Promoting Longitudinal and Developmental Computer-Based Assessments of Clinical Reasoning: Validity Evidence for a Clinical Reasoning Mapping Exercise.

PURPOSE: Clinical reasoning is vitally important for practitioners across the health professions. However, the assessment of clinical reasoning remains a significant challenge. Combined with other assessment methods, non-workplace-based assessment can increase opportunities to address multiple components of clinical reasoning, evaluate growth, and foster learning, but tools with validity evidence to assess clinical reasoning outside the workplace are scare. This study examined validity evidence for a novel clinical reasoning mapping exercise (CResME). METHOD: Data include CResME performance scores from 120 third-year medical students at the University of Central Florida for 3 topics in May 2022. Each CResME was scored by 2 physician raters based on a scoring rubric that included a combined diagnosis and sequence score. Descriptive statistics were used to examine trends in scores. The authors gathered validity evidence for response process, internal structure, and relations to other variables. RESULTS: The overall mean (SD) score across cases was 66 (29). Internal consistency reliability of cases (Cronbach α) ranged from 0.75 to 0.91. The Phi and G coefficients were 0.45 and 0.56, respectively. Students accounted for 10% of the total variance, indicating the ability to differentiate high and low clinical reasoning skills; the interaction between learner and case accounted for 8.1% of the variance, demonstrating case specificity. There was a moderate correlation between the overall CResME scores and the mean overall score of patient encounter notes from an objective structured clinical examination performed at the end of the third year (0.46; P = .001). Significant associations were also found between the CResME scores and subject exam scores. CONCLUSIONS: The CResME can be used to facilitate the assessment of clinical reasoning, supporting the developmental progress of learners throughout the curriculum. Future research is needed to gather validity evidence for CResMEs with different learners across different settings and formats.

Reported Beliefs About COVID-19 Vaccines Among Unvaccinated Hispanic Adults Utilizing a Free Clinic in Orlando, Florida.

BACKGROUND: Subgroups of the general population including Hispanic/Latinx individuals report higher rates of COVID-19 vaccine hesitancy than non-Hispanic White individuals. The purpose of this study was to identify factors that influence attitudes toward COVID-19 vaccines among unvaccinated Hispanic adults utilizing a free community clinic in Orlando, Florida, USA. METHODS: From May 2021 to July 2021, we used convenience sampling to recruit 20 self-identified Hispanic adults who were unvaccinated to complete an individual, semi-structured interview. Interview questions were derived from constructs from the Health Belief Model. Interviews were audio-recorded, transcribed, translated (when necessary), and qualitatively analyzed using inductive content analysis to identify recurring themes. RESULTS: Of the 20 participants in this study, 65% were female (n=13) and they ranged from 21 to 73 years of age (median age =42.5). We identified three primary themes in participant responses regarding their beliefs about COVID-19 vaccines. Primary theme 1: trust and clarity of COVID-19 vaccine information, with subthemes (1a) source trustworthiness, and (1b) clarity of COVID-19 vaccine information. Primary theme 2: personal contextual factors, with subthemes (2a) underlying health conditions, (2b) personal experiences with COVID-19, and (2c) immigration. Primary theme 3: lack of confidence, yet willingness to be vaccinated, with subthemes (3a) fear and distrust and (3b) willingness to be vaccinated. In summary, participants felt hesitant, although not completely opposed, to receiving COVID-19 vaccinations due to the information they gathered on vaccines from various sources received in the context of important personal factors (e.g., immigration, underlying health concerns, etc.). CONCLUSIONS: Overcoming vaccine hesitancy in vulnerable populations such as the Hispanic communities may require addressing issues of message clarity through trusted sources while considering personal contextual factors. Healthcare professionals can begin by initiating discussions with patients to understand individual circumstances and concerns and provide information on COVID-19 vaccines that clarify areas of confusion.

Historia de la Ortopedia y Traumatología en la provincia de Matanzas / History of Orthopedics and Traumatology in Matanzas Province

Introducción: El presente trabajo aborda la historia de la especialidad de Ortopedia y Traumatología desde el momento de su aparición en la provincia de Matanzas en el período pre revolucionario, hasta la actualidad. Objetivos: Exponer las evidencias históricas que muestran el derrotero de esta especialidad, y las figuras que jugaron y juegan un papel importante en la formación de especialistas. Métodos: Se utilizó el método de revisión documental sobre el tema, que contempló los documentos editados de 1941 al 2020. Se confeccionó un cuestionario para recoger la información aportada por los testigos entrevistados. Se revisaron los artículos publicados en la revista Médica que se encuentran en la Biblioteca Gener del Monte, de Matanzas (ejemplares únicos), así como otras investigaciones sobre la historia de la medicina matancera. Conclusiones: El esfuerzo desarrollado por la provincia desde el punto de vista asistencial, docente e investigativo ha contribuido a la preservación de la historia de la Ortopedia matancera y de sus actores para las actuales y futuras generaciones(AU)

Introduction: The present work addresses the history of the specialty of Orthopedics and Traumatology from the moment of its appearance in Matanzas province during the pre-revolutionary period, to the present day. Objectives: To show the historical evidence the historical evidence that displays the course of this specialty, and the personalities who played and play important roles in the training specialists. Methods: The document review method on the subject was used, considering the documents published from 1941 to 2020. A questionnaire was made to collect the information provided by the interviewed witnesses. The articles published in the Medical Journal found in Gener del Monte Library in Matanzas (single copies) were reviewed, as well as other investigations on the history of medicine in Matanzas. Conclusions: The effort established by the province, in care, teaching and research has contributed to the preservation of the history of Matanzas Orthopedics and its players for current and future generations(AU)

Cavity shaving for invasive breast cancer conservative surgery: Reduced specimen volume and margin positive rates.

INTRODUCTION: The cavity shaving (CS) technique was described in breast conserving surgery to reduce the rate of reoperation avoiding the need for intraoperative margin analysis. This study assesses differences in the rates of involvement of the surgical margin (requiring further surgery) and volume of surgical specimens, depending on the use or not of this technique. MATERIAL AND METHODS: A retrospective cohort study was conducted in patients with breast carcinoma who underwent breast conserving surgery between 2013 and 2019. They were divided into two groups depending on whether the cavity shaving technique was used or not. Primary outcomes of the study included presence of final margin involvement, requiring need for further surgery, and the volume of excised tissue comparing the study groups. RESULTS: A total of 202 cases were included: 92 in the control group and 110 in the cavity shaving group. Significant differences were found regarding involvement of the final margin (19.57% control group vs. 4.55% cavity shaving group; p = 0.010). The volume of additional surgical specimens were significantly greater in the traditional technique group than in the shaving technique (46.43 vs 13.32 cm3; p = 0.01) as was total specimen volume (143.40 vs 100.63 cm3; p = 0.022). CONCLUSIONS: CS can reduce the positive margin and re-excision rates without larger-volume resections and should therefore be considered a routine technique in BCS for early-stage breast cancer.

Alberto Jiménez Plá, ortopédico matancero / Alberto Jiménez Plá, a Matanzas Orthopedists

Introducción: En la búsqueda de la historia del desarrollo de la especialidad de Ortopedia y Traumatología en la provincia de Matanzas, aparece el nombre del Dr. Alberto Jiménez Pla, un profesional que no se conoce como debería, si se tiene en cuenta la importancia del trabajo que desarrolló en las primeras cuatro décadas del siglo pasado en la atención de esta población, y el ejemplo que constituye su desarrollo profesional. Objetivo: Exponer las evidencias históricas que muestran la vida profesional del destacado ortopédico matancero Alberto Jiménez Plá. Método: Se utilizó el método de revisión documental que contempló documentos editados desde 1941 hasta 2009. Se revisaron los artículos del Dr. Jiménez Plá publicados en la Revista de Médica que se encuentran en la Biblioteca Gener del Monte, de Matanzas (ejemplares únicos), y otras investigaciones sobre la historia de la medicina matancera. Conclusiones: El presente trabajo constituye un homenaje de los ortopédicos matanceros a la memoria de Alberto Jiménez Plá, para llevar su vida y obra a las nuevas generaciones de ortopédicos(AU)

Introduction: Searching in the history of the development of Orthopedics and Traumatology as an specialty in Matanzas province, the name of Dr. Alberto Jiménez Plá rises, a professional who is not known as he should, if one takes into account the importance of his work during the first four decades of the last century in the care of Matanzas population, he is an example of professional growth. Objective: To show the historical evidence of the outstanding professional life of Matanzas orthopedic Alberto Jiménez Plá. Method: The document review method was used, which included documents published from 1941 to 2009. We reviewed the articles by Dr. Jiménez Plá published in Revista de Médica found in the Gener del Monte at Matanzas Library (unique copies), and other investigations on the history of Matanzas medicine. Conclusions: This paper constitutes a tribute from Matanzas orthopedists to the memory of Alberto Jiménez Plá, to bring his life and work to new generations of specialists(AU)

Is the result of breast Tc-99m mibi scintigraphy a prognostic factor for survival in invasive breast cancer? / ¿Es el resultado de la gammagrafía con Tc-99m MIBI un factor pronóstico para la supervivencia en el cáncer invasor de mama?

Background Breast scintigraphy with Tc-99m MIBI showed utility in diagnosing and monitoring response to neoadjuvant treatment. This work studies if there are differences in long-term survival in breast carcinomas depending on the result of Tc-99 MIBI scintigraphy and to analyze their relationship with other variables of prognostic value. Material and methods A prospective observational study on a series of cases of breast cancer in which scintigraphy with Tc-99m MIBI was carried out prior to its treatment, and which had a minimum follow-up of ten years. Clinical–epidemiological, histopathological and immunohistochemical variables were recorded. Bivariate and multivariate analysis were performed studying the result of Tc99m-MIBI scintigraphy. Differences in OS and DFS were studied using Kaplan Meier curves with the log-rank test between factors. Results The significant relationship was found between Tc-99m-MIBI positive result and palpable tumors (p=0.0001), poorly differentiated (p=0.003), with lymph node involvement (p=0.038) and high cell proliferation (p=0.007), although only the palpability and tumor size are related after multivariate analysis. Patients with Tc-99m MIBI positive tumors showed a worse OS (p=0.043) and DFS (p=0.026), independently of size and palpability of the lesión. Conclusion Tc-99m MIBI scintigraphy showed prognostic importance in invasive breast cancer, relating its positivity to reduced long-term survival. (AU)

Introducción La gammagrafía mamaria con Tc-99m MIBI ha mostrado su utilidad en el diagnóstico y la monitorización de la respuesta al tratamiento neoadyuvante. Este trabajo estudia si hay diferencias en la supervivencia por cáncer de mama a largo plazo dependiendo del resultado de la gammagrafía con Tc-99m MIBI y analizar su relación con otras variables de valor pronóstico. Material y métodos Se realizó un estudio observacional prospectivo sobre una serie de pacientes con cáncer de mama en las que se realizó una gammagrafía con Tc-99m MIBI previa a su tratamiento, y con un seguimiento mínimo de 10 años. Se registraron variables clínico-epidemiológicas, histopatológicas e inmunohistoquímicas. Se realizaron análisis bivariante y multivariante para el resultado de la gammagrafía con Tc-99m MIBI. Se estudiaron la supervivencia glogal y libre de enfermedad mediante la curva de Kaplan-Meier y el test de log-rank entre factores. Resultados Se encontró una relación significativa entre la gammagrafía con Tc-99m MIBI positiva y las lesiones palpables (p=0,0001), pobremente diferenciadas (p=0,003), con afectación ganglionar (p=0,038) y alta proliferación celular (p=0,007), aunque solo la palpabilidad y el tamaño tumoral fueron significativos en el análisis multivariante. Las pacientes con gammagrafía positiva mostraron peor supervivencia global (p=0,043) y libre de enfermedad (p=0,026), independientemente del tamaño o la palpabilidad de la lesión. Conclusión La gammagrafía mamaria con Tc-99m MIBI presenta una relevancia pronóstica en cáncer invasor de mama, relacionando su positividad con menor supervivencia a largo plazo. (AU)

Determining Grades in the Internal Medicine Clerkship: Results of a National Survey of Clerkship Directors.

PURPOSE: Trust in and comparability of assessments are essential in clerkships in undergraduate medical education for many reasons, including ensuring competency in clinical skills and application of knowledge important for the transition to residency and throughout students' careers. The authors examined how assessments are used to determine internal medicine (IM) core clerkship grades across U.S. medical schools. METHODS: A multisection web-based survey of core IM clerkship directors at 134 U.S. medical schools with membership in the Clerkship Directors in Internal Medicine was conducted in October through November 2018. The survey included a section on assessment practices to characterize current grading scales used, who determines students' final clerkship grades, the nature/type of summative assessments, and how assessments are weighted. Respondents were asked about perceptions of the influence of the National Board of Medical Examiners (NBME) Medicine Subject Examination (MSE) on students' priorities during the clerkship. RESULTS: The response rate was 82.1% (110/134). There was considerable variability in the summative assessments and their weighting in determining final grades. The NBME MSE (91.8%), clinical performance (90.9%), professionalism (70.9%), and written notes (60.0%) were the most commonly used assessments. Clinical performance assessments and the NBME MSE accounted for the largest percentage of the total grade (on average 52.8% and 23.5%, respectively). Eighty-seven percent of respondents were concerned that students' focus on the NBME MSE performance detracted from patient care learning. CONCLUSIONS: There was considerable variability in what IM clerkships assessed and how those assessments were translated into grades. The NBME MSE was a major contributor to the final grade despite concerns about the impact on patient care learning. These findings underscore the difficulty in comparing learners across institutions and serve to advance discussions for how to improve accuracy and comparability of grading in the clinical environment.

Reflexiones y evidencias sobre la mastectomía reductora de riesgo / Risk reducing mastectomy: reflections and evidences

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Carcinoma neuroendocrino primario de mama / Primary neuroendocrine carcinoma of the breast

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Pre-clerkship medical students' perceptions of medical professionalism.

BACKGROUND: Professionalism instruction and assessment is a core component of medical education, and essential for professional identity formation (PIF). Thus, understanding the socialization of medical students to the values of the profession (i.e., medical professionalism), and how these may evolve, warrants continued understanding. METHODS: The purpose of this study was to examine and compare pre-clerkship (first and second year) medical students' perceptions of professionalism. First and second year medical students participate in this study. This was a two-phase mixed-methods cohort study conducted across two academic years (2014-2015 and 2015-2016). In Phase I, first and second year medical students participated in a nominal group technique (NGT) session. NGT data was analyzed qualitatively to generate a card-sorting exercise of professionalism attributes for Phase II. In Phase II, data from the sorting task was analyzed using Principle Component Analysis (PCA). RESULTS: The PCA for first year students derived a 7-factor solution. Factors (i.e., professionalism domains) identified were: Self-management and patient-centeredness, ethics and professional reputation, dependability, self-awareness and self-improvement, image, proficiency and lifelong learning and integrity. The PCA for second year students derived a 5-factor solution; factors identified were: "Good Doctor" attributes, responsibility, ethics, innovation and self-improvement and unbiased. CONCLUSIONS: Identification and organization of attributes into an overarching professionalism mental model provide a window into the active reconstruction of students' professional identity during the nascent stages of medical education. M1 professionalism domains were more consistent with the conventional professional image of the physician (e.g. Ethics and Professional reputation, Dependability, Integrity), whereas, M2 domains reflected a more global view (e.g., "Good Doctor" attributes, Responsibility, Ethics). This study provides a lens into the dynamic nature of students' PIF and encourages educators to evaluate PIF pedagogy at their own institutions.

The Clinical Reasoning Mapping Exercise (CResME): a new tool for exploring clinical reasoning.

INTRODUCTION: National organizations have identified a need for the creation of novel approaches to teach clinical reasoning throughout medical education. The aim of this project was to develop, implement and evaluate a novel clinical reasoning mapping exercise (CResME). METHODS: Participants included a convenience sample of first and second year medical students at two US medical schools: University of Central Florida (UCF) and Uniformed Services University of Health Sciences (USUHS). The authors describe the creation and implementation of the CResME. The CResME uses clinical information for multiple disease entities as nodes in different domains (history, physical exam, imaging, laboratory results, etc.), requiring learners to connect these nodes of information in an accurate and meaningful way to develop diagnostic and/or management plans in the process. RESULTS: The majority of medical students at both institutions felt that the CResME promoted their understanding of the differential diagnosis and was a valuable tool to compare and contrast elements of a differential diagnosis. Students at both institutions recommended using the CResME for future sessions. DISCUSSION: The CResME is a promising tool to foster students' clinical reasoning early in medical school. Research is needed on the implementation of the CResME as an instructional and assessment strategy for clinical reasoning throughout medical school training.

A Pilot Study Examining Biofeedback and Structured Napping to Promote Medical Student Wellbeing.

This article was migrated. The article was marked as recommended. Objective: To examine medical students' engagement in wellness activities and evaluate the effects of biofeedback and structured napping on measures of stress, burnout and wellbeing. Method: A randomized trial of heart-rate variability (HRV) biofeedback and structured napping used by pre-clinical medical students at the University of Central Florida College of Medicine compared with a control group was conducted. Baseline measurement occurred in August 2016 with the follow-up period in March 2017. To measure biofeedback, participants used Heartmath Biofeedback® with Inner Balance® software to record HRV measurements while they engaged in self-guided breathing three times weekly. The biofeedback device connected to participants' iPhone or iPad with a sensor that clipped to users' earlobes. HRV recordings were stored in a heart-cloud database, and participants had the option to share their recordings with the researchers. Participants used sleep pods (MetroNaps Energy Pods®) to engage in 20-minute structured naps three times weekly. Participants completed six psychosocial self-report questionnaires at baseline (T1) and two follow-up points (T2, T3). The questionnaires included the Interpersonal Reactivity Index; Perceived Stress Scale; Quality of life scale; Oldenburg Burnout Inventory; and the Physician Well-Being Index. Results: Forty-two students enrolled in the study. Throughout the study, participants recorded 276 structured naps lasting approximately 20 minutes in duration and shared 24 personalized biofeedback recordings. Conclusions: Promotion of structured napping offers promise as an institution-initiated wellness intervention to promote medical students' mental health and wellbeing. HRV biofeedback warrants further study given the lack of conclusive findings in this study.

Mastitis granulomatosa idiopática. Una rara entidad benigna que puede simular un cáncer de mama / Idiopathic granulomatous mastitis. A rare benign entitiy that can simulate breast cancer

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Quantitative and Qualitative Analysis of the Impact of Adoption of a Mobile Application for the Assessment of Professionalism in Medical Trainees.

PURPOSE: Capturing either lapses or excellence in behaviors related to medical professionalism is difficult. The authors report a mixed-methods analysis of a novel mobile platform for assessing medical professionalism in a training environment. METHOD: A mobile Web-based platform to facilitate professionalism assessment in a situated clinical setting (Professional Mobile Monitoring of Behaviors [PROMOBES]) was developed. A professionalism framework consisting of six domains (reliability, adaptability, peer relationships, upholding principles, team relationships, and scholarship) encompassing 25 subelements underpins the reporting structure. This pilot study involved 26 faculty supervising 93 medical trainees at two sites from January 12 to August 8, 2016. Notable professionalism behaviors were linked to the framework domains and elements; narrative details about incidences were captured on mobile devices. Surveys gauged the technological functionality and impact of PROMOBES on faculty assessment of professionalism. Qualitative focus groups were employed to elucidate user experience. RESULTS: Although users anticipated PROMOBES's utility would be for reporting lapses in professionalism, 94.7% of reports were for commendation. Comfort assessing professionalism (P = .04) and recognition of the reporting procedures for professionalism-related concerns (P = .01) improved. PROMOBES attained high acceptance ratings. Focus group analysis revealed that the explicit connection to the professionalism framework was powerful; similarly, the near real-time reporting capability, multiple observer inputs, and positive feedback facilitation were strengths. CONCLUSIONS: Making the professionalism framework visible and accessible via a mobile platform significantly strengthens faculty knowledge and behaviors regarding assessment. The strong desire to capture positive behaviors was an unexpected finding.

Evaluating Student Attitudes: Perceptions of Interprofessional Experiences Following Participation in a Student-Run Free Clinic.

It is increasingly evident that patient health outcomes are improved when they are treated by an effective interdisciplinary healthcare team. Many also endorse that learning to function collaboratively in interdisciplinary settings should start at the onset of one's medical education. Student-run free clinics, such as the University of Central Florida College of Medicine's (UCF COM) KNIGHTS (Keeping Neighbors In Good Health Through Service) Clinic, provide opportunities for students to work in concert with other healthcare professionals. This study aimed to discern whether volunteering in this setting had a positive impact on medical students' perception of working within an interdisciplinary team. A single survey was distributed via Qualtrics to all first and second-year medical students (N = 248) at the UCF COM. The items of interest examined in this study were part of a larger study described elsewhere. The mean responses on a 5-point Likert-like scale to these survey items were recorded and compared between two cohorts: KNIGHTS volunteers and non-volunteers. One hundred twenty-three (49.6%) students responded to the survey and most items showed no statistically significant difference between the two groups (p-value > 0.05). However, there were a few items of interest that did show a significant difference. These included KNIGHTS volunteers being much more likely to have worked with other healthcare professionals (p < 0.001) as well as believing themselves to have a better understanding of the role of medicine within an interprofessional team (p = 0.016). Additionally, KNIGHTS volunteers were more likely to feel like they understood the role of patient education (p = 0.031) and pharmacy (p = 0.040) within an interprofessional team. Interestingly, KNIGHTS volunteers were also more likely to believe that problem-solving skills should be learned with students within their own discipline (p = 0.009) as well as that there is little overlap between the roles of medical students and students from other healthcare disciplines (p = 0.044). Still, overall results showed that both volunteers and non-volunteers had an overall positive perception of interdisciplinary teams and working with other healthcare professionals.

The Effect of Volunteering at a Student-Run Free Healthcare Clinic on Medical Students' Self-Efficacy, Comfortableness, Attitude, and Interest in Working with the Underserved Population and Interest in Primary Care.

INTRODUCTION: The number of primary care physicians in the United States continues to lag behind the number of uninsured people. There has been a growing demand for medical students to improve their self-efficacy, comfortableness, attitude, and interest in working with the underserved and in primary care. This study aims to discern whether volunteering at a student-run, free healthcare clinic has a positive impact on these five variables of interest or not. METHODS: A 95-item survey was distributed through Qualtrics Survey Software (Qualtrics, Provo, UT, USA) to medical students from the Class of 2018 and Class of 2019 at the University of Central Florida College of Medicine. They were recruited via emails, Facebook, and in-classroom announcements. Mean responses on a Likert-like scale to different survey items were collected and compared between two study cohorts: Keeping Neighbors In Good Health Through Service (KNIGHTS) Clinic volunteers and non-volunteers. RESULTS: Results from 128 students showed no significant differences in the means between the two cohorts (p-values were not significant). When volunteers were asked the survey item, "KNIGHTS Clinic positively influenced my attitude towards working with underserved patients," 62% strongly agreed, 26% agreed, 10% were neutral, and 2% disagreed. DISCUSSION: Based on the results, volunteering at KNIGHTS Clinic may not have a positive impact on the five variables of interest. However, the lack of significance may also be due to certain limitations of this study addressed elsewhere in this paper. With the majority of KNIGHTS Clinic volunteers agreeing that "KNIGHTS Clinic positively influenced […their] attitude towards working with underserved patients," there may be a positive impact of volunteering on volunteers' attitude towards working with the underserved.