Medical Student Perception of Lifestyle Medicine and Willingness to Engage in Lifestyle Counseling: A Pilot Study of Allopathic and Osteopathic Medical Students.

Introduction. This study assessed medical students' perception of lifestyle medicine and readiness to engage in lifestyle counseling. Methods. All medical students in one allopathic and one osteopathic medical school received a survey involving items designed to measure their awareness and interest in lifestyle medicine, perception of physicians serving as lifestyle role models for patients, and intent to practice lifestyle counseling. Results. Two hundred and eight-nine subjects (145 allopathic and 144 osteopathic students) responded to the survey. A total of 24.1% of responding allopathic students had heard about lifestyle medicine compared with 53.9% of responding osteopathic students (P < .01). A total of 90.5% of allopathic students rated their current knowledge of lifestyle medicine as inadequate or poor compared with 78.7% of osteopathic students (P < .01). Ninety-two percent of all respondents wanted to learn more about lifestyle medicine, while 95.2% believed they would provide more effective counseling if they were trained sufficiently to serve as a healthy lifestyle role model for their patients. Conclusions. Both cohorts favored learning more about lifestyle medicine and believed physicians should provide lifestyle counseling to patients with chronic diseases. Given these findings, and the demonstrated benefits of lifestyle medicine-based health care, the authors suggest that training in lifestyle medicine be increased in undergraduate medical education.

Semantic competence and prototypical verbalizations are associated with higher OSCE and global medical degree scores: a multi-theory pilot study on year 6 medical student verbalizations.

OBJECTIVES: The organization of medical knowledge is reflected in language and can be studied from the viewpoints of semantics and prototype theory. The purpose of this study is to analyze student verbalizations during an Objective Structured Clinical Examination (OSCE) and correlate them with test scores and final medical degree (MD) scores. We hypothesize that students whose verbalizations are semantically richer and closer to the disease prototype will show better academic performance. METHODS: We conducted a single-center study during a year 6 (Y6) high-stakes OSCE where one probing intervention was included at the end of the exam to capture students' reasoning about one of the clinical cases. Verbalizations were transcribed and coded. An assessment panel categorized verbalizations regarding their semantic value (Weak, Good, Strong). Semantic categories and prototypical elements were compared with OSCE, case-based exam and global MD scores. RESULTS: Students with Semantic 'Strong' verbalizations displayed higher OSCE, case-based exam and MD scores, while the use of prototypical elements was associated with higher OSCE and MD scores. CONCLUSIONS: Semantic competence and verbalizations matching the disease prototype may identify students with better organization of medical knowledge. This work provides empirical groundwork for future research on language analysis to support assessment decisions.

An Epigenetic Perspective on Lifestyle Medicine for Depression: Implications for Primary Care Practice.

Depression is the most common presenting mental health disorder in primary care. It is also a major contributor to somatic complaints, worsening of chronic medical conditions, poor quality of life, and suicide. Current pharmacologic and psychotherapeutic approaches avert less than half of depression's cumulative burden on society. However, there is a growing body of research describing both how maladaptive lifestyle choices contribute to the development and worsening of depression and how lifestyle-oriented medical interventions can reduce the incidence and severity of depression. This research, largely derived from an emerging field called epigenetics, elucidates the interactions between our lifestyle choices and those epigenetic factors which mediate our tendencies toward either health, or the onset, if not worsening of disease. The present review highlights how lifestyle choices involving diet, physical activity, sleep, social relationships, and stress influence epigenetic processes positively or negatively, and thereby play a significant role in determining whether one does or does not suffer from depression. The authors propose that medical training programs consider and adopt lifestyle medicine oriented instructional initiatives that will enable tomorrow's primary care providers to more effectively identify and therapeutically intervene in the maladaptive choices contributing to their patients' depression.

Effects of using an abdominal simulator to develop palpatory competencies in 3rd year medical students.

BACKGROUND: Medical school faculty are hard pressed to provide clerkship students with sufficient opportunity to develop and practice their capacity to perform a competent clinical examination, including the palpatory examination of the abdomen. We evaluated the impact of training with an abdominal simulator, AbSim, designed to monitor the depth, location, and thoroughness of their palpation and to provide concurrent and summative feedback regarding their performance. METHODS: All third-year medical students were given the opportunity to develop their palpatory skills with the AbSim simulator during the family medicine rotation. The performance of those who studied with the simulator was measured by its sensors, before and after a training session that included visual feedback regarding the depth and coverage of the student's manual pressure. Additionally, all students reported their confidence in their evolving abdominal palpation skills at the beginning and end of the rotation. RESULTS: 119 (86.9%) of 137 students filled out the initial questionnaire, and 73 (61.3%) studied with the abdominal simulator. The training produced a highly significant improvement in their overall performance (4 measures, p's < 0.001). Pre-training performance (depth calibration and thoroughness of coverage) was not related to the number of months of previous clinical rotations nor to previous internal medicine or surgery rotations. There was little relation between students' confidence in their abdominal examination skills and objective measures of their palpatory performance; however, students who chose the training started with less confidence, and became more confident after training. CONCLUSIONS: Guided abdominal simulator practice increased medical students' capacity to perform an abdominal examination with more appropriate depth and thoroughness of palpation. Interpretation of changes in confidence are uncertain, because confidence was unrelated to objectively measured performance. However, students with low initial confidence in their abdominal examination seemed to be more likely to choose to study with the abdominal simulator.

An Epigenetics-Based, Lifestyle Medicine-Driven Approach to Stress Management for Primary Patient Care: Implications for Medical Education.

Over 75% of patients in the primary care setting present with stress-related complaints. Curiously, patients and health care providers all too often see stress as a relatively benign sequela of many common illnesses such as heart disease, cancer, lung disease, dementia, diabetes, and mental illness. Unfortunately, various day-to-day lifestyle choices and environmental factors, unrelated to the presence of any disease, can cause stress sufficient to contribute to the development of various diseases/disorders and suboptimal health. There is evidence suggesting that counseling in stress management-oriented therapeutic interventions (as offered by lifestyle medicine-oriented practitioners) may prevent or reduce the onset, severity, duration, and/or overall burden of stress-related illnesses. Such counseling often involves considerations such as the patient's nutrition, physical activity, interest in/capacity to meditate, drug abuse/cessation, and so on. Unfortunately, lifestyle medicine-oriented approaches to stress management are rarely offered in primary care-the patient care arena wherein such counseling would likely be best received by patients. Would health care outcomes improve if primary care providers offered counseling in both stress management and positive lifestyle choices? The purpose of this article is to provide both primary care practitioners and educators in health care training programs with an introductory overview of epigenetics. An emerging field of science offering insights into how factors such as stress and lifestyle choices interact with our genes in ways that can both positively and negatively impact the various micro (eg, cellular) through macro (eg, physiologic, pathophysiologic) processes that determine our tendencies toward illness or wellness. A deeper understanding of epigenetics, as provided herein, should enable primary care providers and medical educators to more confidently advocate for the primary benefits associated with counseling in both stress reduction and the pursuit of healthy lifestyle choices.

Competencies for improving diagnosis: an interprofessional framework for education and training in health care.

Background Given an unacceptably high incidence of diagnostic errors, we sought to identify the key competencies that should be considered for inclusion in health professions education programs to improve the quality and safety of diagnosis in clinical practice. Methods An interprofessional group reviewed existing competency expectations for multiple health professions, and conducted a search that explored quality, safety, and competency in diagnosis. An iterative series of group discussions and concept prioritization was used to derive a final set of competencies. Results Twelve competencies were identified: Six of these are individual competencies: The first four (#1-#4) focus on acquiring the key information needed for diagnosis and formulating an appropriate, prioritized differential diagnosis; individual competency #5 is taking advantage of second opinions, decision support, and checklists; and #6 is using reflection and critical thinking to improve diagnostic performance. Three competencies focus on teamwork: Involving the patient and family (#1) and all relevant health professionals (#2) in the diagnostic process; and (#3) ensuring safe transitions of care and handoffs, and "closing the loop" on test result communication. The final three competencies emphasize system-related aspects of care: (#1) Understanding how human-factor elements influence the diagnostic process; (#2) developing a supportive culture; and (#3) reporting and disclosing diagnostic errors that are recognized, and learning from both successful diagnosis and from diagnostic errors. Conclusions These newly defined competencies are relevant to all health professions education programs and should be incorporated into educational programs.

Aggregated student confidence estimates support continuous quality improvements in a competencies-oriented curriculum.

Introduction: Competencies oriented medical curricula are intended to support the development of those specific tasks likely to improve patient care outcomes. In 2005, our institution developed curricular objectives and instructional activities intended to enable our students to competently perform four specific clinical tasks (diagnose, treat, manage and explain phenomena) for each of approximately 100 common and/or important patient presentations (eg, dyspnoea). However, competencies oriented curricula must also develop outcome metrics aligned with their objectives and instructional activities in order to launch a continuous quality improvement (CQI) programme. This investigation describes how a novel course evaluation methodology produced presentation and task-focused outcome metrics sufficient to support CQIs in our competencies-oriented curriculum. Methods: Literature suggests that aggregated, group opinions are much more reliable than individual opinions in a variety of settings, including education. In 2010, we launched a course evaluation methodology using aggregated student self-assessments of their confidence in performing the four tasks trained to in each presentation-focused instructional activity. These aggregated estimates were transformed into a variety of graphic and tabular reports which faculty used to identify, and then remediate, those specific instructional activities associated with suboptimal presentation and task-focused confidence metrics. Results: With academic year 2010-2011 serving as a baseline and academic year 2015-2016 as an endpoint, analysis of variance revealed a sustained and statistically significant gain in student confidence across this 6-year study period (p<0.001). Discussion: This investigation demonstrated that aggregated, presentation and task-specific confidence estimates enabled faculty to pursue and attain CQIs in a competencies-oriented curriculum. Suggestions for new approaches to confidence-related research are offered.

Faculty Development Directed at Curricular Reforms Designed to Improve Patient Outcomes.

Three initiatives involving quality of patient outcomes that evolved in the late 1990s must be considered in the design of 21st century undergraduate medical curricula. They involve (1) the question of how to best teach and assess medical competencies, (2) growing concerns regarding the frequency and severity of error in medical care, and (3) the role physicians might play in weaving together the overlapping elements of population-, community-, and systems-based practice into a codified approach to medical care. With these initiatives in mind, the University of North Texas Health Science Center Texas College of Osteopathic Medicine has formed an Academy of Medical Educators whose goal is to develop faculty programs intended to expedite curricular modifications and reforms.

Outcomes-Oriented Medical Training: A Critical Curricular Design Consideration in Developing 21st Century Health Care Professionals.

The core competencies of medical schools and residencies have initiated a change in curricular design but have been limited in their execution of systems-based practice. The introduction of milestones and entrustable professional activities has emerged to enhance the current educational paradigm. Linking public health systemic approaches with evidence-based practices focused on population-level health care will affect patients more than current non-systems-based approaches. Curricular redesign, including population health-based strategies, public health competency, health care policy, and education linking the "determinants of health" to patient care, will better prepare future physicians to practice in the emerging paradigm of health care of the future. Thus, the University of North Texas Health Science Center Texas College of Osteopathic Medicine has launched a 3-phase model that addresses the specific foundational needs required to instantiate fundamental systems-based concepts in faculty, undergraduate medical curricula, and clinical practice.

Evidence of the preferential use of disease prototypes over case exemplars among early year one medical students prior to and following diagnostic training.

BACKGROUND: Two core dual processing theory (DPT) System I constructs (Exemplars and Prototypes) were used to: 1) formulate a training exercise designed to improve diagnostic performance in year one medical students, and 2) explore whether any observed performance improvements were associated with preferential use of exemplars or prototypes. METHODS: With IRB approval, 117 year one medical students participated in an acute chest pain diagnostic training exercise. A pre- and post-training test containing the same 27 case vignettes was used to determine if the subjects' diagnostic performance improved via training in both exemplars and prototypes. Exemplar and Prototype theory was also used to generate a unique typicality estimate for each case vignette. Because these estimates produce different performance predictions, differences in the subjects' observed performance would make it possible to infer whether subjects were preferentially using Exemplars or Prototypes. RESULTS: Pre- vs. post-training comparison revealed a significant performance improvement; t=14.04, p<0.001, Cohen's d=1.32. Pre-training, paired t-testing demonstrated that performance against the most typical vignettes>mid typical vignettes: t=4.94, p<0.001; and mid typical>least typical: t=5.16, p<0.001. Post-training, paired t-testing again demonstrated that performance against the most typical vignettes>mid typical: t=2.94, p<0.01; and mid typical>least typical: t=6.64, p<0.001. These findings are more consistent with the performance predictions generated via Prototype theory than Exemplar theory. CONCLUSIONS: DPT is useful in designing and evaluating the utility of new approaches to diagnostic training, and, investigating the cognitive factors driving diagnostic capabilities among early medical students.

Cardiac implanted electronic device-related infective endocarditis: clinical features, management, and outcomes of 80 consecutive patients.

BACKGROUND: The use of cardiac implantable electronic devices (CIEDs) has expanded dramatically over the past decade, but net clinical benefit has been curtailed by increasing infectious complications. In particular, CIED-related infectious endocarditis (IE) is a serious condition with significant morbidity and mortality. METHODS: We performed a single-center, retrospective study between July 2006 and February 2011 with CIED-related IE, defined by either lead vegetations detected on echocardiography or by fulfilling Duke criteria for definite endocarditis. Clinical parameters and outcomes were detailed by electronic medical record review and vital status was confirmed by the Social Security Death Index. RESULTS: Eighty patients (median age 67, interquartile range 56-75, 58 M/22 F) were diagnosed with CIED-related IE. Overall mortality was 36% with a median time to death of 95 days from presentation. Over half (52%) of the deaths were infection related with a median time to death of 29 days. Multivariate analysis showed methicillin-resistant Staphylococcus aureus (MRSA) infection (odds ratio [OR] 0.158; 95% confidence interval [CI], 0.047-0.534; P = .003) and concomitant valve endocarditis (OR 0.141, CI 0.041-0.491, P = .002) independently predicted mortality. CONCLUSION: In this contemporary series, all-cause mortality in patients with CIED-related IE was high with a short time to death from onset of infection. MRSA and concomitant valve infection were the most powerful independent predictors of mortality.

Minimally invasive fibrillating mitral valve replacement for patients with advanced cardiomyopathy: a safe and effective approach to treat a complex problem.

OBJECTIVE: The optimal management of mitral regurgitation (MR) in patients with cardiomyopathy has been controversial. Minimally invasive fibrillating mitral valve replacement (mini-MVR) might limit postoperative morbidity and mortality by minimizing recurrent MR. We hypothesized that mini-MVR with complete chordal sparing would offer low mortality and halt left ventricular (LV) remodeling in patients with severe cardiomyopathy and severe MR. METHODS: From January 2006 to August 2009, 65 patients with an LV ejection fraction (LVEF) of ≤35% underwent mini-MVR. The demographic, echocardiographic, and clinical outcomes were analyzed. RESULTS: The operative mortality compared with the Society of Thoracic Surgeons-predicted mortality was 6.2% versus 6.6%. It was 5.6% versus 7.4% for patients with an LVEF of ≤20% and 8.3% versus 17.9% among patients with a Society of Thoracic Surgeons-predicted mortality of ≥10%. At a median follow-up of 17 months, no recurrent MR or change in the LV dimensions or LVEF had developed, but the right ventricular systolic pressure had decreased (P=.02). At the first postoperative visit and latest follow-up visit, the New York Heart Association class had decreased from 3.0±0.6 to 1.7±0.7 and 2.0±1.0, respectively (P<.0001 for both). Patients with an LVEF of ≤20% and LV end-diastolic diameter of ≥6.5 cm were more likely to meet a composite of death, transplantation, or LV assist device insertion (P=.046). CONCLUSIONS: Our results have shown that mini-MVR is safe in patients with advanced cardiomyopathy and resulted in no recurrent MR, stabilization of the LVEF and LV dimensions, and a decrease in right ventricular systolic pressure. This mini-MVR technique can be used to address severe MR in patients with advanced cardiomyopathy.

Learning sciences principles that can inform the construction of new approaches to diagnostic training.

The author suggests that the ill-defined nature of human diseases is a little appreciated, nonetheless important contributor to persistent and high levels of diagnostic error. Furthermore, medical education's continued use of traditional, non-evidence based approaches to diagnostic training represents a systematic flaw likely perpetuating sub-optimal diagnostic performance in patients suffering from ill-defined diseases. This manuscript briefly describes how Learning Sciences findings elucidating how humans reason in the face of the uncertainty and complexity posed by ill-defined diseases might serve as guiding principles in the formulation of first steps towards a codified, 21st century approach to training and assessing the diagnostic capabilities of future health care providers.

Cognitive and social issues in emergency medicine knowledge translation: a research agenda.

The individual practitioner is a linchpin in the process of translating new knowledge into practice, particularly in the emergency department, where physician autonomy is high, resources are limited, and decision-making situations are complex. An understanding of the cognitive and social processes that affect knowledge translation (KT) in emergency medicine (EM) is crucial and at present understudied. As part of the 2007 Academic Emergency Medicine Consensus Conference on KT in EM, our group sought to identify key research areas that would inform our understanding of these cognitive and social processes. We combined an online discussion group of interdisciplinary stakeholders, an extensive review of the existing literature, and a "public hearing" of the recommendations at the Consensus Conference to establish relative preference for the recommendations, as well as their relevance and clarity to attendees. We identified five key research areas as follows. 1) What provider-specific barriers/facilitators to the use of new knowledge are relevant in the EM setting? 2) Can social psychological theories of behavior change be used to develop better KT interventions for EM? 3) Can the study of "distributed cognition" suggest new vehicles for KT in the emergency department? 4) Can the concept of dual-process reasoning inform our understanding of the KT process? 5) Can patient-specific, immediate feedback serve as a vehicle for KT in EM? We believe that exploring these key research questions will directly lead to improved KT interventions and to further discussion of the cognitive and social factors impacting KT in EM.

Improving diagnostic capabilities of medical students via application of cognitive sciences-derived learning principles.

PURPOSE: There is limited experimental evidence concerning how best to train students to perform differential diagnosis. We compared 2 different methods for training 2nd-year medical students to perform differential diagnosis (DDX) of heart failure: a traditional classroom-based lecture (control group) versus a cognitive sciences-based approach to DDX instruction implemented through a computer-based tutor (treatment group). METHODS: Following random assignment to either group, students were trained for 75 minutes, and then given a 40-item examination comprised of cases that varied along a typicality gradient from prototypical (easy) to less typical (hard). RESULTS: The treatment group diagnosed correctly significantly more test cases than the control group (74% versus 60%, respectively). The treatment group also diagnosed correctly significantly more cases at the extremes of the typicality gradient: 81% versus 65%, respectively, for the prototypical cases; 65% versus 48%, respectively, for the most difficult cases. CONCLUSION: The ability to perform differential diagnosis is enhanced by training based upon principles of cognitive sciences.