Medicine Cut Off From Its Roots: Context Matters In Medical Education

Extracorporeal membrane oxygenation (ECMO) is a form of long-term cardiopulmonary bypass used to treat infants, children, and adults with respiratory and/or cardiac failure despite maximal medical therapy. Mechanical emergencies on extracorporeal membrane oxygenation (ECMO) have an associated mortality of 25%. Thus, acquiring and maintaining the technical, behavioral, and critical thinking skills necessary to manage ECMO emergencies is essential to patient survival. Traditional training in ECMO management is primarily didactic in nature and usually complemented with varying degrees of hands-on training using a water-filled ECMO circuit. These traditional training methods do not provide an opportunity for trainees to recognize and interpret real-time clinical cues generated by human patients and their monitoring equipment. Adult learners are most likely to acquire such skills in an active learning environment. To provide authentic, intensive, interactive ECMO training without risk to real patients, we used methodologies pioneered by the aerospace industry and our experience developing a simulation-based training program in neonatal resuscitation to develop a similar simulation-based training program in ECMO crisis management, ECMO Sim. A survey was conducted at the 19th Annual Children's National Medical Center ECMO Symposium to determine current methods for ECMO training. Using commercially available technology, we linked a neonatal manikin with a standard neonatal ECMO circuit primed with artificial blood. Both the manikin and circuit were placed in a simulated neonatal intensive care unit environment equipped with remotely controlled monitors, real medical equipment and human colleagues. Twenty-five healthcare professionals, all of whom care for patients on ECMO and who underwent traditional ECMO training in the prior year, participated in a series of simulated ECMO emergencies. At the conclusion of the program, subjects completed a questionnaire qualitatively comparing ECMO Sim with their previous traditional ECMO training experience. The amount of time spent engaged in active and passive activities during both ECMO Sim and traditional ECMO training was quantified by review of videotape of each program. Hospitals currently use lectures, multiple-choice exams, water drills, and animal laboratory testing for their ECMO training. Modification of the circuit allowed for physiologically appropriate circuit pressures (both pre- and postoxygenator) to be achieved while circulating artificial blood continuously through the circuit and manikin. Realistic changes in vital signs on the bedside monitor and fluctuations in the mixed venous oxygen saturation monitor were also effectively achieved remotely. All subjects rated the realism of the scenarios as good or excellent and described ECMO Sim as more effective than traditional ECMO training. They reported that ECMO Sim engaged their intellect to a greater degree and better developed their technical, behavioral, and critical thinking skills. Active learning (eg, hands-on activities) comprised 78% of the total ECMO Sim program compared with 14% for traditional ECMO training (P < 0.001). Instructor-led lectures predominated in traditional ECMO training. Traditional ECMO training programs have yet to incorporate simulation-based methodology. Using current technology it is possible to realistically simulate in real-time the clinical cues (visual, auditory, and tactile) generated by a patient on ECMO. ECMO Sim as a training program provides more opportunities for active learning than traditional training programs in ECMO management and is overwhelmingly preferred by the experienced healthcare professionals serving as subjects in this study. Subjects also indicated that they felt that the acquisition of key cognitive, technical, and behavioral skills and transfer of those skills to the real medical domain was better achieved during simulation-based training.

Education: “The process or art of imparting knowledge, skill and judgment; Facts, skills and ideas that have been learnt, either formally or informally.” — Wikipedia 1 The term profession is applied to those persons who have specialized and technical skill or knowledge which they apply, for a fee, to certain tasks that ordinary and unqualified people cannot ordinarily undertake. The term derives from the Latin: “to swear (an oath) …” . — Wikipedia 2 Let’s consider how we as cardiovascular medicine specialists spend our days in the care of people with cardiovascular disease. In the office or making rounds in the hospital, we prescribe drugs and order diagnostic tests; in the noninvasive laboratory, we obtain and interpret images of the heart; in the electrophysiology and cardiac catheterization laboratories, we program and implant devices in patients. When antithrombotic and fibrinolytic drugs are administered, and primary percutaneous coronary intervention is done using balloon catheters and intracoronary stents, lives are saved among patients with acute myocardial infarction. Response by Avorn and Choudhry see p 2221 The mortality risk from heart failure decreases and quality of life increases from the proper and appropriate use of angiotensin-converting enzyme inhibitors and β-blockers. Lipid lowering through the use of statin drugs saves lives and reduces serious cardiovascular complications such as myocardial infarction and stroke when properly prescribed to patients with a variety of manifestations of atherosclerotic vascular diseases. According to a recent publication by Ford and colleagues,3 deaths due to coronary heart disease in the United States declined substantially from 1980 to 2000, resulting in >340 000 fewer deaths in 2000. The authors attributed approximately half of this decline to changes in cardiac risk factors and half to the application of evidence-based therapies. An underlying theme in all of this is that the pharmaceutical, biotechnology, and …

This paper evaluates the active labour market policy instrument called ‘chosen training’ (in Czech zvolené rekvalifikace), introduced to the Czech labour market policy in 2012. This new instrument allows the registered unemployed much more freedom to choose their supposed future career path by selecting the preferred profession for training and preferred training provider than traditional standard training programs. The added value of this paper is in the intentional linking of the provision of new measures with the assessment of impacts. The methodology of this text is based on quantitative program assessment. We used PES administrative data OK Práce for programmes implemented in 2016 and tracked the outcomes for 2016-2020. We compare a new instrument with more traditional training programs that continue to be provided alongside the new tool. We concluded that chosen training provided better results than standard training, and we addressed some of the reasons behind the perceived difference.

A healthy lifestyle is fundamental for the prevention and treatment of cardiovascular disease and other noncommunicable diseases (NCDs). Investment in primary prevention, including modification of health risk behaviors, could result in a 4-fold improvement in health outcomes compared with secondary prevention based on pharmacological treatment. The American Heart Association (AHA) emphasized the importance of lifestyle in its 2020 goals for cardiovascular health promotion and disease reduction. In addition to defining “cardiovascular health” based on criteria for blood pressure and biochemical markers (lipids and glycemia), the AHA Strategic Planning Committee further identified lifestyle characteristics of central importance: nutrition, physical activity, smoking, and maintenance of a healthy body weight.1 The World Health Organization estimated that ≈80% of NCDs could be prevented if 4 key lifestyle practices were followed: a healthy diet, being physically active, avoidance of tobacco, and alcohol intake in moderation.2 To support healthy lifestyle initiatives, major changes are necessary at the societal level to improve population health. Numerous strategies might help to create a culture that promotes and facilitates healthy behaviors, including creating laws and regulations, mounting large-scale public awareness and education campaigns, implementing local community programs, and providing individual counseling.3 Physicians are uniquely positioned to encourage individuals to adopt healthy lifestyle behaviors: Approximately 80% of Americans visit their primary care physician at least once a year. Physicians directly communicate with their patients during clinical encounters across numerous settings, and research indicates that patients highly value recommendations provided by their physicians.4,5 However, data further indicate that lifestyle counseling does not routinely occur in physicians’ offices, thereby representing a lost opportunity. Physicians report that they perform lifestyle counseling during ≈34% of clinic visits.4 Patients, in turn, report an even lower frequency of physician lifestyle counseling. For example, obese patients reported receiving physical activity and …

Background: Functional movement screening (FMS) and Y-balance test (YBT) are assessment procedures used to examine the ‘quality’ of movement patterns and identify individuals that might have specific limitations or asymmetries. Low FMS and YBT scores have been linked with a higher risk of injury among athletic populations. Since FMS and YBT are becoming more widely used screening tools, it is important to examine the various training programs that could improve FMS and YBT scores. Purpose: This pilot study examined the effects of a 10-week periodized and traditional military training program on FMS, and upper and lower quadrant YBT scores of Reserve Officers Training Corps (ROTC) Cadets. Methods: Subjects consisted of 36 Army and Air Force ROTC cadets (male=24, female=12), Age 19.7(yrs)±5.96, Height (cm)=175.7±9.28, Weight(kg)=75.70±13.41. The periodized, intervention group (IG n=24) trained for 1 hour/day, 4 days/week and the control group (CG n=12) participated in traditional ROTC training protocol for 1 hour/day, 3 days/week. A 2×2 mixed factorial analysis of variance (ANOVA) was used to compare mean change values of the FMS, upper, and lower quadrant YBT scores for intervention and control groups. Results: A significant interaction (p≤0.05) was observed for FMS scores. The control group had a much lower initial FMS score and demonstrated more improvement than the intervention group. Both groups demonstrated a significant increase in left side YBT upper (p=0.03) and lower (p=0.02) quadrant scores after 10-weeks of training. Conclusions: Since FMS and YBT scores are being used more frequently as screening tools for risk of injury, it is important to study methods that will improve FMS and YBT scores in diverse athletic populations. This study found larger improvements in FMS scores in ROTC cadets participating in a traditional military training program compared to cadets participating in a periodized strength training program. Scores in the left side of the YBT upper and lower quadrants were improved in both groups suggesting multiple training programs can improve function in non-dominant sides or asymmetries. Future studies are warranted and should address certain limitations that this study encountered (sample size and length of training period). Further exploration of FMS and YBT scores and mechanisms of improvement in tactical athletic populations would be beneficial.

Activity-promoting computer gaming systems, which encourage the use of the body to control game play, are commonly used in rehabilitation. However, the mechanisms by which improvements in clinical outcomes occur after using activity-promoting gaming systems are unknown. Therefore the aims of this study were to compare the physiological cost and enjoyment of Nintendo(®) (Kyoto, Japan) Wii Fit™-based therapy compared with traditional-based physiotherapy training. Young adults (n=35), 20.7±1.6 years old, carried out a traditional physiotherapy training program and a Wii Fit-based training program. Energy expenditure was assessed using indirect calorimetry while at rest and during training modes, and enjoyment was measured using a modified Physical Activity Enjoyment Scale. For the traditional physiotherapy-based program, all physiological measures (oxygen consumption [VO2], energy expenditure, and metabolic equivalents [METs]) were significantly greater (VO2, 0.64 versus 0.51 L/minute; energy expenditure, 186.0 versus 146.5 J/kg/minute; METs, 2.6 versus 2.1) than for the Wii Fit-based program. Enjoyment was rated statistically significantly higher for the Wii Fit-based program (76.0±13.7 percent) compared with the traditional program (67.5±14.8 percent). The lower physiological cost associated with the Wii Fit suggests that it is less demanding than the traditional therapy, even though this modality of training has been shown to elicit improvements in rehabilitative outcomes. This suggests that frailer individuals, whose energy levels are impaired, may benefit from using the Wii Fit as a rehabilitative tool because of the lower demand on energy.

Keck School of Medicine of the University of Southern California.

University of Missouri—Kansas City School of Medicine

Perioperative medicine (POM) is a new and evolving field of medicine that has rapidly spread across the globe. The speed at which POM has emerged and spread has created a demand for clinicians with knowledge and expertise in POM that has outpaced traditional clinical training programs and the ability of clinicians to be trained in the specialty. The skills and knowledge needed for the practice of POM does not fit any one specialty nor are they traditionally taught in medical school or postgraduate training programs. Many of these skills, e.g., team-based leadership and patient-centered communication skills, are amenable to simulation-based education and training (SBET). The rapid emergence and the unique skills required for the practice of this new specialty have created an opportunity for SBET to fill the demand for POM clinicians.

Medical educators: the new generalists identifying the core traditions of the profession to create the next generation of doctors.

In the primitive societies dancing was as essential as eat-ing or sleeping. Dancing was the mode of individual and group expression, and communication with others or even with the nature. The major changes over the history were accompanied with changes in the dancing rituals of every society [1].According to Keogh and collaborators (2009) dancing is a mode of physical activity that may allow people to im-prove their physical function, health, and well-being [2]. Recent study in Greece evaluated the effect of a tradi-tional dance training program on aerobic capacity and muscle strength of adults with hearing loss. The results of this intervention study, following 12-week training program, showed significant improvements in peak physiological parameters for peak minute ventilation, peak oxygen consumption (both absolute and relative), time to exhaustion, and peak torque values between the 2 measurements (initial and final). The authors concluded that adults with hearing loss can improve their physical fitness levels with the application of a systematic and well-designed traditional dance training program [3].In the USA, a pilot study was conducted to test a dance intervention and explore the role of peer support to improve the diabetes outcomes of A1C, weight, body fat, and blood pressure in African American women with type 2 diabe-tes. A total of 46 women, 26 to 83 years of age, were ran-domized to either the 12-week dance group or usual care group. Dancing showed to be beneficial to lower the systo-lic blood pressure and body fat together with significant re-ductions in all the diabetes outcomes including A1C [4]. Parkinson’s disease (PD) is the second most frequent neu-rodegenerative disease for the time being. Recent study compared the effects of partnered and non-partnered tan-go dance on balance and mobility in patients with mild-moderate PD (Hoehn and Yahr stages I-III). Balance and gait were evaluated in the weeks immediately before, im-mediately after, and 1 month after the intervention. Both groups significantly improved on the Berg Balance Scale, comfortable and fast-as-possible walking velocity, and cadence. Improvements were maintained at the 1-month follow-up, with no significant differences between part-nered and non-partnered groups [5]. Another study by the same authors investigated social dance’s feasibility and effects on mood, functional mobility, and balance confi-dence in patients with Severe Mental Illness. Participants danced once per week in 1-hour lessons for 10 weeks. All participants reported enjoying classes, and interest to con-tinue. Also improvements in anxiety, depression, and bal-ance confidence were demonstrated, without significant differences. The only significant improvement was the Timed Up and Go [6].A recent Cochrane Systematic Review investigated the effects of dance therapy for people with schizophrenia or schizophrenia-like illnesses compared with standard care and other interventions. Only one blind study was included according to the inclusion and quality criteria. The results of the study showed non significant improvement, and rec-ommended future work to increase high quality evidence in dance therapy for patients with schizophrenia [7]. In conclusion, dance, besides being fun, seems to have important benefits for mental and physical health. Fur-ther intervention studies with sufficient sample size are strongly needed, especially for treating mental and cog-nitive diseases.

State University of New York Upstate Medical University College of Medicine

Gastroenterology: A Field With Endless Career Opportunities for Physicians and Scientists

Carle Illinois College of Medicine.

As Accessible as a Book on a Library Shelf: The Imperative of Routine Simulation in Modern Health Care