Impact of a family medicine resident wellness curriculum: a feasibility study

BACKGROUND: Up to 60% of practicing physicians report symptoms of burnout, which often peak during residency. Residency is also a relevant time for habits of self-care and resiliency to be emphasized. A growing literature underscores the importance of this; however, evidence about effective burnout prevention curriculum during residency remains limited. OBJECTIVES: The purpose of this project is to evaluate the impact of a new, 1-month wellness curriculum for 12 second-year family medicine residents on burnout, empathy, stress, and self-compassion. METHODS: The pilot program, introduced during a new rotation emphasizing competencies around leadership, focused on teaching skills to cultivate mindfulness and self-compassion in order to enhance empathy and reduce stress. Pre-assessments and 3-month follow-up assessments on measures of burnout, empathy, self-compassion, and perceived stress were collected to evaluate the impact of the curriculum. It was hypothesized that this curriculum would enhance empathy and self-compassion as well as reduce stress and burnout among family medicine residents. RESULTS: Descriptive statistics revealed positive trends on the mean scores of all the measures, particularly the Mindfulness Scale of the Self-Compassion Inventory and the Jefferson Empathy Scale. However, the small sample size and lack of sufficient power to detect meaningful differences limited the use of inferential statistics. CONCLUSIONS: This feasibility study demonstrates how a residency wellness curriculum can be developed, implemented, and evaluated with promising results, including high participant satisfaction

Development of a Clinical Guide to Enhance Care for Suicidal Patients

Suicidal thoughts and behavior are common among mental health patients and are a source of stress for clinicians, who typically receive limited formal training on suicide. The U.S. Air Force initiated a project to enhance care and increase practitioner confidence when working with suicidal patients. A clinical guide was developed containing 18 recommendations for assessing and managing suicidality, strategies for meeting the recommendations, and clinical tools to facilitate quality care. Training opportunities and marketing efforts accompanied distribution of the guide. This initial article reviews the guide\u27s development, content, and evaluation plan as a model that other health care systems, clinics, or training programs can follow to enhance care for suicidal patients. Outcome data will be presented in a follow-up article

Development of Direction Selectivity in Mouse Cortical Neurons

SummaryPrevious studies of the ferret visual cortex indicate that the development of direction selectivity requires visual experience. Here, we used two-photon calcium imaging to study the development of direction selectivity in layer 2/3 neurons of the mouse visual cortex in vivo. Surprisingly, just after eye opening nearly all orientation-selective neurons were also direction selective. During later development, the number of neurons responding to drifting gratings increased in parallel with the fraction of neurons that were orientation, but not direction, selective. Our experiments demonstrate that direction selectivity develops normally in dark-reared mice, indicating that the early development of direction selectivity is independent of visual experience. Furthermore, remarkable functional similarities exist between the development of direction selectivity in cortical neurons and the previously reported development of direction selectivity in the mouse retina. Together, these findings provide strong evidence that the development of orientation and direction selectivity in the mouse brain is distinctly different from that in ferrets

General Practice and Pandemic Influenza: A Framework for Planning and Comparison of Plans in Five Countries

BACKGROUND: Although primary health care, and in particular, general practice will be at the frontline in the response to pandemic influenza, there are no frameworks to guide systematic planning for this task or to appraise available plans for their relevance to general practice. We aimed to develop a framework that will facilitate planning for general practice, and used it to appraise pandemic plans from Australia, England, USA, New Zealand and Canada. METHODOLOGY/PRINCIPAL FINDINGS: We adapted the Haddon matrix to develop the framework, populating its cells through a multi-method study that incorporated the peer-reviewed and grey literature, interviews with general practitioners, practice nurses and senior decision-makers, and desktop simulation exercises. We used the framework to analyse 89 publicly-available jurisdictional plans at similar managerial levels in the five countries. The framework identifies four functional domains: clinical care for influenza and other needs, public health responsibilities, the internal environment and the macro-environment of general practice. No plan addressed all four domains. Most plans either ignored or were sketchy about non-influenza clinical needs, and about the contribution of general practice to public health beyond surveillance. Collaborations between general practices were addressed in few plans, and inter-relationships with the broader health system, even less frequently. CONCLUSIONS: This is the first study to provide a framework to guide general practice planning for pandemic influenza. The framework helped identify critical shortcomings in available plans. Engaging general practice effectively in planning is challenging, particularly where governance structures for primary health care are weak. We identify implications for practice and for research

Effectiveness of a Statewide Abusive Head Trauma Prevention Program in North Carolina

Abusive head trauma (AHT) is a serious condition, with an incidence of approximately 30 cases per 100 000 person-years in the first year of life

Altered versican cleavage in ADAMTS5 deficient mice : a novel etiology of myxomatous valve disease

AbstractIn fetal valve maturation the mechanisms by which the relatively homogeneous proteoglycan-rich extracellular matrix (ECM) of endocardial cushions is replaced by a specialized and stratified ECM found in mature valves are not understood. Therefore, we reasoned that uncovering proteases critical for ‘remodeling’ the proteoglycan rich (extracellular matrix) ECM may elucidate novel mechanisms of valve development. We have determined that mice deficient in ADAMTS5, (A Disintegrin-like And Metalloprotease domain with ThromboSpondin-type 1 motifs) which we demonstrated is expressed predominantly by valvular endocardium during cardiac valve maturation, exhibited enlarged valves. ADAMTS5 deficient valves displayed a reduction in cleavage of its substrate versican, a critical cardiac proteoglycan. In vivo reduction of versican, in Adamts5−/− mice, achieved through Vcan heterozygosity, substantially rescued the valve anomalies. An increase in BMP2 immunolocalization, Sox9 expression and mesenchymal cell proliferation were observed in Adamts5−/− valve mesenchyme and correlated with expansion of the spongiosa (proteoglycan-rich) region in Adamts5−/− valve cusps. Furthermore, these data suggest that ECM remodeling via ADAMTS5 is required for endocardial to mesenchymal signaling in late fetal valve development. Although adult Adamts5−/− mice are viable they do not recover from developmental valve anomalies and have myxomatous cardiac valves with 100% penetrance. Since the accumulation of proteoglycans is a hallmark of myxomatous valve disease, based on these data we hypothesize that a lack of versican cleavage during fetal valve development may be a potential etiology of adult myxomatous valve disease

Integrated primary care could play a starring role in the Amazon-JP Morgan-Buffet health care enterprise

Earlier this year, Amazon, J. P. Morgan, and Berkshire Hathaway announced plans to launch a joint health care company with more than a million covered lives. Dr. Atul Gawande, the prominent Boston-based surgeon and health care thought leader, will become the first chief executive officer of this health care venture, with a mission to get the best results at the lowest costs and remain free from profit-making incentives and constraints. In this presidential column, the author explores what this has to do with the mission in the Collaborative Family Health care Association (CFHA) and the promulgation of integrated health care

Assessing social determinants of health in primary care: Liability or opportunity

Health care is never boring. It changes rapidly based on political winds, financial models, novel terminology, and biomedical advances. In the past decade, there has been large-scale implementation of integrated health care, routine screening for common behavioral health conditions, and the rollout of alternative payment models in primary care. However, even before these advances have been inculcated as the standard of care, we are now witnessing the implementation of health coaches and recommendations to screen for social determinants of health. Social determinants of health (SDOHs) include nonclinical factors that impact health, such as income, education, and the social the conditions in which people are born, grow, live, work and age. While there is strong evidence that health outcomes are only marginally determined by direct clinical care and largely determined, it is unclear what system of care (public health vs. medical care) bears the responsibility of identifying and addressing these issues. Is this really the responsibility and role of primary care? Whether we as a health care system decide that systematically asking about and addressing SDOHs is within our job descriptions remains to be seen. Further research is needed to determine the cost and clinical impact of screening and addressing SDOHs

Dissolving the dichotomy in health and healthcare

The New England Journal of Medicine Catalyst recently published an article entitled It\u27s Time to Treat Physical and Mental Health With Equal Intent (Compton-Phillips and Mohta, 2018). The article describes a survey of the NEJM Catalyst Insights Council, a qualified group (n=565) of U.S. executives, clinical leaders, and clinicians who are directly involved in health care delivery. Ninety nine percent of council members responded that mental health should not only be integrated into ambulatory medical care settings but also embrace a shared concept of mutual responsibility (p. 11). As a long-time clinician, educator, and advocate for integrated care, Runyan was so pleased to see this dogmatic statement in a New England Journal of Medicine publication. Labeling disease as either physical or emotional has never served the individual well and may further exacerbate existing stigma and reluctance to seek the most appropriate services. Runyan argues it is time to use intentional language to avoid deconstructing physical and mental health in our discourse or be complicit when others dichotomize measurement and funding. Runyan challenges leaders and aspiring leaders in the field of integrated care to use language and advocate for measures that blur, if not dissolve, this unhelpful and artificial dichotomy

Psychology can be indispensable to health care reform and the patient-centered medical home

The Patient Protection and Affordable Care Act (PPACA) was passed into legislation in March 2010, making health care reform a reality. Perhaps the most well-developed model of primary care that aligns with the PPACA\u27s agenda is the patient-centered medical home (PCMH). Integrated care, as defined by collaborative care between mental health and primary care providers and systems, will undoubtedly play a critical role in the success of the PCMH. The role of psychology and integrated care in the PCMH as well as training implications for psychologists are discussed. This article is intended to challenge our discipline to embrace psychology as a health care profession that must prepare for and solidify its added value in the health care delivery models of the future. Requisite skill sets for primary care psychologists and existing training opportunities are presented. Finally, possible mechanisms for training psychologists in integrated care and the professional roles primary care psychologists can expect to fill are proposed