Medical schools, primary care and family medicine: clerkship directors' perceptions of the current environment.

BACKGROUND: The culture at a medical school and the positive experiences in primary care clerkships influence student specialty choice. This choice is significant if the demand for primary care physicians is to be met. The aim of this study was to examine family medicine clerkship directors' perceptions of the medical school environment. METHODS: Data were collected as part of the 2015 Council of Academic Family Medicine Educational Research Alliance Family Medicine Clerkship Director survey. Questions asked included how clerkship directors perceived the environment of their medical school towards family medicine, has the environment towards family medicine changed between 2010 and 2015, do they take action to influence student attitudes towards family medicine and whether faculty members in other departments make negative comments about family medicine. RESULTS: The response rate was 79.4%. While most respondents indicated the environment of their medical school has become more positive towards family medicine, a majority of clerkship directors perceived the environment to be either very much against, slightly against or indifferent towards family medicine. Nearly one-half (41.4%) of the clerkship directors were notified more than once a year that a faculty member of another department made a negative comment about family medicine. Results varied among regions of the USA and between schools located in the USA and Canada. CONCLUSION: Family medicine clerkship directors often perceived negativity towards family medicine, a finding that may limit the effectiveness of academic health centres in their mission to better serve their community and profession.

Comparison of Factors Identified by Patients and Physicians Associated with Hospital Readmission (COMPARE2).

OBJECTIVE: Factors contributing to hospital readmission have rarely been sought from the patient perspective. Furthermore, it is unclear how patients and physicians compare in identifying factors contributing to readmission. The objective of the study was to identify and compare factors contributing to hospital readmission identified by patients and physicians by surveying participants upon hospital readmission to a teaching medicine service. METHODS: Patients 18 years and older who were discharged and readmitted to the same service within 30 days and the physicians caring for these patients were surveyed to identify factors contributing to readmission. Secondary outcomes included comparing responses between groups and determining level of agreement. Patients could be surveyed multiple times on subsequent readmissions; physicians could be surveyed for multiple patients. RESULTS: A total of 131 patients and 37 physicians were consented. The mean patient age was 60.1 years (standard deviation 16.8 years) and 55.6% were female; 56.4% were white, and 42.1% were black/African American. In total, 179 patient surveys identified "multiple medical problems" (48.6%), "trouble completing daily activities" (45.8%), and "discharged too soon" (43.6%) most frequently as contributing factors; 231 physician surveys identified "multiple medical problems" (45.0%) and "medical condition too difficult to care for at home" (35.6%) most frequently as contributing factors. Paired survey results were available for 135 readmissions and showed fair agreement for only 1 factor but no agreement for 5 factors. CONCLUSIONS: Patients identified previously unknown factors contributing to readmission. Little agreement existed between patients and physicians. Additional research is needed to determine how best to address patient-identified factors contributing to readmission.

Are Patients Frequently Readmitted to the Hospital Different from the Other Admitted Patients?

INTRODUCTION: Although the characteristics of readmitted patients associated with a family medicine inpatient service have been reported, differing characteristics between groups of patients based on readmission rates have not been studied. The aim of this project was to examine patients with differing rates of readmission. METHODS: Patients admitted to a family medicine inpatient service were classified into 1 of 3 groups based on the number of admission and readmissions in a given year. Demographic data and other characteristics of these patients were collected and used in analysis. Descriptive statistics were used to characterize the 3 groups of admissions. Differences in characteristics of groups were compared using Wilcoxon rank sum test for continuous variables and χ2 test or Fisher exact test for categoric variables. Multivariate logistic regressions were used for predicting high-frequency readmission. RESULTS: Patients in the high-frequency readmission group more commonly had a psychiatric, substance abuse, and chronic pain diagnosis. The primary discharge diagnoses among the 3 groups were similar. Age-group, Charlson severity index, Morse Fall Scale medication list, and problem list were significant for predicting high frequency of readmission. Annually, patients in the high-frequency readmission group had about an 80% turnover rate. CONCLUSIONS: Although this study examined patient care data from only one large academic health center hospital, the results found that patients who experience 3 or more readmissions in a calendar are associated with specific characteristics. In addition, the list of specific individual patients considered to be high utilizers for hospital readmissions was dynamic and significantly changed during 3 consecutive years.

What Are the Characteristics of Fourth-Year Medical Students With Higher Levels of Resilience?

INTRODUCTION: Burnout during medical training, including medical school, has gained attention in recent years. Resiliency may be an important characteristic for medical students to have or obtain. The aim of this study was to examine the level of resiliency in fourth-year medical students and whether certain characteristics were associated with students who have higher levels of resiliency. METHODS: Subjects were fourth-year medical students who completed a survey during a required end-of-year rotation. The survey collected subjects' demographic information including age, gender, race, ethnicity, marital status, and chosen specialty. They were also asked to complete the Brief Resilience Scale (BRS) and answer questions that assessed personal characteristics. RESULTS: The response rate was 92.4%. Most respondents had personal time for themselves after school (92.6%), exercise or participate in physical activity for at least 30 minutes most days of the week (67.2%), were able to stop thinking about medical school after leaving for the day (58.2%), and had current financial stress (51.6%). No differences were noted in demographic information among students across specialty categories. A higher BRS score was associated with being male and having the ability to stop thinking about school. CONCLUSIONS: BRS scores in medical students are associated with specific demographic characteristics and the ability to stop thinking about school. Addressing the modifiable activities may assist students with increasing their resiliency and potentially decreasing their risk of burnout.

Stakeholder Engagement in Developing an Electronic Clinical Support Tool for Tobacco Prevention in Adolescent Primary Care.

Following guideline recommendations to promote tobacco prevention in adolescent primary care, we developed a patient-facing clinical support tool. The electronic tool screens patients for use and susceptibility to conventional and alternative tobacco products, and promotes patient⁻provider communication. The purpose of this paper is to describe the iterative stakeholder engagement process used in the development of the tool. During the pre-testing phase, we consulted with scientists, methodologists, clinicians, and Citizen Scientists. Throughout the development phase, we engaged providers from three clinics in focus groups. Usability testing was conducted via in-depth, cognitive interviewing of adolescent patients. Citizen Scientists (n = 7) played a critical role in the final selection of educational content and interviewer training by participating in mock-up patient interviews. Cognitive interviews with patients (n = 16) ensured that systems were in place for the feasibility trial and assessed ease of navigation. Focus group participants (n = 24) offered recommendations for integrating the tool into clinical workflow and input on acceptability and appropriateness, and anticipated barriers and facilitators for adoption and feasibility. Engaging key stakeholders to discuss implementation outcomes throughout the implementation process can improve the quality, applicability, and relevance of the research, and enhance implementation success.

Evidence-based tobacco treatment utilization among dual users of cigarettes and E-cigarettes.

Dual users of e-cigarettes and cigarettes may represent a unique and receptive population for evidence-based tobacco dependence treatment. We measured the frequency of quit attempts during the past year, and the use of evidence-based tobacco dependence treatments (i.e., behavioral and/or pharmacological treatments), among adult smokers who are current e-cigarette users (dual users) compared with those who do not use e-cigarettes (exclusive smokers). Data were analyzed from the 2015 National Health Interview Survey. Multivariate-adjusted regression models were used to examine the correlates of tobacco treatment use among adult smokers, comparing current e-cigarette users with those who did not use e-cigarettes, stratifying by age group, and adjusting for sociodemographic characteristics. Analyses were based on 5415 adult current cigarette smokers. Compared to exclusive smokers, dual users were more likely to report a quit attempt in the past year among adults <65 years: 18-24 years (odds ratio [OR] = 2.25), 25-44 years (OR = 1.60), and 45-64 years (OR = 1.96). With the exception of adults ≥65 years, dual users reported low rates of using combination (behavioral and pharmacological) treatments that were not statistically different from exclusive smokers: 18-24 years (0.1% vs. 2.1%, respectively), 25-44 years (4.3% vs. 4.7%), and 45-64 years (3.0% vs. 8.3%). Despite higher likelihood for dual users to make a quit attempt, their use of evidence-based tobacco treatment is low, similar to exclusive smokers. Dual users of cigarettes and e-cigarettes represent a prime target for interventions to expand access and utilization of evidence-based tobacco use treatments.

Institutional NIH Research Funding and a Culture of Support for Family Medicine-Their Relationship to Family Medicine Specialty Choice.

BACKGROUND AND OBJECTIVES: The United States suffers from a low proportion of medical students pursuing family medicine (FM). Our objective was to examine institutional characteristics consistent with a focus on National Institutes of Health (NIH) research, institutional support for FM education, and the proportion of medical students choosing FM. METHODS: The 2015 CERA Survey of Family Medicine Clerkship Directors was merged with institutional NIH funding data from 2014 and medical student specialty choice in 2015. Institutional educational support was operationalized as (1) clerkship director's perception of medical school environment toward FM, and (2) amount of negative comments about FM made by faculty in other departments. The outcome was the percentage of students selecting FM. Bivariate statistics were computed. RESULTS: As NIH funding increases, the proportion of students entering FM decreases (r=-.22). Institutions with higher NIH funding had lower clerkship director perceptions of medical school support toward FM (r=-.38). Among private institutions, the negative correlation between NIH funding and the proportion of students entering FM strengthens to r=-.48, P=.001. As perceptions of support for FM increase, the proportion of students entering FM increase (r=.47). Among private schools, perceptions of support toward family medicine was strongly positively correlated with the proportion of students entering FM (r=.72, P=.001). CONCLUSIONS: Higher institutional NIH funding is associated with less support for FM and lower proportions of students choosing FM. These issues appear to be even more influential in private medical schools. Understanding how to integrate the goals of NIH-level research and increasing primary care workforce so that both can be achieved is the next challenge.

Burnout and Resiliency Among Family Medicine Program Directors.

BACKGROUND AND OBJECTIVES: Nearly one-half (46%) of physicians report at least one symptom of burnout. Family medicine residency program directors may have similar and potentially unique levels of burnout as well as resiliency. The primary aims of this study were to examine burnout and resiliency among family medicine residency directors and characterize associated factors. METHODS: The questions used were part of a larger omnibus survey conducted by the Council of Academic Family Medicine (CAFM) Educational Research Alliance (CERA) in 2016. Program and director-specific characteristics were obtained. Symptoms of burnout were assessed using two single-item measures adapted from the full Maslach Burnout Inventory, and level of resiliency was assessed using the Brief Resilience Scale. RESULTS: The overall response rate for the survey was 53.7% (245/465). Symptoms of high emotional exhaustion or high depersonalization were reported in 27.3% and 15.8% of program directors, respectively. More than two-thirds of program directors indicated that they associated themselves with characteristics of resiliency. Emotional exhaustion and depersonalization were significantly correlated with never having personal time, an unhealthy work-life balance, and the inability to stop thinking about work. The presence of financial stress was significantly correlated with higher levels of emotional exhaustion and depersonalization. In contrast, the level of resiliency reported was directly correlated with having a moderate to great amount of personal time, healthy work-life balance, and ability to stop thinking about work, and negatively correlated with the presence of financial stress. CONCLUSIONS: Levels of emotional exhaustion, depersonalization, and resiliency are significantly related to personal characteristics of program directors rather than characteristics of their program.

Job Satisfaction Among Academic Family Physicians.

BACKGROUND AND OBJECTIVES: Family physicians report some of the highest rates of burnout among their physician peers. Over the past few years, this rate has increased and work-life balance has decreased. In academic medicine, many report lack of career satisfaction and have considered leaving academia. Our aim was to explore the factors that contribute to job satisfaction and burnout in faculty members in a family medicine department. METHODS: Six academic family medicine clinics were invited to participate in this qualitative study. Focus groups were conducted to allow for free-flowing, rich dialogue between the moderator and the physician participants. Transcripts were analyzed in a systematic manner by independent investigators trained in grounded theory. The constant comparison method was used to code and synthesize the qualitative data. RESULTS: Six main themes emerged: time (62%), benefits (9%), resources (8%), undervalue (8%), physician well-being (7%), and practice demand (6%). Within the main theme of time, four subthemes emerged: administrative tasks/emails (61%), teaching (17%), electronic medical records (EMR) requirements (13%), and patient care (9%). CONCLUSIONS: Academic family physicians believe that a main contributor to job satisfaction is time. They desire more resources, like staff, to assist with increasing work demands. Overall, they enjoy the academic primary care environment. Future directions would include identifying the specific time restraints that prevent them from completing tasks, the type of staff that would assist with the work demands, and the life stressors the physicians are experiencing.

The "July Effect": A Look at July Medical Admissions in Teaching Hospitals.

PURPOSE: We examined the effect of admission for myocardial infarction, heart failure, or pneumonia during the first academic quarter compared with all other quarters in teaching versus nonteaching hospitals on length of stay, cost, and mortality. METHODS: Using data 2011 Nationwide Inpatient Sample, multivariable modeling with an interaction term was used to test teaching hospital effect by academic quarter. Logistic regression was used for mortality and log-transformed linear models for cost and length of stay. RESULTS: Charlson Index scores were similar in teaching and nonteaching hospitals. Patients admitted to teaching hospitals for myocardial infarction in the first quarter had a higher risk-adjusted mortality (1.217; confidence interval, 1.147-1.290) than those admitted to a nonteaching hospital during the same quarter (0.849; confidence interval, 0.815-0.885). Mean cost heart failure admissions averaged $584 more, and the mean length of stay was longer (0.10; P = .0127), during the first academic quarter. These effects were not present for quarters 2 through 4. CONCLUSIONS: This study suggests small increases in mortality among patients admitted with myocardial infarction in the first academic quarter compared with all other quarters in teaching versus nonteaching hospitals. Increased cost and longer stay were seen for those admitted with heart failure.

Addressing Hospital Readmissions: Impact of Weekly Review.

BACKGROUND AND OBJECTIVES: The prevention of hospital readmissions has become an area for improvement for most health care organizations. Systematic reviews have been unable to identify a single intervention or bundle of interventions that reliably reduced risk of readmission in a generalizable manner. The aim of this quality improvement project was to examine the readmission rate to a family medicine residency program inpatient service following the implementation of a once per week session that reviewed patients who were readmitted during the prior week. METHODS: The inpatient admissions and readmission to the family medicine inpatient service associated with a large academic health center were used for analysis. The impact of a regularly scheduled multidisciplinary team meeting that reviewed a list of patients was examined. Readmitted patients who were at high risk for readmission were specifically identified. Descriptive statistics were used to characterize and summarize the integral data obtained. The weekly readmission rate was presented using a control chart. RESULTS: The readmission rate for the patients hospitalized after the intervention was 18.4%, compared to the readmission rate prior to the intervention (23.0%). While not a statistically different rate, a significant signal was noted. Demographic differences were noted in the group of patients considered to be high risk for readmission. CONCLUSIONS: Regular rounds of an inpatient team that focuses on readmissions during the previous week reduced hospital readmissions. The impact of these sessions appears to be multifactorial.

International Health Experiences in Family Medicine Residency Training.

BACKGROUND AND OBJECTIVES: International health experiences (IHEs) have been associated with improved clinical skills, altruistic attitudes, cross-cultural sensitivity, and exposure to community medicine for residents and medical students. Although an increasing number of family medicine residencies offer IHEs, there are currently no standardized competencies or guidelines for developing IHEs. The aim of this study was to examine the content of IHEs in order to provide an overview of the current landscape of global health training in family medicine residency programs. METHODS: Residency programs self-identifying as offering IHEs on the American Medical Association's (AMA) FREIDA Online website were emailed an electronic survey with questions regarding IHE characteristics, resident selection criteria, faculty support, motivations for participation, challenges to implementation, and funding. RESULTS: Of the 153 programs that responded, 84% still offered IHEs. Most IHEs are 3--4 weeks (71.1%) and are funded by the resident (74.2%). Faculty from the resident's department or institution generally provide supervision (76.6%) and have undergone some type of specialized training in global health (65.6%). Being in good academic standing was the most important eligibility criteria for residents participating in an IHE (86.7%), and funding was reported as the most challenging aspect (62.5%) of offering IHEs. CONCLUSIONS: IHEs are increasing in number and receiving more funding, but the experiences are variable among residency programs. While most program directors believe residents participate in IHEs to gain exposure with underserved populations, only a small percentage (5.5%) include a commitment to community service as part of a requirement for participation in an IHE.

Prediabetes Screening and Treatment in Diabetes Prevention: The Impact of Physician Attitudes.

PURPOSE: Detection and treatment of prediabetes is an effective strategy in diabetes prevention. However, most patients with prediabetes are not identified. Our objective was to evaluate the relationship between attitudes toward prediabetes as a clinical construct and screening/treatment behaviors for diabetes prevention among US family physicians. METHODS: An electronic survey of a national sample of academic family physicians (n 1248) was conducted in 2016. Attitude toward prediabetes was calculated using a summated scale assessing agreement with statements regarding prediabetes as a clinical construct. Perceived barriers to diabetes prevention, current strategies for diabetes prevention, and perceptions of peers were also examined. RESULTS: Physicians who have a positive attitude toward prediabetes as a clinical construct are more likely to follow national guidelines for screening (58.4% vs 44.4; P < .0001) and recommend metformin to their patients for prediabetes (36.4% vs 20.9%; P < .0001). Physicians perceived a number of barriers to treatment, including a patient's economic resources (71.9%), sustaining patient motivation (83.2%), a patient's ability to modify his or her lifestyle (75.3%), and time to educate patient (75.3%) as barriers to diabetes prevention. CONCLUSIONS: How physicians view prediabetes varies significantly, and this variation is related to treatment/screening behaviors for diabetes prevention.

Cost and Utilization: Hospitalized Patients on a Family Medicine Service.

OBJECTIVES: The cost of hospitalizations contributes to the rising expense of medical care in the United States. Providing health insurance to uninsured Americans is a strategy to reduce these costs, but only if costs for uninsured patients are disproportionately high. This study examined hospitalization use patterns for uninsured patients compared with those with Medicaid and commercial insurance. METHODS: We performed a retrospective chart review to analyze inpatient admissions to a family medicine teaching service in a 290-bed, for-profit community hospital during a 2-year period based on insurance status of the patient. Outcome variables investigated were length of stay, emergency department visits, and readmission rates to the hospital and/or emergency department. Secondary outcome variables were mean charges. RESULTS: A total of 1102 admissions to a family medicine teaching service were evaluated. Length of stay, readmission rates to the hospital and the emergency department after hospital discharge, and average length of stay compared with diagnosis-related groups were significantly higher in the Medicaid population than for insured and uninsured individuals. Variable costs also were significantly higher. CONCLUSIONS: Insurance status was found to be a significant factor in hospital charges and utilization data, with Medicaid patients having the highest costs. This suggests that moving uninsured patients to Medicaid may not significantly reduce hospitalization costs.