Missed Opportunities for HPV Vaccination Discussion Among Medical Trainees

MISSED OPPORTUNITIES FOR HPV VACCINATION DISCUSSION AMONG MEDICAL TRAINEES Jahnavi Sunkara, BA Candidate; Emily J Noonan, Ph.D., M.A; Laura A. Weingartner, Ph.D., M.S.Abstract BACKGROUND Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States and can cause serious health problems like genital warts and cancer. However, vaccination can prevent some of these issues. Although the CDC recommends that individuals between 9-26 years old should receive the HPV vaccine, catch-up vaccination until 45 years old is available upon further guidance from healthcare providers. METHODS Standardized patient (SP) encounters (n=28) were randomly sampled from 134 video recordings of rising third-year medical student trainees. Students were prompted to take a patient history for a 32-year-old seeking to establish primary care who had not seen a physician in over a decade. The content of discussions regarding general and HPV vaccinations were coded for recommendation(s), rationale, and who prompted the discussion. RESULTS Medical trainees prompted the general vaccination discussion only 32% of the time and the HPV vaccine was discussed in only 22% of encounters. Of the patients who were recommended to get an HPV vaccine (n=4), all were assigned female at birth. The most commonly cited reason for not providing a vaccine recommendation was no vaccination records (71%). DISCUSSION These data illustrated gaps in HPV and general vaccination discussion among medical trainees, including missed opportunities to discuss HPV vaccination with patients who are assigned male at birth or who have not received care since before the vaccine’s debut. These trends may be reflected in primary care settings, and we thus recommend that routine vaccination history/discussion include the HPV vaccine for new patients establishing care

Caring for ‘Our Kids’: International Adoption Medicine and the Families it Helps Create

This dissertation is an ethnography of international adoption medicine, a U.S. pediatric subfield concerned with the healthcare of internationally adopted children. Two central research questions inform this study: (1) how do the knowledge and practices of international adoption medicine along with its practitioners promote or challenge the kinship identities among members of adoptive families? (2) how do members of adoptive families use the knowledge and practices of international adoption medicine to create kinship? As a specialty focused on one particular family form, international adoption medicine provides a unique site through which the entanglement of contemporary biomedical expertise in the production of families becomes visible. Through interviews with clinicians and adoptive parents and through participant observation in an international adoption medicine clinic and conferences about adoption, I show how the specialty is a practice that aids in the formation of 21st century U.S. families. Inside and outside of the clinic, international adoption medicine and the knowledge it produces are used by adoptive families as they form themselves, negotiate what it means to be an internationally adoptive family, and produce health. International adoption medicine, in turn, builds its expertise on the experiences and needs of adoptive families. Building on a history of the development of international adoption medicine practice, I focus on three processes key to family life: the nurturing of family feeling and cohesion, through discourse and practices of attachment, and through the caretaking and body work related to feces and toileting in which parents engage. Bringing together anthropological literatures on kinship and biomedicine with ethnographic methods, this study highlights the varied and uneven uses of biomedical knowledge, the management of risk at the level of the family, and the social processes that help constitute families.Doctor of Philosoph

HPV Vaccine Discussions Between Medical Students and Standardized Patients

The vaccination against human papillomavirus (HPV) protectsindividuals from cancer by preventing HPV infection. This vaccination is recommended for people who are assigned male or female at birth. However, since these groups are often associated with different risks of HPV infection, there may be gaps in how effectively the vaccination is recommended to patients. We gathered data by viewing recordings of medical students taking histories from standardized patients. We recorded if and which vaccinations were discussed as the patients established primary care. We focused on discussions surrounding HPV vaccines and used discussions around influenza vaccines as a comparison. We recorded if and how each vaccine was recommended, suggested, or discouraged. We reviewed 83 patient encounters. Only61% of students explicitly discussed vaccinations.Within these discussions, students were more likely to recommend or suggest vaccinations against influenza (63%) than HPV (29%). Students discussed the HPV vaccine more frequently with patients who were assigned female (within 56% versus 21% of vaccine discussions) but were slightly more likely to recommend amongthe assigned male patients(80% vs 73%). Many students used ambivalent or suggestive language rather than clear recommendations that communicatedt he importance of vaccination. Targeting HPV vaccine discussions toward patientswho are assigned female at birth leaves a large portion of society at risk for infection and transmission of HPV. Misinformation around vaccinations has caused many people to distrust vaccines, so it is critical for physicians to develop communication skills to effectively discuss and explain vaccines to patients.https://ir.library.louisville.edu/uars/1062/thumbnail.jp

Eliciting Information During a Standardized Patient History

ELICITING INFORMATION DURING A STANDARDIZED PATIENT HISTORY AUTHORS Sydney Greene, BA Candidate; Emily J Noonan, PhD, MA; Laura A. Weingartner, PhD, MS BACKGROUND Learning how to take a detailed patient history is a fundamental skill that is essential for all medical students to master. Understanding the amount of information elicited in various categories of a patient history may reveal areas where many students struggle to engage the patient, gaps in medical education that could be addressed, or possible predictors of patient satisfaction. METHODS I coded videos of rising third year medical students as they took a patient history and counted each time the student elicited information, the student gave explanations, and the patient asked questions. These counts were compared across the main categories of the patient history, which included past medical history, a hormone use discussion specific to this encounter, family medical history, social history, mental health history, sexual history, and the treatment plan. RESULTS On average, students prompted for information 50 times during a new patient encounter while providing about 12 explanations. Under 4% of questions were related to the patient’s mental health on average compared to 23% of student questions about past medical history and 24% about social history. Patients asked about four questions on average, with most being asked during discussions of the treatment plan. DISCUSSION The results may indicate that students feel uncomfortable asking questions relating to mental health or that students feel mental health is less important to consider than other factors when taking a patient history. In comparison, students seem to feel confident and comfortable discussing the past medical history and social history of the patient. REFERENCES: Ha et al. Doctor-Patient Communication: A Review. Ochsner Journal. V(10):2010. Teutsch, Carol. Patient-Doctor Communication. Medical Clinics of North America. V(87):2003

Frequency and Perceived Authenticity of Social Determinants of Health Discussion by Medical Trainees

Introduction Social determinants of health (SDOH)—the conditions in which people live, learn, and work—play a vital, but often neglected role in shaping a community’s health. SDOH influence risk factors for disease and access to healthcare, consequently promoting health inequities among different populations. Examining how providers discuss SDOH with patients can identify opportunities to better integrate social context into care. Methods We analyzed standardized patient (SP) encounters of rising UofL M3 trainees to 1) determine whether SDOH are integrated into healthcare conversations, and 2) investigate what constitutes an authentic conversation to identify how trainees can better express interest in a patient. SP encounters (n=41) were randomly sampled from 139 video recordings of new patient histories. Discussions concerning SDOH categories were coded for content, patient response, and the perceived authenticity of each interaction. Results The most frequently discussed SDOH was employment (80.49% of encounters) while financial security (0%), healthcare access (2.44%), and discrimination (2.44%) were among the least discussed. Trainees appeared more engaged and interested when they empathized with patients, provided reassurance, established personal connections, and displayed a logical/organized flow of thought. Discussion Clinical skills around SDOH could be improved if students were provided more practice incorporating patients’ answers about SDOH into the health management plan. SDOH discussions can be used to get to know the patient holistically and foster strong doctor-patient relationships, both of which are crucial communication/clinical skills assessed by licensing exams. Emphasis on SDOH in medical education can help students advance these skills.https://ir.library.louisville.edu/uars/1039/thumbnail.jp

HDACs and the senescent phenotype of WI-38 cells

BACKGROUND: Normal cells possess a limited proliferative life span after which they enter a state of irreversible growth arrest. This process, known as replicative senescence, is accompanied by changes in gene expression that give rise to a variety of senescence-associated phenotypes. It has been suggested that these gene expression changes result in part from alterations in the histone acetylation machinery. Here we examine the influence of HDAC inhibitors on the expression of senescent markers in pre- and post-senescent WI-38 cells. RESULTS: Pre- and post-senescent WI-38 cells were treated with the HDAC inhibitors butyrate or trichostatin A (TSA). Following HDAC inhibitor treatment, pre-senescent cells increased p21(WAF1 )and β-galactosidase expression, assumed a flattened senescence-associated morphology, and maintained a lower level of proteasome activity. These alterations also occurred during normal replicative senescence of WI-38 cells, but were not accentuated further by HDAC inhibitors. We also found that HDAC1 levels decline during normal replicative senescence. CONCLUSION: Our findings indicate that HDACs impact numerous phenotypic changes associated with cellular senescence. Reduced HDAC1 expression levels in senescent cells may be an important event in mediating the transition to a senescent phenotype

Comparing Medical Student Nonverbal Behavior With Cisgender And Transgender Standardized Patients

It is essential for medical students to effectively communicate with patients of all gender identities. Evaluating nonverbal behavior is one way to assess the quality of patient care – examining providers’ behaviors while working with cisgender and transgender patients can identify potential biases linked to patient identity. To evaluate nonverbal behavior, the authors analyzed video-recorded training sessions with medical students interviewing standardized patients who identified as cisgender or transgender women. All students identified as cisgender men or cisgender women. The authors rated ten nonverbal behaviors from 1-7 and noted whether these behaviors were perceived to detract from the encounter. Average scores for nonverbal behaviors were similar between students working with cisgender and transgender patients. Nodding frequency showed the largest difference between cisgender (m = 5.65) and transgender (m = 4.93) patients. When considering student gender identity, cisgender men had lower facial expressivity and smiling frequency scores on average but higher scores for unnecessary silence compared to cisgender women across encounters. Detracting behaviors that negatively impacted the patient encounters were most likely to be self-touching/unpurposive movements (41%) and unnecessary silences (26%). Among the students, cisgender men demonstrated detracting behaviors at a higher rate than cisgender women. The consistency in nonverbal behavior during encounters with cisgender and transgender patients is encouraging. It is possible that LGBTQ health training in medical education contributed to this outcome; however, differences in verbal communication could contribute more to health disparities for transgender patients. Additional practice with unpurposive movements and unnecessary silences could improve nonverbal communication skills

Exploring Standardized Patients\u27 Nonverbal Responses Toward LGBTQ Microagressions

Nonverbal behaviors play a significant role in the patient-doctor interaction as it provides cues to underlying unspoken emotions and concerns from the patient (Silverman, 2010). Nonverbal behaviors are most significant when they can be used to reinforce or contradict verbal responses. Thus, it is important for medical students to learn to identify patient non-verbal behaviors through their speech patterns, facial expressions, and body posture, and be able to relate these responses to a positive or adverse patient-physician interaction. Rising third year medical students were video recorded taking health histories from standardized patients (SP; n = 84) of all gender identities. A nonverbal behavior scale was adapted to rate 11 items that assess how patients react to LGBTQ microaggressions from medical students. For each microaggression, the patient’s nonverbal behavior was categorized as adverse/reactive or neutral/positive. Qualitative observations regarding the nonverbal responses were also recorded. Self-touching, nodding, leaning away from the student, and gestures were the most frequent adverse/reactive nonverbal behavior across all gender identities. It was found that gender minorities, particularly transgender women exhibited a greater frequency for adverse/reactive responses. This may be because the most frequent microaggression coded was heteronormative and cis-normative assumptions (i.e., assuming patient SAAB, language for body parts, or sexual orientation and gender identity). Interestingly, transgender women, in the face of this type of microaggression would disclose their sexual orientation, gender identity, or sex assigned at birth as medical students would assume incorrectly. This suggests that transgender women would receive more accurate recommendations, screenings, etc., than transgender men who would often remain misgendered. These findings implicate the need for providers to better understand patient nonverbal communication, especially in response to bias or uncomfortable interactions. Future research should address how patient nonverbal behavior affects physician follow-up questioning, diagnosis, and treatment plan. Future research should also explore relationship between physician and patient nonverbal behavior

Prevalence Of Mental Health History Intake By Medical Trainees

BACKGROUND: In the US, 1 in 5 adults experiences a mental illness. Over 9.8 million adults and youths have serious suicidal thoughts, and LGBTQ+ communities experience an even greater burden of mental health disparities. Mental illness is often recognized late by providers, which prevents timely and effective treatment. METHODS: We estimated the frequency and response of healthcare trainees asking about mental health using video-recorded standardized patient interviews conducted by third-year medical students (M3s). Standardized patients are trained to give out specific health history information only when prompted by the student. Students had 30 minutes to complete new patient interviews in a primary care setting. RESULTS: Among a sample of 38 M3s, 60% discussed mental health for an average of 1.3 minutes. Only 26% of these students followed up about a mental health treatment plan. After the mental health disclosure by patients, students responded, I am sorry to hear that (30%), frowned (22%), or offered support and resources to the patient (17%). Not all trainees elicited whether a patient identified as LGBTQ+ or connected patient identity with mental health support. DISCUSSION: We document how mental health histories may not be identified in primary care settings. Many disclosures were also prompted by providers asking about previous hospitalizations rather than mental health specifically. We thus recommend routine mental health history intake for new patients establishing care. Trainees may benefit from comparing interpersonal skills, like empathetic responses between providers and patients, and connecting LGBTQ+ patient identity and terminology to support patients\u27 mental health needs.https://ir.library.louisville.edu/uars/1015/thumbnail.jp