R.I.M.E. and reason: multi-station OSCE enhancement to neutralize grade inflation.

To offset grade inflation, many clerkships combine faculty evaluations with objective assessments including the Medical Examiners Subject Examination (NBME-SE) or Objective Structured Clinical Examination (OSCE), however, standardized methods are not established. Following a curriculum transition removing faculty clinical evaluations from summative grading, final clerkship designations of fail (F), pass (P), and pass-with-distinction (PD) were determined by combined NBME-SE and OSCE performance, with overall PD for the clerkship requiring meeting this threshold in both. At the time, 90% of students achieved PD on the Internal Medicine (IM) OSCE resulting in overall clerkship grades primarily determined by the NBME-SE. The clerkship sought to enhance the OSCE to provide a more thorough objective clinical skills assessment, offset grade inflation, and reduce the NBME-SE primary determination of the final clerkship grade. The single-station 43-point OSCE was enhanced to a three-station 75-point OSCE using the Reporter-Interpreter-Manager-Educator (RIME) framework to align patient encounters with targeted assessments of progressive skills and competencies related to the clerkship rotation. Student performances were evaluated pre- and post-OSCE enhancement. Student surveys provided feedback about the clinical realism of the OSCE and the difficulty. Pre-intervention OSCE scores were more tightly clustered (SD = 5.65%) around a high average performance with scores being highly negatively skewed. Post-intervention OSCE scores were more dispersed (SD = 6.88%) around a lower average with scores being far less skewed resulting in an approximately normal distribution. This lowered the total number of students achieving PD on the OSCE and PD in the clerkship, thus reducing the relative weight of the NMBE-SE in the overall clerkship grade. Student response was positive, indicating the examination was fair and reflective of their clinical experiences. Through structured development, OSCE assessment can provide a realistic and objective measurement of clinical performance as part of the summative evaluation of students.

Online Infectious Diseases Subspecialty Supplementary Curriculum for Medical Students and Residents: Moving Beyond "You Get What You Get".

OBJECTIVES: Students and residents rotating through infectious diseases (ID) electives are instructed primarily by participation in rounds and clinics, with teaching focused on diseases encountered. This "you get what you get" approach allows learners to apply knowledge directly to patient care, however, may miss topics encountered in standardized testing. This multisite study investigates the use of asynchronous web-based learning modules and its impact on student and resident knowledge. METHODS: Students and residents rotating through an ID elective were assigned to their standard elective (old) or asked to complete asynchronous web-based learning modules in addition to the standard curriculum (new). Learners submitted pre- and post-tests and scores were tabulated. In the following academic year, learners at the host site were provided the learning modules and a post-elective survey. RESULTS: Nine learners (100%) completed the pre-test and 5 (55.6%) completed the post-test in the standard (old) curriculum group, while 15 (100%) completed the pre-test and post-test in the new curriculum group. The mean percentage change in accuracy was 9% and 5.3% in the old and new curricula, respectively. Most (94%) survey respondents recommended continued use of the curriculum and expansion to other subspecialty electives. CONCLUSIONS: Subspecialty electives have multiple purposes including assisting learners in exploring careers, providing a well-rounded medical experience, or preparing learners for content in standardized tests. Consistent curricula are not always provided with electives to supplement the clinical experience. Our web curriculum was well-received with perceived knowledge gain, though with very small pre-post-test groups a score improvement could not be determined. An asynchronous online curriculum for learners in ID was feasible and well-received among faculty, and learners felt their knowledge was enhanced. Content areas supplemented those encountered during the ID elective. While an improvement in post-test scores was not demonstrated, learners and faculty felt modules were beneficial.

Effectiveness of a "Suppression Bundle" to improve HIV virologic suppression in an outpatient infectious disease clinic: a pilot implementation study.

Despite effectiveness and accessibility of combined anti-retroviral therapy (cART), only 85% of people living with HIV (PLHIV) in the United States are virologically suppressed. Improving suppression is complex. Our objective was to consider unique factors in PLHIV with non-suppressed viral loads in clinic and improve the percentage of suppressed patients by implementing a "Suppression Bundle" consisting of three to five bundled interventions with the goal of improved suppression. Prior to the study, there were 567 HIV-positive patients receiving care in clinic. Of those, 89 had a measurable viral load (>40 copies/mL). In this pilot pre-post implementation, we focused on the 89 non-suppressed patients to (1) determine feasibility of implementing bundles and (2) increase the number of patients with suppressed viral loads pre- to post-intervention. Of non-suppressed patients, 65 were active in care immediately pre-intervention and participated in the pilot. At the completion of the 9-month intervention, 46 had viral loads <40 copies/mL, demonstrating substantial improvement with 70.1% of the previously non-suppressed patients achieving suppression. By considering unique patient factors, an individualized Suppression Bundle is acceptable, feasible, and may increase virally suppressed patients in an outpatient clinic. Next steps include determining whether suppression bundles can be implemented in differing practices.

Implementation of Effective Smoking Cessation Strategies for People Living with HIV: A Pilot Implementation Study.

Introduction: Use of tobacco products carries significant long-term health risks, and rates of smoking in persons living with HIV are as high as two to three times that of the general population. This study aimed to increase assessment of readiness to quit smoking and provide cessation counseling to patients receiving HIV care through an infectious disease clinic. Methods: This study was a pilot implementation in a single-center teaching hospital. In total, 603 active patients with HIV were followed in clinic at the time of the study start; of these, 79 were active tobacco smokers (13%) and eligible for the intervention. Providers were educated on recommendations for tobacco smoking cessation counseling, intervention strategies, and options for treatment. Patients who smoked tobacco were assessed for readiness to quit. Cessation counseling and tobacco cessation mediations or nicotine replacement were provided at the discretion of the patient and physician based on visit discussions. Primary outcome measures were increase in assessment of readiness to quit and in providing cessation counseling. Secondary measures included tabulation of the number of patients provided with a tobacco smoking cessation treatment and those with a successful quit episode. Results: There was a moderate increase in patients assessed for readiness to quit and who received tobacco smoking cessation counseling and treatment medications during the pilot. In total, 11 patients (8.7%) reported quitting smoking for at least two weeks. Conclusions: Additional work on streamlined mechanisms to identify tobacco use and provide efficient and effective tobacco smoking cessation counseling are needed in this high-risk population.

Assessing Provider Utilization of COVID-19 Inflammatory Marker Trends in Hospitalized Patients and Implications in Optimizing Value-Based Care During a Pandemic.

Introduction: Numerous inflammatory markers may serve a role in prognostication of patients hospitalized with COVID-19 infection. Early in the pandemic, our health system created an admission order set which included daily d-dimer, c-reactive protein (CRP), lactate dehydrogenase (LDH), and ferritin. Given more available outcomes data, limiting standing order of labs that do not affect daily management could result in significant cost savings to the health system without adverse patient outcomes. The purpose of this study was to determine ordering and utilization patterns of inflammatory markers by physicians caring for patients hospitalized with COVID-19 infection. Methods: An anonymous 10-question survey was distributed to 125 physicians (Infectious Disease, Hospitalist, Pulmonary and Critical Care faculty). Responses were tallied and values greater than 50% were identified as the majority of the surveyed group. Results: Of the 125 physicians surveyed, 77 (62%) responded. A total of 57.1% (44/77) of physicians reported ordering daily inflammatory markers for 3 - 10 days from admission. Another 31.2% (24/77) ordered markers until clinical improvement or hospital discharge. D-dimer was used for care decisions by 83.1% (64/77) of respondents; 93.8% (60/64) of those reported utilizing it in determining anticoagulation dose. CRP was used by 61% (47/77) of physicians to help identify a secondary infection or determine steroid dose or duration. LDH and ferritin were not used for management decisions by the majority of physicians. Inflammatory markers were not used routinely after isolation precautions had been discontinued, even when ongoing care required mechanical ventilation. Conclusions: Of the markers studied, both d-dimer and CRP were considered useful by most respondents. LDH and ferritin were used less frequently and were not considered as useful in guiding medical decision making. Discontinuation of standing daily LDH and ferritin orders is believed to have potential to result in cost savings to the health care system with no adverse patient outcomes.

Acanthamoeba Keratitis: A Single-Institution Series of Four Cases With Literature Review.

Acanthamoeba species are free-living protozoa found pervasively in water and soil, which can cause infections of the central nervous system, skin, and eye. Amoebic keratitis (AK) is a vision-threatening, often chronic infection that is associated with the use of soft contact lenses due to corneal microtrauma and improper cleaning and storage. Although AK infections are rare, they cause significant morbidity including vision loss due to the diagnostic and therapeutic challenges they pose. The clinical course is determined by the organism's inherent pathogenicity, delay of diagnosis, and the paucity of data on effective therapeutic regimens. The case series and review of literature that follows examine current latest best practices in AK diagnosis including in vivo confocal microscopy (IVCM) and therapeutic interventions including miltefosine.

Internal Medicine Clerkship ID Curriculum Flip: Will They Prefer to Pre-learn?

Varying pedagogical approaches of undergraduate medical education are utilized in clerkships to supplement bedside teaching. The flipped classroom mode, in which self-paced study precedes the in-person session, is often used in pre-clinical education. This shift allows time with the instructor to focus on guided application of pre-learned concepts. At our institution, the Internal Medicine Clerkship Infectious Diseases lecture was substituted to a flipped classroom with two pre-learning videos. Student satisfaction scores were higher for the flipped classroom and comments were more negative for the traditional lecture. This suggests that senior medical students favor flipped classroom pedagogy despite pre-learning requirements.

Implementation of an Audience Response System in a Case Conference Curriculum: Results of a Placebo-Controlled Trial.

Audience response systems engage learners and facilitate the assimilation of the material. We assessed whether incorporation of one system into a resident case conference would increase retention of information and attentiveness. Pre-tests were administered prior to case conferences. The University Hospital incorporated Poll Everywhere into a conference and the Veterans Administration hospital did not. Participants rated self-perceived attentiveness and completed a post-test following conference. There was an increase in post-test scores compared to pre-tests. There was no significant difference in self-perceived attentiveness or post-test scores between sites. The use of audience response did not increase retention of material or perceived attentiveness when incorporated into the conference.

Life vs Loans: Does Debt Affect Career Satisfaction in Osteopathic Graduates?

BACKGROUND: The cost of undergraduate osteopathic medical education continues to grow. It is important to understand how the rising cost of matriculation negatively affects training and career satisfaction of entering students. OBJECTIVE: To better understand any association between level of educational debt and satisfaction with osteopathic medical education, career choice, and financial services. METHODS: Responses were analyzed from the American Association of Colleges of Osteopathic Medicine survey of pending medical school graduates from 2007 through 2016 regarding indebtedness and specialty selection. RESULTS: From 2007 to 2016, the mean educational debt level at graduation rose consistently among osteopathic graduates (from $155,698 to $240,331, respectively). In all years, there was no significant effect of debt quartile on satisfaction with choice of osteopathic medicine as a career. Quartile variable with debt did not show a significant effect on satisfaction with education experience in 2010, 2013, and 2016. Top quartile debt was associated with higher satisfaction with financial service departments in all years. CONCLUSION: Although debt has consistently increased for osteopathic medical graduates, it does not affect their satisfaction with either their educational experience or their choice of osteopathic medicine as a career.

How Trainees Finance Their Medical Education: Implications of Higher Education Act Reform.

CONTEXT: The Public Service Loan Forgiveness (PSLF) program is among several repayment programs currently available for recipients of federal student loans. Medical education debt has continued to expand at a rapid pace in the decade since PSLF was created. Proposed changes to the Higher Education Act would substantially transform how future medical trainees finance and repay medical education debt. OBJECTIVE: To better understand relationships between debt and personal stress, as well as between repayment- and forgiveness-program use, in the context of competing legislation. METHODS: Surveys were sent to all Accreditation Council for Graduate Medical Education-accredited internal medicine residency programs (osteopathic and allopathic). RESULTS: From a potential pool of 579 residents, data were obtained from 403 unique respondents (response rate, 69.6%) at 12 residency programs, for a program response rate of 2.2%. Of these respondents, 290 (71.9%) completed the demographic portion of the survey. Median education debt was $225,000. Residents with the top quartile of debt burden were more likely to use PSLF (odds ratio [OR], 3.27; P=.02), more likely to enter loan forbearance (OR, 2.14; P=.03), and indicated a higher level of stress (OR, 5.94; P<.001) compared with those in the second and third quartiles. CONCLUSION: Proposed legislative changes to the Higher Education Act would scale back loan repayment options and also eliminate PSLF for future borrowers. Our data suggest that higher debt burdens are associated with increased debt-related stress. Given program popularity and growing use, along with growing concerns of physician burnout, policy makers should weigh the potential downstream effects of policy change on prospective future physicians.

Poll Everywhere to Encourage Learner Satisfaction and Participation in Internal Medicine Fellowship Didactics.

Active learning improves self-reported engagement and satisfaction in medical education. Audience response systems are one mechanism of encouraging participation, especially in a setting in which learners in varying educational levels are present. Three fellowships participated in this educational quality improvement project where Poll Everywhere® was incorporated into didactics. Attendees were invited to complete a 4-question retrospective pre-post satisfaction survey. Incorporation of the Poll Everywhere® audience response system resulted in a shift in more favorable satisfaction scores and self-perceived attentiveness compared to the pre-intervention responses.

Implementation of a standardised sign-up process to increase MyChart enrolment among HIV-positive patients.

Interactive patient portals are a valuable tool for engaging patients in their healthcare, with various functionalities including viewing laboratory results, refilling prescriptions and communicating directly with nurses, physicians and other healthcare providers via electronic messaging. The utility of patient portals is limited primarily from lack of patient uptake and enrolment due to a variety of factors including lack of awareness, low health literacy, poor technology mastery, lack of availability of a smartphone or computer and distrust of the security of their personal health information. We aimed to increase enrolment in the Epic (O2) MyChart patient portal among patients receiving HIV care through our Infectious Diseases clinic via a standardised sign-up protocol during their clinic visits. This intervention resulted in a modest increase in enrolled patients. However, the factors preventing a more dramatic increase in patient uptake remain unclear.

Mycobacterium Avium Prosthetic Hip Infection on Abatacept Presenting as Fever of Unknown Origin.

Non-tuberculous mycobacteria (NTM) are well-described pulmonary pathogens in patients with underlying lung disease. Extra-pulmonary infections with NTM are rare. We describe a prosthetic hip infection with Mycobacterium avium complex. Increased immunosuppressing medications and number of total joint replacements are expected to increase the prevalence of NTM infections in the future.

Role of Debt and Loan Forgiveness/Repayment Programs in Osteopathic Medical Graduates' Plans to Enter Primary Care.

CONTEXT: Osteopathic medicine emphasizes partnering with patients to help them attain or maintain health. This philosophy encourages physicians to practice primary care and a mission of improving community health. However, there is currently a shortage of primary care physicians in many areas of the United States. OBJECTIVE: To determine whether intended practice patterns of recent graduates of colleges of osteopathic medicine favor primary care and whether practice patterns correlate with medical education debt. METHODS: Responses were analyzed from the American Association of Colleges of Osteopathic Medicine survey of pending medical school graduates from 2007 through 2016 regarding indebtedness and specialty selection. RESULTS: The percentage of graduating osteopathic medical students who chose a primary care specialty increased from 28.1% (676 students) in 2007 to 33.2% (1377 students) in 2016. Among graduates, those above the 75th percentile of debt had a general move toward more non-primary care positions, with a value of 74.4% in 2007 and 79.9% in 2016. Graduates below the 25th percentile had a gradual increase in primary care representation, moving from 24.6% in 2007 to 29.4% in 2016. In 2007, graduates with a loan forgiveness/repayment program were more likely to choose primary care over graduates without such a program (OR, 0.681 [95% CI, 0.505-0.920]; P=.02). Analysis of subsequent years showed a declining OR with increasing significance. CONCLUSIONS: Results of this analysis indicated that increased educational debt loan directly influenced physician practice choice. Graduates with high debt burden were more likely to enter primary care fields and use loan forgiveness/repayment programs. Graduates with high debt burden who did not use loan forgiveness/repayment programs were more likely to enter non-primary care specialty fields, with this trend increasing as mean medical school debt increased. This association has implications for policies that could affect choice of primary care. However, further research is needed to fully understand the primary care choice by graduates of colleges of osteopathic medicine.

Practice Area Intentions of Graduates of Colleges of Osteopathic Medicine: What Role Does Debt Play?

CONTEXT: Enrollment in colleges of osteopathic medicine continues to increase, as does the need for physicians practicing in underserved areas. The cost of osteopathic medical education is substantial, with students often incurring debt of $200,000 or more. It is unclear whether practice patterns of new graduates will be affected by debt-to-income ratios. OBJECTIVE: To determine whether the intended practice location of graduates of colleges of osteopathic medicine is associated with medical education debt. METHODS: Using data from the American Association of Colleges of Osteopathic Medicine's annual survey to graduates of colleges of osteopathic medicine, the authors focused on graduates' intention to practice in an underserved area, the amount of debt incurred, and plans to enter a loan-repayment program. Survey data from 2007, 2010, 2013, and 2016 were analyzed. RESULTS: From 2007 to 2016, the percentage of graduates who intended to practice in underserved areas increased (27.5% to 35.3%, respectively). Graduates with the most debt intended to practice in underserved areas at a higher percentage than those with the least amount of debt, and they also planned on using loan-repayment programs at a higher rate. CONCLUSION: There is a strong association among the intention to practice in an underserved area, high debt load, and intention to use a loan-repayment program. Therefore, the osteopathic medical community should support increased access to loan-repayment programs to help its graduates surmount economic and social barriers to providing care in underserved areas.

Mycobacterium bovis Osteomyelitis of the Thoracic Spine Mimicking a Metastatic Lytic Lesion in a Patient Exposed to Intravesicular Bacille Calmette-Guérin Treatment.

An 80-year-old man with previous intravesicular bacille Calmette-Guérin therapy developed mass lesions of the lower thoracic spine. Metastatic disease was suspected. The patient underwent a course of radiation; however, biopsy later demonstrated fibrosis and cultures grew Mycobacterium bovis. The patient was treated with a course of isoniazid, rifampin, and ethambutol.

Integrin-linked kinase regulates integrin signaling in human trabecular meshwork cells.

PURPOSE: To determine whether integrin-linked kinase (ILK) controls the organization of the actin cytoskeleton in the trabecular meshwork (TM) by regulating integrin co-signaling. METHODS: The cell binding domain and the Heparin II (Hep II) domain of fibronectin were used to activate α5ß1 and α4ß1 integrin signaling, respectively, in differentiated human TM (HTM) cells. The role of ILK was determined using either ILK small interfering RNA (siRNA) to knockout ILK expression or the ILK inhibitors, KP392 and QLT0267. The knockdown of ILK expression was verified by Western blot analysis. The presence of actin stress fibers and focal adhesions was determined by labeling cultures with phalloidin and anti-talin or ILK antibodies, respectively. RESULTS: Cell spreading in differentiated HTM cells required ILK, since ILK siRNA and the ILK inhibitors significantly reduced cell spreading, actin polymerization, and the localization of talin and ILK in focal adhesions (FAs). Both cell spreading and the localization of talin and ILK to FAs in differentiated HTM cells could be rescued by inducing α4ß1 integrin signaling with a recombinant Hep II domain of fibronectin, even though α4ß1 integrins were not found in FAs. In the absence of ILK inhibition, the Hep II domain had minimal effect on α5ß1 integrin-mediated spreading. CONCLUSIONS: This study suggests that cooperative α5ß1/α4ß1 integrin signaling may be regulated by ILK trans-dominantly and that alterations in ILK activity may affect actin cytoskeleton organization and contractility in the TM.