Mentoring as a complex adaptive system - a systematic scoping review of prevailing mentoring theories in medical education.

BACKGROUND: Effective mentorship is an important component of medical education with benefits to all stakeholders. In recent years, conceptualization of mentorship has gone beyond the traditional dyadic experienced mentor-novice mentee relationship to include group and peer mentoring. Existing theories of mentorship do not recognize mentoring's personalized, evolving, goal-driven, and context-specific nature. Evidencing the limitations of traditional cause-and-effect concepts, the purpose of this review was to systematically search the literature to determine if mentoring can be viewed as a complex adaptive system (CAS). METHODS: A systematic scoping review using Krishna's Systematic Evidence-Based Approach was employed to study medical student and resident accounts of mentoring and CAS in general internal medicine and related subspecialties in articles published between 1 January 2000 and 31 December 2023 in PubMed, Embase, PsycINFO, ERIC, Google Scholar, and Scopus databases. The included articles underwent thematic and content analysis, with the themes identified and combined to create domains, which framed the discussion. RESULTS: Of 5,704 abstracts reviewed, 134 full-text articles were evaluated, and 216 articles were included. The domains described how mentoring relationships and mentoring approaches embody characteristics of CAS and that mentorship often behaves as a community of practice (CoP). Mentoring's CAS-like features are displayed through CoPs, with distinct boundaries, a spiral mentoring trajectory, and longitudinal mentoring support and assessment processes. CONCLUSION: Recognizing mentorship as a CAS demands the rethinking of the design, support, assessment, and oversight of mentorship and the role of mentors. Further study is required to better assess the mentoring process and to provide optimal training and support to mentors.

A review of proton pump inhibitor use in cystic fibrosis and considerations for deprescribing.

Use of proton-pump inhibitors (PPIs) is common among people with cystic fibrosis (pwCF) both for the management of suspected GERD, as well as pancreatic enzyme replacement therapy augmentation. Despite their use, limited data exist to demonstrate a clinically significant impact of PPIs on key endpoints in pwCF. Furthermore, the advent of cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy may modify the need for use. These notions, coupled with the potential for adverse outcomes associated with long-term PPI use in pwCF, should facilitate re-evaluation of long-term PPI use in pwCF and promote potential deprescribing. Despite limited data on PPI deprescribing in pwCF, it intuitively mirrors the existing guidance in adults in the general population, but with added consideration given to tapering strategy, and monitoring for CF-specific outcomes such as nutritional and respiratory status. The development of a monitoring and re-initiation plan is key to reducing deprescribing inertia. This review aims to summarize the evidence that details the concern for long-term use of PPIs and provide CF clinicians with rationale and guidance on how to approach deprescribing in their practice.

Systematic scoping review on moral distress among physicians.

BACKGROUND: Concepts of moral distress (MD) among physicians have evolved and extend beyond the notion of psychological distress caused by being in a situation in which one is constrained from acting on what one knows to be right. With many accounts involving complex personal, professional, legal, ethical and moral issues, we propose a review of current understanding of MD among physicians. METHODS: A systematic evidence-based approach guided systematic scoping review is proposed to map the current concepts of MD among physicians published in PubMed, Embase, PsycINFO, Web of Science, SCOPUS, ERIC and Google Scholar databases. Concurrent and independent thematic and direct content analysis (split approach) was conducted on included articles to enhance the reliability and transparency of the process. The themes and categories identified were combined using the jigsaw perspective to create domains that form the framework of the discussion that follows. RESULTS: A total of 30 156 abstracts were identified, 2473 full-text articles were reviewed and 128 articles were included. The five domains identified were as follows: (1) current concepts, (2) risk factors, (3) impact, (4) tools and (5) interventions. CONCLUSIONS: Initial reviews suggest that MD involves conflicts within a physician's personal beliefs, values and principles (personal constructs) caused by personal, ethical, moral, contextual, professional and sociocultural factors. How these experiences are processed and reflected on and then integrated into the physician's personal constructs impacts their self-concepts of personhood and identity and can result in MD. The ring theory of personhood facilitates an appreciation of how new experiences create dissonance and resonance within personal constructs. These insights allow the forwarding of a new broader concept of MD and a personalised approach to assessing and treating MD. While further studies are required to test these findings, they offer a personalised means of supporting a physician's MD and preventing burn-out.

Clinical investigation of a point-of-care blood ammonia analyzer.

BACKGROUND: Hyperammonemia has frequently been implicated in the pathogenesis of hepatic encephalopathy. Blood ammonia determination requires minimal delay between sampling and analysis for accurate results. OBJECTIVES: The aim of this study was to investigate the PocketChem BA, a new point-of-care (POC) blood ammonia analyzer for clinical use by determining machine precision, linearity, repeatability, and accuracy. METHODS: Coefficients of variation were determined by repeated measurement of 2 control solutions. Linearity was investigated by testing serial dilutions of a stock solution. For accuracy, samples from clinical cases were used to compare the results on the PocketChem BA with those obtained using an enzymatic reference method for canine plasma. Canine and feline patients were consecutively enrolled if blood ammonia was assayed and samples could be analyzed shortly after collection. Classification of results (as normal or high, using 100 micromol/L as a cutoff value), Bland-Altman and Deming regression plots, and intraclass correlation coefficients were used to compare the methods. Stability of samples and test strips also was assessed over time. RESULTS: Coefficients of variation were 10.6% and 4.8% for low and high controls, respectively. Concentrations of ammonia in diluted stock solutions correlated positively with mean measured concentrations (Pearson coefficient 0.988, P<.001). Of the 54 samples obtained from 38 dogs and 4 cats, 41 had ammonia concentrations within the readable range. Results from the POC analyzer and the reference method were correlated positively (intraclass coefficient 0.800, 95% confidence interval 0.655-0.888), with the POC analyzer having negative constant and proportional biases. The methods agreed in the classification of 45/54 (83.3%) samples, with 7 false negative results on the POC analyzer. Results of repeated sample and strip analyses at 1 and 24 hours were significantly different (P<.05) from those at 0 hour. CONCLUSIONS: The PocketChem BA has acceptable precision, adequate linearity, and satisfactory agreement with a reference method, but negative constant and proportional biases. The POC analyzer may be suitable for clinical use in patients suspected of having hepatic encephalopathy, using a lower reference limit of 60 mumol/L to decrease false negative results.

Candida albicans peritonitis in a dog.

OBJECTIVE: To describe the clinical management of a case of Candida albicans peritonitis in a dog and discuss the pathogenicity of Candida peritonitis along with treatment using the fungistatic agent, fluconazole. CASE SUMMARY: A 15-week-old Papillon developed peritonitis secondary to enterectomy site dehiscence. A pure growth of Candida albicans was obtained from the abdominal fluid. Surgical repair of the dehiscence was performed and antifungal therapy instituted with fluconazole postoperatively. A marked exudative process was noted postoperatively with production of large volumes of fluid from the abdominal drain. Fresh frozen plasma and pentastarch were provided for oncotic support. Recovery was complicated by megaesophagus, however, the patient gradually improved and was discharged 11 days after surgery. NEW OR UNIQUE INFORMATION PROVIDED: To our knowledge, this is the first case report of successful treatment of Candida albicans peritonitis in a dog. A marked exudative process was noted during therapy requiring significant oncotic support. Resolution of the disease process was achieved with surgical intervention and antifungal therapy.