A Qualitative Study on the Barriers to Learning in a Primary Care-Behavioral Health Integration Program in an Academic Hospital: the Family Medicine Perspective.

OBJECTIVE: Integrating behavioral health services into the primary care setting is a recognized approach to improving timely access and building capacity for primary care providers. The aim of this study was to examine barriers to family medicine resident learning in a co-located primary care-behavioral health integration program with psychiatrists in an academic hospital. METHODS: The authors used a descriptive qualitative study design to collect data on participants' learning experiences from focus groups and semi-structured interviews with 5 family medicine residents, 3 psychiatry residents, 5 family physicians, 3 psychiatrists, 2 office coordinators, and 2 educational coordinators. Thematic analysis of transcripts was performed. RESULTS: Three themes were identified with respect to barriers to learning in the program from the family medicine perspective. Organizational barriers encompassed lack of clear vision, goals, roles, and responsibilities. Administrative barriers involved complex appointment bookings and scheduling. Communication and engagement barriers included insufficient communication between team members and lack of patient engagement in the program. CONCLUSIONS: The study findings highlight the importance of several factors for the successful implementation of a co-located academic primary care-behavioral health integrated model. This includes the formalization of program structure that encompasses shared vision, goals, roles, and responsibilities; coordinated processes for appointment bookings; team communication and patient engagement; and diverse educational and longitudinal care opportunities. With the growing number of integrated care programs, these results provide guidance for health care leaders involved in the design and management of primary care-behavioral health integration programs.

Gamma Knife patients' experience: lessons learned from a qualitative study.

BACKGROUND: Gamma Knife stereotactic radiosurgery (GKSRS) is an outpatient radiation therapy procedure in which a highly focused dose of radiation is delivered in a single fraction. It is used to treat a variety of well-demarcated intracranial lesions, including brain tumors. This study aims to explore patients' perspectives of the GKSRS process and the various stages involved. METHODS: Qualitative research methodology was used. Three semi-structured, open-ended interviews were conducted with 29 participants, who were ambulatory adult patients who underwent GKSRS between August 2007 and August 2008. RESULTS: Seven overarching themes emerged from the data: (1) patients were satisfied with the overall treatment experience; (2) the majority of patients had a good knowledge of GKSRS; (3) the quality and amount of patient education were adequate; (4) process expectations were largely met; (5) most patients prioritized outcome over process; (6) most patients had a realistic expectation of outcomes; and (7) pain and anxiety were important issues. CONCLUSIONS: The study results reflected positively on the GKSRS process, but there were some areas identified that require improvement, specifically the referral-consultation process and the management of procedural pain. These insights on the patients' perspectives can lead to better delivery of care and ultimately, improved health outcomes.

Patients' perception of the informed consent process for neurooncology clinical trials.

The informed consent process is a cornerstone of modern medical research. This study was conducted to explore the process in the context of neurooncology clinical trials. Qualitative methodology and analysis were used on open-ended, face-to-face interviews conducted with 21 patients. Six comprehensive themes emerged: (1) general understanding of the objectives and purpose of clinical trials was good, (2) recall of risks was low, (3) patients did not believe that their care would be compromised by forgoing the clinical trial, (4) patients felt participation was voluntary and free of coercion, (5) patients would not have withdrawn from the trial in the event of complications, and (6) patients were satisfied with the informed consent process. Informed consent is a dynamic process; when appropriately executed, it can be a powerful safeguard protecting patient autonomy. If sufficient time is allowed to deliberate participation and ample opportunity is provided for information sharing and disclosure, researchers can be confident that participants are knowledgeable about the trial and aware of their rights.

Neurosurgery patients' feelings about the role of residents in their care: a qualitative case study.

OBJECT: The role of residents in surgery is not clearly explained to patients. The authors undertook a study to explore the level of knowledge and anxiety in patients regarding residents' involvement in their surgery. METHODS: Qualitative case study methodology was used. Thirty face-to-face interviews of patients were conducted prior to elective neurosurgery. Interviews were transcribed and subjected to modified thematic analysis by 4 reviewers. The majority of patients had a postsecondary education, and there was substantial religious and ethnic diversity among them. Most underwent craniotomy for brain tumor. RESULTS: Six prominent themes arose from the analysis: 1) the level of knowledge about residents is low; 2) the level of anxiety about residents is low; 3) it is desirable for patients to meet the residents before surgery; 4) residents' educational needs are understood and supported; 5) anxiety was not increased by the interview; and 6) patients trust in the medical system. CONCLUSIONS: Patients appear to be unaware of the role of residents in their surgical care but do not seem anxious about it. Trust in the medical system helps patients proceed with risky operations. Surgeons could be more forthcoming with patients about the role of residents.

Complications in 622 cases of frame-based stereotactic biopsy, a decreasing procedure.

BACKGROUND: Frame-based stereotactic brain biopsy has played an important role in the management of patients with suspected neoplastic intracranial lesions over the last three decades. We reviewed the surgical experience of one surgeon to determine the nature and frequency of complications associated with this procedure. METHODS: Records were reviewed for 858 patients undergoing frame-based stereotactic procedures from January 1986 to May 2006. Data on each case were prospectively collected by the senior author. Procedures for Ommaya reservoir placement, brachytherapy, stereotactic craniotomy flap localization, shunt placement, or treatment of previously-diagnosed intracranial cystic lesions were excluded, leaving 614 patients in whom a total of 622 procedures were performed for purely diagnostic purposes. Complication rates and their association with clinical variables were sought. RESULTS: Morbidity and mortality rates were 6.9% (43/622) and 1.3% (8/622), respectively. The risk of symptomatic hemorrhage (intracerebral hemorrhage [ICH], subarachnoid hemorrhage [SAH], intraventricular hemorrhage [IVH]) was 4.8%. The risks of transient or permanent neurological deficits were 2.9% (18/622) and 1.5% (9/622), respectively. Biopsy of deep-seated lesions was associated with increased overall complication rate, while biopsy of Glioblastoma Multiforme (GBM) was associated with perioperative mortality. CONCLUSIONS: Overall, complication rates were comparable with those in previous reports. The subgroup of patients with deep-seated lesions or a histologic diagnosis of GBM may possess an elevated risk of overall complications or mortality, respectively, compared to other patients undergoing frame-based stereotactic brain biopsy.

Moral angst for surgical residents: a qualitative study.

BACKGROUND: The ethical dilemmas that residents experience throughout their training have not been explored qualitatively from surgical residents' perspectives. METHODS: Grounded theory methodology was used. All University of Toronto surgical, otolaryngology, and obstetrics and gynecology residents were invited to participate. Twenty-eight face-to-face interviews were conducted. Interviews were transcribed and analyzed by 3 reviewers. RESULTS: Five encompassing themes emerged: (1) residents prefer operating with another resident while the staff watches; (2) residents felt that patients were rarely well informed about their role; (3) residents develop good relationships with patients; (4) residents felt ethically obliged to disclose intraoperative errors; and (5) residents experience ethical distress in certain teaching circumstances. CONCLUSIONS: Residents encounter ethical dilemmas leading to moral angst during their surgical training and need to feel safe to discuss these openly. Staff and residents should work together to establish optimal communication and teaching situations.

What surgeons tell their patients about the intraoperative role of residents: a qualitative study.

BACKGROUND: The issue of residents operating and disclosure to patients about this have not been explored from staff surgeons' perspectives. METHODS: A preliminary survey was sent to all active surgeons at the University of Toronto. A qualitative interview study followed. Thirty-nine face-to-face interviews were conducted with surgeons. Interviews were transcribed and subjected to thematic analysis by 3 reviewers. RESULTS: Four encompassing themes emerged: (1) surgeons are comfortable allowing residents to operate independently with graded responsibility, (2) surgeons do not voluntarily inform patients about the involvement of residents in their operation, (3) residents are seen as important assets in a teaching hospital and are beneficial to patient care, and (4) surgeons recognize the trust their patients place in them. CONCLUSIONS: Surgeons recognize their patient care and teaching responsibilities and the trust that is placed in them. Patients might benefit from a discussion with their surgeon about the role of residents in their surgery.

Increased anxiety-like behavior and enhanced synaptic efficacy in the amygdala of GluR5 knockout mice.

GABAergic transmission in the amygdala modulates the expression of anxiety. Understanding the interplay between GABAergic transmission and excitatory circuits in the amygdala is, therefore, critical for understanding the neurobiological basis of anxiety. Here, we used a multi-disciplinary approach to demonstrate that GluR5-containing kainate receptors regulate local inhibitory circuits, modulate the excitatory transmission from the basolateral amygdala to the central amygdala, and control behavioral anxiety. Genetic deletion of GluR5 or local injection of a GluR5 antagonist into the basolateral amygdala increases anxiety-like behavior. Activation of GluR5 selectively depolarized inhibitory neurons, thereby increasing GABA release and contributing to tonic GABA current in the basolateral amygdala. The enhanced GABAergic transmission leads to reduced excitatory inputs in the central amygdala. Our results suggest that GluR5 is a key regulator of inhibitory circuits in the amygdala and highlight the potential use of GluR5-specific drugs in the treatment of pathological anxiety.