Twelve tips for addressing medical student and resident physician lapses in professionalism.

Medical educators have gained significant ground in the practical and scholarly approach to professionalism. When a lapse occurs, thoughtful remediation to address the underlying issue can have a positive impact on medical students and resident physicians, while failure to address lapses, or to do so ineffectively, can have long-term consequences for learners and potentially patients. Despite these high stakes, educators are often hesitant to address lapses in professionalism, possibly due to a lack of time and familiarity with the process. Attention must be paid to generalizable, hands-on recommendations for daily use so that clinicians and administrators feel well equipped to tackle this often difficult yet valuable task. This article reviews the literature related to addressing unprofessional behavior among trainees in medicine and connects it to the shared experience of medical educators at one institution. The framework presented aims to provide practical guidance and empowerment for educators responsible for addressing medical student and resident physician lapses in professionalism.

SARS-CoV-2 epidemic after social and economic reopening in three U.S. states reveals shifts in age structure and clinical characteristics.

State-level reopenings in late spring 2020 facilitated the resurgence of severe acute respiratory syndrome coronavirus 2 transmission. Here, we analyze age-structured case, hospitalization, and death time series from three states-Rhode Island, Massachusetts, and Pennsylvania-that had successful reopenings in May 2020 without summer waves of infection. Using 11 daily data streams, we show that from spring to summer, the epidemic shifted from an older to a younger age profile and that elderly individuals were less able to reduce contacts during the lockdown period when compared to younger individuals. Clinical case management improved from spring to summer, resulting in fewer critical care admissions and lower infection fatality rate. Attack rate estimates through 31 August 2020 are 6.2% [95% credible interval (CI), 5.7 to 6.8%] of the total population infected for Rhode Island, 6.7% (95% CI, 5.4 to 7.6%) in Massachusetts, and 2.7% (95% CI, 2.5 to 3.1%) in Pennsylvania.

SARS-CoV-2 Attack Rate and Population Immunity in Southern New England, March 2020 to May 2021.

Importance: In emergency epidemic and pandemic settings, public health agencies need to be able to measure the population-level attack rate, defined as the total percentage of the population infected thus far. During vaccination campaigns in such settings, public health agencies need to be able to assess how much the vaccination campaign is contributing to population immunity; specifically, the proportion of vaccines being administered to individuals who are already seropositive must be estimated. Objective: To estimate population-level immunity to SARS-CoV-2 through May 31, 2021, in Rhode Island, Massachusetts, and Connecticut. Design, Setting, and Participants: This observational case series assessed cases, hospitalizations, intensive care unit occupancy, ventilator occupancy, and deaths from March 1, 2020, to May 31, 2021, in Rhode Island, Massachusetts, and Connecticut. Data were analyzed from July 2021 to November 2021. Exposures: COVID-19-positive test result reported to state department of health. Main Outcomes and Measures: The main outcomes were statistical estimates, from a bayesian inference framework, of the percentage of individuals as of May 31, 2021, who were (1) previously infected and vaccinated, (2) previously uninfected and vaccinated, and (3) previously infected but not vaccinated. Results: At the state level, there were a total of 1 160 435 confirmed COVID-19 cases in Rhode Island, Massachusetts, and Connecticut. The median age among individuals with confirmed COVID-19 was 38 years. In autumn 2020, SARS-CoV-2 population immunity (equal to the attack rate at that point) in these states was less than 15%, setting the stage for a large epidemic wave during winter 2020 to 2021. Population immunity estimates for May 31, 2021, were 73.4% (95% credible interval [CrI], 72.9%-74.1%) for Rhode Island, 64.1% (95% CrI, 64.0%-64.4%) for Connecticut, and 66.3% (95% CrI, 65.9%-66.9%) for Massachusetts, indicating that more than 33% of residents in these states were fully susceptible to infection when the Delta variant began spreading in July 2021. Despite high vaccine coverage in these states, population immunity in summer 2021 was lower than planned owing to an estimated 34.1% (95% CrI, 32.9%-35.2%) of vaccines in Rhode Island, 24.6% (95% CrI, 24.3%-25.1%) of vaccines in Connecticut, and 27.6% (95% CrI, 26.8%-28.6%) of vaccines in Massachusetts being distributed to individuals who were already seropositive. Conclusions and Relevance: These findings suggest that future emergency-setting vaccination planning may have to prioritize high vaccine coverage over optimized vaccine distribution to ensure that sufficient levels of population immunity are reached during the course of an ongoing epidemic or pandemic.

Seroprevalence of SARS-CoV-2 among Internal Medicine Residents at a Major Academic Medicine Residency Program.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its associated disease (COVID-19) are a significant cause of morbidity and mortality across the United States. Internal medicine (IM) residents are a critical component of the healthcare workforce yet their seroprevalence of SARS-CoV-2 antibodies is largely unknown. The aim of this research was to ascertain the seroprevalences of SARS-CoV-2 among internal medicine residents during the first peak of COVID-19. METHODS: IM residents were enrolled in a surveillance program that included PCR and antibody testing for SARS-CoV-2 in June 2020. Residents also completed a short questionnaire to obtain sociodemographic information and characterize potential workplace exposure to COVID-19. RESULTS: A total of 101 IM residents participated in the study (out of N=162). Of the 101 samples, three (2.9%) tested positive for SARS-CoV-2 antibodies. No residents tested PCR positive for SARS-CoV-2. DISCUSSION: The implementation of COVID-19 patient cohorting and the incorporation of telemedicine to communicate with hospitalized patients into clinical practice early in the pandemic may have prevented the spread of the virus among the surveyed clinical trainees. CONCLUSION: Despite significant engagement with COVID-19 patients, IM residents demonstrated a low rate of SARS-CoV-2 seroprevalence.

SARS-CoV-2 attack rate and population immunity in southern New England, March 2020 - May 2021.

Estimating an infectious disease attack rate requires inference on the number of reported symptomatic cases of a disease, the number of unreported symptomatic cases, and the number of asymptomatic infections. Population-level immunity can then be estimated as the attack rate plus the number of vaccine recipients who had not been previously infected; this requires an estimate of the fraction of vaccines that were distributed to seropositive individuals. To estimate attack rates and population immunity in southern New England, we fit a validated dynamic epidemiological model to case, clinical, and death data streams reported by Rhode Island, Massachusetts, and Connecticut for the first 15 months of the COVID-19 pandemic, from March 1 2020 to May 31 2021. This period includes the initial spring 2020 wave, the major winter wave of 2020-2021, and the lagging wave of lineage B.1.1.7(Alpha) infections during March-April 2021. In autumn 2020, SARS-CoV-2 population immunity (equal to the attack rate at that point) in southern New England was still below 15%, setting the stage for a large winter wave. After the roll-out of vaccines in early 2021, population immunity in many states was expected to approach 70% by spring 2021, with more than half of this immune population coming from vaccinations. Our population immunity estimates for May 31 2021 are 73.4% (95% CrI: 72.9% - 74.1%) for Rhode Island, 64.1% (95% CrI: 64.0% - 64.4%) for Connecticut, and 66.3% (95% CrI: 65.9% - 66.9%) for Massachusetts, indicating that >33% of southern Englanders were still susceptible to infection when the Delta variant began spreading in July 2021. Despite high vaccine coverage in these states, population immunity in summer 2021 was lower than planned due to 34% (Rhode Island), 25% (Connecticut), and 28% (Massachusetts) of vaccine distribution going to seropositive individuals. Future emergency-setting vaccination planning will likely have to consider over-vaccination as a strategy to ensure that high levels of population immunity are reached during the course of an ongoing epidemic.

SARS-CoV-2 epidemic after social and economic reopening in three US states reveals shifts in age structure and clinical characteristics.

In the United States, state-level re-openings in spring 2020 presented an opportunity for the resurgence of SARS-CoV-2 transmission. One important question during this time was whether human contact and mixing patterns could increase gradually without increasing viral transmission, the rationale being that new mixing patterns would likely be associated with improved distancing, masking, and hygiene practices. A second key question to follow during this time was whether clinical characteristics of the epidemic would improve after the initial surge of cases. Here, we analyze age-structured case, hospitalization, and death time series from three states - Rhode Island, Massachusetts, and Pennsylvania - that had successful re-openings in May 2020 without summer waves of infection. Using a Bayesian inference framework on eleven daily data streams and flexible daily population contact parameters, we show that population-average mixing rates dropped by >50% during the lockdown period in March/April, and that the correlation between overall population mobility and transmission-capable mobility was broken in May as these states partially re-opened. We estimate the reporting rates (fraction of symptomatic cases reporting to health system) at 96.0% (RI), 72.1% (MA), and 75.5% (PA); in Rhode Island, when accounting for cases caught through general-population screening programs, the reporting rate estimate is 94.5%. We show that elderly individuals were less able to reduce contacts during the lockdown period when compared to younger individuals. Attack rate estimates through August 31 2020 are 6.4% (95% CI: 5.8% ‒ 7.3%) of the total population infected for Rhode Island, 5.7% (95% CI: 5.0% ‒ 6.8%) in Massachusetts, and 3.7% (95% CI: 3.1% ‒ 4.5%) in Pennsylvania, with some validation available through published seroprevalence studies. Infection fatality rates (IFR) estimates for the spring epidemic are higher in our analysis (>2%) than previously reported values, likely resulting from the epidemics in these three states affecting the most vulnerable sub-populations, especially the most vulnerable of the ≥80 age group.

Reflective practice and palliative care education: a clerkship responds to the informal and hidden curricula.

The authors discuss the damaging influence of informal and hidden curricula on medical students and describe a two-week clerkship in palliative care and clinical ethics at their school (Weill Medical College of Cornell University). This required clerkship, begun in 1999, uses reflective practice and a special pedagogic technique, participant observation, to counteract the influences of the informal and hidden curricula. This technique seeks to immerse the participant observer in the context of care. In their role as participant observers, students are relieved of any direct clinical responsibilities for two weeks so they have time for the careful observation and reflection required and also can consider the humanistic dimensions of practice, which are often displaced by the need to master diagnostic and therapeutic skills. Course objectives include identifying psychosocial and contextual factors that influence care, principles of pain and symptom management, and ethical and legal issues at the end of life. Students are expected to learn how to apply ethical norms to patient care, describe methods of pain and symptom management, communicate in an effective and humanistic manner, and articulate models of patient-centered advocacy. The clerkship fosters professionalism in patient care, appreciation of cultural diversity, and the student's ability to assume responsibility for developing competency in these areas. Although it is too early to know whether this clerkship will ultimately affect the practice patterns of students who experience it, short-term evaluation has been very favorable.

Prosthetic valve endocarditis: a complication of spinal epidural abscess.

Epidural injections for chronic low back pain are controversial, and their effectiveness is debated. Although epidural injections are considered a minor procedure with low morbidity, catastrophic complications may occur. We describe a case of prosthetic valve endocarditis secondary to an epidural abscess after epidural injection to alert clinicians to this unusual association.