Medication adherence and rejection rates in older vs younger adult liver transplant recipients.

A growing number of older adults are undergoing liver transplantation (LT) in the United States. In some settings, it is thought that adherence declines with age. This retrospective study examined adherence and clinical outcomes in older vs younger adult LT recipients. Medical records of adult LT recipients from 2009 to 2012 from a single urban center were reviewed. The medication level variability index (MLVI) was the predefined primary outcome, with nonadherence defined as MLVI >2.5. The secondary outcome was incidence of rejection. Outcomes were evaluated starting 1 year post-LT until 2015. A total of 42 of 248 patients were ≥65 at transplant. Older adults had significantly better adherence than younger ones (65%≥65 were adherent vs 42% younger adults; chi-square two-tailed P=.02). Survival analyses of rejection between age groups censored by time since transplant showed no difference among the four age groups (χ2 =0.84, P=.84). Older age was not found to be a risk factor for reduced adherence or graft rejection in patients surviving at least 1 year post-LT.

Longitudinal assessment of medical student attitudes toward older people.

Delivering adequate care to older people requires an increasing number of physicians competent in the treatment of this expanding subpopulation. Attitudes toward older adults are important as predictors of the quality of care of older people and of medical trainee likelihood to enter the geriatrics field. This study assessed the attitudes of 404 US medical students (MS) from the start of medical school to graduation using the University of California, Los Angeles (UCLA) Geriatrics Attitude Scale. It is the first study to utilize a longitudinal design to assess attitudes among students in a medical school with a longitudinal geriatrics clinical experience in the first two years and a required geriatrics clerkship in the third year. Participants' attitude scores toward older people were found to significantly decrease from 3.9 during the first two years to 3.7 during the final two. Significant differences existed between MS1 and MS3, MS1 and MS4, MS2 and MS3, and MS2 and MS4. Women and older students held significantly more positive attitudes than men and younger students. These results show that planned clinical exposures to older adults may not be sufficient to halt the decline in attitudes in medical school. A comprehensive empathy-building intervention embedded in the curriculum may better prevent this decline.

Interpreter training for medical students: pilot implementation and assessment in a student-run clinic.

BACKGROUND: Trained medical interpreters are instrumental to patient satisfaction and quality of care. They are especially important in student-run clinics, where many patients have limited English proficiency. Because student-run clinics have ties to their medical schools, they have access to bilingual students who may volunteer to interpret, but are not necessarily formally trained. METHODS: To study the feasibility and efficacy of leveraging medical student volunteers to improve interpretation services, we performed a pilot study at the student-run clinic at the Icahn School of Medicine at Mount Sinai. In each fall semester in 2012-2015, we implemented a 6-h course providing didactic and interactive training on medical Spanish interpreting techniques and language skills to bilingual students. We then assessed the impact of the course on interpreter abilities. RESULTS: Participants' comfort levels, understanding of their roles, and understanding of terminology significantly increased after the course (p < 0.05), and these gains remained several months later (p < 0.05) and were repeated in an independent cohort. Patients and student clinicians also rated participants highly (averages above 4.5 out of 5) on these measures in real clinical encounters. CONCLUSIONS: These findings suggest that a formal interpreter training course tailored for medical students in the setting of a student-run clinic is feasible and effective. This program for training qualified student interpreters can serve as a model for other settings where medical students serve as interpreters.

Recognition of melanoma: a dermatologic clinical competency in medical student education.

BACKGROUND: Non-dermatologist physicians are well positioned for opportunistic melanoma detection; however, education in the skin cancer examination is limited during medical school and traditionally lecture-based. Simulating melanoma cases provides a means to demonstrate whether proficiency in knowledge and recognition of melanoma images translates into improved clinical skill. OBJECTIVE: To evaluate medical student recognition and appropriate response to a prosthetic melanoma placed on a standardized patient (SP) during a simulated clinical encounter. METHODS: In this pilot study, prosthetic mimics of melanoma were placed on the backs of SPs unbeknownst to a convenience sample of 59 second-year medical students. The study took place during clinical skills practice sessions with SPs conducted from February to April 2010 at Mount Sinai School of Medicine (New York, NY). SPs presented with non-dermatologic chief complaints typical for an acute office visit. All students had the opportunity to attend a lecture on the clinical signs of melanoma 2 to 4 months earlier, for which pre-test and post-test data were collected. RESULTS: Recognition and evaluation of a prosthetic melanoma as determined by querying the SPs and reviewing the students' examination notes. During the SP encounter, 37 students (63%) asked about the melanoma moulage; of those, 25 (68%) made recommendations for further evaluation. The moulage was documented in 17 examination notes (43%). Thirty-three students (56%) asked about the skin on review of systems, although this did not predict moulage detection. CONCLUSIONS: Prosthetic mimics of melanoma are useful tools for assessing skin cancer awareness and detection skills among medical students.

Social Determinants, Risk Factors, and Needs: A New Paradigm for Medical Education.

COVID-19 and the escalation of racism and bias that has come in its wake have had a devastating impact on health professions students. In addition to academic challenges and personal health risks, aspects of students' lives that have often gone unnoticed or inadequately addressed have come to light. Financial constraints that impact access to housing and food, neighborhood safety in light of the spike in hate crimes, and the bias inherent in the continuum from premedical education to undergraduate and graduate medical education are some examples. The authors believe that to better understand students' lived experiences and determine how to best support them, the social determinants of health framework should be applied. This framework, the social determinants of education, encompasses concepts such as social risk factors and social needs in an effort to focus more intentionally on what can be done at a policy, institutional, and individual level. In response to the pandemic, the authors expanded their appreciation of students' risk factors and needs by advancing the scope and refining the definitions of 3 key determinants: from well-being to the power of individual and communal resilience, from equity to centering racial justice, and from student health to public health and infection prevention. The authors propose applying this same paradigm to the lived experiences of staff in medical education, whose needs are often neglected in favor of students and faculty, and who, in many cases, were the most negatively impacted by COVID-19 of all the constituents in an academic health center.

The 5-Factor Modified Frailty Index in the Geriatric Surgical Population.

BACKGROUND: The modified frailty index (mFI-11) is a National Surgical Quality Improvement Program (NSQIP)-based 11-factor index that has been proven to adequately reflect frailty and predict mortality and morbidity. In the past years, certain NSQIP variables have been removed from the database; as of 2015, only 5 out of the original 11 factors remain. While the predictive power and usefulness of this 5-factor index (mFI-5) has been proven in previous work, it has yet to be studied in the geriatrics population. The goal of our study was to compare the mFI-5 to the mFI-11 in terms of value and predictive ability for mortality, postoperative infection, and unplanned 30-day readmission for patients aged 65 years and older. METHODS: Spearman's Rho was calculated to compare the value, and unadjusted and adjusted logistic regressions were created for three outcomes in nine surgical subspecialties. Correlation coefficients were above .86 across all surgical specialties except for cardiac surgery. Adjusted and unadjusted models showed similar C-statistics for mFI-5 and 11. RESULTS: Overall predictive values of geriatric mFI-5 and mFI-11 were lower than those for the general population but still had effective predictive value for mortality and post-operative complications (C-Stat ≥ .7) and weak predictive value for 30-day readmission. CONCLUSIONS: The mFI-5 is an equally effective predictor as the mFI-11 in all subspecialties and an effective predictor of mortality and postoperative complication in the geriatric population. This index has credibility for future use to study frailty within NSQIP, within other databases, and for clinical assessment and use.

Impact of a Short-Term Domestic Service-Learning Program on Medical Student Education.

PURPOSE: The number of global health opportunities offered to medical students has increased over the past 20 years. Recognizing the growing prevalence of these experiences, a number of studies have shown that these types of exposures have a significant impact on medical students' education. However, there is a paucity of literature on the educational impacts of short-term domestic service-learning trips, which can be more accessible due to fewer logistical and financial barriers. This mixed-methods qualitative/quantitative study aims to understand the impact of a domestic one-week service learning program on medical students' educational development and career choices. METHODS: The authors conducted a qualitative analysis of journal entries written by a cohort of students during a domestic weeklong service trip. They also administered a survey to all students who had participated in the program between 2009-2016. RESULTS: In 88.6% (n = 31) of the journal entries, students reported learning about border town life, Native American health, and rural medical practice. In 42.8% (n = 15) of entries, participants described experiences they felt would impact their future medical career decisions. The students' reflections also revealed implicit benefits such as becoming aware of privilege within society (n = 14, 40.0%). The majority of survey respondents reported that the trip improved their medical education and influenced the field and location of their future/current practice. CONCLUSION: This study suggests that domestic short-term service-learning trips impact medical students' immediate educational development and may influence their future career plans. Further investigation into the local community's perceptions of this service-learning trip will provide greater understanding of the impact on all involved.

Easing the transition: medical students' perceptions of critical skills required for the clerkships.

OBJECTIVES: The preclinical years of undergraduate medical education provide educational content in a structured learning environment whereas clerkships provide clinical training in a more experiential manner. Although early clinical skills training is emphasized in many medical schools, students still feel unprepared and anxious about starting their clerkships. This study identifies the skills medical students perceive as essential and those skill areas students are most anxious about prior to starting clerkship rotations. METHODS: Open-ended questionnaires were administered to two cohorts of students, preclinical students (PCS) completing their second year and clinical students (CS) in the ninth month of the clinical training of their third year at a single urban US medical school. The following questions were addressed in the survey: which three clinical skills do they perceive are most essential for the clerkships; which skills are students most anxious about as they enter clerkships; and what additional skills training should be provided to students to ease the transition into clerkships. RESULTS: Response rate to the questionnaire was 84%. PCS (n=93) reported the three most essential skills to be prepared for clerkships are: history taking/physical examination (73%), proficiency in oral case presentations (56%), and generation of differential diagnosis (46%). CS (n=105) reported interpersonal skills (80%), history taking/physical examination (37%), and time management (26%) as most essential. PCS were most anxious about their oral case presentation skills (30%), but CS were most concerned about time management and self care (40%). CONCLUSIONS: This study identified the skills that students at one school regard as most important to have mastered before beginning clerkship training and the areas students find most anxiety provoking before and after they make the transition into clerkships. These results can inform medical educators about needed curriculum to facilitate this transition and decrease the anxiety of students entering the clinical realm.

New 5-Factor Modified Frailty Index Using American College of Surgeons NSQIP Data.

BACKGROUND: The modified frailty index (mFI-11) is a NSQIP-based 11-factor index that has been proven to adequately reflect frailty and predict mortality and morbidity. These 11 factors, made of 16 variables, map to the original 70-item Canada Study of Health and Aging Frailty Index. In past years, certain NSQIP variables have been removed from the database; as of 2015, only 5 of the original 11 factors remained. The predictive power and usefulness of these 5 factors in an index (mFI-5) have not been proven in past literature. The goal of our study was to compare the mFI-5 to the mFI-11 in terms of value and predictive ability for mortality, postoperative infection, and unplanned 30-day readmission. STUDY DESIGN: The mFI was calculated by dividing the number of factors present for a patient by the number of available factors for which there were no missing data. Spearman's rho was used to assess correlation between the mFI-5 and mFI-11. Predictive models, using both unadjusted and adjusted logistic regressions, were created for each outcome for 9 surgical sub-specialties using 2012 NSQIP data, the last year all mFI-11 variables existed. RESULTS: Correlation between the mFI-5 and mFI-11 was above 0.9 across all surgical specialties except for cardiac and vascular surgery. Adjusted and unadjusted models showed similar c-statistics for mFI-5 and mFI-11, and strong predictive ability for mortality and postoperative complications. CONCLUSIONS: The mFI-5 and the mFI-11 are equally effective predictors in all sub-specialties and the mFI-5 is a strong predictor of mortality and postoperative complications. It has credibility for future use to study frailty within the NSQIP database. It also has potential in other databases and for clinical use.

The portal of geriatrics online education: a 21st-century resource for teaching geriatrics.

The way students are taught and evaluated is changing, with greater emphasis on flexible, individualized, learner-centered education, including the use of technology. The goal of assessment is also shifting from what students know to how they perform in practice settings. Developing educational materials for teaching in these ways is time-consuming and can be expensive. The Portal of Geriatrics Online Education (POGOe) was developed to aid educators in meeting these needs and become quicker, better-prepared teachers of geriatrics. POGOe contains more than 950 geriatrics educational materials that faculty at 45% of allopathic and 7% of osteopathic U.S. medical schools and the Centers for Geriatric Nursing Excellence have created. These materials include various instructional and assessment methodologies, including virtual and standardized patients, games, tutorials, case-based teaching, self-directed learning, and traditional lectures. Materials with common goals and resource types are available as selected educational series. Learner assessments comprise approximately 10% of the educational materials. POGOe also includes libraries of videos, images, and questions extracted from its educational materials to encourage educators to repurpose content components to create new resources and to align their teaching better with their learners' needs. Web-Geriatric Education Modules, a peer-reviewed online modular curriculum for medical students, is a prime example of this repurposing. The existence of a robust compendium of instructional and assessment materials allows educators to concentrate more on improving learner performance in practice and not simply on knowledge acquisition. It also makes it easier for nongeriatricians to teach the care of older adults in their respective disciplines.

Palliative care module within a required geriatrics clerkship: taking advantage of existing partnerships.

OBJECTIVE: LCME has recently required that all graduating medical students learn about end-of-life care. This program describes the design and integration into an existing geriatrics clerkship of a palliative care module that teaches the foundations of end-of-life and palliative care to medical students. DESCRIPTION: Faculty experts in geriatrics met during a series of weekly meetings in 1999 to design a mandatory four-week-long clinical clerkship in geriatrics. Since the palliative care program is based within the geriatrics department, faculty members with interest and expertise in both geriatrics and palliative care were invited to design a palliative care module that can be integrated into the clerkship. Since LCME does not specify details of what students must learn about end-of-life care, and our goal is to educate and prepare students for any chosen specialty, we wanted to design a basic core curriculum in palliative care that would be useful to any graduating student. After reviewing potential palliative care topics, and given limited curriculum time, we condensed the medical student core curriculum to the following sessions: (1) Systematic Pain Assessment Management, (2) Management of Distressing Symptoms, (3) Communicating Bad News, and (4) Advance Directives. We developed PowerPoint presentations, teaching case vignettes, and a set of reference articles, which can be distributed to students as well as to help faculty teachers prepare for the sessions. Teaching sessions occur in small groups, using case discussions and interactive lectures. Sessions 3 and 4 are co-facilitated by palliative care physicians and ethicists, who use role-plays, reflections, and discussions to teach the topics. At the end of the clerkship, students practice these communication skills with videotaped standardized patient encounters, and debrief with faculty members about their performances and ways to improve their communication skills. DISCUSSION: Palliative care sessions are welcomed by the students, who traditionally have not received much teaching in this area. Even though students have learned about mechanisms regulating pain and other symptoms in the past, they have not learned to assess or treat symptoms in a systematic way. Students often have good questions about the decision-making, legal, and ethical issues that emerge for patients near the end of life. Thus, co-facilitation of physicians with ethicists presents both the practical clinical and the theoretical perspectives, and provides a good model for team teaching. In terms of teaching style, students are more involved and participatory when teachers use case vignettes as compared with slide presentations, even if they are case-based. When using role-plays to teach students how to communicate bad news, we found that students need to feel safe in that environment, need to know they can call for time out when necessary, and want to have seen one done before they are asked to do one.

Teaching medical students how to teach: a national survey of students-as-teachers programs in U.S. medical schools.

PURPOSE: A number of U.S. medical schools started offering formal students-as-teachers (SAT) training programs to assist medical students in their roles as future teachers. The authors report results of a national survey of such programs in the United States. METHOD: In 2008, a 23-item survey was sent to 130 MD-granting U.S. schools. Responses to selective choice questions were quantitatively analyzed. Open-ended questions about benefits and barriers to SAT programs were given qualitative analyses. RESULTS: Ninety-nine U.S. schools responded. All used their medical students as teachers, but only 44% offered a formal SAT program. Most (95%) offered formal programs in the senior year. Common teaching strategies included small-group work, lectures, role-playing, and direct observation. Common learning content areas were small-group facilitation, feedback, adult learning principles, and clinical skills teaching. Assessment methods included evaluations from student-learners (72%) and direct observation/videotaping (59%). From the qualitative analysis, benefit themes included development of future physician-educators, enhancement of learning, and teaching assistance for faculty. Obstacles were competition with other educational demands, difficulty in faculty recruitment/retention, and difficulty in convincing others of program value. CONCLUSIONS: Formal SAT programs exist for 43 of 99 U.S. medical school respondents. Such programs should be instituted in all schools that use their students as teachers. National teaching competencies, best curriculum methods, and best methods to conduct skills reinforcement need to be determined. Finally, the SAT programs' impacts on patient care, on selection decisions of residency directors, and on residents' teaching effectiveness are areas for future research.

Keeping granny safe on July 1: a consensus on minimum geriatrics competencies for graduating medical students.

Competency-based education prepares trainees to perform tasks occurring within the context of practice. There are currently no geriatrics-specific, competency-based consensus performance standards for medical students.The authors present the results of a systematic, multimethod process to identify and define the minimum geriatrics-specific competencies needed by a new intern to adequately care for older adults. An alpha draft was crafted by geriatricians, identifying measurable performance subtasks associated with accepted standards of evidence-based geriatric care, patient safety, and "do no harm" within the first-year resident's expected scope of practice. The competencies were then assessed for content validity by key stakeholders and informants. Of the 315 respondents, 26% were geriatricians, 21% family physicians, 24% general internists, 6% neurology program directors, 14% surgery program directors, and 9% other. Twenty-four were decanal appointees. Faculty from almost half (44%) of U.S. medical schools and representatives of several major medical education organizations were present at the working conference.The final document consists of 26 competencies nested within eight content domains: Medication Management; Self-Care Capacity; Falls, Balance and Gait Disorders; Hospital Care for Elders; Cognitive and Behavioral Disorders; Atypical Presentation of Disease; Health Care Planning and Promotion; and Palliative Care.Setting minimum geriatric competency standards establishes the performance benchmarks for medical school graduates who as first-year residents will care for geriatric patients. Only half-facetiously, they are referred to as the "Don't Kill Granny" competencies. Achievement of these minimum competencies by medical students, grounded in evidence-based principles of quality care for older adults, will assure that, each year, older patients are in safer hands on July 1.