Public and Population Health in U.S. Medical Education: A Review of Guidance in Extraordinary Times.

ABSTRACT: Generations of medical educators have recommended including public and population health (PPH) content in the training of U.S. physicians. The COVID-19 pandemic, structural racism, epidemic gun violence, and the existential threats caused by climate change are currently unsubtle reminders of the essential nature of PPH in medical education and practice. To assess the state of PPH content in medical education, the authors reviewed relevant guidance, including policies, standards, and recommendations from national bodies that represent and oversee medical education for physicians with MD degrees.Findings confirm that guidance across the medical education continuum, from premedical education to continuing professional development, increasingly includes PPH elements that vary in specificity and breadth. Graduate medical education policies present the most comprehensive approach in both primary care and subspecialty fields. Behavioral, quantitative, social, and systems sciences are represented, although not uniformly, in guidance for every phase of training. Quantitative PPH skills are frequently presented in the context of research, but not in relation to the development of population health perspectives (e.g., evidence-based medicine, quality improvement, policy development). The interdependence between governmental public health and medical practice, environmental health, and the impact of structural racism and other systems of oppression on health are urgent concerns, yet are not consistently or explicitly included in curricular guidance. To prepare physicians to meet the health needs of patients and communities, educators should identify and address gaps and inconsistencies in PPH curricula and related guidance.Re-examinations of public health and health care systems in the wake of the COVID-19 pandemic support the importance of PPH in physician training and practice, as physicians can help to bridge clinical and public health systems. This review provides an inventory of existing guidance (presented in the appendices) to assist educators in establishing PPH as an essential foundation of physician training and practice.

Anxiety, PTSD, and stressors in medical students during the initial peak of the COVID-19 pandemic.

PURPOSE: To assess psychological effects of the initial peak phase of the COVID-19 pandemic on United States (US) medical students in clinical training to anticipate sequelae and prepare for future outbreaks. METHODS: Authors emailed a cross-sectional survey in April-May, 2020 to students in clinical training years at six US medical schools which included validated General Anxiety Disorder (GAD-7) and Primary Care-PTSD (PC-PTSD-5) screening tools, and asked students about pandemic-related stress and specific concerns. Authors used quantitative and thematic analysis to present results. RESULTS: Of 2511 eligible students, 741 responded (29.5%). Most students (84.1%) reported at least "somewhat" increased levels of stress and anxiety related to the pandemic. On the GAD-7, 34.3% showed mild, 16.1% moderate, and 9.5% severe anxiety symptoms, with 39.6% demonstrating no/minimal symptoms. One quarter (25.4%) screened positive for PTSD risk symptoms. Top concerns of students chosen from a pre-populated list included inadequate COVID-19 testing, undiagnosed or asymptomatic spread and racial or other disparities in the pandemic. In thematic analysis, students' reactions to removal from clinical learning included: understanding the need to conserve PPE (32.2%), a desire to help (27.7%), worry over infectious risk to others (25.4%) and self (21.2%), and lost learning opportunities (22.5%). Female students were significantly more likely to report anxiety and PTSD risk symptoms. Asian students had a greater risk of moderate anxiety and those underrepresented in medicine (UIM) had greater risk of moderate and severe anxiety symptoms compared to white students. CONCLUSIONS: During the initial peak phase of COVID-19, over 60% of US medical students screened positive for pandemic-related anxiety and one quarter were at risk for PTSD. Female and UIM students were significantly more affected. Medical schools should consider broad support of students, and targeted outreach to female and UIM students.

Effects of the COVID-19 pandemic on medical students: a multicenter quantitative study.

BACKGROUND: The COVID-19 pandemic disrupted the United States (US) medical education system with the necessary, yet unprecedented Association of American Medical Colleges (AAMC) national recommendation to pause all student clinical rotations with in-person patient care. This study is a quantitative analysis investigating the educational and psychological effects of the pandemic on US medical students and their reactions to the AAMC recommendation in order to inform medical education policy. METHODS: The authors sent a cross-sectional survey via email to medical students in their clinical training years at six medical schools during the initial peak phase of the COVID-19 pandemic. Survey questions aimed to evaluate students' perceptions of COVID-19's impact on medical education; ethical obligations during a pandemic; infection risk; anxiety and burnout; willingness and needed preparations to return to clinical rotations. RESULTS: Seven hundred forty-one (29.5%) students responded. Nearly all students (93.7%) were not involved in clinical rotations with in-person patient contact at the time the study was conducted. Reactions to being removed were mixed, with 75.8% feeling this was appropriate, 34.7% guilty, 33.5% disappointed, and 27.0% relieved. Most students (74.7%) agreed the pandemic had significantly disrupted their medical education, and believed they should continue with normal clinical rotations during this pandemic (61.3%). When asked if they would accept the risk of infection with COVID-19 if they returned to the clinical setting, 83.4% agreed. Students reported the pandemic had moderate effects on their stress and anxiety levels with 84.1% of respondents feeling at least somewhat anxious. Adequate personal protective equipment (PPE) (53.5%) was the most important factor to feel safe returning to clinical rotations, followed by adequate testing for infection (19.3%) and antibody testing (16.2%). CONCLUSIONS: The COVID-19 pandemic disrupted the education of US medical students in their clinical training years. The majority of students wanted to return to clinical rotations and were willing to accept the risk of COVID-19 infection. Students were most concerned with having enough PPE if allowed to return to clinical activities.

Teaching Public and Population Health in Medical Education: An Evaluation Framework.

Curriculum models and training activities in medical education have been markedly enhanced to prepare physicians to address the health needs of diverse populations and to advance health equity. While different teaching and experiential learning activities in the public health and population health sciences have been implemented, there is no existing framework to measure the effectiveness of public and population health (PPH) education in medical education programs. In 2015, the Association of American Medical Colleges established the Expert Panel on Public and Population Health in Medical Education, which convened 20 U.S. medical faculty members whose goal was to develop an evaluation framework adapted from the New World Kirkpatrick Model. Institutional leaders can use this framework to assess the effectiveness of PPH curricula for learners, faculty, and community partners. It may also assist institutions with identifying opportunities to improve the integration of PPH content into medical education programs. In this article, the authors present outcomes metrics and practical curricular or institutional illustrations at each Kirkpatrick training evaluation level to assist institutions with the measurement of (1) reaction to the PPH education content, (2) learning accomplished, (3) application of knowledge and skills to practice, and (4) outcomes achieved as a result of PPH education and practice. A fifth level was added to measure the benefit of PPH curricula on the health system and population health. The framework may assist with developing a locally relevant evaluation to further integrate and support PPH education at U.S. medical schools and teaching hospitals.

A Review of Continuous Quality Improvement Processes at Ten Medical Schools.

The Liaison Committee on Medical Education now expects all allopathic medical schools to develop and adhere to a documentable continuous quality improvement (CQI) process. Medical schools must consider how to establish a defensible process that monitors compliance with accreditation standards between site visits. The purpose of this descriptive study is to detail how ten schools in the Association of American Medical Colleges' (AAMC) Southern Group on Educational Affairs (SGEA) CQI Special Interest Group (SIG) are tackling practical issues of CQI development including establishing a CQI office, designating faculty and staff, charging a CQI committee, choosing software for data management, if schools are choosing formalized CQI models, and other considerations. The information presented is not meant to certify that any way is the correct way to manage CQI, but simply present some schools' models. Future research should include defining commonalities of CQI models as well as seeking differences. Furthermore, what are components of CQI models that may affect accreditation compliance negatively? Are there "worst practices" to avoid? What LCME elements are most commonly identified for CQI, and what are the successes and struggles for addressing those elements? What are identifiable challenges relating to use of standard spreadsheet software and engaging information technology for support? How can students be more engaged and involved in the CQI process? Finally, how do these major shifts to a formalized CQI process impact the educational experience?

The association of angiogenic factors and chronic kidney disease.

BACKGROUND: There are limited data on the associations of circulating angiogenic factors with chronic kidney disease (CKD). We investigate the associations of circulating vascular endothelial growth factor (VEGF)-A, angiopoietin-1, angiopoietin-1/VEGF-A ratio, VEGF receptor 1 (VEGFR-1), VEGFR-2, and pentraxin-3 with CKD. METHODS: We recruited 201 patients with CKD and 201 community controls without CKD from the greater New Orleans area. CKD was defined as estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 or presence of albuminuria. Multivariable quantile and logistic regression models were used to examine the relationship between angiogenesis-related factors and CKD adjusting for confounding factors. RESULTS: After adjusting for covariables including traditional cardiovascular disease (CVD) risk factors, C-reactive protein, and history of CVD, the medians (interquartile range) were 133.08 (90.39, 204.15) in patients with CKD vs. 114.17 (72.45, 170.32) pg/mL in controls without CKD (p = 0.002 for group difference) for VEGF-A; 3951.2 (2471.9, 6656.6) vs. 4270.5 (2763.7, 6537.2) pg/mL (p = 0.70) for angiopoietin-1; 25.87 (18.09, 47.90) vs. 36.55 (25.71, 61.10) (p = 0.0001) for angiopoietin-1/VEGF-A ratio; 147.81 (122.94, 168.79) vs. 144.16 (123.74, 168.05) ng/mL (p = 0.25) for VEGFR-1; 26.20 (22.67, 29.92) vs. 26.28 (23.10, 29.69) ng/mL (p = 0.31) for VEGFR-2; and 1.01 (0.79, 1.49)vs. 0.89 (0.58, 1.18) ng/mL (p = 0.01) for pentraxin-3, respectively. In addition, an elevated VEGF-A level and decreased angiopoietin-1/VEGF-A ratio were associated with increased odds of CKD. CONCLUSIONS: These data indicate that plasma VEGF-A and pentraxin-3 levels were increased and the angiopoietin-1/VEGF-A ratio was decreased in patients with CKD. Future prospective studies are warranted to examine whether angiogenic factors play a role in progression of CKD.

Membranoproliferative Glomerulonephritis in Pregnancy.

BACKGROUND: Membranoproliferative glomerulonephritis (MPGN) is an uncommon form of glomerulonephritis and it can be particularly difficult to predict outcomes and manage women with this disorder during pregnancy. MATERIALS AND METHODS: The management of 3 successful pregnancies in women with MPGN from 1 center and previously described cases from the world literature are reviewed. This includes a number of large studies of pregnancy in women with underlying glomerular disease as well as small case series and individual reports. Courses of these pregnancies, maternal and fetal outcomes, and management, when described, were included in this review. RESULTS: Some successful outcomes used antiplatelet therapy and plasmapheresis, but high-dose intravenous, followed by oral, corticosteroid therapy was used most frequently in patients with successful outcomes. CONCLUSIONS: The data provided is meant as a guide for clinicians who provide care for women with MPGN who are considering pregnancy or women who present with this disorder while pregnant.

What are the implications of implementation science for medical education?

BACKGROUND: Derived from multiple disciplines and established in industries outside of medicine, Implementation Science (IS) seeks to move evidence-based approaches into widespread use to enable improved outcomes to be realized as quickly as possible by as many as possible. METHODS: This review highlights selected IS theories and models, chosen based on the experience of the authors, that could be used to plan and deliver medical education activities to help learners better implement and sustain new knowledge and skills in their work settings. RESULTS: IS models, theories and approaches can help medical educators promote and determine their success in achieving desired learner outcomes. We discuss the importance of incorporating IS into the training of individuals, teams, and organizations, and employing IS across the medical education continuum. Challenges and specific strategies for the application of IS in educational settings are also discussed. CONCLUSIONS: Utilizing IS in medical education can help us better achieve changes in competence, performance, and patient outcomes. IS should be incorporated into curricula across disciplines and across the continuum of medical education to facilitate implementation of learning. Educators should start by selecting, applying, and evaluating the teaching and patient care impact one or two IS strategies in their work.

Leptospirosis in New Orleans.

Leptospirosis is an unusual but reemerging zoonotic infectious disease in the United States where the diagnosis may not be suspected when patients initially present. The case report of a patient from New Orleans who presented with jaundice, hypotension and acute kidney injury is presented. In this patient, a broad differential diagnosis was considered on presentation and serologic testing for leptospirosis eventually confirmed the diagnosis. A review of the clinical manifestations, diagnostic studies and treatment are discussed so that leptospirosis will be considered more carefully in the initial evaluation and management of similar patients.

The educational attributes and responsibilities of effective medical educators.

Of the many roles that the academic-educator may fulfill, that of teacher is particularly challenging. Building on prior recommendations from the literature, this article identifies the skill set of teachers across the medical education continuum-characteristics of attitude and attributes, knowledge, and pedagogic skills that permit effective teaching to be linked with effective learning and understanding. This examination which characterizes teachers' attitudes, knowledge, and skills serves to reemphasize the centrality of teaching within medical education, provides direction for faculty and institutions alike in the discharge of academic responsibilities, and makes educational accountability clear. This listing of teacher attitudes and responsibilities was vetted in 2009 by medical education leaders from across North America during a national conference on faculty development.A set of recommendations concerning faculty development issues for medical teachers is offered. The recommendations are intended to establish an academic culture in medical education that values and rewards-academically and fiscally-those centrally committed to the role of teacher. The challenges of defining skills, developing and funding programs, and ongoing evaluation must be faced to achieve success in teaching throughout medical education, now and in the future. Faculty members, fellow learners, and patients deserve no less.

Long-term outcome of adults who undergo transplantation with single pediatric kidneys: how young is too young?

BACKGROUND AND OBJECTIVES: The optimal donor age for transplanting a single pediatric kidney in an adult recipient remains unknown. En block kidney transplantation is usually performed when the donor age is <5 yr. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We compared the outcomes of adult patients who underwent transplantation with single pediatric kidneys from donors who were younger than 5 yr (group 1, n = 40) and from donors who were aged 5 to 10 yr of age (group 2, n = 39) in our center. RESULTS: The donor kidney sizes were significantly smaller in group 1 than in group 2 (P < 0.001), and group 1 required more ureteral stents than group 2 (73 versus 38%). The surgical complications, delayed graft function, and development of proteinuria were similar in both groups. Group 1 had slightly higher rejection episodes than group 2 (25 versus 18%; P = 0.67), and graft function was comparable in both groups. There were no statistical differences between the two groups in patient (P = 0.73) or death-censored graft (P = 0.68) survivals over 5 yr. CONCLUSIONS: Single pediatric kidney transplants from donors who are younger than 5 yr can be used with acceptable complications and long-term outcomes as those from older donors.

Physician practice behavior and practice guidelines: using unannounced standardized patients to gather data.

BACKGROUND: Measuring actual practice behaviors of physicians, particularly as they relate to established clinical guidelines, is challenging. Standardized patients provide one method of collecting such data. OBJECTIVE: To demonstrate the use of unannounced standardized patients in gathering data that may address adherence to guidelines in an office setting. DESIGN: Unannounced standardized patients (SPs) simulating an initial type 2 diabetic visit presented to community offices of 32 internists as "real" patients to record physicians' evaluation and management. PARTICIPANTS: Unannounced SPs presented to the office of 32 internists as "real" patients. MEASUREMENTS: Unannounced SPs, simulating type 2 diabetics, completed a standardized assessment sheet, based on ADA guidelines to record physicians' evaluation and management following an initial visit. Patient charts were also reviewed to determine if evaluation adhered to the guidelines. RESULTS: Unannounced SPs recorded 56 visits with 32 community internists; all SPs remained undetected. All physicians asked SPs about medications. At least 50% of physicians asked about home blood sugar monitoring, last eye exam, smoking, edema, and told patients to stop smoking. Less than 50% of physicians asked about parasthesias, performed fundoscopy, examined feet, referred the patient to a diabetic educator or ophthalmologist, or gave patients suggestions regarding glucose monitoring or exercise. HbA1c was ordered in 78%, metabolic profiles in 86%, and urinalysis/microalbumin in 41% of patients. CONCLUSIONS: Unannounced standardized patients can successfully collect important data regarding physician practices in community settings. This method may be helpful in assessing physician adherence to established clinical practice guidelines.

Impact of Hurricane Katrina on medical student academic performance: the Tulane experience.

BACKGROUND: Hurricane Katrina forced the temporary closure of Tulane University School of Medicine requiring relocation to the Texas Medical Center in Houston, Texas. This required curricular restructuring, and resulted in faculty/student challenges. The effect of these stresses on student performance was studied. METHODS: A pre-Katrina and post-Katrina comparative analysis of all Tulane medical students' performance on standardized exams, internal examination and United States Medical Licensing Examination (USMLE) step exams was performed. A one-way analysis of variance was used to determine if mean examination scores differed from pre-Katrina to post-Katrina. RESULTS: Internal examination scores did not differ significantly. National standardized examination grades significantly decreased pre-Katrina to post-Katrina in Biochemistry, Pharmacology, Pathology, Medicine, Pediatrics and Psychiatry (P < 0.05). There was no statistical change in USMLE scores. CONCLUSIONS: Tulane students had a statistically significant decline in performance on many course and clerkship examinations, though overall performance on licensing examinations was unchanged. Many stresses may have affected students' ability to perform.

Medical school dean as a turnaround agent.

Taking on the role as a new medical school Dean in a new city after Hurricane Katrina posed many challenges. To facilitate turnaround, 3 principles were applied: hit the ground running, promote community involvement, and gain a common vision for the future. This article describes Tulane University's process for implementing change and expands on its vision for the future.

Surviving Hurricane Katrina: reconstructing the educational enterprise of Tulane University School of Medicine.

Hurricane Katrina was one of the greatest natural disasters to ever strike the United States. Tulane University School of Medicine, located in downtown New Orleans, and its three major teaching hospitals were flooded in the aftermath of the storm and forced to close. Faculty, students, residents, and staff evacuated to locations throughout the country. All critical infrastructure that normally maintained the school, including information technology, network communication servers, registration systems, and e-mail, became nonoperational. However, on the basis of experiences learned when Tropical Storm Allison flooded the Texas Medical Center in 2001, Baylor College of Medicine, University of Texas-Houston, University of Texas Medical Branch in Galveston, and Texas A&M School of Medicine created the South Texas Alliance of Academic Health Centers, which allowed Tulane to move its education programs to Houston. Using Baylor's facilities, Tulane faculty rebuilt and delivered the preclinical curriculum, and clinical rotations were made available at the Alliance schools. Remarkably, the Tulane School of Medicine was able to resume all educational activities within a month after the storm. Educational reconstruction approaches, procedures employed, and lessons in institutional recovery learned are discussed so that other schools can prepare effectively for either natural or man-made disasters. Key disaster-response measures include designating an evacuation/command site in advance; backing up technology, communication, financial, registration, and credentialing systems; and establishing partnership with other institutions and leaders.

A new approach to bridging content gaps in the clinical curriculum.

BACKGROUND: In 2004-05 Tulane University School of Medicine implemented a longitudinal Interdisciplinary Seminar Series composed of small-group interactive exercises to address topics that are often overlooked during the clinical education of medical students. The series utilizes five adult learning principles. METHODS: Each of 13 seminars is offered at a fixed time slot, repeated two to six times per year. Students are required to attend a minimum of five seminars, of their choice, during years three and four. Students access an online pre-enrollment system that maximizes learning opportunities by limiting the number of participants. Seminars emphasize active learning with small-group problem-solving exercises and multiple interactive techniques. Clinical vignettes, standardized patients, journal articles, and case-based learning are among the learning methods. RESULTS: Seminar evaluations showed strong support in program content and effectiveness (mean = 4.47 on a five-point scale), facilitators (4.63), and learning opportunities (4.51). Additionally, students strongly endorsed individual seminars to classmates (4.47). Twelve of 13 (92%) seminars received scores higher than 4.0 for program content and effectiveness, facilitators and learning opportunities. CONCLUSIONS: The Interdisciplinary Seminar Series has been a valuable addition to the Tulane clinical curriculum. Students report that the success of the series is due to: (a) their ability to select seminars based on their individualized interests and needs; and (b) faculty development of student-centered seminars with active learning opportunities. This Seminar Series differs from interclerkship initiatives at other medical schools where topics are offered less frequently and to a class as a whole. Tulane's program is a longitudinal intervention with multiple opportunities for student participation during their clinical education. Seminars are repeated to allow greater flexibility in student scheduling. Seminar discussions are rich in content since attendees include both third- and fourth-year students with variable levels of clinical skills and experiences.