What Do Medical Students Actually Want from Learning Communities? A Comprehensive Needs Assessment.

This article was migrated. The article was marked as recommended. Purpose: The demanding nature of medical education has been well-described. Learning Communities (LCs) have been formed in a number of medical schools to address unmet needs such as wellness, social support, and academic/career counseling. However, there is limited information regarding the student perspective in shaping LC goals and activities. This study examined that perspective using a needs assessment survey. Methods: A formal needs assessment survey was completed by 510 medical students. The survey included 16 Likert-scale items and one open response item. Topics focused on student well-being, career planning, meaningful professional relationships, and academic success. Results: As expected, residency success and academic performance were the domains ranked as most important. Of note, the domain of wellness was ranked as less important overall. Results also varied by medical school year and gender. Conclusion: Formal assessment of student needs can serve as a guide to the development of LC programming, hopefully increasing student engagement.

A One-Year Institutional View of Resident Physician Burnout.

OBJECTIVES: This prospective study explores the prevalence, associated characteristics, and trajectory of burnout over one academic year in a multidisciplinary sample of resident physicians using a relatively new burnout survey instrument. METHODS: All residents from a U.S. academic health center (n = 633) were invited to complete the Copenhagen Burnout Inventory (CBI) three times, with 4-month time lags between invitations. A total of 281 (44%) provided complete CBI survey responses at least once, and 43 (7%) did at all three times. Descriptive statistics, cross-sectional analyses, correlations, and multivariable linear regression analyses were computed, as well as repeated measures ANOVAs and paired t tests, as appropriate, for each CBI domain (personal, work, patient-related burnout). RESULTS: About half had CBI scores indicating moderate-to-high levels of personal burnout (49-52%) and work-related burnout (45-49%), whereas patient-related burnout was less common (14-24%). However, patient-related burnout increased significantly from the beginning to the end of the year. Regression analyses indicated patient-related burnout was significantly higher for postgraduate year 1-2 residents compared to PGY 4+ residents, but was not significantly different by gender. Personal and work burnout scores were significantly higher for females. Persistently high burnout was observed in only 6% of respondents. CONCLUSIONS: In this study of resident physicians using the CBI, burnout was prevalent and higher levels of burnout were observed for females on the personal and work burnout domains, while junior residents had higher patient-related burnout. Persistently, high burnout was rare. The CBI demonstrated high reliability, was practical to administer, and produced similar results with existing burnout research.

Differences in burnout prevalence between clinical professionals and biomedical scientists in an academic medical centre: a cross-sectional survey.

OBJECTIVE: To determine the prevalence and associated factors for personal, work-related and patient/client-related burnout in clinical professionals and biomedical scientists in academic medicine. DESIGN: Prevalence survey using the Copenhagen Burnout Inventory. SETTING: Mid-size academic health centre. PARTICIPANTS: Clinical providers (n=6489) and biomedical scientists (n=248) were invited to complete the survey. 1646 completed responses (response rate 24.4%) were analysed. PRIMARY AND SECONDARY OUTCOME MEASURES: Prevalence estimates and adjusted ORs (AOR) were stratified for gender, age and professional category. RESULTS: Type of burnout varies across professional categories, with significant differences between clinicians and scientists. The prevalence of personal burnout was 52.7% (95%CI 50% to 55%), work-related burnout 47.5% (95%CI 45% to 49%) and patient/client-related burnout 20.3% (95%CI 18% to 22%). The prevalence of personal and work-related burnout was higher among women, while those aged 20-30 had a higher prevalence of all three burnout categories. Overall, clinical professionals had higher personal and work-related burnout, while biomedical scientists had higher client-related burnout. Accounting for the effects of gender and age, a significantly higher risk for personal burnout was found for physicians (AOR 1.64; 95%CI 1.3 to 2.1) and nurses (AOR 1.5; 95%CI 1.03 to 2.2). Significantly higher odds of work-related burnout were found for nurses (AOR 1.5; 95%CI 1.2 to 1.9) and residents (AOR 1.9; 95%CI 1.04 to 3.6). Basic scientists (AOR 10.0; 95%CI 5.7 to 17.6), physicians (AOR 2.8; 95%CI 1.9 to 4.1) and nurses (AOR 2.1; 95%CI 1.3 to 3.5) had higher odds of patient/client-related burnout. CONCLUSIONS: Types of burnout are unevenly distributed in academic medical centres. Physicians have higher risk of personal and patient/client-related burnout, residents have higher risk of work-related burnout, basic scientists are at higher risk of client-related burnout and nurses have higher odds of all three types of burnout. Interventions addressing the problem of burnout in clinical environments may be inadequate to support biomedical scientists.

Vitamin D Levels and Sociodemographic and Clinical Correlates in Individuals With Serious Mental Illness Admitted to an Acute Psychiatry Unit.

OBJECTIVE: To describe the prevalence of vitamin D deficiency in psychiatric inpatients with serious mental illness. Associated clinical and sociodemographic factors are also explored. METHOD: Data were collected using a retrospective review of medical records. Eligible subjects were individuals aged ≥ 18 years who were consecutively newly admitted to an adult inpatient teaching unit of a state psychiatric hospital from July 2012 through August 2013. The main outcome measure was prevalence rate of vitamin D deficiency in the target population. Vitamin D deficiency was defined as a level < 20 ng/mL. Psychiatric diagnoses were established using DSM-IV-TR criteria. RESULTS: Of 85 subjects, approximately two-thirds (67%) had a vitamin D level < 20 ng/mL. The mean vitamin D level was 18.4 ng/mL. Among the sociodemographic and clinical factors analyzed, only total serum protein (odds ratio = 0.33; CI, 0.12-0.88; P < .05) was associated with vitamin D deficiency. CONCLUSIONS: The high prevalence of vitamin D deficiency with all the attendant physical and mental health burdens in vulnerable populations such as individuals with serious mental illness requires further large research studies. In the meantime, it seems prudent to institute routine screening for vitamin D deficiency in individuals with mental illness, especially those who are hospitalized.

Adverse childhood experiences and geriatric depression: results from the 2010 BRFSS.

OBJECTIVE: Adverse childhood experiences (ACEs), including physical, sexual, and emotional abuse, have been shown to result in a variety of poor outcomes including depression. The majority of research has examined the impact of such events on adolescents and young adults leaving a dearth of information regarding how these events may affect depressive symptom point prevalence later in life. METHODS: Data from the U.S. CDC's 2010 Behavioral Risk Factor Surveillance Survey (BRFSS) were used to estimate the point prevalence of depression in individuals 60 years of age and greater based on presence or absence of certain ACEs. Depressive symptoms were assessed using eight items from the Patient Health Questionnaire (PHQ). Subjects with a PHQ score of 10 or greater were categorized as depressed. Six different types of ACE were included in the study: parents being physically abusive to each other, being physically harmed by a parent, being sworn at by the parent, being touched sexually by an adult, being forced to sexually touch an adult, and being forced into a sexual encounter. ACEs were categorized as never, single if subject reported it occurring once, or repeated if subject reported multiple episodes. RESULTS: The study sample consisted of 8,051 adults aged 60 years and greater who responded to questions about adverse childhood experiences. The study sample comprised 53% women, 83% Caucasian patients, and had a mean age of 70.4 years. After controlling for age, sex, and race, depression was significantly correlated with repeated ACEs of all types (adjusted odds ratio [AOR] ranging from 2.41 to 9.78, all statistically significant). The only ACE where a single occurrence was significantly associated with late-life depression was forced sexual intercourse (AOR: 2.92, 95% CI: 1.06-8.02). After controlling for all types of abuse in a single model, repeated physical abuse and repeated forced sexual intercourse remained significant (AOR: 2.94, 95% CI: 1.68-5.13; AOR: 3.66, 95% CI: 1.01-13.2, respectively). DISCUSSION: These results indicate a significant association between repeated ACEs and depression in older adults. When controlling for all forms of abuse, repeated physical abuse and forced sexual intercourse are significantly correlated with late-life depression. They emphasize the need to continue developing techniques to help individuals with a history of ACEs in order to decrease their negative effects, not only immediately, but also later in life.

Monitoring for metabolic side effects among outpatients with dementia receiving antipsychotics.

OBJECTIVE: This study examined monitoring for metabolic side effects among older outpatients with dementia starting a new antipsychotic. METHODS: In a retrospective cohort analysis of U.S. Department of Veterans Affairs data, monitoring, as recommended by the American Diabetes Association and the American Psychiatric Association, was examined between October 1, 2005, and September 30, 2011. The sample included outpatients aged ≥60 years with dementia but without a psychotic disorder (N=3,903) and outpatients with a psychotic disorder but without dementia (N=5,779) who were prescribed a new antipsychotic. Because dementia patients differed from psychosis patients in all observed patient characteristics, especially age, metabolic monitoring of dementia patients was compared with a propensity score-matched sample of outpatients with psychosis (1,576 matched pairs). RESULTS: At baseline (±30 days from the index prescription), 68% of the matched dementia patients were weighed, compared with 63.7% of the matched psychosis patients (odds ratio [OR]=1.28, 95% confidence interval [CI]=1.03-1.48). Monitoring for glucose or glycosylated hemoglobin (HBA1c) and low-density lipoprotein (LDL) was not significantly different between the groups: glucose or HBA1c, 41% versus 44%; LDL, 24% versus 27%. At three months (±30 days), metabolic monitoring for all three parameters was significantly lower for the dementia group: weight, OR=.86, CI=.75-.99; glucose or HBA1c, OR=.83, CI=.71-.97; and LDL, OR=.69, CI=.57-.85. CONCLUSIONS: Monitoring rates for metabolic side effects were low for both dementia and psychosis groups, with lower rates for dementia patients at follow-up compared with matched psychosis patients. Quality improvement efforts are needed to improve monitoring, especially for patients with dementia.

The effectiveness of guideline implementation strategies on improving antipsychotic medication management for schizophrenia.

OBJECTIVES: To compare the effectiveness of a conceptually-based, multicomponent "enhanced" strategy with a "basic" strategy for implementing antipsychotic management recommendations of VA schizophrenia guidelines. METHODS: Two VA medical centers in each of 3 Veterans Integrated Service Networks were randomized to either a basic educational implementation strategy or the enhanced strategy, in which a trained nurse promoted provider guideline adherence and patient compliance. Patients with acute exacerbation of schizophrenia were enrolled and assessed at baseline and 6 months and their medical records were abstracted; 291 participants were included in analyses. Logistic regression models were developed for rates of: (1) switching patients from first-generation antipsychotics (FGA) to second-generation antipsychotics (SGA), and (2) guideline-concordant antipsychotic dose. RESULTS: Of participants prescribed FGAs at baseline, those at enhanced sites were significantly more likely than participants at basic sites to have an SGA added to the FGA during the study (29% vs. 8%; adjusted OR = 7.7; 95% CI: 2.0-30.1), but were not significantly more likely to be switched to monotherapy with an SGA (29% vs. 23%). Guideline-concordant antipsychotic dosing was not significantly affected by the intervention. CONCLUSIONS: The enhanced guideline implementation strategy increased addition of SGAs to FGA therapy, but did not significantly increase guideline-recommended switching from FGA to SGA monotherapy. Antipsychotic dosing was not significantly altered. The study illustrates the challenges of changing clinical behavior. Strategies to improve medication management for schizophrenia are needed, and must incorporate recommendations likely to emerge from recent research suggesting comparable effectiveness of SGAs and FGAs.

Guideline implementation and patient-tailoring strategies to improve medication adherence for schizophrenia.

OBJECTIVE: To determine the effectiveness of an intervention to promote medication adherence. METHOD: Data were collected for adults with exacerbation of schizophrenia who were treated at one of 6 U.S. Department of Veterans Affairs (VA) Medical Centers (VAMCs) in 3 regional VA networks (Veterans Integrated Service Networks [VISNs]) from March 1999 to October 2000. All 6 VAMCs received a basic guideline implementation strategy for medication management of schizophrenia using usual VA procedures. One VAMC within each VISN was randomly selected to receive an enhanced implementation strategy designed to promote guideline-concordant prescribing by physicians and medication adherence by patients. In the enhanced strategy, a research nurse worked with study participants to identify medication adherence barriers and to develop patient-specific strategies to overcome those barriers. Participants (N = 349) were interviewed at enrollment and 6 months later, using the Structured Clinical Interview for the Positive and Negative Syndrome Scale (PANSS), the Barnes Akathisia Rating Scale, and the Schizophrenia Outcomes Module (SCHIZOM). Medication adherence was measured via subjects' self-report, using the SCHIZOM, and from data abstracted from medical records. RESULTS: Participants were primarily male (94%) and nonwhite (69%, primarily African American) with a mean age of 46 years. Medication adherence at follow-up was modeled using logistic regression, controlling for adherence at baseline, demographic characteristics, PANSS total score, akathisia at baseline, family history of mental illness, and substance abuse. A logistic regression model for adherence at follow-up was significant (likelihood ratio = 52.72, df = 14, p < .0001). Patients enrolled at sites receiving the enhanced intervention were almost twice as likely to be adherent at follow-up. Those who were nonadherent at baseline were significantly less likely to be adherent at follow-up. In addition, adherence at follow-up was significantly greater at 2 of the VA networks as compared to the third network. CONCLUSIONS: These data suggest that a patient-centered strategy to identify and overcome barriers to adherence can improve adherence to antipsychotic medications.

A pilot study of barriers to medication adherence in schizophrenia.

BACKGROUND: Interventions to improve adherence to antipsychotic medication are needed. The aims of the current study were to identify the most common barriers to medication adherence in a cohort of patients receiving outpatient and inpatient treatment for an acute exacerbation of schizophrenia, compare clinical and demographic characteristics of patients with lower versus higher numbers of barriers, and characterize patients most likely to be nonadherent to antipsychotic medication. METHOD: The present study analyzed data collected during the Schizophrenia Guidelines Project (SGP), a multisite study of strategies to implement practice guidelines that was funded by the U.S. Department of Veterans Affairs and conducted from March 1999 to October 2000. Nurse coordinators had conducted clinical assessments and performed an intervention designed to improve medication adherence by addressing barriers to adherence. Data on patient symptoms, functioning, and side effects had been obtained using the Positive and Negative Syndrome Scale (PANSS), the Schizophrenia Outcomes Module, the Medical Outcomes Study 36-item Short-Form Health Survey, and the Barnes Akathisia Scale (BAS). Administrative data were used to identify patients with an ICD-9 code for schizophrenia. A total of 153 patients who met this criterion and participated in the intervention arm of the SGP had complete data available for analysis in the current study. RESULTS: The most common patient-reported barriers were related to the stigma of taking medications, adverse drug reactions, forgetfulness, and lack of social support. Bivariate analysis showed that patients with high barriers were significantly more likely to be nonadherent (p < or =.02), to have problems with alcohol or drug use (p =.02), to have higher PANSS total scores (p =.03), and to have higher mean BAS scores (p =.02). Logistic regression showed that lower patient education level (odds ratio [OR] = 3.95, p =.02), substance abuse (OR = 3.24, p =.01), high PANSS total scores (OR = 1.02, p =.05), and high barriers (OR = 2.3, p =.05) were significantly associated with the probability of nonadherence. CONCLUSIONS: It may be possible to identify patients most likely to benefit from adherence intervention. The data presented here will help to inform future research of clinical interventions to improve medication adherence in schizophrenia and help to stimulate further work in this area.

Cyclic antidepressants and the risk of sudden cardiac death.

BACKGROUND: Tricyclic and other related cyclic antidepressants (TCAs), used frequently for the treatment of depression and several other indications, have cardiovascular effects that may increase the risk of sudden cardiac death. We thus sought to quantify the risk of sudden cardiac death among TCA users, according to dose, as well as among users of selective serotonin reuptake inhibitors (SSRIs). METHODS: We conducted a retrospective cohort study in Tennessee Medicaid, from Jan 1, 1988, through Dec 31, 1993, which included large numbers of antidepressant users and computer files describing medication use and comorbidity. The cohort included 1,282,091 person-years of follow-up for persons aged 15 to 84 years who were not in a nursing home and were free of life-threatening noncardiac illness. This included 58,956 person-years for current use of TCAs alone, 6291 person-years for SSRIs only, and 96,220 person-years for former use. RESULTS: The cohort included 1487 confirmed sudden cardiac deaths occurring in the community. When compared with nonusers of antidepressants, current users of TCAs had a dose-related increase in the risk of sudden cardiac death. Rate ratios increased from 0.97 (95% confidence interval [CI], 0.72-1.29) for doses lower than 100 mg (amitriptyline or its equivalent) to 2.53 (95% CI, 1.04-6.12) for doses of 300 mg or more (P =.03, test for dose-response). The rate ratio for SSRIs was 0.95 (95% CI, 0.42-2.15). There was no evidence that TCA doses lower than 100 mg increased the risk of sudden cardiac death in subgroups defined by pre-existing cardiovascular disease, female sex, age 65 years or older, or use of amitriptyline. CONCLUSIONS: Our data suggest that SSRI antidepressants and TCAs in doses of less than 100 mg (amitriptyline equivalents) did not increase the risk of sudden cardiac death. However, higher doses of TCAs were associated with increased relative risk, which suggests that such doses should be used cautiously, particularly in patients with an elevated baseline risk of sudden death.

P.R.N. (As-needed) orders and exposure of psychiatric inpatients to unnecessary psychotropic medications.

OBJECTIVE: The objective of this study was to evaluate whether the practice of writing standing p.r.n. (as-needed) orders exposes psychiatric inpatients to unnecessary psychotropic medications. METHODS: Medical records for 223 new hospital admissions between July 15 and October 15, 1999, when p.r.n. orders were allowed, and 224 new admissions between November 15, 1999, and February 15, 2000, when p.r.n. orders were not allowed and only "now" orders were permitted, were reviewed from the three acute adult psychiatric units of the Arkansas State Hospital in Little Rock. Data were collected on demographic and clinical characteristics, scheduled and unscheduled psychotropic medications as noted in the medication administration records, use of seclusion and restraint, and incident reports of physical aggression. The mean numbers of unscheduled psychotropic medication doses administered during the two periods were compared. RESULTS: The number of unscheduled psychotropic medications administered decreased from 1,812 in the first period to 976 in the second period (adjusted mean doses per admission, 7.8 to 4.3). The decrease in use of unscheduled medications when standing p.r.n. orders were no longer allowed was not associated with corresponding increases in adverse events: there were fewer incidents of restraint (four compared with eight), fewer incidents of seclusion (41 compared with 48), and fewer incidents of physical aggression (35 compared with 40). In addition, there were no significant changes in the dosages of scheduled psychotropic medications on day 7 of admission, indicating that physicians were not increasing dosages in response to the elimination of p.r.n. orders. CONCLUSIONS: The practice of writing p.r.n. orders may expose psychiatric inpatients to unnecessary psychotropic medications.

Misclassification of current benzodiazepine exposure by use of a single baseline measurement and its effects upon studies of injuries.

PURPOSE: Measurement of drug exposure is a major methodologic challenge for pharmacoepidemiologic studies of acute effects of medications taken intermittently. If the effect is plausible only during periods of active drug use, daily (or even more frequent) exposure measurement is optimal. Benzodiazepines, episodically used hypnotics and anxiolytics, impair psychomotor function and some epidemiologic studies have reported users have increased risk of unintentional injuries. However, several prospective cohort studies of this question defined benzodiazepine exposure status from a single baseline measurement, and these have not consistently reported increased risk. We used data from an historical cohort study to demonstrate the extent of misclassification potentially induced by this practice. METHODS: The cohort consisted of 2510 Tennessee nursing home residents 65 years of age or older identified in a prior study of antidepressants and falls. Both baseline users (any in 7 days preceding start of follow-up) and current use (use on a given day of follow-up) of benzodiazepines were determined from facility medication administration records, which record information on drugs given to the resident each day. Falls were ascertained from nursing home incident reports and medical records. The effect of benzodiazepine exposure for each ascertainment method was estimated from incidence rate ratios adjusted for multiple fall risk factors by Poisson regression. RESULTS: The 666 baseline benzodiazepine users had current use on 44.6% (95% CI, 40.2-49.2%) of follow-up person-days; baseline non-users had current use for 3.7% of days (2.8-4.7%). Misclassification increased with length of follow-up and with quintile of fall risk. The adjusted fall incidence rate ratios for the baseline user and current use definitions were 1.02 (95% CI, 0.95-1.10) and 1.44 (1.33-1.56), respectively. CONCLUSION: These findings strongly suggest that to avoid potentially serious misclassification, studies of the acute effects of benzodiazepines and other drugs taken intermittently need to track exposure on a day-by-day basis.