Assessing the effects of a mentoring program on professional identity formation.

BACKGROUND: Medical education has enjoyed mixed fortunes nurturing professional identity formation (PIF), or how medical students think, feel and act as physicians. New data suggests that structured mentoring programs like the Palliative Medicine Initiative (PMI) may offer a means of developing PIF in a consistent manner. To better understand how a well-established structured research mentoring program shapes PIF, a study of the experiences of PMI mentees is proposed. METHODOLOGY: Acknowledging PIF as a sociocultural construct, a Constructivist approach and Relativist lens were adopted for this study. In the absence of an effective tool, the Ring Theory of Personhood (RToP) and Krishna-Pisupati Model (KPM) model were used to direct this dual Systematic Evidence-Based Approach (Dual-SEBA) study in designing, employing and analysing semi-structured interviews with PMI mentees and mentoring diaries. These served to capture changes in PIF over the course of the PMI's mentoring stages. Transcripts of the interviews and mentoring diaries were concurrently analysed using content and thematic analysis. Complementary themes and categories identified from the Split Approach were combined using the Jigsaw Approach and subsequently compared with mentoring diaries in the Funnelling Process. The domains created framed the discussion. RESULTS: A total of 12 mentee interviews and 17 mentoring diaries were analysed, revealing two domains-PMI as a Community of Practice (CoP) and Identity Formation. The domains confirmed the centrality of a structured CoP capable of facilitating longitudinal mentoring support and supporting the Socialisation Process along the mentoring trajectory whilst cultivating personalised and enduring mentoring relationships. CONCLUSION: The provision of a consistent mentoring approach and personalised, longitudinal mentoring support guided along the mentoring trajectory by structured mentoring assessments lay the foundations for more effective mentoring programs. The onus must now be on developing assessment tools, such as a KPM-based tool, to guide support and oversight of mentoring relationships.

Professional identity formation amongst peer-mentors in a research-based mentoring programme.

BACKGROUND: Mentoring plays a pivotal yet poorly understood role in shaping a physician's professional identity formation (PIF) or how they see, feel and act as professionals. New theories posit that mentoring nurtures PIF by functioning as a community of practice through its structured approach and its support of a socialisation process made possible by its assessment-directed personalized support. To test this theory and reshape the design, employ and support of mentoring programs, we evaluate peer-mentor experiences within the Palliative Medicine Initiative's structured research mentoring program. METHODS: Semi-structured interviews with peer mentors under the Palliative Medicine Initiative (PMI) at National Cancer Centre Singapore were conducted and triangulated against mentoring diaries to capture longitudinal data of their PMI experiences. The Systematic Evidence-Based Approach (SEBA) was adopted to enhance the trustworthiness of the data. SEBA employed concurrent content and thematic analysis of the data to ensure a comprehensive review. The Jigsaw Perspective merged complementary themes and categories identified to create themes/categories. The themes/categories were compared with prevailing studies on mentoring in the Funnelling Process to reaffirm their accuracy. RESULTS: Twelve peer-mentors participated in the interviews and eight peer-mentors completed the mentoring diaries. The domains identified were community of practice and identity work. CONCLUSIONS: The PMI's structured mentoring program functions as a community of practice supporting the socialisation process which shapes the peer-mentor's belief system. Guided by a structured mentoring approach, stage-based assessments, and longitudinal mentoring and peer support, peer-mentors enhance their detection and evaluation of threats to their regnant belief system and adapt their self-concepts of identity and personhood to suit their context. These insights will help structure and support mentoring programs as they nurture PIF beyond Palliative Medicine.

Visual and Anatomical Outcomes of a Single Intravitreal Dexamethasone in Diabetic Macular Edema: An 8 Year Real-World Study.

IMPORTANCE: Diabetic macular edema (DME) is a major cause of vision loss in patients with diabetes mellitus. Intravitreal dexamethasone is a treatment option for patients unsuitable for or non-responsive to anti-angiogenic agents. OBJECTIVE: To quantify visual and anatomical outcomes from an initial intravitreal dexamethasone injection over the expected 6-month period of dexamethasone release by the implant. Design and enrolment: This is a retrospective cohort study using electronic medical records of patients reviewed between 1 January 2012 and 1 April 2022. SETTING: A tertiary eye-care center in London, United Kingdom; Moorfields Eye Hospital National Healthcare System Foundation Trust. PARTICIPANTS: The cohort comprised 418 adult patients with DME who received an initial treatment of 700 µg intravitreal dexamethasone in the study period. Of these, 240 patients met the inclusion criteria of ≥2 hospital visits following initial injection (≥1 beyond 6 months) and no previous ocular corticosteroid treatment or missing assessment at baseline. EXPOSURE(S): Intravitreal dexamethasone implant (700 µg). MAIN OUTCOME(S) AND MEASURE(S): Probability of a positive visual outcome, defined as ≥5 or ≥10 Early Treatment Diabetic Retinopathy Study (ETDRS)-letter gain after treatment when compared to baseline (Kaplan-Meier models). RESULTS: From the initial intravitreal dexamethasone injection alone, we observed a >75% chance of gaining ≥5 ETDRS letters and >50% chance of gaining ≥10 ETDRS letters within 6 months. There was less than a 50% chance of sustaining either positive visual outcome beyond 4 months. CONCLUSIONS AND RELEVANCE: Most patients can be expected to have a positive visual outcome following an initial injection of dexamethasone implants that subsides within 4 months. Real-world re-treatment was observed to be delayed until after visual benefits were lost in half of the cohort. Further research will be needed to study the effects of delays in re-treatment.

Evidence-guided approach to portfolio-guided teaching and assessing communications, ethics and professionalism for medical students and physicians: a systematic scoping review.

OBJECTIVES: Guiding the development of longitudinal competencies in communication, ethics and professionalism underlines the role of portfolios to capture and evaluate the multiple multisource appraisals and direct personalised support to clinicians. However, a common approach to these combined portfolios continues to elude medical practice. A systematic scoping review is proposed to map portfolio use in training and assessments of ethics, communication and professionalism competencies particularly in its inculcation of new values, beliefs and principles changes attitudes, thinking and practice while nurturing professional identity formation. It is posited that effective structuring of portfolios can promote self-directed learning, personalised assessment and appropriate support of professional identity formation. DESIGN: Krishna's Systematic Evidence-Based Approach (SEBA) is employed to guide this systematic scoping review of portfolio use in communication, ethics and professionalism training and assessment. DATA SOURCES: PubMed, Embase, PsycINFO, ERIC, Scopus and Google Scholar databases. ELIGIBILITY CRITERIA: Articles published between 1 January 2000 and 31 December 2020 were included. DATA EXTRACTION AND SYNTHESIS: The included articles are concurrently content and thematically analysed using the split approach. Overlapping categories and themes identified are combined using the jigsaw perspective. The themes/categories are compared with the summaries of the included articles in the funnelling process to ensure their accuracy. The domains identified form the framework for the discussion. RESULTS: 12 300 abstracts were reviewed, 946 full-text articles were evaluated and 82 articles were analysed, and the four domains identified were indications, content, design, and strengths and limitations. CONCLUSIONS: This review reveals that when using a consistent framework, accepted endpoints and outcome measures, longitudinal multisource, multimodal assessment data fashions professional and personal development and enhances identity construction. Future studies into effective assessment tools and support mechanisms are required if portfolio use is to be maximised.

The Role of Nervous System and Immune System in Herpes Zoster Ophthalmicus Dissemination and Laterality - Current Views.

PURPOSE: Herpes zoster ophthalmicus (HZO) is a sight-threatening condition that is defined as HZ involving the ophthalmic division of the trigeminal nerve. Cases of bilateral HZO in recent literature question the notion of HZO being a strictly unilateral disease. Its pathogenesis is a topic of debate and current literature on VZV dissemination lacks insight into the underlying immunology. This review focuses on novel research in immunology of HZO and aims to formulate hypotheses of spread of lesions through the CNS. METHODS: A literature search was conducted on Entrez PubMed using the search terms "bilateral" and "herpes zoster ophthalmicus". Articles on ("Immunology" or "immune cells") and "herpes zoster ophthalmicus" were also searched for. Articles published from January 1942 to April 2020 that were in English language were included. RESULTS: Our findings revealed that hypothesised mechanisms of dissemination causing bilateral ocular disease include transmission from nerves to vessel walls, the synergistic action of the immune and nervous systems through the action of substance P and the von Szily reaction. CONCLUSIONS: These mechanisms may be investigated using newer models of animal experimentation. It is imperative to define the molecular mechanisms behind VZV transmission to improve methods of identification, treatment, and prevention of HZO.

The Future of Targeted Treatment of Primary Sjögren's Syndrome: A Focus on Extra-Glandular Pathology.

Primary Sjögren's syndrome (pSS) is a chronic, systemic autoimmune disease defined by exocrine gland hypofunction resulting in dry eyes and dry mouth. Despite increasing interest in biological therapies for pSS, achieving FDA-approval has been challenging due to numerous complications in the trials. The current literature lacks insight into a molecular-target-based approach to the development of biological therapies. This review focuses on novel research in newly defined drug targets and the latest clinical trials for pSS treatment. A literature search was conducted on ClinicalTrials.gov using the search term "Primary Sjögren's syndrome". Articles published in English between 2000 and 2021 were included. Our findings revealed potential targets for pSS treatment in clinical trials and the most recent advances in understanding the molecular mechanisms underlying the pathogenesis of pSS. A prominent gap in current trials is in overlooking the treatment of extraglandular symptoms such as fatigue, depression, and anxiety, which are present in most patients with pSS. Based on dryness and these symptom-directed therapies, emerging biological agents targeting inflammatory cytokines, signal pathways, and immune reaction have been studied and their efficacy and safety have been proven. Novel therapies may complement existing non-pharmacological methods of alleviating symptoms of pSS. Better grading systems that add extraglandular symptoms to gauge disease activity and severity should be created. The future of pSS therapies may lie in gene, stem-cell, and tissue-engineering therapies.

Mentoring future mentors in undergraduate medical education.

BACKGROUND: Efforts to support flagging mentoring programs facing shortages of experienced clinical mentors have had an unexpected and welcome effect. Supplementing traditional mentoring programs with peer-mentoring have not only addressed gaps in practice, structure, support and mentee oversight but have offered mentees charged with peer-mentoring duties the opportunity to take on mentoring roles under senior supervision. This study evaluates the experiences of peer-mentors within a local research mentoring program to better understand and advance this endeavor. METHODS: Semi-structured interviews and post-interview surveys based on recent reviews on mentoring were employed. Adapting the Systematic Evidence Based Approach, data was analysed using thematic and content analysis. Results were combined using the Jigsaw Perspective to ensure that key elements of the different mentoring stages were identified. RESULTS: The interviews and surveys revealed the following domains: Motivation, Initiation, Practicing, and Mentoring Environment. CONCLUSION: These findings provide novel insight into a structured framework that may help guide the experiences, training, assessment, and oversight of peer-mentors beyond the auspices of our local program. These general observations will equip host organizations with the direction they need to take in designing and executing peer-mentoring training and assessment programs of their own. Whilst the stages of peer-mentoring need further evaluation and an effective means of assessment and support pivotal, we believe our findings suggest that peer-mentoring may not only help to address the shortfall in mentors but is an invaluable learning experience that prepares and instils key values, beliefs and principles in young would-be mentors.

A systematic scoping review moral distress amongst medical students.

BACKGROUND: Characterised by feelings of helplessness in the face of clinical, organization and societal demands, medical students are especially prone to moral distress (MD). Despite risks of disillusionment and burnout, efforts to support them have been limited by a dearth of data and understanding of MD in medical students. Yet, new data on how healthcare professionals confront difficult care situations suggest that MD could be better understood through the lens of the Ring Theory of Personhood (RToP). A systematic scoping review (SSR) guided by the RToP is proposed to evaluate the present understanding of MD amongst medical students. METHODS: The Systematic Evidence-Based Approach (SEBA) is adopted to map prevailing accounts of MD in medical students. To enhance the transparency and reproducibility, the SEBA methodology employs a structured search approach, concurrent and independent thematic analysis and directed content analysis (Split Approach), the Jigsaw Perspective that combines complementary themes and categories, and the Funnelling Process that compares the results of the Jigsaw Perspective with tabulated summaries to ensure the accountability of these findings. The domains created guide the discussion. RESULTS: Two thousand six hundred seventy-one abstracts were identified from eight databases, 316 articles were reviewed, and 20 articles were included. The four domains identified include definitions, sources, recognition and, interventions for MD. CONCLUSIONS: MD in medical students may be explained as conflicts between the values, duties, and principles contained within the different aspects of their identity. These conflicts which are characterised as disharmony (within) and dyssynchrony (between) the rings of RToP underline the need for personalised and longitudinal evaluations and support of medical students throughout their training. This longitudinal oversight and support should be supported by the host organization that must also ensure access to trained faculty, a nurturing and safe environment for medical students to facilitate speak-up culture, anonymous reporting, feedback opportunities and supplementing positive role modelling and mentoring within the training program.

Knowledge, Attitudes, and Perceptions Toward Dementia Among Middle-Aged Singapore Residents.

BACKGROUND: Dementia is the decline in cognitive function sufficient to impair one's accustomed functioning. Countries with aging populations, such as Singapore, face rising rates of dementia. Dementia patients and their caregivers endure great financial and emotional stress. With the broad aim of minimizing these stresses, this study provides a cross-sectional view of the knowledge, attitudes, and perceptions (KAP) towards dementia in middle-aged Singaporean residents. OBJECTIVE: We aim to examine 1) the associations between demographic correlates and KAP; and 2) the effect of dementia knowledge on attitudes and perceptions towards dementia. METHODS: An online anonymous cross-sectional questionnaire was administered to Singaporeans and Permanent Residents aged 45 to 65 years old in English, Mandarin, and Malay. Knowledge was evaluated across three domains: symptoms, risk factors, and management. Total and domain scores were dichotomized as good or poor knowledge using median cut-offs. Attitudes/perceptions across six domains were evaluated on Likert scales, and responses to each question were dichotomized into positive or negative attitudes/perceptions. RESULTS: From 1,733 responses, 1,209 valid complete responses were accepted (mean age±SD 54.8±5.12 years old, females = 69.6%). Lower socioeconomic status was associated with poorer knowledge and greater barriers to risk-mitigating lifestyle modifications. Lack of personal experience with dementia and poor knowledge were also associated with erroneous attitudes/perceptions. CONCLUSION: Socioeconomic status and personal experience affect KAP towards dementia. Policy and education campaigns to address KAP towards dementia should account for baseline differences across demographics, for greater improvements in dementia incidence and support.

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.

A Systematic Scoping Review on Portfolios of Medical Educators.

BACKGROUND: Heralded as a teaching, assessment and reflective tool, and increasingly as a longitudinal and holistic perspective of the educator's development, medical educator's portfolios (MEP)s are increasingly employed to evaluate progress, assess for promotions and career switches, used as a reflective tool and as a means of curating educational activities. However, despite its blossoming role, there is significant dissonance in the content and structure of MEPs. As such, a systematic scoping review (SSR) is proposed to identify what is known of MEPs and its contents. METHODS: Krishna's Systematic Evidenced Based Approach (SEBA) was adopted to structure this SSR in SEBA of MEPs. SEBA's constructivist approach and relativist lens allow data from a variety of sources to be considered to paint a holistic picture of available information on MEPs. RESULTS: From the 12 360 abstracts reviewed, 768 full text articles were evaluated, and 79 articles were included. Concurrent thematic and content analysis revealed similar themes and categories including: (1) Definition and Functions of MEPs, (2) Implementing and Assessing MEPs, (3) Strengths and limitations of MEPs and (4) electronic MEPs. DISCUSSION: This SSR in SEBA proffers a novel 5-staged evidence-based approach to constructing MEPs which allows for consistent application and assessment of MEPs. This 5-stage approach pivots on assessing and verifying the achievement of developmental milestones or 'micro-competencies' that facilitate micro-credentialling and effective evaluation of a medical educator's development and entrust-ability. This allows MEPs to be used as a reflective and collaborative tool and a basis for career planning.