Even one voice: Teaching legislative advocacy as a core competency in family medicine.

Credentialing bodies increasingly focus on advocacy as a competency to be developed by physicians during residency. The skills of advocacy are especially important with the increased attention on social determinants of health and as restrictive state and federal health policy decisions gain widespread attention in the national news media. This movement is reflected in the ACGME's recently revised statement on the training mission of family medicine residencies and with their most recent update of the Milestones which identifies advocacy as a core competency. Additionally, the major family medicine organizations and governing bodies all similarly identify advocacy as an important professional responsibility for family physicians. Advocacy is a broad term that can be applied across a range of settings and scenarios. For the purposes of this paper we focus primarily on legislative advocacy as a specific area for growing curricular experiences in family medicine residency programs.

Turning the tables: Using resident physicians' experiences as patients for leveraging patient-centered care.

Training physicians to become person-centered is a primary goal of behavioral health curriculum. We have curriculum on doctor-patient communication skills and patient narratives to help physicians relate to the patient's experiences. However, there is nothing more effective than actually being the patient that gives providers an "aha" experience of the patient's perspective. In this article, we will share personal resident physician-patient stories based on their experiences within acute urgent care, chronic disease management, and routine well health care. In each narrative, the physician-patient will describe how their experiences had an impact in three areas: (1) their professional identity, (2) their connection with patients, and (3) their experience of the health-care system and teams. Drawing from the key emotional and cognitive experiences from these stories, we will identify training strategies that can bridge the personal to professional experiences as a way to enhance person-centered care. Our goal is to use the physician's insider perspective on the patient experience as a means to augment the awareness of professional physician role, team-based care, and navigating the health-care system.

Getting It Off the Ground: Key Factors Associated With Implementation of Wellness Programs.

BACKGROUND AND OBJECTIVES: Many residency programs are developing resident wellness curricula to improve resident well-being and to meet Accreditation Council for Graduate Medical Education guidelines. However, there is limited guidance on preferred curricular components and implementation. We sought to identify how specific driving factors (eg, having an identified wellness champion with a budget and protected time to develop wellness programs) impact implementation of essential elements of a resident wellness curriculum. METHODS: We surveyed 608 family medicine residency program directors (PDs) in 2018-2019 on available resources for wellness programs, essential wellness elements being implemented, and satisfaction with wellness programming; 251 PDs provided complete responses (42.5% response rate). Linear and logistic regressions were conducted for main analyses. RESULTS: Having an identified wellness champion, protected time, and dedicated budget for wellness were associated with greater implementation of wellness programs and PD satisfaction with wellness programming; of these, funding had the strongest association. Larger programs were implementing more wellness program components. Program setting had no association with implementation. CONCLUSIONS: PDs in programs allocating money and/or faculty time can expect more wellness programming and greater satisfaction with how resident well-being is addressed.

Review of Helping couples and families navigate illness and disability: An integrated approach.

Reviews the book, Helping Couples and Families Navigate Illness and Disability: An Integrated Approach by John S. Rolland (see record 2018-14404-000). Many health care providers have traveled with their patients and families on the journey of disease, disability, and death. This journey is often filled with unanticipated twists and turns: changes in physical functioning, intense emotional experiences, and demands on intimate relationships. In Helping Couples and Families Navigate Illness and Disability: An Integrated Approach, John Rolland has provided clinicians with a map of the territory, guiding them through the challenges of intersecting systems of family relationships, cultural values, and health care practices. This book is a culmination of John Rolland's expertise and writing over his 40-year career. The book expands on his work in theory development while adding an expansive repertoire of practical questions, suggestions, and interventions. His personal experience coping with the illness and death of his young spouse and his parents' health infuses a tender and personal tone to this academic work. In the context of his own journey, he wondered: "What would have been useful information or support for me and my family members at different phases of the illness that could have made a difference in our ability to cope and adapt?" (pp. viii). This question is at the heart of the book. His clinical expertise, theoretical acumen, and personal experiences comprise this comprehensive and readable book. The book is organized into four sections: (a) a conceptual overview of the Family Systems Illness Model (FSI); (b) the application of the model for families, couples and multigenerations, and family/cultural health beliefs; (c) health-related phases and transitions with specific populations (e.g., terminally ill, chronic conditions, aging individuals, and couples); and (d) the clinician's personal-professional dynamic emotional experience. This book will be an important resource for the growing workforce of behavioral health providers. It provides physicians with a family-oriented transition of care model and is applicable for nurses, nurse practitioners, and mental health professionals who coach families through many phases of care-inpatient, rehabilitation, or hospice. It does not include critical analysis of the research on family-oriented care. There are references to studies, but it is not a systematic review or meta-analysis of best practices for family-oriented health care. For family systems novices, this book will be conceptually dense. It is not entry-level reading but will be accessible if incorporated into a seminar by seasoned faculty. Clinicians will find that the FSI model is a necessary GPS for guiding families through their health care and journey of illness. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A silver lining playbook? My mom's death.

Was this a silver-lining playbook-my mother's death? We had planned for this moment, talked together about her wishes, filled out the paperwork: We were that kind of family-the one that talked and debated about life and death. And my mother, in her true tenacious fashion, rehearsed with us her dying wishes. The papers were filed with her primary care physician, scanned into the Electronic Medical Record (EMR), and a copy placed in their freezer-a clever way to find it in a crisis. The playbook was in place. The rest of the story is on replay in my mind. I remember asking to speak to the physician in a demanding tone and wanting to know why my mom was intubated . . . "Didn't any one look at the paper work?" The Emergency Department (ED) physician explained, "Your mom's blood pressure is dropping. She doesn't have a complicated medical condition so we want to give her pressors so that we can keep her alive." I replied that neither my mom nor the family wanted any intervention. This experience pulled us into the power of the protocols that make it possible to keep hearts beating and lungs breathing. In my mother's case, her uncomplicated medical history in the EMR triggered those standing lifesaving orders. But no one assessed her personhood. No one asked about her level of functioning, her pain, her memory loss, her desires. No one took a minute to ask about this mother of five children who sang her way through life. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Do electronic medical record (EMR) demonstrations change attitudes, knowledge, skills or needs?

INTRODUCTION: Electronic medical records (EMRs) are the future of primary care. Transition to electronic records can have a significant impact on physicians, office staff, nursing staff and patients. There are no published EMR studies combining these four populations or studies that have evaluated the impact of EMR demonstrations. To better understand the impact of EMRs, an online survey was administered before and after EMR demonstrations. METHODS: A longitudinal cohort survey design was used to assess primary outcomes (attitudes, knowledge, skills and needs) related to EMRs in four populations that were divided into two groups--one of physicians and the other of nursing staff, office staff and patients. A total of 39 participants (19 physicians and 20 staff/patients) completed a pretest survey four weeks prior to and post-test surveys at four and ten weeks after EMR demonstrations. Mean composite scores for each primary outcome were calculated for each group and mean differences were calculated and compared within and between groups--from baseline to four weeks and four to ten weeks using paired t-tests and Student's t-tests, respectively. RESULTS: Groups differed in several areas: physicians were younger, had more education and had fewer years of experience in a primary care office. There were no significant differences in gender or computer experience between groups. Staff/patients reported significant improvements in attitudes, knowledge and needs from baseline to four weeks (P<0.05, P<0.01 and P<0.05). Physician attitudes, knowledge and needs significantly increased at week four (P<0.05, P<0.01 and P<0.05). Attitudes, knowledge and needs were sustained in both groups from week four through to week ten. CONCLUSION: EMR demonstrations improved attitudes, knowledge and needs of staff/patients and physicians. EMR demonstrations may be effective in favorably influencing healthcare personnel towards EMRs.

Don Bloch Award acceptance speech: 2017.

Provides Dr. Mary Talen's acceptance speech for the 2017 CFHA Don Bloch Award. (PsycINFO Database Record

Integrative Medicine and Mood, Emotions and Mental Health.

An integrative approach to individuals with mood, emotional or mental health concerns involves a comprehensive model of care that is person-centered. Integrative medicine builds on a patient's personal meaning and goals (spiritual aspects) and includes herbal therapies, nutritional support, movement and physical manipulative therapies, mindfulness, relaxation strategies, and psychotherapies.

Psychiatric Emergencies.

Psychiatric emergencies are acute disturbances in thought, behavior, mood, or social relationship that require immediate intervention as defined by the patient, family, or social unit to save the patient and/or others from imminent danger. Ensuring the safety of the patient, surrounding persons, and the medical team is the first step of evaluation. Treatment focuses on stabilization of the patient, then on specific symptoms and ultimately the cause of symptoms. There are important legal considerations, particularly regarding involuntary admissions. It is important to debrief with the patient, surrounding family, and the health care team to ensure a continued therapeutic alliance and the emotional health of all involved.

Patient Perceptions About Prediabetes and Preferences for Diabetes Prevention.

PURPOSE: The purpose of this study was to explore how adults with prediabetes perceive their risk of developing diabetes and examine their preferences for evidence-based treatment options to prevent diabetes. METHODS: A qualitative study was conducted in 2 large Midwest primary care practices, involving in-depth semistructured interviews with 35 adult patients with prediabetes. RESULTS: This ethnically diverse (77% nonwhite) sample of middle-aged primary care patients exhibited multiple diabetes risk factors. Knowledge gaps about prediabetes and its medical management were pervasive. Most patients overestimated the risk of developing diabetes and were not familiar with evidence-based treatment options for prediabetes. They suggested that receiving brief, yet specific information about these topics during the study interview motivated them to act. The majority of participants considered both intensive lifestyle intervention and metformin acceptable treatment options. Many preferred initial treatment with intensive lifestyle intervention but would take metformin if their efforts at lifestyle change failed and their primary care physician recommended it. Some participants expressed wanting to combine both treatments. CONCLUSIONS: This qualitative study highlights potential opportunities to promote patient-centered dialogue about prediabetes in primary care settings. Providing patients specific information about the risk of developing diabetes and evidence-based treatment options to prevent or delay its onset may encourage action. Physicians' prediabetes counseling efforts should be informed by the finding that most patients consider both intensive lifestyle intervention and metformin acceptable treatment options.

Evaluation of an electronic health record-supported obesity management protocol implemented in a community health center: a cautionary note.

OBJECTIVE: Primary care clinicians are well-positioned to intervene in the obesity epidemic. We studied whether implementation of an obesity intake protocol and electronic health record (EHR) form to guide behavior modification would facilitate identification and management of adult obesity in a Federally Qualified Health Center serving low-income, Hispanic patients. MATERIALS AND METHODS: In three studies, we examined clinician and patient outcomes before and after the addition of the weight management protocol and form. In the Clinician Study, 12 clinicians self-reported obesity management practices. In the Population Study, BMI and order data from 5000 patients and all 40 clinicians in the practice were extracted from the EHR preintervention and postintervention. In the Exposure Study, EHR-documented outcomes for a sub-sample of 46 patients actually exposed to the obesity management form were compared to matched controls. RESULTS: Clinicians reported that the intake protocol and form increased their performance of obesity-related assessments and their confidence in managing obesity. However, no improvement in obesity management practices or patient weight-loss was evident in EHR records for the overall clinic population. Further analysis revealed that only 55 patients were exposed to the form. Exposed patients were twice as likely to receive weight-loss counseling following the intervention, as compared to before, and more likely than matched controls. However, their obesity outcomes did not differ. CONCLUSION: Results suggest that an obesity intake protocol and EHR-based weight management form may facilitate clinician weight-loss counseling among those exposed to the form. Significant implementation barriers can limit exposure, however, and need to be addressed.

An Evidence Roadmap for Implementation of Integrated Behavioral Health under the Affordable Care Act.

The Affordable Care Act (ACA) created incentives and opportunities to redesign health care to better address mental and behavioral health needs. The integration of behavioral health and primary care is increasingly viewed as an answer to address such needs, and it is advisable that evidence-based models and interventions be implemented whenever possible with fidelity. At the same time, there are few evidence-based models, especially beyond depression and anxiety, and thus further research and evaluation is needed. Resources being allocated to adoption of models of integrated behavioral health care (IBHC) should include quality improvement, evaluation, and translational research efforts using mixed methodology to enhance the evidence base for IBHC in the context of health care reform. This paper covers six key aspects of the evidence for IBHC, consistent with mental and behavioral health elements of the ACA related to infrastructure, payments, and workforce. The evidence for major IBHC models is summarized, as well as evidence for targeted populations and conditions, education and training, information technology, implementation, and cost and sustainability.

Creating a culture of wellness: conversations, curriculum, concrete resources, and control.

Burnout and depression across the career life cycle of healthcare providers are increasing at alarming rates. We need to devote our resources and efforts to bolster the next generation of healthcare providers who have the capacity for resiliency and well-being--the antidote to burnout and depression. A handful of organizations have implemented general wellness programs to combat burnout but there are surprisingly few documented, well-researched interventions to build resiliency. Wellness provides an alternative framework to approach the epidemic rates of burnout and depersonalization within the healthcare profession. In this article we describe our rationale for developing a culture of wellness among primary care physicians along with the specific activities and initiatives for creating a culture of wellness throughout medical educational training. Examples of the four core components of a residency wellness program-concrete resources, positive conversations, curriculum, and control-are described with regard to our Family Medicine Residency. A brief description of early efforts to empirically examine the impact of the wellness initiative across systemwide residency programs (Family Medicine and other programs) is described.

Patients' communication with doctors: a randomized control study of a brief patient communication intervention.

In research on doctor-patient communication, the patient role in the communication process has received little attention. The dynamic interactions of shared decision making and partnership styles which involve active patient communication are becoming a growing area of focus in doctor-patient communication. However, patients rarely know what makes "good communication" with medical providers and even fewer have received coaching in this type of communication. In this study, 180 patients were randomly assigned to either an intervention group using a written communication tool to facilitate doctor-patient communication or to standard care. The goal of this intervention was to assist patients in becoming more effective communicators with their physicians. The physicians and patients both rated the quality of the communication after the office visit based on the patients' knowledge of their health concerns, organizational skills and questions, and attitudes of ownership and partnership. The results supported that patients in the intervention group had significantly better communication with their doctors than patients in the standard care condition. Physicians also rated patients who were in the intervention group as having better overall communication and organizational skills, and a more positive attitude during the office visit. This study supports that helping patients structure their communication using a written format can facilitate doctor-patient communication. Patients can become more adept at describing their health concerns, organizing their needs and questions, and being proactive, which can have a positive effect on the quality of the doctor-patient communication during outpatient office visits. (PsycINFO Database Record (c) 2011 APA, all rights reserved).

Obesity and mental health.

Mental health factors contribute to the onset and maintenance of overweight and obese status in children, adolescents, and adults. Binge eating disorder (BED), body image, self-esteem, mood disorders, and social and family factors affect individuals in different ways and contribute to weight gain and failure in weight loss management. Assessment of these mental health factors and treatment by 1 of several mental health treatment models may not only improve self-worth but also weight loss and maintenance.

Patient care management teams: improving continuity, office efficiency, and teamwork in a residency clinic.

UNLABELLED: BACKGROUND AND PROBLEM STATEMENT: The goals of the patient-centered medical home (PCMH) include the efficient and effective delivery of patient-centered care in the context of a continuity relationship. In residency training programs, competing demands on faculty, residents, and office staff create considerable challenge in demonstrating these vital attributes of the PCMH to residents. Given the emphasis on the PCMH, primary care residency programs need to strengthen the methods for teaching and modeling continuity, office efficiency, and team-based approaches to care. INTERVENTION: We designed and implemented a new system of "patient care management teams" in our family medicine residency and evaluated its impact on team members. Our quality improvement interventions included the creation of team structures linking faculty advisors and residents with patients, intrateam management of office tasks, and the implementation of multidisciplinary team meetings. EVALUATION: We surveyed faculty (n  =  11), residents/fellows (n  =  39), and staff (n  =  12) before and at 2 points after the patient care management team interventions, and we collected patient satisfaction data during the intervention time period. RESULTS: The intervention resulted in significant improvements in perceptions of continuity of patient care, office efficiency, and team communication before and after the team interventions. During a 2-year period, the greatest improvements were in the areas of office efficiency and continuity of care. Independent patient satisfaction scores correlated with patient care management team improvements. CONCLUSIONS: Team structures, streamlined team-based management of routine office tasks, and consistent and frequent multidisciplinary meetings can improve the sense of continuity, office efficiency, and team collaboration in primary care residency clinics.

Residents' perspective on the impact of the 80-hour workweek policy.

BACKGROUND: The 80-hour workweek was initiated in 2003 to reduce the resident workweek and subsequently improve the safety and quality of patient care. PURPOSE: The purpose is to assess the impact of the 80-hr workweek from a resident's perspective. METHOD: We surveyed residents with experience before and after the 80-hr workweek policy. The survey assessed residents' perspective on the impact of the 80-hr workweek on 4 areas: patient care/safety, training experience, resident team functioning, and personal life. RESULTS: There were 111 respondents (57% female, 65% married, average age = 32 years, 66% primary care residents). We found the 80-hr workweek had the greatest impact in personal self-care and sleep hygiene. Primary care residents reported a significantly more positive impact of the 80-hr workweek on quality of the training compared to specialty residents. There was no difference between the primary care residents and specialty residents for patient care/safety, resident team functioning, and personal life. Gender, marital status, and having children did not impact how residents' evaluated the 80-hr workweek. CONCLUSION: Residents, with pre- and post-80-hr workweek experience, reported the policy change as having the greatest benefit on their self-care and personal life significantly more than any other area.