A comparison of orthopaedic surgery and internal medicine perceptions of USMLE Step 1 pass/fail scoring.

BACKGROUND: United States Medical Licensing Examination Step 1 will transition from numeric grading to pass/fail, sometime after January 2022. The aim of this study was to compare how program directors in orthopaedics and internal medicine perceive a pass/fail Step 1 will impact the residency application process. METHODS: A 27-item survey was distributed through REDCap to 161 U.S. orthopaedic residency program directors and 548 U.S. internal medicine residency program directors. Program director emails were obtained from the American Medical Association's Fellowship and Residency Electronic Interactive Database. RESULTS: We received 58 (36.0%) orthopaedic and 125 (22.8%) internal medicine program director responses. The majority of both groups disagree with the change to pass/fail, and felt that the decision was not transparent. Both groups believe that the Step 2 Clinical Knowledge exam and clerkship grades will take on more importance. Compared to internal medicine PDs, orthopaedic PDs were significantly more likely to emphasize research, letters of recommendation from known faculty, Alpha Omega Alpha membership, leadership/extracurricular activities, audition elective rotations, and personal knowledge of the applicant. Both groups believe that allopathic students from less prestigious medical schools, osteopathic students, and international medical graduates will be disadvantaged. Orthopaedic and internal medicine program directors agree that medical schools should adopt a graded pre-clinical curriculum, and that there should be a cap on the number of residency applications a student can submit. CONCLUSION: Orthopaedic and internal medicine program directors disagree with the change of Step 1 to pass/fail. They also believe that this transition will make the match process more difficult, and disadvantage students from less highly-regarded medical schools. Both groups will rely more heavily on the Step 2 clinical knowledge exam score, but orthopaedics will place more importance on research, letters of recommendation, Alpha Omega Alpha membership, leadership/extracurricular activities, personal knowledge of the applicant, and audition electives.

Modern Day Scurvy in Pediatric Orthopaedics: A Forgotten Illness.

INTRODUCTION: Scurvy, or vitamin C deficiency, is rare. The goal of this study is to highlight the common risk factors and identify the orthopaedic presentation of scurvy in children. METHODS: A retrospective chart and radiograph review was performed of all patients consulted to the pediatric orthopaedic service from 2010 to 2019 who ultimately had the diagnosis of scurvy confirmed by an abnormally low serum vitamin C level. Data extracted included: patient age, sex, neurological conditions, prematurity, psychiatric conditions, dietary abnormalities, bone pain, arthritis, limb swelling, inability to walk, skin changes, child abuse evaluations, radiographic findings, additional vitamin deficiencies, lab studies, additional tests, response to treatment. Descriptive statistics were performed. RESULTS: Nine patients (7 males, 2 females) with scurvy were studied. The average age was 7 years (range 3 to 13 y). The average body mass index was 21.4 (range, 14 to 30). Five had autism, 2 had a neurological disorder. Two had been born premature. Two had a psychiatric disorder. Seven had an abnormal diet. One presented with bone pain. Four presented with limb swelling. Seven had unilateral and 2 had bilateral leg symptoms. Five presented with inability to walk. Six demonstrated skin changes with ecchymosis or petechiae. Three presented with gingival bleeding. Radiographic findings included subperiosteal hematoma in 2, ring epiphysis in 3, Pelkan spurs in 1, metaphyseal white lines (Frankel sign) in 6, and a metaphyseal zone of rarefaction (Trummerfeld zone) in 3. Seven had additional vitamin deficiencies including: A, B1, B6, B9, D, E, K, iron and zinc. Four had a bone marrow biopsy and 1 had lumbar puncture. All were anemic. The average erythrocyte sedimentation rate was 25.7 (range 6 to 35) and C-reactive protein was 1.5 (range 0.55 to 5.64). Six had a computed tomography, 3 had a magnetic resonance imaging. After treatment with vitamin C lasting 3.4 months (range, 2 wk to 7 mo), all symptoms gradually resolved, including leg pain and swelling. All children began to walk. CONCLUSION: The pediatric orthopaedic surgeon should have an increased awareness about the diagnosis of scurvy when consulted on a child with bone pain or inability to walk. The most common orthopaedic presentation was the refusal to bear weight, the most common radiographic finding was the metaphyseal line of increased density (Frankel sign) and treatment with vitamin c supplementation was excellent in all cases.

A survey of US hospitals' criteria for the allocation of remdesivir to treat COVID-19.

PURPOSE: To determine how hospitals across the United States determined allocation criteria for remdesivir, approved in May 2020 for treatment of coronavirus disease 2019 (COVID-19) through an emergency use authorization, while maintaining fair and ethical distribution when patient needs exceeded supply. METHODS: A electronic survey inquiring as to how institutions determined remdesivir allocation was developed. On June 17, 2020, an invitation with a link to the survey was posted on the Vizient Pharmacy Network Community pages and via email to the American College of Clinical Pharmacy's Infectious Disease Practice and Research Network listserver. RESULTS: 66 institutions representing 28 states responded to the survey. The results showed that 98% of surveyed institutions used a multidisciplinary team to develop remdesivir allocation criteria. A majority of those teams included clinical pharmacists (indicated by 97% of respondents), adult infectious diseases physicians (94%), and/or adult intensivists (69%). Many teams included adult hospitalists (49.2%) and/or ethicists (35.4%). Of the surveyed institutions, 59% indicated that all patients with COVID-19 were evaluated for treatment, and 50% delegated initial patient identification for potential remdesivir use to treating physicians. Prioritization of remdesivir allocation was often determined on a "first come, first served" basis (47% of respondents), according to a patient's respiratory status (28.8%) and/or clinical course (24.2%), and/or by random lottery (22.7%). Laboratory parameters (10.6%), comorbidities (4.5%), and essential worker status (4.5%) were rarely included in allocation criteria; no respondents reported consideration of socioeconomic disadvantage or use of a validated scoring system. CONCLUSION: The COVID-19 pandemic has exposed the inconsistencies of US medical centers' methods for allocating a limited pharmacotherapy resource that required rapid, fair, ethical and equitable distribution. The medical community, with citizen participation, needs to develop systems to continuously reevaluate criteria for treatment allocation as additional guidance and data emerge.

Obesity, Angiotensin-Blocking Drugs, and Acute Kidney Injury in Orthopedic Surgery.

Postoperative acute kidney injury occurs in 7% to 11% of orthopedic surgeries. The effect of preoperative angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) on the development of postoperative acute kidney injury remains controversial. Adipose tissue has its own independently regulated angiotensin system. The primary aim of this study was to examine the effects of obesity and preoperative ACEIs and ARBs on postoperative acute kidney injury. Charts were reviewed of adult elective orthopedic surgery patients during a 2-year period when patients were instructed to take their ACEI or ARB on the morning of surgery. The patients were divided into an obese cohort (body mass index [BMI] ≥30 kg/m2) and a nonobese cohort (BMI <30 kg/m2). A multivariable model was created for the outcome of acute kidney injury, using obesity as a primary predictor and adjusting for demographics, medications, comorbidities, and intraoperative parameters in a logistic regression analysis. Obesity increased the likelihood of developing acute kidney injury after orthopedic surgery (odds ratio [OR], 1.86; 95% CI, 1.07-3.22; P=.028). For every 5-unit increase in BMI, the odds of acute kidney injury were 1.43 (95% CI, 1.26-1.62; P<.001). When receiving ACEIs or ARBs, only the nonobese patients had a statistically increased likelihood of postoperative acute kidney injury (OR, 3.30; 95% CI, 1.12-9.70; P=.030). Obesity is an independent risk factor for postoperative acute kidney injury. Obesity appears to influence the effect that preoperative ACEIs and ARBs have on postoperative acute kidney injury. [Orthopedics. 2021;44(2):e253-e258.].

Social Constructivism in Medical School Where Students Become Patients with Dietary Restrictions.

BACKGROUND: Experiential vertical integration of basic science with clinical concepts remains a challenge in medical school curricula. In addition, training physicians in nutritional competency that translates into patient care is a challenging endeavor ranging from biochemical mechanisms to socioeconomic challenges. METHODS: Employing a social constructivism paradigm, we implemented a collaborative cook-off competition in a basic science course where 140 first-year medical students per year translated their studies of inborn errors of metabolism, energy metabolism, micronutrients and immunology into edible creations intended for people with disorders requiring dietary management. After learning about the disorders in lecture, problem-based learning, team-based learning and through patient interviews, four problem-based learning groups (7 students per group) were assigned to prepare food dishes for one of the five assigned disorders. Together, students researched the dietary requirements, shopped, paid for, prepared, presented and shared their food. To the class, faculty and re-invited patients, the groups explained the dietary restrictions, the chosen ingredients, how they prepared the food, and why their dish was suitable for the disorder. Each category was judged and awarded a first-place food prize with a grand prize at the end. At the completion of the course, student feedback was elicited via anonymous evaluations. Over 3 years, 380 comments were collected. We used grounded theory to generate a codebook that was then analyzed by the authors for overarching themes. RESULTS: Qualitative results described three major themes: increased relevance of basic science to real life, increased empathy towards complying with dietary restrictions, and increased student group cohesiveness. CONCLUSION: The patient-centered cook-off competition taught students the relevance of basic science but in addition, it taught empathy towards the patient experience. We also discovered that the process of food preparation was a bonding experience that promoted collaboration, cohesiveness and friendship within the student class.

Attitude adjustments after global health inter-professional student team experiences.

How medical inter-professional (IP) education should be introduced to students is still a matter of research. We evaluated IP student attitudes before and after a busy "hands-on" clinical experience.During 3 separate trips, first/second year medical and physician assistant students and third/fourth year nursing students traveled to Central America to work together for 1 week in an underserved clinical setting. Student opinions on inter-professional education were obtained before and after Brigade-1 using the Readiness for Inter-professional Learning Scale validated questionnaire. From these results, a modified version of the survey was developed that included quantitative and qualitative responses. For brigades-2 and -3, students received this modified version of the survey pre and post brigade. Quantitative data was analyzed via paired student t test, and qualitative data was analyzed to identify emerging themes using constant comparative methodology by three separate investigators.No significant quantitative differences between IP student groups were observed in their evaluation of the importance of inter-professional education either before or after the brigades. Qualitative data noted pre-brigade expectations of positive IP, experiential and patient-centered cultural learning. Pre- and post-brigade student perspectives maintained a strong belief that high functioning IP care benefited the patient. Post-brigade perspectives revealed a shift in attitude from purely positive expectations to more practical aspects of teamwork, respect, and interpersonal relationships.Students believe that patient care benefits from IP collaboration. After a busy clinical experience requiring collaboration, students realized that functional teams require appropriate skills, roles, and respectful interpersonal relationships.

Applying Metacognition Through Patient Encounters and Illness Scripts to Create a Conceptual Framework for Basic Science Integration, Storage, and Retrieval.

PROBLEM: Medical school curriculum continues to search for methods to develop a conceptual educational framework that promotes the storage, retrieval, transfer, and application of basic science to the human experience. To achieve this goal, we propose a metacognitive approach that integrates basic science with the humanistic and health system aspects of medical education. INTERVENTION: During the week, via problem-based learning and lectures, first-year medical students were taught the basic science underlying a disease. Each Friday, a patient with the disease spoke to the class. Students then wrote illness scripts, which required them to metacognitively reflect not only on disease pathophysiology, complications, and treatments but also on the humanistic and health system issues revealed during the patient encounter. Evaluation of the intervention was conducted by measuring results on course exams and national board exams and analyzing free responses on the illness scripts and student course feedback. The course exams and National Board of Medical Examiners questions were divided into 3 categories: content covered in lecture, problem-based learning, or patient + illness script. Comparisons were made using Student t-test. Free responses were inductively analyzed using grounded theory methodology. CONTEXT: This curricular intervention was implemented during the first 13-week basic science course of medical school. The main objective of the course, Scientific Principles of Medicine, is to lay the scientific foundation for subsequent organ system courses. A total of 150 students were enrolled each year. We evaluated this intervention over 2 years, totaling 300 students. OUTCOME: Students scored significantly higher on illness script content compared to lecture content on the course exams (mean difference = 11.1, P = .006) and national board exams given in December (mean difference = 21.8, P = .0002) and June (mean difference = 12.7, P = .016). Themes extracted from students' free responses included the following: relevance of basic science, humanistic themes of empathy, resilience, and the doctor-patient relationship, and systems themes of cost, barriers to care, and support systems. LESSONS LEARNED: A metacognitive approach to learning through the use of patient encounters and illness script reflections creates stronger conceptual frameworks for students to integrate, store, retain, and retrieve knowledge.