Reexamining the Call of Duty: Teaching Boundaries in Medical School.

Although healthy physician-patient boundaries are essential to medical practice, published research on how to teach this important topic to medical students is lacking. Physician-patient boundaries, the interpersonal limits placed on behavior within a clinical relationship, protect providers and patients alike, and they represent a key component of professionalism. However, these boundaries may be difficult to teach and frequently are not presented as part of the formal curriculum, except in communication-focused specialties such as psychiatry and palliative care. Medical students may be particularly susceptible to boundary concerns due to the inherent ambiguities of their role within the medical team. In this Perspective, the authors present the adapted, anonymized case of a medical student who encountered a boundary issue during a clinical rotation. Following a brief review of the limited published literature regarding the teaching of boundaries during medical school, the authors define key concepts, including the clinical frame, boundary crossings and violations, fiduciary duty, and dual relationships. Next, they provide examples of common boundary challenges that arise during the course of undergraduate medical education and later during clinical practice. The authors present factors that may contribute to boundary concerns, including characteristics of providers and patients, and they describe some of the potential consequences of boundary violations. They propose a curriculum for teaching medical students about boundaries, providing concrete suggestions for how to do so at both the preclinical and clinical levels. Before closing, they apply insights from the Perspective to the example case.

Depressed Mood Modulates Impact of Chronic Rhinosinusitis Symptoms on Quality of Life.

BACKGROUND: It is unknown how severity of depressed mood affects the well-recognized relationship between chronic rhinosinusitis (CRS) symptom burden and decreased general health-related quality of life (QOL). OBJECTIVE: The objective of this study was to determine whether depressed mood would affect the relationship between CRS symptom burden and decreased general health-related QOL. METHODS: For this cross-sectional study, 610 participants with CRS were prospectively recruited. CRS symptom burden was measured with the 22-item Sino-Nasal Outcome Test (SNOT-22). General health-related QOL was measured with the EuroQol 5-dimensional health utility value (EQ-5D HUV) and visual analog scale (EQ-5D VAS). Depressed mood was measured using the Patient Health Questionnaire-2 (PHQ-2). Participants were stratified as having well-controlled CRS symptoms (SNOT-22 < 35) and poorly controlled CRS symptoms (SNOT-22 ≥ 35). Good general health-related QOL was determined as EQ-5D HUV ≥ 0.9 or EQ-5D VAS ≥ 80, in contrast to low general health-related QOL. RESULTS: In participants with well-controlled CRS symptoms, both SNOT-22 and PHQ-2 were significantly and negatively associated with good general health-related QOL (P < .020 in all cases using multivariable regression). In participants with poorly controlled CRS symptoms, the PHQ-2 was significantly and negatively associated with good general health-related QOL using the EQ-5D HUV (adjusted odds ratio [OR] = 0.37, 95% confidence interval [CI]: 0.22-0.62, P < .001) or the EQ-5D VAS (adjusted OR = 0.74, 95% CI: 0.57-0.96, P = .024). In contrast, SNOT-22 was not associated with general health-related QOL in these patients. CONCLUSIONS: Depressed mood modulates the association between CRS symptom burden and general health-related QOL. Our results suggest a threshold of CRS symptom burden or control, beyond which depressed mood-not CRS symptom burden-drives the association with general health-related QOL.

Deficit in a neural correlate of reality monitoring in schizophrenia patients.

Patients who suffer from the devastating psychiatric illness schizophrenia are plagued by hallucinations, bizarre behavior, and delusional ideas, such as believing that they are controlled by malevolent outside forces. A fundamental human cognitive operation that may contribute to these hallmark symptoms is the ability to maintain accurate and coherent self-referential processing over time, such as occurs during reality monitoring (distinguishing self-generated from externally perceived information). However, the neural bases for a disturbance in this operation in schizophrenia have not been fully explored. Using functional magnetic resonance imaging, we asked clinically stable schizophrenia patients to remember whether or not they had generated a target word during an earlier sentence completion task. We found that, during accurate performance of this self-referential source memory task, the schizophrenia subjects manifest a deficit in rostral medial prefrontal cortex (mPFC) activity--a brain region critically implicated in both the instantiation and the retrieval of self-referential information in healthy subjects. Impairment in rostral mPFC function likely plays a key role in the profound subjective disturbances that characterize schizophrenia and that are the aspect of the disorder most troubling to patients and to society at large.

Brain activation patterns during memory of cognitive agency.

Agency is the awareness that one's own self is the agent or author of an action, a thought, or a feeling. The implicit memory that one's self was the originator of a cognitive event - the sense of cognitive agency - has not yet been fully explored in terms of relevant neural systems. In this functional magnetic resonance imaging (fMRI) study, we examined brain activation patterns differentiating memory for the source of previously self-generated vs. experimenter-presented word items from a sentence completion paradigm designed to be emotionally neutral and semantically constrained in content. Accurate memory for the source of self-generated vs. externally-presented word items resulted in activation of dorsal medial prefrontal cortex (mPFC) bilaterally, supporting an emerging body of work that indicates a key role for this region in self-referential processing. Our data extend the function of mPFC into the domain of memory and the accurate retrieval of the sense of cognitive agency under conditions where agency was encoded implicitly.

Reinterpretation of cross-sectional images in patients with head and neck cancer in the setting of a multidisciplinary cancer center.

BACKGROUND AND PURPOSE: Patients referred to tertiary care centers frequently arrive with images obtained at outside institutions; these images require reinterpretation. We assessed the clinical value of reinterpreting cross-sectional imaging studies of patients with head and neck cancer, in the setting of a multidisciplinary cancer center. METHODS: Outside CT and MR images of 136 patients with known or presumed head and neck cancer were reinterpreted by a neuroradiologist. Clinical history and findings on physical examination were available. Reinterpretation was performed before review of outside reports, which were subsequently compared with those generated at the cancer center. Changes in interpretation were noted, and their effects on TNM staging, patient care, and prognosis were assessed. Reliability and statistical significance of rates of change in diagnosis were analyzed with 95% confidence intervals (CIs) and the sign test, respectively. Verification of change in diagnosis was confirmed by pathologic analysis (75%), characteristic radiologic findings (18%), or clinical and imaging follow-up (7%). RESULTS: Change in interpretation occurred in 56 patients (41%) (95% CI: 33-49%, P <.001). Forty-six patients (34%) had a change in T, N, and/or M staging (26-42%, P <.001). Change in T stage occurred in 27 cases (20%) (13-27%, P <.001) (upstaged in 22, downstaged in five), and a change in N stage in 26 cases (19%) (12-26%, P <.001) (upstaged in 20, downstaged in six). Two patients (1.5%) had missed systemic metastases. Three patients with an initial diagnosis of cancer were found to be cancer-free, and six patients had a diagnosis of new second primary cancers that were missed at original interpretation. One patient had a missed middle cerebral artery aneurysm. Changes in image interpretation altered treatment in 55 (98%) of 56 patients and affected prognosis in 53 patients (95%) (P <.001). CONCLUSION: Reinterpretation of cross-sectional images in the setting of a multidisciplinary cancer center has a significant effect on staging, management, and prognosis in patients with head and neck cancer.