Faculty Bibliography

Problem: Much of the medical education literature on clinical reasoning (CR) comes from primarily English-speaking countries. It is less clear how these educational interventions translate to environments with non-native English speakers, and in clinical systems where there is higher patient volumes.
Purpose(s): To implement a CR session for 6th year medical students at a university hospital in Istanbul, Turkey. Description of Program: In November, 2018 we conducted a 3-hour session on CR at Koc University in Istanbul developed from a curriculum at our home institution in the United States. In an interactive case-based didactic, students were introduced to the CR concepts of problem representation (PR), illness scripts, and diagnostic time outs. Students then applied these concepts to a case during facilitated small group breakouts. Outcomes Twenty-four 6th year medical students participated. Retrospective pre-post self-assessments of confidence in and likelihood of using CR concepts on an eight-point Likert scale were completed, and qualitative data on use in clinical practice were obtained. Results were analyzed using a paired t-test. After participating in this session, students were more confident in and more likely to use all domains of the CR framework taught with large effect sizes in eight of ten domains (Figure 1). A common theme in the qualitative data was that the use of PR would be helpful to communicate about patients efficiently in the busy clinical environment.
Discussion(s): Teaching CR skills translated well to an international setting. Critical to the session's success was demonstrating relevance to the local institution's clinical environment, in particular taking into account the higher patient volume experienced by providers, and changing the attitude that better decision-making does not necessarily take longer. The impact of culture and environment was evidenced by what the students found to be most effective-use of PR to communicate efficiently about patients in a busy clinical environment-which is different from our experiences teaching this in the US where learners often highlight the utility of the diagnostic time out. Significance of Findings Our findings speak to the need to contextualize CR concepts within the local learning culture to define relevance and meet the learners' needs. (Figure Presented)

Learning Objectives: Radiologist interpretations contribute to anchoring bias. Differentiating problems with similar presentations requires thorough exams and detailed patient histories. Correct management often requires a patient-centered approach. Case Information: A 48 year old woman developed a limp from pain in the ball of the right foot while training for her fifth half marathon. A radiologist diagnosed Freiberg's Disease Stage 2, a rare avascular necrosis of the metatarsal head, based on an x-ray ordered by her podiatrist. X-ray findings include flattening of the metatarsal head, which is a normal variant in 10% of people. The podiatrist prescribed a fracture boot. The patient consulted an orthopedist who changed management to a metatarsal pad for her insole after reviewing the x-ray without an alternative diagnosis. Doubting her diagnosis, the patient consulted a physiatrist who confirmed Freiberg's Disease. After 6 weeks of pain, her orthopedist ordered an MRI that ruled out Freiberg's and showed a partial plantar plate tear with significant localized bursitis. She was taught to tape her toe, but pain persisted with the metatarsal pad. A new podiatrist noticed that the metatarsal pad was creating gait problems and he altered her running shoe insole instead. After two weeks, she was running again.
Discussion(s): Metatarsalgia has many causes, yet three doctors anchored their diagnosis on an incorrect radiology report. Listening to the nuances of the patient's story and performing an extensive exam may have expedited the correct diagnosis. Many doctors use metatarsal pads, but this management may cause harm in some patients. (Figure Presented)

Background: The growing opioid overdose epidemic has grappled the nation with the CDC now reporting that drug overdose deaths have become the most common cause of death for young people. Medical education has historically ignored substance use disorders, and though they generally require all medical students to learn basic life support, they have not taught how to respond to opioid overdoses. Further, medical education is moving towards modalities which utilize adult learning theory. One such modality are online modules. However, there are few studies comparing their outcomes with traditional lectures. Previously, the authors compared in-person and online training of medical students to respond to opioid overdoses using naloxone in a non-randomized controlled setting, which showed no meaningful differences in knowledge, attitudes, and preparedness outcomes for students. In this paper, the authors attempt to use a randomized controlled trial to compare the two educational modalities at a second urban medical school.
Objective(s): The author's primary objective was to demonstrate non-inferiority of online compared to in-person training for knowledge. Our secondary objective were to show non-inferiority of online compared to in-person training attitudes, and preparedness.
Method(s): Our study received IRB exemption as an education intervention. As a part of a transition to clinical clerkships curriculum used for second year medical students, second year medical students in an urban medical school were randomized into training sessions by the office of medical education without foreknowledge of the planned study. Students taking the online training were provided with a link to online modules with pre- and post-tests and video based lectures. Students randomized to the in-person training group took a pre-test just prior to receiving an oral lecture, and then immediately completed a post-test. Paired student's t-tests were used to compare measurements for each group in knowledge, attitudes, and preparedness, and Cohen's D was used to measure the effect size of the change. We calculated 99% confidence intervals for each measure and utilized a margin of non-inferiority of 5%.
Result(s): The in-person group demonstrated a statistically significant increase in knowledge, a non-statistically significant decrease in self-reported preparedness, and a small non-statistically significant increase in attitudes, see Table 1. The online group demonstrated a statistically significant increase in knowledge and self-reported preparedness, without a statistically significant change in attitudes, see Table 1. 99% CIs were [-0.20, 1.09] for knowledge, [6.51, 10.93] for preparedness, and [-2.32, 1.59] for attitudes, see Figure 1.
Conclusion(s): Online training for opioid overdose prevention training provided non-inferior outcomes for knowledge, preparedness, and attitudes. This study supports the use of online opioid overdose prevention training as a non-inferior alternative to in-person training

The main focus of this study is bridging the "evidence gap" between frontline decision-making in health care and the actual evidence, with the hope of reducing unnecessary diagnostic testing and treatments. From our work in pulmonary embolism (PE) and over ordering of computed tomography pulmonary angiography, we integrated the highly validated Wells' criteria into the electronic health record at two of our major academic tertiary hospitals. The Wells' clinical decision support tool triggered for patients being evaluated for PE and therefore determined a patients' pretest probability for having a PE. There were 12,759 patient visits representing 11,836 patients, 51% had no D-dimer, 41% had a negative D-dimer, and 9% had a positive D-dimer. Our study gave us an opportunity to determine which patients were very low probabilities for PE, with no need for further testing.

Racial and ethnic minorities in the U.S. experience higher incidence of and greater morbidity from chronic disease. Limited English proficiency (LEP) is a known contributor to these health disparities. The Culturally and Linguistically Appropriate Services (CLAS) standards of the U.S. Department of Health and Human Services promote health equity through the incorporation of professional interpreter services. While such services have been shown to improve quality of care, limited data exist on patient perspectives regarding these services. Better understanding patient experiences with telephone interpreter services (TIS), an increasingly used modality for professional interpretation, could elucidate ways of improving care for this population. This study explored Spanish-speaking patient experiences with TIS at an urban community clinic. Qualitative data collected via focus groups was analyzed using content analysis and grounded theory methods. Our findings suggest that TIS are generally well accepted by Spanish-speaking LEP patients. Limited relationship development with providers and physician attitudes toward TIS were among reported barriers to the use of these services.

Background: There is growing evidence for the role of TRPC1 in regulating glucose & lipid metabolism. Secretion of insulin, leptin & adiponectin is sensitive to cell free Ca. TRPC1 may mediate the effects of leptin in anorexigenic hypothalamic neurons. TRPC1 iwas found low in diabetes & we recently found hyperglycemia in null mice. We tested if TRPC1 deficiency produces MetS & if 45% HFD x 3 mon aggravates it.
Method(s): In age-matched TRPC1 +/+. +/-, & -/-mice, we measured glucose & lipids using standard methods & insulin, leptin, & adiponectin by mouse ELISA. We did glucose tolerance test (GTT) by IP glucose (2 mg/kg) after 13 h fast.
Result(s): From 4-30 week, null mice ate & weighed more than +/-& wt. At 4 mon, HOMA-insulin resistance (IR) was up 60% & HOMA beta down 40%. By 12 mon, HOMAIR was up 8 fold. At 7 mon, by GTT, both TRPC1 +/-& -/-mice were diabetic. In null, adiponectin was down 11% but leptin up 77%. At 2 mon, total cholesterol was 85% hgher in null, their liver 36% heavier, & triglyceride content (TGC) 47% higher. Liver echogenicity was up by 50-150% at 7, 11, & 22 mon, confirmed by 140% higher liver TGC. At 12 mon, only null mice had hyperlipidemia (cholesterol up 30%, LDL up 60%, & TG up 200%). In +/-& wt, lipids, liver density at 12 & 19 mon, & liver TGC at 19 mon were all normal. Fasting glucose was high only in null from 1 through 16 mon). Thus on a normal fat diet (NFD), 1 wt allele prevented hyperphagia, obesity, MetS & hepatic steatosis. As expected, HFD vs NFD stimulated leptin & insulin, similarly in all 3 genotypes without altering adiponectin. Unlike NFD, HFD increased liver density in +/-& wt, but not in null. HFD induced the highest HOMA-IR in wt (3.1 vs 1.3 x in +/-) & the largest liver TGC hike in wt (3.3 vs 1.6 x in null). During GTT, AUC for glucose vs time was the highest in wt vs null.
Conclusion(s): 1. Diploid TRPC1 deletion produces hyperphagia, obesity & Met S, all resolvable by caloric restriction, implying hypothalamic resistance to leptin in null mice. 2. HFD raises the risks of dyslipidemia & hepatic steatosis, only in the presence of 1-2 wt alleles, as if deficiency would block the pathogenic Ca-CM-NFAT signaling pathway. 3. TRPC1 -/-is a good model to study MetS