Organizing graduate life sciences education around nodes and connections.

Biomedical education is currently faced with a number of significant challenges, including the explosion of information and the need to train researchers who can work across traditional disciplinary boundaries. We propose a new integrated model for graduate education in the life sciences that addresses these issues.

Sunrise Over Baltimore.

This address calls for eliminating health care disparities and was delivered for the inaugural David G. Nichols Health Equity award at the 2022 Pediatric Academic Societies meeting. As I contemplate the meaning of this award, I am the first to recognize that it is much larger than the current and future recipients and carries far more significance than the person after whom it is being named. This award represents our shared commitment to advancing the health of all children, which cannot be done unless it is done equitably, as called for by the National Academy of Medicine over 2 decades ago.1 I share my journey toward equity and eliminating health care disparities for children with the hope that it will encourage others.

A qualitative study of expert and team cognition on complex patients in the pediatric intensive care unit.

OBJECTIVES: To understand expert and team cognition of complex patients in the pediatric intensive care unit through the use of cognitive task analysis. DESIGN: Qualitative study with semistructured interviews. SETTING: Academic medical center pediatric intensive care unit. PARTICIPANTS: Physicians, nurses, and nurse practitioners. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Semistructured interviews were conducted with members of the critical care team involved with the care of seven complex patients. Interviews were transcribed and themes were identified based on grounded theory and further divided into categories. A focus group of critical care team members further refined and validated the findings. From the interviews, 177 verbal fragments were sorted into 11 themes. Four broad thematic categories were identified and a cognitive framework for the care of complex patients was formulated. We found that at the center of this framework, critical care teams attempt to create and share mental models of their patients. These mental models serve as the framework for delivery of longitudinal care across handovers and shift changes. The analysis revealed that this process is limited by a number of factors such that team members utilize a variety of techniques to overcome these limitations and develop more complete and shared mental models. CONCLUSIONS: An inadequately developed or inadequately shared mental model is a substantial cognitive limitation for expert and team cognition in the complex environment of the pediatric intensive care unit. Providers utilize techniques that may avoid or decrease the variable interpretations of patient condition that would otherwise impair mental model formation and sharing. Future studies should be designed to enhance mental model formation and communication in the pediatric intensive care unit and other environments that deal with complex patients.

The critically ill child with novel H1N1 influenza A: a case series.

OBJECTIVE: To describe the presentation, course, and outcome of critically ill children with novel H1N1 influenza disease. DESIGN: Retrospective case series. SETTING: Pediatric intensive care unit in an urban tertiary academic center. PATIENTS: Thirteen consecutive patients admitted between June 2009 and August 2009 and known or subsequently found to be infected with novel H1N1 influenza A. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Clinical, laboratory, and radiographic data were reviewed. The patients were predominantly male (62%), aged 5 months to 21 yrs, and most (92%) had known risk factors for severe disease. Direct fluorescent antibody testing had a high false-negative rate (62%) and delayed treatment in some cases. The respiratory illness presented clinically with both bronchoconstriction and alveolar consolidation to varying degrees. Bacterial superinfection occurred frequently (23%). Forty-six percent of patients required mechanical ventilation and 23% required inotropic support for hypotension. None of the patients in this series required extracorporeal membrane oxygenation. Intensive care unit length of stay did not differ between an early (within 48 hrs) oseltamivir treatment group (length of stay, 4.2 +/- 4.4 days) vs. a late treatment group (length of stay, 6.8 +/- 8.8 days). All patients survived to hospital discharge. CONCLUSIONS: Underlying chronic illness (especially respiratory illness) seems associated with critical novel H1N1 influenza disease in children. Respiratory manifestations are highly variable among patients and within a single patient involving both bronchoconstriction and alveolar disease. Therapies must be individualized and rapidly adjusted. The duration of critical illness was not different between early and late treatment groups. Whether this is reflective of sample size or indicative of the importance of therapeutic intervention at any time early during infection in critically ill patients is unclear. Bacterial superinfection was more common than previously reported for seasonal influenza A. Moderate novel H1N1 influenza disease, including respiratory failure and hypotension, had 100% survival in our series.

The Role of Certifying Boards in Improving Health: The Example of the American Board of Pediatrics.

The quality of care for children and adults in the United States is variable and often suboptimal. Approaches that improve the systems of care for entire patient populations are needed. The certifying medical boards can contribute to driving change by ensuring that improving care and outcomes for patients and families is the priority. The American Board of Pediatrics has catalyzed collaborative improvement networks, resulting in improved health outcomes for children, fostered partnerships with patients and families, and brought together key stakeholders to advocate for network improvement efforts for sickle cell disease as one action to address health disparities. Similar concerted efforts by certifying boards in collaboration with physicians and patients can improve the quality of care and lead to better patient outcomes.

Maintenance of Certification and the Challenge of Professionalism.

Board certification has been part of the social contract in which physicians commit to maintaining up-to-date scientific knowledge and improving the quality of patient care. However, the maintenance of certification program has been controversial. This review summarizes the philosophical underpinnings, published literature, recent improvements, and future directions of the American Board of Pediatrics maintenance of certification program.

The ABMS MOC Part III Examination: Value, Concerns, and Alternative Formats.

This article describes the presentations and discussions at a conference co-convened by the Council on Medical Education of the American Medical Association (AMA) and by the American Board of Medical Specialties (ABMS). The conference focused on the ABMS Maintenance of Certification (MOC) Part III Examination. This article, reflecting the conference agenda, covers the value of and evidence supporting the examination, as well as concerns about the cost of the examination, and-given the current format-its relevance. In addition, the article outlines alternative formats for the examination that four ABMS member boards are currently developing or implementing. Lastly, the article presents contrasting views on the approach to professional self-regulation. One view operationalizes MOC as a high-stakes, pass-fail process while the other perspective holds MOC as an organized approach to support continuing professional development and improvement. The authors hope to begin a conversation among the AMA, the ABMS, and other professional stakeholders about how knowledge assessment in MOC might align with the MOC program's educational and quality improvement elements and best meet the future needs of both the public and the physician community.

Effects of prolonged mechanical ventilation and inactivity on piglet diaphragm function.

OBJECTIVES: Muscle weakness is associated with immobilization, prolonged mechanical ventilation, critical illness and various critical care therapies. This study used an animal model simulating the critical care environment to investigate the effects of 5 days' mechanical ventilation and inactivity on diaphragm contractility and neurophysiologic function. DESIGN: Prospective laboratory study. SETTING: Animal research laboratory. SUBJECTS: Seven 2-3 month old piglets weighing 20-25 kg. INTERVENTIONS: The animals received constant-flow, volume-controlled mechanical ventilation (Tv 12-15 ml/kg, PEEP 3-5 cmH2O, I:E 1:2) and sedation without paralysis, and spontaneous breathing efforts were prevented. Evoked diaphragm contractions were achieved by transvenous phrenic nerve pacing. MEASUREMENTS AND MAIN FINDINGS: Transdiaphragmatic pressure (Pdi) measurements were used to assess force frequency relationships. Evoked electrophysiologic measures included lowest stimulus threshold and latency, compound muscle action potential (CMAP) amplitude and duration, and amplitude during repetitive nerve stimulation at 3 Hz. Lung function measures included airway pressures, tidal and minute volumes, and dynamic compliance and resistance. There were no clinically significant changes in hemodynamics, oxygenation or ventilation. Indirect measures of lung volume remained stable. Pdi decreased by 20% at all frequencies tested and was accompanied by a 30% decrease in evoked CMAP amplitude, (6.7+/-4.7 mV to 4.5+/-3.9 mV, p=0.01) while CMAP threshold, latency and duration were unchanged and no significant decrement in amplitude was seen during repetitive stimulation at 3 Hz. CONCLUSION: In this in-vivo model of prolonged mechanical ventilation in an intensive caring setting, 5 days of mechanical ventilation with sedation and complete diaphragm inactivity resulted in disturbed diaphragm contractility and activation, while nerve conduction and neuromuscular transmission were not affected. Based on these findings, it is likely that the changes seen occur at the level of peripheral muscle.

"Genes to society"--the logic and process of the new curriculum for the Johns Hopkins University School of Medicine.

In August 2009, the Johns Hopkins University School of Medicine implemented a new curriculum, "Genes to Society" (GTS), aimed at reframing the context of health and illness more broadly, to encourage students to explore the biologic properties of a patient's health within a larger, integrated system including social, cultural, psychological, and environmental variables. This approach presents the patient's phenotype as the sum of internal (genes, molecules, cells, and organs) and external (environment, family, and society) factors within a defined system. Unique genotypic and societal factors bring individuality and variability to the student's attention. GTS rejects the phenotypic dichotomy of health and illness, preferring to view patients along a phenotypic continuum from "asymptomatic and latent" to "critically ill." GTS grew out of a perceived need to reformulate the student experience to meet the oncoming revolution in medicine that recognizes individuality from the genome to the environment. This article describes the five-year planning process that included the definition of objectives, development of the new curriculum, commission of a new education building, addition of enhancements in student life and faculty development, and creation of a vertical and horizontal structure, all of which culminated in the GTS curriculum. Critical ingredients in meeting the challenges of implementing GTS were leadership support, dialogue with faculty, broad engagement of the institutional community, avoidance of tunnel vision, and the use of pilot courses to test concepts and methods. GTS can be viewed as the foundation for the scientific and clinical career development of future physicians.