Donald W. Brady

Teaching the psychosocial aspects of care in the clinical setting: practical recommendations.

Communication skills and the psychosocial dimensions of patient care are increasingly taught in medical schools and generalist residency programs. Evidence suggests they are not reinforced or optimally implemented in clinical training. The authors present the product of an iterative process that was part of a national faculty development program and involved both experts and generalist teachers concerning teaching psychosocial medicine while precepting medical students and residents in clinical settings. Using scientific evidence, educational theory, and experience, the authors developed recommendations, presented them in workshops, and revised them based on input from other experts and teachers, who gave feedback and added suggestions. The results are practical, expert consensus recommendations for clinical preceptors on how to teach and reinforce learning in this area. General skills to use in preparing the trainee for improved psychosocial care are organized into the mnemonic “CAARE MORE”: Connect personally with the trainee; Ask psychosocial questions and Assess the trainees knowledge/attitudes/skills/behaviors; Role model desired attitudes/skills/behaviors; create a safe, supportive, enjoyable learning Environment; formulate specific Management strategies regarding psychosocial issues; Observe the trainees affect and behavior; Reflect and provide feedback on doctor–patient and preceptor-trainee interactions; and provide Educational resources and best Evidence. The preceptor–trainee teaching skills that are recommended parallel good doctor–patient interaction skills. They can be used during both preceptor–trainee and preceptor–trainee–patient encounters. Important common psychosocial situations that need to be managed in patients include substance abuse, depression, anxiety, somatoform disorder, physical and sexual abuse, and posttraumatic stress disorder. For these problems, where high-level evidence exists, specific psychosocial questions for screening and case finding are provided.

Apolipoprotein CII and lipoprotein lipase in human nephrotic syndrome

Plasma apolipoprotein (apo CII), apo CII in plasma very low density lipoproteins (VLDL), plasma post-heparin lipoprotein lipase (LPL) activity and urinary apo CII excretion were assessed in 9 patients with nephrotic syndrome. Apo CII comprised a significantly lower percentage of plasma VLDL protein (mean ± SEM) in nephrotic patients (7.2 ± 0.4%) than normals (10 ± 0.5%), but was similar to levels in patients with primary hypertriglyceridemia and normal renal function (7.4 ± 0.6%). The ability of VLDL from nephrotic patients to activate lipoprotein lipase in vitro (79.8 ± 14.1 units/mg protein and 18.2 ± 3.6 units/M triglyceride TG) was significantly lower than normal (158 ± 11.1 units mg protein and 36.8 ± 4.4 units/M TG) but was similar to primary hypertriglyceridemics cer.0 ± 8.1 units/mg protein and 17.6 ± 2.2 units/M TG). Whereas in primary hypertriglyceridemics the amount of apo CII/mg VLDL protein or M TG was inversely proportional to (log10) total plasma TG, such a relationship was not observed in nephrotic patients. Post-heparin plasma hepatic lipase was significantly lower in male nephrotics (2.9 ± 2.5 μM FFA/ml/h) compared to normals (14.4 ± 4.2). Hepatic LPL correlated inversely with total plasma low density lipoprotein cholesterol (r = −0.49, P < 0.05). Post-heparinnon-hepatic lipase was low in 2 and low normal in 2 of 8 patients studied. Mean 24-h urinary excretion of apo CII was higher in nephrotic patients (241 ± 116 μg) than normals (27 ± 5 μg) and primary hypertriglyceridemics (31 ± 5 μg). Total plasma apo CII in nephrotics (89.1 ± 14.0 μg/ml) was higher than normal (51.8 ± 3.2 μg/ml; P < 0.01) and similar to patients with primary type IIB (89.1 ± 4.6 μg/ml) and primary type IV hyperlipoproteinemia (85.4 ± 6.9 μg/ml). Six of 9 nephrotic patients had 24-h urinary excretion rates of apo CII which were within the normal range while 3 patients had markedly increased apo CII excretion. These studies suggest that in nephrotic syndrome, (a) the decreased LPL activator potency in VLDL may reflect reduced apo CII per VLDL particle, or an excess of LPL inhibitory apolipoproteins and (b) decreased hepatic and extra-hepatic hepoprotein lipase levels may relate to altered lipoprotein catabolism and (c) increased urinary loss of apo CII does not result in its depletion in plasma.

Personal growth during internship: A qualitative analysis of interns' responses to key questions

BACKGROUND: During clinical training, house officers frequently encounter intense experiences that may affect their personal growth. The purpose of this study was to explore processes related to personal growth during internship.DESIGN: Prospective qualitative study conducted over the course of internship.PARTICIPANTS: Thirty-two postgraduate year (PGY)-1 residents from 9 U.S. internal medicine training programs.APPROACH: Every 8 weeks, interns responded by e-mail to an open-ended question related to personal growth. Content analysis methods were used to analyze the interns’ writings to identify triggers, facilitators, and barriers related to personal growth.RESULTS: Triggers for personal growth included caring for critically ill or dying patients, receiving feedback, witnessing unprofessional behavior, experiencing personal problems, and dealing with the increased responsibility of internship. Facilitators of personal growth included supportive relationships, reflection, and commitment to core values. Fatigue, lack of personal time, and overwhelming work were barriers to personal growth. The balance between facilitators and barriers may dictate the extent to which personal growth occurs.CONCLUSIONS: Efforts to support personal growth during residency training include fostering supportive relationships, encouraging reflection, and recognizing interns’ core values especially in association with powerful triggers.

Personal Growth and its Correlates During Residency Training

Objectives  To explore the characteristics of and factors associated with personal growth during residency training.

Building the case for cultural competence

&NA; Cultural competence in the provision of health care is a very important area of investigation and is receiving recognition at multiple levels. Minority groups constitute a significant and growing percentage of our population. However, there has been no commensurate increase in the number of minority physicians. There is a tremendous need for medical professional schools and health care organizations to implement formal cultural competence training for current and future health professionals. In this article, we present the findings of an extensive literature review that describes how several factors have brought the need for cultural competence to the forefront. These factors include a greater appreciation for the impact of culture on health, changes in U.S. demographics, increased awareness in health care disparities, and modifications in legislative and accreditation mandates.

The role of high density lipoprotein apolipoprotein CII in triglyceride metabolism.

The purpose of these studies was (a) to examine the relationship between total plasma triglycerides (TG) and the amount of apolipoprotein CII (apo CII) in triglyceride rich lipoproteins (TRL), and (b) to determine whether TRL could be enriched with apo CII in vitro. In 13 patients with primary endogenous hypertriglyceridemia, (log10) total plasma TG correlated inversely with the amount of apo CII per unit very low density lipoprotein (VLDL) protein (r=−0.76;p<0.005) and VLDL TG (r=−0.75; p<0.005). The potency of VLDL to activate milk lipoprotein lipase (LPL) in hydrolyzing triolein was studied in vitro. LPL activator potency per unit VLDL protein or VLDL TG correlated inversely with (log10) total plasma TG (r=−0.86 and r=−0.76, respectively; p<0.005). LPL activator potency per nM VLDL apo CII also correlated inversely with (log10) total plasma TG (r=−0.49; p<0.01). In seven patients with familial type V hyperlipoproteinemia, the average amount of apo CII in TRL protein was subnormal (5.86±0.62% vs 10.0±0.51% in normal subjects). The higher the (log10) total plasma TG, the lower was the apo CII content in TRL protein (r=−0.93; p<0.01). To determine the factors governing the distribution of apo CII between lipoproteins and whether TRL could be enriched with apo CII, five approaches were undertaken: (a)125I apo CII was added to mixtures of VLDL and HDL. The amount of labelled apo CII in VLDL was proportional to the ratio of VLDL to HDL. (b) TRL from four patients with familial type V hyperlipoproteinemia was incubated with high density lipoprotein (HDL) from a normal subject. An increase in the TRL/HDL ratio was associated with transfer of apo CII from HDL to TRL and a reciprocal transfer of non-apo CII protein from TRL to HDL. Net apo CII enrichment of TRL protein was possible below a HDL/TRL protein ratio of ca. 6 under the experimental conditions. (c) A fixed amount of normal plasma feed of TRL was incubated with different amounts of TRL from two patients with familial type V hyperlipoproteinemia. The amount of apo CII that transferred from normal TRL free plasma to the patient’s TRL was proportional to the amount of TRL in the mixture. (d) A doubling and tripling in the amount of apo CII in TRL was found when apo CII was added directly to TRL from a normal subject and TRL from a patient with familial type V hyperlipoproteinemia, respectively. (e) When apo CII was added directly to normal plasma and plasma from a patient with primary type IV hyperlipoproteinemia, the peptide was taken up mainly by VLDL and HDL, indicating enrichment of these fractions. The distribution of the added apo CII in each lipoprotein fraction resembled the distribution in the native plasma. TRL was isolated after addition of apo CII to plasma from two patients with familial types IV and V, respectively. Enrichment of TRL with apo CII was associated with an approximate 1.5-fold increase in the LPL activator potency per unit TRL protein. These studies suggest that firstly, the amount of apo CII in TRL is inversely related to the severity of hypertriglyceridemia. Secondly, the distribution of apo CII between TRL and HDL is governed by the mass ratios of these two lipoprotein classes. Thirdly, plasma TRL and HDL have a reserve binding capacity of apo CII and fourthly, it is possible to enrich these lipoproteins with this functionally important peptide. Whether net enrichment of TRL with apo CII and also an increase in its biological activity to activate LPL in vitro is related to increased in vivo catabolic rate requires to be determined.

Iterative Method for Learning Skills as an Efficient Outpatient Teacher

Background: We sought to identity the choices and the methods used by ambulatory teachers in a qualitative study, using teacher‐intern‐patient role plays to improve ambulatory teaching. Methods: We used repeated performances of a scripted role play; during each iteration, field notes were taken by the authors. Insights garnered at each iteration were incorporated into the next version of the role play. After 9 iterations, no further insights into outpatient teaching were forthcoming, and our observations were included into a qualitative study. Results: The sequence of steps and major choices to be made in an outpatient teaching encounter were delineated. The goals of the initial opening phase were defined as setting a learning climate, gathering information about the case, and assessing the learner’s level of knowledge. Alternatives posed for setting up the second phase of the interaction with the patient included the choice of being a role model or being a “coach.” Three‐way conversations between patient, learner, and teacher were described in this phase of the encounter. In the final or summary phase of the encounter, we described the choices between giving a “general rule” for learning, and/or exploring higher‐level issues, such as patient‐doctor communication skills, medical ethics, or feedback for the learner. Conclusions: The sequence of steps involved in an outpatient teaching encounter, were defined, and the major choices to be made in the encounter were described.

Incorporating Performance Improvement Methods into a Needs Assessment: Experience with a Nutrition and Exercise Curriculum

BACKGROUNDClinical guidelines recommend that physicians counsel patients on diet and exercise; however, physician counseling remains suboptimal.OBJECTIVESTo determine if incorporating performance improvement (PI) methodologies into a needs assessment for an internal medicine (IM) residency curriculum on nutrition and exercise counseling was feasible and enhanced our understanding of the curricular needs.DESIGN AND PARTICIPANTSOne hundred and fifty-eight IM residents completed a questionnaire to assess their knowledge, attitudes, and practices (KAP) about nutrition and exercise counseling for hypertensive patients. Residents’ baseline nutrition and exercise counseling rates were also obtained using chart abstraction. Fishbone diagrams were created by the residents to delineate perceived barriers to diet and exercise counseling.MAIN MEASURESThe KAP questionnaire was analyzed using descriptive statistics. Chart abstraction data was plotted on run charts and average counseling rates were calculated. Pareto charts were developed from the fishbone diagrams depicting the number of times each barrier was reported.KEY RESULTSAlmost 90% of the residents reported counseling their hypertensive patients about diet and exercise more than 20% of the time on the KAP questionnaire. In contrast, chart abstraction revealed average counseling rates of 3% and 4% for nutrition and exercise, respectively. The KAP questionnaire exposed a clinical knowledge deficit, lack of familiarity with the national guidelines, and low self-efficacy. In contrast, the fishbone analysis highlighted patient apathy, patient co-morbidities, and time pressure as the major perceived barriers.CONCLUSIONSWe found that incorporating PI methods into a needs assessment for an IM residency curriculum on nutrition and exercise counseling for patients at risk of cardiovascular disease was feasible, provided additional information not obtained through other means, and provided the opportunity to pilot the use of PI techniques as an educational strategy and means of measuring outcomes. Our findings suggest that utilization of PI principles provides a useful framework for developing and implementing a medical education curriculum and measuring its effectiveness.

Redesigning Medical Education in Internal Medicine: Adapting to the Changing Landscape of 21st Century Medical Practice

INTRODUCTION Practicing internal medicine in the 21st century has changed. Novel scientific discoveries, diagnostic technologies and therapeutic interventions have evolved rapidly. At the same time, external forces have altered the interactions between internists, their patients and the new healthcare delivery systems incorporating those interactions in ways unforeseen a decade ago. Although most institutions strive to keep the scientific aspects of their curricula current, teaching learners to use this new science effectively in present and future healthcare environments is addressed less commonly. Adopting new models of education can be difficult. Educational change occurs slowly within the confines of the extant system, but the shifting landscape demands rapid change, and many “traditional” medical teachers find themselves on unfamiliar terrain. In the last 10 years, the Society of General Internal Medicine (SGIM), the American College of Physicians (ACP), and the Alliance for Academic Internal Medicine (AAIM) have all published position papers on redesigning Internal Medicine training. The medical education community is recognizing the necessity for learners to demonstrate objectively their ability to care for patients, a so-called “competencybased model” for training and education. Likewise, educational regulatory bodies have deemed that physicians should demonstrate competence for certification. Traditional clinical training, however, inserts learners into established patient care experiences in a fashion that minimally disrupts the system. This current “systemcentered” clinical structure limits the role learners can play and makes assessing their competence a struggle for educators. Thus, an endless loop is created; learners cannot fully participate until they are competent, yet they cannot easily be declared “competent” because there are limited arenas in which they can fully participate. Education is not given as top priority in this “system-centered” structure and adjustments that may be needed to satisfy any new educational requirements are also done in a way that is minimally disruptive for the system. Thus, our learners are having training in a clinical system that is not necessarily designed for education.

Matters of the Heart: A Program Supporting Medical Marriages for Residents at an Academic Medical Center

This article describes a specialized program facilitated by the Employee Assistance Program (EAP), focused on the needs of married house staff (residents and fellows) within an academic medical center. This program was developed in conjunction with the Vanderbilt House Staff Alliance, facilitated by Work/Life Connections-EAP, the internal Employee Assistance Program, and Medical Staff Special Events at Vanderbilt University in Nashville, Tennessee. The program is sponsored by the Vice Chancellor for Health Affairs and his wife, the driving force behind the project. Given the unique stressors faced by married couples during medical training, the Matters of the Heart series was developed to help house staff and their spouses manage the challenges that affect their relationships during this stressful time.