Comparing telehealth to traditional office visits for patient management in the COVID-19 pandemic: A cross-sectional study in a respiratory assessment clinic.

INTRODUCTION: The aim of this study was to examine whether telehealth is as safe and effective as traditional office visits in assessing and treating patients with symptoms consistent with COVID-19. METHODS: In this retrospective cross-sectional study, the primary outcome was any 14-day related healthcare follow-up event(s). Secondary outcomes were the type of 14-day related follow-up event including hospital admission, emergency department visit, office visit, telehealth visit and/or multiple follow-up visits. Individual visit types were identified due to the significant difference between a hospital admission and an office visit. Logistic regressions were done using the predictors of visit type, age, gender and comorbidities and the primary outcome variable of a related follow-up visit and then by follow-up type: hospital admission, emergency department visit or office visit. RESULTS: Of 1305 visits, median age was 42.3 years and 65.8% were female. Traditional office visits accounted for 741 (56.8%) of initial visits, while 564 (43.2%) visits occurred via telehealth. One hundred and forty-six (25.9%) of the telehealth visits resulted in a 14-day related healthcare follow-up visit versus 161 (21.7%) of the office visits (adjusted odds ratio (OR) 1.22, 95% CI 0.94-1.58). DISCUSSION: There was no significant difference in related follow-ups of initial telehealth visits compared to initial office visits including no significant difference in hospital admission or emergency department visits. These findings suggest that based on follow up healthcare utilization, telehealth may be a safe and effective option in assessing and treating patients with respiratory symptoms as the COVID-19 pandemic continues.

Cost Analysis of Integrated Behavioral Health in a Large Primary Care Practice.

A residency-based Family Medicine outpatient clinic chose to implement an integrated behavioral health care program in a large primary care clinic in the Southeast to improve patient access to behavioral health care. We hypothesized that embedding a BHP in a primary care setting would be a cost neutral intervention. We implemented a prospective cohort design and included expenses from both inpatient and outpatient visits. We implemented a mixed effects linear regression model to evaluate pre- and post-BHP exposure costs. A total of 1256 patients were identified in the post-BHP exposure period that had more than one-year post-exposure. After applying exclusion criteria, there were 926 patients included in analysis. These patient had an average total cost during the one-year pre-BHP exposure period of $5113 (SD = 7712) and one-year post-BHP exposure period of $5462 (SD = 7813). Our analysis shows a relatively cost neutral impact following the introduction of BHPs in a primary care setting. The results of this study provide a gauge for future planning of services.

Patient experience of an integrated care model in a family practice clinic & FQHC.

In order to investigate the patient experience of integrated behavioral health care in primary care settings, we implemented a patient cohort model from a combined site sample (N = 727) consisting of a family practice clinic and a Federally Qualified Health Center. Patient experience was measured using 12 questions from a validated measure, the Agency for Healthcare Research and Quality's Consumer Assessment of Health Care Providers and Systems (CAHPS®), Home and Community Based Services version, and six additional questions about interactions with an integrated behavioral health care team. We assessed bivariate relationships between satisfaction with integration and the clinic practice and self-reported physical health or self-reported mental/emotional health. We also utilized multiple regression to evaluate this relationship. Our analyses showed a statistically significant and small to moderate direct correlation between patients' self-reported health (both physical and mental/emotional health) and their ratings of the practice as a whole (p = .0003), such that patients who rated their physical and/or mental/emotional health as better were more likely to rate their overall satisfaction with the practice higher. The results of this study suggest that primary care patients with only mild to moderate health conditions (physical and/or mental/emotional) may experience greater satisfaction with integrated behavioral health care than patients with multiple and/or severe health conditions. In contrast, patients with multiple and/or severe health conditions may experience lower satisfaction with integrated behavioral health care and may be better served through higher levels of care.

Group Medical Visit Training in Family Medicine Residency: A 2015 CERA Program Directors Survey.

BACKGROUND AND OBJECTIVES: Group medical visits (GMV) have been shown to improve clinical outcomes and patient satisfaction and are included as a new tool in the patient-centered medical home (PCMH). The capacity for and interest in developing GMV skills in family medicine residency have not been assessed. This study aims to describe the extent of existing training in GMV as well as attitudes toward and barriers to this training. METHODS: The Council of Academic Family Medicine Educational Research Alliance (CERA) sent a survey in the fall of 2015 to all US family medicine residency program directors (PDs) containing questions about the status of GMV training for their residents. RESULTS: The survey response rate was 53%. Fifty-nine percent of program director respondents report access to GMV and 61% note some form of training in this model of care. Seventy-nine percent of respondents indicate that GMV training is important for residents. Multiple barriers exist to optimizing GMV as part of current family medicine training. CONCLUSIONS: A majority of family medicine PD respondents report both access to and curriculum for GMV. While program directors endorse this practice model as an important element in resident training, they acknowledge challenges that may limit its availability. Opportunities to better understand and overcome barriers may increase programs' capacity to deliver GMV skills.

Using Standardized Patient Assessments to Evaluate a Health Literacy Curriculum.

BACKGROUND AND OBJECTIVES: Patients' health literacy is a growing concern as patients are expected to perform more self-care. While many US schools implement health literacy in their curricula, time spent on the topic ranges from 0 to 8 hours and is largely didactic. Evaluation of health literacy skills is not well defined. The effectiveness of a health literacy curriculum for third-year medical students was evaluated by two standardized patients assessments (SPAs). METHODS: All third-year medical students complete a required 4-week clerkship in family medicine. After participating in seminars on patient-centered communication, health literacy, mindfulness, implicit bias, and chronic disease management, students complete SPA-1. Students also work in two team-based teaching clinics with chronic disease patients with limited health literacy and receive faculty feedback. At week 4, students complete SPA-2. Six raters evaluated all video-recorded SPA performances using the Common Ground validated instrument and a tailored health literacy skills checklist. RESULTS: Using SPAs and reliably-trained nonclinical raters is an effective method for training and evaluating students about health literacy. Two classes (2013 and 2015) had significant improvement in Common Ground core skills from SPA-1 to SPA-2. For all classes, a small but significant increase in student use of health literacy checklist was seen from SPA-1 to SPA-2. CONCLUSIONS: Didactic sessions prepare students to demonstrate competence on Common Ground and health literacy skills. Improvements in students' health literacy and communication skills are feasible in a 4-week clerkship utilizing the curriculum and evaluation process described.

Implementing the Bruker MALDI Biotyper in the Public Health Laboratory for C. botulinum Neurotoxin Detection.

Currently, the gold standard method for active botulinum neurotoxin (BoNT) detection is the mouse bioassay (MBA). A Centers for Disease Control and Prevention-developed mass spectrometry (MS)-based assay that detects active BoNT was successfully validated and implemented in a public health laboratory in clinical matrices using the Bruker MALDI-TOF MS (Matrix-assisted laser desorption ionization-time of flight mass spectrometry) Biotyper. For the first time, a direct comparison with the MBA was performed to determine MS-based assay sensitivity using the Bruker MALDI Biotyper. Mice were injected with BoNT/A, /B, /E, and /F at concentrations surrounding the established MS assay limit of detection (LOD) and analyzed simultaneously. For BoNT/B, /E, and /F, MS assay sensitivity was equivalent or better than the MBA at 25, 0.3, and 8.8 mLD50, respectively. BoNT/A was detected by the MBA between 1.8 and 18 mLD50, somewhat more sensitive than the MS method of 18 mLD50. Studies were performed to compare assay performance in clinical specimens. For all tested specimens, the MS method rapidly detected BoNT activity and serotype in agreement with, or in the absence of, results from the MBA. We demonstrate that the MS assay can generate reliable, rapid results while eliminating the need for animal testing.

Medical student attitudes toward the medically underserved: the USU perspective.

This study examined a cohort of students attending the Uniformed Services University regarding their attitudes toward medical care in underserved populations. Using the previously validated Medical Student Attitudes Toward the Underserved (MSATU), repeated measures analysis of variance showed that student attitudes toward care in underserved populations was less favorable than limited national data at entry and declined over time (Mean MSATU total score Year 1: 46.2 [SD 10.95]; Year 4: 41.7 [SD 12.3] p < 0.01). Differences in medical school debt, exposure to underserved populations, and the definition of "service" in the context of active duty military status might explain some of our findings. Providing broad service learning opportunities within the curriculum could increase student exposure to underserved populations and strengthen the social contract between community and institution.

Two cases of adult botulism caused by botulinum neurotoxin producing Clostridium baratii.

Type F botulism occurs rarely in clinical cases. Two cases of type F botulism in elderly patients that were clustered in time and space are described. Clostridium baratii producing type F botulinum neurotoxin was isolated from both patients; molecular typing of these isolates revealed that they were unrelated strains.

Are medical students aware of their anti-obesity bias?

PURPOSE: Anti-obesity prejudices affect the quality of care obese individuals receive. The authors sought to determine the prevalence of weight-related biases among medical students and whether they were aware of their biases. METHOD: Between 2008 and 2011, the authors asked all third-year medical students at Wake Forest School of Medicine to complete the Weight Implicit Association Test (IAT), a validated measure of implicit preferences for "fat" or "thin" individuals. Students also answered a semantic differential item assessing their explicit weight-related preferences. The authors determined students' awareness of their biases by examining the correlation between students' explicit preferences and their IAT scores. RESULTS: Of 354 medical students, 310 (88%) completed valid surveys and consented to participate. Overall, 33% (101/310) self-reported a significant ("moderate" or "strong") explicit anti-fat bias. No students self-reported a significant explicit anti-thin bias. According to the IAT scores, over half of students had a significant implicit weight bias: 39% (121/310) had an anti-fat bias and 17% (52/310) an anti-thin bias. Two-thirds of students (67%, 81/121) were unaware of their implicit anti-fat bias. Only male gender predicted an explicit anti-fat bias (odds ratio 3.0, 95% confidence interval 1.8-5.3). No demographic factors were associated with an implicit anti-fat bias. Students' explicit and implicit biases were not correlated (Pearson r = 0.03, P = .58). CONCLUSIONS: Over one-third of medical students had a significant implicit anti-fat bias; few were aware of that bias. Accordingly, medical schools' obesity curricula should address weight-related biases and their potential impact on care.

Standardized patient instructors' and physician assistant students' evaluation of diabetes counseling skills.

PURPOSE: Standardized patient instructors (SPIs) have been used in medical and physician assistant (PA) teaching and have been shown to be a valuable resource for assessing interviewing and clinical skills. This study evaluated the agreement between SPI ratings and student self-ratings in the assessment of counseling skills. METHODS: PA students in three graduating classes (2009-2011) participated in this study. SPIs received specialized training to simulate a patient with diabetes. SPIs provided feedback during simulated encounters using the Diabetes Risk Factor Interview Scale (DRFIS). The DRFIS provides a criteria-based scale for student assessment. Students completed the DRFIS as a self-assessment prior to receiving SPI feedback. Agreement between SPI evaluation and student self-evaluation using the DRFIS were evaluated. RESULTS: The total DRFIS score was generally comparable between all three graduation classes. SPI ratings of students by individual DRFIS items for all three classes indicate the highest scores occurred for Rapport and Empathy items while the lowest scores were evident for items including Reinforce Effort and Reframing Failure. The percent agreement between SPI and student self-rating was within one point for greater than 70% for all 12 DRFIS items for the cohort of three graduation classes. CONCLUSION: PA students rated themselves on average lower on the DRFIS than SPIs but within an acceptable overall percentage range. Using an evaluation scale that is focused around patient counseling skills is a viable teaching tool for students and SPIs. Acceptable agreement between students and SPI was found. The DRFIS provides an effective criteria-based scale for student assessment.

Analysis of Clostridium botulinum serotype E strains by using multilocus sequence typing, amplified fragment length polymorphism, variable-number tandem-repeat analysis, and botulinum neurotoxin gene sequencing.

A total of 41 Clostridium botulinum serotype E strains from different geographic regions, including Canada, Denmark, Finland, France, Greenland, Japan, and the United States, were compared by multilocus sequence typing (MLST), amplified fragment length polymorphism (AFLP) analysis, variable-number tandem-repeat (VNTR) analysis, and botulinum neurotoxin (bont) E gene sequencing. The strains, representing environmental, food-borne, and infant botulism samples collected from 1932 to 2007, were analyzed to compare serotype E strains from different geographic regions and types of botulism and to determine whether each of the strains contained the transposon-associated recombinase rarA, involved with bont/E insertion. MLST examination using 15 genes clustered the strains into several clades, with most members within a cluster sharing the same BoNT/E subtype (BoNT/E1, E2, E3, or E6). Sequencing of the bont/E gene identified two new variants (E7, E8) that showed regions of recombination with other E subtypes. The AFLP dendrogram clustered the 41 strains similarly to the MLST dendrogram. Strains that could not be differentiated by AFLP, MLST, or bont gene sequencing were further examined using three VNTR regions. Both intact and split rarA genes were amplified by PCR in each of the strains, and their identities were confirmed in 11 strains by amplicon sequencing. The findings suggest that (i) the C. botulinum serotype E strains result from the targeted insertion of the bont/E gene into genetically conserved bacteria and (ii) recombination events (not random mutations) within bont/E result in toxin variants or subtypes within strains.

Hidden in plain sight: residency coordinators' social support of residents in family medicine residency programs.

BACKGROUND AND OBJECTIVES: Social support resources for family medicine residents have increased over the years in response to the challenges of residency training and Accreditation Council for Graduate Medical Education (ACGME) requirements. In all of the discussions of social support, the role of residency coordinators (RCs) has been overlooked. A national survey was conducted to expose and explore the contribution of RCs to the social support of family medicine residents. METHODS: A questionnaire was developed to identify the specific contributions to social support RCs might make and the amount of time dedicated to social support activities. The questionnaire was mailed to RCs at 459 US family medicine residencies, with a response rate of 69% (n=316). RESULTS: RCs report devoting on average approximately 6 hours a week (14% full-time equivalents) to the social support of residents. They provide ideas for solving personal and professional problems, opportunities for residents to express feelings, and emotional support. They frequently discuss resident issues with the residency director and others and often play a role in progress evaluations. CONCLUSIONS: RCs in family medicine residencies report playing an important yet often unacknowledged role in the social support of family medicine residents and often serving as a conduit for information between residents and the administration. This role raises issues concerning the recruitment, supervision, training, and job expectations of RCs.

Estimation of injury simulation in international women's football.

This study attempted to determine the frequency of apparent injury incidents in women's international football and estimate what proportion was authentic. Broadcast recordings of 47 games from 2 tournaments were reviewed to identify incidents in which a player behaved as if injured. Apparent injuries were considered definite if a player withdrew from participation within 5 minutes or if bleeding was visible. Remaining incidents were considered questionable. A total of 270 apparent injuries were observed at a rate of 5.74/game compared with 11.26/game previously reported in men's football. The definite injury rate was only 0.78/game vs. 4.96/game for questionable injuries. Definite injuries were associated with on-field treatment (P < 0.010), stretcher (P < 0.010), and second half (P = 0.022), while questionable injuries were associated with fouls (P = 0.036), contact (P < 0.010), and being tackled (P = 0.025). Questionable injuries were not associated with the final third of a half or with team success.

Biodiversity of Clostridium botulinum type E associated with a large outbreak of botulism in wildlife from Lake Erie and Lake Ontario.

The genetic relatedness of Clostridium botulinum type E isolates associated with an outbreak of wildlife botulism was studied using random amplification of polymorphic DNA (RAPD). Specimens were collected from November 2000 to December 2008 during a large outbreak of botulism affecting birds and fish living in and around Lake Erie and Lake Ontario. In our present study, a total of 355 wildlife samples were tested for the presence of botulinum toxin and/or organisms. Type E botulinum toxin was detected in 110 samples from birds, 12 samples from fish, and 2 samples from mammals. Sediment samples from Lake Erie were also examined for the presence of C. botulinum. Fifteen of 17 sediment samples were positive for the presence of C. botulinum type E. Eighty-one C. botulinum isolates were obtained from plants, animals, and sediments; of these isolates, 44 C. botulinum isolates produced type E toxin, as determined by mouse bioassay, while the remaining 37 isolates were not toxic for mice. All toxin-producing isolates were typed by RAPD; that analysis showed 12 different RAPD types and multiple subtypes. Our study thus demonstrates that multiple genetically distinct strains of C. botulinum were involved in the present outbreak of wildlife botulism. We found that C. botulinum type E is present in the sediments of Lake Erie and that a large range of bird and fish species is affected.

Issues encountered by physicians during international travel with youth national soccer teams.

BACKGROUND: Little information is available to guide the selection, preparation, and support of a traveling team physician. PURPOSE: To determine the types of injuries and medical problems, as well as general team health and performance issues, encountered by physicians traveling internationally with youth national soccer teams. STUDY DESIGN: Descriptive epidemiology. METHODS: Physicians assigned to travel abroad with the under-17 men's and women's US national soccer teams during a 2-year period documented all encounters with team and staff members. Physicians also documented consultations related to team health and performance issues. RESULTS: The 108 cases (5.71 per 10 days) were evenly divided between injuries (n = 54) and noninjuries (n = 54). Players sought care at a higher rate than did staff (2.28 vs 1.09 per 100 person days). Mean severity for all player cases was 5.19 days missed (injuries, 10.48; noninjuries, 0.23). Nearly 69% of injuries involved the lower extremities: strains, sprains, and contusions accounted for 74.1% of injuries. Gastrointestinal, dermatologic, and otolaryngologic complaints accounted for 77.8% of noninjuries. Medications were administered in 71% of cases, with analgesics, cough and cold remedies, antibiotics, and gastrointestinal agents accounting for the majority. The leading team health and performance concerns were nutrition/hydration, conditioning, prevention, and doping control. CONCLUSION: Physicians traveling internationally with youth soccer teams manage an equal proportion of musculoskeletal and medical problems using simple medications.

Characteristics associated with glycemic control among family medicine patients with type 2 diabetes.

BACKGROUND: As new payment models are developed for chronic diseases such as diabetes, there is a need to understand which patient characteristics impact glycemic control. This study examines the relationship between patient variables and glycemic control, defined as a hemoglobin A1c (A1c) level of <7%, in a cohort of family medicine patients with type 2 diabetes. METHODS: A total of 1,398 medical charts were selected using International Classification of Diseases, Ninth Revision, Clinical Modification codes for diabetes. To gather information not available through chart review, a survey was used to collect data on individual-level characteristics. Information included marital status, education level, income level, insurance status, activity level, receipt of diabetes education, living arrangement, employment status, and annual income. A cross-sectional design was used to obtain, via chart review, data about diabetes outcomes (ie, A1c level, blood pressure, and low-density lipoprotein cholesterol [LDL-C] level). RESULTS: A mailed survey was completed by 669 patients (response rate, 47.9%). Almost half of patients in this sample achieved the goal A1c level, LDL-C level (ie, <100 mg/dL), and/or blood pressure (ie, <130/<80 mm Hg). Medicare insurance (odds ratio [OR], 2.16 [95% confidence interval {CI}, 1.18-3.96]) and female sex (OR, 1.61 [95% CI, 1.01-2.56]) were associated with glycemic control. Other variables, such as annual income, education level, and receipt of diabetes education, that were expected to impact glycemic control were not significantly associated with an A1c level of <7%. LIMITATIONS: The survey response rate was <50%, the study was conducted at a single site, and the chart data were retrospective. CONCLUSIONS: Our findings indicate that Medicare insurance and female sex were associated with glycemic control. Further evaluation is needed to identify determinants that lead to achievement of optimal glycemic control among individuals with type 2 diabetes.

Reflecting on reflections: enhancement of medical education curriculum with structured field notes and guided feedback.

The promotion of reflective capacity within the teaching of clinical skills and professionalism is posited as fostering the development of competent health practitioners. An innovative approach combines structured reflective writing by medical students and individualized faculty feedback to those students to augment instruction on reflective practice. A course for preclinical students at the Warren Alpert Medical School of Brown University, entitled "Doctoring," combined reflective writing assignments (field notes) with instruction in clinical skills and professionalism and early clinical exposure in a small-group format. Students generated multiple e-mail field notes in response to structured questions on course topics. Individualized feedback from a physician-behavioral scientist dyad supported the students' reflective process by fostering critical-thinking skills, highlighting appreciation of the affective domain, and providing concrete recommendations. The development and implementation of this innovation are presented, as is an analysis of the written evaluative comments of students taking the Doctoring course. Theoretical and clinical rationales for features of the innovation and supporting evidence of their effectiveness are presented. Qualitative analyses of students' evaluations yielded four themes of beneficial contributions to their learning experience: promoting deeper and more purposeful reflection, the value of (interdisciplinary) feedback, the enhancement of group process, and personal and professional development. Evaluation of the innovation was the fifth theme; some limitations are described, and suggestions for improvement are provided. Issues of the quality of the educational paradigm, generalizability, and sustainability are addressed.

Working effectively with interpreters: a model curriculum for physician assistant students.

BACKGROUND: Effective patient-provider communication is crucial to achieving good health care outcomes. To accomplish this with patients of limited English proficiency, learning to work effectively with interpreters is essential. AIMS: The primary goal of this study was to determine if physician assistant students could effectively use interpreters to communicate with Spanish speaking patients after implementation of a cultural competency and Medical Spanish curriculum. METHOD: In year one of a three year implementation process, a module for teaching students to work effectively with interpreters was developed and implemented in the Wake Forest University School of Medicine Department of Physician Assistant Studies. After four hours of orientation, practice and role play, students were observed and recorded during a standardized patient assessment and evaluated by clinicians as well as by trained, bi-lingual evaluators. RESULTS: In the Class of 2007, 94% (43 students) and in the Class of 2008, 96% (47 students) demonstrated competence. CONCLUSIONS: Our findings highlight the feasibility and usefulness of training students to work effectively with interpreters. Evaluation and feedback from students and faculty have been positive. Cost for this curriculum enhancement was reasonable, making it feasible to introduce the training into a wide variety of medical and allied health programs.

Migrant farmworker stress: mental health implications.

CONTEXT: The number of Latinos in rural regions of the United States is increasing. Little is known about factors that undermine the mental health of this segment of the rural population. PURPOSE: The goal of this study is to determine which stressors inherent in farmwork and the farmworker lifestyle contribute to poor mental health. METHODS: An interview containing the Migrant Farmworker Stress Inventory (MFWSI) and 3 mental health scales (the PAI [anxiety], CES-D [depression], and CAGE/4M [alcohol abuse]) was administered to a sample of 125 male migrant farmworkers. Factor analysis differentiated discrete domains of stressors in the MFWSI. Regression models identified associations of the MFWSI stressor domains with mental health outcomes. FINDINGS: Thirty-eight percent of participants had significant levels of stress as determined by the MFWSI. The MFWSI reduced to 5 stressor domains: legality and logistics, social isolation, work conditions, family, and substance abuse by others. Some 18.4% of participants had impairing levels of anxiety, 41.6% met caseness for depression, and 37.6% answered yes to 2 or more questions on the CAGE. Social isolation and working conditions were associated with both anxiety and depressive symptoms. However, social isolation was more strongly associated with anxiety, and working conditions were more strongly linked to depression. CONCLUSIONS: Specific categories of stressors (social isolation, working conditions) inherent in farmwork and the farmworker lifestyle are associated with mental health among immigrant farmworkers. Isolating specific categories of stressors helps in designing programs and practice for the prevention and management of mental health disorders in the immigrant, farmworker population.

A longitudinal comparison of pharmacy and medical students' attitudes toward the medically underserved.

OBJECTIVE: To longitudinally assess pharmacy and medical students' attitudes toward the medically underserved. METHODS: The Medical Students' Attitudes Toward the Underserved (MSATU) survey was administered to the entering classes at the schools of pharmacy and medicine at 2 universities in the South. This self-report measure was then completed by these students in each year of the professional curriculum. Data were compared longitudinally to assess students' attitudes toward the underserved. RESULTS: Pharmacy students' attitude scores towards the underserved remained relatively stable over time (MSATU attitudes scores: Year 1 = 45.2, Year 2 = 48.3, Year 4 = 45.7), while medical students' attitude scores declined significantly (MSATU attitudes scores: Year 1 = 55.5, Year 2 = 52.4, Year 4 = 46.4). No differences in scores were associated with gender. CONCLUSION: This initial study comparing pharmacy and medical students' attitudes toward the underserved can serve as a baseline as healthcare professionals seek for solutions to better care for the medically underserved.