Student Perceptions of a New Course Using Argumentation in Medical Education.

Purpose: Critical thinking and the ability to engage with others of differing views in a civil manner is essential to the practice of medicine. A new format for medical student education ("Argue-to-Learn") that uses staged debates followed by small group discussions was introduced into the curriculum of first year medical school at the Penn State College of Medicine. The goal was to create a structured environment for spirited, civil discourse, and to encourage students to think critically about clinically controversial topics. This manuscript describes the development of the program, and presents comparative data on student perceptions of the first two mandatory sessions that focused on the treatment of post-menopausal osteoporosis and on COVID-19 vaccine mandates. Methods: Quantitative results were gathered from standardized post-block student surveys for each session and compared to cumulative results of all other courses included in the learning block. Post-block surveys of students include four session-evaluation questions scored on a 5 point Likert scale. Scores were compared using Student's t-test. Thematic analysis of qualitative data was performed on a single open-ended response from the same survey. Results: Compared to all other courses in the learning block, scores on each of the four questions were either the same or numerically higher for the Argue-to-Learn sessions, but none reached statistical significance. Two important qualitative themes were identified. First, students enjoyed the format, found it interesting and engaging and want more similar sessions. Second, students appreciated hearing opposing viewpoints and presenting their own viewpoints in a safe and supportive environment. Conclusion: These findings support evidence from educational scholarship outside of medicine showing argumentation as a learning tool is well received by students. Further work is needed to determine whether it improves critical thinking skills and enhances learning in medical education.

The prism model: advancing a theory of practice for arts and humanities in medical education.

INTRODUCTION: The arts and humanities have transformative potential for medical education. Realizing this potential requires an understanding of what arts and humanities teaching is and what it aims to do. A 2016 review of exclusively quantitative studies mapped three discursive positions (art as intrinsic to, additive to or curative for medicine) and three epistemic functions (art for mastering skills, perspective taking, and personal growth and activism). A more inclusive sample might offer new insights into the position and function of arts and humanities teaching in medical education. METHODS: Informed by this 2016 framework, we conducted discursive and conceptual analyses of 769 citations from a database created in a recent scoping review. We also analyzed the 15 stakeholder interviews from this review for recurring themes. These three analyses were iteratively compared and combined to produce a model representing the complex relationship among discursive functions and learning domains. RESULTS: The literature largely positioned arts and humanities as additive to medicine and focused on the functions of mastering skills and perspective taking. Stakeholders emphasized the intrinsic value of arts and humanities and advocated their utility for social critique and change. We offer a refined theory of practice-the Prism Model of four functions (mastering skills, perspective taking, personal insight and social advocacy)-to support more strategic use of arts and humanities in medical education across all learning domains. DISCUSSION: The Prism Model encourages greater pedagogical flexibility and critical reflection in arts and humanities teaching, offering a foundation for achieving its transformative potential.

How Are the Arts and Humanities Used in Medical Education? Results of a Scoping Review.

PURPOSE: Although focused reviews have characterized subsets of the literature on the arts and humanities in medical education, a large-scale overview of the field is needed to inform efforts to strengthen these approaches in medicine. METHOD: The authors conducted a scoping review in 2019 to identify how the arts and humanities are used to educate physicians and interprofessional learners across the medical education continuum in Canada and the United States. A search strategy involving 7 databases identified 21,985 citations. Five reviewers independently screened the titles and abstracts. Full-text screening followed (n = 4,649). Of these, 769 records met the inclusion criteria. The authors performed descriptive and statistical analyses and conducted semistructured interviews with 15 stakeholders. RESULTS: The literature is dominated by conceptual works (n = 294) that critically engaged with arts and humanities approaches or generally called for their use in medical education, followed by program descriptions (n = 255). The literary arts (n = 197) were most common. Less than a third of records explicitly engaged theory as a strong component (n = 230). Of descriptive and empirical records (n = 424), more than half concerned undergraduate medical education (n = 245). There were gaps in the literature on interprofessional education, program evaluation, and learner assessment. Programming was most often taught by medical faculty who published their initiatives (n = 236). Absent were voices of contributing artists, docents, and other arts and humanities practitioners from outside medicine. Stakeholders confirmed that these findings resonated with their experiences. CONCLUSIONS: This literature is characterized by brief, episodic installments, privileging a biomedical orientation and largely lacking a theoretical frame to weave the installments into a larger story that accumulates over time and across subfields. These findings should inform efforts to promote, integrate, and study uses of the arts and humanities in medical education.

Entrustable professional activity 7: opportunities to collaborate on evidence-based medicine teaching and assessment of medical students.

BACKGROUND: This study was conducted to examine gaps and opportunities for involvement of librarians in medical education and patient care as well as improve the teaching and assessment of Entrustable Professional Activity 7 (EPA 7) -- the ability to form clinical questions and retrieve evidence to advance patient care. METHODS: The Association of Academic Health Sciences Libraries (AAHSL) Competency-Based Medical Education Task Force surveyed all AAHSL member libraries in October 2016 on health sciences librarian awareness and involvement in teaching and assessing EPA 7. RESULTS: The survey response rate was 54% (88/164 member libraries). While 90% (n = 76) of respondents were regularly engaged in teaching or assessing aspects of EPA 7 only 34 (39%) were involved explicitly in a Core EPA 7 project, 44% (15/34) of these projects were librarian initiated. CONCLUSIONS: Involvement in teaching and assessment of EPA 7 is an untapped opportunity for librarians to collaborate in medical education and patient care. Although librarians are already deeply involved in teaching and assessment of EPA 7 related knowledge, skills, and behaviors, further librarian collaboration can help bolster the planning or updating of existing curricula and assessments of this entrustable professional activity.

Is research on professional identity formation biased? Early insights from a scoping review and metasynthesis.

OBJECTIVE: Despite a recent surge in literature identifying professional identity formation (PIF) as a key process in physician development, the empiric study of PIF in medicine remains in its infancy. To gain insight about PIF, the authors examined the medical literature and that of two other helping professions. METHODS: The authors conducted a scoping review and qualitative metasynthesis of PIF in medicine, nursing and counselling/psychology. For the scoping review, four databases were searched using a combination of keywords to identify empiric studies on PIF in trainees. After a two-step screening process, thematic analysis was used to conduct the metasynthesis on screened articles. RESULTS: A total of 7451 titles and abstracts were screened; 92 studies were included in the scoping review. Saturation was reached in the qualitative metasynthesis after reviewing 29 articles. CONCLUSION: The metasynthesis revealed three inter-related PIF themes across the helping professions: the importance of clinical experience, the role of trainees' expectations of what a helping professional is or should be, and the impact of broader professional culture and systems on PIF. Upon reflection, most striking was that only 10 of the 92 articles examined trainee's sociocultural data, such as race, ethnicity, gender, sexual orientation, age and socio-economic status, in a robust way and included them in their analysis and interpretation. This raises the question of whether conceptions of PIF suffer from sociocultural bias, thereby disadvantaging trainees from diverse populations and preserving the status quo of an historically white, male medical culture.

Chlamydia trachomatis dapF Encodes a Bifunctional Enzyme Capable of Both d-Glutamate Racemase and Diaminopimelate Epimerase Activities.

Peptidoglycan is a sugar/amino acid polymer unique to bacteria and essential for division and cell shape maintenance. The d-amino acids that make up its cross-linked stem peptides are not abundant in nature and must be synthesized by bacteria de novo d-Glutamate is present at the second position of the pentapeptide stem and is strictly conserved in all bacterial species. In Gram-negative bacteria, d-glutamate is generated via the racemization of l-glutamate by glutamate racemase (MurI). Chlamydia trachomatis is the leading cause of infectious blindness and sexually transmitted bacterial infections worldwide. While its genome encodes a majority of the enzymes involved in peptidoglycan synthesis, no murI homologue has ever been annotated. Recent studies have revealed the presence of peptidoglycan in C. trachomatis and confirmed that its pentapeptide includes d-glutamate. In this study, we show that C. trachomatis synthesizes d-glutamate by utilizing a novel, bifunctional homologue of diaminopimelate epimerase (DapF). DapF catalyzes the final step in the synthesis of meso-diaminopimelate, another amino acid unique to peptidoglycan. Genetic complementation of an Escherichia coli murI mutant demonstrated that Chlamydia DapF can generate d-glutamate. Biochemical analysis showed robust activity, but unlike canonical glutamate racemases, activity was dependent on the cofactor pyridoxal phosphate. Genetic complementation, enzymatic characterization, and bioinformatic analyses indicate that chlamydial DapF shares characteristics with other promiscuous/primordial enzymes, presenting a potential mechanism for d-glutamate synthesis not only in Chlamydia but also numerous other genera within the Planctomycetes-Verrucomicrobiae-Chlamydiae superphylum that lack recognized glutamate racemases.IMPORTANCE Here we describe one of the last remaining "missing" steps in peptidoglycan synthesis in pathogenic Chlamydia species, the synthesis of d-glutamate. We have determined that the diaminopimelate epimerase (DapF) encoded by Chlamydia trachomatis is capable of carrying out both the epimerization of DAP and the pyridoxal phosphate-dependent racemization of glutamate. Enzyme promiscuity is thought to be the hallmark of early microbial life on this planet, and there is currently an active debate as to whether "moonlighting enzymes" represent primordial evolutionary relics or are a product of more recent reductionist evolutionary pressures. Given the large number of Chlamydia species (as well as members of the Planctomycetes-Verrucomicrobiae-Chlamydiae superphylum) that possess DapF but lack homologues of MurI, it is likely that DapF is a primordial isomerase that functions as both racemase and epimerase in these organisms, suggesting that specialized d-glutamate racemase enzymes never evolved in these microbes.

A guiding framework to maximise the power of the arts in medical education: a systematic review and metasynthesis.

CONTEXT: A rich literature describes many innovative uses of the arts in professional education. However, arts-based teaching tends to be idiosyncratic, depending on the interests and enthusiasm of individual teachers, rather than on strategic design decisions. An overarching framework is needed to guide implementation of arts-based teaching in medical education. The objective of this study was to review and synthesise the literature on arts-based education and provide a conceptual model to guide design, evaluation and research of the use of the arts in medical education. METHODS: A systematic literature review using the PubMed and ERIC databases. Search terms included humanism, art, music, literature, teaching, education, learning processes, pedagogy and curriculum. We selected empirical studies and conceptual articles about the use of creative arts, imagery and symbolism in the context of professional education. Data synthesis involved a qualitative content analysis of 49 included articles, identifying themes related to educational characteristics, processes and outcomes in arts-based education. RESULTS: Four common themes were identified describing (i) unique qualities of the arts that promote learning, (ii) particular ways learners engage with art, (iii) documented short- and long-term learning outcomes arising from arts-based teaching and (iv) specific pedagogical considerations for using the arts to teach in professional education contexts. CONCLUSIONS: The arts have unique qualities that can help create novel ways to engage learners. These novel ways of engagement can foster learners' ability to discover and create new meanings about a variety of topics, which in turn can lead to better medical practice. At each of these steps, specific actions by the teacher can enhance the potential for learners to move to the next step. The process can be enhanced when learners participate in the context of a group, and the group itself can undergo transformative change. Future work should focus on using this model to guide process design and outcome measurement in arts-based education.

Asking a Great Question: A Librarian Teaches Questioning Skills to First-Year Medical Students.

In a single one-hour session, first-year medical students were taught a framework for differentiating between lower-order questions that lead to knowledge of facts and higher-order questions that lead to integration of concepts and deeper learning, thereby preparing them for problem-based learning (PBL). Students generated lists of questions in response to an assertion prompt and categorized them according to Bloom's Taxonomy. These data were analyzed in addition to data from the course exam, which asked them to formulate a higher-level question in response to a prompt. Categorizing questions according to Bloom's Taxonomy was a more difficult task for students than was formulating higher-order questions. Students reported that the skills that they learned were used in subsequent PBL sessions to formulate higher-order learning objectives that integrated new and previously-learned concepts.

Bloom's taxonomy of cognitive learning objectives.

Information professionals who train or instruct others can use Bloom's taxonomy to write learning objectives that describe the skills and abilities that they desire their learners to master and demonstrate. Bloom's taxonomy differentiates between cognitive skill levels and calls attention to learning objectives that require higher levels of cognitive skills and, therefore, lead to deeper learning and transfer of knowledge and skills to a greater variety of tasks and contexts.

Phosphoproteomic analysis of the Chlamydia caviae elementary body and reticulate body forms.

Chlamydia are Gram-negative, obligate intracellular bacteria responsible for significant diseases in humans and economically important domestic animals. These pathogens undergo a unique biphasic developmental cycle transitioning between the environmentally stable elementary body (EB) and the replicative intracellular reticulate body (RB), a conversion that appears to require extensive regulation of protein synthesis and function. However, Chlamydia possess a limited number of canonical mechanisms of transcriptional regulation. Ser/Thr/Tyr phosphorylation of proteins in bacteria has been increasingly recognized as an important mechanism of post-translational control of protein function. We utilized 2D gel electrophoresis coupled with phosphoprotein staining and MALDI-TOF/TOF analysis to map the phosphoproteome of the EB and RB forms of Chlamydia caviae. Forty-two non-redundant phosphorylated proteins were identified (some proteins were present in multiple locations within the gels). Thirty-four phosphorylated proteins were identified in EBs, including proteins found in central metabolism and protein synthesis, Chlamydia-specific hypothetical proteins and virulence-related proteins. Eleven phosphorylated proteins were identified in RBs, mostly involved in protein synthesis and folding and a single virulence-related protein. Only three phosphoproteins were found in both EB and RB phosphoproteomes. Collectively, 41 of 42 C. caviae phosphoproteins were present across Chlamydia species, consistent with the existence of a conserved chlamydial phosphoproteome. The abundance of stage-specific phosphoproteins suggests that protein phosphorylation may play a role in regulating the function of developmental-stage-specific proteins and/or may function in concert with other factors in directing EB-RB transitions.

Promiscuous and adaptable enzymes fill "holes" in the tetrahydrofolate pathway in Chlamydia species.

Folates are tripartite molecules comprising pterin, para-aminobenzoate (PABA), and glutamate moieties, which are essential cofactors involved in DNA and amino acid synthesis. The obligately intracellular Chlamydia species have lost several biosynthetic pathways for essential nutrients which they can obtain from their host but have retained the capacity to synthesize folate. In most bacteria, synthesis of the pterin moiety of folate requires the FolEQBK enzymes, while synthesis of the PABA moiety is carried out by the PabABC enzymes. Bioinformatic analyses reveal that while members of Chlamydia are missing the genes for FolE (GTP cyclohydrolase) and FolQ, which catalyze the initial steps in de novo synthesis of the pterin moiety, they have genes for the rest of the pterin pathway. We screened a chlamydial genomic library in deletion mutants of Escherichia coli to identify the "missing genes" and identified a novel enzyme, TrpFCtL2, which has broad substrate specificity. TrpFCtL2, in combination with GTP cyclohydrolase II (RibA), the first enzyme of riboflavin synthesis, provides a bypass of the first two canonical steps in folate synthesis catalyzed by FolE and FolQ. Notably, TrpFCtL2 retains the phosphoribosyl anthranilate isomerase activity of the original annotation. Additionally, we independently confirmed the recent discovery of a novel enzyme, CT610, which uses an unknown precursor to synthesize PABA and complements E. coli mutants with deletions of pabA, pabB, or pabC. Thus, Chlamydia species have evolved a variant folate synthesis pathway that employs a patchwork of promiscuous and adaptable enzymes recruited from other biosynthetic pathways. Importance: Collectively, the involvement of TrpFCtL2 and CT610 in the tetrahydrofolate pathway completes our understanding of folate biosynthesis in Chlamydia. Moreover, the novel roles for TrpFCtL2 and CT610 in the tetrahydrofolate pathway are sophisticated examples of how enzyme evolution plays a vital role in the adaptation of obligately intracellular organisms to host-specific niches. Enzymes like TrpFCtL2 which possess an enzyme fold common to many other enzymes are highly versatile and possess the capacity to evolve to catalyze related reactions in two different metabolic pathways. The continued identification of unique enzymes such as these in bacterial pathogens is important for development of antimicrobial compounds, as drugs that inhibit such enzymes would likely not have any targets in the host or the host's normal microbial flora.

Early microRNA expression profile as a prognostic biomarker for the development of pelvic inflammatory disease in a mouse model of chlamydial genital infection.

UNLABELLED: It is not currently possible to predict the probability of whether a woman with a chlamydial genital infection will develop pelvic inflammatory disease (PID). To determine if specific biomarkers may be associated with distinct chlamydial pathotypes, we utilized two Chlamydia muridarum variants (C. muridarum Var001 [CmVar001] and CmVar004) that differ in their abilities to elicit upper genital tract pathology in a mouse model. CmVar004 has a lower growth rate in vitro and induces pathology in only 20% of C57BL/6 mouse oviducts versus 83.3% of oviducts in CmVar001-infected mice. To determine if chemokine and cytokine production within 24 h of infection is associated with the outcome of pathology, levels of 15 chemokines and cytokines were measured. CmVar004 infection induced significantly lower levels of CXCL1, CXCL2, tumor necrosis factor alpha (TNF-α), and CCL2 in comparison to CmVar001 infection with similar rRNA (rs16) levels for Chlamydiae. A combination of microRNA (miRNA) sequencing and quantitative real-time PCR (qRT-PCR) analysis of 134 inflammation-related miRNAs was performed 24 h postinfection to determine if the chemokine/cytokine responses would also be reflected in miRNA expression profiles. Interestingly, 12 miRNAs (miR-135a-5p, miR298-5p, miR142-3p, miR223-3p, miR299a-3p, miR147-3p, miR105, miR325-3p, miR132-3p, miR142-5p, miR155-5p, and miR-410-3p) were overexpressed during CmVar004 infection compared to CmVar001 infection, inversely correlating with the respective chemokine/cytokine responses. To our knowledge, this is the first report demonstrating that early biomarkers elicited in the host can differentiate between two pathological variants of chlamydiae and be predictive of upper tract disease. IMPORTANCE: It is apparent that an infecting chlamydial population consists of multiple genetic variants with differing capabilities of eliciting a pathological response; thus, it may be possible to identify biomarkers specific for a given virulence pathotype. miRNAs are known to regulate genes that in turn regulate signaling pathways involved in disease pathogenesis. Importantly, miRNAs are stable and can reflect a tissue response and therefore have the potential to be biomarkers of disease severity. Currently, with respect to chlamydial infections, there is no way to predict whether an infected patient is more or less likely to develop PID. However, data presented in this study indicate that the expression of a specific miRNA profile associated with a virulent variant early in the infection course may be predictive of an increased risk of pelvic inflammatory disease, allowing more aggressive treatment before significant pathology develops.

Potential novel antibiotics from HTS targeting the virulence-regulating transcription factor, VirF, from Shigella flexneri.

VirF is an AraC-type transcriptional regulator responsible for activating the transcription of virulence genes required for the intracellular invasion and cell-to-cell spread of Shigella flexneri. Gene disruption studies have validated VirF as a potential target for an anti-virulence therapy to treat shigellosis by determining that VirF is necessary for virulence, but not required for bacterial viability. Using a bacteria-based, ß-galactosidase reporter assay we completed a high-throughput screening (HTS) campaign monitoring VirF activity in the presence of over 140,000 small molecules. From our screening campaign, we identified five lead compounds to pursue in tissue culture-based invasion and cell-to-cell spread assays, and toxicity screens. Our observations of activity in these models for infection have validated our approach of targeting virulence regulation and have allowed us to identify a promising chemical scaffold from our HTS for hit-to-lead development. Interestingly, differential effects on invasion versus cell-to-cell spread suggest that the compounds' efficacies may depend, in part, on the specific promoter that VirF is recognizing.

Collaborating to increase access to clinical and educational resources for surgery: a case study.

A case study is described in which collaborations between a Department of Surgery, a Department of Information Technology, and an academic health sciences library resulted in the development of an electronic surgical library available at the bedside, the deployment of tablet devices for surgery residents, and implementation of a tablet-friendly user interface for the institution's electronic medical record.

Uptake of biotin by Chlamydia Spp. through the use of a bacterial transporter (BioY) and a host-cell transporter (SMVT).

Chlamydia spp. are obligate intracellular Gram-negative bacterial pathogens that cause disease in humans and animals. Minor variations in metabolic capacity between species have been causally linked to host and tissue tropisms. Analysis of the highly conserved genomes of Chlamydia spp. reveals divergence in the metabolism of the essential vitamin biotin with genes for either synthesis (bioF_2ADB) and/or transport (bioY). Streptavidin blotting confirmed the presence of a single biotinylated protein in Chlamydia. As a first step in unraveling the need for divergent biotin acquisition strategies, we examined BioY (CTL0613) from C. trachomatis 434/Bu which is annotated as an S component of the type II energy coupling-factor transporters (ECF). Type II ECFs are typically composed of a transport specific component (S) and a chromosomally unlinked energy module (AT). Intriguingly, Chlamydia lack recognizable AT modules. Using (3)H-biotin and recombinant E. coli expressing CTL0613, we demonstrated that biotin was transported with high affinity (a property of Type II ECFs previously shown to require an AT module) and capacity (apparent K(m) of 3.35 nM and V(max) of 55.1 pmol×min(-1)×mg(-1)). Since Chlamydia reside in a host derived membrane vacuole, termed an inclusion, we also sought a mechanism for transport of biotin from the cell cytoplasm into the inclusion vacuole. Immunofluorescence microscopy revealed that the mammalian sodium multivitamin transporter (SMVT), which transports lipoic acid, biotin, and pantothenic acid into cells, localizes to the inclusion. Since Chlamydia also are auxotrophic for lipoic and pantothenic acids, SMVT may be subverted by Chlamydia to move multiple essential compounds into the inclusion where BioY and another transporter(s) would be present to facilitate transport into the bacterium. Collectively, our data validates the first BioY from a pathogenic organism and describes a two-step mechanism by which Chlamydia transport biotin from the host cell into the bacterial cytoplasm.

L,L-diaminopimelate aminotransferase, a trans-kingdom enzyme shared by Chlamydia and plants for synthesis of diaminopimelate/lysine.

The synthesis of meso-diaminopimelic acid (m-DAP) in bacteria is essential for both peptidoglycan and lysine biosynthesis. From genome sequencing data, it was unclear how bacteria of the Chlamydiales order would synthesize m-DAP in the absence of dapD, dapC, and dapE, which are missing from the genome. Here, we assessed the biochemical capacity of Chlamydia trachomatis serovar L2 to synthesize m-DAP. Expression of the chlamydial asd, dapB, and dapF genes in the respective Escherichia coli m-DAP auxotrophic mutants restored the mutants to DAP prototrophy. Screening of a C. trachomatis genomic library in an E. coli DeltadapD DAP auxotroph identified ct390 as encoding an enzyme that restored growth to the Escherichia coli mutant. ct390 also was able to complement an E. coli DeltadapD DeltadapE, but not a DeltadapD DeltadapF mutant, providing genetic evidence that it encodes an aminotransferase that may directly convert tetrahydrodipicolinate to L,L-diaminopimelic acid. This hypothesis was supported by in vitro kinetic analysis of the CT390 protein and the fact that similar properties were demonstrated for the Protochlamydia amoebophila homologue, PC0685. In vivo, the C. trachomatis m-DAP synthesis genes are expressed as early as 8 h after infection. An aminotransferase activity analogous to CT390 recently has been characterized in plants and cyanobacteria. This previously undescribed pathway for m-DAP synthesis supports an evolutionary relationship among the chlamydiae, cyanobacteria, and plants and strengthens the argument that chlamydiae synthesize a cell wall despite the inability of efforts to date to detect peptidoglycan in these organisms.