Comparative effectiveness study of flipped classroom versus online-only instruction of clinical reasoning for medical students.

CONTEXT: Bedside clinical teaching is the backbone of clerkship education. Data-driven methods for supplementing bedside encounters with standardized content from vetted resources are needed. OBJECTIVE: To compare a flipped-classroom versus an interactive online-only instruction for improving knowledge, skills, self-directed learning (SDL) behaviors, and satisfaction in a medical school clerkship. METHODS: An IRB-approved prospective study employing a peer-reviewed clinical reasoning curriculum in neurology was conducted; 2nd-4th year medical students rotating through a required clerkship were enrolled. Students were randomized to flipped-classroom (i.e., flipped) or interactive asynchronous online instruction (i.e., online-only), which supplemented existing bedside teaching. Baseline and end-of-course knowledge, skill development, SDL behaviors, satisfaction, and long-term retention were assessed by peer-reviewed clinical reasoning exam, NBME scores, faculty/resident clinical evaluations, non-compulsory assignment completion, end-of-clerkship surveys, and objective structured clinical exam (OSCE). RESULTS: 104 students (49 flipped, 55 online-only) were enrolled. Age, gender, and training level did not differ by group (all p > 0.43); baseline knowledge was higher in the flipped group (p = 0.003). Knowledge-based exam scores did not differ by group even after adjusting for differences in baseline knowledge (2.3-points higher in flipped group, 95%CI -0.4-4.8, p = 0.07). Clinical skills were significantly higher in the flipped group, including examination skills (4.2 ± 0.5 vs. 3.9 ± 0.7, p = 0.03) and future housestaff potential (4.8 ± 0.3 vs 4.5 ± 0.6, p = 0.03). Students in the online-only group were more likely to engage in SDL (42 vs. 12%, p = 0.001) and reported more hours studying (6.1 vs. 3.8 hours, p = 0.03). Satisfaction (p = 0.51) and OSCE scores (p = 0.28) were not different by group. CONCLUSIONS: In this comparative study of two evidence-based curricular delivery approaches, we observed no difference in knowledge acquired. Greater clinical skills were observed with flipped instruction, while more SDL was observed with online-only instruction. Supplementing bedside teaching with blended instruction that balances live skill development with vetted online resources is optimal for clerkship education.

Facets of personality related to sleep habits in Black adults.

OBJECTIVE: The objective of this study is to explore the relationship between personality traits and sleep in community-dwelling older Blacks, and to examine whether conscientiousness moderates relationships between neuroticism and sleep (quality and duration) within this cohort. METHOD: Black adults (age range: 55-86 years) residing in the Tampa Bay Area, Florida, completed the Big Five Inventory to examine broad personality traits (e.g., neuroticism) and specific facets (e.g., anxiety or depression) and the Pittsburgh Sleep Quality Index to evaluate sleep habits and quality. RESULTS: Ninety-three participants (Mean age: 66.6, standard deviation: 7.4) were included in the final sample. High neuroticism, low extraversion, low conscientiousness, and low openness were each significantly associated with worse overall sleep habits. Individuals high on the facets for neuroticism (e.g., anxiety, depression) and/or low for extraversion (e.g., assertiveness), conscientiousness (e.g., self-discipline and order), and openness (e.g., aesthetics and ideas) were more likely to report poorer sleep. However, only neuroticism and extraversion each remained significantly associated with worse sleep in our regression models adjusting for demographic and health covariates. Adults with both higher neuroticism and lower conscientiousness indicated a greater likelihood for experiencing daytime dysfunction within this population. CONCLUSIONS: Recognizing specific personality traits associated with disrupted sleep, particularly in those who self-identify as Black, may enhance the ability of sleep clinicians to diagnose and deliver more personalized treatments and interventions (e.g., cognitive behavioral therapy). The present study's findings further support existing literature, suggesting that clinicians should incorporate personality assessments to identify individuals most susceptible to severe sleep disturbances.

Connecting clinical aspects to corticomotor excitability in restless legs syndrome: a TMS study.

We assessed corticomotor excitability in the primary motor cortex (M1) of participants with moderate-to-severe restless legs syndrome (RLS) symptoms using transcranial magnetic stimulation (TMS) in relation to the clinical and sleep aspects of the disease. Thirty-five participants (20 F; mean age: 59.23 ± 1.66 years; range: 42-78 years) affected by primary RLS (off medications) and 31 age-matched controls (19 F; mean age: 57.90 ± 1.50 years; range: 43-79 years) underwent TMS following two nights of polysomnography (PSG). Paired-pulse TMS measures [short-interval intracortical inhibition (SICI), long-interval intracortical inhibition (LICI), and intracortical facilitation (ICF)] of the dominant M1hand and M1leg muscles were collected and analyzed in relation to clinical features of RLS and PSG. We found decreased corticomotor excitability in M1hand, whereas it was increased in M1leg, which was greater in patients with more severe RLS. Participants with RLS with a history of dopamine-agonist-induced symptom augmentation showed decreased LICI (reduced inhibition) compared to nonaugmented participants with RLS for M1leg. None of the TMS measures (M1hand or M1leg) correlated with the PSG parameters. This study shows hyperexcitability in M1leg, and this appears related to RLS disease severity and decreased excitability in M1hand. The results provide new insight into the complex neurobiology of RLS, particularly in more advanced stages of the disease.

Education Research: Difficult conversations in neurology: Lessons learned from medical students.

OBJECTIVE: To characterize features of medical student exposure to difficult conversations during a neurology core clerkship. METHODS: This was a cross-sectional concurrent nested mixed methods study, and all students rotating through a required neurology clerkship between 2014 and 2015 were enrolled. Data collection included an electronic communication tracker, baseline and end-of-clerkship surveys, and 4 facilitated focus groups. Students were asked to log exposure to patient-clinician conversations about (1) new disability, (2) poor prognosis, (3) prognostic uncertainty (4), terminal diagnosis, and (5) end-of-life care. RESULTS: A total of 159 students were enrolled and 276 conversations were tracked. Most (70%) students observed at least 1 difficult conversation, and conversations about poor prognosis, new disability, and prognostic uncertainty were most commonly logged. At clerkship end, most students (87%) desired additional bedside training in communication skills. Exposure to one of the predefined conversation types did not improve student perceived preparedness to lead difficult conversations in the future. In focus groups, students noted that the educational value of observation of a difficult conversation could be optimized with preconversation planning and postconversation debriefing. CONCLUSIONS: Difficult conversations are common in neurology, and represent a valuable opportunity to provide communication skills training on the wards. Future curricula should consider ways to leverage these existing opportunities to enhance communication skills training.

Brain iron deficiency in idiopathic restless legs syndrome measured by quantitative magnetic susceptibility at 7 tesla.

OBJECTIVES: Altered brain iron homeostasis with regional iron deficiency has been previously reported in several studies of restless legs syndrome (RLS) patients. Inconsistencies still exist, however, in the reported iron changes in different brain regions and different RLS phenotypes. The purpose of this study was to assess differences in brain iron concentrations between RLS patients and healthy controls and their relation to severity of disease and periodic limb movement during sleep (PLMS). METHODS: Assessment of brain iron was done using quantitative magnetic susceptibility measurement, which has been shown to correlate well with the tissue iron content in brain's gray matter. Thirty-nine RLS patients and 29 age-matched healthy controls were scanned at 7 T. Magnetic susceptibilities in substantia nigra (SN), thalamus, striatum, and several iron-rich gray matter regions were quantified and compared with related clinical measures. RESULTS: Compared with healthy controls, RLS patients showed significantly decreased magnetic susceptibility in the thalamus and dentate nucleus. No significant difference was found in the SN between RLS patients and healthy controls, but a significant correlation was observed between magnetic susceptibility in SN and the PLMS measure. CONCLUSIONS: Using quantitative magnetic susceptibility as an in vivo indicator of brain iron content, the present study supports the general hypothesis of brain iron deficiency in RLS and indicates its possible link to PLMS.

Speaking the same language: Cross-sectional assessment of perceived contributors to professionalism across generations.

BACKGROUND: Professionalism is integral to medical training and practice. Recent studies suggest generational differences in perceptions of professionalism, which have not been adequately explored in academic neurology. METHODS: A cross-sectional study was performed to describe perceptions of professionalism among representative physicians across the academic training spectrum of neurology. A self-report questionnaire adapted from a published instrument was distributed to students, residents, fellows, and faculty in neurology at a single institution. Responders rated 4 domains of professionalism: Personal Characteristics, Interactions with Patients, Social Responsibility, and Interactions with the Health Care Team (5-point Likert scale, not at all important to very important), and selected the "top 2" characteristics critical to professional behavior in each domain. RESULTS: A total of 296 of 312 (95%) responded, including 228 students, 24 residents, 19 fellows, and 25 faculty. Respondents ranked the following components to be important/very important contributors to the expression of professional behavior: Personal Characteristics (98%, mean rating 4.6 ± 0.3), Interactions with Patients (97%, 4.6 ± 0.4), and Interactions with the Health Care Team (96%, 4.6 ± 0.5). Although mean ratings were high for Social Responsibility (4.3 ± 0.6), only 82% indicated that this was important/very important in the expression of professionalism, with a gradual decline from students (4.4 ± 0.6) to residents (3.99 ± 0.8, p = 0.02). The "top 2" contributors to each domain were similar across responders. CONCLUSIONS: Professionalism was perceived as critically important across the academic training spectrum in neurology, and the view regarding the top contributors to the expression of professionalism remained consistent among the respondents.

Neurology clerkship goals and their effect on learning and satisfaction.

OBJECTIVE: To define medical student goals in the neurology clerkship and explore the association between goal setting and student performance, clerkship satisfaction, self-directed learning (SDL), and interest in neurology. METHODS: A 4-year prospective study of consecutive second- to fourth-year medical students rotating through a required 4-week neurology clerkship was conducted. A goal-generating cohort (first 2 years) was enrolled to describe the breadth of student-derived goals. A goal-evaluating cohort (second 2 years) was used to evaluate the frequency of goal achievement and assess associations with performance (e.g., National Board of Medical Examiners [NBME], examination), satisfaction, and SDL behaviors (both based on 5-point Likert scale). RESULTS: Of 440 evaluable students, 201 were goal-generating and 239 goal-evaluating. The top 3 goals were (1) improvement in neurologic examination, (2) understanding neurologic disease, and (3) deriving a differential diagnosis. More than 90% (n = 216/239) of students reported achieving goals. Achievers reported significantly higher clerkship satisfaction (4.2 ± 0.8 vs. 2.8 ± 1.0, p < 0.0001), greater interest in neurology (71% vs. 35%, p = 0.001), and higher observed tendency toward SDL (4.5 ± 0.5 vs. 4.1 ± 0.8, p < 0.0001). After adjusting for age and training, NBME scores were 1.7 points higher in achievers (95% confidence interval 0.1-3.2, p = 0.04). CONCLUSION: Students consistently generated similar goals for a required neurology clerkship. Goal achievers had better adjusted standardized test scores, higher satisfaction, and greater tendency toward SDL. This student-generated, goal-setting program may be particularly appealing to clinicians, educators, and researchers seeking resource-lean mechanisms to improve student experience and performance in the clinical clerkships.