Search

Before the COVID-19 pandemic, teaching communication skills in health care focused primarily on developing skills during face-to-face conversation. Even experienced clinicians were unprepared for the transition in communication modalities necessitated due to physical distancing requirements and visitation restrictions during the COVID-19 pandemic. We aimed to develop and pilot a comprehensive video-mediated communication training program and test its feasibility in multiple institutional settings and medical disciplines.The education team, consisting of clinician-educators in general surgery and emergency medicine (EM) and faculty specialists in simulation and coaching, created the intervention. Surgery and EM interns in addition to senior medical students applying in these specialties were recruited to participate. Three 90-minute sessions were offered focusing on 3 communication topics that became increasingly complex and challenging: breaking bad news, goals of care discussions, and disclosure of medical error. This was a mixed-methods study using survey and narrative analysis of open comment fields.Learner recruitment varied by institution but was successful, and most (75%) learners found the experience to be valuable. All of the participants reported feeling able to lead difficult discussions, either independently or with minimal assistance. Only about half (52%) of the participants reported feeling confident to independently disclose medical error subsequent to the session.We found the program to be feasible based on acceptability, demand, the ability to implement, and practicality. Of the 3 communication topics studied, confidence with disclosure of medical error proved to be the most difficult. The optimal length and structure for these programs warrants further investigation.

Bread wheat (Triticum aestivum, genome BBAADD) is a young hexaploid species formed only 8,500–9,000 years ago through hybridization between a domesticated free-threshing tetraploid progenitor, genome BBAA, and Aegilops tauschii, the diploid donor of the D subgenome. Very soon after its formation, it spread globally from its cradle in the fertile crescent into new habitats and climates, to become a staple food of humanity. This extraordinary global expansion was probably enabled by allopolyploidy that accelerated genetic novelty through the acquisition of new traits, new intergenomic interactions, and buffering of mutations, and by the attractiveness of bread wheat’s large, tasty, and nutritious grain with high baking quality. New genome sequences suggest that the elusive donor of the B subgenome is a distinct (unknown or extinct) species rather than a mosaic genome. We discuss the origin of the diploid and tetraploid progenitors of bread wheat and the conflicting genetic and archaeological evidence on where it was formed and which species was its free-threshing tetraploid progenitor. Wheat experienced many environmental changes throughout its evolution, therefore, while it might adapt to current climatic changes, efforts are needed to better use and conserve the vast gene pool of wheat biodiversity on which our food security depends.

Background The COVID-19 pandemic resulted in a sudden increase in the need to effectively use telehealth in all realms of health care communication, including the delivery of bad news. Methods A single arm, unblinded, feasibility study was performed at a tertiary care center located in Central Virginia to explore the value and utility of providing a telehealth training program based on SPIKES to teach surgical residents and faculty best practice for disclosing difficult news via video-mediated communication (VMC). Surgical interns (categorical and preliminary), surgical residents, and surgical faculty from General, Neuro, Pediatric, Plastics, Oncology, Urology, and Vascular surgical specialties were recruited via email to voluntarily participate in a telehealth simulation-based workshop, with 33 surgical learners participating in the training and 28 completing evaluation surveys. Results Only six respondents (22%) indicated they had prior formal training on telehealth communication with patients or families, while 13 (46%) said they had prior experience giving bad news via telehealth. Comments about improving the training focused on providing more scenarios to practice and more time for feedback. Overall, 25 learners (86%) agreed the activity was a valuable learning experience and the majority (61%) of responses were positive for future use of telehealth for breaking bad news. Discussion Practicing communication skills with VMC was found to be valuable by surgical interns, residents, and faculty. Formal training should be provided for surgeons at every stage of training and practice to improve skill in the delivery of bad news to patients and their families.

INTRODUCTION Authentic clinical experiences and reflection are critical for medical student professional identity formation (PIF). Individualized learning plans and competency-based education accelerate time to graduation, thus creating more demand for students to gain PIF experiences early in medical education. This pilot study investigated student professional identity experiences related to participation in a clinical simulation during the first week of medical school. METHODS All first-year medical students at an academic health center participated in a clinically relevant simulation-based orientation to medical school (SOMS). Participants completed evaluation surveys measuring PIF-related experiences during the SOMS. RESULTS All participants completed the survey (N = 186). Students agreed that the SOMS helped them feel what it is like to be a doctor (90%) and transition to the role of student-physician (91%). Student comments about the SOMS-reflected PIF-related processes, such as building a sense of a community of practice among their peers in their roles as a healthcare team. Students also valued the opportunity to engage in reflection about their roles as student-physicians. CONCLUSIONS Simulation experiences can be used as a trigger for self-reflection to assist in medical student professional identity development as early as the first weeks of medical school. Simulation exercises may improve PIF and could further enhance medical student PIF by adding them longitudinally into the curriculum.

Medical scribes have become a common fixture in healthcare, but little is known about the impact of a scribe experience on medical school performance. The objective of this study was to determine the frequency of scribe experience for medical students and impact on performance. Thirty-four percent of students were scribes prior to medical school. The majority of scribes felt their scribe experience helped them during their pre-clerkship curriculum. However, there were no significant differences in USMLE Step 1 scores, pre-clerkship class rank, post-encounter note grades, and wellbeing between students with and without scribe experience.

Attendance at in-person lectures in medical schools is declining with nearly 28.8% of all active, second-year medical students who reported "almost never" attending in-person lectures during their preclinical years. The objective of this study was to explore the relationship between medical student attendance and performance and investigate students' goal orientation as factors influencing their decision to attend.Participants completed a survey at the end of their second year that asked to self-report attendance during each of the three preclinical semesters, factors that influenced attendance, and measured their goal orientation (GO). Student performance outcomes included all courses in the preclinical curriculum and USMLE Step 1 scores.There was a statistically significant reduction in frequency of attendance after each subsequent semester (The pattern of declining lecture attendance in medical school with the rapid adoption of virtual learning triggered by the Covid-19 pandemic indicates students have taken more control over where and when they learn. Our results showed that students perceived in-person attendance at lectures was more valuable for balancing keeping up with coursework and maintaining social relationships and less valuable for efficient Step 1 preparation. Students' goal orientation may help identify individuals who are less likely to attend in-person. The full impact of the COVID-19 on student learning is yet to be determined.

Medical schools vary in their approach to providing feedback to faculty. The purpose of this study was to test the effects of rapid student feedback in a course utilizing novel virtual learning methods.Second-year medical students were supplied with an optional, short questionnaire at the end of each class session and asked to provide feedback within 48 h. At the close of each survey, results were emailed to faculty. After the course, students and faculty were asked to rate the effectiveness of this method. This study did not affect administration of the usual end-of-course summative evaluations.Ninety-one percent of students who participated noted increased engagement in the feedback process, but only 18% on average chose to participate. Faculty rated rapid feedback as more actionable than summative feedback (67%), 50% rated it as more specific, and 42% rated it as more helpful. Some wrote that comments were too granular, and others noted a negative personal emotional response.Rapid feedback engaged students, provided actionable feedback, and increased communication between students and instructors, suggesting that this approach added value. Care must be taken to reduce the student burden and support relational aspects of the process.

Long-term genetic studies of wild populations are very scarce but are essential for connecting ecological and population genetics models, and are also necessary for understanding how climate change can affect biodiversity. We present a study of the wild ancestor of modern wheat, carried out over a 36-year period during which atmospheric CO2 increased by 70 ppm and temperature by 1.5°C. We genotyped 832 individuals from regular sampling along transects during the course of the experiment. Genotypes were clustered into ecological microhabitats over scales of tens of meters, and this clustering was remarkably stable over the 36 generations of the study. Simulations indicate that neutral processes alone are insufficient to explain this spatial and temporal stability, suggesting a role for fine-scale local adaptation to ecological parameters. Using a common-garden experiment, we showed that the genotypes found in distinct microhabitats differ phenotypically, further supporting the hypothesis of local adaptation. Our results provide a rare insight into the dynamics of a natural population at the scale of individuals over a period of environmental change.

PROBLEM Medical students typically perform worse on clinical clerkships that take place early in their training compared with those that occur later. Some institutions have developed transition-to-clerkship courses (TTCCs) to improve students' preparedness for the clinical phase of the curriculum. Yet, the impact of TTCCs on students' performance has not been evaluated. APPROACH The authors developed and implemented a TTCC at Virginia Commonwealth University School of Medicine and measured its impact on students' clerkship performance. During the 2014-2015 academic year, they introduced a 2-week intersession TTCC. The goal was to improve students' readiness for clerkships by fostering the knowledge, skills, and attitudes required to care for patients throughout a hospitalization. The TTCC included panel discussions, skills development sessions, case-based workshops, and a 4-station standardized patient simulation. The authors assessed the feasibility of designing and implementing the TTCC and students' reactions and clerkship performance. OUTCOMES The total direct costs were $3,500. Students reacted favorably and reported improved comfort on entering clerkships. Summative performance evaluations across clerkships were higher for those students who received the TTCC with simulation compared with those students who received the standard clerkship orientation (P < .001-.04, Cohen's d range = 0.23-0.62). This finding was particularly apparent in those clerkships that occurred earlier in the academic year. NEXT STEPS Future plans include evaluating the impact of the TTCC on student well-being and incorporating elements of the TTCC into the preclinical curriculum.

BACKGROUND Medical student well-being is a critical issue in medical education and is linked to burnout and resilience. Understanding the impact of the clinical learning environment may be crucial to developing effective curricular interventions. Medical student well-being is a critical issue in medical education OBJECTIVE: To determine factors affecting medical student well-being and perceived stress during clinical clerkships and describe any associations with the learning environment, resilience, and performance. METHODS This was a retrospective study of one cohort of medical students surveyed at the conclusion of third-year clinical clerkships using the Medical School Learning Environment Scale, Brief Resilience Scale, Perceived Stress Scale, and the World Health Organization Well-Being Index. The United States Medical Licensing Examination (USMLE), Step 1 scores and clerkship performance were also collected. Analysis included Pearson correlations and linear regression. RESULTS Of the 204 students completing the clerkships, 146 students completed the survey (72%). Well-being correlated positively with learning environment (r = 0.43) and resilience (r = 0.35, p

Background Communication between clinicians, patients, and families is a core component of medical care that requires deliberate practice and feedback to improve. In March 2020, the COVID-19 pandemic caused a sudden transformation in communication practices because of new physical distancing requirements, necessitating physicians to communicate bad news via telephone and video-mediated communication (VMC). This study investigated students' experience with a simulation-based communications training for having difficult conversations using VMC. Methods Thirty-eight fourth-year medical students preparing for their surgical residency participated in a simulated scenario where students discussed a new COVID-19 diagnosis with a standardised family member (SFM) of a sick patient via VMC. Learners were introduced to an established communications model (SPIKES) by an educational video. After the simulation, SFM and course facilitators guided a debrief and provided feedback. Learners completed surveys evaluating reactions to the training, preparedness to deliver bad news, and attitudes about telehealth. Results Twenty-three students completed evaluation surveys (response rate=61%). Few students had prior formal training (17%) or experience communicating bad news using telehealth (13%). Most respondents rated the session beneficial (96%) and felt they could express empathy using the VMC format (83%). However, only 57% felt ready to deliver bad news independently after the training and 52% reported it was more difficult to communicate without physical presence. Comments highlighted the need for additional practice. Conclusion This pilot study demonstrated the value and feasibility of teaching medical students to break bad news using VMC as well as demonstrating the need for additional training.

INTRODUCTION: The Core Entrustable Professional Activities for Entering Residency (Core EPAs) are clinical activities all interns should be able to perform on the first day of residency with indirect supervision. The acting (sub) internship (AI) rotation provides medical students the opportunity to be assessed on advanced Core EPAs. MATERIALS AND METHODS: All fourth-year AI students were taught Core EPA skills and performed these clinical skills under direct supervision. Formative feedback and direct observation data were provided via required workplace-based assessments (WBAs). Supervising physicians rated learner performance using the Ottawa Clinic Assessment Tool (OCAT). WBA and pre-post student self-assessment data were analyzed to assess student performance and gauge curriculum efficacy. RESULTS: In the 2017–2018 academic year, 167 students completed two AI rotations at our institution. By their last WBA, 91.2% of students achieved a target OCAT supervisory scale rating for both patient handoffs and calling consults. Paired sample t tests of the student pre-post surveys showed statistically significant improvement in self-efficacy on key clinical functions of the EPAs. DISCUSSION: This study demonstrates that the AI rotation can be structured to include a Core EPA curriculum that can assess student performance utilizing WBAs of directly observed clinical skills. CONCLUSIONS: Our clinical outcomes data demonstrates that the majority of fourth-year medical students are capable of performing advanced Core EPAs at a level acceptable for intern year by the conclusion of their AI rotations. WBA data collected can also aid in ad hoc and longitudinal summative Core EPA entrustment decisions. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40670-021-01208-y.

Recombination between homeologous chromosomes, also known as homeologous exchange (HE), plays a significant role in shaping genome structure and gene expression in interspecific hybrids and allopolyploids of several plant species. However, the molecular mechanisms that govern HEs are not well understood. Here, we studied HE events in the progeny of a nascent allotetraploid (genome AADD) derived from two diploid progenitors of hexaploid bread wheat using cytological and whole-genome sequence analyses. In total, 37 HEs were identified and HE junctions were mapped precisely. HEs exhibit typical patterns of homologous recombination hotspots, being biased toward low-copy, subtelomeric regions of chromosome arms and showing association with known recombination hotspot motifs. But, strikingly, while homologous recombination preferentially takes place upstream and downstream of coding regions, HEs are highly enriched within gene bodies, giving rise to novel recombinant transcripts, which in turn are predicted to generate new protein fusion variants. To test whether this is a widespread phenomenon, a dataset of high-resolution HE junctions was analyzed for allopolyploid Brassica , rice, Arabidopsis suecica , banana, and peanut. Intragenic recombination and formation of chimeric genes was detected in HEs of all species and was prominent in most of them. HE thus provides a mechanism for evolutionary novelty in transcript and protein sequences in nascent allopolyploids.

A key component of quality improvement (QI) is developing leaders who can implement QI projects collaboratively. A yearlong interprofessional, workplace-based, continuing professional development program devoted to QI trained 2 cohorts of teams (dyads or triads) to lead QI projects in their areas of work using Plan-Do-Study-Act methodology. Teams represented different specialties in both inpatient and outpatient settings. They spent 4 to 6 hours/week on seminars, online modules, bimonthly meetings with a QI coach, and QI project work. Evaluations conducted after each session included pre–post program QI self-efficacy and project milestones. Post-program participants reported higher levels of QI self-efficacy (mean = 3.47; SD = 0.39) compared with pre program (mean = 2.02, SD = 0.51; P = .03, Cohen’s d = 3.19). Impact on clinical units was demonstrated, but varied. The coach was identified as a key factor for success. An interprofessional, workplace-based, continuing professional development program focused on QI increased QI knowledge and skills and translated to improvements in the clinical setting.

Evaluation of medical school curriculum is important to document outcomes, effectiveness of learning, engagement in quality improvement, and to meet accreditation compliance. This monograph provides a roadmap and resource for medical schools to meaningfully evaluate their curriculum based on specific metrics. The method of evaluation includes an examination of Kirkpatrick's levels of outcomes including reactions, learning, behavior, and impact. It is important that student outcomes are mapped in relation to curricular objectives. There are specific outcomes that may be utilized to determine if the curriculum has met the institution's goals. The first is comparison to national metrics (United States Medical Licensing Examinations and American Association of Medical Colleges Graduation Questionnaire). Second, medical schools collect internal program metrics, which include specific student performance metrics, such as number of students graduating, attrition, and matching to specialty. Further, schools may examine student performance and surveys in the preclerkship and clinical phases (e.g., grades, failing courses, survey responses about the curriculum), including qualitative responses on surveys or focus groups. As the learning environment is critical to learning, a deep dive to understand the environment and mistreatment may be important for program evaluation. This may be performed by specifically examining the Graduation Questionnaire, internal surveys, and mistreatment reporting. Finally, there are numerous attitudinal instruments that may help medical schools understand their students' development at one point or over time. These include measurements of stress, wellness, burnout, lifelong learning, and attitudes toward patient safety. Together, examining the composite of outcomes helps to understand and improve the medical school curriculum.

The medical school admissions process seeks to assess a core set of cognitive and non-cognitive competencies that reflect professional readiness and institutional mission alignment. The standardized format of multiple mini-interviews (MMIs) can enhance assessments, and thus many medical schools have switched to this for candidate interviews. However, because MMIs are resource-intensive, admissions deans use a variety of interviewers from different backgrounds/professions. Here, we analyze the MMI process for the 2018 admissions cycle at the VCU School of Medicine, where 578 applicants were interviewed by 126 raters from five distinct backgrounds: clinical faculty, basic science faculty, medical students, medical school administrative staff, and community members. We found that interviewer background did not significantly influence MMI evaluative performance scoring, which eliminates a potential concern about the consistency and reliability of assessment.

Healthcare workers routinely self-contaminate even when using personal protective equipment. Observations of donning/ doffing practices on inpatient units along with surveys were used to assess the need for a personal protective equipment training program. In contrast to low perceived risk, observed doffing behaviors demonstrate significant personal protective equipment technique deficits.Infect Control Hosp Epidemiol 2017;38:226–229

In 2014, the Association of American Medical Colleges (AAMC) developed a list of Core Entrustable Professional Activities (Core EPAs) to optimize the transition from medical school to residency training. In the coming years, medical schools will begin implementing curriculum targeted toward the instruction and assessment of the Core EPAs. The purpose of this convergent mixed methods study was to examine the perspective of recent medical school graduates to describe their perceived preparation for each Core EPA-based skill and to identify potential predictors that contribute to those perceptions. Forty-four first-year residents from a single hospital system (representing 29 unique medical schools) completed a questionnaire and 15 residents participated in focus group sessions. Participants were asked to rate their overall preparedness for each of the Core EPAs and describe the instruction and assessment provided during medical school. Responses were further explored through three focus group sessions. Respondents felt most prepared for Core EPAs which emphasized skills related to history and physical examinations (EPAs 1, 5, and 6) and less prepared in skills such as entering orders and prescriptions (EPA 4), performing handovers (EPA 8), and identifying system failures (EPA 13). Perceived preparation was highly correlated with the presence of early and formal training, opportunities for experience, and explicit methods of assessment. Building upon the results of these data and principles of integrated curriculum design, the authors propose a longitudinal method to focus efforts in developing curriculum for the Core EPAs.

PURPOSE: Today, clinical care is often provided by interprofessional virtual teams—groups of practitioners who work asynchronously and use technology to communicate. Members of such teams must be competent in interprofessional practice and the use of information technology, two targets for health professions education reform. The authors created a Web-based case system to teach and assess these competencies in health professions students. METHOD: They created a four-module, six-week geriatric learning experience using a Web-based case system. Health professions students were divided into interprofessional virtual teams. Team members received profession-specific information, entered a summary of this information into the case system’s electronic health record, answered knowledge questions about the case individually, then collaborated asynchronously to answer the same questions as a team. Individual and team knowledge scores and case activity measures—number of logins, message board posts/replies, views of message board posts—were tracked. RESULTS: During academic year 2012–2013, 80 teams composed of 522 students from medicine, nursing, pharmacy, and social work participated. Knowledge scores varied by profession and within professions. Team scores were higher than individual scores (P < .001). Students and teams with higher knowledge scores had higher case activity measures. Team score was most highly correlated with number of message board posts/replies and was not correlated with number of views of message board posts. CONCLUSIONS: This Web-based case system provided a novel approach to teach and assess the competencies needed for virtual teams. This approach may be a valuable new tool for measuring competency in interprofessional practice.

Background: Mobile prehospital telestroke presents a novel solution to improve stroke diagnosis and reduce treatment times. This study aims to 1) understand perceptions of a mobile ambulance-based telestroke system from all users and 2) evaluate system usability during ambulance transport. Methods: A Critical Care ambulance was equipped with a mobile telemedicine system to perform remote stroke assessments. Scripted scenarios were performed by trained actors during transport and evaluated by physicians using the NIH stroke scale (NIHSS). Scores obtained during transport were compared with independent bedside and original scripted NIHSS scores. Participants completed the System Usability Scale (SUS), NASA task load index (NASA TLX), audio-video quality scale and a modified Acceptability of Technology survey after completing the NIHSS evaluations. In addition, interviews were conducted to evaluate user’s experience and perceptions. Descriptive analysis was used for all surveys. Weighted kappa was used to compare the agreement in NIHSS scores. A regression model was used to further account for variations. Results: Ten scripted scenarios were simulated twice during the mobile transport and once at bedside. All simulations were completed except for one. NIHSS scores between mobile, bedside and original scripted scenarios revealed good agreement [weighted kappa=0.76 (95% CI: 0.63-0.9, p=0.63)]. There were no statistically significant differences in NIHSS scores between mobile and bedside evaluations. The results were independent of stroke scenarios, physicians, and actors. Overall, 92% and 81% raters deemed video and audio quality as “good” or “excellent” (rating < 3) respectively. The overall mean SUS score was 69.1 (13.3). Content analysis identified strengths, usability issues (i.e. audibility and equipment stability during transport), and safety concerns. Conclusion: This study used in-situ simulation to evaluate the viability of a mobile telestroke system. Simulating stroke scenarios using actors during a real ambulance transport allowed us to assess a health technology without risking patient safety while capturing realistic environmental factors.

Background: When early and accurate identification of stroke occurs in the field by Emergency Medical Service (EMS) providers, the chances of reperfusion increases dramatically. Telestroke has made significant strides over the years and hold promise for potential use in the prehospital setting. However, the introduction of such a novel technology within a healthcare system can be complex. Purpose: To describe the use of the combination of clinical simulation and Plan-Do-Study-Act (PDSA) methodology in the design of a mobile prehospital telestroke system. Methods: A multi-stakeholder team with representation from the Departments of Neurology and Emergency Medicine, Office of Telemedicine, Center of Human Simulation and Patient Safety, local EMS agency and a telemedicine developer collaborated to develop a mobile prehospital telestroke system over a 6 month time period. Modifications to telemedicine equipment, teleconferencing software and protocol were implemented based on the results of serial PDSA cycles and clinical simulation testing. We used data collected via direct observation notes, survey results and informal interviews during serial PDSA cycles and clinical simulation to test changes to improve our mobile prehospital telestroke system. Results: (see image of PDSA chart) Conclusion: The combined clinical simulation and PDSA model led to the identification of technical and operational barriers not considered in the original design of the mobile telemedicine platform and placement. Before implementation and financial investment in a mobile prehospital telestroke program, the use of combined clinical simulation and PDSA methodology can improve the quality and optimize the system use. Further PDSA and simulation cycles are needed to improve the design of our mobile system.

Simulation-based training (SBT) is commonly integrated into medical education. This panel examines current uses of SBT in undergraduate, graduate, and continuing medical education and addresses the advantages and different considerations for each. Furthermore, we consider how SBT within the different levels of medical education can inform practices across levels.

Wild emmer wheat, Triticum turgidum subsp. dicoccoides, (2n = 4x = 28; genome BBAA), the progenitor of domesticated wheat, is genetically very close to durum and common wheat. This wild taxon has many characteristics that would be valuable if transferred to domesticated wheat. An appropriate exploitation of the "wild" genome requires its dissection into segments and evaluation of the contribution of each segment separately to the performance of domesticated wheat. This work describes the production of a series of chromosome-arm substitution lines (CASLs) of wild emmer in the background of the Israeli common wheat cultivar Bethlehem (2n = 6x = 42; genome BBAADD). The identity of the "wild" arm in each CASL was confirmed through the use of RFLP and SSR markers that were polymorphic between the two taxa. The product of this work is a series of true-breeding agronomic lines the breeding value of which can be evaluated under field conditions in different geographic regions. The usefulness of CASLs in studying the improvement of qualitative and quantitative traits in wheat is discussed.

Use of simulation-based training is fast becoming a vital source of experiential learning in medical education. Although simulation is a common tool for undergraduate and graduate medical education curricula, the utilization of simulation in continuing medical education (CME) is still an area of growth. As more CME programs turn to simulation to address their training needs, it is important to highlight concepts of simulation technology that can help to optimize learning outcomes. This article discusses the role of fidelity in medical simulation. It provides support from a cross section of simulation training domains for determining the appropriate levels of fidelity, and it offers guidelines for creating an optimal balance of skill practice and realism for efficient training outcomes. After defining fidelity, 3 dimensions of fidelity, drawn from the human factors literature, are discussed in terms of their relevance to medical simulation. From this, research-based guidelines are provided to inform CME providers regarding the use of simulation in CME training.

Competency-based assessment and an emphasis on obtaining higher-level outcomes that reflect physicians’ ability to demonstrate their skills has created a need for more advanced assessment practices. Simulation-based assessments provide medical education planners with tools to better evaluate the 6 Accreditation Council for Graduate Medical Education (ACGME) and American Board of Medical Specialties (ABMS) core competencies by affording physicians opportunities to demonstrate their skills within a standardized and replicable testing environment, thus filling a gap in the current state of assessment for regulating the practice of medicine. Observational performance assessments derived from simulated clinical tasks and scenarios enable stronger inferences about the skill level a physician may possess, but also introduce the potential of rater errors into the assessment process. This article reviews the use of simulation-based assessments for certification, credentialing, initial licensure, and relicensing decisions and describes rater training strategies that may be used to reduce rater errors, increase rating accuracy, and enhance the validity of simulation-based observational performance assessments.

Speciation via interspecific or intergeneric hybridization and polyploidization triggers genomic responses involving genetic and epigenetic alterations. Such modifications may be induced by small RNAs, which affect key cellular processes, including gene expression, chromatin structure, cytosine methylation and transposable element (TE) activity. To date, the role of small RNAs in the context of wide hybridization and polyploidization has received little attention. In this work, we performed high-throughput sequencing of small RNAs of parental, intergeneric hybrid, and allopolyploid plants that mimic the genomic changes occurring during bread wheat speciation. We found that the percentage of small RNAs corresponding to miRNAs increased with ploidy level, while the percentage of siRNAs corresponding to TEs decreased. The abundance of most miRNA species was similar to midparent values in the hybrid, with some deviations, as seen in overrepresentation of miR168, in the allopolyploid. In contrast, the number of siRNAs corresponding to TEs strongly decreased upon allopolyploidization, but not upon hybridization. The reduction in corresponding siRNAs, together with decreased CpG methylation, as shown here for the Veju element, represent hallmarks of TE activation. TE-siRNA downregulation in the allopolyploid may contribute to genome destabilization at the initial stages of speciation. This phenomenon is reminiscent of hybrid dysgenesis in Drosophila.

Nuclear DNA amount, determined by the flow cytometry method, in diploids, natural and synthetic allopolyploids, and natural and synthetic autopolyploids of the tribe Triticeae (Poaceae) is reviewed here and discussed. In contrast to the very small and nonsignificant variation in nuclear DNA amount that was found at the intraspecific level, the variation at the interspecific level is very large. Evidently changes in genome size are either the cause or the result of speciation. Typical autopolyploids had the expected additive DNA amount of their diploid parents, whereas natural and synthetic cytologically diploidized autopolyploids and natural and synthetic allopolyploids had significantly less DNA than the sum of their parents. Thus, genome downsizing, occurring during or immediately after the formation of these polyploids, provides the physical basis for their cytological diploidization, that is, diploid-like meiotic behavior. Possible mechanisms that are involved in genome downsizing and the biological significance of this phenomenon are discussed.

Two classes of 5S DNA units, namely the short (containing units of 410 bp) and the long (containing units of 500 bp), are recognized in species of the wheat (the genera Aegilops and Triticum ) group. While every diploid species of this group contains 2 unit classes, the short and the long, every allopolyploid species contains a smaller number of unit classes than the sum of the unit classes of its parental species. The aim of this study was to determine whether the reduction in these unit classes is due to the process of allopolyploidization, that is, interspecific or intergeneric hybridization followed by chromosome doubling, and whether it occurs during or soon after the formation of the allopolyploids. To study this, the number and types of unit classes were determined in several newly formed allotetraploids, allohexaploids, and an allooctoploid of Aegilops and Triticum. It was found that elimination of unit classes of 5S DNA occurred soon (in the first 3 generations) after the formation of the allopolyploids. This elimination was reproducible, that is, the same unit classes were eliminated in natural and synthetic allopolyploids having the same genomic combinations. No further elimination occurred in the unit classes of the 5S DNA during the life of the allopolyploid. The genetic and evolutionary significance of this elimination as well as the difference in response to allopolyploidization of 5S DNA and rDNA are discussed.

Forty-two undergraduates completed a computer based interactive training simulation that required them to understand a potential hostage situation that arises during a customer service position in an Emergency Room. Each participant was given either deep or surface emotion regulation training prior to participation. Eye movements during the simulation were examined as a function of training type and understanding of the scenes in the simulation. Those given deep training had more fixations, whereas those with greater scene knowledge had longer fixations. Eye movements are predictive of understanding training during a simulation, and could be used as a trigger for adaptive training systems.

Allopolyploidy accelerates genome evolution in wheat in two ways: 1) allopolyploidization triggers rapid genome alterations (revolutionary changes) through the instantaneous generation of a variety of cardinal genetic and epigenetic changes, and 2) the allopolyploid condition facilitates sporadic genomic changes during the life of the species (evolutionary changes) that are not attainable at the diploid level. The revolutionary alterations, occurring during the formation of the allopolyploid and leading to rapid cytological and genetic diploidization, facilitate the successful establishment of the newly formed allopolyploid in nature. On the other hand, the evolutionary changes, occurring during the life of the allopolyploids, increase the intra-specific genetic diversity, and consequently, increased fitness, adaptability and competitiveness. These phenomena, emphasizing the dynamic plasticity of the allopolyploid wheat genome with regards to both structure and function, are described and discussed in this review.

Nuclear DNA amount (1C) was determined by flow cytometry in the autotetraploid cytotype of Hordeum bulbosum , in the cytologically diploidized autotetraploid cytotypes of Elymus elongatus , Hordeum murinum subsp. murinum and Hordeum murinum subsp. leporinum, in Hordeum marinum subsp. gussoneanum, in their progenitor diploid cytotypes, and in a newly synthesized autotetraploid line of E. elongatus. Several lines collected from different regions of the distribution area of every taxon, each represented by a number of plants, were analyzed in each taxon. The intracytotype variation in nuclear DNA amount of every diploid and autotetraploid cytotype was very small, indicating that no significant changes have occurred in DNA amount either after speciation or after autopolyploid formation. The autotetraploid cytotypes of H. bulbosum and the cytologically diploidized H. marinum subsp. gussoneanum had the expected additive amount of their diploid cytotypes. On the other hand, the cytologically diploidized autotetraploid cytotypes of E. elongatus and H. murinum subsp. murinum and H. murinum subsp. leporinum had considerably less nuclear DNA (10%–23%) than the expected additive value. Also, the newly synthesized autotetraploid line of E. elongatus showed similar reduction in DNA as its natural counterpart, indicating that the reduction in genome size occurred in the natural cytotype during autopolyploidization. It is suggested that the diploid-like meiotic behavior of these cytologically dipolidized autotetraploids is caused by the instantaneous elimination of a large number of DNA sequences, different sequences from different homologous pairs, leading to differentiation of the constituent genomes. The eliminated sequences are likely to include those that participate in homologous recognition and initiation of meiotic pairing. A gene system determining exclusive bivalent pairing by utilizing the differentiation between the two groups of homologues has been presumably superimposed on the DNA reduction process.

Durum and bread wheat need transgenic traits such as herbicide and disease resistance due to recent evolution of herbicide resistant grass weeds and an intractable new strain of stem rust. Transgenic wheat varieties have not been commercialized partly due to potential transgene movement to wild/weedy relatives, which occurs naturally to closely related Aegilops and other spp. Recombination does not occur in the F 1 hybrid between wheat and its relatives due to the presence of the Ph 1 gene on wheat chromosome arm 5BL, which acts as a chaperone, preventing promiscuous homoeologous pairing to similar, but not homologous chromosomes of the wild/weedy species. Thus recombination must occur during backcrossing after the wheat Ph 1 gene has been eliminated. Based on these findings, we speculate that Ph 1 could be used to prevent gene introgression into weedy relatives. We propose two methods to prevent such transgene establishment: (1) link the transgene in proximity to the wheat Ph 1 gene and (2) insert the transgene in tandem with the lethal barnase on any chromosome arm other than 5BL, and insert barstar , which suppresses barnase on chromosome arm 5BL in proximity to Ph 1. The presence of Ph 1 in backcross plants containing 5BL will prevent the homoeologous establishment of barnase coupled to the desired transgene in the wild population. 5BL itself will be eliminated during repeated backcrossing to the wild parent, and progeny bearing the desired transgene in tandem with barnase but without the Ph 1- barstar complex will die.

Shared mental models of the team and task have been shown to facilitate better team processes (e.g. coordination) and performance. To this extent, more dynamic measures of mental model measures are needed to better understand how sharedness is through various team macrocognitive stages. This study investigated the relationship between eye patterns and mental model sharedness. Results indicate a positive relationship between mental model sharedness and eye fixation similarity. Implications for future research are discussed.

Recent molecular studies in the genera Aegilops and Triticum showed that allopolyploidization (interspecific or intergeneric hybridization followed by chromosome doubling) generated rapid elimination of low-copy or high-copy, non-coding and coding DNA sequences. The aims of this work were to determine the amount of nuclear DNA in allopolyploid species of the group and to see to what extent elimination of DNA sequences affected genome size. Nuclear DNA amount was determined by the flow cytometry method in 27 natural allopolyploid species (most of which were represented by several lines and each line by several plants) as well as 14 newly synthesized allopolyploids (each represented by several plants) and their parental plants. Very small intraspecific variation in DNA amount was found between lines of allopolyploid species collected from different habitats or between wild and domesticated forms of allopolyploid wheat. In contrast to the constancy in nuclear DNA amount at the intraspecific level, there are significant differences in genome size between the various allopolyploid species, at both the tetraploid and hexaploid levels. In most allopolyploids nuclear DNA amount was significantly less than the sum of DNA amounts of the parental species. Newly synthesized allopolyploids exhibited a similar decrease in nuclear DNA amount in the first generation, indicating that genome downsizing occurs during and (or) immediately after the formation of the allopolyploids and that there are no further changes in genome size during the life of the allopolyploids. Phylogenetic considerations of the origin of the B genome of allopolyploid wheat, based on nuclear DNA amount, are discussed.

We describe here the initial steps of cultivation of wild emmer in the Levant, i.e., the western part of the Fertile Crescent, as well as genetic changes caused by spontaneous mutations, leading to its domestication and to the development of free-threshing tetraploid wheat, Triticum turgidum. Review of archaeological findings from the Pre-Pottery Neolithic A (PPNA) (10,300-9,500 BP; uncalibrated) indicates that wild emmer was first cultivated in the southern Levant. Domesticated emmer (with a nonbrittle spike) appeared several hundred years later in the early PPNB (9,500-9,000 BP), and for a millennium or more was grown in a mixture with wild emmer in many Levantine sites. After the appearance of domesticated emmer, types with naked, free-threshing grains emerged in the late PPNB (9,000-7,500 BP). We support the model in which domestication occurred independently in several sites across the Levant. According to this view, the genes for non-brittleness were transferred to numerous wild emmer genotypes thro...

INTRODUCTION Achieving standardized assessment of medical student competency in patient care is a challenge. Simulation may provide unique contributions to overall assessment. We developed an Internal Medicine Standardized Simulation-Based Examination (SSBE) for the third-year clerkship to assess students' medical knowledge, diagnostic skills, and clinical management skills. We assessed convergent and test criterion validity by comparing the relationship of SSBE scores with United States Medical Licensing Examination step 2 clinical knowledge, shelf examination, eQuiz, objective structured clinical examination, ward evaluation scores, and overall clerkship grades. We hypothesize that the use of the SSBE will allow for a more reliable assessment of these competencies and add value to existing assessments. METHODS A prospective study design was used. The SSBE consisted of a computer-based photo quiz and cases on high-fidelity simulators. Performance on the SSBE was compared with standardized examinations, clinical evaluations, and overall clerkship grades. Students completed an evaluation of the experience. RESULTS Two hundred seven students completed the SSBE, with a mean (SD) score of 76.69 (7.78). The SSBE performance was positively related to other assessments of medical knowledge eQuiz scores (r203 = 0.33, P < 0.01), shelf examination scores (r158 = 0.53, P < 0.01), and clinical performance (ward scores) (r163 = 0.31, P < 0.01) but not to objective structured clinical examination scores. There was a positive relationship to final class grades (r163 = 0.45, P < 0.01), shelf examination (r158 = 0.52, P < 0.01) and step 2 clinical knowledge scores (r76 = 0.54, P < 0.01). Most students (93%) agreed that it was a fair examination. CONCLUSIONS Our results provide validity evidence for the SSBE as an additional assessment tool that uses a novel approach for evaluating competency in patient care at the clerkship level.

This demonstration serves as an introduction to the CARAT scale MOUT (Military Operation in Urban Terrain) facility developed at the Team Performance Laboratory (TPL) at the University of Central Florida (UCF). Advances in automated military vehicles require research to understand how best to allocate control of these vehicles. Whether, discussing uninhabited ground vehicles (UGVs) or air vehicles (UAVs), many questions still exist as to the optimum level of performance with respect to the ratio of human controls to vehicles. The scale MOUT facility at UCF allows researchers to investigate these issues without sacrificing large costly equipment and without requiring vast physical areas, within which to test such equipment. This demonstration provides an introduction to the scale MOUT facility, describes the basic need for this tool, presents its advantages over full size counterparts, as well as several other possible uses for the facility.

In the past few years we have analysed alterations in genome structure and expression that occur in wheat upon allopolyploidization. Our major findings in natural and synthetic allopolyploid wheat are reviewed here. It was found that allopolyploidization brings about rapid genome evolution through the instantaneous generation of a variety of cardinal genetic and epigenetic alterations comprising: (1) non-random elimination of coding and non-coding DNA sequences, (2) epigenetic changes such as DNA methylation of coding and non-coding DNA leading, among others, to gene silencing, and (3) activation of retroelements, which in turn alters the expression of adjacent genes. These changes were reproducible, occurring in the F1 hybrids or in the first generation(s) of a series of nascent allopolyploids corresponding to various interspecific and intergeneric combinations. Moreover, these changes were similar to those that occurred twice in nature: first, at the transition from diploid to tetraploid wheat (-0.5 Mya) and, second, at the transition from tetraploid to hexaploid wheat (-9500 years ago). Elimination of non-coding sequences augments the differentiation of homoeologous chromosomes at the polyploid level, thus increasing the physical divergence between homoeologues and contributing to the diploid-like meiotic behaviour of polyploid wheat. Transcriptional and post-transcriptional alterations of gene activity, including transcriptional activation of retro-elements, led to novel expression patterns. These phenomena emphasize the plasticity of the genome with regard to both structure and gene expression. This plasticity in turn might improve the adaptability of the newly formed allopolyploids and facilitate their rapid and successful establishment in nature.

The origin and evolution of the wheat group (the genera Aegilops, Amblyopyrum, and Triticum) in the wild and under cultivation is reviewed. The diploid species diverged from a common ancestor, about 2–4 million years ago, presumably in the marginal Mediterranean region of Southwest Asia. Speciation resulted in distinct genomes, specialized dispersal unit, and unique eco-geographical environments that are described here. In contrast to the diploids, the allopolyploid species have undergone convergent evolution, exhibiting a wider variation, larger distribution areas and a broader range of ecological conditions. Recent molecular studies show reprograming of gene expression in the allopolyploids and the interactions between genomes. The process of allopolyploidization generates a genetic shock that triggers a variety of cardinal genetic and epigenetic changes leading to cytological and genetic diploidization, enabling various gene dosage effects to take place and providing tolerance to hybridization and introgression. These changes confer the genomic plasticity required for the successful establishment in nature of the nascent allopolyploids and for their success under cultivation.

Retrotransposons are a principal component of most eukaryotic genomes, representing roughly 40% of the human genome and 50-80% of some grass genomes. They are usually transcriptionally silent but can be activated under certain stresses. Despite their considerable contribution to genome structure, their impact on the expression of adjacent genes is not well understood. The steady-state transcript levels originating from Wis 2-1A retrotransposons are much higher in newly synthesized wheat amphiploids (two or more diverged genomes in the same nucleus). On activation, both Wis 2-1A long terminal repeats drive the readout synthesis of new transcripts from adjacent sequences including the antisense or sense strands of known genes. Here we report that activation of these antisense or sense transcripts is associated with silencing or activation of the corresponding genes, respectively. These data, together with the abundance of retrotransposons in genomes and their ability to be activated by various signals, support the view of transposons as potential controlling elements.

Recent studies have shown that speciation through allopolyploidy, i.e., inter-specific or inter-generic hybridization followed by chromosome doubling, is accompanied by a variety of rapid cardinal genetic and epigenetic changes. This paper reviews our studies on the effect of allopolyploidization on several low-copy, non-coding sequences that exist in all the diploid species of the tribe Triticeae, including the progenitors of polyploid wheat, but in polyploid wheat they occur in only one genome, either in one homologous pair (chromosome-specific sequences) or in several pairs of the same genome (genome-specific sequences). Rapid elimination of these sequences from one genome is a general phenomenon in newly synthesized allopolyploids. Elimination was a nonrandom, reproducible event whose direction was determined by the genomic combination of the amphiploid. It was not affected by the genotype of the parental plants, by their cytoplasm, or by the ploidy level, and it did not result from intergenomic recombination. This elimination augmented the differentiation of homeologous chromosomes (partially homologous chromosomes of the different genomes) at the polyploid level, thus providing the physical basis for the diploid-like meiotic behavior characterizing polyploid wheat. This pattern of pairing prevents intergenomic recombination, and consequently, ensures full fertility, disomic inheritance, and permanent heterosis between alleles of different genomes (homeoalleles). Accordingly, rapid elimination of these sequences improves the fitness of newly formed allopolyploids, facilitating their rapid establishment in nature as new successful species. © 2002 Taylor & Francis Group, LLC.

Simulation has been rapidly adopted within the medical community as evidenced by the fact that clinical care providers from all backgrounds (e.g., residents, physicians, nurses, anesthesiologists, ancillary staff, etc.) and all institutions (e.g., hospital, training centers, and medical schools) have incorporated simulation into their training and education curriculums. Although simulators are becoming a staple in clinical education, simulation is not a one-size-fits-all solution. Thus, the objective of the current panel is to combine the expertise of leading human factors and clinical care providers in the fields of learning, simulation, human performance, and human-system interaction to provide their insight and perspective on the following questions: What are the issues to consider when developing, implementing, and evaluating simulation-based training across a broad spectrum of training, education, and improvement applications in the healthcare domain? What are the contributions that human factors sci...

The Ph1 gene has long been considered the main factor responsible for the diploid-like meiotic behavior of polyploid wheat. This dominant gene, located on the long arm of chromosome 5B (5BL), suppresses pairing of homoeologous chromosomes in polyploid wheat and in their hybrids with related species. Here we report on the discovery of genotypic variation among tetraploid wheats in the control of homoeologous pairing. Compared with the level of homoeologous pairing in hybrids between Aegilops peregrina and the bread wheat cultivar Chinese Spring (CS), significantly higher levels of homoeologous pairing were obtained in hybrids between Ae. peregrina and CS substitution lines in which chromosome 5B of CS was replaced by either 5B of Triticum turgidum ssp. dicoccoides line 09 (TTD09) or 5G of Triticum timopheevii ssp. timopheevii line 01 (TIM01). Similarly, a higher level of homoeologous pairing was found in the hybrid between Ae. peregrina and a substitution line of CS in which chromosome arm 5BL of line TTD140 substituted for 5BL of CS. It appears that the observed effect on the level of pairing is exerted by chromosome arm 5BL of T. turgidum ssp. dicoccoides, most probably by an allele of Ph1. Searching for variation in the control of homoeologous pairing among lines of wild tetraploid wheat, either T. turgidum ssp. dicoccoides or T. timopheevii ssp. armeniacum, showed that hybrids between Ae. peregrina and lines of these two wild wheats exhibited three different levels of homoeologous pairing: low, low intermediate, and high intermediate. The low-intermediate and high-intermediate genotypes may possess weak alleles of Ph1. The three different T. turgidum ssp. dicoccoides pairing genotypes were collected from different geographical regions in Israel, indicating that this trait may have an adaptive value. The availability of allelic variation at the Ph1 locus may facilitate the mapping, tagging, and eventually the isolation of this important gene.Key words: diploid-like meiotic behavior, genetic control of pairing, Ph1 gene, Triticum turgidum ssp. dicoccoides, wild emmer.

Interspecific or intergeneric hybridization, followed by chromosome doubling, can lead to the formation of new allopolyploid species. Recent studies indicate that allopolyploid formation is associated with genetic and epigenetic changes, although little is known about the type of changes that occur, how rapidly they occur, and the type of sequences involved. To address these matters, we have surveyed F1 hybrids between diploid species from the wheat (Aegilops and Triticum) group and their derived allotetraploids by screening a large number of loci using amplified fragment length polymorphism and DNA gel blot analysis and by assaying the extent of cytosine methylation. We found that sequence elimination is one of the major and immediate responses of the wheat genome to wide hybridization or allopolyploidy, that it affects a large fraction of the genome, and that it is reproducible. In one cross between AE: sharonensis x AE: umbellulata, 14% of the loci from AE: sharonensis were eliminated compared with only 0.5% from AE: umbellulata, with most changes occurring in the F1 hybrid. In contrast, crosses between AE: longissima x T. urartu showed that sequence elimination was more frequent after chromosome doubling. Alterations in cytosine methylation occurred in approximately 13% of the loci, either in the F1 hybrid or in the allopolyploid. For eight of nine bands that were isolated, the sequences that underwent elimination corresponded to low-copy DNA, whereas alterations in methylation patterns affected both repetitive DNA sequences, such as retrotransposons, and low-copy DNA in approximately equal proportions.

Wild emmer wheat, Triticum turgidum ssp. dicoccoides, the progenitor of most domesticated wheats, was discovered by Aaron Aaronsohn in 1906 in the Levant. The contribution of this discovery to the study of the cytogenetic structure and evolution of the wheats, to an understanding of the processes and site of their domestication and evolution under cultivation, and to the improvement of domesticated wheat is discussed.