Search

Purpose: Many trainees lack competence in performing cold snare polypectomy (CSP), and longer observation periods using assessment tools, such as the Cold Snare Polypectomy Assessment Tool (CSPAT), may be required. However, these tools are not commonly used in busy academic endoscopy practices. This study evaluates the concordance between trainee self-assessment of CSP with expert assessment and assesses factors associated with concordance., Method: Consecutive CSPs performed by gastroenterology trainees from 2 institutions were video recorded and rated by 8 blinded experts from 4 different academic institutions in the United States and Singapore using the CSPAT from August 2017 to February 2020. Trainees self-assessed competence for each CSP immediately after the procedure. Concordance between trainee and trainer was reported as percentage of agreement in competence (score of 3 or 4) or not yet competent (score of 1 or 2)., Results: Twenty-two trainees performed 765 colonoscopies with 2,267 CSPs. Concordance was found between expert and trainee assessment of competence for 1,380 CSPs (60.9%; 95% CI, 58.8%-62.9%; weighted κ = 0.12; 95% CI, 0.08-0.16). Trainees underassessed competence for 541 CSPs (23.9%; 95% CI, 22.1%-25.7%) and overassessed competence for 326 CSPs (15.3%; 95% CI, 13.8%-16.8%). Career plan of private practice general gastroenterology (adjusted odds ratio, 0.40; 95% CI, 0.17-0.92) and lower colonoscopy volume before study (adjusted odds ratio, 0.35; 95% CI, 0.22-0.62) were independently associated with lower likelihood of concordance between expert and trainee assessment of competence. Structured feedback was not associated with concordance, and there was no change as trainees gained experience; however, feedback decreased the proportion of overassessments., Conclusions: There is poor concordance between trainee self-assessment and trainer assessment of CSP. Self-assessment can be used as an initial part of competency assessment, which should then be reconciled with external assessments to improve concordance in assessments., (Copyright © 2025 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Problem: As part of a curriculum renewal, in 2020, Washington University School of Medicine in St. Louis sought to create an integrated curriculum that allows students to explore 4 academic career pathways (advocacy/global health, education, innovation, and research) and engage in scholarship activities-the Inquiry Curriculum. The curriculum needed to focus on foundational scholarship skills that would be applicable to all pathways. This article describes the process used to develop the curriculum learning objectives and lessons learned from initial implementation., Approach: The authors used a modified Delphi process to survey faculty experts from the 4 pathways to determine the objectives (March-May 2020). Twenty-four faculty were surveyed about 48 initial objectives created using Glassick's scholarship criteria. After 2 rounds, 28 objectives met consensus. Further oversight committee review and revisions by session leads resulted in 77 unique objectives for 23 sessions in the curriculum that launched in spring 2021., Outcomes: Four themes were identified from student feedback: (1) the Inquiry Curriculum framework creates opportunities for students to gain exposure to various approaches to understanding and addressing health care problems, (2) the curriculum targeted higher-level objectives for traditional research content and lower-level objectives for nontraditional content, (3) Glassick's criteria provided a useful structure for students to understand the rationale for and ordering of content, and (4) the curriculum had natural overlap with content often taught elsewhere in the curriculum, including evidence-based medicine, health equity, public and population health, and quality improvement and patient safety., Next Steps: The authors plan to consolidate sessions where there is redundancy, expand other sessions that require more time, and more purposefully discuss prior content when redundancy is intentional. Exploring other potential measures of curricular success, such as student learning outcomes, scholarly productivity, and impact on future scholarship engagement and career paths, is part of ongoing work., (Copyright © 2023 the Association of American Medical Colleges.)

Introduction: Cold snare polypectomy (CSP) is strongly recommended as the optimal technique for the complete removal of small polyps. Though significant variability in polypectomy technique and quality has been established, the learning curve and impact of targeted training on CSP are unknown. Video feedback has shown promise as an effective pedagogy to improve performance among surgical trainees. We aimed to compare CSP performance between trainees who received video-based feedback and those who received conventional apprentice-based concurrent feedback. We hypothesized that video-based feedback would accelerate competence., Methods: We conducted a single-blinded, randomized controlled trial on competence for CSP of polyps <1 cm, comparing video-based feedback with conventional feedback. We randomly assigned deidentified consecutively recorded CSP videos to blinded raters to assess using the CSP Assessment Tool. We shared cumulative sum learning curves every 25 CSP with each trainee. The video feedback trainees also received biweekly individualized terminal feedback. Control trainees received conventional feedback during colonoscopy. The primary outcome was CSP competence. We also assessed competence across domains and change over polypectomy volume., Results: We enrolled and randomized 22 trainees, 12 to video-based feedback and 10 to conventional feedback, and evaluated 2,339 CSP. The learning curve was long; 2 trainees (16.7%) in the video feedback achieved competence, after a mean of 135 polyps, and no one in the control ( P = 0.481) achieved competence. Overall and in all steps of CSP, a higher percentage of the video feedback group met competence, increasing 3% every 20 CSP ( P = 0.0004)., Discussion: Video feedback aided trainees to competence in CSP. However, the learning curve was long. Our findings strongly suggest that current training methods are not sufficient to support trainees to competency by the completion of their fellowship programs. The impact of new training methods, such as simulation-based mastery learning, should be assessed to determine whether such methods can result in achievement of competence at a faster rate; ClinicalTrials.gov : NCT03115008., (Copyright © 2023 by The American College of Gastroenterology.)

Background: Heart rate (HR) is considered the main vital sign in newborns during perinatal transition, with a threshold of 100 beats per minute (bpm), below which, intervention is recommended. However, recent changes in delivery room management, including delayed cord clamping, are likely to have influenced normal HR transition., Objective: To summarize the updated knowledge about the factors, including measurement methods, that influence HR in newborn infants immediately after birth. Additionally, this paper provides an overview of delivery room HR as a prognostic indicator in different subgroups of newborns., Methods: We searched PubMed, EMBASE, and Google Scholar with the terms infant, heart rate, delivery room, resuscitation, pulse oximetry, and electrocardiogram., Results: Seven studies that described HR values in newborn infants immediately after birth were included. Pulse oximetry-derived HR percentiles after immediate cord clamping may not be applicable to the current practice of delayed cord clamping and the increasing use of delivery room electrocardiograms. Mask ventilation may adversely affect HR, particularly in premature and non-asphyxiated infants. Prolonged bradycardia is a negative prognostic factor, especially if combined with hypoxemia in infants <32 weeks of gestation., Conclusions: HR assessment in the delivery room remains important. However, the cardiopulmonary transition is affected by delayed cord clamping, gestational age, and underlying conditions.

Study design: Retrospective case series. Objective: Alloplastic temporomandibular joint replacement has been established as a standard technique for end- stage temporomandibular (TMJ) pathologies. Joint replacement when there are extensive mandibular defects remains a challenging clinical problem. Custom-made extended temporomandibular joint replacement is a feasible option but there is limited information about this emerging technique. Methods: Included were all patients undergoing extended TMJ-replacements (TMJe), all operatrions were carried out by the senior author. Surgical technique was either single stage or two stage protocol. Surgical details and pitfalls and outcome of more than 2 years follow-up with reference to thirteen including twelve patients were recorded. Results: The most common diagnosis was ameloblastoma of the mandibular ramus. Single stage or two stagge regime were carried out depending on resection requirements and involvement of teeth. Improved mouth opening of more than 30mm was achieved in 10 of 12 patients. One patient with previous TMJ replacement reported temporary weakness of the facial nerve, which resolved after 10 months. Conclusions: The authors suggest a simplified anatomically based single-stage or two-stage regime, with both regimes achieved excellent anatomic reconstruction, facial appearance and function with low surgical morbidity. Custom-made extended temporomandibular joint protheses appear an advanced and reliable solution for reconstruction of combined complex mandibular defects including the temporomandibular joint. If surgical clearance of the pathology can be achieved, a single-stage regime is favoured., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Problem: Physicians' voices are valued in society and should be present in mainstream social media where they can provide valuable public health messaging and patient education as well as increase opportunities for medical education, mentoring, and collaboration. However, lack of formal education on effective use of social media prevents many physicians from using it., Approach: The authors developed a physician-led social media training program to address the need for formal instruction on social media use. The program was presented to medical students, trainees, and faculty at an academic medical institution in August and September 2020. The virtual format included 5 hour-long sessions with presentations by peer experts in social media. Peer physicians with experience using social media presented on a range of topics, including introductions to platforms, how to reach and grow audiences, and use of social media to advance patient education, medical education, and advocacy., Outcomes: There were 425 cumulative registrations for the 5 sessions of the Social Media Summit. The number of registrants increased for each session, suggesting that interest increased over time. Qualitative and quantitative participant feedback was collected via a brief, voluntary survey. All of the participants who completed the survey (n = 24) reported they were "very satisfied" (58.3%) or "somewhat satisfied" (41.7%) with the Summit., Next Steps: Physician involvement in social media presents opportunities for public health knowledge, medical education, scientific collaboration, and career advancement. Physicians who have been successful in using social media for these purposes are excellent peer educators and can fill the medical education void in social media training. Future plans include building sustainability of the program, collecting additional quantitative and qualitative feedback to guide improvement, and encouraging reproducibility., (Copyright © 2022 by the Association of American Medical Colleges.)

Background: Medical educators struggle to incorporate socio-cultural topics into crowded curricula. The "continuum of learning" includes undergraduate and graduate medical education. Utilizing an exemplar socio-cultural topic, we studied the feasibility of achieving expert consensus among two groups of faculty (experts in medical education and experts in social determinants of health) on which aspects of the topic could be taught during undergraduate versus graduate medical education., Methods: A modified Delphi method was used to generate expert consensus on which learning objectives of social determinants of health are best taught at each stage of medical education. Delphi respondents included experts in medical education or social determinants of health. A survey was created using nationally published criteria for social determinants of health learning objectives. Respondents were asked 1) which learning objectives were necessary for every physician (irrespective of specialty) to develop competence upon completion of medical training and 2) when the learning objective should be taught. Respondents were also asked an open-ended question on how they made the determination of when in the medical education continuum the learning objective should be taught., Results: 26 out of 55 experts (13 social determinants of health and 13 education experts) responded to all 3 Delphi rounds. Experts evaluated a total of 49 learning objectives and were able to achieve consensus for at least one of the two research questions for 45 of 49 (92%) learning objectives. 50% more learning objectives reached consensus for inclusion in undergraduate (n = 21) versus graduate medical education (n = 14)., Conclusions: A modified Delphi technique demonstrated that experts could identify key learning objectives of social determinants of health needed by all physicians and allocate content along the undergraduate and graduate medical education continuum. This approach could serve as a model for similar socio-cultural content. Future work should employ a qualitative approach to capture principles utilized by experts when making these decisions., (© 2022. The Author(s).)

Purpose: Nearly 50% of patients recur within two years after curatively intended resection of colorectal cancer liver metastasis (CRLM). The optimal surveillance strategy is unknown due to the lack of evidence. Here, we explored the potential for improving postoperative CRLM surveillance by performing serial circulating tumour DNA (ctDNA) assessments parallel to standard-of-care surveillance., Experimental Design: 499 prospectively collected serial plasma samples from 96 patients undergoing CRLM resection were analysed using the tumour-agnostic methylation multiplex droplet-digital PCR test 'TriMeth'., Results: Patients with ctDNA postoperatively or post adjuvant chemotherapy experienced a significant lower recurrence-free survival than patients without ctDNA (hazard ratio (HR) 4.5; P < 0.0001 and HR 8.4, P < 0.0001). ctDNA status was a stronger predictor of recurrence than standard clinical risk factors and carcinoembryonic antigen. Serial TriMeth analysis detected ctDNA before radiological recurrence in 55.6% of ctDNA-positive patients, with up to 10.6 months lead-time (median 3.1 months). During surveillance, 24% of patients had inconclusive CT scans, which was associated with a significant delay in recurrence diagnosis (median 3.5 months versus 1.0 month, P < 0.0001). Uniquely, ctDNA status at the time of inconclusive CT scans predicted recurrence with positive and negative predictive values of 100%, and 75% (P = 0.0003). Serial TriMeth analysis allowed ctDNA growth rate assessment and revealed that fast ctDNA growth was associated with poor overall survival (HR: 1.6, P = 0.0052)., Conclusions: Serial postoperative ctDNA analysis has a strong prognostic value and is more sensitive for recurrence detection than standard-of-care CRLM surveillance tools. Altogether, TriMeth provides several opportunities for improving postoperative surveillance of CRLM patients., Competing Interests: Conflict of interest statement The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Washington University School of Medicine has not undergone substantive curricular change for 25 years. In 2018, we embarked on a curriculum transformation project informed by the change leadership principles of James Kotter and William Bridges. This included developing a structured process to create a sense of urgency for why we needed to change, building coalitions to support change, and developing a compelling vision across multiple stakeholder groups. Implementation work began in 2019 with a planned curriculum start of July 2020. The COVID-19 pandemic disrupted these plans. Employing the Cynefin framework for decision making and guided by our core principles, we were able to launch the new curriculum in September 2020. In this paper, I will describe the principles underpinning our curriculum transformation, how the Cynefin framework allowed us to move forward productively during the COVID-19 crisis, and the impact COVID-19 had, both positively and negatively, on the curriculum transformation process., (© 2022 The American Clinical and Climatological Association.)

Although condylar dislocation is not uncommon, terminology, diagnostics, and treatment concepts vary considerably worldwide. This study aims to present a consensus recommendation based on systematically reviewed literature and approved by the European Society of TMJ Surgeons (ESTMJS). Based on the template of the evidence-based German guideline (register # 007-063) the ESTMJS members voted on 30 draft recommendations regarding terminology, diagnostics, and treatment initially via a blinded modified Delphi procedure. After unblinding, a discussion and voting followed, using a structured consensus process in 2019. An independent moderator documented and evaluated voting results and alterations from the original draft. Although the results of the preliminary voting were very heterogenous and differed significantly from the German S3 guideline ( p < 0.0005), a strong consensus was achieved in the final voting on terminology, diagnostics, and treatment. In this voting, multiple alterations, including adding and discarding recommendations, led to 24 final recommendations on assessment and management of TMJ dislocation. To our knowledge, the ESTMJS condylar dislocation recommendations are the first both evidence and consensus-based international recommendations in the field of TMJ surgery. We recommend they form the basis for clinical practice guidelines for the management of dislocations of the mandibular condyle.

Background: Literature describing the effectiveness of teaching strategies in the clinical setting is limited. This realist synthesis review focuses on understanding the effectiveness of teaching strategies used in the clinical setting. Methods: We searched ten databases for English language publications between 1 January 1970 and 31 May 2017 reporting effective teaching strategies, used in a clinical setting, of non-procedural skills. After screening, we used consensus to determine inclusion and employed a standardised instrument to capture study populations, methodology, and outcomes. We summarised what strategies worked, for whom, and in what settings. Results: The initial search netted 53,642 references after de-duplication; 2037 were retained after title and abstract review. Full text review was done on 82 references, with ultimate inclusion of 25 publications. Three specific teaching strategies demonstrated impact on educational outcomes: the One Minute Preceptor (OMP), SNAPPS, and concept mapping. Most of the literature involves physician trainees in an ambulatory environment. All three have been shown to improve skills in the domains of medical knowledge and clinical reasoning. Discussion/conclusions: Apart from the OMP, SNAPPS, and concept mapping, which target the formation of clinical knowledge and reasoning skills, the literature establishing effective teaching strategies in the clinical setting is sparse.

Background and Aims: Gastroenterology fellowships need to ensure that trainees achieve competence in upper endoscopy (EGD) and colonoscopy. Because the impact of structured feedback remains unknown in endoscopy training, this study compared the effect of structured feedback with standard feedback on trainee learning curves for EGD and colonoscopy., Methods: In this multicenter, cluster, randomized controlled trial, trainees received either individualized quarterly learning curves or feedback standard to their fellowship. Assessment was performed in all trainees using the Assessment of Competency in Endoscopy tool on 5 consecutive procedures after every 25 EGDs and colonoscopies. Individual learning curves were created using cumulative sum (CUSUM) analysis. The primary outcome was the mean CUSUM score in overall technical and overall cognitive skills., Results: In all, 13 programs including 132 trainees participated. The intervention arm (6 programs, 51 trainees) contributed 558 EGD and 600 colonoscopy assessments. The control arm (7 programs, 81 trainees) provided 305 EGD and 468 colonoscopy assessments. For EGD, the intervention arm (-.7 [standard deviation {SD}, 1.3]) had a superior mean CUSUM score in overall cognitive skills compared with the control arm (1.6 [SD, .8], P = .03) but not in overall technical skills (intervention, -.26 [SD, 1.4]; control, 1.76 [SD, .7]; P = .06). For colonoscopy, no differences were found between the 2 arms in overall cognitive skills (intervention, -.7 [SD, 1.3]; control, .7 [SD, 1.3]; P = .95) or overall technical skills (intervention, .1 [SD, 1.5]; control, -.1 [SD, 1.5]; P = .77)., Conclusions: Quarterly feedback in the form of individualized learning curves did not affect learning curves for EGD and colonoscopy in a clinically meaningful manner. (Clinical trial registration number: NCT02891304.)., (Copyright © 2020 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Minimum EUS and ERCP volumes that should be offered per trainee in "high quality" advanced endoscopy training programs (AETPs) are not established. We aimed to define the number of procedures required by an "average" advanced endoscopy trainee (AET) to achieve competence in technical and cognitive EUS and ERCP tasks to help structure AETPs., Methods: American Society for Gastrointestinal Endoscopy (ASGE)-recognized AETPs were invited to participate; AETs were graded on every fifth EUS and ERCP examination using a validated tool. Grading for each skill was done using a 4-point scoring system, and learning curves using cumulative sum analysis for overall, technical, and cognitive components of EUS and ERCP were shared with AETs and trainers quarterly. Generalized linear mixed-effects models with a random intercept for each AET were used to generate aggregate learning curves, allowing us to use data from all AETs to estimate the average learning experience for trainees., Results: Among 62 invited AETPs, 37 AETs from 32 AETPs participated. Most AETs reported hands-on EUS (52%, median 20 cases) and ERCP (68%, median 50 cases) experience before starting an AETP. The median number of EUS and ERCPs performed per AET was 400 (range, 200-750) and 361 (range, 250-650), respectively. Overall, 2616 examinations were graded (EUS, 1277; ERCP-biliary, 1143; pancreatic, 196). Most graded EUS examinations were performed for pancreatobiliary indications (69.9%) and ERCP examinations for ASGE biliary grade of difficulty 1 (72.1%). The average AET achieved competence in core EUS and ERCP skills at approximately 225 and 250 cases, respectively. However, overall technical competence was achieved for grade 2 ERCP at about 300 cases., Conclusion: The thresholds provided for an average AET to achieve competence in EUS and ERCP may be used by the ASGE and AETPs in establishing the minimal standards for case volume exposure for AETs during their training. (Clinical trial registration number: NCT02509416.)., (Copyright © 2019 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: Synovial cysts of the temporomandibular joint are rare and treatment is based on consensus from cases reporting unilateral successful outcomes. A patient with a synovial cyst is presented, treated with successful surgical excision of the cyst, but without remission of joint symptoms. Furthermore, the case is supplemented by a critical, literature review., Methods: This case report deals with a patient with a synovial cyst that presented with temporomandibular joint (TMJ) pain and reduced mouth opening. Magnetic resonance imaging verified a TMJ cyst., Results: Surgical excision removed the synovial cyst, and the patient was followed-up for 4 years, with no recurrence of the cyst. Despite successful excision of the cyst, the symptoms did not subside, and the patient is still in treatment. The critical, literature review found 23 case reports describing 24 synovial cysts. In addition, 4 cases were included as their synovial cysts were erroneously described as ganglion cysts. In 4 cases, histological diagnosis could not be confirmed, and they were excluded. All cases described treatment by surgical excision without recurrence. The reported median follow-up was 10 months and postoperative TMJ symptoms were rarely examined or described., Conclusions: The temporomandibular joint symptoms may persist despite successful removal of the synovial cyst. Furthermore, the 4 identified synovial cysts, mislabelled as ganglion cysts, represents almost a quarter of the cases of the reported synovial cysts. Correct labelling and reporting of synovial cysts are still imperative to describe the diverse aspects of treatment outcomes following surgical excision.

Background: While leadership training is increasingly incorporated into residency education, existing assessment tools to provide feedback on leadership skills are only applicable in limited contexts., Objective: We developed an instrument, the Leadership Observation and Feedback Tool (LOFT), for assessing clinical leadership., Methods: We used an iterative process to develop the tool, beginning with adapting the Leadership Practices Inventory to create an open-ended survey for identification of clinical leadership behaviors. We presented these to leadership experts who defined essential behaviors through a modified Delphi approach. In May 2014 we tested the resulting 29-item tool among residents in the internal medicine and pediatrics departments at 2 academic medical centers. We analyzed instrument performance using Cronbach's alpha, interrater reliability using intraclass correlation coefficients (ICCs), and item performance using linear-by-linear test comparisons of responses by postgraduate year, site, and specialty., Results: A total of 377 (of 526, 72%) team members completed the LOFT for 95 (of 519, 18%) residents. Overall ratings were high-only 14% scored at the novice level. Cronbach's alpha was 0.79, and the ICC ranged from 0.20 to 0.79. Linear-by-linear test comparisons revealed significant differences between postgraduate year groups for some items, but no significant differences by site or specialty. Acceptability and usefulness ratings by respondents were high., Conclusions: Despite a rigorous approach to instrument design, we were unable to collect convincing validity evidence for our instrument. The tool may still have some usefulness for providing formative feedback to residents on their clinical leadership skills., Competing Interests: Conflict of interest: The authors declare they have no competing interests.

Background: Sub-Saharan Africa has an inadequate number of health professionals, leading to a reduced capacity to respond to health challenges, including HIV/AIDS. From 2010 to 2015, the Medical Education Partnership Initiative (MEPI)-sponsored by the U.S. Presidents Emergency Plan for AIDS Relief (PEPFAR) and the National Institutes of Health (NIH)-was enthusiastically taken up by the University of Zimbabwe College of Health Sciences (UZCHS) and 12 other sub-Saharan African universities to develop models of training to improve medical education and research capacity. In this article, we describe the outcomes and challenges of MEPI in Zimbabwe., Methods: UZCHS in partnership with the University of Colorado, Denver; Stanford University; University of Cape Town; University College London; and King's College London designed the Novel Education Clinical Trainees and Researchers (NECTAR) program and 2 linked awards addressing cardiovascular disease and mental health to pursue MEPI objectives. A range of medical education and research capacity-focused programs were implemented, including faculty development, research support, mentored scholars, visiting professors, community-based education, information and technology support, cross-cutting curricula, and collaboration with partner universities and the ministries of health and education. We analyzed quantitative and qualitative data from several data sources, including annual surveys of faculty, students, and other stakeholders; workshop exit surveys; and key informant interviews with NECTAR administrators and leaders and the UZCHS dean., Findings: Improved Internet connectivity and electronic resource availability were early successes of NECTAR. Over the 5-year period, 69% (115 of 166) of faculty members attended at least 1 of 15 faculty development workshops. Forty-one faculty members underwent 1-year advanced faculty development training in medical education and leadership. Thirty-three mentored research scholars were trained under NECTAR, and 52 and 12 in cardiovascular and mental health programs, respectively. Twelve MEPI scholars had joined faculty by 2015. Full-time faculty grew by 36% (122 to 166), annual postgraduate and medical student enrollment increased by 61% (75 to 121) and 71% (123 to 210), respectively. To institutionalize and sustain MEPI innovations, the Research Support Center and the Department of Health Professions Education were established at UZCHS., Conclusion: MEPI has synergistically revitalized medical education, research capacity, and leadership at UZCHS. Investments in creating a new research center, health professions education department, and, programs have laid the foundation to help sustain faculty development and research capacity in the country., (© Hakim et al.)

Problem: In medical education, evaluating outcomes from programs intended to transform attitudes or influence career trajectories using conventional methods of monitoring is often difficult. To address this problem, the authors adapted the most significant change (MSC) technique to gain a more comprehensive understanding of the impact of the Medical Education Partnership Initiative (MEPI) program at the University of Zimbabwe College of Health Sciences., Approach: In 2014-2015, the authors applied the MSC to systematically examine the personal significance and level of positive transformation that individuals attributed to their MEPI participation. Interviews were conducted with 28 participants nominated by program leaders. The authors coded results inductively for prevalent themes in participants' stories and prepared profiles with representative quotes to place the stories in context. Stakeholders selected 9 themes and 18 stories to illustrate the most significant changes., Outcomes: Six themes (or outcomes) were expected, as they aligned with MEPI goals-becoming a better teacher, becoming a better clinician, increased interest in teaching, increased interest in research, new career pathways (including commitment to practice in Zimbabwe), and improved research skills. Three themes were unexpected-increased confidence, expanded interprofessional networks, and improved interpersonal interactions., Next Steps: The authors found the MSC to be a useful and systematic evaluation approach for large, complex, and transformative initiatives like MEPI. The MSC seemed to encourage participant reflection, support values inquiry by program leaders, and provide insights into the personal and cultural impacts of MEPI. Additional trial applications of the MSC technique in academic medicine are warranted.

Purpose: During the last two decades in the United States, academies of medical educators (AMEs) have proliferated as formal organizations within faculties of health professions education to recognize teaching excellence, support faculty development, and encourage scholarly activity. AMEs have been effective at rewarding faculty for educational excellence and providing faculty development. However, the impact of an AME on campus culture remains unclear., Method: A qualitative case study asked, How has an AME shaped organizational culture? The authors investigated the University of Colorado health sciences campus AME given its clear mandate to impact organizational culture. The authors interviewed a purposeful sample of 26 AME members and non-AME campus faculty and educational leaders during the 2014-2015 academic year. Two reviewers employed content analysis to code the transcripts., Results: The AME has positively impacted organizational culture by being a symbol of institutional commitment to the educational mission, and by asserting education as an evidence-based practice. At the faculty member level, the AME's impact includes creating a home and community for educators to network. Individual faculty influence departments and programs across campus through teaching and interpersonal connections. However, the AME has not impacted all of campus, due to only reaching self-identified educators, and the siloed nature of departments on campus., Conclusions: Although limited to a single campus and an early established AME, this study contributes significant insight by describing how an AME as a structural unit impacts individual faculty members, who in turn impact organizational campus culture regarding the educational mission.

Background: Some internal medicine residency programs on X+Y schedules have modified clinic preceptor schedules to mimic those of the resident cohort (resident matched). This is in contrast to a traditional model, in which preceptors supervise on the same half-day each week., Objective: We assessed preceptor and resident perceptions of the 2 precepting models., Methods: We surveyed 44 preceptors and 97 residents at 3 clinic sites in 2 academic medical centers. Two clinics used the resident-matched model, and 1 used a traditional model. Surveys were completed at 6 months and 1 year. We assessed resident and preceptor perceptions in 5 domains: relationships between residents and preceptors; preceptor familiarity with complex patients; preceptor ability to assess milestone achievements; ability to follow up on results; and quality of care., Results: There was no difference in perceptions of interpersonal relationships or satisfaction with patient care. Preceptors in the resident-matched schedule reported they were more familiar with complex patients at both 6 months and 1 year, and felt more comfortable evaluating residents' milestone achievements at 6 months, but not at 1 year. At 1 year, residents in the resident-matched model perceived preceptors were more familiar with complex patients than residents in the traditional model. The ability to discuss patient results between clinic weeks was low in both models., Conclusions: The resident-matched model increased resident and preceptor perceptions of familiarity with complex patients and early preceptor perceptions of comfort in assessment of milestone achievements., Competing Interests: Conflict of interest: Dr Aagaard receives small stipends from the American Board of Internal Medicine and the National Board of Medical Examiners for board-related work. This study was presented as a poster at the Society of General Internal Medicine New England Regional Meeting, Boston, Massachusetts, March 11, 2016; as a poster at the Society of General Internal Medicine National Meeting, Hollywood, Florida, May 10, 2016; and as an oral presentation at the University of Vermont Teaching Academy Mud Season Retreat, Burlington, Vermont, April 14–15, 2016.

Purpose: In segmental maxillary procedures, it is imperative to obtain as much of the planned expansion as possible. Lack of obtained expansion, in addition to late relapse after splint removal, can result in relapse of the posterior crossbite. This study investigated the influence of 2 surgical splint designs on achieving the planned transverse expansion in bimaxillary surgery with segmental maxillary procedures., Materials and Methods: Forty-two participants were included in a retrospective observational study. All participants had completed virtually planned bimaxillary surgery with 3-piece maxillary segmentation. The primary outcome variable was the transverse expansion obtained, measured as the expansion between the maxillary first molars on preoperative and postoperative cone-beam computed tomograms. The postoperative scan was performed 1 week after surgery with the splint still in place. To test measurement reliability, all measurements were performed twice by the same observer. The primary predictor variable was the planned expansion according to the virtual surgical plan. The primary covariate with influence on the obtained expansion was the surgical splint design. Other covariates of interest included patient age, patient gender, and surgeon. Descriptive and bivariate statistics were performed using Student t tests and linear regression analysis., Results: Measurements showed high reliability, with an intraclass correlation coefficient of 0.99 and Bland-Altman plots without systematic errors. The obtained expansion was statistically different from the planned expansion (mean, -0.77 mm; standard deviation, 0.83). Surgical splint design meaningfully influenced transverse expansion: 77% of the planned expansion was obtained with high palatal coverage, whereas 50% was obtained with low palatal coverage. No other covariates influenced the expansion obtained., Conclusion: Not all the planned expansion is obtained during segmental bimaxillary surgery. Use of rigid surgical splints with high palatal coverage considerably improves the amount of expansion obtained and is recommended for segmental maxillary procedures., (Copyright © 2017 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Reduced volume of the internal skeletal dimensions of the face is 1 of the main causes of obstructive sleep apnea, and attention to patients' airways is necessary when planning orthognathic treatment. This study aims to describe changes in upper airway volume following virtually planned orthognathic surgery.A retrospective pilot study was designed with 30 randomly selected patients (10 men and 20 women, aged 23.1 ± 6.8 years, molar-relations: 15 neutral, 8 distal, and 7 mesial). Cone-beam computed tomography scans were performed before surgery and 1 week following surgery. The authors did total upper airway volume measurements and obtained 1-mm slices at vertical levels in the velo-, oro-, and hypopharynx and at the smallest visible cross-section.Measurements before and after surgery were compared using Student t test.After orthognathic surgery, the minimum cross-sectional area at the vertical level increased from 83 mm ± 33 before surgery to 102 mm ± 36 after surgery (P = 0.019). In patients with neutral and distal occlusions, the minimum cross-sectional slice volume increased in 87% but in only 57% with mesial occlusion.The present findings suggest that orthognathic surgery increases upper airway volume parameters, but a few patients have continued impairment of the airways following orthognathic surgery. Further studies are needed to confirm an individual surgical planning approach that potentially could bring the minimum cross sectional area out of the risk zone.

Continuity of care is a core value of patients and primary care physicians, yet in graduate medical education (GME), creating effective clinical teaching environments that emphasize continuity poses challenges. In this Perspective, the authors review three dimensions of continuity for patient care-informational, longitudinal, and interpersonal-and propose analogous dimensions describing continuity for learning that address both residents learning from patient care and supervisors and interprofessional team members supporting residents' competency development. The authors review primary care GME reform efforts through the lens of continuity, including the growing body of evidence that highlights the importance of longitudinal continuity between learners and supervisors for making competency judgments. The authors consider the challenges that primary care residency programs face in the wake of practice transformation to patient-centered medical home models and make recommendations to maximize the opportunity that these practice models provide. First, educators, researchers, and policy makers must be more precise with terms describing various dimensions of continuity. Second, research should prioritize developing assessments that enable the study of the impact of interpersonal continuity on clinical outcomes for patients and learning outcomes for residents. Third, residency programs should establish program structures that provide informational and longitudinal continuity to enable the development of interpersonal continuity for care and learning. Fourth, these educational models and continuity assessments should extend to the level of the interprofessional team. Fifth, policy leaders should develop a meaningful recognition process that rewards academic practices for training the primary care workforce.