Table of Contents
The Issue in Brief
Ann Fam Med 16: 2.
The Issue in Brief
Prescription Opioid Use and Satisfaction With Care Among Adults With Musculoskeletal Conditions
Brian D. Sites , and colleagues
Background Physician reimbursement is often based, at least in part, on patient satisfaction scores. This study examines the relationship between use of prescription opioids among adult patients with musculoskeletal conditions and their satisfaction with care.
What This Study Found Patients with musculoskeletal conditions who receive prescription opioids are more satisfied with their care than comparable patients who do not receive opioids. In a study of nationally representative data, 13 percent (2,564) of more than 19,000 patients with musculoskeletal conditions used prescription opioids. Among those who used opioids over time, moderate and heavy use was associated with greater likelihood (55 percent and 43 percent, respectively) of being most satisfied, compared to single or no use of opioids. Although opioids may be expected to offer patients with musculoskeletal conditions improved pain control, patients taking opioids in this study had more pain and worse health and disability than those taking limited or no opioids, suggesting a more complex picture.
Implications
- As clinician compensation is increasingly linked to patient satisfaction, and as the United States struggles with an epidemic in opioid use, the authors suggest it is imperative to determine whether improved satisfaction with care is associated with demonstrable health benefits.
Integrating Community Health Workers Into Medical Homes
Elizabeth A. Rogers , and colleagues
Background There is evidence for the value of community health workers (non-clinical workers from the communities they serve) in helping patients manage chronic diseases, yet they are often not considered an essential part of the health care team. This qualitative study set out to define the roles of community health workers (CHWs) on medical home care teams and identify facilitators and barriers to utilizing a community health worker model.
What This Study Found Community health worker models are facilitated by leaders/champions with knowledge of CHWs, a practice culture of innovation, prioritization of patients' non-medical needs, and sustainable reimbursement strategies. Their roles include outreach, health education and coaching, community resource linkage, system navigation, and facilitating communication between patient and clinician.
Implications
- The authors contend that work remains to raise awareness of community health workers, in spite of growing evidence of their effectiveness.
Detecting Hepatitis B and C by Combined Public Health and Primary Care Birth Cohort Testing
Jeanne Heil , and colleagues
Background Chronic hepatitis C and B virus infections do not usually have symptoms, so many infections remain undetected or are diagnosed at a late stage. In order to detect this hidden population, researchers set out to determine the diagnostic yield (test uptake and positivity rate) of a birth cohort testing strategy in identifyting hepatitis B and C viruses.
What This Study Found A strategy to test the general population for hepatitis B and C viruses in areas of high prevalence had high test uptake but did not detect hidden chronic hepatitis C infections. The study, a public health-primary care collaboration, sought to test individuals between 40 and 70 years of age (n = 6,743) in two Dutch hepatitis hotspots. All family physicians in the hotspots invited their patients to be tested, with implementation and follow-up by the regional public health service. Test uptake was higher than expected at 51 percent (n = 3,434), however no active/chronic hepatitis C infections were detected.
Implications
- This strategy, the authors surmise, could be effective in countries with higher rates of hepatitis or other infectious diseases, but is not recommended for low prevalence countries.
Klaus B. von Pressentin , and colleagues
Background Family medicine is relatively new as a formal medical discipline in South Africa. As the country moves toward a national health insurance system, researchers set out to assess the influence of family physicians in community health centers and district (generalist) hospitals.
What This Study Found District (generalist) hospitals with family physicians have better clinical processes and health system performance, while community health centers with family physicians have lower scores in those domains. In a study across seven South African provinces, district hospitals with family physicians had higher availability of essential services, such as pediatric and emergency care, and better child and neonatal health. In contrast, community health centers with family physicians generally had lower scores for health system performance and clinical care and were associated with significantly lower scores for continuity and coordination of care. These findings differ from a large body of literature which finds that family physicians enhance continuity and coordination. The authors hypothesize that the differences might be due to the areas in which family physicians were deployed (areas of greatest need and workload, which were predisposed to perform more poorly) and/or to differing levels of physician influence (hospital teams were led by doctors, community health center teams were led by nurses).
Implications
- The authors call for training programs that have sufficient focus on community health settings and further exploration of family physicians'roles in community health centers.
Anthony Dowell , and colleagues
Background The quality of communication between clinicians and patients can make a significant difference in health outcomes. In order to gain an in-depth picture of communication processes in a primary health care team over time, this study directly observes patients newly diagnosed with diabetes as they interact with their clinicians.
What This Study Found When patients are diagnosed with diabetes, primary care clinicians display high levels of technical knowledge and communication skill, but initial consultations are often driven by biomedical explanations out of context from patient experience. A qualitative study of 32 patients newly diagnosed with type 2 diabetes found strengths in primary care interactions including high levels of communication skills, coordination of services, and significant allocation of time with patients. Challenges to optimal care remain, however. Despite high levels of generic communication expertise by clinicians, many patients found the style and content of health promotion and lifestyle advice not applicable to their lives. Similarly, although sufficient time was allocated, it was not well coordinated between health professionals. Other concerns included overuse of a checklist approach and a need for more effective methods of sharing patient information.
Implications
- The findings highlight the important role that communication plays in diabetes management and the commitment of primary care teams to engage with patient care. The authors recommend that clinicians employ a biopsychosocial framework for communications with newly diagnosed diabetes patients and coordinate allocation of time when patients see multiple clinicians.
Family Physicians Managing Medical Requests From Family and Friends
Esther Giroldi , and colleagues
Background Although it is discouraged, physicians regularly receive medical requests from family members and friends (non-patients). This study explores the experiences and attitudes of family physicians in training, as well as more experienced family physicians, towards managing medical requests from non-patients.
What This Study Found Physicians follow a complex process in deciding how to respond to medical requests from family or friends (non-patients). According to a focus group study of 33 family medicine residents and 16 senior physicians, physicians first orient themselves to the situation: who is this person; what is he or she asking of me, and where are we? They also consider the nature and strength of the relationship with the non-patient, their level of trust in their own knowledge and skills, potential consequences of making mistakes, the importance of work-life balance, and the risk of disturbing the individual�s relationship with her/his physician. Senior physicians apply more nuanced considerations when deciding whether or not to respond; residents experience more difficulties in dealing with these requests, are less inclined to respond, and are more concerned about disturbing the existing patient-physician relationship.
Implications
- Although non-patient requests of physicians are common, they are rarely formally discussed. The authors suggest developing facilitated group discussions to help residents gain an understanding of and confidence in addressing such issues.
Features of Terra Firma-Forme Dermatosis
Nurad Cifci Aslan , and colleagues
Background Terra firma-forme dermatosis is a hyperpigmented skin disease with a dirt-like appearance. It can be easily diagnosed and treated but, if not recognized, can lead to expensive diagnostic and treatment procedures. This study evaluates the demographic and clinical features of terra firma-forme dermatosis.
What This Study Found In a study of medical records of 79 patients, the dermatoses were found on the trunks of 28 percent of patients, on extremities of 27 percent of patients, in fold zones of 9 percent of patients, and on the heads of 3 percent of patients. Thirty-four percent of patients had more than one lesion. Swabbing the lesions with alcohol serves to both diagnose and treat the condition.
Implications
Predictors of Attrition From Family Medicine Board Certification
Winston Liaw , and colleagues
Background While certification of physicians by a medical board has been linked to improved clinical knowledge, higher quality, and less disciplinary action, some physicians leave the certification process. This study examines the percentage of physicians not attempting recertification after initial certification and describes their characteristics.
What This Study Found Of 51,678 family physicians who received board certification between 1980 and 2000, 5.6 percent did not attempt to recertify, with a slight increase in the most recent cohort. The percentage not attempting recertification increased with each additional failed initial certification attempt, rising to 24 percent for diplomates who failed three or more times. International medical graduates, men, and older diplomates were more likely to not attempt recertification.
Implications
- According to the authors, attrition from board certification may be a transitional step between burnout and leaving the primary care workforce. The authors recommend following these trends, uncovering underlying motivations, and identifying new interventions to minimize attrition.
Medical Students' Views of Medicine as a Calling and Selection of a Primary Care-Related Residency
Audiey C. Kao , and colleagues
Background With the US health care system facing a primary care physician shortage, this study evaluates whether medical students who view medicine as a calling are more likely to enter a primary care (family medicine, internal medicine, or pediatrics) residency program.
What This Study Found Medical students who strongly believe that medicine is a calling are more likely than their counterparts to select a primary care residency. A survey of a random sample of 1,000 fourth-year allopathic and osteopathic medical students found that while most respondents saw the practice of medicine as a calling, those who strongly agreed had significantly greater odds of selecting a primary care-related residency.
Implications
- Fostering, or at least not undermining, a sense of calling among future physicians could be a strategy to help address the looming primary care physician shortage.
Using State Administrative Data to Identify Social Complexity Risk Factors for Children
Kimberly C. Arthur , and colleagues
Background Identifying children with adverse childhood experiences is challenging but critically important, because early intervention has the potential to improve health across the lifespan. This study tests the feasibility of using an integrated state agency administrative database to identify childrens' social complexity risk factors and examine their relationship to emergency department usage.
What This Study Found State administrative data can be used to identify social risk factors for children. Researchers linked administrative data for more than 500,000 children receiving Washington State Medicaid insurance coverage with parent data to identify social complexity risk factors (individual, family, or community characteristics that can affect health outcomes), such as poverty and parent mental illness. They found that social complexity risk factors frequently co-occurred, with approximately one-half the study population having two or more risk factors. Of 11 identifiable risk factors, nine were associated with a higher rate of emergency department utilization. The magnitude of the association with the rate of emergency department utilization was small for individual risk factors, but the rate increased as the number of risk factors increased independent of medical complexity.
Implications
- Providing primary care physicians with a social complexity flag or score, the authors suggest, could facilitate targeted screening of families who are likely to have social risk, with the goal of identifying families who could benefit from care coordination or other supportive services. This, in turn, would help make best use of limited time and resources in primary care.
Medical Interpreters in Outpatient Practice
Barry D. Weiss , and colleagues
Background An estimated 62 million people in the United States speak a language other than English at home, including approximately 25 million people with limited English proficiency. This article--from medical, legal, and education professionals--reports on requirements for and benefits of providing medical interpreters in outpatient practice.
What This Study Found US medical professionals who work with patients with limited English proficiency should rely on trained medical interpreters to give them the best comprehension of what a patient is saying. Federal law requires health programs and clinicians receiving federal funds (eg, federal grants, Medicaid, or Medicare Part A) to take reasonable steps to provide meaningful access to individuals with limited English proficiency, including interpreter services. In some cases, Medicaid or other federally-funded medical insurance will cover the cost of an interpreter.
Implications
- The authors suggest that a language access plan involving professional medical interpreters will provide better health outcomes, ethical patient care, improved patient satisfaction, and reduce costly repeat visits by patients with limited understanding of their clinicians.
Julie M. Stausmire , and colleagues
What This Study Found When a physician experienced chest pain, he denied he could be having a heart attack. When he lost consciousness driving to work, an extraordinary group of people was close by--"the right people with the right equipment in the right place at the right time"--and saved his life. Now, thankful for a second chance, he is determined to make a difference as a clinician and educator.
Where We Belong: An Open Letter to My Colleagues in Training
David Loxterkamp
What This Study Found This essay, by a long-time family physician, reflects on the differences between his generation, in which physicians spent long hours in practices they owned, and a new generation in which physicians are more likely to be employees striving for work-life balance.While he notes their generational differences, the author is more struck by what they have in common: a sense of purpose and a desire to connect. In the end, he suggests that his younger colleagues have both an opportunity and a challenge: "to be there for your patients, on their terms and yours, in communities you both will call home."