Enabling uptake and sustainability of supervision roles by women GPs in Australia: a narrative analysis of interviews

BACKGROUND

Worldwide, the proportion of women entering careers in medicine is increasing. To ensure diversity and capacity in the general practice ("GP") supervision workforce, a greater understanding from the perspective of women GPs engaged in or considering the clinical supervision of trainee doctors is important. This narrative inquiry aims to explore the uptake and sustainability of supervision roles for women GPs in the Australian context.

METHODS

Qualitative interviews with Australian women GPs were conducted between July and September 2021. Women GPs were selected to represent a range of demographics, practice contexts, and supervision experience to promote broad perspectives. Narrative analysis drew on participant perspectives, allowing emergent stories to be explored using story arcs based on the characters, settings, problems, actions, and resolutions. These stories were evaluated by a broad research team and a high level of agreement of the final narratives and counter-narratives was achieved.

RESULTS

Of the 25 women who enrolled, 17 completed interviews. Six narratives emerged, including: power and control, pay, time, other life commitments, quality of supervision, and supervisor identity. These represented significant intersecting issues with the potential to impact the uptake and sustainability of supervision by women GPs. Some women GPs reported a lack of agency to make decisions about their role in supervision and were not remunerated for teaching. Uptake and sustainability of supervision was constrained by other life commitments, which could be buffered by team-sharing arrangements and a supportive practice. Although adding a burden of time atop their complex and sensitive consultations, women GPs were committed to being available to registrars and supervising at a high standard. To foster high quality supervision, women GPs were interested in up-skilling resources, building experience and harnessing support networks. Women sensed imposter syndrome when negotiating a supervisor identity, which could be managed by explicitly valuing their contribution.

CONCLUSION

The findings can inform the development of more specific resources, supports and structures to enable women GPs in Australia to uptake and sustain the supervision of trainee doctors at a level they find both acceptable and rewarding.

Anhedonia and anergia predict mortality in older Australians living in residential aged care

OBJECTIVES

Depression is common in older adults and is linked to morbidity and mortality. The aim of this study was to investigate whether specific symptoms of depression (dysphoria, anhedonia and anergia) predicted mortality in older Australian Aged Care residents.

METHODS

Eighty older adults (M = 83.16 ± 7.14) without cognitive impairment residing in 14 Residential Aged Care facilities located in Melbourne, Australia, completed the 15-item Geriatric Depression Scale-Short Form (GDS-15) and the Standardized Mini Mental State Examination. Residential Aged Care facilities provided the primary end-point of all-cause mortality at follow-up (M = 5.4 years ± 0.1).

RESULTS

Univariate Kaplan-Meier survival curves and Cox Proportional Hazards regression analyses were used to evaluate whether symptoms of depression predicted all-cause mortality, with known prognostic factors controlled. The results indicated that anhedonia (Hazard Ratio = 2.931 [95% CI 1.278-6.722], p = .011) and anergia (Hazard Ratio = 2.783 [95% CI 1.065-7.276], p = .037) were associated with almost a threefold increased risk of mortality in older adults living in RAC in adjusted analyses. Dysphoria did not predict mortality.

CONCLUSIONS

These findings advance understanding of the mortality risks of anhedonia and anergia in an understudied population. Symptoms of anhedonia and anergia should be targeted for screening in older adults living in Aged Care to increase the detection and potential for referral to treatment for depressive presentation.

Pharmacological Restoration of mOod in HEART Failure: outcomes of the PRO-HEART trial

Background

Depression is common in chronic heart failure (CHF) patients and is associated with increased morbidity and mortality. Anti-depressant medication has shown benefits in coronary artery disease but efficacy has not been demonstrated in CHF patients.

Purpose

To assess whether escitalopram is more effective than placebo in treating major and/or minor depression in patients with CHF.

Methods

This was a randomized, placebo-controlled, double-blind, parallel group study. Adult patients with systolic CHF (NYHA Class ≥2, nadir LVEF <40%) were screened for depression using the Cardiac Depression Scale (CDS) for a score ≥95 (sensitivity 97% at 85% specificity for major Depression (MDD)) followed by a clinical diagnosis of major or minor depression using the SCID interview. Patients were randomised to active escitalopram or matching placebo for 6 months, stratified for major or minor depression. Blinded therapy started with 5mg with automatic uptitration to 10mg after 2 weeks and further uptitration to 20mg at 2 months if CDS score remained ≥95. The primary end-point was change in CDS score over 6 months with secondary end-point change in Hamilton Depression Rating Scale (HAM-D).

Results

Of 28 CHF patients (males = 25; mean age = 63.61±10.32), mean CHF diagnosis 5.8 years, ischaemic aetiology (n=18), entry LVEF 42.2±9.6%; eGFR 61.8±15.4, 14 were diagnosed with major and 14 with minor depression. Two-way Mixed Model ANOVA showed a significant improvement from baseline to 6 months in both CDS (F(1,25)=18.76, p<0.001) and HAM-D (F(1,25)=17.32, p<0.001), but no significant interaction between condition and change over time. Three-way Mixed Model ANOVA showed no interaction between baseline depression diagnosis (Major or Minor) and response to treatment by condition. There were 7 SAEs for hospitalisation, unrelated to study medications and no differences between groups on AE/SAEs.

Conclusions

Patients showed a significant improvement in depression with both placebo and active drug but with no benefit of escitalopram over placebo. This suggests that there is no additional benefit from antidepressant therapy for CHF patients beyond that conferred by placebo. Further research is needed to explore whether greater benefits might be achieved by combination therapies or in particular subgroups of depressed CHF patients.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): National Heart Foundation of Australia, Beyond Blue

Confirming a beneficial effect of the six-minute walk test on exercise confidence in patients with heart failure

Background:

Low confidence to exercise is a barrier to engaging in exercise in heart failure patients. Participating in low to moderate intensity exercise, such as the six-minute walk test, may increase exercise confidence.

Aim:

To compare the effects of a six-minute walk test with an educational control condition on exercise confidence in heart failure patients.

Methods:

This was a prospective, quasi-experimental design whereby consecutive adult patients attending an out-patient heart failure clinic completed the Exercise Confidence Scale prior to and following involvement in the six-minute walk test or an educational control condition.

Results:

Using a matched pairs, mixed model design ( n=60; 87% male; Mage=58.87±13.16), we identified a significantly greater improvement in Total exercise confidence ( F(1,54)=4.63, p=0.036, partial η2=0.079) and Running confidence ( F(1,57)=4.21, p=0. 045, partial η2=0.069) following the six-minute walk test compared to the educational control condition. These benefits were also observed after adjustment for age, gender, functional class and depression.

Conclusion:

Heart failure patients who completed a six-minute walk test reported greater improvement in exercise confidence than those who read an educational booklet for 10 min. The findings suggest that the six-minute walk test may be used as a clinical tool to improve exercise confidence. Future research should test these results under randomized conditions and examine whether improvements in exercise confidence translate to greater engagement in exercise behavior.

2204Predicting the trajectory of depression following an acute coronary syndrome: the role of resilience

Background

Depression is common in patients following an Acute Coronary Syndrome (ACS) substantially increases the risk of future events and mortality. Post-ACS depression typically resembles one of four longitudinal trajectories: chronic; absent; recovered, or delayed depression. Early identification of a patient's post-ACS depression trajectory will improve risk stratification, treatment implementation and risk management.

Purpose

To explore whether stable psychosocial traits, such as resilience, predict the trajectory of depression one month and 6 months following an ACS admission.

Method

Consecutive adult ACS patients (STEMI/NSTEMI) admitted to a large general hospital completed the Cardiac Depression Scale (CDS) and the Sense of Coherence scale during their admission, then one and six months following discharge.

Results

132 ACS in-patients (males = 111; mean age = 63.13±13.47) satisfied enrolment criteria. Unconditional linear latent growth modelling identified a 3-class model for the trajectory of depression post-ACS (increasing depression; consistent non-depressed; decreasing non-depressed). For the increasing depression class, resilience at baseline was significant and negative compared to the consistent class, b=−0.06, Wald chi square (1) = 4.42, p=0.036 and the decreasing class, b=−0.09, Wald chi square (1) = 7.20, p=0.007.

Conclusions

Patients who reported lower levels of resilience during an ACS admission were significantly more likely to experience initially high levels of depressive symptoms (CDS ≥85) that exceeded the clinically relevant cut-off (CDS ≥95) at 6 months post-discharge. This study suggests that screening for resilience and depression will improve risk stratification for persistent and delayed depression post-ACS.

Self-Care Interventions That Reduce Hospital Readmissions in Patients With Heart Failure; Towards the Identification of Change Agents

Unplanned hospital readmissions are the most important, preventable cost in heart failure (HF) health economics. Current professional guidelines recommend that patient self-care is an important means by which to reduce this burden. Patients with HF should be engaged in their care such as by detecting, monitoring, and managing their symptoms. A variety of educational and behavioural interventions have been designed and implemented by health care providers to encourage and support patient self-care. Meta-analyses support the use of self-care interventions to improve patient self-care and reduce hospital readmissions; however, efficacy is variable. The aim of this review was to explore methods to achieve greater clarity and consistency in the development and reporting of self-care interventions to enable ‘change agents’ to be identified. We conclude that advancement in this field requires more explicit integration and reporting on the behaviour change theories that inform the design of self-care interventions and the selection of behaviour change techniques. The systematic application of validated checklists, such as the Theory Coding Scheme and the CALO-RE taxonomy, will improve the systematic testing and refinement of interventions to enable ‘change agent/s’ to be identified and optimised.

Low psychological resilience is associated with depression in patients with cardiovascular disease

BACKGROUND

Psychological resilience is associated with an improved capacity to cope with chronic health challenges such as cardiovascular disease.

AIMS

The aim of this cross-sectional study was to examine the relationship between psychological resilience and symptoms of depression in a non-acute cardiac outpatient population.

METHODS

A total of 419 adult cardiac outpatients (288 men; mean±SD age 66.26±14.04 years) attending cardiovascular clinics completed the Sense of Coherence (SOC13) scale as a measure of psychological resilience and the Cardiac Depression Scale (CDS26) prior to their consultation.

RESULTS

The total SOC13 score (mean±SD 64.02±14.24, range 19-91) was within the moderate range. Older patients (⩾65 years) were significantly more resilient than those aged <65 ( p<0.01). Psychological resilience (SOC13) was negatively correlated with depression (CDS26) ( r=-0.79; p<0.001) and inversely associated with affective, cognitive and somatic symptoms of depression. Psychological resilience, particularly meaningfulness, accounted for more of the variance in affective features of depression than for somatic features.

CONCLUSION

These findings show that low psychological resilience was related to depression in this cohort of cardiac outpatients, particularly affective symptoms such as anhedonia and hopelessness. The SOC13 scale offers a complementary measure of psychological status that could be used to monitor, and possibly predict, patient coping and response to treatment throughout the cardiovascular disease trajectory.

Maternal hen calls modulate memory formation in the day-old chick: The role of noradrenaline

Facilitation of memory for discriminative learning in young chicks is enhanced following exposure to a synthesized rhythmic auditory stimulus. Increased arousal, mediated by noradrenergic activation, is believed to underlie this effect. In this report we examine whether ethologically relevant rhythmic auditory stimuli produce the same noradrenaline-mediated memory enhancement in neonate chicks (Gallus gallus domesticus). Maternal hen attraction calls which contained a rhythmic pattern were found to facilitate retention. Intracerebral injection of noradrenaline or the beta(2)-adrenergic antagonist propranolol demonstrated that this enhancement is likely to be mediated by noradrenergic activation of central beta(2)-noradrenergic receptors. In contrast, a rhythmic alarm call inhibited retention. Subcutaneous injection of the alpha(1)-adrenergic antagonist prazosin revealed that this impairment may be due to higher arousal levels resulting in activation of alpha(1)-noradrenergic receptors. It is concluded that the maternal hen calls of domestic chickens can influence the memory ability of the offspring via noradrenaline release in the brain. The current data suggest that call meaning and rhythmicity interact to yield the appropriate levels of beta(2)-adrenergic activation required to facilitate retention for a discriminative task.

Noradrenaline involvement in the memory-enhancing effects of exposure to a complex rhythm stimulus following discriminated passive avoidance training in the young chick

Previous research in our laboratory has demonstrated a significant memory-enhancing effect of exposure to a complex rhythm stimulus following weakly-reinforced passive avoidance learning in chicks. The aim of this study was to explore whether noradrenaline mediates this process. Chicks were trained on a strongly-reinforced single-trial passive avoidance task involving discrimination between two coloured beads. Intracerebral administration of the protein synthesis blocker, anisomycin, revealed that a phase of memory formation sensitive to arousal levels was extended by approximately 35 min following exposure to the complex rhythm stimulus. Administration of 2,4-dinitrophenol showed that this extension occurred during phase B of intermediate-term memory. Finally, a higher dose of the beta-adrenergic receptor antagonist, propranolol, was required to inhibit long-term memory in the presence of the auditory stimulus than in its absence. These findings suggest that the memory-enhancing effects of the complex rhythm stimulus may be mediated by noradrenaline, possibly via an increase in physiological arousal.

Variations in Intensity and Frequency Moderate the Facilitative Effects of a Complex Rhythm Stimulus on Long-Term Memory Consolidation in the Day-Old Chick (Callus gallus)

The authors have previously shown that exposure to 1 min of a complex, but not an isochronous, rhythm stimulus facilitates long-term memory consolidation in chicks (Gallus gallus) trained on a passive-avoidance task (S. R. Toukhsati & N. S. Rickard, 2001). The acoustic parameters of this stimulus were explored further in the current study. Retention was found to be best facilitated when the complex rhythm stimulus was presented at intensities between 5 and 15 dBA above background laboratory noise levels and at a frequency of 1 kHz. Removal of an accent from the stimulus did not moderate the effect. These findings provide confirmation that memory in an avian species can be facilitated by exposure to a complex rhythm stimulus and suggest that pattern repetition may be an important feature of this effect.

Exposure to a rhythmic auditory stimulus facilitates memory formation for the passive avoidance task in the day-old chick

Previous research regarding the beneficial effects of auditory stimuli on learning and memory in humans has been inconsistent. In the current study, day-old chicks were used to reduce the impact of individual differences on responses. Chicks were trained on a passive avoidance task and exposed to various auditory stimuli. Exposure to a complex rhythmic sequence for 1 min strongly facilitated chicks' long-term memory. The optimal time of presentation of the stimulus was between 10 min before and 20 min after training. Moreover, the enhancing effect was not generalized to the other auditory stimuli tested. It is suggested that this effect may be due to arousal because arousal hormones are critical to long-term memory formation. This study indicates that the temporal characteristics and type of stimulus may be important considerations when investigating the effects of auditory stimuli on cognitive functioning.