Relationships between high-stakes clinical skills exam scores and program director global competency ratings of first-year pediatric residents

Responding to mandates from the Accreditation Council for Graduate Medical Education (ACGME) and American Osteopathic Association (AOA), residency programs have developed competency-based assessment tools. One such tool is the American College of Osteopathic Pediatricians (ACOP) program directors’ annual report. High-stakes clinical skills licensing examinations, such as the Comprehensive Osteopathic Medical Licensing Examination Level 2-Performance Evaluation (COMLEX-USA Level 2-PE), also assess competency in several clinical domains.The purpose of this study is to investigate the relationships between program director competency ratings of first-year osteopathic residents in pediatrics and COMLEX-USA Level 2-PE scores from 2005 to 2009.The sample included all 94 pediatric first-year residents who took COMLEX-USA Level 2-PE and whose training was reviewed by the ACOP for approval of training between 2005 and 2009. Program director competency ratings and COMLEX-USA Level 2-PE scores (domain and component) were merged and analyzed for relationships.Biomedical/biomechanical domain scores were positively correlated with overall program director competency ratings. Humanistic domain scores were not significantly correlated with overall program director competency ratings, but did show moderate correlation with ratings for interpersonal and communication skills. The six ACGME or seven AOA competencies assessed empirically by the ACOP program directors’ annual report could not be recovered by principal component analysis; instead, three factors were identified, accounting for 86% of the variance between competency ratings.A few significant correlations were noted between COMLEX-USA Level 2-PE scores and program director competency ratings. Exploring relationships between different clinical skills assessments is inherently difficult because of the heterogeneity of tools used and overlap of constructs within the AOA and ACGME core competencies

Bureaucracy and Wildlife: A Historical Overview

This paper provides a framework for understanding the Government\u27s position on many wildlife topics, including humane ethics. The Government\u27s historical role in wildlife conservation is traced to pertinent theories of bureaucracy. It is shown that Government involvement in wildlife conservation increased through successive stages of change because of interest group activity

Web-Based Objective Structured Clinical Examination with Remote Standardized Patients and Skype: Resident Experience

OBJECTIVE: Using Skype and remote standardized patients (RSPs), investigators sought to evaluate user acceptance of a web-based objective structured clinical examination (OSCE) among resident physicians. METHODS: After participating in four web-based clinical encounters addressing pain with RSPs, 59 residents from different training programs, disciplines and geographic locations completed a 52-item questionnaire regarding their experience with Skype and RSPs. Open-ended responses were solicited as well. RESULTS: The majority of participants (97%) agreed or strongly agreed the web-based format was convenient and a practical learning exercise, and 90% agreed or strongly agreed the format was effective in teaching communication skills. Although 93% agreed or strongly agreed they could communicate easily with RSPs using Skype, 80% preferred traditional face-to-face clinical encounters, and 58% reported technical difficulties during the encounters. Open-ended written responses supported survey results. CONCLUSION: Findings from this study expose challenges with technology and human factors, but positive experiences support the continued investigation of web-based OSCEs as a synchronous e-learning initiative for teaching and assessing doctor-patient communication. Such educational programs are valuable but unlikely to replace face-to-face encounters with patients. PRACTICE IMPLICATIONS: This web-based OSCE program provides physician learners with additional opportunity to improve doctor-patient communication

Correlation Between An Email Based Board Review Program and American Board of Pediatrics General Pediatrics Certifying Examination Scores

Objective To investigate the impact of a weekly email based board review course on individual resident performance on the American Board of Pediatrics (ABP) General Pediatrics Certifying Examination for pediatric residents and, specifically, residents with low ABP In-training Examination (ITE) scores. Methods Weekly board-type questions were emailed to all pediatric residents from 2004–2007. Responses to board-type questions were tracked, recorded, and correlated with ITE scores and ABP General Pediatrics Certifying Examination Scores. Results With regard to total number of questions answered, only total number of questions answered correctly had a significant positive correlation with standard board scores (n = 71, r = 0.24, p = 0.047). For “at risk” residents with ITE scores ≤ 200 (n = 21), number of questions answered in PL 3 year (r = 0.51, p = 0.018) and number of questions answered correctly for all PL years (r = 0.59, p = 0.005) had significant positive correlations with standard board scores. Conclusions Participating regularly in the email-based board review course, answering board style questions, and answering correctly to board style questions were associated with higher standard board scores. This benefit existed for all but was especially prominent among those with poor in-training examination scores

Perspectives of Dermatology Program Directors on the Impact of Step 1 Pass/Fail.

INTRODUCTION: The shift of Step 1 to Pass/Fail has generated several questions and concerns about obtaining residency positions among allopathic and osteopathic students alike. Determining the perspectives of Dermatology Program Directors in regards to post-Step 1 Pass/Fail is critical for students to better prepare for matching into dermatology. METHODS: After receiving Institutional Review Board (IRB) exemption status, the program directors were chosen from 144 Accreditation Council for Graduate Medical Education (ACGME) and 27 American Osteopathic Association (AOA) Dermatology programs using contact information from their respective online website databases. An eight-item survey was constructed on a three-point Likert scale, one free text response, and four demographic questions. The anonymous survey was sent out over the course of three weeks with weekly individualized reminder requests for participation. RESULTS: A total of 54.54% of responders had Letters of Recommendation in their top 3. Forty-five percent of responders had Completed Audition Rotation at Program in their top 3. And, 38.09% of responders had USMLE Step 2 CK Scores in their top 3. CONCLUSION: Approximately 50% of responders agreed that all medical students will have more difficulty matching dermatology. Based on the survey study, Dermatology program directors want to focus more on letters of recommendation, audition rotations, and Step 2 CK scores. Because each field seems to prioritize different aspects of an application, students should attempt to gain as much exposure to different fields such as through research and shadowing to narrow down their ideal specialties. Consequently, the student will have more time to tailor their applications to what residency admissions are looking for

Survey of Osteopathic Medical Students Regarding Physician Shadowing Experiences Before and During Medical School Training.

Introduction: Shadowing a physician is an observational experience which includes a student observing a licensed healthcare provider caring for patients. Shadowing is commonly done by students before and during medical school, but little is known about the nature or extent of these extra-curricular observational experiences. Objective: We hypothesized that shadowing experiences were common yet variable. We investigated the prevalence, nature, and perceived value of medical student experiences with shadowing physicians (both before and during medical school). Methods: This survey-based study was non-experimental with a cross-sectional convenience sample of osteopathic medical students about their shadowing experiences before and during medical school. The survey was sent to all matriculated osteopathic medical students (OMS1-4) for the 2017 to 2018 academic year from two medical schools: Philadelphia College of Osteopathic Medicine (PCOM) (1084 total students) and PCOM-Georgia (554 total students). The final survey instrument included three sections: demographics (6 questions), pre-medical shadowing experiences (21 questions), and medical student shadowing experiences (24 questions). Results: Respondents (357) identified themselves as OMS1 (96), OMS2 (89), OMS3 (73), OMS4 (95) and other (2, OMS5) with enrollment at PCOM-Philadelphia (242) and PCOM-Georgia (115). Among survey respondents, 339 (95.5%) reported shadowing a physician as a pre-medical student, and 110 (30.8%) reported shadowing (outside of their required clinical rotations) a physician during medical school. Requirements to participate were inconsistent; fewer than 50% of shadowing experiences required Health Insurance Portability and Accountability Act of 1996 (HIPAA) training, proof of vaccination, or purified protein derivative (PPD) documentation. In addition to observation, pre-medical and medical students, respectively, participated in history taking (44 [13%], 47 [42.7%]), physical examinations (45 [13.3%], 44 [40%]) and procedures (13, [3.8%], 20 [18.2%]) during their shadowing experiences. Motivations to participate in shadowing varied between pre-medical and medical student experiences, but both groups mentioned their desire to learn more about a particular discipline, obtain letters of recommendation, and gain patient care experience. Students recommended both pre-medical (273 [80.5%]) and medical school (93 [84.5%]) shadowing to future students. Conclusion: Shadowing remains a common and important tool for students to learn about patient care, medicine and careers. The nature of each shadowing experience and participation requirements are quite variable. Measures to ensure patient safety, confidentiality, liability and supervision are inconsistently applied. Promoting guidelines, as well as codes of conduct, for shadowing could serve as a helpful resource for students, academic advisors and supervising clinicians

Through the Looking Glass: Visualizing Leukemia Growth, Migration, and Engraftment Using Fluorescent Transgenic Zebrafish

Zebrafish have emerged as a powerful model of development and cancer. Human, mouse, and zebrafish malignancies exhibit striking histopathologic and molecular similarities, underscoring the remarkable conservation of genetic pathways required to induce cancer. Zebrafish are uniquely suited for large-scale studies in which hundreds of animals can be used to investigate cancer processes. Moreover, zebrafish are small in size, optically clear during development, and amenable to genetic manipulation. Facile transgenic approaches and new technologies in gene inactivation have provided much needed genomic resources to interrogate the function of specific oncogenic and tumor suppressor pathways in cancer. This manuscript focuses on the unique attribute of labeling leukemia cells with fluorescent proteins and directly visualizing cancer processes in vivo including tumor growth, dissemination, and intravasation into the vasculature. We will also discuss the use of fluorescent transgenic approaches and cell transplantation to assess leukemia-propagating cell frequency and response to chemotherapy. Zebrafish Models of Leukemia Zebrafish models of hematological malignancies exhibit striking similarities with human and mouse disease Although characterized by increased circulating white blood counts, chronic leukemias are often much slower growing and take months or years to progress. Leukemias can be further subdivided based on the blood lineage in which cells have become transformed Zebrafish first emerged as a powerful genetic model of leukemia with the description of transgenic approaches in which cMYC was overexpressed in developing thymocytes Advances in Hematology Moreover, GFP+ thymocytes exhibited stereotypical homing to the nasal placode, periocular space, and kidney marrow when assessed by serial fluorescent imaging over days Many exciting new models of hematopoietic malignancy have been created including B-cell acute lymphoblastic leukemia (B-ALL), acute myeloid leukemia (AML), and myeloproliferative neoplasm Fluorescent Transgenic Approaches to Label Leukemia Cells Cell Transplantation Approaches to Visualize Tumor Cell Engraftment Investigators have utilized cell transplantation of fluorescently labeled cancer cells into sublethally irradiated adult zebrafish to assess tumorigenicity Cell Transplantation Approaches to Examine Tumor Cell Homing and Intravasation into Vessels Intravasation of cancer cells into the vasculature is a critical step in cancer progression, allowing the spread of tumor cells beyond the site of origin Fluorescence Imaging to Visualize Leukemia Responses to Drug Treatment and Gamma-Irradiation Fluorescence imaging of transplanted cancer cells can also be used to visualize response to chemotherapy and radiation. For example, the Revskoy group recently showed that GFP-labeled T-ALL cells could be serially transplanted into syngeneic strain larvae Cell Transplantation Approaches to Quantify Leukemia Propagating Cell Frequency and Aggression Leukemia-propagating cells (LPCs) have the capacity to produce all the other cell types contained within the leukemia, are responsible for continued tumor growth, and ultimately drive relapse. Investigators have used fluorescence-activated cell sorting (FACS) to identify unique cell populations and limiting dilution cell transplantation to assess if molecularly defined leukemia cells retain LPC activity in human disease. For example, in AML a rare CD34+, CD38− cell enriches for leukemia-propagating potential Conclusion and Challenges for the Future Zebrafish has fast emerged as a powerful model of leukemia. When coupled with fluorescent transgenic approaches and powerful imaging techniques, these models are uniquely positioned to uncover mechanisms driving tumor dissemination, progression, and relapse. Moreover, the use of multifluorescent transgenic animals will allow for labeling of tumor cell compartments similar to those defined in RASinduced rhabdomyosarcoma model

Clinical Assessment of 4th Year Osteopathic Medical Students: Outdoor Medicine Rotation

Introduction: Securing clinical training sites remains a challenge for medical educators who often resort to paying preceptors or searching for new clinical training sites which haven’t traditionally taken students. We describe a unique partnership between the Boy Scouts of America and PCOM, providing a clinical training opportunity for OMS4 students at PCOM: Outdoor Clinical rotation the Summit Bechtel Family National Boy Scout Reserve in rural West Virginia at the National Scout jamboree, serving 35,000 scouts. Methods and Curricular Design: By the end of the rotation, each PCOM student was able to (1) provide urgent care for common outdoor injuries: fractures, abrasions, insect bites, gastroenteritis, sprains, heat exhaustion, sunburn, eye injuries, etc; (2) provide basic life support, resuscitation and first aid in an outdoor setting; (3) identify and treat common chronic medical conditions (asthma, ADHD, etc) which are common to all children, not just those in a wilderness setting; (4) explain adolescent development and impact on character development, (5) explain the structure and mission of scouting; and (6) identify characteristics of international scouts with regard to culture, background, experience and perspectives. Outcomes: Clinically-based assessments (direct observation, youth protection training, self-reflection, etc) satisfied all 13 Entrustable Professional Activities (AOA)

PHF6 expression levels impact human hematopoietic stem cell differentiation

Transcriptional control of hematopoiesis involves complex regulatory networks and functional perturbations in one of these components often results in malignancies. Loss-of-function mutations in PHF6, encoding a presumed epigenetic regulator, have been primarily described in T cell acute lymphoblastic leukemia (T-ALL) and the first insights into its function in normal hematopoiesis only recently emerged from mouse modeling experiments. Here, we investigated the role of PHF6 in human blood cell development by performing knockdown studies in cord blood and thymus-derived hematopoietic precursors to evaluate the impact on lineage differentiation in well-established in vitro models. Our findings reveal that PHF6 levels differentially impact the differentiation of human hematopoietic progenitor cells into various blood cell lineages, with prominent effects on lymphoid and erythroid differentiation. We show that loss of PHF6 results in accelerated human T cell development through reduced expression of NOTCH1 and its downstream target genes. This functional interaction in developing thymocytes was confirmed in vivo using a phf6-deficient zebrafish model that also displayed accelerated developmental kinetics upon reduced phf6 or notch1 activation. In summary, our work reveals that appropriate control of PHF6 expression is important for normal human hematopoiesis and provides clues towards the role of PHF6 in T-ALL development

Single-Cell Transcriptional Analysis of Normal, Aberrant, and Malignant Hematopoiesis in Zebrafish

Hematopoiesis culminates in the production of functionally heterogeneous blood cell types. In zebrafish, the lack of cell surface antibodies has compelled researchers to use fluorescent transgenic reporter lines to label specific blood cell fractions. However, these approaches are limited by the availability of transgenic lines and fluorescent protein combinations that can be distinguished. Here, we have transcriptionally profiled single hematopoietic cells from zebrafish to define erythroid, myeloid, B, and T cell lineages. We also used our approach to identify hematopoietic stem and progenitor cells and a novel NK-lysin 4+ cell type, representing a putative cytotoxic T/NK cell. Our platform also quantified hematopoietic defects in rag2E450fs mutant fish and showed that these fish have reduced T cells with a subsequent expansion of NK-lysin 4+ cells and myeloid cells. These data suggest compensatory regulation of the innate immune system in rag2E450fs mutant zebrafish. Finally, analysis of Myc-induced T cell acute lymphoblastic leukemia showed that cells are arrested at the CD4+/CD8+ cortical thymocyte stage and that a subset of leukemia cells inappropriately reexpress stem cell genes, including bmi1 and cmyb. In total, our experiments provide new tools and biological insights into single-cell heterogeneity found in zebrafish blood and leukemia