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Background/Purpose: One mission of all academic medical centers is the education of medical students. The resources allocated to the oversight of this mission vary. The status of pediatric undergraduate medical education and the role of the pediatric clerkship director (PCD) was published in 1995. We sought to provide an updated description by surveying current North American PCDs. Methods: A survey was designed by members of the Council on Medical Student Education in Pediatrics and administered via the Internet. Results: Eighty-four percent of U.S. PCDs (110/131) and 50% of Canadian PCDs (8/16) completed the survey. Significant differences compared with 1995 include (a) more clerkship directors are assistant professors, women, and generalists; (b) clerkship directors have more time for clerkship activities but less than they perceive that they need; and (c) traditional scholarship is even more difficult to accomplish than in the past. Conclusion: The position of PCD is perceived to be a legitimate career track, but most PCDs hold lower academic rank and have less traditional scholarly activity than PCDs did 10 years ago. Although PCDs have more time (40% now vs. 28% in 1995), they still feel that it is not adequate, needing almost 50% of their total time to adequately do their job. [ABSTRACT FROM AUTHOR]

OBJECTIVE: E-mail use in the clinical setting has been slow to diffuse for several reasons, including providers' concerns about patients' inappropriate and inefficient use of the technology. This study examined the content of a random sample of patient-physician e-mail messages to determine the validity of those concerns. DESIGN: A qualitative analysis of patient-physician e-mail messages was performed. MEASUREMENTS: A total of 3,007 patient-physician e-mail messages were collected over 11 months as part of a randomized, controlled trial of a triage-based e-mail system in two primary care centers (including 98 physicians); 10% of messages were randomly selected for review. Messages were coded across such domains as message type, number of requests per e-mail, inclusion of sensitive content, necessity of a physician response, and message tone. RESULTS: The majority (82.8%) of messages addressed a single issue. The most common message types included information updates to the physicians (41.4%), prescription renewals (24.2%), health questions (13.2%), questions about test results (10.9%), referrals (8.8%), 'other' (including thank yous, apologies) (8.8%), appointments (5.4%), requests for non-health-related information (4.8%), and billing questions (0.3%). Overall, messages were concise, formal, and medically relevant. Very few (5.1%) included sensitive content, and none included urgent messages. Less than half (43.2%) required a physician response. CONCLUSION: A triage-based e-mail system promoted e-mail exchanges appropriate for primary care. Most patients adhered to guidelines aimed at focusing content, limiting the number of requests per message, and avoiding urgent requests or highly sensitive content. Thus, physicians' concerns about the content of patients' e-mails may be unwarranted. [ABSTRACT FROM AUTHOR]

Limited research has examined a comprehensive set of predictors when evaluating discharge placement decisions for infants exposed to substances prenatally. Using a previously validated medical record data extraction tool, the current study examined prenatal substance exposure, infant intervention (i.e., pharmacologic, or non-pharmacologic), and demographic factors (e.g., race and ethnicity and rurality) as predictors of associations with discharge placement in a sample from a resource-poor state ( N = 136; 69.9% Non-Hispanic White). Latent class analysis (LCA) was used to examine whether different classes emerged and how classes were differentially related to discharge placement decisions. Logistic regressions were used to determine whether each predictor was uniquely associated with placement decisions. Results of the LCA yielded a two-class solution comprised of (1) a Low Withdrawal Risk class, characterized by prenatal exposure to substances with low risk for neonatal abstinence syndrome (NAS) and non-pharmacologic intervention, and (2) a High Withdrawal Risk class, characterized by a high risk of NAS and pharmacologic intervention. Classes were not related to discharge placement decisions. Logistic regressions demonstrated that meth/amphetamine use during pregnancy was associated with greater odds of out of home placement above other substance types. Future research should replicate and continue examining the clinical utility of these classes., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: Advances in genomic techniques have led to increased use of next-generation sequencing (NGS). We evaluated the extent to which these tests guide treatment decisions., Methods: We developed and distributed a survey assessing NGS use and outcomes to a survey pool of ASCO members. Comparisons between groups were performed with Wilcoxon two-sample, chi-square, and Fisher's exact tests., Results: Among 178 respondents, 62% were male, 54% White, and 67% affiliated with academic centers. More than half (56%) indicated that NGS provided actionable information to a moderate or great extent. Use was highest (median ≥ 70% of cases) for lung and gastric cancer, and lowest (median < 25% of cases) in head and neck and genitourinary cancers. Approximately one third of respondents reported that, despite identification of an actionable molecular variant, patients were sometimes or often unable to access the relevant US Food and Drug Administration-approved therapy. When NGS did not provide actionable results, individuals reporting great or moderate guidance overall from NGS in treatment recommendations were more likely to request the compassionate use of an unapproved drug ( P < .001), enroll on a clinical trial ( P < .01), or treat off-label with a drug approved for another indication ( P = .02)., Conclusion: When NGS identifies an actionable result, a substantial proportion of clinicians reported encountering challenges obtaining approved therapies on the basis of these results. Perceived overall impact of NGS appears associated with clinical behavior unrelated to actionable NGS test results, including pursuing off-label or compassionate use of unapproved therapies or referring to a clinical trial., Competing Interests: Mary L. SmithConsulting or Advisory Role: Novartis, PfizerResearch Funding: Genentech, Celgene, Genomic Health, Novartis, Foundation MedicineTravel, Accommodations, Expenses: Genentech/Roche Elda RaileyEmployment: Advanced PharmacyResearch Funding: Genomic Health, Genentech/Roche, Novartis, Celgene, Lilly, Seattle Genetics, PfizerTravel, Accommodations, Expenses: Genentech Carol B. WhiteResearch Funding: Genentech, Genomic Health, Novartis, Celgene, Foundation Medicine, Pfizer Julianne S. DieterichResearch Funding: Genentech, Novartis, Celgene, Pfizer, Foundation Medicine Liz Garrett-MayerConsulting or Advisory Role: Deciphera, Tyme Janet De MoorEmployment: BiogenStock and Other Ownership Interests: BiogenTravel, Accommodations, Expenses: Biogen Stacy W. GrayStock and Other Ownership Interests: Magenta TherapeuticsHonoraria: Triptych Health PartnersConsulting or Advisory Role: Magenta Therapeutics Jason Y. ParkStock and Other Ownership Interests: Targeted Diagnostics & TherapeuticsConsulting or Advisory Role: Miraca HoldingsPatents, Royalties, Other Intellectual Property: Thomas Jeff University, 12 patents; GUCY2C, TAK-164 technology. University of Pennsylvania, two patents on nanotechnology. UT Southwestern, two patent applications on immunotherapy biomarkers David E. GerberStock and Other Ownership Interests: Gilead SciencesConsulting or Advisory Role: Samsung Bioepis, Catalyst Pharmaceuticals, Mirati Therapeutics, Janssen Oncology, BeiGeneResearch Funding: BerGenBio, Karyopharm Therapeutics, AstraZenecaPatents, Royalties, Other Intellectual Property: Royalties from Oxford University Press from two books, Royalties from Decision Support in Medicine from the Clinical Decision Support—Oncology online program, Patent pending: “Prediction and Treatment of Immunotherapeutic Toxicity” (provisional, application number 62/461,455)Uncompensated Relationships: Bristol Myers SquibbNo other potential conflicts of interest were reported.

Background: Although there is increased attention to designing and explaining clinical trials in ways that are clinically meaningful for patients, there is limited information on patient preferences, understanding, and perceptions of this content., Methods: Maximum difference scaling (MaxDiff) methodology was used to develop a survey for assessing patients' understanding of 19 clinical terms and perceived importance of 9 endpoint surrogate phrases used in clinical trials and consent forms. The survey was administered electronically to individuals with metastatic breast cancer affiliated with the Metastatic Breast Cancer Alliance. Analyses were performed using Bayesian P values with statistical software., Results: Among 503 respondents, 77% had a college degree, 70% were diagnosed with metastatic disease ≥2 years before survey completion, and 77% had received ≥2 lines of systemic therapy. Less than 35% of respondents reported understanding "fairly well" the terms symptomatic progression, duration of disease control, time to treatment cessation, and endpoints. Income level and time since onset of metastatic disease correlated with comprehension. Patients who had received ≥6 lines of therapy perceived that time until serious side effects (P < .001) and time on therapy (P < .001) were more important compared with those who had received only 1 line of therapy. Positively phrased parameters were associated with increased perceived importance., Conclusions: Even among educated, heavily pretreated patients, many commonly used clinical research terms are poorly understood. Comprehension and the perceived importance of trial endpoints vary over the course of disease. These observations may inform the design, discussion, and reporting of clinical trials., (© 2020 American Cancer Society.)

Purpose: Prior data suggest that breast cancer patients accept significant toxicity for small benefit. It is unclear whether personalized estimations of risk or benefit likelihood that could be provided by biomarkers alter treatment decisions in the curative setting., Methods: A choice-based conjoint (CBC) survey was conducted in 417 HER2-negative breast cancer patients who received chemotherapy in the curative setting. The survey presented pairs of treatment choices derived from common taxane- and anthracycline-based regimens, varying in degree of benefit by risk of recurrence and in toxicity profile, including peripheral neuropathy (PN) and congestive heart failure (CHF). Hypothetical biomarkers shifting benefit and toxicity risk were modeled to determine whether this knowledge alters choice. Previously identified biomarkers were evaluated using this model., Results: Based on CBC analysis, a non-anthracycline regimen was the most preferred. Patients with prior PN had a similar preference for a taxane regimen as those who were PN naïve, but more dramatically shifted preference away from taxanes when PN was described as severe/irreversible. When modeled after hypothetical biomarkers, as the likelihood of PN increased, the preference for taxane-containing regimens decreased; similarly, as the likelihood of CHF increased, the preference for anthracycline regimens decreased. When evaluating validated biomarkers for PN and CHF, this knowledge did alter regimen preference., Conclusions: Patients faced with multi-faceted decisions consider personal experience and perceived risk of recurrent disease. Biomarkers providing information on likelihood of toxicity risk do influence treatment choices, and patients may accept reduced benefit when faced with higher risk of toxicity in the curative setting.

Objectives: To assess advanced communication skills among second-year medical students exposed either to a computer simulation (MPathic-VR) featuring virtual humans, or to a multimedia computer-based learning module, and to understand each group's experiences and learning preferences., Methods: A single-blinded, mixed methods, randomized, multisite trial compared MPathic-VR (N=210) to computer-based learning (N=211). Primary outcomes: communication scores during repeat interactions with MPathic-VR's intercultural and interprofessional communication scenarios and scores on a subsequent advanced communication skills objective structured clinical examination (OSCE). Multivariate analysis of variance was used to compare outcomes., Secondary Outcomes: student attitude surveys and qualitative assessments of their experiences with MPathic-VR or computer-based learning., Results: MPathic-VR-trained students improved their intercultural and interprofessional communication performance between their first and second interactions with each scenario. They also achieved significantly higher composite scores on the OSCE than computer-based learning-trained students. Attitudes and experiences were more positive among students trained with MPathic-VR, who valued its providing immediate feedback, teaching nonverbal communication skills, and preparing them for emotion-charged patient encounters., Conclusions: MPathic-VR was effective in training advanced communication skills and in enabling knowledge transfer into a more realistic clinical situation., Practice Implications: MPathic-VR's virtual human simulation offers an effective and engaging means of advanced communication training., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Success in residency matching is largely contingent upon standardized exam scores. Identifying predictors of standardized exam performance could promote primary intervention and lead to design insights for preclinical courses. We hypothesized that clinically relevant courses with an emphasis on higher-order cognitive understanding are most strongly associated with performance on United States Medical Licensing Examination Step exams and National Board of Medical Examiners clinical subject exams. Academic data from students between 2007 and 2012 were collected. Preclinical course scores and standardized exam scores were used for statistical modeling with multiple linear regression. Preclinical courses were categorized as having either a basic science or a clinical knowledge focus. Medical College Admissions Test scores were included as an additional predictive variable. The study sample comprised 795 graduating medical students. Median score on Step 1 was 234 (interquartile range 219-245.5), and 10.2 % (81/795) scored lower than one standard deviation below the national average (205). Pathology course score was the strongest predictor of performance on all clinical subject exams and Step exams, outperforming the Medical College Admissions Test in strength of association. Using Pathology score <75 as a screening metric for Step 1 score <205 results in sensitivity and specificity of 37 and 97 %, respectively, and a likelihood ratio of 11.9. Performance in Pathology, a clinically relevant course with case-based learning, is significantly related to subsequent performance on standardized exams. Multiple linear regression is useful for identifying courses that have potential as risk stratifiers.

The purpose of the study was to examine variables that influence patients' decisions to undergo treatment for metastatic breast cancer as part of a larger effort to understand the utility of biomarkers in treatment decisions. An online survey containing treatment scenarios for a conjoint analysis was e-mailed to members of breast cancer support organizations. The survey contained 14 different scenarios in which survey respondents with a history of metastatic breast cancer were asked to choose between two treatments and whether or not they would undergo the treatment. The scenarios were designed based on paclitaxel and capecitabine profiles related to medication format, likelihood of benefit, and side effects. The likelihood of benefit and likelihood/severity of side effects associated with these two drugs were varied based on the range of predictability afforded by current biomarkers. Most of the 641 respondents indicated that they would opt to undergo a treatment with 27 or 33 % likelihood of benefit regardless of the toxicity scenario presented. In general, a high percentage of respondents indicated that they would choose treatment in all of the scenarios (e.g., for an intravenous medication with a 20-50 % likelihood of benefit and a 20-60 % likelihood of moderate peripheral neuropathy for 1 year, 65-94 % of respondents indicated that they would choose treatment). The conclusion is that this study found that likelihood of benefit was more important than toxicity when considering particular benefit and toxicity ranges associated with common treatment options for metastatic breast cancer.

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.

In 2002 the University of Michigan Medical School created a one-month course in advanced medical therapeutics (AMT). All senior medical students were required to complete the course. To provide some flexibility for students who were interviewing for residency positions the AMT course was created using a distance-learning model, and in the 2008-2009 academic year it was offered in a fully online format. The components of the course are weekly case-based modules, a weekly online seminar, quizzes based on modules and seminars, and a research project based on a therapeutic question. The paper discusses the development and components of the AMT course, a survey of fourth-year medical students who participated in the course between 2007 and 2010, and how the course evolved over three years.

This study examined situations where drivers looked-but-failed-to-see (LBFTS) hazards, and whether passenger conversation and gender affected hazard detection rates. To reliably produce LBFTS errors, 40 young drivers (M=20.3) encountered motorcycles and pedestrians while making left turns in the University of Calgary Driving Simulator (UCDS). Prior to turn initiation the UCDS screens flickered using an extension of change blindness methods. In addition, drivers either drove alone or conversed with an attractive confederate passenger. Measures of LBFTS errors, hazard detection and social factors were analyzed. Higher rates of LBFTS errors and hazard detection occurred while conversing than while driving alone. A discriminant function analysis (DFA) using conversation and gender as predictors accurately classified LBFTS errors. Higher passenger attraction and higher extroversion were related to critical events being missed. The basis of LBFTS errors in divided and selective attention and classification implications are discussed., (2010 Elsevier Ltd. All rights reserved.)

Traditionally, medical schools have tended to make assumptions that students will "automatically" engage in self-education effectively after graduation and subsequent training in residency and fellowships. In reality, the majority of medical graduates out in practice feel unprepared for learning on their own. Many medical schools are now adopting strategies and pedagogies to help students become self-regulating learners. Along with these changes in practices and pedagogy, many schools are eliminating a cornerstone of extrinsic motivation: discriminating grades. To study the effects of the switch from discriminating to pass-fail grading in the second year of medical school, we compared internal and external assessments and evaluations for a second-year class with a discriminating grading scale (Honors, High Pass, Pass, Fail) and for a second-year class with a pass-fail grading scale. Of the measures we compared (MCATs, GPAs, means on second-year examinations, USMLE Step 1 scores, residency placement, in which there were no statistically significant changes), the only statistically significant decreases (lower performance with pass fail) were found in two of the second-year courses. Performance in one other course also improved significantly. Pass-fail grading can meet several important intended outcomes, including "leveling the playing field" for incoming students with different academic backgrounds, reducing competition and fostering collaboration among members of a class, more time for extracurricular interests and personal activities. Pass-fail grading also reduces competition and supports collaboration, and fosters intrinsic motivation, which is key to self-regulated, lifelong learning.

Purpose: In May 2007, the Association of American Medical Colleges and the Carl J. Shapiro Institute for Education and Research cosponsored "Millennium Conference 2007: A Collaborative Approach to Educational Research" (MC07). Educational leaders from eight U.S. medical schools and the host school (Harvard Medical School) sought to develop an operational list of the national medical education research priorities identified at the MC07., Method: The authors asked a diverse group of medical educators to evaluate the research priorities broadly outlined by MC07 participants, further refining the priorities, framing them into research questions with testable hypotheses, and ranking them. Through an iterative process among representatives from each of the MC07 participating institutions, 11 research priorities were identified, and each was reframed as a problem to be addressed with a testable hypothesis. Then, in a multiinstitutional survey, MC07 participants ranked each priority by its perceived national importance, feasibility, fundability, and amenability for multiinstitutional research., Results: The impact of medical school simulation training on residents' performance emerged as the highest-rated priority, and the impact of faculty development on learner outcomes was the lowest-rated priority among MC07 participating schools., Conclusions: The process of framing medical education priorities in the form of testable hypotheses with measurable outcomes was an effective way for a diverse group of national medical education leaders to develop an agenda for educational research. The authors hope that this list will inform the national discussion on priorities in medical education research and will serve to help move this agenda forward.

The reader may wonder, "What is COMSEP, and how does an article from COMSEP affect me?" COMSEP, the Council on Medical Student Education in Pediatrics, is a community of pediatric clerkship directors and other educators whose mission is to improve the health of children and their families by advancing the art and science of medical student education in pediatrics.(1) This is the first in what is envisioned to be a quarterly report from the COMSEP to the readership of Pediatrics. In writing these articles, we hope to accomplish 3 key objectives. First, we want to keep the readership updated on trends that could affect both practice and pediatric education, whether they involve the rise of the pediatric hospitalist service or use of electronic medical records. Second, we hope to share educational techniques or strategies that allow for efficient and effective teaching, particularly in community practice settings. Third, we wish to be a voice for the huge number of pediatric practitioners who are critical not only as role models but also as mentors for the next generation of pediatric care providers. To better understand who and what COMSEP is, this first article is dedicated to the history, structure, and fundamental principles of the organization.

Academic achievement indices including GPAs and MCAT scores are used to predict the spectrum of medical student academic performance types. However, use of these measures ignores two changes influencing medical school admissions: student diversity and affirmative action, and an increased focus on communication skills. To determine if GPA and MCAT predict performance in medical school consistently across students, and whether either predicts clinical performance in clerkships. A path model was developed to examine relationships among indices of medical student performance during the first three years of medical school for five cohorts of medical students. A structural equation approach was used to calculate the coefficients hypothesized in the model for majority and minority students. Significant differences between majority and minority students were observed. MCAT scores, for example, did not predict performance of minority students in the first year of medical school but did predict performance of majority students. This information may be of use to medical school admissions and resident selection committees.

Purpose: To investigate whether and how use of an online remediation system requiring reflective review of performance and self-assessment influenced students' performance on objective structured clinical examination (OSCE) station repeats (subsequent to failure on the first attempt) and their self-assessments of their performance (between the first and second attempts)., Method: Fourth-year medical students' performances on seven OSCE stations were videotaped at University of Michigan Medical School in 2006. Failing students took the exam again; remediation included self-assessment and review, plus faculty guidance for failures that were greater than one standard error of measurement of the distribution. A total of 1,171 possible observations of students' actual performance and performance self-assessments were analyzed using independent and dependent t tests and within-subjects ANOVA., Results: Results indicate statistically significant changes in students' performance between first and second attempts and statistically significant improvements in self-assessment between first and second attempts. No significant changes were found between self-assessed and faculty-guided remediation., Conclusions: This study provides evidence that OSCE remediation combining review, reflection, and self-assessment has a salutary effect on (subsequent) performance and self-assessment of performance.

Purpose: The third-year students at one medical school told the authors that values core to patient-centered care were impossible to practice in clerkships, in a culture where supervisors role modeled behaviors in direct conflict with patient-centered care. As they developed a new medical student curriculum, the authors designed the Family Centered Experience (FCE) to help students achieve developmental goals and understand the importance of and provide a foundation for patient-centered care., Method: The authors solicited members of the first cohort to complete the FCE (the class of 2007) to participate in this focus-group-based study halfway through the third year. They explored the influence of the FCE on students' experiences in the third-year clerkships, and how conflicts between the two learning experiences shaped these students' values and behaviors., Results: Students reported that during clerkships they experienced strong feelings of powerlessness and conflict between what they had learned about patient-centered care in the first two years and what they saw role modeled in the third year. Based on students' comments, the authors categorized students into one of three groups: those whose patient-centered values were maintained, compromised, or transformed., Conclusions: Students revealed that their conflict was connected to feelings of powerlessness, along with exacerbating factors including limited time, concerns about expectations for their behavior, and pessimism about change. Role modeling had a significant influence on consequences related to students' patient-centered values.

The synthesis and antibacterial activities of three chemotypes of DNA supercoiling inhibitors based on imidazolo[1,2-a]pyridine and [1,2,4]triazolo[1,5-a]pyridine scaffolds that target the ATPase subunits of DNA gyrase and topoisomerase IV (GyrB/ParE) is reported. The most potent scaffold was selected for optimization leading to a series with potent Gram-positive antibacterial activity and a low resistance frequency.

Purpose: The authors investigated adaptation of Bloom's and Simpson's taxonomies for the medical (student) setting, and using the adapted taxonomies to determine whether a summative objective structured clinical examination (OSCE) used at their medical school was assessing higher-order knowledge, skills, and attitudes., Method: Two faculty members (including H.M.H.) adapted the taxonomies and used them to categorize (knowledge, skills, or attitudes) and rank (by level within the taxonomies) every item on every OSCE station checklist. Interrater reliability was moderate to high., Results: Although there was a range of domains and levels within and across stations, on average every OSCE station was assessing learning behaviors at a lower level than expectations articulated in the school's goals for medical students' education., Conclusions: The adapted taxonomies were useful for assessing the domains and levels of behaviors measured on the summative OSCE, and they can also be used to modify existing checklists or to create new assessment instruments that meet the expectations articulated in a school's goals for medical students' education.

Purpose: To use qualitative analysis of interview transcripts with clinician-educators who facilitate small-group discussions on psychosocial themes--including doctoring--to answer the question, "What impact does facilitating small-group discussions of the patient's experience with chronic illness, the doctor-patient relationship, and doctoring have on faculty instructors' attitudes regarding their roles as clinicians and teachers?", Method: In 2006, in-depth, face-to-face interviews using an open-ended question format were conducted with individual faculty small-group instructors teaching in the Family Centered Experience and Longitudinal Case Studies courses at the University of Michigan Medical School. Interview transcripts were analyzed using grounded theory methodology to identify emerging themes. Accuracy of interpretations and saturation of themes was confirmed by repeated contextual reading of the transcripts., Results: Several major thematic codes emerged from the data. Facilitation of small-group discussions of psychosocial topics and doctoring fostered reflective approaches to patient care and teaching; enhanced interpersonal relationships between facilitators and their students, colleagues, and patients; and acted as a source of fulfillment and renewal among faculty facilitators., Conclusions: Small-group teaching of the art of doctoring may stimulate personal and professional growth among faculty facilitators and renewed interest in teaching and patient care.

Medical school is an academic and developmental path toward a professional life demanding self-regulation and self-education. Thus, many medical schools include in their goals for medical student education their graduates' ability to self-assess and self-regulate their education upon graduation and throughout their professional lives. This study explores links between medical students' use of self-regulated learning as it relates to motivation, autonomy, and control, and how these influenced their experiences in medical school. Subjects were medical students in two distinct medical school environments, "Problem-based learning" and "Traditional." PBL students described a rough transition into medical school, but once they felt comfortable with the autonomy and control PBL gave them, they embraced the independence and responsibility. They found themselves motivated to learning for learning's sake, and able to channel their motivation into effective transitions from the classrooms into the clerkships. Traditional students had a rougher transition from the classrooms to the clerkships. In the first two years they relied on faculty to direct and control learning, and they channeled their motivation toward achieving the highest grade. In the clerkships, they found faculty expected them to be more independent and self-directed than they felt prepared to be, and they struggled to assume responsibility for their learning. Self-regulated learning can help smooth out the transitions through medical school by preparing first and second year students for expectations in the third and fourth years, which can then maximize learning in the clinical milieu, and prepare medical students for a lifetime of learning.

Background: The development of critical consciousness, anchored in principles of social justice, is an essential component of medical education., Aim: In order to assist faculty instructors in facilitating small-group discussions on potentially contentious issues involving race, gender, sexual orientation, and socioeconomic class, a faculty development workshop was created., Methods: The workshop used 'Forum Theater' techniques in which the audience was directly involved in determining the course of a simulated classroom discussion and conflict. We assessed the workshop's impact on the instructors' attitudes regarding facilitation of small-group discussions through two surveys: one to gauge immediate impressions, and another, 9-15 months later, to assess impact over time., Results: Immediately after the workshop, participants reported that the topics covered in the sketch and in the discussion were highly relevant. In the follow-up survey, the instructors agreed that the workshop had raised their awareness of the classroom experiences of minorities and women and had offered strategies for addressing destructive classroom dynamics. 72% reported that the workshop led to changes in their behavior as facilitators. Differences in responses according to gender were observed., Conclusions: A workshop using interactive theater was effective in training faculty to facilitate small-group discussions about multicultural issues. This approach emphasizes and models the need to foster critical consciousness in medical education.

Objective: The goal of this study was to determine the influence of the third-year obstetrics and gynecology (OB/GYN) clerkship on male and female medical students' interest in a career in OB/GYN., Study Design: Third-year medical students were surveyed about anticipated career field before and at the completion of the OB/GYN clerkship. The percentage of students considering OB/GYN as a career was computed before and after the clerkship. A multiple regression analysis was performed to examine the influence of various demographic factors on interest in OB/GYN. A Chi-square test was performed to establish different effects on males and females., Results: A total of 268 students (55%) completed both surveys. Eight percent (mostly females) considered an OB/GYN career pre-clerkship and 15% post-clerkship. Interest in OB/GYN pre-clerkship was the strongest predictor of interest post-clerkship., Conclusion: The OB/GYN clerkship increases students' interest in a career in OB/GYN. Most males are not considering OB/GYN as a career choice before the start of the clerkship.

Mutations of mitochondrial DNA (mtDNA) are an important cause of genetic disease, yet rarely present in the neonatal period. Here we report the clinical, biochemical, and molecular genetic findings of an infant who died at the age of 1 mo with marked biventricular hypertrophy, aortic coarctation, and severe lactic acidosis due to a previously described but unusual mtDNA mutation, a 7-bp intragenic inversion within the mitochondrial gene encoding ND1 protein of complex I (MTND1). In direct contrast to the previous case, an adult with exercise intolerance who only harbored the mutation in muscle, the MTND1 inversion in our patient was present at high levels in several tissues including the heart, muscle, liver, and cultured skin fibroblasts. There was no evidence of the mutation or respiratory complex I defect in a muscle biopsy from the patient's mother. Transmitochondrial cytoplasmic hybrids (cybrids) containing high mutant loads of the inversion expressed the biochemical defect but apparently normal levels of the assembled complex. Our report highlights the enormous phenotypic diversity that exists among pathogenic mtDNA mutations and reemphasizes the need for appropriate genetic counseling for families affected by mtDNA disease.

Purpose: To examine the effects of the new resident work-hour restrictions on medical students, as measured by their perceptions of the quality of their experiences during the required clerkships., Method: Evaluations of four clerkships were compared for two student cohorts at the University of Michigan Medical School. The first cohort, from the class of 2002-03, completed their clinical clerkships the year before the work-hour restrictions were implemented, and the second cohort, from the class of 2003-04, completed their clerkships the same year the restrictions were implemented., Results: There were significant and notable differences in the experiences of the two cohorts. Students' perceptions of the quality of their experiences in the surgery-oriented clerkships (obstetrics-gynecology and surgery) in particular were significantly lower (i.e., more negative) in the 2003-04 cohort than in the previous cohort for the same clerkships. The nonsurgery-oriented clerkships (internal medicine and pediatrics) hired hospitalists, who offset the residents' workload (internal medicine) and assumed teaching responsibilities (pediatrics). Between 2002-03 and 2003-04, students' perceptions of the quality of their experience in the internal medicine clerkship remained mostly stable, and increased in several areas for the students in the pediatrics clerkship., Conclusions: Implementation of resident work-hour restrictions had significant effects on the education of the medical students studied. These effects need to be carefully analyzed and considered to ensure quality education for medical students. The findings also highlight that the nature of students' perceptions was related to preparations made (or not) by specific clerkships as restricted work-hour regulations were adopted.

Objective: The objective of this study was to compare the students' actual work hours with their self-reported work hours during the obstetrics and gynecology clerkship, and to determine whether the number of hours worked correlate with the amount of "scut" reported or students' rating of the quality of the clerkship., Study Design: Students self-reported work hours were compared against their actual scheduled hours over 2 different academic years. Pearson's correlation was performed to correlate the actual hours with the amount of reported "scut" work and the overall rating of the quality of the clerkship., Results: The actual hours per week worked by students averaged 59 hours in 2003 and 48 hours in 2004. Students overestimated their work hours both years. Students who worked more hours rated the clerkship lower and the quality of the clerkship significantly improved from 2003 to 2004 (4.2 vs 3.8 P < .03)., Conclusion: The majority of third-year students overestimate their work hours in obstetrics and gynecology. The rating of the overall quality of the clerkship increase significantly with fewer hours worked, and it is not affected by the amount of "scut" work.

Differences in the social and religious cultures of Arab Americans and American Muslims raise challenges to healthcare access and delivery. These challenges go far beyond language to encompass entire world views, concepts of health, illness, and recovery and even death. Medical professionals need a more informed understanding and consideration of the rich and diverse array of beliefs, expectations, preferences, and behavioral make up of the social cultures of these patients to ensure that they are providing the best and most comprehensive care possible. Improved understanding will enhance a provider's ability to offer quality healthcare and to build trusting relationships with patients. Here, we provide a broad overview of Arab culture and Islamic religious beliefs that will assist providers in delivering culturally sensitive healthcare to these groups. We offer insight into the behaviors, requirements, and preferences of Arab American and American Muslim patients, especially as they apply to women's health.

Computer-assisted instruction (CAI) holds significant promise for meeting the current challenges of medical education by providing consistent and quality teaching materials regardless of training site. The Computer-assisted Learning in Pediatrics Project (CLIPP) was created over three years (2000-2003) to meet this potential through multi-institutional development of interactive Internet-based patient simulations that comprehensively teach the North American core pediatrics clerkship curriculum. Project development adhered to four objectives: (1) comprehensive coverage of the core curriculum; (2) uniform approach to CAI pedagogy; (3) multi-institutional development by educators; and (4) extensive evaluation by users. Pediatrics clerkship directors from 30 institutions worked in teams to develop a series of 31 patient case simulations. An iterative process of case content and pedagogy development, case authoring, peer review, and pilot-testing ensured that the needs of clerkship directors and medical students were met. Fifty medical schools in the United States and Canada are presently using CLIPP. More than 8,000 students have completed over 98,000 case sessions, with an average of 2,000 case sessions completed per week at this time. Each CLIPP case has been completed by more than 3,000 students. The current cost of CLIPP development is approximately $70 per student user, or $6 per case session. The project's success demonstrates that multi-institutional development and implementation of a peer-reviewed comprehensive CAI learning program by medical educators is feasible and provides a useful model for other organizations to develop similar programs. Although CAI development is both time-consuming and costly, the initial investment decreases significantly with broad use over time.

Background: Medical schools are increasingly using community practice sites (CPS) for clerkship training., Purposes: We compared the test performance of all students assigned to CPS with all students trained at an academic medical center (AMC) for their pediatric clerkship for the past 5 years., Methods: Baseline comparability of both groups was established by the group mean scores on 1st and 2nd year medical school grade point average (GPA) and the United States Medical Licensing Examination (USMLE) Step 1 and Step 2. Performance outcome was compared by group mean scores on a written clerkship exam and the National Board of Medical Examiners Pediatric Subject Examination., Results: There was no statistical difference between the two groups with regard to GPA or USMLE scores. Standardized test performance results: [table: see text], Conclusion: The CPS-trained students performed as well or better on standardized written tests compared with AMC-trained students. Community pediatric practices can provide a quality clerkship experience for junior medical students.

Although mortality associated with knee and hip arthroplasty has been reported, there is no information about shoulder arthroplasty. The purpose of this study was to determine the incidence and risk factors associated with perioperative mortality after shoulder arthroplasty. Between 1970 and 2000, 2,953 patients underwent shoulder arthroplasty at our institution. A retrospective review identified all patients who died within 90 days of the procedure. The 90-day mortality incidence was 0.58% (17 of 2,953). Twelve hemiarthroplasties were performed for a pathologic fracture and one for rotator cuff arthropathy. Total shoulder arthroplasties were performed for the sequelae of trauma (2), rheumatoid arthritis (1), and avascular necrosis (1). Ninety-day mortality was closely associated with the underlying diagnosis. Perioperative mortality after shoulder arthroplasty for non-neoplastic conditions is low.

Complications after surgical treatment of closed ankle fractures in patients with diabetes previously have been well documented. The purpose of this study was to evaluate the union rate, infection rate, and soft tissue complication rate in open ankle fractures in patients with diabetes. Between January 1, 1981 and December 31, 2000, 14 open ankle fractures in 13 patients with diabetes were treated. The mean followup was 19 months (range, 6-84 months). All patients were followed up until union, amputation, or for at least 6 months. Nine of 14 extremities (64%) had wound healing complications. Ultimately, five patients (six extremities; 42%) had below the knee amputation. Only three of 14 fractures in three patients healed without complications. Open ankle fractures in patients with diabetes are limb-threatening injuries with high amputation and infection rates despite contemporary techniques of open reduction and internal fixation, intravenous antibiotics, and emergent irrigation and debridement.

Aim: Although studies have examined medical students' ability to self-assess their performance, there are few longitudinal studies that document the stability of self-assessment accuracy over time. This study compares actual and estimated examination performance for three classes during their first 3 years of medical school., Methods: Students assessed their performance on classroom examinations and objective structured clinical examination (OSCE) stations. Each self-assessment was then contrasted with their actual performance using idiographic (within-subject) methods to define three measures of self-assessment accuracy: bias (arithmetic differences of actual and estimated scores), deviation (absolute differences of actual and estimated scores), and covariation (correlation of actual and estimated scores). These measures were computed for four intervals over the course of 3 years. Multivariate analyses of variance and correlational analyses were used to evaluate the stability of these measures., Results: Self-assessment accuracy measures were relatively stable over the first 2 years of medical school with a decease occurring in the third year. However, the correlational analyses indicated that the stability of self-assessment accuracy was comparable to the stability of actual performance over this same period., Conclusion: The apparent decline in accuracy in the third year may reflect the transition from familiar classroom-based examinations to the substantially different clinical examination tasks of the third year OSCE. However, the stability of self-assessment accuracy compares favorably with the stability of actual performance over this period. These results suggest that self-assessment accuracy is a relatively stable individual characteristic that may be influenced by task familiarity.

Study Design: A case of arterial-esophageal fistula related to nasogastric tube placement in a 13-year-old girl after surgical correction of her progressive congenital lumbar kyphosis is presented., Objectives: This case report illustrates the importance of early recognition of "sentinel" hematemesis before massive hemorrhage, as this may allow for timely surgical intervention to prevent fatal exsanguination. The proposed pathogenesis of the arterial-esophageal fistula in the reported patient is discussed., Summary of Background Data: Although arterial-esophageal fistula formation has been recognized as an unusual complication of prolonged nasogastric intubation, to the authors' knowledge, this is the only case that illustrates an association of this complication with short-term nasogastric tube placement., Methods: A 13-year-old girl was evaluated for progressive congenital lumbar kyphosis. Failure of segmentation and an anterior bar at L4-L5 was diagnosed when the patient was 7 years of age. At that time, she showed 28 degrees of kyphosis from L3 to L5. Because of her cardiopulmonary status at the time, she was deemed not to be a candidate for a corrective surgical procedure and followed conservatively until the age of 13 years. At that time, her gibbus deformity was 56 degrees from L3 to L5. She had significant ventral sagittal imbalance, which in combination with her cardiopulmonary abnormalities created difficulty with ambulation. Her preoperative neurologic examination was within normal limits. The patient had an extensive history of congenital cyanotic cardiopulmonary disease. She was born with pulmonary atresia, right-sided aortic arch with mirror image branching, a large coronary sinus type atrial septal defect, and a large ventricular septal defect. She had history of multiple surgical procedures for correction of her congenital cardiopulmonary abnormalities. The patient underwent posterior L3 and L5 wedge pedicle reduction osteotomies with posterior instrumentation and fusion from L2 to S1 using pedicle screw segmental fixation. A nasogastric tube was placed after surgery. On postoperative day 7, profuse bleeding from the patient's mouth and nose developed, which subsequently ceased. Shortly afterward, she became hypotensive and tachycardic. Upper gastrointestinal endoscopy showed a large amount of blood in her stomach without an active source. Cardiac arrest then developed, and she could not be resuscitated. The autopsy findings were consistent with an arterial-esophageal fistula., Results: In the reported patient, the anomalous aortic arch system provided direct contact between the aorta and the esophagus. Dense fibrous adhesions between the aorta and esophagus resulting from multiple previous thoracic surgeries also may have facilitated the development of the fistula by the nasogastric tube in this patient., Conclusions: Patients with congenital cardiac abnormalities frequently also have congenital spinal deformities. These patients may undergo spinal correction procedures requiring nasogastric intubation. Increased awareness of arterial-esophageal fistula among the spine surgery community may enhance early recognition and treatment of this potentially lethal condition.

Metallocene-catalyzed polymerization of 1-alkenes offers fine control of critical polymer attributes such as molecular weight, polydispersity, tacticity, and comonomer incorporation. Enormous effort has been expended on the synthesis and discovery of new catalysts and activators, but elementary aspects of the catalytic processes remain unclear. For example, it is unclear how the catalyst is distributed among active and dormant sites and how this distribution influences the order in monomer for the propagation rates, for which widely varying values are reported. Similarly, although empirical relationships between average molecular weights and monomer have been established for many systems, the underlying mechanisms of chain termination are unclear. Another area of intense interest concerns the role of ion-pairing in controlling the activity and termination mechanisms of metallocene-catalyzed polymerizations. Herein we report the application of quenched-flow kinetics, active site counting, polymer microstructure analysis, and molecular weight distribution analysis to the determination of fundamental rate laws for initiation, propagation, and termination for the polymerization of 1-hexene in toluene solution as catalyzed by the contact ion-pair, [rac-(C(2)H(4)(1-indenyl)(2))ZrMe][MeB(C(6)F(5))(3)] (1) over the temperature range of -10 to 50 degrees C. Highly isotactic (>99% mmmm) poly-1-hexene is produced with no apparent enchained regioerrors. Initiation and propagation processes are first order in the concentrations of 1-hexene and 1 but independent of excess borane or the addition of the contact ion-pair [PhNMe(3)][MeB(C(6)F(5))(3)]. Active site counting and the reaction kinetics provide no evidence of catalyst accumulation in dormant or inactive sites. Initiation is slower than propagation by a factor of 70. The principal termination process is the formation of unsaturates of two types: vinylidene end groups that arise from termination after a 1,2 insertion and vinylene end groups that follow 2,1 insertions. The rate law for the former termination process is independent of the 1-hexene concentration, whereas the latter is first order. Analysis of (13)C-labeled polymer provides support for a mechanism of vinylene end group formation that is not chain transfer to monomer. Deterministic modeling of the molecular weight distributions using the fundamental rate laws and kinetic constants demonstrates the robustness of the kinetic analysis. Comparisons of insertion frequencies with estimated limits on the rates of ion-pair symmetrization obtained by NMR suggest that ion-pair separation prior to insertion is not required, but the analysis requires assumptions that cannot be validated.