Burnout and Health Scores Among Residency Programs as an Indicator of Wellness.

Background: With long hours, significant responsibilities, and a heavy workload, residency can be an incredibly stressful experience. The aim of our study was to assess the impact of residency on mental health and wellness. A secondary aim was to determine if the post-graduate year (PGY) of the different residents impacted their mental health or ability to cope with the stressors of residency. Methods: Residents in anesthesiology, family medicine, internal medicine, and surgery were invited to complete a survey. The first portion of the survey had residents rank their mental health on a scale from 1 to 5. There was also a short-form answer portion, which collected suggestions on how to improve wellness. An analysis of variance was used to compare the means of 2 continuous outcome variables-Patient Health Questionnaire (PHQ) and burnout scores compared across specialties and post-graduate years. Burnout scores were measured using the Oldenburg Burnout Inventory. This survey was created and validated by psychology researchers to assess burnout based on the strongest indicators of burnout-emotional exhaustion and disengagement from work. The PHQ9 survey was chosen as it has a specificity of 91-94% and is a reliable method to screen for depression, a common companion to burnout. Results: PHQ9 scores were highest among surgery residents (7.2 ± 7.07), followed by anesthesia (6.59 ± 6.64), emergency medicine (5.57 ± 4.09), and internal medicine (4.82 ± 3.68). Scoring was also higher among PGY4-6 residents. Burnout scores were highest among surgery (37.8 ± 8.69) and anesthesia (38.17 ± 7.09) residents and among PGY4-6 residents. PGY4-6 residents had a mean burnout score of 38.55 ± 7.67 compared to 36.17 ± 8.69 among first-year residents. Similarly, the P value noted no significant difference among burnout scores across either specialty or year: .5930 and .8061. Conclusion: There was no significant difference among specialties or years in training among their subjective ratings of depression.

Language processing following childhood poverty: Evidence for disrupted neural networks.

Childhood poverty is related to deficits in multiple cognitive domains including adult language function. It is unknown if the brain basis of language is disrupted in adults with childhood poverty backgrounds, controlling for current functioning. Fifty-one adults (age 24) from an existing longitudinal study of childhood poverty, beginning at age 9, were examined on behavioral phonological awareness (LP) and completed an event-related fMRI speech/print processing LP task. Adults from childhood poverty backgrounds exhibited lower LP in adulthood. The middle-income group exhibited greater activation of the bilateral IFG and hippocampus during language processing. In psychophysiological interaction (PPI) analyses, the childhood poverty group exhibited greater coupling between ventral Broca's and the middle temporal gyrus (MTG) as well as coupling between Wernicke's region and bilateralization. Childhood poverty disrupts language processing neural networks in adulthood, after controlling for LP, suggesting that poverty in childhood influences the neurophysiological basis for language processing into adulthood.

Professional Development Needs of Clerkship Directors.

BACKGROUND AND OBJECTIVES: Successful clerkship directors (CDs) must exhibit a variety of leadership, administrative, educational, and interpersonal skills. This study investigates the professional development needs for family medicine CDs to be successful in their role, in relation to career stage, institutional support, and needed resources. METHODS: A cross-sectional survey of CDs at qualifying United States and Canadian medical schools was performed between April 29, 2021 and May 28, 2021. Questions addressed specific training when beginning CD position, professional development activities that have contributed to success, additional professional development skills required to be a successful CD, and planned future development activities. We utilized χ2 square and Mann-Whitney U tests for comparisons. RESULTS: Surveys were completed by 75 CDs, for a response rate of 48.8%. Only 33.3% of respondents reported receiving training specific to their role as CD. The majority of respondents cited informal mentoring and conference attendance as important to their professional development, but none identified graduate degrees as the most important method of professional development. CONCLUSIONS: These findings demonstrate the lack of formal training provided to CDs and highlight the importance of informal training and conference attendance for professional development.

Perception and Counseling for Cardiac Health in Breast Cancer Survivors.

Context: Breast cancer survivors have increased cardiovascular disease (CVD) risk compared to those without cancer history. CVD is the leading cause of death for breast cancer survivors. Objective: To assess current CVD risk counseling practices and risk perception in breast cancer survivors. Study design and analysis: Interviews conducted with breast cancer survivors. Analysis of categorical data by frequency and quantitative variables by mean and standard deviation. Inductive qualitative analysis performed using NVIVO. Setting: Academic Family Medicine Outpatient Practices Population studied: Breast cancer survivors with an identified primary care provider. Intervention/instrument: Interviews on CVD risk behaviors, risk perception, challenges with risk reduction, and previous history of risk counseling. Outcome measures: Self-reported history of CVD, risk perception, and risk behaviors. Results: The average age of participants (n=19) was 57 with 57% being white and 32% African American. Of interviewed women, 89.5% reported a personal history and 89.5% reported a family history of CVD. Only 52.6% had previously reported receipt of CVD counseling. Primary care providers most commonly provided the counseling (72.7%), however it was additionally provided by oncology (27.3%). Among breast cancer survivors, 31.6% perceived they were at increased CVD risk and 47.5% were unsure of their relative CVD risk compared to women their age. Factors affecting perceived CVD risk included family history, cancer treatments, cardiovascular diagnoses, and lifestyle factors. Video (78.9%) and text messaging (68.4%) were the most highly reported mechanisms through which breast cancer survivors requested to receive additional information and counseling on CVD risk and risk reduction. Commonly reported barriers to adopting risk reduction strategies (such as increasing physical activity) included time, resources, physical limitations, and competing responsibilities. Barriers specific to survivorship status include concerns for immune status during COVID, physical limitations associated with cancer treatment, and psychosocial aspects of cancer survivorship. Conclusions: These data suggest improving the frequency and content of CVD risk reduction counseling is needed. Strategies should identify the best methods for providing CVD counseling, and should address general barriers as well as unique challenges faced by cancer survivors.

Social, Individual, and Environmental Characteristics of Family Medicine Resident Burnout: A CERA Study.

BACKGROUND AND OBJECTIVES: Burnout impacts medical students, residents, and practicing physicians. Existing research oversimplifies characteristics associated with burnout. Our study examined relationships between burnout, depressive symptoms, and evidence-based risk factors. METHODS: Our study questions were part of a larger survey conducted by the Council of Academic Family Medicine Educational Research Alliance (CERA), from May 9-23, 2020. Three emails were used to recruit a national sample of family medicine residents (n=283; questions completed via Survey Monkey). We determined descriptive statistics (frequency, means) for demographic and work environment characteristics, UCLA Loneliness Scale items, health behaviors, burnout (emotional exhaustion, depersonalization), and depressive symptoms. Multivariate data analysis included developing three logistic regression (LR) equations (emotional exhaustion, depersonalization, depressive symptoms) based on four blocks of potential risk factors (demographics, work environment characteristics, UCLA Loneliness items, and health behaviors). RESULTS: Rates of psychological distress included 33.1% emotional exhaustion, 31.1% depersonalization, and 53.0% depressive symptoms. We determined stepwise forward-entry LR models for emotional exhaustion (feel isolated OR=6.89, low quality of wellness program OR=5.91, and low companionship OR=4.82); depersonalization (feel isolated OR=5.59, low quality of wellness program OR=15.11, graduate US osteopathic medical school OR=0.329, and African American OR=7.55); and depressive symptoms (feel isolated OR=5.31, inadequate time for restful sleep OR=0.383, and no dependent children OR=2.14). CONCLUSIONS: Current findings document substantial social disconnection, substandard residency wellness programs, inadequate time for exercise, sleep, and other forms of self-care in addition to substantial levels of emotional exhaustion, depersonalization, and depressive symptoms. We explore implications for the design of future burnout prevention efforts and research.

Evaluation of a telemedicine pilot program for the provision of HIV pre-exposure prophylaxis in the Southeastern United States.

Pre-exposure prophylaxis (PrEP) is a daily regimen that reduces the risk of acquiring HIV by up to 97%. There is limited information on the use of telehealth to provide PrEP in a program aimed toward the primary prevention of HIV. This was a 6-month telePrEP feasibility study that assessed process measures, clinical outcomes and patient satisfaction. Descriptive statistics and Chi-square analysis were used to evaluate measures and outcomes from the start to the end of the study. Twenty patients enrolled, and 80% completed the study. Participants were cisgender males (100%) with an average age of 35.6 years, white (95%), and were college graduates or higher (55%). The majority (75%) had very high comfort with video calls before the program. Self-reported adherence to PrEP medication remained high throughout the program (60%-70%). Without this program 31.2% of participants were unlikely to have received PrEP. For obtaining PrEP 56.3% preferred telemedicine only, and 31.2% preferred a combination of telemedicine and in-person office visits. PrEP is an effective method of preventing HIV infection for those at high risk. Our program shows that telemedicine can be useful to expand access to medication for patients at high risk.

Physician Attitudes and Self-reported Practices Toward Prostate Cancer Screening in Black and White Men.

BACKGROUND AND OBJECTIVES: Updated 2018 prostate cancer screening guidelines recommend informed decision-making discussions, which should include education on prostate cancer's disproportionate impact on Black men. It is unknown whether academic family physicians follow these guidelines. METHODS: Family physicians were surveyed as part of the 2020 Council of Academic Family Medicine Educational Research Alliance (CERA) survey. We used χ2 to compare physicians' knowledge and screening practices stratified by physician age, gender, and percentage of Black patients in patient panel. We calculated logistic regressions predicting shared decision-making conversations, barriers to shared decision-making, inclusion of race in prostate cancer screening approach, and prostate-specific antigen (PSA) testing adjusted for physician age, gender, and percentage of Black patients. RESULTS: Physicians reported engaging in shared decision-making for prostate cancer screening in half of eligible men. Only 29.2% of physicians reported routinely informing Black men of their increased prostate cancer risk. In logistic regressions, physician gender (female) and fewer Black patients in panel (<25%) were associated with lower frequency of shared decision-making with Black patients. Physician age (<40 years) was associated with not discussing race during screening discussions (OR 2.24, 95% CI 1.55-3.23). CONCLUSIONS: Most academic family physicians do not appropriately inform Black men of increased prostate cancer risk, with younger physicians less likely to discuss race than older physicians. Female physicians, and physicians who see fewer Black patients, are less likely to have shared decision-making conversations with Black patients. This suggests educational efforts for these groups are needed to address health disparities in prostate cancer.

A Telehealth Initiative to Overcome Health Care Barriers for People Experiencing Homelessness.

People experiencing homelessness (PEH) encounter barriers to health care, increasing their vulnerability to illness, hospitalization, and death. Telehealth can improve access to health care, but its use in PEH has been insufficiently evaluated. Needs assessment surveys completed by clients at an urban drop-in center for PEH (n = 63) showed mental (58.7%) and physical (52.4%) health challenges were common, as was emergency department (ED) use (75.9%, n = 54). Surveys collected after in-person and telehealth clinical visits showed patient satisfaction was >90% for both visit types (n = 125, 44.0% telehealth and 56.0% in person). Without access to telehealth visits, 29.1% of patients would have gone to the ED and 38.2% would not have gotten care. Providers (n = 93, 69.6% telehealth and 30.4% in person) were more likely to agree/strongly agree they made a positive impact on patients' health through telehealth (92.2%) than in person (71.4%) (p = 0.019). Telehealth is a feasible and potentially cost-effective method to increase access to health care and reduce health outcome disparities in PEH.

Cardiovascular Screening and Lipid Management in Breast Cancer Survivors.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death among breast cancer (BC) survivors. BC survivors are at increased risk of CVD due to a higher prevalence of risk factors. Current data are limited on the cardiovascular screening practices and lipid management in this population in primary care settings. METHODS: A retrospective case control study was performed with 105 BC survivors and 210 matched controls (based on age and medical comorbidities of diabetes, hypertension, and hyperlipidemia). BC survivors were established with primary care practices within a large academic institution and had completed primary cancer treatment. Data on screening for CVD and lipid management were collected via a retrospective chart review. RESULTS: The average BC survivor was 63 years old, with 9 years since diagnosis. Compared with matched controls, BC survivors had more cholesterol screening (88% vs 70%, P < .001) and active statin prescriptions (63% vs 40%, P < .05) if indicated by the Atherosclerotic Cardiovascular Disease Calculator. There were no differences in CVD screening in White and African American BC survivors. However, African American BC survivors were more likely to have hypertension (P < .01) and have a body mass index in the overweight and obese category (P < .001) than White BC survivors. Older BC survivors were more likely to receive cholesterol screening. DISCUSSION: This study demonstrates that BC survivors who have an established primary care provider have improved cholesterol screening and statin therapy based on their risk of developing chronic diseases.

Cognitive behavioral social rhythm group therapy versus present centered group therapy for veterans with posttraumatic stress disorder and major depressive disorder: A randomized controlled pilot trial.

BACKGROUND: Cognitive Behavioral Social Rhythm Group Therapy (CBSRT) is a chronobiologically-informed group therapy designed to stabilize social rhythms in veterans with comorbid combat-related PTSD and major depressive disorder (MDD). This randomized controlled pilot trial is the first to examine feasibility and preliminary efficacy of group CBSRT as compared to group Present Centered Therapy (PCT), a well-characterized active attention, psychotherapy condition. METHODS: A total of 43 male veterans with combat-related PTSD, MDD, and disruptions in sleep or daily routine were randomly assigned to CBSRT or PCT. Therapy was provided weekly in a group modality for 12 weeks. Follow-up feasibility and gold-standard PTSD, MDD, and subjective/objective sleep assessments were conducted at post-treatment, 3 months, and 6 months post-treatment. RESULTS: Feasibility results demonstrated that veterans assigned to CBSRT had higher rates of attendance than veterans assigned to PCT. Both CBSRT and PCT were associated with improvements in PTSD and MDD symptoms, sleep efficiency, and number of awakenings; there were no differences between group therapies on these indices. Veterans in the CBSRT group had a greater reduction in the number of nightmares than veterans in the PCT group. LIMITATIONS: Preliminary results must be qualified by the small sample size. CONCLUSIONS: Group CBSRT may be more feasible for veterans than PCT. Both CBSRT and PCT were associated with improvements in psychiatric symptoms with few differences between conditions. CBSRT is a promising new group therapy that may help address the high-rate of PTSD therapy attrition in combat veterans. CLINICAL TRIAL REGISTRATION: NCT00984698.

Cognitive Processing Therapy for Posttraumatic Stress Disorder Is Associated with Negligible Change in Subjective and Objective Sleep.

Background: Patients receiving Cognitive Processing Therapy (CPT), an evidence based therapy for posttraumatic stress disorder (PTSD), report improved sleep quality. However, the majority of studies have examined residual sleep disturbance via self-report surveys or separate items on PTSD measures. This study examined whether CPT delivered to veterans in a VA setting improved sleep indices using state-of-the-art objective and subjective insomnia measures. Participants: Participants were war veterans with a current PTSD diagnosis scheduled to begin outpatient individual or group CPT at two Veteran's Affairs (VA) locations (n = 37). Methods: Sleep symptom severity was assessed using the recommended research consensus insomnia assessment, the consensus daily sleep diary and actigraphy. PTSD symptomatology pre- and post-treatment were assessed using the Clinician Administered PTSD Scale. Results: A small to moderate benefit was observed for the change in PTSD symptoms across treatment (ESRMC = .43). Effect sizes for changes on daily sleep diary and actigraphy variables after CPT were found to be negligible (Range ESRMC = - .16 to .17). Sleep indices remained at symptomatic clinical levels post-treatment. Discussion: These findings support previous research demonstrating a need for independent clinical attention to address insomnia either before, during, or after PTSD treatment.

Social rhythm regularity moderates the relationship between sleep disruption and depressive symptoms in veterans with post-traumatic stress disorder and major depressive disorder.

Approximately 50% to 80% of individuals with posttraumatic stress disorder (PTSD) also meet criteria for major depressive disorder (MDD). Sleep disturbance is a major concern in both PTSD and MDD, and is associated with poor treatment response, poor functional outcome and increased suicide risk. Social rhythm regularity, or the consistency of daily habitual behaviors, is theoretically linked to circadian rhythms and may be disturbed in both PTSD and MDD. The present study examined the relationship between social rhythm regularity, sleep disruption and MDD and PTSD symptoms in a sample of veterans with comorbid PTSD and MDD. Baseline data were obtained from 56 male veterans who met DSM-IV criteria for PTSD and MDD. Veterans completed the Social Rhythm Metric (SRM), a self-report questionnaire that assesses the regularity of routines by determining how regularly individuals completed 17 different types of activities. In a linear regression model, increased minutes awake after sleep onset (WASO) was a significant predictor of increased depression scores on the Hamilton Rating Scale for Depression (p < .05). SRM scores did not significantly predict depressive symptoms, however the interaction of WASO and SRM significantly predicted depressive symptoms (p = <.05), with significant relationships found at SRM scores less than 3.62. Neither minutes awake after sleep onset, SRM scores, nor their interaction was associated with PTSD symptom severity. Social and possibly circadian rhythm regularity may represent a risk or resilience factor for individuals with comorbid PTSD and MDD. Findings highlight the importance of exploring the interactions of sleep and social/circadian rhythms in depression in order to inform continued treatment development.

The Effect of Sleep Disorders, Sedating Medications, and Depression on Cognitive Processing Therapy Outcomes: A Fuzzy Set Qualitative Comparative Analysis.

Cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) is an effortful process requiring engagement in cognitive restructuring. Sleep disorders may lead to avoidance of effortful tasks and cognitive performance deficits. We explored whether sleep disorders, as assessed by polysomnography, were consistently associated with treatment response in combination with other factors. This study included 32 U.S. veterans who were examined both before and after CPT for combat-related PTSD. We employed a novel, case-comparative technique, fuzzy set qualitative comparative analysis (fsQCA), to identify combinations of fuzzy and crisp factors (recipes) that achieve a clinically significant outcome. Approximately one-quarter of cases experiencing clinically significant change were either (a) Vietnam era veterans without sedating medications, moderate sleep disordered breathing, and severe depression; or (b) non-Vietnam era veterans with sedating medications and without severe periodic limb movements (or significant periodic limb movement arousals). Recipes involving the absence of the relevant sleep disorder were associated with the highest coverage values. These results using fsQCA (a) provide valuable information about the heterogeneity of CPT response and (b) suggest that sleep disorders are important factors to consider in theoretical discussions of who responds to CPT for PTSD.

Typologies of Violence Exposure and Cognitive Processing in Incarcerated Male Adolescents.

Incarcerated youth experience high rates of violence exposure (VE), cognitive processing (CP) deficits, and mental health (MH) problems. It is not clear whether VE combined with CP deficits are particularly salient risk factors for MH dysfunction. Male incarcerated youth offenders (n = 115) completed standardized self-reports of MH and VE. CP was measured with executive functioning tasks and academic assessments. Person-centered Ward's Squared Euclidian Distance cluster analysis was used to examine unique patterns of CP and VE. Cluster analysis defined five distinct profiles of MH functioning, CP, and VE rates within incarcerated adolescents. Two groups, with high rates of VE and CP deficits, showed high rates of MH problems. Linear techniques may obscure important differences within this population.

Topographic analysis of the development of individual activation patterns during performance monitoring in medial frontal cortex.

Age-related improvements in human performance monitoring have been linked to maturation of medial frontal cortex (MFC) in healthy youth, however, imaging studies conflict regarding age-related changes in MFC activation patterns. Topographical analysis of single-subject activation enables measurement of variation in location of MFC activation by age, as well as other potentially influential factors (e.g., performance on task). In this study, 22 youth (ages 8-17 years) and 21 adults (ages 23-51 years) underwent functional magnetic resonance imaging during a performance monitoring task examining interference and errors. Single-subject factors (extent of MFC activation, age and accuracy) were entered into a three-level hierarchical linear model to test the influence of these characteristics on location of MFC activation. Activation shifted from a rostral/anterior to a more dorsal/posterior location with increasing age and accuracy during interference. Inclusion of age and accuracy accounted for almost all of the unexplained variance in location of interference-related activation within MFC. This pattern links improvement of performance-monitoring capacity to age-related increases in posterior MFC and decreases in anterior MFC activation. Taken together, these results show the maturation of performance monitoring capacity to depend on more focal engagement of posterior MFC substrate for cognitive control.

Poverty and language development: roles of parenting and stress.

Socioeconomic status affects a variety of mental and physical health outcomes, such as language development. Indeed, with poverty, disparities in the development of language processing are arguably among the most consistently found- with decreases in vocabulary, phonological awareness, and syntax at many different developmental stages. In this review, after considering basic brain systems affected by low socioeconomic status that are important for language development and related peripartum issues, we focus on two theoretical models that link poverty with the brain systems affected in language problems. The family stress model connects poverty with parental emotional distress that affects parenting, whereas the parental investment model involves a focus on basic needs that affects children's language. Understanding the mechanisms through which poverty affects the brain, parenting behaviors and language development may have implications for identification and treatment of individuals as well as social policy.

Parental brain and socioeconomic epigenetic effects in human development.

Critically significant parental effects in behavioral genetics may be partly understood as a consequence of maternal brain structure and function of caregiving systems recently studied in humans as well as rodents. Key parental brain areas regulate emotions, motivation/reward, and decision making, as well as more complex social-cognitive circuits. Additional key environmental factors must include socioeconomic status and paternal brain physiology. These have implications for developmental and evolutionary biology as well as public policy.

Violence Exposure and the Development of School-Related Functioning: Mental Health, Neurocognition, and Learning.

The relation between history of violence exposure and the development of academic and mental health problems is explored. Violence exposed children have an increased risk of developing school-related problems including: mental health problems, learning disabilities, language impairments, and other neurocognitive problems. These problems interact to create a complex web of deficits and disabilities where intervention access points are difficult to assess. Often mental health problems and academic problems develop in parallel. Timing of violence exposure and the developmental stage of the child during exposure complicate our understanding of the underlying mechanism. A model is presented that explores pathways linking violence exposure to aspects of school-related functioning, both academically and behaviorally. Early life stress, in the form of violence exposure, is related to neurocognitive deficits, including executive functioning and problems in self-regulation. Deficits in self-regulation at the level of behavior, and cognitive control and executive functioning, at the level of brain processing, are related to both academic and mental health problems, suggesting a possible psychological mechanism. Biological mechanisms are also included in the model to illustrate the contribution of the stress response, neuroendocrine system response, and neuroanatomical structural and functional impairments associated with violence exposure.

An Ecological Perspective on the Comorbidity of Childhood Violence Exposure and Disabilities: Focus on the Ecology of the School.

Violence exposure and disabilities frequently co-occur. Rates of disabilities among children with violence exposure range from three to eleven times that of non-exposed children. Each can be causal in the development of the other both directly and through less direct pathways. In this paper both direct and indirect influences that can lead to a circular pattern of mutual reinforcement between violence and disabilities are identified. Childhood disability research has historically focused on the individual more than the ecological context. Within the field of childhood violence exposure, the focus is often on perpetrators within the family or community. In this paper the ecological framework is applied to violence and disabilities studies to help integrate the two different research literatures and to examine different levels of influence on the developmental course of both social problems. The experience of school is used as a framework for examining violence and disability transactions at each level of the ecological framework, including the role of bullying and school violence. Finally areas of intervention within the purview of schooling are identified, particularly those that empower students through mastery focused school climate and student involvement.

The mediating role of self-regulation between intrafamilial violence and mental health adjustment in incarcerated male adolescents.

This article investigates the relation between history of intrafamilial violence and self-regulatory capacity, cognitive processing, and mental health adjustment in incarcerated adolescents. Adolescents were incarcerated at the time of the study for various violent offenses, ranging from persistent delinquency to sexual assault (n = 115). A model is proposed that posits that self-regulation, cognitive ability, and cognitive processing are integral to the relation between intrafamilial violence and mental health function. The primary hypothesis of the study tests this mediation model. The relations between mental health, cognitive processing, self-regulation, and intrafamilial violence are also examined. The study was conducted during two sessions at a juvenile facility in the Midwest using survey measures, academic and intelligence testing, and cognitive tasks. Youth were between the ages of 13 and 20. Approximately 70% were previously diagnosed with a disability. Significant Pearson's correlations were found between seven out of eight mental health subscales of the Youth Self-Report (YSR) and intrafamilial violence history. Structural equation modeling was used to examine the role of cognitive processing in the association between intrafamilial violence and mental health function. Nonverbal or performance deficits, a significant difference between verbal skills and nonverbal skills, were related to intrafamilial violence. Self-regulation partially mediated the relation between intrafamilial violence and mental health function. Self-regulation ability may be compromised by intrafamilial violence and be a precursor to both internalizing and externalizing mental health problem in incarcerated youth. Educational, clinical, and research implications are discussed.