Discussing what matters most: designing a medical student curriculum for end of life care

Discussing what matters most: designing a medical student curriculum for end-of-life care Natanya S. Russek, Karrie Lu, Kjersti Knox, Timothy Jessick Background: As the population ages, patients are living longer with complex illnesses. While physicians of all specialties are expected to provide patient-centered end-of-life care, studies demonstrate that medical students lack comfort discussing these topics with patients. Our aims were to identify gaps in medical student education and to design and implement a hands-on, longitudinal curriculum to teach essential skills for providing compassionate and skillful care to patients nearing the end of life. Methods: We followed the six-step approach for medical curriculum development: problem identification, needs assessment, goal-setting, identifying educational strategies, implementation, and evaluation development. We reviewed national and local curricula and surveyed graduating medical students. Goals, objectives, and curriculum design were developed with input from student and faculty interviews. Qualitative and quantitative evaluation is ongoing. Results: Literature review revealed that students are exposed to goals of care, breaking bad news, and code status discussions. However, students lack opportunities to practice and receive feedback on these skills. Ten students training as a cohort in a longitudinal clinical and urban medicine program were surveyed in a needs assessment prior to graduation; all reported exposure to goals of care conversations and 10% reported confidence. Similarly, 100% reported exposure to breaking bad news but only 20% reported confidence. The curriculum includes multiple hands-on teaching sessions where students practice breaking bad news and goals of care conversations. Peers and physician facilitators observe and provide active feedback during mock patient interviews. The initial iteration of the curriculum has been received with positive feedback. Conclusions: Implementing a longitudinal curriculum in palliative and end-of-life care is necessary and feasible to improve education of future physicians. Students are expressing increased confidence after a few sessions, and training is ongoing. Future curriculum evaluation will include comparison of experience and confidence in key clinical skills before and after exposure to this novel curriculum. Integrating hands-on practice in these critical skills into medical student curricula will impact the quality of care provided by trainees as they pursue careers in diverse specialties

Distinct Subtypes of Behavioral Variant Frontotemporal Dementia Based on Patterns of Network Degeneration.

ImportanceClearer delineation of the phenotypic heterogeneity within behavioral variant frontotemporal dementia (bvFTD) will help uncover underlying biological mechanisms and improve clinicians' ability to predict disease course and to design targeted management strategies.ObjectiveTo identify subtypes of bvFTD syndrome based on distinctive patterns of atrophy defined by selective vulnerability of specific functional networks targeted in bvFTD using statistical classification approaches.Design, setting and participantsIn this retrospective observational study, 90 patients meeting the Frontotemporal Dementia Consortium consensus criteria for bvFTD underwent evaluation at the Memory and Aging Center of the Department of Neurology at University of California, San Francisco. Patients underwent a multidisciplinary clinical evaluation, including clinical demographics, genetic testing, symptom evaluation, neurologic examination, neuropsychological bedside testing, and socioemotional assessments. All patients underwent structural magnetic resonance imaging at their earliest evaluation at the memory clinic. From each patient's structural imaging scans, the mean volumes of 18 regions of interest (ROI) constituting the functional networks specifically vulnerable in bvFTD, including the salience network (SN), with key nodes in the frontoinsula and pregenual anterior cingulate, and the semantic appraisal network (SAN), anchored in the anterior temporal lobe and subgenual cingulate, were estimated. Principal component and cluster analyses of ROI volumes were used to identify patient clusters with anatomically distinct atrophy patterns. Data were collected from from June 19, 2002, to January 13, 2015.Main outcomes and measuresEvaluation of brain morphology and other clinical features, including presenting symptoms, neurologic examination signs, neuropsychological performance, rate of dementia progression, and socioemotional function, in each patient cluster.ResultsNinety patients (54 men [60%]; 36 women [40%]; mean [SD] age at evaluation, 55.1 [9.7] years) were included in the analysis. Four subgroups of patients with bvFTD with distinct anatomic patterns of network degeneration were identified, including 2 salience network-predominant subgroups (frontal/temporal [SN-FT] and frontal [SN-F]), a semantic appraisal network-predominant group (SAN), and a subcortical-predominant group. Subgroups demonstrated distinct patterns of cognitive, socioemotional, and motor symptoms, as well as genetic compositions and estimated rates of disease progression.Conclusions and relevanceDivergent patterns of vulnerability in specific functional network components make an important contribution to the clinical heterogeneity of bvFTD. The data-driven anatomic classification identifies biologically meaningful anatomic phenotypes and provides a replicable approach to disambiguate the bvFTD syndrome

Distinct Subtypes of Behavioral Variant Frontotemporal Dementia Based on Patterns of Network Degeneration.

ImportanceClearer delineation of the phenotypic heterogeneity within behavioral variant frontotemporal dementia (bvFTD) will help uncover underlying biological mechanisms and improve clinicians' ability to predict disease course and to design targeted management strategies.ObjectiveTo identify subtypes of bvFTD syndrome based on distinctive patterns of atrophy defined by selective vulnerability of specific functional networks targeted in bvFTD using statistical classification approaches.Design, setting and participantsIn this retrospective observational study, 90 patients meeting the Frontotemporal Dementia Consortium consensus criteria for bvFTD underwent evaluation at the Memory and Aging Center of the Department of Neurology at University of California, San Francisco. Patients underwent a multidisciplinary clinical evaluation, including clinical demographics, genetic testing, symptom evaluation, neurologic examination, neuropsychological bedside testing, and socioemotional assessments. All patients underwent structural magnetic resonance imaging at their earliest evaluation at the memory clinic. From each patient's structural imaging scans, the mean volumes of 18 regions of interest (ROI) constituting the functional networks specifically vulnerable in bvFTD, including the salience network (SN), with key nodes in the frontoinsula and pregenual anterior cingulate, and the semantic appraisal network (SAN), anchored in the anterior temporal lobe and subgenual cingulate, were estimated. Principal component and cluster analyses of ROI volumes were used to identify patient clusters with anatomically distinct atrophy patterns. Data were collected from from June 19, 2002, to January 13, 2015.Main outcomes and measuresEvaluation of brain morphology and other clinical features, including presenting symptoms, neurologic examination signs, neuropsychological performance, rate of dementia progression, and socioemotional function, in each patient cluster.ResultsNinety patients (54 men [60%]; 36 women [40%]; mean [SD] age at evaluation, 55.1 [9.7] years) were included in the analysis. Four subgroups of patients with bvFTD with distinct anatomic patterns of network degeneration were identified, including 2 salience network-predominant subgroups (frontal/temporal [SN-FT] and frontal [SN-F]), a semantic appraisal network-predominant group (SAN), and a subcortical-predominant group. Subgroups demonstrated distinct patterns of cognitive, socioemotional, and motor symptoms, as well as genetic compositions and estimated rates of disease progression.Conclusions and relevanceDivergent patterns of vulnerability in specific functional network components make an important contribution to the clinical heterogeneity of bvFTD. The data-driven anatomic classification identifies biologically meaningful anatomic phenotypes and provides a replicable approach to disambiguate the bvFTD syndrome