Clinical reasoning in real-world practice: a primer for medical trainees and practitioners.

Clinical reasoning is a crucial skill and defining characteristic of the medical profession, which relates to intricate cognitive and decision-making processes that are needed to solve real-world clinical problems. However, much of our current competency-based medical education systems have focused on imparting swathes of content knowledge and skills to our medical trainees, without an adequate emphasis on strengthening the cognitive schema and psychological processes that govern actual decision-making in clinical environments. Nonetheless, flawed clinical reasoning has serious repercussions on patient care, as it is associated with diagnostic errors, inappropriate investigations, and incongruent or suboptimal management plans that can result in significant morbidity and even mortality. In this article, we discuss the psychological constructs of clinical reasoning in the form of cognitive 'thought processing' models and real-world contextual or emotional influences on clinical decision-making. In addition, we propose practical strategies, including pedagogical development of a personal cognitive schema, mitigating strategies to combat cognitive bias and flawed reasoning, and emotional regulation and self-care techniques, which can be adopted in medical training to optimize physicians' clinical reasoning in real-world practice that effectively translates learnt knowledge and skill sets into good decisions and outcomes.

Prevalence and Association of Sarcopenia with Mortality in Patients with Head and Neck Cancer: A Systematic Review and Meta-Analysis.

BACKGROUND: The objective of this meta-analysis was to assess the association of sarcopenia defined on computed tomography (CT) head and neck with survival in head and neck cancer patients. METHODS: Following a PROSPERO-registered protocol, two blinded reviewers extracted data and evaluated the quality of the included studies using the Quality In Prognostic Studies (QUIPS) tool, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework. A meta-analysis was conducted using maximally adjusted hazard ratios (HRs) with the random-effects model. Heterogeneity was measured using the I2 statistic and was investigated using meta-regression and subgroup analyses where appropriate. RESULTS: From 37 studies (11,181 participants), sarcopenia was associated with poorer overall survival (HR 2.11, 95% confidence interval [CI] 1.81-2.45; p < 0.01), disease-free survival (HR 1.76, 95% CI 1.38-2.24; p < 0.01), disease-specific survival (HR 2.65, 95% CI 1.80-3.90; p < 0.01), progression-free survival (HR 2.24, 95% CI 1.21-4.13; p < 0.01) and increased chemotherapy or radiotherapy toxicity (risk ratio 2.28, 95% CI 1.31-3.95; p < 0.01). The observed association between sarcopenia and overall survival remained significant across different locations of cancer, treatment modality, tumor stages and geographical region, and did not differ between univariate and multivariate HRs. Statistically significant correlations were observed between the C3 and L3 cross-sectional area, skeletal muscle mass, and skeletal muscle index. CONCLUSIONS: Among patients with head and neck cancers, CT-defined sarcopenia was consistently associated with poorer survival and greater toxicity.

The rise of medical influencers: The pros and the cons.

In the past few years, the online influencer industry has exponentially expanded, fuelled by the COVID pandemic lockdown, increased social media platforms and lifestyle appeal of influencership. This phenomenon has likewise infiltrated the medical field, where many healthcare practitioners have taken to social media platforms for content creation and influencer marketing. There are many reasons that underlie medical influencership - some may use it to improve public health literacy and correct medical misinformation, engage in medical advocacy or use the platform simply as a means of humanistic expression of the medical career, while others may seek to advertise private practice/medical products, boost personal reputation, and gain popularity and monetary benefits. Regardless of the underlying motivations of the medical influencers, some have fallen afoul of professionally accepted practices and ethical boundaries in their use of social media platforms, leading to serious consequences such as professional sanctioning or termination of employment. In this article, we hope to provide a comprehensive review of the 'good' (positive practices), the 'bad' (practices with possible unintended negative consequences) and the outright unprofessional or unethical behaviours aspects of social media use by medical influencers and offer practical strategies to ensure responsible and meaningful use of influencer platforms at both the physician and health systems level.

Effect of psoas muscle index on early postoperative outcomes in surgically treated spinal tumours in an Asian population.

BACKGROUND: Sarcopenia has been purported to be a pre-operative risk factor that affects patient outcomes in oncological surgery, but no study as of yet has investigated the effect of sarcopenia in patients with spinal tumours. Psoas muscle measurements, including the psoas muscle index (PMI), are an objective way to determine sarcopenia. OBJECTIVES: We investigated if PMI could predict post-operative outcomes (length of hospital stay and post-operative complications) in surgically treated spinal tumour patients in a multi-ethnic Asian population. METHODS: We conducted a retrospective cohort study of patients with spinal tumours who underwent surgery at our tertiary institution from January 2016 to January 2020. PMI was measured on T2-weighted MRI sequences, at the middle of the L3 vertebral body and measurements were collected by 2 independent raters. The primary outcome was length of hospital stay (LOS), and the secondary outcome was post-operative complications. ROC curve was used to attain the cut-off value for PMI and the population was then stratified into 2 groups; sarcopenic if PMI was less than 1.22 and non-sarcopenic if the PMI value was more than or equal to 1.22. Multivariable linear regression was used for LOS, while multivariate logistic regression was used for complications. RESULTS: 57 patients were included with a mean length of stay of 17.8 days (SD 25.1) and the total number of patients with complications were 20 (35.1 %). Mean LOS was significantly higher in the sarcopenic group compared to the non-sarcopenic group. Univariate analysis confirmed the association of lower psoas muscle index corresponding with longer lengths of stay and this was corroborated in a multivariable linear regression model. There were no significant associations between PMI and postoperative complications. CONCLUSIONS: Lower PMI values were significantly associated with a longer LOS. PMI may be warranted for risk stratifying Asian spinal tumour patients undergoing surgery.

Association of head and neck CT-derived sarcopenia with mortality and adverse outcomes: A systematic review.

BACKGROUND: There is growing interest in the association of CT-assessed sarcopenia with adverse outcomes in non-oncological settings. PURPOSE: The aim of this systematic review is to summarize existing literature on the prognostic implications of CT-assessed sarcopenia in non-oncological patients. MATERIALS AND METHODS: Three independent authors searched Medline/PubMed, Embase and Cochrane Library up to 30 December 2023 for observational studies that reported the presence of sarcopenia defined on CT head and neck in association with mortality estimates and other adverse outcomes, in non-oncological patients. The quality of included studies were assessed using the Quality of Prognostic Studies tool. RESULTS: Overall, 15 studies (3829 participants) were included. Nine studies were at low risk of bias, and six were at moderate risk of bias. Patient populations included those admitted for trauma or treatment of intracranial aneurysms, ischemic stroke, transient ischemic attack, and intracranial stenosis. Sarcopenia was associated with increased 30-day to 2-year mortality in inpatients and patients undergoing carotid endarterectomy or mechanical thrombectomy for acute ischemic stroke. Sarcopenia was also associated with poorer neurological and functional outcomes, increased likelihood of admission to long-term care facilities, and longer duration of hospital stays. The observed associations of sarcopenia with adverse outcomes remained similar across different imaging modalities and methods for quantifying sarcopenia. CONCLUSION: CT-assessed sarcopenia was associated with increased mortality and poorer outcomes across diverse patient populations. Measurement and early identification of sarcopenia in vulnerable patients allows for enhanced prognostication, and focused allocation of resources to mitigate adverse outcomes.

Prevalence of tight glycemic control based on frailty status and associated factors in community-dwelling older adults.

BACKGROUND: Tight control of type 2 diabetes (T2DM) in frail older adults has shown to be associated with adverse outcomes. The objective of this study is to determine the prevalence of tight glycemic control based on underlying frailty status and its association with functional and cognitive measures in community-dwelling older adults. METHODOLOGY: Ancillary study of the Singapore Population Health Studies on older adults aged ≥65 years with T2DM. Tight glycemic control cut-offs were based on the 2019 Endocrine Society guideline using HbA1c target range based on a patient's overall health status measured by the FRAIL scale. Data on basic demographics, frailty, cognitive, and functional statuses were collected. Multivariable regression was used to assess potential factors associated with tight glycemic control. RESULTS: Of 172 community-dwelling older adults with diabetes mellitus and HbA1c done, frail (65%) and pre-frail (64.4%) participants were more likely to have tight glycemic control than robust participants (31.6%, P < 0.001). In multi-variate analysis, frailty (OR 6.43, 95% CI 1.08-38.1, P = 0.041), better cognition (OR 1.15, 95% CI 1.02-1.32, P = 0.028), and multi-morbidity (OR 7.36, 95% CI 1.07-50.4, P = 0.042) were found to be significantly associated with increased odds of tight glycemic control. CONCLUSION: Tight glycemic control was highly prevalent in frail and pre-frail older adults, especially in those with multi-morbidity and better cognition. Future prospective longitudinal studies are required to evaluate effectiveness of frailty screening in making treatment decisions and long-term outcomes. Key messages What is already known on this topic:  There is growing recognition that glycemic targets should be adjusted based on health or frailty status. However, there is no consensus on how health status or frailty should be defined when determining glycemic control targets. What this study adds:  Our study found that tight glycemic control was highly prevalent in frail and pre-frail older adults. Our findings highlight the importance of assessing for tight glycemic control based on frailty status and further work is needed to aid implementation of screening and intervention policies to avoid the attendant harms of tight glycemic control.

Health and Community Care workers' Knowledge and Perceptions of Social Prescribing in Singapore.

Objectives: This study aimed to survey knowledge and perceptions of social prescribing (SP) amongst health and community care workers. Study design: Cross sectional online survey conducted in November 2023. Methods: The survey on basic demographics, awareness, knowledge, and practices of SP was completed by 123 health and community care workers. Results: The mean age of respondents was 39.0 years. Nearly two-thirds had heard of SP. A lower proportion of acute hospital doctors (55.6%) and nurses (56.8%) had heard of SP compared with primary and subacute care doctors (75.0%). The majority agreed that SP is beneficial for patients' mental health and reducing healthcare utilisation. Primary care physicians, community nurses and active ageing centres were the top three professionals selected as most responsible for SP by survey respondents. The most commonly cited barriers to SP were seniors' reluctance (63.4%), lacking knowledge on how to refer (59.3%), lack of time (44.7%) and cost to seniors (44.7%). Conclusion: Overall, health and community care workers demonstrated positive attitudes toward SP and were keen to refer patients for SP. However, additional efforts are needed to improve knowledge about how to refer for and provide training on SP.

Effect of sarcopenia and frailty on outcomes among patients with brain metastases.

PURPOSE: Sarcopenia and frailty have been associated with increased mortality and duration of hospitalization in cancer. However, data investigating these effects in patients with brain metastases remain limited. This study aimed to investigate the effects of sarcopenia and frailty on clinical outcomes in patients with surgically treated brain metastases. METHODS: Patients who underwent surgical resection of brain metastases from 2011 to 2019 were included. Psoas cross-sectional area and temporalis thickness were measured by two independent radiologists (Cronbach's alpha > 0.98). Frailty was assessed using the Clinical Frailty Scale (CFS) pre-operatively and post-operatively. Overall mortality, recurrence, and duration of hospitalization were collected. Cox regression was performed for mortality and recurrence, and multiple linear regression for duration of hospitalization. RESULTS: 145 patients were included, with median age 60.0 years and 52.4% female. Psoas cross-sectional area was an independent risk factor for overall mortality (HR = 2.68, 95% CI 1.64-4.38, p < 0.001) and recurrence (HR = 2.31, 95% CI 1.14-4.65, p = 0.020), while post-operative CFS was an independent risk factor for overall mortality (HR = 1.88, 95% CI 1.14-3.09, p = 0.013). Post-operative CFS (ß = 15.69, 95% CI 7.67-23.72, p < 0.001) and increase in CFS (ß = 11.71, 95% CI 3.91-19.51, p = 0.004) were independently associated with increased duration of hospitalization. CONCLUSION: In patients with surgically treated brain metastases, psoas cross-sectional area was an independent risk factor for mortality and recurrence, while post-operative CFS was an independent risk factor for mortality. Post-operative frailty and increase in CFS significantly increased duration of hospitalization. Measurement of psoas cross-sectional area and CFS may aid in risk stratification of surgical candidates for brain metastases.

Providing family updates: a primer for the medical trainee.

Providing family updates is a common clinical task for medical trainees and practitioners working in hospital settings. Good clinical communication skills are essential in clinical care as it is associated with improved patient satisfaction, understanding of condition, treatment adherence, and better overall clinical outcomes. Moreover, poor communications are often the source of medical complaints. However, while patient-centred communication skills training has generally been incorporated into clinical education, there hitherto remains inadequate training on clinical communications with patients' families, which carry different nuances. In recent years, it is increasingly recognized that familial involvement in the care of hospitalized patients leads to better clinical and psychological outcomes. In fact, in Asian populations with more collectivistic cultures, families are generally highly involved in patient care and decision-making. Therefore, effective clinical communications and regular provision of family updates are essential to build therapeutic rapport, facilitate familial involvement in patient care, and also provide a more holistic understanding of the patient's background and psychosocial set-up. In this article, we herein describe a seven-step understand the clinical context, gather perspectives, deliver medical information, address questions, concerns and expectations, provide tentative plans, demonstrate empathy, postcommunication reflections model as a practical guide for medical trainees and practitioners in provision of structured and effective family updates in their clinical practice.

'Insight' in medical training: what, why, and how?

The term 'insight' is generically defined in English language as the ability to perceive deeper truths about people and situations. In clinical practice, patient insight is known to have important implications in treatment compliance and clinical outcomes, and can be assessed clinically by looking for the presence of illness awareness, correct attribution of symptoms to underlying condition, and acceptance of treatment. In this article, we suggest that cultivating insight is actually a highly important, yet often overlooked, component of medical training, which may explain why some consistently learn well, communicate effectively, and quickly attain clinical competency, while others struggle throughout their clinical training and may even be difficult to remediate. We herein define 'insight' in the context of medical training as having an astute perception of personal cognitive processes, motivations, emotions, and ability (strengths, weaknesses, and limitations) that should drive self-improvement and effective behavioural regulation. We then describe the utility of cultivating 'insight' in medical training through three lenses of (i) promoting self-regulated, lifelong clinical learning, (ii) improving clinical competencies and person-centred care, and (iii) enhancing physician mental health and well-being. In addition, we review educational pedagogies that are helpful to create a medical eco-system that promotes the cultivation of insight among its trainees and practitioners. Finally, we highlight several tell-tale signs of poor insight and discuss psychological and non-psychological interventions that may help those severely lacking in insight to become more amenable to change and remediation.

Association between different skeletal muscle mass indices, physical function, and inflammation in obese pre-frail older adults.

OBJECTIVES: There is lack of consensus on measurement of muscle mass and quality in obese older adults. We aim to evaluate the association of four muscle mass indices (appendicular skeletal muscle mass (ASM) over height2(ASMIht), ASM/weight (ASMwt), ASM/body fat percentage (ASMbfp)and ASM/body mass index (BMI) ASMIbmi) with physical function and inflammation in pre-frail obese older adults. METHODS: Cross-sectional study of 407 community dwelling pre-frail older adults. Data on demographics, cognition, and physical function(gait speed, handgrip strength (HGS) and Short Physical Performance Battery (SPPB) test), body composition and inflammation biomarkers were collected. Participants were analysed based on BMI tertiles(T1 lowest,T3 highest). RESULTS: The mean age was 72.67 years, mean BMI 25.42 kg/m2 and 59.5 % were females. Participants in T3 had a mean BMI of 30.75 kg/m2, younger with lower education levels, multimorbidity, polypharmacy and lower prevalence of sarcopenia. In BMI T3, ASMIbmi was significantly associated with EQ-5D index (ß 0.53, 95 % CI 0.04 to 1.03, p = 0.033),HGS (ß 5.28, 95 % CI 0.27 to 10.29, p = 0.039), SPPB (ß 2.19, 95 % CI 0.47 to 3.91, p = 0.013) and IL-6 (ß -4.13, 95 % CI -7.46 to -0.81, p = 0.017). ASMIwt was associated with EQ-5D index (ß 0.17, 95 % CI 0.02 - 0.33, p = 0.047). ASMbfp was associated with HGS (ß 6.97, 95 % CI 0.051 to 13.92, p = 0.049). There was significant association of HGS with all muscle mass indices in BMI T2, and ASMbfpin BMI T1. CONCLUSION: ASMIbmi was significantly associated with SPPB, HGS, EQ-5D index and IL-6 in BMI T3. ASMbfp was associated with HGS in all the tertiles. Our results need further validation at population level.

Spotlighting 'Medical Collegiality'.

'Collegiality' comes from the Latin term 'Collegium', which essentially refers to a community of individuals bounded by their collective pursuit of a common goal. The concept has historical roots in both organised religion and academia, with its use subsequently extended to various industrial and corporate settings including healthcare. Nowadays, 'collegiality' has become a common buzzword adopted by the medical fraternity - often deemed as having a polite and respectful demeanour, maintaining cordial work relationships and being a team player who demonstrates willingness to help others and avoid speaking ill of fellow colleagues. While it is true that workplace incivility, aggression, bullying and verbal abuse are not uncommonly reported in highly stressful healthcare settings, which are concerning phenomena that should be addressed and prevented, the concept of 'medical collegiality' is, in reality, a rich and multi-faceted concept that is not limited to behavioural attributes, but extends to larger cultural principles and organisational constructs. In this article, we herein define 'medical collegiality' as 'a collective manifestation of respect, empathy and solidarity within the medical fraternity, driven by a common pursuit of clinical excellence in patient care, demonstrated through interpersonal/work relationships and organisational culture', by referencing historical origins of 'collegiality' in organised religion and academia. We further review the concept of 'medical collegiality' through three core lenses of cultural, behavioural and structural collegiality. Finally, we discuss the importance of medical collegiality for physician mental health and well-being, and quality of clinical care.

Using the increasing vaccination model and the moderating roles of chronic medical conditions and education to understand COVID-19 vaccination uptake in Singapore.

COVID-19 vaccination programmes have helped reduce deaths and morbidity from the pandemic and allowed for the resumption of normal life. However, vaccine hesitancy remains an issue even with recurrent surges in COVID-19 cases due to new SARS-CoV-2 variants. Purpose: To elucidate psychosocial factors that contribute to our understanding of vaccine hesitancy. 676 Participants in Singapore took part in an online survey on vaccine hesitancy and uptake between May and June 2021. Data on demographics, perception of the COVID-19 pandemic, and vaccine willingness and hesitancy factors were collected. The responses were analyzed using structural equation modeling (SEM). The study found that confidence in the COVID-19 vaccines and risk perception of the COVID-19 situation are significantly associated with vaccination intention, while vaccination intention is also significantly associated with reported vaccination status. Additionally, certain chronic medical conditions moderate the relationship between vaccine confidence/risk perception and vaccine intention. This study contributes to our understanding of factors behind vaccination uptake which can help anticipate challenges to future vaccination campaigns for the next pandemic.

COVID-19 vaccination programmes have helped reduce deaths from the pandemic and allowed for the resumption of normal life. However, vaccine hesitancy among the public remains an issue even with recurrent surges in COVID-19 cases due to new SARS-CoV-2 variants. To understand psychosocial factors that contribute to vaccine uptake, this study surveyed 676 participants in Singapore through an online survey on vaccine hesitancy and uptake between May and June 2021. Data on demographics, perception of the COVID-19 pandemic, and vaccine willingness factors were collected. The responses were analyzed using structural equation modeling (SEM). The study found that confidence in the COVID-19 vaccines and risk perception of the COVID-19 situation are significantly associated with vaccination intention, while vaccination intention is also significantly associated with reported vaccination status. Additionally, certain chronic medical conditions moderate the relationship between vaccine confidence/risk perception and vaccine intention. This study contributes to our understanding of factors behind vaccination uptake which can help anticipate challenges to future vaccination campaigns for the next pandemic.