Demise of the USMLE Step-2 CS exam: Rationalizing a way forward.

The COVID-19 pandemic has compelled rethinking and changes in medical education, the most controversial perhaps being the cancelation of USMLE Step-2 Clinical Skills exam (Step-2 CS). What started in March of 2020 as suspension of this professional licensure exam, because of concerns about infection risk for examinees, standardized patients (SPs), and administrators, soon became permanent cancelation in January 2021. Expectedly, it triggered debate in medical education circles. Positively, however, the USMLE regulatory agencies (NBME and FSMB) saw an opportunity to innovate an exam tainted with perceptions of validity deficits, cost, examinee inconvenience, and worries about future pandemics; they therefore called for a public debate to fashion a way forward. We have approached the issue by defining Clinical Skills (CS), exploring its epistemology and historic evolution, including assessment modalities from Hippocratic times to the modern era. We defined CS as the art of medicine manifest in the physician-patient encounter as history taking (driven by communication skills and cultural competence) and physical examination. We classified CS components into knowledge and psychomotor skill domains, established their relative importance in the physician process (clinical reasoning) of diagnosis, thus establishing a theoretical framework for developing valid, reliable, feasible, fair, and verifiable CS assessment. Given the concerns for COVID-19 and future pandemics, we established that CS can largely be assessed remotely, and what could not, can be assessed locally (school/regional consortia level) as part of a USMLE-regulated/supervised assessment regimen with established national standards, thus maintaining USMLE's fiduciary responsibilities. We have suggested a national/regional program for faculty development in CS curriculum development, and assessment, including standard setting skills. This pool of expert faculty will form the nucleus of our proposed USMLE-regulated External Peer Review Initiative (EPRI). Finally, we suggest that CS evolves into an academic discipline/department of its own, rooted in scholarship.

Reducing Time to Diagnosis of Rare Genetic Diseases in a Medically Underserved Hispanic Population- Lessons Learned for Meaningful Engagement.

Background: The utilization of genomic information to improve health outcomes is progressively becoming more common in clinical practice. Nonetheless, disparities persist in accessing genetic services among ethnic minorities, individuals with low socioeconomic status, and other vulnerable populations. The Rio Grande Valley at the Texas-Mexico border is predominantly Hispanic with a high poverty rate and an increased prevalence of birth defects, with very limited access to genetics services. The cost of a diagnosis is often times out of reach for these underserved families. Funded by the National Center for Advancing Translational Sciences (NCATS), Project GIVE (Genetic Inclusion by Virtual Evaluation) was launched in 2022 to shorten the time to diagnosis and alleviate healthcare inequities in this region, with the goal of improving pediatric health outcomes. Methods: Utilizing Consultagene, an innovative electronic health record (EHR) agnostic virtual telehealth and educational platform, we designed the study to recruit 100 children with rare diseases over a period of two years from this region, through peer-to-peer consultation and referral. Conclusions: Project GIVE study has allowed advanced genetic evaluation and delivery of genome sequencing through the virtual portal, effectively circumventing the recognized socioeconomic and other barriers within this population. This paper explores the successful community engagement process and implementation of an alternate genomics evaluation platform and testing approach, aiming to reduce the diagnostic journey for individuals with rare diseases residing in a medically underserved region.

Augmented Reality Application of Schizocosa ocreata: A Tool for Reducing Fear of Arachnids Through Public Outreach.

This study aims to create a mobile application for public interaction around the subject of wolf spiders, specifically the brush-legged wolf spider. The hope is that the public will have a reduced level of fear towards arachnids when given a chance to view arachnids in a digital setting. To assist this, the application employs augmented reality animation, which has been shown to have a positive impact on the viewer's interest and learning. With the opportunity to view a digital spider interacting with surfaces in a repeatable and informative manner, viewers may find that their fears are more understood and can be controlled for both their benefit and that of the local arachnids. In order to accommodate multiple audiences, the application was set up to have a more cartoonish and simpler text as well as a realistic and advanced text. The area of information covered the brush-legged wolf spider's anatomy, mating behaviour, and general safety practices for handling and avoiding wolf spiders. The modelling and animation were created using Zbrush and Blender, respectively. The programming and application creations used were Unity with Android and AR plugins.

A non-destructive virtual dissection by micro-CT reveals diagnostic characters in the type specimen of Caloptilia stigmatella (Lepidoptera: Gracillariidae).

Nearly a century ago, wing venation was introduced in gracillariid taxonomy as a means to diagnose closely related genera and species groups. Recent advances in non-destructive virtual micro-dissections suggest promising approaches with which to revisit the relevance of wing venation characters on historic primary type specimens. Many unique type specimens in Gracillariidae and other microlepidoptera groups preserved in museum collections are in poor condition, and over the course of history have suffered loss or damage to their abdomens. Consequently, genitalia morphology is not available for diagnoses and comparisons. In this paper we emphasize the need to include the type species and type specimens into the broader context of taxonomic studies on micro-moths in general and the family Gracillariidae in particular. The genus Caloptilia has a world-wide distribution and has been the subject of research for more than 200 years, yet the generic boundaries and groupings within the genus are still unresolved due to the lack of a reliable set of taxonomic characters obtained from the primary types. We describe a method of virtual descaling of the fore- and hindwings using the unset micro-moth type specimen of Caloptilia stigmatella Fabricius, 1781, in order to demonstrate that the study of historic and fragile type specimens and diagnoses of their internal morphological characters becomes possible by applying new and non-destructive technology.

Vibration-guided mate searching in treehoppers: directional accuracy and sampling strategies in a complex sensory environment.

Animal movement decisions involve an action-perception cycle in which sensory flow influences motor output. Key aspects of the action-perception cycle involved in movement decisions can be identified by integrating path information with measurement of environmental cues. We studied mate searching in insects for which the primary sensory cues are mechanical vibrations traveling through the tissues of living plants. We mapped search paths of male thornbug treehoppers locating stationary females through an exchange of vibrational signals. At each of the males' sampling locations, we used two-dimensional laser vibrometry to measure stem motion produced by female vibrational signals. We related properties of the vibrational signals to the males' movement direction, inter-sample distance and accuracy. Males experienced gradients in signal amplitude and in the whirling motion of the plant stem, and these gradients were influenced to varying degrees by source distance and local stem properties. Males changed their sampling behavior during the search, making longer inter-sample movements farther from the source, where uncertainty is higher. The primary directional cue used by searching males was the direction of wave propagation, and males made more accurate decisions when signal amplitude was higher, when time delays were longer between the front and back legs, and when female responses were short in duration. The whirling motion of plant stems, including both the eccentricity and the major axes of motion, is a fundamental feature of vibrational environments on living plants, and we show for the first time that it has important influences on the decisions of vibrationally homing insects.

Establishing the NeuroRecovery Network Community Fitness and Wellness facilities: multi-site fitness facilities provide activity-based interventions and assessments for evidence-based functional gains in neurologic disorders.

BACKGROUND: Physical fitness is a necessity for those living with a spinal cord injury, yet access to fitness facilities, equipment, and specially trained fitness experts are limited. METHODS: This article introduces the concept of a network of fitness facilities specially geared towards individuals with spinal cord injury and other neurological disorders. RESULTS: The Community Fitness and Wellness branch of the NeuroRecovery Network was created to provide a continuum of care after traditional rehabilitation for individuals living with a spinal cord injury and other neurological disorders. Community Fitness and Wellness facilities translate activity-based interventions performed during rehabilitation into a community setting as well as provide other fitness and wellness opportunities. Community Fitness and Wellness facilities are staffed by professionals with training on the specialized needs of individuals living with spinal cord injury or other neurological disorders. Standardized assessments evaluate functional, health, and quality of life gains at regular intervals. A national database gathers information on standardized interventions and assessment outcomes providing a mechanism for evaluation of interventions performed in the community setting. CONCLUSIONS: The establishment of Community Fitness and Wellness facilities allows for the quick translation and evaluation of novel, effective approaches from research to individuals in the community. Implications for Rehabilitation Fitness needs of individuals with spinal cord injury living in the community necessitate the use of special equipment and trained staff. Community Fitness and Wellness Programs offer specially trained staff and adaptive equipment providing a continuity of care for those with spinal cord injuries and other neurological disorders.

Development of the OnTrack Diabetes Program.

BACKGROUND: Type 2 diabetes affects an estimated 347 million people worldwide and often leads to serious complications including blindness, kidney disease, and limb amputation. Comorbid dysphoria is common and is an independent risk factor for poor glycaemic control. Professional support for diabetes self-management and dysphoria has limited availability and involves high costs, especially after regular hours, and in rural and remote areas. Web-based cognitive behavior therapy offers highly accessible, acceptable, and cost-effective support for people with diabetes. This paper describes the development of OnTrack Diabetes, a self-guided, Web-based program to promote improved physical and emotional self-management in people with Type 2 diabetes. OBJECTIVE: The objective of the study is to describe the development of the OnTrack Diabetes program, which is a self-guided, Web-based program aimed to promote euthymia and improved disease self-management in people with Type 2 diabetes. METHODS: Semistructured interviews with 12 general practitioners and 13 patients with Type 2 diabetes identified enablers of and barriers to effective diabetes self-management, requirements for additional support, and potential program elements. Existing resources and research data informed the development of content, and consultants from relevant disciplines provided feedback on draft segments and reviewed the program before release. Using a self-guided delivery format contained costs, in addition to adapting program features and modules from an existing OnTrack program. RESULTS: A separate paper describes the protocol for a randomized controlled trial to provide this required evaluation. CONCLUSIONS: Development of the OnTrack Diabetes program demonstrates strategies that help ensure that a program is acceptable to users. The next stages involve testing users' experiences and examining the program's effectiveness and cost-effectiveness in randomized controlled trials. TRIAL REGISTRATION: The Australian New Zealand Clinical Trials Registry (ACTRN): 12614001126606; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12614001126606 (Archived by WebCite at http://www.webcitation.org/6U0Fh3vOj).

A questionnaire survey comparing the educational priorities of patients and medical students in the management of multiple sclerosis.

OBJECTIVE: To compare the educational priorities patients and students raise concerning the management of multiple sclerosis (MS). DESIGN/SETTING: A single-centre comparative questionnaire survey conducted in a foundation trust hospital which provides teaching for one UK medical school. PARTICIPANTS: A total of 255 people with multiple sclerosis (pwMS) and 125 final year medical students attending a mandatory module were invited to participate. MAIN OUTCOME MEASUREMENTS: Questionnaires were developed and piloted for this study and analysed on the basis of the International Classification of Functioning, Disability and Health terminology. RESULTS: Questionnaires were returned by 125 (50%) pwMS (age range 36-86 years; median 58) and 96 (77%) medical students (age range 22-37 years; median 23). The most commonly reported priority listed by people with MS and students concerned 'environmental contextual factors' (95.5% and 99%, respectively). PwMS focused primarily on the 'social and attitudinal aspects' of the environment (53.6%), while students expressed greater interest in the use of medications (91.7%) and investigations (14.6%) (p < 0.001). People with greater psychological or physical impact of the condition were more likely to prioritise 'health condition' topics. CONCLUSIONS: PwMS and medical students identify different topics when asked to list aspects of management of MS which they deem to be important for medical student teaching. These differences in educational priorities should be taken into consideration when teaching students about MS. The findings may also apply to other long-term neurological conditions and warrant further investigation.