"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.

An age-friendly chart review tool: integrating geriatrics education and quality improvement in a resident primary care clinic.

Resident primary care clinics have no standardized approach for assessing geriatric-specific quality of care measures. This results in wide variability in the quality of care offered to older adults in these clinics and the quality of geriatrics education residents receive in the primary care setting. To address this need, we developed a structured resident self-assessment chart review tool designed to be integrated into a required Geriatrics rotation within an Internal Medicine residency program. Review of the completed chart review tools revealed gaps in resident documentation of geriatric-specific domains, with assessments of cognition, function, and sensory ability most likely to be missing. Qualitative review of open-ended comments included in the chart review exercise identified documentation of patient goals and values as high clinical priority, while documentation of a cognitive assessment was considered to be of low clinical priority. By integrating improving quality of care with resident education, the chart review tool may offer an effective and time-efficient strategy for better patient care, increasing geriatric-specific education within primary care and helping educators identify areas of priority for future curriculum development.

Long-Term Consumption of Nuts (Including Peanuts, Peanut Butter, Walnuts, and Other Nuts) in Relation to Risk of Frailty in Older Women: Evidence from a Cohort Study.

BACKGROUND: Adherence to a healthy diet is inversely associated with frailty. However, the relationship between nuts, a key food group of Mediterranean diet, and frailty is unclear. OBJECTIVES: This study aimed to evaluate the association between nut consumption and frailty in an aging female population. METHODS: This population-based observational study included nonfrail women (≥60 y old) in the NHS from 11 states of the United States. Outcome was incident frailty, defined as having ≥3 of the FRAIL components (fatigue, lower strength, reduced aerobic capacity, multiple chronic conditions, and significant weight loss) and assessed every 4 y from 1992 to 2016. From 1990 to 2014, FFQs were used to assess the intakes of peanuts, peanut butter, walnuts (added in 1998), and other nuts at 4-y intervals. Exposure was total nut consumption, calculated as the sum of intakes of peanuts, peanut butter, walnuts, and other nuts and categorized into <1 serving/mo, 1-3 servings/mo, 1 serving/wk, 2-4 servings/wk, and ≥5 servings/wk. The relations of intakes of peanuts, peanut butter, and walnuts with frailty were also investigated separately. Cox proportional hazards models were used to assess the associations between nut consumption and frailty after adjusting for age, smoking, BMI, EI, diet quality, and medication use. RESULTS: Among 71,704 participants, 14,195 incident frailty cases occurred over 1,165,290 person-years. The adjusted HR (95% CI) for consuming ≥5 servings/wk of nuts was 0.80 (0.73, 0.87), as compared with <1 serving/mo. Higher intakes of peanuts and walnuts, but not peanut butter, were also inversely associated with frailty. CONCLUSIONS: This large prospective cohort study showed a strong and consistent inverse association between regular nut consumption and incident frailty. This suggests that nut consumption should be further tested as a convenient public health intervention for the preservation of health and well-being in older adults.

Finding and doing what matters most: Five productivity strategies for physicians in academic medicine.

While structural change is needed to address the burnout epidemic among healthcare workers, it is important for physicians to avail themselves of the many productivity strategies that can help them succeed in navigating the multiple responsibilities of academic medicine. We present here 5 key strategies within our control that can help increase productivity in the pursuit of work in academic medicine that is meaningful and sustainable: (1) Clarify Priorities, (2) Track Tasks Systematically, (3) Focus and Monotask, (4) Invest in Timesavers, and (5) Celebrate Successes. The specific tools listed under each strategy may help academic physicians feel grounded and maintain our focus on doing meaningful work. While system-wide culture change around expectations, and institutional support for physician wellbeing, is more critical than ever, individual physicians can still benefit from learning strategies to prioritize, track, focus on, delegate and celebrate the work that matters to us in our lives.

Learning about sites of care for older adults: a jigsaw educational session for medical students.

Choosing the appropriate site of care for patients is a vital clinical skill when caring for older adults. For better patient safety and smoother transitions of care, we need improved curricula to train clinicians about the system of sites and services where older adults receive care. Here we present an innovative introduction for medical trainees to the complexities of long-term and post-acute care for geriatric patients. Students participated in a team-based 'jigsaw' learning activity, in which each team researched a particular site of care and then taught a larger group of their peers about that site. It was subsequently converted to a virtual format due to COVID-19. The activity was assessed using students' written feedback and satisfaction scores. Students enjoyed the interactivity and hands-on approach, giving the activity an average score of 3.9 out of 5 (1 = 'poor'; 5 = 'excellent'). The jigsaw provided an engaging, case-based foundation for learning about sites of care and was well-received by students.

'Educator with a capital E': Comparing medical education experiences of student-as-teacher elective participants and peers.

PURPOSE: Student-as-teacher electives are increasingly offered at medical schools, but little is known about how medical education experiences among enrolled students compare with those of their peers. The study's aim was to characterize medical students' education-related experiences, attitudes, knowledge, and skills based on their enrollment status in a student-as-teacher course. MATERIALS/METHODS: We conducted four focus groups at a medical school in the United States: two with graduating students in a student-as-teacher elective (n = 11) and two with unenrolled peers (n = 11). Transcripts were analyzed using the Framework Method to identify themes. RESULTS: Four themes emerged: interest in and attitudes towards medical education; medical education skills, knowledge, and frameworks; strategies for giving/receiving feedback; medical education training as part of medical school. Course participants demonstrated higher-level education-related knowledge and skills. Both groups endorsed teaching skills as important and identified opportunities to incorporate medical education training into medical school curricula. CONCLUSIONS: Medical education knowledge and teaching skills are self-reported as important learning outcomes for medical students, independent of enrollment status in a student-as-teacher course. The structure of such courses, best understood through a deliberate practice-based model, supports students' achievement of key learning outcomes. Certain course elements may warrant inclusion in standard medical school curricula.

Twelve tips for clinical teaching with telemedicine visits.

Telemedicine is now an established mode of clinical care for most medical specialties, and clinical teachers must teach and precept learners in this modality. However, faculty need training on how best to teach students when caring for patients via telemedicine. Effectively incorporating learners into telemedicine visits to optimize their education is a critical skill for clinical teachers. In this article, we review 12 practical tips unique to telemedicine to engage and educate undergraduate medical education learners in building their clinical skills. We outline synchronous and asynchronous elements before, during, and after the patient encounter to facilitate teaching while improving patient care. These principles can also be adapted for teaching in other health professions as well as postgraduate medical education.

A hierarchy of needs for remote undergraduate medical education: lessons from the medical student experience.

PURPOSE: The disruption of undergraduate medical education (UME) by the COVID-19 pandemic has sparked rapid, real-time adjustments by medical educators and students. While much is known about online teaching in general, little guidance is available to medical educators on how to adapt courses not originally designed for the online environment. To guide our faculty in this transition we conducted a needs assessment of students enrolled in virtual courses across all 4 years of UME training. METHODS: Using a mixed-methods approach, we conducted a single-institution virtual learning needs assessment in May and June of 2020. We developed and disseminated a survey to assess student experiences with virtual learning. We conducted quantitative and qualitative analysis of responses (n = 255 or 39%) to identify emergent themes. RESULTS: We identified six interdependent themes that need to be met for medical students to fully reach their learning potential: access to stable internet and quiet study spaces, flexible course design with asynchronous, self-paced components, clear expectations for engagement with content and each other, a sense of connectedness with faculty and peers, synchronous classes that maximize interactivity, and assessments that foster a sense of learning over performance. Interpersonal relationships with faculty and peers affected students' sense of learning more than any other factor. CONCLUSIONS: Based on our findings we propose a hierarchy of needs for virtual learning that provides guidance on adapting existing medical school courses to the remote setting and overcoming common challenges. We highlight opportunities for how virtual elements may enrich in-person courses going forward, including in the clinical setting. Although the solutions required to meet the threshold of need at each level may differ based on the context, attending to these same fundamental needs can be extrapolated and applied to learners across a range of environments beyond the virtual.

My life, my story: Teaching patient centered care competencies for older adults through life story work.

We implemented "My Life, My Story" as an educational activity for enhancing patient-centered care (PCC) competencies across health professions trainees. Four hundred and eighty-two stories were completed for patients (M age = 72.5, SD = 12.7) primarily in inpatient medical settings, by trainees from seven disciplines. Trainees spent approximately 2 hours on the assignment; 84% felt this was a good use of their time. A mixed method survey evaluated the effectiveness of the activity on enhancing PCC competencies using open ended questions and ratings on the Consultation and Relational Empathy (CARE) Measure adapted for this project. The assignment most influenced trainees' ability to understand the patient as a "whole person" along with other PCC competencies such as showing empathy, really listening, building knowledge of values and goals, and building relationships. In addition, trainees perceived the activity enhanced patient care and was a positive contrast to usual care.

Enthesis regeneration: a role for Gli1+ progenitor cells.

The tendon enthesis originates from a specific pool of hedgehog-active Gli1+ progenitor cells that differentiate and produce mineralized fibrocartilage. The current study investigated the regenerative capacity of this cell population by comparing the responses of early postnatal and mature entheses to injury. Lineage tracing studies demonstrated that the original Gli1+ cell population had the capacity to heal immature entheses after injury, but this capacity was lost after the cells differentiated into mature fibrochondrocytes. To further examine the involvement of Gli1+ cells and hedgehog signaling in enthesis healing, Gli1 expression was examined via lineage tracing approaches and the effect of Smo deletion was examined in the injured entheses. Immature injured entheses retained high levels of Gli1 expression, a marker of hedgehog activation, consistent with non-injured controls. In contrast, injured mature entheses had few Gli1+ cells early in the healing process, with limited recovery of the cell population later in the healing process. These results suggest that the presence of activated hedgehog signaling in enthesis cells early in the healing process may enhance healing of enthesis injuries by mimicking developmental processes.

Goals of care and COVID-19: A GOOD framework for dealing with uncertainty.

As the COVID-19 pandemic continues, more patients will require palliative and end-of-life care. In order to ensure goal-concordant-care when possible, clinicians should initiate goals-of-care conversations among our most vulnerable patients and, ideally, among all patients. However, many non-palliative care clinicians face deep uncertainty in planning, conducting, and evaluating such interactions. We believe that specialists within palliative care are aptly positioned to address such uncertainties, and in this article offer a relevant update to a concise framework for clinicians to plan, conduct, and evaluate goals-of-care conversations: the GOOD framework. Once familiar with this framework, palliative care clinicians may use it to educate their non-palliative care colleagues about a timely and critical component of care, now and beyond the COVID-19 era.

Enthesis fibrocartilage cells originate from a population of Hedgehog-responsive cells modulated by the loading environment.

Tendon attaches to bone across a specialized tissue called the enthesis. This tissue modulates the transfer of muscle forces between two materials, i.e. tendon and bone, with vastly different mechanical properties. The enthesis for many tendons consists of a mineralized graded fibrocartilage that develops postnatally, concurrent with epiphyseal mineralization. Although it is well described that the mineralization and development of functional maturity requires muscle loading, the biological factors that modulate enthesis development are poorly understood. By genetically demarcating cells expressing Gli1 in response to Hedgehog (Hh) signaling, we discovered a unique population of Hh-responsive cells in the developing murine enthesis that were distinct from tendon fibroblasts and epiphyseal chondrocytes. Lineage-tracing experiments revealed that the Gli1 lineage cells that originate in utero eventually populate the entire mature enthesis. Muscle paralysis increased the number of Hh-responsive cells in the enthesis, demonstrating that responsiveness to Hh is modulated in part by muscle loading. Ablation of the Hh-responsive cells during the first week of postnatal development resulted in a loss of mineralized fibrocartilage, with very little tissue remodeling 5 weeks after cell ablation. Conditional deletion of smoothened, a molecule necessary for responsiveness to Ihh, from the developing tendon and enthesis altered the differentiation of enthesis progenitor cells, resulting in significantly reduced fibrocartilage mineralization and decreased biomechanical function. Taken together, these results demonstrate that Hh signaling within developing enthesis fibrocartilage cells is required for enthesis formation.

Effects of spaceflight on the muscles of the murine shoulder.

Mechanical loading is necessary for the development and maintenance of the musculoskeletal system. Removal of loading via microgravity, paralysis, or bed rest leads to rapid loss of muscle mass and function; however, the molecular mechanisms that lead to these changes are largely unknown, particularly for the spaceflight (SF) microgravity environment. Furthermore, few studies have explored these effects on the shoulder, a dynamically stabilized joint with a large range of motion; therefore, we examined the effects of microgravity on mouse shoulder muscles for the 15-d Space Transportation System (STS)-131, 13-d STS-135, and 30-d Bion-M1 missions. Mice from STS missions were euthanized within 4 h after landing, whereas mice from the Bion-M1 mission were euthanized within 14 h after landing. The motion-generating deltoid muscle was more sensitive to microgravity than the joint-stabilizing rotator cuff muscles. Mice from the STS-131 mission exhibited reduced myogenic (Myf5 and -6) and adipogenic (Pparg, Cebpa, and Lep) gene expression, whereas either no change or an increased expression of these genes was observed in mice from the Bion-M1 mission. In summary, muscle responses to microgravity were muscle-type specific, short-duration SF caused dramatic molecular changes to shoulder muscles and responses to reloading upon landing were rapid.-Shen, H., Lim, C., Schwartz, A. G., Andreev-Andrievskiy, A., Deymier, A. C., Thomopoulos, S. Effects of spaceflight on the muscles of the murine shoulder.

Gdf5 progenitors give rise to fibrocartilage cells that mineralize via hedgehog signaling to form the zonal enthesis.

The sequence of events that leads to the formation of a functionally graded enthesis is not clearly defined. The current study demonstrates that clonal expansion of Gdf5 progenitors contributes to linear growth of the enthesis. Prior to mineralization, Col1+ cells in the enthesis appose Col2+ cells of the underlying primary cartilage. At the onset of enthesis mineralization, cells at the base of the enthesis express alkaline phosphatase, Indian hedgehog, and ColX as they mineralize. The mineralization front then extends towards the tendon midsubstance as cells above the front become encapsulated in mineralized fibrocartilage over time. The hedgehog (Hh) pathway regulates this process, as Hh-responsive Gli1+ cells within the developing enthesis mature from unmineralized to mineralized fibrochondrocytes in response to activated signaling. Hh signaling is required for mineralization, as tissue-specific deletion of its obligate transducer Smoothened in the developing tendon and enthesis cells leads to significant reductions in the apposition of mineralized fibrocartilage. Together, these findings provide a spatiotemporal map of events - from expansion of the embryonic progenitor pool to synthesis of the collagen template and finally mineralization of this template - that leads to the formation of the mature zonal enthesis. These results can inform future tendon-to-bone repair strategies to create a mechanically functional enthesis in which tendon collagen fibers are anchored to bone through mineralized fibrocartilage.

Stochastic interdigitation as a toughening mechanism at the interface between tendon and bone.

Reattachment and healing of tendon to bone poses a persistent clinical challenge and often results in poor outcomes, in part because the mechanisms that imbue the uninjured tendon-to-bone attachment with toughness are not known. One feature of typical tendon-to-bone surgical repairs is direct attachment of tendon to smooth bone. The native tendon-to-bone attachment, however, presents a rough mineralized interface that might serve an important role in stress transfer between tendon and bone. In this study, we examined the effects of interfacial roughness and interdigital stochasticity on the strength and toughness of a bimaterial interface. Closed form linear approximations of the amplification of stresses at the rough interface were derived and applied in a two-dimensional unit-cell model. Results demonstrated that roughness may serve to increase the toughness of the tendon-to-bone insertion site at the expense of its strength. Results further suggested that the natural tendon-to-bone attachment presents roughness for which the gain in toughness outweighs the loss in strength. More generally, our results suggest a pathway for stochasticity to improve surgical reattachment strategies and structural engineering attachments.