Emergency Palliative Care: Hospice Patients in the Emergency Department.

In this segment of the emergency department (ED) palliative care (PC) case series, we discuss a patient on hospice who presented to the ED for the management of acute symptoms and potential procedural intervention. Hospice patients frequently visit the ED and can challenge typical ED paradigms of care that often include resuscitative efforts and broad workups. Our patient had a history of advanced liver cancer, and his ED presentation was prompted by worsening abdominal pain from ascites requiring serial paracentesis. PC consultation was requested to help address the patient's symptoms and create a plan of care. The PC clinician played an important role in supporting aggressive symptom management, re-evaluating goals of care, addressing concerns about hospice, and facilitating changes in code status requested for a procedure.

Fostering Success and Promoting Professional Development of Clinician Educator Mentees: A Workshop for Mentors.

Introduction: The goal of academic mentoring relationships is to enable the mentee to identify/achieve professional advancement. Although mentors of clinician educators (CEs) must understand the criteria for successful career advancement, few have received formal CE mentor training. Methods: The National Research Mentoring Network convened an expert panel to develop a 90-minute module for training CE mentors. This module included individual development plans, case studies involving challenges for CE faculty, and examples of the broadened scope of scholarly activity. The workshop was delivered to 26 participants across four institutions and evaluated by a retrospective pre/post survey. Results: Using a 7-point scale (1 = very low, 4 = average, 7 = very high), participants rated the overall quality of their CE mentoring as slightly below average preworkshop (M = 3.9) and as above average postworkshop (M = 5.2, p < .001). Areas of greatest self-perceived change in skills on a 7-point scale (1 = not at all skilled, 4 = moderately skilled, 7 = extremely skilled ) included setting clear expectations of the mentoring relationship (pre M = 3.6, post M = 5.1, p < .001), aligning mentor expectations with those of mentees (pre M = 3.6, post M = 5.0, p < .001), and helping mentees set career goals (pre M = 3.9, post M = 5.4, p < .001). Discussion: This module trains CE mentors using an interactive and collective problem-solving approach. Workshop participants better defined demonstrable markers for CE progression with potential to impact tailored guidance for mentees.

United States Medical School Academic Faculty Workforce Diversity, Institutional Characteristics, and Geographical Distributions From 2014-2018.

Purpose Academic healthcare workforce diversity is important in addressing health disparities. Our goal was to evaluate trends and associations in faculty diversity of United States (US) medical schools over a five-year period. Methods We analyzed the Association of American Medical Colleges (AAMC) Faculty Roster data of 151 US medical schools from 2014-2018. Outcome faculty variables were female gender, underrepresented in medicine (UiM), age, and professorial representation. Predictor variables included geographical distributions, and institutional characteristics. Statistical analysis included Jonckheere-Terpstra test, ANOVA, and regression analysis. Results Female faculty increased from 37.6% to 40.4% (p<0.001), senior faculty (age >60 years) from 22.6% to 25.9% (p=0.001) while UiM faculty stayed relatively flat from 9.74% to 10.08% (p=0.773). UiM [adjusted odds ratio (aOR) = 0.39, p=0.015], and female faculty (aOR=0.3, p=0.001) had independently significantly decreased associations with professorial representation, while senior faculty had increased associations (aOR=3.82, p<0.001). Significant independent differences occurred in female, UiM, and professorial faculty distributions within US regions; Hispanic faculty were highest in Southwest (6.57%) and lowest in Midwest region (1.59%), while African-American faculty were highest in Southeast (8.15%) but lowest in the West (3.12%). UiM faculty had significantly independent decreased associations with MD/PhD degree (aOR=0.30, p=0.004) and higher US ranking institutions (aOR=0.45, p=0.009). Conclusions From 2014 to 2018, female faculty increased modestly while the UiM faculty trend remained flat. Female and UiM faculty were less represented at the professor level. UiM faculty were less represented in higher-ranking institutions. Geographic location is associated with faculty diversity.

Teaching Module on Ultrasound-Guided Venous Access Using a Homemade Gel Model for Fourth-Year Medical Students.

INTRODUCTION: Evidence supports an ultrasound-guided approach in patients with difficult vascular access. Prior research on teaching ultrasound-guided intravenous access has included only small groups of first- and second-year medical students. METHODS: We enrolled fourth-year medical students in our teaching module. The module featured a 6-minute prelearning narrated lecture and 5-minute orientation, followed by ultrasound-guided IV placement on homemade gel models. Facilitators were emergency medicine (EM) residents with a prespecified level of procedural ultrasound skills according to EM milestones. Students completed pre- and postmodule surveys. Facilitators completed the Directly Observed Procedural Skills Evaluation. Primary outcomes included global rating, proficiency on six procedural skills, and perceived learning. RESULTS: Our module was completed by 150 fourth-year medical students (94% of the class); 84% cannulated the vein in one attempt. We used a global rating scale to describe the students' cannulation abilities; 59% were trusted to perform this procedure with direct supervision and coaching, 29% with indirect supervision, and 8% without supervision. There was no association between a student's order of attempting IV access within the group and global rating (p = .41). Students reported increased understanding of indications, antecubital anatomy, sonographic anatomy, and procedural comfort (12%, 29%, 38%, and 65% improvement pre- vs. postmodule, respectively; p < .001). DISCUSSION: Our module enabled more than one-third of fourth-year medical students to achieve an indirect supervision or better level of proficiency in ultrasound-guided IV access, with significant improvements in perceived knowledge. This module may be useful for other educators facilitating the transition to residency.

A Framework for Developing Antiracist Medical Educators and Practitioner-Scholars.

With an increasing awareness of the disparate impact of COVID-19 on historically marginalized populations and acts of violence on Black communities in 2020, academic health centers across the United States have been prioritizing antiracism strategies. Often, medical students and residents have been educated in the concepts of equity and antiracism and are ready to tackle these issues in practice. However, faculty are not prepared to respond to or integrate antiracism topics into the curriculum. Leaders in faculty affairs, education, diversity, and other departments are seeking tools, frameworks, expertise, and programs that are best suited to meet this imminent faculty development need. In response to these demands for guidance, the authors came together to explore best practices, common competencies, and frameworks related to antiracism education. The focus of their work was preparing faculty to foster antiracist learning environments at traditionally predominantly White medical schools. In this Scholarly Perspective, the authors describe their collaborative work to define racism and antiracism education; propose a framework for antiracism education for faculty development; and outline key elements to successfully build faculty capacity in providing antiracism education. The proposed framework highlights the interplay between individual learning and growth and the systemic and institutional changes needed to advance antiracist policies and practices. The key elements of the framework include building foundational awareness, expanding foundational knowledge on antiracism, embedding antiracism education into practice, and dismantling oppressive structures and measuring progress. The authors list considerations for program planning and provide examples of current work from their institutions. The proposed strategies aim to support all faculty and enable them to learn, work, and educate others in an antiracist learning environment.

Feasibility of an Assessment Tool as a Data-Driven Approach to Reducing Racial Bias in Biomedical Publications.

The editorial independence of biomedical journals allows flexibility to meet a wide range of research interests. However, it also is a barrier for coordination between journals to solve challenging issues such as racial bias in the scientific literature. A standardized tool to screen for racial bias could prevent the publication of racially biased papers. Biomedical journals would maintain editorial autonomy while still allowing comparable data to be collected and analyzed across journals. A racially diverse research team carried out a three-phase study to generate and test a racial bias assessment tool for biomedical research. Phase 1, an in-depth, structured literature search to identify recommendations, found near complete agreement in the literature on addressing race in biomedical research. Phase 2, construction of a framework from those recommendations, provides the major innovation of this paper. The framework includes three dimensions of race: 1) context, 2) tone and terminology, and 3) analysis, which are the basis for the Race Equity Vetting Instrument for Editorial Workflow (REVIEW) tool. Phase 3, pilot testing the assessment tool, showed that the REVIEW tool was effective at flagging multiple concerns in widely criticized articles. This study demonstrates the feasibility of the proposed REVIEW tool to reduce racial bias in research. Next steps include testing this tool on a broader sample of biomedical research to determine how the tool performs on more subtle examples of racial bias.

United States Best Practice Guidelines for Primary Palliative Care in the Emergency Department.

The growing palliative care needs of emergency department (ED) patients in the United States have motivated the development of ED primary palliative care principles. An expert panel convened to develop best practice guidelines for ED primary palliative care to help guide frontline ED clinicians based on available evidence and consensus opinion of the panel. Results include recommendations for screening and assessment of palliative care needs, ED management of palliative care needs, goals of care conversations, ED palliative care and hospice consults, and transitions of care.

A Multi-Modal Remote Clinical Skills Mini-Course Utilizing a Teaching TeleOSCE.

In the setting of the coronavirus pandemic, medical schools across the world transitioned to a remote learning curriculum with the challenge of developing innovative methods to teach clinical skills. During the pandemic, we designed a 2-week remote clinical skills mini-course for third year medical students. The focus was on clinical reasoning, counseling, and the following the Association of American Medical Colleges (AAMC) Core Entrustable Professional Activities (EPAs): 1 (history and physical exam), 2 (prioritize a differential diagnosis), 3 (recommend and interpret diagnostic tests), and 5 (document a clinical encounter). A multi-modal approach included large and small group virtual case-based discussions, a teaching TeleOSCE (Objective Structured Clinical Examination), and feedback on patient note skills. Students were asked to self-assess their skills before and after the course based on the core EPAs, counseling skills, and overall preparedness for United States Medical Licensing Exam (USMLE) Step 2 Clinical Skills exam. Students demonstrated statistically significant increases in mean self-rated scores in all areas except interpreting results of basic studies. They found the teaching TeleOSCE and feedback on their notes the most useful. Future curricula will consider integration of peer-peer remote OSCE practice sessions as well as faculty feedback for individualized learning plans. Lessons learned will be useful for remote structured clinical skills courses in the setting of the pandemic.

Teaching Residents Communication Skills around Death and Dying in the Trauma Bay.

AbstractBackground: Traumatic events are sudden, unexpected, and often devastating. The delivery of difficult news to patients and families in the trauma setting has unique challenges that necessitate communication skills that may differ from those used in other clinical environments. Objective: Design and implement a novel curriculum to teach, assess, and provide feedback to trauma residents on the communication skills necessary for delivering difficult news to patients and families in the trauma setting. Methods: This communication curriculum was delivered in three separate phases: (1) didactics using a video education e-module, (2) simulated practice of trauma resuscitation with a high-fidelity mannequin followed by role play of delivering difficult news, (3) an observed skills assessment using standardized patients (SPs). Each phase focused on delivery of difficult news of death and of uncertain/poor prognosis after a resuscitation in the trauma bay. Learners were trauma residents that included postgraduate year (PGY) 1-2 general surgery residents and PGY 1-4 emergency medicine residents at a level 1 trauma center. Outcomes include resident comfort, knowledge, and confidence in delivering difficult news in the trauma setting. Results: Thirty-nine trauma residents participated in the three-phase curriculum. There was an increase in the mean scores of resident-reported comfort, knowledge, and confidence in delivering difficult news for the seriously injured. SPs rated 78% of residents as competent to perform delivery of difficult news in the trauma bay independently. Conclusions: A curriculum to teach and assess trauma residents in the skills necessary to deliver difficult news in the trauma setting is both feasible and effective.

Milestone Approach to Designing a Point-of-Care Ultrasound Curriculum for Transition-to-Residency Programs in the United States.

Phenomenon: Point-of-care ultrasound is fast becoming standard clinical bedside practice for diverse specialties. Medical schools are responding by adding ultrasound education, though the majority use it to supplement the learning of basic sciences. Point-of-care ultrasound practice-based clinical skills education is rare. There also is a lack of standardization across curricula, leading to much variability in the ultrasound skills that medical students from different schools bring to residency. To best inform a point-of-care ultrasound curriculum for our Transition-to Residency program, we investigated literature on 1) how medical students are being prepared for use of point-of-care ultrasound in clinical practice, 2) what skills are being taught, 3) what point-of-care ultrasound skills residency programs expect from incoming residents. Approach: We reviewed literature to identify curricula in U.S. medical schools that teach the concepts, knowledge, and skills related to point-of-care ultrasound. We also mapped point-of-care ultrasound expectations set forth by the Entrustable Professional Activities for undergraduate medical education to the specialty-specific milestones identified by the Accreditation Council for Graduate Medical Education. Additionally, we reviewed specialty-specific professional organizations for position statements and guidelines describing the point-of-care ultrasound skills expected for practicing physicians in their respective specialties. The goal was to identify any needs and gaps in education regarding point-of-care ultrasound across the undergraduate to graduate medical education continuum to practice. Findings: We found seven published point-of-care ultrasound curricula for medical students. There was wide variability in these curricula regarding what point-of-care ultrasound content is being taught, as well as when and how this skill is taught. No Entrustable Professional Activity listed point-of-care ultrasound as a skill requirement for graduating medical students. For graduate medical education, there was wide variability across specialties in residency milestones related to point-of-care ultrasound; some (e.g., emergency medicine) listed extensive milestones while others (e.g., internal medicine) listed none. However, we found that many specialty-specific professional organizations do list detailed point-of-care ultrasound expectations for their practicing physicians. Insights: As point-of-care ultrasound is fast becoming common practice across many specialties, standardization of education and related competencies-similar to other clinical skills training-is necessary across medical schools. Mapping point-of-care ultrasound expectations to current teaching across the continuum from undergraduate to graduate medical education may allow schools to tailor point-of-care ultrasound training for Transition-to-Residency programs. We provide a sample pilot point-of-care ultrasound curriculum that we designed for our Transition-to-Residency course.

Integrating Basic and Clinical Sciences Using Point-of-Care Renal Ultrasound for Preclerkship Education.

Introduction: Point-of-care ultrasound (POCUS) is a valuable asset in bedside clinical care. Undergraduate medical education is increasingly using POCUS as an adjunct tool for teaching anatomy, pathophysiology, and physical exam in an integrated manner. Many medical schools teach content in an organ systems-based format in the preclerkship years. POCUS teaching can be very effectively tailored to specific organ systems. Though pilot curricula for generalized ultrasound education exist, few teach organ systems-based content using POCUS. To address this gap, we designed and implemented an integrated POCUS module to supplement anatomy, pathophysiology, and physical exam teaching in the renal course. Methods: The module consisted of (1) a 30-minute didactic lecture introducing students to renal ultrasound technique and image interpretation and (2) a practical hands-on skills session. Pre- and postmodule surveys assessed the efficacy and impact of the curriculum. Results: A total of 31 first-year medical students completed the POCUS renal curriculum. A majority reported that the module positively affected their understanding of renal pathophysiology and the physical exam. They also reported increased confidence in using POCUS to detect renal pathology and make clinical decisions. Discussion: It was feasible to implement a POCUS curriculum to supplement integrated teaching of renal system concepts in the first year of medical school, and students found POCUS teaching valuable. POCUS provides educators with another tool to integrate basic and clinical sciences with hands-on relevant clinical skills practice in early medical school years.

DATA 2000 waiver training for medical students: Lessons learned from a medical school experience.

BACKGROUND: In the midst of this national opioid crisis, it has become apparent that there is a large shortage in the workforce of treatment providers equipped to deliver evidence-based care for opioid use disorders (OUD). Medications for opioid use disorder (MOUD), such as buprenorphine, are crucial in reducing mortality in those with OUD, and yet prescribers must meet federal waiver requirements under the Drug Addiction Treatment Act of 2000 (DATA 2000). There are now several pathways for medical schools to satisfy these waiver requirements for all graduates, but this has not yet become widespread. We propose that including a DATA 2000 waiver training within the medical school curriculum is a feasible and effective way to meet eligibility requirements to prescribe buprenorphine. Methods: As part of a longitudinal opioid curriculum requirement, we implemented a DATA 2000 waiver training for all rising Year 4 medical students. One hundred sixty-nine students completed a hybrid (online and in-person) waiver training. The majority completed a pre- and post-survey. Results: The pre-training survey showed 93% of rising Year 4 medical students (112/120) reported participation in care of patients with OUD. Students six month post-training reported a rise in confidence (1.94 to 2.45; p < 0.01) and knowledge (2.27 to 2.76; p < 0.01) regarding MOUD. They also reported their plans to apply for the buprenorphine waiver once licensed and reported being more likely to prescribe buprenorphine for OUD as a result of the training (mean = 3.35; SD = 1.36; 0 = extremely unlikely to 5 = extremely likely). Conclusions: We successfully implemented a DATA 2000 waiver training as a mandatory requirement for the medical school curriculum. Further studies are needed to determine optimal timing, best format, and frequency of reinforcement of MOUD educational content across the undergraduate and graduate medical education continuum.

Implementing an Interactive Introduction to Complementary Medicine for Chronic Pain Management Into the Medical School Curriculum.

Introduction: In the setting of the opioid crisis, chronic pain management requires new approaches and open dialogue between physicians and patients to explore evidence-based nonpharmacologic treatments. We developed an educational session on the role of complementary and alternative medicine (CAM) for chronic pain management as part of our larger curriculum on health equity and social justice. Methods: Students and faculty developed a novel educational session for second-year medical students consisting of a lecture and an experiential small-group session immersing the students in CAM. We conducted pre- and postsurveys to assess the students' self-reported learning and impressions of the session. Results: Over the academic years of 2018-2019 and 2019-2020, 345 second-year medical students participated in this mandatory session. In matched pre-and postsession surveys, students rated their knowledge of the evidence behind CAM practices, and reported statistically significant increases in their understanding. When asked about the importance of physician familiarity with common CAM practices, students noted both a high baseline agreement and a statistically significant increase after the session concluded. Familiarity with financial costs of each of the practices also saw statistically significant increases after the session. Discussion: Our results indicated that the session met the educational objectives. A critical part of improving our session between academic years involved gathering feedback and implementing changes based on these suggestions. Our model is easy to implement and replicate at medical schools across the country. Future studies should assess the effects of CAM-focused educational interventions on practices in the clinical setting.

Integrating the Bleeding Control Basic course into medical school curriculum.

BACKGROUND: The American College of Surgeons has pioneered hemorrhage control through its lifesaving bleeding control (BCon) basics course. A gap exists in teaching these skills to medical students. We sought to integrate BCon into the medical school curriculum. METHODS: BCon programs taught to entering Year 1 medical students in Academic Years 2017-2018. Post-course surveys assessed effectiveness of teaching and learner confidence in performing skills. Refreshers in Year 2 and Year 3 of study were implemented to reinforce skills. RESULTS: Post-course surveys (n = 348) showed that 98% of students felt that they were effectively taught how to stop bleeding and 92% felt comfortable using these skills. CONCLUSION: The BCon program is feasible to implement in medical school. It is easily integrated into pre-existing curricula in addition to other life support skills taught to medical students. SUMMARY: Bleeding control is increasingly a topic of national concern with mass casualty incidents. We used a peer training model to teach BCon techniques to all our medical students on entry into medical school and these skills were refreshed longitudinally in the next two years. Combining BCon training with other basic life support skills training is feasible and medical students find this training effective.

Cysticercosis masquerading as tuberculous lymphadenitis in supraclavicular region.

Cysticercosis is a parasitic infestation caused by the larvae of the tapeworm Taenia solium. In humans, cysticercosis spreads through fecal-oral route by ingesting food contaminated with eggs of pork tapeworm. The most frequent sites affected are central nervous system, eye, subcutaneous tissue, and skeletal muscle. We report a case of cysticercosis presenting as left supraclavicular swelling which is a rare site, diagnosed on fine-needle aspiration.

Social Determinants of Health Curriculum Integrated Into a Core Emergency Medicine Clerkship.

Introduction: Demand that health centers address health inequities has led medical schools to emphasize social determinants of health (SDH). The Emergency Department often serves as first (or sole) point of health care access, making it an ideal environment in which to identify/explore SDH. Yet there are few SDH curricula targeting core emergency medicine (EM) clerkships. We describe implementation and outcomes of a three-part SDH curriculum instituted in a 4-week EM clerkship. Methods: We created a longitudinal curriculum aimed at fourth-year medical students in their EM clerkship. Students interviewed patients to discuss social and other influences on their health care and wrote reflections. After this, they discussed their individual cases in small groups, selected one patient, and found literature and strategies/systems to fit the patient's needs. Finally, groups presented their work to student-peers and faculty for discussion. Students were assessed for each activity and surveyed for impact of the curriculum. Results: We evaluated the curriculum, with preliminary data showing a wide range of topics covered. On a 5-point scale (1 = Hardly at All, 5 = To a Very High Degree), students responded with means of 4.4 to "I am able to recognize barriers to health that patients and families face from diverse socio-economic backgrounds" and 4.6 to "I feel it is important to recognize and address the social determinants of health as part of whole patient care." Discussion: This curriculum introduces SDH, uses metacognitive skills across multiple domains, and is feasible and has been well received in an EM clerkship.