Allergy immunotherapy: Who, what, when...and how safe?

The evidence-based answers to these and other questions will help you to update your knowledge of allergy immunotherapy.

Active Learning on Center Stage: Theater as a Tool for Medical Education.

Introduction: Knowledge and skill development related to communication must incorporate both affective and behavioral components, which are often difficult to deliver in a learning activity. Using theater techniques and principles can provide medical educators with tools to teach communication concepts. Methods: This 75-minute faculty development workshop presents a variety of techniques from theater and adapts them for use in medical education. Using examples related to diversity and inclusion, this session addresses general educational and theater principles, role-play, sociodrama, applied improvisation, and practical aspects of involving theater partners. The session materials include a PowerPoint presentation with facilitator notes, interactive activities to demonstrate each modality, and an evaluation. The sessions can be extended to longer formats as needed. Results: Forty-five participants at Learn Serve Lead 2016: The AAMC Annual Meeting attended the 75-minute session. We emailed 32 participants 5 months after the conference, and eight responded. Participants reported that their confidence level in using theater techniques as a tool for medical education increased from low-to-medium confidence presession to high confidence postsession. All survey respondents who were actively teaching said they had made changes to their teaching based on the workshop. All commented that they appreciated the active learning in the session. Many indicated they would appreciate video or other follow-up resources. Discussion: Principles and techniques from theater are effective tools to convey difficult-to-teach concepts related to communication. This workshop presents tools to implement activities in teaching these difficult concepts.

Transforming your daily work into scholarship: Tips for a busy clinician-scholar.

This article was migrated. The article was marked as recommended. Academic faculty are pulled in multiple directions during their daily work life. Clinical issues, teaching responsibilities, and administrative duties all take up large amounts of time. At the same time, most faculty have requirements for scholarly activities for promotions. This paper discusses ways that individuals can use much of the work that they do in all of the realms of their jobs and turn it into scholarly projects. By focusing the content of their work, planning ahead, and making everything count twice, faculty can be successful in developing scholarship using their daily work.

Expanding Opportunities for Professional Development: Utilization of Twitter by Early Career Women in Academic Medicine and Science.

The number of women entering medical school and careers in science is increasing; however, women remain the minority of those in senior faculty and leadership positions. Barriers contributing to the shortage of women in academics and academic leadership are numerous, including a shortage of role models and mentors. Thus, achieving equity in a timelier manner will require more than encouraging women to pursue these fields of study or waiting long enough for those in the pipelines to be promoted. Social media provides new ways to connect and augments traditional forms of communication. These alternative avenues may allow women in academic medicine to obtain the support they are otherwise lacking. In this perspective, we reflect on the role of Twitter as a supplemental method for navigating the networks of academic medicine. The discussion includes the use of Twitter to obtain (1) access to role models, (2) peer-to-peer interactions, and continuous education, and (3) connections with those entering the pipeline-students, trainees, and mentees. This perspective also offers suggestions for developing a Twitter network. By participating in the "Twittersphere," women in academic medicine may enhance personal and academic relationships that will assist in closing the gender divide.

Does formal mentoring for faculty members matter? A survey of clinical faculty members.

BACKGROUND: Mentoring relationships, for all medical school faculty members, are an important component of lifelong development and education, yet an understanding of mentoring among medical school clinical faculty members is incomplete. This study examined associations between formal mentoring relationships and aspects of faculty members' engagement and satisfaction. It then explored the variability of these associations across subgroups of clinical faculty members to understand the status of mentoring and outcomes of mentoring relationships. The authors hypothesised that academic clinical faculty members currently in formal mentoring relationships experience enhanced employee engagement and satisfaction with their department and institution. METHODS: Medical school faculty members at 26 self-selected USA institutions participated in the 2011-2014 Faculty Forward Engagement Survey. Responses from clinical faculty members were analysed for relationships between mentoring status and perceptions of engagement by faculty members. RESULTS: Of the 11 953 clinical faculty respondents, almost one-third reported having a formal mentoring relationship (30%; 3529). Most mentored faculty indicated the relationship was important (86%; n = 3027), and over three-fourths were satisfied with their mentoring experience (77%; n = 2722). Mentored faculty members across ranks reported significantly higher levels of satisfaction and more positive perceptions of their roles in the organisation. Faculty members who were not receiving mentoring reported significantly less satisfaction with their workplace environment and lower overall satisfaction. CONCLUSIONS: Mentored clinical faculty members have significantly greater satisfaction with their department and institution. This multi-institutional study provides evidence that fostering mentoring opportunities may facilitate faculty members' satisfaction and engagement, which, in turn, may help medical schools retain high-quality faculty staff committed to the multidimensional academic mission.

Time well spent: the association between time and effort allocation and intent to leave among clinical faculty.

PURPOSE: To explore the relationship between clinical faculty members' time/effort in four mission areas, their assessment of the distribution of that time/effort, and their intent to leave the institution and academic medicine. METHOD: Faculty from 14 U.S. medical schools participated in the 2011-2012 Faculty Forward Engagement Survey. The authors conducted multivariate logistic regression analyses to evaluate relationships between clinical faculty members' self-reported time/effort in each mission area, assessment of time/effort, and intent to leave the institution and academic medicine. RESULTS: Of the 13,722 clinical faculty surveyed, 8,349 (60.8%) responded. Respondents reported an average of 54.5% time/effort in patient care. The authors found no relationship between time/effort in patient care and intent to leave one's institution. Respondents who described spending "far too much/too much" time in patient care were more likely to report intent to leave their institution (odds ratio 2.12, P<.001). Those who assessed their time/effort in all mission areas as "about right" were less likely to report intent to leave their institution (64/1,135; 5.6%) than those who reported "far too little/too little" or "far too much/too much" time/effort in one or more mission areas (535/3,671; 14.6%; P<.001). CONCLUSIONS: Although the authors found no relationship between reported time/effort in patient care and intent to leave, the perception of "far too much/too much" time/effort spent in that mission area was correlated with intent to leave the institution. Efforts to align time/effort spent in each mission area with faculty expectations may improve retention.

Characteristics, satisfaction, and engagement of part-time faculty at U.S. medical schools.

PURPOSE: To describe the demographics of part-time faculty at U.S. medical schools and to examine their satisfaction with and perceptions of their workplace. METHOD: Faculty from 14 Liaison Committee on Medical Education-accredited U.S. medical schools participated in the 2011-2012 Faculty Forward Engagement Survey. The authors calculated descriptive statistics of part-time faculty respondents and used ANOVA and t test analyses to assess significant differences between and among demographic groups. RESULTS: The survey yielded an overall response rate of 62% (9,600/15,490). Of the part-time faculty respondents, most had appointments in clinical departments (634/674; 94%) and were female (415/674; 62%). Just over 80% (384/474) reported a full-time equivalent of 0.5 or higher. The majority of part-time faculty respondents reported satisfaction with their department and medical school as a place to work (372/496 [75%] and 325/492 [66%]); approximately half agreed that their institution had clear expectations for part-time faculty (210/456; 46%) and provided the resources they needed (232/457; 51%). Significant differences existed between part- and full-time faculty respondents regarding perceptions of growth opportunities and compensation and benefits, with part-time faculty respondents feeling less satisfied in these areas. CONCLUSIONS: As institutions work to improve the satisfaction of full-time faculty, they should do the same for part-time faculty. Understanding why faculty choose part-time work is important in encouraging the recruitment and retention of the most talented faculty. The findings of this study indicate multiple opportunities to improve the satisfaction and engagement of part-time faculty.

Challenges in academic obstetrics and gynecology departments.

OBJECTIVE: In 2011, the Association of American Medical Colleges conducted a multicenter survey to assess faculty satisfaction, engagement, and retention. This subanalysis describes the perceptions of academic obstetrician-gynecologists (ob-gyns). METHOD: Fourteen U.S. institutions offered voluntary faculty survey participation. We analyzed demographic information and responses to items within the 10 work-related dimensions. This analysis used pooled cohort data for 329 ob-gyn respondents across institutions. RESULTS: The mean response rate was 61.7% (9,600/15,570) overall and 66.9% for ob-gyn respondents. Most ob-gyn respondents reported satisfaction with work-related autonomy (72.2%) and a sense of accomplishment in their day-to-day activities (81.9%), including clarity about how their day-to-day activities fit into their medical school's mission (68.4%). In an average week, ob-gyn respondents reported working 59.4 hours on average. The mean percentage of effort varied by activity: patient care (54.8%), teaching (18.1%), research and scholarship (17.0%), and administration (15%). The mean proportion of ob-gyn respondents reporting that far too much or too much of their time and effort was spent on patient care was 35.1%, with more than half (59.5%) reporting far too little or too little of their time and effort was spent on research and scholarship and a third (33.3%) reporting far too little or too little time and effort devoted to teaching. Although 60.9% of respondents thought a mentor at their institution was important, only 22.2% reported a formal mentoring relationship. In the next 1-2 years, 13.4% reported seriously planning or being undecided (18.8%) about leaving their medical school. CONCLUSION: Academic obstetrics and gynecology departments face challenges balancing faculty members' academic desires and clinical demands. LEVEL OF EVIDENCE: II.

Predictors of workplace satisfaction for U.S. medical school faculty in an era of change and challenge.

PURPOSE: To examine the current state of satisfaction with the academic medicine workplace among U.S. medical school faculty and the workplace factors that have the greatest influence on global satisfaction. METHOD: The authors used data from the 2009 administration of a medical school faculty job satisfaction survey and used descriptive statistics and χ analyses to assess levels of overall satisfaction within faculty subgroups. Multiple regressions used the mean scores of the 18 survey dimensions and demographic variables to predict three global satisfaction measures. RESULTS: The survey was completed by 9,638 full-time faculty from 23 U.S. medical schools. Respondents were mostly satisfied on global satisfaction measures including satisfaction with their department (6,506/9,128; 71.3%) and medical school (5,796/9,124; 63.5%) and whether they would again choose to work at their medical school (5,968/8,506; 70.2%). The survey dimensions predicted global satisfaction well, with the final models explaining 51% to 67% of the variance in the dependent measures. Predictors across models include organization, governance, and transparency; focus of mission; recruitment and retention effectiveness; department relationships; workplace culture; and nature of work. CONCLUSIONS: Despite the relatively unpredictable environmental challenges facing medical schools today, leaders have opportunities to influence and improve the workplace satisfaction of their faculty. Examples of opportunities include fostering a culture characterized by open communication and occasions for faculty input, and remaining vigilant regarding factors contributing to faculty burnout. Understanding what drives faculty satisfaction is crucial for medical schools as they continue to seek excellence in all missions and recruit and retain high-quality faculty.

Management of acute asthma exacerbations.

Asthma exacerbations can be classified as mild, moderate, severe, or life threatening. Criteria for exacerbation severity are based on symptoms and physical examination parameters, as well as lung function and oxygen saturation. In patients with a peak expiratory flow of 50 to 79 percent of their personal best, up to two treatments of two to six inhalations of short-acting beta2 agonists 20 minutes apart followed by a reassessment of peak expiratory flow and symptoms may be safely employed at home. Administration using a hand-held metered-dose inhaler with a spacer device is at least equivalent to nebulized beta2 agonist therapy in children and adults. In the ambulatory and emergency department settings, the goals of treatment are correction of severe hypoxemia, rapid reversal of airflow obstruction, and reduction of the risk of relapse. Multiple doses of inhaled anticholinergic medication combined with beta2 agonists improve lung function and decrease hospitalization in school-age children with severe asthma exacerbations. Intravenous magnesium sulfate has been shown to significantly increase lung function and decrease the necessity of hospitalization in children. The administration of systemic corticosteroids within one hour of emergency department presentation decreases the need for hospitalization, with the most pronounced effect in patients with severe exacerbations. Airway inflammation can persist for days to weeks after an acute attack; therefore, more intensive treatment should be continued after discharge until symptoms and peak expiratory flow return to baseline.

Barriers to effective teaching.

Medical school faculty members are charged with the critical responsibility of preparing the future physician and medical scientist workforce. Recent reports suggest that medical school curricula have not kept pace with societal needs and that medical schools are graduating students who lack the knowledge and skills needed to practice effectively in the 21st century. The majority of faculty members want to be effective teachers and graduate well-prepared medical students, but multiple and complex factors-curricular, cultural, environmental, and financial-impede their efforts. Curricular impediments to effective teaching include unclear definitions of and disagreement on learning needs, misunderstood or unstated goals and objectives, and curriculum sequencing challenges. Student and faculty attitudes, too few faculty development opportunities, and the lack of an award system for teaching all are major culture-based barriers. Environmental barriers, such as time limitations, the setting, and the physical space in which medical education takes place, and financial barriers, such as limited education budgets, also pose serious challenges to even the most committed teachers. This article delineates the barriers to effective teaching as noted in the literature and recommends action items, some of which are incremental whereas others represent major change. Physicians-in-training, medical faculty, and society are depending on medical education leaders to address these barriers to effect the changes needed to enhance teaching and learning.

Medical Therapy for Asthma: Updates from the NAEPP Guidelines.

Proper care of patients with asthma involves the triad of systematic chronic care plans, self-management support, and appropriate medical therapy. Controller medications (inhaled corticosteroids, long-acting beta2 agonists, and leukotriene receptor antagonists) are the foundation of care for persistent asthma and should be taken daily on a long-term basis to achieve and maintain control of symptoms. Inhaled corticosteroids are the preferred controller medication; studies have demonstrated that when inhaled corticosteroids are used consistently, they improve asthma control more effectively than any other single long-term control medication. Combining long-acting beta2 agonists and inhaled corticosteroids is effective and safe when inhaled corticosteroids alone are insufficient, and such combinations are an alternative to increasing the dosage of inhaled corticosteroids. For patients with mild persistent asthma, leukotriene receptor antagonists are an alternative, second-line treatment option. They are easy to use, have high rates of compliance, and can provide good symptom control in many patients. Leukotriene receptor antagonists can also be used as an adjunctive therapy with inhaled corticosteroids, but for persons 12 years and older the addition of long-acting beta2 agonists is preferred. Inhaled short-acting beta2 agonists are the most effective therapy for rapid reversal of airflow obstruction and prompt relief of asthmatic symptoms. Increasing the use of short-acting beta2 agonists or using them more than two days per week or more than two nights per month generally indicates inadequate control of asthma and the need to initiate or intensify anti-inflammatory therapy. Oral systemic corticosteroids should be used to treat moderate to severe asthma exacerbations.

Latex allergy.

The prevalence of latex allergy in the general population is low; however, the risk of developing latex allergy is higher in persons with increased latex exposure, such as health care workers or persons who work in the rubber industry. Children with spina bifida and others who undergo multiple surgeries or procedures, particularly within the first year of life, are also at greater risk of latex allergy. Reactions to latex allergy can range from type IV delayed hypersensitivity (e.g., contact dermatitis) to type I immediate hypersensitivity (e.g., urticaria, bronchospasm, anaphylaxis). Latex allergy can be diagnosed with clinical history, skin prick testing, latex-specific serum immunoglobulin E testing, and glove provocation testing. The main goals of latex allergy management are avoidance of exposure to latex allergens and appropriate treatment of allergic reactions. The use of nonlatex products from birth may prevent potentially serious allergic reactions. Widespread adoption of nonlatex or low-latex gloves has decreased the incidence of latex sensitization in health care workers.

Overview of changes to asthma guidelines: diagnosis and screening.

The Expert Panel Report 3 of the National Asthma Education and Prevention Program represents a major advance in the approach to asthma care by emphasizing the monitoring of clinically relevant aspects of care and the importance of planned primary care, and by providing patients practical tools for self-management. Treatment of asthma should be guided by a new system of classification that assesses severity at initial evaluation and control at all subsequent visits. Asthma severity is determined by current impairment (as evidenced by impact on day-to-day activities) and risk of future exacerbations (as evidenced by frequency of oral systemic corticosteroid use), and allows categorization of disease as intermittent, persistent-mild, persistent-moderate, and persistent-severe. Initial treatment is guided by the disease-severity category. The degree of control is also determined by the analysis of current impairment and future risk. Validated questionnaires can be used for following the impairment domain of control with patients whose asthma is categorized as "well controlled," "not well controlled," and "very poorly controlled." Decisions about medication adjustment and planned follow-up are based on the category of disease control. Whereas a stepwise approach for asthma management continues to be recommended, the number of possible steps has increased.

Cerumen impaction.

Cerumen is a naturally occurring, normally extruded product of the external auditory canal. It is usually asymptomatic, but when it becomes impacted it can cause complications such as hearing loss, pain, or dizziness. It also can interfere with examination of the tympanic membrane. Depending on available equipment, physician skill, and patient circumstances, treatment options for cerumen impaction include watchful waiting, manual removal, the use of ceruminolytic agents, and irrigation with or without ceruminolytic pretreatment. The overall quality of the evidence on treatment is limited. Referral to an otolaryngologist for further evaluation is indicated if treatment with a ceruminolytic agent followed by irrigation is ineffective, if manual removal is not possible, if the patient develops severe pain or has vertigo during irrigation, or if hearing loss is still present after cerumen has been removed. The use of cotton swabs and ear candles should be avoided.

Childhood asthma: treatment update.

The prevalence of childhood asthma has risen significantly over the past four decades. A family history of atopic disease is associated with an increased likelihood of developing asthma, and environmental triggers such as tobacco smoke significantly increase the severity of daily asthma symptoms and the frequency of acute exacerbations. The goal of asthma therapy is to control symptoms, optimize lung function, and minimize days lost from school. Acute care of an asthma exacerbation involves the use of inhaled beta2 agonists delivered by a metered-dose inhaler with a spacer, or a nebulizer, supplemented by anticholinergics in more severe exacerbations. The use of systemic and inhaled corticosteroids early in an asthma attack may decrease the rate of hospitalization. Chronic care focuses on controlling asthma by treating the underlying airway inflammation. Inhaled corticosteroids are the agent of choice in preventive care, but leukotriene inhibitors and nedocromil also can be used as prophylactic therapy. Long-acting beta2 agonists may be added to one of the anti-inflammatory medications to improve control of asthma symptoms. Education programs for caregivers and self-management training for children with asthma improve outcomes. Although the control of allergens has not been demonstrated to work as monotherapy, immunotherapy as an adjunct to standard medical therapy can improve asthma control. Sublingual immunotherapy is a newer, more convenient option than injectable immunotherapy, but it requires further study. Omalizumab, a newer medication for prevention and control of moderate to severe asthma, is an expensive option.