Vaginitis: Diagnosis and Treatment.

Vaginitis is defined as any condition with symptoms of abnormal vaginal discharge, odor, irritation, itching, or burning. The most common causes of vaginitis are bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis. Bacterial vaginosis is implicated in 40% to 50% of cases when a cause is identified, with vulvovaginal candidiasis accounting for 20% to 25% and trichomoniasis for 15% to 20% of cases. Noninfectious causes, including atrophic, irritant, allergic, and inflammatory vaginitis, are less common and account for 5% to 10% of vaginitis cases. Diagnosis is made using a combination of symptoms, physical examination findings, and office-based or laboratory testing. Bacterial vaginosis is traditionally diagnosed with Amsel criteria, although Gram stain is the diagnostic standard. Newer laboratory tests that detect Gardnerella vaginalis DNA or vaginal fluid sialidase activity have similar sensitivity and specificity to Gram stain. Bacterial vaginosis is treated with oral metronidazole, intravaginal metronidazole, or intravaginal clindamycin. The diagnosis of vulvovaginal candidiasis is made using a combination of clinical signs and symptoms with potassium hydroxide microscopy; DNA probe testing is also available. Culture can be helpful for the diagnosis of complicated vulvovaginal candidiasis by identifying nonalbicans strains of Candida. Treatment of vulvovaginal candidiasis involves oral fluconazole or topical azoles, although only topical azoles are recommended during pregnancy. The Centers for Disease Control and Prevention recommends nucleic acid amplification testing for the diagnosis of trichomoniasis in symptomatic or high-risk women. Trichomoniasis is treated with oral metronidazole or tinidazole, and patients' sex partners should be treated as well. Treatment of noninfectious vaginitis should be directed at the underlying cause. Atrophic vaginitis is treated with hormonal and nonhormonal therapies. Inflammatory vaginitis may improve with topical clindamycin as well as steroid application.

"Where Does the Circle End?": Representation as a Critical Aspect of Reflection in Teaching Social and Behavioral Sciences in Medicine.

OBJECTIVE: This paper describes a reflective learning program within a larger curriculum on behavioral and social science that makes use of close reading, written representation of experience, discussion, and textual response. This response may in turn lead to further reflection, representation, and response in a circular pattern. A unique feature of this program is that it pays attention to the representation itself as the pivotal activity within reflective learning. Using the narrative methods that are the hallmark of this program, faculty writings were analyzed to characterize the essential benefits that derive from these practices. METHODS: In the context of a faculty development seminar on the teaching of behavioral and social sciences in medical curricula, a group of 15 faculty members wrote brief narratives of reflective learning experiences in which they had made use of the methods described above. Their responses were submitted to iterative close reading and discussion, and potential themes were identified. RESULTS: Four themes emerged: writing as attention to self, writing as attention to other, writing as reader/writer contract, and writing as discovery. In each instance, writing provides a new or deepened perspective, and in each case, the dividends for the writer are amplified by the narrative skills of those who read, listen, and respond. CONCLUSIONS: The narrative pedagogy described and modeled herein provides a potentially promising approach to teaching the social, cultural, behavioral, and interpersonal aspects of medical education and practice. Future research will deepen our understanding of the benefits and limitations of this pedagogy and expand our appreciation of its applications.

Columbia COVID-19 Student Service Corps: Harnessing student skills and galvanizing the power of service learning.

The COVID-19 pandemic in New York City led to the forced rapid transformation of the medical school curriculum as well as increased critical needs to the health system. In response, a group of faculty and student leaders at CUIMC developed the COVID-19 Student Service Corps (Columbia CSSC). The CSSC is an interprofessional service-learning organization that galvanizes the skills and expertise of faculty and students from over 12 schools and programs in the response to the COVID-19 pandemic, and is agile enough to shift and respond to future public health and medical emergencies. Since March 2020, over 30 projects have been developed and implemented supporting needs identified by the health system, providers, faculty, staff, and students as well as the larger community. The development of the CSSC also provided critical virtual educational opportunities in the form of service learning for students who were unable to have any in-person instruction. The CSSC model has been shared nationally and nine additional chapters have started at academic institutions across the country.

Reading the Self: Medical Students' Experience of Reflecting on Their Writing Over Time.

PURPOSE: To investigate students' experience (over time) with meta-reflection writing exercises, called Signature Reflections. These exercises were used to strengthen reflective capacity, as part of a 4-year reflective writing portfolio curriculum that builds on a recognized strategy for reflection (narrative medicine) and employs longitudinal faculty-mentors. METHOD: In 2018, the authors conducted 5 focus groups with 18 third-year students from the Columbia University Vagelos College of Physicians and Surgeons class of 2019 to examine students' experience with Signature Reflections. Using an iterative, thematic approach, they developed codes to reflect common patterns in the transcripts, distilled conceptually similar codes, and assembled the code categories into themes. RESULTS: Three core themes (safe space, narrative experience, mirror of self) and 1 overarching theme (moving through time) were identified. Students frequently experienced relief at having a safe reflective space that promoted grappling with their fears or vulnerabilities and highlighted contextual factors (e.g., trusted faculty-mentors, protected time) that fostered a safe space for reflection and exploration. They often emphasized the value of tangible documentation of their medical school journey (narrative experience) and reported using Signature Reflections to examine their emerging identity (mirror of self). Overlapping with the core themes was a deep appreciation for the temporal perspective facilitated by the Signature Reflections (moving through time). CONCLUSIONS: A longitudinal narrative medicine-based portfolio curriculum with pauses for meta-reflection allowed students, with faculty support, to observe their trajectory through medical school, explore fears and vulnerabilities, and narrate their own growth. Findings suggest that narrative medicine curricula should be required and sufficiently longitudinal to facilitate opportunities to practice the skill of writing for insight, foster relationships with faculty, and strengthen students' temporal perspectives of their development.

Implementing an interprofessional narrative medicine program in academic clinics: Feasibility and program evaluation.

Interprofessional education (IPE) is a critical component of medical education and is affected by the characteristics of the clinical teams in which students and residents train. However, clinical teams are often shaped by professional silos and hierarchies which may hinder interprofessional collaborative practice (IPCP). Narrative medicine, a branch of health humanities that focuses on close reading, reflective writing, and sharing in groups, could be an innovative approach for improving IPE and IPCP. In this report, we describe the structure, feasibility, and a process-oriented program evaluation of a narrative medicine program implemented in interprofessional team meetings in three academic primary care clinics. Program evaluation revealed that a year-long narrative medicine program with modest monthly exposure was feasible in academic clinical settings. Staff members expressed engagement and acceptability as well as support for ongoing implementation. Program success required administrative buy-in and sustainability may require staff training in narrative medicine.

Development and implementation of an interprofessional pharmacotherapy learning experience during an advanced pharmacy practice rotation in primary care.

BACKGROUND: There is increased focus and pressure to include interprofessional education during training of health professionals. This program describes an interprofessional education program between pharmacy, medical, and nurse practitioner students during a primary care clinical rotation elective. INTERPROFESSIONAL EDUCATION ACTIVITY: The interprofessional education program (IPE) during a primary care rotation was developed to be included as a learning experience throughout the rotation period. The health professions included have a role in appropriate prescribing; therefore, the content emphasis is primary care disease states where pharmacotherapy is a treatment modality. DISCUSSION: Data assessing the program was collected using the Interprofessional Education Perception Scale (IEPS) from April 2014 to April 2016. A total of 56 IEPS pre- and post-surveys were collected for analysis. A significant difference in the IEPS scale was found in the subgroups of (1) professional competence and autonomy and (2) perceived need for professional competence (p < .05). Qualitative results of the completed surveys show a trend of respectful and positive communication between students, lack of previous IPE experience prior to the intervention, and a collaborative environment where students had the opportunity to learn about each other's professions. Structured interactions between health professions student interactions during clinical rotations can be beneficial for students to learn about each other and may lead to better collaboration. The authors will use the current program as a foundation for other interprofessional activities between students.

Looking Back to Move Forward: First-Year Medical Students' Meta-Reflections on Their Narrative Portfolio Writings.

The day-to-day rigors of medical education often preclude learners from gaining a longitudinal perspective on who they are becoming. Furthermore, the current focus on competencies, coupled with concerning rates of trainee burnout and a decline in empathy, have fueled the search for pedagogic tools to foster students' reflective capacity. In response, many scholars have looked to the tradition of narrative medicine to foster "reflective spaces" wherein holistic professional identity construction can be supported. This article focuses on the rationale, content, and early analysis of the reflective space created by the narrative medicine-centered portfolio at the Columbia University Vagelos College of Physicians and Surgeons. In January 2015, the authors investigated learning outcomes derived from students' "Signature Reflections," end-of-semester meta-reflections on their previous portfolio work. The authors analyzed the Signature Reflections of 97 (of 132) first-year medical students using a constant comparative process. This iterative approach allowed researchers to identify themes within students' writings and interpret the data. The authors identified two overarching interpretive themes-recognition and grappling-and six subthemes. Recognition included comments about self-awareness and empathy. Grappling encompassed the subthemes of internal change, dichotomies, wonder and questioning, and anxiety. Based on the authors' analyses, the Signature Reflection seems to provide a structured framework that encourages students' reflective capacity and the construction of holistic professional identity. Other medical educators may adopt meta-reflection, within the reflective space of a writing portfolio, to encourage students' acquisition of a longitudinal perspective on who they are becoming and how they are constructing their professional identity.

Test your skills: Which imaging studies would you order for these neurologic complaints?

These 3 cases illustrate how to use clinical assessment tools and radiology criteria to determine the need for imaging when you suspect intracranial disorders.

Telephonic nurse case management for patients with diabetes and mental illnesses: a qualitative perspective.

OBJECTIVES: Gold Choice, a partially capitated Medicaid managed care programme for individuals with a behavioural health diagnosis, implemented a telephonic nurse case management (TNCM) programme to improve diabetes self-management. We sought to identify issues faced by patients with co-morbid behavioural health diagnoses and diabetes as documented in the telephonic nurse case manager's progress notes. We also explored the role of the TNCM in addressing members' needs. METHODS: We undertook a qualitative analysis of 853 de-identified progress notes from 539 Gold Choice members and conducted a semi-structured interview with the TNCM. RESULTS: Seven major themes emerged reflecting the nurse's perspectives on challenges faced by Gold Choice members and addressed by the TNCM: (1) Transience of the population. (2) Complex needs, involving not only medical and psychiatric conditions but also housing, transportation and survival. (3) Confusion regarding diabetes diagnosis. (4) Mistrust and suspicion. (5) Difficulties with medical care. (6) Need for diabetes self-management education/skills. (7) Marked appreciation that the TNCM would initiate contact and care about the patient. DISCUSSION: Members with co-morbid behavioural health diagnoses and diabetes constitute a complex population with extensive needs. The TNCM's role extends beyond diabetes care and entails social support as well as navigation of the healthcare and social service systems.