After the Discontinuation of Step 2 CS: A Collaborative Statement from the Directors of Clinical Skills Education (DOCS).

Issue: The United States Medical Licensing Exam (USMLE) Step 2 Clinical Skills Examination (Step 2 CS), the only clinical skills competency testing required for licensure in the United States, has been discontinued. Evidence: This exam, though controversial, propelled a movement emphasizing the value of clinical skills instruction and assessment in undergraduate medical education. While disappointed by the loss of this national driver that facilitated standardization of clinical skills education, the Directors of Clinical Skills Education (DOCS) see prospects for educational innovation and growth. DOCS is a national organization and inclusive community of clinical skills education leaders. This statement from DOCS regarding the discontinuation of USMLE Step 2 CS has been informed by DOCS meetings, listserv discussions, an internal survey, and a review of recent literature. Implications: Rigorous clinical skills assessment remains central to effective and patient-centered healthcare. DOCS shares specific concerns as well as potential solutions. Now free from the external pressure to prepare students for success on Step 2 CS, clinical skills educators can reprioritize content and restructure clinical skills programs to best meet the needs of learners and the ever-evolving healthcare landscape. DOCS, as an organization of clinical skills leaders, makes the following recommendations: 1) Collaboration amongst institutions must be prioritized; clinical skills assessment consortia should be expanded. 2) Governing, accrediting, and licensing organizations should leverage their influence to support and require high quality clinical skills assessments. 3) UME clinical skills leaders should develop ways to identify students who perform with exceptional, borderline, and poor clinical skills at their local institutions. 4) UME leadership should fully commit resources and curricular time to graduate students with excellent clinical skills.

Delirium in the NICU: A Point Prevalence Study.

OBJECTIVES: Delirium is a well-described complication of critical illness, with occurrence rates of >25% in the PICU, and associated morbidity. Infants in the NICU are likely at risk. There have been no previous screening studies to quantify delirium rates in the neonatal population. We hypothesized that delirium was prevalent in term neonates in the NICU. In this pilot study, our objective was to estimate prevalence using a validated pediatric delirium screening tool, which has not yet been tested in NICUs. METHODS: In this point prevalence study, all term or term-corrected infants admitted to the NICU on designated study days were screened for delirium using the Cornell Assessment of Pediatric Delirium. RESULTS: A total of 149 infants were eligible for screening over 8 study days. A total of 147 (98.6%) were successfully screened with the Cornell Assessment of Pediatric Delirium. Overall, 22.4% (n = 33) screened positive for delirium. Delirium was more commonly detected in children on invasive mechanical ventilation (67% vs 17%, P < .01) and those with underlying neurologic disorders (64% vs 13%, P < .01). A multivariate logistic regression revealed that neurologic disability and mechanical ventilation were both independently associated with a positive delirium screen (aOR: 12.3, CI: 4.5-33.6 and aOR: 9.3, CI: 2.5-34.6, respectively). CONCLUSIONS: Our results indicate that delirium likely occurs frequently in term-equivalent infants in the NICU. Further research is necessary to establish feasibility, validity, and interrater reliability of delirium screening in this population.

A Virtual Clinical Reasoning Case for Medical Students Using an Ophthalmology Model: A Case of Red Eye.

Introduction: Triggered by the COVID-19 pandemic, medical education has moved online, tasking medical educators with developing virtual learning experiences. This is particularly challenging for less-represented disciplines, such as ophthalmology. We designed a red eye clinical reasoning case for preclinical medical students, which can be delivered virtually, using video conference software. Methods: We developed a 90-minute red eye/clinical reasoning workshop for which prereading was assigned to students. We then delivered a virtual development session to nonophthalmologist copreceptors and provided a session faculty guide. The entire first-year medical student class (No. = 140) participated in one of four identical workshops, which included virtual small- and large-group discussions. Students completed a knowledge pre- and posttest, and an optional session postsurvey. Results: Knowledge gains from pretest (No. = 94) to posttest (No. = 73) were statistically significant (p < .05), with average scores improving from 57% to 70%. Overall, students were satisfied, rating the following items 4 or 5 out of 5: session (86%, No. = 31), virtual format (83%, No. = 30), and if they recommended future use (69%, No. = 35). Discussion: This novel, virtual clinical reasoning case simulated small- and large-group learning, achieved knowledge gains, and was well received by students. Minor technical challenges were encountered but successfully remedied, without apparent disruption to learning. This virtual medical education model can be used to enhance ophthalmology education in preclinical medical students and can be adapted for virtual design of other curricular content.

Approaches to Teaching the Physical Exam to Preclerkship Medical Students: Results of a National Survey.

PURPOSE: To assess current approaches to teaching the physical exam to preclerkship students at U.S. medical schools. METHOD: The Directors of Clinical Skills Courses developed a 49-question survey addressing the approach, pedagogical methods, and assessment methods of preclerkship physical exam curricula. The survey was administered to all 141 Liaison Committee on Medical Education-accredited U.S. medical schools in October 2015. Results were aggregated across schools, and survey weights were used to adjust for response rate and school size. RESULTS: One hundred six medical schools (75%) responded. Seventy-nine percent of schools (84) began teaching the physical exam within the first two months of medical school. Fifty-six percent of schools (59) employed both a "head-to-toe" comprehensive approach and a clinical reasoning approach. Twenty-three percent (24) taught a portion of the physical exam interprofessionally. Videos, online modules, and simulators were used widely, and 39% of schools (41) used bedside ultrasonography. Schools reported a median of 4 formative assessments and 3 summative assessments, with 16% of schools (17) using criterion-based standard-setting methods for physical exam assessments. Results did not vary significantly by school size. CONCLUSIONS: There was wide variation in how medical schools taught the physical exam to preclerkship students. Common pedagogical approaches included early initiation of physical exam instruction, use of technology, and methods that support clinical reasoning and competency-based medical education. Approaches used by a minority of schools included interprofessional education, ultrasound, and criterion-based standard-setting methods for assessments. Opportunities abound for research into the optimal methods for teaching the physical exam.

Resources Used to Teach the Physical Exam to Preclerkship Medical Students: Results of a National Survey.

PURPOSE: To examine resources used in teaching the physical exam to preclerkship students at U.S. medical schools. METHOD: The Directors of Clinical Skills Courses developed a 49-question survey addressing resources and pedagogical methods employed in preclerkship physical exam curricula. The survey was sent to all 141 Liaison Committee on Medical Education-accredited medical schools in October 2015. Results were averaged across schools, and data were weighted by class size. RESULTS: Results from 106 medical schools (75% response rate) identified a median of 59 hours devoted to teaching the physical exam. Thirty-eight percent of time spent teaching the physical exam involved the use of standardized patients, 30% used peer-to-peer practice, and 25% involved examining actual patients. Approximately half of practice time with actual patients was observed by faculty. At 48% of schools (51), less than 15% of practice time was with actual patients, and at 20% of schools (21) faculty never observed students practicing with actual patients. Forty-eight percent of schools (51) did not provide compensation for their outpatient clinical preceptors. CONCLUSIONS: There is wide variation in the resources used to teach the physical examination to preclerkship medical students. At some schools, the amount of faculty observation of students examining actual patients may not be enough for students to achieve competency. A significant percentage of faculty teaching the physical exam remain uncompensated for their effort. Improving faculty compensation and increasing use of senior students as teachers might allow for greater observation and feedback and improved physical exam skills among students.

Seeing Is Believing: Evaluating a Point-of-Care Ultrasound Curriculum for 1st-Year Medical Students.

PROBLEM: Point-of-care ultrasound has been a novel addition to undergraduate medical education at a few medical schools. The impact is not fully understood, and few rigorous assessments of educational outcomes exist. This study assessed the impact of a point-of-care ultrasound curriculum on image acquisition, interpretation, and student and faculty perceptions of the course. INTERVENTION: All 142 first-year medical students completed a curriculum on ultrasound physics and instrumentation, cardiac, thoracic, and abdominal imaging. A flipped classroom model of preclass tutorials and tests augmenting live, hands-on scanning sessions was incorporated into the physical examination course. Students and faculty completed surveys on impressions of the curriculum, and all students under-went competency assessments with standardized patients. CONTEXT: The curriculum was a mandatory part of the physical examination course and was taught by experienced clinician-sonographers as well as faculty who do not routinely perform sonography in their clinical practice. OUTCOME: Students and faculty agreed that the physical examination course was the right time to introduce ultrasound (87% and 80%). Students demonstrated proper use of the ultrasound machine functions (M score = 91.55), and cardiac, thoracic, and abdominal system assessments (M score = 80.35, 79.58, and 71.57, respectively). Students and faculty valued the curriculum, and students demonstrated basic competency in performance and interpretation of ultrasound. Further study is needed to determine how to best incorporate this emerging technology into a robust learning experience for medical students.

Diagnostic challenges in a child with familial hemophagocytic lymphohistiocytosis type 3 (FHLH3) presenting with fulminant neurological disease.

BACKGROUND: Familial hemophagocytic lymphohistiocytosis (FHLH) is an autosomal recessively inherited multisystem disease characterized by fever, rash, splenomegaly, cytopenias, and variable central nervous system (CNS) manifestations. CASE HISTORY: We report the case of a 3-year-old boy who presented with splenomegaly and normocytic anemia 4 months after returning to the US from a region endemic for Leishmania infection. The child later developed progressive neurological impairment and had radiologic evidence of widespread demyelinating disease. Gene studies showed homozygosity for a mutation at Munc13-4, confirming FHLH type 3. DISCUSSION: The diagnostic uncertainty that accompanies FHLH was compounded by our patient's travel history and CNS disease mimicking acute disseminated encephalomyelitis (ADEM). Diagnostic criteria for hemophagocytic lymphohistiocytosis were not consistently met, despite aggressive disease. CONCLUSIONS: FHLH may present with fulminant demyelinating disease, mimicking ADEM, and without necessarily meeting previously defined clinical and laboratory criteria. We strongly recommend expeditious molecular testing and genetic counseling for FHLH mutations in cases of undiagnosed inflammatory CNS disease in the pediatric population.

Hyperglycemia and outcome in the pediatric intensive care unit.

OBJECTIVE: To identify the frequency of hyperglycemia in children who are nondiabetic and critically ill and assess the independent effect of hyperglycemia on outcome. STUDY DESIGN: Consecutive admissions to the pediatric intensive care unit (PICU) were reviewed. The Pediatric Risk of Mortality III score (PRISM) measured patient acuity. Because maximum glucose level in the first day of PICU admission (GLFD) >200mg/dL contributes to PRISM, 200 mg/dL was used to differentiate high glucose (HG) from normal glucose. RESULTS: Of 1550 patients, 221 (14.3%) had HG. GLFD correlated with PRISM (r = 0.39, P < .001). Without controlling for PRISM, the HG group had more mechanical ventilation days (MVD; P < .001), longer PICU length of stay (PLOS; P < .001) and lower percent survival (P < .001) than the normal glucose group. Controlling for PRISM in survivors, GLFD was not associated with PLOS (P = .75) or with MVD (P = .06). GLFD was not significantly associated with survival (P = .76). In nonsurvivors, GLFD was not associated with PLOS (P = .19) or MVD (P = .31). CONCLUSION: When controlling for disease severity, hyperglycemia within 24 hours of PICU admission was not independently associated with increased mechanical ventilation time, length of stay, or mortality. Prospective evaluation of glycemic control in critically ill children is needed to elucidate its effects on outcome.

Hyperglycemia in the pediatric intensive care unit.

PURPOSE OF REVIEW: Studies on critically ill adults demonstrate the benefits of glycemic control. There is a paucity of data, however, in pediatric intensive care settings. This review summarizes sentinel papers in the adult literature, outlines mechanisms by which hyperglycemia mediates its effects in the critically ill, highlighting those described in pediatrics, and discusses studies that associate hyperglycemia with negative outcome in critically ill children. RECENT FINDINGS: Retrospective studies and prospective cohort studies have linked hyperglycemia to worse outcome in critically ill children. Investigations in small, homogenous groups, such as trauma, sepsis, burn and neonatal patients, have shown negative associations between hyperglycemia and injury-specific outcomes and have elucidated previously proposed mechanisms of tissue injury in children. In addition, certain properties of hyperglycemia, such as duration, peak, and excursion, may be more relevant than absolute levels of glucose. Larger studies generalize findings to heterogeneous pediatric intensive care populations, across ages and diagnoses. Further, in studies accounting for insulin administration, no obvious increases in hypoglycemia-related morbidity have been noted. SUMMARY: Glucose control in pediatric intensive care has been receiving increasing attention. Large, prospective studies are needed to address certain issues in pediatrics, such as differences in diseases, target values, complications of disease, risks and sequelae of hypoglycemia and logistical challenges.

Management of a cadaveric orthotopic liver transplantation in a pediatric patient with complex congenital heart disease.

Pediatric orthotopic liver transplantations (OLT) are commonly performed nowadays. Two primary reasons for OLT in children are complications from either extrahepatic biliary atresia (EHBA) or inborn errors of metabolism. However, congenital liver disease may be associated with significant other congenital abnormalities. We present a case of a successful OLT in a pediatric patient with a history of EHBA, situs inversus, and complex congenital heart disease. The cardiac anomalies include dextrocardia, absence of the atrial septum (single atrium), single atrioventricular valve (a-v canal), and an incomplete ventricular septum. Prior surgery include a Kasai procedure for EHBA, banding of the proximal main pulmonary artery, and Broviac catheter placement. We present the anesthesia concerns and management for this complicated case.