Educational Policy Development as a Leadership Experience: Inclusive Institutional Change.

Medical students have a unique opportunity to advocate for educational policies that promote best practices in undergraduate medical education. At the Geisel School of Medicine at Dartmouth, students play a crucial role in the development of medical education policies. This article describes two innovative, inclusive, and effective approaches to increase student engagement: (1) restructuring Medical Education Subcommittees to diversify student perspectives and (2) including students in a values-based design thinking approach to the development of new academic advancement and promotion and conduct policies. Through deliberate participation, medical students gain valuable skills that can be applied as future educators and academic leaders.

Accelerated Graduation and the Deployment of New Physicians During the COVID-19 Pandemic.

The COVID-19 pandemic has presented unprecedented challenges and opportunities for medical schools in the United States. In this Invited Commentary, the authors describe a unique collaboration between the University of Massachusetts Medical School (UMMS), the only public medical school in the state; the University of Massachusetts Memorial Medical Center (UMMMC); and the Commonwealth of Massachusetts. Through this partnership, UMMS was able to graduate fourth-year medical students 2 months early and deploy them to UMMMC to care for patients and alleviate workforce shortages during the COVID-19 surge, which peaked in Massachusetts in April 2020. The authors describe how they determined if students had fulfilled graduation requirements to graduate early, what commencement and the accompanying awards ceremony looked like this year as virtual events, the special emergency 90-day limited license these new graduates were given to practice at UMMMC during this time, and the impact these new physicians had in the hospital allowing residents and attendings to be redeployed to care for COVID-19 patients.

Pre-clinical medical student reflections on implicit bias: Implications for learning and teaching.

CONTEXT: Implicit bias affects health professionals' clinical decision-making; nevertheless, published reports of medical education curricula exploring this concept have been limited. This research documents a recent approach to teaching implicit bias. METHODS: Medical students matriculating during 2014 and 2015 participated in a determinants of health course including instruction about implicit bias. Each submitted a reflective essay discussing implicit bias, the experience of taking the Implicit Association Test (IAT), and other course content. Using grounded theory methodology, student essays that discussed reactions to the IAT were analyzed for content themes based on specific statements mapping to each theme. Twenty-five percent of essays underwent a second review to calculate agreement between raters regarding identification of statements mapping to themes. OUTCOME: Of 250 essays, three-quarters discussed students' results on the IAT. Theme comments related to: a) experience taking the IAT, b) bias in medicine, and c) prescriptive comments. Most of the comments (84%) related to students' acknowledging the importance of recognizing implicit bias. More than one-half (60%) noted that bias affects clinical decision-making, and one-fifth (19%) stated that they believe it is the physician's responsibility to advocate for dismantling bias. CONCLUSIONS: Through taking the IAT and developing an understanding of implicit bias, medical students can gain insight into the effect it may have on clinical decision-making. Having pre-clinical medical students explore implicit bias through the IAT can lay a foundation for discussing this very human tendency.

Assuring Integrity in the Residency Match Process.

Integrity in medicine is essential. One of the most important competencies a medical student can master is to be honest at all times. Indeed, professionalism is a key competency in the identity formation and development of a medical student. At times, this competency becomes challenged during the resident matching process. The behavior of some students, faculty members, and program directors who participate in the residency program selection process (the Match) often falls short of this ideal when it comes to handling the process that will be most dispositive in directing the future careers of graduating medical students. Violations of both National Resident Matching Program (NRMP) rules and ethical norms have been reported in the literature and experienced by students. In this Invited Commentary, the authors recommend a series of reforms. Substantially more robust enforcement of NRMP rules should be considered, including the creation of an avenue for anonymous reporting by applicants who experience inappropriate pre-Match, postinterview communications.

Screening recipients of increased risk donor organs: A multicenter retrospective study.

Organ Procurement & Transplantation Network policy requires post-transplant screening of recipients of organs from donors at increased risk for transmission of HIV, hepatitis B virus, and hepatitis C virus. Available data suggest that follow-up testing of recipients is not routinely conducted. Data on increased risk donors and recipients of their organs from 2008 to 2012 were retrospectively collected from 6 transplant centers after IRB approval. Descriptive statistics were performed. About 363 (60%) recipients were screened for transmission of HIV, HBV, and/or HCV at some time point; 257 (70.8%) within 90 days of transplant. The type of test used to screen for infection was variable with many recipients (25%-43%) screened with serology alone. Our results reveal that post-transplant screening for HIV, HBV, and HCV in recipients of increased risk donor organs did not universally occur and testing methods were variable.

Adherence to Mediterranean diet is favorably associated with metabolic parameters in HIV-positive patients with the highly active antiretroviral therapy-induced metabolic syndrome and lipodystrophy.

The objective of the study was to investigate whether closer adherence to a Mediterranean dietary pattern is associated with metabolic aspects of the highly active antiretroviral therapy (HAART)-induced metabolic syndrome (fat redistribution [FR], insulin resistance, dyslipidemia) in HIV-positive patients. This was a cross-sectional study. Two hundred twenty-seven HIV-infected patients were evaluated during a single outpatient visit to the General Clinical Research Center of Beth Israel Deaconess Medical Center. Usual dietary intake and physical activity habits were evaluated; the Mediterranean Diet Score (MedDietScore) was calculated. Dual-energy x-ray absorptiometry, computed tomographic findings, anthropometrics, and data from the study interviews and questionnaires were used for the assessment of body composition using specific criteria. A complete metabolic profile was available for all subjects. In the entire study sample, a weak inverse association was found between insulin resistance, estimated using the homeostasis model assessment, and MedDietScore (standardized beta = -0.15, P = .03). Interaction models revealed that this was largely driven by an inverse association in patients with FR (standardized beta = -0.13, P = .02). Moreover, MedDietScore was positively correlated with high-density lipoprotein cholesterol (standardized beta = 0.15, P = .01) and marginally negatively associated with circulating triglyceride levels (standardized beta = -0.16, P = .13) in this group of patients. Adherence to a Mediterranean dietary pattern was favorably related to cardiovascular risk factors in HIV-positive patients with FR. Further clinical studies are needed to confirm our data in different populations and to explore the underlying mechanisms.

Top stories of 2008. No good news yet on anti-HIV microbicides.

Two intravaginal microbicide gels were found to be safe but ineffective.

r-metHuLeptin improves highly active antiretroviral therapy-induced lipoatrophy and the metabolic syndrome, but not through altering circulating IGF and IGF-binding protein levels: observational and interventional studies in humans.

OBJECTIVE: Leptin is an adipocyte secreted hormone and an important regulator of neuroendocrine, metabolic, and immune function. Both r-metHuLeptin and IGF1 administration result in reduced central adipose tissue in subjects with highly active antiretroviral therapy-induced metabolic syndrome (HAART-MS) but whether the effects of leptin are mediated through increasing IGF levels remains unknown. METHODS: To assess whether r-metHuLeptin improves the HAART-MS by regulating circulating IGF and IGFBPs, we first conducted a cross-sectional study of 118 men and women with HIV infection and >6 months of exposure to antiretroviral medications to examine any association between circulating IGF1 and leptin levels. We also performed a randomized, double-blinded, placebo-controlled, crossover trial of recombinant human leptin (r-metHuLeptin) administration to seven HIV positive men with lipoatrophy and leptin deficiency (leptin <3 ng/ml) related to antiretroviral medication use. RESULTS: In the observational study, leptin levels were inversely associated with circulating IGF1 levels after adjusting for age and gender (r=0.27 P=0.002), but this inverse association became non-significant after adjustment for % body fat and exercise. In the interventional leptin study, leptin levels increased significantly during r-metHuLeptin treatment (from 1.34+/-0.20 ng/ml at baseline to 17+/-5.05 ng/ml after 8 weeks P=0.046) and metabolic parameters improved including reduced fasting insulin levels and reduced homeostasis model assessment-insulin resistance (HOMA-IR). Despite the increase in circulating leptin levels, there was no change in IGF1, IGF2, free IGF1, or IGF-binding proteins during the 2-month treatment period. CONCLUSION: The effects of r-metHuLeptin in patients with HAART-MS are not mediated through increasing IGF or IGFBP levels.

Spotting the owl: surreptitious cytomegalovirus disease in a renal transplant recipient.

Cytomegalovirus (CMV) is a known cause of ulcerative oral lesions among HIV-infected patients, but such ulcers have not been previously reported in recipients of solid organ transplants. We describe a case of a renal transplant recipient who developed severe CMV-associated oral lesions despite prophylaxis with valganciclovir, and in the absence of detectable CMV viremia. The diagnosis was made only after multiple biopsies of the lesions. The patient recovered upon reducing immunosuppression. Potential pitfalls in making a prompt diagnosis are reviewed. The differential diagnosis of a large oral ulceration in a transplant recipient is broad, but should include CMV infection.