What can COVID-19 teach us about patient satisfaction in the emergency department? A mixed-methods approach.

OBJECTIVE: The current study explored improved patient satisfaction scores at a single emergency department (ED) during the early phase of the COVID-19 pandemic (March to May 2020). METHODS: A mixed-methods design, integrating qualitative and quantitative data analyses, was employed to explore a total of 289 patient satisfaction survey ratings and 421 comments based on care that took place in the ED during the initial phase of the COVID-19 epidemic. This allowed for comparisons to a more typical time period in the ED along with the emergence of novel categories of influence. RESULTS: The ED census was 31% lower during 2020 (COVID-19) than the previous year, and a significantly greater percentage of patients in 2020 indicated that they would "definitely recommend" the ED compared with 2019. Wait time was mentioned in >40% of dissatisfied patient comments in 2019 but <20% of dissatisfied patient comments in 2020. General negative comments were proportionately greater than general positive comments in 2019, whereas in 2020 the reverse pattern held. Other categories did not differ significantly across 2019 and 2020. CONCLUSIONS: The general circumstances surrounding the early stages of the COVID-19 pandemic included a lower census in the ED and higher reported satisfaction among patients. A comparison of the content of patient comments revealed less concern about wait times and a more positive overall view toward receiving care during the first 3 months of the pandemic.

Violence and Public and Personal Health: Outcomes of Adverse Childhood Experiences.

Adverse childhood experiences include direct abuse, such as emotional, physical, or sexual abuse; neglect, which can be emotional or physical; and family or household problems. Exposure to violence is one of several types of adverse childhood experiences that can affect individuals for the rest of their lives. The effects of exposure to violence during childhood include associated physical and mental health conditions, as well as concerns about involvement in intimate partner violence in adulthood. Family physicians can aid in the prevention of and response to adverse childhood experiences in several ways. On an individual level, they can assess patients for such experiences and provide trauma-informed care. They also can educate children and their parents and caregivers about exposure to violence and adverse childhood experiences. On a societal level, they can advocate for safer media, communities, schools, and home environments for children and adolescents. Early results of studies of physician education in this area have yielded promising results.

Violence and Public and Personal Health: Gun Violence.

The rate of death due to guns is higher in the United States than in other high-income countries. More than 200 Americans are murdered or assaulted with a firearm daily. In the United States, more than 300,000 individuals have died from firearm injuries in the past decade. Firearm injuries cost more than $3 billion per year, and deaths from guns cause more than $20 billion in lifetime work loss and medical costs. Risk factors for being a perpetrator of gun violence include a personal history of or exposure to individuals with violent tendencies, untreated mental disorders, substance abuse, and access to weapons. Physicians can screen patients for risk of firearm-related injury and share strategies to prevent injury and death in the home. Health care-based interventions may increase rates of safe storage of firearms for high-risk groups. Standardized protocols can assist with responses to violent threats in the medical workplace. Various laws have been proposed to prevent gun violence in communities. Laws involving universal background checks and identification requirements at the time of gun purchase have been shown to be most closely related to decreases in mortality rates.

Violence and Public and Personal Health: Intimate Partner Violence.

Intimate partner violence (IPV) refers to abuse (eg, physical, financial, emotional, sexual, contraceptive, reproductive abuse; stalking; coercion) perpetrated by an individual with whom a patient has, or previously had, a personal and/or sexual relationship. IPV is a global public health concern that affects individuals in all categories of socioeconomic status, sex, age, race/ethnicity, and sexual orientation. The U.S. Preventive Services Task Force recommends screening for IPV in all women of childbearing age. Additional red flag signs and symptoms may signal that further investigation is needed. If IPV is identified, the physician should assess basic patient safety, provide referrals, and document details appropriately. Mandatory reporting laws for IPV vary among states in the United States. The approach to prevention of IPV includes a focus on educating patients from a young age about healthy relationships as well as education of physicians and other clinicians about signs of IPV and how to intervene with patients. At a societal level, promotion of stable, nurturing early environments and relationships for children and enactment of laws to support such environments are essential.

Violence and Public and Personal Health: Sexual Violence, Sexual Assault, and Sex Trafficking.

In the United States, approximately 1 in 5 women will experience a sexual assault in her lifetime. In most reported cases, men are identified as perpetrators regardless of the sex of the individual assaulted. There typically is some form of relationship between the survivor and the perpetrator-whether it be an acquaintance, friend, family member, or authority figure. As such, female patients should be asked routinely about a history of sexual assault, particularly if the patient reports relevant physical symptoms and/or substance abuse. Factors that could lead to children experiencing sexual assault (particularly via domestic minor sex trafficking) include a history of abuse, substance use, mental health issues, family dysfunction, and the involvement of Child Protective Services. Short-term goals of primary care include management of physical injuries and psychological needs, evaluation for pregnancy, and prevention of sexually transmitted infections. Long-term effects may include sexual dysfunction, mental disorders (eg, depression, posttraumatic stress disorder), and medical symptoms (eg, chronic headache, infections).

The agitated patient: Steps to take, how to stay safe.

Situations involving agitated patients are not uncommon in health care settings. And no matter where on the spectrum an incident involving an agitated patient falls, it can leave those involved with various levels of physical, emotional, and psychological harm. It can also leave everyone asking themselves: "How can I better prepare for such occurrences?" This article offers some answers by providing tips and guidelines for handling agitated and/or violent patients in various settings.

Mapping Residency Global Health Experiences to the ACGME Family Medicine Milestones.

BACKGROUND AND OBJECTIVES: Global health (GH) experiences are a unique part of family medicine (FM) training that offer an opportunity for residents to demonstrate development across a multitude of the milestones recently implemented by the Accreditation Council for Graduate Medical Education (ACGME). The GH experience presents an opportunity for resident development, and including a component of written reflection can provide tangible evidence of development in areas that can be difficult to assess. METHODS: A mixed methods approach was used to integrate quantitative (frequency) data with qualitative content from the written reflections of 12 of our FM residents who participated in GH experiences. RESULTS: Written reflections touched on each of the 22 milestones, although some milestones were noted more frequently than others. The most commonly identified milestones fell within the competency areas of systems-based practice, professionalism, and practice-based learning and improvement. Our qualitative approach allowed us to gain an appreciation of the unique experiences that demonstrated growth across the various milestones. CONCLUSIONS: We conclude that any program that offers GH experiences should incorporate some form of written reflection to maximize resident growth and offer evaluative faculty a window into that development.

Disorders of childhood growth and development: failure to thrive versus short stature.

Failure to thrive (FTT) describes retarded growth in height and weight, whereas short stature (SS) involves comparison of a child or adolescent's height to that of a reference group or to his or her own height across time. To identify either condition in infants, children, and adolescents, the family physician should focus on accurate measurement of length/height and weight as well as careful plotting and assessment of the rate of linear growth and weight gain based on World Health Organization standards (from birth to 2 years) and Centers for Disease Control and Prevention charts (from age 2 years). Identification of the etiologies of FTT and SS is complex, requiring consideration of such factors as birth weight, prematurity, and familial height. FTT can result from inadequate caloric intake (eg, caused by difficulties with nursing, limited food availability, or incorrect formula preparation), inadequate caloric absorption (eg, resulting from metabolic, gastrointestinal, or other medical conditions), or excessive caloric expenditure/ineffective utilization (eg, due to hyperthyroidism, diabetes, pulmonary or cardiac conditions). Short stature can be due to a primary growth disorder, such as bone disease or chromosomal syndrome; a secondary factor, such as a chronic medical or endocrine disorder; or an undetermined etiology. The management of FTT and SS requires attention to a combination of medical and behavioral/social issues (eg, treating underlying conditions, assisting with the feeding process, addressing stress and social functioning), and often requires a multidisciplinary approach.

Disorders of childhood growth and development: childhood obesity.

The incidence of childhood obesity in the United States is estimated at 17%, or 12 million children ages 2 to 19 years. Obesity is a multifactorial condition with syndromic and nonsyndromic variants. Genetic, social, ethnic, endocrinologic, and behavioral issues are all potential etiologic factors. Preventive efforts should begin with monitoring from birth and include breastfeeding until age 6 months, avoiding juices, and promoting fruit and vegetable consumption and adequate exercise. Childhood obesity is diagnosed based on body mass index; a child is considered overweight at the 85th to 95th percentiles and obese at or above the 95th percentile. After obesity is diagnosed, testing should include blood pressure levels, fasting lipid profile, diabetes screening, and liver function tests. The physician should obtain a detailed history of the physical activity level and food intake and assess possible complications of obesity, including depression and hypertension, annually. Lifestyle interventions with family involvement are the mainstay of management, with pharmacotherapy or bariatric surgery considered for adolescents only if intensive lifestyle modifications have failed and in the presence of comorbidities. Intervention by multiple disciplines (ie, medicine, nutrition, psychology) is recommended, and family physicians are encouraged to become more involved in encouraging physical activity and improved nutrition for children.

Disorders of childhood growth and development: precocious puberty.

Precocious puberty is defined as pubertal development that begins at an earlier age than expected; most US pediatric endocrinology subspecialists use cutoff ages of 8 years for girls and 9 years for boys. Early activation and maturation of the hypothalamic-pituitary-gonadal axis leads to hormonal changes, physical signs of puberty, and acceleration of linear growth. Factors affecting puberty include race/ethnicity, obesity, and endocrine disruptors. The 2 forms of precocious puberty are central (gonadotropin-dependent precocious puberty) and peripheral (gonadotropin-independent precocious puberty). Most cases of the former have no identifiable etiology, whereas the latter is caused by increased secretion of sex hormones by the gonads or adrenal glands. It is important to differentiate progressive from nonprogressive precocious puberty to avoid unnecessary treatment for the latter; if diagnosis is uncertain, the child should be reassessed within several months. Evaluation begins with a detailed history and physical examination followed by an x-ray for bone age; in precocious puberty, bone age is greater than chronologic age. If indicated, additional serum testing (basal luteinizing hormone) and imaging studies should be obtained. Patients should be referred to a pediatric endocrinology subspecialist for treatment. It is essential to manage underlying etiologies. Gonadotropin-releasing hormone agonists should be considered only for children with progressive central precocious puberty to prevent short stature. For children with apparent nonprogressive precocious puberty, follow-up every 3 to 6 months between ages 6 and 7 years is recommended to assess for progression.

Disorders of childhood growth and development: screening and evaluation of the child who misses developmental milestones.

The family physician is one of the few individuals from whom families receive feedback about their children's development; this makes early identification of potential delays an important responsibility. The American Academy of Pediatrics recommends formal developmental screening for all children at the 9-, 18-, and 24- and/or 30-month well-child visits as well as developmental surveillance at every office visit through age 5 years. A formal screening measure is recommended, taking into account administration time and cost, characteristics of the patient population (eg, availability of screening tool in numerous languages), and psychometrics (eg, reliability, sensitivity, specificity). In the case of abnormal screening results, family physicians must determine the need for further medical evaluation (eg, by a developmental pediatric subspecialist or a pediatric neurology, genetics, or physiatry subspecialist) and/or further developmental evaluation (eg, by a physical therapy [PT], occupational therapy [OT], speech/language pathology, psychology, or audiology subspecialist). Knowledge of early intervention and early childhood programs is necessary for directing parents to evaluation and treatment sources. In treating patients with developmental delays, family physicians must possess knowledge regarding traditional modalities (eg, speech/language therapy, OT, PT) as well as newer treatments with less research support (eg, gluten-free/casein-free diet, hyperbaric oxygen therapy, neurodevelopmental treatment) that families may consider.

Self-efficacy in adolescents who have siblings with or without disabilities.

Fifty-four adolescents (27 with and 27 without a sibling who had a disability) were contrasted on levels of self-efficacy. Adolescents completed questionnaires measuring self-efficacy, peer competence, and maternal attitudes toward and modeling of prosocial and empathic behavior. None of the adolescent measures differed significantly between those whose siblings did or did not have disabilities. Females evidenced higher levels of self-efficacy than did males, regardless of sibling's disability status. For adolescents with siblings who did not have disabilities, interpersonal competence was significantly related to self-efficacy. For adolescents whose siblings had disabilities, interpersonal competence and maternal attitudes and modeling were significantly related to self-efficacy. Process-oriented variables associated with self-efficacy were identified and could become targets for intervention efforts to influence this positive set of beliefs in adolescents.