A phenomenological study of italian students’ responses to professional dilemmas. A cross-cultural comparison

Phenomenon: Medical professionalism is a complex construct, based in social and cultural influences, yet little research has been done to show how culture influences the behaviors and attitudes of medical students. We presented Italian students with the same professional dilemmas used in a previous Canadian and Taiwanese cross-cultural study to look for similarities and differences and detect elements of Italian culture that influenced how students responded to dilemmas. The aim was to provide medical educators with some insights into students’ behavioral strategies and feelings when faced with a professional dilemma. Approach: Using Giorgi’s method, we performed a phenomenological analysis of 15 interviews of Italian medical students who responded to standardized video scenarios representing professional dilemmas. These videos were used in Canada and Taiwan and were translated into Italian. All students were from the same degree course, at Year 6, and were recruited on a voluntary basis at the beginning of the Internal Medicine course. Interview transcripts were anonymized before analysis. Findings: Scenarios were perceived as realistic and easy to envision in Italy. Four themes emerged: establishing priority among principles, using tactics to escape the dilemma, defending the self, and defending the relationships. When compared with previous studies, we noted that Italian students did not mention the principles of reporting inappropriate behavior, seeking excellence, or following senior trainees’ advice. Insights: This is the first cross-cultural study of professionalism that involves a Mediterranean country and the observed differences could be interpreted as expressions of Italian cultural traits: distrust toward authority and a cooperative rather than competitive attitude. These findings have practical implications for educators to design and run curricula of professionalism with culturally appropriate topics. They highlight the need for more cross-cultural research

Bone Microarchitecture and Strength in Long‐Standing Type 1 Diabetes

Type 1 diabetes (T1DM) is associated with an increased fracture risk, specifically at nonvertebral sites. The influence of glycemic control and microvascular disease on skeletal health in long‐standing T1DM remains largely unknown. We aimed to assess areal (aBMD) and volumetric bone mineral density (vBMD), bone microarchitecture, bone turnover, and estimated bone strength in patients with long‐standing T1DM, defined as disease duration ≥25 years. We recruited 59 patients with T1DM (disease duration 37.7 ± 9.0 years; age 59.9 ± 9.9 years.; body mass index [BMI] 25.5 ± 3.7 kg/m(2); 5‐year median glycated hemoglobin [HbA1c] 7.1% [IQR 6.82–7.40]) and 77 nondiabetic controls. Dual‐energy X‐ray absorptiometry (DXA), high‐resolution peripheral quantitative computed tomography (HRpQCT) at the ultradistal radius and tibia, and biochemical markers of bone turnover were assessed. Group comparisons were performed after adjustment for age, gender, and BMI. Patients with T1DM had lower aBMD at the hip (p < 0.001), distal radius (p = 0.01), lumbar spine (p = 0.04), and femoral neck (p = 0.05) as compared to controls. Cross‐linked C‐telopeptide (CTX), a marker of bone resorption, was significantly lower in T1DM (p = 0.005). At the distal radius there were no significant differences in vBMD and bone microarchitecture between both groups. In contrast, patients with T1DM had lower cortical thickness (estimate [95% confidence interval]: −0.14 [−0.24, −0.05], p < 0.01) and lower cortical vBMD (−28.66 [−54.38, −2.93], p = 0.03) at the ultradistal tibia. Bone strength and bone stiffness at the tibia, determined by homogenized finite element modeling, were significantly reduced in T1DM compared to controls. Both the altered cortical microarchitecture and decreased bone strength and stiffness were dependent on the presence of diabetic peripheral neuropathy. In addition to a reduced aBMD and decreased bone resorption, long‐standing, well‐controlled T1DM is associated with a cortical bone deficit at the ultradistal tibia with reduced bone strength and stiffness. Diabetic neuropathy was found to be a determinant of cortical bone structure and bone strength at the tibia, potentially contributing to the increased nonvertebral fracture risk. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR)

Effect of Hyponatremia and its Normalization on Patients’ Clinical Outcomes and Bone Metabolism

Background: Hyponatremia is an electrolyte disorder affecting up to 40% of hospitalized patients, and has widely been associated with increased risk of death, rehospitalizations, as well as with falls, fractures and osteoporosis, when present on admission. Despite this association, knowledge about beneficial effects of its correction is scare. Additionally, hyponatremia is mostly considered as a surrogate of disease severity rather than a treatable trait, resulting in many patients being and / or remaining hyponatremic at discharge. Objective: This MD-PhD thesis investigates the hypothesis that correction of hyponatremia in hospitalized, adult patients improves their clinical outcome, with particular focus on bone metabolism. Methods: The first study is a secondary analysis of a prospective, placebo-controlled trial to understand the impact of hyponatremia at discharge on clinical outcomes in hospitalized patients with pneumonia. The second study is a registry analysis to investigate the impact of persistency versus normalization of admission hyponatremia on clinical outcomes in hospitalized patients with stroke. The third and main study is the analysis of plasma bone marker changes in relation to serum sodium levels during a prospective, placebo-controlled interventional trial in hospitalized patients with syndrome of inappropriate antidiuresis- (SIAD) induced hyponatremia. Results: Overall, all three studies support the hypothesis that in-hospital correction of hyponatriemia improves the outcome of affected patients. In the setting of pneumonia, hyponatremia at discharge is associated with increased risk of a recurrence within 6 months. In patients with stroke, persistency of initial hyponatremia is associated with a worse functional outcome at 3 months. In patients with SIAD, a targeted correction of hyponatremia stimulates bone formation. Discussion: Newly developed or persistent hyponatremia at discharge is associated with worse clinical outcomes in hospitalized patients. Correction of hyponatremia reverses the hyponatremia-induced negative effect on bone metabolism by stimulating bone formation. Further interventional studies are needed to clarify whether correction of hyponatremia could improve other hyponatremia associated patients’ relevant clinical outcomes analogue to improving bone metabolism as well as long-term of this effect

TOWARD A FULL INTEGRATION OF TEACHING /LEARNING PROFESSIONALISM AND CLINICAL COMPETENCE IN MEDICAL STUDENTS

The development of professionalism in medical students is a challenging task faced in every medical curriculum. This chapter briefly summarizes some of the international achievements in this field and reports about the initial experience at the Faculty of Medicine and Dentistry of “Sapienza” University of Rome. A vertical integration of teaching/learning professionalism throughout the formal curriculum was set up, according to a spiral learning educational design. The principles of “assessment for learning” were also taken into account, with repeated and progressive tests. We conceive professionalism as the expression of the relationship between the profession and the social and cultural context in which healthcare professionals function. Professionalism encompasses the ability of critical reflection on technical expertise. It is expressed through the ability to act and make decisions when dilemmas or elements of complexity are present. We started offering a special stream of courses along the six years of our curriculum. These courses only partially relate to the acquisition of specific technical knowledge or skills, and mainly deal with the general ability of using knowledge to set and solve problems of increasing complexity. In this light, we focused on the integration of clinical reasoning in problematic socio-cultural, ethical and emotional-relational contexts. According to these principles, a set of multidimensional assessment methods was designed. To set a baseline of data for assessment, a cross-sectional survey was led using three instruments, selected from the literature and translated into Italian. They were designed to measure knowledge and attitudes towards socio-cultural competence, empathy, and the interactions with self, patients, colleagues, and institutions. The Italian versions of the instruments were validated and data were collected from students at the first and third year of course. This first set of empirical data showed a progression of scores from the first to the third year. The next step will be the full integration of clinical reasoning in the framework of professionalism, through the development of Virtual Patients (VPs) and of scripts for Simulated Patients (SPs) in which problems of diagnostic and therapeutic management are embedded in realistic, complex situations requiring communication skills and socio-cultural and ethical competencies. VPs are computer-based simulations, while SPs are probably the best way to assess both clinical competence and professionalism at large. Our final aim is to draw a progress line for the multidimensional assessment of developing professionalism from the first to the sixth year of medical curriculum, moving toward a systemic approach

L'idea di professionalità medica degli studenti di Medicina: Rilevazione di base per uno studio di coorte]

Scopi. La formazione alla professionalità è una sfida internazionale. Questo articolo riporta i risultati della valutazione eseguita su due coorti di studenti del primo anno del corso di laurea in Medicina, relativa agli atteggiamenti verso tre componenti fondamentali del costrutto di professionalità come la sensibilità alle differenze socioculturali, i comportamenti empatici e i comportamenti professionali nella loro dimensione relazionale verso sé stessi, i colleghi, i pazienti e la società. Queste componenti sono analizzate a riguardo alla loro importanza nei processi di cura. Materiali e Metodi. Per la valutazione delle tre componenti sono state utilizzate le versioni italiane validate di tre strumenti: il Socio-Cultural Attitudes in Medicine Inventory, la Jefferson Scale of Empathy e la Nijmegen Professionalism Scale, somministrati per due anni consecutivi a tutti gli studenti del 1° anno del Corso di Laurea C in Medicina dell’Università “Sapienza” di Roma. Risultati. Su un totale di 196 studenti, le risposte non hanno evidenziato sostanziali differenze di genere o relative al tipo di scuola superiore frequentata per le tre componenti esaminate. Si manifesta viceversa una tendenza verso una influenza legata alla presenza di un genitore medico e un’idea di professionalità più tecnica che orientata agli aspetti comunicativi ed empatici. Conclusioni. Lo studio di follow up di queste coorti di studenti fornirà indicazioni importanti per l’ulteriore progettazione educativa.AIMS: Education for professionalism is an international challenge. This paper reports the results of the assessment performed on two cohorts of first year students of Medicine, relating to attitudes toward three basic components of the construct of professionalism such as sensitivity to sociocultural differences, empathetic behaviors and professional skills in relationship to self, colleagues, patients and society. These components are analyzed with respect to their importance in the process of healthcare. MATERIALS AND METHODS: The assessment of the three components was performed through the validated Italian versions of three instruments: the Socio-Cultural Attitudes in Medicine Inventory, the Jefferson Scale of Empathy and the Nijmegen Professionalism Scale, administered for two consecutive years to all the students of the C curriculum in Medicine of Sapienza University of Rome (Italy). RESULTS: On a total of 196 students, the responses showed no significant differences related to gender or type of high school for the three examined components. A trend is present toward a familiar influence when one of the parents is a doctor and an idea of professionalism more technical-oriented than addressed to communication and empathy. CONCLUSIONS: The follow up study of these cohorts of students will provide important information for further educational design

Developing professionalism in Italian medical students: an educational framework.

Developing and assessing professionalism in medical students is an international challenge. This paper, based on preliminary research at the Faculty of Medicine and Dentistry of the University Sapienza of Rome, Italy, briefly summarizes the main issues and experiences in developing professionalism among Italian undergraduate medical students. It concludes with a proposed framework suited to the Italian medical curricula. In our educational system, professionalism is defined as the context of medical expertise, the combination of rules, conditions, and meanings in which the act of health care occurs, as well as the ability of critical reflection on technical expertise. It is a multidimensional construct of ethical, sociocultural, relational, and epistemological competencies, requiring a wide range of tools for assessment. With reference to Italian versions of validated tools of measure, vignettes, videos, and a student's portfolio of reflective writings, this paper outlines the manner in which education for professionalism is embedded in the existing curriculum and overall framework of assessment

Risk of Malignancy from Thyroid Nodular Disease as an Element of Clinical Management of Patients with Hashimoto's Thyroiditis.

BACKGROUND: Many studies have investigated the association between chronic lymphocytic thyroiditis (CLT) and papillary thyroid carcinoma (PTC), but clinical management of this condition has never been addressed specifically, even in recent guidelines. Surprisingly the likelihood of a nodule as being cancerous in a CLT has never been explicitly expressed in terms of relative risk. METHODS: This study was based on a retrospective analysis of 404 patients undergoing total thyroidectomy. RESULTS: Sixty-nine patients (17.1%) had histological findings of true CLT, and 36.2% had concurrent PTC versus 22.6% of patients in the non-CLT group (p < 0.05), with a tumour risk in the CLT group of ×1.6 (95% CI = 1.21-1.94, likelihood ratio = +1.63). CONCLUSIONS: Patients with CLT and a nodular condition have a ×1.6 increased risk of harbouring a PTC. Moreover, these patients develop multicentric PTC more frequently, and, as a result, total thyroidectomy should always be considered

Chloride and Potassium Assessment are a helpful tool for Differential Diagnosis of Thiazide Associated Hyponatremia.

CONTEXT Differential diagnosis of thiazide associated hyponatremia (TAH) is challenging. Patients can eitherhave volume depletion or a syndrome of inappropriate antidiuresis (SIAD)-like presentation. OBJECTIVE To evaluate the impact of the simplified apparent strong ion difference in serum (aSID), sodium + potassium-chloride) as well as the urine chloride and potassium score (ChU, chloride-potassium in urine) in the differential diagnosis of TAH, in addition to assessment of fractional uric acid excretion (FUA). DESIGN Post-hoc analysis of prospectively collected data from June 2011 to August 2013. SETTING Hospitalized patients enrolled at University Hospital Basel and University Medical Clinic Aarau, Switzerland. PATIENTS 98 patients with TAH < 125 mmol/l were included, divided according to treatment response in volume-depleted TAH requiring volume substitution or SIAD-like TAH requiring fluid restriction. INTERVENTION We computed sensitivity analyses with ROC curves. MAIN OUTCOME MEASURE positive predictive value (ppv) and negative predictive value (npv) of aSID, ChU, and FUA in differential diagnosis of TAH. RESULTS An aSID > 42 mmol/l had a ppv of 79.1% in identifying patients with volume-depleted TAH, whereas a value < 39 mmol/l excluded it with a npv of 76.5%. In patients for whom aSID was inconclusive, a ChU < 15 mmol/l had a ppv of 100% and a npv of 83.3% whereas FUA < 12% had a ppv of 85.7% and a npv of 64.3% in identifying patients with volume-depleted TAH. CONCLUSION In patients with TAH, assessment of aSID, potassium and chloride in urine can help identifying patients with volume-depleted TAH requiring fluid substitution from patients with SIAD-like TAH requiring fluid restriction