Resolution of bilateral testicular masses after viral infection.

We present a case of viral-associated orchitis with bilateral testicular masses initially concerning for malignancy on scrotal ultrasound. In this case, patient underwent observation after discussing management options. Literature search revealed two cases of benign testicular mass after viral infection that was managed with radical orchiectomy. The previously documented case allowed for appropriate counseling to delay surgical intervention and allow for spontaneous resolution of the viral-induced testicular masses.

Ten Ways Artificial Intelligence Will Transform Primary Care.

Artificial intelligence (AI) is poised as a transformational force in healthcare. This paper presents a current environmental scan, through the eyes of primary care physicians, of the top ten ways AI will impact primary care and its key stakeholders. We discuss ten distinct problem spaces and the most promising AI innovations in each, estimating potential market sizes and the Quadruple Aims that are most likely to be affected. Primary care is where the power, opportunity, and future of AI are most likely to be realized in the broadest and most ambitious scale. We propose how these AI-powered innovations must augment, not subvert, the patient-physician relationship for physicians and patients to accept them. AI implemented poorly risks pushing humanity to the margins; done wisely, AI can free up physicians' cognitive and emotional space for patients, and shift the focus away from transactional tasks to personalized care. The challenge will be for humans to have the wisdom and willingness to discern AI's optimal role in twenty-first century healthcare, and to determine when it strengthens and when it undermines human healing. Ongoing research will determine the impact of AI technologies in achieving better care, better health, lower costs, and improved well-being of the workforce.

Actual and Standardized Patient Evaluations of Medical Students' Skills.

BACKGROUND AND OBJECTIVES: Physicians must communicate effectively with patients. Actual patients (APs) rarely evaluate medical students' clinical skills; instead, standardized patients (SPs) provide proxy ratings. It is unclear how well SP ratings mirror AP experiences. The aim of this study was to compare AP and SP assessments of medical students' communication skills and professionalism. We hypothesized that their perspectives would be similar, but distinct, and offer insight about how to more reliably include the patient's voice in medical education. METHODS: Using a mixed methods design, data were gathered from both APs and SPs using a modified SEGUE (Set the stage, Elicit information, Give information, Understand the patient's perspective, End the encounter) framework. Authors analyzed Likert-scale surveys using Spearman's rho (ρ) correlations, and qualitatively analyzed open-ended comments about students' interpersonal skills and professionalism. RESULTS: For APs, the domains of "trusted the student," "discussed treatment," and "reviewed next steps" were positively correlated with whether they would recommend the student to others (ρ.89, ρ.89, ρ.88, respectively, all P<.001). For SPs, feeling like they "trusted the student," "student appeared professionally competent," and "made personal connection" were most highly correlated with recommending the student to others (ρ.86, ρ.86, ρ.76, respectively, all P<.001). CONCLUSIONS: Feedback from APs provides unique perspectives, complementing those of SPs, and prompts insights into incorporating patients' voices and values into training. Students may benefit from learning experiences focused on sharing and clarifying information. Providing opportunities for deliberate practice and feedback during both AP and SP encounters may enhance mastery of these skills.

Impact of a scholarly track on quality of residency program applicants.

INTRODUCTION: It is generally believed that residency programs offering scholarly tracks attract higher quality applicants, although there is little evidence of this in the literature. We explored the impact of a clinician-educator track on the quality of applicants to our residency program by comparing the volume and characteristics of applicants before (2008-2011) and after (2012-2015) the track was introduced. METHODS: The total number of applications received was compared between the pre-track and post-track years. Among interviewees, data on United States Medical Licensing Examination (USMLE) Step 1 scores, Step 2 Clinical Knowledge (CK) scores, Medical Student Performance Evaluation (MSPE) scores, and proportion of candidates with an advanced degree (e.g. MPH, PhD) were compared. An online survey was administered to all interviewees in 2014-2015 to measure interest in the track. RESULTS: The total number of applications to the residency program increased significantly from the pre-track to the post-track years. Compared to the pre-track years, interviewees during the post-track years had statistically higher USMLE Step 1 and Step 2 CK scores, better MSPE scores, and were more likely to have an advanced degree. Two-thirds of survey respondents reported that the track increased their interest in the residency program. DISCUSSION: A residency clinician-educator track may be associated with increased overall interest from applicants, higher application volume, and better measures of applicant quality based on USMLE scores, MSPE scores, and proportion of candidates with an advanced degree. Residency programs may consider a potential increase in the quality of their applicants as an added benefit of offering a scholarly track.

Documentation and treatment of hypertension: quality of care and missed opportunities in a family medicine resident clinic.

BACKGROUND: In the USA, uncontrolled hypertension contributes to 1000 deaths a day. However, little is known about the quality of hypertension management in family medicine resident clinics. OBJECTIVES: To examine rates of documentation and treatment of elevated blood pressure, and to identify missed opportunities to address hypertension. Study design A cross-sectional chart review of 1011 adult patient visits between 2 January and 4 February 2013 was performed in a resident-run federally qualified health centre. For patients with elevated blood pressure at time of visit, we noted whether or not the residents had documented a diagnosis or discussion of hypertension and the presence or absence of a treatment plan. We compared these rates with those from a national sample of primary care physicians. RESULTS: 262/1011 (26%) of adult patients had elevated blood pressure at time of visit. Of those, 115/262 (44%) had documentation and a plan for treatment, 79/262 (30%) had documentation but no plan, and 68/262 (26%) had neither documentation nor plan. Nationally, 45% of patients are diagnosed and treated compared with 44% of study visits with documentation and treatment. CONCLUSIONS: Fewer than half of visits of patients with elevated blood pressure resulted in both documentation and a treatment plan. Nevertheless, these rates are comparable to national providers. Elevated blood pressure was more likely to be missed during acute visits and in patients with less elevated blood pressure.

Hepatitis B Screening in Asian and Pacific Islanders: New Guidelines, Old Barriers.

Chronic hepatitis B virus (HBV) infection is a serious liver disease that disproportionately affects Asian and Pacific Islander immigrants. In May 2014, the U.S. Preventive Services Task Force released new HBV screening guidelines that expanded screening to non-pregnant adolescents and adults who were born in Asia and the Pacific Islands, and U.S.-born persons not vaccinated as infants whose parents were born in Central or Southeast Asia. Although the guidelines empower health care providers and community health workers to expand their screening efforts, old barriers to screening remain deeply rooted in this population. These barriers include cultural beliefs about wellness, myths and misconceptions about HBV, and lack of access to appropriate, culturally sensitive care. Through a combination of strategies--retooling the current health care workforce to be more culturally sensitive providers, involving oriental medicine practitioners in patient education, and engaging grassroots organizations--we can overcome barriers and take full advantage of the new HBV screening guidelines.

The symptom cluster-based approach to individualize patient-centered treatment for major depression.

Unipolar major depressive disorder is a common, disabling, and costly disease that is the leading cause of ill health, early death, and suicide in the United States. Primary care doctors, in particular family physicians, are the first responders in this silent epidemic. Although more than a dozen different antidepressants in 7 distinct classes are widely used to treat depression in primary care, there is no evidence that one drug is superior to another. Comparative effectiveness studies have produced mixed results, and no specialty organization has published recommendations on how to choose antidepressants in a rational, evidence-based manner. In this article we present the theory and evidence for an individualized, patient-centered treatment model for major depression designed around a targeted symptom cluster-based approach to antidepressant selection. When using this model for healthy adults with major depressive disorder, the choice of antidepressants should be guided by the presence of 1 of 4 common symptom clusters: anxiety, fatigue, insomnia, and pain. This model was built to foster future research, provide a logical framework for teaching residents how to select antidepressants, and equip primary care doctors with a structured treatment strategy to deliver optimal patient-centered care in the management of a debilitating disease: major depressive disorder.

Stopping a silent killer in the underserved asian and pacific islander community: a chronic hepatitis B and liver cancer prevention clinic by medical students.

OBJECTIVES: To assess and alleviate the burden of chronic hepatitis B virus (HBV) infection among low-income, uninsured Asian and Pacific Islanders (APIs) in San Jose, California. METHODS: From 2007 to 2008, we provided free HBV testing and follow-up to 510 patients, 74% of whom were foreign-born Vietnamese. Patients were tested for hepatitis B surface antigen and surface antibody. Chronically infected patients who elected to undergo follow-up monitoring were evaluated for liver damage (ALT), liver cancer (AFP), and HBV replication (HBV DNA). RESULTS: Overall, 17% were chronically infected; 33% of these were unaware that they were infected. Of those who underwent follow-up monitoring, 100% had elevated ALT, 9% had elevated AFP, and 24% had HBV DNA levels that exceeded the threshold for treatment. Patients who were candidates for antiviral therapy were enrolled in drug assistance programs, and those with elevated AFP levels were referred for CT scans. Uninfected patients lacking protective antibodies were provided free HBV vaccinations. CONCLUSIONS: More liver cancer prevention in the medically underserved API community is needed, including universal screening for HBV and follow-up for those chronically infected.

Why we should routinely screen Asian American adults for hepatitis B: a cross-sectional study of Asians in California.

UNLABELLED: Chronic hepatitis B virus (HBV) infection is a serious liver disease that, if left undiagnosed or without appropriate medical management, is associated with a 25% chance of death from cirrhosis or liver cancer. To study the demographics and prevalence of chronic HBV infection and HBV vaccination in the Asian American population, we provided free HBV serological screening and administered a survey to 3163 Asian American adult volunteers in the San Francisco Bay Area between 2001 and 2006. Of those screened, 8.9% were chronically infected with HBV. Notably, one-half to two-thirds (65.4%) of the chronically infected adults were unaware that they were infected. Of those who were not chronically infected, 44.8% lacked protective antibodies against HBV and were likely susceptible to future infection. Men were twice as likely as women to be chronically infected (12.1% versus 6.4%). Asian Americans born in East Asia, Southeast Asia, or the Pacific Islands were 19.4 times more likely to be chronically infected than those born in the United States. Self-reporting of prior vaccination was unreliable to assess protection against HBV. Among the 12% who reported having been vaccinated, 5.2% were chronically infected, and 20.3% lacked protective antibodies. CONCLUSION: Given the high prevalence of unrecognized chronic HBV infection in the Asian American population, we call for healthcare providers to routinely screen Asian adults for HBV, regardless of their vaccination status. Those who test positive should be provided with culturally appropriate information to prevent disease transmission and proper medical management to reduce their risk of liver disease.

Hepatitis B and liver cancer knowledge and preventive practices among Asian Americans in the San Francisco Bay Area, California.

Chronic hepatitis B virus (HBV) infection causes liver cancer and disproportionately affects the Asian community in the U.S. In order to advance HBV and liver cancer awareness and prevention, it is important to identify existing gaps in knowledge and preventive practices among Asian Americans. Therefore, the authors administered a written questionnaire to 199 adults in the Asian-American community of the San Francisco Bay Area, California. Although the majority of adults had at least a college education, knowledge regarding HBV transmission, prevention, symptoms, risks, and occurrence was low. Fewer than 60% reported having been tested for HBV, only 31% reported having been vaccinated against HBV, and only 44% reported having had their children vaccinated. Asians, especially those born in China or Southeast Asia, had significantly poorer knowledge regarding HBV and liver cancer than non-Asians. Those with higher knowledge levels were significantly more likely to have been tested for HBV and to have had their children vaccinated. Younger adults, women, Caucasians, more highly educated individuals, those not born in China or Hong Kong, and those with a personal or family history of liver disease were more likely to have taken preventive action against HBV. Our results suggest that HBV and liver cancer knowledge among Asian Americans, especially Chinese Americans, is poor, and that better knowledge is associated with increased preventive practices. Thus, there is a need for increased HBV education and improved community-based interventions to prevent HBV-related liver disease in the high-risk Asian-American community.

Building partnerships with traditional chinese medicine practitioners to increase hepatitis B awareness and prevention.

OBJECTIVES: The annual Hepatitis B Prevention and Education Symposium aims to develop partnerships between non-Western and Western health care providers to prevent chronic hepatitis B virus (HBV) infection and death from liver cancer among Asians and Pacific Islanders (APIs). DESIGN: Each year from 2004 through 2007, we partnered with professional, academic, and community-based organizations to organize an educational symposium for Traditional Chinese Medicine practitioners and acupuncturists in California. Participants completed pre- and postsymposium surveys assessing knowledge about HBV and liver cancer. SETTING: The symposia were held in San Francisco, Los Angeles, and Stanford, California. SUBJECTS: Over 1000 participants attended the four symposia combined; most were born in Asia. INTERVENTION: Symposium activities included educational lectures and games, presentation of a physician's guide to HBV management, and case studies. OUTCOME MEASURES: Chi-square tests were used to compare the proportion of correct responses to each knowledge-based question, as well as the total number of correct responses, before and after the symposium. RESULTS: Knowledge about HBV and liver cancer was low prior to the symposium. The proportion of correct responses to the most commonly mistaken questions increased significantly at the conclusion of each symposium. The total number of correct responses rose from below 60% to above 75% each year. CONCLUSIONS: Similar educational symposia targeting health care providers who serve API patients can improve HBV and liver cancer awareness and prevention throughout the API community.