Gina Luciano

AJM onlineReviewPostprandial Hypotension

Postprandial hypotension is both common in geriatric patients and an important but under-recognized cause of syncope. Other populations at risk include those with Parkinson disease and autonomic failure. The mechanism is not clearly understood, but appears to be secondary to a blunted sympathetic response to a meal. This review discusses the epidemiology, risk factors, and pathophysiology of postprandial hypotension in the elderly, as well as diagnosis and treatment strategies. Diagnosis can be made based on ambulatory blood pressure monitoring and patient symptoms. Lifestyle modifications such as increased water intake before eating or substituting 6 smaller meals daily for 3 larger meals may be effective treatment options. However, data from randomized, controlled trials are limited. Increased awareness of this disease may lead to improved quality of life, decreased falls and injuries, and the avoidance of unnecessary testing.

Residents-as-Teachers: Implementing a Toolkit in Morning Report to Redefine Resident Roles

Background: Morning report was initially created to meet service needs. Purpose: The objective was to improve morning report through a toolkit combining principles of learning theory with resident teaching. Methods: The toolkit consists of three parts: a guideline describing expectations, a worksheet outlining teaching plans, and a feedback form facilitating post-presentation feedback. In 2009–2010, internal medicine residents met with a chief resident before their presentations to refine teaching plans. The chief resident then supported the presenter in achieving their objectives and provided post-presentation feedback. Residents were surveyed before and 6 months after the intervention. Mean scores were compared using an unpaired t test. Results: Residents’ ratings improved in the following domains: understanding expectations (3.10 vs. 4.02, p = .0003), presentation organization (3.50 vs. 4.25, p = .005), and creating and accomplishing learning objectives (3.31 vs. 4.00, p = .002). Residents commented positively on the improved presentations. Conclusions: This toolkit, based on educational principles, improved morning report presentations.

Building chief residents’ leadership skills

What problem was addressed? In many American residency programmes, chief residents are selected for an additional year by programme leaders to provide educational and administrative leadership to other residents. Traditionally, chief residents have acquired leadership skills ‘on-the-job’ and have long felt that the demands of their role without formal leadership training have been challenging. The chief resident year is a unique opportunity for those residents to formally acquire leadership skills, not only with their own departmental leaders, but also via interaction with other hospital colleagues. To realise this potential, we created an intra-institutional leadership seminar series to help chief residents develop leadership skills through formal discussion and reflection. What was tried? Medicine, medicine–paediatrics and paediatric chief residents and programme directors at Baystate Medical Center were invited to attend a 1-hour session every other week over the course of an academic year. Seminar topics were selected initially by facilitators, internal medicine programme directors. However, topics and their order evolved quickly during the first year as a community of practice evolved and as the group itself identified skills that addressed commonly encountered institutional, programmatic and individual challenges that arose. To formalise this process, incoming, current and past chief residents completed a ‘chief resident year survey’. Incoming chief residents were asked to describe their fears about their upcoming role; current and past chief residents were asked to identify leadership skills to be acquired prior to the chief resident year, plus those best built during the chief resident year itself. Facilitators also reviewed relevant literature. Incoming chief residents worried most about overcoming the impostor syndrome (feeling undeserving of one’s role), handling conflicts, saying ‘no’ and maintaining a healthy work–life balance. Current chief residents felt that conflict resolution, giving feedback and managerial skills were important skills built during the chief resident year. Past chief residents suggested adapting one’s leadership style, diplomacy and learning to use one’s leadership strengths. Topics address common challenges and responsibilities chief residents face at particular times throughout the year. For example, as chief residents are often nervous about both the managerial and the hierarchical responsibilities of their roles early in the year, concepts of prioritisation and organisation, impostor syndrome and psychological size (the status relationship between two people) are covered. Later, discussions focus on conflict resolution, management and communication. Before each session, chief residents complete preparatory topic-related reading. During sessions, participants engage in a community of practice through sharing, critiquing and contrasting their own relevant experiences. A complete description of our seminar series with resources can be found at http://libguides.baystatehealth.org/ CRleadership_curriculum. What lessons were learned? Two major lessons arose from a review of anonymous seminar evaluations collected at the end of each year. First, a major success of the seminar is the development of an active community of practice, which has fostered educational and practice exchanges, enhanced by peer support, topic-related anecdotes and problem-solving of current cases. Chief residents have asked that the series be offered to all hospital chief residents to expand that community of practice. Second, we now vary topic timing slightly from year to year to reflect individual and programmatic evolution. The topic order is now a mutual decision by the group based on current, immediate needs.

Training the ambulatory internist: rebalancing residency education

doctor time and attention for patient care. What was tried? Initial improvements included switching to an electronic medical record (EMR)based written handover and creating a standard format for verbal handover. However, we inconsistently applied the template and handover sessions continued to vary in content and length. Based on resident-driven discussions, we then designed a system of peer observation and feedback to help identify and address common pitfalls in applying our standard format. Once weekly, an off-service resident observed handover, evaluated the team using a standardised instrument, and provided 1–2 minutes of direct feedback, including at least one strength and at least one area for improvement. We trained residents in providing feedback and using the feedback instrument during a 45-minute conference. We also provided materials online for later reference. Residents evaluated these changes and our overall handover competence as a group before and after the 4month period of peer feedback. Residents also tracked time spent in sign-out per patient each day during the implementation of these changes. What lessons were learned? The standard format and weekly peer feedback improved resident ratings of our programme’s overall competence in handover, with 35% and 77%, respectively, of residents rating our competence at 4 or 5 on a 5-point Likert scale before and after these changes. All residents felt comfortable receiving and providing peer feedback, and agreed with the statements: ‘It did not affect the sign-out environment and felt collegial’ and ‘I felt comfortable and appropriate giving both positive and negative feedback.’ Most residents also felt that receiving and providing peer feedback was useful, and agreed with the statements: ‘Feedback was specific, organised, and has positively affected my sign-out skill’ and ‘I feel my feedback will improve my own and the team’s future signouts.’ About half of the residents were able to recall feedback they had either received or provided. Samples of peer feedback include: ‘Quiet sign-out with minimal interruptions, good question and answer at end of each patient. Recommend working on clear patient status (i.e. sick patients) and clear if/then/because statements’ and ‘Good use of “if x, then y”. Perhaps don’t need to give all details – ex. “patient had extensive out-patient workup for weight loss” instead of listing every test. Ideally, night team would read that information.’ The standard format also decreased the average time spent in handover; however, peer feedback alone had no additional impact on the length of handover sessions. Given residents’ positive responses to this intervention, peer feedback may represent an innovative tool for improvement. Residents in our programme have identified other areas to be targeted in the future, including the peer review of written communication skills.

Elephantiasis nostras verrucosa.

A 79-year-old woman presented from a nursing home with unusual lower extremity skin changes. Her medical history included congestive heart failure, morbid obesity, chronic lymphedema, and deep vein thrombosis with inferior vena cava filter placement. There was no history of cellulitis, filariasis, or travel to endemic areas. The patient was afebrile without adenopathy and had bilateral lower extremity edema with hyperpigmented, cobble-stoned, hyperkeratotic skin and verrucous nodules on the inner thighs (Figures 1 and 2). Elephantiasis nostras verrucosa secondary to longstanding lymphedema and obesity was diagnosed by the dermatology consultant. The patient was treated with compression stockings and topical emollients. Elephantiasis nostras verrucosa is a rare disorder secondary to chronic noninfectious or recurrent cellulitic lymphedema that results in hyperplastic fibrotic dermal changes. Diagnosis is clinical, but biopsy to exclude malignancies such as Stewart-Treves syndrome is needed in atypical cases. Treatment options include compression stockings, limb elevation, topical keratolytics, emollients, retinoids, and surgical debridement.

Ambulatory Morning Report: A Case-Based Method of Teaching EBM Through Experiential Learning.

Objectives Evidence-based medicine (EBM) skills are important to daily practice, but residents generally feel unskilled incorporating EBM into practice. The Kolb experiential learning theory, as applied to curricular planning, offers a unique methodology to help learners build an EBM skill set based on clinical experiences. We sought to blend the learner-centered, case-based merits of the morning report with an experientially based EBM curriculum. We describe and evaluate a patient-centered ambulatory morning report combining the User’s Guides to the Medical Literature approach to EBM and experiential learning theory in the internal medicine department at Baystate Medical Center. Methods The Kolb experiential learning theory postulates that experience transforms knowledge; within that premise we designed a curriculum to build EBM skills incorporating residents’ patient encounters. By developing structured clinical questions based on recent clinical problems, residents activate prior knowledge. Residents acquire new knowledge through selection and evaluation of an article that addresses the structured clinical questions. Residents then apply and use new knowledge in future patient encounters. Results To assess the curriculum, we designed an 18-question EBM test, which addressed applied knowledge and EBM skills based on the User’s Guides approach. Of the 66 residents who could participate in the curriculum, 61 (92%) completed the test. There was a modest improvement in EBM knowledge, primarily during the first year of training. Conclusions Our experiential curriculum teaches EBM skills essential to clinical practice. The curriculum differs from traditional EBM curricula in that ours blends experiential learning with an EBM skill set; learners use new knowledge in real time.

A Curriculum to Teach Learners How to Develop and Present a Case Report

Introduction Residents are required by the Accreditation Council for Graduate Medical Education to complete a scholarly project during residency, but they may not have dedicated time or instruction to be able to successfully achieve this goal. Methods In 2013 at Baystate Medical Center, we developed the Case Report Curriculum to guide internal medicine interns through the process of writing and presenting a case report. Core faculty and chief residents facilitate six sessions, which are scheduled throughout the year. Sessions combine large- and small-group discussion with facilitated independent work as well as postsession assignments and timely feedback from course facilitators. Topics include selecting a case report, crafting learning objectives, writing a discussion, authorship and creating a title, generating a poster, and presenting a poster. At the culmination of the conference series, interns present their completed case reports at an institutional academic day where judges critique and score their posters. Results Over the past 4 years, 95%-100% of our interns have participated in the required curriculum and presented their posters. We found that the majority of interns go on to present additional scholarly works at regional and national meetings during their second and third postgraduate years. Due to the success of the curriculum, interns from additional programs within the institution now attend the conference series. Discussion The Case Report Curriculum is a successful conference series that guides interns through the process of writing a case and can inspire additional scholarship during residency.

A case report curriculum to promote scholarship

Engaging in scholarly activity during residency can facilitate the acquisition of important skills; however, residents may encounter barriers such as unclear expectations as to what constitutes scholarship, a paucity of dedicated time and a lack of mentorship.

Is Training in a Primary Care Internal Medicine Residency Associated with a Career in Primary Care Medicine

T o the EditorWe wholeheartedly agree with Stanley et. al. about how the residency experience seems to dissuade residents from pursuing primary care careers, and agree that graduate medical education reform is imperative. As the authors describe, there are many reasons why this is the case. Training programs overwhelmingly favor hospital-based rotations, with outpatient medicine typically representing not more than one-third of training time. Simply increasing ambulatory time does not address the challenges that discourage residents from pursuing primary care careers. Additionally, many residency clinics provide care to socioeconomically disadvantaged patients with complex needs. Expecting trainees to be confident and fully engaged in ambulatory care with our current training models is unrealistic. We have designed a primary care training program to address these challenges, with >50 % of the training in the ambulatory environment. To prepare primary care residents for complex disease management in an ambulatory setting, our residents participate in year-long longitudinal subspecialty ambulatory electives with subspecialty preceptors, as opposed to hospital-based subspecialty electives. These subspecialty preceptors have become resources for our residents, allowing them to experience the importance of teamwork and collaboration in primary care. We have implemented a second primary care continuity site to expose residents to diverse patient populations and ambulatory environments. To preserve the passion for advocacy that residents possess, we have integrated a community project into our program. Protected time allows residents to pursue advocacy projects of their choice. Examples of projects include a Spanish/English language and cultural exchange program, a high school nutrition curriculum, promoting health education in a homeless shelter and volunteering services to a local free clinic. Each self-selected project helps to keep our residents grounded in what initially attracted them to primary care. Mentorship is an essential feature of our program. Just as residents are encouraged to pursue subspecialty careers, it is equally important to enthusiastically encourage primary care careers. Quarterly get-togethers with the primary care codirectors are instrumental in maintaining engagement. During these dinners, we discuss medical, political and cultural issues in primary care, facilitate dialogue about career goals and promote peer group mentoring. We have graduated two classes of primary care residents to date, and 80 % of our graduates have pursued primary care careers. Additionally, several categorical residents have transferred into our program, while none of the primary care residents have left. We believe that continued innovation and mentorship will help to successfully build and maintain resident interest in primary care.