SHARP (SHort Answer, Rationale Provision): A New Item Format to Assess Clinical Reasoning.

PROBLEM: Many non-workplace-based assessments do not provide good evidence of a learner's problem representation or ability to provide a rationale for a clinical decision they have made. Exceptions include assessment formats that require resource-intensive administration and scoring. This article reports on research efforts toward building a scalable non-workplace-based assessment format that was specifically developed to capture evidence of a learner's ability to provide a justification for a clinical decision that they had made. APPROACH: The authors developed a 2-step item format called SHARP (SHort Answer, Rationale Provision), referring to the 2 tasks that comprise the item. In collaboration with physician-educators, the authors integrated short-answer questions into a patient medical record-based item starting in October 2021 and arrived at an innovative item format in December 2021. In this format, a test-taker interprets patient medical record data to make a clinical decision, types in their response, and pinpoints medical record details that justify their answers. In January 2022, a total of 177 fourth-year medical students, representing 20 U.S. medical schools, completed 35 SHARP items in a proof-of-concept study. OUTCOMES: Primary outcomes were item timing, difficulty, reliability, and scoring ease. There was substantial variability in item difficulty, with the average item answered correctly by 44% of students (range, 4%-76%). The estimated reliability (Cronbach α) of the set of SHARP items was 0.76 (95% CI, 0.70-0.80). Item scoring is fully automated, minimizing resource requirements. NEXT STEPS: A larger study is planned to gather additional validity evidence about the item format. This study will allow comparisons between performance on SHARP items and other examinations, the examination of group differences in performance, and possible use cases for formative assessment purposes. Cognitive interviews are also planned to better understand the thought processes of medical students as they work through the SHARP items.

Exploring the Validity Based on Internal Structure of the Oldenburg Burnout Inventory - Medical Student (OLBI-MS).

CONSTRUCT: The study gathers validity evidence for the use of the Oldenburg Burnout Inventory - Medical Student (OLBI-MS), a 16-item scale used to measure medical student burnout. The 16 items on the OLBI-MS are split to form two subscales, disengagement and exhaustion. BACKGROUND: Medical student burnout has been empirically linked to several detrimental professional and personal consequences. In recognition of the high prevalence of medical student burnout, one recommendation has been to regularly measure burnout using standardized measures that have strong validity evidence for their intended use. The OLBI-MS, a frequently used measure of medical student burnout, was adapted from the Oldenburg Burnout Inventory (OLBI). The OLBI has been studied in many occupational settings and been found to have a two-factor solution in majority of these populations, but there is limited validity evidence available that supports the use of the OLBI-MS subscales in a medical student population. APPROACH: Two years of Association of American Medical College Year 2 Questionnaire data (n = 24,008) were used in the study for a series of exploratory and confirmatory factor analyses. The data from the first year (n = 11,586) was randomly split into a confirmatory and exploratory sample, with the data from the second year (n = 12,422) used as a secondary confirmatory sample. Because the questionnaire is administered to medical students during their second year of undergraduate medical education, we consider this a study as providing validity evidence specifically for the measure's use with that population. FINDINGS: The two-factor structure of the OLBI-MS was not empirically supported in the second year medical-student population. Several of the items had low inter-item correlations and/or moderate correlations with unexpected items. Three modified versions of the OLBI-MS were tested using subsets of the original items. Two of the modified versions were adequate statistical explanations of the relationships in the data. However, it is unclear if these revised scales appropriately measure all aspects of the construct of burnout and additional validity evidence is needed prior to their use. CONCLUSIONS: The use of the OLBI-MS is not recommended for measuring second-year medical student burnout. It is unclear if the OLBI-MS is appropriate for medical students at all, or if different measures are necessary at different stages in a medical student's professional development. Additional research is needed to either improve the OLBI-MS or use it as a foundation for a new measure.Supplemental data for this article is available online at at www.tandfonline.com/htlm .

COP2ING With a New Normal: Navigating the Return to Society for Older Adults With Dementia and Their Caregivers.

COVID-19 has stressed the healthcare system in ways our society has not seen before. Less visibly, elderly patients and their caregivers have been stressed as well, both by the virus and by the public health measures required to slow its spread. After months of isolating, patients with dementia and their caregivers are worried about reentering a society with different rules and expectations. Although an extremely complex topic, the re-entry of individuals with cognitive impairment back into society is critical for both the wellbeing of the person as well as the caregiver. Successful re-entry into society will vary based on a person's interests and baseline cognition, however, the ability to participate in activities and events that previously provided joy and stimulation is the first step. This paper, written by practicing geriatricians and palliative clinicians, offers some concrete counseling strategies and tips for caregivers to help navigate re-entry into society with their loved ones.

Investigation of answer changes on the USMLE® Step 2 Clinical Knowledge examination.

BACKGROUND: Examinees often believe that changing answers will lower their scores; however, empirical studies suggest that allowing examinees to change responses may improve their performance in classroom assessments. To date, no studies have been able to examine answer changes during large scale professional credentialing or licensing examinations. METHODS: In this study, we expand the research on answer changes by analyzing responses from 27,830 examinees who completed the Step 2 Clinical Knowledge (CK) examination between August of 2015 and August of 2016. RESULTS: The results showed that although 68% of examinees changed at least one item, the overall average number of changes was small. Among the examinees who changed answers, approximately 45% increased their scores and approximately 28% decreased their scores. On average, examinees spent shortest time on the item changes from wrong to right and they were more likely to change their scores from wrong to right than right to wrong. CONCLUSIONS: Consistent with previous studies, these findings support the beneficial effects of answer changes in high-stakes medical examinations and suggest that examinees who are overly cautious about changing answers may put themselves at a disadvantage.

Testing and evaluation: the present and future of the assessment of medical professionals.

The aim of this review is to highlight recent and potential future enhancements to the United States Licensing Examination (USMLE) program. The USMLE program is co-owned by the National Board of Medical Examiners (NBME) and the Federation of State Medical Boards. The USMLE includes four examinations: Step 1, Step 2 Clinical Knowledge, Step 2 Clinical Skills, and Step 3; every graduate of Liaison Committee on Medical Education-accredited allopathic medical schools and all international medical graduates must pass this examination series to practice medicine in the United States. From 2006 to 2009, the program underwent an indepth review resulting in five accepted recommendations. These recommendations have been the primary driver for many of the recent enhancements, such as an increased emphasis on foundational science and changes in the clinical skills examination, including more advanced communication skills assessment. These recommendations will continue to inform future changes such as access to references (e.g., a map of metabolic pathways) or decision-making tools for use during the examination. The NBME also provides assessment services globally to medical schools, students, residency programs, and residents. In 2015, >550,000 assessments were provided through the subject examination program, NBME self-assessment services, and customized assessment services.

Casein phosphopeptides drastically increase the secretion of extracellular proteins in Aspergillus awamori. Proteomics studies reveal changes in the secretory pathway.

BACKGROUND: The secretion of heterologous animal proteins in filamentous fungi is usually limited by bottlenecks in the vesicle-mediated secretory pathway. RESULTS: Using the secretion of bovine chymosin in Aspergillus awamori as a model, we found a drastic increase (40 to 80-fold) in cells grown with casein or casein phosphopeptides (CPPs). CPPs are rich in phosphoserine, but phosphoserine itself did not increase the secretion of chymosin. The stimulatory effect is reduced about 50% using partially dephosphorylated casein and is not exerted by casamino acids. The phosphopeptides effect was not exerted at transcriptional level, but instead, it was clearly observed on the secretion of chymosin by immunodetection analysis. Proteomics studies revealed very interesting metabolic changes in response to phosphopeptides supplementation. The oxidative metabolism was reduced, since enzymes involved in fermentative processes were overrepresented. An oxygen-binding hemoglobin-like protein was overrepresented in the proteome following phosphopeptides addition. Most interestingly, the intracellular pre-protein enzymes, including pre-prochymosin, were depleted (most of them are underrepresented in the intracellular proteome after the addition of CPPs), whereas the extracellular mature form of several of these secretable proteins and cell-wall biosynthetic enzymes was greatly overrepresented in the secretome of phosphopeptides-supplemented cells. Another important 'moonlighting' protein (glyceraldehyde-3-phosphate dehydrogenase), which has been described to have vesicle fusogenic and cytoskeleton formation modulating activities, was clearly overrepresented in phosphopeptides-supplemented cells. CONCLUSIONS: In summary, CPPs cause the reprogramming of cellular metabolism, which leads to massive secretion of extracellular proteins.

Update on teaching in the long-term care setting.

Since the advent of the teaching nursing home, made formal in the 1980s, long-term care has been used to teach geriatric medicine. Despite this, national surveys have indicated a need for more training during residency to facilitate the appropriate care for the frail long-term care patient population. In addition to medical knowledge, the long-term care site is appropriate for teaching the Accreditation Council of Graduate Medical Education's core competencies of "practice-based learning and improvement," "interpersonal and communication skills," and "systems-based practice." Program planners should emphasize opportunities for students to demonstrate their skill in one of these competencies.

Age as a deciding factor in the consideration of futility for a medical intervention in patients among internal medicine physicians in two practice locations.

OBJECTIVES: This study explores physicians' concepts of futility and use of age as a deciding factor in considering medical futility in clinical interventions. DESIGN: Survey. SETTING: Five academic hospitals in the United States. PARTICIPANTS: Participants were 355 internal medicine physicians, including 162 residents, 98 fellows, and 95 attending physicians. MEASUREMENT: Anonymous questionnaire in which respondents were asked to define futility and to rate patient scenarios as futile or not, unaware that these were pairs of patient scenarios with similar clinical severity and treatment, but different age. RESULTS: Forty-five percent (n = 159) of physicians used the most accepted definition of futility in the literature: "a therapy that will not benefit the patient in attaining a specific goal." Physicians rated patient scenarios as futile for 58% of elder (> or =65 years) and for 59% of nonelder (<65 years) cases (P = .21). By training level, resident physicians rated more elder cases as futile (60%) than fellow/attending physicians (56%, P = .03). Rating of medical futility did not differ by practice location (59% in Missouri and 59% in Puerto Rico, P = .13). CONCLUSION: Physicians did not use age as a factor in deciding the futility of a medical intervention. In patient scenarios with comparable clinical severity of illness, medical interventions were similarly rated as futile in elder and nonelder persons. Less-experienced physicians (residents) were more likely to rate elder cases as futile compared with experienced physicians (attending/fellows).

A competency-based medical student curriculum targeting key geriatric syndromes.

The University of Miami Miller School of Medicine (UMMSM) has developed and implemented a competency-based undergraduate medical education (UME) curriculum that targets 61 learning objectives for three geriatric syndromes: dementia, falls, and delirium. This curriculum redesign changed the educational focus from what is taught to what is learned. Students complete 13 different competency assessments throughout their four years of training and are required to meet specific performance standards. Documentation of competency is now provided for 600 students annually. This paper describes the design, development, implementation, and evaluation of this curriculum, reviews our data-driven curriculum quality improvement efforts, and discusses the challenges to translating student competency into routine practice.

Atypical antipsychotics for the treatment of delirious elders.

BACKGROUND: Delirium occurs frequently in hospitalized patients and is reported to occur at a rate of 10% to 40% in hospitalized elderly patients. The gold standard of treatment is to treat the underlying cause of delirium and use high-potency antipsychotics such as haloperidol to target the behavioral disturbances. Since the development of atypical antipsychotics, many psychiatric conditions that were previously only treatable using high-potency antipsychotics may now be managed with the atypical agents. This review will examine the current literature on atypical antipsychotics and summarize the results from published trials in order to evaluate the efficacy and potential benefits of atypical antipsychotics for the treatment of delirium in the elderly population. METHODS: A search of the published literature was conducted using MEDLINE and PubMed. The PubMed search was limited to articles that were (1) written in the English language, (2) focused on human subjects above age 65, and (3) were in the format of review articles, randomized controlled trials (RCTs), clinical trials, or meta-analyses. The initial PubMed search was conducted in March 2006 with follow-up investigations in April 2006 and July 2007. RESULTS: Risperidone, the most thoroughly studied atypical antipsychotic, was found to be approximately 80% to 85% effective in treating the behavioral disturbances of delirium at a dosage of 0.5 to 4 mg daily. Studies of olanzapine indicated that it was approximately 70% to 76% effective in treating delirium at doses of 2.5 to 11.6 mg daily. Very few studies have been conducted using quetiapine; it also appears to be a safe and effective alternative to high-potency antipsychotics. In comparison to haloperidol, the frequency of adverse reactions and side effects was found to be much lower with the use of atypical antipsychotic medications. In the limited number of trials comparing atypical antipsychotics to haloperidol, haloperidol consistently produced a higher rate (an additional 10% to 13%) of extrapyramidal side effects. CONCLUSIONS: A review of current literature supports the conclusion that atypical antipsychotic medications demonstrate similar rates of efficacy as haloperidol for the treatment of delirium in the elderly patient, with a lower rate of extrapyramidal side effects. There is limited evidence of true efficacy, since no double-blind placebo trials exist.

The demented elder with insomnia.

Elders with dementia experience a high prevalence of disordered sleep that can present as agitation, sleep-disordered breathing, or excessive daytime napping. One must also consider broader contextual issues in the evaluation and treatment of the demented elder with insomnia, such as the caregiver and staff, as well as the setting in which the patient resides. The treatment approach to the demented elder with insomnia is difficult and largely based on clinical experience rather than a broad evidence base. Using a "less is better" approach in attempting nonpharmacologic interventions before initiating a trial of drug therapy is the optimal first step.

Comprehensive geriatric assessment.

This paper presents the essentials of the comprehensive assessment of the geriatric patient.

Older patients presenting to a county hospital ED after a fall: missed opportunities for prevention.

Little is known about the characteristics of elderly persons who present to an ED after a fall or about the nature of the care received for the fall itself. We identified elders presenting to a large urban United States ED after a fall, determined risk factors that may have contributed to the fall, and assessed the extent to which falls were addressed in the ED setting. One hundred seventeen fallers were identified. Nearly half were aged 80 years or older. After age, polypharmacy was the most common fall risk factor, followed by more than 1 contributing medical condition and cognitive impairment. Fall risk factors differed significantly for older compared with younger subgroups. More than half (57%) who had fallen were admitted. Of the remainder who fell and were discharged, more than half were scheduled for follow-up of their fall-related injury only, with no follow-up scheduled to address prevention of future falls. In summary, elders who present to an ED after having fallen have a variety of risk factors for falls that can be addressed to reduce their risk of future falls and injury; however, many may not receive such follow-up care. There must be increased awareness among ED providers of the need for a medical evaluation of a fall. Randomized trials evaluating the effect of a focused fall risk factor assessment after presentation to the ED may be warranted.

BMI and low bone mass in an elderly male nursing home population.

INTRODUCTION: Little is known about osteoporosis in institutionalized older adults. Risk factors such as low body mass index (BMI) have been investigated in female populations, but remain understudied in men. The objective of this study was to examine characteristics of older men residing in a nursing home who received bone mineral density evaluations. METHODS: 57 male Miami Veterans Affairs Medical Center (VAMC) nursing home residents were screened for osteoporosis using a peripheral dual X-ray (pDXA) technique. T-scores were categorized into three groups: normal (0 > -1); osteopenic (-1 to -2.49); osteoporotic (< -2.5). RESULTS: Average age was 76.2 years (standard deviation = 11.5; range: 48-100). T-scores indicated that 37.3% of the population was normal, 35.6% osteopenic, and 27.1% osteoporotic. 35.6% of patients had normal BMIs, 3.4% were underweight, 47.5% were overweight, and 13.6% were considered obese. There was a high prevalence of overweight and obese individuals (61.1%) in the osteopenic and osteoporotic groups. CONCLUSION: As expected, there was a high prevalence of low bone mass in our population (62%). However, overweight and obese men were more likely to have osteoporosis and osteopenia, contrary to literature and clinical knowledge. This finding may be partially explained by the prevalence of sedentary lifestyle and relative lack of weight-bearing activity in this group of men.