Patient loneliness in an urban, underserved family medicine residency clinic: prevalence and relationship to health care utilization.

BACKGROUND: Mounting evidence suggests that loneliness increases the risk of poor health outcomes, including cardiovascular disease and premature mortality.Objective: This study examined the prevalence of loneliness in an urban, underserved family medicine residency clinic and the association of loneliness with health care utilization. METHODS: Adult patients (N = 330; M age = 42.1 years, SD = 14.9; 63% female; 58% African American) completed the 3-item UCLA Loneliness screener at their primary care visits between November 2018 and January 2019. A retrospective case-control study design was used to compare health care utilization [hospitalizations, emergency department (ED) visits, primary care visits, no-shows and referrals] in the prior 2 years between patients who identified as lonely versus those who did not. Covariates included demographics and clinical characteristics. RESULTS: Nearly half (44%) of patients exceeded the cut-off for loneliness. Patients who were lonely were more likely to identify as African American, have depression and have a substance use disorder. Patients in the lonely group had significantly longer hospital stays and more primary care visits, no-shows and referrals than patients in the non-lonely group; there were no differences in number of hospitalizations or ED visits. CONCLUSIONS: The prevalence of loneliness in an urban, underserved primary care clinic was much higher than prior prevalence estimates in primary care. Patients who are lonely may use more health care resources than patients who are not lonely. Primary care may be an ideal setting in which to identify patients who are lonely to further understand the impact of loneliness on health care outcomes.

Syphilis: Far from Ancient History.

Rates of primary, secondary, and congenital syphilis are increasing in the United States, and reversing this trend requires renewed vigilance on the part of family physicians to assist public health agencies in the early detection of outbreaks. Prompt diagnosis of syphilis can be challenging, and not all infected patients have common manifestations, such as a genital chancre or exanthem. The U.S. Preventive Services Task Force recommends screening for syphilis in all patients at increased risk, particularly those who reside in high-prevalence areas, sexually active people with HIV infection, and men who have sex with men. Other groups at increased risk include males 29 years or younger and people with a history of incarceration or sex work. All pregnant women should be screened for syphilis at the first prenatal visit, and those at increased risk should be screened throughout the pregnancy. The Centers for Disease Control and Prevention recommends the traditional screening algorithm for most U.S. populations. Penicillin is the preferred treatment across all stages of syphilis, although limited research suggests a possible role for other antibiotics in penicillin-allergic patients with primary or secondary syphilis. Pregnant women with syphilis who are allergic to penicillin should undergo penicillin desensitization before treatment.

Communicating statin evidence to support shared decision-making.

BACKGROUND: The practice of clinical medicine rests on a foundation of ethical principles as well as scientific knowledge. Clinicians must artfully balance the principle of beneficence, doing what is best for patients, with autonomy, allowing patients to make their own well-informed health care decisions. The clinical communication process is complicated by varying degrees of confidence in scientific evidence regarding patient-oriented benefits, and by the fact that most medical options are associated with possible harms as well as potential benefits. DISCUSSION: Evidence-based clinical guidelines often neglect patient-oriented issues involved with the thoughtful practice of shared decision-making, where individual values, goals, and preferences should be prioritized. Guidelines on the use of statin medications for preventing cardiovascular events are a case in point. Current guidelines endorse the use of statins for people whose 10-year risk of cardiovascular events is as low as 7.5%. Previous guidelines set the 10-year risk benchmark at 20%. Meta-analysis of randomized trials suggests that statins can reduce cardiovascular event rates by about 25%, bringing 10-year risk from 7.5 to 5.6%, for example, or from 20 to 15%. Whether or not these benefits should justify the use of statins for individual patients depends on how those advantages are valued in comparison with disadvantages, such as side effect risks, and with inconveniences associated with taking a pill each day and visiting clinicians and laboratories regularly. CONCLUSIONS: Whether or not the overall benefit-harm balance justifies the use of a medication for an individual patient cannot be determined by a guidelines committee, a health care system, or even the attending physician. Instead, it is the individual patient who has a fundamental right to decide whether or not taking a drug is worthwhile. Researchers and professional organizations should endeavor to develop shared decision-making tools that provide up-to-date best evidence in easily understandable formats, so as to assist clinicians in helping their patients to make the decisions that are right for them.

"Can we have a little humanity here?": Patient perspectives on the impact of a standardized care process for patients who use opioids for the management of chronic pain.

OBJECTIVE: Standardized processes have evolved in response to the opioid epidemic. The impact of standardized processes on patients has not been adequately described. METHODS: Five focus groups were held at four affiliated academic family medicine clinics. All participants experienced a transition to a standardized process for their ongoing opioid use for chronic, non-cancer pain. Data was analyzed and coded using a grounded theory approach with NVivo12 (QSR International). RESULTS: Thirty patients participated. Five main themes emerged: experience of pain; view of opioid medications; view of opioid prescribing process changes; "good patients" and trust; and experience with medical clinicians and clinics. CONCLUSIONS: Standardized processes created to improve the safety of opioid prescribing have burdened patients and resulted in a loss of trust and autonomy. Patients perceived greater risks for other patients prescribed opioids and processes are a result of their actions. PRACTICE IMPLICATIONS: Healthcare systems must acknowledge patients' burden, shift away from interventions that are limited in supporting data, reinforce patient agency and shift the conversation to unsafe medications rather than supervision of "bad actors".

Risk of Thromboembolic Events Following COVID-19 Diagnosis Without Hospitalization.

INTRODUCTION: Current research shows no increased risk of thromboembolic events with mild COVID-19 but does not account for comorbidities. The aim of this study was to examine the incidence of thromboembolic events, including pulmonary embolism, cerebral infarction, and deep vein thrombosis, in nonhospitalized patients diagnosed with COVID-19 while accounting for comorbidities such as diabetes, asthma, COPD and cancer. METHODS: We completed a large retrospective observational analysis of adult patients within a large urban health system. RESULTS: Using a logit framework (with and without propensity score weighting), there was no increased risk of thromboembolic events among patients positive for SARS-CoV-2 who did not require hospitalization for COVID-19. CONCLUSION: This data suggest prophylactic anticoagulation is likely not warranted in the outpatient setting.

Asthma management: How the guidelines compare.

This quick guide details the similarities and differences between recommendations from the National Asthma Education and Prevention Program and the Global Initiative for Asthma.

A New Pandemic of Loneliness.

Loneliness is the subjective feeling people experience when they feel less socially connected to others than they desire. Beyond the impact to mental health and well-being, loneliness is linked to detrimental health outcomes. During the COVID-19 pandemic, social distancing and isolation requirements likely exacerbated the prevalence of loneliness, which was reported by 1 in 5 American adults before the pandemic. Whether it be through in-person or virtual visits, primary care clinicians have tools and expertise to screen patients for loneliness, provide them supportive consultations, and refer persons with loneliness to helpful resources. As the societal changes from the pandemic continue to evolve, we recommend that primary care providers include loneliness screens as part of their standard workflow and consult with patients about effective interventions to reduce loneliness.

Knowledge Retention Using "Relay": A Novel Active-Learning Technique.

Introduction: Many residency programs utilize passive didactic lectures despite mixed evidence for knowledge retention. This prospective study investigated the efficacy of "relay," an active-learning technique, as measured by residents' knowledge retention and attitudes compared to traditional format. Methods: Faculty presented lectures to four family medicine residency programs on a randomized schedule. Lectures were followed by a 15-minute question-and-answer (Q&A) session or relay session. A relay is a collaborative, question-based game. The primary outcome was knowledge retention at 3 months, comparing Q&A to relay sessions as measured by a multiple-choice assessment. Responses were only included if a given resident completed knowledge assessments for both Q&A and relay sessions, to allow for intraresident adjustments, in addition to program, training year, and lecturer/topic. Secondary outcomes included residents' self-perceived knowledge and engagement as surveyed by an ordinal scale immediately following the learning session. Results: The primary analysis included 51 responses from 18 unique residents. The adjusted mean knowledge assessment score at 3 months was not statistically different after the relay sessions compared to Q&A (67% vs 60%, respectively; 7% difference, 95% CI: -4 to 18%, P=.20). For the secondary outcomes of learner attitudes (n=143 responses), learners reported greater engagement after the relay sessions compared to Q&A (51% vs 28% "very engaged"; overall P=.003), but self-perceived knowledge was not significantly different (overall P=.05, rounded down). Conclusions: The relay technique did not show significant difference in 3-month knowledge retention, nor immediate self-perceived knowledge, despite greater learner self-perceived engagement.

Education and Attitudes on Medical Cannabis in Family Medicine Residency Programs.

BACKGROUND AND OBJECTIVES: Medical cannabis has become increasingly prevalent in the United States, however the extent of family medicine resident education on this topic remains unknown. The objective of this study was to ascertain the current state of medical cannabis education across this population and identify patterns in education based on state legality and program director (PD) practices. METHODS: Survey questions were part of the Council of Academic Family Medicine Educational Research Alliance (CERA) omnibus survey from May 2019 to July 2019. PDs from all Accreditation Council for Graduate Medical Education (ACGME)-accredited US family medicine residency programs received survey invitations by email. RESULTS: A total of 251 (40.7%) PDs responded, with 209 (83.6% [209/250]) reporting at least 1 hour of didactic curriculum regarding cannabis. The most common context was substance misuse (mean 3.0±4.1 hours per 3 years), followed by pain management (2.7±3.4 hours), and management of other conditions (2.1±2.7 hours). Thirty-eight programs (15.2% [38/250]) offered clinical experiences related to medical cannabis, and PDs who had previously prescribed or recommended medical cannabis were more likely to offer this experience (P<.0001). Experiences peaked after 3 to 5 years of medical cannabis legality. PD confidence in resident counseling skills was low overall, but did increase among programs with clinical experiences (P=.0033). CONCLUSIONS: The current trajectory of medical cannabis use in the United States makes it likely that residents will care for patients interested in medical cannabis, therefore it is important residents be prepared to address this reality. Opportunities exist for improving medical cannabis education in family medicine residency programs.

Implicit Bias Training in a Residency Program: Aiming for Enduring Effects.

BACKGROUND AND OBJECTIVES: Implicit bias often affects patient care in insidious ways, and has the potential for significant damage. Several educational interventions regarding implicit bias have been developed for health care professionals, many of which foster reflection on individual biases and encourage personal awareness. In an attempt to address racism and other implicit biases at a more systemic level in our family medicine residency training program, our objectives were to offer and evaluate parallel trainings for residents and faculty by a national expert. METHODS: The trainings addressed how both personal biases and institutional inequities contribute to structural racism, and taught skills for managing instances of implicit biases in one's professional interactions. The training was deliberately designed to increase institutional capacity to engage in crucial conversations regarding implicit bias. Six months after the trainings, an external evaluator conducted two separate 1-hour focus groups, one with residents (n=18) and one with program faculty and leadership (n=13). RESULTS: Four themes emerged in the focus groups: increased awareness of and commitment to addressing racial bias; appreciation of a safe forum for sharing concerns; new ways of addressing and managing bias; and institutional capacity building for continued vigilance and training regarding implicit bias. CONCLUSIONS: Both residents and faculty found this training to be important and empowering. All participants desired an ongoing programmatic commitment to the topic.

PURLs: SSRIs for depression/heart failure patients? Not so fast.

This study should put to rest the practice of starting SSRIs in depressed patients with heart failure in an attempt to affect CVD outcomes.

The Times They Are A-Changin': Knowledge and Perceptions Regarding Medical Cannabis in an Academic Family Medicine Department.

BACKGROUND AND OBJECTIVES: The United States has seen an evolving perspective on the medical use of cannabis in recent years. Although a majority of states have enacted medical cannabis programs, physicians practicing in these states report a lack of knowledge, lingering concerns, and a need for more training regarding medical cannabis. This study provides a current snapshot of medical cannabis education in an academic family medicine department in a state with a medical cannabis program. METHODS: An electronic survey was sent to all 134 faculty physicians and residents within a family medicine department to assess current knowledge and attitudes regarding medical cannabis. Study authors performed descriptive statistical analysis of the survey data. RESULTS: Of the 61 individuals to complete the survey, 34 were residents and 27 were faculty. Overall, respondents displayed poor understanding of the state's medical cannabis program as well as cannabis regulations. A majority of both faculty and residents reported low self-rated competency levels for medical cannabis efficacy, adverse effects, and safety using Likert scales (1 to 5; 1=low competency, 5=high competency). A majority of faculty (56%) expressed that they did not intend to certify patients for medical cannabis compared to only 33% of residents. Residents were statistically more likely to think of a patient who might benefit from medical cannabis compared to faculty (39% vs 11%, P=.004, chi-square). CONCLUSIONS: Increasingly, family physicians will be called on to provide informed patient counseling regarding medical cannabis. These results highlight a knowledge gap for family medicine learners in a changing practice landscape.

Visit Patterns for Severe Mental Illness with Implementation of Integrated Care: A Pilot Retrospective Cohort Study.

There is increasing interest in models that integrate behavioral health services into primary care. For patients with severe mental illness, a population with disproportionate morbidity and mortality, little is known about the impact of such models on primary care clinic utilization and provider panels. We performed a retrospective cohort pilot study examining visit patterns for 1,105 patients with severe mental illness (SMI), overall and by provider, before and after the implementation of a primary care behavioral health model which had a ramp up period from 5/06-8/07. We used 2003-2012 electronic health record data from two clinics of a Federally Qualified Health Center and conducted interrupted time series and chi-square analyses. During the intervention period there was a significant increase in the proportion of visits per month to the clinic for patient with SMI relative to overall visits (0.27; 95% CI 0.22-0.32). After the intervention period, this rate declined (-0.23; -0.19-0.28) but remained above the pre-intervention period. After integration of behavioral health into our primary care clinics, there was a sharp increase in the number of patients with severe mental illness, suggesting patient willingness to explore receiving care under this model. Clinics looking to adopt the model should be mindful of potential changes in patient subpopulations and proactively manage this transition.

Screening strategies for cardiovascular disease in asymptomatic adults.

The purpose of this article is to update the primary care community on the evidence and guidelines for cardiovascular disease screening in a general-risk adult population, with the goal of assisting clinicians in developing an evidence-based approach toward screening. This article discusses global risk assessment and screening strategies, including blood pressure, lipids, C-reactive protein, homocysteine, coronary artery calcium score, carotid intima-media thickness, ultrasound of the abdominal aorta, and electrocardiography.

The shrinking case for saw palmetto.

Findings of this study should make physicians and patients alike reconsider the popularity of this herbal remedy for BPH symptoms.

Communicating methylmercury risks and fish consumption benefits to vulnerable childbearing populations.

Methylmercury is a known neurotoxin especially harmful to the fetus, infant, and child. Preventing exposure to this environmental toxin is best accomplished through consumer messages specifically adapted for local populations. Health care providers play an important role in the dissemination of information. The purpose of this article is to review the benefits and risks of fish consumption and identify strategies for presenting effective risk communication messages to vulnerable groups, particularly women of childbearing age.