The Impact of Changing Step 1 to Pass/Fail Reporting on Anxiety, Learning Approaches, and Curiosity.

Purpose: Given the significance of the US Medical Licensing Exam (USMLE) Step 1 score moving from a 3-digit value to pass/fail, the authors investigated the impact of the change on students' anxiety, approach to learning, and curiosity. Method: Two cohorts of pre-clerkship medical students at three medical schools completed a composite of four instruments: the State-Trait Anxiety Inventory, the revised two-factor Study Process Questionnaire, the Interest/Deprivation Type Epistemic Curiosity Scale, and the Short Grit Scale prior to taking the last 3-digit scored Step 1 in 2021 or taking the first pass/fail scored Step 1 in 2022. Responses of 3-digit and pass/fail exam takers were compared (Mann-Whitney U) and multiple regression path analysis was performed to determine the factors that significantly impacted learning strategies. Results: There was no difference between 3-digit (n = 86) and pass/fail exam takers (n = 154) in anxiety (STA-I scores, 50 vs. 49, p = 0.85), shallow learning strategies (22 vs. 23, p = 0.84), or interest curiosity scores (median scores 15 vs. 15, p = 0.07). However, pass/fail exam takers had lower deprivation curiosity scores (median 12 vs. 11, p = 0.03) and showed a decline in deep learning strategies (30 vs. 27, p = 0.0012). Path analysis indicated the decline in deep learning strategies was due to the change in exam scoring (ß = - 2.0428, p < 0.05). Conclusions: Counter to the stated hypothesis and intentions, the initial impact of the change to pass/fail grading for USMLE Step 1 failed to reduce learner anxiety, and reduced curiosity and deep learning strategies. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01878-w.

An integrated pre-clerkship curriculum to build cognitive medical schema: It's not just about the content.

Both physiology and pathophysiology are essential disciplines in health professional education however, clinicians do not use this knowledge in isolation. Instead, physicians use inter-disciplinary concepts embedded within integrated cognitive schema (illness scripts) established through experience/knowledge that manifest as expert-level thinking. Our goal was to develop a pre-clerkship curriculum devoid of disciplinary boundaries (akin to the physician's illness script) and enhance learners' clerkship and early clinical performance. As well as developing curricular content, the model considered non-content design elements such as learner characteristics and values, faculty and resources and the impact of curricular and pedagogical changes. The goals of the trans-disciplinary integration were to develop deep learning behaviors through, 1) developing of integrated, cognitive schema to support the transition to expert-level thinking, 2) authentic, contextualization to promote knowledge transfer to the clinical realm 3) allowing autonomous, independent learning, and 4) harnessing the benefits of social learning. The final curricular model was a case-based approach with independent learning of basic concepts, differential diagnosis and illness scripting writing, and concept mapping. Small-group classroom sessions were team-taught with basic scientists and physicians facilitating learners' self-reflection and development of clinical reasoning. Specifications grading was used to assess the products (written illness scripts and concept maps) as well as process (group dynamics) while allowing a greater degree of learner autonomy. Although the model we adopted could be transferred to other program settings, we suggest it is critical to consider both content and non-content elements that are specific to the environment and learner.

A Simple and Sustainable Exercise to Enhance Student Self-Reflection on Error-Making, Focus Support, and Guide Curricular Design.

Problem: Self-reflection is a critical component of professional development and clinical practice, but medical students' ability to self-reflect is typically limited. While inadequate self-reflection impacts future clinical decision-making, it may also adversely impact current learning through an inability to identify learning-behavior deficits. This may be exacerbated by common use of multiple-choice questions (MCQ) where incorrect responses provide less insight than other measures for students, faculty, or academic support. To address this, an Error Reflection Method (ERM) was developed to help students focus on 'why' they got an MCQ wrong rather than 'what' they got wrong, thereby promoting self-reflection and a learning-focus on assessment. Understanding students' learning-behavior deficits could also enrich engagement with academic support services and guide curricular design. Intervention: The ERM is a list of 10 common types of exam errors that were either 'test-taking' (unwitting) errors or 'learning-behavior' errors that reflected learning deficits. The ERM is simple, transferable, and sustainable, allowing longitudinal and regular monitoring of individual and collective error-making to focus support and guide curricular development. Context: Undergraduate medical students at the Virginia Tech Carilion School of Medicine, USA, used the ERM in formative assessment review sessions in pre-clinical years to select an error type that best described the cause of each incorrect response. Impact: Initial findings suggest the ERM is robust and associated with improved student performance and curricular development. Analysis of 3,775 student-identified errors showed the error types in the ERM described 96% of errors students made. Learning-behavior errors were more common (76%), but surprisingly, 19% were test-taking errors, allowing academic support to focus on test-taking skills in a population previously thought of as consummate test-takers. The most common error type reported was 'the content looked familiar but I couldn't answer the question' (32%); which we suggest is consistent with shallow learning. This finding has helped steer recent curricular development toward active and applied learning techniques. Lessons Learned: By formally and regularly identifying learning deficits, students may be more capable of addressing them and improve summative exam performance. As well as focusing academic support, understanding common student errors has been useful in guiding curricular design and content delivery. Further potential of the ERM may be realized in faculty development and directing assessment culture toward a learning focus.

Dyspnea.

The clinical term dyspnea (a.k.a. breathlessness or shortness of breath) encompasses at least three qualitatively distinct sensations that warn of threats to breathing: air hunger, effort to breathe, and chest tightness. Air hunger is a primal homeostatic warning signal of insufficient alveolar ventilation that can produce fear and anxiety and severely impacts the lives of patients with cardiopulmonary, neuromuscular, psychological, and end-stage disease. The sense of effort to breathe informs of increased respiratory muscle activity and warns of potential impediments to breathing. Most frequently associated with bronchoconstriction, chest tightness may warn of airway inflammation and constriction through activation of airway sensory nerves. This chapter reviews human and functional brain imaging studies with comparison to pertinent neurorespiratory studies in animals to propose the interoceptive networks underlying each sensation. The neural origins of their distinct sensory and affective dimensions are discussed, and areas for future research are proposed. Despite dyspnea's clinical prevalence and impact, management of dyspnea languishes decades behind the treatment of pain. The neurophysiological bases of current therapeutic approaches are reviewed; however, a better understanding of the neural mechanisms of dyspnea may lead to development of novel therapies and improved patient care.

Changing Medical Education, Overnight: The Curricular Response to COVID-19 of Nine Medical Schools.

Issue: Calls to change medical education have been frequent, persistent, and generally limited to alterations in content or structural re-organization. Self-imposed barriers have prevented adoption of more radical pedagogical approaches, so recent predictions of the 'inevitability' of medical education transitioning to online delivery seemed unlikely. Then in March 2020 the COVID-19 pandemic forced medical schools to overcome established barriers overnight and make the most rapid curricular shift in medical education's history. We share the collated reports of nine medical schools and postulate how recent responses may influence future medical education. Evidence: While extraneous pandemic-related factors make it impossible to scientifically distinguish the impact of the curricular changes, some themes emerged. The rapid transition to online delivery was made possible by all schools having learning management systems and key electronic resources already blended into their curricula; we were closer to online delivery than anticipated. Student engagement with online delivery varied with different pedagogies used and the importance of social learning and interaction along with autonomy in learning were apparent. These are factors known to enhance online learning, and the student-centered modalities (e.g. problem-based learning) that included them appeared to be more engaging. Assumptions that the new online environment would be easily adopted and embraced by 'technophilic' students did not always hold true. Achieving true distance medical education will take longer than this 'overnight' response, but adhering to best practices for online education may open a new realm of possibilities. Implications: While this experience did not confirm that online medical education is really 'inevitable,' it revealed that it is possible. Thoughtfully blending more online components into a medical curriculum will allow us to take advantage of this environment's strengths such as efficiency and the ability to support asynchronous and autonomous learning that engage and foster intrinsic learning in our students. While maintaining aspects of social interaction, online learning could enhance pre-clinical medical education by allowing integration and collaboration among classes of medical students, other health professionals, and even between medical schools. What remains to be seen is whether COVID-19 provided the experience, vision and courage for medical education to change, or whether the old barriers will rise again when the pandemic is over.

Air Hunger: A Primal Sensation and a Primary Element of Dyspnea.

The sensation that develops as a long breath hold continues is what this article is about. We term this sensation of an urge to breathe "air hunger." Air hunger, a primal sensation, alerts us to a failure to meet an urgent homeostatic need maintaining gas exchange. Anxiety, frustration, and fear evoked by air hunger motivate behavioral actions to address the failure. The unpleasantness and emotional consequences of air hunger make it the most debilitating component of clinical dyspnea, a symptom associated with respiratory, cardiovascular, and metabolic diseases. In most clinical populations studied, air hunger is the predominant form of dyspnea (colloquially, shortness of breath). Most experimental subjects can reliably quantify air hunger using rating scales, that is, there is a consistent relationship between stimulus and rating. Stimuli that increase air hunger include hypercapnia, hypoxia, exercise, and acidosis; tidal expansion of the lungs reduces air hunger. Thus, the defining experimental paradigm to evoke air hunger is to elevate the drive to breathe while mechanically restricting ventilation. Functional brain imaging studies have shown that air hunger activates the insular cortex (an integration center for perceptions related to homeostasis, including pain, food hunger, and thirst), as well as limbic structures involved with anxiety and fear. Although much has been learned about air hunger in the past few decades, much remains to be discovered, such as an accepted method to quantify air hunger in nonhuman animals, fundamental questions about neural mechanisms, and adequate and safe methods to mitigate air hunger in clinical situations. © 2021 American Physiological Society. Compr Physiol 11:1449-1483, 2021.

Using Near-Peer Teaching to Address Concepts of Cystic Fibrosis in Undergraduate Medical Learners.

Introduction: Cystic fibrosis (CF) is a high-yield undergraduate medical education topic that lends itself to adaptability of content. We used a CF case paired with activities to deliver content in a near-peer teaching session. First-year (M1) and second-year (M2) medical students contributed acquired knowledge of protein structure and obstructive lung disease, respectively, to generate a concept map and address discussion questions. Methods: Combined groups of M1 and M2 students reviewed a CF case and a concept map prompt. For 30 minutes, they created a concept map describing connections between molecular biology and clinical manifestations. We summarized by reviewing concept maps and discussion questions. The efficacy of the session was determined by comparing exam performance of class attenders and nonattenders (M2) and performance on questions related and unrelated to the exercise (M1). We also determined students' perception of the session and incorporation of additional core competencies. Results: M2 students' performance was 3.8% higher (p = .296) and M1 students' performance was 1.8% higher (p = .286) than their respective controls. Students commented positively on the exercise and perceived more than one core competency as part of the session. Discussion: Although there was no significant improvement in exam performance, this curriculum used near-peer teaching to reinforce previously learned material and apply recently acquired material in an engaging format without detriment to either group. This method can be adapted to different learner groups and provides an opportunity to deliver and assess other core medical competencies.

Integrating Acid-Base and Metabolic Lab Panels Across Systems in an M1 Classroom Activity.

Introduction: It is important to deliver acid-base balance concepts in the context of multiple physiological systems and metabolic processes that influence acid-base homeostasis. This activity combines the interactions of the respiratory, gastrointestinal, and renal systems in conjunction with basic metabolism to generate an integrated activity for first-year medical students. Methods: We developed four concise case scenarios around various presentations of acid-base disturbance along with five sets of arterial blood gases (ABGs) and five different metabolic lab panels. M1 students were given class time to match the three different types of data in order to address how the underlying biochemistry and physiology of a scenario translated into ABG and metabolic laboratory values. Results: Although not statistically significant, the students' performance on acid-base questions was marginally higher than on standardized National Board of Medical Examiners questions on other topics covered in the same exam, and the improvement over national average scores on the same questions increased. Student evaluation of the activity was positive, with general appreciation of its application and integration of concepts. Discussion: The incorporation of this activity into the M1 year was positively received and enhanced integration of content related to acid-base balance. The activity is flexible and can be adapted to most any curricular structure, with the potential to include additional content depending on the level of the learner.

Electromagnetic Navigational Bronchoscopy Reduces the Time Required for Localization and Resection of Lung Nodules.

OBJECTIVE: The aims of the study were to evaluate electromagnetic navigational bronchoscopy (ENB) and computed tomography-guided placement as localization techniques for minimally invasive resection of small pulmonary nodules and determine whether electromagnetic navigational bronchoscopy is a safer and more effective method than computed tomography-guided localization. METHODS: We performed a retrospective review of our thoracic surgery database to identify patients who underwent minimally invasive resection for a pulmonary mass and used either electromagnetic navigational bronchoscopy or computed tomography-guided localization techniques between July 2011 and May 2015. RESULTS: Three hundred eighty-three patients had a minimally invasive resection during our study period, 117 of whom underwent electromagnetic navigational bronchoscopy or computed tomography localization (electromagnetic navigational bronchoscopy = 81; computed tomography = 36). There was no significant difference between computed tomography and electromagnetic navigational bronchoscopy patient groups with regard to age, sex, race, pathology, nodule size, or location. Both computed tomography and electromagnetic navigational bronchoscopy were 100% successful at localizing the mass, and there was no difference in the type of definitive surgical resection (wedge, segmentectomy, or lobectomy) (P = 0.320). Postoperative complications occurred in 36% of all patients, but there were no complications related to the localization procedures. In terms of localization time and surgical time, there was no difference between groups. However, the down/wait time between localization and resection was significant (computed tomography = 189 minutes; electromagnetic navigational bronchoscopy = 27 minutes); this explains why the difference in total time (sum of localization, down, and surgery) was significant (P < 0.001). CONCLUSIONS: We found electromagnetic navigational bronchoscopy to be as safe and effective as computed tomography-guided wire placement and to provide a significantly decreased down time between localization and surgical resection.

Cthrc1 lowers pulmonary collagen associated with bleomycin-induced fibrosis and protects lung function.

Idiopathic pulmonary fibrosis (IPF) involves collagen deposition that results in a progressive decline in lung function. This process involves activation of Smad2/3 by transforming growth factor (TGF)-ß and Wnt signaling pathways. Collagen Triple Helix Repeat-Containing-1 (Cthrc1) protein inhibits Smad2/3 activation. To test the hypothesis that Cthrc1 limits collagen deposition and the decline of lung function, Cthrc1 knockout (Cthrc1-/-) and wild-type mice (WT) received intratracheal injections of 2.5 U/kg bleomycin or saline. Lungs were harvested after 14 days and Bronchoalveolar lavage (BAL) TGF-ß, IL1-ß, hydroxyproline and lung compliance were assessed. TGF-ß was significantly higher in Cthrc1-/- compared to WT (53.45 ± 6.15 ng/mL vs. 34.48 ± 11.05) after saline injection. Bleomycin injection increased TGF-ß in both Cthrc1-/- (66.37 ± 8.54 ng/mL) and WT (63.64 ± 8.09 ng/mL). Hydroxyproline was significantly higher in Cthrc1-/- compared to WT after bleomycin-injection (2.676 ± 0.527 µg/mg vs. 1.889 ± 0.520, P = 0.028). Immunohistochemistry of Cthrc1-/- lung sections showed intracellular localization and activation of ß-catenin Y654 in areas of tissue remodeling that was not evident in WT Lung compliance was significantly reduced by bleomycin in Cthrc1-/- but there was no effect in WT animals. These data suggest Cthrc1 reduces fibrotic tissue formation in bleomycin-induced lung fibrosis and the effect is potent enough to limit the decline in lung function. We conclude that Cthrc1 plays a protective role, limiting collagen deposition and could form the basis of a novel therapy for pulmonary fibrosis.