Neuromyelitis optica: Clinical course and potential prognostic indicators.

BACKGROUND: Neuromyelitis optica spectrum disorder (NMOSD) is a rare autoimmune neurological disorder associated with antibodies to aquaporin-4 (AQP4). NMOSD has been thought to follow a progressive disease course, with step-wise accumulation of disability over time, even in patients undergoing immunosuppressive/immunomodulatory therapy. The influence of factors such as AQP4 seropositivity, AQP4 serum titer levels, and administration of plasmapheresis on NMOSD prognosis is, as yet, unclear. METHODS: We performed a retrospective chart review of 53 persons with NMOSD at Duke University Hospital-collecting data on longitudinal disease course, imaging, demographics, and serum AQP4 titers (measured using the ELISA or FACS method). Most patients in our cohort were treated with high-dose corticosteroids and, following diagnosis, received maintenance immunosuppressive/immunomodulatory therapies. Longitudinal data on EDSS scores were used to calculate the slope of disability over time for each participant. We additionally investigated the correlation between initial AQP4 seropositivity, initial AQP4 serum titer levels, and treatment with plasmapheresis on disability progression for each participant. RESULTS: Contrary to current views on NMOSD disease course, the majority of our participants showed either no change (31.9%) or improvement (27.1%) in disability over time. Our results additionally revealed no significant association between clinical prognosis and initial AQP4 seropositivity (p = 0.830), initial AQP4 serum titer levels (p = 0.338), or administration of plasmapheresis (p = 0.1149). CONCLUSIONS: Our study presents a contemporary view of the clinical course of NMOSD and shows a more favorable view of its disease course than prior studies (performed before high-efficacy disease modifying therapies became widely-used for this patient population). Most patients in this study received treatment with high-dose corticosteroids following NMOSD flares, as well as a variety of maintenance immunosuppressive therapies. The results of this study cannot shed light on the disease course of untreated NMOSD. Our findings additionally challenge the theory that AQP4 seropositivity or serum titer levels at time of diagnosis may be used to effectively predict NMOSD prognosis. While we were unable to find evidence supporting a favorable effect of plasmapheresis administration on disease outcomes, further research is needed to determine the role plasmapheresis ought to play in the treatment of NMOSD.

Myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease: Presentation and outcomes of adults at a single center.

BACKGROUND/INTRODUCTION: Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a chronic demyelinating disorder that has been increasingly recognized since the serum antibody became commercially available in 2017. The most common clinical presentation is optic neuritis, and first line acute treatment is intravenous (IV) steroids. However, there are many questions that remain unanswered. For clinicians and patients, the primary question is whether relapses will occur and whether to treat with chronic therapy. METHODS: This retrospective chart review examined characteristics of thirty-three known adult MOGAD cases at a single institute. Data was collected on patient demographics, clinical presentation, objective diagnosis with MRI and serum antibody levels, acute and chronic treatment and disease outcomes. RESULTS: Our MOGAD cases revealed a slight female to male predominance of 1.5:1. No racial groups were affected disproportionately, and age of symptom onset spanned a large range with a median of 40 years. The most common clinical and radiologic presentation was optic neuritis followed by transverse myelitis and brainstem symptoms/lesions. IV methylprednisolone was used in the vast majority of cases for acute treatment. 83.3% of our patients were treated with chronic therapy at some point during their disease course. Therapies include rituximab, IVIG, ocrelizumab, mycophenolate mofetil and ofatumumab. The majority of our patients were treated with rituximab and we did not see a significant benefit of yearly relapse reduction for rituximab versus other therapies. Our cohort had a higher-than- expected percentage of cases with relapsing disease (56.3%) compared to monophasic (43.8%). DISCUSSION/CONCLUSION: Our study confirms prior data regarding the demographics, clinical presentation and radiologic presentation of MOGAD. There is no consensus on whether maintenance therapy should be started for MOGAD cases with a single clinical event. Our cohort showed a higher relapse rate than has been reported previously and all known relapses occurred within one year of diagnosis. More data is necessary to confirm risk of relapse in the years following diagnosis. In addition, further data on biomarkers are needed to predict the disease course could help guide management.

Do Physician Assistant Students Use Retrieval-Based Strategies While Studying?

INTRODUCTION: Research on learning indicates that active retrieval of information (ie, testing) enhances student retention of knowledge, yet, it is underutilized by learners. This research investigated physician assistant (PA) students' study strategies and the extent to which retrieval-based strategies (RBS) are used. METHODS: A survey instrument adapting items from Hartwig and Dunlosky's Study Habits Survey was administered to first-year PA students to investigate their study behaviors over a 4-week time frame in preparation for multiple-choice exams. RESULTS: Seventy-eight students (88%) completed the survey. The most common study strategies were reviewing lecture slide decks (83%), reading notes (78%), and taking notes (73%). Retrieval-based study strategies most often used were practicing test questions (38%) and creating questions and responding to them (12%). DISCUSSION: Many PA students are underutilizing retrieval-based study strategies and might benefit from more awareness of this learning approach as well as faculty guidance about how to incorporate it into their exam preparation.

Physician Assistant Program Policies to Assess and Address Student Reports of Mistreatment During Clinical Training.

INTRODUCTION: Many physician assistant (PA) students experience mistreatment in clinical learning environments, and accredited PA programs are required to define, publish, and make readily available policies and procedures for student reports of mistreatment. The purpose of this study is to describe the prevalence, content, and dissemination of program policies to address students' reports of mistreatment involving preceptors during supervised clinical experiences. METHODS: To conduct a national policy analysis, the investigators included 10 new survey items in the 2019 Physician Assistant Education Association annual program survey. Deidentified data were analyzed by using descriptive statistics. RESULTS: The program response rate to the survey items was 99% (232). Approximately 76% of PA programs reported having a learner mistreatment policy. Policy content across programs varied widely, and several student reporting mechanisms were available. Program directors, clinical faculty, and institutional leadership were most likely to be involved in the management of reports. A majority programs actively assessed for mistreatment and most did so through clinical course evaluations and at the end of each clinical phase course. Most programs disseminated information about policy to faculty, students, and preceptors at least once a year. DISCUSSION: The descriptions of policy content, procedures, and dissemination increase educators' understanding of current policies across PA programs in the context of renewed efforts to write or revise policy that is specific to mistreatment. The authors discuss key policy priorities to define mistreatment, offer a range of confidential reporting mechanisms, review the management of reports, and consider how to optimize dissemination strategies.

Creating a win-win for the health system and health Profession's education: a direct observation clinical experience with feedback iN real-time (DOCENT) for low acuity patients in the emergency department.

BACKGROUND: Clinical education across the professions is challenged by a lack of recognition for faculty and pressure for patient throughput and revenue generation. These pressures may reduce direct observation of patient care provided by students, a requirement for both billing student-involved services and assessing competence. These same pressures may also limit opportunities for interprofessional education and collaboration. METHODS: An interprofessional group of faculty collaborated in a sequential quality improvement project to identify the best patients and physical location for a student teaching clinic. Patient chief complaint, use of resources, length of stay, estimated severity of illness and student participation and evaluation of the clinic was tracked. RESULTS: Clinic Optimization and Patient Care: Five hundred and thirty-two emergency department (ED) patients were seen in the first 19 months of the clinic. A clinic located near the ED allowed for patients with higher emergency severity index and greater utilization of imaging. Patients had similar or lower lengths of stay and higher satisfaction than patients who remained in the ED (p < 0.0001). In the second clinic location, from October 2016-June 2019, 644 patients were seen with a total of 667 concerns; the most common concern was musculoskeletal (50.1%). Student Interprofessional Experience: A total of 991 students participated in the clinic: 68.3% (n = 677) medical students, 10.1% (n = 100) physician assistant students, 9.7% (n = 96) undergraduate nursing students, 9.1% (n = 90) physical therapy students, and 2.8% (n = 28) nurse practitioner students. The majority (74.5%, n = 738) of student participants worked with students from other professions. More than 90% of students reported that faculty set a positive learning environment respectful of students. However, 20% of students reported that faculty could improve provision of constructive feedback. Direct Observation: Direct observation of core entrustable professional activities for medical students was possible. Senior medical students were more likely to be observed generating a differential diagnosis or management plan than first year medical students. CONCLUSIONS: Creation of a DOCENT clinic in the emergency department provided opportunities for interprofessional education and observation of student clinical skills, enriching student experience without compromising patient care.

Increasing Physician Assistant Students' Team Communication Skills and Confidence Throughout Clinical Training.

PURPOSE: An intervention was designed to increase physician assistant students' team communication skills using the Situation-Background-Assessment-Recommendation (SBAR) tool. METHODS: A variety of learning activities were implemented longitudinally over 9 months of clinical education. Instructional activities included an interactive lecture, deliberate practice of SBAR at clinical training sites, self-assessment, and small group discussion. Evaluation involved survey of students' perceived learning outcomes and direct observation of students' proficiency using SBAR during a simulated patient encounter. RESULTS: At the beginning of their clinical training, many students (75%) did not have a structured tool for communicating on health care teams. The SBAR tool was readily understood by students following a lecture (89%) and increased their confidence in communicating with preceptors (62%-83%) and nonpreceptors (62%-79%). A majority of students proficiently demonstrated the SBAR components (82%-86%) at the conclusion of the program. CONCLUSION: This approach can be adopted and adapted by other programs aiming to teach and evaluate SBAR and other team skills to better prepare new health professionals to effectively communicate on health care teams.

A novel curriculum to train physician assistant students how to write effective discharge summaries.

Background: Physician assistants (PAs) are an integral part of inpatient care teams, but many PAs do not receive formal education on authoring discharge summaries. High-quality discharge summaries can mitigate patient risk during transitions of care by improving inter-provider communication. Objective: To understand the current state of discharge summary education at our institution, and describe a novel curriculum to teach PA students to write effective discharge summaries. Design: Students completed a pre-survey to assess both knowledge and comfort levels regarding discharge summaries. They wrote a discharge summary and received feedback from two evaluators, an inpatient provider (IPP) familiar with the described patient and a simulated primary care provider (PCP). Students completed a post-survey reassessing knowledge and comfort. Results: Prior to instituting this curriculum, the majority of students (92.9%) reported rarely or never receiving feedback on discharge summaries. Eighty-four of 88 (95.5%) eligible students participated. There was discordance between IPP and simulated PCP feedback on their assessment of the quality of discharge summaries; simulated PCPs gave significantly lower global quality ratings (7.9 versus 8.5 out of 10, p = 0.006). Key elements were missing from >10% of discharge summaries. Student response was favorable. Conclusion: Clinically relevant deficiencies were common in students' discharge summaries, highlighting the need for earlier, structured training. IPPs and simulated PCPs gave discordant feedback, emphasizing differing needs of different providers during transitions of care. This novel curriculum improved students' knowledge and confidence.

A Program's Analysis of Communication Methods With Clinical Preceptors.

PURPOSE: Preceptors value communication with physician assistant (PA) educational programs. This study describes preceptors' perspectives about one PA program's established and new communication strategies to promote preceptor development and retention. METHODS: An electronic survey of preceptors was conducted in December 2014. Quantitative and qualitative data were analyzed using descriptive statistics. RESULTS: Eighty-eight of 209 preceptors completed the survey (42% response rate). Preceptors reported satisfaction with communication frequency and quality. The most preferred topics were preceptor benefits, teaching strategies, feedback about students' performance, and program policy updates. Many preceptors reported not receiving communications sent by mail. A majority of preceptors preferred site visits at least once per year and in person. CONCLUSIONS: Understanding preceptors' preferred topics helped the study program increase its emphasis on those topics. Knowledge that many preceptors do not receive mailed communications has prompted the program to use electronic communication for all communication types. The results reinforced the program's approach to site visits.

Preceptors' Perceptions of Interprofessional Practice, Student Interactions, and Strategies for Interprofessional Education in Clinical Settings.

PURPOSE: This study describes clinical preceptors' perceptions of interprofessional practice, the nature and variety of physician assistant (PA) students' interprofessional interactions during clinical training, and factors that facilitate or hinder interprofessional education (IPE) in clinical settings. METHODS: This qualitative study involved interviews with preceptors that were audio-recorded, transcribed, and then analyzed through an iterative process to identify key conceptual themes. RESULTS: Fourteen preceptors from a variety of clinical settings participated. Four themes were identified: (1) preceptors define interprofessional practice differently; (2) students learn about teams by being a part of teams; (3) preceptors separate students to avoid diluting learning experiences; and (4) preceptors can facilitate IPE by introducing students to members of the team and role modeling team skills. CONCLUSIONS: The themes may inform PA educators' efforts to increase IPE in clinical settings through educational interventions with both preceptors and students.

Interprofessional Interactions and Competencies on Clinical Rotations: Preceptors' Perspectives of Student Experiences.

PURPOSE: This study describes (1) preceptors' perceptions of interprofessional encounters that PA students had at clinical sites and (2) ways that the preceptors report evaluating the PA students' interprofessional practice skills. METHODS: This study disseminated a single electronic survey of clinical preceptors who were affiliated with an accredited PA program. Descriptive statistics were used to analyze the results. RESULTS: Of 195 preceptors, 66 completed the survey. Practice specialties of respondents and nonrespondents were similar. Preceptors indicated that PA students had frequent interactions with a wide variety of health professionals and students. These interactions occurred with greater frequency in specialty settings and academic medical centers than in other settings. Preceptors reported that they assess interprofessional practice competencies, although many were not familiar with the definitions that the health care profession has endorsed. CONCLUSION: Findings suggest that educators may identify specific clinical sites or settings that are more optimal for interprofessional education interventions and that focused preceptor development may encourage deliberate assessment of students' interprofessional practice competencies.

Promoting faculty professionalism: a case-based approach.

INTRODUCTION: Professionalism is a key attribute for health professionals. Yet, it is unknown how much faculty development is directed toward skills and behaviours of faculty professionalism. Faculty professionalism includes boundaries in teacher-student relationships, self-reflection, assuring one's own fitness for duty, and maintaining confidentiality when appropriate. METHODS: For five years, we have incorporated faculty professionalism as a routine agenda item for the monthly Physician Assistant Programme faculty meetings, allowing faculty members to introduce issues they are comfortable sharing or have questions about. We also have case discussions of faculty professionalism within faculty meetings every three months. RESULTS: Faculty professionalism is important in the daily work lives of faculty members and including this as part of routine agendas verifies its importance. A faculty survey showed that a majority look forward to the quarterly faculty professionalism case discussions. These have included attempted influence in the admissions process, student/faculty social boundaries, civic professionalism, students requesting medical advice, and self-disclosure. CONCLUSION: A preventive approach works better than a reactionary approach to faculty missteps in professionalism. Routine discussion of faculty professionalism normalizes the topic and is helpful to both new and experienced faculty members. We recommend incorporation of faculty professionalism as a regular agenda item in faculty meetings.

Reinventing the Wheel: One Program's Approach to Redesign of Didactic Courses.

Curriculum and course redesign are expected and intentional efforts in health professions education. For physician assistant (PA) education, ongoing program self-assessment is a required accreditation standard and may guide deliberate changes within curriculum. The purpose of this article is to describe one PA program's approach to the redesign of 4 courses into 3 courses that span the entire didactic phase. Significant lessons learned include the importance of planning ahead, identifying key players, documenting the process as part of ongoing self-assessment, competency mapping, and being prepared to make real-time modifications and changes based on course evaluations and faculty feedback. Our approach and guiding principles to the successful redesign of the didactic courses may provide both established and new PA educational programs with useful methods to apply in their own unique curricula.

Enlisting New Teachers in Clinical Environments (ENTICE); novel ways to engage clinicians.

PURPOSE: To explore the barriers and incentives that affect primary care providers who precept students in outpatient clinics in the US. METHOD: In 2013, leadership of our large primary care group sent a 20-question survey via e-mail to all of the 180 providers within the network. The survey assessed provider demographics, precepting history, learner preferences, and other issues that might affect future decisions about teaching. RESULTS: The response rate was 50% (90 providers). The top reasons for precepting in the past were enjoyment for teaching and personal interaction with learners. The most commonly cited reason for not precepting previously was a perceived lack of time followed by increased productivity demands. When questioned about the future, 65% (59 respondents) indicated that they were likely to precept within the next 6 months. A desired reduction in productivity expectations was the most commonly cited motivator, followed by anticipated monetary compensation and adjusted appointment times. A top barrier to future precepting was a belief that teaching decreases productivity and requires large amounts of time. CONCLUSION: This survey represents an opportunity to study a change in focus for a cohort of busy clinicians who were mostly new to teaching but not new to clinical practice. The survey provides further insight into clinician educators' perceptions regarding the education of a variety of different learners. The results align with data from previous studies in that time pressures and productivity demands transcend specific programs and learner backgrounds. This information is critical for future clerkship directors and hospital administrators in order to understand how to increase support for potential preceptors in medical education.

Tales from the trenches: physician assistants' perspectives about precepting students.

PURPOSE: A national survey of physician assistants (PAs) found that only 25% of respondents were involved as preceptors for PA students in 2011, and it also identified important barriers and incentives to precept PA students. These findings offer limited information for understanding the nature of this complex phenomenon within its context. The purpose of this study was to further describe key factors that influence the involvement of PAs as preceptors. METHODS: A qualitative study of four focus groups with clinically practicing PAs (N = 29) was conducted at the American Academy of Physician Assistants' annual conference in May 2012. Semistructured interview questions and follow-up probes were used to elicit participants' perspectives about their own and/or witnessed preceptor experiences. The group discussions were audio-recorded, professionally transcribed, and then analyzed line-by-line by four investigators using conceptual and free coding. The independently coded transcripts were merged, and iterative analysis was used to identify recurrent themes until saturation was reached. RESULTS: Four themes emerged: (1) The preceptor role provides an opportunity to "pay back," or contribute to future colleagues' training while advancing the clinician's own knowledge; (2) Student qualities that incentivize precepting are characterized by motivation and self-directed learning, independent of the level of medical knowledge and/or prior experience; (3) Preceptors value feeling connected with the PA program through initial and ongoing communication; (4) Significant competition for clinical rotation sites for various health professional learners limits the access to sites and preceptors. CONCLUSION: PAs identified key areas for potential preceptor recruitment and retention interventions.