Longitudinality Matters: Qualitative Perspectives on a Longitudinal Clinical Experience in a Psychiatry Residency Training Program.

OBJECTIVE: Longitudinal models of clinical care and education can positively impact the patient and provider experience in terms of health outcomes, satisfaction, and motivation. While residency programs have seen an increase in primary care longitudinal clinical experiences (LCEs), defined as outpatient clinics in which patients are seen by residents over the course of their entire training, less is known about such opportunities in psychiatry residency programs. This qualitative study explores the impact of a longitudinal training model on psychiatric resident skill development, relationships in the clinical learning environment, and professional identity formation. METHODS: The authors conducted 24 semi-structured interviews of residents, graduates, and faculty in three well-established LCE clinics in a single, multi-site, academic psychiatry residency program. Transcripts were analyzed using inductive thematic analysis techniques. RESULTS: Themes were categorized into benefits and challenges. For benefits, themes included longitudinal relationships, improved feedback, near-peer teaching, early outpatient exposure, graduated independence, skill development, patient population expertise, and solidification of professional identity. For challenges, themes included system logistics, offsite panel management, and intermittent presence of junior trainees. CONCLUSION: Results suggest that overall, residents and faculty find the LCE a positive learning opportunity that has contributed to their professional development. LCEs do appear to have distinct challenges, largely logistical in nature, which can interfere with the favorability of residents' experiences. Developing strategies up front to minimize these logistical challenges will support the success of a longitudinal program.

Self-Reported Recovery Likelihood Predicts Higher Physician Ratings: A Survey of Patients After Orthopaedic Surgery.

OBJECTIVES: What are the differences between elective and trauma patient satisfaction and do patient and diagnosis factors predict physician scores? DESIGN: Prospective cohort study. SETTING: Urban Level 1 Trauma center. PATIENTS/PARTICIPANTS: Three hundred twenty-three trauma patients and 433 elective orthopaedic patients treated at our center by the same surgeons. INTERVENTION: Trauma patients treated surgery for one or more fractures; elective patients treated with hip, knee, or shoulder arthroplasty, or rotator cuff repair. MAIN OUTCOME MEASUREMENTS: Telephone survey regarding patient experience and satisfaction with their care. The survey included questions from Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys, and responses were rated on a 1-5 point Likert scale (5 best). RESULTS: Elective surgery patients had mean age of 56.4 years, and trauma patients were mean 50.3 years of age. Trauma patients rated their likelihood to make a full recovery lower than elective patients (median, interquartile range), 5.0 (1.0) versus 4.0 (2.0) (P < 0.001). After multivariate binary logistic regression, patients who rated the hospital higher (≥4 vs. ≤3) were more likely (odds ratio = 10.0, 95% confidence interval, 6.4-15.8) to score physicians better. Similarly, patients who scored their overall likelihood of recovering ≥4 compared with ≤3 were more likely (odds ratio = 3.6, 95% confidence interval, 2.9-5.6) to rate their physicians more positively. CONCLUSIONS: Patient perceptions including their likelihood to make a full recovery and their overall impression of the hospital predicted higher physician scores. We conclude that these physician scores are subject to patient perception biases and are not independent of the overall care experience. We recommend HCAHPS and physician ratings' web sites include internal controls, such as the patient perception of overall likelihood to recover, to aid in interpreting survey results.

Violence: heightened brain attentional network response is selectively muted in Down syndrome.

BACKGROUND: The ability to recognize and respond appropriately to threat is critical to survival, and the neural substrates subserving attention to threat may be probed using depictions of media violence. Whether neural responses to potential threat differ in Down syndrome is not known. METHODS: We performed functional MRI scans of 15 adolescent and adult Down syndrome and 14 typically developing individuals, group matched by age and gender, during 50 min of passive cartoon viewing. Brain activation to auditory and visual features, violence, and presence of the protagonist and antagonist were compared across cartoon segments. fMRI signal from the brain's dorsal attention network was compared to thematic and violent events within the cartoons between Down syndrome and control samples. RESULTS: We found that in typical development, the brain's dorsal attention network was most active during violent scenes in the cartoons and that this was significantly and specifically reduced in Down syndrome. When the antagonist was on screen, there was significantly less activation in the left medial temporal lobe of individuals with Down syndrome. As scenes represented greater relative threat, the disparity between attentional brain activation in Down syndrome and control individuals increased. There was a reduction in the temporal autocorrelation of the dorsal attention network, consistent with a shortened attention span in Down syndrome. Individuals with Down syndrome exhibited significantly reduced activation in primary sensory cortices, and such perceptual impairments may constrain their ability to respond to more complex social cues such as violence. CONCLUSIONS: These findings may indicate a relative deficit in emotive perception of violence in Down syndrome, possibly mediated by impaired sensory perception and hypoactivation of medial temporal structures in response to threats, with relative preservation of activity in pro-social brain regions. These findings indicate that specific genetic differences associated with Down syndrome can modulate the brain's response to violence and other complex emotive ideas.

Intraluminal thrombus, intraplaque hemorrhage, plaque thickness, and current smoking optimally predict carotid stroke.

BACKGROUND AND PURPOSE: Intraplaque hemorrhage (IPH) is associated with acute and future stroke. IPH is also associated with lumen markers of stroke risk including stenosis, plaque thickness, and ulceration. Whether IPH adds further predictive value to these other variables is unknown. The purpose of this study was to determine whether IPH improves carotid-source stroke prediction. METHODS: In this retrospective cross-sectional study, patients undergoing stroke workup were imaged with MRI and IPH detection. Seven hundred twenty-six carotid-brain image pairs were analyzed after excluding vessels with noncarotid plaque stroke sources (420) and occlusions (7) or near-occlusions (3). Carotid imaging characteristics were recorded, including percent diameter and mm stenosis, plaque thickness, ulceration, intraluminal thrombus, and IPH. Clinical confounders were recorded, and a multivariable logistic regression model was fitted. Backward elimination was used to determine essential carotid-source stroke predictors with a threshold 2-sided P<0.10. Receiver operating characteristic analysis was performed to determine discriminatory value. RESULTS: Significant predictors of carotid-source stroke included intraluminal thrombus (odds ratio=103.6; P<0.001), IPH (odds ratio=25.2; P<0.001), current smoking (odds ratio=2.78; P=0.004), and thickness (odds ratio=1.24; P=0.020). The final model discriminatory value was excellent (area under the curve=0.862). This was significantly higher than the final model without IPH (area under the curve=0.814), or models using only stenosis as a continuous variable (area under the curve=0.770) or cutoffs of 50% and 70% (area under the curve=0.669), P<0.001. CONCLUSIONS: After excluding patients with noncarotid plaque stroke sources, optimal discrimination of carotid-source stroke was obtained with intraluminal thrombus, IPH, plaque thickness, and smoking history but not ulceration and stenosis.