Denise M. Connor

Testosterone decreases the potential for song plasticity in adult male zebra finches.

Zebra finches are age-limited learners; males crystallize their songs at 90 days and do not subsequently alter those songs. However, a variety of interventions, including deafening and syringeal denervation, result in long-term changes to the crystallized song. These changes can be prevented by lesioning nucleus LMAN. As different social contexts for song production result in differential activation of LMAN, we asked whether the social context experienced by adult males would affect their ability to alter their songs in response to syringeal denervation. Males able to see and direct their songs to females made fewer changes to their songs than did males that could hear but not see females, but this trend was not significant. The volume of a males HVc, a forebrain song control nucleus, also failed to predict the degree to which a male would change his song. However, testis mass was significantly correlated with the number of changes made to the song, indicating that variations in testosterone modulate adult song plasticity. We directly tested the effect of circulating testosterone on adult song plasticity by implanting adult males with either testosterone or flutamide, a testosterone receptor blocker, and tracking song changes triggered by ts nerve injury. As predicted, males implanted with testosterone changed their songs less than did males that received flutamide implants. These results suggest that the high testosterone concentrations associated with sexual maturity and song crystallization in zebra finches continue to act in adult males to reduce the potential for vocal plasticity.

Kappa opioid receptors in the rostral ventromedial medulla of male and female rats

Kappa opioid receptor (KOR) ligands alter nociceptive responses when applied to the rostral ventromedial medulla (RVM). However, the effects of kappa opioid receptor ligands are distinct in males and females. The present study examined the distribution of kappa opioid receptor immunoreactivity in the RVM of male and female rats. KOR immunoreactivity was found at pre‐ and postsynaptic sites within the RVM of both sexes. The most common KOR‐immunoreactive (KOR‐ir) neuronal structures were unmyelinated axons, followed by axon terminals, dendrites, and somata. Different proportions of KOR‐ir axon terminals and dendrites were found in females at different estrous stages. Specifically, dendrites containing KOR immunoreactivity were less abundant in proestrus females compared with estrus females and showed a trend toward being less abundant in males, suggesting that KOR ligands applied to the RVM may be less potent in proestrus females. These findings suggest that the distribution of KORs in the RVM may be influenced by reproductive hormone levels. We also found KOR immunoreactivity in many spinally projecting neurons within the RVM of female rats. These findings are consistent with the hypothesis that KOR ligands influence nociceptive behaviors by altering the activity of specific populations of neurons within the RVM. The abundance of KOR in axons and axon terminals in RVM indicates a substantial role for presynaptic effects of KOR ligands through pathways that have not been clearly delineated. Altering the balance between pre‐ and postsynaptic receptive sites may underlie differences in the effects of KOR agonists on nociceptive responses in males and females. J. Comp. Neurol. 500:465–476, 2007.

Impact of Automatic Orders to Discontinue Vancomycin Therapy on Vancomycin Use in an Antimicrobial Stewardship Program

We examined the possible unintended consequences of a 72-hour automatic order to discontinue vancomycin therapy in an antimicrobial stewardship program (ASP). Of 120 patients, 11 had vancomycin therapy discontinued at 72 hours without a call to the ASP, and 7 experienced a treatment interruption of 6-36 hours. All discontinuation of therapy was considered appropriate, and the 7 treatment interruptions did not have clear clinical consequences. Only one-third of patients had ASP stickers that warned of impending discontinuation of vancomycin therapy placed appropriately in the medical record.

Does Research Training During Residency Promote Scholarship and Influence Career Choice? A Cross-Sectional Analysis of a 10-Year Cohort of the UCSF–PRIME Internal Medicine Residency Program

ABSTRACT Problem: The Association of Program Directors in Internal Medicine, the Accreditation Council for Graduate Medical Education, the Alliance for Academic Internal Medicine, and the Carnegie Foundation report on medical education recommend creating individualized learning pathways during medical training so that learners can experience broader professional roles beyond patient care. Little data exist to support the success of these specialized pathways in graduate medical education. Intervention: We present the 10-year experience of the Primary Care Medicine Education (PRIME) track, a clinical-outcomes research pathway for internal medicine residents at the University of California San Francisco (UCSF). We hypothesized that participation in an individualized learning track, PRIME, would lead to a greater likelihood of publishing research from residency and accessing adequate career mentorship and would be influential on subsequent alumni careers. Context: We performed a cross-sectional survey of internal medicine residency alumni from UCSF who graduated in 2001 through 2010. We compared responses of PRIME and non-PRIME categorical alumni. We used Pearsons chi-square and Students t test to compare PRIME and non-PRIME alumni on categorical and continuous variables. Outcome: Sixty-six percent (211/319) of alumni responded to the survey. A higher percentage of PRIME alumni published residency research projects compared to non-PRIME alumni (64% vs. 40%; p = .002). The number of PRIME alumni identifying research as their primary career role was not significantly different from non-PRIME internal medicine residency graduates (35% of PRIME vs. 29% non-PRIME). Process measures that could explain these findings include adequate access to mentors (M 4.4 for PRIME vs. 3.6 for non-PRIME alumni, p < .001, on a 5-point Likert scale) and agreeing that mentoring relationships affected career choice (M 4.2 for PRIME vs. 3.7 for categorical alumni, p = .001). Finally, 63% of PRIME alumni agreed that their research experience during residency influenced their subsequent career choice versus 46% of non-PRIME alumni (p = .023). Lessons Learned: Our results support the concept that providing residents with an individualized learning pathway focusing on clinical outcomes research during residency enables them to successfully publish manuscripts and access mentorship, and may influence subsequent career choice. Implementation of individualized residency program tracks that nurture academic interests along with clinical skills can support career development within medicine residency programs.

The Unbefriended Patient: An Exercise in Ethical Clinical Reasoning

Exercises in Clinical Reasoning The Unbefriended Patient: An Exercise in Ethical Clinical Reasoning Denise M. Connor, MD, G. David Elkin, MD, Kewchang Lee, MD, Vanessa Thompson, MD, and Heather Whelan, MD Division of HospitalMedicine, San FranciscoVAHealthCare System, San Francisco, CA, USA; Department ofMedicine, University of California San Francisco, San Francisco, CA, USA; Mental Health Service, San Francisco VAHealth Care System, San Francisco, CA, USA; Psychiatry Service, San Francisco General Hospital, San Francisco, CA, USA; Department of Psychiatry, University of California San Francisco, San Francisco, CA, USA; Division of General Internal Medicine, San Francisco General Hospital, San Francisco, CA, USA; San Francisco VA Health Care System, San Francisco, CA, USA.

Feedback and Remediation: Reinforcing Strengths and Improving Weaknesses

Remediation imparts information that can change the trajectory of a learner’s academic progress. Feedback is both the valuable information and the complex process that can help trainees and practicing professionals improve their performance. Effective feedback is nonjudgmental and requires skill development in many different domains, including characterizing the learner’s problem, overcoming resistance, and coaching for success. The authors draw on current literature about feedback to construct a model designed to help mentors bridge gaps in their knowledge base and build confidence in giving feedback to learners who fail to meet educational standards. This chapter provides a four-phase primer with step-by-step guidance for mentors who are remediators.

Improving clerkship preparedness: a hospital medicine elective for pre-clerkship students

ABSTRACT Background: Medical students often struggle to apply their nascent clinical skills in clerkships. While transitional clerkships can orient students to new roles and logistics, students may benefit from developing clinical skills in inpatient environments earlier in their curriculum to improve readiness for clerkships. Intervention: Our four- to six-session elective provides pre-clerkship students with individualized learning in the inpatient setting with the aim of improving clerkship preparedness. Students work one-on-one with faculty who facilitate individualized learning through mentoring, deliberate practice, and directed feedback. Second-year medical students are placed on an attending-only, traditionally ‘non-teaching’ service in the hospital medicine division of a Veterans Affairs (VA) hospital for half-day sessions. Most students self-select into the elective following a class-wide advertisement. The elective also accepts students who are referred for remediation of their clinical skills. Outcome: In the elective’s first two years, 25 students participated and 47 students were waitlisted. We compared participant and waitlisted (non-participant) students’ self-efficacy in several clinical and professional domains during their first clerkship. Elective participants reported significantly higher clerkship preparedness compared to non-participants in the areas of physical exam, oral presentation, and formulation of assessments and plans. Conclusions: Students found the one-on-one feedback and personalized attention from attending physicians to be a particularly useful aspect of the course. This frequently cited benefit points to students’ perceived needs and the value they place on individualized feedback. Our innovation harnesses an untapped resource – the hospital medicine ‘non-teaching’ service – and serves as an attainable option for schools interested in enhancing early clinical skill-building for all students, including those recommended for remediation. Abbreviations: A&P: Assessment and plan; H&P: History and physical; ILP: Individual learning plan

A Curriculum for Diagnostic Reasoning: JGIM’s Exercises in Clinical Reasoning

University ofCalifornia, San Francisco, San Francisco,CA, USA; Veterans AffairsMedicalCenter, San Francisco, San Francisco,CA, USA; University of Washington, Seattle, WA, USA; University of Colorado School of Medicine, Aurora, CO, USA; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA; Johns Hopkins University School of Medicine, Baltimore, MD, USA.

When the Script Doesn’t Fit: An Exercise in Clinical Reasoning

Exercises in Clinical Reasoning When the Script Doesn’t Fit: An Exercise in Clinical Reasoning Daniel J. Wheeler, MD, Thomas Cascino, MD, Bradley A. Sharpe, MD, and Denise M. Connor, MD Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA; Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; Division of Hospital Medicine, San Francisco VA Medical Center, San Francisco, CA, USA.