Professional identity formation in medical education for humanistic, resilient physicians: pedagogic strategies for bridging theory to practice.

Recent calls for an expanded perspective on medical education and training include focusing on complexities of professional identity formation (PIF). Medical educators are challenged to facilitate the active constructive, integrative developmental process of PIF within standardized and personalized and/or formal and informal curricular approaches. How can we best support the complex iterative PIF process for a humanistic, resilient health care professional? How can we effectively scaffold the necessary critical reflective learning and practice skill set for our learners to support the shaping of a professional identity?The authors present three pedagogic innovations contributing to the PIF process within undergraduate and graduate medical education (GME) at their institutions. These are (1) interactive reflective writing fostering reflective capacity, emotional awareness, and resiliency (as complexities within physician-patient interactions are explored) for personal and professional development; (2) synergistic teaching modules about mindful clinical practice and resilient responses to difficult interactions, to foster clinician resilience and enhanced well-being for effective professional functioning; and (3) strategies for effective use of a professional development e-portfolio and faculty development of reflective coaching skills in GME.These strategies as "bridges from theory to practice" embody and integrate key elements of promoting and enriching PIF, including guided reflection, the significant role of relationships (faculty and peers), mindfulness, adequate feedback, and creating collaborative learning environments. Ideally, such pedagogic innovations can make a significant contribution toward enhancing quality of care and caring with resilience for the being, relating, and doing of a humanistic health care professional.

How we made professionalism relevant to twenty-first century residents.

The complexity of the current medical trainee work environment, including the impact of social media participation, is underappreciated. Despite rapid adoption of social media by residents and the introduction of social media guidelines targeted at medical professionals, there is a paucity of data evaluating practical methods to incorporate social media into professionalism teaching curricula. We developed a flipped classroom program, focusing on the application of professionalism principles to challenging real-life scenarios including social media-related issues. The pre-workshop evaluation showed that the participants had a good understanding of basic professionalism concepts. A post-workshop survey assessed residents' comfort level with professionalism concepts. The post-workshop survey revealed that the postgraduate trainees perceived significant improvement in their understanding of professionalism (p < 0.05). Resident responses also exposed some challenges of real-life clinical settings. There was an apparent contradiction between placing a high value on personal health and believing that physicians ought to be available to patients at any time. Participants' satisfaction with the course bodes well for continual modification of such courses. Innovative flipped classroom format in combination with simulation-based sessions allows easy incorporation of contemporary professionalism issues surrounding social media.

Fitness level moderates executive control disruption during exercise regardless of age.

The purpose of this study was to assess the effects of exercise intensity, age, and fitness levels on executive and nonexecutive cognitive tasks during exercise. Participants completed a computerized modified-Stroop task (including denomination, inhibition, and switching conditions) while pedaling on a cycle ergometer at 40%, 60%, and 80% of peak power output (PPO). We showed that a bout of moderate-intensity (60% PPO) to high-intensity (80% PPO) exercise was associated with deleterious performance in the executive component of the computerized modified-Stroop task (i.e., switching condition), especially in lower-fit individuals (p < .01). Age did not have an effect on the relationship between acute cardiovascular exercise and cognition. Acute exercise can momentarily impair executive control equivalently in younger and older adults, but individual's fitness level moderates this relation.

Suppression of central sleep apnea by continuous positive airway pressure and transplant-free survival in heart failure: a post hoc analysis of the Canadian Continuous Positive Airway Pressure for Patients with Central Sleep Apnea and Heart Failure Trial (CANPAP).

BACKGROUND: In the main analysis of the Canadian Continuous Positive Airway Pressure (CPAP) for Patients with Central Sleep Apnea (CSA) and Heart Failure Trial (CANPAP), CPAP had no effect on heart transplant-free survival; however, CPAP only reduced the mean apnea-hypopnea index to 19 events per hour of sleep, which remained above the trial inclusion threshold of 15. This stratified analysis of CANPAP tested the hypothesis that suppression of CSA below this threshold by CPAP would improve left ventricular ejection fraction and heart transplant-free survival. METHODS AND RESULTS: Of the 258 heart failure patients with CSA in CANPAP, 110 of the 130 randomized to the control group and 100 of the 128 randomized to CPAP had sleep studies 3 months later. CPAP patients were divided post hoc into those whose apnea-hypopnea index was or was not reduced below 15 at this time (CPAP-CSA suppressed, n=57, and CPAP-CSA unsuppressed, n=43, respectively). Their changes in left ventricular ejection fraction and heart transplant-free survival were compared with those in the control group. Despite similar CPAP pressure and hours of use in the 2 groups, CPAP-CSA-suppressed subjects experienced a greater increase in left ventricular ejection fraction at 3 months (P=0.001) and significantly better transplant-free survival (hazard ratio [95% confidence interval] 0.371 [0.142 to 0.967], P=0.043) than control subjects, whereas the CPAP-CSA-unsuppressed group did not (for left ventricular ejection fraction, P=0.984, and for transplant-free survival, hazard ratio 1.463 [95% confidence interval 0.751 to 2.850], P=0.260). CONCLUSIONS: These results suggest that in heart failure patients, CPAP might improve both left ventricular ejection fraction and heart transplant-free survival if CSA is suppressed soon after its initiation.

Continuous positive airway pressure for central sleep apnea and heart failure.

BACKGROUND: The Canadian Continuous Positive Airway Pressure for Patients with Central Sleep Apnea and Heart Failure trial tested the hypothesis that continuous positive airway pressure (CPAP) would improve the survival rate without heart transplantation of patients who have central sleep apnea and heart failure. METHODS: After medical therapy was optimized, 258 patients who had heart failure (mean age [+/-SD], 63+/-10 years; ejection fraction, 24.5+/-7.7 percent) and central sleep apnea (number of episodes of apnea and hypopnea per hour of sleep, 40+/-16) were randomly assigned to receive CPAP (128 patients) or no CPAP (130 patients) and were followed for a mean of two years. During follow-up, sleep studies were conducted and measurements of the ejection fraction, exercise capacity, quality of life, and neurohormones were obtained. RESULTS: Three months after undergoing randomization, the CPAP group, as compared with the control group, had greater reductions in the frequency of episodes of apnea and hypopnea (-21+/-16 vs. -2+/-18 per hour, P<0.001) and in norepinephrine levels (-1.03+/-1.84 vs. 0.02+/-0.99 nmol per liter, P=0.009), and greater increases in the mean nocturnal oxygen saturation (1.6+/-2.8 percent vs. 0.4+/-2.5 percent, P<0.001), ejection fraction (2.2+/-5.4 percent vs. 0.4+/-5.3 percent, P=0.02), and the distance walked in six minutes (20.0+/-55 vs. -0.8+/-64.8 m, P=0.016). There were no differences between the control group and the CPAP group in the number of hospitalizations, quality of life, or atrial natriuretic peptide levels. An early divergence in survival rates without heart transplantation favored the control group, but after 18 months the divergence favored the CPAP group, yet the overall event rates (death and heart transplantation) did not differ (32 vs. 32 events, respectively; P=0.54). CONCLUSIONS: Although CPAP attenuated central sleep apnea, improved nocturnal oxygenation, increased the ejection fraction, lowered norepinephrine levels, and increased the distance walked in six minutes, it did not affect survival. Our data do not support the use of CPAP to extend life in patients who have central sleep apnea and heart failure.

Prospective evaluation of nocturnal oximetry for detection of sleep-related breathing disturbances in patients with chronic heart failure.

BACKGROUND: Because patients with chronic heart failure (CHF) can benefit from specific treatment for coexisting obstructive and central sleep apnea (CSA), there is a need to develop accurate screening tools to identify or exclude these sleep-related breathing disturbances (SRBDs) in patients with CHF. OBJECTIVES: To evaluate, prospectively, the diagnostic value of nocturnal home oximetry in identifying SRBD in CHF patients and in distinguishing central events from obstructive events. DESIGN: Blinded comparison of hospital and home oximetry, and polysomnographic nocturnal recordings SETTING: Cardiac heart failure and sleep clinics in three tertiary referral centers. PATIENTS: Fifty consecutive patients who were investigated for participation in the Canadian Continuous Positive Airway Pressure Trial for Congestive Heart Failure with Central Sleep Apnea and were recruited from three different centers. MEASUREMENTS AND RESULTS: Patients underwent two oximetry recordings, one at home and one during a polysomnographic study. The criterion for an SRBD was the presence of > 15 apneas and hypopneas per hour of sleep during polysomnography or an oxygen desaturation index of > 10 events per hour during oximetry. The pattern of desaturation/resaturation during oximetry was also examined to distinguish obstructive events from central events. Using a 2% fall in pulse oximetric saturation as the criterion for oxygen desaturation, home oximetry had a 85% sensitivity and a 93% specificity (p < 0.001) for detecting an SRBD. However, the desaturation/resaturation pattern did not accurately distinguish between obstructive events and central events (eg, 100% sensitivity, 17% specificity for identifying CSA). The interpretation of the oximetry recording was highly consistent between scorers (p < 0.001). CONCLUSIONS: Overnight home oximetry is a sensitive and specific tool for identifying SRBDs in patients with CHF, but not for distinguishing between obstructive and central events in such patients.

Six-month outcomes after single- and multi-lesion percutaneous coronary intervention: results from the ROSETTA registry.

BACKGROUND: The American College of Cardiology/American Heart Association exercise testing guidelines suggest that routine functional testing may benefit patients at high risk of restenosis, such as those undergoing multi-lesion percutaneous coronary intervention (PCI). OBJECTIVES: To compare the six-month post-PCI clinical and procedural outcomes in patients following single- and multi-lesion PCI, and to examine the use of routine functional testing (ie, in all patients) versus selective functional testing (ie, only in those with recurrent symptoms) following multi-lesion PCI. METHODS: Six-month outcomes among 562 patients after single-lesion PCI and 229 patients after multi-lesion PCI were examined. All patients were enrolled in the Routine versus Selective Exercise Treadmill Testing after Angioplasty (ROSETTA) registry, a prospective, multicentre registry examining the use of functional testing after successful PCI. RESULTS: For single- versus multi-lesion PCI patients, respectively, rates of death (1.8% versus 2.2%, P=0.7) and myocardial infarction (0.7% versus 2.6%, P=0.03) were low in both groups. Rates of unstable angina (12.0% versus 11.7%, P=0.9) and the composite clinical end point of death, myocardial infarction or unstable angina (13.5% versus 13.9%, P=0.9) were similar. Multi-lesion PCI patients had a higher number of repeat PCI procedures (6.6% versus 13.4%, P=0.02) but there was no difference in the rates of coronary artery bypass graft surgery (3.0% versus 2.6%, P=0.7). A routine functional testing strategy was used in 28.0% of single-lesion and 31.6% of multi-lesion patients. In a multivariate analysis of the multi-lesion patients, routine functional testing was not associated with a significant reduction in the composite clinical event rate (odds ratio 0.5, 95% CI 0.2 to 1.7, P=0.27). CONCLUSIONS: During the six-month period following successful PCI, clinical event rates were similar among patients undergoing single- or multi-lesion PCI. Routine functional testing was not associated with a statistically significant benefit in patients after multi-lesion PCI. However, additional study is required to better define the role of routine functional testing in this subgroup of patients.

Utility of routine functional testing after percutaneous transluminal coronary angioplasty: results from the ROSETTA registry.

BACKGROUND: There is little consensus regarding the use of functional testing after percutaneous transluminal coronary angioplasty (PTCA). Some physicians employ a routine functional testing strategy, and others employ a symptom-driven strategy. OBJECTIVE: To examine the effects of routine post-PTCA functional testing on the use of follow-up cardiac procedures and clinical events. METHODS: The Routine versus Selective Exercise Treadmill Testing after Angioplasty (ROSETTA) Registry is a prospective multicenter observational study examining the use of functional testing after PTCA. A total of 788 patients (pts) were enrolled in the ROSETTA Registry at 13 clinical centers in 5 countries. The frequencies of functional testing, cardiac procedures and clinical events were examined during the first 6 months following a successful PTCA. RESULTS: Patients were predominantly elderly men (mean age, 61+/-11 years; 76% male) who underwent single-vessel PTCA (85%) with stent implantation (58%). During the 6-month follow-up, a total of 237 pts were observed to undergo a routine functional testing strategy (100% having functional testing for routine follow-up), while 551 pts underwent a selective (or clinically-driven) strategy (73% having no functional testing and 27% having functional testing for a clinical indication). Patients in the routine testing group underwent a total of 344 functional tests compared with 165 tests performed in the selective testing group (mean, 1.45 tests/patient versus 0.3 tests/patient; p<0.0001). There was little difference in the rates of follow-up cardiac procedures among the pts undergoing the routine and selective testing strategies [cardiac catheterization, 13.9% versus 17.5% (p=NS); percutaneous coronary intervention (PCI), 8.4% versus 8.7% (p=NS); coronary artery bypass graft surgery, 2.1% versus 3.3% (p=NS)]. However, clinical events were less common among pts who underwent routine functional testing, e.g., unstable angina (6.1% versus 14.4%; p=0.001), myocardial infarction (0.4% versus 1.6%; p=NS), death (0% versus 2.2%; p=0.02) and composite clinical events (6.3% versus 16.3%; p<0.0001). After controlling for baseline clinical and procedural differences, routine functional testing had a persistent independent association with a reduction in the composite clinical event rate (odds ratio, 0.45; 95% confidence interval, 0.24-0.81; p=0.008). CONCLUSION: Routine functional testing after PTCA is associated with a reduction in the frequency of follow-up clinical events. This association may be attributable to the early identification and treatment of pts at risk for follow-up events, or it may be due to clinical differences between pts who are referred for routine and selective functional testing.