Translating Provider and Staff Engagement Results to Actionable Planning and Outcomes.

Staff and provider engagement leads to better quality and experience of care and less turnover and burnout. In this program, we describe an approach to better understand underlying factors that lead to low staff and provider engagement and address such factors by creating actionable plans that drive improved engagement measures. Focus groups were conducted with staff, advance practice providers, and faculty to better understand low scored areas in an annual third-party engagement survey. Focus group results were analyzed, and thematic action plans were then developed by a leadership team. These plans and the status of addressing the identified issues were published and disseminated back to all staff and providers using a "stoplight report." The leadership team met every 2 to 4 weeks until all issues were addressed and communicated back to the department. The subsequent year's engagement scores statistically increased across all engagement score domains for both staff and faculty. We conclude that using a qualitative approach to understanding low-scored engagement domains will allow a deeper and authentic understanding of the root factors that drive low engagement scores. This approach allows teams to develop responsive action plans, resulting in higher engagement scores, which will eventually lead to better service and care to patients.

Collaborating to Achieve the Optimal Family Medicine Workforce.

When the Family Medicine for America's Health (FMAHealth) Workforce Education and Development Tactic Team (WEDTT) began its work in December 2014, one of its charges from the FMAHealth Board was to increase family physician production to achieve the diverse primary care workforce the United States needs. The WEDTT created a multilevel interfunctional team to work on this priority initiative that included a focus on student, resident, and early-career physician involvement and leadership development. One major outcome was the adoption of a shared aim, known as 25 x 2030. Through a collaboration of the WEDTT and the eight leading family medicine sponsoring organizations, the 25 x 2030 aim is to increase the percentage of US allopathic and osteopathic medical students choosing family medicine from 12% to 25% by the year 2030. The WEDTT developed a package of change ideas based on its theory of what will drive the achievement of 25 x 2030, which led to specific projects completed by the WEDTT and key collaborators. The WEDTT offered recommendations for the future based on its 3-year effort, including policy efforts to improve the social accountability of US medical schools, strategy centered around younger generations' desires rather than past experiences, active involvement by students and residents, engagement of early-career physicians as role models, focus on simultaneously building and diversifying the family medicine workforce, and security of the scope future family physicians want to practice. The 25 x 2030 initiative, carried forward by the family medicine organizations, will use collective impact to adopt a truly collaborative approach toward achieving this much needed goal for family medicine.

Accreditation and implications of clinical postgraduate PA training programs.

No consensus definition exists for postgraduate physician assistant (PA) training. This report from the AAPA Task Force on Accreditation of Postgraduate PA Training Programs describes the types of clinical training programs and their effects on hiring and compensation of PAs. Although completing a postgraduate program appears to have no effect on compensation, PAs who complete these programs may be favored in the hiring process and frequently report greater confidence in their skills. More research is needed and program accreditation is key to monitoring the effectiveness of these programs.

The development of clinical reasoning and interprofessional behaviors: service-learning at a student-run free clinic.

This article examines the benefits of a student run free clinic (SRFC) as a service learning experience for students in medicine, pharmacy, occupational therapy, physical therapy and physician assistant programs. We hypothesized that students who participate in an interprofessional service learning course and volunteer at a SRFC would demonstrate significant increases in perceptions and attitudes for working in interprofessional health care teams and clinical reasoning skills compared to students who did not participate. Three assessments were administered to an experimental and control group of pre-clinical students from medical, occupational therapy, physical therapy, pharmacy and physician assistant programs before and after participation in an interprofessional service-learning course and volunteering at the SRFC. The tools were the Interdisciplinary Education Perception Scale (IEPS), Readiness for Interprofessional Learning Scale (RIPLS) and the Self-Assessment of Clinical Reflection and Reasoning (SACRR). Students who completed the course had improvements in interprofessional perceptions and attitudes (p = 0.03) and perceptions of clinical reasoning skills when compared to the control group (p = 0.002). This study is novel as it examined students' perceptions of interprofessional attitudes and clinical reasoning following participation in an interprofessional service-learning course and participation in a SRFC.

Identification and treatment of depression in minority populations.

Depression is a common condition, representing close to 6% of visits to primary care providers. Although minorities are more likely to have chronic depression, they are more likely to be incorrectly diagnosed and less likely to receive treatment when compared to the mainstream population. Screening and appropriate treatment within primary care is recommended in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up. This recommendation is especially relevant for treatment of minority populations, as they are more likely to seek care for mental health problems from primary care providers rather than specialists. A number of self-report screening tools that simplify screening are available. Treatment modalities that are supported by evidence are psychotherapy, prescription medications, and electroconvulsive therapy for severe depression. Selective serotonin reuptake inhibitors (SSRIs) have become the cornerstone of therapy for depression since the Food and Drug Administration (FDA) approval of fluoxetine in 1987. No substantial differences in efficacy of SSRIs have been found, although data suggest differences with respect to onset of action and adverse effects that may be relevant in the choice of one medicine over another. Common side effects of serotonin reuptake inhibitors include nausea, diarrhea, insomnia, somnolence and dizziness, akathisia, and sexual dysfunction. While most of these symptoms tend to subside within several weeks of use, sexual dysfunction appears to be a long-term side effect that typically reverses within a few days after discontinuation of the causative medication. Selective norepinephrine reuptake inhibitors (SNRIs), bupropion, mirtazapine, and tricyclic antidepressants (TCAs) are other commonly used medications. Complementary and alternative treatments, such as St. John's wort (Hypericum perforatum), exercise, acupuncture, music therapy, and relaxation, have limited data supporting their efficacy.

Oral manifestations of systemic disease.

Careful examination of the oral cavity may reveal findings indicative of an underlying systemic condition, and allow for early diagnosis and treatment. Examination should include evaluation for mucosal changes, periodontal inflammation and bleeding, and general condition of the teeth. Oral findings of anemia may include mucosal pallor, atrophic glossitis, and candidiasis. Oral ulceration may be found in patients with lupus erythematosus, pemphigus vulgaris, or Crohn disease. Additional oral manifestations of lupus erythematosus may include honeycomb plaques (silvery white, scarred plaques); raised keratotic plaques (verrucous lupus erythematosus); and nonspecific erythema, purpura, petechiae, and cheilitis. Additional oral findings in patients with Crohn disease may include diffuse mucosal swelling, cobblestone mucosa, and localized mucogingivitis. Diffuse melanin pigmentation may be an early manifestation of Addison disease. Severe periodontal inflammation or bleeding should prompt investigation of conditions such as diabetes mellitus, human immunodeficiency virus infection, thrombocytopenia, and leukemia. In patients with gastroesophageal reflux disease, bulimia, or anorexia, exposure of tooth enamel to acidic gastric contents may cause irreversible dental erosion. Severe erosion may require dental restorative treatment. In patients with pemphigus vulgaris, thrombocytopenia, or Crohn disease, oral changes may be the first sign of disease.

Oral health curricula in physician assistant programs: a survey of physician assistant program directors.

PURPOSE: a review of the medical literature indicates that physician assistants (PAs) are not educationally prepared for oral health issues. The purpose of this study was to evaluate the status of oral health curricula and the knowledge and skills taught within PA curricula. METHODS: a survey examining oral health curricula in PA education was distributed electronically to the directors of all 142 accredited PA programs in the United States. The survey focused on aspects of oral health that programs currently teach and aspects that merit future inclusion. The survey data were analyzed using SPSS version 17. RESULTS: eighty-three of the 142 PA program directors (58.4%) responded to the survey. Over 74% believed that dental disease prevention should be addressed in PA education, yet only 21% of programs actually did so. Most respondents (94.7%) also agreed that PAs should routinely assess and screen for early signs of dental disease and counsel patients on preventing dental problems. Currently, over half of PA programs teach examination of children's teeth for cavities (55.6%), dedicating on average 3.6 hours toward oral health education. Most respondents (more than 90%) expressed a desire to implement an oral health module in their programs. On average, program directors felt that 5.3 hours should be dedicated to oral health. CONCLUSION: many PA program directors believe that PA programs are responsible for educating students about oral health; however, most PA program directors report a lack of oral health education within their curricula.

Patient satisfaction in a student-run free medical clinic.

BACKGROUND AND OBJECTIVES: There are currently more than 100 student-run medical clinics in the United States, operated in conjunction with various allopathic medical schools. However, there have been no reports regarding patient satisfaction with these free clinic services. METHODS: Fifty-two of 60 patients seen at the C.A.R.E.S. clinic over a 4-week period in the winter of 2007 completed a questionnaire. RESULTS: Patients were highly satisfied with laboratory services, staff friendliness, amount of time spent being interviewed, and the depth of the explanations. They were less satisfied with the hours of operation and wait time. CONCLUSIONS: Patients seen at a student-run clinic are very satisfied with the services they received.

Assessing Student Attitudes as a Result of Participating in an Interprofessional Healthcare Elective Associated with a Student-Run Free Clinic.

BACKGROUND: An interprofessional elective using a student-run clinic can introduce students to professional roles, collaborative patient care, and health disparities. METHODS AND FINDINGS: Students from four professions (pharmacy, medicine, physician assistant, and physical therapy) participated in a service-learning elective where they received weekly didactic lectures and provided healthcare in a student-run free clinic. Additional interprofessional activities included a quality improvement project and a case presentation. Students were administered anonymous surveys before and after the elective to assess changes in their attitudes toward interprofessional teamwork. A total of 93 and 74 students completed the pre-survey and post-survey, respectively. After participating in the elective, significantly more students reported working in interprofessional teams and understood the role of physician assistants. The majority of other attitudes about interprofessional collaboration and professional roles were sustained or improved after the elective. CONCLUSION: An interprofessional service-learning elective using didactic and experiential learning in an interprofessional, student-run free clinic sustained or improved student attitudes toward interprofessional teamwork. The elective had a significant impact on increased student experience working in interprofessional healthcare teams and increased understanding of health professions' roles. Continued assessment of the impact on student behaviours and patient outcomes is warranted.

Common oral conditions in older persons.

Older persons are at risk of chronic diseases of the mouth, including dental infections (e.g., caries, periodontitis), tooth loss, benign mucosal lesions, and oral cancer. Other common oral conditions in this population are xerostomia (dry mouth) and oral candidiasis, which may lead to acute pseudomembranous candidiasis (thrush), erythematous lesions (denture stomatitis), or angular cheilitis. Xerostomia caused by underlying disease or medication use may be treated with over-the-counter saliva substitutes. Primary care physicians can help older patients maintain good oral health by assessing risk, recognizing normal versus abnormal changes of aging, performing a focused oral examination, and referring patients to a dentist, if needed. Patients with chronic, disabling medical conditions (e.g., arthritis, neurologic impairment) may benefit from oral health aids, such as electric toothbrushes, manual toothbrushes with wide-handle grips, and floss-holding devices.

Screening for and diagnosis of oral premalignant lesions and oropharyngeal squamous cell carcinoma: role of primary care physicians.

UNLABELLED: OBJECTIVE; To describe the role that primary care physicians can play in early recognition of oral and oropharyngeal squamous cell carcinomas (OOSCCs) and to review the risk factors for OOSCCs, the nature of oral premalignant lesions, and the technique and aids for clinical examination. QUALITY OF EVIDENCE: MEDLINE and CANCERLIT literature searches were conducted using the following terms: oral cancer and risk factors, pre-malignant oral lesions, clinical evaluation of abnormal oral lesions, and cancer screening. Additional articles were identified from key references within articles. The articles contained level I, II, and III evidence and included controlled trials and systematic reviews. MAIN MESSAGE: Most OOSCCs are in advanced stages at diagnosis, and treatment does not improve survival rates. Early recognition and diagnosis of OOSCCs might improve patient survival and reduce treatment-related morbidity. Comprehensive head and neck examinations should be part of all medical and dental examinations. The head and neck should be inspected and palpated to evaluate for OOSCCs, particularly in high-risk patients and when symptoms are identified. A neck mass or mouth lesion combined with regional pain might suggest a malignant or premalignant process. CONCLUSION: Primary care physicians are well suited to providing head and neck examinations, and to screening for the presence of suspicious oral lesions. Referral for biopsy might be indicated, depending on the experience of examining physicians.

A study of lower extremity amputation rates in older diabetic South Carolinians.

Several studies have shown that lower extremity non-traumatic amputations for diabetic patients disproportionately affect senior minorities. Our study uses population and Medicare data from the year 2000 to profile the magnitude of this disparity by county in South Carolina and its relation to race, gender, per capita income, and the number of primary care physicians. Data from 1998-2001 is used to investigate trends in amputation rates for the state as a whole and for individual counties. Lower extremity non-traumatic amputation (LEA) rates in black diabetic Medicare patients are more than twice that of White diabetic Medicare patients. In 2000, the three counties with the highest LEA rates for black males were Barnwell (5.06%), Allendale (4.87%), and Florence (4.50%). LEA rates are not related to the number of primary care physicians per 10,000 county residents or per capita income. All gender/race groups saw declines in LEA rates. Although our study could not explain the socioeconomic factors involved, it does mirror other prior studies that show a racial disparity in LEAs. Similarly, men have a greater risk of diabetic non-traumatic LEAs. Interestingly however, having more primary care physicians per 10,000 county residents does not decrease the rate of amputations. Policy makers and insurance brokers may utilize our findings to target the areas of most need for intervention and further studies. Improved adherence to guidelines by primary care physicians, decreasing barriers to health care access, educating patients about the severity of diabetes and its complications, and providing more culturally competent care may lessen the burden of this disability for our minority patients. In the era of "pay for performance", the rate of LEAs as a proxy of poor diabetic care management must clearly improve. Fortunately, the decrease in LEA rates over time as shown in our study is a step in the right direction. However, the decrease is not consistent across all counties in South Carolina.

Common oral lesions: Part I. Superficial mucosal lesions.

Common superficial oral lesions include candidiasis, recurrent herpes labialis, recurrent aphthous stomatitis, erythema migrans, hairy tongue, and lichen planus. Recognition and diagnosis require taking a thorough history and performing a complete oral examination. Knowledge of clinical characteristics such as size, location, surface morphology, color, pain, and duration is helpful in establishing a diagnosis. Oral candidiasis may present as pseudomembranous candidiasis, glossitis, or perlèche (angular cheilitis). Oral candidiasis is common in infants, but in adults it may signify immune deficiency or other illness. Herpes labialis typically is a mild, self-limited condition. Recurrent aphthous stomatitis most often is a mild condition; however, severe cases may be caused by nutritional deficiencies, autoimmune disorders, or human immunodeficiency virus infection. Erythema migrans is a waxing and waning disorder of unknown etiology. Hairy tongue represents elongation and hypertrophy of the filiform papillae and most often occurs in persons who smoke heavily. Oral lichen planus is a chronic inflammatory condition that may be reticular or erosive. Certain risk factors have been associated with each of these lesions, such as poor oral hygiene, age, tobacco use, and alcohol consumption, and some systemic conditions may have oral manifestations. Many recommended therapies for oral lesions are unsupported by randomized controlled trials.

Common oral lesions: Part II. Masses and neoplasia.

Certain common oral lesions appear as masses, prompting concern about oral carcinoma. Many are benign, although some (e.g., leukoplakia) may represent neoplasia or cancer. Palatal and mandibular tori are bony protuberances and are benign anomalies. Oral pyogenic granulomas may appear in response to local irritation, trauma, or hormonal changes of pregnancy. Mucoceles represent mucin spillage into the oral soft tissues resulting from rupture of a salivary gland duct. Oral fibromas form as a result of irritation or masticatory trauma, especially along the buccal occlusal line. Oral cancer may appear clinically as a subtle mucosal change or as an obvious mass. Oral leukoplakia is the most common premalignant oral lesion. For persistent white or erythematous oral lesions, biopsy should be performed to rule out neoplastic change or cancer. Most oral cancers are squamous cell carcinomas. Tobacco and heavy alcohol use are the principal risk factors for oral cancer. Family physicians should be able to recognize these lesions and make appropriate referrals for biopsy and treatment.

Smiles for Life: A National Oral Health Curriculum for Family Medicine. A model for curriculum development by STFM groups.

The Society of Teachers of Family Medicine Group on Oral Health released Smiles for Life: A National Oral Health Curriculum for Family Medicine in October 2005 to address a need for high-quality residency and medical school curricula in an area of documented physician knowledge deficit. This article describes the background, planning, fund-raising, development, dissemination, and impact of the curriculum. Lessons learned, particularly in the areas of long-distance collaboration, fund-raising, and marketing are reviewed with a goal of serving as a model for future curriculum development efforts.

Family medicine residency directors' knowledge and attitudes about pediatric oral health education for residents.

The Surgeon General's report on oral health called for improved education about oral health, a renewed understanding of relationships between oral and overall health, and an interdisciplinary approach to oral health involving primary care providers. This study examined the following: 1) family medicine residency directors' knowledge of preventive dental care, 2) status of an oral heath curriculum in family medicine residencies, and 3) the likelihood of initiating an oral health curriculum. We conducted a fifty-item survey of family medicine program directors emphasizing pediatric oral health assessed demographics, knowledge of preventive procedures, existing oral health curriculum, composition, and time commitment for an oral health curriculum. Directors returned 208 (45 percent) surveys. Approximately 95 percent agreed that oral health knowledge should be a component of residency training. Most programs are teaching anticipatory guidance. The mean time program directors felt should be given to an oral health curriculum was four hours. Program directors lack knowledge of preventive dental procedures and oral health care recommendations. Oral health care knowledge is felt to be an important component of residency training. Program directors need faculty development for a successful delivery of an oral health curriculum.

Practices and Perceptions of Family Practice Residency Directors toward International Medical Graduate Applicants: A National Survey.

Purpose - International Medical Graduates (IMGs) are increasingly filling Family Medicine residency positions. (1) To what extent are residency programs recruiting and accepting IMG applicants? (2) What are program directors' perceptions of IMG applicants? (3) What program characteristics are associated with their practices and perceptions? Methods - A 2002 national survey of Family Medicine program directors assessed program demographics and directors' recruiting practices and perceptions regarding IMG applicants. Results - Although 88% of respondents would rank IMG applicants, only 40% agreed that they would perform as well as U.S. graduates. Programs with IMG faculty were more likely to have IMG residents (p˂0.01). Program directors with IMG faculty or more IMG residents reported more positive perceptions of IMG residents' performance (p˂0.01). Conclusion - More experience with IMGs, such as having IMG faculty or higher numbers of IMG residents, is associated with recruitment of IMG residents and may contribute to more positive beliefs about their performance.

Physicians' oral health education in Kentucky.

OBJECTIVES: The Physicians' Oral Health Education in Kentucky (POHEK) curriculum was developed to teach family medicine residents to (1) perform oral health screening and risk assessment and (2) recognize and manage common oral conditions for children ages 5 years and under. METHODS: Family medicine residents in urban and rural settings received didactics and hands-on experience providing oral screening, risk assessments, and counseling for their pediatric patients. EVALUATION: Residents were evaluated by comparing pretest and posttest means of surveys that assessed attitudes and knowledge. Chart audits were also performed. CONCLUSIONS: Residents' knowledge and attitudes improved in the oral health care of their pediatric patients.