The use of EPA assessments in decision-making: Do supervision ratings correlate with other measures of clinical performance?

BACKGROUND

Entrustable professional activities (EPAs) have been introduced as a framework for teaching and assessment in competency-based educational programs. With growing use, has come a call to examine the validity of EPA assessments. We sought to explore the correlation of EPA assessments with other clinical performance measures to support use of supervision ratings in decisions about medical students' curricular progression.

METHODS

Spearman rank coefficients were used to determine correlation of supervision ratings from EPA assessments with scores on clerkship evaluations and performance on an end-of-clerkship-year Objective Structured Clinical Examination (CPX).

RESULTS

Both overall clinical evaluation items score (rho 0.40; n = 166) and CPX patient encounter domain score (rho 0.31; n = 149) showed significant correlation with students' overall mean EPA supervision rating during the clerkship year. There was significant correlation between mean supervision rating for EPA assessments of history, exam, note, and oral presentation skills with scores for these skills on clerkship evaluations; less so on the CPX.

CONCLUSIONS

Correlation of EPA supervision ratings with commonly used clinical performance measures offers support for their use in undergraduate medical education. Data supporting the validity of EPA assessments promotes stakeholders' acceptance of their use in summative decisions about students' readiness for increased patient care responsibility.

Burnout and Well-Being Among Cardiology Fellowship Program Directors

OBJECTIVES

The third annual Cardiovascular Diseases (CV) Fellowship Program Directors (PDs) Survey sought to understand burnout and well-being among CV fellowship PDs.

BACKGROUND

Physician burnout is a common phenomenon. Data on burnout among cardiologists, specifically CV PDs, remain limited.

METHODS

The survey contained 8 questions examining satisfaction, stress, and burnout among CV fellowship PDs. Burnout was defined based on the self-reported presence of ≥1 symptom of burnout, constant feelings of burnout, or complete burnout.

RESULTS

Survey response rate was 57%. Most respondents were men (78%) and 54% represented university-based programs. Eighty percent reported satisfaction with their current job as PD, and 96% identified interactions with fellows as a driver of their satisfaction. Forty-five percent reported feeling a great deal of stress from their job. Stress was higher among women PDs, early-career PDs, and PDs of larger and university-based programs. Twenty-one percent reported some symptoms of burnout, and only 36% reported enjoyment without stress or burnout. Rates of enjoyment without stress or burnout were higher among men and late-career PDs, PDs of smaller programs, and PDs of community-based programs. Seventeen percent of PDs reported a high likelihood of resigning in the next year, of which the most common reason was the tasks of PDs were becoming overwhelming.

CONCLUSIONS

Most CV fellowship PDs are satisfied with their position, but stress and burnout remain common. Women PDs, early-career PDs, and PDs of larger, university-based programs demonstrate more adverse markers of well-being. Opportunities exist to support CV fellowship PDs in their critical role.

Program Directors Survey on Diversity in Cardiovascular Training Programs

BACKGROUND

Women and minorities are under-represented in cardiovascular disease (CVD) specialties. It remains unknown how characteristics of the CVD learning environment affect diversity and how program directors (PDs) approach these critical issues.

OBJECTIVES

The second annual Cardiovascular PD Survey aimed to investigate characteristics of the CVD learning environment that may affect diversity and strategies PDs use to approach these issues.

METHODS

The survey contained 20 questions examining U.S.-based CVD PD perceptions of diversity in CVD and related characteristics of the CVD fellowship learning environment.

RESULTS

In total, 58% of PDs completed the survey. Responding programs demonstrated geographic diversity. The majority were university-based or -affiliated. A total of 86% of PDs felt diversity in CVD as a field needs to increase, and 70% agreed that training programs could play a significant role in this. In total, 89% of PDs have attempted to increase diversity in fellowship recruitment. The specific strategies used were associated with PD sex and the presence of under-represented minority trainees in the program. PDs identified lack of qualified candidates and overall culture of cardiology as the 2 most significant barriers to augmenting diversity. A majority of programs have support systems in place for minority fellows or specific gender groups, including procedures to report issues of harassment or an unsafe learning environment. PDs identified shared best practices for recruitment and implicit bias training, among others, as important resources in their efforts to support diversity in CVD training.

CONCLUSIONS

Diversity is important to CVD PDs. They are striving to increase it in their programs through recruitment and strategies directed toward the fellowship learning environment. The CVD community has opportunities to standardize strategies and provide national resources to support PDs in these critical efforts.

How a Year of Clinical Experience Affects Students' Perspectives About the Supervision They Need to Perform Entrustable Professional Activities

Assessment of entrustable professional activities (EPAs) requires a supervisor to determine a learner's need for supervision to perform the tasks. This study examines medical students' perspectives, after completing their core clerkships, about the supervision they need to perform tasks defined by the core EPAs for entering residency. Compared with assertions at the start of the clerkship year, on retrospective self-assessment, students reported needing higher levels of supervision predominantly for activities commonly done during clinical rotations. Students remain confident in their ability to perform tasks with autonomy in the post-clerkship phase, however, raising concern about their abilities to discern limitations and appropriately request supervision.

The Clinical Anatomy and Imaging Laboratory: Vertical Integration in the Preclerkship Curriculum

INTRODUCTION

As medical schools implement integrated curricula, anatomy education especially has experienced increased pressure to make foundational content clinically relevant. We designed a novel type of integrative anatomy laboratory experience where students could use foundational anatomy concepts in concert with modern imaging/diagnostic techniques to enhance important clinical concepts.

METHODS

We selected a process called Lesson Study to develop the multidisciplinary Clinical Anatomy and Imaging Laboratory (CAIL) in the cardiovascular and gastrointestinal systems. We utilized soft-embalmed cadavers extensively for their highly realistic tissue appearance and texture, which allowed instructors and students to perform a wide array of procedures in case-based scenarios similar to practicing clinicians. We conducted field observations of participating students, focus-group discussions, and knowledge-based exams to examine efficacy of the CAIL.

RESULTS

Approximately 150 first- and second-year students participated in each of the CAIL activities on an annual basis. Most focus-group participants felt the CAIL was a great learning experience. They commented on how the lab provided relevance to anatomy knowledge and helped integrate prior classroom learning more deeply. Instructors noted that students asked more advanced, clinically relevant questions than in a typical anatomy lab. Knowledge improved significantly after the CAIL, although it is unclear if this translates to summative exams.

DISCUSSION

The CAIL creates a unique learning experience where students use prior foundational anatomy knowledge in conjunction with modern imaging and diagnostic techniques to reinforce important clinical concepts. We have continued to integrate CAIL experiences into more clinical systems in our medical school curriculum.

A case of familial calcific aortic and mitral stenosis in association with hereditary sclerosing poikiloderma

Hereditary sclerosing poikiloderma is a rare, familial disease with the primary clinical features being dermatologic. Widespread poikiloderma, as well as linear hyperkeratotic and sclerotic bands, tends to be the most common sign of this disease. It has been suggested that cardiac involvement may represent an important element of this disorder; however, this has not been well studied. We confirm here a case of hereditary sclerosing poikiloderma in a patient and his family with significant cardiac involvement characterized by heavily calcified stenotic aortic and mitral valves on echocardiography. Due to the patient's symptomatic severe valvular disease, he underwent simultaneous aortic and mitral valve replacement. Histopathologic analysis of the valves confirmed severe calcification of the aortic and mitral valve leaflets, suggesting a potential common mechanism between the cardiac and skin pathology of this disease. Multiple other family members had presented with similar cardiac and skin manifestations. Further research is needed to better understand the cardiac pathophysiology of this disease.

An interactive web-based module to teach physician assistants about venous thromboembolism

OBJECTIVE

Questions about venous thromboembolism (VTE) management result in a high number of cardiovascular consults at one large teaching hospital. However, many of these consults are deemed "inappropriate" by the receiving consultants. This combination presented an opportunity to examine the efficacy of interprofessional education through an interactive web-based module to teach physician assistants (PAs) about VTE management.

METHODS AND RESULTS

A web-based module and survey with interactive cases encompassing key VTE management decisions was distributed to 41 inpatient oncology PAs. Usability, satisfaction, and efficacy were evaluated using knowledge and Likert-scale items. Participating PAs improved their VTE knowledge with a pre-module assessment score of 31.7% correct and post-module score of 63.3% (P = 0.0016).There was an increase in self-reported comfort for managing VTE (mean 3.92 vs. 3.07; P= 0.004) and calling cardiovascular consults (4.08 vs. 2.50; P < 0.0001). The PAs would highly recommend the module and use it in their practice with 76.9% of them ranking it as their most preferred learning method.

CONCLUSION

A brief, interactive web-based module increased knowledge and comfort level with VTE management among PAs. This module design can serve as a template for a wide range of cardiovascular learning tools.

Nonantithrombotic medical options in acute coronary syndromes: old agents and new lines on the horizon

Acute coronary syndromes (ACS) constitute a spectrum of clinical presentations ranging from unstable angina and non-ST-segment elevation myocardial infarction to ST-segment myocardial infarction. Myocardial ischemia in this context occurs as a result of an abrupt decrease in coronary blood flow and resultant imbalance in the myocardial oxygen supply-demand relationship. Coronary blood flow is further compromised by other mechanisms that increase coronary vascular resistance or reduce coronary driving pressure. The goals of treatment are to decrease myocardial oxygen demand, increase coronary blood flow and oxygen supply, and limit myocardial injury. Treatments are generally divided into disease-modifying agents or interventions that improve hard clinical outcomes and other strategies that can reduce ischemia. In addition to traditional drugs such as β-blockers and inhibitors of the renin-angiotensin-aldosterone system, newer agents have expanded the number of molecular pathways targeted for treatment of ACS. Ranolazine, trimetazidine, nicorandil, and ivabradine are medications that have been shown to reduce myocardial ischemia through diverse mechanisms and have been tested in limited fashion in patients with ACS. Attenuating the no-reflow phenomenon and reducing the injury compounded by acute reperfusion after a period of coronary occlusion are active areas of research. Additionally, interventions aimed at ischemic pre- and postconditioning may be useful means by which to limit myocardial infarct size. Trials are also underway to examine altered metabolic and oxygen-related pathways in ACS. This review will discuss traditional and newer anti-ischemic therapies for patients with ACS, exclusive of revascularization, antithrombotic agents, and the use of high-intensity statins.

Murine CENPF interacts with syntaxin 4 in the regulation of vesicular transport

Syntaxin 4 is a component of the SNARE complex that regulates membrane docking and fusion. Using a yeast two-hybrid screen, we identify a novel interaction between syntaxin 4 and cytoplasmic murine CENPF, a protein previously demonstrated to associate with the microtubule network and SNAP-25. The binding domain for syntaxin 4 in CENPF was defined by yeast two-hybrid assay and co-immunoprecipitation. Confocal analyses in cell culture reveal a high degree of colocalization between endogenously expressed proteins in interphase cells. Additionally, the endogenous SNARE proteins can be isolated as a complex with CENPF in immunoprecipitation experiments. Further analyses demonstrate that murine CENPF and syntaxin 4 colocalize with components of plasma membrane recycling: SNAP-25 and VAMP2. Depletion of endogenous CENPF disrupts GLUT4 trafficking whereas expression of a dominant-negative form of CENPF inhibits cell coupling. Taken together, these studies demonstrate that CENPF provides a direct link between proteins of the SNARE system and the microtubule network and indicate a diverse role for murine CENPF in vesicular transport.

CytLEK1 is a regulator of plasma membrane recycling through its interaction with SNAP-25

SNAP-25 is a component of the SNARE complex that is involved in membrane docking and fusion. Using a yeast two-hybrid screen, we identify a novel interaction between SNAP-25 and cytoplasmic Lek1 (cytLEK1), a protein previously demonstrated to associate with the microtubule network. The binding domains within each protein were defined by yeast two-hybrid, coimmunoprecipitation, and colocalization studies. Confocal analyses reveal a high degree of colocalization between the proteins. In addition, the endogenous proteins can be isolated as a complex by immunoprecipitation. Further analyses demonstrate that cytLEK1 and SNAP-25 colocalize and coprecipitate with Rab11a, myosin Vb, VAMP2, and syntaxin 4, components of the plasma membrane recycling pathway. Overexpression of the SNAP-25-binding domain of cytLEK1, and depletion of endogenous Lek1 alters transferrin trafficking, consistent with a function in vesicle recycling. Taken together, our studies indicate that cytLEK1 is a link between recycling vesicles and the microtubule network through its association with SNAP-25. This interaction may play a key role in the regulation of the recycling endosome pathway.

Cytoplasmic LEK1 is a regulator of microtubule function through its interaction with the LIS1 pathway

LIS1 and nuclear distribution gene E (NudE) are partner proteins in a conserved pathway regulating the function of dynein and microtubules. Here, we present data that cytoplasmic LEK1 (cytLEK1), a large protein containing a spectrin repeat and multiple leucine zippers, is a component of this pathway through its direct interaction with NudE, as determined by a yeast two-hybrid screen. We identified the binding domains in each molecule, and coimmunoprecipitation and colocalization studies confirmed the specificity of the interaction between cytLEK1 and NudE. Confocal deconvolution analysis revealed that cytLEK1 exhibits colocalization with endogenous NudE and with the known NudE binding partners, LIS1 and dynein. By localizing the NudE-binding domain of cytLEK1 to a small domain within the molecule, we were able to disrupt cytLEK1 function by using a dominant negative approach in addition to LEK1 knockdown and, thus, examine the role of the cytLEK1-NudE interaction in cells. Consistent with a defect in the LIS1 pathway, disruption of cytLEK1 function resulted in alteration of microtubule organization and cellular shape. The microtubule network of cells became tightly focused around the nucleus and resulted in a rounded cell shape. Additionally, cells exhibited a severe inability to repolymerize their microtubule networks after nocodazole challenge. Taken together, our studies revealed that cytLEK1 is essential for cellular functions regulated by the LIS1 pathway.

Ultrafast primary processes in photosystem I of the cyanobacterium Synechocystis sp. PCC 6803

Ultrafast primary processes in the trimeric photosystem I core antenna-reaction center complex of the cyanobacterium Synechocystis sp. PCC 6803 have been examined in pump-probe experiments with approximately 100 fs resolution. A global analysis of two-color profiles, excited at 660 nm and probed at 5 nm intervals from 650 to 730 nm, reveals 430 fs kinetics for spectral equilibration among bulk antenna chlorophylls. At least two lifetime components (2.0 and 6.5 ps in our analysis) are required to describe equilibration of bulk chlorophylls with far red-absorbing chlorophylls (>700 nm). Trapping at P700 occurs with 24-ps kinetics. The multiphasic bulk left arrow over right arrow red equilibration kinetics are intriguing, because prior steady-state spectral studies have suggested that the core antenna in Synechocystis sp. contains only one red-absorbing chlorophyll species (C708). The disperse kinetics may arise from inhomogeneous broadening in C708. The one-color optical anisotropy at 680 nm (near the red edge of the bulk antenna) decays with 590 fs kinetics; the corresponding anisotropy at 710 nm shows approximately 3.1 ps kinetics. The latter may signal equilibration among symmetry-equivalent red chlorophylls, bound to different monomers within trimeric photosystem I.

Electronic spectra of PS I mutants: the peripheral subunits do not bind red chlorophylls in Synechocystis sp. PCC 6803

Steady-state fluorescence and absorption spectra have been obtained in the Qy spectral region (690-780 nm and 600-750 nm, respectively) for several subunit-deficient photosystem I mutants from the cyanobacterium Synechocystis sp. PCC 6803. The 77 K fluorescence spectra of the wild-type and subunit-deficient mutant photosystem I particles are all very similar, peaking at approximately 720 nm with essentially the same excitation spectrum. Because emission from far-red chlorophylls absorbing near 708 nm dominates low-temperature fluorescence in Synechocystis sp., these pigments are not coordinated to any the subunits PsaF, Psa I, PsaJ, PsaK, PsaL, or psaM. The room temperature (wild-type-mutant) absorption difference spectra for trimeric mutants lacking the PsaF/J, PsaK, and PsaM subunits suggest that these mutants are deficient in core antenna chlorophylls (Chls) absorbing near 685, 670, 675, and 700 nm, respectively. The absorption difference spectrum for the PsaF/J/I/L-deficient photosystem I complexes at 5 K reveals considerably more structure than the room-temperature spectrum. The integrated absorbance difference spectra (when normalized to the total PS I Qy spectral area) are comparable to the fractions of Chls bound by the respective (groups of) subunits, according to the 4-A density map of PS I from Synechococcus elongatus. The spectrum of the monomeric PsaL-deficient mutant suggests that this subunit may bind pigments absorbing near 700 nm.