Exercise interventions for advanced cancer palliative care patients: A systematic literature review and descriptive evidence synthesis of randomized controlled trials.

BACKGROUND: Exercise is often recommended for cancer patients. However, for advanced cancer palliative care patients, it is unclear whether exercise, as a lifestyle intervention, is beneficial for palliative outcomes. AIM: To examine randomized controlled trials assessing the effectiveness of lifestyle exercise interventions on palliative outcomes in patients with advanced stage cancer. DESIGN: Systematic review and descriptive evidence synthesis. DATA SOURCES: Pubmed/Medline, Embase, CINAHL, PsychInfo, and Web of Science were systematically searched from inception to 2022. Two reviewers identified articles and removed duplicates. Next two reviewers independently screened titles and abstracts and then assessed full-texts articles for eligibility. Finally, all six reviewers examined full-text articles for eligibility and conducted the evidence synthesis. RESULTS: Eight randomized controlled trials were included. Studies were heterogeneous making direct comparisons challenging, but were grouped along three categories: aerobic, resistance, or resistance-aerobic exercises. One of three aerobic studies had positive quality-of-life outcomes. Fatigue improved in one aerobic and one combination resistance-aerobic study. Most resistance-aerobic studies and one aerobic study showed improved physical function. All resistance studies showed improvement in at least one outcome. Across all studies, ill health was the most common reason for participant dropout. The most commonly used assessment tools were: Functional Assessment of Cancer Therapy: Fatigue, European Organization for Research and Treatment of Cancer Quality-of-life Questionnaire Core 30, and accelerometer. CONCLUSION: Current randomized controlled trials regarding effects of exercise interventions on palliative outcomes for advanced cancer patients show great variability. While studies show promise, no generalizable conclusions can be made. Further research is needed.

Successes, challenges and needs regarding rural health medical education in continental Central America: a literature review and narrative synthesis.

INTRODUCTION: Central American countries, like many others, face a shortage of rural health physicians. Most medical schools in this region are located in urban areas and focus on tertiary care training rather than on community health or primary care, which are better suited for rural practice. However, many countries require young physicians to do community service in rural communities to address healthcare provider shortages. This study aimed to: (a) synthesize what is known about the current state of medical education preparing physicians for rural practice in this region, and (b) identify common needs, challenges and opportunities for improving medical education in this area. METHODS: A comprehensive literature review was conducted between December 2013 and May 2014. The stepwise, reproducible search process included English and Spanish language resources from both data-based web search engines (PubMed, Web of Science/Web of Knowledge, ERIC and Google Scholar) and the grey literature. Search criteria included MeSH terms: 'medical education', 'rural health', 'primary care', 'community medicine', 'social service', in conjunction with 'Central America', 'Latin America', 'Mexico', 'Guatemala', 'Belize', 'El Salvador', 'Nicaragua', 'Honduras', 'Costa Rica' and 'Panama'. Articles were included in the review if they (1) were published after 1984; (2) focused on medical education for rural health, primary care, community health; and (3) involved the countries of interest. A narrative synthesis of the content of resources meeting inclusion criteria was done using qualitative research methods to identify common themes pertaining to the study goals. RESULTS: The search revealed 20 resources that met inclusion criteria. Only four of the 20 were research articles; therefore, information about this subject was primarily derived from expert opinion. Thematic analysis revealed the historical existence of several innovative programs that directly address rural medicine training needs, suggesting that expertise is present in this region. However, numerous challenges limit sustainability or expansion of successful programs. Common challenges include: (a) physicians' exposure to rural medicine primarily takes place during social service commitment time, rather than during formal medical training; (b) innovative educational programs are often not sustainable due to financial and leadership challenges; (c) the majority of physician manpower is in urban areas, resulting in few rural physician role models and teachers; and (d) there is insufficient collaboration to establish clinical and educational systems to meet rural health needs. Recurring suggestions for curricular changes include: (a) making primary care training a core component of medical school education; and (b) expanding medical school curricula in cross-cultural communication and social determinants of disease. Suggestions for health system changes include: (a) improving living and working conditions for rural physicians; and (b) establishing partnerships between educational, governmental and non-governmental organizations and rural community leadership, to promote rural health training and systems. CONCLUSIONS: Expertise in rural medicine and training exists in continental Central America. However, there are numerous challenges to improving medical education to meet the needs of rural communities. Overcoming these challenges will require creative solutions, new partnerships, and evaluation and dissemination of successful educational programs. There is a great need for further research on this topic.

Fostering professional formation in residency: development and evaluation of the "forum" seminar series.

BACKGROUND: Residency training is a critical time for physicians' professional formation. However, few structured interventions exist to support residents in this transformative process of integrating personal and professional values, a process that is essential to physician identity formation and preservation of core values such as service and compassion. PURPOSES: The authors created a seminar series, the "Forum," to support resident professional formation and address the hidden curriculum as part of a larger intervention to support self-directed learning skills such as goal setting and reflection. METHODS: Ninety-minute sessions with senior residents and faculty held every other month include opportunities for individual reflection, small- and large-group discussion, and brief didactic components focused on skills such as teaching and leadership. The qualitative program evaluation included analyses of individual semistructured interviews with resident and faculty participants from 2008 to 2011 and of notes recorded by an observer during the 1st year's sessions. RESULTS: Residents appreciated the focus on relevant issues, presence of faculty, opportunities for reflection and interactivity, and inclusion of practical skills. Effects attributed to the Forum included gaining practical skills, feeling a deeper connection to one another and a sense of community, and recognizing progress in their own professional development and growth. Elements described in the literature as essential to professional formation, including encouraging reflection, use of narrative, role modeling, addressing the hidden curriculum, and fostering an authentic community, were recognized by participants as integral to the Forum's success. CONCLUSIONS: A group forum for reflection and discussion with peers and role models, tailored to local needs, offers an effective structure to foster professional formation in residency.

Exploring the Beliefs, Values, and Understanding of Quality End-of-Life Care in the Latino Community: A Spanish-Language Qualitative Study.

Context: Hospice services are underutilized by the Latino community in the United States. Previous research has identified that language is a key barrier contributing to disparities. However, very few studies have been conducted in Spanish to specifically explore other barriers to hospice enrollment or values related to end-of-life (EOL) care in this community. Here, we remove the language barrier in order to gain an in-depth understanding of what members of the diverse Latino community in one state in the USA considers high quality EOL and barriers to hospice. Methods: This exploratory semi-structured individual interview study of Latino community members was conducted in Spanish. Interviews were audio-recorded, transcribed verbatim and translated to English. Transcripts were analyzed by three researchers, using a grounded-theory approach to identify themes and sub-themes. Main Findings: Six major themes emerged: (1) concept of "a good death"-spiritual peace, family/community connection, no burdens left behind; (2) centrality of family; (3) lack of knowledge about hospice/palliative care; (4) Spanish language as critical; (5) communication style differences; and (6) necessity for cultural understanding. The central theme of "a good death" was closely linked to having the entire family physically and emotionally present. The four other themes represent interrelated, compounding barriers to achieving this "good death." Principal Conclusions: Healthcare providers and the Latino community can work together to decrease hospice utilization disparities by: actively involving family at every step; addressing misconceptions regarding hospice; conducting important conversations in Spanish; and improving provider skills in culturally sensitive care, including communication style.

Trust as a Central Factor in Hospice Enrollment Disparities Among Ethnic and Racial Minority Patients: A Qualitative Study of Interrelated and Compounding Factors Impacting Trust.

Background: Disparities in end-of-life (EOL) care remain among ethnic/racial minority populations. Choosing hospice care in the United States depends on goals-of-care discussions founded on trust. While studies examine hospice enrollment disparities and others explore trust in hospice settings in general, very few explicitly examine the role of trust in hospice enrollment disparities. Objectives: To explore factors impacting trust and how these might contribute to disparities in hospice enrollment. Design: A qualitative, individual interview study, based on grounded theory. Setting/Subjects: Setting: Rhode Island, USA. Participants: Multiple stakeholders in EOL care, with diverse professional and personal backgrounds. Measurements: In-depth semistructured individual interviews were audio-recorded and transcribed as part of a broader study of hospice enrollment barriers in diverse patients. Analysis: Five researchers did a secondary data analysis, focusing on trust as the central phenomenon of interest. Researchers independently analyzed transcripts, then held iterative group analysis meetings until they reached consensus regarding themes, subthemes, and relationships. Results: Twenty-two participants included five physicians, five nurses, three social workers, two chaplains, one nursing assistant, three administrators, and three patient caregivers/family. Interviews reveal that trust is multidimensional, involving personal- and systems-level trust, and both locus and degree of trust. Factors impacting trust include: fear; communication/relationships; knowledge of hospice; religious/spiritual beliefs; language; and cultural beliefs/experiences. While some are common across groups, several are more prevalent in minority populations. These factors appear to interact in complex ways, unique to individual patients/families, compounding their impact on trust. Conclusions: While gaining patient/family trust regarding EOL decision making is challenging across all groups, minority patients often experience additional compounding factors impacting trust building. More research is needed to mitigate the negative ways these interacting factors impact trust.

"Are They Saying It How I'm Saying It?" A Qualitative Study of Language Barriers and Disparities in Hospice Enrollment.

CONTEXT: Language barriers contribute significantly to disparities in end-of-life (EOL) care. However, the mechanisms by which these barriers impact hospice care remains underexamined. OBJECTIVES: To gain a nuanced understanding of how language barriers and interpretation contribute to disparities in hospice enrollment and hospice care for patients with limited English proficiency. METHODS: Qualitative, individual interviews were conducted with a variety of stakeholders regarding barriers to quality EOL care in diverse patient populations. Interviews were audiorecorded and transcribed verbatim. Data were coded using NVivo 11 (QSR International Pty Ltd., Melbourne, Australia). Three researchers analyzed all data related to language barriers, first individually, then in group meetings, using a grounded theory approach, until they reached consensus regarding themes. Institutional review board approval was obtained. RESULTS: Twenty-two participants included six nurses/certified nursing assistants, five physicians, three administrators, three social workers, three patient caregivers, and two chaplains, self-identifying from a variety of racial/ethnic backgrounds. Three themes emerged regarding language barriers: 1) structural barriers inhibit access to interpreters; 2) variability in accuracy of translation of EOL concepts exacerbates language barriers; and 3) interpreters' style and manner influence communication efficacy during complex conversations about prognosis, goals of care, and hospice. Our theoretical model derived from the data suggests that Theme 1 is foundational and common to other medical settings. However, Theme 2 and particularly Theme 3 appear especially critical for hospice enrollment and care. CONCLUSION: Language barriers present unique challenges in hospice care because of the nuance and compassion required for delicate goals of care and EOL conversations. Reducing disparities requires addressing each level of this multilayered barrier.

Spirituality in Primary Palliative Care and Beyond: A 20-Year Longitudinal Qualitative Study of Interacting Factors Impacting Physicians' Spiritual Care Provision Over Time.

CONTEXT: Spiritual care (SC) is central to palliative care. However, a mismatch between patients' desire for SC and physicians' SC provision remains. The shortage of specialty-trained palliative physicians, necessitates that all physicians provide primary palliative care, including SC. Although several quantitative studies explore physicians' barriers to SC, few qualitative studies and no longitudinal studies exist. OBJECTIVE: To gain in-depth understanding of factors influencing physicians' ability to provide SC over time. METHODS: A 20-year longitudinal, individual interview study. In study year-1, we interviewed all residents in a USA primary care residency (full study-group) regarding SC beliefs, experiences and skills. The longitudinal study-group (PGY1 subgroup) was interviewed again in study-years 3, 11, and 20. Interviews were audio-recorded and transcribed. Four researchers analyzed transcripts using a grounded theory approach. IRB approval was obtained. RESULTS: We analyzed 66 interviews from 34 physicians. Physicians had diverse personal spiritual beliefs. Seven themes emerged from both groups (response rate 89%): patients' needs; practice setting; beliefs regarding physician's role; personal spiritual beliefs; SC training; life experiences (professional, personal); self-care and reflection. Longitudinal interviews revealed thematic evolution and interactions over 20-years: patients' needs and physicians' belief in whole-person care remained primary motivators; cross-cultural SC communication training diminished impact of personal spiritual beliefs and worries; life experiences enhanced SC skills; work environment helped or hindered SC provision; and spiritual self-care/reflection fostered patient-centered, compassionate SC. CONCLUSION: Facilitating SC provision by nonpalliative care specialists is complex and may require both individual and systems level interventions fostering motivation, SC skill development, and supportive work environments.

Lifestyle Medicine Interventions in Patients With Advanced Disease Receiving Palliative or Hospice Care.

Background: Lifestyle medicine interventions have the potential to improve symptom management, daily function, and quality of life (QOL) in patients with advanced or terminal disease receiving palliative or hospice care. The goal of this review is to summarize the current state of the literature on this subject. Methods: The authors used a broad search strategy to identify relevant studies, reviews, and expert opinions, followed by narrative summary of available information. Results: Four main categories of lifestyle interventions feature prominently in the palliative care literature: exercise, nutrition, stress management, and substance use. High-quality studies in this vulnerable population are relatively sparse. Some interventions show promise. However, most show mixed results or inadequate evidence. For some interventions, risks in this generally frail population outweigh the benefits. Clinical decision making involves balancing research findings, including the risks and benefits of interventions, with a clear understanding of patients' prognosis, goals of care, and current physical, emotional, and spiritual state. Achieving optimum QOL, safety, and ethical care are emphasized. Conclusions: The use of lifestyle interventions in patients receiving palliative or hospice care is a complex undertaking, requiring tailoring recommendations to individual patients. There is potential for considerable benefits; however, more research is needed.

Multiple Stakeholders' Perspectives Regarding Barriers to Hospice Enrollment in Diverse Patient Populations: A Qualitative Study.

CONTEXT: Although studies show disparities in hospice care utilization, many questions remain regarding the causes of these disparities. Most studies focus on a single ethnic/racial group, and most use physician informants. None compare and contrast views of multiple stakeholders or use a systems approach within a single geographic region. OBJECTIVES: To gain an in-depth understanding of causes of hospice enrollment disparities in diverse patient populations within one state in the U.S. METHODS: We conducted in-depth, individual interviews with multiple stakeholders in hospice care for diverse communities in Rhode Island. We identified participants through purposeful and snowball sampling strategies, aiming for a maximum variation sample. Interviews were audio-recorded, transcribed verbatim, and analyzed using a multistep grounded theory approach. RESULTS: Participants, self-identifying from a wide variety of ethnic backgrounds, included physicians, nurses, social workers, chaplains, nursing assistants, administrators, and caregivers. Five themes emerged regarding patient- and provider-level barriers to hospice enrollment: 1) universal challenges of goals of care (GOC) conversations; 2) cultural norms and beliefs; 3) language barriers; 4) provider-specific challenges; and 5) trust. In minority populations, the central theme of GOC conversation challenges was intensified by the other four themes. Suggested solutions included 1) increased palliative care training; 2) "cultural interpreters" from local communities; 3) specially trained "GOC language interpreters"; 4) improved workforce diversity; and 5) community-level advocacy. CONCLUSION: The disparity in hospice enrollment among diverse patient populations is a complex and nuanced problem, involving numerous interrelated barriers. Addressing this disparity will require innovative solutions at multiple levels.

The 3 H and BMSEST models for spirituality in multicultural whole-person medicine.

PURPOSE: The explosion of evidence in the last decade supporting the role of spirituality in whole-person patient care has prompted proposals for a move to a biopsychosocial-spiritual model for health. Making this paradigm shift in today's multicultural societies poses many challenges, however. This article presents 2 theoretical models that provide common ground for further exploration of the role of spirituality in medicine. METHODS: The 3 H model (head, heart, hands) and the BMSEST models (body, mind, spirit, environment, social, transcendent) evolved from the author's 12-year experience with curricula development regarding spirituality and medicine, 16-year experience as an attending family physician and educator, lived experience with both Hinduism and Christianity since childhood, and a lifetime study of the world's great spiritual traditions. The models were developed, tested with learners, and refined. RESULTS: The 3 H model offers a multidimensional definition of spirituality, applicable across cultures and belief systems, that provides opportunities for a common vocabulary for spirituality. Therapeutic options, from general spiritual care (compassion, presence, and the healing relationship), to specialized spiritual care (eg, by clinical chaplains), to spiritual self-care are discussed. The BMSEST model provides a conceptual framework for the role of spirituality in the larger health care context, useful for patient care, education, and research. Interactions among the 6 BMSEST components, with references to ongoing research, are proposed. CONCLUSIONS: Including spirituality in whole-person care is a way of furthering our understanding of the complexities of human health and well-being. The 3 H and BMSEST models suggest a multidimensional and multidisciplinary approach based on universal concepts and a foundation in both the art and science of medicine.

Mutiny on the balint: balancing resident developmental needs with the balint process.

BACKGROUND AND OBJECTIVES: Many residency training programs offer Balint groups as a means of encouraging residents in reflective practice. Residency Balint groups around the country are variable with regard to format when compared to the recommended structure. This paper describes a resident Balint group in which the residents initially expressed strong dissatisfaction with the group, although they understood its purpose and expected format and were committed to the group process and goals. The seminar was modified to address their concerns, and the subsequent group process was studied to evaluate the effect of the changes. METHODS: The subjects were 11 second-year residents in a 13-13-13 program in the northeastern United States. A needs assessment using a qualitative survey and focus group-style discussion was performed. The immersion-crystallization method was used at all stages. Field notes from subsequent sessions, combined with leader reflections, captured the group process. RESULTS: The first sessions addressed requested professional development topics. The residents then spontaneously returned to a process more consistent with traditional Balint, although discussion of the patient perspective was infrequent. CONCLUSIONS: Our experience suggests that modification of Balint group structure and process may be necessary with some groups of learners to pave the way for a more meaningful Balint experience over the course of training.

A spirituality and medicine elective for senior medical students: 4 years' experience, evaluation, and expansion to the family medicine residency.

BACKGROUND: Evidence suggests that spirituality is important in patient care and medical education, yet there are few reports of spirituality and medicine curricular evaluation. METHODS: We developed, implemented, and evaluated a 17-hour elective on spirituality and patient care for 4 consecutive years. We presented the elective to 10 fourth-year medical students (MS4s) in years one and two and to eight MS4s and 15 residents, faculty, and staff in years three and four. We evaluated knowledge and skills using pre-course and post-course questionnaires and written cases and learner satisfaction using course evaluations. RESULTS: Students' knowledge improved on the evidence about spirituality, clinical resources, role of chaplains, approaches to patient care, and recognizing spiritual distress. Reported course strengths included diversity of topics and instructors, universal principles, small-group format, case discussions, and opportunity for self-reflection. Comments reflected enhanced value in the "meaning in medicine" and "whole person care." CONCLUSIONS: Senior medical students rated the elective positively and increased their knowledge of spirituality and medicine. It was also positively received by residents, faculty, and staff and paved the way for residency curricula in this subject.

Rising Waters and a Smaller Island: What Should Physicians Do for Tuvaluans?

Residents of the island nation of Tuvalu will be among the first of the 1.7 million Pacific Islanders to be displaced by the effects of climate change (including rising sea levels, changing distributions of agriculture, and unpredictable weather patterns). Already 3,500 Tuvaluans live in New Zealand (approximately 25 percent of the world's Tuvaluan population), some of whom moved due to climate change. Immigrating to New Zealand presents several challenges for Tuvaluans, including limited job opportunities, health care disparities, and dietary changes. Nevertheless, Tuvaluans in New Zealand continue their culture as they redefine their identity in a new country. Given the growing effects of climate change, physicians around the world will soon care for a new generation of immigrants and will play an important role in advocating for health equity and self-determination among climate-sensitive populations. This article uses personal stories and photographs of Tuvaluans and photographs of Tuvalu and New Zealand to present Tuvaluans' struggles and ethical issues pertaining to health that arise in relocating Tuvaluans.

Family Medicine Global Health Fellowship Competencies: A Modified Delphi Study.

BACKGROUND AND OBJECTIVES: Many US medical schools and family medicine departments have responded to a growing interest in global health by developing global health fellowships. However, there are no guidelines or consensus statements outlining competencies for global health fellows. Our objective was to develop a mission and core competencies for Family Medicine Global Health Fellowships. METHODS: A modified Delphi technique was used to develop consensus on fellowship competencies. A panel, comprised of 13 members with dual expertise in global health and medical education, undertook an iterative consensus process, followed by peer review, from April to December 2014. RESULTS: The panel developed a mission statement and identified six domains for family medicine global health fellowships: patient care, medical knowledge, professionalism, communication and leadership, teaching, and scholarship. Each domain includes a set of core and program-specific competencies. CONCLUSION: The family medicine global health competencies are intended to serve as an educational framework for the design, implementation, and evaluation of individual family medicine global health fellowship programs.

A 10-Year Longitudinal Study of Effects of a Multifaceted Residency Spiritual Care Curriculum: Clinical Ability, Professional Formation, End of Life, and Culture.

CONTEXT: Although spiritual care (SC) is recognized as important in whole-person medicine, physicians infrequently address patients' spiritual needs, citing lack of training. Although many SC curricula descriptions exist, few studies report effects on physicians. OBJECTIVES: To broadly examine immediate and long-term effects of a required, longitudinal, residency SC curriculum, which emphasized inclusive patient-centered SC, compassion, and spiritual self-care. METHODS: We conducted in-depth individual interviews with 26 physicians (13 intervention; 13 comparison) trained at a 13-13-13 residency. We interviewed intervention physicians three times over 10 years-1) preintervention, as PGY1s, 2) postintervention, as PGY3s, 3) eight-year postintervention, as practicing physicians. We interviewed comparison physicians as PGY3s. Interviews were audio-recorded, transcribed, and analyzed by four researchers. RESULTS: Forty-nine interviews were analyzed. General: Both groups were diverse regarding personal importance of spirituality/religion. All physicians endorsed the value of SC, sharing rich patient stories particularly related to end of life and cultural diversity. Curricular effects: 1) skills/barriers-intervention physicians demonstrated progressive improvements in clinical approach, accompanied by diminishing worries related to SC. PGY3 comparison physicians struggled with SC skills and worries more than PGY3 intervention physicians, 2) physician formation-most physicians described residency as profoundly challenging and transformative. Even after eight years, many intervention physicians noted that reflection on their diverse beliefs and values in safety, coupled with compassion shown to them through this curriculum, had deeply positive effects. High impact training: patient-centered spiritual assessment; chaplain rounds; spiritual self-care workshop/retreats; multicultural SC framework. CONCLUSION: A longitudinal, multifaceted residency SC curriculum can have lasting positive effects on physicians' SC skills and their professional/personal formation.

Scholarly development for primary care residents.

BACKGROUND: Development, evaluation and dissemination of primary care innovations are essential for the future of health care; however, primary care physicians including family physician, lag behind hospital-based physicians in research productivity. Family medicine residencies struggle to implement scholarly skills training programmes for busy family physicians. The Primary Care Scholarly Development Program (PC-SDP) aimed to empower residents to incorporate innovation with scholarship into future practice, by facilitating successful resident scholarly projects and reducing perceived barriers. METHODS: Educational intervention. The required PC-SDP was piloted through a family medicine residency programme in the USA. Key elements included: rigorous but achievable requirements; emphasis on Boyer's scholarship of application, teaching and discovery; resident engagement, through the support of their 'professional passions'; basic research training; multilevel mentoring; and modest curriculum time. EVALUATION: A mixed-methods longitudinal evaluation included: (1) a qualitative study of intervention class; (2) assessing the scholarly output of the intervention class versus the comparison class; and (3) a follow-up survey of both groups after 3 or 4 years. RESULTS: Data were analysed from all 25 residents in the classes of 2008 and 2009 (12 intervention; 13 comparison). Qualitative interviews of residents from the intervention group revealed that their initial feelings of trepidation about scholarly work gave way to feelings of accomplishment and confidence in their ability to integrate scholarship into busy careers. Residents in the intervention group had a greater volume of scholarly output at graduation, and follow-up surveys suggest that they value incorporating scholarship into their careers more so than physicians from the comparison group. DISCUSSION: The PC-SDP seems to foster enthusiasm for scholarship by supporting residents' professional passions and facilitating successful projects. This may foster improved participation in scholarship in future clinical practice. Primary care physicians, including family physicians, lag behind hospital-based physicians in research productivity.

Effects of adding a new PCMH block rotation and resident team to existing longitudinal training within a certified PCMH: primary care residents' attitudes, knowledge, and experience.

BACKGROUND: Although the patient-centered medical home (PCMH) model is considered important for the future of primary care in the USA, it remains unclear how best to prepare trainees for PCMH practice and leadership. Following a baseline study, the authors added a new required PCMH block rotation and resident team to an existing longitudinal PCMH immersion and didactic curriculum within a Level 3-certified PCMH, aiming for "enhanced situated learning". All 39 residents enrolled in a USA family medicine residency program during the first year of curricular implementation completed this new 4-week rotation. This study examines the effects of this rotation after 1 year. METHODS: A total of 39 intervention and 13 comparison residents were eligible participants. This multimethod study included: 1) individual interviews of postgraduate year (PGY) 3 intervention vs PGY3 comparison residents, assessing residents' PCMH attitudes, knowledge, and clinical experience, and 2) routine rotation evaluations. Interviews were audiorecorded, transcribed, and analyzed using immersion/crystallization. Rotation evaluations were analyzed using descriptive statistics and qualitative analysis of free text responses. RESULTS: Authors analyzed 23 interviews (88%) and 26 rotation evaluations (67%). Intervention PGY3s' interviews revealed more nuanced understanding of PCMH concepts and more experience with system-level PCMH tasks than those of comparison PGY3s. More intervention PGY3s rated themselves "extremely prepared" to implement PCMH than comparison PGY3s; however, most self-rated "somewhat prepared". Their reflections demonstrated deeper understanding of PCMH implementation and challenges than comparison PGY3s but inadequate experience to directly see the results of successful solutions. Rotation evaluations from PGY1, PGY2, and PGY3s revealed strengths and several areas for improvement. CONCLUSION: Adding one 4-week block rotation to existing longitudinal training appears to improve residents' PCMH knowledge, skills, and experience from "basic" to "intermediate". However, this training level appears inadequate for PCMH leadership or for teaching junior learners. Further study is needed to determine the optimum training for different settings.

Patient-Centered Medical Home Knowledge and Attitudes of Residents and Faculty: Certification Is Just the First Step.

BACKGROUND: The patient-centered medical home (PCMH) is an accepted framework for delivering high-quality primary care, prompting many residencies to transform their practices into PCMHs. Few studies have assessed the impact of these changes on residents' and faculty members' PCMH attitudes, knowledge, and skills. The family medicine program at Brown University achieved Level 3 PCMH accreditation in 2010, with training relying primarily on situated learning through immersion in PCMH practice, supplemented by didactics and a few focused clinical activities. OBJECTIVE: To assess PCMH knowledge and attitudes after Level 3 PCMH accreditation and to identify additional educational needs. METHODS: We used a qualitative approach, with semistructured, individual interviews with 12 of the program's 13 postgraduate year 3 residents and 17 of 19 core faculty. Questions assessed PCMH knowledge, attitudes, and preparedness for practicing, teaching, and leading within a PCMH. Interviews were analyzed using the immersion/crystallization method. RESULTS: Residents and faculty generally had positive attitudes toward PCMH. However, many expressed concerns that they lacked specific PCMH knowledge, and felt inadequately prepared to implement PCMH principles into their future practice or teaching. Some exceptions were faculty and resident leaders who were actively involved in the PCMH transformation. Barriers included lack of time and central roles in PCMH activities. CONCLUSIONS: Practicing in a certified PCMH training program, with passive PCMH roles and supplemental didactics, appears inadequate in preparing residents and faculty for practice or teaching in a PCMH. Purposeful curricular design and evaluation, with faculty development, may be needed to prepare the future leaders of primary care.