Internal Medicine Resident Barriers to Advance Care Planning in the Primary Care Continuity Clinic.

Background: While primary care providers regularly engage in Advance Care Planning (ACP) conversations, it is not well known what challenges resident physicians face to achieving this core competency. Objectives: We aimed to assess resident perceptions of barriers and potential interventions to outpatient ACP. Methods: We distributed an electronic survey to Internal Medicine and Medicine-Psychiatry residents at our institution in 2022. Questions addressed outpatient ACP barriers and potential interventions in several domains: structural issues, personal knowledge, and communication skills. We reported results using descriptive statistics and Wilcoxon rank-sum tests, comparing responses by residency year (interns vs upperyears). Likert-scale responses were dichotomized to a "not at all or slightly" vs "moderate or extreme" barrier or helpful intervention. Results: Of 149 residents, 71 completed the survey (48%). Highest scoring barriers were structural, including 1) lack of clinic time (99%), 2) need to prioritize other medical problems (94%), and 3) lack of patient continuity (62%). Highest scoring interventions included the ability to schedule dedicated ACP visits with themselves (96%) or another clinician (82%). Interns were statistically significantly less confident in their ability to conduct ACP, and more likely to report lack of knowledge (i.e., not understanding ACP, patient prognosis, or how to complete paperwork, P < .05). Conclusions: Residents report significant structural barriers to outpatient ACP, including limitations in time, continuity, and competing medical priorities, that may warrant greater program attention to interventions such as clinic schedules and work-flow. Additional trainings may be most beneficial if targeted to the beginning of intern year.

Patient Religiosity and Desire for Chaplain Services in an Outpatient Primary Care Clinic.

Outpatient chaplaincy is a new specialty in healthcare, with a relative paucity of research studies exploring the need for spiritual care interventions in ambulatory settings. Over the past 3 years, our interdisciplinary team at the Duke Outpatient Clinic has piloted the extension of professional spiritual care into this hospital-based resident teaching clinic offering primary care to underserved populations in Durham, NC. In this article, we report the results of a series of surveys that we conducted at the clinic to assess patients' perceptions of chaplain services, understanding of Chaplains' roles, and desire for chaplain services in specific hypothetical scenarios. As part of this survey, we also asked patients about their personal levels of extrinsic and intrinsic religiosity using the well-validated Duke University Religion Index. Our results indicate which chaplain interventions are most desired among this patient population in relation to patients' self-reported religiosity. We hypothesized that only our more religious patients would strongly desire chaplain support for the majority of scenarios presented. We were surprised to find that a majority of our patients-regardless of their own level of religiosity-express desire for support from an outpatient healthcare chaplain when they need a listening ear, are grieving a loss, or are seeking prayer.

Identifying core curricular components for behavioral health training in internal medicine residency: Qualitative interviews with residents, faculty, and behavioral health clinicians.

OBJECTIVE: Behavioral health services frequently delivered by primary care providers include care for mental health and substance abuse disorders and assistance with behavioral risk factor reduction. Internal medicine residencies in the United States lack formal expectations regarding training in behavioral health for residents. This qualitative study aimed to determine learners' and teachers' perceptions about appropriate behavioral health curricular components for internal medicine residents. METHOD: Focus groups and interviews were conducted with the following individuals from the Duke Outpatient Clinic: residents with continuity practice (n = 27), advanced practice providers (n = 2), internal medicine attending physicians (n = 4), internal medicine/psychiatry attending physicians (n = 2), and behavioral health clinicians (n = 4). A focus group leader asked regarding residents' successes and challenges in managing behavioral health issues and about specific learning components considered necessary to understand and manage these behavioral health conditions. Transcripts were coded using an editing analysis style to identify central themes and concordance/discordance between groups. RESULTS: Regarding mental health management (Theme 1), residents emphasized a need for better care coordination with specialty mental health, while attendings and behavioral health clinicians gave priority to residents' skills in primary management of mental health. Residents, attendings, and behavioral health clinicians all emphasized advanced interviewing skills (Theme 2) with subthemes: eliciting the patient's perspective, managing time in encounters, improving patients' understanding, and patient counseling. CONCLUSIONS: Internal medicine residents, attendings, and behavioral health clinicians may differ significantly in their perceptions of primary care's role in mental health care. Future internal medicine behavioral health curricula should specifically address these attitudinal differences. Curricula should also emphasize interview skills training as an essential component of behavioral health learning.

"Conversational Advice": A mixed-methods analysis of medical residents' experiences co-managing primary care patients with behavioral health providers.

OBJECTIVE: When integrated behavioral health clinicians (IBHCs) and residents co-manage patients, residents may learn new approaches. We aimed to understand the effect of co-management on residents' behavioral health (BH) management learning. METHODS: Residents completed a web-based survey enquiring: whether co-management included a shared visit and/or face-to-face meeting with an IBHC, whether residents received feedback from the IBHC, and what they learned. Qualitative responses were coded thematically using a constant comparative method. RESULTS: Among 117 respondents (overall response rate 72%, 117/163), from five residencies recruited from 40 residencies with BH integration, residents were significantly more likely to receive feedback if they had a shared visit with the patient and an IBHC (yes 69% vs. no 33%; adjusted OR 3.0, 95% CI 1.2-7.6). Residents reported three major learning themes: interpersonal communication skills awareness, BH skills awareness, and newly adopted attitudes toward BH. Residents who received feedback were more likely to report themes of interpersonal communication skills awareness (yes 26.6% vs. no 9.4%). CONCLUSION: BH integration promotes increased feedback for residents practicing face-to-face co-management with IBHCs, and a positive influence regarding residents' attitudes and perceived skills. PRACTICAL IMPLICATIONS: Residency programs can meaningfully improve residents' learning by promoting face-to-face co-management with IBHCs.

Residents' Confidence Providing Primary Care With Behavioral Health Integration.

BACKGROUND AND OBJECTIVES: Behavioral health integration (BHI) entails integrated behavioral health clinicians (IBHCs) providing care-generally for mental health and substance abuse disorders and behavioral comorbidity- within the operational functioning of primary care. Because limited data exist regarding BHI in residency, we studied its impact on resident education by examining whether increased behavioral health (BH) co-management improved residents' perceived ability to treat BH conditions. METHODS: We included residents from internal and family medicine training programs using BHI in residents' continuity clinics and assessed the level of co-management between primary care and IBHCs and the following domains: (1) confidence in managing BH conditions, (2) barriers to BH provision, (3) perception of autonomy when working with IBHCs, (4) satisfaction with the clinic, and (5) perceived educational value of BH learning modes. RESULTS: Altogether, 117 residents participated in our survey (73.1% response rate). Residents who had co-managed ≥ five patients alongside IBHCs reported significantly higher confidence than those who had co-managed < five patients with BH conditions. The association remained significant after adjustment for residents' level of training and specialty. In rating BH learning modes, residents rated most highly active collaboration with IBHCs and observation with feedback from clinic preceptors. CONCLUSIONS: BHI training within residency enhances perceived learning and confidence in providing BH care.

Recognizing and Managing Geriatric Depression: A Two-Part Self-Learning Module Set.

INTRODUCTION: The number of geriatric patients will increase dramatically over the next 2 decades, and providers across all specialties will need skills in diagnosis and management of common geriatric disorders. Geriatric depression is common and associated with significant psychiatric and medical morbidity yet is frequently not taught in clinical clerkships. To provide foundational knowledge on geriatric depression, we designed a two-part, online, self-learning module set for health professions learners. METHODS: Learning objectives and content were chosen based upon consensus from a national panel of internal medicine and psychiatry clinician-educators. The two-part module set covers recognition of depression and use of screening tools for diagnosis, suicide assessment, patient education, and initial management approaches. Articulate software was used to create two complementary 20-minute modules that incorporate teaching points, interactive quizzes, and video clips of a clinician interviewing a standardized patient and her husband during the course of an initial clinical evaluation. RESULTS: The modules were piloted with 11 senior medical students. Mean number of correct answers on 10 knowledge-test questions improved from 8.1 on pretesting to 9.4 on posttesting. On a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree), participants affirmed that the modules were easy to navigate (4.91) and increased understanding of geriatric depression (4.82) and that the videos added to the learner's understanding of objectives (4.64). DISCUSSION: These modules can be used by learners in health professions schools to improve foundational knowledge in geriatric depression and prepare for advanced clinical work with older patients.

Risks, Benefits, and Recommendations for Pastoral Care on Inpatient Psychiatric Units: A Systematic Review.

OBJECTIVE: A systematic review was conducted of the biomedical literature regarding pastoral care (PaC) providers on inpatient psychiatric units with the aim of answering 3 questions: (1) What are the risks and benefits of PaC providers' presence on inpatient psychiatric units? (2) What are current recommendations for integration of PaC providers into a psychiatric team? and (3) What gaps exist in the literature? METHODS: PubMed, PsycInfo, Embase, CINAHL, and Scopus were searched from the start of each database to July 9, 2014 using terms related to PaC providers and inpatient psychiatry. Two independent reviewers performed full-text reviews of each article identified by independent review of all titles/abstracts from the electronic search and by a hand search of articles included in reference lists. Inclusion criteria were: English-language article, published in a peer-reviewed journal, and focus on a PaC provider working in a psychiatric hospital setting. One author performed data extraction. RESULTS: Forty-nine articles were identified by electronic (84%) and hand search (16%), 18 of which were evaluative studies: 5 qualitative and 13 quantitative. Most of the literature viewed integration of PaC providers in inpatient treatment teams as beneficial. Potential harms were noted and mitigation strategies suggested, including providing training to PaC providers concerning psychiatric illness, clearly defining roles, and enhancing team integration. None of the articles reported outcomes data. CONCLUSIONS: Psychiatric inpatients often have unmet spiritual needs. Although the literature suggests potential benefits of PaC providers for psychiatric inpatients, more rigorous studies are needed to establish these benefits as efficacious. The authors of this review recommend the cautious integration of PaC providers into the psychiatric inpatient care team.

Chaplains on the Medical Team: A Qualitative Analysis of an Interprofessional Curriculum for Internal Medicine Residents and Chaplain Interns.

Improved collaboration between physicians and chaplains has the potential to improve patient experiences. To better understand the benefits and challenges of learning together, the authors conducted several focus groups with participants in an interprofessional curriculum that partnered internal medicine residents with chaplain interns in the clinical setting. The authors derived four major qualitative themes from the transcripts: (1) physician learners became aware of effective communication skills for addressing spirituality. (2) Chaplain interns enhanced the delivery of team-based patient-centered care. (3) Chaplains were seen as a source of emotional support to the medical team. (4) The partnership has three keys to success: adequate introductions for team members, clear expectations for participants, and opportunities for feedback. The themes presented indicate several benefits of pairing physicians and chaplains in the setting of direct patient care and suggest that this is an effective approach to incorporating spirituality in medical training.

Prospects of antiviral and anti-inflammatory therapy for respiratory syncytial virus infection.

Respiratory syncytial virus is the leading viral cause of death in children less than 2 years of age, and is an increasing cause of morbidity and mortality in transplant patients and the elderly. Respiratory syncytial virus causes upper and lower respiratory tract infections, which can lead to severe bronchiolitis and pneumonia. High-risk groups for severe respiratory syncytial virus infection include infants with a history of premature birth with or without chronic lung disease, children with congenital heart disease, children with cystic fibrosis or chronic lung diseases, and immunosuppressed patients or patients with immunodeficiency. However, the majority of infants who have severe respiratory syncytial virus disease are born at full term and are otherwise healthy. It is unclear why children, the elderly and the immunosuppressed are at much higher risk for severe disease; however, a respiratory syncytial virus-induced immune pathologic mechanism has long been suspected. Attempts to develop a safe and effective vaccine against respiratory syncytial virus have failed. Antirespiratory syncytial virus immunotherapy, although effective prophylactically, does not provide any beneficial clinical outcome when administered therapeutically, indicating that respiratory syncytial virus-induced pathology is most likely the result of the inflammatory response to infection, rather than a direct viral cytopathic effect. Thus, a combined antiviral and anti-inflammatory therapy may represent the safest and most efficient treatment for acute respiratory syncytial virus infection. In this review, the current knowledge that has set the rationale for the development of such therapy is summarized.

siRNAdb: a database of siRNA sequences.

Short interfering RNAs (siRNAs) are a popular method for gene-knockdown, acting by degrading the target mRNA. Before performing experiments it is invaluable to locate and evaluate previous knockdown experiments for the gene of interest. The siRNA database provides a gene-centric view of siRNA experimental data, including siRNAs of known efficacy and siRNAs predicted to be of high efficacy by a combination of methods. Linked to these sequences is information such as siRNA thermodynamic properties and the potential for sequence-specific off-target effects. The database enables the user to evaluate an siRNA's potential for inhibition and non-specific effects. The database is available at http://siRNA.cgb.ki.se.