What/Why/When/Where/How Framework and Faculty Development Workshop to Improve the Utility of Narrative Evaluations for Assessing Internal Medicine Residents.

Introduction: Clinical competency committees (CCCs) rely on narrative evaluations to assess resident competency. Despite the emphasis on these evaluations, their utility is frequently hindered by lack of sufficient detail for use by CCCs. Prior resources have sought to improve specificity of comments and use of evaluations by residents but not their utility for CCCs in assessing trainee performance. Methods: We developed a 1-hour faculty development workshop focused on a newly devised framework for Department of Medicine faculty supervising internal medicine residents. The what/why/when/where/how framework highlighted key features of useful narrative evaluations: behaviors of strength and growth, contextualized observations, improvement over time, and actionable next steps. Workshop sessions were implemented at a large multisite internal medicine residency program. We assessed the workshop by measuring attendee confidence and skill in writing narrative evaluations useful for CCCs. Skill was assessed through a rubric adapted from literature on the utility of narrative evaluations. Results: Fifty-four participants started the presurvey, and 33 completed the workshop, for a response rate of 61%. Participant confidence improved pre-, post-, and 3 months postworkshop. Total utility scores improved in mock evaluations from 12.4 to 15.5 and in real evaluations from 13.7 to 15.0, but only some subcomponent scores improved, with fewer improving in the real evaluations. Discussion: A short workshop focusing on our framework improves confidence and utility of narrative evaluations of internal medicine residents for use by CCCs. Next steps should include developing more challenging components of narrative evaluations for continued improvement in trainee performance and faculty assessment.

Adapting Existing Resources for Serious Illness Communication Skills Training for Internal Medicine Residents.

OBJECTIVES: Goals of care discussions are a vital component of patient care, but Internal Medicine residents receive limited training in these skills. Existing curricula often require simulated patients or faculty development, limiting implementation in many residency programs. Thus, we developed and implemented a curriculum leveraging existing educational resources with the goal of improving resident attitudes and confidence in conducting goals of care discussions in training settings. METHODS: We developed cases and a detailed faculty guide for small-group discussion with three exercises to standardize the learner experience and minimize the need for faculty development. Exercises introduced established communication skill frameworks including SPIKES (setting, perception, invitation, knowledge, empathy, summary) and REMAP (reframe, emotion, map, align, propose a plan) for how to break bad news, respond to strong emotions, and conduct a goals of care discussion. Participants were 163 Internal Medicine postgraduate year 1, -2, and -3 residents at a large urban academic institution, where residency-wide curriculum is delivered in weekly half-day didactic sessions during the course of 5 weeks. Primary outcomes were resident self-reported confidence with goals of care communication skills. RESULTS: A total of 109 (response rate 67%) of residents reported improvement in overall confidence in goals of care discussion skills (3.6 ± 0.9 vs 4.1 ± 0.6, P < 0.001), responding to emotions (3.5 ± 0.9 vs 3.9 ± 0.6, P = 0.004), making care recommendations (3.5 ± 1.0 vs 3.9 ± 0.7, P < 0.001), and quickly conducting a code status discussion (3.6 ± 1.0 vs 4.0 ± 0.7, P < 0.001). Residents also expressed an increased desire for supervision and feedback to further develop these skills. CONCLUSIONS: This goals of care communication curriculum improves resident confidence and requires minimal resources. It may be ideal for programs that have limited access to simulated patients and/or faculty trained in communication skill simulation, but desire enhanced education on this important aspect of patient-doctor communication and high-quality patient care. Future studies measuring clinical outcomes and changes in learner behavior as a result of this intervention are needed. Ongoing observation and feedback on these skills will be important to solidify learning and sustain impact.

Tau-mediated NMDA receptor impairment underlies dysfunction of a selectively vulnerable network in a mouse model of frontotemporal dementia.

Frontotemporal dementia (FTD) is a neurodegenerative behavioral disorder that selectively affects the salience network, including the ventral striatum and insula. Tau mutations cause FTD, but how mutant tau impairs the salience network is unknown. Here, we address this question using a mouse model expressing the entire human tau gene with an FTD-associated mutation (V337M). Mutant, but not wild-type, human tau transgenic mice had aging-dependent repetitive and disinhibited behaviors, with synaptic deficits selectively in the ventral striatum and insula. There, mutant tau depleted PSD-95, resulting in smaller postsynaptic densities and impaired synaptic localization of NMDA receptors (NMDARs). In the ventral striatum, decreased NMDAR-mediated transmission reduced striatal neuron firing. Pharmacologically enhancing NMDAR function with the NMDAR co-agonist cycloserine reversed electrophysiological and behavioral deficits. These results indicate that NMDAR hypofunction critically contributes to FTD-associated behavioral and electrophysiological alterations and that this process can be therapeutically targeted by a Food and Drug Administration-approved drug.