Amy R. Weinstein

The joint effects of physical activity and body mass index on coronary heart disease risk in women.

BACKGROUND Physical activity and body mass index (calculated as weight in kilograms divided by height in meters squared) independently alter the risk of coronary heart disease (CHD); however, their combined effect on CHD is not established. Our objective was to study the combined association of physical activity and body mass index on CHD. METHODS Prospective cohort study of 38,987 women free of cardiovascular disease, cancer, and diabetes at baseline in the Womens Health Study, with 10.9 mean years of follow-up. Weight, height, and recreational activities were reported on entry. Body mass index was categorized as normal weight (<25), overweight (25 to <30), and obese (> or =30). Active was defined as 1000 kilocalories or more expended on recreational activities weekly. Six joint body weight-physical activity categories were defined. The main outcome measure was the occurrence of incident CHD during follow-up, defined as a cardiovascular event including nonfatal myocardial infarction, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, or CHD death. RESULTS A total of 948 cases of incident CHD occurred during follow-up. Higher body mass index and physical inactivity were individual predictors of CHD. In joint analyses, compared with active normal-weight individuals, the multivariate-adjusted hazard ratios (95% confidence intervals) were 1.54 (1.14-2.08) for overweight-active; 1.87 (1.29-2.71) for obese-active; 1.08 (0.84-1.39) for normal weight-inactive; 1.88 (1.46-2.42) for overweight-inactive; and 2.53 (1.94-3.30) for obese-inactive. Increasing levels of walking also resulted in significant reductions in CHD risk for overweight and obese individuals. CONCLUSIONS The risk of CHD associated with elevated body mass index is considerably reduced by increased physical activity levels. However, the risk is not completely eliminated, reinforcing the importance of being lean and physically active.

The Relationship Between Obesity and Atherosclerotic Progression and Prognosis Among Patients With Coronary Artery Bypass Grafts: The Effect of Aggressive Statin Therapy

OBJECTIVES This study examines whether obesity accelerates atherogenic progression or adverse outcomes after coronary artery bypass graft (CABG) surgery. BACKGROUND Obesity is a major risk factor for developing coronary heart disease. Whether obesity accelerates disease progression after CABG is unclear. METHODS We examined how body mass index (BMI) related to atherosclerotic graft progression and a clinical composite outcome of death, nonfatal myocardial infarction, stroke, CABG surgery, or angioplasty among 1,314 participants in the Post CABG trial. Participants who had undergone CABG surgery were randomly assigned in a 2 x 2 factorial design to warfarin versus placebo and aggressive low-density lipoprotein cholesterol (LDL-C) lowering with lovastatin 40 to 80 mg/day (to achieve LDL-C of 60 to 85 mg/dl) versus moderate LDL-C lowering with lovastatin 2.5 to 5 mg/day (to achieve LDL-C of 130 to 140 mg/dl). Angiographic progression was assessed by coronary angiography at 4 to 5 years. RESULTS Higher BMI was associated with a higher likelihood of angiographic progression (p trend = 0.003) after adjustment for demographic factors, treatment assignment, smoking status, and years since CABG surgery, but not with clinical events (p trend = 0.81). In stratified analyses, higher BMI was associated with angiographic progression in the low-dose lovastatin group (p trend <0.001) but not in the high-dose group (p = 0.03 for test for interaction of BMI and statin treatment). In the high-dose lovastatin group, higher BMI appeared to be protective against clinical events (p trend = 0.06, test of interaction: 0.02). CONCLUSIONS Higher BMI is strongly associated with atherogenic progression after CABG surgery. Aggressive statin therapy may be protective against obesity-related acceleration of coronary heart disease.

Joint Effects of Physical Activity and Body Weight on Diabetes and Cardiovascular Disease

Recent studies have evaluated the interrelationship between physical activity and body weight on the incidence of chronic diseases such as diabetes and cardiovascular disease (CVD). The combined effect seems to be different and to be dependent on the disease mechanism. Studies reveal that body weight has a greater influence on diabetes, and physical activity plays a greater role in CVD.

Teaching medical students about obesity: a pilot program to address an unmet need through longitudinal relationships with bariatric surgery patients.

Background. Despite obesity’s relevance and impact, curricula addressing obesity are underrepresented in clinical medical education. A novel pilot program to begin teaching medical students about care of the obese patient was developed and student attitudes toward obesity and bariatric surgery were assessed. Methods.The authors paired third-year students with obese patients undergoing bariatric surgery. Students established a longitudinal patient relationship, received faculty mentorship, and kept a reflections journal. An attitude assessment survey was administered before and after third year. Reflections were analyzed for common themes. Results. Baseline student responses differed from those previously reported for practicing physicians on many survey statements, including more strongly agreeing with the relationship between obesity and serious medical conditions (P < .001), the need to educate patients about obesity risks (P < .001), and willingness to recommend bariatric surgery evaluation (P = .004). These differences were maintained after clinical clerkships. Reflection themes included recognition of obesity stereotypes, improved estimation of body mass index, and awareness of physicians’ attitudes about obesity. Conclusion. Development and assessment of a novel pilot program to teach third-year medical students about obesity and bariatric surgery suggests a potential impact on student attitudes and understanding of obesity and obesity surgery. Students today may have different attitudes toward obesity than those reflected in prior data for physicians in practice, and programs such as this may help maintain positive attitudes.

Relation of Heart Rate Response to Exercise With Prognosis and Atherosclerotic Progression After Coronary Artery Bypass Grafting

Impaired heart rate response to exercise is associated with adverse clinical outcomes in healthy adults and those with established coronary artery disease. It is unclear whether this association persists in subjects who have undergone coronary artery bypass grafting (CABG). In this study, 920 subjects enrolled in the Post CABG trial who had undergone CABG with patent saphenous vein grafts at baseline and known to have discontinued beta blockers before exercise were studied. A maximal symptom-limited exercise treadmill test was performed on study entry. Chronotropic variables were measured at peak exercise. Participants were followed for a composite end point of death, myocardial infarction, stroke, or revascularization. Quantitative coronary angiography was performed at follow-up and compared with baseline angiography, with prespecified angiographic end points of the substantial progression of graft disease and complete occlusion. In multivariate analysis, a low chronotropic index was strongly associated with an increased risk for the composite clinical end point (p for trend = 0.04) and angiographic complete occlusion (p for trend = 0.007) but only weakly associated with angiographic substantial progression (p for trend = 0.07). In conclusion, impaired chronotropic response to exercise identifies subjects at risk for clinical outcomes and graft occlusion, even after revascularization with CABG.

How we used a patient visit tracker tool to advance experiential learning in systems-based practice and quality improvement in a medical student clinic

Abstract Poorly designed healthcare systems increase costs and preventable medical errors. To address these issues, systems-based practice (SBP) education provides future physicians with the tools to identify systemic errors and implement quality improvement (QI) initiatives to enhance the delivery of cost-effective, safe and multi-disciplinary care. Although SBP education is being implemented in residency programs and is mandated by the Accreditation Council for Graduate Medical Education (ACGME) as one of its core competencies, it has largely not been integrated into undergraduate medical education. We propose that Medical Student–Faculty Collaborative Clinics (MSFCCs) may be the ideal environment in which to train medical students in SBPs and QI initiatives, as they allow students to play pivotal roles in project development, administration, and management. Here we describe a process of experiential learning that was developed within a newly established MSFCC, which challenged students to identify inefficiencies, implement interventions, and track the results. After identifying bottlenecks in clinic operations, our students designed a patient visit tracker tool to monitor clinic flow and implemented solutions to decrease patient visit times. Our model allowed students to drive their own active learning in a practical clinical setting, providing early and unique training in crucial QI skills.

Defining curricular priorities for student-as-teacher programs: A National Delphi Study

Abstract Background: “Student-as-Teacher” (SaT) programs have been growing in number to prepare medical students for their teaching roles in residency and beyond, but it remains unknown what content areas should be covered in SaT curricula. Aim: To determine five to ten “essential” content areas for inclusion in SaT curricula using expert opinion. Methods: Using a three-round Delphi process, moderators iteratively surveyed a panel of 28 medical educators (25 academy directors and three individuals identified as having expertise in undergraduate medical education) representing 25 medical schools in the United States. This “SaT Delphi Working Group” was tasked with rating topics for inclusion in SaT curricula on a 3-point scale (i.e. 1. “essential,” 2. “important, but not essential” 3. “not important”). Topics achieving ≥70% consensus as “essential,” “important” or “not important” were accepted by the moderators and removed from subsequent rounds. Results: Hundred per cent response rate (n = 28) was achieved for all survey rounds. Five content areas reached consensus as “essential” for inclusion in a SaT curriculum: feedback, bedside teaching and clinical precepting, small-group teaching, case-based teaching and professionalism as a medical educator. Conclusion: This consensus from a group of leaders in medical education is a first step toward the implementation of more developmentally-appropriate SaT competencies.

Integration of systematic clinical interprofessional training in a student-faculty collaborative primary care practice

ABSTRACT The changing healthcare environment and movement toward team-based care are contemporary challenges confronting health professional education. The primary care workforce must be prepared with recent national interprofessional competencies to practice and lead in this changing environment. From 2012 to 2014, the weekly Beth Israel Deaconess Crimson Care Collaborative Student-Faculty Practice collaborated with Northeastern University to develop, implement and evaluate an innovative model that incorporated interprofessional education into primary care practice with the goal of improving student understanding of, and ability to deliver quality, team-based care. In the monthly interprofessional clinic, an educational curriculum empowered students with evidence-based, team-based care principles. Integration of nursing, pharmacy, medicine, and masters of public health students and faculty into direct patient care, provided the opportunity to practice skills. The TeamSTEPPS® Teamwork Attitudes Questionnaire was administered pre- and post-intervention to assess its perceived impact. Seventeen students completed the post-intervention survey. Survey data indicated very positive attitudes towards team-based care at baseline. Significant improvements were reported in attitudes towards situation monitoring, limiting personal conflict, administration support and communication. However, small, but statistically significant declines were seen on one team structure and two communication items. Our program provides further evidence for the use of interprofessional training in primary care.

Assessing Interprofessional education in a student–faculty collaborative practice network

Abstract Although interprofessional relationships are ubiquitous in clinical practice, undergraduate medical students have limited opportunities to develop these relationships in the clinical setting. A few student–faculty collaborative practice networks (SFCPNs) have been working to address this issue, but limited data exist examining the nature and extent of these practices. A systematic survey at a Harvard-affiliated SFCPN is utilised to evaluate the quantity and quality of interprofessional interactions, isolate improvements, and identify challenges in undergraduate interprofessional education (IPE). Our data corroborate previous findings in which interprofessional clinical learning was shown to have positive effects on student development and align with all four domains of Interprofessional Education Collaborative core competencies, including interprofessional ethics and values, roles and responsibilities, interprofessional communication, and teams and teamwork. These results highlight the unique opportunity and growing necessity of integrating IPE in SFCPNs to endorse the development of collaborative and professional competencies in clinical modalities of patient care.

A Chronic Disease Management Student-Faculty Collaborative Practice: Educating Students on Innovation in Health Care Delivery.

PROBLEM In the current transformative health care landscape, it is imperative that clinician educators inspire future clinicians to practice primary care in a dynamic environment. A focus on patient-centered, goal-oriented care for patients with chronic conditions is critical. APPROACH In 2009, Harvard Medical School founded the Crimson Care Collaborative, a student-faculty collaborative practice (SFCP) network. With the aim of expanding clinical and educational opportunities for medical students and improving patient control of chronic disease (i.e., hypertension, obesity, and diabetes) in an innovative learning environment, in 2012, the authors developed a novel SFCP at their hospital-based academic primary care practice. In this SFCP, students learn to explore patient priorities, provide focused counseling and education, and assist patients with self-management goals during clinical visits. OUTCOMES From 2012 to 2014, 250 student volunteers participated in the SFCP as clinicians, innovators, educators, and leaders, with between 80 and 95 medical students engaging each semester. Between January 2012 and March 2014, there were 476 urgent care or chronic disease management visits. Patients with chronic diseases were seen at least twice on average, and by 2014, chronic disease management visits accounted for approximately 74% of visits. NEXT STEPS Work is under way to create assessment tools to evaluate the practices educa tional impact and student understanding of the current health care system, develop interdisciplinary care teams, expand efforts in registry management and broaden the patient recruitment scope, further emphasize patient engage ment and retention, and evaluate chronic disease management and patient satisfaction effectiveness.