Clinical Encounters Research Articles

Transformational learning and professional identity formation in postgraduate competency-based medical education.

Residency programmes are in transition to a framework for competency-based medical education (CBME). The intersection of CBME with transformational learning (TL) experiences and professional identity formation (PIF) - particularly within senior learners in transitional states - is unknown but important to understand in order to develop and implement strategies to support trainees' professional development. Through inductive qualitative methods, we conducted semi-structured interviews (n= 22) of current trainees and recent graduates from adult cardiology residency training programmes within Canada to explore the impact of TL experiences on residents' professional growth and identity formation. Interviews were analysed using thematic analysis informed by TL theory. CBME did not appear to influence trainees' experiences of disorienting dilemmas and TL. Important clinical encounters and interpersonal relationships - in particular, those between mentor and mentee - shaped trainees' professional development as cardiologists ('enabling factors' for TL and PIF). 'Imposter phenomenon' was widely prevalent in our sample study population even among graduates who had already completed their training. Requisite elements for transformation (disorienting dilemmas, critical reflection, discourse and action) also contributed to PIF. TL experiences influenced PIF in senior learners but infrequently intersected with CBME; these experiences were more commonly prompted by disorienting dilemmas relating to clinical outcomes or interpersonal interactions independent of CBME-specific architecture.

Temporal trends in the prevalence of GP registrars’ long-term paediatric asthma control medications prescription

Asthma is one of the most common chronic illnesses affecting children. Long-term asthma control medications (LTACMs) are an important aspect of asthma management, with under-prescription associated with poor asthma control and increased asthma deaths. This study aimed to document temporal trends in the prescribing of LTACMs for paediatric patients for asthma-related presentations to Australian general practice registrars (trainees). Longitudinal analyses of data from 2010 to 2022 from the Registrars Clinical Encounters in Training study were undertaken. Proportions of paediatric presentations where LTACMs were prescribed were calculated, and temporal trends analysed and graphed. There was no change over time in registrar prescribing of LTACMs for paediatric asthma, although temporal changes were seen in the types of LTACMs prescribed. The lack of temporal increase in overall LTACMs prescription, despite evidence showing their importance in preventing asthma morbidity and mortality, has significant educational, clinical, and policy implications.

Time Motion Study of Tuberculosis Patients Attending a Hospital in an Indian State

Abstract Objectives: To analyse the time taken in availing various services by a patient of cardinal symptoms of Tuberculosis in TB Hospital, Bhopal, India and to determine the satisfaction of patients regarding care. Methods: This is a time–motion observational study of patients who came with symptoms of TB. A sample of 210 was calculated using Cochran’s formula. Results: Amongst the 210 patients studied, the majority were males, i.e. 123 (58.6%). A striking feature was found during this study that reports of sputum were given 2–5 days after collection. Conclusion: This busy hospital dedicated to providing comprehensive healthcare pertaining to TB had multiple patient queues, long clinical visits and short clinical encounters. Although the patients were satisfied with the clinical consultations from the doctors, they found difficulty in availing laboratory and X-ray services.

'The MRI-scan says it is completely normal': Reassurance attempts in clinical encounters among patients with chronic musculoskeletal pain.

In clinical guidelines for patients with chronic musculoskeletal pain, reassurance is a key element. The purpose of reassuring patients is to change their views on their illness and, thereby, their actions. However, when symptoms persist without pathological findings, reassurance can be difficult to achieve. Drawing on observations of nineteen naturally occurring hospital consultations with chronic musculoskeletal pain patients, followed by individual interviews with both patients and clinicians, we study how they interact in relation to reassurance. Our main aim is to explore the ways in which clinicians explicitly attempt to provide reassurance, and how patients receive these attempts, before reflecting on facilitating and hindering factors for successful reassurance in relation to the sociocultural context in which their interaction takes place. Through a thematic analysis, four dominating elements of explicit reassurance were identified: (1) education through visualisation, (2) validation through technological findings, (3) validation through physical examination and (4) normalising pain. To gain a deeper understanding of the reassurance process, we then narratively explored dialogical extracts containing these elements. The analysis shows a potential lack of congruence between what patients experience, and the biomedical knowledge clinicians rely on. Despite employing a combination of affective and cognitive modes of reassurance, clinicians tend to build their final conclusions not on patients experiences but on biomedical knowledge, which is knowledge that holds epistemic primacy for themselves. In that sense, their efforts to reassure the patients might also be a way in which they seek to reassure themselves.

PrescDRL: deep reinforcement learning for herbal prescription planning in treatment of chronic diseases

Treatment planning for chronic diseases is a critical task in medical artificial intelligence, particularly in traditional Chinese medicine (TCM). However, generating optimized sequential treatment strategies for patients with chronic diseases in different clinical encounters remains a challenging issue that requires further exploration. In this study, we proposed a TCM herbal prescription planning framework based on deep reinforcement learning for chronic disease treatment (PrescDRL). PrescDRL is a sequential herbal prescription optimization model that focuses on long-term effectiveness rather than achieving maximum reward at every step, thereby ensuring better patient outcomes. We constructed a high-quality benchmark dataset for sequential diagnosis and treatment of diabetes and evaluated PrescDRL against this benchmark. Our results showed that PrescDRL achieved a higher curative effect, with the single-step reward improving by 117% and 153% compared to doctors. Furthermore, PrescDRL outperformed the benchmark in prescription prediction, with precision improving by 40.5% and recall improving by 63%. Overall, our study demonstrates the potential of using artificial intelligence to improve clinical intelligent diagnosis and treatment in TCM.

A Queer Silence: Dissociation in the Clinical Encounter

ABSTRACT If psychoanalytic psychotherapy’s work is contingent on patients speaking, then what is one to do when the patient is unable to speak? Is silence the death of psychotherapy or rather a space that gives meaning to words spoken or unspoken? The author examines silence, as utilized by a queer adolescent who completed 12 sessions of psychoanalytic psychotherapy as a potential medium of dissociation. The paper seeks to explore silences as a paradoxical means of protection, connection, and disconnection. By viewing silences through these multiple and at times paradoxical functions the author recommends that paradox gives way to understanding queerness.

Health sciences training for disability inclusion: the need to engage with emotion

Material aspects of disability inequality, such as access to quality services, housing and employment, are an urgent, worldwide concern. Less recognised though, are psychological layers of prejudice and discrimination, which...

Identification of Novel Genetic Risk Variants Associated with Hidradenitis Suppurativa in an Exome Sequencing Cohort of 92,455 Individuals

Introduction: Hidradenitis suppurativa (HS) is a prevalent and persistent inflammatory skin disorder, lacking a known cure or effective biomarkers for early diagnosis at present. The genetic determinants of HS have not been fully documented, but it is believed to result from a combination of genetic and environmental factors. Methods: To identify relevant HS gene variants in sporadic HS patients, this study utilized longitudinal electronic health records (EHRs) and whole-exome sequencing. DNA exome sequencing data from 92,455 participant samples in the MyCode biobank, linked to Geisinger’s EHR, were analyzed. This cohort included 1,092 HS cases and 91,363 healthy controls. The MyCode EHR has a median longitudinal follow-up of 15 years per participant, with an average of 87 clinical encounters, 687 laboratory tests, and 7 procedures. Results: There were 1,092 (901 females and 191 males) participants aged 14–89 years (median 47 years) with HS (L73.2), indicating a 1.18% prevalence and accounting for a 4.7:1 female-to-male ratio among the individuals presenting for clinical care. γ-secretase complex, syndromic, and autoinflammatory gene variants were assessed. Potential pathogenic variants were identified among 66 individuals in the HS genes studied. Molecularly, the estimated HS variant prevalence was 1:1,400 in the cohort, 12.3% of variant carriers had HS diagnosis in EHR. Conclusions: Using longitudinal EHR data, genomic screening identified HS-associated gene variants in a defined group of sporadic HS patients to augment the clinical diagnosis, particularly in cases of ambiguity. Based on this study, the field of skin disorders can benefit from a personalized approach to HS diagnosis using large-scale sequencing.

Counseling About Cannabis Use During Pregnancy and Lactation: A Qualitative Study of Patient and Clinician Perspectives.

Legalization in many jurisdictions has increased the prevalence of cannabis use, including during pregnancy and lactation. Accordingly, clinicians providing perinatal and infant care are increasingly required to counsel about this topic, even if they do not feel comfortable or prepared for this conversation. The aim of this research was to explore how prenatal clinicians and pregnant and lactating women interact with cannabis consumption. Using qualitative description, we conducted semi-structured interviews with 75 individuals in Canada: 23 clinicians who provide pregnancy and lactation care, and 52 individuals who made cannabis consumption decisions during pregnancy and/or lactation. Data were analyzed using inductive content analysis. Three phases of the clinical encounter influenced decision-making about cannabis consumption: initiation of a discussion about cannabis, sense-making, and the outcome of the encounter. Patients and clinicians described similar ideals for a counseling encounter about cannabis consumption during pregnancy or lactation: open, patient-centered conversation grounded in an informed decision-making model to explore the benefits, risks, and alternatives to cannabis. While clinicians described these values as reflecting real clinical interactions, patients reported that in their experience, actual interactions did not live up to these ideals. Clinicians and pregnant and lactating people report desiring the same things from a counseling interaction about cannabis: sharing of information, identification of values, and facilitation of a decision. Both groups endorse an open, nonjudgemental counseling approach that explores the reasons why a patient is considering cannabis consumption and reflects these reasons against available evidence and alternatives known to be safe.

Cultural considerations when working with Jewish students and supervisees

ABSTRACT The author examines the marginalization of Jewish identities in multicultural clinical education and supervision amid rising antisemitism in the U.S., proposing the use of cultural democracy to address these issues. He critiques the erasure of Jewish identity due to the neglect of Jewish backgrounds in key theories and inaccuracies in clinical literature. He further underscores the importance of Jewish cultural considerations, including accommodating Jewish practices such as holidays, Sabbath observance, mourning customs, and dietary laws, while advocating for flexibility and sensitivity. Finally, he addresses considerations when supervisees experience antisemitism from a person at the center of a clinical encounter.

6771 New onset Graves’ Disease in a Patient with Hashimoto's Thyroiditis and Positive Thyroid Peroxidase Autoantibodies. Case Report

Abstract Disclosure: M.M. Eid: None. J.L. Zapater: None. Introduction: Hashimoto’s Thyroiditis (HT) and Graves’ Disease (GD) are the most common thyroid autoimmune disorders. Transition of GD to HT is common, but transition of HT to GD is rare. Case: A 55 year old, female with depression, HTN and fibromyalgia. She was referred for evaluation of chronic fatigue and reduction in functional capacity. Five years earlier, she had also been evaluated for fatigue. Labs at that time: TSH 3.80 µIU/ml (0.35-3.74 µIU/ml), free T4 0.8 ng/dl (0.76-1.46 ng/dl), thyroid peroxidase antibody (anti-TPO) 605.6 U/ml (0-60 U/ml), and anti-thyroglobulin antibody (anti-TG) 37.2 U/ml (0-60 U/ml). Subclinical hypothyroidism was diagnosed, but no levothyroxine was initiated. Her TSH was found to be normal in 2019 and 2021. At the current clinical encounter, other than fatigue she denies weight/voice change, tremor, palpitation, anxiety, recent flu like illness or radiation exposure, neck swelling/pain, heat intolerance, or difficulty swallowing. Her daily medications are amlodipine 10mg and duloxetine 20mg. She had menopause 2 years ago. She has no known allergy. She has a brother with rheumatoid arthritis. She denies smoking or alcohol consumption. On exam, vital signs are normal, and BMI is 28.1. There is diffuse, firm thyromegaly without a palpable nodule. There is no cervical lymphadenopathy, tremor, neck tenderness, exophthalmos, or lid lag. Creatinine, liver enzymes are normal but hemoglobin is 9gm/dl. Anti-tissue transglutaminase and anti-gliadin antibodies were negative. Her thyroid labs were: TSH <0.008 uIU/ml, free T4 1.06ng/dl, free T3 4.07 pg/ml (2.3-4.2 pg/ml), total T3 1.74 ng/ml (0.60-1.81 ng/ml), anti-TPO antibody 12,414 U/ml, anti-TG antibody 22 U/ml, thyrotropin receptor antibody (TRAB) 15.24 IU/L (0-1.75 IU/L), and thyroid stimulating immunoglobulin (TSI) 331% (<130%). Thyroid uptake scan showed 49% iodine-131 uptake in symmetric and homogenous uptake, and no hot or cold nodules. GD was diagnosed, methimazole 5mg daily was initiated. Conclusion: Our case had subclinical HT with positive anti-TPO antibodies 5 years preceding the onset of GD. Causes of autoimmune conversion are not well understood. Viral infection or radiation exposure in genetic susceptible patients have been assumed as triggers (1). The blocking and stimulating action of TRAB on TSH receptors is considered as a possible mechanism of switching between hypothyroidism and hyperthyroidism. Clinical and biochemical evaluation for possible conversion to GD in patients with HT is recommended (2).

They Will Surveil You to Death: Gangstalking as a Cultural Concept of Distress.

Understanding local worldviews is a challenge during clinical encounters, especially when they involve cultural references without acceptance from the medical community. Gangstalking is a Western cultural notion which refers to systematic harassment, surveillance, and torture from unseen or covert assailants or networks. It is not a 'real phenomenon' compared with genuine stalking, but experients report worse depression, post-traumatic symptoms, suicidal ideation, and longer lasting encounters. They report physical pain and impossible feats of espionage technologically orchestrated by unknown malevolent actors. Using conversational data from targeted individual podcasts, I explore gangstalking as a cultural concept of distress (CCD) by highlighting associated explanations, idioms, and symptoms. Clinically, gangstalking is likely diagnosed as paranoid schizophrenia. However, its association with frightening events parallels Susto and Nervios. Physical symptoms parallel Open Mole and Brain Fag Syndrome. Like many CCDs, gangstalking is a multi-dimensional phenomenon not neatly mapped onto psychiatric categories. Misinterpreting gangstalking cases as unique or isolated is a likely outcome even when they fit within a well-known Western subculture and techno-science belief system. Moving past prior, outdated notions of folk illnesses and culture-bound syndromes, gangstalking as a CCD helps end the assumption that only the other has exotic or non-psychiatric categories of distress.

The Barriers and Facilitators of Shared Decision Making in Pediatric Otolaryngology: A Qualitative Study.

To identify barriers and facilitators to implementing shared decision making (SDM) in pediatric otolaryngology. A qualitative study. Semistructured interviews of pediatric otolaryngologists. The Theoretical Domains Framework (TDF) was used as a guide for data collection and analysis to consider capability, opportunity, and motivation (COM-B) factors. The focal surgical procedures were tonsillectomy, adenoidectomy, and tympanostomy tube placement. Deductive and inductive coding of interview transcripts according to TDF/COM-B domains were performed by 2 separate reviewers. A total of 11 interviews were conducted to achieve data saturation. The 4 dominant themes were: (1) inconsistent inclusion of SDM elements in practice, (2) social influences from parents, (3) environmental context, and (4) applicability of SDM in otolaryngology. Theme 1 identified that surgeons perceived SDM as a feature of their practice. However, the discussion of parents' values was seen as less explicit and structured interview formats were not commonly employed. Theme 2 demonstrated that surgeons saw parents' preconsult "agenda" as influencing their openness to consider multiple treatment options. Theme 3 pointed to the barriers of short appointment times, challenges in the use of support staff and lack of decision aids. Theme 4 emphasized surgeons' belief in the value of SDM and that parents' involvement in decision making reduced likelihood of decisional regret. Pediatric otolaryngologists strongly support the value of SDM during clinical encounters, particularly to allow parent ownership of decisions regarding treatment. The major barriers were lack of clinical translation of SDM knowledge, social influences, and environmental factors.

Close, yet so far away: a phenomenology of the praecox feeling in the diagnosis of schizophrenia as intercorporeal alienness.

Debates concerning the reliability and validity of operationalized criteria and diagnostic tools have surrounded the issue of schizophrenia diagnosis and clinical decision-making related to the disorder. The notion of the praecox feeling (PF) has played a prominent role in the discussions as an example of the possibility of a rapid and potentially valid diagnosis based solely on "intuition" or a peculiar emotional experience or impression arising in a physician during an interaction with a patient with schizophrenia. In this paper, we argue that PF is enabled by the (phenomenologically understood) intercorporeal dimension of the clinical encounter. Intercorporeality in this sense denotes intertwinement between embodied expressions that may lead to feelings of connection but also, as in the case of PF, of disconnection and strangeness-the experience of alienness. Following Waldenfels, alienness ranges from the average social encounter to more extreme and peculiar forms-such as PF. To prove our point, we analyze the metaphors used by physicians in various cultural contexts (the United States, the United Kingdom, and Poland) to express the apparently ineffable experience of the PF. We focus on two dominant metaphors of distance: the first expressing spatial distance by referring to an "object in-between" the physician and the patient and the second expressing mental distance by referring to the "other-worldliness" of the patient. We interpret the object in-between metaphors as reflecting the sense of separateness and the other-worldliness metaphors as reflecting the sense of strangeness, with both meanings unified in the notion of "close remoteness." Such unsettling but speculation-provoking feeling of close remoteness may be rendered by the concept of "the eerie" (Mark Fisher). We conclude that metaphor and phenomenological analysis facilitate an understanding of the experiential profile of PF in the clinical encounter, outlining relevant clinical implications.

Health Care Workers' Perspectives on Collecting Sexual Orientation and Gender Identity in the Adult Primary Care Setting.

Despite numerous calls for standardized collection of sexual orientation and gender identity (SOGI) data in clinical settings, uptake of this practice still lags. This study conducted a preimplementation assessment of staff attitudes toward SOGI data collection within an adult primary care practice in an urban academic medical center in the northeastern United States. We created a process map of the flow of patient data from the point of registration to the clinical encounter to identify all staff roles associated with registration and patient demographic data collection. We purposively sampled staff members across these roles and conducted semistructured virtual interviews between November 2021 and February 2022. The research team used deductive and inductive coding and conducted a thematic analysis to identify barriers and facilitators to implementation. Nine clinical staff and eleven nonclinical staff were interviewed. Participants were asked about their general experiences with lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients, their perspectives on collecting this data, and potential barriers and facilitators to incorporating this into the workflow. The main themes that emerged were the relevance of SOGI data to the clinical practice; concerns about patient acceptability; the prevalence of cis-gender, heteronormative assumptions; and concerns about linguistic, cultural, and generational differences. Differences were noted between clinical and nonclinical staff. Greater education is needed to help both clinical and nonclinical staff understand how patients' SOGI demographics can be used to provide affirming, patient-centered care. Implementation strategies can be tailored to address specific barriers at the individual, organizational, and social levels.

Optimal Pediatric Outpatient Antibiotic Prescribing

In the US, 50% of all pediatric outpatient antibiotics prescribed are unnecessary or inappropriate. Less is known about the appropriateness of pediatric outpatient antibiotic prescribing. To identify the overall percentage of outpatient antibiotic prescriptions that are optimal according to guideline recommendations for first-line antibiotic choice and duration. This cross-sectional study obtained data on any clinical encounter for a patient younger than 20 years with at least 1 outpatient oral antibiotic, intramuscular ceftriaxone, or penicillin prescription filled in the state of Tennessee from January 1 to December 31, 2022, from IQVIA's Longitudinal Prescription Claims and Medical Claims databases. Each clinical encounter was assigned a single diagnosis corresponding to the lowest applicable tier in a 3-tier antibiotic tier system. Antibiotics prescribed for tier 1 (nearly always required) or tier 2 (sometimes required) diagnoses were compared with published national guidelines. Antibiotics prescribed for tier 3 (rarely ever required) diagnoses were considered to be suboptimal for both choice and duration. Primary outcome was the percentage of optimal antibiotic prescriptions consistent with guideline recommendations for first-line antibiotic choice and duration. Secondary outcomes were the associations of optimal prescribing by diagnosis, suboptimal antibiotic choice, and patient- and clinician-level factors (ie, age and Social Vulnerability Index) with optimal antibiotic choice, which were measured by odds ratios (ORs) and 95% CIs calculated using a multivariable logistic regression model. A total of 506 633 antibiotics were prescribed in 488 818 clinical encounters (for 247 843 females [50.7%]; mean [SD] age, 8.36 [5.5] years). Of these antibiotics, 21 055 (4.2%) were for tier 1 diagnoses, 288 044 (56.9%) for tier 2 diagnoses, and 197 660 (39.0%) for tier 3 diagnoses. Additionally, 194 906 antibiotics (38.5%) were optimal for antibiotic choice, 259 786 (51.3%) for duration, and 159 050 (31.4%) for both choice and duration. Acute otitis media (AOM) and pharyngitis were the most common indications, with 85 635 of 127 312 (67.3%) clinical encounters for AOM and 42 969 of 76 865 (55.9%) clinical encounters for pharyngitis being optimal for antibiotic choice. Only 257 of 4472 (5.7%) antibiotics prescribed for community-acquired pneumonia had a 5-day duration. Optimal antibiotic choice was more likely in patients who were younger (OR, 0.98; 95% CI, 0.98-0.98) and were less socially vulnerable (OR, 0.84; 95% CI, 0.82-0.86). This cross-sectional study found that less than one-third of antibiotics prescribed to pediatric outpatients in Tennessee were optimal for choice and duration. Four stewardship interventions may be targeted: (1) reduce the number of prescriptions for tier 3 diagnoses, (2) increase optimal prescribing for AOM and pharyngitis, (3) provide clinician education on shorter antibiotic treatment courses for community-acquired pneumonia, and (4) promote optimal antibiotic prescribing in resource-limited settings.

How Should Clinicians Partner With Families to Promote Children's Sleep Health?

Short sleep duration, poor sleep quality, and irregular timing of sleep are prevalent sleep troubles for children, but fully assessing children's sleep environments and effectively promoting children's overall sleep health is nearly impossible during brief clinical encounters. This commentary on a case suggests strategies for navigating this problem with a patient- and family-centered approach that prioritizes identifying family sleep-related beliefs, values, and goals and maintaining flexibility when offering evidence-based recommendations to improve children's sleep.

Optimizing influenza vaccination among oncology patients through quality improvement cycles.

285 Background: Influenza poses significant risks to cancer patients, who are especially vulnerable due to immunosuppression caused by both their disease and treatment. (Cooksley et al., 2005) Sidney Kimmel Cancer Center – Jefferson Health (SKCC)’s Quality Improvement (QI) initiative aimed to increase influenza vaccination rates among adult cancer patients in our Center City clinic from October 2023 to March 2024. At baseline in the 2022-2023 flu season, 49% of our patients had a documented vaccination against influenza, leaving most of our patient population at increased risk for influenza infection. Methods: A series of four Plan-Do-Study-Act (PDSA) cycles were implemented over the course of the vaccination season. Cycle 1 collected baseline data on vaccination status via electronic health records (EHRs) and identified gaps in patient knowledge and vaccine hesitancy. Cycle 2 trained medical assistants (MAs) to engage in effective vaccination conversations, emphasizing the use of presumptive communication techniques and the reconciliation of immunization records in EHRs. Cycle 3 integrated patient education materials on vaccination in the clinical encounter. Cycle 4 scaled assessment protocols across teams. Results: Cumulatively, 68% (2,592/3,824) of unique oncology patients had a documented influenza vaccination by the completion of the season in March 2024. Integration of vaccine reconciliation into the MA workflow was the iteration that led to the biggest increase in vaccination rate among the PDSA cycles tested. We surpassed our initial aim for the season (59%) in this metric. Conclusions: The QI project at SKCC demonstrates that layered strategies involving both patients and care teams can improve vaccination rates among adult cancer patients. Integration of vaccine assessment into clinic workflows was an effective tactic. Future efforts will focus on replicating these successes with other vaccines. Rates of influenza vaccination by PDSA cycle. Cycle # Date Cycle Description Outcome Metric: Cumulative Vaccination Rate (%) 1 Oct 2023 Provider perception survey of vaccination knowledge 65 2 Nov 2023 Integration of vaccine reconciliation in MA workflow 69 3 Dec 2023 Integration of patient education materials to clinical encounter 70 4 Jan 2024 – Mar 2024 Scaling of updated workflows to entire clinic 68

Correlation between illness perceptions and self-reported degree-of-worry in somatic ill patients in emergency care: a Danish cross-sectional study.

The study aimed to investigate the correlation between illness perceptions and self-reported degree-of-worry (DOW) in patients presenting to the emergency department with acute somatic illness. A cross-sectional survey study collected data from a survey on DOW, the Brief-illness Perception Questionnaire (B-IPQ) and demographics. An emergency department at a university hospital in the Capital Region of Denmark. 944 patients (≥18 years) presenting to the emergency department with acute somatic illness. Data collection was conducted during day and evening shifts on weekdays from 13 January to 19 December 2020. Correlations between B-IPQ scores and DOW, including (1) the total B-IPQ score, (2) emotional representations (emotion and illness concern combined) and (3) the single items, respectively. Secondary analysis: linear relationships between the single B-IPQ items and DOW. Analyses included the variables sex, age, reason for contact, self-reported comorbidity, employment, highest educational attainment, cohabitation status and region of origin. The study found moderate correlations between the total illness perceptions score and DOW of 0.47 (95% CI 0.42 to 0.52) and emotional representations and DOW of 0.57 (95% CI 0.52 to 0.61). Linear regression showed the largest and most significant changes in DOW with an increasing score of the B-IPQ items for consequence, illness concern and emotion. Illness perceptions overall and perceptions of consequences of symptoms, illness concern and emotional representations are correlated with patients' DOW, with increasing DOW related to more negative illness perceptions. This finding contributes to insight into how illness perceptions are related to illness worry when presenting to the emergency department. Incorporating the novel DOW scale may aid triage and clinical encounters in the emergency department. ClinicalTrails.gov reference: NCT04226040.

Narrative Accounts of Youth and Their Mothers With Chronic Headache: Application of a Socio-narratology Framework to Pain Narratives.

This study was the first to apply a socio-narratology framework to the narratives about child pain as told by youth with chronic pain and their parents, all of whom experience chronic headaches. Storytelling is a powerful social transaction that occurs within systems (eg, families, clinical encounters) and is both shaped by, and can shape, the pain experience. Narrative can be harnessed as a clinical tool to aid in the ability to listen, understand, and improve clinical encounters. Twenty-six youth (aged 11 to 18y) and their mothers, both with chronic headaches, recruited from a tertiary level pediatric pain clinic separately completed in-depth interviews about children's pain journey narratives. Data were analyzed using narrative analysis, which incorporated elements of socio-narratology to compare similarities and differences between and within dyads' narratives. Five narrative types were generated: (1) The trauma origin story-parents, but not youth, positing traumatic events as the causal link to children's pain; (2) mistreated by the medical system-neglect, harm, and broken promises resulting in learned hopelessness or relying on the family system; (3) the invalidated-invalidation of pain permeated youth's lives, with mothers as empathic buffers; (4) washed away by the pain-challenges perceived as insurmountable and letting the pain take over; and (5) taking power back from pain-youth's ability to live life and accomplish goals despite the pain. Findings support the clinical utility of narrative in pediatric pain, including both parents' and youths' narrative accounts to improve clinical encounters and cocreate more youth-centred, empowering narratives.