How to Teach Medical Students About Pain and Dementia: E-Learning, Experiential Learning, or Both?

OBJECTIVE: Pain management in persons with mild to moderate dementia poses unique challenges because of altered pain modulation and the tendency of some individuals to perseverate. We aimed to test the impact of an e-learning module about pain in communicative people with dementia on third-year medical students who had or had not completed an experiential geriatrics course. DESIGN: Analysis of pre- to postlearning changes and comparison of the same across the student group. SETTING: University of Pittsburgh School of Medicine and Saint Louis University School of Medicine. SUBJECTS: One hundred four University of Pittsburgh and 57 Saint Louis University medical students. METHODS: University of Pittsburgh students were randomized to view either the pain and dementia module or a control module on pain during a five-day geriatrics course. Saint Louis University students were asked to complete either of the two modules without the context of a geriatrics course. A 10-item multiple choice knowledge test and three-item attitudes and confidence questionnaires were administered before viewing the module and up to seven days later. RESULTS: Knowledge increase was significantly greater among students who viewed the dementia module while participating in the geriatrics course than among students who viewed the module without engaging in the course (P < 0.001). The modules did not improve attitudes in any group, while student confidence improved in all groups. CONCLUSIONS: Medical students exposed to e-learning or experiential learning demonstrated improved confidence in evaluating and managing pain in patients with dementia. Those exposed to both educational methods also significantly improved their knowledge.

Factors Associated With Successfully Filling Faculty Vacancies in Family Medicine.

BACKGROUND AND OBJECTIVES: Faculty vacancies are a concern for chairs of academic family medicine departments who regularly face having to recruit new faculty. Faculty physicians who report lack of support for research and teaching or excessive time in activities that are not meaningful may experience burnout resulting in leaving academic medicine. METHODS: Data were collected via a Council of Academic Family Medicine Educational Research Alliance (CERA) survey of US family medicine department chairs. To determine characteristics associated with success in hiring new physician faculty, chairs answered questions about the number of vacancies in the previous 12 months, the number of vacancies filled in the previous 12 months, the months the longest vacancy was open, starting salary, whether signing bonus was offered, and the full-time equivalent (FTE) for clinical, research, teaching, and administrative time. RESULTS: The response rate was 52%. Chairs reported an average of 3.9 vacancies in the previous 12 months, and an average of 2.5 (66%) were filled. Chairs who didn't offer protected time for teaching filled a higher percentage of their vacancies, but they did not fill them faster than departments that did offer teaching time. Higher salary and a signing bonus were associated with filling positions faster. Chairs who offered a signing bonus filled positions nearly 4 months sooner than those who didn't. CONCLUSIONS: Offering protected time for teaching or research and FTE allocation for clinical, teaching, research, and administrative time were not associated with success in hiring new faculty. Chairs who offered higher salaries and signing bonuses were able to hire faculty more quickly than those who didn't.

Primary Care of Breast Cancer Survivors.

With declining mortality rates, the number of breast cancer survivors is increasing. Ongoing care after breast cancer treatment is often provided by primary care physicians. This care includes surveillance for cancer recurrence with a history and physical examination every three to six months for the first three years after treatment, every six to 12 months for two more years, and annually thereafter. Mammography is performed annually. Magnetic resonance imaging of the breast is not indicated unless patients are at high risk of recurrence, such as having a hereditary cancer syndrome. Many breast cancer survivors experience long-term sequelae from the disease or treatment. Premature menopause with hot flashes can occur and is managed with pharmacologic and nonpharmacologic treatments. Vaginal dryness is treated with vaginal lubricants and gels. Because cardiotoxicity from chemotherapy is possible, clinicians should be alert for this complication and perform echocardiography if appropriate. Impaired cognition after chemotherapy is also common; treatment includes cognitive rehabilitation therapy. Patients with treatment-induced menopause develop decreased bone density and should receive dual energy x-ray absorptiometry and pharmacologic and nonpharmacologic therapies. Others experience lymphedema, often best managed with weight loss and complex decongestive therapy. Some women develop chronic pain, which is treated by addressing psychological factors and with appropriate pharmacologic therapy.

Race in Older but Not Younger Patients Associated With Greater Glycemic Burden in Primary Care Patients.

PURPOSE: The purpose of this study is to determine if race disparities in glycemic control differ in young vs older white and African American patients with diabetes. METHODS: Electronic medical record data were gathered from 1431 primary care patients ≥18 years old, diagnosed with type 2 diabetes, who had ≥2 A1C measurements between July 1, 2008, and June 30, 2015. A1C values were used to compute the average monthly glycemic burden (AMGB). AMGB is the average monthly cumulative amount of A1C >7.5. Age-stratified (18-50 vs >50 years old) linear regression models were computed to measure the association between race and AMGB before and after adjusting for covariates. RESULTS: Younger compared to older patients had significantly greater AMGB. In younger patients, AMGB was not significantly different in African American vs white patients. In older patients, African Americans had significantly greater AMGB compared to whites, and this association remained significant after adjusting for all covariates in a linear regression model. CONCLUSIONS: Results narrow the known race disparity in glycemic control to older African American patients. Substantial AMGB in white and African American younger patients warrants aggressive clinical and public health interventions that could help patients manage their diabetes and reduce their risk for diabetes-related health conditions.

Teaching Chronic Pain in the Family Medicine Residency.

BACKGROUND AND OBJECTIVES: Chronic pain is a significant condition affecting many Americans. Primary care physicians play an important role in chronic pain management, but many residents and physicians feel poorly prepared to manage it. METHODS: Data were collected as part of the 2016 Council of Academic Family Medicine Educational Research Alliance (CERA) Program Director Survey, which was sent electronically to 484 program directors in the United States. The authors sought to determine whether residency directors' attitudes about treating chronic pain were associated with the amount of time devoted to teaching family medicine residents about chronic pain assessment, therapy (use of opioids, use adjuvant pain medications, use of other nonopioids, use of nonpharmacological treatments), and risk management (risk assessment, use of pain management contracts, informed consent when prescribing opioids, and urine drug monitoring). Attitudes were assessed by asking whether: (1) chronic pain is best managed by a primary care physician (PCP); (2) prescribing opioid medications is time consuming; (3) prescribing opioids is high-risk; (4) prescribing opioids contributes to opioid misuse; and (4) effective nonopioid treatments exist. An additional question assessed confidence in treating chronic pain. RESULTS: The response rate was 53%. The average family medicine residency devotes about 33 hours to education about pain management topics including 5.4 hours on chronic pain assessment, 16.2 hours on therapy, and 11.4 hours on risk assessment. Residency directors' belief that there are effective nonopioid treatments for chronic pain was the only attitude item that was associated with teaching about chronic pain. CONCLUSIONS: Residency directors' attitudes do not predict the time devoted to teaching chronic pain in family medicine residencies.

Comparison of Family Medicine and General Internal Medicine on Diabetes Management.

The majority of patients with type 2 diabetes are managed in primary care, either in family medicine (FM) or general internal medicine (GIM). Variances in training, beliefs and practice decisions between FM and GIM may result in differing approaches to diabetes management. This study found that differences do exist in the choice of treatment by FM vs GIM; however, these differences are driven by patient characteristics and does not result in glycemic control disparities. BACKGROUND AND OBJECTIVES: Approach to management of chronic health conditions differs between family medicine (FM) and general internal medicine (GIM). Differences might be due to beliefs, patient case mix, training, and/or experience. This study determined if FM and GIM diabetes management differences exist, and if so, resulted in better or worse glycemic control. METHOD: Electronic medical record data from 2008-2013 were used to identify 976 patients (287 FM and 689 GIM) with type 2 diabetes and prescriptions for metformin. GEE-type regression models were computed to control for repeated measures and estimate the association between primary care specialty and glycemic control, defined as percent of patients with HgA1c<8.5 and average HgA1c. Covariates included demographics, comorbidities, smoking and health care utilization, and diabetes treatment. RESULTS: Compared to FM patients, significantly more GIM patients received a non-metformin medication (35.9% vs 47.2%) and insulin (16.4% vs 23.8%). After adjusting for covariates, FM patients had significantly lower HgA1c values (B = -.47; 95% CI: -0.68, -0.27) and were less likely to have an HgA1c>8.5 (OR=0.55; 95%CI:0.40-0.77). FM vs GIM patients did not differ in degree of HgA1c improvement over time. CONCLUSIONS: FM patients vs GIM patients are less likely to receive a non-metformin and insulin medication. Differences in diabetes management likely correspond to degree of HgA1c control. Choice of treatment appears to reflect patient needs as both FM and GIM patients experienced equal improvement in HgA1c. Primary care specialty differences in beliefs and practices around diabetes management do not result in disparities in patient care.

Teaching Chronic Pain in the Family Medicine Clerkship: Influences of Experience and Beliefs About Treatment Effectiveness: A CERA Study.

BACKGROUND: Chronic pain is a common and important disease state in North America, but many medical students and practicing physicians feel poorly prepared to treat this condition. METHODS: Data were collected via the 2014 CERA Family Medicine Clerkship Director survey, which was electronically sent to 121 US and 16 Canadian clerkship directors. The authors sought to determine the quantity of chronic pain management instruction included in clerkship curricula and any characteristics of clerkship directors that correlated with the teaching of various pain topics. Survey items included the total amount of time spent teaching about chronic pain, various subtopics addressed, and personal characteristics of clerkship directors (years as clerkship director, number of years since graduation, amount of pain-related CME taken yearly, confidence in caring for patients with chronic pain, and belief in efficacy of various treatments). RESULTS: The response rate was 91%. Half of respondents indicated that they do not teach about chronic pain during the clerkship at all. The mean number of minutes spent teaching about chronic pain during the family medicine clerkship was 48 minutes (SD=65.). The majority of clerkship directors felt confident about their ability to treat chronic pain, and there was a positive correlation between confidence and time teaching about chronic pain during the family medicine clerkship. Confidence in treating chronic pain patients also correlated with the likelihood of covering several specific pain subtopics, including pain assessment, documentation skills, non-pharmacologic treatment, treatment with opioids, and treatment with non-opioids. CONCLUSIONS: Chronic pain management is currently taught in only about half of family medicine clerkships. Confidence in caring for chronic pain patients is the only characteristic of clerkship directors that predicts whether the subject of chronic pain will be taught within the family medicine clerkship.

Common questions about chronic low back pain.

More than 30% of U.S. adults report having experienced low back pain within the preceding three months. Although most low back pain is nonspecific and self-limiting, a subset of patients develop chronic low back pain, defined as persistent symptoms for longer than three months. Low back pain is categorized as nonspecific low back pain without radiculopathy, low back pain with radicular symptoms, or secondary low back pain with a spinal cause. Imaging should be reserved for patients with red flags for cauda equina syndrome, recent trauma, risk of infection, or when warranted before treatment (e.g., surgical, interventional). Prompt recognition of cauda equina syndrome is critical. Patient education should be combined with evidence-guided pharmacologic therapy. Goals of therapy include reducing the severity of pain symptoms, pain interference, and disability, as well as maximizing activity. Validated tools such as the Oswestry Disability Index can help assess symptom severity and functional change in patients with chronic low back pain. Epidural steroid injections do not improve pain or disability in patients with spinal stenosis. Spinal manipulation therapy produces small benefits for up to six months. Because long-term data are lacking for spinal surgery, patient education about realistic outcome expectations is essential.

Teaching integrated behavioral health in a primary care clerkship.

BACKGROUND: Most behavioral health care is actually delivered by primary care physicians. Primary care clerkship students have a unique opportunity to learn about behavioral health and the integrated care model. Integrated care is an effective multidisciplinary model for delivering high quality care. PURPOSE: Evaluate the efficacy of a brief curriculum in increasing students' knowledge regarding common behavioral health issues. METHODS: We designed an interactive, 90-minute curriculum to introduce students to the unique model of integrated care, and to build skills in addressing a number of common behavioral health issues. Each problem is presented from both the medical and behavioral perspective. We evaluated this intervention with a pre- and post-clerkship test assessing knowledge regarding behavioral health care. RESULTS: There was significant improvement on the overall score and on seven of eight individual questions. CONCLUSIONS: This curriculum is an effective intervention for introducing integrated care and increasing knowledge of several common behavioral problems.