Psychological safety and accountability in longitudinal integrated clerkships: a dual institution qualitative study.

BACKGROUND: Psychological safety and accountability are frameworks to describe relationships in the workplace. Psychological safety is a shared belief by members of a team that it is safe to take interpersonal risks. Accountability refers to being challenged and expected to meet expectations and goals. Psychological safety and accountability are supported by relational trust. Relational continuity is the educational construct underpinning longitudinal integrated clerkships. The workplace constructs of psychological safety and accountability may offer lenses to understand students' educational experiences in longitudinal integrated clerkships. METHODS: We performed a qualitative study of 9 years of longitudinal integrated clerkship graduates from two regionally diverse programs-at Harvard Medical School and the University of North Carolina School of Medicine. We used deductive content analysis to characterize psychological safety and accountability from semi-structured interviews of longitudinal integrated clerkship graduates. RESULTS: Analysis of 20 graduates' interview transcripts reached saturation. We identified 109 discrete excerpts describing psychological safety, accountability, or both. Excerpts with high psychological safety described trusting relationships and safe learning spaces. Low psychological safety included fear and frustration and perceptions of stressful learning environments. Excerpts characterizing high accountability involved increased learning and responsibility toward patients. Low accountability included students not feeling challenged. Graduates' descriptions with both high psychological safety and high accountability characterized optimized learning and performance. CONCLUSIONS: This study used the workplace-based frameworks of psychological safety and accountability to explore qualitatively longitudinal integrated clerkship graduates' experiences as students. Graduates described high and low psychological safety and accountability. Graduates' descriptions of high psychological safety and accountability involved positive learning experiences and responsibility toward patients. The relational lenses of psychological safety and accountability may inform faculty development and future educational research in clinical medical education.

Association of Maternal Buprenorphine or Methadone Dose with Fetal Growth Indices and Neonatal Abstinence Syndrome.

OBJECTIVE: Our objective was to compare fetal growth and incidence of neonatal abstinence syndrome requiring treatment across pregnant women with opioid use disorders on two types and two dose categories of medication-assisted treatment. STUDY DESIGN: A retrospective cohort study was conducted in a comprehensive, perinatal program in western North Carolina comparing growth percentiles on third-trimester ultrasound and at birth, and diagnosis of neonatal abstinence syndrome requiring treatment. Singletons were exposed in utero to low- to moderate-dose buprenorphine (≤16 mg/day; n = 70), high-dose buprenorphine (≥17 mg/day; n = 36), low- to moderate-dose methadone (≤89 mg/day; n = 41), or high-dose methadone (≥90 mg/day; n = 74). Multivariate analysis of variance with posthoc Bonferroni comparisons (p ≤ 0.01) and multinomial logistic regressions (adjusted odds ratio, 99% confidence interval) were conducted. RESULTS: Differences in neonatal outcomes reached statistical significance for larger head circumference for buprenorphine doses (p = 0.01) and for longer length (p < 0.01) and lower odds of neonatal abstinence syndrome requiring treatment (p < 0.01) with low- to moderate-dose buprenorphine versus high-dose methadone. CONCLUSION: Among pregnant women using medication-assisted treatment for opioid use disorders, low- to moderate-dose buprenorphine (≤16 mg/day) was associated with the most favorable neonatal outcomes. However, more rigorous control of confounders with a larger sample is necessary to determine if low- to moderate-dose buprenorphine is the better treatment choice.

Using a Community Engagement Approach to Enhance Contraception Awareness in Rural Western North Carolina.

BACKGROUND Unintended pregnancy rates remain higher than the national average in North Carolina. Although long-acting reversible contraception (LARC) use has reduced rates of unintended pregnancy, this contraceptive method is widely underused, often due to low community awareness. Boot Camp Translation is a community engagement process that promotes community awareness of evidence-based medical recommendations by designing culturally meaningful messages.METHODS We tested the feasibility of the Boot Camp Translation process to expand awareness about LARC in 2 rural Western North Carolina counties. After our intervention, we conducted surveys at 4 local clinics, asking patients if and where they saw LARC messages.RESULTS The recruited community members had a participation rate of 93% throughout the intervention. A local nurse practitioner, health department nursing supervisor, health educator, and pre-medical student collaborated with local community members to disseminate culturally meaningful messages about LARC through social media, a website, promotional items, posters, and sexual education talks at local schools. Among women surveyed, 48.9% saw LARC campaign messages and of those, 57% saw messages through social media posts. Post-intervention, 6 local schools implemented a comprehensive sexual education curriculum.LIMITATIONS Our pilot project was not designed to quantitatively assess the community reception to our intervention, our intervention's impact on community knowledge about LARC methods, or changes in contraception practices.CONCLUSIONS We have demonstrated the feasibility of implementing Boot Camp Translation as a tool to enhance public awareness of contraception. This community engagement method underscores the benefit of empowering community members in public health projects.

A Cohort Comparison of Differences Between Regional and Buncombe County Patients of a Comprehensive Perinatal Substance Use Disorders Program in Western North Carolina.

BACKGROUND Pregnant patients from rural counties of Western North Carolina face additional barriers when accessing comprehensive perinatal substance use disorders care at Project CARA as compared to patients local to the program in Buncombe County. We hypothesized regional patients would be less engaged in care.METHOD Using a retrospective cohort design, univariate analyses (χ2, t-test; P < .05) compared patients' characteristics, engagement in care, and delivery outcomes. Engagement in care, the primary outcome, was operationalized as: attendance at expected, program-specific prenatal and postpartum visits, utilization of in-house counseling, community-based and/or inpatient substance use disorders treatment, and maternal urine drug screen at delivery negative for illicit substances.RESULTS Regional patients (n = 324) were more likely than Buncombe County patients (n = 284) to have opioid [209 (64.5%) versus 162 (57.0%)] or amphetamine/methamphetamine use disorders (25 [7.7%] versus 13 [4.6%]), but less likely to have cannabis use (19 [5.9%] versus 38 [13.4%]; P = .009) and concurrent psychiatric disorders (214 [66.0%] versus 220 [77.5%]; P = .002). Engagement at postpartum visits was the significantly different outcome between patients (110/221 [49.8%] versus 146/226 [64.6%]; P = .002).LIMITATIONS Outcomes were available for 66.8% of regional and 79.6% of Buncombe County patients of one program in one predominately white, non-Hispanic region of the state.CONCLUSION Contrary to our hypothesis, regional and Buncombe County women engaged in prenatal care equally. However, a more formal transition into the postpartum period is needed, especially for regional women. A "hub-and-spokes" model that extends delivery of perinatal substance use disorders care into rural communities may be more effective for engagement retention.

Adaption and validation of the Working Alliance Inventory for General Practice: qualitative review and cross-sectional surveys.

BACKGROUND: Relational aspects of primary care are important, but we have no standard measure for assessment. The 'working alliance' incorporates elements of the therapeutic relationship, shared decision-making, goal setting and communication skills. The Working Alliance Inventory (short form) (WAI-SF) has been used in adult psychology, and a high score on the survey is associated with improved outcomes for clients. OBJECTIVE: To adapt the WAI-SF for use between GPs and patients and to test its concurrent validity with measures of shared decision-making and the doctor-patient relationship and discriminant validity with measures of social desirability. METHODS: Two rounds of online survey feedback from 55 GPs and 47 patients were used to adapt the WAI-SF-the WAI-GP. The tool was then completed by 142 patients in waiting rooms after seeing their GP and by 16 GPs at the end of their session. Concurrent validity with measures of shared decision-making and patient-doctor depth of relationship was determined using Spearman Rho correlations. Patients also completed two social desirability surveys, and discriminant validity with WAI-GP was assessed. RESULTS: Following feedback, the survey was re-worded to remove phrases that were perceived as judgmental or irrelevant. The patient measure of the WAI-GP was strongly correlated with Dyadic OPTION (rho = 0.705, P = 0.0001) and Patient-Doctor Depth of Relationship scale (rho = 0.591, P = 0.0001) and not with measures of social desirability. CONCLUSION: The psychometric properties of the WAI-GP support its use for measuring GP-patient alliance. Possibilities for use include assessing the influence of therapeutic alliance on the effectiveness of interventions.

Evaluation of the need for a fracture liaison service in a patient-centered medical home.

OBJECTIVES: To evaluate the need for a fracture liaison service (FLS) based on postfracture care in a patient-centered medical home (PCMH). METHODS: Patients in a PCMH who presented to a local 763-bed community teaching hospital with fragility fracture of the hip, spine, or forearm between January 1, 2013, and December 31, 2014, were identified using ICD-9 codes. A retrospective chart review of inpatient and outpatient medical records 2 years before the fracture and 1 year afterward was conducted. The primary outcome was dual X-ray absorptiometry (DXA) scan utilization or pharmacotherapy for osteoporosis 6 months after fracture. RESULTS: One hundred eighty-two patients were identified, and 75 patients were included in the analysis. The median age of the cohort was 84 years, and 70.7% of patients were white women. Fragility fractures included hip fracture (42.7%), vertebral fracture (40.0%), and forearm fracture (17.3%). Six months after fracture, 30.7% of patients were prescribed prescription therapy for osteoporosis, and 6.7% had received a DXA scan. Although nearly all patients had a follow-up visit in the PCMH during the year after fracture, only 8.3% were seen in an established osteoporosis clinic. Twenty-three percent of patients were deceased at 1 year. CONCLUSIONS: More patients in this PCMH received a DXA scan or pharmacotherapy, or both, for osteoporosis 6 months after fragility fracture than observed nationally. However, approximately 70% of patients were undertreated. Incorporating principles of an FLS into an existing osteoporosis clinic is warranted.

Physician perceptions of integrating advanced practice pharmacists into practice.

OBJECTIVES: Barriers have prevented full integration of advanced practice pharmacists (APPs) into collaborative practice in some areas despite evidence describing their value. APPs in North Carolina can be recognized as Clinical Pharmacist Practitioners (CPPs) under a collaborative practice agreement and provide comprehensive medication management under physician supervision. This study describes the perceptions of physicians regarding the barriers and benefits of integrating CPPs into interprofessional teams and compares physician and CPP perceptions. METHODS: This prospective descriptive study surveyed CPP supervising physicians in North Carolina. The questionnaire consisted of 17 multiple-choice and free-response questions. Questions included demographics, perceived benefits and challenges of incorporating CPPs into health care teams, and services provided by CPPs. Findings were compared with previously published data that assessed CPP perceptions about the same topics to gain insight into common perspectives of team members. RESULTS: Fifty-six physicians (23.1%) responded, identifying enhanced clinical outcomes (87.5%), access to drug knowledge (58.9%), and creation of a multidisciplinary model for learners (57.1%) as the top benefits of working with CPPs. Primary barriers included limited reimbursement (60.7%) and billing difficulties (51.8%). More CPPs acknowledged provider acceptance as a barrier (25.9% vs. 3.6%; P = 0.001). Twelve physicians (21.4%) and no CPPs identified space as a barrier. CONCLUSION: Physicians identified enhanced clinical outcomes, access to drug knowledge, and creation of a multidisciplinary model for learners as the top benefits of incorporating CPPs into teams, and billing difficulties and limited reimbursement were the primary barriers. These findings were similar to the perceptions of CPPs, with exceptions being that physicians were more concerned about space limitations and CPPs noted that provider acceptance may be difficult. These findings may provide guidance to providers desiring to establish collaborative practice.

Parity as a predictor of obstetric fistula classification.

INTRODUCTION AND HYPOTHESIS: Obstetric fistulas are injuries to the genital tract in women without emergency obstetric services. Parity may predict the characteristics of fistulas that affect closure success and residual incontinence. Circumferential fistulas may predispose patients to postoperative incontinence. We hypothesized that primiparous women have more distal fistulas than multiparous women, leading to more scarring and circumferential fistulas. METHODS: A retrospective observational study was conducted on 1,856 women with obstetric fistula evaluated at three sites by three providers. Fistulas were classified using the Goh classification system. Women aged 10 to 55 years were classified as primiparas or multiparas. Analysis by parity of fistula type and size, degree of scarring, and presence of circumferential defect used the Chi squared or Fisher's exact test, and binary logistic regression. RESULTS: Of the 1,841 (99.2 %) women included, 878 (47.7 %) were primiparas and 963 (52.3 %) were multiparas. Primiparas were more likely to have distal fistulas, type 4 being most common (31.5 %), whereas multiparas were more likely to have proximal fistulas, most commonly type 1 (48.1 %). Primiparas were more likely to have moderate to severe scarring (11.7 % vs 5.6 %; p < 0.001), and category III (57.1 % vs 39.2 %; p < 0.001), but not to develop circumferential fistulas (5.6 % vs 4.0 %; p = 0.127), be present for repeat surgery (7.1 % vs 7.6 %; p = 0.721), or have ureteric involvement (1.5 % vs 2.2 %; p = 0.301). Multivariate analyses confirmed increased risk with primiparity for distal fistula and scarring. CONCLUSIONS: As hypothesized, primiparas were more likely to have distal fistulas and more scarring, but were not more likely to have circumferential fistulas. Surgeons should plan accordingly.

Improved Utilization of Preventive Services Among Patients Following Team-Based Annual Wellness Visits.

BACKGROUND The Annual Wellness Visit was designed to enhance preventive services utilization among Medicare beneficiaries; Annual Wellness Visits are underutilized with sparse documented effectiveness. Patients of 3 community-based and 2 retirement community outpatient clinics in western North Carolina had team-based Annual Wellness Visits over a 20-month program, with the goal of improving the uptake and delivery of the Annual Wellness Visit. A clinical pharmacist saw high-complexity patients (≥5 medications) and a licensed practical nurse saw low-complexity patients. We examined the effectiveness of team-based Annual Wellness Visits on patients' use of preventive services.METHOD We conducted a retrospective chart review on a random sample of 500 patients for 12 months post-Annual Wellness Visit. Change over time in use of preventive services was assessed using McNemar's test. Adjusted relative risks of use within 6 months were calculated using generalized linear models with the Poisson loglinear function.RESULTS Overall, utilization of Annual Wellness Visit increased from 14% at baseline to 44% after the 20-month program. The percentage of patients up-to-date with all recommended services increased from 17.4% at the Annual Wellness Visit to 42% within 6 months. Age-appropriate preventive screens and vaccines demonstrated the most improvement (55.8% to 75.4% and 36% to 52.2%, respectively). Community-based patients were less likely to obtain recommended services (RR = 0.618; 95% confidence interval [CI], 0.442-0.865), while patients with supplemental insurance (RR = 1.484; 95% CI, 1.023-2.153), patients seen in subsequent Annual Wellness Visits (RR = 1.405; 95% CI, 1.062-1.858), and patients who were men (RR = 1.422; 95% CI, 1.053-2.041) were more likely to obtain recommended services.LIMITATIONS Generalization is limited by the pre-/post design of one organizational model.CONCLUSION Team-based Annual Wellness Visits with a clinical pharmacist or an LPN, who were supervised by physicians, were associated with significantly improved utilization of preventive services. Use will likely continue to improve as more patients access team-based Annual Wellness Visits yearly.

Evaluation of a Team-Based, Transition-of-Care Management Service on 30-Day Readmission Rates.

BACKGROUND: Transitions of care from the hospital to the outpatient setting often fail to meet the Triple Aim of improving quality, improving the health of populations, and decreasing the cost of care. A major push to improve the quality of transitions and reduce hospital readmissions is under way. METHODS: We implemented a team-based, transition-of-care model and assessed the impact on 30-day readmission rates. The 3 components of the intervention were contact with a nurse care manager, medication reconciliation, and follow-up with a physician. We compared 30-day readmission rates for the period before versus after implementation of this intervention. RESULTS: The 30-day readmission rate decreased from 14.2% in the usual care group to 5.3% in the intervention group (P = .011). Almost 90% of patients in the intervention group received all 3 components of the intervention. LIMITATIONS: Generalizability is limited to practices with embedded team members. Not all patients received all 3 components of the intervention. CONCLUSIONS: Development of a team-based intervention was associated with a significant reduction in hospital readmissions. This method could be implemented in other primary care offices with team-based care.

Implementation of an electronic genomic and family health history tool in primary prenatal care.

"The Pregnancy and Health Profile," (PHP) is a free genetic risk assessment software tool for primary prenatal providers that collects patient-entered family (FHH), personal, and obstetrical health history, performs risk assessment, and presents the provider with clinical decision support during the prenatal encounter. The tool is freely available for download at www.hughesriskapps.net. We evaluated the implementation of PHP in four geographically diverse clinical sites. Retrospective chart reviews were conducted for patients seen prior to the study period and for patients who used the PHP to collect data on documentation of FHH, discussion of cystic fibrosis (CF) and hemoglobinopathy (HB) carrier screening, and CF and HB interventions (tests, referrals). Five hundred pre-implementation phase and 618 implementation phase charts were reviewed. Documentation of a 3-generation FHH or pedigree improved at three sites; patient race/ethnicity at three sites, father of the baby (FOB) race/ethnicity at all sites, and ancestry for the patient and FOB at three sites (P < 0.001-0001). CF counseling improved for implementation phase patients at one site (8% vs. 48%, P < 0.0001) and CF screening/referrals at two (2% vs. 14%, P < 0.0001; 6% vs. 14%; P = 0.05). Counseling and intervention rates did not increase for HB. This preliminary study suggests that the PHP can improve documentation of FHH, race, and ancestry, as well as the compliance with current CF counseling and intervention guidelines in some prenatal clinics. Future evaluation of the PHP should include testing in a larger number of clinical environments, assessment of additional performance measures, and evaluation of the system's overall clinical utility.

Evaluation of a novel electronic genetic screening and clinical decision support tool in prenatal clinical settings.

"The Pregnancy and Health Profile" (PHP) is a free prenatal genetic screening and clinical decision support (CDS) software tool for prenatal providers. PHP collects family health history (FHH) during intake and provides point-of-care risk assessment for providers and education for patients. This pilot study evaluated patient and provider responses to PHP and effects of using PHP in practice. PHP was implemented in four clinics. Surveys assessed provider confidence and knowledge and patient and provider satisfaction with PHP. Data on the implementation process were obtained through semi-structured interviews with administrators. Quantitative survey data were analyzed using Chi square test, Fisher's exact test, paired t tests, and multivariate logistic regression. Open-ended survey questions and interviews were analyzed using qualitative thematic analysis. Of the 83% (513/618) of patients that provided feedback, 97% felt PHP was easy to use and 98% easy to understand. Thirty percent (21/71) of participating physicians completed both pre- and post-implementation feedback surveys [13 obstetricians (OBs) and 8 family medicine physicians (FPs)]. Confidence in managing genetic risks significantly improved for OBs on 2/6 measures (p values ≤0.001) but not for FPs. Physician knowledge did not significantly change. Providers reported value in added patient engagement and reported mixed feedback about the CDS report. We identified key steps, resources, and staff support required to implement PHP in a clinical setting. To our knowledge, this study is the first to report on the integration of patient-completed, electronically captured and CDS-enabled FHH software into primary prenatal practice. PHP is acceptable to patients and providers. Key to successful implementation in the future will be customization options and interoperability with electronic health records.

Accessing perinatal substance use disorder care in your local community: A case study of an innovative hub and spoke network in western North Carolina.

INTRODUCTION: The incidence of substance use disorders (SUD) in the general population and in the pregnant person population has risen over the last 20 years. Concurrently, both perinatal and SUD care in rural areas is laden with access barriers including but not limited to geographical distance from potential treatment and stigma. An integrated outpatient perinatal substance use disorder (PSUD) clinic in an urban area in western North Carolina (WNC) found that patients who traveled further for prenatal care were less likely to continue seeking care in the postpartum period. Acknowledging that the risk of overdose increases in the postpartum period, the PSUD clinic utilized a hub and spoke model to promote healthcare accessibility. METHODS: The clinic adapted the Vermont hub and spoke model and the CHARM (Children and Recovering Mothers) collaborative. The urban hub in WNC has now developed eight spokes in rural communities. The hub provides education and technical assistance to the rural spokes, and the two engage in bidirectional referral pathways. This manuscript details the model and analyzes the existing strengths and barriers at two spokes, a family medicine Federally Qualified Health Center and a hospital affiliated obstetrics and gynecology practice and analyzes their process of implementation of integrated outpatient perinatal substance use care. RESULTS: Both spokes found coaching relationships and the sharing of resources such as clinical guidelines useful to begin prescribing buprenorphine for PSUD. Their context led one spoke to begin prescribing within one year while the other took two years. CONCLUSION: Comparing and contrasting these spokes serves to demonstrate that across many contexts, a hub and spoke model is a replicable intervention for rural perinatal substance use access to care barriers. Comparing the two spokes emphasizes the need for adaptation as well as standardization of the model to improve evidence-based PSUD care most effectively.

Addressing cannabis consumption among patients with hyperemesis gravidarum.

Severe nausea and vomiting of pregnancy and hyperemesis gravidarum affect up to 3% of all pregnant people, causing substantial maternal and neonatal morbidity, suffering, and financial cost. Evidence supports the association of cannabis consumption with symptoms of severe nausea and vomiting of pregnancy or hyperemesis gravidarum as the general public has come to believe that cannabis is a natural, safe antiemetic. Cannabis consumption in pregnancy is discouraged strongly by the Surgeon General of the United States and the American College of Obstetricians and Gynecologists because of evidence of potential harms. Symptoms of intractable, severe nausea and vomiting of pregnancy or hyperemesis gravidarum associated with cannabis consumption may be unrecognized cannabinoid hyperemesis syndrome, and this syndrome may be more common than previously thought. Cannabis consumption is especially detrimental when causing or exacerbating debilitating symptoms such as the intense, persistent, recurrent, or cyclic vomiting and associated dehydration and other sequelae of cannabinoid hyperemesis syndrome. Open discussion of cannabis consumption during pregnancy is very challenging for patients and maternity care providers in our current environment of variable legal status across states and variable degrees of personal and societal acceptance. Evidence-based medical knowledge, guidance, tools, and skills are needed to differentially diagnose and treat cannabinoid hyperemesis syndrome in pregnancy. Researchers, clinicians, and medical specialty organizations must work together to strengthen the evidence base and develop or refine the necessary guidelines and tools for maternity care provider skill development, and to increase public and patient awareness of cannabinoid hyperemesis syndrome, specifically during pregnancy.

Cesarean delivery on maternal request: a western North Carolina perspective.

Cesarean delivery on maternal request (CDMR), a primary cesarean without medical indication for a singleton, term pregnancy, has been identified by physicians as one factor in the increasing rate of cesarean delivery despite nationwide efforts to the contrary. The purpose of this project was to better understand women's preferences and motivations for their desired mode of delivery. A 62-item survey was administered to pregnant women asking for their delivery preference, their reasons, sources of information, feelings about this pregnancy, and opinions about delivery options. Responses were analyzed for candidates for CDMR or for repeat cesarean section, separately; the standard error of measure is ±4% (95% CI). 396 patients returned surveys (response rate = 63.2%). CDMR was desired by 34/316 (11%) candidates; repeat cesarean was desired by 32/70 (46%) patients. Significant correlates of CDMR included choosing during the first trimester (22% vs. 8.2%; RR = 2.72; P = 0.015), smoking during pregnancy (19.7% vs. 7.6%; RR = 2.60; P = 0.036), and being worried about the delivery (P = 0.004). Desire for CDMR increased as worries increased from unworried (4.4%) to somewhat (11.8%) to very worried (27.6%). Primary reasons included existing medical complications and preventing birth injury. The majority of patients believed CDMR should be an "informed choice"; other opinions varied by delivery preference. The majority of women preferred vaginal deliveries suggesting little contribution of CDMR to the increasing cesarean rate. Contrary to physicians' beliefs, the women's primary objective was their infants' health rather than their own well-being.

The red dress survey: Awareness among women in Western North Carolina of heart disease and stroke in women.

BACKGROUND: The aim of this cross-sectional survey was to measure knowledge about cardiovascular disease (CVD) among low-income women in Western North Carolina. METHODS: A self-administered survey was distributed to a convenience sample of women presenting for obstetrical or gynecological care at resident and faculty clinics in Asheville, North Carolina, from July 2011 through February 2012. RESULTS: Responses from 340 completed surveys were analyzed. The response rate was 51.7%. The majority of respondents (57.1%) were either overweight or obese, and 23.2% reported that they currently use tobacco products. Overall, accuracy on knowledge questions ranged from 0% to 90%, with a mean score of 57.8% (SD = 16%). Women in their 20s, minorities, and smokers had lower knowledge scores (P = 0.03, 0.022, and 0.009, respectively). Gender variations in symptoms and consequences of CVD for women were not widely understood by this group. Most knew that it is appropriate to respond rapidly to symptoms of heart attack or stroke. Increasing daily physical activity and managing stress effectively were picked most often as the behavioral strategies patients might initiate or increase to reduce their health risks. LIMITATIONS: This was a convenience sample and the response rate was only 51.7%, so results maybe biased. CONCLUSIONS: This group's overall knowledge of CVD in women was poor, with most scores below 70%, and gaps in knowledge existed for minorities. These results are consistent with findings from national awareness surveys. Educational strategies need to include gender-specific risks, symptoms, and consequences, and they need to target tobacco users, minorities, and young adults. Resources are needed for obstetrician-gynecologists to use as they assist patients in becoming more aware of CVD and reducing personal risk through lifestyle modification.

What happy physicians have in common: A qualitative study of workplace perceptions of physicians with low burnout scores.

Introduction: Burnout is a phenomenon in the medical field that adversely affects patient care, physician retention, and physician well-being. The preponderance of burnout research has primarily focused on exploring what parts of medical practice and individual characteristics contribute to burnout. Our research aims to add to the growing body of evidence exploring what physicians who love their work have in common. Methods: Physician participants in this qualitative study were recruited through their local medical society from those who indicated a willingness to share tips for joy in practice. Potential participants were then screened for low probability of burnout using a validated single-item burnout inventory. Nine primarily mid- to late-career physicians engaged in semi-structured interviews and thematic analysis was used to analyze data. Of the interviewed physicians, five were practicing in the primary care specialties of family or internal medicine and four in specialties outside of primary care. Results: Six major themes arose from the nine interviews and included variety in work, a sense of empowerment, connection with patients, visible impact of one's work, feelings of community with coworkers and colleagues, and experiencing a sense of calling. Conclusion: While further research is needed to demonstrate the transferability of the themes from these interviews, an asset-rooted approach to physician wellness is a direction for research and intervention that deserves further attention. Focusing only on alleviating the factors that contribute to burnout is a worthy goal, but ignores the necessity of designing training systems and workplaces that are built to foster the elements of medicine that bring joy and fulfillment to practice.

The association of cannabis use late in pregnancy with engagement and retention in perinatal substance use disorder care for opioid use disorder: A cohort comparison.

BACKGROUND: Prenatal use of cannabis and opioids are increasing and very concerning. Engagement and retention in comprehensive, perinatal substance use disorder (PSUD) care are associated with better outcomes for mothers and babies. We compared the characteristics and engagement in care among women with opioid use disorder who used cannabis late in pregnancy versus those who didn't. METHODS: The primary outcome, "overall engagement and retention in PSUD care" included: utilization of substance use treatment prenatally, negative screening/toxicology at delivery (excluding cannabis), and attendance at expected prenatal and postpartum visits. Cannabis use late in pregnancy was objectively assessed at delivery via maternal urine drug screen and/or neonatal meconium/cord toxicology. Between-group comparisons utilized chi square, t-test or Mann-Whitney. Associations were assessed using Spearman Rho and two multivariate, binary logistic regressions for cannabis use and the primary outcome. RESULTS: 18.0% (85/472) consumed cannabis late in pregnancy. Women of color, younger women, and those diagnosed with concurrent cannabis use disorder were more likely to consume cannabis. Engagement and retention in PSUD care was not associated with cannabis use, but rather, with prescribed pharmacotherapy for psychiatric disorders. The use of prescribed buprenorphine+naloxone was associated with cannabis avoidance late in pregnancy. CONCLUSIONS: Cannabis use late in pregnancy, compared to none, did not impact engagement and retention in our PSUD program. Adjunctive psychotropic medication and/or buprenorphine+naloxone prescription were associated with cannabis avoidance suggesting the use and interactions of pharmacotherapies in an opioid dependent population is complex. A shared decision-making process during PSUD care is warranted.

Buprenorphine and Naloxone Versus Buprenorphine for Opioid Use Disorder in Pregnancy: A Cohort Study.

OBJECTIVE: To compare maternal and fetal outcomes among dyads prescribed buprenorphine and naloxone or buprenorphine during pregnancy. METHODS: Retrospective cohort study of patients with opioid use disorder obtaining care in a comprehensive, perinatal program. Patients utilized medication for opioid use disorder: a buprenorphine and naloxone combination product or buprenorphine monotherapy. The primary outcome was neonatal abstinence syndrome requiring treatment. Maternal secondary outcomes included: negative urine drug screen at delivery, obstetrical care attendance, primary cesarean delivery, and preterm delivery. Neonatal secondary outcomes included neonatal biometry, admission to neonatal intensive care, appropriate findings on cord toxicology, and length of stay. Univariate analyses included Chi square, Fisher exact, t-, or Mann-Whitney tests, as appropriate. Multivariate binary logistic regressions examined the association of type of buprenorphine product with diagnosis of neonatal abstinence syndrome requiring treatment and adjusted for variables significantly different in between-group comparisons and correlates of treatments and the primary outcome. RESULTS: The rate of neonatal abstinence syndrome was significantly higher (P = 0.007) among infants exposed in utero to buprenorphine versus buprenorphine and naloxone: 59/108 (54.6%) versus 30/85 (35.3%), respectively. The combined product, relative to the monoproduct, was associated with lower odds of neonatal abstinence syndrome: odds ratio (OR) = 0.453 (95% confidence interval [CI] 0.253-0.813; P = 0.008). Adjusting for dose of buprenorphine product at delivery, year of expected delivery, type of prescriber, diagnosis of hepatitis C, and preterm delivery negated these results: adjusted OR = 0.627 (95% CI 0.309-1.275). Secondary outcomes were similar. CONCLUSION: Compared with buprenorphine monotherapy, the combined buprenorphine and naloxone product was an acceptable alternative pharmacologic treatment for opioid use disorder during pregnancy.