How Do Postgraduate Trainees Prepare for New Clinical Learning Environments.

Background: Transitioning to a new clinical learning environment (CLE) requires learning new skills, roles, teams, workflows, and culture. We previously identified activities and questions to guide orientation in the categories of who, what, where, when, why, and how. There is limited literature about how learners plan for this transition. Objective: Describe how postgraduate trainees prepare for a clinical rotation, based on qualitative analysis of narrative responses within a simulated orientation experience. Methods: In June 2018, incoming residents and fellows in multiple specialties at Dartmouth Hitchcock Medical Center completed an online simulated orientation that asked how they intended to prepare for their first rotation. We used directed content analysis to code their anonymously collected responses using the orientation activities and question categories from our prior study. We used open coding to describe additional themes. Results: Narrative responses were available for 97% (116 of 120) of learners. While 46% (53 of 116) of learners listed preparations related to what happens in the CLE, responses fitting into other question categories were less frequent: who (9%, 11 of 116), where (7%, 8 of 116), when (4%, 5 of 116), why (<1%, 1 of 116), and how (0%, 0 of 116). Learners also infrequently described activities to aid the transition: reading orientation materials (11%, 13 of 116), speaking with a colleague (11%, 13 of 116), and arriving early (3%, 3 of 116). They more frequently commented on content reading (40%, 46 of 116), asking for advice (28%, 33 of 116), and self-care (12%, 14 of 116). Conclusions: When describing preparation for a new CLE, residents focused on tasks in the what category more than understanding the system and learning goals in other categories.

Learning Outcomes from an Academic Internal Medicine Morbidity and Mortality Conference.

BACKGROUND: Morbidity and Mortality (M&M) conferences are widely utilized clinical teaching forums across the USA. Recent literature demonstrates heterogeneity in the educational objectives of M&M, with prior authors suggesting a variety of overarching purposes of the conference, including teaching quality improvement methods; promotion of patient safety; enhancement of clinical knowledge and skills; and reflection on humanistic aspects of medical practice. There is less information in the published literature regarding learning outcomes of M&M participants. OBJECTIVE: The goal of this study was to describe learning outcomes from the Internal Medicine Morbidity, Mortality, and Improvement conference at Dartmouth-Hitchcock Medical Center. DESIGN: Directed content analysis of learning outcomes statements. PARTICIPANTS: Internal medicine physicians who requested Maintenance of Certification credit for one or more conference sessions during the 2017-2018 academic year. APPROACH: Two independent reviewers analyzed 347 learning outcomes statements submitted by 49 conference participants. The reviewers used an iterative process to code content themes (the category of medical or healthcare delivery knowledge learned) and learning implementation domains (the context or manner in which learning would be applied), and to identify comments regarding the shared experience of practicing medicine. KEY RESULTS: Seventy-eight percent of comments described learning related to clinical knowledge and skills, and 28%, 34%, and 9% of comments described learning related to clinical reasoning skills, systems knowledge, and the need for systems change, respectively. Most conferences generated learning within a variety of themes and across multiple domains. Sixty-four percent of conferences included at least one reflection on the shared experience of practicing medicine. CONCLUSIONS: Participants derived several types of learning from this Internal Medicine M&M conference. Although clinical knowledge and skills represent the most common type of learning, the conference also produces rich learning in other domains as well as reflections on the humility, challenges, and meaning of being a physician.

Resources for clinical learning environment orientation.

INTRODUCTION: Each clinical learning environment (CLE) requires learners to navigate a different set of complex interactions to engage in safe patient care while learning from real patients. Orientation forms the foundation for learning, yet CLE models in the literature are primarily written for an educator audience and practical advice for orienting learners to a new CLE is limited. To address this gap, we designed resources to support both supervisors and learners in the orientation process. MATERIALS/METHODS: We reviewed the CLE literature to select critical content for orientation and interviewed high performing residents to identify their best practices. We synthesized the literature and resident interviews into a visually appealing and easy to digest infographic designed to simultaneously remind teachers of the critical areas to cover in orientation and empower learners to ask about them. We integrated these principles into an online module for Graduate Medical Education onboarding and surveyed users about how well they could meet the module learning objectives. RESULTS: We organized the literature review and resident advice regarding questions learners should ask about a new CLE into the typical question categories (why, who, what, when, where, and how) and described strategies for orientation to each category. Our infographic has been incorporated into CLE orientation for multiple types of learners at our institution. After completing the orientation module, 112/124(90%) residents indicated that they could, 'Orient yourself or a learner to a clinical learning environment using orientation questions' moderately to extremely well. DISCUSSION: We developed resources that can be used by educators to create orientation materials and by learners to ensure they understand important features, resources, and expectations in a new CLE. Because the foundational principles of CLE apply to a variety of clinical settings and learner types, the resources may be broadly applicable.

Prevalence and sociodemographic determinants of dyspepsia in the general population of Rwanda.

INTRODUCTION: Dyspepsia accounts for a significant burden of worldwide disease, but there is a relative paucity of data from the sub-Saharan African setting. We undertook to describe the burden, risk factors and severity of dyspepsia across Rwanda. METHODS: We performed a population-based clustered cross-sectional survey between November 2015 and January 2016, nationwide in Rwanda, using the Short Form Leeds Dyspepsia Questionnaire to describe the presence and severity of dyspepsia, and the Short Form Nepean Dyspepsia Index to describe the concomitant quality of life effects. Univariate and multivariate logistic regression models were constructed to correlate measured sociodemographic factors with dyspepsia. RESULTS: The prevalence of clinically significant dyspepsia in the general Rwandan population was 14.2% (283/2000). The univariate factors that significantly predicted severity were gender, profession, socioeconomic status, and non-steroidal anti-inflammatory drug, aspirin and alcohol use, with gender, current smoking, aspirin use both in the past and currently, and alcohol use in the past remaining significant on multivariate modelling. Dyspeptics had a significantly lower gastrointestinal-related quality of life, though the sociodemographic factors measured did not modify the observed quality of life. CONCLUSION: Dyspepsia is prevalent in the Rwandan setting and is associated with a significant burden on quality of life. More work is required to determine the pathological entities involved, and the optimal approach to mitigating this burden.

Use of Simulated Patient Encounters to Teach Residents to Respond to Patients Who Discriminate Against Health Care Workers.

BACKGROUND: Previous studies indicate that medical trainees frequently experience discrimination by patients. Little is known about effective strategies to teach trainees to respond to this discrimination. AIM: To create a workshop for first-year residents utilizing standardized patients to improve skills in responding to patients exhibiting discrimination towards members of the health care team. SETTING: The Patient Safety Training Center at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire. PARTICIPANTS: First-year residents in the Internal Medicine Residency Program. PROGRAM DESCRIPTION: An introductory didactic session including a communication skills framework was followed by simulated encounters with four standardized patients. Learners received feedback from a trained facilitator, peers, and the standardized patients. PROGRAM EVALUATION: One hundred percent of the 19 learners who participated agreed that the simulated exercises were realistic and improved their readiness to address patient bias. The proportion of learners who reported being somewhat or very confident in their preparedness to respond to patients exhibiting discrimination increased from 74% before the workshop to 100% (p = 0.07) after the workshop. DISCUSSION: A workshop incorporating standardized patients may improve resident confidence in responding to patients with discriminatory behaviors. The workshop could be modified to incorporate other learners and staff, or for inter-disciplinary training.

Impact of numeracy on understanding of prostate cancer risk reduction in PSA screening.

Prostate-specific antigen (PSA) screening for prostate cancer in men of average risk remains controversial. Patients' ability to incorporate risk reduction data into their decision-making may depend on their numeracy. We assessed the impact of patients' numeracy on their understanding of the risk reduction benefits of PSA screening. Men attending a general internal medicine clinic were invited to complete a survey. Four versions of the survey each included a three-item numeracy test and PSA risk reduction data, framed one of four ways: absolute (ARR) versus relative risk reduction (RRR), with or without baseline risk (BR). Respondents were asked to adjust their perceived risk of prostate-cancer mortality using the data presented. Accuracy of risk reduction was evaluated relative to how risk data were framed. Among a total of 200 respondents, a majority incorrectly answered one or more of the numeracy items. Overall accuracy of risk adjustment was only 20%. Accuracy varied with data framing: when presented with RRR, respondents were 13% accurate without BR and 31% accurate with BR; when presented with ARR, they were 0% accurate without BR and 35% accurate with BR. Including BR data significantly improved accuracy for both RRR (P = 0.03) and ARR groups (P < 0.01). Accuracy was significantly related to numeracy; numeracy scores of 0, 1, 2, and 3 were associated with accuracy rates of six, five, nine, and 36 percent, respectively (P < 0.01). Overall, numeracy was significantly associated with the accuracy of interpreting quantitative benefits of PSA screening. Alternative methods of communicating risk may facilitate shared decision-making in the use of PSA screening for early detection of prostate cancer.

Bioidentical Estrogen for Menopausal Depressive Symptoms: A Systematic Review and Meta-Analysis.

BACKGROUND: Proponents of bioidentical estrogens claim that they are superior for treating menopausal symptoms, including depressive symptoms. Small trials examining the effects of bioidentical estrogens on depressive symptoms show conflicting results. We conducted a systematic review to assess the effectiveness and safety of bioidentical estrogens for treatment of depressive symptoms in peri- and postmenopausal women. METHODS: We searched the scientific literature for randomized controlled trials of at least 4 weeks duration, comparing bioidentical estrogen with placebo for depressive symptoms in menopausal women. The main outcome measure was improvement in depressive symptoms on a validated scale. RESULTS: We found 12 clinical trials that met inclusion criteria, two of which contained insufficient data for quantitative analysis. In the 10 studies (inclusive of 1208 subjects) for which complete data were available for inclusion in the meta-analysis, bioidentical estrogen had no clinically significant effect on depressive symptoms (standardized mean difference [SMD] -0.02; confidence interval [95% CI] -0.41 to +0.38). Pooled studies were highly heterogeneous, and numerous approaches to reducing heterogeneity were unsuccessful. Subgroup analyses showed no significant difference in effect for women treated with adjunctive progestogen, women treated with unopposed estrogen, perimenopausal, or postmenopausal and mixed populations. A possible benefit in perimenopausal women treated with unopposed estradiol may have been diluted by studies including older postmenopausal women whose depressive symptoms were unrelated to menopause. CONCLUSIONS: In this first systematic review of bioidentical hormone replacement therapy, we found that bioidentical estrogen has no clear benefit in treating depressive symptoms in menopausal women, but heterogeneity of available studies limits the potential for definitive conclusions. Future research should compare bioidentical estrogen with nonbioidentical estrogen for treatment of depressive symptoms in perimenopausal women.