Explaining Evolutionary Agent-Based Models via Principled Simplification.

Understanding how evolutionary agents behave in complex environments is a challenging problem. Agents can be faced with complex fitness landscapes derived from multi-stage tasks, interaction with others, and limited environmental feedback. Agents that evolve to overcome these can sometimes access greater fitness, as a result of factors such as cooperation and tool use. However, it is often difficult to explain why evolutionary agents behave in certain ways, and what specific elements of the environment or task may influence the ability of evolution to find goal-achieving behaviours; even seemingly simple environments or tasks may contain features that affect agent evolution in unexpected ways. We explore principled simplification of evolutionary agent-based models, as a possible route to aiding their explainability. Using the River Crossing Task (RCT) as a case study, we draw on analysis in the Minimal River Crossing (RC-) Task testbed, which was designed to simplify the original task while keeping its key features. Using this method, we present new analysis concerning when agents evolve to successfully complete the RCT. We demonstrate that the RC- environment can be used to understand the effect that a cost to movement has on agent evolution, and that these findings can be generalised back to the original RCT. Then, we present new insight into the use of principled simplification in understanding evolutionary agents. We find evidence that behaviour dependent on features that survive simplification, such as problem structure, are amenable to prediction; while predicting behaviour dependent on features that are typically reduced in simplification, such as scale, can be invalid.

Thinking about Trust: People, Process, and Place.

This brief paper is about trust. It explores the phenomenon from various angles, with the implicit assumptions that trust can be measured in some ways, that trust can be compared and rated, and that trust is of worth when we consider entities from data, through artificial intelligences, to humans, with side trips along the way to animals. It explores trust systems and trust empowerment as opposed to trust enforcement, the creation of trust models, applications of trust, and the reasons why trust is of worth.

A Self-Aware and Scalable Solution for Efficient Mobile-Cloud Hybrid Robotics.

Backed by the virtually unbounded resources of the cloud, battery-powered mobile robotics can also benefit from cloud computing, meeting the demands of even the most computationally and resource-intensive tasks. However, many existing mobile-cloud hybrid (MCH) robotic tasks are inefficient in terms of optimizing trade-offs between simultaneously conflicting objectives, such as minimizing both battery power consumption and network usage. To tackle this problem we propose a novel approach that can be used not only to instrument an MCH robotic task but also to search for its efficient configurations representing compromise solution between the objectives. We introduce a general-purpose MCH framework to measure, at runtime, how well the tasks meet these two objectives. The framework employs these efficient configurations to make decisions at runtime, which are based on: (1) changing of the environment (i.e., WiFi signal level variation), and (2) itself in a changing environment (i.e., actual observed packet loss in the network). Also, we introduce a novel search-based multi-objective optimization (MOO) algorithm, which works in two steps to search for efficient configurations of MCH applications. Analysis of our results shows that: (i) using self-adaptive and self-aware decisions, an MCH foraging task performed by a battery-powered robot can achieve better optimization in a changing environment than using static offloading or running the task only on the robot. However, a self-adaptive decision would fall behind when the change in the environment happens within the system. In such a case, a self-aware system can perform well, in terms of minimizing the two objectives. (ii) The Two-Step algorithm can search for better quality configurations for MCH robotic tasks of having a size from small to medium scale, in terms of the total number of their offloadable modules.

Community Preceptor Perspectives on Recruitment and Retention: The CoPPRR Study.

BACKGROUND AND OBJECTIVES: Medical schools are increasingly challenged to recruit and retain community-based preceptors. Physicians experience various incentives and deterrents to teaching medical students while providing patient care. Self-determination theory (SDT) posits people act in response to internal and external motivations and suggests autonomy, competence, and relatedness are basic psychological needs for well-being and integrity. The applicability of SDT to explain why physicians become or remain a preceptor is uncertain. This study explores physicians' motivations for precepting medical students within the framework of SDT. METHODS: Focus groups were conducted at seven institutions chosen to represent national diversity using a semistructured interview guide based on SDT. Community-based family physicians discussed benefits and barriers to precepting. Interviews were recorded, transcribed, and coded using open codes. Thematic analysis was performed utilizing the conceptual framework of SDT emphasizing the domains of autonomy, competence, and relatedness. RESULTS: Feeling competent about their medical practice and teaching skills, reporting connectedness to the institution and students, and having autonomy over their teaching increased preceptor motivation to teach. Concerns about clinical workload demands, negative teaching experiences, and institutional bureaucracy decreased motivation. CONCLUSIONS: Preceptors choose to become and remain preceptors based on a combination of intrinsic motivating factors and effective external motivators. SDT appears to be a useful framework for assessing and responding to the needs of community-based family medicine preceptors and may be a useful guide for medical educators and policy makers seeking to identify and implement effective strategies to recruit and retain community preceptors to work with medical students.

The Suffering Medical Students Attribute to Their Undergraduate Medical Education.

BACKGROUND AND OBJECTIVES: The purpose of this study was to explore medical student perceptions of their medical school teaching and learning about human suffering and their recommendations for teaching about suffering. During data collection, students also shared their percerptions of personal suffering which they attributed to their medical education. METHODS: In April through May 2015, we conducted focus groups involving a total of 51 students representing all four classes at two US medical schools. RESULTS: Some students in all groups reported suffering that they attributed to the experience of medical school and the culture of medical education. Sources of suffering included isolation, stoicism, confusion about personal/professional identity and role as medical students, and witnessing suffering in patients, families, and colleagues. Students described emotional distress, dehumanization, powerlessness, and disillusionment as negative consequences of their suffering. Reported means of adaptation to their suffering included distraction, emotional suppression, compartmentalization, and reframing. Students also identified activities that promoted well-being: small-group discussions, protected opportunities for venting, and guidance for sharing their experiences. They recommended integration of these strategies longitudinally throughout medical training. CONCLUSIONS: Students reported suffering related to their medical education. They identified common causes of suffering, harmful consequences, and adaptive and supportive approaches to limit and/or ameliorate suffering. Understanding student suffering can complement efforts to reduce medical student distress and support well-being.

Medical Student Perceptions of Their Education About Suffering.

BACKGROUND AND OBJECTIVES: To explore student perceptions of their medical school teaching and learning about human suffering and to elicit student recommendations for better approaches to teaching about suffering. METHODS: Qualitative study involving focus groups of students from each class at two US medical schools. RESULTS: Students reported that teaching about human suffering was variable, rarely explicit, and occurred primarily in the pre-clinical curriculum. In the clinical curriculum, addressing patient suffering was neither overtly valued nor evaluated by attending physicians. Students perceived little or no explicit educational attention to the suffering of patients and their families, with the exceptions of specific rotations and attendings. They described little or no teaching of clinical skills to identify and manage suffering and desired such training. Students learned about the clinical management of suffering primarily by ad hoc observation of role models. Some also noted that exposure to patient suffering and the demands of medical education contributed to their own suffering. Students recommended intentional, integrated and longitudinal teaching about suffering, with regular reinforcement and evaluation, across the medical school curriculum. CONCLUSIONS: Students perceived teaching about human suffering as insufficient at the institutions studied and desired to learn clinical skills to identify and help patients manage suffering. Medical educators should explicitly address patient suffering and create longitudinal curricula with improved clinical teaching, faculty role modeling, and student evaluation.

Adverse Effects of Common Drugs: General Concepts.

Adverse drug reactions (ADRs) contribute to substantial morbidity and mortality and add to rising health care costs. Many ADRs are preventable with appropriate prescribing and monitoring because they often occur as an extension of a drug's mechanism of action or known drug interactions. Patients at higher risk of ADRs include those at the extremes of age, those with multiple comorbidities, those taking multiple drugs, and patients admitted to intensive care units or experiencing transitions of care. Because the risk of ADRs becomes greater as the number of drugs and dietary supplements taken increases, it is imperative that prescribers be vigilant about the prescribing cascade and take steps to discontinue drugs that are likely to be more harmful than helpful. Pharmacists serve as important partners in clinical care environments by conducting comprehensive drug reviews, aiding in drug/dosage selection, and developing therapeutic monitoring plans. Although the potential exists for clinicians to use electronic health record systems to aid in clinical decision making through drug safety decision support tools, computer systems should never replace clinical judgment. Clinicians also are encouraged to report ADRs to the Food and Drug Administration Adverse Event Reporting System.

Adverse Effects of Common Drugs: Children and Adolescents.

Drug use and harms are increasingly common among newborns, infants, children, and adolescents during ambulatory practice, emergency department, and in-hospital treatment, including treatment in pediatric intensive care units. The pharmacokinetic and pharmacodynamic parameters of drugs often are different for children compared with adults and must be considered before prescribing. Drug exposure and the potential for harms also should be considered for fetuses and breastfeeding infants. As with adult patients, a thorough drug and allergy history (including nonprescription drugs and herbal and dietary supplements) should be obtained and reviewed at each medical visit. Children and adolescents are increasingly at risk of drug harm/overdose through accidental or intentional ingestion of nonprescription and prescription drugs (eg, cough and cold preparations, candy-appearing vitamins, stimulants, narcotics). Parents and caregivers should receive training in the proper use, storage, and administration of all drugs. Prescribing clinicians should be vigilant in withholding unnecessary drugs, such as antibiotics for viral infections. When prescribing, clinicians should be aware of common drugs frequently associated with adverse reactions, including stimulants, antipsychotics, analgesics, asthma therapies, acne therapies, and tumor necrosis factor inhibitors. Scientifically based prescribing practices should be used and consultation with evidence-based resources and pharmacists sought as needed.

Adverse Effects of Common Drugs: Dietary Supplements.

Dietary supplement-induced adverse effects often resolve quickly after discontinuation of the offending product, especially in younger patients. The potential for unwanted outcomes can be amplified in elderly patients or those taking multiple prescription drugs, especially where interactions exist with drugs metabolized by cytochrome P450 enzymes. Attributing injury or illness to a specific supplement can be challenging, especially in light of multi-ingredient products, product variability, and variability in reporting, as well as the vast underreporting of adverse drug reactions. Clinicians prescribing a new drug or evaluating a patient with a new symptom complex should inquire about use of herbal and dietary supplements as part of a comprehensive evaluation. Clinicians should report suspected supplement-related adverse effects to the local or state health department, as well as the Food and Drug Administration's MedWatch program (available at https://www.safetyreporting.hhs.gov). Clinicians should consider discussing suspected adverse effects involving drugs, herbal products, or dietary supplements with their community- and hospital-based pharmacists, and explore patient management options with medical or clinical toxicology subspecialists.

Adverse Effects of Common Drugs: Adults.

Although drugs can be an essential and lifesaving component of the care of adult patients, their use frequently is accompanied by adverse effects and life-threatening adverse drug reactions that can result in significant disability and mortality. The potential for drug-related severe morbidity and mortality is compounded during periods of hospitalization, when high-risk drugs such as anticoagulants or insulin are used, and when care in an intensive care unit is required. Patient factors in adults that can increase the risk of drug harms include immunosuppression, cognitive impairment, depression, alcoholism and other substance abuse disorders, chronic kidney disease, hepatic dysfunction, coagulopathies, limited English proficiency, institutional/nursing home care, and underinsurance or lack of insurance. Physician factors that can increase the risk of drug harms include inappropriate prescribing of drugs (including to pregnant and breastfeeding women), failure to appropriately discontinue/deprescribe drugs, insufficient drug reconciliation, failure to coordinate care among multiple prescribing clinicians, and failure to elicit and incorporate into health histories and clinical decision-making the widespread use of nonprescription drugs, herbal products, and dietary supplements.

Frequency and negative impact of medical student mistreatment based on specialty choice: a longitudinal study.

PURPOSE: According to responses to the Association of American Medical Colleges' Medical School Graduation Questionnaire, 17% to 20% of medical students report mistreatment. This study examined the longitudinal nature of medical student mistreatment based on specialty choice. METHOD: From 2003 to 2010, the authors surveyed all medical students at one institution at the end of their third year, assessing the frequency and impact of any mistreatment based on specialty choice. They analyzed quantitative data on the frequency, impact, sources, and trends over time and qualitative data from students' open-ended responses and compared data by specialty interest (primary care versus subspecialty). RESULTS: Of the 1,059 students sent the survey, 801 (76%) responded. Mistreatment based on specialty choice was common. The frequency and impact of such mistreatment were tightly correlated (Pearson r = 0.8, P < .001). The nature of mistreatment differed between students interested in primary care and those interested in a subspecialty, occurred more commonly on specific clerkships, and originated most often from resident physicians. Students perceived that teaching opportunities and evaluations were negatively affected by their specialty choice. An association was found between the theme of respect and students reconsidering their specialty choice. These patterns of mistreatment were stable over the study period, despite several professionalism initiatives. CONCLUSIONS: Mistreatment based on specialty choice is a distinct and common phenomenon perpetuated by faculty, residents, and peers. More research is needed to explore the potential hidden curriculum drivers of these findings and to develop interventions specifically targeting this type of mistreatment.

Medical student perceptions of medical school education about suffering: a multicenter pilot study.

BACKGROUND AND OBJECTIVES: Little is known about what students perceive they are taught about suffering in medical school. We sought to explore medical student perceptions of their medical school education about suffering. METHODS: We used an online survey of medical students enrolled in four US medical schools with chi-square analysis of responses by gender and preclinical/clinical status. RESULTS: A total of 1,043 students (38%) responded and indicated that teaching about suffering is occurring in the schools surveyed. Respondents most strongly endorsed statements that their medical school education explicitly teaches that the relief of suffering is an inherent function of being a physician (46.5%) and that most of what they learned about dealing with suffering patients is taught by modeling (46.6%). They reported that their education explicitly teaches about suffering (32.8%), provides a good understanding of suffering (31.7%), and teaches how to interact with suffering patients (31.7%). Students gave the least support to statements that their education prepares them to personally deal with their reactions to the suffering of patients (25.1%) and teaches how to diagnose suffering (15.3%). Responses varied markedly according to gender and clinical status at two of the four schools surveyed. CONCLUSIONS: Teaching about suffering is occurring in the schools surveyed and can be variably experienced according to gender and clinical status. Implied curricular gaps include teaching about how to diagnose suffering and how to personally deal with the feelings that arise when caring for suffering patients. Further research on how students are learning about suffering is warranted to guide curriculum development and implementation.

Primary care providers' needs and preferences for information about colorectal cancer survivorship care.

BACKGROUND: The Institute of Medicine (IOM) proposed that cancer survivors and their primary care providers (PCPs) should receive survivorship care plans to inform ongoing care. We aimed to determine PCPs' preferences for the content of survivorship care plans for colorectal cancer (CRC) survivors. METHODS: PCPs in 3 practice-based research networks completed a survey regarding 45 topics of CRC information based on the IOM's survivorship care plan framework. RESULTS: One hundred fifty-six PCPs completed the survey. For 35 topics (78%), at least half of respondents felt the topic was very important. Most PCPs reported receiving too little information about problems with chemotherapy (68%) or radiation (60%) and whether the oncologist intended to monitor for other cancers (71%). PCPs widely agreed that they do not have enough information about increased risk of second CRCs, other cancers, and other diseases (78%); long-term effects of chemotherapy (73%) and radiation (67%); and genetic counseling (83%). CONCLUSIONS: PCPs endorse the IOM's survivorship care plan framework as relevant and often report needing more information. Survivorship care plans may provide important information to PCPs by communicating patients' cancer histories and making recommendations regarding which aspects of care should be provided by the oncologist or the PCP.

Tobacco world: evaluation of a tobacco cessation training program for third-year medical students.

BACKGROUND: Training in tobacco cessation counseling is deficient in medical schools. Tobacco World, a tobacco cessation training program, was implemented in a family medicine clerkship and subsequently evaluated. METHOD: In the pilot year, students were assigned to either standard clerkship training (comparison group) or a group that also received Tobacco World training (intervention group). All students received intervention training in the second year of the study. A 35-item questionnaire was administered before and after the four-week clerkship to assess knowledge, attitude, and confidence regarding tobacco cessation counseling. RESULTS: Intervention training was highly rated. Students in the intervention group from both years demonstrated significant improvements in some key measurements of knowledge, attitude, confidence, and increased frequency of tobacco cessation counseling. CONCLUSIONS: This smoking cessation training program addresses an underrepresented area of medical school education and has the potential to translate into improved smoking cessation counseling by future physicians.

The psychosocial experience of women with PCOS--a case control study.

Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting 5-10% of women. It is characterised by androgenisation and anovulation, with sufferers being at increased risk of metabolic problems such as noninsulin dependent diabetes mellitus and dyslipidaemia. An increased risk of cardiovascular disease is speculated. Clinically, sufferers may experience acne, obesity, hirsutism and/or male pattern baldness.