Listen Before You Auscultate: An Active-Learning Approach to Bedside Cardiac Assessment.

Introduction: Bedside cardiac assessment (BCA) is deficient across a spectrum of noncardiology trainees. Learners not taught BCA well may become instructors who do not teach well, creating a self-perpetuating problem. To improve BCA teaching and learning, we developed a high-quality, patient-centered curriculum for medicine clerkship students that could be flexibly implemented and accessible to other health professions learners. Methods: With a constructivist perspective, we aligned learning goals, activities, and assessments. The curriculum used a "listen before you auscultate" framework, capturing patient history as context for a six-step, systematic approach. In the flipped classroom, short videos and practice questions preceded two 1-hour class activities that integrated diagnostic reasoning, pathophysiology, physical diagnosis, and reflection. Activities included case discussions, jugular venous pressure evaluation, heart sound competitions, and simulated conversations with patients. Two hundred sixty-eight students at four US and international medical schools participated. We incorporated feedback, performed thematic analysis, and assessed learners' confidence and knowledge. Results: Low posttest data capture limited quantitative results. Students reported increased confidence in BCA ability. Knowledge increased in both BCA and control groups. Thematic analysis suggested instructional design strategies were effective and peer encounters, skills practice, and encounters with educators were meaningful. Discussion: The curriculum supported active learning of day-to-day clinical competencies and promoted professional identity formation alongside BCA ability. Feedback and increased confidence on the late-clerkship posttest suggested durable learning. We recommend approaches to confirm this and other elements of knowledge, skill acquisition, or behaviors and are surveying impacts on professional identity formation-related constructs.

Derivation and Validation of a Clinical Risk Assessment Model for Cancer-Associated Thrombosis in Two Unique US Health Care Systems.

PURPOSE: Venous thromboembolism (VTE), especially pulmonary embolism (PE) and lower extremity deep vein thrombosis (LE-DVT), is a serious and potentially preventable complication for patients with cancer undergoing systemic therapy. METHODS: Using retrospective data from patients diagnosed with incident cancer from 2011-2020, we derived a parsimonious risk assessment model (RAM) using least absolute shrinkage and selection operator regression from the Harris Health System (HHS, n = 9,769) and externally validated it using the Veterans Affairs (VA) health care system (n = 79,517). Bootstrapped c statistics and calibration curves were used to assess external model discrimination and fit. Dichotomized risk strata using integer scores were created and compared against the Khorana score (KS). RESULTS: Incident VTE and PE/LE-DVT at 6 months occurred in 590 (6.2%) and 437 (4.6%) patients in HHS and 4,027 (5.1%) and 3,331 (4.2%) patients in the VA health care system. Assessed at the time of systemic therapy initiation, the new RAM included components of the KS with the modified cancer subtype, cancer staging, systemic therapy class, history of VTE, history of paralysis/immobility, recent hospitalization, and Asian/Pacific Islander race. The c statistic was 0.71 in HHS and 0.68 in the VA health care system (compared with 0.65 and 0.60, respectively, for KS). Furthermore, the new RAM appropriately reclassified 28% of patients and increased the proportion of VTEs in the high-risk group from 37% to 68% in the validation data set. CONCLUSION: The novel RAM stratified patients with cancer into a high-risk group with 8%-10% cumulative incidence of VTE and 7% PE/LE-DVT at 6 months (v 3% and 2%, respectively, in the low-risk group). The model had improved performance over the original KS and doubled the number of VTE events in the high-risk stratum. We encourage additional external validation from prospective studies.[Media: see text].

The impact of COVID-19 and rapid policy exemptions expanding on access to medication for opioid use disorder (MOUD): A nationwide Veterans Health Administration cohort study.

BACKGROUND: In March 2020, Veterans Health Administration (VHA) enacted policies to expand treatment for Veterans with opioid use disorder (OUD) during COVID-19. In this study, we evaluate whether COVID-19 and subsequent OUD treatment policies impacted receipt of therapy/counseling and medication for OUD (MOUD). METHODS: Using VHA's nationwide electronic health record data, we compared outcomes between a comparison cohort derived using data from prior to COVID-19 (October 2017-December 2019) and a pandemic-exposed cohort (January 2019-March 2021). Primary outcomes included receipt of therapy/counseling or any MOUD (any/none); secondary outcomes included the number of therapy/counseling sessions attended, and the average percentage of days covered (PDC) by, and months prescribed, each MOUD in a year. RESULTS: Veterans were less likely to receive therapy/counseling over time, especially post-pandemic onset, and despite substantial increases in teletherapy. The likelihood of receiving buprenorphine, methadone, and naltrexone was reduced post-pandemic onset. PDC on MOUD generally decreased over time, especially methadone PDC post-pandemic onset, whereas buprenorphine PDC was less impacted during COVID-19. The number of months prescribed methadone and buprenorphine represented relative improvements compared to prior years. We observed important disparities across Veteran demographics. CONCLUSION: Receipt of treatment was negatively impacted during the pandemic. However, there was some evidence that coverage on methadone and buprenorphine may have improved among some veterans who received them. These medication effects are consistent with expected COVID-19 treatment disruptions, while improvements regarding access to therapy/counseling via telehealth, as well as coverage on MOUD during the pandemic, are consistent with the aims of MOUD policy exemptions.

The Veterans Affairs Precision Oncology Data Repository, a Clinical, Genomic, and Imaging Research Database.

The Veterans Affairs Precision Oncology Data Repository (VA-PODR) is a large, nationwide repository of de-identified data on patients diagnosed with cancer at the Department of Veterans Affairs (VA). Data include longitudinal clinical data from the VA's nationwide electronic health record system and the VA Central Cancer Registry, targeted tumor sequencing data, and medical imaging data including computed tomography (CT) scans and pathology slides. A subset of the repository is available at the Genomic Data Commons (GDC) and The Cancer Imaging Archive (TCIA), and the full repository is available through the Veterans Precision Oncology Data Commons (VPODC). By releasing this de-identified dataset, we aim to advance Veterans' health care through enabling translational research on the Veteran population by a wide variety of researchers.

Associations of medical student empathy with clinical competence.

OBJECTIVE: Empathy is a crucial skill for medical students that can be difficult to evaluate. We examined if self-reported empathy in medical students was associated with clinical competence. METHODS: This study combined cross-sectional data from four consecutive years of medical students (N=590) from the Boston University School of Medicine. We used regression analysis to evaluate if self-reported empathy (Jefferson Scale of Physician Empathy (JSPE)) predicted scores in clinical clerkships, United States Medical Licensing Examinations, and OBJECTIVE: Structured Clinical Examinations (OSCEs). We separately analyzed overall and OSCE communication scores based on interpersonal skills reported by standardized patients. We controlled for age, gender, debt, and specialty affinity. RESULTS: JSPE scores of medical students were positively associated with OSCE communication scores, and remained significant when controlling for demographics. We found that JSPE score was also predictive of overall OSCE scores, but this relationship was confounded by gender and age. JSPE scores were associated with performance in the Pediatrics clerkship, but not other clerkships or standardized tests. CONCLUSION: JSPE scores were positively associated with OSCE communication scores in medical students. PRACTICE IMPLICATIONS: This study supports that self-reported empathy may predict OSCE performance, but further research is needed to examine differences by gender and age.

Logo-autobiography and its effectiveness on depressed Korean immigrant women.

This study aimed to explore the effectiveness of logo-autobiography (LA) as a therapeutic modality for Korean immigrant women suffering from depression and perceiving their lives as meaningless. A nonrandomized quasi-experimental study was conducted with pretest, posttest, and a 4-week follow-up test. Forty subjects--20 with antidepressants and 20 without--were divided quarterly and assigned to the experimental group and the control group. The experimental group reported a significant lower score on depressive symptoms (F = 6.832, p = .013; F = 19.800, p ≤ .001) and a higher score on meaning of life (F = 12.294, p = .001; F = 12.232, p = .001) than did the control group immediately after completing the LA and a 4-week follow-up. The LA was more effective for the subjects in the nonmedication group than in the medication group. In conclusion, LA is effective in reducing depressive symptoms and increasing a sense of meaning in life among Korean immigrant women suffering from depression.

Characterizing changes in student empathy throughout medical school.

BACKGROUND: Empathy is important in the physician-patient relationship. Prior studies suggest that medical student empathy declines with clinical training. AIMS: We examined the trend of empathy longitudinally; determined differences in empathy according to gender and medical specialty preferences; and determined empathy and career preference differences among students admitted through different medical school admission pathways. METHOD: The data for this study were collected using a longitudinal cohort design and included 2652 observations nested within 1162 individuals. Participants were medical students at a university-based medical school surveyed yearly from 2007 through 2010. Empathy was measured by the Jefferson Scale of Physician Empathy-Student Version (JSPE-S), a validated, 20-item self-administered questionnaire. Predictors of JSPE-S scores included gender, age, anticipated financial debt upon graduation and future career interest. RESULTS: Empathy scores of students in preclinical years were higher than in clinical years. Gender was a significant predictor of empathy, with women having higher empathy scores than men. Students preferring technology-oriented specialties had lower empathy scores. When career preference was controlled, higher levels of debt were significantly associated with greater empathy. Students with high baseline empathy decreased less than students with low baseline empathy during medical school. Students in traditional four-year medical school programs had higher baseline empathy than those in early pathway programs. CONCLUSIONS: Self-reported empathy for patients, a possibly critical factor in high-quality patient-centered care, wanes as students advance in clinical training, particularly among those entering technology-oriented specialties. In the era of new health care policy and primary care shortages, our research may have implications for the medical education system and admission policy.

Comparing a self-administered measure of empathy with observed behavior among medical students.

PURPOSE: Studies show that measures of physician and medical students' empathy decline with clinical training. Presently, there are limited data relating self-reported measures to observed behavior. This study explores a self-reported measure and observed empathy in medical students. METHOD: Students in the Class of 2009, at a university-based medical school, were surveyed at the end of their 2nd and 3rd year. Students completed the Jefferson Scale of Physician Empathy-Student Version (JSPE-S), a self-administered scale, and were evaluated for demonstrated empathic behavior during Objective Structured Clinical Examinations (OSCEs). RESULTS: 97.6% and 98.1% of eligible students participated in their 2nd and 3rd year, respectively. The overall correlation between the JSPE-S and OSCE empathy scores was 0.22, p < 0.0001. Students had higher self-reported JSPE-S scores in their 2nd year compared to their 3rd year (118.63 vs. 116.08, p < 0.0001), but had lower observed empathy scores (3.96 vs. 4.15, p < 0.0001). CONCLUSIONS: Empathy measured by a self-administered scale decreased, whereas observed empathy increased among medical students with more medical training.

Segmental duplications flank the multiple sclerosis locus on chromosome 17q.

Large chromosomal rearrangements, duplications, and inversions are relatively common in mammalian genomes. Here we report interesting features of DNA strands flanking a Multiple Sclerosis (MS) susceptibility locus on Chromosome 17q24. During the positional cloning process of this 3-Mb locus, several markers showed a radiation hybrid clone retention rate above the average (1.8-fold), suggestive for the existence of duplicated sequences in this region. FISH studies demonstrated multiple signals with three of the tested regional BACs, and 24 BACs out of 187 showed evidence for duplication in shotgun sequence comparisons of the 17q22-q24 region. Specifically, the MS haplotype region proved to be flanked by palindromic sequence stretches and by long segmental intrachromosomal duplications in which highly homologous DNA sequences (>96% identity) are present at both ends of the haplotype. Moreover, the 3-Mb DNA segment, flanked by the duplications, is inverted in the mouse genome when compared with the orientation in human and chimp. The segmental duplication architecture surrounding the MS locus raises the possibility that a nonallelic homologous recombination between duplications could affect the biological activity of the regional genes, perhaps even contributing to the genetic background of MS.

Comparison of GenFlex Tag array and Pyrosequencing in SNP genotyping.

With the completion of the Human Genome Project, over 2 million sequence-verified single nucleotide polymorphisms (SNPs) have been deposited in public databases. The challenge has shifted from SNP identification to high-throughput SNP genotyping. Although this has had little impact on molecular diagnostics, it provides the potential for future molecular diagnostics of complex traits to include SNP profiling. Accordingly, efficient, accurate, and flexible SNP genotyping are needed. In addition, the drive for low cost has pushed genotyping reactions toward multiplexing capability. We compared two SNP genotyping techniques: Affymetrix GenFlex Tag array and Pyrosequencing. The reference method was a well-established, solid-phase, single nucleotide extension reaction technique based on tritium detection. Fourteen SNPs were selected from the fine mapping project of a multiple sclerosis locus on chromosome 17q. Using all three techniques and the reference method, the SNPs were analyzed in 96 related individuals. Without extensive optimization, we successfully genotyped 11 of 14 SNPs with both GenFlex and Pyrosequencing. Our study suggests that the Pyrosequencing technique provides higher accuracy between the two systems which is most likely due to the single-stranded template in the extension reaction. Thus, Pyrosequencing has potential for diagnostic applications. Pyrosequencing, however, is not optimal for large SNP profiling analyses wherein multiplexing potential is an advantage.