The Pretravel Consultation.

Key components of the pretravel consultation include intake questions regarding the traveler's anticipated itinerary and medical history; immunizations; malaria prophylaxis; and personal protection measures against arthropod bites, traveler's diarrhea, and injury. Most vaccinations that are appropriate for international travelers are included in the routine domestic immunization schedule; only a few travel-specific vaccines must also be discussed. The most common vaccine-preventable illnesses in international travelers are influenza and hepatitis A. Malaria prophylaxis should be offered to travelers to endemic regions. Personal protection measures, such as applying an effective insect repellent to exposed skin and permethrin to clothing and using a permethrin-impregnated bed net, should be advised for travelers to the tropics. Clinicians should offer an antibiotic prescription that travelers can take with them in case of traveler's diarrhea. Additional topics to address during the pretravel consultation include the risk of injury from motor vehicle crashes and travel-specific risks such as altitude sickness, safe sex practices, and emergency medical evacuation insurance.

A Curriculum on Care for Complex Patients: Resident Perspectives.

BACKGROUND AND OBJECTIVES: Caring for patients with a challenging mix of medical, psychological, and social problems may easily overwhelm residents. We developed a month-long "Care for Complex Patients" curriculum for second-year residents to improve their ability to care for this group of patients by increasing their understanding of why the care is complex and by building communication, teamwork, and resource management skills. METHODS: Surveys and focus groups were used to assess the impact of the curriculum. Quantitative and qualitative methods were used to evaluate responses. RESULTS: Between 2008 and 2010, 24 residents completed our rotation. Eighty-three percent completed the pre-curriculum and post-curriculum surveys. Residents' self-ratings significantly improved in all 11 complex care management skills, and residents reported increased confidence when working with patients whose care was complex. Residents were surprised to learn about all the community resources and began using these resources when providing care for these patients. Despite rating themselves improved, a large number of residents still rated themselves as not competent in many of the skills. CONCLUSIONS: A curriculum for residents focused on education in 11 key skill areas in the care of complex patients led to increased self-confidence and willingness to provide complex care. However, 1 month of training is an insufficient amount of time to help most learners achieve self-assessed ratings of capable and competent in using these key skills when caring for complex patients.

Using the diffusion of innovations theory to assess socio-technical factors in planning the implementation of an electronic health record alert across multiple primary care clinics.

BACKGROUND: Adverse drug events (ADEs) are a leading cause of death in the United States. Patients with stage 3 and 4 chronic kidney disease (CKD) are at particular risk because many medications are cleared by the kidneys. Alerts in the electronic health record (EHR) about drug appropriateness and dosing at the time of prescription have been shown to reduce ADEs for patients with stage 3 and 4 CKD in inpatient settings, but more research is needed about the implementation and effectiveness of such alerts in outpatient settings. OBJECTIVE: To explore factors that might inform the implementation of an electronic drug-disease alert for patients with CKD in primary care clinics, using Rogers' diffusion of innovations theory as an analytic framework. METHODS: Interviews were conducted with key informants in four diverse clinics using various EHR systems. Interviews were audio recorded and transcribed. results Although all clinics had a current method for calculating glomerular filtration rate (GFR), clinics were heterogeneous with regard to current electronic decision support practices, quality improvement resources, and organizational culture and structure. CONCLUSION: Understanding variation in organizational culture and infrastructure across primary care clinics is important in planning implementation of an intervention to reduce ADEs among patients with CKD.

Seasonal affective disorder, grief reaction, and adjustment disorder.

Seasonal affective disorder is a subtype of other affective disorders. The most studied treatment is light therapy, although second-generation antidepressants are also an option. Grief reactions are normal for patients experiencing loss, and primary care providers (PCPs) should be aware of both the expected course of grief and the more severe symptoms that indicate complex grief. Adjustment disorder is a time-limited abnormal response to a stressor. PCPs can manage patients with adjustment disorder by arranging counseling, screening for suicidality, assessing for substance abuse, and ruling out other psychiatric diagnoses. At present there are no reliable data to suggest medication management.

Primary care residency choice and participation in an extracurricular longitudinal medical school program to promote practice with medically underserved populations.

PURPOSE: In 2006, the University of Washington School of Medicine (UWSOM) launched the Underserved Pathway (UP), an extracurricular longitudinal experience supporting student interest in caring for underserved populations. This study examined the association between UP participation and residency choice. METHOD: The study population was 663 UWSOM graduates who matched to a residency from 2008 to 2011; 69 were UP participants. Outcomes included matching to primary care residencies (family medicine, internal medicine, pediatrics, or medicine-pediatrics). The authors calculated graduate rates and odds of UP participants versus nonparticipants matching to primary care residencies overall and to residencies in individual primary care specialties. This analysis included all graduates and 513 graduates who had dual interest in primary care and underserved care at matriculation. Of 336 graduates matching to primary care, the authors calculated rates of entering the individual specialties with respect to UP participation. RESULTS: UP participants matched at significantly higher rates than nonparticipants to primary care (72.5% versus 48.1%, adjusted odds ratio [OR] 2.2) and family medicine residencies (33.3% versus 15.0%, adjusted OR 2.9). Of graduates with dual matriculation interest in primary care and underserved care, 73.4% of participants versus 53.5% of nonparticipants matched to primary care (adjusted OR 1.9), and 31.2% of participants versus 18.0% of nonparticipants matched to family medicine (adjusted OR 2.1). Of primary care matched graduates, 46.0% of participants versus 31.1% of nonparticipants entered family medicine. CONCLUSIONS: Supporting student interest in underserved careers is associated with higher rates of graduates entering primary care residencies, specifically family medicine.

Nursing home practice among recent family medicine residency graduates.

BACKGROUND AND OBJECTIVES: As the US population ages, nursing homes need more care providers. However, family physicians are narrowing their scope of practice. Characterizing family medicine practice patterns is essential for educational and workforce planning related to nursing home practice. METHODS: We analyzed a survey of 1,506 family medicine residency graduates from the Pacific Northwest between 1997 and 2009, examining whether they practiced in nursing homes and felt prepared for this practice. RESULTS: Nursing home practice among recent family medicine residency graduates declined from 61.4% in 1997 to 25.9% in 2009, despite no change in perceived level of preparedness for this practice. CONCLUSIONS: The Pacific Northwest has experienced a significant decline in nursing home practice among recent family medicine residency graduates. Further research is needed to elucidate the reasons for this workforce change and to plan for the increased need in nursing home providers.

Clinical inquiries. Which regimen treats vitamin D deficiency most effectively?

Several vitamin D replacement regimens are effective. Cumulative dosing may be more important than frequency of dosing (strength of recommendation [SOR]: C, inconsistent results from randomized controlled trials [RCTs] of disease-oriented outcomes).Vitamin D3 (cholecalciferol) may increase serum 25-hydroxy vitamin D (25[OH]D) concentrations more effectively than vitamin D2 (ergocalciferol) (SOR: C, a single RCT of disease-oriented outcomes).