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Congenital heart defects (CHD) represent a growing burden of illness among adults. We estimated the lifetime health, education, labor, and social outcomes of adults with CHD in the USA using the Future Adult Model, a dynamic microsimulation model that has been used to study the lifetime impacts of a variety of chronic diseases. We simulated a cohort of adult heads of households > 25 years old derived from the Panel Survey of Income Dynamics who reported a childhood heart problem as a proxy for CHD and calculated life expectancy, disability-free and quality-adjusted life years, lifetime earnings, education attainment, employment, development of chronic disease, medical spending, and disability insurance claiming status. Total burden of disease was estimated by comparing to a healthy cohort with no childhood heart problem. Eighty-seven individuals reporting a childhood heart problem were identified from the PSID and were used to generate the synthetic cohort simulated in the model. Life expectancy, disability-free, quality-adjusted, and discounted quality-adjusted life years were an average 4.6, 6.7, 5.3, and 1.4 years lower than in healthy adults. Lung disease, cancer, and severe mental distress were more common compared to healthy individuals. The CHD cohort earned $237,800 less in lifetime earnings and incurred higher average total medical spend by $66,600 compared to healthy individuals. Compared to healthy adults, the total burden of CHD is over $500K per adult. Despite being among the healthiest adults with CHD, there are significant decrements in life expectancy, employment, and lifetime earnings, with concomitant increases in medical spend.

The objective of this analysis was to update trends in LOS and costs by survivorship and ECMO use among neonates with hypoplastic left heart syndrome (HLHS) undergoing stage 1 palliation surgery using 2016 data from the Healthcare Cost and Utilization Project Kids' Inpatient Database. We identified neonates ≤ 28 days old with HLHS undergoing Stage 1 surgery, defined as a Norwood procedure with modified Blalock-Taussig (BT) shunt, Sano modification, or both. Multivariable regression with year random effects was used to compare LOS and costs by hospital region, case volume, survivorship, and ECMO vs. no ECMO. An E-value analysis, an approach for conducting sensitivity analysis for unmeasured confounding, was performed to determine if unmeasured confounding contributed to the observed effects. Significant differences in total costs, LOS, and mortality were noted by hospital region, ECMO use, and sub-analyses of case volume. However, other than ECMO use and mortality, the maximum E-value confidence interval bound was 1.71, suggesting that these differences would disappear with an unmeasured confounder 1.71 times more associated with both the outcome and exposure (e.g., socioeconomic factors, environment, etc.) Our findings confirm previous literature demonstrating significant resource utilization among Norwood patients, particularly those undergoing ECMO use. Based on our E-value analysis, differences by hospital region and case volume can be explained by moderate unobserved confounding, rather than a reflection of the quality of care provided. Future analyses on surgical quality must account for unobserved factors to provide meaningful information for quality improvement.

Background: Communication breakdowns and care coordination problems often cause preventable adverse patient care events, which can be especially acute in the trauma setting, in which ad hoc teams have little time for advanced planning. Existing teamwork curricula do not address the particular issues associated with ad hoc emergency teams providing trauma care., Methods: Ad hoc trauma teams completed a preinstruction simulated trauma encounter and were provided with instruction on appropriate team behaviors and team communication. Teams completed a postinstruction simulated trauma encounter immediately afterward and 3 weeks later, then completed a questionnaire. Blinded raters rated videotapes of the simulations., Results: Participants expressed high levels of satisfaction and intent to change practice after the intervention. Participants changed teamwork and communication behavior on the posttest, and changes were sustained after a 3-week interval, though there was some loss of retention., Conclusions: Brief training exercises can change teamwork and communication behaviors on ad hoc trauma teams., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: Little is known about the acquisition of clinical reasoning skills in medical school, the development of clinical reasoning over the medical curriculum as a whole, and the impact of various curricular methodologies on these skills. This study investigated (1) whether there are differences in clinical reasoning skills between learners at different years of medical school, and (2) whether there are differences in performance between students at schools with various curricular methodologies., Method: Students (n = 2,394) who had completed zero to three years of medical school at five U.S. medical schools participated in a cross-sectional study in 2008. Students took the same diagnostic pattern recognition (DPR) and clinical data interpretation (CDI) tests. Percent correct scores were used to determine performance differences. Data from all schools and students at all levels were aggregated for further analysis., Results: Student performance increased substantially as a result of each year of training. Gains in DPR and CDI performance during the third year of medical school were not as great as in previous years across the five schools. CDI performance and performance gains were lower than DPR performance and gains. Performance gains attributable to training at each of the participating medical schools were more similar than different., Conclusions: Years of training accounted for most of the variation in DPR and CDI performance. As a rule, students at higher training levels performed better on both tests, though the expected larger gains during the third year of medical school did not materialize.

Our cardiology community is responding to the growing number of emerging adults with often complex congenital heart disease. Collaborations are springing up between adult and pediatric cardiologists, advanced practice nurses, patients, and families to address the health care, research, and advocacy needs for this population. Workforce and institutional needs are being defined and research collaborations are being formed. Meanwhile, health care reform is evolving through fits and starts with little predictability regarding its medium and long-term impact. Since ultimately finances trump philosophy, it is essential that we understand the financial underpinnings of healthcare delivery to patients with this unique model of chronic disease in order to carry out these plans. What is unique about this population with chronic disease? The most obvious feature is that they have the potential of contributing to the GDP for 40+ years. Another is that for the more complex lesions, society has already invested a considerable amount to achieve survival into adult life. Finally, the period of early adulthood is relatively uneventful in terms of complications and resource utilization compared with early childhood and later adult life. Thus, the basic needs to maintain cardiovascular status and prevent secondary disability may be modest in comparison with treating some of the severe consequences of their disease, such as poorly managed valve regurgitation or arrhythmia that eventually requires costly solutions such as transplantation. It is important, therefore, to define the resource requirements and potential health outcomes of a healthcare system that would be designed for this population.

Background: Current remediation strategies for students failing standardized patient examinations represent poorly targeted approaches since the specific nature of clinical performance weaknesses has not been defined., Purpose: The purpose is to determine the impact of a specifically targeted clinical performance course required of students who failed a clinical performance examination., Methods: A month-long clinical performance course, targeted to treat specific types of clinical performance deficiencies, was designed to remediate students failing standardized patient examinations in 2007 (n=8) and 2008 (n=5). Participating students were assessed on pre- and postperformance measures, including multiple-choice tests that measured diagnostic pattern recognition and clinical data interpretation and clinical performance measures using standardized clinical encounters. Comparisons between average pre- and postintervention performance scores were computed using paired sample t tests. Results were adjusted for regression toward the mean., Results: In both 2007 and 2008, the mean preintervention clinical data interpretation and standardized patient examination scores were below the criterion referenced passing standard set for the clinical competency exam. In both years the mean postintervention scores for the participants were above the passing standard for these two examinations. Pre- and postintervention differences were statistically significant in both cases., Conclusions: This study provides insight into the reasons that students fail clinical performance examinations and elucidates one method by which such students may be successfully remediated.

Background: The aim of this study was to compare the laboratory teaching of a basic technical skill by a nonphysician skills coach and a faculty surgeon., Methods: Medical students were randomized to instruction of skin suturing in the skills laboratory by a faculty surgeon or by a nonphysician skills coach. Testing of performance occurred at 3 time points. Other faculty surgeons, blinded to identities and training groups, rated performance., Results: Forty-nine students participated. Baseline fourth-year student mean scores showed no significant difference between training groups. Third-year and fourth-year student performance showed no difference between training groups on postintervention testing. Delayed testing also showed no difference in third-year student scores., Conclusions: Training by either a nonsurgeon skills coach or a faculty surgeon resulted in no difference in performance on a basic surgical skill. This was true for students with and without prior experience and was also true after subsequent clinical experiences. Nonphysician coaches may ease the teaching burden of surgical faculty members while providing similar quality of instruction for trainees.

Background: Working knowledge of physicians manifests as a combination of diagnostic pattern recognition and clinical data interpretation (analytic fact checking)., Purpose: The purpose was to study medical student acquisition of these abilities as a function of years of medical training/experience., Methods: A cross-sectional study involving students who had completed 0, 1, 2, and 3 years of medical school. All students at all levels of training took the same tests of diagnostic pattern recognition and clinical data interpretation. Percent correct scores were calculated and used to estimate learning curves. A cohort of family physicians also took the test to provide a benchmark., Results: Student diagnostic pattern recognition and clinical data interpretation ability demonstrated a steady upward growth curve but leveled off in Year 3. Diagnostic pattern recognition performance was consistently higher than clinical data interpretation performance. The rate of diagnostic performance gain with training and experience was also higher., Conclusions: Medical students acquired diagnostic pattern recognition ability and all years of medical training contributed. The rate of clinical data interpretation performance improvement was slower, and the absolute performance level was lower. What was surprising was the lower rate of improvement in diagnostic pattern recognition and clinical data interpretation performance for students during their 1st year of clinical training. Students' understanding of findings and their relationships to disease processes may be affected by their limited patient experience.

Background: This study investigated the concurrent and predictive validity of end-of-rotation (EOR) clinical performance ratings., Study Design: Surgeon EOR ratings of residents were collected and compared with end-of-year (EOY) progress decisions and to EOR and EOY confidential judgments of resident ability to provide patient care without direct supervision., Results: Eighty percent to 85% of EOR ratings were Excellent or Very Good. Five percent or fewer were Fair or Poor. Almost all residents receiving Excellent or Very Good EOR ratings also received positive EOR judgments about ability to provide patient care without direct supervision. Residents rated Fair or Poor received negative EOR judgments about ability to provide patient care without direct supervision. As the cumulative percent of Good, Fair, and Poor EOR ratings increased, the number of residents promoted without stipulations at the end of the year decreased and the percentage of faculty members who judged the residents capable of providing effective patient care without direct supervision at the end of the year declined. All residents receiving 40% or more EOR ratings below Very Good had stipulations associated with their promotion., Conclusions: Despite use of descriptive anchors on the scale, clinical performance ratings have no direct meaning. Their meaning needs to be established in the same manner as is done in setting normal values for diagnostic tests, ie, by establishing the relationship between EOR ratings and practice outcomes.

Background: The surgery clerkship director is a key individual in the surgery department's educational mission and yet there has been no prior effort to describe this group or identify their learning needs. The purpose of this study was to develop a demographic profile and an educational needs assessment for surgery clerkship directors., Methods: A survey instrument was designed based on existing literature and distributed to surgery clerkship directors in the United States and Canada., Results: Surveys were returned from 108 subjects (77%). The majority of clerkship directors strongly agree that directing is a positive experience but express concern that the job demands may impede their professional careers. The perceived educational needs identified related primarily to the development and management of the student education curriculum., Conclusions: Surgery clerkship directors are experienced academic surgeons who report high levels of satisfaction. They identify a number of important educational needs of the position and express concern about the requirements of the position on their academic careers.

In July 2001 the Accreditation Council for Graduate Medical Education (ACGME) charged U.S. residency training programs to implement a curriculum and evaluation plan covering six competencies. The authors describe the curriculum and evaluation strategy of the first surgical training program developed to meet the competencies, and list each competency and the teaching method and measurement instruments used. Implementation began July 1, 2001, and the program was fully operational on July 1, 2002. Meeting the curriculum challenges required modification of the existing curriculum and the addition of new instructional units. Nine additional evaluation instruments were needed. The largest investment was in planning and implementation, a one-time development cost. Staff workload increased by 252 hours; this is expected to be a continuing annual requirement. Faculty workload increased by two hours per resident and each resident's workload increased by 112 hours per year (2.3 hours per week). The transition was smoother than expected. Faculty and residents' buy-in was crucial. Faculty and residents were alerted to upcoming changes at the beginning of the year in a grand rounds presentation on the ACGME competencies and the approach to meeting requirements. Updates were presented periodically. The authors recommend that residency programs engaged in similar efforts make effective use of instruments developed elsewhere and collaborate with other programs rather than develop everything locally. The program's benefits include time savings and the availability of validity data and norms to inform decision making on residents' and program progress.

Criteria are presented for determining whether licensure and/or achievement test results should be used as a basis for making various types of comparisons and judgments about medical education programs for program evaluation purposes. United States Medical Licensing Examination (USMLE) examinations and National Board of Medical Examiners (NBME) subject tests are then considered as sources of evaluation data for medical education programs by evaluating these examinations in the light of the proposed criteria. It is concluded that NBME examination and USMLE results may properly be considered one of several tools to use in an evaluation of medical education programs but are not recommended as the sole basis for a judgment of program effectiveness. However, care must be taken to ensure that test score differences are large enough to be real and to have practical significance. Furthermore, changes in curriculum should not be considered or implemented on the basis of NBME/USMLE results unless the changes in test scores are maintained for at least two years. The focus should generally be on inordinately high failure rates rather than on changes in mean class scores. Efforts to develop objective, standardized, and controlled measures of other clinical competencies for national use should be encouraged to minimize the temptation to use USMLE Step 1 and Step 2 scores as the sole basis for comparisons of medical education programs.

Objective: To develop an assessment of clinical competence of graduates of foreign medical schools and to determine the reliability and validity of the assessment and the feasibility of large-scale administration., Design: The Educational Commission for Foreign Medical Graduates (ECFMG) clinical competence study included (1) clinical encounters with standardized patients to assess history taking, physical examination, and communication skills; (2) laser videodisk pictorials to assess identification and interpretation of diagnostic procedures; (3) written clinical vignettes to assess diagnosis and management skills; and (4) assessment of spoken English. A uniform method of operating the test centers and of training the standardized patients was developed., Setting: Medical schools and their primary teaching hospitals and affiliated hospitals., Participants: Six hundred twenty-four first-year residents, of whom 525 are graduates of foreign medical schools., Main Outcome Measures: Scores, reliability coefficients, validity measures, feasibility of multisite administration, trends of scores over time, and acceptability by examinees., Results: The ECFMG clinical competence assessment was conducted at four geographically separate test centers. Reliability coefficients were high (.85) for the integrated clinical encounter and were in a reasonable range (.71 to .82) for all test components. The assessment adds to the predictability of the residents' performance in the hospital over that of current ECFMG certification examinations. Test security was addressed by demonstrating no consistent pattern of change in scores over testing dates. Virtually all examinees thought the assessment was appropriate. Standardized patients were able to assess spoken English accurately., Conclusion: The feasibility of conducting a reliable and valid test of clinical competence for graduates of foreign medical schools was demonstrated for this test population.

Objective: To describe the natural history and disease progression of the eosinophilia-myalgia syndrome and to assess the therapeutic effects of orally administered steroids on the disorder as of October 1990., Design: Case-series analysis. A cohort of 45 patients with the eosinophilia-myalgia syndrome was followed prospectively by periodic telephone interviews and medical examinations for an average of 14 months after onset of illness., Setting: Washington state., Patients: The cases of 47 patients were reported to the Washington State Department of Health from 1 July to 12 December 1989. Two patients were unavailable for follow-up, and the remaining 45 completed the study., Main Results: Patients were predominantly non-Hispanic white women (87%) with an average age of 49 years. Symptoms typically progressed from early onset of myalgia and fatigue to later development of neurologic and scleroderma-like skin changes. Six (13%) patients recovered completely within 2 to 5 months of symptom onset. After 14 months of illness, over half of the patients who initially presented with myalgia, fatigue, or scleroderma-like skin changes remained symptomatic. The average severity of each major symptom was measured using interviews and patient self-reports and has improved subjectively by at least 40%. Statistical analyses showed no significant difference in long-term symptom duration or severity between patients treated and those not treated with prednisone., Conclusions: The eosinophilia-myalgia syndrome is a long-term illness characterized by progressive improvement during the first 25 weeks after symptom onset, followed by a protracted phase of symptom resolution. We could not show a clear-cut benefit of prednisone in reducing the long-term severity or duration of the disease.