Do acting interns need residents? A comparison of acting intern experience on hospital medicine resident versus nonresident teams.

BACKGROUND: The clinical demands for hospitalist groups have grown at academic medical centers, without similar growth of teaching opportunities for faculty. Traditional resident teaching teams are often crowded with learners which can limit acting intern (or subintern) patient encounters. Medical students are often placed on nonresident teaching teams, although there are few studies on learner experience on a nonresident teaching team model. METHODS: To address these concerns, we created two nonresident teaching teams composed of one attending and two acting interns. We compared acting intern experience on the nonresident teaching teams to the traditional resident teams to determine if there were significant differences in student experience by reviewing course evaluation data on the two team models. RESULTS: Of the 276 students who completed the Internal Medicine Acting Internship from 2019 to 2023, 224 students (81%) completed the course evaluation. The course was highly rated, and the ratings were similar in both models demonstrating that the nonresident teaching team model is an effective option for acting interns. CONCLUSION: The nonresident teaching team model can offload crowded teaching teams, add additional acting intern experiences, and add teaching opportunities for hospital medicine attendings.

Making narrative feedback meaningful.

BACKGROUND: Narrative written feedback given to students by faculty often fails to identify areas for improvement and recommended actions to lead to this improvement. When these elements are missing, it is challenging for students to improve and for medical schools to use narrative feedback in promotion decisions, to guide coaching plans and to pass on meaningful information to residency programs. Large-group faculty development has improved narrative written feedback, but less is known about individualised faculty development to supplement large-group sessions. To fill this gap, we built a curriculum with general and individualised faculty development to improve narrative written feedback from Internal Medicine faculty to clerkship students. APPROACH: We used Kern's steps to build a curriculum with general and individualised one-on-one faculty development to improve the problem of inadequate narrative written feedback. We used a novel narrative feedback rubric for pre and post-intervention faculty scores. RESULTS/FINDINGS/EVALUATION: Through general and individualised one-on-one faculty development with peer comparison scores, we were able to improve narrative written feedback from 3.7/6 to 4.6/6, for an increase of 23%. IMPLICATIONS: We found our faculty development program effective in improving feedback and was easy to implement. Our rubric was easy to use, and faculty were receptive to feedback in one-on-one meetings. We plan to extend this work locally to other divisions/departments and into graduate medical education; it should also be easily extended to other medical disciplines or health professions.

Clinicopathological and pedigree investigation of a novel spinocerebellar neurological disease in juvenile Quarter Horses in North America.

BACKGROUND: In 2020, a novel neurologic disease was observed in juvenile Quarter Horses (QHs) in North America. It was unknown if this was an aberrant manifestation of another previously described neurological disorder in foals, such as equine neuroaxonal dystrophy/equine degenerative myeloencephalopathy (eNAD/EDM). HYPOTHESIS/OBJECTIVES: To describe the clinical findings, outcomes, and postmortem changes with Equine Juvenile Spinocerebellar Ataxia (EJSCA), differentiate the disease from other similar neurological disorders, and determine a mode of inheritance. ANIMALS: Twelve neurologically affected QH foals and the dams. METHODS: Genomic DNA was isolated and pedigrees were manually constructed. RESULTS: All foals (n = 12/12) had a history of acute onset of neurological deficits with no history of trauma. Neurological deficits were characterized by asymmetrical spinal ataxia, with pelvic limbs more severely affected than thoracic limbs. Clinicopathological abnormalities included high serum activity of gamma-glutamyl transferase and hyperglycemia. All foals became recumbent (median, 3 days: [0-18 days]), which necessitated humane euthanasia (n = 11/12, 92%; the remaining case was found dead). Histological evaluation at postmortem revealed dilated myelin sheaths and digestion chambers within the spinal cord, most prominently in the dorsal spinocerebellar tracts. Pedigree analysis revealed a likely autosomal recessive mode of inheritance. CONCLUSIONS AND CLINICAL IMPORTANCE: EJSCA is a uniformly fatal, rapidly progressive, likely autosomal recessive neurological disease of QHs <1 month of age in North America that is etiologically distinct from other clinically similar neurological disorders. Once the causative variant for EJSCA is validated, carriers can be identified through genetic testing to inform breeding decisions.

Congenital Heart Disease.

More people are living with congenital heart disease (CHD) because many children now survive to adulthood with advances in medical and surgical treatments. Patients with CHD have ongoing complex health-care needs in the various life stages of infancy, childhood, adolescence, and adulthood. Primary care providers should collaborate with pediatric specialists to provide ongoing care for people living with CHD and to create smooth transitions of care.

MULTISPECIES SHIGELLA FLEXNERI OUTBREAK IN A ZOOLOGICAL COLLECTION COINCIDING WITH A CLUSTER IN THE LOCAL HUMAN POPULATION.

Shigella flexneri is a nonmotile gram-negative bacillus that affects humans and nonhuman primates. In August 2021, 15 primates at the ABQ BioPark demonstrated clinical signs of Shigella infection: 3 out of 4 Sumatran and hybrid orangutans (Pongo abelii), 6 out of 8 gorillas (Gorilla gorilla), 2 out of 9 chimpanzees (Pan troglodytes), and 4 out of 4 siamangs (Hylobates syndactylus). Three siamangs and one gorilla succumbed to complications of shigellosis during the initial outbreak and a chimpanzee died 10 mon later. Although it is well documented that Shigella may cause morbidity and mortality in nonhuman primates, the rapid and devastating nature of the outbreak, the difference from previous reports in zoological collections (enzootic vs outbreak), and the chronological overlap with the increase in human cases in the region makes discussion of this Shigella outbreak of significance. The cases presented here are significantly different than previous reports, because these were part of an outbreak that arose and subsided, versus other reports where the authors describe an enzootic disease with persistently infected animals. Close communication with the New Mexico Department of Health allowed for the investigation into possible sources of the outbreak, recommendations regarding biosecurity protocols, and staff education.

Preparing Interns as Teachers: Teaching Fourth-Year Medical Students the Tenets of the One-Minute Preceptor Model.

Introduction: Often, interns are expected to teach medical students early in their residency, but most are not formally taught how to be effective teachers before residency. Currently, there is emphasis on developing teaching skills of residents rather than students before they become residents. Most published student-as-teacher courses are voluntary and do not assess skill acquisition. Methods: We taught 290 fourth-year medical students across two academic years (2020-2022) the tenets of the One-Minute Preceptor (OMP) using a 2-hour workshop during their transition to residency course. A variety of role-play cases allowed students to practice the different parts of the OMP in isolation and combined. Then, we assessed their teaching skills after the workshop using an objective structured teaching exam (OSTE). Results: Two hundred seventy-eight students (96%) completed the self-assessment of their confidence demonstrating the skills of the OMP before and after the workshop. Their confidence improved in all domains, with ps < .001. Additionally, all students successfully demonstrated competency on the OSTE. Discussion: We used a 2-hour workshop based on the OMP to improve fourth-year medical students' confidence in their teaching skills and allow them to demonstrate competence in those skills before starting their intern year.

Practice Doesn't Make Perfect: Clinical Experience With Procedures Does Not Correlate Well With Competence in Third-Year Medical Students.

OBJECTIVE: There is limited data available about factors which promote competence with procedures in medical students. Specifically, the relationship between procedural clinical experience and performance on an assessment is unclear. We sought to determine whether a correlation exists between the amount and type of clinical experience with a procedure and student performance on a standardized assessment of that procedure. DESIGN: Faculty performed standardized assessments of third-year medical students on ten procedures using simulation. We prospectively surveyed students about 3 types of experience (performed, observed, and simulated) with these procedures during their clerkships. We then analyzed whether a correlation exists between student experience and their competency assessment scores using Pearson's correlation. SETTING/PARTICIPANTS: Third-year medical students at the University of Kentucky College of Medicine. RESULTS: In 2018 to 2019, 131 students were assessed on procedural competency with 10 failures. One hundred and twenty students (91.6%) completed the clinical experience survey. Correlations between types of experience and competency scores were small to moderate, with only 5 of 40 being significant. We found no correlation between experience having performed a procedure and competency score. CONCLUSIONS: Overall, we did not find convincing evidence of a correlation between experience with procedures during clerkships and performance on a competency assessment. This suggests other factors may be contributing to procedural competence, which has implications for how educators should develop procedural competence in students.

Development of a Community Hospital Medicine Affiliated Inpatient Rotation for Family Medicine Residents-A Collaborative Success.

Background: Hospitalists perform key roles as inpatient educators for family medicine residents. For the past decade, Duke University Family Medicine Residency Program had its inpatient family medicine resident rotation at non-Duke facilities. Objective: The authors describe the steps taken in 2020 to develop an inpatient Duke family medicine rotation at a North Carolina community hospital, Duke Regional Hospital, and provide outcomes data. Methods: Duke Family Medicine Residency and Duke Regional Hospital Medicine collaborated in addressing key issues to develop an inpatient rotation for family medicine residents. Performance metrics of patients cared for by both the family medicine inpatient resident team and internal medicine teams were compared. Resident satisfaction survey results were reviewed. Results: Retrospective cohort evaluation comparing the two inpatient services (internal medicine and family medicine) revealed the family medicine resident inpatient service performed comparatively in length of stay and 30-day readmission rates. Resident evaluation surveys of the family medicine inpatient rotation showed overall satisfaction with learning objectives. Conclusions: This new family medicine inpatient rotation has benefitted all parties. Key quality performance metrics such as LOS and readmissions are comparable to internal medicine, hospitalists have more teaching opportunities, and Duke family medicine has its residents training in a Duke-affiliated community hospital for their core inpatient rotation.

Impact of Bedside Rounding on Attending Teaching Evaluations.

OBJECTIVE: To examine associations between bedside rounding (BSR) and other rounding strategies (ORS) with resident evaluations of teaching attendings and self-reported attending characteristics. METHODS: Faculty from three academic medical centers who attended resident teaching services for ≥4 weeks during the 2018-2019 academic year were invited to complete a survey about personal and rounding characteristics. The survey instrument was iteratively developed to assess rounding strategy as well as factors that could affect choosing one rounding strategy over another. Survey results and teaching evaluation scores were linked, then deidentified and analyzed in aggregate. Included evaluation items assessed resident perceptions of autonomy, time management, professionalism, and teaching effectiveness, as well as a composite score (the numeric average of each attending's scores for all of the items at his or her institution). BSR was defined as spending >50% of rounding time in patients' rooms with the team. Hallway rounding and conference room rounding were combined into the ORS category and defined as >50% of rounding time in these settings. All of the scores were normalized to a 10-point scale to allow aggregation across sites. RESULTS: A total of 105 attendings were invited to participate, and 65 (62%) completed the survey. None of the resident evaluation scores significantly differed based on rounding strategy. Composite scores were similar for BSR and ORS (difference of <0.1 on a 10-point scale). Spearman correlation coefficients identified no statistically significant correlation between rounding strategy and evaluation scores. An exploratory analysis of variance model identified no single factor that was significantly associated with composite teaching scores (P > 0.45 for all) or the domains of teaching efficacy, professionalism, or autonomy (P > 0.13 for all). Having a formal educational role was significantly associated with better evaluation scores for time management, and the number of lectures delivered per year approached statistical significance for the same domain. CONCLUSIONS: Conducting BSR did not significantly affect resident evaluations of teaching attendings. Resident perception of teaching effectiveness based on rounding strategy should be neither a motivator nor a barrier to widespread institution of BSR.

Candy Gland: A Diabetes Board Game for Medical Students.

Introduction: Diabetes mellitus can be a challenging topic for medical students. Educational games can engage students, encourage collaboration and peer teaching, and support friendly competition. To enhance student training on diabetes diagnosis and management, we developed a flashcard-style board game to review these concepts and provide a formative assessment. Methods: In this 50-minute session, 102 second-year medical students used a game board and playing cards to compete in small groups. To play, teams took turns answering flashcard-style playing cards and moved forward on the board with correct answers. The first team to reach the end of the board won. Students completed a survey about their confidence in the topic and a multiple-choice test before and after the session to measure the effectiveness of this intervention. Results: Medical knowledge scores improved from 7.3 before the intervention to 8.0 after (10-point scale, p < .001). Students' ratings of their confidence in diabetes pharmacology, diagnosis, and management all improved (ps < .05 for all), with the greatest improvement seen in pharmacology. Student satisfaction ratings and narrative feedback were very positive. Discussion: This educational game effectively improved student knowledge and confidence in diabetes diagnosis, pharmacology, and management in an engaging, unique session. The intervention would be easy for other institutions to implement.

Partnerships to Care for Our Patients and Communities During COVID-19.

The Coronavirus disease 2019 (COVID-19) pandemic forced not only rapid changes in how clinical care and educational programs are delivered but also challenged academic medical centers (AMCs) like never before. The pandemic made clear the need to have coordinated action based on shared data and shared resources to meet the needs of patients, learners, and communities. Family medicine departments across the country have been key partners in AMCs' responses. The Duke Department of Family Medicine and Community Health (FMCH) was involved in many aspects of Duke University's and Health System's responses, including leadership contributions in delivering employee health and student health services. The pandemic also surfaced the biological and social interactions that reveal underlying socioeconomic inequalities, for which family medicine has advocated since its inception. Key to success was the department's ability to integrate "horizontally" with the broader community, thereby accelerating the institution's response to the pandemic.

Implementation and Impact of a Risk-Stratified Prostate Cancer Screening Algorithm as a Clinical Decision Support Tool in a Primary Care Network.

BACKGROUND: Implementation methods of risk-stratified cancer screening guidance throughout a health care system remains understudied. OBJECTIVE: Conduct a preliminary analysis of the implementation of a risk-stratified prostate cancer screening algorithm in a single health care system. DESIGN: Comparison of men seen pre-implementation (2/1/2016-2/1/2017) vs. post-implementation (2/2/2017-2/21/2018). PARTICIPANTS: Men, aged 40-75 years, without a history of prostate cancer, who were seen by a primary care provider. INTERVENTIONS: The algorithm was integrated into two components in the electronic health record (EHR): in Health Maintenance as a personalized screening reminder and in tailored messages to providers that accompanied prostate-specific antigen (PSA) results. MAIN MEASURES: Primary outcomes: percent of men who met screening algorithm criteria; percent of men with a PSA result. Logistic repeated measures mixed models were used to test for differences in the proportion of individuals that met screening criteria in the pre- and post-implementation periods with age, race, family history, and PSA level included as covariates. KEY RESULTS: During the pre- and post-implementation periods, 49,053 and 49,980 men, respectively, were seen across 26 clinics (20.6% African American). The proportion of men who met screening algorithm criteria increased from 49.3% (pre-implementation) to 68.0% (post-implementation) (p < 0.001); this increase was observed across all races, age groups, and primary care clinics. Importantly, the percent of men who had a PSA did not change: 55.3% pre-implementation, 55.0% post-implementation. The adjusted odds of meeting algorithm-based screening was 6.5-times higher in the post-implementation period than in the pre-implementation period (95% confidence interval, 5.97 to 7.05). CONCLUSIONS: In this preliminary analysis, following implementation of an EHR-based algorithm, we observed a rapid change in practice with an increase in screening in higher-risk groups balanced with a decrease in screening in low-risk groups. Future efforts will evaluate costs and downstream outcomes of this strategy.

Developing Physical Exam Skills in Residency: Comparing the Perspectives of Residents and Faculty About Values, Barriers, and Teaching Methods.

BACKGROUND: The physical examination (PE) skills of residents are often not improved since medical school. Unfortunately, how residents learn PE is not well understood. There is a paucity of research on the factors involved and the differences between resident and faculty perspectives. The authors sought to determine resident and faculty perceptions about the value of PE, the major barriers to learning PE, and the most effective teaching methods. METHODS: Based on a rigorous process of literature review and semi-structured interviews, the authors developed an online survey which was sent to 406 internal medicine residents and 93 faculty at 3 institutions. Residents and faculty answered questions about both their own opinions and about their perception of the other group's opinions. RESULTS: About 283 residents (70%) and 61 faculty (66%) completed the survey. Both residents and faculty rated the importance of PE similarly. Residents rated being too busy, followed by a lack of feedback, as the most significant barriers to learning PE. Faculty rated a lack of feedback, followed by a lack of resident accountability, as the most significant barriers. Both groups rated the availability of abnormal findings as the least significant barrier. Both groups agreed that faculty demonstration at the bedside was the most effective teaching method. CONCLUSION: This survey can serve as a needs assessment for educational interventions to improve the PE skills of residents by focusing on areas of agreement between residents and faculty, specifically faculty demonstration at the bedside combined with feedback about residents' skills.

Evaluating the effectiveness of undergraduate clinical education programs.

Medical schools should use a variety of measures to evaluate the effectiveness of their clinical curricula. Both outcome measures and process measures should be included, and these can be organized according to the four-level training evaluation model developed by Donald Kirkpatrick. Managing evaluation data requires the institution to employ deliberate strategies to monitor signals in real-time and aggregate data so that informed decisions can be made. Future steps in program evaluation includes increased emphasis on patient outcomes and multi-source feedback, as well as better integration of existing data sources.

Knowledge and Preferences of Primary Care Providers in Delivering Head and Neck Cancer Survivorship Care.

Long-term care for head and neck cancer (HNC) survivors is complex and requires coordination among multiple providers. Clinical practice guidelines highlight the role of primary care providers (PCPs) in screening for secondary cancer/recurrence, assessment of late/long-term side effects, and referrals for appropriate specialty management of toxicity. However, these responsibilities may be difficult to meet within the scope of primary care practice. We conducted this study to explore preferences, comfort, and knowledge of PCPs in the care of HNC survivors. We piloted a 40-item web-based survey developed with oncologist and PCP input targeted for family medicine and internal medicine providers. Responses were collected within a single university health system over 2 months. PCPs (n = 28; RR = 11.3%) were interested in learning about health promotion after cancer treatment (89%) and generally agree that their current practice patterns address healthy lifestyle behaviors (82%). However, only 32% of PCPs felt confident they could manage late/long-term side effects of chemotherapy, radiation, or surgery. Only 29% felt confident they could provide appropriate cancer screening. Looking at shared care responsibilities with oncology providers, PCPs perceived being responsible for 30% of care in the first year after treatment and 81% of care after 5 years. Seventy-one percent of PCPs agreed that oncologists provided them necessary information, yet 32% of PCPs found it difficult to coordinate with cancer providers. While these PCPs perceive increased care responsibility for long-term survivors, most are uncomfortable screening for recurrence and managing late/long-term side effects. Education and mutual coordination between PCPs and oncology providers may improve survivor care.

Competency-Based Medical Education in the Internal Medicine Clerkship: A Report From the Alliance for Academic Internal Medicine Undergraduate Medical Education Task Force.

As medical educators continue to redefine learning and assessment across the continuum, implementation of competency-based medical education in the undergraduate setting has become a focus of many medical schools. While standards of competency have been defined for the graduating student, there is no uniform approach for defining competency expectations for students during their core clerkship year. The authors describe the process by which an Alliance for Academic Internal Medicine task force developed a paradigm for competency-based assessment of students during their inpatient internal medicine (IM) clerkship. Building on work at the resident and fellowship levels, the task force focused on the development of key learning outcomes as defined by entrustable professional activities (EPAs) that were specific to educational experiences on the IM clerkship, as well as identification of high-priority assessment domains. The work was informed by a national survey of clerkship directors.Six key EPAs emerged: generating a differential diagnosis, obtaining a complete and accurate history and physical exam, obtaining focused histories and clinically relevant physical exams, preparing an oral presentation, interpreting the results of basic diagnostic studies, and providing well-organized clinical documentation. A model for assessment was proposed, with descriptors aligned to the scale of supervision and mapped to Accreditation Council for Graduate Medical Education domains of competence. The proposed paradigm offers a standardized template that may be used across IM clerkships, and which would effectively bridge competency evaluation in the clerkship to fourth-year assessment as well as eventual postgraduate training.

NCCN Guidelines Insights: Central Nervous System Cancers, Version 1.2017.

For many years, the diagnosis and classification of gliomas have been based on histology. Although studies including large populations of patients demonstrated the prognostic value of histologic phenotype, variability in outcomes within histologic groups limited the utility of this system. Nonetheless, histology was the only proven and widely accessible tool available at the time, thus it was used for clinical trial entry criteria, and therefore determined the recommended treatment options. Research to identify molecular changes that underlie glioma progression has led to the discovery of molecular features that have greater diagnostic and prognostic value than histology. Analyses of these molecular markers across populations from randomized clinical trials have shown that some of these markers are also predictive of response to specific types of treatment, which has prompted significant changes to the recommended treatment options for grade III (anaplastic) gliomas.

Recognizing Patients' Emotions: Teaching Health Care Providers to Interpret Facial Expressions.

PURPOSE: Facial expressions are an important clue to a patient's emotions. The authors developed a 90-minute workshop in May 2011 to teach physicians and physicians-in-training to interpret facial expressions and to use that skill in the context of patient care. METHOD: The workshop included a didactic presentation in which facial expression features were taught using progressively more difficult examples, followed by three interactive exercises. The authors presented the workshop at six separate venues in the United States in 2011 and 2012. To test the effectiveness of this workshop, the authors designed a comprehensive pre- and postworkshop evaluation which assessed participants' skill, knowledge, attitude (toward importance), and confidence. RESULTS: A total of 156 health care providers participated in the workshop and completed pre- and postworkshop evaluations. Participants showed substantial improvement in skill and knowledge (fact- and case-based) scores, as well as modest improvement in importance and confidence ratings. Faculty and medical students demonstrated similar baseline measures of skill, knowledge, and importance, though faculty reported a slightly higher confidence in their skills. No correlation was found between baseline ratings of confidence in abilities and any baseline measure of performance. CONCLUSIONS: Given the similar baseline performance of faculty and medical students, the ability to interpret facial expressions does not appear to be learned through routine clinical practice, highlighting the need for dedicated facial expression training. The authors were able to demonstrate that physicians and physicians-in-training could effectively learn to recognize emotion by interpreting facial expressions through a short workshop.

Prostate cancer screening.

Universal screening for prostate cancer (Pca) using prostate-specific antigen-based testing is not recommended, as the potential harms of screening (overdiagnosis and overtreatment) outweigh potential benefits. The case for Pca screening requires a paradigm shift, which emphasizes the risks of screening over the risks of undetected cancer. Physicians are encouraged to use shared decision making with patients who express an interest in Pca screening, taking into account both the patient's screening preferences and individual risk profile. New models of care informed by the Patient Protection and Affordable Care Act are intended to assist clinicians in providing recommended preventive services.

Intraocular and periocular lymphoma in dogs and cats: a retrospective review of 21 cases (2001-2012).

OBJECTIVE: To immunologically phenotype and histologically classify canine and feline intraocular and periocular lymphomas. METHODS: The databases of four veterinary medical diagnostic laboratories were searched to identify cases of intraocular or periocular lymphoma in dogs and cats between 2001 and 2012. Hematoxylin and eosin (H&E) stained slides were reviewed for confirmation and classification of lymphoma, and immunohistochemistry for CD3 (T-cell marker) and CD79a and/or CD20 (B-cell markers) was examined to determine the lineage of the neoplastic lymphocytes. RESULTS: Six canine and 15 feline cases of ocular lymphoma were identified. In the canine cases, there were three intraocular and three periocular lymphomas where two intraocular and one periocular lymphomas were B-cell, one of each intraocular and periocular lymphomas were T-cell and one periocular lymphoma was nonreactive with CD3, CD79a or CD20. In the feline cases, there were six intraocular and nine periocular lymphomas where five intraocular and six periocular lymphomas were B-cell, and one intraocular and three periocular lymphomas were T-cell. Only one canine case had concurrent generalized lymphadenopathy, only one canine conjunctival lymphoma had simultaneous cutaneous lymphoma, and only one feline case had bilateral ocular involvement when they were diagnosed. CONCLUSION: Canine and feline intraocular and periocular lymphomas are often of B-cell phenotype. Although in general terms lymphoma is not considered a primary tumor when it occurs in or adjacent to the globe, these tumors frequently first become evident in the globe and/or periocular area. An accurate early diagnostic approach is crucial for the patient's quality of life because B-cell lymphomas are generally more amenable to chemotherapy than T-cell lymphomas.