Long-term Effects of a Health Literacy Curriculum for Family Medicine Residents.

INTRODUCTION: Improving education about health literacy for health care professionals has been recommended, and many US family medicine residency programs have developed such curricula. Few studies have evaluated the effectiveness of health literacy curricula for health care professionals. This pilot study aimed to determine whether a longitudinal health literacy curriculum for family medicine residents could achieve long-term sustained improvements in health literacy knowledge and clear communication practices. METHODS: Self-reported pre- and postassessments were conducted for a series of four health literacy didactic and experiential trainings over 11 months with a cohort of 12 first-year family medicine residents (study adequately powered for cohort of 10 or more). RESULTS: Five out of five health literacy knowledge items showed sustained significant improvement immediately after the initial didactic training. Two out of eight clear communication behaviors (eliciting patients' questions through an open-ended approach, and using a teach-back method to check for patients' understanding) showed sustained significant improvements in the 11-month follow-up period. The remaining six behaviors demonstrated a saw-tooth pattern, wherein each training session produced improvements in planned behaviors, which were, however, not maintained at subsequent follow-up assessments. CONCLUSIONS: These data suggest that residents learned the cognitive material related to health literacy and clear communication easily, but had difficulty integrating many trained skills into clinical practice, despite the use of experiential learning techniques. Future studies should use an observational design to assess clear communication behaviors, and should include assessment of potential barriers to implementing clear communication skills in clinical practice.

Performance of a Patient Reported Outcomes Measurement Information System (PROMIS) Short Form in Older Adults with Chronic Musculoskeletal Pain.

OBJECTIVE: To assess reliability, validity, and responsiveness of a 29-item short-form version of the Patient Reported Outcomes Measurement Information System (PROMIS) and a novel "impact score" calculated from those measures. DESIGN: Prospective cohort study. SETTING: Rural primary care practices. SUBJECTS: Adults aged ≥ 55 years with chronic musculoskeletal pain, not currently receiving prescription opioids. METHODS: Subjects completed the PROMIS short form at baseline and after 3 months. Patient subsets were compared to assess reliability and responsiveness. Construct validity was tested by comparing baseline scores among patients who were or were not applying for Worker's Compensation; those with higher or lower catastrophizing scores; and those with or without recent falls. Responsiveness was assessed with mean score changes, effect sizes, and standardized response means. RESULTS: Internal consistency was good to excellent, with Cronbach's alpha between 0.81 and 0.95 for all scales. Among patients who rated their pain as stable, test-retest scores at 3 months were around 0.70 for most scales. PROMIS scores were worse among patients seeking or receiving worker's compensation, those with high catastrophizing scores, and those with recent falls. Among patients rating pain as "much less" at 3 months, absolute effect sizes for the various scales ranged from 0.24 (Depression) to 1.93 (Pain Intensity). CONCLUSIONS: Results indicate that the PROMIS short 29-item form may be useful for the study of patients with chronic musculoskeletal pain. Our findings also support use of the novel "impact score" recommended by the National Institutes of Health (NIH) Task Force on Research Standards for Chronic Low Back Pain.

Challenges to depression care documentation in an EHR.

BACKGROUND AND OBJECTIVES: Patients with depression most frequently present in primary care. Electronic health records (EHR) have the potential to improve depression care through improved clinical documentation and information exchange. This report provides an example of how an EHR can fail to capture important information regarding depression care. METHODS: A 6-month baseline period in 2009 was defined to identify ambulatory patients age 18 or older in the EHR with an ICD-9 coded new depression diagnosis. Data was abstracted electronically, and charts were reviewed by hand for patient demographics and to assess the clinical documentation of depression screening, diagnosis, and treatment practices among four community-based family medicine clinics. RESULTS: Electronic abstraction of baseline data identified 200 adult patients with a documented new diagnosis of depression. Review of charts by hand was required to obtain clinical documentation of screening (9% of patients), use of diagnostic tools (73%), discussion of treatment options (83%), medication treatment (71%), and follow-up characteristics (75%). CONCLUSIONS: Despite having a robust EHR, we encountered significant challenges finding documentation of depression care, which also made it difficult to track and evaluate the implementation of evidence-based treatment. Clinical documentation in the EHR needs to be simplified and standardized if data extraction and exporting processes of clinician performance data are to become efficient and routine practice.

Correlates of higher-dose opioid medication use for low back pain in primary care.

UNLABELLED: Factors associated with high-dose opioid therapy for noncancer pain are poorly understood. We documented the prevalence of high-dose opioid use as well as associated demographic, clinical, and health service utilization correlates among low back pain patients. Patients prescribed higher doses of opioids (≥100 mg/day morphine equivalent at last dispensing; n = 453) and receiving opioids for 90+ consecutive days were compared to 2 groups: lower-dose opioid group (1-99 mg/day; n = 4,815) or no-opioid group (n = 10,184). Higher-dose opioid use occurred in 2.9% of patients who received any opioids and in 8.6% of patients who received opioids long-term. The median dose in the higher-dose group was 180.0 mg/day. Compared to the no-opioid group, higher-dose users reported poorer health. Compared to either comparison group, patients in the higher-dose group had higher rates of mental health and substance use disorders, concurrent sedative-hypnotic use (60.5%; n = 274), and health service utilization. After adjusting for select covariates, male gender (odds ratio [OR] = 1.68, 95% confidence interval [CI] = 1.37-2.06), higher comorbidity, Medicare coverage (OR = 1.65, 95% CI = 1.22-2.23), any mental health or substance use diagnosis (OR = 1.58, 95% CI = 1.28-1.95), co-prescriptions of sedative-hypnotics (OR = 1.75, 95% CI = 1.42-2.16), and more emergency department and specialty pain clinic visits were associated with higher likelihood of high-dose prescriptions. PERSPECTIVE: Higher-dose opioid therapy is being prescribed to 8.6% of back pain patients who receive long-term opioids. These patients had higher mental health and medical comorbidities and co-prescriptions of sedative-hypnotics, raising potential safety concerns.

The legacy of altruism in health care: the promotion of empathy, prosociality and humanism.

OBJECTIVES: This study aimed to examine concepts of altruism and empathy among medical students and professionals in conjunction with health care initiatives designed to support the maintenance of these qualities. METHODS: We searched for the terms 'altruism', 'altruistic', 'helping', 'prosocial behaviour' and 'empathy' in the English-language literature published from 1980 to the present within the Ovid MEDLINE, PsycInfo and PubMed databases. We used conceptual analysis to examine the relationships among altruism, empathy and related prosocial concepts in health care in order to understand how such factors may relate to emotional and career burnout, cynicism, decreased helping and decreased patient-centredness in care. RESULTS: Altruistic ideals and qualities of empathy appear to decrease among some medical students as they progress through their education. During this process, students face increasingly heavy workloads, deal with strenuous demands and become more acquainted with non-humanistic informal practices inherent in the culture of medicine. In combination, these factors increase the likelihood that emotional suppression, detachment from patients, burnout and other negative consequences may result, perhaps as a means of self-preservation. Alternatively, by making a mindful and intentional choice to endeavour for self-care and a healthy work-life balance, medical students can uphold humanistic and prosocial attitudes and behaviours. CONCLUSIONS: Promoting altruism in the context of a compensated health care career is contradictory and misguided. Instead, an approach to clinical care that is prosocial and empathic is recommended. Training in mindfulness, self-reflection and emotion skills may help medical students and professionals to recognise, regulate and behaviourally demonstrate empathy within clinical and professional encounters. However, health care initiatives to increase empathy and other humanistic qualities will be limited unless more practical and feasible emotion skills training is offered to and accepted by medical students. Success will be further moderated by the culture of medicine's full acceptance of empathy and humanism into its customs, beliefs, values, interactions and daily practices.

Prioritizing prevention: culture, context, and cervical cancer screening among Vietnamese American women.

Few studies have investigated what Vietnamese American women believe about the Pap smear or how those beliefs might influence behavior. Thirty-one Vietnamese American women recruited through snowball sampling were interviewed about their beliefs regarding the Pap smear. Interviews were qualitatively analyzed using a theoretically informed, inductive approach. The women interviewed emphasized the importance of primary prevention of disease through culturally-informed personal health regimens. They were also largely unfamiliar with the Pap smear, but believed that gynecological exams in general were effective and necessary for disease detection. Finally, when access to gynecological care was difficult, women's faith in their own preventive behaviors helped alleviate their concerns over lack of care. While culturally associated beliefs do not simply "cause" Vietnamese American women to seek or avoid Pap smears, they do influence screening behaviors to a greater or lesser degree, depending on other contextual variables.