The therapeutic potential of bedside art observation in hematologic cancer inpatients: a randomized controlled pilot study.

PURPOSE: Prior research has suggested that art-based interventions may reduce anxiety in cancer patients and enhance dialogue in the healthcare setting. Through implementing Art at the Bedside, an art-based hospital visitation program, we sought to examine whether dedicated art observation sessions, and varying formats (with and without guided discussion), could have therapeutic effects on cancer patients' mental wellbeing. METHODS: This randomized controlled pilot study evaluated the effects of bedside art observation on anxiety in a sample of 73 hematologic cancer inpatients. We compared state anxiety, as measured by an abbreviated form of the Spielberger State-Trait Anxiety Inventory (STAI Y-6), across three groups (participants who observed an electronic selection of artwork with and without guided discussion, and a control group that did not engage in either dedicated art observation activity). RESULTS: We found that mean anxiety scores were significantly lower among those who participated in guided art observation, compared to those who did not (8.92 versus 12.1, scored on a scale of 6 to 24, p = 0.009, with a medium effect size (η2 = 12.7)). The majority of participants who engaged in art observation felt that the activity provided positive distraction (85.7%) and decreased boredom (79.6%), and many noted that it reduced feelings of anxiety (46.9%) and depression (24.5%). CONCLUSION: These findings suggest that bedside art observation, particularly with guided discussion, may be a promising complementary therapy for reducing cancer-related anxiety and improving the patient experience in the inpatient hematology/oncology setting, and would benefit from further inquiry.

Predictors of faculty narrative evaluation quality in medical school clerkships.

INTRODUCTION: Narrative approaches to assessment provide meaningful and valid representations of trainee performance. Yet, narratives are frequently perceived as vague, nonspecific and low quality. To date, there is little research examining factors associated with narrative evaluation quality, particularly in undergraduate medical education. The purpose of this study was to examine associations of faculty- and student-level characteristics with the quality of faculty member's narrative evaluations of clerkship students. METHODS: The authors reviewed faculty narrative evaluations of 50 students' clinical performance in their inpatient medicine and neurology clerkships, resulting in 165 and 87 unique evaluations in the respective clerkships. The authors evaluated narrative quality using the Narrative Evaluation Quality Instrument (NEQI). The authors used linear mixed effects modelling to predict total NEQI score. Explanatory covariates included the following: time to evaluation completion, number of weeks spent with student, faculty total weeks on service per year, total faculty years in clinical education, student gender, faculty gender, and an interaction term between student and faculty gender. RESULTS: Significantly higher narrative evaluation quality was associated with a shorter time to evaluation completion, with NEQI scores decreasing by approximately 0.3 points every 10 days following students' rotations (p = .004). Additionally, women faculty had statistically higher quality narrative evaluations with NEQI scores 1.92 points greater than men faculty (p = .012). All other covariates were not significant. CONCLUSIONS: The quality of faculty members' narrative evaluations of medical students was associated with time to evaluation completion and faculty gender but not faculty experience in clinical education, faculty weeks on service, or the amount of time spent with students. Findings advance understanding on ways to improve the quality of narrative evaluations which are imperative given assessment models that will increase the volume and reliance on narratives.

Associations of Lifetime Trauma and Chronic Stress With C-reactive Protein in Adults Ages 50 Years and Older: Examining the Moderating Role of Perceived Control.

OBJECTIVE: The aim of the study was to investigate whether high perceived control mitigates systemic inflammatory risk associated with traumatic and chronic stress exposures in older adults. METHODS: A sample of community-dwelling adults ages 50 years and older (N = 4779) was drawn from the Health and Retirement Study. Structural equation models tested interactions of lifetime trauma and chronic stress with mastery and perceived constraints predicting baseline levels and 4-year change in C-reactive protein (CRP). RESULTS: There were significant interactions of lifetime trauma (ß = -.058, p = .012) and chronic stress (ß = -.069, p = .010) with mastery as related to baseline CRP levels. Both measures were associated with higher CRP at low (ß = .102, p = .003; ß = .088, p = .015) but not high levels of mastery. In addition, chronic stress interacted with baseline mastery (ß = .056, p = .011) and change in mastery (ß = -.056, p = .016) to predict 4-year change in CRP. Chronic stress was associated with an increase in CRP at high baseline mastery (ß = .071, p = .022) and when mastery decreased during follow-up (ß = .088, p = .011). There were no main effects of stress or control variables other than an association of constraints with a larger increase in CRP (ß = .062, p = .017). Interactions were minimally attenuated (<15%) upon further adjustment for negative affect, body mass index, smoking, and physical activity. CONCLUSIONS: High mastery may protect against elevated systemic inflammation associated with substantial lifetime trauma exposure. Individuals who experience declines in mastery may be most susceptible to increases in inflammation associated with chronic stress.

Correction: Clinical reasoning education in the clerkship years: A cross-disciplinary national needs assessment.

[This corrects the article DOI: 10.1371/journal.pone.0273250.].

Minding the gap: towards a shared clinical reasoning lexicon across the pre-clerkship/clerkship transition.

Teaching and learning of clinical reasoning are core principles of medical education. However, little guidance exists for faculty leaders to navigate curricular transitions between pre-clerkship and clerkship curricular phases. This study compares how educational leaders in these two phases understand clinical reasoning instruction. Previously reported cross-sectional surveys of pre-clerkship clinical skills course directors, and clerkship leaders were compared. Comparisons focused on perceived importance of a number of core clinical reasoning concepts, barriers to clinical reasoning instruction, level of familiarity across the undergraduate medical curriculum, and inclusion of clinical reasoning instruction in each area of the curriculum. Analyses were performed using the Mann Whitney U test. Both sets of leaders rated lack of curricular time as the largest barrier to teaching clinical reasoning. Clerkship leaders also noted a lack of faculty with skills to teach clinical reasoning concepts as a significant barrier (p < 0.02), while pre-clerkship leaders were more likely to perceive that these concepts were too advanced for their students (p < 0.001). Pre-clerkship leaders reported a higher level of familiarity with the clerkship curriculum than clerkship leaders reported of the pre-clerkship curriculum (p < 0.001). As faculty transition students from the pre-clerkship to the clerkship phase, a shared understanding of what is taught and when, accompanied by successful faculty development, may aid the development of longitudinal, milestone-based clinical reasoning instruction.

Engaging students and faculty: implications of self-determination theory for teachers and leaders in academic medicine.

BACKGROUND: Much of the work of teachers and leaders at academic health centers involves engaging learners and faculty members in shared goals. Strategies to do so, however, are seldom informed by empirically-supported theories of human motivation. DISCUSSION: This article summarizes a substantial body of motivational research that yields insights and approaches of importance to academic faculty leaders. After identification of key limitations of traditional rewards-based (i.e., incentives, or 'carrots and sticks') approaches, key findings are summarized from the science of self-determination theory. These findings demonstrate the importance of fostering autonomous motivation by supporting the fundamental human needs for autonomy, competence, and relatedness. In turn, these considerations lead to specific recommendations about approaches to engaging autonomous motivation, using examples in academic health centers. SUMMARY: Since supporting autonomous motivation maximizes both functioning and well-being (i.e., people are both happier and more productive), the approaches recommended will help academic health centers recruit, retain, and foster the success of learners and faculty members. Such goals are particularly important to address the multiple challenges confronting these institutions.

Assessing a method to limit influence of standardized tests on clerkship grades.

BACKGROUND: Grading committees give excessive weight to standardized-examination scores. PURPOSE: Understanding that biases are often ingrained in grading processes, we sought to assess the influence of a structured grading policy in limiting this effect. METHODS: All 7 clerkship grading committees derived students' clinical scores while blinded to examination scores. Scores were combined to yield a final rank order, which was used to derive grade cutoffs. Logit regression was performed to assess the contribution of clinical and examination scores to final grades. Results were compared to a similar analysis where committees were not blinded to examination scores. RESULTS: In contrast to prior findings, grading committees consistently assigned greater weight to clinical-performance scores in assigning final grades when blinded to examination scores. CONCLUSIONS: Grading committees may be unaware of the extent to which they discount clinical assessments when they are at odds with the results of standardized examinations. This can be addressed with a procedure that blinds grading committees to examination scores.

Medical student attitudes toward patients in diverse care settings: the impact of a patient evaluation course.

BACKGROUND: First-year medical students typically have limited exposure to patients in diverse care settings, such as rehabilitation facilities and nursing homes. PURPOSE: It is unknown whether students bring predetermined attitudes toward these patients, or whether attitudes are influenced by early exposure. We studied this in a new course that provides opportunities for students to interact with patients of various ages and disabilities. METHODS: We conducted surveys of 1st-year medical students at the University of Rochester in the year prior to the new course and during its initial year. We used factor analysis to derive underlying dimensions of students' responses. We also investigated the impact that the course had on their perceptions. RESULTS: In both years, we found that students conceptualize patient care along 2 affective dimensions (comfort and pleasure) and 2 attitudinal dimensions (bias and pessimism), rather than by type of disability. CONCLUSIONS: This 10-week course improved their affect toward these patient groups but had little effect on their general attitudes toward the value of caring for them.

A Crocheted Model Activity for Teaching Embryonic Lateral Folding to Medical Students.

Knowledge of embryology is foundational for understanding normal anatomy and birth defects, yet, embryology is a notoriously difficult subject for medical students. Embryonic lateral folding in particular is one of the most challenging concepts in embryology. Highly effective teaching methods that promote active engagement with dynamic, three-dimensional models may be helpful for teaching this content. The aim of this study was to determine whether a hands-on modeling activity utilizing premade crocheted pieces constructed from durable, inexpensive yarn helped medical students enrolled in a pre-matriculation course to understand embryonic lateral folding. Change in knowledge was assessed using a pre-post design. Students also completed subjective evaluations regarding their satisfaction with the activity. Quiz scores in means (±SD) increased from 62.7 (±24.1) % before the activity to 77.0 (±17.1) % after the activity (P = 0.0495, two-tailed paired t test; d = 0.68). Generally, students reported that the activity was helpful and enjoyable, and the model pieces were easy to manipulate. These promising results suggest that hands-on activities with dynamic, three-dimensional models constitute an effective method for teaching embryology.

Moderate to Severe Chronic Pain in Later Life: Risk and Resilience Factors for Recovery.

Despite extensive research on the development and risk factors of chronic pain, the process of recovery from chronic pain in later life has been rarely studied. We estimated the recovery rate of moderate to severe chronic pain (chronic pain of moderate or severe severity or interfering with usual activities) among older adults and investigated predictors of recovery. Leveraging the longitudinal Health and Retirement Study 2006-2016 data (6 waves), we estimated the biennial national attrition-adjusted recovery rate of moderate to severe chronic pain among 6,132 US adults aged 65-75 at baseline. Generalized estimating equation Poisson models examined pain-related, sociodemographic, psychosocial and health-related factors in relation to recovery within any 2-year interval using longitudinal lagged design. Between 2006-2016, the prevalence of moderate to severe chronic pain increased from 28% to 33% with the incidence increasing from 14% to 18% and the recovery rate approximately 30%. Previous chronic pain duration, age, chronic diseases and a personality trait (agreeableness) were associated with a lower probability of recovery. Greater financial wealth and physical activity, better sleep quality and self-reported health were associated with a greater probability of recovery. Interventions that improve physical activity and sleep quality may be important avenues for reducing chronic pain burden among older adults. PERSPECTIVE: Our longitudinal findings suggested that recovery from moderate to severe chronic pain is common in later life and we further identified several key factors associated with this recovery process. Future research should consider the potential of interventions that improve physical activity and sleep quality to enhance recovery among older adults.

Relationship between clinical assessment and examination scores in determining clerkship grade.

CONTEXT: Grades in clinical clerkships are typically based on a combination of clinical assessments from teachers, as well as results of more reliable (but perhaps less valid) scores on standardised tests of knowledge. It is not clear how these scores are combined in practice to yield a final summative grade. METHODS: Our subjects were 83 students who rotated through five clinical clerkships during a single year. After computing univariate correlations between clinical assessment scores and standardised examination scores, we performed logistic regression analyses for each clerkship to predict the final grade from these two variables. We compared actual grade with predicted grade under various hypothetical policies for combining these two variables. Finally, we assessed whether some students would systematically benefit from these policies. RESULTS: Clerkships varied in their univariate correlations between scores on clinical assessments and scores on standardised examinations. Clerkships with the lowest correlations tended to give more weight to standardised examination scores. Grading committees adjusted a substantial minority of grades to account for factors that were not reflected in either score. There did not appear to be a systematic bias in grading committee effect across the five clerkships. CONCLUSIONS: These results suggest a number of testable hypotheses about the cognitive processes by which evaluators combine various pieces of information to yield a summative performance score.

Development of an audit method to assess the prevalence of the ACGME's general competencies in an undergraduate medical education curriculum.

BACKGROUND: Despite the use of competency-based frameworks to evaluate physicians, the role of competency-based objectives in undergraduate medical education remains uncertain. PURPOSE: By use of an audit methodology, we sought to determine how the six Accreditation Council for Graduate Medical Education (ACGME) competencies, conceptualized as educational domains, would map onto an undergraduate medical curriculum. METHODS: Standardized audit forms listing required activities were provided to course directors, who were then asked to indicate which of the domains were represented in each activity. Descriptive statistics were calculated. RESULTS: Of 1,500 activities, there was a mean of 2.13 domains per activity. Medical Knowledge was the most prevalent (44%), followed by Patient Care (20%), Interpersonal and Communication Skills (12%), Professionalism (9%), Systems-Based Practice (8%), and Practice-Based Learning and Improvement (7%). There was considerable variation by year and course. CONCLUSIONS: The domains provide a useful framework for organizing didactic components. Faculty can also consider activities in light of the domains, providing a vocabulary for instituting curricular change and innovation.

Education Research: The Narrative Evaluation Quality Instrument: Development of a tool to assess the assessor.

OBJECTIVE: Determining the quality of narrative evaluations to assess medical student neurology clerkship performance remains a challenge. This study sought to develop a tool to comprehensively and systematically assess quality of student narrative evaluations. METHODS: The Narrative Evaluation Quality Instrument (NEQI) was created to assess several components within clerkship narrative evaluations: performance domains, specificity, and usefulness to learner. In this retrospective study, 5 investigators scored 123 narrative evaluations using the NEQI. Inter-rater reliability was estimated by calculating interclass correlation coefficients (ICC) across 615 NEQI scores. RESULTS: The average overall NEQI score was 6.4 (SD 2.9), with mean component arm scores of 2.6 for performance domains (SD 0.9), 1.8 for specificity (SD 1.1), and 2.0 for usefulness (SD 1.4). Each component arm exhibited moderate reliability: performance domains ICC 0.65 (95% confidence interval [CI] 0.58-0.72), specificity ICC 0.69 (95% CI 0.61-0.77), and usefulness ICC 0.73 (95% CI 0.66-0.80). Overall NEQI score exhibited good reliability (0.81; 95% CI 0.77-0.86). CONCLUSION: The NEQI is a novel, reliable tool to comprehensively assess the quality of narrative evaluation of neurology clerks and will enhance the study of interventions seeking to improve clerkship evaluation.

Association between hand-off patients and subject exam performance in medicine clerkship students.

BACKGROUND: Teaching hospitals increasingly rely on transfers of patient care to another physician (hand-offs) to comply with duty hour restrictions. Little is known about the impact of hand-offs on medical students. OBJECTIVE: To evaluate the impact of hand-offs on the types of patients students see and the association with their subsequent Medicine Subject Exam performance. DESIGN: Observational study over 1 year. PARTICIPANTS: Third-year medical students in an Inpatient Medicine Clerkship at five hospitals with night float systems. PRIMARY OUTCOME: Medicine Subject Exam at the end of the clerkship; explanatory variables: number of fresh (without prior evaluation) and hand-off patients, diagnoses, subspecialty patients, and full evaluations performed during the clerkship, and United Stated Medical Licensing Examination (USMLE) Step I scores. MAIN RESULTS: Of the 2,288 patients followed by 89 students, 990 (43.3%) were hand-offs. In a linear regression model, the only variables significantly associated with students' Subject Exam percentile rankings were USMLE Step I scores (B = 0.26, P < 0.001) and the number of full evaluations completed on fresh patients (B =0.20, P = 0.048; model r (2) = 0.58). In other words, for each additional fresh patient evaluated, Subject Exam percentile rankings increased 0.2 points. For students in the highest quartile of Subject Exam percentile rankings, only Step I scores showed a significant association (B = 0.22, P = 0.002; r (2) = 0.5). For students in the lowest quartile, only fresh patient evaluations demonstrated a significant association (B = 0.27, P = 0.03; r (2) = 0.34). CONCLUSIONS: Hand-offs constitute a substantial portion of students' patients and may have less educational value than "fresh" patients, especially for lower performing students.

Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians.

CONTEXT: Primary care physicians report high levels of distress, which is linked to burnout, attrition, and poorer quality of care. Programs to reduce burnout before it results in impairment are rare; data on these programs are scarce. OBJECTIVE: To determine whether an intensive educational program in mindfulness, communication, and self-awareness is associated with improvement in primary care physicians' well-being, psychological distress, burnout, and capacity for relating to patients. DESIGN, SETTING, AND PARTICIPANTS: Before-and-after study of 70 primary care physicians in Rochester, New York, in a continuing medical education (CME) course in 2007-2008. The course included mindfulness meditation, self-awareness exercises, narratives about meaningful clinical experiences, appreciative interviews, didactic material, and discussion. An 8-week intensive phase (2.5 h/wk, 7-hour retreat) was followed by a 10-month maintenance phase (2.5 h/mo). MAIN OUTCOME MEASURES: Mindfulness (2 subscales), burnout (3 subscales), empathy (3 subscales), psychosocial orientation, personality (5 factors), and mood (6 subscales) measured at baseline and at 2, 12, and 15 months. RESULTS: Over the course of the program and follow-up, participants demonstrated improvements in mindfulness (raw score, 45.2 to 54.1; raw score change [Delta], 8.9; 95% confidence interval [CI], 7.0 to 10.8); burnout (emotional exhaustion, 26.8 to 20.0; Delta = -6.8; 95% CI, -4.8 to -8.8; depersonalization, 8.4 to 5.9; Delta = -2.5; 95% CI, -1.4 to -3.6; and personal accomplishment, 40.2 to 42.6; Delta = 2.4; 95% CI, 1.2 to 3.6); empathy (116.6 to 121.2; Delta = 4.6; 95% CI, 2.2 to 7.0); physician belief scale (76.7 to 72.6; Delta = -4.1; 95% CI, -1.8 to -6.4); total mood disturbance (33.2 to 16.1; Delta = -17.1; 95% CI, -11 to -23.2), and personality (conscientiousness, 6.5 to 6.8; Delta = 0.3; 95% CI, 0.1 to 5 and emotional stability, 6.1 to 6.6; Delta = 0.5; 95% CI, 0.3 to 0.7). Improvements in mindfulness were correlated with improvements in total mood disturbance (r = -0.39, P < .001), perspective taking subscale of physician empathy (r = 0.31, P < .001), burnout (emotional exhaustion and personal accomplishment subscales, r = -0.32 and 0.33, respectively; P < .001), and personality factors (conscientiousness and emotional stability, r = 0.29 and 0.25, respectively; P < .001). CONCLUSIONS: Participation in a mindful communication program was associated with short-term and sustained improvements in well-being and attitudes associated with patient-centered care. Because before-and-after designs limit inferences about intervention effects, these findings warrant randomized trials involving a variety of practicing physicians.

Understanding of Brain Death Among Health-Care Professionals at a Transplant Center.

INTRODUCTION: There is considerable variation in brain death understanding and policies between medical institutions, however, studies have not yet compared different health-care professionals working in the same hospital. RESEARCH QUESTIONS: The overall aim of this study was to evaluate understanding of brain death among health-care professionals within intensive care units (ICUs) at a single institution. DESIGN: Study participants included 217 attending physicians, residents, nurses, medical students, and other ICU team members in 6 ICUs. Participants completed a 21-question survey pertaining to knowledge of brain death and related institutional policies as well as opinions about brain death. RESULTS: We found a wide range of brain death understanding among health-care professionals in ICUs. Attending physicians have the greatest understanding (94.7%), followed by nurses (72.4%). In contrast, approximately half of the students and residents do not have a basic understanding of brain death. Brain death understanding was correlated to health-care role, years of experience, and whether the participant had formal training in brain death. Although most participants had been involved in cases of brain death, a much smaller number had received formal training on death by neurological criteria. DISCUSSION: The present study observed a paucity of clinical training in brain death among health-care professionals in the study ICUs. There is an opportunity for improved clinical education on brain death that could improve communication with families about brain death and potentially increase the number of organs transplanted.

Kinase array design, back to front: biaryl amides.

New kinase inhibitors can be found by synthesis of targeted arrays of compounds designed using system-based knowledge as well as through screening focused or diverse compounds. Most array strategies aim to add functionality to a fragment that binds in the purine subpocket of the ATP-site. Here, an alternative pharmacophore-guided array approach is described which set out to discover novel purine subpocket-binding groups. Results are shown for p38alpha and cFMS kinase, for which multiple distinct series with nanomolar potency were discovered. Some of the compounds showed potency in cell-based assays and good pharmacokinetic properties.

Biphenyl amide p38 kinase inhibitors 1: Discovery and binding mode.

The biphenyl amides (BPAs) are a novel series of p38 MAP kinase inhibitors. The discovery of the series through structure-based focused screening is described, and the binding mode of the compounds is explained with reference to X-ray crystal structures.

Further challenges in measuring communication skills: accounting for actor effects in standardised patient assessments.

CONTEXT: Subjective rating scales for communication skills may yield more personally meaningful responses than more standardised rating schemes. It is unclear, however, whether such evaluations may be overly biased by respondents' rating styles, which may lead to unreliable measurement of examinees' communication skills. METHODS: Our study involved 212 students from the classes of 2005 and 2006 at the University of Rochester School of Medicine and Dentistry. All students were rated by actors depicting standardised patients (SPs) on the same seven cases using the 19-item Rochester Communication Rating Scale (RCRS). Different students were assigned to different actors playing the same SP. We assessed the extent to which actors' personal rating styles influenced the scores they assigned to students. Main outcome measures were: between-actor variability in responses; the degree to which actors' response styles contribute to overall scores, and improvements in reliability achieved by standardising actors' ratings. RESULTS: There were statistically significant differences between actors in their mean assigned scores. Scores aggregated over 18 separate SP cases have an expected generalisability coefficient of 0.79. If raw RCRS scores are used, a total of 27 replications of the RCRS are required to achieve a Cronbach's alpha of 0.8; standardisation reduces this number to 18. CONCLUSIONS: Although actors are variable in their use of a standardised subjective scale of communication, such differences contribute to an acceptably small proportion of the total variance if scores are combined across a large number of cases. Reliability can be markedly improved by standardising scores across raters.