Virtual Balint Groups During COVID-19: Exploring Race and Equity in a CHC-Based Family Medicine Residency Program.

The Lawrence Family Medicine residency was created in the 1990s as the first community health center- sponsored residency with the goal of reducing health disparities. Balint groups have been a part of the wellbeing and behavioral health curriculum for many years. The population of Lawrence, MA is primarily a resource-poor, Latinx, immigrant population. In March of 2020, the Covid pandemic highlighted health disparities in this community. The spike in cases in 2020 also impacted the residency community with overwhelming needs of sick and dying patients in newly created, resident and faculty-run Covid units. Our early ignorance about transmission, prophylaxis, treatment and even prognosis made the work incredibly difficult. George Floyd's murder added the additional stress of social unrest in response to a persistent pattern of racism and unequal justice. To help process trauma residents felt working in terrifying conditions, often in medically futile situations with patients who spent their last hours without family at the bedside, we turned to biweekly Balint groups and added additional resident support sessions on the off weeks. Residents seamlessly adopted videoconferencing as the Balint platform, allowing them to attend a group session without risk of infection. The residents, being a diverse group, were able to offer multiple perspectives and process the traumatic issues of disproportionate suffering for their patients, uncertainty and frustration of the COVID-19 pandemic and systemic racism. We found a video Balint group permitted residents to explore their divergent experiences and feelings and offer support to each other in a very uncertain time.

Abnormally Low Hemoglobin A1c as Harbinger of Hemoglobinopathy.

Hemoglobin A1c is frequently used in primary care to screen for and monitor disorders of glucose metabolism. A number of clinical syndromes may impact the accuracy of this laboratory value. This report describes a case of abnormally low hemoglobin A1c that was the result of an asymptomatic compound hemoglobinopathy (homozygous hemoglobin S disease and hereditary persistence of fetal hemoglobin) that had gone previously undiagnosed. Primary care physicians must be aware of such pitfalls in the use of this laboratory value and be prepared to use other values to monitor for and assess disorders of glucose metabolism.

Delayed diagnoses of cervical intraepithelial neoplasia and cancer after negative evaluation for atypical glandular cell pap smear: does age matter?

OBJECTIVE: At initial evaluation, 1 in 6 women with atypical glandular cells (AGCs) on Pap smear has cervical intraepithelial neoplasia (CIN) or cancer. Years later, a greater-than-expected incidence of "significant delayed diagnoses" has been reported in women who had negative initial evaluation results. This study aimed to test the premise that AGC represents a lesser future risk for CIN 2/CIN 3/carcinoma in situ (CIS) and cancer after negative evaluation results in a population diagnosed at a young age (<35 years). MATERIALS AND METHODS: Cohort study consists of 43,000 community health center patients who had 83,542 Pap smears (1997-2010); 213 were diagnosed with AGC, and 117 met inclusion criteria. Completed evaluation was consistent with American Society for Colposcopy and Cervical Pathology guidelines without finding CIN 2/CIN 3/CIS or cancer. Follow-up lasted for longer than 1 year. Categorical data were evaluated with χ. RESULTS: During the follow-up period that averaged for 85.3 months, the cohort had 4.5 mean Pap smears and reported 46 cytological diagnoses of low-grade squamous intraepithelial lesions, 3 diagnoses of high-grade squamous intraepithelial lesions, and 10 repeated diagnoses of AGCs. Two CIN 2/CIN 3/CIS lesions, 1 cervical cancer, and 1 endometrial intraepithelial neoplasia were confirmed on biopsy. Average age of patients at index Pap smear was 34.2 years (range = 15-64 years). Compared with a published report where the average age at index Pap smear was 41.5 years, our cohort developed a total of 4.3% significant delayed diagnoses versus 10.8% (significant difference, p = .046). CONCLUSIONS: During a 7-year follow-up, this cohort of 117 women with AGC and negative initial evaluation findings developed fewer significant delayed diagnoses than expected when compared with an older reported group and had no new extragynecological cancers. Age seems to be a risk factor for delayed diagnoses in patients with AGC.

Spanish language immersion and reinforcement during residency: a model for rapid acquisition of competency.

BACKGROUND: Residencies serving non-English-speaking populations face the challenge of language training in addition to usual resident education issues. The clinic for the Lawrence Family Medicine residency is based in a 45,000-person Community Health Center serving a majority Spanish-language preference population. Although translators are available, they increase visit time for patients. DESCRIPTION: Three successive intern classes and one faculty member (n = 24) participated in a preresidency, 10-day immersion program at a nearby language institute; thrice-monthly classroom instruction for a year; and personal instruction during continuity clinics by a teacher/translator during the R1 year. RESULTS: An independent examiner tested participants (average age = 29.5; 15 female) using a competency examination based on American Council of Teachers of Foreign Languages scoring. Prior Spanish preparation averaged 2 years in high school and 1 year of college, but was variable. Results were compared with Tukey's Honestly Significant Differences test of repeated measures. All individuals improved following immersion, 4.8 to 6.3, (p <.01), and 6 months of reinforcement, 6.3 to 7.4 (p <.05). The first cohort (n = 7), including those entering with little Spanish ability, scored at a level permitting use of five verb tenses after 2 years (cost = $5,035.00/resident). CONCLUSIONS: This study demonstrates significant improvement in Spanish competency after 10-day immersion, and continued improvement following 6 months of reinforcement.

Measurement of colposcopy-associated distress using the psychosocial effects of having an abnormal pap smear-questionnaire in a Latina population.

OBJECTIVE: To elicit factors associated with distress in Latina colposcopy patients. MATERIALS AND METHODS: Three hundred two Caribbean Latinas attending a colposcopy clinic took the Psychosocial Effects of Having an Abnormal Pap Smear-Questionnaire, which measures distress using 14 questions grouped into four dimensions. A Spanish-language translation was tested. RESULTS: Age ranged from 15 to 65 years (mean = 27 years); 220 of 301 women (73%) were undergoing a first colposcopy; 51 of 301 (16.9%) reported depression, and 25 of 298 (8.4%) reported anxiety. A majority of women were distressed at the prospect of having cancer (166/299; 55.6%), of their results being positive for cancer (164/299; 54.8%), and of dying (150/300; 50%); "worry about the ability to have a baby" and "feeling tense" during the procedure followed. Younger women (<27 years) scored higher (p < 0.03) on all four dimensions. First-time patients scored higher on all questions and dimensions; "worry about infectivity" and "effect on sexual relationships,"p = .05 and p = .005. A Spanish translation correlated well with English, Po = (0.83-1.0), kappa >/= 0.73, for 13 of 14 questions. Depressed or anxious patients and Spanish speakers were not more distressed than their counterparts. CONCLUSIONS: The prospect of having cancer and dying is the greatest source of distress in Caribbean Latina colposcopy patients, not the procedure itself. Younger and first-time patients were more distressed than older, experienced ones. Speaking Spanish was not associated with greater distress.