Exploring the Impact of Age, Frailty, and Multimorbidity on the Effect of ICU Interventions: A Systematic Review of Randomized Controlled Trials.

OBJECTIVES: To date, age, frailty, and multimorbidity have been used primarily to inform prognosis in older adults. It remains uncertain, however, whether these patient factors may also predict response to critical care interventions or treatment outcomes. DATA SOURCES: We conducted a systematic search of top general medicine and critical care journals for randomized controlled trials (RCTs) examining critical care interventions published between January 1, 2011, and December 31, 2021. STUDY SELECTION: We included RCTs of critical care interventions that examined any one of three subgroups-age, frailty, or multimorbidity. We excluded cluster RCTs, studies that did not report interventions in an ICU, and studies that did not report data examining subgroups of age, frailty, or multimorbidity. DATA EXTRACTION: We collected study characteristics (single vs. multicountry enrollment, single vs. multicenter enrollment, funding, sample size, intervention, comparator, primary outcome and secondary outcomes, length of follow-up), study population (inclusion and exclusion criteria, average age in intervention and comparator groups), and subgroup data. We used the Instrument for assessing the Credibility of Effect Modification Analyses instrument to evaluate the credibility of subgroup findings. DATA SYNTHESIS: Of 2037 unique citations, we included 48 RCTs comprising 50,779 total participants. Seven (14.6%) RCTs found evidence of statistically significant effect modification based on age, whereas none of the multimorbidity or frailty subgroups found evidence of statistically significant subgroup effect. Subgroup credibility ranged from very low to moderate. CONCLUSIONS: Most critical care RCTs do not examine for subgroup effects by frailty or multimorbidity. Although age is more commonly considered, the cut-point is variable, and relative effect modification is rare. Although interventional effects are likely similar across age groups, shared decision-making based on individual patient preferences must remain a priority. RCTs focused specifically on critically ill older adults or those living with frailty and/or multimorbidity are crucial to further address this research question.

Practicing Confidence: An Autoethnographic Exploration of the First Years as Physicians.

Phenomenon: Every year is heralded with a cohort of newly-minted medical school graduates. Through intense residency training and supervision, these learners gradually develop self-assurance in their newfound skills and ways of practice. What remains unknown, however, is how this confidence develops and on what it is founded. This study sought to provide an insider view of this evolution from the frontline experiences of resident doctors. Approach: Using an analytic collaborative autoethnographic approach, two resident physicians (Internal Medicine; Pediatrics) documented 73 real-time stories on their emerging sense of confidence over their first two years of residency. A thematic analysis of narrative reflections was conducted iteratively in partnership with a staff physician and a medical education researcher, allowing for rich, multi-perspective input. Reflections were analyzed and coded thematically and the various perspectives on data interpretation were negotiated by consensus discussion. Findings: In the personal stories and experiences shared, we take you through our own journey and development of confidence, which we have come to appreciate as a layered and often non-linear process. Key moments include fears in the face of the unknown; the shame of failures (real or perceived); the bits of courage gained by everyday and mundane successes; and the emergence of our personal sense of growth and physicianship. Insights: Through this work, we - as two Canadian resident physicians - have ventured to describe a longitudinal trajectory of confidence from the ground up. Although we enter residency with the label of 'physician,' our clinical acumen remains in its infancy. We graduate from residency still as physicians, but decidedly different in terms of our knowledge, attitudes, and skills. We sought to capitalize on the vulnerability and authenticity inherent in autoethnography to enrich our collective understanding of confidence acquisition in the resident physician and its implications for the practice of medicine.

Associations Between Patient Characteristics and Unplanned or Delayed Discharges From Geriatric Rehabilitation: A Retrospective Chart Review.

ABSTRACT: Returning home is considered an indicator of successful rehabilitation for community-dwelling older adults. However, the factors associated with unplanned discharge remain uncertain. This retrospective chart review included patients 65 yrs and older admitted to a geriatric rehabilitation unit from medical and surgical wards in an academic hospital. Patient characteristics and outcomes were abstracted from the electronic medical record. The primary outcome was unplanned discharge destination defined as anything other than return to patients' preexisting residence. The associations between patient variables and unplanned discharge destination were analyzed using Pearson χ 2 and univariate logistic regression. Of the 251 charts screened, 25 patients (10.0%) had an unplanned discharge destination, and 74 of the remaining 226 (32.7%) experienced a delayed discharge (beyond 20 days). Requiring assistance for activities of daily living (odds ratio [OR], 2.80; 95% confidence interval [CI], 1.17-7.47), a diagnosis of chronic obstructive pulmonary disease (OR, 4.04; 95% CI, 1.63-9.71), and lower serum albumin level (OR, 1.67; 95% CI, 1.06-2.72) were associated with unplanned discharge. Variables commonly associated with worse outcomes such as age, cognitive scores, delirium, and number of comorbidities were not barriers to returning home and should therefore not be used on their own to limit access to geriatric rehabilitation.

Assessing the learning needs of physical medicine and rehabilitation residents to develop a geriatric medicine and rehabilitation curriculum.

BACKGROUND: Older adults with functional impairment are cared for by physiatrists in rehabilitation, but physiatrist training in geriatric-related competencies remains suboptimal. To develop a geriatric rehabilitation (GR) curriculum and explore opportunities for improvement, a needs assessment of stakeholders was conducted to understand physical medicine and rehabilitation (PMR) residents' comfort levels and learning needs in geriatrics. METHODS: A mixed-methods design was employed. PMR residents (n = 18) and practicing physiatrists (n = 40) completed a questionnaire; and PMR residents, physiatrists and key informants (n = 9; n = 4; n = 6) participated in focus groups and semi-structured interviews to explore geriatric experiences of trainees and educational needs in geriatrics and rehabilitation. Data were qualitatively analyzed using constructivist-grounded theory. RESULTS: Residents and physiatrists highlighted similar topics as areas of low comfort in knowledge. Interviews prioritized critical geriatric topics (gait assessment, falls, cognitive impairment, movement disorders, and polypharmacy) and highlighted disposition planning and end-of-life care as areas needing further curriculum support. Challenges in delivering geriatric education were also identified. CONCLUSION: What emerged from the needs assessment was a series of critical geriatric educational priorities for the development of a GR curriculum for physiatry trainees - arising at an opportune time given the shift toward competency-based residency education.

A mixed methods evaluation of a 4-week geriatrics curriculum in strengthening knowledge and comfort among orthopaedic surgery residents.

BACKGROUND: In 2014, the University of Toronto Faculty of Medicine implemented a 4-week "Orthogeriatrics" rotation for orthopaedic surgery residents. We sought to assess the rotation's impact on trainees' knowledge, attitudes, and behaviours toward caring for older adults, and explore areas for improvement. METHODS: We used a mixed methods concurrent triangulation design. The Geriatrics Clinical Decision-Making Assessment (GCDMA) and Geriatric Attitudes Scale (GAS) compared knowledge, attitudes, and behaviours between trainees who were or were not exposed to the curriculum. Rotation evaluations and semi-structured interviews with trainees and key informants explored learning experiences and the curriculum's impact on resident physician growth and development in geriatric competencies. RESULTS: Among trainees who completed the GCDMA (n = 19), those exposed to the rotation scored higher in knowledge compared to the unexposed cohort (14.4 ± 2.1 vs. 11.3 ± 2.0, p < 0.01). The following themes emerged from the qualitative analysis of 29 stakeholders: Increased awareness and comfort regarding geriatric medicine competencies, appreciation of the value of orthogeriatric collaboration, and suggestions for curriculum improvement. CONCLUSIONS: These results suggest that the Orthogeriatrics curriculum strengthens knowledge, behaviour, and comfort towards caring for older adults. Our study aims to inform further curriculum development and facilitate dissemination of geriatric education in surgical training programs across Canada and the world.

Capturing the Moments: An Autoethnographic Exploration of Self-Preservation in Clerkship.

PhenomenonFor most medical students, clerkship represents a transitional phase into the 'real world' of medicine. This transition is often accompanied by significant mental stressors, burnout, and empathy decline. Educator led resilience curricula designed to support students during this critical period often focus on teaching generalized strategies to promote wellness and lack the student input and perspective in their development. Thus, they may be of minimal value when learners are faced with acute moments of challenge and distress in their day-to-day work. The following project seeks to provide an insider view on the experience, interpretation, and response to these moments of challenge and distress from the frontline perspective of clinical clerks. Approach: Using collaborative autoethnography, two medical students documented 85 reflections on their emerging professional identity over the course of a core clerkship year. A narrative analysis was conducted iteratively in partnership with a staff internist and a medical education researcher experienced in autoethnography, allowing for robust multi-perspective input. Reflections were analyzed and coded thematically; disagreements were resolved by consensus discussion. Findings: A key theme of the reflections was self-preservation, conceptualized within two principal contexts: (i) Clerk-patient relationships, wherein we found ourselves in emotionally difficult situations; and (ii) Clerk-preceptor relationships, in which self-preservation manifested through a series of self-protective mechanisms. Insights: The practice of self-preservation is understood as the conscious act of boundary-setting and psychological defense in situations that pose a real (or perceived) threat to the clerk's wellbeing. At best, self-preservation serves as a temporary compromise to the stressors and burnout of clerkship. We speculate, however, that, left unchecked, acts of self-preservation may lead to habitual selfishness and apathy, qualities that are in diametric opposition to those expected of future physicians, and may manifest later (when these learners progress through the hierarchy) as the unprofessional behaviors that perpetuate the cycle of the hidden curriculum.

Do Interest Groups Cultivate Interest? Trajectories of Geriatric Interest Group Members.

BACKGROUND: Minimal exposure, misconceptions, and lack of interest have historically driven the shortage of health-care providers for older adults. This study aimed to determine how medical students' participation in the National Geriatrics Interest Group (NGIG) and local Geriatrics Interest Groups (GIGs) shapes their career development in the care of older adults. METHODS: An electronic survey consisting of quantitative and qualitative metrics to assess the influence of Interest Groups was distributed to all current and past members of local GIGs at Canadian universities since 2017, as well as current and past executives of the NGIG since 2011. Descriptive statistics and thematic analysis were performed. RESULTS: Thirty-one responses (27.7% response rate) were collected from medical students (13), residents (16), and physicians (2). 79% of resident respondents indicated they will likely have a geriatrics-focused medical practice. 45% of respondents indicated GIG/NGIG involvement facilitated the establishment of strong mentorship. Several themes emerged on how GIG/NGIG promoted interest in geriatrics: faculty mentorship, networking, dispelling stigma, and career advancement. CONCLUSION: The positive associations with the development of geriatrics-focused careers and mentorship compel ongoing support for these organizations as a strategy to increase the number of physicians in geriatrics-related practices.

Navigating Tensions of Efficiency and Caring in Clerkship: A Qualitative Study.

Phenomenon: Clerkship is a challenging transition during which medical students must learn to navigate the responsibilities of medical school and clinical medicine. We explored how clerks understand their roles as both medical learners and developing professionals and some of the tensionss that arise therein. Understanding how the clinical learning environment shapes the clerkship role can help educators foster compassionate care. Approach: We conducted 5 focus groups and 1 interview with 3rd-year medical students (n = 14) at University of Toronto between January and June 2016 regarding the perceived role of the clerk, compassionate care, assessment and feedback. Data were analyzed thematically. Findings: In addition to transitioning to a new learning environment, clerkship students assume different roles in response to complex and often competing expectations from preceptors. We identified three main themes: learning to impress preceptors with varying expectations, providing compassionate care-sometimes supported by preceptors, other times being secondary to efficiency-and passing assessments that required a different skill set than simply being a "good clerk." Insights: Clerks perceive their role as providing compassionate care to patients and balance this with fulfilling the (sometimes) competing roles of being a student and developing medical professional. In a system where efficiency is often prioritized, medical students are afforded an opportunity to help satisfy the demand for greater compassion in patient-centered care.

Room for improvement: Palliating the ego in feedback-resistant medical students.

Feedback in medical education provides the impetus for growth in a field pressured to demonstrate continuous progress. Unfortunately, as it always incorporates some level of judgment, certain students appear more resistant than receptive to receiving feedback. Coupled with the ubiquitous stressors of medicine-examinations, perpetual knowledge acquisition, competition for employment-there subtly emerges a learning environment in which the mindset of medical trainees morphs from collegiality to outperformance of one's peers. As the unconscious mind is ultimately focused on self-protection, the cognitive response of reflecting upon received feedback is overcome by an emotional response to safeguard one's self-image against criticism in a culture of comparison. Although self-confidence plays a critical role in mitigating burnout, the relationship between resiliency and ego-armoring is rarely discussed in the literature. Consequently, despite the best intentions of educators in fostering clinical maturity among their trainees, the fact remains that insecurity, inadequacy and invulnerability continue to drive feedback-resistance among medical students.

Fool me once: The illusion of empathy in interactions with standardized patients.

Empathy - cultivated through lived experiences - finds itself at the foundation of patient-centered care. Through establishing rapport, medical students learn to acquire unique perspectives of their patients during their training years. Given its basis in cognition, it is generally agreed that empathy is a skill amenable to nurturing, and can thus be evaluated. Unfortunately, when empathy, compassion, and perspective-taking are put under the scrutiny of a standardized examination (e.g. OSCEs - objective structured clinical exams), students find themselves feigning a substandard level of empathy in order to appease their evaluators' criteria. The fact that a standardized clinical encounter is little more than a performance results in both the student and the standardized patient (SP) vying to convince each other that their performances are realistic, and medical students' desire for positive evaluations hinders their ability or willingness to connect authentically with the "patient." Consequently, for many years, medical educators have been faced with a paradox: empathy cannot exist in an inauthentic environment, and if assessment promotes inauthenticity, then it appears that empathy is a quality which cannot be assessed.

On being examined: do students and faculty agree?

Students measure out their lives, not with coffee spoons, but with grades on examinations. But what exams mean and whether or not they are a bane or a boon is moot. Senior undergraduates (A. Perrella, J. Koenig, and H. Kwon) designed and administered a 15-item survey that explored the contrasting perceptions of both students (n = 526) and faculty members (n = 33) in a 4-yr undergraduate health sciences program. A series of statements gauged the level of agreement on a 10-point scale. Students and faculty members agreed on the value of assessing student learning with a variety of methods, finding new information to solve problems, assessing conceptual understanding and logical reasoning, having assessments with no single correct answer, and having comments on exams. Clear differences emerged between students and faculty members on specific matters: rubrics, student choice of exam format, assessing creativity, and transfer of learning to novel situations. A followup questionnaire allowed participants to clarify their interpretation of select statements, with responses from 71 students and 17 faculty members. All parties strongly agreed that exams should provide a good learning experience that would help them prepare for the future (students: 8.64 ± 1.71 and faculty members: 8.03 ± 2.34).