Identity influences on medical students' orientation to feedback during third year clinical rotations

Medical students' feedback orientation (their attitudes about and preferences for feedback from preceptors) may change over the course of the third year of medical school and is likely influenced by identity-related factors. This study proposed that both how students view themselves personally (i.e., impostor syndrome) and how they view themselves in relation to the group (i.e., identification with the profession) are identity factors related to related to feedback orientation during clinical rotations. 177 third-year medical students enrolled in a four-phase longitudinal survey study beginning at the start of clinical rotations and continuing every twelve weeks of the academic year thereafter. Feedback orientation was conceptualized and measured as comprising aspects of utility (i.e., feedback is valuable and useful), sensitivity (i.e., feeling intimidated or threatened by corrective feedback), confidentiality (i.e., public/private context of feedback), and retention (i.e., feedback remembered). Results indicated that these aspects of feedback orientation did not significantly change during the third year. Instead, impostor syndrome was at least marginally, significantly associated with all aspects of feedback orientation across phases. Group identity was associated with feedback utility and retention, and female-identifying students reported significantly greater feedback confidentiality and feedback retention. Interventions may be needed to improve medical students' attitudes about feedback, particularly for those who experience impostor syndrome. Fostering group cohesion among medical students may influence how well students remember feedback and find it useful.

The Impact of Health Communication Research on Medical and Health Professional Education and Training

In this essay, we review how health communication scholarship has been translated into various communication skills trainings (CSTs), we present four case studies of how health communication research informed the development and implementation of specific CSTs, and we reflect on how we can productively define "impact" in looking back as well as looking forward within this line of research.

Factors affecting the ability of patients with complex vascular anomalies to navigate the healthcare system

BACKGROUND

Vascular anomalies (VAs) are rare congenital disorders that can cause pain, disfigurement, coagulopathy, asymmetric growth, and disability. Patients with complex VAs experience multiple barriers to accessing expert care. It is imperative to understand which factors support these patients' ability to navigate the healthcare system.

RESULTS

We surveyed adult patients with VAs using previously validated measures, recruiting participants from five patient advocacy groups and multidisciplinary VA clinics. The primary outcome was self-reported ability to access needed medical care, using the "Navigating the Healthcare System" subscale of the Health Literacy Questionnaire. We evaluated factors associated with the ability to navigate the healthcare system using multivariate linear regression (n = 136). We also performed an exploratory model that included the primary care doctor's knowledge of VAs for the subset of participants with a primary care doctor (n = 114). Participants were predominantly women (n = 90, 66%), White and non-Hispanic (n = 109, 73%), and college-educated (n = 101, 73%). Most participants had PIK3CA-Related Overgrowth Spectrum (n = 107, 78%). Most participants reported that navigating the healthcare system was "sometimes" or "usually difficult" (mean score 16.4/30, standard deviation 5.6). In multivariate linear regression, ability to navigate the healthcare system was associated positively with quality of information exchange (β = 0.38, 95% Confidence Interval (CI) 0.22 to 0.55, p <.001) and whether patients had VA specialists (β = 2.31, 95% CI 0.35 to 4.28, p =.021), but not associated with patient self-advocacy, anxiety, education, age, race and ethnicity, gender, or having a primary care doctor. In exploratory analysis of participants with primary care doctors, ability to navigate the healthcare system was positively associated with quality of information exchange (β = 0.27, 95% CI 0.09 to 0.45, p =.004), having a VA specialist (β = 2.31, 95% CI 0.22 to 4.39, p =.031), and primary care doctors' VA knowledge (β = 0.27, 95% CI 0.04 to 0.50, p =.023).

CONCLUSION

Patients with VAs struggle to navigate the healthcare system. High-quality information from clinicians and more knowledgeable primary care doctors might help patients to access needed care. Relying on patient self-advocacy is insufficient. Future efforts should focus on patient-directed and clinician-directed educational interventions. Additionally, future work should assess the structural barriers that impede healthcare access for these patients.

Family Communication in Autism Spectrum Disorder: Applying the Family Caregiver Communication Typology to Parent Caregivers

Parents of children with Autism Spectrum Disorder (ASD) experience greater stress and caregiver burden than parents of children with other disabilities. To cope with the stress of long-term caregiving, they rely on professionals for support and guidance. However, parents continue to report unmet communication and support needs. To inform tailored communication for parents of a child with ASD, this study used the existing Family Caregiver Communication Typology framework which identifies four caregiver communication types (manager, carrier, partner, and lone) and their unique communication and support needs. In-depth, structured interviews were conducted with parents (n = 22) and ASD professionals (n = 28) to explore communication characteristics of ASD parent caregivers. A thematic analysis revealed communication behaviors among four ASD parent caregiver types, further validating the typology. Future research is needed to develop targeted interventions for improving family-centered care based on ASD parent caregiver types.

Mental and physical health of adult patients affected by complex vascular anomalies

OBJECTIVE

We examined care and communication factors that affect physical and mental health for patients with complex vascular anomalies (VAs).

METHODS

VA patients (N = 135) completed an online survey with measures of ability to navigate healthcare, quality of information exchange, perceived stigma, and demographic variables. We performed linear regression to determine if these variables were associated with mental and physical health.

RESULTS

Physical and mental health were associated with information exchange (β = .41, 95% CI=.12 -.69; β = .33, 95% CI=.04 -.62), stigma (β = -.49, 95% CI=-.74 to -.24; β = -.63, 95% CI=-.89 to -.38), and education (β = 4.00, 95% CI=.63 - 7.38; β = 3.44, 95% CI=.06 to 6.82). Ability to navigate healthcare was associated with health outcomes in our bivariate model, but not significant in a multivariate model.

CONCLUSION

The results underscore the importance of effective information exchange. Poor information exchange was associated with worse physical and mental health. VA patients with lower education levels and higher perceived stigma reported poorer health outcomes and likely face many struggles accessing care.

PRACTICE IMPLICATIONS

Patient-centered information exchange between clinicians and patients is needed to address unmet information needs. Clinicians can also reduce perceived stigma by validating patients, and should provide resources to reduce disparities related to education.

US Medical Students' Attitudes, Subjective Norms, and Perceived Behavioral Control Regarding Social Media and Online Professionalism: A Single Institution Study

Phenomenon: In 2011, the American Medical Association added a section on professionalism and social media (i.e., e-professionalism) to the Code of Medical Ethics. Given the constantly evolving nature of social media use, research is needed to explore the attitudes and behaviors of current medical students, for most of whom social media has been a central facet of interpersonal communication and society since they were born. The goal of the current study is to examine students' social media use and attitudes related to online professionalism. Approach: Two-hundred-twenty-two medical students completed a mixed-methods cross-sectional online survey assessing perceptions of professionalism on social media. The survey was informed using the theory of planned behavior and included validated measures of attitudes, norms, and perceived behavioral control related to social media use and online professionalism. We analyzed data using thematic analysis and descriptive statistics and t-tests were conducted using SPSS 26. Qualitative and quantitative data were integrated during the data interpretation phase. Findings: Quantitative results revealed that students had a positive attitude toward having a social media presence as medical students and future physicians. Students reported: positive attitudes toward sharing positive thoughts, posting photos with family members, and posting photos in white coats or scrubs; neutral attitudes toward posting personal and political opinions; negative attitudes toward posting photos with alcohol, commenting about colleagues or the workplace, using profanity, connecting with patients, and commenting about patients. T-tests revealed significant differences between what students consider to be professional online behaviors for themselves as medical students versus what they believe society will expect of them as a physician. Students reported strong perceived behavioral control regarding professional social media behavior. While students reported they would face some difficulty "cleaning up" some previous content, students strongly disagreed that people's opinions of their online professional image were beyond their control. The qualitative analysis revealed students' perceptions of (a) what it means to demonstrate "online professionalism," (b) the challenges they face related to social media, and (c) training and standards related to social media use. Insights: Overall, our study confirms that students would benefit from e-professionalism training that is not merely disciplinary, but offers them evidence-based recommendations for maintaining medical professionalism while also embracing their personal identity and the benefits of social media as a (future) physician. Policies, guidelines, and training programs should constantly evolve as social norms regarding online communication and online identities evolve.

Pediatricians' Communication about Medical Uncertainty: Goal-Oriented Communication and Uncertainty Management

Despite the prevalence of uncertainty in medicine, many physicians experience anxiety as a result of medical uncertainty and are reluctant to discuss uncertainty with others. When pediatricians do disclose uncertainty to parents, they are managing both the parents' and their own feelings of uncertainty. The current study applies uncertainty management theory and multiple goals theory to explore pediatricians' communication about uncertainty. We collected data using in-depth semi-structured interviews with 18 pediatricians. The results suggest that pediatricians prioritize task and relational goals with parents and task and identity goals with fellow physicians. Though, their appraisal of uncertainty influences their goal-oriented communication. The results highlight the relationship between uncertainty management theory and a multiple goals framework. These frameworks provide a valuable approach for gaining a more thorough understanding of pediatrician communication in the context of uncertainty.

"I Want Them to Still Trust Me with Their Child's Care": A Longitudinal Study of Pediatric Residents' Reactions to and Communication with Parents about Medical Uncertainty across Residency

Physicians in residency training experience high levels of medical uncertainty, yet they are often hesitant to discuss uncertainty with parents. Guided by the theory of motivated information management and a multiple goals perspective, this mixed-methods longitudinal study examines associations among residents' tolerance of and reactions to uncertainty, efficacy communicating about uncertainty, and perceptions of parents' trust in them as physicians. To contextualize these associations, we also examined residents' task, identity, and relational goals when communicating about uncertainty with parents. We surveyed 47 pediatric residents at the beginning of each year of their residency program. As they progressed through their training, residents' uncertainty-related anxiety and reluctance to communicate uncertainty to parents decreased, and their efficacy communicating uncertainty with parents increased. Residents' concerns about bad outcomes remained unchanged. Residents pursued multiple, often conflicting, conversational goals when communicating uncertainty with parents. Results reveal important considerations for addressing how residents can manage their uncertainty in productive ways.

Burdens of disease and caregiver burden in complex vascular malformations

INTRODUCTION

Vascular malformations (VMs) are rare diseases that affect a wide age range of patients and require complicated care and management. The strain these conditions put on patients and their caretakers is not well understood. This study aims to characterize those burdens in young adult patients and parents of patients with VMs to improve communication, health-related quality of life, and caregiver burden.

METHODS

We performed semi-structured interviews with patients and parents of patients with VMs. Interviews were conducted via telephone or video-call software, recorded, and transcribed. The transcriptions were analyzed to identify burden themes through multiple rounds of codebook development and refinement. The final codebook was applied to all interviews.

RESULTS

Twenty-five young adult patients and 34 parent interviews were performed and led to the identification of four primary themes of disease burden that showed up in almost every interview: burdens of the disease process, logistical and financial burdens, psychological and emotional burdens, and social burdens. Persistent uncertainty was prominent and exacerbated all other burdens as well.

DISCUSSION

We found that patients and parents struggle with burdens in a wider breadth of life experiences than have been previously characterized in the literature. They feel stressors of isolation, struggles with their identity, and even traumatic experiences from prior medical encounters. It is critical for providers of these patients and families to be aware of the burdens that they face outside of the immediate medical context. Acknowledging and providing space to address these burdens has the potential to greatly improve therapeutic relationships.

Navigating care for rare diseases: Caregiver and patient advice for families and clinicians managing care for vascular malformations

OBJECTIVE

Families affected by rare diseases face many challenges finding adequate care and often report poor communication with clinicians. In the current study, we explore patient and caregiver advice for families and clinicians in the context of complex vascular malformations (VMs), a condition that is frequently misunderstood and misdiagnosed.

METHODS

We performed semi-structured interviews with 21 adult patients with complex VMs and 24 caregivers of children with VMs. We analyzed the transcripts using thematic analysis.

RESULTS

Participants advised patients and caregivers to advocate for care, address mental and emotional well-being, seek social support, and promote self-management and self-care. Participants advised clinicians to show care and concern, show commitment, empower and validate, communicate information clearly, address mental/emotional well-being, acknowledge the broad impact of disease and treatment, acknowledge your limitations, work as a team, and commit to learning.

CONCLUSION

Participants' advice revealed challenges related to family-centered communication and patient and caregiver quality of life and demonstrated the importance of self-advocacy and social support.

PRACTICE IMPLICATIONS

The result of this study can help newly-diagnosed families overcome challenges related to care and communication. Clinicians can also use the results to support families by offering them our accompanying handout to validate families' experiences and relay this advice.

The effect of postgraduate osteopathic manipulative treatment training on practice: a survey of osteopathic residents

CONTEXT

Osteopathic medical students receive an abundance of training in osteopathic manipulative treatment (OMT) during their first 2 years of medical school and less during the second 2 years. Family Medicine residency programs often include significantly more OMT training during residency, but it is less frequently applied in other residencies.

OBJECTIVES

This survey was designed utilizing the theory of planned behavior to see whether specific training in osteopathic manipulative medicine (OMM) after osteopathic medical school was an influence in changing behavior, attitudes, and knowledge around OMT in osteopathic residents.

METHODS

A total of 188 osteopathic medicine residents were invited to complete an anonymous cross-sectional online survey. The survey asked residents about their postgraduate OMT training and their knowledge, attitudes, norms, intentions, and behavior regarding OMT. Inferential statistics were utilized to determine whether significant differences existed by specialty and by type of training.

RESULTS

Sixty residents (31.9% response rate) completed the survey. This response rate is consistent with previous online survey studies, but it may indicate that residents chose not to participate due to survey fatigue or a lack of interest in OMM. Overall, residents who completed postgraduate training reported significantly stronger positive attitudes about the value of OMT in patient care (t=3.956; p<0.001). Primary care residents talk to their patients about OMT and perform OMT more frequently than residents in surgical (p<0.01) and other subspecialties (p<0.01). Residents who completed postgraduate training (n=41) reported significantly more knowledge about the fundamental principles (p=0.04), benefits (p=0.03), and common techniques (p=0.01) of OMT, and rated their ability to perform OMT (p=0.001) higher than those who had not completed postgraduate training. Trained residents also talked to patients about OMT (p<0.001), referred patients for OMT (p=0.01), and performed OMT (p<0.001) more frequently. They also reported significantly stronger subjective norms (p=0.000; p<0.001), perceived behavioral control (p=0.02; p=0.004), positive attitudes (p=0.004; p=0.003), and intentions (p<0.001; p<0.001) regarding talking to patients and performing OMT, respectively. Residents who completed in-person training reported talking to their patients about OMT (p=0.002) and performing OMT (p=0.001) more frequently, and having more confidence in their ability to perform OMT (p=0.02). Residents who completed in-person training reported significantly stronger subjective norms (p<0.001; p<0.001), perceived behavioral control (p=0.001; p=0.002), positive attitudes (p=0.05; p=0.03), and intentions (p<0.001; p=0.001) regarding talking to patients about OMT and performing OMT, respectively. Residents who completed in-person training reported stronger subjective norms (p=0.05) related to referring patients for OMT.

CONCLUSIONS

Residents who complete postgraduate training perform OMT, talk to their patients about OMT, and refer patients for OMT more frequently. Residents who participate in training, particularly in-person training, have stronger subjective norms, perceived behavioral control, positive attitudes, and behavioral intentions regarding talking with patients about OMT and performing OMT. These variables are validated predictors of behavior, making them important outcomes for training to promote OMT in patient care.

Fostering Interdisciplinary Boundary Spanning in Health Communication: A Call for a Paradigm Shift

Scholarship in the field of health communication is broad, with interdisciplinary contributions from researchers trained in a variety of fields including communication, nursing, medicine, pharmacy, public health, and social work. In this paper, we explore the role of "health communication boundary spanners" (HCBS), individuals whose scholarly work and academic appointment reflect dual citizenship in both the communication discipline and the health professions or public health. Using a process of critical reflective inquiry, we elucidate opportunities and challenges associated with HCBS across the spectrum of health communication in order to provide guidance for individuals pursuing boundary spanning roles and those who supervise and mentor them. This dual citizen role suggests that HCBS have unique skills, identities, perspectives, and practices that contribute new ways of being and knowing that transcend traditional disciplinary boundaries. The health communication field is evolving in response to the need to address significant healthcare and policy problems. No one discipline has the ability to single-handedly fix our current healthcare systems. Narrative data from this study illustrate the importance of seeing HCBS work beyond simply being informed by disciplinary knowledge. Rather, we suggest that adapting ways of knowing and definitions of expertise is an integral part of the solution to solving persistent health problems.

A longitudinal study of third-year medical students' communication competence, communication anxiety, and attitudes toward patient-centered care

OBJECTIVE

We investigated changes in medical students' communication competence and communication anxiety during their third year of training when they are immersed in formative clinical experiences that shape their patient-centered care and communication skills.

METHODS

We invited 282 students to complete a longitudinal, four-phase online survey during their third-year. Our response rate was 62.8% at Phase I (n = 177), 34.0% at Phase II (n = 96), 37.9% at Phase III (n = 107), and 48.9% at Phase IV (n = 138). Measures included communication competence, communication anxiety, and patient-centered attitudes and orientation. We employed hierarchical linear modeling to analyze the data.

RESULTS

Students' communication competence and anxiety improved over time. Female students reported greater communication anxiety and less competence related to information giving. At each phase, patient-centered attitudes significantly predicted communication competence and communication anxiety.

CONCLUSION

Students' competence and anxiety regarding communication during medical encounters improve during their third year and are significantly influenced by their attitudes and orientation towards patient-centered care and communication.

PRACTICE IMPLICATIONS

Schools should integrate curriculum that fosters positive attitudes toward patient-centered communication and provides opportunities to practice complex communication skills, which may increase competence and recognition that patient-centered communication is an important clinical skill.

Medical Students' Stress and Uncertainty During the COVID-19 Pandemic

The COVID-19 pandemic triggered extraordinary levels of stress and uncertainty nationwide. In the current study, we use stress and coping theory and uncertainty management theory to examine how medical students coped with the stress and uncertainty associated with the disruption COVID-19 created in their training. Students completed a mixed-methods cross-sectional online survey one week after shifting to online instruction due to COVID-19. The survey included a measure of coping strategies and a series of open-ended questions designed to capture barriers and facilitators of coping and uncertainty management. In total, 360 students from one US medical school completed the survey. Students relied most frequently on coping strategies of distraction, acceptance, planning, positive reframing, and emotional support. However, coping strategies differed significantly by year in training. Personal uncertainty emerged as the most salient form of uncertainty. This uncertainty resulted from the loss of structure and resources, disruption of academic timelines, and, ultimately, disrupted identity as a (future) physician. Students described important barriers and facilitators of coping and uncertainty management. The barriers included constant exposure, inadequate information, rumination, and extreme responses. The facilitators included distraction, avoidance, instrumental support, emotional support, network support, and positive reframing. Overall, our results suggest that medical students experienced significant uncertainty related to their professional skills and identities as future physicians and faced many dilemmas coping with stress and managing uncertainty, mainly related to information and social support.

Medical Students’ Reactions to Uncertainty During Clinical Rotations

Background and Objectives: Family physicians routinely manage uncertainty in their clinical practice. During their first year of clinical rotations, medical students learn communication and patient care skills that will influence the care they provide as future physicians. However, little is known about how their reactions to uncertainty change during this formative year, and medical education often fails to teach students how to manage uncertainty effectively. This study employs a repeated measures analysis of students’ reactions to uncertainty over the course of their third year. Methods: We surveyed 273 medical students at four time points during their third year and employed hierarchical linear modeling to analyze a series of models in which phase and intolerance of uncertainty were entered as covariates. We modeled age and gender as control variables. Results: Analyses revealed that students’ affective reactions to uncertainty did not significantly change during the third year, but reluctance to disclose uncertainty to physicians and patients significantly decreased across phases. Analyses also showed that general intolerance of uncertainty predicted affective reactions to medical-specific uncertainty. Conclusions: These findings confirm that students experience negative reactions to uncertainty during clinical rotations. Students would benefit from curriculum designed to mitigate consequences of negative affective reactions to uncertainty, particularly those students characteristically higher in intolerance of uncertainty. Given that students demonstrated more willingness to communicate about their uncertainty over time, medical school should equip students with the communication skills needed to discuss their uncertainty effectively with patients and preceptors.

"Confessions of a Reluctant Caregiver" Palliative Educational Program: The Results of a Survey Assessing Physicians' Perceptions of Drama-Based Education for End-of-Life Care

Inadequate palliative care training in medical education is associated with many physicians feeling unprepared to care for dying patients and their families. Therefore, an opportunity exists to offer physicians continuing medical education that increases their understanding of and comfort with complex palliative care issues. The goal of the current study was to evaluate The Confessions of a Reluctant Caregiver Palliative Educational Program as an educational tool for physicians. The study employed a cross-sectional post-performance evaluation survey assessing physicians' perceptions of the Confessions of a Reluctant Caregiver Palliative Educational Program. The program was presented to members of four professional healthcare organizations. A total of 50 physicians completed the evaluation survey. Overall, physicians rated the Confessions of a Reluctant Caregiver Palliative Educational Program positively. Their understanding of and comfort with end-of-life issues increased significantly after participating in the program. Moreover, they considered the program to be more useful than didactic lectures and journal articles. The results suggest that the Confessions of a Reluctant Caregiver Palliative Educational Program is a valuable education tool for palliative care training. More research is needed to explore its utility as an option for continuing medical education.

Exploring Family Caregiver Communication Difficulties and Caregiver Quality of Life and Anxiety

BACKGROUND

When family caregivers are involved in patient care, both patients and caregivers experience better clinical outcomes. However, caregivers experience communication difficulties as they navigate a complex health care system and interact with health care providers. Research indicates that caregivers experience a communication burden that can result in topic avoidance and distress; however, little is known about how burden stemming from communication difficulties with health care providers relates to caregiving outcomes.

OBJECTIVES

To investigate how family caregiver communication difficulties with health care providers influence caregiver quality of life and anxiety.

METHODS

Data were collected in a cross-sectional online survey of 220 caregivers with communication difficulties resulting from caregiver avoidance of caregiving-related topics, inadequate reading and question-asking health literacy, and low communication self-efficacy.

RESULTS

Caregiver outcomes were not affected by reading health literacy level but did differ based on question-asking health literacy level. Adequate question-asking health literacy was associated with lower anxiety and a higher quality of life. Caregivers who avoided discussing caregiving topics reported higher anxiety and lower quality of life and caregivers with increased communication self-efficacy reported a higher quality of life.

CONCLUSION

Involvement of family caregivers in care is likely to require tailored approaches that address caregiver communication and health literacy skills. Findings from this study suggest that hospice and palliative care providers should identify and provide support for caregiver communication difficulties in order to positively influence caregiver quality of life and anxiety.

Memorable Messages Parents of Children with Vascular Birthmarks Receive from Others: Implications for Stigma and Identity

Parents of children with visible illnesses and physical differences, such as vascular birthmarks (VBs), often fear that their child will be stigmatized by others. Despite their use of various strategies to minimize this stigma, parents still frequently receive comments and questions from others about their child's condition. In the current study, we explore the source, content, and valence of these messages using a memorable messages framework. We also examine how parents react to messages from others and why those messages are considered memorable. To collect data, we administered a cross-sectional online survey through the website and social media pages of a national support group for parents of children with vascular birthmarks. A total of 70 parents completed the survey and, altogether, recalled 92 memorable messages. Our analyses revealed that the significance of the memorable messages coalesced around identity. Specifically, the messages described carried implications for a) participants in terms of their identities as parents, and b) participants' children in terms of their identities as stigmatized individuals. When messages were directed at parents, parents appraised them negatively or positively to the extent that they made parents feel judged or validated as parents of children with VBs. When messages were directed at children, parents appraised them negatively or positively to the extent that they labeled children and their VB as abnormal, unattractive, and undesirable, or accepted and complimented children as unique, special, and beautiful. The current research extends previous research exploring the role of memorable messages in negotiating identity.

Confessions of a Reluctant Caregiver Palliative Educational Program: Using Readers' Theater to Teach End-of-Life Communication in Undergraduate Medical Education

End-of-life care can be stressful for patients, caregivers, and providers. Caregivers often experience high levels of burden from caregiving duties such as performing medical tasks, communicating with providers, and making decisions. Similarly, many physicians feel unprepared to provide end-of-life care or communicate with patients and families about sensitive issues associated with death and dying. Physicians often attribute their lack of preparation to inadequate training in medical school. Previous research suggests that drama-based learning opportunities are valuable supplements to existing end-of-life curricula. The current study evaluates the success of the Confessions of a Reluctant Caregiver Palliative Educational Program - a drama-based educational program that depicts patient and caregiver experiences. A total of 477 osteopathic medical students participated in the program, which includes viewing a play, engaging in a facilitated post-performance talkback session, and completing an evaluation survey. The results suggest the program is a valuable learning experience that is positively associated with important facets of experiential learning using narratives such as perceived realism, increased reflection, strong emotions, and increased comfort with difficult behaviors. The program offers a safe environment for medical students to identify, understand, and process the sensitive and complex issues associated with end-of-life care. Moreover, the play offers insight into the often-overlooked experiences of family caregivers who are at risk of experiencing high caregiver burden while managing health-related communication and decision-making.

Moving toward Narrative Competence and Inclusive Healthcare through the Open Book Project

This essay offers a layered account of the origins and enactment of a narrative medicine program at the Ohio University Heritage College of Osteopathic Medicine titled the Open Book Project (OBP). Narrative medicine positions clinical judgment as involving both scientific and narrative reasoning, a set of practices particularly well-suited to fostering inclusive health care and social justice. The OBP involved first-year medical students who met bi-monthly to witness, reflect on, and write about literary passages, visual images, music and lyrics, and other works of art. Sessions also provided opportunities for participants to attentively listen and respond to others, opening themselves to diverse ways of knowing and being. The authors move between academic literature, participants' compositions developed during the project, and students' testimonies to illustrate the dividends and difficulties of narrative medicine.

Variation in health literacy among family caregiver communication types

OBJECTIVE

Previously, four caregiver types have been identified as a result of communication patterns between patient and caregiver, revealing unique caregiver information needs and preferences. The purpose of this study was to explore variation in health literacy among the four family caregiver communication types: manager, partner, carrier, and lone caregivers.

METHODS

The sample consisted of 115 cancer caregivers. Participants completed the Family Caregiver Communication Tool and the Health Literacy of Caregivers Scale-Cancer.

RESULTS

A significant difference in health literacy domains was found between caregiver types for cancer-related communication with the care recipient (P = .038) and understanding of the health care system (P = .003). Of the health literacy domains, mean scores were highest on understanding the health care system for both lone and carrier caregivers. Manager and partner caregivers were highest on the social support domain. The self-care domain was lowest for the carrier, lone, and manager caregivers.

CONCLUSIONS

There was a variation across health literacy domains among caregiver communication types, further validating the Family Caregiver Communication Typology. Findings showed a need for educational programs for cancer caregivers to strengthen their health literacy skills. As cancer caregivers have a prominent role in the delivery and quality of cancer care, it is pivotal for health care centers to provide caregiver communication training and support.

Communication and the Appraisal of Uncertainty: Exploring Parents' Communication with Credible Authorities in the Context of Chronic Childhood Illness

Individuals with chronic illnesses must manage long-term uncertainty as they cope with the ways the illness influences their lives. In the context of pediatric illnesses, parents must manage uncertainty during the diagnosis and treatment of their child's illness. It is common for children with complex chronic illnesses to see multiple specialists for the treatment of their condition. While previous research has explored parents' uncertainty during a child's diagnosis and during end-of-life care, less is known about these experiences when the child is referred to a team of specialists for treatment. The aim of the current study was to explore how specialists, as credible authorities, influence parents' uncertainty during parents' first visit to a multidisciplinary clinic for the care of their child's complex chronic illness. Data were collected through semi-structured interviews with 29 parents after their child's first visit to a vascular anomaly clinic at a large Midwestern children's hospital. The results suggest parents' communication with credible authorities facilitates effective uncertainty management primarily through the mechanism of uncertainty reappraisal. The results also suggest that specialists, as credible authorities, are a key mechanism in the appraisal of uncertainty for conditions that are often misdiagnosed and mismanaged.

Hospital-Community Partnerships: Facilitating Communication for Population Health on Columbus' South Side

Previous studies have focused on the role anchor institutions play in community development. However, less attention has been directed to how hospitals can effectively partner with community-organizations and residents as part of population health efforts. This article examines community views of one initiative developed by a major American children's hospital in partnership with local community organizations. The data for this study come from 35 in-depth interviews with local residents from the neighborhood adjacent to the hospital and two interviews with hospital administrators. Our findings suggest that the contexts in which hospitals and other non-profit corporations operate pose unique challenges to effective communication. In particular, hospitals and community organizations may think differently about the merits and nature of open communication. Especially when acting as anchor institutions working beyond their formal medical expertise, hospitals may struggle to communicate the scope and goals of their non-medical work in the community.

Students' Perceptions of Trigger Warnings in Medical Education

Phenomenon: Trigger warnings are verbal statements or written warnings that alert students in advance to potentially distressing material. Medical education includes numerous subjects frequently identified as triggers, such as abuse, rape, self-injurious behaviors, eating disorders, drug and alcohol addiction, and suicide. Thus, exploring medical students' perceptions of trigger warnings may provide a valuable perspective on the use of these warnings in higher education.

APPROACH

As part of a larger descriptive, cross-sectional survey study on medical education, we assessed 1st- and 2nd-year medical students' perceptions of trigger warnings in the preclinical curriculum. Five questions specific to trigger warnings explored students' knowledge, prior experience, and perceptions of trigger warnings in medical education. Frequencies of individual question responses were calculated, and qualitative data were analyzed via content and thematic analyses.

FINDINGS

Of the 424 medical students invited to participate, 259 completed the survey (M = 24.8 years, SD + 3.4, 51.4% female, 76.1% White, 53.7% 1st-year students). Few students (11.2%) were aware of the term trigger warning and its definition. However, after being presented with a formal definition on the online survey, 38.6% reported having had a professor use one. When asked whether they supported the use of trigger warnings in medical education, respondents were distributed fairly equally by response (yes = 31.0%, maybe = 39.2%, no = 29.7%). Qualitative analysis revealed three themes: (a) Trigger Warnings Allow Students to Know What is Coming and Prepare Themselves: Respondents believed that trigger warnings would benefit students with a history of trauma by providing them additional time to prepare for the material and, if appropriate, seek professional help; (b) Students Need to Learn How to Handle Distressing Information: Respondents agreed that they needed to learn and cope with highly sensitive material because they would be confronted with difficult and unexpected situations in clinical practice; and (c) Trigger Warnings Help Students Understand the Severity of the Material: Respondents felt that trigger warnings may help students understand the severity of the material being covered and increase awareness about trauma and its effects on health and well-being. Insights: Findings did not reach consensus for or against the use of trigger warnings in medical school; however, students emphasized the importance of learning how to cope with distressing material. Trigger warnings may represent a teaching tool to facilitate classroom discussions about the severity of trauma-related material and problem-focused coping strategies.

Rethinking Risk: Prospect Theory Application in Health Message Framing Research

Although prospect theory conceptualizes risk as uncertainty, health message framing research based on the theory typically conceptualizes risk as severity. This study reports the results of two experiments designed to explore these alternative conceptualizations of risk and their effect on health decision making. Participants (N₁ = 768, N₂ = 532) were randomly assigned to one of four conditions that presented a hypothetical scenario of a sexually transmitted disease (STD) outbreak. The conditions were defined by message prompt (deadly vs. easily curable STD) and response option frame (gain vs. loss). Participants selected which of two programs (certain outcome vs. uncertain outcome) they would prefer to combat the outbreak. Across both experiments, participants expressed strong preferences for certain (low risk) outcomes in the gain-framed conditions and no preferences in the loss-framed conditions. These differences held regardless of the consequence severity of the scenario. We discuss the theoretical and practical implications of these results and offer directions for future research.

Parental uncertainty in illness: managing uncertainty surrounding an "orphan" illness

Parents of children with complex chronic illnesses experience substantial uncertainty that is heightened when the condition is an "orphan" illness not belonging to one medical specialty. The current study explores uncertainty experienced by parents of children with "orphan" illnesses requiring multidisciplinary care.

METHOD

Participant-observations over 13 months (n=200) were combined with questionnaire data (n=55) to assess parental uncertainty at a multidisciplinary pediatric clinic.

RESULTS

Five unique types of uncertainty emerged from a grounded analysis (Glaser & Strauss, 1967), revealing 11 interrelated uncertainties these parents experience. Findings can help providers understand parents' uncertainty and assist in family-centered decision-making.

Lovesick: immunological costs of mating to male sagebrush crickets

A growing body of evidence suggests that resources invested in reproduction often come at the expense of the ability to mount an immune response. During mating, female sagebrush crickets, Cyphoderris strepitans, consume the ends of the male's hind wings and ingest his haemolymph. Previous research has shown that this behaviour impairs the ability of males to secure additional matings. One hypothesis to account for this effect is that wing wounding triggers an energetically costly immune response, such that nonvirgin males are unable to sustain the costly acoustical signalling needed to attract additional females. To test this hypothesis, we injected virgin males with lipopolysaccharides (LPS) to provoke an immune response, and monitored their mating success in the field. LPS-injected virgin males took significantly longer to mate than sham-injected virgin males, and spent significantly less time calling. We also compared virgin, nonvirgin and experimentally wing-wounded virgin males with respect to: (1) their ability to encapsulate a foreign invader via the accumulation of haemocytes and deposition of melanin and (2) baseline levels of phenoloxidase (PO), a key enzyme in the biochemical cascade leading to the production of melanin. Although encapsulation ability did not differ with reproductive experience, virgin males had significantly higher levels of PO than either nonvirgin or experimentally wing-wounded virgin males. These results suggest that wing-wounding alone is sufficient to impair male immunity, and that males trade-off investment in reproduction and immunity.

People with MECP2 mutation-positive Rett disorder who converse

BACKGROUND

People with useful speech after regression constitute a distinct group of those with mutation-positive Rett disorder, 6% (20/331) reported among mutation-positive people in the British Survey. We aimed to determine the physical, mental and genetic characteristics of this group and to gain insight into their experience of Rett syndrome.

METHODS

Clinical and molecular data for people with Rett, aged 10 or more years at follow-up (the study group, n = 13), with the ability to converse and a MECP2 mutation are presented. They were compared with an age-matched control group (n = 110), who could not converse and had a pathogenic MECP2 mutation.

RESULTS

The study group differed significantly from the control group with regard to their disease severity (P < 0.001); feeding difficulty scores (P < 0.001); health scores (P < 0.001); epilepsy (P < 0.001); head circumference (P < 0.004); age at onset of the regression period (P < 0.001) (six in the study group did not regress) and mutation frequency (C-terminal deletions P = 0.014, R133C P < 0.006). The results indicate that favourable skewing of X-inactivation is only present in a small proportion of mild cases. Speech was fragmented with a soft, breathless quality, and all but two had obviously irregular breathing. One person with an R168X mutation preferred signing to speech. All enjoyed interpersonal contact, showing affection and preferring people to objects, clearly distinguishing the condition from autism. Most were habitually anxious. Music was a source of pleasure and relaxation also providing a valuable educational asset. Even in these most able cases, understanding was severely restricted in most and little initiative was shown.

CONCLUSIONS

While the Rett profile is present in these people they are commonly not classic, and the presence of speech, good head growth and lack of regression may lead to missed diagnoses. A strong association was demonstrated between this milder form of the disease and R133C and C-terminal deletions.

Nurse recognition of early deviation in development in home videos of infants with Rett disorder

BACKGROUND

In the genetic Rett disorder (RD), infants make some progress then suffer a dramatic developmental regression, usually before 2 years of age. Home videos, taken before the problems are recognized, offer an objective source for detecting early signs.

METHODS

Thirty-six health visitors and midwives were invited to view brief examples from home videos of a cohort of 14 infants with RD and 11 control infants with normal development in the first year of life, and to indicate, by pressing a button, points in the recordings which aroused their suspicion of developmental deviation. They were then invited to comment on their selection. The participants were blind as to whether any individual example showed an infant with normal development or one with some form of developmental disturbance.

RESULTS

From the first month of life and throughout the first year, infants with RD received more button presses than controls (46%, 361 out of 778 viewings) in comparison with the control group (12%, 67 of 558). The consistent nature of the health professionals' comments made possible their categorization under four headings: appearance, posture, movement and contact. In the first month of life, the hand postures of infants with RD received particular comment from midwives (23 out of 37 comments overall on posture).

CONCLUSIONS

The present study strongly suggests the presence of early signs of developmental deviation in infants with RD, although, in most cases, formal developmental screening procedures have failed to detect these before the ages of 12 or 18 months.

Motion analysis of stereotyped hand movements in Rett syndrome

BACKGROUND

Rett syndrome is a genetic developmental disorder, and stereotyped hand movements are a striking feature of this condition. The aim of the present study was to subject these movements to objective analysis and compare the results in one girl at different ages.

METHOD

The hand movements of a 10-year-old girl with Rett syndrome were subjected to accurate, three-dimensional (3D) computerized motion analysis and compared to two-dimensional (2D) video analysis of the same girl at 3 years of age.

RESULTS

Three-dimensional computerized analysis revealed regular patterns with strong coupling between the hands. Frequency analysis showed a dominant frequency at 1.2 Hz, with a higher component at 2.4 Hz that may relate to the activity of basic rhythm generators. The same coupling characteristics were extracted from standard, 2D video recordings made at the same time as the 3D capture.

CONCLUSION

An informal video of the same girl taken when she was 3 years of age was analysed in the same way as the 2D video and showed the same characteristics, indicating the possible future use of automated video analysis for early screening and intervention evaluation.

Medical needs of people with intellectual disability require regular reassessment, and the provision of client- and carer-held reports

BACKGROUND

Previous work has indicated a wide range of unmet medical health needs in people with intellectual disability (ID).

METHODS

A profile of recorded medical needs was produced for 589 people with ID through a detailed search of individual medical and nursing case records. Specialist optometric and audiological assessments were offered, and reports were provided in technical and plain English terms. A Health Watch project delivered folders with copies of the plain English reports to 60 individuals and carers.

RESULTS

The case record review indicated a wide range of medical disorders; however, exact diagnoses and counselling regarding underlying neurological conditions were seldom recorded. Assessed levels of hearing and vision loss were much greater than had been previously recognized. The Health Watch reports were welcomed by the clients and carers.

CONCLUSIONS

If satisfactory healthcare is to be achieved for people with ID, medical needs must be monitored, regular specialist reassessments offered, access to specialist services facilitated and reports clearly explained to carers.

Mind and brain in Rett disorder

Development and retention of speech is reported in 265 people with Rett syndrome: 30% (80) never gained real words, 55% (145) gained real words and lost them, 15%(40) retained some words and 6% of the total (16/265) continued to use phrases appropriately. Morphological studies of the cytoarchitecture of the speech areas in 14 cases indicate the existence of interhemispheric differences which form part of the infrastructure for speech processing. Ten adults with Rett syndrome and with meaningful speech are compared to age matched adults without speech. The profile of mind and strategies for coping with its problems are described by a family. Although the range in severity is wide the mental profile is remarkably consistent across the severity range with regard to both positive and negative aspects.

Towards a full life with Rett disorder

In 1999, mutations in the gene methyl CpG2 (MECP2) were found to be the cause of the profoundly intellectually disabling Rett syndome. Through the combined efforts of laboratory and clinical scientists, therapists, educators and the families of affected people, many of its underlying anatomical, neurochemical, physiological and functional associations are now known, and some practical experience has been gained in therapeutic intervention. It is clear that there is considerable potential for reduced dependence and the provision of a happy and interesting life in this developmental disorder and there remains a need to identify the neural mechanisms which are available to people with Rett and to ensure that appropriate services are accessible.

Characterisation of breathing and associated central autonomic dysfunction in the Rett disorder

AIM

To investigate breathing rhythm and brain stem autonomic control in patients with Rett disorder.

SETTING

Two university teaching hospitals in the United Kingdom and the Rett Centre, Sweden.

PATIENTS

56 female patients with Rett disorder, aged 2-35 years; 11 controls aged 5-28 years.

DESIGN

One hour recordings of breathing movement, blood pressure, ECG R-R interval, heart rate, transcutaneous blood gases, cardiac vagal tone, and cardiac sensitivity to baroreflex measured on-line with synchronous EEG and video. Breathing rhythms were analysed in 47 cases.

RESULTS

Respiratory rhythm was normal during sleep and abnormal in the waking state. Forced and apneustic breathing were prominent among 5-10 year olds, and Valsalva breathing in the over 18 year olds, who were also most likely to breathe normally. Inadequate breathing peaked among 10-18 year olds. Inadequate and exaggerated breathing was associated with vacant spells. Resting cardiac vagal tone and cardiac sensitivity to baroreflex were reduced.

CONCLUSIONS

Labile respiratory rhythms and poor integrative inhibition in Rett disorder suggest brain immaturity. Linking this to an early monoaminergic defect suggests possible targets for the MECP2 gene in clinical intervention. Exaggerated and inadequate autonomic responses may contribute to sudden death.

Guidelines for reporting clinical features in cases with MECP2 mutations

An international group recommends that papers relating phenotypes to genotypes involving mutations in the X chromosome gene MECP2 should provide a minimum data set reporting the range of disturbances frequently encountered in Rett Syndrome. A simple scoring system is suggested which will facilitate comparison among the various clinical profiles. Features are described which should prompt screening for MECP2 mutations.

Abnormalities in urinary pterin levels in Rett syndrome

The pterins, neopterin and biopterin, occur naturally in body fluids including urine. Increased neopterin levels are associated with activation of the cellular immune system and reduced biopterins are essential for biosynthesis of the monoamine neurotransmitters. The present study measured urinary neopterin and biopterin by high-performance liquid chromatography in 40 subjects with Rett syndrome, eight of their healthy sisters and 29 female control volunteers (age range 2-54 years). The results confirm earlier preliminary findings that urinary neopterin levels are raised in a proportion of young girls with Rett syndrome but not in the older women. In contrast urinary biopterin levels are not different from controls in the youngest children but remain low while control values increase with age. These findings may indicate immune activation during the regression phase of Rett syndrome but also raise the possibility that an inherited fault in tetrahydrobiopterin metabolism increases the risk of developing the disorder.

Bi-penta-bi-decaradial symmetry: A review of evolutionary and developmental trends in holothuroidea (echinodermata)

Holothuroidea, comprising the sea cucumbers, is the least studied class of extant echinoderms, yet this group possesses a wealth of features of potential interest to developmental and evolutionary biologists. Holothuroids include the most morphologically derived echinoderms, including pelagic species and spheroid, plated taxa with mouth and anus adjacent at the end of a long, flexible stalk. To begin investigating this diversity of body form, we first estimated evolutionary relationships in the class Holothuroidea based on maximum parsimony analyses of 1,075 nt of the nuclear small subunit rDNA (for six species in four orders) and on 52 informative morphological characters (for the 25 extant families). Both the morphological and molecular evidence suggests almost an inversion of the prevailing higher level classification. Character-state optimizations indicated that pronounced adult bilateral symmetry evolved three times. In one group even a regain of secondary radial symmetry is found. Respiratory trees, structures unique to holothuroids, are a relatively late innovation, are ectodermally derived, and are bilaterally symmetric, supporting the possibility that the secondary gain of bilateral symmetry in holothuroids is ectodermally derived analogous to, say, the derivation of vertebrate limb dorso-ventral axis. The test of imbricating plates found in 10% of living holothuroids is apparently not homologous with that of other heavily armored echinoderms, evolving much later and at least twice. Indirectly developing larvae, auriculariae, occur in two evolutionarily disparate clades and unlike echinoids comprise a minority of clades. We suggest that this implies the parallel convergent evolution of this larval type or, more speculatively, some form of retention of developmental constraints. J. Exp. Zool. (Mol. Dev. Evol.) 285:93-103, 1999. Copyright 1999 Wiley-Liss, Inc.

Functional evidence of brain stem immaturity in Rett syndrome

Autonomic activity and respiration were studied in Rett syndrome (RS) and age matched controls. Breathing movements were monitored using a pletysmograph around the chest. Sympathetic activity was monitored by measuring blood pressure (BP) using the Finapres. Cardiac parasympathetic activity was monitored by measuring the cardiac response to baroreflex using the NeuroScope which outputs measure of cardiac vagal tone (CVT) in units of a linear vagal scale (LVS). Resting CVT (means +/- SEM) was 10.5 +/- 0.9 units in the LVS and BP was 94.6 +/- 6.4 mmHg in controls. The BP was 78 +/- 4.33 mmHg and CVT was 3.6 +/- 0.7 units in the LVS in girls with RS, 65% lower than in their age matched controls (p < 0.001), but equal to previously reported level in neonates. Each girl with RS had at least 6 types of breathing dysrhythmias, a sign of instability of the respiratory oscillator. The sympathetic system controlled the HR and BP smoothly during breath holding in control girls, but there were oscillations and rebounds in RS. The HR and BP were under parasympathetic influence during hyperventilation in normal girls but not in RS. The CVT was invariably withdrawn at the height of sympathetic activity during both hyperventilation and breath holding in RS, leading to sympathovagal imbalance with the risk of cardiac arrhythmias and possibly sudden death. Neonatal level of CVT, poor autonomic integration and multiple breathing dysrhythmias shows medullary immaturity in RS. It is the first demonstration of immaturity of the brain which could be used for screening in early childhood and potentially useful for diagnosis and management of RS.

Rett syndrome: analysis of deaths in the British survey

The mortality rate in Rett syndrome is 1.2% per annum, 48% of deaths occurring in debilitated people, 13% from natural causes, 13% with prior severe seizures and 26% sudden and unexpected. Respiratory dysrhythmias were usually present. Neuropathology confirmed reductions in cortical dendrites and in one case immaturity of cardiac conducting tissues.

Rett syndrome: critical examination of clinical features, serial EEG and video-monitoring in understanding and management

We studied data on seizures, vacant spells and breathing dysrhythmia from the British Rett Survey and 150 electroencephalographic records from 78 classic cases, including 23 with prolonged synchronous recordings of EEG, respiration and movement. The proportion of abnormal records increased from 6 of 18 (33%) during the first 6 months of the regression period to 44 of 59 (75%) in the later period to 6 years, the increase in abnormality following rather than preceding the onset of regression. In young girls the EEG abnormality increased in sleep but decreased during episodic hyperventilation and breath-holding. Epileptogenic activity was commonly present without clinical seizures. Eleven vacant spells were monitored and were not epileptic but related to the breathing abnormality. Full monitoring is essential when supposed seizures are intractable. The intermittent EEG abnormality and behavioural changes indicate abnormal fluctuating arousal possibly of midbrain or brainstem origin.

Visual function in Rett syndrome

The authors examined refractive error, pattern onset visual evoked potentials, ocular posture and they performed internal and external eye examinations in 11 subjects with Rett syndrome (aged between four and 24 years) and 18 normal controls (aged between six and 20 years). Substantial refractive errors were common in the Rett syndrome group. Spectacle correction had never previously been worn and glasses were provided where appropriate. No subjects had nystagmus or optic nerve pallor and only one was strabismic. All subjects had recognisable and reproducible pattern-onset VEPs and latencies and amplitudes did not differ significantly from those of the controls. All demonstrated VEP thresholds of at least 24'. In contrast to other populations with profound disabilities, people with Rett syndrome have good function of the afferent visual pathways and, in view of their substantial refractive errors, are likely to benefit from spectacle correction.

Early clinical signs in the Rett disorder

This review of the period from birth until the end of regression in classic Rett syndrome (RS) is based on personal experience of more than 600 cases over 12 years including video material on 42 cases showing behaviour before regression. A period of undoubted developmental progress followed by loss of skill is apt to persuade the physician that a fresh toxic or infective insult has afflicted a normal child but close scrutiny of classic Rett syndrome cases indicates that the cognitive and motor problems of the disorder are detectable from birth, that a developmental ceiling limits progress and that the timing and nature of the regression event and subsequent behaviour of the child indicate inherently defective central receptive processing with a highly specific profile. A model illustrates how the characteristic disturbances may express incompetent higher control. The robust mid infancy level skills of the Rett child and woman deserve careful analysis and offer potential for therapy. Metabolic and immune sequelae may occur as the developmental defect becomes manifest and such cascade events demand careful evaluation and offer further opportunities for intervention.

Short fourth toes in Rett syndrome: a biological indicator

Classic Rett syndrome is now well-known as a non-dysmorphic developmental disorder almost certainly of genetic origin. Short 4th toe (uni- or bi-lateral) is inherited as an autosomal dominant with 27% penetrance and is found also in certain dysmorphic syndromes. Having observed the anomaly in several Rett cases, we examined a cohort of classic Rett people at advisory clinics and all the residents in an adult learning disabled hospital in order to determine the significance of the association. Among the Rett clinic group 28 of 137 showed the anomaly (20%). Among the heterogeneous hospital group it was found in 19 of 526 people, 9 of 206 females (4%) and 10 of 320 males (3%). Rett syndrome was present in 7% of all the women (14 of 206 women). Four of the Rett women showed the toe anomaly (28% of the Rett cases). The anomaly was found in 4 men and 4 women with Down syndrome, representing 16% (8 of 49). Diagnoses in other men with the anomaly included foetal alcohol syndrome, toxoplasmosis, 18/2 translocation and birth injury. The only other woman with the anomaly was profoundly disabled with short limbs. The strong positive association of the anomaly with Rett syndrome and Down syndrome throws new light on the developmental processes affected by these diseases.