Implementation of Formal Curriculum on Health Care Disparities in Military Family Medicine Residency.

BACKGROUND AND OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) requires education on health care disparities (HCD), but research assessing formal curricula is limited. To improve knowledge and confidence in HCD, the family medicine residency program at Darnall Army Medical Center implemented a formal HCD curriculum. METHODS: During the 2021-2022 academic year, starting July 2021, a formal HCD curriculum was implemented for family medicine residents and faculty. Ten lectures on HCDs and implicit bias were given over the course of the year. Residents and faculty were asked to incorporate HCD into their regular continuing medical education lectures. ACGME survey data as well as a pre- and postcurriculum survey were used to assess HCD knowledge and confidence. Descriptive statistics and a paired-sample t tests were calculated to compare pre- to postcurriculum changes. RESULTS: The percentage of residents who reported that they had received HCD education increased from 72% on the 2021 ACGME survey to 100% in 2022 (N=18). We found a significant (P<.05) improvement in knowledge and confidence across 11 of 12 questions on the pre- and postcurriculum survey. CONCLUSIONS: A formal curriculum in a military family medicine residency setting was effective for improving self-reported HCD knowledge and confidence.

Polymyalgia Rheumatica and Giant Cell Arteritis: Rapid Evidence Review.

Polymyalgia rheumatica and giant cell arteritis are inflammatory conditions that occur predominantly in people 50 years and older, with peak incidence at 70 to 75 years of age. Polymyalgia rheumatica is more common and typically presents with constitutional symptoms, proximal muscle pain, and elevated inflammatory markers. Diagnosis of polymyalgia rheumatica is clinical, consisting of at least two weeks of proximal muscle pain, constitutional symptoms, and elevated erythrocyte sedimentation rate or C-reactive protein. Treatment of polymyalgia rheumatica includes moderate-dose glucocorticoids with a prolonged taper. Giant cell arteritis, also known as temporal arteritis, usually presents with new-onset headache, visual disturbances or changes, constitutional symptoms, scalp tenderness, and temporal artery symptoms. Inflammatory markers are markedly elevated. Temporal arterial biopsy should be used for diagnosis. However, color duplex ultrasonography, magnetic resonance imaging, and fluorodeoxyglucose positron emission tomography may be helpful when biopsy is negative or unavailable. All patients with suspected giant cell arteritis should receive empiric high-dose glucocorticoids because the condition may lead to blindness if untreated. Tocilizumab is approved by the U.S. Food and Drug Administration for giant cell arteritis and should be considered in addition to glucocorticoids for initial therapy. Polymyalgia rheumatica and giant cell arteritis respond quickly to appropriate dosing of glucocorticoids but typically require prolonged treatment and have high rates of relapse; therefore, monitoring for glucocorticoid-related adverse effects and symptoms of relapse is necessary. Methotrexate may be considered as an adjunct to glucocorticoids in patients with polymyalgia rheumatica or giant cell arteritis who are at high risk of relapse.

Institutional Characteristics Influencing Medical Student Selection of Primary Care Careers: A Narrative Review and Synthesis.

BACKGROUND AND OBJECTIVES: There is an ongoing shortage of primary care physicians in the United States. Medical schools are under pressure to address this threat to the nation's health by producing more primary care graduates, including family physicians. Our objective was to identify institutional characteristics associated with more medical students choosing primary care. METHODS: We conducted a systematic literature review with narrative synthesis to identify medical school characteristics associated with increased numbers or proportions of primary care graduates. We included peer-reviewed, published research from the United States, Canada, Australia, and New Zealand. The existing literature on characteristics, including institutional geography, funding and governance, mission, and research emphasis, was analyzed and synthesized into summary statements. RESULTS: Ensuring a strong standing of the specialty of family medicine and creating an atmosphere of acceptance of the pursuit of primary care as a career are likely to increase an institution's percentage of medical students entering primary care. Training on regional campuses or providing primary care experiences in rural settings also correlates with a larger percentage of graduates entering primary care. A research-intensive culture is inversely correlated with primary care physician production among private, but not public, institutions. The literature on institutional financial incentives is not of high enough quality to make a firm statement about influence on specialty choice. CONCLUSIONS: To produce more primary care providers, medical schools must create an environment where primary care is supported as a career choice. Medical schools should also consider educational models that incorporate regional campuses or rural educational settings.

Influences of Medical School Admissions Practices on Primary Care Career Choice.

BACKGROUND AND OBJECTIVES: Medical schools should understand how to matriculate students who are more likely to enter primary care specialties and put admissions processes into place that achieve this result. However, there are no existing reviews that have systematically evaluated medical school admission practices and primary care specialty choice. METHODS: We conducted a narrative synthesis utilizing a systematic literature search to evaluate the effectiveness of medical school admission strategies designed to increase the percentage of graduates entering primary care specialties. RESULTS: We included 34 articles in the narrative review. Multiple prematriculation programs that appear to produce students with a high likelihood of entering primary care have been described in the literature. However, all of these studies are from single institutions, were observational, and limited by selection bias. Applicants who self-identify an interest in primary care, grew up with a rural background, and are older at matriculation are more likely to enter primary care, with stated interest in primary care being most predictive. Gender and race have been associated with primary care specialty choice in some studies, but not all. Insufficient literature on admissions policies and procedures exists to draw conclusions about best practices. CONCLUSIONS: Medical schools that want to increase the percentage of graduates entering primary care should consider developing a prematriculation program that attracts and prepares motivated and talented students with primary care interest. Admissions committees should understand which demographic criteria are associated with increased likelihood of entering primary care. The most important identifiable trait is an applicant's stated interest in primary care.

Medical School Characteristics, Policies, and Practices That Support Primary Care Specialty Choice: A Scoping Review of 5 Decades of Research.

BACKGROUND AND OBJECTIVES: The United States, like many other nations, faces a chronic shortage of primary care physicians. The purpose of this scoping review was to synthesize literature describing evidence-based institutional practices and interventions that support medical students' choices of primary care specialties, published in the United States, Canada, Australia, and New Zealand. METHODS: We surveyed peer-reviewed, published research. An experienced medical librarian conducted searches of multiple databases. Articles were selected for inclusion based on explicit criteria. We charted articles by topic, methodology, year of publication, journal, country of origin, and presence or absence of funding. We then scored included articles for quality. Finally, we defined and described six common stages of development of institutional interventions. RESULTS: We reviewed 8,083 articles and identified 199 articles meeting inclusion criteria and 41 related articles. As a group, studies were of low quality, but improved over time. Most were quantitative studies conducted in the United States. Many studies utilized one of four common methodologic approaches: retrospective surveys, studies of programs or curricula, large-scale multi-institution comparisons, and single-institution exemplars. Most studies developed groundwork or examined effectiveness or impact, with few studies of planning or piloting. Few studies examined state or regional workforce outcomes. CONCLUSIONS: Research examining medical school interventions and institutional practices to support primary care specialty choice would benefit from stronger theoretical grounding, greater investment in planning and piloting, consistent use of language, more qualitative methods, and innovative approaches. Robust funding mechanisms are needed to advance these goals.

A Cluster of Exertional Rhabdomyolysis Cases in a ROTC Program Engaged in an Extreme Exercise Program.

Exertional rhabdomyolysis (ER) is on the rise among service members and high school and college athletes. Reported risk factors for ER include fitness level, sudden increase in exercise intensity and duration, and eccentric predominant exercise. This study examined an ER cluster among Reserve Officer Training Corps cadets who participated in a mandatory, timed, extreme conditioning program (ECP) workout. Forty-four cadets participated in this ECP; 11 were subsequently hospitalized with ER. Thirty-five cadets, including all who developed ER, completed a questionnaire to assess ECP times, prior fitness scores, and other ER risk factors. Cadets completed the ECP workout as individuals or in teams. Nine of 25 (36%) individual and two of 10 (20%) team participants were hospitalized with ER. Among the cadets, no associations were noted between hospitalization for ER and finish time, previous fitness scores, or dietary supplement use. The relative risk of developing ER was significantly increased in those who consumed alcohol in the week preceding the ECP (RR = 4.20; 95% CI 1.95, 9.03). In this cohort of Reserve Officer Training Corps cadets, an ECP resulted in a high rate of hospitalization for ER. Contrary to reported ER risk factors, higher baseline fitness was not protective. Rather, cadet knowledge that ECP performance was strongly linked to final cadet ranking greatly influenced intensity of effort.

Same Content, Different Methods: Comparing Lecture, Engaged Classroom, and Simulation.

BACKGROUND AND OBJECTIVES: There is a push to use classroom technology and active teaching methods to replace didactic lectures as the most prevalent format for resident education. This multisite collaborative cohort study involving nine residency programs across the United States compared a standard slide-based didactic lecture, a facilitated group discussion via an engaged classroom, and a high-fidelity, hands-on simulation scenario for teaching the topic of acute dyspnea. The primary outcome was knowledge retention at 2 to 4 weeks. METHODS: Each teaching method was assigned to three different residency programs in the collaborative according to local resources. Learning objectives were determined by faculty. Pre- and posttest questions were validated and utilized as a measurement of knowledge retention. Each site administered the pretest, taught the topic of acute dyspnea utilizing their assigned method, and administered a posttest 2 to 4 weeks later. Differences between the groups were compared using paired t-tests. RESULTS: A total of 146 residents completed the posttest, and scores increased from baseline across all groups. The average score increased 6% in the standard lecture group (n=47), 11% in the engaged classroom (n=53), and 9% in the simulation group (n=56). The differences in improvement between engaged classroom and simulation were not statistically significant. CONCLUSIONS: Compared to standard lecture, both engaged classroom and high-fidelity simulation were associated with a statistically significant improvement in knowledge retention. Knowledge retention after engaged classroom and high-fidelity simulation did not significantly differ. More research is necessary to determine if different teaching methods result in different levels of comfort and skill with actual patient care.

Current concepts in concussion: evaluation and management.

Concussion is a disturbance in brain function caused by direct or indirect force to the head. It is a functional rather than structural injury that results from shear stress to brain tissue caused by rotational or angular forces-direct impact to the head is not required. Initial evaluation involves eliminating cervical spine injury and serious traumatic brain injury. Headache is the most common symptom of concussion, although a variety of clinical domains (e.g., somatic, cognitive, affective) can be affected. Signs and symptoms are nonspecific; therefore, a temporal relationship between an appropriate mechanism of injury and symptoms must be determined. There are numerous assessment tools to aid diagnosis, including symptom checklists, neuropsychological tests, postural stability tests, and sideline assessment tools. These tools are also used to monitor recovery. Cognitive and physical rest are the cornerstones of initial management. There are no specific treatments for concussion; therefore, focus is on managing symptoms and return to play. Because concussion recovery is variable, rigid classification systems have mostly been abandoned in favor of an individualized approach. A graded return-to-play protocol can be implemented once a patient has recovered in all affected domains. Children, adolescents, and those with a history of concussions may require a longer recovery period. There is limited research on the management of concussions in children and adolescents, but concern for potential consequences of injury to the developing brain suggests that a more conservative approach to management is appropriate in these patients.