Precision Education: The Future of Lifelong Learning in Medicine.

ABSTRACT: The goal of medical education is to produce a physician workforce capable of delivering high-quality equitable care to diverse patient populations and communities. To achieve this aim amidst explosive growth in medical knowledge and increasingly complex medical care, a system of personalized and continuous learning, assessment, and feedback for trainees and practicing physicians is urgently needed. In this perspective, the authors build on prior work to advance a conceptual framework for such a system: precision education (PE).PE is a system that uses data and technology to transform lifelong learning by improving personalization, efficiency, and agency at the individual, program, and organization levels. PE "cycles" start with data inputs proactively gathered from new and existing sources, including assessments, educational activities, electronic medical records, patient care outcomes, and clinical practice patterns. Through technology-enabled analytics , insights are generated to drive precision interventions . At the individual level, such interventions include personalized just-in-time educational programming. Coaching is essential to provide feedback and increase learner participation and personalization. Outcomes are measured using assessment and evaluation of interventions at the individual, program, and organizational levels, with ongoing adjustment for repeated cycles of improvement. PE is rooted in patient, health system, and population data; promotes value-based care and health equity; and generates an adaptive learning culture.The authors suggest fundamental principles for PE, including promoting equity in structures and processes, learner agency, and integration with workflow (harmonization). Finally, the authors explore the immediate need to develop consensus-driven standards: rules of engagement between people, products, and entities that interact in these systems to ensure interoperability, data sharing, replicability, and scale of PE innovations.

Utility of TTMV-HPV DNA in resolving indeterminate findings during oropharyngeal cancer surveillance.

OBJECTIVES: Clinical and imaging examinations frequently have indeterminate results during cancer surveillance, which can lead to overtreatment and cause psychological and financial harm to the patient. This study addresses the critical need to enhance diagnostic precision and decision-making in the management of HPV-associated oropharyngeal cancer. This study evaluated the utility of tumor tissue-modified viral (TTMV)-HPV DNA to resolve indeterminate disease status following definitive treatment for HPV-associated oropharyngeal cancer. MATERIALS AND METHODS: In this retrospective cohort, patients treated for HPV-associated oropharyngeal cancer at eight U.S. institutions and who received one or more TTMV-HPV DNA tests during post-treatment surveillance between February 2020 and January 2022 were included. RESULTS: Among 543 patients, 210 patients (38.7%; 210/543) experienced one or more clinically indeterminate findings (CIFs) during surveillance, with 503 CIFs recorded. Of those patients with an "indeterminate" disease status at a point during surveillance, 79 were associated with contemporaneous TTMV-HPV DNA testing. TTMV-HPV DNA testing demonstrated high accuracy (97.5%; 77/79) in correctly determining recurrence status. Patients whose disease status was "indeterminate" at the time of a positive TTMV-HPV DNA test were clinically confirmed to recur faster than those whose disease status was "no evidence of disease." Only 3% of patients (17/543) experienced indeterminate TTMV-HPV DNA tests during surveillance. Discordance between TTMV-HPV DNA tests and clinical results was minimal, with only 0.6% (3/543) of patients showing positive tests without recurrence. CONCLUSION: Our findings support the utility of circulating TTMV-HPV DNA in resolving indeterminate disease status and informing the subsequent clinical course.

Medical education reform in wuhan university, china: a preliminary report of an international collaboration.

BACKGROUND: In 2008 Wuhan University Medical School in China proposed to reform its curriculum by adapting the curriculum of the University of Chicago Medical School. DESCRIPTION: An assessment of Wuhan University Medical School's traditional curriculum conducted in 2009 informed the reform directions, which included course integration, use of clinical cases, improved relevance of basic sciences to clinical medicine, reduction of lecture time, increase in group and independent learning, and the use of formative assessments. Fifty student volunteers per year were chosen to participate in the reform, and the rest remained in the traditional curriculum. EVALUATION: A student survey was conducted in 2011 to evaluate the reform by comparing the attitudes of those in the reform and standard curricula. CONCLUSIONS: The reform met the needs of the school, was generally well received, improved satisfaction in reform participants, and had a positive impact on students. Areas needing improvement were also identified.

Framework and Schema are False Synonyms: Defining Terms to Improve Learning.

Clinical reasoning is an essential expertise of health care professionals that includes the complex cognitive processes that lead to diagnosis and management decisions. In order to optimally teach, learn, and assess clinical reasoning, it is imperative for teachers and learners to have a shared understanding of the language. Currently, educators use the terms schema and framework interchangeably but they are distinct concepts. In this paper, we offer definitions for schema and framework and use the high-stakes field of aviation to demonstrate the interplay of these concepts. We offer examples of framework and schema in the medical education field and discuss how a clear understanding of these concepts allows for greater intentionality when teaching and assessing clinical reasoning.

Negative Predictive Value of Circulating Tumor Tissue Modified Viral (TTMV)-HPV DNA for HPV-driven Oropharyngeal Cancer Surveillance.

PURPOSE: Human papillomavirus (HPV) is causally linked to oropharyngeal squamous cell carcinoma (OPSCC). Consensus guidelines recommend clinical exams and imaging in decreasing frequency as part of posttreatment surveillance for recurrence. Plasma tumor tissue modified viral (TTMV)-HPV DNA testing has emerged as a biomarker which can inform disease status during surveillance. EXPERIMENTAL DESIGN: This retrospective observational cohort study involved 543 patients who completed curative-intent therapy for HPV-associated OPSCC between February 2020 and January 2022 at eight U.S. cancer care institutions. We determined the negative predictive value (NPV) of TTMV-HPV DNA for recurrence when matched to physician-reported clinical outcome data (median follow-up time: 27.9 months; range: 4.5-154). RESULTS: The cohort included mostly men with a median age of 61 who had locoregionally advanced disease. HPV status was determined by p16 positivity in 87% of patients, with a positive HPV PCR/ISH among 55%; while pretreatment TTMV-HPV DNA status was unknown for most (79%) patients. Patients had a mean of 2.6 tests and almost half had three or more TTMV-HPV DNA results during surveillance. The per-test and per-patient sensitivity of the assay was 92.5% [95% confidence interval (CI): 87.5-97.5] and 87.3% (95% CI: 79.1-95.5), respectively. The NPV for the assay was 99.4% (95% CI: 98.9-99.8) and 98.4% (95% CI: 97.3-99.5), respectively. CONCLUSIONS: TTMV-HPV DNA surveillance testing yields few false negative results and few missed recurrences. These data could inform decisions on when to pursue reimaging following first disease restaging and could inform future surveillance practice. Additional study of how pretreatment TTMV-HPV DNA status impacts sensitivity for recurrence is needed.

Use of a structured approach and virtual simulation practice to improve diagnostic reasoning.

OBJECTIVES: In 2015, the National Academy of Medicine IOM estimated that 12 million patients were misdiagnosed annually. This suggests that despite prolonged training in medical school and residency there remains a need to improve diagnostic reasoning education. This study evaluates a new approach. METHODS: A total of 285 medical students were enrolled in this 8 center, IRB approved trial. Students were randomized to receive training in either abdominal pain (AP) or loss of consciousness (LOC). Baseline diagnostic accuracy of the two different symptoms was assessed by completing a multiple-choice question (MCQ) examination and virtual patient encounters. Following a structured educational intervention, including a lecture on the diagnostic approach to that symptom and three virtual patient practice cases, each student was re-assessed. RESULTS: The change in diagnostic accuracy on virtual patient encounters was compared between (1) baseline and post intervention and (2) post intervention students trained in the prescribed symptom vs. the alternate symptom (controls). The completeness of the student's differential diagnosis was also compared. Comparison of proportions were conducted using χ2-tests. Mixed-effects regressions were used to examine differences accounting for case and repeated measures. Compared with baseline, both the AP and LOC groups had marked post-intervention improvements in obtaining a correct final diagnosis; a 27% absolute improvement in the AP group (p<0.001) and a 32% absolute improvement in the LOC group (p<0.001). Compared with controls (the groups trained in the alternate symptoms), the rate of correct diagnoses increased by 13% but was not statistically significant (p=0.132). The completeness and efficiency of the differential diagnoses increased by 16% (ß=0.37, p<0.001) and 17% respectively (ß=0.45, p<0.001). CONCLUSIONS: The study showed that a virtual patient platform combined with a diagnostic reasoning framework could be used for education and diagnostic assessment and improved correct diagnosis compared with baseline performance in a simulated platform.

Navigating the storm: report and recommendations from the Atlantic Storm exercise.

Atlantic Storm was a tabletop exercise simulating a series of bioterrorism attacks on the transatlantic community. The exercise occurred on January 14, 2005, in Washington, DC, and was organized and convened by the Center for Biosecurity of UPMC, the Center for Transatlantic Relations of Johns Hopkins University, and the Transatlantic Biosecurity Network. Atlantic Storm portrayed a summit meeting of presidents, prime ministers, and other international leaders from both sides of the Atlantic Ocean in which they responded to a campaign of bioterrorist attacks in several countries. The summit principals, who were all current or former senior government leaders, were challenged to address issues such as attaining situational awareness in the wake of a bioattack, coping with scarcity of critical medical resources such as vaccine, deciding how to manage the movement of people across borders, and communicating with their publics. Atlantic Storm illustrated that much might be done in advance to minimize the illness and death, as well as the social, economic, and political disruption, that could be caused by an international epidemic, be it natural or the result of a bioterrorist attack. These lessons are especially timely given the growing concerns over the possibility of an avian influenza pandemic that would require an international response. However, international leaders cannot create the necessary response systems in the midst of a crisis. Medical, public health, and diplomatic response systems and critical medical resources (e.g., medicines and vaccines) must be in place before a bioattack occurs or a pandemic emerges.

The impact of information technology on emergency health care outcomes.

We analyze the productivity of information technology in emergency response systems. "Enhanced 911" (E911) is information technology that links caller identification to a location database and so speeds up emergency response. We assess the impact of E911 on health outcomes using Pennsylvania ambulance and hospital records between 1994 and 1996, a period of substantial adoption. We find that as a result of E911 adoption, patient health measured at the time of ambulance arrival improves, suggesting that E911 speeds up emergency response. Further analysis using hospital discharge data shows that E911 reduces mortality and hospital costs.

Computer-assisted medical education: current and potential roles.

Medical education remains a time-consuming and complex task whose goals are to provide students with sufficient factual information and the clinical reasoning tools to ensure the competency of its graduates. Today, this task is especially challenging because of the exponential growth in biomedical information and the ever-increasing time pressure placed upon medical educators. Electronic tools have the capacity to facilitate medical education, as well as to fundamentally improve our ability to ensure the competency of our graduates. This article reviews some of the approaches to electronic education developed at the University of Chicago.

Sternocleidomastoid myocutaneous esophagoplasty for benign cervical stricture.

Benign strictures of the cervical esophagus that are resistant to dilation present a formidable challenge to the surgeon. Numerous varied techniques have been developed to restore swallowing. Reports of the sternocleidomastoid myocutaneous pedicled flap for repair of benign cervical strictures are scarce. We are reporting a case of residual lye stricture that was treated with sternocleidomastoid myocutaneous esophagoplasty in order to promote awareness of this procedure. This one-stage operation took 1 hour to complete. The patient began eating on postoperative day 4 and has not had any further symptoms.

Practice trends in the management of prostate disease by family practice physicians and general internists: an internet-based survey.

OBJECTIVES: To assess, using an Internet-based survey, the practice patterns of primary care physicians in the management of prostate disease and to assess the differences between family physicians and general internists. Prostate cancer and benign prostatic hyperplasia are common in the elderly population. The optimal management of these diseases is debated. METHODS: An 18-item survey was designed and administered on an Internet website. Members of the Society of General Internal Medicine and members of the Illinois, North Carolina, and New York chapters of the Academy of Family Physicians were surveyed. RESULTS: A total of 354 responses were obtained from 381 primary care physicians who viewed the survey web page. For patients 50 years old and older, 75% of physicians (87% of family physicians and 69% of general internists; P <0.001) recommended annual prostate cancer screening with digital rectal examination and 49% (67% of family physicians and 40% of general internists; P <0.001) recommended annual prostate cancer screening with prostate-specific antigen measurement. For patients diagnosed with prostate cancer, 76% of the primary care physicians estimated that less than one half of their patients are seen by a radiation oncologist. For the treatment and/or prevention of prostate cancer, 62% of physicians surveyed (76% of family physicians and 55% of general internists; P <0.001) believe there is a potential role for alternative herbal and nutritional therapies. CONCLUSIONS: Compared with general internists, family physicians are more likely to screen for prostate cancer and are more likely to believe there is a role for alternative therapies for prostate cancer.