The Effect of Patient-Physician Concordance on Perinatal Care: The Family Physicians' Perspective.

Demographic concordance between patients and clinicians has been associated with better outcomes. The current perinatal care workforce is not adequately diverse to allow for patient-clinician concordance. In this mixed-methods study, we aimed to understand family physicians' perception of the impact of patient-clinician concordance on perinatal care. The predominantly (91%) non-Hispanic White sample of 1,505 family physicians (FPs) perceived gender and language concordance to affect perinatal care more than racial or ethnic concordance. Religious concordance is not perceived to greatly affect perinatal care. Nearly half (721) of the respondents chose to leave a free-text comment on the impact of concordance on perinatal care. Four categories emerged (patients, physicians, the patient-physician relationship, and potential ways to mitigate the impact of discordance). Based on the perceptions of FPs experienced in perinatal care, intentionally supporting continuity of care between patients and clinicians may help to mitigate the negative impact of discordance on perinatal outcomes.

Retaining the perinatal care workforce: Lessons learned from experienced physicians who no longer attend deliveries.

OBJECTIVE: To inform policy supporting the retention of family physicians (FPs) in the perinatal care workforce by identifying physician characteristics that are associated with retention. DATA SOURCES AND STUDY SETTING: We surveyed FPs who had been in practice for at least 11 years and reported attending deliveries as part of their practice. STUDY DESIGN: We compared the characteristics of FPs who continue to provide perinatal care to those who have ceased and explored their reasons for no longer attending deliveries. DATA COLLECTION/EXTRACTION METHODS: We estimated a probit regression with the dependent variable: whether the physician currently delivers babies. Open-ended survey responses were analyzed and close-coded using a conceptual content analysis approach. PRINCIPLE FINDINGS: Of the FPs who received a survey, 1505 (37%) responded. Those who continue attending deliveries were more likely to receive a stipend or be paid per hour/shift in addition to their salary versus those paid a salary (percentage point difference = 13), and less likely to work part-time versus full-time (percentage point difference = -20). Those who ceased attending deliveries cite lifestyle (n = 208), call structure (n = 113), and delivery volume (n = 89) among the reasons for doing so. CONCLUSIONS: Evidence-based policies aimed at preventing attrition from the perinatal care workforce, which might include targeting compensation models and work-life balance.

Therapist and supervisor perspectives about two train-the-trainer implementation strategies in schools: A qualitative study.

Background: Train-the-trainer (TT) implementation strategies (in which designated clinicians are trained to then train others in an intervention) are promising approaches to support mental health clinician use of evidence-based interventions in school contexts. However, there is little evidence to date examining clinicians' perceptions of the acceptability and feasibility of TT strategies, or comparing clinicians' perceptions of different types of TT strategies. Methods: The current study was conducted as part of a larger hybrid effectiveness-implementation trial, in which school-based therapists and supervisors received one of two different types of implementation support to implement cognitive behavioral therapy (CBT) groups for anxiety: TT (i.e., initial training for therapists and supervisors) or enhanced TT (TT+; i.e., initial training for therapists and supervisors, and ongoing external consultation for supervisors). We used applied thematic analysis to compare qualitative interview transcripts from 28 therapist interviews and 33 supervisor interviews from therapists and supervisors who received TT or TT+ support and report themes that were similar and different across the two groups. Results: Most themes were similar across the TT and TT+ conditions: therapists and supervisors in both conditions perceived the group anxiety intervention as acceptable and viewed supervision as acceptable, helpful, and feasible. Therapists and supervisors in both conditions had mixed impressions of the contextual appropriateness of the group anxiety intervention, and some reported logistical challenges with weekly supervision. Some unique themes were identified among the TT+ condition, including supervisors experiencing professional growth, and therapists and supervisors perceiving supervision as critically important and enjoyable. Conclusions: These results suggest that TT implementation support, using a model in which an internal supervisor receives initial training and then provides ongoing supervision, is acceptable and feasible to support a group CBT intervention in schools. The results also highlight additional benefits that therapists and supervisors perceived when supervisors received ongoing consultation. Clinical Trial Registration Information: The clinical trial from which these data were derived was registered at ClinicalTrials.gov (https://clinicaltrials.gov/) prior to the time of first patient enrollment. The registration number is: NCT02651402.

It is important to understand how to best support mental health clinicians in using evidence-based interventions in school contexts. Train-the-trainer (TT) strategies, in which designated clinicians receive training to then support others in using the intervention, may be promising, and it is important to determine the optimal TT model. However, little is known about how clinicians perceive the acceptability and feasibility of implementing evidence-based mental health interventions with different types of TT support, which can include training and/or ongoing consultation for internal trainers. To address this gap, we used a qualitative approach to examine and compare themes from semistructured interviews with therapists and supervisors participating in two different types of TT implementation support to deliver an evidence-based group CBT intervention for anxiety within schools. Therapists and supervisors receiving both kinds of support had mostly positive perceptions of the intervention and implementation support. They viewed the group anxiety intervention as acceptable and impactful, although they had mixed perceptions about its contextual appropriateness. They viewed supervision as acceptable, helpful, and generally feasible, although challenging at times. However, unique themes among the group who received the more intensive type of TT support, such as supervisors experiencing professional growth over time, suggest that there may be additional benefits to the more intensive support. Overall, these results suggest that TT strategies are an acceptable and feasible approach to support clinicians in delivering group CBT in schools. This study highlights the benefit of embedding qualitative interviews within randomized controlled trials to better understand clinician experiences and perspectives.

The Workforce Providing Prenatal and Postpartum Care Decreases When Family Physicians Stop Attending Deliveries.

The impact of the declining proportion of family physicians who attend deliveries on the provision of other perinatal care during pregnancy, postpartum, and neonatal periods is unclear. We found a strong association between stopping attending deliveries and stopping providing prenatal and postpartum care among family physicians, suggesting that policies which support family physicians to maintain a full scope of practice including all or some aspects of perinatal care may help alleviate shortages in the perinatal workforce and fill gaps in access to obstetric care.

Providing Obstetric Care: Suggestions From Experienced Family Physicians.

BACKGROUND AND OBJECTIVES: The number of family physicians who include obstetric care in their scope of practice is declining, resulting in lower access for patients to obstetric care, especially in rural and underserved communities. In our study, we aimed to understand the experiences of mid- to late-career family physicians and capture suggestions regarding how to maintain obstetric deliveries as part of practice throughout their careers. METHODS: We administered a 30-item online survey to mid- to late-career family physicians regarding their obstetrical care practice and their suggestions for family physicians to continue attending deliveries throughout the course of their career. We developed descriptive statistics of individual and practice characteristics and thematically analyzed open-text comments offering suggestions for continuing to provide obstetric care. RESULTS: About 1,500 family physicians agreed to participate in the online survey, 992 of whom responded to an open-text question asking for suggestions for family physicians hoping to continue providing obstetric care throughout their careers (56% response rate). The primary themes included suggestions regarding interprofessional relationships, call coverage/backup, training and education, practice characteristics, practice setting, work-life balance, job seeking, policy, and compensation. CONCLUSIONS: The findings revealed individual- and structural-level considerations to improve longevity in obstetric scope of practice. Support from multiple levels is necessary to ensure that competent family physicians continue attending deliveries throughout their careers. Practices and hospital systems can have a sizeable impact by directly helping family physicians provide obstetric primary care within their scope of practice, while national organizations can influence health care system-level changes.

A comparison of two group cognitive behavioral therapy protocols for anxiety in urban schools: appropriateness, child outcomes, and cost-effectiveness.

Background: Cognitive behavioral therapy (CBT) for pediatric anxiety is efficacious for reducing anxiety symptoms and improving functioning, but many children are unable to access CBT for anxiety in community settings. Schools are an important setting in which children access mental health care, including therapy for anxiety. In this setting, therapy is usually delivered by Masters-level therapists. Objectives: Friends for Life (FRIENDS), a 12-session, manualized, group CBT program for anxiety has demonstrated effectiveness when implemented in schools. However, prior research has also found challenges regarding feasibility and cultural fit when delivering FRIENDS in the urban school context. To address these challenges, we adapted FRIENDS for implementation in the school setting so that it might be more feasible and culturally appropriate for low-income, urban schools in the United States, while maintaining the core components of treatment. The current study uses a mixed-method approach to compare the effectiveness, cost-effectiveness, and perceived appropriateness of FRIENDS and CATS when delivered by Masters-level therapists with train-the-trainer support. Materials and methods: First, we compared change scores for student outcomes (i.e., child-report MASC-2 total score, parent-report MASC-2 total score, teacher-report Engagement and Disaffection subscale scores) from pre- to post- treatment between students receiving FRIENDS and students receiving CATS to assess whether the two conditions resulted in equivalent outcomes. Second, we compared the cost and cost-effectiveness between the groups. Finally, we used an applied thematic analysis to compare appropriateness of the interventions as perceived by therapists and supervisors. Results: The mean change score for the child-reported MASC-2 was 1.9 (SE = 1.72) points in the FRIENDS condition and 2.9 (SE = 1.73) points in the CATS condition; results indicated that the conditions were similar in their treatment effects, and symptom reductions were small in both groups. The modified protocol, CATS, was shown to cost significantly less to implement compared to FRIENDS and showed greater cost-effectiveness. Finally, compared to therapists and supervisors in the CATS condition, therapists and supervisors in the FRIENDS condition more strongly described aspects of the intervention that were not appropriate for their context and in need of more extensive adaptations. Conclusion: Relatively brief, group CBT for anxiety, with adaptations to improve cultural fit, is a promising approach to treat youth anxiety symptom when delivered by school-based therapists with train-the-trainer implementation support.

Development of an Online Training Platform and Implementation Strategy for School-Based Mental Health Professionals in Rural Elementary Schools: A Mixed-Methods Study.

Children in rural settings are less likely to receive mental health services than their urban and suburban counterparts and even less likely to receive evidence-based care. Rural schools could address the need for mental health interventions by using evidence-based practices within a tiered system of supports such as positive behavioral interventions and supports. However, very few school professionals, with or without mental health training, have received training on evidence-based practices. Rural schools need implementation strategies focused on training to prepare school personnel for the implementation of interventions with fidelity. Little is known about training strategies that are feasible and appropriate for the rural school context. User-centered design is an appropriate framework for the development of training strategies for professionals in rural schools because of its participatory approach and the development of products that fit the context where they are going to be used. The purpose of the study was to develop and assess components of an online training platform and implementation strategy based on the user-centered design. Quantitative and qualitative data from 25 participants from an equal number of schools in rural areas of Pennsylvania were used in the study. A mixed-methods design utilizing complementary descriptive statistics and theme analyses indicated that the training platform and implementation strategy were perceived as highly acceptable, appropriate, feasible and usable by school professionals. The resulting training platform and implementation strategy will fill a void in the training literature in rural schools.

Be in the Digital Room Where it Happens, Part II: Social Media for Neurology Educators.

Social media has changed the way we communicate and interact. Unsurprisingly, it has also changed how we teach and learn. Younger generations of learners have transitioned from traditional educational sources to digital ones. Medical educators need to adapt to trends in medical education and develop fluency in the digital methods used by medical learners today. This is part two of a two-part series on social media and digital education in neurology. This article provides an overview of how social media can be used as a teaching tool in medical education and provides an overview in which it is grounded. We offer practical strategies on how social media can promote lifelong learning, educator development, educator support, and foster educator identity with accompanying neurology-specific examples. We also review considerations for incorporating social media into teaching and learning practices and future directions for integrating these tools in neurology education.

The Prevalence of Retinal Disease and Associated CNS Disease in Young Patients with Incontinentia Pigmenti.

PURPOSE: To evaluate the prevalence of retinal disease on fluorescein angiography (FA) in patients with incontinentia pigmenti (IP) and to compare the severity of retinal disease in those with and without known central nervous system (CNS) disease. DESIGN: Multi-institutional consecutive retrospective case series. SUBJECTS: New patients with a diagnosis of IP were seen at the Casey Eye Institute at the Oregon Health and Science University (OHSU), Moran Eye Center, University of Utah, or Bascom Palmer Eye Institute, University of Miami from December 2011 to September 2018. METHODS: Detailed ophthalmoscopic examination and FA were recommended for all new patients and performed on every patient who had parental consent. Ophthalmoscopic findings and FA images were graded for severity by 2 masked graders on a 3-point scale: 0 = no disease, 1 = vascular abnormalities without leakage, 2 = leakage or neovascularization, and 3 = retinal detachment. The presence of known CNS disease was documented. Additional cases were obtained from a pediatric retina listserv for examples of phenotypic variation. MAIN OUTCOME MEASURES: The proportion of eyes noted to have disease on ophthalmoscopy compared with FA and the severity of retinal disease in those with and without known CNS disease. RESULTS: Retinal pathology was detected in 18 of 35 patients (51%) by indirect ophthalmoscopy and 26 of 35 patients (74%) by FA (P = 0.048) in a predominantly pediatric population (median age, 9 months). Ten patients (29%) had known CNS disease at the time of the eye examination. A Wilcoxon rank-sum test indicated that the retinal severity scores for patients with CNS disease (median, 2) were significantly higher than the retinal severity scores for patients without CNS disease (median, 1), z = -2.12, P = 0.034. CONCLUSIONS: Retinal disease is present in the majority of patients with IP, and ophthalmoscopic examination is less sensitive than FA for detection of disease. There may be a correlation between the severity of retinal and CNS disease.

Be in the Digital Room Where it Happens, Part I: Tweeting & Technology for Career Development.

Social media has become a part of everyday life. It has changed the way we obtain and distribute information, connect, and interact with others. As the number of platforms and users grow, medical professionals have learned the value social media can have in education, research, advocacy, and clinical care initiatives. Platforms provide opportunities to network, build collaborations, and develop a reputation. This is part one of a two-part series. This article provides an overview on how social media can benefit professional career development for clinicians and researchers, as well as for advocacy to raise awareness against biases, disparities, and for patient benefit. We review challenges, limitations, and best practices for social media use by medical professionals with neurology-specific examples.

Development and evaluation of a remote training strategy for the implementation of mental health evidence-based practices in rural schools: pilot study protocol.

BACKGROUND: An increasing number of schools in rural settings are implementing multi-tier positive behavioral interventions and supports (PBIS) to address school-climate problems. PBIS can be used to provide the framework for the implementation of evidence-based practices (EBPs) to address children's mental health concerns. Given the large service disparities for children in rural areas, offering EBPs through PBIS can improve access and lead to better long-term outcomes. A key challenge is that school personnel need technical assistance in order to implement EBPs with fidelity and clinical effectiveness. Providing ongoing on-site support is not feasible or sustainable in the majority of rural schools, due to their remote physical location. For this reason, remote training technology has been recommended for providing technical assistance to behavioral health staff (BHS) in under-served rural communities. OBJECTIVES: The purpose of this study is to use the user-centered design, guided by an iterative process (rapid prototyping), to develop and evaluate the appropriateness, feasibility, acceptability, usability, and preliminary student outcomes of two online training strategies for the implementation of EBPs at PBIS Tier 2. METHODS: The study will employ a pragmatic design comprised of a mixed-methods approach for the development of the training platform, and a hybrid type 2, pilot randomized controlled trial to examine the implementation and student outcomes of two training strategies: Remote Video vs. Remote Video plus Coaching. DISCUSSION: There is a clear need for well-designed remote training studies focused on training in non-traditional settings. Given the lack of well-trained mental health professionals in rural settings and the stark disparities in access to services, the development and pilot-testing of a remote training strategy for BHS in under-served rural schools could have a significant public health impact. ETHICS AND DISSEMINATION: The project was reviewed and approved by the institutional review board. Results will be submitted to ClinicalTrials.gov and disseminated to community partners and participants, peer-reviewed journals, and academic conferences. TRIAL REGISTRATION: ClinicialTrials.gov, NCT05034198 and NCT05039164.

The Association Between Distance Learning, Stress Level, and Perceived Quality of Education in Medical Students After Transitioning to a Fully Online Platform.

BACKGROUND: Before COVID-19, preclinical medical students traditionally attended didactic lectures in in-person settings. Due to social distancing, students were required to switch to online meeting platforms, such as Zoom. For medical students accustomed to in-person interactions, these changes may add more stress to the already stressful medical school experience. Furthermore, it was unclear if students' stress levels were related to their preference for one learning modality over another. The purpose of this study was thus to explore associations between lecture modality (synchronous Zoom lectures versus live, in-person lectures) and stress in second-year medical students after they transitioned from a face-to-face learning experience to a fully online lecture platform. METHODOLOGY: Cross-sectional data were collected from 112 second-year medical students enrolled in a large U.S. medical school using an anonymous questionnaire delivered electronically via social media and emails. The survey contained items pertaining to students' attitudes towards different types of lecture modalities and how they relate to personal stress. Descriptive data and Spearman's rank correlation tests were conducted using IBM Corp. Released 2020. IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp. RESULTS: This study examined correlations between preclinical medical school lecture delivery and personality type, stress levels, attendance, and burnout. Overall, no significance was found between mode of delivery and personality type. On the other hand, the mode of delivery significantly affected stress levels, attendance, and burnout. Moderate to strong correlations were found between the item "Zoom lectures have reduced stress compared to in-person lectures" and preference for Zoom, quality of education using Zoom compared to the in-person lectures, belief that Zoom lectures should continue as part of the curriculum delivery method, staying motivated with lectures fully online with Zoom, and liking that Zoom lectures save commute time to campus. CONCLUSIONS: Findings suggest that a fully online curriculum may play a role in reducing stress in medical students without compromising the quality of education.

Impact of COVID-19 on perinatal care: Perceptions of family physicians in the United States.

BACKGROUND: Patient-centered care is the best practice in the care of pregnant and postpartum patients. The COVID-19 pandemic prompted changes in perinatal care policies, which were often reactive, resulting in unintended consequences, many of which made the delivery of patient-centered care more difficult. This study aimed to understand the impact of the COVID-19 pandemic on perinatal health care delivery from the perspective of family physicians in the United States. METHODS: From October 5 to November 4, 2020, we surveyed mid- to late-career family physicians who provide perinatal care. We conducted descriptive analyses to measure the impact of COVID-19 on prenatal care, labor and delivery, postpartum care, patient experience, and patient volume. An immersion-crystallization approach was used to analyze qualitative data provided as open-text comments. RESULTS: Of the 1518 survey respondents, 1062 (69.8%) stated that they currently attend births; 595 of those elaborated about the impact of COVID-19 on perinatal care in free-text comments. Eight themes emerged related to the impact of COVID-19 on perinatal care: visitation, patient decisions, testing, personal protective equipment, care continuity, changes in care delivery, reassignment, and volume. The greatest perceived impact of COVID-19 was on patient experience. CONCLUSIONS: Family physicians who provided perinatal care during the COVID-19 pandemic noted a considerable impact on patient experience, which particularly affected the ability to deliver patient-centered and family-centered care. Continued research is needed to understand the long-term impact of policies affecting the delivery of patient-centered perinatal care and to inform more evidence-based, proactive policies to be implemented in future pandemic or disaster situations.

ASRM müllerian anomalies classification 2021.

There are many proposed classification systems for müllerian anomalies. The American Fertility Society (AFS) Classification from 1988 has been the most recognized and utilized. The advantages of this iconic classification include its simplicity, recognizability, and correlation with clinical pregnancy outcomes. However, the AFS classification has been criticized for its focus primarily on uterine anomalies, with exclusion of those of the vagina and cervix, its lack of clear diagnostic criteria, and its inability to classify complex aberrations. Despite this classification and others, the wide range of müllerian anomalies is still largely unknown and confusing to many providers. Consequently, müllerian anomalies may go undiagnosed for extended periods, receive inappropriate or inadequate surgical interventions, and result in persistent issues such as pain or loss of reproductive function. The American Society for Reproductive Medicine Task Force on Müllerian Anomalies Classification was formed and charged with designing a new classification. The Task Force set goals for a new classification and chose to base it on the iconic AFS classification from 1988 because of its simplicity and recognizability, while expanding and updating it to include all categories of anomalies. In addition, this was recognized as an opportunity to raise awareness of this area of medicine, educate providers and learners, and promote patient advocacy. Presented here is the new American Society for Reproductive Medicine Müllerian Anomalies Classification 2021.

The power of a checklist: Decrease in emergency department epistaxis transfers after clinical care pathway implementation.

BACKGROUND: Annually, epistaxis costs US hospitals over $100 million dollars. Many patients visit emergency departments (ED) with variable treatment, thus providing opportunity for improvement. OBJECTIVE: To implement an epistaxis clinical care pathway (CCP) in the ED, and analyze its effects on treatment and ED transfers. METHODS: An interdisciplinary team developed the CCP to be implemented at a tertiary hospital system with 11 satellite EDs. The analysis included matched eight-month periods prior to pathway implementation and after pathway implementation. Subjects included patients with ICD-10 code diagnosis of epistaxis. Patients under 18 years old, recent surgery or trauma, or bleeding disorders were excluded. There were 309 patients from the pre-implementation cohort, 53 of which were transferred and 37 met inclusion criteria; 322 from the post-implementation cohort, 37 of which were transferred, and 15 met inclusion criteria. Outcome measures included epistaxis intervention by ED providers and otolaryngologists before and after pathway implementation. RESULTS: CCP implementation resulted in a 61% reduction in patient transfers (p < 0.001). ED providers showed a 51% increase in documentation of anterior rhinoscopy with proper equipment, 34% increased use of topical vasoconstrictors, 40% increased use of absorbable packing, 7% decrease in use of unilateral non-absorbable packing, and 17% decrease in use of bilateral non-absorbable packing. CONCLUSIONS: Prior to CCP implementation, ED treatment of epistaxis varied significantly. CCP resulted in standardized treatment and significant reduction in transfers. A CCP checklist is an effective way to standardize care and prevent unnecessary hospital transfers.