Browsing by Author "Fettig, Lyle"
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Item Code status orders in hospitalized patients with COVID-19(Elsevier, 2023-08-23) Comer, Amber R.; Fettig, Lyle; Bartlett, Stephanie; Sinha, Shilpee; D’Cruz, Lynn; Odgers, Aubrey; Waite, Carly; Slaven, James E.; White, Ryan; Schmidt, Amanda; Petras, Laura; Torke, Alexia M.; Medicine, School of MedicineBackground: The COVID-19 pandemic created complex challenges regarding the timing and appropriateness of do-not-attempt cardiopulmonary resuscitation (DNACPR) and/or Do Not Intubate (DNI) code status orders. This paper sought to determine differences in utilization of DNACPR and/or DNI orders during different time periods of the COVID-19 pandemic, including prevalence, predictors, timing, and outcomes associated with having a documented DNACPR and/or DNI order in hospitalized patients with COVID-19. Methods: A cohort study of hospitalized patients with COVID-19 at two hospitals located in the Midwest. DNACPR code status orders including, DNI orders, demographics, labs, COVID-19 treatments, clinical interventions during hospitalization, and outcome measures including mortality, discharge disposition, and hospice utilization were collected. Patients were divided into two time periods (early and late) by timing of hospitalization during the first wave of the pandemic (March-October 2020). Results: Among 1375 hospitalized patients with COVID-19, 19% (n = 258) of all patients had a documented DNACPR and/or DNI order. In multivariable analysis, age (older) p =< 0.01, OR 1.12 and hospitalization early in the pandemic p = 0.01, OR 2.08, were associated with having a DNACPR order. Median day from DNACPR order to death varied between cohorts p => 0.01 (early cohort 5 days versus late cohort 2 days). In-hospital mortality did not differ between cohorts among patients with DNACPR orders, p = 0.80. Conclusions: There was a higher prevalence of DNACPR and/or DNI orders and these orders were written earlier in the hospital course for patients hospitalized early in the pandemic versus later despite similarities in clinical characteristics and medical interventions. Changes in clinical care between cohorts may be due to fear of resource shortages and changes in knowledge about COVID-19.Item Code Status Orders: Do the Options Matter?(Springer, 2023) Patel, Roma; Comer, Amber; Pelc, Gregory; Jawed, Areeba; Fettig, Lyle; Medicine, School of MedicineBackground: Code status orders in hospitalized patients guide urgent medical decisions. Inconsistent terminology and treatment options contribute to varied interpretations. Objective: To compare two code status order options, traditional (three option) and modified to include additional care options (four option). Design: Prospective, randomized, cross-sectional survey conducted on February-March 2020. Participants were provided with six clinical scenarios and randomly assigned to the three or four option code status order. In three scenarios, participants determined the most appropriate code status. Three scenarios provided clinical details and code status and respondents were asked whether they would provide a particular intervention. This study was conducted at three urban, academic hospitals. Participants: Clinicians who routinely utilize code status orders. Of 4006 participants eligible, 549 (14%) were included. Main measures: The primary objective was consensus (most commonly selected answer) based on provided code status options. Secondary objectives included variables associated with participant responses, participant code status model preference, and participant confidence about whether their selections would match their peers. Key results: In the three scenarios participants selected the appropriate code status, there was no difference in consensus for the control scenario, and higher consensus in the three option group (p-values < 0.05) for the remaining two scenarios. In the scenarios to determine if a clinical intervention was appropriate, two of the scenarios had higher consensus in the three option group (p-values 0.018 and < 0.05) and one had higher consensus in the four option group (p-value 0.001). Participants in the three option model were more confident that their peers selected the same code status (p-value 0.0014); however, most participants (72%) preferred the four option model. Conclusions: Neither code status model led to consistent results. The three option model provided consistency more often; however, the majority of participants preferred the four option model.Item Emerging from the Pandemic: AAIM Recommendations for Internal Medicine Residency and Fellowship Interview Standards(Elsevier, 2022) Luther, Vera P.; Wininger, David A.; Lai, Cindy J.; Dao, Anthony; Garcia, Maria M.; Harper, Whitney; Chow, Timothy M.; Correa, Ricardo; Gay, Lindsey J.; Fettig, Lyle; Dalal, Bhavin; Vassallo, Patricia; Barczi, Steven; Sweet, Michelle; Medicine, School of MedicinePerspectives Viewpoints: •New standards are needed moving forward to guide residency and fellowship interviews in response to Coalition for Physician Accountability recommendations and dramatic changes in the interview landscape over the past 2 years. •Processes should be based on principles of equity for applicants and programs while taking into consideration personal and public health and safety. •Ongoing evaluation of advantages and disadvantages of interview practices should continue with iterative adjustments in guidance based on available data.Item Identifying Goals of Care(Elsevier, 2020-09) Comer, Amber; Fettig, Lyle; Torke, Alexia M.; Medicine, School of MedicineGoals of care conversations are important but complex for clinicians caring for older adults. Although clinicians tend to focus on specific medical interventions, these conversations are more successful if they begin with gaining a shared understanding of the medical conditions and possible outcomes, followed by discussion of values and goals. Although training in the medical setting is incomplete, there are many published and online resources that can help clinicians gain these valuable skills.Item Physician self-reported use of empathy during clinical practice(Sage, 2022) Comer, Amber; Fettig, Lyle; Bartlett, Stephanie; D'Cruz, Lynn; Umythachuk, Nina; Health Sciences, School of Health and Human SciencesObjectives The use of empathy during clinical practice is paramount to delivering quality patient care and is important for understanding patient concerns at both the cognitive and affective levels. This study sought to determine how and when physicians self-report the use of empathy when interacting with their patients. Methods A cross-sectional survey of 76 physicians working in a large urban hospital was conducted in August of 2017. Physicians were asked a series of questions with Likert scale responses as well as asked to respond to open-ended questions. Results All physicians self-report that they always (69%) or usually (29.3%) use empathic statements when engaging with patients. 93.1% of physicians believe that their colleagues always (20.7%) or usually (69%) use empathic statements when communicating with patients. Nearly one-third of physicians (33%) indicated that using the words “I understand” denotes an empathic statement. Although 36% of physicians reported that they would like to receive more training or assistance about how and when to use empathy during clinical practice. Significance of Results Despite the self-reported prevalent use of empathic statements, one-third of physicians indicate a desire for more training in what empathy means and when it should be used in a clinical setting. Additionally, nearly one-third of physicians in this study reported using responses that patients may not perceive as being empathic, even when intended to be empathic. This suggests that many physicians feel uncertain about a clinical skill they believe should be used in most, if not all, encounters.Item Prevalence, Predictors and Outcomes of Documented DNR and/or DNI Orders in COVID-19 Patients (S522)(Elsevier, 2022) Comer, Amber; Fettig, Lyle; Bartlett, Stephanie; Schmidt, Amanda; Endris, Katelyn; Zepeda, Isabel; Waite, Carly; Slaven, James; Torke, Alexia; Medicine, School of MedicineOutcomes: 1. Understand the prevalence, predictors, and outcomes associated with DNR and DNI orders for hospitalized patients with COVID-19 throughout the pandemic 2. Understand the reasons for differences in code status order utilization for hospitalized patients with COVID-19 throughout the pandemic Original Research Background: The COVID-19 pandemic created complex challenges regarding timing and appropriateness of do not resuscitate (DNR) and do not intubate (DNI) orders. Research Objectives: This study sought to determine the prevalence, predictors, timing, and outcomes associated with having a documented DNR or DNI order for hospitalized patients with COVID-19. Methods: A retrospective multisite chart review of hospitalized patients with COVID-19 was performed to determine characteristics, medical treatments received, and outcomes associated with having a documented DNR or DNI order. Patients were divided into two cohorts (early and late) by timing of hospitalization during the pandemic. Results: Among 1,358 hospitalized patients with COVID-19, 19% (n = 259) had a documented DNR or DNI order. In multivariate analysis, age (older) (p < .01, OR 1.13), race (White) (p = .01, OR 0.55), and hospitalization during the early half of the pandemic (p = .02, OR 1.8) were associated with having a DNR or DNI order. Palliative care consultation occurred more often in the early cohort (p < .01). Medical treatments, including ICU (p = .31) and level of ventilator support (p = .32) did not differ between cohorts. Hospital mortality was similar between the early and late cohorts (p = .27); however, among hospital decedents median hospital day from DNR or DNI order to death differed between cohorts (p < .01) (6 days from order to death in early vs 2 days in the late cohort). Conclusion: More frequent use of DNR orders and orders written farther from death in decedents characterized the early pandemic phase. White patients were more likely to have DNR or DNI orders, consistent with prior research. Implications for Research, Policy, or Practice: Uncertainty in prognosis may have played a role in the frequency and timing of DNR and DNI orders early in the pandemic. Additional factors, such as fear of resource shortage and transmission of COVID-19 to healthcare workers, may have also played a role.Item Twelve Tips for Just in Time Teaching of Communication Skills for Difficult Conversations in the Clinical Setting(Taylor & Francis, 2017) Hinkle, Laura; Fettig, Lyle; Carlos, W. Graham; Bosslet, Gabriel; Medicine, School of MedicineThe ability to communicate well with patients and other members of the healthcare team is a vital skill for physicians to have, but one that is often not emphasized in medical education. Learners of all levels can obtain and develop good communication skills regardless of their natural ability in this area, and the clinical setting represents an underutilized resource to accomplish this task. With this in mind, we have reviewed the growing body of literature on the subject and organized our findings into twelve tips to help educators capitalize on these missed opportunities. While our emphasis is helping learners with difficult discussions, these tips can be easily adapted to any other clinical encounter requiring clear communication. Teaching effective communication skills in the clinical setting requires some extra time, but the steps outlined should not take more than a few minutes to complete. Taking the time to develop these skills in our learners will make a significant difference not only their lives but also their patients and their families.