Facilitating the transition to residency: A resident-as-coach pilot program.

BACKGROUND: The transition from medical school to residency is a critical developmental phase; coaching may help students prepare for this role transition. AIMS: We explored whether near-peer coaching could improve a specific workplace skill prior to residency. METHODS: A resident-as-coach program was piloted for the medicine sub-internship, an advanced acting internship rotation. Between March and June 2021, 26 students were assigned a resident coach (n = 16). Resident coaches completed one training session, and student-coach dyads met for one coaching session on 'pre-rounding'- gathering patient data before rounds. The program was evaluated through surveys and focus groups. RESULTS: 20/26 students and 14/16 residents completed the survey. 19/20 students identified a pre-rounding challenge and reported increased pre-rounding efficiency; all committed to one actionable step for improvement. All 16 residents felt their coaching skills improved. In focus groups, students valued the program's focus on honing a relevant skill in a safe, near-peer setting. Residents expressed their intent to incorporate coaching into their future work. CONCLUSIONS: A resident-as-coach model can be effective in preparing students for residency, while concurrently building residents' coaching skills.

Coproducing clinical curricula in undergraduate medical education: Student and faculty experiences in longitudinal integrated clerkships.

PURPOSE: Educational coproduction, in which learners partner with educators to create and improve their educational experiences, can facilitate student-centered medical education. Empirical descriptions of best practices for involving students in clinical curricular coproduction are needed. We aimed to understand faculty and student perspectives on methods, perceived benefits, and common barriers and solutions to clinical curricular coproduction. METHODS: We conducted an international mixed-methods study of clinical curricular coproduction in undergraduate medical education and longitudinal integrated clerkships specifically. Faculty and students identified through an international listserv received an electronic survey to identify methods, benefits, and challenges of clinical curricular coproduction. We conducted semi-structured interviews with a subset of survey participants. We present descriptive statistics for survey data and themes derived from inductive qualitative analysis. RESULTS: Two hundred forty-seven individuals (104 faculty; 143 students) representing 52 medical schools in eight countries completed the survey. Methods for clinical curricular coproduction ranged from informal, low-intensity learner involvement (e.g. verbal feedback) to formal, high-intensity learner involvement (e.g. committee membership). Perceived benefits included improvements in student-faculty relationships, program culture and design, and student development. Structural issues (e.g. scheduling) were the most common perceived barriers. CONCLUSIONS: Clinical curricular coproduction among faculty and students is perceived to enhance collaboration, enable curriculum change, and support students' professional development. Our study offers empirical guidance for involving students as partners in clinical curricular coproduction.

Will it Hurt? The Intrauterine Device Insertion Experience and Long-Term Acceptability Among Adolescents and Young Women.

STUDY OBJECTIVE: To examine how the intrauterine device (IUD) insertion experience affects long-term IUD acceptability among adolescents. DESIGN: Text to Web survey study. SETTING: Boston Children's Hospital and Cambridge Health Alliance in Massachusetts. PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Nulliparous adolescents aged 13-21 years who received an IUD or etonogestrel implant between January 2012 and May 2018. RESULTS: We received survey responses from 95 adolescents (n = 46 IUD; n = 49 implant; response rate = 95/1098 (9%)). Mean current age (20.8 years) and time since device insertion (2.4 years) were similar between groups. Although a large proportion of both groups (64%) experienced moderate to severe preprocedural anxiety, IUD users expected more insertional pain compared with implant users (55.6 vs 39.6; P = .01). Compared with implant users, more IUD users experienced moderate to severe insertional pain (80% vs 18%; P < .0001), recalled that the procedure hurt more than expected (52% vs 4%; P < .0001), and endorsed lower rates of pain management satisfaction (72.4 vs 85.6; P = .04). Most respondents would recommend their method to a friend (75%) or consider getting the same device in the future (63%). When explicitly asked, more IUD users reported that dislike of the insertion procedure might or would probably prevent them from getting the same device in the future (41% vs 14%; P = .005). CONCLUSION: Compared with implant users, IUD users reported more negative insertion experiences, although preprocedural anxiety was prevalent in both groups. Dislike of the insertion experience might negatively affect adolescents' willingness to continue using an IUD in the future. Findings should encourage multimodal interventions to holistically improve the IUD insertion experience.

Fostering Student-Faculty Partnerships for Continuous Curricular Improvement in Undergraduate Medical Education.

PROBLEM: A number of medical schools have used curricular reform as an opportunity to formalize student involvement in medical education, but there are few published assessments of these programs. Formal evaluation of a program's acceptability and use is essential for determining its potential for sustainability and generalizability. APPROACH: Harvard Medical School's Education Representatives (Ed Reps) program was created in 2015 to launch alongside a new curriculum. The program aimed to foster partnerships between faculty and students for continuous and real-time curricular improvement. Ed Reps, course directors, and core faculty met regularly to convey bidirectional feedback to optimize the learning environment in real time. OUTCOMES: A survey to assess the program's impact was sent to students and faculty. The majority of students (202/222; 91.0%) reported Ed Reps had a positive impact on the curriculum. Among faculty, 35/37 (94.6%) reported making changes to their courses as a result of Ed Reps feedback, and 34/37 (91.9%) agreed the program had a positive impact on the learning environment. Qualitative feedback from students and faculty demonstrated a change in school culture, reflecting the primary goals of partnership and continuous quality improvement (CQI). NEXT STEPS: This student-faculty partnership demonstrated high rates of awareness, use, and satisfaction among faculty and students, suggesting its potential for local sustainability and implementation at other schools seeking to formalize student engagement in CQI. Next steps include ensuring the feedback provided is representative of the student body and identifying new areas for student CQI input as the curriculum becomes more established.

Cell-type Dependent Alzheimer's Disease Phenotypes: Probing the Biology of Selective Neuronal Vulnerability.

Alzheimer's disease (AD) induces memory and cognitive impairment in the absence of motor and sensory deficits during its early and middle course. A major unresolved question is the basis for this selective neuronal vulnerability. Aß, which plays a central role in AD pathogenesis, is generated throughout the brain, yet some regions outside of the limbic and cerebral cortices are relatively spared from Aß plaque deposition and synapse loss. Here, we examine neurons derived from iPSCs of patients harboring an amyloid precursor protein mutation to quantify AD-relevant phenotypes following directed differentiation to rostral fates of the brain (vulnerable) and caudal fates (relatively spared) in AD. We find that both the generation of Aß and the responsiveness of TAU to Aß are affected by neuronal cell type, with rostral neurons being more sensitive than caudal neurons. Thus, cell-autonomous factors may in part dictate the pattern of selective regional vulnerability in human neurons in AD.

Genomic DISC1 Disruption in hiPSCs Alters Wnt Signaling and Neural Cell Fate.

Genetic and clinical association studies have identified disrupted in schizophrenia 1 (DISC1) as a candidate risk gene for major mental illness. DISC1 is interrupted by a balanced chr(1;11) translocation in a Scottish family in which the translocation predisposes to psychiatric disorders. We investigate the consequences of DISC1 interruption in human neural cells using TALENs or CRISPR-Cas9 to target the DISC1 locus. We show that disruption of DISC1 near the site of the translocation results in decreased DISC1 protein levels because of nonsense-mediated decay of long splice variants. This results in an increased level of canonical Wnt signaling in neural progenitor cells and altered expression of fate markers such as Foxg1 and Tbr2. These gene expression changes are rescued by antagonizing Wnt signaling in a critical developmental window, supporting the hypothesis that DISC1-dependent suppression of basal Wnt signaling influences the distribution of cell types generated during cortical development.

Comparison and optimization of hiPSC forebrain cortical differentiation protocols.

Several protocols have been developed for human induced pluripotent stem cell neuronal differentiation. We compare several methods for forebrain cortical neuronal differentiation by assessing cell morphology, immunostaining and gene expression. We evaluate embryoid aggregate vs. monolayer with dual SMAD inhibition differentiation protocols, manual vs. AggreWell aggregate formation, plating substrates, neural progenitor cell (NPC) isolation methods, NPC maintenance and expansion, and astrocyte co-culture. The embryoid aggregate protocol, using a Matrigel substrate, consistently generates a high yield and purity of neurons. NPC isolation by manual selection, enzymatic rosette selection, or FACS all are efficient, but exhibit some differences in resulting cell populations. Expansion of NPCs as neural aggregates yields higher cell purity than expansion in a monolayer. Finally, co-culture of iPSC-derived neurons with astrocytes increases neuronal maturity by day 40. This study directly compares commonly employed methods for neuronal differentiation of iPSCs, and can be used as a resource for choosing between various differentiation protocols.

The familial Alzheimer's disease APPV717I mutation alters APP processing and Tau expression in iPSC-derived neurons.

Alzheimer's disease (AD) is a complex neurodegenerative disorder characterized by extracellular plaques containing amyloid ß (Aß)-protein and intracellular tangles containing hyperphosphorylated Tau protein. Here, we describe the generation of inducible pluripotent stem cell lines from patients harboring the London familial AD (fAD) amyloid precursor protein (APP) mutation (V717I). We examine AD-relevant phenotypes following directed differentiation to forebrain neuronal fates vulnerable in AD. We observe that over differentiation time to mature neuronal fates, APP expression and levels of Aß increase dramatically. In both immature and mature neuronal fates, the APPV717I mutation affects both ß- and γ-secretase cleavage of APP. Although the mutation lies near the γ-secretase cleavage site in the transmembrane domain of APP, we find that ß-secretase cleavage of APP is elevated leading to generation of increased levels of both APPsß and Aß. Furthermore, we find that this mutation alters the initial cleavage site of γ-secretase, resulting in an increased generation of both Aß42 and Aß38. In addition to altered APP processing, an increase in levels of total and phosphorylated Tau is observed in neurons with the APPV717I mutation. We show that treatment with Aß-specific antibodies early in culture reverses the phenotype of increased total Tau levels, implicating altered Aß production in fAD neurons in this phenotype. These studies use human neurons to reveal previously unrecognized effects of the most common fAD APP mutation and provide a model system for testing therapeutic strategies in the cell types most relevant to disease processes.