Best Practices for Teaching Care Management of Undocumented Patients.

Different standards of care for undocumented Latino patients raises ethical questions for teachers and learners. This lack of parity can cause moral distress for both and prompts consideration of whether decisions made on a patient's behalf are ethical. Teaching advocacy and creating projects and partnerships to improve access and quality of care for this vulnerable population can help fight burnout and improve health outcomes.

A better approach to opioid prescribing in primary care.

PURPOSE: Primary care physicians are at the center of a national prescription opioid epidemic, with little training or knowledge about the management of patients on opioids for chronic noncancer pain (CNCP). We developed an electronic medical record (EMR)-based protocol and educational intervention to standardize documentation and management of patients prescribed opioids by primary care providers. Our objective was to evaluate provider adherence to this protocol, attitudes toward the management of these patients, and knowledge of opioid prescribing. METHODS: We trained providers and select staff from 3 primary care practices at the Division of General Internal Medicine at the University of Pennsylvania in the use of a protocol for managing patients taking opioids for CNCP. The following served as measures of protocol adherence: 1) the provider used a standard diagnosis (chronic pain, ICD-9 code 338.29A) in the problem list, 2) the provider ordered at least one urine drug screen (UDS) for the patient in the past year, and 3) the patient came in for at least one office visit every 6 months. We assessed physician and staff attitudes and knowledge with pre- and post-intervention surveys. Adherence to the protocol was linked to a monetary incentive. RESULTS: Provider adherence to the protocol significantly improved measured outcomes. The number of UDSs ordered increased by 145%, and the diagnosis of chronic pain on the problem list increased by 424%. There was a statistically significant improvement in providers' role adequacy, role support, and job satisfaction/role-related self-esteem when working with patients taking opioids. In addition, provider knowledge of proper management of these patients improved significantly. Eighty-nine percent of our physicians attained the monetary incentive. CONCLUSIONS: We developed a quality improvement intervention that addressed the need for better regulation of opioid prescribing, resulted in increased adherence to best-practice guidelines, and improved provider knowledge and attitudes.

Talking to patients about screening colonoscopy--where conversations fall short.

INTRODUCTION: A physician's recommendation is a powerful motivator for a patient to undergo colonoscopy for colorectal cancer screening, yet little is known about how physicians address this topic. METHODS: We recruited 30 primary care physicians and physicians-in-training from 4 practices to counsel a "patient," simulated by a researcher, regarding the need for screening colonoscopy. Audiotapes of the encounters were transcribed. Preserving physician anonymity, we assessed each encounter for key informational points, positive or negative message framing, type of numeracy information, and use of colloquial or technical language. RESULTS: Most physicians (>/=80%) discussed the benefits of colorectal cancer screening, its status as a standard exploratory procedure, and the use of sedation. However, few (<20%) addressed the risks of colonoscopy, the nuances of scheduling, or the need for dietary and medication changes. Nearly all physicians (98%) used messages that focused on the positive aspects of screening, and many (67%) also used messages that focused on the risk of not screening. Numeracy information generally was expressed simply, but half of physicians used statistical terms. Half used colloquial terms to describe the prep and procedure. CONCLUSION: Though most physicians used positive, simple terms to describe colonoscopy, they often omitted key information. Correcting for the areas of insufficient information found in our study--perhaps with supplementary educational sources--will help ensure that patients are adequately prepared for colonoscopy.