level clinical skills, such as the ability to discriminate between normal and abnormal in the physical examination, require real patients with real signs. Our first step is the establishment of a database of patients willing and able to help. 2. Observe Residents’ Practice. Direct observation and appraisal of trainees by trainers must increase both in informal day-to-day working practice or with new or established tools. We are piloting our own bedside skills assessment, with real patients and facultylevel assessors, modeled on the Membership of the Royal College of Physicians (MRCP) PACES examination, which is conducted worldwide (and for which A.E. serves as chair of the examining board). 3. Demonstrate Clinical Skills. Direct observation is a two-sided coin—trainees must also observe the clinical method of their trainers. In Workshops: We devote four morning report sessions each month to a Stanford Medicine 25 session: a hands-on demonstration of a physical diagnosis technique.11 At the Bedside: Our core group of attendings are our hospitalists, who have taken the lead in our bedside medicine efforts; their continued interest and experience as bedside teachers leverage A PIECE OF MY MIND

Heterogeneity of functional responses in differentiated myeloid cell lines reveals EPRO cells as a valid model of murine neutrophil functional activation

Mature neutrophils display multiple functional responses upon activation that include chemotaxis, adhesion to and transmigration across endothelial cells, phagocytosis, and pathogen destruction via potent microbicidal enzymes and reactive oxygen species. We are using myeloid cell line models to investigate the signaling pathways that govern neutrophil functional activation. To facilitate these studies, we have performed a direct comparison of functional responses of human and murine myeloid cell line models upon neutrophil differentiation. Our results show that EPRO cells, promyelocytes that undergo complete neutrophil maturation, demonstrate a full spectrum of functional responses, including respiratory burst, chemotaxis toward two murine chemokines, and phagocytosis. We also extend previous studies of granulocyte‐colony stimulating actor‐induced 32Dcl3 cells, showing they domonstrate chemotaxis and phogocytosis but completely lack a respiratory burst as a result of the absent expression of a critical oxidase subunit, gp91phox. Induced human leukemic NB4 and HL‐60 cells display a respiratory burst and phagocytosis but have defective chemotaxis to multiple chemoattractants. We also tested each cell line for the ability to up‐regulate cell‐surface membrane‐activated complex‐1 (Mac‐1) expression upon activation, a response mediating neutrophil adhesion and a surrogate marker for degranulation. We show that EPRO cells, but not 32Dcl3 or NB4, significantly increase Mac‐1 surface expression upon functional activation. Together, these data show that EPRO and MPRO cells demonstrate complete, functional activation upon neutrophil differentiation, suggesting these promyelocytic models accurately reflect the functional capacity of mature murine neutrophils.

Long-term outcomes of septal reduction for obstructive hypertrophic cardiomyopathy.

BACKGROUND Surgical myectomy and alcohol septal ablation (ASA) aim to decrease left ventricular outflow tract (LVOT) gradient in hypertrophic cardiomyopathy (HCM). Outcome of myectomy beyond 10 years has rarely been described. We describe 20 years of follow-up of surgical myectomy and 5 years of follow-up for ASA performed for obstructive HCM. METHODS We studied 171 patients who underwent myectomy for symptomatic LVOT obstruction between 1972 and 2006. In addition, we studied 52 patients who underwent ASA for the same indication and who declined surgery. Follow-up of New York Heart Association (NYHA) functional class, echocardiographic data, and vital status were obtained from patient records. Mortality rates were compared with expected mortality rates of age- and sex-matched populations. RESULTS Surgical myectomy improved NYHA class (2.74±0.65 to 1.54±0.74, p<0.001), reduced resting gradient (67.4±43.4mmHg to 11.2±16.4mmHg, p<0.001), and inducible LVOT gradient (98.1±34.7mmHg to 33.6±34.9mmHg, p<0.001). Similarly, ASA improved functional class (2.99±0.35 to 1.5±0.74, p<0.001), resting gradient (67.1±26.9mmHg to 23.9±29.4mmHg, p<0.001) and provoked gradient (104.4±34.9mmHg to 35.5±38.6mmHg, p<0.001). Survival after myectomy at 5, 10, 15, and 20 years of follow-up was 92.9%, 81.1%, 68.9%, and 47.5%, respectively. Of note, long-term survival after myectomy was lower than for the general population [standardized mortality ratio (SMR)=1.40, p<0.005], but still compared favorably with historical data from non-operated HCM patients. Survival after ASA at 2 and 5 years was 97.8% and 94.7%, respectively. Short-term (5 year) survival after ASA (SMR=0.61, p=0.48) was comparable to that of the general population. CONCLUSION Long-term follow-up of septal reduction strategies in obstructive HCM reveals that surgical myectomy and ASA are effective for symptom relief and LVOT gradient reduction and are associated with favorable survival. While overall prognosis for the community HCM population is similar to the general population, the need for surgical myectomy may identify a sub-group with poorer long-term prognosis. We await long-term outcomes of more extensive myectomy approaches adopted in the past 10 years at major institutions.

Improving communication with patients: learning by doing.

“Learning by doing” has been the mantra of clinical education since the days of Osler. Simulation (for example, in laparoscopy or in enhancing communication skills) is a relatively recent teaching innovation. It allows for a controlled setting andminimizationof patient risk anddiscomfort. Thehope for any formof simulation is that itwill be an effective pedagogic tool, avaluableadjunct toexperiencewithrealpatients.1Teaching physicians the skills to communicatewellwith patients at the end of life is a worthy goal, because it is profoundly beneficial to patients when done correctly.2,3 In this issueof JAMA, Curtis andcolleagues4describe their use of a 4-day simulation-based workshop using standardizedpatients to improve the end-of-life communication skills of 178 internal medicine trainees and 33 nurse practitioner or registered nurse trainees, compared with a control group of 198 internal medicine traineesand36nursepractitioneror registerednurse trainees. In an attempt to answer the question ofwhether this previously validated workshop method5 makes a difference to patients and others in the real world, the authors included a 10-month follow-up period during which participants were evaluated by actual patients and families as well as by supervising faculty; the goal was to determine how well participantsperformed in thedomainsof communicationand inproviding end-of-life care. Even though the workshop was associated with improved skills among theparticipants (as evaluatedby the standardized patients), the authors were unable to show that it helped in subsequent interactionswith real patients.After adjustment, comparing the interventionwith control, therewas nosignificantdifference in thequalityof communicationscore forpatients (difference,0.4points [95%CI,−0.1 to0.9];P = .15) or families (difference, 0.1 [95% CI, −0.8 to 1.0]; P = .81) and no difference in quality of end-of-life care score for patients (difference, 0.3 [95% CI, −0.3 to 0.8]; P = .34) or families (difference, 0.1 [95%CI, −0.7 to 0.8]; P = .88). Indeed, patients of the trainees in the intervention group were actually found to have significantly increased depression scores. There are many possible reasons for the unexpected results. Patients and families are not formally trained to evaluate communicationskills.Additionally, theacquisitionof skills was tested over the course of a 10-month period following workshop participation and not immediately following specific end-of-life discussions. It is possible that the improvement inparticipants’ skillswasnot enough tomake ameasurable difference to patients; conversely, it is possible that trainees did not recall training and so were not able to apply the communication skills. The finding of increased depression scores in patients of trainees in the intervention group is intriguing. The phenomenon was more common with the patients of interns than with patients of more senior trainees. Perhaps in the world of a busy intern, with many tasks competing for time and attention, and with work-hour restrictions, it is a challenge to reproduce what was learned in the setting of a controlled workshop. Accordingly, one conclusion from the study might be that end-of-life conversations should be left to more senior physicians. Ericsson’s idea of deliberate practice,6 in which motivated trainees emphasize specific learning objectives, receive timely and relevant feedback, self-reflect, andengage in focused repetition, can be applied well in a simulated controlled environment.7 But even with the best learning methods, simulation has inherent limitations: for example, hightech mannequins with audio recordings are not a perfect substitute for real patients when teaching cardiac examination skills.8 The study by Curtis et al4 raises the question of whether standardized patients can convincingly display and express feelings they are not really feeling. Can trainees in simulation experience empathy, knowing they are hearing a standardized patient script? If the trainee learns to speak and act in a manner that represents empathy, is that the same as beingtrulyempathetic?9Nonverbal communication (bodyposture, facial expression, and gestures) can be intentional, but it is just as often nonintentional and registered by others at a conscious or subconscious level. For the trainee to “act” the partmight not only be insufficient, itmight seem insincere to a real patient.10 Ultimately, there isprobablynoperfect substitute for trainees’ engaging in the deliberate practice of reevaluating themselves, raising the bar to learn more advanced skill sets, and receiving constant feedback from patients and supervisors. This may require both simulation and longitudinal experiences with real patients, for whom the complexity, nuances, and unique challenges of communication are preserved. The study by Curtis et al4 should make educators reflect onhowwell traineesaredoingwith theskills imparted to them. For example, everymedical school teaches some version of a physical diagnosis course in the first and second years. There usually is a substantial investment in standardized patients, not to mention faculty, space, and money. An end-of-course test affirms the acquisitionof knowledge, if not skill. Butwhat does it all mean in the real world of patient care? Patients and Related article page 2271 Opinion

A cascade of Ca2+/calmodulin-dependent protein kinases regulates the differentiation and functional activation of murine neutrophils

OBJECTIVE The function of neutrophils as primary mediators of innate immunity depends on the activity of granule proteins and critical components of the nicotinamide adenine dinucleotide phosphate (NADPH) oxidase complex. Expression of their cognate genes is regulated during neutrophil differentiation by a complex network of intracellular signaling pathways. In this study, we have investigated the role of two members of the calcium/calmodulin-dependent protein kinase (CaMK) signaling cascade, CaMK I-like kinase (CKLiK) and CaMKKalpha, in regulating neutrophil differentiation and functional activation. MATERIALS AND METHODS Mouse myeloid cell lines were used to examine the expression of a CaMK cascade in developing neutrophils and to examine the effects of constitutive activation vs inhibition of CaMKs on neutrophil maturation. RESULTS Expression of CaMKKalpha was shown to increase during neutrophil differentiation in multiple cell lines, whereas expression of CKLiK increased as multipotent progenitors committed to promyelocytes, but then decreased as cells differentiated into mature neutrophils. Expression of constitutively active CKLiKs did not affect morphologic maturation, but caused dramatic decreases in both respiratory burst responses and chemotaxis. This loss of neutrophil function was accompanied by reduced secondary granule and gp91(phox) gene expression. The CaMK inhibitor KN-93 attenuated cytokine-stimulated proliferative responses in promyelocytic cell lines, and inhibited the respiratory burst. Similar data were observed with the CaMKKalpha inhibitor, STO-609. CONCLUSIONS Overactivation of a cascade of CaMKs inhibits neutrophil maturation, suggesting that these kinases play an antagonistic role during neutrophil differentiation, but at least one CaMK is required for myeloid cell expansion and functional activation.

The Five-Minute Moment

In todays hospital and clinic environment, the obstacles to bedside teaching for both faculty and trainees are considerable. As electronic health record systems become increasingly prevalent, trainees are spending more time performing patient care tasks from computer workstations, limiting opportunities to learn at the bedside. Physical examination skills rarely are emphasized, and low confidence levels, especially in junior faculty, pose additional barriers to teaching the bedside examination.

A Pilot Study of the Chronology of Present Illness: Restructuring the HPI to Improve Physician Cognition and Communication

BackgroundPatient history-taking is an essential clinical skill, with effects on diagnostic reasoning, patient–physician relationships, and more. We evaluated the impact of using a structured, timeline-based format, the Chronology of Present Illness (CPI), to guide the initial patient interaction.ObjectiveTo determine the feasibility and impact of the CPI on the patient interview, written notes, and communication with other providers.DesignInternal medicine residents used the CPI during a 2-week night-float rotation. For the first week, residents interviewed, documented, and presented patient histories according to their normal practices. They then attended a brief educational session describing the CPI, and were asked to use this method for new patient interviews, notes, and handoffs during the second week. Night and day teams evaluated the method using retrospective pre–post comparisons.ParticipantsTwenty-two internal medicine residents in their second or third postgraduate year.InterventionAn educational dinner describing the format and potential benefits of using the CPI.Main MeasuresRetrospective pre–post surveys on the efficiency, quality, and clarity of the patient interaction, written note, and verbal handoff, as well as open-ended comments. Respondents included night-float residents, day team residents, and attending physicians.Key ResultsAll night-float residents responded, reporting significant improvements in written note, verbal sign-out, assessment and plan, patient interaction, and overall efficiency (p < 0.05). Day team residents (n = 76) also reported increased clarity in verbal sign-out and written note, improved efficiency, and improved preparedness for presenting the patient (p < 0.05). Attending physician ratings did not differ between groups.ConclusionsResident ratings indicate that the CPI can improve key aspects of patient care, including the patient interview, note, and physician–physician communication. These results suggest that the method should be taught and implemented more frequently.

Characterizing Inpatient Medicine Resident Electronic Health Record Usage Patterns Using Event Log Data

Amid growing rates of burnout, physicians report increasing electronic health record (EHR) usage alongside decreasing clinical facetime with patients. There exists a pressing need to improve physician-computer-patient interactions by streamlining EHR workflow. To identify interventions to improve EHR design and usage, we systematically characterize EHR activity among internal medicine residents at a tertiary academic hospital across various inpatient rotations and roles from June 2013 to November 2016. Logged EHR timestamps were extracted from Stanford Hospital’s EHR system (Epic) and cross-referenced against resident rotation schedules. We tracked the quantity of EHR logs across 24-hour cycles to reveal daily usage patterns. In addition, we decomposed daily EHR time into time spent on specific EHR actions (e.g. chart review, note entry and review, results review). In examining 24-hour usage cycles from general medicine day and night team rotations, we identified a prominent trend in which night team activity promptly ceased at the shift’s end, while day team activity tended to linger post-shift. Across all rotations and roles, residents spent on average 5.38 hours (standard deviation=2.07) using the EHR. PGY1 (post-graduate year one) interns and PGY2+ residents spent on average 2.4 and 4.1 times the number of EHR hours on information review (chart, note, and results review) as information entry (note and order entry). Analysis of EHR event log data can enable medical educators and programs to develop more targeted interventions to improve physician-computer-patient interactions, centered on specific EHR actions.

The Role of Technology in the Bedside Encounter

Technology has the potential to both distract and reconnect providers with their patients. The widespread adoption of electronic medical records in recent years pulls physicians away from time at the bedside. However, when used in conjunction with patients, technology has the potential to bring patients and physicians together. The increasing use of point-of-care ultrasound by physicians is changing the bedside encounter by allowing for real-time diagnosis with the treating physician. It is a powerful example of the way technology can be a force for refocusing on the bedside encounter.

Lean-Based Redesign of Multidisciplinary Rounds on General Medicine Service

BACKGROUND Multidisciplinary rounds (MDR) facilitate timely communication amongst the care team and with patients. We used Lean techniques to redesign MDR on the teaching general medicine service. OBJECTIVE To examine if our Lean-based new model of MDR was associated with change in the primary outcome of length of stay (LOS) and secondary outcomes of discharges before noon, documentation of estimated discharge date (EDD), and patient satisfaction. DESIGN, SETTING, PATIENTS This is a pre-post study. The preperiod (in which the old model of MDR was followed) comprised 4000 patients discharged between September 1, 2013, and October 22, 2014. The postperiod (in which the new model of MDR was followed) comprised 2085 patients between October 23, 2014, and April 30, 2015. INTERVENTION Lean-based redesign of MDR. MEASUREMENTS LOS, discharges before noon, EDD, and patient satisfaction. RESULTS There was no change in the mean LOS. Discharges before noon increased from 6.9% to 10.7% (P < .001). Recording of EDD increased from 31.4% to 41.3% (P < .001). There was no change in patient satisfaction. CONCLUSIONS Lean-based redesign of MDR was associated with an increase in discharges before noon and in recording of EDD.