Osteopathic manipulative treatment for the allopathic resident elective: does it change practice after graduation?

CONTEXT: Osteopathic manipulative treatment (OMT) for the allopathic resident is an elective at the University of Minnesota North Memorial Residency that engages the resident in the basic tenants of osteopathic medicine, with exposure to the vast application of OMT with a curricular focus on low back pain management. Implementing an elective curriculum is a feasible way to improve attitudes in OMT for MDs in a Family Medicine residency, and residents can learn OMT in an elective rotation. OBJECTIVES: This article aims to determine if MDs who complete an OMT for the allopathic physician elective rotation have higher comfort caring for patients with back pain compared to those who do not complete the elective. Further, this article is designed to evaluate if these MDs continue to incorporate OMT into the care they provide once they graduate from their residency programs. METHODS: Graduates from the University of Minnesota North Memorial Family Medicine Residency (2013 to 2019) were sent an email invitation in August 2020 to complete a Qualtrics survey regarding their comfort with caring for patients with back pain, referral patterns for these patients, and the ongoing use of OMT in their practices. Doctor of Osteopathic Medicine (DO) graduates who responded to the survey were removed from the analysis. RESULTS: Among emailed graduates, 61.8% (42/68) completed the survey, with representation from each class ranging from 1 to 7 years postresidency. The five DO graduates who responded were removed from the analysis. Among the remaining 37 respondents, 27 had completed the OMT for the allopathic rotation ("elective participants") during their residency training and 10 had not ("control"). Half (50.0%) of the control group provide OMT care compared to 66.7% of the elective participants, with a comfort score of 22.6 (standard deviation [SD] 32.7) in the control group vs. 34.0 (SD 21.0) in elective participants (on a 0-100 scale; 100 being completely comfortable; p=0.091). Among the control group, 40.0% regularly refer to a DO provider compared to 66.7% of those who completed the elective (p=0.257). The mean comfort score for performing a physical examination on patients presenting with back pain was 78.7 (SD 13.1) and 80.9 (SD 19.3) in the control and elective participants groups, respectively (p=0.198). CONCLUSIONS: Allopathic Family Medicine residents who completed an elective rotation in OMT have a slight increase in frequency of referring to DOs. They also have a meaningful increase in comfort performing OMT. With the limited number of DOs being a common barrier to OMT care, more widely implemented training in OMT for allopathic Family Medicine residents may be a reasonable intervention to improve the care of patients with back pain.

Asthma management: How the guidelines compare.

This quick guide details the similarities and differences between recommendations from the National Asthma Education and Prevention Program and the Global Initiative for Asthma.

Knowledge Retention Using "Relay": A Novel Active-Learning Technique.

Introduction: Many residency programs utilize passive didactic lectures despite mixed evidence for knowledge retention. This prospective study investigated the efficacy of "relay," an active-learning technique, as measured by residents' knowledge retention and attitudes compared to traditional format. Methods: Faculty presented lectures to four family medicine residency programs on a randomized schedule. Lectures were followed by a 15-minute question-and-answer (Q&A) session or relay session. A relay is a collaborative, question-based game. The primary outcome was knowledge retention at 3 months, comparing Q&A to relay sessions as measured by a multiple-choice assessment. Responses were only included if a given resident completed knowledge assessments for both Q&A and relay sessions, to allow for intraresident adjustments, in addition to program, training year, and lecturer/topic. Secondary outcomes included residents' self-perceived knowledge and engagement as surveyed by an ordinal scale immediately following the learning session. Results: The primary analysis included 51 responses from 18 unique residents. The adjusted mean knowledge assessment score at 3 months was not statistically different after the relay sessions compared to Q&A (67% vs 60%, respectively; 7% difference, 95% CI: -4 to 18%, P=.20). For the secondary outcomes of learner attitudes (n=143 responses), learners reported greater engagement after the relay sessions compared to Q&A (51% vs 28% "very engaged"; overall P=.003), but self-perceived knowledge was not significantly different (overall P=.05, rounded down). Conclusions: The relay technique did not show significant difference in 3-month knowledge retention, nor immediate self-perceived knowledge, despite greater learner self-perceived engagement.

What is success in treatment for opioid use disorder? Perspectives of physicians and patients in primary care settings.

INTRODUCTION: Clinicians and researchers have traditionally relied on treatment retention and opioid abstinence as the primary measures of treatment success for people with opioid use disorder (OUD). However, these measures may not capture the range of clinically important treatment outcomes. The study sought to identify indicators of success in primary care-based medication for OUD (MOUD) treatment from the perspectives of patients with OUD and the physicians who treat them. METHODS: The study recruited patients (N = 18; M age = 38.1 years, SD = 11.5; 44% female) and physicians (N = 14; M age = 34.6, SD = 6.8 years; 57% female) from two academic family medicine residency clinics in the upper Midwest to participate in semi-structured qualitative interviews. Participants reflected on signs of progress and success in primary care MOUD treatment. Interviews were recorded, transcribed, and analyzed using an inductive thematic analysis approach. RESULTS: Seven themes of success emerged: (1) staying sober; (2) tapering off buprenorphine; (3) taking steps to improve physical and mental health; (4) improved psychological well-being; (5) improved relationships; (6) improved role functioning; and (7) decreased stigma and shame. Interviews with both patients and physicians supported five of the seven themes, with patients also describing themes of tapering off buprenorphine and reduced stigma and shame. CONCLUSIONS: Themes suggest that a wider view of success, in addition to maintaining sobriety, is needed when considering outcomes for MOUD programs delivered in primary care settings. Future work should identify appropriate outcome measures and potential adjunctive treatments.

Longitudinal assessment of mental health and well-being in patients being treated with medications for opioid use disorder in primary care.

Opioid use disorder (OUD) continues to be a significant problem in the United States, contributing to overdose and death. Recent efforts to expand access to treatment of OUD in primary care have increased the availability of medications for OUD (MOUDs). However, OUD is often accompanied by poor mental health and well-being, and it is not known if treatment with MOUDs alone is associated with improved psychological well-being. This study's purpose was to examine changes in mental health and well-being in the first 6 months of treatment with MOUDs in a family medicine residency clinic. Patients (N = 126; M age = 34.6 years, SD = 10.6; 54.8% male; 71.4% white) completed validated screeners of mental health and well-being (depression, anxiety, anger, loneliness, perceived stress, meaning in life, and life satisfaction) at baseline (induction visit for buprenorphine), 1-month, and 6-months. Results indicated that the mental health and well-being indices did not significantly change over the first 6 months of treatment on MOUDs. There were initial decreases in depression and anxiety at 1-month; however, both increased and were equivalent to baseline levels at 6-months. These results suggest that MOUD treatment alone does not significantly impact mental health or well-being in patients with OUD. Additional treatments or supports are clearly needed to address the comorbid mental health and well-being challenges in this population, as these factors can be both antecedents and consequences of substance misuse.

Achieving Equity in Telehealth: "Centering at the Margins" in Access, Provision, and Reimbursement.

The SARS-CoV-2 epidemic has led to rapid transformation of health care delivery and access with increased provision of telehealth services despite previously identified barriers and limitations to this care. While telehealth was initially envisioned to increase equitable access to care for under-resourced populations, the way in which telehealth provision is designed and implemented may result in worsening disparities if not thoughtfully done. This commentary seeks to demonstrate the opportunities for telehealth equity based on past research, recent developments, and a recent patient experience case example highlighting benefits of telehealth care in underserved patient populations. Recommendations to improve equity in telehealth provision include improved virtual visit technology with a focus on patient ease of use, strategies to increase access to video visit equipment, universal broadband wireless, and inclusion of telephone visits in CMS reimbursement criteria for telehealth.

Predictors of Family Medicine Patient Retention in Opioid Medication-Assisted Treatment.

PURPOSE: Opioid use disorder is a prevalent and chronic condition that can lead to adverse outcomes if untreated. Medication-assisted treatment (MAT) with buprenorphine in a primary care setting has the potential to increase availability of treatment and reduce harm; however, retention in MAT is key for patient success. This study's purpose was to examine predictors of retention in a MAT program for OUD in a family medicine residency clinic. METHODS: A retrospective chart review was conducted for 238 patients diagnosed with OUD and receiving MAT at a family medicine residency clinic between 2015 to 2017, with visit and prescription data collected through December 2018. Cox-proportional hazards models were used to examine the length of time in treatment. RESULTS: Over three-fourths of our patients were retained for at least 3 months, 69% for at least 6 months, and 48% retained for at least 1 year. Physician continuity of care and having insurance coverage significantly predicted retention and longer duration of treatment. CONCLUSIONS: Continuity of care and having health insurance were key predictors of patient retention in MAT care. Our findings emphasize the clinical significance of maintaining physician continuity of care to improve retention of patients with OUD in MAT programs. Future research could explore what aspects of continuity of care lead to retention in OUD treatment.

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.

Buprenorphine to treat opioid use disorder: A practical guide.

Medication-assisted treatment is demonstrably superior to abstinence and counseling in maintaining sobriety. The authors examine this effective agent.

Video Review Process: Enhancing Impact and Resident/Faculty Satisfaction.

INTRODUCTION: Although video review (VR) is a common component of family medicine (FM) resident education, levels of faculty and resident satisfaction and the perceived impact of the VR process are unknown. Our FM residency program made several changes to our VR process, including a new feedback form highlighting strengths and areas for growth, a post-VR email to the resident including a tip sheet on an identified skill, and follow-up shadowing by a behavioral health clinician to increase VR impact and reinforce skill development. METHODS: FM residency faculty (n=11) and residents (n=34) completed an anonymous 20-item online survey. The survey was administered twice, first at baseline and then 9 months after the changes were instituted. Survey questions targeted the preceding 9 months and assessed satisfaction with VRs and perceived value and impact of the VR process. RESULTS: At baseline, both faculty and residents reported low levels of satisfaction and perceived impact and value of the VR process. Among both residents and faculty, significant improvements emerged in ratings of satisfaction and perceived value of the VR process. At postsurvey, significantly more residents reported feeling equipped with specific tips on how to improve their communication skills after VR than at baseline. CONCLUSION: Our evaluation documented significant improvements in satisfaction and perceived value in our VR process following the changes in our procedures. Future research could develop measures to assess communication skills that are more sensitive to change, thereby strengthening this line of research by supplementing self-report data with more objective observational data.

Best uses of osteopathic manipulation.

With the growing number of DOs and the high utilization of osteopathic manipulative treatment (OMT), it is important for all physicians to understand the role OMT can play in the treatment of conditions ranging from low back pain to irritable bowel syndrome so that patients may be offered, or referred for, the treatment when appropriate.

Integrated care clinic: Creating enhanced clinical pathways for integrated behavioral health care in a family medicine residency clinic serving a low-income, minority population.

INTRODUCTION: Research examining the implementation and effectiveness of integrated behavioral health (BH) care in family medicine/primary care is growing. However, research identifying ways to consistently use integrated BH in busy family medicine/primary care settings with underserved populations is limited. This study describes 1 family medicine clinic's transformation into a fully integrated BH care clinic through the development of an Integrated Care Clinic (ICC) and enhanced clinical pathways to promote regular use of behavioral health clinicians (BHCs). METHOD: We implemented the ICC at the Broadway Family Medicine Clinic serving a low-income (<$25,000 annual income/year) and minority population (>70% African American) in Minnesota. We conducted a pre- and postevaluation of the ICC during regular clinic activity. RESULTS: Pilot findings indicated that the creation of ICC and the use of enhanced clinical pathways (e.g., 5-2-1-0 obesity prevention messages, Transitional Care Management, postpartum depression screening visits, warm hand-offs) to facilitate regular use of integrated BH care resulted in 6 integrated care visits per BHC per clinic half-day. In addition, changes in the behavioral/mental health therapy appointment time slot (from 60 to 30 min) reduced therapy no-show rates. Transitional Care Management (TCM) visits also showed improved pre- and postchanges in patient and clinician satisfaction and reductions in patient hospital readmission rates. DISCUSSION: The transformation into a fully integrated BH family medicine clinic through the creation of ICC and enhanced clinical pathways to facilitate regular integrated BH care showed promising pilot results. Future research is needed to examine associations between ICC and patient outcomes (e.g., weight, depressive symptoms). (PsycINFO Database Record

This asthma treatment has a lasting side effect in children.

A new study finds that when children with asthma use inhaled corticosteroids, the effect on growth may not be temporary, as once thought.