How a Team Effectiveness Approach to Health Systems Science Can Illuminate Undergraduate Medical Education Outcomes.

ABSTRACT: Health care delivery requires physicians to operate in teams to successfully navigate complexity in caring for patients and communities. The importance of training physicians early in core concepts of working in teams (i.e., "teaming") has long been established. Over the past decade, however, little evidence of team effectiveness training for medical students has been available. The recent introduction of health systems science as a third pillar of medical education provides an opportunity to teach and prepare students to work in teams and achieve related core competencies across the medical education continuum and health care delivery settings. Although educators and health care system leaders have emphasized the teaching and learning of team-based care, conceptual models and evidence that inform effective teaming within all aspects of undergraduate medical education (including classroom, clinical, and community settings) are needed to advance the science regarding learning and working in teams. Anchoring teaming through the core foundational theory of team effectiveness and its operational components could catalyze the empirical study of medical student teams, uncover modifiable factors that lead to the evidence for improved student learning, and improve the link among competency-based assessments between undergraduate medical education and graduate medical education. In this article, authors articulate several implications for medical schools through 5 conceptual areas: admissions, the design and teaching of team effectiveness in health systems science curricula, the related competency-based assessments, and course and program evaluations. The authors then discuss the relevance of the measurable components and intended outcomes to team effectiveness in undergraduate medical education as critical to successfully prepare students for teaming in clerkships and eventually residency and clinical practice.

Precise single base substitution in the shibire gene by CRISPR/Cas9-mediated homology directed repair in Bactrocera tryoni.

BACKGROUND: Pest eradication using the Sterile Insect Technique (SIT) involves high-density releases of sterilized males that mate with wild females and ultimately suppress the population. Sterilized females are not required for SIT and their removal or separation from males prior to release remains challenging. In order to develop genetic sexing strains (GSS), conditional traits such as temperature sensitive lethality are required. RESULTS: Here we introduce a known Drosophila melanogaster temperature sensitive embryonic lethal mutation into Bactrocera tryoni, a serious horticultural pest in Australia. A non-synonymous point mutation in the D. melanogaster gene shibire causes embryonic lethality at 29 °C and we successfully used CRISPR/Cas9 technology to recreate the orthologous shibire temperature sensitive-1 (shits1) mutation in B. tryoni. Genotypic analyses over three generations revealed that a high fitness cost was associated with the shits1 mutant allele and shits1 homozygotes were not viable at 21 °C, which is a more severe phenotype than that documented in D. melanogaster. CONCLUSIONS: We have demonstrated the first successful use of CRISPR/Cas9 to introduce precise single base substitutions in an endogenous gene via homology-directed repair in an agricultural pest insect and this technology can be used to trial other conditional mutations for the ultimate aim of generating genetic sexing strains for SIT.

Resident and Faculty Perspectives on Prevention of Resident Burnout: A Focus Group Study.

CONTEXT: The high prevalence and negative implications of resident physicians' burnout is well documented, yet few effective interventions have been identified. OBJECTIVE: To document resident and faculty perspectives on resident burnout, including perceived contributing factors and their recommended strategies for attention and prevention. DESIGN: We conducted 14 focus groups with core faculty and residents in 5 specialties at a large integrated health care system in Southern California. Training programs sampled included family medicine, internal medicine, obstetrics and gynecology, pediatrics, and psychiatry. Discussions were recorded, transcribed, and analyzed using a matrix-based approach to identify common themes. MAIN OUTCOME MEASURES: Resident and faculty perspectives regarding causes of burnout, preventive factors, and potential intervention strategies. RESULTS: Five themes captured the range of factors participants identified as contributing or protective factors for resident burnout: 1) having or lacking a sense of meaning at work; 2) fatigue and exhaustion; 3) cultural norms in medicine; 4) the steep learning curve from medical school to residency; and 5) social relationships at and outside work. Recommended intervention strategies targeted individuals, residents' social networks, and the learning and work environment. CONCLUSION: We engaged residents and core faculty across specialties in the identification of factors contributing to burnout and possible targets for interventions. Our results highlight potential focus areas for future burnout interventions and point to the importance of interventions targeted at the social environments in which residents' work and learn.

Identification of Y-chromosome scaffolds of the Queensland fruit fly reveals a duplicated gyf gene paralogue common to many Bactrocera pest species.

Bactrocera tryoni (Queensland fruit fly) are polyphagous horticultural pests of eastern Australia. Heterogametic males contain a sex-determining Y-chromosome thought to be gene poor and repetitive. Here, we report 39 Y-chromosome scaffolds (~700 kb) from B. tryoni identified using genotype-by-sequencing data and whole-genome resequencing. Male diagnostic PCR assays validated eight Y-scaffolds, and one (Btry4096) contained a novel gene with five exons that encode a predicted 575 amino acid protein. The Y-gene, referred to as typo-gyf, is a truncated Y-chromosome paralogue of X-chromosome gene gyf (1773 aa). The Y-chromosome contained ~41 copies of typo-gyf, and expression occurred in male flies and embryos. Analysis of 13 tephritid transcriptomes confirmed typo-gyf expression in six additional Bactrocera species, including Bactrocera latifrons, Bactrocera dorsalis and Bactrocera zonata. Molecular dating estimated typo-gyf evolved within the past 8.02 million years (95% highest posterior density 10.56-5.52 million years), after the split with Bactrocera oleae. Phylogenetic analysis also highlighted complex evolutionary histories among several Bactrocera species, as discordant nuclear (116 genes) and mitochondrial (13 genes) topologies were observed. B. tryoni Y-sequences may provide useful sites for future transgene insertions, and typo-gyf could act as a Y-chromosome diagnostic marker for many Bactrocera species, although its function is unknown.

A county-level analysis of persons living with HIV in the southern United States.

This study uses county-level surveillance data to systematically analyze geographic variation and clustering of persons living with diagnosed HIV (PLWH) in the southern United States in 2011. Clusters corresponding to large metropolitan areas - including Miami, Atlanta, and Baltimore - had HIV prevalence rates higher (p < .001) than the regional rate. Regression analysis within the counties included in these clusters determined that race was a significant indicator for PLWH. These results provide a general picture of the distribution of PLWH in the southern United States at the county level and provide insights for identifying local geographic areas with a high number of PLWH, as well as subpopulations that may have an increased risk of infection.

Reflective writing and its impact on empathy in medical education: systematic review.

PURPOSE: Medical schools are increasingly aware of the ways in which physician empathy can have a profound impact on patients' lives and have developed humanities initiatives to address this concern. Reflective writing in particular is more commonly promoted in medical curricula, but there is limited research on the impact of reflective writing on medical student empathy levels. It aims to find the emotional effects of reflective writing interventions on medical and healthcare students by systemic review. METHODS: Two investigators independently reviewed educational publications for critical analysis. This review focused systematically on quantitative papers that measure the impact of reflective writing on empathy. RESULTS: Of the 1,032 studies found on Medline and CINAHL, only 8 used quantitative measures pre- and postwritten reflection to measure any impact on empathy outcomes. The outcomes measured included impact of reflective writing exercises on student wellness, aptitude, and/or clinical skills. Of these studies, a significant change in student empathy was observed in 100% of the studies, demonstrating a significant change in outcomes. CONCLUSION: Although the lack of homogeneity in outcome measurement in the literature limits possible conclusion from this review, the overwhelmingly positive reporting of outcomes suggests that reflective writing should be considered in any medical curriculum.

High prevalence of chronic non-communicable conditions among adult refugees: implications for practice and policy.

The global rise in non-communicable disease (NCD) suggests that US-based refugees are increasingly affected by chronic conditions. However, health services have focused on the detection of infectious disease, with relatively limited data on chronic NCDs. Using data from a retrospective medical record review of a refugee health program in the urban Northeast (n = 180), we examined the prevalence of chronic NCDs and NCD risk factors among adult refugees who had recently arrived in the US, with attention to region of origin and family composition. Family composition was included because low-income adults without dependent children are at high risk of becoming uninsured. We found that half of the adult refugees in this sample had at least one chronic NCD (51.1%), and 9.5% had three or more NCDs. Behavioral health diagnoses were most common (15.0%), followed by hypertension (13.3%). Half of adults were overweight or obese (54.6%). Chronic NCDs were somewhat more common among adults from Iraq, but this difference was not significant (56.8 vs. 44.6%). Chronic NCDs were common among adults with and without dependent children (61.4 vs. 44.6%, respectively), and these two groups did not significantly differ in their likelihood of having a chronic NCD after adjustment for age and gender (AOR = 0.78, 95% CI = 0.39, 1.55). This study suggests that chronic NCDs are common among adult refugees in the US, including refugees at high risk for uninsurance. We propose that refugee health services accommodate screening and treatment for chronic NCDs and NCD risk factors, and that insurance outreach and enrollment programs target recently arrived refugees.

The implications of urine drug testing in pain management.

In the treatment of pain management, physicians employ a variety of drugs, ranging from low-impact to highly potent, and to maximize patient health, urine toxicology analyses can significantly improve the delivery of pain treatment. Drugs such as opioids that are used for pain management are peculiar in that they provide effective pain relief and have a high risk of addiction. The use of illicit drugs in the general population has been on the rise; however, self-reporting and close monitoring of patient behavior are insufficient means to detect drug abuse and confirm compliance. Therefore, in order to create more effective drug treatment plans, physicians must understand and account for the implications of patient drug use history. Urine toxicology analysis is an important tool for pain physicians because it is more sensitive than most alternative blood tests, more efficient and cost-effective. Urine testing in addition to improving patient pain management also has forensic and legal implications. There are however limitations to urine toxicology methods as they can produce false-positive and false-negative results and are prone to human error and sample contamination There is also a need for more specific and rapid urine drug testing. Healthcare professionals should therefore be familiar with the limitations of various urine drug testing methods, and possess skills necessary to properly interpret these results. This review suggests that the overall benefits incurred by both the patient's short-term and long-term health support the routine integration of urine toxicology analysis in routine clinical care. In addition to improving health care and patient health, it has a strong potential to improve patient-physician relationships and protects the interest of involved healthcare practitioners.