Background: Clinical reasoning (CR) is a core competency in medical education. Few studies have examined efforts to train faculty to teach CR and lead CR curricula in medical schools and residencies. In this report, we describe the development and preliminary evaluation of a faculty development workshop to teach CR grounded in CR theory. Methods: Twenty-six medicine faculty (nine hospitalists and 17 subspecialists) participated in a workshop that introduced a framework to teach CR using an interactive, case-based didactic followed by role-play exercises. Faculty participated in pre-and post-Group Observed Structured Teaching Exercises (GOSTE), completed retrospective pre-post assessments (RPPs), and made commitment to change statements (CTCs). Results: In the post-GOSTE, participants significantly improved in their use of problem representation and illness scripts to teach CR. RPPs revealed that faculty were more confident in their ability and more likely to teach CR using educational strategies grounded in CR educational theory. At 2-month follow-up, 81% of participants reported partially implementing these teaching techniques. Conclusions: After participating in this 3-h workshop, faculty demonstrated increased ability to use these teaching techniques and expressed greater confidence and an increased likelihood to teach CR. The majority of faculty reported implementing these newly learned educational strategies into practice.

participated. During the 2-hour experiential onboarding, participants complete three 10-minute objective structured clinical examination cases: discussing and addressing a medical error, managing the patient’s goals for care upon discharge, and responding to a learner with a learning impairment. During each encounter, participants interact with highly-trained standardised patients (SPs) or standardised learners (SLs) who use behaviourally-anchored checklists to evaluate provider performance on communication and casespecific skills. Following each encounter, participants complete a self-assessment and the SPs and SLs complete a behaviour-specific checklist. After these have been completed, the SP or SL provides confidential and actionable feedback. Following the entire experience, participants are encouraged to set individual learning goals that they plan to implement in their work, complete a programme evaluation, and engage in a debrief with experienced facilitators. Participants also receive their performance checklists in addition to an institutional guide containing relevant resources and contacts. What lessons were learned? Traditional orientations are not well recalled and do not address potential knowledge gaps or skills in real time. Our approach to onboarding, setting institutional expectations, and supporting the transition from trainee to attending physician adds to the limited literature on faculty orientations. New faculty staff are heterogeneous with respect to their clinical communication skills and the other challenges faced in these SP and SL cases. A total of 86% (of 57) of participants successfully elicited the patient’s story during the discharge case compared with 66% in the other two cases. Regarding casespecific skills during the discharge case, 77% (of 57) of participants addressed pain management in keeping with the patient’s goals, whereas 44% did not discuss any side-effects of the medication. Since its inception in 2017, participants have universally found this onboarding to be useful and relevant. Specifically, 98% agreed/strongly agreed that the programme was an effective way to reinforce good habits in health care communication, 96% felt it enhanced their confidence in their ability to communicate effectively, and 96% felt it reinforced the institutional culture of safety (of 56 participants). All 56 participants agreed/strongly agreed that the event was engaging and well-designed, and 93% felt it was a good use of their time and said they would recommend the programme. Although an experiential orientation requires additional resources, participants are enthusiastic about our low-stakes, safe introduction to the institution’s patient engagement and safety standards. This programme sets high standards for patient–physician communication and patient safety, and introduces a new model for skills-based onboarding, which may lead to improved patient outcomes.

e18814Background: Extended RAS testing in colorectal cancer predicts response to therapy with EGFR-directed therapies cetuximab and panitumumab (EGFR mab’s). In 2010 VA policy recommended testing o...

e18832 Background: Oral tyrosine kinase inhibitors (TKIs) have substantially improved treatment and outcomes of chronic myeloid leukemia (CML) since Imatinib approval in 2001. Treatment options for newly diagnosed adult patients expanded with the addition of newer-generation TKIs (NGTKIs), Dasatinib and Nilotinib, as first-line therapies. We examined CML treatment with the three TKIs across the Department of Veterans Affairs (VA) in the period 2006-2015. Methods: We identified Veterans newly diagnosed with CML in 2006-2015 using national data from the VA cancer registry and Corporate Data Warehouse. We collected patient characteristics at diagnosis, including age, race, rural/urban residence, clinical comorbidities, and TKI prescriptions through December 2015. We examined patient characteristics associated with treatments using logistic regression, and overall survival using a Cox proportional hazards model. Results: Among 468 patients diagnosed with CML, 436 (93%) initiated TKI treatment with a median time of 21 days from diagnosis (interquartile range, 8 to 89 days). Patients not treated with TKI were significantly older than those treated (mean age, 74years (SD 10) versus 64 (SD 14), P < 0.001). In 2010-2015 Imatinib remained the common first-line TKI (average % of first TKI prescriptions per year: 79%, [95%CI, 75%-83%]; versus Dasatinib, 13% [9%-16%], and Nilotinib, 8% [6%-12%]). Controlling for diagnosis year, the use of NGTKIs versus Imatinib was less likely with older age (OR 0.97 [95%CI, 0.95-0.99]), higher comorbidity (OR 0.47 [95%CI, 0.26-0.88] and among patients in rural areas (OR 0.38 [95%CI, 0.17-0.83]; we observed no difference by patient race. Adjusting for age, race and comorbidities, overall survival at three years with use of any TKI was 91%, with no differences by treatment with Imatinib versus NGTKIs. Conclusions: Most Veterans diagnosed with CML in 2009-2015 received treatment with TKIs, and Imatinib remained the predominant TKI used at VA for CML. Lower use of Dasatinib and Nilotinib among older patients and those with more comorbidities warrant further study, as evidence is growing that they present the same safety profile than Imatinib but may lead to faster and deeper response.

PURPOSE:It is unknown whether there is a benefit to starting androgen deprivation therapy (ADT) prior to rather than concurrently with definitive radiation therapy in men with high-risk prostate cancer. We studied the National Cancer Data Base to determine whether the timing of ADT impacts survival.METHODS:Men diagnosed with high-risk prostate adenocarcinoma who received external beam radiation therapy (EBRT) to a dose of 70-81 Gy along with ADT from 2004-2011 were included. Those who started ADT 42-90 days before EBRT were identified as having received neoadjuvant hormonal therapy (N-HT) and those who received ADT from 14 days before their radiation until 84 days after the start of EBRT were categorized as receiving concurrent/adjuvant treatment (C-HT). We used the log-rank test to compare Kaplan-Meier survival curves and multivariable Cox regression to assess the impact of covariables on overall survival (OS).RESULTS:Among 11,491 included patients, those receiving N-HT were 1 year older (p<0.001) and more likely to have Gleason 8-10 disease (p = 0.01) and cT3-4 disease (p = 0.002). Men receiving N-HT had a 5-year and median OS of 80.6% and 111.4 months, respectively, compared to 78.3% and 108.9 months, respectively, in those receiving C-HT (p = 0.03). This benefit remained significant on multivariable analysis (hazard ratio 0.86, 95% confidence interval 0.77-0.96, p = 0.008). Duration of ADT was not available to report.CONCLUSIONS:External beam radiation therapy with N-HT was associated with improved overall survival compared to C-HT. This study is hypothesis-generating and further studies are needed to best qualify the sequencing of hormone therapy with the duration of treatment.

Novel insights into the critical role that angiogenesis plays in non-small cell lung cancer (NSCLC) have led to the development of multiple antiangiogenic strategies. These agents target the vascular endothelial growth factor (VEGF)/VEGF receptor pathway, a key mediator of tumor survival, migration, and mobilization, and broadly fall into 2 categories: neutralizing monoclonal antibodies and small-molecule tyrosine kinase inhibitors. This article reviews the clinical experience with these agents in advanced NSCLC, and discusses future implications and strategies of such an approach.