Culinary Medicine Experiences for Medical Students and Residents in the U.S. and Canada: A Scoping Review.

PHENOMENON: Despite the importance of diet in the prevention and management of many common chronic diseases, nutrition training in medicine is largely inadequate in medical school and residency. The emerging field of culinary medicine offers an experiential nutrition learning approach with the potential to address the need for improved nutrition training of physicians. Exploring this innovative nutrition training strategy, this scoping review describes the nature of culinary medicine experiences for medical students and resident physicians, their impact on the medical trainees, and barriers and facilitators to their implementation. APPROACH: This scoping review used the Joanna Briggs Institute methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR) checklist as guides. Eligible publications described the nature, impact, facilitators, and/or barriers of nutrition and food preparation learning experiences for medical students and/or residents. Additional inclusion criteria were location (U.S. or Canada), allopathic or osteopathic, English, human subjects, and publication year (2002 or later). The search strategy included 4 electronic databases. Two reviewers independently screened titles/abstracts and a third reviewer resolved discrepancies. The full-text review consisted of 2 independent reviews with discrepancies resolved by a third reviewer or by consensus if needed, and the research team extracted data from the included articles based on the nature, impact, barriers, and facilitators of culinary medicine experiences for medical trainees. FINDINGS: The publication search resulted in 100 publications describing 116 experiences from 70 institutions. Thirty-seven publications described pilot experiences. Elective/extracurricular and medical student experiences were more common than required and resident experiences, respectively. Experiences varied in logistics, instruction, and curricula. Common themes of tailored culinary medicine experiences included community engagement/service-based learning, interprofessional education, attention to social determinants of health, trainee well-being, and cultural considerations. Program evaluations commonly reported the outcome of experiences on participant attitudes, knowledge, skills, confidence, and behaviors. Frequent barriers to implementation included time, faculty, cost/funding, kitchen space, and institutional support while common facilitators of experiences included funding/donations, collaboratives and partnerships, teaching kitchen access, faculty and institutional support, and trainee advocacy. INSIGHTS: Culinary medicine is an innovative approach to address the need and increased demand for improved nutrition training in medicine. The findings from this review can guide medical education stakeholders interested in developing or modifying culinary medicine experiences. Despite barriers to implementation, culinary medicine experiences can be offered in a variety of ways during undergraduate and graduate medical education and can be creatively designed to fulfill some accreditation standards.

Strengthening Parent - Physician Communication: A Mixed Methods Study on Attuned Communication Training for Pediatric Residents.

Problem: High-quality communication improves patient satisfaction and clinical outcomes, yet formal communication training in residency is often minimal. Many studies on empathic communication show mixed results and are often hindered and skewed by brief study lengths, insufficiently and ambiguously defined concepts, and limited methods for objective measurements. Intervention: The FAN Curriculum is a unique communication curriculum, based on the conceptual frameworks of patient-centered communication, reflective practice, mindfulness, and attunement using the Facilitating Attuned Interactions (FAN) model. The first part of the FAN Curriculum was delivered as a 3-hour interactive workshop involving didactics, group discussion, and role play with pediatric residents. Residents then completed weekly self-reflections, a follow-up one-hour training to reinforce concepts, and five monthly mentor sessions, all emphasizing reflective practice. Context: This longitudinal, mixed-methods study examined the effects of the FAN Curriculum on residents' empathy levels and ability to communicate with parents in the clinical setting. The study was conducted at two urban, academic, medium-sized pediatric residency programs in Chicago between October 2016 and November 2017. First- and second-year pediatric residents whose continuity clinic site was located at their home institution participated. Residents received training in the use of the FAN Communication Tool using a delayed-start crossover study design. Impact: At five time points, residents and parents completed instruments validated for measuring physician empathy and mindfulness. Post-study interviews were conducted for one institution's residents and mentors and were evaluated using open and focused coding. Participants (n = 23) demonstrated a high degree of use of the FAN Communication Tool six months post-training and a significant rise in self-reported comfort with four of five FAN core processes. One parent-completed survey (Consultation and Relational Empathy, CARE) showed a statistically significant rise of 3.26% in resident relational empathy and collaboration after training (p = 0.02). In qualitative analysis of interviews, residents and mentors found the FAN Communication Tool beneficial, making clinic visits more efficient and collaborative. Both groups noted improvement in the residents' relationship-building skills; residents were able to use enhanced communication skills to better approach challenging encounters and work through parent concerns. Lessons Learned: Family-centered communication training can improve physician-perceived empathy and mindfulness. Effective communication for pediatric residents incorporates an empathic approach, and introduction to this formal curriculum supported their growth in connecting and engaging with children and parents. The FAN Curriculum may provide a useful method for improving resident communication skills with a positive impact on pediatricians' collaboration with patients and families.

Parent Perspectives on Adverse Childhood Experiences & Unmet Social Needs Screening in the Medical Home: A Qualitative Study.

OBJECTIVES: To explore parental perspectives regarding disclosure of child and parental adverse childhood experiences (ACE) and family unmet social needs (USN) and to elicit parental recommendations for screening in the pediatric medical home. METHODS: We conducted a qualitative study using a purposive sample of English- and Spanish-speaking parents in our urban academic community clinic. Between January 2018 and March 2019, each parent underwent one semistructured interview that was audiotaped, transcribed, and independently coded in Atlas.ti by 2 study team members. Data analysis was based in constructivist grounded theory methodology to identify common themes and subthemes. RESULTS: We interviewed 25 English-speaking and 15 Spanish-speaking parents who were mostly female, racial/ethnic minorities with ≥1 ACE. English-speaking subjects were more likely to have a high school degree and be single parents. Four themes were identified: 1) Pediatricians should ask about ACE and USN. 2) Disclosure is a longitudinal process, not a discrete event. 3) Barriers to disclosure are significant, involving concrete and emotional risks for the family. 4) Trauma-informed providers and practices support disclosure. CONCLUSIONS: Families support pediatricians addressing ACE and USN in the medical home despite significant barriers. Even if providers screen using trauma-informed principles, parents may prefer not to disclose ACE initially because they regard disclosure as a stepwise process. These findings contribute to a new conceptual framework for thinking of ACE screening not merely as a way to generate information, but as an interactive, therapeutic relationship-building activity irrespective of whether or when it produces disclosure.

Spontaneous Pneumothorax as a Late Complication of Mild COVID-19 Infection: A Case Report.

Spontaneous pneumothorax (PTX) is a rare but life-threatening complication of lung injuries sustained from severe COVID-19 infection, most commonly associated with mechanical ventilation. Development of spontaneous PTX in patients after only mild COVID-19 infections not requiring hospitalization is even rarer. Here, we present the case of a 37-year-old male with spontaneous PTX secondary to a mild COVID-19 infection diagnosed one-month prior. A computed tomography (CT) scan of the chest revealed new air-filled cysts thought to be mediated by the inflammatory response to his acute infection, and his PTX was thought to be secondary to cyst wall rupture due to prolonged coughing. He was successfully treated with a chest tube and supplemental oxygen and, at a two-month follow-up, demonstrated clinical and radiographic improvement.

Climate Change and the Practice of Medicine: Essentials for Resident Education.

Despite calls for including content on climate change and its effect on health in curricula across the spectrum of medical education, no widely used resource exists to guide residency training programs in this effort. This lack of resources poses challenges for training program leaders seeking to incorporate evidence-based climate and health content into their curricula. Climate change increases risks of heat-related illness, infections, asthma, mental health disorders, poor perinatal outcomes, adverse experiences from trauma and displacement, and other harms. More numerous and increasingly dangerous natural disasters caused by climate change impair delivery of care by disrupting supply chains and compromising power supplies. Graduating trainees face a knowledge gap in understanding, managing, and mitigating these many-faceted consequences of climate change, which-expected to intensify in coming decades-will influence both the health of their patients and the health care they deliver. In this article, the authors propose a framework of climate change and health educational content for residents, including how climate change (1) harms health, (2) necessitates adaptation in clinical practice, and (3) undermines health care delivery. The authors propose not only learning objectives linked to the Accreditation Council for Graduate Medical Education core competencies for resident education but also learning formats and assessment strategies in each content area. They also present opportunities for implementation of climate and health education in residency training programs. Including this content in residency education will better prepare doctors to deliver anticipatory guidance to at-risk patients, manage those experiencing climate-related health effects, and reduce care disruptions during climate-driven extreme weather events.

Reported Pediatrics Milestones (Mostly) Measure Program, Not Learner Performance.

PURPOSE: Semiannually, U.S. pediatrics residency programs report resident milestone levels to the Accreditation Council for Graduate Medical Education (ACGME). The Pediatrics Milestones Assessment Collaborative (PMAC, consisting of the National Board of Medical Examiners, American Board of Pediatrics, and Association of Pediatric Program Directors) developed workplace-based assessments of 2 inferences: readiness to serve as an intern with a supervisor present (D1) and readiness to care for patients with a supervisor nearby in the pediatric inpatient setting (D2). The authors compared learner and program variance in PMAC scores with ACGME milestones. METHOD: The authors examined sources of variance in PMAC scores and milestones between November 2015 and May 2017 of 181 interns at 8 U.S. pediatrics residency programs using random effects models with program, competency, learner, and program × competency components. RESULTS: Program-related milestone variance was substantial (54% D1, 68% D2), both in comparison to learner milestone variance (22% D1, 14% D2) and program variance in the PMAC scores (12% D1, 10% D2). In contrast, learner variance represented 44% (D1) or 26% (D2) of variance in PMAC scores. Within programs, PMAC scores were positively correlated with milestones for all but one competency. CONCLUSIONS: PMAC assessments provided scores with little program-specific variance and were more sensitive to differences in learners within programs compared with milestones. Milestones reflected greater differences by program than by learner. This may represent program-based differences in intern performance or in use of milestones as a reporting scale. Comparing individual learner milestones without adjusting for programs is problematic.

The Acculturation Toolkit: An Orientation for Pediatric International Medical Graduates Transitioning to the United States Medical System.

Introduction: International medical graduates (IMGs) consistently contribute to the US physician workforce. In fact, 25% of practicing pediatricians in the US are IMGs, highlighting the needs of IMG trainees. IMGs face unique challenges with acculturation compared to their peers due to unfamiliarity with the US medical system, especially the dynamics around patient-centered care. The literature supports the need for formal acculturation curricula. Methods: A cohort of program directors who train pediatric IMGs coupled findings from the literature with local themes from IMG focus groups to identify topics for an acculturation curriculum. Three small-group workshops utilized didactics, discussion, and role-play to cover topics related to patient-centered care, challenging communication with patients, complex psychosocial histories, and health literacy. The pilot was modified based on feedback and to enhance generalizability. The resulting four-module curriculum with presentations and supplemental materials is presented here. Results: After a 3-year pilot with 36 PGY 1 trainees, postcurriculum surveys reported 8.1 out of 10 in workshop satisfaction, plus increased knowledge and skills related to patient-centered care and communication with patients. Role-plays were the favorite activity. A 1-year follow-up survey reported the workshops to be influential on satisfaction with patient relationships and easing transition to residency. Discussion: A pilot acculturation curriculum addressing needs of pediatric IMG trainees was well received by participants and improved their comfort level in addressing challenging patient-communication scenarios. Pediatric programs that train IMGs can incorporate this curriculum to aid residents' transition to clinical practice in the US.

Cultivating a way of being and doing: Individual strategies for physician well-being and resilience.

The practice of medicine is rewarding on many levels, but demands of the work can result in mental and emotional exhaustion, self-isolation, burnout, depression, suicidal ideation and tragically, completed suicide. It is critical to have effective strategies to address the unique stressors of a medical career, mitigate burnout, and buffer the physiologic toll of chronic stress. Using Zwack and Schweitzer's widely published description of approaches to maintaining resilience and approaches to wellness, we have organized these strategies into three broad domains relevant to medical practice: (1) gratification (connection and communication, meaning and purpose); (2) resilience building practices (self-reflection, time for oneself, self-compassion, spirituality); and (3) useful attitudes (acceptance, flexibility, self-awareness). Several techniques are described including mindfulness-based stress reduction, narrative medicine, skillful communication, and practices in self-compassion, gratitude, and spirituality. The focus of the work is to introduce a spectrum of resilience strategies for individual consideration that can be tailored and combined to meet a physician's changing needs over the course of medical training and practice.

Implementing Emotional Debriefing in Pediatric Clinical Education.

Challenging situations and intense emotions are inherent to clinical practice. Failure to address these emotions has been associated with health care provider burnout. One way to combat this burnout and increase resilience is participation in emotional debriefing. Although there are many models of emotional debriefings, these are not commonly performed in clinical practice. We provide a guide for implementing emotional debriefing training utilizing the American Academy of Pediatrics Resilience Curriculum into clinical training programs, with a focus on preparing senior residents and fellows to act as debriefing facilitators. Senior residents and fellows can provide in-the-moment emotional debriefing which allows for greater health care provider participation, including medical students and other pediatric trainees. Training of senior residents and fellows may allow more frequent emotional debriefing and in turn may help to improve the resilience of pediatricians when they face challenging situations in clinical practice.

Screening for Toxic Stress Risk Factors at Well-Child Visits: The Addressing Social Key Questions for Health Study.

OBJECTIVES: To determine the prevalence of and demographic characteristics associated with toxic stress risk factors by universal screening, the impact of screening on referral rates to community resources, and the feasibility and acceptability of screening in a medical home setting. STUDY DESIGN: We developed the Addressing Social Key Questions for Health Questionnaire, a 13-question screen of adverse childhood experiences (ACEs) and unmet social needs. Parents/guardians of children 0-17 years of age received this questionnaire at well-child visits at 4 academic clinics from August 1, 2016 to February 28, 2017. Providers reviewed the tool and referred to community resources as needed. A subset of families completed demographic and satisfaction surveys. Prevalence of ACEs and unmet social needs, community referral rates at 1 site with available data, and family acceptability data were collected. Analyses included frequency distributions, χ2 tests, and Poisson regression. RESULTS: Of 2569 families completing an Addressing Social Key Questions for Health Questionnaire, 49% reported ≥1 stressor; 6% had ≥1 ACE; 47% had ≥1 unmet social need. At 1 site, community referral rates increased from 2.0% to 13.3% (P < .0001) after screening implementation. Risk factors for having a stressor include male sex and African American or Hispanic race. 86% of 446 families want clinics to continue screening. CONCLUSIONS: Universal screening for toxic stress risk factors in pediatric primary care improved identification and management of family needs. Screening was feasible and acceptable to families. Prevalence of unmet social needs but not ACEs was comparable with prior studies. Further evaluation and modification of the screening protocol is needed to increase screening and identification.

Validity Evidence From Ratings of Pediatric Interns and Subinterns on a Subset of Pediatric Milestones.

PURPOSE: To investigate evidence for validity of faculty members' pediatric milestone (PM) ratings of interns (first-year residents) and subinterns (fourth-year medical students) on nine subcompetencies related to readiness to serve as a pediatric intern in the inpatient setting. METHOD: The Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network (APPD LEARN) and the National Board of Medical Examiners collaborated to investigate the utility of assessments of the PMs for trainees' performance. Data from 32 subinterns and 179 interns at 17 programs were collected from July 2012 through April 2013. Observers used several tools to assess learners. At each site, a faculty member used these data to make judgments about the learner's current developmental milestone in each subcompetency. Linear mixed models were fitted to milestone judgments to examine their relationship with learner's rank and subcompetency. RESULTS: On a 5-point developmental scale, mean milestone levels for interns ranged from 3.20 (for the subcompetency Work effectively as a member of a team) to 3.72 (Humanism) and for subinterns from 2.89 (Organize and prioritize care) to 3.61 (Professionalization). Mean milestone ratings were significantly higher for the Professionalism competency (3.59-3.72) for all trainees compared with Patient Care (2.89-3.24) and Personal and Professional Development (3.33-3.51). Mean intern ratings were significantly higher than mean subintern ratings for all nine subcompetencies except Professionalization, Humanism, and Trustworthiness. CONCLUSIONS: The PMs had a coherent internal structure and could distinguish between differing levels of trainees, which supports their validation for documenting developmental progression of pediatric trainees.

Acculturation Needs of Pediatric International Medical Graduates: A Qualitative Study.

Phenomenon: International medical graduates (IMGs) play a key role in host countries' health systems but face unique challenges, which makes effective, tailored support for IMGs essential. Prior literature describing the acculturation needs of IMGs focused primarily on communication content and style. We conducted a qualitative study to explore acculturation that might be specific to IMG residents who care for children. APPROACH: In a study conducted from November 2011 to April 2012, we performed four 90-minute semistructured focus groups with 26 pediatric IMG residents from 12 countries. The focus group transcripts were analyzed using open and focused coding methodology. FINDINGS: The focus groups and subsequent analysis demonstrated that pediatric IMG residents' socialization to their home culture impacts their transition to practice in the United States; they must adjust not only to a U.S. culture, different from their own, but also to the culture of medicine in the United States. We identified the following new acculturation themes: understanding the education system and family structure, social determinants of health, communication with African American parents, contraception, physician handoffs, physicians' role in prevention, adolescent health, and physicians' role in child advocacy. We further highlight the acculturation challenges faced by pediatric IMG residents and offer brief recommendations for the creation of a deliberate acculturation curriculum for pediatric IMG residents. Insight: Residency training is a unique period in physicians' personal and professional development and can be particularly challenging for IMGs. There is a significant gap in the identified acculturation needs and the current curricula available to IMG residents who care for children.

The AAP Resilience in the Face of Grief and Loss Curriculum.

A career in pediatrics can bring great joy and satisfaction. It can also be challenging and lead some providers to manifest burnout and depression. A curriculum designed to help pediatric health providers acquire resilience and adaptive skills may be a key element in transforming times of anxiety and grief into rewarding professional experiences. The need for this curriculum was identified by the American Academy of Pediatrics Section on Medical Students, Residents and Fellowship Trainees. A working group of educators developed this curriculum to address the professional attitudes, knowledge, and skills essential to thrive despite the many stressors inevitable in clinical care. Fourteen modules incorporating adult learning theory were developed. The first 2 sections of the curriculum address the knowledge and skills to approach disclosure of life-altering diagnoses, and the second 2 sections focus on the provider's responses to difficult patient care experiences and their needs to develop strategies to maintain their own well-being. This curriculum addresses the intellectual and emotional characteristics patient care medical professionals need to provide high-quality, compassionate care while also addressing active and intentional ways to maintain personal wellness and resilience.

A novel approach to postpartum contraception: a pilot project of Pediatricians' role during the well-baby visit.

BACKGROUND: Postpartum women are at high risk of unintended pregnancy as many do not receive timely postpartum contraception. Utilization of routine postpartum care varies widely. Conversely, the Well-Baby Visit (WBV) for newborns is highly utilized and provides an opportunity to discuss contraception with mothers. This project aimed to test the feasibility and acceptability of having pediatric residents administer a simplified Reproductive Life Plan Tool (RLPT) with postpartum women during routine infant care. METHODS: Pediatric resident physicians used the RLPT with mothers of infants 16-weeks of age or less during WBVs. The RLPT prompts physicians to ask general questions about women's contraceptive needs and offer referral services for mothers who desire contraception services. Residents participated in a feedback session and survey to assess acceptance and perceived feasibility of using the RLPT during routine care. RESULTS: Pediatric residents completed 50 RLPTs. Seventeen percent of eligible women accepted a referral to contraception services. During feedback sessions, pediatric residents (n = 18) reported comfort implementing the intervention and acceptance of the RLPT for discussing contraception. Concerns included limited time during the WBV and the potential to shift focus away from infant. On a post-intervention survey (n = 14), 92.9 % of physicians reported comfort in using the RLPT, and 71.4 % reported that the tool was easily understood although findings were varied regarding ease of implementing a RLPT in practice. CONCLUSIONS: Findings indicate that use of the RLPT is generally feasible during routine infant care and acceptable to pediatric resident physicians with recognition of challenges to implementation. Acceptance of a referral was low among postpartum women in this pilot study.

Educational interventions for international medical graduates: a review and agenda.

CONTEXT: International medical graduates (IMGs) play key roles in the health systems of their host countries, but face unique challenges, which makes the provision of effective, tailored support for IMGs essential. OBJECTIVES: Research on the effectiveness of educational interventions for IMGs was reviewed to characterise current knowledge and guide future research and education. METHODS: PubMed, Web of Science and EMBASE were searched for relevant articles published to October 2014, describing a systematic evaluation of educational interventions designed for IMGs that included at least one post-intervention outcome. Articles were coded independently by two or more researchers for content and methodology, and discussed to reach consensus. RESULTS: Twenty-two articles were identified, describing a wide variety of interventions, content and durations of intervention. Clinical topics and general principles of cross-cultural competency were the most common content areas included in curricula (13 and 12 articles, respectively). All studies deemed the interventions evaluated to be successful. However, only one study drew from theory on cross-cultural differences to guide either the curriculum or evaluation. Additionally, study designs were generally weak; no studies featured random assignment to treatment versus control groups, most studies did not use control groups at all, and no studies compared the effectiveness of different interventions. CONCLUSIONS: Research into education for IMGs is critically important but currently underdeveloped. An abundance of justification studies and lack of clarification studies parallel other areas of medical education. Academic fields outside medical education, such as those of cross-cultural psychology and expatriate management, are highly relevant; researchers from these areas should be sought for collaboration. Future research should employ conceptual frameworks in order to facilitate a broader, more nuanced consideration of the diversity of individual IMGs, educational and medical contexts, interventions and outcomes. Rigorous comparative effectiveness research is lacking, but represents a promising avenue for future scholarship.

Interventions to curb the overuse of Acid-suppressive medications on an inpatient general medicine service.

PURPOSE: We conducted a study to measure the impact of three sequential levels of intervention on prescribing patterns of acid-suppressive medications (ASMs) on an inpatient internal medicine service at a university hospital. METHODS: THIS RETROSPECTIVE REVIEW COMPARED PRESCRIBING PATTERNS ON FOUR DIFFERENT TIERS: a phase 1 study, conducted one year before the phase 2 intervention study; and three phase 2 interventions. Each group was assessed for the percentage of all patients receiving ASMs and the percentage of patients receiving these drugs with an inappropriate indication. The three phase 2 studies are described in this article. RESULTS: Intervention A (a beginning-of-year lecture to all interns) was not enough to decrease total in-hospital use of these medications, compared with the phase 1 historical controls (62% vs. 66%, respectively); however, it did decrease the rate of inappropriate use from 59% to 37% (P < 0.001). When Intervention B (an early-in-the-month rotation "reminder lecture") was added, the volume of agents used was significantly reduced to 53% (P = 0.025) and the number of inappropriate prescriptions was reduced to 32% (P < 0.001), compared with rates in phase 1. Finally, when Intervention C (a clinical pharmacist making rounds with the health care team on most post-call days) was added to Interventions A and B, the total volume of drug use in the hospital declined to 53% (P = 0.025) and the number of inappropriate prescriptions fell to 19%, compared with rates in phase 1 (P < 0.001). CONCLUSION: Providing educational lectures for interns was helpful in curbing the inappropriate prescribing of ASMs, but the benefit was augmented when a clinical pharmacist was added to the team.

Influenza vaccine for high-risk non-elderly adults: a national survey of subspecialists.

Despite long-standing recommendations for non-elderly adults with certain chronic pulmonary, cardiovascular and metabolic conditions to receive influenza vaccine, vaccination rates remain low. Visits to subspecialists represent an important vaccination opportunity, but little is known regarding subspecialists' perceptions related to influenza vaccination. In February 2003, we conducted a cross-sectional mail survey of a random sample (N = 2,007) of board-certified cardiologists, endocrinologists and pulmonologists from the entire United States who provided outpatient care to adults aged 18-64 years, to assess their patterns of and attitudes toward administering influenza vaccine to high-risk, non-elderly patients. The overall response rate was 33%. Among 621 eligible respondents, 483 stocked influenza vaccine in their practice (Stockers) and 138 did not stock the vaccine (Non-Stockers). Pulmonologists were most likely to stock vaccine and strongly recommend vaccination; cardiologists were least likely. Among Stockers, barriers to vaccination varied by subspecialty. Among Non-Stockers, the most common factor in the decision to not stock vaccine was the perception that patients will receive the vaccine elsewhere. Most subspecialists who provide care to a large proportion of high-risk, non-elderly persons recommend influenza vaccination to some degree, particularly pulmonologists. To reduce missed opportunities overall, subspecialists should be encouraged to vaccinate patients who say that they plan to get the vaccine elsewhere. For cardiologists in particular, barriers to stocking influenza vaccine and recommending vaccination more strongly must be addressed.