Evaluating medical students' knowledge of patient-reported outcomes and the impact of curriculum intervention in consecutive cohorts.

BACKGROUND: Patient-reported outcomes (PROs) collection and utilization improves patient-provider communication, symptom reporting, and patient satisfaction. Despite their significance, the science and utility of PROs are not part of required curriculum in medical education. The authors describe the results of a survey distributed to medical students evaluating their experience, knowledge, and perceptions of PROs, report on outcomes of the impact of formal PRO education on medical student knowledge, and describe strategies to foster the spread of PRO education into other programs. METHODS: The authors developed and distributed a 20-question web-based survey distributed to medical students at two U.S. medical schools to evaluate students' experience, knowledge, and perceptions of PROs. To compare medical students' knowledge in their pre-clinical years (M1-M2) to those in their clinical years (M3-M4), the authors calculated odds ratios and determined significance determined using chi-squared tests. To determine the utility of formal education on medical students' knowledge of PROs, the authors invited 4th year medical students at a single institution to participate in a survey before and two weeks after receiving formal PRO education as part of the medical school curriculum, spanning three years. RESULTS: 137 (15%) medical students responded to the initial survey. Respondents' knowledge of PROs was low and did not differ when comparing pre-clinical to clinical years in school. Less than 10% had received education on PROs and only 16% felt prepared to use PROs in patient care. Respondents demonstrated positive attitudes towards PROs, with 84% expressing interest in learning about PROs. In the second phase education cohort of 231 (77% response rate) 4th -year medical students over three years, formal education improved correct response rates to PRO questions. After education, 90% (121/134) agreed PROs are an important component of high-quality care. CONCLUSIONS: This study identifies a gap in knowledge about PROs among medical students irrespective of year in training. It also shows that structured education may help fill the PRO knowledge gap, potentially providing future clinicians with the skills to implement PROs into clinical practice, aligning with the broader shift towards patient-centric evidence-based healthcare practices.

Over-Application and Interviewing in the 2021 United States Primary Care Virtual Recruitment Season.

Importance Over-application and interviewing are believed to be widespread in residency recruitment. These may have increased during the 2021 virtual recruitment season. The increase does not correspond to an increase in available residency positions and likely results in more interviews with low probabilities of yielding matches. Prior work demonstrates that such marginal interviews are identifiable ­ from key explanatory factors like same-state for interviewee and program ­ in sufficient volume to allow programs to substantially decrease interviews. Objective To evaluate the importance of same-state relationships in primary care and to determine the extent of over-interviewing in the 2021 virtual recruitment season. Design The National Resident Matching Program and Thalamus merged match (outcomes) and interview (explanatory variables) data from primary care specialties (family medicine, internal medicine, pediatrics). Data were analyzed by logistic regression, trained on the 2017-2020 seasons, and projected on the 2021 season for testing. Setting The setting was the 2017-2021 main residency matches. Participants This comprised 4,442 interviewees applying to 167 residency programs in primary care. Intervention This included the transition to virtual recruitment from in-person recruitment in the 2021 residency recruitment season. Measurements A total of 20,415 interviews and 20,791 preferred programs with program and interviewee characteristics and match outcomes were included. Results Same-state geographic relations predicted match probability in primary care residency interviews better than medical school/residency affiliation, with 86.0% of interviewees matching consistently with their preferences for the same state. Same-state was more effective than medical school affiliations with programs in predicting matching. Eliminating interviews with less than a 5% probability of matching (upper 95% prediction limit) removed 31.5% of interviews. Conclusions and relevance The large number of low-match probability interviews demonstrates over-interviewing in primary care. We suggest that programs eliminate interview offers to applications falling below their chosen match probability threshold.

Reducing Over-Interviewing in the Anesthesiology Residency Match.

Background The U.S. residency recruitment process is expensive and time-consuming because of application inflation and over-invitation. Objective Using interview and match data, we quantify the predicted effects if anesthesiology residency programs excluded interviews for applicants who are very unlikely to match. Methods We previously published the validity and accuracy of the logistic regression model based on data from interview scheduling software used by 32 U.S. anesthesiology residency programs and 1300 applicants from 2015-18. Data used were program region, applicant address, numbers of interviews of the interviewee, medical school US News and World Report (USNWR) rank, the difference between United States Medical Licensing Exam (USMLE) Step 1 and 2 Clinical Knowledge (CK) scores, and the historical average of USMLE scores of program residents. In the current study completed in 2020, the predicted probabilities and their variances were summed among interviewees for 30 deidentified programs. Results For anesthesiology, the median residency program could reduce their interviews by 16.9% (97.5% confidence interval 8.5%-24.1%) supposing they would not invite applicants if the 99% upper prediction limit for the probability of matching was less than 10.0%. The corresponding median savings would be 0.80 interviews per matched spot (0.34-1.33). In doing so, the median program would sustain a risk of 5.3% (97.5% confidence interval 2.3%-7.9%) of having at least one interviewee removed from their final rank-to-match list. Conclusion Using novel interview data and analyses, we demonstrate that residency programs can substantively reduce interviews with less effect on rank-to-match lists. The data-driven approach to manage marginal interviews allows program leadership to better weigh costs and benefits when composing their annual list of interviewees.

Venous Gas Embolism During Radical Robotic Prostatectomy: A Case Report and Evidence-Based Management Algorithm.

Robotic-assisted radical prostatectomy (RARP) has gained rapid popularity in the last two decades after early reports of excellent survival rates, quick learning curves, and minimal invasion or tissue damage. Given the anatomical location of surgical prostatectomies and the utilization of intra-abdominal gas during laparoscopy, there is a risk of developing venous air embolism (VAE). We present a case of a 62-year-old male with hypothyroidism and benign prostatic hyperplasia who underwent robotic suprapubic prostatectomy under general anesthesia. One hour after incision the ETCO2 suddenly dropped (40 mmHg to 25 mmHg) as did the SpO2 (98% to 90%). There were no other vital sign changes, nor was there significant blood loss. The surgical team was notified, which prompted the surgeon to inform us that he had just been dissecting around the pelvic venous plexus. At this point, with the clinical suspicion of VAE, abdominal insufflation pressure was lowered, and inspired oxygen was increased to 100%. After 10 minutes, SpO2 and ETCO2 normalized. A debrief and literature review inspired us to develop a laparoscopic-specific VAE management algorithm, with attention to robotic-case management issues. To the best of our knowledge, this is a rare case report describing a clinical VAE during RARP.

Adverse Drug Reaction: Midazolam-Induced Extrapyramidal Symptoms: A Case Report.

Midazolam is commonly used for sedation during procedures because of its relative safety and predictability. Still, some rare undesirable medication reactions have been described. We report a case in which midazolam given before a peripheral nerve block caused acute onset dyskinetic extrapyramidal symptoms. These symptoms ultimately resolved following reversal of the midazolam with flumazenil. Given the widespread and multidisciplinary use of midazolam, practitioners should be aware of the potential for rare adverse reactions and be prepared to manage these scenarios.

A Randomized, Prospective, Double-Blinded Study of Physostigmine to Prevent Sedation-Induced Ventilatory Arrhythmias.

BACKGROUND: Physostigmine, a centrally acting acetylcholinesterase inhibitor, is most commonly used by anesthesiologists in the postanesthetic setting to reverse confusion caused by central anticholinergic medication effects. It has also been proposed as a treatment for sleep-disordered breathing. We investigated whether physostigmine was effective in decreasing the frequency of ventilatory arrhythmias produced during moderate sedation with midazolam and remifentanil during the conditions of breathing room air or 2 L/min nasal O2. METHODS: Ten healthy male volunteers participated in this randomized, double-blind control trial of physostigmine (0.24 µg·kg·min) versus placebo. Moderate sedation was achieved with infusions of midazolam and remifentanil and monitored with full and processed electroencephalogram. Analgesia was quantified with subjective pain score to thermal stimulation. Ventilatory arrhythmias, as measured by the sedation apnea-hypopnea index (S-AHI), were scored as the number of apneas and hypopneas during two 1-hour periods on room air or 2 L/min nasal O2. RESULTS: All subjects tolerated the sedation and physostigmine without significant adverse effects. Sedation during placebo infusion resulted in clinically significant (S-AHI > 15) ventilatory arrhythmias in 5 conditions in 3 subjects (2 on room air and then O2, and 1 on O2 only). Physostigmine did not significantly (P > 0.46) reduce the total number of ventilatory arrhythmias on either room air or O2 (13.4 ± 18.8 events/h [mean ± SEM], 95% confidence interval [CI] = -9.9 to 62.7; and 6.2 ± 8.0, 95% CI = -3.1 to 28.7, respectively). Physostigmine did reduce the S-AHI in all 5 instances of clinically significant ventilatory arrhythmias (S-AHI decreased by 67.0 ± 22.2; CI = 29.2-111.7; P = 0.04). CONCLUSIONS: Physostigmine does not appear to be useful as a pretreatment to prevent ventilatory arrhythmias during moderate sedation. However, it may be useful as a treatment for clinically significant ventilatory arrhythmias during moderate sedation.

Validation of a measurement to predict upper airway collapsibility during sedation for colonoscopy.

Techniques to quantify the effects of sedation on upper airway collapsibility have been used as research tools in the laboratory and operating room. However, they have not been used previously in the usual clinical practice environment of colonoscopy sedation. The propensity for upper airway collapsibility, quantified as the critical pharyngeal pressure (P(crit)), was hypothesized to correlate with the need for clinical intervention to maintain ventilation. Twenty patients scheduled for colonoscopy with sedation were prospectively recruited to undergo measurement of upper airway collapsibility using negative airway pressure (NAP) provocation with a minimum pressure of -18 cmH(2)O. The P(crit) was the negative pressure that collapses the airway, either directly or by extrapolation from the pressure-flow relationship. An exponential transformation was applied to the P(crit) data for statistical analysis. A clinical intervention score (CIS) was used to quantify required interventions by the sedation nurse. The measurement of the P(crit) during sedation was significantly larger (less negative) than both the baseline ("awake") (P = 0.0029) and late recovery (P = 0.01) values. The CIS was not predicted by the transformed baseline or sedated P(crit) with or without including demographics associated with sleep apnea syndrome. Although the NAP technique showed the expected changes with sedation in this clinical situation, we did not find that it predicted the need for clinical intervention during endoscopy. Our study was not large enough to test for subpopulations in which the test might be predictive; further studies of these particular groups are needed to determine the clinical utility of the NAP measurement.

Update and review of moderate and deep sedation.

The administration of sedation/analgesia to allow patients to tolerate diagnostic or therapeutic procedures and tests is a fact of life. Approximately 200,000,000 such sedations are administered every year in the United States. Any morbidity or mortality associated with sedation is likely to be deemed avoidable. There will never be adequate resources or personnel so that trained anesthesia providers administer all sedations, and there probably is no need for such an approach. Clinicians from many specialties now safely and effectively administer sedation. With attention to updated guidelines and concepts, as outlined in this article, the safety and efficacy of sedation/analgesia can and should be excellent.