A case study of a unique advanced clinical skills elective at the David Geffen School of Medicine at UCLA.

Proficiency in clinical examination skills upon graduation from medical school is a core competency. Over the last few decades, the ability and confidence in this fundamental and crucial skill set has declined. The motivation and interest in meticulous physical examination by recently graduated residents has also eroded. In this case study, we describe a comprehensive, innovative, and immersive advanced clinical skills elective taken during the second half of the final year of medical school for students at the David Geffen School of Medicine. The course utilizes novel approaches to inspire, refresh and consolidate essential bedside observation skills and examination techniques. This approach gives senior students the confidence and fundamental understanding of how dedication to the patient exam can improve the doctor-patient relationship, core clinical reasoning and the practice of cost-effective and evidence-based care through their careers. We describe how the integration of fine art appreciation and introductory biding techniques are used to help students hone their visual diagnostic skills. We show how this is solidified through a longitudinal series of clinical image review sessions with diagnostic reasoning principles to formulate a clear differential. Point of care ultrasound, EKG analysis, advanced cardiac auscultation and diagnostic imaging skills are integrated in a comprehensive and memorable fashion. We present this case study to inspire clinical skills teachers everywhere to replicate our methods in resurrecting the importance of physical exams for their learners. Opening their trainees' eyes to new methods of honing their visual intelligence and developing healthy habits for stress and burnout reduction will aid the rest of their professional careers.

Enhancing existing medical school curricula with an innovative healthcare disparities curriculum.

BACKGROUND: Effective healthcare disparities curricula seek to train physicians who are well equipped to address the health needs of an increasingly diverse society. Current literature on healthcare disparities curricula and implementation focuses on courses created independent of existing educational materials. Our aim was to develop and implement a novel resource-conserving healthcare disparities curriculum to enhance existing medical school lectures without the need for additional lectures. METHODS: This non-randomized intervention was conducted at the University of California Los Angeles. The curriculum was offered to all first-year medical students in the class of 2021 (n=188). With institutional approval, a new healthcare disparities curriculum was created based on the Society of General Internal Medicine's core learning objectives for effective healthcare disparities curricula (J General Internal Med 25:S160-163, 2010). Implementation of the curriculum made use of "teachable moments" within existing medical school lectures. Teachable moments were broad lecture topics identified by the research team as suitable for introducing relevant healthcare disparities content. The new lecture-enhancing healthcare disparities curriculum was delivered with the related lecture via integrated PDF documents uploaded to an online learning management system. Students were encouraged to complete pre- and post- course assessments to examine changes in disparities knowledge and self-rated confidence in addressing disparities. Matched χ2 tests were used for statistical analysis. RESULTS: Participating students (n=92) completed both pre- and post-course assessments and were retrospectively stratified, based on self-reported use of the new lecture enhancing curriculum, into the "high utilizer" group (use of materials "sometimes" or "very often," n=52) and the comparison "low utilizer" group (use of the materials "rarely" or "very rarely," n=40). Students who self-identified as underrepresented racial and ethnic minorities in medicine were more likely to utilize the material (41% of the high utilizers vs. 17% of the low utilizer group, p<.01). Post-course knowledge assessment scores and self-reported confidence in addressing healthcare disparities improved only in the high utilizer group. CONCLUSIONS: Integrating new guideline based curricula content simultaneously into pre-existing lectures by identifying and harnessing teachable moments may be an effective and resource-conserving strategy for enhancing healthcare disparities education among first year medical students.

Student-Written Multiple-Choice Questions-a Practical and Educational Approach.

The purpose of our student-led project was to fulfill junior medical students' demand for instructive, curriculum-specific practice questions while providing a learning experience and teaching opportunity for participating senior students. Eleven second-year students were taught how to write high-quality multiple-choice questions through an interactive workshop. Subsequently, they were instructed to write questions with detailed explanations for their assigned lecture topics. Thirty-four student-written and faculty-reviewed questions were combined with 16 purely faculty-written questions to create a 50-question exam. No significant difference was found in question difficulty between the student-written (79.5%) and faculty-written (84.0%) questions (p = 0.37). The discrimination index and point biserial correlation were higher for student-written (0.29, 0.32) vs. faculty-written (0.17, 0.25) questions (p < .01, < .05). The test-takers learned key course topics, while the test-writers reviewed key first-year objectives and refined their test-taking strategies. The project provided a model for feasibly developing comprehensive, high-quality, and curriculum-specific questions.

Barriers to Early Hospital Discharge: A Cross-Sectional Study at Five Academic Hospitals.

BACKGROUND: Understanding the issues delaying hospital discharges may inform efforts to improve hospital throughput. OBJECTIVE: This study was conducted to identify and determine the frequency of barriers contributing to delays in placing discharge orders. DESIGN: This was a prospective, cross-sectional study. Physicians were surveyed at approximately 8:00 AM, 12:00 PM, and 3:00 PM and were asked to identify patients that were "definite" or "possible" discharges and to describe the specific barriers to writing discharge orders. SETTING: This study was conducted at five hospitals in the United States. PARTICIPANTS: The study participants were attending and housestaff physicians on general medicine services. PRIMARY OUTCOMES AND MEASURES: Specific barriers to writing discharge orders were the primary outcomes; the secondary outcomes included discharge order time for high versus low team census, teaching versus nonteaching services, and rounding style. RESULTS: Among 1,584 patient evaluations, the most common delays for patients identified as "definite" discharges (n = 949) were related to caring for other patients on the team or waiting to staff patients with attendings. The most common barriers for patients identified as "possible" discharges (n = 1,237) were awaiting patient improvement and for ancillary services to complete care. Discharge orders were written a median of 43-58 minutes earlier for patients on teams with a smaller versus larger census, on nonteaching versus teaching services, and when rounding on patients likely to be discharged first (all P < .003). CONCLUSIONS: Discharge orders for patients ready for discharge are most commonly delayed because physicians are caring for other patients. Discharges of patients awaiting care completion are most commonly delayed because of imbalances between availability and demand for ancillary services. Team census, rounding style, and teaching teams affect discharge times.

Competency-based Standard Setting for a High-stakes Objective Structured Clinical Examination (OSCE): Validity Evidence.

This article was migrated. The article was marked as recommended. Introduction Medical educators need to demonstrate that their trainees meet expected competency levels when progressing through medical education. This study aimed to develop competency-based pass/fail cut-scores for a graduation required Objective Structured Clinical Examination (OSCE), and examine validity evidence for new standards. Methods Six clinicians used the modified Angoff method to determine the cut-scores for an 8-station OSCE. The clinicians estimated the percentage of minimally competent students who would answer each checklist item correctly. Inter-rater reliability, differences in other academic achievements between pass/fail groups, educational impact, and response process were examined. Results One hundred seventy-four rising 4th-year medical students participated in the OSCE. The cut-scores determined for the OSCE resulted in a substantially lower failure rate (5% vs. 29% of the previous year). The inter-rater reliability across domains and cases was .98 (95% CI = .97 - .99). The pass/fail groups significantly differed in six of the eight measures of academic achievements included in the study. Discussion The impact of the standards setting was substantial as it significantly reduced the failure rate and burdens of remediation for both students and faculty. The very high inter-rater reliability indicates that the modified Angoff method produced reliable cut-scores. The significant differences between the pass/fail groups in other measures support external validity of the standards and ensure no false passes. The study also supports response process validity by including discussion among judges and check of previous student performances, as well as recruiting and training multiple clinician educators experienced in medical student teaching. Conclusion Findings of the study provide strong evidence supporting validity of the new cut-scores from a wide spectrum of validity metrics, including response process, internal structure, relations to other variables, and consequences. The study also added to the literature the value of the modified Angoff method in determining competency-based standards for OSCEs.

Analysis of 30-day readmissions among neurosurgical patients: surgical complication avoidance as key to quality improvement.

UNLABELLED: OBJECT.: In terms of measuring quality of care and hospital performance, an outcome of increasing interest is the 30-day readmission rate. Recent health care policy making has highlighted the necessity of understanding the factors that influence readmission. To elucidate the rate, reason, and predictors of readmissions at a tertiary/quaternary neurosurgical service, the authors studied 30-day readmissions for the Department of Neurosurgery at two University of California, Los Angeles (UCLA), hospitals. METHODS: Over a 3-year period, the authors retrospectively identified adult and pediatric patients who had been discharged from the UCLA Medical Center after having undergone a major neurosurgical procedure and being readmitted within 30 days. Data were obtained on demographics, follow-up findings, diagnosis and reason for readmission, major operations performed, and length of stay during index admission and readmission. Reasons for readmission were broadly categorized into surgical, medical diagnosis/complication, problem associated with the original diagnosis, neurological decompensation, pain management, and miscellaneous. For further characterization, subgroup analysis and in-depth chart review were performed. RESULTS: Over the study period, 365 (6.9%) of 5569 patients were readmitted within 30 days. The most common diagnosis at index admission was brain tumor (102 patients), followed by CSF shunt malfunction (63 patients). The most common reason for readmission was surgical complication (50.1%). Among those with surgical complications, the largest subgroup consisted of patients with CSF shunt-related problems (77 patients). The second and third largest subgroups were surgical site infection and CSF leakage (41 and 31 patients, respectively). Medical diagnosis/complication was the second most frequent (27.9%) reason for readmission. CONCLUSIONS: Surgical complications seem to be a major reason for readmission at the neurosurgical practice studied. Results indicate that the outcomes that are amenable to and would have the greatest effect on quality improvement are CSF shunt-related complications, surgical site infections, and CSF leaks.

Nitric oxide in physiologic concentrations targets the translational machinery to increase the proliferation of human breast cancer cells: involvement of mammalian target of rapamycin/eIF4E pathway.

Nitric oxide (NO) in nanomolar (nmol/L) concentrations is consistently detected in tumor microenvironment and has been found to promote tumorigenesis. The mechanism by which NO enhances tumor progression is largely unknown. In this study, we investigated the possible mechanisms and identified cellular targets by which NO increases proliferation of human breast cancer cell lines MDA-MB-231 and MCF-7. DETA-NONOate, a long acting NO donor, with a half-life of 20 h, was used. We found that NO (nmol/L) dramatically increased total protein synthesis in MDA-MB-231 and MCF-7 and also increased cell proliferation. NO specifically increased the translation of cyclin D1 and ornithine decarboxylase (ODC) without altering their mRNA levels or half-lives. Critical components in the translational machinery, such as phosphorylated mammalian target of rapamycin (mTOR) and its downstream targets, phosphorylated eukaryotic translation initiation factor and p70 S6 kinase, were up-regulated following NO treatment, and inhibition of mTOR with rapamycin attenuated NO induced increase of cyclin D1 and ODC. Activation of translational machinery was mediated by NO-induced up-regulation of the Raf/mitogen-activated protein/extracellular signal-regulated kinase (ERK) kinase/ERK (Raf/MEK/ERK) and phosphatidylinositol 3-kinase (PI-3 kinase)/Akt signaling pathways. Up-regulation of the Raf/MEK/ERK and PI-3 kinase/Akt pathways by NO was found to be mediated by activation of Ras, which was cyclic guanosine 3',5'-monophosphate independent. Furthermore, inactivation of Ras by farnesyl transferase inhibitor or K-Ras small interfering RNA attenuated NO-induced increase in proliferation signaling and cyclin D1 and ODC translation, further confirming the involvement of Ras activation during NO-induced cell proliferation.