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With specific tasks to fulfill, physicians often interact superficially with patients and their families to provide health care in the form of diagnosis and treatment. They miss so-called hallway conversations that may contain important information about the patient and family’s mental and social well-being. How, then, are they able to comprehensively address the more cryptic effects of cancer therapy that are not directly related to their patient’s physical health? In this study, a team of pre-clinical medical students analyzed 120 narrative journals written over an 11-year period by 119 3rd and 4th -year medical students who shadowed patients and their families in the pediatric hematology/oncology department of an academic medical center. These students did not fulfill clinical duties but learned about the cancer experience by shadowing pediatric patients and their families. The goal of this narrative study was to analyze these journals for content that revealed experiences of patients and their families that are not necessarily recognized by the healthcare team. These students were often involved in the most intimate moments of the cancer journey: receiving bad news, witnessing a child’s pain, and dealing with the death of a loved one. These experiences allowed the students to describe reactions that are often unobserved using narrative writing. With this information, multi-faceted treatment plans that go beyond the physical health of the child can be developed that incorporate the more obscure psychosocial, mental, and emotional health needs. This narrative style may also serve as a novel strategy for future clinical rotations.

Over the course of medical school, students’ optimism and hopefulness often devolve into a cynical view of medicine that continues throughout clinical rotations and beyond (Neumann et al., Acad Med 86(8):996–1009, 2011). Here, we present a qualitative evaluation of a novel immersive elective in pediatric psycho-oncology coupled with narrative medicine and its impact on students. Participants were third- and fourth-year medical students who were relieved of traditional clinical duties. Alternatively, they shadowed pediatric cancer patients, keeping narrative journals of their observations and insights. A trained team of pre-clinical medical students and faculty conducted a retrospective analysis of 120 journals written between 2008 and 2019. They compared recurring concepts to assess how blending experiential learning and reflective writing influenced the attitudes and behaviors of students. Consistent themes emerged related to developing a rich understanding of patient experiences, a humanistic appreciation of the context of illness, the ability to meaningfully reflect on insights to critically ill children, and an appreciation for the unique learning opportunity. Additionally, families expressed gratitude for the students’ attentiveness to their emotional needs. By the conclusion of the elective, most students discovered that they had reignited their intrinsic empathic behaviors and were provided with beneficial insights that they believed would continue into future rotations. Experiential teaching methods paired with narrative reflection may be a valuable and therapeutic tool to learn the intricacies of the patient perspective, with the potential to enhance humanism in students during a critical time in their medical training when empathy tends to drift. Longitudinal and quantitative studies are warranted to better understand the degree and duration of specific benefits.

In critical care units, distressing events related to patient and family-centered care can influence job dissatisfaction and emotional distress.1-8 Strategies for processing difficult incidents are limited, creating a need for standardized real-time debriefing tools. This study evaluated an innovative nurse-led program that was developed and piloted in one acute care unit of a large academic medical center. An evidence-based practice nurse-led debriefing process provided a sequential process for facilitation of an interdisciplinary group after the occurrence of a distressing event. Throughout a 2-year period, 104 real-time debriefings (>380 staff participation) took place. Emergent situations precipitated the most debriefings followed by disruptive patient/family behavior. Over 80% of the participants affirmed the debriefing process was beneficial, assisted them in coping with the traumatic event, and recommended this type of debriefing to others. These results show that members of an interdisciplinary team will engage in a brief (∼10 minute) nurse-led debriefing program when offered the opportunity to do so, and that this intervention was successful beyond the acute care unit where it originated.

Background The ANA Code of Ethics for Nurses, regularly revised since 1896, may not provide guidance in an era of pandemic and sociopolitical unrest. Purpose This study explored whether the Code of Ethics comprehensively address current nursing challenges. Methods 23 nurses participated in six Zoom focus groups to discuss whether provisions were applicable to their current practice. An iterative approach was used to review transcripts independently and then merge findings to identify ethical themes. Findings Provisions 4, 6, and 8 were most relevant. None of the provisions addressed the guilt secondary to isolating patients from support systems and not being “on the front lines” of COVID care. Discussion The co-occurring crises of COVID-19 and social unrest created an ethical crisis for many nurses. The Code of Ethics provided a useful guide for framing discussion and formulating strategies for change, but did not eliminate distress during a time of novel challenges.

Background: Irritability, a common behavioral problem for school-aged children, is often first assessed by primary care providers, who manage about a third of mental health conditions in children. Until recent changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM), irritability was often associated with mood disorders, which may have led to increases in bipolar disorder diagnosis and prescription of mood stabilizing medication. Objective: Our aim was to explore differences between the approaches psychiatric and primary care providers use to assess irritability. Methods: A single trained interviewer conducted detailed interviews and collected demographic data from a homogeneous group of physicians that saturated with a sample size of 17 pediatric, family medicine, and psychiatric providers who evaluate and treat school-aged children. Qualitative and quantitative data were collected and analyzed. Results: In general, primary care providers chose to refer children with irritability to mental health specialists when medication management became complex, while the psychiatric providers chose behavior modification and parent education strategies rather than medications. The psychiatric group had a significantly higher caseload mix, prior experience with irritability, and more confidence in their assessment capabilities. There was lack of continuing medical education about irritability in all groups. Conclusion: This preliminary study highlights the importance of collaboration between primary care and subspecialties to promote accurate assessment and subsequent treatment of school-aged children with irritability, who can represent a safety concern for self and others. More research is needed to establish an efficient method of assessing and managing irritability in primary care and better utilization of specialists.

Background: Fruit and vegetable prescription (FVRx) programs provide “prescriptions” for produce, but increased access to nutritional food may be insufficient for long-term behavior change. Purpose: We integrated nutritional education into an FVRx program at a farmers' market and community garden at Penn State Medical Center by pairing medical student “mentors” with 4 families with overweight/obese children. Methods: Each head of household completed a presurvey that included basic demographic information, as well as a question about barriers to healthy eating. Families made up to 4 visits to the market with mentors, during which students discussed and documented produce utilization. A 1-hour focus group with mentors was conducted and transcribed. Thematic analysis was performed on qualitative data. Results: Two families completed all visits. On average, families spent 32 minutes at the market/garden per visit, had expenditures of $40.68, and reported one weekly produce item going unused. Families valued o...

Objective To determine how primary care versus specialist practitioners assess and treat school-aged children with irritability. Methods Seventeen providers from family medicine, pediatrics, and psychiatry participated in in-depth interviews from June to August 2016 about the process they use to evaluate irritability. Data on demographic traits and measures of confidence were also collected. Results Primary care (family medicine and pediatrics) participants expressed frustration over the lack of time and specialized knowledge they had to accurately assess children with irritability, even though they were often the first clinician consulted when problems arose. There were clear and sometimes contradictory differences between how practitioners with a general versus specialized practice assessed mental health status in the clinic setting. Input on treatment approaches revealed that medication prescription was more common by primary care participants, and therapy was preferred by the psychiatry participants. Conclusions Overall, family medicine and pediatric practitioners were significantly less confident in their ability to evaluate mental health status, while child and adolescent psychiatry participants were supportive of having more initial triage and possible treatment occur at the primary care level, suggesting a need for more training about childhood irritability in the primary care setting.

Background Childcare providers are often “first responders” for suspected child abuse, and how they understand the concept of “reasonable suspicion” will influence their decisions regarding which warning signs warrant reporting.

The goal of this article is to describe the concept of irritability in children and youth, which has been revisited in the DSM-5. Traditionally, this behavior has been more commonly associated with mood disorders, which may account for the rising incidence of bipolar disorder diagnosis and overuse of mood-stabilizing medications in pediatric patients. While not predictive of mania, persistent nonepisodic irritability, if undetected, may escalate to violent behavior with potentially serious outcomes. It is therefore important to educate clinicians about how to accurately assess irritability in pediatric patients. Language: en