A team-based learning approach to interprofessional education of medical and pharmacy students.

BACKGROUND: As collaborative team-based healthcare expands, there is a need for effective interprofessional education (IPE). Although the desired outcomes of IPE are defined by the Interprofessional Education Collaborative (IPEC), resources often limit IPE implementation. The purpose of this study is to assess the effectiveness of a novel interprofessional activity in improving health professions students' interprofessional competencies using team-based learning (TBL). INTERPROFESSIONAL EDUCATION ACTIVITY: Teams of second year pharmacy and medical students participated in a novel IPE session targeting roles and responsibilities. This activity was designed and implemented by a small number of faculty and used TBL to educate a large number of students using limited resources. Class averages for individual and team readiness assurance test (iRAT/tRAT) scores were collected, and students were invited to complete the Interprofessional Collaborative Competencies Attainment Survey (ICCAS) to evaluate the effectiveness of the activity. DISCUSSION: On average, tRAT scores were 20% higher than iRAT scores. While there was significant improvement for all items on the ICCAS, questions within the roles and responsibilities domain of the ICCAS were most affected. IMPLICATIONS: This novel IPE activity was successful in teaching a large group of professional students in the targeted domain of roles and responsibilities in a single session. This activity was a rich experience in which students learned together using limited resources which can be easily replicated at other institutions to help professional students gain proficiency in interprofessional competencies.

Using virtual standardized patients to accurately assess information gathering skills in medical students.

Introduction: Practicing a medical history using standardized patients is an essential component of medical school curricula. Recent advances in technology now allow for newer approaches for practicing and assessing communication skills. We describe herein a virtual standardized patient (VSP) system that allows students to practice their history taking skills and receive immediate feedback. Methods: Our VSPs consist of artificially intelligent, emotionally responsive 3D characters which communicate with students using natural language. The system categorizes the input questions according to specific domains and summarizes the encounter. Automated assessment by the computer was compared to manual assessment by trained raters to assess accuracy of the grading system. Results: Twenty dialogs chosen randomly from 102 total encounters were analyzed by three human and one computer rater. Overall scores calculated by the computer were not different than those provided by the human raters, and overall accuracy of the computer system was 87%, compared with 90% for human raters. Inter-rater reliability was high across 19 of 21 categories. Conclusions: We have developed a virtual standardized patient system that can understand, respond, categorize, and assess student performance in gathering information during a typical medical history, thus enabling students to practice their history-taking skills and receive immediate feedback.

PARTICIPATORY BULLSEYE TOOLKIT INTERVIEW: IDENTIFYING PHYSICIANS' RELATIVE PRIORITIZATION OF DECISION FACTORS WHEN ORDERING RADIOLOGIC IMAGING IN A HOSPITAL SETTING.

Critical Decision Method (CDM), a popular cognitive task analysis (CTA) method, is an in-depth retrospective interview that uses a historical non-routine incident to identify experts' decision-making factors in complex socio-technical settings with high consequences for failure. However, it is challenging to use CDM to make comparisons, including those between experts and trainees. We describe an alternative CTA method used to study physicians' decision making for ordering diagnostic imaging. After being primed with 11 simulated patient scenarios, nine attending and 11 resident physicians were asked to map out and present their decision-making process with a bullseye participatory design toolkit. Interviews were analyzed qualitatively, revealing four common decision factors: diagnostic efficacy, patient safety, organizational constraints, and patient comfort. The bullseye maps were used to quantitatively measure priority differences between these decision factors. Attending and resident physicians both prioritized diagnostic efficacy over the other factors (2.38 vs. 3.71, p <.01, and 2.59 vs. 3.52, p<.01, respectively), but attending physicians' decisions had a higher proportion of non-diagnostic items (65% vs. 50%, p = .008). Our results demonstrate the usefulness of this method in eliciting decision factors for a complex, face-valid task and for identifying differences due to levels of expertise and training.

Developing a Conversational Virtual Standardized Patient to Enable Students to Practice History-Taking Skills.

INTRODUCTION: Although traditional virtual patient simulations are designed to teach and assess clinical reasoning skills, few employ conversational dialogue with the patients. The virtual standardized patients (VSPs) described herein represent standardized patients that students interview using natural language. Students take histories and develop differential diagnoses of the VSPs as much as they would with standardized or actual patients. The student-VSP interactions are recorded, creating a comprehensive record of questions and the order in which they were asked, which can be analyzed to assess information-gathering skills. Students document the encounter in an electronic medical record created for the VSPs. METHODS: The VSP was developed by integrating a dialogue management system (ChatScript) with emotionally responsive 3D characters created in a high-fidelity game engine (Unity). The system was tested with medical students at the Ohio State University College of Medicine. Students are able to take a history of a VSP, develop a differential diagnosis, and document the encounter in the electronic medical record. RESULTS: Accuracy of the VSP responses ranged from 79% to 86%, depending on the complexity of the case, type of history obtained, and skill of the student. Students were able to accurately develop an appropriate differential diagnosis on the basis of the information provided by the patient during the encounter. CONCLUSIONS: The VSP enables students to practice their history-taking skills before encounters with standardized or actual patients. Future developments will focus on creating an assessment module that will automatically analyze VSP sessions and provide immediate student feedback.

Comparing the Effectiveness of Alerts and Dynamically Annotated Visualizations (DAVs) in Improving Clinical Decision Making.

OBJECTIVE: The aim of this study was to compare the effectiveness of two types of real-time decision support, an interrupting pop-up alert and a noninterrupting dynamically annotated visualization (DAV), in reducing clinically inappropriate diagnostic imaging orders. BACKGROUND: Alerts in electronic health record software are frequently disregarded due to high false-alarm rates, interruptions, and uncertainty about what triggered the alert. In other settings, providing visualizations and improving understandability of the guidance has been shown to improve overall decision making. METHOD: Using a between-subject design, we examined the effect of two forms of decision support, alerts and DAVs, on reducing the proportion of inappropriate diagnostic imaging orders for 11 patients in a simulated environment. Nine attending and 11 resident physicians with experience using an electronic health record were randomly assigned to the form of decision support. Secondary measures were self-reported understandability, algorithm transparency, and clinical relevance. RESULTS: Fewer inappropriate diagnostic imaging tests were ordered with DAVs than with alerts (18% vs. 34%, p < .001). The DAV was rated higher for all three secondary measures (p < .001) for all participants. CONCLUSION: DAVs were more effective than alerts in reducing inappropriate imaging orders and were preferred for all patient scenarios, especially scenarios where guidance was ambiguous or based on inaccurate information. APPLICATION: Creating visualizations that are permanently displayed and vary in the strength of their guidance can mitigate the risk of system performance degradation due to incomplete or incorrect data. This interaction paradigm may be applicable for other settings with high false-alarm rates or where there is a need to reduce interruptions during decision making.

Determining the rate of change in exposure to ionizing radiation from CT Scans: a database analysis from one hospital.

PURPOSE: Cancer risks associated with radiation from CT procedures have recently received increased attention. An important question is whether the combined impact of CT volume and dose reduction strategies has reduced radiation exposure to adult patients undergoing CT examinations. The aim of this study was to determine differences in radiation exposure from 2008 to 2012 to patients receiving CT scans of the abdomen, head, sinus, and lumbar spine at a midwestern academic medical center that implemented dose reduction strategies. METHODS: Data were collected from two internal data sets from 2008 to 2012 for general medicine and intensive care unit patients. These data were used to calculate annual CT volume, rate, average effective dose, radiation exposure, and estimated cancer risk. RESULTS: A 37% reduction in abdominal CT volume was found from 2008 to 2012. However, no volume reductions were found for CT examinations of the head or lumbar spine, and the decrease in sinus imaging was minimal. Dose reduction strategies resulted in 30% to 52% decreases in radiation exposure for the targeted body areas. The combined reduction in volume and dose per procedure reduced estimated induced cancers by 63%. CONCLUSIONS: Exposure to ionizing radiation from these examinations was reduced at one institution because of reduced volumes of procedures and the reduction of each procedure's effective dose through new protocols and technologies. Although both the volume reduction and dose reduction strategies contributed to the reduced exposure, it seems that investments in implementing the protocols and new technology had the greatest effect on future cancer risk.

Handoff practices in undergraduate medical education.

BACKGROUND: Growing data demonstrate that inaccuracies are prevalent in current handoff practices, and that these inaccuracies contribute to medical errors. In response, the Accreditation Council for Graduate Medical Education (ACGME) now requires residency programs to monitor and assess resident competence in handoff communication. Given these changes, undergraduate medical education programs must adapt to these patient safety concerns. OBJECTIVES: To obtain up-to-date information regarding educational practices for medical students, the authors conducted a national survey of Clerkship Directors in Internal Medicine (CDIM) members. DESIGN AND PARTICIPANTS: In June 2012, CDIM surveyed its institutional members, representing 121 of 143 Departments of Medicine in the U.S. and Canada. The section on handoffs included 12 questions designed to define the handoff education and practices of third year clerkship and fourth year sub-internship students. KEY RESULTS: Ninety-nine institutional CDIM members responded (82%). The minority (15%) reported a structured handoff curriculum provided during the internal medicine (IM) core clerkship, and only 37% reported a structured handoff curriculum during the IM sub-internship. Sixty-six percent stated that third year students do not perform handoff activities. However, most respondents (93%) reported that fourth year sub-internship students perform patient handoff activities. Only twenty-six (26%) institutional educators in CDIM believe their current handoff curriculum is adequate. CONCLUSIONS: Despite the growing literature linking poor handoffs to adverse events, few medical students are taught this competency during medical school. The common practice of allowing untrained sub-interns to perform handoffs as part of a required clerkship raises safety concerns. Evidence-based education programs are needed for handoff training.

Hospital medicine in the internal medicine clerkship: results from a national survey.

BACKGROUND: Hospital medicine is growing rapidly. This changing inpatient work force has had consequences on medical education, with an increasing hospitalist presence in resident and student training. Initially met with apprehension, there is growing literature to suggest that hospitalists are perceived to be more effective clinical teachers than non-hospitalists. However, the extent to which hospitalists are involved in teaching Internal Medicine (IM) to medical students is not known. METHODS: In order to determine the role of hospitalists in medical student education within the United States and Canada, we queried clerkship directors in Internal Medicine as part of the 2010 annual Clerkship Directors in Internal Medicine (CDIM) survey. In June 2010, CDIM surveyed its North American institutional members, which represent 110 of 143 Departments of Medicine in the US and Canada. RESULTS: Eight-two of 107 departments responded to the survey (77%). Seventy-five (91%) indicated that hospitalists served as teaching attendings at their teaching hospital. In twenty-two (27%) IM departments, 75% to 100% of students rotate with a hospitalist during their IM clerkships. Thirty-three (42%) departments report that students are directly supervised by in-house hospitalists during their nighttime call requirements. Sixty-six (81%) indicated that academic hospitalists hold educational administrative positions. Hospitalists are significantly less likely to have additional clinical commitment as compared to non-hospitalist teaching attendings (16% vs 53%, (χ 21df = 33.1; P < 0.0001). CONCLUSIONS: Hospitalists are involved in medical student education in the large majority of Departments of Internal Medicine throughout the US and Canada, reflecting the growth of hospital medicine nationally.

Interprofessional education in the internal medicine clerkship: results from a national survey.

PURPOSE: Growing data support interprofessional teams as an important part of medical education. This study describes attitudes, barriers, and practices regarding interprofessional education (IPE) in internal medicine (IM) clerkships in the United States and Canada. METHOD: In 2009, a section on IPE was included on the Clerkship Directors in Internal Medicine annual survey. This section contained 23 multiple-choice questions exploring both core and subinternship experiences. Data were analyzed using descriptive statistics and Rasch analysis. RESULTS: Sixty-nine of 107 institutional members responded to the survey (64% response rate). Approximately 68% of responding clerkship directors believed that IPE is important to the practice of IM. However, only 57% believed that it should become a part of the undergraduate clinical curriculum. The three most significant barriers to IPE in the IM clerkship were scheduling alignment, time in the existing curriculum, and resources in time and money. Although more than half of respondents felt IPE should be included in the clinical curriculum, 81% indicated that there was no formal curriculum on IPE in their core IM clerkship, and 84% indicated that there was no formal curriculum during IM subinternship rotations at their institution. CONCLUSIONS: There is limited penetration of IPE into one of the foundational clinical training episodes for medical students in Liaison Committee for Medical Education-accredited schools. This may be related to misperceptions of the relative value of these experiences and limitations of curricular time. Learning in and from successful models of interprofessional teams in clinical practice may help overcome these barriers.

Perillyl alcohol as a chemopreventive agent in N-nitrosomethylbenzylamine-induced rat esophageal tumorigenesis.

Perillyl alcohol (POH) is a monoterpene found in lavender, spearmint, and cherries. Phase I clinical trials with this agent have shown a favorable toxicity profile and preliminary data indicate some chemotherapeutic efficacy in advanced cancers. Animal studies have demonstrated the ability of POH to inhibit tumorigenesis in the mammary gland, liver, and pancreas. Although the precise mechanism of action is unclear, POH has been shown to inhibit the farnesylation of small G-proteins, including Ras, up-regulate the mannose-6-phosphate receptor, and induce apoptosis. Previous studies in our laboratory using the rat model of squamous cell carcinoma of the esophagus have shown that a specific Ha-ras codon 12 mutation is important for tumor promotion and progression. Given the limited toxicity of POH in humans, its proven efficacy in several animal models and its potential to inhibit Ha-ras farnesylation, we conducted an animal study to evaluate the efficacy of POH as a chemopreventive agent for squamous cell carcinoma of the esophagus. Male Fischer-344 rats were treated s.c. with 0.25 mg/kg b.w. of N-nitrosomethylbenzylamine three times a week for 5 weeks. Three days after the final carcinogen dose, they were started either on control diet or diets containing 0.5 or 1.0% POH. At 25 weeks, the animals were sacrificed, and esophageal tumors were counted. Animals fed either dose of POH showed a significant increase in dysplasia when compared with controls (P < 0.05) and a nonsignificant trend toward increased tumor multiplicity. Additionally, 1.0% POH did not affect Ras membrane localization. These data indicate that POH has a weakly promoting effect early in nitrosamine-induced esophageal tumorigenesis and suggest that POH may not be an effective chemopreventive agent for esophageal cancer in humans.

Piroxicam is an ineffective inhibitor of N-nitrosomethylbenzylamine-induced tumorigenesis in the rat esophagus.

Epidemiological studies indicate an association between the frequent use of nonsteroidal anti-inflammatory drugs and decreased risk for esophageal cancer. These studies suggest that limiting excess prostaglandin production, via inhibition of cyclooxygenase (COX)-mediated arachidonic acid metabolism, may be an important strategy for the prevention of this type of malignancy. N-Nitrosomethylbenzylamine (NMBA)-induced tumorigenesis in the rat esophagus is a model of human esophageal squamous cell carcinoma used for investigations of chemical carcinogenesis and for the evaluation of putative chemopreventive agents. In this study, we characterized COX-mediated arachidonic acid metabolism in NMBA-induced rat esophageal tumorigenesis by measuring COX-1 and COX-2 expression and prostaglandin E(2) production. In addition, we evaluated the ability of piroxicam, a potent COX inhibitor, to prevent postinitiation events of NMBA-induced tumorigenesis in the rat esophagus. After a 2-week acclimatization period, groups of 30 male F344 rats received s.c. injections of NMBA (0.5 mg/kg b.w.) three times/week for 5 weeks. Seventy-two h after the final NMBA treatment and for the remainder of the study, piroxicam was administered in the diet at 200 and 400 ppm. Twenty-five weeks after the initiation of NMBA treatment, we observed an elevation in COX mRNA and protein expression and prostaglandin E(2) production in NMBA-treated esophageal tissues compared with normal epithelium. However, these changes were associated with data indicating that a COX inhibitor is not preventive in NMBA-induced rat esophageal tumorigenesis. Administration of piroxicam in the diet produced no significant reductions in esophageal tumor incidence, multiplicity, or size. The reasons for the lack of effect are largely unknown but may be related to the inability of piroxicam to modulate other biochemical pathways involved in NMBA-induced tumorigenesis.