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1.
BMC Med Educ ; 23(1): 345, 2023 May 17.
Artigo em Inglês | MEDLINE | ID: mdl-37198639

RESUMO

BACKGROUND: Preclinical medical education is content-dense and time-constrained. Flipped classroom approaches promote durable learning, but challenges with unsatisfactory student preparation and high workload remain. Cognitive load theory defines instructional design as "efficient" if learners can master the presented concepts without cognitive overload. We created a PReparatory Evaluation Process (PREP) to systematically assess and measure improvement in the cognitive-load efficiency of preparatory materials and impact on study time (time-efficiency). METHODS: We conducted this study in a flipped, multidisciplinary course for ~ 170 first year students at Harvard Medical School using a naturalistic post-test design. For each flipped session (n = 97), we assessed cognitive load and preparatory study time by administering a 3-item PREP survey embedded within a short subject-matter quiz students completed before class. Over three years (2017-2019), we evaluated cognitive load- and time- based efficiency to guide iterative revisions of the materials by content experts. The ability of PREP to detect changes to the instructional design (sensitivity) was validated through a manual audit of the materials. RESULTS: The average survey response rate was ≥ 94%. Content expertise was not required to interpret PREP data. Initially students did not necessarily allocate the most study time to the most difficult content. Over time, the iterative changes in instructional design increased the cognitive load- and time-based efficiency of preparatory materials with large effect sizes (p < .01). Furthermore, this increased the overall alignment of cognitive load with study time: students allocated more time to difficult content away from more familiar, less difficult content without increasing workload overall. CONCLUSIONS: Cognitive load and time constraints are important parameters to consider when designing curricula. The PREP process is learner-centered, grounded in educational theory, and works independently of content knowledge. It can provide rich and actionable insights into instructional design of flipped classes not captured by traditional satisfaction-based evaluations.


Assuntos
Currículo , Educação Médica , Humanos , Aprendizagem , Inquéritos e Questionários , Cognição , Aprendizagem Baseada em Problemas
2.
BMC Med Educ ; 22(1): 423, 2022 Jun 02.
Artigo em Inglês | MEDLINE | ID: mdl-35655160

RESUMO

PURPOSE: The disruption of undergraduate medical education (UME) by the COVID-19 pandemic has sparked rapid, real-time adjustments by medical educators and students. While much is known about online teaching in general, little guidance is available to medical educators on how to adapt courses not originally designed for the online environment. To guide our faculty in this transition we conducted a needs assessment of students enrolled in virtual courses across all 4 years of UME training. METHODS: Using a mixed-methods approach, we conducted a single-institution virtual learning needs assessment in May and June of 2020. We developed and disseminated a survey to assess student experiences with virtual learning. We conducted quantitative and qualitative analysis of responses (n = 255 or 39%) to identify emergent themes. RESULTS: We identified six interdependent themes that need to be met for medical students to fully reach their learning potential: access to stable internet and quiet study spaces, flexible course design with asynchronous, self-paced components, clear expectations for engagement with content and each other, a sense of connectedness with faculty and peers, synchronous classes that maximize interactivity, and assessments that foster a sense of learning over performance. Interpersonal relationships with faculty and peers affected students' sense of learning more than any other factor. CONCLUSIONS: Based on our findings we propose a hierarchy of needs for virtual learning that provides guidance on adapting existing medical school courses to the remote setting and overcoming common challenges. We highlight opportunities for how virtual elements may enrich in-person courses going forward, including in the clinical setting. Although the solutions required to meet the threshold of need at each level may differ based on the context, attending to these same fundamental needs can be extrapolated and applied to learners across a range of environments beyond the virtual.


Assuntos
COVID-19 , Educação de Graduação em Medicina , Estudantes de Medicina , COVID-19/epidemiologia , Humanos , Pandemias , Inquéritos e Questionários
3.
JAMA ; 327(14): 1379-1391, 2022 04 12.
Artigo em Inglês | MEDLINE | ID: mdl-35412560

RESUMO

Importance: Pulmonary arterial hypertension (PAH) is a subtype of pulmonary hypertension (PH), characterized by pulmonary arterial remodeling. The prevalence of PAH is approximately 10.6 cases per 1 million adults in the US. Untreated, PAH progresses to right heart failure and death. Observations: Pulmonary hypertension is defined by a mean pulmonary artery pressure greater than 20 mm Hg and is classified into 5 clinical groups based on etiology, pathophysiology, and treatment. Pulmonary arterial hypertension is 1 of the 5 groups of PH and is hemodynamically defined by right heart catheterization demonstrating a mean pulmonary artery pressure greater than 20 mm Hg, a pulmonary artery wedge pressure of 15 mm Hg or lower, and a pulmonary vascular resistance of 3 Wood units or greater. Pulmonary arterial hypertension is further divided into subgroups based on underlying etiology, consisting of idiopathic PAH, heritable PAH, drug- and toxin-associated PAH, pulmonary veno-occlusive disease, PAH in long-term responders to calcium channel blockers, and persistent PH of the newborn, as well as PAH associated with other medical conditions including connective tissue disease, HIV, and congenital heart disease. Early presenting symptoms are nonspecific and typically consist of dyspnea on exertion and fatigue. Currently approved therapy for PAH consists of drugs that enhance the nitric oxide-cyclic guanosine monophosphate biological pathway (sildenafil, tadalafil, or riociguat), prostacyclin pathway agonists (epoprostenol or treprostinil), and endothelin pathway antagonists (bosentan and ambrisentan). With these PAH-specific therapies, 5-year survival has improved from 34% in 1991 to more than 60% in 2015. Current treatment consists of combination drug therapy that targets more than 1 biological pathway, such as the nitric oxide-cyclic guanosine monophosphate and endothelin pathways (eg, ambrisentan and tadalafil), and has shown demonstrable improvement in morbidity and mortality compared with the previous conventional single-pathway targeted monotherapy. Conclusions and Relevance: Pulmonary arterial hypertension affects an estimated 10.6 per 1 million adults in the US and, without treatment, typically progresses to right heart failure and death. First-line therapy with drug combinations that target multiple biological pathways are associated with improved survival.


Assuntos
Insuficiência Cardíaca , Hipertensão Arterial Pulmonar , Adulto , Anti-Hipertensivos/uso terapêutico , Antagonistas dos Receptores de Endotelina/uso terapêutico , Endotelinas/uso terapêutico , Guanosina Monofosfato/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/etiologia , Humanos , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/tratamento farmacológico , Hipertensão Pulmonar/etiologia , Recém-Nascido , Óxido Nítrico/uso terapêutico , Hipertensão Arterial Pulmonar/diagnóstico , Hipertensão Arterial Pulmonar/tratamento farmacológico , Hipertensão Arterial Pulmonar/etiologia , Tadalafila/uso terapêutico , Estados Unidos
4.
Med Sci Educ ; 31(6): 1779-1788, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34956697

RESUMO

Teamwork skills are recognized as a core competency of physicians. To more effectively prepare trainees for the demands of their future work, medical educators are increasingly turning to group-based instructional formats. We employ case-based collaborative learning (CBCL) - a format which requires daily in-class discussion and collaboration in assigned small groups. While students overwhelmingly embraced CBCL as stimulating and thought-provoking, some students reported that social dynamics among group members adversely impacted their experience. Using mixed methods, we demonstrate that a short intervention that asked students to discuss how they can best learn together improved small group dynamics, and promoted psychological safety among peers. Importantly, no specific instruction in team work was required, students overall had a clear understanding how they could improve, but they did not know how to start this conversation with each other. To promote team learning, we propose that educators emphasize students' accountability to their peers' learning in addition to their own, and devote some time in class for teams to reflect and discuss how to improve learning with each other. Our observations are of interest to anyone frequently relying on group work without peer assessment or formal feedback on group performance.

7.
Acad Med ; 95(11): 1687-1695, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32134787

RESUMO

As the U.S. health care system changes and technology alters how doctors work and learn, medical schools and their faculty are compelled to modify their curricula and teaching methods. In this article, educational leaders and key faculty describe how the Pathways curriculum was conceived, designed, and implemented at Harvard Medical School. Faculty were committed to the principle that educators should focus on how students learn and their ability to apply what they learn in the evaluation and care of patients. Using the best evidence from the cognitive sciences about adult learning, they made major changes in the pedagogical approach employed in the classroom and clinic. The curriculum was built upon 4 foundational principles: to enhance critical thinking and provide developmentally appropriate content; to ensure both horizontal integration between courses and vertical integration between phases of the curriculum; to engage learners, foster curiosity, and reinforce the importance of student ownership and responsibility for their learning; and to support students' transformation to a professional dedicated to the care of their patients and to their obligations for lifelong, self-directed learning.The practice of medicine is rapidly evolving and will undoubtedly change in multiple ways over the career of a physician. By emphasizing personal responsibility, professionalism, and thinking skills over content transfer, the authors believe this curriculum will prepare students not only for the first day of practice but also for an uncertain future in the biological sciences, health and disease, and the nation's health care system, which they will encounter in the decades to come.


Assuntos
Competência Clínica , Currículo , Educação de Graduação em Medicina , Aprendizagem Baseada em Problemas , Participação dos Interessados , Pensamento , Avaliação Educacional , Docentes de Medicina , Humanos , Avaliação das Necessidades , Ensino
10.
Eur J Prev Cardiol ; 24(11): 1190-1199, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28506086

RESUMO

Background Unexplained dyspnea is a common diagnosis that often results in repeated diagnostic testing and even delayed treatments while a determination of the cause is being investigated. Through a retrospective study, we evaluated the diagnostic efficacy of a multidisciplinary dyspnea evaluation center (MDEC) using invasive cardiopulmonary exercise test to diagnose potential causes of unexplained dyspnea. Methods We reviewed the medical records of all patients referred with unexplained dyspnea to the MDEC between March 2011 and October 2014. We assessed the diagnostic efficacy before and after presentation to the MDEC. Results During the study period a total of 864 patients were referred to the MDEC and, of those, 530 patients underwent further investigation with invasive cardiopulmonary exercise test and constituted the study sample. The median age was 57 (44-68) years, 67.2% were women, and median body mass index was 26.22 (22.78-31.01). A diagnosis was made in 530 patients including: exercise pulmonary arterial hypertension of 88 (16.6%), heart failure with preserved ejection fraction of 94 (17.7%), dysautonomia 112 (21.1%), oxidative myopathy of 130 (24.5%), primary hyperventilation of 43 (8.1%), and other 58 (10.9%). The time from initial presentation to referral was significantly longer than time to diagnosis after referral for non-standardized conventional methods versus diagnosis through MDEC using invasive cardiopulmonary exercise test (511 days (292-1095 days) vs. 27 days (13-53 days), p < 0.0001). In a subgroup analysis, we reviewed that patients referred from cardiovascular clinics were more likely to have a greater number of diagnostic tests performed and, conversely, patients referred from pulmonary clinics were more likely to have a greater number of treatments prescribed before referral to MDEC. Conclusions As a result of this retrospective study, we have evaluated that a multidisciplinary approach that includes invasive cardiopulmonary exercise test dramatically reduces the time to diagnosis compared with traditional treatment and testing methods.


Assuntos
Dispneia/diagnóstico , Tolerância ao Exercício/fisiologia , Insuficiência Cardíaca/complicações , Hipertensão Pulmonar/complicações , Adulto , Idoso , Dispneia/etiologia , Dispneia/fisiopatologia , Teste de Esforço/métodos , Feminino , Seguimentos , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Humanos , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/fisiopatologia , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Tempo
11.
Med Teach ; 39(6): 653-659, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28332912

RESUMO

Increasingly over the past decade, faculty in medical and graduate schools have received requests from digital millennial learners for concise faculty-made educational videos. At our institution, over the past couple of years alone, several hundred educational videos have been created by faculty who teach in a flipped-classroom setting of the pre-clinical medical school curriculum. Despite the appeal and potential learning benefits of digital chalk-talk videos first popularized by Khan Academy, we have observed that the conceptual and technological barriers for creating chalk-talk videos can be high for faculty. To this end, this tips article offers an easy-to-follow 12-step conceptual framework to guide at-home production of chalk-talk educational videos.


Assuntos
Carbonato de Cálcio , Currículo , Gravação de Videoteipe , Humanos , Aprendizagem , Faculdades de Medicina
12.
Pulm Circ ; 5(3): 435-65, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26401246

RESUMO

Pregnancy outcomes in patients with pulmonary hypertension remain poor despite advanced therapies. Although consensus guidelines recommend against pregnancy in pulmonary hypertension, it may nonetheless occasionally occur. This guideline document sought to discuss the state of knowledge of pregnancy effects on pulmonary vascular disease and to define usual practice in avoidance of pregnancy and pregnancy management. This guideline is based on systematic review of peer-reviewed, published literature identified with MEDLINE. The strength of the literature was graded, and when it was inadequate to support high-level recommendations, consensus-based recommendations were formed according to prespecified criteria. There was no literature that met standards for high-level recommendations for pregnancy management in pulmonary hypertension. We drafted 38 consensus-based recommendations on pregnancy avoidance and management. Further, we identified the current state of knowledge on the effects of sex hormones during pregnancy on the pulmonary vasculature and right heart and suggested areas for future study. There is currently limited evidence-based knowledge about both the basic molecular effects of sex hormones and pregnancy on the pulmonary vasculature and the best practices in contraception and pregnancy management in pulmonary hypertension. We have drafted 38 consensus-based recommendations to guide clinicians in these challenging topics, but further research is needed in this area to define best practices and improve patient outcomes.

13.
Handb Exp Pharmacol ; 218: 229-55, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-24092343

RESUMO

Nitric oxide (NO) signaling plays a key role in modulating vascular tone and remodeling in the pulmonary circulation. The guanylate cyclase/cyclic guanylate monophosphate-signaling pathway primarily mediates nitric oxide signaling. This pathway is critical in normal regulation of the pulmonary vasculature, and is an important target for therapy in patients with pulmonary hypertension. In the pulmonary vasculature, degradation of cGMP is primarily regulated by PDE-5, and inhibition of this enzyme has important effects on pulmonary vasculature smooth muscle tone. Large randomized placebo-controlled trials of PDE-5 inhibitors demonstrated improved exercise capacity, hemodynamics and quality of life in adult patients with PAH. This chapter will discuss the mechanisms of NO signaling in the vasculature, characteristics of the PDE5-inhibitors approved for treatment of PH, and review available data on the use of phosphodiesterase inhibitors in PH.


Assuntos
Hipertensão Pulmonar/tratamento farmacológico , Inibidores da Fosfodiesterase 5/uso terapêutico , Animais , Proteínas Quinases Dependentes de GMP Cíclico/fisiologia , Humanos , Hipertensão Pulmonar/fisiopatologia , Óxido Nítrico/fisiologia , Inibidores da Fosfodiesterase 5/efeitos adversos , Inibidores da Fosfodiesterase 5/farmacologia , Transdução de Sinais , Volume Sistólico/efeitos dos fármacos
15.
J Heart Lung Transplant ; 32(4): 381-7, 2013 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23415728

RESUMO

BACKGROUND: Patients with severe pulmonary arterial hypertension (PAH) face significant morbidity and death as a consequence of progressive right heart failure. Surgical shunt placement between the left PA and descending aorta (Potts shunt) appears promising for PAH palliation in children; however, surgical mortality is likely to be unacceptably high in adults with PAH. METHODS: We describe a technique for transcatheter Potts shunt (TPS) creation by fluoroscopically guided retrograde needle perforation of the descending aorta at the site of apposition to the left PA to create a tract for deployment of a covered stent between these vessels. This covered stent-anchored by the vessel walls and surrounding tissue-serves as the shunt. RESULTS: TPS creation was considered in 7 patients and performed in 4. The procedure was technically successful in 3 patients; 1 patient died during the procedure as a result of uncontrolled hemothorax. One acute survivor, critically ill at the time of TPS creation, later died of comorbidities. The 2 mid-term survivors (follow-up of 10 and 4 months) are well at home, with symptomatic improvement and no late complications. The 3 candidate patients in whom the procedure was not performed died within 1 month of consideration, underscoring the tenuous nature of this population. CONCLUSIONS: TPS creation is feasible and may offer symptomatic relief to select patients with refractory PAH. Further study of this innovative approach is warranted.


Assuntos
Aorta Torácica/cirurgia , Hipertensão Pulmonar/cirurgia , Artéria Pulmonar/cirurgia , Adolescente , Adulto , Anastomose Cirúrgica/métodos , Hipertensão Pulmonar Primária Familiar , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Vasculares/métodos
16.
Chest ; 135(6): 1648-1650, 2009 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-19497900

RESUMO

Extrinsic compression of the left main coronary artery (LMCA) can occur in patients with severe pulmonary hypertension and enlarged pulmonary artery trunk. It has been usually described in the setting of congenital defects such as atrial septal defect, ventricular septal defect, and, more rarely, isolated persistent ductus arteriosus. Functional and structural evaluation of such patients can currently be performed noninvasively with the use of cardiac CT scanning and/or MRI. The optimal management of symptomatic patients remains unknown. We report a case of extrinsic compression of the LMCA in a symptomatic patient with Eisenmenger syndrome who underwent unprotected LMCA stent implantation. We also performed a literature review of the reported cases concerning patients treated with LMCA stent implantation for the management of this condition.


Assuntos
Angioplastia Coronária com Balão/métodos , Doenças da Aorta/complicações , Estenose Coronária/etiologia , Estenose Coronária/terapia , Hipertensão Pulmonar/complicações , Doenças da Aorta/diagnóstico , Procedimentos Cirúrgicos Cardíacos/métodos , Angiografia Coronária , Estenose Coronária/diagnóstico por imagem , Permeabilidade do Canal Arterial/complicações , Permeabilidade do Canal Arterial/diagnóstico , Permeabilidade do Canal Arterial/cirurgia , Feminino , Seguimentos , Transplante de Coração-Pulmão , Humanos , Hipertensão Pulmonar/diagnóstico por imagem , Pessoa de Meia-Idade , Radiografia Torácica , Medição de Risco , Índice de Gravidade de Doença , Stents , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Listas de Espera
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