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.

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.

T cell recognition of an engineered MHC class I molecule: implications for peptide-independent alloreactivity.

Previously, we described H-2K(bW9) (K(bW9)), an engineered variant of the murine MHC class I molecule H-2K(b) (K(b)), devoid of the central anchor ("C") pocket owing to a point mutation on the floor of the peptide binding site; this substitution drastically altered selection of bound peptides, such that the peptide repertoires of K(b) and K(bW9) are largely nonoverlapping in vivo. On the basis of these observations, we used K(bW9) and K(b) to revisit the role of peptides in alloreactive T cell recognition. We first compared Ab and TCR recognition of K(bW9) and K(b). Six of six K(b)-specific mAbs, directed against different parts of the molecule, recognized K(bW9) well, albeit at different levels than K(b). Furthermore, K(bW9) readily served as a restriction element for a peptide-specific syngeneic CTL response. Therefore, K(bW9) mutation did not result in gross distortions of the TCR-interacting surface of class I, which was comparable between K(b) and K(bW9). Interestingly, when K(bW9) was used to stimulate allogeneic T cells, it induced an infrequent CTL population that cross-reacted against K(b) and was specific for peptide-independent MHC epitopes. By contrast, K(b)-induced alloreactive CTLs recognized K(b) in a peptide-specific manner, did not cross-react on K(bW9), and were present at much higher frequencies than those induced by K(bW9). Thus, induction of rare peptide-independent CTLs depended on unique structural features of K(bW9), likely due to the elevated floor of the peptide-binding groove and the consequent protruding position of the peptide. These results shed new light on the relationship between TCR and peptide-MHC complex in peptide-independent allorecognition.

Early intensive resuscitation of patients with upper gastrointestinal bleeding decreases mortality.

OBJECTIVE: Despite advances in diagnostic and therapeutic endoscopy, the mortality of patients with upper gastrointestinal bleeding (UGIB) has remained relatively constant. Inadequate early resuscitation is believed to be a major factor in the persistently high mortality rate in patients with UGIB. In order to evaluate the role of intensive resuscitation in the outcome of patients with UGIB, we conducted the following prospective study. METHODS: A consecutive series of patients with UGIB complicated by hemodynamic instability related to bleeding were enrolled in the study. An initial cohort of patients (Observation Group) was followed by a team of physicians to collect data. After recording demographic information, the time interval between presentation with UGIB and the correction of hemodynamic instability, hematocrit (HCT), and coagulopathy was prospectively recorded. Medical treatment, endoscopic intervention, and subsequent outcome were also prospectively recorded. A subsequent cohort of patients (Intensive Resuscitation Group) was then prospectively followed and similar demographic and outcome data were collected. However, in this cohort, the physicians involved in collecting the data also provided guidance to the health care team managing the patients. The goal for this group of patients was to allow a more rapid correction of hemodynamic instability, HCT, coagulopathy, and medical/endoscopic intervention. RESULTS: Seventy-two patients were included in the study, 36 males, 36 females, mean age 70 yr (range 21-94). Thirty-six patients were followed in the Observational Group, and 36 in the Intensive Resuscitation Group. There were no significant differences with regard to age, gender, number and type of comorbid diseases, history of prior gastrointestinal bleeding, or etiology of bleeding between the two groups. Patients treated in the Intensive Resuscitation Group had a significant decrease in the time interval from admission to the stabilization of hemodynamics and the correction of HCT. There were no significant differences in the time interval from admission to endoscopic intervention, length-of-stay (LOS), or the number of units of blood given. Fewer patients in the Intensive Resuscitation Group suffered myocardial infarction (p= 0.04). Mortality was lower in the Intensive Resuscitation Group (one death) compared to the Observational Group (four deaths), (p= 0.04). CONCLUSION: Early intensive resuscitation of patients with upper gastrointestinal bleeding significantly decreases mortality. Physicians involved in the care of patients with UGIB should focus on early and rapid correction of hemodynamics, HCT, and underlying coagulopathy.