Using machine learning to identify key subject categories predicting the pre-clerkship and clerkship performance: 8-year cohort study.

BACKGROUND: Medical students need to build a solid foundation of knowledge to become physicians. Clerkship is often considered the first transition point, and clerkship performance is essential for their development. We hope to identify subjects that could predict the clerkship performance, thus helping medical students learn more efficiently to achieve high clerkship performance. METHODS: This cohort study collected background and academic data from medical students who graduated between 2011 and 2019. Prediction models were developed by machine learning techniques to identify the affecting features in predicting the pre-clerkship performance and clerkship performance. Following serial processes of data collection, data pre-processing before machine learning, and techniques and performance of machine learning, different machine learning models were trained and validated using the 10-fold cross-validation method. RESULTS: Thirteen subjects from the pre-med stage and ten subjects from the basic medical science stage with an area under the ROC curve (AUC) greater than 0.7 for either pre-clerkship performance or clerkship performance were found. In each subject category, medical humanities and sociology in social science, chemistry and physician scientist-related training in basic science, and pharmacology, immunology-microbiology, and histology in basic medical science have predictive abilities for clerkship performance above the top tertile. Using a machine learning technique based on random forest, the prediction model predicted clerkship performance with 95% accuracy and 88% AUC. CONCLUSION: Clerkship performance was predicted by selected subjects or combination of different subject categories in the pre-med and basic medical science stages. The demonstrated predictive ability of subjects or categories in the medical program may facilitate students' understanding of how these subjects or categories of the medical program relate to their performance in the clerkship to enhance their preparedness for the clerkship.

The effects of electroencephalography functional connectivity during emotional recognition among patients with major depressive disorder and healthy controls.

BACKGROUND: The brain of major depressive disorder (MDD) is associated with altered functional connectivity (FC) compared to that of healthy individuals when processing positive and negative visual stimuli. Building upon alterations in brain connectivity, some researchers have employed electroencephalography (EEG) to study FC in MDD, aiming to enhance both diagnosis and treatment; however, the results have been inconsistent and the studies involving FC during emotional recognition are limited. This study aims to 1) investigate the effects of MDD on EEG patterns during visual emotional processing, 2) explore the therapeutic effects of antidepressant treatment on brain FC within the first week, and assess whether these effects can be predictive of treatment outcomes four weeks later, and 3) study baseline FC parameter biomarkers that can be used to predict treatment responsiveness in MDD patients. METHODS: This clinical observational study recruited 38 healthy controls (HC) and 48 MDD patients. Patients underwent an EEG exam while looking at validated images of happy and sad faces at week 0 and 1. MDD patients were categorized into treatment responders and non-responders after 4 weeks of treatment. We conducted the FC analysis (node strength (NS), global efficiency (GE), and cluster coefficient (CC)) on HC and MDD patients using graph theoretical analysis. Multivariable linear regression was used to evaluate the influence of MDD on FC compared to HC, while controlling for confounding variables including age, gender, and academic degrees. RESULTS: At week 0 and week 1, MDD patients revealed to have significant reductions in FC parameters (NS, GE and CC) compared to HC. When comparing MDD patients at week 1 post-antidepressant treatment and pre-treatment, no significant differences in FC changes were observed. Multivariable regression revealed a significant negative effect on FC of MDD. Compared to the treatment non-responsive group, the responsive group revealed a significantly higher FC in delta band frequency at baseline. CONCLUSIONS: MDD patient group showed impaired FC during visual emotion-processing and we observed baseline FC parameters to be associated with treatment response at week 4. While signs of FC changes were observed in the brain after a week of treatment, it is possible that one week may still be insufficient to demonstrate significant alterations in the brain. Our results suggest the potential utilization of EEG-based FC as an indicative measure for predicting treatment response and monitoring treatment progress in MDD patients.

Negative effects on medical students' scores for clinical performance during the COVID-19 pandemic in Taiwan: a comparative study.

PURPOSE: Coronavirus disease 2019 (COVID-19) has heavily impacted medical clinical education in Taiwan. Medical curricula have been altered to minimize exposure and limit transmission. This study investigated the effect of COVID-19 on Taiwanese medical students' clinical performance using online standardized evaluation systems and explored the factors influencing medical education during the pandemic. METHODS: Medical students were scored from 0 to 100 based on their clinical performance from 1/1/2018 to 6/31/2021. The students were placed into pre-COVID-19 (before 2/1/2020) and midst-COVID-19 (on and after 2/1/2020) groups. Each group was further categorized into COVID-19-affected specialties (pulmonary, infectious, and emergency medicine) and other specialties. Generalized estimating equations (GEEs) were used to compare and examine the effects of relevant variables on student performance. RESULTS: In total, 16,944 clinical scores were obtained for COVID-19-affected specialties and other specialties. For the COVID-19-affected specialties, the midst-COVID-19 score (88.513.52) was significantly lower than the pre-COVID-19 score (90.143.55) (P<0.0001). For the other specialties, the midst-COVID-19 score (88.323.68) was also significantly lower than the pre-COVID-19 score (90.063.58) (P<0.0001). There were 1,322 students (837 males and 485 females). Male students had significantly lower scores than female students (89.333.68 vs. 89.993.66, P=0.0017). GEE analysis revealed that the COVID-19 pandemic (unstandardized beta coefficient=-1.99, standard error [SE]=0.13, P<0.0001), COVID-19-affected specialties (B=0.26, SE=0.11, P=0.0184), female students (B=1.10, SE=0.20, P<0.0001), and female attending physicians (B=-0.19, SE=0.08, P=0.0145) were independently associated with students' scores. CONCLUSION: COVID-19 negatively impacted medical students' clinical performance, regardless of their specialty. Female students outperformed male students, irrespective of the pandemic.

Functional connectivity analysis on electroencephalography signals reveals potential biomarkers for treatment response in major depression.

BACKGROUND: The treatment efficacy varies across individual patients with major depressive disorder (MDD). It lacks robust electroencephalography (EEG) markers for an antidepressant-responsive phenotype. METHOD: This is an observational study enrolling 28 patients with MDD and 33 healthy controls (mean age of 40.7 years, and 71.4% were women). Patients underwent EEG exams at baseline (week0) and week1, while controls' EEG recordings were acquired only at week0. A resting eye-closing EEG segment was analyzed for functional connectivity (FC). Four parameters were used in FC analysis: (1) node strength (NS), (2) global efficiency (GE), (3) clustering coefficient (CC), and (4) betweenness centrality (BC). RESULTS: We found that controls had higher values in delta wave in the indices of NS, GE, BC, and CC than MDD patients at baseline. After treatment with antidepressants, patients' FC indices improved significantly, including GE, mean CC, and mean NS in the delta wave. The FC in the alpha and beta bands of the responders were higher than those of the non-responders. CONCLUSIONS: The FC of the MDD patients at baseline without treatment was worse than that of controls. After treatment, the FC improved and was close to the values of controls. Responders showed better FC in the high-frequency bands than non-responders, and this feature exists in both pre-treatment and post-treatment EEG.

The quantified analysis of the correlation between medical humanities curriculums and medical students' performance.

BACKGROUND: A high-quality medical humanities (MH) education program is essential to developing a successful medical practitioner and can influence clinical performance. It is also vital to improve the evaluation of MH education to restore harmonious mutual relationships in medical care. However, studies have yet to discuss the correlation between the learning quality and quantity of medical humanities curriculums (MHC) and medical students' scores of clinical curriculums and clinical performance. The study aimed to assess the correlation between the learning quality and quantity of MHC and medical students' performance. METHODS: We conducted a retrospective cohort study by analyzing a dataset of students' learning records. After excluding students with missing demographic information (n = 1) and overseas Chinese students (n = 15), the study included six- and seven-year program medical school students (n = 354) at National Yang-Ming University who were admitted between 2012 and 2014. The correlation between learning quality and quantity in MHC and students' following performance was evaluated by multivariable-adjusted regression analyses. RESULTS: After adjusting for potential confounders (gender, residential area, age at enrollment, type of administration, and school program), the number of MHC with good learning outcomes was significantly correlated with clinical curriculum scores (p < 0.05), clerkship performance (p < 0.001), and weighted average mark (p < 0.001). CONCLUSIONS: Our study found a correlation between MHC with good learning outcomes and medical students' following performance. A future study of improving the quality of MH education is warranted.

Investigating genetic variants for treatment response to selective serotonin reuptake inhibitors in syndromal factors and side effects among patients with depression in Taiwanese Han population.

Major depressive disorder (MDD) is associated with high heterogeneity in clinical presentation. In addition, response to treatment with selective serotonin reuptake inhibitors (SSRIs) varies considerably among patients. Therefore, identifying genetic variants that may contribute to SSRI treatment responses in MDD is essential. In this study, we analyzed the syndromal factor structures of the Hamilton Depression Rating Scale in 479 patients with MDD by using exploratory factor analysis. All patients were followed up biweekly for 8 weeks. Treatment response was defined for all syndromal factors and total scores. In addition, a genome-wide association study was performed to investigate the treatment outcomes at week 4 and repeatedly assess all visits during follow-up by using mixed models adjusted for age, gender, and population substructure. Moreover, the role of genetic variants in suicidal and sexual side effects was explored, and five syndromal factors for depression were derived: core, insomnia, somatic anxiety, psychomotor-insight, and anorexia. Subsequently, several known genes were mapped to suggestive signals for treatment outcomes, including single-nucleotide polymorphisms (SNPs) in PRF1, UTP20, MGAM, and ENSG00000286536 for psychomotor-insight and in C4orf51 for anorexia. In total, 33 independent SNPs for treatment responses were tested in a mixed model, 12 of which demonstrated a p value <0.05. The most significant SNP was rs2182717 in the ENSR00000803469 gene located on chromosome 6 for the core syndromal factor (ß = -0.638, p = 1.8 × 10-4) in terms of symptom improvement over time. Patients with a GG or GA genotype with the rs2182717 SNP also exhibited a treatment response (ß = 0.089, p = 2.0 × 10-6) at week 4. Moreover, rs1836075352 was associated with sexual side effects (p = 3.2 × 10-8). Pathway and network analyses using the identified SNPs revealed potential biological functions involved in treatment response, such as neurodevelopment-related functions and immune processes. In conclusion, we identified loci that may affect the clinical response to treatment with antidepressants in the context of empirically defined depressive syndromal factors and side effects among the Taiwanese Han population, thus providing novel biological targets for further investigation.

Equal Z standard-setting method to estimate the minimum number of panelists for a medical school's objective structured clinical examination in Taiwan: a simulation study

PURPOSE: Undertaking a standard-setting exercise is a common method for setting pass/fail cut scores for high-stakes examinations. The recently introduced equal Z standard-setting method (EZ method) has been found to be a valid and effective alternative for the commonly used Angoff and Hofstee methods and their variants. The current study aims to estimate the minimum number of panelists required for obtaining acceptable and reliable cut scores using the EZ method. METHODS: The primary data were extracted from 31 panelists who used the EZ method for setting cut scores for a 12-station of medical school's final objective structured clinical examination (OSCE) in Taiwan. For this study, a new data set composed of 1,000 random samples of different panel sizes, ranging from 5 to 25 panelists, was established and analyzed. Analysis of variance was performed to measure the differences in the cut scores set by the sampled groups, across all sizes within each station. RESULTS: On average, a panel of 10 experts or more yielded cut scores with confidence more than or equal to 90% and 15 experts yielded cut scores with confidence more than or equal to 95%. No significant differences in cut scores associated with panel size were identified for panels of 5 or more experts. CONCLUSION: The EZ method was found to be valid and feasible. Less than an hour was required for 12 panelists to assess 12 OSCE stations. Calculating the cut scores required only basic statistical skills.

Medical school grades may predict future clinical competence.

BACKGROUND: In real-world medical education, there is a lack of reliable predictors of future clinical competencies. Hence, we aim to identify the factors associated with clinical competencies and construct a prediction model to identify "improvement required" trainees. METHODS: We analyzed data from medical students who graduated from National Yang-Ming University with clerkship training and participated in the postgraduate year (PGY) interview at Taipei Veterans General Hospital. Clinical competencies were evaluated using grades of national objective structured clinical examination (OSCEs). This study used data from medical students who graduated in July 2018 as the derivation cohort (N = 50) and those who graduated in July 2020 (n = 56) for validation. RESULTS: Medical school grades were associated with the performance of national OSCEs (Pearson r = 0.34, p = 0.017), but the grades of the structured PGY interviews were marginally associated with the national OSCE (Pearson r = 0.268, p = 0.06). A prediction model was constructed to identify "improvement required" trainees, defined: trainees with the lowest 25% of scores in the national OSCEs. According to this model, trainees with the lowest 25% medical school grades predicted a higher risk of the "improvement required" clinical performance (Q1-Q3 vs Q4 = 15% vs 60%, odds ratio = 8.5 [95% confidence interval = 1.8-39.4], p = 0.029). In the validation cohort, our prediction model could accurately classify 76.7% "improvement required" and "nonimprovement required" students. CONCLUSION: Our study suggests that interventions for students with unsatisfactory medical school grades are warranted to improve their clinical competencies.

Enhancing the learning and transfer of preprocedural communication skills during clerkship using audio-visual material: a prospective case-controlled study over 2 years.

OBJECTIVE/DESIGN/SETTING: This study aims to develop preprocedural communication-specific framework that emphasises the use of audiovisual materials and compares its acceptability by trainees with a regular module. TRAINEES: Between October 2018 and July 2021, 96 medical clerks were enrolled and randomly divided into regular and intervention groups. Another 48 trainees whose did not join the framework-based training but complete self-assessments were enrolled as the control group. INTERVENTIONS: In the intervention training module, the key steps of preprocedural communication-specific skills were structuralised into a framework using the acronym of OSCAR. PRIMARY AND SECONDARY OUTCOME MEASURES: This study compared the acceptability of trainees for two modules by measuring the degree of increase in the end-of-rotation and follow up (4 weeks later) competency from baseline by trainees' self-assessments and physician assessments after serial trainings. RESULTS: In comparison with regular group trainees, greater degree of improvements (framework-1 statement: 111%±13% vs 27%±5%, p<0.001; framework-2 statement: 77%±9% vs 48%±2%, p<0.05; skill-1 statement: 105%±9% vs 48%±3%, p<0.001); skill-2 statement: 71%±11% vs 50%±9%, p<0.05) were noted in the framework-related and skill-related statement 1-2 (the familiarity and confidence to use the framework and skills) than those of intervention group. At the end-of-rotation stage, the trainees ability to use the 'A-step: using audiovisual materials' of the OSCAR was significantly improved (229%±13%, p<0.001), compared with other steps. In the intervention group, the degree of improvement of the end-of-rotation data of trainees' self-assessment from baseline was significantly correlated with the degree of the improvement in physicians' assessment data in the aspects of skills, framework and steps in framework (R=0.872, p<0.01; R=0.813, p<0.001; R=0.914, p<0.001). CONCLUSIONS: The OSCAR framework-based intervention module is well accepted by medical clerks and motivates them to integrate the acquired skills in clinical practice, which leads to trainees' primary care patients being satisfied with their preprocedural communication.

Comparison of OSCE performance between 6- and 7-year medical school curricula in Taiwan.

BACKGROUND: The year 2013 marks a watershed in the history of medical education in Taiwan. Following Taiwan's Taskforce of Medical School Curriculum Reform recommendations, the medical school curriculum was reduced from 7 to 6 years. This study aimed to analyze the impact of medical school curriculum reform on medical students' performance in objective structured clinical examinations (OSCEs). METHODS: We retrospectively analyzed the OSCE records at Taipei Veterans General Hospital (Taipei VGH), one of Taiwan's largest tertiary medical centers, between November 2016 and July 2020. The eligibility criteria were medical students receiving a full one-year clinical sub-internship training at Taipei VGH and in their last year of medical school. All medical students received a mock OSCE-1 at the beginning of their sub-internship, a mock OSCE-2 after six months of training, and a national OSCE at the end of their sub-internship. The parameters for performance in OSCEs included "percentage of scores above the qualification standard" and "percentage of qualified stations." RESULTS: Between November 2016 and July 2020, 361 undergraduates underwent clinical sub-internship training at Taipei VGH. Among them, 218 were taught under the 7-year curriculum, and 143 were instructed under the 6-year curriculum. Based on baseline-adjusted ANCOVA results, medical students under the 7-year curriculum had a higher percentage of scores above the qualification standard than those under the 6-year curriculum at the mock OSCE-1 (7-year curriculum vs. 6-year curriculum: 33.8% [95% CI 32.0-35.7] vs. 28.2% [95% CI 25.9-30.4], p < 0.001), and mock OSCE-2 (7-year curriculum vs. 6-year curriculum: 89.4% [95% CI 87.4-91.4] vs. 84.0% [95% CI 81.5-86.4], p = 0.001). Moreover, medical students in the 7-year curriculum had a higher percentage of qualified stations in mock OSCE-1 (7-year curriculum vs. 6-year curriculum: 89.4% [95% CI 87.4-91.4] vs. 84.0% [95% CI 81.5-86.4], p = 0.001) and mock OSCE-2 (7-year curriculum vs. 6-year curriculum: 91.9% [95% CI 90.1-93.8] vs. 86.1% [95% CI 83.8-88.3], p = 0.001). After clinical sub-internship training, there were no differences in the percentage of scores above the qualification standard (7-year curriculum vs. 6-year curriculum: 33.5% [95% CI 32.2-34.9] vs. 34.6 [95% CI 32.9-36.3], p = 0.328) and percentage of qualified stations (7-year curriculum vs. 6-year curriculum: 89.4% [95% CI 88.1-90.7] vs. 90.2% [95% CI 88.6-91.8], p = 0.492). CONCLUSIONS: At the beginning of the sub-internship, medical students under the 7-year curriculum had better OSCE performance than those under the 6-year curriculum. After the clinical sub-internship training in Taipei VGH, there was no difference in the national OSCE score between the 6- and 7-year curricula. Our study suggests that clinical sub-internship is crucial for the development of clinical skills and performance in the national OSCE.

Immersive virtual reality (VR) training increases the self-efficacy of in-hospital healthcare providers and patient families regarding tracheostomy-related knowledge and care skills: A prospective pre-post study.

BACKGROUND: Virtual reality (VR)-based simulation in hospital settings facilitates the acquisition of skills without compromising patient safety. Despite regular text-based training, a baseline survey of randomly selected healthcare providers revealed deficiencies in their knowledge, confidence, comfort, and care skills regarding tracheostomy. This prospective pre-post study compared the effectiveness of regular text- and VR-based intervention modules in training healthcare providers' self-efficacy in tracheostomy care skills. METHODS: Between January 2018 and January 2020, 60 healthcare providers, including physicians, nurses, and respiratory therapists, were enrolled. For the intervention, a newly developed head-mounted display (HMD) and web VR materials were implemented in training and clinical services. Subsequently, in-hospital healthcare providers were trained using either text or head-mounted display virtual reality (HMD-VR) materials in the regular and intervention modules, respectively. For tracheostomy care skills, preceptors directly audited the performance of trainees and provided feedback. RESULTS: At baseline, the degree of trainees' agreement with the self-efficacy-related statements, including the aspects of familiarity, confidence, and anxiety about tracheostomy-related knowledge and care skills, were not different between the control and intervention groups. At follow-up stage, compared with the regular group, a higher percentage of intervention group' trainees reported that they are "strongly agree" or "somewhat agree" that the HMD-VR simulation increases their self-efficacy, including the aspects of familiarity and confidence, and reduced their anxiety about tracheostomy-related knowledge and care skills. After implementation, a higher degree of trainees' average satisfaction with VR-based training and VR materials was observed in the intervention group than in the regular group. Most reported that VR materials enabled accurate messaging and decreased anxiety. The increasing trend of the average written test and hands-on tracheostomy care skills scores among the intervention group trainees was significant compared to those in the regular group. The benefits of HMD-VR simulations and web-VR material-based clinical services for in-hospital healthcare providers and patient families persisted until 3 to 4 weeks later. CONCLUSION: The current study suggests that VR materials significantly enhance trainees' self-efficacy (increased familiarity, increased confidence, and reduced anxiety) and their satisfaction with the training, while motivating them to use acquired knowledge and skills in clinical practice.

The association between depression and chronic lower back pain from disc degeneration and herniation of the lumbar spine.

OBJECTIVE: Chronic lower back pain induced by lumbar disc degeneration or herniation exerts a great impact on patients' daily lives. Depression and anxiety often exist among patients with lower back pain. Some studies mentioned about mechanisms, such as inflammatory biomarkers, which are commonly seen in herniated intervertebral disc (HIVD) and major depressive disorder (MDD). Method: Our study used a large database from the National Health Insurance to explore the incidence rate of MDD in patients with HIVD and correlated risk factors. A total of 41,874 patients with HIVD were included in this work. The control group was matched by using propensity scores. Results: The results showed a temporal association between prior HIVD and subsequent MDD after adjusting for potential confounding factors. Patients with HIVD were at high risk of developing MDD (hazard ratio, HR: 9.00, 95% confidence interval, CI: 7.196-11.257) even after adjusting for demographic characteristics and comorbidities (HR: 8.47, 95% CI: 6.84-10.49, p < 0.0001). Conclusions: The combination of HIVD and MDD represents an important health problem that is associated with higher disability rates, socioeconomic disadvantage, and greater utilization of health care resources. Early detection and combined treatment of depressive symptoms may benefit patients with HIVD.

Effects of a simulation-based blended training model on nurses' treatment decision-related knowledge about oral cancer in Taiwan: a pilot survey.

The present study aimed to evaluate the effects of virtual reality (VR) simulations combined with bedside assignments on nurses' self-efficacy in providing pre-treatment educational services. Between March 2019 and November 2020, we conducted a study of VR educational materials that were developed to cover information about the treatment of oral cancers. The effects of the VR simulation, the thinking-path tracking map method, and bedside assignments on the nurses' treatment decision-related knowledge were evaluated in a ward for oral cancer patients at Taipei Veterans General Hospital, Taipei, Taiwan. The blended training model significantly increased nurses' familiarity (P<0.01) and confidence (P<0.03) regarding their knowledge of treatments and treatment decision-related knowledge. This model also significantly increased their confidence in their skills in bedside pre-treatment education for admitted oral cancer patients (P<0.002). Oral cancer-specific VR materials enhanced the effectiveness of skills training among nurses in the oral cancer ward.

Investigation of early and lifetime clinical features and comorbidities for the risk of developing treatment-resistant depression in a 13-year nationwide cohort study.

BACKGROUND: To investigate the risk of treatment-resistant depression (TRD) in patients with depression by examining their clinical features, early prescription patterns, and early and lifetime comorbidities. METHODS: In total, 31,422 depressive inpatients were followed-up from diagnostic onset for more than 10-years. Patients were diagnosed with TRD if their antidepressant treatment regimen was altered ≥two times or if they were admitted after at least two different antidepressant treatments. Multiple Cox regression model were used to determine whether physical and psychiatric comorbidities, psychosis, and prescription patterns increased the risk of TRD by controlling for relevant demographic covariates. Survival analyses were performed for important TRD-associated clinical variables. RESULTS: Females with depression (21.24%) were more likely to suffer from TRD than males (14.02%). Early anxiety disorders were more commonly observed in the TRD group than in the non-TRD group (81.48 vs. 58.96%, p < 0.0001). Lifetime anxiety disorders had the highest population attributable fraction (42.87%). Seventy percent of patients with multiple psychiatric comorbidities developed TRD during follow-up. Cox regression analysis further identified that functional gastrointestinal disorders significantly increased TRD risk (aHR = 1.19). Higher doses of antidepressants and benzodiazepines and Z drugs in the early course of major depressive disorder increased TRD risk (p < 0.0001). CONCLUSION: Our findings indicate the need to monitor early comorbidities and polypharmacy patterns in patients with depression associated with elevated TRD risk.

Panic Disorder Correlates With the Risk for Sexual Dysfunction.

BACKGROUND: Reports have suggested that sexual dysfunction is an underestimated complication of panic disorder, but little research has focused on sexual dysfunction associated specifically with panic disorder. The purpose of this systematic review was to investigate whether patients with panic disorder who are not currently receiving treatment had a higher risk of sexual dysfunction than healthy people, as well as to clarify the appropriate treatment for this patient group. METHODS: Articles that reported panic disorder complicated with sexual dysfunction were identified by a systematic literature search of electronic databases, including PubMed, the Cochrane databases, EMBASE, and PsycINFO. RESULTS: Six articles were included in the review. Patients with panic disorder showed a high prevalence of sexual aversion (35.7% to 64%) and sexual infrequency (36% to 44%). One cohort study indicated that untreated patients with panic disorders had a higher risk of erectile dysfunction than controls. Another article that focused specifically on female patients reported that the patients with panic disorder exhibited decreased frequency of sexual behavior and decreased sexual desire compared with the controls. However, 2 studies found conflicting results after adjustment for confounding factors. CONCLUSIONS: Although the results were mixed, it appears that patients with panic disorder tended to be more susceptible to sexual dysfunction than the general population. Further trials with larger sample sizes and rigorous research designs are needed to establish the relationship between sexual dysfunction and panic disorder.

Sustained effects of faculty leadership development modules for clinical instructors of core competences education in Taiwan: a four-year explanatory case study.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) core competencies (CC) in general medicine-based primary care are essential for junior medical trainees. In this country, a regular faculty development (FD) program aimed at training faculty in instructing (teaching and assessing) these CC had operated. However, leadership was not emphasized. In a new intervention module, the roles and associated responsibilities of clinical instructors to conduct, design, and lead CC-based education were emphasis. AIMS: This follow-up explanatory case study compares the effectiveness of intervention module with that of the previous regular module. METHODS: The regular group (n = 28) comprised clinical instructors who participated in the FD module during the 2013-2014 year while the intervention group (n = 28) was composed of 2015-2016 participants. Prior to the formal (hands-on) training, participants in the intervention group were asked to study the online materials of the regular module. These participants then received a 30-h hands-on training in conducting, designing, and leading skills. Finally, they prepared a 10-h reflective end-of-module presentation of their real-world practices. RESULTS: Following the training, a higher degree improvement in participants self-reported familiarity with CC education, self-confidence in their ability to deliver CC education and sustained involve CC education were noted among the intervention FD group, compared with the regular FD group. In the intervention group, senior academicians (associate and full professor) are more substantially involved in designing and leading CC-based courses than junior academicians (lecturers and assistant professors). Among non-teaching award winners of in the intervention FD group, the follow-up degree of sustained involvement in delivering, designing and leading CC-based courses was significantly higher than that of the regular group. CONCLUSIONS: Our study demonstrated that leadership training in the intervention FD modules substantially motivated clinical instructors to become leaders in CC education.

Standard setting made easy: validating the Equal Z-score (EZ) method for setting cut-score for clinical examinations.

BACKGROUND: This study aims to assess the feasibility, reliability and validity of the panel-based Equal Z-score (EZ) method applied to objective structural clinical examination (OSCE) of Chinese medical students and undertaking a comparison with the statistical techniques-based Borderline Regression Method (BRM). METHODS: Data received from two cohorts of 6th and 7th year medical students in Taiwan who set the mock OSCE as a formative assessment. Traditionally this medical school uses BRM to set the pass/fail cut-score. For the current study, 31 OSCE panellists volunteered to participate in the EZ method in parallel to the BRM. RESULTS: In the conduct of this study, each panel completed this task for an OSCE exam comprising 12 stations within less than 60 min. Moreover, none of the 31 panellists, whose are busy clinicians, had indicated that the task was too difficult or too time-consuming. Although EZ method yielded higher cut-scores than the BRM it was found reliable. Intraclass correlation (ICC) measuring absolute agreement, across the three groups of panellists was .893 and .937 for the first and second rounds respectively, demonstrating high level of agreement across groups with the EZ method and the alignment between the BRM and the EZ method was visually observed. The paired t-test results identified smaller differences between the cut-scores within methods than across methods. CONCLUSIONS: Overall this study suggests that the EZ method is a feasible, reliable and valid standard setting method. The EZ method requires relatively little resources (takes about an hour to assess a 12 station OSCE); the calculation of the cut-score is simple and requires basic statistical skills; it is highly reliable even when only 10 panellists participate in the process; and its validity is supported by comparison to BRM. This study suggests that the EZ method is a feasible, reliable and valid standard setting method.

Effect of virtual reality training to decreases rates of needle stick/sharp injuries in new-coming medical and nursing interns in Taiwan.

PURPOSE: Senior nursing and medical interns' lack of familiarity and confidence with respect to practicing universal precaution for the prevention of occupational needle stick (NSI)/sharp (SI) injuries may harm themselves. Trainees' self-reported NSI/SI rate was known to be especially high during the first two months of internship in Taiwan. This prospective cohort study aimed to know the effect of new developed (virtual reality (VR) game, which uses the Gangne's learning model to improved universal precaution for NSI/SI prevention and decrease the rates of needle stick/sharp injuries in new-coming medical and nursing interns in Taiwan. . METHODS: From 2017 to 2019, the VR system was developed and applied in training of 59 new-coming nursing and 50 medical interns. Occupational NSI/SI prevention was sought to be achieved through a game of right and wrong choices for safe or unsafe universal precaution behaviors. RESULTS: In comparison with medical interns, a higher proportion of nursing interns have had the past experiences of deep occupational NSI/SI. Before VR training, the familiarity and confidence for NSI/SI prevention were higher among nursing interns than medical interns. Trainees with past experiences of deep NSI/SI exhibited better performance on the accuracy rate and time need for complete 20 decisions than those without past experiences in VR practice. The performances of all trainees were improved after VR training. A high proportion of trainees reported that the VR-based training significantly decreased their anxiety about NSI/SI prevention. CONCLUSION: This self-developed VR game system using Gangne's flow improved universal precaution for NSI/SI prevention and reduced the NSI/SI rates in the first two months of nursing and medical internship.

Dreyfus scale-based feedback increases the medical student's satisfaction with the complex cluster part of the interviewing and physical examination course and skills' readiness in Taiwan.

PURPOSE: Different from the basic core part of the clinical interviewing and physical examination (PE) skills course in basic, head-to-toe, and thorax systems, learners need structural feedback for the development of the complex skills in cluster part including abdominal, neuromuscular and musculoskeletal systems. It aimed to evaluate the effects of replacing Dreyfus scale, which having elements of continuous professional development, with Likert scale in the feedback in cluster part of training in Taiwan. METHODS: Instructors and final-year medical students of class 2015-2016 comprised the regular cohort, whereas those of class 2017-2018 formed the intervention cohort. In the intervention cohort, Dreyfus scale-based feedback rather than Likert scale based feedback was used in the cluster part of the course in National Yang-Ming university, Taiwan. RESULTS: Among the regular cohort, poor pre-trained standardized patients (SPs) rated class climate, low grouped students satisfaction with the instructors and course, and low grouped student self-assessed readiness were noted in the cluster part than those in the core part. In comparison with regular cohort, greater improvement of post-cluster part end-of-course group objective structured clinical examination (GOSCE) scores was noted in intervention cohort. In other word, the implementation of Dreyfus scale-based feedback in the cluster part improved the deficit in this part of the course among the intervention cohort. CONCLUSION: The implementation of Dreyfus scale-based feedback helped instructors to create a good class climate in the cluster parts of clinical interviewing plus PE skills course in our study. Simultaneously, this new intervention achieved the goal of medical students competency in interviewing, PE and self-directed learning (SDL) skills.

Newly Diagnosed Bipolar Disorder and the Subsequent Risk of Erectile Dysfunction: A Nationwide Cohort Study.

BACKGROUND: Although erectile dysfunction (ED) is a common problem in men with mental disorders, there are few reports in the literature on the relation between bipolar disorder (BD) and ED. AIMS: To establish the incidence rate of ED in men with BD and assess the risk of ED in patients with BD according to type of treatment offered or no active treatment with medication during the 1st year of onset. METHODS: We identified 5,150 men with newly diagnosed BD using Taiwan's National Health Insurance Research Database. 2 matched controls per case were selected using the propensity score and a greedy matching method to obtain a balanced control group. Multivariate Cox regression analysis was used to examine the independent risk factors for ED, including obesity and comorbidities. Hazard ratios (HRs) for ED risk were calculated for the different psychotropic therapy groups, including antidepressants, antipsychotics, and mood stabilizers. OUTCOME: HRs for ED risk were calculated for the different psychotropic therapy groups, including antidepressants, antipsychotics, and mood stabilizers. Patients with BD had a significantly higher HR for an ED diagnosis than controls. RESULTS: Patients with BD had a higher HR for an ED diagnosis than controls. Although some psychotropic medications can increase the risk of ED, patients with BD not actively treated with medication still showed a higher risk of ED than controls. CLINICAL IMPLICATIONS: Because ED might be more prevalent in patients with BD than in the general population, clinicians should assess erectile function when selecting appropriate treatment for patients with BD to minimize the risk of ED as an annoying side effect and improve treatment compliance. STRENGTHS AND LIMITATIONS: This is the first large-scale population-based study to explore the association between BD and ED. A particular strength of this study is its nationwide, population-based study design, which afforded substantial statistical power for detecting subtle differences between the 2 cohorts, thereby minimizing selection bias. There are some limitations to the present study. (i) Data on other potential risk factors is lacking. (ii) Patient compliance and dose effect between psychotropic medication and ED could not be established. (iii) We could not assess the relation between ED and the severity and phases of BD. CONCLUSION: This cohort study found a temporal association between BD and subsequent ED in a large national sample of men. Clinicians should consider the risk of ED when choosing treatment for patients with BD. Hou P-H, Mao FC, Chang G-R, et al. Newly Diagnosed Bipolar Disorder and the Subsequent Risk of Erectile Dysfunction: A Nationwide Cohort Study. J Sex Med 2018;15:183-191.