Handedness of healthy elderly and patients with Alzheimer's disease.

Purpose/Aim of the study: Research has suggested decreasing proportions of non-right handers in older age groups and reduced incidence of non-right handedness among individuals with Alzheimer's disease (AD). We hypothesized that healthy elderly individuals would have a higher proportion of non-right handers than individuals with AD and that the proportion of non-right handers would decrease with increasing age. Further, we investigated whether the proportions of non-right handers differed between those with early and late onset of AD.Materials and Methods: Two-hundred and fifty-six healthy elderly and 182 individuals with AD served as participants. Hand dominance was recorded based on side of writing during testing and self-report. We analyzed proportions of right handers and non-right handers for three age ranges (≤ 69, 70 - 79, and ≥ 80 years). A second analysis focused on the proportions of right and non-right handers among patients with AD classified as either early or late disease onset.Results: Handedness proportions did not differ between the controls and ADs. For AD but not for controls, there was a trend towards reduced proportions of non-right handers with increasing age. Early onset AD was associated with a larger proportion of non-right handers compared to those with late onset AD.Conclusions: Results did not support a trend of decreasing non-right handedness with increasing age in controls, but did provide support for such a trend in individuals with AD. The results provided support for the hypothesis of increased incidence of non-right handedness in early onset vs. late onset AD.

Neuropsychological differences between men and women with Alzheimer's disease.

BACKGROUND: It has been suggested that men and women with Alzheimer's disease (AD) at comparable levels of global cognitive impairment perform differently on neuropsychological measures. Such differences may have practical implications for designing cognitive interventions that address symptoms of dementia. METHODS: We compared men (n = 86) and women (n = 96) with AD on tests of immediate and delayed prose memory, verbal fluency, semantic fluency, semantic memory and confrontation naming. Mean years for age, education and duration of illness were 70.81 (SD = 7.55), 13.37 (SD = 3.38) and 2.17 (SD = 1.72) for men and 73.11(SD = 8.53), 12.27 (SD = 2.86) and 2.42 (SD = 1.92) for women. The groups were comparable in global cognitive functioning as indicated by Dementia Rating Scale total scores for men of 89.27 (SD = 29.80) and women of 90.86 (SD = 30.20). RESULTS: Men earned significantly better scores in immediate prose memory, semantic verbal fluency, semantic memory and response naming. Men and women performed similarly on the remaining tests. When the variables of age, education and duration of disease were controlled, the significant effect of gender was maintained only on tests of semantic fluency, semantic memory and confrontation naming. CONCLUSIONS: The hypothesis of the study was partially confirmed in that women with AD evidenced greater impairment than men with AD on three of six neuropsychological measures even after potentially confounding variables were controlled.

Medical Student Perspectives of Active Learning: A Focus Group Study.

Phenomenon: Medical student perspectives were sought about active learning, including concerns, challenges, perceived advantages and disadvantages, and appropriate role in the educational process. APPROACH: Focus groups were conducted with students from all years and campuses of a large U.S. state medical school. FINDINGS: Students had considerable experience with active learning prior to medical school and conveyed accurate understanding of the concept and its major strategies. They appreciated the potential of active learning to deepen and broaden learning and its value for long-term professional development but had significant concerns about the efficiency of the process, the clarity of expectations provided, and the importance of receiving preparatory materials. Most significantly, active learning experiences were perceived as disconnected from grading and even as impeding preparation for school and national examinations. Insights: Medical students understand the concepts of active learning and have considerable experience in several formats prior to medical school. They are generally supportive of active learning concepts but frustrated by perceived inefficiencies and lack of contribution to the urgencies of achieving optimal grades and passing United States Medical Licensing Examinations, especially Step 1.

On the Origins of Perceptions: Student Perceptions of Active Learning and Their Implications for Educational Reform.

This Conversation Starters article presents a selected research abstract from the 2016 Association of American Medical Colleges Central Region Group on Educational Affairs annual spring meeting. The abstract is paired with the integrative commentary of three experts who shared their thoughts stimulated by the study. These thoughts highlight the value of exploring what drives student perceptions of active learning in order to reform medical education.

Does a Vacation Break Impact the Outcomes of Required Clinical Clerkships?

BACKGROUND AND OBJECTIVES: Our objective was to assess the impact of disruption by a new 2-week vacation break on outcomes of required third-year clerkships. METHODS: Mean scores on National Board of Medical Examiners (NBME) clerkship specific clinical science subject ("subject") examinations and overall student evaluations were compared for clerkships with the break and those over the previous 3 years without the break. Students were surveyed about the impact of the break on learning and the time spent studying during the break. RESULTS: No significant differences were found in examination scores between clerkships with the break and those without. Overall student clerkship evaluations were significantly different only for the surgery clerkship. The break was regarded more favorably by students on the 8-week than the 6-week clerkships, but student perspectives varied significantly by specialty. The time reported studying varied significantly by specialty and campus. Student comments were predominantly supportive of the break and focused on the advantages of opportunity to relax, spend time with family, and to study. Concerns included forgetting content knowledge, losing skills, and having difficulty regaining momentum on return to the clerkship. CONCLUSIONS: Interruption of clerkships by a 2-week break was not associated with any significant change in subject examination scores or overall student evaluation of the clerkship, despite predominantly positive comments. Significant differences were reported by specialty in student perception of benefit and reported time studying during the break.

Minding the gap: Interprofessional communication during inpatient and post discharge chasm care.

OBJECTIVE: Poor communication is cited as a main cause of poor patient outcomes and errors in healthcare, and clear communication can be especially critical during transitions such as discharge. In this project, communication was standardized for clarity, and techniques were implemented to continue care from inpatient, to discharge, across the post-discharge chasm, to hand-off with the primary care provider (PCP). METHODS: The interprofessional (IP) quality improvement initiative included: (1) evidence-based teamwork system; (2) in situ simulation; (3) creation of an IP model of care; and (4) innovations in use of telehealth technology to continue care post-discharge. RESULTS: Measures inpatient/parent satisfaction and the attitudes of the care team have improved. CONCLUSIONS: Traditional methods of communication and transition do not meet patient or healthcare provider needs. Communication must be standardized to be understandable and be used by the IP team. Care must continue post-discharge by utilizing technology to increase quality and continuity of care. PRACTICE IMPLICATIONS: Improving and practicing communication skills may lead to reductions in healthcare errors and readmissions, and may decrease the length of stay and improve satisfaction of care teams.

Performance of third-year medical students on a rural family medicine clerkship.

BACKGROUND AND OBJECTIVES: In 1999 the University of Kansas School of Medicine established a rural option for the required family medicine clerkship to increase student exposure to rural locations. The emphasis at these sites was in experiential learning, and students did not attend lectures. To assure that students who chose the rural option were receiving an equivalent educational experience, we compared the performance of rural students to their peers that received the standard clerkship experience. METHODS: We used data from family medicine clerkship students during 1999--2011 to compare rural students with those that remained on the main campus. Comparison of the groups was made with regard to previous academic performance and demographic data to assess for initial differences. While the rural students were more likely to be Caucasian, there was otherwise no statistical significance between the groups. We then compared their National Board of Medical Examiners (NBME) exam performance and their overall grade. RESULTS: Students who chose a rural location had a significantly higher clerkship grade. This was due to higher clinical evaluations. CONCLUSIONS: Students who completed a rural family medicine clerkship are not at an academic disadvantage. There are many possible explanations for better clinical evaluations, and a comparison of performance on the clinical skills assessment would be useful to determine whether the increased clinical experience during the rural option created a difference in clinical skills.

Development of an ambulatory geriatrics knowledge examination for internal medicine residents.

BACKGROUND: The number of older adults needing primary care exceeds the capacity of trained geriatricians to accommodate them. All physicians should have basic knowledge of optimal outpatient care of older adults to enhance the capacity of the system to serve this patient group. To date, there is no knowledge-assessment tool that focuses specifically on geriatric ambulatory care. OBJECTIVE: We developed an examination to assess internal medicine residents' knowledge of ambulatory geriatrics. METHODS: A consensus panel developed a 30-question examination based on topics in the American Board of Internal Medicine (ABIM) Certification Examination Blueprint, the ABIM in-training examinations, and the American Geriatrics Society Goals and Objectives. Questions were reviewed, edited, and then administered to medical students, internal medicine residents, primary care providers, and geriatricians. RESULTS: Ninety-eight individuals (20 fourth-year medical students, 57 internal medicine residents, 11 primary care faculty members, and 10 geriatrics fellowship-trained physicians) took the examination. Based on psychometric analysis of the results, 5 questions were deleted because of poor discriminatory power. The Cronbach α coefficient of the remaining 25 questions was 0.48; however, assessment of interitem consistency may not be an appropriate measure, given the variety of clinical topics on which questions were based. Scores increased with higher levels of training in geriatrics (P < .001). CONCLUSION: Our preliminary study suggests that the examination we developed is a reasonably valid method to assess knowledge of ambulatory geriatric care and may be useful in assessing residents.

Base rates of "10 to 11" clocks in Alzheimer's and Parkinson's disease.

We extended the work of Rouleau et al. (I. Rouleau, D. P. Salmon, N. Butters, C. Kennedy, & K. McGuire, Quantitative and qualitative analyses of clock drawings in Alzheimer's and Huntington's disease. Brain and Cognition, 18, 1992, 70-87) and Ryan et al. (J. J. Ryan, S. J. Lopez, & S. W. Sumerall, Base rate of "10 to 11" clocks among patients referred for neuropsychological evaluation. Perceptual and Motor Skills, 81, 1995, 1138) by providing base rates for "10 to 11" clocks in samples of healthy elderly (n = 168), Alzheimer's disease (AD; n = 81), and Parkinson's disease (PD; n = 105). Groups were comparable in age and education. Stimulus bound clocks occurred in 3.0% of controls, 30.9% of AD, 5.7% of PD, and 10.2% of the combined sample. The 10.2% base rate is consistent with Ryan et al. for a mixed sample and Rouleau et al. for healthy elderly and patients with AD or Huntington's disease.

Predicting neuropsychological test performance on the basis of temporal orientation.

Temporal orientation is often disrupted in the context of psychiatric or neurological disease; tests assessing this function are included in most mental status examinations. The present study examined the relationship between scores on the Temporal Orientation Scale (TOS) and performance on a battery of tests that assess memory, language, and cognitive functioning in a sample of patients with Alzheimer's disease (N = 55). Pearson-product moment correlations showed that, in all but two instances, the TOS was significantly correlated with each neuropsychological measure, p values < or = .05. Also, severely disoriented (i.e., TOS score < or = -8) patients were consistently 'impaired' on memory tests but not on tests of language and general cognitive functioning.

Which U.S. medical graduates plan to become specialty-board certified? Analysis of the 1997-2004 national association of American Medical Colleges Graduation Questionnaire database.

BACKGROUND: Predictors of U.S. allopathic medical-school graduates' board-certification plans have not been characterized. METHOD: Using multivariable logistic regression, graduates' responses to 11 questions on the 1997-2004 Association of American Medical Colleges Graduation Questionnaire were analyzed to identify independent predictors of plans for specialty-board certification. RESULTS: The proportion of 108,408 graduates planning specialty-board certification decreased from 97.3% in 1997 to 88.4% in 2004. Among 101,805 (93.9%) graduates with complete data, graduates who were Hispanic, rated their clinical clerkships, quality of medical education, and confidence in clinical skills more highly, had any debt, and planned "University-faculty" careers were more likely to plan becoming board certified. Females, Asians/Pacific Islanders, and graduates who planned to practice in underserved areas, planned "other" nonclinical-practice careers, and graduated with MD/other (non-PhD) degrees were less likely to plan becoming board certified. CONCLUSION: Specialty-board certification does not appear to be among the professional goals for a growing proportion of U.S. medical graduates.

A comparison of students from main and alternate admission lists at one school: the potential impact on student performance of increasing enrollment.

PURPOSE: If medical schools increase enrollment to meet anticipated physician shortages, more students from alternate lists will likely be accepted. This study compared the performance of alternate- and main-list students during and one year after medical school. METHOD: The authors assessed admission and performance measures for 1,188 students matriculating from 1997-2003 at the University of Kansas School of Medicine. Measures included Medical College Admission Test scores, basic and clinical science grade point averages, United States Medical Licensing Examination Step 1 and Step 2 scores, residency match information, and residency director ratings. Chi-square analyses, proportional analyses, and independent t-tests were performed. RESULTS: The results indicated that both the admission measures and performance of alternate-list students were generally lower than main-list students, but the differences were small and probably not meaningful. CONCLUSIONS: As long as the applicant pool does not substantially change from its current makeup, increasing enrollment by accepting more students from alternate lists may not adversely affect overall student performance.

Absence of the apolipoprotein E epsilon4 allele is associated with working memory impairment in Parkinson's disease.

The apolipoprotein E (APOE) epsilon4 allele has been associated with an increased risk of Alzheimer's disease (AD) and weaker episodic memory among elderly. Although this APOE allele has been linked to earlier onset of Parkinson's disease (PD), an association with dementia in PD has been only inconsistently demonstrated. Given the heterogeneity of cognitive impairment patterns in PD, this study sought to determine whether an association exists between APOE genotype and specific cognitive deficits in PD. The neuropsychological test performance of 42 PD patients without an epsilon4 allele (PD-Non4) and of 20 with at least one epsilon4 allele (PD-epsilon4) was compared to that of 146 elderly control subjects (NC). The PD groups were comparable in overall severity of cognitive impairment and disease duration, but the PD-epsilon4 group was younger, had an earlier disease onset, and contained a higher proportion of persons with dementia. Both PD groups showed wide-ranging cognitive impairments relative to NC. Once age differences between groups were controlled for, the PD groups generally did not differ from each other in cognitive performance. However, only the PD-Non4 group demonstrated working memory/attention impairments (digit span, visual span, Trailmaking test) relative to the NC group. Results suggest that the APOE genotype may influence the cognitive phenotype of PD, and specifically that absence of the epsilon4 allele is associated with working memory impairment. Additionally, results are consistent with prior findings showing an association between the epsilon4 allele and earlier onset of PD and presence of dementia.

Student treatment on clerkships based on their specialty interests.

BACKGROUND: Student clerkship experiences may suffer if teachers are not sympathetic to students' clinical interests. PURPOSE: In this study, we quantified these experiences, compared reports of primary care and focused specialty students, and identified clerkships and teachers that posed special problems. METHODS: Students starting their 4th year at 6 schools completed a survey. RESULTS: The response rate was 75%. Students reported that these experiences, which were provoked by their clinical interests, were common: hearing deprecating comments about their interests, being denied learning opportunities, receiving lower evaluations, being discouraged from pursing their interests, and needing to be evasive for self-protection. Primary care students reported less mistreatment than focused specialty students. Students identified some clerkships and types of teachers as special problem sources. Students reported mistreatment triggered by clinical interests at twice the national rates for mistreatment triggered by race or sex. CONCLUSIONS: Such mistreatment is common and challenges medical schools to ensure that students are treated well regardless of their career aspirations.

Effects of writing about emotions versus goals on psychological and physical health among third-year medical students.

A randomized, controlled trial compared writing about emotional topics (EMO) to writing about goals as the "best possible self" (BPS; after King, 2001) and evaluated emotional approach coping, i.e., efforts to cope through processing and expressing emotion, as a moderator of writing effects on psychological and physical health in 64 third-year medical students. In participants with higher baseline hostility, the EMO condition was associated with less hostility at 3 months compared to the BPS and control conditions. Emotional processing (EP) and emotional expression (EE) moderated the effect of experimental condition on depressive symptoms at 3 months; high EP/EE participants reported fewer depressive symptoms in the EMO condition, whereas low EP/EE individuals reported fewer depressive symptoms in the BPS condition compared to the EMO and control conditions. A moderating effect of EP on physical health was also identified, such that low EP individuals who wrote about goals (BPS) had fewer health care visits at 3 months compared to low EP participants in the EMO and control conditions.

Discrimination of healthy and brain-damaged elderly using the WAIS-R.

The authors evaluated the ability of WAIS-R variables to discriminate normal from brain-damaged persons 75 years of age and older. Fifty-four brain-damaged patients and 54 healthy elderly were matched on the variables of age, education, sex, and race. Significant level of performance differences emerged between the groups on all subtests and the three IQs. No group differences were found on the VIQ-PIQ discrepancy score or range of subtest scatter. Step-wise discriminant analysis revealed that Digit Symbol was the most potent WAIS-R variable, accounting for 34% of the variance and correctly classifying 79.6% of the subjects.

Keys to career satisfaction: insights from a survey of women pediatric surgeons.

BACKGROUND/PURPOSE: Declining interest in the field of surgery is attributed to lifestyle issues, more women per class, high debt, and long residency. To maintain surgery as a premier career choice, female students must find surgery to be professionally and personally rewarding. METHODS: A 35-item questionnaire was mailed to 95 women pediatric surgeons (WPS), assessing multiple professional and personal factors. Responses were entered into a confidential database and analyzed by chi2 or t tests. RESULTS: Seventy-nine percent of surveys were returned; practice was identified as academic (60%) and private (40%). Respondents were grouped by age: A, less than 44 years (41%); B, 45 to 54 years (37%); and C, greater than 55 years (22%). For academic WPS, 81% are on timeline for promotion. Insufficient protected time was a significant obstacle for a successful academic career in groups A and B (P =.001). Clinical load, on-call responsibilities, lack of mentorship, and departmental support were major obstacles in all groups (P =.05). Seventy-three percent of WPS in private practice were satisfied with their role in practice management; poor practice conditions were cited as the most frequent reason for job relocation. Sixty-one percent of WPS are married, and 46% are raising children. WPS had statistically significant more responsibilities for child care and household tasks in comparison with their partners. Eighty-three percent report career satisfaction but desire more time with family and for personal interests. Part-time and flexible work schedules were identified as attractive ways to achieve career-family balance. Eighty-four percent believe that quality-of-life issues are the dominant reason that fewer medical students choose surgical fields. CONCLUSIONS: WPS express career satisfaction but share the concerns of their female colleagues in other surgical disciplines. Quality of life is viewed as central to career choice for the current generation of medical students; female role models are key to recruiting women into pediatric surgery.

Action verbal fluency normative data for the elderly.

An emerging body of literature points to the prominent role of the frontal lobes in the retrieval of verbs, whereas production of common and proper nouns arguably is mediated primarily by posterior and anterior temporal regions, respectively. Although the majority of studies examining the neuroanatomic distinctions between verb and noun retrieval have relied on action naming tasks (naming depicted activities, e.g., running) as indicators of verb retrieval abilities, recent studies have utilized an action (verb) verbal fluency measure, the Action Fluency Test (AFT), to assess verb retrieval. Findings from these studies suggest that action fluency is sensitive to the integrity of fronto-subcortical neural circuitry and that it is a valid measure of executive and language functions. The AFT is an easily administered executive function measure, but no normative data for the AFT or other action fluency tasks has been published. This study was undertaken to provide initial AFT normative data for a sample of 145 healthy elderly subjects. As education is significantly correlated with AFT scores, the normative data are stratified by educational level.

Comparison and cross-validation of simple and multiple logistic regression models to predict USMLE step 1 performance.

BACKGROUND: Early identification of students who may have difficulty with the United States Medical Licensing Examination-Step 1 examination is important for medical schools and students. Numerous models that predict Step 1 performance have been identified, but few of these models have been cross-validated. PURPOSE: To cross-validate different prediction models of Step 1 performance. METHODS: The development sample was 686 students from a Midwestern medical school. The cross-validation sample was 147 different students. Logistic regression was used to develop the multiple model and Year 1 grade point average (GPA) and Year 2 Fall GPA were used as the simple models. Receiver Operating Characteristic graphs were used to select optimal cutoffs for each model. Kappa coefficients were used to determine level of agreement, and sensitivity and specificity were used to assess classification accuracy. RESULTS: The Year 1 GPA model had relatively poor agreement with actual Step 1 performance, but the other models evidenced fair agreement. The multiple and Year 1 GPA models demonstrated statistically significant loss of classification accuracy on cross-validation, whereas the Year 2 Fall GPA model did not. CONCLUSIONS: Cross-validation is necessary to determine the generalizability and overall utility of prediction models.

Treatment of medical students during clerkships based on their stated career interests.

BACKGROUND: Clerkship students often face questions from teachers about their career interests and may perceive that their responses change their clerkship experiences significantly. PURPOSE: To explore student experiences with "career interest" inquiries and how responses may influence clerkship experiences. METHODS: A qualitative study of 4th-year medical students by use of focus groups, whose experienced facilitators used a structured interview protocol. Purposeful sampling identified a representative group of participants. Transcribed focus group proceedings were analyzed with a predetermined theme matrix. RESULTS: Participants reported frequently facing career interest inquiries, feeling comfortable with some, and feeling threatened by others. The tone of inquiries ranged from casual to confrontational. Participants perceived that their responses could significantly influence the quality of teaching relationships, access to clinical opportunities, and grades. Students often responded vaguely or deceptively for self-protection. CONCLUSIONS: For clerkship students, career interest inquiries and how students respond can be high-stakes issues, potentially compromising teaching quality, equitable treatment, and fair evaluations. Further quantitative study is essential