The Impact of Communication Strategies on Faculty Members' Readiness for Curricular Change.

Curricular change is the "new normal" for medical schools. Assessing faculty readiness, perceptions about the necessity and urgency of change, and confidence in the capacity of the organization to successfully implement the process, have been identified as essential to managing the curricular change process. We used The Medical School's Organizational Readiness for Curriculum Change Questionnaire (MORC) to assess and monitor faculty readiness for change. This 53-item survey uses a 5-point Likert scale to assess 3 factors. This project focused on the seven-item Communication subscale in order to guide the strategy for informing and involving faculty in the curricular change process. The MORC was distributed electronically to full-time faculty in December 2014 (pre-change), August 2016 (mid-change), and September 2017 (post-change). Respondents reported significantly increasing support and positive attitudes about curricular change, supporting the hypothesis that the communication strategies informed by MORC findings had a positive impact on faculty members' perceptions of the process. As the leading faculty concerns reported in the MORC shifted from the merits of change to practical concerns about implementation, we adapted communications to address their priorities. The MORC proved useful in capturing quantitative data on faculty perceptions of curricular change but its value was limited by low response rates and unrepresentative samples. Scientists, full professors and tenure track faculty members were overrepresented in survey respondents. Survey lengths were identified as limiting participation. Our experience supports the development of a shorter version of MORC to retain validity and reliability while potentially increasing response rate.

Palliative Care Quality Indicators for Patients with End-Stage Liver Disease Due to Cirrhosis.

BACKGROUND AND AIMS: There are guidelines for the medical management of cirrhosis and associated quality indicators (QIs), but QIs focusing on standards for palliative aspects of care are needed. METHODS: We convened a 9-member, multidisciplinary expert panel and used RAND/UCLA modified Delphi methods to develop palliative care quality indicators for patients with cirrhosis. Experts were provided with a report based on a systematic review of the literature that contained evidence concerning the proposed candidate QIs. Panelists rated QIs prior to a planned meeting using a standard 9-point RAND appropriateness scale. These ratings guided discussion during a day-long phone conference meeting, and final ratings were then provided by panel members. Final QI scores were computed and QIs with a final median score of greater than or equal to 7, and no disagreement was included in the final set. RESULTS: Among 28 candidate QIs, the panel rated 19 as valid measures of quality care. These 19 quality indicators cover care related to information and care planning (13) and supportive care (6). CONCLUSIONS: These QIs are evidence-based process measures of care that may be useful to improve the quality of palliative care. Research is needed to better understand the quality of palliative care provided to patients with cirrhosis.

Cross-sectional survey of disturbed behaviour in patients in general hospitals in Leeds.

AIM: To describe the prevalence and nature of disturbed behaviour, in the general hospital setting. METHOD: A cross-sectional survey was conducted, from July to October 2006, in all adult inpatient wards within the six general hospitals in Leeds of patients presenting with disturbed behaviour in the preceding 7 days. Disturbed behaviour was defined as behaviour interfering with care of the patient or with that of other patients, or behaviour that placed the patient, the staff or others at risk. Anonymised data were collected using a semi-structured questionnaire. RESULTS: All of the 87 hospital wards were studied, containing a total of 1773 beds. 42 male and 26 female patients (n = 68) were identified by nursing staff as patients with disturbed behaviour in the time period covered, with 33 patients being 65 years of age). An almost equal proportion of the younger and older patient groups placed themselves or others at risk. In the majority of cases, aggressive behaviour by patients was directed towards staff rather than other patients. 60 patients required additional staff time due to the disturbed behaviour, 34 required additional medication, and 22 patients were referred to liaison psychiatry. CONCLUSIONS: Disturbed behaviour presents in the general hospital in less than 4% of patients, both above and below the age of 65 years, but consumes a disproportionate amount of resources. Responses required to manage this include additional medication, additional staff time or other interventions. The quantity and nature of disturbed behaviour in the general hospital have implications for effective service provision and development.

Maximizing the use of a Web-based teaching skills curriculum for community-based volunteer faculty.

BACKGROUND: The University of Kansas School of Medicine in Wichita created an Internet-based faculty development curriculum for community-based faculty. Because relatively few physicians use Internet-based continuing medical education (CME), the most cost-effective methods of encouraging use need to be identified. METHOD: Five interventions intended to increase use of the curriculum were assessed. The number of times the CME curriculum Webpages were accessed was correlated with the interventions. RESULTS: Demonstrating the Website to faculty at a semiannual meeting elicited the most Website "hits." Electronic mail and flyers also appeared to be effective in stimulating interest in the Website. Only four community-based faculty applied for CME credit for completing the curricular modules. FINDINGS: Multiple modalities should be used in advertising and stimulating interest in an Internet-based faculty development curriculum. Demonstrating the Website to faculty at a meeting appeared to achieve the greatest return. Offering CME credit was not helpful in stimulating interest.

Administrative relationships between medical schools and community preceptors.

PURPOSE: To determine the current administrative relationships between medical schools and community preceptors, with special emphasis on arrangements for academic appointment, review, and promotion. METHOD: In 1999, administrative contacts at all 126 U.S. allopathic medical schools were mailed a ten-item questionnaire to elicit information concerning the current practices of the schools regarding community preceptors, who were defined as volunteer or part-time physician faculty, primarily practicing at non-university-owned facilities, who contribute to medical students' and/or residents' education in various specified ways. RESULTS: Responses were received from 71 (56%) of the schools; they were in general a representative sample of U.S. medical schools. The numbers of preceptors per school ranged from 40 to 3,500. Sixty-seven percent of reporting schools identified clinical departments as the main administrative interface with preceptors. Only three schools used a central office; none exclusively used a regionalized system. Forty-four schools (63.8%) reported using formal written criteria for all preceptor appointments. Sixty-six schools (93%) used consistent academic titling systems, with 83.3% using titles including the word "clinical." Thirty-three schools (47.8%) reported that their departments conducted regular preceptor reviews; an additional 28 reported reviews by some departments. Preceptors were eligible for promotion at 94.4% of the responding schools. At 46.8%, specific promotion criteria exist; four schools were developing such criteria. Preceptors' interest in academic promotion was perceived to be moderate or low. CONCLUSION: A substantial proportion of U.S. medical schools have taken action to recognize preceptors as a unique faculty group. The comments received indicate that this is an active area of development in faculty affairs policy.

Preliminary report from the Kansas Hartford Geriatrics Project: a model of community university collaboration in geriatric medicine faculty development.

OBJECTIVES: This paper describes the development, implementation, and participant satisfaction of a faculty development program for community-based clinician educators with competencies in geriatric medicine. DESIGN: One group, ongoing trial. SETTING: University of Kansas School of Medicine, Kansas City, Kansas. PARTICIPANTS: Family physicians and general internists from throughout the state of Kansas (n = 30). INTERVENTION: This is an integrated faculty development curriculum of clinical geriatrics and educational process offered in nine sessions over 3 years. MEASUREMENTS: Project retention, session attendance, and participant satisfaction are the measures of program success. MAIN RESULTS: Project retention at 18 months, the midpoint of this project, has been 87%, with 91% of the retained participants attending all of the sessions to date. More than 95% of the participants have rated each of the first five sessions as highly satisfactory or excellent in meeting their needs as a clinician educator. Satisfaction for on-site and interactive televideo participation has been equally high. CONCLUSIONS: Our preliminary results indicate the Kansas Hartford Geriatrics Project model of community-university collaboration in geriatric faculty development is successful in recruitment and satisfaction of participants. The curriculum is highly attractive and rewarding to faculty. Interactive televideo provides a successful innovation in aging-oriented faculty development.

Subtalar arthrodesis for complications of intra-articular calcaneal fractures.

Eighty six subtalar arthrodeses performed between 1985 and 1996 for complications associated with intra-articular calcaneal fractures were retrospectively evaluated. Patients were divided into three Groups: (I) 59 patients with calcaneal malunions (II) 13 patients with failed open reduction and internal fixation, and (III) eight patients undergoing open reductions and primary fusion for highly comminuted fractures. In each scenario, internal fixation was achieved with cancellous lag screws. Bone graft material consisted of either autogenous iliac crest graft, local graft obtained from the lateral wall exostectomy of the malunion, or freeze-dried cancellous allograft. Fusions in Groups II and III were performed in situ. Fusions in Group I were performed either in situ or utilizing a variety of reconstructive procedures depending upon the type of malunion encountered. Eighty three of the 86 fusion attempts were successful following the initial operations for a union rate of 96%. Fusion rates were similar regardless of the graft material used. Complications included four varus malunions, four cases of osteomyelitis, and two cases of reflex sympathetic dystrophy. A statistically significant shorter hospital stay was found for patients not undergoing iliac crest bone graft procedures. Eighty patients with at least two year follow up achieved a mean American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score of 75.0. Scores were similar for all three groups and for the various types of reconstructive procedures used. No correlation was found between postoperative talar declination angle and the AOFAS ankle-hindfoot score. Worker's compensation patients tended to have a poorer clinical outcome.

Amyotrophic lateral sclerosis: Lou Gehrig's disease.

Amyotrophic lateral sclerosis (ALS), commonly called Lou Gehrig's disease, is a progressive neuromuscular condition characterized by weakness, muscle wasting, fasciculations and increased reflexes. Approximately 30,000 Americans currently have the disease. The annual incidence rate is one to two cases per 100,000. The disease is most commonly diagnosed in middle age and affects more men than women. It usually presents with problems in dexterity or gait resulting from muscle weakness. Difficulty in speaking or swallowing is the initial symptom in the bulbar form of the disease. Over a period of months or years, patients with ALS develop severe, progressive muscular weakness and other symptoms caused by loss of function in both upper and lower motor neurons. Sphincter control, sensory function, intellectual abilities and skin integrity are preserved. Patients become completely disabled, often requiring ventilatory support and gastrostomy. Death usually occurs within five years of diagnosis and is attributed to respiratory failure or cachexia. The etiology of the disease is unknown. Current research is focused on abnormalities of neuronal cell metabolism involving glutamate and the role of potential neurotoxins and neurotrophic factors. New drugs are being developed based on these theories. Current management involves aggressive, individualized alleviation of symptoms and complications.

Ki-1+ large-cell anaplastic lymphoma after Ewing sarcoma.

PURPOSE: A large cell anaplastic lymphoma that developed after treatment of a Ewing sarcoma (ES) is described. PATIENT: An 11-year-old girl with a pelvic ES developed a large cell, Ki-1+, anaplastic lymphoma in the same anatomic location 10 months after multimodal therapy. RESULTS: ES recurred in the primary site 16 months after allogeneic marrow transplantation and 3.5 years after initial diagnosis, but the patient remains in remission from her lymphoma. CONCLUSION: The occurrence of lymphoma and ES in a short time interval in the same patient is very unusual. Whether etiologic factors other than chemoradiotherapy, including genetic disposition, play a role remains to be elucidated.

Subtalar repositional arthrodesis for adult acquired flatfoot.

Arthrodesis of the subtalar joint is well recognized treatment option for moderate or severe flatfoot associated with adult acquired flatfoot secondary to posterior tibial tendon dysfunction. The success of the subtalar arthrodesis is dependent on restoration of normal bony relationships in the hindfoot and midfoot. For this reason, a distinction is made between a repositional arthrodesis and the traditional in situ type of arthrodesis. An in vitro study of the adult acquired flatfoot identifies an anteroposterior subluxation of the subtalar articulation that can be corrected durably and reliably through a repositional talocalcaneal arthrodesis. Intraoperative reduction techniques are useful in obtaining reduction of the peritalar subluxation. There are certain clinical features that help identify patients with flatfoot deformities who are good candidates for subtalar fusion. As the pathoanatomy of the flatfoot deformity is better elucidated, treatment techniques are modified to better address the key elements of the deformity. A repositional subtalar arthrodesis was shown to produce excellent correction in a moderate to severe in vitro flatfoot example in the authors' clinical series.

Triple arthrodesis.

Twenty-five adult patients with 32 fused hind-feet were evaluated at an average of 4.3 years after triple arthrodesis. All patients had Stage 3 or 4 deformity secondary to adult acquired flatfoot. All operations were performed using a standardized technique using rigid internal fixation. Postoperative American Orthopaedic Foot and Ankle Society hindfoot scores improved an average of 36 points. There was one nonunion and two residual varus malunions in patients who underwent additional procedures to obtain satisfactory position and fusion. All but one patient were satisfied with the result of their procedures and would have surgery again. With careful attention given to positioning, a triple arthrodesis is an acceptable treatment for late stage deformities in patients with adult acquired flatfoot.