Suicide inquiry in primary care: creating context, inquiring, and following up.

PURPOSE: We wanted to describe the vocabulary and narrative context of primary care physicians' inquiries about suicide. METHODS: One hundred fifty-two primary care physicians (53% to 61% of those approached) were randomly recruited from 4 sites in Northern California and Rochester, New York, to participate in a study assessing the effect of a patient's request for antidepressant medication on a physician's prescribing behavior. Standardized patients portraying 2 conditions (carpal tunnel syndrome and major depression, or back pain and adjustment disorder with depressed mood) and 3 antidepressant request types (brand-specific, general, or none) made 298 unannounced visits to these physicians between May 2003 and May 2004. Standardized patients were instructed to deny suicidality if the physician asked. We identified the subset of transcripts that contained a distinct suicide inquiry (n = 91) for inductive analysis and review. Our qualitative analysis focused on elucidating the narrative context in which inquiries are made, how physicians construct their inquiries, and how they respond to a patient's denial of suicidality. RESULTS: Most suicide inquiries used clear terminology related to self-harm, suicide, or killing oneself. Three types of inquiry were identified: (1) straightforward (eg, "Are you feeling like hurting yourself?"); (2) supportive framing (eg, "Sometimes depression gets so bad that people feel that life is no longer worth living. Have you felt this way?"); and (3) no problem preferred (eg, "You're not feeling suicidal, are you?"). Four inquiries were glaringly awkward, potentially inhibiting a patient's disclosure. Most (79%) suicide inquiries were preceded by statements focusing on psychosocial concerns, and most (86%) physician responses to a standardized patient's denial of ideation were followed up with relevant statements (eg, "I hope you would tell me if you did."). CONCLUSION: Although most suicide inquiries by primary care physicians are sensitive, clear, and supportive, some language is used that may inhibit suicide disclosure. Some physician responses may unintentionally reinforce patients for remaining silent about their risk. This study will inform future research in the development of quality improvement interventions to support primary care physicians in making clear, appropriate, and sensitive inquires about suicide.

An academic-community partnership to improve care for the underserved.

Despite the need for a robust primary care workforce, the number of students and residents choosing general internal medicine careers continues to decline. In this article, the authors describe their efforts at the University of California, Davis School of Medicine to bolster interest in internal medicine careers and improve the quality of care for medically underserved populations through a tailored third-year residency track developed in partnership with the Sacramento County Department of Health and Human Services. The Transforming Education and Community Health (TEACH) Program improves continuity of care between inpatient and outpatient settings, creates a new multidisciplinary teaching clinic in the Sacramento County health system, and prepares residents to provide coordinated care for vulnerable populations. Since its inception in 2005, 25 residents have graduated from the TEACH Program. Compared with national rates, TEACH graduates are more likely to practice general internal medicine and to practice in medically underserved settings. TEACH residents report high job satisfaction and provide equal or higher-quality diabetes care than that indicated by national benchmarks. The authors provide an overview of the TEACH Program, including curriculum details, preliminary outcomes, barriers to continued and expanded implementation, and thoughts about the future of the program.