Learning through Teaching: Peer Teaching and Mentoring Experiences among Third-Year Medical Students.

PHENOMENON: Classroom studies of peer-led teaching and mentoring report benefits for students both as teachers and learners. Such benefits include both improved content mastery and personal and professional development. While benefits of peer-led teaching in the clinical setting have been well characterized among other health professions, less is known within undergraduate medical education. In this study, we explored medical students' perceptions and experiences relevant to peer teaching and mentoring in outpatient clinical clerkships. APPROACH: Third-year medical students enrolled in two different longitudinal primary care clerkships, Education Centered Medical Home (ECMH) or Individual Preceptorship (IP), participated in semi-structured interviews in 2018. Students were asked to describe their peer teaching experiences during the clerkship and to reflect on their experiences serving as role models or mentors. We analyzed transcripts utilizing a two-cycle team-based inductive approach. FINDINGS: Thirty-three students completed interviews. We derived three main themes: (1) diversity of peer teaching and mentoring opportunities, (2) transitioning one's role from learner to teacher, and (3) personal and professional development. While participants from both clerkships participated in peer teaching and mentoring experiences, ECMH students described more opportunities to interact with students across all years of medical school training, noting that "getting that guidance and in turn being able to teach is a valuable experience." ECMH students further perceived the responsibility of creating a comfortable learning environment for others. Students from both clerkships reflected on 'learning through teaching,' that teaching served as a reaffirmation of the knowledge they gained, and that teaching experience contributed to their personal and professional growth. INSIGHTS: Students perceived their participation in peer teaching and mentoring experiences in the clinical setting as contributing positively to personal and professional development. Students from both clerkships reflected on their teaching and mentoring opportunities as a facilitator of growth in their own teaching skills; ECMH students further described a heightened sense of self-confidence and fulfillment. These findings highlight the importance of creating learning environments that foster peer teaching and mentoring, as such opportunities may lead to further growth as a learner and as a physician.

From Passive Gatekeeper to Quarterback: Evolving Perceptions of Primary Care Among Medical Students in Longitudinal Outpatient Clerkships.

BACKGROUND: Longitudinal clerkships provide students with meaningful clinical care roles that promote learning and professional development. It remains unclear how longitudinal primary care clerkships inform students' perceptions of primary care. OBJECTIVE: To explore perceptions of primary care among medical students enrolled in longitudinal primary care clerkships. DESIGN: Qualitative, semi-structured interviews with medical students over 4 years. PARTICIPANTS: Thirty-eight medical students participated at baseline; 35 participated in a 2-year follow-up interview; 24 participated at 4 years. Each student was enrolled in one of two longitudinal primary care clerkships: a team-based Education-Centered Medical Home (ECMH) or a one-on-one individual preceptorship (IP). APPROACH: De-identified interview transcripts were analyzed using a process of open and axial coding, followed by elaborative coding for longitudinal analysis. Codes were compiled into a set of themes and compared across time periods and between clerkships. KEY RESULTS: Students reported that primary care serves as a first point of contact, emphasizing longitudinal care with a wide scope of practice and approaching patient care with a biopsychosocial perspective. Student perceptions of primary care greatly expanded over the course of 4 years: for instance, initial perceptions of primary care physicians evolved from "passive gatekeeper" to a more nuanced "quarterback." Students in ECMH, whose clerkship provided more opportunity for patient continuity, further reflected on the relationships they themselves developed with patients. CONCLUSIONS: Regardless of their eventual specialty choice, longitudinal experiences may aid all students in fostering a sense of the broad scope and importance of primary care. However, without numerous opportunities to witness continuity of care, students may perceive primary care as having limited scope and importance. Longitudinal clerkships, emphasizing continuity with patients and preceptors, may foster in students a broad and nuanced perspective of the scope of primary care as a field.

The Neuroanatomical Ultrastructure and Function of a Biological Ring Attractor.

Neural representations of head direction (HD) have been discovered in many species. Theoretical work has proposed that the dynamics associated with these representations are generated, maintained, and updated by recurrent network structures called ring attractors. We evaluated this theorized structure-function relationship by performing electron-microscopy-based circuit reconstruction and RNA profiling of identified cell types in the HD system of Drosophila melanogaster. We identified motifs that have been hypothesized to maintain the HD representation in darkness, update it when the animal turns, and tether it to visual cues. Functional studies provided support for the proposed roles of individual excitatory or inhibitory circuit elements in shaping activity. We also discovered recurrent connections between neuronal arbors with mixed pre- and postsynaptic specializations. Our results confirm that the Drosophila HD network contains the core components of a ring attractor while also revealing unpredicted structural features that might enhance the network's computational power.

Continuity With Patients, Preceptors, and Peers Improves Primary Care Training: A Randomized Medical Education Trial.

PURPOSE: Infusing continuity of care into medical student clerkships may accelerate professional development, preserve patient-centered attitudes, and improve primary care training. However, prospective, randomized studies of longitudinal curricula are lacking. METHOD: All entering Northwestern University Feinberg School of Medicine students in 2015 and 2016 were randomized to the Education Centered Medical Home (ECMH), a 4-year, team-based primary care clerkship; or a mentored individual preceptorship (IP) for 2 years followed by a traditional 4-week primary care clerkship. Students were surveyed 4 times (baseline, M1, M2, and M3 year [through 2018]); surveys included the Maslach Burnout Inventory (MBI); the Communication, Curriculum, and Culture (C3) survey assessing the hidden curriculum; and the Attitudes Toward Health Care Teams (ATHCT) scale. The authors analyzed results using an intent-to-treat approach. RESULTS: Three hundred twenty-nine students were randomized; 316 (96%) participated in surveys. Seventy percent of all respondents would recommend the ECMH to incoming first-year students. ECMH students reported a more positive learning environment (overall quality, 4.4 ECMH vs 4.0 IP, P < .001), greater team-centered attitudes (ATHCT scale, 3.2 vs 3.0, P = .007), less exposure to negative aspects of the hidden curriculum (C3 scale, 4.6 vs 4.3, P < .001), and comparable medical knowledge acquisition. ECMH students established more continuity relationships with patients (2.2 vs 0.3, P < .001) and reported significantly higher professional efficacy (MBI-PE, 4.1 vs 3.9, P = .02). CONCLUSIONS: In this randomized medical education trial, the ECMH provided superior primary care training across multiple outcomes compared with a traditional clerkship-based model, including improved professional efficacy.

Continuity in Undergraduate Medical Education: Mission Not Accomplished.

Evidence is mounting that longitudinal medical student clerkships provide better educational experiences than traditional block clerkship "silos." Education studies across institutions demonstrate positive effects of continuity on medical students, including creating patient-centered learning environments, improving fidelity of evaluations and feedback, improving medical student patient-centeredness, enabling more autonomous functioning in the clinical workplace, and increased recruitment and retention of students into primary care careers. Outcome studies show potential for longitudinal students to add value to patient care. This perspective piece summarizes the current evidence basis for longitudinal clerkships broken down by Kirkpatrick level (reactions, perceptions/attitudes, knowledge, behaviors, and patient benefits). Despite this evidence, expansion of longitudinal clerkships has been slow-i.e., fewer than half of current US medical schools offer one. While more recent curricular innovations center around Entrustable Professional Activities (EPAs), there are clear opportunities for medical schools to use longitudinal clerkships as a lens through which EPAs can be effectively evaluated. This perspective highlights the synergy between longitudinal clerkships and EPAs, showing that successful implementation of the former should empower the latter. While large, complex educational interventions are daunting tasks, change is needed. Regulatory organizations should mandate continuity-focused experiences for US medical graduates.

Perceptions of Patient-Centered Care among First-Year Medical Students.

Phenomenon: Teaching patient-centered care (PCC) is a key component of undergraduate medical curricula. Prior frameworks of PCC describe multiple domains of patient-centeredness, ranging from interpersonal encounters to systems-level issues. Medical students' perceptions of PCC are thought to erode as they progress through school, but little is known about how students view PCC toward the beginning of training. This study explores the perceptions of PCC among 1st-year medical students to inform curricular development and evaluation. Approach: Medical students participated in semistructured, in-person interviews within 4 months of starting medical school as part of a longitudinal study. Transcripts were analyzed using a grounded theory approach and the constant comparative method to describe responses and characterize emergent themes. Transcripts were reviewed to compare codes and compile a final codebook. Findings: Thirty-eight students completed interviews. Students provided heterogeneous definitions of PCC, including perceptions that PCC is implicit and obvious. Many students were unable to provide a concrete definition of PCC, juxtaposing PCC with other priorities such as profit- or physician-centered care, whereas others thought the term was jargon. Some participants defined PCC as upholding patient values using hypothetical examples centered around physician behavior. Insights: Although students appeared to enter medical school with a range of perceptions about PCC, many of their descriptions were limited and only scratch the surface of existing frameworks. Rather than their perceptions of PCC eroding during medical school, students may never fully develop a foundational understanding of PCC. Our findings reinforce the need for authentic, clinically experiential learning opportunities that promote PCC from the earliest stages of medical education.

Learning to be a doctor: Medical students' perception of their roles in longitudinal outpatient clerkships.

OBJECTIVE: To understand how medical students perceive their roles in early longitudinal primary care clerkships. METHODS: Medical students enrolled in one of two longitudinal primary care clerkships - Education-Centered Medical Home (ECMH) or Individual Preceptorship (IP) - participated in semi-structured interviews. Interviews were recorded, transcribed, and analyzed using a grounded theory and constant comparative approach. RESULTS: Students (N = 35) in both clerkships perceived benefits of early clinical exposure, reflecting positively on having time to interact with patients. Identified roles ranged from shadower to collaborator to diagnostician; a progression from position-centered to more patient-centered roles emerged. ECMH students also identified as health educators, care managers, and mentors. IP students described the clerkship primarily as an opportunity to acquire clinical knowledge and practice skills, expressing perceptions of being a transient "visitor" in the clinic, whereas ECMH students reported taking an active role in continuity care of patients. CONCLUSION: Students identified benefits of early longitudinal outpatient primary care clerkships, supporting the inclusion of these experiences within medical school curricula. Clerkships with an emphasis on longitudinal and team-based care may further promote student participation in patient care and professional development. PRACTICE IMPLICATIONS: Longitudinal, team-based early clinical experiences may best promote student involvement in patient care.

The insect central complex.

Hordes of tourists flock to Washington, D.C. every spring to see the cherry trees blossom. Once in the city, they must find their way to the Tidal Basin where the Japanese trees grow. Fortunately, a number of visual landmarks can help them to navigate. In 1910, the United States Congress passed The Height of Buildings Act, limiting the elevation of commercial and residential structures in D.C. to 130 feet. Thus, the 555-foot-tall Washington Monument often looms large against the horizon, serving as an anchor point to help set the tourists' sense of direction. Once their heading is set, they can lose sight of the monument behind buildings or groups of tall Scandinavian visitors and still use their internal compass to navigate to the Basin. This compass keeps track of their paces and turns and updates their sense of where they are and where they need to go. Yet while their heading informs their actions, it does not dictate them. Tourists who have been to D.C. in the past can, for example, use remembered views to alter their routes to avoid crowds. On an even finer scale, their leg movements also depend on their current state - they might increase the frequency and length of their strides if hunger pangs compete with their desire to see cherry blossoms, for example. The way in which these disparate cues and motivations influence exploration is a neuroscience mystery across creatures large and small.

Four-Year Educational and Patient Care Outcomes of a Team-Based Primary Care Longitudinal Clerkship.

BACKGROUND: Longitudinal clerkships show promise in improving undergraduate primary care education. This study examines the Education-Centered Medical Home (ECMH), a longitudinal clerkship embedding teams of students across all four years into primary care clinics to provide patient care and serve as health coaches for high-risk patients. METHOD: All students graduating in 2015 were surveyed to assess attitudes, experiences, and preferences regarding primary care education. ECMH students were compared with students receiving their primary care training in a traditional curriculum (TC) using paired measures of comparison. To assess the impact of the ECMH on patient care quality, authors performed a detailed chart review at one site. RESULTS: Seventy-six percent of eligible students participated in the study. ECMH students (n = 69) and TC students (n = 68) had similar baseline academic performance and career interests. ECMH students reported more continuity-of-care experiences, higher satisfaction with their primary care learning climate (86% versus 61% in the EMCH and TC cohorts, respectively), more confidence in their quality improvement skills, and scored higher on measures of perceived patient centeredness. Students from both groups recommended the ECMH (91% and 57%, respectively). Student involvement at one ECMH site was correlated with increased patient contacts and improved delivery of recommended preventive care. CONCLUSIONS: Incorporating students longitudinally into primary care clinics is highly rated by students. The ECMH model led to improved continuity, improved perceptions of the learning climate, and higher patient centeredness. Preliminary data suggest that students add value and improve patient outcomes during longitudinal clinical experiences.

Medical students' observations, practices, and attitudes regarding electronic health record documentation.

BACKGROUND: Medical students are increasingly documenting their patient notes in electronic health records (EHRs). Documentation short-cuts, such as copy-paste and templates, have raised concern among clinician-educators because they may perpetuate redundant, inaccurate, or even plagiarized notes. Little is known about medical students' experiences with copy-paste, templates and other "efficiency tools" in EHRs. PURPOSES: We sought to understand medical students' observations, practices, and attitudes regarding electronic documentation efficiency tools. METHODS: We surveyed 3rd-year medical students at one medical school. We asked about efficiency tools including copy-paste, templates, auto-inserted data, and "scribing" (documentation under a supervisor's name). RESULTS: Overall, 123 of 163 students (75%) responded; almost all frequently use an EHR for documentation. Eighty-six percent (102/119) reported at least sometimes observing residents copying data from other providers' notes and 60% (70/116) reported observing attending physicians doing so. Most students (95%, 113/119) reported copying from their own previous notes, and 22% (26/119) reported copying from residents. Only 10% (12/119) indicated that copying from other providers is acceptable, whereas 83% (98/118) believe copying from their own notes is acceptable. Most students use templates and auto-inserted data; 43% (51/120) reported documenting while signed in under an attending's name. Greater use of documentation efficiency tools is associated with plans to enter a procedural specialty and with lack of awareness of the medical school copy-paste policy. CONCLUSIONS: Students frequently use a range of efficiency tools to document in the electronic health record, most commonly copying their own notes. Although the vast majority of students believe it is unacceptable to copy-paste from other providers, most have observed clinical supervisors doing so.

Educating future physicians to track health care quality: feasibility and perceived impact of a health care quality report card for medical students.

PURPOSE: Quality improvement (QI) requires measurement, but medical schools rarely provide opportunities for students to measure their patient outcomes. The authors tested the feasibility and perceived impact of a quality metric report card as part of an Education-Centered Medical Home longitudinal curriculum. METHOD: Student teams were embedded into faculty practices and assigned a panel of patients to follow longitudinally. Students performed retrospective chart reviews and reported deidentified data on 30 nationally endorsed QI metrics for their assigned patients. Scorecards were created for each clinic team. Students completed pre/post surveys on self-perceived QI skills. RESULTS: A total of 405 of their patients' charts were abstracted by 149 students (76% response rate; mean 2.7 charts/student). Median abstraction time was 21.8 (range: 13.1-37.1) minutes. Abstracted data confirmed that the students had successfully recruited a "high-risk" patient panel. Initial performance on abstracted quality measures ranged from 100% adherence on the use of beta-blockers in postmyocardial infarction patients to 24% on documentation of dilated diabetic eye exams. After the chart abstraction assignment, grand rounds, and background readings, student self-assessment of their perceived QI skills significantly increased for all metrics, though it remained low. CONCLUSIONS: Creation of an actionable health care quality report card as part of an ambulatory longitudinal experience is feasible, and it improves student perception of QI skills. Future research will aim to use statistical process control methods to track health care quality prospectively as our students use their scorecards to drive clinic-level improvement efforts.

Flexible, transparent contacts for inorganic nanostructures and thin films.

A transparent, flexible contact is developed using Ni nanoparticles and Ag nanowires and demonstrated on free-standing, polymer embedded, Si microwire solar cells. Contact yields of over 99% and a series resistance of 14 Ω cm² are demonstrated.

The patient centered medical home as curricular model: perceived impact of the "education-centered medical home".

BACKGROUND: The patient-centered medical home (PCMH) model aims to provide patient-centered care, lower costs, and improve health outcomes. Medical students have not been meaningfully integrated in this model. AIM: To test the feasibility of a longitudinal clerkship based on PCMH principles and anchored by PCMH educational objectives. SETTING: Two community-based family medicine clinics, one academic internal medicine clinic, and one pediatric clinic affiliated with an urban medical school. PARTICIPANTS: 56 medical student volunteers. PROGRAM DESCRIPTION: We embedded student teams in existing faculty practices and recruited a high-risk patient panel for each team. Clinical education occurred through a traditional clinic preceptor model and was augmented by 3rd and 4th year students directly observing 1st and 2nd year students. Didactic content included monthly Grand Rounds conferences. PROGRAM EVALUATION: Students attended 699 clinics, recruited 273 continuity patients, and participated in 9 Grand Rounds conferences. Student confidence with PCMH principles increased and attitudes regarding continuity were highly positive. "Continuity," "early clinical exposure," and "peer teaching" were the most powerful themes expressed by students. Faculty response to the pilot was highly positive. DISCUSSION: An Education-Centered Medical Home (ECMH) is feasible and is highly rated by students and faculty. Expansion of this model is underway.

Validity and reliability of a new method for measuring putting stroke kinematics using the TOMI system.

The purpose of this study was to determine the validity and reliability of a new method for measuring three-dimensional (3D) putting stroke kinematics using the TOMI device. A putting robot and a high-speed camera were used to simultaneously collect data for the validity evaluation. The TOMI device, when used in conjunction with standard 3D coordinate data processing techniques, was found to be a valid and reliable method for measuring face angle, stroke path, putter speed, and impact spot at the moment of ball contact. The validity of the TOMI(R) measurement system was quantified using the 95% limits of agreement method for each aforementioned variable. The practical significance of each validity score was assessed by incorporating the maximum estimated measurement error into the stroke of the putting robot for 10 consecutive putts. All putts were executed from a distance of 4 m on a straight and flat synthetic putting surface. Since all putts were holed successfully, the measurement error for each variable was deemed to be negligible for the purposes of measuring putting stroke kinematics. The influence of key kinematic errors, at impact, on the outcome of a putt was also determined.

Enhanced absorption and carrier collection in Si wire arrays for photovoltaic applications.

Si wire arrays are a promising architecture for solar-energy-harvesting applications, and may offer a mechanically flexible alternative to Si wafers for photovoltaics. To achieve competitive conversion efficiencies, the wires must absorb sunlight over a broad range of wavelengths and incidence angles, despite occupying only a modest fraction of the array's volume. Here, we show that arrays having less than 5% areal fraction of wires can achieve up to 96% peak absorption, and that they can absorb up to 85% of day-integrated, above-bandgap direct sunlight. In fact, these arrays show enhanced near-infrared absorption, which allows their overall sunlight absorption to exceed the ray-optics light-trapping absorption limit for an equivalent volume of randomly textured planar Si, over a broad range of incidence angles. We furthermore demonstrate that the light absorbed by Si wire arrays can be collected with a peak external quantum efficiency of 0.89, and that they show broadband, near-unity internal quantum efficiency for carrier collection through a radial semiconductor/liquid junction at the surface of each wire. The observed absorption enhancement and collection efficiency enable a cell geometry that not only uses 1/100th the material of traditional wafer-based devices, but also may offer increased photovoltaic efficiency owing to an effective optical concentration of up to 20 times.

Energy-conversion properties of vapor-liquid-solid-grown silicon wire-array photocathodes.

Silicon wire arrays, though attractive materials for use in photovoltaics and as photocathodes for hydrogen generation, have to date exhibited poor performance. Using a copper-catalyzed, vapor-liquid-solid-growth process, SiCl4 and BCl3 were used to grow ordered arrays of crystalline p-type silicon (p-Si) microwires on p+-Si(111) substrates. When these wire arrays were used as photocathodes in contact with an aqueous methyl viologen(2+/+) electrolyte, energy-conversion efficiencies of up to 3% were observed for monochromatic 808-nanometer light at fluxes comparable to solar illumination, despite an external quantum yield at short circuit of only 0.2. Internal quantum yields were at least 0.7, demonstrating that the measured photocurrents were limited by light absorption in the wire arrays, which filled only 4% of the incident optical plane in our test devices. The inherent performance of these wires thus conceptually allows the development of efficient photovoltaic and photoelectrochemical energy-conversion devices based on a radial junction platform.

Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary.

BACKGROUND: Deficits in information transfer between inpatient and outpatient physicians are common and potentially dangerous. OBJECTIVE: To evaluate the effect of a newly-created electronic discharge summary. DESIGN AND PARTICIPANTS: Pre-post evaluation of discharge summaries using a survey of outpatient physicians and a medical records review. MEASUREMENTS: Outpatient physicians' ratings of satisfaction with discharge summaries before and after implementation of an electronic discharge summary using a 5-point Likert scale (1 = very dissatisfied; 5 = very satisfied). Additionally, 196 randomly selected discharge summaries before and after implementation were rated for timeliness and presence of 16 key content areas by 3 internists. RESULTS: Two hundred and twenty-six of 416 (54%) and 256 of 397 (64%) outpatient physicians completed the baseline and postimplementation surveys. Satisfaction with quality and timeliness of discharge summaries improved with the use of the electronic discharge summary (mean quality rating 3.04 versus 3.64; P < 0.001, mean timeliness rating 2.59 versus 3.34; P < 0.001). A higher percentage of electronic discharge summaries were completed within 3 days of discharge as compared with dictated discharge summaries (44.8% versus 74.1%; P < 0.001). Several elements of the discharge summary were present more often with the electronic discharge summary, including discussion of follow-up issues (52.0% versus 75.8%; P = 0.001), pending test results (13.9% versus 46.3%; P < 0.001), and information provided to the patient and/or family (85.1% versus 95.8%; P = 0.01). CONCLUSIONS: The use of an electronic discharge summary significantly improved the quality and timeliness of discharge summaries.

Photovoltaic measurements in single-nanowire silicon solar cells.

Single-nanowire solar cells were created by forming rectifying junctions in electrically contacted vapor-liquid-solid-grown Si nanowires. The nanowires had diameters in the range of 200 nm to 1.5 microm. Dark and light current-voltage measurements were made under simulated Air Mass 1.5 global illumination. Photovoltaic spectral response measurements were also performed. Scanning photocurrent microscopy indicated that the Si nanowire devices had minority carrier diffusion lengths of approximately 2 microm. Assuming bulk-dominated recombination, this value corresponds to a minimum carrier lifetime of approximately 15 ns, or assuming surface-dominated recombination, to a maximum surface recombination velocity of approximately 1350 cm s(-1). The methods described herein comprise a valuable platform for measuring the properties of semiconductor nanowires, and are expected to be instrumental when designing an efficient macroscopic solar cell based on arrays of such nanostructures.

Label-free immunodetection with CMOS-compatible semiconducting nanowires.

Semiconducting nanowires have the potential to function as highly sensitive and selective sensors for the label-free detection of low concentrations of pathogenic microorganisms. Successful solution-phase nanowire sensing has been demonstrated for ions, small molecules, proteins, DNA and viruses; however, 'bottom-up' nanowires (or similarly configured carbon nanotubes) used for these demonstrations require hybrid fabrication schemes, which result in severe integration issues that have hindered widespread application. Alternative 'top-down' fabrication methods of nanowire-like devices produce disappointing performance because of process-induced material and device degradation. Here we report an approach that uses complementary metal oxide semiconductor (CMOS) field effect transistor compatible technology and hence demonstrate the specific label-free detection of below 100 femtomolar concentrations of antibodies as well as real-time monitoring of the cellular immune response. This approach eliminates the need for hybrid methods and enables system-scale integration of these sensors with signal processing and information systems. Additionally, the ability to monitor antibody binding and sense the cellular immune response in real time with readily available technology should facilitate widespread diagnostic applications.