Teaching Health Equity in the Time of COVID-19: a Virtual Look Through the Lens of Structural Racism.

INTRODUCTION: In the context of marked health disparities affecting historically marginalized communities, medical schools have an obligation to rapidly scale up COVID-19 education through the lens of structural racism. AIM: To develop and implement a virtual curriculum on structural racism in a required COVID-19 course for medical students using "just-in-time" training. SETTING: Academic medical institution during the height of COVID-19 in the spring of 2020. PARTICIPANTS: Three hundred ninety-three 3rd and 4th-year medical students prior to re-entry into clinical care. PROGRAM DESCRIPTION: Three educational sessions focused on (1) racial health disparities, (2) othering and pandemics, and (3) frameworks to address health inequity. The virtual teaching methods included narrated recorded presentations, reflections, and student-facilitated small group dialogue. PROGRAM EVALUATION: In matched pre- and post-surveys, participants reported significant changes in their confidence in achieving the learning objectives and high satisfaction with small group peer facilitation. DISCUSSION: The use of "just-in-time" training exploring the intersection between COVID-19 and structural racism facilitated the delivery of time-relevant and immediately clinically applicable content as students were preparing to re-enter a transformed clinical space. Similar approaches can be employed to adapt to changing healthcare landscapes as academic medical centers strive to build more equitable health systems.

DATA 2000 waiver training for medical students: Lessons learned from a medical school experience.

BACKGROUND: In the midst of this national opioid crisis, it has become apparent that there is a large shortage in the workforce of treatment providers equipped to deliver evidence-based care for opioid use disorders (OUD). Medications for opioid use disorder (MOUD), such as buprenorphine, are crucial in reducing mortality in those with OUD, and yet prescribers must meet federal waiver requirements under the Drug Addiction Treatment Act of 2000 (DATA 2000). There are now several pathways for medical schools to satisfy these waiver requirements for all graduates, but this has not yet become widespread. We propose that including a DATA 2000 waiver training within the medical school curriculum is a feasible and effective way to meet eligibility requirements to prescribe buprenorphine. Methods: As part of a longitudinal opioid curriculum requirement, we implemented a DATA 2000 waiver training for all rising Year 4 medical students. One hundred sixty-nine students completed a hybrid (online and in-person) waiver training. The majority completed a pre- and post-survey. Results: The pre-training survey showed 93% of rising Year 4 medical students (112/120) reported participation in care of patients with OUD. Students six month post-training reported a rise in confidence (1.94 to 2.45; p < 0.01) and knowledge (2.27 to 2.76; p < 0.01) regarding MOUD. They also reported their plans to apply for the buprenorphine waiver once licensed and reported being more likely to prescribe buprenorphine for OUD as a result of the training (mean = 3.35; SD = 1.36; 0 = extremely unlikely to 5 = extremely likely). Conclusions: We successfully implemented a DATA 2000 waiver training as a mandatory requirement for the medical school curriculum. Further studies are needed to determine optimal timing, best format, and frequency of reinforcement of MOUD educational content across the undergraduate and graduate medical education continuum.

Orbital cellulitis, sinusitis and intracranial abnormalities in two adolescents with COVID-19.

We review two cases of adolescents with orbital cellulitis, sinusitis and SARS- CoV-2 infection presenting to emergency departments within a 24 hour period. SARS-CoV-2 samples obtained within 24 hours were positive, supporting prior infection despite relatively limited early symptoms of COVID-19. Unusual clinical and radiographic characteristics included hemorrhagic abscess with blood of varying age in the first, intracranial epidural abscess in the second, radiographic signal consistent with hemorrhagic or thrombotic phenomena, retro-maxillary antral fat changes, and meningeal enhancement or extension in both cases. Radiographic findings thereby mimic fungal infection, although final cultures and ancillary investigation for allergic and invasive fungal disease have remained negative. These cases highlight two unusual orbital presentations of cellulitis occurring in the context of SARS-CoV-2 co-infection.

Testing the Effects of Individual Residents' Retrieval Practice on Standardized Examination Scores.

Background: Residents have limited time and much to learn. Retrieval practice-studying using exam-style review questions-is a powerful educational tool for aggregate groups of learners, but it has not been tested for individual graduate medical education (GME) trainees. Methods: We conducted a retrospective observational study examining how individual residents' self-directed retrieval practice affected their learning. We used linear regression models to compare the number of exam-style multiple-choice practice questions each resident answered per year to their scores on annual In-Training Exams (ITE). Results: We found that the higher a resident's ITE score was at the start of a year, the fewer practice questions they answered that year for both first- (p = 0.023) and second-year (p = 0.020) trainees. Then, the more questions a resident answered in a year, the more their ITE score increased over that year for both first- and second-year trainees (p = 0.026 and 0.025, respectively). Residents' prior ITE scores also independently predicted their subsequent ITE scores (p = 0.024 in the first and 0.007 in the second year), and the effect of their baseline scores was larger than the effect of the number of practice questions they answered. Conclusions: Individual residents' prior exam scores significantly predict their future exam scores, and their independent retrieval practice using exam-style review questions also significantly predicts the annual improvement in their scores. These findings add to the growing evidence supporting retrieval practice in GME, and they can inform individualized educational coaching for GME trainees.

Moving Beyond the Near-Peer Teaching Model with the Rutgers New Jersey Medical School Teaching Assistant Program.

Medical students will become educators teaching peers, healthcare students, patients, and families. At Rutgers New Jersey Medical School, the "Teaching Assistants in Medical Education" program provides fourth-year medical students with the skills and experiences needed to prepare them as medical educators. The program goes beyond the near peer teaching model to support student development in curricular design, assessment, and communication skills through a Clinical Skills or Anatomy track. Investment in the development of medical students as future educators will yield immediate and long-term rewards.

Using ChatGPT in the Development of Clinical Reasoning Cases: A Qualitative Study.

Background There has been an explosion of commentary and discussion about the ethics and utility of using artificial intelligence in medicine, and its practical use in medical education is still being debated. Through qualitative research methods, this study aims to highlight the advantages and pitfalls of using ChatGPT in the development of clinical reasoning cases for medical student education. Methods Five highly experienced faculty in medical education were provided instructions to create unique clinical reasoning cases for three different chief concerns using ChatGPT 3.0. Faculty were then asked to reflect on and review the created cases. Finally, a focus group was conducted to further analyze and describe their experiences with the new technology. Results Overall, faculty found the use of ChatGPT in the development of clinical reasoning cases easy to use but difficult to get to certain objectives and largely incapable of being creative enough to create complexity for student use without heavy editing. The created cases did provide a helpful starting point and were extremely efficient; however, faculty did experience some medical inaccuracies and fact fabrication. Conclusion There is value to using ChatGPT to develop curricular content, especially for clinical reasoning cases, but it needs to be comprehensively reviewed and verified. To efficiently and effectively utilize the tool, educators will need to develop a framework that can be easily translatable into simple prompts that ChatGPT can understand. Future work will need to strongly consider the risks of recirculating biases and misinformation.

Learning in the Pandemic: Medical Students' Perceived Effects of COVID-19 on Their Clinical Experiences and Career Choices During the Internal Medicine Clerkship.

Introduction: The COVID-19 pandemic forced changes to undergraduate medical education with its impact still not fully understood. This is the first US study to assess the pandemic's perceived impact on medical education after return to in-person clerkships. Materials and Methods: We conducted a survey of third-year medical students completing their medicine clerkship during the 2020-2021 and 2021-2022 academic years (AY). Survey questions assessed students' attitudes on perceived risk of COVID-19 infection, impact on clinical encounters, and students' specialty interests. Results: Of 312 students enrolled, 283 (90.71%) completed the survey. Concern for COVID-19 infection was highest in the second rotation (3.98 [95% CI 3.64, 4.31]) of the 2020-2021 AY and the third rotation of the 2021-2022 AY (3.41 [95% CI 3.06, 3.76]), corresponding to the surges of COVID-19 cases and subsequent variants. Conversely, as incidence increased, students reported a greater perceived impact on histories, physicals, and time spent with patients with no differences in patient rapport or specialty interests. Discussion: Although concern for infection was initially high, it decreased after the introduction of the COVID-19 vaccine despite increasing incidence nationally and then peaked again during the Omicron surge. The degree of concern did not exceed initial levels, despite unprecedentedly high disease prevalence. Higher infection rates correlated with greater perceived impact on clinical experiences. Our study underscores the importance of vaccination, highlights learners' concerns and resilience throughout the pandemic, and should be considered in balancing student exposure with maintaining clinical opportunities. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01589-8.

Teaching Module on Ultrasound-Guided Venous Access Using a Homemade Gel Model for Fourth-Year Medical Students.

INTRODUCTION: Evidence supports an ultrasound-guided approach in patients with difficult vascular access. Prior research on teaching ultrasound-guided intravenous access has included only small groups of first- and second-year medical students. METHODS: We enrolled fourth-year medical students in our teaching module. The module featured a 6-minute prelearning narrated lecture and 5-minute orientation, followed by ultrasound-guided IV placement on homemade gel models. Facilitators were emergency medicine (EM) residents with a prespecified level of procedural ultrasound skills according to EM milestones. Students completed pre- and postmodule surveys. Facilitators completed the Directly Observed Procedural Skills Evaluation. Primary outcomes included global rating, proficiency on six procedural skills, and perceived learning. RESULTS: Our module was completed by 150 fourth-year medical students (94% of the class); 84% cannulated the vein in one attempt. We used a global rating scale to describe the students' cannulation abilities; 59% were trusted to perform this procedure with direct supervision and coaching, 29% with indirect supervision, and 8% without supervision. There was no association between a student's order of attempting IV access within the group and global rating (p = .41). Students reported increased understanding of indications, antecubital anatomy, sonographic anatomy, and procedural comfort (12%, 29%, 38%, and 65% improvement pre- vs. postmodule, respectively; p < .001). DISCUSSION: Our module enabled more than one-third of fourth-year medical students to achieve an indirect supervision or better level of proficiency in ultrasound-guided IV access, with significant improvements in perceived knowledge. This module may be useful for other educators facilitating the transition to residency.

Building a Community Partnership in a Pandemic: NJ Pediatric Residency Advocacy Collaborative.

The New Jersey Pediatric Residency Advocacy Collaborative (NJPRAC) is a statewide collaborative with faculty leads from each of the 10 New Jersey pediatric residency programs. The 2 major goals of the collaborative were to build community partnerships between pediatric residency programs and local organizations and develop a core advocacy curriculum. In this article, we focus on how the NJPRAC built community partnerships with Family Success Centers (FSCs) across the state over the course of a 2-year period. FSCs are located within every county in the state and fall under the New Jersey Department of Children and Families, providing resources and supports for families in crisis, with a focus on child abuse prevention services. Amid this growing partnership, the coronavirus disease 2019 (COVID-19) pandemic forced the NJPRAC to swiftly pivot its partnership and develop innovative programs to support families during the COVID-19 pandemic. As FSC leadership communicated families' concerns to the collaborative, we initiated the Virtual House Call webinar, which incorporated pediatricians, community leaders, and allied health professionals to answer COVID-19 questions. These webinars quickly expanded into weekly interprofessional series, with experts in mental health, law, nutrition, and dentistry partnering with pediatricians from various subspecialties. Key to the webinars' success was responding in real time to audience questions, collaborating with the FSC leadership on content, and garnering the support from the local New Jersey Chapter, American Academy of Pediatrics and the national American Academy of Pediatrics. A key challenge remains to meaningfully incorporate pediatric trainees into community partnerships. The NJPRAC plans to continue the Virtual House Call series with continuous input from the FSCs and participating families.

A Multi-Modal Remote Clinical Skills Mini-Course Utilizing a Teaching TeleOSCE.

In the setting of the coronavirus pandemic, medical schools across the world transitioned to a remote learning curriculum with the challenge of developing innovative methods to teach clinical skills. During the pandemic, we designed a 2-week remote clinical skills mini-course for third year medical students. The focus was on clinical reasoning, counseling, and the following the Association of American Medical Colleges (AAMC) Core Entrustable Professional Activities (EPAs): 1 (history and physical exam), 2 (prioritize a differential diagnosis), 3 (recommend and interpret diagnostic tests), and 5 (document a clinical encounter). A multi-modal approach included large and small group virtual case-based discussions, a teaching TeleOSCE (Objective Structured Clinical Examination), and feedback on patient note skills. Students were asked to self-assess their skills before and after the course based on the core EPAs, counseling skills, and overall preparedness for United States Medical Licensing Exam (USMLE) Step 2 Clinical Skills exam. Students demonstrated statistically significant increases in mean self-rated scores in all areas except interpreting results of basic studies. They found the teaching TeleOSCE and feedback on their notes the most useful. Future curricula will consider integration of peer-peer remote OSCE practice sessions as well as faculty feedback for individualized learning plans. Lessons learned will be useful for remote structured clinical skills courses in the setting of the pandemic.

Down to the Last Dollar: Utilizing a Virtual Budgeting Exercise to Recognize Implicit Bias.

INTRODUCTION: As social determinants of health and implicit bias are recognized as critical components of medical education, there is a need for novel approaches beyond didactics. We developed a small-group budgeting exercise to simulate the impact of poverty. Pediatrics exemplifies the effects of poverty on the family. This exercise allowed students to recognize the effects of food insecurities on health and reflect on biases regarding patients living in poverty. METHODS: The virtual interactive budgeting exercise (1.5-2 hours) introduced third-year pediatric clerkship students to the challenges faced by a single parent living in poverty, requiring them to make choices on which budget items were most important. Students attempted to balance budgets within small breakout groups, followed by a group reflection on biases encountered. A faculty facilitator then debriefed with the larger group. RESULTS: Within the first four rotations of the 2020-2021 academic year, 75 students completed the budgeting exercise and reflection, with 61 students completing the postexercise survey evaluation. Between 94% and 98% rated the objectives as met to a moderate, considerable, or very high degree. In addition, 98% of students noted the group discussion heightened their awareness regarding biases, and 95% agreed or strongly agreed the activity was conducted virtually without difficulty. DISCUSSION: This simulated budgeting exercise provides a well-rounded experience for medical students, that can be administered at either the preclerkship or clerkship level, at a minimal cost, with interactive engagement of students in a virtual environment and reflection on biases within a group context.

Environments, processes, and outcomes - using the LEPO framework to examine medical student learning preferences with traditional and electronic resources.

Changes in medical student learning preferences help drive innovation in teaching and require schools and commercial resources to quickly adapt. However, few studies have detailed the relationship of learner preferences to the environment and teaching modalities used in the pre-clerkship years, nor do they incorporate third-party resources. Our study attempts to analyze learner preferences by comparing the use of traditional and third-party resources. In 2017-18, a survey was distributed to medical students and residents at two accredited medical schools. Participants noted preferred styles of learning regarding lecture duration, timing, location, format, third-party resources, learner types and USMLE Step 1 scores. The 'Learning Environment, Learning Processes, and Learning Outcomes' (LEPO) framework [5] was used to examine learner preferences, with responses compared using the Mann-Whitney U and two proportion z-tests. A total of 329 respondents completed the survey: 62.7% medical students and 37.3% residents. The majority of participants identified their learning style by Kolb [6] as converging (33.0%) or accommodating (39.2%). Students preferred lectures 30-40 minutes long (43.3%), during morning hours (54.2%), in their own homes (52.0%), via online lectures with simultaneous drawings (56.0%), and classroom/podcast lectures with PowerPoint® presentations (54.3%). Overall, students rated third-party resource characteristics higher than traditional curricula, including effectiveness of teachers, length, quality, time of day, and venue (p < 0.001), but also preferred small group formats. Students reported animated videos (46.6%) and simultaneous drawings (46.5%) as the most effective means of retaining information. Understanding changing learner preferences is important in creating optimal curricula for today's students. Using the LEPO framework, this study identifies critical preferences in successfully teaching medical students, inclusive of commercial and traditional resources. These results can also help guide changes in pedagogy necessary due to the more recent COVID-19 pandemic.

Creating Disability-Competent Medical Students Via Community Outreach.

INTRODUCTION: Medical students often have limited exposure to providing care to physically and cognitively disabled patients. To address this gap, Involvement with Disability Education and Advancement (IDEA) was started in 2015 at Rutgers New Jersey Medical School (NJMS). The organization provides NJMS students the opportunity to visit a school dedicated to disabled students and lead educational sessions on health topics. MATERIALS AND METHODS: We conducted a survey study in 2018 to compare comfort levels between IDEA members and non-members in eliciting information from and providing medical attention to nonverbal, cognitively impaired, and physically disabled patients. The survey-based study utilized yes/no questions, and a Likert scale questionnaire to determine IDEA member and non-member comfort levels in working with various disabilities. Statistical analysis was performed using SAS Enterprise Guide 7.1; p value < 0.05 was considered statistically significant. RESULTS AND DISCUSSION: A total of 56 responses (19 members, 37 non-members) were analyzed. Regardless of IDEA membership, medical students of all years perceived themselves to have more comfort caring for physically disabled than cognitively impaired or nonverbal patients. IDEA members also recorded higher comfort levels with eliciting information from cognitively impaired patients and lower comfort levels with providing medical attention to physically disabled patients. IMPLICATIONS: IDEA members may have increased comfort interacting with cognitively impaired individuals due to their regular experience and lower levels of comfort providing medical attention to physically disabled patients due to awareness of complex problems specific to the population. The current results warrant continued data collection and further evaluation.

Coming Together: How Medical Students, Academic Administrators, and Hospital Administrators Approached Student Volunteering During the COVID-19 Pandemic.

The COVID-19 pandemic caused dramatic interruptions and shifts to medical education, but students at schools nationwide responded by volunteering to support their physician educators on the frontlines. Relationships between student leaders, school administrators, and hospital administrators were key to the successful creation and organization of volunteer responses. This perspective piece from medical students, as well as hospital and medical school leadership, explores the evolving relationships in the creation of Rutgers New Jersey Medical School's Student COVID Team. By reflecting on choices made by each group in parallel points in time, the piece highlights where interests and actions aligned and diverged.

Integrating the Bleeding Control Basic course into medical school curriculum.

BACKGROUND: The American College of Surgeons has pioneered hemorrhage control through its lifesaving bleeding control (BCon) basics course. A gap exists in teaching these skills to medical students. We sought to integrate BCon into the medical school curriculum. METHODS: BCon programs taught to entering Year 1 medical students in Academic Years 2017-2018. Post-course surveys assessed effectiveness of teaching and learner confidence in performing skills. Refreshers in Year 2 and Year 3 of study were implemented to reinforce skills. RESULTS: Post-course surveys (n = 348) showed that 98% of students felt that they were effectively taught how to stop bleeding and 92% felt comfortable using these skills. CONCLUSION: The BCon program is feasible to implement in medical school. It is easily integrated into pre-existing curricula in addition to other life support skills taught to medical students. SUMMARY: Bleeding control is increasingly a topic of national concern with mass casualty incidents. We used a peer training model to teach BCon techniques to all our medical students on entry into medical school and these skills were refreshed longitudinally in the next two years. Combining BCon training with other basic life support skills training is feasible and medical students find this training effective.

Narrative Performance Level Assignments at Initial Entrustment and Graduation: Integrating EPAs and Milestones to Improve Learner Assessment.

PURPOSE: To determine which narrative performance level for each general pediatrics entrustable professional activity (EPA) reflects the minimum level clinical competency committees (CCCs) felt should be associated with graduation as well as initial entrustment and compare expected narrative performance levels (ENPLs) for each EPA with actual narrative performance levels (ANPLs) assigned to residents at initial entrustment. METHOD: A series of 5 narratives, corresponding to the 5 milestone performance levels, were developed for each of the 17 general pediatrics EPAs. In academic year (AY) 2015-2016, the CCCs at 22 Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network member sites reported ENPLs for initial entrustment and at time of graduation. From AYs 2015-2016 to 2017-2018, programs reported ANPLs for initial entrustment decisions. ENPLs and ANPLs were compared using a logistic mixed effects model. RESULTS: ENPLs for graduation and entrustment were most often level 3 (competent) followed by level 4 (proficient). For 8 EPAs, the ENPLs for graduation and entrustment were the same. For the remaining 9, some programs would entrust residents before graduation or graduate them before entrusting them. There were 4,266 supervision level reports for initial entrustment for which an ANPL was provided. ANPLs that were lower than the ENPLs were significantly more likely to be assigned to the medical home-well child (OR = 0.39; 95% CI: 0.26-0.57), transition to adult care (OR = 0.43; 95% CI: 0.19-0.95), behavioral or mental health (OR = 0.36; 95% CI: 0.18-0.71), make referrals (OR = 0.31; 95% CI: 0.17-0.55), lead a team (OR = 0.34; 95% CI: 0.22-0.52), and handovers (OR = 0.18; 95% CI: 0.09-0.36) EPAs. CONCLUSIONS: CCCs reported lower ENPLs for graduation than for entrustment for 5 EPAs, possibly indicating curricular gaps that milestones and EPAs could help identify.

Novel mutation in mitochondrial DNA in 2 siblings with Leigh syndrome.

Leigh syndrome is clinically and genetically heterogeneous, associated with mutations in mitochondrial and nuclear genes.(1) Diagnostic criteria include progressive disorder with motor and intellectual delay/regression; signs and symptoms of brainstem and/or basal ganglia disease; raised lactate concentration in blood and/or CSF; and one or more of the following: (1) characteristic features on neuroimaging (bilateral symmetrical hyperintensities in brainstem, basal ganglia, dentate nuclei, and optic nerves on T2-weighted MRI); (2) typical neuropathologic changes; and (3) typical neuropathology in a similarly affected sibling.(2) We describe 2 African American siblings who have a mutation in the mitochondrial MT-TL2 gene and a clinical diagnosis of Leigh syndrome. The same mutation is also identified in their neurologically asymptomatic mother.