Cross-Sectional Survey of Two Community-Based Health Fairs: Demographics, Healthcare Attitudes, and Hepatitis B.

Asian Americans Pacific Islanders (AAPI) share a disproportionate burden of chronic hepatitis B (CHB) in both the United States and New York State. Current hepatitis B virus (HBV) screening and research efforts have focused on urban communities. We administered a cross-sectional survey to 64 attendants at two free health fairs hosted by AAPI organizations on suburban Long Island, New York. We report the demographic make-up, healthcare attitudes, and HBV-related health histories of event attendees in Nassau and Suffolk Counties. Participants in Nassau County generally had more access to healthcare (97.1% vs 74.1% insured, 91.4% vs. 63.0% annual physician visit) and more familiarity with HBV screening (57.1% vs 17.2% history of HBV screening, 42.9% vs 3.9% physician recommendation for HBV screening). AAPI are a heterogenous population. Communities in close proximity may be demographically distinct and efforts to screen for HBV should be tailored to individual communities.

Longitudinal Assessment of Resident Performance Using Entrustable Professional Activities.

Importance: Entrustable professional activities (EPAs) are an emerging workplace-based, patient-oriented assessment approach with limited empirical evidence. Objective: To measure the development of pediatric trainees' clinical skills over time using EPA-based assessment data. Design, Setting, and Participants: Prospective cohort study of categorical pediatric residents over 3 academic years (2015-2016, 2016-2017, and 2017-2018) assessed on 17 American Board of Pediatrics EPAs. Residents in training at 23 pediatric residency programs in the Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network were included. Assessment was conducted by clinical competency committee members, who made summative assessment decisions regarding levels of supervision required for each resident and each EPA. Data were collected from May 2016 to November 2018 and analyzed from November to December 2018. Interventions: Longitudinal, prospective assessment using EPAs. Main Outcomes and Measures: Trajectories of supervision levels by EPA during residency training and how often graduating residents were deemed ready for unsupervised practice in each EPA. Results: Across the 5 data collection cycles, 1987 residents from all 3 postgraduate years in 23 residency programs were assigned 25 503 supervision level reports for the 17 general pediatrics EPAs. The 4 EPAs that required the most supervision across training were EPA 14 (quality improvement) on the 5-level scale (estimated mean level at graduation, 3.7; 95% CI, 3.6-3.7) and EPAs 8 (transition to adult care; mean, 7.0; 95% CI, 7.0-7.1), 9 (behavioral and mental health; mean, 6.6; 95% CI, 6.5-6.6), and 10 (resuscitate and stabilize; mean, 6.9; 95% CI, 6.8-7.0) on the expanded 5-level scale. At the time of graduation (36 months), the percentage of trainees who were rated at a supervision level corresponding to "unsupervised practice" varied by EPA from 53% to 98%. If performance standards were set to align with 90% of trainees achieving the level of unsupervised practice, this standard would be met for only 8 of the 17 EPAs (although 89% met this standard for EPA 17, performing the common procedures of the general pediatrician). Conclusions and Relevance: This study presents initial evidence for empirically derived practice readiness and sets the stage for identifying curricular gaps that contribute to discrepancy between observed practice readiness and standards needed to produce physicians able to meet the health needs of the patient populations they serve. Future work should compare these findings with postgraduation outcomes data as a means of seeking validity evidence.

Self-Reported Use of Tobacco, E-cigarettes, and Marijuana Versus Urinary Biomarkers.

BACKGROUND: Surveys have been instrumental in describing adolescent use of tobacco, electronic cigarettes (e-cigarettes), and marijuana. However, objective biomarker data are lacking. We compared adolescent self-reported use to urinary biomarkers. METHODS: From April 2017 to April 2018, adolescents 12 to 21 years old completed an anonymous questionnaire regarding tobacco, e-cigarette, and marijuana use and provided a urine sample. Urine was analyzed for biomarkers cotinine, total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol, and tetrahydrocannabinolic acid (THCA). RESULTS: Of 517 participants, 2.9% reported using tobacco, 14.3% e-cigarettes, and 11.4% marijuana in the past week. Only 2% reporting no smoking had total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol levels above cutoff (14.5 pg/mL); 2% of non-e-cigarette users had cotinine above cutoff (10 ng/mL); 2% of those denying marijuana use had THCA above cutoff (10 ng/mL). Daily e-cigarette users showed significantly higher median cotinine than nondaily users (315.4 [interquartile range (IQR) 1375.9] vs 1.69 ng/mL [IQR 28.2]; P < .003). Overall, 40% who reported using nicotine-free products had cotinine >10 ng/mL. Pod users' median cotinine was significantly higher than in nonpod users (259.03 [IQR 1267.69] vs 1.61 ng/mL [IQR 16.3]; P < .003). Median THCA among daily marijuana users was higher than in nondaily users (560.1 [IQR 1248.3] vs 7.2 ng/mL [IQR 254.9]; P = .04). Sixty-one percent of those with cotinine >10 ng/mL vs 39% of those with cotinine<10 ng/mL had THCA >10 ng/mL (P < .001). CONCLUSIONS: Adolescents' self-report correlated with measured urinary biomarkers, but subjects were unaware of their nicotine exposure. More frequent e-cigarette and pod use correlated with elevated biomarkers. Co-use of tobacco, e-cigarettes, and marijuana was corroborated by higher THCA in those with higher cotinine.

Integrating Bayesian reasoning into medical education using smartphone apps.

Background Diagnostic reasoning is an important topic in medical education, and diagnostic errors are increasingly recognized as large contributors to patient morbidity and mortality. One way to improve learner understanding of the diagnostic process is to teach the concepts of Bayesian reasoning and to make these concepts practical for clinical use. Many clinician educators do not fully understand Bayesian concepts and they lack the tools to incorporate Bayesian reasoning into clinical practice and teaching. Methods The authors developed an interactive workshop using visual models of probabilities and thresholds, clinical cases, and available smartphone apps to teach learners about Bayesian concepts. Results Evaluations from 3 years of workshops at a national internal medicine chief resident conference showed high satisfaction, with narrative comments suggesting learners found the visual and smartphone tools useful for applying the concepts with future learners. Conclusions Visual models, clinical cases, and smartphone apps were well received by chief residents as a way to learn and teach Bayesian reasoning. Further study will be needed to understand if these tools can improve diagnostic accuracy or patient outcomes.

Corneal Nerve Morphology and Tear Film Substance P in Diabetes.

PURPOSE: This work aims to characterize the relationship between tear film neuropeptide substance P and the structural integrity of the sub-basal nerve plexus in diabetes. METHODS: Seventeen healthy control participants and nine participants with diabetes were recruited in this cross-sectional study. Total protein content and substance P concentrations were determined in the flush tears of participants. Corneal nerve morphology was assessed by capturing the corneal sub-basal nerve plexus using the Heidelberg Retinal Tomograph II with the Rostock Corneal Module (Heidelberg Engineering GmbH, Heidelberg, Germany) in the central cornea. Corneal nerve fiber density (CNFD) was measured using ACCMetrics (M.A. Dabbah, Imaging Science and Biomedical Engineering, Manchester, UK) on eight captured images. Comparisons between groups were made using independent samples t-tests. Correlations between parameters were analyzed using Pearson's correlations. RESULTS: Substance P concentrations were significantly higher in the tears of the control group compared to participants with diabetes (4150 ± 4752 and 1473 ± 1671 pg/mL, respectively, P = .047). There was no significant difference in total protein content between the groups (3.4 ± 1.8 and 2.6 ± 1.7 mg/mL in the control and diabetes groups, respectively, P = .262). CNFD was significantly lower in the participants with diabetes compared to the control group (16.1 ± 5.7 and 21.5 ± 7.0 mm/mm, respectively, P = .041). There was a moderate correlation between substance P and CNFD (r = 0.48, P = .01). CONCLUSIONS: Substance P is expressed at a significantly lower level in the tears of people with diabetes compared with healthy controls. The positive correlation between substance P and corneal nerve density indicates that substance P may be a potential biomarker for corneal nerve health.

Entrusting Observable Practice Activities and Milestones Over the 36 Months of an Internal Medicine Residency.

PURPOSE: Competency-based medical education and milestone reporting have led to increased interest in work-based assessments using entrustment over time as an assessment framework. Little is known about data collected from these assessments during residency. This study describes the results of entrustment of discrete work-based skills over 36 months in the University of Cincinnati internal medicine (IM) residency program. METHOD: Attending physician and peer/allied health assessors provided entrustment ratings of resident performance on work-based observable practice activities (OPAs) mapped to Accreditation Council for Graduate Medicine Education/American Board of Internal Medicine reporting milestones for IM. These data were translated into milestones data and tracked longitudinally. The authors analyzed data from this new entrustment system's first 36 months (July 2012-June 2015). RESULTS: During the 36-month period, assessors made 364,728 milestone assessments (mapped from OPAs) of 189 residents. Residents received an annualized average of 83 assessment encounters, producing means of 3,987 milestone assessments and 4,325 words of narrative assessment. Mean entrustment ratings (range 1-5) from all assessors for all milestones rose from 2.46 for first-month residents to 3.92 for 36th-month residents (r = 0.9252, P < .001). Attending physicians' entrustment ratings were lower than peer/allied health assessors' ratings. Medical knowledge and patient care milestones were rated lower than professionalism and interpersonal and communication skills milestones. CONCLUSIONS: Entrustment of milestones appears to rise progressively over time, with differences by assessor type, competency, milestone, and resident. Further research is needed to elucidate the validity of these data in promotion, remediation, and reporting decisions.

Entrustment and mapping of observable practice activities for resident assessment.

Entrustable Professional Activities (EPAs) and the Next Accreditation System reporting milestones reduce general competencies into smaller evaluable parts. However, some EPAs and reporting milestones may be too broad to use as direct assessment tools. We describe our internal medicine residency curriculum and assessment system, which uses entrustment and mapping of observable practice activities (OPAs) for resident assessment. We created discrete OPAs for each resident rotation and learning experience. In combination, these serve as curricular foundation and tools for assessment. OPA performance is measured via a 5-point entrustment scale, and mapped to milestones and EPAs. Entrustment ratings of OPAs provide an opportunity for immediate structured feedback of specific clinical skills, and mapping OPAs to milestones and EPAs can be used for longitudinal assessment, promotion decisions, and reporting. Direct assessment and demonstration of progressive entrustment of trainee skill over time are important goals for all training programs. Systems that use OPAs mapped to milestones and EPAs provide the opportunity for achieving both, but require validation.