The Impact of Internal Medicine Clerkship Characteristics and NBME Subject Exams on USMLE Step 2 Clinical Knowledge Exam Performance.

BACKGROUND: Residency program directors will likely emphasize the United States Medical Licensing Exam (USMLE) Step 2 clinical knowledge (CK) exam more during residency application given the recent USMLE Step 1 transition to pass/fail scoring. We examined how internal medicine clerkship characteristics and NBME subject exam scores affect USMLE Step 2 CK performance. DESIGN: The authors used univariable and multivariable generalized estimating equations to determine associations between Step 2 CK performance and internal medicine clerkship characteristics and NBME subject exams. The sample had 21,280 examinees' first Step 2 CK scores for analysis. RESULTS: On multivariable analysis, Step 1 performance (standardized ß = 0.45, p < .001) and NBME medicine subject exam performance (standardized ß = 0.40, p < .001) accounted for approximately 60% of the variance in Step 2 CK performance. Students who completed the internal medicine clerkship last in the academic year scored lower on Step 2 CK (Mdiff = -3.17 p < .001). Students who had a criterion score for passing the NBME medicine subject exam scored higher on Step 2 CK (Mdiff = 1.10, p = .03). There was no association between Step 2 CK performance and other internal medicine clerkship characteristics (all p > 0.05) nor with the total NBME subject exams completed (ß=0.05, p = .78). CONCLUSION: Despite similarities between NBME subject exams and Step 2 CK, the authors did not identify improved Step 2 CK performance for students who had more NBME subject exams. The lack of association of Step 2 CK performance with many internal medicine clerkship characteristics and more NBME subject exams has implications for future clerkship structure and summative assessment. The improved Step 2 CK performance in students that completed their internal medicine clerkship earlier warrants further study given the anticipated increase in emphasis on Step 2 CK.

Modeling roadway impacts and recovery from volcanic ashfall from the 2021 St. Vincent eruption.

Ashfall from the April 2021 La Soufrière volcano eruption significantly impacted the Caribbean Island of St. Vincent. Out of all infrastructure sectors, transportation was the most affected across the island, with damages totaling $27.5 million (USD). Removal of ash is a debris management, public health, and disaster concern. This study uses the United States Geological Survey Ash3d model to estimate the thickness of ashfall covering roads, structures, and agricultural lands, totaling 9.4 million ft.3 on roadways, 4.8 million ft.3 on structures, and 147 million ft.3 in agricultural areas. Total ashfall on the island was estimated at 1.3 billion ft.3 Long-term planning and recovery challenges include the remote island location, limited resources, and the existing social and humanitarian needs intensified by the disaster. A staged approach to cleanup, debris management, temporary storage of ash, and sustainable reuse of ash as an aggregate for paving and building materials is proposed. The benefits of new technologies for converting ash into building materials using both off- and on-island systems should be considered for reconstruction materials. Using alternatives to sand mining and developing the adaptive reuse of disaster debris would support long-term recovery and resilience.

Coordinating science during an eruption: lessons from the 2020-2021 Kilauea volcanic eruption.

Data collected during well-observed eruptions can lead to dramatic increases in our understanding of volcanic processes. However, the necessary prioritization of public safety and hazard mitigation during a crisis means that scientific opportunities may be sacrificed. Thus, maximizing the scientific gains from eruptions requires improved planning and coordinating science activities among governmental organizations and academia before and during volcanic eruptions. One tool to facilitate this coordination is a Scientific Advisory Committee (SAC). In the USA, the Community Network for Volcanic Eruption Response (CONVERSE) has been developing and testing this concept during workshops and scenario-based activities. The December 2020 eruption of Kilauea volcano, Hawaii, provided an opportunity to test and refine this model in real-time and in a real-world setting. We present here the working model of a SAC developed during this eruption. Successes of the Kilauea SAC (K-SAC) included broadening the pool of scientists involved in eruption response and developing and codifying procedures that may form the basis of operation for future SACs. Challenges encountered by the K-SAC included a process of review and facilitation of research proposals that was too slow to include outside participation in the early parts of the eruption and a decision process that fell on a small number of individuals at the responding volcano observatory. Possible ways to address these challenges include (1) supporting community-building activities between eruptions that make connections among scientists within and outside formal observatories, (2) identifying key science questions and pre-planning science activities, which would facilitate more rapid implementation across a broader scientific group, and (3) continued dialog among observatory scientists, emergency responders, and non-observatory scientists about the role of SACs. The SAC model holds promise to become an integral part of future efforts, leading in the short and longer term to more effective hazard response and greater scientific discovery and understanding.

The largest deep-ocean silicic volcanic eruption of the past century.

The 2012 submarine eruption of Havre volcano in the Kermadec arc, New Zealand, is the largest deep-ocean eruption in history and one of very few recorded submarine eruptions involving rhyolite magma. It was recognized from a gigantic 400-km2 pumice raft seen in satellite imagery, but the complexity of this event was concealed beneath the sea surface. Mapping, observations, and sampling by submersibles have provided an exceptionally high fidelity record of the seafloor products, which included lava sourced from 14 vents at water depths of 900 to 1220 m, and fragmental deposits including giant pumice clasts up to 9 m in diameter. Most (>75%) of the total erupted volume was partitioned into the pumice raft and transported far from the volcano. The geological record on submarine volcanic edifices in volcanic arcs does not faithfully archive eruption size or magma production.

Takayasu arteritis presenting as embolic stroke.

A 52-year-old Caucasian woman presented to the emergency department with symptoms of acute ischaemic stroke (right-side weakness, confusion and aphasia) that resolved completely after administration of tissue plasminogen activator. During stroke work-up, she was found to have an enhancing infiltrate of the aorta at the level of the take-off of the great vessels, most consistent with early Takayasu arteritis. After being discharged home on steroids and dual antiplatelet therapy, she returned 2 days later with re-presentation of weakness and aphasia. Further work-up revealed two intraluminal clots in the left common carotid and left internal carotid arteries that had not been discovered during previous testing. This case illustrates the need to screen for sources of embolic stroke in patients with Takayasu arteritis, especially those with recurring symptoms.

Valproic acid overdose: a case report and review of therapy.

Valproic acid (VPA) is available as an antiepileptic therapy and has been used to treat bipolar disorder and migraine headaches. Reports to poison centers of VPA exposures have increased over the last few years, and there have been concerns about delayed toxicity after an overdose of VPA. We report a case of a woman with acute overdose of VPA who developed many of the complications commonly associated with the medication and review the current options available for treatment. There are many clinical manifestations of VPA overdose that are characteristic for the drug.

Methamphetamine-associated shock with intestinal infarction.

Methamphetamine abuse has increased rapidly in the United States over the last few years. Besides socioeconomic hardships acquired from using the drug, there are several adverse medical outcomes. Although there have been many reports of cardiovascular and central nervous system toxicities, there are few case reports of bowel ischemia induced by the drug. We report an unusual case of methamphetamine-associated intestinal infarction.

Internal medicine clerkship characteristics associated with enhanced student examination performance.

PURPOSE: To determine which internal medicine (IM) clerkship characteristics are associated with better student examination performance. METHOD: The authors collected data from 17 U.S. medical schools (1,817 students) regarding characteristics of their IM clerkships, including structural characteristics, pedagogical approaches, patient contact, and clinical teacher characteristics. Outcomes of interest were postclerkship National Board of Medical Examiners (NBME) subject examination score, United States Medical Licensing Examination (USMLE) 2 score, and change in score from USMLE 1 to 2. To examine how associations of various clerkship characteristics and examination performance may differ for students of different prior achievement, the authors categorized students into those who scored in the top (1/4) of the cohort on USMLE 1 and the bottom (1/4). The authors conducted analyses at both the school and the individual student levels. RESULTS: In school-level analyses (using a reduced four-variable model), independent variables associated with higher NBME subject examination score were more small-group hours/week and use of community-based preceptors. Greater score increase from USMLE 1 to 2 was associated with students caring for more patients/day. Several variables were associated with enhanced student examination performance at the student level. The most consistent finding was that more patients cared for per day was associated with higher examination performance. More structured learning activities were associated with higher examination scores for students with lower baseline USMLE 1 achievement. CONCLUSION: Certain clerkship characteristics are associated with better student examination performance, the most salient being caring for more patients per day.

The impact of the 2004 tsunami on coastal Thai communities: assessing adaptive capacity.

The suddenness and scale of the 26 December 2004 tsunami and the challenges posed to affected communities highlighted the benefits of their members having a capacity to confront and adapt to the consequences of such a disaster. Research into adaptive capacity or resilience has been conducted almost exclusively with Western populations. This paper describes an exploratory study of the potential of a measure of collective efficacy developed for Western populations to predict the capacity of members of a collective society, Thai citizens affected by the 2004 tsunami, to confront effectively the recovery demands associated with this disaster. Following a demonstration that this measure could predict adaptive capacity, the role of religious affiliation, ethnicity and place of residence in sustaining collective efficacy is discussed. The implications of the findings for future research on, and intervention to develop, adaptive capacity among Thai citizens in particular and collectivist societies in general are discussed.

Personal digital assistant-based drug information sources: potential to improve medication safety.

OBJECTIVES: This study compared the potential for personal digital assistant (PDA)-based drug information sources to minimize potential medication errors dependent on accurate and complete drug information at the point of care. METHODS: A quality and safety framework for drug information resources was developed to evaluate 11 PDA-based drug information sources. Three drug information sources met the criteria of the framework: Eprocrates Rx Pro, Lexi-Drugs, and mobileMICROMEDEX. Medication error types related to drug information at the point of care were then determined. Forty-seven questions were developed to test the potential of the sources to prevent these error types. Pharmacists and physician experts from Creighton University created these questions based on the most common types of questions asked by primary care providers. Three physicians evaluated the drug information sources, rating the source for each question: 1=no information available, 2=some information available, or 3 = adequate amount of information available. RESULTS: The mean ratings for the drug information sources were: 2.0 (Eprocrates Rx Pro), 2.5 (Lexi-Drugs), and 2.03 (mobileMICROMEDEX). Lexi-Drugs was significantly better (mobileMICROMEDEX t test; P=0.05; Eprocrates Rx Pro t test; P=0.01). CONCLUSION: Lexi-Drugs was found to be the most specific and complete PDA resource available to optimize medication safety by reducing potential errors associated with drug information. No resource was sufficient to address the patient safety information needs for all cases.

Dimensions of clinical medicine: an interclerkship program.

BACKGROUND: During the 3rd year of medical school, clerkships provide essential clinical experiences. However, other aspects of patient care may be overlooked during this critical phase of medical education. Faced with the challenge of integrating "orphan" topics central to effective and compassionate medical practice, medical schools have begun to develop interclerkships or intersessions. DESCRIPTION: The Dimensions of Clinical Medicine (DCM) interclerkship series at Creighton University included evidence-based medicine, sexuality in clinical medicine, palliative care, professionalism, cultural sensitivity/awareness, complementary and alternative medicine, bioterrorism, and clinical ethics. Each interclerkship comprises 2 half-day sessions conducted at the end of each clerkship rotation. EVALUATION: Students approved of the interclerkship format and valued the active learning strategies employed in the course. Many students felt the time allotted for each program was excessive. We describe educational issues and practical concerns that are central to an effective intersession program. CONCLUSION: The interclerkship format is a viable approach for incorporating orphan topics into the clinical curriculum.

Developing a peer review process for web-based curricula: minting a new coin of the realm.

The World Wide Web creates new challenges and opportunities for medical educators. Prominent among these are the lack of consistent standards by which to evaluate web-based educational tools. We present the instrument that was used to review web-based innovations in medical education submissions to the 2003 Society of General Internal Medicine (SGIM) national meeting, and discuss the process used by the SGIM web-based clinical curriculum interest group to develop the instrument. The 5 highest-ranked submissions are summarized with commentary from the reviewers.

Student understanding of the relationship between the health professions and the pharmaceutical industry.

BACKGROUND: Pharmaceutical sales representatives and direct-to-consumer advertising may influence physician practices, particularly prescribing. Identifying the relevant knowledge and attitudes students possess about the pharmaceutical industry may help professional curricula address these influences. PURPOSES: To assess knowledge and attitudes toward pharmaceutical industry marketing, ethical principles guiding drug company interactions, pharmaceutical sales representatives as a source of drug information, and confidence level in addressing consumers seeking a prescription from a direct-to-consumer advertisement among senior-level medical, PharmD, and nurse practitioner students. METHODS: A cross-sectional survey design was used to assess student knowledge and attitudes of four domains associated with the pharmaceutical industry. RESULTS: Significant deficiencies were noted in student knowledge of pharmaceutical marketing expenditures, professional ethics regarding interactions with drug companies, and accuracy of drug information from sales representatives. CONCLUSIONS: Health professional students' knowledge and attitudes toward the pharmaceutical industry are formed prior to graduation. Professional curricula must address the influences of sales representatives before postgraduate training.