The development of a current events and dialogue forum at a large U.S. academic medical center

BACKGROUND

The Vanderbilt Community Circle (VC2) was designed to provide all faculty, staff, and students within the entire Vanderbilt University Medical Center community a dedicated venue to discuss current events and ongoing societal issues.

APPROACH

During the 2017-18 academic year, four VC2 events were held on: "Race, identity, and conflict in America," "Gun violence in America," "Gender in the workplace," and "Immigration in America." Facilitators guided participants to share their views and perspectives on these matters with pre-developed open-ended questions. Attendees started discussions in small groups and then eventually combined into a large one. Pre- and post-event surveys were administered to measure the program's effectiveness.

EVALUATION

One-hundred and twenty-four participants were included, 75 of whom completed both the pre- and post-event surveys. Sixty-four of the 75 (85%) agreed or strongly agreed that "multiple perspectives and opinions were represented" and 73% felt that their "own perspective was broadened on the issue." Most (89%) believed that the format and setting of the event was conducive to dialogue and discussion, and almost all (91%) reported that they would attend a similar event in the future. Groningen Reflection Ability Scale scores were high before (94 [25th-75th: 88-99]) and remained high after the events (93 [25th-75th: 88-93.3], p > 0.05).

REFLECTION

We successfully implemented a medical center-wide, recurring current events and dialogue forum in hopes of increasing reflection, unity, and understanding across our own community.

A Call for LGBTQ Content in Graduate Medical Education Program Requirements

A well-developed body of literature demonstrates that lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals experience poorer health outcomes and report worse health care experiences than straight/cisgender individuals. Many reforms since 2010 have addressed the LGBTQ-related education of future health care professionals at the undergraduate medical education (UME) level; however, reforms at the graduate medical education (GME) level are lagging, and new literature suggests that didactic education at the UME level is not enough to prepare future physicians to properly and compassionately care for LGBTQ patients. Recently, the Accreditation Council for Graduate Medical Education (ACGME) implemented a major revision of its Common Program Requirements that requires residents to demonstrate, as a competence, respect and responsiveness to diverse populations. Given these revisions and the ongoing failure of many GME training programs to adequately prepare future physicians to care for LGBTQ patients, the authors argue that now is the time for the ACGME to develop and implement LGBTQ health-related residency requirements. In addition, the authors outline a path by which the academic medical community may develop and implement these requirements.

A Systems Approach to Addressing Covid-19 Health Inequities

Racial and ethnic minorities are dying from Covid-19 at alarmingly high rates, which demands immediate action. Health system leaders cannot allow other priorities to interfere with a commitment to address health inequities. Vanderbilt University Medical Center (VUMC) has embedded strategies to mitigate health inequities in its Covid-19 Command Center. A key strategy is the creation of interactive dashboards, which are reviewed daily and allow disaggregation by race, ethnicity, language, and ZIP Code. Of the first 45,954 patients tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) at VUMC, 2,310 had limited English proficiency (LEP). The positivity rate for patients with LEP was 26% compared with 6% for patients with English as a primary language. In addition to alerting local and state health departments of these higher rates, we created multilingual resources, assessed our interpreter services capacity, and engaged trusted community organizations. Early lessons learned at VUMC may help others implement a systems approach and immediately begin addressing Covid-19 health equity.

Clinical Immersion and Biomedical Engineering Design Education: "Engineering Grand Rounds"

Grand Rounds is a ritual of medical education and inpatient care comprised of presenting the medical problems and treatment of a patient to an audience of physicians, residents, and medical students. Traditionally, the patient would be in attendance for the presentation and would answer questions. Grand Rounds has evolved considerably over the years with most sessions being didactic-rarely having a patient present (although, in some instances, an actor will portray the patient). Other members of the team, such as nurses, nurse practitioners, and biomedical engineers, are not traditionally involved in the formal teaching process. In this study we examine the rapid ideation in a clinical setting to forge a system of cross talk between engineers and physicians as a steady state at the praxis of ideation and implementation.

Resolution limitations in intravascular ultrasound imaging

Interest in the use of ultrasound to characterize the structure and composition of blood vessel walls has risen dramatically as a result of the development of intravascular ultrasonic imaging transducers mounted on the tips of small-diameter catheters. A study of the resolution of these transducers is needed to understand the limitations in the visualization of these structures. Theoretic and experimental studies of the resolution of the two principal designs of intravascular ultrasonic transducers, the mechanically scanned single element and the multielement circular array, were carried out. Comparisons of the two designs reveal that they have similar resolutions. However, the resolutions in two of the three dimensions are shown to decrease linearly with increasing radial distance. Significant errors in image interpretation, particularly in larger diameter vessels, will result if this variation in resolution is not accounted for.

Effects of time required for reperfusion (thrombolysis or angioplasty, or both) and location of acute myocardial infarction on left ventricular functional reserve capacity several months later

The purpose of this study was to determine whether reperfusion of acute myocardial infarction (AMI) by recombinant tissue-type plasminogen activator (rt-PA) or percutaneous transluminal coronary angioplasty, or both, would improve left ventricular (LV) function when it is measured several months later at rest or maximal bicycle exercise, or both. Radionuclide angiography was performed in 44 patients 5 months (range 6 weeks to 9 months) after AMI to assess function, and tomographic myocardial thallium-201 imaging was performed at maximal exercise and delayed rest to determine whether there was any evidence of myocardial ischemia. As expected, no patient had chest pain or redistribution of a thallium defect during the exercise test, because patients had undergone angioplasty (n = 28) or coronary bypass graft surgery (n = 5) where clinically indicated for revascularization. The LV ejection fraction was plotted as a function of the time elapsed between the onset of chest pain and the time when coronary angiography confirmed patency of the infarct-related artery (achieved in 91% of 44 patients by rt-PA [n = 31] or percutaneous transluminal coronary angioplasty [n = 9] ). Functional responses differed markedly between patients with anterior (n = 20) versus inferior (n = 24) wall AMI. LV ejection fraction during exercise correlated with time to reperfusion in patients with an anterior wall AMI (r = -0.58; standard error of the estimate = 11.9%; p less than 0.02) but not in patients with an inferior AMI (r = 0.10; standard error of the estimate = 13.1%; difference not significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Normal SPECT thallium-201 bull's-eye display: gender differences

The bull's-eye technique synthesizes three-dimensional information from single photon emission computed tomographic 201TI images into two dimensions so that a patient's data can be compared quantitatively against a normal file. To characterize the normal database and to clarify differences between males and females, clinical data and exercise electrocardiography were used to identify 50 males and 50 females with less than 5% probability of coronary artery disease. Results show inhomogeneity of the 201TI distributions at stress and delay: septal to lateral wall count ratios are less than 1.0 in both females and males; anterior to inferior wall count ratios are greater than 1.0 in males but are approximately equal to 1.0 in females. Washout rate is faster in females than males at the same peak exercise heart rate and systolic blood pressure, despite lower exercise time. These important differences suggest that quantitative analysis of single photon emission computed tomographic 201TI images requires gender-matched normal files.

Right atrial thromboemboli: clinical, echocardiographic and pathophysiologic manifestations

In six patients with clinically unsuspected right atrial thromboemboli the diagnosis was made with two-dimensional echocardiography. Five patients had pulmonary emboli, and one had systemic embolization. Three patients had congestive cardiomyopathy, two with tricuspid regurgitation; of the remaining three, one had cor pulmonale complicated by tricuspid regurgitation, one had thrombophlebitis and one had no discernible cardiac illness. Four patients had dizziness or syncope, four had dyspnea, three had chest pain, three had hypotension and tow had cyanosis. Five patients were treated with thrombolytic or anticoagulant therapy, or a combination of the two. In three patients, surgical removal of the thrombus was undertaken because of recurrent pulmonary emboli or tricuspid regurgitation, or both, and progressive right heart failure. The thromboemboli were removed in all three, but one patient died. On two-dimensional echocardiography, four of the six patients' thromboemboli were snake-like, unattached to the right atrium and prolapsed freely across the tricuspid valve into the right ventricle in diastole and back into the right atrium in systole. The other two patients' thromboemboli were attached to the right atrium and did not prolapse across the tricuspid valve. Our cases, together with a review of other reports, suggest that right atrial thromboemboli: 1) can be accurately diagnosed by two-dimensional echocardiography; and 2) result from two different pathophysiologic mechanisms developing a) in situ, either on a foreign body or secondary to reduced cardiac output, or b) as a result of an embolus from systemic vein thromboses.