Assessing efficacy of a web-based smoking cessation tool - QuitAdvisorMD: Protocol for a practice-based, clustered, randomized control trial.

Background: Smoking remains the leading cause of preventable death, yet physicians inconsistently provide best-practices cessation advice to smokers. Point-of-care digital health tools can prompt and assist physicians to provide improved smoking cessation counseling. QuitAdvisorMD is a comprehensive web-based counseling and management digital health tool designed to guide smoking cessation counseling at the point-of-care. The tool enables clinicians to assess patient readiness to change and then deliver stage-appropriate interventions, while also incorporating Motivational Interviewing techniques. We present the research protocol to assess the efficacy of QuitAdvisorMD to change frequency and quality of smoking cessation counseling and its effect on patient quit rates. Methods: A practice-based, clustered, randomized controlled trial will be used to evaluate QuitAdvisorMD. Cluster design will be used where patients are clustered within primary care practices and practices will be randomized to either the intervention (QuitAdvisorMD) or control group. The primary outcome is frequency and quality of clinician initiated smoking cessation counseling. Secondary outcomes include, 1) changes in physician knowledge, skills and perceived self-efficacy in providing appropriate stage-based smoking cessation counseling and 2) patient quit attempts. Analyses will be conducted to determine pre- and post-test individual clinician outcomes and between intervention and control group practices for patient outcomes. Conclusion: Results from this study will provide important insights regarding the ability of an integrated, web-based counseling and management tool (QuitAdvisorMD) to impact both the quality and efficacy of smoking cessation counseling in primary care settings.

Engaging Family Medicine Residents in a Structured Patient Panel Reassignment Process.

BACKGROUND AND OBJECTIVES: The patient panels of graduating residents must be reassigned by the end of residency. This process affects over 1 million patients annually within the specialty of family medicine. The purpose of this project was to implement a structured, year-end reassignment system in a family medicine residency program. METHODS: Our structured reassignment process took place from December 2017 through June 2020. Panel lists of current, active patients were generated and residents were responsible for reassigning their own panels during a panel reassignment night. We created a tip sheet that addressed patient complexity and continuity, a risk stratification algorithm based on patients' medical and social complexity, and a tool that tracked the number of patients assigned to each future provider. Outcome measures included a resident satisfaction survey administered in 2018-2020 and patient-provider continuity measured with a run chart from December 2016 through August 2020. RESULTS: The resident survey response rate was 75%. Seventy-three percent felt the panel reassignment night was very helpful; 87% thought the reassignment timeline was extremely reasonable, and 87% indicated that they had the necessary information to reassign their patients. Residents also felt confident that their patients were reassigned appropriately (33% extremely confident, 67% somewhat confident). Patient continuity improved with a 13-point run above the median, indicating nonrandom variation. Patient continuity remained above the median until the impact of COVID-19 in April 2020. CONCLUSION: Our structured reassignment process was received positively by residents and resulted in improved patient continuity.

Enhancing your scholarship as a family medicine junior faculty member.

Family medicine faculty are often expected to produce some form of scholarship as members of academic departments. However, this can be challenging given a range of contextual factors, including limited research capacity in many departments, increased competition for funding and individual challenges around balancing multiple roles, unclear expectations and lack of mentorship, to name a few. The purpose of this reflection is to discuss seven content areas that might be addressed by faculty in order to promote scholarship, particularly among junior faculty. These include: 1) knowing your academic track and its associated expectations by rank, as well as the scholarship expectations within your department; 2) considering your personal goals, interests, professional development needs and the relationship between meaningful work and burnout; 3) starting small and building towards a niche content area; 4) finding collaborators and the benefits of collaboration; 5) seeking alignment between your scholarship and work that you already are performing; 6) educating yourself about available outlets for scholarship and 7) seeking mentorship.

Common Medical Concerns of the Female Athlete.

Women are increasingly participating in more and more sporting activities. For years, women athletes have been treated as the "female" equivalent of male athletes, with similar medical approaches but this is changing. The concept that women are unique in their "athletic arena" is further underscored with emerging scientific evidence--from the physiologic details not visible to the eye, to the more overt biomechanical and anatomic differences. We review a handful of conditions active women potentially may encounter: pregnancy, the female athlete triad, patellofemoral pain, potential injuries to the anterior cruciate ligament, and anemia.

School Absenteeism in Children and Adolescents.

Frequent school absenteeism has immediate and long-term negative effects on academic performance, social functioning, high school and college graduation rates, adult income, health, and life expectancy. Previous research focused on distinguishing between truancy and anxiety-driven school refusal, but current policy has shifted to reducing absenteeism for any reason. Chronic absenteeism appears to be driven by overlapping medical, individual, family, and social factors, including chronic illness, mental health conditions, bullying, perceived lack of safety, health problems or needs of other family members, inconsistent parenting, poor school climate, economic disadvantage, and unreliable transportation. Family physicians are well positioned to identify patients with frequent absences, intervene early, and tailor treatment plans to the patient's medical and social needs. Informing parents of the link between school attendance and achievement can be effective in reducing absences. If absenteeism is caused by chronic illness, management should include clear expectations about school attendance and care coordination with school personnel. Mental health conditions that interfere with school attendance can often be treated with cognitive behavior therapy and/or pharmacotherapy. When assessing a child with frequent absences, physicians should inquire about bullying, even if the patient is not known to identify with a vulnerable group. Families and schools are key collaborators in interventions via parent education, parental mental health treatment, and school-based intervention programs.

Celiac Disease and Gluten Sensitivity.

Celiac disease is an immune-mediated enteropathy triggered by gluten that affects genetically predisposed individuals, typically causing intestinal symptoms and malabsorption. Diagnosis requires stepwise evaluation with anti-tissue transglutaminase IgA and histologic analysis of the small bowel. Strict adherence to a gluten-free diet is the primary treatment. Patients with symptoms thought to be related to gluten but without evidence of celiac disease are difficult to diagnose and treat. Consider first advising general nutritional improvements. If symptoms persist, involve a trained dietitian for restrictive diets and consider evaluation for small intestinal bacterial overgrowth or other treatments for irritable bowel syndrome.

Responding to a changing nation: are faculty prepared for cross-cultural conversations and care?

BACKGROUND AND OBJECTIVES: The United States is becoming increasingly diverse. Health disparities continue with little improvement despite national policies and standards. Medical institutions are modifying their curricula; however, little is known about faculty attitudes and comfort in addressing cultural issues. The purpose of this study was to determine faculty attitudes, self-perceived levels of comfort and skill, and future knowledge needs pertaining to cultural competence. METHODS: A survey was administered to all clinical faculty at the University of Virginia School of Medicine. Survey questions addressed faculty attitudes and self-perceived levels of comfort and skill in dealing with cultural issues, as well as perceived need and interest in future cultural competence training. RESULTS: When considering each phase of education (medical school, residency, continuing medical education [CME]), fewer than 25% of the respondents reported receiving formal instruction in cultural competency in any given phase, although 93% felt that cultural competency training was important. Fifty-eight percent felt "very comfortable" caring for diverse patients, although this dropped to 30% when specifying limited English proficiency. The situation in which the highest percentage of respondents felt "not particularly comfortable" or "not at all comfortable" was breaking bad news to a patient's family first if this was more culturally appropriate (47%). Respondents felt most skilled in working with medical interpreters, apologizing for cross-cultural misunderstandings, and eliciting the patients' perspectives about their health and illness. Respondents felt the least skilled providing culturally sensitive end-of-life care and dealing with cross-cultural conflicts. CONCLUSIONS: Clinical faculty have received limited instruction on cultural competency, and the reported levels of comfort and skill in many challenging areas of multicultural health leave much room for improvement. Until faculty become more comfortable and are able to model and teach these behaviors to learners, positive responses to national policies in culturally competent care are likely to be limited.

Improving smoking cessation counseling using a point-of-care health intervention tool (IT): from the Virginia Practice Support and Research Network (VaPSRN).

PURPOSE: Primary care practices are an ideal setting for reducing national smoking rates because >70% of smokers visit their physician annually, yet smoking cessation counseling is inconsistently delivered to patients. We designed and created a novel software program for handheld computers and hypothesized that it would improve clinicians' ability to provide patient-tailored smoking cessation counseling at the point of care. METHODS: A handheld computer software program was created based on smoking cessation guidelines and an adaptation of widely accepted behavioral change theories. The tool was evaluated using a validated before/after survey to measure physician smoking cessation counseling behaviors, knowledge, and comfort/self-efficacy. RESULTS: Participants included 17 physicians (mean age, 41 years; 71% male; 5 resident physicians) from a practice-based research network. After 4 months of use in direct patient care, physicians were more likely to advise patients to stop smoking (P = .049) and reported an increase in use of the "5 As" (P = .03). Improved self-efficacy in counseling patients regarding smoking cessation (P = .006) was seen, as was increased comfort in providing follow-up to patients (P = .04). CONCLUSIONS: Use of a handheld computer software tool improved smoking cessation counseling among physicians and shows promise for translating evidence about smoking cessation counseling into practice and educational settings.

Evaluation of a screening and counseling tool for alcohol misuse: a Virginia Practice Support and Research Network (VaPSRN) trial.

BACKGROUND: Surveys reveal limited screening and counseling for alcohol misuse by primary care physicians despite evidence-based recommendations. We developed and evaluated an alcohol screening and misuse counseling tool designed to assist clinicians at the point of care (POC). METHODS: This was a mixed methods, prospective cohort study conducted with licensed clinicians in a practice-based research network. A software tool was designed to guide clinicians through evidence-based alcohol misuse assessment and interventions. RESULTS: Participants (N = 12) used the tool an average of 3 sessions and 71% were satisfied with the tool. Participants increased their ability to differentiate between patients who are "at risk" drinkers versus those with alcohol use disorders including dependence/abuse (21%; t = 2.4; P = .04). Thematic analysis of interviews suggests that barriers to overall use included perceptions of alcohol use; clinical need to intervene; time; and issues with use of technology, most often at the POC. However, the tool added confidence and a valuable framework for interventions and was valued as an educational tool. Users felt that increased training and practice could increase comfort and impact future POC use. Increased POC usability also may be achieved through simplification of the tool and additional flexibility in options for POC use. CONCLUSIONS: A computer-assisted counseling tool for alcohol misuse and abuse can be implemented in primary care settings and shows promise for improving physician screening and interventions for alcohol misuse. To enhance utility in daily clinical practice we recommend design enhancements and strategies to enhance usage as described in this research.

The glass is half full: geriatric precepting encounters in family medicine.

Approximately 19% to 20% of all family medicine office visits involve care to patients older than age 65, yet limited research addresses family medicine geriatric education in the outpatient setting. This study explored how geriatric content is incorporated into resident/attending precepting encounters, using direct observation. An observer recorded the content of 259 sequential precepting interactions, including 33 encounters involving patients older than age 64. Eighty-five percent of these 33 encounters included discussion of a geriatric issue. Although precepting encounters for geriatric and nongeriatric patients were of similar length, more time was spent during geriatric encounters discussing functional issues. We conclude that resident continuity clinics are a source of geriatric education.

Using a supervisory dialogue process in the performance management of family medicine faculty.

BACKGROUND AND OBJECTIVES: The supervisory dialogue (SD) is based on a structured series of annual discussions between faculty members and their supervisors and was initiated in 2001. Our objective was to assess the effect of a new SD performance management process on 21 academic family medicine faculty. METHODS: The SD was evaluated through a post-implementation survey, comparisons to a broader Health System clinical faculty survey, and through descriptive analyses of existing departmental data. RESULTS: The family medicine survey response rate was 90%. Of respondents, 100% of family medicine faculty indicated that their professional goals over the next year were clear to them, 79% felt their current job description accurately reflected their time allocation, 100% indicated an improved understanding with their supervisor, and 84% indicated an improved linkage between their role and the department's mission and goals. In addition, family medicine faculty scored significantly higher than Health System clinical faculty in four areas: defining goals, being informed about promotion and tenure, receiving effective mentoring, and having a collegial work environment. The department also experienced increases in clinical, grant, and academic productivity. The time required to conduct the SD was cited by faculty as the primary barrier to success. CONCLUSIONS: The SD improved faculty communication and faculty morale, grounded faculty in their goals, and facilitated alignment between faculty and the department.

Beyond the horizon: the role of academic health centers in improving the health of rural communities.

Academic health centers (AHCs) face increasing pressures from federal, state, and community stakeholders to fulfill their social missions to the communities they serve. Yet, in the 21st century, rural communities in the United States face an array of health care problems, including a shortage of physicians, health problems that disproportionately affect rural populations, a need to improve quality of care, and health disparities related to disproportionate levels of poverty and shifting demographics. AHCs have a key role to play in addressing these issues. AHCs can increase physician supply by targeting their admissions policies and educational programs. Specific health concerns of rural populations can be further addressed through increased use of telemedicine consultations. By partnering with providers in rural areas and through the use of innovative technologies, AHCs can help rural providers increase the quality of care. Partnerships with rural communities provide opportunities for participatory research to address health disparities. In addition, collaboration between AHCs, regional planning agencies, and rural communities can lead to mutually beneficial outcomes. At a time when many AHCs are operating in an environment with dwindling resources, it is even more critical for AHCs to build creative partnerships to help meet the needs of their regional communities.

A handheld computer smoking intervention tool and its effects on physician smoking cessation counseling.

OBJECTIVE: The objective of this study was to evaluate a handheld computer smoking cessation intervention tool designed to assist physicians in their smoking cessation counseling with patients. METHODS: This study used a pre/post survey design, with a 4-month trial period for the software. Study participants included 22 faculty and resident physicians from the University of Virginia. Paired samples t tests were used to assess mean differences in the 4 main subscales (physician behavior, attitudes, comfort related to counseling patients about smoking cessation, and knowledge). RESULTS: No statistically significant mean differences were found for physician behavior (mean increase = 0.44, P = .55) or physician attitude (mean increase = 0.44, P = .16). A statistically significant mean increase of 2.29 was observed for the physician comfort subscale (t = 3.87, df = 16, P = .001). Physicians indicated improved comfort in counseling patients about smoking cessation (P = .007) and improved comfort in using the Public Health Service Clinical Practice Guidelines (P = .012). CONCLUSION: Physician comfort level in counseling patients about smoking cessation can be improved through handheld computer software. When used in conjunction with other practice modifications, this tool has the potential to improve physician smoking cessation intervention practices.

Effect of generalist preceptor specialty in a third-year clerkship on career choice.

BACKGROUND AND OBJECTIVES: An association exists between student participation in a family medicine clerkship and student selection of family practice as a career. The effect of student exposure to other generalist specialties on career choice is unknown. This study determined if the specialty of an assigned generalist preceptor during a third-year ambulatory clerkship affected medical students' choice of a generalist career. METHODS: We conducted a retrospective cohort study of 464 medical students who were randomly assigned to either a family physician or a general internist for a 4-week, third-year ambulatory clerkship. RESULTS: There was no significant relationship between preceptor assignment and students' generalist career choice. Students assigned to general internal medicine preceptors were not more likely to choose careers in general internal medicine, nor were students assigned to family medicine preceptors more likely to select careers in family practice. CONCLUSIONS: Previous studies have suggested that generalist experiences during medical school can influence students' career preference. This study, however, indicates that the type of generalist experience received during the third year did not affect students' choice of a generalist career, nor did it influence their career choice between the generalist specialties.