Optimizing Patient Engagement in Treatment for Opioid Use Disorder: Primary Care Team Perspectives on Influencing Factors.

BACKGROUND: Opioid use disorder (OUD) care engagement rates in primary care (PC) settings are often low. Little is known about PC team experiences when delivering OUD treatment and potential factors that influence their capacity to engage patients in treatment. Exploring PC team experiences may inform needed supports that can optimize OUD care delivery and improve outcomes for patients with OUD. OBJECTIVE: We explored multidisciplinary PC team perspectives on barriers and facilitators to engaging patients in OUD treatment. DESIGN: Qualitative study using in-depth interviews. PARTICIPANTS: Primary care clinical teams. APPROACH: We conducted semi-structured interviews (n = 35) with PC team members involved in OUD care delivery, recruited using a combination of criterion and maximal variation sampling. Data collection and analysis were informed by existing theoretical literature about patient engagement, specifically that patient engagement is influenced by factors across individual (patient, provider), interpersonal (patient-provider), and health system domains. Interviews were professionally transcribed and doubled-coded using a coding schema based on the interview guide while allowing for emergent codes. Coding was iteratively reviewed using a constant comparison approach to identify themes and verified with participants and the full study team. KEY RESULTS: Analysis identified five themes that impact PC team ability to engage patients effectively, including limited patient contact (e.g., phone, text) in between visits, varying levels of provider confidence to navigate OUD treatment discussions, structural factors (e.g., schedules, productivity goals) that limited provider time, the role of team-based approaches in lessening discouragement and feelings of burnout, and lack of shared organizational vision for reducing harms from OUD. CONCLUSIONS: While the capacity of PC teams to engage patients in OUD care is influenced across multiple levels, some of the most promising opportunities may involve addressing system-level factors that limit PC team time and collaboration and promoting organizational alignment on goals for OUD treatment.

Patient and Provider Perspectives on Processes of Engagement in Outpatient Treatment for Opioid Use Disorder: A Scoping Review.

Effective treatment for opioid use disorder (OUD) is available, but patient engagement is central to achieving care outcomes. We conducted a scoping review to describe patient and provider-reported strategies that may contribute to patient engagement in outpatient OUD care delivery. We searched PubMed and Scopus for articles reporting patient and/or provider experiences with outpatient OUD care delivery. Analysis included: (1) describing specific engagement strategies, (2) mapping strategies to patient-centered care domains, and (3) identifying themes that characterize the relationship between engagement and patient-centered care. Of 3,222 articles screened, 30 articles met inclusion criteria. Analysis identified 14 actionable strategies that facilitate patient engagement and map to all patient-centered care domains. Seven themes emerged that characterize interpersonal approaches to OUD care engagement. Interpersonal interactions between patients and providers play a pivotal role in encouraging engagement throughout OUD treatment. Future research is needed to further evaluate promising engagement strategies.

Which learning experiences support an interprofessional identity? A scoping review.

In recent years, health professions researchers have suggested that a dual identity that includes both a professional and interprofessional identity is essential to interprofessionality. This scoping review sought to describe the learning experiences that may support the development of an interprofessional identity, providing direction for future research. A scoping review was conducted to identify papers published between 2000 and 2020 that provided empiric evidence to support the impact of planned or spontaneous learning experiences involving two or more healthcare professions that fostered the development of an "interprofessional identity," or a sense of belonging to an interprofessional community. Twelve papers were identified for inclusion. Articles varied regarding both the professional groups studied and the developmental levels of their participants. A wide variety of learning experiences were described in the identified studies, including designed activities and programs, as well as those occurring spontaneously in authentic clinical environments. Examples of longitudinal and integrated programs were also identified. The construct of an interprofessional identity and its potential impact on interprofessional practice has yet to be sufficiently studied. The results of this scoping review suggest that a variety of experiences that occur throughout the professional development trajectory may foster an interprofessional identity. Longitudinal, integrated interprofessional learning programs may result in a more long-lasting impact on interprofessional identity and these types of programs should be the focus of future research.

"Heroin Mothers," "Methadone Babies," and the Medical Controversy over Methadone Maintenance in the Early 1970s.

This article situates the emergence of sensationalized news reports of "infant addicts" and the concurrently evolving study of neonatal drug withdrawal within the context of the expansion of methadone maintenance treatment (MMT) in the United States. It details how, in the early 1970s, concerns about pregnant narcotic addicts and their infants became part of the politically charged debate over methadone maintenance. The popular press amplified the apprehensions of a vocal group of pediatricians who saw in infants' withdrawal an indication of methadone's inherent harmfulness and potential toxicity. Increased access to MMT and its presumed normalizing effects on reproductive functions augmented these concerns. The ensuing controversy led clinical researchers to define, measure, and systematically study "neonatal abstinence syndrome," whereas the emerging media trope of the infant drug addict effectively undermined the claims made by MMT's proponents about the drug's therapeutic utility.

Exploring residents' perceptions of PA and NP roles and barriers to collaboration.

OBJECTIVE: Developing competencies for interprofessional collaboration, including understanding other professionals' roles on interprofessional teams, is an essential component of medical education. This study explored resident physicians' perceptions of the clinical roles and responsibilities of physician assistants (PAs) and NPs in the clinical learning environment. METHODS: Using a constructivist grounded theory approach, semistructured interviews were conducted with 15 residents in one academic setting. Transcripts were analyzed using an iterative approach to inductive coding. RESULTS: Participants typically perceived PAs' and NPs' roles as being "like a resident," less commonly as independent clinicians, and rarely as collaborators. Barriers to understanding PA and NP roles and perceiving them as collaborators included the lack of preparatory instruction about PAs and NPs, the hierarchical structure of medical education, and inadequate role modeling of interprofessional collaboration. CONCLUSIONS: This study suggests that barriers in the clinical learning environment and the structure of medical education itself may impede residents' learning about PAs and NPs and how to collaborate with them.

Duration of SARS-CoV-2 RNA detection in COVID-19 patients in home isolation, Rhineland-Palatinate, Germany, 2020 - an interval-censored survival analysis.

We analysed consecutive RT-qPCR results of 537 symptomatic coronavirus disease (COVID-19) patients in home quarantine. Respectively 2, 3, and 4 weeks after symptom onset, 50%, 25% and 10% of patients had detectable RNA from severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). In patients with mild COVID-19, RNA detection is likely to outlast currently known periods of infectiousness by far and fixed time periods seem more appropriate in determining the length of home isolation than laboratory-based approaches.

[How to do Things with Metaphors: Reflections on the Role of Metaphors and Metaphor Theory for the History of Science Using the Example of Shock Metaphors in Medicine]. / Was tun mit Metaphern? Überlegungen zur Bedeutung von Metaphern und Metapherntheorie für die Wissenschaftsgeschichte am Beispiel medizinischer Schockmetaphorik.

In recent decades, metaphors have attracted a great deal of interest within the history, philosophy, and sociology of science. The article takes the growing interest in epistemic metaphors as the starting point of a discussion of two conflicting motives prevalent in theories of metaphor and metaphoricity: On the one hand, metaphors are associated with the indeterminacy of scientific discovery and the emergence of new epistemic objects; and on the other hand, metaphors are said to provide a filter of possible meanings and vantage-points. It is argued that an approach, which aims to do justice to both tendencies, cannot exclusively rely on linguistic models but must expand its scope of inquiry to include the practical trajectories of a metaphor's usage as well as the problematizations to which they respond, since both engender metaphorical meaning, albeit at the cost of semantic precision. The exemplary case discussed in the article, the psychologization of nervous shock in nineteenth century medical discourse, demonstrates that the incremental process of shock's shifting semantics would be inadequately characterized as a metaphorical transfer. Instead, it is shown how the actualization of earlier meanings, in particular of shock as a state of altered consciousness, in novel professional and cultural contexts acted as a catalyst for the psychologization of shock and related nascent concepts such as psychic trauma. As a possible, and methodologically fruitful way of overcoming the one-sidedness of linguistic notions of metaphor, a combination of Jìrgen Link's concept of inter-discourse with a philosophical metaphorology (Blumenberg) is discussed in the final section of the paper.

Primary care team perspectives on approaches to engaging patients in treatment for opioid use disorder.

INTRODUCTION: Engagement is a critical component of successful treatment for opioid use disorder (OUD). However, rates of patient engagement in OUD treatment, especially in outpatient settings, are variable and often low. Little is known about the specific strategies members of primary care teams use to initiate and encourage ongoing participation in OUD treatment. In a national cohort of primary care clinics in the U.S., we explored the perspectives of primary care team members on the meaning of and approaches to OUD treatment engagement. METHODS: We conducted semi-structured interviews with 35 providers from multidisciplinary primary care teams in an existing national cohort of 13 clinics across seven states. Teams were delivering OUD treatment via the Collaborative Care Model, a model that combines primary care providers (PCP), behavioral health care managers (BHCM) and consulting psychiatric providers (CPP) in a structured way to provide patient-centered, team-based, and measurement-based care. Interview participants included 14 PCPs, 13 BHCMs, and 8 CPPs. Interviews asked open-ended questions about provider experiences and practices that aided or hindered patient engagement in OUD treatment. Interview transcripts were double-coded by trained qualitative researchers and analyzed using a combination of deductive and inductive approaches to identify themes. RESULTS: Two themes emerged that describe provider perspectives on the meaning of engagement: 1) qualifying engagement by the volume of contact with patients, and 2) the need for more multidimensional measures of engagement. Six themes emerged that characterized provider engagement practices: 1) creating an environment of disclosure, 2) normalizing OUD treatment, 3) offering gentle but persistent outreach, 4) providing human connection and encouragement, 5) tailoring treatment to patient needs, and 6) avoiding stigmatizing responses. Analysis identified multiple replicable strategies that providers used to support these engagement practices. CONCLUSIONS: Providers consistently apply a range of strategies when trying to engage patients in OUD treatment. Specific engagement strategies used embodied compassion and pragmatism, hallmarks of patient-centered care. Further research is needed to understand the impact of scaling engagement approaches across all care settings.

The "therapeutic relationship:" emergence, eclipse, and transformations of a social technology.

This essay situates the history of "the relationship" as a therapeutic technology within the broader context of changing social relations in the twentieth-century United States. More specifically, it outlines the emergence and subsequent diffusion of practices that aim to cultivate a social bond between therapist and patient that may serve as a psychotherapeutic tool. The article highlights the transformations of this technology as its institutional and epistemic foundations became challenged. Initially conceived as an "artificial" social relation designed to help with "personal adjustment," the therapeutic relationship was soon also deployed by non-experts and became a model for more healthful social relations. More recently, it has been fashioned as collaborative and combined with a range of other methods.

Implementing complex interventions to mitigate burnout among qualified healthcare professionals: a realist review protocol.

INTRODUCTION: Reported burnout rates among qualified healthcare professionals (QHP) are alarming. Systematic reviews evaluating the effectiveness of burnout interventions for QHP exist; however, findings are contradictory. In addition, to date, there is no indication of how these interventions work and what specific intervention elements mitigate burnout. This review aims to explain how burnout interventions work and the contextual factors that mediate the intended outcomes. Our ultimate goal is to formulate actionable recommendations to guide the implementation of complex burnout interventions for QHP working in the hospital setting. METHODS AND ANALYSIS: In light of the heterogeneity and complexity of the interventions designed to address burnout, we will conduct a realist review using Pawson's five iterative stages to explore and explain how burnout interventions work, for whom, and in what circumstances. We will search PubMed, CINAHL, Scopus, PsycINFO and Web of Science from inception to December 2022. Grey literature sources will also be considered. The results will be reported according to the Realist and Meta-Narrative Evidence Syntheses-Evolving Standards quality and publication standards ETHICS AND DISSEMINATION: Findings will be disseminated in a peer-reviewed journal, conference presentations and through the development of infographics and relevant educational material to be shared with stakeholders and key institutions. This study is a secondary data analysis; thus, a formal ethics review is not applicable. PROSPERO REGISTRATION NUMBER: CRD42021293154.

Exploring Professional Anticipatory Socialization: Who Are the Messengers Influencing Future Physicians' Perceptions of Advanced Practice Providers?

PURPOSE: Evidence exists that physicians in training and practice often do not understand advanced practice providers (APPs) and their roles in professional practice. This study asked the question: What are the messages and messengers during the anticipatory professional socialization period that potentially influence how residents perceive APPs? METHODS: Semistructured interviews were conducted with 15 residents in one academic setting. Transcripts were analyzed using an inductive approach to coding to identify the messages and sources of those messages (messengers) that had influenced how residents perceived APPs. RESULTS: Participants reported limited exposure to APPs before medical school, although most had heard of APPs from family, friends, or advisors or through their own experience in a clinical setting. The messages that participants received were related to how physicians and APPs compare in their training and clinical roles, and how APPs and physicians (and the people who pursue these professions) differ based on their presumed personal attributes. Some messages appeared to support biases against APPs. CONCLUSION: While interprofessional education in medical school aims to prepare physicians to collaborate across professions, attention to anticipatory professional socialization occurring before medical school may also be important to mitigate professional biases that interfere with effective teamwork.

The uses of trauma in experiment: Traumatic stress and the history of experimental neurosis, c. 1925-1975.

The article retraces the shifting conceptualizations of psychological trauma in experimental psychopathological research in the middle decades of the twentieth century in the United States. Among researchers studying so-called experimental neuroses in animal laboratories, trauma was an often-invoked category used to denote the clash of conflicting forces believed to lead to neurotic suffering. Experimental psychologists, however, soon grew skeptical of the traumatogenic model and ultimately came to reject neurosis as a disease entity. Both theoretical differences and practical circumstances, such as the technical challenge of stabilizing neurotic symptoms in rats, led to this demise. Yet, despite their reservations, experimental psychologists continued to employ traumatic stimuli to produce psychopathological syndromes. In the 1960s, a new understanding of trauma evolved, which emphasized the loss of control experienced by traumatized animal subjects. These shifting ideas about trauma, I argue, reflect both varying experimental cultures, epistemic norms as well as changing societal concerns.

The "therapeutic relationship": emergence, eclipse, and transformations of a social technology / A "relação terapêutica": surgimento, obscurecimento e transformações de uma tecnologia social

Abstract This essay situates the history of "the relationship" as a therapeutic technology within the broader context of changing social relations in the twentieth-century United States. More specifically, it outlines the emergence and subsequent diffusion of practices that aim to cultivate a social bond between therapist and patient that may serve as a psychotherapeutic tool. The article highlights the transformations of this technology as its institutional and epistemic foundations became challenged. Initially conceived as an "artificial" social relation designed to help with "personal adjustment," the therapeutic relationship was soon also deployed by non-experts and became a model for more healthful social relations. More recently, it has been fashioned as collaborative and combined with a range of other methods.

Resumo O artigo identifica a história da "relação terapêutica" como uma tecnologia inserida em um contexto mais amplo de relações sociais marcadas por mudanças nos EUA do século XX. Mais especificamente, sintetiza o surgimento e a subsequente difusão de práticas voltadas para o cultivo do vínculo social entre terapeuta e paciente que podem servir como ferramenta psicoterapêutica. O artigo destaca as transformações dessa tecnologia à medida que passam a ser contestados os alicerces institucionais e epistemológicos da psicoterapia. Em princípio concebida como uma relação social "artificial", criada para colaborar com o "ajuste pessoal", a relação terapêutica não tardou a ser aplicada também por não especialistas e se tornou um modelo para relações sociais mais saudáveis. Nos últimos tempos, passou a figurar como prática colaborativa e a ser associada a uma série de outros métodos.

In vitro isolation and cell culture of vestibular inner ear melanocytes.

INTRODUCTION: Melanocytes of the membranous labyrinth of the inner ear have been described morphologically in various contexts. Nature and functions of these cells are as yet not completely clear, even though several hypotheses exist regarding the same. The limited knowledge is due in part to a lack of methods regarding in vitro cell culture. The aim of this study was to describe conditions for the successful cell culture of vestibular inner ear melanocytes (VIEM), to compare their growth properties with those of epidermal melanocytes, and to characterize them immunohistochemically. MATERIALS AND METHODS: Membranous labyrinth cells from freshly slaughtered sheep were isolated, and melanocytes and fibroblasts subsequently cultured. In addition, melanocytes from the skin of the same sheep were cultured. Antibodies specific to tyrosinase, tyrosinase-related protein 1 (TRP-1/Mel-5), and melanoma-specific antigen A (Melan A) were used to analyze the cultured cells. RESULTS: The proliferation of VIEM was retarded in comparison to epidermal melanocytes. After 14 days, VIEM began to proliferate for the first time, whereas epidermal melanocytes proliferated already after 7 days. In contrast to epidermal melanocytes, the culturing process of VIEM seemed to be dependent on the presence of fibroblasts, and VIEM often accumulated in the vicinity of fibroblasts forming three-dimensional clusters. Moreover, VIEM showed a higher ratio of highly pigmented cells with a round cell shape and small dendrites in comparison to epidermal melanocytes. Immunohistochemical techniques proved the VIEM to be positive for Melan A, TRP-1 and, in the majority of cases, also for tyrosinase. CONCLUSION: We successfully cultured melanocytes of the inner ear vestibular labyrinth for the first time and demonstrated melanocytic characteristics of these cells. This accomplishment will provide the opportunity to investigate VIEM in more detail in future experiments.