Development of antibiotic metrics for hospitalists via multi-institutional modified Delphi survey

BACKGROUND

Closing the gap between evidence-supported antibiotic use and real-world prescribing among clinicians is vital for curbing excessive antibiotic use, which fosters antimicrobial resistance and exposes patients to antimicrobial side effects. Providing prescribing information via scorecard improves clinician adherence to quality metrics.

OBJECTIVE

We aimed to delineate actionable, relevant antimicrobial prescribing metrics extractable from the electronic health record in an automated way.

DESIGN

We used a modified Delphi consensus-building approach.

SETTINGS AND PARTICIPANTS

Our study entailed two iterations of an electronic survey disseminated to hospital medicine physicians at 10 academic medical centers nationwide.

MAIN OUTCOMES AND MEASURES

Main outcomes comprised consensus metrics describing the quality of antibiotic prescribing to hospital medicine physicians.

RESULTS

Twenty-eight participants from 10 United States institutions completed the first survey version containing 38 measures. Sixteen respondents completed the second survey, which contained 37 metrics. Sixteen metrics, which were modified based on qualitative survey feedback, met criteria for inclusion in the final scorecard. Metrics considered most relevant by hospitalists focused on the appropriate de-escalation of antimicrobial therapy, selection of guideline-concordant antibiotics, and appropriate duration of treatment for common infectious syndromes. Next steps involve prioritization and implementation of these metrics based on quality gaps at our institution, focus groups exploring impressions of clinicians who receive a scorecard, and analysis of antibiotic prescribing patterns before and after metric implementation. Other institutions may be able to implement metrics from this scorecard based on their own quality gaps to provide hospitalists with automated feedback related to antibiotic prescribing.

Online Learning for Infectious Disease (ID) Fellows – a needs assessment

Background

Online resources and social media have become increasingly ubiquitous in medical education. Little is known about the need for educational resources aimed at infectious disease (ID) fellows.

Methods

We conducted an educational needs assessment through a survey that aimed to describe ID fellows’ current use of online and social media tools, assess the value of online learning, and identify the educational content preferred by ID fellows. We subsequently convened focus groups with ID fellows to explore how digital tools contribute to fellow learning.

Results

A total of 110 ID fellows responded to the survey. Over half were second-year fellows (61, 55%). Although many respondents were satisfied with the educational resources provided by their fellowship program (70, 64%), the majority were interested in an online collaborative educational resource (97, 88%). Twitter was the most popular social media platform for education and the most valued online resource for learning. Focus groups identified several themes regarding social medial learning: broadened community, low barrier to learning, technology-enhanced learning, and limitations of current tools. Overall, the focus groups suggest that fellows value social media and online learning.

Conclusions

ID fellows are currently using online and social media resources, which they view as valuable educational tools. Fellowship programs should consider these resources as complementary to traditional teaching and as a means to augment ID fellow education.

The Digital Classroom: How to Leverage Social Media for Infectious Diseases Education

Social media (SoMe) platforms have been increasingly used by infectious diseases (ID) learners and educators in recent years. This trend has only accelerated with the changes brought to our educational spaces by the coronavirus disease 2019 pandemic. Given the increasingly diverse SoMe landscape, educators may find themselves struggling with how to effectively use these tools. In this Viewpoint we describe how to use SoMe platforms (e.g., Twitter, podcasts, and open-access online content portals) in medical education, highlight medical education theories supporting their use, and discuss how educators can engage with these learning tools effectively. We focus on how these platforms harness key principles of adult learning and provide a guide for educators in the effective use of SoMe tools in educating ID learners. Finally, we suggest how to effectively interact with and leverage these increasingly important digital platforms.

How do internal medicine subspecialty societies support clinician-educator careers? A qualitative exploratory study

BACKGROUND

Internal Medicine (IM) subspecialty professional societies can provide valuable community, recognition, resources, and leadership opportunities that promote career success. Historically, this support focused on clinical and research dimensions of academic careers, but educational dimensions have gained more attention recently. This study explores how IM subspecialty professional societies support their clinician-educator members.

METHODS

Using a qualitative study with two phases, the authors collected information from each IM subspecialty society's website about support for medical education. Using information from the first phase, we developed an interview guide for subspecialty society leaders. We used inductive thematic analysis to analyze interview transcripts.

RESULTS

Website analysis identified various mechanisms used by several IM subspecialty societies to promote medical education. These included websites focused on medical education, dedicated medical education poster/abstract sessions at annual meetings, and strategies to promote networking among clinician-educators. Interviews with eight subspecialty society leaders about the professional societies' roles with respect to medical education yielded four main themes: [1] varying conceptions of "medical education" in relation to the society [2] strategies to advance medical education at the society level [3] barriers to recognizing medical education [4] benefits of clinician-educators to the societies. Integrating these themes, we describe recommended strategies for professional societies to better serve clinician-educators.

CONCLUSIONS

We explore how IM subspecialty societies attend to a growing constituency of clinician-educators, with increasing recognition and support of the career path but persistent barriers to its formalization. These conversations shed light on opportunities for professional subspecialty societies to better serve the needs of their clinician-educator members while also enabling these members to make positive contributions in return.

1133. Qualitative Analysis of Pharmacists’ Therapeutic Reasoning Processes Applied to Antimicrobial Selection and Stewardship Activities

Background

Relative to the study of diagnostic reasoning, less is known about how clinicians make therapeutic decisions. Past work has explored how physicians choose particular antimicrobials in specific cases (antimicrobial therapeutic reasoning - ATR), but how pharmacists make similar determinations has remained unexplored. Understanding ATR by pharmacists could inform pharmacist education and improve antimicrobial stewardship (AS).

Methods

We conducted individual interviews with a purposeful sample of 11 pharmacists (5 ID specialist pharmacists and 6 non-specialists), adapting a protocol for semi-structured interviews utilizing clinical vignettes based on a prior study in physicians. In addition, participants were asked to describe their ATR process generally using a novel notecard exercise. Interviews were transcribed and analyzed with Dedoose, using the prior study’s codebook as an initial framework and adding and adapting codes through an iterative process.

Results

We found that pharmacists generally engage in the same major ATR steps (Naming the Syndrome, Delineating Pathogens, Selecting the Antimicrobial) previously described in physicians (Figure 1). Pharmacists also seemed to incorporate similar patient- and system-factors and to utilize “therapy scripts”. However, specific factors and therapy script categories did not overlap completely, with some new factors and nuances emerging (Table 1). Overall, the antimicrobial reasoning framework described for physicians encompassed pharmacists’ AR, but some pharmacists described “Revisiting the Syndrome” in light of the clinical data and in some cases pharmacists appeared to filter script options (for example, due to allergies) before proceeding.

Figure 1 - Antimicrobial Therapeutic Reasoning Framework

Table 1 - Factors Involved in Pharmacists’ Antimicrobial Reasoning Process

Conclusion

The framework describing pharmacist antimicrobial ATR and is similar to that in a prior study of physicians, with some nuances that may be attributable to the pharmacist’s reviewer role in AS. Application of this framework has potential to aid in teaching learners, identifying where error or bias may occur, improving multidisciplinary AS efforts, and providing a common framework for communication.

Disclosures

All Authors: No reported disclosures

1124. Increasing Student Confidence in Antimicrobial Prescribing with a Novel Teaching Framework

Background

Physicians frequently prescribe antimicrobials inappropriately, increasing rates of resistance and adverse effects. Difficulty with antimicrobial reasoning likely begins during medical school, where many students learn infectious diseases by memorization. Past work has shown that learners benefit from tools such as schema and checklists. We report our experience using an antimicrobial reasoning teaching tool in a pilot medical student workshop.

Figure 1: Antimicrobial Selection Tool

Methods

We converted a published antimicrobial reasoning framework into a teaching tool (Fig 1). Students enrolled in the 2020 Internal Medicine Residency Preparation Course participated in one of two identical hour-long antimicrobial reasoning workshops. We started with an interactive didactic introducing the tool. Students used the tool to work through a clinical vignette in small groups, followed by a facilitated discussion. Students filled out pre- and post-surveys assessing their identification of factors impacting antimicrobial selection, and their self-efficacy regarding antimicrobial selection. The number of factors identified was analyzed using a t-test, while the change in self-efficacy scores was analyzed using a paired t-test. Students also rated the utility of the session.

Results

87% of students (52/60) completed surveys. Prior to the session, only 59% (n=29) of students felt prepared to prescribe antimicrobials and the majority of students (59%, n=30) felt less confident managing infections than other conditions. After the session, there was a significant increase in students’ perception of their preparation to prescribe antimicrobials (t=2.08, p=0.04) and ability to identify factors important to antimicrobial selection (t=2.13, p=0.036). The majority of students found both the session and tool to be useful for future practice (Fig 2).

Conclusion

At baseline, medical students feel unprepared to prescribe antimicrobials and are less confident managing infections than other conditions. This workshop assessed the feasibility of using an antimicrobial reasoning tool to teach students. Despite its brevity, students felt more prepared to prescribe antimicrobials after the session and rated it as useful for future practice. They felt a simpler tool and longer session would improve future efforts.

Disclosures

All Authors: No reported disclosures

The Struggling Infectious Diseases Fellow: Remediation Challenges and Opportunities

Remediation of struggling learners is a challenge faced by all educators. In recognition of this reality, and in light of contemporary challenges facing infectious diseases (ID) fellowship program directors, the Infectious Diseases Society of America Training Program Directors' Committee focused the 2018 National Fellowship Program Directors' Meeting at IDWeek on "Remediation of the Struggling Fellow." Small group discussions addressed 7 core topics, including feedback and evaluations, performance management and remediation, knowledge deficits, fellow well-being, efficiency and time management, teaching skills, and career development. This manuscript synthesizes those discussions around a competency-based framework to provide program directors and other educators with a roadmap for addressing common contemporary remediation challenges.

1946. An Exploratory Study of the Therapeutic Reasoning Underlying Antimicrobial Selection

Background

Clinical reasoning research has helped illuminate how clinicians make diagnoses but offers less insight into management decisions. The need to understand therapeutic choices is particularly salient within infectious diseases (ID), where antimicrobial prescribing has broad implications given increasing rates of resistance. Researchers have examined general factors underlying antibiotic prescribing. Our study advances this work by exploring the factors and processes underlying physician choice of specific antimicrobials.

Methods

We conducted individual interviews with a purposeful sample of Hospitalists and ID attendings. Our semi-structured interview explored the reasoning underlying antimicrobial choice through clinical vignettes. We identified steps and factors after 12 interviews then conducted 4 more to confirm and refine our findings. We generated a codebook through an iterative, inductive process and used Dedoose to code the interviews and facilitate analysis.

Results

We identified three antibiotic reasoning steps (Naming the Syndrome, Delineating Pathogens, Antimicrobial Selection) and four factors involved in the reasoning process (Host Features, Case Features, Provider and Healthcare System Factors, Treatment Principles) (Table 1). Participants considered host and case features when determining likely pathogens and antimicrobial options; the other two factors influenced only antimicrobial selection. From these data, we developed an antimicrobial reasoning framework (Figure 1). We also determined that participants seemed to have a “script” with specific content for each antimicrobial they considered, functioning much like the illness scripts common to diagnostic reasoning (Table 2).

Conclusion

Our antimicrobial reasoning framework details the cognitive processes underlying antimicrobial choice. Our results build on general therapeutic reasoning frameworks while elaborating factors specific to ID. We also provide evidence of the existence of “therapy scripts” that mirror diagnostic reasoning’s “illness scripts.” Our framework has implications for medical education and antimicrobial stewardship.

Disclosures

All Authors: No reported Disclosures.

2544. An Exploratory Study of Resource Utilization by Practitioners when Managing Infections

Background

Antimicrobial prescribing mistakes are common and adherence to guidelines for treatment of infections is poor. Effective use of clinical resources could help ameliorate these issues, but little is known about the use of such resources by physicians and pharmacists. We thus aimed to explore how practitioners utilize clinical resources in the management of infections.

Methods

We conducted individual interviews with a purposeful sample of eight Hospitalists, eight ID attendings, four ID pharmacists, and six non-ID pharmacists. As part of a larger, semi-structured interview exploring ID practice patterns, we asked respondents how they utilize resources when managing infections. We describe the resources mentioned by the different practitioners, as well as the frequency of their reported use.

Results

All respondents reported using at least one resource to help manage infections, with a mean of 5.6 resources each. The majority of respondents use resources daily, although some ID practitioners use resources more frequently and some general practitioners less frequently (Figure 1). The types of resources utilized by respondents fell into six main categories: local ID resources, outside ID resources, primary literature, guidelines, colleagues, and pharmacy resources (Figure 2). In general, local resources are utilized more frequently by non-ID practitioners, while guidelines and the primary literature are utilized more frequently by ID practitioners. ID physicians use pharmacy resources more frequently than non-ID physicians. Six respondents spontaneously reported being motivated to review resources for their own interest or learning. Several also commented that accessibility was important in choosing resources.

Conclusion

Providers report use of resources to manage infections, although the type of resource and frequency of use varies. ID practitioners utilize more detailed resources than nonspecialists. Accessibility seems to influence resource utilization, which may explain the popularity of local ID resources. As such, efforts to make local ID resources as accessible and clear as possible may have an impact on appropriate antibiotic use. Future quantitative studies could help illuminate rates and perceived advantages of specific resource utilization.

Disclosures

All authors: No reported disclosures.

2547. Prioritizing Antimicrobial Resistance Learning Objectives Through a Modified, Two-Round, One-Day Delphi at a Multidisciplinary Conference

Background

Antimicrobial resistance (AMR) is a global public health problem, but the learning needs of the medical profession on this topic are not well understood. The World Health Organization has called for better educational resources on AMR. Thus, we aimed to identify AMR learning objectives for physicians and medical trainees.

Methods

We designed a modified, two-round Delphi process to build consensus around these objectives, recruiting attendees at a one-day, multidisciplinary, international AMR symposium. Through review of the literature and discussion with experts in AMR, we generated an initial list of 17 objectives. We asked participants to rate the importance of including each objective in an AMR curriculum for physicians on a 5-point Likert scale, which ranged from “do not include” (1) to “very important to include” (5). Consensus for inclusion was predefined as ≥ 80% of participants rating the objective ≥ 4.

Results

The first round was completed by 30 participants, and the second by 21. Nobody declined to participate, but several people had to leave between rounds. Participants included physicians, researchers, graduate students, and a pharmacist, foundation manager, patient advocate, leader of an international financial institution, health administrator, and biomedical scientist. After the first round, 16 objectives met the consensus criteria, and participants suggested five additional topics. After the second round, 12 objectives met the consensus criteria (see Table 1). Objectives related to treatment of AMR most frequently met consensus criteria. Specific objectives with the highest consensus ratings were related to identifying infections not requiring antibiotics and recognizing the importance of using the narrowest spectrum antibiotic for the shortest period of time.

Conclusion

We successfully employed a modified, one-day Delphi process at an international, multidisciplinary AMR symposium to build consensus among experts and stakeholders regarding key learning objectives for AMR. This technique may be useful for guideline committees and other taskforces in the Infectious Diseases community. Our generated list may be useful for those developing AMR training materials for medical students and physicians.

Disclosures

All authors: No reported disclosures.

2536. Evaluation of Anticipatory Guidance Provided by Internal Medicine Residents for the Care of Patients with Fever

Background

Overnight fever is common in hospitalized patients. Past work has analyzed cross-covering resident practices regarding overnight fever, but little is known about how residents provide anticipatory guidance for overnight fever. We aimed to further our understanding of resident sign-out practices for overnight fever by analyzing the specific content of the guidance they provide and evaluating whether the presence of infection impacts the guidance provided.

Methods

We performed a cross-sectional study of resident sign-outs on an inpatient Internal Medicine service between September 2018 and April 2019 using a data collection tool we developed. Data collected included patient’s primary reason for hospitalization, whether fever was an anticipated problem, whether a differential diagnosis for fever was included, evaluation and management instructions for fever, and any rationale provided for the instructions. We analyzed the data using descriptive statistics and chi-squared analysis.

Results

Among 216 sign-outs reviewed, 38% indicated infection was the primary hospital diagnosis. Fever was an anticipated issue in 169 (78%) of sign-outs (Table 1). Of sign-outs recommending fever evaluation, 79% specified at least one diagnostic test but 34% still utilized a nonspecific phrase such as “full fever work-up” (Table 2). Only 62% of fever sign-outs included antibiotic guidance. In addition, rationales were provided for evaluation or management guidance in only 41% and 61% of sign-outs, respectively (Table 3). Chi-squared analysis did not show a statistically significant association between primary hospital problem and the sign-out including fever anticipatory guidance (P = 0.78), recommending in-person assessment (P = 0.11), or providing antibiotic guidance (P = 0.15).

Conclusion

Fever anticipatory guidance is commonly included in resident-written sign-out regardless of primary hospital problem. Specific evaluation instructions for fever are used more commonly than nonspecific fever work-up terms, but rationales for testing are given uncommonly. Future educational interventions around signing-out and evaluating fever overnight may lead to more effective anticipatory guidance and rationale testing and treatment.

Disclosures

All authors: No reported disclosures.

2534. Development of an Infectious Diseases Fellowship Well-Being Program

Background

Burnout in graduate medical education is common and reported in ~70% of Internal Medicine (IM) residents. Most studies have described interventions focused on residency training, but fellowship training suffers from similar challenges and likely similar levels of burnout. After conducting a needs assessment amongst fellows within our Infectious Diseases (ID) fellowship program, we developed a wellness program to address these issues.

Methods

In Spring 2018, we reviewed the existing literature and consulted with local experts on trainee well-being. Based on our findings, we designed a multi-tiered approach to enhance wellness amongst fellows. An ID Fellowship Well-Being Committee (WBC) was created in September 2018 to lead the intervention. The WBC includes an even mix of fellows and faculty at multiple levels at all three main teaching hospitals associated with the program. Meetings occur every other month, and co-chairs (one faculty and one fellow) report back to the program director quarterly. Topic areas and interventions are described in Table 1. Fellows were sent a qualitative survey to evaluate the impact of the well-being interventions to date.

Results

Four of 5 first year fellows responded to the survey, and all felt the retreat should be repeated yearly. Themes identified from the survey included benefits of having protected time together, convening in a low pressure and informal setting to provide feedback, and spending quality time in a non-clinical setting with co-fellows. Fellows cited the wellness retreat as a strength at our annual fellowship external program review.

Conclusion

Burnout is likely high among IM sub-specialty fellows, and interventions are needed to support the well-being of those trainees. We describe a roadmap for the development of a well-being program at a relatively large, academic ID fellowship program led by a mixed fellow and faculty committee. We will continue to monitor data on fellow burnout and make programmatic changes based on feedback. We are hopeful that our work will empower other programs to engage in developing their own well-being programs.

Disclosures

All authors: No reported disclosures.

1948. Impact of @WuidQ, a Free Open-access Medical Education Twitter Resource, on Infectious Disease Learning and Teaching

Background

Free open-access medical education (FOAMed) is increasingly used as a web-based platform for learning/teaching, with Twitter emerging as a leading medium. However, FOAMed resources in infectious disease (ID) are limited. @WuidQ is the first FOAMed Twitter resource to provide review of ID through board-style, multiple-choice questions (MCQs). We describe its creation and impact to date.

Methods

Two ID faculties created MCQs, vetting them based on accuracy and clarity. MCQs were posted a few times weekly using Twitter’s poll function, with answers tweeted as “threads” linked to the MCQ (Figure 1). We reviewed followers’ profiles to determine their demographics. We also used Twitter metrics to assess participation, including the average number of poll voters, impression (number of tweet views), engagement (number of retweets, clicks), and engagement rate (engagement divided by impression). In order to gauge follower satisfaction, we posted an anonymous online survey that included both close-ended questions utilizing Likert scale and open-ended questions.

Results

Over its first 9 months, @WuidQ reached 1,339 followers (56% based in the United States, 47% healthcare professionals, 13% students/trainees) (Table 1). During this time, it earned 582,400 impressions and had a 3.1% mean engagement rate. We posted 103 MCQs, with a mean of 143 (range 70–316) poll voters per MCQ. Forty-five followers completed the survey; of whom, 49% were ID doctors, 22% were ID fellows, and 11% were medical residents. The vast majority of respondents were between 25 and 44 years of age. Almost all agreed that @WuidQ is engaging and accessible (Figure 2). The majority of respondents who were taking exams agreed that @WuidQ helped them with test preparation. Of those who indicated teaching was a relevant practice, 80% said it helped them teach ID. Lack of time to read and learners’ short attention span were the most common learning barriers addressed by @WuidQ (Figure 4).

Conclusion

@WuidQ is an effective Twitter resource for ID education, filling a gap in FOAMed resources for ID. It has a global reach and caters to learners/teachers across a spectrum of training levels. Given its success, more work is warranted to understand practices for engaging learners and teachers in FOAMed for ID.

Disclosures

All Authors: No reported Disclosures.

979. Standardizing Medical Student Learning for Infectious Diseases Consult Electives: Prioritizing Content

Background

The goals of 4th-year medical student electives vary, and students’ learning during clinical electives may occur solely through the subspecialty cases that students encounter. We aim to standardize learning during electives by creating a toolkit to guide elective directors in the development of curricula that reinforce basic science principles, highlight areas for high-value care, and provide opportunities for further inquiry. The first step is to determine the core specialty topics applicable to students regardless of career choice. Here, we describe this content prioritization process within the context of an infectious diseases (ID) elective pilot curriculum.

Methods

We conducted a modified, 2-round Delphi process to develop consensus on ID topics that all graduating medical students should know. Through review of the literature for common diagnoses and high value care, and the medical school curriculum, the authors generated an initial list of 16 topics. An interdisciplinary group of 90 expert faculty educators from Internal Medicine, Family Medicine, Emergency Medicine, and Surgery rated these topics’ importance using a 5-point Likert scale, from 0 (absolutely do not include) to 4 (very important). We considered items rated at least 3 (important) by at least 80% of participants to have reached consensus.

Results

Sixty of 90 (67%) educators responded to the initial survey, and 48/60 (80%) completed both surveys. Nine additional topics were proposed by first-round participants. After the second round, 14 topics met the consensus criterion. Many common conditions, several dangerous infections, and infectious issues overrepresented in the local population met consensus. However, while many of the topics failing to meet consensus addressed rare conditions or those typically managed by subspecialists, some were also common conditions.

Conclusion

Standardizing medical student learning during elective rotations begins with identifying key topics. Our process included a diverse group of educators to determine key topics. We will use this list to guide the content of a new asynchronous, online ID elective curriculum, and we will describe our process as part of a curriculum development toolkit for other elective directors.

Disclosures

All authors: No reported disclosures.

'Til Death Do Us Part: End-of-Life Experiences of Married Couples in a Nationally Representative Survey

OBJECTIVES

To determine whether end-of-life (EOL) experiences in the first spouse in a marriage are associated with EOL experiences in the other spouse.

DESIGN

Nationally representative, longitudinal survey.

SETTING

Health and Retirement Study, Waves 1992-2012 linked to Medicare claims PARTICIPANTS: Community-dwelling older adults who died (N=4,558), representing 2,279 married heterosexual couples.

MEASUREMENTS

We examined 3 EOL experiences: enrollment in hospice for >3 days before death, lack of advance care planning (ACP) before death, and intensive care unit (ICU) use during the last 30 days of life. We used multiple logistic regression to determine whether the EOL experience of the first spouse was a significant predictor of the EOL experience of the second spouse after adjusting for demographic characteristics, socioeconomic status, health status, and time between the first and second spouses' deaths.

RESULTS

First spouses who died were on average 80 years old, and 62% were male; second spouses were on average 85 years old, and 62% were female. After adjustment, second spouses were more likely to use hospice if the first spouse used hospice (odds ratio (OR)=1.68, 95% confidence interval (CI)=1.29-2.20). Second spouses were less likely to have ACP when the first spouse did not have ACP (OR=2.91, 95% CI=2.02-4.21). Hospice and ACP associations were stronger when deaths were closer in time to one another (p-value for interaction < .05). Second spouses were more likely to use ICU services if the first spouse did (OR=1.80, 95% CI=1.27-2.55).

CONCLUSIONS

The EOL experiences of older spouses are strongly associated, which may be relevant when framing ACP discussions. J Am Geriatr Soc 66:2360-2366, 2018.

Variability in student perceptions of mistreatment

BACKGROUND

As medical schools strive to improve the learning environment, it is important to understand medical students' perceptions of mistreatment. The purpose of this study was to explore student interpretations of previously reported mistreatment incidents to better understand how they conceptualise the interactions.

METHODS

Medical students were presented with case scenarios of previously reported instances of mistreatment and asked to indicate their agreement as to whether the scenarios demonstrated mistreatment, using a five-point Likert scale (1, strongly disagree; 5, strongly agree). It is important to understand medical student's perceptions of mistreatment RESULTS: One hundred and twenty-seven third-year medical students gave feedback on 21 mistreatment cases. There was variability in the categorisation of the scenarios as mistreatment. The highest degree of consensus (96% agreement) was for a scenario in which a resident claimed a student made statements about a patient's status that the student did not make. There was also relative consensus on three additional scenarios: (1) a patient making disparaging remarks about a student's role in health care in relation to the student's ethnicity (88% agreement); (2) a resident asking a student to run personal errands (86% agreement); and (3) a nurse calling a student an expletive in front of others (77% agreement). For the majority of the cases, there was no consensus amongst students as to whether mistreatment had occurred. Students self-identifying as minorities and students who had previously reported mistreatment were more likely to perceive mistreatment in the scenarios.

CONCLUSIONS

There is remarkable variability, and in many cases a lack of agreement, in medical student perceptions of mistreatment. This inconsistency needs to be considered in order to effectively address and mitigate the issue.

Using a Modified A3 Lean Framework to Identify Ways to Increase Students' Reporting of Mistreatment Behaviors

PROBLEM

The proportion of students who experience mistreatment is significantly higher than the proportion of students who report mistreatment. Identifying ways to improve students' reporting of these incidents is one strategy for increasing opportunities to achieve resolution and prevent future occurrences.

APPROACH

The authors applied a modified A3 Lean framework to examine medical student reporting of mistreatment behaviors at the University of Michigan Medical School (UMMS) in 2013-2016. The A3 Lean framework is a stepwise approach that involves outlining the background to establish the context of the problem, describing the current condition, identifying the goal or desired outcome, analyzing causes of the problem, providing proposed countermeasures for improvement, and creating follow-up plans. The authors identified three reasons for the difference between students' experiences and reporting of mistreatment and developed five countermeasures/action plan items to address this difference.

OUTCOMES

The proportion of students reporting mistreatment at UMMS increased 21.4% between 2013 and 2016. Compared with 2013, more students in 2016 indicated not reporting because the incident did not seem important enough or because they resolved the issue on their own.

NEXT STEPS

The authors have enlisted the support of the health system's human resources department and presented the inaugural grand rounds on improving the learning environment in 2016. Among other things, they are also partnering with this team to add questions about student mistreatment and civility to the annual employee engagement survey distributed to all 20,000 employees.

Evaluating the risks of clinical research: direct comparative analysis

OBJECTIVES

Many guidelines and regulations allow children and adolescents to be enrolled in research without the prospect of clinical benefit when it poses minimal risk. However, few systematic methods exist to determine when research risks are minimal. This situation has led to significant variation in minimal risk judgments, raising concern that some children are not being adequately protected. To address this concern, we describe a new method for implementing the widely endorsed "risks of daily life" standard for minimal risk. This standard defines research risks as minimal when they do not exceed the risks posed by daily life activities or routine examinations.

METHODS

This study employed a conceptual and normative analysis, and use of an illustrative example.

RESULTS

Different risks are composed of the same basic elements: Type, likelihood, and magnitude of harm. Hence, one can compare the risks of research and the risks of daily life by comparing the respective basic elements with each other. We use this insight to develop a systematic method, direct comparative analysis, for implementing the "risks of daily life" standard for minimal risk. The method offers a way of evaluating research procedures that pose the same types of risk as daily life activities, such as the risk of experiencing anxiety, stress, or other psychological harm. We thus illustrate how direct comparative analysis can be applied in practice by using it to evaluate whether the anxiety induced by a respiratory CO2 challenge poses minimal or greater than minimal risks in children and adolescents.

CONCLUSIONS

Direct comparative analysis is a systematic method for applying the "risks of daily life" standard for minimal risk to research procedures that pose the same types of risk as daily life activities. It thereby offers a method to protect children and adolescents in research, while ensuring that important studies are not blocked because of unwarranted concerns about research risks.

Assent in research: the voices of adolescents

PURPOSE

Adolescents join clinical research after investigators obtain their positive agreement or "assent." Although intended to respect adolescents, little is known about the views of adolescents or their parents regarding assent or research enrollment decisions. This study aimed to better understand perspectives of adolescent research participants and their parents about assent and parental permission.

METHODS

Structured interviews were conducted with 13- through 17-year-old teens, enrolled in clinical research at the National Institutes of Health or Seattle Children's Hospital, and separately with one parent.

RESULTS

One hundred and seventy-seven adolescent-parent pairs were interviewed. Teens were well distributed by age and gender, represented a wide variety of research and illnesses ranging in severity from mild to life threatening; 20% were healthy volunteers. Teens and parents were generally satisfied with the assent/permission process. Normally, they made the enrollment decision together and teens wanted parents' input and support. About 25% of teens reported pressure to enroll, not only from parents or relatives but also from doctors/nurses/research teams. Only 2% of teens preferred not to sign a consent form.

CONCLUSIONS

Despite some differing views about how decisions should be made, the current assent/permission process is perceived as satisfactorily respectful by most teens in research. Many teens want to sign consent forms, and teens' signatures should generally be sought. Flexible guidance allows research teams and Institutional Review Boards to customize the assent process for teens in particular studies in order to facilitate an appropriate balance between giving teens a voice reflective of their emerging independence and enabling supportive collaboration with parents.

Views of adolescents and parents on pediatric research without the potential for clinical benefit

OBJECTIVE

Critics argue that pediatric research without the potential for clinical benefit is unethical because it treats children as mere means, exposing those who cannot consent to risks for the benefit of others. The present survey was designed to assess whether this claim is consistent with the views of adolescents who actually participate in research, or their parents.

METHODS

Interviews were conducted with adolescents participating in research at the NIH Clinical Center or Seattle Children's Hospital, and their parents, from June 2008 through April 2010.

RESULTS

Interviews were completed with 177 of 186 adolescent/parent pairs (response rate= 95.2%). Overall, 90% of the adolescents and parents were willing to have the adolescent undergo a few extra blood draws, and 65% were willing to have the adolescent undergo an extra skin biopsy, for research purposes. The vast majority felt that the adolescents were making an important contribution to help others, and 80.8% of the adolescents felt proud to be doing so. Respondents overall were equally willing to have the adolescent face risks to help others in a research study or in a charitable activity.

CONCLUSIONS

The views and experiences of these respondents do not support the claim that pediatric research without the potential for clinical benefit treats subjects as mere means. Instead, the findings provide proof of principle for the claim that non-beneficial pediatric research involves a type of charitable activity which offers children the opportunity to contribute to a valuable project to help others.

Using data to improve surrogate consent for clinical research with incapacitated adults

Current practice relies on surrogates to enroll incapacitated adults in research. Yet, it is unclear to what extent this practice protects adults who have lost the ability to consent for themselves. To address this question, we conducted two literature searches to identify articles which report empirical data on three issues central to protecting adults who have lost the ability to consent: (1) adults' willingness to participate in research should they lose the ability to consent; (2) adults' willingness to allow a surrogate to make research decisions for them; and (3) the extent to which surrogates' enrollment decisions are consistent with their charges' preferences and values. These searches identified 21 articles, representing 20 distinct datasets. The data indicate that many adults are willing to participate in research should they lose the ability to consent, and many are willing to allow their family members to make research decisions for them if they become incapacitated. The data also raise concern that surrogates may be making research enrollment decisions that, in some cases, are inconsistent with their charges' preferences and values. These findings suggest that modifications to current practice should be considered to better protect adults who have lost the ability to consent. One option would be to require, in addition to surrogate permission and subject assent, sufficient evidence that enrollment is consistent with the individual's preferences and values.

Does it matter whether investigators intend to benefit research subjects?

There has been long-standing, albeit largely implicit, debate over whether investigator intentions are relevant to the ethical appropriateness of clinical research. Some commentators argue that whether investigators intend to collect generalizable knowledge or to benefit subjects is central to the ethics of clinical research. Others do not even mention investigator intentions when evaluating what makes clinical research ethical. To shed light on this debate, the present paper considers the reasons why investigator intentions might be ethically relevant. This analysis reveals that investigator intentions are related to, but distinct from three ethical requirements: whether subjects understand that they are contributing to a project to help others, whether the included interventions have an appropriate risk/benefit ratio, and whether subjects' interests are adequately protected. Provided these three requirements are satisfied, the ethical appropriateness of clinical research does not depend on what intentions investigators have in conducting it.

The ethics of phase 0 oncology trials

Recent guidance from the Food and Drug Administration supports the conduct of a new type of exploratory clinical trial, commonly called phase 0 clinical trials. Proponents argue that phase 0 clinical trials have the potential to expedite the development of new oncology drugs while exposing fewer research subjects to the risks of experimental treatments. At the same time, phase 0 oncology trials raise important ethical concerns that have received little attention. In particular, there is a question of whether it is ethical to enroll individuals in research that offers them no potential for clinical benefit. Further concern focuses on the inclusion of terminally ill and consequently vulnerable cancer patients in these trials. To evaluate these concerns, this article considers relevant empirical data from phase 1 oncology trials and develops several recommendations regarding the conduct of phase 0 clinical trials in oncology.