Beth W. Liston

Incidence and effects of Ha‐ras codon 12 G→A transition mutations in preneoplastic lesions induced by N‐nitrosomethylbenzylamine in the rat esophagus

N‐nitrosomethylbenzylamine (NMBA)–induced rat esophageal tumorigenesis is an important model for squamous cell carcinoma of the human esophagus. In this model, previous studies have shown that the GGA→GAA Ha‐ras codon 12 mutation is present in the majority of papillomas. No other Ha‐ras mutation has been identified. Studies using other models of chemical carcinogenesis suggest that Ha‐ras activation has a critical role during tumor initiation. We have used laser‐capture microdissection and polymerase chain reaction–restriction fragment length polymorphism analysis to study the role of codon 12 Ha‐ras mutation at various stages of tumor development in the rat esophagus. Our results indicate that Ha‐ras mutation was present infrequently (4.3%) in premalignant lesions. The incidence of Ha‐ras mutation was high in papillomas (57.1%), however, and 50% of papillomas expressed mutant Ha‐ras RNA message. Additionally, there was a linear trend correlating increased incidence of Ha‐ras mutation with later papilloma stage. These data suggest the role of ras activation later in neoplastic development. To evaluate the potential mechanism of action by which Ha‐ras contributes to promotion and progression in this model, we compared mRNA expression of cyclin D1 and p27 in Ha‐ras mutant and Ha‐ras normal papillomas. We found no differences in mRNA expression of either cyclin D1 or p27 between these two papilloma populations. Our data suggest an important paradigm shift for the role of ras mutations in this model of chemical carcinogenesis, indicating a functional role of Ha‐ras activation in promotion/progression and not in the initiation phase of NMBA‐induced papillomagenesis.

Interprofessional education in the internal medicine clerkship: results from a national survey.

Purpose Growing data support interprofessional teams as an important part of medical education. This study describes attitudes, barriers, and practices regarding interprofessional education (IPE) in internal medicine (IM) clerkships in the United States and Canada. Method In 2009, a section on IPE was included on the Clerkship Directors in Internal Medicine annual survey. This section contained 23 multiple-choice questions exploring both core and subinternship experiences. Data were analyzed using descriptive statistics and Rasch analysis. Results Sixty-nine of 107 institutional members responded to the survey (64% response rate). Approximately 68% of responding clerkship directors believed that IPE is important to the practice of IM. However, only 57% believed that it should become a part of the undergraduate clinical curriculum. The three most significant barriers to IPE in the IM clerkship were scheduling alignment, time in the existing curriculum, and resources in time and money. Although more than half of respondents felt IPE should be included in the clinical curriculum, 81% indicated that there was no formal curriculum on IPE in their core IM clerkship, and 84% indicated that there was no formal curriculum during IM subinternship rotations at their institution. Conclusions There is limited penetration of IPE into one of the foundational clinical training episodes for medical students in Liaison Committee for Medical Education–accredited schools. This may be related to misperceptions of the relative value of these experiences and limitations of curricular time. Learning in and from successful models of interprofessional teams in clinical practice may help overcome these barriers.

Determining the Rate of Change in Exposure to Ionizing Radiation From CT Scans: A Database Analysis From One Hospital

PURPOSE Cancer risks associated with radiation from CT procedures have recently received increased attention. An important question is whether the combined impact of CT volume and dose reduction strategies has reduced radiation exposure to adult patients undergoing CT examinations. The aim of this study was to determine differences in radiation exposure from 2008 to 2012 to patients receiving CT scans of the abdomen, head, sinus, and lumbar spine at a midwestern academic medical center that implemented dose reduction strategies. METHODS Data were collected from two internal data sets from 2008 to 2012 for general medicine and intensive care unit patients. These data were used to calculate annual CT volume, rate, average effective dose, radiation exposure, and estimated cancer risk. RESULTS A 37% reduction in abdominal CT volume was found from 2008 to 2012. However, no volume reductions were found for CT examinations of the head or lumbar spine, and the decrease in sinus imaging was minimal. Dose reduction strategies resulted in 30% to 52% decreases in radiation exposure for the targeted body areas. The combined reduction in volume and dose per procedure reduced estimated induced cancers by 63%. CONCLUSIONS Exposure to ionizing radiation from these examinations was reduced at one institution because of reduced volumes of procedures and the reduction of each procedures effective dose through new protocols and technologies. Although both the volume reduction and dose reduction strategies contributed to the reduced exposure, it seems that investments in implementing the protocols and new technology had the greatest effect on future cancer risk.

Comparing the Effectiveness of Alerts and Dynamically Annotated Visualizations (DAVs) in Improving Clinical Decision Making

Objective: The aim of this study was to compare the effectiveness of two types of real-time decision support, an interrupting pop-up alert and a noninterrupting dynamically annotated visualization (DAV), in reducing clinically inappropriate diagnostic imaging orders. Background: Alerts in electronic health record software are frequently disregarded due to high false-alarm rates, interruptions, and uncertainty about what triggered the alert. In other settings, providing visualizations and improving understandability of the guidance has been shown to improve overall decision making. Method: Using a between-subject design, we examined the effect of two forms of decision support, alerts and DAVs, on reducing the proportion of inappropriate diagnostic imaging orders for 11 patients in a simulated environment. Nine attending and 11 resident physicians with experience using an electronic health record were randomly assigned to the form of decision support. Secondary measures were self-reported understandability, algorithm transparency, and clinical relevance. Results: Fewer inappropriate diagnostic imaging tests were ordered with DAVs than with alerts (18% vs. 34%, p < .001). The DAV was rated higher for all three secondary measures (p < .001) for all participants. Conclusion: DAVs were more effective than alerts in reducing inappropriate imaging orders and were preferred for all patient scenarios, especially scenarios where guidance was ambiguous or based on inaccurate information. Application: Creating visualizations that are permanently displayed and vary in the strength of their guidance can mitigate the risk of system performance degradation due to incomplete or incorrect data. This interaction paradigm may be applicable for other settings with high false-alarm rates or where there is a need to reduce interruptions during decision making.

Developing a Conversational Virtual Standardized Patient to Enable Students to Practice History-Taking Skills

Introduction Although traditional virtual patient simulations are designed to teach and assess clinical reasoning skills, few employ conversational dialogue with the patients. The virtual standardized patients (VSPs) described herein represent standardized patients that students interview using natural language. Students take histories and develop differential diagnoses of the VSPs as much as they would with standardized or actual patients. The student-VSP interactions are recorded, creating a comprehensive record of questions and the order in which they were asked, which can be analyzed to assess information-gathering skills. Students document the encounter in an electronic medical record created for the VSPs. Methods The VSP was developed by integrating a dialogue management system (ChatScript) with emotionally responsive 3D characters created in a high-fidelity game engine (Unity). The system was tested with medical students at the Ohio State University College of Medicine. Students are able to take a history of a VSP, develop a differential diagnosis, and document the encounter in the electronic medical record. Results Accuracy of the VSP responses ranged from 79% to 86%, depending on the complexity of the case, type of history obtained, and skill of the student. Students were able to accurately develop an appropriate differential diagnosis on the basis of the information provided by the patient during the encounter. Conclusions The VSP enables students to practice their history-taking skills before encounters with standardized or actual patients. Future developments will focus on creating an assessment module that will automatically analyze VSP sessions and provide immediate student feedback.

Hospital medicine in the internal medicine clerkship: Results from a national survey

BACKGROUND Hospital medicine is growing rapidly. This changing inpatient work force has had consequences on medical education, with an increasing hospitalist presence in resident and student training. Initially met with apprehension, there is growing literature to suggest that hospitalists are perceived to be more effective clinical teachers than non-hospitalists. However, the extent to which hospitalists are involved in teaching Internal Medicine (IM) to medical students is not known. METHODS In order to determine the role of hospitalists in medical student education within the United States and Canada, we queried clerkship directors in Internal Medicine as part of the 2010 annual Clerkship Directors in Internal Medicine (CDIM) survey. In June 2010, CDIM surveyed its North American institutional members, which represent 110 of 143 Departments of Medicine in the US and Canada. RESULTS Eight-two of 107 departments responded to the survey (77%). Seventy-five (91%) indicated that hospitalists served as teaching attendings at their teaching hospital. In twenty-two (27%) IM departments, 75% to 100% of students rotate with a hospitalist during their IM clerkships. Thirty-three (42%) departments report that students are directly supervised by in-house hospitalists during their nighttime call requirements. Sixty-six (81%) indicated that academic hospitalists hold educational administrative positions. Hospitalists are significantly less likely to have additional clinical commitment as compared to non-hospitalist teaching attendings (16% vs 53%, (χ 21df = 33.1; P < 0.0001). CONCLUSIONS Hospitalists are involved in medical student education in the large majority of Departments of Internal Medicine throughout the US and Canada, reflecting the growth of hospital medicine nationally.

Participatory Bullseye Toolkit Interview: Identifying Physicians’ Relative Prioritization of Decision Factors When Ordering Radiologic Imaging in a Hospital Setting

Critical Decision Method (CDM), a popular cognitive task analysis (CTA) method, is an in-depth retrospective interview that uses a historical non-routine incident to identify experts’ decision-making factors in complex socio-technical settings with high consequences for failure. However, it is challenging to use CDM to make comparisons, including those between experts and trainees. We describe an alternative CTA method used to study physicians’ decision making for ordering diagnostic imaging. After being primed with 11 simulated patient scenarios, nine attending and 11 resident physicians were asked to map out and present their decision-making process with a bullseye participatory design toolkit. Interviews were analyzed qualitatively, revealing four common decision factors: diagnostic efficacy, patient safety, organizational constraints, and patient comfort. The bullseye maps were used to quantitatively measure priority differences between these decision factors. Attending and resident physicians both prioritized diagnostic efficacy over the other factors (2.38 vs. 3.71, p <.01, and 2.59 vs. 3.52, p<.01, respectively), but attending physicians’ decisions had a higher proportion of non-diagnostic items (65% vs. 50%, p = .008). Our results demonstrate the usefulness of this method in eliciting decision factors for a complex, face-valid task and for identifying differences due to levels of expertise and training.

Journal Watch From ACE (Alliance for Clinical Education): Annual Review of Medical Education Articles in Internal Medicine Journals, 2012–2013

This journal watch is sponsored by the Alliance for Clinical Education (ACE). The purpose of this article is to summarize medical education manuscripts from specialty journals that are important and relevant to educators across specialties. Specialties included in our review were cardiology, gastroenterology, general internal medicine, pulmonology, nephrology, hematology and oncology, endocrinology, rheumatology, infectious disease, and neurology. We are grateful to Teaching and Learning in Medicine and ACE for giving us the opportunity to publish this review. The Clerkship Directors in Internal Medicine Research Committee conducted this review. Included are English articles published from September 2006 through September 2007. PubMed was searched for peer-reviewed research publications reporting primary data on medical education. Medical subject heading terms included combinations of medical education, medical student, residency training, practice, undergraduate medical education, graduate medical educat...