Climate Change Curricula in Family Medicine Residency Programs: Program Directors' Perspectives From a CERA Survey.

BACKGROUND AND OBJECTIVES: Climate change is a major threat to the health of people worldwide. The health care system deals with the immediate health-related effects of climate change and, at the same time, is a major emitter of greenhouse gas. This study aimed to investigate (a) the awareness and perception of climate change among family medicine residency program directors, and (b) the state of climate change education in family medicine residency programs. METHODS: The Council of Academic Family Medicine Educational Research Alliance (CERA) conducted a cross-sectional survey of family medicine program directors in the United States in April 2023. We analyzed anonymous data using descriptive and bivariate statistics. RESULTS: We analyzed responses from 284 family medicine residency program directors (response rate 41.1%). Of these, 56.8% indicated not having any lectures/seminars dedicated to climate change and no plans to introduce such curricula, with considerably higher rates in East South Central United States (92.8%). A majority considered principles of climate change, carbon emissions emitted by the health care system, and discussion of climate change with patients of lesser importance for residency program education. CONCLUSIONS: While climate change is an emerging topic affecting health and the provision of health care worldwide, our study suggests that many family medicine residency programs do not teach about it. Family medicine trainees may not always receive sufficient education about the risks posed to their patients by climate change, which could lead to them having limited knowledge and skills when discussing this topic with their patients in the future.

Association between sociodemographic factors, clinic characteristics and mental health screening rates in primary care.

BACKGROUND: Screening for mental health problems has been shown to be effective to detect depression and initiate treatment in primary care. Current guidelines recommend periodic screening for depression and anxiety. This study examines the association of patient sociodemographic factors and clinic characteristics on mental health screening in primary care. DESIGN: In this retrospective cohort study, electronic medical record (EMR) data from a 14-month period from 10/15/2021 to 12/14/2022 were analyzed. Data were retrieved from 18 primary care clinics from the Corewell Health healthcare system in West Michigan. The main outcome was documentation of any Patient Health Questionnaire (PHQ-4/PHQ-9/GAD-7) screening in the EMR within the 14-month period at patient level. General linear regression models with logit link function were used to assess adjusted odds ratio (aOR) of having a documented screening. RESULTS: In total, 126,306 unique patients aged 16 years or older with a total of 291,789 encounters were included. The prevalence of 14-month screening was 79.8% (95% CI, 79.6-80.0). Regression analyses revealed higher screening odds for patients of smaller clinics (<5,000 patients, aOR 1.88; 95% CI 1.80-1.98 vs. clinics >10.000 patients), clinics in areas with mental health provider shortages (aOR 1.69; 95% CI 1.62-1.77), frequent visits (aOR 1.80; 95% CI, 1.78-1.83), and having an annual physical / well child visit encounter (aOR 1.52; 95% CI, 1.47-1.57). Smaller positive effect sizes were also found for male sex, Black or African American race, Asian race, Latinx ethnicity (ref. White/Caucasians), and having insurance through Medicaid (ref. other private insurance). DISCUSSION: The 14-month mental health screening rates have been shown to be significantly lower among patients with infrequent visits seeking care in larger clinics and available mental health resources in the community. Introducing and incentivizing mandatory mental health screening protocols in annual well visits, are viable options to increase screening rates.

Development and validation of the provider assessed quality of consultations with language interpretation scale (PQC-LI).

OBJECTIVE: With the growing immigrant communities in the western world, there is an urgent need to address language barriers to care, and health disparities as a whole. Studies on limited English proficiency patients (LEP) have focused on patient perspectives of office visits, however little is known about health care provider perspectives of medical visits using interpretive services. We aimed to develop a pragmatic brief questionnaire for assessing providers' views of the quality of communication in outpatient visits with patients with LEP. The questionnaire was validated in a cross-sectional study (n = 99) using principal component analyses (PCA) with oblimin rotation. Internal consistency was analyzed using Cronbach's alpha. RESULTS: Based on theory and literature, a seven-item scale was developed that captures two relevant concepts: (1) Provider - patient interaction during the consultation and (2) perceived quality of translation. The questionnaire was used to assess 99 LEP consultations and demonstrated good feasibility in a clinical setting. PCA revealed the two theory-based components with good factor loadings and internal consistency of α = 0.77. These preliminary results indicate that the questionnaire provides medical professionals with a validated tool to evaluate LEP patient encounters. Further confirmatory validation of the Provider-assessed Quality of Consultations with Language Interpretation (PQC-LI) in larger samples is warranted.

Primary Care Clinicians' Attitude, Knowledge, and Willingness to Address Climate Change in Shared Decision-Making.

BACKGROUND: Climate change poses a threat to the health of people worldwide. Little is known about the awareness of primary care clinicians toward climate change and if they are open and prepared to address climate change issues with their patients. As pharmaceuticals are the main source of carbon emissions in primary care, avoiding the prescription of particular climate-harmful medications is a meaningful contribution to the reduction of greenhouse gases. METHODS: This is a cross-sectional questionnaire survey among primary care clinicians in West Michigan conducted in November 2022. RESULTS: One hundred three primary care clinicians responded (response rate 22.5%). Nearly 1/3 (29.1%) were classified as climate change unaware clinicians who perceived that global warming is not happening, or expressed that it is happening but not caused by human activities or is affecting the weather. In a theoretical scenario on a prescription of a new drug, clinicians tended to prescribe the less harmful drug without discussing options with patients. Although 75.5% of clinicians agreed that climate change aspects have its place in shared decision-making, 76.6% of clinicians expressed a lack of knowledge to advise patients in this regard. In addition, 60.3% of clinicians feared that raising climate change issues in consultations may adversely affect the relationship with the patient. DISCUSSION: Although many primary care clinicians are open to addressing climate change in their working environment and with their patients, they lack knowledge and confidence to do so. In contrast, the majority of the US population is willing to do more to mitigate climate change. Although curricula on climate change topics are increasingly implemented in student education, programs to educate mid- and late-career clinicians are lacking.

Racial disparities in emergency department utilization among patients with newly diagnosed depression.

OBJECTIVE: To test the hypothesis that racial and ethnic minorities have increased emergency department visit rates, despite being established with a primary care provider. METHODS: In this retrospective cohort study, ED visits without hospital admission in a 12-month period among patients with a new primary care provider-issued diagnosis of depression were assessed. Electronic medical record (EMR) data was obtained from 47 family medicine clinics in a large Michigan-based healthcare system. General linear regression models with Poisson distribution were used to predict frequency of ED visits. RESULTS: A total of 4159 patients were included in the analyses. In multivariable analyses, Black / African American race was associated with an additional 0.90 (95% CI 0.64, 1.16) ED visits and American Indian or Alaska Native race was associated with an additional 1.39 (95% CI 0.92, 1.87) ED visits compared to White or Caucasians (null value 0). These risks were only exceeded by patients who received a prescription for a typical antipsychotic drug agent. CONCLUSION: Despite being established patients at primary care providers and having follow-up encounters, Black / African American and American Indian or Alaska Native patients with depression were considerably more likely to seek ED treatment compared to White/Caucasian patients with depression.

Mental Health Screening Differences in Non-English Speaking Patients: Results From a Retrospective Cohort Study.

PURPOSE: To assess differences in mental health screening based on patient's preferred language. METHODS: For this retrospective cohort study, data for 85 725 unique patients from 10 primary care clinics in West Michigan were analyzed if patients received at least 1 mental health screening with the Patient Health Questionnaire 4 (PHQ-4) within a 12-month period (10/15/2021-10/14/2022). A general linear regression model was used to assess the adjusted odds ratios (aOR) of being screened. RESULTS: Patients having a preferred language other than English (n = 2755) had an 87.0% chance of receiving the recommended mental health screening, compared to 76.7% of English-speaking patients (P < .001). A multivariable model revealed decreased screening odds for Kinyarwanda (aOR 0.29, 95% CI 0.19-0.45) and Persian/Dari/Pashto (aOR 0.46, 95% CI 0.23-0.91) speaking patients and higher screening odds for Spanish (aOR 1.45, 95% CI 1.19-1.77), Bosnian (aOR 2.13, 95% CI 1.11-4.11), and Vietnamese (aOR 2.25 95% CI 1.64-3.08) speaking patients compared to English speaking patients. CONCLUSIONS: Results highlight the inequities between the language groups that are probably the result of the challenges to access multilingual depression and anxiety screening instruments. Furthermore, providers may be prone to bias about who they think "needs" a mental health screening. We suggest that measures are implemented to ensure consistency in mental health screening regardless of a patients' preferred language.

Thinking "Green" When Treating "Pink Puffers" and "Blue Bloaters"-Reducing Carbon Footprint When Prescribing Inhalers.

The impact of man-made climate change is already affecting millions of people worldwide. The health care sector in the US is a relevant contributor, accounting for about 8 to 10% of national greenhouse gas emissions. This special communication describes the harmful impact of propellant gases in metered dose inhalers (MDI) on the climate and summarizes and discusses current knowledge and recommendations from European countries. Dry powder inhalers (DPI) are a good alternative to MDIs and are available for all inhaler drug classes recommended in current asthma and COPD guidelines. Changing an MDI to PDI can significantly reduce carbon footprints. The majority of the US population is willing to do more to protect the climate. Primary care providers can engage in this by addressing the impacts of drug therapy on climate change in medical decision making.

Impact of limited English proficiency on the control of diabetes and associated cardiovascular risk factors. The National Health and Nutrition Examination Survey, 2003-2018.

Language barriers pose a challenge to managing health conditions for various personal, interpersonal, and structural reasons. This study estimates the impact of limited English proficiency (LEP) on diabetes mellitus control and associated cardiovascular risk factors in a large representative sample of United States adults. Cross-sectional data from the National Health and Nutrition Examination Survey (NHANES, 2003-18) was used to estimate the impact of language proficiency on glycemic control (glycated hemoglobin [HbA1c]) and cardiovascular risk status (blood pressure [BP] and low-density lipoprotein [LDL]) in adult participants with known diabetes disease. The analysis included descriptive statistics and generalized linear models to adjust for sociodemographic characteristics. The study sample included 5017 participants with self-reported, physician-diagnosed diabetes mellitus. Most participants completed NHANES interview in English (90.8%), whereas some participants completed the interview in Spanish (LEP-Spanish; 6.6%) or requested an interpreter (LEP-interpreter; 2.6%). Compared to English-speaking participants, LEP-interpreter participants were more likely to have HbA1c ≥ 7% (OR = 1.6, 95% CI = 1.1, 2.4) or a combination of HbA1c ≥ 7%, LDL ≥ 2.6 mmol/L, and BP ≥ 130/80 mmHg (OR = 3.1; 95% CI = 1.2, 8.2). We observed no differences in the odds of diabetes control. between English-speaking and LEP-Spanish participants, whereas LEP-interpreter participants had worse diabetes control, possibly owing to the greater likelihood of patient-provider language discordance for non-English non-Spanish-speaking patients. Given that many patients, yet few providers, speak languages other than English or Spanish, innovative ways are needed to facilitate patient-provider communications (e.g., digital communication assistance tools).

Multilingual competencies among ambulatory care providers in three German Federal States.

BACKGROUND: Providing medical care to newly arrived migrants presents multiple challenges. A major challenge is a lack of a common language in the absence of language interpretation services. We examine the multilingualism of German physicians and clinical psychotherapists providing ambulatory care. METHODS: We retrieved publicly available data from the Associations of Statutory Health Insurance Physicians provider registry of three German federal states (Lower Saxony, Saarland, Bavaria). We selected and grouped relevant practice-based disciplines. We used descriptive statistics to analyze the provider's multilingualism among different disciplines. RESULTS: 69.6% of ambulatory providers offer consultations only in German. 15.5% of providers reported offering consultations in one additional non-German language, and 14.9% in two or more additional languages. Most common additional languages were English (28.6%) and French (9.9%). 1.4% of providers reported offering consultation in at least one language of the Middle Eastern region (Arabic, Dari, Hebrew, Kurdish, Pashtu, Farsi, and Turkish). There were differences in the offered languages between the medical disciplines with the highest mean rates found for gynecologists and obstetricians, urologists, and general surgeons. Psychotherapeutic disciplines offered consultation in other languages significantly less often. CONCLUSION: Our study suggests a significant numeric mismatch in the number of providers offering consultations in the languages of people seeking protection in Germany. The resulting language barriers are compromising equitable access and quality of care.

Point-of-Care Ultrasound in Family Medicine Residencies 5-Year Update: A CERA Study.

BACKGROUND AND OBJECTIVES: In 2014, family medicine residency programs began to integrate point-of-care ultrasound (POCUS) into training, although very few had an established POCUS curriculum. This study aimed to evaluate the resources, barriers, and scope of POCUS training in family medicine residencies 5 years after its inception. METHODS: Questions regarding current training and use of POCUS were included in the 2019 Council of Academic Family Medicine Educational Research Alliance (CERA) survey of family medicine residency program directors, and results compared to similar questions on the 2014 CERA survey. RESULTS: POCUS is becoming a core component of family medicine training programs, with 53% of program directors reporting establishing or an established core curriculum. Only 11% of program directors have no current plans to add POCUS training to their program, compared to 41% in 2014. Despite this increase in training, the reported clinical use of POCUS remains uncommon. Only 27% of programs use six of the eight surveyed POCUS modalities more than once per year. The top three barriers to including POCUS in residency training in 2019 have not changed since 2014, and are (1) a lack of trained faculty, (2) limited access to equipment, and (3) discomfort with interpreting images without radiologist review. CONCLUSIONS: Training in POCUS has increased in family medicine residencies over the last 5 years, although practical use of this technology in the clinical setting may be lagging behind. Further research should explore how POCUS can improve outcomes and reduce costs in the primary care setting to better inform training for this technology.

Obesity education in the family medicine clerkship: a US and Canadian survey of clerkship directors' beliefs, barriers, and curriculum content.

BACKGROUND: Despite concerns regarding the increasing obesity epidemic, little is known regarding obesity curricula in medical education. Medical school family medicine clerkships address common primary care topics during clinical training. However, studies have shown that many family physicians feel unprepared at addressing obesity. The purpose of this study was to evaluate factors related to obesity education provided during family medicine clerkships as well as identify future plans regarding obesity education. METHODS: Data were collected through the 2017 Educational Research Alliance (CERA) survey of Family Medicine Clerkship Directors (CDs) in the United States and Canada. Survey items included the level of importance of obesity education, teaching methods, barriers to teaching, and obesity related topics taught during the clerkship. Survey data were summarized and analyzed. RESULTS: The survey response rate was 71.2%. The most frequent barrier to teaching obesity related topics was time constraints (89%). The most commonly taught topics were co-morbid conditions (82.1%), diet (76.9%), and exercise (76.9%). The least commonly taught topics were addressed less than 30% of the time, and included cultural aspects, obesity bias, medications than can cause weight gain, medications to treat obesity, and bariatric surgery. Over half of CDs (59%) are not planning to change existing curriculum, with 39% planning to add to the current curriculum. The CDs' perceptions of the importance of obesity education were significantly associated with the number of topics covered during clerkship (p <  0.001). No relationship was found between clerkship duration and the number of obesity topics taught. CONCLUSION: The majority of clerkship directors are planning no changes to their existing curricula which consist of three common topics: obesity related co-morbid conditions, diet, and exercise. While time was the largest self-rated barrier in teaching obesity related topics, clerkship duration didn't impact the number of topics taught. However, the relative amount of importance placed by CDs upon obesity education was significantly associated with the number of topics covered during clerkship.

Canadian national survey of point-of-care ultrasound training in family medicine residency programs.

OBJECTIVE: To assess the current state of point-of-care ultrasound (POCUS) training in Canadian family medicine residency programs. DESIGN: Cross-sectional survey to evaluate POCUS education in accredited Canadian family medicine residency programs; only 1 completed survey was accepted per residency program. SETTING: Seventeen accredited Canadian family medicine residency programs. PARTICIPANTS: Fourteen directors of family medicine programs across Canada. MAIN OUTCOME MEASURES: Opinions of program directors in family medicine education on the relevance of POCUS in family medicine, and the role of POCUS training in family medicine residency programs. RESULTS: The Web-based, anonymous survey, which was completed during the months of March and April 2016, achieved a response rate of 82% (14 out of 17 program directors). About one-fifth (21%) of program directors reported having an established ultrasound curriculum. Almost all directors (93%) believed that POCUS teaching should be integrated into family medicine residency curricula. Barriers to establishing training included the following: lack of adequate equipment (57%), lack of instructors (57%), lack of available time in the curriculum (57%), and lack of funding available to support training (71%). Seventy-one percent of respondents believed that POCUS could be used in outpatient family medicine clinics to alter clinical decision making. Some potential benefits associated with POCUS in primary care include more rapid diagnosis, improved patient outcomes, and potential to reduce health care costs. CONCLUSION: Although only a few Canadian family medicine residency program directors reported actually having an established ultrasound curriculum, most of them believed that POCUS training should be offered to family medicine residents and that its use could positively affect primary care. A growing number of family medicine residency programs are considering incorporating ultrasound training into their curricula, but resource availability remains a considerable barrier to implementation.

Point of Care Ultrasound in Family Medicine Residency Programs: A CERA Study.

BACKGROUND AND OBJECTIVES: Point-of-care (POC) ultrasound is increasingly used by clinicians across multiple medical specialties. Current perceptions and prevalence of POC ultrasound practice and training in family medicine residency programs has not been described. METHODS: Questions were included in the 2014 Council of Academic Family Medicine Educational Research Alliance (CERA) survey of family medicine residency directors. The survey included questions regarding current use and current curricula regarding POC ultrasound. It also asked rank order questions of perceived benefits and perceived barriers to expanding such training. RESULTS: Fifty percent (n=224) of residency program directors completed the 2014 CERA survey. Few programs (2.2%) reported an established ultrasound curriculum. However, 29% indicated they have started a program within the past year, and 11.2% reported starting the process of establishing such training. Ultrasound assistance for procedural guidance was the most commonly reported (44%) use out of seven POC examples. The three leading perceived benefits of POC ultrasound were: making a more rapid diagnosis, the potential to save health care costs, and the potential to improve patient outcomes. The three leading barriers to expanding training were a lack of appropriately trained faculty, limited access to ultrasound equipment, and a lack of comfort in interpreting images without radiologist review. CONCLUSIONS: A small, but rapidly growing, number of family medicine residencies currently use POC ultrasound. Further research is needed to explore how POC ultrasound can improve patient outcomes in the ambulatory setting and to develop appropriate training methods for this technology.