Differences in Cannabidiol-Related Attitudes and Practice Behaviors Between U.S. Primary Care Physicians Practicing in a Single Health Care System Across States With and Without Marijuana Legalization.

Introduction: Dramatic shifts in marijuana laws, along with federal deregulation of hemp with the 2018 Farm Bill, have resulted in increased availability and use of cannabidiol (CBD) supplements throughout the United States (US). Given the rapid increase in CBD use in the U.S. general population, in this study, we aim to characterize primary care physician (PCP) attitudes and practice behaviors and to assess whether differences in provider attitudes and behaviors vary as a function of marijuana legalization (ML) status in the state of practice. Materials and Methods: Data are from an online provider survey on CBD supplement-related attitudes, beliefs, and behaviors administered to 508 PCPs as part of a larger mixed methods study. Participating PCPs were recruited from the Mayo Clinic Healthcare Network and provided medical care in primary care settings across four U.S. states (Minnesota, Wisconsin, Florida, and Arizona). Results: The survey response rate was 45.4% (n=236/508). According to providers, CBD was frequently brought up in PCP settings, typically by patients. PCPs were generally hesitant to screen for or discuss CBD with their patients and identified multiple barriers to open patient-provider dialogue about CBD. PCPs practicing in states that had passed ML were more receptive to patients using CBD supplements, whereas PCPs practicing in states that had not passed ML were more concerned about CBD-related side effects. Regardless of state ML status, most PCPs did not feel that they should be recommending CBD supplements to their patients. Most PCPs reported believing that CBD was unhelpful for most conditions for which it is marketed, with chronic non-cancer pain and anxiety/stress being exceptions. PCP respondents generally felt that they had insufficient knowledge/training around CBD. Conclusions: Results from this mixed methods study show that PCPs practicing in the U.S. rarely screen for or discuss CBD use with their patients and report several barriers to engage in proactive CBD-focused practice behaviors. Furthermore, survey results show that some PCP attitudes, practice behaviors, and barriers vary as a function of state ML status. These findings may guide medical education efforts and inform primary care practice modifications aimed at enhancing screening and monitoring of patient CBD use by PCPs.

Atomoxetine Reduced Binge/Purge Symptoms in a Case of Anorexia Nervosa Binge/Purge Type.

ABSTRACT: Psychopharmacologic treatments for eating disorders (EDs) remain unclear, particularly for anorexia nervosa. As in attention-deficit hyperactivity disorder, a dopaminergic mechanism has been implicated in EDs, prompting our use of atomoxetine in an 18-year-old woman with anorexia nervosa, binge/purge type. Atomoxetine is a highly selective norepinephrine reuptake inhibitor with nonaddictive properties and limited effects of appetite suppression. Doses followed those used in a previous trial of atomoxetine in the treatment of binge ED, and response was assessed over 4 months, with significant improvement in ED behaviors and mood. Larger-scale, randomized studies that assess the efficacy of atomoxetine in the treatment of anorexia nervosa, binge/purge type are warranted.

Dysphagia: Evaluation and Collaborative Management.

Dysphagia is common but may be underreported. Specific symptoms, rather than their perceived location, should guide the initial evaluation and imaging. Obstructive symptoms that seem to originate in the throat or neck may actually be caused by distal esophageal lesions. Oropharyngeal dysphagia manifests as difficulty initiating swallowing, coughing, choking, or aspiration, and it is most commonly caused by chronic neurologic conditions such as stroke, Parkinson disease, or dementia. Symptoms should be thoroughly evaluated because of the risk of aspiration. Patients with esophageal dysphagia may report a sensation of food getting stuck after swallowing. This condition is most commonly caused by gastroesophageal reflux disease and functional esophageal disorders. Eosinophilic esophagitis is triggered by food allergens and is increasingly prevalent; esophageal biopsies should be performed to make the diagnosis. Esophageal motility disorders such as achalasia are relatively rare and may be overdiagnosed. Opioid-induced esophageal dysfunction is becoming more common. Esophagogastroduodenoscopy is recommended for the initial evaluation of esophageal dysphagia, with barium esophagography as an adjunct. Esophageal cancer and other serious conditions have a low prevalence, and testing in low-risk patients may be deferred while a four-week trial of acid-suppressing therapy is undertaken. Many frail older adults with progressive neurologic disease have significant but unrecognized dysphagia, which significantly increases their risk of aspiration pneumonia and malnourishment. In these patients, the diagnosis of dysphagia should prompt a discussion about goals of care before potentially harmful interventions are considered. Speech-language pathologists and other specialists, in collaboration with family physicians, can provide structured assessments and make appropriate recommendations for safe swallowing, palliative care, or rehabilitation.

Academic Detailing From Medical Students: Part of a Plan to Emphasize Feedback in One Clerkship.

INTRODUCTION: Medical schools have an enduring need to provide ongoing faculty development and to foster educational alliances between teachers and learners, so that feedback provided to learners is both frequent and of high quality. We hypothesized that medical students trained as academic detailers with a mission to increase the emphasis on feedback could serve in this role during our clerkship, while still being evaluated as students in our clerkship rotation. METHODS: The family medicine clerkship at Mayo Clinic School of Medicine launched a revised curriculum in 2016 in which students were taught how they might build an educational alliance with preceptors, were taught characteristics of high-quality feedback, and practiced requesting more useful feedback when initial quality was poor. After utilizing a clerkship-specific curriculum with small group sessions on receiving feedback, and training students and preceptors on the SNAPPs model, students were then directed to request feedback from their preceptors and model successful feedback conversations for preceptors. The study evaluated the medical students' summative evaluations to compare the rate from the preintervention year (2015-2016) and the intervention year (2016-2017) at which preceptors added comments on students' use of feedback. RESULTS: Preceptors' written comments about students seeking feedback increased at about a four-fold rate (74.4% vs 18.8%, P<.001) after implementing a suite of changes to our clerkship curriculum. CONCLUSIONS: Using medical students to change preceptor behaviors was an important part of our suite of interventions. This intervention directed preceptor attention toward our instructional goal of increased medical student feedback.

The role of the generalist in the initial treatment of adolescent anorexia nervosa. .

Anorexia nervosa is a potentially serious illness characterized by the sufferer having a malignant fear of gaining weight and being fat. It was believed to stem from psychosocial problems. Treatment of the adolescent with anorexia has typically involved an inpatient stay in a specialized center where he or she can receive therapy aimed at changing thinking and exploring family dynamics. A newer strategy, family-based treatment, focuses on the young person's physical state. It can be initiated by a primary care physician during an outpatient visit. This article introduces this new paradigm for treating anorexia nervosa in adolescents and outlines the role of the primary care physician in diagnosing, treating and supporting the patient.