When and How Would You Screen This Patient for Cervical Cancer? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

Successful screening programs based on cervical cytology have dramatically reduced the incidence of cervical cancer in the United States. Human papillomavirus immunization is poised to reduce it further as an increasing percentage of vaccinated women reach adulthood. A recent guideline from the American Cancer Society advises that cervical cancer screening begin at age 25 and that high-risk human papillomavirus testing is the preferred screening test. The U.S. Preventive Services Task Force recommends screening begin at age 21 and that cytology remain incorporated into screening. Here, 2 experts debate how to apply these guidelines to Ms. L, a 22-year-old woman who has never undergone cervical cancer screening.

Opportunities and challenges for a standardized curriculum in a student-run clinic network.

PURPOSE: Student-run clinics (SRCs) are prevalent in medical schools. Although these are popular among students and provide ample learning opportunities, these opportunities are not well-characterized. SRCs are poised to support medical schools' ability to meet accreditation standards and student growth and learning, particularly in areas missing from traditional curricula, such as social determinants of health, interprofessional education and inequities. MATERIALS AND METHODS: At the Crimson Care Collaborative (CCC), a network of 7 Harvard Medical School affiliated student-faculty practices in the greater Boston area, we sought to understand what learning opportunities and challenges exist and if a standardized curriculum could improve learning and result in less duplication of teaching efforts. We conducted semi-structured individual interviews of student and faculty leaders and conducted a thematic analysis of the data. RESULTS: Four key themes emerged: (1) Standardization provides opportunities and challenges, (2) Embrace the unique learning opportunities of each clinic, (3) Educational coaches enhance learning opportunities and increase efficiency, (4) Reflection is a useful tool for improvement & learning. DISCUSSION: Our results demonstrate a benefit to both a standardized curriculum for all SRC sites focused on broad clinical, skill-based training and site-specific teaching focusing on the unique clinical needs of each student-run clinic.

Innovation and Missed Opportunities in Internal Medicine Undergraduate Education During COVID-19: Results from a National Survey.

BACKGROUND: COVID-19 disrupted undergraduate clinical education when medical schools removed students from clinical rotations following AAMC recommendations. Clerkship directors (CDs) had to adapt rapidly and modify clerkship curricula. However, the scope and effects of these modifications are unknown. OBJECTIVE: To examine the effects of the initial phase of COVID-19 on the internal medicine (IM) undergraduate clinical education. DESIGN: A nationally representative web survey. PARTICIPANTS: IM CDs from 137 LCME-accredited US medical schools in 2020. MAIN MEASURES: Items (80) assessed clerkship structure and curriculum, assessment in clerkships, post-clerkship IM clinical experiences, and CD roles and support. The framework of Understanding Crisis Response (Royal Society for Encouragement of Arts, Manufactures, and Commerce) was used to determine whether curricular modifications were "amplified," "restarted," "let go," or "ended." KEY RESULTS: Response rate was 74%. In response to COVID-19, 32% (32/101) of clerkships suspended all clinical activities and 66% (67/101) only in-person. Prior to clinical disruption, students spent a median of 8.0 weeks (IQR: 2) on inpatient and 2.0 weeks (IQR: 4) on ambulatory rotations; during clinical re-entry, students were spending 5.0 (IQR: 3) and 1.0 (IQR: 2) weeks, respectively. Bedside teaching and physical exam instruction were "let go" during the early phase. Students were removed from direct patient care for a median of 85.5 days. The sub-internship curriculum remained largely unaffected. Before the pandemic, 11% of schools were using a pass/fail grading system; at clinical re-entry 47% and during the survey period 23% were using it. Due to the pandemic, 78.2% of CDs assumed new roles or had expanded responsibilities; 51% reported decreased scholarly productivity. CONCLUSIONS: Curricular adaptations occurred in IM clerkships across US medical schools as a result of COVID-19. More research is needed to explore the long-term implications of these changes on medical student education and clinical learning environments.

A systematic literature review to identify ethical, legal, and social responsibilities of nonprofit organizations when funding clinical trials in pediatric cancer.

Nonprofit organizations (NPOs) play critical roles as funding sources, research partners, and disseminators of drug developments in pediatric cancer. Yet the literature provides limited guidance about ethical best practices when NPOs make trial funding decisions in this space. We conducted a systematic review of the literature indexed in PubMed and Web of Science to identify the ethical, legal, and social responsibilities of NPOs to four key stakeholder groups in funding pediatric cancer trials: (i) patients/families, (ii) researchers, (iii) industry sponsors, and (iv) donors. We applied the lifecycle framework for patient engagement in drug research and development proposed by Geissler and colleagues to analyze themes related to NPOs' responsibilities across 54 articles that met our inclusion criteria. Emergent themes included transparency surrounding conflicts of interest, the rigor of scientific review, and communication with patients/communities about trial progress. Our research identified critical gaps in best practices for negotiating research partnerships, managing competing research priorities, and pursuing alternative financing models including venture philanthropy. Results from our review informed a set of best practices to guide NPOs in making trial funding decisions that align with stakeholder values and interests.

Defining curricular priorities for student-as-teacher programs: A National Delphi Study.

BACKGROUND: "Student-as-Teacher" (SaT) programs have been growing in number to prepare medical students for their teaching roles in residency and beyond, but it remains unknown what content areas should be covered in SaT curricula. AIM: To determine five to ten "essential" content areas for inclusion in SaT curricula using expert opinion. METHODS: Using a three-round Delphi process, moderators iteratively surveyed a panel of 28 medical educators (25 academy directors and three individuals identified as having expertise in undergraduate medical education) representing 25 medical schools in the United States. This "SaT Delphi Working Group" was tasked with rating topics for inclusion in SaT curricula on a 3-point scale (i.e. 1. "essential," 2. "important, but not essential" 3. "not important"). Topics achieving ≥70% consensus as "essential," "important" or "not important" were accepted by the moderators and removed from subsequent rounds. RESULTS: Hundred per cent response rate (n = 28) was achieved for all survey rounds. Five content areas reached consensus as "essential" for inclusion in a SaT curriculum: feedback, bedside teaching and clinical precepting, small-group teaching, case-based teaching and professionalism as a medical educator. CONCLUSION: This consensus from a group of leaders in medical education is a first step toward the implementation of more developmentally-appropriate SaT competencies.

Integration of systematic clinical interprofessional training in a student-faculty collaborative primary care practice.

The changing healthcare environment and movement toward team-based care are contemporary challenges confronting health professional education. The primary care workforce must be prepared with recent national interprofessional competencies to practice and lead in this changing environment. From 2012 to 2014, the weekly Beth Israel Deaconess Crimson Care Collaborative Student-Faculty Practice collaborated with Northeastern University to develop, implement and evaluate an innovative model that incorporated interprofessional education into primary care practice with the goal of improving student understanding of, and ability to deliver quality, team-based care. In the monthly interprofessional clinic, an educational curriculum empowered students with evidence-based, team-based care principles. Integration of nursing, pharmacy, medicine, and masters of public health students and faculty into direct patient care, provided the opportunity to practice skills. The TeamSTEPPS® Teamwork Attitudes Questionnaire was administered pre- and post-intervention to assess its perceived impact. Seventeen students completed the post-intervention survey. Survey data indicated very positive attitudes towards team-based care at baseline. Significant improvements were reported in attitudes towards situation monitoring, limiting personal conflict, administration support and communication. However, small, but statistically significant declines were seen on one team structure and two communication items. Our program provides further evidence for the use of interprofessional training in primary care.

Assessing Interprofessional education in a student-faculty collaborative practice network.

Although interprofessional relationships are ubiquitous in clinical practice, undergraduate medical students have limited opportunities to develop these relationships in the clinical setting. A few student-faculty collaborative practice networks (SFCPNs) have been working to address this issue, but limited data exist examining the nature and extent of these practices. A systematic survey at a Harvard-affiliated SFCPN is utilised to evaluate the quantity and quality of interprofessional interactions, isolate improvements, and identify challenges in undergraduate interprofessional education (IPE). Our data corroborate previous findings in which interprofessional clinical learning was shown to have positive effects on student development and align with all four domains of Interprofessional Education Collaborative core competencies, including interprofessional ethics and values, roles and responsibilities, interprofessional communication, and teams and teamwork. These results highlight the unique opportunity and growing necessity of integrating IPE in SFCPNs to endorse the development of collaborative and professional competencies in clinical modalities of patient care.

How we used a patient visit tracker tool to advance experiential learning in systems-based practice and quality improvement in a medical student clinic.

Poorly designed healthcare systems increase costs and preventable medical errors. To address these issues, systems-based practice (SBP) education provides future physicians with the tools to identify systemic errors and implement quality improvement (QI) initiatives to enhance the delivery of cost-effective, safe and multi-disciplinary care. Although SBP education is being implemented in residency programs and is mandated by the Accreditation Council for Graduate Medical Education (ACGME) as one of its core competencies, it has largely not been integrated into undergraduate medical education. We propose that Medical Student-Faculty Collaborative Clinics (MSFCCs) may be the ideal environment in which to train medical students in SBPs and QI initiatives, as they allow students to play pivotal roles in project development, administration, and management. Here we describe a process of experiential learning that was developed within a newly established MSFCC, which challenged students to identify inefficiencies, implement interventions, and track the results. After identifying bottlenecks in clinic operations, our students designed a patient visit tracker tool to monitor clinic flow and implemented solutions to decrease patient visit times. Our model allowed students to drive their own active learning in a practical clinical setting, providing early and unique training in crucial QI skills.

Comparing Perceptions of Virtual and In-Person Interviews: Results From a National Survey of Internal Medicine Residents.

Background Since 2020, virtual interviews have become the typical way in which applicants assess residency programs. It is unknown whether the change from in-person to virtual interviews has been associated with changes in perceptions of the quality of information gathered by prospective applicants. Objective To ascertain perspectives on the satisfaction with, quality of, and accuracy of information gathered by internal medicine (IM) residency applicants from virtual and in-person interviews. Methods Twenty-nine thousand, seven hundred and seventy-six residents from US and Puerto Rico residency programs sitting for the 2022 American College of Physicians Internal Medicine In-Training Examination (IM-ITE) were surveyed. An optional, 5-question survey was administered at the end of the examination. Responses were analyzed based on interview format-virtual (postgraduate year [PGY]-1-2) or in-person (PGY-3)-and PGY. Results Of 29 776, 23 161 residents responded to the survey (77.8% response rate). Regardless of PGY, respondents reported a high degree of satisfaction with the quality of information gathered from their interview day, though there was a statistically significant difference between virtual and in-person [somewhat/very satisfied: In-person 5938 of 7410 (80.1%); 95% CI [79.2, 81.0] vs virtual 12 070 of 15 751 (76.6%); 95% CI [76.0, 77.3]:P<.001]. Residents in all PGYs reported sessions with residents and one-on-one interviews as the most important factors when creating their rank lists. Conclusions We found differences in satisfaction and perceptions of the quality of information gathered between IM residents who participated in virtual and in-person interviews. However, regardless of format, most respondents reported satisfaction with their interview experience.

Moving Beyond the Dichotomous Assessment of Professionalism in the Internal Medicine Clerkship: Results of a National Survey of Clerkship Directors.

PURPOSE: This study examines how internal medicine clerkship faculty and leadership conceptualize professionalism and professional behaviors and attitudes, identifies whether and how faculty use metrics to assess professionalism and factor it into clerkship grades, and describes barriers that prevent faculty from feeling prepared to support the development of professional behaviors in students. METHOD: The Clerkship Directors in Internal Medicine opened a call for thematic survey section proposals to its physician-faculty members, blind-reviewed all submissions, and selected 4 based on internal medicine clinical clerkship training experience relevance. The survey launched on October 5 and closed on December 7, 2021. Data were analyzed using descriptive statistics. RESULTS: Of 137 core clerkship directors (CDs) at Liaison Committee on Medical Education-accredited medical schools, 103 (75.2%) responded to the survey. Of 102 respondents (1 nonrespondent), 84 (82.4%) identified professional behavior lapses in involvement and 60 (58.8%) identified introspection lapses. Of 103 respondents, 97 (94.2%) reported that their clerkships ask clinical faculty and residents to formally evaluate professionalism, and 64 (62.1%) reported that they factor professionalism assessments into final clerkship grades. CDs reported multiple barriers to addressing professionalism directly with students, including logistical barriers, professionalism assessment subjectivity concerns, and the possible adverse effect of an unprofessional label for students. CONCLUSIONS: Professionalism assessment and remediation in medical education currently center on a deficit model that seeks to identify and remediate professionalism lapses, rather than a developmental model that seeks to nurture growth. This dichotomous characterization of behaviors as professional or unprofessional limits assessment and can adversely affect the learning environment. The authors propose a shift to a developmental model that considers professionalism as a continuous process parallel to the acquisition of clinical skills and medical knowledge.

Paediatric strategy forum for medicinal product development of PI3-K, mTOR, AKT and GSK3ß inhibitors in children and adolescents with cancer.

Phosphatidylinositol 3-kinase (PI3-K) signalling pathway is a crucial path in cancer for cell survival and thus represents an intriguing target for new paediatric anti-cancer drugs. However, the unique clinical toxicities of targeting this pathway (resulting in hyperglycaemia) difficulties combining with chemotherapy, rarity of mutations in childhood tumours and concomitant mutations have resulted in major barriers to clinical translation of these inhibitors in treating both adults and children. Mutations in PIK3CA predict response to PI3-K inhibitors in adult cancers. The same mutations occur in children as in adults, but they are significantly less frequent in paediatrics. In children, high-grade gliomas, especially diffuse midline gliomas (DMG), have the highest incidence of PIK3CA mutations. New mutation-specific PI3-K inhibitors reduce toxicity from on-target PI3-Kα wild-type activity. The mTOR inhibitor everolimus is approved for subependymal giant cell astrocytomas. In paediatric cancers, mTOR inhibitors have been predominantly evaluated by academia, without an overall strategy, in empiric, mutation-agnostic clinical trials with very low response rates to monotherapy. Therefore, future trials of single agent or combination strategies of mTOR inhibitors in childhood cancer should be supported by very strong biological rationale and preclinical data. Further preclinical evaluation of glycogen synthase kinase-3 beta inhibitors is required. Similarly, even where there is an AKT mutation (∼0.1 %), the role of AKT inhibitors in paediatric cancers remains unclear. Patient advocates strongly urged analysing and conserving data from every child participating in a clinical trial. A priority is to evaluate mutation-specific, central nervous system-penetrant PI3-K inhibitors in children with DMG in a rational biological combination. The choice of combination, should be based on the genomic landscape e.g. PTEN loss and resistance mechanisms supported by preclinical data. However, in view of the very rare populations involved, innovative regulatory approaches are needed to generate data for an indication.

Transitions curriculum impact on students and care.

BACKGROUND: Transitions of patient care from the inpatient to outpatient setting is a high-risk time often resulting in medical errors and adverse events. Transitions of care programmes have been demonstrated to reduce negative outcomes. Several professional societies have highlighted care transitions as a central pillar of patient care and therefore a crucial aspect of health professional education; however, little data exist on medical student education in this area. APPROACH: The Transitions of Care Curriculum was developed and delivered to all Harvard Medical School Core I Internal Medicine Clerkship students at Beth Israel Deaconess Medical Center, Boston, MA between January 2017 and March 2019, where 12-14 students participated each quarter and included didactic teaching followed by experiential learning. Student data were collected via postclerkship survey. Patient data were collected via chart review. Student self-reported comfort level with transitions in care skills and medical errors were analysed. EVALUATION: All student measures related to comfort with transitions in care skills demonstrated statistically significant improvement after curriculum participation(p < 0.001). Of the patients with a completed postdischarge note, students identified ≥1 postdischarge related issue in 33 of 70 patients, with multiple issues identified in many of these patients. Seventy-six total issues were identified. IMPLICATIONS: The Transitions of Care Curriculum demonstrated promising student and patient outcomes, suggesting that students can successfully learn and advance clinical skills while having a positive impact on a highly needed and important aspect of patient care by reducing postdischarge errors and adverse events.

Paediatric Strategy Forum for medicinal product development in mitogen-activated protein kinase pathway inhibitors: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration.

As the mitogen-activated protein kinase (MAPK) signalling pathway is activated in many paediatric cancers, it is an important therapeutic target. Currently, a range of targeted MAPK pathway inhibitors are being developed in adults. However, MAPK signals through many cascades and feedback loops and perturbing the MAPK pathway may have substantial influence on other pathways as well as normal development. In view of these issues, the ninth Paediatric Strategy Forum focused on MAPK inhibitors. Development of MAPK pathway inhibitors to date has been predominantly driven by adult indications such as malignant melanoma. However, these inhibitors may also target unmet needs in paediatric low-grade gliomas, high-grade gliomas, Langerhans cell histiocytosis, juvenile myelomonocytic leukaemia and several other paediatric conditions. Although MAPK inhibitors have demonstrated activity in paediatric cancer, the response rates and duration of responses needs improvement and better documentation. The rapid development and evaluation of combination approaches, based on a deep understanding of biology, is required to optimise responses and to avoid paradoxical tumour growth and other unintended consequences including severe toxicity. Better inhibitors with higher central nervous systempenetration for primary brain tumours and cancers with a propensity for central nervous system metastases need to be studied to determine if they are more effective than agents currently being used, and the optimum duration of therapy with MAPK inhibition needs to be determined. Systematic and coordinated clinical investigations to inform future treatment strategies with MAPK inhibitors, rather than use outside of clinical trials, are needed to fully assess the risks and benefits of these single agents and combination strategies in both front-line and in the refractory/relapse settings. Platform trials could address the investigation of multiple similar products and combinations. Accelerating the introduction of MAPK inhibitors into front-line paediatric studies is a priority, as is ensuring that these studies generate data appropriate for scientific and regulatory purposes. Early discussions with regulators are crucial, particularly if external controls are considered as randomised control trials in small patient populations can be challenging. Functional end-points specific to the populations in which they are studied, such as visual acuity, motor and neuro psychological function are important, as these outcomes are often more reflective of benefit for lower grade tumours (such as paediatric low-grade glioma and plexiform neurofibroma) and should be included in initial study designs for paediatric low-grade glioma. Early prospective discussions and agreements with regulators are necessary. Long-term follow-up of patients receiving MAPK inhibitors is crucial in view of their prolonged administration and the important involvement of this pathway in normal development. Further rational development, with a detailed understanding of biology of this class of products, is crucial to ensure they provide optimal benefit while minimising toxicity to children and adolescents with cancer.

Teaching medical students about obesity: a pilot program to address an unmet need through longitudinal relationships with bariatric surgery patients.

BACKGROUND: Despite obesity's relevance and impact, curricula addressing obesity are underrepresented in clinical medical education. A novel pilot program to begin teaching medical students about care of the obese patient was developed and student attitudes toward obesity and bariatric surgery were assessed. METHODS: The authors paired third-year students with obese patients undergoing bariatric surgery. Students established a longitudinal patient relationship, received faculty mentorship, and kept a reflections journal. An attitude assessment survey was administered before and after third year. Reflections were analyzed for common themes. RESULTS: Baseline student responses differed from those previously reported for practicing physicians on many survey statements, including more strongly agreeing with the relationship between obesity and serious medical conditions (P < .001), the need to educate patients about obesity risks (P < .001), and willingness to recommend bariatric surgery evaluation (P = .004). These differences were maintained after clinical clerkships. Reflection themes included recognition of obesity stereotypes, improved estimation of body mass index, and awareness of physicians' attitudes about obesity. CONCLUSION: Development and assessment of a novel pilot program to teach third-year medical students about obesity and bariatric surgery suggests a potential impact on student attitudes and understanding of obesity and obesity surgery. Students today may have different attitudes toward obesity than those reflected in prior data for physicians in practice, and programs such as this may help maintain positive attitudes.

Cognitive function in relapsing multiple sclerosis: minimal changes in a 10-year clinical trial.

BACKGROUND: Although cognitive impairment is common in patients with multiple sclerosis (MS), its value as a clinical trial endpoint remains uncertain. For example, in the randomized, blinded, pivotal trial of glatiramer acetate (GA) in patients with relapsing MS, improvements occurred in neuropsychological test scores during 2 years of treatment regardless of whether patients received GA or placebo, likely due to practice effects. OBJECTIVES: To assess long-term changes in neuropsychological status following 10 years of prospective evaluation in a typical immunotherapy trial cohort. METHODS: Participants in the ongoing open-label GA extension study repeated the Brief Repeatable Battery of Neuropsychological Tests an average of 10.6+/-0.4 years after their initial baseline evaluation. RESULTS: Mean scores on tests of memory and semantic retrieval were not significantly changed over 10 years of follow-up, but tests of attention showed declines for the group as a whole. Using a threshold of a 0.5 SD decline to define significant worsening, individual tests showed declines in 27-49% of participants and a composite score showed worsening in 19%. Controlling for age, gender, and education level, cognitive tests tended to worsen more in participants with better baseline cognitive test scores and higher EDSS scores. Changes in cognitive test scores during the first 2 years of observation were predictive of 10-year changes. CONCLUSIONS: Most patients with relapsing MS had stable cognitive performance during 10 years of prospective evaluation, some of which may be related to a therapeutic effect of GA. Because cognitive changes occur slowly on average, they may not be responsive enough to serve as useful endpoints in studies of course-modifying therapies in relapsing MS.

A Chronic Disease Management Student-Faculty Collaborative Practice: Educating Students on Innovation in Health Care Delivery.

PROBLEM: In the current transformative health care landscape, it is imperative that clinician educators inspire future clinicians to practice primary care in a dynamic environment. A focus on patient-centered, goal-oriented care for patients with chronic conditions is critical. APPROACH: In 2009, Harvard Medical School founded the Crimson Care Collaborative, a student-faculty collaborative practice (SFCP) network. With the aim of expanding clinical and educational opportunities for medical students and improving patient control of chronic disease (i.e., hypertension, obesity, and diabetes) in an innovative learning environment, in 2012, the authors developed a novel SFCP at their hospital-based academic primary care practice. In this SFCP, students learn to explore patient priorities, provide focused counseling and education, and assist patients with self-management goals during clinical visits. OUTCOMES: From 2012 to 2014, 250 student volunteers participated in the SFCP as clinicians, innovators, educators, and leaders, with between 80 and 95 medical students engaging each semester. Between January 2012 and March 2014, there were 476 urgent care or chronic disease management visits. Patients with chronic diseases were seen at least twice on average, and by 2014, chronic disease management visits accounted for approximately 74% of visits. NEXT STEPS: Work is under way to create assessment tools to evaluate the practice's educa tional impact and student understanding of the current health care system, develop interdisciplinary care teams, expand efforts in registry management and broaden the patient recruitment scope, further emphasize patient engage ment and retention, and evaluate chronic disease management and patient satisfaction effectiveness.