The Weight of a Differential.

In this narrative medicine essay, when a physician's mother begins experiencing postmenopausal bleeding, the author wonders what it would be like to hear someone's signs and symptoms and not automatically begin to build a differential.

Eight Domains of Pediatrician Wellness: A Stakeholder Informed Model.

BACKGROUND: Physician wellness is important to health care systems and quality patient care. There has been limited research clarifying the physician wellness construct. We aimed to develop a stakeholder-informed model of pediatrician wellness. METHODS: We performed a group concept mapping (GCM) study to create a model of pediatrician wellness. We followed the four main steps of GCM and recruited pediatricians at multiple sites and on social media. During brainstorming, pediatricians individually responded to a prompt to generate ideas describing the concept of pediatrician wellness. Second, pediatricians sorted the list of brainstormed ideas into conceptually similar groups and rated them on importance. Sorted data were analyzed to create maps showing each idea as a point, with lines around groups of points to create clusters of wellness. Mean importance scores for each cluster were calculated and compared using pattern match. RESULTS: Pediatricians in this study identified eight clusters of wellness: 1) Experiencing belonging and support at work, 2) Alignment in my purpose, my work, and my legacy, 3) Feelings of confidence and fulfillment at work, 4) Skills and mindset for emotional well-being, 5) Harmony in personal, professional, and community life, 6) Time and resources to support holistic sense of self, 7) Work boundaries and flexibility, and 8) Organizational culture of inclusion and trust. There were no significant differences in mean cluster rating score; the highest rated cluster was Harmony in personal, professional and community life (3.62). CONCLUSION: Pediatricians identified eight domains of wellness, spanning professional and personal life, work, and individual factors.

The strength of our stories: a qualitative analysis of a multi-institutional GME storytelling event.

Context: Storytelling is a powerful tool for encouraging reflection and connection among both speakers and listeners. While growing in popularity, studying the benefits of formal oral storytelling events within graduate medical education remains rare. Our research question was: could an oral storytelling event for GME trainees and faculty be an effective approach for promoting well-being and resilience among participants?Methods: We used multiple approaches to gather perspectives from physician participants (storytellers and audience members) at an annual oral storytelling event for residents, fellows, and faculty from seven academic health systems in Minnesota. Data sources included short reflections written by participants during the event, an immediate post-event survey exploring participants' experiences during the event, social media postings, and targeted follow-up interviews further exploring the themes of connection and burnout that were raised in post-event survey responses. We performed a qualitative analysis using both deductive and inductive coding to identify themes.Results: There were 334 participants, including 197 physicians. At the event, 129 real-time written reflections were collected. There were also 33 Twitter posts related to the event. Response rate for the post-event survey was 65% for physicians, with 63% of physician respondents volunteering for targeted follow-up interviews. Of those, 38% completed the follow-up interview. Themes that emerged from the multi-modal qualitative analysis included a sense of connection and community, re-connection with meaning and purpose in work, renewal and hope, gratitude, and potential impact on burnout.Conclusion: The large turnout and themes identified show how an oral storytelling event can be a powerful tool to build community in graduate medical education. Qualitative analysis from multiple sources obtained both in real-time at the event and upon deeper reflection afterwards showed the event positively impacted the well-being of participants and that oral storytelling events can be an effective approach for promoting resilience in GME.

Case-based simulation empowering pediatric residents to communicate about diagnostic uncertainty.

Background Uncertainty is ubiquitous in medical practice. The Pediatrics Milestones from the Accreditation Council on Graduate Medical Education state that advanced learners should acknowledge and communicate about clinical uncertainty. If uncertainty is not acknowledged, patient care may suffer. There are no described curricula specifically aimed to improve learners' ability to acknowledge and discuss clinical uncertainty. We describe an educational intervention designed to fill this gap. Methods Second-year pediatric residents engaged in a two-phase simulation-based educational intervention designed to improve their ability to communicate about diagnostic uncertainty with patients and caregivers. In each phase, residents engaged in two simulated cases and debriefs. Performance was assessed after each simulated patient encounter using standardized metrics, along with learner perceptions of the experience. Results Residents' skills in communicating with patients and families about diagnostic uncertainty improved after this intervention (mean score post 3.84 vs. 3.28 pre on a five-point Likert scale, p<0.001). Residents rated the experience as relevant, challenging and positive. Conclusions This prospective study suggests that a simulation-based intervention was effective in improving resident physicians' skills in communicating about diagnostic uncertainty with patients and families. Further study is needed to determine how learners perform in real clinical environments.

Education for the Next Frontier in Patient Safety: A Longitudinal Resident Curriculum on Diagnostic Error.

Diagnostic error is a common, serious problem that has received increased attention recently for its impact on both patients and providers. Presently, most graduate medical education programs do not formally address this topic. The authors developed and evaluated a longitudinal, multimodule resident curriculum about diagnostic error and medical decision making. Key components of the curriculum include demystifying the medical decision-making process, building skills in critical thinking, and providing strategies for diagnostic error mitigation. Special attention was paid to avoiding the second victim effect and to fostering a culture that supports constructive, productive feedback when an error does occur. The curriculum was rated by residents as helpful (96%), and residents were more likely to be aware of strategies to reduce cognitive error (27% pre vs 75% post, P < .0001) following its implementation. This article describes the development, implementation, and effectiveness of this curriculum and explores generalizability of the curriculum to other programs.

Bioethics education and resources.

Ethics education based upon everyday ethical dilemmas can help trainees place themselves within the situation and encourage them to reflect on their role and responsibility in reaching its resolution.• Three elements can help augment the bioethics teaching experience: (a) identifying the ethical dilemma, (b) employing methods of ethical analysis, and(c) having knowledge of additional bioethics resources.An increasing number of bioethics resources are available to clinicians, including clinical ethics consultation (CEC) and print and Web-based resources.

Clergy-laity support and patients' mood during serious illness: a cross-sectional epidemiologic study.

OBJECTIVES: Religious participation is positively associated with mental health, but attendance at worship services declines during serious illness. This study assessed whether home visits by clergy or laity provide benefits to seriously ill patients who may have difficulty attending religious services. METHOD: A cross-sectional study design nested in an observational epidemiologic cohort study was used. The regionally representative sample of patients had metastatic lung, colorectal, breast, and prostate cancer (n = 70); Class III and IV congestive heart failure (n = 70); or chronic obstructive pulmonary disease with hypercapnea (n = 70) and were observed regarding clergy-laity support in their natural environments. DEPENDENT VARIABLE: 10-item Center for Epidemiologic Studies - Depression Scale. INDEPENDENT VARIABLE: A one-item question measuring how much helpful support patients received from clergy or other persons from church, temple, synagogue, or mosque. Covariates: demographic, health, social support, religiousness. RESULTS: Depressed mood was negatively associated with clergy-laity support in a non-linear pattern. Depressed mood was also positively associated with functional deficits and a lifetime history of difficulties related to religious involvement. SIGNIFICANCE OF RESULTS: In lieu of worship attendance when people are sick, home visits by members of a patient's religious community may bolster mood by providing continuity of instrumental, emotional, and spiritual support.

Comparing oncologist, nurse, and physician assistant attitudes toward discussions of negative emotions with patients.

PURPOSE: Although research shows that empathic communication improves patient outcomes, physicians often fail to respond empathically to patients. Nurses and physician assistants (PAs) may be able to help fill the need for empathic communication. Our study compares the attitudes of oncologists, nurses, and PAs toward communication with patients who demonstrate negative emotions. METHODS: We analyzed surveys from 48 oncologists, 26 PAs, and 22 nurses who participated in the Studying Communication in Oncologist-Patient Encounters trial. Surveys included previously validated items that examined attitudes toward communication with patients about emotion. RESULTS: The mean age of oncology physicians was higher (49 years) than that of PAs (40 years) or nurses (43 years), and 19% of physicians, 81% of PAs, and 100% of nurses were female. Race, years of oncology experience, and previous communication training were similar across provider types. Most nurses (82%) and PAs (68%) described themselves as having a socioemotional orientation, while most oncologists (70%) reported a technological/scientific orientation (p < .0001). PAs and nurses indicated more comfort with psychosocial talk than did oncologists (p < .0001). Discomfort with disclosing uncertainty and provider confidence and expectations when addressing patient concerns were similar across provider types. CONCLUSIONS: PAs and nurses were more oriented toward socioemotional aspects of medicine and were more comfortable with psychosocial talk than were oncologists. Future studies should examine whether these differences are attributable to other factors, including gender, and whether nurses and PAs are more likely than physicians to demonstrate empathic behaviors when patients express negative emotions.

Impact of income and income inequality on infant health outcomes in the United States.

OBJECTIVES: The goal was to investigate the relationships of income and income inequality with neonatal and infant health outcomes in the United States. METHODS: The 2000-2004 state data were extracted from the Kids Count Data Center. Health indicators included proportion of preterm births (PTBs), proportion of infants with low birth weight (LBW), proportion of infants with very low birth weight (VLBW), and infant mortality rate (IMR). Income was evaluated on the basis of median family income and proportion of federal poverty levels; income inequality was measured by using the Gini coefficient. Pearson correlations evaluated associations between the proportion of children living in poverty and the health indicators. Linear regression evaluated predictive relationships between median household income, proportion of children living in poverty, and income inequality for the 4 health indicators. RESULTS: Median family income was negatively correlated with all birth outcomes (PTB, r = -0.481; LBW, r = -0.295; VLBW, r = -0.133; IMR, r = -0.432), and the Gini coefficient was positively correlated (PTB, r = 0.339; LBW, r = 0.398; VLBW, r = 0.460; IMR, r = 0.114). The Gini coefficient explained a significant proportion of the variance in rate for each outcome in linear regression models with median family income. Among children living in poverty, the role of income decreased as the degree of poverty decreased, whereas the role of income inequality increased. CONCLUSIONS: Both income and income inequality affect infant health outcomes in the United States. The health of the poorest infants was affected more by absolute wealth than relative wealth.