Personal history of proliferative breast disease with atypia and risk of multifocal breast cancer.

BACKGROUND: A history of proliferative breast disease with atypia (PBDA) may be indicative of an increased risk not just of breast cancer but also of a more aggressive form of breast cancer. METHODS: Multifocal breast cancer (MFBC), defined as 2 or more tumors in the same breast upon a diagnosis of cancer, is associated with a poorer prognosis than unifocal (single-tumor) breast cancer. PBDA, including atypical ductal hyperplasia and atypical lobular hyperplasia, is a known risk factor for breast cancer. Using New Hampshire Mammography Network data collected for 3567 women diagnosed with incident breast cancer from 2004 to 2014, this study assessed the risk of MFBC associated with a previous diagnosis of PBDA. RESULTS: Women with a history of PBDA were found to be twice as likely to be subsequently diagnosed with MFBC as women with no history of benign breast disease (BBD; odds ratio [OR], 2.23; 95% confidence interval [CI], 1.08-4.61). Ductal carcinoma in situ on initial biopsy was associated with a 2-fold increased risk of MFBC in comparison with invasive cancer (OR, 2.13; 95% CI, 1.58-2.88). BBD and proliferative BBD without atypia were not associated with MFBC. CONCLUSIONS: Women with a history of previous PBDA may be at increased risk for MFBC. Women with a history of PBDA may benefit from additional presurgical clinical workup. Cancer 2018;124:1350-7. © 2017 American Cancer Society.

Identifying Duplicate Cancer Cases Across State Boundaries: Pseudonymization as a Method to Encrypt Identifiers.

Identifying potential duplicate cancer cases across state boundaries has been a topic of interest for many years. Duplicate cases could distort our understanding of the burden of cancer in a state, region, or even nationally, and waste cancer surveillance resources. This paper reports a pilot quality improvement project to use a publicly available tool to encrypt a standard set of patient identifiers and then link cases across state boundaries as a way to identify and reconcile possible duplicate cases among a group of neighboring states. The paper describes the protocol, challenges, and preliminary results, and suggests future efforts.

Concordance of Rural-Urban Self-identity and ZIP Code-Derived Rural-Urban Commuting Area (RUCA) Designation.

PURPOSE: This study examined the concordance between individuals' self-reported rural-urban category of their community and ZIP Code-derived Rural-Urban Commuting Area (RUCA) category. METHODS: An Internet-based survey, administered from August 2017 through November 2017, was used to collect participants' sociodemographic characteristics, self-reported ZIP Code of residence, and perception of which RUCA category best describes the community in which they live. We calculated weighted kappa (ĸ) coefficients (95% confidence interval [CI]) to test for concordance between participants' ZIP Code-derived RUCA category and their selection of RUCA descriptor. Descriptive frequency distributions of participants' demographics are presented. FINDINGS: A total of 622 survey participants, residents of New Hampshire (63%) and Vermont (37%), responded to the survey's self-reported rural-urban category. The overall ĸ was 0.33 (95% CI: 0.27-0.38). The highest concordance was found among those living in a small rural area (N = 81, 13%): 62% of this group identified their communities as small rural. Sixty-five percent (300/459) of participants residing in urban or large rural areas reported their community as more rural (small rural or isolated). Sixty-eight percent (111/163) of participants living in small rural or isolated areas identified their community as more urban (large rural or urban). CONCLUSIONS: Discordance was found between self-report of rural-urban category and ZIP Code-derived RUCA designation. Caution is warranted when attributing rural-urban designation to individuals based on geographic unit, since perceived rurality/urbanicity of their community that relates to health behaviors may not be reflected.

A web-based system for students to document their experiences within six core competency domains during all clinical clerkships.

The authors describe the design and implementation of a new Web-based system that allows students to record important features of their clinical encounters during all 10 required clinical clerkships, document their learning experiences in six major competency domains, and generate detailed real-time reports for themselves and their clerkship directors. A new Web-based system, DMEDS (Dartmouth Medical Encounter Documentation System), accepts input from computers and PDAs. Its design permits students to describe their patients, learning sites, interactions with preceptors, and important aspects of their clinical encounters in all of our medical school's competency domains. Using a common format for all required clerkships, clerkship directors select specific items most relevant to their clerkships from a common menu and set learning targets for specific diagnoses and clinical skills. This new system was designed in the fall of 2003, tested in the spring of 2004, and implemented in all clerkships for the 2004 to 2005 academic year. During the first full academic year that DMEDS was used, students documented nearly 32,000 discrete student-patient-preceptor encounters, an average of between 21 and 120 clinical encounters per Year 3 clerkship. Highlights of the analysis of these initial data include the following: (1) insights into how educational targets are set, (2) the extent of site-to-site variation in clerkship experiences, (3) the epidemiology of patients' declining student involvement, and (4) student experiences in and understanding of the newer competency domains.DMEDS can be used in all clinical clerkships and can address student experiences in all competency domains. It provides substantial value to students, clerkship directors, preceptors, and medical school administrators. As secondary benefits, the authors found that DMEDS facilitates educational research and is readily adapted for use in residency and fellowship programs as well. Student feedback highlights the need to pay close attention to the time invested by students documenting their clinical encounters. Course directors must ensure that the benefits to students (such as knowledge of meeting learning targets and preceptors providing direct feedback to students) are transparent. Finally, for other schools contemplating the change to a competency-based curriculum with the use of a clinical encounter documentation system, the time required for both students and faculty to adopt and fully engage these major educational culture shifts seems to be at least several years.

Ambulatory care education: how do academic medical centers, affiliated residency teaching sites, and community-based practices compare?

PURPOSE: Little is known about how different ambulatory sites compare as clinical educational settings. The authors used students' log data to compare the educational content and processes in academic medical center-based clinics (AMCs), affiliated residency teaching sites (ARTs), and local community-based practices (CBPs) at one medical school. METHOD: Students recorded their experiences with symptoms, counseling, procedures, and common medical conditions as well as characteristics of the learning process during a required eight-week third-year ambulatory clerkship in family medicine. Descriptive statistics, chi-square for differences in categorical variables, and analysis of variance and multivariate analysis of variance for differences in continuous variables were used to compare the educational settings. RESULTS: Over 9,000 encounters were analyzed; 29.7% occurred in AMCs, 14.8% in ARTs, and 55.5% in CBPs. The proportion of continuity visits was lowest in the AMCs and highest in CBPs (13% versus 22%, respectively; p <.01). Students saw almost 57,000 symptoms and conditions. Of 19 symptoms compared, seven differed significantly among the three settings: back pain, cough, dyspnea, ENT (ears, nose, throat problems), fatigue, knee pain, and vomiting. All but one of these were least likely to occur in ARTs. Procedures were performed more frequently, whereas counseling skills were called upon less frequently in CBPs. Students reported being more likely to work unobserved while conducting physical examinations in ARTs and CBPs. Amount of feedback provided on clinical skills did not differ, but students reported receiving more teaching about patient management in ARTs and AMCs versus CBPs (74%, 72%, and 66% of encounters, respectively; p <.01). CONCLUSIONS: Academic and community settings can complement each other as learning sites for an ambulatory clerkship in family medicine, and common curricular expectations can be achieved. Settings' differences and similarities should be taken into account when developing, implementing, or revising clerkship programs and should be considered with students' interests and previous clinical experiences before assigning students to a teaching site.

Development of a handheld computer documentation system to enhance an integrated primary care clerkship.

Documentation systems are used by medical schools and residency programs to record the clinical experiences of their learners. The authors developed a system for their school's (Dartmouth's) multidisciplinary primary care clerkship (family medicine, internal medicine, pediatrics) that documents students' clinical and educational experiences and provides feedback designed to enhance clinical training utilizing a timely data-reporting system. The five critical components of the system are (1) a valid, reliable and feasible data-collection instrument; (2) orientation of and ongoing support for student and faculty users; (3) generation and distribution of timely feedback reports to students, preceptors, and clerkship directors; (4) adequate financial and technical support; and (5) a database design that allows for overall evaluation of educational outcomes. The system, whose development began in 1997, generated and distributed approximately 150 peer-comparison reports of clinical teaching experiences to students, preceptors, and course directors during 2001, in formats that are easy to interpret and use to individualize learning. The authors present report formats and annual cost estimate comparisons of paper- and computer-based system development and maintenance, which range from $35,935 to $53,780 for the paper-based system and from $46,820 to $109,308 for the computer-based system. They mention ongoing challenges in components of the system. They conclude that a comprehensive documentation and feedback system provides an essential infrastructure for the evaluation and enhancement of community-based teaching and learning in primary care ambulatory clerkships, whether separate or integrated.

An analysis of students' clinical experiences in an integrated primary care clerkship.

PURPOSE: Combining complementary clinical content into an integrated clerkship curriculum should enhance students' abilities to develop skills relevant to multiple disciplines, but how educational opportunities in primary care ambulatory settings complement each other is unknown. The authors conducted an observational analytic study to explore where opportunities exist to apply clinical skills during a 16-week integrated primary care clerkship (eight weeks of family medicine, four weeks of ambulatory pediatrics, and four weeks of ambulatory internal medicine). METHOD: Using handheld computers, students recorded common problems, symptoms, and diagnoses they saw. The students also recorded information about the educational process of the clerkship. Two data files were created from the database. Descriptive statistics were used to characterize the students' clerkship experiences, and ANOVA was used to evaluate differences among these blocks within the clerkship. RESULTS: Students encountered different frequencies of presenting symptoms, the majority of which occurred in pediatrics (23.2 per student per week versus 16.3 in medicine and 16.8 in family medicine; p =.01). Students provided more behavioral change counseling in family medicine (5.2 episodes per student per week versus 4.2 and 2.0 in internal medicine and pediatrics, respectively; p =.01), and they performed more clinical procedures in family medicine (1.9 per student per week versus 0.6 and 1.1 in pediatrics and internal medicine, respectively; p =.001). Students were more likely to encounter specific conditions in internal medicine (35.3 per student per week versus 30.0 and 21.4 in family medicine and pediatrics, respectively; p =.01). Elements of the teaching and learning processes also differed by clerkship. CONCLUSIONS: Very little overlap was found in symptoms, conditions, procedures, and other educational opportunities in the ambulatory pediatrics, internal medicine, and family medicine blocks that constitute the integrated primary care clerkship. The blocks provided different and complementary learning opportunities for students. These findings will assist in clerkship planning and in guiding students to seek opportunities that will ensure educational excellence.

Shared decision making: skill acquisition for year III medical students.

BACKGROUND: A foundation of care within a Patient-centered Medical Home (PCMH) is respect for patients' values and preferences. Shared decision making (SDM) involves a set of principles and approaches to working with patients that integrates medical information and data with the preferences, values, and support systems of individual patients facing medical decisions. The value of SDM is increasingly evidenced by the incorporation of principles of SDM into the definitions of patient-centered care and PCMHs, accountable care organizations, and the language of the Health Reform Act of 2010. METHODS: We developed and integrated a curriculum on SDM in the third-year Family Medicine Clerkship at Dartmouth Medical School. The curriculum consisted of a mix of experiential, classroom, and online experiences designed to provide students with opportunities to learn content, practice skills, and share observations from their preceptorships. RESULTS: Student feedback was an important component of evaluating the SDM curriculum. Themes identified from students' reflections on their own behavior in a Simulated Patient Encounter included an increase in confidence and competence in their ability to use SDM, while noting the disconnect that may exist between what is taught in the clerkship and what they experience in their preceptorships. CONCLUSIONS: As this curriculum has developed, we have acquired a deep appreciation of the benefits and challenges of attempting to teach sophisticated communication and decision-making precepts to medical students who are working to master fundamentals of clinical work and who may or may not see such precepts reinforced in practice.

Integrating practice-based learning and improvement into medical student learning: evaluating complex curricular innovations.

BACKGROUND: Because practice-based learning and improvement (PBLI) is a core competency for residents, the fundamentals of PBLI should be developed in medical school. PURPOSE: Evaluate the effects of a PBLI module for 1st-year students at Dartmouth Medical School in 2004-05. METHODS: Design. Randomized two-group trial (early and late intervention). Intervention. One half of students received the standard curriculum--reviewing student-patient-preceptor reports with their small-group facilitator and student colleagues. The other half received the PBLI-DMEDS module--reviewing student-patient-preceptor reports and applying PBLI methods to history and physical exam skills. ANALYSIS: The module was assessed on (a) core learning of PBLI (pre- and postmodule); (b) student self-assessed proficiency in PBLI (pre- and postmodule); (c) student, faculty, and course leaders' satisfaction; and (d) time costs. RESULTS: Pretest PBLI knowledge scores were similar in both groups; intervention students scored significantly higher after the PBLI-DMEDS module. satisfaction of students, faculty, and course leaders was mixed. the time cost required to implement the module was excessive. CONCLUSIONS: The intervention effectively taught the basics of PBLI but did not integrate well into the core curriculum. Our multifaceted evaluation approach allowed us to amplify aspects of the intervention that worked well and discard those that did not.

Preclinical preceptorships in medical school: can curricular objectives be met in diverse teaching settings?

BACKGROUND: Although preclinical preceptorships for medical students during the first 2 years are now common, little is known about how well the curricular objectives can be met in clinical training sites. PURPOSE: To evaluate whether a clinical encounter system can help align preclinical preceptorship experiences with the core curriculum. METHODS: Using a PDA documentation system, 27 students collected student-preceptor-patient encounter information on all patients (N = 2,953) during a 2-year clinical training course. We compared Years 1 and 2 teaching and learning processes, common symptoms seen, and counseling skills performed and examined how well these clinical experiences aligned with the curricular goals. RESULTS: The majority of encounters in Year 1 involved the student observing the preceptor perform a history (47%) or physical exam (40%). In Year 2, there was a shift to student and preceptor both participating in the history (Year 1, 12%; Year 2, 24%; p = .004) and physical exam (Year 1, 34%; Year 2, 47%; p = .002). Cardiovascular; pulmonary; and head, eyes, ears, nose, and throat examinations were most common in Year 1 and increased in Year 2. Genitourinary, gynecologic, and neurological examinations occurred least often, and only the neurological examinations increased significantly in Year 2. Overall, at least 75% of students could find opportunities in Years 1 and 2 to achieve the majority of curricular goals. CONCLUSIONS: Knowing what students experience at their preceptor sites is vital for clinical skills course evaluation. Student-preceptor-patient encounter data should be used to complement other course evaluations to aid curriculum planning and decrease variability in student experiences.

Factors associated with interval adherence to mammography screening in a population-based sample of New Hampshire women.

BACKGROUND: Interval adherence to mammography screening continues to be lower than experts advise. The authors evaluated, using a population-based mammography registry, factors associated with adherence to recommended mammography screening intervals. METHODS: The authors identified and recruited 625 women aged 50 years and older who did and did not adhere to interval mammography screening. Demographic and risk characteristics were ascertained from the registry and were supplemented with responses on a mailed survey to assess knowledge, perceived risk, anxiety regarding breast carcinoma and its detection, and women's experiences with mammography. RESULTS: The authors found no differences in risk factors or psychologic profiles between adhering and nonadhering women. Women who did not adhere had a statistically higher body mass index than women who did adhere (27.6 versus 26.1, P = 0.003). Exploration of mammographic experiences by group found that care taken by technologists in performing or talking women through the exam was higher in adhering women than nonadhering women (75.6% vs 65.71% for performing the exam, and 71.6% vs 60.8% for talking patients through the exam, respectively, P < 0.05). CONCLUSIONS: The authors found that previous negative mammographic experiences, particularly those involving mammography technologists, appear to influence interval adherence to screening and that patient body size may be an important factor in this negative experience.