Perceptions of Parenting Residents Among Family Medicine Residency Directors.

BACKGROUND AND OBJECTIVES: Parenting during residency is increasingly common, and resident parents face unique demands on their time and emotional and cognitive resources. Physicians at all levels of training perceive negative impacts of parenting on career and family life. Surveys of program directors (PDs) in other specialties reveal concern about performance and quality of life of parenting residents. The primary aims of this study were to examine family medicine PDs' perceptions of parenting residents' performance and the adequacy of parenting support structures. METHODS: Data were collected from the 2017 Council of Academic Family Medicine (CAFM) Educational Research Alliance (CERA) Family Medicine Residency Program Directors survey. Directors provided the number and status of parenting residents and rated adequacy of parenting resources, resident performance, and impact of parenting on residents using a Likert scale. Results were compared between male/female PDs and male/female residents. RESULTS: Response rate was 57.1%. Less than half of PDs reported adequate parenting support structures in their program (46%). Over 40% of PDs reported that 81%-100% of female residents who take parental leave end up extending their residency training, the most common response category. PDs did not report gender-based differences in performance of parenting residents. PDs most often reported significantly worse well-being for female parenting residents but perceived improved well-being of male parents. CONCLUSIONS: Less than half of family medicine PDs feel their program has adequate parenting resources. Female parenting residents commonly extend residency training. PDs perceive parenting negatively impacts well-being of female residents, but not male residents.

Effect of peer support interventions on cardiovascular disease risk factors in adults with diabetes: a systematic review and meta-analysis.

BACKGROUND: Peer support by persons affected with diabetes improves peer supporter's diabetes self-management skills. Peer support interventions by individuals who have diabetes or are affected by diabetes have been shown to improve glycemic control; however, its effects on other cardiovascular disease risk factors in adults with diabetes are unknown. We aimed to estimate the effect of peer support interventions on cardiovascular disease risk factors other than glycemic control in adults with diabetes. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials comparing peer support interventions to a control condition in adults affected by diabetes that measured any cardiovascular disease risk factors [Body Mass Index, smoking, diet, physical activity, cholesterol level, glucose control and blood pressure]. Quality was assessed by Cochrane's risk of bias tool. We calculated standardized mean difference effect sizes using random effects models. RESULTS: We retrieved 438 citations from multiple databases including OVID MEDLINE, Cochrane database and Scopus, and author searches. Of 233 abstracts reviewed, 16 articles met inclusion criteria. A random effects model in a total of 3243 participants showed a positive effect of peer support interventions on systolic BP with a pooled effect size of 2.07 mmHg (CI 0.35 mmHg to 3.79 mmHg, p = 0.02); baseline pooled systolic blood pressure was 137 mmHg. There was a non-significant effect of peer support interventions on diastolic blood pressure, cholesterol, body mass index, diet and physical activity. Cardiovascular disease risk factors other than glycemic control outcomes were secondary outcomes in most studies and baseline values were normal or mildly elevated. Only one study reported smoking outcomes. CONCLUSIONS: We found a small (2 mmHg) positive effect of peer support interventions on systolic blood pressure in adults with diabetes whose baseline blood pressure was on average minimally elevated. Additional studies need to be conducted to further understand the effect of peer support interventions on high-risk cardiovascular disease risk factors in adults with diabetes.

Peer Support Interventions for Adults With Diabetes: A Meta-Analysis of Hemoglobin A1c Outcomes.

PURPOSE: Peer support intervention trials have shown varying effects on glycemic control. We aimed to estimate the effect of peer support interventions delivered by people affected by diabetes (those with the disease or a caregiver) on hemoglobin A1c (HbA1c) levels in adults. METHODS: We searched multiple databases from 1960 to November 2015, including Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, CINAHL, and Scopus. We included randomized controlled trials (RCTs) of adults with diabetes receiving peer support interventions compared with otherwise similar care. Seventeen of 205 retrieved studies were eligible for inclusion. Quality was assessed with the Cochrane risk of bias tool. We calculated the standardized mean difference (SMD) of change in HbA1c level from baseline between groups using a random effects model. Subgroup analyses were predefined. RESULTS: Seventeen studies (3 cluster RCTs, 14 RCTs) with 4,715 participants showed an improvement in pooled HbA1c level with an SMD of 0.121 (95% CI, 0.026-0.217; P = .01; I2 = 60.66%) in the peer support intervention group compared with the control group; this difference translated to an improvement in HbA1c level of 0.24% (95% CI, 0.05%-0.43%). Peer support interventions showed an HbA1c improvement of 0.48% (95% CI, 0.25%-0.70%; P <.001; I2 = 17.12%) in the subset of studies with predominantly Hispanic participants and 0.53% (95% CI, 0.32%-0.73%; P <.001; I2 = 9.24%) in the subset of studies with predominantly minority participants; both were clinically relevant. In sensitivity analysis excluding cluster RCTs, the overall effect size changed little. CONCLUSIONS: Peer support interventions for diabetes overall achieved a statistically significant but minor improvement in HbA1c levels. These interventions may, however, be particularly effective in improving glycemic control for people from minority groups, especially those of Hispanic ethnicity.

Resident duty hour changes: impact in the patient-centered medical home.

BACKGROUND AND OBJECTIVES: Family medicine residency programs are challenged with balancing hospital-based training with a longitudinal primary care continuity experience. In response to the Preparing the Personal Physician for Practice (P4) Initiative, the University of Missouri (MU) Family Medicine Residency Program sought to increase the presence of its residents in their continuity clinic, ie, the patient-centered medical home (PCMH). While initially successful, these efforts encountered formidable barriers with the July 2011 duty hour regulations from the Accreditation Council for Graduate Medical Education (ACGME). METHODS: PCMH hours and visit numbers were collected and analyzed for MU residents from July 2005 through June 2012. RESULTS: Comparing the 2 years before the P4 schedule changes to the first 3 years after the P4 changes, MU first-year residents experienced a 27% increase in patient visits with a 13% increase in hours. In the subsequent 2 years, which incorporated compliance with the new ACGME regulations, first-year residents experienced a 33% decrease in visits with a 25% decrease in hours. This negated the increases seen with the previous P4 schedule changes, and residents in all years of training experienced less visits, less hours, and less visits per hour. CONCLUSIONS: New duty hour regulations not only limit the time resident physicians spend in the hospital but also their experience in the ambulatory setting. Considering the emphasis family medicine training programs place on continuity of care and the PCMH, the new regulations will have significant implications for these programs.

Viscerocutaneous Loxoscelism in an Adult with Acute Generalized Exanthematous Pustulosis.

This case describes an unusual presentation of a woman with viscerocutaneous (VCT) loxoscelism and exanthematous pustulosis. Due to a complex presentation resembling sepsis and errant information, she was unnecessarily treated with multiple antibiotics and intravenous immunoglobulin (IVIG) which may have complicated her course. Given recent reports of quick progression and death from a similar presentation, it is imperative that clinicians be familiar with signs, symptoms and complications of VCT loxoscelism, which can include hemolysis and acute exanthematous pustulosis.

Faculty development needs in residency redesign for practice in patient-centered medical homes: a P4 report.

OBJECTIVES: The study's objective was to describe faculty development skills needed for residency redesign in 14 family medicine residencies associated with the Preparing the Personal Physician for Practice (P4) project. METHODS: We used self-administered surveys to assess ratings of existing faculty development efforts and resident attitudes about faculty teaching between 2007 and 2011. Telephone interviews were conducted to assess faculty development activities and needs at baseline. Early project faculty development needs were addressed using tailored sessions delivered during site visits. We conducted a detailed content analysis of 14 site-specific comprehensive reports to characterize ongoing faculty development needs and faculty themes related to residency redesign. RESULTS: Early in the P4 project, faculty needs included skills in using the electronic health record (EHR) in teaching, change management, curriculum design, evaluation, learning portfolios and individualized learning plans, career coaching, qualitative research, competency-based assessment, and leadership. As the project progressed, the need for a "learning together" approach when training residents in transformed practices emerged. Using the EHR more effectively, evaluation and competency-based assessment skills, individualized curriculum design, better career coaching skills, shared leadership, and team-based care skills were consistent faculty development needs. Redesign strategies included having a committed core faculty group, faculty retreats, curricular change process management, intra-residency collaboration, and providing adequate support for key individuals. CONCLUSIONS: Faculty attempting to redesign residencies to train residents in patient-centered medical homes need new skills, and understanding these needs can inform faculty development programs nationally to achieve the crucial mission of training the workforce to accomplish this transformation.

Assessing the impact of innovative training of family physicians for the patient-centered medical home.

BACKGROUND: New approaches to enhance access in primary care necessitate change in the model for residency education. PURPOSE: To describe instrument design, development and testing, and data collection strategies for residency programs, continuity clinics, residents, and program graduates participating in the Preparing the Personal Physician for Practice (P(4)) project. METHODS: We developed and pilot-tested surveys to assess demographic characteristics of residents, clinical and operational features of the continuity clinics and educational programs, and attitudes about and implementation status of Patient Centered Medical Home (PCMH) characteristics. Surveys were administered annually to P(4) residency programs since the project started in 2007. Descriptive statistics were used to profile data from the P(4) baseline year. RESULTS: Most P(4) residents were non-Hispanic white women (60.7%), married or partnered, attended medical school in the United States and were the first physicians in their families to attend medical school. Nearly 85% of residency continuity clinics were family health centers, and about 8% were federally qualified health centers. The most likely PCMH features in continuity clinics were having an electronic health record and having fully secure remote access available; both of which were found in more than 50% of continuity clinics. Approximately one-half of continuity clinics used the electronic health record for safety projects, and nearly 60% used it for quality-improvement projects. CONCLUSIONS: We created a collaborative evaluation model in all 14 P(4) residencies. Successful implementation of new surveys revealed important baseline features of residencies and residents that are pertinent to studying the effects of new training models for the PCMH.

Preparing the personal physician for practice (p4): site-specific innovations, hypotheses, and measures at baseline.

BACKGROUND AND OBJECTIVES: This study's purpose was to describe the innovations, hypotheses being tested, and measures used in residency training redesign in 14 family medicine residencies associated with the P4 project. METHODS: We conducted a content analysis of site visit reports to identify and categorize the curricular innovations that are part of the P4 Project. Similarly, we cataloged specific hypotheses to be tested and both site-specific measures and core measures collected by the evaluation team to assess hypotheses. RESULTS: Selected P4 programs include three university-based programs; three community-based, university-administered programs, and eight community-based, university-affiliated programs. These 14 programs had 24 continuity clinics, and 334 residents were enrolled in the baseline cohort (2006--2007). Between two and five innovations were proposed by programs in the baseline period linked to 70 planned hypotheses, with a range of three to seven hypotheses (mean of 4.5). Seven programs (50%) focused on Patient-centered Medical Home practice redesign, and seven (50%) assessed different aspects of a 4-year curriculum as the two most common innovations. Team-based care and team training were tested in six programs, and five tested an individualized curriculum tailored to each resident. Eight programs submitted 11 grants, and six programs were successful in obtaining funding to support P4 activities. The sources of funding primarily included the Health Resources and Services Administration, US Department of Health and Human Services, and local foundations, and the mean number of dollars attained was $659,528 (range=$50,000--$2,500,000). Seven grants were received through local sources, totaling $3,219,884 with an average of $459,983 per program. CONCLUSIONS: The P4 project had a successful launch and to date has retained all 14 programs that started in 2007. Though no direct funding was provided by P4 to individual sites, all have focused on important contemporary challenges for training excellent family physicians, all are engaged in important evaluations, and nearly half have successfully obtained project funding to support their specific P4 activities during the baseline period.

Intentions of older homebound women to reduce the risk of falling again.

PURPOSE: Researchers have tested interventions to prevent recurrent falls for older people without exploring their intentions to prevent another fall. Lack of knowledge about such intentions is an impediment to intervention effectiveness. The purpose was to describe intentions to prevent another fall as discerned during a study with older homebound women. METHODS: Data were obtained during a series of four in-home interviews over 18 months with monthly telephone contacts between interviews; fall history was updated at each contact. A descriptive phenomenological method was used to analyze data. FINDINGS: Of the 40 women, 36 (aged 85 to 98 years) had fallen at home at least once before enrolling in the study, or had a subsequent or initial fall during the study. The overall intention was reducing my risk of falling again at home, with its components figuring out the reason that I fell and changing my ways to reduce my risk of falling again at home. Most women explained reasons for a fall and voiced intentions to prevent a similar fall. Women who viewed falls as unexpected events were uncertain that they could prevent a fall or felt unable to do so and voiced few preventive intentions. A few women voiced generalized preventive intentions to change health-related behaviors or habits. CONCLUSIONS: Most intentions were tied directly to the situation in which a fall had occurred. Such specificity could limit effectiveness of personal efforts to prevent falls in other situations. CLINICAL RELEVANCE: Practitioners should converse with older women who have fallen about their intentions to prevent another fall and weigh the need to help them generalize both the risk of falling again and their risk reduction intentions.

The University of Missouri integrated residency: evaluating a 4-year curriculum.

BACKGROUND AND OBJECTIVES: Several approaches to merging residency training and medical school education have been attempted over the past 20 years. This study describes and evaluates an integrated family medicine residency programa 4-year program that overlaps with the final year of medical school. METHODS: We retrospectively analyzed multiple data sources, including In-Training Examination scores, patient visit profiles, resident demographics, and graduate surveys. RESULTS: Integrated residents (IRs) perform significantly better than traditional residents on In-Training Examinations at each year of residency training, with the difference in mean scores decreasing over time (67.8, 39.6, and 33.0 points better in the first, second, and third residency years). No evidence of increased patient continuity or panel size was noted. A higher proportion of IRs serve as chief residents, rate their residency experience as "excellent," and remain with the program through graduation. Practice characteristics immediately after residency do not significantly differ. Financial benefits are evident for the IRs as well as the hosting department. CONCLUSIONS: This integrated program offers several benefits for both the medical student and the residency program, and it is a potential model for academic residencies aiming to recruit and retain a higher percentage of their own schools' students.

Elder mistreatment in the nursing home: a systematic review.

Because of their significant dependence on others for their care, nursing home residents are potentially vulnerable to abuse and/or neglect. The topic of elder mistreatment, whether in the nursing home or other living environments, received little attention from clinicians and researchers until the past 2 decades. Original research is now emerging that sheds light on the scope of the problem and the challenges to timely prevention, identification, and management. Practitioners may use this information to recognize and change factors associated with a higher likelihood of nursing home mistreatment.

Improving care at lower cost for end-stage heart and lung disease: integrating end of life planning with home care.

Patients with advanced heart and lung disease experience exacerbations resulting in hospitalizations and interventions the patient may not desire. Strategies are needed that address end of life issues, honor preferences, and improve care without increasing cost. This study examines the impact on hospitalization and care cost of an integrated system of end of life care and interdisciplinary home care for mid-Missouri veterans with advanced congestive heart failure or chronic obstructive pulmonary disease.

The primary care physician's role in adult perioperative care.

Family physicians and general internists are often consulted to evaluate preoperative risk and manage postoperative complications. Essential to such consultations is a familiarity with preoperative risk assessment, potentially helpful preoperative inter-ventions, and common postoperative complications. This article reviews these issues and discusses the role of the medical consultant throughout the surgical patient's hospital stay.