Storylines of family medicine III: core principles-primary care, systems and family.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'III: core principles-primary care, systems, and family', authors address the following themes: 'Continuity of care-building therapeutic relationships over time', 'Comprehensiveness-combining breadth and depth of scope', 'Coordination of care-managing multiple realities', 'Access to care-intersectional, systemic, and personal', 'Systems theory-a core value in patient-centered care', 'Family-oriented practice-supporting patients' health and well-being', 'Family physician as family member' and 'Family in the exam room'. May readers develop new understandings from these essays.

Using Photovoice to Explore Family Medicine Residents' Burnout Experiences and Resiliency Strategies.

BACKGROUND AND OBJECTIVES: Physician burnout is well described in the literature. In response, experts are now shifting to try to understand physician resiliency. We sought to better understand burnout and resiliency from the perspective of family medicine residents through the qualitative analysis of photographs and discussion. METHODS: We used Photovoice, a qualitative research method, to understand how residents describe and cope with burnout. Faculty assigned residents at a Midwest family medicine residency program to take photographs and provide captions that reflected personal experiences of burnout and resilience. Residents viewed the collective photographs and discussed their impact during three audio-recorded small-group sessions. Researchers qualitatively analyzed the captions and recordings using a hermeneutic phenomenology approach, and analyzed the visual content of the photographs using a standardized rubric. RESULTS: We identified six themes for the resident description of burnout: basic needs deficiency, physical exhaustion, self-neglect, personal depletion, being overwhelmed, and feeling like an outsider. Six themes were also identified for cultivating resilience: self-care, nurturing relationships, seeking the comforts of home, escaping to refuel, self-reflection, and identifying strengths from adversities. Resilience pictures were more likely to have been taken in a natural setting; burnout photographs were duller in color. CONCLUSIONS: Family medicine residents experience burnout in specific, unique ways, and are able to identify common sources of resilience. Family medicine educators can use the Photovoice methodology to help residents capture their personal experiences of burnout, share their experiences with peers, and discover sources of resilience.

Evaluation of a Residency Peer-to-Peer Intervention in Opioid Prescribing.

BACKGROUND AND OBJECTIVES: Family physicians play a crucial role in addressing the opioid epidemic. We studied a novel peer-review opioid prescribing educational intervention for family medicine residents that incorporates guided instruction from an interdisciplinary care team. METHODS: We used a mixed-methods study design in the setting of a family medicine residency program in the Midwestern United States. Residents participated in small group, peer-to-peer discussions of patients chronically prescribed opioids with guidance and input from faculty, a pharmacist, and pharmacy students. Discussions followed a structured approach to evaluation based on guidelines, and written recommendations were given to the patients' resident primary care physician (PCP). For each patient, we reviewed electronic medical records to assess whether PCPs implemented the written recommendations. We used one-way analyses of variance to determine the statistical significance of changes made. The principal investigator interviewed seven participating residents to survey their satisfaction with the curriculum and collated suggestions for improvement. RESULTS: Over a 3-year period, we reviewed 59 patients as part of the intervention; of these, 53 had complete records reviewed for this study. Patients' morphine milligram equivalent dosage (MME) declined modestly (P=.035). The number and proportion of recommendations implemented was correlated with the decline in MME (P=.004 and P=.013, respectively). Interviewed residents unanimously evaluated the curriculum positively, citing that the structured approach helped align their practices with guidelines. CONCLUSIONS: The guided peer-review intervention effectively decreased chronic opioid use among patients, and residents positively evaluated the curriculum.

Deprescribing Inappropriate Proton Pump Inhibitors in a Family Medicine Residency Practice Office.

INTRODUCTION: Proton pump inhibitors (PPIs) are often prescribed beyond their medically-approved duration of use. Long-term PPI use has been linked with numerous adverse effects and contributes to polypharmacy. This study sought to understand the effect of evidence-based education to resident and faculty physicians on deprescribing inappropriate PPIs. We hypothesized that this educational intervention would result in fewer inappropriate PPI prescriptions. METHODS: We performed a chart review on all adult patients in a family medicine residency program practice, identifying those inappropriately taking PPIs. All physicians in the practice participated in an educational intervention regarding deprescribing inappropriate PPIs and were given frequent reminders to continue their deprescribing efforts. We reviewed charts at the end of the study to identify patients with successful deprescribing attempts. RESULTS: Of the 187 patients prescribed inappropriate PPIs in the study, 100 remained on PPIs at the end of the study (46.6% success rate). There was a significant decrease in the number of patients inappropriately prescribed PPIs by each physician over the course of the study, from a mean of 17.0 (beginning) to 9.1 (end). CONCLUSION: Physician education with reminders is an effective means of reducing the number of inappropriate PPIs prescribed in a family medicine residency practice. Future studies could investigate the effectiveness of educational interventions with other medication classes that are often prescribed inappropriately.

Innovative patient-centered skills training addressing challenging issues in cancer communications: Using patient's stories that teach.

This workshop demonstrated the utility of a patient-centered web-based/digital Breaking Bad News communication training module designed to educate learners of various levels and disciplines. This training module is designed for independent, self-directed learning as well as group instruction. These interactive educational interventions are based upon video-recorded patient stories. Curriculum development was the result of an interdisciplinary, collaborative effort involving faculty from the East Tennessee State University (ETSU) Graduate Storytelling Program and the departments of Family and Internal Medicine at the James H. Quillen College of Medicine. The specific goals of the BBN training module are to assist learners in: (1) understanding a five-step patient-centered model that is based upon needs, preferences, and expectations of patients with cancer and (2) individualizing communication that is consistent with patient preferences in discussing emotions, informational detail, prognosis and timeline, and whether or not to discuss end-of-life issues. The pedagogical approach to the training module is to cycle through Emotional Engagement, Data, Modeled Practices, Adaptation Opportunities, and Feedback. The communication skills addressed are rooted in concepts found within the Reaching Common Ground communication training. A randomized control study investigating the effectiveness of the Breaking Bad News module found that medical students as well as resident physicians improved their communication skills as measured by an Objective Structured Clinical Examination. Four other similarly designed modules were also created: Living Through Treatment, Transitions: From Curable to Treatable/From Treatable to End-of-Life, Spirituality, and Family.

Self-report tool for recognizing mania (SToRM): a new scale for aiding in the diagnosis of bipolar disorder.

OBJECTIVE: Bipolar disorder is a disabling disease that is difficult to diagnose. Primary care physicians share in the burden of diagnosing and caring for significant mental illness, including bipolar disorder, but they lack an adequate screening and diagnostic tool that can fit into use in a primary care practice. Modeling after the Patient Health Questionnaire-9, we created the Self-report Tool for Recognizing Mania (SToRM) to aid primary care physicians in the screening and diagnosis of bipolar disorder. METHODS: A 13-question tool was created and distributed to returning patients over an 11-month time period at the psychiatric clinic of a university health center. Each completed questionnaire was scored as positive or negative and then compared to the preexisting psychiatric diagnosis for that respondent, as shown on the problem list of the respondent's electronic medical record. RESULTS: A total of 102 subjects completed and returned their questionnaires. Twenty-eight surveys were scored as positive for bipolar disorder while 25 subjects carried this diagnosis on their problem list, giving a sensitivity of 72% and a specificity of 87% (CI at 95%). When alternative scoring was used, sensitivity increased to 96% with only a slight decrease in specificity to 84%. CONCLUSIONS: In this pilot study, we find that the SToRM shows potential in the pursuit of a highly reliable, self-report tool which could help primary care providers screen and diagnose bipolar disorder. As such, the SToRM deserves further study.

Teaching family in family medicine residency programs: results of a national survey.

BACKGROUND AND OBJECTIVES: Integrating family into family medicine has been recognized as important for the discipline, yet there is little known about how family-oriented care is taught in training environments. This paper presents results of a national survey assessing the status of teaching family concepts/skills in family medicine residency programs. METHODS: We sought to survey the program director (PD), a behavioral science faculty (BSF), and a chief resident (CR) from all 454 Accreditation Council for Graduate Medical Education (ACGME) family medicine residency programs. RESULTS: Respondents (n=489) were PDs (29%), CRs (34%), and BSF (36%). Of all respondents, 47% to 66% believe that integrating family concepts/skills into family medicine training is very important (highest level of importance). However, only 19%--23% believe their own programs place this level of importance on this curricular area. Less weight is given to family topics when compared with other behavior science subjects. Behavioral scientists who reported inclusion of (1) family concepts/skills in the formulation of ACGME competencies, (2) evaluation of residents on these skills, or (3) the presence of a family champion or scholar in the program, all reported teaching significantly more family-oriented skills compared to those that did not, respectively, 1 (6.96 versus 4.48), 2 (6.55 versus 4.97), and 3 (6.62 versus 4.54). CONCLUSIONS: Teaching about the family in family medicine continues to be highly valued among educators and their trainees; however, it is not perceived to be similarly valued in residency programs. Current changes in health care offer opportunities to promote and affirm family-oriented care. New curricular strategies are needed so that family-oriented care continues to define the uniqueness of family medicine.