Out and About in Medicine: GW Out For Health

The time is right to devise and implement a more coordinated approach to LGBT patient care and health professional training within the Washington, DC metropolitan area and beyond. The following George Washington University School of Medicine and Health Sciences (GWSMHS) and Hospital (GWUH) LGBT Health Initiative proposal highlights possible strategies for addressing this need through a more centralized fashion. The seven focus areas proposed for the GW LGBT Health Initiative include: 1) Climate/Visibility; 2) Health Education; 3) Policy/Advocacy; 4) Community Outreach; 5) Research; 6) Patient Care; and 7) HIV/AIDS. A key stakeholder that is helping to realize this vision of a comprehensive, coordinated GW LGBT Health Initiative is the student organization GW Out for Health (GWOFH). Led by an executive board of medical students and a faculty advisor, GWOFH has been working to improve the climate for LGBT and ally professional health students and visibility of LGBT health issues on campus through grass roots efforts. GWOFH has approached these goals by emulating aspects of successful student organizations, namely Student National Medical Association, as well as reaching out and building relationships with LGBT resources in the community. Altogether, members of the group will provide critical perspectives on the initial needs assessment and gap analysis of LGBT health at GWSMHS and GWUH necessary to developing a strategic plan for the GW LGBT Health Initiative. In the past year, GWOFH has achieved concrete steps towards improving the climate and visibility of LGBT health issues by building up their organizational infrastructure and membership, which is evidenced by the three-fold growth in membership and creation of a private campus Listserv. To provide social support for LGBT and ally medical students, GWOFH hosted a welcome potluck for GWSMHS students and a social mixer with the LGBT student organizations at Georgetown and Howard medical schools. To improve the visibility of LGBT health issues on campus, GWOFH launched a successful Lunchtime Lecture Series on current research and best practices for reducing LGBT health disparities. GWOFH’s accomplishments have set a solid foundation for providing professional and social support for incoming LGBT and ally professional health students. Furthermore, GWOFH’s reputable presence on campus will be leveraged to help support the proposed GW LGBT Health Initiative in the coming year by providing an advisory role on the development of an initial needs assessment and gap analysis, especially in the areas of climate and visibility, health education, political advocacy, and patient care

Clinical Public Health Integration in Medical School Curriculum: Transitioning Medical Student Training from Medical Problems to Health Solutions

The current chronic disease burden, growing health disparities, and evolution of our healthcare system require that medical students be equipped with basic public health education to effectively manage patients, navigate the healthcare system, and advocate for health(1,2,3,4,5,6). The Institute of Medicine and the AAMC emphasize the need for physicians to be trained in public health(1,8). The inaugural year of the revised curriculum at The George Washington University School of Medicine and Health Sciences (GW SMHS) represented a first step at the institution to integrate clinical public health into medical education. As part of this process, the Clinical Public Health (CLiPH) Working Group, a student formed curriculum advisory board, was created to give real time feedback and assess the Public Health & Health Policy theme curriculum in the first year at GW SMHS. The project objectives were: 1.) To review and evaluate the effectiveness of the public health theme curriculum in the first year of the revised curriculum, including first year medical students’ perceptions and knowledge of the public health theme. 2.) To develop a proposal to maximize opportunities and achieve better integration of the public health theme into the curriculum. The group aims toward clinical public health integration across the four year medical degree curriculum and better collaboration with the GW Milken School of Public Health (SPH) to create an expanded scope of practice within public health for practicing physicians. Over the summer, the working group engaged with multiple stakeholders to forward the clinical public health agenda at GW SMHS. To conduct the curriculum assessment, the students developed a template and the group reviewed over fifty sessions, in the Public Health & Health Policy Theme, Clinical Skills and Reasoning Course (CSR), and intersession activities. Outside research was done to supplement resources to recommend and improve integration of the clinical public health material into the revised preclinical curriculum. Recommended revisions and developments were sent to faculty stakeholders as resources for the revision process of the curriculum. Future work to revise the curriculum should include study of the evolution of students’ knowledge, attitudes, and beliefs surrounding clinical public health and the impact it has on their development as a physician. To better inform the development of the curriculum and how best to engage students with clinical public health, major stakeholders, such as health departments, community stakeholders, public health experts, and most importantly students should continue to be a part of the dialogue

Relationship between antiretroviral prescribing patterns and treatment guidelines in treatment-naive HIV-1-infected US veterans

Objective: To analyze temporal patterns of antiretroviral (ARV) prescribing practices relative to nationally defined guidelines in treatment-naive patients with HIV-1 infection

Results of Antiretroviral Treatment Interruption and Intensification in Advanced Multi-Drug Resistant HIV Infection from the OPTIMA Trial

BACKGROUND: Guidance is needed on best medical management for advanced HIV disease with multidrug resistance (MDR) and limited retreatment options. We assessed two novel antiretroviral (ARV) treatment approaches in this setting. METHODS AND FINDINGS: We conducted a 2×2 factorial randomized open label controlled trial in patients with a CD4 count≤300 cells/µl who had ARV treatment (ART) failure requiring retreatment, to two options (a) re-treatment with either standard (≤4 ARVs) or intensive (≥5 ARVs) ART and b) either treatment starting immediately or after a 12-week monitored ART interruption. Primary outcome was time to developing a first AIDS-defining event (ADE) or death from any cause. Analysis was by intention to treat. From 2001 to 2006, 368 patients were randomized. At baseline, mean age was 48 years, 2% were women, median CD4 count was 106/µl, mean viral load was 4.74 log(10) copies/ml, and 59% had a prior AIDS diagnosis. Median follow-up was 4.0 years in 1249 person-years of observation. There were no statistically significant differences in the primary composite outcome of ADE or death between re-treatment options of standard versus intensive ART (hazard ratio 1.17; CI 0.86-1.59), or between immediate retreatment initiation versus interruption before re-treatment (hazard ratio 0.93; CI 0.68-1.30), or in the rate of non-HIV associated serious adverse events between re-treatment options. CONCLUSIONS: We did not observe clinical benefit or harm assessed by the primary outcome in this largest and longest trial exploring both ART interruption and intensification in advanced MDR HIV infection with poor retreatment options. TRIAL REGISTRATION: Clinicaltrials.gov NCT00050089

A controlled trial of two nucleoside analogues plus indinavir in persons with human immunodeficiency virus infection and CD4 cell counts of 200 per cubic millimeter or less

Background: The efficacy and safety of adding a protease inhibitor to two nucleoside analogues to treat human immunodeficiency virus type 1 (HIV-1) infection are not clear. We compared treatment with the protease inhibitor indinavir in addition to zidovudine and lamivudine with treatment with the two nucleosides alone in HIV-infected adults previously treated with zidovudine. Methods: A total of 1156 patients not previously treated with lamivudine or protease inhibitors were stratified according to CD4 cell count (50 or fewer vs. 51 to 200 cells per cubic millimeter) and randomly assigned to one of two daily regimens: 600 mg of zidovudine and 300 mg of lamivudine, or that regimen with 2400 mg of indinavir. Stavudine could be substituted for zidovudine. The primary end point was the time to the development of the acquired immunodeficiency syndrome (AIDS) or death. Results: The proportion of patients whose disease progressed to AIDS or death was lower with indinavir, zidovudine (or stavudine), and lamivudine (6 percent) than with zidovudine (or stavudine) and lamivudine alone (11 percent; estimated hazard ratio, 0.50; 95 percent confidence interval, 0.33 to 0.76; P�0.001). Mortality in the two groups was 1.4 percent and 3.1 percent, respectively (estimated hazard ratio, 0.43; 95 percent confidence interval, 0.19 to 0.99; P=0.04). The effects of treatment were similar in both CD4 cell strata. The responses of CD4 cells and plasma HIV-1 RNA paralleled the clinical results. Conclusions: Treatment with indinavir, zidovudine, and lamivudine as compared with zidovudine and lamivudine alone significantly slows the progression of HIV-1 disease in patients with 200 CD4 cells or fewer per cubic millimeter and prior exposure to zidovudine. (N Engl J Med 1997;337:725-33.

An Evaluation Guideline for a Service-Learning Curriculum Implemented in Medical Education

Introduction The purpose of this project is to evaluate the impact of student community service activities on recall, comprehension, and application of learning objectives from the Clinical Public Health (CPH) aspects of the medical curriculum. CPH theme lectures and Summits were added to the medical curriculum at The George Washington University School of Medicine and Health Sciences (GW SMHS) in 2014. Many GW medical students perform community service during medical school through voluntary student activities such as The Healing Clinic, Whitman-Walker Health and activities of various student organizations. This project is being conducted in the context of an overall evaluation of the CPH curriculum. The specific objective of this project is to create an evaluation guideline for a Service-Learning Curriculum in medical education. This information will aid in the development of the pilot program because it will provide how the program will be evaluated on deliverables. Methods An initial retrospective analysis of existing literature specific to the area of service-learning curriculum within medical education was undertaken utilizing the following methods: PubMed, Himmelfarb, and Journal of Graduate Medical Education. A deficiency in this specific area was identified. Follow-up discussion with experts in the field provided an outline for critical information which was incorporated into guidelines by our team. Results The evaluation guideline was designed. From the literature and advice from experts, it was emphasized that a thorough evaluation would need both qualitative and quantitative data. In the context of a service-learning curriculum, this means reflections from students and community partners as well as evaluations of perception of success from faculty. In addition to this, quantitative data will be collected in the form of a survey with statements/questions to agree/disagree from a scale of 1 to 5. Conclusion To our knowledge, this is the first evaluation guideline of service-learning curriculum in medical education that will be released for universal use. The implications of this evaluation guideline are to be used to determine the success of the implemented service-learning curriculum for GW SMHS and other medical schools

Discovering the Roots: A Qualitative Analysis of Medical Students Exploring Their Unconscious Obesity Bias

Bias against individuals with obesity in medical settings has negative implications for patients, including stigmatization, poor health outcomes, and reduced healthcare utilization. This study explored reflections of medical students when confronted with their own implicit obesity bias. A group of 188 pre-clinical second-year medical students from George Washington University School of Medicine and Health Sciences completed the Weight Implicit Association Test (IAT) in 2020 and were instructed to write a reflective response based on their results. Participants reflected upon their preferences ( fat vs. thin ) and described the factors that influenced their perceptions of obesity. Inductive coding techniques were used to generate themes from medical students\u27 responses using Dedoose Version 8.3.35 (SocioCultural Research Consultants LLC, Los Angeles, California). Regarding IAT results, 7% of medical students preferred fat over thin, 14% had no preference, and 78% preferred thin over fat. Reflection themes highlighted medical students\u27 difficulty accepting IAT results, perspectives on the origins of obesity in individuals, personal and family challenges with obesity and body image, medical training\u27s perceived influence on bias, reservations about discussing obesity with patients, and desires to change current and future practices. Many medical students expressed a desire to provide optimal care for patients of all weight classes despite demonstrating a strong unconscious bias against individuals with obesity on the IAT. Medical school should provide targeted opportunities to acknowledge and mitigate obesity bias by expanding on medical students\u27 pre-established and often harmful understandings of obesity and highlighting the complexities of this disease. Such training would better equip medical students to facilitate successful interactions with patients as future physicians

Teaching Trauma-Informed Care: A Symposium for Medical Students.

Introduction A large body of evidence links exposure to childhood trauma with negative health outcomes. Training future physicians to recognize and respond to trauma is paramount, and engaging medical students in the preclinical years affords the opportunity to foster the development of a trauma-informed lens that can then be solidified during clinical clerkships. Methods We developed and implemented a 4-hour trauma-informed care (TIC) symposium for 179 second-year medical students at the George Washington University School of Medicine and Health Sciences during the Patients, Populations, and Systems course. The symposium included three interactive didactic sessions focusing on the connection between trauma and health and TIC principles. A facilitated small-group discussion allowed students to apply TIC principles to a patient case, followed by reflection and evaluation. Results The overall rating of the TIC symposium was 4 out of 5. Strengths included integration of a small-group case with discussion on application of TIC in practice, experience of the lecturers and small-group facilitators, and review of research relating adversity to specific health outcomes. Suggestions for improvement included incorporating role-play and standardized patients. Content analysis of student reflections mapped to the domains of physician competency. Discussion A 4-hour symposium can affect student knowledge and understanding of TIC. Teaching TIC presents an opportunity to prepare medical students for a career in medicine through cultivation of required physician competencies. Next steps include enhanced opportunities to practice TIC and follow-up analysis of participants to determine behavior change during clinical years