The impact of patient death experiences early in training on resident physicians: a qualitative study.

BACKGROUND: Patient death is an inevitability during medical training, with subsequent psychologic distress, decreased empathy and worse learning outcomes. We aimed to explore resident experiences with patient death early in training, including the immediate and delayed impacts of these experiences, preparedness of trainees for these events and coping strategies used, potentially identifying gaps and opportunities to further support trainees during difficult or traumatic events. METHODS: We performed a qualitative study using phenomenology methodology to understand trainees' personal experiences with patient death. Resident physicians who had completed an internal medicine rotation at McMaster University, Hamilton, Ontario, were invited to participate from December 2020 to April 2021. Semistructured interviews were conducted to understand circumstances, emotional responses, support, coping mechanisms and preparedness regarding the patient death experience. Interviews were transcribed and coded to identify emerging themes with the use of thematic and interpretive analysis. RESULTS: Eighteen participants were interviewed. On average, the interviews were 40 minutes in length. The participants' mean age was 27 years. The majority of trainees (10 [56%]) were in their first year of residency, with 5 (28%) from family medicine and 4 (22%) from internal medicine. Most participants (13 [72%]) had experienced their first patient death during medical school. Three themes were identified: patient death circumstances, immediate and delayed emotional impact, and preparedness and coping mechanisms. Unexpected death, pronouncing death, cardiopulmonary resuscitation and communicating with families were common challenges. Feelings of guilt, helplessness and grief followed the events. Feeling underprepared contributed to emotional consequences, including difficulties sleeping, intrusive thoughts and emotional distancing; however, these experiences were consistently normalized by participants. INTERPRETATION: Patient death during medical training can be traumatic for trainees and may perpetuate loss of empathy, changes to practice and residual emotional effects. Educational initiatives to prepare trainees for patient death and teach adaptive coping strategies may help mitigate psychologic trauma and loss of empathy; further research is required to explore these strategies.

Barriers to Accessing Mental Health Support Services in Undergraduate Medical Training: A Multicenter, Qualitative Study.

PURPOSE: Medical students report higher levels of burnout, anxiety, and depression compared with age-matched peers. These mental health challenges have been linked to reduced workplace productivity, empathy, and professionalism. Yet, students experiencing mental health issues often decide not to access mental health resources, citing limited time and concerns about confidentiality, stigma, and the cost of private therapy. This study aimed to provide a framework for understanding barriers medical students face regarding access to mental health resources. METHOD: A constructivist grounded theory approach was employed, with 24 students from 6 medical schools in Ontario, Canada, participating in semistructured telephone interviews between May 2019 and February 2020. Participants were purposively sampled to capture a broad range of experiences, institutional contexts, and training levels. The authors then developed a framework to conceptualize the barriers that medical students face while accessing mental health resources. RESULTS: The information obtained from the interviews revealed that the barriers were both overt and covert. Overt barriers were primarily administrative challenges, including restrictive leave of absence policies and sick days, mandatory reporting of extended sick leave time during the residency selection process, time-restricted academic and clinical schedules, and difficulty in accessing mental health supports during distance education. Covert barriers to accessing mental health supports included a medical culture not conducive to mental health, felt stigma (i.e., fear of stigma and being labeled as weak), and the hidden curriculum (i.e., the unofficial or unintended rules and mannerisms propagated within medical education systems). CONCLUSIONS: Better understanding the overt and covert barriers that medical students to face while accessing mental health supports may help guide and inspire new advocacy efforts to enhance medical student well-being.

A new bleb-independent surgery namely penetrating canaloplasty for corticosteroid-induced glaucoma: a prospective case series.

AIM: To report the outcomes of penetrating canaloplasty for corticosteroid-induced glaucoma in a case series. METHODS: Penetrating canaloplasty is a bleb-independent filtering surgery unifying canaloplasty and trabeculectomy. In this study, the surgery was performed to restore the natural outflow through surgically expanded Schlemm's canal and generated trabeculum ostium. A total of 10 eyes of 8 patients were treated with penetrating canaloplasty for corticosteroid-induced glaucoma. Intraocular pressure (IOP) and the number of glaucoma medications at postoperative 3, 6, 12, 18, 24, 36, and 48mo were documented as primary endpoint. Complications after the surgery were recorded as secondary endpoint. RESULTS: Penetrating canaloplasty was accomplished successfully for all 10 eyes, with a mean follow-up of 20.4±13.0mo (range 6-48mo). The mean preoperative IOP and number of anti-glaucoma medications were 45.1±6.5 mm Hg and 3.3±0.5 respectively. The mean post-operative IOP at 3, 6, 12, 18, 24, 36, and 48mo were 15.8±6.0, 14.7±3.3, 15.3±2.0, 15.6±2.6, 17.5±1.8, 16.5±4.9, and 14.0 mm Hg. The number of anti-glaucoma medications at these time points were all 0. This surgery failed to control the IOP in 1 eye at 1mo after surgery. Hyphaema occurred in 3 eyes on the first day after surgery. Postoperative transient IOP increasing was encountered with in two eyes from 1wk to 1mo after surgery. Choroidal detachment developed in one eye but responded well to conservative treatment. CONCLUSION: Penetrating canaloplasty is effective for corticosteroid-induced glaucoma without serious complications, making it a viable or preferred alternative option.

Phylogenomics and diversification drivers of the Eastern Asian - Eastern North American disjunct Podophylloideae.

Evolutionary and biogeographic processes determine species richness patterns of vascular plants between Eastern Asia (EA) and Eastern North America (ENA). However, the strikingly higher species richness of EA relative to ENA remains poorly understood from this perspective. Here, we studied the relative importance of biogeographical, evolutionary and ecological factors underlying differences in species richness between EA and ENA in Podophylloideae (Berberidaceae, Ranunculales; in total 10 spp. in EA vs. 2 spp. in ENA). Based on large-scale transcriptome data, our phylogenomic analyses strongly supported Podophylloideae and its two multi-species genera, i.e. Dysosma (EA) and Diphylleia (EA/ENA), as monophyletic groups. Sinopodophyllum hexandrum (EA) was identified as sister to the remainder of Podophylloideae. Dysosma (7 spp.) was recovered as sister to Podophyllum peltatum (ENA), forming an EA-ENA disjunct pair with a strong bias of species diversity in the EA counterpart. Our biogeographic analyses support the 'out-of-Tibet' hypothesis, suggesting that Podophylloideae started to diversify in the Himalaya-Hengduan Mountains (Mid-Miocene) and migrated eastward (since the Late Miocene) into Central-eastern China, Japan, and ENA (only P. peltatum and Diphylleia cymosa). Overall, we conclude that the striking species diversity anomaly between EA and ENA in Podophylloideae may be explained by a combination of (1) a longer period of time available to accumulate species in EA; and (2) a greater diversification rate in EA, which might have been promoted by greater physiographic and environmental heterogeneity in this region.

Plastome organization, genome-based phylogeny and evolution of plastid genes in Podophylloideae (Berberidaceae).

Species of Podophylloideae (Berberidaceae, Ranunculales) are of great pharmacogenetic importance and represent the classic biogeographic disjunction between eastern Asia (EA; 10 ssp.) and eastern North America (ENA; 2 ssp.). However, previous molecular studies of this group suffered from low phylogenetic resolution and/or insufficient marker variability. This study is the first to report whole-plastome sequence data for all 12 species of Podophylloideae (14 individuals) and a close relative, Achlys triphylla. These 15 plastomes proved highly similar in overall size (156,240-157,370 bp), structure, gene order and content, also when compared to other Ranunculales, but also revealed some structural variations caused by the expansion or contraction of the inverted repeats (IRs) into or out of adjacent single-copy regions. Our phylogenomic analysis, based on 63 plastome-derived protein-coding genes (CDS), supported the monophyly of Podophylloideae and its two major genera (EA: Dysosma, EA/ENA: Diphylleia), with Podophyllum peltatum L. (ENA) being more closely related to Diphylleia than to the group's earliest diverging species, Sinopodophyllum hexandrum (EA). Furthermore, within this subfamily/dataset, matK was identified as the fastest evolving gene, which proved to be under positive selection especially in more recently derived, lower-elevation lineages of Dysosma, possibly reflecting an adaptive response to novel environmental (i.e. subtropical compared to higher-elevation/alpine) conditions. Finally, several highly variable noncoding regions were identified in the plastomes of Podophylloideae and Ranunculales. These highly variable loci should be the best choices for future phylogenetic, phylogeographic, and population-level genetic studies. Overall, our results demonstrate the power of plastid phylogenomics to improve phylogenetic resolution, and contribute to a better understanding of plastid gene evolution in Podophylloideae.