Reimagining Undergraduate Medical Education in a Post-COVID-19 Landscape

Online education due to the COVID-19 pandemic caused many medical schools to increasingly employ asynchronous and virtual learning that favored student independence and flexibility. At the same time, the COVID-19 pandemic highlighted existing shortcomings of the healthcare field in providing for marginalized and underserved communities. This perspective piece details the authors’ opinions as medical students and medical educators on how to leverage the aspects of pandemic medical education to train physicians who can better address these needs.KEY WORDS: undergraduate medical education, social determinants of health, virtual learning

“American medical education needed a revolution,” writes Professor Jon M. Barry in The Great Influenza: The Story of the Deadliest Pandemic in History¹. He described a different era of medical education, a time in the late 1800s when medical students graduated without having ever touched a patient. The revolution began at Johns Hopkins Hospital with William Osler’s teaching hospital model for postgraduate training, a model that spread across the nation and has formed the foundation for modern medical education². A few decades later, the Flexner Report commissioned by the American Medical Association codified recommendations for standardized curriculum based on Osler’s program at Hopkins, giving rise to the biomedical model of medical education^{3, 4}. In the same decade, the 1918 influenza pandemic, one of the deadliest pandemics in the history of humankind, infected approximately one-third of the world’s population, causing an estimated 50 million deaths⁵. Clearly, as Barry describes, it was a time of great crisis, ripe for great change.The Flexner Report and 1918 pandemic thus led to many medical schools adopting the biomedical model and overhauling their curricula. Since then, shortcomings of the Flexner Report, such as limiting the opportunities of Black physicians and excluding social determinants of health from the medical model^{4, 6}, have been acknowledged and medical education has increasingly prioritized diversity and inclusion and public health education to better serve the diverse health needs of society^7–9. The biopsychosocial model of medicine has largely supplanted the biomedical model^{7, 8}, and many medical schools have modified their biomedical curricula to incorporate systems-based learning and social determinants of health.Yet healthcare is far from perfect today, with issues of cost, access, and systemic inequality still plaguing patients. As medical students and medical educators, we strive for a medical education that will better prepare the next generation of physicians to address these failures of the profession. We also have experienced how the current COVID-19 pandemic, similar to the 1918 influenza pandemic, has caused great crises in healthcare and changes in medical education^10–12. As vaccines have made a post-COVID era more tangible, we believe the medical field is once again ripe for revolution. In this perspective piece, we detail how we can leverage the current flux in medical education, capitalizing on asynchronous and virtual learning with a focus on social determinants and disparities, to better train physicians who will be prepared to serve the public health in a post-COVID era.     

Undiagnosed Behçet's Disease Complicated by Multiple Pseudoaneurysms and COVID-19 Infection

Behcet''s disease (BD) is a rare multiorgan systemic disorder characterized by recurrent episodes of acute inflammation. Involvement of the vascular system, gastrointestinal tract, and central nervous system portends a poor prognosis.We report the case of a 54-year-old man who presented with a 2-week history of symptoms attributable to infrarenal aortic and left tibioperoneal trunk pseudoaneurysms, defined by CT angiography which also revealed right lower lobe pulmonary artery (PA) and right anterior tibial arterial aneurysms. A prior history of recurrent oral ulceration, periodic fever, cerebral venous sinus thrombosis, and aseptic endocarditis with pulmonary emboli invoked a diagnosis of BD. Immunosuppression was commenced immediately, following synchronous endovascular and open arterial intervention, except the PA aneurysm.He developed a fever and cough 8 days postoperatively as a consequence of COVID-19 infection from which he recovered without complications.The management of the patient''s four aneurysms in different vascular territories and postoperative COVID-19 infection in the presence of mandatory immunosuppression are discussed.     

Numbness Following Total Knee Arthroplasty: Role of Incision Length And Position - A Randomized Study

BackgroundOne of the symptoms annoying patients after total knee replacement (TKR) is numbness around the operative scar. Some studies have shown that altering the incision in terms of placement or length may decrease the incidence of numbness. It still remains unknown whether numbness affects patient-reported outcomes.MethodsWe conducted a randomized study to compare a short-length incision (n = 50) and a lateral exit incision (n = 50) with a standard midline TKR incision (n = 50) in terms of the incidence of numbness and its progress over 1 year of follow-up. Our secondary objective was to look at the involved zone, area of numbness, and secondary symptoms. We also looked at patient-reported outcome in terms of satisfaction in all groups using a visual analog scale and Forgotten Joint Score.ResultsAt 3 months postoperatively, the incidence of numbness was least in the lateral exit group: 46.2% as compared to midline (62%) and short (58.3%), but the difference was not significant (p = 0.07). At 6 months, the short incision group had a significantly lower incidence (8%) of residual numbness as compared to 30% in the other two groups (p = 0.003). At 1 year, most patients recovered sensation loss and had similar function.ConclusionsPlacement or length of an incision did not significantly affect the incidence of numbness; however, the short incision led to early recovery of numbness. At 1 year of follow-up, most patients did not complain of loss of sensation and had similar functional outcome.     

Impact of oral potentially malignant disorders on quality of life

Background

Oral potentially malignant disorders (OPMDs) could have a significant psychological impact on patients, principally because of the unknown risk of malignant transformation, while the physical and functional impairments could differ. This study aimed to assess the impact of three different OPMDs and their disease stages on the quality of life (QoL) of affected patients.

Methods

Oral leukoplakia (OL), oral lichen planus (OLP) and oral submucous fibrosis (OSF) patients who were undergoing treatment at an oral medicine clinic of a dental teaching hospital in India were the study population. All subjects completed the recently developed OPMDQoL questionnaire and a short form 12 item (version 2) health survey questionnaire (SF‐12v2). OPMDQoL questionnaire consists of 20 items over four dimensions. A higher score denotes poor OHRQoL. SF‐12v2 has two components, a Physical Component Summary (PCS) and Mental Component Summary (MCS).

Results

A total of 150 subjects (50 each of OL, OLP and OSF) participated. OL patients (37.7 ± 7.9) reported significantly better OPMDQoL scores than OLP (47.3 ± 5.8) and OSF (45.4 ± 9.2) patients. OLP patients reported significant problems in obtaining a clear diagnosis for their condition, more so than the other OPMDs. OL patients reported fewer problems for the dimension, “physical impairment and functional limitations” than the OLP and OSF patients. A significant trend was observed with the overall OPMDQoL and MCS, deteriorating as the disease stage increased.

Conclusions

OLP and OSF have a significant impact on the QoL of affected individuals: OL less so. Increasing stage of the disease is associated with worsening QoL.     

ATP7B mutations in families in a predominantly Southern Indian cohort of Wilson's disease patients.

OBJECTIVE: To analyze ATP7B mutations in Wilson's disease (WD) patients from the Indian subcontinent and to correlate these with WD phenotype. METHODS: We studied 27 WD patients from 25 unrelated families. Twenty-two families were from three southern Indian states - Tamil Nadu andhra Pradesh and Kerala. We applied conformation- sensitive gel electrophoresis (CSGE) to screen for the mutations in patients and their families. PCR products exhibiting aberrant patterns in CSGE were subjected to direct DNA sequencing. As siblings affected by WD within a family share identical ATP7B genotype, we compared WD phenotype among affected siblings within families. RESULTS: ATP7B mutations were detected in 22 of the 25 probands -13 were homozygotes and 9 were compound heterozygotes. Eleven novel mutations were detected. Only two common mutations were found: G3182A in 4 (16%) and C813A in 3 (12%) probands. 'Hot spots' for ATP7B mutations were exons 18 and 13. Lack of common dominant mutations prevented correlation of individual ATP7B mutations with WD phenotype. Symptomatic WD in a live sibling was not found in any family. In 8 families, a sibling died of presumed WD - in 6 of these, WD phenotype was identical to that in the proband. CONCLUSIONS: We describe the spectrum of ATP7B mutations including 11 novel mutations in Indian WD patients and document lack of a single dominant mutation. Identical WD phenotype among siblings in only 6 of 8 families with >1 child affected by WD suggests that factors other than ATP7B mutations influence WD phenotype.