Experiences of early graduate medical students working in New York hospitals during the COVID-19 pandemic: a mixed methods study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic presented the world with a sudden need for additional medical professionals. Senior medical students were identified as potential workers and many worldwide graduated early to serve as Junior Physicians in hospitals. The authors sought to identify factors that informed the decision to work, describe experiences in this capacity, and elucidate benefits for trainees. METHODS: The investigators conducted a mixed-methods observational cohort study of early medical graduates eligible to work as Junior Physicians at two New York medical centers in April/May 2020 during an initial surge in COVID-19 hospitalizations. Graduates were surveyed, and a sample of Junior Physicians participated in a focus group. Survey responses of those who worked were compared to those who did not. Focus group responses were transcribed, coded, and thematically analyzed. RESULTS: Fifty-nine graduates completed the study methods and 39 worked as Junior Physicians. Primary reasons for working included duty to help (39 [100%]), financial incentive (32 [82%]), desire to learn about pandemic response (25 [64%]), and educational incentive (24 [62%]). All had direct contact with COVID-19 patients, believed working was beneficial to their medical training, and were glad they worked. None contracted a symptomatic infection while working. Compared with non-Junior Physicians, Junior Physicians reported increased comfort levels in completing medical intern-level actions like transitions of care functions, such as writing transfer notes (P < 0.01), writing discharge orders (P = 0.01), and providing verbal sign out (P = 0.05), and they reported more comfort in managing COVID-19 patients. Sixteen themes emerged from the focus group and were placed into four categories: development of skills, patient care, safety, and wellness. CONCLUSIONS: Senior medical students chose to work as Junior Physicians for both personal and educational reasons. Experiences were beneficial to trainees and can inform future innovations in medical education.

Fostering student and faculty scholarship in an accelerated three-year medical school.

Background: In acknowledgement of the importance of research competency in academic medicine, an extracurricular student research program and faculty development researcher pathway was developed to promote scholarly productivity at New York University (NYU) Long Island School of Medicine (LISOM), a three-year accelerated Liaison Committee on Medical Education (LCME)-accredited medical school. The aim was to enhance medical students' and faculty scholarly productivity, by creating new training programs targeting research skills and academic collaboration. Impact was assessed by initial review of the extracurricular student research program and faculty development researcher pathway. Methods: Electronic surveys via Google were sent out to all current (n = 72) students on 9/20/2021 and the faculty identified based on their primary appointment to NYU LISOM in the learning management system on 9/17/2021 to determine participation in research, presentation of research findings, satisfaction with the program, and research opportunities for students.  Student scholarly productivity was tracked using PubMed, restricted to search years 2020 through 2022.  For the faculty development researcher pathway, publications were tracked for each participant before and after completion of the program, with pre- and post-completion dates ranging from 2012 through 2020.  Results: Student survey results (29 responses out of 72) indicated 28% of students were involved in research with institutional faculty and 59% were interested in starting a research project. Most students involved in extracurricular research were satisfied with their experience and eight students have publications with faculty.  For the faculty development researcher pathway, 35% of the participants increased publications after program graduation. Conclusions: Outcomes from the student research program and faculty researcher pathway were positive regarding student research engagement and faculty scholarly productivity, though long-term outcomes are yet to be evaluated. Progress will be tracked as students continue through undergraduate and graduate medical education, and as both students and faculty progress throughout their career.

Retinol binding protein 4 is associated with adiposity-related co-morbidity risk factors in children.

OBJECTIVE: In adults, elevated levels of retinol binding protein 4 (RBP4) have been associated with biochemical markers of adiposity-related co-morbidities including insulin resistance, dyslipidemia, hypertension, and abdominal obesity. This study examined the relationship between RBP4 and risk factors for co-morbidities of adiposity in a population of ethnically diverse children in early- to mid-adolescence in the public school system of New York City. MATERIALS/METHODS: We analyzed anthropometric (body mass index, % body fat, waist circumference), metabolic (lipids, glucose), and inflammatory (TNF-alpha, interleukin-6, C-reactive protein, adiponectin) markers for adiposity-related co-morbidities and serum alanine aminotransferase (ALT) in 106 school children (65 males, 41 females) 11-15 years of age (mean +/- SD = 13.0 +/- 0.1 years) who were enrolled in the Reduce Obesity and Diabetes (ROAD) project. Insulin sensitivity was assessed by quantitative insulin sensitivity check index. Insulin secretory capacity was measured as acute insulin response and glucose disposal index. RESULTS: Serum RBP4 was significantly correlated directly with ALT, triglycerides, and triglyceride z-score, and inversely correlated with adiponectin. Correlations with ALT and adiponectin remained significant when corrected for % body fat, age, and gender. There were significant ethnic differences in the relationship of RBP4 to ALT, glucose disposal index and adiponectin. CONCLUSIONS: In early- to mid-adolescents, circulating concentrations of RBP4 are correlated with multiple risk factors for adiposity-related co-morbidities. The observation that many associations persisted when corrected for % body fat, suggests that RBP4 can be viewed as an independent marker of adiposity-related co-morbidity risk in children.

Lessons from pediatrics residency program directors' experiences with work hour limitations in New York State.

PURPOSE: To evaluate the impact of residency work hour limitations on pediatrics residency programs in New York State, and to learn lessons that can be used nationally with the implementation of the Accreditation Council of Graduate Medical Education's similar rules. METHOD: A three-page questionnaire was mailed to all pediatrics residency program directors in New York. The questionnaire assessed methods used to accommodate the work hour limitations and perceptions of the limitations' effects. RESULTS: Twenty-one program directors responded (68%). Only large programs used night floats and night teams to meet work hour requirements. Programs of all sizes and in all settings used cross coverage and sent residents home immediately post call. About half of the programs hired additional nonresident staff, usually nurse practitioners, physician assistants, and/or attendings. The most frequently reported effects were decreases in the amount of time residents spent in inpatient settings, patient continuity in inpatient settings, flexibility of residents' scheduling, and increased logistical work needed to maintain continuity clinic. A summary of advice to other program directors was "be creative" and "be flexible." CONCLUSIONS: New York's pediatrics residency programs used a variety of mechanisms to meet work hour restrictions. Smaller programs had fewer methods available to them to meet such restrictions. Although the logistical work needed to maintain continuity clinic increased greatly, continuity and outpatient settings themselves were not greatly affected by work hour limitations. Inpatient settings were more affected and experienced much more in the way of change.

Alanine transferase: An independent indicator of adiposity related comorbidity risk in youth.

BACKGROUND: Elevated levels of alanine aminotransferase (ALT) are associated with obesity and are often a consequence of non-alcoholic fatty liver disease (NAFLD). The aim of the present study was to assess the relationship between ALT and risk factors for adiposity-related co-morbidities in a diverse population of middle school children. METHODS: We measured height, weight, body fatness (bioelectrical impedance), waist circumference, insulin sensitivity, phase 1 insulin release (acute insulin response following intravenous glucose), beta-cell function (acute insulin response corrected for insulin sensitivity), ALT, lipid profiles, and circulating concentrations of interleukin-6 (IL-6), C-reactive protein, adiponectin, and tumor necrosis factor-α (TNF-α) in a multi-ethnic/racial population of 106 middle school students (aged 11-14 years, 45 female) of varying body mass indexes (BMI). RESULTS: Alanine aminotransferase was significantly correlated with BMI, % body fat, fat mass, waist circumference, fasting insulin, insulin resistance, triglycerides, and was inversely correlated with high-density lipoprotein cholesterol in children, even though all values of ALT were "normal" (range of 4.0-33.0 U/L). ALT was significantly higher in males than females even when corrected for body fatness. Significant correlations with lipids and insulin resistance persisted even when adjusted for age, gender, and body fatness. CONCLUSION: Even within the normative range, ALT levels were significantly correlated with anthropomorphic and biochemical risk factors for adiposity-related co-morbidities in youth. Therefore, because ALT is correlated with dyslipidemia, insulin resistance, and central fat distribution, it might also serve as a marker of risk for adiposity-related co-morbidities beyond NAFLD.

Mentoring program design and implementation in new medical schools.

PURPOSE: Mentoring is considered a valuable component of undergraduate medical education with a variety of programs at established medical schools. This study presents how new medical schools have set up mentoring programs as they have developed their curricula. METHODS: Administrators from 14 US medical schools established since 2006 were surveyed regarding the structure and implementation of their mentoring programs. RESULTS: The majority of new medical schools had mentoring programs that varied in structure and implementation. Although the programs were viewed as valuable at each institution, challenges when creating and implementing mentoring programs in new medical schools included time constraints for faculty and students, and lack of financial and professional incentives for faculty. CONCLUSIONS: Similar to established medical schools, there was little uniformity among mentoring programs at new medical schools, likely reflecting differences in curriculum and program goals. Outcome measures are needed to determine whether a best practice for mentoring can be established.

Effects of parental origins and length of residency on adiposity measures and nutrition in urban middle school students: a cross-sectional study.

BACKGROUND: The prevalence of obesity in U.S. has been rising at an alarming rate, particularly among Hispanic, African, and Asian minority groups. This trend is due in part to excessive calorie consumption and sedentary lifestyle. We sought to investigate whether parental origins influence eating behaviors in healthy urban middle school students. METHODS: A multiethnic/racial population of students (N = 182) enrolled in the ROAD (Reduce Obesity and Diabetes) Study, a school-based trial to assess clinical, behavioral, and biochemical risk factors for adiposity and its co-morbidities completed questionnaires regarding parental origins, length of US residency, and food behaviors and preferences. The primary behavioral questionnaire outcome variables were nutrition knowledge, attitude, intention and behavior, which were then related to anthropometric measures of waist circumference, BMI z-scores, and percent body fat. Two-way analysis of variance was used to evaluate the joint effects of number of parents born in the U.S. and ethnicity on food preference and knowledge score. The Tukey-Kramer method was used to compute pairwise comparisons to determine where differences lie. Analysis of covariance (ANCOVA) was used to analyze the joint effects of number of parents born in the US and student ethnicity, along with the interaction term, on each adiposity measure outcome. Pearson correlation coefficients were used to examine the relationships between maternal and paternal length of residency in the US with measures of adiposity, food preference and food knowledge. RESULTS: African Americans had significantly higher BMI, waist circumference and body fat percentage compared to other racial and ethnic groups. Neither ethnicity/race nor parental origins had an impact on nutrition behavior. Mothers' length of US residency positively correlated with students' nutrition knowledge, but not food attitude, intention or behavior. CONCLUSIONS: Adiposity measures in children differ according to ethnicity and race. In contrast, food behaviors in this middle school sample were not influenced by parental origins. Longer maternal US residency benefited offspring in terms of nutrition knowledge only. We suggest that interventions to prevent obesity begin in early childhood.

Racial/ethnic differences in clinical and biochemical type 2 diabetes mellitus risk factors in children.

OBJECTIVE: To examine whether periadolescent children demonstrate the significant racial/ethnic differences in body fatness relative to BMI and in the prevalence and relationship of body composition to risk factors for type 2 diabetes (T2DM) as in adults. DESIGN AND METHODS: Family history of obesity and T2DM, anthropometry, insulin sensitivity and secretory capacity, lipids, and cytokines (IL-6, CRP, TNF-α, and adiponectin) were examined in a cohort of 994 middle school students (47% male, 53%, female; 12% African American, 14% East Asian, 13% South Asian, 9% Caucasian, 44% Hispanic, and 8% other). RESULTS: Fractional body fat content was significantly greater at any BMI among South Asians. There were racial/ethnic specific differences in lipid profiles, insulin secretory capacity, insulin sensitivity, and inflammatory markers corrected for body fatness that are similar to those seen in adults. Family history of T2DM was associated with lower insulin secretory capacity while family history of obesity was more associated with insulin resistance. CONCLUSIONS: Children show some of the same racial/ethnic differences in risk factors for adiposity-related comorbidities as adults. BMI and waist circumference cutoffs to identify children at-risk for adiposity-related comorbidities should be adjusted by racial/ethnic group as well as other variables such as birthweight and family history.

Bronchoscopic findings in children with chronic wet cough.

OBJECTIVES: Protracted bacterial bronchitis is defined as the presence of more than 4 weeks of chronic wet cough that resolves with appropriate antibiotic therapy, in the absence of alternative diagnoses. The diagnosis of protracted bacterial bronchitis is not readily accepted within the pediatric community, however, and data on the incidence of bacterial bronchitis in children are deficient. The objective of this study was to determine the frequency of bacterial bronchitis in children with chronic wet cough and to analyze their bronchoscopic findings. METHODS: We performed a retrospective review of charts of children who presented with chronic wet cough, unresponsive to therapy, before referral to the pediatric pulmonary clinic. RESULTS: A total of 197 charts and bronchoscopy reports were analyzed. Of 109 children who were 0 to 3 years of age, 33 (30.3%) had laryngomalacia and/or tracheomalacia. The bronchoscopy showed purulent bronchitis in 56% (110) cases and nonpurulent bronchitis in 44% (87). The bronchoalveolar lavage bacterial cultures were positive in 46% (91) of the children and showed nontypable Haemophilus influenzae (49%), Streptococcus pneumoniae (20%), Moraxella catarrhalis (17%), Staphylococcus aureus (12%), and Klebsiella pneumoniae in 1 patient. The χ(2) analysis demonstrated that positive bacterial cultures occurred more frequently in children with purulent bronchitis (74, 69.8%) than in children with nonpurulent bronchitis (19, 19.8%) (P < .001). CONCLUSIONS: Children who present with chronic wet cough are often found to have evidence of purulent bronchitis on bronchoscopy. This finding is often indicative of a bacterial lower airway infection in these children.

Vitamin D, osteocalcin, and risk for adiposity as comorbidities in middle school children.

Nonclassic actions of vitamin D include potential regulation of immune function and glucose homeostasis. The bone-metabolism loop has recently been expanded to include osteocalcin, which appears to play a more direct role in pancreatic beta cell function and energy metabolism. We hypothesized that both vitamin D and osteocalcin would correlate negatively with indices of adiposity-related comorbidity risk in periadolescents, varying by ethnic group. We analyzed anthropometric, metabolic, and inflammatory markers from a multiethnic population of 106 school children 11 to 14 years of age studied as part of the Reduce Obesity and Diabetes (ROAD) consortium. As expected, 25-hydroxyvitamin D (25-OH vitamin D) was inversely correlated with intact parathyroid hormone (iPTH); total osteocalcin (OCN) and uncarboxylated osteocalcin (uOCN) were directly correlated with each other. OCN and uOCN concentrations correlated inversely with age. Vitamin D deficiency was most prevalent among East Asians (EA) and African Americans (AA). The highest lipid risk scores and homeostatic model for assessment of insulin resistance (HOMA-IR) values were seen in the South Asian (SA) group. Overall, adiposity measures were inversely correlated with OCN and iPTH, whereas such relationships were not observed for vitamin D. Acute insulin response to glucose challenge correlated negatively with uOCN in all subjects; however, lipid risk score correlated negatively with uOCN only in whites. The relationships between markers of calcium metabolism and body composition, glucose homeostasis, lipids, and inflammation all showed racial and ethnic differences. No consistent relationship was found between vitamin D and adiposity or vitamin D and glucose metabolism; instead vitamin D levels varied by race and ethnicity in this school-based group. These findings are consistent with the hypothesis that markers of calcium and bone metabolism may reflect risk for adiposity-related comorbidities in children.

Endothelial function as measured by peripheral arterial tonometry increases during pubertal advancement.

BACKGROUND/AIMS: Sex steroids, such as estrogens, are known to influence endothelial function by their vasodilator action. The aim of this study was to study the relation of puberty and sex steroids with endothelial function using peripheral arterial tonometry (PAT). METHODS: In 89 healthy school boys and girls, we determined height, weight, waist circumference, percent body fat, BMI, BMI z-score, blood pressure (BP), BP percentiles, lipid profile, insulin, and glucose levels after overnight fast. Estrone (E(1)), estradiol (E(2)), DHEAS and E(1)-sulfate were measured using ultrasensitive assays. Participants were divided into 3 pubertal groups on the basis of their estrogen levels: group 1 (Tanner stage I), group 2 (Tanner stages II-III), and group 3 (Tanner stages IV-V). Endothelial function was measured by Endo-PAT 2000® and expressed as PAT index. A higher PAT index represents a higher reactive hyperemia response. RESULTS: The PAT index was lowest at 1.42 ± 0.44 (mean ± SD) in group 1 and significantly increased in group 2 at 1.71 ± 0.35 (p = 0.02) and group 3 at 1.92 ± 0.38 (p < 0.001). The PAT index correlated positively with E(2), DHEAS and age. CONCLUSION: Enhancement of the PAT index was associated with an increment in Tanner stages. The changes in E(2) and DHEAS levels may contribute to increasing endothelial response to shear stress or arterial blood flow.

Paediatric experiences with work-hour limitations.

OBJECTIVES: To evaluate the perceived impact of work-hour limitations on paediatric residency training programmes and to determine the various strategies used to accommodate these restrictions. METHODS: A three-page pre-tested survey was administered to programme directors at the 2004 Association of Paediatric Programme Directors meeting. The impact of work-hours was evaluated with Likert-type questions and the methods used to meet work-hour requirements were compared between large programmes (>or=30 residents) and small programmes. RESULTS: Surveys were received from 53 programme directors. The majority responded that work-hour limitations negatively impacted inpatient continuity, time for education, schedule flexibility and attending staff satisfaction. Supervision by attending staff was the only aspect to significantly improve. Perceived resident satisfaction was neutral. To accommodate work-hour limitations, 64% of programmes increased clinical responsibility to existing non-resident staff, 36% hired more non-resident staff and 17% increased the number of residents. Only one programme hired additional non-clinical staff. Large programmes were more likely to use more total methods on the inpatient wards (P < 0.01) and in the intensive care units (P < 0.05) to accommodate work-hour limitations. CONCLUSIONS: Programme directors perceived a negative impact of work-hours on most aspects of training without a perceived difference in resident satisfaction. While a variety of methods are used to accommodate work-hour limitations, programmes are not widely utilizing non-clinical staff to alleviate clerical burdens.