Clinical Case Vignettes Research Articles

Do malpractice claim clinical case vignettes enhance diagnostic accuracy and acceptance in clinical reasoning education during GP training?

BackgroundUsing malpractice claims cases as vignettes is a promising approach for improving clinical reasoning education (CRE), as malpractice claims can provide a variety of content- and context-rich examples. However, the effect on learning of adding information about a malpractice claim, which may evoke a deeper emotional response, is not yet clear. This study examined whether knowing that a diagnostic error resulted in a malpractice claim affects diagnostic accuracy and self-reported confidence in the diagnosis of future cases. Moreover, suitability of using erroneous cases with and without a malpractice claim for CRE, as judged by participants, was evaluated.MethodsIn the first session of this two-phased, within-subjects experiment, 81 first-year residents of general practice (GP) were exposed to both erroneous cases with (M) and erroneous cases without (NM) malpractice claim information, derived from a malpractice claims database. Participants rated suitability of the cases for CRE on a five-point Likert scale. In the second session, one week later, participants solved four different cases with the same diagnoses. Diagnostic accuracy was measured with three questions, scored on a 0–1 scale: (1) What is your next step? (2) What is your differential diagnosis? (3) What is your most probable diagnosis and what is your level of certainty on this? Both subjective suitability and diagnostic accuracy scores were compared between the versions (M and NM) using repeated measures ANOVA.ResultsThere were no differences in diagnostic accuracy parameters (M vs. NM next step: 0.79 vs. 0.77, p = 0.505; differential diagnosis 0.68 vs. 0.75, p = 0.072; most probable diagnosis 0.52 vs. 0.57, p = 0.216) and self-reported confidence (53.7% vs. 55.8% p = 0.390) of diagnoses previously seen with or without malpractice claim information. Subjective suitability- and complexity scores for the two versions were similar (suitability: 3.68 vs. 3.84, p = 0.568; complexity 3.71 vs. 3.88, p = 0.218) and significantly increased for higher education levels for both versions.ConclusionThe similar diagnostic accuracy rates between cases studied with or without malpractice claim information suggests both versions are equally effective for CRE in GP training. Residents judged both case versions to be similarly suitable for CRE; both were considered more suitable for advanced than for novice learners.

Perceived Overqualification Among Therapists: An Experimental Study

The goal of the current study was to experimentally manipulate perceived overqualification (POQ) among a sample of therapists and assess this manipulation’s effect on task meaningfulness, positive affect, and negative affect. To conduct the experiment, we had participants read a clinical case vignette and then randomly assigned them to answer questions using their specialized clinical skills (control group) or using simple recall and transcription (perceived overqualification group). The POQ group reported significantly greater perceived overqualification and significantly less task meaningfulness than the control group. Perceived overqualification also mediated the relation between the experimental condition and task meaningfulness. The groups did not differ on positive or negative affect. Results support previous research and theory suggesting that perceived overqualification can have deleterious effects on job attitudes, which has implications for organizational and individual interventions.

Adages, Aphorisms, and Proverbs in Psychiatry and Psychotherapy: Tools for Assessment and Treatment.

This study aimed to examine how adages, aphorisms, and proverbs arise in psychiatric management and psychotherapy and how they might be used to assist assessment and treatment. A selective narrative literature review was conducted to supplement clinical observations and case vignettes. Adages appear to act as heuristic cognitive structures that serve as shortcuts for assessing situations, educating, persuading, aiding emotional self-regulation, and influencing courses of action. Some types of psychotherapy-such as dialectical behavior therapy, rational emotive behavior therapy, and acceptance and commitment therapy-and self-help programs such as Alcoholics Anonymous routinely utilize adages. The extent to and contexts in which adages spontaneously arise during general psychiatric and psychotherapeutic interactions have not been systematically studied. Clinicians can ascertain patients' favorite adages and appraise how patients respond to other sayings through exploratory questioning and by evoking responses to stock series of adages. As therapeutic tools, adages may help patients more easily conceptualize clinicians' interpretations and insights and may serve as encouraging affirmations. Considering the potential utility of adages as therapeutic cognitive scaffolds, how patients and clinicians spontaneously use adages, how adages are used therapeutically, and the adages most suitable for particular patients in particular circumstances deserve further study. In psychiatric management and psychotherapy, clinicians' sensitivity to timing and patients' circumstances, culture, and receptivity may determine whether introducing a particular aphorism or proverb will have a positive impact or come across as a vapid and potentially harmful platitude.

Clinician perception of pathological narcissism in females: a vignette-based study.

The DSM-5 reports that up to 75% of those diagnosed with Narcissistic Personality Disorder (NPD) are males, which denotes that narcissism is a clinical phenomenon that operates differently in men and women. Vulnerable narcissism, which tends to be more prevalent in females and is currently under-appreciated in the DSM-5, may be diagnosed as other "vulnerable" disorders (e.g., Borderline Personality Disorder; BPD). The current study investigated gender differences in clinicians' perceptions of narcissistic pathology. Adopting an online vignette-based study, clinicians (N = 108; 79 females) read clinical case vignettes of hypothetical patients and provided diagnostic ratings of existing personality disorders. Clinicians' diagnostic ratings of NPD were concurrent with the vignette containing grandiose narcissism symptoms, irrespective of patient gender. However, when presented with a vulnerable narcissism vignette, clinicians were significantly more likely to attribute a BPD diagnosis in female patients, compared to male patients. Clinicians with a psychodynamic approach and more experience in practice were also more likely to label vulnerable narcissism symptoms as NPD, compared to those with a CBT approach and less experience in practice. The clinical implications of these results support the shift toward assessing personality dysfunction based on dimensional trait domains.

“Do-not-resuscitate” preferences of the general Swiss population: Results from a national survey

AIMSTo assess the do-not-resuscitate preferences of the general Swiss population and to identify predictors influencing decision-making. MethodsA nationwide web-based survey was conducted in Switzerland on a representative sample of the adult population. The primary endpoint was the preference for a “Do Not Resuscitate” order (DNR Code Status) vs. cardiopulmonary resuscitation (CPR Code Status) in a clinical case vignette of an out-of-hospital cardiac arrest. Secondary endpoint were participants’ own personal preferences for DNR. Results1138 subjects participated in the web-based survey, 1044 were included in the final analysis. Preference for DNR code status was found in 40.5% (n = 423) in the case vignette and in 20.3% (n = 209) when making a personal decision for themselves. Independent predictors for DNR Code Status for the case vignette were: Personal preferences for their own DNR Code Status (adjusted OR 2.44, 95%CI 1.67 to 3.55; p < 0.001), intubation following respiratory failure (adjusted OR 1.95, 95%CI 1.20 to 3.18; p = 0.007), time-period after which resuscitation should not be attempted (adjusted OR 0.91, 95%CI 0.89 to 0.93); p < 0.001), and estimated chance of survival in case of a cardiac arrest (adjusted OR per decile 0.91, 95%CI 0.84 to 0.99, p = 0.02; which was overestimated by all participants. ConclusionsMain predictors for a DNR Code Status were personal preferences and the overestimation of good neurological outcome after cardiac arrest. Overestimation of positive outcomes after cardiac arrest seems to influence patient opinion and should thus be addressed during code status discussions.

Knowledge Attainment and Engagement Among Medical Students: A Comparison of Three Forms of Online Learning.

This study compared knowledge attainment and student enjoyment and engagement between clinical case vignette, patient-testimony videos and mixed reality (MR) teaching via the Microsoft HoloLens 2, all delivered remotely to third year medical students. The feasibility of conducting MR teaching on a large scale was also assessed. Medical students in Year 3 at Imperial College London participated in three online teaching sessions, one in each format. All students were expected to attend these scheduled teaching sessions and to complete the formative assessment. Inclusion of their data used as part of the research trial was optional. The primary outcome measure was performance on a formative assessment, which served to compare knowledge attainment between three forms of online learning. Moreover, we aimed to explore student engagement with each form of learning via a questionnaire, and also feasibility of applying MR as a teaching tool on a large scale. Comparisons between performances on the formative assessment between the three groups were investigated using a repeated measures two-way ANOVA. Engagement and enjoyment were also analysed in the same manner. A total of 252 students participated in the study. Knowledge attainment of students using MR was comparable with the other two methods. Participants reported higher enjoyment and engagement (p<0.001) for the case vignette method, compared with MR and video-based teaching. There was no difference in enjoyment or engagement ratings between MR and the video-based methods. This study demonstrated that the implementation of MR is an effective, acceptable, and feasible way of teaching clinical medicine to undergraduate students on a large scale. However, case-based tutorials were found to be favoured most by students. Future work could further explore the best uses for MR teaching within the medical curriculum.

General and Case-Specific Approval of Coercion in Psychiatry in the Public Opinion.

Psychiatric patients are subjected to considerable stigmatization, in particular, because they are considered aggressive, uncontrollable, and dangerous. This stigmatization might influence the approval of coercive measures in psychiatry by the public and healthcare professionals and might have an influence on the clinical practice of coercive measures. We examined whether the general approval of coercive measures for psychiatric patients with dangerous behaviors differs from case-specific approval. We conducted a representative survey of the general population (n = 2207) in the canton of Basel-Stadt, Switzerland. In total, 1107 participants assessed a case vignette depicting a fictitious character with a mental illness and indicated whether they would accept coercive measures (involuntary hospitalization, involuntary medication, and seclusion) for the person in the vignette. It was explicitly stated that within the last month, the fictitious character displayed no dangerous behavior (Vignette ND) or dangerous behavior (Vignette D). Another 1100 participants were asked whether they would approve coercive measures (involuntary hospitalization, involuntary medication, and seclusion) for psychiatric patients with dangerous behavior in general (General D), i.e., without having received or referring to a specific case vignette. The logistic regression model containing all variables explained 45% of the variance in approval of any type of coercive measures. Assessment of case vignettes without dangerous behavior (Vignette ND) was associated with significantly reduced approval of coercive measures compared to assessment of a case vignette with dangerousness (Vignette D), while approval for coercive measures in a person with mental health disorder with dangerous behavior in general (General D) was significantly higher than for the case vignette with dangerousness. The general approval of coercive measures for people with mental disorders seems to differ depending on if the respondents are asked to give a general assessment or to examine a specific and detailed clinical case vignette, indicating an increased role of stigmatization when asking about generalized assessments. This may contribute to diverging findings on the acceptance of coercive measures in the literature and should be considered when designing future studies.

Using telehealth clinical case vignettes to enhance clinical confidence and competence in veterinary students.

Veterinarians contribute substantially to the health of their patients and enhance the communities in which they live. Delivery of veterinary curricula continues to evolve to ensure that veterinary graduates are prepared to meet their professional obligations on Day One of their careers. In this study, veterinary practitioners were recruited to deliver telehealth case rounds to veterinary students at Kansas State University and Texas A&M University. Case discussions were hosted virtually once per month in the 2020-2021 and 2021-2022 academic years for a total of 16 sessions. Each presenting practitioner was instructed to develop a brief presentation for a case routinely seen in their practice, and to discuss important clinical decision points in diagnosis, treatment and management. Cases could also highlight important ethical or communication issues encountered in veterinary medicine. The overall goals of this project were to increase the quantity and diversity of clinical cases to which veterinary students were exposed during their professional training and to evaluate the feasibility and acceptability of telehealth technology as a teaching strategy. Student participants were surveyed to determine the effectiveness of telehealth sessions in increasing overall confidence and competence in case management, and veterinary presenters were surveyed to determine motivations for participating in the project and perceived value of the telehealth sessions. More than 95% of students indicated that participation in telehealth sessions increased their clinical confidence and competence. Presenting practitioners unanimously indicated that they would participate in similar instruction in the future. Recommendations are provided to improve the educational experience for future adopters of telehealth teaching sessions.

A Clinical Pharmacology and Therapeutics Teacher's Guide to Race-Based Medicine, Inclusivity, and Diversity.

The relationship between race and biology is complex. In contemporary medical science, race is a social construct that is measured via self-identification of study participants. But even though race has no biological essence, it is often used as variable in medical guidelines (e.g., treatment recommendations specific for Black people with hypertension). Such recommendations are based on clinical trials in which there was a significant correlation between self-identified race and actual, but often unmeasured, health-related factors such as (pharmaco)genetics, diet, sun exposure, etc. Many teachers are insufficiently aware of this complexity. In their classes, they (unintentionally) portray self-reported race as having a biological essence. This may cause students to see people of shared race as biologically or genetically homogeneous, and believe that race-based recommendations are true for all individuals (rather than reflecting the average of a heterogeneous group). This medicalizes race and reinforces already existing healthcare disparities. Moreover, students may fail to learn that the relation between race and health is easily biased by factors such as socioeconomic status, racism, ancestry, and environment and that this limits the generalizability of race-based recommendations. We observed that the clinical case vignettes that we use in our teaching contain many stereotypes and biases, and do not generally reflect the diversity of actual patients. This guide, written by clinical pharmacology and therapeutics teachers, aims to help our colleagues and teachers in other health professions to reflect on and improve our teaching on race-based medical guidelines and to make our clinical case vignettes more inclusive and diverse.

Diagnosis and Management of Isolated Neutropenia: A Survey of Pediatric Hematologists Oncologists

Background: Isolated neutropenia is a common referral to pediatric hematology oncology. Guidelines exist regarding the management of severe congenital neutropenia as well as the differential diagnosis for isolated neutropenia. However, no expert guidelines exist to inform practice patterns on the diagnosis and management of patients with asymptomatic neutropenia or individuals with typical neutrophil counts associated with the Duffy null phenotype (Fy[a-/b-]). Understanding the practice patterns of pediatric hematologists oncologists may inform future efforts to reduce unnecessary medical testing and follow-up in these patient populations. Methods: We distributed a twenty-one-question electronic survey to pediatric hematologists oncologists through the American Society of Pediatric Hematology Oncology's member discussion board from March 2022 until April 2022. The purpose of the survey was to identify practice patterns regarding patients referred for isolated neutropenia. Eligible participants included attending physicians and those who regularly see referrals for neutropenia. All trainees, advanced care providers, and individuals who do not regularly see patients with neutropenia were excluded. The survey explored: 1) common diagnostic studies physicians use to evaluate patients referred with asymptomatic and isolated neutropenia, 2) frequency of patient follow-up, 3) use of limited red cell phenotyping in pediatric patients with isolated neutropenia, 4) common terminology used to describe isolated neutropenia, and 5) whether physicians support removal of the term "benign ethnic neutropenia" from practice. We also presented two clinical case vignettes of asymptomatic and isolated neutropenia in a one-year-old male and a twelve-year old female. We compared management responses to the two vignettes to general neutropenia practice patterns. Results: One hundred and twenty-six pediatric hematology oncology attending physicians who regularly see neutropenia referrals completed the survey and were included in the analysis. Selected survey responses are shown in the Table. The most common tests ordered for pediatric patients with isolated neutropenia include complete blood cell count (CBC) (98%), peripheral smear (75%), anti-neutrophil antibody testing (29%), and immunoglobulins (24%). In the clinical vignettes, providers were more likely to order an anti-neutrophil antibody in toddlers (p=0.0085), and antinuclear antibody (ANA) panels in adolescents (p<0.001). Half of providers ask for additional CBCs prior to their initial consultation. Most respondents suggest referring patients with mild neutropenia after demonstrating a decline in absolute neutrophil count (ANC) (51%). For patients with mild neutropenia, most providers order an additional CBC to ensure resolution of their neutropenia or do not follow after their initial evaluation (87%). For patients with moderate neutropenia, most providers continue to follow patients even after their initial evaluation (46%). The three most important factors that influence continued follow-up of patients with isolated neutropenia include: history of recurrent/severe infections (98%), family history of blood disorders (98%), and more severe/progressively worsening neutropenia (97%). Seventy percent of respondents have diagnosed patients with the term "benign ethnic neutropenia," and 75% support replacement of the term to "typical neutrophil count with Fy(a-/b-) status," if confirmed with limited red cell phenotyping. Conclusion: We identify the common practice patterns of pediatric hematologists oncologists caring for patients referred for asymptomatic and isolated neutropenia. Data from this study is providing the framework for a cost-effectiveness study aimed to reduce the healthcare and family burden of referrals for isolated neutropenia to pediatric hematologists oncologists. Furthermore, this survey demonstrates support for replacement of the term "benign ethnic neutropenia" with "typical neutrophil count with Fy(a-/b-) status" in applicable patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Race, ethnicity, and gender representation in clinical case vignettes: a 20-year comparison between two institutions

BackgroundThe medical case vignette has long been used in medical student education and frequently includes demographic variables such as race, ethnicity and gender. However, inclusion of demographic variables without context may reinforce assumptions and biases. Yet, the absence of race, sexual orientation, and social determinants of health may reinforce a hidden curriculum that reflects cultural blindness. This replication study compared proportions of race, ethnicity, and gender with University of Minnesota (UMN) findings. This study sought to determine if there has been progress in the representation of demographic characteristics in case vignettes. Methods: University of North Carolina (UNC) case vignettes from 2015–2016 were analyzed and compared to UMN case vignettes from 1996–1998. Data included mentions of race, ethnicity, gender and social determinants of health. Results: In the 278 UNC vignettes, white race was noted in 19.7% of cases, black race was in 7.9% cases, and 76.6% of cases were unspecified. In the 983 UMN vignettes, white race was recorded in 2.85% cases, and black race in 0.41% cases. The institutions were significantly different in the proportion of their cases depicting race (0.20; 95% CI (0.15, 0.25)). Males were represented in the majority of vignettes. Discussion: Comparing case vignettes results from two medical schools suggests that reporting explicit demographic diversity was not significantly different. The findings illustrate that sex was the demographic characteristic consistently described, where males were over-represented. Based on these findings, greater cultural diversity as it intersects with social determinants of health is needed in medical student education.

An exploration of expectations and perceptions of practicing physicians on the implementation of computerized clinical decision support systems using a Qsort approach

BackgroundThere is increasing interest in incorporating clinical decision support (CDS) into electronic healthcare records (EHR). Successful implementation of CDS systems depends on acceptance of them by healthcare workers. We used a mix of quantitative and qualitative methods starting from Qsort methodology to explore expectations and perceptions of practicing physicians on the use of CDS incorporated in EHR.MethodsThe study was performed in a large tertiary care academic hospital. We used a mixed approach with a Q-sort based classification of pre-defined reactions to clinical case vignettes combined with a thinking-aloud approach, taking into account COREQ recommendations The open source software of Ken-Q Analysis version 1.0.6. was used for the quantitative analysis, using principal components and a Varimax rotation. For the qualitative analysis, a thematic analysis based on the four main themes was performed based on the audiotapes and field notes.ResultsThirty physicians were interviewed (7 in training, 8 junior staff and 15 senior staff; 16 females). Nearly all respondents were strongly averse towards interruptive messages, especially when these also were obstructive. Obstructive interruption was considered to be acceptable only when it increases safety, is adjustable to user expertise level and/or allows deviations when the end-user explains why a deviation is desirable in the case at issue. Transparency was deemed an essential feature, which seems to boil down to providing sufficient clarification on the factors underlying the recommendations of the CDS, so that these can be compared against the physicians’ existing knowledge, beliefs and convictions.ConclusionAvoidance of disruptive workflows and transparency of the underlying decision processes are important points to consider when developing CDS systems incorporated in EHR.

Pharmacy students' knowledge and confidence of COVID-19 following an interactive didactic class.

BackgroundCOVID‐19 education for the pharmacy workforce is important to ensure pharmacists are optimizing patient care for the prevention and management of COVID‐19. However, there are currently no reports to our knowledge of education and training experiences for COVID‐19 prevention and management in the Doctor of Pharmacy (PharmD) curricula.ObjectiveTo evaluate pharmacy students' knowledge and confidence regarding COVID‐19 prevention and management before and after an interactive didactic class (IDC).MethodsA multicenter, quasi‐experimental, cross‐sectional survey study was performed among pharmacy students before and after IDC on COVID‐19 at two schools of pharmacy. The IDC on COVID‐19 consisted of student‐led presentations on a COVID‐19 drug, an infectious disease pharmacist faculty‐led interactive lecture on COVID‐19 prevention and management, and clinical case vignettes to assess COVID‐19 management strategies. An anonymous, voluntary, electronic survey was distributed to students (n = 85) before and after. The pre‐ and postintervention survey contained 10 COVID‐19 knowledge‐based questions and multi‐step, 5‐point Likert scale statements related to COVID‐19 prevention and management confidence. The postintervention survey also evaluated students' perceptions of the COVID‐19 IDC. Descriptive statistics were performed, and Student t test was used to compare pre‐ and postintervention responses.ResultsAbout 61 surveys were completed resulting in a response rate of 72%. COVID‐19 knowledge scores (mean ± SD) increased overall following the IDC (5.9 ± 1.31 vs 8.6 ± 1.29). Pharmacy students' COVID‐19 confidence scores (mean ± SD) also improved following the IDC (2.66 ± 0.75 vs 4.03 ± 0.53). Students performed well on the COVID‐19 clinical case vignettes with a mean ± SD score of 22.41 ± 0.46 out of 25. Pharmacy students' perceptions of the IDC on COVID‐19 were also positive overall.ConclusionPharmacy students' knowledge and confidence of COVID‐19 prevention and management improved following an IDC. This may be an effective strategy to provide COVID‐19 education during the PharmD curricula.

Assessing feasibility and utility of an implicit bias training program for addressing disparities in cancer clinical trial participation.

e18599 Background: Low participation of Black, Hispanic, Latinx and other underrepresented racial/ethnic groups in clinical research remains a problem across the U.S. Recent studies have highlighted that stereotypes, assumptions, and bias play a role in lack of diversity in cancer trial participation. To help address this, the Association of Community Cancer Centers (ACCC) and American Society of Clinical Oncology (ASCO) piloted an implicit bias training program for clinical research teams. Methods: Adapted from the Duke University Just Ask™ program, the pilot program is comprised of eLearning modules which can be completed in about 60 minutes. Features include education on diversity, equity, and bias in clinical trial participation, case vignettes, and strategies to mitigate disparities. A call was issued to members of both organizations. After completing the training, all individual participants were asked to complete a retrospective pre/post survey to assess change in knowledge and attitude. Focus groups explored participants’ experience with the training. Another survey was administered 6 weeks later to assess sustainability of changes. Results: Research teams from 50 programs were selected for the pilot. 129 individuals consented, and 126 completed the training and evaluations (98% response rate). 48% of participants reported that they had completed training on implicit bias and/or related topics prior to the pilot. Increased levels of knowledge were reported across all key training concepts, with an average % increase from 19% to 45%. Similar increases were observed for strategies for addressing implicit bias, with an average % increase from 10% to 31%. At 6 weeks post-training, there was a slight decrease in knowledge across most items, from -1% to -8%. Most (92%) participants reported satisfaction with the course, and most (92%) indicated they would recommend it to a colleague and would recommend implementing it at their program. Suggestions to improve the course included streamlining content and providing additional tools and resources. Conclusions: Pilot findings support the feasibility and utility of the training, which can help cancer programs to address disparities in clinical research. Next steps include modifying the course based on participant feedback, disseminating the training and supplementary resources, and exploring options for assessing the impact on upstream outcomes such as diversity in trial participation.[Table: see text]

"Many roads lead to Rome and the Artificial Intelligence only shows me one road": an interview study on physician attitudes regarding the implementation of computerised clinical decision support systems.

Research regarding the drivers of acceptance of clinical decision support systems (CDSS) by physicians is still rather limited. The literature that does exist, however, tends to focus on problems regarding the user-friendliness of CDSS. We have performed a thematic analysis of 24 interviews with physicians concerning specific clinical case vignettes, in order to explore their underlying opinions and attitudes regarding the introduction of CDSS in clinical practice, to allow a more in-depth analysis of factors underlying (non-)acceptance of CDSS. We identified three general themes from the results. First, ‘the perceived role of the AI’, including items referring to the tasks that may properly be assigned to the CDSS according to the respondents. Second, ‘the perceived role of the physician’, referring to the aspects of clinical practice that were seen as being fundamentally ‘human’ or non-automatable. Third, ‘concerns regarding AI’, including items referring to more general issues that were raised by the respondents regarding the introduction of CDSS in general and/or in clinical medicine in particular. Apart from the overall concerns expressed by the respondents regarding user-friendliness, we will explain how our results indicate that our respondents were primarily occupied by distinguishing between parts of their job that should be automated and aspects that should be kept in human hands. We refer to this distinction as ‘the division of clinical labor.’ This division is not based on knowledge regarding AI or medicine, but rather on which parts of a physician’s job were seen by the respondents as being central to who they are as physicians and as human beings. Often the respondents’ view that certain core parts of their job ought to be shielded from automation was closely linked to claims concerning the uniqueness of medicine as a domain. Finally, although almost all respondents claimed that they highly value their final responsibility, a closer investigation of this concept suggests that their view of ‘final responsibility’ was not that demanding after all.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12910-022-00787-8.

Introduction to Cognitive Restructuring for Medical Students.

IntroductionMedical students list stigma and lack of time as reasons to avoid seeking mental health care. Many patients do not receive appropriate mental health care due to a lack of knowledge regarding available treatments among their medical providers. We created this activity to enhance medical student knowledge and well-being by introducing cognitive restructuring principles and skills in a highly interactive module.MethodsWe administered a 90-minute learning activity, which included a short videotaped lecture, clinical case vignette, small-group discussion, and application exercise. Immediately following the learning activity, students and faculty completed anonymous evaluations.ResultsA total of 139 first-year medical students and 152 second-year medical students completed the activity. For the first-year cohort, upwards of 80% of students and 100% of faculty respondents rated the session either good or excellent. For the second-year cohort, over 80% of students and over 90% of faculty rated the session either good or excellent. Approximately 90% of first- and second-year medical students and 100% of faculty recommended offering the session to future students. Open-ended feedback from students was overwhelmingly positive.DiscussionThe resources included in this module allow educators at any institution to implement this learning activity, as no specific content knowledge/expertise is required of faculty. As the activity was well received by students and faculty, the investment of curricular time appears to have been well spent.

Failure to demonstrate effects of interruptions on diagnostic reasoning: three experiments

BackgroundDiagnostic error is a major source of patient suffering. Researchshows that physicians experience frequent interruptions while being engaged with patients and indicate that diagnostic accuracy may be impaired as a result. Since most studies in the field are observational, there is as yet no evidence suggesting a direct causal link between being interrupted and diagnostic error. Theexperiments reported in this article were intended to assess this hypothesis.MethodsThree experiments were conducted to test the hypothesis that interruptions hurt diagnostic reasoning and increase time on task. In the first experiment (N = 42), internal medicine residents, while diagnosing vignettes of actual clinical cases were interrupted halfway with a task unrelated to medicine, solving word-spotting puzzles and anagrams. In the second experiment (N = 78), the interruptions were medically relevant ones. In the third experiment (N = 30), we put additional time pressure on the participants. In all these experiments, a control group diagnosed the cases without interruption. Dependent variables were diagnostic accuracy and amount of time spent on the vignettes.ResultsIn none of the experiments interruptions were demonstrated to influence diagnostic accuracy. In Experiment 1: Mean of interrupted group was 0.88 (SD = 0.37) versus non- interrupted group 0.91 (SD = 0.32). In Experiment 2: Mean of interrupted group was 0.95 (SD = 0.32) versus non-interrupted group 0.94 (SD = 0.38). In Experiment 3: Mean of interrupted group was 0.42 (SD = 0.12) versus non-interrupted group 0.37 (SD = 0.08). Although interrupted residents in all experiments needed more time to complete the diagnostic task, only in Experiment 2, this effect was statistically significant.ConclusionsThese three experiments, taken together, failed to demonstrate negative effects of interruptions on diagnostic reasoning. Perhaps physicians who are interrupted may still have sufficient cognitive resources available to recover from it most of the time.

"You are the problem, not me": Personality Disorders in Later Life

Personality is defined by the unigue set of attributes, qualities and characteristics that shape how we cope with our lives. These emotional patterns, degree of reactivity and common behaviors define us over our lifespan. While a great deal of personality style is attributed to inherited traits; environmental and cultural influences clearly shape how we cope with life stressors and manage interpersonal relationships over time. Personality disorders emerge in early adulthood and persist into later life. Older adults who present with chronic and maladaptive patterns of coping pose unique challenges across a variety of clinical settings. The prevalence of these disorders in late life ranges from 5% to 13%, indicating that most clinicians will encounter these patients on a daily basis.The limited attention to cultural norms in the assessment and diagnosis of personality disorders is of significant concern. Available studies show trends in diagnosis related to culture and ethnicity such as a higher rate of Histrionic Persoanlity Disorder found among Latinx men compared to African American and Caucasian males. In addition a greater rate of Borderline Personality Disorder among Caucasian and African American women was found compared to Asian females. Woman in most culutral groups are more likley than men to be diagnosed with Dependent Personality Disorder. It is suggested that language issues and the interpretation of culturally appropriate behaviors may paly a role in diagnostic assessment drift and bias. The bias has a great impact in how we address clinical and treatment needs.The goal of treatment of personality disorders in late life is to decrease the intensity and frequency of disturbing symptoms and disruptive behaviors while trying to promote comfort and quality of life. This symposium will feature clinical case vignettes of older adults across a variety of backgrounds with features of personality disorders who have engaged in care in a large urban tertiary care program that serves a multicultural and socioeconomically diverse population. Issues faced by these patients over time include being labeled as "difficult," "needy," high maintenance," and "rejecting," with frequent switches in providers and lapses in care. The range of personality types and symptoms treated included avoidant, antisocial, borderline, histrionic, dependent, passive aggressive, narcissistic, paranoid and schizotypal. Sympotms were often mixed accross personality types and at times limited to one area. Individual treatment approaches for each patient were developed based on distressing symptoms, types of cluster traits and rational use of medication therapies with psychotherapuetic interventions lead to overall improvment in satifaction with care.In this session Dr. Kecia-Ann Blissett will present an overview of case vignettes to illustrate assessment, diagnosis and therapuetic treatment strategies. Dr. Melinda S Lantz will describe the barriers to treatment that older adults face focusing on access to care, cultural bias and the stigma facing oder adults who are labeled as difficult. Dr. Nikhil Tondehal will address the approach to culturally sensitive assessment and diagnosis of personality disorders in late life, focusing on attention to normative behaviors and coping skills accross ethnic backgrounds and cultures.

A Call for a Rational Polypharmacy Policy: International Insights From Psychiatrists.

ObjectiveRecently, rational polypharmacy approaches have been proposed, regardless of the lower risk and cost of monotherapy. Considering monotherapy as first-line treatment and polypharmacy as rational treatment, a balanced attitude toward polypharmacy is recommended. However, the high prevalence of polypharmacy led the Japanese government to establish a polypharmacy reduction policy. Based on this, the association between the policy and psychiatrists’ attitude toward polypharmacy has been under debate. MethodsWe developed an original questionnaire about Psychiatrists’ attitudes toward polypharmacy (PAP). We compared the PAP scores with the treatment decision-making in clinical case vignettes. Multiple regression analyses were performed to quantify associations of explanatory variables including policy factors and PAP scores. The anonymous questionnaires were administered to psychiatrists worldwide. ResultsThe study included 347 psychiatrists from 34 countries. Decision-making toward polypharmacy was associated with high PAP scores. Multiple regression analysis revealed that low PAP scores were associated with the policy factor (β=-0.20, p=0.004). The culture in Korea was associated with high PAP scores (β=0.34, p<0.001), whereas the culture in India and Nepal were associated with low scores (β=-0.15, p=0.01, and β=-0.17, p=0.006, respectively). ConclusionPolicy on polypharmacy may influence psychiatrists’ decision-making. Thus, policies considering rational polypharmacy should be established.

Screening Sleep Abnormalities in Children with Prader–Willi Syndrome: Challenges in the Indian Scenario

There is a high prevalence of sleep-related breathing disorders in the form of obstructive and central sleep apnea as well as spontaneous oxygen desaturation in children with Prader–Willi syndrome (PWS). Most cases are asymptomatic and if untreated go on to develop unfavorable neurodevelopmental, cardiovascular, and cerebrovascular outcomes. Hence, sleep study or polysomnography (PSG) is recommended in all children at the time of diagnosis as well as with the development of certain risk factors including symptoms of sleep apnea, before and after initiation of recombinant growth hormone (rGH) therapy. The use of rGH in children with PWS has been shown to improve central sleep apnea but also shown to be associated with worsening of OSA. PSG is ideally performed in a sleep laboratory. Various types of PSG devices are available depending on the biological parameters that are desired to be monitored. Sleep disorders in children are distinct from those seen in adults and have different diagnostic scoring criteria necessitating a trained pediatric sleep specialist to analyze the PSG recording. Through the clinical case vignette of a 14-year-old girl with PWS, severe obesity, and sleep disordered breathing, this review aims to highlight the need, timing, types, analysis, and interpretation of sleep studies in infants and older children with PWS, particularly in relation to rGH therapy. There is a paucity of literature on sleep studies in children with PWS in the local setting. Thus this review also suggests the need for adapting the existing Western guidelines for PSG in Indian children with PWS.