Sequential third-year medical student quality assurance (QA) clerkship projects appear to introduce a culture of continuous quality improvement across New Jersey family medicine practices

Background

In recent years, Rutgers New Jersey Medical School Department of Family Medicine has integrated a quality assurance (QA) project as a required component of their 5-week medical student clerkship. This project requires each student to conduct a QA study at an assigned family practice and discuss the results with their preceptor. The aim of this study was to determine if sequential medical student QA projects impact physician readiness to improve guideline adherence over time.

Methods

A retrospective analysis of student reports was conducted to determine if physician readiness to improve compliance improved post implementation of the QA project using James Prochaska’s Transtheoretical Model of Behavioral Change. Fisher’s exact test or the χ² test were used as applicable to compare the change in results.

Results

In academic year 2015–2016, there were 11 (6%) instances where physicians were precontemplating on change, 43 (24%) instances where physicians were contemplating, 101 (57%) instances where physicians were preparing to make change, 18 (10%) instances where physicians were acting, and 4 (2%) of instances where a physician were maintaining previous changes. The following year, the numbers were: 15 (8%), 38 (21%), 82 (46%), 34 (19%) and 11 (6%), respectively. There were increases of physicians in stages of precontemplation (p=0.047), action (p=0.02) and maintenance (p=0.047), a decrease in physicians that were in the stage of preparation (p=0.05) and no significant change in the instances they were in a stage of contemplation (p=0.60).

Conclusion

Student QA projects appear to leverage physician readiness to improve guideline adherence. Future studies will determine if raising awareness through these clerkship projects results in practice behavioural change.

Refining your approach to hypothyroidism treatment

Thyroid hormone supplementation can be complicated by a number of factors. These tips can help to ensure that you provide the best treatment possible.

Exploring the therapeutic alliance in Belgian family medicine and its association with doctor-patient characteristics: a cross-sectional survey study

OBJECTIVES

Patient-centred care is related to better health outcomes, greater patient satisfaction and reduced healthcare costs. One of the core components of patient-centred care, defined in the patient-centred clinical method, is enhancing the patient-doctor relationship. In this study, we aim to measure the therapeutic alliance in consultations between patients and family doctors in Belgium, and explore which patient, provider and practice characteristics are associated with the strength of the therapeutic alliance.

DESIGN

Cross-sectional cohort study using the Working Alliance Inventory for General Practice (WAI-GP). The patients and family doctors completed a survey after the consultation. The survey consisted of the WAI-GP, demographics, consultation characteristics and variables related to the patient-doctor relationship.

SETTING

Belgian primary care.

PARTICIPANTS

Every third patient (both practice and house call visits) was invited to participate. 170 patient-doctor dyads from four practices were included. Total of 10 doctors (30% men, age range 24-63 years) and 170 patients (35.9% men, age range 18-92 years).

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was the WAI-GP score and its correlations with characteristics of the doctor (gender, age) and patients (gender, age, chronic disease, number of annual consultations).

RESULTS

The median WAI-GP score reported after these consultations was 4.5±0.62. Higher WAI-GP scores were reported for consultations with male doctors and by older patients. In the subsample of patients with a chronic illness, higher WAI-GP scores were reported by patients who had more than 10 follow-up consultations per year.

CONCLUSIONS

Consultation quality is an important aspect of healthcare, but attention is needed to understand how the WAI-GP performs in relation to variables that are beyond control, such as gender of the physician, age of the patient and variables related to building continuity of care. This has implications for the measurement of quality of healthcare.

Closing the Gap: A Resident-Led Quality Improvement Project to Improve Colorectal Cancer Screening in Primary Care Community Clinics

BACKGROUND

Despite the prevalence and mortality associated with colorectal cancer (CRC), 67.4% of US adults aged 50 to 75 years received recommended screening tests in 2016.

OBJECTIVE

We created a quality improvement project in resident-run outpatient clinics to increase CRC screening rates to ≥ 50% from 2016 to 2018, with emphasis on vulnerable patient populations.

METHODS

We applied a comprehensive, multidisciplinary approach involving internal medicine and family medicine residents and staff from various hospital network departments, selecting 4 clinics to participate whose screening rates were below our network's average of 41%. Our intervention consisted of a needs assessment, resident-led educational sessions for clinicians, staff, and patients, use of fecal immunochemical tests as a first screening option, and application of care gap analysts at each clinic to answer patients' screening questions and to follow up regarding their screening status.

RESULTS

We obtained approximately 100 patient surveys from each clinic, a 100% staff completion rate (68 of 68), and a 90% clinician completion rate (85 of 94). Staff and clinician surveys revealed concerns about reducing patient screening fears, inconsistent documentation of screening outcomes, and need for education about CRC prevention, early detection, and screening recommendations. Patient surveys revealed educational deficits and concerns about perceived screening obstacles (eg, transportation and insurance). While CRC screening rates increased across all participating clinics, one clinic experienced an increase from 23% to 48%.

CONCLUSIONS

Our multitargeted approach in primary care residency practices yielded increased CRC screening rates in vulnerable patient populations.

Screening and Counseling Adolescents and Young Adults: A Framework for Comprehensive Care

Healthy development is likely to occur when an adolescent's risk factors are limited and when protective factors are fostered. Healthy development is further encouraged when youth feel valued, empowered, and form healthy social connections. Threats to the well-being of adolescents typically result from experimentation and psychosocial stressors. SSHADESS (strengths, school, home, activities, drugs, emotions/eating, sexuality, safety) is a mnemonic to facilitate collection of psychosocial history of critical life dimensions emphasizing strengths within a youth's life experience instead of solely focusing on risks, which in isolation can provoke feelings of shame. Because adolescents are more likely to access health care and share sensitive information when confidentiality is assured, clinicians should regularly offer confidential screening and counseling. When limited for time, a brief psychosocial screen may include current stressors, availability of a confidant, and school or work experience as a proxy for well-being. Clinicians should provide education to prevent initiation of tobacco use. Long-acting reversible contraceptives are safe and effective in adolescents and should be offered as first-line options to prevent pregnancy. Sexually active females 24 years or younger should be screened for gonorrhea and chlamydia annually. Adolescents 12 years or older should be screened for major depressive disorder when systems are available to ensure accurate diagnosis, treatment, and follow-up. Adolescents with body mass index at the 95th percentile or higher should be referred for comprehensive behavioral interventions. Seatbelt use and avoidance of distracted or impaired driving should be discussed. Clinicians should discuss digital literacy and appropriate online boundary setting and display of personal information.

The Cost-Effectiveness Analysis of Cervical Cancer Screening Using a Systematic Invitation System in Lithuania

In Lithuania, cytological screening of cervical cancer (CC) is largely opportunistic. Absence of standardized systematic invitation practice might be the reason for low participation rates. The study aimed to assess the cost-effectiveness of systematic invitation approach in CC screening programme from the perspective of a healthcare provider. A decision tree was used to compare an opportunistic invitation by a family doctor, a personal postal invitation letter with appointment time and place, and a personal postal invitation letter with appointment time and place with one reminder letter. Cost-effectiveness was defined as an incremental cost-effectiveness ratio (ICER) per one additionally screened woman and per one additional abnormal Pap smear test detected. The ICER of one personal postal invitation letter was €9.67 per one additionally screened woman and €55.21 per one additional abnormal Pap smear test detected in comparison with the current screening practice. The ICER of a personal invitation letter with an additional reminder letter compared to one invitation letter was €13.47 and €86.88 respectively. Conclusions: A personal invitation letter approach is more effective in increasing the participation rate in CC screening and the number of detected abnormal Pap smears; however, it incurs additional expenses compared with current invitation practice.

Management of gastroesophageal reflux disease in pediatric patients with cerebral palsy

Question As a family physician who provides care to a large pediatric population in the community, I see children with various neurologic impairments, many with cerebral palsy (CP), presenting with gastroesophageal reflux disease (GERD). What are the current recommendations to manage GERD in pediatric patients with CP?Answer A variety of lifestyle modifications can be used to manage GERD in pediatric patients with CP, including raising the head of the patient's bed, reducing patient weight, limiting exposure to smoke, and avoiding caffeine, spicy foods, fatty foods, and chocolate. The primary pharmacologic treatments currently recommended are histamine-2 receptor antagonists and proton pump inhibitors. Surgical treatments for GERD, like the Nissen fundoplication, might result in complications, so there is ongoing research looking at the benefits of using high-pectin diets, baclofen, and prokinetic agents like mosapride instead.

Head & neck cancers: What you'll see, how to proceed

What physical findings should raise your suspicion? How are tumors treated and what follow-up care can you provide? Here's what you need to know.

An FP's guide to AI-enabled clinical decision support

To better understand the capabilities and challenges of artificial intelligence and machine learning, we look at the role they can play in screening for retinopathy and colon cancer.

Suicide screening: How to recognize and treat at-risk adults

Worsening nausea, vomiting, and dizziness for 2-months, resulting in a 20-pound weight loss. Pruritus. Ataxia. Mild hearing loss, with reoccurring episodes of falls.

[The rural health physician and the promotion of health: perspectives from Andalusia]

The rural environment is eminently diverse and complex, and the concept of rurality is controversial and contentious depending on the countries and the context. However, there is a set of global dynamics that affect rural enclaves and their social organization, as well as the social determinants on which much of the health of their inhabitants depends. The family doctor in rural areas is in a strategic position thanks to the knowledge of her or his territory and community, and her or his close relation to it that is needed to carry out a contextual analysis of these external influences on the functioning of the community, on the conditions and lifestyles that affect the people in the community. In addition, rural medicine as a professional setting for the promotion of health, has a mobilizing instrument, the social capital that the rural doctor is able to accumulate to a greater extent than in an urban environment, in order to carry out empowering and salutogenic participatory-based community actions and to advocate for health. Likewise, the family doctor and the provision of health services are key pieces in the process of healing, assisting and caring for the development and support of rural enclaves, in order to maintain the habitability of these communities and to effectively exercise the right to equitable health services.

[Burnout in family practice: comment on the NHG guideline 'Stress and burnout']

Burnout is a serious health problem and the cause of career disruption in 15% of women and 9% of men who quit their job. Of all work-related complaints, 37% is attributable to workload and stress. Many workers visit their general practitioner with work-related complaints. Recently, the Dutch College of General Practitioners (NederlandsHuisartsenGenootschap) published a guideline on burnout. While the guideline provides a good framework for managing patients with a burnout, additional attention could be paid to prevention and how to distinguish burnout from depression.

Practice patterns among early-career primary care (ECPC) physicians and workforce planning implications: protocol for a mixed methods study

INTRODUCTION

Canadians report persistent problems accessing primary care despite an increasing per-capita supply of primary care physicians (PCPs). There is speculation that PCPs, especially those early in their careers, may now be working less and/or choosing to practice in focused clinical areas rather than comprehensive family medicine, but little evidence to support or refute this. The goal of this study is to inform primary care planning by: (1) identifying values and preferences shaping the practice intentions and choices of family medicine residents and early career PCPs, (2) comparing practice patterns of early-career and established PCPs to determine if changes over time reflect cohort effects (attributes unique to the most recent cohort of PCPs) or period effects (changes over time across all PCPs) and (3) integrating findings to understand the dynamics among practice intentions, practice choices and practice patterns and to identify policy implications.

METHODS AND ANALYSIS

We plan a mixed-methods study in the Canadian provinces of British Columbia, Ontario and Nova Scotia. We will conduct semi-structured in-depth interviews with family medicine residents and early-career PCPs and analyse survey data collected by the College of Family Physicians of Canada. We will also analyse linked administrative health data within each province. Mixed methods integration both within the study and as an end-of-study step will inform how practice intentions, choices and patterns are interrelated and inform policy recommendations.

ETHICS AND DISSEMINATION

This study was approved by the Simon Fraser University Research Ethics Board with harmonised approval from partner institutions. This study will produce a framework to understand practice choices, new measures for comparing practice patterns across jurisdictions and information necessary for planners to ensure adequate provider supply and patient access to primary care.