Training internal medicine residents to manage chronic pain and prescription opioid misuse.

BACKGROUND: Residents feel unprepared to care for patients with chronic pain on long-term opioids who exhibit signs of prescription opioid misuse. OBJECTIVE: Describe an educational intervention for internal medicine residents to improve confidence, practices, attitudes, and self-reported knowledge of resources for chronic pain and opioid misuse. METHODS: The intervention included 2 sessions. Session 1 (3 hours): a lecture on chronic pain, prescription opioid misuse, and opioid use disorders and communication skills practice. The residents were asked to use one of these skills during the following week. Session 2 (1.5 hours): debriefing of patient encounters and overview of: prescription opioid monitoring strategies, discontinuation of prescription opioids when appropriate, and treatment for opioid use disorders. Pre- and post-assessments evaluated change in residents' safe opioid prescribing confidence, self-reported practices, attitudes, and self-reported knowledge of available patient resources. RESULTS: Ninety-one residents completed the intervention, with 44 and 43 completing the pre- and post-assessments, respectively. Utilizing a 4-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = agree 4 = strongly agree), residents reported improved confidence in skills managing patients with chronic pain (3.0 vs. 2.4, P < .0001), skills identifying which patients with chronic pain have developed an opioid use disorder (3.0 vs. 2.4, P < .0001), and understanding how to monitor for benefit versus harm (3.0 vs. 2.5, P < .0005). They also noted improved ability identifying resources for patients with chronic pain and opioid use disorders. There was a nonsignificant improvement in resident reported comfort talking to patients about the need to discontinue opioids. Residents did not report an increase in use of safe opioid prescribing monitoring strategies or feelings of support in their prescribing decisions by preceptors. CONCLUSIONS: A brief training can improve residents' self-reported knowledge and confidence in managing patients with chronic pain and safe opioid prescribing practices. How this change in confidence affects patient care requires further study.

Phase I/IIa study evaluating the safety, efficacy, pharmacokinetics, and pharmacodynamics of lucitanib in advanced solid tumors.

BACKGROUND: Lucitanib is a potent, oral inhibitor fibroblast growth factor receptor types 1 and 2 (FGFR), vascular endothelial growth factor receptor types 1, 2, and 3 (VEGFR), platelet-derived growth factor receptor types α and ß (PGFRα/ß), which are essential kinases for tumor growth, survival, migration, and angiogenesis. Several tumor types, including breast carcinoma, demonstrate amplification of fibroblast growth factor (FGF)-related genes. There are no approved drugs for molecularly defined FGF-aberrant (FGFR1- or FGF3/4/19-amplified) tumors. METHODS: This open-label phase I/IIa study involved a dose-escalation phase to determine maximum tolerated dose (MTD), recommended dose (RD), and pharmacokinetics of lucitanib in patients with advanced solid tumors, followed by a dose-expansion phase to obtain preliminary evidence of efficacy in patients who could potentially benefit from treatment (i.e. with tumors harboring FGF-aberrant pathway or considered angiogenesis-sensitive). RESULTS: Doses from 5 to 30 mg were evaluated with dose-limiting toxic effects dominated by vascular endothelial growth factor (VEGF) inhibition-related toxic effects at the 30 mg dose level (one case of grade 4 depressed level of consciousness and two cases of grade 3 thrombotic microangiopathy). The most common adverse events (all grades, all cohorts) were hypertension (91%), asthenia (42%), and proteinuria (57%). Exposure increased with dose and t½ was 31-40 h, suitable for once daily administration. Seventy-six patients were included. All but one had stage IV; 42% had >3 lines of previous chemotherapy. Sixty-four patients were assessable for response; 58 had measurable disease. Clinical activity was observed at all doses tested with durable Response Evaluation Criteria In Solid Tumors (RECIST) partial responses in a variety of tumor types. In the angiogenesis-sensitive group, objective RECIST response rate (complete response + partial response) was 26% (7 of 27) and progression-free survival (PFS) was 25 weeks. In assessable FGF-aberrant breast cancer patients, 50% (6 of 12) achieved RECIST partial response with a median PFS of 40.4 weeks for all treated patients. CONCLUSION: Lucitanib has promising efficacy and a manageable side-effect profile. The spectrum of activity observed demonstrates clinical benefit in both FGF-aberrant and angiogenesis-sensitive populations. A comprehensive phase II program is planned.

Physicians caring for physicians: the perspective of the primary care physician.

OBJECTIVES: How physicians provide longitudinal primary care to physician-patients (ie, physicians as patients) has not been well studied. The potential challenges of providing care to physician-patients include maintaining professional boundaries and adhering to practice guidelines. The objective was to explore the differences in identifying how physicians perceive caring for physicians-patients in the longitudinal setting versus caring for other patients in the general population. METHODS: The study consisted of focus groups, followed by quantitative survey. Participants were primary care physicians (internal medicine and family medicine) at an academic multispecialty group practice. Thematic analysis of focus groups informed the development of the survey. RESULTS: In focus groups, participants identified several benefits, challenges, and differences in caring for physician-patients versus the general population. When these findings were explored further by quantitative survey, participants noted differences in care regarding chart documentation protocols, communication of results, and accommodation of schedules. They agreed that there were benefits to providing care to physician-patients, such as believing their work was valued and discussing complex issues with greater ease. There also were challenges, including anxiety or self-doubt. Participants also agreed on the following strategies when caring for this population: make recommendations based on evidence-based medicine, follow routine assessment and examination protocols, follow routine scheduling and communication protocols, recommend the same follow-up visit schedule, and define boundaries of the relationship. CONCLUSIONS: Physicians perceive caring for physician-patients as different and rewarding, although some find that it provokes anxiety. Many are willing to make concessions regarding scheduling and testing. With increasing experience, the anxiety decreased as did the need to follow protocols and maintain boundaries. Further investigation is needed to determine the impact of physician experience and training on the quality of care for physician-patients.

Patient perceptions of having 1st- and 2nd-year medical students involved in their care.

BACKGROUND: Medical student education has shifted to earlier clinical experiences and increased use of ambulatory settings. Little is known about patient perceptions of having 1st- and 2nd-year medical students involved in their care. PURPOSES: The purpose of this article is to study patient perceptions of having 1st- and 2nd-year medical students involved in their care in an ambulatory setting. METHODS: In 2011 we surveyed 314 patients seen in 2 primary care clinics who saw 1st- or 2nd-year medical students. The survey included questions regarding patient visit satisfaction and perception of overall quality of the visit, adequacy of visit time, benefit of having a student involved in their care, and willingness to see a student in clinic again. Comparisons were made for patients who saw a student and a preceptor (n = 201) and patients who saw only the preceptor (n = 113). RESULTS: Overall visit satisfaction was very high for patients who saw students (83% very satisfied) and patients who saw only the preceptor (91% very satisfied). More than 95% of patients were satisfied with the visit time, and all patients rated the overall quality of their visit as good or excellent. Eighty-five percent of patients would want to see a student again or had no preference. Forty-three percent of patients felt the presence of a student added value to their visit. White patients were more likely than non-White patients to be very satisfied with their visit and rated the overall quality of the visit as excellent. There were no differences based on student gender or year of training. CONCLUSIONS: Our results suggest that 1st- and 2nd-year students can be successfully integrated into clinical settings while maintaining patient satisfaction and perceived value of the care they receive.

Diversity, equity, and inclusion: one model to move from commitment to action in medical education.

The summer of 2020 riveted the attention of our nation with a sense of urgency to address structural racism. Cities declared racism a public health crisis, and organizations called for increased awareness of persistent historic racial inequities and advocacy for change. In medical education, students and institutional leaders felt compelled to transition from passive advocacy to energetic action in order to build a culture of anti-racism. In our institution, we applied J Mierke and V. Williamson's 6-step framework to achieve organizational culture change which is as follows: 1. Identify the catalyst for change; 2. Strategically plan for successful change; 3. Engage and empower organizational members; 4. Cultivate leaders at all levels; 5. Foster innovation, creativity, and risk-taking; 6. Monitor progress, measure success, and celebrate (even the small changes) along the way. In addition, we noted two key considerations for the success of the process: A. Transparency in communication, and B. Flexibility and adjustment to emerging situations. We share our approach using this framework which we believe is generalizable to other organizations. We draw from literature on organizational psychology and lastly call for the continuation and sustainability of the work that will continue to build a diverse, equitable, inclusive, antiracist and vibrant education community.

The impact of COVID-19 on professional identity.

BACKGROUND: The COVID-19 pandemic has had a profound impact on medical care and medical student education as clinical rotations were halted and students' clinical activities were drastically curtailed. Learning experiences in medical school are known to promote identity formation through teamwork, reflection, and values-based community discussion. This study explored the impact of the COVID-19 pandemic on medical students' professional identity formation (PIF). METHODS: Students in all cohorts of medical education were invited by email in May 2020 to submit a written reflection about their learning experiences and impact of the pandemic on their PIF. We used iterative individual and team reviews, known as the "immersion/crystallisation" method, to code and analyse the data. FINDINGS: Twenty-six students (20%) submitted reflections in which they discussed "changing conceptions of the role and image of a physician," "views about medical education," and the "role of students in a pandemic." Students viewed physicians as altruistic, effective communicators, and pledged to be like them in the future. Their perceptions of virtual learning were mixed, along with considerations of lost interactions with patients, and wanting to be more useful as professionals-in-training. DISCUSSION: COVID-19 has impacted students' views of themselves and reshaped their ideas, both negatively and positively, about the profession they are entering and their role(s) in it. CONCLUSION: Exploring PIF and the impact of disruptions has allowed us to address the issues raised regarding clinical learning now and into the future. Reflection enhances PIF and unexpected events, such as COVID-19, offer opportunities for reflection and development.

Climate Change and Medical Education: An Integrative Model.

Medical schools face a challenge when trying to include new topics, such as climate change and health (CCH), in their curricula because of competing demands from more traditional biomedical content. At the same time, an understanding of CCH topics is crucial for physicians as they have clear implications for clinical practice and health care delivery. Although some medical schools have begun to incorporate CCH into curricula, the inclusion usually lacks a comprehensive framework for content and implementation. The authors propose a model for integrating CCH into medical school curricula using a practical, multistakeholder approach designed to mitigate competition for time with existing content by weaving meaningful CCH examples into current curricular activities. After the authors identified stakeholders to include in their curricular development working group, this working group determined the goals and desired outcomes of the curriculum; aligned those outcomes with the school's framework of educational objectives, competencies, and milestones; and strove to integrate CCH goals into as many existing curricular settings as possible. This article includes an illustration of the proposed model for one of the curricular goals (understanding the impacts of climate change on communities), with examples from the CCH curriculum integration that began in the fall of 2020 at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. The authors have found that this approach does minimize competition for time with existing content and allows mapping of content to existing curricular competencies and milestones, while encouraging a broad understanding of CCH in the context of individual patients, populations, and communities. This model for curricular integration can be applied to other topics such as social determinants of health, health equity, disability studies, and structural racism.

In Search of Medical Professionalism Research: Preliminary Results from a Review of Widely Read Medical Journals.

INTRODUCTION: Professionalism is a core concept in medicine. The extent to which knowledge about professionalism is anchored in empirical research is unknown. Understanding the current state of research is necessary to identify significant gaps and create a road map for future professionalism efforts. The authors conducted an exploratory literature review to characterize professionalism research published in widely read medical journals, identify knowledge gaps, and describe the sources of funding for the identified studies. METHODS: The authors focused on Medline's Abridged Index Medicus and 4 core Medline education-oriented journal and developed a search filter using text words found in the article title or abstract addressing professionalism. Articles were further filtered to include those indicating a research focus. RESULTS: The search strategy resulted in 461 professionalism research articles for analysis. Articles were divided into themes of education (n = 212, 45.9%), performance (n = 83, 18%), measurement development (n = 13, 2.8%), remediation (n = 53, 11.5%), and well-being (n = 100, 21.6%). There were 36 studies from 1980 to 2002 (Era 1: before publication of Accreditation Council for Graduate Medical Education competencies) and 425 from 2003 to 17 (Era 2: after Accreditation Council for Graduate Medical Education publication of competencies). Professionalism education was the most common topic area, and most studies were from single institutions with results based on convenience samples. Most studies received no funding or were funded by the authors' own institution. DISCUSSION: Little empirical research is available on professionalism in widely read medical journals. There has been limited external research funding available to study this topic. CONCLUSION: More investment in high quality professionalism research is justified and should be encouraged.

Glutamate spillover mediates excitatory transmission in the rat olfactory bulb.

In the CNS, glutamate typically mediates excitatory transmission via local actions at synaptic contacts. In the olfactory bulb, mitral cell dendrites release glutamate at synapses formed only onto the dendrites of inhibitory granule cells. Here, I show excitatory transmission mediated solely by transmitter spillover between mitral cells in olfactory bulb slices. Dendritic glutamate release from individual mitral cells causes self-excitation via local activation of N-methyl-D-aspartate (NMDA) receptors. Paired recordings reveal that glutamate release from one cell generates NMDA receptor-mediated responses in neighboring mitral cells that are enhanced by blockade of glutamate uptake. Furthermore, spillover generates spontaneous NMDA receptor-mediated population responses. This simultaneous activation of neighboring mitral cells by a diffuse action of glutamate provides a mechanism for synchronizing olfactory principal cells.

Channels underlying the slow afterhyperpolarization in hippocampal pyramidal neurons: neurotransmitters modulate the open probability.

The slow afterhyperpolarization in hippocampal pyramidal neurons is mediated by a calcium-activated potassium current (IAHP) and is a target for variety of different neurotransmitters. The characteristics of the channels underlying IAHP and how they are modulated by neurotransmitters are, however, unknown. In this study, we have examined the properties of the channels underlying IAHP using fluctuation analysis of the macroscopic current. Our results indicate that this channel has a unitary conductance of 2-5 pS and a mean open time of about 2 ms. When the peak amplitude of IAHP was maximal, these channels have an open probability of 0.4. Noradrenaline and carbachol reduced IAHP amplitude by lowering open channel probability. These result indicate that a novel calcium-activated potassium channel underlies IAHP. This channel is modulated in a similar fashion by two different transmitter systems that utilize distinct protein kinases.

Counting quanta: direct measurements of transmitter release at a central synapse.

Contradictory hypotheses regarding the nature of synaptic transmission in the CNS have arisen from indirect methods of quantal analysis. In this study, we directly count the quanta released following nerve stimulation to examine synaptic transmission at a fast glutamatergic synapse in the mammalian auditory brainstem. Our results demonstrate the relationship between spontaneous and nerve-evoked synaptic events, indicate that asynchronous transmitter release governs the time course of evoked transmission, and show that the stochastic quantal release process, as originally proposed at the neuromuscular junction, is highly conserved at this central synapse.

GABA(B)-mediated presynaptic inhibition of excitatory transmission and synaptic vesicle dynamics in cultured hippocampal neurons.

Local recycling of synaptic vesicle membrane at nerve terminals is necessary to maintain a readily releasable pool of transmitter. To what extent are the dynamics of vesicle recycling subject to modulation? We examined the influence of presynaptic GABA(B) receptors on vesicle dynamics at single synapses using optical imaging of FM1-43 in cultured rat hippocampal neurons. The kinetics of FM1-43 destaining indicate that synapses from a single neuron have a unimodal distribution of release probabilities, and GABA(B)-mediated inhibition occurs uniformly at all sites. Electrical and optical recordings from single cells show that the inhibition of excitatory transmission is entirely accounted for by a rapidly reversible reduction of exocytosis. In contrast, GABA(B) receptors do not alter the rate or extent of endocytosis.

Olfactory reciprocal synapses: dendritic signaling in the CNS.

Synaptic transmission between dendrites in the olfactory bulb is thought to play a major role in the processing of olfactory information. Glutamate released from mitral cell dendrites excites the dendrites of granule cells, which in turn mediate GABAergic dendrodendritic inhibition back onto mitral dendrites. We examined the mechanisms governing reciprocal dendritic transmission in rat olfactory bulb slices. We find that NMDA receptors play a critical role in this dendrodendritic inhibition. As with axonic synapses, the dendritic release of fast neurotransmitters relies on N- and P/Q-type calcium channels. The magnitude of dendrodendritic transmission is directly proportional to dendritic calcium influx. Furthermore, recordings from pairs of mitral cells show that dendrodendritic synapses can mediate lateral inhibition independently of axonal action potentials.

Glutamate-mediated extrasynaptic inhibition: direct coupling of NMDA receptors to Ca(2+)-activated K+ channels.

NMDA receptors (NMDARs) typically contribute to excitatory synaptic transmission in the CNS. While Ca(2+) influx through NMDARs plays a critical role in synaptic plasticity, direct actions of NMDAR-mediated Ca(2+) influx on neuronal excitability have not been well established. Here we show that Ca(2+) influx through NMDARs is directly coupled to activation of BK-type Ca(2+)-activated K+ channels in outside-out membrane patches from rat olfactory bulb granule cells. Repetitive stimulation of glutamatergic synapses in olfactory bulb slices evokes a slow inhibitory postsynaptic current (IPSC) in granule cells that requires both NMDARs and BK channels. The slow IPSC is enhanced by glutamate uptake blockers, suggesting that extrasynaptic NMDARs underlie the response. These findings reveal a novel inhibitory action of extrasynaptic NMDARs in the brain.

Local and diffuse synaptic actions of GABA in the hippocampus.

In the CNS, gamma-aminobutyric acid (GABA) acts as an inhibitory transmitter via ligand-gated GABAA receptor channels and G protein-coupled GABAB receptors. Both of these receptor types mediate inhibitory postsynaptic transmission in the hippocampus. In addition to these direct postsynaptic actions, GABAB receptor agonists inhibit excitatory transmission through presynaptic receptors on excitatory afferent terminals. However, a physiological role for the GABAB receptors on excitatory nerve endings has not been established. In this study, we have found a brief, heterosynaptic depression of excitatory synaptic transmission in the CA1 region of the hippocampal slice following short-lasting repetitive stimulation and determined that this inhibition is mediated by presynaptic GABAB receptors. The inhibition of GABA uptake greatly enhanced both the presynaptic action of GABA and the slow GABAB-mediated inhibitory postsynaptic current. Transmitter uptake was also found to regulate the "spill-over" of GABA at conventional GABAA synapses. These results suggest that uptake mechanisms restrict the spatial range of both point-to-point synaptic transmission mediated by GABA and its action at a distance.

Evaluation of DualMesh for repair of large hiatus hernia in a porcine model.

BACKGROUND: Prosthetic fascial grafts are frequently used for augmentation of cruroplasty in large hiatus hernia repair to decrease the chances of recurrence. Potential complications such as intraluminal erosion may be related to the constant movement of mesh and diaphragm over the outer surface of the esophagus. This study aimed to evaluate DualMesh for repair of large hiatal defects in a porcine model. METHODS: In this study, 18 Landrace x large white x Duroc crossbred pigs underwent either primary hiatal repair or tension-free prosthetic repair using DualMesh (80 x 50 mm or 80 x 100 mm). The animals were killed at 3 or 28 weeks for macroscopic and histologic evaluation of the hiatal region and gastroesophageal junction. RESULTS: All grafts had become encapsulated at 28 weeks, and the majority had filmy adhesions only to the visceral aspect. In all models, the esophagus moved freely over the cut edge of the prosthesis. No signs of intraluminal erosion were documented. At histologic examination, significant ingrowth was noted on the porous side of the mesh, whereas no defined mesothelial layer was identified on the capsule of the nonporous side. CONCLUSION: In this animal model of large hiatus hernia repair, DualMesh showed optimal characteristics in terms of host tissue incorporation on the porous side and absence of adhesions on the visceral side of the prosthesis. The absence of adhesions and intraluminal erosion in this study may provide reassurance to surgeons using mesh at the hiatus.

Silent Witnesses: Faculty Reluctance to Report Medical Students' Professionalism Lapses.

PURPOSE: Assessing students' professionalism is a critical component of medical education. Nonetheless, faculty reluctance to report professionalism lapses remains a significant barrier to the effective identification, management, and remediation of such lapses. The authors gathered information from faculty who supervise medical students to better understand their perceived barriers to reporting. METHOD: In 2015-2016, data were collected using a group concept mapping methodology, which is an innovative, asynchronous, structured mixed-methods approach using qualitative and quantitative measures to identify themes characterizing faculty reluctance to report professionalism lapses. Participants from four U.S. and Canadian medical schools brainstormed, sorted, and rated statements about perceived barriers to reporting. Multidimensional scaling and hierarchical cluster analyses were used to analyze these data. RESULTS: Of 431 physicians invited, 184 con-tributed to the brainstorming task (42.7%), 48 completed the sorting task (11.1%), and 83 completed the rating task (19.3%). Participants identified six barriers or themes to reporting lapses. The themes "uncertainty about the process," "ambiguity about the 'facts,'" "effects on the learner," and "time constraints" were rated highest as perceived barriers. Demographic subgroup analysis by gender, years of experience supervising medical students, years since graduation, and practice discipline revealed no significant differences (P > .05). CONCLUSIONS: The decision to report medical students' professionalism lapses is more complex and nuanced than a binary choice to report or not. Faculty face challenges at the systems level and individual level. The themes identified in this study can be used for faculty development and to improve processes for reporting students' professionalism lapses.

Impact of a brief faculty training to improve patient-centered communication while using electronic health records.

OBJECTIVE: Despite rapid EHR adoption, few faculty receive training in how to implement patient-centered communication skills while using computers in exam rooms. We piloted a patient-centered EHR use training to address this issue. METHODS: Faculty received four hours of training at Cleveland Clinic and a condensed 90-minute version at the University of Chicago. Both included a lecture and a Group-Objective Structured Clinical Exam (GOSCE) experience. Direct observations of 10 faculty in their clinical practices were performed pre- and post-workshop. RESULTS: Thirty participants (94%) completed a post-workshop evaluation assessing knowledge, attitude, and skills. Faculty reported that training was important, relevant, and should be required for all providers; no differences were found between longer versus shorter training. Participants in the longer training reported higher GOSCE efficacy, however shorter workshop participants agreed more with the statement that they had gained new knowledge. Faculty improved their patient-centered EHR use skills in clinical practice on post- versus pre-workshop ratings using a validated direct-observation rating tool. CONCLUSION: A brief lecture and GOSCE can be effective in training busy faculty on patient-centered EHR use skills. PRACTICE IMPLICATIONS: Faculty training on patient-centered EHR skills can enhance patient-doctor communication and promotes positive role modeling of these skills to learners.