Residents' Reflections on Cost-Conscious Care after International Health Electives: A Single-Center Qualitative Study.

BACKGROUND: Estimates suggest 30% of health care expenditures are wasteful. This has led to increased educational interventions in graduate medical education (GME) training aimed to prepare residents for high value, cost-conscious practice. International health electives (IHE) are widely available in GME training and may be provide trainees a unique perspective on principles related to high value, cost-conscious care (HVCCC). OBJECTIVE: The purpose of this study was to explore how trainee reflections on IHE experiences offer insight into HVCCC. DESIGN: The authors conducted an applied thematic analysis of narrative reflective reports of GME trainees' IHE experiences to characterize their perceptions of HVCCC. PARTICIPANTS: The Mayo International Health Program (MIHP) supports residents and fellows from all specialties across all Mayo Clinic sites. We included 546 MIHP participants from 2001 to 2020. APPROACH: The authors collected post-elective narrative reports from all MIHP participants. Reflections were coded and themes were organized into model for transformative learning during IHEs, focusing on HVCCC. KEY RESULTS: GME trainees across 24 different medical specialties participated in IHEs in 73 different countries. Three components of transformative learning were identified: disorienting dilemma, critical reflection, and commitment to behavior change. Within the component of critical reflection, three topics related to HVCCC were identified: cost transparency, resource stewardship, and reduced fear of litigation. Transformation was demonstrated through reflection on future behavioral change, including cost-aware practice, stepwise approach to health care, and greater reliance on clinical skills. CONCLUSIONS: IHEs provide rich experiences for transformative learning and reflection on HVCCC. These experiences may help shape trainees' ideology of and commitment to HVCCC practices.

Graduate medical education competencies for international health electives: A qualitative study.

BACKGROUND: Residency programs offer international health electives (IHEs), providing multiple educational benefits. This study aimed to identify how IHEs fulfill the Accreditation Council for Graduate Medical Education (ACGME) core competencies. METHODS: We conducted a thematic analysis of post-rotation reflective reports from residents who participated in IHEs through the Mayo International Health Program. We coded reports using a codebook created from the ACGME competencies. Using a constant comparative method, we identified significant themes within each competency. RESULTS: Residents from 40 specialties participated in 377 IHEs in 56 countries from 2001 to 2014. Multiple themes were identified within each of the six ACGME core competencies: Patient Care and Procedural Skills (4), Medical Knowledge (5), Practice-Based Learning and Improvement (3), Interpersonal and Communication Skills (5), Professionalism (4), and Systems-Based Practice and Improvement (3). Themes included improving physical exam and procedural skills, providing care in resource-limited setting, gaining knowledge of tropical and non-tropical diseases, identifying socioeconomic determinants of health, engaging in the education of others, and increasing communication across cultures and multidisciplinary teams. CONCLUSIONS: Through IHEs, residents advanced their knowledge, skills, and attitudes in each of the six ACGME competencies. These data can be used for development of IHE competencies and milestones for resident assessment.

Dual-energy CT for the diagnosis of gout: an accuracy and diagnostic yield study.

OBJECTIVES: To assess the accuracy of dual-energy CT (DECT) for diagnosing gout, and to explore whether it can have any impact on clinical decision making beyond the established diagnostic approach using polarising microscopy of synovial fluid (diagnostic yield). METHODS: Diagnostic single-centre study of 40 patients with active gout, and 41 individuals with other types of joint disease. Sensitivity and specificity of DECT for diagnosing gout was calculated against a combined reference standard (polarising and electron microscopy of synovial fluid). To explore the diagnostic yield of DECT scanning, a third cohort was assembled consisting of patients with inflammatory arthritis and risk factors for gout who had negative synovial fluid polarising microscopy results. Among these patients, the proportion of subjects with DECT findings indicating a diagnosis of gout was assessed. RESULTS: The sensitivity and specificity of DECT for diagnosing gout was 0.90 (95% CI 0.76 to 0.97) and 0.83 (95% CI 0.68 to 0.93), respectively. All false negative patients were observed among patients with acute, recent-onset gout. All false positive patients had advanced knee osteoarthritis. DECT in the diagnostic yield cohort revealed evidence of uric acid deposition in 14 out of 30 patients (46.7%). CONCLUSIONS: DECT provides good diagnostic accuracy for detection of monosodium urate (MSU) deposits in patients with gout. However, sensitivity is lower in patients with recent-onset disease. DECT has a significant impact on clinical decision making when gout is suspected, but polarising microscopy of synovial fluid fails to demonstrate the presence of MSU crystals.

Health Care Providers Working Cross-Culturally: Pitfalls, Pearls, and Preparation Resources for Culture Shock.

Health care providers engaging in cross-cultural work will likely experience culture shock, a psychological, behavioral, and physiologic response to new cultural environments that can significantly affect travelers. Culture shock has the potential for both negative and positive outcomes. Well-being, health, and professionalism can be negatively influenced during the peak of culture shock, but the experience may also positively promote transformative learning and professional identity formation. Culture shock has been carefully researched for different types of sojourners, such as undergraduate students and business personnel, but minimally for health care providers. This article defines culture shock, describes different health care-related cross-cultural opportunities, identifies factors contributing to culture shock, describes complexities related to measuring culture shock, depicts common cross-cultural challenges encountered by traveling health care providers, and offers tangible guidance to help prepare for culture shock. We conclude with a call for further research and resource development to support the well-being of an increasingly global health care workforce. [Pediatr Ann. 2023;52(9):e335-e343.].

Skin Biopsy Techniques.

Because many skin lesions and disorders can appear similar, primary care clinicians often struggle to diagnose them definitively without histopathologic information obtained from a biopsy. This review article explains how to decide whether a lesion should be biopsied and what type of biopsy technique to use and then outlines the stepwise approach to each of the most common skin biopsy techniques: shave, saucerization, punch, fusiform, and subcutaneous nodule biopsies. Finally, potential pitfalls and complications are discussed so the clinician can avoid those and can provide a cosmetically acceptable result from these common outpatient procedures.

Vitamin D Status and Severe COVID-19 Disease Outcomes in Hospitalized Patients.

BACKGROUND: Vitamin D deficiency may increase the risk of severe COVID-19 disease. OBJECTIVES: To determine if 25-hydroxyvitamin D [25(OH)D] levels in patients hospitalized for COVID-19 were associated with the clinical outcomes of days on oxygen, duration of hospitalization, ICU admission, need for assisted ventilation, or mortality. METHODS: We conducted a retrospective study of 92 patients admitted to the hospital with SARS-CoV-2 infection between April 16, 2020 and October 17, 2020. Multivariable regression was performed to assess the independent relationship of 25(OH)D values on outcomes, adjusting for significant covariates and the hospitalization day the level was tested. RESULTS: About 15 patients (16.3%) had 25(OH)D levels <20 ng/mL. Only 1 patient (3.4%) who had documented vitamin D supplementation prior to admission had 25(OH)D <20 ng/mL. Serum 25(OH)D concentrations were not significantly associated with any of our primary outcomes of days on oxygen, duration of hospitalization, intensive care unit (ICU) admission, need for mechanical ventilation, or mortality in any of the adjusted multivariable models. Adjusting for the hospital day of 25(OH)D sampling did not alter the relationship of 25(OH)D with any outcomes. CONCLUSION: Vitamin D status was not related to any of the primary outcomes reflecting severity of COVID-19 in hospitalized patients. However, our sample size may have lacked sufficient power to demonstrate a small effect of vitamin D status on these outcomes.

Trigger Finger? Just Shoot!

Trigger finger is a common condition usually curable by a safe, simple corticosteroid injection. Trigger finger results from a stenotic A1 pulley that has lost its gliding surface producing friction and nodular change in the tendon. This results in pain and tenderness to palpation of the A1 pulley, progressing to catching and then locking. Splinting for 6 to 9 weeks produces gradual improvement in most patients as does a quick steroid injection with the latter resulting in resolution of pain in days and resolution of catching or locking in a few weeks. Percutaneous or open release should be reserved for injection failures particularly those at high risk for continued injection failure including diabetics and those with multiple trigger fingers. We present a step-by-step method for injection with illustrations to encourage primary care providers to offer this easily performed procedure to their patients.

Youth, unemployment, and male gender predict mortality in AIDS patients started on HAART in Nigeria.

This retrospective study identifies risk factors for mortality in a cohort of HIV-positive adult patients treated with highly active antiretroviral therapy (HAART) in Jos, Nigeria. We analyzed clinical data from a cohort of 1552 patients enrolled in a HIV/acquired immune deficiency syndrome treatment program and started on HAART between December 2004 and 30 April 2006. Death was our study endpoint. Patients were followed in the study until death, being lost to follow-up, or the end of data collection, 1 December 2006. Baseline patient characteristics were compared using Wilcoxon Rank Sum Test for continuous variables and Pearson Chi-Square test for categorical variables to determine if certain demographic factors were associated with more rapid progression to death. The Cox proportional hazard multivariate model analysis was used to find risk factors. As of 1 December 2006, a total of 104 cases progressed to death. In addition to the expected association of CD4 count less than 50 at initiation of therapy and active tuberculosis with mortality, the patient characteristics independently associated with a more rapid progression to death after initiation of HAART were male gender, age less than 30 years old, and unemployment or unknown occupation status. Future research is needed to identify the confounding variables that may be amenable to targeted interventions aimed at ameliorating these health disparities.

Dealing With Patient Death on International Health Electives: A Qualitative Study of Residents' Experiences.

PURPOSE: International health electives (IHEs) provide numerous educational benefits; potential harms are less well understood. One potential harm is trainee distress associated with increased patient death during IHEs. The purpose of this study was to explore residents' and fellows' IHE experiences with patient death. METHOD: The authors used applied thematic analysis to explore residents' and fellows' IHE experiences with patient death. The Mayo International Health Program supports IHEs from all specialties across three Mayo Clinic sites. Data were collected and analyzed in two steps. First the authors collected, coded, and analyzed narrative reflections from 43 postrotation reports gathered in 2001-2017 and identified themes relating to experiences with patient death. Second, in 2016-2017 the authors conducted semistructured interviews with six previous participants to refine thematic analysis. RESULTS: Participants described impacts of experiencing increased patient death and identified themes in two domains: difficult experiences with patient death and potential interventions to help residents process their experiences. They identified four themes illustrating why these experiences were difficult: lack of preparation for increased exposure to death, lack of closure, consequences of limited resources, and differences in cultural beliefs regarding death. While pretrip preparation for dealing with death was viewed as important, trainees identified support during and debriefing after IHEs as additional important interventions. CONCLUSIONS: Given the popularity of IHEs, residency programs should consider the effect on trainees of increased exposure to patient death. Study findings can inform IHE preparation, support, and debriefing to minimize distress associated with witnessing patient deaths on IHEs.

The preferences of adult outpatients in medical or dental care settings for giving saliva, urine or blood for clinical testing.

BACKGROUND: The design of new diagnostic tests would benefit from knowing patients' preferences for the collection of bodily fluids. These preferences, however, are unknown. The authors assessed patients' preferences for the collection of saliva, urine and blood as diagnostic fluids. METHODS: The authors handed out surveys adult outpatients who sought treatment at two medical care sites and one dental care site at a medical center regarding the comfort, convenience and ease of collection of saliva, urine and blood for diagnostic testing. RESULTS: A total of 413 surveys were completed. Subjects regarded the donation of saliva as more comfortable and convenient than that of blood or urine at the doctor's (physician's or dentist's) office, and they reported that saliva and urine are easiest to collect at home compared with blood. Male subjects and subjects who had ever donated saliva were more likely to perceive saliva donation in the doctor's office favorably. Subjects at all care sites regarded the donation of saliva as more comfortable and convenient than that of blood or urine; however, subjects at the dental care site perceived saliva donation more favorably than did subjects at the medical care sites. In addition, respondents said they were more willing to participate in research and medical testing if it required saliva donation rather than urine or blood collection. CONCLUSIONS: In terms of convenience and comfort, saliva compared well with blood and urine as a diagnostic fluid for clinical and research testing. Patients who sought care at both medical and dental sites shared these perceptions. CLINICAL IMPLICATIONS: Given strong patient preferences, saliva may be the fluid of choice for the development and implementation of patient-centered diagnostic tests in research and practice.

Transformative Learning and Professional Identity Formation During International Health Electives: A Qualitative Study Using Grounded Theory.

PURPOSE: International health electives (IHEs) are widely available during residency and provide unique experiences for trainees. Theoretical models of professional identity formation and transformative learning may provide insight into residents' experiences during IHEs. The purpose of this study was to explore transformative learning and professional identity formation during resident IHEs and characterize the relationship between transformative learning and professional identity formation. METHOD: The authors used a constructivist grounded theory approach, with the sensitizing concepts of transformative learning and professional identity formation to analyze narrative reflective reports of residents' IHEs. The Mayo International Health Program supports residents from all specialties across three Mayo Clinic sites. In 2015, the authors collected narrative reflective reports from 377 IHE participants dating from 2001 to 2014. Reflections were coded and themes were organized into a model for transformative learning during IHEs, focusing on professional identity. RESULTS: Five components of transformative learning were identified during IHEs: a disorienting experience; an emotional response; critical reflection; perspective change; and a commitment to future action. Within the component of critical reflection, three domains relating to professional identity were identified: making a difference; the doctor-patient relationship; and medicine in its "purest form." Transformation was demonstrated through perspective change and a commitment to future action, including continued service, education, and development. CONCLUSIONS: IHEs provide rich experiences for transformative learning and professional identity formation. Understanding the components of transformative learning may provide insight into the interaction between learner, experiences, and the influence of mentors in the process of professional identity formation.

A patient-centered decision rule for referral of patients to weight-loss programs.

BACKGROUND: The obesity epidemic threatens to shorten life expectancy and reduce the quality of life for large segments of the population. The purpose of this study was to develop a decision rule for referral to a weight-loss program on the basis of the relationship between body mass index (BMI) and self-rated overall health. METHODS: We employed a patient satisfaction survey of family medicine patients treated in Mayo Clinic in Rochester, Minnesota, linked with medical record information, to test the theory that, in primary care patients, BMI exhibits an inverse and independent relationship with overall self-rated health after adjusting for age, gender, marital status, and cigarette smoking. Interviews were linked to medical records for 679 adult patients. RESULTS: Adjusting for age and other confounders using multiple logistic regression analysis revealed that overweight (BMI = 25-30 kg/m(2)) was not a risk factor for poor self-rated health and only BMI above 35 kg/m(2) was significantly related to poor overall health (adjusted odds ratio = 0.33, confidence interval = 0.17-0.64, P = .0012). CONCLUSIONS: Quality improvement programs should monitor whether obesity is being addressed in clinical settings. A patient-centered decision rule for addressing obesity could involve referral of patients whose BMI is above 35 kg/m(2) to weight management programs, monitoring of patients whose BMI scores are between 30 and 35 kg/m(2), and encouragement of patients whose BMI is above 25 kg/m(2) to avoid weight gain.

Mental illness in Bwindi, Uganda: Understanding stakeholder perceptions of benefits and barriers to developing a community-based mental health programme.

BACKGROUND: Mental illness has been increasingly recognised as a source of morbidity in low- and middle-income countries and significant treatment gaps exist worldwide. Studies have demonstrated the effectiveness of task sharing through community-based treatment models for addressing international mental health issues. AIM: This paper aims to evaluate the perceptions of a wide range of mental health stakeholders in a Ugandan community regarding the benefits and barriers to developing a community-based mental health programme. SETTING: Bwindi Community Hospital (BCH) in south-west Uganda provides services through a team of community health workers to people in the Kanungu District. METHODS: Thematic analysis of 13 semi-structured interviews and 6 focus group discussions involving 54 community members and 13 mental health stakeholders within the BCH catchment area. RESULTS: Stakeholders perceived benefits to a community-based compared to a hospital-based programme, including improved patient care, lower costs to patients and improved community understanding of mental illness. They also cited barriers including cost, insufficient workforce and a lack of community readiness. CONCLUSIONS: Stakeholders express interest in developing community-based mental health programmes, as they feel that it will address mental health needs in the community and improve community awareness of mental illness. However, they also report that cost is a significant barrier to programme development that will have to be addressed prior to being able to successfully establish such programming. Additionally, many community members expressed unique sociocultural beliefs regarding the nature of mental illness and those suffering from a psychiatric disease.

Community perceptions of mental illness in rural Uganda: An analysis of existing challenges facing the Bwindi Mental Health Programme.

OBJECTIVES: To assess community perceptions of mental illness in the Bwindi Community Hospital (BCH) catchment area: to recognise beliefs about the causes and the treatments for mental illness. To provide community data to staff at BCH as they work to develop more effective community mental health programmes. BACKGROUND: A shortage of mental health providers in Uganda has prompted research into community-based task-sharing models for the provision of mental health services in underserved communities. METHODS: Six focus group discussions, with a total of 54 community members (50% male, n = 27; mean age + s.d. [39.9 + 10.9 years]) from the BCH catchment area, were conducted to assess community member and stakeholder perceptions of mental illness and belief in the feasibility of community-based programming. Qualitative study of data through thematic analysis was conducted to assess the presence of commonly occurring perceptions. RESULTS: Qualitative thematic analysis revealed two major themes: (1) belief that any given patient's metal illness results from either an intrinsic or an extrinsic cause and (2) belief in a need to determine treatment of mental illness based on the believed cause. CONCLUSION: As BCH designs community-based mental health services, our findings provide support for the need for further education of community members and training of community health workers to address and integrate the above-stated beliefs regarding mental illness.

Primary Care Management of Skin Abscesses Guided by Ultrasound.

BACKGROUND: Primary care providers often manage skin abscesses in the outpatient setting. Estimating the size and depth of an abscess, and distinguishing abscess from cellulitis by clinical examination can be challenging due to surrounding firm tissue induration. Definitive treatment of abscess requires incision and drainage, and the approach chosen may be altered by abscess size, depth, and surrounding neurovascular structures. METHODS: For 31 consecutive patients seen in the primary care outpatient clinic, we prospectively compared the estimated size of skin abscesses by clinical examination with that determined by ultrasound. Prior to incision and drainage, a limited point-of-care ultrasound examination was performed and the abscess dimensions were measured, the depth was determined, and adjacent vascular structures were noted. Based on ultrasound findings, physicians reported whether the decision to perform the procedure or the techniques used to perform the procedure were altered by the scan. RESULTS: The clinical examination was inaccurate for size estimation by >0.5 cm in 16 of 31 patients (52%). Ultrasound examination changed the physician decision of whether or not incision and drainage should be performed in 7 patients (23%) and altered the technique/approach in an additional 10 patients (32%); thus, management was changed in 55% of cases. Physician confidence in performing the procedure was improved in 16 cases (52%). CONCLUSION: Outpatient procedural management of skin abscesses by primary care physicians was altered in more than half the cases by performing point-of-care ultrasound prior to incision and drainage.

Comparison of Clinical Risk Tools for Predicting Osteoporosis in Women Ages 50-64.

OBJECTIVE: The objective of this study was to compare the performance of the US Preventive Services Task Force (USPSTF) recommended WHO Fracture Risk Assessment Tool (FRAX) threshold score of 9.3% (calculated without femoral neck bone density) with the Simple Calculated Osteoporosis Risk Estimate (SCORE), Osteoporosis Self-Assessment Tool (OST), and the Osteoporosis Risk Assessment Instrument (ORAI) to identify osteoporosis in younger women. METHODS: We conducted a retrospective review of women ages 50 to 64 years who underwent dual-energy radiographic absorptiometry (DXA) at our institution over a 6-month period. Scores for the FRAX, ORAI, OST, and SCORE tools were calculated using various thresholds: FRAX ≥9.3%, SCORE ≥6, OST <2, and ORAI ≥9. Sensitivity, specificity, and area under the receiver-operating characteristic curve for detection of densitometric osteoporosis by DXA for each tool were compared. RESULTS: A total of 290 women were identified. Of these, 284 (97.9%) were white, and the mean ± standard deviation age was 56.6 ± 3.4 years. Fifty (17.2%) had osteoporosis of the lumbar spine and/or femoral neck on DXA. Sensitivity, specificity, and area under the receiver-operating characteristic curve for identifying densitometric osteoporosis at the femoral neck and/or spine were 36%, 73%, and 0.55 for FRAX; 74%, 42%, and 0.58 for SCORE; 56%, 69%, and 0.63 for the OST; and 52%, 67%, and 0.60 for the ORAI, respectively. CONCLUSIONS: DXA screening based on the USPSTF-recommended FRAX threshold score of 9.3% has a low sensitivity to identify densitometric osteoporosis in women ages 50 to 64. Lowering the threshold score would increase sensitivity but would also increase the number of women sent for screening DXA. Use of the validated SCORE tool would improve sensitivity to identify osteoporosis in this age group.

Impact of predictors upon the reduction of lipid parameters in family medicine practice.

CONTEXT AND OBJECTIVE: To evaluate predictors of changes in lipid parameters consisting of LDL-C (low-density lipoprotein cholesterol), TC (total cholesterol) and non-HDL-C (non-high density lipoprotein cholesterol) among primary care patients. DESIGN AND SETTING: Retrospective study conducted on family medicine patients. METHODS: Demographic features and other clinically relevant information were abstracted from medical records. The primary outcome was the difference in LDL-C level from initial testing to the index test. Secondary outcomes were the changes in TC and non-HDL-C levels between two measurements. RESULTS: Three hundred and eleven participants were included in the final secondary analysis. Multiple linear regression revealed that male patients (ß = 4.97, P = 0.040), diabetes (ß = 9.75, P = 0.003) and higher LDL-C levels at baseline (ß = 0.35, P < 0.001) were positively associated with LDL variance, whereas longer time period (ß = -0.15, P = 0.045) and familial hypercholesterolemia history (ß = -7.56, P = 0.033) were negatively associated. Male patients (ß = 8.45, P = 0.002), DM (ß = 9.26, P = 0.011), higher TC levels at baseline (ß = 0.35, P < 0.001) and taking statins (ß = 7.31, P = 0.023) were positively associated with TC variance, whilst longer time period (ß = -0.183, P = 0.031) and familial hypercholesterolemia (ß = -10.70, P = 0.008) were negatively associated. CONCLUSION: In the present study, patients who were male, on statin treatment, diagnosed with diabetes and had higher baseline lipid values were more likely associated with better lipid outcomes at future testing.

Variations in lipid screening frequency in family medicine patients with cardiovascular risk factors.

RATIONALE, AIMS AND OBJECTIVES: This study was undertaken to assess the frequency of lipid screening in comparison with the United States Preventive Services Task Force guideline in a sample of family medicine patients. In addition, we sought to determine the association between testing frequency and achievement of lipid targets. METHODS: A random sample was extracted from 271 patients from among all patients cared for in our Department of Family Medicine for whom lipid screening was ordered from March to September 2012 and who had ≥2 well-defined cardiovascular risk factors. Lipid testing frequency was classified in three ways: semi-annual or less often (0-12 tests over 6 years), annual or less often (0-6 tests), or biennial (0-3 tests). RESULTS: Multiple logistic regression analysis revealed that the predictors of lipid screening more often than semi-annually were age ≥60 years [odds ratio (OR) = 3.7] and diabetes mellitus (DM) (OR = 30.6). Predictors of screening more often than annually were DM (OR = 4.3), hypertension (OR = 2.1), family history of premature coronary artery disease (OR = 5.6) and statin treatment (OR = 3.5). Lipid goal attainment was not associated with testing frequency except with regard to low-density lipoprotein levels (P = 0.043, P < 0.001, P = 0.005, by semi-annual, annual and biennial, respectively) and total cholesterol levels (P = 0.015, P = 0.025 by semi-annual and annual, respectively). CONCLUSIONS: Questionable high frequency of lipid testing was detected even when the more conservative approach of annual monitoring was assumed. Frequency of testing was not associated with goal attainment for most parameters. Physicians should request the lipid testing based on overall risk assessment and person variability in accordance with published guidelines.