Impact of a hospital unit-based leadership triad on key performance metrics.

We piloted a triad leadership model consisting of a unit-based hospitalist medical director, nurse manager, and case manager on five medical inpatient units. The purpose of this explanatory case study was to determine what, if any, impact the triad team would have on commonly measured operational and quality metrics: observed to expected length of stay, likelihood to recommend the hospital, hand-washing compliance, all-cause 30-day readmission rates, percent of discharges by noon, and percent of discharge to skilled nursing facilities. Over the course of a year triad units demonstrated improvement in most metrics in comparison to the baseline period. While trends for the metrics were favorable, most striking was a statistically significant improvement in the observed to expected length of stay ratio (1.25 to 1.15, p < 0.001) which is the organization's most widely used marker for efficient hospital patient flow.As a result of these sustained operational, safety, quality, and financial performance metrics the model is being generalized to other medical as well as surgical units, including our observation unit. Intangible benefits include creating leadership development path for hospitalist, nursing, and case management colleagues.

Schema and deviation effects in remembering repeated unfamiliar stories.

In today's globalized world, we frequently encounter unfamiliar events that we may have difficulty comprehending - and in turn remembering - due to a lack of appropriate schemata. This research investigated schema effects in a situation where participants established a complex new schema for an unfamiliar type of story through exposure to four variations. We found that immediate recall increased across subsequent stories and that distortions occurred less frequently - participants built on the emerging schema and gradually established representations of parts of the story that were initially transformed. In recall with delays increasing up to 1 month, quantitative measures indicated forgetting while distortions increased. The second focus of this research was on content and order deviation effects on recall. The content deviation, in contrast with previous repeated-event research, was not remembered well and was associated with lower recall; the order deviation had a similar (but expected) effect. We discuss discrepancies between results of this study and previous literature, which had focused on schemata for familiar events, in relation to stages of schema development: it seems that in unfamiliar repeated events, a complex new schema is in the early stages of formation, where the lack of attentional resources limits active processing of deviations.

An Interactive Lifestyle Medicine Curriculum for Third-Year Medical Students to Promote Student and Patient Wellness.

Introduction: Although lifestyle intervention and behavior modification are effective in the prevention and treatment of chronic disease, few medical schools provide specific training in stress management, nutrition, or physical activity. While the prevalence of chronic disease rises, medical students and physicians lack sufficient knowledge and skills to promote their patients' as well as their own wellness across these domains. Methods: We developed three hour-long workshops delivered to third-year medical students. We employed interactive lectures, small-group discussions, and reflective activities to teach the pillars of lifestyle medicine. These sessions focused on knowledge and skills to advance lifestyle counseling and behavior modification interventions with patients and to promote student wellness. We assessed student satisfaction with each session as well as self-perceived knowledge, skills, and attitudes toward lifestyle medicine and behavior change before and after the curriculum. Results: Over 2 years, 183 students participated in the workshop series. The sessions received high ratings, with a mean of 4.2 on a 5-point Likert scale. Participating in the curriculum significantly enhanced students' understanding of the connection between lifestyle factors and the health of patients and improved their confidence about counseling for behavioral change. Discussion: Lifestyle medicine provides an evidence-based framework for teaching students about the impact of lifestyle modification on chronic disease. While receiving knowledge and skills to advance patient care in the domains of stress management, nutrition, and physical activity, students who completed this curriculum also had the opportunity to reflect on their own health promotion, which could mitigate professional burnout.

Impact of Endocrinology eConsults on Access to Endocrinology Care for Medicaid Patients.

Background: Access to endocrinologists is a particular challenge for medically underserved populations. Introduction: Electronic consultations (eConsults) are a promising tool to help address this problem. Materials and Methods: This retrospective cohort study compared two groups: (1) Medicaid patients referred to an endocrinologist 1 year before the implementation of eConsults and (2) those referred in the 1 year after implementation. Data included patient demographics, dates of referral requests, appointment dates, eConsult response dates and times, diagnosis codes, and consultants' recommendations. Provider perspectives of eConsults were determined by using a survey. Results: Before eConsult implementation, only 138 out of 365 (37.8%) of referrals to endocrinology were completed. Postimplementation, 281 out of 469 (59.9%) of referrals were completed either by a confirmed face-to-face visit with an endocrinologist or by an eConsult, of whom 194 (41.4%) did not require a face-to-face visit. Thyroid conditions were the most common reason for a consult, accounting for roughly 40% of all consults. Overall, 32 out of 36 (89%) primary care providers (PCPs) indicated that they were satisfied with eConsults and 19 out of 36 (53%) felt that the process did not create additional work or burden for them. Discussion: These findings demonstrate that eConsult use can help address poor access to specialty care for Medicaid-insured patients. eConsults were able to significantly decrease the need for face-to-face visits and enabled PCPs to address specialty-related issues in primary care. Conclusions: Widespread adoption of eConsults could be a potential solution for major challenges that our health care system faces today.

The reminiscence bump without memories: The distribution of imagined word-cued and important autobiographical memories in a hypothetical 70-year-old.

The reminiscence bump is the disproportionate number of autobiographical memories dating from adolescence and early adulthood. It has often been ascribed to a consolidation of the mature self in the period covered by the bump. Here we stripped away factors relating to the characteristics of autobiographical memories per se, most notably factors that aid in their encoding or retention, by asking students to generate imagined word-cued and imagined 'most important' autobiographical memories of a hypothetical, prototypical 70-year-old of their own culture and gender. We compared the distribution of these fictional memories with the distributions of actual word-cued and most important autobiographical memories in a sample of 61-70-year-olds. We found a striking similarity between the temporal distributions of the imagined memories and the actual memories. These results suggest that the reminiscence bump is largely driven by constructive, schematic factors at retrieval, thereby challenging most existing theoretical accounts.

Recent Advances in Understanding the Reminiscence Bump: The Importance of Cues in Guiding Recall from Autobiographical Memory.

The reminiscence bump is the increased proportion of autobiographical memories from youth and early adulthood observed in adults over 40. It is one of the most robust findings in autobiographical memory research. Although described as a single period of increased memories, a recent meta-analysis which reported the beginning and ending ages of the bump from individual studies found that different classes of cues produce distinct bumps that vary in size and temporal location. The bump obtained in response to cue words is both smaller and located earlier in the lifespan than the bump obtained when important memories are requested. The bump obtained in response to odor cues is even earlier. This variation in the size and location of the reminiscence bump argues for theories based primarily on retrieval rather than encoding and retention, which most current theories stress. Furthermore, it points to the need to develop theories of autobiographical memory that account for this flexibility in the memories retrieved.

The breadth and mnemonic consequences of the youth bias.

We have recently demonstrated the existence of the youth bias, referring to a tendency to favour adolescence and early adulthood over other lifetime periods when making inferences about the timing of important public events across the lifespan of a typical individual within one's culture. The youth bias integrates two discrete lines of research, that is, the literature on the privileged status of adolescence and early adulthood in human memory and cognition, and the literature on cognitive biases. Here we first examined whether the youth bias holds for specific categories of public events (i.e., deaths of public figures, United States presidential elections, and sporting events). We then investigated the possible role of the youth bias in structuring recall for public events, by probing, within subjects, for the relation between: (1) these expectations of the timing, in a typical person's life, of the most important exemplar from each public event category, and (2) the age at which the cited event occurred on a recall question asking participants to cite the most important exemplar, in their own lifetime, from each category. We found a youth bias for each category. Additionally, responses to the youth bias question were correlated with the age at which the recalled event occurred, but only where particularly salient historical events did not play a central role in driving recall (i.e., for sporting events). We conclude that the youth bias holds across different types of public events and provides a default structure for organizing recall of public events.

The reminiscence bump in autobiographical memory and for public events: A comparison across different cueing methods.

The reminiscence bump has been found for both autobiographical memories and memories of public events. However, there have been few comparisons of the bump across each type of event. In the current study, therefore, we compared the bump for autobiographical memories versus the bump for memories of public events. We did so between-subjects, through two cueing methods administered within-subjects, the cue word method and the important memories method. For word-cued memories, we found a similar bump from ages 5 to 19 for both types of memories. However, the bump was more pronounced for autobiographical memories. For most important memories, we found a bump from ages 20 to 29 in autobiographical memory, but little discernible age pattern for public events. Rather, specific public events (e.g., the Fall of the Berlin Wall) dominated recall, producing a chronological distribution characterised by spikes in citations according to the years these events occurred. Follow-up analyses suggested that the bump in most important autobiographical memories was a function of the cultural life script. Our findings did not yield support for any of the dominant existing accounts of the bump as underlying the bump in word-cued memories.

The cultural life script as cognitive schema: how the life script shapes memory for fictional life stories.

We tested, across three studies, the effect of the cultural life script on memory and its phenomenological properties. We focused in particular on the mnemonic effects of both schema-consistency and frequency in the life script. In addition to testing recognition (in Study 1) and recall (in Studies 2 and 3), we also collected remember/know judgements for remembered events (in Studies 1 and 2) and memory for their emotional valence (in Study 2). Our primary finding was that, across all three studies, higher-frequency events were more memorable than lower-frequency events, as measured through either recognition or recall. We also attained three additional, complementary effects: First, schema-inconsistent events received remember ratings more often than schema-consistent events (in Study 2, with a trend to this effect in Study 1); second, where an event's emotional valence was inconsistent with the life script, memory for its valence was reconstructed to fit the script (in Study 2); and, third, intrusions in recall were disproportionately for life script events (in Study 3), although that was not the case in recognition (in Study 1). We conclude that the life script serves as a cognitive schema in how it shapes memory and its phenomenological properties.

Does everything happen when you are young? Introducing the youth bias.

The reminiscence bump refers to the disproportionate number of individuals' autobiographical memories that date from young adulthood. A similar bump is found in cultural life scripts: When people are asked to nominate and date major transitional events in a typical life course in their culture, a disproportionate number of the events cited are likewise expected to occur in young adulthood. Across two online studies, we tested whether these effects reflect a broader tendency to ascribe most important events to young adulthood. Specifically, we probed, in adult USA samples, for when individuals expect the most important public event of a typical person's life to take place. Although the occurrence of such public events should be randomly distributed across the lifespan, we found a bump in young adulthood. We found this bump in both subjective (Study 1; probing cultural expectations for the expected timing of the public event that a typical person considers to be the most important of their lifetime) and objective (Study 2; probing cultural expectations for the expected timing of the objectively most important public event of a typical person's lifetime) conditions. We term this set of cultural expectations the youth bias and discuss its implications for human cognition.

Remembering President Barack Obama's inauguration and the landing of US Airways Flight 1549: a comparison of the predictors of autobiographical and event memory.

We examined and compared the predictors of autobiographical memory (AM) consistency and event memory accuracy across two publicly documented yet disparate public events: the inauguration of Barack Obama as the 44th president of the United States on January 20th 2009, and the emergency landing of US Airways Flight 1549, off the coast of Manhattan, on January 15th 2009. We tracked autobiographical and event memories for both events, with assessments taking place within 2½ weeks of both events (Survey 1), and again between 3½ and 4 months after both events (Survey 2). In a series of stepwise regressions we found that the psychological variables of recalled emotional intensity and personal importance/centrality predicted AM consistency and event memory accuracy for the inauguration. Conversely, the rehearsal variables of covert rehearsal and media attention predicted, respectively, AM consistency and event memory accuracy for the plane landing. We conclude from these findings that different factors may underlie autobiographical and event memory for personally and culturally significant events (e.g., the inauguration), relative to noteworthy, yet less culturally significant, events (e.g., the plane landing).

Psychosocial predictors of nicotine dependence among women during their mid-sixties.

Although there is considerable research demonstrating the prospective association between earlier maladaptive personal attributes and later nicotine dependence, there is less work on the psychosocial mediators of this relationship. Maladaptive personal attributes appear in the form of depression, anxiety, and interpersonal sensitivity. This study was designed to assess the prospective relationship between earlier maladaptive personal attributes (mean age = 40) and later nicotine dependence ( age = 65.2) within an understudied female community sample. The participants were given self-administered questionnaires. The results supported a model by which earlier maladaptive personal attributes predicted later nicotine dependence through several indirect pathways. In addition to cigarette smoking, several domains mediated the relation of earlier maladaptive personal attributes and later nicotine dependence. These domains included internal factors (ie, later maladaptive personal attributes), interpersonal factors (ie, marital/partner conflict), later contextual factors (ie, family financial difficulty). Our multidimensional longitudinal findings have important implications for the prevention and treatment of nicotine dependence. The results identify earlier and later significant psychosocial risk factors to be targeted, and suggest the timing of interventions to reduce or eliminate nicotine dependence.

Toward a Science of Silence: The Consequences of Leaving a Memory Unsaid.

Silence about the past permeates acts of remembering, with marked mnemonic consequences. Mnemonic silence-the absence of expressing a memory-is public in nature and is embedded within communicative acts, such as conversations. As such, silence has the potential to affect both speakers-the source of the silence-and listeners-those attending to the speaker. Although the topic of silence is widely discussed, it is rarely mentioned in the empirical literature on memory. Three factors are employed to classify silence into different types: whether a silence is accompanied by covert remembering, whether the silence is intentional or unintentional, and whether the silenced memory is related or unrelated to the memories emerging in a conversation. These factors appear to be critical when considering the mnemonic consequences. Moreover, the influence of silence on memory varies between speaker and listener. Although rarely mentioned, recent empirical research on memory clearly has a bearing on a topic of such general interest as silence.

Psychosocial factors related to cannabis use disorders.

The objective of this study was to explore the association between psychosocial risk and protective factors and cannabis use disorders (CUDs) in a cohort of African American and Puerto Rican young adults. A representative sample (N = 838) from the East Harlem area of New York City was assessed at 4 points in time (at mean ages 14.1, 19.2, 24.5, and 29.2). The psychosocial measures came from 6 domains: personality attributes, family, peer, work, neighborhood, and substance use. The psychosocial measures were assessed at each of the first 3 waves of the study, and CUDs were assessed at the fourth and final wave of the study. Multivariate logistic regression and a cumulative risk analysis were conducted. Increased psychological symptoms (odds ratio [OR] = 1.21; 95% confidence interval [CI], 1.05-1.39; P < .01), problems resulting from cannabis use (OR = 2.69; 95% CI, 1.33-5.46; P < .01), frequent arguments with one's partner (OR = 1.84; 95% CI, 1.09-3.10; P < .05), high levels of deviance (OR = 1.81; 95% CI, 1.21-2.71; P < .01), and frequent acts of violence directed toward the participant (OR = 1.19; 95% CI, 1.01-1.42; P < .05) were all associated with an increased risk for CUDs. An increase in the number of risks was associated with an increase in the probability of having CUDs at the fourth wave (again, at a mean age of 29.2). A decrease in the number of risk factors may lead to a decrease in CUDs.

Unexpected benefits: pathways from smoking restrictions in the home to psychological well-being and distress among urban Black and Puerto Rican Americans.

INTRODUCTION: This study examined the pathways from smoking policies in the home (no ban, partial ban, and total ban on smoking) to psychological well-being (e.g., self-esteem) and psychological symptoms (e.g., depressive symptoms) as mediated by a healthy lifestyle (engaging in exercise, eating healthful foods, and sleeping enough) and cigarette smoking among a sample of urban Black and Puerto Rican Americans. METHODS: Questionnaire data were collected from 816 participants (mean age = 32 years). Structural equation modeling (SEM) was employed to examine the pathways of restrictions on smoking in the home to a healthy lifestyle, cigarette smoking, psychological well-being, and psychological distress. RESULTS: The SEM showed mediational pathways linking higher levels of restrictions on smoking in the home with a healthy lifestyle, which in turn was related negatively to psychological distress and positively to psychological well-being. Higher levels of restrictions on smoking in the home were also related inversely to cigarette smoking, which was related positively to psychological distress and negatively to psychological well-being. CONCLUSIONS: Findings show that higher levels of restrictions on smoking in the home are associated with a healthier lifestyle and less cigarette smoking, which in turn are associated with better psychological functioning. Greater restrictions on smoking in the home may thus support positive lifestyle choices, including exercise and nutrition, as well as psychological functioning.

Association between attention-deficit/hyperactivity disorder in adolescence and substance use disorders in adulthood.

OBJECTIVES: To determine whether attention-deficit/hyperactivity disorder (ADHD) in adolescence is related to substance use disorders (SUDs) in adulthood and whether conduct disorder (CD) mediates this relationship. DESIGN: A prospective design incorporating 5 assessments in participants spanning the mean ages of 14 to 37 years. Two baseline assessments were taken at ages 14 and 16 years, and 3 outcome assessments were taken between ages 27 and 37 years. SETTING: United States. PARTICIPANTS: A community sample of individuals initially drawn from upstate New York in 1975 and observed to a mean age of 37 years. INTERVENTIONS: The Diagnostic Interview Schedule for Children was used to assess ADHD and CD and the University of Michigan Composite International Diagnostic Interview was used to assess SUDs. MAIN OUTCOME MEASURE: A diagnosis of SUDs given to participants in adulthood. RESULTS: The odds ratios for ADHD and CD in adolescence as related to SUDs in adulthood were 1.9 and 3.5, respectively. The association between ADHD and SUDs, however, was indirect because CD served as a mediator between ADHD and SUDs. CONCLUSIONS: Pediatricians should focus on adolescent ADHD when it progresses to CD because CD is a major predictor of SUDs in adulthood.

Predictors of DSM and Fagerstrom-defined nicotine dependence in African American and Puerto Rican young adults.

This study examined the psychosocial predictors of nicotine dependence, as defined by a variant of the criteria employed in the DSM-IV-specifically that of the University of Michigan Composite International Diagnostic Interview (UM-CIDI)-and the Fagerstrom Test for Nicotine Dependence (FTND). The study was conducted with a community sample of African American and Puerto Rican young adults (N = 475; mean age = 26). Predictor variables included physiologically based psychosocial (i.e., depressive symptoms and family problems with smoking) as well as social-behavioral psychosocial (i.e., rebelliousness and partner's problems with smoking) predictors of nicotine dependence. Using multiple regression analyses, UM-CIDI-defined dependence was predicted by each of the four psychosocial variables, while FTND-defined dependence was predicted only by the social-behavioral variables. These findings bear out the disparate dimensions of nicotine dependence each measure taps. Research and clinical implications of the findings are discussed, and the study's limitations are noted.

Pathways from earlier marijuana use in the familial and non-familial environments to self-marijuana use in the fourth decade of life.

We examined the longitudinal pathways from marijuana use in the familial environment (parents and siblings) and non-familial environment (peers and significant other), throughout adolescence and young adulthood, to the participants' own marijuana use in their fourth decade of life (n = 586). Longitudinal pathways to marijuana use were assessed using structural equation modeling. Familial factors were mediated by non-familial factors; sibling marijuana use also had a direct effect on the participants' marijuana use. In the non-familial environment, significant other marijuana use had only a direct effect, while peer marijuana use had direct as well as indirect effects on the participants' marijuana use. Results illustrate the importance of both modeling and selection effects in contributing to marijuana use. Regarding prevention and treatment, this study suggests the need to consider aspects of familial and non-familial social environments.

Silence is not golden: a case for socially shared retrieval-induced forgetting.

The present research explored the effect of selective remembering and the resulting "silences" on memory. In particular, we examined whether unmentioned information is more likely to be forgotten by a listener if related information is recollected by the speaker than if related information is not recollected by the speaker. In a modification of the retrieval-induced forgetting paradigm, pairs of individuals studied material, but in the practice phase, only one member of each pair selectively recalled it, while the other listened. Experiment 1 employed paired associates, and Experiment 2 used stories. Experiment 3 involved not controlled practice, but free-flowing conversation. In each case, results from a final memory test established not only within-individual retrieval-induced forgetting, but also socially shared retrieval-induced forgetting. The results demonstrate that listening to a speaker remember selectively can induce forgetting of related information in the listener.