Evidence-Based Updates on the First Week of Exclusive Breastfeeding Among Infants ≥35 Weeks.

The nutritional and immunologic properties of human milk, along with clear evidence of dose-dependent optimal health outcomes for both mothers and infants, provide a compelling rationale to support exclusive breastfeeding. US women increasingly intend to breastfeed exclusively for 6 months. Because establishing lactation can be challenging, exclusivity is often compromised in hopes of preventing feeding-related neonatal complications, potentially affecting the continuation and duration of breastfeeding. Risk factors for impaired lactogenesis are identifiable and common. Clinicians must be able to recognize normative patterns of exclusive breastfeeding in the first week while proactively identifying potential challenges. In this review, we provide new evidence from the past 10 years on the following topics relevant to exclusive breastfeeding: milk production and transfer, neonatal weight and output assessment, management of glucose and bilirubin, immune development and the microbiome, supplementation, and health system factors. We focus on the early days of exclusive breastfeeding in healthy newborns ≥35 weeks' gestation managed in the routine postpartum unit. With this evidence-based clinical review, we provide detailed guidance in identifying medical indications for early supplementation and can inform best practices for both birthing facilities and providers.

Medical Education and Leadership in Breastfeeding Medicine.

Physicians' experience with high quality training in breastfeeding during their medical education is historically varied. The process of becoming a board-certified physician entails more than 20 years of education, and although medical school and residency training timelines and courses are relatively standardized across the United States and even internationally, breastfeeding education varies greatly across schools and programs. The Academy of Breastfeeding Medicine (ABM) exists, in part, because historically, physicians have received too little clinical training in breastfeeding and infant nutrition. An overarching goal of ABM, which is a multispecialty organization of doctors around the world, is to educate all maternal-child healthcare professionals, not just physicians, about breastfeeding. Within the field of medicine, family doctors, pediatricians, and obstetrician/gynecologists are considered the most logical source of breastfeeding expertise. However, the need for breastfeeding education goes beyond those providers who have obvious interactions with mothers and babies. We must educate anesthesiologists, surgeons, internists, and psychiatrists, among others. Building pipelines of physicians who are well educated in breastfeeding medicine allows more effective collaboration and care of mothers and infants among providers in various medical and surgical specialties as well as between doctors and other healthcare providers. This evidence-based education needs to be multifaceted, with didactic curricula for a strong knowledge base complemented by clinical experiences for skill development and application. Clinical knowledge and skills can also be reinforced during nonclinical opportunities in teaching, research, advocacy, and professional development. In this article, we describe a foundational framework for physician education in breastfeeding medicine as well as several creative noncurricular opportunities to develop breastfeeding expertise in future physician leaders. We conclude with a case study.

An assisted living facility curriculum to introduce geriatrics to first-year medical students.

Many U.S. medical schools have developed curricula in geriatric medicine to address the growing older adult population. At our university, the authors have integrated an assisted living facility (ALF) program into a required first-year clinical skills course. During the 2011 to 2012 academic year, an electronic survey was distributed to 109 first-year medical students prior to and after the program. Eighty-eight percent and 85% of students completed the pre- and postintervention survey, respectively. Students reported a positive attitude toward caring for older adults (92.5% post- vs. 80.2% preintervention), an understanding of the medical and social needs of older adults (89.2% post- vs. 38.5% preintervention), an acquisition of the skills to assess the health of older adults (71% post- vs. 14.5% preintervention), and an understanding of ALFs as nonmedical supportive housing (92.5% post- vs. 70.8% preintervention). The authors' curriculum offers an innovative method to integrate geriatrics education early in medical education and to involve medical students in their community.

An intensive medical education elective for senior medical students.

Peer teaching by medical students is increasingly consid- ered an effective and efficient instructional modality with value for both teachers and learners. In 2012, twelve senior medical students participated in an inaugural, four-week Medical Education Elective at The Alpert Medical School of Brown University. The first week emphasized education theory and skills. During the remaining three weeks, participants served as a core group of instructors in a Clinical Skills Clerkship (CSC), a three-week required course transitioning rising third-year students to clinical clerkships. Senior near-peer instructors (NPIs) gained substantive experience in developing curriculum, facilitating small group sessions, teaching clinical skills, mentoring, providing feedback, and grading an Objective Structured Clinical Examination (OSCE). Based on direct observation by faculty and written anonymous evaluations by learners (n=98), NPIs demonstrated a high degree of teaching competence. This innovative, by-invitation-only, annual elective is the most substantive medical education experience for medical students described in the literature.

A new clinical skills clerkship for medical students.

BACKGROUND AND OBJECTIVES: The transition to clinical clerkships can be challenging for medical students. In the context of a formal clinical curriculum redesign, a curriculum team led by family physicians systematically planned and implemented a 3-week course to prepare new third-year students for specialty-specific clerkships. METHODS: Informed by a formal needs assessment, we developed a classroom-based Clinical Skills Clerkship (CSC) with varied instructional approaches. The three major curriculum components are (1) specialty-specific, longitudinal clinical care of a three-generation virtual family that is taught in lectures and small groups and assessed with an objective structured clinical examination (OSCE), (2) clinical skills including procedure stations and interprofessional education experiences, and (3) a series of professional development activities. The CSC has 90 hours of curriculum taught by more than 120 faculty members from a wide variety of specialties and disciplines. A cohort of senior medical students teach in the course as part of a medical education elective. RESULTS: The CSC was first delivered to 98 students in 2012 who performed well on the course's OSCE. Quantitative and qualitative evaluations of both the curriculum components and the senior medical student teachers were positive. Performance on comparable CSC and Internal Medicine Clerkship OSCE stations and a series of student focus groups demonstrate longer-term impact. CONCLUSIONS: A successful curriculum redesign requires considerable planning and coordination. We designed and implemented a comprehensive CSC that was both well received and effective. Peer teaching programs can provide medical education leadership experiences with benefits for learners, teachers, and medical educators.

ABM clinical protocol #2: Guidelines for hospital discharge of the breastfeeding term newborn and mother: "The going home protocol," revised 2014.

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Electronic health record training in undergraduate medical education: bridging theory to practice with curricula for empowering patient- and relationship-centered care in the computerized setting.

While electronic health record (EHR) use is becoming state-of-the-art, deliberate teaching of health care information technology (HCIT) competencies is not keeping pace with burgeoning use. Medical students require training to become skilled users of HCIT, but formal pedagogy within undergraduate medical education (UME) is sparse. How can medical educators best meet the needs of learners while integrating EHRs into medical education and practice? How can they help learners preserve and foster effective communication skills within the computerized setting? In general, how can UME curricula be devised for skilled use of EHRs to enhance rather than hinder provision of effective, humanistic health care?Within this Perspective, the authors build on recent publications that "set the stage" for next steps: EHR curricula innovation and implementation as concrete embodiments of theoretical underpinnings. They elaborate on previous calls for maximizing benefits and minimizing risks of EHR use with sufficient focus on physician-patient communication skills and for developing core competencies within medical education. The authors describe bridging theory into practice with systematic longitudinal curriculum development for EHR training in UME at their institution, informed by Kern and colleagues' curriculum development framework, narrative medicine, and reflective practice. They consider this innovation within a broader perspective-the overarching goal of empowering undergraduate medical students' patient- and relationship-centered skills while effectively demonstrating HCIT-related skills.

An integrated virtual family curriculum to introduce specialty-specific clinical skills to rising third-year medical students.

BACKGROUND: Transitioning from a preclinical to a clinical curriculum can be challenging for medical students. As a central component of a new 3-week transition course, we designed, implemented, and evaluated an innovative Virtual Family Curriculum to introduce rising 3rd-year medical students to the knowledge, skills, and cultures of 6 core medical and surgical specialties. DESCRIPTION: The authors designed a 6-case, 24-hour, 3-generation Virtual Family Curriculum and a 6-station summative Objective Structured Clinical Examination (OSCE). Each case contains a lecture, video, discussion questions, skills practice, and faculty guide. We used both qualitative and quantitative evaluation methods. EVALUATION: Ninety-eight students took the inaugural course in 2012. All students passed the final OSCE. Students rated the virtual family curriculum a 5.17/6 (6 = highest). Comments about the curriculum were uniformly positive. CONCLUSIONS: We created and implemented an integrated Virtual Family Curriculum that systematically teaches specialty-specific knowledge and skills. This curriculum facilitates students' transition to clinical clerkships.

Introducing technology into medical education: two pilot studies.

OBJECTIVES: Educators are integrating new technology into medical curriculum. The impact of newer technology on educational outcomes remains unclear. We aimed to determine if two pilot interventions, (1) introducing iPads into problem-based learning (PBL) sessions and (2) online tutoring would improve the educational experience of our learners. METHODS: We voluntarily assigned 26 second-year medical students to iPad-based PBL sessions. Five students were assigned to Skype for exam remediation. We performed a mixed-method evaluation to determine efficacy. RESULTS: Pilot 1: Seventeen students completed a survey following their use of an iPad during the second-year PBL curriculum. Students noted the iPad allows for researching information in real time, annotating lecture notes, and viewing sharper images. Data indicate that iPads have value in medical education and are a positive addition to the curriculum. Pilot 2: Students agreed that online tutoring is at least or more effective than in-person tutoring. CONCLUSIONS: In our pilot studies, students experienced that iPads and Skype are beneficial in medical education and can be successfully employed in areas such as PBL and remediation. PRACTICE IMPLICATIONS: Educators should continue to further examine innovative opportunities for introducing technology into medical education.

Developing a peer-mentor program for medical students.

BACKGROUND: Doctoring is a 2-year preclinical course designed to teach medical students fundamental clinical skills. PURPOSE: We designed, implemented, and evaluated an innovative and cost-effective peer-mentoring program embedded within Doctoring. Our Teaching Academy (TA) included a formal orientation for teaching "Fellows." METHODS: During academic years 2008-09 and 2009-10, 2nd-year students were systematically selected by course faculty and then trained as TA Fellows to peer-mentor 1st-year students. Both TA Fellows and 1st-year medical students completed anonymous written surveys. RESULTS: Peer-mentors reported a significant increase of confidence in their ability to provide feedback (p < .001). First-year students reported a significant increase of confidence in their ability to conduct a medical interview and perform a physical exam (p < .001 for each). CONCLUSIONS: Student participation in a formal peer-mentor program embedded within a clinical skills course significantly increased, for both teachers and learners, confidence in their skills. Our program is easily transferrable to other courses and institutions.

Breastfeeding support for mothers in workplace employment or educational settings: summary statement.

The Academy of Breastfeeding Medicine is a worldwide organization of physicians dedicated to the promotion, protection, and support of breastfeeding and human lactation. Our mission is to unite into one association members of the various medical specialties with this common purpose.

Developing a national collaborative of medical educators who lead clinical skills courses.

BACKGROUND: The majority of US medical schools now have pre-clerkship clinical skills (PCCS) courses. Course directors for these often logistically complicated courses may be in different medical specialties and, historically, have had few formal opportunities for communication and collaboration with their counterparts at other institutions. As such, we hypothesized that leaders of PCCS courses would benefit from a national network. SUMMARY: In this paper, we outline the methodology used to form a national collaborative from grass roots interest. Over three years, a self-identified eleven-person task force with national representation has created an organization for PCCS course directors from US medical schools called Directors Of Clinical Skills courses (DOCS) that meets annually. CONCLUSIONS: Through iterative presentations at regional and national medical education meetings, we have produced an inventory of educational issues for those developing, administering, and evaluating PCCS courses. Further development of this nascent organization is ongoing. Our process is generalizable.

Fostering and evaluating reflective capacity in medical education: developing the REFLECT rubric for assessing reflective writing.

PURPOSE: Reflective writing (RW) curriculum initiatives to promote reflective capacity are proliferating within medical education. The authors developed a new evaluative tool that can be effectively applied to assess students' reflective levels and assist with the process of providing individualized written feedback to guide reflective capacity promotion. METHOD: Following a comprehensive search and analysis of the literature, the authors developed an analytic rubric through repeated iterative cycles of development, including empiric testing and determination of interrater reliability, reevaluation and refinement, and redesign. Rubric iterations were applied in successive development phases to Warren Alpert Medical School of Brown University students' 2009 and 2010 RW narratives with determination of intraclass correlations (ICCs). RESULTS: The final rubric, the Reflection Evaluation for Learners' Enhanced Competencies Tool (REFLECT), consisted of four reflective capacity levels ranging from habitual action to critical reflection, with focused criteria for each level. The rubric also evaluated RW for transformative reflection and learning and confirmatory learning. ICC ranged from 0.376 to 0.748 for datasets and rater combinations and was 0.632 for the final REFLECT iteration analysis. CONCLUSIONS: The REFLECT is a rigorously developed, theory-informed analytic rubric, demonstrating adequate interrater reliability, face validity, feasibility, and acceptability. The REFLECT rubric is a reflective analysis innovation supporting development of a reflective clinician via formative assessment and enhanced crafting of faculty feedback to reflective narratives.