Swimming With Sharks: Teaching Residents Value-Based Medicine and Quality Improvement Through Resident-Pitched Projects

BackgroundTo create meaningful quality improvement (QI) curricula for graduate medical education (GME) trainees, institutions strive to improve coordination of QI curricula with hospital improvement infrastructure.ObjectiveWe created a curriculum to teach residents about QI and value-based medicine (VBM) and assessed curricular effectiveness.MethodsWe designed a 2-week required curriculum for internal medicine residents at a large academic program. After participating in basic skills workshops, trainees developed QI/VBM project ideas with faculty and nonclinical support and pitched them to hospital leaders at the end of the rotation. Pre-post and 1-year follow-up surveys were conducted for residents to self-assess knowledge, attitudes, and skills, participation in QI/VBM projects, and career intentions. We tracked QI/VBM project implementation.ResultsIn the first 2 years (2017-2018), 92 trainees participated, and 71 of 76 (93%) recommended the curriculum. Surveys (76 of 92, 83%) show improvement in our learning objectives (12%-60% pre to 62%-97% post; P < .001 for all; Cohen's d effect size 0.7-1.2), which are sustained at 1-year follow-up (57%-95%; P < .01). Four of 19 projects have been implemented. At 1 year, 95% of residents had presented a quality/value poster presentation, 44% were involved in QI/VBM beyond required rotations, and 26% plan to pursue careers focused on improving quality, safety, or value.ConclusionsOur project-based curriculum culminating in a project pitch to hospital leadership was acceptable to GME trainees, improved self-assessed skills sustained at 1 year, and resulted in successfully implemented QI/VBM projects

NSAID-induced Antral Ulcers are Associated with Distinct Changes in Mucosal Gene Expression

AIMS: The basis for individual variation in gastroduodenal vulnerability to NSAIDs is not well understood. We aimed to assess whether a gene expression signature was associated with susceptibility to gastroduodenal ulcerations. METHODS: Twenty-five H pylori negative adults were treated for 7 days with naproxen 500 mg BID. Subjects underwent baseline and post-treatment endoscopy, during which biopsies were taken from antrum and duodenum. RNA extraction and cDNA synthesis were performed, followed by PCR of 23 genes relevant to mucosal injury and repair. Fold changes in gene expression were compared between subjects who developed ulcers and those who did not. RESULTS: Compared to subjects who did not develop ulcers (n=18), subjects who developed antral ulcers (n=7) had significantly greater mucosal up-regulation of interleukin-8 [Fold change = 33.5 (SEM = 18.5) versus −7.7 (3.2)] and of cyclo-oxygenase-2 [2.3 (1.7) versus −10.8 (2.2)]. Conversely, non-ulcer subjects had significantly greater up-regulation of toll-like receptor-4, cyclo-oxygenase-1, and hepatocyte growth factor [14.0 (2.2) vs. −0.8 (1.0), 9.8 (2.4) vs. 0.0 (0.7), and 8.2 (2.6) vs. −2.2 (0.3), respectively]. CONCLUSIONS: NSAID-induced antral ulcers are associated with a specific pattern of gastroduodenal mucosal gene expression. These patterns may provide insight into the molecular basis of individual susceptibility to mucosal injury