Core and cluster or head to toe?: a comparison of two types of curricula for teaching physical examination skills to preclinical medical students.

BACKGROUND: Despite the central importance of physical examination (PE) skills to patient evaluation, early trainees struggle with its correct application and interpretation. This struggle may reflect the instructional strategies of PE courses which have largely ignored the clinical reasoning necessary to accurately apply these skills. The "core + cluster" (C + C) is a recent approach to teaching PE to clerkship-level medical students that combines a basic 'core' exam with 'cluster' based on the student's hypothesis about their patient's clinical presentation. Our institution developed a novel C + C curriculum to teach PE to preclinical students. We aimed to assess the impact of this new curriculum on students' clinical skills and course evaluations in comparison to the traditional "head-to-toe" approach we'd used previously. METHODS: This was a retrospective study comparing two consecutive medical school cohorts exposed to the new (C + C) and prior (HTT) curricula respectively. We studied two complete cohorts of first-year medical students at our institution who matriculated in 2014 and 2015. The 2014 cohort received PE training via an HTT approach. The 2015 cohort received PE training via a C + C approach. Outcomes included performance scores on a statewide clinical performance exam (CPX) and student course evaluations. RESULTS: We found no statistically significant difference in mean CPX scores between the two cohorts. However, student course ratings were significantly higher in the C + C cohort and students rated the C + C format as highly useful in clinical encounters. CONCLUSIONS: The C + C curriculum appears to be as effective a method of teaching PE to preclinical students as the HTT approach and is better received by students. We believe that this approach more appropriately reflects the way PE is used in clinical encounters and may help students with diagnostic hypothesis generation.

A pirate ship sailed into the yacht club: How we built a novel pediatric emergency medicine curriculum for an emergency medicine training program.

BACKGROUND: Pediatric emergency medicine (PEM) has seen little progression toward a standardized PEM educational framework. The 2018 Academic Emergency Medicine Consensus Conference on Advancing PEM Education addressed this gap in core EM education. Absent elements include a "broad needs assessment to identify and evaluate existing curricula and systems gaps in EM training" and a "clearly defined core PEM curriculum that unifies and drives the learning process." PEM education innovators were called to construct a "unified foundation in PEM education for all levels of emergency care" and to "promote innovation in teaching and learning strategies in curricula." We endeavored to meet this challenge at our institution. METHODS: The PEM curriculum design is based on the Kern model of curriculum development and included a needs assessment, development of goals and objectives, educational strategies, implementation, evaluation, and programmatic feedback. We committed to using effective learning strategies and active learning methods in developing our curriculum and conducted a 1-year pilot within our EM residency's didactic conference. We used exit surveys to collect feedback for each session as well as midyear focus groups to gauge the program's effectiveness. At the start and end of the pilot year residents completed the PEM survey regarding the effect of the PEM curriculum on their self-assessed knowledge, training, and comfort in managing PEM topics. RESULTS: Feedback regarding the PEM curriculum was positive. Following 1 year of the pilot curriculum, learners in the PGY-1 and PGY-3 classes demonstrated statistically significant improvement in their self-assessed knowledge, training, and comfort with PEM topics. The PGY-2 class had a similar statistically significant improvement in self-assessed knowledge in PEM topics. CONCLUSIONS: Our novel PEM curriculum was well received and has shown early evidence of improving self-assessed knowledge and comfort among EM residents.

Introduction to Health Systems Science: Experiential Learning Through Patient Interviews in the Emergency Department.

Increased complexity in health care delivery is now a problem of national proportions. Traditional medical education fails to sufficiently prepare students for the realities of practicing medicine in the 21st century. To address this critical problem, health systems science (HSS), which focuses on the broader system of care, has emerged as the "third pillar" of undergraduate medical education complementing the basic and clinical sciences. The authors identified a need to increase the amount and quality of HSS education in a way that would engage students and provide a platform to learn how patients interact with the health care system. UNITED (Understanding Needs in the Emergency Department) was thus designed and implemented to introduce preclinical medical students to HSS through patient interactions in the emergency department (ED). EDs serve as America's health care "safety net" and there is no lack of opportunity to learn how the current system of care does and does not work for patients. Qualitative analysis of students' written reflections revealed the following themes of the UNITED experience: 1) medical students question their understanding of the health care system after listening to patients' stories, 2) focused patient interviews about the health care system provides a unique perspective of the patient experience not found elsewhere in the preclinical curriculum, and 3) discussing the realities of being a patient in the U.S. health care system is an emotional experience for students. Based on these data, the authors concluded that asking preclinical students to interview patients about their experience in the health care system leads to emotional activation and a subsequent stated desire to improve care delivery.

Heart Rate Variability and Acute Stress Among Novice Airway Managers.

BACKGROUND: The nature of medical emergencies places emergency physicians at risk for high levels of acute psychological stress (APS). Stress-modifying techniques like visualization, breath control, and mental practice may help mitigate APS, but objective markers of stress are difficult to measure in the clinical setting. We explored the relationship between heart rate variability (HRV), a real-time measure of autonomic arousal, and self-reported APS among emergency medicine (EM) residents learning to intubate on actual patients. METHODS: This was a prospective study of postgraduate year 1 (PGY-1) EM residents at a single academic medical center during their 1-month anesthesia rotation. We obtained repeated measures of HRV immediately before and during the first intubation attempt each day. Participants completed the modified Spielberger State-Trait Anxiety Inventory (STAI-6) before intubation attempts and scored intubation difficulty using the Intubation Difficulty Scale. We analyzed HRV using root mean square of successive differences and analyzed data using clustered data methods and Pearson correlation coefficients. RESULTS: We enrolled eight PGY-1 residents and recorded 64 intubations. Mean HRV in the 2 minutes before intubation (17.88 ± 9.22) and during intubation (21.17 ± 13.46) was significantly lower than resting baseline (32.09 ± 15.23; adjusted mean difference [95% CI] = -13.90 [-20.35 to -7.45], p < 0.001; and -10.77 [-17.65 to -3.88], p = 0.02). Preintubation anxiety was negatively correlated with HRV (r = -0.39 [-0.58 to -0.16], p = 0.001). Intubation difficulty was not significantly correlated with HRV (r = -0.12 [-0.36 to 0.13], p = 0.35). CONCLUSIONS: HRV shows promise as a real-time index of autonomic arousal and may serve as an outcome measure in the evaluation of stress-modifying interventions.

How do novices learn physical examination skills? A systematic review of the literature.

BACKGROUND: Physical Examination (PE) skills are vital for patient care, and many medical students receive their first introduction to them in their pre-clinical years. A substantial amount of curriculum time is devoted to teaching these skills in most schools. Little is known about the best way to introduce PE skills to novice learners. OBJECTIVE: Our objective was to conduct a systematic review of how medical students are first taught PE skills and the evidence supporting these strategies. DESIGN: We searched ERIC, SCOPUS, MEDLINE, PubMed and EMBASE for descriptions of complete PE curricula for novice learners. Inclusion criteria were: (1) English language; (2) subjects were enrolled in medical school and were in the preclinical portion of their training; (3) description of a method to teach physical examination skills for the first time; (4) description of the study population; (5) Description of a complete PE curriculum. We used the Medical Education Research Study Quality Instrument (MERSQI) score to evaluate the quality of evidence provided. RESULTS: Our search returned 5,418 articles; 32 articles met our inclusion criteria. Two main types of curricula were reported: comprehensive 'head-to-toe' PE curricula (18%) and organ system-based curricula (41%). No studies compared these directly, and only two evaluated trainees' clinical performance. The rest of the articles described interventions used across curricula (41%). Median MERSQI score was 10.1 Interquartile range 8.1-12.4. We found evidence for the use of non-faculty teaching associates, technology-enhanced PE education, and the addition of clinical exposure to formal PE teaching. CONCLUSIONS: The current literature on teaching PE is focused on describing innovations to head-to-toe and organ system-based curricula rather than their relative effectiveness, and is further limited by its reliance on short-term outcomes. The optimal strategy for novice PE instruction remains unknown.

Pharmacologic Treatment of Cannabinoid Hyperemesis Syndrome: A Systematic Review.

Cannabinoid hyperemesis syndrome (CHS) has become more prevalent with increasing cannabis use. CHS is often resistant to standard antiemetics. The objective of this study is to review the current evidence for pharmacologic treatment of CHS. Medline, PsycINFO, DARE, OpenGrey, Google Scholar, and the Cochrane Library were searched from inception to February 2017. Articles were selected and reviewed independently. Evidence was graded using Oxford Center for Evidence-Based Medicine guidelines. The search resulted in 1262 articles with 63 of them eligible for inclusion (205 human subjects). There were 4 prospective level-2, 3 retrospective level-3 studies, 12 level-4 case series, and 44 level-5 case reports. Among level-2 studies (64 subjects), tricyclic antidepressants (TCAs) and lorazepam were discussed as effective long- and short-term treatments, respectively, in two studies. Ondansetron, promethazine, diphenhydramine, and opioids were also mentioned, but the authors did not comment on their efficacy. Among level-3 studies (43 subjects), one reported effective treatment with antiepileptics zonisamide and levetiracetam, but not TCAs. Another reported favorable response to morphine, ondansetron, and lorazepam but did not specify the actual number of patients receiving specific treatment. Among the level-4 case series (54 subjects), benzodiazepines, haloperidol, and capsaicin were reported as helpful. For level-5 case reports (44 subjects), benzodiazepines, metoclopramide, haloperidol, ondansetron, morphine, and capsaicin were reported as effective. Effective treatments mentioned only once included fentanyl, diazepam, promethazine, methadone, nabilone, levomepromazine, piritramide, and pantoprazole. Hot showers and baths were cited in all level-4 and -5 articles as universally effective. High-quality evidence for pharmacologic treatment of CHS is limited. Benzodiazepines, followed by haloperidol and capsaicin, were most frequently reported as effective for acute treatment, and TCAs for long-term treatment. As the prevalence of CHS increases, future prospective trials are greatly needed to evaluate and further define optimal pharmacologic treatment of patients with CHS.

Neutral sphingomyelinase 2: a novel target in cigarette smoke-induced apoptosis and lung injury.

Chronic obstructive pulmonary disease (COPD) is caused by exposure to cigarette smoke (CS). One mechanism of CS-induced lung injury is aberrant generation of ceramide, which leads to elevated apoptosis of epithelial and endothelial cells in the alveolar spaces. Recently, we discovered that CS-induced ceramide generation and apoptosis in pulmonary cells is governed by neutral sphingomyelinase (nSMase) 2. In the current experiments, we expanded our studies to investigate whether nSMase2 governs ceramide generation and apoptosis in vivo using rodent and human models of CS-induced lung injury. We found that exposure of mice or rats to CS leads to colocalizing elevations of ceramide levels and terminal deoxynucleotidyl transferase mediated X-dUTP nick end labeling-positive cells in lung tissues. These increases are nSMase2 dependent, and are abrogated by treatment with N-acetyl cysteine or anti-nSMase2 small interfering RNA (siRNA). We further showed that mice that are heterozygous for nSMase2 demonstrate significant decrease in ceramide generation after CS exposure, whereas acidic sphingomyelinase (aSMase) knockout mice maintain wild-type ceramide levels, confirming our previous findings (in human airway epithelial cells) that only nSMase2, and not aSMase, is activated by CS exposure. Lastly, we found that lung tissues from patients with emphysema (smokers) display significantly higher levels of nSMase2 expression compared with lung tissues from healthy control subjects. Taken together, these data establish the central in vivo role of nSMase2 in ceramide generation, aberrant apoptosis, and lung injury under CS exposure, underscoring its promise as a novel target for the prevention of CS-induced airspace destruction.

Epidermal growth factor receptor exposed to cigarette smoke is aberrantly activated and undergoes perinuclear trafficking.

Exposure to hydrogen peroxide (H2O2), one of the reactive oxidants in the gas phase of cigarette smoke (CS), induces aberrant phosphorylation of the epidermal growth factor receptor (EGFR), resulting in the lack of ubiquitination by c-Cbl, and impaired degradation. EGFR activation without the feedback regulation of normal degradation leads to uncontrolled cell growth and tumor promotion. Using immunoprecipitation, immunoblotting, and confocal microscopy, we now demonstrate that the pattern of EGFR activation by CS is similar to H2O2. We found that exposure of human airway epithelial cells to CS, as with exposure to H2O2, not only results in an increase in EGFR activation over time, but the EGFR activated by H2O2 or CS is neither ubiquitinated nor subsequently degraded due to its inability to bind the E3 ubiquitin ligase, c-Cbl, either directly or indirectly via the Grb2 adapter protein. Moreover, the stabilized H2O2- and CS-activated EGFR remains plasma membrane-bound, while a population of the receptor is trafficked to a perinuclear region. Concomitantly, CS exposure results in the activation of downstream Akt and ERK1/2 survival and proliferation pathways. Therefore, exposure to CS, like exposure to H2O2, results in prolonged signaling by the EGFR and may contribute to uncontrolled lung cell growth.