Jaideep S. Talwalkar

The Approach to Pseudomonas aeruginosa in Cystic Fibrosis.

There is a high prevalence of Pseudomonas aeruginosa in patients with cystic fibrosis and clear epidemiologic links between chronic infection and morbidity and mortality exist. Prevention and early identification of infection are critical, and stand to improve with the advent of new vaccines and laboratory methods. Once the organism is identified, a variety of treatment options are available. Aggressive use of antipseudomonal antibiotics is the standard of care for acute pulmonary exacerbations in cystic fibrosis, and providers must take into account specific patient characteristics when making treatment decisions related to antibiotic selection, route and duration of administration, and site of care.

Diabetes mellitus and bone disease in cystic fibrosis.

Patients with cystic fibrosis are frequently affected with pancreatic insufficiency and are predisposed to the development of diabetes mellitus (DM) and bone demineralization. Cystic fibrosis-related diabetes mellitus is a clinical entity distinct from type 1 and type 2 diabetes, with important implications for the nutritional and pulmonary health of cystic fibrosis patients. This form of diabetes owes largely to insulin deficiency, but alterations in insulin sensitivity and hepatic glucose production have also been described. Therapy for cystic fibrosis-related diabetes differs substantially from type 2 DM, with careful attention to prandial glycemic excursions crucial to controlling its metabolic effects. Bone disease, including osteopenia and osteoporosis, also occurs with increased frequency in cystic fibrosis, owing to defects in intestinal absorption, chronic inflammation, lung disease, low body weight, and gonadal dysfunction. The pathogenesis, implications, diagnosis, and therapy of cystic fibrosis-related bone demineralization are discussed, with attention to recommended approaches to prevention of and treatment of established bone disease.

Improving linguistic and cultural competence in the health sector: a medical Spanish curriculum for resident physicians

Existing medical Spanish curricula have improved language skills, but are incompatible with resident-physician schedules, and do not always integrate cultural education. A 2009 survey at our institution revealed that residents saw Spanish-speaking patients regularly and wanted a medical Spanish curriculum designed for them. Our objective was to improve medical Spanish and cultural competency among resident physicians at our institution. Kramschs (1998) principle of combining language and cultural instruction, Gardners (1983) theory of multiple intelligences, and the American Council for the Teaching of Foreign Languages 5Cs provided a framework for the self-directed curriculum, which consisted of nine-month long modules with online and in-person grammar, vocabulary, listening comprehension and conversation practice. We conducted pre-intervention, midterm and final assessments of language and cultural competency. We found moderate correlations between the number of modules completed and self-reported flu...

A longitudinal study of health professional students’ attitudes towards interprofessional education at an American university

ABSTRACT Efforts to improve interprofessional education (IPE) are informed by attitudes of health professional students, yet there are limited US data on student characteristics and experiences associated with positive attitudes towards IPE. A cohort of US medical, nursing, and physician associate students was surveyed in their first and third years, using the Readiness for Interprofessional Learning Scale and Interdisciplinary Education Perception Scale. Information was also collected on demographics and experiences during training. Health professional students differed in their attitudes towards IPE; characteristics associated with having more positive attitudes at both time points included being a nursing student, female, older, and having more previous healthcare experience. Students who participated in interprofessional extracurricular activities (particularly patient-based activities) during training reported more positive attitudes in the third year than those who did not participate in such activities. Based on these findings, schools may consider how student characteristics and participation in interprofessional extracurricular activities can affect attitudes regarding IPE. Building on the positive elements of this interprofessional extracurricular experience, schools may also want to consider service-learning models of IPE where students work together on shared goals.

An innovative medical Spanish curriculum for resident doctors.

What problems were addressed? Monolingual Spanish speakers make up a large part of the US patient population and language concordance is associated with improved communication with these patients. In a local needs assessment, the majority of residents at Yale–New Haven Hospital (YNHH) noted seeing Spanish-speaking patients weekly or more often, and expressed interest in a medical Spanish curriculum designed for residents. Existing medical Spanish offerings were too inflexible and, to our knowledge, there were no rigorous medical Spanish curricula that integrated well with a traditional resident schedule. What was tried? Working with the YNHH Office of Interpreter Services and a local non-profit Latino advocacy organisation, we created a medical Spanish curriculum consisting of nine systems-based, self-directed modules (e.g. on cardiovascular or pulmonary topics). Each module required approximately 8 hours and was to be completed within a month. Residents could choose which months to participate and were allowed to take 3 months off to allow for breaks during busy rotations. The curriculum incorporated multiple learning modalities including reading, writing, listening and speaking. Each module consisted of online grammar and vocabulary activities, a chapter from a medical Spanish video, self-scheduled role-play of common patient scenarios with a bilingual volunteer, and a simulated medical counselling session with a volunteer student of English as a second language from the non-profit organisation’s office. We hypothesised that residents would be satisfied with the curriculum, which would be feasible to complete, and would show improvements in written and oral evaluation scores. To this end, residents tracked their progress and were asked to complete preand post-curriculum surveys and written and oral evaluations, as well as to attend a focus group at the end of the year. Twenty selfselected paediatrics, internal medicine and combined medicine and paediatrics residents with at least a conversational level of Spanish participated during the 2010–2011 academic year. What lessons were learned? Overall, 83% of respondents to the final survey were satisfied with the curriculum and 67% felt their medical Spanish had improved. In the survey and focus group, residents reported they had difficulty in completing all of the modules, citing time as the main barrier. The practice sessions with the student-volunteers were identified as the most helpful part of the curriculum, but were the least well attended. The sessions were off-site and required advance scheduling, which made it more difficult for residents to attend. Additionally, residents had difficulty in attending the oral evaluation sessions because of their schedules, but the mean score on the written test, which was available online and thus easier to complete, improved from 30% initially to 45% at the end of the year (the difference was nonsignificant). The only cost of the curriculum was US

Cystic Fibrosis Transmembrane Regulator Modulators: Implications for the Management of Depression and Anxiety in Cystic Fibrosis

70 per participant for the medical Spanish video. Given the preliminary success of the curriculum, we obtained financial support from the hospital to offer the curriculum to all hospital residents and have 55 participants enrolled for the 2011–2012 year. We will use the funding to improve curricular activities, to increase the programme’s convenience for residents (e.g. by offering transportation and meals to volunteers to enable them to come to the hospital) and to create more robust participant and curricular evaluations.

Use of extramural ambulatory care curricula in postgraduate medical training

BACKGROUND Individuals with cystic fibrosis (CF) are at high risk for depression and anxiety, which are associated with worse medical outcomes. Novel therapies for CF hold great promise for improving physical health, but the effects of these therapies on mental health remain poorly understood. OBJECTIVE This review aims to familiarize psychiatrists with the potential effect of novel CF therapies on depression and anxiety. METHODS We discuss novel therapies that directly target the mutant CF protein, the CF transmembrane regulator (CFTR), which are called CFTR modulators. We summarize depression and anxiety screening and treatment guidelines under implementation in accredited CF centers. Case vignettes highlight the complexities of caring for individuals with CF with comorbid depression and anxiety, including patients experiencing worsening depression and anxiety proximate to initiation of CFTR modulator therapy, and management of drug-drug interactions. CONCLUSIONS Although CFTR modulator therapies provide hope for improving clinical outcomes, worsening depression and anxiety occurs in some patients when starting these novel agents. This phenomenon may be multifactorial, with hypothesized contributions from CFTR modulator-psychotropic medication interactions, direct effects of CFTR modulators on central nervous system function, the psychologic effect of starting a potentially life-altering drug, and typical triggers of depression and anxiety such as stress, pain, and inflammation. The medical and psychiatric complexity of many individuals with CF warrants more direct involvement of mental health specialists on the multidisciplinary CF team. Inclusion of mental health variables in patients with CF registries will facilitate further examination at an epidemiologic level.

Perceptions of Pediatric Residents Regarding Counseling About Use of Social Networking Sites

IntroductionExtramural curricula developed for the purpose of sharing with other institutions have been designed to improve education on important topics in ambulatory care. We sought to assess the usage rates of these curricula among paediatric, internal medicine, and combined medicine-paediatrics residency programmes in the United States.MethodsSurveys on aspects of trainee continuity clinic were sent to paediatric and medicine-paediatrics programme directors in 2012. Surveys contained an item asking respondents about their use of extramural ambulatory care curricula. Since no similar recent data were available for internal medicine, and to verify the accuracy of the paediatric survey data, we queried the editors of four widely used curricula for subscription information. Descriptive and inferential statistics were calculated.ResultsResponses from paediatric programmes indicated that 48 of 111 (43 %) were using an extramural curriculum, compared with 39 of 60 (65 %) medicine-paediatrics programmes (p = 0.007). Editor query revealed a collective subscription rate of internal medicine programmes (300 of 402, 75 %), which was greater than the subscription rate of paediatric programmes (90 of 201, 45 %) (p < 0.001).DiscussionTraining programmes in paediatrics, internal medicine, and combined medicine-paediatrics utilize extramural curricula to guide education in ambulatory care, but internal medicine and medicine-paediatrics programmes employ these curricula at greater rates than paediatric programmes.

Observations: Milestones for Combined Training Programs—Innovation or Burden?

Increasing use of social networking sites (SNS) among youth prompted professional organizations to urge pediatricians to promote healthy media use. Electronic questionnaires were distributed to 76 pediatric residents at one academic center measuring attitudes, practices, and familiarity with SNS. Of 43 respondents (response rate = 57%), most reported personal SNS use (98%) and familiarity with SNS used by youth (72%), and 88% agreed that pediatricians should provide counseling on SNS use. Only 5% felt they had adequate training on SNS use in children, and just 26% felt comfortable advising families. Residents were less likely to discuss SNS use than general media use (19% vs 56%, P = .007). Media counseling was correlated with SNS counseling (r = .38, P = .01). Pediatric residents recognize the importance of guiding families on SNS use, yet do not routinely provide counseling despite high levels of personal SNS use and familiarity. Focused training is necessary for pediatricians to prioritize practical guidance.

Optimizing the Involvement of Language Interpreters During the Clinical Encounter

The Accreditation Council for Graduate Medical Education has adopted strategic priorities to (a) foster innovation and improvement in the learning environment; (b) increase the accreditation emphasis on educational outcomes; (c) increase efficiency and reduce burden in accreditation; and (d) improve communication and collaboration with key external stakeholders.”1 The Milestone Project is intended to advance these priorities.2 We suggest that b and d are true, but perhaps a and c are false, at least for combined training programs. The recent adaption of the Milestones shows great promise for thoughtful, quality evaluation of residents across all disciplines. The emphasis on the gradual increase in autonomy and outcome-driven skills is a fundamental shift toward the authentic evaluation of trainees. The Milestones also strike a balance between simple Likert scores and narrative-based evaluations, and Milestones also addresses a fundamental question: Can our trainees function independently? To date, there are 20 combined specialties, representing 187 programs and nearly 2000 residents.3 The largest of these programs are the combined internal medicine-pediatrics programs with 80 programs and more than 1400 trainees (table).3 TABLE ACGME Accredited Combined Specialty Residency Programsa Because the 6 core competencies are the same across specialties, the Milestones echo similar themes. However, the uniqueness of specific Milestones poses challenges for combined training programs. Simply stated, the challenge for combined training programs is how can we accurately, authentically measure these Milestones without the checklists becoming another empty Likert-scale exercise? Does the volume of distinct and nonparallel Milestones, each with well-crafted goals, cause the overall assessment to become too complex? If the aim of the Milestones is to contribute to better assessment, does their rigid language, sheer number, and misalignment pose an administrative burden on combined programs that may stifle innovation? Thoughtful Clinical Competency Committees likely will find their way through the Milestones, and the administrative burden may perhaps decrease with time, as the specifics will become second nature to residency program leaders. However, we are concerned that the demand of the Milestones on combined programs may be a more convoluted tracking standard. Authentic evaluation remains elusive, and yet, there is no substitute for direct, immediate, ongoing feedback and reflection from a supervisor to a trainee. This entails sustained commitment from the supervisor, trainee, and training program. The Milestones get us part of the way. As we move forward with their use, we must be careful not to let complexity get in the way.