INNOVATIONS IN FELLOWSHIP TRAINING AT UAMS Paulette Mehta MD MPH UAMS/CAVHS Little Rock, AR

Disclosures :Paulette Mehta MD MPH Employment University of Arkansas for Medical Sciences and the Central Arkansas Veterans Healthcare System, Little Rock, Arkansas Consultancy Celgene Co; Novartis Co. Equity Ownership None Research Funding None Honoraria None Patents & Royalties None Speakers Bureau None Membership on Board of Directors/Advisory Committee AVAHO (Association of VA Hematologists/Oncologists) Other None Presentation includes a description of the following off-label use of a drug or medical device No drugs or devices will be discussed 52 nd ASH Annual Meeting ♦ Orlando, FL

Innovations at UAMS Editorial Clubs Ethics-in-Oncology Forums IRB/PRMC Rotations Triaging referrals

Innovations at UAMS Editorial Clubs Ethics-in-Oncology Forums IRB/PRMC Rotations Triaging referrals

Editorial Clubs We developed an editorial club in 2001 as a novel method of teaching systems-based competency in a hematology/oncology fellowship program. (Safar AM, O'Sullivan P, Ray L, Hutchins L, Mehta P. Editorial clubs as a new teaching tool in postgraduate training. 1. J Cancer Educ Fall;21(3):163-5.)

Goals Editorial clubs focused on topics of broad economic, political, and legal ramifications of hematology/oncology and thereby helped to develop systems competency as required by the Accreditation Council for Graduate Medical Education. Sources of articles: Journal of Clinical Oncology; JAMA; NEJM; Wall Street Journal; Atlantic; New Yorker; NY Times;

Evaluation Methods Attendance (12 fellows,>80% present at each meeting; 8 attendings, >50% attendance) 21-item survey to assess attendees’ perceptions regarding systems and practice based systems, professionalism and comparison with journal clubs Each item was rated from 1 to 5 (agree  disagree)

Assessment Of System Based Proficiency Enhanced my understanding of: The healthcare system 4.0±1.1 Society’s effect on practice of medicine 3.9±1.2 Impact of costs on society 4.1±0.5 My role as advocate for patients 3.8±0.7 Future directions of care 3.9±0.7 Historical context of current practice 4.2±0.4

Assessment Tool: Practice Based Learning Inspired potential research ideas 3.7±1.1 Improved my presentation skills 3.8±0.9 Helped me analyze my practice 3.7±0.8 Helped me better evaluate literature 4.1±0.7 Opportunity to identify research mentor 2.9±1.1

Assessment: Professionalism Professionalism: – Chances to interact with colleagues 4.2±0.8 – Propensity to think critically 4.3±0.9 – Chances to discuss ideas freely 4.4±0.7 Compared to journal clubs: – More time to discuss ideas 4.4±0.9 – Obtain broader perspective 4.4±0.9 – Can apply what we discuss 3.7±0.9 – Can think more creatively 4.1±0.8

Conclusions Topics were diverse, fellow and faculty attendance was excellent, and fellows reported improved systems-based competency.

Innovations at UAMS Editorial Clubs Ethics-in-Oncology Forums IRB/PRMC Rotations Triaging referrals

Ethics-in-Oncology Forums Fellows chose cases which were most problematic to them during their rotations They presented case, reviewed literature, facilitated discussion, and then summarized, wrote, edited, and published results. Goal was to help fellows to crystallize ethics issues and to better understand health systems management. Mehta P, Hester M, Safar A M, Thompson R, Ethics-in-Oncology Forums. J Cancer Educ 2007; 22:

Topics Doctor-patient relationships Informed consent, shared decision making Prognosis determination and communication Physician disclosure of prognosis End-of-life care Palliative care decision making Advance care planning Physician-assisted suicide Resource utilization Confidentiality Privacy (e.g., genomics) Who owns the patients’ tissue? Public vs. private stem cell banks Stem cell research Reproductive technology Avoiding conflict of interest with pharmaceutical companies Avoiding conflict of commitment with pharmaceutical

Ethics-in-Oncology Forums 1. Were the presentations helpful? 2. In what ways was the course helpful? 3. Do you ever refer to these cases in your clinical practice? 4. If so describe an example. 5. How did you choose your case? 6. How helpful was choosing the case in terms of helping you to prioritize ethical issues? 7. How well did presenting the case help you to clarify your ethical and moral values? 8. Did the discussion help you to clarify and resolve conflicts? 9. In what ways did the discussion help you? 10. How helpful were the faculty? 11. Did you write up any of the cases? 12. Was this helpful? 13. Explain how writing up the cases helped you. 14. What is the single most important aspect of this program? 15. what improvements can we make?

Results Forums were helpful 4.3±0.8 Prioritizing ethical issues: somewhat helpful 3.9±0.8 Clarifying their own positions 4.2±0.7 Solving conflicts 4.0±0.7 Hearing how faculty handle difficult cases 4.6±0.5 For fellow who wrote cases, experience was very helpful 4.6±0.6 Open ended comments: Helpful discussions, value in seeing faculty struggle with and debate issues Wanted more input from lawyers Those who completed writing assignment: best predictor were those who wrote papers in past; no difference between gender, level of training, anticipated type of future practice, US vs. foreign school, etc.

Fellows’ Publications Nagarajan A, Mehta J, Safar M, Thompson R, Mehta P. When patient, family and doctors disagree on treatment. Federal Practitioner 2005; l5-18. Gentry R, Mehta J, Hester M, Thompson R, Safar M, Kyasa MJ, Mehta P. Disclosing prognoses, when patients don’t ask. Federal Practitioner 2006; 23: Midathada, Govindarajan RG, Hester M, Thompson R, Safar M, Kyasa MJ, Mehta P. Treatment when the patient is an alcoholic; Federal Practitioner, in press September 2006; 23 (9): Kunthur A, Safar AM, Kyasa M, Makhoul I, Harrington S, Mehta P. Addressing end-of-life care—when the patient or family doesn't want to let go. Fed Pract 2010;27(5): Wang-Gillam A, Mehta J, Thompson R, Mehta P. When it’s time to stop cancer treatment: helping patients prepare for death. Ethics-in-Oncology Forum. Federal Practitioner, 2005; 22 : l4-23. Keshava-Prasad H, Hester DM, Mehta J, Mehta P. Ethics Forum: Informed consent in medical oncology. Fed Pract 2008;25(7): 26, 29–31, 35. Cheema P et al. Pediatric stem cell transplantation: ethical concerns in Mehta P, ed, Pediatric Stem Cell Transplantation, Jones and Bartlett Publishers, Massachusetts, 2004.

Innovations at UAMS Editorial Clubs Ethics in Oncology Forums IRB/PRMC Rotations Triaging referrals

IRB and PRMC Rotations Since 1999, 20 H/O fellows rotated on IRB/PRMC committees for at least 3 months 1-4 protocols assigned to each fellow to review Survey: 13 quantitative questions, 1 yes/no, and 4 open-ended questions 13 questions: – Understanding research protocols – Clinical trial administration – Subject safety – Oversight of federal agencies – Important of informed consent – Would they recommend the experience (yes/no): Open ended questions and comments were invited Demographic questionnaire Wang-Gillam A, Valentine J, Sherman AC, Mehta P. Experiences of IRB and PRMC R rotations in hematology/oncology training. J Cancer Educ 2008;23:71-73.

IRB/PRMC 14 responders (3 current fellows,11 graduates) 11 graduates: – 4 in academia:3 currently involved in IRB/PRMC; – 7 in private practice:3 currently involved in IRB, PRMC, Of the 14 responders:11 recommended that it be permanent, 3 were not sure.

Evaluation of IRB/PRMC experience Benefits: Most benefit: understanding informed consent Least beneficial: cost- effectiveness PRMC more beneficial than IRB Comments: Understood process better, Learned to critique protocols, Exposed to regulatory system, Understood efforts involved in clinical trials

Innovations at UAMS Editorial Clubs Ethics in Oncology Forums IRB/PRMC Rotations Triaging referrals

Triaging Referrals Developed new project of triaging referrals during fellows’ consultation rotation at CAVHS. Goals: – improve timeliness of response, – gain experience in 1- minute differential diagnosis of patients – review with attendings, – communicate with referring MDs Kyei M, Lavelle E, Kyasa J, Safar M, Makhoul I, Mehta P. Triaging referrals as part of hematology/oncology fellowship training. J Cancer Educ 2010.

Fellows’ Responses 1. Helped me gain speed in doing consultations 2.6 ± Provided the opportunity to get to know referring physicians 2.4 ± Helped me to understand how to work with referring physicians 2.6 ± Helped me to distinguish between urgent, semi- & non-urgent consults 3.3 ± Helped me to teach referring MDs to handle problem sets themselves 2.9 ± Helped me communicate with attending MDs regarding my findings 2.8 ± Helped me to do a “1-min DDX” regarding the likely problem 2.5 ± Helped me use the system effectively before the visit. 2.9 ± Supervision of the triage patients was adequate 2.8 ± Participation made me more confident to begin my practice 2.4 ± 1.1 Strongly agree = 4, Agree = 3,Disagree = 2, Strongly disagree = 1, Don’t Know Question +- S.D.

Attendings’ Questionnaire 1. Helped fellows develop speed in doing consultations 3.0 ± Helped fellows get to know referring physicians 2.8 ± Helped fellows learn how to work with referring physicians 2.6 ± Helped fellows distinguish urgent, semi, and non-urgent consults 2.6 ± Helped fellows teach referring MDs to handle the problems 3.4 ± Helped fellows communicate with attending MDs 2.7± Helped fellows to do a “1-min DDX” 2.8± Helped fellows use the system effectively before the visit. 3.0± Developed fellows’ confidence to begin practice 2.2±0.4 Strongly agree = 4, Agree = 3,Disagree = 2, Strongly disagree = 1, Don’t Know Question +- S.D.

Major Advantages Time management Use of electronic system to communicate with other Doctors Prioritization skills Skill in pre-ordering tests effectively Skill in communicating with supervisory attendings Skill in completing consults effectively The major perceived disadvantage was the amount of time

Conclusions Editorial Clubs Ethics-in-Oncology Forums IRB/PRMC Rotations Triaging referrals