A value analysis of longitudinal integrated clerkships: consideration of costs and benefits.

Longitudinal Integrated Clerkships (LICs) prioritise longitudinal relationships with faculty, patients, and place. Research shows that LICs benefit students and faculty, but most medical schools have limited LIC programmes. This is likely due to perceptions that LICs are more costly and complex than traditional block rotations (TBRs). The perceived cost versus evidence-based value related to clerkship education has not been examined in detail. Until recently, no 'All-LIC' medical school exemplars existed in the US, limiting the value of this model as well as the ability to examine relative cost and complexity. In this paper, we draw on our experience launching three 'All-LIC' medical schools in the United States - schools in which the entire clerkship class participates in a comprehensive clerkship-year LIC. We propose that the known benefits of LICs coupled with cost-mitigation strategies related to running an 'All LIC' model for core clinical clerkships, rather than block and LIC models simultaneously, results in a higher value for medical schools.

Characterization of Distinctive Teaching Practices in Longitudinal Integrated Clerkships: Perspectives From Students and Faculty.

Phenomenon: Longitudinal integrated clerkships (LICs) are novel curricula that place medical students in long-term learning and coaching relationships with faculty and require adaptation of teaching practices on the behalf of faculty to maximize learning outcomes. An understanding of how teaching in an LIC model differs from teaching trainees in more traditional models is critical to ensuring curricular innovation success through faculty development. Approach: A qualitative approach was used to describe the teaching practices of faculty and learning experiences of student participants in longitudinal integrated clerkships in different clinical and community settings. Forty-five faculty and 20 students participated in focus groups. Thematic analysis of focus group data was used to identify differences and similarities between groups, sites, and specialties. Findings: Two groupings of themes emerged in thematic analysis: (1) precepting strategies distinctive to the longitudinal integrated clerkship model and (2) precepting strategies enhanced when employed in the LIC model. Distinct to the LIC model, preceptors and students described the importance of understanding the curricular structure and supporting students in longitudinal care of patients. Enhanced in the LIC model are the strategies of relationship-based teaching, support of autonomy, feedback, and support of longitudinal growth in skills. Insights: Students and faculty across LIC sites were broadly aligned in their opinions of best practices for teaching in an LIC model. The longitudinal relationship between student and faculty in an LIC distinguishes this model from traditional block rotations and a distinctive approach to successful teaching is demonstrated. Preceptors use time afforded to build trusting relationships with students, which created opportunity for novel teaching approaches and enhanced otherwise effective teaching strategies. A focus on orientation to the curricular model and support of longitudinal relationships with patients may serve as an anchor for faculty development efforts in the development of an LIC.

How to implement a "standard of care" regulatory model for pharmacists.

National pharmacy associations have increasingly explored regulation according to a "standard of care." In such a model, pharmacists can provide a wide range of clinical services aligned with their education and training. Based on Idaho's experience implementing this model, there are five critical steps states must take to enact a standard of care: 1) Adopt a broad definition of "practice of pharmacy;" 2) Allow elasticity for practice innovation over time; 3) Decide which limited instances still necessitate prescriptive regulation; 4) Eliminate all unnecessary regulations; and 5) Strengthen accountability for deviations from the standard of care. States wishing to adopt a standard of care approach can follow this five-step process to enhance patient care and mitigate the lag that is otherwise constant between laws and practice.

Single Ion Pair Is Essential for Stabilizing SHP2's Open Conformation.

Src-homology-2-domain-containing PTP-2 (SHP2) is a widely expressed signaling enzyme whose misregulation is associated with multiple human pathologies. SHP2's enzymatic activity is controlled by a conformational equilibrium between its autoinhibited ("closed") state and its activated ("open") state. Although SHP2's closed state has been extensively characterized, the putative structure of its open form has only been revealed in the context of a highly activated mutant (E76K), and no systematic studies of the biochemical determinants of SHP2's open-state stabilization have been reported. To identify amino-acid interactions that are critical for stabilizing SHP2's active state, we carried out a mutagenic study of residues that lie at potentially important interdomain interfaces of the open conformation. The open/closed equilibria of the mutants were evaluated, and we identified several interactions that contribute to the stabilization of SHP2's open state. In particular, our findings establish that an ion pair between glutamate 249 on SHP2's PTP domain and arginine 111 on an interdomain loop is the key determinant of SHP2's open-state stabilization. Mutations that disrupt the R111/E249 ion pair substantially shift SHP2's open/closed equilibrium to the closed state, even compared to wild-type SHP2's basal-state equilibrium, which strongly favors the closed state. To the best of our knowledge, the ion-pair variants uncovered in this study are the first known SHP2 mutants in which autoinhibition is augmented with respect to the wild-type protein. Such "hyperinhibited" mutants may provide useful tools for signaling studies that investigate the connections between SHP2 inhibition and the suppression of human disease progression.

The spacing effect: Improving electrocardiogram interpretation.

BACKGROUND: Accurate electrocardiogram (ECG) interpretation is critical for safe patient care, making this skill a necessary competency for medical school graduation. Improved long-term memory retention with repeated exposure to material is one of the most evidenced-based components of adult learning science. This curricular innovation aimed to determine if implementing spaced repetition and retrieval practice using ECG quizzes during the principal clinical year would improve ECG interpretation skills among medical students enrolled in a Longitudinal Integrated Clerkship (LIC). APPROACH: The curricular innovation applied the spacing effect and retrieval practice. Cognitive science demonstrates enhanced long-term retention through repeated interval exposure to learned material. Studies of spaced retrieval indicate that memory retention is enhanced through tests involving effortful recall. LIC students in an intervention group were exposed to the spacing effect with periodic ECG quizzes throughout their clinical clerkship year. EVALUATION: The results of the 17-item post-test for 140 students were analysed: LIC intervention, N = 54; block control, N = 62; and LIC control, N = 24. The ANOVA test was significant (p < 0.001). Games-Howell post hoc testing showed that the mean score in the LIC intervention group was significantly higher compared with the LIC control group (p < 0.001) and the block control group (p < 0.001). There was no significant difference between the LIC control and block control groups (p = 0.59). IMPLICATIONS: Spaced repetition of material through ECG quizzes improved ECG interpretation skills on an ECG post-test and mitigates the forgetting curve, maintaining student competency in ECG interpretation.

Nanoscale patterning of collagens in C. elegans apical extracellular matrix.

Apical extracellular matrices (aECMs) are complex extracellular compartments that form important interfaces between animals and their environment. In the adult C. elegans cuticle, layers are connected by regularly spaced columnar structures known as struts. Defects in struts result in swelling of the fluid-filled medial cuticle layer ('blistering', Bli). Here we show that three cuticle collagens BLI-1, BLI-2, and BLI-6, play key roles in struts. BLI-1 and BLI-2 are essential for strut formation whereas activating mutations in BLI-6 disrupt strut formation. BLI-1, BLI-2, and BLI-6 precisely colocalize to arrays of puncta in the adult cuticle, corresponding to struts, initially deposited in diffuse stripes adjacent to cuticle furrows. They eventually exhibit tube-like morphology, with the basal ends of BLI-containing struts contact regularly spaced holes in the cuticle. Genetic interaction studies indicate that BLI strut patterning involves interactions with other cuticle components. Our results reveal strut formation as a tractable example of precise aECM patterning at the nanoscale.

Human Salmonellosis Outbreak Linked to Salmonella Typhimurium Epidemic in Wild Songbirds, United States, 2020-2021.

Salmonella infection causes epidemic death in wild songbirds, with potential to spread to humans. In February 2021, public health officials in Oregon and Washington, USA, isolated a strain of Salmonella enterica serovar Typhimurium from humans and a wild songbird. Investigation by public health partners ultimately identified 30 illnesses in 12 states linked to an epidemic of Salmonella Typhimurium in songbirds. We report a multistate outbreak of human salmonellosis associated with songbirds, resulting from direct handling of sick and dead birds or indirect contact with contaminated birdfeeders. Companion animals might have contributed to the spread of Salmonella between songbirds and patients; the outbreak strain was detected in 1 ill dog, and a cat became ill after contact with a wild bird. This outbreak highlights a One Health issue where actions like regular cleaning of birdfeeders might reduce the health risk to wildlife, companion animals, and humans.

Structure-Activity Relationships of Low Molecular Weight Alginate Oligosaccharide Therapy against Pseudomonas aeruginosa.

Low molecular weight alginate oligosaccharides have been shown to exhibit anti-microbial activity against a range of multi-drug resistant bacteria, including Pseudomonas aeruginosa. Previous studies suggested that the disruption of calcium (Ca2+)-DNA binding within bacterial biofilms and dysregulation of quorum sensing (QS) were key factors in these observed effects. To further investigate the contribution of Ca2+ binding, G-block (OligoG) and M-block alginate oligosaccharides (OligoM) with comparable average size DPn 19 but contrasting Ca2+ binding properties were prepared. Fourier-transform infrared spectroscopy demonstrated prolonged binding of alginate oligosaccharides to the pseudomonal cell membrane even after hydrodynamic shear treatment. Molecular dynamics simulations and isothermal titration calorimetry revealed that OligoG exhibited stronger interactions with bacterial LPS than OligoM, although this difference was not mirrored by differential reductions in bacterial growth. While confocal laser scanning microscopy showed that both agents demonstrated similar dose-dependent reductions in biofilm formation, OligoG exhibited a stronger QS inhibitory effect and increased potentiation of the antibiotic azithromycin in minimum inhibitory concentration and biofilm assays. This study demonstrates that the anti-microbial effects of alginate oligosaccharides are not purely influenced by Ca2+-dependent processes but also by electrostatic interactions that are common to both G-block and M-block structures.

Multistate outbreak of turtle-associated salmonellosis highlights ongoing challenges with the illegal sale and distribution of small turtles.

The sale and distribution of small turtles (shell length <4 inches) as pets has been banned in the United States since 1975 because of the risk of Salmonella transmission, especially to children. Despite this 48-year-old ban, salmonellosis outbreaks continue to be linked to contact with small turtles. During investigations of turtle-associated outbreaks, information regarding the turtle farm of origin is difficult to obtain because turtles are commonly sold by transient vendors. During 2020-2021, public health officials investigated a multistate illness outbreak caused by Salmonella enterica serotype Typhimurium linked to pet small turtles. Cases were defined as a laboratory-confirmed Salmonella Typhimurium infection highly related (within 0-6 allele differences) to the outbreak strain based on whole-genome sequencing analysis by core-genome multilocus sequence typing with illness onset occurring during 27 August 2020-14 May 2021. Forty-three patients were identified from 12 states; of these, 35% (15/43) were children <5 years old. Among patients with available information, 37% (14/38) were hospitalized, and one death was reported. Seventy-four percent (25/34) of patients reported turtle exposure in the week before illness onset, and 84% (16/19) specified exposure to small turtles. The outbreak strain was isolated from samples collected from a Pennsylvania patient's small turtle tank. Two patients reported purchasing their small turtles from pet stores. Salmonella Braenderup was isolated from samples collected from small turtles and their habitat at one of these stores; however, at that time, this strain was not associated with any human illnesses. This investigation was notable because of the documented sale of small turtles from several pet stores combined with the identification of a single small turtle supplier to these pet stores. The high proportion of children involved in this outbreak highlights the continued need to educate the pet industry as well as parents and caregivers about the risk of turtle-associated salmonellosis especially in children. Understanding and addressing the persisting challenges related to the illegal sale and distribution of small turtles could reduce the burden of turtle-associated salmonellosis.

The proprotein convertase BLI-4 promotes collagen secretion prior to assembly of the Caenorhabditis elegans cuticle.

Some types of collagens, including transmembrane MACIT collagens and C. elegans cuticle collagens, are N-terminally cleaved at a dibasic site that resembles the consensus for furin or other proprotein convertases of the subtilisin/kexin (PCSK) family. Such cleavage may release transmembrane collagens from the plasma membrane and affect extracellular matrix assembly or structure. However, the functional consequences of such cleavage are unclear and evidence for the role of specific PCSKs is lacking. Here, we used endogenous collagen fusions to fluorescent proteins to visualize the secretion and assembly of the first collagen-based cuticle in C. elegans and then tested the role of the PCSK BLI-4 in these processes. Unexpectedly, we found that cuticle collagens SQT-3 and DPY-17 are secreted into the extraembryonic space several hours before cuticle matrix assembly. Furthermore, this early secretion depends on BLI-4/PCSK; in bli-4 and cleavage-site mutants, SQT-3 and DPY-17 are not efficiently secreted and instead form large intracellular puncta. Their later assembly into cuticle matrix is reduced but not entirely blocked. These data reveal a role for collagen N-terminal processing in intracellular trafficking and the control of matrix assembly in vivo. Our observations also prompt a revision of the classic model for C. elegans cuticle matrix assembly and the pre-cuticle-to-cuticle transition, suggesting that cuticle layer assembly proceeds via a series of regulated steps and not simply by sequential secretion and deposition.

Battling professional self-sabotage: Embracing standard of care as the future of pharmacy regulation.

Laws and regulations are intended to protect the public; however, overregulation of the profession can block initiatives focused on patient safety and public health. This article discusses the 3 main regulatory approaches to pharmacy practice: standard of care (SOC), bright line, and right touch. An SOC regulatory model supports practitioners delivering patient care within their scope of practice and clinical training. Patient safety is maintained by measuring care against other practitioners within the same practice setting while supporting practitioners practicing at the top of their clinical ability. Compared with bright line and right touch approaches, the SOC regulatory model provides the adaptability needed to respond to different practice scenarios and settings, thus increasing access to health care and opportunities for innovation. To have a lasting impact on the profession and support patients, all pharmacy professionals must be fluent in regulatory approaches and advocate for states to transition to SOC regulatory models.

Preliminary Workforce Outcomes of an Urban Longitudinal Integrated Clerkship.

PURPOSE: The authors examined whether students participating in an urban longitudinal integrated clerkship (LIC) with a curriculum focused on care for underserved populations have a sustained commitment to urban underserved care through residency training and into practice. METHOD: This mixed-methods study collected data from medical student application essays to the Denver Health LIC (DH-LIC), end-of-course surveys, residency match outcomes, and postgraduation surveys annually for academic years 2014 to 2022. The authors analyzed students' responses to the surveys on interest in working with underserved patients, understanding the rewards and challenges of working in safety net institutions, working in the community to improve health, and working at DH. The authors qualitatively coded the 70 application essays of all selected students using summative content analysis. RESULTS: Seventy DH-LIC students were compared with 1,450 medical students between 2014 and 2022. Qualitative analysis of LIC application essays revealed 3 themes: interest in working with underserved populations, work experience with underserved populations, and personal experience with medical vulnerability. Fifty-seven DH-LIC participants (81.4%) expressed high levels of career interest in working with underserved populations, 45 (64.3%) had high levels of work experience with underserved populations, and 18 (25.7%) expressed high levels of personal experience. Graduates of the DH-LIC program demonstrated a high degree of continuing interest in practicing in urban underserved settings throughout medical school and postgraduate training. Ten graduates (71.4%) in practice work in urban underserved settings. Participants reported a high or very high level of interest and commitment to working with underserved populations (96.7%-100%), understanding the safety net health care system (91.7%-98.6%), and working in communities (95.0%-100%) at all time points studied. CONCLUSIONS: Early data indicate high rates of graduates working in urban underserved settings. These preliminary outcomes suggest the LIC may support the development of a committed workforce for urban underserved communities.

Revisiting the continuum of pharmacist prescriptive authority.

Pharmacists in all states have prescriptive authority in some form. We identify two broad categories of pharmacist prescribing: dependent and independent. There are gradients within these broad categories that allow us to chart pharmacist prescribing on a continuum from most restrictive to least restrictive. Independent prescribing has seen the most innovation in recent years at the state level, with at least three states adopting a "standard of care" prescribing framework that allows pharmacists to exercise broad prescriptive authority including for conditions that require a diagnosis. Each of the approaches to pharmacist prescriptive authority have perceived advantages and disadvantages as it relates to improving patient care.

Embedding anti-racism in Schools of Public Health: a pathway to accountability for progress towards equity.

The importance of seeing race as a socially constructed idea continues to produce unfair differences between humans and establishes power relations that lead to injustice and exposure to death. Since the racial justice movement in early 2020, there has been a heightened awareness of, and increased interest in, addressing historic racial disparities across Schools of Public Health (SPH) in Canada. Steps have been taken to recognize systemic racism and increase diversity through structural reforms to advance equity and inclusion; however, addressing racism demands collectively uprooting racist institutional designs still inherent in learning, teaching, research, service, and community engagement. This commentary highlights the need for sustained commitment to establishing longitudinal benchmarks for greater racial equity among students, staff, and faculty; revising curricula to include historic and contemporary narratives of colonialism and slavery; and providing community-engaged learning opportunities as instrumental to dismantle systemic drivers of racial health inequities locally and globally. We also advocate for intersectoral collaboration, mutual learning, and sharing of resources across SPH and partner agencies to accomplish a continual collective agenda for racial health equity and inclusion that is intersectional in Canada, while being held accountable to Indigenous and racialized communities.

RéSUMé: L'importance de voir la race comme une idée socialement construite continue de produire des différences inéquitables entre les gens et d'établir des relations de pouvoir qui mènent à l'injustice et à l'exposition à la mort. Depuis que le mouvement pour la justice raciale s'est enclenché au début de 2020, il existe une conscience aiguë des disparités raciales historiques entre les écoles de santé publique (ESP) du Canada et un intérêt accru pour le redressement de ces disparités. Des mesures ont été prises pour reconnaître le racisme systémique et accroître la diversité par des réformes structurelles visant à promouvoir l'équité et l'inclusion; cependant, pour aborder le racisme, il faut collectivement arracher les modèles institutionnels racistes qui font encore partie intégrante de l'apprentissage, de l'enseignement, de la recherche, des services et de la participation de la communauté. Dans notre commentaire, nous soulignons le besoin d'un engagement soutenu à établir des repères longitudinaux pour une plus grande équité raciale dans la population étudiante, au sein du personnel et dans le corps professoral, à revoir les programmes d'études pour y inclure les discours historiques et contemporains du colonialisme et de l'esclavage, et à offrir des possibilités d'enseignement faisant appel aux communautés, car elles contribueront à démanteler les moteurs systémiques des iniquités raciales en santé à l'échelle locale et mondiale. Nous promulguons aussi la collaboration intersectorielle, l'apprentissage mutuel et le partage des ressources entre les ESP et les organismes partenaires afin de concrétiser un plan d'action collective continue en faveur de l'équité raciale en santé et de l'inclusion ­ un plan qui sera intersectionnel au Canada et qui rendra des comptes aux communautés autochtones et racisées.

AACP Strategic Engagement Committee Report: Report of the 2022-2023 Strategic Engagement Standing Committee.

The American Association of Colleges of Pharmacy recognizes strategic engagement as critical to the success of pharmacy education, contributing to the expansion of pharmacy and public health practice, the fulfillment of institutional missions, and the meeting of programmatic needs. The 2022-2023 Strategic Engagement Committee or the Committee was charged with identifying ways professional advocacy is being emphasized in Doctor of Pharmacy and graduate education curricula to optimize active student engagement and share new resources for the ongoing resource guide being developed by the association. The Committee was also tasked with identifying advocacy champions at each member institution, integrating them into the work of the American Association of Colleges of Pharmacy Policy Advisory Task Force, and identifying strong advocacy partnerships between colleges and schools of pharmacy and state pharmacy organizations that can be replicated to advance the legislative or regulatory priorities of the profession. The Committee conducted a 2-part, sequential advocacy survey to identify advocacy champions at member institutions and to gain better insight into the breadth and depth of current advocacy efforts within pharmacy programs. The Committee also developed suggestions for the advocacy activities that should be required in pharmacy curricula, as well as exemplary activities identified through surveying advocacy champions.

Our Patients Need Empathy Training across Healthcare Professions.

Vulnerable populations are those who experience disparity at a disproportionate rate. For this article, specific vulnerable populations of interest include people who experience intellectual or developmental disorders, mental illness, or substance misuse. Vulnerable populations are some of the most stigmatized populations in our society. Research shows that vulnerable populations receive less empathic care than general health care populations, resulting in reduced quality of care and disparities in health outcomes. Empathy, a necessary health care competency, is associated with improved patient outcomes, enhanced job satisfaction, and increased retention and resilience across health care professions. However, there is no current standard for how empathy is taught, assessed, or sustained. Even when empathy education is implemented in healthcare professions curricula, research has demonstrated that it appears to erode with experience and time. In addition, the COVID-19 pandemic has exacerbated inequities in health care systems, with consequences for both patients and providers. There is an urgent need to develop efficacious training in empathy across health care professions to foster and sustain a robust workforce and improve health care experiences and outcomes.

Opportunities for pharmacist prescriptive authority of buprenorphine following passage of the Mainstreaming Addiction Treatment (MAT) Act.

In December 2022, Congress passed the Mainstreaming Addiction Treatment Act, which removed the federal legal barrier to pharmacist buprenorphine prescribing. As a result, each state can now decide whether or not to allow pharmacists to prescribe buprenorphine as an additional access point to reduce fatal opioid overdoses. At least 10 states allow pharmacists to prescribe controlled substances under collaborative practice agreements. Two states (California and Idaho) have also created pathways for independent prescribing of buprenorphine by pharmacists. Additional states should seek to enable pharmacists to prescribe buprenorphine to increase access to a proven beneficial treatment and help reduce fatal opioid overdoses.