Alex Stagnaro-Green

Thyroid disorders in pregnancy

The thyroid gland is substantially challenged during pregnancy. Total T3 and T4 levels increase by 50% during pregnancy owing to a 50% increase in thyroxine-binding globulin levels. Serum TSH levels decrease in the first trimester and increase in the second and third trimesters; however, not to prepregnancy levels. Hypothyroidism is present in up to 3% of all pregnant women. Subclinical hypothyroidism during pregnancy is associated with an increased rate of miscarriage and preterm delivery, and a decrease in the IQ of the child. Overt hyperthyroidism is present in less than 1% of pregnant women but is linked to increased rates of miscarriage, preterm delivery and maternal congestive heart failure. In women who are euthyroid, thyroid autoantibodies are associated with an increased risk of spontaneous miscarriage and preterm delivery. Postpartum thyroiditis occurs in 5.4% of all women following pregnancy; moreover, 50% of women who are euthyroid in the first trimester of pregnancy but test positive for thyroid autoantibodies will develop postpartum thyroiditis. The need for the essential nutrient iodine increases during pregnancy and in women who are breastfeeding, and the effect of treatment of mild iodine deficiency on maternal and fetal outcomes is consequently being evaluated in a prospective study. The debate regarding the pros and cons of universal screening for thyroid disease during pregnancy is ongoing.

Iodine Supplementation During Pregnancy and Lactation

DIETARY IODINE INTAKE IS OBLIGATORY FOR THE PROduction of thyroid hormones. Despite substantial public health advances over the past 3 decades, iodine deficiency currently affects 1.92 billion people globally. Dietary iodine requirements are increased during pregnancy due to increased thyroid hormone production, increased renal iodine losses, and fetal iodine requirements. Dietary requirements remain increased in lactation due to the concentration of iodine in breast milk. Adverse effects of iodine deficiency in pregnancy, when the deficiency leads to severe decreases in maternal thyroxine (T4), include maternal and fetal goiter, cretinism, intellectual impairments, neonatal hypothyroidism, and increased pregnancy loss and infant mortality. Decreases in maternal T4 associated with even mild iodine deficiency may have adverse effects on the cognitive function of offspring, and iodine deficiency remains the leading cause of preventable intellectual disability worldwide.

Use of flawed multiple-choice items by the New England Journal of Medicine for continuing medical education

Physicians in the United States are required to complete a minimum number of continuing medical education (CME) credits annually. The goal of CME is to ensure that physicians maintain their knowledge and skills throughout their medical career. The New England Journal of Medicine (NEJM) provides its readers with the opportunity to obtain weekly CME credits. Deviation from established item-writing principles may result in a decrease in validity evidence for tests. This study evaluated the quality of 40 NEJM MCQs using the standard evidence-based principles of effective item writing. Each multiple-choice item reviewed had at least three item flaws, with a mean of 5.1 and a range of 3 to 7. The results of this study demonstrate that the NEJM uses flawed MCQs in its weekly CME program.

Personal viewApplying adult learning principles to medical education in the United States

An extensive literature on adult learning principles has been developed over the last 40 years. Simultaneously, undergraduate medical educational programs have undergone varying degrees of curricular reform. The present paper discusses the educational and societal factors that have functioned as a catalyst for innovations in medical education, and reviews the major initiatives which have been undertaken. Data are analyzed to assess the extent to which some of these changes have been incorporated into medical curricula. A comprehensive review of adult learning principles is than presented, in order to provide a framework for the incorporation of principles of adult learning into the next wave of medical education reform. The review of adult learning principles reveals that undergraduate medical educational reform has underutilized the robust literature on adult learning. The present paper concludes with suggestions for medical education reform that incorporates the principles of adult learning and discusses the major impediment to curricular reform.

Maternal subclinical hypothyroidsm and gestational diabetes mellitus: A meta-analysis

OBJECTIVE The association between subclinical hypothyroidism (SCH) and gestational diabetes mellitus (GDM) is controversial. This review evaluates whether the risk of GDM is different in pregnant women with SCH compared to euthyroid pregnant women. METHODS A computerized search of the MEDLINE and EMBASE databases was conducted from their inceptions to July 2013 and was complemented with the perusal of the reference sections of the retrieved articles. Prespecified criteria were applied to assess eligibility, and standard meta-analytic methodology was employed for evidence synthesis. RESULTS Six cohort studies, reporting data on 35,350 pregnant women (1,216 women with SCH), were identified. The risk of GDM in pregnant women with SCH was found to be substantially higher compared to euthyroid pregnant women (5 studies, pooled unadjusted odds ratio [OR]: 1.35, 95% confidence interval [CI]: 1.05-1.75, I2: 41%, Harbord test P = .44). Similarly, the risk of GDM was estimated to be significantly higher in pregnant women with SCH when using adjusted estimates (3 studies, pooled adjusted OR: 1.39, 95% CI: 1.07-1.79, I2: 0%). Neither finding remained significant in sensitivity analyses. CONCLUSION A modestly increased risk of GDM might be present in pregnant women with SCH compared to euthyroid pregnant women. Assuming a 5% baseline risk of GDM and that SCH increases the risk of GDM by 50% (in odds) compared to a euthyroid population, then there would be 1 extra case of GDM in every 43 pregnant women with SCH. This preliminary finding warrants further investigation.

Implementing an Entrustable Professional Activities Framework in Undergraduate Medical Education: Early Lessons From the Aamc Core Entrustable Professional Activities for Entering Residency Pilot

In 2014, the Association of American Medical Colleges (AAMC) published a list of 13 Core Entrustable Professional Activities for Entering Residency (Core EPAs) that medical school graduates might be expected to perform, without direct supervision, on the first day of residency. Soon after, the AAMC commissioned a five-year pilot with 10 medical schools across the United States, seeking to implement the Core EPA framework to improve the transition from undergraduate to graduate medical education. In this article, the pilot team presents the organizational structure and early results of collaborative efforts to provide guidance to other institutions planning to implement the Core EPA framework. They describe the aims, timeline, and organization of the pilot as well as findings to date regarding the concepts of entrustment, assessment, curriculum development, and faculty development. On the basis of their experiences over the first two years of the pilot, the authors offer a set of guiding principles for institutions intending to implement the Core EPA framework. They also discuss the impact of the pilot, its limitations, and next steps, as well as how the pilot team is engaging the broader medical education community. They encourage ongoing communication across institutions to capitalize on the expertise of educators to tackle challenges related to the implementation of this novel approach and to generate common national standards for entrustment. The Core EPA pilot aims to better prepare medical school graduates for their professional duties at the beginning of residency with the ultimate goal of improving patient care.

Chief residents as educators: An effective method of resident development

Background: The importance of teaching residents how to instruct medical students is recognized, but time and logistics challenge the implementation of teaching skills programs. No study has described a dissemination model with chief residents as trainers and managers of a teaching skills program. Description: All chief residents in three departments (n = 16), participated in an 8-hr train-the-trainer teaching skills program and then trained 178 residents through seven 1-hr sessions. Outcome was measured through student surveys using a validated instrument with seven teaching domains and overall assessment of teaching effectiveness. Evaluation: Survey results revealed a significant improvement in the vast majority of teaching domains 9 months after implementation of the program in all three departments. Student perceptions of overall teaching effectiveness improved in two departments and trended upwards in the third. Conclusion: A resident teaching skills program utilizing chief residents as trainers resulted in improved 3rd-year medical student ratings of resident teaching.

Clinical aspects of hyperthyroidism, hypothyroidism, and thyroid screening in pregnancy.

OBJECTIVE To evaluate the peer-reviewed literature on hypothyroidism, hyperthyroidism, and thyroid autoimmunity in pregnancy. METHODS We review published studies on thyroid autoimmunity and dysfunction in pregnancy, the impact of thyroid disease on pregnancy, and discuss implications for screening. RESULTS Overt hyperthyroidism and hypothyroidism are responsible for adverse obstetric and neonatal events. Several studies of association suggest that either subclinical hypothyroidism or thyroid autoimmunity increase the risk of complications. One randomized controlled trial showed that pregnant women with subclinical hypothyroidism benefit from treatment in terms of obstetric and neonatal complications, whereas another study demonstrated no benefit in the intelligence quotient of babies born to women with subclinical hypothyroidism. Thyroid autoimmunity has been associated with increased rate of pregnancy loss, recurrent miscarriage, and preterm delivery. CONCLUSION Current guidelines agree that overt hyperthyroidism and hypothyroidism need to be promptly treated and that as potential benefits outweigh potential harm, subclinical hypothyroidism also requires substitutive treatment. The chance that women with thyroid autoimmunity may benefit from levothyroxine treatment to improve obstetric outcome is intriguing, but adequately powered randomized controlled trials are needed. The issue of universal thyroid screening at the beginning of pregnancy is still a matter of debate, and aggressive case-finding is supported.

The Mount Sinai humanities and medicine program: an alternative pathway to medical school.

In 1984 the AAMC report of the Panel on the General Professional Education of the Physician recommended that students preparing for medical school should strive for a curriculum that provides a broad study in both the sciences and the humanities and that required courses should be kept to a minimum. One way to encourage premedical students to follow a truly broad liberal arts education would be to accept students to medical school early in their college careers, thereby alleviating the pressure to focus excessively on the traditional science-based curriculum. Because there is no evidence to suggest that science majors are necessarily more qualified for medical school, we initiated an experimental program that encouraged humanities and social science majors to pursue their individual interests in college and to obtain a broad, maturing, liberal arts education. Such students might be expected to be less focused on the technology of medicine, bring different perspectives to the practice of medicine, and simultaneously diversify the student body. In 1989 the Mount Sinai School of Medicine (MSSM) started the Humanities and Medicine (H&M) Program, an early-assurance-of-admission program designed for humanities and social science majors at a targeted group of five liberal arts colleges and universities (Amherst, Brandeis, Princeton, Wesleyan, and Williams). Students in this program are selected during the first semester of their sophomore year in college. Admission into the program is based on a written application with personal essays, verbal and math SAT scores, high school and college transcripts, letters of recommendation, and personal interviews. The students are required to major in the humanities or social sciences and are required to complete only one year of college biology and one year of college chemistry with a grade of B or better. Admission to MSSM is contingent upon successful completion of undergraduate studies, provided the GPA does not drop below a minimum of 3.0. MCAT scores are not required. In addition, students are required to spend an eight-week summer term at Mount Sinai after their junior year, during which they are exposed to clinical activities and complete a much abbreviated course on the principles of organic chemistry and physics relevant to medicine. Housing and a stipend are provided. Students admitted to the H&M program are under no obligation to attend Mount Sinai should their career choices change or another medical school appear more attractive. Also, the students have the option of deferring their admission to medical school for one year after obtaining the undergraduate degree. This study reports the outcomes of ten years’ experience with the H&M Program. Our experience shows that although students in this program have more academic difficulties in the preclinical years, they excel in the clinical/community setting and have greatly enriched the medical school environment. This program demonstrates that success in medical school does not depend on a traditional premed science curriculum.

The dean's letter summary statement: valuing scholarship, leadership, and academic achievement.

The dean’s letter is a statement of evaluation constituting a critical component of medical students’ applications for residency positions. In 1989, the Association of American Medical Colleges (AAMC) proposed guidelines for the dean’s letter in an effort to standardize its content. Among the guidelines presented, use of ‘‘comparative performance data’’ was recommended to allow residency admission committees to estimate a candidate’s performance in comparison with those of his or her peers. Within the summary section of the dean’s letter, many institutions have adopted the use of a summary statement, otherwise known as a final descriptor, key word, or key phrase, as a means of providing this comparative information. The use of summary statements varies considerably. Studies have demonstrated that between 53% and 85% of U.S. medical schools report the use of summary statements. The different scales vary as well, with ‘‘good, very good, excellent, outstanding’’ being among the more common. Although readers of dean’s letters have valued this quantifiable method of comparing large numbers of applicants, the meanings of numerous summary statements are often unclear. One study showed, nevertheless, that students whose schools provided summary statements or other ‘‘comparative’’ performance data achieved higher rankings from the residency selection committee than did students from ‘‘non-comparative’’ schools. Despite their value, there is no literature examining the methods by which medical schools create such ranking scales. Prior to 1995, Mount Sinai School of Medicine (MSSM) assigned students’ summary statements based solely on third-year academic performances. The algorithm was modified in order to reflect more accurately those attributes and skills valued by the school: involvement in community service, demonstration of leadership, and publication of abstracts and papers. This study evaluated the impact of the new algorithm on the summary statement in the dean’s letter.