Denosumab versus Bisphosphonates for Reducing Fractures in Postmenopausal Women with Osteoporosis: A Meta-Analysis.

BACKGROUND: There are multiple classes of pharmacologic agents approved for treatment of osteoporosis, but their costs vary widely, and systematic data on their efficacy compared with the traditional standard, bisphosphonates, for reducing fractures in postmenopausal women are lacking. The objective was to perform a systematic review and meta-analysis assessing the efficacy of denosumab compared with bisphosphonates. METHODS: Researchers selected randomized controlled trials (RCTs) comparing denosumab to bisphosphonates that included information on clinical and/or osteoporotic fracture events over the follow-up period. Each clinical outcome was meta-analyzed using a fixed-effects analysis, with clinical and osteoporotic fractures as the outcomes of interest. A meta-regression was performed using change in bone mineral density (BMD) as the moderator variable. RESULTS: Seven RCTs were included. Denosumab was not associated with a reduction in clinical or osteoporotic fractures compared with bisphosphonates. There was no association between the change in BMD with denosumab and bisphosphonates and denosumab's effect on both osteoporotic and clinical fractures. DISCUSSION: Existing data do not support the use of the more expensive denosumab as a first-line agent over bisphosphonates for reduction of fractures in postmenopausal women with osteoporosis. One limitation in this study was each RCT was not individually powered for fracture incidences.

Educating for the 21st-Century Health Care System: An Interdependent Framework of Basic, Clinical, and Systems Sciences.

In the face of a fragmented and poorly performing health care delivery system, medical education in the United States is poised for disruption. Despite broad-based recommendations to better align physician training with societal needs, adaptive change has been slow. Traditionally, medical education has focused on the basic and clinical sciences, largely removed from the newer systems sciences such as population health, policy, financing, health care delivery, and teamwork. In this article, authors examine the current state of medical education with respect to systems sciences and propose a new framework for educating physicians in adapting to and practicing in systems-based environments. Specifically, the authors propose an educational shift from a two-pillar framework to a three-pillar framework where basic, clinical, and systems sciences are interdependent. In this new three-pillar framework, students not only learn the interconnectivity in the basic, clinical, and systems sciences but also uncover relevance and meaning in their education through authentic, value-added, and patient-centered roles as navigators within the health care system. Authors describe the Systems Navigation Curriculum, currently implemented for all students at the Penn State College of Medicine, as an example of this three-pillar educational model. Simple adjustments, such as including occasional systems topics in medical curriculum, will not foster graduates prepared to practice in the 21st-century health care system. Adequate preparation requires an explicit focus on the systems sciences as a vital and equal component of physician education.

SOAP-V: Introducing a method to empower medical students to be change agents in bending the cost curve.

Medical students must learn how to practice high-value, cost-conscious care. By modifying the traditional SOAP (Subjective-Objective-Assessment-Plan) presentation to include a discussion of value (SOAP-V), we developed a cognitive forcing function designed to promote discussion of high-value, cost-conscious care during patient delivery. The SOAP-V model prompts the student to consider (1) the evidence that supports a test or treatment, (2) the patient's preferences and values, and (3) the financial cost of a test or treatment compared to alternatives. Students report their findings to their teams during patient care rounds. This tool has been successfully used at 3 medical schools. Preliminary results find that students who have been trained in SOAP-V feel more empowered to address the economic healthcare crisis, are more comfortable in initiating discussions about value, and are more likely to consider potential costs to the healthcare system.

A Curriculum for Clerkship Students to Foster Professionalism Through Reflective Practice and Identity Formation.

INTRODUCTION: Research suggests that students become less patient-centered and empathetic in response to both internal and external factors, including the organizational culture, or hidden curriculum, of medical school. Students often feel compelled to make compromises when they experience tension between competing values in clinical teaching environments. To address this, we implemented a modular, longitudinal professionalism curriculum for third-year medical students, based on a conceptual model that highlights a student's ideal, as well as the internal and environmental forces that can either sustain or change their ideal over time. METHODS: As students progressed through the third year, they participated in various modules linked to different clerkships, each focusing on a different aspect of the conceptual model. Each module includes a reflective writing exercise followed by a faculty-facilitated discussion. RESULTS: In general, students rated the group discussions and faculty facilitation as the most useful parts of each session and the writing exercises as the least useful. Written comments were mostly favorable and suggested that the session facilitated self-reflection and provided a safe environment for students to discuss stressors of third-year clerkships. DISCUSSION: This curriculum represents a unique approach to fostering professional role formation through its broad potential applicability to multiple types and levels of learners, its adaptability to fit various course lengths and learning environments, and its incorporation of a conceptual model that allows individual learners to address different facets of the sustaining and acculturating forces that impact their personal professional identity formation for future encounters.

A national survey of eating disorder training.

OBJECTIVE: Eating disorders (EDs) result in the highest mortality rate of all psychiatric disorders, and in the United States, approximately one in twenty females suffers from an eating disorder. However, training provided within residency programs to address the needs of these patients is sparse. The objective of this study was to conduct a national survey that assesses the amount of EDs training for trainees across five ACGME accredited specialties: internal medicine, pediatrics, family medicine, psychiatry, and child and adolescent psychiatry. The results of the survey will be used to develop strategies to improve eating disorder education among residents. METHOD: Eight hundred eighty training coordinators were contacted using information available on the ACGME website and asked to complete the survey. RESULTS: Of the 637 responding programs, 514 did not offer any scheduled or elective rotations for EDs. Of the 123 programs offering rotations, only 42 offered a formal, scheduled rotation. Child and adolescent psychiatry offered the most clinical experiences, and pediatric programs offered the greatest number of didactic hours on EDs. DISCUSSION: Training in EDs is limited. Simulated patient encounters, massive open online courses, web-based curricula, dedicated rotations and clinical experiences, didactic curricula, and brief-training programs may help to improve eating disorder diagnostic and treatment skills among trainees.

Quality and safety during the off hours in medicine units: a mixed methods study of front-line provider perspectives.

BACKGROUND: Hospital off-hours care is associated with poor outcomes. Mutual conceptualization among provider groups may facilitate improvement efforts. Provider-perceived threats to quality are unreported. OBJECTIVES: The objectives of this study were to identify perceived off-hours quality and safety issues, assess the most significant, and evaluate differences between nurses, and attending and housestaff physicians, and providers with day and night experience. DESIGN: Prospective, sequential, exploratory mixed-methods study. MEASURES: Open-ended descriptions of adverse events/near misses occurring overnight (n = 190) were analyzed using thematic analysis. From these results, a survey was developed to assess perceptions of quality/frequency of each issue (7-point scale, 7 = the highest rating) and highest-quality overnight period (7-10 pm, 10 pm-1 am, 1-4 am, 4-7 am). RESULTS: Primary issues related to mismanagement, delivery processes, and communication/coordination. Of 214 surveys, 160 responses (75%) were received. Least-optimal issues related to "communication" (2.93) and "timeliness/safety" (3.89) of emergency department transfers; most-optimal issues related to timely lab reporting (4.70). On the 7-point scale, comparisons among nurses, and attending and housestaff physicians revealed differences in quality of "communication between physicians" (4.29 vs 6.00 vs 5.14) and "communication between consultants-primary providers" (3.46 vs 5.75 vs 4.35, P < 0.001). Comparisons between day-night providers revealed lower ratings from day providers in 12/24 items (P < 0.05), including "communication during emergency department transfers" (4.81 vs 3.86). All groups ranked 4 to 7am lowest in quality. CONCLUSIONS: Nurses, and attending and housestaff physicians lack a shared mental model of off-hours care. Several issues, including emergency department transfers and timeliness of consults, were identified by all providers as problematic, meriting further investigation and intervention.

Teaching behavior change concepts and skills during the third-year medicine clerkship.

Risky health behaviors and social factors are linked to half of all causes of morbidity and mortality in the United States. Physicians report lack of training as one of the barriers to providing behavior change counseling. Formal behavior change curricula are infrequent in medical schools, and where they are available, they are often isolated from clinical experiences or presented through a limited approach. The authors developed the Health Beliefs and Behavior (HBB) course at University of Medicine and Dentistry-New Jersey Medical School (UMDNJ-NJMS) to teach the impact of unhealthy behaviors on health and wellness, to broaden students' understanding of the many factors that affect behavior, and to give medical students tools to facilitate health behavior change in patients. To the authors' knowledge, this is the only comprehensive, clinically integrated course on health behavior change in a U.S. medical school.The authors intercalated the 60-hour HBB course in the four-week, third-year internal medicine clerkship ambulatory block. Thus, students practice learned techniques in both the ambulatory and classroom settings, and they gain insight into health behavior by applying learned health models to patients and engaging in experiential exercises. Course components stress the biopsychosocial and patient-centered approach. The authors measure the impact of the course through student surveys. Third-year medical students at UMDNJ-NJMS who have completed the HBB course report enhanced understanding of the principles of behavior change and improved ability to perform behavior change counseling.

Chief residents as educators: an effective method of resident development.

BACKGROUND: The importance of teaching residents how to instruct medical students is recognized, but time and logistics challenge the implementation of teaching skills programs. No study has described a dissemination model with chief residents as trainers and managers of a teaching skills program. DESCRIPTION: All chief residents in three departments (n = 16), participated in an 8-hr train-the-trainer teaching skills program and then trained 178 residents through seven 1-hr sessions. Outcome was measured through student surveys using a validated instrument with seven teaching domains and overall assessment of teaching effectiveness. EVALUATION: Survey results revealed a significant improvement in the vast majority of teaching domains 9 months after implementation of the program in all three departments. Student perceptions of overall teaching effectiveness improved in two departments and trended upwards in the third. CONCLUSION: A resident teaching skills program utilizing chief residents as trainers resulted in improved 3rd-year medical student ratings of resident teaching.