Exploring Competency-Based Medical Education Through the Lens of the UME-GME Transition: A Qualitative Study.

PURPOSE: Competency-based medical education (CBME) represents a shift to a paradigm with shared definitions, explicit outcomes, and assessments of competence. The groundwork has been laid to ensure all learners achieve the desired outcomes along the medical education continuum using the principles of CBME. However, this continuum spans the major transition from undergraduate medical education (UME) to graduate medical education (GME) that is also evolving. This study explores the experiences of medical educators working to use CBME assessments in the context of the UME-GME transition and their perspectives on the existing challenges. METHOD: This study used a constructivist-oriented qualitative methodology. In-depth, semistructured interviews of UME and GME leaders in CBME were performed between February 2019 and January 2020 via Zoom. When possible, each interviewee was interviewed by 2 team members, one with UME and one with GME experience, which allowed follow-up questions to be pursued that reflected the perspectives of both UME and GME educators more fully. A multistep iterative process of thematic analysis was used to analyze the transcripts and identify patterns across interviews. RESULTS: The 9 interviewees represented a broad swath of UME and GME leadership positions, though most had an internal medicine training background. Analysis identified 4 overarching themes: mistrust (a trust chasm exists between UME and GME); misaligned goals (the residency selection process is antithetical to CBME); inadequate communication (communication regarding competence is infrequent, often unidirectional, and lacks a shared language); and inflexible timeframes (current training timeframes do not account for individual learners' competency trajectories). CONCLUSIONS: Despite the mutual desire and commitment to move to CBME across the continuum, mistrust, misaligned goals, inadequate communication, and inflexible timeframes confound such efforts of individual schools and programs. If current efforts to improve the UME-GME transition address the themes identified, educators may be more successful implementing CBME along the continuum.

Learning by doing and creation of the shared discovery curriculum.

BACKGROUND: The Michigan State College of Human Medicine began as an experiment to teach medical students in community-based settings and to create a primary care workforce for the state. Decades later, CHM faced internal and external challenges that spurred creation of a new curriculum - the Share Discovery Curriculum - founded on learning by doing and other learning theories. METHODS: A curricular design group (CDG) developed guiding principles for reform. Based on this, pedagogies and structures were selected to achieve this vision and developed into a curricular structure. Components of the first-year curriculum were piloted with a group of students and faculty members. RESULTS: Six guiding principles were endorsed, grounded in learning theories such as Dewey's Learning by Doing. Based upon these, several key features of the new curriculum emerged: learning communities; one-on-one coaches for students; symptom-based presentations for content; simulation, authentic clinical tasks, flipped classrooms, and modified practice-based learning as primary teaching modalities; early, integrated clinical and scientific learning; milestones as course learning objectives; and a multidimensional, competency-based assessment system. DISCUSSION: The process and outcomes described here are intended as an exemplar for schools undertaking curricular change. Early stakeholder engagement, faculty development, sustainable administrative systems, and managing complexity are core to the success of such endeavors.

Advanced Case of Cardiac Amyloidosis Presents With Chronic Diarrhea.

Late diagnosis of light chain (AL) amyloidosis can lead to catastrophic consequences on the quality of life of affected patients and overall disease prognosis. Therefore, clinicians should have high suspicion and recognize clinical red flags for amyloidosis. This case report presents a 65-year-old female who presented to the emergency department with chronic diarrhea and significant weight loss with significant hypotension. The patient was treated four weeks prior to admission with a five-day course of nitrofurantoin for urinary tract infection. The initial workup was positive for Clostridium difficile(C.diff), which was treated medically; however, the patient started to complain of mild shortness of breath accompanied by mildly elevated brain natriuretic peptide (BNP). Later on, the patient had a cardiac arrest and was appropriately resuscitated. Subsequent ECHO showed significant left ventricular hypertrophy, raising high suspicion of myocardial infiltration. Because of persistent diarrhea despite aggressive medical management and an inconclusive workup, the patient underwent colonoscopy with duodenum biopsy, which revealed amyloid deposition confirmed by Congo red staining. The patient afterward suffered from a stroke and recurrent syncopal episodes requiring critical care admission. Due to a compromised quality of life, the patient eventually opted for hospice care. In view of insufficient prospective data spotlighting AL amyloidosis, all patients should be treated within clinical trials whenever possible and ideally evaluated for autologous hematopoietic cell transplantation (HCT) eligibility.

An Exemplar Milestone Framework for Scaffolding a Competency-Based Medical School Curriculum.

A strong competency and milestone framework is imperative for medical schools adopting competency-based education and assessment. Milestones can be used to align what is taught and what students are asked to demonstrate from matriculation to graduation. We describe the creation and implementation of our milestone framework as an exemplar. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01558-1.

Growth in basic science knowledge in first-year medical school and USMLE Step 1 results: a longitudinal investigation at one school.

PURPOSE: Our US medical school uses National Board of Medical Examiners (NBME) tests as progress tests during the pre-clerkship curriculum to assess students. In this study, we examined students' growth patterns using progress tests in the first year of medical school to identify students at risk for failing United States Medical Licensing Examination (USMLE) Step 1. METHOD: Growth Mixture Modeling (GMM) was used to examine the growth trajectories based on NBME progress test scores in the first year of medical school. Achieving a passing score on the USMLE Step 1 at the end of the second year of medical school was used as the distal outcome, controlling for Medical College Admissions Test (MCAT) scores and underrepresented in medicine (URiM) status. RESULTS: A total of 518 students from a US medical school were included in the analysis. Five different growth patterns were identified based on students' NBME test results. Seventy-eight students identified in Group 1 had the lowest starting NBME test score (mean = 33.6, 95% CI 32.0-35.2) and lowest growth rate (mean = 2.30, 95% CI 2.06-2.53). All 26 students who failed Step 1 at the end of the second year were in Group 1 (failing rate = 33%). Meanwhile Group 4 (n = 65 students) had moderate starting NBME test scores (mean = 37.9, 95% CI 36.3-39.0) but the highest growth rate with mean slope at 6.07 (95% CI 5.40-6.73). This group of students achieved significant higher USMLE Step1 scores comparing with the 3 other groups of students (P < 0.05). CONCLUSIONS: Our study found students had heterogeneous growth patterns in progress test results in their first year of medical school. Growth patterns were highly predictive of USMLE step 1 results. This study can provide performance benchmarks for our future students to assess their progress and for medical educators to identify students who need support and guidance.

Brevundimonas diminuta coinfection as source of pyogenic liver abscess.

Brevundimonas diminuta, a non-fermenting gram-negative bacterium, is emerging as an important multidrug resistant opportunistic pathogen. It has been described in cases of bacteremia, pleuritis, keratitis and peritoneal dialysis-associated peritonitis. We describe, for the first time, a case of pyogenic liver abscess caused by coinfection of B. diminuta and Streptococcus anginosus, and briefly review pyogenic liver abscesses and the literature regarding B. diminuta.

Using Markov chain model to evaluate medical students' trajectory on progress tests and predict USMLE step 1 scores---a retrospective cohort study in one medical school.

BACKGROUND: Medical students must meet curricular expectations and pass national licensing examinations to become physicians. However, no previous studies explicitly modeled stages of medical students acquiring basic science knowledge. In this study, we employed an innovative statistical model to characterize students' growth using progress testing results over time and predict licensing examination performance. METHODS: All students matriculated from 2016 to 2017 in our medical school with USMLE Step 1 test scores were included in this retrospective cohort study (N = 358). Markov chain method was employed to: 1) identify latent states of acquiring scientific knowledge based on progress tests and 2) estimate students' transition probabilities between states. The primary outcome of this study, United States Medical Licensing Examination (USMLE) Step 1 performance, were predicted based on students' estimated probabilities in each latent state identified by Markov chain model. RESULTS: Four latent states were identified based on students' progress test results: Novice, Advanced Beginner I, Advanced Beginner II and Competent States. At the end of the first year, students predicted to remain in the Novice state had lower mean Step 1 scores compared to those in the Competent state (209, SD = 14.8 versus 255, SD = 10.8 respectively) and had more first attempt failures (11.5% versus 0%). On regression analysis, it is found that at the end of the first year, if there was 10% higher chance staying in Novice State, Step 1 scores will be predicted 2.0 points lower (95% CI: 0.85-2.81 with P < .01); while 10% higher chance in Competent State, Step 1scores will be predicted 4.3 points higher (95% CI: 2.92-5.19 with P < .01). Similar findings were also found at the end of second year medical school. CONCLUSIONS: Using the Markov chain model to analyze longitudinal progress test performance offers a flexible and effective estimation method to identify students' transitions across latent stages for acquiring scientific knowledge. The results can help identify students who are at-risk for licensing examination failure and may benefit from targeted academic support.

Medical Student Progress Examination Performance and Its Relationship With Metacognition, Critical Thinking, and Self-Regulated Learning Strategies.

PURPOSE: Metacognition and critical thinking are essential for academic success. The relationship between these components and medical student learning, as assessed with progress examinations, informs curriculum development and efforts to ensure learning progression of all students. This study assessed learning mechanisms by modeling medical students' progress test performance longitudinally at Michigan State University College of Human Medicine. METHOD: Medical students' (n = 184) medical knowledge was assessed 5 times from fall 2017 through spring 2019 using the Comprehensive Basic Science Examination (CBSE). Structural equation modeling was conducted to investigate associations between 3 latent structures-metacognitive awareness, critical thinking, and self-regulation-and their relationship with students' initial CBSE scores and growth in such scores. The authors measured metacognitive knowledge and regulation by the Metacognitive Awareness Inventory, critical thinking skills by the Watson-Glaser Critical Thinking Appraisal, and self-regulation by the Learning and Study Strategies Inventory. RESULTS: Students' aggregate performance on 5 CBSE scores grew 31.0% the first semester, 16.5% the second semester, 30.1% the third semester, and 22.4% the last semester. Critical thinking had a significant positive relationship with initial performance (JOURNAL/acmed/04.03/00001888-202102000-00048/inline-graphic1/v/2021-01-22T214722Z/r/image-tiff1.956, P < .001), self-regulation had a significant positive relationship with growth (JOURNAL/acmed/04.03/00001888-202102000-00048/inline-graphic2/v/2021-01-22T214722Z/r/image-tiff3.287, P < .05), and metacognitive awareness had a negative relationship with growth of student performance in the progress test (JOURNAL/acmed/04.03/00001888-202102000-00048/inline-graphic3/v/2021-01-22T214722Z/r/image-tiff-3.426, P < .01). CONCLUSIONS: This structural equation framework is useful for examining the relationships among 3 latent structures-critical thinking, metacognition, and self-regulation-and their relationships with students' progress scores in academic achievement. The initial status of progress examination scores was explained by students' critical thinking ability, but their learning growth on the progress scores was explained by their self-regulation and metacognitive ability. These findings help explain student performance on standardized progress examinations and can aid in interventions to promote student success.

Assessing the growth in clinical skills using a progress clinical skills examination.

BACKGROUND: This study evaluates the generalizability of an eight-station progress clinical skills examination and assesses the growth in performance for six clinical skills domains among first- and second-year medical students over four time points during the academic year. METHODS: We conducted a generalizability study for longitudinal and cross-sectional comparisons and assessed growth in six clinical skill domains via repeated measures ANOVA over the first and second year of medical school. RESULTS: The generalizability of the examination domain scores was low but consistent with previous studies of data gathering and communication skills. Variations in case difficulty across administrations of the examination made it difficult to assess longitudinal growth. It was possible to compare students at different training levels and the interaction of training level and growth. Second-year students outperformed first-year students, but first-year students' clinical skills performance grew faster than second-year students narrowing the gap in clinical skills over the students' first year of medical school. CONCLUSIONS: Case specificity limits the ability to assess longitudinal growth in clinical skills through progress testing. Providing students with early clinical skills training and authentic clinical experiences appears to result in the rapid growth of clinical skills during the first year of medical school.

Using Team Census Caps to Optimize Education, Patient Care, and Wellness: A Survey of Internal Medicine Residency Program Directors.

PURPOSE: To discover whether internal medicine (IM) residency program directors use lower-than-required caps on general medicine wards, critical care units, and inpatient subspecialty wards; describe justifications for lower-than-required general medicine ward caps and strategies for when caps have been exceeded or the number of patients is a detriment to critical thinking or education; and assess whether caps were associated with program characteristics. METHOD: From August to December 2016, the Association of Program Directors in Internal Medicine surveyed all member program directors about team caps and their effects on the learning environment. Responses were appended with publicly available or licensed third-party data. Programs were categorized by type, size, and region. RESULTS: Overall response rate was 65.7% (251/382 programs). Nearly all (244/248; 98.4%) reported caps for general medicine ward teams (mean = 17.0 [standard deviation (SD) = 4.2]). Fewer (171/247; 69.2%) had caps for critical care teams (mean = 13.8 [SD = 5.4]). Fewer still (131/225; 58.2%) had caps for inpatient subspecialty ward teams (mean = 14.8 [SD = 6.0]). Fewer first-quartile programs (0-28 residents) reported having caps on inpatient subspecialty teams (P < .001). Directors reported higher caps compromised education (109/130; 83.8%), patient care (89/130; 68.5%), and/or resident wellness (77/130; 59.2%). Nonteaching services (181/249; 72.7%), patient transfers (110/249; 44.2%), or "backup" residents (67/249; 26.9%) were used when caps are reached or the number of patients is detrimental to critical thinking or education. CONCLUSIONS: IM program directors frequently exercise discretion when setting caps. Accrediting bodies should explicitly encourage such adjustments and allow differentiation by setting.

Early morphological changes in cardiac mitochondria after subcutaneous administration of trastuzumab in rabbits: possible prevention with oral selenium supplementation.

Trastuzumab-mediated cardiotoxicity poses a significant challenge in the treatment of human epidermal growth factor receptor 2-positive breast cancer. To understand the underlying mechanisms, we conducted experiments to determine ultrastructural changes of rabbit cardiac tissue under different experimental conditions, including differing doses of trastuzumab and supplementation with oral sodium selenite, an antioxidant. Histopathology revealed lymphocyte and macrophage infiltration in myocardium of rabbits receiving four doses of trastuzumab. Transmission electron microscopy showed substantial changes with trastuzumab, including edema with separation of myofibril bundles and rupture of sarcomeres. Within mitochondria, edema resulted in disorganization of the cristae. Some mitochondria exhibited eccentric projections of their membranes with disruption of both inner and outer membranes. These changes were seen to a lesser extent in rabbits who received oral sodium selenite prior to trastuzumab. Selenium is integral to functioning of mitochondrial glutathione peroxidases, important antioxidants that also maintain membrane integrity. If mitochondria are disrupted as part of trastuzumab cardiac toxicity, selenium supplementation might be an important therapeutic or preventive consideration. Larger studies to explore this hypothesis are warranted.

Chylothorax: complication attributed to dasatinib use.

A 63-year-old woman with a medical history of chronic myelogenous leukaemia treated with dasatinib, chronic obstructive pulmonary disease and heart failure with preserved ejection fraction presented with difficulty in breathing. Chest X-ray showed large right-sided pleural effusion, which was confirmed on a CT angiogram of the chest. Echocardiogram showed an ejection fraction of 61% with moderate to severely dilated right ventricle and right ventricular systolic pressure of 60 mm Hg. Diagnostic and therapeutic thoracentesis was performed, and 2.2 L of pleural fluid was removed. Pleural fluid analysis was consistent with chylothorax. Significant symptomatic improvement was noted after thoracentesis. In the absence of an alternate explanation, chylothorax was attributed to dasatinib, which was switched to nilotinib. This resulted in resolution of her pleural effusions.

The dilemma in the management of haemodynamically stable pulmonary embolism with right heart thrombus.

Right ventricular thrombus (RVT) can be life-threatening, since it has the potential to embolise and cause saddle pulmonary embolism (PE). We present a patient who initially presented with haemodynamically stable PE with evidence of RVT on echocardiogram. She was placed on heparin drip; however, she later developed cardiac arrest and died due to embolisation of RVT to the pulmonary vasculature. Although management of haemodynamically stable PE in patients with RVT is still a matter of debate, 1 given the outcome we suggest that thrombolysis or emergent embolectomy at the presentation, in this case, may have had a favourable outcome.

Removing the problem: parathyroidectomy for calciphylaxis.

Calcific uremic arteriolopathy (CUA), widely known as calciphylaxis, is a rare and lethal disease that usually affects patients with end-stage renal disease. It is characterised by widespread vascular calcification leading to tissue ischaemia and necrosis and formation of characteristic skin lesions with black eschar. Treatment options include sodium thiosulfate, cinacalcet, phosphate binders and in resistant cases, parathyroidectomy. We report a case of recurrent, treatment-resistant CUA successfully treated with parathyroidectomy. Her postoperative course was complicated by hungry bone syndrome and worsening of her wounds before they completely healed. We then discuss the morbidity of CUA, including the controversy around the use of parathyroidectomy and risk of aggressive management of hungry bone syndrome.

Attendance, engagement and performance in a medical school curriculum: early findings from competency-based progress testing in a new medical school curriculum.

INTRODUCTION: Medical students often do not value attending in-person large group sessions. It is also not clear from prior research whether attendance at large group sessions impact on performance in medical school. The goal of this study was to assess the relationship between voluntary attendance in large group sessions organized as a "flipped classroom" in a new innovative curriculum and students' mastery of clinical applications of basic science knowledge. METHODOLOGY: Our students' ability to apply basic science knowledge to clinical problems is assessed via progress testing using three methodologies: a locally developed multiple-choice examination, written examination developed through the National Board of Medical Examiners (NBME) Customized Assessment Services Program and post encounter questions included in a clinical skills examination. We analyzed the relationship between voluntary attendance at weekly large group "flipped classroom" sessions and the students' performance on examinations given at four intervals over the initial 24-week module of the medical school curriculum. RESULTS: Complete data were available for 167 students. A total of 82 students (49.1%) attended all large group sessions, 65 students (38.9%) missed one or two sessions and 20 students (12.0%) missed three or more sessions. There were no difference between the students in the groups on their medical admission (MCAT) examination scores. The growth in performance from each time point until the next was statistically significant. There was no statistically significant difference in growth between the students who had no absences and those who had one or two absences. Students who missed three or more sessions performed significantly lower than their peers over the 24 week module and were more likely to score one or more standard deviations below the class mean on the assessments. CONCLUSIONS: We found no relationship between attendance and MCAT scores suggesting the differences in performance on the progress tests was not due to initial differences in knowledge or reasoning skills. While the study was not experimental, it suggests large group sessions using a "flipped classroom" approach to provide reinforcement, feedback and practice may be effective for increasing learning and retention in the application of basic science knowledge among first year medical students.

Teaching residents mental health care.

OBJECTIVE: We tested the hypothesis that trained medical faculty can train residents effectively in a mental health care model. METHODS: After the authors trained medical faculty intensively for 15 months in primary care mental health, the newly trained faculty taught medical residents intensively. Residents were evaluated pre- and post-residency and compared to non-equivalent control residents in another city. Using ANOVA, the primary endpoint was residents' use of a mental health care model with simulated patients. Secondary endpoints were residents' skills using models for patient-centered interviewing and for informing and motivating patients. RESULTS: For the mental health care model, there was a significant interaction between study site and time (F = 33.51, p < .001, Eta2 = .34); mean pre-test and post-test control group scores were 8.15 and 8.79, respectively, compared to 7.44 and 15.0 for the intervention group. Findings were similarly positive for models of patient-centered interviewing and informing and motivating. CONCLUSIONS: Training medical faculty to teach residents a mental health care model offers a new educational approach to the widespread problem of poor mental health care. PRACTICE IMPLICATIONS: While the models tested here can provide guidance in conducting mental health care, further evaluation of the train-the-trainer program for preparing residents is needed.

Lemierre's syndrome and 2016 American College of Physician guidelines for pharyngitis: no to empiric coverage for bacterial pharyngitis. While no role for routine Fusobacterium PCR, keep suspicion for this pathogen.

An 18-year-old woman presented to clinic with acute pharyngitis with 4/4 Centor criteria. Rapid streptococcal antigen test was negative. The patient, who was allergic to penicillin, was prescribed azithromycin. Ultimately, after 5 days and without any corticosteroids, she presented to the emergency department with 10/10 chest pain and was admitted to the intensive care unit. CT showed nodular lung disease and blood cultures on admission grew Fusobacterium, likely Fusobacterium nucleatum. She sustained two cardiac arrests, three tube thoracostomies, acute kidney injury requiring dialysis and ventilatory failure requiring tracheostomy. After 16 days in hospital and 18 days in long-term acute care, the patient was discharged home. It is unclear how much of this could have been prevented by prescribing an antimicrobial that had activity against Fusobacterium When severe pharyngitis occurs, Fusobacterium needs to be considered as an underlying cause. In vitro macrolides have marginal activity against most anaerobes, such as this pathogen, and should be avoided.