Storylines of family medicine VII: family medicine across the lifespan.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'VII: family medicine across the lifespan', authors address the following themes: 'Family medicine maternity care', 'Seeing children as patients brings joy to work', 'Family medicine and the care of adolescents', 'Reproductive healthcare across the lifespan', 'Men's health', 'Care of older adults', and 'Being with dying'. May readers appreciate the range of family medicine in these essays.

Living fully in the shadow of mortal time: psychosocial assets in advanced cancer.

OBJECTIVE: This study aimed to characterize the strategies and psychosocial conditions that influence how resilient people live in the face of advanced cancer. METHODS: Grounded theory interviews and a survey of 10 resilient people with advanced cancer were collected and analyzed. FINDINGS: Personal assets - including positive relationships, purpose in life, faith, and mastery--contributed to living fully in mortal time. Strategies included embracing paradox, reframing time, deepening connections, and aligning actions with priorities. Open-ended interviews yielded rich illness and life stories; many participants requested a copy of the transcript. CONCLUSION: Resilient people use a range of strategies to thrive in the face of advanced cancer.

Top Ten Tips Palliative Care Clinicians Should Know About Integrative Palliative Care.

Integrative medicine (IM) use is widespread among individuals living with serious illness. There is a natural alignment between the fields of IM and palliative care (PC) rooted in their shared core values. Integrative palliative care (IPC) is an emerging focus within the field of PC that aims to broaden the healing toolkit available to patients with serious illness by combining standard-of-care biomedical treatments with evidence-informed integrative and complementary medicine practices with the goal of enhancing quality of life at every stage of a person's health journey. This article is an evidence-based guide to incorporating IPC practices into the care of seriously ill individuals.

Placebo effects and the common cold: a randomized controlled trial.

PURPOSE: We wanted to determine whether the severity and duration of illness caused by the common cold are influenced by randomized assignment to open-label pills, compared with conventional double-blind allocation to active and placebo pills, compared with no pills at all. METHODS: We undertook a randomized controlled trial among a population with new-onset common cold. Study participants were allocated to 4 parallel groups: (1) those receiving no pills, (2) those blinded to placebo, (3) those blinded to echinacea, and (4) those given open-label echinacea. Primary outcomes were illness duration and area-under-the-curve global severity. Secondary outcomes included neutrophil count and interleukin 8 levels from nasal wash at intake and 2 days later. RESULTS: Of 719 randomized study participants, 2 were lost and 4 exited early. Participants were 64% female, 88% white, and aged 12 to 80 years. Mean illness duration for each group was 7.03 days for those in the no-pill group, 6.87 days for those blinded to placebo, 6.34 days for those blinded to echinacea, and 6.76 days for those in the open-label echinacea group. Mean global severity scores for the 4 groups were no pills, 286; blinded to placebo, 264; blinded to echinacea, 236; and open-label echinacea, 258. Between-group differences were not statistically significant. Comparing the no-pill with blinded to placebo groups, differences (95% confidence interval [CI]) were -0.16 days (95% CI, -0.90 to 0.58 days) for illness duration and -22 severity points (95% CI, -70 to 26 points) for global severity. Comparing the group blinded to echinacea with the open-label echinacea group, differences were 0.42 days (95% CI, -0.28 to 1.12 days) and 22 severity points (95% CI, -19 to 63 points). Median change in interleukin 8 concentration and neutrophil cell count, respectively by group, were 30 pg/mL and 1 cell for the no-pill group, 39 pg/mL and 1 cell for the group binded to placebo, 58 pg/mL and 2 cells for the group blinded to echinacea, and 70 pg/mL and 1 cell for the group with open-label echinacea, also not statistically significant. Among the 120 participants who at intake rated echinacea's effectiveness as greater than 50 on a 100-point scale for which 100 is extremely effective, illness duration was 2.58 days shorter (95% CI, -4.47 to -0.68 days) in those blinded to placebo rather than no pill, and mean global severity score was 26% lower but not significantly different (-97.0, 95% CI, -249.8 to 55.8 points). In this subgroup, neither duration nor severity differed significantly between the group blinded to echinacea and the open-label echinacea group. CONCLUSIONS: Participants randomized to the no-pill group tended to have longer and more severe illnesses than those who received pills. For the subgroup who believed in echinacea and received pills, illnesses were substantively shorter and less severe, regardless of whether the pills contained echinacea. These findings support the general idea that beliefs and feelings about treatments may be important and perhaps should be taken into consideration when making medical decisions.

Unmet needs and opportunities for improving care for patients with advanced lung cancer on targeted therapies: a qualitative study.

OBJECTIVE: Lung cancer is increasingly recognised as a heterogeneous disease. Recent advances with targeted therapies for lung cancer with oncogenic mutations have greatly improved the prognosis for this subset of patients, yet little is known about their experiences. This study aimed to identify the needs and explore the healthcare experiences of these advanced patients with oncogenic mutation driven lung cancer. DESIGN: Qualitative interviews with patients with advanced or metastatic non-small cell lung cancer with oncogenic alterations in anaplastic lymphoma kinase, epidermal growth factor receptor or c-ros oncogene 1. SETTINGS: Patients were recruited from online lung cancer support groups within the USA. Interviews were conducted remotely or in person, transcribed verbatim and analysed using an iterative inductive and deductive process. PARTICIPANTS: We included 39 patients (11 males and 28 females) with a median age of 48. RESULTS: Two primary theme categories emerged: patients' unmet needs and improving healthcare experiences. Unmet needs are related to patients' desire to view their disease as a chronic illness, aspire to live a meaningful existence without financial devastation, desire for understanding along with emotional support and needing help with practical matters. Improving healthcare experiences involved patients' desire to trust the expertise of clinical providers, receive reliable care and be treated holistically and as informed partners. CONCLUSIONS: Patients with lung cancer with oncogenic mutations live uncharted experiences. Targeted therapy brings hope, but uncertainty is daunting. Patients grapple with the meaning and purpose of their lives while day-to-day obligations remain challenging. Healthcare teams are instrumental in their care experiences, and patients desire providers who are up-to-date on advances in the field and treat them as whole persons.

Family medicine residency educational characteristics and career satisfaction in recent graduates.

BACKGROUND AND OBJECTIVES: Career satisfaction among family physicians has declined over the last 15 years. The purpose of this study was to determine what aspects of residency training are associated with family medicine career satisfaction in recent graduates. METHODS: This was a cross-sectional national survey of 1000 family physicians who graduated within the last 10 years. Questions were primarily Likert type. Exploratory factor analysis was used to identify retained factors. Bivariate and multivariate linear regression analyses were performed to identify residency characteristics, demographics, and current work characteristics that were associated with career satisfaction. RESULTS: The response rate was 55.8% (558/1000). Exploratory factor analysis found three factors that explained the majority of the variance in career satisfaction: overall work life, rigorous residency training, and demographic factors. Many features of residency training were associated with career satisfaction on bivariate analysis. Multivariate analysis found that training that was exceptionally broad and in-depth was independently associated with career satisfaction. The factors with the largest association with career satisfaction were medical career satisfaction and current work satisfaction. DISCUSSION: Our findings suggest that residency education that was broad and in-depth was associated with early family medicine career satisfaction. This construct reflected rigorous training that included hands-on procedural experience, breadth of experiences with patients and illness, and care for complex hospitalized patients.

Suffering in Advanced Cancer: A Randomized Control Trial of a Narrative Intervention.

BACKGROUND: Advanced cancer can erode patients' wellbeing. Narrative interventions have improved patients' wellbeing, but might not be feasible for widespread implementation. OBJECTIVES: (1) Test the effects of miLivingStory, a telephone-based life review and illness narrative intervention with online resources and social networking, on community-dwelling advanced cancer patients' wellbeing. (2) Explore intervention use and satisfaction. PATIENTS AND SETTING: Stage III or IV cancer patients having completed initial therapy were randomized to miLivingStory or to an active control group, miOwnResources. Data and Analysis: Primary outcomes measured at baseline, two and four months included subscales for the FACIT-Sp peace and meaning and the POMS-SF depressed, anxious, and angry mood, scored on 0-4-point Likert scales. Linear mixed modeling, controlling for baseline primary outcome scores, tested for group comparisons of repeated outcome measures. Pairwise comparisons tested for within- and between-group differences. Intervention use and satisfaction data were collected automatically and by survey. RESULTS: Eighty-six primarily white, female patients with high baseline wellbeing completed the study. There were no between-group differences at baseline or at two months. At four months, miLivingStory had a direct and positive effect for peace (2.86 vs. 2.57, p = 0.029), a trend effect for lower depressed mood (0.55 vs. 0.77, p = 0.097), and appeared to protect against the control group's declining wellbeing between two and four months. miLivingStory use was low and assessed as helpful to quite helpful. CONCLUSIONS: Telephone-based narrative interventions hold promise in improving advanced cancer patients' wellbeing. Further testing of delivery and implementation strategies is warranted.

Rationale and methods for a trial assessing placebo, echinacea, and doctor-patient interaction in the common cold.

BACKGROUND: Clinical medicine and healthcare policy are increasingly guided by randomized controlled trials, which in turn are dependent on the validity of placebo control. It is important to understand the effects of placebo control on outcome measurement, especially for assessment of symptoms and functional impairments where subjectivity, expectancy, and motivation may significantly impact outcome evaluation. This paper describes the rationale and methodology of a trial designed to evaluate placebo effects related to taking pills and to compare these with effects attributable to standard or enhanced (patient-oriented) doctor-patient interaction. DESIGN: This trial uses two-way factorial allocation to randomize people with new onset common cold in two directions: pill related and doctor related. In one direction, participants are randomized to (1) no pills, (2) blinded placebo, (3) blinded echinacea, or (4) unblinded open-label echinacea. In the other direction, participants are randomized to: (1) no doctor-patient interaction, (2) standard doctor-patient interaction, and (3) enhanced doctor-patient interaction. Enhanced interaction includes education, empathy, empowerment, positive prognosis, and connectedness. Area under the time severity curve is the primary outcome, with the Wisconsin Upper Respiratory Symptom Survey (WURSS-21) the measure of severity. A priori power studies called for a sample size of N = 720 trial finishers to detect 15% to 20% between-group differences in this outcome. Secondary outcomes include general health-related quality of life, perceived stress, interpersonal support, optimism, patient satisfaction, and positive and negative affectivity. Two biomarkers are also assessed: interleukin-8 (inflammatory cytokine) and neutrophil count from nasal wash. IMPORTANCE: This paper describes the rationale and methodology of a trial assessing placebo effects related to pills and to doctor-patient interaction. This is one of very few similar studies and is the first in the common cold. Data collected will also provide an excellent opportunity to investigate relationships among demographic (age, sex, education, income) and psychosocial (perceived stress, interpersonal support, optimism, affectivity) indicators in relation to common cold outcomes.

Qualitative aspects of nasal irrigation use by patients with chronic sinus disease in a multimethod study.

PURPOSE: We qualitatively assessed attitudes regarding use of hypertonic saline nasal irrigation (HSNI) for frequent rhinosinusitis and chronic sinonasal symptoms in a 3-part, multimethod study. METHODS: We conducted semistructured, in-depth interviews with 28 participants who recently used nasal irrigation in studies assessing HSNI. RESULTS: Four themes emerged: (1) HSNI improved self-management of sinus symptoms, creating a sense of empowerment; (2) HSNI produced rapid and long-term improvement in quality of life; (3) participants identified discomfort, time, and mild side effects as barriers to HSNI use; and (4) participants identified aspects of training and at-home use that overcame these barriers. CONCLUSION: HSNI is a safe, well-tolerated, inexpensive, effective, long-term therapy that patients with chronic sinonasal symptoms can and will use at home with minimal training and follow-up. Success with HSNI will likely be improved by patient education.

Building successful coalitions for promoting advance care planning.

Advance care planning (ACP) has had few successful initiatives. This qualitative study explores the challenges and successes of an advance care planning coalition in Wisconsin called Life Planning 2000 using key informant interviews (n = 24) and grounded theory. Major themes included: commitment (the need for leadership, recruitment of key members, and funding); cohesiveness (disparate groups collaborating toward a common purpose), and outcomes (shift in paradigm from signing documents to process of advanced care planning, new-found collaborative relationships, and educational tool development). Coalitions need to define short-, intermediate-, and long-term goals that result in measurable outcomes and an evaluation process. Resources must be commensurate with goals. Strong leadership, paid staff adequate funding, and the collaboration of diverse groups working toward common goals are the basic requirements of a successful coalition.

Quality of work life of independent vs employed family physicians in Wisconsin: a WReN study.

PURPOSE: Family physicians in Wisconsin who are mainly employed by large health care organizations have voiced concerns regarding the quality of their work lives. We explored the quality of work life and its relationship to employment by health care organizations. METHODS: We conducted a cross-sectional survey of the 1,482 active members of the Wisconsin Academy of Family Physicians in 2000. RESULTS: A 47% overall response rate was obtained, and 584 respondents could be identified as independent or employed by a health care organization. There were no differences in age or sex between the 2 groups. The independent physicians worked longer hours, were in smaller work groups, and had been in practice longer and in their current practice longer than the employed physicians. Independent physicians reported better working relationships, more satisfaction with family time, more influence over management decisions, better satisfaction with being a physician, better perceived quality of the care they provided, greater ability to achieve professional goals, and lesser intention to leave the practice. CONCLUSIONS: Independent physicians have significantly more positive ratings of several aspects of the quality of their work life compared with physicians employed by health care organizations. Health care organizations need to address these issues if they are to have a satisfied and stable workforce.

Building successful coalitions to promote advance care planning.

This qualitative study explored the challenges and successes of an advance care planning (ACP) coalition formed at the University of Wisconsin called Life Planning 2000. Data were obtained from key informant interviews (n = 24) and grounded theory. Major themes included commitment (the need for leadership, recruitment of key persons, and funding); cohesiveness (disparate groups collaborating toward a common purpose); and outcomes (including educational tool development). Coalitions need to define short-, intermediate-, and long-term goals that result in measurable outcomes and an evaluation process. Resources must be commensurate with goals. Results indicate that strong leadership, paid staff adequate funding, and the collaboration of diverse groups working toward a common goal are essential if a coalition promoting end-of-life (EOL) care planning is to be successful.

Optimal collection technique and devices for a quality pap smear.

BACKGROUND: Collection technique is critical in the performance of the Papanicolaou (Pap) smear as an important screening tool for cervical cancer. While superior devices have been established, less effective devices continue to be used for both conventional and liquid-based Pap smears. Our aim is to determine the performance of collection devices currently used in obtaining conventional Pap smears and whether sequence of collection is important for higher quality results. METHODS: This prospective, blinded, cohort study used 2 cytology labs to analyze Pap smears done within a 1-year period. Study participants were 128 clinicians who practice in Dane County, Wis, who send their Pap smears to either of the 2 study cytology labs. Participants included advance practice nurses, family physicians, and obstetrician/gynecologists. Logistic regression was utilized for analysis. RESULTS: In conventional Pap smears, sequence of collection did not affect any quality indicators. The Cervex-brush (broom) was associated with absent endocervical cells (Odds Ratio = 3.12, P < .001), limited or unsatisfactory results (OR = 1.68, P < .01), and obscuring inflammation (OR = 2.01, P < .01). Of those clinicians who had high levels of absent endocervical cells on their Pap smears (defined as > 3/30 Pap smears), 47% used the broom alone. The Cytobrush optimized quality indicators, and the combination of the Cytobrush for the endocervix and spatula for the ectocervix was superior. Presence of infectious agents also contributed to the absence of endocervical cells (OR = 3.09, P < .001). CONCLUSIONS: The combination of the Cytobrush (endocervix) and spatula (ectocervix) is superior for a quality Pap smear. The sequence of collection was not important in conventional Pap smears. The broom alone performs poorly. Presence of infection decreases quality.

Shared presence: The heart of the therapeutic relationship.

Shared presence is cultivated in every clinical experience, but some interactions lend themselves to shared presence more easily than others. Shared presence requires at least two people to be in relationship, and the patient side of shared presence can be influenced by physician or clinician factors, but not completely. We can only cultivate the qualities in ourselves that facilitate shared presence, and invite the patient, family, and others to enter into this presence with us. But we do know that if we do our part to cultivate presence, the likelihood of a more meaningful interaction with patients may occur together with all of the benefits outlined in this article.

Death pronouncements: using the teachable moment in end-of-life care residency training.

INTRODUCTION: Performing death pronouncement and communicating effectively with gathered family is an important skill relevant to end-of-life care. Often it is a responsibility of first-year residents who lack proper training or emotional preparation for the task. Residents' tension about this task presents an opportunity to positively effect their emotions and build skills for providing end of life care in the future. This paper describes a death pronouncement workshop including its objectives specific to Accreditation Council on Graduate Medical Education (ACGME) competencies, its format and its evolution over 8 years. METHODS: Multiple media and methods are used in the 90-minute workshop for first-year family practice residents including poetry, prose, and narratives on doing death pronouncements by senior residents; reviews and discussion of protocols for death pronouncement, autopsy, and organ donation; and a role-play of a death pronouncement with the opportunity for reflection. RESULTS: Residents consistently provide high ratings for the overall value of workshop. CONCLUSIONS: The death pronouncement workshop serves to prepare residents emotionally to deal with dying patients and provides them the skills to effectively and compassionately communicate with those patients' families while addressing all six ACGME core competencies.

Integrating the art and science of medical practice: innovations in teaching medical communication skills.

BACKGROUND AND OBJECTIVES: This paper describes the content and methods used to teach communication skills in Undergraduate Medical Education for the 21st Century (UME-21) schools and provides suggestions for future efforts. METHODS: Faculty leaders of curriculum projects at UME-21 schools provided reports describing new communication curriculum projects. Reports were reviewed and analyzed, curriculum content and methods were categorized into themes, and findings were confirmed through phone interviews with lead faculty at each participating school. RESULTS: Curriculum projects were designed to improve medical students' communication skills during the clerkship years at 12 participating UME-21 schools. These skills were addressed through a variety of teaching methods and applied in interactions with patients, health teams, and community members. Curricular themes included conflict resolution, delivery of bad news, addressing patient preferences for end-of-life care, patient and community health education, communicating with families, and working effectively with patients from diverse backgrounds. Students' communication skill competencies were assessed through a variety of methods including objective structured clinical examinations, focused observation and feedback, and debriefing sessions based on recall, audiotapes, or videotapes of encounters. CONCLUSIONS: Opportunities for students to develop, apply, and refine their communication skills can be embedded throughout the medical school curricula. Our findings illustrate the variety of methods that may be used to teach and evaluate medical students' communication skill competencies. Future challenges include development of comprehensive longitudinal curricula, practical teaching methods, valid evaluation tools, and faculty development.

Themes of holism, empowerment, access, and legitimacy define complementary, alternative, and integrative medicine in relation to conventional biomedicine.

Complementary and alternative medicine (CAM) has been defined largely in relation to conventional biomedicine. CAM therapies that are used instead of conventional medicine are termed "alternative." CAM therapies used alongside conventional medicine are said to be "complementary." "Integrative medicine" results from the thoughtful incorporation of concepts, values, and practices from alternative, complementary, and conventional medicines. The evolving process of integration between CAM and conventional medicine evokes new conceptual frameworks, as well as new terminology. Interview-based qualitative research at the University of Wisconsin-Madison seeks to probe and develop this theoretical structure. Interviews with users and practitioners of CAM therapies have revealed four primary themes: holism, empowerment, access, and legitimacy (HEAL). These themes characterize CAM and contrast it with conventional medicine. CAM is said to be more holistic and empowering yet less legitimate than conventional medicine. CAM is more intuitive; conventional is more deductive. While CAM is perhaps more psychologically accessible to many patients in that it better reflects commonly held values, it is often less financially and institutionally accessible, at least for those with conventional health insurance and limited income. Substantive barriers--including economic, organizational and scientific differences, as well as an apparent widespread lack of understanding--continue to thwart attempts at integration. More and better evidence is needed if CAM therapies are to be accepted by mainstream medicine. State-of-the-art research methods developed by conventional science will be needed to test CAM therapies. Conventional medicine, however, has much to learn from CAM. By incorporating a more holistic, empowering and accessible therapeutic approach, conventional medicine could build on its present legitimacy, and thereby enhance its power to "HEAL."

Current cervical cancer screening practices of Dane County, Wisconsin primary care clinicians.

PURPOSE: This study explores clinician Papanicolaou (Pap) smear collection and management strategies in light of current research, guidelines, and recommendations. METHODS: Two hundred thirty eligible obstetrician/gynecologists, family physicians, and advance practice nurses in Dane County, Wisconsin completed a survey. Descriptive statistics. RESULTS: The wooden spatula is most frequently (68%) used to collect ectocervical cells; the Cytobrush (75%) for endocervical cells. Most clinicians (63%) collect ectocervical cells first, endocervical cells second. Eighty-nine percent of clinicians are familiar with liquid-based Pap smears; 57% use them. Most clinicians (59%) prepare the cervix as needed prior to collecting a sample. Management of inflammation is variable. Forty-five percent of clinicians have no age limit in discontinuing Pap smears; 43% continue after benign hysterectomy. Training for doing Pap smears occurs primarily in residency (89%) or graduate nursing education (83%). CONCLUSIONS: Despite current research and guidelines, great variability exists among clinicians in Pap smear collection and management. Textbooks, articles, and clinician training must emphasize optimal collection technique and management to improve Pap smear quality and decrease unnecessary costs.

Quality of work life of family physicians in Wisconsin's health care organizations: a WReN study.

PROBLEM CONSIDERED: Most family physicians in Wisconsin are employed by large health care organizations. Because of its impact on physician recruitment, retention, commitment to the organization, and patient care, the quality of physician work life is an important problem. METHODS: A survey was designed based on a literature review and augmented by focus group data. It was sent to all 1482 members of the Wisconsin Academy of Family Physicians in 2000. RESULTS: Overall response rate was 47%. Three hundred ninety-seven of the respondents were employed by 18 different health care organizations having 10 or more respondents. There were significant differences among Wisconsin's health care organizations in terms of physicians' satisfaction with their organization. There was a strong significant negative correlation between satisfaction with one's organization and turnover intention and a strong positive correlation between satisfaction with one's organization and ability to achieve one's professional goals. There were also significant, though less strong, correlations between satisfaction with one's organization and satisfaction with being a physician and perceived quality of care delivered. CONCLUSIONS: Some of Wisconsin's health care organizations are doing better than others at working with their family physicians to maximize these physicians' satisfaction with the organization, reduce the likelihood of turnover, and enable them to reach their professional goals.