Long-term physical and psychological symptoms in Syrian men subjected to detention, conflict-related sexual violence and torture: cohort study of self-reported symptom evolution.

Background: Since March 2011, more than 1 million people, mostly men, have been arrested, detained, and tortured by the Assad regime. Published literature does not reflect the evolution of symptoms after male sexual and physical violence in detention. This cohort study examines the constellation and evolution of self-reported symptoms after male conflict-related sexual violence (CRSV) in Syrian state detention. Methods: Sexual, psychological, and physical symptoms and conditions experienced by a cohort of 106 male detainees after CRSV in Syrian regime detention were evaluated over a ten-year period (2012-2022). Men sought forensic medical expert evaluations (FMEs) to document torture and later consented to semi-structured interviews (SSIs), a median of 8.8 years after their detention. A standard data collection tool was used to assess symptoms and conditions during FMEs (Time 3), and at the time of the SSI (Time 4), during which men also reported symptoms experienced during detention (Time 1) and after detention release (Time 2). Findings: 30.2% of men spent more than 1 year in detention and 9.4% were detained >5 years. 90% reported being slapped, punched, kicked, hit with objects, 60.4% of men reported torture with multiple devices, and 48.1% reported being burned or electrocuted. Multiple sexual violence types were reported during detention: 97.2% forced nudity, 45.3% violence to genitals or anus, 30.2% collective sexual humiliation, and 9.4% rape. Men recalled nearly universal presence of acute pain, bleeding wounds, skin infections, sleep disturbances, fear, sadness, anxiety, and despair during detention. By Time 4, acute physical and psychological conditions were fading or absent, while scars, avoidance, intrusive memories, lack of trust, self-isolation, chronic pain, anger, and low self-esteem were reported by ≥50%. The most persistently reported symptoms following detention through the SSI included scars, pain, intrusive memories, and avoidance in ≥50% of men. At the SSI, 26.4% of men reported erectile dysfunction and 23.6% challenges with sexual relations. Interpretation: Men reported persistent symptoms and conditions years after CRSV, torture and detention. The unique constellation of findings and their evolution in male CRSV survivors, particularly increasing rates of anger, distrust, and self-isolation, must urgently inform design and delivery of support services and health care. Funding: This study was funded by the United Kingdom Foreign Commonwealth and Development Office and the Arts and Humanities Research Council through the project 'Understanding and Addressing the Impact of Invisibility on Conflict-Related Male Sexual Violence in Syria'.

Academic Health Centers and Humanitarian Crises: One Health System's Response to Unaccompanied Children at the Border.

University of California Health (UCH) provided a system-wide, rapid response to the humanitarian crisis of unaccompanied children crossing the southern U.S. border in the midst of the COVID-19 pandemic in 2021. In collaboration with multiple federal, state, and local agencies, UCH mobilized a multidisciplinary team to deliver acute general and specialty pediatric care to unaccompanied children at 2 Californian emergency intake sites (EISs). The response, which did not disrupt normal UCH operations, mobilized the capacities of the system and resulted in a safe and developmentally appropriate environment that supported the physical and mental health of migrant children during this traumatic period. The capacities of UCH's 6 academic health centers ensured access to trauma-informed medical care and culturally sensitive psychological and social support. Child life professionals provided access to exercise, play, and entertainment. Overall, 260 physicians, 42 residents and fellows, 4 nurse practitioners participated as treating clinicians and were supported by hundreds of staff across the 2 EISs. Over 5 months and across both EISs, a total of 4,911 children aged 3 to 17 years were cared for. A total of 782 children had COVID-19, most infected before arrival. Most children (3,931) were reunified with family or sponsors. Continuity of care after reunification or placement in a long-term shelter was enhanced by use of an electronic health record. The effort provided an educational experience for residents and fellows with instruction in immigrant health and trauma-informed care. The effort benefitted from UCH's recent experience of providing a system-wide response to the COVID-19 pandemic. Lessons learned are reported to encourage the alignment and integration of academic health centers' capacities with federal, state, and local plans to better prepare for and respond to the accelerating need to care for those in the wake of disasters and humanitarian crises.

Implementing a Trauma-Informed Approach at a Student-Run Clinic for Individuals Seeking Asylum.

PROBLEM: Health care professionals complete forensic medical evaluations (FMEs) to corroborate evidence of persecution among individuals seeking asylum. Many FMEs are conducted at student-run clinics for individuals seeking asylum (or student-run asylum clinics; SRACs). Trauma-informed care (TIC) recognizes that trauma is pervasive and seeks to mitigate reexposure to trauma in health care interactions. Given that FMEs involve recalling trauma, TIC is an ideal model for supporting the individuals involved in an FME. APPROACH: The authors operationalized TIC principles in an SRAC model (the Human Rights Cooperative) at the University of California, San Francisco. Between April 2019 and April 2022, the SRAC provided 3 to 10 pro bono FMEs per month, as well as community referrals for individuals seeking asylum, clinician and medical student training on FMEs and TIC, and research on FMEs. This report describes the SRAC operations, organized by the 10 implementation domains of the Substance Abuse and Mental Health Services Administration guidance to organizations for implementing a trauma-informed approach. OUTCOMES: Between April 2019 and April 2022, the SRAC completed 160 FMEs. Sixty-nine clinicians performed FMEs, and 119 first-year medical students participated in the accompanying elective. Qualitative survey responses by clinicians, lawyers, students, and clients (individuals seeking asylum) highlighted the trauma-informed principles of safety; trustworthiness and transparency; empowerment, voice, and choice; peer support; collaboration and mutuality; and cultural, historical, and gender issues. All students who acted as leaders sustained their engagement with the SRAC over time. NEXT STEPS: Future research should use validated tools to assess secondary trauma and resilience within SRACs. The SRAC concept, which engages medical students and experienced clinicians in learning skills that can be used in the pursuit of health justice and equity, should be expanded and supported in U.S. medical schools across the country, which is facing unprecedented levels of migration.

Asylum seeker trauma in a student-run clinic: reducing barriers to forensic medical evaluations.

Introduction This research, through the analysis of the case-law of the Inter-American Court of Human Rights (IACtHR), seeks to shed light on the nexus between families of the missing' claims, their agency and State compliance with reparations. The IACtHR has a unique follow-up system in the area of reparations, where victims can directly address the judges during hearings. This paper suggests that victims' participation - before and after the judgment- pervades the legal rigidity of international jurisdictions and contributes to a better understanding of reparations. INTRODUCTION: The number of forcibly displaced immigrants seeking asylum in the United States continues to rapidly increase. Movement from Latin America to the United States was the third-largest migration worldwide in 2017 (Leyva-Flores et al., 2019). As migration patterns change, understanding the background and trauma profile of newly displaced populations is essential to meet their health needs and aid successful resettlement. University-affiliated student-run asylum clinics conduct a growing number of forensic medical evaluations of asylum seekers and provide a vital lens to study changes in this population's profile over time. METHODS: A retrospective review was conducted of the first 102 asylum seekers receiving forensic medical evaluations between 2019 and 2021 at a university-affiliated student- run clinic, reporting demographics; trauma, medical, and mental health histories; referral patterns; and legal outcomes. Bivariate statistics were used to investigate the relationship between past trauma and mental health outcomes. RESULTS: Clients reported an average of 4.4 different types of physical, psychological, and sexual ill-treatment per person. The current mental health burden was extensive with 86.9 percent of clients reporting symptoms of PTSD and/or depression. Clinician-student teams evaluated clients within a clinic structure deploying a continuous improvement model to reduce common barriers to forensic evaluations and promote longitudinal follow- up and referrals. DISCUSSION: This study demonstrates the complexity of trauma exposure reported by asylum seekers, contributes to the evidence on how trauma results in mental health outcomes, and describes trauma-centred clinic adaptations that reduce barriers to forensic evaluations known to improve the rates of legal protection.

Evaluation of a pilot forensic dermatology curriculum in the USA.

Physician participation in asylum medicine through forensic medical evaluations increases the likelihood that asylum seekers are granted legal status. Based on a review of existing literature and input from content experts, we designed and implemented a forensic dermatology curriculum for dermatology residents at University of California, San Francisco. Our pilot curriculum led to improvements in learners' attitudes regarding physician participation in asylum medicine and their confidence in describing skin findings of torture or abuse.

Primary Care Clinician Burnout and Engagement Association With Clinical Quality and Patient Experience.

BACKGROUND: Burnout and engagement are commonly conceptualized as opposite ends of a spectrum, and there is concern that high clinician burnout and lack of engagement may adversely impact patient care. METHODS: We matched self-reported data on burnout and engagement for 182 primary care clinicians with data on clinical quality (cancer screenings, hypertension and diabetes control) and patient experience (Clinician and Group Survey-Consumer Assessment of Healthcare Providers and Systems [CG-CAHPS] communication scores, overall rating, and likelihood to recommend the clinic). Multivariable linear regression models examined burnout, engagement, or burnout-engagement phenotype (eg, high burnout-low engagement) as predictors of quality and patient experience. RESULTS: One-third of clinicians in this sample did not fall along the spectrum of low burnout-high engagement to high burnout-low engagement. Neither burnout nor engagement on their own was associated with quality or patient experience measures. However, clinicians with high burnout who also were highly engaged had the highest average ratings for all 3 patient experience domains: clinician communication, overall rating of the clinician, and overall rating of the clinic. DISCUSSION: The results of our study challenge the assumptions that burnout and engagement are opposite ends of a spectrum and that burnout or low engagement adversely impact quality of care and patient experience. Greater understanding is needed of how best to support dedicated clinicians who may provide quality care at the expense of their personal well-being.

Recognizing and intervening in child sex trafficking.

Know the risk factors, choose from among 3 validated screening tools, and use a trauma-informed approach with those likely involved in trafficking.

Utilizing Lean Leadership Principles to Build an Academic Primary Care Practice of the Future.

This Perspective presents a case study of multidimensional clinical transformation in an academic general internal medicine practice. In the face of increasing internal and external pressures, health systems and individual medical practices have pursued multiple strategies to improve quality, patient experience, and efficiency, while reducing staff and provider stress and burnout. We describe a Lean-informed approach that emphasizes the importance of organizational alignment in goals, evidence-based problem solving, and leadership behaviors to support a culture of continuous improvement. Our aim in this Perspective is to provide a real-world example of a feasible process for the planning, preparation, and execution of effective transformation, and to present lessons that may be useful to other academic health center practices seeking to develop innovative models to achieve the quadruple aim.

A Longitudinal Study of Trends in Burnout During Primary Care Transformation.

PURPOSE: The quadruple aim of primary care transformation includes promoting well-being among the primary care workforce. We longitudinally assessed burnout among clinicians and staff in 2 health delivery organizations engaged in primary care redesign guided by a shared transformation model. METHODS: We conducted a descriptive longitudinal study, using repeated cross-sectional measures from 6 waves of surveys of employed primary care clinicians (physicians, nurse practitioners, physician assistants) and staff conducted between 2012 to 2018 in the San Francisco Health Network and in UCSF Health. The 2018 wave had 613 respondents (response rate 88%). Outcome measures were scores on the Maslach Burnout Inventory emotional exhaustion and cynicism subscales. We used regression models to test for time trends in mean scores. RESULTS: Trends in burnout differed by system and occupation. In one system, mean clinician scores steadily improved for emotional exhaustion (P = .04) and cynicism (P = .07). In the other system, clinician burnout scores initially worsened and then returned to baseline levels. In both systems, burnout trends among staff tended to move in the opposite direction from trends among clinicians. CONCLUSIONS: The divergent trends of steady reduction in clinician burnout in one system and clinician burnout getting worse before getting better in the other system suggest that the effects of primary care transformation are influenced by the organizational context. Moreover, practice changes that reduce clinician burnout may not decrease-and may potentially even worsen-burnout among staff. Primary care transformation requires continuing efforts to promote meaningful work and sustainable workloads among all members of the primary care team.

Burnout and Health Care Workforce Turnover.

PURPOSE: Levels of burnout among primary care clinicians and staff are alarmingly high, and there is widespread belief that burnout and lack of employee engagement contribute to high turnover of the workforce. Scant research evidence exists to support this assertion, however. METHODS: We conducted a longitudinal cohort study using survey data on burnout and employee engagement collected in 2013 and 2014 from 740 primary care clinicians and staff in 2 San Francisco health systems, matched to employment roster data from 2016. RESULTS: Prevalence of burnout, low engagement, and turnover were high, with 53% of both clinicians and staff reporting burnout, only 32% of clinicians and 35% of staff reporting high engagement, and 30% of clinicians and 41% of staff no longer working in primary care in the same system 2 to 3 years later. Burnout predicted clinician turnover (adjusted odds ratio = 1.57; 95% CI, 1.02-2.40); there was also a strong trend whereby low engagement predicted clinician turnover (adjusted odds ratio with high engagement = 0.58; 95% CI, 0.33-1.04). Neither measure significantly predicted turnover for staff. CONCLUSIONS: High rates of burnout and turnover in primary care are compelling problems. Our findings provide evidence that burnout contributes to turnover among primary care clinicians, but not among staff. Although reducing clinician burnout may help to decrease rates of turnover, health care organizations and policymakers concerned about employee turnover in primary care need to understand the multifactorial causes of turnover to develop effective retention strategies for clinicians and staff.

Signs of physical abuse and neglect in the mature patient.

Neglect and physical abuse of elderly are worrisome health problems, which are expected to grow even further, considering the aging of the population. By 2060, the number of people aged above 65 years is expected to double, whereas birth rates are low. This trend will cause a significant imbalance between different age groups and put more senior adults at risk for abuse. Risk factors, associated with abuse and neglect, are well established and can be categorized in sociodemographic-, victim-, or perpetrator-related risk factors. The effects of these risk factors depend mainly on the setting, which can be community-dwelling or institutionalized older adults. In community-based settings, 90% of perpetrators are family members. In each setting, suspicious physical injuries should be recognized and addressed promptly. This can be very challenging in elderly, among others, due to the age-related skin changes, which can mimic abuse; however, there are some cutaneous clues that should always raise suspicion of abuse, such as patterned shape or distribution, different healing stages of wounds, parallel injuries, signs of blunt trauma, and irregular patches of alopecia. General awareness is needed, and the advice of dermatologists, who are best trained to differentiate between those lesions, should be systematically sought, to reduce false-positive and false-negative interpretations.

Taking Risk: Early Results From Teaching Hospitals' Participation in the Center for Medicare and Medicaid Innovation Bundled Payments for Care Improvement Initiative.

The authors describe observations from the 27 teaching hospitals constituting the Association of American Medical Colleges (AAMC) cohort in the Center for Medicare and Medicaid Innovation (CMMI) Bundled Payments for Care Improvement (BPCI) initiative. CMMI introduced BPCI in August 2011 and selected the first set of participants in January 2013. BPCI participants enter into Medicare payment arrangements for episodes of care for which they take financial risk. The first round of participants entered risk agreements on October 1, 2013 and January 1, 2014. In April 2014, CMMI selected additional participants who started taking financial risk in 2015. Selected episodes include congestive heart failure (CHF), major joint replacement (MJR), and cardiac valve surgery. The AAMC cohort of participating hospitals selected clinical conditions on the basis of patient volume, opportunity to impact savings and quality, organizational and clinical team readiness, and prior process improvement experience. Early financial results suggest that focused attention to postacute care utilization and outcomes, rapid changes in care processes, program pricing rules, and team composition drove savings and losses. The first cohort of participants generated savings in MJR, CHF, and cardiac valve episodes; losses were experienced in stroke, percutaneous coronary intervention, and spine surgery. Although about one-quarter of U.S. teaching hospitals are participating in BPCI, the proliferation of existing and new payment models, as well as the 2015 announcement to increasingly pay providers according to value, mandates close scrutiny of program outcomes. The authors conclude by proposing additional opportunities for research related to alternative payment models.

Is parental consanguinity associated with reduced ovarian reserve?

This observational study assessed whether women descending from consanguineous unions have reduced ovarian reserve compared with daughters of non-consanguine couples. Two hundred and ninety-one women (≤39 years) were treated in a tertiary care centre in Kuwait. Women underwent a complete anamnesis, including an evaluation of the possible presence of parental consanguinity, transvaginal ultrasound on day 2/3 of the cycle to obtain the antral follicle count (AFC), determination of serum concentrations of FSH, LH, oestradiol and in case of low ovarian reserve (AFC < 9) anti-Müllerian hormone (AMH). The median AFC of non-consanguineous daughters was 11, while daughters from consanguineous parents displayed a significantly lower median AFC (7; P < 0⋅0001). FSH was slightly higher in the consanguineous patients, while LH and oestradiol concentrations did not vary between groups. In total, 29.9% of consanguineous patients had an AFC ≥ 9, compared with 63.9% of non-consanguineous patients. Consanguineous patients did not exhibit an age-dependent AFC-decline and displayed reduced AFC and AMH concentrations. The multivariate analysis revealed female consanguinity, as well as surgical history in non-consanguineous women, as strong positive predictors of low ovarian reserve. Parental consanguinity is strongly associated with reduced ovarian reserve. Future studies should evaluate a possible association between parental consanguinity and infertility.

Behavior changes in patients with diabetes and hypertension after experiencing shared medical appointments.

PURPOSE: This project examined recently implemented shared medical appointments (SMAs) at a free clinic for patients with diabetes and/or hypertension. Changes in patients' self-managing behaviors, specifically exercise and goal-setting activity, were explored after participating in SMAs for 4 months. DATA SOURCES: The study employed a pretest-posttest quasi-experimental design. Participants completed a questionnaire of their self-managing behaviors and a behavioral action plan at each SMA. The SMAs were facilitated in English, Spanish, and bilingually (English and Spanish) with a total of 37 participants. CONCLUSIONS: Descriptive analysis showed a significant increase in exercise time with a mean increase of 86 min per week at post-SMA (p= .002, 95% confidence interval [CI]). Each participant identified a measurable goal, and 97% of participants reported achieving or almost achieving their goals. Males reported a significantly (p= .002, 95% CI) larger increase in exercise time than women. Variance of self-managing behaviors among the English, Spanish, and bilingual SMAs was statistically not significant. IMPLICATIONS FOR PRACTICE: Though much evidence exists demonstrating that SMAs provide effective quality care, literature is lacking in examining patients' self-managing behaviors after participation in language-specific SMAs. Understanding patients' response to programs that address the needs of the individual leads to more effective programs.

Physicians' perceptions of institutional and leadership factors influencing their job satisfaction at one academic medical center.

PURPOSE: Academic physicians' perceptions about their institution's function and leadership should provide insights toward improving faculty recruitment and retention. METHOD: The authors surveyed 105 non-management and non-emeritus physicians who had been hired by (57%) or left (43%) the University of Missouri-Columbia School of Medicine (MUHC) in 1991-1998. The questionnaire measured both the importance and the availability of 14 institutional and leadership factors and the physicians' perceptions of satisfaction with their careers. Open-ended questions assessed additional concerns. RESULTS: In all, 56% of the overall satisfaction scores were unfavorable and, when grouped by faculty department, correlated inversely with departure rates (p =.04). Scores were surprisingly similar between those who left and those who remained at the institution. "Protected time for research or personal use" was the highest faculty priority regardless of level of overall satisfaction. "Equitable distribution of salary/resources" (p =.007) and "trust-communication with chair/division head" (p =.003) predicted good satisfaction independently. Openended responses for remaining at the university related to the pleasant local community (49%), intellectual issues (46%), and humanitarian issues (5%). Responses for considering opportunities elsewhere were administrative frustration (59%), income enhancement (18%), career advancement (9%), academic frustration (9%), and other (5%). Recommendations for enhancing recruitment and retention were fix administrative concerns (45%); improve research (20%), income (9%), physician support (9%), clinical programs (8%), and autonomy (5%); and other (4%). CONCLUSIONS: Surveying physicians who were recently hired or who have left an institution provides useful information to promote organizational changes that could improve physician retention.

Developing a comprehensive electronic adverse event reporting system in an academic health center.

BACKGROUND: In September 2000 University of Missouri Health Care (MUHC) conducted an assessment of patient safety activities. At least six separate data systems for reporting adverse events, with multiple conflicting paper reports, were found during this analysis. The disparate nature of these systems and their inability to be linked ensured that few systemic prevention activities were undertaken. In January 2001 an interdisciplinary team was convened with the goal of creating a comprehensive approach to patient safety reporting and resolution. IMPLEMENTATION: A secure, Web-based system, the MUHC Patient Safety Network System (PSN), was created that allows staff, physicians, patients, families, and visitors to report comments, adverse events, and near-miss events from any computer in the hospital and from home, using the Internet. Anonymous reporting is an option for near-miss events. Reports are immediately available to department managers responsible for resolution; managers are alerted to the presence of a report by e-mail. As a result, a pilot study performed in two MUHC intensive care units documented dramatic reductions in resolution time using the PSN. The pilot also demonstrated an increased willingness to report by physicians and respiratory therapists. Training was accomplished in the fall of 2001, and the PSN was successfully implemented throughout the hospital on January 1, 2002. NEXT STEPS: Implementation of the PSN has recently been extended to all ambulatory care settings. An additional component of the PSN that is being built will allow physicians to report complications.