Carol Landau

Stress in social and family relationships during the medical residency

A study of stress during residency training involved data analysis of questionnaires completed by 108 residents and fellows in internal medicine. Over 40 percent of the respondents experienced important problems with their spouse or partner. Of these, 72 percent believed that these problems were due to the residency, and 61 percent reported that their spouse or partner agreed with this assessment. Only 21 percent of the residents with relationship problems felt that their hospital work was being affected negatively. A multiple regression analysis showed that 10 variables accounted for 50 percent of the variance in predicting relationship stress. The results suggest that scheduling and structural changes in residencies are necessary in order to reduce stress among residents. Perhaps equally important is the finding that stress can be buffered by family relationships and social contact. The authors conclude that social support systems need to be fostered during the residency.

Caring for Vulnerable Populations: Curricula in U.S. Internal Medicine Residencies

ABSTRACT The Accreditation Council for Graduate Medical Education (ACGME) encourages internal medicine training programs to include specific curricula devoted to health care issues of vulnerable populations. Our aim was to determine the prevalence of curricula involving selected vulnerable populations among U.S. Internal Medicine residencies. We conducted a survey of Program Directors of all US Internal Medicine Residencies assessing whether the program had a curriculum for six vulnerable populations (racial and ethnic minorities, non-English speaking patients, lesbians, gay men, victims of domestic violence and patients with substance abuse problems). Most residencies address substance abuse and victims of domestic violence, while there remains a lack of dedicated teaching on other vulnerable populations, including lesbians, gay men, racial and ethnic minorities and non-English speaking patients.

Psychiatric diagnoses in problem patients.

Abstract Fifty-two problem patients referred primarily by internal medicine residents were seen by a psychosocial team. Forty-nine proved to meet DSM-III criteria for psychiatric diagnoses, in large part (33 patients) for psychogenic pain disorder, conversion disorder, or major depression. Twenty-seven of the first 32 patients were reinterviewed an average of six months after evaluation. Thirteen had improved, often after psychotherapy, ten reported no change, and four had worsened. A shorter duration of symptoms and higher socioeconomic status were associated with a better prognosis.

Assessment and treatment of depression during the menopause: A preliminary report

&NA; With the high prevalence of depressive symptoms in women, the assessment and treatment of depression in menopause is of critical importance. A collaborative model of assessment of depression during the menopause, based on recent literature, is proposed, with appropriate treatment recommendations. Collaboration between primary care physicians and mental health professionals is suggested, as is attention to doetor‐patient communication and patient preferences.

Enhancing medical professionalism through interactive seminars.

professionalism. Brazilian national curriculum guidelines (NCG) highlight the desired professional profile of a humanist, critical and reflective doctor with the capacity to act at different levels of health care. Accordingly, two public medical schools in the state of Rio Grande do Norte in northeastern Brazil have used an innovative educational model for developing ethical humanist skills in undergraduate medical students using the arts. This active method is not focused on the acquisition of technical and scientific knowledge, but on goals of comprehensiveness and humanisation in the development of medical practitioners. What was tried? Undergraduate medical students in Years 1 and 2 participated in a workshop entitled ‘Imitating Art’ in order to develop appreciation of artworks by renowned painters and to identify relationships with their current educational experience and future professional practice. The masterpieces analysed included, among others, Mona Lisa (da Vinci), The Scream (Munch) and The Anatomy Lesson of Dr Nicolaes Tulp (Rembrandt). Students were encouraged to deconstruct the paintings and rebuild them, thereby acting as protagonists in an artistic context by reproducing scenes from medical practice. In this process, details such as adjusting light, colours and expressions were addressed by the students. After rereading the staging of the art masterpiece, photographic records were made and students were stimulated to reflect on the entire process. The workshop was evaluated using an online survey with the aim of highlighting perceptions on the development of the following competencies contained in the NCG: health care; decision making; communication; leadership; administration and management; continuing education; ethics; professionalism, and teamwork. What lessons were learned? Students welcomed the Imitating Art workshop, reporting that it expanded their view of ethical humanist attitudes. Two thirds of the students responded that the workshop favoured the development of the majority of NCG competencies. Additionally, 90% specifically pointed to perceptions on the development of teamwork, leadership, decision making, communication and professionalism. Student-generated reproductions were classified by faculty members as high-quality pictures and with high potential to promote critical reflection. Thus, this student-centred educational intervention resulted in a practical and creative work environment that supported the development of important components involved in the comprehensive formation of doctors and other health professionals. Because most students and educators continue to value the acquiring of technical and scientific knowledge above other learning, the adoption of this innovative learning activity, in conjunction with the art, seems to represent a promising strategy for encouraging them to meet current educational requirements.

Evaluation strategies selected by residents: The roles of self‐assessment, training level, and sex

Thirty internal medicine residents, 10 from each of 3 years, participated in standardized patient interviews. They selected from 17 strategies the way they would like to receive evaluation/feedback about their performances. Eighty percent selected as their primary choice a highly diagnostic strategy—a trend more likely in women. Women also were more likely to select multiple strategies using themselves as evaluators. There was no association of choice with year, initial self‐rating, or desire for ranking versus objective score rating performance. The results support the idea that residents, regardless of level of confidence in their abilities, seek informative feedback even when it could be avoided.

Dietary supplements: an important component of alternative medicine curricula.

To the Editor:— We commend the initiative by Milan and colleagues on teaching residents about acupuncture, chiropractic, massage therapy, and homeopathy. 1 The popularity and respectability of complementary/alternative medicine (CAM) in the United States have grown considerably over the past few years. This trend has already been recognized by the National Institutes of Health, and Wetzel et al. recently reported in JAMA that up to 64% of American medical schools offer courses or selected topics on the subject. 2 However, as physicians working in a large geriatric practice, we care for a segment of the population with unique patterns of CAM utilization. In our experience, elderly patients are much more likely to use alternative supplements like vitamins, herbs, and other natural products than to use alternative systems like acupuncture or chiropractic. Given the increasing geriatric population, we believe that a CAM curriculum should involve a component on such supplements. The quality and quantity of scientific evidence supporting the use of some of these supplements have increased steadily over recent years. For example, the use of St. John’s wort for the treatment of depression and related disorders is widespread in certain European countries and has been extensively researched. 3 The use of garlic in the management of hypercholesterolemia and mild hypertension is being studied both in the United States and abroad, albeit with mixed results. 4 Ginkgo has been investigated as a therapeutic approach in patients with Alzheimer’s disease 5 and peripheral vascular disease. Although none of these supplements has obtained FDA approval as yet, they are frequently used by patients in our geriatric practice. Part of our role as health care providers is to be aware of the potential efficacy and complications of compounds used by our patients and to be able to provide appropriate counseling. This awareness and training should begin in medical school.— Jose Ness, MD, Cynthia Pan, MD, Department of Geriatrics, Mount Sinai Hospital, New York City, N.Y.