British Society of Gastroenterology Best Practice Guidance: outpatient management of cirrhosis - part 3: special circumstances.

The prevalence of cirrhosis has risen significantly over recent decades and is predicted to rise further. Widespread use of non-invasive testing means cirrhosis is increasingly diagnosed at an earlier stage. Despite this, there are significant variations in outcomes in patients with cirrhosis across the UK, and patients in areas with higher levels of deprivation are more likely to die from their liver disease. This three-part best practice guidance aims to address outpatient management of cirrhosis, in order to standardise care and to reduce the risk of progression, decompensation and mortality from liver disease. Part 1 addresses outpatient management of compensated cirrhosis: screening for hepatocellular cancer, varices and osteoporosis, vaccination and lifestyle measures. Part 2 concentrates on outpatient management of decompensated disease including management of ascites, encephalopathy, varices, nutrition as well as liver transplantation and palliative care. In this, the third part of the guidance, we focus on special circumstances encountered in managing people with cirrhosis, namely surgery, pregnancy, travel, managing bleeding risk for invasive procedures and portal vein thrombosis.

British Society of Gastroenterology Best Practice Guidance: outpatient management of cirrhosis - part 1: compensated cirrhosis.

The prevalence of cirrhosis has risen significantly over recent decades and is predicted to rise further. Widespread use of non-invasive testing means cirrhosis is increasingly diagnosed at an earlier stage. Despite this, there are significant variations in outcomes in patients with cirrhosis across the UK, and patients in areas with higher levels of deprivation are more likely to die from their liver disease. This three-part best practice guidance aims to address outpatient management of cirrhosis, in order to standardise care and to reduce the risk of progression, decompensation and mortality from liver disease. Here, in part one, we focus on outpatient management of compensated cirrhosis, encompassing hepatocellular cancer surveillance, screening for varices and osteoporosis, vaccination and lifestyle measures. We also introduce a compensated cirrhosis care bundle for use in the outpatient setting. Part two concentrates on outpatient management of decompensated disease including management of ascites, encephalopathy, varices, nutrition as well as liver transplantation and palliative care. The third part of the guidance covers special circumstances encountered in managing people with cirrhosis: surgery, pregnancy, travel, managing bleeding risk for invasive procedures and portal vein thrombosis.

British Society of Gastroenterology Best Practice Guidance: outpatient management of cirrhosis - part 2: decompensated cirrhosis.

There are two distinct phases in the natural history of cirrhosis: compensated disease (corresponding to Child Pugh A and early Child Pugh B disease), where the patient may be largely asymptomatic, progressing with increasing portal hypertension and liver dysfunction to decompensated disease (corresponding to Child Pugh late B-C), characterised by the development of overt clinical signs, including jaundice, hepatic encephalopathy (HE), ascites, renal dysfunction and variceal bleeding. The transition from compensated cirrhosis to decompensated cirrhosis (DC) heralds a watershed in the nature and prognosis of the disease. DC is a systemic disease, characterised by multiorgan/system dysfunction, including haemodynamic and immune dysfunction. In this second part of our three-part series on the outpatient management of cirrhosis, we address outpatient management of DC, including management of varices, ascites, HE, nutrition, liver transplantation and palliative care. We also introduce an outpatient DC care bundle. For recommendations on screening for osteoporosis, hepatocellular carcinoma surveillance and vaccination see part one of the guidance. Part 3 of the guidance focusses on special circumstances encountered in patients with cirrhosis, including surgery, pregnancy, travel, management of bleeding risk for invasive procedures and portal vein thrombosis.

Optimal training in communication model (OPTiCOM): A programmatic roadmap.

OBJECTIVES: Teaching primary care residents patient communication skills is essential, complex, and impeded by barriers. We find no models guiding faculty how to train residents in the workplace that integrate necessary system components, the science of physician-patient communication training and competency-based medical education. The aim of this project is to create such a model. METHODS: We created OPTiCOM using four steps: (1) communication educator interviews, analysis and theme development; (2) initial model construction; (3) model refinement using expert feedback; (4) structured literature review to validate, refine and finalize the model. RESULTS: Our model contains ten interdependent building blocks organized into four developmental tiers. The Foundational value tier has one building block Naming relationship as a core value. The Expertize and resources tier includes four building blocks addressing: Curricular expertize, Curricular content, Leadership, and Time. The four building blocks in the Application and development tier are Observation form, Faculty development, Technology, and Formative assessment. The Language and culture tier identifies the final building block, Culture promoting continuous improvement in teaching communication. CONCLUSIONS: OPTiCOM organizes ten interdependent systems building blocks to maximize and sustain resident learning of communication skills. Practice Implications Residency faculty can use OPTiCOM for self-assessment, program creation and revision.

Wellness in the Time of COVID: A CERA Follow-up Survey of Program Directors.

BACKGROUND AND OBJECTIVES: Residency program directors (PDs) are tasked with supporting resident well-being, and a 2018-2019 CERA survey found PDs to be generally satisfied with residency wellness curricula. However, less is known about graduate medical education wellness programming following the unprecedented social and public health stressors of 2020. This study aimed to evaluate PDs' satisfaction with wellness programming and perceived changes in wellness program implementation in the context of these factors. METHODS: An online survey was administered by CERA to the program directors of all ACGME-accredited, US-based family medicine residencies. The survey replicated a 2018 CERA survey and assessed PDs' satisfaction with the wellness curriculum and which wellness curricular elements were currently implemented in the residency. RESULTS: The survey was completed by 263 PDs (42% response rate). There was no difference in total number of wellness curricular elements reported in programs in 2021 (M=9.85) vs 2018 (M=9.57; P=.377). Compared to the 2018 survey, PDs reported increased assessment of resident burnout (P=.02), increased scheduled time for personal needs (P=.002), but decreased scheduled time for interpersonal connection (P=.017). Most PDs reported increased emphasis on wellness and the same or increased access to wellness resources compared to 2018 χ2 indicated no significant difference in PD satisfaction with wellness programming between the two years (P=.84). CONCLUSIONS: Despite significant social and public health challenges to curriculum delivery, family medicine PDs did not perceive significant reductions in wellness programming, and in fact reported increases in some specific curricular elements and an overall increased emphasis on well-being. Future studies should explore the factors that facilitate and impede the implementation of wellness programming.

Quality standards for the management of non-alcoholic fatty liver disease (NAFLD): consensus recommendations from the British Association for the Study of the Liver and British Society of Gastroenterology NAFLD Special Interest Group.

Non-alcoholic fatty liver disease (NAFLD) is common, affecting approximately 25% of the general population. The evidence base for the investigation and management of NAFLD is large and growing, but there is currently little practical guidance to support development of services and delivery of care. To address this, we produced a series of evidence-based quality standard recommendations for the management of NAFLD, with the aim of improving patient care. A multidisciplinary group of experts from the British Association for the Study of the Liver and British Society of Gastroenterology NAFLD Special Interest Group produced the recommendations, which cover: management of people with, or at risk of, NAFLD before the gastroenterology or liver clinic; assessment and investigations in secondary care; and management in secondary care. The quality of evidence for each recommendation was evaluated by the Grading of Recommendation Assessment, Development and Evaluation tool. An anonymous modified Delphi voting process was conducted individually by each member of the group to assess the level of agreement with each statement. Statements were included when agreement was 80% or greater. From the final list of statements, a smaller number of auditable key performance indicators were selected to allow services to benchmark their practice. It is hoped that services will review their practice against our recommendations and key performance indicators and institute service development where needed to improve the care of patients with NAFLD.

Getting It Off the Ground: Key Factors Associated With Implementation of Wellness Programs.

BACKGROUND AND OBJECTIVES: Many residency programs are developing resident wellness curricula to improve resident well-being and to meet Accreditation Council for Graduate Medical Education guidelines. However, there is limited guidance on preferred curricular components and implementation. We sought to identify how specific driving factors (eg, having an identified wellness champion with a budget and protected time to develop wellness programs) impact implementation of essential elements of a resident wellness curriculum. METHODS: We surveyed 608 family medicine residency program directors (PDs) in 2018-2019 on available resources for wellness programs, essential wellness elements being implemented, and satisfaction with wellness programming; 251 PDs provided complete responses (42.5% response rate). Linear and logistic regressions were conducted for main analyses. RESULTS: Having an identified wellness champion, protected time, and dedicated budget for wellness were associated with greater implementation of wellness programs and PD satisfaction with wellness programming; of these, funding had the strongest association. Larger programs were implementing more wellness program components. Program setting had no association with implementation. CONCLUSIONS: PDs in programs allocating money and/or faculty time can expect more wellness programming and greater satisfaction with how resident well-being is addressed.

Making Sense of Family Medicine Resident Wellness Curricula: A Delphi Study of Content Experts.

BACKGROUND AND OBJECTIVES: The Association of Family Medicine Residency Directors (AFMRD) Physician Wellness Task Force released a comprehensive Well-Being Action Plan as a guide to help programs create a culture of wellness. The plan, however, does not offer a recommendation as to which elements may be most important, least resource intensive, or most feasible. This study sought to identify the most essential components of the AFMRD's Well-Being Action Plan, as rated by expert panelists using a modified Delphi technique. METHODS: Sixty-eight selected experts were asked to participate; after three rounds of surveys, the final sample included 27 participants (7% residents, 38% MD faculty, 54% behavioral science faculty). RESULTS: Fourteen elements were rated as essential by at least 80% of the participants. These components included interventions at both the system and individual level. Of those elements ranked in the top five by a majority of the panel, all but one do not mention specific curricular content, but rather discusses the nature of a wellness curriculum. CONCLUSIONS: The expert consensus was that an essential curriculum should begin early, be longitudinal, identify a champion, and provide support for self-disclosure of struggles.

A Curriculum on Care for Complex Patients: Resident Perspectives.

BACKGROUND AND OBJECTIVES: Caring for patients with a challenging mix of medical, psychological, and social problems may easily overwhelm residents. We developed a month-long "Care for Complex Patients" curriculum for second-year residents to improve their ability to care for this group of patients by increasing their understanding of why the care is complex and by building communication, teamwork, and resource management skills. METHODS: Surveys and focus groups were used to assess the impact of the curriculum. Quantitative and qualitative methods were used to evaluate responses. RESULTS: Between 2008 and 2010, 24 residents completed our rotation. Eighty-three percent completed the pre-curriculum and post-curriculum surveys. Residents' self-ratings significantly improved in all 11 complex care management skills, and residents reported increased confidence when working with patients whose care was complex. Residents were surprised to learn about all the community resources and began using these resources when providing care for these patients. Despite rating themselves improved, a large number of residents still rated themselves as not competent in many of the skills. CONCLUSIONS: A curriculum for residents focused on education in 11 key skill areas in the care of complex patients led to increased self-confidence and willingness to provide complex care. However, 1 month of training is an insufficient amount of time to help most learners achieve self-assessed ratings of capable and competent in using these key skills when caring for complex patients.

The 2012 Don Bloch Award: presented by the Collaborative Family Healthcare Association to Larry Mauksch, MEd, October 5, 2012.

The Don Bloch Award is presented annually by the Collaborative Family Healthcare Association (CFHA) to a person who has made singular contributions to forwarding the cause of collaborative family health care. At the 2012 conference in Austin, Texas, the award was presented to Larry Mauksch of the Department of Family Medicine at the University of Washington. Three nominating talks given at that occasion and Larry's acceptance remarks are provided.

United States version of the Stroke Driver Screening Assessment: a pilot study.

BACKGROUND: Most stroke survivors who resume driving in the United States do so within the first year. More than 87% of these individuals resume driving without a formal evaluation of their fitness to drive because of the absence of standard practices and generally accepted and valid screening tools. The Stroke Driver Screening Assessment (SDSA) is an established battery for predicting stroke survivors' driving performance but is not currently used in the United States. This pilot study investigated the predictive ability of the US version of the battery in a US-based cohort of stroke survivors. METHOD: Fifteen first-ever stroke survivors (age, 52±12 years) and 16 healthy adults (age, 40±16 years) were administered the US version of the SDSA in a standardized format. Performance on the SDSA was compared with driving performance in a high-fidelity driving simulator. RESULTS: Stroke and healthy participants' driving performance was predicted with 87% and 88% accuracy, respectively. CONCLUSION: The US version of the SDSA battery has the potential to be a good predictor of driving performance of mildly impaired stroke survivors. Larger studies are needed to further establish its predictive accuracy.

Interdisciplinary direct observation: impact on precepting, residents, and faculty.

BACKGROUND: Direct observation of residents for training and assessment is a core recommendation in medical education policy initiatives. Limited research exists about the impact of direct observation on precepting, and we are unaware of any research examining the impact of interdisciplinary precepting on trainees or preceptors. Over the past 3 years we have implemented an Interdisciplinary Direct Observation Precepting Model (IDOPM). Residents are directly observed via closed-circuit television by a behavioral scientist and family physician team. METHODS: Surveys and focus groups were used to examine the impact of the IDOPM. Authors analyzed survey responses and focus group transcripts using an immersion/crystallization approach to arrive at themes. RESULTS: Between February and June 2009, 24 residents, 14 physician faculty, and eight behavioral science faculty members participated in 19 IDOPM clinics. Eighty-two percent of residents and 95% of faculty responded to surveys. Key findings were (1) Residents and faculty report addressing topics that are not usually discussed in traditional precepting, including communication skills, time management, electronic medical record use, responding to emotional complexity, and physical exam skills, (2) The model reinforced a biopsychosocial approach to care, (3) Residents report ambivalent feelings about being observed, and (4) Faculty value the team approach to strengthen training and promote faculty development. CONCLUSIONS: The IDOPM addresses many core skills that are overlooked in traditional precepting encounters. Interdisciplinary direct observation may strengthen faculty ability to provide formative competency assessment in preparing residents to work in the complex world of primary care.

A patient centered care plan in the EHR: improving collaboration and engagement.

Patients attempting to manage their chronic conditions require ongoing support in changing and adopting self-management behaviors. However, patient values, health goals, and action plans are not well represented in the electronic health record (EHR) impeding the ability of the team (MA and providers) to provide respectful, ongoing self-management support. We evaluated whether a team approach to using an EHR based patient centered care plan (PCCP) improved collaborative self-management planning. An experimental, prospective cohort study was conducted in a family medicine residency clinic. The experimental group included 7 physicians and a medical assistant who received 2 hr of PCCP training. The control group consisted of 7 physicians and a medical assistant. EHR charts were analyzed for evidence of 8 behavior change elements. Follow-up interviews with experimental group patients and physicians and the medical assistant assessed their experiences. We found that PCCP charts had more documented behavior change elements than control charts in all 8 domains (p < .001). Experimental group physicians valued the PCCP model and suggested ways to improve its use. Patient feedback demonstrated support for the model. A PCCP can help team members to engage patients with chronic illnesses in goal setting and action planning to support self-management. An EHR design that stores patient values, health goals, and action plans may strengthen continuity and quality of care between patients and primary care team members. (PsycINFO Database Record (c) 2012 APA, all rights reserved).

Success of a multidisciplinary heart failure clinic for initiation and up-titration of key therapeutic agents.

BACKGROUND: Heart failure has a poor prognosis, yet drugs known to improve outcomes are either not prescribed, or prescribed at sub-therapeutic doses. The National Service Framework (NSF) for coronary heart disease recommended specialist heart failure clinics to address this problem but their efficacy has not been evaluated. OBJECTIVES: To determine the effectiveness of a protocol-driven heart failure clinic staffed by nurse and pharmacist specialists for improving symptoms and optimising treatment with key therapeutic agents, without adversely affecting renal function. RESULTS: Of the 234 patients with at least one follow-up visit, 127 (57%) were receiving none or only one key therapeutic agent when first seen, this was reduced to 25 patients (11%) at most recent follow-up. The improvement in prescription rates was accompanied by significant up-titration of dose, the proportion of patients on "medium" or "high" doses rising from 43 (18%) to 134 (57%) for beta-blockers, and from 129 (55%) to 201 (86%) for ACE-inhibitors/angiotensin receptor blockers. Clinical improvement was reflected in reductions in patients with NYHA functional classes III and IV (93 (40%) to 53 (23%)), and in patients with moderate or severe symptoms. Significant reductions in alcohol consumption and cigarette smoking were recorded. Up-titration of treatment was associated with reductions in heart rate and systolic blood pressure; increases in serum potassium and creatinine concentrations were small. CONCLUSION: In a heart failure clinic staffed by nurse and pharmacist specialists, it is possible to achieve target doses of key therapeutic agents and improve symptoms without adversely affecting electrolytes or renal function.

Applications of narrative theory and therapy to the practice of family medicine.

This article presents narrative theory and therapy as an approach with significant potential for providing family physicians with additional tools to assist them in dealing with difficult clinician-patient encounters. We first define narrative therapy, then briefly describe its theoretical assumptions in relation to psychosocial concepts already familiar to family physicians. Important aspects of narrative therapy are examined, including the unique role of questioning in the narrative process; understanding and helping patients change their problem-saturated stories; renaming and externalizing the patient problem; and the use of rituals, documents, and audience in recognizing and reinforcing patient change. The article concludes with thoughts about how narrative approaches can contribute to more-healing doctor-patient relationships.