Becoming a Community-Based Physician Researcher.

Years ago, as a contented community family physician practicing with 4 physician colleagues, I focused on applying medical knowledge to help patients. After a young patient's death from smoking I became interested in improving our strategy for helping smokers quit. A researcher offered us the opportunity to test a cessation intervention that had been successful in an academic setting. I was concerned that this study would interfere with my patient care duties until I visited a practitioner researcher in Wales. I was inspired and worked with a research professional to build colleague support and carry out this project. After this gratifying experience I had similar experiences working with other research teams. As an ordinary practitioner I had expanded my role to become significantly involved in research. In this role I was working with a team to improve patient care. It was a fundamental change that brought me great satisfaction.

Retirement Tea.

In this narrative essay, the author, a family physician, remembers his encounters with patients at his 2008 retirement tea following 34 years in practice. The physician and the patients explored their experiences working together and expressed their gratitude to each other. The author looks back at how these long-standing relationships led to better care and better health.

Patient Perspectives: Valuable Food Insecurity Interventions.

INTRODUCTION: Food insecurity (FI), defined as "limited or uncertain availability of nutritionally adequate and safe foods, or limited or uncertain ability to acquire acceptable foods in socially acceptable ways," affects over 12% of US households. Embarrassment persists for patients with FI, and due to the potential consequences of FI, including increased utilization of the health care system, it is important to find causes and potential interventions for FI. The purpose of this project was to better understand FI from the patient perspective, including contributing factors, perceived health effects, and helpful interventions. METHODS: Interviews (N=21) were conducted with suburban community residency clinic patients who screened positive for FI in the last 12 months. Six open-ended questions and a ranking question examined contributors to FI, effects of FI, perceptions of clinic intervention helpfulness, and ideas for novel interventions. RESULTS: Patients identified lack of income (85.7%) as the primary issue they faced. Secondary identified issues were lack of transportation (38.1%), too much debt (33.3%), and food assistance programs not providing for all needs (33.3%). FI effects on patients' health included difficulty adhering to specialized diets and the need to modify eating patterns due to lack of food. Surprisingly, 28.6% perceived no FI related-health effects. Patients felt that the most valuable clinic intervention was provision of urgent need food boxes, followed by FI screening and referrals to community food resources. CONCLUSIONS: Frequent FI screening is in itself useful to patients. Screening paired with community food resource referrals and urgent-need food boxes are the most helpful interventions according to patients.

Improving Identification of Food-Insecure Patients in an Outpatient Clinic Setting.

INTRODUCTION: Food insecurity (FI) is defined as limited or uncertain access to enough nutritious food for all household members to lead an active and healthy life. In 2017, roughly 12% of US households reported FI. FI screening is not standard practice despite FI's association with poor health outcomes. This study compared FI screening strategies in a community-based family medicine residency clinic to determine which strategies identified the largest number of FI patients. METHODS: We conducted this study using a validated two-question screening tool with high sensitivity and specificity for identifying FI. Three implementation strategies of the screening tool were tested: two clinician-initiated and one staff-initiated. Data measured included opportunities to screen, patients actually screened, and the number of positive (disclosure) responses. RESULTS: Clinician-initiated screening rates increased when clinicians followed a standard note template with embedded FI questionnaire vs no template (58.6% vs 7.1%). Despite this improvement, staff-initiated screening returned an even higher screening rate (95.2%). The disclosure of FI determined by staff-initiated screening was also higher (12.2%, similar to previously published data) than clinician-initiated screening (2.3%). CONCLUSIONS: Staff-initiated screening for FI was the best way of identifying FI patients and yielded results consistent with local and national estimates. Clinicians did not screen patients for FI often enough for this approach to be effective, but embedding FI screening into templated notes improved clinician screening rates. Disclosure of FI when staff conducted screening far exceeded disclosure when screening was initiated by clinicians.

Views of primary care providers on follow-up care of cancer patients.

BACKGROUND AND OBJECTIVES: Primary care providers (PCPs) are often involved in the care of cancer survivors. This study asked PCPs about their role in the follow-up care of breast and colorectal cancer patients and elicited opinions on improving the transfer of care from oncologists to PCPs. METHODS: A total of 175 PCPs in a large health care system with an electronic medical record system were mailed a questionnaire that addressed (1) their comfort and confidence regarding surveillance for cancer recurrence, (2) when patients should be seen in primary care, (3) evaluation of the transfer of care, (4) potential problems with that process, and (5) suggestions for improving that process. RESULTS: The response rate was 75.4%. Overall, 52% were comfortable having responsibility for surveillance of cancer recurrence, and 43% were confident they are following standard guidelines for cancer recurrence. Both of the aforementioned measures increased with years of practice. More than half rated the current transfer of care from oncologist to PCP as fair or poor. The most common problems identified were uncertainty regarding the type (62.6% for breast, 56.5% for colorectal), frequency (72.5%, 66.4%), and duration (74.8%, 67.2%) of surveillance testing. CONCLUSIONS: Levels of comfort, confidence, and satisfaction were generally low. PCPs need more specific guidance regarding surveillance for cancer recurrence.

Smoking-related attitudes and clinical practices of medical personnel in Minnesota.

CONTEXT: Effective clinic-based, smoking-cessation activities are not widely implemented. OBJECTIVE: To compare and contrast the smoking-cessation attitudes and clinical practices of five types of primary healthcare team members. DESIGN AND SETTING: From July to October 2002, a cross-sectional survey was mailed to randomly selected primary care physicians (MDs), advanced practice nurses (APRNs), registered nurses (RNs), licensed practical nurses (LPNs), and medical assistants (MAs). MAIN OUTCOME MEASURES: Factors associated with limited smoking-cessation service delivery. RESULTS: The overall response rate was 68% (n =3021). Most respondents reported that patients' smoking status was consistently documented at their clinic (79%); other system prompts were less common (30%). Many respondents reported documenting smoking status or recommending quitting; few reported consistently assessing, assisting, or arranging follow-up. The mean rank of smoking cessation as an important preventive service among nine preventive services declined from MDs (1.9) to APRNs (2.5), RNs (3.4), LPNs (4.2), and MAs (4.6). Smoking prevalence increased from 1% in MDs to 3% APRNs, 9% RNs, 17% LPNs, and 22% MAs. Those who reported no consistent smoking-cessation service delivery were more likely to be RNs, LPNs, or MAs, currently smoke, and work more hours. They were less likely to consider patients receptive to cessation messages, to consider themselves qualified to counsel on smoking, or to work in clinics that had smoking-cessation guidelines or system prompts such as chart reminders. CONCLUSIONS: Smoking-cessation service delivery may be enhanced if educational offerings, system changes, and training include all clinical staff members.

A nurse-based pilot program to reduce cardiovascular risk factors in a primary care setting.

OBJECTIVE: To evaluate the effectiveness of a nurse-based cardiovascular disease (CVD) risk factor reduction program among patients at a primary care outpatient clinic. STUDY DESIGN: Preintervention and postintervention longitudinal, prospective pilot study to evaluate patients' achievement of CVD risk factor reduction. PATIENTS AND METHODS: A total of 436 patients at a primary care clinic in suburban Minneapolis, Minnesota, were enrolled in 2 years; 286 patients were followed up with additional visits. The nurse intervention included comprehensive CVD risk assessment, patient education, and counseling. Algorithms guided the development of individualized care plans based on laboratory test values, blood pressure readings, tobacco use, and history of cardiovascular events. Physicians were consulted for serious changes in patients' medical conditions or for medication changes. Three measures were compared from baseline to the end of the program: blood pressure, low-density lipoprotein cholesterol levels, and tobacco use. RESULTS: Statistically significant reductions were achieved from baseline to the final nurse visit in systolic blood pressure (from 155.8 to 143.4 mm Hg), diastolic blood pressure (from 94.4 to 84.0 mm Hg), and dyslipidemia (low-density lipoprotein cholesterol, from 4.15 to 3.80 mmol/L [from 160 to 147 mg/dL]) (P < .001 for all). Of the 40 tobacco users who participated in the program, 12 discontinued use (30%). CONCLUSIONS: This pilot study provides preliminary evidence of the effectiveness of a nurse-based CVD risk reduction program. Further study is needed to target high-risk patients and to compare results in the nurse intervention group with those in patients receiving usual care.

The TEAM project: the effectiveness of smoking cessation intervention with hospital patients.

BACKGROUND: This study evaluated the effectiveness of three smoking cessation interventions for this population: (1) modified usual care (UC); (2) brief advice (A); and (3) brief advice plus more extended counseling during and after hospitalization (A + C). METHODS: Smokers (2,095) who were in-patients in four hospitals were randomly assigned to condition. Smoking status was ascertained via phone interview 7 days and 12 months post-discharge. At 12 months, reports of abstinence were validated by analysis of saliva cotinine. Intent to treat analyses were performed. RESULTS: At 7-day follow-up, 24.2% of participants reported abstinence in the previous 7 days. There were no differences between conditions. At 12-month follow-up, self-reported abstinence was significantly higher in the A + C condition (UC (15.0%) vs. A (15.2%) vs. A + C (19.8%)). There was no significant difference among conditions in cotinine-validated abstinence, however (UC (8.8%) vs. A (10.0%) vs. A + C (9.9%)). CONCLUSIONS: These interventions for hospital in-patients did not increase abstinence rates. Features of the study that might have contributed to this finding were the inclusiveness of the participation criteria, the fact that pharmacological aids were not provided, and a stage-matching approach that resulted in less intensive counseling for participants unwilling to set a quit date.