Training residents in depression and grief.

BACKGROUND: About 20 per cent of Americans will experience depression in their lifetimes, and almost all will experience the death of a loved one. Both depression and grief have been associated with adverse health outcomes, including a decline in quality of life and excess mortality. Primary care physicians (PCPs) are the initial health care contact for most patients with depression and grief, yet often perceive that they lack the skills to adequately address these issues. Previous studies have investigated whether educational efforts improve PCP depression and grief knowledge or perceived skills, but few have focused on medical residents. There is the potential that resident education may impact practice over a longer span of time than later career training, simply because it occurs earlier in one's medical career. METHODS: The authors examined whether a brief educational curriculum, delivered in two 2-hour sessions to 40 internal medicine residents, was associated with changes in knowledge, attitudes, comfort level and reported behaviours, with regards to grieving or depressed patients. Self-report surveys were administered before and about 5 months after receipt of the new curriculum. RESULTS: Residents receiving the curriculum reported increases in knowledge, confidence and self-reported behaviours in working with patients suffering depression and grief. Both depression and grief have been associated with adverse health outcomes DISCUSSION: Although more research is needed to determine whether these findings can be replicated in other settings, the results are promising. Further dissemination of such training may ultimately enhance the detection and treatment of depression and grief in primary care, and decrease the associated emotional and functional burdens in patients.

Faculty development in point of care ultrasound for internists.

Lack of general medicine faculty expertise is a likely contributor to the slow adoption of point of care ultrasound (POCUS) by internal medicine (IM) residency training programs. We developed a 10-week faculty development program, during which 15 faculty members participated in 2 hours and 10 hours of online didactic and hands-on training, respectively. Pre-post comparisons showed that there were statistically significant improvements in faculty participants' ability to interpret images (p<0.001), perceived understanding of the capabilities and limitations of POCUS (p=0.003), comfort using POCUS to make clinical decisions (p=0.003), and perceptions regarding the extent to which POCUS can improve patient care (p=0.026). The next challenge for IM programs is to improve access to ultrasound machines and provide follow-up workshops to facilitate further development of skills and integration of POCUS into daily practice by general medicine faculty.

Using peer-assisted learning to teach and evaluate residents' musculoskeletal skills.

Although direct observation and corrective feedback are established methods of increasing select aspects of residents' musculoskeletal (MSK) clinical skills, the evaluation and management of patients with MSK complaints remains an underemphasized part of internal medicine training. This paper reports on the development of an innovative peer-assisted learning (PAL) model to teach five MSK areas (back, knee, shoulder, neck, or hip pain). Based on data from 42 participating interns and 44 senior residents from an urban US academic medical center, results from an objective structured clinical exam (OSCE) demonstrate gains in both knowledge and self-reported confidence in MSK skills. Moreover, subsequent focus group results reveal a strong preference for the PAL model. In conclusion, an educational module that utilizes the OSCE format holds much promise for teaching MSK skills to both intern and senior residents.

Assessing Effectiveness of a Geriatrics Rotation for Second-Year Internal Medicine Residents.

BACKGROUND: Residents need to acquire an understanding of the biopsychosocial aspects of caring for older adults with chronic illness, along with effective use of interdisciplinary services inside and outside of the hospital. OBJECTIVE: We expanded the geriatric medicine experience for second-year internal medicine residents and present the results of the first year's experience. METHODS: We paired a mandatory rotation for postgraduate year-2 internal medicine residents (2 weeks of day and 1 week of night inpatient experience in the Acute Care for Elders Unit), and a 1-week outpatient systems-based practice experience with online modules and readings. Evaluation included a case presentation, an oral examination, a written questionnaire for all residents, and a global assessment of the residents' performance on the geriatrics portion of the 2012 In-Training Examination (ITE). RESULTS: All residents passed their oral examination; there was little difference between classes in systems-based practice knowledge. More than 90% (21 of 23) of the residents who took the rotation reported that it left a lasting impression on how they would care for their patients. Mean ITE scores in geriatrics for all residents increased from 53% (versus 61% overall) in 2010 to 87% (versus 81%) in 2012, although they dropped to 69% (versus 82%) in 2013. CONCLUSIONS: A rotation in geriatrics that is highly rated and covers both acute care and systems-based practice concepts is feasible for internal medicine residents. Residents did not learn detailed knowledge about specific programs for older adults, but clinical geriatrics knowledge improved.

Morphological effects of estrogen on cholinergic neurons in vitro involves activation of extracellular signal-regulated kinases.

In the present study, we examined the ability of estrogen to enhance cholinergic neurite arborization in vitro and identified the signal transduction cascade associated with this effect. Basal forebrain primordia collected from rat pups on postnatal day 1 were cultured for 2 weeks and then treated with 5 nm 17beta-estradiol for 24 hr. Cholinergic neurons were identified immunocytochemically with an antibody against the vesicular acetylcholine transporter and digitally photographed. Morphological analysis indicated that female cultures respond to estrogen treatment with an increase in total neurite length per neuron (4.5-fold over untreated controls) and in total branch segment number per neuron (2.3-fold over controls). In contrast, there was no change in total neurite length per neuron in male cultures, and we also observed a decrease in total branch segment number per neuron (0.5-fold below controls). Detailed histograms indicated that estrogen increases primary and secondary branch length and number and also increases terminal neuritic branches to the seventh order in female cultures. In a second set of experiments, we investigated the signal transduction cascade involved in this response, and found that an upstream extracellular signal-regulated kinase (ERK) inhibitor blocked the ability of estrogen to enhance outgrowth in female cultures. Our study provides strong evidence in support of the fact that the ERK pathway is required for estrogen-induced structural plasticity in the cholinergic system of female rats. Understanding the intracellular processes that underlie the response of cholinergic neurons to estrogen provides a necessary step in elucidating how cholinergic neurons can be particularly susceptible to degeneration in postmenopausal women.