John E. McManigle

The feasibility, reliability, and validity of a program director's (supervisor's) evaluation form for medical school graduates.

Purpose To determine the feasibility, reliability, and validity of the supervisor’s evaluation form for first-year residents as an outcome measure for programmatic evaluation. Method Prospective feedback has been sought from supervisors for the Uniformed Services University of the Health Sciences (USUHS) graduates during their internship year. Supervisors are sent yearly evaluation forms with up to three additional mailings. Using a six-point scale, supervisors rate residents on 18 items. The authors used evaluation data from 1993 to 2002. Feasibility was estimated by response rate. Internal consistency was assessed by calculating Cronbach’s alpha and analyzing scores on a year-to-year and interrater basis. Validity was determined by exploratory factor analysis with oblique rotations, comparing ratings with end-of-medical school GPA and United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores (Pearson correlations), and by analyzing the range of scores to include the percentage of scores below acceptable level. Results A total of 1,247 evaluations were collected for the 1,559 USUHS graduates (80%). Cronbach’s alpha was .96 with no significant difference in scores by supervisor specialty or year. Factor analysis found that the evaluation form collapsed into two domains accounting for 68% of the variance: professionalism and expertise. End-of-medical school GPA and USMLE Step 1 and 2 scores correlated with expertise but not with professionalism. Mean scores across items were 3.5–4.31 with a median of 4.0 for all items (SD .80–1.21). Four percent of graduates received less-than-satisfactory ratings. Conclusions This evaluation form has high feasibility and internal consistency. Factory analysis revealed two complimentary domains supporting its validity. Correlation with end-of-medical school measurements and analysis of range of scores supports the form’s validity.

NMDA receptors are involved at the ventrolateral nucleus tractus solitarii for termination of inspiration

The purpose of the present study was to determine whether blockade of excitatory amino acid receptors at the ventrolateral nucleus of the tractus solitarius would influence respiratory activity. This was done by microinjecting excitatory amino acid receptor antagonists into the ventrolateral nucleus of the tractus solitarius of alpha-chloralose-anesthetized animals while monitoring respiratory activity using a Fleisch pneumotachograph and arterial blood pressure and heart rate. Bilateral microinjection of the NMDA receptor antagonist, 3-[(R)-carboxypiperazin-4-yl]-propyl-1- phosphomic acid (CPP), 5.62 nmol per side, produced an increase in inspiratory duration (+4 +/- 1.6 s, n = 8) which progressed to an apneustic pattern of breathing. Similar results were obtained with CPP microinjected into the ventrolateral nucleus of the tractus solitarius of three vagotomized animals. Bilateral microinjection of a second NMDA receptor antagonist, 2-amino-7-phosphono-heptanoic acid (AP7), 562 nmol per side, produced qualitatively similar effects on respiration as seen with CPP. In contrast, blockade of non-NMDA receptors with 6-cyano-7-nitroquinoxaline-2,3-dione (CNXQ), 0.125 nmol per side, had very little effect on respiration. Activation of NMDA receptors at the ventrolateral nucleus of the tractus solitarius with bilateral microinjection of NMDA, 39 pmol, produced a large increase in expiratory duration (+11 +/- 3 s, n = 8), and apnea during the expiratory phase of the respiratory cycle in half of the animals studied. Similar results were obtained with D,L-alpha-amino-3-hydroxy-5-methyl-4-isoxazol-proprionate (AMPA). These results indicate that an endogenous excitatory amino acid released at the ventrolateral nucleus of the tractus solitarius and acting at the NMDA receptor, plays a significant role in respiratory timing.

Potentiation of MK-801-induced breathing impairment by 2,3-dihydroxy-6-nitro-7-sulfamoyl-benzo(F) quinoxaline

The purpose of our study was to examine whether a significant interaction occurs between NMDA and non-NMDA receptor antagonists on respiratory function. For this purpose chloralose-anesthetized cats were used and respiratory minute volume (VE), tidal volume (Vt) respiratory rate (f), inspiratory and expiratory durations, and end tidal CO2 (FeCO2) were monitored. In some animals, phrenic nerve activity was also continuously recorded. In five spontaneously breathing animals, the NMDA receptor antagonist MK-801 was administered in a dose of 0.1 mg/kg i.v., and produced decreases in VE, Vt, f and increases in inspiratory duration and FeCO2. Using these five animals exhibiting respiratory effects from prior MK-801 dosing, we then administered the non-NMDA receptor antagonist NBQX (2,3-dihydroxy-6-nitro-7-sulfamoyl-benzo(F)quinoxaline) i.v. in a dose of 3 mg/kg. This dose is too low to produce a neuroprotective effect in animal models of brain ischemia. In each of the five animals NBQX administration produced an immediate impairment of respiration, culminating in apneusis within 55 s after i.v. injection. In terms of phrenic nerve discharge, inspiratory duration was increased approximately 4-fold by MK-801, and with the addition of NBQX, continuous discharge of the phrenic nerve occurred. Finally, NBQX given i.v. to animals not pretreated with MK-801 had only a slight depressant effect on respiratory activity. These results obtained with co-administration of low doses of two drugs that block NMDA and non-NMDA receptors raise the spector that combined use of these agents to ameliorate disorders in neurological function may be extremely deleterious to respiratory function.

Respiratory effects produced by microinjection of L-glutamate and an uptake inhibitor of L-glutamate into the caudal subretrofacial area of the medulla

The purposes of our study were to determine the type of respiratory changes that would occur when either an excitatory amino acid receptor agonist or an uptake inhibitor was administered into the caudal subretrofacial area. This was done by microinjecting either L-glutamate or L-pyrrolidine-2,4-dicarboxylate (L-trans-2,4-PDC) into the caudal subretrofacial area while monitoring tidal volume, respiratory rate, mean arterial blood pressure and heart rate. Bilateral microinjection of 2.5 nmol of L-glutamate into the caudal subretrofacial area produced apnea in eight of eight animals tested, and the duration of apnea was 27 +/- 2 s. To determine the type of L-glutamate receptor responsible for mediating the apneic response, antagonists of the N-methyl-D-aspartate (NMDA) and non-NMDA receptor, namely, 3-[(RS)-carboxypiperazin-4-yl]-propyl-phosphonic acid (CPP), and 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX), respectively, were tested. Neither antagonist in doses that blocked NMDA (in the case of CPP) and amino-3-hydroxy-5-methyl-isoxazole-4-propionic acid (AMPA) (in the case of CNQX) blocked apnea elicited by L-glutamate. In addition, kynurenic acid, an antagonist of NMDA and non-NMDA ionotropic receptors, failed to block the effect of L-glutamate. Microinjection of the metabotropic receptor agonist drug, trans-L-1-amino-1,3-cyclopentone-dicarboxylic acid (L-trans-ACPD), into the caudal subretrofacial area failed to have any effect on respiratory activity. Because of the inability to block the effect of L-glutamate in the caudal subretrofacial area, and the lack of effect of L-trans-ACPD, the data suggest that the apneic response produced by L-glutamate is mediated by an as yet undefined receptor. Microinjection of the L-glutamate uptake inhibitor, L-trans-2,4-PDC, was found to produce apnea. Using the dose of 0.5 nmol of L-trans-2,4-PDC, we examined the type of excitatory amino acid receptor that mediated the response. Neither pretreatment with the NMDA receptor antagonist, CPP, nor the non-NMDA receptor antagonist, CNQX, affected L-trans-2,4-PDC-induced apnea. However, combined use of these two antagonists prevented L-trans-2,4-PDC-induced apnea. These data suggest that the effect of synaptically released exitatory amino acid at the caudal subretrofacial area on breathing is apnea, and that this effect is mediated by simultaneous activation of both NMDA and non-NMDA ionotropic receptors.

The Long-Term Career Outcome Study (LTCOS): What Have We Learned From 40 Years of Military Medical Education and Where Should We Go?

The work of the Long-Term Career Outcome Study (LTCOS), F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences (USU) has been a multidisciplinary effort spanning more than 5 years. Borrowing from the established program evaluation and quality assurance literature, the LTCOS team has organized its evaluation and research efforts into three phases: before medical school, during medical school, and after medical school. The purpose of this commentary is to summarize the research articles presented in this special issue and to answer two fundamental questions: (1) what has been learned from LTCOS research conducted to date, and (2) where should the LTCOS team take its evaluation and research efforts in the future? Answers to these questions are relevant to USU, and they also can inform other medical education institutions and policy makers. What is more, answers to these questions will help to ensure USU meets its societal obligation to provide the highest quality health care to military members, their families, and society at large.

Career Accomplishments of Uniformed Services University of the Health Sciences Medical Graduates: Classes 1980–2001

PURPOSE To report accomplishments of graduates of the F. Edward Hébert School of Medicine who have left, retired, or are near the end of their uniformed career in several professional domains: military career milestones, medical professional education, academic landmarks, and leadership. METHODS This study utilized an earlier questionnaire that was modified to capture additional career landmarks and improve the clarity of several items. The modified survey was sent electronically to alumni who graduated from 1980-2001 in March, 2012. RESULTS The questionnaire was sent to 2,825 alumni for whom we had e-mail addresses. We estimate that we reached 2,400 alumni. A total of 1,189 alumni returned the questionnaire, yielding an estimated response rate of 50%. For this cohort, the board certification was 95%, over 20% obtained additional degrees, 92.8% had worked as a full-time physician, nearly two-thirds had deployed for combat, 13.9% had received the Legion of Merit, and 68.6% had published at least one peer-reviewed manuscript. CONCLUSION Many accomplishments including board certification rates, deployment experience, academic and military leadership positions, military awards, promotion rates, and academic medicine contributions are indicators that USU is continuing to meet its unique mission.

40 Years of Military Medical Education: An Overview of the Long-Term Career Outcome Study (LTCOS)

In 2005, the Long-Term Career Outcome Study (LTCOS) was established by the Dean, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences (USU). The original charge to the LTCOS team was to establish an electronic database of current and past students at USU. Since its inception, however, the LTCOS team has broadened its mission and started collecting and analyzing data on a continuous basis for the purposes of program evaluation and, in some cases, research. The purpose of this commentary is to review the history of the LTCOS, including details about USU, a brief review of prior LTCOS work, and progress made since our last essay on LTCOS efforts. This commentary also provides an introduction to the special issue, which is arranged as a series of articles that span the medical education continuum (i.e., before, during, and after medical school). The relative balance of articles in each phase of training represents the LTCOS teams efforts to address the entire continuum of medical education.

Assessing Curriculum Effectiveness: A Survey of Uniformed Services University Medical School Graduates

PURPOSE This study assessed alumni perceptions of their preparedness for clinical practice using the Accreditation Council for Graduate Medical Education (ACGME) competencies. We hypothesized that our alumnis perception of preparedness would be highest for military-unique practice and professionalism and lowest for system-based practice and practice-based learning and improvement. METHOD 1,189 alumni who graduated from the Uniformed Services University (USU) between 1980 and 2001 completed a survey modeled to assess the ACGME competencies on a 5-point, Likert-type scale. Specifically, self-reports of competencies related to patient care, communication and interpersonal skills, medical knowledge, professionalism, systems-based practice, practice-based learning and improvement, and military-unique practice were evaluated. RESULTS Consistent with our expectations as the nations military medical school, our graduates were most confident in their preparedness for military-unique practice, which included items assessing military leadership (M = 4.30, SD = 0.65). USU graduates also indicated being well prepared for the challenges of residency education in the domain of professionalism (M = 4.02, SD = 0.72). Self-reports were also high for competencies related to patient care (M = 3.86, SD = 0.68), communication and interpersonal skills (M = 3.88, SD = 0.66), and medical knowledge (M = 3.78, SD = 0.73). Consistent with expectations, systems-based practice (M = 3.50, SD = 0.70) and practice-based learning and improvement (M = 3.57, SD = 0.62) were the lowest rated competencies, although self-reported preparedness was still quite high. DISCUSSION Our findings suggest that, from the perspective of our graduates, USU is providing both an effective military-unique curriculum and is preparing trainees for residency training. Further, these results support the notion that graduates are prepared to lead and to practice medicine in austere environments. Compared to other competencies that were assessed, self-ratings for systems-based practice and practice-based learning and improvement were the lowest, which suggests the need to continue to improve USU education in these areas.

A conceptual framework for leader and leadership education and development

ABSTRACT Conceptual frameworks for Leader and Leadership Education and Development guide the curriculum and assessment of students, faculty, and programs. This commentary defines leader and leadership and presents a leadership conceptual framework that includes four ‘C’ elements (FourCe) – Character, Competence, Context, and Communication – across four levels of psychosocial interaction – Personal, Interpersonal, Team, and Organizational (PITO). This FourCe-PITO framework delineates elements of leadership, considers interactions of these elements, guides curriculum content, and is the basis for assessments. The application of this framework is discussed for all levels of education.

Seven Steps to Establish a Leader and Leadership Education and Development (LEAD) Program

Despite long-standing debates about whether leaders are born or made, current thinking within the leadership field is that leaders can be developed. In the arena of health and healthcare, developing effective, value-driven and outcome-focused leaders is critical to address the many challenges facing systems that promote and maintain health as well as focus on healthcare delivery and practices. Effective health and healthcare leaders are needed to set thoughtful policies; educate the public about primary prevention strategies; identify best practices (administrative and clinical); allocate healthcare resources wisely; address healthcare needs and disparities; focus on optimal clinical outcomes and value in the delivery of care; and encourage individuals to engage in behaviors that enhance well-being. This chapter presents seven steps to establish a Leader and Leadership Education and Development (LEAD) program. These steps were based on the authors’ experience establishing a LEAD program at the Uniformed Services University of the Health Sciences (USU) where physicians, advanced practice nurses, dentists, psychologists, and scientists are trained for the Army, Navy, Air Force, and Public Health Service, and civilians are trained to become scientists, academicians, and clinicians with a focus on national service and health. These same steps also could be used as a guide to establish programs that educate and develop leaders for other professions and careers.