Applying holistic review practices to a Combined Baccalaureate/Medical Degree Program: Reflections on lessons learned

PROBLEM

Despite the implementation of holistic review in the medical school application process, there is little information about how this can be utilized in Combined Baccalaureate/Medical Degree pipeline programs, especially since many programs offer reserved spots to their students in the medical school. Implementing holistic review in a Combined Baccalaureate/Medical Degree program and intentionally structuring it to align with the medical school mission and admissions practices and processes, can improve the diversification of the physician workforce, contribute to more primary care doctors, and promote in-state practice.

INTERVENTION

Utilizing the medical school admissions by-laws, committee structure, shared training, and educational processes, we successfully engrained in our committee members the values and mission alignment to select the best applicants to fulfill the medical school mission using holistic review. To our knowledge, no other program has written about how holistic review is used in Combined Baccalaureate/Medical Degree programs and how it contributes to program outcomes.

CONTEXT

The Combined Baccalaureate/Medical Degree Program is a partnership between the undergraduate College of Arts and Sciences and the School of Medicine. The Combined Baccalaureate/Medical Degree admissions committee is a subcommittee of the School of Medicine admissions committee but has a separate membership. Hence, the holistic admissions process for the program mirrors the School of Medicine admissions process. To determine the outcome of this process, we analyzed practice specialty, practice location, gender, race and ethnicity of program alumni.

IMPACT

To date, the Combined Baccalaureate/Medical Degree holistic admissions processes have supported the medical school mission, "…To meet the physician workforce needs of the state by selection of students who are likely to train in specialty areas of need and to remain in or return to the areas of our state needing physicians." This implementation has resulted in 75% (37/49) of our practicing alumni selecting a primary care specialty, and 69% (34/49) practicing in the state. In addition, 55% (27/49) identify as Underrepresented in Medicine.

LESSONS LEARNED

We observed that having an intentional structured alignment in place allowed for implementation of holistic practices in the Combined Baccalaureate/Medical Degree admissions process. The high retention rates and specialty of graduates from the Combined Baccalaureate/Medical Degree Program support our intentional efforts to diversify our admissions committees and align the Combined Baccalaureate/Medical Degree program's holistic review admissions process with our School of Medicine mission and admissions practices and processes, as key strategies to reach our diversity-related goals.

A Cross-Sectional Geographic Information Systems Study of a Pediatric Emergency Department Child Restraint System Distribution Program

INTRODUCTION

A pediatric ED program sought to promote injury prevention through distribution of child restraint systems. Program funds are paid for child passenger safety technician certification of all personnel. Pediatric emergency nurses distributed child restraint systems at hospital discharge and dedicated technicians at fitting stations. Researchers described program characteristics, developed a baseline understanding of program outreach using geographic information systems, and evaluated adherence to manufacturer guidelines with a sensitivity analysis.

METHODS

This retrospective cross-sectional study used distribution forms linked to hospital records from 2013 to 2016. Testing for differences used nonparametric methods. Median values and interquartile ranges for weight and height of children were compared with manufacturer guidelines. Geographic information systems visualized recipients' street addresses and motor vehicle crashes on an underlying base map.

RESULTS

There were 312 child restraint systems distributed: of which 179 (57.4%) at the hospital, 126 (40.4%) at fitting stations, and 7 (2.2%) missing a location. Among those on Medicaid, 64.4% received a child restraint system at the hospital compared with 35.6% at fitting stations (χ² = 5.40, P < .02). Fitting stations had limited outreach to rural residents. Finally, results from the sensitivity analysis showed that devices were issued according to manufacturer guidelines.

DISCUSSION

Despite the workplace pressures of clinical care, pediatric emergency nurses delivered educational information and demonstrated hands-on installation at similar rates to dedicated technicians. Distribution of child restraint systems through the hospital reached a uniquely underserved population. Further research should investigate methods to improve fitting station outreach among Medicaid recipients.

Outcome Prediction of Higher-Risk Brief Resolved Unexplained Events

OBJECTIVES

Brief resolved unexplained events (BRUEs) are classified as higher risk on the basis of patient and event characteristics, but there is limited evidence to guide management decisions. The authors of this study aim to describe patients with a higher-risk BRUE, determine the yield of diagnostic evaluation, and explore predictors of clinical outcomes.

METHODS

A retrospective medical record review was conducted for patients ≤365 days of age who were evaluated in a tertiary-care pediatric emergency department with a discharge diagnostic code indicative of a BRUE. Demographic and clinical characteristics, including diagnostic evaluation, are reported. Univariate and multivariate analyses were used to test the association of risk factors with clinical outcomes (serious underlying diagnosis, recurrent events, and return hospitalization).

RESULTS

Of 3325 patients, 98 (3%) met BRUE criteria and 88 were classified as higher risk; 0.6% of laboratory and 1.5% of ancillary tests were diagnostic, with 4 patients having a serious underlying diagnosis. Nine patients had recurrent events during hospitalization, and 2 were readmitted for a recurrent BRUE after their index visit. Prematurity was the only characteristic significantly associated with an outcome, increasing the odds of a recurrent event (odds ratio = 9.4; P = .02).

CONCLUSIONS

The majority of patients with a BRUE are higher risk, but the yield of diagnostic evaluation is low. Published risk criteria do not appear to be associated with adverse clinical outcomes except for prematurity and recurrent events. Future multicentered prospective studies are needed to validate risk stratification and develop management guidance for the higher-risk BRUE population.

Implementing lower-risk brief resolved unexplained events guideline reduces admissions in a modelled population

RATIONALE

American Academy of Pediatrics released a clinical practice guideline (CPG) in 2016 recommending the term apparent life-threatening events (ALTE) be replaced by brief resolved unexplained events (BRUE). The CPG provides recommendations for the clinical evaluation and management of infants with this condition based on the risk of a serious underlying disorder or repeat event. The lower-risk CPG was applied to a modelled population, studying predictors of hospital admission, defined as length of stay (LOS) ≥ 24 hours.

METHODS

An algorithm was derived using a Pediatric Emergency Care Applied Research Network database. Propensity score weighting, based on probability of following the CPG, determined the adjusted odds ratio (aOR) and 95% confidence interval (CI) of hospital admission. Multiple imputation allowed any missing data problems be addressed and a sensitivity analysis of database robustness.

RESULTS

Applying the modelling algorithm, 3116 observations were identified, among whom 1974 (63.4%) the CPG was followed and 1142 (36.6%) not followed. The CPG was followed for 60.1% of infants staying ≥24 hours compared with 76.6% of infants staying <24 hours (P < .001). After propensity score weighting and multiple imputation, the likelihood of hospital admission was significantly lower when the CPG was followed (aOR = 0.49; 95% CI, 0.39-0.62, P < .001).

CONCLUSIONS

Results suggest that use of the CPG under strict conditions would lead to fewer hospital admissions among infants with a lower-risk BRUE. Implementation of CPGs in modelled populations may help clinicians identify unanticipated factors and address these issues beforehand. We noted differences in care based on race, necessitating further investigation.

Combined Baccalaureate/Medical Degree Students Match Into Family Medicine Residencies More Than Similar Peers: A Matched Case-Control Study

BACKGROUND AND OBJECTIVES

We sought to evaluate whether the University of New Mexico (UNM) Combined Baccalaureate/Medical Degree (BA/MD) program increases the likelihood that students match into family medicine residencies.

METHODS

We used binary logistic regression to predict interest and actual residency match in family medicine. We compared BA/MD participants to similar peers (one-to-one match subject design) and all other students for the nine cohorts of medical students who have matriculated into UNM School of Medicine since the inception of the BA/MD program (medical school matriculation years 2009-2017). We also investigated whether BA/MD students were more likely to select family medicine as their specialty choice at the time of matriculation using survey responses.

RESULTS

At the time of matriculation, the differences in identifying family medicine as a first specialty choice between BA/MD, similar peers, and all other students were small and not statistically significant. However, upon graduation, 33% of BA/MD students matched into family medicine compared to 17% of similar peers, a statistically significant difference even after controlling for United States Medical Licensing Examination (USMLE) test scores and several demographic factors.

CONCLUSIONS

The University of New Mexico Combined Baccalaureate/Medical Degree students match into family medicine at nearly twice the rate of traditional medical degree students, suggesting that the UNM BA/MD program serves to increase the growth rate of the family medicine workforce.

A Framework for Evaluation of the Higher-Risk Infant After a Brief Resolved Unexplained Event

In 2016, the American Academy of Pediatrics published a clinical practice guideline that more specifically defined apparent life-threatening events as brief resolved unexplained events (BRUEs) and provided evidence-based recommendations for the evaluation of infants who meet lower-risk criteria for a subsequent event or serious underlying disorder. The clinical practice guideline did not provide recommendations for infants meeting higher-risk criteria, an important and common population of patients. Therefore, we propose a tiered approach for clinical evaluation and management of higher-risk infants who have experienced a BRUE. Because of a vast array of potential causes, the initial evaluation prioritizes the diagnosis of time-sensitive conditions for which delayed diagnosis or treatment could impact outcomes, such as child maltreatment, feeding problems, cardiac arrhythmias, infections, and congenital abnormalities. The secondary evaluation addresses problems that are less sensitive to delayed diagnosis or treatment, such as dysphagia, intermittent partial airway obstruction, and epilepsy. The authors recommend a tailored, family-centered, multidisciplinary approach to evaluation and management of all higher-risk infants with a BRUE, whether accomplished during hospital admission or through coordinated outpatient care. The proposed framework was developed by using available evidence and expert consensus.

Recruiting American Indian/Alaska Native Students to Medical School: A Multi-Institutional Alliance in the U.S. Southwest

PROBLEM

Despite national efforts to diversify the physician workforce, American Indian/Alaska Native (AI/AN) individuals have the least representation of all major racial and ethnic groups. Limited resources at state medical schools present institution-level recruitment challenges. Unified efforts to engage AI/AN students in premedical education activities are needed.

APPROACH

The medical schools at the Universities of Arizona (Phoenix and Tucson), Colorado, New Mexico, and Utah identified a collective need to increase student diversity, particularly with regard to AI/AN students. The schools partnered with the Association of American Indian Physicians to support AI/AN students applying to medical school and to grow the overall AI/AN applicant pool. Each year from 2011 to 2016, these institutions hosted a two-day preadmissions workshop (PAW) to prepare participants for applying to medical school.

OUTCOMES

From 2011 to 2016, 130 AI/AN students participated in the PAWs. Of these, 113 were first-time attendees, 15 participated on two separate occasions, and 1 participated on three separate occasions. Nineteen (21%) of the 90 first-time participants from 2011 to 2015 matriculated to a U.S. medical school in the past five years. Twenty-two of 23 participants (96% response rate) in 2016 responded to the postworkshop survey. Results indicated that interview preparation, individual consultation, and writing preparation ranked as the three most beneficial sessions/activities.

NEXT STEPS

Standardized evaluation of future PAWs will identify best practices for recruiting AI/AN students to medical school, and future initiatives will include more robust measures of success.

Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants

This is the first clinical practice guideline from the American Academy of Pediatrics that specifically applies to patients who have experienced an apparent life-threatening event (ALTE). This clinical practice guideline has 3 objectives. First, it recommends the replacement of the term ALTE with a new term, brief resolved unexplained event (BRUE). Second, it provides an approach to patient evaluation that is based on the risk that the infant will have a repeat event or has a serious underlying disorder. Finally, it provides management recommendations, or key action statements, for lower-risk infants. The term BRUE is defined as an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of ≥1 of the following: (1) cyanosis or pallor; (2) absent, decreased, or irregular breathing; (3) marked change in tone (hyper- or hypotonia); and (4) altered level of responsiveness. A BRUE is diagnosed only when there is no explanation for a qualifying event after conducting an appropriate history and physical examination. By using this definition and framework, infants younger than 1 year who present with a BRUE are categorized either as (1) a lower-risk patient on the basis of history and physical examination for whom evidence-based recommendations for evaluation and management are offered or (2) a higher-risk patient whose history and physical examination suggest the need for further investigation and treatment but for whom recommendations are not offered. This clinical practice guideline is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient outcomes, support implementation, and provide direction for future research. Each key action statement indicates a level of evidence, the benefit-harm relationship, and the strength of recommendation.

Commentary: profiling by appearance and assumption: beyond race and ethnicity

In this issue, Acquaviva and Mintz highlight issues regarding racial profiling in medicine and how it is perpetuated through medical education: Physicians are taught to make subjective determinations of race and/or ethnicity in case presentations, and such assumptions may affect patient care. The author of this commentary believes that the discussion should be broadened to include profiling on the basis of general appearance. The author reports personal experiences as someone who has profiled and been profiled by appearance-sometimes by skin color, sometimes by other physical attributes. In the two cases detailed here, patient care could have been affected had the author not become aware of his practices in such situations. The author advocates raising awareness of profiling in the broader sense through training.

Production of proteoglycans by human lung fibroblasts (IMR-90) maintained in a low concentration of serum

Maintenance of fibroblasts in 0.5% serum results in viable but non-proliferative cells that may be analogous to fibroblasts in vivo. The synthesis of proteoglycans by human embryo lung fibroblasts in Eagle's minimal essential medium with 0.5% newborn-bovine serum or with 10% serum has been compared. A similar amount of [35S]sulphate-labelled glycosaminoglycan per cell was secreted by fibroblasts in 10% or 0.5% serum. 35SO42-incorporation into sulphated glycosaminoglycans was enhanced in 0.5% serum when expressed per mg of cell protein, but [3H]glucosamine incorporation was decreased. The charge density of these glycosaminoglycans was not changed as determined by ion-exchange chromatography. It was concluded that decreased protein/ cell resulted in an apparent increase in 35S-labelled glycosaminoglycan synthesis/mg of cell protein, whereas decreased uptake of [3H]glucosamine resulted in a decrease in their glucosamine labelling. The proteoglycans secreted by fibroblasts in 0.5% serum were similar in glycosaminoglycan composition, chain length and buoyant density to the dermatan sulphate proteoglycan, which is the major secreted component of cells in 10% serum. Larger heparan sulphate and chondroitin sulphate proteoglycans, which comprise about 40% of the total secreted proteoglycans of cultures in 10% serum, were greatly diminished in the medium of cultures in 0.5% serum. The proteoglycan profile of medium from density-inhibited cultures in 10% serum resembles that of proliferating cultures, indicating that lack of proliferation was not responsible for the alteration. The dermatan sulphate proteoglycan, participating in extracellular matrix structure, may be the primary tissue product of lung fibroblasts in vivo.