Introduction to Disability and Antiableist Health Care: A Pilot, Student-Led Module for Preclinical Medical Students

ABSTRACT

Physical medicine and rehabilitation physicians often care for disabled patients, who comprise America's largest marginalized population. Despite medical students' and physicians' discomfort with caring for disabled patients and the pervasiveness of ableism in health care, medical education lacks disability-focused education. Kern's approach to curriculum development and disability community input were used to design a three-part, elective curriculum for first-year medical students. Part one introduced disability models and language. Part two described how to perform a comprehensive history and physical examination for a disabled patient using ADEPT-CARE. Part three provided an overview of disability history and the disability rights movement. The curriculum's goal was to improve students' attitudes regarding disability health and self-perceived knowledge and confidence in caring for patients with disabilities. The curriculum was evaluated through presurvey and postsurvey. Students favorably reviewed the curriculum. One hundred percent of students ( n = 21) agreed or strongly agreed that the curriculum improved their knowledge of disability health, increased their perceived confidence in caring for patients with disabilities, and enhanced their medical education. There were no statistically significant differences in students' attitudes toward patients with disabilities after curriculum completion. Our asynchronous module provides one potential curriculum for increasing preclinical medical students' self-perceived knowledge of disability health.

Teaching Future Physician Assistants to Provide ADEPT-CARE to Disabled Patients: A Novel Application of Disability Curriculum

INTRODUCTION

Physician assistant (PA) students will be certain to provide care to patients with disabilities in their future careers. However, there is a dearth of literature on disability-related education in PA training. This curriculum sought to fill this need. The specific aims of this study were to (1) evaluate the implementation of a 3-part disability-focused education curriculum in PA education, (2) assess changes in PA students' self-perceived confidence and attitudes toward patients with disabilities, and (3) assess students' attitudes toward ADEPT-CARE.

METHODS

A 3-part disability curriculum was implemented into the first-year PA curriculum at a single Mid-Atlantic institution. Students could voluntarily complete pre and post-surveys which assessed their self-perceived confidence and attitudes toward people with disabilities, perception of the curriculum, and attitudes toward ADEPT-CARE and disability health.

RESULTS

Thirty students participated in the study, with a 100% survey response rate. Nearly all participants agreed or strongly agreed that this curriculum enhanced their medical education (n = 28, 96.6%, frequency missing n = 1). After curriculum completion, there was a statistically significant improvement in participants' confidence in their ability to assess patients with disability (46.7%-93.3%, P < 0.001), ability to provide the same quality of care to patients with disability as those without disability (80.0%-96.7%, P = 0.025), and perception of quality of life of persons with disabilities (P = 0.030).

DISCUSSION

This curriculum was well received by PA students and improved their attitudes toward patients with disabilities, thereby fulfilling a critical need for PA educators.

Systems-Based Practice: Expert Perspectives on the Origin and Evolution of an Ambiguous Competency

PURPOSE

Systems-based practice (SBP) has been a core competency in graduate medical education in the United States since 1999, but it has been difficult to operationalize in residency programs due to its conceptual ambiguity. The authors explored the historical origin and subsequent development of the SBP competency from the perspective of individuals who were influential across critical phases of its implementation and ensuing development. The goal of this study was to elicit the history of SBP from the perspective of individuals who have expertise in it and to use those findings to inform the current SBP construct.

METHOD

Between March and July 2021, 24 physicians, nurses, educators, and leaders in the field of SBP were individually interviewed about the origin and meaning of SBP as practiced in U.S. medical education using a semistructured guide. Individuals were selected based upon their influence on the origin or evolution of the SBP competency. Data were iteratively collected and analyzed using real-time analytic memos, regular adjudication sessions with the research team, and thematic analysis. Researchers identified themes from participants' perspectives and agreed upon the final results and quotations.

RESULTS

Five themes were identified: SBP has many different definitions, SBP was intentionally designed to be vague, systems thinking was identified as the foundation of the SBP competency, the 6 core competencies established in the United States by the Accreditation Council for Graduate Medical Education were developed to be interdependent, and the SBP and practice-based learning and improvement competencies are uniquely related and synergistic.

CONCLUSIONS

Interview data indicate that since its inception, SBP has been a nuanced and complex competency, resulting in a lack of mutually shared understanding among stakeholders. This deliberate historical examination of expert perspectives provides insight into specific areas for improving how SBP is taught and learned.

Breaking Down Silos Between Medical Education and Health Systems: Creating an Integrated Multilevel Data Model to Advance the Systems-Based Practice Competency

ABSTRACT

The complexity of improving health in the United States and the rising call for outcomes-based physician training present unique challenges and opportunities for both graduate medical education (GME) and health systems. GME programs have been particularly challenged to implement systems-based practice (SBP) as a core physician competency and educational outcome. Disparate definitions and educational approaches to SBP, as well as limited understanding of the complex interactions between GME trainees, programs, and their health system settings, contribute to current suboptimal educational outcomes elated to SBP. To advance SBP competence at individual, program, and institutional levels, the authors present the rationale for an integrated multilevel systems approach to assess and evaluate SBP, propose a conceptual multilevel data model that integrates health system and educational SBP performance, and explore the opportunities and challenges of using multilevel data to promote an empirically driven approach to residency education. The development, study, and adoption of multilevel analytic approaches to GME are imperative to the successful operationalization of SBP and thereby imperative to GME's social accountability in meeting societal needs for improved health. The authors call for the continued collaboration of national leaders toward producing integrated and multilevel datasets that link health systems and their GME-sponsoring institutions to evolve SBP.

Implementation and Evaluation of an Interprofessional Health Systems Science Professional Development Program

PROBLEM

Few interprofessional development programs focused on learning knowledge and skills in health systems science (HSS) have been described. The authors implemented a professional development program (the HSS Academy) for interprofessional clinicians and trainees. The authors describe the HSS Academy, report preliminary outcomes, and describe strategies for use in other programs.

APPROACH

The HSS Academy (an 8-month active learning classroom and project-based curriculum) was implemented at Penn State College of Medicine in 2015. To create an interprofessional environment, participants were selected from various professions and phases of training. The curriculum was anchored in HSS competencies (e.g., high-value care, quality improvement, social determinants of health, health system strategy and delivery) and included 2 distinct threads focused on systems thinking competencies and academic skill development. It featured course speakers and faculty from diverse roles and disciplines both inside and outside the health system, application of HSS competencies in local system contexts, and networking with interprofessional colleagues.

OUTCOMES

From 2015 to 2021, 121 of 128 participants, including physicians, medical students, and nurses, completed the HSS Academy (95% completion rate). Over 90 individuals, including faculty and system leaders, contributed to the HSS Academy as educators. Comparisons of pre-post evaluations demonstrated statistically significant self-perceived improvements in HSS knowledge and skills, systems thinking, and HSS teaching knowledge and skills. Projects (n = 110) most commonly focused on health care delivery, quality improvement, or patient safety. Teaching strategies to meet each objective, several barriers encountered, and strategies to address those barriers are described.

NEXT STEPS

Next steps will be to address financial support for creating and sustaining the HSS Academy, ensure a mutually shared understanding of the HSS Academy's goals among all stakeholders, facilitate meaningful change from scholars' work, and provide networking and opportunities for scholars to continue work in HSS after completion of the HSS Academy.

ADEPT-CARE: A Pilot, Student-Led Initiative to Improve Care for Persons with Disabilities via a Novel Teaching Tool

BACKGROUND

Over one-quarter of United States adults live with a disability. Despite persistent ableism, defined as discrimination and prejudice against people with disabilities, in healthcare, disability-focused training remains largely absent from medical education.

OBJECTIVE

The aim of this study was to pilot and evaluate a novel teaching mnemonic (ADEPT-CARE) for performing a comprehensive history and physical exam for disabled patients.

METHODS

In Spring 2022, first-year medical students at a suburban Mid-Atlantic institution could electively participate in a learning module that included ADEPT-CARE. Surveys were administered to students before and following exposure to the ADEPT-CARE protocol.

RESULTS

Of 142 eligible students, 33 and 21 completed the pre- and post-surveys, respectively. The ADEPT-CARE protocol made sense to 95.2% of students. All (100%) students reported that they will use the ADEPT-CARE protocol in the assessment of patients with disabilities. Students were more likely to agree or strongly agree that they had a consistent approach or strategy in mind when assessing a patient with a disability after exposure to ADEPT-CARE (85.7% vs. 39.4%, respectively, p = 0.002). There was no statistically significant difference in students' perceived confidence in their ability to assess a patient with a disability after curriculum completion compared to before (85.7% vs. 81.8%, respectively, p = 1.0).

CONCLUSIONS

The ADEPT-CARE protocol has the potential to be an effective teaching tool by providing a framework to equitably care for disabled patients. Future research should assess whether students' self-reported increased confidence and intention to utilize ADEPT-CARE translates into the clinical setting.

Letter to the editor to update the article "Remote monitoring for heart failure using implantable devices: a systematic review, meta-analysis, and meta-regression of randomized controlled trials"

Our recently published systematic review and meta-analysis of heart failure (HF) remote monitoring using implantable devices (Hajduczok et al. in HF Reviews 1–20, 1) has been updated to reflected new data from the GUIDE-HF trial (Lindenfeld et al. in Lancet 398(10304):991-1001, 2). Data from randomized controlled trials (RCTs) was assessed to determine the effectiveness of implantable remote monitoring on the improvement of outcomes in HF patients. With the inclusion of the data from 1000 patients followed for 12 months in GUIDE-HF, our conclusions remain unchanged: Compared to standard of care, remote monitoring using implantable devices did not reduce mortality, CV, or HF hospitalizations. However, right ventricular/pulmonary pressure monitoring may reduce HF hospitalizations.

Patient Preparation for Outpatient Blood Work and the Impact of Surreptitious Fasting on Diagnoses of Diabetes and Prediabetes

Objective

To describe patient preparation for routine outpatient blood work and examine the implications of surreptitious fasting on interpretation of glucose results.

Patients and Methods

We designed a survey and administered it between September 1, 2016, and April 30, 2017, to assess fasting behaviors in a convenience sample of 526 adults presenting for outpatient blood work in 2 health systems between 7 am and 12 pm. We reviewed the electronic health records to extract glucose results. We describe the frequency of clinician-directed fasting and surreptitious fasting. In those surreptitiously fasting, we describe the frequency of missed diagnoses of prediabetes and diabetes.

Results

Of 526 participants, 330 (62.7%) self-identified as fasting, and 304 (92.1%) of those fasting met American Diabetes Association fasting criteria. Only 131 (24.9%) of those fasting were told to fast by their health care team. Almost 50% (257 of 526) believed it was important to fast for every blood test. Of the 64 patients with diabetes who were taking insulin, 37 (57.8%) fasted and took their insulin as prescribed. Among the 89 patients without diabetes who fasted without knowledge of their health care team and had glucose tested, 2 (2.2%) had a missed diagnosis of diabetes and 18 (20.2%) had a missed diagnosis of prediabetes.

Conclusion

Fasting for outpatient blood work is common, and patients frequently fast without awareness of their health care team. Failure to capture fasting status at the time of glucose testing is a missed opportunity to identify undiagnosed cases of diabetes and prediabetes.

The Impact of Block Ambulatory Scheduling on Internal Medicine Residencies: a Systematic Review

BACKGROUND

Over the past decade, nearly half of internal medicine residencies have implemented block clinic scheduling; however, the effects on residency-related outcomes are unknown. The authors systematically reviewed the impact of block versus traditional ambulatory scheduling on residency-related outcomes, including (1) resident satisfaction, (2) resident-perceived conflict between inpatient and outpatient responsibilities, (3) ambulatory training time, (4) continuity of care, (5) patient satisfaction, and (6) patient health outcomes.

METHOD

The authors reviewed the following databases: Ovid MEDLINE, Ovid MEDLINE InProcess, EBSCO CINAHL, EBSCO ERIC, and the Cochrane Library from inception through March 2017 and included studies of residency programs comparing block to traditional scheduling with at least one outcome of interest. Two authors independently extracted data on setting, participants, schedule design, and the outcomes of interest.

RESULTS

Of 8139 studies, 11 studies of fair to moderate methodologic quality were included in the final analysis. Overall, block scheduling was associated with marked improvements in resident satisfaction (n = 7 studies, effect size range - 0.3 to + 0.9), resident-perceived conflict between inpatient and outpatient responsibilities (n = 5, effect size range + 0.3 to + 2.6), and available ambulatory training time (n = 5). Larger improvements occurred in programs implementing short (1 week) ambulatory blocks. However, block scheduling may result in worse physician continuity (n = 4). Block scheduling had inconsistent effects on patient continuity (n = 4), satisfaction (n = 3), and health outcomes (n = 3).

DISCUSSION

Although block scheduling improves resident satisfaction, conflict between inpatient and outpatient responsibilities, and ambulatory training time, there may be important tradeoffs with worse care continuity.

The Association Between Major Depressive Disorder and Outcomes in Older Veterans Hospitalized With Pneumonia

BACKGROUND

Major depressive disorder ("depression") has been identified as an independent risk factor for mortality for many comorbid conditions, including heart failure, cancer and stroke. Major depressive disorder has also been linked to immune suppression by generating a chronic inflammatory state. However, the association between major depression and pneumonia has not been examined. The aim of this study was to examine the association between depression and outcomes, including mortality and intensive care unit admission, in Veterans hospitalized with pneumonia.

MATERIALS AND METHODS

We conducted a retrospective national study using administrative data of patients hospitalized at any Veterans Administration acute care hospital. We included patients ≥65 years old hospitalized with pneumonia from 2002-2012. Depressed patients were further analyzed based on whether they were receiving medications to treat depression. We used generalized linear mixed effect models to examine the association of depression with the outcomes of interest after controlling for potential confounders.

RESULTS

Patients with depression had a significantly higher 90-day mortality (odds ratio 1.12, 95% confidence interval 1.07-1.17) compared to patients without depression. Patients with untreated depression had a significantly higher 30-day (1.11, 1.04-1.20) and 90-day (1.20, 1.13-1.28) mortality, as well as significantly higher intensive care unit admission rates (1.12, 1.03-1.21), compared to patients with treated depression.

CONCLUSION

For older veterans hospitalized with pneumonia, a concurrent diagnosis of major depressive disorder, and especially untreated depression, was associated with higher mortality. This highlights that untreated major depressive disorder is an independent risk factor for mortality for patients with pneumonia.