Pragmatic Trial of Hospitalization Rate in Chronic Kidney Disease.

BACKGROUND: Despite the availability of effective therapies for patients with chronic kidney disease, type 2 diabetes, and hypertension (the kidney-dysfunction triad), the results of large-scale trials examining the implementation of guideline-directed therapy to reduce the risk of death and complications in this population are lacking. METHODS: In this open-label, cluster-randomized trial, we assigned 11,182 patients with the kidney-dysfunction triad who were being treated at 141 primary care clinics either to receive an intervention that used a personalized algorithm (based on the patient's electronic health record [EHR]) to identify patients and practice facilitators to assist providers in delivering guideline-based interventions or to receive usual care. The primary outcome was hospitalization for any cause at 1 year. Secondary outcomes included emergency department visits, readmissions, cardiovascular events, dialysis, and death. RESULTS: We assigned 71 practices (enrolling 5690 patients) to the intervention group and 70 practices (enrolling 5492 patients) to the usual-care group. The hospitalization rate at 1 year was 20.7% (95% confidence interval [CI], 19.7 to 21.8) in the intervention group and 21.1% (95% CI, 20.1 to 22.2) in the usual-care group (between-group difference, 0.4 percentage points; P = 0.58). The risks of emergency department visits, readmissions, cardiovascular events, dialysis, or death from any cause were similar in the two groups. The risk of adverse events was also similar in the trial groups, except for acute kidney injury, which was observed in more patients in the intervention group (12.7% vs. 11.3%). CONCLUSIONS: In this pragmatic trial involving patients with the triad of chronic kidney disease, type 2 diabetes, and hypertension, the use of an EHR-based algorithm and practice facilitators embedded in primary care clinics did not translate into reduced hospitalization at 1 year. (Funded by the National Institutes of Health and others; ICD-Pieces ClinicalTrials.gov number, NCT02587936.).

The Impact of Internal Medicine Clerkship Characteristics and NBME Subject Exams on USMLE Step 2 Clinical Knowledge Exam Performance.

BACKGROUND: Residency program directors will likely emphasize the United States Medical Licensing Exam (USMLE) Step 2 clinical knowledge (CK) exam more during residency application given the recent USMLE Step 1 transition to pass/fail scoring. We examined how internal medicine clerkship characteristics and NBME subject exam scores affect USMLE Step 2 CK performance. DESIGN: The authors used univariable and multivariable generalized estimating equations to determine associations between Step 2 CK performance and internal medicine clerkship characteristics and NBME subject exams. The sample had 21,280 examinees' first Step 2 CK scores for analysis. RESULTS: On multivariable analysis, Step 1 performance (standardized ß = 0.45, p < .001) and NBME medicine subject exam performance (standardized ß = 0.40, p < .001) accounted for approximately 60% of the variance in Step 2 CK performance. Students who completed the internal medicine clerkship last in the academic year scored lower on Step 2 CK (Mdiff = -3.17 p < .001). Students who had a criterion score for passing the NBME medicine subject exam scored higher on Step 2 CK (Mdiff = 1.10, p = .03). There was no association between Step 2 CK performance and other internal medicine clerkship characteristics (all p > 0.05) nor with the total NBME subject exams completed (ß=0.05, p = .78). CONCLUSION: Despite similarities between NBME subject exams and Step 2 CK, the authors did not identify improved Step 2 CK performance for students who had more NBME subject exams. The lack of association of Step 2 CK performance with many internal medicine clerkship characteristics and more NBME subject exams has implications for future clerkship structure and summative assessment. The improved Step 2 CK performance in students that completed their internal medicine clerkship earlier warrants further study given the anticipated increase in emphasis on Step 2 CK.

Using the NAM diagnostic process framework to teach clinical reasoning in computerized case presentations to 251 medical students.

OBJECTIVES: Explicit education on diagnostic reasoning is underrepresented relative to the burden of diagnostic errors. Medical educators report curricular time is a major barrier to implementing new curricula. The authors propose using concise student-identified educational opportunities -- differential diagnosis and summary statement writing -- to justify curriculum development in diagnostic reasoning. METHODS: Eighteen clerkship and 235 preclinical medical students participated in a 1 h computerized case presentation and facilitated discussion. Students were surveyed on their attitudes toward the case. RESULTS: All 18 (100% response) clerkship students and 121 of the 235 preclinical students completed the survey. Students felt the module was effective and relevant. They proposed medical schools consider longitudinal computerized case presentations as an educational strategy. CONCLUSIONS: A computerized case presentation is a concise instructional strategy to teach critical points in diagnosis to clerkship and preclinical medical students.

Checking in on check-out: Survey of Learning Priorities in Primary Care Residency Teaching Clinics.

Background: Despite focus on increasing the quality of ambulatory education training, few studies have examined residents' perceptions of learning during case discussions with their preceptors (i.e., "check-out"). The objective of this study was to assess the difference between residents' and preceptors' perceptions of behaviors that should occur during check-out discussions. Methods: We conducted a cross-sectional survey of categorical internal medicine and family medicine residents and preceptors. The survey was distributed electronically and assessed 20 components of the check-out discussion. Results: Of 38 preceptors, 22 (61%) completed the survey. Of 172 residents, 82 (48%) completed the survey. For residents, we identified discrepancies in desired and perceived check-out behaviors. Specifically, utilizing a dependent sample t-test, residents felt that all 20 areas needed additional teaching during check-out (P < 0.05). Preceptors believed that demonstrating physical examination skills in the patient room during check-out was significantly more important than did residents (P = 0.01). Increasing years of preceptor experience did not statistically relate to their valuation of components important to residents. Discussion: Our research highlighted a major deficiency in training in the check-out process, with residents desiring more patient management education in all components. Moreover, faculty and residents do not necessarily agree with what is an important focus in the "teachable moment." Our results serve as a training needs assessment for future faculty development seminars and highlight the need to consider resident learning needs in general.

No Medical Student Left Behind: A Study to Examine the Effects of Structured Step 1 Support within our Curriculum.

This article was migrated. The article was marked as recommended. Introduction:The University of Texas Southwestern Medical School (UT Southwestern) developed a required, pass/fail Step 1 preparation course in conjunction with their new curriculum to support students with structure, encouragement, and accountability. This study examined the Step 1 performance of students who have taken the prep course after completing pre-clinical coursework and factors which predicted outcomes. Methods: Data were collected between January 2017 and July 2018 from 453 2 nd-year medical students enrolled in the six week course. Multilinear regression and Chi-squared analysis were performed to compare pre-clinical course performance with Step 1 readiness and outcomes. Results: Average course final exam scores and CBSSA results were significantly and directly associated with Step 1 scores. Pre-clinical exam performance, practice exam scores at the beginning of the Step 1 preparation period and an increase in practice exam scores over the study period correlated with Step 1 performance. The percent pass rates and mean scores in 2017 were at 97% and 235, but in 2018, no student failed Step 1 (100% pass rate), and the mean score rose to 239. Discussion and Conclusion: A structured Step 1 Prep Course was well-accepted by students. Exam performance can be predicted from pre-clerkship performance and progress made during the course on practice exams and early intervention for at-risk students can improve performance of at-risk students.

Integration of Dermatology-Focused Physical Diagnosis Rounds and Case-Based Learning within the Internal Medicine Medical Student Clerkship.

BACKGROUND: Over half of dermatologic conditions are seen by nondermatologists, yet medical students receive little dermatology education. Medical students in the clinical years of training at our institution felt insecure in their physical diagnosis skills for dermatologic conditions. OBJECTIVE: The objective of this study was to implement dermatology-focused curricula within the Internal Medicine (IM) Core Clerkship to increase student confidence in diagnosing skin diseases. METHODS: Two dermatology-focused sessions were integrated into the IM Clerkship. A faculty dermatologist leads students on a dermatology-focused physical diagnosis "Skin Rounds", where patients are seen at the bedside and students practice describing skin lesions and forming a differential diagnosis. Students also participate in a case-based active learning session. A dermatologist selects images of common skin conditions that students describe utilizing appropriate terminology and offer a differential diagnosis. The impact of these sessions was assessed through survey-based student feedback and by comparing the results from the IM Shelf Exam before and after intervention. RESULTS: A total of 74 students completed the skin rounds survey (32% response rate). About 99% (n = 73) of students felt that skin rounds were effective and useful, and 92% (n = 68) of students reported that they felt more confident in describing skin lesions afterward. A total of 43 students completed the case-based learning session survey (37% response rate), and 98% (n = 42) of students strongly agreed or agreed that the session was effective and useful. Performance on the dermatologic questions of the IM Shelf Exam was analyzed. While not statistically significant at P < 0.05, students improved from an average of 77% correct responses before intervention to 79% afterward (P = 0.60). CONCLUSIONS: Our case-based and bedside teaching interventions were met with high satisfaction from medical students and increased their confidence in describing skin lesions. This intervention can serve as a model to improve dermatology education and can be adapted to utilize the IM clerkship to address curriculum inadequacies at other institutions.

Senior Medical Student-Led Interactive Small-Group Module on Acute Fracture Management.

INTRODUCTION: Medical students receive insufficient training in musculoskeletal diagnosis and management. To address this deficiency, a senior medical student at our institution designed and moderated small-group interactive discussions with third-year medical students on acute fracture management during their family medicine clerkship. METHODS: In these sessions, students learned how to diagnose and comprehensively work up a case of a suspected fracture, how to effectively communicate findings from physical exam and X-ray, and when to appropriately consult a surgeon for treatment. RESULTS: This module was piloted with a total of 14 students in two separate small groups. One hundred percent of students regarded the module as very useful, and there was a 50% improvement in pre- versus posteducational assessment. DISCUSSION: Our experience suggests that students can quickly improve clinical skills for fracture management in a focused smallgroup interactive session. In addition, these sessions can be effectively designed and implemented by senior medical students. This module may be used with either clinical or preclinical students, but we believe that this information would be best received by clinical students on family medicine, emergency medicine, or orthopedic rotations.

Existence and stability of steady states of a reaction convection diffusion equation modeling microtubule formation.

We generalize the Dogterom-Leibler model for microtubule dynamics (Dogterom and Leibler in Phys Rev Lett 70(9):1347-1350, 1993) to the case where the rates of elongation as well as the lifetimes of the elongating shortening phases are a function of GTP-tubulin concentration. We analyze also the effect of nucleation rate in the form of a damping term which leads to new steady-states. For this model, we study existence and stability of steady states satisfying the boundary conditions at x=0. Our stability analysis introduces numerical and analytical Evans function computations as a new mathematical tool in the study of microtubule dynamics.