By Medical Students, for Medical Students: A Narrative Medicine Antiracism Program.

Objectives: Medical schools have sought to incorporate concepts of race and racism in their curricula to facilitate students' abilities to grapple with healthcare disparities in the United States; however, these efforts frequently fail to address implicit bias or equip students with cultural humility, reflective capacity, and interpersonal skills required to navigate racialized systems in healthcare. The purpose of this study was to develop and evaluate an antiracism narrative medicine (NM) program designed by and for preclinical medical students. Method: Preclinical medical students at a single center were eligible to participate from June-July 2021. Program evaluation included a postprogram qualitative interview and electronic survey. The semistructured interview included questions about program experience, lessons learned, and perspectives on antiracism curricula in medical education. Interviews were qualitatively analyzed using open and axial coding. Survey data were analyzed with descriptive statistics. Results: A total of 30 students registered. All (100%) respondents reported "somewhat true" or "very true" in the postprogram survey when asked about their ability to reflect on their own racial identity, racial identity of others, and influence of their racial identity on their future role as a healthcare worker through the program. Qualitative analysis revealed 3 themes: (1) curricular engagement; (2) racism and antiracism in medicine; and (3) group experience. Subthemes included: meaningful theoretical content; multimodal works and unique perspectives; race, identity, and intersectionality; deeper diversity, equity, and inclusion engagement; reconstructive visions; future oriented work; close reading and writing build confidence in discomfort; community and support system; and authentic space among peer learners. Conclusion: This virtual, peer-facilitated antiracism NM program provided an engaging and challenging experience for participants. Postprogram interviews revealed the program deepened students' understanding of racism, promoted self-reflection and community building, and propagated reconstructive visions for continuing antiracism work.

Building Authentic Connection in the Patient-Physician Relationship.

INTRODUCTION/OBJECTIVES: Delivering optimal patient care is impacted by a physician's ability to build trusting relationships with patients. Identifying techniques for rapport building is important for promoting patient-physician collaboration and improved patient outcomes. This study sought to characterize the approaches highly skilled primary care physicians (PCPs) use to effectively connect with diverse patients. METHODS: Using an inductive thematic analysis approach, we analyzed semi-structured interview transcripts with 10 PCPs identified by leadership and/or colleagues for having exceptional patient communication skills. PCPs practiced in 3 diverse clinic settings: (1) academic medical center, (2) Veterans Affairs clinic, and (3) safety-net community clinic. RESULTS AND CONCLUSIONS: The thematic analysis yielded 5 themes that enable physicians to establish connections with patients: Respect for the Patient, Engaged Curiosity, Focused Listening, Mutual Participation, and Self-Awareness. Underlying all of these themes was a quality of authenticity, or a state of symmetry between one's internal experience and external words and actions. Adopting these communication techniques while allowing for adaptability in order to remain authentic in one's interactions with patients may facilitate improved connection and trust with patients. Encouraging physician authenticity in the patient-physician relationship supports a shift toward relationship-centered care. Additional medical education training is needed to facilitate authentic connection between physicians and patients.

Roadmap for Trauma-Informed Medical Education: Introducing an Essential Competency Set.

Research has established that trauma is nearly universal and a root cause of numerous health and social problems, including 6 of the 10 leading causes of death, with devastating consequences across the life course. Scientific evidence now recognizes the complex injurious nature of structural and historical trauma (i.e., racism, discrimination, sexism, poverty, and community violence). Meanwhile, many physicians and trainees grapple with their own trauma histories and face direct and secondary traumatization on the job. These findings substantiate the profound impact of trauma on the brain and body and why trauma training is critical to the education and practice of physicians. However, a critical lag remains in translating essential research insights into clinical teaching and care. Recognizing this gap, the National Collaborative on Trauma-Informed Health Care Education and Research (TIHCER) formed a task force charged with developing and validating a summary of core trauma-related knowledge and skills for physicians. In 2022, TIHCER released the first-ever validated set of trauma-informed care competencies for undergraduate medical education. The task force focused on undergraduate medical education so that all physicians would be taught these foundational concepts and skills from the outset of training, recognizing that faculty development is needed to achieve this goal. In this Scholarly Perspective, the authors offer a roadmap for implementation of trauma-informed care competencies starting with medical school leadership, a faculty-student advisory committee, and sample resources. Medical schools can use the trauma-informed care competencies as a scaffold to customize integration of curricular content (what is taught) and efforts to transform the learning and clinical environments (how it is taught). Using the lens of trauma will ground undergraduate medical training in the latest science about the pathophysiology of disease and provide a framework to address many of our greatest challenges, including health disparities and professional burnout.

A Novel Narrative Medicine Approach to DEI Training for Medical School Faculty.

Problem:Diversity, Equity, and Inclusion (DEI) trainings for medical school faculty often lack self-reflective and pedagogically focused components that may promote incorporation of anti-racism and social justice into medical school curricula. Intervention: A four-session Narrative Medicine (NM) anti-racism program was designed for medical school faculty using critical race theory, phenomenology, and NM methods. Each workshop consisted of a lecture on key NM concepts and a small-group breakout session incorporating group discussion, close reading, and reflective writing. Context: This NM anti-racism program was developed and implemented in April 2021 by two medical students for faculty at an institution in the southeastern U.S. The program was supported by the Office of Inclusive Excellence at the institution and held in collaboration with the institution's medical education teaching academy. Program evaluation consisted of pre- and post-program surveys, which queried participants' previous experiences with DEI and medical humanities programs, perceptions of self-identity and privilege, and confidence in teaching concepts of anti-racism. Of the total program participants (n = 32), 19 completed both surveys (54.3%). Survey data were analyzed using bivariate testing methods and qualitative thematic analysis. Impact: Post-program surveys showed 13 (68.4%) participants felt "somewhat more" or "more" comfortable engaging in concepts of race, and 12 (63.2%) participants felt "somewhat more" or "more" comfortable including topics of race into their teaching compared to before the program. Five themes were generated following qualitative analysis: (1) the value of longitudinal narrative reflection in a small-group setting for DEI work; (2) desire to commit more time to DEI, anti-racist, and social justice work while balancing busy teaching and clinical schedules; (3) the value of storytelling in DEI and anti-racism programming; (4) an understanding of deconstructive and reconstructive work of anti-racism in medicine; and (5) an increased ability to educate and enact change through teaching, activism, and institutional cultural and policy changes. Lessons Learned: This novel NM DEI training for medical school faculty was successful in increasing comfort discussing and teaching concepts of race in the medical school classroom, while providing a uniquely reflective space for personal growth. Participation in this longitudinal reflective experience was limited by physician schedules, therefore efforts to make time to participate in similar longitudinal interventions must be undertaken.

An interprofessional experience preparing a collaborative workforce to care for older adults.

The development and evaluation of an interprofessional education (IPE) pre-professional geriatrics experience involving learners from 10 different health discipline programs is described. The experience provided learners with opportunities to use small-group collaborative approaches in two 3-hour interprofessional sessions. Learners gained exposure to geriatric principles and awareness of the needs of older adults and their families using case studies developed by experienced interprofessional faculty. Learners completed pre- and post-experience surveys and worksheets on their confidence to function in interprofessional teams, knowledge of other disciplines, perceptions of importance of each discipline in providing older adult care, and the qualities considered for a successful team. Data were collected over three offerings of the experience (2016, 2017, 2018) and analyzed using paired sample t-tests and ANOVA. A total of 562 learners participated with outcome measures indicating increased knowledge of older adult services different health professionals provide and increased confidence in knowing when to complete care referrals. Mean increase in learners' confidence to function in interprofessional teams was significant, suggesting the experience was effective in facilitating confidence in functioning and improving views of other disciplines' roles. This experience demonstrated that learners gained exposure to apply geriatric principle skills and critical thinking as interprofessional team members.

Intimate partner violence and trauma-informed care in pregnancy.

Intimate partner violence is defined as any behavior within an intimate relationship that causes physical, psychological, or sexual harm to those in the relationship. Globally, women are disproportionately victims of intimate partner violence. The risk increases during pregnancy, with estimated rates of as high as 20% among pregnant persons. Intimate partner violence is associated with adverse perinatal outcomes, including perinatal and maternal death. Given that pregnancy is a period of frequent interaction with the healthcare system, it is an opportune time to screen and intervene for intimate partner violence. Universal screening at the first prenatal visit and subsequently every trimester is recommended, with either written or verbal validated tools. Pregnant persons experiencing intimate partner violence need nonjudgmental, compassionate, confidential, and trauma-informed care. The goal of this review is to outline pregnancy-specific care considerations.

Mindful Opportunity to Reflect on Experience: Interdisciplinary Mind-Body Medicine Skills Training for Health-care Professionals.

Interventions that support employee wellness and resilience hold potential to improve patient care, increase staff engagement, and decrease burnout. This repeat-measures study evaluated whether an abbreviated version of mind-body medicine skills training could decrease stress and improve mindfulness among an interdisciplinary cohort of health-care professionals. The study also assessed whether participants incorporated the mind-body medicine skills into their personal and professional lives. Aggregate results from this unpaired cohort showed decreased stress and increased mindfulness. Postcourse surveys demonstrated increased personal and professional use of mind-body medicine skills. There was high favorability among participants. These preliminary results suggest that a modest investment of time and resources to learn mind-body medicine skills may positively affect employee wellness among health-care professionals. In addition, skills learned could translate into improved patient care and increased staff engagement. Further study with larger cohorts and a paired design is needed.

Development of NAMASTE (New Anxiety Management Algorithm Standardizing Treatment Experience) and Implementation in Primary Care.

Evidence-based depression treatment in primary care is well established. However, clinicians are less likely to be trained to diagnose and treat anxiety disorder, which is frequently comorbid, poses an independent risk for suicidality, and complicates disease management. The University of North Carolina's Internal Medicine Clinic developed a measurement-guided approach to identifying and treating anxiety disorder using the seven-item Generalized Anxiety Disorder Scale, treatment algorithms, medication charts, case-based training for best practices, onsite behavioral counseling, and psychiatric consultation. NAMASTE (new anxiety management algorithm standardizing treatment experience) offers a treatment approach for primary care and addresses a major unmet need in public health and medical education.

Views of institutional leaders on maintaining humanism in today's practice.

OBJECTIVE: To explore leadership perspectives on how to maintain high quality efficient care that is also person-centered and humanistic. METHODS: The authors interviewed and collected narrative transcripts from a convenience sample of 32 institutional healthcare leaders at seven U.S. medical schools. The institutional leaders were asked to identify factors that either promoted or inhibited humanistic practice. A subset of authors used the constant comparative method to perform qualitative analysis of the interview transcripts. They reached thematic saturation by consensus on the major themes and illustrative examples after six conference calls. RESULTS: Institutional healthcare leaders supported vision statements, policies, organized educational and faculty development programs, role modeling including their own, and recognition of informal acts of kindness to promote and maintain humanistic patient-care. These measures were described individually rather than as components of a coordinated plan. Few healthcare leaders mentioned plans for organizational or systems changes to promote humanistic clinician-patient relationships. CONCLUSIONS: Institutional leaders assisted clinicians in dealing with stressful practices in beneficial ways but fell short of envisaging systems approaches that improve practice organization to encourage humanistic care. PRACTICE IMPLICATIONS: To preserve humanistic care requires system changes as well as programs to enhance skills and foster humanistic values and attitudes.

Healthcare at the Crossroads: The Need to Shape an Organizational Culture of Humanistic Teaching and Practice.

BACKGROUND: Changes in the organization of medical practice have impeded humanistic practice and resulted in widespread physician burnout and dissatisfaction. OBJECTIVE: To identify organizational factors that promote or inhibit humanistic practice of medicine by faculty physicians. DESIGN: From January 1, 2015, through December 31, 2016, faculty from eight US medical schools were asked to write reflectively on two open-ended questions regarding institutional-level motivators and impediments to humanistic practice and teaching within their organizations. PARTICIPANTS: Sixty eight of the 92 (74%) study participants who received the survey provided written responses. All subjects who were sent the survey had participated in a year-long small-group faculty development program to enhance humanistic practice and teaching. As humanistic leaders, subjects should have insights into motivating and inhibiting factors. APPROACH: Participants' responses were analyzed using the constant comparative method. KEY RESULTS: Motivators included an organizational culture that enhances humanism, which we judged to be the overarching theme. Related themes included leadership supportive of humanistic practice, responsibility to role model humanism, organized activities that promote humanism, and practice structures that facilitate humanism. Impediments included top down organizational culture that inhibits humanism, along with related themes of non-supportive leadership, time and bureaucratic pressures, and non-facilitative practice structures. CONCLUSIONS: While healthcare has evolved rapidly, efforts to counteract the negative effects of changes in organizational and practice environments have largely focused on cultivating humanistic attributes in individuals. Our findings suggest that change at the organizational level is at least equally important. Physicians in our study described the characteristics of an organizational culture that supports and embraces humanism. We offer suggestions for organizational change that keep humanistic and compassionate patient care as its central focus.

Straddling care and education: Developing interprofessional collaboration through a hotspotting service learning project.

Interprofessional (IP) team work has been shown to decrease burnout and improve care and decrease costs. However, institutional barriers have challenged adoption in practice and education. Faculty and students are turning to IP service-learning projects to help students gain experience and provide needed services. This paper highlights a "hotspotting" program where students from different health professions work collaboratively to improve high utilizing patients' health. Benefits, challenges and preliminary results including cost savings and student efficacy are shared. Institutions should surmount barriers that make hotspotting service-learning challenging as IP team-based experiences prepare students for the workplace and can help mitigate burnout.

Developing a pilot curriculum to foster humanism among graduate medical trainees.

BACKGROUND: Humanism is a central tenant of professionalism, a required competency for all residency programs. Yet, few residencies have formal curriculum for teaching this critical aspect of medicine. Instead, professionalism and humanism are often taught informally through role-modeling. With increased burnout, faculty professionalism may suffer and may compromise resident role-modeling. The objective of this study was to design a pilot curriculum to foster humanism in among residents and assess its ability to do so. MATERIALS AND METHODS: Two-phase exploratory sequential mixed methods study. Phase 1: a qualitative analysis of residents' narratives regarding challenges to humanistic behavior, and identified themes of compassion, fatigue, communication challenges, and work-life balance. Themes used as needs assessment to build curriculum. Phase 2: three sessions with themes taken from faculty development course. Participants and controls completed baseline and 60-day follow-up questionnaires assessing burnout, compassion, satisfaction, and ability to practice psychological medicine. Phase one included Obstetrics/Gynecology and internal medicine residents. Phase two included residents from the above programs, who attended at least 2/3 interactive sessions designed to address the themes identified above. RESULTS: Twelve participants began and ten completed curriculum (83%). The curriculum met course objectives and was well-received (4.8/5). Burnout decreased (-3.1 vs. 2.5, P = 0.048). A trend toward improved compassion (4.4 vs.-0.6, P = 0.096) for participants compared to controls was noted. CONCLUSION: A pilot humanism curriculum for residents was well-received. Participants showed decreased burnout and trended to improved compassion scores. Development and evaluation of an expanded curriculum would further explore feasibility and effectiveness of the intervention.

New in Vitro Assay Measuring Direct Interaction of Nonsense Suppressors with the Eukaryotic Protein Synthesis Machinery.

Nonsense suppressors (NonSups) induce "readthrough", i.e., the selection of near cognate tRNAs at premature termination codons and insertion of the corresponding amino acid into nascent polypeptide. Prior readthrough measurements utilized contexts in which NonSups can promote readthrough directly, by binding to one or more of the components of the protein synthesis machinery, or indirectly, by several other mechanisms. Here we utilize a new, highly purified in vitro assay to measure exclusively direct nonsense suppressor-induced readthrough. Of 16 NonSups tested, 12 display direct readthrough, with results suggesting that such NonSups act by at least two different mechanisms. In preliminary work we demonstrate the potential of single molecule fluorescence energy transfer measurements to elucidate mechanisms of NonSup-induced direct readthrough, which will aid efforts to identify NonSups having improved clinical efficacy.

A Multi-Institutional Longitudinal Faculty Development Program in Humanism Supports the Professional Development of Faculty Teachers.

The authors describe the first 11 academic years (2005-2006 through 2016-2017) of a longitudinal, small-group faculty development program for strengthening humanistic teaching and role modeling at 30 U.S. and Canadian medical schools that continues today. During the yearlong program, small groups of participating faculty met twice monthly with a local facilitator for exercises in humanistic teaching, role modeling, and related topics that combined narrative reflection with skills training using experiential learning techniques. The program focused on the professional development of its participants. Thirty schools participated; 993 faculty, including some residents, completed the program.In evaluations, participating faculty at 13 of the schools scored significantly more positively as rated by learners on all dimensions of medical humanism than did matched controls. Qualitative analyses from several cohorts suggest many participants had progressed to more advanced stages of professional identity formation after completing the program. Strong engagement and attendance by faculty participants as well as the multimodal evaluation suggest that the program may serve as a model for others. Recently, most schools adopting the program have offered the curriculum annually to two or more groups of faculty participants to create sufficient numbers of trained faculty to positively influence humanistic teaching at the institution.The authors discuss the program's learning theory, outline its curriculum, reflect on the program's accomplishments and plans for the future, and state how faculty trained in such programs could lead institutional initiatives and foster positive change in humanistic professional development at all levels of medical education.

How physicians draw satisfaction and overcome barriers in their practices: "It sustains me".

OBJECTIVE: Major reorganizations of medical practice today challenge physicians' ability to deliver compassionate care. We sought to understand how physicians who completed an intensive faculty development program in medical humanism sustain their humanistic practices. METHODS: Program completers from 8 U.S. medical schools wrote reflections in answer to two open-ended questions addressing their personal motivations and the barriers that impeded their humanistic practice and teaching. Reflections were qualitatively analyzed using the constant comparative method. RESULTS: Sixty-eight physicians (74% response rate) submitted reflections. Motivating factors included: 1) identification with humanistic values; 2) providing care that they or their family would want; 3) connecting to patients; 4) passing on values through role modelling; 5) being in the moment. Inhibiting factors included: 1) time, 2) stress, 3) culture, and 4) episodic burnout. CONCLUSIONS: Determination to live by one's values, embedded within a strong professional identity, allowed study participants to alleviate, but not resolve, the barriers. Collaborative action to address organizational impediments was endorsed but found to be lacking. PRACTICE IMPLICATIONS: Fostering fully mature professional development among physicians will require new skills and opportunities that reinforce time-honored values while simultaneously partnering with others to nurture, sustain and improve patient care by addressing system issues.

Ribosome-Templated Azide-Alkyne Cycloadditions: Synthesis of Potent Macrolide Antibiotics by In Situ Click Chemistry.

Over half of all antibiotics target the bacterial ribosome-nature's complex, 2.5 MDa nanomachine responsible for decoding mRNA and synthesizing proteins. Macrolide antibiotics, exemplified by erythromycin, bind the 50S subunit with nM affinity and inhibit protein synthesis by blocking the passage of nascent oligopeptides. Solithromycin (1), a third-generation semisynthetic macrolide discovered by combinatorial copper-catalyzed click chemistry, was synthesized in situ by incubating either E. coli 70S ribosomes or 50S subunits with macrolide-functionalized azide 2 and 3-ethynylaniline (3) precursors. The ribosome-templated in situ click method was expanded from a binary reaction (i.e., one azide and one alkyne) to a six-component reaction (i.e., azide 2 and five alkynes) and ultimately to a 16-component reaction (i.e., azide 2 and 15 alkynes). The extent of triazole formation correlated with ribosome affinity for the anti (1,4)-regioisomers as revealed by measured Kd values. Computational analysis using the site-identification by ligand competitive saturation (SILCS) approach indicated that the relative affinity of the ligands was associated with the alteration of macrolactone+desosamine-ribosome interactions caused by the different alkynes. Protein synthesis inhibition experiments confirmed the mechanism of action. Evaluation of the minimal inhibitory concentrations (MIC) quantified the potency of the in situ click products and demonstrated the efficacy of this method in the triaging and prioritization of potent antibiotics that target the bacterial ribosome. Cell viability assays in human fibroblasts confirmed 2 and four analogues with therapeutic indices for bactericidal activity over in vitro mammalian cytotoxicity as essentially identical to solithromycin (1).