Table of Contents
PLAIN LANGUAGE SUMMARIES
Plain Language Summaries, Volume 21, Issue 6
November-December 2023
Commentary on the CRISP Statement
José E. Rodríguez and colleagues
Background Drs. José Rodriguez, Sherri Sheinfeld Gorin, and Vincent Van Vugt, primary care researchers and Annals of Family Medicine associate editors, compose this issue’s editorial about the new Consensus Reporting Items for Studies in Primary Care (CRISP) Statement and Checklist. The checklist was created by an international team of primary care researchers to address the field’s unique perspectives, approaches, and research concerns.
What This Study Found While the editorialists applaud the team’s efforts at creating the checklist, they encourage primary care researchers to use race/ethnicity and gender when describing patients as a means to promote health equity. They also encourage their fellow scientists to involve more patients in the research process, considering that primary care strives to be patient-focused. They note that the checklist is a dynamic tool for change and encourage the primary care research community to review the CRISP guidelines and offer input on what they feel may or may not work. Input can be provided here: https://crisp-pc.org.
Implications
- Rodriguez et al argue that by working together, the primary care research community can make these guidelines more meaningful for the growing community of family medicine researchers.
Benjamin Littenberg and colleagues;
Background Researchers from around the United States collaborated on a clinical trial to test
the effectiveness of a practice intervention for improving outcomes for patients with
both physical and mental health problems by enhancing integrated behavioral health
(IBH) activities. The research team recruited 42 primary care practice sites in 13
states, including internal medicine, family medicine, small and large groups, for-profit,
academic, and safety-net clinics. Each site had a co-located behavioral health provider
(a psychologist, social worker, or licensed counselor in the same building) working
at least 0.5 FTE and a Practice Integration Profile (PIP) score (a measure of staff
perception of IBH activities) below 75 out of 100. Electronic health records were
used to identify eligible adult patients with multiple chronic medical and behavioral
conditions at these practices, of whom 2,426 agreed to participate in the study.
Twenty practices randomly assigned to the active group were required to assemble an
intervention team with a facilitator. They had access to an intervention toolkit with
workbooks to guide quality improvement (QI) strategies within the practice and in
care management; online education tailored to clinic roles; and remote coaching for
the facilitator and intervention team. The 22 practices randomly assigned to the control
group did not implement the intervention. At the start, midpoint, and two-year mark
of the study, staff at all participating practices completed the PIP survey, while
all patient participants (967 in the active group, 1,459 in the control group) completed
the Patient-Reported Outcomes Measurement Information System (PROMIS-29) survey. The
research team measured changes in the level of practice integration as indicated by
the six domains of the PIP survey (Workflow, Clinical Services, Workspace, Integration
of Providers, Patient Identification, and Patient Engagement) and changes in the eight
PROMIS-29 domain scores (Physical Function, Anxiety, Depression, Fatigue, Sleep Disturbance,
Social Functioning, Pain Intensity, and Pain Interference).
What This Study Found Total PIP scores improved minimally for both active and control practices. Though
there was no significant difference between their overall levels of improvement, the
active group’s Workflow scores had a nearly 10-point increase, while the control group
showed marginal improvement. Overall, the PROMIS-29 scores revealed no significant
difference in the amount of change reported by patients at the active practices compared
with patients at the control practices; patient outcomes also tended to be higher
at practices that started with a higher level of IBH. However, patient outcomes showed
greater improvement at the 13 active practices that followed the intervention workbook
to completion.
Implications
Family Physician Motivation and Well-Being in the Digital Era
Adam Neufeld and colleagues
Background Canadian researchers examined how the rapid shift to using virtual care during the COVID-19 pandemic has impacted primary care doctors’ well-being at work. They utilized a self-determination theory (SDT) lens to examine how autonomous (vs. controlled) motivation among family physicians impacted their well-being when shifting to virtual care, and whether satisfaction (vs. frustration) of their basic psychological needs at work mediated that relationship. The researchers gathered qualitative data by surveying 156 family physicians in Alberta, Canada. The questionnaire contained validated scales for measuring motivational quality, workplace psychological need fulfillment, and subjective well-being. They performed descriptive, correlational, and mediation analyses.
What This Study Found The authors found that primary care doctors who felt that they had little choice in using virtual care had decreased well-being, and frustration of their basic psychological needs for autonomy, competence, and relatedness fully mediated that relationship. Conversely, basic psychological need satisfaction at work was associated with higher well-being.
Implications
Saharuddin Ahmad and colleagues
Background Researchers studied communication about erectile dysfunction (ED) between doctors and 120 Asian male patients with diabetes in a primary care clinic in Kedah, Malaysia. At the outset of the study, all participating physicians received a brief introduction to the fundamentals of ED treatment. Prior to a regular consultation, 60 men (the intervention group) were given a simple prompt sheet on which they could indicate whether they wanted to discuss, or were already discussing, ED with their doctor; physicians in the intervention group were provided with a knowledge translation flipchart developed by the researchers to assist with ED discussion. The flipchart featured concise, plain-language text and colorful illustrations, presented on paired patient- and physician-facing panels. Neither patients nor doctors in the control group received materials to facilitate discussion. Following consultation, all 120 men in the study completed a survey providing demographic information, an ED diagnostic sheet (the 5-item International Index of Erectile Function, or IIEF-5), and questions about any discussion of ED with their physician.
What This Study Found About two-thirds of the intervention group discussed ED-related issues with their
physician, compared with 8.3% of the control group. ED medications were prescribed
to 57.5% of subjects in the intervention group, but to none in the control group.
Physicians used the flipchart in 82.5% of intervention group consultations, and all
patients with whom the flipchart was used reported that they were satisfied with their
consultations.
Implications
Veterans and Nonveterans Coping With Stress During 4 Months of COVID-19
Jorie M. Butler and colleagues
Background Researchers assessed Veterans Affairs participants’ patterns of coping strategies, as well as the stability and change in strategies, at three timepoints (December 2020-March 2021) when COVID-19 vaccines became widely available. Two thousand and eighty-five participants completed surveys at any time point during the specified time frame and 930 participants completed all three surveys. Researchers identified three distinct coping styles: Adaptive, Distressed, and Disengaged. They then assessed stability and change over time in these strategies.
What This Study Found They found that the majority of the sample (71%) changed their coping style at least
once during the study period. Participants who used stable coping styles across all
three points reported lower levels of anxiety and depression.
Implications
- Study results suggest that coping styles are not necessarily evolving in a direction
of growth, resilience, or adaptation, making it important to understand how a change
in coping styles over time may impact well-being and to support patients during coping
with stress.
Home Monitoring of Asthma Exacerbations in Children and Adults With Use of an AI-Aided Stethoscope
Kamil Janeczek and colleagues
Background Adults and older children with asthma can take objective measures of symptoms such
as peak expiratory flow (PEF), the volume of airflow in one forced exhalation, at
home. This provides a more complete picture of their disease and helps them detect
asthma exacerbations or negative changes to their condition at the onset. Assessment
of these symptoms, still primarily done by doctors using stethoscopes in face-to-face
visits, can be largely subjective, especially when judged by those who are not medical
professionals. There is no objective tool currently recommended for parents to monitor
their young children’s symptoms at home.
Researchers conducted a six-month observational study on 149 home-monitored asthma
patients of various ages in Poland. They investigated which symptoms are crucial to
measure in detecting exacerbation. To what extent could an AI-aided home stethoscope
support detection, especially in young children? Standard certified medical devices
were used to take objective measures of certain asthma symptoms (pulse oximeters for
peripheral capillary oxygen saturation, and peak flow meters for expiratory flow)
in study participants over five years old but not for participants under 5 years old.
For more subjective, auditory symptoms, a Conformité Européenne-certified StethoMe,
an AI-based home stethoscope, recorded auscultatory sounds from standard chest points
of all study participants and transferred the sound files to a cell phone app.
The recordings were automatically analyzed by an AI module and the generated results
(pathological auscultatory sound intensities, heart rate, respiratory rate, inspiration-to-expiration
duration ratio) were displayed in the app. All data were analyzed by physicians via
an online platform to identify exacerbation occurrences.
What This Study Found Results suggest that, while taking multiple measures is preferable, AI analysis of
home stethoscope recordings alone can efficiently detect asthma exacerbation in patients
of all ages, including children under 5 years old.
Implications
Jennifer Shuldiner and colleagues
Background In Ontario, Canada, most COVID-19 vaccinations were administered by public health
organizations and pharmacies rather than by family physicians. Researchers devised
a practice facilitation intervention program to help family physicians proactively
engage with their patients who were not yet vaccinated for COVID-19.
Six trained practice facilitators helped 90 family physicians identify unvaccinated
patients and offered resources to address COVID-19 vaccine hesitancy, scripts and
email templates for patient outreach, and connections to trained medical student volunteers
to work as physician-delegates by conducting patient telephone outreach and motivational
interviewing. At the end of the four-month intervention, the researchers interviewed
both the practice facilitators and the physicians participating in the study about
their experiences. They also analyzed quantitative data capturing the amount of time
facilitators spent working with participating clinics and the percentage of physicians
requesting each type of available support.
What This Study Found The results suggest that the most useful service provided by the facilitators was
helping physicians identify unvaccinated patients; medical students who shared a language
or cultural background with patients were also appreciated. Barriers to implementing
practice facilitation included resistance by physicians and/or staff and time required
for onboarding and training. The most popular types of support, such as robocalls
to patients, required minimal engagement and time commitments from physicians and
clinic staff.
Implications
Patients Who Seek to Hasten Death by Voluntarily Stopping Eating and Drinking: A Qualitative Study
Eva Elizabeth Bolt and colleagues
Background Some patients choose to voluntarily stop eating and drinking (VSED) as a way of hastening death. Researchers from the Amsterdam University Medical Centre conducted a study to describe patients’ motives for doing so, how they decide to voluntarily stop eating and drinking, and the way in which they prepare to do so, along with how they involve others. The researchers conducted qualitative interviews with 29 patients living in the Netherlands. Among 29 cases, 24 started VSED and 19 died. Thirteen cases were included before and during VSED and 16 afterwards. Study participants include 17 patients, 18 informal caregivers, and 10 professional caregivers.
What This Study Found Researchers identified three specific groups of patients who decided to adopt VSED to hasten death. Older people who felt their lives were complete and valued control over the end of their lives were well prepared to carry out VSED and could overlook the need for help and the emotional burden they would have placed on relatives. The second group were older, care-dependent patients with poor quality of life. They often started VSED suddenly and relied heavily on mostly informal caregivers for the preparation and execution of their end-of-life plans. The third group were mostly younger psychiatric patients with a long-lasting, though often fluctuating, wish to control their own deaths. These patients often prepared for VSED in secrecy or initiated VSED unprepared.
Implications
Implications of Overturning Roe v Wade on Abortion Training in US Family Medicine Residency Programs
Sarah Wulf and colleagues
Background Researchers performed an analysis to assess the proportion of accredited U.S. family
medicine residency programs and trainees in states with abortion restrictions. Of
693 accredited family medicine residency programs in the U.S., 201 programs (29%)
were in states where abortion was banned or heavily restricted as of August 2, 2023.
Fourteen of the 17 states in this category had complete abortion bans.
What This Study Found While most (63.8%) family medicine residency programs were in states with at least
some abortion restrictions, 251 programs (36.2%) were in states with laws protecting
abortion. Of the 13,541 residents in accredited U.S. family medicine programs, 3,930
(29%) were training in states that had banned abortion or where abortion was very
restricted and 5,020 residents
(37.1%) were in states with protective policies. Most residency programs with abortion
training (85%) were in states with protective abortion policies.
Implications
William R. Phillips and colleagues
Background In an effort to fill the need for primary care–focused guidelines, an international
group of top researchers has developed the Consensus Reporting Items for Studies in
Primary Care (CRISP) Checklist, which outlines 24 items that describe the research
team, patients, study participants, health conditions, clinical encounters, care teams,
interventions, study measures, settings of care, and implementation of findings and
results in primary care. The CRISP Working Group conducted a scoping review of literature
on the state of primary care research reporting as well as several rounds of online
surveys to assess the needs of a broad range of primary care researchers, practitioners,
journal editors, and patients and other lay research users worldwide. At each stage,
the group refined the options for potential reporting items based on survey participants’
responses, thereby moving toward a consensus CRISP Checklist.
What This Study Found Pilot testing of the checklist with a small group of participants across primary care
constituencies yielded largely positive feedback. The CRISP Working Group considers
the checklist to be a living document that will evolve as more people promote and
use it. To that end, they welcome feedback through the CRISP website at www.crisp-pc.org.
The CRISP Checklist appears in the article, and an Explanation & Example report further
elaborating on the checklist items is included as an appendix.
Implications
reports of PC research. It summarizes items that the PC community feels are essential for
transparency, quality, and usefulness. However, the CRISP guidance does not constrain effective or creative research communication. Final decisions on content and form rest with authors and editors.
The Seven Words That Changed My Perspective on Patient Care
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Samantha Gogola
Background Medical student Samantha Gogola writes about the power of open-ended questions in interactions with various patients. From the woman who has lived with pain for decades to the physically wounded man in the wheelchair who is also experiencing homelessness, Gogola writes about the common thread that emerges in each of her medical encounters with these patients, specifically the profound impact that a simple personal question can have on clinical encounters.
What This Study Found She notes that oftentimes, patients will respond, “No one’s ever asked me that before,” when she has asked them open-ended questions. To Gogola, their responses echo with a sense of longing and unmet needs. She writes that this left her thinking of the ways elicitation of personal narratives can foster the expression of fears and struggles, aiding in both emotional and physical recovery.
Implications
PurpLE Clinic: A Primary Care Pilot for Survivors of Sexual Violence, Abuse, and Exploitation
Anita Ravi
Background Survivors of interpersonal trauma—including people who have experienced human trafficking, intimate partner violence, and sexual assault—may avoid health care due to fear of stigmatization and potential re-traumatization in health care settings. A family medicine physician founded a clinic within a federally qualified health center in New York City to provide health care, as well as referrals to social and mental health services, to survivors of sexual violence, abuse, and exploitation.
What This Study Found During its 3.5 years, the program received nearly 700 referrals from 75 community
partners, with 287 patients ultimately connecting for care (62% had repeat visits,
ranging from 2 to 43 visits). Survivors (and their children) received routine primary
care, including reproductive, HIV, LGBTQ+, and preventative health care, regardless
of age,
documentation, or insurance status.
Implications