"Are You Safe at Home?": Clinician's Assessments for Intimate Partner Violence at the Initial Obstetric Visit.

Few studies have empirically examined patient-clinician conversations to assess how intimate partner violence (IPV) screening is performed. Our study sought to examine audio-recorded first obstetric encounters' IPV screening conversations to describe and categorize communication approaches and explore associations with patient disclosure. We analyzed 247 patient encounters with 47 providers. IPV screening occurred in 95% of visits: 57% used direct questions, 25% used indirect questions, 17% repeated IPV screening later in the visit, 11% framed questions with a reason for asking, and 10% described IPV types. Patients disclosed IPV in 71 (28.7%) visits. There were no associations between disclosure and any categories of IPV screening.

The elephant in the room: Intimate partner violence, women, and traumatic brain injury in sub-Saharan Africa.

Background: Intimate partner violence (IPV) is a gendered form of violence that has been linked with traumatic brain injury (TBI). The prevalence of IPV in sub-Saharan Africa (SSA) is estimated to be one of the highest globally. Yet, little is known about the association between IPV and TBI in the SSA context. In this scoping review, we examine the intersection between IPV and TBI in SSA to identify gaps, as well as intervention opportunities. Methods: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Review (PRISMA-ScR) guidelines to guide our analyses and reporting, we searched for published articles indexed in the four largest and most comprehensive library databases: Pubmed, Embase, Web of Science and PsychInfo. Given the increasing attention that has been placed on gender disparities and health in recent years, we focused on studies published between 2010 and 2021. Results: Our search yielded 5,947 articles and 1,258 were IPV and SSA related. Out of this, only ten examined the intersection between IPV and TBI. All focused on outcomes in female populations from South Africa (n = 5), Ghana (n = 3), Uganda (n = 1), and Cameroon (n = 1). They were a mix of qualitative studies (n = 3), neuro-imaging/biomarker studies (n = 3), case studies/reports (n = 2), quantitative surveys (n = 1) and mixed qualitative/quantitative study (n = 1). Six studies evaluated subjective reporting of IPV-induced TBI symptoms such as headaches, sleep disruptions, and ophthalmic injuries. Three examined objective assessments and included Hypothalamic-Pituitary-Adrenal (HPA) dysregulation detected by salivary cortisol levels, magnetic resonance imaging (MRI) including diffusion tensor imaging (DTI) to evaluate brain connectivity and white matter changes. One final study took a forensic anthropology lens to document an autopsy case report of IPV-induced mortality due to physical head and face trauma. Conclusion: Our findings demonstrate that both subjective and objective assessments of IPV and TBI are possible in "resource-limited" settings. The combination of these outcomes will be critical for viewing IPV through a clinical rather than a cultural lens, and for substantiating the assertion that gender, is indeed, a social determinant of brain health.

A Multifaceted Intimate Partner Violence Communication Skills Curriculum Increases Screening Among Internal Medicine Residents.

Background: Intimate partner violence (IPV) is common, yet physicians do not routinely screen patients for IPV. There are no clear recommendations for best educational practices for physician trainees that improve screening rates. Materials and Methods: We implemented an IPV curriculum combining didactics and communication skills training for internal medicine residents. Didactics included definitions, risk factors, screening recommendations, and documentation; communication skills training included developing unique screening and response phrases; and two simulated patient exercises. The primary outcome was screening documentation rates as measured through pre- and postcurriculum chart review. Secondary outcomes included knowledge, comfort, and attitudes measured through pre- and postcurriculum administration of an adapted Physician Readiness to Manage Intimate partner violence Survey (PREMIS). Postcurriculum semistructured interviews provided further details regarding behaviors and attitudes. Results: Forty residents completed the curriculum. 29/40 (73%) completed both pre- and postsurveys. Fifteen participated in semistructured interviews. Residents demonstrated increased screening documentation postcurriculum (p < 0.05). Residents showed improvement in 80% of objective knowledge questions, and in all perceived knowledge and comfort-based questions (p < 0.01). Statistically significant improvement was noted in many attitudinal domains, including reported screening rates (p < 0.05). In the semistructured interviews, participants reported experiencing both practice-based improvements and ongoing screening barriers. Practice-based improvements included increased screening comfort and frequency, and strengthening of the doctor-patient relationship. Ongoing screening barriers included time, resistance to practice change, competing medical needs, and personal discomfort. Conclusions: A multifaceted IPV curriculum for residents significantly improved documentation rates, knowledge, comfort, and attitudes. Residents reported increased comfort with screening and strengthened patient relationships but acknowledged ongoing barriers to screening.

When the Reading Room Meets the Team Room: Resident Perspectives From Radiology and Internal Medicine on the Effect of Personal Communication After Implementing a Resident-Led Radiology Rounds.

OBJECTIVE: Current radiology and internal medicine (IM) residents have trained to varying degrees depending on program in the post picture archiving and communication systems implementation era and thus have largely missed out on the benefits of in-person, 2-way communication between radiologists and consulting clinicians. The purpose of this study is to broadly explore resident perspectives from these groups on the desire for personal contact between radiologists and referring physicians and the effect of improved contact on clinical practice. MATERIALS AND METHODS: A radiology rounds was implemented in which radiology residents travel to the IM teaching service teams to discuss their inpatients and review ordered imaging biweekly. Surveys were given to both cohorts following 9 months of implementation. RESULTS: A total of 23/49 diagnostic radiology (DR) and 72/197 IM residents responded. In all, 83% of DR and 96% of IM residents desired more personal contact between radiologists and clinicians. Of all, 92% of DR residents agree that contact with referring clinicians changes their approach to a study, 96% of IM residents agree that personal contact with a radiologist has changed patient management in a way that they otherwise would not have done having simply read a report, 85% of DR residents report that more clinician contact will improve resource use, and 96% report that it will improve care quality. Furthermore, 99% of IM residents report that increased access to a radiologist would make selecting the most appropriate imaging study easier in various clinical scenarios. A majority of IM residents prefer radiology reports that provide specific next-step recommendations and that include arrows/key-image series. CONCLUSION: We conclude that the newest generation of physicians is already attuned to the value of a radiologist who plays an active, in-person role in the clinical decision-making process.

The 50/50 Block Schedule: Impact on Residents' and Preceptors' Perceptions, Patient Outcomes, and Continuity of Care.

PROBLEM: Traditionally, internal medicine continuity clinic consists of a half day per week, regardless of rotation, which may create conflict with ongoing inpatient responsibilities. A 50/50 block schedule, which alternates inpatient and outpatient rotations and concentrates continuity clinic during outpatient rotations, minimizes conflicting responsibilities. However, its impact on patient care has not been widely studied. Continuity is a concern, and intervisit continuity in particular has not been evaluated. INTERVENTION: We implemented a 50/50 block model with "clinic buddy" system to optimize continuity and assessed outcomes pre- and postintervention. Residents alternated inpatient and elective blocks, with clinic 1 full day per week on elective blocks only. Resident and preceptor perceptions were measured using 5-point Likert surveys to evaluate impact on clinic experience and workload. The authors calculated visit and intervisit continuity using a Usual Provider of Care index and measured blood pressure and hemoglobin A1c as quality markers to evaluate the impact on continuity and quality of care. CONTEXT: Participants were 208 medicine residents and 39 core faculty members at 3 University of Pittsburgh Medical Center clinics. The intervention was implemented in June 2014. OUTCOME: In the 50/50 system, inpatient distractions decreased (3.59 vs. 1.71, p < .001). Residents more strongly agreed that there was adequate time for conferences (3.33 vs. 4.05), they worked well within the system to achieve best patient care (3.13 vs. 3.61), and multidisciplinary teams worked well together (3.51 vs. 4.08) (all p < .001). Intervisit continuity was unchanged (73%, both models, p = .79). Visit continuity decreased (67.2% vs. 63.7%, p < .001). Blood pressure and hemoglobin A1c were unchanged. LESSONS LEARNED: This 50/50 model minimized inpatient distractions in clinic and increased perceived time for learning. Residents reported improved sense of patient ownership, relations within the multidisciplinary team, and integration into the clinic system. Intervisit continuity was preserved, visit continuity was slightly decreased, and patient outcomes were not impacted in this model.

Physicians' Perceived Roles, as Well as Barriers, Toward Caring for Women Sex Assault Survivors.

BACKGROUND: Sexual assault (SA) affects about 40% of women in the United States and has many mental and physical health sequelae. Physicians often do not address SA with patients, although SA survivors describe a desire to talk to physicians to obtain additional help. Little information exists on how providers perceive their roles regarding caring for women SA survivors and what barriers they face in providing this care. METHODS: We performed a qualitative study using semistructured one-on-one interviews with 16 faculty physicians from five specialties: obstetrics and gynecology (n = 4), internal medicine (n = 4), family medicine (n = 1), emergency medicine (n = 3), and psychiatry (n = 4). Interviews were conducted between July 2011 and July 2012, transcribed verbatim, and coded using a constant comparative approach. Once a final coding scheme was applied to all transcripts, we identified patterns and themes related to perceived roles and barriers to caring for SA survivors. RESULTS: Physicians described two main categories of roles: clinical tasks (e.g., testing and treating for sexually transmitted infections, managing associated mental health sequelae) and interpersonal roles (e.g., providing support, acting as patient advocate). Physician barriers fell into three main categories: 1) internal barriers (e.g., discomfort with the topic of SA), 2) physician-patient communication, and 3) system obstacles (e.g., competing priorities for time). CONCLUSIONS: Although physicians describe key roles in caring for SA survivors, several barriers hinder their ability to fulfill these roles. Training interventions are needed to reduce the barriers that would ultimately improve clinical care for SA survivors.

Education for the mind and the heart? Changing residents' attitudes about addressing unhealthy alcohol use.

BACKGROUND: Screening and brief intervention counseling for unhealthy alcohol use are among the top 10 recommended clinical preventive services for US adults. Although federally funded training programs in alcohol screening, brief intervention, and referral to treatment (SBIRT) have focused on increasing physicians' professional readiness to address drinking with their patients, programs typically focus on knowledge and skill acquisition, with less attention to attitudinal change. The purpose of this study was to assess the impact of a multicomponent SBIRT training program on changes in internal medical residents' professional readiness for working with patients with unhealthy alcohol use. METHODS: Between 2011 and 2013, first-year internal medicine residents (n = 80) at a large academic medical center participated in a 16-hour SBIRT training program, consisting of two 3-hour didactic sessions, online modules, and a half-day clinical experience, during the Ambulatory Care month of the residency training year. Residents completed a modified Alcohol and Problems Perceptions Questionnaire (AAPPQ) at the beginning and end of the residency year to assess changes in professional readiness to work with adults with unhealthy alcohol use across 6 domains: Role Adequacy, Role Legitimacy, Role Support, Motivation, Task-Specific Self-esteem, and Satisfaction. Wilcoxon signed-rank tests were used to evaluate changes in the 6 AAPPQ subscale scores over time. RESULTS: Residents reported significant increases in Role Adequacy (alcohol-related knowledge/skills; pre: 34 and post: 39.5; P < .0001) and Role Support (professional support; pre: 16 and post: 18; P = .005) scores. No significant differences in the remaining AAPPQ subscales were detected. CONCLUSIONS: Residents in the SBIRT training program indicated improvements in knowledge, skills, and professional role support but not in motivation, task-specific self-esteem, or satisfaction for working with patients with unhealthy alcohol use. Explicit curricular attention to these domains may be required to facilitate SBIRT skills application and sustained practice change.

Training Residents to Work in a Patient-Centered Medical Home: What Are the Outcomes?

Background The patient-centered medical home (PCMH) provides a setting to enhance resident training in systems-based practice. Few studies have addressed the impact of PCMHs on resident knowledge and confidence. Objective The goal of this study was to evaluate resident knowledge, confidence, behavior, and patient outcomes in a PCMH. Methods Our curriculum emphasized patient panel report card interpretation, a telephone medicine curriculum, and interdisciplinary team-based care of chronic medical conditions. We measured resident satisfaction, knowledge, and confidence. Patient outcomes included hemoglobin A1c (HbA1c) and blood pressures. Prescores and postscores were compared using paired t tests for continuous measures and McNemar's test for binary measures. Results A total of 154 residents were eligible for the curriculum. All residents participated in the curriculum, though not all residents completed the evaluation. Completion rates for paired pre-post knowledge and confidence surveys were 38% and 37%, respectively. Nearly 80% (69 of 87) of residents indicated that the curriculum was above average or outstanding. Our evaluation revealed very small immediate improvements in knowledge and confidence. No significant improvement in patients' HbA1cs or blood pressures occurred after the curriculum. Conclusions Explicit training to work in a PCMH was feasible and resulted in high levels of resident satisfaction and immediate small improvements in knowledge and confidence.

Transforming primary care training--patient-centered medical home entrustable professional activities for internal medicine residents.

INTRODUCTION: The U.S. faces a critical gap between residency training and clinical practice that affects the recruitment and preparation of internal medicine residents for primary care careers. The patient-centered medical home (PCMH) represents a new clinical microsystem that is being widely promoted and implemented to improve access, quality, and sustainability in primary care practice. AIM: We address two key questions regarding the training of internal medicine residents for practice in PCMHs. First, what are the educational implications of practice transformations to primary care home models? Second, what must we do differently to prepare internal medicine residents for their futures in PCMHs? PROGRAM DESCRIPTION: The 2011 Society of General Internal Medicine (SGIM) PCMH Education Summit established seven work groups to address the following topics: resident workplace competencies, teamwork, continuity of care, assessment, faculty development, 'medical home builder' tools, and policy. The output from the competency work group was foundational for the work of other groups. The work group considered several educational frameworks, including developmental milestones, competencies, and entrustable professional activities (EPAs). RESULTS: The competency work group defined 25 internal medicine resident PCMH EPAs. The 2011 National Committee for Quality Assurance (NCQA) PCMH standards served as an organizing framework for EPAs. DISCUSSION: The list of PCMH EPAs has the potential to begin to transform the education of internal medicine residents for practice and leadership in the PCMH. It will guide curriculum development, learner assessment, and clinical practice redesign for academic health centers.

Once is not enough: effective strategies for medical student education on intimate partner violence.

Training in intimate partner violence (IPV) improves health professionals' knowledge and comfort regarding IPV; the optimal training frequency and format is unknown. We assessed how various types and amounts of IPV education for medical students affected knowledge and attitudes. Medical students at a large, urban university completed a survey concerning IPV-related knowledge and attitudes and participation in didactic and experiential IPV training activities. This was a one-time assessment. Of 586 students, 279 (48%) completed the survey. IPV-related knowledge increased with increased number of training activities. Knowledge and attitude scores were higher (p < .001) for respondents with experiential, versus only didactic, activities.

Faculty member review and feedback using a sign-out checklist: improving intern written sign-out.

PURPOSE: Although residents commonly perform patient care sign-out during training, faculty do not frequently supervise or evaluate sign-out. The authors designed a sign-out checklist, and they investigated whether use of the checklist, paired with faculty member review and feedback, would improve interns' written sign-out. METHOD: In a randomized, controlled design in 2011, the authors compared the sign-out content and the overall sign-out summary scores of interns who received twice-monthly faculty member sign-out evaluation with those of interns who received the standard sign-out instruction. A sign-out checklist, which the authors developed on the basis of internal needs assessment and published sign-out recommendations, guided the evaluation of written sign-out content and sign-out organization as well as the twice-monthly, face-to-face evaluation that the interns in the intervention group received. RESULTS: Using the sign-out checklist and receiving feedback from a faculty member led to statistically significant improvements in interns' sign-out. Through regression analysis, the authors calculated a 23% difference in the sign-out content (P = .005) and a 2.2-point difference in the overall summary score (on a 9-point scale, P = .009) between the interns who received sign-out feedback and those who did not. The content and quality of the intervention group's sign-outs improved, whereas the content and quality of the control group's worsened. CONCLUSIONS: A sign-out checklist paired with twice-monthly, face-to-face feedback from a faculty member led to improvements in the content and quality of interns' written sign-out.

Effect of an educational Inpatient Diabetes Management Program on medical resident knowledge and measures of glycemic control: a randomized controlled trial.

OBJECTIVE: To investigate the effectiveness of an Inpatient Diabetes Management Program (IDMP) on physician knowledge and inpatient glycemic control. METHODS: Residents assigned to General Internal Medicine inpatient services were randomized to receive the IDMP (IDMP group) or usual education only (non-IDMP group). Both groups received an overview of inpatient diabetes management in conjunction with reminders of existing order sets on the hospital Web site. The IDMP group received print copies of the program and access to an electronic version for a personal digital assistant (PDA). A Diabetes Knowledge Test (DKT) was administered at baseline and at the end of the 1-month rotation. The frequency of hyperglycemia among patients under surveillance by each group was compared by using capillary blood glucose values and a dispersion index of glycemic variability. IDMP users completed a questionnaire related to the program. RESULTS: Twenty-two residents participated (11 in the IDMP group and 11 in the non-IDMP group). Overall Diabetes Knowledge Test scores improved in both groups (IDMP: 69% ± 1.7% versus 83% ± 2.1%, P = .003; non-IDMP: 76% ± 1.2% versus 84% ± 1.4%, P = .02). The percentage of correct responses for management of corticosteroid-associated hyperglycemia (P = .004) and preoperative glycemic management (P = .006) improved in only the IDMP group. The frequency of hyperglycemia (blood glucose level >180 mg/dL) and the dispersion index (5.3 ± 7.6 versus 3.7 ± 5.6; P = .2) were similar between the 2 groups. CONCLUSION: An IDMP was effective at improving physician knowledge for managing hyperglycemia in hospitalized patients treated with corticosteroids or in preparation for surgical procedures. Educational programs directed at improving overall health care provider knowledge for inpatient glycemic management may be beneficial; however, improvements in knowledge do not necessarily result in improved glycemic outcomes.

The educational impact of weekly e-mailed fast facts and concepts.

PURPOSE: Educational interventions such as electives, didactics, and Web-based teaching have been shown to improve residents' knowledge, attitudes, and skills. However, integrating curricular innovations into residency training is difficult due to limited time, faculty, and cost. In this study, the authors assessed the educational impact of weekly Fast Facts and Concept (FFAC) e-mails on residents' knowledge of palliative care topics, self-reported preparedness in palliative care skills, and satisfaction with palliative care education. METHOD: Internal medicine interns at the University of Pittsburgh and Medical College of Wisconsin were randomized to control and intervention groups in July 2009. Pretests and posttests assessed medical knowledge through 24 multiple choice questions, preparedness on 14 skills via a 4-point Likert scale and satisfaction based on ranking of education quality. The intervention group received 32 weekly e-mails. RESULTS: The study group included 82 interns with a pretest response rate of 100% and posttest response rate of 70%. The intervention group showed greater improvement in knowledge than the control (18% increase compared to 8% in the control group, p = 0.005). Preparedness in symptom management skills (converting between opioids, differentiating types of pain, treating nausea) improved in the intervention group more than the control group (p = 0.04, 0.01, and 0.02, respectively). There were no differences in preparedness in communication skills or satisfaction between the control and intervention groups. CONCLUSIONS: E-mailed FFAC are an educational intervention that increases intern medical knowledge and self-reported preparedness in symptom management skills but not preparedness in communication skills or satisfaction with palliative care education.

Understanding turning points in intimate partner violence: factors and circumstances leading women victims toward change.

OBJECTIVE: When counseling women experiencing intimate partner violence (IPV), healthcare providers can benefit from understanding the factors contributing to a women's motivation to change her situation. We wished to examine the various factors and situations associated with turning points and change seeking in the IPV situation. METHODS: We performed qualitative analysis on data from 7 focus groups and 20 individual interviews with women (61 participants) with past and/or current histories of IPV. RESULTS: The turning points women identified fell into 5 major themes: (1) protecting others from the abuse/abuser; (2) increased severity/humiliation with abuse; (3) increased awareness of options/access to support and resources; (4) fatigue/recognition that the abuser was not going to change; and (5) partner betrayal/infidelity. CONCLUSIONS: Women experiencing IPV can identify specific factors and events constituting turning points or catalyst to change in their IPV situation. These turning points are dramatic shifts in beliefs and perceptions of themselves, their partners, and/or their situation that alter the women's willingness to tolerate the situation and motivate them to consider change. When counseling women experiencing IPV, health providers can incorporate understanding of turning points to motivate women to move forward in their process of changing their IPV situation.