Perceived Efficacy of Medical Cannabis in the Treatment of Co-Occurring Health-Related Quality of Life Symptoms.

For persons living with chronic conditions, health-related quality of life (HRQoL) symptoms, such as pain, anxiety, depression, and insomnia, often interact and mutually reinforce one another. There is evidence that medical cannabis (MC) may be efficacious in ameliorating such symptoms and improving HRQoL. As many of these HRQoL symptoms may mutually reinforce one another, we conducted an exploratory study to investigate how MC users perceive the efficacy of MC in addressing co-occurring HRQoL symptoms. We conducted a cross-sectional online survey of persons with a state medical marijuana card in Illinois (N = 367) recruited from licensed MC dispensaries across the state. We conducted tests of ANOVA to measure how perceived MC efficacy for each HRQoL symptom varied by total number of treated symptoms reported by participants. Pain was the most frequently reported HRQoL treated by MC, followed by anxiety, insomnia, and depression. A large majority of our sample (75%) reported treating two or more HRQoL symptoms. In general, perceived efficacy of MC in relieving each HRQoL symptom category increased with the number of co-occurring symptoms also treated with MC. Perceived efficacy of MC in relieving pain, anxiety, and depression varied significantly by number of total symptoms experienced. This exploratory study contributes to our understanding of how persons living with chronic conditions perceive the efficacy of MC in treating co-occurring HRQoL symptoms. Our results suggest that co-occurring pain, anxiety, and depression may be particularly amenable to treatment with MC.

Mad Men as health communication: health-related themes in the hit AMC television series.

As a popular contemporary text, the appeal of cable television's Mad Men (AMC) lies in its capacity to highlight the differences between 1960s sensibilities and 21st-century assumptions. Viewers can enjoy a sense of superiority by recognizing the "folly" of the beliefs and actions of the characters with the benefit of historic hindsight, as well as noting the evolution of technology, philosophy, and human rights. Health-related scenes and themes in the series are a particularly interesting focus for analysis. We employ Burke's four master tropes as an analytical lens and argue that the dominant dramatic technique of irony, particularly in the form that we call strategic anachronism-derived from an audience's enjoyment of historical hindsight-highlights the racism, sexism, homophobia, and overall conservatism of the early 1960s while simultaneously serving to obfuscate the ways in which we still have much to critique in the delivery of contemporary health care and other body politics.

Use of Cinacalcet for the Management of Primary Hyperparathyroidism in Pregnancy.

Primary hyperparathyroidism in pregnancy is uncommon. Consequently, there are no randomized controlled studies that address treatment of primary hyperparathyroidism in pregnancy, and the efficacy and safety of medical management with cinacalcet in this setting is unknown. We report a case of a 28-year-old woman with primary hyperparathyroidism and hypercalcemia that worsened during her third trimester of pregnancy. Cinacalcet led to achievement of normocalcemia, allowing the delay of parathyroidectomy until after delivery of the baby. We also review the published literature on cinacalcet use in the management of primary hyperparathyroidism during pregnancy. Cinacalcet is typically reserved for pregnant patients with severe and symptomatic hypercalcemia, primarily serving as a last resort to delay parathyroidectomy until either the second trimester or the postpartum period.

The Difficult Case Consultation: An intervention for interprofessional health communication.

An interprofessional group of healthcare practitioners sought a new approach to the early detection, prevention, and resolution of "difficult cases" in the inpatient care context. An action research project addressed this need by developing a narrative re-framing tool that helped reveal entrenched assumptions regarding the root causes of difficult cases in the hospital. The intervention method that emerged from the project - the Difficult Case Consultation (DCC) - is a theoretically-grounded process that helps teams to analyze and address complex communication problems in interprofessional healthcare contexts. Collaborative processes grounded in theory have proven to be the most successful when seeking to optimize healthcare team communication. The article describes the collaborative development of the DCC, presents two cases illustrating the process, and describes systemic factors that exacerbated the emergence of difficult cases in the inpatient context.

Gender Differences in Medical Cannabis Use: Symptoms Treated, Physician Support for Use, and Prescription Medication Discontinuation.

Background: Medical cannabis (MC) utilization continues to expand in the United States, as a growing body of evidence supports the use of cannabis and cannabinoids in the treatment of a range of chronic conditions. To date, gender-related differences in MC use are not widely reported, and little is known regarding physicians' support of patients' use of MC to address symptoms associated with chronic conditions. Materials and Methods: We conducted a cross-sectional online survey of MC users in Illinois (n = 361). We summarized participants' qualifying conditions, symptoms treated with MC, perceived physician support for MC use, use of MC and prescription medications, then analyzed differences by participant gender. Results: Bivariate analyses indicate that men report higher levels of support for MC use from both specialist and primary care physicians. Women were significantly more likely to increase use of cannabis after acquiring an MC card, and to discontinue prescription medications through MC use. Multivariable analyses indicate that being a woman, using MC to treat multiple symptoms, and reporting higher levels of support for MC use from a primary care provider significantly increased the likelihood of discontinuing prescription medication through MC use. Discussion: Women are more likely to report decreased use of prescription medications to treat symptoms, and report lower levels of support from physicians for MC use. Future research on gender differences in this population may benefit from more detailed data related to symptomology, utilization, dosing, and outcomes associated with MC, and interactions with the health care system to extend these findings.

Self-Efficacy in Researching and Obtaining Medical Cannabis by Patients With Chronic Conditions.

Background. Due to the increasing availability of medical-grade cannabis for treatment of chronic conditions, we examined how prospective users navigate the process of researching, procuring, and using cannabis. Given the barriers prospective users experience, self-efficacy may be a factor for those who incorporate cannabis into treatment. Aims. The purpose of this study was to identify behaviors associated with self-efficacy in the context of researching, procuring, and using cannabis. We analyzed narratives of patients who obtained legal medical cannabis in the currently complex medical, legal, and social landscape. Method. Data were collected through 30 telephone interviews utilizing a semistructured interview protocol, which were analyzed using inductive coding. The protocol emphasized four topics: (a) symptom management/pain reduction, (b) provider communication about chronic conditions/cannabis, (c) perspectives on medicinal cannabis and stigma, and (d) views on recreational cannabis. Results. Participants demonstrated self-efficacy in three contexts: (a) self-directed experimentation with cannabis strains, dosages, and administration methods; (b) managing care by selecting and educating their providers; and (c) information-seeking and research behaviors. Discussion. High self-efficacy may be an important factor in navigating the medical cannabis process. Results suggest that providers who are not prepared to partner with patients as they seek information about medical cannabis may be replaced by dispensaries and websites with expertise in cannabis but without understanding of patients' medical conditions and individual needs. Conclusion. Patients with higher self-efficacy may engage in various activities to investigate, procure, experiment with, and incorporate medical cannabis into their condition management outside the purview of their providers.

Preferences for Medical Marijuana over Prescription Medications Among Persons Living with Chronic Conditions: Alternative, Complementary, and Tapering Uses.

OBJECTIVES: Despite expanded legalization and utilization of medical cannabis (MC) internationally, there is a lack of patient-centered data on how MC is used by persons living with chronic conditions in tandem with or instead of prescription medications. This study describes approaches to use of MC vis-à-vis prescription medications in the treatment of selected chronic conditions. DESIGN: Participants completed semistructured telephone interviews with open-ended questions. Content analysis of qualitative data identified themes and subthemes relating to patient approaches to using MC products. PARTICIPANTS: Thirty persons (mean age = 44.6 years) living with a range of chronic conditions (e.g., rheumatoid arthritis, Crohn's disease, spinal cord injury/disease, and cancer) who had qualified for and used MC in Illinois. RESULTS: Participants described a range of approaches to using MC, including (1) as alternatives to using prescription or over-the-counter medications; (2) complementary use with prescription medications; and (3) as a means for tapering off prescription medications. Motives reported for reducing or eliminating prescription medications included concerns regarding toxicity, dependence, and tolerance, and perceptions that MC improves management of certain symptoms and has quicker action and longer lasting effects. CONCLUSIONS: MC appears to serve as both a complementary method for symptom management and treatment of medication side-effects associated with certain chronic conditions, and as an alternative method for treatment of pain, seizures, and inflammation in this population. Additional patient-centered research is needed to identify specific dosing patterns of MC products associated with symptom alleviation and produce longitudinal data assessing chronic disease outcomes with MC use.

Using Telemedicine Technology to Assess Physician Outpatient Teaching.

BACKGROUND AND OBJECTIVES: Video conferencing technology (telemedicine) can be applied to many settings within the medical community; we assessed the feasibility of its use in conducting observations of faculty at remote family medicine teaching sites. METHODS: We deployed seven telemedicine units to five family medicine residency sites and two observation stations within our division. Practice managers and physician faculty members received on-site training on the basic functionality of the technology, as well as "best practices" and minor troubleshooting techniques. Quick reference guides and other support documents were developed and provided for each site. During the remote faculty observation, two observers simultaneously viewed the resident being precepted, assessing the faculty member using a standardized tool. After the experience, all participants were asked to complete a survey on the usability of the technology. RESULTS: Nineteen observations were successfully conducted from November 2011 to December 2012. From a qualitative perspective, faculty accepted this as a viable means of faculty development. Minor technical hurdles were captured in the survey and improved upon as staff and faculty became more comfortable with the technology and as our technical capabilities allowed. Overall, the technology was rapidly accepted into the practices. CONCLUSIONS: Video teleconferencing represents a valuable tool that contributes to the development of faculty by making observation available to numerous sites, including remote areas that may have been previously challenging to reach due to logistics. Recent improvements in technology should make the process easier and allow more aspects of the encounters to be readily observed.

Patients with disabilities as teachers.

BACKGROUND AND OBJECTIVES: Medical schools and residencies lack training in communication skills with patients with disabilities, thereby creating potential barriers to care. To address this shortcoming, the Department of Family Medicine at Lehigh Valley Health Network developed an innovative program in which the patients themselves serve as medical educators. The P-DAT (Patients With Disabilities as Teachers) program is designed to teach basic communication skills and disability etiquette to promote sensitivity to issues unique to this patient population. As such, it conforms to the established principles of the patient-centered medical home. METHODS: Two persons with disabilities who were patients of the residency-affiliated clinic underwent training to become educators. In the resulting interactive education session with medical students, the P-DAT educators describe their daily routines and health care experiences while encouraging their learners to ease anxieties in interacting with patients with disabilities by asking questions. RESULTS: The 44 student participants evaluated the program by responding to a series of Likert scale and open-ended questions. Tallies of the post-program survey results reveal that prior to the disability etiquette training a majority (89%) felt uncomfortable in communicating with patients with disabilities. The survey revealed that 98% of respondents found the program beneficial because it increased overall awareness and sensitivity (52%) and improved competency for future interactions with patients (46%). CONCLUSIONS: Although these evaluation results reflect the early stages of P-DAT implementation, the preliminary feedback indicates that medical students are eager to close the gap in their knowledge about disability etiquette so they can improve their care of this patient population.

RAFT (Resident Assessment Facilitation Team): supporting resident well-being through an integrated advising and assessment process.

BACKGROUND AND OBJECTIVES: During medical residency, indicators of well-being decline while rates of burnout increase. As part of a Preparing the Personal Physician for Practice (P4) innovation, this residency program used a relationship-centered periodic resident assessment process to reinforce values of adult learning within the curriculum. It was predicted that the revised assessment process would contribute to an improved educational climate for residents as reflected in global scores of well-being either remaining at the same level or improving throughout residency. METHODS: Resident Assessment Facilitation Team (RAFT) is an innovative feedback process utilizing small-group dialogue that replaces the traditional semi-annual, faculty-wide review of resident performance. As a pilot study to investigate the impact of RAFT, the Arizona Integrative Outcome Scale (AIOS) was used to describe trends in the well-being of P4 resident cohorts from internship through PGY-3. A comparison group was derived from a resident cohort that started before full implementation of the P4 curriculum and also completed the AIOS. RESULTS: ANOVA comparing AIOS scores across PGY cohort groups was not significant. An independent samples t test comparing AIOS scores from the PGY-3 pre-P4 group with those of the PGY-3 post-P4 group was also not significant. Although this pilot study was not powered for a complete inferential analysis, the descriptive data suggest a downward trend in the pre-RAFT group and stable measures of well-being in the post-RAFT group. CONCLUSIONS: The trend in our pilot data suggests a stability of well-being among our residents that contrasts with patterns of resident burnout noted in existing research. The RAFT has become a key feature of our assessment and advising culture that is intended to mitigate the deleterious effects of more autocratic assessment processes. It may also be an important factor in the stability of resident well-being indicated by this pilot.

Generating developmentally appropriate competency assessment at a family medicine residency.

BACKGROUND AND OBJECTIVES: Ten years after the Accreditation Council for Graduate Medical Education's (ACGME) mandate that residency programs evaluate learners' competency, research is needed to guide efforts to meet this challenge. During an innovative residency redesign, the authors developed a process to effectively measure "competence." This particular family medicine residency admits six residents per class year and is sponsored by an academic community hospital. Our objective was to generate developmentally appropriate observable behaviors that assess competencies. METHODS: Eight steps guided the development of this assessment system: (1) Generate residency-specific competencies, (2) Define residency-specific competencies, (3) Identify principles of assessment, (4) Compose and analyze narratives of excellence within each competency, (5) Distill standard statements from narratives and organize into Dreyfus levels of competence, (6) Derive observable behaviors from standard statements to directly correlate behaviors and competency levels, (7) Design assessment tools (based on observable behaviors) for six residency learning sites, and (8) Translate assessment tools for ACGME competencies. RESULTS: The results of this process include an assessment system that (1) features six tools used with strategic frequency throughout the academic year and (2) generates global assessment of residents' performance in both ACGME and residency-specific competencies. CONCLUSIONS: Narrative reflection was an effective method to tie observable behaviors to competencies. The process was time intensive; however, greater efficiency and enthusiasm is expected in the use of these assessment tools, with greater confidence in the program's capacity to assess training outcomes. Future research should include comparison of these tools with those of other programs.