Exploring the challenges and ethical requirements of medical sciences education during COVID-19: a qualitative study

The controversial role of ethics in clinical education and its ability to draw the attention of a large audience is inevitable. The issues and challenges of the COVID-19 pandemic have transformed the clinical education environment. This study was conducted to explore the challenges and ethical requirements of medical sciences education during the COVID-19 pandemic in 2020. The study was qualitative research and the instrument was a semi-structured interview. The participants included faculty members of the basic and clinical Sciences at Iran University of Medical Sciences. After 16 rounds of interviews, theoretical saturation was achieved. Qualitative data were analysed using conventional content analysis, which resulted in 81 preliminary codes and 28 sub-categories. Finally, two themes of "ethical challenges" and "ethical requirements", and 10 categories were achieved. The sub-categories were consisted of "being patient-centred", "social accountability of curriculums", "ethical challenges of the clinical environment", "the poor performance of the clinical faculty members and students", "being justice-centred", "raising awareness", "observing clinical research ethics", "preservation and promotion of mental health", "patient confidentiality", and "respect for individuals". We hope the ethical challenges in medical education that were created due to the emergence of Covid-19 can be reduced and eliminated by defining a framework for ethical requirements.

Priorities for research in child and adolescent anxiety and depression: a priority setting partnership with youth and professionals

Background: A starting point for evaluating the effectiveness of treatments should be to identify evidence gaps. Furthermore, such evaluations should consider the perspectives of patients, clinicians and carers to ensure relevance and potentially influence future research initiatives. Methods: Our approach, inspired by the James Lind Alliance methods, involved three steps. First, we performed a document analysis by identifying interventions and outcomes in two recently published overviews of systematic reviews, which summarised the effects of interventions for anxiety and depression in children and adolescents. Second, we surveyed children and adolescents with personal experiences of depression or anxiety as well as clinicians, and asked them to suggest treatments and outcomes associated with uncertainty. Finally, we facilitated a consensus process where clinicians and youth mental health patient representatives were invited to prioritise research uncertainties in separate consensus processes. Results: The survey included 674 respondents who reported a total of 1267 uncertainties. Independent coding by four investigators revealed 134 suggestions for treatments of anxiety, 90 suggestions for treatments of depression, 84 for outcomes of interventions for anxiety and 71 suggestions for outcomes of interventions for depression. Two separate priority setting workshops with eight clinicians and ten youth resulted in four independent top ten priority lists. Conclusion: Top ten lists of treatments and outcome domains of anxiety and depression in children and adolescents was identified by youth and clinicians. The results may influence the research agenda, and ultimately benefit patients.

The South East Texas Geriatric Workforce Enhancement Program: Reach, Teach, Innovate

Through collaboration between academic and community partners, the South East Texas Geriatric Workforce Enhancement Program (SETx GWEP) aims to promulgate the 4Ms framework via a range of educational initiatives. The faculty and audience is interprofessional and diverse, representing the residents of South East Texas. Specific initiatives focus on Alzheimer’s disease and related dementias, elder abuse, geriatric mental health, patient priorities, transitions of care, and geriatric dental care. Training modalities include online modules, Project ECHO sessions, webinars, discussion forums, and simulation. During the COVID19 pandemic the SETx GWEP adapted to meet the needs of its stakeholders, including increasing the number of online activities, hosting town hall meetings, and developing training to address the impact of COVID19 on the older adult population. The SETxGWEP trained over 1000 people in 2020. To address healthcare disparities among older adults, SETx GWEP developed training on the practice of cultural humility in older adult care.

130 Adaptation of IHI Joy-in-Work framework to reduce burnout among postgraduate trainees

Primary Subject area Physician Wellness Background Physician burnout is a psychological phenomenon with serious and pervasive consequences on physicians’ mental health, patient safety, and quality of care. Burnout is multifactorial, originating from systemic issues, organizational culture and individual coping skills. Burnout is more common in residency training. Residents experience burnout more intensely due to lack of autonomy, self-efficacy and exposure to mistreatment. Residents are also frontline workers and the future healthcare givers. Organization-led interventions mostly focus on building resilience and mindfulness without addressing systems-level issues. In our study, we attempted to shift the paradigm to address system-level concerns first. We aimed to adapt Joy-in-Work: a quality improvement framework developed by the Institute for Healthcare Improvement (IHI). This program allows residents to identify system problems that are meaningful to them and empower them to work as a team, taking back their autonomy and self-efficacy. Objectives To demonstrate that Joy-in-Work can be adapted effectively into a residency training program to reduce burnout and improve psychological safety among residents. Design/Methods The four steps of Joy-in-Work were implemented for residents in a level 3 neonatal intensive care unit. Residents engaged in “what matters” conversations through survey and group meetings, and identified impediments to Joy-in-Work. By applying QI methodology, residents identified priority interventions to eliminate impediments. Finally, the effectiveness of interventions was evaluated. Primary outcomes included prevalence of burnout and psychological safety; secondary outcomes assessed control over workload, and organizational culture. An IHI 12-item questionnaire was administered at baseline and after the interventions. To assess sustainability, a survey was also conducted one year after the implementation. We assessed adherence to interventions, nurse practitioners’ satisfaction and residents’ workload indicators. Results Through the implementation of Joy-in-Work, residents identified autonomy and work life integration as priorities. Stakeholders developed two interventions: change call schedule according to residents’ preferences and earlier afternoon handover time. Burnout was 77.8%, 50% and 75% for three survey periods respectively. Psychological safety increased consistently from 16.7% to 37.5% to 43.8%. Lack of control over workload dropped sharply from 72.2% to 12.5%, with a rebound to 56.3%. Most secondary outcomes demonstrated a similar pattern of positive change initially with reversion to baseline. Conclusion We demonstrated that Joy-in-Work is successfully adaptable into a residency setting. Implementation through residents’ engagement and empowerment can decrease burnout and improve psychological safety significantly. The process itself was likely the key driver for achieving positive outcomes rather than the actual interventions. Sustainability remains a key issue that requires systems support.

Prevalence and Workplace Drivers of Burnout in Cancer Care Physicians in Ontario, Canada

PURPOSE: Provider well-being has become the fourth pillar of the quadruple aim for providing quality care. Exacerbated by the global COVID-19 pandemic, provider well-being has become a critical issue for health care systems worldwide. We describe the prevalence and key system-level drivers of burnout in oncologists in Ontario, Canada. METHODS: This is a cross-sectional survey study conducted in November-December 2019 of practicing cancer care physicians (surgical, medical, radiation, gynecologic oncology, and hematology) in Ontario, Canada. Ontario is Canada's largest province (with a population of 14.5 million), and has a single-payer publicly funded cancer system. The primary outcome was burnout experience assessed through the Maslach Burnout Inventory. RESULTS: A total of 418 physicians completed the questionnaire (response rate was 44% among confirmed oncologists). Seventy-three percent (n = 264 of 362) of oncologists had symptoms of burnout (high emotional exhaustion and/or depersonalization scores). Significant drivers of burnout identified in multivariable regression modeling included working in a hectic or chaotic atmosphere (odds ratio [OR] = 15.5; 95% CI, 3.4 to 71.5; P < .001), feeling unappreciated on the job (OR = 7.9; 95% CI, 2.9 to 21.3; P < .001), reporting poor or marginal control over workload (OR = 7.9; 95% CI, 2.9 to 21.3; P < .001), and not being comfortable talking to peers about workplace stress (OR = 3.0; 95% CI, 1.1 to 7.9; P < .001). Older age (≥ 56 years) was associated with lower odds of burnout (OR = 0.16; 95% CI, 0.1 to 0.4; P < .001). CONCLUSION: Nearly three quarters of participants met predefined standardized criteria for burnout. This number is striking, given the known impact of burnout on provider mental health, patient safety, and quality of care, and suggests Oncologists in Ontario may be a vulnerable group that warrants attention. Health care changes being driven by the COVID-19 pandemic provide an opportunity to rebuild new systems that address drivers of burnout. Creating richer peer-to-peer and leadership engagement opportunities among early- to mid-career individuals may be a worthwhile organizational strategy.

Thematic Analysis of Military Medical Ethics Publications From 2000 to 2020—A Bibliometric Approach

ABSTRACT Introduction There has been external criticism of the compliance of military health personnel with internationally agreed principles in military medical ethics (MME). In response, a number of authors have called for clarity on the principles and topics within the domain of MME. This complements an increased acknowledgment of the need for education in MME for military health personnel. Our paper utilizes bibliometric techniques to identify key themes in MME to inform the development of a curriculum for this subject. Materials and Methods We designed a search strategy to find publications over the period January 1, 2000-December 31, 2020 in the domain of MME from the three databases, PubMed, Web of Science, and Scopus, using the search string (ethic* OR bioethics* OR moral*) AND military AND (medic* OR health*). We obtained a total of 1,115 publications after duplication removal. After exclusion based on topic, year, and study design, we analyzed a total of 633 publications using Scopus’s embedded analysis tool and the software VOSViewer. We generated a co-occurrence word map from the abstracts of each of the publications. We deduced themes of MME based on the clusters shown in the word map, and we categorized each publication into one of these themes to analyze the change of themes over time. Results We observed a 10-fold increase in annual publications on MME between 2000 and 2020. The majority of papers were written by U.S. (72%) and UK (13%) authors, although a total of 15 countries were represented. After using VOSViewer to identify co-occurring keywords in titles and abstracts from these publications, nine themes were identified: biomedical research, care to detained populations, disaster/triage, mental health, patient-focused foundations, technology, dual loyalty, education/training, and frameworks. The relative proportion of each of these themes changed over the study period, with mental health being dominant by the end. Conclusions This study has identified key themes that might inform the development of a curriculum for teaching MME. It is noticeable that the majority of themes cover MME from the perspective of professional practice on military operations; noting, the research and technology themes also pertain to the generation of knowledge for military operations. There were a limited number of publications covering practice in the non-deployed or garrison settings, and these were codified under the themes of “framework” and “dual loyalty”. The results are skewed toward English-speaking countries and exclude non-academic publications. Further work will search for other open-source information and non-English publications. To our knowledge, this exploratory bibliometric analysis on MME in the academic literature is the first of its kind. This article has demonstrated the use of bibliometric techniques to evaluate the evolution of knowledge in MME, including the identification of key themes. These will be used to support further work to develop a curriculum for the teaching of MME to military medical audiences.

Mental Health, Resilience and Sports Activity in the Initial Phase of The First COVID-19 Lockdown in Germany

Background Quarantine and social-distancing measures during the COVID-19 pandemic situation resulted in a radical change in lifestyle behaviors. While the reduction of total physical activity is assumed to negatively impact psychological health (higher stress and anxiety levels), regular sports activity during lockdown conditions has beneficial effects on health. Mechanisms are however unclear. The present analysis therefore examined the associations of sports activity with mental health, and assessed whether this is due to a direct effect on experiencing positive emotions and mental health, due to a stress-buffering mechanism, and/or through protecting/enhancing resilience. Methods An online survey, accessible from April 7th to April 30th 2020, gathered data on sports activity (Physical Activity, Exercise, and Sport Questionnaire, BSA), mental health (Patient Health Questionnaire-4, PHQ-4, WHO Wellbeing Index, WHO-5), momentary stress (single item), and resilience (i.e. feeling determined, cheerful, content, and being interested in the things one is doing). The final data set comprised 742 subjects including 534 (72.0%) women and ranging in age from 16 to 83 years (mean: 28.13 ± 11.46 years). Results Across all participants, sports activity was related to higher wellbeing and resilience but lower affective psychopathology. Importantly, all coefficients were below 0.2 indicating only small-sized associations. Moderation analyses confirmed a direct effect of sports activity on affective symptoms and wellbeing. Stress-buffering effects were not confirmed for either outcome but a resilience-protecting effect was seen for both wellbeing and affective psychopathology. Conclusions During the initial phase of the first COVID-19 lockdown, sports activity was associated with better mental health and wellbeing. Besides this direct effect, there was also evidence for a resilience-protecting effect of sport. The assumed stress-buffering effect could not be confirmed. Present findings indicate resilience-protective mechanisms to be a major contributor to sports beneficial effects on mental health during quarantine. Though, results from this cross-sectional, predominantly female, and convenience sample study must be confirmed in more diverse samples.

Investigating Patient Interactions with an Automated Conversational Agent Delivering Pre-test Genetics Education: A Descriptive Study (Preprint)

BACKGROUND Cancer genetic testing has grown exponentially in the past decade in its use for quantifying hereditary cancer risk, while also its use for targeting treatment and care. With this continued growth and shortage of healthcare workforces, there is a need for automated strategies that provide high quality genetics services to patients in order to reduce clinical demand on genetics providers. Conversational agents have shown promise in managing mental health, patient pain management, and chronic conditions and are increasingly being used in cancer genetic services. However, research on how these agents are utilized by patients is limited. OBJECTIVE Therefore, our current study aim was to assess users’ interactions with a conversational agent for pre-test genetics education prior to genetic testing. METHODS The conversational agent provided scripted content similar to what is delivered in a pre-test genetic counseling visit for cancer genetic testing. Outside of a core set of information delivered to all patients, users were able to navigate within the chat to request additional content in areas of interest. An AI preprogrammed library was also established to allow users to ask open-ended questions of the conversational agent. Descriptives statistics were used for quantitative measures and thematic analysis was used for qualitative responses. RESULTS Of 93 National Comprehensive Cancer Network guidelines eligible patients offered access to the conversational agent, 36 started the chat (38.7%), with 30 completed the chat (32.3%). Once a participant completed a chat, a transcript of the interaction was developed for the research team, from which we extracted the following data and compiled results. The majority of users who completed the chat indicated that they wanted to continue with genetic testing (70%, n=21); 30% were unsure (n=9) and no patients declined moving forward with testing. Those who decided to test spent an average of 10 minutes on the chat (SD=2.57), selected an average of 1.2 additional pieces of information, and generally did not ask open-ended questions. Those who were unsure spent 4.0 more minutes on average (mean=14.1, SD=7.41, P=.03) with the chat, selected an average of 2.9 additional pieces of information, and asked at least 1 open-ended question. CONCLUSIONS Our results indicate that the chat met the information needs of the majority of patients considering cancer genetic testing. However, a subset of patients may need additional education or interpersonal support prior to making a testing decision. Such high-information seeking patients may need additional support from a clinical provider to make a testing decision. Genetic counseling team members should follow up with patients who have additional questions and concerns to alleviate any remaining concerns. Therefore, conversational agents have the potential to be a scalable alternative for pre-test genetics education, reducing clinical demand on genetics providers.

Considerations for Acute and Emergent Deployed Mental Health Patient Management and Theater Transports: A Scoping Review

ABSTRACT Background Although combat stress and psychiatric casualties of war have consistently contributed to the need for deployed patient transport to higher echelons of care, little is known regarding specific evidence-based strategies for providing psychological support and optimal transport interventions for warriors. Study Objective The purpose of this scoping review is to map existing literature related to considerations for deployed mental health patient transport. The review’s primary aims are to identify the existing scientific research evidence, determine research and training gaps, and recommend critical areas for future military research. Methods We used Arksey and O’Malley’s six-stage scoping review methodological framework (identify the research question, identify relevant studies, select studies, chart data, report results, and consultation). Using a systematic search strategy, we evaluated peer-reviewed literature from five databases (PubMed, CINAHL, PsycINFO, Web of Science, and Embase) and gray literature from the Defense Technical Information Center. All publications were independently screened for eligibility by two researchers during three review rounds (title, abstract, and full text). Results We identified 1,384 publications, 61 of which met our inclusion criteria. Most publications and technical reports were level IV evidence and below, primarily retrospective cohort studies and epidemiologic surveillance reports. Few rigorously designed studies were identified. Eight research themes and a variety of research and critical training gaps were derived from the reviewed literature. Themes included (1) characterizing mental health patients aeromedically evacuated from theater; (2) in-flight sedation medications; (3) need for aeromedical evacuation (AE) in-theater education, training, and guidelines for staff; (4) epidemiological surveillance of AE from theater; (5) mental health management in deployed settings; (6) suicide-related event management; (7) transport issues for mental health patients; and (8) psychological stressors of AE. Research is needed to establish clinical practice guidelines for mental health condition management in theater and throughout the continuum of en route care.