Nancy R. Angoff

Cerebrospinal fluid HIV escape associated with progressive neurologic dysfunction in patients on antiretroviral therapy with well controlled plasma viral load.

Objective:To characterize HIV-infected patients with neurosymptomatic cerebrospinal fluid (CSF) ‘escape’, defined as detectable CSF HIV RNA in the setting of treatment-suppressed plasma levels or CSF RNA more than 1-log higher than plasma RNA. Design:Retrospective case series. Setting:Four urban medical centers in the United States and Europe. Participants:Virologically controlled HIV-infected patients on antiretroviral therapy (ART) with progressive neurologic abnormalities who were determined to have CSF ‘escape’. Intervention:Optimization of ART based upon drug susceptibility and presumed central nervous system exposure. Main outcome measures:Levels of CSF HIV RNA and inflammatory markers, clinical signs and symptoms, and MRI findings. Results:Ten patients presented with new neurologic abnormalities, which included sensory, motor, and cognitive manifestations. Median CSF HIV RNA was 3900 copies/ml (range 134–9056), whereas median plasma HIV RNA was 62 copies/ml (range <50 to 380). Median CD4+ T-cell count was 482 cells/&mgr;l (range 290–660). All patients had been controlled to less than 500 copies/ml for median 27.5 months (range 2–96) and five of 10 had been suppressed to less than 50 copies/ml for median 19.5 months (range 2–96). Patients had documentation of a stable ART regimen for median 21 months (range 9–60). All had CSF pleocytosis or elevated CSF protein; seven of eight had abnormalities on MRI; and six of seven harbored CSF resistance mutations. Following optimization of ART, eight of nine patients improved clinically. Conclusion:The development of neurologic symptoms in patients on ART with low or undetectable plasma HIV levels may be an indication of CSF ‘escape’. This study adds to a growing body of literature regarding this rare condition in well controlled HIV infection.

Teaching Pre-clinical Medical Students an Integrated Approach to Medical Interviewing: Half-day Workshops Using Actors

Teaching medical students to integrate patient-centered skills into the medical interview is challenging. Longitudinal training requires significant curricular and faculty time. Unsupervised students risk harm if they uncover and inappropriately manage psychosocial issues in actual patients. They fear saying the wrong thing in emotionally charged situations. Two half-day workshops for pre-clinical students integrate patient- and physician-centered interviewing. The first occurs early in the first year. The second, late in the second year, presents interview challenges (e.g., breaking bad news). Ten professional actors portray standardized patients (SPs). Groups of 10 to 15 students interview an SP, each eliciting a part of the patient’s story. Qualitative evaluation revealed that, for many students, SPs afford the opportunity to experiment without harming real patients. Students view the workshops as effective (mean score for first-year students, 6.6 [standard deviation (SD), 1.0], second-year students, 7.1 [SD, 0.7] on a Likert-type scale: 1=not at all effective to 8=very effective).

Power Day: Addressing the Use and Abuse of Power in Medical Training.

Problem: Medical student mistreatment, as well as patient and staff mistreatment by all levels of medical trainees and faculty, is still prevalent in U.S. clinical training. Largely missing in interventions to reduce mistreatment is acknowledgement of the abuse of power produced by the hierarchical structure in which medicine is practiced. Approach: Beginning in 2001, Yale School of Medicine has held annual “Power Day” workshops for third year medical students and advanced practice nursing students, to define and analyse power dynamics within the medical hierarchy and hidden curriculum using literature, guest speakers, and small groups. During rotations, medical students write narratives about the use of power witnessed in the wards. In response to student and small group leader feedback, workshop organizers have developed additional activities related to examining and changing the use of power in clinical teams. Outcome: Emerging narrative themes included the potential impact of small acts and students feeling “mute” and “complicit” in morally distressing situations. Small groups provided safe spaces for advice, support, and professional identity formation. By 2005, students recognized residents that used power positively with Power Day awards and alumni served as keynote speakers on the use of power in medicine. By 2010, departments including OB/GYN, surgery, psychiatry, and paediatrics, had added weekly team Power Hour discussions. Next Steps: The authors highlight barriers, benefits, and lessons learned. Barriers include the notion of clinical irrelevance and resistance to the word “power” due to perceived accusation of abuse. Benefits include promoting open dialogue about power, fostering inter-professional collaboration, rewarding positive role modelling by residents and faculty, and creating a network of trainee empowerment and leadership. Furthermore, faculty have started to ask that issues of power be addressed in a more transparent way at their level of the hierarchy as well.

Test anxiety and United States Medical Licensing Examination scores

Many medical students experience test anxiety, which may impair their performance in examinations. We examined the relationship between test anxiety and United States Medical Licensing Examination (USMLE) step‐1 scores and determined the effect of a test‐taking course on anxiety and USMLE scores.

Characteristics of test anxiety among medical students and congruence of strategies to address it

Introduction Medical students may experience test anxiety associated with ‘high stakes’ exams, such as Step 1 of the United States Medical Licensing Examination. Methods We collected qualitative responses about test anxiety at three points in time from 93 second-year medical students engaged in studying for and taking Step 1. Results Causes of test anxiety as reported by students were related to negative self-talk during preparation for the exam. Effects of anxiety had to do with emotional well-being, cognitive functioning, and physical well-being. Strategies included socializing with others and a variety of cognitive and physical approaches. Comparison of individuals’ strategies with causes and effects showed some congruence, but substantial incongruence between the types of strategies chosen and the reported causes and effects of test anxiety. Discussion Students’ adoption of a ‘menu’ of strategies rather than one or two carefully selected strategies suggest inefficiencies that might be addressed by interventions, such as advisor-directed conversations with students and incorporating student self-assessment and strategies for managing anxiety within courses on test-taking. Such interventions are in need of further study. An annotated list of evidence-based strategies would be helpful to students and educators. Most important, test anxiety should be viewed by medical educators as a ‘real’ experience, and students would benefit from educator support.

Utilization and Effectiveness of a Peer Advocate Program for Medical Students

Considerable evidence exists that medical students experience mental and emotional distress, including depression, anxiety, and suicidal ideation, at higher rates than the general population [1–3]. In spite of increased awareness and programmatic interventions, there are known barriers to medical students’ access to resources, including: reticence to use support services out of fear of appearing unstable in a setting of pervasive stigma surrounding mental health, perceived lack of time to take advantage of resources, fear of an effect on their academic record, and fear of an unwanted intervention [1, 4, 5]. It has been demonstrated that having a peer support system in place may be an effective way to encourage students to reach out for help [6]. A perusal of websites gives evidence that medical schools encourage peer networks and mentoring as a support mechanism, but their actual use and effectiveness for medical students is under-reported in the literature. At Yale School of Medicine, we implemented the Peer Advocate (PA) program, which has helped medical students navigate a variety of challenges by helping to facilitate vetting strategies and brainstorming solutions. The PA program has worked to connect students with the appropriate university and community resources, depending on each student’s needs. In this case report, we provide details on both the implementation and student evaluation of the PA program’s effectiveness. Peer Advocate Program

Passing the torch: A proposed amendment to “A Physician Charter”

A Physician Charter has received widespread attention throughout the medical community since its publication in 2002. The Charter, which lays out three principles and 10 commitments that “reaffirm the fundamental and universal principles and values of medical professionalism …” omits an essential principle and its corollary commitment. That fourth principle, essential to the successful perpetuation of the aims of the Charter, we call the Principle of Generativity: Physicians must contribute to the education and development of the next generation of practitioners in order to ensure that the profession lives on and thrives, grounded in its fundamental professional values. Only by emphasizing our obligation to teach professional values to the next generation of physicians, can we expect to “pass the torch” of the profession.

When patients hurt us

Abstract In this thoughtful article, medical educators in various stages of their careers (resident, mid-career clinician-educators, medical school deans) reflect upon increasing reports of harassment and mistreatment of trainees by patients. In addition to providing a general overview of the limited literature on this topic, the authors describe their own experience collecting information on trainee mistreatment by patients at their institution. They explore the universal difficulty that educators face regarding how to best address this mistreatment and support both faculty and trainees. Given the current sociopolitical climate, there has never been a more urgent need to critically examine this issue. The authors call on the greater medical education community to join them in these important conversations.

The Stranger in the Room

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