Traci Adams

Utility of Bronchoalveolar Lavage and Transbronchial Biopsy in Patients with Hypersensitivity Pneumonitis

IntroductionMaking the diagnosis of HP is challenging due to a lack of consensus criteria and variability of both pathologic and radiographic findings. The purpose of this retrospective study was to determine the diagnostic utility of the combination of BAL lymphocyte count and TBBX in patients with HP.MethodsWe conducted a retrospective cohort study of all patients with a MDD diagnosis of HP at a single center.Results155 patients were included in the study. 49% of patients who underwent BAL had a lymphocyte count > 20, 42% had a lymphocyte count > 30, and 34% had lymphocyte count > 40%. The median BAL lymphocyte count was higher in inflammatory HP compared to fibrotic HP. The addition of TBBX to BAL significantly increased the diagnostic yield regardless of the BAL lymphocyte cutoff used. The yield of bronchoscopy with TBBX and BAL when a lymphocyte count > 40% was used as a cutoff was 52%.ConclusionsOur study suggests that the combination of TBBX with BAL significantly increases the likelihood that the procedure will provide adequate additional information to allow a confident MDD diagnosis of HP and may reduce the need for SLB in the diagnostic workup of HP.

Time dilation in simultaneous simulation

Simulationbased health professional education can improve patient care processes and outcomes by allowing health care professionals to learn from simulated patient scenarios that closely approximate their realworld patient encounters. 1,2 Multitasking simulation in interprofessional education and graduate medical education introduces deliberate interruptions into complex patient care scenarios, often involving multiple team members, in order to simulate the frequently chaotic environment of the medical wards. 1 I suggest that these multitasking simulations may increase fi delity to realworld practice compared with traditional sequential case simulation by producing ‘time dilation’, or the perception of an infl ated duration of an event.

Resident versus faculty member simulation debriefing

Near‐peer teaching is effective in graduate medical education, but it has not been compared with faculty member teaching in resident simulation. In this study, we sought to compare debriefing sessions of internal medicine (IM) intern simulation sessions led by academic faculty doctors with those led by senior IM residents in order to measure the effectiveness of near‐peer teaching in this setting.

Curiosity and independent reading among residents.

In the era of dutyhour limitations, resident selfdirected learning has become increasingly important. Several types of resident reading interventions have been implemented, 1 and each seems to have had a different effect on curiosity in the learner. By understanding curiosity and its effect on selfdirected learning, residency programmes can tailor their reading interventions to different types of learners and understand the limitations of these interventions.

Cobalt related interstitial lung disease

Cobalt exposure in the hard metal and bonded diamond tool industry is a well-established cause of ILD. The primary theories regarding the underlying mechanism of cobalt related ILD include an immunologic mechanism and an oxidant injury mechanism. Cobalt related ILD may present in subacute and chronic forms and often has associated upper respiratory symptoms. The evaluation begins with a thorough occupational history and includes PFTs, HRCT, and bronchoalveolar lavage. HRCT findings are nonspecific and may resemble NSIP, UIP, sarcoidosis, or HP. The finding of cannibalistic multinucleated giant cells is diagnostic provided there is a history of exposure and appropriate changes on imaging; however, when these cells are not found on lavage, lung biopsy is required for diagnosis. Giant cell interstitial pneumonia is the classic pathologic pattern, but cobalt related ILD may also present with pathologic findings of UIP, DIP, or HP. When cobalt related ILD is suspected, removal from exposure is the most important step in treatment. Case reports suggest that treatment with steroids results in symptomatic, physiologic, and radiographic improvement.

Multitasking simulation: Present application and future directions

Abstract The Accreditation Council for Graduate Medical Education lists multi-tasking as a core competency in several medical specialties due to increasing demands on providers to manage the care of multiple patients simultaneously. Trainees often learn multitasking on the job without any formal curriculum, leading to high error rates. Multitasking simulation training has demonstrated success in reducing error rates among trainees. Studies of multitasking simulation demonstrate that this type of simulation is feasible, does not hinder the acquisition of procedural skill, and leads to better performance during subsequent periods of multitasking. Although some healthcare agencies have discouraged multitasking due to higher error rates among multitasking providers, it cannot be eliminated entirely in settings such as the emergency department in which providers care for more than one patient simultaneously. Simulation can help trainees to identify situations in which multitasking is inappropriate, while preparing them for situations in which multitasking is inevitable.

Hospitalist Perspective of Interactions with Medicine Subspecialty Consult Services

BACKGROUND Medicine subspecialty consultation is becoming increasingly important in inpatient medicine. OBJECTIVE We conducted a survey study in which we examined hospitalist practices and attitudes regarding medicine subspecialty consultation. DESIGN AND SETTING The survey instrument was developed by the authors based on prior literature and administered online anonymously to hospitalists at 4 academic medical centers in the United States. MEASUREMENTS The survey evaluated 4 domains: (1) current consultation practices, (2) preferences regarding consultation, (3) barriers to and facilitating factors of effective consultation, and (4) a comparison between hospitalist–fellow and hospitalist–subspecialty attending interactions. RESULTS One hundred twenty-two of 261 hospitalists (46.7%) responded. The majority of hospitalists interacted with fellows during consultation. Of those, 90.9% reported that in-person communication occurred during less than half of consultations, and 64.4% perceived pushback at least “sometimes” in their consult interactions. Participants viewed consultation as an important learning experience, preferred direct communication with the consulting service, and were interested in more teaching during consultation. The survey identified a number of barriers to and facilitating factors of an effective hospitalist–consultant interaction, which impacted both hospitalist learning and patient care. Hospitalists reported more positive experiences when interacting with subspecialty attendings compared to fellows with regard to multiple aspects of the consultation. CONCLUSION The hospitalist–consultant interaction is viewed as important for both hospitalist learning and patient care. Multiple barriers and facilitating factors impact the interaction, many of which are amenable to intervention.

Mentorship in the health professions

Mentor relationships are important to trainee development. Two interventions were implemented to improve mentorship among trainee doctors: (1) identifi cation of a doctor advisor and (2) a mentorship training programme with funded mentoring time. Both interventions increased the percentage of trainees who reported having a mentor, compared with controls. Mentored trainees were more likely to be satisfi ed with their programmes and to feel supported. By fi nancially supporting mentorship initiatives, training programmes can increase the number of mentoring relationships and improve trainee satisfaction.

Use of the morning report to teach high-value care

I was interested to read the description of the highvalue care morning report by Bowman et al. 1 Academic medical centres (AMCs) provide more expensive care than their nonacademic counterparts, in part because of factors that may be modifi able with trainee education. 2 One such factor is the overrepresentation of rare diagnoses in conferences such as the morning report. 3 This may ultimately skew residents’ assessment of the pretest probability of these rare conditions, and lead to the increased ordering of diagnostic tests to evaluate for rare diagnoses in patients presenting with common disorders. Furthermore, in my experience, interprofessional pressures inherent in a hierarchical practice model push trainees to order excessive diagnostic testing in order to demonstrate their breadth of knowledge to their attending physicians . Finally, inexperienced trainees are unlikely to have an adequate knowledge of the costs of the diagnostic tests that they order. 1

Barriers to hospitalist fellow interactions

Hospitalists are attending physicians who serve as general medical providers for hospitalised patients, whereas fellows are trainees in a medical subspecialty. Both hospitalists and fellows have completed a residency, which is the training period that physicians enter following the completion of medical school. Several barriers seem to make hospitalists a learner group that is distinct from residents. As attending physicians, hospitalists are a step above fellows in the hierarchical hospital structure, which could limit fellows’ confidence in their role as teachers and hospitalists’ confidence in their role as learners. Secondly, the primary team structure and familiarity between residents and fellows were identified as barriers to fellows teaching residents in the study by Miloslavsky et al., and these challenges are even more profound in the hospitalist‒fellow dynamic. Although many fellows completed residency at the same institution and are likely to know the location of resident workrooms and the structure of resident schedules, they are less likely to have access to this data for hospitalists, making face-to-face encounters more challenging. In addition, many hospitalists care for a given patient for only a few days at a time before rotating off service, so there are fewer opportunities for interaction than there are with residents, who often spend several weeks on a service. Finally, fellows have a limited ability to identify with hospitalists as learners because few fellows have worked as a hospitalist; by contrast, having recently undergone the transition from resident to subspecialist, fellows can relate to residents’ desire to learn a subspecialty. By addressing these barriers, we can improve teaching and learning on the medical wards. On a practical level, encouraging fellows to meet the hospitalists and understand their schedules and time constraints could improve hospitalist‒fellow communication. Cultural change is also necessary in order to move away from a medical hierarchy toward a collaborative effort to learn as we take care of patients. We should strive to create a learning environment in which fellows are encouraged to teach both residents and hospitalists during consultations.