The population health performance of medical students at two medical schools

Public Health and medicine are complimentary disciplines dedicated to the health and well-being of humankind. Worldwide, medical school accreditation bodies require the inclusion of population health in medical education. In 2003, the Institutes of Medicine (IOM) recommended that all medical students receive basic public health training in population-based prevention. The purpose of this study was to (1) examine the public health clinical performance of third-year medical students at two independent medical schools, (2) compare the public health clinical practice performance of the schools, and (3) identify underlying predictors of high and low public health clinical performance at one of the medical schools. ^ This study is unique in its analysis and report of observed medical student public health clinical practices. The cohort consisted of 751 third-year medical students who completed a required clinical performance exam using trained standardized patients. Medical student performance scores on 24 consensus public health items derived from nine patient cases were analyzed.^ The analysis showed nearly identical results for both medical schools at the 60%, 65%, and 70% pass rate. Students performed poorly on items associated with prevention, behavioral science, and surveillance. Factors associated with high student performance included being from an underrepresented minority, matching to a primary care residency, and high class ranking. A review of medical school curriculum at both schools revealed a lack of training in four public health domains. Nationally, 32% of medical students reported inadequate training in public health in the year 2006.^ These findings suggest more dedicated teaching time for public health domains is needed at the medical schools represented in this study. Finally, more research is needed to assess attainment of public health knowledge and skills for medical students nationwide if we are to meet the recommendations of the IOM. ^

Are Today’s Medical School Graduates Performing the Same Number of Medical Procedures Compared to Graduates Ten Years Ago? A case for Simulation?

INTRODUCTION: Medical schools are charged with providing both a strong basic science and clinical curriculum for their students. In most institutions instruction in performing the core clinical procedures is part of the curriculum, but because of many constraints do medical students practice these procedures as many times as medical students in the past? Several studies have concluded that medical students today feel incompetent to perform basic clinical procedures at the time of graduation. [See PDF for complete abstract]

Educational Technology-Benefits and Barriers

Statement of Problem: The second background paper for the Medical School Objective Project (MSOP), defined Educational Technology (ET) as the use of information technology to facilitate student’s learning.1 Medical schools as a group have made limited progress in accomplishing the recommended educational technology goals and there had been much greater use of such technology in basic sciences courses than in clinical clerkships. We will explore the positive and negative implications of incorporating ET into the educational experience of TMC schools. [See PDF for complete abstract]

Waking Up to Sleep Medicine Education

Background: Sleep disorders are an important cause of morbidity among our population with billions of dollars spent on direct and indirect costs attributed to sleep disorders. In spite of raising prevalence and morbidity, surveys have shown inadequate education in sleep medicine at all levels at medical school. According to national sleep disorders research plan data, in 1990 about 37 % of medical schools did not offer any sleep education and of the schools which offered it, the average time devoted to sleep medicine was about 2 hours. Sleep disorders have found to be uniformly under diagnosed in primary care settings. [See PDF for complete abstract]

Operationalizing Professionalism: A Course in Ethical Decision Making

All U.S. medical schools require some medical ethics education and must now ensure that their graduates, residents, and faculty exhibit competence in the area of professionalism and professional medical ethics. However, there remain many challenges to implementing formal ethics and professionalism education into medical school curricula. [See PDF for complete abstract]

Women physicians' specialty choices

Three hypotheses have been offered to explain the historical specialty selection by women physicians. They are: (1) women choose the specialty for which the training requirements and working conditions interfere least with their commitments to marriage and children; (2) women tend to select the more "feminine" specialties such as pediatrics and psychiatry, and to avoid the "masculine" fields such as surgery; and (3) women have been deliberately excluded from male-dominated fields such as surgery. While the above hypotheses may be true to a greater or lesser degree, none of them has been adequately tested.^ The major study hypotheses are as follows: (1) female physicians' choice of specialty is influenced by the following reasons: (a) family responsibilities; (b) sex role expectations; and (c) sex discrimination; (2) female physicians' choice of specialty is also influenced by their age and ethnicity; and (3) the primary reasons for choosing a given specialty vary by type of specialty.^ The reasons for specialty selection will be explored based on a survey of women graduates of one of the oldest medical schools in the United States, The University of Texas Medical Branch (UTMB) in Galveston, Texas (n = 930). The survey response rate was 75.3% (700 respondents).^ The results for the first study hypothesis showed that fewer than 14% of the respondents agreed that sex role expectations, sex discrimination and family responsibilities played a role in their choice of specialty. Fifty nine percent of the respondents disagreed with the idea that sex role expectations influenced specialty selection and 64% disagreed that family responsibilities had an effect on the selection of their specialty. Around half (49%) were uncertain of the influence of sex discrimination. It was concluded that sex discrimination, sex role expectations and family responsibilities did not have a major impact on specialty selection.^ With respect to the second hypothesis, age was significant in Internal Medicine, Obstetrics/Gynecology and Psychiatry. Women physicians in Internal Medicine and Obstetrics/Gynecology were significantly younger (less than 45 years old) while physicians in Psychiatry were significantly older (45 years or older) than other specialties studied.^ The third hypothesis was confirmed: the reasons for choosing a given specialty varied by specialty.^ Respondents' comments written on the survey provided insight into other possible reasons for specialty selection including exploration of the role of mentoring and job satisfaction.^ The retrospective cross-sectional study design used in this study does not adequately capture the fact that different reasons may be given for the choice of specialty at different points in time, e.g., as the time of choosing a residency program versus several years into the future.^ In conclusion, approaches that explore the range of reasons that women elect to enter and stay within a given specialty must be explored to gain richer understanding of the complex and dynamic nature of women physicians' professional lives. (Abstract shortened by UMI.) ^

Evaluation of Knowledge Regarding Diagnostic Strategies for Genetic Diseases in Select Residents

Genetics education for physicians has been a popular publication topic in the United States and in Europe for over 20 years. Decreasing numbers of medical genetics professionals and an increasing volume of genetic information has created a dire need for increased genetics training in medical school and in clinical practice. This study aimed to assess how well pediatrics-focused primary care physicians apply their general genetics knowledge to clinical genetic testing using scenario-based questions. We chose to specifically focus on knowledge of the diagnostic applicability of Chromosomal Microarray (CMA) technology in pediatrics because of its recent recommendation by the International Standard Cytogenomic Array (ISCA) Consortium as a first-tier genetic test for individuals with developmental disabilities and/or congenital anomalies. Proficiency in ordering baseline genetic testing was evaluated for eighty-one respondents from four pediatrics-focused residencies (categorical pediatrics, pediatric neurology, internal medicine/pediatrics, and family practice) at two large residency programs in Houston, Texas. Similar to other studies, we found an overall deficit of genetic testing knowledge, especially among family practice residents. Interestingly, residents who elected to complete a genetics rotation in medical school scored significantly better than expected, as well as better than residents who did not elect to complete a genetics rotation. We suspect that the insufficient knowledge among physicians regarding a baseline genetics work-up is leading to redundant (i.e. concurrent karyotype and CMA) and incorrect (i.e. ordering CMA to detect achondroplasia) genetic testing and is contributing to rising health care costs in the United States. Our results provide specific teaching points upon which medical schools can focus education about clinical genetic testing and suggest that increased collaboration between primary care physicians and genetics professionals could benefit patient health care overall.

Characterization and optimization of antigen-specific T cell responses during ex vivo expansion of melanoma tumor-infiltrating lymphocytes

Treatment of metastatic melanoma with tumor reactive T cells (adoptive T cell therapy, ACT) is a promising approach associated with a high clinical response rate. However, further optimization of this treatment modality is required to increase the clinical response after this therapy. ACT in melanoma involves an initial phase (pre-REP) of tumor-infiltrating lymphocyte (TIL) expansion ex vivo from tumor isolates followed by a second phase, “rapid expansion protocol” (REP) generating the billions of cells used as the TIL infusion product. The main question addressed in this thesis was how the currently used REP affected the responsiveness of the CD8+ T cells to defined melanoma antigens. We hypothesized that the REP drives the TIL to further differentiate and become hyporesponsive to antigen restimulation, therefore, proper cytokine treatment or other ways to expand TIL is required to improve upon this outcome. We evaluated the response of CD8+ TIL to melanoma antigen restimulation using MART-1 peptide-pulsed mature DC in vitro. Post-REP TILs were mostly hypo-responsive with poor proliferation and higher apoptosis. Phenotypic analysis revealed that the expression of CD28 was significantly reduced in post-REP TILs. By sorting experiment and microarray analysis, we confirmed that the few CD28+ post-REP TILs had superior survival capacity and proliferated after restimulation. We then went on to investigate methods to maintain CD28 expression during the REP and improve TIL responsiveness. Firstly, IL-15 and IL-21 were found to synergize in maintaining TIL CD28 expression and antigenic responsiveness during REP. Secondly, we found IL-15 was superior as compared to IL-2 in supporting the long-term expansion of antigen-specific CD8+ TIL after restimulation. These results suggest that current expansion protocols used for adoptive T-cell therapy in melanoma yield largely hyporesponsive products containing CD8+ T cells unable to respond in vivo to re-stimulation with antigen. A modification of our current approaches by using IL-15+IL-21 as supporting cytokines in the REP, or/and administration of IL-15 instead of IL-2 after TIL infusion, may enhance the anti-tumor efficacy and long-term persistence of infused T cells in vivo.

Repeat length and RNA expression level are not primary determinants in CUG expansion toxicity in Drosophila models.

Evidence for an RNA gain-of-function toxicity has now been provided for an increasing number of human pathologies. Myotonic dystrophies (DM) belong to a class of RNA-dominant diseases that result from RNA repeat expansion toxicity. Specifically, DM of type 1 (DM1), is caused by an expansion of CUG repeats in the 3'UTR of the DMPK protein kinase mRNA, while DM of type 2 (DM2) is linked to an expansion of CCUG repeats in an intron of the ZNF9 transcript (ZNF9 encodes a zinc finger protein). In both pathologies the mutant RNA forms nuclear foci. The mechanisms that underlie the RNA pathogenicity seem to be rather complex and not yet completely understood. Here, we describe Drosophila models that might help unravelling the molecular mechanisms of DM1-associated CUG expansion toxicity. We generated transgenic flies that express inducible repeats of different type (CUG or CAG) and length (16, 240, 480 repeats) and then analyzed transgene localization, RNA expression and toxicity as assessed by induced lethality and eye neurodegeneration. The only line that expressed a toxic RNA has a (CTG)(240) insertion. Moreover our analysis shows that its level of expression cannot account for its toxicity. In this line, (CTG)(240.4), the expansion inserted in the first intron of CG9650, a zinc finger protein encoding gene. Interestingly, CG9650 and (CUG)(240.4) expansion RNAs were found in the same nuclear foci. In conclusion, we suggest that the insertion context is the primary determinant for expansion toxicity in Drosophila models. This finding should contribute to the still open debate on the role of the expansions per se in Drosophila and in human pathogenesis of RNA-dominant diseases.

Commentary: Dedication of Additional Resources to Evaluation and Low-Income Schools is Critical to Increasing Levels of Safe Walking and Bicycling to School

A commentary on Mendoza et al.'s article entitled, "Ethnic Minority Children’s Active Commuting to School and Association with Physical Activity and Pedestrian Safety Behaviors."

Empowering Medical Professionals to Help Victims of Trafficking

Purpose: to provide commentary of two review articles that discuss the role of medical professionals in combating human trafficking: “Health Care Providers' Training Needs Related to Human Trafficking: Maximizing the Opportunity to Effectively Screen and Intervene” by Isaac, Solak, and Giardino, and “Human Trafficking: What is the Role of the Health Care Provider?” by Crane and Moreno. Findings: Both articles provide a good introduction and explanation of the psychosocial and medical issues faced by many trafficking victims; however, they succeed only to varying degrees in describing all the gaps in the medical system and the vital next steps forward. Conclusion: The key next steps in the fight against human trafficking include: multidisciplinary teams need to improve coordination on all forms of human maltreatment; schools for all medical professions and social work need to significantly strengthen their curriculum on diagnosing and treating human maltreatment; and groups that provide training on human trafficking should partner with other agencies and organizations that provide training on child maltreatment and domestic violence.

Dispelling the Myth: What Parents Really Think about Sex Education in Schools

Background: School-based sex education is effective in reducing risky sexual behavior among adolescents that may lead to unintended pregnancies and sexually transmitted infections. However, most sex education policies in the US do not support evidence-based programs. Understanding parental attitudes around sex education is crucial to overcoming perceived barriers to implementing school-based sex education. Little research has been published on the opinions of parents in Texas, which accounts for 12% of the nation’s teen births. Purpose: The purpose of this study was to examine whether Texas parents favor teaching sex education in schools, in what grades they think sex education should be taught, what content they think should be taught, and who they think should make decisions regarding sex education. Methods: We commissioned a telephone survey of parents of children 18 years or younger in Harris County, Texas. Survey questions assessed demographic characteristics and opinions about sex education. We used chi-square tests to examine differences across sociodemographic characteristics. Results: 1,201 parents completed the survey. The majority of parents (80%) responded that sex education should begin in middle school or earlier, and two-thirds said that it should include information about condoms and contraception. Hispanic parents showed the highest support for teaching sex education and providing medically accurate information on condoms and contraception in middle school or earlier. Conclusion: Parents in Harris County overwhelmingly support sex education that includes medically accurate information about condoms and contraception beginning before high school. These data provide evidence to change sex education policies to better reflect parental opinions.

Choosing and Maintaining Programs for Sex Education in Schools: The CHAMPSS Model

Background: Despite effective solutions to reduce teen birth rates, Texas teen birth rates are among the highest in the nation. School districts can impact youth sexual behavior through implementation of evidence-based programs (EBPs); however, teen pregnancy prevention is a complex and controversial issue for school districts. Subsequently, very few districts in Texas implement EBPs for pregnancy prevention. Additionally, school districts receive little guidance on the process for finding, adopting, and implementing EBPs. Purpose: The purpose of this report is to present the CHoosing And Maintaining Programs for Sex education in Schools (CHAMPSS) Model, a practical and realistic framework to help districts find, adopt, and implement EBPs. Methods: Model development occurred in four phases using the core processes of Intervention Mapping: 1) knowledge acquisition, 2) knowledge engineering, 3) model representation, and 4) knowledge development. Results: The CHAMPSS Model provides seven steps, tailored for school-based settings, which encompass phases of assessment, preparation, implementation, and maintenance: Prioritize, Asses, Select, Approve, Prepare, Implement, and Maintain. Advocacy and eliciting support for adolescent sexual health are also core elements of the model. Conclusion: This systematic framework may help schools increase adoption, implementation, and maintenance for EBPs.

Rediscovering the Evidence: Parental Support for Sex Education in Schools

Invited commentary on Dispelling the Myth: What Parents Really Think about Sex Education in Schools

A Coordinated and Systematic Model for Adopting, Implementing and Maintaining Effective Sexual Health Education Programs in Schools

Getting evidence-based sexual health education activities into schools can be a complicated process. Working models that assist our educational system in the selection, implementation, and maintenance of effective school-based adolescent health programs are needed. Replicating sexual health programs in school-based settings: A model for schools provides a comprehensive and applied approach that engages all of the important stakeholders within a school district. The results from this study hold much potential to inform Texas and the nation about how a coordinated and practical model can assist school districts to increase the use of evidence-based programs addressing teen pregnancy prevention and sexual health issues.