The clinically excellent primary care physician: examples from the published literature.

Clinical excellence is the ultimate goal in patient care. Exactly what the clinically excellent primary care physician (PCP) looks like and her characteristics have not been explicitly described. This manuscript serves to illustrate clinical excellence in primary care, using primarily case reports exemplifying physicians delivering holistic and patient-centred care to their patients. With an ever increasing demand for accessible and accountable health care, an understanding of the qualities desirable in primary care providers is now especially relevant.A literature review was conducted to identify compelling stories showing how excellent PCPs care for their patients. In the 2397 published works reviewed, we were able to find case reports and studies that exemplified every domain of the description of clinical excellence proposed and published by the Miller Coulson Academy of Clinical Excellence (MCACE). After reviewing these reports, the authors felt that the domains of excellence, as described by the MCACE, are practically applicable and relevant for primary care physicians. It is our hope that this paper prompts readers to reflect on clinical excellence in primary care.

Ethical concerns related to grateful patient philanthropy: the physician's perspective.

BACKGROUND: Philanthropic contributions to academic medical centers from grateful patients support research, patient care, education, and capital projects. The goal of this study was to identify the ethical concerns associated with philanthropic gifts from grateful patients. METHODS: A qualitative study design was selected. Investigators conducted in-depth semi-structured interviews with 20 Department of Medicine physicians at Johns Hopkins who were identified by Development Office staff as experienced and successful in this realm-those having relationships with multiple patients who have made philanthropic contributions. Interview transcripts were independently coded by two investigators. Content analysis identified several themes related to ethical concerns. RESULTS: Eighteen informants (90 %) were Associate Professors or Professors; two (10 %) were females. Four thematic domains emerged related to ethical concerns associated with philanthropy from grateful patients: (i) impact of gift on the doctor-patient relationship; (ii) gift acquisition considered beyond the physician's professional role; (iii) justice and fairness; and (iv) vulnerability of patients. Despite acknowledging at least one of the aforementioned concerns, eleven physician informants (55 %) expressed the view that there were no ethical issues involved with grateful patient philanthropy. CONCLUSIONS: In this paper, we report that physicians involved in grateful patient philanthropy are aware of, and in some cases troubled by, the ethical concerns related to this activity. Further studies could examine how best to prepare faculty for the challenges that may accompany these gifts so as to help them maintain expected professional and ethical standards when accepting grateful patient philanthropy.

Self-reported cancer rates in two rural areas of West Virginia with and without mountaintop coal mining.

Mountaintop coal mining in the Appalachian region in the United States causes significant environmental damage to air and water. Serious health disparities exist for people who live in coal mining portions of Appalachia, but little previous research has examined disparities specifically in mountaintop mining communities. A community-based participatory research study was designed and implemented to collect information on cancer rates in a rural mountaintop mining area compared to a rural non-mining area of West Virginia. A door-door health interview collected data from 773 adults. Self-reported cancer rates were significantly higher in the mining versus the non-mining area after control for respondent age, sex, smoking, occupational history, and family cancer history (odds ratio = 2.03, 95% confidence interval = 1.32-3.13). Mountaintop mining is linked to increased community cancer risk. Efforts to reduce cancer and other health disparities in Appalachia must focus on mountaintop mining portions of the region.

Engaging youths with serious mental illnesses in treatment: STARS study consumer recommendations.

OBJECTIVE: The purpose of this study was to identify better methods of engaging youths in mental health services by asking experienced mental health consumers for suggestions for clinicians. METHODS: 177 members of an integrated health plan, ranging in age from 16-84 years and diagnosed with schizophrenia, schizoaffective disorder, bipolar disorder, or affective psychosis, completed four in-depth semistructured interviews over 24 months as part of a study of recovery from serious mental illness. We transcribed and coded interviews, extracted a set of common themes addressing consumer recommendations to clinicians, and compared these themes across age groups. RESULTS: Five primary themes emerged in participants' recommendations: (1) use an age-appropriate approach that reflects youth culture and lifestyles; (2) foster development of autonomy; (3) take a personal, rather than diagnostic, approach; (4) be empathetic and authentic; and (5) create a safe and supportive environment. Consumers age 30 and older described three additional areas in which clinicians could contribute to youths' well being: (1) help find the right diagnosis and the right medication, (2) counsel youths to avoid using alcohol and drugs, and (3) take steps to help prevent social isolation. CONCLUSIONS: Study findings suggest that many strategies recommended for working with adults may benefit young people, but that developmentally appropriate modifications to these approaches are needed to foster treatment engagement among youths.

Coaching Primary Care Clinicians in the Ambulatory Setting: Direct Observation and Deliberate Practice.

BACKGROUND AND OBJECTIVES: Clinical coaching programs can improve clinician performance through feedback following direct observation and the promotion of reflection. This study assessed the feasibility and acceptability of a primary care coaching program applied in community-based practices. METHODS: Using a 31-item behavioral checklist that was iteratively revised, four faculty observed 18 community-based primary care clinicians (15 of whom were physicians) across 36 patient encounters. Each behavior was scored as a binary variable (observed or not observed). After watching them care for patients, each clinician participated in a focused feedback session to discuss strengths and areas for improvement. RESULTS: Behaviors observed with the highest frequency were: reflects compassion (100%), appears to enjoy caring for the patient (100%), leads and follows with open-ended questions (97%), and asks thoughtful and smart questions (95%). Areas for improvement were those behaviors done less commonly: apologizes for running behind schedule (18%), acknowledges computer and/or explains role in patient care (14%), and assesses understanding (teachback; 7%). Most clinicians agreed or strongly agreed that they would like to be coached again in the future (81%), and that the coaching feedback would help them become more effective in primary care practice (94%). Nearly all patients surveyed substantiated that it did not bother them to have another doctor in the room and that it is a good idea to offer coaching to clinicians to help them improve. CONCLUSIONS: Coaching busy primary care clinicians is feasible and a valued experience. Focusing on specific observable behaviors can identify clinicians' strengths and opportunities for improvement. Patients are pleased to learn that their clinicians are receiving coaching as part of their professional development.

Do fears of malpractice litigation influence teaching behaviors?

BACKGROUND: Medical malpractice is prominently positioned in the consciousness of American physicians, and the perceived threat of malpractice litigation may push physicians to practice defensively and alter their teaching behaviors. PURPOSE: The purposes of this study were to characterize the attitudes of academic medical faculty toward malpractice litigation and to identify teaching behaviors associated with fear of malpractice litigation. METHODS: We surveyed 270 full-time clinically active physicians in the Department of Medicine at a large academic medical center. The survey assessed physicians' attitudes toward malpractice issues, fear of malpractice litigation, and self-reported teaching behaviors associated with concerns about litigation. RESULTS: Two hundred and fifteen physicians responded (80%). Faculty scored an average of 25.5 +/- 6.9 (range = 6-42, higher scores indicate greater fear) on a reliable malpractice fear scale. Younger age (Spearman's rho = 0.19, p = .02) and greater time spent in clinical activities (rho = 0.26, p < .001) were correlated with higher scores on the Malpractice Fear Scale. Faculty reported that because of the perceived prevalence of lawsuits and claims made against physicians, they spend more time writing clinical notes for patients seen by learners (74%), give learners less autonomy in patient care (44%), and limit opportunities for learners to perform clinical procedures (32%) and deliver bad news to patients (33%). Faculty with higher levels of fear on the Malpractice Fear Scale were more likely to report changing their teaching behaviors because of this perceived threat (rho = 0.38, p < .001). CONCLUSIONS: Physicians report changes in teaching behaviors because of concerns about malpractice litigation. Although concerns about malpractice may promote increased supervision and positive role modeling, they may also limit important educational opportunities for learners. These results may serve to heighten awareness to the fact that teaching behaviors and decisions may be influenced by the malpractice climate.

Clinically Excellent Use of the Electronic Health Record: Review.

BACKGROUND: The transition to the electronic health record (EHR) has brought forth a rapid cultural shift in the world of medicine, presenting both new challenges as well as opportunities for improving health care. As clinicians work to adapt to the changes imposed by the EHR, identification of best practices around the clinically excellent use of the EHR is needed. OBJECTIVE: Using the domains of clinical excellence previously defined by the Johns Hopkins Miller Coulson Academy of Clinical Excellence, this review aims to identify best practices around the clinically excellent use of the EHR. METHODS: The authors searched the PubMed database, using keywords related to clinical excellence domains and the EHR, to capture the English-language, peer-reviewed literature published between January 1, 2000, and August 2, 2016. One author independently reviewed each article and extracted relevant data. RESULTS: The search identified 606 titles, with the majority (393/606, 64.9%) in the domain of communication and interpersonal skills. Twenty-eight of the 606 (4.6%) titles were excluded from full-text review, primarily due to lack of availability of the full-text article. The remaining 578 full-text articles reviewed were related to clinical excellence generally (3/578, 0.5%) or the specific domains of communication and interpersonal skills (380/578, 65.7%), diagnostic acumen (31/578, 5.4%), skillful negotiation of the health care system (4/578, 0.7%), scholarly approach to clinical practice (41/578, 7.1%), professionalism and humanism (2/578, 0.4%), knowledge (97/578, 16.8%), and passion for clinical medicine (20/578, 3.5%). CONCLUSIONS: Results suggest that as familiarity and expertise are developed, clinicians are leveraging the EHR to provide clinically excellent care. Best practices identified included deliberate physical configuration of the clinical space to involve sharing the screen with patients and limiting EHR use during difficult and emotional topics. Promising horizons for the EHR include the ability to augment participation in pragmatic trials, identify adverse drug effects, correlate genomic data to clinical outcomes, and follow data-driven guidelines. Clinician and patient satisfaction with the EHR has generally improved with time, and hopefully continued clinician, and patient input will lead to a system that satisfies all.

Experience, expertise, or specialty? Uses and misuses of a reference.

OBJECTIVE: To analyze systematically the manner in which the results of a published study are presented in subsequent publications that refer to it. STUDY DESIGN: We identified a convenience sample of 121 scientific papers that referred to an often-cited 1996 study by Kitahata and colleagues. This study reported that greater primary care physician experience with AIDS was associated with lower mortality among their patients with AIDS. OUTCOMES MEASURED: We determined the manner in which the results of the Kitahata and coworkers study were presented, the type of article, and whether its focus was on HIV care. RESULTS: Most of the articles reviewed (78%) appropriately referred to the study as evidence of improved outcomes with increasing provider experience. However, 8% of the articles reviewed referred to the study as evidence of improved outcomes with specialty care and 3% referred to it as evidence of the benefits of expert care. Articles that referred to the study as evidence of improved outcomes with specialty care were more likely to be review articles and articles with a non-HIV focus. CONCLUSIONS: This study demonstrates that misrepresentation of the findings of published studies is not uncommon. More needs to be done to ensure the accuracy of references in scientific publications.

Facing the malpractice crisis: academic physicians' willingness to accept quick fix solutions.

BACKGROUND: We sought to determine the willingness of academic physicians to accept strategies to contain institutional malpractice costs. METHODS: We surveyed all 270 Department of Medicine physicians at a large academic center. Respondents were asked about their knowledge regarding malpractice premiums, willingness to reduce patient-care activities and accept decreases in compensation. RESULTS: The response rate was 80%. Respondents estimated the annual increase in malpractice premiums from 2004 to 2005 to be 29%. The true increase was 28% (P = 0.55). Almost all opposed eliminating patient care (95%) or providing patient care every other year at double effort and withdrawing from patient care on alternate years (97%). Seventy percent would limit their clinical procedures. Most physicians opposed salary reduction (97%) or decreases in fringe benefits (99%). CONCLUSIONS: Few academic physicians are willing to limit patient care or accept decreases in compensation to recoup institutional malpractice costs.