Objective Outcome Data Research Articles

The legacy of Dr Marjory Warren's publications.

While the contributions of Dr Marjory W. Warren to geriatric medicine are widely acknowledged, their specifics have become obscured by the passage of time. The primary objective of this narrative review of her medical publications was to clarify the contributions she made for this field of medical practice. A total of 82 publications were found. In them Warren presented a then novel and hopeful approach to the management of older patients that included making care plans derived from comprehensive assessments, implementing team-based interventions, and ensuring continuity of care. These innovations, though, took years to implement and included what would now be considered a number of paternalistic and hierarchical aspects. Objective patient outcome data was rarely presented. While responsible for innovations that remain key to the field, some of what she proposed are either no longer possible (e.g. large in-patient units with prolonged lengths of stay) or have required modifications to align with current practice.

Factors predicting the outcome of percutaneous epididymal sperm aspiration in men with obstructive azoospermia

To report on the live birth rates (LBRs) following percutaneous epididymal sperm aspiration (PESA) in men with obstructive azoospermia (OA) and factors affecting treatment outcome which is under reported in the literature. This is a multicenter study that was conducted in Egypt including all couples undergoing intra cytoplasmic sperm injection (ICSI) for OA using PESA-derived sperms. Men were subdivided according to aetiology into congenital, iatrogenic and idiopathic groups. Fertilization, pregnancy and LBRs were determined and compared in each group. The longitudinal LBR, crude and expected cumulative delivery rates (CCDR, ECDR) were calculated. Multiple logistic regression analysis was used to determine significant associations between maternal, paternal and ICSI factors with successful live births. Ninety couples were included in the study. Viable sperm for ICSI was retrieved in 89 men (98.9%). A total of 155 ICSI cycles with 17 frozen embryo transfers resulted in 81 pregnan-cies and 55 live births. After 5 cycles, the longitudinal LBR, CCDR and ECDR were 30%, 57.3% and 88.6% respectively. Maternal age and number of fertilized eggs were the only fac-tors significantly affecting LBRs. PESA is a minimally invasive procedure for secur-ing viable sperm for ICSI in OA men, with high cumulative delivery rates. Maternal age and number of fertilized eggs are the only factors that significantly affecting LBR. The contempo-rary longitudinal and cumulative LBRs provide objective out-come data to counsel OA patients undergoing fertility treat-ments.

Advances in perforator imaging through holographic CTA and augmented reality: a systematic review

**Introduction** Free tissue transfer has become a mainstay in reconstructive plastic surgery, and techniques to plan such surgery continue to evolve. Novel technologies and increases in computational power have enabled computed tomographic angiography (CTA) data augmentation onto patients to assist in pedicle identification and dissection. Given the rapidly evolving field and research in this domain, a systematic review was un-undertaken to establish the evidence for its usefulness in pedicle identification and dissection.**Methods** An extensive search using keywords in EMBASE and PubMed® with bibliographic linkage following PRISMA guidelines was performed. We identified 107 articles. Duplicate articles were removed prior to review. Two reviewers independently screened the titles for appropriate topic relevance. Full articles were then screened for review. **Results** Eleven articles were appropriate for review. Two articles analysed the time taken to identify perforators using augmented reality (AR) compared to Doppler ultrasound. The remainder of the articles analysed time to perforator identification, differences between projected location and dissected perforator location, qualitative feedback from surgeons on the use of AR systems for perforator identification and proof of concept and the usefulness of AR in perforator flap surgery. **Conclusion** This review demonstrates that while established methods of data rendering and projection can achieve holographic projection and AR, there is a lack of objective outcome data to demonstrate its usefulness. This, combined with a cost analysis, are the main obstructions to this technology being more widely adopted.

The relationship between leader support, staff influence over decision making, work pressure and patient satisfaction: a cross-sectional analysis of NHS datasets in England

ObjectiveTo explore the relationships between leader support, staff influence over decisions, work pressure and patient satisfaction.DesignA cross-sectional study of large National Health Service (NHS) datasets in England in 2010.Setting and...

Utilizing Patient-Reported Quality of Life Measures to Optimize Individualized Treatment Options for Patients with Cholangiocarcinoma

Introduction: Although surgery remains the only curative option for cholangiocarcinoma, for patients with oncologically high-risk disease, it is difficult to reconcile an attempt at resection with the risk of morbidity, recurrence, and impediment to health-related quality-of-life (HRQoL). Neoadjuvant chemotherapy (NAC) is increasingly being utilized for high-risk malignancies; however, its association with functional limitations related to toxicity and HRQoL is not known. Method: Patients engaged in the Cholangiocarcinoma Foundation completed two validated HRQoL surveys: Functional Assessment of Cancer Therapy (FACT)-Hepatobiliary; COmprehensive Score for financial Toxicity (COST). Subscales and composite scores were calculated according to the FACIT-Manual, higher values indicating improved HRQoL. Results: 208pts were enrolled. 75% (n=156) had intrahepatic cholangiocarcinoma, 57% (n=119) underwent resection, of which 47% (n=56) had recurrence. 40% (n=42) received neoadjuvant or perioperative chemotherapy; 60% (n=64) received adjuvant chemotherapy (AC) alone. Among patients with localized non-metastatic unresectable disease, 38% (n=34) received chemotherapy/radiation as definitive treatment. Patients who underwent resection and had disease recurrence still reported improved functional-well-being compared to those who received only chemotherapy/radiation (effect size 0.46, p=0.04; Table1). Patients who received NAC prior to resection reported nearly equivalent HRQoL compared to those who underwent upfront resection followed by AC. Conclusions: Despite a surgeon’s desire to first “do-no-harm”, patients with expectedly poor oncologic outcomes still prefer an attempt at resection as depicted by increased functional-well-being, reflecting contentment with HRQoL and acceptance of their illness. Importantly, administering NAC, particularly in the context of high-risk disease, does not result in reduced HRQoL. Incorporating objective patient-reported outcomes data will aid in patient counseling and optimize individualized treatment plans.

Quantification of Mucosal Activity from Colonoscopy Reports via the Simplified Endoscopic Mucosal Assessment for Crohn's Disease.

Endoscopic mucosal healing is the gold standard for evaluating Crohn's disease (CD) treatment efficacy. Standard endoscopic indices are not routinely used in clinical practice, limiting the quality of retrospective research. A method for retrospectively quantifying mucosal activity from documentation is needed. We evaluated the simplified endoscopic mucosal assessment for CD (SEMA-CD) to determine if it can accurately quantify mucosal severity recorded in colonoscopy reports. Pediatric patients with CD underwent colonoscopy that was video recorded and evaluated via Simple Endoscopic Score for CD (SES-CD) and SEMA-CD by central readers. Corresponding colonoscopy reports were de-identified. Central readers blinded to clinical history and video scoring were randomly assigned colonoscopy reports with and without images. The SEMA-CD was scored for each report. Correlation with video SES-CD and SEMA-CD were assessed with Spearman rho, inter-rater, and intrarater reliability with kappa statistics. Fifty-seven colonoscopy reports were read a total of 347 times. The simplified endoscopic mucosal assessment for CD without images correlated with both SES-CD and SEMA-CD from videos (rho = 0.82, P < .0001 for each). The addition of images provided similar correlation. Inter-rater and intrarater reliability were 0.93 and 0.92, respectively. The SEMA-CD applied to retrospective evaluation of colonoscopy reports accurately and reproducibly correlates with SES-CD and SEMA-CD of colonoscopy videos. The SEMA-CD for evaluating colonoscopy reports will enable quantifying mucosal healing in retrospective research. Having objective outcome data will enable higher-quality research to be conducted across multicenter collaboratives and in clinical registries. External validation is needed.

Objective Real-World Outcomes of Patients Suffering from Painful Neurogenic Claudication Treated with the mild® Procedure: Interim 6-Month Report of a Randomized Controlled Trial.

BackgroundLumbar spinal stenosis (LSS) is a serious degenerative condition of the spine that can cause significant functional disability. Therapies for these patients generally begin with conservative management, since more invasive interventions such as open surgery and spinal implants are associated with higher complication rates. Early in the treatment algorithm for LSS patients, multiple conventional medical management (CMM) therapies are often combined as an initial low-risk treatment strategy. This composite first-line treatment plan may include conservative care together with early interventional treatment options such as epidural steroid injections, radiofrequency ablation and the mild® Procedure.MethodsThis prospective randomized controlled trial evaluates patients aged 50 to 80 years treated with mild plus CMM, compared to those treated with CMM alone, as the active control. Walking tolerance test outcomes and incidence of subsequent disallowed procedures provided objective real-world outcome data. The incidence of device or procedure-related adverse events was analyzed. Follow-up includes 6-month, 1-year and 2-year assessments, with 1-year being primary. Patients in the mild+CMM group are followed at 3, 4, and 5 years. This is a report of interim 6-month outcomes.ResultsOf 155 patients enrolled at 19 US interventional pain management centers, 78 were allocated to CMM-Alone, and 77 to mild+CMM. At 6-months, the validated walking tolerance test demonstrated statistical superiority of mild+CMM versus CMM-Alone (p<0.001). The incidence of patients receiving a subsequent disallowed procedure, and thereby considered treatment failures in their study group, was statistically significantly higher in CMM-Alone versus mild+CMM (p<0.001). There were no device or procedure-related adverse events in either group.ConclusionAt 6-months, the mild Procedure combined with CMM provided statistically superior objective real-world outcomes versus CMM-Alone. There were no device or procedure-related adverse events reported in either study group. With its excellent safety profile and superior efficacy, mild is uniquely positioned as early first-line therapy.

Benefits and challenges of developing an eco-social orientation: implications for marketing practice

PurposeSocial and environmental actors have been added to the stakeholder balancing act required of organizations in today’s competitive marketplace. To address this, the firms may create orientations to convey their strategic priorities. The purpose of this paper is to explore how different levels of environmental orientation (EO) and social orientation (SO) influence firm outcomes. This paper leverages logic from the too-much-of-a-good-thing effect to predict that firms must strategically align their resources with performance goals to optimize these resources.Design/methodology/approachThe paper outlines a step-by-step guide that combines latent moderated structural equation modeling with response surface analysis to estimate curvilinear relationships. The approach leverages the benefits of both techniques to produce precise results and more nuanced – and meaningful – implications.FindingsThe procedure is effective in uncovering a curvilinear relationship between the indicator variables. Specifically, firms optimize environmental performance when EO is higher than SO. The opposite is the case for the outcome of social value and manager trust. Economic performance is highest when both indicators are simultaneously high.Research limitations/implicationsThis study tests the relationships between social and EOs and performance. As such, the exploratory data in this study are US-centric and self-assessment in design. These limitations open the door to confirmatory studies using objective outcome data and cross-cultural comparisons. Such studies should embrace more variables and examine potential moderating influences. Most importantly, future research should work to expand and verify the development of the eco-SO construct presented here, as the dynamics of these relationships have been overlooked in most social responsibility and sustainability research. Future studies should adopt this construct into extant models and also consider the dynamics and inter-organizational fit for partner firms with competing orientations.Practical implicationsFor managers, the results show that conveying an environmental or social outcome has unique benefits to the firm. Further, there is an incentive to try and do both simultaneously. However, there is a critical point where the effects taper off, which can guide managers as they implement social and/or environmental strategies.Social implicationsThe research questions ask if a company can simultaneously deliver: economic value to shareholders, environmental value to the planet and social value to consumers while maintaining the trust of its managers. The results generally support that to fully serve one group, a firm must underserve another.Originality/valueThe study introduces SO as a valid construct to mirror EO and then models their interaction in three-dimensional space to present an optimal firm strategy.

Improving Consumption and Purchases of Healthier Foods in Retail Environments: A Systematic Review.

This review examines current research on manipulations of U.S. food retail environments to promote healthier food purchasing and consumption. Studies reviewed use marketing strategies defined as the 4Ps (product, price, placement, promotion) to examine results based on single- and multi-component interventions by study design, outcome, and which of the “Ps” was targeted. Nine electronic databases were searched for publications from 2010 to 2019, followed by forward and backward searches. Studies were included if the intervention was initiated by a researcher or retailer, conducted in-store, and manipulated the retail environment. Of the unique 596 studies initially identified, 64 studies met inclusion criteria. Findings show that 56 studies had at least one positive effect related to healthier food consumption or purchasing. Thirty studies used single-component interventions, while 34 were multi-component. Promotion was the most commonly utilized marketing strategy, while manipulating promotion, placement, and product was the most common for multi-component interventions. Only 14 of the 64 studies were experimental and included objective outcome data. Future research should emphasize rigorous designs and objective outcomes. Research is also needed to understand individual and additive effects of multi-component interventions on sales outcomes, substitution effects of healthy food purchases, and sustainability of impacts.

Comparing Light-Driven Contact Hearing Aids with Acoustic Hearing Aids: Data and Clinical Tips

Introduction: Contact hearing aids (CHA) offer potential advantages over conventional acoustic hearing aids (AHA) in terms of sound quality, reduced occlusion, and increased high-frequency gain. This study evaluates objective and subjective outcome data for CHA compared to AHA. Methods: Clinical outcome data were retrospectively reviewed for patients wearing CHA. Individual and group data were analyzed and then compared to unaided and AHA data. Adverse effects, device complaints, and clinical utility were documented throughout the device fitting and follow-up process. Results: CHA outcomes were better than unaided hearing and AHA for all patients completing the 3-month CHA trial period (45%). However, CHA return rate was high (55%), most often due to device repair and fit issues. Two patients returned the devices due to poor hearing benefit, though both were off-label audiometric candidates. Significantly more clinical time was required from both audiologists and otolaryngologists to successfully fit and maintain maximum device benefit. Conclusions: For proper audiometric and otologic candidates, this light-driven CHA can offer significant improvements in high-frequency sound fidelity, word recognition, and sound quality compared to AHA technology. Administering questionnaires was helpful in illuminating real-world improvements. Device fit, alignment, and quality control issues are improving, though still contributing to high device return rates at this time. Operational factors should be considered when incorporating CHA into a hearing health care practice.

Tibial Plateau Leveling Osteotomy for Cranial Cruciate Ligament Rupture in Canines: Patient Selection and Reported Outcomes.

Cranial cruciate ligament (CCL) rupture is one of the most common causes of pelvic limb lameness in dogs. In a CCL deficient stifle, joint lameness develops from cranial tibial translation in relation to the distal femoral condyles. The tibial plateau leveling osteotomy (TPLO) is a well-described surgical procedure that neutralizes tibiofemoral shear force by altering the tibial plateau via a proximal tibial osteotomy, and subsequently restores normal limb function. Current literature for the TPLO was reviewed and used to describe the optimal patient selection and to report clinical outcome with the TPLO in comparison to other surgical options for CCL rupture. The clinical outcomes reported to date, particularly those utilizing objective outcome data, support the TPLO as being able to consistently return dogs to normal limb function with a low risk for long-term morbidity. The TPLO procedure was found to be widely applicable to dogs ranging from small breed to large and giant breed, and does not appear to have some of the limitations that exist with alternative surgical options. This review concludes that the TPLO is an excellent treatment option for any dog with CCL rupture due to the excellent long-term outcome and high rate of owner satisfaction previously reported. Despite these conclusions, it is important to remember that treatment selection for CCL rupture remains dependent on multiple considerations including patient factors, surgeon experience, and costs.

Sub-SMAS Transposition of the Buccal Fat Pad.

Regardless of the technique chosen to treat the aging midface, the isolated lateral approach facelift has a limited impact on the midface volume deficit. In an effort to overcome this limitation, modern facial rejuvenation procedures incorporate an additional modality for replenishing the midface volume. Some of the author's facelift patients present with bulging buccal fat pads despite volume deficiency in the inframalar region. The author's technique is designed to utilize the buccal fat pad to replenish the inframalar volume deficit. The author sought to present the fat pad transposition surgical technique along with objective outcome data. This study was a retrospective review of nonconsecutive cases where the sub-superficial-musculo-aponeurotic-system transposition of the buccal fat pad was performed. A total of 22 patients underwent the fat pad transposition technique by the author (O.B.) between July 2013 and December 2017. Patient data were obtained from patient records, 3-dimensional models, magnetic resonance images, and standardized photography. Preoperative differences in midface volume were assessed utilizing curvilinear surface measurements on 3-dimensional models and the Allergan midface volume deficit scale on standardized photography. The average midface volume deficit score significantly improved, and the average midfacial curvilinear surface measurement significantly increased after surgery. Magnetic resonance imaging confirmed a stable position of the buccal fat pad after surgery. The sub-superficial-musculo-aponeurotic-system transposition of the buccal fat pad is an effective technique that can be safely employed for autologous inframalar augmentation in patients with a favorable facial morphology.

Three-dimensional endoscopy: The future of nasoendoscopic training.

Three-dimensional (3D) endoscopy is an emerging tool in surgery that provides real-time depth perception. Its benefits have been investigated in surgical training, but the current literature lacks significant objective outcome data. We aimed to objectively compare the efficacy of two-dimensional (2D) versus 3D high-definition endoscopes in novice users. Prospective, randomized crossover study. Ninety-two novice medical students who used both 2D and 3D endoscopes to complete two validated tasks in a box trainer participated in the study. Time taken and error rates were measured, and subjective data were collected. Wilcoxon tests showed 3D technology was significantly faster than 2D (78 vs. 95 seconds, P = .004), and errors per task were significantly lower (3 vs. 5, P < .001). Sixty-nine percent of participants preferred the 3D endoscope. 3D high-definition endoscopy could be instrumental in training the next generation of endoscopic surgeons. Further research is required in a clinical setting. 2b Laryngoscope, 129:1280-1285, 2019.

Experiential learning exercise to achieve objective assessment of interprofessional education

Abstract At the undergraduate medical education level, many U.S. medical students have only experienced interprofessional patient care by observation or intermittent discussion-based educational activities. However, we believe medical students will gain the most impactful understanding of the allied health professionals they will collaborate with in the future through both real or simulated practice as learners as well as witnessing the direct benefit to patient care. Given the lack of objective assessment of interprofessional education (IPE) competencies, specifically those with a direct impact on patients, we developed an innovative simulated exercise focusing on a medical student discharge plan before and after an interprofessional team meeting. We hypothesized that the interprofessional team of medical, nursing, and pharmacy students will assist the medical student in producing a discharge summary with higher specificity and completeness than a discharge summary produced by a medical student alone. Data obtained from discharge plan scoring and post-intervention narrative survey was analyzed via convergent parallel mixed-methods design. The mean post-intervention score of the discharge plan showed improvement, but did not meet statistical significance. However, when evaluated by each individual domain, the Follow-up section of the post-intervention discharge plan showed significant improvement. This exercise is a first step in the direction of obtaining more objective outcomes data as a result of students engaging in simulated interprofessional team-based care. Evaluation data demonstrated a positive trend towards a more comprehensive, and by extension, safer discharge plan. We are hopeful that our work contributes to other exercises intended to help move from students merely “enjoying” the IPE experience toward demonstrating the first-hand benefit to patients, which substantiates and supports the motivation for future physicians to move toward competence in team based care.

Hierarchical Linear Modeling for Analysis of Ecological Momentary Assessment Data in Physical Medicine and Rehabilitation Research.

Ecological momentary assessment (EMA) methods collect real-time data in real-world environments, which allow physical medicine and rehabilitation researchers to examine objective outcome data and reduces bias from retrospective recall. The statistical analysis of EMA data is directly related to the research question and the temporal design of the study. Hierarchical linear modeling, which accounts for multiple observations from the same participant, is a particularly useful approach to analyzing EMA data. The objective of this paper was to introduce the process of conducting hierarchical linear modeling analyses with EMA data. This is accomplished using exemplars from recent physical medicine and rehabilitation literature.

Clinical benefit of atrio-ventricular delay optimization in patients with a dual-chamber pacemaker: a pilot study. The CBRAVO trial (NCT01998256)

Objective Outcome data on exercise capacity following atrio-ventricular (AV) optimization of dual-chamber pacing are sparse. Pacemaker settings are often left at manufacturers’ nominal values upon implantation. We studied the short-term effect of AV optimization on exercise capacity in patients with a dual-chamber pacemaker.Methods and results Twenty-eight patients (mean age 73 ± 14 y) with a dual-chamber pacemaker, were randomized towards either nominal AV settings (group 1) or echo-guided AV optimization using the iterative mitral inflow VTI (velocity time integral) method (group 2) at baseline. At 4 weeks, patients were crossed-over to AV optimization in group 1 and returned to nominal AV settings in group 2 for another period of 4 weeks.Oxygen uptake efficiency slope improved significantly after AV optimization (by 126.7 mL/logL ± 190.7 mL/logL; P= 0.003).Conclusions AV optimization in dual-chamber pacing significantly improved functional capacity after 4 weeks. These data provide the background for further validation studies.

Manual laryngeal reposturing as a primary approach for mutational falsetto.

Mutational falsetto is a functional voice disorder characterized by failure of the male high-pitched preadolescent voice to transition to the lower pitch of adolescence and adulthood. Few objective outcomes data exist regarding the effectiveness of voice therapy for this poorly understood disorder. This study examined the immediate effects of a single therapy session using manual laryngeal reposturing as a primary approach in the management of mutational falsetto. Retrospective case series, pre-/posttreatment. Manual circumlaryngeal techniques, including digital laryngeal reposturing maneuvers, were used as the primary approach to treat 12 consecutive males with mutational falsetto (mean age 17.5 yrs., range 14-25 years). Pre- and posttreatment audiorecordings of connected speech and sustained vowel samples were submitted to auditory-perceptual and acoustic analysis to assess the effects of a single voice therapy session. Acoustic estimates of severity in both connected speech and sustained vowel productions were computed using the Cepstral Spectral Index of Dysphonia (CSID), a multivariate dysphonia summary tool that incorporates cepstral and spectral measures. Pre- and posttreatment comparisons confirmed a significant change in the direction of normal vocal function within a single treatment session for both listener- and CSID-based estimates of dysphonia severity. Behavioral therapy using manual laryngeal reposturing by an experienced voice clinician is an effective and efficient primary approach for mutational falsetto. 4. Laryngoscope, 127:645-650, 2017.

Criteria for Evaluating Ophthalmology Departments Based on the U.S. News &amp; World Report Ranking System

Purpose To propose a methodology for ranking U.S. clinical ophthalmology programs which utilizes an existing framework of both objective structural (or resource) information and outcome data as well as subjective reputational scores currently used by U.S. News & World Report for most clinical specialties. Design Evidence-based manuscript. Topic The U.S. News & World Report annual “Best Hospital Rankings by Specialty” provides the public with information regarding the relative strengths of U.S. medical and surgical departments in providing care and treatments for patients with complex diseases. For most medical and surgical specialties, these rankings are determined by considering a combination of objective structural (or resource) information and outcome data along with subjective reputational scores. Clinical Relevance In ophthalmology, U.S. News & World Report annual rankings are currently generated only from subjective reputational scores submitted by a small number of voting ophthalmologists. No objective clinical or outcome data are considered. Literature Reviewed Methodology for determining “Best Hospital Rankings by Specialty” utilized by RTI International on behalf of U.S. News & World Report. Results The ranking system of U.S. departments of ophthalmology presently employed by U.S. News & World Report presents an incomplete picture of the relative strengths and weaknesses of the departments listed. Conclusion With the changes in health insurance that increasingly shift decision-making responsibility and cost to consumers, providing mechanisms to allow the public to make informed decisions is an emerging imperative for ophthalmology and other specialties. Revision of the current “reputation-only” ranking system used for ophthalmology to also include objective clinical and outcome data would benefit patients by providing more accurate and impartial information on which to base their eye care decisions.

Sleep and academic performance in later adolescence: results from a large population-based study.

The aim of the current study was to assess the association between sleep duration and sleep patterns and academic performance in 16-19 year-old adolescents using registry-based academic grades. A large population-based study from Norway conducted in 2012, the youth@hordaland-survey, surveyed 7798 adolescents aged 16-19years (53.5% girls). The survey was linked with objective outcome data on school performance. Self-reported sleep measures provided information on sleep duration, sleep efficiency, sleep deficit and bedtime differences between weekday and weekend. School performance [grade point average (GPA)] was obtained from official administrative registries. Most sleep parameters were associated with increased risk for poor school performance. After adjusting for sociodemographic information, short sleep duration and sleep deficit were the sleep measures with the highest odds of poor GPA (lowest quartile). Weekday bedtime was associated significantly with GPA, with adolescents going to bed between 22:00 and 23:00hours having the best GPA. Also, delayed sleep schedule during weekends was associated with poor academic performance. The associations were somewhat reduced after additional adjustment for non-attendance at school, but remained significant in the fully adjusted models. In conclusion, the demonstrated relationship between sleep problems and poor academic performance suggests that careful assessment of sleep is warranted when adolescents are underperforming at school. Future studies are needed on the association between impaired sleep in adolescence and later functioning in adulthood.

Course Offerings in the Fourth Year of Medical School: How U.S. Medical Schools Are Preparing Students for Internship.

The fourth year of medical school remains controversial, despite efforts to reform it. A committee from the Clerkship Directors in Internal Medicine and the Association of Program Directors in Internal Medicine examined transitions from medical school to internship with the goal of better academic advising for students. In 2013 and 2014, the committee examined published literature and the Web sites of 136 Liaison Committee on Medical Education-accredited schools for information on current course offerings for the fourth year of medical school. The authors summarized temporal trends and outcomes when available.Subinternships were required by 122 (90%) of the 136 schools and allow students to experience the intern's role. Capstone courses are increasingly used to fill curricular gaps. Revisiting basic sciences in fourth-year rotations helps to reinforce concepts from earlier years. Many schools require rotations in specific settings, like emergency departments, intensive care units, or ambulatory clinics. A growing number of schools require participation in research, including during the fourth year. Students traditionally take fourth-year clinical electives to improve skills, both within their chosen specialties and in other disciplines. Some students work with underserved populations or seek experiences that will be henceforth unavailable, whereas others use electives to "audition" at desired residency sites. Fourth-year requirements vary considerably among medical schools, reflecting different missions and varied student needs. Few objective outcomes data exist to guide students' choices. Nevertheless, both medical students and educators value the fourth year of medical school and feel it can fill diverse functions in preparing for residency.