Impact of early waves of the COVID-19 pandemic on family medicine residency training: Analysis of survey data.

OBJECTIVE: To identify how graduating and incoming family medicine residents (FMR) experienced changes to their education during the early waves of the COVID-19 pandemic. DESIGN: The Family Medicine Longitudinal Survey was modified with questions related to the impact of COVID-19 on FMR and their training. Short-answer responses underwent thematic analysis. Responses to Likert scale and multiple-choice questions were reported as summary statistics. SETTING: Department of Family and Community Medicine at the University of Toronto in Ontario. PARTICIPANTS: Graduating FMR in spring 2020 and incoming FMR in fall 2020. MAIN OUTCOME MEASURES: Residents' perceptions of the impact of COVID-19 on clinical skills acquisition and preparedness for practice. RESULTS: Surveys response rates were 124 of 167 (74%) and 142 of 162 (88%) for graduating and incoming residents, respectively. Important themes for both cohorts included reduced access to clinical environments, reduced patient volumes, and lack of exposure to procedural skills. While the graduating cohort indicated they felt confident to begin practising family medicine, they described being impacted by the loss of a tailored learning environment, including canceled or altered electives. In contrast, incoming residents reported the loss of core skills, such as physical examination competency, as well as the loss of face-to-face communication, rapport, and relationship-building opportunities. However, both cohorts endorsed gaining new skills during the pandemic, including conducting telemedicine appointments, pandemic planning, and interfacing with public health. CONCLUSION: Based on these results, residency programs can specifically tailor solutions and modifications to address common themes across cohorts to facilitate optimal learning environments in pandemic times.

Physicians' knowledge and practices regarding screening adult patients for adverse childhood experiences: a survey.

BACKGROUND: Adverse Childhood Experiences (ACEs) are common and associated with many illnesses. Most physicians do not routinely screen for ACEs. We aimed to determine if screening is related to knowledge or medical specialty, and to assess perceived barriers. METHODS: Physicians in Ontario, Canada completed an online survey in 2018-2019. Data were analyzed in 2019. RESULTS: Participants were 89 family physicians, 46 psychiatrists and 48 other specialists. Participants screened for ACEs "never or not usually" (N = 58, 31.7%), "when indicated" (N = 67, 36.6%), "routinely" (N = 50, 27.3%) or "other" (N = 5, 2.7%). Screening was strongly associated with specialty (Chi2 = 181.0, p < .001). The modal responses were: family physicians - "when indicated" (66.3%), psychiatrists - "routinely" (91.3%), and other specialists - "never or not usually" (77.1%). Screening was not related to knowledge of prevalence of ACEs, or of the link between ACEs and mental health, but was significantly associated with knowing that ACEs are associated with physical health. Knowing that ACEs are linked to stroke, ischemic heart disease, COPD, and diabetes predicted greater screening (Chi2 15.0-17.7, each p ≤ .001). The most prevalent perceived barriers to screening were lack of mental health resources (59.0%), lack of time (59.0%), concern about causing distress (49.7%) and lack of confidence (43.7%). CONCLUSIONS: Enhancing knowledge about ACEs' negative influence on physical illness may increase screening. Efforts to promote screening should address concerns that screening is time-consuming and will increase referrals to mental health resources. Education should focus on increasing confidence with screening and with managing patient distress.

The prevalence and clinical correlates of adverse childhood experiences in a cross-sectional study of primary care patients with cardiometabolic disease or risk factors.

BACKGROUND: Adverse childhood experiences (ACEs) are associated with risk of poor adult health, including cardiometabolic diseases. Little is known about the correlates of ACEs for adults who have already developed cardiometabolic diseases, or who are at elevated risk. METHODS: Adult primary care patients with cardiometabolic disease (hypertension, diabetes, stroke, angina, myocardial infarction, coronary artery bypass graft, angioplasty) or with a risk factor (obesity, smoking, high cholesterol, family history) were surveyed regarding ACEs, psychological distress, attachment insecurity, quality of life, behavior change goals, stages of change, and attitudes toward potential prevention strategies. RESULTS: Of 387 eligible patients, 74% completed the ACEs survey. Exposure to ACEs was reported by 174 participants (61%). Controlling for age, gender, relationship status and income, number of ACEs was associated with psychological distress (F = 3.7, p = .01), quality of life (F = 8.9, p = .001), attachment anxiety (F = 3.4, p = .02), drinking alcohol most days (F = 4.0, p = .008) and smoking (F = 2.7, p = .04). Greater ACE exposure was associated with less likelihood of selecting diet or physical activity as a behavior change goal (linear-by-linear association p = .009). Stage of change was not associated with ACEs. ACEs exposure was not related to preferred resources for behavior change. CONCLUSIONS: ACEs are common among patients at cardiometabolic risk and are related to quality of life, psychological factors that influence cardiometabolic outcomes and behavior change goals. ACEs should be taken into account when managing cardiometabolic risk in family medicine.

What influences success in family medicine maternity care education programs? Qualitative exploration.

OBJECTIVE: To ascertain how program leaders in family medicine characterize success in family medicine maternity care education and determine which factors influence the success of training programs. DESIGN: Qualitative research using semistructured telephone interviews. SETTING: Purposive sample of 6 family medicine programs from 5 Canadian provinces. PARTICIPANTS: Eighteen departmental leaders and program directors. METHODS: Semistructured telephone interviews were conducted with program leaders in family medicine maternity care. Departmental leaders identified maternity care programs deemed to be "successful." Interviews were audiorecorded and transcribed verbatim. Team members conducted thematic analysis. MAIN FINDINGS: Participants considered their education programs to be successful in family medicine maternity care if residents achieved competency in intrapartum care, if graduates planned to include intrapartum care in their practices, and if their education programs were able to recruit and retain family medicine maternity care faculty. Five key factors were deemed to be critical to a program's success in family medicine maternity care: adequate clinical exposure, the presence of strong family medicine role models, a family medicine-friendly hospital environment, support for the education program from multiple sources, and a dedicated and supportive community of family medicine maternity care providers. CONCLUSION: Training programs wishing to achieve greater success in family medicine maternity care education should employ a multifaceted strategy that considers all 5 of the interdependent factors uncovered in our research. By paying particular attention to the informal processes that connect these factors, program leaders can preserve the possibility that family medicine residents will graduate with the competence and confidence to practise full-scope maternity care.

Thinking More or Feeling Less? Explaining the Foreign-Language Effect on Moral Judgment.

Would you kill one person to save five? People are more willing to accept such utilitarian action when using a foreign language than when using their native language. In six experiments, we investigated why foreign-language use affects moral choice in this way. On the one hand, the difficulty of using a foreign language might slow people down and increase deliberation, amplifying utilitarian considerations of maximizing welfare. On the other hand, use of a foreign language might stunt emotional processing, attenuating considerations of deontological rules, such as the prohibition against killing. Using a process-dissociation technique, we found that foreign-language use decreases deontological responding but does not increase utilitarian responding. This suggests that using a foreign language affects moral choice not through increased deliberation but by blunting emotional reactions associated with the violation of deontological rules.

Nudging physician prescription decisions by partitioning the order set: results of a vignette-based study.

BACKGROUND: Healthcare professionals are rapidly adopting electronic health records (EHRs). Within EHRs, seemingly innocuous menu design configurations can influence provider decisions for better or worse. OBJECTIVE: The purpose of this study was to examine whether the grouping of menu items systematically affects prescribing practices among primary care providers. PARTICIPANTS: We surveyed 166 primary care providers in a research network of practices in the greater Chicago area, of whom 84 responded (51% response rate). Respondents and non-respondents were similar on all observable dimensions except that respondents were more likely to work in an academic setting. DESIGN: The questionnaire consisted of seven clinical vignettes. Each vignette described typical signs and symptoms for acute respiratory infections, and providers chose treatments from a menu of options. For each vignette, providers were randomly assigned to one of two menu partitions. For antibiotic-inappropriate vignettes, the treatment menu either listed over-the-counter (OTC) medications individually while grouping prescriptions together, or displayed the reverse partition. For antibiotic-appropriate vignettes, the treatment menu either listed narrow-spectrum antibiotics individually while grouping broad-spectrum antibiotics, or displayed the reverse partition. MAIN MEASURES: The main outcome was provider treatment choice. For antibiotic-inappropriate vignettes, we categorized responses as prescription drugs or OTC-only options. For antibiotic-appropriate vignettes, we categorized responses as broad- or narrow-spectrum antibiotics. KEY RESULTS: Across vignettes, there was an 11.5 percentage point reduction in choosing aggressive treatment options (e.g., broad-spectrum antibiotics) when aggressive options were grouped compared to when those same options were listed individually (95% CI: 2.9 to 20.1%; p = .008). CONCLUSIONS: Provider treatment choice appears to be influenced by the grouping of menu options, suggesting that the layout of EHR order sets is not an arbitrary exercise. The careful crafting of EHR order sets can serve as an important opportunity to improve patient care without constraining physicians' ability to prescribe what they believe is best for their patients.

Incentivizing wellness in the workplace: sticks (not carrots) send stigmatizing signals.

Companies often provide incentives for employees to maintain healthy lifestyles. These incentives can take the form of either discounted premiums for healthy-weight employees ("carrot" policies) or increased premiums for overweight employees ("stick" policies). In the three studies reported here, we demonstrated that even when stick and carrot policies are formally equivalent, they do not necessarily convey the same information to employees. Stick but not carrot policies were viewed as reflecting negative company attitudes toward overweight employees (Study 1a) and were evaluated especially negatively by overweight participants (Study 1b). This was true even when overweight employees paid less money under the stick than under the carrot policy. When acting as policymakers (Study 2), participants with high levels of implicit overweight bias were especially likely to choose stick policies-often on the grounds that such policies were cost-effective-even when doing so was more costly to the company. Policymakers should realize that the framing of incentive programs can convey tacit, and sometimes stigmatizing, messages.

Development and evaluation of a primary care antimicrobial stewardship program (PC-ASP) in Toronto, Ontario, Canada.

Background: Effective community-based antimicrobial stewardship programs (ASPs) are needed because 90% of antimicrobials are prescribed in the community. A primary care ASP (PC-ASP) was evaluated for its effectiveness in lowering antibiotic prescriptions for six common infections. Methods: A multi-faceted educational program was assessed using a before-and-after design in four primary care clinics from 2015 through 2017. The primary outcome was the difference between control and intervention clinics in total antibiotic prescriptions for six common infections before and after the intervention. Secondary outcomes included changes in condition-specific antibiotic use, delayed antibiotic prescriptions, prescriptions exceeding 7 days duration, use of recommended antibiotics, and emergency department visits or hospitalizations within 30 days. Multi-method models adjusting for demographics, case mix, and clustering by physician were used to estimate treatment effects. Results: Total antibiotic prescriptions in control and intervention clinics did not differ (difference in differences = 1.7%; 95% CI -12.5% to 15.9%), nor did use of delayed prescriptions (-5.2%; 95% CI -24.2% to 13.8%). Prescriptions for longer than 7 days were significantly reduced (-21.3%; 95% CI -42.5% to -0.1%). However, only 781 of 1,777 encounters (44.0%) involved providers who completed the ASP education. Where providers completed the education, delayed prescriptions increased 17.7% (p = 0.06), and prescriptions exceeding 7 days duration declined (-27%; 95% CI -48.3% to -5.6%). Subsequent emergency department visits and hospitalizations did not increase. Conclusions: PC-ASP effectiveness on antibiotic use was variable. Shorter prescription durations and increased use of delayed prescriptions were adopted by engaged primary care providers.

Historique: Des programmes de gestion antimicrobienne (PGA) communautaires efficaces doivent exister, parce que 90 % des antimicrobiens sont prescrits dans la communauté. Des chercheurs ont évalué un PGA en première ligne (PGA-PL) afin d'en déterminer l'efficacité à réduire les prescriptions d'antibiotiques pour six infections courantes. Méthodologie: Les chercheurs ont évalué un programme de formation polyvalent au moyen d'une méthodologie avant-après dans quatre cliniques de soins de première ligne entre 2015 et 2017. Le résultat clinique primaire était la différence entre les cliniques de contrôle et d'intervention pour ce qui est du total de prescriptions antibiotiques contre six infections courantes avant et après l'intervention. Les résultats cliniques secondaires incluaient des modifications à l'utilisation des antibiotiques propres au trouble de santé, le report des prescriptions d'antibiotiques, des prescriptions de plus de sept jours, l'utilisation des antibiotiques recommandés et les visites à l'urgence ou les hospitalisations dans les 30 jours. Les chercheurs ont utilisé des méthodes multimodèles tenant compte de la démographie, du mélange de cas et du regroupement par médecin pour évaluer l'effet des traitements. Résultats: Les prescriptions totales d'antibiotiques dans les cliniques de contrôle et d'intervention ne différaient pas (différences des différences = 1,7 %; IC à 95 %, ­12,5 % à 15,9 %), ni l'utilisation de prescriptions reportées (­5,2 %; IC à 95 %, ­24,2 % à 13,8 %). Les prescriptions de plus de sept jours étaient très peu courantes (­21,3 %; IC à 95 %, ­42,5 % à ­0,1 %). Cependant, seulement 781 des 1 777 rencontres (44,0 %) avaient eu lieu avec des dispensateurs qui avaient suivi la formation sur le PGA. Lorsque les dispensateurs avaient suivi la formation, les reports de prescriptions augmentaient de 17,7 % (p = 0,06) et les prescriptions de plus de sept jours diminuaient (­27 %; IC à 95 %, ­48,3 % à ­5,6 %). Les visites subséquentes à l'urgence et les hospitalisations n'ont pas augmenté. Conclusions: L'efficacité du PGA-PL pour l'utilisation d'antibiotiques était variable. Les dispensateurs de soins de première ligne qui y avaient participé préparaient des prescriptions de moins longue durée et reportaient davantage leurs prescriptions.

Barriers and facilitators to the uptake of an antimicrobial stewardship program in primary care: A qualitative study.

The overuse of antimicrobials in primary care can be linked to an increased risk of antimicrobial-resistant bacteria for individual patients. Although there are promising signs of the benefits associated with Antimicrobial Stewardship Programs (ASPs) in hospitals and long-term care settings, there is limited knowledge in primary care settings and how to implement ASPs in these settings is unclear. In this context, a qualitative study was undertaken to explore the perceptions of primary care prescribers of the usefulness, feasibility, and experiences associated with the implementation of a pilot community-focused ASP intervention in three primary care clinics. Qualitative interviews were conducted with primary care clinicians, including local ASP champions, prescribers, and other primary health care team members, while they participated in an ASP initiative within one of three primary care clinics. An iterative conventional content analyses approach was used to analyze the transcribed interviews. Themes emerged around the key enablers and barriers associated with ASP implementation. Study findings point to key insights relevant to the scalability of community ASP activities with primary care providers.

Civic honesty around the globe.

Civic honesty is essential to social capital and economic development but is often in conflict with material self-interest. We examine the trade-off between honesty and self-interest using field experiments in 355 cities spanning 40 countries around the globe. In these experiments, we turned in more than 17,000 lost wallets containing varying amounts of money at public and private institutions and measured whether recipients contacted the owners to return the wallets. In virtually all countries, citizens were more likely to return wallets that contained more money. Neither nonexperts nor professional economists were able to predict this result. Additional data suggest that our main findings can be explained by a combination of altruistic concerns and an aversion to viewing oneself as a thief, both of which increase with the material benefits of dishonesty.

The state-of-play in physician health systems leadership research.

PURPOSE: This paper aims to review a decade of evidence on physician participation in health system leadership with the view to better understand the current state of scholarship on physician leadership activity in health systems. This includes examining the available evidence on both physicians' experiences of health systems leadership (HSL) and the impact of physician leadership on health system reform. DESIGN/METHODOLOGY/APPROACH: A state-of-the-art review of studies (between 2007 and 2017); 51 papers were identified, analyzed thematically and synthesized narratively. FINDINGS: Six main themes were identified in the literature as follows: (De)motivation for leadership, leadership readiness and career development, work demands and rewards, identity matters: acceptance of self (and other) as leader, leadership processes and relationships across health systems and leadership in relation to health system outcomes. There were seemingly contradictory findings across some studies, pointing to the influence of regional and cultural contextual variation on leadership practices as well entrenched paradoxical tensions in health system organizations. RESEARCH LIMITATIONS/IMPLICATIONS: Future research should examine the influence of varying structural and psychological empowerment on physician leadership practices. Empirical attention to paradoxical tensions (e.g. between empowerment and control) in HSL is needed, with specific attention to questions on how such tensions influence leaders' decision-making about system reform. ORIGINALITY/VALUE: This review provides a broad synthesis of diverse papers about physician participation in health system leadership. Thus, it offers a comprehensive empirical synthesis of contemporary concerns and identifies important avenues for future research.

Is postgraduate leadership education a match for the wicked problems of health systems leadership? A critical systematic review.

PURPOSE: There have been a growing number of leadership education programs for physicians. However, debates about the value and efficacy of leadership education in medicine persist, and there are calls for systematic and critical perspectives on medical leadership development. Here, we review evidence on postgraduate leadership education and discuss findings in relation to contemporary evidence on leadership education and practice. METHOD: We searched multiple databases for papers on postgraduate leadership development programs, published in English between 2007 and 2017. We identified 4,691 papers; 31 papers met the full inclusion criteria. Data regarding curricular content and design, learner demographics, instructional methods, and learning outcomes were abstracted and synthesized. RESULTS: There was modest evidence for effectiveness of programs in influencing knowledge and skills gains in select domains. However, the conceptual underpinnings of the 'leadership' training delivered were often unclear. Contemporary theory and evidence on leadership practice was not widely incorporated in program design. Programs were almost exclusively uni-professional, focused on discrete skill development, and did not address systems-level leadership issues. Broader leadership capacity building strategies were underutilized. A new wave of longitudinal, integrated clinical and leadership programming is observed. CONCLUSIONS: Our findings raise questions about persistent preparation-practice gaps in leadership education in medicine. Leadership education needs to evolve to incorporate broader collective capacity building, as well as evidence-informed strategies for leadership development. Barriers to educational reform need to be identified and addressed as educators work to re-orientate education programs to better prepare budding physician leaders for the challenges of health system leadership.

A comparative analysis of the perceived continuing medical education needs of a cohort of rural and urban Canadian family physicians.

OBJECTIVE: To assess the perceived continuing medical education (CME) needs of a cohort of Canadian family physicians. METHODS: We distributed a questionnaire survey to Canadian family physicians who became Certificant members of the College of Family Physicians in 2001 and practised outside the province of Quebec. Main outcome measures were self-reported CME needs, professional development needs and preferences for CME delivery methods. RESULTS: We distributed 482 surveys and 197 questionnaires were returned for a response rate of 40.9%. Significant differences between rural and urban respondents' self-reported CME needs were found in the clinical areas of dermatology, endocrinology, emergency medicine, musculoskeletal, ophthalmology, otolaryngology, psychiatry and urology. Generally, a greater proportion of rural respondents reported significantly higher CME needs in emergency medicine. Urban respondents reported a significant preference for consulting colleagues as a method of CME, while rural respondents reported a significant preference for videoconferencing. CONCLUSION: Self-reported CME needs and preferences for CME delivery methods differ on the basis of region of practice and size of the community in which family physicians' practise.