Interprofessional education: Operationalizing longitudinal competency-based assessment

Health professions schools are moving toward implementing competency-based education, and interprofessional education (IPE) provides an opportunity to achieve critical competencies within healthcare teams. While there are several established IPE competency frameworks (1,2), schools often need to adapt these frameworks to align with their desired IPE program outcomes. Additionally, schools must determine appropriate milestones according to the developmental trajectory for these competencies. Finally, robust instruments are required to operationalize a longitudinal program of assessment. In this small group discussion, the presenters will describe their experience developing and implementing a longitudinal program of assessment for a competency-based IPE curriculum, including establishment and iterative refinement of competencies and milestone language, as well as how assessment modalities were selected. This will then serve as a springboard to engage the audience in creative solutioning to address the challenges inherent in this process at their home institution and beyond

A novel escape room to prepare students for clinical rotations

Objective or purpose of innovation: To teach, through a game-based, escape room format, key clinical skills needed to manage common patient care scenarios in core clerkships. Background and/or theoretical framework and importance to the field: Escape rooms are themed games, involving groups of players cooperating to solve puzzles. The interactivity and emphasis on goal-oriented collaboration have led to the adaptation of escape rooms for educational purposes, with evidence suggesting that game-based instruction may have advantages over traditional didactics for knowledge and/or skill acquisition. The transition to clinical rotations represents a challenging and often stressful period in undergraduate medical training, given the new skills and expectations compared to classroom learning. Escape rooms may facilitate this transition by introducing aspects of clinical work in a low-stakes, immersive setting. Design: Students beginning their core clerkship year participated in an escape room activity prior to starting their rotations (n=49). Learning objectives included recognizing the initial approach to resuscitation in an emergent care scenario; identifying common surgical tubes, lines, and drains; and practicing teamwork skills. The escape room puzzles were constructed to provide repetitive, hands-on practice of clinical and procedural skills. Learners spent 60 minutes immersed in the escape room, followed by a 30-minute debriefing. Outcomes: Student survey data showed a significant increase in self-reported knowledge related to the learning objectives (p<0.001) and increased excitement about the upcoming core clerkship year after participation in the escape room. Students strongly preferred the escape room format to traditional methods of instruction. Innovation’s strengths and limitations: This activity was well received by learners and resulted in self-reported gains in knowledge. More work is needed to study the effects of this introductory activity on knowledge retention and clerkship performance. Feasibility and generalizability: The foundational content covered in the activity is applicable to all students entering clinical rotations. While it incorporates the use of part-task trainers, adaptations can be made for lower resourced settings by prioritizing knowledge acquisition over skills practice

Exploring creative solutions to clinical reasoning assessment: The NBME OSCE for Clinical Reasoning Creative Community

Clinical reasoning is a critical competency for the practice of medicine; however, existing methods of assessment often are unable to provide learners with sufficiently detailed or actionable feedback to guide performance improvement. While there is interest in adapting or creating new forms of assessment to address this challenge, resource constraints may preclude individual institutions from developing or implementing innovative solutions. The National Board of Medical Examiners (NBME) thus established the OSCE for Clinical Reasoning Creative Community in order to leverage experience and expertise across multiple medical schools. Participating institutions are partnering closely with NBME assessment experts to generate and pilot solutions for clinical reasoning assessment challenges, via a structured, evidence-centered design process. In this small group discussion, the presenters will describe their experience participating in the Creative Community thus far, including key learnings and themes related to clinical reasoning assessment and barriers to innovation. The presenters will then engage the audience in a conversation about their initial reactions to the process and preliminary output of the Creative Community, as well as solicit ideas for how to maximize the value and generalizability of this work for their own institutions

Konexión Paciente: Redefining Medical Spanish Education for Spanish-Speaking Medical Students Through Patient-Based Simulation

Background and/or theoretical framework and importance to the field The disproportionate lack of Spanish-speaking (SS) physicians in U.S. regions with many SS residents emphasizes the need for increased medical Spanish education. While many schools offer Medical Spanish courses, our co-curricular, simulation-based program (Konexión Paciente/KPAX) aims to optimize learner engagement and outcomes through longitudinal integrated design, provision of feedback using validated assessment instruments, and incorporating issues of equity and inclusion. Design KPAX is a student-designed optional program that complements the formal clinical skills curriculum. Learners participate in simulated Spanish-language patient encounters adapted from institutionally-validated, English curricular material. Students are assessed on linguistic adaptability, attention to health disparities, and empathy, in addition to clinical skills proficiency. Feedback is provided based on standardized patient checklists for Spanish-language communication, general communication, and task-specific clinical skills, as well as narrative comments from physician facilitators. Outcomes Students reported greater self-efficacy and comfort in SS encounters after participating in KPAX. Participants also scored significantly higher than nonparticipant peers on general communication skills in a subsequent English curricular OSCE encounter assessing clinical content addressed in a pilot KPAX session (p Innovation's strengths and limitations KPAX provides opportunities to engage in higher-order language utilization and emphasizes patient-centeredness and linguistic/ethnocultural diversity in healthcare delivery. Further investigation is needed to address how baseline clinical skills proficiency affects acquisition of language-associated skills, as well as to define the developmental arc of Spanish-language care provision as a competency. The evolution of student performance on the assessment instruments over the course of the program is currently under investigation. Feasibility and generalizability KPAX empowers future clinician-leaders to care for the SS community. The program can be adapted for any language community at institutions with simulation capabilities, using existing curricular materials. References Dragan, A. The Importance of Addressing Linguistic Ethno‐cultural Diversity in the Delivery of Public Health Services: a Literature Review. 2009 Dec; Region of Peel Public Health. Accessed Oct 28, 2022. https://tinyurl.com/53hc9mhx. Flores-Rodarte J, Topmiller M, Jabbarpour Y. Distribution of Spanish-Speaking Family Physicians, 2013-2019. Am Fam Physician. 2022 Jun;105(6):654-655. PMID: 35713629. Marrast LM, Zallman L, Woolhandler S, Bor DH, McCormick D. Minority Physicians’ Role in the Care of Underserved Patients: Diversifying the Physician Workforce May Be Key in Addressing Health Disparities. JAMA Intern Med. 2014;174(2):289–291. doi:10.1001/jamainternmed.2013.12756 Ortega P, Pérez N, Robles B, Turmelle Y, Acosta D. Strategies for Teaching Linguistic Preparedness for Physicians: Medical Spanish and Global Linguistic Competence in Undergraduate Medical Education. Health Equity. 2019 Jul 1;3(1):312-318. doi: 10.1089/heq.2019.0029. PMID: 31294243; PMCID: PMC6615346. Ortega P, Pérez N, Robles B, Turmelle Y, Acosta D. Teaching Medical Spanish to Improve Population Health: Evidence for Incorporating Language Education and Assessment in U.S. Medical Schools. Health Equity. 2019 Nov 1;3(1):557-566. doi: 10.1089/heq.2019.0028. PMID: 31701080; PMCID: PMC6830530.<p/

Setting a common standard in clinical skills assessment: The experience of the California Consortium for the Assessment of Clinical Competence

Objective or purpose of innovation: To identify common clinical skills competency thresholds across schools by centralizing standard setting for a multi-institutional assessment. Background and/or theoretical framework and importance to the field: The California Consortium for the Assessment of Clinical Competence (CCACC) comprises 10 medical schools that administer a common multi-station clinical skills assessment (CPX). Previously, each institution determined their own, largely norm-referenced passing thresholds for the examination. With the elimination of USMLE Step 2 CS, there is a recognized need for robust clinical skills assessment beyond the individual institutional level. A collaboratively developed, multi-institutional examination with passing thresholds established via a rigorous process offers greater validity evidence for summative decisions made based on its results. Accordingly, the CCACC undertook centralized, criterion-based standard setting for the CPX. Design: Passing thresholds for the six core CPX cases were determined via two methods: modified Angoff, using expert raters from multiple institutions, and borderline regression, using global encounter ratings assigned by standardized patients. Results from the two methods were compared to each other and to institutions’ prior thresholds. Outcomes: Both methods yielded the same cumulative cut score based on averages across all cases (70%), but exhibited variation between individual cases, suggesting case-specificity. Compared with prior thresholds, some institutions’ pass rates would have been higher using the common criterion-referenced cut score, while others would have been lower. Innovation’s strengths and limitations: This study demonstrates the feasibility of centralizing standard setting across multiple institutions using two criterion-based methods. Standardized patient ratings may generate similar passing thresholds to those determined by clinicians. Further studies are necessary to determine whether these findings generalize to other case types and how best to apply centralized standards within each institution’s context. Feasibility and generalizability: The CCACC’s standard setting approaches may be applied across other institutions sharing an assessment, allowing for comparison of learner performance to a common standard. Given the similar results, the choice of method may be determined by resource availability

Identification of subjects with polycystic ovary syndrome using electronic health records

Background: Polycystic ovary syndrome (PCOS) is a heterogeneous disorder because of the variable criteria used for diagnosis. Therefore, International Classification of Diseases 9 (ICD-9) codes may not accurately capture the diagnostic criteria necessary for large scale PCOS identification. We hypothesized that use of electronic medical records text and data would more specifically capture PCOS subjects. Methods: Subjects with PCOS were identified in the Partners Healthcare Research Patients Data Registry by searching for the term “polycystic ovary syndrome” using natural language processing (n = 24,930). A training subset of 199 identified charts was reviewed and categorized based on likelihood of a true Rotterdam PCOS diagnosis, i.e. two out of three of the following: irregular menstrual cycles, hyperandrogenism and/or polycystic ovary morphology. Data from the history, physical exam, laboratory and radiology results were codified and extracted from notes of definite PCOS subjects. Thirty-two terms were used to build an algorithm for identifying definite PCOS cases and applied to the rest of the dataset. The positive predictive value cutoff was set at 76.8 % to maximize the number of subjects available for study. A true positive predictive value for the algorithm was calculated after review of 100 charts from subjects identified as definite PCOS cases with at least two documented Rotterdam criteria. The positive predictive value was compared to that calculated using 200 charts identified using the ICD-9 code for PCOS (256.4; n = 13,670). In addition, a cohort of previously recruited PCOS subjects was submitted for algorithm validation. Results: Chart review demonstrated that 64 % were confirmed as definitely PCOS using the algorithm, with a 9 % false positive rate. 66 % of subjects identified by ICD-9 code for PCOS could be confirmed as definitely PCOS, with an 8.5 % false positive rate. There was no significant difference in the positive predictive values using the two methods (p = 0.2). However, the number of charts that had insufficient confirmatory data was lower using the algorithm (5 % vs 11 %; p < 0.04). Of 477 subjects with PCOS recruited and examined individually and present in the database as patients, 451 were found within the algorithm dataset. Conclusions: Extraction of text parameters along with codified data improves the confidence in PCOS patient cohorts identified using the electronic medical record. However, the positive predictive value was not significantly different when using ICD-9 codes or the specific algorithm. Further studies are needed to determine the positive predictive value of the two methods in additional electronic medical record datasets. Electronic supplementary material The online version of this article (doi:10.1186/s12958-015-0115-z) contains supplementary material, which is available to authorized users

New genetic loci link adipose and insulin biology to body fat distribution.

Body fat distribution is a heritable trait and a well-established predictor of adverse metabolic outcomes, independent of overall adiposity. To increase our understanding of the genetic basis of body fat distribution and its molecular links to cardiometabolic traits, here we conduct genome-wide association meta-analyses of traits related to waist and hip circumferences in up to 224,459 individuals. We identify 49 loci (33 new) associated with waist-to-hip ratio adjusted for body mass index (BMI), and an additional 19 loci newly associated with related waist and hip circumference measures (P < 5 × 10(-8)). In total, 20 of the 49 waist-to-hip ratio adjusted for BMI loci show significant sexual dimorphism, 19 of which display a stronger effect in women. The identified loci were enriched for genes expressed in adipose tissue and for putative regulatory elements in adipocytes. Pathway analyses implicated adipogenesis, angiogenesis, transcriptional regulation and insulin resistance as processes affecting fat distribution, providing insight into potential pathophysiological mechanisms

Abdominal aortic aneurysm is associated with a variant in low-density lipoprotein receptor-related protein 1

Abdominal aortic aneurysm (AAA) is a common cause of morbidity and mortality and has a significant heritability. We carried out a genome-wide association discovery study of 1866 patients with AAA and 5435 controls and replication of promising signals (lead SNP with a p value &lt; 1 × 10-5) in 2871 additional cases and 32,687 controls and performed further follow-up in 1491 AAA and 11,060 controls. In the discovery study, nine loci demonstrated association with AAA (p &lt; 1 × 10-5). In the replication sample, the lead SNP at one of these loci, rs1466535, located within intron 1 of low-density-lipoprotein receptor-related protein 1 (LRP1) demonstrated significant association (p = 0.0042). We confirmed the association of rs1466535 and AAA in our follow-up study (p = 0.035). In a combined analysis (6228 AAA and 49182 controls), rs1466535 had a consistent effect size and direction in all sample sets (combined p = 4.52 × 10-10, odds ratio 1.15 [1.10-1.21]). No associations were seen for either rs1466535 or the 12q13.3 locus in independent association studies of coronary artery disease, blood pressure, diabetes, or hyperlipidaemia, suggesting that this locus is specific to AAA. Gene-expression studies demonstrated a trend toward increased LRP1 expression for the rs1466535 CC genotype in arterial tissues; there was a significant (p = 0.029) 1.19-fold (1.04-1.36) increase in LRP1 expression in CC homozygotes compared to TT homozygotes in aortic adventitia. Functional studies demonstrated that rs1466535 might alter a SREBP-1 binding site and influence enhancer activity at the locus. In conclusion, this study has identified a biologically plausible genetic variant associated specifically with AAA, and we suggest that this variant has a possible functional role in LRP1 expression

Genome-wide association identifies nine common variants associated with fasting proinsulin levels and provides new insights into the pathophysiology of type 2 diabetes.

OBJECTIVE: Proinsulin is a precursor of mature insulin and C-peptide. Higher circulating proinsulin levels are associated with impaired β-cell function, raised glucose levels, insulin resistance, and type 2 diabetes (T2D). Studies of the insulin processing pathway could provide new insights about T2D pathophysiology. RESEARCH DESIGN AND METHODS: We have conducted a meta-analysis of genome-wide association tests of ∼2.5 million genotyped or imputed single nucleotide polymorphisms (SNPs) and fasting proinsulin levels in 10,701 nondiabetic adults of European ancestry, with follow-up of 23 loci in up to 16,378 individuals, using additive genetic models adjusted for age, sex, fasting insulin, and study-specific covariates. RESULTS: Nine SNPs at eight loci were associated with proinsulin levels (P < 5 × 10(-8)). Two loci (LARP6 and SGSM2) have not been previously related to metabolic traits, one (MADD) has been associated with fasting glucose, one (PCSK1) has been implicated in obesity, and four (TCF7L2, SLC30A8, VPS13C/C2CD4A/B, and ARAP1, formerly CENTD2) increase T2D risk. The proinsulin-raising allele of ARAP1 was associated with a lower fasting glucose (P = 1.7 × 10(-4)), improved β-cell function (P = 1.1 × 10(-5)), and lower risk of T2D (odds ratio 0.88; P = 7.8 × 10(-6)). Notably, PCSK1 encodes the protein prohormone convertase 1/3, the first enzyme in the insulin processing pathway. A genotype score composed of the nine proinsulin-raising alleles was not associated with coronary disease in two large case-control datasets. CONCLUSIONS: We have identified nine genetic variants associated with fasting proinsulin. Our findings illuminate the biology underlying glucose homeostasis and T2D development in humans and argue against a direct role of proinsulin in coronary artery disease pathogenesis