One change, different effects: the impacts of reducing clerkship length.

BACKGROUND: Medical school curricula are constantly evolving and change has potential positive and negative effects. At East Tennessee State University Quillen College of Medicine, a broader understanding of the effects of a curriculum change (reduction in clerkship length for one transitional year) was explored. METHODS: A broad, system-wide evaluation was used to evaluate impacts on all stakeholders. Curriculum management data, including qualitative and quantitative data and short-term and follow-up perspectives of stakeholders, were used for evaluation. RESULTS: Students evaluated the change positively. Academic performance in the transitional year was similar to the prior year. Differences in students' clerkship evaluations were not statistically significant. Clerkship directors were concerned that students' clinical experience suffered and noted that implementing changes was time consuming but recognized the benefits for students. Administrators dedicated a significant amount of time to planning the transitional year; however, the additional weeks at the beginning of fourth year made the scheduling process easier. CONCLUSION: This article demonstrates an overall positive result with this tool for curriculum change but also indicates the impacts differed across stakeholders. Knowledge gained from this experience can help other schools successfully anticipate challenges and prepare for a variety of outcomes in implementing necessary curriculum change.

Developing a Physician׳s Professional Identity Through Medical Education.

Professionalism represents a fundamental characteristic of physicians. Professional organizations have developed professionalism competencies for physicians and medical students. The aim of teaching medical professionalism is to ensure the development of a professional identity in medical students. Professional identity formation is a process developed through teaching principles and appropriate behavioral responses to the stresses of being a physician. Addressing lapses and critical reflection is an important part of the educational process. The "hidden curriculum" within an institution plays an important role in professional identity formation. Assessment of professionalism involves multiple mechanisms. Steps in remediating professionalism lapses include (1) initial assessment, (2) diagnosis of problems and development of an individualized learning plan, (3) instruction encompassing practice, feedback and reflection and (4) reassessment and certification of competence. No reliable outcomes data exist regarding the effectiveness of different remediation strategies.

A Career Exploration Program: An Effective Alternative to the Traditional Use of Faculty Advisors.

PROBLEM: Providing medical students with resources to make effective career choices is challenging for medical schools as career options outnumber the formal clinical rotations students can experience during their undergraduate education. APPROACH: In 2009, the authors introduced the Career Exploration (CE) courses into the required curriculum at the Quillen College of Medicine. This three-course sequence includes large-group sessions addressing broad issues related to career choices, small-group specialty interest groups, individual student self-assessments, assignments through which students receive individualized feedback, and individual student advising sessions. The overall objective of the course sequence is to involve all students in career planning from the beginning of medical school so as to help them make more informed career decisions. OUTCOMES: The authors used improvement in student satisfaction with career planning activities as a surrogate measure for the outcome of helping students make more informed career choices. Students evaluated the CE courses positively, and overall satisfaction scores averaged 4 (1 = poor to 5 = excellent). Scores on Association of American Medical Colleges Graduation Questionnaire items related to career planning showed improved student satisfaction from 2010 to 2015. NEXT STEPS: Succession planning for the first- and second-year career advisor is vital-as is faculty development for all clinical advisors to ensure that they have current information regarding both the curriculum and Match process, especially as residency selection becomes increasingly competitive. Enhancing the role of fourth-year students who serve as CE III mentors has the potential to prepare these students to be better teachers as residents.

Vitamin D insufficiency/deficiency management.

OBJECTIVES: In recent years, vitamin D deficiency has been recognized increasingly often in patients, and different supplement regimens have been prescribed to treat it. There has been no consensus on treatment regimens. This study was conducted to determine the management of vitamin D deficiency/insufficiency in outpatient adults in northeast Tennessee. METHODS: A retrospective record review was conducted in an internal medicine teaching clinic for patients seen from July 2007-July 2008 in Johnson City, Tennessee. A total of 626 nonelectronic charts listed with vitamin D measurements were used in the analysis. Data regarding the level of vitamin D, whether treatment was prescribed, dose and duration of treatment prescribed, and repeat levels of vitamin D, if any were ordered, were collected. Vitamin D deficiency was defined as levels <20 ng/mL; vitamin D insufficiency was defined as levels ranging from 20 to 29.9 ng/mL. RESULTS: Of the 626 patients, 325 (52%) were vitamin D deficient or insufficient. Of these 325 patients, 184 were given a low-dose supplement and 54 received a high-dose supplement. Eighty-seven were either not prescribed any replacement or the dose was unknown (not documented in the chart). The mean change in serum vitamin D levels was significantly different for the high dose compared with the low dose prescribed. There was no significant sex difference in response to the dose given. On average, those who were vitamin D deficient experienced a greater change than those who were insufficient and a greater change, on average, was observed in those who received a higher dose. CONCLUSIONS: Vitamin D deficiency and insufficiency are highly prevalent. Clinicians tended to prescribe a high dose of treatment for lower levels of serum vitamin D. The response is higher in high-dose treatment. Documentation regarding whether vitamin D supplements were given or the dose of supplements was given and followed up with repeat levels of vitamin D after treatment was poor.

Numismedica: health problems caused by coins.

Coins occasionally cause health problems. These have a wide range of presentations and can affect multiple organ systems. This article presents a review of the medical literature addressing health problems caused by coins. These problems can be categorized as follows: (1) respiratory manifestations of ingested coins, (2) gastrointestinal manifestations of swallowed coins, (3) systemic effects of swallowed coins, (4) clinical management of swallowed coins, (5) allergic manifestations of coin exposure, and (6) miscellaneous health issues related to swallowed coins.

Ethics committees in small, rural hospitals in East Tennessee.

BACKGROUND: Little research has been conducted to observe the impact that rural settings have on the structure and function of hospital ethics committees. Additionally, studies need to focus on ethics committees, as it is often the body which protects the values of the community as globalization increases. The purpose of this study is to provide an overview of ethics committees in rural hospitals in East Tennessee. METHODS: From a list of fifteen hospitals in East Tennessee, eleven hospitals in communities of 15,000 people or less were contacted, ten of which had functioning ethics committees. Phone calls were made to identify members of the ethics committee and interviews were set up with nine of the hospitals. A structured interview format was used to address the range of topics. Hospital size ranged from 6 to 230 beds. RESULTS: The most unique trait afforded to small hospital ethics committees was their ability to communicate effectively and efficiently due to their small size. The culture of the area subtly impacted the type of issues the committees faced as did the hospital network affiliation. CONCLUSIONS: While connection to a network provides abundant resources, small hospital size reduces the inefficiency created by the bureaucracy of larger hospitals and enhances communication. Ethics committees in rural hospitals are variably effective and contain a level of organization comparable to that of larger hospitals.

Prevalence of vitamin D deficiency and insufficiency in northeast Tennessee.

BACKGROUND: Vitamin D deficiency is increasingly being recognized as a highly prevalent and undertreated problem. This study was conducted to determine the prevalence of vitamin D deficiency/insufficiency in hospitalized adults in northeast Tennessee. METHODS: A prospective cohort study was conducted on 99 inpatients admitted to an internal medicine teaching service from July through October 2006 at a single private hospital in Johnson City, Tennessee. A single measurement of 25-hydroxyvitamin D was performed on all patients. RESULTS: Of the 99 patients, 53% were vitamin D deficient or insufficient (30% deficient with a level of <20 ng/mL and 23% insufficient with a level between 20-29.9 ng/mL). The highest frequency of deficiency was in females <50 years. CONCLUSION: Vitamin D deficiency is highly prevalent in all age groups and in both females and males in this population. Clinicians should consider measuring the vitamin D level of all inpatients on a routine basis.

Rural health professions education at East Tennessee State University: survey of graduates from the first decade of the community partnership program.

CONTEXT: To help meet rural Appalachian needs, and with initial support from the W.K. Kellogg Foundation, East Tennessee State University partnered with 2 counties to implement a health curriculum for nursing, public health, and medical students in a rural setting. The Community Partnerships Program 3-year longitudinal curriculum included theoretical, conceptual, and practice elements of the 3 disciplines incorporated into an experiential, inquiry-based, service-learning program. Interdisciplinary learning, problem solving, and reinforcement of career choices in medically underserved rural communities were emphasized. PURPOSE: To compare career choices, attitudes, and practice locations of Community Partnerships Program graduates with traditional graduates. METHODS: Surveys were mailed to Community Partnerships Program and traditional program graduates matriculating from 1992 to 2002 (response rates 58/84 and 72/168, respectively). FINDINGS: Community Partnerships Program graduates indicated a significantly greater interest in rural primary care, care for the underserved and interdisciplinary group collaboration, and were more likely to practice in rural locations than did their traditionally educated peers. Family, personal factors, and the availability of employment were major influences in determining the decision to choose a career in a rural location. Community Partnerships Program graduates indicated they were better prepared to work in interdisciplinary teams and were more likely to work in community-based programs and activities than did the traditional graduates. CONCLUSION: A program that enrolls students interested in rural health care and provides training in rural communities produces graduates who will practice in rural areas.

The financial value of services provided by a rural community health fair.

There has been little discussion in the literature regarding the financial value of the services provided to the participants in health fairs. This article examines the financial value of preventive services provided through a community health fair in an economically depressed area of southwest Virginia. Current Procedural Terminology codes were assigned to the services provided in order to estimate costs participants might incur for such services. An average 50-year-old man would have paid up to $320 to obtain commonly recommended preventive services available free at the fair. An average 50-year-old woman would have paid up to $495. Overall, over $58,000 in services were provided through the health fair. This community health fair provided preventive services that many participants otherwise might have found to be cost-prohibitive.

Plasmapheresis as an adjuvant therapy for hypertriglyceridemia-induced pancreatitis.

Hypertriglyceridemia is an uncommon cause of pancreatitis. A serum triglyceride level of more then 1000 to 2000 mg/dL is an identifiable risk factor. Interestingly, serum pancreatic enzyme levels may be normal or only minimally elevated in such cases. The reduction of triglyceride level to below 1000 mg/dL effectively prevents further episodes of pancreatitis. The mainstay of treatment for the hypertriglyceridemia associated with pancreatitis includes dietary restriction of fat and administration of lipid-lowering agents. It is thought that within 24 to 48 hours of the onset of pancreatitis, in the majority of patients, triglyceride levels fall rapidly as a result of fasting status, as the absorption of chylomicrons to the blood is cut off. Experiences with plasmapheresis are limited. We report a case of hypertriglyceridemic necrotizing pancreatitis with mildly elevated amylase and lipase, treated successfully with plasmapheresis.

Chinese red rice-induced myopathy.

A middle-aged man presented with joint pain and muscle weakness that had begun 2 months before presentation. Three months before presentation, he had begun to take the herbal preparation Chinese red rice. Laboratory testing revealed a moderately elevated creatine phosphokinase level. Symptoms and laboratory abnormalities resolved with discontinuation of the Chinese red rice. Eight months later, he resumed the product and his creatine phosphokinase level rose again. Lovastatin is a naturally occurring component of Chinese red rice and was the probable cause of his myopathy.

Septic discitis: an important cause of back pain.

A 65-year-old man with a 3-month history of intractable back pain had previously received cytotoxic curative chemotherapy for non-Hodgkin's lymphoma. His postchemotherapy course had been complicated by febrile neutropenia, recurrent coagulase-negative staphylococcal bacteremia, and gastrostomy site infections. He was admitted with severe intractable lower back pain requiring high doses of intravenous narcotic analgesia. Magnetic resonance imaging of the spine was highly suggestive of disk infection. Fluoroscopically guided needle aspiration of the disk space was confirmatory, and both tissue and blood cultures were positive for coagulase-negative Staphylococcus species. Treatment included i.v. vancomycin and oral levofloxacin. The most common organism causing disk space infection is Staphylococcus aureus. but Staphylococcus epidermis should be considered in immunocompromised patients. Septic discitis is an important differential diagnosis of back pain and should be considered in any clinical situation associated with bacteremia.

Absolute versus relative values: effects on family practitioners and psychiatrists.

BACKGROUND: Research demonstrates that religious values clearly impact on the judgments made by physicians and their patients. One basic dichotomy--belief in ethical values that do not change (absolute values) versus belief in values that change depending on the situation (relative values)--has recently been experimentally associated with different ethical decision-making patterns. METHODS: An anonymous, randomized, national survey and 1-week response prompt with 1-month follow-up mailing as necessary were distributed to nationwide samples of board-certified American family practitioners and psychiatrists. Physicians answered descriptive questions and standardized personality assessments and responded to three vignettes describing ethically sensitive scenarios concerning birth control medication for sexually active single women, euthanasia, and abortion. RESULTS: Response rates were 34% for psychiatrists and 38% for family practitioners. Family practitioners and absolutists were significantly more supportive of religious activities and had more religious parents than psychiatrists and relativists. Furthermore, family practitioners and absolutists were less approving of the vignettes than other groups. CONCLUSION: Family practitioners were more supportive of religious activities than psychiatrists as reported in previous research. The absolute versus relative value dichotomy is a useful concept in examining physician attitudes as they affect health care and personal behavior. However, questions concerning place of worship attendance and giving in addition to specific religious value labels may be more efficient experimentally. Physicians should be aware of their own biases in discussions with patients, families, and other health care providers.

A Model Rural Health Orientation Course Using Interdisciplinary, Community Oriented, Inquiry Based Strategies.

Introduction to Rural Health was developed as the introductory course for the Community Partnerships in Health Education - a new curriculum educating students using interdisciplinary, community oriented, and inquiry based strategies. Medical students, nursing students, and public health students participated in an elective curriculum designed to teach interdisciplinary groups of students to deliver primary health care in under-served communities. The curriculum began with an intensive one-week course designed to introduce students to the community, its people, their health care needs, and the process of working in interdisciplinary groups. The course was taught using a variety of community based activities. Student evaluations indicated that students strongly agreed that the course objectives were met using this nontraditional methodology. Qualitative analysis indicated that students regarded the team-building aspects of the course as the most influential. Community members indicated a high level of satisfaction with their input in the developmental process and with the extent to which community resources and interests were included.