Tilling the soil while sowing the seeds: combining resident education with medical home transformation.

In order to successfully integrate screening, brief intervention, and referral to treatment (SBIRT) into primary care, education of clinicians must be paired with sustainable transformation of the clinical settings in which they practice. The SBIRT Oregon project adopted this strategy in an effort to fully integrate SBIRT into 7 primary care residency clinics. Residents were trained to assess and intervene in their patients' unhealthy substance use, whereas clinic staff personnel were trained to carry out a multistep screening process. Electronic medical record tools were created to further integrate and track SBIRT processes. This article describes how a resident training curriculum complemented and was informed by the transformation of workflow processes within the residents' home clinics.

Prescribing yoga.

More than 15.8 million people in the United States now practice some form of yoga, and nearly half of current practitioners stated they began yoga practice as a means of improving overall health. More broadly understood in a modern context, yoga is a set of principles and practices designed to promote health and well-being through the integration of body, breath, and mind. This article outlines the history of yoga and describes several forms, including asana-based yoga, which is becoming popular in the United States. Research findings related to use of yoga as a therapy for various health problems are reviewed. Guidelines for finding a yoga teacher are offered, as are a number of book and Internet sources of further information.

Integration of acupuncture into family medicine teaching clinics.

OBJECTIVES: As growing numbers of patients use complementary and alternative medicine (CAM), improvement is needed in communication between providers of CAM and allopathic medicine. This study describes collaborative acupuncture clinics (CACs) run by providers from Oregon Health and Science University (OHSU) and the Oregon College of Oriental Medicine (OCOM) in the setting of family medicine teaching clinics. It examines patient demographics, quality of education for medical learners, referral practices of primary care physicians (PCPs), and quality of communication between acupuncturists and PCPs at these clinics. DESIGN: Demographic data were abstracted from electronic medical records of patients treated at least three times in the CACs between 2006 and 2007. A survey on quality of education at the CACs was given to acupuncture interns, medical students, and acupuncture supervisors. A separate survey collected information from PCPs at the family medicine clinics regarding referral practices to acupuncture and quality of communication between PCPs and acupuncturists. RESULTS: Of the 96 patients seen at the clinics, 74% were female, 76% were European-American, and the mean age was 45.9 years. Sixty-one percent (61%) of patients were insured through private insurance, 31.3% had Medicare or Medicaid, and 7.3% did not have insurance. Most of the 51 acupuncture providers who responded were satisfied with the quality of education at the CACs. Eighty percent of responding PCPs had referred at least one patient to the CACs. The majority of referrals was for a pain condition. Most PCPs would find a summary of the acupuncture visit helpful. Referral practices to different modalities were most influenced by patient interest and physician's belief in whether or not the modality would help. CONCLUSIONS: Demographics of patients at the CACs were comparable to those of patients seen in other acupuncture clinics. The collaborative structure of the CACs allowed for a unique learning experience and improved communication between providers of CAM and conventional medicine.

High prevalence rates of diabetes and hypertension among refugee psychiatric patients.

There is increasing evidence that immigrants and traumatized individuals have elevated prevalence of medical disease. This study focuses on 459 Vietnamese, Cambodian, Somali, and Bosnian refugee psychiatric patients to determine the prevalence of hypertension and diabetes. The prevalence of hypertension was 42% and of diabetes was 15.5%. This was significantly higher than the US norms, especially in the groups younger than 65. Diabetes and hypertension were higher in the high-trauma versus low-trauma groups. However, in the subsample with body mass index (BMI) measurements subjected to logistic regression, only BMI was related to diabetes, and BMI and age were related to hypertension. Immigrant status, presence of psychiatric disorder, history of psychological trauma, and obesity probably all contributed to the high prevalence rate. With 2.5 million refugees in the country, there is a strong public health concern for cardiovascular disease in this group.

Competency-based evaluation tools for integrative medicine training in family medicine residency: a pilot study.

BACKGROUND: As more integrative medicine educational content is integrated into conventional family medicine teaching, the need for effective evaluation strategies grows. Through the Integrative Family Medicine program, a six site pilot program of a four year residency training model combining integrative medicine and family medicine training, we have developed and tested a set of competency-based evaluation tools to assess residents' skills in integrative medicine history-taking and treatment planning. This paper presents the results from the implementation of direct observation and treatment plan evaluation tools, as well as the results of two Objective Structured Clinical Examinations (OSCEs) developed for the program. METHODS: The direct observation (DO) and treatment plan (TP) evaluation tools developed for the IFM program were implemented by faculty at each of the six sites during the PGY-4 year (n = 11 on DO and n = 8 on TP). The OSCE I was implemented first in 2005 (n = 6), revised and then implemented with a second class of IFM participants in 2006 (n = 7). OSCE II was implemented in fall 2005 with only one class of IFM participants (n = 6). Data from the initial implementation of these tools are described using descriptive statistics. RESULTS: Results from the implementation of these tools at the IFM sites suggest that we need more emphasis in our curriculum on incorporating spirituality into history-taking and treatment planning, and more training for IFM residents on effective assessment of readiness for change and strategies for delivering integrative medicine treatment recommendations. Focusing our OSCE assessment more narrowly on integrative medicine history-taking skills was much more effective in delineating strengths and weaknesses in our residents' performance than using the OSCE for both integrative and more basic communication competencies. CONCLUSION: As these tools are refined further they will be of value both in improving our teaching in the IFM program and as competency-based evaluation resources for the expanding number of family medicine residency programs incorporating integrative medicine into their curriculum. The next stages of work on these instruments will involve establishing inter-rater reliability and defining more clearly the specific behaviors which we believe establish competency in the integrative medicine skills defined for the program.

The integrative family medicine program: an innovation in residency education.

The Integrative Family Medicine (IFM) Program is a four-year combined family medicine residency program and integrative medicine fellowship. It was created in 2003 to address the needs of four constituencies: patients who desire care from well trained integrative physicians, physicians who seek such training, the health care system which lacks a conventional integrative medicine training route, and educational leaders in family medicine who are seeking new strategies to reverse the declining interest in family medicine amongst U.S. graduates. The program was designed jointly by the University of Arizona Program in Integrative Medicine (PIM) and family medicine residency programs at Beth Israel/Albert Einstein College of Medicine (AECOM), Maine Medical Center, Middlesex Hospital, Oregon Health & Science University, and the Universities of Arizona and Wisconsin. One or two residents from each of these institutions may apply, and when selected, commit to extending their training by a fourth year. They complete their family medicine residencies at their home sites, enroll in the distributed learning associate fellowship at PIM, and are mentored by local faculty members who have training in integrative medicine. To date three classes totaling twenty residents have entered the program. Evaluation is performed jointly: PIM evaluates the residents during residential weeks and through online modules and residency faculty members perform direct observation of care and review treatment plans. Preliminary data suggest that the program enhances interest amongst graduating medical students in family medicine training. The Accreditation Council of Graduate Medical Education Family Medicine residency review committee has awarded the pilot experimental status.

An evaluation of the care provided to patients prescribed controlled substances for chronic nonmalignant pain at an academic family medicine center.

BACKGROUND AND OBJECTIVES: Prescribing medications for chronic nonmalignant pain (CNMP) can be challenging for physicians for many reasons. In 1999, the state of Oregon implemented new guidelines governing the prescription of medications for CNMP. This study assessed the quality of care provided to CNMP patients, including the extent of compliance with the new state requirements 2 years after they were implemented. METHODS: We used telephone records to identify patients who had called for prescription refills between mid 2001 and mid 2002. We then reviewed medical records of those patients to identify those who received refills for opioids or benzodiazepines for treatment of chronic pain. Medical records were evaluated to measure the percentage of records exhibiting documentation of compliance with state prescribing laws and other features indicative of a high standard of care. RESULTS: Ninety seven percent of records included documentation of the diagnosis for which chronic therapy was indicated. Required Material Risk Notification Forms were absent from 100% of charts. Seventy-five percent of records document consultation with a pain specialist or other physician with specialty pertinent to the patient's source of pain. Medication contracts were only present in 39% of records, and documentation of a pain evaluation and functional evaluation was present in 67% and 54% of records, respectively. CONCLUSIONS: Review of medical records in our clinic documented less-than-optimal compliance with state laws regulating prescribing for CNMP and the need for improvement in assessment and care of these patients.