Together or not together:Paving the way to boundary crossing

The authors discuss how interprofessional education could ease the transition into collaborative practice by laying the foundation for interprofessional boundary crossing, suggesting that virtual IPE be used to nurture interprofessional feedback‐seeking behaviours

Co-Constructive Patient Simulation as an Experiential Tool for Continuing Professional Development in Healthcare

In this commentary, we examine how to use the recently developed educational method called Co-constructive Patient Simulation (CCPS) to improve continuous professional development in healthcare. CCPS invites learners to participate in the creation of meaningful simulated scenarios while fostering reflection-in/on/for-action and community-building. By participating in the creation of the simulated scenarios, learners guarantee that the challenges addressed by the learning activities are aligned with their developmental stages and needs. Additionally, as learners may invite supervisors to take the "hot seat" during the simulation session, the CCPS approach allows learners to witness how supervisors would handle situations perceived as challenging. This exchange of roles creates an opportunity for camaraderie, as supervisors expose themselves and assume a vulnerable position. This camaraderie facilitates educational bonding and community building. As a result, in this participatory and co-creative approach to simulation, experts become the facilitators of a learner-centred activity, which increases motivation and allows tailored and contextualised learning. This co-constructive approach to simulation adds to the repertoire of more traditional CPD strategies by fostering spontaneity and authenticity. It integrates learning opportunities in clinical practice, amplifies learner's critical reflection and autonomy, and harnesses real-life challenges to offer meaningful solutions to lifelong learning. The democratic environment optimised by experts joining the activity and sharing their vulnerabilities with trainees further catalyzes the creation of a community for teaching, learning, and shared development.</p

S-nitrosação : um novo mecanismo de resistencia a insulina

Orientadores: Mario Jose Abdalla SaadTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias MedicasResumo: Evidências recentes implicam a indução da NO-sintase induzível (iNOS) no desenvolvimento de resistência à insulina associada à obesidade e endotoxemia. A induçãoda iNOS está associada ao aumento da produção de NO, que vem se mostrando um importante sinalizador intra-celular, modificando a função protéica por diversos mecanismos, incluindo Nitrosilação, Nitração e S-nitrosação. A S-nitrosação ocorre pela adição de um grupamento NO ao radical tiol (S-H) de um resíduo de cisteína, formando um nitrosotiol (S-NO). Neste estudo, investigamos se drogas doadoras de NO, Nitrosogluatationa (GSNO) ou Nitrosocisteína (CISNO), e a própria indução da iNOS seriam capazes de provocar S-nitrosação e com isso modificar a função de proteínas envolvidas na via de sinalização insulínica. A insulina inicia suas ações intra-celulares após a ligação à subunidade a do seu receptor transmembrana, o que provoca mudança conformacional e conseqüente auto-fosforilação da subunidade ß, o que ativa sua capacidade tirosina-quinase. Ocorre, então, associação e fosforilação do substrato 1 do receptor de insulina (IRS-1), que uma vez fosforilado, se associa e ativa a fosfatidil inositol 3 quinase (PI 3 quinase), passo fundamental para a ativação da Akt, serina-quinase que modula tanto ações metabólicas quanto de crescimento desencadeadas pela insulina. Neste estudo demonstramos que tanto GSNO quanto CISNO foram capazes de provocar resistência à insulina, tanto em músculo isolado, quanto em animais intactos. Esta resistência foi associada a menor sinalização de insulina pela via IRß/IRS-1/Akt. Após o tratamento com GSNO ou CISNO de músculo isolado ou de animais intactos, observamos S-nitrosação da subunidade ß do receptor de insuilna, o que provocou menor auto-fosforilação e menor atividade tirosina-quinase após estímulo com insulina. Observamos também S-nitrosação do IRS-1, e após o tratamento crônico com droga doadora, os níveis teciduais desta proteína estavam diminuídos. A Akt também foi alvo de S-nitrosação, que aconteceu em paralelo com a perda de sua capacidade serina-quinase, tanto basal , quanto estimulada por insulina. Observamos indução da iNOS em três modelos de resistência à insulina, na obesidade induzida por dieta hiperlipídica, no camundongo diabético ob/ob e na endotoxemia induzida pela infusão de LPS. Nestes três modelos, a sinalização de insulina pela via IRß/IRS-1/Akt estava diminuída, e os níveis de S-nitrosação destas proteínas estava aumentado. Os níveis teciduais de IRS-1 também estavam diminuídos nos três modelos. O bloqueio da indução da iNOS por rosiglitazona no animal com obesidade induzida por dieta, ou por interferência na transcrição da iNOS no camundongo ob/ob, ou pela anulação do gene codificador da iNOS na endotoxemia induzida por LPS, diminuiu o desenvolvimento de resistência à insulina nestes modelos, e impediu a S-nitrosação destas proteínas. Portanto, a S-nitrosação de proteínas envolvidas na transmissão do sinal de insulina é um novo mecanismo molecular de resistência à insulina associado a indução da iNOSAbstract: Evidence demonstrates that exogenous nitric oxide (NO) and the NO produced by inducible nitric oxide synthase (iNOS) can induce insulin resistance in muscle. Here, we investigated whether this insulin resistance could be mediated by S-nitrosation of proteins involved in early steps of the insulin signal transduction pathway. Exogenous NO donated by S-nitrosoglutathione (GSNO) or by Nitrosocysteine (CYSNO) induced in vitro and in vivo S-nitrosation of the insulin receptor ß subunit (IRß) and protein kinase B/Akt (Akt), and reduced their kinase activity in muscle. Insulin receptor substrate (IRS)-1 was also rapidly S-nitrosated, and its expression was reduced after chronic GSNO treatment. In tree animal models of insulin resistance associated with enhanced iNOS expression ¿ diet-induced obesity, the ob/ob diabetic mice and endotoxemia induced by LPS infusion ¿ we observed enhanced S-nitrosation or IRß/IRS-1 and Akt in muscle. Blocking iNOS induction in muscle by Rosiglitazone in diet-induced obesity, by iNOS anti-sense in ob/ob mice or by genetic knockout in endotoxemia reversed S-nitrosation of these proteins yielding an improvement in insulin action through this pathway. Thus, S-nitrosation of proteins related to insulin signal transduction is a novel molecular mechanism of iNOS-induced insulin resistanceDoutoradoClinica MedicaDoutor em Clínica Médic

Twelve tips for implementing a community of practice for faculty development

Teaching and learning practices often fail to incorporate new concepts in the ever-evolving field of medical education. Although medical education research provides new insights into curricular development, learners' engagement, assessment methods, professional development, interprofessional education, and so forth, faculty members often struggle to modernize their teaching practices. Communities of practice (CoP) for faculty development offer an effective and sustainable approach for knowledge management and implementation of best practices. A successful CoP creates and shares knowledge in the context of a specific practice toward the development of expertise. CoPs' collaborative nature, based on the co-creation of practical solutions to daily problems, aligns well with the goals of applying best practices in health professions education and training new faculty members. In our article, we share 12 tips for implementing a community of practice for faculty development. The tips were based on a comprehensive literature review and the authors' experiences

Anatomy 3.0:Rediscovering Theatrum Anatomicum in the wake of Covid-19

The Covid-19 pandemic has challenged medical educators internationally to confront the challenges of adapting their present educational activities to a rapidly evolving digital world. In this article, the authors use anatomy education as proxy to reflect on and remap the past, present, and future of medical education in the face of these disruptions. Inspired by the historical Theatrum Anatomicum (Anatomy 1.0), the authors argue replacing current anatomy dissection laboratory (Anatomy 2.0) with a prototype anatomy studio (Anatomy 3.0). In this studio, anatomists are web-performers who not only collaborate with other foundational science educators to devise meaningful and interactive content but who also partner with actors, directors, web-designers, computer engineers, information technologists, and visual artists to master online interactions and processes in order to optimize students' engagement and learning. This anatomy studio also offers students opportunities to create their own online content and thus reposition themselves digitally, a step into developing a new competency of stage presence within medical education. So restructured, Anatomy 3.0 will prepare students with the skills to navigate an emergent era of tele and digital medicine as well as help to foreshadow forthcoming changes in medical education

“Every day that I stay at home, it's another day blaming myself for not being at #Frontline”–Understanding medical students' sacrifices during COVID-19 Pandemic

COVID-19 struck the world and stretched the healthcare system and professionals. Medical students engaged in the pandemic effort, making personal and professional sacrifices. However, the impact of these sacrifices on students` professional development is still unknown. We applied constructivist grounded theory to individual audio diaries (total time = 5h38 min) and interviews (total time = 11h57min) performed with 18 last-year medical students during the first wave of COVID-19 pandemic in Brazil. The perspective of making sacrifices caused initial emotional distress in medical students, followed by a negotiation process revolving around three themes: predisposition to sacrifice, sense of competence, and sense of belonging. This negotiation process led to three response patterns: Pattern A: “No sense of duty”–the sacrifice was perceived as meaningless, and students showed intense anger and a desire to flee; Pattern B: “Sense of duty with hesitation to act”–the sacrifice was acknowledged as legitime, but students felt unprepared to contribute, leading to feelings of frustration and shame; and, Pattern C: “Sense of duty with readiness to act”–the engagement with the sacrifice was perceived as an opportunity to grow as a doctor, leading to fulfillment and proudness. Students ready to engage with the COVID-19 effort experienced identity consonance, reinforcing their professional identities. Students who felt incompetent or found the sacrifice meaningless experienced identity dissonance, which led to emotional suffering and the consideration of abandoning the course. Monitoring students' emotional reactions when facing professional challenges creates opportunities to problematize the role of sacrifice in the medical profession and scaffold professional identity development.</p

Perfil da população atendida em uma unidade de emergência referenciada

Acquiring knowledge concerning the characteristics of the population that seeks an emergency department can support the planning of health actions. This study identifies the socio-demographic profile and the main complaints of the adult population cared for in a Referral Emergency Unit (RECU). This descriptive and retrospective study was conducted in the RECU of a university hospital in the State of Sao Paulo, Brazil. The sample was composed of the services care forms generated for the period between January and December 2008. The instrument was based on data contained in the care forms. Young women (14 to 54 years old), residents of neighborhoods near the RECU, spontaneously sought the service during the week from 7am to 7pm. The most frequent complaints were headache, back pain, abdominal and chest pain. The conclusion is that most of the sample was young adults, of productive age, female, who spontaneously sought the service on weekdays during the day. Most complaints were of low complexity.El objetivo del estudio fue identificar el perfil sociodemográfico y las principales quejas de la población adulta atendida en la Unidad de Emergencia de Referencia (UER). El conocimiento de las características de la población que frecuenta un servicio de emergencia constituye una herramienta de planificación de las acciones en salud. Se trata de un estudio descriptivo/retrospectivo desarrollado en la UER de un hospital de enseñanza en el interior del estado de Sao Paulo. La muestra fue constituida por los boletines de atención(BAU) del período de enero a diciembre de 2.008. El instrumento utilizado fue estructurado con base en los datos del BAU. La búsqueda espontánea fue hecha por mujeres jóvenes (14 a 54 años) de los barrios próximos a la UER durante la semana y en el horario de las siete a las diecinueve horas. Las quejas más frecuentes fueron: cefalea, lumbago, dolores (abdominal, torácica). Se concluye que el perfil de la muestra fue en su mayoría adulto y joven, en edad productiva, de sexo femenino, con demanda espontánea y en el período diurno en días útiles. Las atenciones apuntaron para quejas de baja complejidad.O conhecimento das características da população que frequenta um serviço de emergência constitui ferramenta de planejamento de ações em saúde. O objetivo deste estudo foi identificar o perfil sociodemográfico e as principais queixas da população adulta, atendida na unidade de emergência referenciada (UER). O método usado foi o descritivo/retrospectivo, desenvolvido na UER de um hospital de ensino no interior do Estado de São Paulo. A amostra ficou constituída pelos boletins de atendimento (BAU), referentes ao período de janeiro a dezembro/2008. O instrumento utilizado foi estruturado com base nos dados do BAU.. Os resultados mostraram que a procura espontânea foi feita por mulheres jovens (14 aos 54 anos) dos bairros próximos à UER, durante a semana e no horário das sete às dezenove horas. As queixas mais frequentes foram: cefaleia, lombalgia, dores (abdominal, torácica). Conclui-se que o perfil da amostra foi, na maioria, composta por adulto jovem, idade produtiva, sexo feminino, demanda espontânea e no período diurno em dias úteis. Os atendimentos apontaram para queixas de baixa complexidade

Use of portfolios in teaching communication skills and professionalism for Portuguese-speaking medical students

Objectives: This study aimed to analyse the effect of a portfolio with three activities fostering students' reflection, self-efficacy and teaching of communication skills and professionalism. Methods: A cross-sectional study was applied with a sample of third- and fourth-year medical students in one Portuguese and three Brazilian universities. A three-activity portfolio (course evaluation and learning, self-efficacy activity and free reflective writing) was used during a two-month course on communication skills and professionalism. The 69 students enrolled in the course were invited to complete the three-activity portfolio via Likert-type questionnaires, open-ended questions and narrative. Content and lexical analysis and the Reflection Evaluation for Learners' Enhanced Competencies Tool (REFLECT) were used for assessing the qualitative data. The questionnaires were evaluated using principal components analysis and Cronbach's α. Pearson's correlation was applied to portfolio activities. Results: Of the 69 participants, 85.5% completed at least one activity. Reflecting on what they learned in the communication module, the students did not mention professionalism themes. In the self-efficacy activity on communication, 25% of the fragments were related to professionalism themes. There was a negative correlation between students' self-efficacy and the REFLECT rubric score (r(19)=-0.744; p< 0.0001). Conclusions: Teachers must consider the activity's influence on the reflections when assessing the portfolio. This model of a three-activity portfolio provided diverse ways of encouraging and assessing reflections, supporting teaching improvement and adaptation, evaluating students' self-efficacy and showing that students' higher reflective capacity may promote feelings of low effectiveness.Financial support for the authors was provided by scholarships from the Conselho Nacional de Desenvolvimento Científico e Tecnológico (Brazilian National Council of Technological and Scientific Development, 229753/2013-2) and the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Coordination for the Improvement of Higher Education Personnel, Brazil, 13271/13-0)