Training medical educators to teach: bridging the gap between perception and reality

Teaching is a core expectation of physicians in academic hospitals and academic medical centers, but best practices for training physicians to teach have not been established. There is significant variability in how physicians are trained to teach medical students and residents across the world, and between Israeli hospitals. In an article published earlier this year in the Israel Journal of Health Policy Research, Nothman and colleagues describe a survey of 245 Israeli physicians in departments of internal medicine, pediatrics, and obstetrics and gynecology, at four different faculties of medicine across Israel. The majority of Israeli physicians responding to this survey reported receiving minimal training to teach, with only 35% receiving any training focused on medical education skills, most (55%) receiving training of only 1–2 days duration. In addition, the physicians surveyed perceived their training as inadequate and not aligned with their self-perceived educational needs. Furthermore, the respondents felt strongly that “compensation and appreciation” for medical education was less than for those involved in research. Despite the general lack of training in teaching skills and the perception that teaching physicians are less valued than researchers, survey respondents rated themselves as highly confident in most domains of medical education. In this context, this commentary reviews the disconnect between the general perception that all physicians can and should engage in teaching in the clinical setting with the well-described observation that competence in medical education requires dedicated and longitudinal training. Leveraging best practices in curriculum design by aligning educational interventions for teaching physicians with their self-perceived needs is discussed, and models for dedicated faculty development strategies for teaching medical education skills to physicians are reviewed. Finally, the importance of and potential strategies for assessing teaching physicians’ effectiveness in Israel and elsewhere are considered as a means to address these physicians’ perception that they are not as valued as researchers. Understanding teaching physicians’ perspectives on and motivations for training medical students and residents is critical for supporting the frontline teaching faculty who educate future healthcare providers at the bedside in medical schools, hospitals, and academic medical centers in Israel and beyond.

907. The HCV Care Continuum Among Hospitalized Persons Who Inject Opiates: Missed Opportunities for Screening and Referral to Treatment

Background Despite an effective cure, hepatitis C virus (HCV) remains a major public health problem for persons who inject opiates. Hospitalization provides an opportunity to identify chronic HCV infection and provide referral and linkage to outpatient care upon discharge. We examined the HCV care continuum among hospitalized persons who inject drugs and have opiate use disorder (OUD). Methods The CHOICE Study is a retrospective chart review of adults hospitalized with infectious complications of OUD and injection drug use at four academic medical centers (University of Maryland, George Washington University, University of Alabama, and Emory University). The sample included patients hospitalized between 1/1/2018-12/31/2018, had ICD9/10 diagnosis codes consistent with OUD and acute bacterial/fungal infection, and chart review verification of active infection associated with OUD. Data on HCV antibody (Ab) and RNA testing and referral to HCV treatment within the medical system were abstracted from medical records. Results Of 287 patients, median age was 40 (IQR: 32-52), 59% were male, and 63% were white and 34% black. Overall, 38% (n=108) had known HCV infection at hospitalization; of those with unknown status, only 41% (n=73) were screened for HCV. Among those, 67% were HCV Ab+. Of patients who were HCV Ab+ or had known HCV infection (n=157), only 52% were tested for HCV RNA, of whom 61% had detectable RNA. Only 40% of those with detectable RNA received a treatment referral prior to discharge (Fig. 1). The length of stay of the admission was not associated with treatment referral, but a shorter length of stay was significantly associated with not being screened for HCV Ab or RNA tested (p< 0.05). Of five patients who were referred to care within the medical system, four initiated HCV treatment, and two achieved known sustained viral response. Figure 1. HCV Continuum of care for hospitalized patients who inject drugs with opioid use disorder (OUD) at four academic medical centers in the United States, January 2018-December 2018 Conclusion Hospitalization is a missed opportunity for HCV screening and linkage. Despite opportunities to address HCV infection among this highly impacted population, there were sizeable gaps in the HCV continuum of care among hospitalized persons who inject opiates. Structural reasons such as length of stay may be a factor in implementing HCV testing. Disclosures Sarah Kattakuzhy, MD, Gilead Sciences (Scientific Research Study Investigator, Research Grant or Support) Ellen Eaton, MD , Gilead (Grant/Research Support) Ellen Eaton, MD , Gilead (Individual(s) Involved: Self): Research Grant or Support Greer A. Burkholder, MD, MSPH, Eli Lilly (Grant/Research Support) Elana S. Rosenthal, MD, Gilead Sciences (Research Grant or Support)Merck (Research Grant or Support)

611. No Source Control: Low Rates of Medication for Opioid Use Disorder in Individuals Hospitalized with Infectious Complications of Injection Opioid Use at Four Academic Medical Centers

Background Rates of hospitalization for bacterial infections due to opioid use disorder (OUD) are rising. Medication for OUD (MOUD) is an evidence-based intervention to treat OUD; however, MOUD initiation during hospitalization remain suboptimal. We aim to understand the continuum of MOUD and impact of MOUD initiation on outcomes of patients hospitalized with infectious complications of OUD. Methods CHOICE is a retrospective review of adults hospitalized with an infectious complication of OUD and IDU at four academic medical centers (Figure 1). Patients were hospitalized between 1/1/2018 and 12/31/2018, had ICD9/10 diagnosis codes consistent with OUD and acute bacterial/fungal infection, and chart review verification of active infection associated with OUD. Data were abstracted regarding demographics, inpatient interventions, transitions of care, and 1 year outcomes. Linear regression model with generalized estimating equation was used to evaluate associations of MOUD initiation with outcomes. Results 287 patients were predominately male (59%), white (63%), and median age 40 (32;52), with 72 (25%) uninsured, 103 (36%) unstably housed, and 84 (29%) were on MOUD prior to admission. 129 (45%) received MOUD during admission, 113 (39%) had MOUD prescribed on discharge, and 24 (8.4%) were linked to MOUD after admission [fig 2]. During sentinel admission, 62 (22%) were discharged prematurely/eloped, of whom 43 (69%) left without an antibiotic plan. Of the 202 (71%) not on MOUD at baseline, 55 (27%) initiated MOUD during admission. MOUD initiation was associated with higher odds of planned discharge (OR 6.7; p=0.0002) and being discharged on MOUD (OR 174; p< 0.0001) [fig 3]. Being uninsured was associated with lower odds of planned discharge (OR 0.55; < 0.0001) and discharge on MOUD (OR 0.59; p=0.02). CHOICE Baseline Demographics (N=287) Conclusion Across four healthcare systems, we found that patients hospitalized with infectious complications of OUD had low rates of MOUD initiation and high rates of premature discharge with incomplete ID treatment. Interventions to increase MOUD initiation and expand access to insurance may serve to mitigate the morbidity and mortality associated with OUD-related infections. Disclosures Elana S. Rosenthal, MD, Gilead Sciences (Research Grant or Support)Merck (Research Grant or Support) Ellen Eaton, MD , Gilead (Grant/Research Support) Ellen Eaton, MD , Gilead (Individual(s) Involved: Self): Research Grant or Support Greer A. Burkholder, MD, MSPH, Eli Lilly (Grant/Research Support) Sarah Kattakuzhy, MD, Gilead Sciences (Scientific Research Study Investigator, Research Grant or Support)

610. Tele-ID Consult Services at Academic Medical Centers: Experience and Outcomes During the SARS-CoV-2 Pandemic

Background Remote telemedicine ID consults (Tele-ID) appear to be effective for inpatients at community hospitals. Tele-ID is not used at academic medical centers (AMCs) because of the availability of onsite ID physicians. During the COVID-19 pandemic, intra-hospital Tele-ID was implemented because of insufficient PPE and the risk of SARS-CoV-2 exposure. To understand the effectiveness of intra-hospital Tele-ID, we compared outcomes following Tele vs. in-person ID consultation. Methods This is a longitudinal, matched, case-control study at two tertiary AMCs in Pittsburgh. Cases were evaluated via Tele-ID only (video, e-consults +/- inpatient phone call) between 3/1/20 – 5/31/20. Controls had in-person consults between 3/1/19 – 11/30/19 matched to cases by sex, race, ethnicity, transplant, age, BMI, Elixhauser score, and ID-specific coded diagnosis. Both groups were evaluated by existing general ID (GID) or transplant ID (TID) service physicians. Patients with COVID-19 diagnosis were excluded. Outcomes included ICU admission, hospital and ICU length of stay (LOS), in-hospital, 30 and 60-day mortality, and 30 and 60-day readmission. Results Among the Tele-ID group, 125 inpatients were evaluated by GID and 81 by TID. The majority were Caucasian, male, and non-ICU (Table 1). A broad range of ID diagnosis were made, most commonly bacteremia and pneumonia (Fig 1). Average hospital LOS post-ID consult was 6.26 days (GID) and 6.5 days (TID). For ICU patients, average LOS was 12 days (GID) and 7.6 days (TID). There were 5 (4%) and 3 (3.7%) in-hospital deaths, and 3 (2.4%) and 5 (6.2%) deaths at 30 days for GID and TID, respectively (Table 1). 65 cases could be matched to 633 controls by exact ID coded diagnosis (Table 2). Comparison of Tele-ID cases to in-person controls showed shorter ICU LOS (118.1 vs 269.2 hours; p = 0.002) and lower 30-day readmission (5.1 vs 17.3%; p = 0.004) for cases (Table 2). ICU admission and mortality were similar. Conclusion During the pandemic, intra-hospital Tele-ID proved to be an effective alternative to in-person ID consults at large AMCs, as evidenced by shorter ICU LOS and lower 30-day readmission for Tele-ID, and no difference in mortality. This experience suggests that Tele-ID could be used at AMCs as an alternative to in-person consults in non-pandemic settings. Disclosures Rima Abdel-Massih, MD, Infectious Disease Connect (Employee, Director of Clinical Operations) Rima Abdel-Massih, MD, Infectious Disease Connect (Individual(s) Involved: Self): Chief Medical Officer, Other Financial or Material Support, Other Financial or Material Support, Shareholder John Mellors, MD, Abound Bio, Inc. (Shareholder)Accelevir (Consultant)Co-Crystal Pharma, Inc. (Other Financial or Material Support, Share Options)Gilead Sciences, Inc. (Advisor or Review Panel member, Research Grant or Support)Infectious DIseases Connect (Other Financial or Material Support, Share Options)Janssen (Consultant)Merck (Consultant)

Optimizing active surveillance for low-risk prostate cancer: Characterizing provider and patient perspectives.

250 Background: The number of men on active surveillance (AS) for low-risk prostate cancer is rapidly increasing. While AS requires routine clinical exams, labs, imaging, and prostate biopsies, many men do not receive all recommended components. Understanding the perspectives of key stakeholders regarding recommended surveillance is critical to ensuring the optimization of AS as a management strategy. Methods: We conducted in-depth, semi-structured, virtual interviews with a purposive sample of 15 men with low-risk prostate cancer who were on AS as their primary management strategy and their partners, and 15 urologists and 19 primary care providers (PCPs) with experience in AS management between June 2020 and March 2021. We used the Theoretical Domains Framework (TDF), an implementation science framework developed to understand determinants of behaviors and to inform the design of interventions, to guide our interview guide. Questions assessed knowledge, barriers and facilitators, and preferences for provider roles in AS management. Interviews were recorded, transcribed, and deductively coded into TDF domains and constructs. Three independent coders iteratively developed and used a shared coding framework. Participant recruitment continued until data saturation by group. Results: Our study included 15 men (on AS between 1-16 years), 5 partners, 15 urologists (3 female, 5 in private practice, 3 in academic medical centers), and 19 PCPs (9 female, 4 in community practices, 15 in academic medical centers). The TDF domain of “knowledge” and the construct, “barriers and facilitators” were most commonly reported as factors impacting receipt of recommended surveillance across all groups. While urologists were most knowledgeable about AS, PCPs noted limitations in understanding for whom AS is recommended, and what it entails. Patients who had made an effort to research or learn about AS found that this knowledge enabled them to be proactive about receiving all recommended components. Urologists and patients noted several common procedural barriers to receiving recommended surveillance, including pain with repeated biopsies, and becoming lost to follow-up. Patients and PCPs were uncertain about what tests were needed and when. Urologists were concerned about PCP knowledge while PCPs described insufficient communication from urologists as barriers to shared care. Procedural facilitators included electronic medical records (EMR) to remind providers and patients of frequency and timing of tests. Conclusions: Key opportunities for optimizing AS include improving patient and PCP knowledge about the components and delivery of AS, facilitating communication between providers, and leveraging EMR to ensure those on AS are followed. The development of an intervention that combines several of these components will be critical to ensuring men on AS receive the recommended surveillance.