Intelligent play: How improv can improve clinician's emotional intelligence.

BACKGROUND: Emotional intelligence (EI) of physicians significantly impacts their personal well-being and professional success with broad implications in health care. A focused training on EI is often lacking in medical curricula. We sought to understand the impact of improvisation training on clinicians' EI. APPROACH: Four online medical improv workshops were offered to a diverse group of physicians with varied levels of practice experience including medicine-paediatric residents, paediatric educators, practising paediatricians and internal/family medicine clinicians. The improv training was thoughtfully curated and remained consistent for all four cohorts, lasting 2 h. Self-reported EI scales (pre and post) were captured using an online survey tool. The overall EI score and the scores of three EI components were compared before and after training. EVALUATION: Out of 64 participants, 41 participants (64%) completed both the pre- and post-surveys and were included in the final analysis. Participant's pre-training score (mean:123.9, range: 121.1-126.7) was compared to their post-training score (mean:128.9, range: 126.3-131.3). The t tests comparing EI scores showed that compared to pre-intervention, participants on average scored 4.9 points higher (95% CI: 3.1-6.7; p < 0.01) on the overall scale, 2.2 points higher (95% CI: 1.2-3.2; p < 0.01) on the appraisal score, 1.4 points higher (95% CI: 0.8-2.0; p < 0.01) on the regulation score and 1.2 points higher (95% CI: 0.4-2.1; p = 0.01) on the utilisation score. IMPLICATIONS: Improv training is an innovative method to fill the crucial gap in EI curricula. There was a statistically significant improvement in average score for clinicians' EI after a pilot improv training programme.

Innovative Approaches to Improve COVID-19 Case Investigation and Contact Tracing Among Refugees, Immigrants, and Migrants: Lessons Learned from a Newly Established National Resource Center.

Effective COVID-19 case investigation and contact tracing (CICT) among refugee, immigrant, and migrant (RIM) communities requires innovative approaches to address linguistic, cultural and community specific preferences. The National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM) is a CDC-funded initiative to support state and local health departments with COVID-19 response among RIM communities, including CICT. This note from the field will describe NRC-RIM and initial outcomes and lessons learned, including the use of human-centered design to develop health messaging around COVID-19 CICT; training developed for case investigators, contact tracers, and other public health professionals working with RIM community members; and promising practices and other resources related to COVID-19 CICT among RIM communities that have been implemented by health departments, health systems, or community-based organizations.

Simulation as a Teaching Method: Evaluation of the University of Minnesota Humanitarian Crisis Simulation.

OBJECTIVE: The University of Minnesota Crisis Humanitarian Simulation provides trans-disciplinary training in disaster response. The course directors wished to better understand the learning outcomes and experiences of simulation participants. METHODS: The learning outcomes and experiences of participants in the 2019 simulation were assessed using 3 modalities: 1) pre-and post-simulation test, 2) participants' self-assessment of learning, and 3) qualitative feedback via an anonymous evaluation. RESULTS: Participant scores on the knowledge survey were significantly higher after the simulation than before the simulation (mean percent correct 71% vs. 48%, P < 0.0001). A significant majority of participants who completed the assessment believed they had main gains within each learning objective. Anonymous evaluations contained both positive feedback and constructive criticism leading to plans for refinements in subsequent training events. CONCLUSIONS: The Humanitarian Crisis Simulation is an effective experiential training program that increases participants' knowledge in the field of disaster response. Participants also believed they had made gains in each learning objective. The authors' analysis of elements that have contributed to the success of the program and areas for future program growth and improvement are discussed.

Global Health Education during the COVID-19 Pandemic: Challenges, Adaptations, and Lessons Learned.

Global health education programs should strive continually to improve the quality of education, increase access, create communities that foster excellence in global health practices, and ensure sustainability. The COVID-19 pandemic forced the University of Minnesota's extensive global health education programs, which includes a decade of hybrid online and in-person programing, to move completely online. We share our experience, a working framework for evaluating global health educational programming, and lessons learned. Over the decades we have moved from a predominantly passive, lecture-based, in-person course to a hybrid online (passive) course with an intensive hands-on 2-week requirement. The pandemic forced us to explore new active online learning models. We retained our on-demand, online passive didactics, which used experts' time efficiently and was widely accessible and well received. In addition, we developed a highly effective synchronous online component that we felt replaced some of the hands-on activities effectively and led us to develop new and innovative "hands-on" experiences. This new, fully online model combining quality asynchronous and synchronous learning provided many unanticipated advantages, such as increasing access while decreasing our carbon footprint dramatically. By sharing our experience, lessons learned, and resources, we hope to inspire other programs likewise to innovate to improve quality, access, community, and sustainability in global health, especially if these innovations can help decrease negative aspects of global health education such as its environmental impact.

Global Is Local: Does Formal Resident Global Health Medical Education Improve Clinical Care in the United States?

We administered a standardized 41-item questionnaire to a convenience sample of graduates of five residency programs with formal global health pathways and compared findings to a national cohort of practicing physicians to evaluate the comparative effectiveness of an overarching global health pathway on residency program graduates. Compared with the national cohort database, global health pathway graduates self-reported that they felt better prepared to treat immigrants, refugees, patients with limited English proficiency (LEP), racial/ethnic minorities, those with non-Western health beliefs, international travelers, and military veterans (P < 0.05). They were more likely to report using best practices when working with lesbian, gay, bisexual, transgender, queer/questioning patients, immigrant and refugee patients, patients with non-Western health beliefs, patients with LEP, and patients communicating via American Sign Language (P < 0.05). They also reported being more familiar with 11 of 14 high-impact or common infections encountered in travelers, immigrants, and military personnel (P < 0.05). Our findings suggest that formal postgraduate training focused on global health improves knowledge, attitudes, and self-reported medical practices when caring for diverse and marginalized populations in the United States.

Craving Empathy: Studying the Sustained Impact of Empathy Training on Clinicians.

Evidence is sparse when it comes to the longitudinal impact of educational interventions on empathy among clinicians. Additionally, most available research on empathy is on medical trainee cohorts. We set out to study the impact of empathy and communication training on practicing clinicians' self-reported empathy and whether it can be sustained over six months. An immersive curriculum was designed to teach empathy and communication skills, which entailed experiential learning with simulated encounters and didactics on the foundational elements of communication. Self-reported Jefferson Scale of Empathy (JSE) was scored before and at two points (1-4 weeks and 6 months) after the training. Overall, clinicians' mean self-empathy scores increased following the workshop and were sustained at six months. Specifically, the perspective taking domain of the empathy scale, which relates to cognitive empathy, showed the most responsiveness to educational interventions. Our analysis shows that a structured and immersive training curriculum centered on building communication and empathy skills has the potential to positively impact clinician empathy and sustain self-reported empathy scores among practicing clinicians.

Guillain-Barré Syndrome Associated with Zika Virus Infection in a Traveler Returning from Guyana.

Zika virus (ZIKV) is a mosquito-borne flavivirus with a significant public health impact highlighted by the ongoing epidemic in the Americas. We describe a 44-year-old male presenting to our tropical medicine center with complaints of fever, headache, joint pain, and rash after recent travel to Guyana. The patient subsequently developed gait imbalance and lower extremity weakness with clinical examination, cerebrospinal fluid studies, and magnetic resonance imaging of the spine consistent with a diagnosis of Guillain-Barré syndrome (GBS). ZIKV infection was confirmed via detection of ZIKV RNA in urine by polymerase chain reaction. The patient was treated with intravenous immunoglobulin and experienced near-complete neurologic recovery, reporting ongoing mild paresthesia up to 2 months later. This case highlights the diagnostic challenges posed by ZIKV and underscores the need for clinician awareness of the potential for neurological complications such as GBS with ZIKV infection.

HIV/AIDS and associated conditions among HIV-infected refugees in Minnesota, 2000­2007.

In 2010, the requirement for human immunodeficiency virus (HIV) testing of adult refugees prior to US resettlement was removed, thus leading to a potential for missed diagnosis. We reviewed refugee health assessment data and medical charts to evaluate the health status of HIV-infected refugees who arrived in Minnesota during 2000-2007, prior to this 2010 policy change. Among 19,292 resettled adults, 174 were HIV-infected; 169 (97%) were African (median age 26.4 (range: 17-76) years). Charts were abstracted for 157 (124 (79%) with ≥ 1 year of follow-up). At initial presentation, two of 74 (3%) women were pregnant; 27% became pregnant during follow-up. HIV clinical stage varied (59%, asymptomatic; 11%, mild symptoms; 10%, advanced symptoms; 3%, severe symptoms; 17%, unknown); coinfections were common (51 tuberculosis, 13 hepatitis B, 13 parasites, four syphilis). Prior to arrival 4% had received antiretrovirals. Opportunistic infections were diagnosed among 13%; 2% died from AIDS-related causes. Arrival screening may be needed to identify these HIV-infected refugees and prevent HIV-related morbidity and mortality.

Global health and primary care: increasing burden of chronic diseases and need for integrated training.

Noncommunicable diseases, including cardiovascular disease, chronic respiratory disease, diabetes, cancer, and mental illness, are the leading causes of death and disability worldwide. These diseases are chronic and often mediated predominantly by social determinants of health. Currently there exists a global-health workforce crisis and a subsequent disparity in the distribution of providers able to manage chronic noncommunicable diseases. Clinical competency in global health and primary care could provide practitioners with the knowledge and skills needed to address the global rise of noncommunicable diseases through an emphasis on these social determinants. The past decade has seen substantial growth in the number and quality of US global-health and primary-care training programs, in both undergraduate and graduate medical education. Despite their overlapping competencies, these 2 complementary fields are most often presented as distinct disciplines. Furthermore, many global-health training programs suffer from a lack of a formalized curriculum. At present, there are only a few examples of well-integrated US global-health and primary-care training programs. We call for universal acceptance of global health as a core component of medical education and greater integration of global-health and primary-care training programs in order to improve the quality of each and increase a global workforce prepared to manage noncommunicable diseases and their social mediators.

Impact of global health residency training on medical knowledge of immigrant health.

Lack of global health knowledge places immigrants at risk of iatrogenic morbidity. Although global health education programs have grown in popularity, measurable impact is lacking. We previously surveyed 363 physicians in training across 15 programs in four countries in 2004 regarding basic parasite knowledge and recognition of Strongyloides risk through a theoretical case scenario. In 2005, the University of Minnesota implemented a formal global health training program (GHP). In 2009, the identical survey was repeated. Strongyloidiasis recognition increased from 11.1% (19/171) in 2004 to 39.4% (50/127) in 2009 (P < 0.001). Trainees participating in formal didactic and interactive curriculum had superior recognition (77% versus 29%; P < 0.001). In a multivariate model of GHP training activities, participation in an American Society of Tropical Medicine and Hygiene-accredited global health certificate course increased recognition (odds ratio = 9.5, 95% confidence interval = 2.5-36, P = 0.001), whereas participation in international electives alone did not (P = 0.9). A formal GHP curriculum was associated with improved knowledge regarding common parasitic infections and the risk of iatrogenic morbidity and mortality due to strongyloidiasis.

Pediatric travelers visiting friends and relatives (VFR) abroad: illnesses, barriers and pre-travel recommendations.

Global mobility has shown a steady rise in recent years, with increased immigration and international travel. The VFR traveler is a traveler whose primary purpose of travel is to visit friends and relatives (VFR), where there is a gradient of risk between home and destination. Children are more likely to be VFR travelers than adults. Pediatric VFR travelers have higher risks for certain infectious travel-related illnesses and face multiple barriers in receiving comprehensive pre-travel care. This review focuses on the current state of knowledge of the pediatric VFR traveler, including epidemiological risks, barriers to adequate pre-travel services, and specific recommendations for disease prevention.

Clinical presentation and aetiologies of acute or complicated headache among HIV-seropositive patients in a Ugandan clinic.

BACKGROUND: We set out to define the relative prevalence and common presentations of the various aetiologies of headache within an ambulant HIV-seropositive adult population in Kampala, Uganda. METHODS: We conducted a prospective study of adult HIV-1-seropositive ambulatory patients consecutively presenting with new onset headaches. Patients were classified as focal-febrile, focal-afebrile, non-focal-febrile or non-focal-afebrile, depending on presence or absence of fever and localizing neurological signs. Further management followed along a pre-defined diagnostic algorithm to an endpoint of a diagnosis. We assessed outcomes during four months of follow up. RESULTS: One hundred and eighty patients were enrolled (72% women). Most subjects presented at WHO clinical stages III and IV of HIV disease, with a median Karnofsky performance rating of 70% (IQR 60-80).The most common diagnoses were cryptococcal meningitis (28%, n = 50) and bacterial sinusitis (31%, n = 56). Less frequent diagnoses included cerebral toxoplasmosis (4%, n = 7), and tuberculous meningitis (4%, n = 7). Thirty-two (18%) had other diagnoses (malaria, bacteraemia, etc.). No aetiology could be elucidated in 28 persons (15%). Overall mortality was 13.3% (24 of 180) after four months of follow up. Those without an established headache aetiology had good clinical outcomes, with only one death (4% mortality), and 86% were ambulatory at four months. CONCLUSION: In an African HIV-infected ambulatory population presenting with new onset headache, aetiology was found in at least 70%. Cryptococcal meningitis and sinusitis accounted for more than half of the cases.

Low prevalence of antibodies to preerythrocytic but not blood-stage Plasmodium falciparum antigens in an area of unstable malaria transmission compared to prevalence in an area of stable malaria transmission.

In areas where levels of transmission of Plasmodium falciparum are high and stable, the age-related acquisition of high-level immunoglobulin G (IgG) antibodies to preerythrocytic circumsporozoite protein (CSP) and liver-stage antigen 1 (LSA-1) has been associated with protection from clinical malaria. In contrast, age-related protection from malaria develops slowly or not at all in residents of epidemic-prone areas with unstable low levels of malaria transmission. We hypothesized that this suboptimal clinical and parasitological immunity may in part be due to reduced antibodies to CSP or LSA-1 and/or vaccine candidate blood-stage antigens. Frequencies and levels of IgG antibodies to CSP, LSA-1, thrombospondin-related adhesive protein (TRAP), apical membrane antigen 1 (AMA-1), erythrocyte binding antigen 175 (EBA-175), and merozoite surface protein 1 (MSP-1) were compared in 243 Kenyans living in a highland area of unstable transmission and 210 residents of a nearby lowland area of stable transmission. Levels of antibodies to CSP, LSA-1, TRAP, and AMA-1 in the oldest age group (>40 years) in the unstable transmission area were lower than or similar to those of children 2 to 6 years old in the stable transmission area. Only 3.3% of individuals in the unstable transmission area had high levels of IgG (>2 arbitrary units) to both CSP and LSA-1, compared to 43.3% of individuals in the stable transmission area. In contrast, antibody levels to and frequencies of MSP-1 and EBA-175 were similar in adults in areas of stable and unstable malaria transmission. Suboptimal immunity to malaria in areas of unstable malaria transmission may relate in part to infrequent high-level antibodies to preerythrocytic antigens and AMA-1.

Maltreatment of Strongyloides infection: case series and worldwide physicians-in-training survey.

BACKGROUND: Strongyloidiasis infects hundreds of millions of people worldwide and is an important cause of mortality from intestinal helminth infection in developed countries. The persistence of infection, increasing international travel, lack of familiarity by health care providers, and potential for iatrogenic hyperinfection all make strongyloidiasis an important emerging infection. METHODS: Two studies were performed. A retrospective chart review of Strongyloides stercoralis cases identified through microbiology laboratory records from 1993-2002 was conducted. Subsequently, 363 resident physicians in 15 training programs worldwide were queried with a case scenario of strongyloidiasis, presenting an immigrant with wheezing and eosinophilia. The evaluation focused on resident recognition and diagnostic recommendations. RESULTS: In 151 strongyloidiasis cases, stool ova and parasite sensitivity is poor (51%), and eosinophilia (>5% or >400 cells/microL) commonly present (84%). Diagnosis averaged 56 months (intra-quartile range: 4-72 months) after immigration. Presenting complaints were nonspecific, although 10% presented with wheezing. Hyperinfection occurred in 5 patients prescribed corticosteroids, with 2 deaths. Treatment errors occurred more often among providers unfamiliar with immigrant health (relative risk of error: 8.4; 95% confidence interval, 3.4-21.0; P <.001). When presented with a hypothetical case scenario, US physicians-in-training had poor recognition (9%) of the need for parasite screening and frequently advocated empiric corticosteroids (23%). International trainees had superior recognition at 56% (P <.001). Among US trainees, 41% were unable to choose any parasite causing pulmonary symptoms. CONCLUSIONS: Strongyloidiasis is present in US patients. Diagnostic consideration should occur with appropriate exposure, nonspecific symptoms including wheezing, or eosinophilia (>5% relative or >400 eosinophils/microL). US residents' helminth knowledge is limited and places immigrants in iatrogenic danger. Information about Strongyloides should be included in US training and continuing medical education programs.

Strongyloides hyperinfection presenting as acute respiratory failure and gram-negative sepsis.

STUDY OBJECTIVES: Disseminated strongyloides is a rarely reported phenomenon and occurs in immunosuppressed patients with chronic Strongyloides stercoralis infection. Typically, patients present with pulmonary symptoms but subsequently acquire Gram-negative sepsis. Several cases have been noted in Minnesota, and their presentation, diagnostic evaluation, and clinical outcomes were reviewed. DESIGN: A retrospective chart review was conducted of complicated strongyloides infections from 1993 to 2002 in Minneapolis and St. Paul, MN. Cases were identified by reviewing hospital microbiology databases. SETTING: Metropolitan hospitals with large immigrant populations. RESULTS: Nine patients, all of Southeast Asian heritage, were identified. Eight patients immigrated to the United States > or = 3 years prior to acute presentation. All patients were receiving antecedent corticosteroids; in five patients, therapy was for presumed asthma. Absolute eosinophil counts > 500/microL occurred in only two patients prior to steroid initiation. Eight patients presented with respiratory distress, and Gram-negative sepsis developed in four patients. Four patients had evidence of right-heart strain on ECG or echocardiography at the time of presentation. Three patients died; all had eosinophil counts of < 400/microL. CONCLUSIONS: Serious complications, including death, may occur in patients with chronic strongyloides infection treated with corticosteroids. Strongyloides hyperinfection usually presents as acute respiratory failure and may initially mimic an asthma exacerbation or pulmonary embolism. Southeast Asian patients presenting with new-onset "asthma," acute respiratory distress, and/or Gram-negative sepsis should undergo evaluation to exclude strongyloides infection.