Applications of the reflective practice questionnaire in medical education.

BACKGROUND: We sought to determine whether the Reflective Practice Questionnaire (RPQ) is a reliable measure of reflective capacity and related characteristics in medical students. We also planned to learn how the RPQ could be used in medical education. METHODS: The RPQ is a 40 item self-report questionnaire that includes a multi-faceted approach to measuring reflective capacity. It also includes sub-scales on several other theoretically relevant constructs such as desire for improvement, confidence, stress, and job satisfaction. The reliabilities of reflective capacity and other sub-scales were determined by calculating their Cronbach alpha reliability values. In the present study, the RPQ was answered by 98 graduating fourth-year medical students from an American University, and these RPQ scores were compared with general public and mental health practitioner samples from a prior study using ANOVA and Bonferroni adjusted comparisons. RESULTS: Medical students reported a higher reflective capacity than the general public sample, but students were statistically indistinguishable from the mental health practitioner sample. For medical students, reflective capacity was associated with features of confidence, stress, and desire for improvement. Job satisfaction was positively associated with confidence in communication with patients, and negatively associated with stress when interacting with patients. A cluster analysis revealed that around 19% of the medical students exhibited a relatively high level of anxiety interacting with patients, 23% were less engaged, 5% were dissatisfied, and 7% expressed a level of over-confidence in their knowledge and skills that was concerning. CONCLUSIONS: The RPQ is a reliable measure of reflective capacity (Chronbach's alpha value = 0.84) and related characteristics (Cronbach's alpha values from 0.75 to 0.83) in medical students. The RPQ can be used as part of pre-post evaluations of medical education initiatives, to complement student self-reflection activities in the curriculum, and to identify students who might benefit from targeted intervention.

Colon carcinogenesis in wild type and immune compromised mice after treatment with azoxymethane, and azoxymethane with dextran sodium sulfate.

The association between inflammation and the risk of colorectal cancer (CRC) is well documented in animal models and in humans, but the mechanistic role of inflammation in CRC is less well understood. To address this question, the induction of colon tumors was evaluated in (i) wild type (WT) and athymic BALB/c mice treated with the colon carcinogen azoxymethane (AOM) as a single agent, and (ii) in an inflammation model of colon cancer employing AOM and dextran sodium sulfate (DSS) in WT, athymic, TCRß(-/-) , TCRδ(-/-) and TCRß(-/-) TCRδ(-/-) C57Bl/6 mice. The athymic BALB/c mice treated with only AOM developed 90% fewer tumors than the WT mice. The difference in response was not due to metabolic activation of AOM or repair of DNA adducts. In the inflammation model using a standard sequential exposure to AOM followed by DSS treatment, the tumor incidence in WT mice was 58% with 7 adenomas and 6 adenocarcinomas. In contrast, the TCRß(-/-) , TCRδ(-/-) and TCRß(-/-) TCRδ(-/-) C57Bl/6 mice showed adenoma incidences of 10, 33, and 11%, respectively, and none of the immune compromised mice developed adenocarcinomas. When the DSS exposure was increased and the AOM lowered, no difference was observed between WT and TCRß(-/-) mice due to an increase in the incidence in the TCR null mice without concomitant increase in the WT mice. No tumors were observed in mice treated with AOM or DSS alone. © 2015 Wiley Periodicals, Inc.

Addison disease: early detection and treatment principles.

Primary adrenal insufficiency, or Addison disease, has many causes, the most common of which is autoimmune adrenalitis. Autoimmune adrenalitis results from destruction of the adrenal cortex, which leads to deficiencies in glucocorticoids, mineralocorticoids, and adrenal androgens. In the United States and Western Europe, the estimated prevalence of Addison disease is one in 20,000 persons; therefore, a high clinical suspicion is needed to avoid misdiagnosing a life-threatening adrenal crisis (i.e., shock, hypotension, and volume depletion). The clinical manifestations before an adrenal crisis are subtle and can include hyperpigmentation, fatigue, anorexia, orthostasis, nausea, muscle and joint pain, and salt craving. Cortisol levels decrease and adrenocorticotropic hormone levels increase. When clinically suspected, patients should undergo a cosyntropin stimulation test to confirm the diagnosis. Treatment of primary adrenal insufficiency requires replacement of mineralocorticoids and glucocorticoids. During times of stress (e.g., illness, invasive surgical procedures), stress-dose glucocorticoids are required because destruction of the adrenal glands prevents an adequate physiologic response. Management of primary adrenal insufficiency or autoimmune adrenalitis requires vigilance for concomitant autoimmune diseases; up to 50% of patients develop another autoimmune disorder during their lifetime.

Substantial Increases in Healthcare Students' State Empathy Scores Owing to Participation in a Single Improvisation Session.

PURPOSE: To determine whether the 12-item state empathy scale could be modified reliably to measure empathy in healthcare professions students and to detect changes in their empathy owing to a single improvisation (improv) session. METHODS: Three cohorts of students from two healthcare professions programs (total = 165 students) participated in an improv session. During the session, one of the researchers (BS) tasked the students with several improv activities. Participants' self-reported state empathy scores were assessed at three time points (pre-improv, post-improv, and end of semester) using revised, in-class paper versions of the State Empathy Scale. RESULTS: The exploratory factor analysis revealed a single factor solution for the revised scale, justifying the creation of an overall state empathy score from the questionnaire. Cronbach's alpha reliability values averaged 0.87. Students' mean empathy scores were higher directly after the improv session than directly prior to the session (p < 0.0001; effect size = r = 0.67, 0.55, and 0.79 for cohorts 1, 2, and 3, respectively). CONCLUSIONS: These findings show that a single one- or two-hour improv session can foster substantial increases in healthcare professional students' state empathy for one another. Greater healthcare professional empathy and compassion foster better healthcare team cooperation and patient outcomes, so healthcare professionals and their students should engage in such empathy-enhancing activities at regular intervals throughout their training and careers.

Further development of the reflective practice questionnaire.

Background: This article provides an update of the Reflective Practice Questionnaire (RPQ). The original RPQ consisted of 40-items with 10-sub-scales. In this article, the RPQ is streamlined into a 10-item single reflective practice construct, and a 30-item extended version that includes additional sub-scales of confidence, uncertainty/stress, and work satisfaction. Methods: A total of 501 university students filled out an online questionnaire that contained the original Reflective Practice Questionnaire, and two general measures of reflection: The Self-Reflection and Insight Scale, and the Rumination-Reflection Questionnaire. Results: Based on factor analysis, the RPQ was streamlined into a brief 10-item version, and an extended 30-item version. Small positive correlations were found between the RPQ reflective practice measure and the two measures of general reflection, providing discriminant validity evidence for the RPQ. The RPQ was found to be sensitive to differences among industries, whereas the general measures of reflection were not. Average reflective practice scores were higher for health and education industries compared to retail and food/accommodation industries.

Photodistributed Stevens-Johnson syndrome and toxic epidermal necrolysis: a systematic review and proposal for a new diagnostic classification.

BACKGROUND: Ultraviolet radiation (UVR) exposure is commonly reported as a risk factor for Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). However, minimal evaluation of photo-induced SJS/TEN has been conducted. Thus, this review identifies all cases of SJS/TEN that are linked to an acute exposure of UVR and outlines the unifying characteristics of these cases. Furthermore, the theoretical pathogenesis, differential diagnoses, and proposed diagnostic criteria are defined. METHODS: PubMed, Google Scholar, and other databases and websites were searched from inception to September 2021 to identify studies that met inclusion criteria. The following keywords were utilized: "Stevens-Johnson syndrome" and "toxic epidermal necrolysis" with "ultraviolet," "photodistributed," "photo-induced," "photosensitivity," and "photo." One reviewer assessed study characteristics, with confirmation by a second. The risk of bias was assessed independently by another. RESULTS: Thirteen patient cases were identified, all reporting ultraviolet radiation prior to rash onset and an underlying causal drug. Case classifications included 7/13 SJS and 6/13 TEN. All cases described the rash as photodistributed with UVR exposure prior to rash onset (delay of 1-3 days) and a causal drug. 10 cases provided evidence that the photodistributed rash lacked linear demarcation (as in a sunburn) with satellite target-like lesions. No cases described a flu-like prodrome. DISCUSSION: Mucositis, palmar and plantar rash, a positive Nikolsky sign, and a prolonged disease course can help distinguish from photosensitive reactions, while a negative direct immunofluorescence test is important to distinguish from other photo-induced disorders. CONCLUSION: Physicians should be aware that UVR may precipitate SJS/TEN in patients taking susceptible drugs. After a 24-h delay from UVR exposure, a non-distinct, photodistributed rash appears with no flu-like prodrome and progresses for at least 48 h to include vesiculobullous eruptions and mucous membrane involvement. Photodistributed SJS/TEN appears to be photo-drug-induced with a unique onset and rash presentation that should be recognized as a distinct diagnosis.

Survey of attitudes toward performing and reflecting on required team service-learning (SASL): psychometric data and reliability/validity for healthcare professions students in preclinical courses.

Purpose: Previously we assessed healthcare professional students' feelings about team-based learning, implicit bias, and service to the community using an in-house paper survey. In this study, we determined whether this survey is a reliable and valid measure of prospective medical students' attitudes toward required service-learning in an Immunology course. To our knowledge, no published questionnaire has been shown to be dependable and useful for measuring such attitudes using only eight survey items. Methods: Fifty-eight prospective medical students in Colorado (CO) and 15 in Utah (UT) completed the same Immunology course using remote technology. In addition to the usual course content, students were required to write critical reflections on required team service-learning. On the last day of class, they completed the survey of attitudes toward service-learning (SASL). Results: Data analyses found Cronbach's alpha values of 0.84 and 0.85 for the surveys of UT and CO students, respectively. Factor analysis of CO student data revealed only one Eigenvalue greater than one (3.95) justifying retention of a single factor termed "attitudes toward required service-learning." In addition, CO students' attitudes toward community service were highly positive, while UT students' attitudes were nearer neutral (p < 0.0001). Conclusion: Our factor analysis and good Cronbach's alpha values support the conclusion that the SASL was a reliable measure of prospective medical students' attitudes toward required team service-learning for an Immunology course. Moreover, we used the SASL to distinguish these attitudes in CO versus UT students, and, thus, the SASL appears to be a valid measure of this difference. Calculation of similarly good Cronbach's alpha values - for a predecessor of the SASL among pharmacy, masters, and medical students at another institution - indicates that the SASL may be useful more widely. However, the reliability and validity of the SASL needs to be demonstrated more rigorously for other healthcare students at different universities.

SPLUNC1 promotes lung innate defense against Mycoplasma pneumoniae infection in mice.

Short palate, lung, and nasal epithelium clone 1 (SPLUNC1) protein is highly expressed in normal airways, but is dramatically decreased in allergic and cigarette smoke exposure settings. We have previously demonstrated SPLUNC1 in vitro antibacterial property against Mycoplasma pneumoniae (Mp). However, its in vivo biological functions remain unclear. The objectives of this study were to determine the in vivo functions of SPLUNC1 following bacterial (eg, Mp) infection, and to examine the underlying mechanisms. We generated SPLUNC1-deficient mice and utilized transgenic mice overexpressing human SPLUNC1 exclusively within the airway epithelium. These mice were infected with Mp and, twenty-four hours post infection, their host defense responses were compared to littermate controls. Mp levels and inflammatory cells increased in the lungs of SPLUNC1(-/-) mice as compared to wild type controls. SPLUNC1 deficiency was shown to contribute to impaired neutrophil activation. In contrast, mice overexpressing hSPLUNC1 exclusively in airway epithelial cells demonstrated lower Mp levels. Furthermore, neutrophil elastase activity was significantly increased in mice overexpressing hSPLUNC1. Lastly, we demonstrated that SPLUNC1 enhanced Mp-induced human neutrophil elastase (HNE) activity, and HNE directly inhibited the growth of Mp. Our findings demonstrate a critical in vivo role of SPLUNC1 in host defense against bacterial infection, and likely provide a novel therapeutic approach to restore impaired lung innate immune responses to bacteria in patients with chronic lung diseases.

Critical reflection on required service to the community propels prospective medical students toward higher empathy, compassion, and bias mitigation but are these gains sustainable?

Purpose: We observed increased cognitive empathy and reflective capacity scores when prospective medical students wrote critical reflections on mandatory team service-learning in a Medical Humanities course, but these findings did not include a control group. Here we compare these survey results in similar courses with and without required service-learning. Methods: Forty-three prospective medical students completed a Medical Humanities course requiring critical reflection on team service-learning. In comparison, 32 students finished a similar course in which service to the community was not mandatory. Before starting the courses, students completed reliable surveys of their cognitive empathy and reflective capacity, and more than 93% of the students completed the same surveys after finishing the courses. Results: Students' cognitive empathy and reflective capacity scores increased significantly when service-learning was required, but the scores did not increase significantly when service to the community was not required. The effect size for the empathy increase was of crucial practical importance (r = 0.50), whereas it was of moderate practical importance for the increase in reflective capacity (r = 0.34). Conclusions: These and prior findings strongly support the conclusion that students' critical reflection on mandatory team service-learning fosters development of their cognitive empathy and reflective capacity. We present a model program to incorporate critical reflection on service to the community throughout the curricula of all healthcare professions trainees.

Impact of a Pandemic and Remote Learning on Team Development and Elements of Compassion in Prospective Medical Students Taking a Medical Humanities Course.

INTRODUCTION: We reported previously that when teams of students reflect on readings about communication, unconscious bias, and service-learning, their critical reflection, implicit bias mitigation, empathy, and compassionate behavior all increase. However, would these gains occur when intimate classroom settings, in-person team meetings, and direct interactions with people served were lost owing to the COVID-19 pandemic and remote learning? METHODS: Before an online Medical Humanities course began in August 2020 and following the course in December 2020, 61 prospective medical students (54.1% female) completed reliable surveys of their reflective capacity (RC) and cognitive empathy (compassion). Students also completed surveys about their implicit biases and team community service in December 2020. RESULTS: Both RC and empathy scores increased in students after they reflected on difficulties in communication, unconscious biases, and team service-learning experiences in the course. In written reflections, they reported how their compassionate behavior also grew owing to bias mitigation. Most students concurred that "unconscious bias might affect some of (their) clinical decisions or behaviors as a healthcare professional" and vowed to remain aware of these biases in clinical settings. CONCLUSIONS: Compared to previous years, the pandemic and remote learning had minimal effects on the benefits of our Medical Humanities course.

SPLUNC1 regulation in airway epithelial cells: role of Toll-like receptor 2 signaling.

BACKGROUND: Respiratory infections including Mycoplasma pneumoniae (Mp) contribute to various chronic lung diseases. We have shown that mouse short palate, lung, and nasal epithelium clone 1 (SPLUNC1) protein was able to inhibit Mp growth. Further, airway epithelial cells increased SPLUNC1 expression upon Mp infection. However, the mechanisms underlying SPLUNC1 regulation remain unknown. In the current study, we investigated if SPLUNC1 production following Mp infection is regulated through Toll-like receptor 2 (TLR2) signaling. METHODS: Airway epithelial cell cultures were utilized to reveal the contribution of TLR2 signaling including NF-κB to SPLUNC1 production upon bacterial infection and TLR2 agonist stimulation. RESULTS: Mp and TLR2 agonist Pam3CSK4 increased SPLUNC1 expression in tracheal epithelial cells from wild type, but not TLR2(-/-) BALB/c mice. RNA interference (short-hairpin RNA) of TLR2 in normal human bronchial epithelial cells under air-liquid interface cultures significantly reduced SPLUNC1 levels in Mp-infected or Pam3CSK4-treated cells. Inhibition and activation of NF-κB pathway decreased and increased SPLUNC1 production in airway epithelial cells, respectively. CONCLUSIONS: Our data for the first time suggest that airway epithelial TLR2 signaling is pivotal in mycoplasma-induced SPLUNC1 production, thus improving our understanding of the aberrant SPLUNC1 expression in airways of patients suffering from chronic lung diseases with bacterial infections.

Fostering Empathy, Implicit Bias Mitigation, and Compassionate Behavior in a Medical Humanities Course.

Increases in compassionate behavior improve patient outcomes and reduce burnout among healthcare professionals. We predicted that selecting and performing service-learning projects by teams of prospective medical students in a Medical Humanities course would foster students' compassion by raising their reflective capacity, empathy, and unconscious bias mitigation. In class, we discussed difficulties in communication and implicit bias. In this observational study, teams wrote individual and team critical reflections on these class discussions and their service-learning experiences, and we analyzed these reflections for dissonance, self-examination, bias mitigation, dissonance reconciliation, and compassionate behavior. Thirty-two students (53% female) completed the Reflective Practice Questionnaire and the Jefferson Scale of Empathy before the course in August 2019 and after it in December 2019. In December, students were surveyed concerning their attitudes toward team service-learning projects and unconscious bias. The students reported changes in their behavior to mitigate biases and become more compassionate, and their reflective capacity and empathy grew in association with discussions and team service-learning experiences in the course. Virtually all students agreed with the statement "Unconscious bias might affect some of my clinical decisions or behaviors as a healthcare professional," and they worked to control such biases in interactions with the people they were serving.

Selecting and Performing Service-Learning in a Team-Based Learning Format Fosters Dissonance, Reflective Capacity, Self-Examination, Bias Mitigation, and Compassionate Behavior in Prospective Medical Students.

More compassionate behavior should make both patients and their providers happier and healthier. Consequently, work to increase this behavior ought to be a major component of premedical and medical education. Interactions between doctors and patients are often less than fully compassionate owing to implicit biases against patients. Such biases adversely affect treatment, adherence, and health outcomes. For these reasons, we studied whether selecting and performing service-learning projects by teams of prospective medical students prompts them to write reflections exhibiting dissonance, self-examination, bias mitigation, dissonance reconciliation, and compassionate behavior. Not only did these students report changes in their behavior to become more compassionate, but their reflective capacity also grew in association with selecting and performing team service-learning projects. Components of reflective capacity, such as reflection-on-action and self-appraisal, correlated strongly with cognitive empathy (a component of compassion) in these students. Our results are, however, difficult to generalize to other universities and other preprofessional and professional healthcare programs. Hence, we encourage others to test further our hypothesis that provocative experiences foster frequent self-examination and more compassionate behavior by preprofessional and professional healthcare students, especially when teams of students are free to make their own meaning of, and build trust and psychological safety in, shared experiences.

A Model to Promote Public Health by Adding Evidence-Based, Empathy-Enhancing Programs to All Undergraduate Health-care Curricula.

Fostering empathy in future health-care providers through service-learning is emerging as central to public health promotion. Patients fare better when their caregivers have higher relationship-centered characteristics such as the ones measured by the Jefferson Scale of Empathy. Unfortunately, these characteristics often deteriorate during health-care professional training. Nevertheless, growing literature documents how we can promote empathy, and other patient-centered characteristics, throughout health-care professional students' undergraduate education. As for proven treatment plans, we believe we should also use evidence-based guidelines to foster relationship-centered characteristics in our students when training them to practice as part of an interdisciplinary health-care team.