Development and Pilot Testing of a Longitudinal Skills-Based Feedback and Conflict Resolution Curriculum for Internal Medicine Residents.

PROBLEM: Physicians in training are responsible for leading clinical teams, coordinating interdisciplinary management, navigating conflict, and supervising and giving feedback to junior learners. Giving feedback and resolving conflict are key leadership skills for internal medicine (IM) residents, many of whom desire additional training. Although these skills are integral to successful leadership for physicians in training, residents receive little explicit education and existing curricula have not established best practices for skill acquisition. APPROACH: Study authors designed a pilot longitudinal, skills-based curriculum to teach first- through third-year IM residents at the University of Pittsburgh how to give formative feedback and engage in conflict resolution. From February to May 2021, authors delivered a series of interactive lectures utilizing frameworks, workplace-based scenarios, skills practice, and discussion. Skills transfer was evaluated with novel pre- and postcurriculum objective structured clinical examinations (OSCEs) wherein participants played the role of senior resident. Each OSCE involved 2 feedback and 2 conflict resolution stations. OSCE performances were evaluated using an author-created checklist with a 1-4 rating scale. The exposure group comprised post-OSCE participants who attended the curriculum. Data were analyzed using a mixed effects regression model. OUTCOMES: Thirty-six residents participated in curriculum evaluation, and 23 were included in postcurriculum data analysis. Within feedback, the skill "explores feedback content" significantly improved for exposure group participants (precurriculum median, 2.64; postcurriculum, 3.24; P < .05). For conflict resolution, among the exposure group, the skill "identifies a common goal, value, or purpose" significantly improved (pre, 3.10; post, 3.62; P < .05). NEXT STEPS: This curriculum and evaluation can serve as a stepping stone for further evidence-based leadership frameworks, curricula, and evaluations developed specifically for physicians within their unique leadership roles. The feedback and conflict resolution frameworks used in this curriculum can be applied to various medical specialties, with specialty-relevant scenario adaptations for interactive skills practice.

Update on Breast Cancer.

This article reviews recent advances in the treatment of breast cancer. The goal in selecting these recent articles was to help identify literature that may change the clinical practice of women's health for practitioners in the primary care setting. Articles were identified by reviewing the high-impact medical and women's health journals, national guidelines, ACP JournalWise, and NEJM Journal Watch. In this Clinical Update, we selected recent publications relevant to the treatment and complications of treatment of breast cancer.

Updates in Cardiovascular Disease Prevention, Diagnosis, and Treatment in Women.

Cardiovascular disease (CVD) is the leading cause of death for American women. CVD is preventable although risk reduction goals are not achieved for women compared with men. Considering a woman's cardiometabolic profile for prevention counseling and prescribing may help. Coronary artery calcium scores provide additional risk assessment and reproductive and menopause histories identify risk enhancers. Diagnosis of CVD is often delayed, and treatment is less optimal for women compared with men. Differences in presentation and underlying CVD etiology (Including spontaneous coronary artery dissection and microvascular disease) may partially account for these disparities. Improvements in CVD imaging to better diagnose these etiologies may benefit women's care.

Clinical Update in Women's Heart Disease.

The goal in selecting these recent articles was to help identify literature that may change the clinical practice of women's health for practitioners in the primary care setting. Articles were identified by reviewing high-impact medical and women's health journals, national guidelines, ACP JournalWise, and NEJM Journal Watch. In this clinical update, we selected recent publications relevant to the prevention, risk assessment, and diagnosis of cardiovascular disease (CVD) in women. Breastfeeding now has data suggesting a robust reduction in subsequent CVD, and migraine with aura and severe and early- and late-onset hot flashes can now be considered risk factors for CVD. The decision to initiate menopausal hormone therapy is influenced by estimation of underlying vascular risk, and new data suggest that CVD risk scores are more accurate in predicting CVD risk than the traditionally used age and years since menopause and should be incorporated into counseling. Finally, new data support the growing belief that breast arterial calcification on mammography is a promising noninvasive marker that can enhance CVD risk prediction in women.

A Video- and Case-Based Curriculum on the Management of Alcohol Use Disorder for Internal Medicine Residents.

Introduction: Alcohol use disorder (AUD) is commonly undertreated. Physicians cite discomfort with AUD medication as a barrier to treatment. While several curricula teach and assess screening and brief interventions, few teach and assess learner knowledge of treatment options. Methods: We created a video- and case-based curriculum for internal medicine residents delivered by 16 internal medicine faculty in three 30-minute sessions at four clinic sites. Learner knowledge, attitudes, and confidence were assessed before and after the curriculum. We used qualitative methods to evaluate learner reflections. We also assessed faculty satisfaction with the curriculum. Results: Of 153 residents receiving the curriculum, 35 (23%) completed both pre- and postsurveys. Median percent correct on knowledge questions improved from 67% pre- to 80% postcurriculum (p < .001). Confidence increased for all three items assessing it, with a notable increase in confidence with pharmacotherapy (2.9 pre- vs. 4.5 postcurriculum on a 7-point Likert scale with high scores indicating greater confidence, p < .001). Positive attitudes toward people with AUD increased from 3.4 pre- to 3.9 postcurriculum (p < .001) on a 7-point Likert scale. Learners continued to express concerns about prescribing logistics, the role of primary care, and management of ongoing use. Thirteen of 16 faculty (83%) completed the postcurricular survey; all said they would be happy to facilitate again. Discussion: Implementation of this curriculum for the management of AUD improved resident knowledge, attitudes, and confidence in AUD treatment. The curriculum was acceptable to faculty and is ideal for programs looking to expand teaching about AUD.

Dormant Nfatc1 reporter-marked basal stem/progenitor cells contribute to mammary lobuloalveoli formation.

The Mammary gland undergoes complicated epithelial remodeling to form lobuloalveoli during pregnancy, in which basal epithelial cells remarkably increase to form a basket-like architecture. However, it remains largely unknown how dormant mammary basal stem/progenitor cells involve in lobuloalveolar development. Here, we show that Nfatc1 expression marks a rare population of mammary epithelial cells with the majority being basal epithelial cells. Nfatc1 reporter-marked basal epithelial cells are relatively dormant mammary stem/progenitor cells. Although Nfatc1 reporter-marked basal epithelial cells have limited contribution to the homeostasis of mammary epithelium, they divide rapidly during pregnancy and contribute to lobuloalveolar development. Furthermore, Nfatc1 reporter-marked basal epithelial cells are preferentially used for multiple pregnancies. Using single-cell RNA-seq analysis, we identify multiple functionally distinct clusters within the Nfatc1 reporter-marked cell-derived progeny cells during pregnancy. Taken together, our findings underscore Nfatc1 reporter-marked basal cells as dormant stem/progenitor cells that contribute to mammary lobuloalveolar development during pregnancy.

Mini-Residencies to Improve Care for Women Veterans: A Decade of Re-Educating Veterans Health Administration Primary Care Providers.

Background: Many primary care providers (PCPs) in the Veterans Health Administration need updated clinical training in women's health. The objective was to design, implement, and evaluate a training program to increase participants' comfort with and provision of care to women Veterans, and foster practice changes in women's health care at their local institutions. Methods: The Women's Health Mini-Residency was developed as a multi-day training program, based on principles of adult learning, wherein knowledge gleaned through didactic presentations was solidified during small-group case study discussions and further enhanced by hands-on training and creation of a facility-specific action plan to improve women Veterans' care. Pre, post, and 6-month surveys assessed attendees' comfort with and provision of care to women. The 6-month survey also queried changes in practice, promulgation of program content, and action plan progress. Results: From 2008 to 2019, 2912 PCPs attended 26 programs. A total of 2423 (83.2%) completed pretraining and 2324 (79.3%) completed post-training surveys. The 6-month survey was sent to the 645 attendees from the first 14 programs; 297 (46.1%) responded. Comparison of pre-post responses indicated significant gains in comfort managing all 19 content areas. Six-month data showed some degradation, but comfort remained significantly improved from baseline. At 6 months, participants also reported increases in providing care to women, including performing more breast and pelvic examinations, dissemination of program content to colleagues, and progress on action plans. Conclusions: This interactive program appears to have been successful in improving PCPs' comfort in providing care for women Veterans and empowering them to implement institutional change.

Nfatc1's Role in Mammary Epithelial Morphogenesis and Basal Stem/progenitor Cell Self-renewal.

Mammary gland is an outstanding system to study the regulatory mechanisms governing adult epithelial stem cell activity. Stem cells in the basal layer of the mammary gland fuel the morphogenesis and regeneration of a complex epithelial network during development and upon transplantation. The self-renewal of basal stem/progenitor cells is subjected to regulation by both cell-intrinsic and extrinsic mechanisms. Nfatc1 is a transcription factor that regulates breast tumorigenesis and metastasis, but its role in mammary epithelial development and stem cell function has not been investigated. Here we show that Nfatc1 is expressed in a small subset of mammary basal epithelial cells and its epithelial-specific deletion results in mild defects in side branching and basal-luminal cell balance. Moreover, Nfatc1-deficient basal cells exhibit reduced colony forming ability in vitro and somewhat compromised regenerative potential upon transplantation. Thus, our study provides evidence for a detectable yet non-essential role of Nfatc1 in mammary epithelial morphogenesis and basal stem/progenitor cell self-renewal.

Correlation of Coping, Mentorship, and Life Events with Burnout in Internal Medicine Residents.

Physician burnout is a widespread problem. We examined how coping, mentorship, and life events correlated with burnout in Internal Medicine Residents. We performed a cross-sectional study of survey data collected over multiple time points and used Spearman correlation of coping, mentorship, and life events to emotional exhaustion (EE) and cynicism (CYN). Burnout was assessed using the Maslach Burnout Inventory-General Survey (MBI-GS), coping skills were measured using the Brief COPE, mentorship with an institutional mentoring survey, and life events with a shortened Social Readjustment Rating Scale (SRRS). Two thousand one surveys were distributed to 616 residents from 2010 to 2015. There were 1144 cases of completion of both the Brief COPE and the MBI-GS (58%), 744 of the MBI-GS and the Mentoring survey (47%), and 1138 of the MBI-GS and Life Events Scale (57%). There were correlations between acceptance (ρ 0.1-0.24), denial (ρ 0.13-0.20), substance abuse (ρ 0.15-0.22), behavioral disengagement (ρ 0.18-.037), self-blame (ρ 0.27-0.45), self-distraction (ρ 0.18-0.32) and venting (ρ 0.15-0.47) and EE. There were correlations with acceptance (ρ 0.11-0.15), denial (ρ 0.18-0.26), humor (ρ 0.13-0.20), substance abuse (ρ 0.10-0.29), behavioral disengagement (ρ 0.19-0.40), self-blame (ρ 0.24-0.35), self-distraction (ρ 0.14-0.34) and venting (ρ 0.12-0.38) and CYN. There was a negative correlation between mentorship and EE (ρ - 0.15, - 0.18) and CYN (ρ - 0.30 to - 0.20). There were correlations between life events and EE (ρ 0.15-0.20) and CYN (ρ = 0.14-0.15). Maladaptive coping mechanisms, acceptance, and life stressors correlate with burnout in internal medicine residents and mentoring may be protective.

Menopause.

This review focuses on the diagnosis and management of menopause, highlighting both hormonal and nonhormonal treatment options. In particular, the article focuses on recent data on the risks and benefits of hormone therapy to help clinicians better counsel their patients about decision making with regard to understanding and treating menopause symptoms.

Avoiding Death by Meeting: An Interactive Workshop for Academic Faculty Highlighting Strategies to Facilitate Effective Team Meetings.

Introduction: Effective meetings are a key marker of team function and are critical for task management. While important, the skill set for running an effective meeting is poorly understood. Methods: We developed an interactive curriculum that provided physician leaders in academic medicine with generalizable knowledge and skills to effectively plan and lead various types of team meetings, leverage engagement, and troubleshoot challenging personalities. This workshop (either 60 or 90 minutes) included a video-based demonstration, interactive and facilitated small- and large-group discussion, and a brief didactic to teach best practices in leading meetings. Participants included academic physicians across a spectrum of rank, specialty, and leadership experience. Knowledge, attitudes, and anticipated behavior changes were evaluated using postsurveys including 5-point Likert-type scale questions (1 = poor, 5 = outstanding) and free-text responses. Results: Fifty-seven participants rated the workshop highly with regard to content (M = 4.8), audiovisual materials (M = 4.7), and overall (M = 4.8). Most participants (82%) indicated a plan to change future design or utilization of an agenda as a result of this workshop. Feedback highlighted the need to incorporate practice opportunities in future iterations of the workshop. Discussion: Our results demonstrated that this standalone, interactive workshop focused on skills to effectively lead team meetings was well received and improved knowledge and attitudes of participants across a spectrum of rank, specialty, and leadership experience. The curriculum was time-efficient, widely generalizable, and can be easily adapted for use within academic medical centers to improve meeting effectiveness.

A Multifaceted Intimate Partner Violence Communication Skills Curriculum Increases Screening Among Internal Medicine Residents.

Background: Intimate partner violence (IPV) is common, yet physicians do not routinely screen patients for IPV. There are no clear recommendations for best educational practices for physician trainees that improve screening rates. Materials and Methods: We implemented an IPV curriculum combining didactics and communication skills training for internal medicine residents. Didactics included definitions, risk factors, screening recommendations, and documentation; communication skills training included developing unique screening and response phrases; and two simulated patient exercises. The primary outcome was screening documentation rates as measured through pre- and postcurriculum chart review. Secondary outcomes included knowledge, comfort, and attitudes measured through pre- and postcurriculum administration of an adapted Physician Readiness to Manage Intimate partner violence Survey (PREMIS). Postcurriculum semistructured interviews provided further details regarding behaviors and attitudes. Results: Forty residents completed the curriculum. 29/40 (73%) completed both pre- and postsurveys. Fifteen participated in semistructured interviews. Residents demonstrated increased screening documentation postcurriculum (p < 0.05). Residents showed improvement in 80% of objective knowledge questions, and in all perceived knowledge and comfort-based questions (p < 0.01). Statistically significant improvement was noted in many attitudinal domains, including reported screening rates (p < 0.05). In the semistructured interviews, participants reported experiencing both practice-based improvements and ongoing screening barriers. Practice-based improvements included increased screening comfort and frequency, and strengthening of the doctor-patient relationship. Ongoing screening barriers included time, resistance to practice change, competing medical needs, and personal discomfort. Conclusions: A multifaceted IPV curriculum for residents significantly improved documentation rates, knowledge, comfort, and attitudes. Residents reported increased comfort with screening and strengthened patient relationships but acknowledged ongoing barriers to screening.

Headaches in Adults in Primary Care: Evaluation, Diagnosis, and Treatment.

Headaches are common in primary care. The diagnosis is made by a careful history and physical examination. Imaging is generally not warranted. Several general principles underlie the acute treatment of headache: early initiation of therapy and adequate dosing at first dose. Careful attention to avoiding too frequent administration of acute therapy is important to avoid medication overuse headaches. Opioids should always be avoided. Preventive treatment is indicated for frequent headaches. Successful treatment entails low-dose medication with careful titration and monitoring of headache frequency. Behavioral strategies are important and should be part of any comprehensive headache management plan.

A Robust Faculty Development Program for Medical Educators: A Decade of Experience.

OBJECTIVES: Faculty development programs (FDPs) foster learning communities and enhance professional identity formation for medical educators. Competency-based frameworks for faculty development drive skill development across clinical practice, teaching, and scholarship domains. The aims of this study are to outline the context, content, and evolution of a novel FDP; map the individual conferences that make up the FDP to established faculty development competencies; identify steps to implement similar programming; and demonstrate outcomes to date. METHODS: The FDP consists of four, 1-hour-long conferences held weekly on a rotating basis since 2007 at the University of Pittsburgh School of Medicine: Academy of Master Educators, Medical Education Research, Medical Education Journal Club, and Medical Education Research Methods and Innovative Design conference. Authors outline the relation of each of these four conferences to faculty development competencies and describe early outcomes for each conference over four consecutive academic years from 2014 to 2018. Participants include attendees and presenters in four consecutive academic years from 2014 to 2018. RESULTS: The well-attended FDP meets all established competencies for educator faculty. Presenters and attendees were diverse in terms of academic rank and represented a breadth of clinical and basic science specialties. CONCLUSIONS: This integrated FDP fosters a community of medical educators and develops faculty skills across established medical educator competencies.

Does Formal Training in Medical Education and Professional Development Lead to Better Career Outcomes for Clinician Educators?

OBJECTIVES: Medical school and residency training programs rely on skilled clinician-educators to provide high-quality educational experiences. In 2002, the University of Pittsburgh's Institute for Clinical Research Education created a master's-level degree-granting program in medical education, which now has more than a decade of graduates. METHODS: All graduates between 2004 and 2014 were invited to complete an anonymous electronic survey regarding their experiences with the program and their perception of whether the master's program adequately prepared them in domains pertinent to medical educators. Participants also were asked to upload their current curricula vitae (CV) to assess objective measures of academic productivity among program graduates. RESULTS: More than 75% of surveys were completed (47/60) and 75% of CVs were submitted (45/60). Demographics of respondents showed that 66% were woman. The racial demographics of respondents revealed 13% Hispanic/Latino, 28% Asian, and 59% white, respectively. More than 90% of respondents agreed that because they completed the program, they were competent in multiple teaching and learning domains; 94% of respondents believed that they were more effective educators than peers who did not complete this degree. CV abstraction revealed that 98% of respondents currently held academic positions. Number of publications and number of years since program graduation were used to determine the rate of productivity of the graduates. Twenty-six graduates (58%) successfully published at least one peer-reviewed article per year since they graduated. This equated to approximately 3.77 publications per year for these 26 respondents and 2.27 publications per year for the entire cohort. CONCLUSIONS: Program graduates attributed their competence in several key domains that are crucial to excellence as a clinician-educator to their participation in the degree-granting program. The results of this study suggest that receipt of a graduate-level degree in medical education develops and enhances teaching skills and academic productivity among clinician-educators.