Lessons learned about empathy during our interview seasons.

Empathy is one of the most valuable skills sought by patients from their physicians as well as by educators from their trainees. However, in medical education there is a general concern that, if not cultivated among students and residents, empathy may decline. We have assessed empathy self-perception among potential candidates who were applying to our internal medicine residency program. Interestingly, we observed that they have a good understanding and great appreciation of empathy values. Our candidates expressed that as medical students they were sympathetic and with experience, they are becoming more empathetic. They also depicted the different ways in which they learned about empathy. The lessons we learned from them lead us to conclude that the development of empathy is a multifaceted and a lifelong process, which must be cultivated during training years through many different modalities. We suggest that the patient's story, coaching skills and self-reflection, might be the most powerful ways of learning empathy.

A Recurrent Case of Cryoglobulin-related Leukocytoclastic Vasculitis with an Unexpected Etiology.

We report a 64-year-old man presenting with cutaneous leukocytoclastic vasculitis, the underlying etiology of which was established as hepatitis C infection with associated cryoglobulinemia. This pathophysiologic state presented clinically as recurrent cutaneous vasculitic eruptions with the absence of any other clinical manifestations except for mild ankle swelling and weakness. This case clearly relates the need to consider hepatitis C as a potential etiologic factor in all patients with cutaneous vasculitis, and we suggest that viral hepatitis screening should be done routinely in all patients presenting with cutaneous vasculitis.

When Coaching Meets Mentoring: Impact of Incorporating Coaching into an Existing Mentoring Program at a Community Hospital.

Introduction One in two physicians experiences professional burnout. Resident coaching is a novel method to provide emotional support and professional development to residents. The feasibility of implementing coaching at a community hospital has not been reported. This curricular innovation examined the feasibility and impact of integrating positive psychology coaching at a community hospital. Methods The Massachusetts General Hospital (MGH) Professional Development Coaching Program (PDCP) curriculum was used to train faculty coaches and for the informal pre-coaching session refreshers. Participants were paired and expected to participate in four 1:1 coaching sessions. The impact of the PDCP was assessed through pre- and post-PDCP online surveys. Results Twelve interns and nine faculty coaches were included in the program and surveyed. Survey completion was 10/12 (83%) and 6/9 (67%) at baseline and 9/12 (75%) and 7/9 (78%) at end of year (EOY) for interns and coaches, respectively. For interns, Emotional Exhaustion (EE) using the Maslach Burnout Inventory (MBI) was high or medium for 60% of respondents at baseline, and 56% at EOY. Fifty percent of coaches scored medium on EE at baseline, compared to only 14.3% at EOY. Seventy-five percent of respondents rated their PDCP experience as excellent or good. Nearly all interns rated the quality of communication with their coaches highly on a five-point Likert Scale. Conclusions Implementation of a coaching program in a community hospital residency program is feasible. Burnout using the MBI was stable from beginning to EOY for interns, but improved for coaches. Interns and coaches rated their professional development coaching program experience highly, and would recommend it to others.

The Emergence of a Forgotten Entity: Dermatomyositis-like Presentation of Lyme Disease in Rural Wisconsin.

Dermatomyositis (DM) is one of the rare clinical manifestations of tickborne-related autoimmune presentations; we report an uncommon case of Borrelia-related DM-like presentation from rural Wisconsin. A 76-year-old female presented with fatigue, malaise, weight loss and progressive proximal muscle weakness after a flare-up of shoulder arthritis. She had a heliotrope rash and a Shawl sign in addition to generalized cutaneous erythema with edema. There was no history of tick bite, Lyme disease (LD) or DM. The physical exam revealed erythema migrans (EM) and DM-like musculocutaneous findings. Enzyme-linked immunosorbent assay and western blot were positive for LD. The patient received intravenous ceftriaxone and doxycycline for five days, leading to the resolution of EM lesions and improvement in her muscle weakness. In addition, DM-like features resolved with antiborrelial treatment and required no steroids or immunosuppressants. Workup including electromyography, skin or muscle biopsy could not be performed as the patient improved clinically. At six months post-treatment, she remained in remission.

Impact of Marital Status on Tumor Stage at Diagnosis and on Survival in Male Breast Cancer.

The effect of marital status (MS) on survival varies according to cancer type and gender. There has been no report on the impact of MS on survival in male breast cancer (MBC). This study aims to determine the influence of MS on tumor stage at diagnosis and survival in MBC. Men with MBC ≥18 years of age in the SEER database from 1990 to 2011 were included in the study. MS was classified as married and unmarried (including single, divorced, separated, widowed). Kaplan-Meier method was used to estimate the 5-year cancer-specific survival. Multivariate regression analyses were done to determine the effect of MS on presence of Stage IV disease at diagnosis and on cancer-specific mortality. The study included 3,761 men; 2,647 (70.4%) were married. Unmarried men were more often diagnosed with Stage IV MBC compared with married (10.7% vs. 5.5%, p < .001). Unmarried men (compared with married) were significantly less likely to undergo surgery (92.4% vs. 96.7%, p < .001). Overall unmarried males with Stages II, III, and IV MBC have significantly worse 5-year cancer-specific survival compared with married. On multivariate analysis, being unmarried was associated with increased hazard of death (HR = 1.43, p < .001) and increased likelihood of Stage IV disease at diagnosis ( OR = 1.96, p < .001). Unmarried males with breast cancer are at greater risk for Stage IV disease at diagnosis and poorer outcomes compared with married males.

Chryseobacterium indologenes: an emerging infection in the USA.

Nursing home-associated infections and antibiotic resistant pathogens constitute common and serious problems in the geriatric population.Chryseobacterium indologenes, a non-motile Gram-negative rod, though widely distributed in nature, is an uncommon human pathogen. Typically thought of as an organism of low virulence, it may cause serious infections, particularly among the immunocompromised. The majority of reported cases are nosocomial, often associated with immunosuppression or indwelling catheters. It has been reported as the causative agent in bacteraemia, peritonitis, pneumonia, empyema, pyelonephritis, cystitis, meningitis and central venous catheter-associated infections. We report a rare case of C. indologenesinfection affecting a nursing home resident in the USA and we provide a review of similar cases. This report emphasises the importance of individualised treatment and promotes awareness about this organism as one of several emerging pathogens in immunocompromised adults and in the frail elderly who are often nursing home residents, in the Western Hemisphere.

The use of the pulse oximetric saturation to fraction of inspired oxygen ratio in an automated acute respiratory distress syndrome screening tool.

PURPOSE: To determine the relationship between the pulse oximetric saturation to fraction of inspired oxygen (SF) ratio and the arterial partial pressure of oxygen to the fraction of inspired oxygen (PF) ratio, and to assess the usefulness of the SF ratio in an automated acute respiratory distress syndrome (ARDS) screening tool. MATERIAL AND METHODS: This was a retrospective cohort study using the Multiparameter Intelligent Monitoring in Intensive Care II database. The relationship was derived and validated in all patients ventilated for at least 24 hours. RESULTS: The total data set included 7544 paired measurements from 3767 intensive care unit admissions. The correlation between SF ratio and PF ratio in the whole data set was good (Spearman ρ = 0.72, P < .001). An automated ARDS diagnostic tool using the derived SF cutoff had excellent agreement with the same tool using the PF ratio of 300 (κ = 0.87). CONCLUSION: The SF ratio may be an adequate substitute for the PF ratio in an automated ARDS screening tool.

Internal medicine residents' acceptance of self-directed learning plans at the point of care.

OBJECTIVES: We implemented a curriculum using self-directed learning plans (SDLPs) based on clinical questions arising from the residents' practice, and we report on perceptions and attitudes from residents in internal medicine regarding the use of SDLPs conceived at point of care. METHODS: Internal medicine residents at a single community hospital in the Midwest were surveyed in 2006 regarding SDLPs. We report their perceived effectiveness in identifying knowledge gaps, the processes used to fill those gaps, and the resident outcomes using descriptive statistics. RESULTS: A total of 26 out of 37 residents (70%) responded. Most (24 of 26; 92%) perceived SDLPs helped them to identify and fill knowledge gaps and that their skills in framing questions (23 of 26; 88%), identifying resources (21 of 26; 81%), and critically appraising the evidence (20 of 26; 77%) improved through regular use. They also felt these plans led to a meaningful change in their practice or provided further direction for learning (17 of 26; 65%). Most (21 of 26; 81%) reported their intent to include point-of-care learning in their continuing education after residency. We found no significant differences in the responses of first-year compared with second- or third-year residents. CONCLUSIONS: Questions arising during patient care are strong motivators for physician self-directed learning. The residents' responses indicated that they accepted the SDLPs and intend to use them in practice. Embedding the discussion of the SDLPs in preclinic conferences has ensured sustainability during the past 5 years and has enabled us to demonstrate teaching of practice-based learning and improvement.

Prevalence of vitamin D deficiency in uninsured women.

BACKGROUND: Vitamin D deficiency, an important risk factor for osteoporosis and other chronic medical conditions, is epidemic in the United States. Uninsured women may be at an even higher risk for vitamin D deficiency than others owing to low intake of dietary and supplemental vitamin D and limited sun exposure. OBJECTIVE: Our goal was to determine the prevalence of vitamin D deficiency in this vulnerable population. SETTING AND PARTICIPANTS: We enrolled 145 uninsured women at a County Free Medical Clinic in urban Michigan. Questionnaires were used to obtain information about demographics, medical history, vitamin supplementation, sunlight exposure, and dietary vitamin D intake. RESULTS: The 96 women who were tested for vitamin D status ranged in age from 21 to 65 years (mean 48 +/- 11), and 67% were vitamin D deficient as indicated by a 25-hydroxyvitamin D [25(OH)D)] level <50 nmol/L (20 ng/mL). Non-Caucasians were 3 times more likely than Caucasians to be vitamin D deficient (P = .049). Mean dietary vitamin D intake was low (125 +/- 109 IU/d) and only 24% of the participants used any supplemental vitamin D. Participants with total vitamin D intake <400 IU/day from diet and supplements were 10 times more likely to be vitamin D deficient than others (P < .001). CONCLUSIONS: These results demonstrate a high prevalence of vitamin D deficiency in an uninsured, medically underserved female population. Uninsured women should be strongly encouraged to increase their vitamin D intake.