Recent Publications by CFE Educators

BACKGROUND & AIMS

United Network of Organ Sharing (UNOS) has adopted uniform criteria for downstaging (UNOS-DS) of hepatocellular carcinoma (HCC) before liver transplantation (LT), but the downstaging success rate and intention-to-treat outcomes across broad geographic regions are unknown.

METHODS

In this first multiregional study (7 centers, 4 UNOS regions), 209 consecutive patients with HCC undergoing downstaging based on UNOS-DS criteria were prospectively evaluated from 2016 to 2019.

RESULTS

Probability of successful downstaging to Milan criteria and dropout at 2 years from the initial downstaging procedure was 87.7% and 37.3%, respectively. Pretreatment with lectin-reactive α-fetoprotein ≥10% (hazard ratio, 3.7; P = .02) was associated with increased dropout risk. When chemoembolization (n = 132) and yttrium-90 radioembolization (n = 62) were compared as the initial downstaging treatment, there were no differences in Modified Response Evaluation Criteria In Solid Tumors response, probability of or time to successful downstaging, waiting list dropout, or LT. Probability of LT at 3 years was 46.6% after a median of 17.2 months. In the explant, 17.5% had vascular invasion, and 42.8% exceeded Milan criteria (understaging). The only factor associated with understaging was the sum of the number of lesions plus largest tumor diameter on the last pre-LT imaging, and the odds of understaging increased by 35% per 1-unit increase in this sum. Post-LT survival at 2 years was 95%, and HCC recurrence occurred in 7.9%.

CONCLUSION

In this first prospective multiregional study based on UNOS-DS criteria, we observed a successful downstaging rate of >80% and similar efficacy of chemoembolization and yttrium-90 radioembolization as the initial downstaging treatment. A high rate of tumor understaging was observed despite excellent 2-year post-LT survival of 95%. Additional LRT to reduce viable tumor burden may reduce tumor understaging.

INTRODUCTION

Hematology/oncology fellows must achieve bone marrow biopsy proficiency. However, opportunities for fellows to perform bone marrow biopsies on patients are highly dependent on clinical volume. An easily accessible and feasible system to practice these procedures repetitively has not been described. Other specialties use 3-dimensional (3D)-printed models to practice procedures, but hematology/oncology has not yet incorporated this novel medical education tool, which has the potential to provide such an accessible and feasible system for procedural practice.

METHODS

We used design thinking to develop and pilot a bone marrow biopsy simulation using 3D-printed pelvis models. We printed and optimized 2 models through iterative prototyping. In July 2019, we conducted a 1-hour session with 9 fellows. After an anatomy review, fellows practiced biopsies using the models with faculty feedback. To evaluate feasibility, we reviewed session evaluations, measured fellow comfort, surveyed supervising attendings, and gathered fellow and attending feedback.

RESULTS

Fellows rated the 3D session highly. Fellow comfort improved after orientation. Supervisors noted no difference between the 2019 fellows and prior years. Fellows praised the opportunity to rehearse mechanics, receive feedback, and internalize anatomy. Fellows suggested incorporating a female pelvis and more soft tissue. Attending feedback on the model aligned with fellow feedback. We implemented the session again in 2020 with adjustments based on feedback.

CONCLUSIONS

Three-dimensional printing represents an accessible and feasible educational tool. Three-dimensional-printed models provide opportunities for iterative practice, feedback, and anatomy visualization. Future iterations should continue to incorporate user feedback to optimize model utility.

CONTEXT

Medical educators are increasingly paying attention to how bias creates inequities that affect learners across the medical education continuum. Such bias arises from learners' social identities. However, studies examining bias and social identities in medical education tend to focus on one identity at a time, even though multiple identities often interact to shape individuals' experiences.

METHODS

This article examines prior studies on bias and social identity in medical education, focusing on three social identities that commonly elicit bias: race, gender and profession. By applying the lens of intersectionality, we aimed to generate new insights into intergroup relations and identify strategies that may be employed to mitigate bias and inequities across all social identities.

RESULTS

Although different social identities can be more or less salient at different stages of medical training, they intersect and impact learners' experiences. Bias towards racial and gender identities affect learners' ability to reach different stages of medical education and influence the specialties they train in. Bias also makes it difficult for learners to develop their professional identities as they are not perceived as legitimate members of their professional groups, which influences interprofessional relations. To mitigate bias across all identities, three main sets of strategies can be adopted. These strategies include equipping individuals with skills to reflect upon their own and others' social identities; fostering in-group cohesion in ways that recognise intersecting social identities and challenges stereotypes through mentorship; and addressing intergroup boundaries through promotion of allyship, team reflexivity and conflict management.

CONCLUSIONS

Examining how different social identities intersect and lead to bias and inequities in medical education provides insights into ways to address these problems. This article proposes a vision for how existing strategies to mitigate bias towards different social identities may be combined to embrace intersectionality and develop equitable learning environments for all.

Despite widespread adoption of electronic health records (EHRs), most hospitals are not ready to implement data science research in the clinical pipelines. Here, we develop MEDomics, a continuously learning infrastructure through which multimodal health data are systematically organized and data quality is assessed with the goal of applying artificial intelligence for individual prognosis. Using this framework, currently composed of thousands of individuals with cancer and millions of data points over a decade of data recording, we demonstrate prognostic utility of this framework in oncology. As proof of concept, we report an analysis using this infrastructure, which identified the Framingham risk score to be robustly associated with mortality among individuals with early-stage and advanced-stage cancer, a potentially actionable finding from a real-world cohort of individuals with cancer. Finally, we show how natural language processing (NLP) of medical notes could be used to continuously update estimates of prognosis as a given individual's disease course unfolds.

To describe a health equity curriculum created for pharmacy students and evaluate students' perceptions and structural competency after completion of the curriculum. A health equity curriculum (HEC) based on transformative learning and structural competency frameworks was implemented as a 10-week mandatory component of the pass-no pass neuropsychiatric theme for second-year pharmacy students. Each week, students reviewed materials around a neuropsychiatric-related health equity topic and responded to discussion prompts through asynchronous forums or synchronous Zoom discussions. The HEC was evaluated through assessment of structural competency through a validated instrument (SCI), an objective structured clinical examination (OSCE), and a questionnaire. All enrolled second-year pharmacy students (n=124) participated in the HEC. Of the 75 (68%) students who completed the SCI, 46 (61%) were able to identify structural determinants of health, explain how structures contribute to health disparities, or design structural interventions. Ninety-six (77%) students were able to address their OSCE standardized patient's mistrust in the healthcare system. Thematic analysis of student comments elucidated three themes-allyship, peer connection, and self-awareness. Students rated asynchronous discussion forums as significantly less effective than Zoom discussions and patient cases for achieving curricular objectives. A remote, mandatory, blended health equity curriculum demonstrated an effective model for social justice-oriented education. From our experience, a curriculum spread throughout the didactic curriculum with a blended approach is an effective way to incorporate health equity conversations into existing programs and could be an important step in training student pharmacists to be advocates for social justice.