A Theoretical Foundation to Inform the Implementation of Precision Education and Assessment.

ABSTRACT: Precision education (PE) uses personalized educational interventions to empower trainees and improve learning outcomes. While PE has the potential to represent a paradigm shift in medical education, a theoretical foundation to guide the effective implementation of PE strategies has not yet been described. Here, the authors introduce a theoretical foundation for the implementation of PE, integrating key learning theories with the digital tools that allow them to be operationalized. Specifically, the authors describe how the master adaptive learner (MAL) model, transformative learning theory, and self-determination theory can be harnessed in conjunction with nudge strategies and audit and feedback dashboards to drive learning and meaningful behavior change. The authors also provide practical examples of these theories and tools in action by describing precision interventions already in use at one academic medical center, concretizing PE's potential in the current clinical environment. These examples illustrate how a firm theoretical grounding allows educators to most effectively tailor PE interventions to fit individual learners' needs and goals, facilitating efficient learning and ultimately improving patient and health system outcomes.

What Happened and Why: Responding to Racism, Discrimination, and Microaggressions in the Clinical Learning Environment.

Introduction: Within clinical learning environments, medical students are uniquely faced with power differentials that make acts of racism, discrimination, and microaggressions (RDM) challenging to address. Experiences of microaggressions and mistreatment are correlated with higher rates of positive depression screening and lower satisfaction with medical training. We developed a curriculum for medical students beginning clerkship rotations to promote the recognition of and response to RDM. Methods: Guided by generalized and targeted needs assessments, we created a case-based curriculum to practice communication responses to address RDM. The communication framework, a 6Ds approach, was developed through adaptation and expansion of established and previously learned communication upstander frameworks. Cases were collected through volunteer submission and revised to maintain anonymity. Faculty and senior medical students cofacilitated the small-group sessions. During the sessions, students reviewed the communication framework, explored their natural response strategies, and practiced all response strategies. Results: Of 196 workshop participants, 152 (78%) completed the evaluation surveys. Pre- and postsession survey cohort comparison demonstrated a significant increase in students' awareness of instances of RDM (from 34% to 46%), knowledge of communication strategies to mitigate RDM (presession M = 3.4, postsession M = 4.6, p < .01), and confidence to address RDM (presession M = 3.0, postsession M = 4.4, p < .01). Discussion: Students gained valuable communication skills from interactive sessions addressing RDM using empathy, reflection, and relatability. The workshop empowered students to feel prepared to enter professional teams and effectively mitigate harmful discourse.

Disparities in the allocation of inpatient physical and occupational therapy services for patients with COVID-19.

BACKGROUND: Survivors of the novel coronavirus (COVID-19) experience significant morbidity with reduced physical function and impairments in activities of daily living. The use of in-hospital rehabilitation therapy may reduce long-term impairments. OBJECTIVE: To determine the frequency of therapy referral and treatment amongst hospitalized COVID-19 patients, assess for disparities in referral and receipt of therapy, and identify potentially modifiable factors contributing to disparities in therapy allocation. DESIGN, SETTING AND PARTICIPANTS: Retrospective cohort study using data collected from the University of Colorado Health Data Compass data warehouse assessing therapy referral rates and estimated delivery based on available administrative billing. MEASUREMENTS: Multivariable logistic regression was used to determine the association between sex and/or underrepresented minority race with therapy referral or delivery. RESULTS: Amongst 6239 COVID-19-related hospitalization, a therapy referral was present in 3952 patients (51.9%). Hispanic ethnicity was independently associated with lower odds of receipt of therapy referral (adjusted OR [aOR]: 0.78, 95% confidence interval [CI]: 0.67-0.93, p = .001). Advanced age (aOR: 1.53, 95% CI: 1.46-1.62, p < .001), greater COVID illness severity (aOR for intensive care unit admission: 1.63, 95% CI: 1.37-1.94, p < .01) and hospital stay (aOR: 1.14, 95% CI: 1.12-1.15, p < .01) were positively associated with referral. CONCLUSIONS AND RELEVANCE: In a cohort of patients hospitalized for COVID-19 across a multicenter healthcare system, we found that referral rates and delivery of physical therapy and/or occupational therapy sessions were significantly reduced for patients of Hispanic identity compared with patients of non-Hispanic, Caucasian identity after adjustment for potential confounding by available demographic and illness severity variables.

The Predictive Potential of Elevated Serum Inflammatory Markers in Determining the Need for Intubation in CoVID-19 Patients.

Introduction: The predictive potential of demographics, clinical characteristics, and inflammatory markers at admission to determine future intubation needs of hospitalised CoVID-19 patients is unknown. The study aimed to determine the predictive potential of elevated serum inflammatory markers in determining the need for intubation in CoVID-19 Patients. Methods: In a retrospective cohort study of hospitalised SARS-CoV2 positive patients, single and multivariable regression analyses were used to determine covariate effects on intubation odds, and a minimax concave penalty regularised logistic regression was used to build a predictive model. A second prospective independent cohort tested the model. Results: Systemic inflammatory markers obtained at admission were higher in patients that required subsequent intubation, and adjusted odds of intubation increased for every standard deviation above the mean for c-reactive protein (CRP) OR:2.8 (95% CI 1.8-4.5, p<0.001) and lactate dehydrogenase OR:2.1 (95% CI 1.33.3, p=0.002). A predictive model incorporating C-reactive protein, lactate dehydrogenase, and diabetes status at the time of admission predicted intubation status with an area under the curve (AUC) of 0.78 with corresponding sensitivity of 86%, specificity of 63%. This predictive model achieved an AUC of 0.83, 91% sensitivity, and 41% specificity on the validation cohort. Conclusion: In patients hospitalised with CoVID-19, elevated serum inflammatory markers measured within the first twenty-four hours of admission are associated with an increased need for intubation. Additionally, a model of C-reactive protein, lactate dehydrogenase, and the presence of diabetes may play a predictive role in determining the future need for intubation.