Bridging medical education goals and health system outcomes: An instrumental case study of pre-clerkship students' improvement projects.

INTRODUCTION: Many medical schools engage students in health system improvement (HSI) efforts. Evaluation of these efforts often focuses on students' learning outcomes and rarely considers the impact on health systems, despite the significant commitment health systems make to these efforts. Our study identified and evaluated system-level outcomes of pre-clerkship medical students' engagement in HSI efforts. METHODS: We used an instrumental case study approach to examine the effects of pre-clerkship medical students' engagement in HSI projects as part of a 15-month experiential curriculum. We extracted data from 53 project summaries and posters completed during the 2017-18 academic year and follow-up survey data collected in May 2019 from physician coaches and health system professionals who mentored students, contributed to these projects, and worked in the clinical microsystems where the projects occurred. RESULTS: We identified three categories and ten indicators of health system outcomes relevant to medical student engagement in HSI. Using these indicators, our evaluation found multiple benefits to the microsystems in which projects occurred. These included achievement of project aims, perceived immediate and sustained project impact on the health system, and development and implementation of projects with aims that aligned with national and health system priorities. CONCLUSION: Evaluation of HSI curricula needs to include effects on health systems so that program design can optimize the experience for all involved. Our study offers a framework others can use to evaluate system-level effects of project-based HSI curricula and shows several ways in which students' engagement can add value to health systems.

Twelve tips for responding to microaggressions and overt discrimination: When the patient offends the learner.

Microaggressions and expressions of overt discrimination negatively affect the experience of medical trainees at all levels. Mistreatment of trainees, including abusive and discriminatory behavior by patients and families, occurs commonly and is receiving increased attention in both the medical literature and popular press. Heightened awareness of the problem has sparked a call to engage in substantive conversations about bias in health professions education. The emphasis on direct observation in medical education makes the bedside a common setting for educators to witness these behaviors firsthand. Many educators are committed to developing a positive climate for learners but lack the training and skills to facilitate discussions about discrimination. As a result, these difficult but important conversations may not occur. The authors present a three-phase approach to responding to microaggressions and discrimination toward trainees from patients, and offer a communication toolkit that frontline medical educators can use in their daily practice.

Risk factors for tuberculin skin test conversion among HIV-infected patients in New York City.

BACKGROUND: We assessed the incidence of and risk factors for tuberculin skin test (TST) conversion among HIV-infected adults at a New York City clinic. METHODS: All adult HIV-infected patients were eligible for inclusion if they had a negative baseline TST result and at least one subsequent documented TST test result. RESULTS: A total of 414 HIV-infected patients had a negative baseline TST result; 288 (69.6%) were male. Among 348 patients who had a place of birth documented, 50% were born outside of mainland USA. Twenty-two (5.3%) of 414 patients had documented TST conversions, giving a crude incidence rate of 1.77 per 100 person-years. Being a foreign-born Asian individual (p=0.02), having lived in a shelter (p=0.004), and having an increase in CD4 cell count (p=0.02) while under care were independent risk factors for TST conversion. CONCLUSIONS: We found a high TST conversion rate among HIV-infected patients attending an urban clinic. Annual TST testing is particularly important for patients who are foreign-born from high-endemic countries, those with a history of homelessness, and those with an increase in CD4 cell count since the baseline negative TST test.

Indice de resistencia de las arterias umbilical y cerebral media fetal en gestaciones normales de 20 a 40 semanas / Resistance index of borth the umbilical and middle cerebral fetal arteries in normal patients during the second hall of the pregnancy

Objetivo: Determinar el índice de resistencia (IR) de la arteria umbilical y la arteria cerebral media fetal en pacientes normales que cursan la segunda mitad del embarazo. Diseño: Estudio prospectivo longitudinal de gestantes sin complicaciones desde las 20 semanas hasta el término. Material y método: Se seleccionó 125 pacientes sin factores de riesgo. Se evaluó el índice de resistencia en la arteria umbilical y en la arteria cerebral media utilizando el equipo logiq 500 MD/MR 3 de GE. Resultados: El IR de la arteria umbilical a las 20 semanas es alrededor de 0,750; luego disminuye en forma sostenida, más rápidamente entre las 26 y 34 semanas y, al término de la gestación, es menor de 0,600. El IR de la arteria cerebral media fetal parte de un valor medio cercano a 0,900 a las 20 semanas, observándose una disminución rápida hasta las 24 semanas para luego mantener una disminución lenta y progresiva hasta el término, con IR alrededor de 0,700. Conclusión: Durante la segunda mitad del embarazo la resistencia del flujo, medido por el IR de la arteria cerebral media fetal, es mayor que el de la arteria umbilical, con una relación normalmente mayor de uno.