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Good Clinical Judgment (GCJ) is associated with clinical excellence and accolades whereas poor clinical judgment is often associated with suboptimal care and the need for remediation. Although commonly referenced in practice, a shared definition for GCJ based on primary data is lacking. We interviewed 16 clinicians and surgeons across different specialties at one Canadian academic center to understand their conceptualization of GCJ. The data analysis led to the formulation of three pillars that were viewed by participants as core ingredients of GCJ. These included (1) a strong baseline knowledge and breadth of clinical experience, (2) the demonstration of curiosity, reflection, and wisdom, and (3) an ability to attend to contextual factors and understand the “bigger picture” when providing care to patients. Although there were inconsistent opinions regarding whether GCJ is innate or learned, participants reflected on strategies to support the development or improvement in clinical judgement for trainees.

Good Clinical Judgment (GCJ) is associated with clinical excellence and accolades whereas poor clinical judgment is often associated with suboptimal care and the need for remediation. Although commonly referenced in practice, a shared definition for GCJ based on primary data is lacking. We interviewed 16 clinicians and surgeons across different specialties at one Canadian academic center to understand their conceptualization of GCJ. The data analysis led to the formulation of three pillars that were viewed by participants as core ingredients of GCJ. These included (1) a strong baseline knowledge and breadth of clinical experience, (2) the demonstration of curiosity, reflection, and wisdom, and (3) an ability to attend to contextual factors and understand the “bigger picture” when providing care to patients. Although there were inconsistent opinions regarding whether GCJ is innate or learned, participants reflected on strategies to support the development or improvement in clinical judgement for trainees.

Background Trainees in acute care specialties often grapple with the decision to perform an invasive procedure in a rapidly decompensating patient, for whom the benefits and risks are inherently uncertain. The difference between trainees who know when to act and when to seek supervision and those who do not is often linked to individual trainee psychological and cultural perceptions of uncertainty. But how much comfort with uncertainty relates to the situational context rather than the trainee traits is underexplored. Objective The objective of this study was to explore trainee actions around decompensating patients and assess the degree to which invasive intervention and supervision seeking depend on situational certainty or individual trait-based perceptions of uncertainty. Methods A total of 41 internal medicine residents completed a survey to measure anxiety related to uncertainty using the Physicians’ Reactions to Uncertainty (PRU) tool and to measure uncertainty avoidance using the Values Survey Module (VSM) before responding to 14 written emergency situations. Half of the scenarios contain sufficient diagnostic certainty to warrant aggressive intervention, and half lack sufficient diagnostic clarity to offset the risk of intervention. Mixed multivariable modeling was used to identify the relationship between planned invasive intervention, situational uncertainty, and trait-based perceptions of uncertainty measured in the PRU and VSM. Results Trainees’ first actions were appropriate in 60% of cases. Multivariable modeling suggested that situational certainty was more predictive of upfront intervention (odds ratio [OR], 30.5; P

Background While program director (PD) letters of recommendation (LOR) are subject to bias, especially against those underrepresented in medicine, these letters are one of the most important factors in fellowship selection. Bias manifests in LOR in a number of ways, including biased use of agentic and communal terms, doubt raising language, and description of career trajectory. To reduce bias, specialty organizations have recommended standardized PD LOR. Objective This study examined PD LOR for applicants to a cardiology fellowship program to determine the mechanism of how bias is expressed and whether the 2017 Alliance for Academic Internal Medicine (AAIM) guidelines reduce bias. Methods Fifty-six LOR from applicants selected to interview at a cardiology fellowship during the 2019 and 2020 application cycles were selected using convenience sampling. LOR for underrepresented (Black, Latinx, women) and non-underrepresented applicants were analyzed using directed qualitative content analysis. Two coders used an iteratively refined codebook to code the transcripts. Data were analyzed using outputs from these codes, analytical memos were maintained, and themes summarized. Results With AAIM guidelines, there appeared to be reduced use of communal language for underrepresented applicants, which may represent less bias. However, in both LOR adherent and not adherent to the guidelines, underrepresented applicants were still more likely to be described using communal language, doubt raising language, and career trajectory bias. Conclusions PDs used language in a biased way to describe underrepresented applicants in LOR. The AAIM guidelines reduced but did not eliminate this bias. We provide recommendations to PDs and the AAIM on how to continue to work to reduce this bias.

Background There are significant risks of parenteral prostacyclin use in patients with pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD), which may limit their use. Selexipag is an oral, selective prostacyclin analogue that has been shown to reduce disease progression and improve exercise capacity in patients with PAH-CHD. Administering Selexipag in patients with PAH-CHD could potentially overcome some of the risks of parenteral therapy while improving clinical outcomes. Case summary We report five cases highlighting the clinical uses of Selexipag in patients with PAH-CHD. In the first two cases, Selexipag was initiated as part of a Treat-to-close strategy. In the third case, initiation of Selexipag improved symptoms and objective exercise capacity in a patient with Eisenmenger syndrome. In the fourth and fifth cases, rapid cross-titration protocols were used to transition from parenteral prostacyclins to Selexipag. In the fourth case, Selexipag was initiated in the context of significant side effects limiting parenteral prostacyclin use. In the fifth case, Selexipag was used to down-titrate from parenteral prostacyclins following closure of a sinus venosus atrial septal defect and redirection of anomalous pulmonary veins. Discussion Selexipag is a promising oral therapy for patients with at various stages of the spectrum of PAH-CHD to improve symptoms, exercise capacity and, in some cases, haemodynamics. Our cases also highlight practical aspects of Selexipag use including targeting the individualized maximally tolerated dose for each patient, managing side effects and managing dose interruptions.

PURPOSE Although workplace learning environments provide authentic tasks to promote learning, elements of clinical settings may distract trainees and impede learning. The characteristics of workplace learning environments that require optimization are ill-defined. Applying principles of cognitive load theory (CLT) to optimize learning environments by managing intrinsic load (complexity of the task matched to learner knowledge and skill), minimizing extraneous load (any aspect that is not part of task completion), and increasing germane load (processing for storage in long-term memory) could be advantageous. The authors explored trainee perceptions of characteristics that helped or impaired learning from a cognitive load perspective. Echocardiography interpretation was used as a model. METHOD The authors conducted semistructured interviews between December 2018 and March 2019 with a purposeful sample of 10 cardiology trainees at the University of California, San Francisco, School of Medicine until thematic sufficiency was achieved. Participants represented a range of training levels (3 fourth-year trainees, 2 fifth-year trainees, 3 sixth-year trainees, and 2 advanced echocardiography fellows) and career aspirations (4 desired careers in imaging). Two independent coders analyzed interview transcripts using template analysis. Codes were mapped to CLT subcomponents. RESULTS Trainees selected their own echocardiograms to interpret; if trainees' skill levels and the complexity of the selected echocardiograms were mismatched, excess intrinsic load could result. Needing to look up information essential for task completion, interruptions, reporting software, and time pressures were characteristics that contributed to extraneous load. Characteristics that related to increasing germane load included the shared physical space (facilitating reading echocardiograms with attendings and just-in-time guidance from near peers) and the availability of final reports to obtain feedback independent of teachers. CONCLUSIONS As interpreted from a cognitive load perspective, findings highlight characteristics of workplace learning environments that could be optimized to improve learning. The findings have direct application to redesigning these learning environments.

We present this case of a 22-year-old woman with congenital heart disease as the youngest reported patient, to the best of our knowledge, to successfully undergo treatment of medically refractory torrential tricuspid regurgitation with the MitraClip system as an adjunct to guideline directed therapy. (Level of Difficulty: Advanced.), Graphical abstract, We present this case of a 22-year-old woman with congenital heart disease as the youngest reported patient, to the best of our knowledge, to…

Structured Abstract Background While percutaneous closure is preferred in adults with a patent ductus arteriosus (PDA), the extent of cardiac remodeling following percutaneous PDA closure in adults is not well understood. We performed a meta-analysis to characterize cardiac remodeling following percutaneous PDA closure in adults. Methods MEDLINE and EMBASE were systematically searched for original studies that reported echocardiographic variables at baseline, immediately post-procedure (24 h), and at follow-up (>1 month) in adults undergoing percutaneous PDA closure. Additionally, we included data from patients >18 years of age that underwent percutaneous PDA closure between January 2015–December 2019 at our centre. Weighted averages were calculated for parameters with sufficient data. Pooled differences were presented as weighted mean differences (WMD). Results After screening 278 abstracts, 5 studies were identified. When combined with our cohort, our meta-analysis encompassed 244 patients. Immediately post-procedure, LVEF was the only parameter to change significantly (64 vs 52%, WMD -8.64 95%, CI -14.04 to −3.25). All parameters significantly decreased from baseline to follow-up: LVEF: 64 vs 60% (WMD -3.95, CI -5.80 to −2.09), LVEDD: 62 vs 53 mm (WMD -8.79, CI -12.78 to −4.81) LVEDVI 172 vs 123 mL/m2 (WMD -26.60, CI -45.4 to −7.85), LVESD 42 vs 36 mm (WMD -4.64, CI -9.10 to −0.17) and LA dimension: 42 vs 37 mm (WMD -5.87, CI -9.85 to −1.90). Conclusions As compared to the baseline values, left ventricular and left atrial sizes decreased. The LVEF decreased immediately following PDA closure and, while it recovers, it remained lower on follow-up testing.

Introduction Despite the increasing reliance on simulation to train residents as code blue leaders, the perceived role and effectiveness of code blue simulations from the learners' perspective have not been explored. A code blue Simulation Program (CBSP), developed based on evidence-based simulation principles, was implemented at our institution. We explored the role of simulation in code blue training and the differences between real and simulated code blues from the learner perspective. Methods Using a thematic analysis approach and a purposeful sampling strategy, residents who participated in the CBSP were invited to participate in one of the three focus groups. Data were collected through small group discussions guided by semistructured interviews. The interviews were audio-recorded and transcribed. Interview transcripts were coded to assess underlying themes. Results Thematic analysis revealed that participants believed that the CBSP enhanced preparedness by capturing aspects of real codes (eg, inclusion of precode scenarios with awake patients, lack of readily available information) and facilitating automatization of code blue processes. Despite efforts to develop a high-fidelity simulation, participants noted that they experienced more anxiety, observed more chaos in the environment, and encountered different communication challenges in real codes. Conclusions The CBSP enhanced resident preparedness to serve as code blue leaders. Learners highlighted that they valued the CBSP; however, differences remain between simulated and real codes that could be addressed to enhance the fidelity of future simulations.

Introduction: Patent ductus arteriosus (PDA) is often recognized and treated with percutaneous closure in adults. However, the impact on cardiac reverse remodeling following PDA closure in adults is not clear. We performed a meta-analysis to characterize the extent of cardiac remodeling following percutaneous PDA closure in adults. Methods: MEDLINE and EMBASE were systematically searched for original studies that reported echocardiographic variables at baseline, immediately post-procedure (within 24 hours), and at follow-up (>1 month) in adults undergoing percutaneous PDA closure. Additionally, we included echocardiographic data from a cohort of patients >18 years of age that underwent percutaneous PDA closure between 01/2015 and 12/2019 at our centre. For parameters with sufficient data for pooling, weighted averages were calculated, and pooled differences were presented as weighted mean differences. Heterogeneity was assessed using the I 2 statistic. Results: After screening 278 abstracts, 5 studies were identified. When combined with our own cohort of 13 patients, our meta-analysis encompassed 244 patients. The weighted mean age of all patients was 33 years with all studies predominantly comprised of female patients and the median follow-up was 12 months (ranging from 1 month- 5 years across the studies). When compared to baseline, left ventricular ejection fraction (LVEF) decreased significantly immediately post-procedure and all parameters significantly decreased at follow-up (Table 1). Conclusions: As demonstrated by the decreases in the left ventricular and left atrial sizes, reverse remodeling was observed in adults who underwent percutaneous PDA closure. The significantly lower LVEF immediately post-procedure could reflect withdrawal of chronic volume overload or increased afterload. The clinical significance of the statistically significant lower LVEF on follow-up testing is unclear and requires further evaluation.

A 37-year-old woman presented with chest pain and shortness of breath in the third trimester of pregnancy. Diagnostic imaging demonstrated a saddle pulmonary embolism, severe impairment of right ventricular function, and an extensive deep venous thrombus. She underwent catheter-directed thrombolysis with tissue plasminogen activator and delivered a healthy infant at term. (Level of Difficulty: Intermediate.), Graphical abstract

Graphical abstract, Highlights • A case of exertional dyspnea was found to be symptomatic right ventricular masses. • Echocardiography is the first-line imaging modality for cardiac masses. • Cardiac MRI is useful for tissue characterization of cardiac masses. • Multimodality imaging is useful in differentiating thrombus from cardiac tumors.

The modified World Health Organization (mWHO) classification is known to estimate the risk of maternal cardiovascular (CV) events in pregnancy and up to 6 months (mo) postpartum among women with congenital heart disease (CHD). However, predictors of maternal CV events > 6 mo after delivery have not

Introduction Schema-based instruction has been shown to improve diagnostic performance and reduce cognitive load. However, to date, this has only been studied in controlled research settings. More distractions in classrooms may limit generalizability to real-world settings. We evaluated whether schema-based instruction would maintain its effects on cognitive load optimization and performance in a classroom. Methods Focused on the approach of interpreting cardiac auscultation findings, 101 first-year medical students at Western University were randomized to receive a traditional (n = 48) or a schema-based lecture (n = 53). Students completed four written questions to test diagnostic performance and a cognitive load assessment at the end of the lecture. Diagnostic performance and cognitive load were compared with independent t-tests. Results Schema-based instruction was associated with increased diagnostic performance on written questions (64 ± 22 % vs 44 ± 25 % p

Background Many medical students find choosing a residency challenging. There are several steps involved, including determining one's own priorities, arranging electives, choosing a training program and site, and preparing an in-depth application and a rank order list. Many resources are available to assist students, including the Canadian Resident Matching Service website, program websites, career counselors, career information sessions, mentors, peers, family/friends, and the Canadian Medical Residency Guide. Our study explored the relative impact of these resources on the career decision-making process. Method We invited medical students in their final year at 12 Canadian medical schools to complete an online survey. Questions included identifying the relative utility of resources in the context of each component of the decision-making process. Responses were analyzed using descriptive statistics. Results The response rate was 71% (1076 of 1518). Overall, mentors, family/friends, and peers had the most impact on students' decision making. Career counselors, websites, and the Canadian Medical Residency Guide had much less impact. Family/friends were most frequently cited as essential to the process; however, family/friends and peers were equal in having some impact. Conclusions Our findings suggest that students are most influenced by family, friends, and peers, who are not involved in the formal residency selection effort. Appreciating the impact of these influences on students' decision making is important to understanding how they decide on their future careers. The study supports continuation of mentorship programs. Future work could focus on qualitative research to further characterize resource use.