Community paramedicine in dementia care.

BACKGROUND: Novel hospital diversion strategies are needed to support a growing number of patients with dementia living in the community. One promising model is community paramedicine (CP), which deploys paramedics to the home, who consult with a physician to coordinate treatment and assess disposition. While evidence suggests CP can manage many patients without escalation to the emergency department (ED), no studies have evaluated optimal CP utilization for patients with dementia. Therefore, we compare the use and outcomes of CP for homebound patients with and without dementia. METHODS: This retrospective cohort study examines 251 homebound patients receiving home-based primary care, who utilized a physician-led CP service between March 2017 and May 2022. Linked electronic health record data included patient demographics, clinical characteristics, and CP encounter details. Dementia status and CP outcomes, including rates of ED transport, over-transport (i.e., transported, but not hospitalized), and under-transport (i.e., not transported, but ED visit within 3 days), were determined via chart review. Using logistic regression, we modeled the association of dementia status with over- and under-transport, adjusting for age, sex, and chief complaint. RESULTS: Fifty-three percent of CP patients had dementia. Their most common chief complaints were dyspnea (24.3%), altered mental status (17.9%), and generalized weakness (9.8%). We found no significant difference in ED transport rates by dementia status (25.4 vs. 22.8%, p = 0.54). Dementia diagnosis was associated with lower rates of over-transport (OR = 0.21, p = 0.03, CI [0.05, 0.85]) and comparable rates of under-transport (OR = 0.70, p = 0.47, CI [0.27, 1.83]) in adjusted models. CONCLUSIONS: CP has effectively managed a diverse population of homebound patients with dementia cared for via home-based primary care. Future work should examine potential cost savings and use of CP in dementia care across geographic and healthcare settings.

If You Give Them Away, It Still May Not Work: Challenges to Video Telehealth Device Use Among the Urban Homebound.

The growing homebound population may particularly benefit from video telehealth. However, some patients do not have the ability or resources to successfully use this modality. This report presents the experience of a large urban home-based primary care program disseminating cellular-enabled tablets with basic instruction to a subset of its patients who would not otherwise have had the ability to engage in video telehealth. Program goals included: increasing the number of patients able to engage in video encounters and leveraging technology to help achieve greater equity. While 123 homebound patients received devices for telehealth, only one-third successfully utilized them. We identified multiple barriers to telehealth utilization beyond physical access to a device, including a lack of skill. Efforts to increase video encounters among patient groups who are less experienced with technology cannot simply rely on device provision or basic instruction but must include reinforced learning strategies combined with ongoing technical assistance.

Barriers to telehealth access among homebound older adults.

BACKGROUND/OBJECTIVES: To identify major barriers to video-based telehealth use among homebound older adults. DESIGN: Cross-sectional survey. SETTING: A large home-based primary care (HBPC) program in New York City (NYC) serving 873 homebound patients living in the community. PARTICIPANTS: Sixteen primary care physicians. MEASUREMENTS: An 11-item assessment of provider perceptions of patients' experience with and barriers to telehealth. RESULTS: According to physicians in the HBPC program, more than one-third (35%) of homebound patients (mean age of 82.7; 46.6% with dementia; mean of 4 comorbidities/patient) engaged in first-time video-based telehealth encounters between April and June 2020 during the first COVID-19 surge in NYC. The majority (82%) required assistance from a family member and/or paid caregiver to complete the visit. Among patients who had not used telehealth, providers deemed 27% (n = 153) "unable to interact over video" for reasons including cognitive or sensory impairment and 14% lacked access to a caregiver to assist them with technology. Physicians were not knowledgeable of their patients' internet connectivity, ability to pay for cellular plans, or video-capable device access. CONCLUSION: The COVID-19 pandemic resulted in a large and dramatic shift to video-based telehealth use in home-based primary care. However, 4 months into the pandemic a majority of patients had not participated in a video-based telehealth encounter due to a number of barriers. Patients lacking caregiver support to assist with technology may benefit from novel approaches such as the deployment of community health workers to assist with device setup. Physicians may not be able to identify potentially modifiable barriers to telehealth use among their patients, highlighting the need for better systematic data collection before targeted interventions to increase video-based telehealth use.

Too Many Hats? Conflicts of Interest in Learning Community Faculty Roles.

PURPOSE: Many US medical schools have adopted learning communities to provide a framework for advising and teaching functions. Faculty who participate in learning communities often have additional educator roles. Defining potential conflicts of interest (COIs) among these roles is an important consideration for schools with existing learning communities and those looking to develop them, both for transparency with students and also to comply with regulatory requirements. METHODS: A survey was sent to the institutional contact for each of the 42 Learning Communities Institute (LCI) member medical schools to assess faculty opinions about what roles potentially conflict. The survey asked the role of learning community faculty in summative and formative assessment of students and whether schools had existing policies around COIs in medical education. RESULTS: In all, 35 (85%) LCI representatives responded; 30 (86%) respondents agreed or strongly agreed that learning community faculty should be permitted to evaluate their students for formative purposes, while 19 (54%) strongly agreed or agreed that learning community faculty should be permitted to evaluate their students in a way that contributes to a grade; 31 (89%) reported awareness of the accreditation standard ensuring "that medical students can obtain academic counseling from individuals who have no role in making assessment or promotion decisions about them," but only 10 (29%) had a school policy about COIs in education. There was a wide range of responses about what roles potentially conflict with being a learning community faculty. CONCLUSION: The potential for COIs between learning community faculty and other educator roles concerns faculty at schools with learning communities, but most schools have not formally addressed these concerns.

Medical Students' Experiences of Unplanned Leaves of Absence.

CONTEXT: Many medical students take leaves of absence (LOA), both planned and unplanned. Unplanned LOA relate to personal or academic situations which arise and create the need for a student to temporarily suspend their medical education. This can be a high-stakes decision for the student and the school. However, there is a dearth of published literature regarding the experience of students who take a LOA to guide decision-makers. The aim of this study is to examine the experiences of medical students who took an unplanned LOA and subsequently returned to school. METHODS: A phenomenological analysis of semi-structured interviews of eight medical students returning from unplanned LOAs at two urban, academic medical centers was conducted. Transcripts were analyzed and themes were coded, and consensus regarding all themes was reached through an iterative process. RESULTS: Eight themes were identified. Some important concerns included having a sense of choice to take a LOA, the burden of logistical issues, clear communication from administrators, and worries about stigma upon return. The students retrospectively viewed their LOA as helpful and their subsequent return as less stressful than feared. DISCUSSION: The experiences of these students indicate several primary concerns that medical schools can anticipate in order to support students considering or taking an unplanned LOA. The more information a school is able to share with these students, the greater the potential to reduce anxiety at this vulnerable stage. Future research should attempt to explore these findings in a larger sample and correlate them with academic and other outcomes.

Developing Professionalism and Professional Identity Through Unproctored, Flexible Testing.

The medical education community has devoted a great deal of attention to the development of professionalism in trainees within the context of clinical training-particularly regarding trainees' handling of ethical dilemmas related to clinical care. The community, however, knows comparatively less about the development of professional behavior in medical students during the preclerkship years. In medical schools with flexible testing, students take quizzes or examinations in an unproctored setting at a time of their choosing-as long as it falls within a specified window of time. Unproctored, flexible testing offers students early opportunities to develop appropriate professional behavior. In this Perspective, the authors outline different flexible testing models from three institutions-University of Virginia School of Medicine, University of Michigan Medical School, and Icahn School of Medicine at Mount Sinai-all of which offer various levels of testing flexibility in relation to time and location. The authors' experiences with these models suggest that preclinical medical students' early development of professional behavior requires scaffolding by faculty and staff. Scaffolding involves setting clear, specific expectations for students (often through the form of an honor code), as well as active engagement and discussion with learners about the expectations and procedures for self-regulation in the academic environment.

Scylla and Charybdis: The MCAT, USMLE, and Degrees of Freedom in Undergraduate Medical Education.

In recent years, medical educators have been making meaningful attempts to rethink how premedical students are prepared for medical school, and how medical students are prepared for residency. Among the many challenges to redesigning premedical and medical school curricula, one that stands out is the constraint imposed by our current methods of assessing aptitude, particularly our use of the Medical College Admissions Test (MCAT) and the United States Medical Licensing Examination (USMLE). For much of the past century, medical school and residency admissions committees have relied heavily on MCAT and USMLE scores to evaluate and rank candidates to their programs. These high-stakes exams determine to a large extent what is taught, and what is stressed, in preparation for and during medical school-despite the fact that scores have limited ability to predict future success in clinical medicine or biomedical research. Additionally, evidence indicates that students from disadvantaged and minority backgrounds do not fare as well on these exams and, as a result, may be disproportionately excluded from the medical profession. While medical school admissions committees have made limited incremental gains in holistic review, residency programs appear to be increasingly focused on USMLE Step scores and veering away from the spirit of holistic review. The authors propose that substantive change will remain slow in coming unless members of the medical education community radically rethink how we report scores from these exams, and how we use them in our selection of future medical students and residents.

Health Literacy in Transitions of Care: An Innovative Objective Structured Clinical Examination for Fourth-Year Medical Students in an Internship Preparation Course.

BACKGROUND: Low health literacy is associated with adverse health outcomes, especially during transitions of care. Competency-based assessments may improve communication during this time. AIM: To develop an Objective Structured Clinical Examination (OSCE) for medical students to demonstrate communication skills to be used during the hospital discharge process with patients of low health literacy. SETTING: The OSCE was integrated into the curriculum of an internship preparatory clerkship. PARTICIPANTS: One hundred and one fourth-year medical students participated. PROGRAM DESCRIPTION: Students received a skills-based health literacy workshop. In the OSCE, learners counseled standardized patients regarding initiation of anticoagulation at discharge and wrote discharge instructions. PROGRAM EVALUATION: Fifty-seven students completed the workshop prior to the OSCE, and 44 participated in the workshop after the completing the OSCE. Participants who completed the workshop first outperformed their peers on the checklist (15.1 vs. 13.4, p < 0.0001) and on the reading level of their written instructions (9.9 vs. 10.6, p = 0.01); 82% felt confident communicating with patients of low health literacy after the workshop and OSCE. DISCUSSION: This OSCE is a tool to train and evaluate future interns' ability to communicate with patients of limited health literacy levels at hospital discharge. Such innovations may make this period of time safer for patients, improving health outcomes.

Long case or case vignettes: a comparison of two instructional methods in inpatient geriatrics for medical students.

The varied, atypical manifestations of geriatric syndromes make knowledge transfer the ability to extend knowledge from one context to another a particularly relevant concept. The authors hypothesized that multiple, contrasting short cases, by facilitating knowledge transfer, would improve knowledge more than a single long case in geriatric medicine. The authors' objective was to assess the impact of two instructional methods (a single long case vs. contrasting short cases) on knowledge and knowledge retention among 3rd-year medical students on their Internal Medicine-Geriatrics Clerkship. They participated in the curriculum which consisted of four weekly mandatory sessions covering five content areas based on a systematic needs assessment. Instructional method alternated by month. Knowledge and knowledge retention were measured using an online multiple-choice question test administered before, immediately after, and one year following the curriculum. Students also completed a demographic survey prior to the curriculum and an evaluation of the curriculum following the curriculum. There was significant improvement in test scores from pre- to postcurriculum in both groups that persisted one year after the experience with no significant differences between the two groups. The two case-based instructional methods resulted in significant and enduring knowledge improvement, but one method was not better than the other.

Medical students' experiences with authorship in biomedical research: a national survey.

PURPOSE: To explore authorship issues related to medical students' primary research projects, assess medical students' knowledge about authorship issues in biomedical research, and determine their interest in learning about authorship guidelines. METHOD: In 2011, the authors developed and conducted an electronic survey of 243 U.S. medical students who attended an educational event at the National Institutes of Health as part of their funded, yearlong research fellowship programs. The authors then analyzed the results using descriptive statistics. RESULTS: Of 243 students, 152 (63%) responded. Most (120/151; 79%) had completed or were in the process of writing a manuscript based on their projects. Of these, most (95/119; 80%) wrote the entire manuscript independently or with guidance. Whereas almost two-thirds (99/152; 65%) indicated that expectations and criteria for authorship were clarified for them, 26% (40/152) indicated that they were not. Most students (108/118; 92%) were in the authorship position they expected and had no concerns about who the other authors were (91/119; 77%). Of those with concerns, 52% (11/21) did not raise the issue for fear of challenging their mentor. Two-thirds (95/145; 66%) never received formal training in authorship guidelines, and 41% (42/103) believed such training would be valuable. CONCLUSIONS: Although a majority of students had conversations about authorship and were clear about the guidelines for ethical authorship, additional work is needed. The authors recommend that academic institutions develop a menu of options for teaching students about this important area in research ethics.

Incidence of venous thromboembolism in a homebound population.

Venous thromboembolism (VTE) is a source of morbidity and mortality for high risk populations. The incidence of VTE has been characterized in many populations, but the incidence in homebound patients, a growing demographic, is unknown. The objective of this study was to estimate the incidence of VTE occurring at home in a cohort of patients enrolled in the Mount Sinai Visiting Doctor's Program (VDP), a home-based primary care program. The medical records of patients enrolled in the VDP over a 4 year period were examined. Incident VTE in a home setting was defined as the diagnosis of any symptomatic deep vein thrombosis or pulmonary embolism that did not occur during a hospitalization, within 4 weeks of a medical hospitalization, or within 12 weeks of a hospitalization for surgery. Functional status was abstracted for all patients, when available. Of 1,910 patients active during the study period, 39 cases of at-home VTE were identified (8.0 per 1,000 person years [95 % CI = 7.6-8.3]). Of these events, 30 of 39 were confirmed by radiological testing and considered definite, and 9 were considered probable. There was no statistically significant difference in age, race, or sex between the patients with and without VTE. In conclusion the estimated incidence of symptomatic VTE in a homebound population is low. There is insufficient evidence to support routine surveillance or prophylaxis strategies for VTE in homebound patients.

Readability of patient education materials available at the point of care.

BACKGROUND: Many patient education materials (PEMs) available on the internet are written at high school or college reading levels, rendering them inaccessible to the average US resident, who reads at or below an 8(th) grade level. Currently, electronic health record (EHR) providers partner with companies that produce PEMs, allowing clinicians to access PEMs at the point of care. OBJECTIVE: To assess the readability of PEMs provided by a popular EHR vendor as well as the National Library of Medicine (NLM). DESIGN: We included PEMs from Micromedex, EBSCO, and MedlinePlus. Micromedex and EBSCO supply PEMs to Meditech, a popular EHR supplier in the US. MedlinePlus supplies the NLM. These PEM databases have high market penetration and accessibility. MEASUREMENTS: Grade reading level of the PEMs was calculated using three validated indices: Simple Measure of Gobbledygook (SMOG), Gunning Fog (GFI), and Flesch-Kincaid (FKI). The percentage of documents above target readability and average readability scores from each database were calculated. RESULTS: We randomly sampled 100 disease-matched PEMs from three databases (n = 300 PEMs). Depending on the readability index used, 30-100% of PEMs were written above the 8(th) grade level. The average reading level for MedlinePlus, EBSCO, and Micromedex PEMs was 10.2 (1.9), 9.7 (1.3), and 8.6 (0.9), respectively (p ≤ 0.000) as estimated by the GFI. Estimates of readability using SMOG and FKI were similar. CONCLUSIONS: The majority of PEMS available through the NLM and a popular EHR were written at reading levels considerably higher than that of the average US adult.

Effect of a 1-week clinical rotation in palliative medicine on medical school graduates' knowledge of and preparedness in caring for seriously ill patients.

OBJECTIVES: To assess the effect of a required 1-week clinical rotation in palliative medicine during a 12-week internal medicine-geriatrics clerkship on graduating medical students' knowledge and self-assessed preparedness in caring for seriously ill patients. DESIGN: Historical control trial. SETTING: Mount Sinai School of Medicine (MSSM), New York, New York. PARTICIPANTS: Students from the MSSM classes of 2007 (MS07) and 2008 (MS08). INTERVENTION: MS08 was the first class to complete the required clinical rotation in palliative medicine. MS07 served as a historical control, having received only didactics in palliative care but no clinical rotation. MEASUREMENTS: Both classes were invited to complete an anonymous online survey designed to assess experiences and preparedness in caring for seriously ill patients and a 30-question multiple choice knowledge examination. RESULTS: Fifty-eight (55%) students from MS07 and 59 (51%) students from MS08 completed the survey. Students from MS08 rated their skill level in several areas of pain management and communication more favorably than did students from MS07. Mean scores on the knowledge portion of the survey were not significantly different between the two classes. CONCLUSION: Graduating medical students who had a 1-week clinical rotation in palliative medicine had higher self-assessed skills in pain management and communication than students who received no clinical exposure. A brief clinical experience in palliative care should be considered for integration into the curriculum at all medical schools.

Medical student documentation in the medical record: is it a liability?

Medical students have routinely documented patient encounters in both inpatient and outpatient care venues. This hands-on experience has provided a way for students to reflect on patient encounters, learn proper documentation skills, and attain a sense of being actively involved in and responsible for the care of patients. Over the last several years, the practice of student note writing has come into question. Institutional disincentives to student documentation include insurance regulations that restrict student documentation from substantiating billing claims, concerns about the legal status of student notes, and implementation of electronic medical records that do not allow or restrict student access. The increased scrutiny of the medical record from pay-for-performance programs and other quality measures will likely add to the pressure to exclude students from writing notes. This trend in limiting medical student documentation may have wide-ranging consequences for student education, from delaying the learning of proper documentation skills to limiting training opportunities. This article reviews the educational value of student note writing, the factors that have made student documentation problematic, and the potential educational impact of limiting student documentation. In addition, it offers some suggestions for future research to guide policy in this area.