Minding the gap: towards a shared clinical reasoning lexicon across the pre-clerkship/clerkship transition.

Teaching and learning of clinical reasoning are core principles of medical education. However, little guidance exists for faculty leaders to navigate curricular transitions between pre-clerkship and clerkship curricular phases. This study compares how educational leaders in these two phases understand clinical reasoning instruction. Previously reported cross-sectional surveys of pre-clerkship clinical skills course directors, and clerkship leaders were compared. Comparisons focused on perceived importance of a number of core clinical reasoning concepts, barriers to clinical reasoning instruction, level of familiarity across the undergraduate medical curriculum, and inclusion of clinical reasoning instruction in each area of the curriculum. Analyses were performed using the Mann Whitney U test. Both sets of leaders rated lack of curricular time as the largest barrier to teaching clinical reasoning. Clerkship leaders also noted a lack of faculty with skills to teach clinical reasoning concepts as a significant barrier (p < 0.02), while pre-clerkship leaders were more likely to perceive that these concepts were too advanced for their students (p < 0.001). Pre-clerkship leaders reported a higher level of familiarity with the clerkship curriculum than clerkship leaders reported of the pre-clerkship curriculum (p < 0.001). As faculty transition students from the pre-clerkship to the clerkship phase, a shared understanding of what is taught and when, accompanied by successful faculty development, may aid the development of longitudinal, milestone-based clinical reasoning instruction.

Predictors of faculty narrative evaluation quality in medical school clerkships.

INTRODUCTION: Narrative approaches to assessment provide meaningful and valid representations of trainee performance. Yet, narratives are frequently perceived as vague, nonspecific and low quality. To date, there is little research examining factors associated with narrative evaluation quality, particularly in undergraduate medical education. The purpose of this study was to examine associations of faculty- and student-level characteristics with the quality of faculty member's narrative evaluations of clerkship students. METHODS: The authors reviewed faculty narrative evaluations of 50 students' clinical performance in their inpatient medicine and neurology clerkships, resulting in 165 and 87 unique evaluations in the respective clerkships. The authors evaluated narrative quality using the Narrative Evaluation Quality Instrument (NEQI). The authors used linear mixed effects modelling to predict total NEQI score. Explanatory covariates included the following: time to evaluation completion, number of weeks spent with student, faculty total weeks on service per year, total faculty years in clinical education, student gender, faculty gender, and an interaction term between student and faculty gender. RESULTS: Significantly higher narrative evaluation quality was associated with a shorter time to evaluation completion, with NEQI scores decreasing by approximately 0.3 points every 10 days following students' rotations (p = .004). Additionally, women faculty had statistically higher quality narrative evaluations with NEQI scores 1.92 points greater than men faculty (p = .012). All other covariates were not significant. CONCLUSIONS: The quality of faculty members' narrative evaluations of medical students was associated with time to evaluation completion and faculty gender but not faculty experience in clinical education, faculty weeks on service, or the amount of time spent with students. Findings advance understanding on ways to improve the quality of narrative evaluations which are imperative given assessment models that will increase the volume and reliance on narratives.

The therapeutic potential of bedside art observation in hematologic cancer inpatients: a randomized controlled pilot study.

PURPOSE: Prior research has suggested that art-based interventions may reduce anxiety in cancer patients and enhance dialogue in the healthcare setting. Through implementing Art at the Bedside, an art-based hospital visitation program, we sought to examine whether dedicated art observation sessions, and varying formats (with and without guided discussion), could have therapeutic effects on cancer patients' mental wellbeing. METHODS: This randomized controlled pilot study evaluated the effects of bedside art observation on anxiety in a sample of 73 hematologic cancer inpatients. We compared state anxiety, as measured by an abbreviated form of the Spielberger State-Trait Anxiety Inventory (STAI Y-6), across three groups (participants who observed an electronic selection of artwork with and without guided discussion, and a control group that did not engage in either dedicated art observation activity). RESULTS: We found that mean anxiety scores were significantly lower among those who participated in guided art observation, compared to those who did not (8.92 versus 12.1, scored on a scale of 6 to 24, p = 0.009, with a medium effect size (η2 = 12.7)). The majority of participants who engaged in art observation felt that the activity provided positive distraction (85.7%) and decreased boredom (79.6%), and many noted that it reduced feelings of anxiety (46.9%) and depression (24.5%). CONCLUSION: These findings suggest that bedside art observation, particularly with guided discussion, may be a promising complementary therapy for reducing cancer-related anxiety and improving the patient experience in the inpatient hematology/oncology setting, and would benefit from further inquiry.

Moderate to Severe Chronic Pain in Later Life: Risk and Resilience Factors for Recovery.

Despite extensive research on the development and risk factors of chronic pain, the process of recovery from chronic pain in later life has been rarely studied. We estimated the recovery rate of moderate to severe chronic pain (chronic pain of moderate or severe severity or interfering with usual activities) among older adults and investigated predictors of recovery. Leveraging the longitudinal Health and Retirement Study 2006-2016 data (6 waves), we estimated the biennial national attrition-adjusted recovery rate of moderate to severe chronic pain among 6,132 US adults aged 65-75 at baseline. Generalized estimating equation Poisson models examined pain-related, sociodemographic, psychosocial and health-related factors in relation to recovery within any 2-year interval using longitudinal lagged design. Between 2006-2016, the prevalence of moderate to severe chronic pain increased from 28% to 33% with the incidence increasing from 14% to 18% and the recovery rate approximately 30%. Previous chronic pain duration, age, chronic diseases and a personality trait (agreeableness) were associated with a lower probability of recovery. Greater financial wealth and physical activity, better sleep quality and self-reported health were associated with a greater probability of recovery. Interventions that improve physical activity and sleep quality may be important avenues for reducing chronic pain burden among older adults. PERSPECTIVE: Our longitudinal findings suggested that recovery from moderate to severe chronic pain is common in later life and we further identified several key factors associated with this recovery process. Future research should consider the potential of interventions that improve physical activity and sleep quality to enhance recovery among older adults.

A Crocheted Model Activity for Teaching Embryonic Lateral Folding to Medical Students.

Knowledge of embryology is foundational for understanding normal anatomy and birth defects, yet, embryology is a notoriously difficult subject for medical students. Embryonic lateral folding in particular is one of the most challenging concepts in embryology. Highly effective teaching methods that promote active engagement with dynamic, three-dimensional models may be helpful for teaching this content. The aim of this study was to determine whether a hands-on modeling activity utilizing premade crocheted pieces constructed from durable, inexpensive yarn helped medical students enrolled in a pre-matriculation course to understand embryonic lateral folding. Change in knowledge was assessed using a pre-post design. Students also completed subjective evaluations regarding their satisfaction with the activity. Quiz scores in means (±SD) increased from 62.7 (±24.1) % before the activity to 77.0 (±17.1) % after the activity (P = 0.0495, two-tailed paired t test; d = 0.68). Generally, students reported that the activity was helpful and enjoyable, and the model pieces were easy to manipulate. These promising results suggest that hands-on activities with dynamic, three-dimensional models constitute an effective method for teaching embryology.

Education Research: The Narrative Evaluation Quality Instrument: Development of a tool to assess the assessor.

OBJECTIVE: Determining the quality of narrative evaluations to assess medical student neurology clerkship performance remains a challenge. This study sought to develop a tool to comprehensively and systematically assess quality of student narrative evaluations. METHODS: The Narrative Evaluation Quality Instrument (NEQI) was created to assess several components within clerkship narrative evaluations: performance domains, specificity, and usefulness to learner. In this retrospective study, 5 investigators scored 123 narrative evaluations using the NEQI. Inter-rater reliability was estimated by calculating interclass correlation coefficients (ICC) across 615 NEQI scores. RESULTS: The average overall NEQI score was 6.4 (SD 2.9), with mean component arm scores of 2.6 for performance domains (SD 0.9), 1.8 for specificity (SD 1.1), and 2.0 for usefulness (SD 1.4). Each component arm exhibited moderate reliability: performance domains ICC 0.65 (95% confidence interval [CI] 0.58-0.72), specificity ICC 0.69 (95% CI 0.61-0.77), and usefulness ICC 0.73 (95% CI 0.66-0.80). Overall NEQI score exhibited good reliability (0.81; 95% CI 0.77-0.86). CONCLUSION: The NEQI is a novel, reliable tool to comprehensively assess the quality of narrative evaluation of neurology clerks and will enhance the study of interventions seeking to improve clerkship evaluation.

Understanding of Brain Death Among Health-Care Professionals at a Transplant Center.

INTRODUCTION: There is considerable variation in brain death understanding and policies between medical institutions, however, studies have not yet compared different health-care professionals working in the same hospital. RESEARCH QUESTIONS: The overall aim of this study was to evaluate understanding of brain death among health-care professionals within intensive care units (ICUs) at a single institution. DESIGN: Study participants included 217 attending physicians, residents, nurses, medical students, and other ICU team members in 6 ICUs. Participants completed a 21-question survey pertaining to knowledge of brain death and related institutional policies as well as opinions about brain death. RESULTS: We found a wide range of brain death understanding among health-care professionals in ICUs. Attending physicians have the greatest understanding (94.7%), followed by nurses (72.4%). In contrast, approximately half of the students and residents do not have a basic understanding of brain death. Brain death understanding was correlated to health-care role, years of experience, and whether the participant had formal training in brain death. Although most participants had been involved in cases of brain death, a much smaller number had received formal training on death by neurological criteria. DISCUSSION: The present study observed a paucity of clinical training in brain death among health-care professionals in the study ICUs. There is an opportunity for improved clinical education on brain death that could improve communication with families about brain death and potentially increase the number of organs transplanted.

Perceived control and frailty: The role of affect and perceived health.

Mechanisms underlying prospective associations of perceived control with frailty and other health outcomes are not well understood. In the present study we used 3 waves of data from the Health and Retirement Study (N = 2,127) to test potential psychological and biological pathways linking perceived control with frailty over an 8-year period, and whether 4-year change in control predicts frailty independent of initial control. Lower odds of increasing frailty were associated with higher initial levels of perceived control (odds ratio [OR] = .74, p < .001, 95% confidence interval [CI] [.65, .83]) and a more positive change in perceived control (OR = .82, p = .006, 95% CI [.73, .92]), independent of the personality traits neuroticism and conscientiousness. In cross-lagged mediation models, the association of initial perceived control with frailty was partially mediated by positive affect, negative affect, and self-rated health, but not C-reactive protein or allostatic load. Associations of perceived control with positive and negative affect were bidirectional, with mediation in both directions. Initial frailty status was not related to 4-year change in perceived control. Perceived control may affect frailty risk through influences on affective states as well as perceived health. Findings also extend evidence that changes in perceived control may be prognostic of future health outcomes in older adults. (PsycINFO Database Record

Social Relationships and Inflammatory Markers in the MIDUS Cohort: The Role of Age and Gender Differences.

OBJECTIVE: To better understand age and gender differences in associations of social relationships with chronic inflammation. METHOD: Using a sample of middle-aged and older adults ( N = 963) from the Midlife Development in the United States (MIDUS) biomarker project, we examined interactions of age and gender with structural and functional social network measures in predicting interleukin-6 (IL-6) and C-reactive protein (CRP). RESULTS: Significant interactions involving age and gender showed that social support was associated with lower IL-6 in older women, whereas perceived positive relationships and social integration were related to lower IL-6 in both men and women of advanced age. Functional measures were associated with higher CRP in both men and women after adjustment for health conditions and behaviors, with some further variation by age. DISCUSSION: Greater social support may be related to lower IL-6 in older women. Further research is needed to understand observed associations of social support with higher CRP.

Perceived Control Mediates Effects of Socioeconomic Status and Chronic Stress on Physical Frailty: Findings From the Health and Retirement Study.

Objective: To investigate the psychosocial etiology of physical frailty by examining the influence of chronic stress and perceived control. Method: Using population-based samples of older adults from the Health and Retirement Study, this study employed structural equation modeling in cross-sectional (N = 5,250) and longitudinal (N = 2,013) samples to estimate the effects of chronic stress and socioeconomic status (SES) on baseline frailty and change in frailty status over 4 years and the extent to which perceived control mediates or moderates effects of chronic stress. Results: Perceived control fully mediated effects of chronic stress and partially mediated effects of SES on both baseline frailty and change in frailty. Multigroup analyses revealed that the mediating role of perceived control was consistent across age, gender, and racial/ethnic subgroups. There was no evidence to support a moderating role of perceived control in the chronic stress and frailty relationship. Discussion: Findings provide novel evidence for a mediating role of perceived control in pathways linking SES and chronic stress to frailty, further underscoring the importance of psychosocial constructs to the development and progression of frailty in older adults.

The Medical Humanities Effect: a Pilot Study of Pre-Health Professions Students at the University of Rochester.

Qualitative and quantitative research on the impact of medical and health humanities teaching in baccalaureate education is sparse. This paper reviews recent studies of the impact of medical and health humanities coursework in pre-health professions education and describes a pilot study of baccalaureate students who completed semester-long medical humanities courses in the Division of Medical Humanities & Bioethics at the University of Rochester. The study format was an email survey. All participants were current or former baccalaureate students who had taken one or more courses in literature and narrative in medicine, bioethics, history of medicine, and/or visual arts and healthcare during the past four years. The survey gathered numerical data in several areas: demographic information, career plans, self-reported influence of coursework on educational and career plans, and self-reported influence of coursework on intellectual skills and abilities. It also gathered narrative commentary that elaborated on students' responses to the numerically-based questions. Notable findings from preliminary analysis of the data include higher scores of self-reported impact of the coursework on specific habits of mind and on preparedness for intended career rather than on gaining admission to future educational programs. Discussion of the results focuses on several potential future directions this type of study might take, including multi-center, longitudinal, and sequential approaches.

Associations of Lifetime Trauma and Chronic Stress With C-reactive Protein in Adults Ages 50 Years and Older: Examining the Moderating Role of Perceived Control.

OBJECTIVE: The aim of the study was to investigate whether high perceived control mitigates systemic inflammatory risk associated with traumatic and chronic stress exposures in older adults. METHODS: A sample of community-dwelling adults ages 50 years and older (N = 4779) was drawn from the Health and Retirement Study. Structural equation models tested interactions of lifetime trauma and chronic stress with mastery and perceived constraints predicting baseline levels and 4-year change in C-reactive protein (CRP). RESULTS: There were significant interactions of lifetime trauma (ß = -.058, p = .012) and chronic stress (ß = -.069, p = .010) with mastery as related to baseline CRP levels. Both measures were associated with higher CRP at low (ß = .102, p = .003; ß = .088, p = .015) but not high levels of mastery. In addition, chronic stress interacted with baseline mastery (ß = .056, p = .011) and change in mastery (ß = -.056, p = .016) to predict 4-year change in CRP. Chronic stress was associated with an increase in CRP at high baseline mastery (ß = .071, p = .022) and when mastery decreased during follow-up (ß = .088, p = .011). There were no main effects of stress or control variables other than an association of constraints with a larger increase in CRP (ß = .062, p = .017). Interactions were minimally attenuated (<15%) upon further adjustment for negative affect, body mass index, smoking, and physical activity. CONCLUSIONS: High mastery may protect against elevated systemic inflammation associated with substantial lifetime trauma exposure. Individuals who experience declines in mastery may be most susceptible to increases in inflammation associated with chronic stress.

Statolith Morphometrics Can Discriminate among Taxa of Cubozoan Jellyfishes.

Identification of potentially harmful cubomedusae is difficult due to their gelatinous nature. The only hard structure of medusae, the statolith, has the potential to provide robust measurements for morphometric analysis. Traditional morphometric length to width ratios (L: W) and modern morphometric Elliptical Fourier Analysis (EFA) were applied to proximal, oral and lateral statolith faces of 12 cubozoan species. EFA outperformed L: W as L: W did not account for the curvature of the statolith. Best discrimination was achieved with Canonical Discriminant Analysis (CDA) when analysing proximal + oral + lateral statolith faces in combination. Normalised Elliptical Fourier (NEF) coefficients classified 98% of samples to their correct species and 94% to family group. Statolith shape agreed with currently accepted cubozoan taxonomy. This has potential to assist in identifying levels of risk and stock structure of populations in areas where box jellyfish envenomations are a concern as the severity of envenomation is family dependent. We have only studied 12 (27%) of the 45 currently accepted cubomedusae, but analyses demonstrated that statolith shape is an effective taxonomic discriminator within the Class.

Factors impacting musculoskeletal knowledge and clinical confidence in graduating medical students.

BACKGROUND: Despite the prevalence of musculoskeletal disorders, the degree to which medical schools are providing students with the knowledge and confidence to treat these problems is unclear. This study evaluated the factors that impact musculoskeletal knowledge and clinical confidence among fourth-year medical students. METHODS: Over a three-year period, 253 fourth-year medical students participated in the study at a single institution. Musculoskeletal knowledge was evaluated using a National Board of Medical Examiners' musculoskeletal medicine subject examination. Factors analyzed included sex, class year, musculoskeletal elective experience, duration of musculoskeletal elective, career choice, and musculoskeletal curriculum satisfaction. RESULTS: The participation rate was 95%. The mean National Board of Medical Examiners' musculoskeletal assessment score (and standard deviation) was 70.7 ± 9.5 points for all fourth-year medical students. Taking a musculoskeletal elective significantly increased knowledge (p < 0.001) but not clinical confidence. Increased satisfaction with how musculoskeletal medicine was taught was associated with increased clinical confidence (p < 0.001). No significant differences were seen if students were going into musculoskeletal medicine or primary care for either musculoskeletal knowledge or clinical confidence. Multivariate analysis of musculoskeletal knowledge found that taking a musculoskeletal elective for two weeks led to an increase of 6 points (from a possible 100 points) in the National Board of Medical Examiners' subject examination scores. CONCLUSIONS: This study reveals that participation in a clinical elective is the only factor that led to a significant increase in musculoskeletal knowledge in fourth-year medical students. A two-week clinical elective can be sufficient time to have an impact on musculoskeletal knowledge, but it alone does not increase clinical confidence. Further studies are needed to determine how to improve musculoskeletal clinical confidence.

Predictors of older adults' technology use and its relationship to depressive symptoms and well-being.

OBJECTIVE: To extend the empirical evidence regarding the predictors of older adults' use of information and communications technology (ICT) and to further examine its relationship to depressive symptoms and well-being. METHOD: This cross-sectional study utilized a sample of community-dwelling older adults from the National Health and Aging Trends Study (N = 6,443). Structural equation modeling was used to estimate the effects of predictor variables on ICT use and the effects of use on depressive symptoms and well-being. Tests of moderation by demographic characteristics and level of ICT use were also performed. RESULTS: Socioeconomic status (SES), age, and cognitive function accounted for approximately 60% of the variance in ICT use. SES was a stronger predictor for Blacks/African Americans, whereas cognitive function was a stronger predictor for Whites. ICT use was unrelated to depressive symptoms or well-being. However, it acted as a moderator, such that limitations in activities of daily living (ADLs) was a stronger predictor of depressive symptoms for high ICT users, whereas ill-health was a stronger predictor for non/limited users. DISCUSSION: Findings do not support the claim that ICT use directly enhances mental health or well-being among older adults although it may protect against depressive symptoms for individuals coping with health conditions other than ADL impairments.

Engaging students and faculty: implications of self-determination theory for teachers and leaders in academic medicine.

BACKGROUND: Much of the work of teachers and leaders at academic health centers involves engaging learners and faculty members in shared goals. Strategies to do so, however, are seldom informed by empirically-supported theories of human motivation. DISCUSSION: This article summarizes a substantial body of motivational research that yields insights and approaches of importance to academic faculty leaders. After identification of key limitations of traditional rewards-based (i.e., incentives, or 'carrots and sticks') approaches, key findings are summarized from the science of self-determination theory. These findings demonstrate the importance of fostering autonomous motivation by supporting the fundamental human needs for autonomy, competence, and relatedness. In turn, these considerations lead to specific recommendations about approaches to engaging autonomous motivation, using examples in academic health centers. SUMMARY: Since supporting autonomous motivation maximizes both functioning and well-being (i.e., people are both happier and more productive), the approaches recommended will help academic health centers recruit, retain, and foster the success of learners and faculty members. Such goals are particularly important to address the multiple challenges confronting these institutions.

Assessing a method to limit influence of standardized tests on clerkship grades.

BACKGROUND: Grading committees give excessive weight to standardized-examination scores. PURPOSE: Understanding that biases are often ingrained in grading processes, we sought to assess the influence of a structured grading policy in limiting this effect. METHODS: All 7 clerkship grading committees derived students' clinical scores while blinded to examination scores. Scores were combined to yield a final rank order, which was used to derive grade cutoffs. Logit regression was performed to assess the contribution of clinical and examination scores to final grades. Results were compared to a similar analysis where committees were not blinded to examination scores. RESULTS: In contrast to prior findings, grading committees consistently assigned greater weight to clinical-performance scores in assigning final grades when blinded to examination scores. CONCLUSIONS: Grading committees may be unaware of the extent to which they discount clinical assessments when they are at odds with the results of standardized examinations. This can be addressed with a procedure that blinds grading committees to examination scores.

Maturation of medical student musculoskeletal medicine knowledge and clinical confidence.

PURPOSE: Despite the prevalence of musculoskeletal (MSK) disorders, the degree to which medical schools are providing students the knowledge and confidence to treat these problems is unclear. This study evaluated MSK knowledge in second and fourth year medical students using a newly developed written assessment tool and examined the maturation of clinical confidence in treating core MSK disorders. METHODS: Over a 3-year period, the National Board of Medical Examiners (NBME) MSK subject examination consisting of 75 items was administered to 568 second and fourth year students at a single institution. Students were also asked to rate their confidence in treating a selection of medicine/pediatric and MSK clinical scenarios on a 5-point Likert scale. RESULTS: Participation rate was 98%. The NBME MSK assessment score was 59.2 ± 10.6 for all second year medical students and 69.7 ± 9.6 for all fourth year medical students. There was a significant increase in NBME scores between the second and fourth years (p<0.0001). Students were more confident in treating internal medicine/pediatric conditions than MSK medicine conditions (p=0.001). Confidence in treating MSK medicine conditions did not improve between the second and fourth years (p=0.41). CONCLUSIONS: To our knowledge, this is the first study to report increased MSK medicine knowledge as measured by a standardized examination after completing medical school core clinical rotations. Despite increased MSK knowledge, low levels of MSK clinical confidence among graduating students were noted. Further research is needed to determine the factors that influence MSK knowledge and clinical confidence in medical students.