Physician wellness: Managing stress and preventing burnout

Physician burnout is increasing, but navigating its prevention involves a complex intersection of physical, psychological, social, and organizational strategies.

Gamers' and non-gamers' perspectives on the development of problematic video game play

Gaming Disorder was recently included in the 11th Edition of the International Classification of Diseases and Internet Gaming Disorder may be introduced in the sixth edition of The Diagnostic and Statistical Manual. Much is not understood about how problems with video games develop. This qualitative study aimed to better understand the development of problematic gaming through focus groups. Eleven young adult "frequent gamers," twelve young adult "non-frequent or non-gamers," and five older adult "non-gamers" discussed vulnerabilities and risk factors of problematic gaming. Participants across all groups believed that problematic gaming developed when people used video games as a primary means of meeting basic psychological needs that were unsatisfied, thwarted, or blocked outside of video games. Frequent and non-frequent gamers, compared to older adult non-gamers, were more likely to view video games as a healthy way to meet basic psychological needs and less likely to stereotype gamers. Video games are equipped to meet basic psychological needs for autonomy, competence, and relatedness. That is, gamers often experience a sense of agency, skill, and connection to others when playing video games. However, problematic gaming may develop when people with unmet psychological needs rely exclusively on video games to meet them. Treatment and prevention approaches to problematic gaming can benefit from greater attention to helping at risk individuals meet needs for autonomy, competence, and relatedness outside of video games.

Birth Outcomes Related to Distance in Rural and Frontier Kansas

Introduction

Women from rural communities must travel greater distances to secure obstetrical care. This study sought the extent to which distance traveled by mothers for obstetrical services affects birth outcomes in rural and frontier counties of Kansas.

Methods

Medical students invited women over the age of 18 to participate in a recall survey regarding their children under three years old. Participants were a sample of convenience, and the length of data collection was a month. A bivariate analysis was performed on the responses gathered regarding obstetrical measures as a function of self-reported distance traveled to the hospital of delivery.

Results

Eighty-five women completed the survey, but only 76 satisfied all eligibility requirements. No statistical difference in birth outcomes were found between women who travel more than or less than 20 miles. However, when correlating data to that of the Kansas Hospital Association and the Kansas Department of Health and Environment, counties without birth facilities had a higher percentage of very low birth weights (< 1,500 grams) and more babies born at full-term when compared to counties that offer birth facilities. Babies born to mothers who reside in counties with obstetrical services were born at an earlier gestational age than those without birth facilities. Lastly, babies born into a family with income less than $50,000 weighed less and had a shorter gestational age than those from a more affluent household.

Conclusions

The results revealed counterintuitive findings that deserve to be explored further by a study with greater statistical power.

Mental Health and Psychosocial Needs of Patients Being Treated for Opioid Use Disorder in a Primary Care Residency Clinic

Purpose: Primary care is an ideal setting to deliver efficacious treatments for opioid use disorder (OUD). Primary care providers need to be aware of other concerns patients with OUD might have in order to provide comprehensive care. This study describes the prevalence of mental health, comorbid substance use, and psychosocial concerns of patients seeking treatment for OUD in primary care and their relation to 6-month treatment retention. Methods: Patients (N = 100; M age = 34.9 years (SD = 10.8), 74% white, 46% female) with OUD who were starting treatment with buprenorphine at an academic family medicine residency clinic completed surveys of mental health concerns (depression, anxiety, trauma), psychosocial needs (food insecurity, income, transportation, employment), and demographic variables. Chart reviews were conducted to gather information on comorbid substance use, mental health diagnoses, and 6-month treatment retention. Results: Mental health symptoms were highly prevalent in this sample (44% screened positive for anxiety, 31% for depression, and 52% for posttraumatic stress disorder). Three-quarters reported use of illicit substances other than opioids. Many patients also had significant psychosocial concerns, including unemployment (54%), low income (75%), food insecurity (51%), and lacking reliable transportation (64%). Two-thirds (67%) of the sample were retained at 6 months; patients who previously used intravenous opioids were more likely to discontinue treatment (P = .003). Conclusions: Many patients receiving treatment for OUD have significant mental health problems, comorbid substance use, and psychosocial concerns; interestingly, none of these factors predicted treatment retention at 6 months. Primary care clinics would benefit from having appropriate resources, interventions, and referrals for these comorbid issues in order to enhance overall patient well-being and promote recovery.

Providing addiction services during a pandemic: Lessons learned from COVID-19

During the COVID-19 pandemic, social distancing measures have made in-person mutual help groups inaccessible to many individuals struggling with substance use disorders (SUDs). Prior to the pandemic, stakeholders in our community had sponsored a program to train volunteers to facilitate local Self-Management and Recovery Training (SMART Recovery) groups. As a result, the community established seven weekly SMART Recovery groups, which more than 200 community members attended. In March 2020, the community discontinued these groups due to the COVID-19 pandemic. To provide SMART Recovery during social distancing, we developed a one-on-one phone-in service for people with SUDs and addictions: the SMART Recovery Line (SMARTline). In this paper, we share our experience training volunteers to facilitate SMART Recovery groups and SMARTline. As a result of our experience, we have learned to: (1) establish plans in advance to migrate services from face-to-face settings to remote platforms; (2) consider remote platforms that are easily accessible to the greatest number of individuals; (3) include as many stakeholders in the planning process as possible; (4) consider recruiting volunteers to help in the provision of services, especially since many people want to help fellow community members during crises; and (5) anticipate and prepare for crises well before they occur.

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People with addictions rely on mutual help groups (e.g., AA, NA, SMART Recovery).

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We have developed a program to train volunteers to facilitate SMART Recovery groups.

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SMART Recovery groups were established, but were discontinued due to COVID-19.

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In response we developed a novel phone adaptation of SMART Recovery (SMARTline).

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We share recommendations for providing remote addiction services during COVID-19.

Insecure attachment and addiction: Testing the mediating role of emotion dysregulation in four potentially addictive behaviors

Insecure attachment has been associated with an array of addictive behaviors. However, the mechanism by which insecure attachment leads to addictive behaviors remains largely unknown. In the present research we tested whether emotion dysregulation mediated the relationship between insecure attachment (anxious, avoidant) in substance use (alcohol, marijuana) and DSM-5 (Internet gaming) and non-DSM-5 (texting) behavioral dependencies. A sample (N = 712) of participants recruited from a university in the United States completed an online battery of instruments, assessing adult attachment style, emotion dysregulation, and self-reported DSM-5 symptoms adapted from substance use disorder criteria. In separate mediation analyses, anxious attachment was associated with self-reported DSM-5 symptoms for alcohol, marijuana, texting, but not Internet gaming; whereas emotion dysregulation was associated with self-reported DSM-5 symptoms of all four potentially addictive behaviors. Avoidant attachment was not associated with self-reported DSM-5 symptoms for any of the addictive behaviors. Emotion dysregulation mediated the relationship between both anxious and avoidant attachment and self-reported DSM-5 symptoms for alcohol, marijuana, and texting. In contrast, emotion dysregulation mediated the relationship between anxious but not avoidant attachment and Internet gaming. Insecure attachment, specifically anxious attachment and emotion dysregulation may be important psychological characteristics that increase the risk for alcohol, marijuana and texting, while Internet gaming corresponds with unique characteristics. Whereas attachment styles may be resistant to change, emotion dysregulation has been found to be modifiable and may provide a potential target in the treatment of substance use disorders and some behavioral dependencies for those who manifest attachment insecurities.

The Self-perception of Text-message Dependency Scale (STDS): Psychometric update based on a United States sample

BACKGROUND

Some have suggested that text messaging is an addictive behavior. However, this characterization is uncertain, partly due to lack of well-validated measures of text messaging attitudes and behaviors. One standard instrument for measuring text messaging attitudes and behaviors is the Self-perception of Text-message Dependency Scale (STDS), though the psychometric properties of this scale have only been examined with a sample of Japanese youth.

OBJECTIVES

The primary objective of this study was to evaluate the STDS in the United States to determine its utility as a measure of text messaging dependence. We were interested in examining the factor structure and determining the extent to which this scale would correlate with two important outcome measures: motor vehicle accidents (MVAs) and moving violations.

METHODS

We analyzed data from 468 adults (age 18-74; 274 women) recruited via Amazon's Mechanical Turk (mTurk) service. Participants completed the STDS and provided information about their driving-related incidents in the past year.

RESULTS

First we performed a confirmatory factor analysis, which supported the instrument's original factor structure. Then we tested the relationship between scores on the STDS and two important variables, MVAs and moving violations. We found that the STDS significantly correlated with both MVAs and moving violations.

CONCLUSION

The present study confirms that the STDS is a potentially useful instrument for studying texting dependence in the United States and with adults of all ages. The instrument may be particularly useful in predicting motor vehicle outcomes.

College student marijuana involvement: Perceptions, use, and consequences across 11 college campuses

BACKGROUND

Marijuana is currently the most commonly used illicit drug in the United States, and with the movement toward legalization of recreational marijuana, the country faces numerous issues regarding policy, prevention, and treatment of marijuana use. The present study examines the prevalence of marijuana use and consequences and compares users and non-users on a wide range of other marijuana-related constructs among college students across 11 universities.

METHOD

Participants included 8141 college students recruited from the psychology department participant pools of 11 universities throughout the US, including four major regions of the US (West, South, Midwest, Northeast) and states with varying policies regarding the legality of marijuana use.

RESULTS

We observed marijuana use rates similar to representative samples of young adults and college students (i.e., 53.3% lifetime marijuana users, 26.2% past month marijuana users). About 1 in 10 past month marijuana users experienced no consequences from their use, whereas nearly 1 in 10 experienced 19 or more consequences. Lifetime marijuana users had more positive perceptions of marijuana compared to non-users on a wide-range of marijuana-related constructs.

CONCLUSIONS

We report descriptive statistics on a wide range of marijuana-related variables. We hope that these data provide a useful baseline prior to increased legalization of recreational marijuana use. Multi-site studies like this one are needed to study the risky and protective factors for problematic marijuana use. These findings can inform interventions and public policy.

Failing to diagnose and failing to treat an addicted client: Two potentially life-threatening clinical errors

Psychotherapists risk making 2 types of errors with clients who struggle with addictive behaviors: failure to diagnose addictive behaviors and failure to effectively treat addictive behaviors. Given the high prevalence of addictive behaviors in clinical populations, therapists are in a unique position to assist individuals with these problems. It is assumed that therapists possess general diagnostic and treatment skills and yet many do not diagnose or do not treat addictive behaviors. Reasons for making these errors include prohibitive beliefs and limited knowledge about addictive behaviors. We offer specific recommendations to reduce these psychotherapy errors. These include: (a) more deliberate screening and diagnosis of addictive behaviors, (b) increased application of empirically supported addiction treatments, (c) required education and training in addictive behaviors, (d) modification of prohibitive attitudes about addressing addictive behaviors, and (e) increased attention paid to the addictive behaviors by professional psychotherapy organizations.

Teaching psychological knowledge and skills to family physicians

Psychological problems (e.g., anxiety, depression, substance abuse) are prevalent in primary care medical settings. Family physicians (FPs) treat more patients than any other primary care medical specialists. Thus, FPs can play an extremely important role in providing psychological services to their patients. In contrast to other specialists (e.g., internists, obstetricians), FPs are required to complete behavioral science training in their residencies. In this paper, we describe standard undergraduate, graduate, and postgraduate training of FPs. We present our unique program for teaching psychological principles and skills to family practice residents at the University of Kansas Medical Center. And finally, we introduce an instrument, the Interview Rating Scale (IRS), for evaluating the interviewing skills of physicians and residents.

Back to basics: fundamental cognitive therapy skills for keeping drug-dependent individuals in treatment

Cognitive therapists who treat drug-dependent patients are likely to lose at least 50 percent of their patients to dropout. This chapter has presented a cognitive model for conceptualizing missed sessions and dropout, along with strategies for reducing the likelihood of missed sessions and dropout. The following should serve to highlight these strategies. 1. Therapists are encouraged to offer warm, empathetic, collaborative relationships in which drug-dependent patients can feel accepted, understood, and validated. 2. Therapists are encouraged to develop comprehensive, accurate case conceptualizations, with attention paid to the potential for missed sessions and dropout. Case conceptualizations should ultimately guide cognitive and behavioral techniques. 3. Therapists are encouraged to structure sessions and elicit feedback regarding their patient's thoughts and beliefs about therapy and the therapist. This feedback is facilitated by such questions as, "What do you like most about therapy?" "What do you like least?" "What has changed in your life as a result of therapy?" "How do you view our relationship?" 4. Therapists are encouraged to socialize patients in a timely, appropriate manner. 5. Similar to the process of socialization, therapists are encouraged to use cognitive and behavioral techniques in a timely, appropriate manner. It is unrealistic to think that the problems of missed sessions and dropout from drug treatment will ever be fully resolved. Nonetheless, the authors believe that the conceptual models and fundamental strategies presented in this chapter represent a significant step in addressing these problems.

Group cognitive-behavioral therapy for women with PTSD and substance use disorder

This paper describes a model of group cognitive-behavioral therapy (CBT) for women with posttraumatic stress disorder (PTSD) and substance use disorder (SUD). The need for specialized treatment derives from the high incidence of these comorbid disorders among women as well as from their particular clinical presentation and treatment needs. The treatment educates patients about the two disorders, promotes self-control skills to manage overwhelming affects, teaches functional behaviors that may have deteriorated as a result of the disorders, and provides relapse prevention training. The program draws on educational principles to make it accessible for this population: visual aids, education for the patient role, teaching for generalization, emphasis on structured treatment, testing of acquired knowledge of CBT, affectively engaging themes and materials, and memory enhancement devices.

Prenatal predictors of cesarean section due to labor arrest

Cesarean section due to labor arrest occurs because the fetus is too large for the maternal outlet tract. If these women could be identified prior to labor, patient management could be optimized for both the clinician and the woman. A case-control study was designed to identify predictors of Cesarean section due to labor arrest. A five year retrospective review identified 32 cases and 329 controls with complete data for the prenatal maternal variables. Both cases and controls were considered for the stepwise logistic regression model. The prenatal variables predicting Cesarean section due to labor arrest are parity, history of past macrosomia, maternal age, term fundal height and maternal height. This model can be considered a pilot model that can be tested in a large international/inter-ethnic population.

Coping With Life-Threatening Illness: A Cognitive Therapy Perspective

For years, behavioral scientists have been examining the process of coping with life-threatening illnesses. In fact, much of the work in this area has been influenced by cognitive-behavioral theories (e.g., Lazarus & Folkman, 1984). The purpose of this article is to apply Beck’s model of cognitive therapy to coping, to discuss specific cognitive processes related to life-threatening illnesses, and to suggest specific interventions appropriate for individuals diagnosed with life-threatening illnesses. AIDS, cancer, and myocardial infarction are discussed in terms of the emotional reactions they may produce (e.g., anxiety, depression, and anger). Cognitive processes related to these emotions are examined and cognitive therapy techniques are suggested for helping individuals with maladaptive emotional and behavioral coping responses.

The KUFP five-visit quit-smoking program

This article has presented an overview of the Quit-Smoking Program developed and modified at the KUMC Department of Family Practice. Originally, this clinic was designed as a group treatment program, facilitated by a psychologist and physician. Recently, however, the program has been modified for office-based primary care physicians. Because smoking is such a deadly habit, it is hoped that physicians will take a more active role in smoking cessation efforts with their patients who are currently smokers.

Dual-doctor marriages: career development

BACKGROUND

Career development of married doctor couples has not previously been studied. This research evaluated the career development of physicians in dual-doctor marriages to determine whether one spouse's career development took priority over that of the other.

METHODS

We studied 21 dual-doctor marriages in England that had been referred to us by other married physician couples. A same-sex interviewer interviewed each partner of each couple alone in a one-hour interview that included closed- and open-ended questions.

RESULTS

More than half of the female physicians selected a specialty based on its anticipated effect on their spouses and on childbearing considerations. Only 5% of male physicians considered these factors in selecting a specialty. In contrast to wives, husbands generally worked longer hours, took more call, earned more money, and pursued their professional training in an uninterrupted fashion, never working part time and only rarely changing job location because of the wife's job.

CONCLUSIONS

In dual-doctor marriages in Britain, there is a tendency for the husband's career development to take priority over the wife's. Husbands more frequently choose a specialty without considering domestic factors.

Dual-doctor marriages: the British experience

While dual-doctor marriages are increasingly common, the attributes of these marriages, as seen by both partners, are little studied. We interviewed both partners in 21 married-doctor couples in Britain using a structured interview format. Results indicated that the doctors were minimally competitive with their spouses, generally sympathetic with their partners' needs for personal time, supportive of their spouses' careers, reasonably satisfied with their sex lives, had some difficulty relaxing, and communicated relatively well with their spouses. The division of household chores reflected traditional sex-role stereotyping. Overall, the most highly rated sources of conflict in the marriages were the amount of time the husband was away from home at work, in-laws, and bringing work home. Respondents generally rated their marriages high and believed the major advantage of a dual-doctor marriage was understanding on the part of both partners of all aspects of being a doctor. That one partner's career must take precedence and lack of time for other pursuits were seen as the major disadvantages.

Obstetrical practices of members of the Kansas Academy of Family Physicians

Data reported from this survey of the members of the Kansas Academy of Family Physicians indicate that members performing obstetrics are paying significantly higher professional liability premiums than members not providing such services. This difference, as well as the overall escalating costs of professional liability insurance, can be expected to result in loss of family physician-provided obstetrical services. As family physicians are providing the only readily available obstetrical services in a substantial number of rural areas, it seems likely that rural areas will experience a significant loss of access to obstetrical care. Although delivery fees have risen, they have not risen at the same rate as premiums. A net loss of family physicians providing obstetrical services has been noted during the period of 1985-88, and such losses appear to be an accelerating future trend.

Factors predictive of heightened third-day bilirubin levels: a multiple stepwise regression analysis

The purpose of this research was to prospectively study the variables contributing to the variance in third-day bilirubin levels in healthy, full-term newborns. The study subjects were 252 full-term, healthy infants born at the University of Kansas Medical Center over a four-month period. Using a multiple stepwise regression analysis, six factors were found to be significant predictors of higher third-day bilirubin levels: higher cord bilirubin level; lower total serum protein in the infant on admission to the nursery; sex of the child; administration of promethazine hydrochloride during labor; greater weight loss in the infant; and breast-feeding. Several other factors which have been implicated previously--including use of oxytocin for induction or augmentation of labor, previous use of birth control pills by the mother, prolonged rupture of membranes prior to delivery, type of delivery, race, and epidural anesthesia--were not found to be significant predictors of third-day bilirubin levels once the six variables listed had been taken into consideration. The results are discussed in terms of past research as well as implications for clinical practice.

An experimental study of two methods for teaching sexual history taking skills

The purpose of this study was to test two distinct components of a sexual history taking training program in a controlled, randomized experiment. Twenty-four family practice residents were divided into two groups. One group received skills oriented training and the other received sexual awareness oriented training. Both groups received active listening skills training and general information about sexual dysfunction. The effects of the two treatment groups were assessed by residents' performance in videotaped simulated sexual history interviews. Results strongly suggested that the skills oriented method was more effective than the awareness oriented method for teaching residents to take a sexual history. No residents elicited information about sexual orientation. These results are discussed in terms of their implications for teaching and research in sexual history taking skills.

Perceptions and treatment of sexual problems

In this research, perceptions and beliefs which affect the family physician's treatment of sexual problems were studied. A 66-item questionnaire, the Survey of Sexual Problem Care (SSPC), was completed by 68 individuals. Respondents reported that they would be more likely to consult a family physician for the treatment of sexual problems than any other individual; however, few (11%) of those surveyed had actually sought treatment for sexual problems. Confidentiality was reported to be the most important characteristic in persons consulted for sexual problems, and treatment was more likely to be sought from family physicians when problems were believed to have a physical (vs. psychological) etiology. The implications of these results are discussed.

A strategy to improve developmental screening during well baby visits

There is evidence that the developmental exam is frequently neglected during the well baby exam because of time constraints. We placed a simple, standardized developmental screening instrument on the medical record of children under two years of age and then monitored physician use of the chart for the next 18 months. Developmental screening increased from 15.7% during the 12 months prior to our intervention to 41.9% during the 12 months after our intervention. Use of the screening instrument by faculty appeared to have an important influence on resident physician use of the instrument during the well baby exam.

Alcoholics who drink mouthwash: the spectrum of nonbeverage alcohol use

Nonbeverage alcohol (NBA), or substitutes for traditional forms of beverage alcohol, includes such substances as mouthwash, aftershave lotion and alcohol-based fuels. Literature pertaining to the prevalence, clinical significance and toxicity of this practice is reviewed, using illustrative cases from a series of 48 NBA consumers. It was found that 10-15% of alcoholics hospitalized in detoxication units have consumed NBA; half of these patients are regular consumers. Addiction to NBA itself may occur. Its use is primarily related to easy accessibility, rather than social or monetary factors. Polydrug misuse and antisocial personality disorder are more frequent in NBA users, but use is not pathognomic of end-stage alcoholism. The 48 NBA users reported surprisingly few toxic symptoms from acute ingestion, perhaps because tolerance to some substances in NBA may occur. Isopropyl alcohol was the exception, reproducibly causing symptoms suggestive of severe gastritis.