An Analysis of Workplace-Based Assessments for Core Entrustable Professional Activities for Entering Residency: Does Type of Clinical Assessor Influence Level of Supervision Ratings?

PURPOSE: The authors describe use of the workplace-based assessment (WBA) coactivity scale according to entrustable professional activities (EPAs) and assessor type to examine how diverse assessors rate medical students using WBAs. METHOD: A WBA data collection system was launched at Oregon Health and Science University to visualize learner competency in various clinical settings to foster EPA assessment. WBA data from January 14 to June 18, 2021, for medical students (all years) were analyzed. The outcome variable was level of supervisor involvement in each EPA, and the independent variable was assessor type. RESULTS: A total of 7,809 WBAs were included. Most fourth-, third-, and second-year students were assessed by residents or fellows (755 [49.5%], 1,686 [48.5%], and 918 [49.9%], respectively) and first-year students by attending physicians (803 [83.0%]; P < .001). Attendings were least likely to use the highest rating of 4 (1 was available just in case; 2,148 [56.7%] vs 2,368 [67.7%] for residents; P < .001). Learners more commonly sought WBAs from attendings for EPA 2 (prioritize differential diagnosis), EPA 5 (document clinical encounter), EPA 6 (provide oral presentation), EPA 7 (form clinical questions and retrieve evidence-based medicine), and EPA 12 (perform general procedures of a physician). Residents and fellows were more likely to assess students on EPA 3 (recommend and interpret diagnostic and screening tests), EPA 4 (enter and discuss orders and prescriptions), EPA 8 (give and receive patient handover for transitions in care), EPA 9 (collaborate as member of interprofessional team), EPA 10 (recognize and manage patient in need of urgent care), and EPA 11 (obtain informed consent). CONCLUSIONS: Learners preferentially sought resident vs attending supervisors for different EPA assessments. Future research should investigate why learners seek different assessors more frequently for various EPAs and if assessor type variability in WBA levels holds true across institutions.

The Effects of Citric Acid Crosslinking on Fabrication and Characterization of Gelatin/Curcumin-Based Electrospun Antioxidant Nanofibers.

Nanofibers, produced through the novel method of electrospinning, have a high ratio of surface area to volume, which allows them to have different optical, electrical, thermal, and mechanical properties than macroscale materials. In this study, it was aimed to produce nanofibers with gelatin and curcumin. The effects of gelatin concentration and crosslinking with citric acid on the characteristics of electrospun nanofibers were studied. Gelatin film containing neither citric acid nor curcumin was used as control. Solutions were evaluated by solution conductivity, color analysis, and rheological properties. Obtained nanofibers were characterized by morphological analysis (SEM), antioxidant activity (AA), thermal properties (TGA, XRD, DSC), water vapor permeability (WVP), and Fourier transform infrared (FTIR) analysis. It was found that the functional groups of gelatin were not changed significantly but some degree of crosslinking was seen, as indicated by the changes in AA, crystallinity, etc. Improvement in antioxidant activities was seen, which was the highest for gelatin and curcumin films (32%). The highest melting temperature (78 °C) and WVP (2.365 × 10-10 gm-1 s-1 Pa-1) was seen for gelatin and curcumin films crosslinked with 0.5% citric acid. Gelatin with curcumin films crosslinked with 1% citric acid showed the lowest crystallinity (1.56%). It was concluded that even though citric acid might not prove to be a stable crosslinking agent for the protein (gelatin), it contributed to the antioxidant nature of the films, along with curcumin. These films are promising candidates to be applied on cut fruits, to reduce water loss and oxidation and hence extend their shelf lives.

Automatic Clustering and Classification of Coffee Leaf Diseases Based on an Extended Kernel Density Estimation Approach.

The current methods of classifying plant disease images are mainly affected by the training phase and the characteristics of the target dataset. Collecting plant samples during different leaf life cycle infection stages is time-consuming. However, these samples may have multiple symptoms that share the same features but with different densities. The manual labelling of such samples demands exhaustive labour work that may contain errors and corrupt the training phase. Furthermore, the labelling and the annotation consider the dominant disease and neglect the minor disease, leading to misclassification. This paper proposes a fully automated leaf disease diagnosis framework that extracts the region of interest based on a modified colour process, according to which syndrome is self-clustered using an extended Gaussian kernel density estimation and the probability of the nearest shared neighbourhood. Each group of symptoms is presented to the classifier independently. The objective is to cluster symptoms using a nonparametric method, decrease the classification error, and reduce the need for a large-scale dataset to train the classifier. To evaluate the efficiency of the proposed framework, coffee leaf datasets were selected to assess the framework performance due to a wide variety of feature demonstrations at different levels of infections. Several kernels with their appropriate bandwidth selector were compared. The best probabilities were achieved by the proposed extended Gaussian kernel, which connects the neighbouring lesions in one symptom cluster, where there is no need for any influencing set that guides toward the correct cluster. Clusters are presented with an equal priority to a ResNet50 classifier, so misclassification is reduced with an accuracy of up to 98%.

Referral Order Placement Decreases Time to Transfer to Adult Congenital Heart Disease Care.

Pediatric patients with moderate and great complexity congenital heart disease (CHD) may benefit from coordinated transfer to adult congenital heart disease (ACHD) centers to reduce the risk of complications; however, there are a variety of transfer practices. We examined the impact of referral order placement at the last pediatric cardiology visit on time to transfer to an ACHD center. We analyzed data collected from pediatric patients with moderate and great complexity CHD who were eligible to transfer to our tertiary center's accredited ACHD center. We examined transfer outcomes and time-to-transfer between those with a referral order placed at the last pediatric cardiology visit and those without using Cox proportional hazards modeling. The sample (n = 65) was 44.6% female and mean age at study start was 19.5 years (± 2.2). Referral orders were placed for 32.3% of patients at the last pediatric cardiology visit. Those who had a referral order placed at the last visit had significantly higher number of successful transfers to the ACHD center compared to those who did not (95% vs 25%, p < 0.001). In a Cox regression model, placement of a referral order at the last pediatric cardiology visit was associated significantly with a sooner time to transfer (HR 6.0; 95% CI 2.2-16.2, p > 0.001), adjusting for age, sex, complexity, living location, and pediatric cardiology visit location. Placement of a referral order at the last pediatric cardiology visit may improve transfer occurrence and time to transfer to accredited ACHD centers.

Impact of Students' Scheduling Choice on Clerkship Examination Score Performance in a Time-Varying Competency-Based Curriculum.

PURPOSE: Standardized end-of-clerkship examinations typically occur on the last day of the clerkship. However, recent trends toward time-varying competency-based medical education have offered students more test scheduling flexibility, creating an opportunity to study the impact of student-selected examination timing. METHOD: Starting with the graduating class of 2018, students took the required standardized end-of-core clerkship examinations at any available time they chose during their clinical years. Before this change, these examinations were administered to all students on the last day of the clerkship. Students' examination dates relative to clerkship completion were analyzed between 2017 and 2020 (inclusive of before and after flexible exam timing) to assess the impact that student-selected exam timing had on test performance on National Board of Medical Examiners shelf clinical science examinations for required core clerkships. RESULTS: Data on 146 medical students in 2017 (fixed exam timing) and 466 medical students between 2018 and 2020 (flexible exam timing) were included. Among students offered flexible exam timing, between 2.7% (internal medicine) and 14.6% (psychiatry) took their exam before actually taking clerkship, while between 22.7% (psychiatry) and 40.0% (surgery) took their exam more than 90 days after the clerkship ended. Exam scores were statistically higher for those who took the exam at a time of their choosing compared with those who were required to take it at the end of individual rotations and when the exam scores were combined (fixed exam timing mean = 73.9, standard deviation [SD] = 7.8; flexible exam timing mean = 77.4, SD = 6.0, P < .001). The percent of students with passing scores was statistically higher in internal medicine, pediatrics, and psychiatry. CONCLUSIONS: Self-selection of shelf exam timing appears to increase shelf exam scores. As more medical schools transition to competency-based medical education, providing scheduling flexibility appears not to negatively affect student achievement.

"They were an advocate for me": A Qualitative Study Exploring Medical Student Longitudinal Relationships and Patient Well-Being.

BACKGROUND: Patient navigators, community health workers, and care management teams improve patient experience and health outcomes. Medical student involvement in these roles is limited. Evaluation of these programs focuses on the student experience with less attention to patient participants. OBJECTIVES: We sought (1) to understand the experience of being a participant in a medical education program; (2) to explore the patient-medical student relationship; and (3) to describe the impact of this relationship on patient health and well-being. DESIGN: This was a qualitative study that utilized in-depth semi-structured interviews. PARTICIPANTS: Participants were selected based on enrollment in a preceptorship program at an urban academic medical center between 2017 and 2020. Participants worked with a medical student during an 18-month period in which the medical student was embedded in a primary care medical home, serving as a health systems navigator for 1-2 medically and socially complex patients. APPROACH: Nine participants completed 1-h compensated phone interviews. This study was deemed IRB exempt. KEY RESULTS: Three themes and eight subthemes were identified, including Navigators Were Key to Accessing the System, Interpersonal Partnerships Improved Health, and Fulfillment in Teaching of Lived Experience. Navigators eased the burden of chronic illness by being a point of contact in the health system, which improved participants' overall experience. Participants also described the relationship as therapeutic, citing improvement and stability in both mental and physical health. Lastly, participants found meaning in chronic illness by teaching their students empathy. CONCLUSIONS: Longitudinal patient-medical student relationships may provide stability and health benefits. These partnerships have the possibility of adding value to patients' healthcare experiences. This study complements current literature highlighting the value of these relationships for pre-clinical medical students. As such, additional opportunities for and additional research regarding the value of longitudinal patient connection should be incorporated in undergraduate medical education.

Leveraging existing education innovations to establish a community of practice to promote medical education scholar development.

PROBLEM: While some academic health centers have organizational structures to support educational scholarship, such as Medical Education Research Units (MERU), many education scholars may lack access to such institutional resources to support their research agenda and professional growth. APPROACH: In 2014, as part of an externally funded education grant, three faculty educators established a unique education data management system Research & Evaluation Data for Educational Improvement (REDEI). Lacking an institutional MERU, they established an educational research community of practice (CoP) using REDEI as the research dataset. The senior faculty member's effort to facilitate the group is funded by the Dean's Office. OUTCOMES: The CoP meets every 2 weeks to generate research ideas, discuss analytic approach and strategy, review analyses designed to address or explore a research question, and plans for manuscript development. Our CoP has grown from 3 to 18 members representing faculty educators, administrators, and staff across many departments in the School of Medicine. As of 2021, the REDEI system contains performance data on 1,246 students across all years of undergraduate medical education. To date, we have published 11 peer-reviewed educational research manuscripts. Five learners have served as coauthors (three medical students and two residents), three of whom were first authors. Eleven additional papers are in process. This community of practice supports productivity, provides mentorship, overcomes barriers, and is flexible enough for people to join when they can or when an area of interest is actively under development. NEXT STEPS: We are working on educational interdisciplinary research grant submission and creating collaborations with other institutions. Our focus remains on honing skills in grantsmanship, identification of impactful research questions, application of rigorous methods and instrumentation to address them, and refining process of budget development, timelines, and other planning strategies.

Emergency Department Visits Increase in Transition-Age Patients Empaneled in a Primary Care Network at a Major Academic Medical Center.

PURPOSE: The aim of this study is to identify important predictors of emergency department (ED) utilization within a population of transition-aged patients empaneled within a primary care network, particularly with high-risk chronic conditions of childhood (HRC). METHODS: We analyzed cross-sectional data of patients aged 12-29 within a primary care network (n = 19,989). We used negative binomial regression modeling to identify important predictors of ED visits in the last year. RESULTS: Nearly 10% (n = 1,975) of the patients had one or more identified HRCs. Our final adjusted model showed that, among others, age 18-23 years (incidence rate ratio [IRR] 1.94, 95% confidence interval [CI] 1.74-2.15), presence of a high-risk condition (IRR 1.74, 95% CI 1.54-1.96]), transfer between two primary care providers in system (IRR 1.43, 95% CI 1.18-1.72), presence of care manager (IRR 2.19, 95% CI 1.68-1.72), and public insurance status (IRR 2.85, 95% CI 2.62-3.10) were all independent predictors of higher ED utilization. Conditions associated with a high incidence of ED utilization included sickle cell anemia (IRR 5.41, 95% CI 2.78-10.54), history of transplant (IRR 2.53, 95% CI 1.11-5.80), type 1 diabetes (IRR 2.12, 95% CI 1.42-3.15), and seizure disorder (IRR 2.01, 95% CI 1.61-2.51). We estimated that for each added chronic condition, the IRR increased 1.23-fold (95% CI 1.00-1.51). CONCLUSIONS: Our results demonstrate significantly greater use of high-cost healthcare services for patients in the 18- to 23-year age group and for patients with multiple complex medical conditions. These findings prompt a call for systems-wide processes to improve the pediatric-to-adult transition process.

A randomized controlled trial of an online health tool about Down syndrome.

PURPOSE: We sought to determine if a novel online health tool, called Down Syndrome Clinic to You (DSC2U), could improve adherence to national Down syndrome (DS) guidelines. We also sought to determine if primary care providers (PCPs) and caregivers are satisfied with this personalized online health tool. METHODS: In a national, randomized controlled trial of 230 caregivers who had children or dependents with DS without access to a DS specialist, 117 were randomized to receive DSC2U and 113 to receive usual care. The primary outcome was adherence to five health evaluations indicated by national guidelines for DS. DSC2U is completed electronically, in all mobile settings, by caregivers at home. The outputs-personalized checklists-are used during annual wellness visits with the patient's PCP. RESULTS: A total of 213 participants completed a 7-month follow-up evaluation. In the intention-to-treat analysis, the intervention group had a 1.6-fold increase in the number of indicated evaluations that were recommended by the primary care provider or completed compared with controls. Both caregivers and PCPs reported high levels of satisfaction with DSC2U. CONCLUSIONS: DSC2U improved adherence to the national DS health-care guidelines with a novel modality that was highly valued by both caregivers and PCPs.

Implementing a Real-time Workplace-based Assessment Data Collection System Across an Entire Medical School's Clinical Learning Environment.

This article was migrated. The article was marked as recommended. Background & Objectives: Workplace-based assessments (WBAs) are a vital aspect of medical student competency assessment for the core Entrustable Professional Activities (EPAs), but pose significant challenges since assessment must occur in real-time during the routine care of patients. We developed an online WBA system designed to overcome these challenges, and implemented it across an entire undergraduate medical education program to address the need for EPA competency assessment. We describe the development and implementation process, and present initial results from our inaugural medical student cohort. Methods: The WBA tool was designed to be student-driven, easy to use, and minimally disruptive to clinical care. Students trigger assessments by choosing the desired EPA to be assessed within a custom-built Qualtrics XM survey application. Their clinical assessor is prompted to select their level of involvement in the activity using the modified Ottawa co-activity scale and provide brief written feedback. Direct verbal feedback at time of discussion is encouraged. Results: 3,568 WBAs were completed. The mean number of assessments per student for all EPAs combined was 24.27 with a range of 1-103. All students completed at least one WBA. Over the course of 12 months, the mean number of EPAs recorded per student in this cohort was lowest for EPA 10 (Recognizing a Patient Requiring Urgent or Emergent Care and Initiate Evaluation and Management) (mean=0.36; range 0-4; n=53) and was highest for EPA 6 (Provide an Oral Presentation for a Clinical Encounter) (mean=5.46; range 1-17; n=803). The mean number of minutes it took to complete the assessments was 2.7 minutes with a standard deviation of 1.2 minutes (n=2,803). Conclusion: An electronic application-based survey collecting real-time WBAs to assess progress toward attaining competence in EPA performance resulted in increased assessment data within a medical school cohort.

Early longitudinal experiences increase medical student self-efficacy.

This article was migrated. The article was marked as recommended. Background: The purpose of this study was to investigate the impact of early longitudinal preceptorship experiences on the evolution of general self-efficacy and patient-centeredness self-efficacy through medical school. Methods:Validated surveys for general self-efficacy and patient-centeredness self-efficacy were administered in an allopathic medical school at three timepoints. These data were stratified by traditional and longitudinal preceptorship groups and analyzed using Generalized Estimating Equations. Qualitative analysis of narrative medicine essays by the same cohort during their preceptorship experiences was also performed. Results: While general self-efficacy remained largely unchanged over time, patient-centeredness self-efficacy measures increased throughout medical school in the whole cohort (N=157). The longitudinal preceptorship group had higher gains in patient-centeredness self-efficacy, especially in the domain of exploring patient perspectives (p<0.05). The qualitative analysis of narrative medicine essays showed those in longitudinal preceptorships were more likely to discuss health care systems issues, consider psychosocial factors, and perceive themselves as active members of the care team. Discussion:Our study indicates greater patient-centeredness attitudes over time among students who have early longitudinal experiences, perhaps due to the self-efficacy building nature of these experiences. Our research suggest that medical school programs should consider incorporating opportunities for early longitudinal clinical experiences for their students.

Impact of polycystic ovary syndrome on eating behavior, depression and health related quality of life: A cross-sectional study in Riyadh.

BACKGROUND & OBJECTIVES: Polycystic ovary syndrome (PCOS) is the most common endocrinal disorder, and the greatest cause of infertility in women. Despite availability of individual data on impact of multiple endocrinal, reproductive and even metabolic factors in PCOS individuals, the data on the co-existence of BED and depression in PCOS patients with its relationship on the quality of life in Saudi Arabian females is not found. Hence this study is aimed to elucidate the implication of PCOS on eating behaviour, induction of depression and general health quality in Saudi Arabian population of Riyadh. MATERIALS AND METHODS: This is a cross-sectional study carried out in multiple health facilities of Riyadh from January to March 2019. The study samples (494) were recruited by convenience sampling and administered validated questionnaire by trained research participants. The data obtained was analysed by binary logistic regression using SPSS-IBM 25. RESULTS: Of the total 494 women participated in the study, 23.48% (116) were PCOS individuals. The odds of developing abnormal health related quality of (HRQ) in patients with PCOS was significantly (P = 0.000, OR = 3.472) high when compared to non-PCOS participants. The odds of showing high binge eating disorder (BED, P = 0.007, OR = 2.856) and depression (P = 0.000, OR = 2.497) scores in PCOS participants were significantly more than patients who were not having PCOS. Out of the three parameters studied, abnormal health related quality of life possessed a higher influence of PCOS compared to depression and abnormal eating behavior. INTERPRETATION & CONCLUSION: In conclusion, the present study shows that women with PCOS are at a significant risk for depressive disorders, disorganized eating behavior and impaired quality of life. Therefore, necessary care and screening is required to minimize the impact of PCOS on already burdened individuals.

Review of the State of the Art of Deep Learning for Plant Diseases: A Broad Analysis and Discussion.

Deep learning (DL) represents the golden era in the machine learning (ML) domain, and it has gradually become the leading approach in many fields. It is currently playing a vital role in the early detection and classification of plant diseases. The use of ML techniques in this field is viewed as having brought considerable improvement in cultivation productivity sectors, particularly with the recent emergence of DL, which seems to have increased accuracy levels. Recently, many DL architectures have been implemented accompanying visualisation techniques that are essential for determining symptoms and classifying plant diseases. This review investigates and analyses the most recent methods, developed over three years leading up to 2020, for training, augmentation, feature fusion and extraction, recognising and counting crops, and detecting plant diseases, including how these methods can be harnessed to feed deep classifiers and their effects on classifier accuracy.

Student-Led Adaptation of Improvement Science Learning During the COVID-19 Pandemic.

INTRODUCTION: In response to the COVID-19 pandemic and the restriction of students participating in face-to-face instruction, two medical students rapidly adapted a preclinical curriculum that virtually teaches improvement science and equips learners with the knowledge to address patient needs. METHODS: Eight first-year medical students participating in a longitudinal patient navigation and health systems science program completed 15 interactive video sessions. After learning about the Model for Improvement and various quality improvement tools, students worked in teams of four to conduct several plan-do-study-act cycles. Postsession surveys captured student satisfaction, session feedback, and reflections about conducting improvement work. Two medical students then applied conventional content analysis to identify themes to describe the data. RESULTS: Student projects focused on addressing patients' health care and social resource needs through telephone and electronic interactions. Five themes were identified in the survey results: (1) learning by doing in the dynamic nature of improvement work; (2) enjoyment of virtual team-based learning; (3) project relevance to COVID-19; (4) utility of quality improvement tools; and (5) continuous curriculum improvement with student feedback. CONCLUSIONS: In this student-led endeavor, we implemented a virtual improvement curriculum where first-year medical students apply improvement science knowledge to patient needs during the COVID-19 pandemic. Results demonstrate the feasibility of teaching improvement in a virtual setting where learning is action-based with project work being relevant to health care priorities. Our work provides a framework for others to continue teaching this integral component of medical education.

COVID-19 and Telehealth: Prevention of Exposure in a Medically Complex Patient With a Mild Presentation.

The novel coronavirus disease-2019 (COVID-19) was declared a pandemic by the World Health Organization on March 11, 2020. We discuss a less common presentation of COVID-19 in a patient where the use of telemedicine technology prevented the exposure of the healthcare team in an academic general pediatrics clinic. A medically complex 20-year-old male presented via virtual visit for unilateral eye redness and discharge. He received topical ophthalmic antibiotics for presumed acute bacterial conjunctivitis and was counseled on return precautions. Three days later, the patient developed shortness of breath, fever to 102.6°F, and chest pain. COVID-19 testing returned positive. Conjunctivitis is a presenting symptom in 32% of COVID-19 cases. Current evidence suggests that these patients may transmit their illness at the time of presentation. Using telehealth, we avoided exposure to a COVID-19-positive patient who would not have met criteria for testing or droplet precautions. Telehealth allows providers to triage patients, identifying those who need to be seen in person, thereby minimizing exposure. Transitioning toward virtual practice, particularly during a pandemic, prepares for the possibility of healthcare workers being quarantined but still able to provide care and minimizes exposure to asymptomatic patients or those with atypical symptoms.