An instant messaging mobile phone application for promoting HIV pre-exposure prophylaxis uptake among Chinese gay, bisexual and other men who have sex with men: A mixed methods feasibility and piloting randomized controlled trial study.

BACKGROUND: Mobile health (mHealth) is a promising intervention mode for HIV prevention, but little is known about its feasibility and effects in promoting pre-exposure prophylaxis (PrEP) uptake among Chinese gay, bisexual and other men who have sex with men (GBMSM). METHODS: We evaluated an instant messaging application using a WeChat-based mini-app to promote PrEP uptake among GBMSM via a mixed-methods design that includes a 12-week, two-arm randomized controlled pilot trial and in-depth progress interviews in Guangzhou, China. Primary outcomes include the number of PrEP initiations, individual-level psychosocial variables related to PrEP initiation, and usability of the PrEP mini-app. RESULTS: Between November 2020 and April 2021, 70 GBMSM were successfully enrolled and randomized into two arms at 2:1 ratio (46 to the intervention arm, 24 to the control arm). By the end of 12-week follow-up, 22 (31.4%) participants completed the initial consultation and lab tests for PrEP, and 13 (18.6%) filled their initial PrEP prescription. We observed modest but non-significant improvements in participants' intention to use PrEP, actual PrEP initiation, PrEP-related self-efficacy, stigma, and attitudes over 12 weeks when comparing the mini-app and the control arms. Qualitative interviews revealed the key barriers to PrEP uptake include anticipated stigma and discrimination in clinical settings, burden of PrEP care, and limited operating hours of the PrEP clinic. In-person clinic navigation support was highly valued. CONCLUSIONS: This pilot trial of a mobile phone-based PrEP mini-app demonstrated feasibility and identified limitations in facilitating PrEP uptake among Chinese GBMSM. Future improvements may include diversifying the content presentation in engaging media formats, adding user engagement features, and providing off-line in-clinic navigation support during initial PrEP visit. More efforts are needed to understand optimal strategies to identify and implement alternative PrEP provision models especially in highly stigmatized settings with diverse needs. TRIAL REGISTRATION: Trial registration: The study was prospectively registered on clinicaltrials.gov (NCT04426656) on 11 June, 2020.

Teacher Immediacy for Effective Teaching in Medical Education.

This article introduces the concept of "teacher immediacy," defined as the teacher's communication behaviors that reduce the psychological distance between teacher and students. Though well investigated and recognized in the area of instructional communication, this concept is still new to the field of medical education. The authors first describe the origin, definition, and indicators of teacher immediacy, and then present empirical research findings on teacher immediacy's positive associations with effective teaching. The authors also introduce findings of teacher immediacy research related to the online learning environment. They recommend medical educators adopt the term "teacher immediacy" and explore it in practice.

Co-creation using crowdsourcing to promote PrEP adherence in China: study protocol for a stepped-wedge randomized controlled trial.

BACKGROUND: Adherent pre-exposure prophylaxis (PrEP) uptake can prevent HIV infections. Despite the high HIV incidence, Chinese key populations have low PrEP uptake and adherence. New interventions are needed to increase PrEP adherence among key populations in China. Co-creation methods are helpful to solicit ideas from the community to solve public health problems. The study protocol aims to describe the design of a stepped-wedge trial and to evaluate the efficacy of co-created interventions to facilitate PrEP adherence among key populations in China. METHODS: The study will develop intervention packages to facilitate PrEP adherence among Chinese key populations using co-creation methods. The study will then evaluate the efficacy of the co-created intervention packages using a stepped-wedge randomized controlled trial. This four-phased closed cohort stepped-wedge design will have four clusters. Each cluster will start intervention at three-month intervals. Seven hundred participants who initiated PrEP will be recruited. Participants will be randomized to the clusters using block randomization. The intervention condition includes receiving co-created interventions in addition to standard of care. The control condition is the standard of care that includes routine clinical assessment every 3 months. All participants will also receive an online follow-up survey every 3 months to record medication adherence and will be encouraged to use a WeChat mini-app for sexual and mental health education throughout the study. The primary outcomes are PrEP adherence and retention in PrEP care throughout the study period. We will examine a hypothesis that a co-created intervention can facilitate PrEP adherence. Generalized linear mixed models will be used for the primary outcome analysis. DISCUSSION: Developing PrEP adherence interventions in China faces barriers including suboptimal PrEP uptake among key populations, the lack of effective PrEP service delivery models, and insufficient community engagement in PrEP initiatives. Our study design addresses these obstacles by using co-creation to generate social media-based intervention materials and embedding the study design in the local healthcare system. The study outcomes may have implications for policy and intervention practices among CBOs and the medical system to facilitate PrEP adherence among key populations. TRIAL REGISTRATION: The study is registered in Clinical Trial databases in China (ChiCTR2100048981, July 19, 2021) and the US (NCT04754139, February 11, 2021).

Community-engaged mHealth intervention to increase uptake of HIV pre-exposure prophylaxis (PrEP) among gay, bisexual and other men who have sex with men in China: study protocol for a pilot randomised controlled trial.

INTRODUCTION: The large number of key populations in China who would benefit from HIV pre-exposure prophylaxis (PrEP) in the context of limited health system capacity and public awareness will pose challenges for timely PrEP scale-up, suggesting an urgent need for innovative and accessible interventions. This study aims to develop and pilot test a theory-informed, tailored mobile phone intervention that was codeveloped by young gay men, HIV clinicians and public health researchers to increase engagement in PrEP education and initiation among Chinese gay, bisexual and other men who have sex with men (GBMSM), who bear a disproportionate burden of HIV infections and remain underserved in the healthcare system. METHODS AND ANALYSIS: This two-phase study includes a formative assessment using in-depth interviews (N=30) and a 12-week experimental pilot study using a two-arm randomised controlled trial design (N=70). The primary intervention is delivered through a WeChat-based mini-app (a program built into a Chinese multipurpose social media application) developed by young GBMSM from a 2019 crowdsourcing hackathon. Using mixed methods, we will further investigate the specific needs and concerns among GBMSM in terms of using PrEP as an HIV prevention strategy, how their concerns and PrEP use behaviours may change with exposure to the mini-app intervention during the study period and how we can further refine this intervention tool to better meet GBMSM's needs for broader implementation. ETHICS AND DISSEMINATION: This study and its protocols have been reviewed and approved by the Institutional Review Boards of the University of North Carolina at Chapel Hill, USA (19-3481), the Guangdong Provincial Dermatology Hospital, China (2020031) and the Guangzhou Eighth People's Hospital, China (202022155). Study staff will work with local GBMSM community-based organisations to disseminate the study results to participants and the community via social media, workshops and journal publications. TRIAL REGISTRATION NUMBER: The study was prospectively registered on clinicaltrials.gov (NCT04426656) on 11 June 2020.

Providing support in a pandemic: A medical student telehealth service for ambulatory patients with COVID-19.

During the early months of the COVID-19 pandemic, when health systems were overwhelmed with surging hospitalizations and a novel virus, many ambulatory patients diagnosed with COVID-19 lacked guidance and support as they convalesced at home. This case report offers insight into the implementation of a telehealth service utilizing third- and fourth-year medical students to provide follow-up to ambulatory patients diagnosed with COVID-19. The service was evaluated using medical student surveys and retrospective chart review to assess the clinical and social needs of patients during the spring of 2020. Students assessed symptoms for 416 patients with COVID-19 from April 8 to May 20 and provided clinical information and resources. Eighteen percent of these patients sought higher levels of medical care, in part from student referrals. Three key implementation lessons from this experience that may be relevant for others include: 1) Vulnerable patient populations face unique stressors exacerbated by the pandemic and may benefit from intensive follow-up after COVID-19 diagnosis to address both medical and social needs; 2) Medical students can play value-added roles in providing patient education to prevent the spread of COVID-19, assisting patients with escalating care or resource connection, and providing emotional support to those who have lost loved ones; 3) Continuous re-assessment of the intervention was important to address evolving patient needs during the COVID-19 outbreak. Future work should focus on identifying high-risk patient populations and tailoring follow-up interventions to meet the unique needs of these patient populations.

When educators are locked down: transitioning an international faculty development program from in-person to online during the COVID-19 pandemic in China.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic forced international faculty development programs in medical education to forgo in-person activities and transition to online learning. We sought to examine changes in international medical educators' evaluations of our faculty development program as it transitioned due to the pandemic. Methods: We compared survey responses from participants in our International Medical Educators Program between 2019 (in-person) and 2020 (online). The 43-item survey addressed aspects such as program evaluation and self-assessment of curriculum development and teaching skills. We analyzed data using t-tests to compare means and chi-square test for categorical variables, and performed thematic analysis of open-ended responses. Results: We found that trainees in both cohorts rated the program highly with regard to overall program quality and self-assessed learning outcomes, but the 2019 group reported stronger relationships with peers and instructors. Some scores for self-assessed outcomes were lower for the 2020 class, but no statistically significant differences were found in pre- and post- training scores between the two cohorts. Four themes emerged from the feedback: positive program utility, IMEP as an example of good curriculum design, timing issues, and online learning environment challenges. Conclusions: Despite pandemic challenges, the transition to online faculty development was favorably evaluated, with high confidence in the applicability of learned skills. Future efforts should focus on fostering community and optimizing interaction times to enhance learning experiences. The study contributes insights for global medical education communities in pandemic circumstances.

Linking doctor-patient relationship to medical residents' work engagement: The influences of role overload and conflict avoidance.

BACKGROUND: Chinese residents' practical work experiences are different from those described in Western studies. To explore potential mechanisms underlying the effects of doctor-patient relationships on medical residents' work engagement, verifying a posited mediating effect of role overload, and moderating effect of conflict avoidance, in the Chinese context. METHODS: Based on the conservation of resources theory, a composite model was constructed. This study's data were collected from four different Chinese tertiary hospitals; 195 residents undergoing regularization training took this survey. Hierarchical moderated and mediated regression analyses were utilized. RESULTS: Doctor-patient relationship were found to be positively related to residents' work engagement (ß=0.31, p≤0.001). Role overload partially mediated the effect of these relationships on work engagement, and the moderating role of conflict avoidance in the relationship between doctor-patient relationship and conflict avoidance was negative. CONCLUSION: Maintaining good doctor-patient relationship can prompt residents to increase their engagement in work in order to meet their patients' needs. Furthermore, role overload has a particular influence in early career stages. Not only is it necessary for residents to gain a sense of recognition and support while they carry out their job responsibilities, especially while dealing with complex doctor-patient relationship, but it is also important to create work environments that can help residents shape their professional competency.

Some Learning Theories for Medical Educators.

Perspectives on the nature of learning influence decisions about curriculum design, teaching and learning strategies, and assessment of students. Current literature on medical education suggests that medical teachers have much interest in using theories to inform their practice. This article describes the following learning theories that have been discussed to various degrees in previous literature on medical education: cognitivism, constructivism, experiential learning, adult learning, self-directed learning, community of practice and situated learning, cognitive apprenticeship, and reflective learning. Each theory is explained in sufficient detail to help readers grasp its essence. Then, medical education literature is cited to show how the theory has been used or can be used to guide practice in medical education. Finally, this article analyzes the problem-based learning approach as an example to illustrate how the theories may be reflected in practice. Throughout the introduction of the various theories, this article aims at their application in medical education and attempts to draw connections among the theories rather than represent them as unrelated or competing ideas.

Serum Uric Acid Concentrations and Risk of Adverse Outcomes in Patients With COVID-19.

Background: Although hyperuricemia frequently associates with respiratory diseases, patients with severe coronavirus disease 2019 (COVID-19) and severe acute respiratory syndrome (SARS) can show marked hypouricemia. Previous studies on the association of serum uric acid with risk of adverse outcomes related to COVID-19 have produced contradictory results. The precise relationship between admission serum uric acid and adverse outcomes in hospitalized patients is unknown. Methods: Data of patients affected by laboratory-confirmed COVID-19 and admitted to Leishenshan Hospital were retrospectively analyzed. The primary outcome was composite and comprised events, such as intensive care unit (ICU) admission, mechanical ventilation, or mortality. Logistic regression analysis was performed to explore the association between serum concentrations of uric acid and the composite outcome, as well as each of its components. To determine the association between serum uric acid and in-hospital adverse outcomes, serum uric acid was also categorized by restricted cubic spline, and the 95% confidence interval (CI) was used to estimate odds ratios (OR). Results: The study cohort included 1854 patients (mean age, 58 years; 52% women). The overall mean ± SD of serum levels of uric acid was 308 ± 96 µmol/L. Among them, 95 patients were admitted to ICU, 75 patients received mechanical ventilation, and 38 died. In total, 114 patients reached composite end-points (have either ICU admission, mechanical ventilation or death) during hospitalization. Compared with a reference group with estimated baseline serum uric acid of 279-422 µmol/L, serum uric acid values ≥ 423 µmol/L were associated with an increased risk of composite outcome (OR, 2.60; 95% CI, 1.07- 6.29) and mechanical ventilation (OR, 3.01; 95% CI, 1.06- 8.51). Serum uric acid ≤ 278 µmol/L was associated with an increased risk of the composite outcome (OR, 2.07; 95% CI, 1.18- 3.65), ICU admission (OR, 2.18; 95% CI, 1.17- 4.05]), and mechanical ventilation (OR, 2.13; 95% CI, 1.06- 4.28), as assessed by multivariate analysis. Conclusions: This study shows that the association between admission serum uric acid and composite outcome of COVID-19 patients was U-shaped. In particular, we found that compared with baseline serum uric acid levels of 279-422 µmol/L, values ≥ 423 µmol/L were associated with an increased risk of composite outcome and mechanical ventilation, whereas levels ≤ 278 µmol/L associated with increased risk of composite outcome, ICU admission and mechanical ventilation.

Cancer, transplant, and immunocompromising conditions were not significantly associated with severe illness or death in hospitalized COVID-19 patients.

OBJECTIVE: Patients with cancer, transplant, and other immunocompromising conditions are at uncertain risk of severe COVID-19 illness. This study aimed to clarify whether patients with immunocompromising conditions were more likely to develop severe COVID-19 illness in a single urban academic medical center. METHODS: A retrospective chart review and electronic data extraction of the first 401 patients at the University of Chicago Hospitals with SARS-CoV-2 infection was performed. Patients met criteria for severe COVID-19 illness if they required ICU level care, high flow oxygen, positive pressure support, helmet non-invasive ventilation, mechanical ventilation, or ECMO, developed ARDS, or died. RESULTS: The mean age was 60 years, 52% were women, 90% were African American, and mortality at 30 days post discharge was 13%. Severe COVID-19 illness was found in 168 (40%) patients. Of the 56 patients with past or current cancer, 25 (45%) had severe illness (p=0.76). Of the 55 patients with other immunocompromised conditions, 24 (44%) had severe illness (p=0.89) After controlling for age, sex, and race, neither cancer (p=0.73) nor immunocompromised conditions (p=0.64) were associated with severe illness. CONCLUSION: No association was found between severe COVID-19 illness and cancer, transplant, and other immunocompromising conditions in a cohort of mostly African American patients.

Learning at a social distance: A medical student telehealth service for COVID-19 patients.

This article was migrated. The article was marked as recommended. COVID-19 has disrupted traditional forms of clinical practice in both inpatient and outpatient settings. This novel, potentially-fatal infection proliferated to such a degree that many patients with mild disease had to engage in self-care at home. This disruption to clinical services has also upended in-person clerkship education across the country, leading to sustained periods of student furloughing. We developed a telehealth service-learning opportunity for COVID-19 patients who were advised to self-care in their homes. The service was staffed by medical students in their clinical training years, providing triage advice to patients, their families, and co-habitants until their symptoms improved. Callers set patient education around red flag symptoms as their first priority, but also offered counsel on home infection control and self-isolation strategies, composed work letters, offered resources regarding home management issues such as food and sanitation, and attended to the mental health needs of the patients and their families. An attending was on-call daily to assist and educate students about issues relating to clinical decision-making and the social determinants of health. A survey assessed medical students' opinions on the service. Student respondents found the service valuable, with 100% agreeing or strongly agreeing that the service was worth their time and important. Respondents reported learning important telehealth skills such as triage and patient education. Overwhelmingly, students found emotional connections with patients to be the most meaningful aspects of the service. Our telehealth service allowed students to learn from patients in a longitudinal manner, while remaining safely away from clinical settings. This service may prove a useful model for others in the case of another outbreak, particularly when medical students are furloughed. We hope to develop more clinical experiences in telehealth for medical students moving forward.

Challenges of Residency Training at the Center of the COVID-19 Pandemic in Wuhan, China.

This article was migrated. The article was marked as recommended. Soon after the identification of the novel coronavirus in Wuhan, the city experienced a massive outbreak of COVID-19 that severely strained the existing health system. All of the city's teaching hospitals repurposed buildings for COVID-19 patients, and recruited physicians and trainees of all backgrounds to care of these patients. The authors discuss some of the challenges faced by residency training programs during this period and how they were addressed.

Linking hospital culture to the training performance of residents: The roles of leader-member exchange and transactional leadership style.

BACKGROUND: Hospital culture is a crucial aspect of residents' training. However, the mechanisms related to stakeholder culture (SC) and teacher-resident interaction remain unclear. The study investigated the relationship between hospital culture and training performance of residents. Also, it explored the mediating effect of teacher-resident exchange and the moderating effect of the teacher's transactional leadership style within a Chinese context. METHODS: Based on stakeholder and leadership member exchange theories, we constructed a composite model. Data were collected from 296 residents from five tertiary hospitals in China. Hierarchical moderated regression analyses were used to test the hypotheses. RESULTS: (a) Both the employee-orientation culture (EOC) (ß = .14, P ≤ .05) and patient-orientation culture (POC) (ß = .47, P ≤ .001) in the hospital were significantly related to residents' training performance. (b) Teacher-resident exchange fully mediated the relationship between EOC and training performance and partially mediated the relationship between POC and training performance. (c) The moderating role of transactional leadership style (TLS) in the relationship between EOC and leader-member exchange (LMX) (ß = -.17, P ≤ .05) was negative; it was not significant in the interaction between POC and TLS (ß = .06, P > .1). CONCLUSION: The results suggest that trainers should consider the value of multiple cultures and ensure balance among stakeholders rather than focusing on a single one. Furthermore, a positive interaction improves teacher-student relationship and training performance. Most importantly, educational departments should pay attention to establishing assessment tools, using rewards and incentives in residents' training.

Evaluation of geriatrics education at a Chinese University: A survey of attitudes and knowledge among undergraduate medical students.

Despite widespread reforms in medical education across China, nationally there has been no mandate or movement toward systemically incorporating geriatrics into curricula. To what degree medical students are trained and have exposure to geriatric topics remains unclear. We surveyed 190 medical students during their final year of medical school at a Chinese medical university, graduating from reformed and also traditional curricula. The survey was comprised of a subjective assessment of attitudes and reported knowledge, as well as an objective assessment of knowledge via a multiple choice test. Student attitudes were favorable toward geriatrics, with 91% supporting the addition of specialized clinical experiences to the curriculum. Students generally reported low exposure to geriatrics, with no statistically significant differences between reform and traditional curricula. There was a statistically significant difference in performance on the multiple choice test between curricula but at a degree unlikely to be practically significant. Students had very favorable attitudes toward geriatrics as a field and specialty; however scored poorly on competency exams, with the lowest performance around diagnosis and treatment of specific geriatric conditions. Our results suggest that there is a need and desire for increased geriatric-oriented learning at Chinese medical schools.

Strategic elements of residency training in China: transactional leadership, self-efficacy, and employee-orientation culture.

BACKGROUND: The standardized training of resident physicians in China is significant and robust. During the training, clinical teachers act as leaders. The training taking place in public hospitals requires a transactional leadership style (TLS), but existing research studies seldom analyze how to promote residents' performance from this perspective. METHODS: Two hundred and ninety six new residents undertaking standardized training were recruited from five tertiary hospitals in two provinces of China. Hierarchical moderated and mediated regression analyses were used to test the hypotheses. The hypotheses include that TLS is positively related to the training performance; mediating effect of self-efficacy and moderating effect of employee-orientation organizational culture (EOC) are significant. RESULTS: (1) Two kinds of teachers' TLS, punishment and reward, have significant positive influence on residents' performance. (2) Self-efficacy of residents partly mediates the positive relationship. (3) EOC moderates the relationship between the punitive behavior of clinical teachers with TLS and the self-efficacy of the residents. CONCLUSIONS: Empirical evidence has shown the positive relationship between teachers' TLS and residents' performance outcomes in China. Teachers can enhance training performance by promoting self-efficacy of residents. This study also advances our understanding of EOC by examining the demonstrated moderating effects of cultural background in the relationship between teachers' TLS and the self-efficacy of residents.

Religious Characteristics of Physicians Who Care for Underserved Populations or Work in Religiously Oriented Practices.

OBJECTIVES: This study examined the relation between physicians' religious characteristics and working for medically underserved populations or in religiously oriented practices. METHODS: Secondary data analysis of 2009-2010 national survey of 896 primary care physicians (PCPs) and 312 psychiatrists. Predictors included physicians' religious characteristics. RESULTS: Adjusted response rates among eligible physicians were 63% (896 of 1427) for PCPs and 64% (312 of 487) for psychiatrists. Overall, 41.3% of US PCPs and 53.2% of US psychiatrists reported working with medically underserved populations. A smaller percentage reported working in religiously oriented practices. Physicians who rated religion as most important in their lives were more likely to report working for medically underserved populations (52.5% most important vs 36.7% not important, P = 0.02) or report working in religiously oriented practices (23.9% most important vs 6.8% not important, P < 0.01). CONCLUSIONS: Religious physicians may be serving in medically underserved areas or religiously oriented practices as a way to integrate their professional and personal identities.

Standardized residency training in China: the new internal medicine curriculum.

China formally established a system of national standardized medical residency training in 2014, which affects the health of its 1.4 billion people. Accompanying this system were new guidelines and standards for internal medicine residency training. However, the majority of the standards focused on process measurements, such as minimum case requirements of diseases and procedural skills, rather than describing broader physician competencies in the domains of professionalism, patient care, communication, teamwork, quality improvement, and scholarship. While China has taken a large step forward with standardization of certain aspects of internal medicine residency training, the next step should focus on outcome measures and creating a system that is competency-based.