George Mejicano

Defining characteristics of educational competencies

Context  Doctor competencies have become an increasing focus of medical education at all levels. However, confusion exists regarding what constitutes a competency versus a goal, objective or outcome.

Vertebral osteomyelitis due to Candida species: case report and literature review.

Candida species uncommonly cause vertebral osteomyelitis. We present a case of lumbar vertebral osteomyelitis caused by Candida albicans and review 59 cases of candidal vertebral osteomyelitis reported in the literature. The mean age was 50 years, and the lower thoracic or lumbar spine was involved in 95% of patients. Eighty-three percent of patients had back pain for >1 month, 32% presented with fever, and 19% had neurological deficits. The erythrocyte sedimentation rate was elevated in 87% of patients, and blood culture yielded Candida species for 51%. C. albicans was responsible for 62% of cases, Candida tropicalis for 19%, and Candida glabrata for 14%. Risk factors for candidal vertebral osteomyelitis were the presence of a central venous catheter, antibiotic use, immunosuppression, and injection drug use. Medical and surgical therapies were both used, and amphotericin B was the primary antifungal agent. Prognosis was good, with an overall clinical cure rate of 85%.

Infections Acquired during Cardiopulmonary Resuscitation: Estimating the Risk and Defining Strategies for Prevention

And he went up, and lay upon the child, and put his mouth upon his mouth, and his eyes upon his eyes, and his hands upon his hands: and he stretched himself upon the child; and the flesh of the child waxed warm. II Kings 4:34 From the time of this first written description of rescue breathing [1], it was nearly 3000 years before mouth-to-mouth ventilation achieved widespread medical acceptance [2]. The National Research Council first recommended mouth-to-mouth ventilation in 1957, and the first reported out-of-hospital resuscitation took place in 1960 [3]. Today, mouth-to-mouth ventilation combined with external chest compressions, termed cardiopulmonary resuscitation (CPR), form the initial treatment of patients with cardiac arrest. In the United States, an estimated 100 000 resuscitations are done annually, and more than 20 million citizens to date have been formally trained in basic life support [3]. Large-scale educational programs have put CPR at the forefront of public health initiatives on the basis of the knowledge that prompt action can save lives, both inside and outside of the hospital [4, 5]. Average survival rates for patients with cardiac arrest are low, even with prompt administration of CPR-10% to 15% [6, 7]-and factors such as age [4], location of arrest [4, 5], and duration of arrest [4] profoundly influence the outcome of resuscitation. However, the strongest predictors of success are whether the arrest is witnessed [4, 6, 8], the initial cardiac rhythm [6, 8, 9], the time from collapse to initiation of CPR [8, 10-12], and the quality of the CPR administered [9]. The highest rates of survival and hospital discharge, up to 43%, occur when CPR is started within 3 to 4 minutes of arrest [7, 8, 12]. When CPR is combined with immediate on-site defibrillation, the survival rate may be as great as 70% [11]. The most recent guidelines from the American Heart Association [13] emphasize that prompt intervention is the key to success: A first responder must be willing to act without hesitation. Unfortunately, fear of contracting a communicable disease, especially HIV infection, has become a major barrier to immediate response [14, 15]. Impact of AIDS on Initiation of Cardiopulmonary Resuscitation Most students in the health professions [16], nurses [17-19], and house officers [20, 21] have stated in surveys that they would not perform mouth-to-mouth ventilation on a patient with AIDS. A recent survey [22] found that 45% of 433 internists and 80% of 152 nurses would not perform mouth-to-mouth ventilation on a stranger. The main reason for reluctance was fear of contracting a serious communicable disease, especially HIV infection. Even CPR instructors harbor these fears. A survey of 1794 instructors in Virginia found that 49% had performed CPR within 3 years. Of these providers, 40% reported that they had hesitated to provide mouth-to-mouth ventilation at least once, usually because of fear of exposure to a contagious disease [23]. Not surprisingly, many instructors also have concerns about exposure to infectious diseases during group training done by using mannequins [23-25]. In 1989, the Emergency Cardiac Care Committee of the American Heart Association [26] sought to allay concerns about potential exposure to infectious agents, particularly HIV and hepatitis B virus (HBV). They stressed that delayed ventilation could mean death or disablement for an otherwise healthy person, while risk to the rescuer, even with a known HBV/HIV-positive victim, is considered very low. An editorial and a position paper from the Heart and Stroke Foundation of Canada [27, 28] reaffirmed this position. The current American Heart Association guidelines [26] state that health care workers and public protection professionals have moral, ethical, and, in certain situations, legal obligations to provide CPR. We concur with these statements but believe that it will take more than reassurances and ethical arguments to persuade health care workers and the lay public that fear of infection should not be a deterrent to the initiation of CPR. Although the absolute level of risk is low, health care workers have an increased risk for occupationally acquired infection, particularly infection with Mycobacterium tuberculosis and HBV [29-31]. Yet recent reviews of occupationally acquired infection in health care workers have not addressed the risk for infection as a consequence of administering CPR. By examining the available data on the likelihood of transmission of infectious organisms (particularly HIV and other ubiquitous bloodborne pathogens) during CPR and the documented cases of infections acquired during CPR and by summarizing essential infection-control measures that reduce risk even further, we believe that it is possible to convince potential CPR providers that the risk for acquiring an infection during CPR is not zero but is very low and that there should be no reluctance to begin CPR, including mouth-to-mouth ventilation, when the procedure is medically and ethically indicated. Risk for Salivary Transmission of Bloodborne Viruses HIV It is now abundantly clear that HIV is not transmitted through casual contact [32-35] (Table 1). Even household members who have shared numerous personal items with HIV-infected persons, such as eating utensils, razors, or toothbrushes, have not become infected [34]. Infection with HIV is acquired through sexual contact; exposure to unscreened blood products; intravenous drug use; and, among health care workers, exposure to contaminated sharps. Infants acquire HIV in utero or during parturition [32, 46]. Transmission by all other routes seems to be very rare [32, 39]. Table 1. Risk for Salivary Transmission of HIV Human immunodeficiency virus is isolated rarely, and then in very low concentrations, from the saliva of HIV-infected patients [47, 48]. The low concentration of HIV in saliva is probably the major reason why dental professionals have a very low risk for occupationally acquired HIV infection [36, 37]. In the United States, no rigorously documented cases of transmission of HIV from a patient to a dental worker have been reported, although seven cases may have derived from dental exposures [37]. In one study of 1309 dental professionals who had no behavioral risk factors for HIV infection but had cared for multiple patients known to have AIDS or risk factors for HIV infection [36], only 1 dentist was seropositive for HIV. In a long-term prospective study of health care workers heavily exposed to patients with HIV infection [38], none of the 63 persons exposed to the saliva of HIV-positive patients on a daily basis developed antibody to the virus. Even persons who have been bitten by an HIV-infected person seem to be at low risk: Only four cases of HIV infection have been ascribed to human bites, and none of these cases have been confirmed epidemiologically by RNA subtyping [41-44]. Of 8 HIV-seronegative children bitten by HIV-infected playmates and 38 health care workers bitten by patients with AIDS, none have seroconverted despite prolonged followup [39, 40, 49]. Moreover, two nurses who performed mouth-to-mouth ventilation on a patient with AIDS have not developed HIV infection during prolonged follow-up [45]. In summary, although there has been speculation that salivary transmission of HIV may occur, the evidence does not support this [32, 41, 50, 51] (Table 1). Hepatitis B Virus In contrast to HIV, HBV poses substantial risks to health care workers [41, 52-54]. Hepatitis B surface antigen (HBsAg) was found in the saliva of 31 of 41 patients (76%) with acute hepatitis and was found intermittently in 75 of 93 patients (81%) with chronic HBV infection [55]. Thus, salivary exchange may be one mechanism for nonparenteral transmission of HBV within families [56-58], and cases of HBV infection acquired through human bites have been reported [59, 60] (Table 2). Table 2. Risk for Salivary Transmission of Hepatitis B Virus However, the sum total of the evidence suggests that salivary transmission of HBV is rare (Table 2). Only one case of HBV infection was found after 35 upper gastrointestinal procedures were done with endoscopes that were presumably contaminated with HBV [61, 62]. Moreover, none of 12 students who were exposed to HBsAg-positive saliva through the sharing of musical instruments with an infected teacher seroconverted or developed clinical evidence of hepatitis [63]. Finally, none of 39 persons exposed to HBsAg-positive saliva during CPR training became infected [63, 64], and no cases of HBV infection acquired as a consequence of giving CPR or participating in CPR training have been documented. The most likely reason why salivary transmission is so infrequent is that the concentration of HBV in saliva is only 1/3000 of that in serum [65]. The risk for acquiring HBV infection as a result of performing mouth-to-mouth ventilation is very low and can almost certainly be mitigated by immunization of the health care workers and public protection officials most likely to be called on regularly to perform CPR [66]. Hepatitis C Virus Unlike patients infected with HIV and HBV, up to one third of persons with antibody to the hepatitis C virus (HCV) have no identifiable risk factors for bloodborne infection [67, 68]. Hepatitis C virus RNA has been found by polymerase chain reaction (PCR) in many body fluids, including sweat [69], urine [68-70], and saliva [68-76]. The prevalence of HCV positivity in saliva has ranged widely, from none of 14 HCV-seropositive patients in one study [77] to 20% to 62% of HCV-infected patients in others [70, 74, 75]; this suggests wide differences in the sensitivity of the assays used to assess positivity. It seems clear, however, that the concentration of HCV in blood is several orders of magnitude greater than the concentration of HCV in saliva [70]. In one study (Table 3), none of 62 household contacts of HCV-seropositive family members showed serologic eviden

Building a Competency-Based Curriculum: The Agony and the Ecstasy.

Physician competencies have increasingly been a focus of medical education at all levels. Although competencies are not a new concept, when the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) jointly agreed on six competencies for certification and maintenance of certification of physicians in 1999, it brought about renewed interest. This article gives a brief overview of how a competency-based curriculum differs from other approaches and then describes the issues that need to be considered in the design and implementation of such a curriculum. In order to achieve success, a competency-based curriculum requires careful planning, preparation and a long-term commitment from everyone involved in the educational process. Building a competency-based curriculum is really about maintaining quality control and relinquishing control to those who care the most about medical education, our students. In the face of the many challenges that are facing undergraduate medical education (UME), including declining availability of teaching patients and over-burdened faculty, instituting quality control and relinquishing control will be necessary to maintain high quality.

Perspective: Competency-Based Medical Education: A Defense Against the Four Horsemen of the Medical Education Apocalypse

Medical education is facing a convergence of challenges that the authors characterize as the four horsemen of the medical education apocalypse: teaching patient shortages, teacher shortages, conflicting systems, and financial problems. Rapidly expanding class sizes and new medical schools are coming online as medical student access to teaching patients is becoming increasingly difficult because of the decreasing length and increasing intensity of hospital stays, concerns about patient safety, patients who are stressed for time, teaching physician shortages and needs for increasing productivity from those who remain, and increasing emphasis on translational research. Further, medical education is facing reductions in funding from all sources, just as it is mounting its first major expansion in 40 years. The authors contend that medical education is on the verge of crisis and that little outside assistance is forthcoming. If medical education is to avoid a catastrophic decline, it will need to take steps to reinvent itself and make optimum use of all available resources. Curriculum materials developed nationally, increased reliance on simulation and standardized patient experiences, and adoption of quality-control methods such as competency-based education are suggested as ways to keep medical education vital in an environment that is increasingly preoccupied with fending off the four horsemen. The authors conclude with a call for a national dialogue about how the medical education community can address the problems represented by the four horsemen, and they offer some potential ways to maintain the vitality of medical education in the face of such overwhelming problems.

Factors contributing to successful interorganizational collaboration: The case of CS2day

&NA; Continuing medical educations transition from an emphasis on dissemination to changing clinical practice has made it increasingly necessary for CME providers to develop effective interorganizational collaborations. Although interorganizational collaboration has become commonplace in most sectors of government, business, and academia, our review of the literature and experience as practitioners and researchers suggest that the practice is less widespread in the CME field. The absence of a rich scholarly literature on establishing and maintaining interorganizational collaborations to provide continuing education to health professionals means there is little information about how guidelines and principles for effective collaboration developed in other fields might apply to continuing professional development in health care and few models of successful collaboration. The purpose of this article is to address this gap by describing a successful interorganizational CME collaboration—Cease Smoking Today (CS2day)—and summarizing what was learned from the experience, extending our knowledge by exploring and illustrating points of connection between our experience and the existing literature on successful interorganizational collaboration. In this article, we describe the collaboration and the clinical need it was organized to address, and review the evidence that led us to conclude the collaboration was successful. We then discuss, in the context of the literature on effective interorganizational collaboration, several factors we believe were major contributors to success. The CS2day collaboration provides an example of how guidelines for collaboration developed in various contexts apply to continuing medical education and a case example providing insight into the pathways that lead to a collaborations success.

Fostering the Development of Master Adaptive Learners: A Conceptual Model to Guide Skill Acquisition in Medical Education.

Change is ubiquitous in health care, making continuous adaptation necessary for clinicians to provide the best possible care to their patients. The authors propose that developing the capabilities of a Master Adaptive Learner will provide future physicians with strategies for learning in the health care environment and for managing change more effectively. The concept of a Master Adaptive Learner describes a metacognitive approach to learning based on self-regulation that can foster the development and use of adaptive expertise in practice. The authors describe a conceptual literature-based model for a Master Adaptive Learner that provides a shared language to facilitate exploration and conversation about both successes and struggles during the learning process.

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.

Organization development strategies for continuing medical education

Background: The purpose of this study was to identify organizational strategies for improving staff performance in primary care practices. The study rationale was based on theory, research, and practice regarding educational interventions that help people help themselves. Analysis of qualitative and quantitative data produced both plausible explanations of organizational change and implications for future efforts. Methods: The Health Education and Research Trial (HEART) Project was an experimental study designed to improve prevention services for cardiovascular disease. Primary care clinics were randomized into four experimental treatments. Two representative practices from each treatment arm were chosen for an in‐depth cross‐case analysis. Extensive data from each selected practice included patient medical record reviews and questionnaires, interviews and questionnaires from physicians and clinic staff, project records, and follow‐up interviews. After detailed case descriptions were created for each practice, a cross‐case analysis was performed. Results: Each practice improved cardiovascular prevention services somewhat. However, there was a great range of impact, likely reflecting both experimental intervention and local contingencies. Eight positive influences were identified: effective leadership, priority setting, joint planning, cooperation and teamwork, acquisition of resources, increased support and ownership, accomplishment of improvements, and personal changes. Major influences that hindered improvement included patient load, turmoil related to reorganization, lack of widespread routines, hospital‐affiliated practice, poor communication, and fragmentation within a clinic. Findings: Continuing medical education providers can enhance preventive services to improve patient health status by promoting organizational change. Suggested strategies supported by this study include selecting able leaders, focusing on accomplishments, obtaining agreement on prevention priorities, addressing local contingencies, increasing teamwork, engaging in joint planning, emphasizing quality improvement, acquiring resources, encouraging persistence, and reducing hindrances.

Physician Practice Change I: A Critical Review and Description of an Integrated Systems Model

The long lag time between medical discovery and when Americans benefit from that discovery has a huge cost in terms of morbidity and mortality. Medicine needs more effective methods for moving discovery to practice. In this article, the authors first offer a critical review of the models of structure and change process gleaned from the physician change literature. Next, they describe the Integrated Systems Model (ISM) that they derive from this review. The ISM has four major components: superstructure, change motivators, change process, and functional interactions. The ISM considers the physician practice to operate as a complex adaptive system requiring diversion of resources from reserves to make a change. In the ISM, resource return is a function of improved quality of care and reimbursement for services. Changes decreasing the resources of the system (parasitic) will be harder to make than those that increase resources (symbiotic) because of resistance to resource loss. The authors extend the ISM to the individual level and describe the need to consider whether individuals within the practice have sufficient reserves to fulfill their part in making the change. Any given change is generally competing with other changes for adoption. Finally, the authors consider the strengths and weaknesses of their model, concluding that by keeping patient welfare, quality care, and finances in the forefront, the ISM provides a more complete picture of forces affecting medical practice change.