Survey of stigma across healthcare workers in an urban, academic medical center regarding perinatal patients using opioids.

BACKGROUND AND OBJECTIVES: To examine healthcare workers' attitudes towards pregnant woman using opioids across provider type, specialty, and years of service. METHODS: Cross-sectional, anonymous survey of healthcare workers at an urban, academic medical center regarding attitudes towards pregnant women using opioids. RESULTS: One hundred and nineteen surveys were completed. Nurses were less likely to feel sympathetic towards pregnant women that use opioids (p = .016). DISCUSSION AND CONCLUSIONS: Differences in attitudes towards pregnant women using opioids were found between clinicians and nurses. SCIENTIFIC SIGNIFICANCE: Training and experience may contribute to attitude differences towards pregnant women using opioids.

Revisiting our approach to behavioral health referrals.

This system of matching referrals to behavioral health practitioners' historical effectiveness seeks to strengthen patient outcomes.

Dyspareunia: Keys to biopsychosocial evaluation and treatment planning.

Asking the questions identified here can guide your care. Knowing which treatment options are-and aren't-supported by the evidence is also key.

The Next Step in Integrated Care: Universal Primary Mental Health Providers.

Current models of mental health care often do not address three barriers to mental health: the binary view of mental illness (healthy vs. mentally ill), stigma, and prevention. Care models where some patients are selected for referral or consultation with a mental health professional can reinforce this binary view and the stigma associated with seeing mental health services. By only selecting patients who currently are experiencing mental health problems, current integrated care models do not offer sufficient avenues for prevention. To address these barriers, this article proposes building on current models through the development of primary mental health providers (PMHPs). PMHPs-like primary care providers-would provide regular check-ups, assessments, prevention interventions, first-line treatment, or referral to more specialized professionals. This universal approach will help decrease the binary view of mental health, decrease the stigma of seeing a mental health professional through universal access, and improve prevention efforts.

An Online, Self-Directed Curriculum of Core Research Concepts and Skills.

Introduction: Existing scholarly curricula often underemphasize basic research skills and do not address the individual learning needs of residents, whose level of prior exposure to research concepts varies widely. A supplemental educational experience was developed to address educational gaps in a family medicine residency curriculum, including systematic exploration and interpretation of the medical literature, development and exploration of clinically pertinent questions, and development of residents' written communication skills. Methods: A 2-week, online, self-directed research curriculum was developed. The five-module curriculum included (I) Research Methods and Data Analysis, (II) Article Review, (III) Board Review, (IV) Literature Search, and (V) Literature Review and Proposal. Two years after implementation, residents who completed the curriculum were surveyed to assess the overall rotation and its success in meeting learning objectives. Results: Eighteen residents completed the new rotation and demonstrated objectives through assignment completion and review. Additionally, residents reported improved skills on all objectives and were satisfied with the new curriculum and its self-led, online format. Those planning to do research after graduation were more likely to report several benefits from the rotation, including learning more about data analyses and being more likely to complete a future scholarly project. Discussion: An online, self-directed curriculum can provide a feasible and effective educational approach to efficient use of faculty and resident time, allowing time to be focused on resident-specific knowledge gaps and learning needs, rather than presenting all learning material uniformly. The online, accessible format aligned with residents' existing reliance on the internet as a primary information source.

Posttraumatic stress disorder: Often missed in primary care.

DeSean W, a 47-year-old man, returned to his primary care clinic with a new complaint of epigastric burning that had been bothering him for the past 4 months. He had tried several over-the-counter remedies, which provided no relief. He also remained concerned--despite assurances to the contrary at previous clinic visits--that he had contracted a sexually-transmitted disease (STD) after going to a bar one night 4 to 5 months ago. At 2 other clinic visits since that time, STD test results were negative. At this current visit, symptoms and details of sexual history were unchanged since the last visit, with the exception of the epigastric pain. When asked if he thought he had contracted an STD through a sexual encounter the night he went to the bar, he emphatically said he would not cheat on his wife. Surprisingly, given his concern, he avoided further discussion on modes of contracting an STD. The physician prescribed ranitidine 150 mg bid for the epigastric burning and explained, once more, the significance of the STD test results. However, he also decided to further examine Mr. W's concern about STDs and the night he may have contracted one. HOW WOULD YOU PROCEED WITH THIS PATIENT?

Patient Satisfaction with Bedside Teaching Rounds Compared with Nonbedside Rounds.

OBJECTIVES: Many barriers have been cited in reference to why bedside teaching rounds have decreased in frequency during graduate medical education. One perceived barrier to the use of bedside teaching rounds is a fear of it causing patient discomfort or dissatisfaction. The objective of this study was to compare patient perception of bedside versus nonbedside teaching rounds. METHODS: Study participants were adults admitted to a family medicine inpatient team at a large university teaching hospital. Upon admission, participants were randomized to receive bedside or nonbedside teaching rounds conducted by a team consisting of medical students, family medicine residents, and one attending physician. Each participant completed a questionnaire administered on the day of discharge assessing patients' perception of their involvement in medical decision making, trust in the medical team, satisfaction with care, and provider compassion. Statistical analysis was performed to examine any differences between the two groups. RESULTS: The vast majority of the sample indicated that they knew what they were being treated for in the hospital (n = 105, 98%), reported the medical team spent an adequate amount of time with them (n = 100, 94%), and reported the medical team explained the diagnosis and care in easy-to-understand terms (n = 101, 94%). On 1- to 5-point scales, participants reported that the medical team involved them in making decisions (4.62, standard deviation [SD] 0.72), they trusted the medical team (4.91, SD 0.32), they were satisfied with their care (4.85, SD 0.38), and their medical team was compassionate toward them (4.84, SD 0.44). Overall levels of satisfaction were positive on all of the measures, with no statistical significance between the two groups regarding measures of involvement in medical decision making, trust in the medical team, and satisfaction with care. Interestingly, subjects perceived level of compassion of their medical team to be significantly higher with a bedside teaching approach compared with a nonbedside approach. CONCLUSIONS: Despite concerns that bedside teaching rounds may lead to patient discomfort, this study found no evidence supporting this perception. In fact, patients may perceive a medical team that engages in bedside teaching rounds as being more compassionate providers, supporting a patient-centered argument that teaching rounds should return to the bedside.

Behavioral influences on prescription inhaler acquisition for persistent asthma in a patient-centered medical home.

BACKGROUND: Medication adherence can be said to begin with the patient acquiring, or picking up their prescribed medications. There has been considerable study of asthma patients' adherence beliefs once they have possessed medication; however, little is known about attitudes that facilitate or impede their acquisition of such medication. OBJECTIVES: The purpose of this study was to examine the behavioral influences, motivation, and self-efficacy that may guide a patient's decision to pick up asthma controller medications from the pharmacy for the treatment of persistent asthma. METHODS: A chart review of patients with an asthma diagnosis treated at an academic family medicine practice identified 582 English-speaking adults prescribed an asthma medication. Participants were contacted in a randomized order via telephone and asked to complete an investigator-developed survey based upon the Theory of Planned Behavior. Descriptive statistics, chi square and t-tests were used for data analysis. RESULTS: 240 individuals were contacted, and 27 individuals consented and completed a survey. Eighteen individuals (67%) were prescribed a controller inhaler in the past year, fourteen of whom picked up their prescription from the pharmacy. Individuals who did not pick up their prescription reported more strongly than those who did that using their inhaler is important (P = 0.01). No other statistically significant differences were identified. CONCLUSION: Use of an inhaler is important to the patient based upon survey results; however, this belief did not correlate with adherence. Future studies that investigate patient-specific motivators would allow practitioners to better target clinical interventions to improve medication adherence in patients with asthma.

Highly active antiretroviral therapy reduces pulmonary IL-8 in HIV-positive women smokers.

Increased levels of the proinflammatory cytokine IL-8 are detected in the sputum of patients with chronic obstructive pulmonary disease (COPD) and during the pathological pulmonary manifestations of HIV infection : To explore a potential interrelationship between smoking, highly active antiretroviral therapy (HAART) and HIV immune status, we collected sputum samples, along with complete pulmonary function tests from groups of HIV-infected women smokers who were either on or off HAART. Analysis of the patient's sputum for cell count along with quantitative measures of IL-8 was performed and correlated with concurrent assessment of pulmonary function test (PFT). We found that HIV-positive smokers had decreased measurements on PFT of the diffusing capacity of the lung for carbon monoxide (D(LCO)) compared to standard reference values that did not differ with HAART usage. HAART, when controlled for CD4, showed a suppressive effect on the levels of pro inflammatory cytokine IL-8 in sputum. We conclude that in the era of HAART, HIV along with concurrent tobacco smoking is associated with declines in PFT in HIV-infected women. The use of HAART in patients appears to mitigate the increases in IL-8 levels in relation to immune status based on CD4 count.

Engaging families through motivational interviewing.

Helping parents change key behaviors may reduce the risk of child maltreatment. However, traditional provider-centered approaches to working with the parents of pediatric patients may increase resistance to behavioral change. Motivational interviewing (MI) is a patient-centered communication technique that helps address problems of provider-centered approaches. In this article, evidence for use of MI to address several risk factors for child maltreatment is reviewed, including parental substance abuse, partner violence, depression treatment, harsh punishment, and parental management of children's health. Fundamental components of MI that may be incorporated into clinical practice are presented.

Patient preferences in discussing sexual dysfunctions in primary care.

BACKGROUND AND OBJECTIVES: There are multiple barriers that limit patients and primary care physicians (PCPs) from discussing sexual dysfunctions (SDs) during medical appointments. Exploring patient preferences in discussing SDs with PCPs may help address some barriers, which can improve doctor-patient communication about SDs, delivery of health care, and patient quality of life. METHODS: A sample (n=108) of adult patients from an urban primary care clinic completed a 5--10 minute anonymous opinion questionnaire about their preferences in discussing SDs with PCPs. RESULTS: The majority of participants agreed that PCPs should give information to all patients (74%), ask all patients (69%), and have questions on medical history forms (55%) about SDs. Fifty-eight (58%) participants preferred to start the conversations about SDs with PCPs themselves, but all of these participants did not object to PCPs asking them about SDs. Participants who had ever experienced SD symptoms were more likely to want questions on medical history forms and for PCPs to ask about SDs. CONCLUSIONS: Participants preferred discussions about SDs with PCPs through various means (ie, medical history forms, medical appointments). Although participants were divided on who (patient versus PCP) should start conversations about SDs, the majority of participants did not object to PCPs inquiring about SDs during office visits or on medical history forms. Patients in poorer health and with self-reported SDs may need PCPs to inquire about SDs. Recommendations to improve health care delivery are suggested, including PCPs inquiring about SDs with all patients, especially with individuals in poorer health or with histories of SDs.

Residents' knowledge of standard drink equivalents: implications for screening and brief intervention for at-risk alcohol use.

BACKGROUND AND OBJECTIVES: Screening and brief intervention for reducing alcohol consumption has been demonstrated to be effective in various medical settings. The NIAAA has recommended that physicians screen all patients for at-risk and problem drinking. Often, screening is based on the concept of a "standard drink." METHODS: We administered a survey to residents (N=270) in order to assess their knowledge of standard drink equivalents and quantities of alcohol in various sizes of bottles. RESULTS: Although 89% of the responders stated that they had previously learned about screening for at-risk alcohol use, the majority did not know basic facts about standard drink equivalents. DISCUSSION AND CONCLUSIONS: Many trainees are not familiar with typical standard drink equivalents. This can have a significant impact on the screening of patients for problem drinking using screening tools that rely on standard drink equivalents.

A guide to performing pelvic speculum exams: a patient-centered approach to reducing iatrogenic effects.

PURPOSE: Current training in the United States for pelvic speculum examinations (PSEs) has a primary focus on the physician-centered goal of visualizing the cervix but may not inform practitioners of potential iatrogenic effects. Such oversight leaves trainees unprepared and unskilled in preventing and addressing adverse outcomes. This article incorporates a literature review into a step-by-step guide to aid the teaching of PSEs. SUMMARY: Iatrogenic effects of PSEs may include mild discomfort, extreme pain, anxiety, psychological (re)traumatization, and sexual pain disorders. A literature-based guide is presented to identify patients at risk for adverse outcomes, set up the exam room, set up the patient, perform the exam, calm distressed patients, and avoid exam-interfering behaviors. CONCLUSIONS: Although PSEs can lead to adverse outcomes, awareness of the iatrogenic effects allows clinicians to utilize techniques to prevent or reduce negative effects. A method of incorporating techniques described in this article into teaching is provided.