Warnings in early narrative assessment that might predict performance in residency: signal from an internal medicine residency program

Introduction Narrative assessment data are valuable in understanding struggles in resident performance. However, it remains unknown which themes in narrative data that occur early in training may indicate a higher likelihood of struggles later in training, allowing programs to intervene sooner. Methods Using learning analytics, we identified 26 internal medicine residents in three cohorts that were below expected entrustment during training. We compiled all narrative data in the first 6 months of training for these residents as well as 13 typically performing residents for comparison. Narrative data were blinded for all 39 residents during initial phases of an inductive thematic analysis for initial coding. Results Many similarities were identified between the two cohorts. Codes that differed between typical and lower entrusted residents were grouped into two types of themes: three explicit/manifest and three implicit/latent with six total themes. The explicit/manifest themes focused on specific aspects of resident performance with assessors describing 1) Gaps in attention to detail, 2) Communication deficits with patients, and 3) Difficulty recognizing the “big picture” in patient care. Three implicit/latent themes, focused on how narrative data were written, were also identified: 1) Feedback described as a deficiency rather than an opportunity to improve, 2) Normative comparisons to identify a resident as being behind their peers, and 3) Warning of possible risk to patient care. Discussion Clinical competency committees (CCCs) usually rely on accumulated data and trends. Using the themes in this paper while reviewing narrative comments may help CCCs with earlier recognition and better allocation of resources to support residents’ development.

The Experience of Maltreatment in Young Children Whose Mothers Have Borderline Personality Disorder: Reflections in Their Narrative Representations

Child maltreatment is an etiological factor in borderline personality disorder (BPD), which may be transmitted to the children of mothers with BPD. We assessed maltreatment in 36 children aged 4–7 whose mothers have BPD and in 34 normative comparisons. Children whose mothers have BPD were more likely to have experienced sexual abuse, physical abuse, and neglect than were normative comparisons. Mothers’ self-reported borderline features were significantly correlated with children's maltreatment. Neglect was associated with mothers’ affective instability, identity disturbance, negative relationships, and self-harm; sexual abuse was associated with mothers’ identity disturbance, and negative relationships; and physical abuse was associated with mothers’ self-harm. Maltreatment mediated the relationship between all four of mothers’ borderline features and children's narrative representations of the caregiver–child relationship, which included fear of abandonment, role reversal, and mother–child relationship expectations. The authors discuss results in the context of risk for developing BPD in early adulthood and early preventive interventions targeting children's representations.

An Operational Definition of ‘Abnormal Cognition’ to Optimize the Prediction of Progression to Dementia: What Are Optimal Cut-Off Points for Univariate and Multivariate Normative Comparisons?

Background: In neuropsychology and neurology, there is no consensus on the definition of abnormal cognition. Objective: To operationally define ‘abnormal cognition’ for optimally predicting progression to dementia in a memory clinic sample, and to test whether multivariate profile analysis of cognitive test results improves this prediction compared to standard clinical evaluation. Methods: We used longitudinal data from 835 non-demented patients of the Amsterdam Dementia Cohort. For 10 cognitive measures at baseline, we determined which number of abnormal tests and which magnitude of score deviations best predicted progression. Results: Predictive ability for progression to dementia of one, two, and three abnormal test scores out of 10 is highly similar (Cox hazard ratios: 3.7–4.1) provided cut-off values are adapted appropriately. Cut-offs have to be less stringent if the number of abnormal tests required increases: the optimal cut-off is z < –1.45 when one deviating score is required, z < –1.15 when two abnormal tests are required, and z < –0.70 when three abnormal tests are required. The profile analysis has similar predictive ability at the cut-off of p < 0.22 (hazard ratio 3.8). A likelihood ratio test showed that this analysis improves prediction of progression to dementia when added to standard clinical evaluation (p < 0.001). Conclusion: Abnormal cognition may be defined as one, two, or three abnormal test scores out of 10 if the magnitude of score deviations is adapted accordingly. An abnormal score profile predicts decline to dementia equally well, and improves the prediction when used complimentary to standard clinical evaluation.

Winter is coming: age and early psychological concomitants of the Covid-19 pandemic in England

Purpose This paper aims to demonstrate early psychological concomitants of the Covid-19 pandemic in England on a sample of younger and older people. Design/methodology/approach A cross-sectional quantitative questionnaire (n = 1608) was conducted on the Prolific website. Participants completed the PERMA Scale (Flourishing), the four Office of National Statistics (ONS4) Well-being Questions, the Clinical Outcomes Measure in Routine Evaluation (CORE-10) and the short University of California Los Angeles Brief Loneliness Scale. Findings Data were gathered on March 18, 2020, near the start of the Covid-19 pandemic. This study looks at the effects of the developing pandemic on younger participants (18 to 25 years, n = 391) and older participants (60 to 80 years, n = 104). Flourishing levels for older participants were significantly higher (M = 107.96) than for younger participants (M = 97.80). Younger participants scored significantly higher on the ONS4 for anxiety and lower than the older participants for happiness, life satisfaction and having a worthwhile life. Levels of psychological distress (CORE-10) were also significantly lower for older participants (M = 9.06) than for younger participants (M = 14.61). Finally, younger participants scored significantly higher on the Brief UCLA Loneliness Scale (M = 6.05) than older participants (M = 4.64). Research limitations/implications From these findings, the Covid-19 pandemic was having a significantly greater effect on younger people in England, less than one week before the UK went into “lockdown”. Scores for both the Younger and Older groups on all the study measures were worse than normative comparisons. The study had no specific measure of Covid-19 anxiety, but nor was one available at the time of the survey. Practical implications This study suggests that younger people (18 to 25) may be a more vulnerable group during the Covid-19 pandemic than many may have realized. Social implications As a recent British Psychological Society report concluded, there is a lot of untapped wisdom amongst older groups in society. Originality/value This is one of the earliest studies to look at psychological distress before England went into “lockdown.”

TO004IMPACT OF RENAL TRANSPLANT ON COGNITIVE FUNCTION AMONG ESRD PATIENTS ON DIALYSIS

Background and Aims Kidney transplantation can help in mitigating neuropsychological (NP) impairments in end-stage renal disease (ESRD). Evidences have shown mixed responses on the the nature of cognitive function in patients who have undergone renal transplantation.Present study looked into the factors impacting cognitive domains and impact post transplant. Method 43 patients who were stable ESRD on thrice a week hemodialysis were investigated 6 months pre and post transplant using a battery of neurophysiological testing assessing attention–concentration, psychomotor ability and memory. Formal kinetic modelling of dialysis delivery ensured adequate renal replacement therapy. Transplant function was assessed on regular interval and following a stable graft function and on stable doses of immunosuppressive medication 6 months post transplant were reassessed Results Within-subject comparisons showed statistically significant improvement in memory performance after kidney transplant. Other NP measures (attention– concentration and psychomotor abilities) showed non-significant improvements. Normative comparisons showed NP impairments on dialysis, which were not apparent after transplant Conclusion These data demonstrate improvements in cognition following kidney TX and emphasize the reversibility of the memory problems evidenced in dialysis

Predicting Progression to Parkinson’s Disease Dementia Using Multivariate Normative Comparisons

Objective: Parkinson’s disease with mild cognitive impairment (PD-MCI) is a risk factor for progression to PD dementia (PDD) at a later stage of the disease. The consensus criteria of PD-MCI use a traditional test-by-test normative comparison. The aim of this study was to investigate whether a new multivariate statistical method provides a more sensitive tool for predicting dementia status at 3- and 5-year follow-ups. This method allows a formal evaluation of a patient’s profile of test scores given a large aggregated database with regression-based norms. Method: The cognitive test results of 123 newly diagnosed PD patients from a previously published longitudinal study were analyzed with three different methods. First, the PD-MCI criteria were applied in the traditional way. Second, the PD-MCI criteria were applied using the large aggregated normative database. Last, multivariate normative comparisons (MNCs) were made using the same aggregated normative database. The outcome variable was progression to dementia within 3 and 5 years. Results: The MNC was characterized by higher sensitivity and higher specificity in predicting progression to PDD at follow-up than the two PD-MCI criteria methods, although the difference in classification accuracy did not reach statistical significance. Conclusion: We conclude that MNCs could allow for a more accurate prediction of PDD than the traditional PD-MCI criteria, because there are encouraging trends in both increased sensitivity and increased specificity. (JINS, 2019, 25, 678–687)