It's a spiral staircase, not just two steps: An iterative approach to assessing patient capacity for medical decision-making.

The assessment of medical decision-making capacity as part of the process of clinical informed consent has been considered a bioethical housekeeping matter for decades. Yet in practice, the reality bears little resemblance to what is described in the medical literature and professed in medical education. Most literature on informed consent refers to medical decision-making capacity as a precondition to the consent process. That is, a clinician must first determine if a patient has capacity, and only then may the clinician engage with the patient for the rest of informed consent. The problem with this two-step approach is that it makes no sense in actual practice. We see the assessment of medical decision-making capacity within the process of informed consent as a spiral staircase, not just two steps, requiring clinicians to keep circling up and around, making progress, until they get to where they need to be: 1. Clinicians start with a general presumption of capacity for most adults, sometimes having a provisional appraisal of capacity based on prior patient contact. 2. Then, they begin performing informed consent for the current situation and intervention options. 3. Next, they must reassess capacity during this process. 4. After that, they continue with informed consent. 5. If capacity is not yet clear, they repeat 1-4.

Prevalence of Moral Injury, Burnout, Anxiety, and Depression in Healthcare Workers 2 Years in to the COVID-19 Pandemic.

ABSTRACT: COVID-19 has led to marked increases in healthcare worker distress. Studies of these phenomena are often limited to a particular element of distress or a specific subset of healthcare workers. We administered the Moral Injury Symptom Scale for Healthcare Professionals, Copenhagen Burnout Inventory, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7 via online survey to 17,000 employees of a large academic medical center between December 2021 and February 2022. A total of 1945 participants completed the survey. Across all roles, the prevalence of moral injury, burnout, depression, and anxiety were 40.9%, 35.3%-60.6%, 25.4%, and 24.8%, respectively. Furthermore, 8.1% had been bothered by thoughts that they would be better off dead or of hurting themselves for "several days" or more frequently. Healthcare workers across all roles and practice settings are experiencing unsustainable levels of distress, with 1 in 12 regularly experiencing thoughts of self-harm.

Validating the TeenHITSS to Assess Child Abuse in Adolescent Populations.

PURPOSE: The purpose of this study is to establish the psychometric properties and diagnostic accuracy of the Teen Hurt-Insult-Threaten-Scream-Sex (TeenHITSS), a 5-item measure used to screen adolescents for family violence in clinical settings. METHODS: Study participants included 251 adolescent participants (n=197 not at-risk subsample; n=56 at-risk subsample), recruited from ambulatory care clinics, a medical center at-risk referral clinic, and area shelters. Participants completed a cross-sectional survey, including the TeenHITSS and Parent-Child Conflict Tactics Scales (CTSPC) questionnaires. We calculated internal reliability, validity, and sensitivity and specificity for the full sample and both subsamples for each screening instrument. RESULTS: Concurrent validity between the TeenHITSS and CTSPC was strong (r=.71, P<.000). We determined an optimal cutpoint based on sensitivity and specificity for correctly identifying abuse victims as a score of one or greater on the TeenHITSS. The TeenHITSS also proved slightly superior to the CTSPC in differentiating between victims and nonvictims of adolescent abuse (AUC=.79 vs .73, respectively). CONCLUSIONS: The TeenHITSS screening tool performed as well as the CTSPC in correctly classifying at-risk and not-at-risk teenagers and offers much greater utility to providers by supplying an actionable cut score. The findings of this study suggest that TeenHITSS is a valid and reliable tool to screen for physical and sexual abuse in children ages 13 years and older in clinical settings and can help health care providers detect adolescent abuse and initiate intervention and prevention of future abuse.

Predictors of mood or anxiety problems among transgender individuals seeking hormone therapy.

BACKGROUND: Mental health needs of transgender individuals can be complex with individual, social, and medical factors impacting symptoms. This study examines predictors of mood or anxiety problems among transgender individuals seeking hormone therapy (HT). METHODS: A retrospective chart review was conducted at 2 clinics providing gender-affirming HT. Cross-sectional data from initial patient encounters (N = 311) were used in this study. Bivariate correlations and multiple logistic regression analyses were carried out. RESULTS: Transgender women (TW) were 2.2 times more likely to have mood or anxiety problems while transgender men (TM) were 2.6 times more likely as the number of medical comorbidities increased. For both TW and TM, White race significantly increased the likelihood of mood or anxiety problems. Neither previous nor current HT were associated with mood or anxiety problems for TW and TM. However, receiving multiple gender-affirming procedures decreased the likelihood of mood or anxiety problems for TM. CONCLUSIONS: Gender-affirming care and addressing comorbidities can be important aspects of mental health needs for transgender individuals.

The majority of transgender men and women reported 1 or more chronic health conditions. These health conditions were associated with transgender individuals being more likely to have a mood or anxiety problem. Currently receiving or previously receiving hormonal therapy was not associated with mood or anxiety problems for transgender men or women, but having received 1 or multiple gender-affirming procedures was associated with a decrease in likelihood of having a mood or anxiety problem for transgender men. White race also was associated with increased likelihood of having a mood or anxiety problem for transgender men and women. These results highlight the need for primary care physicians to take a comprehensive approach when dealing with the mental health needs of transgender patients by ensuring that general health care needs are met while receiving gender-affirming care.

A General Framework for Exploring Ethical and Legal Issues in Sports Medicine.

BACKGROUND: Medicolegal dilemmas faced by Sports Medicine providers differ from those of other primary care physicians in type and frequency. Exotic, high-profile challenges are widely covered in the literature and offer guidance on how to navigate challenging situations. However, there is a gap in the literature on how to approach more mundane, but nevertheless common, medicolegal dilemmas. PURPOSE: The purpose of this article is to provide Sports Medicine providers simple tools for determining whether a course of action is legal or ethical and offer Sports Medicine educators a model for teaching these skills. METHODS: We searched U.S. federal and state law using the LexisNexis® database for laws regulating Sports Medicine practice, and PubMed for articles related to physician approaches to Sports Medicine legal and ethical challenges. Searches started with the term sports medicine, and included winnowing terms of ethics, ethical practice, ethical guidelines, law, and legal guidelines. We used current ethical practice guidelines followed by the American Medical Association and described in detail by Beauchamp and Childress. RESULTS: We offer a framework for how to approach legal challenges in Sports Medicine and apply it to four common scenarios that Sports Medicine physicians often face. We further suggest that the profession formally address this literature gap with a standardized curriculum in Sports Medicine law. CONCLUSION: A curriculum using this framework and clinical vignettes provides learners and practitioners with familiarity and confidence when legal and ethical challenges arise in Sports Medicine.

Community-Based HIV and Viral Hepatitis Fellowship Evaluation: Results from a Qualitative Study.

PURPOSE: The UMass Chan Medical School/New England AIDS Education and Training Center Community-Based HIV and Viral Hepatitis Fellowship was launched in 2014 to train physicians and nurse practitioners to become experts in outpatient management of HIV, hepatitis B and C, and latent tuberculosis. The purpose of this study was to identify areas of strength and improvement and understand fellows' perceptions of the program and its impact on their current positions and career trajectories. METHODS: Qualitative study utilizing a semi-structured interview guide with (11) fellowship graduates (8 MDs; 3 NPs). 45 to 60 min interviews were conducted in April and May 2021, recorded and transcribed. Transcripts were analyzed for representative themes and general patterns in the data. RESULTS: Results indicate high satisfaction with the fellowship, which left a positive and indelible impact on their careers and patient care. Fellows highlighted the program's commitment to health equity, its role in transforming them into leaders and advocates for HIV in primary care, and their ability to balance their work and training demands with their personal lives and needs. The fellowship motivated them to become more involved in public health initiatives, serve marginalized communities and reduce their health disparities. They expressed confidence in their ability to independently manage outpatient HIV, viral hepatitis B and C, and latent tuberculosis, and found areas of overlap with their work in primary care. CONCLUSION: As the care of people with HIV becomes more commonplace in primary care clinics, it is imperative that primary care providers receive the necessary training and education to meet this need. Our study of 11 former fellows shows that the Community-Based HIV and Viral Hepatitis Fellowship offers such training, spreads it to other institutions, and can be a model for other programs nationwide.

Assessing the Factors That Influence Medical Students' Attitudes Toward Working With Medically Underserved Populations.

Introduction: The needs of medically-underserved populations (MUPs) are consistently outpacing the number of physicians caring for them. Medical students' motivations toward working with MUPs consistently decline as they progress through medical school. Given the shortage of doctors caring for MUPs, the objective of our study was to further investigate factors that influence medical students' motivation to work with MUPs while they progress through their education. By identifying these elements, we hope to recommend identified factors within medical education that support the development of more physicians who care for MUPs. Methods: This cross-sectional study is an assessment of medical students at the University of Texas at Southwestern Medical School (UTSW). The study utilized the Medical Student Attitudes Toward the Underserved (MSATU), a validated survey that assesses medical student motivations toward the provision of medical care to MUPs. Surveys were administered at three time points selected to represent key transition points in medical education. Results: There was no significant difference between MSATU scores among the three time points. MSATU scores were higher among students who identified as female, had higher empathy, had higher value placed on teamwork, and had higher community-centeredness. MSATU scores were also higher among students planning to specialize in primary care compared to students planning to specialize in a non-primary care field (P=.239). Conclusion: This study identifies factors associated with high MSATU scores within UTSW medical education, including female identification, higher empathy score, higher emphasis on teamwork, higher community-centeredness, and plans to practice primary care. Additionally, the results support maintenance of MSATU scores across all three time points. Future research should examine individual-level data to determine whether individual students are maintaining their MSATU scores or if individual fluctuations are neutralized by group changes.

Adverse Childhood Experiences and Diabetes: Testing Violence and Distress Mediational Pathways in Family Medicine Patients.

Type 2 diabetes mellitus (diabetes) is increasing in frequency and creating a significant burden on the United States healthcare system. Adverse childhood experiences (ACE) and interpersonal violence (IV) have been shown to have detrimental effects on mental and physical health. How ACE can influence IV as an adult and how this can influence the management of diabetes is not known. The purpose of the current study is to understand the relationship between violence and social determinants of health (SDoH), and its effect on patients with type 2 diabetes mellitus. A practiced-based research network (PBRN) of family medicine residency programs was utilized to collect cross-sectional data from seven family medicine residency program primary care clinics. In total, 581 participants with type 2 diabetes were recruited. A serial/parallel mediation model were analyzed. The majority of participants (58.3%) had a Hemoglobin A1c (HbA1c) that was not controlled. ACE was associated with an increase in Hurt-Insult-Threaten-Scream (HITS) scores, which in turn was positively associated with an increase in emotional burden, and finally, emotional burden decreased the likelihood that one's HbA1c was controlled (Effect = -.054, SE = .026 CI [-.115, -.013]). This indirect pathway remained significant even after controlling for several SDoH and gender. The impact of ACE persists into adulthood by altering behaviors that make adults more prone to experiencing family/partner violence. This in turn makes one more emotionally distressed about their diabetes, which influences how people manage their chronic condition. Family physicians should consider screening for both ACE and family/partner violence in those patients with poorly controlled diabetes.

Experiential QI Activity for Residents to Improve Women's Preventive Services.

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) requires family medicine residents to complete a quality improvement (QI) project. There is a need for more QI training activities to be shared to meet this requirement. Our objective was to describe an activity for residents to improve women's preventive health services in an underserved clinic. Specific aims were to determine: (1) how women's receipt of preventive services compared to benchmarks, (2) physician and staff knowledge of the process and barriers to receiving services, and (3) whether an intervention to increase awareness among physicians and staff improved preventive services. METHODS: Residents (N=30) evaluated charts (N=505) to determine receipt of mammograms, pap tests, colon cancer screenings, and pneumonia vaccines. We compared estimates to existing clinic benchmarks. We presented initial (preintervention) results to physicians and staff at clinic team meetings. We collected perceptions of processes and barriers to preventive services. Preintervention methods were replicated (N=100) and results were compared (postintervention). RESULTS: Preintervention, mammograms (72%) and Pap tests (65%) were lower than clinic benchmarks. Most (81%) women ages 65 and older received a pneumonia vaccine; however, this was lower than the national Healthy People 2020 goal. Fear, knowledge, and scheduling were identified as top barriers. Post-intervention, there was a statistically significant increase in Pap tests (P=.0013). CONCLUSION: This activity trained residents how to impact their practice through QI methods and can be used in other programs as a foundation for developing basic QI initiatives. Future efforts should focus on evaluating barriers to preventive services from the patient perspective.

Emergency department presentation of opioid use disorder and alcohol use disorder.

Mixing alcohol and opioid prescription medications can have serious health consequences. This study examines demographic and geographic differences in opioid use disorders (OUD) and alcohol use disorders (AUD) in emergency department (ED) presentations in the state of Texas. Using all diagnosis codes, the study examined discharge records for ED visits related to AUD and OUD in Texas for 2017. The study classified visits into three mutually exclusive groups (AUD-only, OUD-only, and AUD/OUD) and reported the number of visits, fatalities, total charges, proportions, and rates per 100,000 population by patient demographic characteristics. Chi square statistics assessed the association between patient characteristics and ED visit type, and the study used analysis of variance to compare ED visit rates by patient demographics. The study also fitted a multinomial logistic regression w to predict ED visit type by patient demographic and geographic characteristics. There were 221,363 OUD and AUD ED visits from Texans in 2017. Among them, 3863 had both AUD and OUD. There were 2443 fatalities related to AUD-only ED visits, whereas this rate was 292 for OUD-only ED visits. The majority of these patients had Medicare and Medicaid. AUD-only ED visits were more prevalent (680.7 vs 112.5 per 100,000 population) and resulted in higher overall charges than OUD-only ED visits ($6.1 billion vs $1 billion in total charges). However, AUD/OUD ED visits resulted in higher total charges on average than either OUD-only or AUD-only ED visits. Compared to patients with outpatient discharge, patients with inpatient admissions were more likely to belong to the OUD-only visit group (OR = 1.20, 95% CI: 1.17-1.23) or the AUD/OUD visit group (OR = 2.44, 95% CI: 2.28-2.61) than to the AUD-only visit group. Compared to urban patients, rural patients were less likely to belong to OUD-related visit groups than the AUD-only visit group. In conclusions, AUD was more prevalent than OUD among ED visits and resulted in a higher number of fatalities and higher medical charges. Current health policy regarding substance use that is heavily tilted toward curbing the opioid crisis remains woefully tolerant to AUDs. While efforts to curb opioid misuse should continue, future efforts should raise awareness among ED providers of the disease burden of and social harms caused by alcoholism and alcohol addiction.

The Consent Continuum: A New Model of Consent, Assent, and Nondissent for Primary Care.

The practice around informed consent in clinical medicine is both inconsistent and inadequate. Indeed, in busy, contemporary health care settings, getting informed consent looks little like the formal process developed over the past sixty years and presented in medical textbooks, journal articles, and academic lectures. In this article, members of the Society of Teachers of Family Medicine (STFM) Collaborative on Ethics and Humanities review the conventional process of informed consent and its limitations, explore complementary and alternative approaches to doctor-patient interactions, and propose a new model of consent that integrates these approaches with each other and with clinical practice. The model assigns medical interventions to a consent continuum defined by the discrete categories of traditional informed consent, assent, and nondissent. Narrative descriptions and clinical exemplars are offered for each category. The authors invite colleagues from other disciplines and from the academic ethics community to provide feedback and commentary.

Recognizing Moral Injury: Toward Legal Intervention for Physician Burnout.

The writers respond to the commentary "Physician Burnout Calls for Legal Intervention," by Sharona Hoffman, in the November-December 2019 issue of the Hastings Center Report.

Utilizing Home Visits to Assess Social Determinants of Health During Family Medicine Residency.

INTRODUCTION: Home visits can improve quality of care and health outcomes and provide a unique opportunity to learn more about patients' social context and assess patients' various social determinants of health (SDH). The objectives of this study were to assess patient self-reported SDH, resident reflections on patient social status, the utility of a SDH survey during home visits, and resident comfort levels addressing patient SDH. METHODS: This was a mixed-methods pilot study utilizing patient self-reported data and open-ended reflection questions. Participants included adult patients aged more than 18 years from an urban safety-net clinic and family medicine residents who provide their care. RESULTS: We received forty-two surveys from 42 home visits. Most patients were female (61.9%) and African-American (45.2%), aged from 25 to 88 years (mean=60.24). Top patient-reported SDH include transportation, paying bills, and food insecurity. Common themes of resident responses included positive utility of the survey for assessing patient SDH; variation in comfort level when inquiring about patient SDH with positive influence from prior experience, assistance from colleagues, or prior good relations with patients; and expressed intention to include SDH assessment in future practice. CONCLUSIONS: Residents recognized the value of assessing SDH during home visits and expressed intent to include it in future practice. Thorough assessment of patient SDH may help to craft a more robust and standardized system to prioritize patients who would most benefit from receiving home visits.

PedHITSS: A Screening Tool to Detect Childhood Abuse in Clinical Settings.

BACKGROUND AND OBJECTIVES: Though child abuse is prevalent and detrimental, health care providers fail to screen for abuse at sufficient rates to detect or preempt events. Current child abuse screening tools lack brevity and usefulness in clinical settings. To validate the Pediatric Hurt-Insult-Threaten-Scream-Sex (PedHITSS) screening tool, a 5-item questionnaire designed to detect and prompt provider investigation into child abuse in clinical settings, the PedHITSS was compared to the Conflict Tactics Scale: Parent-Child Version (CTSPC) screening measure. METHODS: Participants included 422 pediatric patients (n=242 nonabused; n=180 abused subsample) recruited from an ambulatory care setting, a medical center at-risk referral clinic, or homeless shelter clinic. Parents were asked to complete a cross-sectional survey, including PedHITSS and CTSPC questionnaires. Concurrent validity of PedHITSS was tested with 242 participants identified as nonabused. Construct validity was assessed with 180 participants previously identified as victims of child abuse. RESULTS: Concurrent validity between the CTSPC and PedHITSS was strong, rs=.70 (P<.01). Sensitivity and specificity for correctly identifying abuse victims (≤12 years) was optimal at a cutpoint of one or greater. There was no significant difference in sensitivity and specificity of HITSS and CTSPC in correctly identifying victims of child abuse. CONCLUSIONS: This study indicates that PedHITSS performs as well as CTSPC in identifying and differentiating victims and nonvictims of child abuse. PedHITSS allows health care providers to confidently screen and report suspected cases of child abuse and serves as a mechanism to confirm abuse status through validated means.