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.

Team-based care: an expanded medical assistant role - enhanced rooming and visit assistance.

Primary care practices face significant challenges as they pursue the Quadruple Aim. Redistributing care across the interprofessional primary care team by expanding the role of the medical assistant (MA) is a potential strategy to address these challenges. Two sequential, linked processes to expand the role of the MA, called Enhanced Rooming and Visit Assistance, were implemented in four family medicine residency clinics in Minnesota. In Enhanced Rooming, MAs addressed preventive services, obtained a preliminary visit agenda, and completed a warm hand-off to the provider. In Visit Assistance, MAs stayed in the room the entire visit to assist with the visit workflow. Enhanced Rooming and Visit Assistance processes were successfully implemented and sustained for over one year. MAs and providers were satisfied with both processes, and patients accepted the expanded MA roles. Mammogram ordering rates increased from 10% to 25% (p < 0.0001). After Visit Summary (AVS) print rates increased by 12% (p < 0.0001). Visit Turn-Around-Time (TAT) decreased 3.1 minutes per visit (p = 0.0001). Expanding the MA role in a primary care interprofessional team is feasible and a potentially useful tool to address the Quadruple Aim.

Change that Matters: A Health Behavior Change and Behavioral Health Curriculum for Primary Care.

Although primary care is an ideal setting in which to address behavioral influences on health, clinicians spend little time discussing preventive care, including lifestyle counseling. There is a dearth of comprehensive training and evidence-based resources to educate clinicians in how to effectively engage with patients about these topics. This study describes and evaluates the acceptability of Change that Matters: Promoting Healthy Behaviors, a ten-module curriculum to train clinicians in brief, evidence-based interventions. Each module includes three parts: interactive patient handouts, didactic training, and electronic health record templates to guide the discussion and after visit summary. A two-part, mixed-methods pilot study was used to evaluate the acceptability of the curriculum in a family medicine residency clinic. In Study 1, external family medicine faculty experts (N = 11) provided written feedback on the patient handouts. In Study 2, 20 residents and 20 patients completed qualitative interviews regarding their experience with curricular materials. Content analysis was used to extract qualitative themes. Experts rated the patient handouts as highly understandable and actionable. Resident themes indicated that the curriculum provided concrete tools to address health behavior change, helped structure patient discussions, and increased confidence. Patients felt empowered to make behavior changes. This new curriculum addresses a gap in existing resources, and is available for free download online which can facilitate dissemination ( https://changethatmatters.umn.edu/ ). Research has found the curriculum to be acceptable to experts, residents, and patients. Future studies need to explore its impact on the behavior of both clinicians and patients.

Values-Based Behavioral Activation for Chronic Pain in Primary Care: A Pilot Study.

Chronic pain is prevalent and can be complex to manage in primary care. Encouraging patients with chronic pain to engage in valued activities has been associated with reduced disability and distress. This single-arm, mixed methods pilot study examined whether adding a values-based behavioral activation intervention to a chronic pain protocol is feasible and acceptable in an urban, underserved family medicine residency clinic. Patients (N = 30) living with chronic pain completed a values assessment and co-created a plan with a psychologist to engage in values-based activities. Patients completed self-report measures of psychological health and functioning pre- and post-intervention and a qualitative interview at the follow-up visit. The intervention was considered feasible and acceptable. Patients reported high levels of satisfaction and enjoyment of the intervention and significantly less pain interference at follow-up compared to baseline. Values-based behavioral activation for chronic pain may be implemented as part of behavioral health practice in primary care.

Erratum: A better approach to the diagnosis of PE.

The author list for the June 2019 PURL ("A better approach to the diagnosis of PE." J Fam Pract. 2019;68:286,287,295) should have read: Andrew H. Slattengren, DO; Shailendra Prasad, MBBS, MPH; David C. Bury, DO; Michael M. Dickman, DO; Nick Bennett, DO; Ashley Smith, MD; Robert Oh, MD, MPH, FAAFP; Robert Marshall, MD, MPH, MISHM, FAAFP.

PURL: A better approach to the diagnosis of PE.

A simple diagnostic algorithm is all that's needed to safely and effectively reduce our reliance on CT pulmonary angiography to diagnose PE.

Personal Manuscript Acceptance Rates: Metrics for Self-assessment in Scholarship.

INTRODUCTION: There is no established baseline for how frequently clinical researchers personally encounter manuscript rejection, making it difficult for faculty to put their own evolving experience in context. The purpose of this study was to determine the feasibility of obtaining personal acceptance per submission (APS) and acceptance per manuscript (APM) rates for individual faculty members. METHODS: We performed a cross-section survey pilot study of clinical faculty members of two departments (family medicine and pediatrics), in one academic health center in the academic year 2017-2018. The survey asked participants to report the number of attempted submissions required per journal article they have had accepted in the prior 2 years as well as any submissions that did not lead to publication. RESULTS: Sixty-eight of 136 eligible faculty (50%) completed the questionnaire. Academic clinicians in the sample eventually published 80% of the manuscripts submitted, with 39% of papers rejected per submission attempt. Associate professors had the highest APS (0.71) and APM (0.88). CONCLUSIONS: In this pilot, we demonstrated the feasibility of retrospectively collecting data that could identify baseline manuscript acceptance rates and were able to generate department averages and rank specific averages for manuscript acceptance and rejection. We confirmed that rejection is common among academic clinicians. The APS and APM can be used by academic clinicians to track their own progress from day one of their publishing careers as a method of self-assessment, rather than having to wait for citations to accumulate.

Similarities and differences between families who have frequent and infrequent family meals: A qualitative investigation of low-income and minority households.

INTRODUCTION: Numerous quantitative studies have examined the association between family meal frequency and child/adolescent weight and weight-related behaviors. However, limited qualitative research has been conducted to identify mealtime characteristics (e.g., child behavior during meals, rules/expectations, family dynamics) that occur during family meals that may explain why some families engage in frequent family meals and others do not. This is particularly important within racially/ethnically diverse households, as these demographic groups are at higher risk for weight-related problems. The current study aimed to identify similarities and differences in mealtime characteristics between households that have frequent and infrequent family meals within a low-income and minority population. METHODS: This qualitative study included 118 parents who participated in Family Meals, LIVE!, a mixed-methods, cross-sectional study. Parents (90% female; mean age = 35) were racially/ethnically diverse (62% African American, 19% White, 4% Native American, 4% Asian, 11% Mixed/Other) and from low-income (73% < $35,000/yr.) households. Data were analyzed using inductive content analysis. RESULTS: Results indicated some similar mealtime characteristics (i.e., picky eating, involving family members in meal preparation) between households having frequent and infrequent family meals. Additionally, several differences in mealtime characteristics were identified between households having frequent (i.e., importance of family meals, flexibility in the definition of family meals, family meal rules, no pressure-to-eat feeding practices) versus infrequent family meals (i.e., pressure-to-eat parent feeding practices, family meals are dinner meals only, and difficult meal time behaviors). DISCUSSION: Study findings may be useful for developing intervention targets for low-income and racially/ethnically diverse households so more families can benefit from the protective nature of family meals.

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

Clinical Pharmacist Faculty Contribution to Evidence-Based Medicine and Milestones.

INTRODUCTION: Family medicine residency programs (FMRPs) endeavor to meet evidence-based medicine (EBM) subcompetencies through the milestones project. Comprehensive descriptions of clinical pharmacists' contributions in teaching EBM within the context of residency are limited. METHODS: Over a study period of 2 months, clinical pharmacists across five FMRPs in four states were invited to track their interactions with physician residents. EBM resources, skills, and targeted milestone data were collected. Pharmacists also quantified their nonpatient care contributions to EBM. RESULTS: Of the 16 clinical pharmacists invited, 16 (100%) participated in the October and 12 (75.0%) in the March collection period. A total of 598.9 half days over 2 months (42 working days) of available teaching time were reported. The tracking tool captured 1,253 EBM teaching encounters with a total average of 2.1 encounters per half day. Of those encounters, point-of-care references were most commonly used (63.7%) and "apply" was the most common EBM skill taught (83.8%). The most commonly tracked milestone was Medical Knowledge 2 (75.3%) at Level 2. Nine out of 10 faculty pharmacists included in this study reported performing the following roles: preceptor (100%), lecturer (89.9%), provider (77.8%), expert/consultant (77.8%), health care team (66.7%), and other (11.1%). Faculty pharmacists also reported directly evaluating milestones for physician residents through: committee work (44.4%), resident evaluations (77.8%), and rotation evaluations (77.8%). CONCLUSIONS: As FMRPs strive to meet ACGME EBM-related competencies, clinical pharmacists across multiple sites demonstrated contributions to teaching EBM in medical resident education. Using a nonphysician faculty for this purpose may provide an example for other FMRPs.

Do autologous blood and PRP injections effectively treat tennis elbow?

Both approaches reduce pain, but the improvement with platelet-rich plasma (PRP) is not clinically meaningful. Autologous blood injections (ABIs) are more effective than corticosteroid injections for reducing pain and disability in patients with tennis elbow in both the short and long term.

Qualitative Assessment of Patients Receiving Prolotherapy for Knee Osteoarthritis in a Multimethod Study.

OBJECTIVE: Randomized and open-label studies assessing prolotherapy for knee osteoarthritis have found quantitative improvement on the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC) compared with baseline status and control therapies. This study assessed the qualitative response of participants receiving prolotherapy, an injection-based complementary treatment for symptomatic knee osteoarthritis (OA). DESIGN: Qualitative study using semi-structured in-depth interviews at 52 weeks after enrollment; transcribed responses were discussed by coauthors to identify themes; disagreement was resolved by consensus. SETTING: Outpatient. PARTICIPANTS: Twenty-two participants treated with prolotherapy for symptomatic knee OA who were exited from three randomized and open-label studies. INTERVENTIONS: Intra- and extra-articular hypertonic dextrose injection (prolotherapy). MAIN OUTCOME MEASURES: Patient narrative and composite WOMAC questionnaire (0-100 points) scores. RESULTS: Participants had baseline demographic and knee OA severity similar to those of participants in three prior intervention trials, as well as similar robust follow-up WOMAC score change (19.9 ± 12.6 points), suggesting a representative subsample. Seven themes were identified from participant narratives: (1) improvement in knee-specific quality of life (n = 18), (2) safety and comfort, (3) pretreatment counseling enhanced treatment adherence and optimism, (4) overall positive experience with prolotherapy, (5) limited response to prolotherapy (n = 4), (6) consistency with anecdotal clinical prolotherapy experience; and (7) functional improvement without pain reduction. CONCLUSIONS: Most participants reported substantially improved knee-specific effects, resulting in improved quality of life and activities of daily living; four participants reported minimal or no effect. Clear, complete description of procedural rationale may enhance optimism about and adherence to treatment appointments.

PURLs: Kidney stones? It's time to rethink those meds.

Despite being recommended for ureteral stone expulsion, tamsulosin or nifedipine are no more effective than placebo.