Relationships Matter: Enhancing Trainee Development with a (Simple) Clerkship Curriculum Reform.

PROBLEM: The traditional clerkship model of brief encounters between faculty and students results in reduced meaningful learning opportunities due to the lack of a relationship that enables repeated observation, supervisor feedback, trust formation, and growth. INTERVENTION: Clinical clerkships at our institution were restructured to decrease fragmentation of supervision and foster an educational alliance between faculty and student. A mixed-methods approach was used to study the impact of this curriculum reform on the student experience in the obstetrics and gynecology clerkship. Student participation in patient care was assessed by comparing the number of common obstetric procedures performed before and after clerkship reform. Separate qualitative analyses of comments from student surveys and a faculty focus group revealed themes impacting student involvement. The supervisor-trainee relationship was further investigated by analysis of "rich picture" discussions with students and faculty. CONTEXT: Clerkships in the 3rd year of our 4-year undergraduate medical curriculum were converted from an experience fragmented by both didactic activities and multiple faculty supervisors to one with a single supervisor and the elimination of competing activities. OUTCOMES: Students in the revised clerkship performed twice the number of obstetric procedures. Objective measures (United States Medical Licensing Examination Step 1 scores, receiving clerkship honors, self-reported interest in obstetrics, and gender) did not correlate with the number of procedures performed by students. Qualitative analysis of student survey comments revealed that procedure numbers were influenced by being proactive, having a supervisor with a propensity to teach (trust), and contextual factors (busy service or competition with other learners). Themes identified by faculty that influenced student participation included relationship continuity; growth of patient care skills; and observed student engagement, interest, and confidence. The quality of the relationship was cited by both students and faculty as a factor influencing meaningful clinical participation. Discussions of "rich pictures" drawn by students and faculty revealed that relationships are influenced by continuity, early alignment of goals, and the engagement and attitude of both student and faculty. LESSONS LEARNED: Clinical curricular reforms that strengthen the continuity of the supervisor-trainee relationship promote mutual trust and can result in a more meaningful training experience in less time. Reciprocal engagement and early alignment of goals between supervisor and trainee are critical for creating a positive relationship.

D-methionine (D-met) significantly reduces kanamycin-induced ototoxicity in pigmented guinea pigs.

OBJECTIVE: Test D-methionine (D-met) as an otoprotectant from kanamycin-induced ototoxicity and determine the lowest maximally protective D-met dose. DESIGN: Auditory brainstem responses (ABR) were measured at 4, 8, 14, and 20 kHz at baseline and two, four, and six weeks after kanamycin and D-met administration initiation. ABR threshold shifts assessed auditory function. Following six-week ABR testing, animals were decapitated and cochleae collected for outer hair cell (OHC) quantification. STUDY SAMPLE: Eight groups of 10 male pigmented guinea pigs were administered a subcutaneous kanamycin (250 mg/kg/dose) injection once per day and an intraperitoneal D-met injection (0 (saline), 120, 180, 240, 300, 360, 420, or 480 mg/kg/day) twice per day for 23 days. RESULTS: Significant ABR threshold shift reductions and increased OHC counts (p ≤ 0.01) were measured at multiple D-met-dosed groups starting at two-week ABR assessments. A 300 mg/kg/day optimal otoprotective D-met dose provided 34-41 dB ABR threshold shift reductions and OHC protection. Lesser, but significant, D-met otoprotection was measured at lower and higher D-met doses. CONCLUSIONS: D-met significantly reduced ABR threshold shifts and increased OHC percentages compared to kanamycin-treated controls. Results may be clinically significant particularly for multidrug-resistant tuberculosis patients who frequently suffer from kanamycin-induced hearing loss in developing countries.

D-methionine pre-loading reduces both noise-induced permanent threshold shift and outer hair cell loss in the chinchilla.

OBJECTIVE: This study tested multiple dosing epochs of pre-loaded D-methionine (D-met) for otoprotection from noise-induced hearing loss (NIHL). DESIGN: Auditory brainstem response (ABR) thresholds were measured at baseline, 1 day, and 21 days following a 6-hour 105 dB sound pressure level (SPL) octave band noise (OBN) exposure. Outer hair cell (OHC) counts were measured after day 21 sacrifice. STUDY SAMPLE: Three groups of five Chinchillas laniger each were given a 2-day regimen comprising five doses of D-met (200 mg/kg/dose) intraperitoneally (IP) starting 2, 2.5, or 3 days prior to noise exposure. A control group (n = 5) received five doses of equivalent volume saline IP starting 2.5 days prior to noise exposure. RESULTS: ABR threshold shifts from baseline to day-21 post-noise exposure were reduced in all D-met groups versus controls, reaching significance (p < 0.05) in the 3-day group. D-met groups showed reduced OHC loss relative to controls at day-21 post-noise exposure, reaching significance (p < 0.05) at all frequency regions in the 3-day group and at the 2, 4, and 8 kHz frequency regions in the 2.5-day group. CONCLUSIONS: D-met administration in advance of noise-exposure, without further administration, significantly protects from noise-induced ABR threshold shift and OHC loss.

From test validity to construct validity and back?

CONTEXT: Major changes in thinking about validity have occurred during the past century, shifting the focus in thinking from the validity of the test to the validity of test score interpretations. These changes have resulted from the 'new' thinking about validity in which construct validity has emerged as the central or unifying idea of validity today. Construct validity was introduced by Cronbach and Meehl in the mid-1950s in an attempt to address the validity of those many psychological concepts that have no clear referent in reality. To do this, construct validity theory required a nomological network--an elaborate theoretical network of constructs and observations connected by scientific laws--to validate the constructs. However, nomological networks are hard to come by and none that would do the job required by construct validity has been forthcoming to date. Thus, the current construct validity approach has retreated to one of simply 'interpretation and argument', but this seems to be too general to tie down the constructs in the way a nomological network would do to give credibility to the validity of the construct. As a result, the concept of validity seems to have been watered down and the credibility of validity claims weakened. OBJECTIVES: The purpose of this paper is to encourage a discussion of the use of construct validity in medical education, and to suggest that test developers and users reconsider the use of abstract theoretical constructs that have no referent apart from theory. METHODS: We present a critical review of these concerns about construct validity and provide for contrast a brief overview of a recently proposed view of measurement based on scientific realism and causality analysis.

Chemokine/cytokine profiling after rituximab: reciprocal expression of BCA-1/CXCL13 and BAFF in childhood OMS.

The aim of the study was to test the hypothesis that B-cell repopulation following rituximab (anti-CD20) therapy is orchestrated by chemokines and non-chemokine cytokines. Twenty-five children with opsoclonus-myoclonus syndrome (OMS) received rituximab with or without conventional agents. A comprehensive panel of 40 chemokines and other cytokines were measured in serum by ELISA and multiplexed fluorescent bead-based immunoassay. Serum BAFF concentration changed dramatically (even after first infusion) and inversely with B-cell depletion/repopulation and CXCL13 concentration at 1, 3, and 6 months. Negative correlations were found for BAFF concentration vs blood B cell percentage and serum CXCL13 concentration; positive correlations with serum rituximab concentrations. Six months after initiation of therapy, no significant difference in the levels of APRIL, CXCL10, IL-6, or 17 other cytokines/chemokines were detected. These data reveal a major role for BAFF in peripheral B cell repopulation following rituximab-induced B-cell depletion, and novel changes in CXCL13. ClinicalTrials.gov NCT0024436.

B cell depletion therapy for new-onset opsoclonus-myoclonus.

Twelve immunotherapy-naïve children with opsoclonus-myoclonus syndrome and CSF B cell expansion received rituximab, adrenocorticotropic hormone (ACTH), and IVIg. Motor severity lessened 73% by 6 mo and 81% at 1 yr (P < 0.0001). Opsoclonus and action myoclonus disappeared rapidly, whereas gait ataxia and some other motor components improved more slowly. ACTH dose was tapered by 87%. Reduction in total CSF B cells was profound at 6 mo (-93%). By study end, peripheral B cells returned to 53% of baseline and serum IgM levels to 63%. Overall clinical response trailed peripheral B cell and IgM depletion, but improvement continued after their levels recovered. All but one non-ambulatory subject became ambulatory without additional chemotherapy; two relapsed and remitted; four had rituximab-related or possibly related adverse events; and two had low-titer human anti-chimeric antibody. Combination of rituximab with conventional agents as initial therapy was effective and safe. A controlled trial with long-term safety monitoring is indicated.

Pediatric dosing of rituximab revisited: serum concentrations in opsoclonus-myoclonus syndrome.

To longitudinally assess serum concentrations of rituximab, it was administered intravenously to 25 children with opsoclonus-myoclonus syndrome at 375 mg/m2 on each of 4 consecutive weeks with (Group I and II) or without (Group III) conventional immunotherapy. Serum rituximab levels, drawn before and after each infusion and at later intervals, were analyzed by enzyme-linked immunosorbent assay. Rituximab concentration increased stepwise with each infusion, dropping by the next infusion, thereby forming 4 discrete peaks (Cmax) and troughs (Cmin). It then fell precipitously to trace levels at 4 months. However, Cmax and Cmin curves differed significantly between groups. Compared with the youngest children (Group I), the oldest (Group III) had a 34% lower rituximab concentration at the fourth infusion, 45% less IgM depletion 1 month later, and received 20% less rituximab when the dose was recalculated as mg/kg. Serum IgM and rituximab levels were negatively correlated. Peak rituximab concentration did not correlate with adrenocorticotropic hormone dose. These results indicate that the degree of serum IgM depletion is a useful indicator for rituximab dose equivalency in children of different ages. They also suggest that pediatric rituximab dosing should be based on body weight, not surface area. (ClinicalTrials.gov NCT00244361).

Peer assessment of professionalism: a five-year experience in medical clerkship.

INTRODUCTION: Faculty assessment of students' professionalism is often based upon sporadic exposure to students. Peers are in a unique position to provide valid judgments of these behaviors. AIMS: (1) To learn if peer assessments of professional conduct correlate with traditional performance measures; (2) to determine if peer assessments of professionalism influence the designation of honors, and (3) to explore student and faculty opinions regarding peer assessment. SETTING: Internal Medicine Clerkship at Southern Illinois University. PROGRAM DESCRIPTION: Since 2001 anonymous student peer assessments of professionalism have been used in assigning clerkship grades. PROGRAM EVALUATION: Peer assessments of professionalism had weak, though significant, correlations with faculty ratings (r = 0.29), performance on the NBME subject test (r = 0.28), and performance on a cumulative performance assessment (r = 0.30), and did not change the total number of honors awarded. A majority of students (71%) felt comfortable evaluating their peers, and 77% would keep the peer evaluation procedure in place. A majority of faculty (83%) indicated that peer assessments added valuable information. DISCUSSION: Peer assessments of professional conduct have little correlation with other performance measures, are more likely to have a positive influence on final clerkship grades, and have little impact on awarding honors.

Characteristics of smokers calling a national reactive telephone helpline.

PURPOSE: Although reactive telephone helplines for quitting smoking are increasingly popular in the United States, the characteristics of callers using this resource have not been adequately studied. The objective of this study was to describe the characteristics of the current smokers calling a national reactive telephone helpline (i.e., study population). DESIGN AND SETTING: In this cross-sectional study, information was obtained from eligible participants telephonically. SUBJECTS: The study included 890 adult current smokers who were new callers to a national reactive helpline. MEASURES: The information collected included selected demographic and smoking-related characteristics. ANALYSIS: The proportions of the above characteristics were analyzed. RESULTS: There was a significant overepresentation of blacks, non-Hispanics, women, and urban residents, as well as poorer, older, less educated, and heavier smokers in the study population (p < .01 for all comparisons). CONCLUSIONS: Reactive telephone helplines may be preferentially used by population segments who are disadvantaged or smoke heavily and thus are in greatest need for assistance. These helplines may therefore fill a much-needed niche in the marketplace of smoking cessation strategies.

Meta-analysis of quasi-experimental research: are systematic narrative reviews indicated?

CONTEXT: Meta-analyses are commonly performed on quasi-experimental studies in medical education and other applied field settings, with little or no apparent concern for biases and confounds present in the studies synthesised. The implicit assumption is that the biases and confounds are randomly distributed across the studies and are averaged or cancelled out by the synthesis. OBJECTIVES: We set out to consider the possibility that the results and conclusions of meta-analyses in medical education are subject to biases and confounds and to illustrate this possibility with a re-examination of the studies synthesised in an important, recently published meta-analysis of problem-based learning. METHODS: We carefully re-examined the studies in the meta-analysis. Our aims were to identify obvious biases and confounds that provided plausible alternative explanations of each study's results and to determine whether these threats to validity were considered and convincingly ruled out as plausible rival hypotheses. RESULTS: Ten of the 11 studies in the meta-analysis used quasi-experimental designs; all 10 were subject to constant biases and confounds that favoured the intervention condition. Threats to validity were not ruled out in the individual studies, nor in the meta-analysis itself. CONCLUSIONS: Our re-examination of the results and conclusions of the meta-analysis illustrates our concerns about the validity of meta-analyses based primarily on quasi-experimental studies. Our tentative conclusion is that the field of medical education might be better served in most instances by systematic narrative reviews that describe and critically evaluate individual studies and their results in light of threats to their validity.

Correlates of physical activity self-efficacy among breast cancer survivors.

OBJECTIVE: To determine physical activity (PA) self-efficacy correlates in breast cancer survivors. METHODS: Mail survey of 192 breast cancer survivors. RESULTS: Structural equation analyses demonstrated significant and direct associations for perceived PA barriers (beta=-.29), fatigue (beta=-.24), social support (beta=.12), enjoyment (beta=.12), and prediagnosis PA (beta=.11) with barriers self-efficacy. Prediagnosis PA (beta=.51), social support (beta=.26), and barriers self-efficacy (beta=.13) demonstrated direct associations with current leisure PA. Task self-efficacy analysis results were similar except perceived barriers and prediagnosis PA were not associated with task self-efficacy. CONCLUSIONS: Multiple potential efficacy correlates exist and may vary based on the aspect of self-efficacy examined.

Prevalence and Distribution of Potential Vascularized Composite Allotransplant Donors, Implications for Optimizing the Donor-recipient Match.

BACKGROUND: Vascularized composite allotransplantation (VCA) is an emerging and growing field. Little is known about the prevalence and distribution of the adult potential donor population in the United States now that it falls under the oversight of the United Network for Organ Sharing (UNOS). METHODS: We assessed the UNOS database from 2008 to 2015 to estimate the prevalence and distribution of adult potential vascularized composite allograft donors. Donor inclusion and exclusion criteria were developed in a way to minimize risk to recipients and were applied to the dataset. Donors were categorized by factors that influence vascularized composite allograft matching including ABO blood type, cytomegalovirus status, and ethnicity (correlate for skin color) and sorted by UNOS region. RESULTS: Just under half of all brain dead donors met the inclusion/exclusion criteria. Blood type O, cytomegalovirus+, White donors represented the most frequent donor profile while blood type AB, cytomegalovirus-, Asian donors were the least common. UNOS region 3 had the most and region 1 had the least potential VCA donors per year. Nearly all potential VCA donors were solid organ donors with the liver being the most commonly donated solid organ in this population. CONCLUSIONS: A large portion of the solid organ donor pool would qualify as adult vascularized composite allograft donors in the current UNOS system. These data will assist transplant teams in determining the prevalence and distribution of vascularized composite allograft donors for their individual patients awaiting composite allografts based on relevant matching characteristics in addition to standard transplant criteria.

Prevention of noise- and drug-induced hearing loss with D-methionine.

A number of otoprotective agents are currently being investigated. Various types of agents have been found in animal studies to protect against hearing loss induced by cisplatin, carboplatin, aminoglycosides, or noise exposure. For over a decade we have been investigating D-methionine (D-met) as an otoprotective agent. Studies in our laboratory and others around the world have documented D-met's otoprotective action, in a variety of species, against a variety of ototoxic insults including cisplatin-, carboplatin-, aminoglycoside- and noise-induced auditory threshold elevations and cochlear hair cell loss. For cisplatin-induced ototoxicity, protection of the stria vascularis has also been documented. Further D-met has an excellent safety profile. D-met may act as both a direct and indirect antioxidant. In this report, we provide the results of three experiments, expanding findings in D-met protection in three of our translational research areas: protection from platinum based chemotherapy-, aminoglycoside- and noise-induced hearing loss. These experiments demonstrate oral D-met protection against cisplatin-induced ototoxicity, D-met protection against amikacin-induced ototoxicity, and D-met rescue from permanent noise-induced hearing loss when D-met is initiated 1h after noise exposure. These studies demonstrate some of the animal experiments needed as steps to translate a protective agent from bench to bedside.

Using indirect questions to detect intimate partner violence: the SAFE-T questionnaire.

A screening instrument for detecting intimate partner violence (IPV) was developed using indirect questions. The authors identified 5 of 18 items studied that clearly distinguished victims of IPV from a random group of health conference attendees with a sensitivity of 85% and a specificity of 87%. This 5-item instrument (SAFE-T) was then tested on 435 women presenting to three emergency departments and the results compared to a direct question regarding current abuse. The SAFE-T questions detected only 54% of the women who admitted being abused and correctly classified 81% of the women who said they were not victims. The 1-year prevalence of IPV in this sample of women presenting to an emergency department was 11.6%. The authors conclude that indirect questioning of women appears to be more effective at ruling out IPV in an emergency department population and may be less useful for women "early" in an abusive relationship.

d-Methionine reduces tobramycin-induced ototoxicity without antimicrobial interference in animal models.

BACKGROUND: Tobramycin is a critical cystic fibrosis treatment however it causes ototoxicity. This study tested d-methionine protection from tobramycin-induced ototoxicity and potential antimicrobial interference. METHODS: Auditory brainstem responses (ABRs) and outer hair cell (OHC) quantifications measured protection in guinea pigs treated with tobramycin and a range of d-methionine doses. In vitro antimicrobial interference studies tested inhibition and post antibiotic effect assays. In vivo antimicrobial interference studies tested normal and neutropenic Escherichia coli murine survival and intraperitoneal lavage bacterial counts. RESULTS: d-Methionine conferred significant ABR threshold shift reductions. OHC protection was less robust but significant at 20kHz in the 420mg/kg/day group. In vitro studies did not detect d-methionine-induced antimicrobial interference. In vivo studies did not detect d-methionine-induced interference in normal or neutropenic mice. CONCLUSIONS: d-Methionine protects from tobramycin-induced ototoxicity without antimicrobial interference. The study results suggest d-met as a potential otoprotectant from clinical tobramycin use in cystic fibrosis patients.

The prediction of breast reduction weight.

Reimbursement for reduction mammaplasty has become more stringent because many insurers require specific documentation of patient symptoms and estimated weight of planned breast resection. The purpose of this study was to develop a simple, clinically useful method for predicting weight of breast tissue to be removed, using routine, easily obtained predictors (i.e., height, weight, age, measurements from sternal notch to nipple, and measurements from sternal notch to inframammary crease). Data were available from a retrospective review of 263 women undergoing reduction mammaplasty. Analyses were performed to predict resected weights obtained both in the operating room and by a pathologist for left and right breasts separately. Regression analyses showed that the sternal notch-to-nipple measurement accounted for nearly all of the explained variance in the resected weights, with correlations around 0.80 between sternal notch to nipple and resected weight. For sternal notch-to-nipple measurements > or 28.5 cm, predicted resected weights were approximately 600 g or more, and in general, 80 percent or more patients had specimen weights >500 grams. From 25.5 to 28 cm, the predicted weights ranged from about 400 to 600 g and the prediction rate of weights >500 g was 50 percent. The senior author predicted the resected breast weight to be >500 g 94 percent of the time. The equation alone did not produce an accurate prediction in the critical range, 400 to 600 g. The experienced surgeon more accurately predicted resected weights with use of practiced spatial relationship skills.

CSF neurofilament light chain is elevated in OMS (decreasing with immunotherapy) and other pediatric neuroinflammatory disorders.

Using a panel of seven brain cell-specific biomarkers in cerebrospinal fluid (CSF), pediatric opsoclonus-myoclonus syndrome (OMS) (n=234) was compared to pediatric non-inflammatory neurological controls (n=84) and other inflammatory neurological disorders (OIND) (n=44). Only CSF NFL was elevated in untreated OMS versus controls (+83%). It was 87% higher in OIND than in OMS. On combination treatment with front-loaded ACTH, IVIg, rituximab, median CSF NFL decreased by 60% to control levels. These biochemical data suggest neuronal/axonal injury in some children with OMS without indicators of astrogliosis, and reduction on sufficient immunotherapy.

Variations in senior medical student diagnostic justification ability.

PURPOSE: To determine the diagnostic justification proficiency of senior medical students across a broad spectrum of cases with common chief complaints and diagnoses. METHOD: The authors gathered diagnostic justification exercise data from the Senior Clinical Comprehensive Examination taken by Southern Illinois University School of Medicine's students from the classes of 2011 (n = 67), 2012 (n = 66), and 2013 (n = 79). After interviewing and examining standardized patients, students listed their key findings and diagnostic possibilities considered, and provided a written explanation of how they used key findings to move from their initial differential diagnoses to their final diagnosis. Two physician judges blindly rated responses. RESULTS: Student diagnostic justification performance was highly variable from case to case and often rated below expectations. Of the students in the classes of 2011, 2012, and 2013, 57% (38/67), 23% (15/66), and 33% (26/79) were judged borderline or poor on diagnostic justification performance for more than 50% of the cases on the examination. CONCLUSIONS: Student diagnostic justification performance was inconsistent across the range of cases, common chief complaints, and underlying diagnoses used in this study. More than 20% of students exhibited borderline or poor diagnostic justification performance on more than 50% of the cases. If these results are confirmed in other medical schools, attention needs to be directed to investigating new curricular methods that ensure deliberate practice of these competencies across the spectrum of common chief complaints and diagnoses and do not depend on the available mix of patients.