Teledermatology: Simulating Hybrid Workflows for Telemedicine Education.

Given the importance of telemedicine in improving healthcare access for underserved patients, professional students need experience using virtual clinical workflows. We developed an educational workshop with (1) readings, (2) a knowledge assessment test, (3) dermatology and teledermatology lectures, (5) a telemedicine simulation with a standardized patient, and (6) a debriefing session. The simulation included a "hybrid" workflow with live videoconferencing and store-and-forward image review. We measured student performance using three American Association of Medical Colleges (AAMC) Telemedicine Competencies for medical education. Ninety-eight medical and physician assistant students completed this workshop between 2021 and 2022, and 80% were entrustable or approaching entrustment in each competency. Some students struggled with data collection and technology use. Our results suggest that this workshop offers a practical and generalizable way to teach about multiple virtual workflows and strengthen students' telemedicine competencies.

Simulating Telemedicine, Medication Reconciliation, and Social Determinants: A Novel Instructional Approach to Health Systems Competencies.

While medication reconciliation is necessary to reduce errors, it is often challenging to gather an accurate history in the clinic. Telemedicine offers a relative advantage over clinic and hospital-based interviews by enabling the clinician to inspect the home environment, review pill bottles, and identify social determinants affecting adherence, such as financial instability. To be effective, however, clinicians must be trained in best-practice interview methods and the proper use of telemedicine. There is very little information in the literature describing the best strategies for teaching students or measuring competencies in telemedicine. Therefore, we created an educational module with a telemedicine simulation and an evaluation rubric. We piloted this module with 48 medical and physician assistant students. Most students could complete a virtual interview and gather a medication history. However, only half identified an over-the-counter medication missing from the list. Most students were either entrustable or approaching entrustment in the six telemedicine competencies measured in this simulation. This simulation is valuable for teaching students about medication reconciliation, using telemedicine to close gaps in access to care, and identifying health-related social needs affecting medication adherence.

Automation vs. Innovation: Unexplored Strategies to Improve Virtual Care.

While there is a global desire to increase digital health capacity, digital health should transform health services delivery rather than simply automate - or worse - replicate existing practices. Failing to capitalize on this transformative potential misses an opportunity to engage patients and other users to provide a more person-centered experience. However, digital transformation done recklessly can disrupt workflow, alienate users, and jeopardize patient safety, as we have observed with implementation of many digital health tools. This paper uses a telemedicine example to provide insight into how digital health innovation can be a meaningful enabler of health system transformation. Examining different ways to leverage digital health technologies is crucial to best capitalize on their potential.

Identifying Failure Modes in Telemedicine: An Instructional Needs Assessment.

Technology failures in telehealth are common, and clinicians need the skills to diagnose and manage them at the point of care. However, there are issues beyond technology failures mediating the effective use of telehealth. We must teach best-practice procedures for conducting telemedicine visits and include in instructional simulations commonly encountered failure modes so students can build their skills. To this end, we recruited medical students to conduct a Healthcare Failure Modes and Effects Analysis (HFMEA) to predict failures in telemedicine, their potential causes, and the consequences to develop and teach prevention strategies. Sixteen students observed telehealth appointments independently. Based on their observations, we identified four categories of failures in telemedicine: technical issues, patient safety, communication, and social and structural determinants. We proposed a normalized workflow that included management and prevention strategies. Our findings can inform the creation of new curricula.

Assessing Telemedicine Competencies: Developing and Validating Learner Measures for Simulation-Based Telemedicine Training.

In 2021, the Association of American Medical Colleges published Telehealth Competencies Across the Learning Continuum, a roadmap for designing telemedicine curricula and evaluating learners. While this document advances educators' shared understanding of telemedicine's core content and performance expectations, it does not include turn-key-ready evaluation instruments. At the University of Oklahoma School of Community Medicine, we developed a year-long telemedicine curriculum for third-year medical and second-year physician assistant students. We used the AAMC framework to create program objectives and instructional simulations. We designed and piloted an assessment rubric for eight AAMC competencies to accompany the simulations. In this monograph, we describe the rubric development, scores for students participating in simulations, and results comparing inter-rater reliability between faculty and standardized patient evaluators. Our preliminary work suggests that our rubric provides a practical method for evaluating learners by faculty during telemedicine simulations. We also identified opportunities for additional reliability and validity testing.

Using Simulations to Train Medical Students for Unanticipated Technology Failures in Telemedicine.

Simulations offer a safe environment for health professional training and the opportunity to predictably and consistently introduce events or variables that may be rare or dangerous in a live setting. Exposing trainees to unanticipated events during simulations can improve their ability to adapt and improvise. The COVID-19 pandemic accelerated the adoption of telehealth worldwide and highlighted the need for better training in health professional schools. In the United States, the Association of American Medical Colleges (AAMC) published new telehealth competency standards in 2021. The AAMC stated that health care providers should be aware of the risks of technology failures, capable of troubleshooting them, and lead systems interventions to improve safety. However, the AAMC does not provide guidance on the specific failures or solutions. In this study, we developed a set of technology failures that can be simulated in a telehealth curriculum. We incorporated one technology failure into a simulated telehealth encounter and gathered students' (N = 53) feedback on the exercise. Students' feedback was overwhelmingly positive. They agreed that integrating technology failures into telehealth simulations provides important practice managing these events during clinical encounters. While telehealth is an important healthcare delivery modality that can improve access-to-care, it is imperative to train medical students to navigate technology failures so that can adeptly manage these issues in clinical practice.

Teaching Teledermatology: A Simulation Pilot for Health Professional Students.

We developed a teledermatology simulation to give medical and physician assistant students practice with live videoconferencing and store-and-forward workflows. The simulation included (1) pre-session reading; (2) a brief teledermatology didactic; (3) a simulated encounter with a standardized patient; and (4) faculty-led debriefs. The faculty observed students during the simulation and distributed a post-session learner satisfaction survey. Although students had mixed feelings about the simulation, 88% said the workshop met or exceeded expectations.

A Telepsychiatry Simulation for Suicide Assessment: Teaching Telemedicine Safety Competencies.

Educators must provide controlled scenarios for health professional students to develop patient safety competencies related to telemedicine, including when and how to escalate care. We developed a telepsychiatry workshop to give students experience with a high-stakes mental health condition. The workshop included (1) pre-session readings; (2) didactics on mood disorders and telepsychiatry; (3) a motivational interviewing exercise; (4) a simulated telemedicine encounter; and (5) a faculty-led group debrief. We evaluated teaching effectiveness using a competency assessment with three scales: (1) medical knowledge; (2) interpersonal and communication skills; and (3) telemedicine competencies. Between 0 and 59% of students were entrustable for each telemedicine competency. Our workshop demonstrates how to teach students about the safe use of telehealth technology and provides practice triaging mental health conditions commonly encountered in primary care and mental health telemedicine clinics.

Podcasts for the Delivery of Medical Education and Remote Learning.

Podcasts are increasingly being recognized as an effective platform to facilitate the continuous professional development (CPD) of health care professionals (HCPs). Compared with face-to-face meetings and other more traditional forms of CPD, podcasts allow for flexible learning and are less expensive to develop. Podcasts are at the cutting edge of digital education and can be an important element of a pharmaceutical company's multichannel communications plan to improve HCP engagement and CPD in specific therapy areas. However, developing a successful podcast can have significant challenges. In this viewpoint paper, we provide our perspectives on medical podcasts as a medium for educating HCPs in the digital age. We describe our experience in developing an HIV-focused podcast for Australian HCPs, creating a series that has now expanded to other therapy areas in several countries. Practical considerations and unique challenges associated with industry-sponsored podcasts are outlined. Overall, we believe that the process of developing a podcast can be a challenging but rewarding experience, and CPD delivered via podcasting should be more routinely considered by pharmaceutical companies.

Single cell, super-resolution imaging reveals an acid pH-dependent conformational switch in SsrB regulates SPI-2.

After Salmonella is phagocytosed, it resides in an acidic vacuole. Its cytoplasm acidifies to pH 5.6; acidification activates pathogenicity island 2 (SPI-2). SPI-2 encodes a type three secretion system whose effectors modify the vacuole, driving endosomal tubulation. Using super-resolution imaging in single bacterial cells, we show that low pH induces expression of the SPI-2 SsrA/B signaling system. Single particle tracking, atomic force microscopy, and single molecule unzipping assays identified pH-dependent stimulation of DNA binding by SsrB. A so-called phosphomimetic form (D56E) was unable to bind to DNA in live cells. Acid-dependent DNA binding was not intrinsic to regulators, as PhoP and OmpR binding was not pH-sensitive. The low level of SPI-2 injectisomes observed in single cells is not due to fluctuating SsrB levels. This work highlights the surprising role that acid pH plays in virulence and intracellular lifestyles of Salmonella; modifying acid survival pathways represents a target for inhibiting Salmonella.

Coordination of Chromosome Segregation and Cell Division in Staphylococcus aureus.

Productive bacterial cell division and survival of progeny requires tight coordination between chromosome segregation and cell division to ensure equal partitioning of DNA. Unlike rod-shaped bacteria that undergo division in one plane, the coccoid human pathogen Staphylococcus aureus divides in three successive orthogonal planes, which requires a different spatial control compared to rod-shaped cells. To gain a better understanding of how this coordination between chromosome segregation and cell division is regulated in S. aureus, we investigated proteins that associate with FtsZ and the divisome. We found that DnaK, a well-known chaperone, interacts with FtsZ, EzrA and DivIVA, and is required for DivIVA stability. Unlike in several rod shaped organisms, DivIVA in S. aureus associates with several components of the divisome, as well as the chromosome segregation protein, SMC. This data, combined with phenotypic analysis of mutants, suggests a novel role for S. aureus DivIVA in ensuring cell division and chromosome segregation are coordinated.

Super-resolution imaging of the cytokinetic Z ring in live bacteria using fast 3D-structured illumination microscopy (f3D-SIM).

Imaging of biological samples using fluorescence microscopy has advanced substantially with new technologies to overcome the resolution barrier of the diffraction of light allowing super-resolution of live samples. There are currently three main types of super-resolution techniques - stimulated emission depletion (STED), single-molecule localization microscopy (including techniques such as PALM, STORM, and GDSIM), and structured illumination microscopy (SIM). While STED and single-molecule localization techniques show the largest increases in resolution, they have been slower to offer increased speeds of image acquisition. Three-dimensional SIM (3D-SIM) is a wide-field fluorescence microscopy technique that offers a number of advantages over both single-molecule localization and STED. Resolution is improved, with typical lateral and axial resolutions of 110 and 280 nm, respectively and depth of sampling of up to 30 µm from the coverslip, allowing for imaging of whole cells. Recent advancements (fast 3D-SIM) in the technology increasing the capture rate of raw images allows for fast capture of biological processes occurring in seconds, while significantly reducing photo-toxicity and photobleaching. Here we describe the use of one such method to image bacterial cells harboring the fluorescently-labelled cytokinetic FtsZ protein to show how cells are analyzed and the type of unique information that this technique can provide.

Division site positioning in bacteria: one size does not fit all.

Spatial regulation of cell division in bacteria has been a focus of research for decades. It has been well studied in two model rod-shaped organisms, Escherichia coli and Bacillus subtilis, with the general belief that division site positioning occurs as a result of the combination of two negative regulatory systems, Min and nucleoid occlusion. These systems influence division by preventing the cytokinetic Z ring from forming anywhere other than midcell. However, evidence is accumulating for the existence of additional mechanisms that are involved in controlling Z ring positioning both in these organisms and in several other bacteria. In some cases the decision of where to divide is solved by variations on a common evolutionary theme, and in others completely different proteins and mechanisms are involved. Here we review the different ways bacteria solve the problem of finding the right place to divide. It appears that a one-size-fits-all model does not apply, and that individual species have adapted a division-site positioning mechanism that best suits their lifestyle, environmental niche and mode of growth to ensure equal partitioning of DNA for survival of the next generation.

3D-SIM super resolution microscopy reveals a bead-like arrangement for FtsZ and the division machinery: implications for triggering cytokinesis.

FtsZ is a tubulin-like GTPase that is the major cytoskeletal protein in bacterial cell division. It polymerizes into a ring, called the Z ring, at the division site and acts as a scaffold to recruit other division proteins to this site as well as providing a contractile force for cytokinesis. To understand how FtsZ performs these functions, the in vivo architecture of the Z ring needs to be established, as well as how this structure constricts to enable cytokinesis. Conventional wide-field fluorescence microscopy depicts the Z ring as a continuous structure of uniform density. Here we use a form of super resolution microscopy, known as 3D-structured illumination microscopy (3D-SIM), to examine the architecture of the Z ring in cells of two Gram-positive organisms that have different cell shapes: the rod-shaped Bacillus subtilis and the coccoid Staphylococcus aureus. We show that in both organisms the Z ring is composed of a heterogeneous distribution of FtsZ. In addition, gaps of fluorescence were evident, which suggest that it is a discontinuous structure. Time-lapse studies using an advanced form of fast live 3D-SIM (Blaze) support a model of FtsZ localization within the Z ring that is dynamic and remains distributed in a heterogeneous manner. However, FtsZ dynamics alone do not trigger the constriction of the Z ring to allow cytokinesis. Lastly, we visualize other components of the divisome and show that they also adopt a bead-like localization pattern at the future division site. Our data lead us to propose that FtsZ guides the divisome to adopt a similar localization pattern to ensure Z ring constriction only proceeds following the assembly of a mature divisome.

A simple plasmid-based system that allows rapid generation of tightly controlled gene expression in Staphylococcus aureus.

We have established a plasmid-based system that enables tightly controlled gene expression and the generation of GFP fusion proteins in Staphylococcus aureus simply and rapidly. This system takes advantage of an Escherichia coli-S. aureus shuttle vector that contains the replication region of the S. aureus theta-mode multiresistance plasmid pSK41, and is therefore a stable low-copy-number plasmid in the latter organism. This vector also contains a multiple cloning site downstream of the IPTG-inducible Pspac promoter for insertion of the gene of interest. Production of encoded proteins can be stringently regulated in an IPTG-dependent manner by introducing a pE194-based plasmid, pGL485, carrying a constitutively expressed lacI gene. Using GFP fusions to two essential proteins of S. aureus, FtsZ and NusA, we showed that our plasmid allowed tightly controlled gene expression and accurate localization of fusion proteins with no detrimental effect on cells at low inducer concentrations. At higher IPTG concentrations, we obtained sixfold overproduction of protein compared with wild-type levels, with FtsZ-GFP-expressing cells showing lysis and delocalized fluorescence, while NusA-GFP showed only delocalized fluorescence. These results show that our system is capable of titratable induction of gene expression for localization or overexpression studies.