Volume 121, Issue 9

Context “Spin” is a form of bias that involves highlighting study results in a way that presents the conclusions about benefit or efficacy beyond the scope of the data. Spin in the abstract of published studies has the potential to affect patient care, making investigations about its presence and prevalence important for readers. Objectives To evaluate the most severe types of spin in the abstracts of systematic reviews and metaanalyses focused on percutaneous coronary intervention. Methods Using a cross sectional study design, the authors searched MEDLINE and Embase with the terms “percutaneous coronary intervention,” “percutaneous coronary revascularization,” “PCI,” “systematic review,” “meta analysis,” and “meta-analysis.” To be considered for this study, the article must have (1) focused on PCI; (2) had either a systematic review or metaanalysis study design; (3) been conducted on human subjects; and (4) been available in English. Reviews were excluded if these criteria were not met. Each included article was assessed for the nine most severe types of spin as defined in a previously published article, as well as other study characteristics (type of intervention being compared, date the review was received, adherence of systematic review and/or meta-analysis to Preferred Reporting for Systematic Reviews or Metanalyses (PRISMA) guidelines, requirement of PRISMA guidelines by the publishing journal, the publishing journal’s five-year impact factor, and sources of funding). Results Our database search retrieved 7,038 records; 2,190 duplicates were removed. Initial title and abstract screening led to the exclusion of 4,367 records, and an additional 281 records were excluded during full text screening. An arbitrary limit of 200 articles was applied for this analysis; five additional articles were excluded for ineligible study design, so 195 were included in our final analysis. Spin was present in the abstracts of 43 studies from that pool (22.1%). Spin type 3— selective reporting of or overemphasis on efficacy outcomes or analysis favoring the beneficial effect of the experimental intervention —occurred most frequently (29; 14.8%). The presence of spin was not associated with any of the extracted study characteristics. Conclusions Our data showed that spin occurred in more than one in every five systematic reviews or metaanalyses of PCI. Spin has the potential to distort a reader’s ability to translate the true findings of a study; therefore, efforts are needed to prevent spin from appearing in article summaries.

Context Although the coronavirus 2019 (COVID-19) pandemic has accelerated the use of telemedicine platforms across the country, medical students may lack confidence in their ability to conduct satisfactory patient encounters and practice clinical medicine through telemedicine. Objectives To evaluate the role of a standardized patient encounter on first year medical student confidence and satisfaction in using telemedicine. Methods One hundred and sixty two first year medical students recruited from Edward Via College of Osteopathic Medicine-Carolinas campus were surveyed on their confidence and satisfaction with using telemedicine platforms before and after conducting a patient encounter. Participant confidence and satisfaction were assessed with a five point Likert scale: “not confident,” “a little confident,” “somewhat confident,” “confident,” and “extremely confident.” Results Of 162 students, 103 (63.6%) completed the preencounter survey and 74 (45.7%) completed the postencounter survey. Before the standardized patient encounter, 37 participants (35.9%) reported that they were “a little confident” and 20 participants (19.4%) reported that they were “not confident” in their ability to conduct a patient interview using a telemedicine platform. Following the encounter, 24 students (32.4%) reported feeling “somewhat confident”, and 32 (43.2%) reported feeling “confident” in their ability. Conclusions Medical students’ confidence and satisfaction with telemedicine improved after a standardized patient telemedicine experience in this study. This experience allowed students to practice the unique skills required for telemedicine. Medical schools might consider adding a telemedicine curriculum and standardized patient experiences in the undergraduate medical setting.

The 5 year transition period for American Osteopathic Association (AOA) training programs to apply for and receive Accreditation Council for Graduate Medical Education (ACGME) accreditation (i.e., the single graduate medical education system) was completed June 30, 2020. Of the previously AOA accredited programs that applied for or received osteopathic recognition (OR), only 24.5% are nonprimary care specialty programs according to the ACGME. The reluctance of specialty programs to apply for OR may be because osteopathic principles and practices (OPP) are not assessed. In order for programs to receive OR, they must have a standard method of assessment to assess osteopathic knowledge, including OPP and osteopathic manipulative treatment. In this Commentary, based on our assessment of the results of a literature review, we propose a model to provide a focused osteopathic assessment for the purposes of maintaining OR within residency training based on the ACGME six core competencies. Examples of multiple choice and essay questions are provided, as is a rubric for grading. The model is applied to the field of dermatology in this article and could serve as a blueprint to other subspecialties. With this framework, collaboration among programs will streamline the process to obtain OR in the ACGME single accreditation system.

Context Whiplash type injuries resulting from a rear end motor vehicle accident (REMVA) are thought to be caused by excessive loading and displacement of structural components of the cervical spine. On impact, the seat propels the driver’s torso forward relative to the head, resulting in forced flexion of the occipitoatlantal (OA) joint, accompanied by forced stretching of the rectus capitis posterior minor (RCPm) muscles. Flexion of the OA joint and stretching of the RCPm muscles continues to increase until the vehicle’s headrest strikes the back of the driver’s head. It is known that externally applied forces that attempt to move the OA joint beyond its anatomic barrier can result in fracture, dislocation, or soft tissue damage to its structural components. However, the magnitude of headrest backset, defined as the distance between the driver’s head and the vehicle’s headrest, that would result in RCPm muscles being stretched to a length that would put them at risk for a muscle strain injury is unknown. Objectives To quantify the relationships among flexion of the OA joint, RCPm muscle stretch, and backset, and to quantify the biomechanical response of RCPm muscles to increasing levels of axial load due to stretching. Methods Unembalmed head and neck specimens from three White females aged 85, 63, and 70 years were obtained from the Anatomical Services Division at the University of Maryland. Donors had provided written consent allowing use of their body for research purposes. Using an analytic model of the OA joint, the relationships between flexion of the OA joint and RCPm muscle stretch as a function of backset were estimated. RCPm muscles were removed from the cadavers and forcibly stretched using a servomechanism controlled hydraulic testing machine to quantify the load/displacement properties. After testing, the tissues were sectioned, mounted, and stained using Masson’s trichrome to selectively stain muscle fibers red and collagen blue. Results Forced flexion of the OA joint was seen to be directly related to the magnitude of headrest backset. For values of backset greater than 7.2 cm, biomechanical testing of the RCPm muscles revealed that strain injuries ranged from the tearing of a few muscle fibers to complete rupture of the muscle and separation of the tendon at the posterior process of C1. Conclusions Results showed that headrest backset at the time of vehicle impact is an important factor in estimating the risk of muscle strain injury to RCPm muscles. Muscle strain injury would be expected to impact the functional relationship between the RCPm muscles and the pain sensitive spinal dura. Physicians should be alert to the possibility that cervicogenic pain patients who have experienced whiplash associated with REMVA may show clinically relevant structural damage to the RCPm muscles on MRI.

Context Primary care physicians need a strong foundation in diabetes management, as they are the first line of care for patients with this complex disease, which is increasing in frequency in the United States. This foundational training begins in medical school, but its applications become more important during residency. Objectives To quantify osteopathic and allopathic family medicine residents’ amount of exposure to diabetes in residency training, investigate referral patterns related to diabetes management, and assess comfort levels with various diabetes treatment modalities. Methods An 18-item cross sectional survey was sent via email using Qualtrics to program directors and chief residents of 16 different training programs located in seven different health systems and four different states; the programs were focused on family medicine, internal medicine, pediatrics, and combined internal medicine/pediatrics programs. The link was also posted on Twitter using specific “handles” to “tag” professional associations and groups related to primary care. Emails and tweets were initiated on October 15, 2018 and responses were collected through April 15, 2019. Data collection was reinitiated via email only from May 1, 2020 through July 31, 2020 due to low initial response rate. The study, which included multiple choice and Likert scale questions with some skip logic, was designed by study investigators. Data was exported from Qualtrics to an Excel spreadsheet and analyzed using descriptive statistics, which are reported as percentages. Results A total of 61 residents responded to the survey, with most (52; 85.2%) enrolled in family medicine or internal medicine programs. Residents were mostly located in rural (28; 45.9%) and suburban (25; 41.0%) areas. Respondents reported being extremely comfortable with metformin (45; 73.8%), basal insulin (24; 39.3%), and healthy lifestyle education (32; 52.5%) for the treatment of diabetes. They reported being least comfortable with diabetes technology, with 51 (83.6%) uncomfortable or extremely uncomfortable with insulin pumps and 43 (70.5%) uncomfortable with continuous glucose monitoring systems for diabetes treatment. Referral rates to endocrinologists were low, with 47 (77%) reporting referral of diabetes patients 10–15% of the time. Residents reported interest in workshops and online continuing medical education for further training opportunities, but interest in additional formal training was low (3; 4.9%). Conclusions Residents in this study reported confidence in diabetes management and referral rates among this group were low. However, reported comfort levels with treatment modalities beyond metformin and lifestyle changes were not strong. Referral rates may have been low due to the low number of endocrinologists in rural areas and therapeutic inertia. Diabetes fellowships could increase resource availability for patient referral. Utilization of diabetologists in primary care programs may also add benefit and improve skills among trainees including more familiarity with diabetes technology and use of newer medications used in diabetes management.

In 1998, a seminal study identified a strong connection between participants’ exposures to adverse childhood experiences (ACEs) and the development of risk factors for serious health conditions later in life. More than two decades later, leaders in both policy and health care professions now appreciate the impact of social determinants of health, including the enormous societal costs incurred by deleterious experiences, and recognize that treating illness begins with prevention in early childhood. The trauma informed care (TIC) model offers a treatment approach that lends consideration to the traumatic experiences that impact a given patient and allows for more complete treatment by their physician. Delivering care under the TIC model encourages trauma identification, early intervention, system level awareness and policy change, and avoiding retraumatization in the therapeutic setting. Various programs across the country seek to employ these methods at the community, state, and federal level. Several programs aimed at introducing medical students to these principles have contributed to an incorporation of TIC within the physician pipeline. In this Commentary, the author proposes an expansion of the Tenets of Osteopathic Medicine with a fifth principle—considering the implications of a patient’s past formative experiences, their present life circumstances, and their future prospects—as a vehicle for instilling TIC principles ubiquitously throughout osteopathic medical training to develop physicians who treat the whole person more completely and are better equipped to manage this public health crisis.