Dr. Jeremey Walker joins Sara for this Febrile Digest to discuss ID Fellows Cup and breakdown a few of the most commonly missed questions from prior game sessions. 

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Hello everyone.

Welcome to Febrile - a cultured podcast about all things infectious disease.

My name is Sara Dong.

I'm your host and a Med-Peds ID fellow.

In today's Febrile Digest, I'm joined by Jeremey Walker.

Jeremey, can you say hello and introduce herself.

Yes.

Hello.

Thank you so much for having me on Sara.

I'm really excited to be here.

My name is Jeremey Walker.

I'm an Assistant Professor in Infectious Disease at UAB.

Um, my clinical interests are in transplant and hospital epidemiology, but what I'm here and what I really, uh, I guess is my passion is medical education and specifically making that fun, uh, through some elements of gamification.

Yeah, love it.

Um, and so today we're going to chat a little bit about ID Fellows Cup, which I suspect a lot of our listeners already know about or heard of, but for those who haven't, can you just give a quick overview of what ID Fellows Cup is?

Absolutely.

So the Fellows Cup is really based out of, uh, an app, the Kaizen education app, which was created by one of my mentors, James Willig.

And what that does is it's really a tool to help educators deliver content.

And so it allows you to create multiple choice board style questions and deliver that through a mobile app.

So it's really crisp and clean.

Um, but what separates it a bit from a question bank?

It actually releases the content rather than just a large bank of questions, it releases it daily at a certain pattern, and then it also has some additional game elements to help keep it fun and engaging.

Um, so we, my first experience with that was actually within microbiology for our first-year medical students.

And so the story of the Fellows Cup is that we had this experience and found that our learners really enjoyed it.

And we were able to actually present it as an abstract at ID week.

And then through that ended up meeting some of the people from the ID Fellows Networks, specifically Nathan Nolan and Miguel Chavez.

And then we just started dreaming about what that could look like, um, in fellows education, and thus came the ID Fellows Cup.

And so for last year, what we actually were able to do is we had two competitions.

Uh, one was in the spring and one was in the fall.

Each was three to four weeks.

And so it ended up being a total of about a hundred questions.

And then in January of 2022, we actually had what we called a consolidation game.

And so we revisited some of the questions that hit in that 60 to 70% accuracy.

And we released those right before the in-training exam, just as an opportunity for some spaced learning, um, and to get everyone kind of geared up for that upcoming in-training experience.

So really our goals with the Fellows Cup have been to provide a platform to engage fellows in both creation, as well as review of board relevant ID content, and then to connect learners to useful online med ed resources.

Love it.

And it perfectly aligns with what I hope Febrile can do.

And I think all of us as fellows probably have those, um, talks where you go over the most commonly missed questions on your in training exam, so we're going to kind of do the same thing today and chat about commonly missed questions or topics in the recent competition.

So I'm excited.

Um, and I actually have the first question.

We have a young carnival worker who presented with progressive right arm symptoms after sustaining an injury on the arm, repairing a macaque monkey habitat.

A few days after the injury, he has a local vesicular rash, and it's followed by some regional numbness.

And now it's been about three weeks later and he has lymphadenopathy, parasthesias, and fever.

And so the way this actually was created originally, it was a two-step question.

But the first thing we're asking ourselves is what infection is this?

What is the monkey to blame for?

Exactly to be honest, I probably should have stuck with the first step.

You know, our goal in creating these questions is to hit it about 60 to 80% accuracy.

That's where you're kind of flexing your muscles.

Um, but yet not just kind of getting blown away the difficulty.

And so I think if you are approaching this question and you have no association with monkeys necessarily.

The question, stem itself, screams zoonotic exposure.

And if you're thinking in that zone, and you're thinking about a regional syndrome with lymphadenopathy and fevers, some things like Bartonella or tularemia may come to mind, and that was what some of the distractor choices were getting at.

The progressive neurologic features probably brought to mind rabies, and that was another one of the distractor choices, but none of those fit perfectly.

And in particular, because you said something about a vesicular rash.

And so that brings up to the association that you do need to have, which is herpes B virus, which is associated with macaque monkey exposure

Yeah.

And I know most of us don't get called too frequently about monkey bites, but it's really important to recognize herpes B virus because it can be fatal without treatment.

And so how is this treated?

Yeah.

So in this example, actually the answer would be, IV ganciclovir.

Because uh, they were already demonstrating neurologic involvement, so that is the agent that is gone to at that time.

Really in an ideal world, they would receive prophylaxis before they got to that stage.

And so the prophylactic answer is actually valacyclovir.

And that was actually the most commonly chosen distractor choice as well.

So I think in retrospect, I should have just asked what prophylaxis could have prevented this.

And I think a lot of people were right on there.

Um, but there was a nice paper in the notes, which kind of addresses when prophylaxis should be considered, but I think the most important takeaway is this is something that's truly unique to macaque monkey exposure.

Yeah.

Yeah.

And I think it's a association that once you have a question like this, it, it probably sticks.

The same way, I think of, uh, that picture of orf virus.

I suspect I'll never see that, but I feel like because I've done questions on it, I'm going to remember it somewhere wedged in my brain forever.

And you know, you've referenced a little bit about the writing process and things that you learn as you go through these iterations of the game.

How do you feel like question writing has changed since you guys had that first game in April?

So the biggest change is this the number of people involved.

So it really began with just five fellows and five attendings kind of reviewing that initial question set, but on our second game, we're actually able to open it up.

Uh, and fellows from around the world submitted questions.

And then we had a team of mentors that helped develop them.

And so for our upcoming game in April, this year, we actually have 47 separate fellows that are writing questions and 12 question mentors, helping to develop.

Which is so cool.

I mean, just another way to build community amongst ID fellows.

Are there any other impacts from opening it up that you have noticed?

I mean, I think the first is just, the questions are so much better.

So initially when we approached or developed this, a lot of it was for community building and to help collaborate.

Also to provide an opportunity to get some feedback, which is so rare in medical education, to help develop better question writers.

And I do hope we are doing that.

But in addition, we're just getting this variety in clinical experience and exposures and interests, and people are asking questions in ways that we could have never envisioned on our own or as individual creating them.

And so it's been really interesting to learn from one another.

So the next question I'll share is actually an example of this.

It's about a topic that I think is near to both of our hearts, rashes in immunocompromised patients.

Yes.

Okay.

I'm ready.

So the stem is a middle-aged person with myelodysplastic syndrome on azacitadine for several months with severe neutropenia and who presents with progressive skin lesions for two weeks.

So the first lesion appeared on the right arm and grew to three centimeters.

And now she has innumerable lesions across torso and upper extremities.

They all begin as red nodules, but then grow to be bullous in the center.

She's had no fevers or chills and her vitals are normal on presentation.

She lives in Appalachia, hikes on cultivated trails, but no concerning exposures of note and, I've actually rewrote this again so it's a single step.

But what is your differential when you're approaching cases like this.

Yeah.

I mean, I think the one we worry about or sort of one of the scarier ones is ecthyma or ecthyma gangrenosum , which we classically think of Pseudomonas, but can definitely be a variety of other bacteria or molds even such as Fusarium.

And then I think anytime you think of echythma in an immunocompromised host, you're also probably thinking about disseminated fungal infection in general, whether that's candidiasis or Crypto.

And so you're kind of stuck biopsying these to rule out infection because it's really hard to know just from looking at it.

But in this stem it's been around for a little while and has been relatively stable.

And it makes you think about non ID etiologies of rashes that look like this , so leukemia cutis, and I have the benefit of seeing the picture, but what looks like neutrophilic dermatosis or sweet syndrome.

That's exactly right.

Uh, we seem to have a new case of rash in a neutropenic patient every week that I'm on the IC service, and that differential is just so important.

And so it is challenging to write a question that incorporates that because ultimately so many things do come back, uh, to the biopsy.

But the mobile app will use Kaizen can actually embed content such as pictures and, uh, which will allow you to be able to see some of these components of the physical exam or micro content as we'll discuss later.

Um, and then it also has links that you can link out to other resources, which is really part of my favorite component of this.

And so you can include a succinct explanation, uh, for each question.

On top of that, you can have these various links that they can go to to learn more.

And we usually try to have one link that's a little bit easier to digest, something quick and simple, like a Twitter post, another question, a tweetorial.

And then we like to have something that's a little bit more detailed and robust, like a nice review article or an excellent podcast, such as Febrile.

Nice.

A very nice plug.

And, you know, as reminder, we're going to put these question samples on the Consult Notes for the Febrile website, and also I will remember to put them out on Twitter.

Um, but I have our third question.

So, in this scenario, we had a middle-aged patient with diabetes who came into the ED with severe sepsis.

And so she had just returned from a rafting trip in Northern Australia and had acute onset of fever, chills, productive cough, and dyspnea.

Her workup then reveals a left upper lobe consolidation as well as hypotension and hypoxia that unfortunately required transfer to the ICU.

And so a CT scan shows splenic abscesses and the blood cultures are now growing aerobic gram-negative rods with bipolar staining.

And so in this scenario, there was a picture of that.

So Jeremey, what's our most likely diagnosis here?

So I love a question that allows a couple routes to the answer, right?

So you can approach this by thinking about the clinical history and epidemiology.

So you have severe sepsis with pneumonia and multiorgan abscesses.

You layer in that epi history of rafting in Northern Australia.

And you've probably arrived at your correct answer.

We could have changed the stem a bit to be someone from the U S who's an avid user of essential oil aromatherapy sprays, um, although thankfully uh that has, that outbreak has been found and addressed.

But the micro picture tells you a lot as well.

There's only a few organisms that are known for bipolar staining.

Yes.

This is one of those buzzwords that I think all of us probably have a little note scratched somewhere.

The list I have is - there are, you know, a couple of things in the genital ulcer realm.

So Klebsiella granulomatosis and Haemophilus ducreyi.

And then when I think about systemic illness, which is a better fit for this patient, the ones that stand out in particular are Yersinia pestis, which I feel like is usually an answer we think of, but in this scenario, Burkholderia pseudomallei.

Yes exactly.

And, you know, it's a perfect example of why it's always worth a trip to the micro lab.

Um, you know, as I stated, I, this started for me, at least with our micro course.

And so one of the fun things from this past year is I actually took, uh, some of the ID Fellows Cup questions that had a significant microbiology component.

And I did it as part of a trivia round with some of our, with our med students that were first years and despite not having any of the clinical context, they were able to get several of these questions just by knowing those key micro components.

So it's really, it's nice to see those two things play together.

And I, I think it's an important thing for us still to know, cause it comes up, you know, at least once a week on rounds, especially on the immune compromised service where we need to go down to the micro lab and talk about some things, but the original stem actually it took us to, um, treatment.

And so it, it implied that the patient was on a broad coverage with Vanc and Zosyn, everyone's favorite, um, and that just wasn't doing the trick.

All right.

So what are we thinking about for drug of choice then?

Given this as critical illness, the answer is meropenem, but ceftazidime would also work for those with moderate disease and Bactrim or doxy has activity as well.

You know, we've picked, obviously we're reviewing some of the most missed questions that are a little bit more challenging.

How do you strike that balance between making the questions difficult, but also trying to keep it a bit more fun and entertaining.

It's an excellent question, Sara.

Gamification is a little different than serious gaming, which I know you've had some, some serious gamers on as well.

So at the heart of a serious game is a game.

It's a game that's designed to learn, but it's, it's the activity itself as a game.

And the difference with gamification is at the heart of it is an educational activity with game elements added in.

And so at the heart of Kaizen is truly a question bank and we all know that question banks are incredibly effective for learning.

It's how we have learned medicine, essentially since we began studying for step one, but we also know it can be kind of challenging.

And the reason it works is because it is challenging, right?

It's forces you to pull up and retrieve prior information to form new connections and all of that takes work.

And it's hard to get yourself geared up, to do that extra work day in and day out to kind of have that frequent exposure that's most helpful to really learn.

And so what, um, the game elements help us to do is it just helps to keep you coming back to help make it a little bit fun.

And it's really not unlike what a lot of fitness apps or gyms or other things will kind of utilize to help getting people to come back day in and day out, um, to continue an activity they know is good, um, but also can sometimes be a little bit, uh, taxing.

Yeah.

And what are some of those things that you guys do?

I I'm already thinking of some from, from thinking about playing the game, but maybe you can point out a couple.

Yeah.

So the obvious are those that really play off those who are competitive at heart.

Right.

And so you have each question answered correct gives you points.

And so there's a leaderboard and you can see where you fall on that.

Um, uh, really across everyone who's playing and then there's also badges that you get for answering so many questions correct in a row, et cetera.

But then there's, there's more, um, subtle things that play off people's intrinsic motivation.

So ability to complete a task, you can get the badges for reaching a certain level of, for playing for so many days in a row.

And then I think one of the most important aspects really is the team component.

That many people were playing as a group, as part of an institution.

And they felt like they were competing together as a team, uh, through these questions.

Yeah.

And you guys did a couple versions of teams right.

Where sometimes it was by institution and sometimes it was sort of a group of others that didn't necessarily come in as a program.

How does that sort of team play work?

Yeah, so each person, I mean, practically each person receives the same questions.

And so you're answering each question as an individual, but then your group score is the average of those, uh, and so for those who are playing as an institution, I think it's really helpful because generally you have someone on the ground that was excited that signed the team up so they can kind of help rally the troops if you will, and get people, you know, engaged in playing.

Oftentimes what I've seen, at least at UAB, is after the questions are answered, there's kind of review of some of the question contents.

Things will come up in other lecture platforms and other places.

Sometimes that's a helpful learning thing.

Sometimes that's just a well spirited grumble, but both are helpful, right, for team building.

Um, and then the people who, uh, were joining as individuals for them, we just put them on teams with people, for other people from around the world who wanted to join as an individual.

And we did try to separate, especially for the second game, we realized that there was different levels of competitiveness.

So we had to ask, so we said, you know, how competitive are you?

And we tried to put people on similarly competitive teams so that everyone would have a good time.

Yeah.

So I think we have time for one more question and we're back to skin rashes and immune compromised hosts.

And this one I think is really fair to ask you because you helped to develop this question as one of the mentors.

So, but we have a different host this time.

So it's a kidney transplant patient, or a recipient, who is from Texas and presents with two weeks of subcutaneous nodules.

Her immune suppression has been stable and her exam is only notable for these multiple tender brown to purple nodules on extremities.

A punch biopsy reveals granulomatous inflammation and acid fast bacilli are found, which grow after four days.

So the question again, takes you to the second step and asks how you would treat.

Oh, well, I'm thinking about rapid growers and I will plug when we had Ruvandhi on way back in like episode seven, thinking about NTMs.

Yes.

You had some great infographics there for both breaking NTMs down by lab ID techniques, but also clinical centers.

Yeah.

So I'm thinking about a Mycobacterium chelonae or maybe abscessus here since it's rapid growing.

Um, those also are the ones that you sort of keep in mind, as you think about syndromes with multiple skin lesions in someone who's immunocompromised.

Fortuitum is also a rapid grower, and I feel like we classically get the stem that they've had some sort of procedure, cosmetic procedure, like a pedicure.

Um, but often they have more localized disease.

But for chelonae and abscessus, you would need at least two antibiotics, if not a third.

And so I think amino glycosides and linezolid and macrolides would be our common initial agents.

Uh, but I always have to look up the issue with using macrolides and maybe you'll tell me.

Yes, um well the erm gene, uh, is an inducible resistance to macrolides that several of our rapid growers have.

And this is primarily fortuitum, but it's seen an abscessus as well.

Chelonae however, is safer.

The other thing that we have to think about if it's a transplant, patient is macrolides can interact with calcineurin inhibitors.

And so it's going to bump up those drug levels.

And I think azithro does this less than clarithromycin.

And so I'd probably pick that as part of my regimen.

I feel like we're really shifting towards azithro in general for most cases anyways.,

You're absolutely right.

And this question actually emphasized that by having both macrolides as options with appropriate regimens.

And so the best choice would have been as azithro.

Oh, I love it.

We're just sprinkling in a little bit of fun of transplant as well.

And so, you know, we are approaching the end of time for the episode and I, I just wanted to end by asking how do you see ID Fellows Cup growing and expanding this coming year?

Yeah, I think I'm most excited about having gained so many new question writers.

The question we just reviewed actually was from the October game from Suha Khalaf at Missouri.

And I've just been amazed by the quality and varied perspective that has been generated by having all these different contributors.

And the ID Fellows Network has actually allowed us to incorporate these former questions on their websites, which gives us a place to backlog these questions, as well as allow our question writers a place to point towards their questions in the future.

And so I'm just excited to see where these ongoing collaborations take us, and hope that we can add to the grow in a kind of fountain of ID Med Ed resources that are being developed, um, as well as just have some fun through our questions and build some of those bridges with other resources.

Yeah.

I think, I think that's our end goal is to make this mega ID Med Ed collaboration or force.

But yeah, as you kind of mentioned connecting resources, is there anything else that you had in mind?

And there's just so much great content out there.

Um, but it's so hard to stay up to date and I'm, I'm honestly incredibly impressed by people like yourself.

I feel like you just are always just like have your finger on the pulse of what's going on and all these different resources.

And I find myself often like getting a case or having something come up on the wards and I'm having to go through looking for tweetorials or, you know, other sorts of resources that will help point me to this, people who have dealt with this question previously.

And so what we found actually is that because people are signing up as groups, a lot of times we're reaching people initially who have, um, a lot of exposure to online MedEd, but about a third to half of our players end up being recruited from those people at their institution and don't use a lot of online med ed resources.

And so we're hopeful we can kind of collate some helpful resources for the question at hand that they're seeing, um, so that they could visit that or maybe save it for the future if a desired.

So I'm super excited about the upcoming game.

We're going to post the link for everyone to sign up, but you can also follow ID Fellows Cup on Twitter to make sure that you stay updated.

Absolutely.

And just wanted to thank you again so much for having me on Sara.

It's really been a pleasure and I do want to thank everyone that's been involved, um, with ID Fellows Cup, which has included both our question writers and mentors, the people who have rallied their institution, as you said, the kind of team captains at each individual institution.

But most importantly, my co game managers, Nico Herrera, Mauricio Kahn, they've really done an incredible job, and it's been so fun to partner with so many incredible people like yourself.

Yeah.

Yeah, no, likewise.

And I'm very grateful for everyone who participates in projects like this, because, you know, you didn't really talk about this necessarily, but it takes a lot of effort to make a good question, in the same way that it can be difficult or time-consuming to make a podcast episode or a quality tweetorial.

And I think these skillsets, although they remain a little bit under appreciated, all of us would benefit from knowing how to create and educate in these different formats, but also as learners and test-takers, there really are multiple benefits for working on projects like this.

Well, with that all wrap us up for the day.

Uh, thank you so much, Jeremy, for coming on the show.

Thank you for having me.

All right.

So we will have links to the signups for the upcoming ID Fellows Cup game.

Remember that you can find ID Fellows Cup as well as Febrile on Twitter and the website febrilepodcast.com.

I can't wait to have you back next week and we'll have our next episode of Curious Congenital Conundrums, featuring Drs.

Ella Dzora and Jason Brophy.

Thanks for listening.