Clinician and Staff Perspectives on Participating in Practice-based Research (PBR): A Report from the Wisconsin Research and Education Network (WREN).

BACKGROUND: The success of practice-based research (PBR) depends on the willingness of clinicians and staff to incorporate meaningful and useful research protocols into already demanding clinic schedules. The impact of participation on those who implement multiple projects and how to address the issues that arise during this complex process remain incompletely described. This article reports a qualitative evaluation of the experiences of primary care clinicians and clinic staff who participated in multiple PBR projects with the Wisconsin Research and Education Network (WREN). Also included are their suggestions to researchers and clinicians for future collaborations. METHODS: For program evaluation purposes, WREN conducted 4 focus groups at its 2014 annual meeting. The main focus group question was, "How has participation in PBR affected you and your clinic?" A total of 27 project members from 13 clinics participated in 4 groups (physicians, nurses, managers, and other clinical staff). The 2-hour sessions were recorded, transcribed, and analyzed to identify recurring themes. RESULTS: Five major focus group themes emerged: receptivity to research, outcomes as a result of participation, barriers to implementation, facilitators of success, and advice to researchers and colleagues. Focus group members find research valuable and enjoy participating in projects that are relevant to their practice, even though many barriers exist. They indicated that research participation produces clinical changes that they believe result in improved patient care. They offered ways to improve the research process, with particular emphasis on collaborative early planning, project development, and communication before, during, and after a project. CONCLUSIONS: Clinics that participate in WREN projects remain willing to risk potential work constraints because of immediate or impending benefits to their clinical practice and/or patient population. Including a broader array of clinic personnel in the communication processes, especially in the development of relevant research ideas and planning for clinic implementation and ongoing participation in research projects, would address many of the barriers identified in implementing PBR. The themes and supporting quotes identified in this evaluation of WREN projects may inform researchers planning to collaborate with primary care clinics and clinicians and staff considering participating in research endeavors.

Part-time physicians...prevalent, connected, and satisfied.

OBJECTIVE: The health care workforce is evolving and part-time practice is increasing. The objective of this work is to determine the relationship between part-time status, workplace conditions, and physician outcomes. DESIGN: Minimizing error, maximizing outcome (MEMO) study surveyed generalist physicians and their patients in the upper Midwest and New York City. MEASUREMENTS AND MAIN RESULTS: Physician survey of stress, burnout, job satisfaction, work control, intent to leave, and organizational climate. Patient survey of satisfaction and trust. Responses compared by part-time and full-time physician status; 2-part regression analyses assessed outcomes associated with part-time status. Of 751 physicians contacted, 422 (56%) participated. Eighteen percent reported part-time status (n = 77, 31% of women, 8% of men, p < .001). Part-time physicians reported less burnout (p < .01), higher satisfaction (p < .001), and greater work control (p < .001) than full-time physicians. Intent to leave and assessments of organizational climate were similar between physician groups. A survey of 1,795 patients revealed no significant differences in satisfaction and trust between part-time and full-time physicians. CONCLUSIONS: Part-time is a successful practice style for physicians and their patients. If favorable outcomes influence career choice, an increased demand for part-time practice is likely to occur.

Prevalence of interpersonal abuse in primary care patients prescribed opioids for chronic pain.

BACKGROUND: Interpersonal abuse is associated with clinical problems including chronic pain disorders. OBJECTIVES: The objective of this study is to describe 30-day and lifetime prevalence of emotional, physical, and sexual abuse found in men and women prescribed opioids for chronic pain. DESIGN: Cross-sectional interview is the design of this study. PARTICIPANTS: Patients, 1,009, currently prescribed opioids for chronic noncancer pain. They were recruited from the practices of 235 Family Physicians and Internists in Wisconsin. The most common pain diagnoses were arthritis, low back pain, headache, and fibromyalgia/myofascial pain. MEASUREMENT: Data for this secondary analysis on rates of interpersonal abuse were based on 3 questions from the Addiction Severity Index (ASI) regarding 30-day and lifetime emotional, physical, and sexual abuse. RESULTS: Forty-seven percent of women and 22% of men reported a history of lifetime physical abuse. Thirty -five percent of women and 10% of men reported lifetime sexual abuse. Binary logistic regression identified the following variables associated with lifetime physical abuse: female gender (RR 2.81, CI 2.01-3.94), age 31-50 (RR1.77, CI 1.30-2.41), Caucasian (RR1.67, CI 1.19-2.35), increased psychiatric symptoms as measured by the ASI (RR 2.14, CI 1.56-2.94), and lifetime suicide attempts (RR 3.98, CI 2.76-5.74). CONCLUSIONS: This study reports prevalence of abuse in both men and women prescribed opioids for chronic pain in primary care settings. Subjects who report experiencing interpersonal abuse also report significantly higher rates of suicide attempts and score higher on the ASI psychiatric scale. Screening patients taking opioids for chronic pain for interpersonal abuse may lead to a better understanding of contributors to their physical and mental health.

History, physical and laboratory findings, and clinical outcomes of lactating women treated with antibiotics for chronic breast and/or nipple pain.

This chart review study describes the history, physical and laboratory findings, and clinical outcomes in patients who presented to a lactation specialist between 1997 and 2002 and were treated with antibiotics for their chronic breast and/or nipple pain. A total of 69 charts were reviewed. Five were excluded because of loss of follow-up. Eighty-two percent of patients described postpartum breast tenderness, 74% had nipple sores postpartum, and 79% were tender on physical examination. Nipple lesions were present among 73% of the women. Breast milk or nipple cultures were performed for 60 of 64 patients and were positive for pathogenic bacteria among 50% of the patients cultured. The average duration of antibiotic treatment was 5.7 weeks, and 94% of the women had pain resolution. Symptoms of deep breast aching, breast tenderness on palpation, and nipple lesions may be suggestive of a bacterial lactiferous duct infection. Treatment with antibiotics for 4 to 6 weeks may be appropriate.

The Family Empowerment Network: a service model to address the needs of children and families affected by Fetal Alcohol Spectrum Disorders.

Fetal Alcohol Spectrum Disorders (FASD) represent a leading cause of mental retardation and learning disabilities in children seen in pediatric offices today. This article provides an overview of FASD and describes a model program, the Family Empowerment Network (FEN). FEN is an information, referral, and support network for children and families affected by Fetal Alcohol Spectrum Disorders (FASD) and the professionals who serve them. FEN's mission includes: (a) increasing awareness about FASD by providing education, training and resources to families, providers, and the general public; (b) providing support and referrals to families affected; and (c) increasing opportunities for diagnosis and intervention. We hope to increase awareness of the resources available to nurses and their patients and provide a template that can be replicated in other service delivery systems. Pediatric nurses are in a unique position not only to assist in the recognition of children at risk of FASD, to link families to appropriate diagnostic and intervention services, but also to work to develop additional local and regional resources with other providers.

Secondary outcomes of a pilot randomized trial of azithromycin treatment for asthma.

OBJECTIVES: The respiratory pathogen Chlamydia pneumoniae (C. pneumoniae) produces acute and chronic lung infections and is associated with asthma. Evidence for effectiveness of antichlamydial antibiotics in asthma is limited. The primary objective of this pilot study was to investigate the feasibility of performing an asthma clinical trial in practice settings where most asthma is encountered and managed. The secondary objectives were to investigate (1) whether azithromycin treatment would affect any asthma outcomes and (2) whether C. pneumoniae serology would be related to outcomes. This report presents the secondary results. DESIGN: Randomized, placebo-controlled, blinded (participants, physicians, study personnel, data analysts), allocation-concealed parallel group clinical trial. SETTING: Community-based health-care settings located in four states and one Canadian province. PARTICIPANTS: Adults with stable, persistent asthma. INTERVENTIONS: Azithromycin (six weekly doses) or identical matching placebo, plus usual community care. OUTCOME MEASURES: Juniper Asthma Quality of Life Questionnaire (Juniper AQLQ), symptom, and medication changes from baseline (pretreatment) to 3 mo posttreatment (follow-up); C. pneumoniae IgG and IgA antibodies at baseline and follow-up. RESULTS: Juniper AQLQ improved by 0.25 (95% confidence interval; -0.3, 0.8) units, overall asthma symptoms improved by 0.68 (0.1, 1.3) units, and rescue inhaler use decreased by 0.59 (-0.5, 1.6) daily administrations in azithromycin-treated compared to placebo-treated participants. Baseline IgA antibodies were positively associated with worsening overall asthma symptoms at follow-up (p = 0.04), but IgG was not (p = 0.63). Overall asthma symptom improvement attributable to azithromycin was 28% in high IgA participants versus 12% in low IgA participants (p for interaction = 0.27). CONCLUSIONS: Azithromycin did not improve Juniper AQLQ but appeared to improve overall asthma symptoms. Larger community-based trials of antichlamydial antibiotics for asthma are warranted.

Feasibility of a practical clinical trial for asthma conducted in primary care.

BACKGROUND: Practical clinical trials (PCTs) are essential to generate relevant evidence-based information to improve patient health. Primary care physicians' experience performing randomized controlled trials (RCTs) on representative patient populations is limited. We implemented a pilot practice-based asthma PCT to answer the following feasibility questions: (1) Was clinician interest initiated and maintained? (2) Did clinicians enroll patients into an RCT and complete follow-up? (3) Was an interactive voice-response (IVR) telephone system useful to collect patient-reported data? METHODS: The protocol included (1) broadly representative adult asthma eligibility criteria, (2) self-reported patient-oriented outcomes, and (3) use of IVR to collect these data. Physicians in practice-based research networks, managed care organizations, and academic networks volunteered to participate. RESULTS: Of 13 physician volunteers, 10 (8 single-person office practices, 1 emergency department physician, 1 clinical researcher) from 4 states and 1 Canadian province enrolled 58 subjects and randomized 45 meeting final eligibility criteria; 39 (87%) attended the follow-up visit. However, only 34 (76%) provided adequate follow-up IVR self-report data, and subjects with less than a high school education provided significantly (P <.001) less data than other groups. CONCLUSIONS: Physician recruiting, randomizing, and completing a representative sample of adult asthma patients was feasible. The utility of IVR in primary care research requires further study.

What complementary and alternative medicine practitioners say about health and health care.

BACKGROUND: We wanted to explore the beliefs and practices of complementary and alternative medicine (CAM) practitioners. METHODS: A representative sample of local CAM practitioners was selected for 32 face-to-face in-depth interviews. Interviews were taped, transcribed, and reviewed by all coauthors. Analysis and interpretation were reached by consensus, using an iterative process in multidisciplinary group meetings. RESULTS: The CAM practitioners interviewed stressed the holistic, empowering, and person-centered nature of CAM. They described themselves as healers, employing attentiveness, touch, and love to increase self-awareness and strengthen the healing process, usually in chronic illness, often with pain. They affirmed goodwill and respect toward conventional medicine, calling for greater integration of conventional and complementary health care; however, they identified the major differences of conventional medicine and several formidable barriers. They displayed concern about accessibility issues in health care and stressed that attitudes and beliefs were often larger impediments to integration than were economic or scientific considerations. CONCLUSIONS: In general, CAM practitioners want to work with physicians and other conventional health care workers in seeking a holistic, accessible, patient-centered, integrated health care system.

Family medicine residents and the impostor phenomenon.

BACKGROUND AND OBJECTIVES: Some family medicine residents often doubt their ability to become competent family physicians. Individuals who believe themselves to be less intelligent and less competent than others perceive them to be are described in the psychological literature as having the "impostor phenomenon." This study sought to determine the prevalence of the impostor phenomenon in family medicine residents. METHODS: We conducted a mail survey of all 255 family medicine residents in Wisconsin. The survey included the Clance Imposter Scale and two scales measuring depression and anxiety. RESULTS: A total of 185 surveys were returned, for a 73% response rate. Forty-one percent of women and 24% of men scored as "impostors." Impostor symptoms were highly correlated with depression and anxiety. CONCLUSIONS: About one third of family medicine residents believe they are less intelligent and less competent than others perceive them to be. These residents suffer psychological distress and do not believe they will be ready to practice family medicine after graduation. Teachers may assist these learners by letting them know such feelings are common and by providing regular, timely, and positive feedback.

Themes of holism, empowerment, access, and legitimacy define complementary, alternative, and integrative medicine in relation to conventional biomedicine.

Complementary and alternative medicine (CAM) has been defined largely in relation to conventional biomedicine. CAM therapies that are used instead of conventional medicine are termed "alternative." CAM therapies used alongside conventional medicine are said to be "complementary." "Integrative medicine" results from the thoughtful incorporation of concepts, values, and practices from alternative, complementary, and conventional medicines. The evolving process of integration between CAM and conventional medicine evokes new conceptual frameworks, as well as new terminology. Interview-based qualitative research at the University of Wisconsin-Madison seeks to probe and develop this theoretical structure. Interviews with users and practitioners of CAM therapies have revealed four primary themes: holism, empowerment, access, and legitimacy (HEAL). These themes characterize CAM and contrast it with conventional medicine. CAM is said to be more holistic and empowering yet less legitimate than conventional medicine. CAM is more intuitive; conventional is more deductive. While CAM is perhaps more psychologically accessible to many patients in that it better reflects commonly held values, it is often less financially and institutionally accessible, at least for those with conventional health insurance and limited income. Substantive barriers--including economic, organizational and scientific differences, as well as an apparent widespread lack of understanding--continue to thwart attempts at integration. More and better evidence is needed if CAM therapies are to be accepted by mainstream medicine. State-of-the-art research methods developed by conventional science will be needed to test CAM therapies. Conventional medicine, however, has much to learn from CAM. By incorporating a more holistic, empowering and accessible therapeutic approach, conventional medicine could build on its present legitimacy, and thereby enhance its power to "HEAL."