Menopause.

This review focuses on the diagnosis and management of menopause, highlighting both hormonal and nonhormonal treatment options. In particular, the article focuses on recent data on the risks and benefits of hormone therapy to help clinicians better counsel their patients about decision making with regard to understanding and treating menopause symptoms.

Nfatc1's Role in Mammary Epithelial Morphogenesis and Basal Stem/progenitor Cell Self-renewal.

Mammary gland is an outstanding system to study the regulatory mechanisms governing adult epithelial stem cell activity. Stem cells in the basal layer of the mammary gland fuel the morphogenesis and regeneration of a complex epithelial network during development and upon transplantation. The self-renewal of basal stem/progenitor cells is subjected to regulation by both cell-intrinsic and extrinsic mechanisms. Nfatc1 is a transcription factor that regulates breast tumorigenesis and metastasis, but its role in mammary epithelial development and stem cell function has not been investigated. Here we show that Nfatc1 is expressed in a small subset of mammary basal epithelial cells and its epithelial-specific deletion results in mild defects in side branching and basal-luminal cell balance. Moreover, Nfatc1-deficient basal cells exhibit reduced colony forming ability in vitro and somewhat compromised regenerative potential upon transplantation. Thus, our study provides evidence for a detectable yet non-essential role of Nfatc1 in mammary epithelial morphogenesis and basal stem/progenitor cell self-renewal.

Internal Medicine Resident Perceptions of Patients with Substance Use Disorder After Attending a Mutual Support Group Meeting.

BACKGROUND: Mutual support groups (MSGs) are support systems for patients with substance use disorders (SUDs), yet medical residents lack awareness in the role MSGs play in addiction treatment. AIM: We developed an educational intervention to expose residents to MSGs and improve attitudes toward patients with SUD. SETTING: The study took place from October 2017 to March 2018 within a large academic medical center. PARTICIPANTS: First- to third-year internal medicine residents participated. PROGRAM DESCRIPTION: Residents attended a MSG meeting. They completed surveys pre- and post-meeting and attended a focus group debrief session. Focus group transcripts were coded and thematically analyzed. PROGRAM EVALUATION: Sixty-eight residents participated in the curriculum, 54 attended the focus group and 47 completed the pre- and post-survey. Qualitative themes included (1) appreciation for the sense of community at meetings, (2) improved perspective taking of patients with SUDs, (3) concern regarding religion, and (4) improved confidence in MSG referrals. Post-intervention, residents had more positive attitudes toward patients with SUD (p < 0.05 for 9 of 14 questions) and toward MSGs (p < 0.05 for 2 of 4 questions). DISCUSSION: Implementing an educational intervention on MSGs gives residents an experience that impacts attitudes toward patients with SUD and confidence with MSG referrals.

A Robust Faculty Development Program for Medical Educators: A Decade of Experience.

OBJECTIVES: Faculty development programs (FDPs) foster learning communities and enhance professional identity formation for medical educators. Competency-based frameworks for faculty development drive skill development across clinical practice, teaching, and scholarship domains. The aims of this study are to outline the context, content, and evolution of a novel FDP; map the individual conferences that make up the FDP to established faculty development competencies; identify steps to implement similar programming; and demonstrate outcomes to date. METHODS: The FDP consists of four, 1-hour-long conferences held weekly on a rotating basis since 2007 at the University of Pittsburgh School of Medicine: Academy of Master Educators, Medical Education Research, Medical Education Journal Club, and Medical Education Research Methods and Innovative Design conference. Authors outline the relation of each of these four conferences to faculty development competencies and describe early outcomes for each conference over four consecutive academic years from 2014 to 2018. Participants include attendees and presenters in four consecutive academic years from 2014 to 2018. RESULTS: The well-attended FDP meets all established competencies for educator faculty. Presenters and attendees were diverse in terms of academic rank and represented a breadth of clinical and basic science specialties. CONCLUSIONS: This integrated FDP fosters a community of medical educators and develops faculty skills across established medical educator competencies.

Does Formal Training in Medical Education and Professional Development Lead to Better Career Outcomes for Clinician Educators?

OBJECTIVES: Medical school and residency training programs rely on skilled clinician-educators to provide high-quality educational experiences. In 2002, the University of Pittsburgh's Institute for Clinical Research Education created a master's-level degree-granting program in medical education, which now has more than a decade of graduates. METHODS: All graduates between 2004 and 2014 were invited to complete an anonymous electronic survey regarding their experiences with the program and their perception of whether the master's program adequately prepared them in domains pertinent to medical educators. Participants also were asked to upload their current curricula vitae (CV) to assess objective measures of academic productivity among program graduates. RESULTS: More than 75% of surveys were completed (47/60) and 75% of CVs were submitted (45/60). Demographics of respondents showed that 66% were woman. The racial demographics of respondents revealed 13% Hispanic/Latino, 28% Asian, and 59% white, respectively. More than 90% of respondents agreed that because they completed the program, they were competent in multiple teaching and learning domains; 94% of respondents believed that they were more effective educators than peers who did not complete this degree. CV abstraction revealed that 98% of respondents currently held academic positions. Number of publications and number of years since program graduation were used to determine the rate of productivity of the graduates. Twenty-six graduates (58%) successfully published at least one peer-reviewed article per year since they graduated. This equated to approximately 3.77 publications per year for these 26 respondents and 2.27 publications per year for the entire cohort. CONCLUSIONS: Program graduates attributed their competence in several key domains that are crucial to excellence as a clinician-educator to their participation in the degree-granting program. The results of this study suggest that receipt of a graduate-level degree in medical education develops and enhances teaching skills and academic productivity among clinician-educators.

Teaching to Teach: An Effective and Feasible Teaching Curriculum for Internal Medicine Interns.

OBJECTIVES: New competency requirements from the Accreditation Council for Graduate Medical Education have prompted greater emphasis on developing residents' teaching skills. Many residents make their first foray into teaching during internship, making it an important yet underrecognized opportunity to develop basic teaching skills. In addition, in the current graduate medical education climate, residents' tasks are compressed into an even shorter time, which has caused teaching opportunities and expectations to be balanced with the need for efficiency. After performing needs assessment surveys of medicine interns and medical students, we developed an interns-as-teachers curriculum to equip internal medicine interns with skills specific to their unique role as medical student teachers. METHODS: We conducted a workshop focused around four specific skills: role modeling, using teachable moments (ie, teaching on the fly), thinking out loud, and coaching. We evaluated the curriculum by comparing pre- and postcurricular teaching knowledge, attitudes, and self-reported teaching behaviors among 51 interns in the intervention group with 20 interns in the comparison group from the previous year's class. RESULTS: Sixty-one interns participated in the curriculum, and 51 (84%) completed both surveys. Knowledge and several self-reported teaching behaviors improved significantly among the intervention group, but not in the comparison group. CONCLUSIONS: Interns participating in a half-day interns-as-teachers workshop aimed at preparing them to teach medical students in clinical settings achieved significant improvement in teaching knowledge and in several core, self-reported teaching behaviors.

Neonatal Abstinence Syndrome: Trend and Expenditure in Louisiana Medicaid, 2003-2013.

Objectives Determine trends in incidence and expenditure for perinatal drug exposure and neonatal abstinence syndrome (NAS) among Louisiana's Medicaid population. We also describe the maternal characteristics of NAS affected infants. Methods Retrospective cohort analysis using linked Medicaid and vital records data from 2003 to 2013. Conducted incidence and cost trends for drug exposed infants with and without NAS. Also performed comparison statistics among drug exposed infants with and without NAS and those not drug exposed. Results As rate of perinatal drug exposure increased, NAS rate per 1000 live Medicaid births also increased, from 2.1 (2003) to 3.6 (2007) to 8.0 (2013) (P for trend <0.0001). Total medical cost paid by Medicaid also increased from $1.3 million to $3.6 million to $8.7 million (P for trend <0.0001). Compared with drug exposed infants without NAS and those not drug exposed, infants with NAS were more likely to be white, have feeding difficulties, respiratory distress syndrome, sepsis, and seizures, all of which had an association at P < 0.0001. Over one-third (33.2%) of the mothers of infants with NAS had an opioid dependency in combination with a mental illness; with depression being most common. Conclusions for Practice Over an 11-year period, NAS rate among Louisiana's Medicaid infants quadrupled and the cost for caring for the affected infants increased six-fold. Medicaid, as the predominant payer for pregnant women and children affected by substance use disorders, must play a more active role in expanding access to comprehensive substance abuse treatment programs.

Hold-over admissions: are they educational for residents?

PURPOSE: Since implementation of resident duty-hour restrictions, many academic medical centers utilize night-float teams to admit patients during off hours. Patients are transferred to other resident physicians the subsequent morning as "hold-over admissions." Despite the increase of hold-over admissions, there are limited data on resident perceptions of their educational value. This study investigated resident perceptions of hold-over admissions, and whether they approach hold-over admissions differently than new admissions. METHOD: Survey of internal medicine residents at an academic medical center. RESULTS: A total of 111 residents responded with a response rate of 71 %. Residents reported spending 56.2 min (standard deviation [SD] 18.9) compared to 80.0 min (SD 25.8) admitting new patients (p < 0.01). Residents reported spending significantly (p < 0.01) less time reviewing the medical record, performing histories, examining patients, devising care plans and writing orders in hold-over admissions compared to new admissions. Residents had neutral views on the educational value of hold-over admissions. Features that significantly (p < 0.01) increased the educational value of admissions included severe illness, patient complexity, and being able to write the initial patient care orders. Residents estimated 42.5 % (SD 14) of their admissions were hold-over patients. CONCLUSIONS: Residents spend less time in all aspects of admitting hold-over patients. Despite less time spent admitting hold-over patients, residents had neutral views on the educational value of such admissions.

Needs assessment of palliative care education in gynecologic oncology fellowship: we're not teaching what we think is most important.

OBJECTIVES: We sought to characterize gynecologic oncology fellowship directors' perspectives on (1) inclusion of palliative care (PC) topics in current fellowship curricula, (2) relative importance of PC topics and (3) interest in new PC curricular materials. METHODS: An electronic survey was distributed to fellowship directors, assessing current teaching of 16 PC topics meeting ABOG/ASCO objectives, relative importance of PC topics and interest in new PC curricular materials. Descriptive and correlative statistics were used. RESULTS: Response rate was 63% (29/46). 100% of programs had coverage of some PC topic in didactics in the past year and 48% (14/29) have either a required or elective PC rotation. Only 14% (4/29) have a written PC curriculum. Rates of explicit teaching of PC topics ranged from 36% (fatigue) to 93% (nausea). Four of the top five most important PC topics for fellowship education were communication topics. There was no correlation between topics most frequently taught and those considered most important (rs=0.11, p=0.69). All fellowship directors would consider using new PC curricular materials. Educational modalities of greatest interest include example teaching cases and PowerPoint slides. CONCLUSIONS: Gynecologic oncology fellowship directors prioritize communication topics as the most important PC topics for fellows to learn. There is no correlation between which PC topics are currently being taught and which are considered most important. Interest in new PC curricular materials is high, representing an opportunity for curricular development and dissemination. Future efforts should address identification of optimal methods for teaching communication to gynecologic oncology fellows.

Development and Pilot Testing of a Longitudinal Skills-Based Feedback and Conflict Resolution Curriculum for Internal Medicine Residents.

PROBLEM: Physicians in training are responsible for leading clinical teams, coordinating interdisciplinary management, navigating conflict, and supervising and giving feedback to junior learners. Giving feedback and resolving conflict are key leadership skills for internal medicine (IM) residents, many of whom desire additional training. Although these skills are integral to successful leadership for physicians in training, residents receive little explicit education and existing curricula have not established best practices for skill acquisition. APPROACH: Study authors designed a pilot longitudinal, skills-based curriculum to teach first- through third-year IM residents at the University of Pittsburgh how to give formative feedback and engage in conflict resolution. From February to May 2021, authors delivered a series of interactive lectures utilizing frameworks, workplace-based scenarios, skills practice, and discussion. Skills transfer was evaluated with novel pre- and postcurriculum objective structured clinical examinations (OSCEs) wherein participants played the role of senior resident. Each OSCE involved 2 feedback and 2 conflict resolution stations. OSCE performances were evaluated using an author-created checklist with a 1-4 rating scale. The exposure group comprised post-OSCE participants who attended the curriculum. Data were analyzed using a mixed effects regression model. OUTCOMES: Thirty-six residents participated in curriculum evaluation, and 23 were included in postcurriculum data analysis. Within feedback, the skill "explores feedback content" significantly improved for exposure group participants (precurriculum median, 2.64; postcurriculum, 3.24; P < .05). For conflict resolution, among the exposure group, the skill "identifies a common goal, value, or purpose" significantly improved (pre, 3.10; post, 3.62; P < .05). NEXT STEPS: This curriculum and evaluation can serve as a stepping stone for further evidence-based leadership frameworks, curricula, and evaluations developed specifically for physicians within their unique leadership roles. The feedback and conflict resolution frameworks used in this curriculum can be applied to various medical specialties, with specialty-relevant scenario adaptations for interactive skills practice.

Evaluation of VA Women's Health Fellowships: developing leaders in academic women's health.

BACKGROUND: The Department of Veterans Affairs (VA) instituted the VA Women's Health Fellowship (VAWHF) Program in 1994, to accommodate the health needs of increasing numbers of female veterans and to develop academic leaders in women's health. Despite the longevity of the program, it has never been formally evaluated. OBJECTIVE: To describe the training environments of VAWHFs and career outcomes of female graduates. DESIGN AND PARTICIPANTS: Cross-sectional web-based surveys of current program directors (2010-2011) and VAWHF graduates (1995-2011). RESULTS: Responses were received from six of seven program directors (86 %) and 42 of 74 graduates (57 %). The mean age of graduates was 41.2 years, and mean time since graduation was 8.5 years. Of the graduates, 97 % were female, 74 % trained in internal medicine, and 64 % obtained an advanced degree. Those with an advanced degree were more likely than those without an advanced degree to pursue an academic career (82 % vs. 60 %; P<0.01). Of the female graduates, 76 % practice clinical women's health and spend up to 66 % of their time devoted to women's health issues. Thirty percent have held a VA faculty position. Seventy-nine percent remain in academics, with 39 % in the tenure stream. Overall, 94 % had given national presentations, 88 % had received grant funding, 79 % had published in peer-reviewed journals, 64 % had developed or evaluated curricula, 51 % had received awards for teaching or research, and 49 % had held major leadership positions. At 11 or more years after graduation, 33 % of the female graduates in academics had been promoted to the rank of associate professor and 33 % to the rank of full professor. CONCLUSIONS: The VAWHF Program has been successful in training academic leaders in women's health. Finding ways to retain graduates in the VA system would ensure continued clinical, educational, and research success for the VA women veteran's healthcare program.

Updates in Cardiovascular Disease Prevention, Diagnosis, and Treatment in Women.

Cardiovascular disease (CVD) is the leading cause of death for American women. CVD is preventable although risk reduction goals are not achieved for women compared with men. Considering a woman's cardiometabolic profile for prevention counseling and prescribing may help. Coronary artery calcium scores provide additional risk assessment and reproductive and menopause histories identify risk enhancers. Diagnosis of CVD is often delayed, and treatment is less optimal for women compared with men. Differences in presentation and underlying CVD etiology (Including spontaneous coronary artery dissection and microvascular disease) may partially account for these disparities. Improvements in CVD imaging to better diagnose these etiologies may benefit women's care.

Update on Breast Cancer.

This article reviews recent advances in the treatment of breast cancer. The goal in selecting these recent articles was to help identify literature that may change the clinical practice of women's health for practitioners in the primary care setting. Articles were identified by reviewing the high-impact medical and women's health journals, national guidelines, ACP JournalWise, and NEJM Journal Watch. In this Clinical Update, we selected recent publications relevant to the treatment and complications of treatment of breast cancer.

Teaching the teachers: faculty preparedness and evaluation of a retreat in screening, brief intervention, and referral to treatment.

Effective clinical faculty are essential for disseminating substance abuse screening, brief intervention, and referral to treatment (SBIRT). The authors developed an 8-hour SBIRT training for internal medicine faculty preceptors. Trainers conducted SBIRT lectures and small-group communication practice sessions. The authors assessed participants' (n = 27) knowledge, skills, and attitudes using an enhanced Alcohol and Alcohol Problems Perceptions Questionnaire (AAPPQ). Participants self-assessed their changes in SBIRT competence and comfort. Faculty trainees did not feel competent in SBIRT, particularly in intervention and referral to treatment. AAPPQ subscale scores were highest in Role Legitimacy and Motivation and lowest in Role Adequacy and Satisfaction. After training, faculty members reported greater likelihood of performing and teaching SBIRT. In some topic areas, faculty attending an SBIRT training reported limited knowledge and competence for treating drinkers; however, their interest and motivation for doing so was high. Ongoing faculty and organizational development efforts may help close these gaps.