A Week Devoted to Wellness in the Preclinical Phase: Lessons Learned

Background During the 2017-2018 academic year, a large private medical college underwent a complete transformation of its curriculum from a primarily lecture based, traditional format to an integrated, longitudinal format that included both time limited blocks and longitudinal threads of content. Wellness, conceptualized at both wellness of the provider and the patient, is one of the eight threads. Goals Provide a structured pause in medical school for you to reflect on your own wellness Allow time to explore the ideas of resilience Provide time for rejuvenation Allow you to start building productive habits to last you throughout your entire medical careershttps://jdc.jefferson.edu/rmposters/1005/thumbnail.jp

Rehabilitation of a Patient with Diabetic Myonecrosis: A Case Report

Setting: Inpatient rehabilitation unit at a university hospital Patient: 37-year-old male with diabetic myonecrosis. Case Description: The patient had a long-standing history of uncontrolled diabetes mellitus with multiple comorbidities, including end-stage renal disease on dialysis and diabetic myonecrosis of the left biceps femoris diagnosed by biopsy and magnetic resonance imaging (MRI.) On this admission, he presented with right leg pain and swelling, found to be a reoccurrence of diabetic myonecrosis in the vastus lateralis, medialis, and intermedius, diagnosed by MRI only. Prior to admission, he lived alone in a wheelchair inaccessible duplex and required minimal assistance with housekeeping. Assessment/Results: Upon initial consultation, he ambulated 25-50 feet at a minimum assistance level with a single point cane. As he was unsafe to return home alone, he was transferred to inpatient rehabilitation after a two week acute hospitalization. During his rehabilitation stay, he increasingly was unable to tolerate standing secondary to pain, and at discharge, he was non-ambulatory despite many attempts at pain control and assistive devices for ambulation. His right leg swelling persisted throughout his stay. After five weeks on our unit, he was discharged to a long-term care facility at a wheelchair independent level. One year later he still was not ambulating, and still lived in the long-term care facility. Discussion: Diabetic myonecrosis is an uncommon complication of both insulin-dependent and non-insulin dependent diabetics. Symptoms usually resolve on their own with rest and analgesics within weeks to several months. There are reports of physical therapy prolonging the recovery period and exacerbating symptoms, which may have happened with our patient. Conclusions: Download poster

Utilization of Dantrolene in Stiff-Person Syndrome: A Case Report

Setting: University hospital-based acute rehabilitation. Patient: 75-year-old woman with Stiff-Person Syndrome (SPS) with a recent fall and Colles fracture. Case Description: Four months prior to admission, the patient was diagnosed with SPS, negative for anti-GAD antibodies. Diagnosis was based on a 3-year history of progressive rigidity leading to frequent falls and fractures. Anxiety and fear of falling limited her mobility, and she sustained a sacral pressure ulcer during acute hospitalization. On admission, history was remarkable for unsteady gait and muscle cramps exacerbated when startled or excited. Examination was remarkable for rigidity in her axial and limb muscles. She presented at the maximal assist level for transfers and toileting and moderate assist level for grooming and ambulation using a platform walker (right arm in cast). She was unable to tolerate titration of diazepam due to sedation, or baclofen due to hypotension. Results: During acute rehabilitation, rigidity was treated with titration of dantrolene (from 25 to 50 mg four times daily) in addition to maximal tolerated doses of diazepam (1 mg qAM/2 mg qPM) and baclofen (20mg TID). The addition of dantrolene reduced rigidity and improved range of motion, both subjectively per patient and objectively by exam. Functional gains stalled with dose decrease and resumed with dose increase. She had pronounced gains in grooming to the supervision level, modest gains in transfers and toileting to the moderate assist level, but remained at the moderate assist level for ambulation. Progress was limited due to a change to non-weight bearing status of her right arm. Anxiety and depression were improved with buspirone, paroxetine, and psychological counseling. Discussion: SPS results in significant activity of daily life and ambulatory dysfunction as exemplified by her pressure ulcer and multiple falls. Although GABA agonists are the preferred treatment for SPS, the adverse effects of high doses can increase the risk of falls. Dantrolene reduced muscle rigidity and improved function without sedative or hypotensive effects. Conclusion: Dantrolene is a useful additional treatment for SPS rigidity

The Role of Critical Case Analysis in Interprofessional Education

Goals for interprofessional education include preparing students to work in collaborative practice, teaching them how to work in teams and to asses and improve the quality of patient care. (Barr, 2007, Thibault, 2013). Four core competency domains have been established to inform interprofessional education (Interprofessional Education Collaborative Expert Panel, 2011). These are ethics/values, roles/responsibilities, interprofessional communication and teams/teamwork. Various pedagogical approaches have been used to help students meet these competencies. The Josiah Macy, Jr. Foundation (2013) recommends development and implementation of innovative models to link interprofessional education and practice. Thibault (2013) recommends students engage in “real work” as part of their interprofessional education experience

Intolerance of Uncertainty and Attitudes Towards Persons Living with Disabilities in Medical Students: Is There a Correlation?

INTRODUCTION: Patients living with a disability experience an illness trajectory that may be uncertain. While navigating clinical uncertainty has been well-researched, health professionals\u27 intolerance of uncertainty for patients living with disabilities has yet to be explored. We examined the relationship between medical students\u27 intolerance of uncertainty with their attitudes towards people living with disabilities to better inform curricular efforts. METHODS: We employed a survey-based design consisting of the Intolerance of Uncertainty Scale (IUS) and Disability Attitudes in Healthcare (DAHC) Scale to medical students upon completion of core clerkships (end of third-year of training). Data were de-identified. Mean DAHC and IUS scores were compared with published values RESULTS: Response rate was 97% (268/275 students). Mean IUS score did not differ from previously cited medical student scores, but mean DAHC score was significantly higher than previously cited scores. We observed a statistically-significant relationship between IUS and DAHC scores. Students with greater intolerance of uncertainty had lower scores for disability attitudes [ CONCLUSION: We identified a weak negative correlation between IUS and DAHC scores in medical students. Further research is needed to clarify findings and identify best practices that equip trainees with skills to care for patients with uncertain illness trajectories and patients living with disabilities

I Don\u27t Have a Diagnosis for You: Preparing Medical Students to Communicate Diagnostic Uncertainty in the Emergency Department

Introduction: Diagnostic uncertainty abounds in medicine, and communication of that uncertainty is critical to the delivery of high-quality patient care. While there has been training in communicating diagnostic uncertainty directed towards residents, a gap remains in preparing medical students to understand and communicate diagnostic uncertainty. We developed a session to introduce medical students to diagnostic uncertainty and to practice communicating uncertainty using a checklist during role-play patient conversations. Methods: This virtual session was conducted for third-year medical students at the conclusion of their core clerkships. It consisted of prework, didactic lecture, peer role-play, and debriefing. The prework included reflection prompts and an interactive online module. The role-play featured a patient complaining of abdominal pain being discharged from the emergency department without a confirmed diagnosis. Students participated in the role of patient, provider, or observer. Results: Data from an anonymous postsession survey (76% response rate; 202 of 265 students) indicated that most students (82%; 152 of 185) felt more comfortable communicating diagnostic uncertainty after the session. A majority (83%; 166 of 201) indicated the session was useful, and most (81%; 149 of 184) indicated it should be included in the curriculum. Discussion: This virtual session requires few facilitators; has peer role-play, eliminating the need for standardized patients; and is adaptable for in-person teaching. As its goal was to introduce an approach to communicating diagnostic uncertainty, not achieve mastery, students were not individually assessed for proficiency using the Uncertainty Communication Checklist. Students felt the session intervention was valuable

Teaching TeamSTEPPS to Interprofessional Students or Staff to Promote Teamwork and Patient Safety

TeamSTEPPS stands for Team Strategies and Tools to Enhance Performance and Patient Safety

Paradigms of Disability and the Americans with Disabilities Act

Objectives Compare and contrast different models of disability you will encounter in medicine Understand how the Americans with Disabilities Act applies to physician

Implementation of a Four Year Rehabilitation Curriculum for Medical Students

In 2009 the Vice-Dean of Undergraduate Medical Education modified the 4th year curriculum by eliminating the required clerkship in Rehabilitation Medicine, and the Department was tasked with the creation of a four year curricular thread. While disappointing, this was a blessing in disguise. For years, we attempted to fit a great deal of content into an ever decreasing timespan, to increasingly disinterested students. Our teachers were also burned out with the sheer volume of students. Through collaboration with other course directors, we inserted content where it fit the developmental needs of the students. We were also able to introduce students to physiatric role models earlier in training. The curriculum development had one guiding goal: “Students should be able to explain how a person’s functional abilities intersect with environment and societal roles to affect quality of life. “ In the preclinical years, we run or participate in physical exam workshops, have introduced the usage of the International Classification of Functioning, Disability and Health (ICF) to the two year longitudinal interprofessional education program; found ways to increase required exposure of students to patients with a wide range of disabilities, are present in the anatomy lab, and run a panel on access to care for individuals with disabling conditions. In addition, faculty members are involved in small group experiences with the students in the doctoring course. In the clinical years, we have required curriculum in the internal medicine, neurology, and family medicine rotations; and also run a required half day devoted to chronic pain. For more interested students there is both a 3rd year and a 4th year elective in Rehabilitation Medicine, and an interdepartmental outpatient sub-internship in Musculoskeletal Medicine. None of this would be possible without the support and guidance of the Vice-Dean, the Department Chair, and the sustained collaboration with course directors

Liver Transplant Recipient with Calcineurin-inhibitor Induced Pain Syndrome: A Case Report

Setting: University Hospital Patient: 65-year-old female status-post liver transplant secondary to cirrhosis. Case Description: Prior to the rehabilitation consult on post-operative day 42, she had an episode of acute rejection requiring rapid escalation of cyclosporine dosage, later changed to high dose tacrolimus for immunosuppression, resulting in high blood levels of both calcineurin inhibitors. She then complained of paroxysms of 10/10 pain over her entire body not relieved by opioids despite escalation in medication by the acute pain service. She was not participating in a rehabilitation program because of pain. Examination revealed an anxious woman for whom any tactile stimulation caused profound pain, precluding a thorough neuromuscular examination. She demonstrated spontaneous movement in all four limbs with akathesias. Assessment/Results: After a literature search and discussion with the transplant team to determine if calcineurin-inhibitor induced pain syndrome (CIPS) was a likely cause for her pain, the patient’s immunosuppressive regimen was adjusted, as she was no longer in acute rejection. Tacrolimus was stopped, and cyclosporine dosage was gradually increased over several weeks. After her calcineurin inhibitor levels dropped, she had relief of pain such that she no longer required opioids, and could participate fully in an inpatient rehabilitation program. After less than two weeks on our inpatient service, she was discharged at a supervision level for household ambulation with a rolling walker. Discussion: CIPS has been described as a cause of disabling pain after organ transplantation. In our patient, treatment of CIPS resulted in improved function. Reducing the blood levels of calcineurin inhibitor is the preferred treatment in the literature, as with our patient. In cases where this is not possible, calcium channel blockers have been used for pain relief. Conclusions: Download Poste