"Flipped classroom" for academic and career advising: an innovative technique for medical student advising.

INTRODUCTION: Career advising for medical students can be challenging for both the student and the adviser. Our objective was to design, implement, and evaluate a "flipped classroom" style advising session. METHODS: We performed a single-center cross-sectional study at an academic medical center, where a novel flipped classroom style student advising model was implemented and evaluated. In this model, students were provided a document to review and fill out prior to their one-on-one advising session. RESULTS: Ninety-four percent (95% CI, 88%-100%) of the medical students surveyed felt that the advising session was more effective as a result of the outline provided and completed before the session and that the pre-advising document helped them gain a better understanding of the content to be discussed at the session. CONCLUSION: Utilization of the flipped classroom style advising document was an engaging advising technique that was well received by students at our institution.

Patients are well served by Collis gastroplasty when indicated.

BACKGROUND: Debate persists over the impact of Collis gastroplasty (CG) on outcomes after anti reflux surgery. This study analyzed operative and quality of life (QOL) outcomes from one of the largest series of laparoscopic anti reflux surgery (LARS) with CG reported to date. METHODS: A retrospective review was conducted to compare outcomes between patients undergoing LARS with CG versus without CG at two large centers with expertise in foregut surgery from October 2004-December 2011 and July 2012-September 2016. Demographic, perioperative, and QOL data were reviewed. Four validated surveys were used for QOL outcomes: reflux symptom index (RSI), gastroesophageal reflux disease health-related QOL (GERD-HRQL), laryngopharyngeal reflux health-related QOL (LPR-HRQL), and swallowing QOL (SWAL-QL). RESULTS: 480 patients consisted of 149 Collis vs 331 non-Collis with mean age of 66.3 vs 58.9 years (P ≤ .001), BMI of 28.6 vs 29.7 (P = .040) and ASA score of 2.4 vs 2.2 (P = .005) were included. Collis patients underwent longer duration operations (133.2 mins vs 94.2; P ≤ .001) with greater duration of hospital stay (3.1 vs 1.8; P ≤ .001). Thirty-day readmission and reoperation rates were equivalent between the two groups. Wound and non-wound related complications were also comparable. After mean 12 month follow up, QOL assessment revealed significant improvements for all patients post-surgery with comparable results between Collis and non-Collis patients. Furthermore, CG did not contribute to post-operative dysphagia, reflux, or a significant leak rate. CONCLUSION: Patients who require a CG to address a true short esophagus during LARS have comparable operative and QOL benefits as non-Collis patients without added morbidity or mortality.

Primary versus redo paraesophageal hiatal hernia repair: a comparative analysis of operative and quality of life outcomes.

INTRODUCTION: We compared patient outcomes after initial versus redo paraesophageal hernia (PEH) repair at two high-volume GI surgery centers. MATERIALS AND METHODS: Retrospective review analyzed one-year outcomes after initial versus redo elective laparoscopic PEH repair, including wound/non-wound-related complications and quality of life benefits as measured by four validated instruments: reflux symptom index, gastroesophageal reflux disease health-related, laryngopharyngeal reflux, and swallowing scales. RESULTS: Three hundred and seventeen patients (271 initial and 46 redo) underwent laparoscopic PEH repair. Groups differed with respect to age (64.6 vs. 60.2 years, p = 0.027), but were comparable in gender (71.2 vs. 67.4% female, p = 0.596), BMI (29.0 vs. 27.6 kg/m2, p = 0.100), and ASA score (2.3 vs. 2.3 p = 0.666). Redo surgery was more complex with longer mean operative times (112.2 vs. 139.1 min, p < 0.001). Groups did not statistically differ with respect to 30-day wound (0.7 vs. 2.2%, p = 0.363) and non-wound (6.0 vs. 8.7%, p = 0.511)-related complications. After one year of follow-up, QOL analysis revealed that initial versus redo groups significantly benefited from operative intervention. CONCLUSIONS: Although redo PEH repairs are more complex, patients enjoy equivalent operative outcomes and quality of life benefits compared to initial surgery lending support to the significance of surgeon experience and high-volume centers in optimizing outcomes.

Inconsistency as a diagnostic tool in a society of intelligent agents.

OBJECTIVE: To use the detection of clinically relevant inconsistencies to support the reasoning capabilities of intelligent agents acting as physicians and tutors in the realm of clinical medicine. METHODS: We are developing a cognitive architecture, OntoAgent, that supports the creation and deployment of intelligent agents capable of simulating human-like abilities. The agents, which have a simulated mind and, if applicable, a simulated body, are intended to operate as members of multi-agent teams featuring both artificial and human agents. The agent architecture and its underlying knowledge resources and processors are being developed in a sufficiently generic way to support a variety of applications. RESULTS: We show how several types of inconsistency can be detected and leveraged by intelligent agents in the setting of clinical medicine. The types of inconsistencies discussed include: test results not supporting the doctor's hypothesis; the results of a treatment trial not supporting a clinical diagnosis; and information reported by the patient not being consistent with observations. We show the opportunities afforded by detecting each inconsistency, such as rethinking a hypothesis, reevaluating evidence, and motivating or teaching a patient. CONCLUSIONS: Inconsistency is not always the absence of the goal of consistency; rather, it can be a valuable trigger for further exploration in the realm of clinical medicine. The OntoAgent cognitive architecture, along with its extensive suite of knowledge resources an processors, is sufficient to support sophisticated agent functioning such as detecting clinically relevant inconsistencies and using them to benefit patient-centered medical training and practice.

Integrating cognitive simulation into the Maryland virtual patient.

This paper briefly describes four cognitively-related aspects of modeling a virtual patient: interoception, decision-making, natural language processing and learning. These phenomena are treated within the Maryland Virtual Patient simulation and training environment.

Revealing the conceptual substrate of biomedical cognitive models to the wider community.

The patient authoring interface for each disease in the Maryland Virtual Patient simulation environment reveals the conceptual substrate of the disease model. Revealing the disease model to the community both explains how the interactive simulations work and invites collaboration from the wider community.

Laparoscopic Nissen fundoplication effectively relieves symptoms in patients with laryngopharyngeal reflux.

INTRODUCTION: The utility of laparoscopic Nissen fundoplication in the treatment of laryngopharyngeal reflux symptoms remains controversial. We hypothesized that a carefully selected population with these symptoms would benefit from antireflux surgery. MATERIALS AND METHODS: Sixty-one consecutive patients have undergone antireflux surgery for laryngopharyngeal reflux at a single institution. Preoperative evaluation including upper endoscopy, laryngoscopy, and 24-h ambulatory pharyngeal pH probe monitoring confirmed the diagnosis. Patients completed two validated symptom assessment instruments preoperatively and at multiple time points postoperatively. RESULTS: Patients were followed for up to 3 years with a mean follow-up of 15.2 months. A significant improvement in reflux symptom index score (preoperative= 1.5+/-7.4 vs 3 years=12.4+/-10.9, p<0.01), laryngopharyngeal reflux health-related quality of life overall score (preoperative=55.0+/-26.0 vs 3 years=11.3+/-13.9, p<0.01), and symptom domain scores (voice, cough, throat clearing, and swallowing) occurred within 1 month of surgery and remained improved over the course of the study. CONCLUSION: Laparoscopic Nissen fundoplication is effective in relieving the symptoms of laryngopharyngeal reflux in a carefully selected patient population. Benefits are seen within 1 month of surgery and persist for at least 3 years.

An interactive, cognitive simulation of gastroesophageal reflux disease.

The Maryland Virtual Patient (MVP) Project seeks to create realistically functioning virtual humans endowed with automatic physiological and cognitive function that can be used in the training of medical personnel. Physiologically, the state of an MVP changes in response to internal pathophysiological stimuli and external stimuli, the latter initiated by either by the patient or the trainee. Cognitively, the MVP can communicate with trainees about current symptoms, lifestyle, history, adherence to prescribed treatments, etc. We will demonstrate simulation in the MVP environment using the example of patients suffering from gastroesophageal reflux disease (GERD).