Designing a Situational Judgment Test for Use in Medical School Admissions.

ABSTRACT: It has long been acknowledged that professional competencies are required for success in medical school, residency training, and medical practice. Over the last decade, medical schools have begun to introduce standardized assessments of professional competencies, but many still rely on interviews to assess these competencies, which occur after about half of the applicant pool has already been screened out. In this article, the authors discuss the development, evaluation, and launch of the Association of American Medical Colleges (AAMC) situational judgment test (SJT) for use in medical school admissions. The AAMC SJT is designed to assess an examinee's understanding of effective and ineffective behaviors related to the core competencies for entering medical students, including service orientation, social skills, cultural competence, teamwork, ethical responsibility to self and others, reliability and dependability, resilience and adaptability, and capacity for improvement. The authors evaluate the evidence for the need for SJTs in medical school admissions by exploring common derailers in medical school, gaps in the admissions process regarding information about professional competencies, and the challenge of conducting holistic review in a high-volume context. They summarize existing research from the employment, international medical education, and residency selection contexts suggesting that SJT scores are positively associated with subsequent performance and may add value to the admissions process. The authors discuss 5 goals that were the foundation for developing the AAMC SJT: (1) assess the professional competencies needed for success in medical school using a proven method, (2) enable holistic review in a high-volume admissions context, (3) create and share a program of research to support the appropriate use of SJT scores, (4) signal the need for preparation in professionalism to learners, and (5) balance the need for a new assessment with minimizing the burden and risk for applicants.

Safety and functional outcomes of early antiplatelet therapy within 24 hours following mechanical thrombectomy for secondary prevention in emergent large-vessel occlusion strokes: a registry study.

OBJECTIVE: The aim of this study was to demonstrate the safety and functional outcomes of antiplatelet use within 24 hours following mechanical thrombectomy (MT). METHODS: A retrospective review of prospectively collected data for consecutive patients who underwent MT for acute ischemic stroke (AIS) between 2016 and 2020 was performed. Patient demographics, comorbidities, Alberta Stroke Program Early CT Score (ASPECTS), antiplatelet use, neurological status, and tissue plasminogen activator use were collected. Patients were stratified into two groups, early (< 24 hours) or late (> 24 hours), based on when antiplatelet therapy was initiated post-MT. The primary outcome was safety, determined based on the rate of symptomatic intracranial hemorrhage (sICH) and inpatient mortality. The secondary outcome was functional independence (defined as modified Rankin Scale [mRS] score ≤ 2) at discharge and 30 days and 90 days postoperatively. The two cohorts were compared using univariate analysis. Multiple imputations were used to create complete data sets for missing data. Multivariable analysis was used to identify predictors for sICH and functional outcomes. RESULTS: A total of 190 patients met inclusion criteria (95 per group). Significant differences between the early and late groups included sex, preoperative intravenous thrombolysis, angioplasty, stent placement, and thrombectomy site. ICH (symptomatic and asymptomatic) and inpatient mortality were not significantly different between the groups. The mRS score was significantly lower at discharge (p < 0.001), 30 days (p = 0.011), and 90 days (p = 0.024) following MT in the early group. Functional independence was significantly higher in the early antiplatelet group at discharge (p = 0.015) and at 30 days (p = 0.006). Early antiplatelet use was independently associated with significantly increased odds of achieving functional independence at discharge (OR 3.07, p = 0.007) and 30 days (OR 5.78, p = 0.004). Early antiplatelet therapy was not independently associated with increased odds of sICH. CONCLUSIONS: Early antiplatelet initiation after MT in patients with AIS was independently associated with significantly increased odds of improved postoperative functional outcomes without increased odds of developing sICH.

Skin Color Representation in Teaching Photographs: One Institution's Approach to Addressing Visual Racism in Medical Education.

Problem: Visual racism refers to both the underrepresentation and inappropriate representation of darker skin types in medical education. By not teaching medical students and resident physicians to recognize common conditions in darker skin, it perpetuates biases that contribute to healthcare disparities for racial and ethnic minoritized groups. In this paper we describe our efforts to engage in institutional anti-racism work by addressing imbalances in representation of darker skin types in visual teaching images within our institution's curriculum. Intervention: We initially surveyed preclinical medical students regarding their perceptions of skin color representation in two courses. Researchers recorded the skin types of all teaching photographs in these courses in 2020. We then provided feedback and education to faculty, proposing that they increase brown and black skin color representation in educational content. During 2021, we reviewed the same courses and surveyed students again to ascertain the implementation and impact of our proposal. Context: We applied our intervention to two courses, Host & Defense (H&D) and Skin, Muscle, Bone, and Joint (SMBJ) since both courses utilize a large number of teaching images. Impact: From 2020 to 2021, both H&D and SMBJ significantly increased the proportion of visual teaching images that included darker skin types, with an increase from 28% to 42% in H&D and 20% to 30% in SMBJ. Significantly more students in the courses' 2021 iterations (73% in H&D, 93% in SMBJ) felt that lectures had appropriate representations of darker skin types when compared to students who took the course in 2020 (8% in H&D, 51% in SMBJ). Students in 2021 felt more confident in recognizing dermatological signs and symptoms in patients with darker skin than students in 2020. The majority of students in both 2020 and 2021 reported wanting to see a gradient of skin types for every dermatological condition discussed. Lessons learned: Our work suggests that addressing visual racism can be achieved partly by setting expectations for increased visual representation, collaborating across educational departments, and establishing clear metrics for assessing implementation. Future interventions will require a continual feedback loop of monitoring learning material, assessing faculty and student perception, refining resources, and recommending revisions to improve visual representation across the entire curriculum.

Fusion and patient-reported outcomes after navigated decortication and direct arthrodesis in minimally invasive sacroiliac joint fusion using cylindrical threaded implants: a case series and literature review.

OBJECTIVE: Sacroiliac joint (SIJ) dysfunction is a significant cause of back pain. Despite recent advances in minimally invasive (MIS) SIJ fusion, the fusion rate remains controversial. This study sought to demonstrate that a navigated decortication and direct arthrodesis technique in MIS SIJ fusion would result in satisfactory fusion rates and patient-reported outcomes (PROs). METHODS: The authors retrospectively reviewed consecutive patients who underwent MIS SIJ fusion from 2018 to 2021. SIJ fusion was performed using cylindrical threaded implants and SIJ decortication employing the O-arm surgical imaging system and StealthStation. The primary outcome was fusion, evaluated using CT at 6, 9, and 12 months postoperatively. Secondary outcomes included revision surgery, time to revision surgery, visual analog scale (VAS) score for back pain, and the Oswestry Disability Index (ODI), measured preoperatively and 6 and 12 months postoperatively. Patient demographics and perioperative data were also collected. PROs over time were analyzed using ANOVA followed by a post hoc analysis. RESULTS: One hundred eighteen patients were included in this study. The mean (± SD) patient age was 58.56 ± 13.12 years, and most patients were female (68.6% vs 31.4% male). There were 19 smokers (16.1%) with an average BMI of 29.92 ± 6.73. One hundred twelve patients (94.9%) underwent successful fusion on CT. The ODI improved significantly from baseline to 6 months (Δ7.73, 95% CI 2.43-13.03, p = 0.002) and from baseline to 12 months (Δ7.54, 95% CI 1.65-13.43, p = 0.008). Similarly, VAS back pain scores improved significantly from baseline to 6 months (Δ2.31, 95% CI 1.07-3.56, p < 0.001) and from baseline to 12 months (Δ1.63, 95% CI 0.25-3.00, p = 0.015). CONCLUSIONS: MIS SIJ fusion with navigated decortication and direct arthrodesis was associated with a high fusion rate and significant improvement in disability and pain scores. Further prospective studies examining this technique are warranted.

Virtual Shadowing: An Effective Approach to Gaining Exposure to the Field of Emergency Medicine.

Purpose: Shadowing is an important part of medical student education. The COVID-19 pandemic limited medical students' hospital access. At the same time, virtual access to learning experiences has expanded greatly. In response, we implemented a novel virtual shadowing system to provide students with convenient and safe exposure to the Emergency Department (ED). Patients and Methods: Six EM faculty hosted 2-hour virtual shadowing for up to 10 students per experience. Students registered via signupgenius.com. Virtual shadowing was conducted using a HIPAA-compliant ZOOM account on an ED issued mobile telehealth Monitor/iPad. The physician would bring the iPad into the room, obtain consent from patients, and ensure students were able to see the encounter. Between visits, students were encouraged to ask questions using the chat function and microphone. A short de-briefing followed each shift. Each participant received a survey about the experience. The survey consisted of 4 questions for demographics, 9 Likert style questions to assess efficacy, and 2 free response sections for comments and feedback. All survey responses were anonymous. Results: In total, 58 students participated in 18 virtual shadowing sessions with an average of 3-4 students per session. Survey responses were collected between October 20, 2020 and November 20, 2020. The overall response rate was 96.6% (56/58 surveys completed). Of respondents, 46 (82.1%) rated the experience as "effective" or "very effective" at providing exposure to Emergency Medicine. Fifty-three (94.6%) said they would participate in virtual shadowing in the ED again, and 48 (85.7%) would do virtual shadowing in another specialty were it available. Conclusion: We found virtual shadowing to be an easy to implement and effective way for students to shadow physicians in the ED. Even in post-pandemic times, virtual shadowing should be explored as an accessible and effective way to expose students to a broad array of specialties.

Preventing Surgical Site Hematoma Using Topical with or Without Intravenous Tranexamic Acid in Lumbosacral Surgery: A Quality Improvement Project.

BACKGROUND: Postoperative surgical site hematoma (SSH) following lumbosacral surgery carries significant morbidity and increased length of stay (LOS). Intravenous tranexamic acid (ivTXA) has been shown to reduce SSH rate. Topical TXA (tTXA) could benefit patients with contraindications to ivTXA. However, this has not been widely studied. We sought to demonstrate that a quality improvement (QI) protocol using tTXA with/without ivTXA in patients undergoing elective open and minimally invasive lumbosacral surgery could decrease the SSH rate and LOS with no increase in associated complications. METHODS: A retrospective chart review for July 2018-June 2019 demonstrated our preimplementation baseline SSH rate. We conducted interdisciplinary meetings to develop standardized institutional measures and perioperative tTXA administration protocol. The primary outcome was SSH necessitating evacuation. The secondary outcome was LOS and TXA-related complications. The postimplementation data were collected prospectively from July 2020-October 2020. Univariate analysis was used to compare preimplementation and postimplementation cohorts. We considered a P-value <0.05 significant. RESULTS: Comparing consecutive lumbosacral surgical patients in pre- (219 patients) and postimplementation (258 patients), the postimplementation group demonstrated a significantly reduced rate of SSH requiring evacuation (0.38% vs. 3.3%, P < 0.001), significantly increased tTXA utilization (86.0% vs. 9.6%, P < 0.001), significantly lower incidence of SSH in tTXA patients (0.45% vs. 4.8%, P = 0.037), and significantly decreased LOS (3.4 ± 2.5 vs. 3.1 ± 2.7, P = 0.003). There were no complications attributable to TXA use. CONCLUSIONS: Our Quality Improvement (QI) project successfully increased compliance with the use of tTXA. Post-implementation rate of SSH requiring evacuation and LOS was significantly lowered with no associated complications.

Measuring the Learning Orientation Fostered by Pediatric Residency Programs With the Graduate Medical Education Learning Environment Inventory Instrument.

INTRODUCTION: Mastery learning orientation, conceptualized as a growth mindset, can be beneficial to learners in medical education and is supported by a program...s learning environment. Currently, there are no instruments which reliably assess the learning orientation of a graduate medical education program...s learning environment. OBJECTIVE: To explore the reliability and validity of the Graduate Medical Education Learning Environment Inventory (GME-LEI). METHODS: Leaders of the Education in Pediatrics Across the Continuum (EPAC) project revised Krupat...s Educational Climate Inventory to create the GME-LEI. We investigated the GME-LEI...s reliability and validity through confirmatory factor and parallel factor analyses and calculated Cronbach...s alpha for each subscale. We compared mean subscale scores between residents in traditional programs and the EPAC project. As EPAC is known to foster a mastery-focused learning orientation, we hypothesized differences detected between resident groups would strengthen the instrument...s validity. RESULTS: One hundred and twenty-seven pediatric residents completed the GME-LEI. The final 3-factor model was an acceptable fit to the data, and Cronbach...s alpha for each subscale was acceptable (Centrality: 0.87; Stress: 0.73; Support: 0.77). Mean scores on each subscale varied by program type (EPAC vs traditional) with EPAC residents reporting statistically significant higher scores in the Centrality of Learning subscale (2.03, SD 0.30, vs 1.79, SD 0.42; P.ß=.ß.023; scale of 1...4). CONCLUSIONS: The GME-LEI reliably measures 3 distinct aspects of the GME learning environment with respect to learning orientation. The GME-LEI may be used to help programs better monitor the learning environment and make changes to support mastery-oriented learning.

The Effect of Preoperative Symptom Duration on Patient-Reported Outcomes After Anterior Cervical Discectomy and Fusion in Nonmyelopathic Patients: Analyses From the Michigan Spine Surgery Improvement Collaborative (MSSIC).

BACKGROUND: The effect of preoperative symptom duration (PSD) on patient-reported outcomes (PROs) in anterior cervical discectomy and fusion (ACDF) for radiculopathy is unclear. OBJECTIVE: To determine whether PSD is a predictor for PRO after ACDF for radiculopathy. METHODS: The Michigan Spine Surgery Improvement Collaborative registry was queried between March, 2014, and July, 2019, for patients who underwent ACDF without myelopathy and PROs (baseline, 90 days, 1 year, 2 years). PROs were measured by numerical rating scales for neck/arm pain, Patient-Reported Outcomes Measurement Information System Short Form-Physical Function (PROMIS-PF), EuroQol-5D (EQ5D), and North American Spine Society satisfaction. Univariate analyses were used to evaluate the proportion of patients reaching minimal clinically important differences (MCID). PSD was <3 months, 3 month-1 year, or >1 years. Multiple logistic regression models were used to estimate the association between PSD and PRO reaching MCID. The discriminative ability of the model was evaluated by receiver operating characteristic curve. RESULTS: We included 2233 patients who underwent ACDF with PSD <3 months (278, 12.4%), 3 month-1 year (669, 30%), and >1 years (1286, 57.6%). Univariate analyses demonstrated a greater proportion of patients achieving MCID in <3-month cohort for arm numerical rating scales, PROMIS-PF, EQ5D, and North American Spine Society Satisfaction. Multivariable analyses demonstrated using <3 months PSD as a reference, PSD >1 years was associated with decreased odds of achieving MCID for EQ5D (odds ratio 0.5, CI 0.32-0.80, P = .004). Private insurance and increased baseline PRO were associated with significantly higher odds for achieving PROMIS-PF MCID and EQ5D-MCID. CONCLUSION: Preoperative symptom duration greater than 1 year in patients who underwent ACDF for radiculopathy was associated with worse odds of achieving MCID for multiple PROs.

Comparison of a Self-Care Therapeutics Course Taught in the P1 vs the P2 Year.

Objective: The objective of this study was to compare student learning outcomes, behaviors, and attitudes in a non-prescription drug and self-care therapeutics course taught in the second professional (P2) year vs the first professional (P1) year at one pharmacy school. Methods: Mean performance of students by class year on case consultations and exam scores was compared. Focus groups with student volunteers and course teaching assistants (TAs) and one-on-one interviews with a subset of instructors were conducted by an outside educational evaluation specialist to capture perceptions of student learning behaviors and attitudes. Results: There was no difference in performance on graded case consultations (mean difference = 0.16, P = .74, 95% CI [-0.77 to 1.09]), mid-term examinations (mean difference = 0.53, P = .62, 95% CI [-1.59 to 2.65]), or final examinations (mean difference = 0.73, P = .57, 95% CI [-1.83 to 3.30]) between P1 and P2 students. P1 students reported being more consistent in completing pre-class readings and in feeling less distracted by other courses than did P2 students. Students, TAs, and instructors consistently spoke about advantages of the course in the P1 year (e.g., less stress and greater eagerness to learn and apply skills at work) and disadvantages in the P2 year (e.g., distraction from concurrent P2 integrated pharmacotherapeutics course and tension between real-world experience and constraints of grading rubric). Conclusion: P1 students, despite one year earlier in their curriculum, performed equally well as P2 students. All stakeholders agree that the advantages of teaching a self-care course on students' learning behaviors and attitudes in the P1 year outweigh disadvantages.

A Longitudinal, Qualitative Examination of Participant Intent-To-Change Statements that do not Match the Stated Learning Objectives of American Association of Neurological Surgeons-Sponsored Continuing Medical Education Activities.

OBJECTIVE: Continuing medical education (CME) programs are planned to provide medical professionals with the opportunity to stay abreast of new developments in their field. After each program, CME attendees are given the chance to evaluate the success of the activity in meeting its defined learning objectives. Over one-third of intent-to-change statements from CME evaluations do not match the stated learning objectives. We examined unmatched objectives and intent-to-change statements to determine their usefulness for future meeting planning. METHODS: This retrospective mixed-method content analysis used quantitative, deductive content analysis to compare intent-to-change statements and learning objectives from American Association of Neurological Surgeons-sponsored CME activities to explore unintended learning themes. RESULTS: We examined 85 CME activities with 424 meeting objectives and 1950 intent-to-change statements. Approximately 37% of intent-to-change statements were unrelated to any meeting objective, and 15% of learning objectives had no associated intent-to-change statements. Among unmatched objectives, those regarding more general subject matter often failed to be met with intent-to-change statements for multiple years, whereas those related to clinical practice were more likely to be unmatched for only 1 year. Some CME learning objectives are repeated for the same meeting for multiple years without change, although 22.6% of unmatched intent-to-change statements led to new learning objectives in subsequent years. CONCLUSIONS: An analysis of intent-to-change statements that are unmatched to meeting learning objectives is a potential avenue for understanding outcomes of CME activities. Our observations about general versus specific learning objective language may prove useful for CME planners' future educational event formulation.

The effect of ketorolac on posterior minimally invasive transforaminal lumbar interbody fusion: an interim analysis from a randomized, double-blinded, placebo-controlled trial.

BACKGROUND CONTEXT: Postoperative pain control following posterior lumbar fusion continues to be challenging and often requires high doses of opioids for pain relief. The use of ketorolac in spinal fusion is limited due to the risk of pseudarthrosis. However, recent literature suggests it may not affect fusion rates with short-term use and low doses. PURPOSE: We sought to demonstrate noninferiority regarding fusion rates in patients who received ketorolac after undergoing minimally invasive (MIS) posterior lumbar interbody fusion. Additionally, we sought to demonstrate ketorolac's opioid-sparing effect on analgesia in the immediate postoperative period. STUDY DESIGN/SETTING: This is a prospective, randomized, double-blinded, placebo-controlled trial. We are reporting our interim analysis. PATIENT SAMPLE: Adults with degenerative spinal conditions eligible to undergo a one to three-level MIS transforaminal lumbar interbody fusion (TLIF). OUTCOME MEASURES: Six-month and 1-year radiographic fusion as determined by Suk criteria, postoperative opioid consumption as measured by intravenous milligram morphine equivalent, length of stay, and drug-related complications. Self-reported and functional measures include validated visual analog scale, short-form 12, and Oswestry Disability Index. METHODS: A double-blinded, randomized placebo-controlled, noninferiority trial of patients undergoing 1- to 3-level MIS TLIF was performed with bone morphogenetic protein (BMP). Patients were randomized to receive a 48-hour scheduled treatment of either intravenous ketorolac (15 mg every 6 hours) or saline in addition to a standardized pain regimen. The primary outcome was fusion. Secondary outcomes included 48-hour and total postoperative opioid use demonstrated as milligram morphine equivalence, pain scores, length of stay (LOS), and quality-of-life outcomes. Univariate analyses were performed. The present study provides results from a planned interim analysis. RESULTS: Two hundred and forty-six patients were analyzed per protocol. Patient characteristics were comparable between the groups. There was no significant difference in 1-year fusion rates between the two treatments (p=.53). The difference in proportion of solid fusion between the ketorolac and placebo groups did not reach inferiority (p=.072, 95% confidence interval, -.07 to .21). There was a significant reduction in total/48-hour mean opioid consumption (p<.001) and LOS (p=.001) for the ketorolac group while demonstrating equivalent mean pain scores in 48 hours postoperative (p=.20). There was no significant difference in rates of perioperative complications. CONCLUSIONS: Short-term use of low-dose ketorolac in patients who have undergone MIS TLIF with BMP demonstrated noninferior fusion rates. Ketorolac safely demonstrated a significant reduction in postoperative opioid use and LOS while maintaining equivalent postoperative pain control.

Age as a Risk Factor for Complications Following Anterior Cervical Discectomy and Fusion: Analysis From the Michigan Spine Surgery Improvement Collaborative (MSSIC).

STUDY DESIGN: Retrospective analysis of prospectively collected registry data using multivariable analyses of imputed data. OBJECTIVE: We sought to demonstrate that age would not be associated with complications in patients undergoing anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Elderly patients (≥70 yrs) undergoing ACDF are considered a higher risk for complications. However, conclusive evidence is lacking. The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a quality improvement collaborative with 30 hospitals across Michigan. METHODS: The study included all patients who had 1 to 4 level ACDF (September 2015-August 2019) for 90-day complications. Major and minor complications were defined using a validated classification. Multiple imputations were used to generate complete covariate datasets. Generalized estimating equation model was used to identify associations with complications using the whole cohort and elderly subgroup analyses. Bonferroni correction was used. RESULTS: Nine thousand one hundred thirty five patients (11.1% ≥ 70 yrs and 88.9% <70 yrs) with 2266 complications were analyzed. Comparing elderly versus non-elderly, the elderly had a significantly higher rate of any complications (31.5% vs. 24.0%, P < 0.001) and major complications (14.1% vs. 7.0%, P < 0.001). On multivariable analysis, age was not independently associated with any complication. POD#0 ambulation and preop independent ambulation were independently associated with significantly decreased odds of any complication. In the elderly, independent preoperative ambulation was protective for any complication (odds ratio [OR] 0.53, 0.39-0.73 95% confidence interval [CI]), especially major complications (OR 0.41, 0.27-0.61 95% CI). CONCLUSION: Age was not an independent risk factor for complications in patients that underwent ACDF. In the elderly, independent preoperative ambulation was especially protective for major complications.Level of Evidence: 3.

Longitudinal Comparison of Continuing Medical Education Learning Objectives and Intent-to-Change Statements of Participants.

INTRODUCTION: Successful completion of continuing medical education (CME) activities is often required for ongoing physician board certification, licensure, and hospital privileges. CME activities are designed to address professional knowledge or practice gaps. The authors examined participants' "intent to change" after CME activities to evaluate whether CME activity content was suitably linked with the stated learning objectives. METHODS: The authors performed a retrospective mixed-methods thematic content analysis of written and electronic records from American Association of Neurological Surgeons-sponsored CME activities. Data from 2011 through 2016 were analyzed using a quantitative, deductive content analysis approach. Data were examined for each year separately as well as longitudinally over the six consecutive years. Intent-to-change data that did not align with meeting objectives were analyzed inductively using a qualitative content analysis approach to explore potential unintended learning themes. RESULTS: The authors examined 85 American Association of Neurological Surgeons CME activities (424 CME objectives). The objectives were compared with 1950 intent-to-change statements. Thematic patterns of recurrent intent-to-change statements that matched with CME objectives included topics of resident education, complication avoidance, clinical best practices and evidence, new innovations, and novel surgical techniques. Just over a third of intent-to-change statements (37.3%) were not related to any meeting objective. Approximately a quarter of these unmatched statements led to new learning objectives in subsequent years. CONCLUSIONS: An examination of CME learning objectives and participant intent-to-change statements provides information for examination of both meeting planner and learner attitudes for future CME activity planning.

Documenting Educational Impact in the Promotion Dossier with an Enhanced Curriculum Vitae.

ABSTRACT: Faculty with a career focus on education in the health professions often have difficulty representing their academic accomplishments for due consideration in promotion decisions at their respective institutions. This problem occurs because the traditional curriculum vitae (CV) format which is most often used tends to focus on peer-reviewed accomplishments easily presented in lists, such as grants and publications. In some institutions, an educator portfolio is required in place of or in addition to the CV. However, creating or reviewing such a narrative-oriented document takes large amounts of time-time that most faculty or reviewers do not have. Having to use an educator portfolio also calls out the educator as different from the traditional research faculty member. To address this problem, we propose the solution of an Enhanced CV. The Enhanced CV includes much of what is presented in an educator portfolio but in a format closer to the traditional CV. Unlike a traditional CV, the Enhanced CV includes categories inclusive of educational contributions (eg, teaching, mentoring, and course leadership) and includes brief descriptions and/or impact statements to clarify the significance of the listed accomplishments. The Enhanced CV has been adopted at two very different institutions, where evidence is accumulating regarding the viability of the Enhanced CV as a solution to educators' problem of presenting their accomplishments for promotions. The lessons learned from these institutions illustrate how the Enhanced CV can increase the ability of educators to present their accomplishments and advance in rank in their academic careers.

Conducting qualitative research through time: how might theory be useful in longitudinal qualitative research?

This paper explores the use of theory in longitudinal qualitative research, an approach to research which explores lived experiences as they unfold. The authors illustrate how the complexity of conducting qualitative research through time drives an understanding and use of theory that differs from other research approaches. Longitudinal qualitative research considers time as fluid, subjective, and unbounded-in contrast to the more common taken-for-granted understanding of time as fixed, objective, and linear. Furthermore, longitudinal qualitative research is predicated on a premise of trust in the context of enduring research relationships. Therefore, while subject-matter theories used to investigate topics of interest to health professions educators may be useful frameworks for other types of research, longitudinal qualitative research needs theories that accommodate the myriad of changes in lived experiences through time. The authors share their decade-long, longitudinal qualitative research story, highlighting their decision points and insights. In doing so, they foreground issues such as time as fluid as an important contribution to health professions education literature.

The Effect of Morbid Obesity on Complications, Readmission, and Patient-Reported Outcomes Following Minimally Invasive Transforaminal Lumbar Interbody Fusion: An Inverse Propensity Score Weighted Analysis.

STUDY DESIGN: Retrospective review of prospectively collected data at a single institution. OBJECTIVE: To compare perioperative and clinical outcomes in morbidly obese patients who underwent minimally invasive transforaminal lumbar interbody fusion (MiTLIF). SUMMARY OF BACKGROUND DATA: Obesity remains a serious public health concern. Obese patients who undergo lumbar fusion have historically thought to be at higher risk for complications and fare worse regarding quality-of-life outcomes. However, recent literature may demonstrate comparable risk and outcomes in obese patients. An increasing number of patients are categorized as morbidly obese (body mass index [BMI] ≥ 40 kg/m2). Perioperative and patient-reported outcomes (PROs) are lacking in this patient population. METHODS: The authors retrospectively reviewed a prospectively collected database of all morbidly obese and non-obese patients that underwent MiTLIF between 2015 and 2018 for degenerative conditions who had minimum 1-year follow-up for outcome assessment. An inverse propensity/probability of treatment weighting was utilized to create a synthetic weighted sample in which covariates were independent of obesity designation to adjust for imbalance between groups. Generalized estimating equations (GEE) was used to estimate the association of morbid obesity and complications and 1-year PROs. RESULTS: A total of 292 patients were analyzed with 234 non-obese patients and 58 morbidly obese patients. Multivariate analysis failed to demonstrate any association between morbid obesity and achieving minimal clinically important difference (MCID) for Oswestry disability index (ODI), visual analog scale (VAS), or short form-12 (SF-12) physical component score. However, morbid obesity was associated with significant decrease in odds of achieving MCID for SF-12 mental component score (P = 0.001). Increased surgery duration was significantly associated with morbid obesity (P = 0.001). Morbid obesity exhibited no statistically significant association with postoperative complications, readmission, pseudarthrosis, or adjacent segment disease (ASD). CONCLUSION: Morbidly obese patients who undergo MiTLIF can achieve meaningful clinical improvement comparable to nonobese patients. Morbid obesity was associated with longer surgical times but was not associated with postoperative complications, readmission, or ASD.Level of Evidence: 3.

Encapsulated Intracerebral Hematoma Presenting as Cerebral Abscess.

Chronic encapsulated intracerebral hematoma is a rare pathology which may present after spontaneous intracerebral hemorrhage (ICH) or radiosurgery for arteriovenous malformations. A 66-year-old male presented with recent diagnosis of cerebrovascular accident (CVA) status post-treatment with tissue plasminogen activator and mechanical thrombectomy. His recent diagnoses included infective endocarditis, septic bacteremia, meningitis, and aspiration pneumonia. One month following his CVA, the patient presented with delayed altered mental status. In the setting of increasing lethargy, computed tomography and magnetic resonance imaging of the brain were performed, which suggested a brain abscess, septic emboli, and ventriculitis. The patient was taken to surgery emergently. Intraoperatively, the patient was found to have an encapsulated mass of liquid consistency. Tissue pathology demonstrated ischemic cortical tissue and hemorrhage. Multiple cultures were negative for growth. The patient was ultimately determined to have an encapsulated intracerebral hematoma. Encapsulated intracerebral hematoma should be a part of the differential diagnosis when presented with a brain abscess in the setting of a patient who is at risk of ICH.

Medical student attitudes and actions that encourage teaching on surgery clerkships.

INTRODUCTION: Surgical faculty and residents are responsible for the clinical education of medical students during their core surgical clerkship, sub-internships, and clinical electives. Much attention has been paid to faculty development in teaching, as well as residents-as-teachers programs, to enhance student learning in the surgical environment. This focus to "train the trainers" has not addressed what medical students can do to take ownership of and improve their own learning, as partners in educational interactions. The purpose of this exploratory study was to investigate how medical students' attitudes and actions can enhance clinical teaching interactions during surgical rotations. METHODS: Previously collected data from a multiple case study that explored the learning environment at a single academic medical center was analyzed to understand the roles that students play in their learning. The data includes transcriptions from semi-structured interviews with four 4th year mediacl students, three general surgery residents, and four surgery attendings, and focus groups with two sets of 3rd year medical students. Two authors employed thematic analysis to code the data. RESULTS: Findings were organized into five themes: eagerness, humility, confidence, team player, and adaptability. Each attitudinal theme was associated with specific actions that students adopted to encourage teaching behaviors from resident and faculty surgeons during their surgery rotations. Participants discussed the importance of students "seek[ing] out opportunities" for learning (eagerness) and being "willing to be wrong" (humility). Student expressions of confidence in their knowledge and skills were marked by following "steps that I know," which signaled to teachers that they could be entrusted to participate in patient care. Students categorized as team players "follow[ed] up on information without specifically being told." Finally, students categorized as adaptable responded to "immediate feedback" by making "adjustments." CONCLUSIONS: Medical students are important stakeholders and contributors to teaching interactions and are likely to impact their own learning experience through the adoption of key attitudes and associated actions.

Age as a Predictor for Complications and Patient-reported Outcomes in Multilevel Transforaminal Lumbar Interbody Fusions: Analyses From the Michigan Spine Surgery Improvement Collaborative (MSSIC).

STUDY DESIGN: Retrospective review of a multi-institutional data registry. OBJECTIVE: The authors sought to determine the association between age and complications & patient-reported outcomes (PRO) in patients undergoing multilevel transforaminal interbody lumbar fusion (MTLIF). SUMMARY OF BACKGROUND DATA: Elderly patients undergoing MTLIF are considered high risk. However, data on complications and PRO are lacking. Additionally, safety of multilevel lumbar fusion in the elderly remains uncertain. METHODS: Patients ≥50-year-old who underwent MTLIF for degenerative lumbar spine conditions were analyzed. Ninety-day complications and PROs (baseline, 90-d, 1-y, 2-y) were queried using the MSSIC database. PROs were measured by back & leg visual analog scale (VAS), Patient-reported Outcomes Measurement Information System (PROMIS), EuroQol-5D (EQ-5D), and North American Spine Society (NASS) Patient Satisfaction Index. Univariate analyses were used to compare among elderly and complication cohorts. Generalized estimating equation (GEE) was used to identify predictors of complications and PROs. RESULTS: A total of 3120 patients analyzed with 961 (31%) ≥ 70-y-o and 2159 (69%) between 50-69. A higher proportion of elderly experienced postoperative complications (P = .003) including urinary retention (P = <.001) and urinary tract infection (P = .002). Multivariate analysis demonstrated that age was not independently associated with complications. Number of operative levels was associated with any (P = .001) and minor (P = .002) complication. Incurring a complication was independently associated with worse leg VAS and PROMIS scores (P = <.001). Preoperative independent ambulation was independently associated with improved PROMIS, and EQ5D (P = <.001). Within the elderly, preoperative independent ambulation and lower BMI were associated with improved PROMIS (P = <.001). Complications had no significant effect on PROs in the elderly. CONCLUSIONS: Age was not associated with complications nor predictive of functional outcomes in patients who underwent MTLIF. Age alone, therefore, may not be an appropriate surrogate for risk. Furthermore, baseline preoperative independent ambulation was associated with better clinical outcomes and should be considered during preoperative surgical counseling.Level of Evidence: 3.