Bostwick, John

Diversity initiatives in U.S. medical education, following the passage of the Civil Rights Act of 1964, were geared toward increasing the representation of African Americans—blacks born in the United States whose ancestors suffered under slavery and Jim Crow laws. Over time, blacks and, subsequently, underrepresented minorities in medicine (URMs), became a proxy for African Americans, Puerto Ricans, Mexican Americans, and Native Americans, thus obscuring efforts to identify and recruit specifically African Americans. Moreover, demographic shifts resulting from the recent immigration of black people from Africa and the Caribbean have both expanded the definition of “African American medical students” and shifted the emphasis from those with a history of suffering under U.S. oppression and poverty to anyone who meets a black phenotype. Increasingly, research indicates that African American patients fare better when their physicians share similar historical and social experiences. While all people of color risk discrimination based on their skin color, not all have the lived experience of U.S.-based, systematic, multigenerational discrimination shared by African Americans. In the high-stakes effort to increase URM representation in medical school classes, admissions committees may fail to look beyond the surface of phenotype, thus missing the original intent of diversity initiatives while simultaneously conflating all people of color, disregarding their divergent historical and social experiences. In this Perspective, the authors contend that medical school admissions committees must show greater discernment in their holistic reviews of black applicants if historical wrongs and continued underrepresentation of African Americans in medicine are to be redressed.

Purpose Physician suicide rates are reportedly higher than those of the general population, but medical student suicide rates are not well studied. It is difficult to determine whether physician suicide rates can be predicted by medical student risk factors for suicide and difficult to identify those risk factors without knowing medical student suicide rates. The authors systematically reviewed the literature to collate data on medical student suicide rates. Method The authors searched the PubMed, Web of Science, and Library of Congress databases for papers published in any language before November 11, 2017. They identified 3,429 papers; after the initial screening process, they assessed 82 full-text articles for eligibility. Twelve ultimately met the full inclusion criteria; meta-analysis was not possible. Data regarding medical student suicide numbers and rates were extracted and compared with contemporaneous general population suicide rates using public epidemiological data, when available. Results Medical student suicide rates were infrequently reported in the historical and international literature, and data collection techniques were inconsistent. Generally, U.S. medical student suicide rates were lower than those of the contemporaneous general population. Proportionate mortality of medical students (number of deaths by a particular cause such as suicide divided by total number of deaths) was not reported in the literature. Conclusions Gaps exist in knowledge of medical student suicide rates, risk factors, and targets for intervention. Significant barriers have impeded information collection. Yet, more comprehensive data collection is needed to understand suicide risk in this population and to implement and improve effective intervention strategies.

Pain in cancer therapy is a common condition and there is a need for new options in therapeutic management. While phytochemicals have been proposed as one pain management solution, knowledge of their utility is limited. The objective of this study was to perform a systematic review of the biomedical literature for the use of phytochemicals for management of cancer therapy pain in human subjects. Of an initial database search of 1,603 abstracts, 32 full-text articles were eligible for further assessment. Only 7 of these articles met all inclusion criteria for this systematic review. The average relative risk of phytochemical versus control was 1.03 [95% CI 0.59 to 2.06]. In other words (although not statistically significant), patients treated with phytochemicals were slightly more likely than patients treated with control to obtain successful management of pain in cancer therapy. We identified a lack of quality research literature on this subject and thus were unable to demonstrate a clear therapeutic benefit for either general or specific use of phytochemicals in the management of cancer pain. This lack of data is especially apparent for psychotropic phytochemicals, such as theCannabisplant (marijuana). Additional implications of our findings are also explored.

BACKGROUNDMunchausen syndrome by proxy (MSBP), more formally known as factitious disorder imposed on another, is a form of abuse in which a caregiver deliberately produces or feigns illness in a person under his or her care so that the proxy will receive medical care that gratifies the caregiver. Although well documented in the pediatric literature, few cases of MSBP with adult proxies (MSB‐AP) have been reported. This study reviews existing literature on MSB‐AP to provide a framework for clinicians to recognize this disorder.METHODSWe searched Ovid MEDLINE, Ovid EMBASE, PubMed, Web of Knowledge, and PsychINFO, supplemented by bibliographic examination.RESULTSWe identified 13 cases of MSB‐AP. Perpetrators were caregivers, most (62%) were women, and many worked in healthcare. The age range of the victims was 21 to 82 years. Most were unaware of the abuse, although in 2 cases the victim may have colluded with the perpetrator. Disease fabrication most often resulted from poisoning.CONCLUSIONSMSB‐AP should be included in the differential diagnosis of patients presenting with a complex constellation of symptoms without a unifying etiology and an overly involved caregiver with suspected psychological gain. Early identification is necessary so that healthcare providers do not unknowingly perpetuate harm through treatments that satisfy the perpetrator's psychological needs at the proxy's expense. Journal of Hospital Medicine 2015;10:32–35. © 2014 Society of Hospital Medicine

Summary Objective We aimed to assess the prevalence of impulse control disorders ( ICD s) in patients with prolactin‐secreting adenomas treated with dopamine agonists ( DA s), to identify associated factors and to compare it with a group of patients with nonfunctioning pituitary adenoma. Subjects, Design and Measurement In a postal survey, 77 patients from Group A (patients with prolactinomas and present or past use of DA s) and 70 patients from Group B (patients with nonfunctioning pituitary adenoma and no history of DA therapy) responded to a questionnaire on compulsive shopping, pathologic gambling, hypersexuality and punding. Associated clinical information was obtained through the survey and review of medical electronic records. Results The total ICD prevalence was 24·68% in Group A and 17·1% in Group B ( P = 0·31). Group A had an increased rate of hypersexuality ( P = 0·03). Subgroup analysis revealed that men in Group A had a significantly increased frequency of total ICD s when compared with men in Group B (27·7 vs 3·7%, P = 0·01). No differences in rates of total ICD s were found between women of Groups A and B (20 vs 25·6%, P = 0·78). No association with type, dose or duration of treatment with DA was noted. Conclusions Males with prolactinomas treated with DA s were 9·9 times more likely to develop an ICD than their counterparts with nonfunctioning pituitary adenomas. Until prospective studies on the relationship of DA use in patients with prolactinoma and ICD s are available, the authors propose that patients with prolactinoma be forewarned of possible ICD development with DA therapy.