Reimagining Core Entrustable Professional Activities for Undergraduate Medical Education in the Era of Artificial Intelligence.

The proliferation of generative artificial intelligence (AI) and its extensive potential for integration into many aspects of health care signal a transformational shift within the health care environment. In this context, medical education must evolve to ensure that medical trainees are adequately prepared to navigate the rapidly changing health care landscape. Medical education has moved toward a competency-based education paradigm, leading the Association of American Medical Colleges (AAMC) to define a set of Entrustable Professional Activities (EPAs) as its practical operational framework in undergraduate medical education. The AAMC's 13 core EPAs for entering residencies have been implemented with varying levels of success across medical schools. In this paper, we critically assess the existing core EPAs in the context of rapid AI integration in medicine. We identify EPAs that require refinement, redefinition, or comprehensive change to align with the emerging trends in health care. Moreover, this perspective proposes a set of "emerging" EPAs, informed by the changing landscape and capabilities presented by generative AI technologies. We provide a practical evaluation of the EPAs, alongside actionable recommendations on how medical education, viewed through the lens of the AAMC EPAs, can adapt and remain relevant amid rapid technological advancements. By leveraging the transformative potential of AI, we can reshape medical education to align with an AI-integrated future of medicine. This approach will help equip future health care professionals with technological competence and adaptive skills to meet the dynamic and evolving demands in health care.

Right ventricular failure predicted from right bundle branch block: cardiac magnetic resonance imaging validation.

BACKGROUND: Right ventricular (RV) failure has proven to be independently associated with adverse outcomes. Electrocardiographic parameters assessing RV function are largely unknown, making echocardiography the first line for RV function assessment. It is however, limited by geometrical assumptions and is inferior to cardiac magnetic resonance imaging (CMRI) which is widely regarded as the most accurate tool for assessing RV function. METHODS: We seek to determine the correlation of ECG parameters of right bundle branch block (RBBB) with RV ejection fraction (EF) and RV dimensions using the CMRI. QRS duration, R amplitude and R' duration were obtained from precordial lead V1; S duration and amplitude were obtained from lead I and AVL. RV systolic dysfunction was defined as RV EF <40%. RV systolic dysfunction group (mean EF of 24±10%) were compared with normal RV systolic function group which acted as control (mean EF of 48±8%). CMRI and ECG parameters were compared between the two groups. Rank correlations and scatter diagrams between individual CMRI parameters and ECG parameters were done using medcalc for windows, version 12.5. Sensitivity, specificity and area under the curve (AUC) were calculated. RESULTS: RV systolic dysfunction group was found to have larger RV end systolic volumes (90±42 vs. 59±40 mL, P=0.02). ECG evaluation of RV dysfunction group revealed longer R' duration (103±22 vs. 84±18 msec, P=0.005) as compared to the control group. The specificity of R' duration >100 msec to detect RV systolic dysfunction was found to be 93%. R' duration was found to have an inverse correlation with RV EF (r=-0.49, P=0.007). CONCLUSIONS: Larger RV end systolic volumes seen with RV dysfunction can affect the latter part of right bundle branch leading to prolonged R' duration. We here found prolonged R' duration in lead V1 to have a highly specific inverse correlation to RV systolic function. ECG can be used as an inexpensive tool for RV function assessment and should be used alongside echocardiography to evaluate RV dysfunction when CMRI is not available.

Estimating the Net Career Income of a Geriatrician and a Nurse Practitioner: Still Want to Be a Doctor?

OBJECTIVES: With a continual shortage of geriatricians, adult-gerontology primary care nurse practitioners have assumed a greater role in the delivery of outpatient care for older adults. Given the long duration of physician training, the high cost of medical school, and the lower salaries compared with subspecialists, the financial advantage of a career as a geriatrician as opposed to a nurse practitioner is uncertain. This study compares the estimated career earnings of a geriatrician and an adult-gerontology primary care nurse practitioner. METHODS: We used a synthetic model of estimated net earnings during a 43-year career span for a 22-year old person embarking on a career as a geriatrician versus a career as an adult-gerontology primary care nurse practitioner. We estimated annual net income and net retirement savings using different annual compound rates and calculated the financial impact of forgiving medical student loans, shortening the duration of physician training, and reinstituting the practice pathway for geriatric medicine certification. RESULTS: Career net incomes for the geriatrician did not match the nurse practitioner until almost age 40. At 65 years of age, the difference between the geriatrician and nurse practitioner was 30.6%. A higher annual compound rate was associated with an even smaller percentage difference. Combining all three health policy interventions lowered the break-even age to 28 and more than doubled the difference in career earnings. CONCLUSIONS: Small estimated differences in net career earnings exist between geriatricians and adult-gerontology primary care nurse practitioners. Health policy interventions had a dramatic positive effect on geriatricians' lifetime net earnings in calculated estimates.

Just-in-time learning is effective in helping first responders manage weapons of mass destruction events.

BACKGROUND: Chemical, biologic, radiologic, nuclear, and explosive (CBRNE) incidents require specialized training. The low frequency of these events leads to significant skill decay among first responders. To address skill decay and lack of experience with these high-impact events, educational modules were developed for mobile devices to provide just-in-time training to first responders en route to a CBRNE event. This study assessed the efficacy and usability of the mobile training. METHODS: Ninety first responders were randomized to a control or an intervention group. All participants completed a pretest to measure knowledge of CBRNE topics. The intervention group then viewed personal protective equipment and weapons of mass destruction field management videos as an overview. Both groups were briefed on a disaster scenario (chemical nerve agent, radiologic, or explosives) requiring them to triage, assess, and manage a patient. Intervention group participants watched a mobile training video corresponding to the scenario. The control group did not receive prescenario video training. Observers rated participant performance in each scenario. After completing the scenarios, all participants answered a cognitive posttest. Those in the intervention group also answered a questionnaire on their impressions of the training. RESULTS: The intervention group outperformed the control group in the explosives and chemical nerve agent scenarios; the differences were statistically significant (explosives, mean of 26.32 for intervention and 22.85 for control, p < 0.01; nerve agent, mean of 23.14 for intervention and 16.61 for control, p < 0.01). There was no statistically significant difference between the groups in the radiologic scenario (mean, 12.7 for intervention and 11.8 for control; p = 0.51). The change in pretest to posttest cognitive scores was significantly higher in the intervention group than in the control group (t = 3.28, p < 0.05). CONCLUSION: Mobile just-in-time training improved first-responder knowledge of CBRNE events and is an effective tool in helping first responders manage simulated explosive and chemical agent scenarios. LEVEL OF EVIDENCE: Therapeutic/care management study, level II.

It is time to consider cultural differences in debriefing.

SUMMARY STATEMENT: Debriefing plays a critical role in facilitated reflection of simulation after the experiential component of simulation-based learning. The concept of framing and reflective learning in a debriefing session has emanated primarily from Western cultures. However, non-Western cultures have significant characteristics that manifest themselves in teaching and learning practices substantially different from Western cultures. We need to consider how to balance standardization in debriefing with a culture-sensitive interpretation of simulation-based learning so that learners receive the maximum benefit from debriefing sessions. Our goal was to raise awareness of cultural differences and stimulate work to make progress in this regard.

The accuracy of the electrocardiogram during exercise stress test based on heart size.

BACKGROUND: Multiple studies have shown that the exercise electrocardiogram (ECG) is less accurate for predicting ischemia, especially in women, and there is additional evidence to suggest that heart size may affect its diagnostic accuracy. HYPOTHESIS: The purpose of this investigation was to assess the diagnostic accuracy of the exercise ECG based on heart size. METHODS: We evaluated 1,011 consecutive patients who were referred for an exercise nuclear stress test. Patients were divided into two groups: small heart size defined as left ventricular end diastolic volume (LVEDV) <65 mL (Group A) and normal heart size defined as LVEDV ≥65 mL (Group B) and associations between ECG outcome (false positive vs. no false positive) and heart size (small vs. normal) were analyzed using the Chi square test for independence, with a Yates continuity correction. LVEDV calculations were performed via a computer-processing algorithm. SPECT myocardial perfusion imaging was used as the gold standard for the presence of coronary artery disease (CAD). RESULTS: Small heart size was found in 142 patients, 123 female and 19 male patients. There was a significant association between ECG outcome and heart size (χ(2) = 4.7, p = 0.03), where smaller hearts were associated with a significantly greater number of false positives. CONCLUSIONS: This study suggests a possible explanation for the poor diagnostic accuracy of exercise stress testing, especially in women, as the overwhelming majority of patients with small heart size were women.

Exercise testing in the presence of complete heart block.

A 28-yr-old female presented for preoperative evaluation. The resting ECG revealed sinus arrhythmia with complete heart block with a junctional escape rhythm and a ventricular rate of 43 bpm. The patient was in no apparent distress, and resting blood pressure was 80/50 mm Hg. Physical examination was largely unremarkable, with the exception of a soft, nontender, movable abdominal mass. The patient complained of mild dyspnea with stair climbing, but she was otherwise asymptomatic. Although high-grade atrioventricular (AV) block is considered a relative contraindication for exercise testing, this patient was referred for an exercise ECG stress test to assist in determining whether a electronic pacemaker or other therapy was necessary. A symptom-limited maximal ECG treadmill test was performed using the Bruce protocol. The resting HR before the test was 47 bpm, and resting blood pressure was 70/50 mm Hg. Beginning with the first stage of the test, sinus rhythm with a first-degree AV block was observed. The patient achieved 10.2 METs, with an HRpeak of 122 bpm and a peak blood pressure of 122/70 mm Hg. No ectopy was noted during exercise, no ST segment changes occurred during exercise or recovery, and the patient remained asymptomatic. The test was terminated because of the patient's inability to keep pace with the treadmill. On the basis of these results, no medical therapy or electronic pacemaker was recommended at this time, and the patient was permitted to undergo surgery for uterine fibroid tumors. This case illustrates that although complete heart block is a relative contraindication to exercise testing in some patients, the benefits of testing outweigh the risks.

Fragmented left sided QRS in absence of bundle branch block: sign of left ventricular aneurysm.

BACKGROUND: A left ventricular aneurysm (LVA) occurs between 3.5% and 9.4% of all cases of acute myocardial infarction. A fragmented left sided QRS (RSR; pattern or its variant RSr;, rSR;, or rSr;) without evidence of bundle branch block (QRS duration

Repetitive monomorphic ventricular tachycardia associated with exercise--a case report.

The case of a 45-year-old man suffering from a catecholamine-sensitive ventricular tachycardia originating from the right ventricular outflow tract is reported. The authors describe a novel noninvasive treatment strategy for the management of this patient.

Usefulness of P-wave morphology during submaximal treadmill exercise to predict coronary artery disease.

Standard electrocardiographic criteria for exercise testing require near maximal exertion and fail to detect ischemia in the presence of previous infarction or conduction or repolarization abnormalities, in women, or in the presence of certain drugs. Changes in P-wave morphology have been suggested as having diagnostic utility; however, no specific criteria exist, and it is not clear which changes are most useful. This investigation evaluated the ability to detect the presence of coronary artery disease by examining changes in P-wave morphology during exercise. A group of 123 consecutive patients underwent maximum (symptom-limited) exercise nuclear stress tests. The electrocardiograms at rest, 2 minutes of exercise, 50% of maximum exercise time, maximum exercise, and 3 minutes of recovery were analyzed for the duration of the P wave in lead II, the duration of the terminal negative component of the P wave in lead V1, the amplitude of the terminal negative component of the P wave in lead V1, and the duration of the P wave in lead V5. These variables were then analyzed for their relation to the presence of perfusion defects. Of all the P-wave criteria tested, a change in amplitude of the negative component of the P wave in lead V1 from at rest to 50% of maximum exercise time of <0.025 mV was the most predictive of coronary artery disease.

Gatifloxacin induced torsades de pointes.

The authors present an unusual case of torsades de pointes in an elderly woman treated with intravenous gatifloxacin antibiotic therapy.

New-onset congestive heart failure secondary to a "huge" right atrial mass--a case report.

Transesophageal echocardiography is a useful adjunct to other diagnostic modalities in uncovering the etiology of congestive heart failure. The authors describe the case of a 75-year-old woman with a 4-week history of progressive congestive heart failure, in whom transesophageal echocardiography played a critical role in the diagnosis of a right atrial mass, accounting for this patient's constellation of symptoms.

Correction of AV-nodal block in a 27-year-old man with severe obstructive sleep apnea--a case report.

A 27-year-old morbidly obese man diagnosed with severe obstructive sleep apnea (OSA) and experiencing significant ventricular asystoles at times exceeding 8 seconds, during polysomnography. The bradyarrhythmias were successfully corrected with the application of a nasal continuous positive airway pressure (CPAP) mask. Follow-up 24-hour ambulatory Holter monitoring without the aid of a nasal CPAP mask and repeat polysomnography with a CPAP mask after several weeks of continuous CPAP therapy during sleep revealed no evidence of ventricular asystole, despite no change in the patient's body mass index. We discuss several mechanisms explaining the findings in this particular patient.

Amiodarone-induced torsade de pointes during bladder irrigation: an unusual presentation--a case report.

The authors present a case of early (within 4 days) development of torsade de pointes (TdP) associated with oral amiodarone therapy. Consistent with other reports this case of TdP occurred in the context of multiple exacerbating factors including hypokalemia and digoxin excess. Transient prolongation of the QT during bladder irrigation prompted the episode of TdP. It is well known that bradycardia exacerbates acquired TdP. The authors speculate that the increased vagal tone during bladder irrigation, a vagal maneuver, in the context of amiodarone therapy resulted in amiodarone-induced proarrhythmia. In the absence of amiodarone therapy, a second bladder irrigation did not induce TdP despite hypokalemia and hypomagnesemia.

Cardioversion of atrial fibrillation with ibutilide: when is it most effective?

BACKGROUND: Atrial fibrillation (AF) is found in 1% of persons above the age of 60 years. More than 5% of the population older than 69 years and about 14% of octogenarians are at risk for this arrhythmia. It is estimated that 1.5 to 3 million persons in the United States alone suffer from AF. The public health implications and attendant morbidity are a significant drain on our health care system. HYPOTHESIS: The purpose of this study was to determine the clinical and echocardiographic predictors of success in converting AF of > or = 24 h duration. METHODS: Demographic and clinical and echocardiographic parameters of 101 patients with recent onset AF (> 24 h) who received ibutilide were studied. RESULTS: Of 101 patients, 56 (55%) converted to sinus rhythm. Age, gender, hypertension, diabetes mellitus, left ventricular ejection fraction (< or = 35%), congestive heart failure, and previous medication for rate control had no significant effect on the conversion rate. Conversion rate was only 30% (9/30 patients) in the presence of an enlarged left atrium (LA > or = 5 cm) and 37.7% (23/61 patients) in the presence of mitral valve disease (MVD), whereas the conversion rate was 82.5% (33/40 patients) in the absence of MVD and 85% (29/34 patients) in the absence of both enlarged LA and MVD (p = <0.001). Patients with coronary artery disease (CAD) also exhibited a significantly greater response to ibutilide than patients without CAD (77 vs. 46%, p-value 0.005). CONCLUSION: As a therapy for cardioversion of AF, ibutilide is most effective in a selected subgroup patients, such as in patients with CAD and in patients without MVD and/or markedly enlarged left atrium.