Empire State EPIC

MAPP to CU is a two-year longitudinal pipeline program that partners the CUIMC Department of Emergency Medicine with local high schools. Students from these high schools attend monthly workshops at the medical center campus. Emergency Medicine faculty and trainees and other healthcare providers mentor these students and teach practical healthcare-related skills. Participating high school students represent and reflect the communities served by CUIMC and many are from households where English is not the first language.

Topics covered during the skills-based MAPP to CU workshops include chest compressions, airway management, Stop the Bleed skills, suturing, splinting and bedside ultrasound. These workshops were designed to provide both background education and hands-on experience to pique interest in healthcare. Students learn vital signs, CPR and tourniquet skills that may someday prove crucial and lifesaving within their communities. Also, through these workshops, students are exposed to variety of healthcare professions such as pre-hospital care, nursing, pharmacy, social work and physical therapy.

During their second year in MAPP to CU, students further explore careers in medicine and healthcare with professionals from other specialties including surgery and pediatrics. Students participate in more advanced activities such as a toxicology walk and a comprehensive simulation incorporating skills learned in the first year. Additionally, second-year students are mentored one-on-one in conducting research on a medical or healthcare topic of interest and presenting their findings to their peers. This activity provides students with experience in the process of formulating and answering a research question and communicating their findings. It also promotes self-efficacy and intellectual curiosity.

For high school students, participation in extracurricular activities increases their success in the college application process and facilitates self-discovery. However, for students from lower-income households, afterschool activities often compete with jobs students may need to contribute income to their households. To help address financial barriers that may prevent students from participating in MAPP to CU, students are given gift cards based on their attendance.

MAPP to CU recently completed its third year and celebrated its first class of alumni returning for the second class’s graduation. Thus far, we have noticed students becoming increasingly more confident as they progressed through the program. Many students began the program needing translation services because English was not their first language. At the end of the two-year cycle, many were able to present independently in English their research on complex medical and healthcare topics. Additionally, with increased confidence levels, these students have aspired to goals that may have previously seemed unrealistic or impossible. With the most recent class of MAPP to CU graduates, several students developed plans to pursue careers in nursing and surgery because of their participation in MAPP to CU. The long-term impact of this pipeline program on the participating students and their communities is still unfolding. We are optimistic that students will remain engaged and continue their paths towards careers in medicine and healthcare with MAPP to CU supporting them.

In summary, like other pipeline programs, MAPP to CU aims to address the educational and mentorship needs of students from racial, economic and social backgrounds historically underrepresented in medicine and improve the representation of these students in medical student enrollment and the physician workforce. More specifically, MAPP to CU focuses on students from the population the CUIMC Emergency Department serves. When developed, the overarching goals of MAPP to CU were to provide underrepresented students with opportunities they would not have had otherwise and to increase diversity in the healthcare workforce by exposing these students to healthcare careers and supporting them in their healthcare career aspirations. With the successful graduation of two MAPP to CU classes, we believe we are well on our way to achieving these goals.

References

• Whitla D, Orfield G, Silen W, et al. Educational benefits of diversity in medical school: a survey of students. Acad Med. 2003;78(5):460-6.
• Saha S, Komaromy M, Koepsell T, et al. Patient-physician racial concordance and the perceived quality and use of health care. Arch Intern Med. 1999;159(9):997-1004.
• Laveist TA, Nuru-Jeter A. Is doctor-patient race concordance associated with greater satisfaction with care? J Health Soc Behav. 2002;43(3):296- 306.
• Cooper LA, Powe N. Disparities in patient experiences, health care processes, and outcomes: the role of patient–provider racial, ethnic, and language concordance. Commonwealth Fund 2004.
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• . FACTS: applicants, matriculants, enrollment, graduates, MD-PhD, and residency applicants data. December 12, 2023. Accessed July 15, 2024. https://www.aamc.org/data-reports/students-residents/report/facts
• Cervantes L, Chu E, Nogar C, et al. A Hospitalist mentoring program to sustain interest in healthcare careers in under-represented minority undergraduates. J Hosp Med. 2014 Sep;9(9):586-9.
• Robinson M, Douglas-Vail M, Bryce J, et al. Medical school outreach and mentorship for rural secondary school students: a pilot of the Southwestern Ontario Medical Mentorship Program. Can J Rural Med. 2017 Spring;22(2):62-67.
• Shaw K, Schmidt C, Richards-May K, et al. Abstract 13914: Development of a high school mentorship and scholarship program to promote interest in healthcare among students underrepresented in medicine. Circulation. 2023;148(Suppl 1).
• Patel S, Rodriguez P, Gonzales R. The implementation of an innovative high school mentoring program designed to enhance diversity and provide a pathway for future careers in healthcare related fields. J Racial Ethn Health Disparities. 2015 Sep;2(3):395-402.
• Muncan B, Majumder N, Tudose N. From high school to hospital: how early exposure to healthcare affects adolescent career ideas. Int Journal of Med Educ. 2016;7:370–371.
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The year is 2026. A 60-year-old female with a past medical history of smoking, obesity and hypertension presents to the Emergency Department (ED) after losing consciousness while waiting for the bus. She remembers feeling light-headed prior to fainting, but had no chest pain, palpitations, headache or shortness of breath before or after the episode. She ate a normal breakfast this morning and has not changed any of her hypertension medications. There was no head or neck trauma, as she was slowly lowered to the floor by a kind bystander. This has never happened to her before. In the ED, her vital signs are normal, except for mildly elevated blood pressure (142/82) and her physical exam is entirely unremarkable. Her ECG reveals a normal sinus rhythm without acute ischemic changes and normal intervals. You ordered a chest x-ray and blood work, including a high-sensitivity troponin and these have all returned within normal limits. She has never had an echocardiogram performed. She is worried about this episode of syncope and is asking you why she passed out. Does this patient need admission to the hospital for further testing and monitoring?

Challenges in acute syncope care

Syncope continues to be a common reason for patients to present to the ED. As the US population ages, we can expect to see an increased number of patients with this complaint. Finding the exact etiology of the syncopal event remains a challenge for emergency physicians; though patients frequently ask us why they fainted, it is too often a question we cannot answer. There are two primary objectives in the emergency department evaluation of syncope: diagnostic and prognostic. The first objective is to uncover an acute serious diagnosis that may be associated with or have caused, the syncopal event, such as pulmonary embolism or cardiac dysrhythmia. The second objective is to accurately risk-stratify the patient to determine the intensity of care which would be appropriate in the short-term. Additional investigations, such as in-patient cardiac monitoring and echocardiography are often ordered, but are generally low yield. Risk stratification of patients with unexplained syncope has been a focus of clinical research for over two decades and many clinical decision tools have been published. Despite these efforts, no clear winner among these many tools has emerged, though there is ongoing research that may shed light on this issue. Further, the management of patients with syncope in the ED will be the focus of the next GRACE clinical practice guidelines from the Society of Academic Emergency Medicine (SAEM) that will be published in 2025. These guidelines will explicitly focus on, among other topics, the validated risk-stratification tools currently available. Meanwhile, new analytic approaches using artificial intelligence could provide the next frontier in clinical risk-stratification for ED patients with syncope.

Risk-stratification tools still need external validation

A recent scoping review found 19 different risk-stratification tools for patients with syncope.¹ The majority of these had neither been externally validated nor compared with unstructured physician gestalt. Perhaps the most recognizable of these, the San Francisco Syncope Rule, was found to have inadequate sensitivity in subsequent validation studies.^2,3 The more rigorous Canadian Syncope Risk Score has been validated in a multicenter study in Canada, but not has not been studied in the US.⁴ The FAINT Score, which was derived in a large, multicenter cohort of older adults in the US is pending external validation.⁵ Fortunately, there is an ongoing NIHfunded, multicenter study named “PACES: Practical Approaches to Care in Emergency Syncope” which is nearing completion and could significantly advance this field of research. Data collection will be completed in fall 2024. Results from the PACES study will provide external validation for and compare performance of, the Canadian and FAINT scores, as well as comparing both to unstructured physician gestalt.

Potential applications of Articificial Intelligence

Researchers have begun to apply various artificial intelligence (AI) techniques, such as machine learning and deep learning, to clinical riskstratification problems. With a large and accurately labeled dataset, machine learning could theoretically provide highly accurate risk-stratification for patients with unexplained syncope. One key challenge to this is that retrospective clinical data, while plentiful, often lacks complete and accurate information on clinical outcomes post-discharge, while prospective datasets generally do capture follow-up, but lack the scale required to properly train such AI models.

However, there is exciting work emerging that hones in on a more specific clinical question in the management of ED patients with syncope – whether the patient would benefit from an echocardiogram. A deep learning model, named EchoNext, was recently developed to predict the results of an echocardiogram using a 12-lead ECG alone.⁶ This model was trained on over 425,000 ECG-echocardiogram pairs using significant structural heart disease as the primary outcome. It is currently undergoing external validation in a cohort of adult ED patients with unexplained syncope and if validated, could help optimize echocardiography utilization, a test that is often ordered but rarely changes clinical management.

Need for implementation research

Both conventional and AI-based tools will need to be thoughtfully implemented to have a beneficial real-world impact on patients. Some specific challenges are foreseeable. One is acceptance. Physicians are known to have “algorithm aversion”, that is, “the tendency of humans to shy away from using algorithms even when algorithms observably outperform their human counterpart”.⁷ Another is workflow integration. Significant cooperation between clinicians, bioinformaticists and organizational leaders will be necessary to make sure tools built into electronic health record systems can be meaningfully used within the context of actual clinical care. And finally, even if these tools are successfully implemented, we will need properly conducted clinical trials to demonstrate the sustainable and positive impact on patient-oriented outcomes of these new tools.