Medical Education Program Highlights The Cooper Medical School of Rowan University (CMSRU), founded in 2009, accepted our charter class in 2012. Located in Camden, New Jersey, one of our nation’s most vulnerable communities, we are deeply committed to our motto “Camden is our classroom, Camden is our home.” We have graduated 5 classes in our medical education program, all of whom have exemplified our commitment to provide humanistic education in the art and science of medicine within a scientific and scholarly community. We aspire toward excellence in patient care, innovative teaching, research, and service to our community. We are proud to be the 2019 recipient of the AAMC’s Spencer Foreman Award for Outstanding Community Engagement. CMSRU’s medical education program includes the following: Clinical experiences that begin in the first year as part of an integrated basic and clinical science educational program that includes didactic, case-based, and self-directed learning. The interprofessional ambulatory clerkship experience for first-, second-, and third-year students is delivered in the student-run Cooper Rowan Clinic (CRC) and incorporates medical, pharmacy, physical therapy, and social work students. The hybrid third-year experience includes traditional core discipline blocks and a longitudinal integrated clerkship. Our systemic 4-year commitment to service learning focuses on the needs of our Camden community. A 4-year longitudinal course in health systems science called Scholar’s Workshop culminates in a required capstone project. A unique primary care 3-year track leads to primary care residency in internal medicine or pediatrics. Curriculum Curriculum description The CMSRU curriculum has 2 phases. Phase 1, foundation and integration, prepares students for Phase 2, application, exploration, and advancement. In Phase 1, students develop the essential scientific knowledge along with medical practice skills and behaviors to prepare them for clinical practice. Phase 2 provides for the expansion of basic knowledge in the clinical environment and supports career development. The entire curriculum has an emphasis on evidence-based medicine, critical thinking, problem solving, clinical reasoning, understanding the social context of illness, and developing the skills of lifelong learning. Four unique components provide students with opportunities to support their development as physicians: An interprofessional ambulatory clerkship experience for first-, second-, and third-year students that is delivered in the student-run, faculty supervised CRC. A hybrid third year that incorporates traditional core discipline blocks and the Cooper longitudinal integrated clerkship (CLIC). Students complete 6-week blocks with 4 weeks devoted to inpatient experiences and 2 weeks completed in an integrated ambulatory experience with assigned preceptors from each of the core disciplines. This permits 14 weeks of continuity experience with their discipline-based preceptors over the course of the third year. A 4-year longitudinal Scholars Workshop course that incorporates evidence-based medicine, epidemiology, biostatistics, research methodology, quality improvement and patient safety, and health systems science, culminating in a capstone project with thesis and poster presentation. Students have the opportunity to take selectives and electives that connect them to the humanistic side of medicine and encourage development of cultural competence and ethical values. See Supplemental Digital Appendix 1—Curriculum Schematic—at https://links.lww.com/ACADMED/A923. Assessment The CMSRU medical education program objectives correspond to the framework of the ACGME domains of competence. In addition, we identified 3 competencies linked directly to our mission and core values: scholarly inquiry, learning and working in teams, and health partnership. We have disaggregated our competencies into specific objectives that link to national and locally developed assessments. See Table 1—Sample Program Objectives and Assessment Methods.Table 1: Sample Program Objectives and Assessment MethodsParallel curriculum or tracks There are 2 curricular tracks at CMSRU: a traditional 4-year track and a 3-year accelerated track. The 3-year accelerated track is for students who are interested in primary care internal medicine or pediatrics and is referred to as PC3. Students accepted into the track have a provisional acceptance into our primary care residency in internal medicine or pediatrics, fostering the continuum of medical education across UME to GME. The PC3 program includes 2 unique courses (an immersion in communication skills and physical diagnosis and a course on transforming health care in urban environments), a patient-centered medical home clerkship that is a venue for interprofessional education, and a hybrid longitudinal integrated clerkship in the third year that is a modification of the CLIC for the 4-year track. There is a required subinternship at the end of the third year. See Supplemental Digital Appendix 2—Primary Care Track Curriculum and Third-Year Details—at https://links.lww.com/ACADMED/A923. Pedagogy As a new medical school, we have researched a variety of educational pedagogical activities and, in consideration of best practice in adult learning theory, have minimized the amount of time students spend in lectures. We have refocused learning and instructional time to emphasize case-based learning, group discussions, laboratory and application sessions, and simulation/standardized patients. Active learning groups (ALGs) encompass 6 hours weekly for first- and second-year students. The cases are developed by course faculty, reviewed by the ALG Subcommittee of the Curriculum Committee, and cofacilitated by both basic science and clinical faculty teams. There are 8–9 students per group. Group discussions are the focus of both the Scholars Workshop and Foundations of Medical Practice courses. Faculty facilitators provide short instructional segments and discussions. The Foundations of Medical Practice course incorporates workshops that develop clinical skills. Laboratory and application sessions are part of the core blocks in Phase 1 of the curriculum. The fully integrated nature of the basic sciences within block structures allows for dissection-based anatomy to occur from the latter part of the first-year curriculum, beginning with the skin and musculoskeletal systems block through the entire second year. In courses that do not have anatomical dissection, application sessions permit deep exploration of virtual microscopy, team-based learning activities, and simulations. The Clinical Skills and Simulation Center provides instruction for a variety of courses and clerkships throughout the curriculum. In fall 2019, our simulation center relocated to a new 12,000-square-foot facility. Our students in all curricular years are able to take advantage of on-demand standardized patient activities. Teams of 4 students can request a 2-hour practice session to review and practice skills being developed within the curriculum, as well as prepare for their OSCEs or the USMLE Step 2 CS examination. Clinical experiences All of our clinical experiences are provided through our affiliation with Cooper University Health Care (CUHC). The expansive network of services and disciplines and wide breadth of patient population associated with CUHC allows students to have a variety of experiences at every level of their training. CMSRU students are involved in patient care and clinical reasoning activities from the beginning of the first year. The ambulatory clerkship (years 1–3) adopted an interdisciplinary team-based approach to patient care. Teams are made up of first- through third-year medical and pharmacy students. These comprehensive teams provide care for CRC patients under the supervision of faculty from both disciplines. Both medical and pharmacy students have a specific role on the team relative to their level of training. All patients receive medications via the student-run pharmacy. A social work student intern staffs the clinic and provides support for issues that surface during the patient visit such as housing or food insecurity. Two clinics per month include physical therapy students. Patients may be referred to other services at CUHC. These additional services are provided at no cost to the patient, and 1 or 2 students often accompany patients to their referral visits. This interprofessional team approach provides an invaluable service to the most vulnerable members of our Camden community. All CMSRU students rotate exclusively through CUHC in their third-year clerkships. This permits students continuity of experience with the health system, the EMR, and patient population. The fourth-year students have 4 required clerkships: critical care, emergency medicine, subinternship with student choice of discipline, and interprofessional care of patients with chronic conditions (ICCC). A unique clerkship, ICCC addresses the specific needs of these complicated patients within several pillars of care: The Urban Health Institute is made up of interdisciplinary teams that support patients to ameliorate the impact of poverty and chronic stress as social determinants of health. ICCC hematology–oncology emphasizes goals of care in treatment and transitions to hospice. Geriatric medicine/postacute long-term care emphasizes how aging, compounded with multiple complex medical conditions, affects functional, cognitive, and emotional status. Palliative care medicine works with the inpatient palliative care service. Collaborative/transitional care provides a combination of experiences in family medicine practice using collaborative care teams, and with inpatient transitional care nurse teams addressing the transition from the acute care unit to home-based care. Metabolic and bariatric surgery provides an experience with interdisciplinary teams to support patients to reach their health goals. Physical medicine and rehabilitation offers experience with well-coordinated interprofessional teams that improve patient function and quality of life. Curricular Governance The CMSRU Curriculum Committee comprises elected and appointed faculty members with voting privileges and Office of Medical Education ex officio members, without vote. The associate dean for medical education works closely with the Curriculum Committee chair to operationalize the decisions made by the committee. There are 5 permanent subcommittees: Phase 1, Phase 2, Assessment, ALG Case Study Review, and Exam Question Review. Several ad hoc subcommittees assemble as necessary to address curricular enhancements, the biennial review of curricular phases, or the full review of the entire curriculum. See Figure 1—Curricular governance, support, and implementation.Figure 1: Curricular governance, support, and implementation.Education Staff CMSRU is responsible for both undergraduate and graduate medical education. The Office of Medical Education is responsible for implementation of the educational program; assessment of students; learning support; and evaluation of courses, clerkships, and faculty. There is a separate Office for Graduate Medical Education that has oversight of GME. The Office of Student Affairs is responsible for nonacademic student support, wellness, activities, career and personal advisement, and student development. The Office of Medical Education has responsibility for the administration, planning, implementation, and evaluation of the curriculum and for the development and maintenance of the tools to support curriculum delivery, monitoring, and management. A variety of software tools are used to enhance delivery of the curriculum including one45 for our assessment, evaluation, and curricular mapping. Examsoft is used for our examination system, and Progress IQ is used to provide dashboard services of student academic success for our students, advisory college directors, and administrative team. Faculty Development and Support in Education CMSRU faculty development programs assist our faculty to provide exceptional educational experiences for our UME and GME learners, and promote professional vitality and growth. In addition, teaching is highly valued at CMSRU and is 1 of the 4 domains by which faculty are assessed on an annual basis and for promotion and/or tenure. Faculty development programs include the CMSRU medical education grand rounds series, targeted medical education-related workshops specific to UME and/or GME, and a research seminar series. On a biannual basis, CMSRU hosts a faculty development week; experts in the field of medical education are invited to address specific needs in medical education. Two academic tracks, the clinician–educator track and the academic educator track, endorse excellence in teaching as part of the criteria for promotion and/or tenure. The Scholarship of Practice and Teaching Pathway for clinical faculty provides an additional means to promotion for clinical faculty whose primary interest is in clinical medicine and teaching.

OBJECTIVES:To examine whether introduction of Team-based Learning (TBL) improves student learning resulting in improved performance on final examination questions and decreased failures in an infectious diseases course. METHODS:To improve mastery of course content, we designed an intervention, which provided weekly TBL exercises in study years 2 and 3 to review concepts presented during didactic lectures and laboratory exercises. The remaining course structure and content was essentially unchanged. All students taking the course (n=50 in year 1, n=64 in year 2, and n=72 in year 3) participated in this study. Student final examination performance and performance on individual final examination questions were collected and analyzed for changes in response to the study intervention. RESULTS:Addition of weekly TBL exercises improved student performance on the course final examination as demonstrated by a statistically significant increase in the distribution of correct answer percentages for questions in common between the final examinations in years 1 and 2 and between years 1 and 3 (t(99) = 3.1454, p<0.05 and t(99) = 4.1268, p<0.01, respectively; Student-Newman-Keuls). There was no statistical difference (t(97) = 0.9814, p> 0.05; Student-Newman-Keuls) in the distribution of correct answer percentages between years two and three. There was also a decrease in final examination failures in years two and three. CONCLUSIONS:The results suggest that TBL could be used to improve mastery and retention of course content in a preclinical infectious diseases course. Weekly exercises allow students to identify and ameliorate weaknesses in understanding and make adjustments early in the course.

UNLABELLED:Our objective was to determine tuberculin skin test conversion rate of health care workers traveling to Botswana. The rate of tuberculin skin test conversion was 4.2% for the entire group studied or 6.87 per 1000 person weeks (95% CI, 1.87-17.60). BACKGROUND:International travel by health care workers traveling from low incidence countries to areas of the world where tuberculosis is highly endemic places the health care worker at an increased risk of acquiring tuberculosis. OBJECTIVES:To determine the tuberculin skin test conversion rate of health care workers living in the United States with previously negative tuberculin skin test results working for less than 1 year in a hospital in Botswana where tuberculosis is highly endemic. METHODS:We performed a cross-sectional survey among health care workers affiliated with the University of Pennsylvania School of Medicine who participated in patient care in Botswana between July 1st 2004 and June 30th 2009. We recruited health care workers after returning from Botswana who had a documented negative tuberculin skin test in the year prior to travel, who spent at least 2 weeks but not more than 1 year and who had a documented tuberculin skin test 2-3 months post travel. The main study outcome was a positive tuberculin skin test 6-12 weeks after returning from Botswana, defined by an area of at least 10mm induration 48-72h after placement of the tuberculin skin test. RESULTS:95 Subjects participated in the study and there were 4 tuberculin skin test conversions. The rate of tuberculin skin test conversion in our study population was 4.2% for the entire group studied or 6.87 per 1000 person weeks (95% CI, 1.87-17.60). CONCLUSIONS:The tuberculin skin test conversion rate was higher than the reported conversion rates for those not working in a health care setting.

Background The CPCRA 064 study examined the effect of structured treatment interruption (STI) of up to 4 months followed by salvage treatment in patients failing therapy with multi-drug resistant HIV. We examined the relationship between the reversion rate of major reverse transcriptase (RT) resistance-associated mutations and change in viral replication capacity (RC). The dataset included 90 patients with RC and genotypic data from virus samples collected at 0 (baseline), 2 and 4 months of STI. Principal Findings Rapid shift towards wild-type RC was observed during the first 2 months of STI. Median RC increased from 47.5% at baseline to 86.0% at 2 months and to 97.5% at 4 months. Between baseline and 2 months of STI, T215F had the fastest rate of reversion (41%) and the reversion of E44D and T69D was associated with the largest changes in RC. Among the most prevalent RT mutations, M184V had the fastest rate of reversion from baseline to 2 months (40%), and its reversion was associated with the largest increase in RC. Most rates of reversion increased between 2 months and 4 months, but the change in RC was more limited as it was already close to 100%. The highest frequency of concurrent reversion was found for L100I and K103N. Mutagenesis tree models showed that M184V, when present, was overall the first mutation to revert among all the RT mutations reported in the study. Conclusion Longitudinal analysis of combined phenotypic and genotypic data during STI showed a large amount of variability in prevalence and reversion rates to wild-type codons among the RT resistance-associated mutations. The rate of reversion of these mutations may depend on the extent of RC increase as well as the co-occurring reversion of other mutations belonging to the same mutational pathway.

Background: Over the past two decades, the frequency and type of invasive fungal infections have increased greatly and thus have driven the need for new antifungal agents. Anidulafungin is the newest addition to the echinocandin armamentarium. Objective: The intention of this review is to provide a drug evaluation of anidulafungin, including its spectrum of activity, pharmacokinetics, pharmacodynamics, clinical efficacy, adverse event profile, and its role in the treatment of invasive candidiasis. Methods: A PubMed search was performed to gather the most current and pertinent articles. Conclusions: Clinical trials have demonstrated anidulafungin's efficacy and tolerability in invasive candidiasis. Anidulafungin is not associated with any drug-drug interactions and does not require dosage adjustment in patients with renal and/or hepatic impairment.

Over the past two decades, the frequency and type of invasive fungal infections have increased greatly and thus have driven the need for new antifungal agents. Anidulafungin is the newest addition to the echinocandin armamentarium.The intention of this review is to provide a drug evaluation of anidulafungin, including its spectrum of activity, pharmacokinetics, pharmacodynamics, clinical efficacy, adverse event profile, and its role in the treatment of invasive candidiasis.A PubMed search was performed to gather the most current and pertinent articles.Clinical trials have demonstrated anidulafungin's efficacy and tolerability in invasive candidiasis. Anidulafungin is not associated with any drug-drug interactions and does not require dosage adjustment in patients with renal and/or hepatic impairment.

The introduction of protease inhibitors (PIs) and highly active antiretroviral therapy in the mid-1990s dramatically altered the treatment of HIV infection, enabling suppression of viral replication to undetectable levels and preventing disease progression. Most PIs present a strong barrier against viral resistance; the accumulation of multiple mutations is often required to produce resistance. However, there is variability of resistance within the PI class, as demonstrated by the fact that some PIs require fewer mutations to confer resistance compared with others. Resistance to individual PIs as well as the development of broad cross-resistance to multiple agents in this class remain major challenges in clinical practice. Resistance to PIs may involve primary or secondary mutations in the protease gene in addition to mutations outside of protease in the gag cleavage and noncleavage sites. Primary mutations may be sufficient to confer resistance to select PIs. Secondary mutations may be required to produce resistance with some PIs, whereas other mutations may be compensatory, restoring activity of the viral protease or increasing the replicative capacity of the virus. Specific resistance patterns associated with individual PIs have been identified. Strategies to prevent PI cross-resistance and to manage its occurrence involve rational sequencing of PIs, ritonavir boosting to maintain a strong barrier against viral resistance, the use of newer PIs with activity against resistant viruses or unique resistance profiles, avoidance of PI combinations with overlapping resistance patterns, and application of knowledge of mutations associated with hypersusceptibility to other agents in this class.

With the increase in prevalence of fungal infections, newer antifungal agents are needed to effectively treat invasive disease, and at the same time minimize adverse effects from therapy. The echinocandins comprise a novel class of antifungals; their mechanism of action involves inhibiting 1,3-β-D-glucan synthase, which is essential in cell wall synthesis for certain fungi. All three echinocandins are US FDA-approved for the treatment of esophageal candidiasis. Caspofungin and anidulafungin are licensed for the treatment of candidemia, and other select forms of invasive candidiasis. Micafungin is at present the only echinocandin approved for prophylaxis of fungal infections in hematopoietic stem cell transplants; whereas caspofungin is approved for empiric therapy of febrile neutropenia. Although all three echinocandins are active against Aspergillus, only caspofungin is presently approved for salvage therapy in invasive aspergillosis. Combination therapy with echinocandins plus other licensed antifungal therapy shows promise in treating invasive aspergillosis. This article will explore the similarities and differences among the echinocandins.