Leading the Charge: Effectiveness of a Workshop to Enhance Faculty Education of Health Inequity.

INTRODUCTION: Medical educators in residency programs have unique opportunities to teach health inequities, social determinants of health (SDOH), and implicit bias. However, faculty are not adequately trained to effectively teach these topics. The aim is to assess the effectiveness of a faculty-level workshop to teach health inequity. METHODS: An interactive workshop was designed by an interprofessional faculty from a major urban teaching hospital, addressing SDOH, implicit bias, an "Enhanced Social History," and the benefits of interprofessional care. Before and after completion, workshop participants completed surveys regarding comfort in teaching these concepts. Survey results were analyzed to assess benefits of the intervention. RESULTS: Sixty-four percent of participants completed preworkshop and postworkshop surveys. Participants reported increased contemplation and improved comfort in teaching SDOH, barriers to medical care, and implicit bias. CONCLUSION: Faculty comfort in teaching health inequity increased after this workshop. This may help bridge the gap between the expectation of clinical faculty to evaluate trainee practice of patient-centered, culturally competent care, and faculty possession of and confidence in health inequity teaching skills in clinical settings. Future research should focus on learner- and patient-based outcomes, including teaching time and impact on delivery of care.

"Friction by Definition": Conflict at Patient Handover Between Emergency and Internal Medicine Physicians at an Academic Medical Center.

INTRODUCTION: Patient handoffs from emergency physicians (EP) to internal medicine (IM) physicians may be complicated by conflict with the potential for adverse outcomes. The objective of this study was to identify the specific types of, and contributors to, conflict between EPs and IM physicians in this context. METHODS: We performed a qualitative focus group study using a constructivist grounded theory approach involving emergency medicine (EM) and IM residents and faculty at a large academic medical center. Focus groups assessed perspectives and experiences of EP/IM physician interactions related to patient handoffs. We interpreted data with the matrix analytic method. RESULTS: From May to December 2019, 24 residents (IM = 11, EM = 13) and 11 faculty (IM = 6, EM = 5) from the two departments participated in eight focus groups and two interviews. Two key themes emerged: 1) disagreements about disposition (ie, whether a patient needed to be admitted, should go to an intensive care unit, or required additional testing before transfer to the floor); and 2) contextual factors (ie, the request to discuss an admission being a primer for conflict; lack of knowledge of the other person and their workflow; high clinical workload and volume; and different interdepartmental perspectives on the benefits of a rapid emergency department workflow). CONCLUSIONS: Causes of conflict at patient handover between EPs and IM physicians are related primarily to disposition concerns and contextual factors. Using theoretical models of task, process, and relationship conflict, we suggest recommendations to improve the EM/IM interaction to potentially reduce conflict and advance patient care.

A Simulation-Based Prospective Cohort Study on Teaching Best Practices in Firearms Safety.

BACKGROUND: Gun violence in the United States is a significant public health concern. The high rate of weapons carriage by Americans places medical providers at risk for exposure to firearms in the workplace and provides an opportunity for patient safety counseling. Few curricular interventions have been published on teaching firearms safety principles to medical providers. Given the risk of encountering firearms in the workplace and the opportunity to engage patients in firearms safety counseling, providers may benefit from dedicated training on safely handling firearms. METHODS: This was a prospective cohort pilot study of a simulation-based educational intervention for third- and fourth-year medical students enrolled in an emergency medicine subinternship and emergency medicine bootcamp elective. Before undergoing the educational intervention, students completed a preintervention simulation case during which they discovered a model firearm in the patient's belongings and were asked to remove it. Students then received the intervention that included a discussion and demonstration on how to safely remove a firearm in the clinical setting. Two weeks later, the students were presented with a model firearm in a different simulation case, which they needed to remove. During the preintervention and postintervention simulations, students were evaluated on their performance of the critical actions in firearm removal using an 8-item checklist. Students' scores on this checklist were compared. RESULTS: Fifty-three students participated in the study, 25 of whom completed the postintervention assessment. The median number of correctly performed critical actions preintervention was 5 (interquartile range = 4-6) and postintervention was 7 (interquartile range = 6-8, P < 0.001). Students showed particular improvement in 4 steps: holding the firearm by the grip only, pointing the firearm in a safe direction at all times, removing the firearm from the immediate patient care area and placing it in a safe area, and ensuring that the firearm is monitored and untouched until police or security personnel arrive to secure it. CONCLUSIONS: This educational intervention is the first to formally teach students about the safe handling of firearms found in the clinical care space. This low-cost pilot project is easily transferrable to other training centers for teaching principles of safe firearms handling.

Difficult Intraoperative Heparinization Following Andexanet Alfa Administration.

Direct oral anticoagulants are now commonplace, and reversal agents are recently becoming available. Andexanet alfa (AnXa), approved by the United States Food and Drug Administration in 2018, is a novel decoy molecule that reverses factor Xa inhibitors in patients with major hemorrhage. We present a case of a 70-year-old man taking rivaroxaban with hemodynamic instability from a ruptured abdominal aortic aneurysm. He received AnXa prior to endovascular surgery, and intraoperatively he could not be heparinized for graft placement. Consideration should be given to the risks and benefits of AnXa administration in patients who require anticoagulation after hemorrhage has been controlled.

A Multimodal Curriculum With Patient Feedback to Improve Medical Student Communication: Pilot Study.

INTRODUCTION: Despite the extraordinary amount of time physicians spend communicating with patients, dedicated education strategies on this topic are lacking. The objective of this study was to develop a multimodal curriculum including direct patient feedback and assess whether it improves communication skills as measured by the Communication Assessment Tool (CAT) in fourth-year medical students during an emergency medicine (EM) clerkship. METHODS: This was a prospective, randomized trial of fourth-year students in an EM clerkship at an academic medical center from 2016-2017. We developed a multimodal curriculum to teach communication skills consisting of 1) an asynchronous video on communication skills, and 2) direct patient feedback from the CAT, a 15-question tool with validity evidence in the emergency department setting. The intervention group received the curriculum at the clerkship midpoint. The control group received the curriculum at the clerkship's end. We calculated proportions and odds ratios (OR) of students achieving maximum CAT score in the first and second half of the clerkship. RESULTS: A total of 64 students were enrolled: 37 in the control group and 27 in the intervention group. The percentage of students achieving the maximum CAT score was similar between groups during the first half (OR 0.70, p = 0.15). Following the intervention, students in the intervention group achieved a maximum score more often than the control group (OR 1.65, p = 0.008). CONCLUSION: Students exposed to the curriculum early had higher patient ratings on communication compared to the control group. A multimodal curriculum involving direct patient feedback may be an effective means of teaching communication skills.

Standardized Video Interview Scores Correlate Poorly with Faculty and Patient Ratings.

The Standardized Video Interview (SVI) was developed by the Association of American Medical Colleges to assess professionalism, communication, and interpersonal skills of residency applicants. How SVI scores compare with other measures of these competencies is unknown. The goal of this study was to determine whether there is a correlation between the SVI score and both faculty and patient ratings of these competencies in emergency medicine (EM) applicants. This was a retrospective analysis of a prospectively collected dataset of medical students. Students enrolled in the fourth-year EM clerkship at our institution and who applied to the EM residency Match were included. We collected faculty ratings of the students' professionalism and patient care/communication abilities as well as patient ratings using the Communication Assessment Tool (CAT) from the clerkship evaluation forms. Following completion of the clerkship, students applying to EM were asked to voluntarily provide their SVI score to the study authors for research purposes. We compared SVI scores with the students' faculty and patient scores using Spearman's rank correlation. Of the 43 students from the EM clerkship who applied in EM during the 2017-2018 and 2018-2019 application cycles, 36 provided their SVI scores. All 36 had faculty evaluations and 32 had CAT scores available. We found that SVI scores did not correlate with faculty ratings of professionalism (rho = 0.09, p = 0.13), faculty assessment of patient care/communication (rho = 0.12, p = 0.04), or CAT scores (rho = 0.11, p = 0.06). Further studies are needed to validate the SVI and determine whether it is indeed a predictor of these competencies in residency.

Fourth-year medical students do not perform a focused physical examination during a case-based simulation scenario.

BACKGROUND: The art of physical examination is one of the most valuable diagnostic tools bestowed upon new generations of medical students. Despite traditional educational techniques and significant attention on a national level, both trainees and educators have noticed a decrease in physical examination proficiency. Simulation has been identified as a potential way to improve physical examination techniques within undergraduate medical education. We sought to determine the utility of a cardiac case-based simulation scenario to assess physical examination performance of fourth-year medical students during an emergency medicine (EM) clerkship. MATERIALS AND METHODS: Fourth-year medical students enrolled in a 4-week EM clerkship were prospectively evaluated during a case-based scenario using a simulation mannequin (Laerdal SimMan®). The case involved a patient presenting with chest pain that evolved into cardiac arrest. All simulations were video recorded and two emergency physicians reviewed each video. The reviewers recorded whether or not each student completed the essential components of a focused physical examination. RESULTS: Twenty-seven students participated in the simulation. The percentage of students completing each of the four components of the physical examination was as follows: cardiac auscultation 33.3% (95% CI 18.5-52.3), lung auscultation 29.6% (95% CI 15.7-48.7), pulse and extremity examination 55.6% (95% CI 37.3-72.4), and abdominal examination 3.70% (95% CI 0-19.8). None of the students completed all four of these components. CONCLUSION: Our study showed that fourth-year medical students did not uniformly perform components of a focused physical examination during a high-acuity chest pain simulation scenario. Although our study showed limited physical examination performance, simulation allows evaluators to observe and provide constructive feedback and may lead to an improvement in these skills. These findings call for improved technology to increase authenticity of simulators and continued faculty development for more creative, meaningful integration of physical examination skills into high-acuity simulation cases.

Influence of hydroxyl content on selected properties of 45S5 bioactive glass.

Numerous material properties may be influenced by the concentration of chemically dissolved hydroxyl species within a glass. A tube furnace connected to a steam generator was used to create hydroxyl-saturated 45S5 glass under 1 atm of water at 1100 degrees C. Selected properties of as-melted and hydroxyl-saturated samples were compared to assess the sensitivity of 45S5 to excess hydroxylation. The glass transition temperature and the peak crystallization temperature of the treated 45S5 glass were reduced in comparison to the as-melted 45S5 glass. In addition, the treated glass exhibited a broad endothermic signal that may be indicative of enhanced viscous flow. A simple dissolution experiment indicated that the treated 45S5 glass was also less durable than the as-melted 45S5 glass.

Distribution of Honors Grades Across Fourth-year Emergency Medicine Clerkships.

BACKGROUND: Medical student grades during emergency medicine (EM) rotations are a key factor in resident selection. The variability in grading among EM clerkships is not well understood. OBJECTIVE: The objective was to describe the current grade distribution of fourth-year EM clerkships. METHODS: This was an observational study at an EM residency program. We identified grade distributions by reviewing the standard letter of evaluation from individuals applying to our residency program for the 2016 match. Descriptive statistics of proportions, standard deviations (SDs), and p-values were calculated. RESULTS: A total of 1,075 applications from 236 individual clerkships were reviewed. Thirty-four programs did not give an honors grade during the previous year. Four of these programs distributed a highest grade of "high pass" and 30 gave only "pass" and/or "fail." Of the remaining 202 programs, the percentage of grades that were given as honors ranged from 1% to 87% with a mean (±SD) of 25% (±17.2%). Of the 202 programs that granted honors grades, 63 (31.2%) sites gave between 1 and 14.9% honors grades, 69 (34.2%) gave 15% to 29.9% honors grades, 27 (13.4%) gave 30% to 44.9% honors grades, and 24 (11.9%) programs granted honors to greater than 45% of their students. Medical schools required an EM rotation at 82 (40.6%) sites. Among these programs, honors grades were given to 24% (±16.7%) of students with a range of 4% to 85% while programs that did not require clerkships gave a mean (±SD) of 26% (±17.5%) with a range of 1% to 87% and a p-value of 0.54. CONCLUSIONS: Honor grade distribution varies markedly across U.S. fourth-year EM clerkship sites. Requiring EM clerkships does not affect honor percentages. A minority of sites only give pass/fail grades. Program directors should consider this marked variation in grades when reviewing EM residency applications.

Physician Variability in Management of Emergency Department Patients with Chest Pain.

INTRODUCTION: Chest pain is a common emergency department (ED) presentation accounting for 8-10 million visits per year in the United States. Physician-level factors such as risk tolerance are predictive of admission rates. The recent advent of accelerated diagnostic pathways and ED observation units may have an impact in reducing variation in admission rates on the individual physician level. METHODS: We conducted a single-institution retrospective observational study of ED patients with a diagnosis of chest pain as determined by diagnostic code from our hospital administrative database. We included ED visits from 2012 and 2013. Patients with an elevated troponin or an electrocardiogram (ECG) demonstrating an ST elevation myocardial infarction were excluded. Patients were divided into two groups: "admission" (this included observation and inpatients) and "discharged." We stratified physicians by age, gender, residency location, and years since medical school. We controlled for patient- and hospital-related factors including age, gender, race, insurance status, daily ED volume, and lab values. RESULTS: Of 4,577 patients with documented dispositions, 3,252 (70.9%) were either admitted to the hospital or into observation (in an ED observation unit or in the hospital), while 1,333 (29.1%) were discharged. Median number of patients per physician was 132 (interquartile range 89-172). Average admission rate was 73.7±9.5% ranging from 54% to 96%. Of the 3,252 admissions, 2,638 (81.1%) were to observation. There was significant variation in the admission rate at the individual physician level with adjusted odds ratio ranging from 0.42 to 5.8 as compared to the average admission. Among physicians' characteristics, years elapsed since finishing medical school demonstrated a trend towards association with a higher admission probability. CONCLUSION: There is substantial variation among physicians in the management of patients presenting with chest pain, with physician experience playing a role.

Biodegradable radiation delivery system utilizing glass microspheres and ethylenediaminetetraacetate chelation therapy.

Dysprosium lithium-borate (DyLB) glass microspheres have been developed as a biodegradable radiation delivery vehicle for the treatment of rheumatoid arthritis and other diseases. Radioactive microspheres of these glasses are intended to be injected into a joint infected with rheumatoid arthritis to safely deliver a localized dose (100 Gy) of beta radiation. Once injected, the microspheres react nonuniformly with body fluids. The nonradioactive, lithium-borate component is dissolved from the glass, whereas the radioactive (165)Dy reacts with phosphate anions in the body fluids, and becomes "chemically" trapped in a solid, dysprosium phosphate reaction product that has the same size as the unreacted microsphere. The glass microspheres lose approximately 80% of their weight after nonuniform reaction (<1 day), but the dysprosium phosphate reaction product is slowly metabolized by the body over several months. Ethylenediaminetetraacetate (EDTA) chelation therapy can be used to dissolve the dysprosium phosphate reaction product in vitro in <2 h. The dysprosium phosphate reaction product which formed in vivo in the joint of a Sprague-Dawley rat was also dissolved by EDTA chelation therapy in <1 week, without causing any detectable joint damage. The combination of DyLB glass microspheres and EDTA chelation therapy provides a unique "tool" for the medical community because it can deliver a large dose (>100 Gy) of localized beta radiation to a treatment site within the body, followed by complete biodegradability.

Fill volume as an indicator of surface heterogeneity in glass vials for parenteral packaging.

The chemical durability of glass vials for parenteral packaging is typically assessed by completely filling the vial with a medium of interest. This testing approach can mask the heterogeneous dissolution behavior of vials produced by conversion of glass tubing. In this study, the corrosion behavior of vials provided by four suppliers was evaluated as a function of fill volume. Vials were filled with incrementally increasing volumes of water for injection (WFI) up to near-maximum capacity and then autoclaved. The pH and levels of extracted ions were measured. The pH of autoclaved WFI generally increased for low fill volumes relative to pure WFI, presumably because of extraction of alkali from the heel region. The pH was found to generally decrease with increasing fill volume as the concentration of extractables was diluted. Analysis of dissolution profiles supports the altered surface chemistry of the heel region relative to the body. The results of this study demonstrate the potential limitations of conventional hydrolytic resistance tests and the susceptibility of the heel region to aqueous corrosion.

Abrogation of the inflammatory response in LPS-stimulated RAW 264.7 murine macrophages by Zn- and Cu-doped bioactive sol-gel glasses.

The attenuation of an in vitro inflammatory response in RAW 264.7 murine macrophages stimulated with lipopolysaccharide (LPS) endotoxin was tested using sol-gel-derived bioactive glasses. Three general types of sol-gel-derived samples were evaluated: 58S, zinc-containing glasses, and copper-containing glasses. Distinct experimental procedures were used to test the potential of bioactive glasses to attenuate the inflammatory response in three situations: (1) therapeutically following LPS stimulation, (2) prophylactically before LPS stimulation of macrophages, and (3) indirectly via the glass dissolution products after stimulation with LPS. A sandwich enzyme-linked immunosorbent assay (ELISA) was used to monitor the concentration of tumor necrosis factor-alpha (TNF-alpha) secreted by macrophage cells. The strongest reduction in TNF-alpha concentration was observed when macrophage cells were first incubated with bioactive glass powder and then stimulated with LPS. This suggests a possible prophylactic application of these bioactive glasses for the prevention of inflammation. The 58S glass was capable of reducing the expression of TNF-alpha by macrophages, although the zinc- and copper-containing were more effective at suppressing the inflammatory response. The additional benefit of using zinc- and copper-doped bioactive glasses may be explained by the direct interactions of zinc and copper ions in key regulatory pathways for the inflammation response.

Bioactive evaluation of 45S5 bioactive glass fibres and preliminary study of human osteoblast attachment.

Bioactive glass fibres can be used as tissue engineering scaffolds. In this investigation, the bioactive response of 45S5 glass fibres was assessed in simulated body fluid (SBF). Preliminary attachment of osteoblasts to the fibre surface was assessed, as were the fibre tensile strength and fracture toughness. Fourier transform infrared spectroscopy (FTIR) analysis revealed that hydroxyapatite (HA) was formed on the fibres' surface after 2-4 days in SBF. Raman micro-spectroscopic analysis was used to monitor development of the HA layer during immersion. A correlation was found between increase in intensity of the PO4(3-) peak near 964cm(-1) and appearance of crystalline HA (P-O bending peaks) using FTIR. Such results are encouraging for in situ bioactivity monitoring, as Raman spectra are insensitive to the presence of water, unlike FTIR. Average tensile strength of 45S5 fibres (79 microm diameter) was 340+/-140 MPa. Fracture toughness, determined using fracture surface analysis, was 0.7+/-0.1 MPa m1/2. Confocal microscopy revealed osteoblasts attached and spread along the fibres after 15-90 min culture. Scanning electron microscopy analysis showed that cells with filopodia and dorsal ruffles remained attached after 14 days in culture. These results are encouraging, as cell adhesion is an important first step prior to proliferation and differentiation.