Recent Publications by CFE Educators

BACKGROUND

Preceptors rarely follow medical students' developing clinical performance over time and across disciplines. This study analyzes preceptors' descriptions of longitudinal integrated clerkship (LIC) students' clinical development and their identification of strategies to guide students' progress.

METHODS

We used a common evaluation framework, reporter-interpreter-manager-educator, to guide multidisciplinary LIC preceptors' discussions of students' progress. We conducted thematic analysis of transcripts from preceptors' (seven longitudinal ambulatory preceptors per student) quarterly group discussions of 15 students' performance over one year.

RESULTS

All students' clinical development progressed, although most experienced obstacles. Lack of structure in the history and physical exam commonly obstructed progression. Preceptors used templates for data gathering, and modeling or experiences in the inpatient setting to provide time and solidify structure. To advance students' knowledge acquisition, many preceptors identified focused learning topics with their students; to promote application of knowledge, preceptors used reasoning strategies to teach the steps involved in synthesizing clinical data. Preceptors shared accountability for helping students advance as the LIC allowed them to follow students' response to teaching strategies.

DISCUSSION

These results depict preceptors' perceptions of LIC students' developmental continuum and illustrate how multidisciplinary preceptors can use a common evaluation framework to identify strategies to improve performance and follow students' performance longitudinally.

It has recently been demonstrated that specific patterns of correlation exist in diffusion tensor imaging (DTI) parameters across white matter tracts in the normal human brain. These microstructural correlations are thought to reflect phylogenetic and functional similarities between different axonal fiber pathways. However, this earlier work was limited in three major respects: (1) the analysis was restricted to only a dozen selected tracts; (2) the DTI measurements were averaged across whole tracts, whereas metrics such as fractional anisotropy (FA) are known to vary considerably within single tracts; and (3) a univariate measure of correlation was used. In this investigation, we perform an automated multivariate whole-brain voxel-based study of white matter FA correlations using independent component analysis (ICA) of tract-based spatial statistics computed from 3T DTI in 53 healthy adult volunteers. The resulting spatial maps of the independent components show voxels for which the FA values within each map co-vary across individuals. The strongest FA correlations were found in anatomically recognizable tracts and tract segments, either singly or in homologous pairs. Hence, ICA of DTI provides an automated unsupervised decomposition of the normal human brain into multiple separable microstructurally correlated white matter regions, many of which correspond to anatomically familiar classes of white matter pathways. Further research is needed to determine whether whole-brain ICA of DTI represents a novel alternative to tractography for feature extraction in studying the normal microstructure of human white matter as well as the abnormal white matter microstructure found in neurological and psychiatric disorders.

CONTEXT

The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) study, which provided optimal medical therapy (OMT) to all patients and demonstrated no incremental advantage of percutaneous coronary intervention (PCI) on outcomes other than angina-related quality of life in stable coronary artery disease (CAD), suggests that a trial of OMT is warranted before PCI. It is unknown to what degree OMT is applied before PCI in routine practice or whether its use increased after the COURAGE trial.

OBJECTIVE

To examine the use of OMT in patients with stable angina undergoing PCI before and after the publication of the COURAGE trial.

DESIGN, SETTING, AND PARTICIPANTS

An observational study of patients with stable CAD undergoing PCI in the National Cardiovascular Data Registry between September 1, 2005, and June 30, 2009. Analysis compared use of OMT, both before PCI and at the time of discharge, before and after the publication of the COURAGE trial. Optimal medical therapy was defined as either being prescribed or having a documented contraindication to all medicines (antiplatelet agent, β-blocker, and statin).

MAIN OUTCOME MEASURES

Rates of OMT before PCI and at discharge (following PCI) between the 2 study periods.

RESULTS

Among all 467,211 patients (173,416 before [37.1%] and 293,795 after [62.9%] the COURAGE trial) meeting study criteria, OMT was used in 206,569 patients (44.2%; 95% confidence interval [CI], 44.1%-44.4%) before PCI and in 303,864 patients (65.0%; 95% CI, 64.9%-65.2%) at discharge following PCI (P .001). Before PCI, OMT was applied in 75,381 patients (43.5%; 95% CI, 43.2%-43.7%) before the COURAGE trial and in 131,188 patients (44.7%; 95% CI, 44.5%-44.8%) after the COURAGE trial (P .001). The use of OMT at discharge following PCI before and after the COURAGE trial was 63.5% (95% CI, 63.3%-63.7%) and 66.0% (95% CI, 65.8%-66.1%), respectively (P .001).

CONCLUSION

Among patients with stable CAD undergoing PCI, less than half were receiving OMT before PCI and approximately two-thirds were receiving OMT at discharge following PCI, with relatively little change in these practice patterns after publication of the COURAGE trial.

INTRODUCTION

Deceased donors are considered high infectious risk donors (IRDs) based on criteria thought to be associated with risk of HIV transmission. Significant variation exists in provider willingness to utilize IRD kidneys. Little is known about how patients view these organs. Our aim was to explore patient attitudes toward IRDs and IRD kidney transplantation.

METHODS

Patients were recruited from a single-center deceased donor waitlist. Focus groups stratified by age and race were conducted to ascertain patient attitudes toward IRD kidney transplantation. Transcripts were examined using standard qualitative methods.

RESULTS

Patients considered IRD kidneys most appropriate for patients at high risk of death or with poor quality of life on dialysis. Patients felt unprepared to receive organ offers, especially from IRDs. They desired information about IRD behaviors, kidney quality, and probability of undetected infection. Patients weighed the opinion of their nephrologist most heavily when deciding about organ offers. A brief education session about donor screening resulted in increased willingness to consider IRD kidneys.

CONCLUSIONS

Lack of preparedness contributes to patient apprehension toward IRD organs. Ongoing transplant education seems necessary. The non-transplant nephrologist seems to be the most trusted source of information.

BACKGROUND

Pharmaceutical and medical device company funding supports up to 60% of accredited continuing medical education (CME) costs in the United States. Some have proposed measures to limit the size, scope, and potential influence of commercial support for CME activities. We sought to determine whether participants at CME activities perceive that commercial support introduces bias, whether this is affected by the amount or type of support, and whether they would be willing to accept higher fees or fewer amenities to decrease the need for such funding.

METHODS

We delivered a structured questionnaire to 1347 participants at a series of 5 live CME activities about the impact of commercial support on bias and their willingness to pay additional amounts to eliminate the need for commercial support.

RESULTS

Of the 770 respondents (a 57% response rate), most (88%) believed that commercial support introduces bias, with greater amounts of support introducing greater risk of bias. Only 15%, however, supported elimination of commercial support from CME activities, and less than half (42%) were willing to pay increased registration fees to decrease or eliminate commercial support. Participants who perceived bias from commercial support more frequently agreed to increase registration fees to decrease such support (2- to 3-fold odds ratio). Participants greatly underestimated the costs of ancillary activities, such as food, as well as the degree of support actually provided by commercial funding.

CONCLUSION

Although the medical professionals responding to this survey were concerned about bias introduced from commercial funding of CME, many were not willing to pay higher fees to offset or eliminate such funding sources.

BACKGROUND

The incidence of adrenal tumors increases with age. We examined the impact of older age (>60 years) on clinical and economic outcomes after adrenalectomy.

METHODS

Adult patients who underwent adrenalectomy in the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) from 2003-2008 were categorized into age groups: ≤60 years, 61-70 years, and >70 years. Outcomes were compared using χ(2) and ANOVA; multivariate regression was used to assess the independent effect of older age on adrenalectomy outcomes.

RESULTS

There were 6,416 patients: 21.9% were 61-70 years, and 12.9% were >70 years. Compared with patients ≤60 years, patients 61-70 and >70 years had more complications (14.1% vs. 19.9 and 22.6%; p 0.001) and mortality (0.4% vs. 1.3 and 2.3%; p 0.001), longer mean length of stay (LOS) (3.3 vs. 4.0 and 4.9 days; p 0.001), and higher mean costs ($12,307 vs. $13,226 and $14,649; p 0.001). After adjustment, older age remained independently associated with sustaining one or more complications after adrenalectomy (odds ratio (OR) 1.4, 95% confidence interval (CI) 1.1-1.7, for patients 61-70 years; OR 1.7, 95% CI 1.3-2.2 for patients >70 years) and longer adjusted LOS (1-day difference, p 0.01). Age >70 years was independently associated with increased mortality after adrenalectomy (OR 2.8; 95% CI 1.4-5.6). Complications, LOS, and costs were reduced if patients underwent surgery by high-volume compared with low-volume surgeons.

CONCLUSIONS

Older age seems to be independently associated with adverse short-term clinical and economic outcomes after adrenalectomy. Enhanced access to high-volume surgeons is a potentially modifiable factor of particular importance in these patients.

This study examines velopharyngeal, speech, and dental parameters as possible diagnostic aids in 22q11.2 deletion syndrome. It is a retrospective study on 56 individuals. Twenty-one percent had a submucous cleft palate and 41 percent required palate surgery for speech. Common dental findings included poor oral hygiene, multiple carious lesions, congenitally missing teeth, class II malocclusion, and open bite.There are common findings that can aid the dental practitioner in recognizingthe syndrome and make appropriate referrals.

OBJECTIVES

Methods for evaluating student performance in clerkships traditionally suffer shortcomings, partly as a result of clerkship structure. The purpose of this study was to compare preceptors' and students' perceptions of student evaluation in block clerkships and longitudinal integrated clerkships (LICs).

METHODS

From 2007 to 2009, preceptors who taught on both block clerkships and an LIC were surveyed on their perceptions of clerkship evaluation. Year 3 students were surveyed on their perceptions of clerkship evaluation at the year end. Responses from preceptors who completed both block clerkship and LIC surveys were compared using paired-samples t-test; student responses were compared using independent-samples t-test.

RESULTS

Overall, 66% (67/102) of block clerkship and 75% (77/102) of LIC preceptors responded; 44% of preceptors (45/102) completed both block and LIC surveys. In total, 62% (68/110) of block clerkship and 83% (19/23) of LIC students responded. Both preceptors and students favoured evaluation in the LIC on three factors (p ≤ 0.01): validity of evaluation process, quality of clinical skill evaluation, and willingness to provide constructive feedback.

CONCLUSIONS

Preceptors and students perceived evaluation in an LIC more favourably than evaluation on block clerkships. For educators working to improve student evaluation, further examination of the LIC structure and evaluation processes that seem to enhance both formative assessment and summative evaluation may be useful to improve the quality of evaluation and feedback.

OBJECTIVE

To provide pharmacists with the basic knowledge to counsel caregivers in appropriate infant formula selection and use.

SUMMARY

Although the majority of infants are initially breast-fed, a transition to infant formula by the age of 6 months, either as a supplement or a replacement for human milk, is common in the United States. Manufacturers have capitalized on this growing demand for infant formulas to more closely mimic human milk by creating a variety of formulations. The mainstay of the formula market is iron-fortified cow's milk, which may have a distinct variation in carbohydrate, protein, and fat sources, depending on the manufacturer. Formulations are also available to match specific needs of the infant or family, including added rice for reflux, partially or extensively hydrolyzed for allergen sensitivity, or soy based for a vegan diet preference.

CONCLUSION

With an extensive array of infant formulas available, pharmacists and caregivers can be overwhelmed when selecting an appropriate product. However, with careful questioning and a basic knowledge of the available formulas, an initial selection can be provided to caregivers. In addition to assisting in infant formula selection, pharmacists should provide information on proper preparation, handling, and storage of the product.