Development and Pilot Testing of a Longitudinal Skills-Based Feedback and Conflict Resolution Curriculum for Internal Medicine Residents.

PROBLEM: Physicians in training are responsible for leading clinical teams, coordinating interdisciplinary management, navigating conflict, and supervising and giving feedback to junior learners. Giving feedback and resolving conflict are key leadership skills for internal medicine (IM) residents, many of whom desire additional training. Although these skills are integral to successful leadership for physicians in training, residents receive little explicit education and existing curricula have not established best practices for skill acquisition. APPROACH: Study authors designed a pilot longitudinal, skills-based curriculum to teach first- through third-year IM residents at the University of Pittsburgh how to give formative feedback and engage in conflict resolution. From February to May 2021, authors delivered a series of interactive lectures utilizing frameworks, workplace-based scenarios, skills practice, and discussion. Skills transfer was evaluated with novel pre- and postcurriculum objective structured clinical examinations (OSCEs) wherein participants played the role of senior resident. Each OSCE involved 2 feedback and 2 conflict resolution stations. OSCE performances were evaluated using an author-created checklist with a 1-4 rating scale. The exposure group comprised post-OSCE participants who attended the curriculum. Data were analyzed using a mixed effects regression model. OUTCOMES: Thirty-six residents participated in curriculum evaluation, and 23 were included in postcurriculum data analysis. Within feedback, the skill "explores feedback content" significantly improved for exposure group participants (precurriculum median, 2.64; postcurriculum, 3.24; P < .05). For conflict resolution, among the exposure group, the skill "identifies a common goal, value, or purpose" significantly improved (pre, 3.10; post, 3.62; P < .05). NEXT STEPS: This curriculum and evaluation can serve as a stepping stone for further evidence-based leadership frameworks, curricula, and evaluations developed specifically for physicians within their unique leadership roles. The feedback and conflict resolution frameworks used in this curriculum can be applied to various medical specialties, with specialty-relevant scenario adaptations for interactive skills practice.

Adapting Existing Resources for Serious Illness Communication Skills Training for Internal Medicine Residents.

OBJECTIVES: Goals of care discussions are a vital component of patient care, but Internal Medicine residents receive limited training in these skills. Existing curricula often require simulated patients or faculty development, limiting implementation in many residency programs. Thus, we developed and implemented a curriculum leveraging existing educational resources with the goal of improving resident attitudes and confidence in conducting goals of care discussions in training settings. METHODS: We developed cases and a detailed faculty guide for small-group discussion with three exercises to standardize the learner experience and minimize the need for faculty development. Exercises introduced established communication skill frameworks including SPIKES (setting, perception, invitation, knowledge, empathy, summary) and REMAP (reframe, emotion, map, align, propose a plan) for how to break bad news, respond to strong emotions, and conduct a goals of care discussion. Participants were 163 Internal Medicine postgraduate year 1, -2, and -3 residents at a large urban academic institution, where residency-wide curriculum is delivered in weekly half-day didactic sessions during the course of 5 weeks. Primary outcomes were resident self-reported confidence with goals of care communication skills. RESULTS: A total of 109 (response rate 67%) of residents reported improvement in overall confidence in goals of care discussion skills (3.6 ± 0.9 vs 4.1 ± 0.6, P < 0.001), responding to emotions (3.5 ± 0.9 vs 3.9 ± 0.6, P = 0.004), making care recommendations (3.5 ± 1.0 vs 3.9 ± 0.7, P < 0.001), and quickly conducting a code status discussion (3.6 ± 1.0 vs 4.0 ± 0.7, P < 0.001). Residents also expressed an increased desire for supervision and feedback to further develop these skills. CONCLUSIONS: This goals of care communication curriculum improves resident confidence and requires minimal resources. It may be ideal for programs that have limited access to simulated patients and/or faculty trained in communication skill simulation, but desire enhanced education on this important aspect of patient-doctor communication and high-quality patient care. Future studies measuring clinical outcomes and changes in learner behavior as a result of this intervention are needed. Ongoing observation and feedback on these skills will be important to solidify learning and sustain impact.

Tau-mediated NMDA receptor impairment underlies dysfunction of a selectively vulnerable network in a mouse model of frontotemporal dementia.

Frontotemporal dementia (FTD) is a neurodegenerative behavioral disorder that selectively affects the salience network, including the ventral striatum and insula. Tau mutations cause FTD, but how mutant tau impairs the salience network is unknown. Here, we address this question using a mouse model expressing the entire human tau gene with an FTD-associated mutation (V337M). Mutant, but not wild-type, human tau transgenic mice had aging-dependent repetitive and disinhibited behaviors, with synaptic deficits selectively in the ventral striatum and insula. There, mutant tau depleted PSD-95, resulting in smaller postsynaptic densities and impaired synaptic localization of NMDA receptors (NMDARs). In the ventral striatum, decreased NMDAR-mediated transmission reduced striatal neuron firing. Pharmacologically enhancing NMDAR function with the NMDAR co-agonist cycloserine reversed electrophysiological and behavioral deficits. These results indicate that NMDAR hypofunction critically contributes to FTD-associated behavioral and electrophysiological alterations and that this process can be therapeutically targeted by a Food and Drug Administration-approved drug.