LGBTQ+ Health-a Novel Course for Undergraduate Students.

The concept of providing focused, competency-based LGBTQ+ health education outside the setting of health professional programs, specifically for undergraduates, is quite uncharted. However, the issue at the core of our rationale is one shared by those with and without clinical exposure: how to best support the development of cultural competence in providers who are or will be caring for LGBTQ+ patients. Traditional health professional education programs have enacted a number of curricular initiatives in this regard, designed for advanced learners. By focusing specifically on the undifferentiated learner, we offer a new perspective on the timing of LGBTQ+ health-related education. Our course is not intended to supplant the critical learning and application that must occur in the clinic or hospital room. Rather, we present a framework for cultivating understanding of the healthcare issues faced by the LGBTQ+ community that may help a learner to acquire and apply skills subsequently with greater cultural competence.

Investigating Group Differences in Examinees' Preparation for and Performance on the New MCAT Exam.

In 2015, the Medical College Admission Test (MCAT) was redesigned to better assess the concepts and reasoning skills students need to be ready for the medical school curriculum. During the new exam's design and rollout, careful attention was paid to the opportunities examinees had to learn the new content and their access to free and low-cost preparation resources. The design committee aimed to mitigate possible unintended effects of the redesign, specifically increasing historical mean group differences in MCAT scores for examinees from lower socioeconomic status (SES) backgrounds and races/ethnicities underrepresented in medicine compared with those from higher SES backgrounds and races/ethnicities not underrepresented in medicine.In this article, the authors describe the characteristics and scores of examinees who took the new MCAT exam in 2017 and compare those trends with historical ones from 2013, presenting evidence that the diversity and performance of examinees has remained stable even with the exam's redesign. They also describe the use of free and low-cost MCAT preparation resources and MCAT preparation courses for examinees from higher and lower SES backgrounds and who are enrolled in undergraduate institutions with more and fewer resources, showing that examinees from lower SES backgrounds and who attend institutions with fewer resources use many free and low-cost test preparation resources at lower rates than their peers. The authors conclude with a description of the next phase of this research: to gather qualitative and quantitative data about the preparation strategies, barriers, and needs of all examinees, but especially those from lower SES and underrepresented racial/ethnic backgrounds.

Burnout, perceived stress, and empathic concern: differences in female and male Millennial medical students.

The 'Millennial' generation faces medical education learning environment challenges differently. We explore gender differences in burnout, perceived stress, and empathic concern in third-year medical students. A sample size of 654 third-year medical students completed an annual survey over 6 years. Survey items included: the Maslach Burnout Inventory-Student Scale (MBI-SS), Interpersonal Reactivity Index (IRI), and Perceived Stress Scale (PSS). We examined demographic differences using independent sample t-tests and performed a two-way ANOVA to test for potential interactions. Female students were more likely to have higher empathic concern compared to male students (IRI) (20.9±3.9 versus 19.1±4.1, p<0.001), and reported more personal distress (IRI) (9.0±4.4 versus 7.6±3.8, p<0.001), emotional exhaustion (MBI-SS) (15.6±5.9 versus 14.4±5.9, P<0.013), and perceived stress (PSS) (17.3±6.1 versus 15.2±6.7, p<0.001). Male students were more likely to have cynicism (MBI-SS) and lower professional efficacy (MBI-SS) scores. Results of multivariate analyses yielded no significant interactions between gender, age, and ethnicity. Self-reported experiences of burnout and stress differed in male and female third-year medical students. Burnout and perceived stress scores while statistically significant were small. These findings suggest that support services should be made broadly available to all medical students, but should be targeted to the specific needs of male and female students.

Leading Practices and Future Directions for Technical Standards in Medical Education.

The medical profession first addressed the need for technical standards (TS), defining the nonacademic requirements deemed essential for participation in an educational program, in guidelines published by the Association of American Medical Colleges in 1979. Despite many changes in the practice of medicine and legal, cultural, and technological advances that afford greater opportunities for people with disabilities, the profession's approach to TS largely has not changed over the ensuing four decades. Although physicians with disabilities bring unique perspectives to medicine and contribute to a diverse physician workforce of culturally competent practitioners, they remain underrepresented in the profession.As part of an initiative sponsored by the Association of Academic Physiatrists, the authors describe the need for an updated TS framework, outlining interval changes in the legal and regulatory climate, medical practice, and medical education since the initial TS guidelines were put forth. They conclude by offering eight recommendations and two functional approaches to TS that are consistent with now-prevalent competency-based medical education constructs.The profession's commitment to diversity and inclusion should extend explicitly to people with disabilities, and this stance should be clearly communicated through medical schools' TS and procedures for requesting accommodations. To this end, schools should consider the principles of universal design to create policies and assessments that work for all learners, to the greatest extent possible, without the need for after-the-fact accommodations. A thoughtful and concerted effort along these lines is long overdue in medical education.

Strategies for Achieving Diversity through Medical School Admissions.

The relative lack of diversity in medicine is a rate limiting factor in efforts to eliminate health care disparities. Many medical schools struggle to matriculate student bodies that reflect the diversity of this country. Actively recruiting is one tactic to diversify a medical school's applicant pool, but in isolation is not enough. Our medical school admissions committee made a number of programmatic changes that contributed to our current compositional diversity that may be instructive to others. This report from the field on the experience of one U.S. medical school describes several admissions committee initiatives that can be undertaken to increase the yield of students from groups underrepresented in medicine who matriculate to medical school.

A National Long-term Outcomes Evaluation of U.S. Premedical Postbaccalaureate Programs Designed to Promote Health care Access and Workforce Diversity.

UNLABELLED: The National Postbaccalaureate Collaborative (NPBC) is a partnership of Postbaccalaureate Programs (PBPs) dedicated to helping promising college graduates from disadvantaged and underrepresented backgrounds get into and succeed in medical school. This study aims to determine long-term program outcomes by looking at PBP graduates, who are now practicing physicians, in terms of health care service to the poor and underserved and contribution to health care workforce diversity. METHODS: We surveyed the PBP graduates and a randomly drawn sample of non-PBP graduates from the affiliated 10 medical schools stratified by the year of medical school graduation (1996-2002). RESULTS: The PBP graduates were more likely to be providing care in federally designated underserved areas and practicing in institutional settings that enable access to care for vulnerable populations. CONCLUSION: The NPBC graduates serve a critical role in providing access to care for underserved populations and serve as a source for health care workforce diversity.

A framework for analysis of sentinel events in medical student education.

PROBLEM: Although previous studies have addressed student factors contributing to dismissal or withdrawal from medical school for academic reasons, little information is available regarding institutional factors that may hinder student progress. APPROACH: The authors describe the development and application of a framework for sentinel event (SE) root cause analysis to evaluate cases in which students are dismissed or withdraw because of failure to progress in the medical school curriculum. The SE in medical student education (MSE) framework was piloted at the Ohio State University College of Medicine (OSUCOM) during 2010-2012. Faculty presented cases using the framework during academic oversight committee discussions. OUTCOMES: Nine SEs in MSE were presented using the framework. Major institution-level findings included the need for improved communication, documentation of cognitive and noncognitive (e.g., mental health) issues, clarification of requirements for remediation and fitness for duty, and additional psychological services. Challenges related to alternative and combined programs were identified as well. The OSUCOM undertook system changes based on the action plans developed through the discussions of these SEs. NEXT STEPS: An SE analysis process appears to be a useful method for making system changes in response to institutional issues identified in evaluation of cases in which students fail to progress in the medical school curriculum. The authors plan to continue to refine the SE in MSE framework and analysis process. Next steps include assessing whether analysis using this framework yields improved student outcomes with universal applications for other institutions.

The impact of acute care medications on rehabilitation outcome after traumatic brain injury.

OBJECTIVES: To examine the impact of medications with known central nervous system (CNS) mechanisms of action, given during the acute care stages after traumatic brain injury (TBI), on the extent of cognitive and motor recovery during inpatient rehabilitation. DESIGN: Retrospective extraction of data utilizing an inception cohort of moderate and severe TBI survivors. METHODS: The records of 182 consecutive moderate and severe TBI survivors admitted to a single, large, Midwestern level I trauma centre and subsequently transferred for acute inpatient rehabilitation were abstracted for the presence of 11 categories of medication, three measures of injury severity (worst 24 hour Glasgow Coma Scale, worst pupillary response, intra-cranial hypertension), three measures of outcome (Function Independence Measure (FIM) Motor and Cognitive scores at both rehabilitation admission and discharge and duration of post-traumatic amnesia (PTA)). MAIN OUTCOME AND RESULTS: The narcotics, benzodiazepines and neuroleptics were the most common categories of CNS active medications (92%, 67% and 43%, respectively). The three categories of medications appeared to have no significant outcome on the FIM outcome variables. The neuroleptics affected cognitive recovery with almost 7 more days required to clear PTA in the neuroleptic treated group. The presence of benzodiazepines did tend to obscure the impact of neuroleptics on PTA duration but the negative impact of neuroleptics on PTA duration remained significant. CONCLUSIONS: The results suggest that the use of neuroleptics during the acute care stage of recovery has a negative impact on recovery of cognitive function at discharge from inpatient rehabilitation. Due to the paucity of subjects with hemiplegia in this cohort, conclusions could not be drawn as to the impact of acute care medications on motor recovery.

Gender differences in agitation after traumatic brain injury.

OBJECTIVE: To determine sex differences in extent and type of posttraumatic agitation during acute rehabilitation. DESIGN: This prospective, observational study was performed at a Midwest, regional, university-based acute rehabilitation center. RESULTS: In a total of 158 subjects, comprising 120 men (76%) and 38 women (24%), there were no significant differences between male and female subjects for age, Glasgow Coma Scale score, Rancho Los Amigos Level of Cognitive Functioning Scale, Mini Mental State Exam, days in acute hospital, and days in rehabilitation. No difference in incidence was observed between sexes based on the criterion of agitation as three or more abnormal total Agitated Behavior Scale scores in 48 hrs (P = 0.890). Also, no difference in posttraumatic agitation between the two sexes (P = 0.396) was observed with the criterion of agitation as two or more abnormal total Agitated Behavior Scale scores in 2 days. There were no differences observed between the sexes for peak intensity and average intensity for the total score or each of the factor scores of the Agitated Behavior Scale. CONCLUSION: Posttraumatic agitation is seen in approximately 50% of patients after traumatic brain injury and usually lasts for <10 days. There are no significant sex differences in the frequency, duration, presentation, or extent of posttraumatic agitation. These data imply that both sexes, despite any predetermined notions, should be treated equally with respect to posttraumatic agitation management.

Cost-effectiveness of duplex ultrasound surveillance in spinal cord injury.

OBJECTIVE: To determine cost-effectiveness of surveillance with duplex ultrasound for thromboembolic disease in individuals with acute traumatic spinal cord injury at admission to rehabilitation. DESIGN: In this retrospective sequential case series study, individuals with traumatic spinal cord injury admitted to our rehabilitation facility between July 1, 1988, and December 31, 1998, were identified. Cost at our institution for treatment of thromboembolic disease was tabulated in 2001-2002 dollar amounts. Using this cost information, in a statistical model founded on available medical evidence, analysis for cost-effectiveness was then performed. RESULTS: A total of 369 subjects met inclusion criteria. Based on the statistical model, the cost and estimated mortality from thromboembolic disease per subject when performing admission duplex ultrasounds was $449.28 and 0.016%, respectively. The estimated total cost per subject when not performing admission duplex ultrasounds was $136.29, with predicted mortality of 0.524% due to thromboembolic disease. Therefore, cost of one life saved when performing admission duplex ultrasound surveillance is calculated to be $61,542, with cost per life year gained between $1193 and $9050, depending on age at time of injury and severity of injury. CONCLUSION: Duplex ultrasound is a cost-effective tool for deep venous thrombosis surveillance in individuals with acute traumatic spinal cord injury admitted to rehabilitation programs.

Surveillance with duplex ultrasound in traumatic spinal cord injury on initial admission to rehabilitation.

OBJECTIVE: To determine the prevalence of deep vein thrombosis (DVT) by surveillance duplex ultrasound in the traumatic spinal cord injury (SCI) population on admission to rehabilitation. DESIGN: Retrospective sequential case series. SETTING: Midwest regional, university-based, Commission on Accreditation of Rehabilitation Facilities-accredited acute rehabilitation center. METHODS: Charts of all patients with traumatic SCI admitted and discharged from January 1, 1996 through December 31, 1998 were reviewed. Preadmission data were collected on demographics, severity of injury, and DVT prophylaxis information, along with rehabilitation duplex ultrasound results and incidence of thromboembolic events. RESULTS: Ninety-two participants met the inclusion criteria. There were 68 men and 24 women with a mean age on admission of 32.4 years. On admission, 45 participants (49%) were classified as tetraplegic and 47 (51%) were classified as paraplegic; 63 (69%) had motor-complete lesions and 29 (31%) had motor-incomplete lesions. Of all the participants, 8 (8.7%) were found to have DVT on admission to rehabilitation. There were no statistically significant differences among participants with regard to age, sex, level of injury, or completeness of injury, when comparing those participants with DVT on admission, those without DVT on admission, and those with thromboembolic events diagnosed later in their hospitalization. Of the 84 participants who had negative duplex ultrasounds on admission, 4 individuals (4.8%) were found to have DVT and 4 (4.8%) had pulmonary emboli subsequently. In these 84 participants, DVT prophylaxis with low-molecular-weight heparin was found to be more effective than was adjusted-dose heparin in preventing thromboembolic phenomenon. CONCLUSION: Incidence of DVT remains high despite prophylaxis in traumatic SCI patients. Two thirds of DVT diagnosed in rehabilitation was identified on admission and one third was diagnosed later. Duplex ultrasound is an effective and valuable tool that assists in the diagnosis of asymptomatic DVT in patients with traumatic SCI who are initiating in-patient rehabilitation.