Peer Observation of Teaching Program for the Busy Hospitalist.

BACKGROUND: Peer observation of teaching (POT) is a well-documented faculty development tool, but published research focuses mostly on programs in which participating physicians had protected time in their schedule in which to complete observations. Most programs nationally depend on hospitalists who have minimal, if any, protected time in their schedule and thus in order to complete these observations, will need to figure out a way to schedule these into their regular working day. Objective: We determined whether a POT program, focused on hospitalists with minimal non-clinical time, scheduled around clinical responsibilities, could be feasible and acceptable. METHODS: Seven hospitalists participated in a POT pilot program from January 2019 to June 2019. Each hospitalist completed three 30-minute observations during this interval. At the completion of the pilot, the hospitalists were surveyed on their experience and results were assessed via open-ended narrative questions, which underwent thematic analysis. RESULTS: Twenty of the 21 scheduled observations (95%) were completed. Of the completed observations, 100% were completed while the observer was assigned to concomitant clinical duties. The survey response rate was 100%. From free-text responses, the following themes emerged: (1) Acceptable time commitment with minor inconvenience, (2) learning through observing and reflecting for personal growth, and (3) stress-free peer observations. CONCLUSIONS: This study demonstrates the successful development and implementation of a POT program that served as a faculty development initiative focused primarily on hospitalists with minimal protected time.

Rapid Mobilization of Medical Student Volunteers to Administer Vaccines During the COVID-19 Pandemic.

In December 2020, the first COVID-19 vaccines were approved for emergency use by the U.S. Food and Drug Administration, and vaccination efforts rapidly launched across the country. Concurrently, New York City experienced an increase in COVID-19 hospitalizations. This created an immediate need to inoculate frontline workers in a strained health system that lacked sufficient personnel to meet the demand. In response, New York State permitted medical students with appropriate clinical experience to administer vaccinations. Albert Einstein College of Medicine students rapidly stepped in to administer vaccines and serve as clinic navigators. Student leaders at Einstein collaborated with Montefiore Medical Center to rapidly implement a student vaccination initiative. Medical students underwent virtual and on-site training regarding COVID-19 vaccines and their administration. In January 2021, students began to staff vaccine clinics across the Bronx. By July 2021, 291 out of 830 eligible medical and Medical Scientist Training Program (MSTP) students (35.1%) had volunteered >2400 h. Of the 291 volunteers, 77 (26.5%) worked as vaccinators and administered approximately 2929 COVID-19 vaccines from January to May 2021. We demonstrate success using the concept of Entrustable Professional Activities (EPAs) in the context of training medical students in a specific clinical skill. Our framework resulted in the administration of approximately 2929 COVID-19 vaccines from January to May 2021. The authors believe that this framework can be implemented at peer institutions to alleviate the burden on hospital systems and outpatient clinics vaccinating their communities against COVID-19, or to meet future clinical needs.

Moving Medical Students into Shared Housing During the COVID-19 Pandemic.

A new academic year began in the midst of the COVID-19 pandemic. In order to allow for in-person learning, a fundamental part of medical education, some medical schools grappled with how to safely move students into shared on-campus housing. The authors describe a behavior-based strategy to safely move students from all parts of the United States to the Albert Einstein College of Medicine in the Bronx, New York. This strategy included a school-organized phased move-in that included 14-day quarantines for students coming from states with high COVID prevalence; requiring students to sign a COVID-agreement; the use of a phone-based daily COVID risk assessment; and facilitation of safe in-person social activities with peer monitoring of adherence to behavior guidelines. This strategy resulted in no known transmission of SARS-CoV-2 in student housing between July and October of the 2020 to 2021 academic year. The authors share this strategy in the hope that colleagues at other medical schools will find it useful in utilizing similar behavior-based strategies to keep students safe in shared housing.

Medical student remote eConsult participation during the COVID-19 pandemic.

BACKGROUND: Undergraduate medical education was severely impacted by the COVID-19 pandemic. As traditional clinical rotations were suspended, medical students quickly began alternative, novel educational experiences. Third-year medical students at an academic medical center were given the opportunity to join inpatient eConsult teams within the department of medicine. This study describes the development and implementation of this program as well as the experiences of student and faculty participants. METHODS: Student eConsult participation was rapidly developed and implemented within medical subspecialty teams in either infectious diseases (ID) or nephrology. Twelve third-year medical students and 15 subspecialty attendings participated in this program during an eight-week period from April 6 through May 29, 2020. Breadth of student clinical experience was assessed via review of clinical documentation and surveys. Participating students and attending physicians completed surveys to reflect upon their impressions of the program. Surveys were returned by nine students and eight faculty members. Survey responses were summarized with descriptive statistics. RESULTS: Over an eight-week period, student consultants wrote 126 notes on 100 patients; 74 of these patients (74%) were hospitalized with COVID-19. Student experiences were largely positive with most strongly agreeing that attendings promoted interactive and engaged learning (N = 8 of 8, 100%), that the experience helped to expand their knowledge about consultant roles (N = 6, 75%), and that they would participate in a remote eConsult program again if given the opportunity (N = 6, 75%). Faculty also were largely positive about the experience with most agreeing or strongly agreeing with the importance of teaching medical students about telehealth (N = 7 of 8, 88%) and eConsults (N = 6, 75%). In narrative responses, students and faculty agreed that teaching was a strength of the program whereas lack of in-person contact was a challenge. CONCLUSIONS: Rapid development of an inpatient eConsult-based educational experience for third-year medical students was feasible and successful. Student-consultants saw a range of pathology including COVID-19 and related complications. Students were satisfied with the program. They were able to develop a strong relationship with attendings while learning about the role of a consultant. Faculty agreed with the importance of teaching students about telehealth and eConsults specifically.

Medical Student Attitudes toward USMLE Step 1 and Health Systems Science - A Multi-Institutional Survey.

Phenomenon: Because of its importance in residency selection, the United States Medical Licensing Examination Step 1 occupies a critical position in medical education, stimulating national debate about appropriate score use, equitable selection criteria, and the goals of undergraduate medical education. Yet, student perspectives on these issues and their implications for engagement with health systems science-related curricular content are relatively underexplored. Approach: We conducted an online survey of medical students at 19 American allopathic medical schools from March-July, 2019. Survey items were designed to elicit student opinions on the Step 1 examination and the impact of the examination on their engagement with new, non-test curricular content related to health systems science. Findings: A total of 2856 students participated in the survey, representing 23.5% of those invited. While 87% of students agreed that doing well on the Step 1 exam was their top priority, 56% disagreed that studying for Step 1 had a positive impact on engagement in the medical school curriculum. Eighty-two percent of students disagreed that Step 1 scores should be the top item residency programs use to offer interviews. When asked whether Step 1 results should be reported pass/fail with no numeric score, 55% of students agreed, while 33% disagreed. The majority of medical students agreed that health systems science topics were important but disagreed that studying for Step 1 helped learn this content. Students reported being more motivated to study a topic if it was on the exam, part of a course grade, prioritized by residency program directors, or if it would make them a better physician in the future. Insights: These results confirm the primacy of the United States Medical Licensing Examination Step 1 exam in preclinical medical education and demonstrate the need to balance the objectives of medical licensure and residency selection with the goals of the broader medical profession. The survey responses suggest several potential solutions to increase student engagement in health systems science curricula which may be especially important after Step 1 examination results are reported as pass/fail.

Guiding principles for undergraduate medical education in the time of the COVID-19 pandemic.

As the early epicenter of the COVID-19 pandemic, New York City's medical schools experienced dramatic disruptions in every aspect of medical education. Remote learning was created, seemingly overnight, clerkships were disrupted, licensing examinations were cancelled, teaching faculty were redeployed, student volunteers rallied, and everyone was required to shelter at home. Seismic changes were required to adapt the authors' educational programs to a constantly evolving, unpredictable, and ever-worsening public health crisis. Entirely new communication strategies were adopted and thousands of decisions had to be made, often with little time to carefully reflect on the consequences of those decisions. What allowed each school to navigate these treacherous waters was a set of guiding principles that were used to ground each conversation, and inform every decision. While the language varied somewhat between schools, the core principles were universal and framed a way forward at a time when information, data, precedent, and best practices did not exist. The authors share these guiding principles in the hope that colleagues at other medical schools will find them to be a useful framework as we all continue to cope with the impact of COVID-19 on the future of medical education.

Implementation of a Hypothesis-Driven Physical Exam Session in a Transition to Clerkship Program.

Introduction: The head-to-toe approach to teaching the physical examination (PE) focuses on technique and performing a comprehensive PE whereas core + clusters and hypothesis-driven PE (HDPE) approaches integrate clinical reasoning into performing a focused PE. These approaches can be implemented in a developmental sequence. We report the implementation and evaluation of an HDPE educational session. Methods: We designed a 3-hour HDPE session as part of a transition to clerkship program. For each of five clinical vignettes, rising third-year students worked in pairs and then in small groups to generate a differential diagnosis and determine relevant PE maneuvers. Students next performed these maneuvers on peers with facilitator observation and feedback. Students completed postsession surveys on their retrospective pre- and postsession knowledge and confidence, as well as their satisfaction with the session. We completed quantitative and qualitative analyses on survey data. Results: One hundred ninety-two students participated, and 140 (73%) completed the survey. Students were significantly more likely to report feeling confident generating a differential diagnosis and using it to select PE maneuvers for common complaints postsession. Over 80% of respondents felt the session improved critical thinking about patient presentations and would help them in clerkships. Discussion: Our session increased student confidence in the progression to performing an HDPE just prior to the start of clerkships. The session is feasible and straightforward to implement. It requires a large number of faculty to facilitate, but the breadth of cases used allows inclusion of faculty from all fields.

Expanding OSCE-related Learning Opportunities For Pre-Clerkship Students: Insights From an Assessment for Learning Curriculum.

Pre-clerkship clinical skills courses at many medical schools use objective structured clinical examinations (OSCEs) to assess students' development as it relates to the foundational clinical skills of history taking, communication, and physical examination. The authors report on a curriculum in which OSCEs also serve as a springboard for additional learning by linking them to activities that include patient write-ups, oral presentations, clinical reasoning discussions, clinical question generation, and video review with faculty. The rationale for using OSCEs as an assessment for learning tool is discussed, and some lessons learned are reported.

Abstract Submission and Acceptance Rates for Men and Women in Academic Pediatric Orthopaedic Surgery: An Analysis of POSNA Annual Meeting Abstract Submissions 2012-2015.

BACKGROUND: It has recently been demonstrated that women members of the Pediatric Orthopaedic Society of North America (POSNA) participate at the Annual Meeting at disproportionately lower rates than men members, as defined by accepted abstract(s). We hypothesize that this discrepancy is associated with lower abstract submission rates by women members. METHODS: POSNA membership directories for the years 2012-2015 were used to record the name, sex, membership category, and years of membership for each member. Final programs for Annual Meetings and abstract submission records for the same time period were used to record the number of accepted and rejected abstracts for each member. General estimating equations with a binomial model and logit link were used to compare the proportion of abstract acceptances between sexes across years. RESULTS: During the period 2012-2015, active members included 534 men (83.8%) and 103 women (16.2%), whereas candidate members included 207 men (64.7%) and 113 women (35.3%). When active and candidate members were considered collectively, men were significantly more likely to have an accepted abstract (P=0.009) and this significant difference did not change over the 4-year period (P=0.627). However, men submitted significantly more abstracts per member per year than women (means: 1.5 abstracts/man/y; 0.8 abstracts/woman/y; P<0.001). This held true for both candidate members (early career) (P=0.001) as well as active members (mid-career) (P<0.001). When the total number of abstract submissions per year per member was taken into account, the percentage of abstract acceptances was similar for men and women (men=42%, women=40%; P=0.847). CONCLUSIONS: Abstract acceptance rates were similar for women and men members of POSNA for the 2012-2015 Annual Meetings. However, men had a significantly greater number of abstract submissions per member than women, and consequently, men presented a higher proportion of abstracts relative to their membership numbers. This supports our hypothesis that the disproportionately lower rate of active participation amongst women members at POSNA Annual Meetings, defined as abstract acceptance, is due to lower rates of abstract submissions, rather than to lower rates of acceptances. LEVEL OF EVIDENCE: It is not applicable as it is not a clinical or basic science study.

Applying four-component instructional design to develop a case presentation curriculum.

Medical students must gain proficiency with the complex skill of case presentations, yet current approaches to instruction are fragmented and often informal, resulting in suboptimal transfer of this skill into clinical practice. Whole task approaches to learning have been proposed to teach complex skill development. The authors describe a longitudinal case presentation curriculum developed using a whole task approach known as four-component instructional design (4-C/ID). 4­C/ID is based on cognitive psychology theory, and carefully attends to titrating a learner's cognitive load, aiming to always keep students in their zone of proximal development. A multi-institutional group of medical educators convened to develop expert consensus regarding case presentation instruction using the 4­C/ID model. A curriculum consisting of 1) learning tasks, 2) supportive information, 3) just-in-time information, and 4) part-task practice was developed. Domains were identified that make the task of delivering a case presentation complex. A simplifying conditions approach was applied to each domain to develop sequential task class descriptions. Examples of the four components are given to facilitate understanding of the 4­C/ID model, making it more accessible to medical educators. Applying 4­C/ID to curriculum development for the complex skill of case presentation delivery may optimize instruction. The provision of the complete curricular outline may facilitate transfer and implementation of this case presentation curriculum, as well as foster the application of 4­C/ID to other complex skill development in medical education.

Step Up-Not On-The Step 2 Clinical Skills Exam: Directors of Clinical Skills Courses (DOCS) Oppose Ending Step 2 CS.

Recently, a student-initiated movement to end the United States Medical Licensing Examination Step 2 Clinical Skills and the Comprehensive Osteopathic Medical Licensing Examination Level 2-Performance Evaluation has gained momentum. These are the only national licensing examinations designed to assess clinical skills competence in the stepwise process through which physicians gain licensure and certification. Therefore, the movement to end these examinations and the ensuing debate merit careful consideration. The authors, elected representatives of the Directors of Clinical Skills Courses, an organization comprising clinical skills educators in the United States and beyond, believe abolishing the national clinical skills examinations would have a major negative impact on the clinical skills training of medical students, and that forfeiting a national clinical skills competency standard has the potential to diminish the quality of care provided to patients. In this Perspective, the authors offer important additional background information, outline key concerns regarding the consequences of ending these national clinical skills examinations, and provide recommendations for moving forward: reducing the costs for students, exploring alternatives, increasing the value and transparency of the current examinations, recognizing and enhancing the strengths of the current examinations, and engaging in a national dialogue about the issue.

Medical students review of formative OSCE scores, checklists, and videos improves with student-faculty debriefing meetings.

BACKGROUND: Performance feedback is considered essential to clinical skills development. Formative objective structured clinical exams (F-OSCEs) often include immediate feedback by standardized patients. Students can also be provided access to performance metrics including scores, checklists, and video recordings after the F-OSCE to supplement this feedback. How often students choose to review this data and how review impacts future performance has not been documented. OBJECTIVE: We suspect student review of F-OSCE performance data is variable. We hypothesize that students who review this data have better performance on subsequent F-OSCEs compared to those who do not. We also suspect that frequency of data review can be improved with faculty involvement in the form of student-faculty debriefing meetings. DESIGN: Simulation recording software tracks and time stamps student review of performance data. We investigated a cohort of first- and second-year medical students from the 2015-16 academic year. Basic descriptive statistics were used to characterize frequency of data review and a linear mixed-model analysis was used to determine relationships between data review and future F-OSCE performance. RESULTS: Students reviewed scores (64%), checklists (42%), and videos (28%) in decreasing frequency. Frequency of review of all metric and modalities improved when student-faculty debriefing meetings were conducted (p<.001). Among 92 first-year students, checklist review was associated with an improved performance on subsequent F-OSCEs (p = 0.038) by 1.07 percentage points on a scale of 0-100. Among 86 second year students, no review modality was associated with improved performance on subsequent F-OSCEs. CONCLUSION: Medical students review F-OSCE checklists and video recordings less than 50% of the time when not prompted. Student-faculty debriefing meetings increased student data reviews. First-year student's review of checklists on F-OSCEs was associated with increases in performance on subsequent F-OSCEs, however this outcome was not observed among second-year students.

Disproportionate Participation of Males and Females in Academic Pediatric Orthopaedics: An Analysis of Abstract Authorship at POSNA 2009-2013.

BACKGROUND: Despite increasing numbers of female orthopaedic surgeons, we hypothesized that women were not actively participating at national and international meetings in numbers proportional to their membership. METHODS: A retrospective review of the 2009-2013 POSNA Annual Meeting Final Programs was performed. The following information was recorded for all members: name, sex, membership level, years of membership, and if the individual was an author on at least 1 abstract. To compare proportion of abstract authorship between sexes across years, while controlling for years of membership, general estimating equations with a binomial model and logit link were used. The study population was limited to candidate and active POSNA members only, as this group represents the most active practicing pediatric orthopaedic surgeons. RESULTS: Over the 5-year period studied, females comprised 16.6% (204/1227) of the total POSNA membership and 20.9% (184/880) of members at candidate and active status. The percentage of females with candidate or active member status in POSNA who had at least 1 abstract presentation during the 5 years was 37% and this was significantly lower (P=0.003) than the percentage of men (49%) who presented at least 1 abstract. Analysis across the 5 years showed a consistent difference between the sexes with no trend of convergence in abstract rates (P=0.65). Controlling for years membership, female members still presented abstracts at lower rates than their male colleagues (P=0.002). CONCLUSIONS: Female members of POSNA, in the most active part of their careers, participated at significantly lower rates than their male peers as accepted abstract authors for the 2009-2013 POSNA meetings than would be expected for their proportional size of total membership.

Structure, function, and amyloidogenesis of fungal prions: filament polymorphism and prion variants.

Infectious proteins (prions) became an important medical issue when they were identified as agents of the transmissible spongiform encephalopathies. More recently, prions have been found in fungi and their investigation has been facilitated by greater experimental tractability. In each case, the normal form of the prion protein may be converted into the infectious form (the prion itself) in an autocatalytic process; conversion may either occur spontaneously or by transmission from an already infected cell. Four fungal prion proteins have been studied in some depth-Ure2p, Sup35p, and Rnq1p of Saccharomyces cerevisiae and HET-s of Podospora anserina. Each has a "prion domain" that governs infectivity and a "functional domain" that contributes the protein's activity in a wild-type cell, if it has one. This activity is repressed in prion-infected cells for loss-of-activity prions, [URE3] (the prion of Ure2p) and [PSI] (the prion of Sup35p). For gain-of-activity prions, [PIN] (the prion of Rnq1p) and [Het-s] (the prion of HET-s), the prion domain is also involved in generating a new activity in infected cells. In prion conversion, prion domains polymerize into an amyloid filament, switching from a "natively unfolded" conformation into an amyloid conformation (stable, protease-resistant, rich in cross-beta structure). For Ure2p and probably also Sup35p, the functional domain retains its globular fold but is inactivated by a steric mechanism. We review the evidence on which this scenario is based with emphasis on filament structure, summarizing current experimental constraints and appraising proposed models. We conclude that the parallel superpleated beta-structure and a specific beta-helical formulation are valid candidates while other proposals are excluded. In both the Ure2p and Sup35p systems, prion domain amyloid filaments exhibit polymorphic variation. However, once a certain structure is nucleated, it is maintained throughout that filament. Electron microscopy of several Ure2p-related constructs indicates that the basis for polymorphism lies mainly if not entirely in the prion domain. Filament polymorphism appears to underlie the phenomenon of prion "variants" which differ in the severity of their phenotype, that is, for Ure2p and Sup35p, the stringency with which their activity is switched off. We discuss a possible structural basis for this phenomenon.