Patterns of relating between physicians and medical assistants in small family medicine offices.

PURPOSE: The clinician-colleague relationship is a cornerstone of relationship-centered care (RCC); in small family medicine offices, the clinician-medical assistant (MA) relationship is especially important. We sought to better understand the relationship between MA roles and the clinician-MA relationship within the RCC framework. METHODS: We conducted an ethnographic study of 5 small family medicine offices (having <5 clinicians) in the Cincinnati Area Research and Improvement Group (CARInG) Network using interviews, surveys, and observations. We interviewed 19 MAs and supervisors and 11 clinicians (9 family physicians and 2 nurse practitioners) and observed 15 MAs in practice. Qualitative analysis used the editing style. RESULTS: MAs' roles in small family medicine offices were determined by MA career motivations and clinician-MA relationships. MA career motivations comprised interest in health care, easy training/workload, and customer service orientation. Clinician-MA relationships were influenced by how MAs and clinicians respond to their perceptions of MA clinical competence (illustrated predominantly by comparing MAs with nurses) and organizational structure. We propose a model, trust and verify, to describe the structure of the clinician-MA relationship. This model is informed by clinicians' roles in hiring and managing MAs and the social familiarity of MAs and clinicians. Within the RCC framework, these findings can be seen as previously undefined constraints and freedoms in what is known as the Complex Responsive Process of Relating between clinicians and MAs. CONCLUSIONS: Improved understanding of clinician-MA relationships will allow a better appreciation of how clinicians and MAs function in family medicine teams. Our findings may assist small offices undergoing practice transformation and guide future research to improve the education, training, and use of MAs in the family medicine setting.

Early Identification of Family Physicians Using Qualitative Admissions Data.

BACKGROUND AND OBJECTIVES: The medical community has been concerned about the shortage of family physicians for decades. Identification of likely family medicine (FM) student matches early in medical school is an efficient recruitment tool. The objective of this study was to analyze qualitative data from medical school applications to establish themes that differentiate future family physicians from their non-FM counterparts. METHODS: We conducted a qualitative analysis of admissions essays from two groups of 2010-2019 medical school graduates: a study group of students who matched to FM (n=135) and a random sample comparison group of non-FM matches (n=136). We utilized a natural language modeling platform to recognize semantic patterns in the data. This platform generated keywords for each sample, which then guided a more traditional content analysis of the qualitative data for themes. RESULTS: The two groups shared two themes: emotions and science/academics, but with some differences in thematic emphasis. The study group tended toward more positive emotions and the comparison group tended to utilize more specialized scientific language. The study group exhibited two unique themes: special interests in service and community/people. A secondary theme of religious faith was evident in the FM study group. The comparison group exhibited two unique themes: lab/clinical research and career aspirations. CONCLUSIONS: Aided by machine learning, a novel analytical approach revealed key differences between FM and non-FM student application materials. Findings suggest qualitative application data may contain identifiable thematic differences when comparing students who eventually match into FM residency programs to those who match into other specialties. Assessing student potential for FM could help guide recruitment and mentorship activities.

Opioid dose and pain effects of an online pain self-management program to augment usual care in adults with chronic pain: a multisite randomized clinical trial.

ABSTRACT: Readily accessible nonpharmacological interventions that can assist in opioid dose reduction while managing pain is a priority for adults receiving long-term opioid therapy (LOT). Few large-scale evaluations of online pain self-management programs exist that capture effects on reducing morphine equivalent dose (MED) simultaneously with pain outcomes. An open-label, intent-to-treat, randomized clinical trial recruited adults (n = 402) with mixed chronic pain conditions from primary care and pain clinics of 2 U.S. academic healthcare systems. All participants received LOT-prescriber-provided treatment of MED ≥ 20 mg while receiving either E-health (a 4-month subscription to the online Goalistics Chronic Pain Management Program), or treatment as usual (TAU). Among 402 participants (279 women [69.4%]; mean [SD] age, 56.7 [11.0] years), 200 were randomized to E-health and 202 to TAU. Of 196 E-heath participants, 105 (53.6%) achieved a ≥15% reduction in daily MED compared with 85 (42.3%) of 201 TAU participants (odds ratio, 1.6 [95% CI, 1.1-2.3]; P = 0.02); number-needed-to-treat was 8.9 (95% CI, 4.8, 66.0). Of 166 E-health participants, 24 (14.5%) achieved a ≥2 point decrease in pain intensity vs 13 (6.8%) of 192 TAU participants (odds ratio, 2.4 [95% CI, 1.2-4.9]; P = 0.02). Benefits were also observed in pain knowledge, pain self-efficacy, and pain coping. The findings suggest that for adults on LOT for chronic pain, use of E-health, compared with TAU, significantly increased participants' likelihood of clinically meaningful decreases in MED and pain. This low-burden online intervention could assist adults on LOT in reducing daily opioid use while self-managing pain symptom burdens.

Developing Innovative Virtual Reality Simulations to Increase Health Care Providers' Understanding of Social Determinants of Health.

INTRODUCTION: Health care providers (HCPs) who work primarily with Medicaid patients must be competent in identifying and addressing social determinants of health (SDH). A curricular gap exists between promoting an understanding of SDH and teaching HCPs how to recognize and increase empathy to manage them. The project aim was to develop two virtual reality simulations (VRSs) as innovative methods to teach HCPs to identify and manage SDH. A secondary aim was to decrease unconscious bias and increase empathy by experiencing SDH from their patients' perspective. METHODS: Scripts for two VRSs were created by two HCP educators and clinicians. Scripts were evaluated by experts using an index of content validity (CVI). An advisory panel critiqued the scripts for appropriateness for VRSs, adequacy of evidence-based practice, and use of VRS equipment and software. The panel participated in a focus group and completed a final evaluation. The VRSs then were pilot tested with five HCPs who assessed content and utility and participated in interviews. This led to iterative improvements. Qualitative data were analyzed using a content analysis approach. RESULTS: The VRS scripts demonstrated adequate content-related validity evidence with CVI scores of 0.81 and 0.75. The expert panel found the VRS easy to use, useful as an educational tool, while promoting empathy for patients. Overall, participants were satisfied with using the VRS as an educational experience. DISCUSSION: Through VRS technology, this project addresses a curricular gap in HCP training on SDH. VRS can be a useful tool to increase HCPs' understanding of SDH and, potentially, their empathy for patients.

Forming Cardi-OH: A Statewide Collaborative to Improve Cardiovascular Health in Ohio.

Background Cardiovascular risk factor control is challenging, especially in disadvantaged populations. However, few statewide efforts exist to tackle this challenge. Therefore, our objective is to describe the formation of a unique statewide cardiovascular health collaborative so others may learn from this approach. Methodology With funding from the Ohio Department of Medicaid's Ohio Medicaid Technical Assistance and Policy Program, we used a collective impact model to link the seven medical schools in Ohio, primary care clinics across the state, the Ohio Department of Medicaid, and Ohio's Medicaid Managed Care Plans in a statewide health improvement collaborative for expanding primary care capacity to improve cardiovascular health in Ohio. Results Initial dissemination activities for primary care teams included a virtual case-based learning series focused on hypertension and social determinants of health, website resources, a monthly newsletter with clinical tips, webinars, and in-person conferences. The collaborative is aligned with a separately funded hypertension quality improvement project for paired implementation. Conclusions The collective impact model is a useful framework for developing a statewide collaborative focused on the dissemination and implementation of evidence-based best practices for cardiovascular health improvement and disparity reduction. Statewide collaboratives bringing payers, clinicians, and academic partners together have the potential to substantially impact cardiovascular health.

Impact of immersive virtual reality simulations for changing knowledge, attitudes, and behaviors.

BACKGROUND: Virtual reality has promise as a training method within the affective domain, but investigation is still needed for intention to change behaviors based on social determinants of health. OBJECTIVE: The objective of this study was to describe the self-reported changes in knowledge and/or attitudes and planned behavior changes by healthcare workers for their future care of persons with challenges to their social determinants of health following completion of a first-person virtual reality experience. DESIGN: A descriptive qualitative design was used. SETTINGS: This study was conducted in clinics and private practice settings in Ohio (United States). PARTICIPANTS: This study was conducted with 206 healthcare workers. METHODS: Participants completed a virtual reality simulation followed by qualitative, open-ended questions about changes to their knowledge, attitudes, and behaviors. Responses were analyzed using a content analysis method. RESULTS: Four overarching themes were derived from the qualitative data: (1) Acknowledgement of Social Determinants of Health, (2) An Improved Provider Experience for Patients, (3) Patient as a Person with Complex Needs, and (4) The Learning Experience. CONCLUSION: Findings suggest virtual reality has strong merits for impacting affective domain of learning demonstrated by increased empathy. Virtual reality along with increased empathy also helps improve attitudes and behaviors for the betterment of patients.

Tell Me Your Story: Experiential learning using in-home interviews of healthy older adults.

PURPOSE: To create a curriculum innovation for early preclinical medical students to explore personal perspectives by listening to and learning from the lived experience of community-living older adults. METHOD: Tell Me Your Story (TMYS) paired first-year medical students (MS1s) with community-dwelling older adult partners (OAPs) residing in the independent living portion of a continuing care retirement community (CCRC) for a half-day educational experience. MS1s conducted 1-hour semi-structured interviews with their OAP and then formed small groups with geriatric faculty members to explore experiences and views that were either reinforced or challenged. The authors evaluated the effectiveness of this exercise using post-activity surveys. A mixed-methods analysis of 7 years of data (2013-2019) was conducted. RESULTS: TMYS had 1251 MS1 participants from 2013 to 2019. Students completed 1052 surveys for a response rate of 84%. During the semi-structured interview with OAP, the frequency of issues discussed included relationships (94%), professionalism/art of medicine (91%), healthcare accessibility (83%), death/dying/grieving/loss (72%), nutrition (69%), ethics (64%), and cultural competence (61%). Exactly 97% (n = 1023) responded that the overall organization was "good, very good or excellent." The most prominent themes identified by student responses highlighted person-centered care, patient perspective, life experience/personal stories, and doctor-patient relationship. Fifty-three faculty members completed the post-program survey. Exactly 100% (53/53) rated the quality of this exercise as an educational experience high. CONCLUSION: TMYS was highly valued by students and provided an important experiential learning activity in preclinical medical education. Themes related to person-centered care emerged from the intervention.

Design considerations for a remote randomized multi-site clinical trial evaluating an e-health self-management program for chronic pain patients receiving opioid therapy.

Based on the adverse consequences and inadequate evidence of effectiveness for long-term opioid therapy (LOT), the CDC developed recommendations to decrease the use of LOT and morphine equivalent dose (MED) for patients receiving LOT. However, the majority of these patients report that opioid medication is significantly beneficial for pain management and are hesitant to reduce/decrease its use. Compounding the problem is poor access to non-pharmacologic therapies for many patients due to insurance reimbursement structures and limited pain-service availability. EMPOWER is an intent-to-treat, two-arm, open-label, randomized controlled trial evaluating a web-based self-management chronic pain program (E-Health) that has been found to reduce self-reported MED, while also decreasing pain, in two randomized controlled trials. Approximately 400 chronic pain patients receiving LOT at a daily average prescribed MED ≥ 20 mg at one of two U.S. healthcare systems, located in North Carolina and Ohio, will be randomized in a 1:1 ratio to treatment as usual (TAU) or TAU plus E-Health (E-Health+). TAU consists of LOT from a prescribing clinician. E-Health+ participants are provided with a 4-month E-Health subscription (active treatment phase). All participants will complete web-based self-report measures at baseline, the end of the active treatment phase, and 6-months post-active treatment. Opioid prescription information will be collected from the participants' electronic health record (EHR) from baseline through 6 months post-active treatment. This paper describes design considerations for this unique trial which is conducted completely remotely, with no in-person visits, and utilizes the EHR for participant identification and primary outcome collection.

Using Patient Voice to Personalize the Opioid Epidemic: An Evaluation of 2 Educational Interventions.

Despite rising opioid fatalities, attitudes remain indifferent toward those with opioid use disorder (OUD). Utilizing patient voice may be one way to move providers to action. We included persons with OUD in 2 educational sessions as an important tool of attitude change. Post-session surveys demonstrate increased compassion, deeper understanding of challenges, and positive change in attitude. Inclusion of patient voice was identified as the most useful feature of both educational sessions. Four themes emerged: value of patient voice; change in attitude; barriers to change; and enhanced provider role. Future educational sessions should include the voice of persons living with OUD.

Home Visits Improve Attitudes and Self-Efficacy: A Longitudinal Curriculum for Residents.

OBJECTIVES: To develop a competency-based, adaptable home visit curricula and clinical framework for family medicine (FM) residents, and to examine resident attitudes, self-efficacy, and skills following implementation. DESIGN: Quantitative analysis of resident survey responses and qualitative thematic analysis of written resident reflections. SETTING: Urban FM residency program. PARTICIPANTS: A total of 43 residents and 20 homebound patients in a home-based primary care program. INTERVENTION: A home-based primary care practice and accompanying curriculum for FM residents was developed and implemented to improve learners' confidence and skills to perform home visits. MEASUREMENTS: A 10-question survey with a 4-point Likert scale and open-ended responses. Written resident reflections following home visits. RESULTS: Over 3 years, 43 unique respondents completed a total of 79 surveys evaluating attitudes, skills, and barriers to home care. Some residents may have completed the survey more than once at different stages in their training. Overall, 86% are interested in home visits in future practice, and 78% of survey responses indicated an increased likelihood to perform home visits with more training. Learners with two or more home visits reported significantly improved confidence. Themes across all resident reflections included social determinants of health, patient-physician relationship, patient-home assessment, patient autonomy/independence, and physician wellness/attitudes. Residents described how home visits encourage more holistic care to improve outcomes for patients who are homebound. CONCLUSION: Our home visit curriculum provided new learning, an enhanced desire to practice home-based primary care, improved learner confidence, and could help residents meet the need of a growing population of adults who are homebound. J Am Geriatr Soc 68:852-858, 2020.

I Live Alone but Don't Feel Alone: Social Isolation and Loneliness From the Patient Perspective.

A growing homebound population may be at risk for social isolation and loneliness. Health-related social needs play a contributing role in these conditions. Research shows social isolation and loneliness are drivers of health outcomes. This pilot feasibility study seeks to explore patient-centered insight into perceptions of social isolation and loneliness in a homebound population. Eight participants were recruited from a home-based primary care practice within a family medicine residency program. One 30-minute semi-structured interview was completed in participants' homes. The interview focused on loneliness and social isolation, using the 6-item De Jong Gerveld loneliness scale. Three qualitative analysts open-coded transcriptions independently. Themes were defined using thematic analysis, then triangulated around a consensus of themes. Patients denied loneliness, but most described social isolation, highlighting the potential need for more targeted documentation and intervention in this arena. The most reported barrier affecting social isolation in our study population was mobility issues. The patient perspective is useful to focus the target of approach. Based on this pilot, additional research with a larger sample size across multiple sites is warranted to further explore homebound patients' experience of loneliness and social isolation in order to better guide assessment and interventions for these common problems.

Clinical evaluation of e-Quit worRx: a mobile app to enhance smoking cessation shared decision making in primary care.

BACKGROUND: Smoking is the leading preventable cause of morbidity and mortality in the United States. Primary care providers (PCPs) have a unique opportunity to engage patients to quit smoking, but to be effective, clinicians must be able to personalize evidence-based interventions that are useful and appealing to patients in a time efficient manner. We pilot tested a novel iPad application (app), called e-Quit worRx™, designed to enhance patient-centered shared-decision making (SDM) about smoking cessation, with the primary goal of determining feasibility in primary care offices. METHODS: A total of 73 patients from three offices within a local diverse primary care network were enrolled in a pragmatic single crossover-controlled trial. The decision aid app was incorporated into current smokers' waiting time for their PCP in the exam room, and their PCP reviewed their personal responses and selections to finalize treatment choices. Mixed methods were used in the evaluation and the primary outcomes were app feasibility in primary care and enhanced SDM. RESULTS: Our app was determined to be feasible for use in primary care for both patients and PCPs. It significantly increased time spent discussing smoking cessation with their PCP and the likelihood that a decision was made at the time of the visit. While not significant, mean differences were observed in other study measures including SDM, decisional conflict, quality of patient-provider communication, and stage of change progression at 12 weeks post-trial. CONCLUSIONS: We created a usable and acceptable iPad app-based decision aid for use in primary care offices. The design process presented several challenges including integration into a clinical setting. Despite these challenges, we successfully ran a pragmatic pilot trial in three primary care offices using a technology novel to many of the users.

Meaningful Partnerships: Stages of Development of a Patient and Family Advisory Council at a Family Medicine Residency Clinic.

BACKGROUND: Partnering with patients and families is a crucial step in optimizing health. A patient and family advisory council (PFAC) is a group of patients and family members working together collaboratively with providers and staff to improve health care. OBJECTIVE: This study aimed to describe the creation of a PFAC within a family medicine residency clinic. To understand the successful development of a PFAC, challenges, potential barriers, and positive outcomes of a meaningful partnership will be reported. METHODS: The stages of PFAC development include leadership team formation and initial training, PFAC member recruitment, and meeting launch. Following a description of each stage, outcomes are outlined and lessons learned are discussed. PFAC members completed an open-ended survey and participated in a focus group interview at the completion of the first year. Interviewees provided feedback regarding (1) favorite aspects or experiences, (2) PFAC impact on a family medicine clinic, and (3) future projects to improve care. Common themes will be presented. RESULTS: The composition of the PFAC consisted of 18 advisors, including 8 patient and family advisors, 4 staff advisors, 4 resident physician advisors, and 2 faculty physician advisors. The average meeting attendance was 12 members over 11 meetings in the span of the first year. A total of 13 out of 13 (100%) surveyed participants were satisfied with their experience serving on the PFAC. CONCLUSIONS: PFACs provide a platform for patient engagement and an opportunity to drive home key concepts around collaboration within a residency training program. A framework for the creation of a PFAC, along with lessons learned, can be utilized to advise other residency programs in developing and evaluating meaningful PFACs.

Challenges in the Development of e-Quit worRx: An iPad App for Smoking Cessation Counseling and Shared Decision Making in Primary Care.

BACKGROUND: Smoking is the leading preventable cause of morbidity and mortality in the United States, killing more than 450,000 Americans. Primary care physicians (PCPs) have a unique opportunity to discuss smoking cessation evidence in a way that enhances patient-initiated change and quit attempts. Patients today are better equipped with technology such as mobile devices than ever before. OBJECTIVE: The aim of this study was to evaluate the challenges in developing a tablet-based, evidence-based smoking cessation app to optimize interaction for shared decision making between PCPs and their patients who smoke. METHODS: A group of interprofessional experts developed content and a graphical user interface for the decision aid and reviewed these with several focus groups to determine acceptability and usability in a small population. RESULTS: Using a storyboard methodology and subject matter experts, a mobile app, e-Quit worRx, was developed through an iterative process. This iterative process helped finalize the content and ergonomics of the app and provided valuable feedback from both patients and provider teams. Once the app was made available, other technical and programmatic challenges arose. CONCLUSIONS: Subject matter experts, although generally amenable to one another's disciplines, are often challenged with effective interactions, including language, scope, clinical understanding, technology awareness, and expectations. The successful development of this app and its evaluation in a clinical setting highlighted those challenges and reinforced the need for effective communications and team building.

Development of an instrument to measure seniors' patient safety health beliefs: the Seniors Empowerment and Advocacy in Patient Safety (SEAPS) survey.

OBJECTIVE: To develop a survey to measure seniors' embracement of ambulatory patient safety self-advocacy behaviors, the Senior Empowerment and Advocacy in Patient Safety (SEAPS) survey. METHODS: Content was developed by review of published recommendations combined with interviews and focus groups with community members; items were generated for subscales based on the health belief model (HBM). Psychometric characteristics were assessed by cluster and correlation analyses on a pilot test of 143 community dwelling seniors; the ability of the subscales and demographic variables to predict reported behavior was investigated by multiple regression. RESULTS: The four subscales of the SEAPS were outcome efficacy (OE), attitudes (ATT), self-efficacy (SE) and behaviors (BEH). Cronbach alphas were 0.74 for ATT, 0.79 for BEH, and 0.91 for OE and SE. Analysis of variance showed that there were no differences in any subscale score by race, education level or frequency of doctor visits, but women were noted to have significantly higher scores (p<.01) on the ATT and SE subscales and for the total of all the scales. Multiple regressions showed that SE significantly predicted self-reported behavior (p<.001). OE was a significant predictor for whites (p<.001) but not for African-Americans (p=.24). CONCLUSIONS: We have developed a short, 21-item self-administered survey to assess seniors' views about their participation in safety tasks. PRACTICE IMPLICATIONS: We believe the SEAPS shows promise to be a tool for evaluating interventions and training programs aimed at improving seniors' self-advocacy skills. Effective interventions may improve the involvement of patients in their own safety in the clinical setting.

Congruence of Patient Self-Rating of Health with Family Physician Ratings.

BACKGROUND: A single self-rated health (SRH) question is associated with health outcomes, but agreement between SRH and physician-rated patient health (PRPH) has been poorly studied. We studied patient and physician reasoning for health ratings and the role played by patient lifestyle and objective health measures in the congruence between SRH and PRPH. METHODS: Surveys of established family medicine patients and their physicians, and medical record review at 4 offices. Patients and physicians rated patient health on a 5-point scale and gave reasons for the rating and suggestions for improving health. Patients' and physicians' reasons for ratings and improvement suggestions were coded into taxonomies developed from the data. Bivariate relationships between the variables and the difference between SRH and PRPH were examined and all single predictors of the difference were entered into a multivariable regression model. RESULTS: Surveys were completed by 506 patients and 33 physicians. SRH and PRPH ratings matched exactly for 38% of the patient-physician dyads. Variables associated with SRH being lower than PRPH were higher patient body mass index (P = .01), seeing the physician previously (P = .04), older age, (P < .001), and a higher comorbidity score (P = .001). Only 25.7% of the dyad reasons for health status rating and 24.1% of needed improvements matched, and these matches were unrelated to SRH/PRPH agreement. Physicians focused on disease in their reasoning for most patients, whereas patients with excellent or very good SRH focused on feeling well. CONCLUSIONS: Patients' and physicians' beliefs about patient health frequently lack agreement, confirming the need for shared decision making with patients.

The extent and frequency of abuse in the lives of older women and their relationship with health outcomes.

PURPOSE: This study assessed the extent of different types of abuse, repeated and multiple abuse experiences among women aged 60 and older, and their effects on the women's self-reported health. DESIGN AND METHODS: A cross-sectional study of a clinical sample of 842 community-dwelling women aged 60 and older completed a telephone survey about type and frequency of abuse, self-reported health status and health conditions, and demographic characteristics. Bivariate and multivariate analyses were performed using SPSS 11.5 and STATA 7.0. RESULTS: Nearly half of the women had experienced at least one type of abuse--psychological/emotional, control, threat, physical, or sexual--since turning 55 years old. Sizable proportions were victims of repeat abuse. Many women experienced multiple types of abuse and experienced abuse often. Abused older women were significantly more likely to report more health conditions than those who were not abused. Women who experienced psychological/emotional abuse--alone, repeatedly, or with other types of abuse--had significantly increased odds of reporting bone or joint problems, digestive problems, depression or anxiety, chronic pain, and high blood pressure or heart problems. IMPLICATIONS: It is important that health care and service providers acknowledge psychological/emotional, control, threat, physical, and sexual abuse against older women and understand their health implications. In addition, it is important for providers to be trained in both aging and domestic violence services and resources.

What do family physicians consider an error? A comparison of definitions and physician perception.

BACKGROUND: Physicians are being asked to report errors from primary care, but little is known about how they apply the term "error." This study qualitatively assesses the relationship between the variety of error definitions found in the medical literature and physicians' assessments of whether an error occurred in a series of clinical scenarios. METHODS: A systematic literature review and pilot survey results were analyzed qualitatively to search for insights into what may affect the use of the term error. The National Library of Medicine was systematically searched for medical error definitions. Survey participants were a random sample of active members of the American Academy of Family Physicians (AAFP) and a selected sample of family physician patient safety "experts." A survey consisting of 5 clinical scenarios with problems (wrong test performed, abnormal result not followed-up, abnormal result overlooked, blood tube broken and missing scan results) was sent by mail to AAFP members and by e-mail to the experts. Physicians were asked to judge if an error occurred. A qualitative analysis was performed via "immersion and crystallization" of emergent insights from the collected data. RESULTS: While one definition, that originated by James Reason, predominated the literature search, we found 25 different definitions for error in the medical literature. Surveys were returned by 28.5% of 1000 AAFP members and 92% of 25 experts. Of the 5 scenarios, 100% felt overlooking an abnormal result was an error. For other scenarios there was less agreement (experts and AAFP members, respectively agreeing an error occurred): 100 and 87% when the wrong test was performed, 96 and 87% when an abnormal test was not followed up, 74 and 62% when scan results were not available during a patient visit, and 57 and 47% when a blood tube was broken. Through qualitative analysis, we found that three areas may affect how physicians make decisions about error: the process that occurred vs. the outcome that occurred, rare vs. common occurrences and system vs. individual responsibility. CONCLUSION: There is a lack of consensus about what constitutes an error both in the medical literature and in decision making by family physicians. These potential areas of confusion need further study.

A lifetime of intimate partner violence: coping strategies of older women.

Little is known about how older women cope in long-term abusive intimate relationships. Understanding their coping strategies may give insight into how to further support their effective coping efforts. Interviews were conducted with 38 women older than age 55 years. Grounded theory analysis demonstrated that women who remained in their abusive relationships employed mainly cognitive (emotion-focused) strategies to find meaning in a situation that was perceived as unchangeable. By reappraising themselves, their spouses, and their relationships they refocused energies in certain roles, set limits with their abusers, and reached out to others (friends, family, and community organizations). Some women appeared to thrive, others merely survived, but all maintained the appearance of conjugal unity.

Older women's descriptions and understandings of their abusers.

Thirty-eight women who were in abusive relationships since age 55 years were interviewed to understand their abuse stories, ways of coping, and health care experiences. In responding to these questions, women described the nature of the abuse perpetrated by their elderly partners and tried to "make sense" of what they had experienced and to define "who" these men were. This took various forms, from personal theories about aging, to labels (ethnic stereotyping, demonizing, pathologizing) to characterizations of the abuser's private versus public behaviors. The authors explore the implications these findings have for assisting the elderly victim and perpetrator.