Using Self-Regulated Learning Microanalysis to Examine Regulatory Processes in Clerkship Students Engaged in Practice Questions.

Introduction: Self-regulated learning is a cyclical process of forethought, performance, and self-reflection that has been used as an assessment tool in medical education. No prior studies have evaluated SRL processes for answering multiple-choice questions (MCQs) and most evaluated one or two iterations of a non-MCQ task. SRL assessment during MCQs may elucidate reasons why learners are successful or not on these questions that are encountered repeatedly during medical education. Methods: Internal medicine clerkship students at three institutions participated in a SRL microanalytic protocol that targeted strategic planning, metacognitive monitoring, causal attributions, and adaptive inferences across seven MCQs. Responses were transcribed and coded according to previously published methods for microanalytic protocols. Results: Forty-four students participated. In the forethought phase, students commonly endorsed prioritizing relevant features as their diagnostic strategy (n = 20, 45%) but few mentioned higher-order diagnostic reasoning processes such as integrating clinical information (n = 5, 11%) or comparing/contrasting diagnoses (n = 0, 0%). However, in the performance phase, students' metacognitive processes included high frequencies of integration (n = 38, 86%) and comparing/contrasting (n = 24, 55%). In the self-reflection phase, 93% (n = 41) of students faulted their management reasoning and 84% (n = 37) made negative references to their abilities. Less than 10% (n = 4) of students indicated that they would adapt their diagnostic reasoning process for these questions. Discussion: This study describes in detail student self-regulatory processes during MCQs. We found that students engaged in higher-order diagnostic reasoning processes but were not explicit about it and seldom reflected critically on these processes after selecting an incorrect answer. Self-reflections focused almost exclusively on management reasoning and negative references to abilities which may decrease self-efficacy. Encouraging students to identify and evaluate diagnostic reasoning processes and make attributions to controllable factors may improve performance.

Management of SIADH-related hyponatremia due to psychotropic medications - An expert consensus from the Association of Medicine and Psychiatry.

OBJECTIVE: Hyponatremia is the most common electrolyte imbalance encountered in clinical practice and is associated with negative healthcare outcomes and cost. SIADH is thought to account for one third of all hyponatremia cases and is typically an insidious process. Psychotropic medications are commonly implicated in the etiology of drug induced SIADH. There is limited guidance for clinicians on management of psychotropic-induced SIADH. METHODS: After an extensive review of the existing literature, clinical-educators from the Association of Medicine and Psychiatry developed expert consensus recommendations for management of psychotropic-induced SIADH. A risk score was proposed based on risk factors for SIADH to guide clinical decision-making. RESULTS: SSRIs, SNRIs, antipsychotics, carbamazepine, and oxcarbazepine have moderate to high level of evidence demonstrating their association with SIADH. Evaluation for an avoidance of medications that cause hyponatremia is particularly important. Substitution with medication that is less likely to cause SIADH should be considered when appropriate. We propose an algorithmic approach to monitoring hyponatremia with SIADH and corresponding treatment depending on symptom severity. CONCLUSIONS: The proposed algorithm can help clinicians in determining whether psychotropic medication should be stopped, reduced or substituted where SIADH is suspected with recommendations for sodium (Na+) monitoring. These recommendations preserve a role for clinical judgment in the management of hyponatremia with consideration of the risks and benefits, which may be particularly relevant for complex patients that present with medical and psychiatric comorbidities. Further studies are needed to determine whether baseline and serial Na+ monitoring reduces morbidity and mortality.

QTc monitoring in adults with medical and psychiatric comorbidities: Expert consensus from the Association of Medicine and Psychiatry.

OBJECTIVE: Several psychiatric medications have the potential to prolong the QTc interval and subsequently increase the risk for ventricular arrhythmias such as torsades de pointes (TdP). There is limited guidance for clinicians to balance the risks and benefits of treatments. METHODS: After a review of the existing literature, clinical-educators from the Association of Medicine and Psychiatry developed expert consensus guidelines for ECG monitoring of the QTc interval for patients with medical and psychiatric comorbidities who are prescribed medications with the potential to prolong the QTc interval. A risk score was developed based on risk factors for QTc prolongation to guide clinical decision-making. RESULTS: A baseline ECG may not be necessary for individuals at low risk for arrythmia. Those individuals with a risk score of two or more should have an ECG prior to the start of a potentially QTc-prolonging medication or be started on a lower risk agent. Antipsychotics are not equivalent in causing QTc prolongation. A consensus-based algorithm is presented for the management of those identified at high (QTc >500 msec), intermediate (males with QTc 450-499 msec or females with QTc > 470-499 msec), or low risk. CONCLUSIONS: The proposed algorithm can help clinicians in determining whether ECG monitoring should be considered for a given patient. These guidelines preserve a role for clinical judgment in selection of treatments that balance the risks and benefits, which may be particularly relevant for complex patients with medical and psychiatric comorbidities. Additional studies are needed to determine whether baseline and serial ECG monitoring reduces mortality.

Patient and Family Descriptions of Ethical Concerns.

Ethically challenging situations routinely arise in the course of illness and healthcare. However, very few studies have surveyed patients and family members about their experiences with ethically challenging situations. To address this gap in the literature, we surveyed patients and family members at three hospitals. We conducted a content analysis of their responses to open-ended questions about their most memorable experience with an ethical concern for them or their family member. Participants (N = 196) described 219 unique ethical experiences that spanned many of the prevailing themes of bioethics, including the patient-physician relationship, end-of-life care, decision-making capacity, healthcare costs, and genetic testing. Participants focused on relational issues in the course of experiencing illness and receiving medical care and concerns regarding the patient-physician encounters. Many concerns arose outside of a healthcare setting. These data indicate areas for improvement for healthcare providers but some concerns may be better addressed outside of the traditional healthcare setting.

Retention in HIV care depends on patients' perceptions of the clinic experience.

Institutional barriers in HIV primary care settings can contribute substantially to disparities in retention in HIV treatment and HIV-related outcomes. This qualitative study compared the perceptions of clinic experiences of persons living with HIV (PLWH) in a Veterans Affairs HIV primary care clinic setting who were retained in care with the experiences of those who were not retained in care. Qualitative data from 25 in-depth interviews were analyzed to identify facilitators and barriers to retention in HIV care. Results showed that participants not retained in care experienced barriers to retention involving dissatisfaction with clinic wait times, low confidence in clinicians, and customer service concerns. For participants retained in care, patience with procedural issues, confidence in clinicians, and interpersonal connections were factors that enhanced retention despite the fact that these participants recognized the same barriers as those who were not retained in care. These findings can inform interventions aimed at improving retention in HIV care.

The continuum of HIV care in a Veterans' Affairs clinic.

The cascade of HIV care in the United States has become a focus for interventions aimed at improving the success of HIV treatment. The Atlanta VA Medical Center (AVAMC) Infectious Disease Clinic (IDC) is an urban clinic that provides care for over 1,400 people living with HIV (PLHIV) annually. Using data from the HIV Atlanta VA Cohort Study (HAVACS), we modeled the continuum of care in the AVAMC IDC and explored similarities and differences with national models. We conducted a cross-sectional analysis of 1,474 individuals receiving care in the AVAMC IDC. We estimated total PLHIV and defined several categories within the spectrum of HIV care. We then developed the continuum of care using two methodologies. The first required each stage to be a dependent subset of the immediate upstream stage. The second allowed each stage to be independent of upstream stages. Dependent stage categorization estimated that 95.3% of individuals were diagnosed with HIV, 89.8% of individuals were linked to care, 73.0% of individuals were retained in care, 65.9% of individuals were eligible for antiretroviral treatment (ART), 62.8% were prescribed ART, and 52.4% had a suppressed viral load (VL). Independent stage categorization estimated that 83.9% of individuals were prescribed ART and 61.5% had a suppressed VL. Our analyses showed that the AVAMC IDC estimates were significantly better than national estimates at every stage. This may reflect the benefits of a universal healthcare system. We propose the use of independent stages for the continuum as this more accurately represents healthcare utilization.