Is the Altman Rule a proxy for glycemic load?

The evidence supports patient use of this simple equation to evaluate the nutrition labels of packaged carbohydrate foods in the grocery aisle in order to make healthier decisions.

Clinical Quality Measures: A Challenge for-and to-Family Physicians.

INTRODUCTION: Improving design, selection and implementation of appropriate clinical quality measures can reduce harms and costs of health care and improve the quality and experience of care delivery. These measures have not been evaluated for appropriateness for use in performance measurement in a systematic, reproducible, and widely accepted manner. METHODS: We defined 10 criteria for evaluation of measure appropriateness in 4 domains: Patient-centeredness of outcomes, specification of population measured and measure detail, reliable evidence that benefits likely outweigh harms, and independence from significant confounders. We applied these criteria to 24 measures under consideration for statewide use in Massachusetts in public and private incentive-based programs. We appraised each measure as Appropriate or Not Appropriate for such use. RESULTS: We rated 15 measures as Appropriate (62.5%). Three measures (12.5%) were considered Appropriate only if applied at a system level but not for patient-provider assessment and 6 measures (25%) were rated Not Appropriate. Reasons for designation as "Not Appropriate" included benefits not clearly outweighing harms, lack of preservation of patient autonomy, inappropriate specification of population and measure detail, confounding by locus of control, and confounding by social determinants of health. CONCLUSIONS: Using this consensus-driven, 10-criteria methodology we were able to evaluate appropriateness of clinical quality measures. This methodology may improve measure design and inform selection of the most appropriate measures for use in quality measurement, financial incentives, and reporting.

Exploring COVID-19 Vaccine Hesitancy Amongst Black Americans: Contributing Factors and Motivators.

PURPOSE: To determine reasons for hesitancy towards COVID-19 vaccination and motivators to increase COVID-19 vaccine uptake among Black Americans. DESIGN: Mixed-methods. SETTING: Individual interviews in March-April 2021. PARTICIPANTS: Black adults (20-79 years) who attended a church in Boston, MA and identified as "vaccine hesitant" (n = 18). METHODS: Individual in-depth Zoom interviews to elicit participant views on vaccines in general, specific reasons for COVID-19 vaccine hesitancy, and trusted sources of information. Participants were also asked about possible motivators that could increase COVID-19 vaccine uptake. Transcripts were de-identified and analyzed for major themes using an inductive approach. RESULTS: Analysis included 18 complete interviews. Lack of trust in the government, healthcare, or pharmaceutical companies (n = 18), rushed development (n = 14), fear of side effects (n = 12), history of medical mistreatment (n = 12), and a perception of low risk of disease (n = 9) were the top-cited reasons for COVID-19 vaccine hesitancy. Motivators likely to increase COVID-19 vaccine uptake included more data (n = 17), friends and family getting vaccinated (not celebrities) (n = 11), and increased opportunities that come along with being vaccinated (n = 8). CONCLUSION: There were many reasons for COVID-19 vaccine hesitancy, as reported by participants who were all Black Americans in the Boston area. The public health challenge of increasing vaccine uptake in the Black community is nuanced and intervention efforts may be more successful if delivered by trusted members of the community and tailored to the needs of individuals.

Do Medical Scribes Help Primary Care Providers Respond More Quickly to Out-of-Visit Tasks?

PURPOSE: Medical scribes are charged with decreasing documentation burden associated with patient visits. Reducing time spent on documentation may afford providers the opportunity to respond to out-of-visit inbox tasks faster. METHODS: We compare changes in the time taken to address patient portal messages, prescription requests, and test results from before to after scribe implementation among scribed primary care providers (PCPs), compared with nonscribed PCPs during the same time period. We used generalized estimating equations with robust standard errors to account for repeated measures and the hierarchical nature of the data, and adjusted for provider and patient characteristics. RESULTS: We examined 472,411 tasks, including 27,645 tasks for 5 scribed PCPs and 444,766 tasks of 74 nonscribed PCPs. In unadjusted analyses, we found no change in time to completion for prescription refill requests, results and patient portal messages; the change in time to completion from pre to post intervention among scribed PCPs was 1.02 times that of nonscribed providers (P = .585) for prescription refill requests, 1.06 times that of nonscribed providers (P = .516) for patient portal messages, and 1.02 times that of nonscribed providers (P = .787) for results. Adjustment for provider and patient characteristics did not change these findings. CONCLUSIONS: Our study suggests that scribes are not associated with improved time to completion of inbox messages for PCPs. While scribes seem to have many benefits, our study suggests they may not improve time to completion of out-of-visit tasks. Reducing the time to completion for these tasks likely requires other interventions targeted to achieve those outcomes.

The financial advantages of medical scribes extend beyond increased visits.

Employing medical scribes can boost revenue for a practice, the authors show, well beyond being an opportunity to expand patient volume.

How do I ask about your disability? An examination of interpersonal communication processes between medical students and patients with disabilities.

Medical student behaviors were examined through digital recordings of interpersonal skills communication training framed around a brief curriculum on disability within a family medicine clerkship. This analysis focuses on interpersonal communication processes and ways medical students ask standardized patient educators about visually apparent disability (N = 142). Primary themes of asking about or avoiding disability were identified with regard to language and nonverbal communication in how medical students asked and whether they integrated chronic disability with new musculoskeletal pain complaints. Secondary themes related to timing and communication further contextualized the primary themes. Seventy-four percent of students asked about the disability. Analysis of feedback sessions immediately following the interactions revealed that more than half the students who did not ask about disability spontaneously recognized that they avoided disability language. Results suggest that some ways of asking about disability may inhibit patient disclosure and restrict relationship building. In particular, asking about disability, but then avoiding integrating disability disclosure into the treatment plan, or responding to disability-related disclosure with overly positive, infantilizing-type communication, may pose more difficult dilemmas than never asking about the disability. On the contrary, students who ignored disability altogether often also recognized they missed disability cues, thus providing a learning experience of considerable value. Underlying student attitudes and possibilities for integrating biomedical concerns with social-psychological impacts of disability are addressed.

What Barriers Exist in the Minds of Vaccine-Hesitant Parents, and How Can We Address Them?

BACKGROUND AND OBJECTIVES: Despite substantial health benefits and prolific research efforts to demonstrate safety and increase uptake, vaccine hesitancy has increased dramatically. This study aimed to systematically analyze available literature on vaccine hesitancy in the United States and determine the rationale behind vaccine-hesitant parents and potential interventions. METHODS: We conducted a literature search and identified 232 articles; we included 90 after screening. We pulled information from each article using standardized questions for "type of study," "population," "specific vaccine," "reasons for hesitancy," "hesitancy prevalence," "attempt at change," "results of intervention," and "future interventions." We created recurrent themes from the data and analyzed these themes via descriptive statistics. RESULTS: Vaccine safety was the most commonly identified reason for vaccine hesitancy amongst studies (50%), followed by not enough information (30%), side effects (26%), low risk of disease (26%), social norms (22%), vaccine schedule (21%), not recommended by doctor (21%), efficacy (18%), cost/access (13%), sexual concerns (12%) and distrust of establishment (7%). Only 20% of papers documented an intervention, and <50% of these reported increased vaccination rates or intent. More research was the most commonly identified next step (49%). CONCLUSIONS: Despite large amounts of research on vaccination rates, patients are still reporting not enough information and safety as the most common reasons for vaccine hesitancy. Interventions were few and without promising results. More research was the most suggested intervention. Such research must address concerns of the vaccine-hesitant community, comparing risks and benefits of each vaccination in a longitudinal, coherent, and transparently unbiased fashion.

Applying a Medical Wellness Group Visit Model to a Community Setting Yielding Weight Loss and Improved Laboratory Results.

PURPOSE: To determine the feasibility of applying a medical wellness group (WG) model to a community setting to improve cardiometabolic health. DESIGN: This quasi-experiment was designed to compare individuals participating in the WG to participants in the control group who received general lectures on nutrition, physical activity, and sleep. SETTING: A suburb north of Boston, Massachusetts. PARTICIPANTS: Forty-five adults were in the WG and 10 in the control group. INTERVENTION: Fourteen weekly 90-minute sessions, led by a physician and dietitian, focusing on nutrition, physical activity, and sleep, compared to controls receiving two 30-minute general wellness lectures provided within 3 months. MEASURES: Pre- and postweight, waist circumference, hemoglobin A1C (HbA1c), and serum lipids; a survey measuring beliefs, attitudes, and intentions related to behavioral change. ANALYSIS: T tests examined the mean change in biometric measurements. The Wilcoxon test was used to compare the ordinal questions in baseline and final survey results. The Mann-Whitney test was used to compare final survey results between groups. RESULTS: The WG demonstrated desirable difference-in-difference between groups in weight (P < .001), waist circumference (P < .001), and total cholesterol (P = .03) compared to the control group. Mean change of HbA1c and triglycerides was not different between groups. Survey results showed that attitudes, perceived behavioral control, and feeling supported about wellness behaviors significantly improved from baseline to final visit in the WG (P = .002; P = .019, P = .006, respectively), but not among controls. CONCLUSION: Wellness groups are feasible and provide high levels of support and accountability that empower people to make behavioral changes to improve health.

What can I learn from this interaction? A qualitative analysis of medical student self-reflection and learning in a standardized patient exercise about disability.

Patients with disabilities receive fewer health services than the general population, yet they have greater health needs. Similarly, physicians report limited training in disability. The current project examines medical students' learning about disability in a project using individuals with disabilities as medical educators. Family medicine clerkship students (N = 138) across an academic year were videotaped during interviews with standardized patient educators with disabilities and during feedback sessions following the interactions. Qualitative analysis of feedback transcripts identifies three primary areas of integrating learning, reflective practice, and disability: (1) learning how disability impacts the treatment plan, (2) self-reflection and recognizing attitudes about disability, and (3) learning about the practice of medicine generally from the disability exercise. Themes are identified within each of the primary learning areas. Medical student reflection provides evidence of learning to connect disability with pain, everyday life, and treatment. Medical students learned to recognize patients' expertise in their own condition and in health care navigation. Medical students also examined how their language implies attitude. The current investigation provided evidence of the ways examining disability can serve as a cornerstone for building relationship-centered patient care and encouraging reflective practice overall.

Medical Education: Guidelines for Effective Teaching of Managing Challenging Patient Encounters.

Health care providers require strong communication skills to effectively interact with and assist patients on a daily basis. However, medical professionals and trainees are often not equipped with the tools necessary to conduct productive exchanges, especially with challenging patient encounters. Communicating thoughtfully can become extremely challenging when patients exhibit problematic behaviors or attitudes. The following guidelines-inspired by a workshop for medical students at Tufts University School of Medicine (TUSM) and further developed by the authors' interdisciplinary experiences and research-offer comprehensive criteria for medical instructors to lead an experiential seminar on how students can succeed in challenging patient encounters.

Taking a Shot at Immunization Adherence Group Visits for Vaccine-Averse Parents.

INTRODUCTION: Decreased vaccination rates in children have played a role in the deaths of several children in the United States over the last decade. Interventions to date have been ineffective at changing vaccination patterns. No studies have evaluated a conciliatory patient-centered approach where parent concerns were acknowledged and addressed in a group setting. METHODS: Vaccine-averse parents with incompletely vaccinated children were recruited from a family medicine practice. These parents attended three group visit sessions centered on vaccine safety and efficacy. Pre and post surveys were given at each session. The children's vaccination records were examined in the year prior and the year following the groups. One year after the group visits, parents were interviewed about their attitudes toward vaccination. RESULTS: There were no significant attitude changes in parents attending the group visits. In the year following the visits, the percentage of recommended vaccines that children had received did not increase. Interviews with parents revealed a broad range of concerns about vaccines and a widespread desire for a longer-term study designed to address these concerns. CONCLUSIONS: Surveys and vaccination records revealed no significant change in attitudes or behavior after three group visit sessions, consistent with other research on interventions with vaccine-averse parents. The phone interviews demonstrated a desire for further research into long-term effects of vaccines, with most parents stating that they would consider changing their beliefs if the research was free from commercial bias, addressed their concerns, and was extended out over a long period of time.

Impact of a Novel Wellness Group Visit Model on Obesity and Behavior Change.

BACKGROUND: Increasing weight-related illness in the United States has led to 120,000 preventable deaths annually and soaring medical costs. Treating patients in a group setting may be more effective than traditional care (TC) in achieving behavioral change. We studied a wellness-group (WG) model to determine whether it could generate sustained behavioral change and weight loss in a subset of patients. METHODS: 99 patients with a body mass index (BMI) >30 kg/m2 from 1 family practice volunteered to participate in a 15-visit WG co-led by a family physician and dietitian. We compared these WG patients with 190 patients who had a BMI >30 kg/m2 and who received TC in the form of an annual physical during the same time period. The patients were mostly white, highly educated, and of middle-to-high-income households. All patients were surveyed on their ability to sustain 12 wellness behaviors 3 months after completing their WG or physical. Patients were not paid to complete the survey. We reviewed medical charts for weight, BMI, blood pressure, lipids, and glycohemoglobin before and at least 1 year after the WG or physical. WG patients' weights were recorded at the beginning and end of the WG as was the weight from their most recent office visit. RESULTS: WG patients were more likely to report sustaining 12 of 12 wellness behaviors than patients who received TC with an annual physical. At 1 year, WG patients also lost more weight than TC patients (-13.21 pounds for WG vs +1.94 pounds for TC) and achieved greater reduction in their systolic blood pressure (-6.96 mm Hg for WG vs -1.13 mm Hg for TC). Average weight gained after the WG was 6.9 pounds. Among WG patients, 61% lost a clinically relevant amount of weight (>5%). Of the WG patients who lost clinically relevant weight, 71% were able to maintain at least half of their weight loss 3 years later. CONCLUSIONS: An observational study of a novel WG model showed that WG patients sustained wellness behaviors and weight loss over time when compared with patients who received TC.

When rapport building extends beyond affiliation: communication overaccommodation toward patients with disabilities.

INTRODUCTION: Physician rapport with patients is described as a vital component of relationship-centered care, but rapport-building communication behaviors may exceed boundaries and instead indicate patronizing behavior toward patients with disabilities. This paper addresses the types of communication behaviors and contexts for interpreting when rapport building extends beyond boundaries toward patients with disabilities. METHODS: Videotaped interactions between third- and fourth-year medical students (N = 142) and standardized patient educators with physical disabilities were qualitatively analyzed. RESULTS: Results suggest six primary themes of exceeding expected rapport boundaries, including baby talk (ie, exaggerated nonverbal gestures and "we" language to indicate "you"), kinesic movement (ie, stiff posture and awkward handshakes), vocalics (ie, volume or pitch that interfered with the flow of conversation), relationship assumptions (ie, communicating assumptions that relationships were grounded in care-receiving), emotional divergence from patient disclosure (ie, minimizing or embellishing disability), and inconsistency with patient emotional cues (ie, responding to negative or neutral disclosure by overly accentuating positive interpretation). DISCUSSION: This study suggests that communication behaviors generally described as positive, rapport-building behaviors can pose negative implications when they exceed the expected quantity or duration, when they are inconsistent with patient verbal disclosure, or when verbal and nonverbal messages are inconsistent. Identified themes serve as examples to understand when rapport building exceeds beyond affiliation and instead appears to indicate patronizing behavior toward patients with disabilities. Suggestions for interpreting communication behaviors within the context of patient disclosure and building capacity to distinguish attitudes and biases limiting communication are addressed.