Twelve tips for developing simulation-based mastery learning clinical skills checklists.

Simulation-based mastery learning is a powerful educational paradigm that leads to high levels of performance through a combination of strict standards, deliberate practice, formative feedback, and rigorous assessment. Successful mastery learning curricula often require well-designed checklists that produce reliable data that contribute to valid decisions. The following twelve tips are intended to help educators create defensible and effective clinical skills checklists for use in mastery learning curricula. These tips focus on defining the scope of a checklist using established principles of curriculum development, crafting the checklist based on a literature review and expert input, revising and testing the checklist, and recruiting judges to set a minimum passing standard. While this article has a particular focus on mastery learning, with the exception of the tips related to standard setting, the general principles discussed apply to the development of any clinical skills checklist.

Communicating Diagnostic Uncertainty at Emergency Department Discharge: A Simulation-Based Mastery Learning Randomized Trial.

PURPOSE: There are no standardized approaches for communicating with patients discharged from the emergency department with diagnostic uncertainty. This trial tested efficacy of the Uncertainty Communication Education Module, a simulation-based mastery learning curriculum designed to establish competency in communicating diagnostic uncertainty. METHOD: Resident physicians at 2 sites participated in a 2-arm waitlist randomized controlled trial from September 2019 to June 2020. After baseline (T1) assessment of all participants via a standardized patient encounter using the Uncertainty Communication Checklist (UCC), immediate access physicians received training in the Uncertainty Communication Education Module, which included immediate feedback, online educational modules, a smartphone-based application, and telehealth deliberate practice with standardized patients. All physicians were retested 16-19 weeks later (T2) via in-person standardized patient encounters; delayed access physicians then received the intervention. A final test of all physicians occurred 11-15 weeks after T2 (T3). The primary outcome measured the percentage of physicians in the immediate versus delayed access groups meeting or exceeding the UCC minimum passing standard at T2. RESULTS: Overall, 109 physicians were randomized, with mean age 29 years (range 25-46). The majority were male (n = 69, 63%), non-Hispanic/Latino (n = 99, 91%), and White (n = 78, 72%). At T2, when only immediate access participants had received the curriculum, immediate access physicians demonstrated increased mastery (n = 29, 52.7%) compared with delayed access physicians (n = 2, 3.7%, P < .001; estimated adjusted odds ratio of mastery for the immediate access participants, 31.1 [95% CI, 6.8-143.1]). There were no significant differences when adjusting for training site or stage of training. CONCLUSIONS: The Uncertainty Communication Education Module significantly increased mastery in communicating diagnostic uncertainty at the first postintervention test among emergency physicians in standardized patient encounters. Further work should assess the impact of clinical implementation of these communication skills.

I Don't Have a Diagnosis for You: Preparing Medical Students to Communicate Diagnostic Uncertainty in the Emergency Department.

INTRODUCTION: Diagnostic uncertainty abounds in medicine, and communication of that uncertainty is critical to the delivery of high-quality patient care. While there has been training in communicating diagnostic uncertainty directed towards residents, a gap remains in preparing medical students to understand and communicate diagnostic uncertainty. We developed a session to introduce medical students to diagnostic uncertainty and to practice communicating uncertainty using a checklist during role-play patient conversations. METHODS: This virtual session was conducted for third-year medical students at the conclusion of their core clerkships. It consisted of prework, didactic lecture, peer role-play, and debriefing. The prework included reflection prompts and an interactive online module. The role-play featured a patient complaining of abdominal pain being discharged from the emergency department without a confirmed diagnosis. Students participated in the role of patient, provider, or observer. RESULTS: Data from an anonymous postsession survey (76% response rate; 202 of 265 students) indicated that most students (82%; 152 of 185) felt more comfortable communicating diagnostic uncertainty after the session. A majority (83%; 166 of 201) indicated the session was useful, and most (81%; 149 of 184) indicated it should be included in the curriculum. DISCUSSION: This virtual session requires few facilitators; has peer role-play, eliminating the need for standardized patients; and is adaptable for in-person teaching. As its goal was to introduce an approach to communicating diagnostic uncertainty, not achieve mastery, students were not individually assessed for proficiency using the Uncertainty Communication Checklist. Students felt the session intervention was valuable.

"Unfortunately, I don't have an answer for you": How resident physicians communicate diagnostic uncertainty to patients during emergency department discharge.

OBJECTIVE: To describe how emergency medicine resident physicians discuss diagnostic uncertainty during a simulated ED discharge discussion. METHODS: A secondary content analysis of simulated clinical encounter audiotapes completed by emergency medicine residents across two sites. RESULTS: When discussing lack of diagnosis, residents explained the evaluation revealed no cause for symptoms, noted concerning diagnoses that were excluded, and acknowledged both symptoms and patients' feelings. Residents used explicit and implicit language to discuss diagnostic uncertainty with similar frequency. Almost half of the residents discussed the ED role as focused on emergent illness to give patients context for their uncertain diagnoses. However, 28% of residents in this study did not discuss diagnostic uncertainty in any form. All residents provided reassurance. CONCLUSION: Residents use a range of approaches to discuss diagnostic uncertainty with patients at the time of a simulated ED discharge, with some residents omitting discussion of uncertainty entirely. PRACTICE IMPLICATIONS: These findings represent the current state of communication, which needs improvement. These findings do not immediately transfer to clinical practice recommendations, but rather support a need for both further study and development of formal communication training on this topic.

Effects of Brief Mental Skills Training on Emergency Medicine Residents' Stress Response During a Simulated Resuscitation: A Prospective Randomized Trial.

BACKGROUND: Acute stress impairs physician decision-making and clinical performance in resuscitations. Mental skills training, a component of the multistep, cognitive-behavioral technique of stress inoculation, modulates stress response in high-performance fields. OBJECTIVE: We assessed the effects of mental skills training on emergency medicine (EM) residents' stress response in simulated resuscitations as well as residents' perceptions of this intervention. METHODS: In this prospective, educational intervention trial, postgraduate year-2 EM residents in seven Chicago-area programs were randomly assigned to receive either stress inoculation training or not. One month prior to assessment, the intervention group received didactic training on the "Breathe, Talk, See, Focus" mental performance tool. A standardized, case-based simulation was used for assessment. We measured subjective stress response using the six-item short form of the Spielberger State-Trait Anxiety Inventory (STAI-6). Objective stress response was measured through heart rate (HR) and heart rate variability (HRV) monitoring. We measured subjects' perceptions of the training via survey. RESULTS: Of 92 eligible residents, 61 participated (25 intervention; 36 control). There were no significant differences in mean pre-/post-case STAI-6 scores (-1.7 intervention, 0.4 control; p = 0.38) or mean HRV (-3.8 milliseconds [ms] intervention, -3.8 ms control; p = 0.58). Post-assessment surveys indicated that residents found this training relevant and important. CONCLUSION: There was no difference in subjective or objective stress measures of EM resident stress response after a didactic, mental performance training session, although residents did value the training. More extensive or longitudinal stress inoculation curricula may provide benefit.

There's an app for that: Teaching residents to communicate diagnostic uncertainty through a mobile gaming application.

BACKGROUND: Clear communication is integral to good clinical care; however, communication training is cost and time intensive. Mobile applications (apps) may provide a useful adjunct to traditional simulation skills training. OBJECTIVE: To evaluate (1) use of an app for teaching communication skills about diagnostic uncertainty, (2) feedback on app use, and (3) the association between use and skill mastery. PATIENT INVOLVEMENT: The app under study is designed to improve doctor-patient communication. METHODS: The study was a planned sub-analysis of a randomized controlled waitlist trial with emergency medicine resident physicians randomized to receive immediate or delayed access to an educational curriculum focused on diagnostic uncertainty. The curriculum included a web-based interactive module and the app. Metrics describing participants' use of the app, feedback on use, and association of use and achieving mastery in communicating diagnostic uncertainty are reported. Differences between groups utilizing the app were analyzed using Chi-squared test; logistic regression assessed the association between app use and achieving mastery of the communication skill. RESULTS: Among 109 participants completing the trial, only 34 (31.2%) used the app. Most participants engaged with the app on one occasion for a median of 50 min (IQR 31, 87). Senior residents were more likely to use the app than junior residents (41.3% vs 23.8%, p=0.05). Overall reviews were positive; 76% reported the app helped them learn. There was no significant association between app use and achieving mastery of the communication skill in the trial [OR 2.1, 95% CI (0.91-4.84)]. DISCUSSION: Despite positive reviews of app use, overall use was low and there was no association with achieving mastery. PRACTICAL VALUE: Offering an app as an auxiliary training opportunity may be beneficial to some residents, but shouldn't be planned for use as a primary didactic modality unless there is evidence for effectiveness and use is mandated. AVAILABILITY OF DATA AND MATERIALS: The datasets generated and/or analyzed during the current study are not publicly available since some data may be identifiable but are available from the corresponding author on reasonable request.

Simulation-based Mastery Learning Improves Emergency Medicine Residents' Ability to Perform Temporary Transvenous Cardiac Pacing.

INTRODUCTION: Temporary transvenous cardiac pacing (TVP) is a critical intervention that emergency physicians perform infrequently in clinical practice. Prior simulation studies revealed that emergency medicine (EM) residents and board-certified emergency physicians perform TVP poorly during checklist-based assessments. Our objective in this report was to describe the design and implementation of a simulation-based mastery learning (SBML) curriculum and evaluate its impact on EM residents' ability to perform TVP. METHODS: An expert panel of emergency physicians and cardiologists set a minimum passing standard (MPS) for a previously developed 30-item TVP checklist using the Mastery Angoff approach. Emergency medicine residents were assessed using this checklist and a high-fidelity TVP task trainer. Residents who did not meet the MPS during baseline testing viewed a procedure video and completed a 30-minute individual deliberate practice session before retesting. Residents who did not meet the MPS during initial post-testing completed additional deliberate practice and assessment until meeting or exceeding the MPS. RESULTS: The expert panel set an MPS of correctly performing 28 (93.3%) checklist items. Fifty-seven EM residents participated. Mean checklist scores improved from 13.4 (95% CI 11.8-15.0) during baseline testing to 27.5 (95% CI 26.9-28.1) during initial post-testing (P < 0.01). No residents met the MPS at baseline testing. The 21 (36.8%) residents who did not meet the MPS during initial post-testing all met or exceeded the MPS after completing one additional 30-minute deliberate practice session. CONCLUSION: Emergency medicine residents demonstrated significantly improved TVP performance with reduced variability in checklist scores after completing a simulation-based mastery learning curriculum.

Developing standardized patient-based cases for communication training: lessons learned from training residents to communicate diagnostic uncertainty.

Health professions education has benefitted from standardized patient (SP) programs to develop and refine communication and interpersonal skills in trainees. Effective case design is essential to ensure an SP encounter successfully meets learning objectives that are focused on communication skills. Creative, well-designed case scenarios offer learners the opportunity to engage in complex patient encounters, while challenging them to address the personal and emotional contexts in which their patients are situated. Therefore, prior to considering the practical execution of the patient encounter, educators will first need a clear and structured strategy for writing, organizing, and developing cases. The authors reflect on lessons learned in developing standardized patient-based cases to train learners to communicate to patients during times of diagnostic uncertainty, and provide suggestions to develop a set of simulation cases that are both standardized and diverse. Key steps and workflow processes that can assist educators with case design are introduced. The authors review the need to increase awareness of and mitigate existing norms and implicit biases, while maximizing variation in patient diversity. Opportunities to leverage the breadth of emotional dispositions of the SP and the affective domain of a clinical encounter are also discussed as a means to guide future case development and maximize the value of a case for its respective learning outcomes.

Development of a Rigorously Designed Procedural Checklist for Assessment of Emergency Medicine Resident Performance of Temporary Transvenous Cardiac Pacing.

OBJECTIVES: Temporary transvenous cardiac pacing (TVP) is a potentially lifesaving intervention included in the list of essential core procedures for emergency medicine (EM) training; however, opportunities to perform TVP during residency cannot be guaranteed. EM graduates report feeling subjectively underprepared for this procedure, but objective performance data are lacking. Checklist-based simulated assessment is an increasing focus of competency-based medical education, particularly for invasive procedures like TVP. The objectives of this paper were as follows: first, to enlist a multidisciplinary team of experts to create an assessment tool for TVP using best practices in checklist development; second, to determine the reliability of checklist scoring; and third, to assess EM residents' baseline ability to perform TVP using a dedicated task trainer. METHODS: This study was conducted at a single 4-year EM residency. A panel of emergency physicians and cardiologists designed a TVP checklist using a modified Delphi approach. After consensus was achieved on a final checklist, EM residents were assessed using a dedicated TVP task trainer. Inter-rater reliability was determined using Cohen's kappa coefficient. Resident performance was determined by number of correctly performed checklist items. RESULTS: The expert panel achieved consensus on a 30-item checklist after three rounds of revisions. The Cohen's kappa coefficient for the overall checklist score was 0.87, with individual checklist items ranging from 0.63 to 1.00. In total, 58 residents were assessed with a mean score of 13.5 of 30 checklist items. Scores increased with each year of training. CONCLUSIONS: This study details the rigorous development of a TVP checklist designed by a multidisciplinary team of experts. Checklist scores demonstrated strong inter-rater reliability. The overall poor performance of this cohort suggests the current approach to TVP training does not provide sufficient preparation for EM residents. Competency-based techniques, such as simulation-based mastery learning, should be explored.

Creation and Implementation of a Mastery Learning Curriculum for Emergency Department Thoracotomy.

INTRODUCTION: Emergency department thoracotomy (EDT) is a lifesaving procedure within the scope of practice of emergency physicians. Because EDT is infrequently performed, emergency medicine (EM) residents lack opportunities to develop procedural competency. There is no current mastery learning curriculum for residents to learn EDT. The purpose of this study was to develop and implement a simulation-based mastery learning curriculum to teach and assess EM residents' performance of the EDT. METHODS: We developed an EDT curriculum using a mastery learning framework. The minimum passing standard (MPS) for a previously developed 22-item checklist was determined using the Mastery Angoff approach. EM residents at a four-year academic EM residency program underwent baseline testing in performing an EDT on a simulation trainer. Performance was scored by two raters using the checklist. Learners then participated in a novel mastery learning EDT curriculum that included an educational video, hands-on instruction, and deliberate practice. After a three-month period, residents then completed initial post testing. Residents who did not meet the minimum passing standard after post testing participated in additional deliberate practice until mastery was obtained. Baseline and post-test scores, and time to completion of the procedure were compared with paired t-tests. RESULTS: Of 56 eligible EM residents, 54 completed baseline testing. Fifty-two residents completed post-testing until mastery was reached. The minimum passing standard was 91.1%, (21/22 items correct on the checklist). No participants met the MPS at the baseline assessment. After completion of the curriculum, all residents subsequently reached the MPS, with deliberate practice sessions not exceeding 40 minutes. Scores from baseline testing to post-testing significantly improved across all postgraduate years from a mean score of 10.2/22 to 21.4/22 (p <0.001). Mean time to complete the procedure improved from baseline testing (6 minutes [min] and 21 seconds [sec], interquartile range [IQR] = 4 min 54 sec - 7 min 51 sec) to post-testing (5 min 19 seconds, interquartile range 4 min 17sec - 6 min 15 sec; p = 0.001). CONCLUSION: This simulation-based mastery learning curriculum resulted in all residents performing an EDT at a level that met or exceeded the MPS with an overall decrease in time needed to perform the procedure.

Use of a simulation-based mastery learning curriculum for neurology residents to improve the identification and management of status epilepticus.

BACKGROUND: Appropriate and timely treatment of status epilepticus (SE) decreases morbidity and mortality. Therefore, skill-based training in the identification and management of SE is crucial for clinicians. OBJECTIVE: The objective of the study was to develop and evaluate the impact of a simulation-based mastery learning (SBML) curriculum to train neurology residents on the identification and management of SE. METHODS: We used pretest-posttest design with a retention test on SE skills for this study. Neurology residents in the second postgraduate year (PGY-2) were eligible to participate in the SE SBML curriculum. Learners completed a baseline-simulated SE skills assessment (pretest) using a 26-item dichotomous skills checklist. Next, they participated in a didactic session about the identification and management of SE, followed by deliberate skills practice. Subsequently, participants completed another skills assessment (posttest) using the same 26-item checklist. All participants were required to meet or exceed a minimum passing standard (MPS) determined by a panel of 14 SE experts using the Mastery Angoff standard setting method. After meeting the MPS at posttest, participants were reassessed during an unannounced in situ simulation session on the medical wards. We compared pretest with posttest simulated SE skills performance and posttest with reassessment in situ performance. RESULTS: The MPS was set at 88% (23/26) checklist items correct. Sixteen neurology residents participated in the intervention. Participant performance improved from a median of 44.23% (Interquartile range (IQR): 34.62-55.77) at pretest to 94.23% (IQR: 92.13-100) at the posttest after SBML (p < .001). There was no significant difference in scores between the posttest and in situ test up to 8 months later (94.23%; IQR: 92.31-100 vs. 92.31%; IQR: 88.46-96.15; p = .13). CONCLUSIONS: Our SBML curriculum significantly improved residents' SE identification and management skills that were largely retained during an unannounced simulated encounter in the hospital setting.

Emergency Department Thoracotomy: Development of a Reliable, Validated Checklist for Procedural Training.

OBJECTIVES: Emergency department thoracotomy (EDT) is a rare and challenging procedure. Emergency medicine (EM) residents have limited opportunities to perform the procedure in clinical or educational settings. Standardized, reliable, validated checklists do not exist to evaluate procedural competency. The objectives of this project were twofold: 1) to develop a checklist containing the critical actions for performing an EDT that can be used for future procedural skills training and 2) to evaluate the reliability and validity of the checklist for performing EDT. METHODS: After a literature review, a preliminary 22-item checklist was developed and disseminated to experts in EM and trauma surgery. A modified Delphi method was used to revise the checklist. To assess usability of the checklist, EM and trauma surgery faculty and residents were evaluated performing an EDT while inter-rater reliability was calculated with Cohen's kappa. A Student's t-test was used to compare the performance of participants who had or had not performed a thoracotomy in clinical practice. Item-total correlation was calculated for each checklist item to determine discriminatory ability. RESULTS: A final 22-item checklist was developed for EDT. The overall inter-rater reliability was strong (κ = 0.84) with individual item agreement ranging from moderate to strong (κ = 0.61 to 1.00). Experts (attending physicians and senior residents) performed well on the checklist, achieving an average score of 80% on the checklist. Participants who had performed EDT in clinical practice performed significantly better than those that had not, achieving an average of 80.7% items completed versus 52.3% (p < 0.05). Seventeen of 22 items had an item-total correlation greater than 0.2. CONCLUSIONS: A final 22-item consensus-based checklist was developed for the EDT. Overall inter-rater reliability was strong. This checklist can be used in future studies to serve as a foundation for curriculum development around this important procedure.

Setting a Minimum Passing Standard for the Uncertainty Communication Checklist Through Patient and Physician Engagement.

BACKGROUND: Historically, medically trained experts have served as judges to establish a minimum passing standard (MPS) for mastery learning. As mastery learning expands from procedure-based skills to patient-centered domains, such as communication, there is an opportunity to incorporate patients as judges in setting the MPS. OBJECTIVE: We described our process of incorporating patients as judges to set the MPS and compared the MPS set by patients and emergency medicine residency program directors (PDs). METHODS: Patient and physician panels were convened to determine an MPS for a 21-item Uncertainty Communication Checklist. The MPS for both panels were independently calculated using the Mastery Angoff method. Mean scores on individual checklist items with corresponding 95% confidence intervals were also calculated for both panels and differences analyzed using a t test. RESULTS: Of 240 eligible patients and 42 eligible PDs, 25 patients and 13 PDs (26% and 65% cooperation rates, respectively) completed MPS-setting procedures. The patient-generated MPS was 84.0% (range 45.2-96.2, SD 10.2) and the physician-generated MPS was 88.2% (range 79.7-98.1, SD 5.5). The overall MPS, calculated as an average of these 2 results, was 86.1% (range 45.2-98.1, SD 9.0), or 19 of 21 checklist items. CONCLUSIONS: Patients are able to serve as judges to establish an MPS using the Mastery Angoff method for a task performed by resident physicians. The patient-established MPS was nearly identical to that generated by a panel of residency PDs, indicating similar expectations of proficiency for residents to achieve skill "mastery."

Development of the Uncertainty Communication Checklist: A Patient-Centered Approach to Patient Discharge From the Emergency Department.

Clear communication with patients upon emergency department (ED) discharge is important for patient safety during the transition to outpatient care. Over one-third of patients are discharged from the ED with diagnostic uncertainty, yet there is no established approach for effective discharge communication in this scenario. From 2017 to 2019, the authors developed the Uncertainty Communication Checklist for use in simulation-based training and assessment of emergency physician communication skills when discharging patients with diagnostic uncertainty. This development process followed the established 12-step Checklist Development Checklist framework and integrated patient feedback into 6 of the 12 steps. Patient input was included as it has potential to improve patient-centeredness of checklists related to assessment of clinical performance. Focus group patient participants from 2 clinical sites were included: Thomas Jefferson University Hospital, Philadelphia, PA, and Northwestern University Hospital, Chicago, Illinois.The authors developed a preliminary instrument based on existing checklists, clinical experience, literature review, and input from an expert panel comprising health care professionals and patient advocates. They then refined the instrument based on feedback from 2 waves of patient focus groups, resulting in a final 21-item checklist. The checklist items assess if uncertainty was addressed in each step of the discharge communication, including the following major categories: introduction, test results/ED summary, no/uncertain diagnosis, next steps/follow-up, home care, reasons to return, and general communication skills. Patient input influenced both what items were included and the wording of items in the final checklist. This patient-centered, systematic approach to checklist development is built upon the rigor of the Checklist Development Checklist and provides an illustration of how to integrate patient feedback into the design of assessment tools when appropriate.

Simulation-based mastery learning compared to standard education for discussing diagnostic uncertainty with patients in the emergency department: a randomized controlled trial.

BACKGROUND: Diagnostic uncertainty occurs frequently in emergency medical care, with more than one-third of patients leaving the emergency department (ED) without a clear diagnosis. Despite this frequency, ED providers are not adequately trained on how to discuss diagnostic uncertainty with these patients, who often leave the ED confused and concerned. To address this training need, we developed the Uncertainty Communication Education Module (UCEM) to teach physicians how to discuss diagnostic uncertainty. The purpose of the study is to evaluate the effectiveness of the UCEM in improving physician communications. METHODS: The trial is a multicenter, two-arm randomized controlled trial designed to teach communication skills using simulation-based mastery learning (SBML). Resident emergency physicians from two training programs will be randomly assigned to immediate or delayed receipt of the two-part UCEM intervention after completing a baseline standardized patient encounter. The two UCEM components are: 1) a web-based interactive module, and 2) a smart-phone-based game. Both formats teach and reinforce communication skills for patient cases involving diagnostic uncertainty. Following baseline testing, participants in the immediate intervention arm will complete a remote deliberate practice session via a video platform and subsequently return for a second study visit to assess if they have achieved mastery. Participants in the delayed intervention arm will receive access to UCEM and remote deliberate practice after the second study visit. The primary outcome of interest is the proportion of residents in the immediate intervention arm who achieve mastery at the second study visit. DISCUSSION: Patients' understanding of the care they received has implications for care quality, safety, and patient satisfaction, especially when they are discharged without a definitive diagnosis. Developing a patient-centered diagnostic uncertainty communication strategy will improve safety of acute care discharges. Although use of SBML is a resource intensive educational approach, this trial has been deliberately designed to have a low-resource, scalable intervention that would allow for widespread dissemination and uptake. TRIAL REGISTRATION: The trial was registered at clinicaltrials.gov (NCT04021771). Registration date: July 16, 2019.

The KRAS-variant and its impact on normal breast epithelial cell biology.

MicroRNA (miRNA)-binding site variants in 3' untranslated regions (3'UTRs) are a novel class of germ-line, functional mutations, which are now recognized as powerful biomarkers of human cancer risk and biology. The first mutation discovered in this class is the KRAS-variant, a let-7-binding site mutation in the 3'UTR of the KRAS oncogene. The KRAS-variant predicts increased cancer risk for certain populations, is a predictive biomarker of cancer treatment response across cancer types, leads to conserved tumor biology and elevated AKT signaling in KRAS-variant patient tumors, and was recently found to predict elevated TGF-ß and immunosuppression in cancer patients. Based on the functional biology of the KRAS-variant in cancer patients, here we chose to investigate altered normal cellular biology in the presence of the KRAS-variant, through interrogation of an isogenic normal breast epithelial cell line model with and without the KRAS-variant. We find that KRAS-variant normal breast epithelial cells exhibit a mesenchymal phenotype, which appears to be due to numerous molecular changes, including miRNA dysregulation and autocrine pathway alterations, including elevated TGF-ß, resulting in ZEB and SNAIL upregulation. Our findings support the hypothesis that the KRAS-variant has a fundamental biological impact on normal cellular biology, that is conserved in these patients when they develop cancer.

A Mastery Learning Capstone Course to Teach and Assess Components of Three Entrustable Professional Activities to Graduating Medical Students.

PROBLEM: Thirteen measurable Entrustable Professional Activities (EPAs) have been proposed by the Association of American Medical Colleges as a means to operationalize medical school graduates' patient care qualifications. Mastery learning is an effective method for boosting clinical skills, but its applicability to the EPAs remains to be studied. The authors designed this study to evaluate a mastery learning intervention to teach and assess components of 3 of the 13 EPAs in a 4th-year capstone course. INTERVENTION: The course featured mastery learning principles and addressed three EPA-based skills: (a) obtain informed consent, (b) develop a differential diagnosis and write admission orders, and (c) write discharge prescriptions. All students underwent a baseline skills assessment, received feedback, engaged in deliberate practice with actionable feedback, and completed a similar skills-based posttest assessment. Students continued with practice and testing until the minimum passing standards (MPSs) were reached for each posttest. CONTEXT: All medical students at a single medical school (Northwestern University, Feinberg School of Medicine) who matriculated in 2012 and graduated with the class of 2016 participated in a required transition to residency course immediately prior to graduation. OUTCOME: There were 134 students eligible to participate, and 130 (97.0%) completed all curricular requirements and assessments. All 130 medical students who completed the course met or exceeded the MPS for each of the three EPA-based clinical skills. Reliability coefficients for outcome data were uniformly high. Measures for each of the three clinical skills showed statistically significant improvement. LESSONS LEARNED: The capstone course was an effective approach to teach and assess components of three EPA-based clinical skills to mastery learning standards in a 4th-year capstone course. We learned that this approach for implementation is feasible and results in significant improvement in components of EPA skill performance. Next steps will include developing assessments incorporating the mastery model into components of additional EPAs, identifying the best location within the curriculum to insert this content, and expanding the number of assessments as part of a larger assessment system.

Antisense oligonucleotides extend survival and reverse decrement in muscle response in ALS models.

Mutations in superoxide dismutase 1 (SOD1) are responsible for 20% of familial ALS. Given the gain of toxic function in this dominantly inherited disease, lowering SOD1 mRNA and protein is predicted to provide therapeutic benefit. An early generation antisense oligonucleotide (ASO) targeting SOD1 was identified and tested in a phase I human clinical trial, based on modest protection in animal models of SOD1 ALS. Although the clinical trial provided encouraging safety data, the drug was not advanced because there was progress in designing other, more potent ASOs for CNS application. We have developed next-generation SOD1 ASOs that more potently reduce SOD1 mRNA and protein and extend survival by more than 50 days in SOD1G93A rats and by almost 40 days in SOD1G93A mice. We demonstrated that the initial loss of compound muscle action potential in SOD1G93A mice is reversed after a single dose of SOD1 ASO. Furthermore, increases in serum phospho-neurofilament heavy chain levels, a promising biomarker for ALS, are stopped by SOD1 ASO therapy. These results define a highly potent, new SOD1 ASO ready for human clinical trial and suggest that at least some components of muscle response can be reversed by therapy.

A Multicenter Collaboration for Simulation-Based Assessment of ACGME Milestones in Emergency Medicine.

STATEMENT: In 2014, the six allopathic emergency medicine (EM) residency programs in Chicago established an annual, citywide, simulation-based assessment of all postgraduate year 2 EM residents. The cases and corresponding assessment tools were designed by the simulation directors from each of the participating sites. All assessment tools include critical actions that map directly to numerous EM milestones in 11 different subcompetencies. The 2-hour assessments provide opportunities for residents to lead resuscitations of critically ill patients and demonstrate procedural skills, using mannequins and task trainers respectively. More than 80 residents participate annually and their assessment experiences are essentially identical across testing sites. The assessments are completed electronically and comparative performance data are immediately available to program directors.