Integrating Oral Health into Health Professions School Curricula.

Oral health is essential to human health. Conditions associated with poor oral health involve all organ systems and many major disease categories including infectious disease, cardiovascular disease, chronic pain, cancer, and mental health. Outcomes are also associated with health equity. Medical education organizations including the Association of American Medical Colleges and National Academy of Medicine recommend that oral health be part of medical education. However, oral health is not traditionally included in many medical school, physician assistant, or nurse practitioner curricula. Several challenges explain this exclusion including lack of time, expertise, and prioritization; we therefore provide suggestions for integrating oral health education into the health professions school curriculum. These recommendations offer guidance for enhancing the oral health curriculum across institutions. We include key organizational and foundational steps, strategies to link oral health with existing content, and approaches to achieve curricular sustainability.

Eight Ways to Mitigate US Rural Health Inequity.

Rural residents in the United States are less likely to have dental insurance and more likely to face environmental and geographic barriers to oral health and dental care. This article discusses oral health inequity, evidence of oral health's influence on overall health, and why the primary care workforce is well positioned to provide prevention, screening, and referrals for oral health and dental care. Six strategies by which oral health and dental care are integrated into primary care delivery streams can help mitigate rural health inequity.

The impact of family physicians in rural maternity care.

BACKGROUND: Reduced access to maternity care in rural areas of the United States presents a significant burden to pregnant persons and infants. The objective of this study was to estimate the impact of family physicians (FPs) on access to maternity care in rural United States hospitals, especially where other providers may not be available. METHODS: We administered a survey to 216 rural hospitals in 10 US states inquiring about the number of babies delivered from 2013 to 2017, the types of delivering physicians, and the maternity services offered. We calculated the percentage of rural hospitals in our sample where FPs performed vaginal deliveries, cesareans, and vaginal births after cesarean (VBACs), and the percentage of all babies delivered by FPs. We estimated the distance patients would have to travel for care if FPs were not providing care locally. RESULTS: The final study population consisted of 185 rural hospitals. FPs delivered babies in 67% of these hospitals and were the only physicians who delivered babies in 27% of these hospitals. FPs provided VBAC at 18% and cesarean birth services at 46% of the rural hospitals, but with wide geographic differences. Many patients would have to drive an average of 86 miles round-trip to access care if those FPs were to stop delivering. CONCLUSIONS: Family physicians are essential providers of maternity care in the rural United States. Family Medicine residency programs should ensure that trainees who intend to practice in rural locations have adequate maternity care training to maintain and expand access to maternity care for rural patients and their families.

Contributions of US Medical Schools to Primary Care (2003-2014): Determining and Predicting Who Really Goes Into Primary Care.

BACKGROUND AND OBJECTIVES: Schools of medicine in the United States may overstate the placement of their graduates in primary care. The purpose of this project was to determine the magnitude by which primary care output is overestimated by commonly used metrics and identify a more accurate method for predicting actual primary care output. METHODS: We used a retrospective cohort study with a convenience sample of graduates from US medical schools granting the MD degree. We determined the actual practicing specialty of those graduates considered primary care based on the Residency Match Method by using a variety of online sources. Analyses compared the percentage of graduates actually practicing primary care between the Residency Match Method and the Intent to Practice Primary Care Method. RESULTS: The final study population included 17,509 graduates from 20 campuses across 14 university systems widely distributed across the United States and widely varying in published ranking for producing primary care graduates. The commonly used Residency Match Method predicted a 41.2% primary care output rate. The actual primary care output rate was 22.3%. The proposed new method, the Intent to Practice Primary Care Method, predicted a 17.1% primary care output rate, which was closer to the actual primary care rate. CONCLUSIONS: A valid, reliable method of predicting primary care output is essential for workforce training and planning. Medical schools, administrators, policy makers, and popular press should adopt this new, more reliable primary care reporting method.

Machine Learning-Augmented Propensity Score-Adjusted Multilevel Mixed Effects Panel Analysis of Hands-On Cooking and Nutrition Education versus Traditional Curriculum for Medical Students as Preventive Cardiology: Multisite Cohort Study of 3,248 Trainees over 5 Years.

BACKGROUND: Cardiovascular disease (CVD) annually claims more lives and costs more dollars than any other disease globally amid widening health disparities, despite the known significant reductions in this burden by low cost dietary changes. The world's first medical school-based teaching kitchen therefore launched CHOP-Medical Students as the largest known multisite cohort study of hands-on cooking and nutrition education versus traditional curriculum for medical students. METHODS: This analysis provides a novel integration of artificial intelligence-based machine learning (ML) with causal inference statistics. 43 ML automated algorithms were tested, with the top performer compared to triply robust propensity score-adjusted multilevel mixed effects regression panel analysis of longitudinal data. Inverse-variance weighted fixed effects meta-analysis pooled the individual estimates for competencies. RESULTS: 3,248 unique medical trainees met study criteria from 20 medical schools nationally from August 1, 2012, to June 26, 2017, generating 4,026 completed validated surveys. ML analysis produced similar results to the causal inference statistics based on root mean squared error and accuracy. Hands-on cooking and nutrition education compared to traditional medical school curriculum significantly improved student competencies (OR 2.14, 95% CI 2.00-2.28, p < 0.001) and MedDiet adherence (OR 1.40, 95% CI 1.07-1.84, p = 0.015), while reducing trainees' soft drink consumption (OR 0.56, 95% CI 0.37-0.85, p = 0.007). Overall improved competencies were demonstrated from the initial study site through the scale-up of the intervention to 10 sites nationally (p < 0.001). DISCUSSION: This study provides the first machine learning-augmented causal inference analysis of a multisite cohort showing hands-on cooking and nutrition education for medical trainees improves their competencies counseling patients on nutrition, while improving students' own diets. This study suggests that the public health and medical sectors can unite population health management and precision medicine for a sustainable model of next-generation health systems providing effective, equitable, accessible care beginning with reversing the CVD epidemic.

An Assessment of Participant-Described Interprofessional Oral Health Referral Systems Across Rurality.

PURPOSE: As a means to identify and quantify oral health interprofessional collaborative practice (IPP), we examined participant-described medical-to-dental (M2D) referral networks and how they function across rurality. METHODS: We conducted a cross-sectional survey on the appraisal of IPP referral systems in 2016. Secondarily, we examined if rural health clinics (RHCs) have different experiences with M2D referrals compared to other practice types. Independent variables included geographic and organizational indicators, referral system attributes, and respondent characteristics. Data were coded by Census region and state Medicaid expansion status. Bivariable and multivariable analyses were conducted using SAS. FINDINGS: A convenience cohort (n = 559) from 44 states was examined. Nearly, half (48.7%) reported dependable M2D referral systems. In bivariate analysis, all independent variables were significant except for state Medicaid expansion status. In multivariable analysis, Census region retained significance (P = .0093). Organization type and practice issues with no shows/missed appointments continued to have significance (P < .001 and .002, respectively). Accountable care organizations were over 5 times (5.72, P = .001) more likely than RHCs to report dependable M2D referral systems. Federally qualified health clinics were slightly over 3 times more likely than RHCs to report dependable M2D referral (3.04, P < .001). No differences between RHCs and other private practices were observed. CONCLUSIONS: The importance of IPP continues to be promoted in the current health care environment. Our study demonstrates that, in this motivated study population, M2D referrals can work well, even in rural areas. Organization type, directionality of referral, broken appointment rates, and electronic health information management were all found to significantly impact the respondents' rating on the dependability of an M2D referral process.

Using Ultrasound to Enhance Medical Students' Femoral Vascular Physical Examination Skills.

OBJECTIVES: To determine whether the addition of ultrasound to traditional physical examination instruction improves junior medical students' abilities to locate the femoral pulse. METHODS: Initially, 150 second-year medical students were taught the femoral pulse examination using traditional bedside teaching on standardized patients and online didactic videos. Students were then randomized into 2 groups: group 1 received ultrasound training first and then completed the standardized examination; and group 2 performed the standardized examination first and then received ultrasound training. On the standardized patients, the femoral artery was marked with invisible ink before the sessions using ultrasound. Compared to these markers, students were then evaluated on the accuracy of femoral artery pulse palpation and the estimated location of the femoral vein. All students completed a self-assessment survey after the ultrasound sessions. RESULTS: Ultrasound training improved the students' ability to palpate the femoral pulse (P= .02). However, ultrasound did not facilitate correct estimation of the femoral vein's anatomic location (P = .09). Confidence levels in localizing the femoral artery and vein were equal between groups at baseline, and both increased after the ultrasound sessions. CONCLUSIONS: The addition of ultrasound teaching to traditional physical examination instruction enhanced medical student competency and confidence with the femoral vascular examination. However, understanding of anatomy may require emphasis on precourse didactic material, but further study is required.

The impact of Advanced Life Support in Obstetrics (ALSO) training in low-resource countries.

OBJECTIVE: To examine the effects of the Advanced Life Support in Obstetrics (ALSO) program on maternal outcomes in four low-income countries. METHODS: Data were obtained from single-center, longitudinal cohort studies in Colombia, Guatemala, and Honduras, and from an uncontrolled prospective trial in Tanzania. RESULTS: In Colombia, maternal morbidity and the number of near misses increased after ALSO training, but maternal mortality decreased. In Guatemala, sustained reductions in overall maternal mortality and mortality from postpartum hemorrhage (PPH) were recorded after ALSO implementation. In Honduras, there was a significant decrease in episiotomy rates, and increases in active management of the third stage of labor (AMTSL), vacuum-assisted delivery, and reported comfort managing obstetric emergencies. In Tanzania, the frequency of PPH and severe PPH decreased after training, while management improved. CONCLUSION: In low-income countries, ALSO training was associated with decreased in-hospital maternal mortality, episiotomy use, and PPH. AMTSL and vacuum-assisted vaginal delivery increased in frequency after ALSO training.

Interdisciplinary rural immersion week.

INTRODUCTION: Health professions students interested in future rural practice locations spend a week learning about and investigating all aspects of small town personal, professional and community life. This augments the mainly clinical experience provided by clinical rotations they complete as part of their professional academic training program. METHODS: Students from professional programs in medicine, physician assistant, pharmacy, nursing, public health and psychology travel to a small community, receive an orientation and in small interprofessional groups investigate health care, education, government, law enforcement, public health, economy and natural resources. RESULTS: Participants report that the experience raises their interest in future rural practice, answers questions they have about rural life and enhances their understanding of the issues they must learn more about before making a career location choice. CONCLUSIONS: The interdisciplinary rural immersion program provides students with the time, structure and permission to move out of their clinical 'comfort zone' and think about the cultural, economic and environmental aspects of rural life and work.

Endoscopy training in primary care: innovative training program to increase access to endoscopy in primary care.

BACKGROUND AND OBJECTIVES: Colorectal cancer (CRC) is a significant source of morbidity and mortality in the United States. Colonoscopy can be an extension of the care provided by a family physician to help substantially reduce CRC morbidity and mortality. Family physicians trained in colonoscopy can provide access to care in rural and medically underserved areas. METHODS: The Department of Family Medicine and the Colorado Area Health Education Center (AHEC) developed the Endoscopy Training for Primary Care (ETPC) program to teach primary care physicians to perform colonoscopy. The program included online didactic education, a formal endoscopy simulator experience, and proctoring by a current endoscopist. Participants completed a baseline and follow-up survey assessing CRC screening knowledge and the effectiveness of the endoscopy training for ongoing screening activities. RESULTS: To date, 94 practitioners and health professional students have participated in the study. Ninety-one (97%) completed the online didactic portion of the training. Sixty-five participants (77%) were physicians or medical students, and the majority (64%) was in the field of family medicine. The year 4 (2011) follow-up cohort was comprised of 62% respondents working in an urban background and 26% in rural communities. Many participants remain in a queue for proctoring by a trained endoscopist. Several participants are successfully performing a significant number of colonoscopies. CONCLUSIONS: ETPC program showed success in recruiting a large number of physicians and students to participate in training. The program enhanced perceptions about the value of colon cancer screening and providing screening endoscopy in primary care practice. Providing sites for simulation training throughout Colorado provided opportunity for providers in rural regions to participate. As a result of this training, thousands of patients underwent testing to prevent colon cancer. Future research relating to colonoscopy training by family physicians should focus on quality assurance and determining best methods for procedural competence.

Tiered maternity care training in family medicine.

BACKGROUND AND OBJECTIVES: Maternity care training in family medicine is a major component of our specialty. The Association of Family Medicine Residency Directors (AFMRD) issued a position paper calling for a two-tiered system of training for family physicians based on concern that some residency programs are unable to meet the current Residency Committee-Family Medicine (RC-FM) requirements for maternity care training. This two-tiered system was also endorsed by other family medicine organizations, including the AAFP, ADFM, NAPCRG, and STFM. Despite this support of the new system, there remains concern among some family medicine educators about this two-tiered approach. The Society of Teachers of Family Medicine Group on Hospital Medicine and Procedural Training met in 2009 and 2010 to develop an alternative tiered system for the training of family medicine residents in maternity care. METHODS: Working from previous requirements for maternity care training and the AFMRD document, the group used a multi-voting process to identify the tiers and their elements. RESULTS: The group generated a three-tier system for maternity care training in family medicine residencies. These included curriculum, patient volume, faculty expectations, and institutional requirements. CONCLUSIONS: The three tiers we propose address the importance of maternity care, the limitations that some residencies face in providing adequate patient volumes, and the need to teach more advanced skills to those family medicine residents who will work in rural and underserved areas upon graduation. We urge family medicine governing bodies to adopt this system and believe that it will help preserve the essential role that family physicians serve in the care of pregnant women starting with basic maternity care and extending to advanced roles including care of complicated pregnancies and cesarean delivery.

First trimester bleeding.

Vaginal bleeding in the first trimester occurs in about one fourth of pregnancies. About one half of those who bleed will miscarry. Guarded reassurance and watchful waiting are appropriate if fetal heart sounds are detected, if the patient is medically stable, and if there is no adnexal mass or clinical sign of intraperitoneal bleeding. Discriminatory criteria using transvaginal ultrasonography and beta subunit of human chorionic gonadotropin testing aid in distinguishing among the many conditions of first trimester bleeding. Possible causes of bleeding include subchorionic hemorrhage, embryonic demise, anembryonic pregnancy, incomplete abortion, ectopic pregnancy, and gestational trophoblastic disease. When beta subunit of human chorionic gonadotropin reaches levels of 1,500 to 2,000 mIU per mL (1,500 to 2,000 IU per L), a normal pregnancy should exhibit a gestational sac by transvaginal ultrasonography. When the gestational sac is greater than 10 mm in diameter, a yolk sac must be present. A live embryo must exhibit cardiac activity when the crown-rump length is greater than 5 mm. In a normal pregnancy, beta subunit of human chorionic gonadotropin levels increase by 80 percent every 48 hours. The absence of any normal discriminatory findings is consistent with early pregnancy failure, but does not distinguish between ectopic pregnancy and failed intrauterine pregnancy. The presence of an adnexal mass or free pelvic fluid represents ectopic pregnancy until proven otherwise. Medical management with misoprostol is highly effective for early intrauterine pregnancy failure with the exception of gestational trophoblastic disease, which must be surgically evacuated. Expectant treatment is effective for many patients with incomplete abortion. Medical management with methotrexate is highly effective for properly selected patients with ectopic pregnancy. Follow-up after early pregnancy loss should include attention to future pregnancy planning, contraception, and psychological aspects of care.

Changing policies on vaginal birth after cesarean: impact on access.

BACKGROUND: The issue of vaginal birth after cesarean (VBAC) has become highly visible and contentious. In 1999, the American College of Obstetricians and Gynecologists advocated a policy that surgical capability be "immediately available" for women in labor attempting VBAC. METHODS: Every hospital in Colorado, Montana, Oregon, and Wisconsin was contacted by telephone at least once during the period 2003 to 2005. Using a semistructured interview, respondent hospitals were asked whether and when their policies for VBAC had changed and what was the availability of VBAC services before and after the 1999 policy was issued. RESULTS: Of 314 hospitals contacted, 312 responded to the survey (response rate 99.4%). Babies were delivered at 230 (74%) respondent hospitals. Almost one-third, 68 of 222 (30.6%), of responding delivery hospitals that previously offered VBAC services had stopped doing so; seven hospitals had never allowed VBAC. Of the hospitals that still allowed VBAC, 68 percent had changed their VBAC policies since 1999, with the most frequent changes requiring the in-house presence of surgery (53%) and anesthesia (44%) personnel when women desiring VBAC presented in labor. Compared with hospitals that stopped allowing VBAC, those that currently permit VBAC were larger (156.6 vs 58.1 beds, t = 7.02, p < 0.001), closer to other delivery hospitals (20.9 vs 39.2 miles, t = 4.33, p < 0.001), annually delivered more babies (1009.9 vs 458.3, t = 4.41, p < 0.001), and annually had more cesarean deliveries (226.7 vs 105.7, t = 3.91, p < 0.001). CONCLUSIONS: In the years following advocacy of the 1999 policy, the availability of VBAC services significantly decreased, especially among smaller or more isolated hospitals.

Advanced life support in obstetrics (ALSO) international development.

BACKGROUND: The Advanced Life Support in Obstetrics (ALSO) program helps pregnancy care providers learn the information and skills necessary to deal with urgent and emergent conditions that arise during pregnancy and delivery by using mannequins, mnemonics, and evidence-based approaches. Since its origin, the program has been disseminated internationally. Outside of North America, more than 18,000 clinicians have taken the ALSO course, and more than 1,200 ALSO individuals have been approved as ALSO instructors. Some of the international programs have become self-sustaining, others have not. METHODS: Features of ALSO programs were analyzed in all countries in which ALSO has been introduced to identify characteristics associated with the program becoming self-sustaining. RESULTS: Characteristics of self-sustaining ALSO programs include a strong organizational structure, use of a train-the-trainer model to introduce the course, and encouragement of competing groups to work together. Overall, the program has been sustained by drawing on the expertise of international collaborators for medical content and by balancing customization of content against preservation of core information and skills. CONCLUSIONS: When the ALSO program is introduced to a new country or region, methods that have resulted in programs becoming self-sustaining should be used.