Educational Relative Value Units as a Measure of Academic Productivity: A Systematic Review.

INTRODUCTION: Academic Health Centers (AHCs) have complex, often competing missions. Many have developed mission-based management (MBM) systems to support their clinical and non-clinical missions. There are limited data on MBM use for their educational missions. Our scoping review explored how AHCs employed such systems.  Materials and methods: Arksey and O'Malley's six-stage framework guided our review. Based on pre-defined criteria, English language articles from PubMed, EMBASE, SCOPUS, and the Healthcare Administration Database published between 2010 and 2020 were loaded into a reference manager. The search included all health professions education schools. Articles were excluded if they were review articles, commentaries, or clearly did not involve funding for education. From the final list of selected articles, data were extracted using a data extraction sheet we developed. Two researchers reviewed each article again to ensure extracted data were reported consistently and with sufficient detail.  Results: Of the 1729 manuscripts identified, 35 met inclusion criteria. Sixteen (46%) contained data in some form but did not have a formal methods section describing the specific approach to data collection and analysis. Moreover, there was marked variability in how educational effort was quantified, what counted as educational effort (educational scholarship versus teaching) and the impacts of such quantification (departmental funding versus individual faculty incentives). None of the studies reported on the impact on faculty promotion. Faculty satisfaction with the system was reported in seven studies (20%) and was generally positive. CONCLUSIONS: A systematic description of how systems were developed to support the educational mission was lacking. Clear goals, methods of development, uniform data on educational productivity and quality, and program evaluation were not defined by most articles. This lack of process clarity presents a challenge, but more importantly an opportunity for academic health centers to unify efforts and continue to further their educational mission.

Expectations of and for Clerkship Directors 2.0: A Collaborative Statement from the Alliance for Clinical Education.

This article presents an update of the collaborative statement on clerkship directors (CDs), first published in 2003, from the national undergraduate medical education organizations that comprise the Alliance for Clinical Education (ACE). The clerkship director remains an essential leader in the education of medical students on core clinical rotations, and the role of the CD has and continues to evolve. The selection of a CD should be an explicit contract between the CD, their department, and the medical school, with each party fulfilling their obligations to ensure the success of the students, the clerkship and of the CD. Educational innovations and accreditation requirements have evolved in the last two decades and therefore this article updates the 2003 standards for what is expected of a CD and provides guidelines for the resources and support to be provided.In their roles as CDs, medical student educators engage in several critical activities: administration, education/teaching, coaching, advising, and mentoring, faculty development, compliance with accreditation standards, and scholarly activity. This article describes (a) the work products that are the primary responsibility of the CD; (b) the qualifications for the CD; (c) the support structure, resources, and personnel that are necessary for the CD to accomplish their responsibilities; (d) incentives and career development for the CD; and (e) the dedicated time that should be provided for the clerkship and the CD to succeed. Given all that should rightfully be expected of a CD, a minimum of 50% of a full-time equivalent is recognized as appropriate. The complexity and needs of the clerkship now require that at least one full-time clerkship administrator (CA) be a part of the CD's team.To better reflect the current circumstances, ACE has updated its recommendations for institutions and departments to have clear standards for what is expected of the director of a clinical clerkship and have correspondingly clear guidelines as to what should be expected for CDs in the support they are provided. This work has been endorsed by each of the eight ACE member organizations.

Should Medical Educators Help Learners Reframe Imposterism?

Issue: Impostor syndrome, impostor phenomenon, or imposterism, is a very common, likely ubiquitous, psychological construct in the general population and certainly among health care providers. It has been the subject of many, mostly descriptive, articles and blogs in the medical literature as well as in the lay press and on social media. Evidence: Imposterism has been associated with, but not demonstrated to be causative of, psychological conditions including stress, shame, guilt, and burnout, and behaviors such as "hiding out," which impede career development. The authors argue that to avoid these more serious potential manifestations of imposterism, the approach to imposterism should be reframed, and medical students, residents, and physicians should be helped to view episodic feelings of imposterism as appropriate situational responses. Implications: As feelings of imposterism are virtually universal for those on the journey from medical/graduate student through practicing physician/scientist, handling them appropriately could hopefully channel them into positive responses that mitigate potential psychological and behavioral consequences and improve emotional health.

Iothalamate versus estimated GFR in a Hispanic-dominant pediatric renal transplant population.

BACKGROUND: Accurate knowledge of glomerular filtration rate (GFR) is essential to the practice of nephrology. Routine surveillance of GFR is most commonly executed using estimated GFR (eGFR) calculations, most often from serum creatinine measurements. However, cystatin C-based equations have demonstrated earlier sensitivity to decline in renal function. The literature regarding eGFR from cystatin C has few references that include transplant recipients. Additionally, for most of the published eGFR equations, patients of Hispanic ethnicity have not been enrolled in sufficient numbers. METHODS: The applicability of several eGFR equations to the pediatric kidney transplant population at our center were compared in the context of determining whether Hispanic ethnicity was associated with equation performance. RESULTS: Updated Schwartz, CKiD, and Zappitelli eGFR estimation equations demonstrated the highest correlations. CONCLUSIONS: The authors recommend further prospective investigations to validate and identify factors contributing to these findings.

Long-term outcome in children after Henoch-Schonlein purpura nephritis.

This study investigated predictors of renal survival in children with Henoch-Schönlein purpura glomerulonephritis. Records of patients with Henoch-Schönlein purpura glomerulonephritis evaluated at our center, from 1953-1990, were reviewed. Data were abstracted from records of patients seen within 5 years. Others were mailed a questionnaire or contacted by telephone. Primary outcome measures were renal survival and presence of urinary abnormalities or hypertension. Of the 65 eligible patients with Henoch Schönlein purpura glomerulonephritis, follow-up data was obtainable for 81.5%. The median follow-up was 20 years. At last follow-up, 66% of patients had normal renal function and urinalyses, and 21% had progressed to end-stage renal disease. The only factor associated with the development of end-stage renal disease was the use of cytotoxic agents. There are no features at initial presentation that identify children at risk of disease progression. Close follow-up of all children with Henoch Schönlein purpura glomerulonephritis is warranted.

Childhood obesity among Head Start enrollees in southeastern Minnesota: prevalence and risk factors.

BACKGROUND: Up to 32% of US Head Start enrollees in inner-city settings have been reported to be obese. However, little is known about the prevalence of overweight and associated risk factors in Head Start enrollees in non-inner-city settings. OBJECTIVES: To determine the prevalence of childhood obesity from 1998 to 2001 and associated risk factors for overweight among Head Start enrollees in southeast Minnesota. METHODS: The study was designed as a cross-sectional study. Subjects were 788 children ages three to five years who were enrolled in Head Start of Olmsted and Freeborn Counties, Minnesota, between 1998 and 2001. Anthropometric data and other sociodemographic variables were collected. The Centers for Disease Control and Prevention (CDC) classification for body mass index (BMI) was used (ie, overweight is > 95th percentile BMI for age). Data were fit to a logistic regression model to identify risk factors associated with overweight. RESULTS: From 1998 to 2001, the overall prevalence of overweight and at risk for overweight was 12.9% and 12.2%, respectively. The prevalence of overweight from 1998 to 2001 remained steady, but the prevalence of at risk doubled from 8.2% in 1998 to 16.1% in 2001. On the basis of BMI at the time of enrollment in Head Start, Mexican origin (OR = 2.76; P = .002) and speaking English as a second language (ESL) at home (OR = 1.75; P = .026) were independent predictors for overweight. CONCLUSIONS: The Head Start setting in a nonurban area does not confer any more or less risk for overweight for enrollees, compared to those in urban settings. Children within a certain ethnic group (eg, Mexican) and those who speak English as a second language at home have a higher risk of being overweight. Specific early interventions for these children in a Head Start setting are warranted.

Anthropometric prediction of total body water in children who are on pediatric peritoneal dialysis.

Accurate estimation of total body water (TBW) is a critical component of dialysis prescription in peritoneal dialysis (PD). Gold-standard isotope dilution techniques are laborious and costly; therefore, anthropometric prediction equations that are based on height and weight are commonly used to estimate TBW. Equations have been established in healthy populations, but their validity is unclear in children who undergo PD, in whom altered states of hydration and other confounding alterations in normal physiology, particularly retarded growth and pubertal delay, may exist. TBW was measured by heavy water (H2O18 or D2O) dilution in 64 pediatric patients who were aged 1 mo to 23 yr and receiving chronic PD in the United States and Germany to establish and validate population-specific anthropometric TBW prediction equations and to compare the predictive power of these equations with formulas that have been established in healthy children. The best-fitting equations are as follows: For boys, TBW = 0.10 x (HtWt)0.68 - 0.37 x weight; for girls, TBW = 0.14 x (HtWt)0.64 - 0.35 x weight. The height x weight parameter also predicts body surface area (BSA). These equations can be simplified, with slightly less precision, to the following: For boys, TBW = 20.88 x BSA - 4.29; for girls, TBW = 16.92 x BSA - 1.81. TBW is predicted without systematic deviations and equally well in boys and girls, North American and European, obese and nonobese, growth-retarded and normally sized, and pre- and postpubertal children. In contrast, previous anthropometric equations that were derived from healthy children systematically overpredicted TBW and were less precise in this pediatric PD population. In summary, a new set of anthropometric TBW prediction equations that are suited specifically for use in pediatric PD patients have been provided.

Medical students' exposure to and attitudes about drug company interactions: a national survey.

CONTEXT: While exposure to and attitudes about drug company interactions among residents have been studied extensively, relatively little is known about relationships between drug companies and medical students. OBJECTIVE: To measure third-year medical students' exposure to and attitudes about drug company interactions. DESIGN, SETTING, AND PARTICIPANTS: In 2003, we distributed a 64-item anonymous survey to 1143 third-year students at 8 US medical schools, exploring their exposure and response to drug company interactions. The schools' characteristics included a wide spectrum of ownership types, National Institutes of Health funding, and geographic locations. In 2005, we conducted a national survey of student affairs deans to measure the prevalence of school-wide policies on drug company-medical student interactions. MAIN OUTCOME MEASURES: Monthly frequency of students' exposure to various activities and gifts during clerkships, and attitudes about receiving gifts. RESULTS: Overall response rate was 826/1143 (72.3%), with range among schools of 30.9%-90.7%. Mean exposure for each student was 1 gift or sponsored activity per week. Of respondents, 762/818 (93.2%) were asked or required by a physician to attend at least 1 sponsored lunch. Regarding attitudes, 556/808 (68.8%) believed gifts would not influence their practices and 464/804 (57.7%) believed gifts would not affect colleagues' practices. Of the students, 553/604 (80.3%) believed that they were entitled to gifts. Of 183 students who thought a gift valued at less than $50 was inappropriate, 158 (86.3%) had accepted one. The number of students who simultaneously believed that sponsored grand rounds are educationally helpful and are likely to be biased was 452/758 (59.6%). Students at 1 school who had attended a seminar about drug company-physician relationships were no more likely than the nonattending classmates to show skepticism. Of the respondents, 704/822 (85.6%) did not know if their school had a policy on these relationships. In a national survey of student affairs deans, among the 99 who knew their policy status, only 10 (10.1%) reported having school-wide policies about these interactions. CONCLUSIONS: Student experiences and attitudes suggest that as a group they are at risk for unrecognized influence by marketing efforts. Research should focus on evaluating methods to limit these experiences and affect the development of students' attitudes to ensure that physicians' decisions are based solely on helping each patient achieve the greatest possible benefit.

Early subclinical coronary artery calcification in young adults who were pediatric kidney transplant recipients.

Coronary artery disease (CAD) is the leading cause of death in adults after successful kidney transplantation. Children who have undergone successful kidney transplantation are entering young adulthood; however, the prevalence and extent of CAD in this population is unknown. We conducted a pilot study in young adults with stable allograft function, who received kidney transplants as children to measure coronary artery calcification (CAC), a marker of coronary artery atherosclerosis and CAD. We evaluated 19 young adults after successful pediatric kidney transplantation for known CAD risk factors; these patients underwent noninvasive imaging with electron-beam computed tomography (EBCT) for measurement of CAC. Prevalence and quantity of CAC were then compared to asymptomatic individuals from the community. All patients had multiple risk factors for CAD. Mean age at evaluation was 32 years (range: 21-48 years). CAC is uncommon in individuals in the community in this age range; however, nearly half of our patients had CAC detected with the quantity of CAC comparable to asymptomatic individuals from the community 10-40 years older. These data suggest young adults who received pediatric kidney transplants are at increased risk for developing early CAC and need close monitoring to detect early CAD so as to prevent premature cardiac morbidity and mortality.

Hand-assisted laparoscopic donor nephrectomy for pediatric kidney allograft recipients.

Laparoscopic donor nephrectomy (LDN) is the method of choice for procuring kidneys from living donors at many transplant centers. The aim of this study was to assess the feasibility as well as outcome of LDN in pediatric recipients. Twenty-two pediatric patients, 18-yr old or younger received kidneys procured by a hand-assisted LDN technique. The mean operative time was no different (p = 0.9) and the mean length of stay was more than 1 day shorter in the LDN group (p = 0.0001) compared with the 13 pediatric patients who received kidneys by standard open nephrectomy. Body mass index (BMI), number of donor kidney vessels, or laterality of the kidney did not impact the donor operation or outcome. Actuarial 1-yr patient survival was 100% and allograft survival was 95%, which are equivalent to registry data. There were no donor mortalities and there were five morbidities. None required hospitalization. There were no conversions from LDN to open nephrectomy. One kidney was lost because of overwhelming infection necessitating withdrawal of immunosuppression. In conclusion, hand-assisted LDN is a safe method of procuring kidneys from potential donors with no significant negative outcomes to the pediatric recipients.

Thrombotic complications in childhood-onset idiopathic membranous nephropathy.

While the most common clinical feature of nephrotic syndrome is generalized edema, patients are at risk of developing other problems, such as bacterial infections, electrolyte abnormalities, and venous thromboses. Adults with membranous nephropathy appear to be at the greatest risk for developing thromboses, especially renal vein thrombosis. However, the same is not true for children with membranous nephropathy. A review of pediatric membranous nephropathy stated that renal vein thrombosis is unrecorded in childhood-onset membranous nephropathy. We present our experience in managing two children with idiopathic membranous nephropathy who developed venous thromboses. To our knowledge, this is the first report of pediatric patients with membranous nephropathy to develop a thromboembolic complication without evidence of predisposing factors or coagulation abnormalities. This report emphasizes the need for appropriate evaluation of patients with membranous nephropathy who develop signs and symptoms suggestive of arterial or venous occlusion in order to avoid missing this potentially life-threatening medical complication.

Validity of protein-osmolality versus protein-creatinine ratios in the estimation of quantitative proteinuria from random samples of urine in children.

BACKGROUND: Proteinuria is an important marker of kidney disease. Simple methods to determine the presence of proteinuria in a semiquantitative fashion require measurement of either a protein-creatinine or protein-osmolality ratio. METHODS: Urine samples from 134 healthy infants and children and 150 children from the pediatric nephrology practice were analyzed to develop normative data for protein-osmolality ratios on random urine samples and compare protein-osmolality with protein-creatinine ratio as a predictor of 24-hour urine protein excretion. Children were grouped according to age. Three groups were established: infants (<2 years), younger children (2 to 8 years), and older children (9 to 18 years). An adult cohort was similarly analyzed. RESULTS: For healthy children older than 2 years, the optimal value discriminating normal from abnormal protein excretion was determined to be a protein-osmolality ratio of 0.15 mg x kg H2O/mOsm. L; for children between 2 and 8 years old, 0.14; and for children older than 8 years, 0.17 (P = not significant between age groups). The corresponding optimal cutoff value for protein-creatinine ratio for the entire group of children older than 2 years is 0.20. Area under the curve analysis of receiver operator characteristic curves showed protein-creatinine ratio was superior to protein-osmolality ratio for predicting abnormal amounts of proteinuria in children and adolescents (P < 0.0001). In adults, both ratios are equally accurate. CONCLUSION: Given the superiority of protein-creatinine ratio in children, it would be appropriate to screen urine samples for proteinuria using protein-creatinine ratio rather than protein-osmolality ratio.

Estimating total body water in children on the basis of height and weight: a reevaluation of the formulas of Mellits and Cheek.

An estimate of total body water (TBW) has important implications in clinical practice. For patients on peritoneal dialysis (PD), the estimate is critical when determining the delivered dialysis dose. The formulas of Mellits and Cheek have been recommended to estimate TBW in children on PD. These formulas were derived from healthy children, and very few infants were included. To assess the accuracy of these formulas, the original data were obtained and additional data from a broad literature review were compiled. The majority of the new data points were in the infant age range. Data were fitted using least-squares methodology and backward elimination to obtain a parsimonious model. Best fits were obtained using age, gender, and weight or a height x weight term. The results of the curves are as follows: Infants 0 to 3 mo (n= 71): TBW = 0.887 x (Wt)(0.83) Children 3 mo to 13 yr(n = 167): TBW = 0.0846 x 0.95([if female]) x (Ht xWt)(0.65) Children > 13 yr (n = 99): TBW = 0.0758 x 0.84([if female]) x (Ht x Wt)(0.69) When compared with the previous Mellits and Cheek formulas, the new formula fits better for infants (comparison of prediction errors, P < 0.0004). These newer formulas do not perform significantly better for the older two groups. Actual TBW measurement in children on PD must still be determined to verify the use of these formulas and to accurately assess dialysis delivery and adequacy.