Departmental Metrics to Guide Equity, Diversity, and Inclusion for Academic Family Medicine Departments.

PROBLEM: Equity, diversity, and inclusion (EDI) efforts have accelerated over the past several years, without a traditional guidebook that other missions often have. To evaluate progress over time, departments of family medicine are seeking ways to measure their current EDI state. Across the specialty, unity regarding which EDI metrics are meaningful is absent, and discordance even exists about what should be measured. APPROACH: This paper provides a general metrics framework, including a wide array of possibilities to consider measuring, for assessing individual departmental progress in this broad space. These measures are designed to be general enough to provide common language and can be customized to align with strategic priorities of individual family medicine departments. OUTCOMES: The Diversity, Equity, and Inclusion Committee of the Association of Departments of Family Medicine has produced a common framework to facilitate measurement of EDI outcomes in the following areas: care delivery and health, workforce recruitment and retention, learner recruitment and training, and research participation. This framework allows departments to monitor progress across these domains that impact the tripartite mission, providing opportunities to capitalize on measured gains in EDI. NEXT STEPS: Departments can review this framework and consider which metrics are applicable or develop their own metrics to align with their strategic priorities. In the future, collective departments could compare notes and measure aggregate progress together. Evaluating progress is a step in the journey toward the goal of ensuring that departments are operating from inclusive and just academic systems.

Managing TIA: Early action and essential risk-reduction steps.

Your patient with a focal neurologic deficit is rushed to the ED for diagnostic imaging. Which initial and longterm interventions can best reduce their risk of recurrent TIA and stroke?

Caring for patients with co-occurring mental health & substance use disorders.

Consider substance abuse if Tx for mood or anxiety disorders is ineffective. Don't defer treating a mental health issue until a substance use disorder is resolved.

Integrating Simulated Patients in TBL: a Strategy for Success in Medical Education.

BACKGROUND: Successful use of team-based learning (TBL) and simulated patients (SP) in medical schools is growing. We hypothesized that integrating SPs into TBL would enhance the traditional TBL. ACTIVITY: From 2016 to 2018, we taught fourth-year medical students through an SP-TBL hybrid, utilizing an integrated SP interview. A 9-item evaluation was analyzed (n = 114). RESULTS AND DISCUSSION: Students expressed favorable attitudes toward the SP-TBL hybrid with Likert-scale items (mean 4.26/5). Qualitatively, four positive themes emerged: (1) practice; (2) engagement; (3) SP use; and (4) feedback. Integrating SPs into TBL avoids disadvantages with both traditional TBL and OSCEs. Practice, engagement, and immediate feedback are advantages over traditional TBL.

Being Reproductive.

Women's reproductive health maintenance begins in the early years of growth and development. Routine care is the basis for early detection of menstrual dysfunction and delays or acceleration of physical development. Patients and their families may not address menstruation concerns because of the sensitive nature of the topic, the patient's self-conscious attitudes, and the parent's apprehension. Providers should be able to provide early detection of menstrual abnormalities, which may uncover underlying health concerns and structural abnormalities. Early intervention and treatment may accelerate or decelerate physical growth, preserve fertility, and promote healthy behaviors with decreased psychological stress for patients and families.

Recurrent Ischemic Stroke: Strategies for Prevention.

Recurrent strokes make up almost 25% of the nearly 800,000 strokes that occur annually in the United States. Risk factors for ischemic stroke include hypertension, diabetes mellitus, hyperlipidemia, sleep apnea, and obesity. Lifestyle modifications, including tobacco cessation, decreased alcohol use, and increased physical activity, are also important in the management of patients with a history of stroke or transient ischemic attack. Antiplatelet therapy is recommended to reduce the risk of recurrent ischemic stroke. The selection of antiplatelet therapy should be based on timing, safety, effectiveness, cost, patient characteristics, and patient preference. Aspirin is recommended as initial treatment to prevent recurrent ischemic stroke. Clopidogrel is recommended as an alternative monotherapy and in patients allergic to aspirin. The combination of clopidogrel and aspirin is not recommended for long-term use (more than two to three years) because of increased bleeding risk. Aspirin/dipyridamole is at least as effective as aspirin alone, but it is not as well tolerated. Warfarin should not be used for prevention of recurrent ischemic stroke.

Roadmap for creating an accelerated three-year medical education program.

Medical education is undergoing significant transformation. Many medical schools are moving away from the concept of seat time to competency-based education and introducing flexibility in the curriculum that allows individualization. In response to rising student debt and the anticipated physician shortage, 35% of US medical schools are considering the development of accelerated pathways. The roadmap described in this paper is grounded in the experiences of the Consortium of Accelerated Medical Pathway Programs (CAMPP) members in the development, implementation, and evaluation of one type of accelerated pathway: the three-year MD program. Strategies include developing a mission that guides curricular development - meeting regulatory requirements, attaining institutional buy-in and resources necessary to support the programs, including student assessment and mentoring - and program evaluation. Accelerated programs offer opportunities to innovate and integrate a mission benefitting students and the public. ABBREVIATIONS: CAMPP: Consortium of accelerated medical pathway programs; GME: Graduate medical education; LCME: Liaison committee on medical education; NRMP: National residency matching program; UME: Undergraduate medical education.

The Rules of Engagement: Perspectives on Secure Messaging From Experienced Ambulatory Patient Portal Users.

BACKGROUND: Patient portals have shown promise in engaging individuals in self-management of chronic conditions by allowing patients to input and track health information and exchange secure electronic messages with their providers. Past studies have identified patient barriers to portal use including usability issues, low health literacy, and concerns about loss of personal contact as well as provider concerns such as increased time spent responding to messages. However, to date, studies of both patient and provider perspectives on portal use have focused on the pre-implementation or initial implementation phases and do not consider how these issues may change as patients and providers gain greater experience with portals. OBJECTIVE: Our study examined the following research question: Within primary care offices with high rates of patient-portal use, what do experienced physician and patient users of the ambulatory portal perceive as the benefits and challenges of portal use in general and secure messaging in particular? METHODS: This qualitative study involved 42 interviews with experienced physician and patient users of an ambulatory patient portal, Epic's MyChart. Participants were recruited from the Department of Family Medicine at a large Academic Medical Center (AMC) and included providers and their patients, who had been diagnosed with at least one chronic condition. A total of 29 patients and 13 primary care physicians participated in the interviews. All interviews were conducted by telephone and followed a semistructured interview guide. Interviews were transcribed verbatim to permit rigorous qualitative analysis. Both inductive and deductive methods were used to code and analyze the data iteratively, paying particular attention to themes involving secure messaging. RESULTS: Experienced portal users discussed several emergent themes related to a need for greater clarity on when and how to use the secure messaging feature. Patient concerns included worry about imposing on their physician's time, the lack of provider compensation for responding to secure messages, and uncertainty about when to use secure messaging to communicate with their providers. Similarly, providers articulated a lack of clarity as to the appropriate way to communicate via MyChart and suggested that additional training for both patients and providers might be important. Patient training could include orienting patients to the "rules of engagement" at portal sign-up, either in the office or through an online tutorial. CONCLUSIONS: As secure messaging through patient portals is increasingly being used as a method of physician-patient communication, both patients and providers are looking for guidance on how to appropriately engage with each other using this tool. Patients worry about whether their use is appropriate, and providers are concerned about the content of messages, which allow them to effectively manage patient questions. Our findings suggest that additional training may help address the concerns of both patients and providers, by providing "rules of engagement" for communication via patient portals.

Preterm Labor: Prevention and Management.

In the United States, preterm delivery is the leading cause of neonatal morbidity and is the most common reason for hospitalization during pregnancy. The rate of preterm delivery (before 37 weeks' gestation) has been declining since 2007. Clinical diagnosis of preterm labor is made if there are regular contractions and concomitant cervical change. Less than 10% of women with a clinical diagnosis of preterm labor will deliver within seven days of initial presentation. Women with a history of spontaneous preterm delivery are 1.5 to two times more likely to have a subsequent preterm delivery. Antenatal progesterone is associated with a significant decrease in subsequent preterm delivery in certain pregnant women. Current recommendations are to prescribe vaginal progesterone in women with a shortened cervix and no history of preterm delivery, and to use progesterone supplementation regardless of cervical length in women with a history of spontaneous preterm delivery. Cervical cerclage has been used to help correct structural defects or cervical weakening in high-risk women with a shortened cervix. A course of corticosteroids is the only antenatal intervention that has been shown to improve postdelivery neonatal outcomes, including a reduction in neonatal mortality, intracranial hemorrhage, necrotizing enterocolitis, and neonatal infection. Tocolytics, especially prostaglandin inhibitors and calcium channel blockers, may allow time for the administration of antenatal corticosteroids and transfer to a tertiary care facility if necessary. When used in specific at-risk populations, magnesium sulfate provides neuroprotection and decreases the incidence of cerebral palsy in preterm infants.