"What's Going to Happen?": Internal Medicine Resident Experiences of Uncertainty in the Care of Older Adults.

PURPOSE: Internal medicine residents care for clinically complex older adults and may experience increased moral distress due to knowledge gaps, time constraints, and institutional barriers. We conducted a phenomenological study to explore residents' experiences and challenges through the lens of uncertainty. METHODS: Between January and March 2022, six focus groups were conducted comprising a total of 13 internal medicine residents in postgraduate years 2 and 3, who had completed a required 2-week geriatrics rotation. Applying the Beresford taxonomy of uncertainty as a conceptual model, data were analyzed using the framework method. RESULTS: All challenging experiences described by residents caring for older adults were linked to uncertainty. Sources of uncertainty were categorized and mapped to the Beresford taxonomy: (1) lack of geriatrics knowledge or clinical guidelines (technical); (2) difficulty applying knowledge to complex older adults (conceptual); and (3) lack of longitudinal relationship with the older patient (personal). Residents identified capacity evaluation and discharge planning as two major geriatric knowledge areas linked with uncertainty. While the majority of residents reacted to uncertainty with some degree of distress, several reported positive coping strategies. CONCLUSIONS: Internal medicine residents face uncertainty when caring for older adults, particularly related to technical and conceptual factors. Strategies for mitigating uncertainty in the care of older adults are needed given links with moral distress and trainee well-being.

The impact of yoga on aging physiology: A review.

Frailty represents diminished reserve across multiple physiologic systems, accompanied by increased vulnerability to stressors and increased morbidity and mortality. With population aging, strategies to prevent and manage frailty are priorities in clinical medicine and public health. Current evidence-based approaches to frailty management are multimodal in nature. Yoga, an increasingly popular and highly adaptable mind-body practice, is multi-component, incorporating physical postures, breathing practices, meditation, and other elements, and may be a strategy for frailty management. Here, we summarize the evidence linking yoga practice to mitigation of age-related degradation across multiple physiologic systems, including cardiovascular, pulmonary, musculoskeletal, and nervous systems. We discuss putative mechanisms of action including modulation of the hypothalamic-pituitary-adrenal axis. Finally, we consider implications for clinical practice and future research.

Strategic response to bleeding in laparoscopic hepato-pancreato-biliary surgery: an intraoperative checklist.

BACKGROUND: The aim is to develop and test the utility of an event-initiated, team-based check list to optimize the response to bleeding during laparoscopic HPB surgery. METHODS: To build a checklist for managing bleeding events, we conducted a systematic review. Using nominal group technique (NGT), a checklist consisting of four domains was developed. Following team-based training of anesthesia and surgical staff, the checklist was implemented. HPB cases before and after implementation of the checklist were compared for adverse outcomes, bleeding complications, and transfusions. RESULTS: NGT identified four domains: Communicate Control, Expose, and Repair under which the checklist was organized. Supplemental Video for a detailed review of how each domain was applied to a specific case example. We compared 169 HPB cases before to 53 cases after implementation. We found a significant decrease in mean EBL (from 518 ± 852.8 to 151.5 ± 221.7 ml (P = 0.001)) for cases performed after implementation of the checklist and a trends toward less volume of pRBC transfused (2.7 ± 2.5 vs 2.3 ± 1.7 units/per patient, P = 0.611) and transfusion rates (22% vs 11%, P = 0.703). CONCLUSION: An event-initiated, team-based response to an adverse bleeding event during laparoscopic HPB surgery correlates with positive effects on bleeding management, and transfusion rates.