Weight management counseling experiences of first year medical students before starting medical school and their self-perceived impact on treating patients with obesity.

Physicians can play a vital role in counseling patients on overweight and obesity. This secondary analysis examined whether experiences in patient care specific to weight management before starting medical school were associated with students' intentions and confidence to provide weight management counseling (WMC) to patients who have overweight or obesity, and perceived impact as future physicians on patients' motivation to manage weight. First-year medical students (n = 1305) in the entering class of 2020 at eight medical schools nationwide completed questions relating to their prior experiences in patient care and WMC using the 5As. Also assessed were their intentions to treat patients with overweight or obesity, and confidence in counseling patients to help manage their weight. Over half the students (58.3%) who completed the survey had prior experience in patient care and nearly half (47.4%) began medical school with prior WMC experiences. Prior experiences correlated positively with higher confidence in performing WMC and students' intentions to treat patients with overweight or obesity. Given the relatively high rates of exposure to some type of weight management or lifestyle counseling among students before enrolling in medical school, the curriculum could build on established student interest and experience by offering treatment strategies including counseling for patients with overweight and obesity. By making prior experiences advantageous for admission, medical schools could gravitate towards admitting students who have brief but valuable insights about weight management in health care, thus increasing the possibility of filling important gaps.

Sustainable and replicable clinical and financial outcomes in an interprofessional education and collaborative practice nexus.

Our Interprofessional Education and Collaborative Practice (IPECP) Nexus previously reported significant reductions in Emergency Department (ED) visits, hospitalizations, hemoglobin A1c levels, and patient charges. This study examines sustainability of these results over two additional years and replication in two subsequent independent patient cohorts. Participants in the sustainability cohort (N = 276) met ≥1 of the following criteria: (a) ≥3 ED visits in first or second half of the year, (b) hemoglobin A1c level ≥ 9, or (c) Length of Stay, Acuity, Comorbidities, and ER (Emergency Room) Visits (LACE) score ≥ 10. Participants in two replicability cohorts (N = 255) and (N = 160) met the same criteria, but the LACE criterion was changed to ≥3 hospitalizations in baseline years. The Nexus, housed in a family medicine (FM) residency clinic, included professionals and students from multiple disciplines. IPECP skills and interventions included communication, team building, and conflict engagement skills training, daily huddles and pre-visit planning, immediate consultations, small teamlet IPECP interactions, and weekly IPECP case conferences for complex patients. Original health improvements and charge reductions were sustained for two additional years for ED visits, hospitalizations, A1c, and patient charges, and replicated in two additional patient cohorts. The IPECP Nexus interventions were associated with Quadruple Aim outcomes while training the next generation of health care professionals.

Dialing back opioids for chronic pain one conversation at a time.

In this study, significant opioid tapering was achieved following frank discussions and the use of a tapering protocol. And patient-physician relationships weren't jeopardized.

Design and rationale of the medical students learning weight management counseling skills (MSWeight) group randomized controlled trial.

Physicians have an important role addressing the obesity epidemic. Lack of adequate teaching to provide weight management counseling (WMC) is cited as a reason for limited treatment. National guidelines have not been translated into an evidence-supported, competency-based curriculum in medical schools. Weight Management Counseling in Medical Schools: A Randomized Controlled Trial (MSWeight) is designed to determine if a multi-modal theoretically-guided WMC educational intervention improves observed counseling skills and secondarily improve perceived skills and self-efficacy among medical students compared to traditional education (TE). Eight U.S. medical schools were pair-matched and randomized in a group randomized controlled trial to evaluate whether a multi-modal education (MME) intervention compared to traditional education (TE) improves observed WMC skills. The MME intervention includes innovative components in years 1-3: a structured web-course; a role play exercise, WebPatientEncounter, and an enhanced outpatient internal medicine or family medicine clerkship. This evidence-supported curriculum uses the 5As framework to guide treatment and incorporates patient-centered counseling to engage the patient. The primary outcome is a comparison of scores on an Objective Structured Clinical Examination (OSCE) WMC case among third year medical students. The secondary outcome compares changes in scores of medical students from their first to third year on an assessment of perceived WMC skills and self-efficacy. MSWeight is the first RCT in medical schools to evaluate whether interventions integrated into the curriculum improve medical students' WMC skills. If this educational approach for teaching WMC is effective, feasible and acceptable it can affect how medical schools integrate WMC teaching into their curriculum.

Timed Up and Go (TUG) Test: Normative Reference Values for Ages 20 to 59 Years and Relationships With Physical and Mental Health Risk Factors.

PURPOSE: The Timed Up and Go (TUG) test is a reliable, cost-effective, safe, and time-efficient way to evaluate overall functional mobility. However, the TUG does not have normative reference values (NRV) for individuals younger than 60 years. The purpose of this study was to establish NRV for the TUG for individuals aged between 20 and 59 years and to examine the relationship between the TUG and demographic, physical, and mental health risk factors. METHODS: Two hundred participants, 50 per decade (ages 20-29, 30-39, 40-49, 50-59 years) were selected at their primary care visit, and timed as they performed the TUG by standing up out of a chair, walking 3 m, turning around, walking back to the chair, and sitting down. Information regarding the risk factors socioeconomic status, body mass index, an index of multimorbidities, perceptions of overall physical and mental health was obtained and used as predictors of TUG time independent of age. RESULTS: TUG times were significantly different among the decades ( F = 6.579, P = .001) with slower times occurring with the 50-year-old decade compared with the 20s ( P = .001), 30s ( P = .001), and 40s ( P = .020). Slower TUG times were associated with lower SES, higher body mass index, more medical comorbidities, and worse perceived physical and mental health. Regression results indicated that perceived physical and mental health accounted for unique variance in the prediction of TUG time beyond age, gender, and socioeconomic status. CONCLUSIONS: This study provided TUG NRV for adults in their 20s, 30s, 40s, and 50s. The TUG may have utility for primary care providers as they assess and monitor physical activity in younger adults, especially those with physical and mental health risk factors.

Anxiety and depression: Easing the burden in COPD patients.

Anxiety and depression are common comorbidities of COPD. The simple evaluation tools and therapy options described here can help improve patients' quality of life.

A brief primary care intervention to reduce fear of movement in chronic low back pain patients.

Fear avoidance model of chronic pain-based interventions are effective, but have not been successfully implemented into primary care. It was hypothesized that speed walking times and key measures of the fear avoidance model would improve following the brief intervention delivered in primary care. A brief primary care-based intervention (PCB) that included a single educational session, speed walking (an in vivo desensitization exposure task), and visual performance feedback was designed to reduce fear avoidance beliefs and improve function in 4 patients with chronic low back pain. A multiple baseline across subjects with a changing criterion design indicated that speed walking times improved from baseline only after the PCB intervention was delivered. Six fear avoidance model outcome measures improved from baseline to end of study and five of six outcome measures improved from end of study to follow-up. This study provides evidence for the efficacy of a brief PCB fear avoidance intervention that was successfully implemented into a busy clinic for the treatment of chronic pain.

Obesity bias in primary care providers.

BACKGROUND AND OBJECTIVES: At the forefront of the obesity epidemic, obesity bias is an under-recognized and widely prevalent barrier to optimal care of the obese patient, even among primary care professionals. Recommendations for the reduction of obesity bias include increasing provider awareness about the complex etiology of obesity and the difficulties obtaining sustainable weight loss. METHODS: Obesity bias was measured in primary care professionals (n=233) participating in a continuing education program, using the Anti-Fat Attitudes Questionnaire (AFAQ). Three sub-factors, "Fear of Fat," "Willpower," and "Dislike," were evaluated. Participants were divided into three primary care experience groups: least experienced (0--9 years, n=67), moderately experienced (10--19 years, n=49), and most experienced (20+ years, n=98). "Fear of Fat" and "Willpower" components were found to be more prevalent than "Dislike"; however, scores on the "Dislike" subscale were highest and significantly more prevalent in the group with the most experience. RESULTS: Results indicated that more experienced primary care professionals reported greater bias toward obese people than less experienced colleagues. CONCLUSIONS: Ongoing continuing education that recognizes the wide prevalence of obesity, encourages respect for people of size, and mitigates obesity stigma should be promoted for all providers, particularly those who have been in practice for many years.

Relationship between acceptance of illness and functional outcomes following cardiac rehabilitation.

PURPOSE: Acceptance, a cognitive-behavioral concept successfully applied to chronic pain and chronic illness in an HIV/AIDS population, was examined for applicability in patients in a cardiac rehabilitation program. The study examined the internal reliability of the Activities Engagement (AE) and Illness Willingness (IW) scales of the Chronic Illness Acceptance Questionnaire (CIAQ), their relationships with functional outcomes, and their ability to predict functional outcomes after controlling for demographic and medical variables. METHODS: Subjects were 36 patients recruited from a cardiac rehabilitation program at an urban Midwestern Medical Center. Subjects completed the CIAQ and physical and emotional functional outcome measures including the Minnesota Living with Heart Failure Questionnaire, 36-item Short Form Health Survey (SF-36), and Beck Depression Inventory. RESULTS: Internal reliability scores of the AE and IW scales of the CIAQ were modest. The AE scale was significantly related to measures of emotional functioning, but not physical functioning. The IW scale was not related to any of the emotional or physical outcomes. In multiple regression analyses, AE was a significant predictor of the 2 emotional outcome measures beyond demographic and medical variables, but not the physical measures. Illness Willingness was not predictive of any of the functional outcome variables. CONCLUSIONS: The AE aspect of acceptance was related to emotional outcomes and predicted these outcomes beyond demographic and medical variables. Lack of a relationship between IW and any outcomes may have been due to a small sample size or that acceptance is a one-dimensional construct.

Relationship between acceptance of HIV/AIDS and functional outcomes assessed in a primary care setting.

Acceptance, a third wave cognitive-behavioral concept originally developed for chronic pain patients, was applied to acceptance of chronic illness in an HIV/AIDS population. This study examined the internal reliability of two scales of the chronic illness acceptance questionnaire (CIAQ) called activities engagement (AE), and illness willingness (IW), their relationships with functional outcomes, and their ability to predict functional outcomes after controlling for demographic and medical variables. Sixty-nine HIV-positive persons served as subjects while attending a routine visit at an urban Midwestern US Family Medicine clinic. Mean scores for the AE, IW, and total scales of the CIAQ were slightly higher than pretreatment, but slightly lower than post-treatment scores originally reported for chronic pain patients. Internal reliability values for AE, IW, and total scales of the CIAQ were excellent and consistent with those found in chronic pain acceptance studies. In addition, the AE and IW scales were significantly related to the criterion dimensions of depression, mental functioning, and physical functioning. In multiple regression analyses, it was found that only AE was a significant predictor of the three functional outcome measures beyond demographic and medical variables. In contrast, IW was not predictive of any of the three functional outcome variables.

Attributions regarding unmet treatment goals after interdisciplinary chronic pain rehabilitation.

BACKGROUND: The goal violation effect (GVE), a component of the relapse process model, occurs when patients make internal, stable, global, and uncontrollable rather than external, unstable, specific, and controllable attributions about the causes for unmet goals. GVE consistent attributions lead to guilt and self-blame, reduced self-efficacy, and greater probability that a lapse will lead to a full-blown relapse. OBJECTIVES: To determine if chronic pain patients make attributions regarding the causes of unmet goals consistent with the GVE and to determine differences for the GVE and the individual attributions making up the GVE among unmet coping skills, medication, exercise, social, and work goals. METHODS: In the last week of an interdisciplinary pain program, patients stated 4 to 6 treatment goals. At 6 months follow-up, 100 patients rated the cause for each of their own unmet goals using 7-point scales assessing whether they made internal, stable, global, and uncontrollable attributions. Together, 165 unmet goals were rated and a GVE was calculated for each unmet goal by adding the 4 individual attributions and dividing by 4. RESULTS: The GVE for each of the 5 goal types was above the midpoint toward model consistent attributions. A multivariate analysis of variance was significant for goal type (P<0.0001). No significant differences were found among goal types for the GVE, the stable or global attributions. However, work and social goals were found to have lower internal attributions compared with coping, medication, and exercise goals. Work goals were found to have great uncontrollable attributions compared with coping, medication, and exercise whereas coping was found to be lower than social and exercise goals. DISCUSSION: Patients made attributions for unmet treatment goals consistent with the GVE component of the relapse process model. Internal and uncontrollable attributions for causes of unmet goals varied with goal type, which has implications for the design of relapse prevention strategies.

A practical guide to crisis management.

Family physicians often treat patients who are experiencing psychological or medical crises. Any event perceived as overwhelming by the patient may trigger a crisis reaction consisting of psychological and physiological symptoms. Physicians are encouraged to assist patients who are experiencing a crisis by: (1) providing reassurance and support; (2) evaluating the nature of the problem and determining the patient's mental, psychiatric, suicidal or homicidal, and medical statuses; (3) ensuring the safety of the patient and others; (4) assisting the patient in developing an action plan that minimizes distress, and obtaining patient commitment to the plan; and (5) following up with the patient and other relevant persons to ensure follow-through, assess progress, and provide additional assistance and support. Medication or referral for psychiatric or psychological counseling may be necessary for patients with continuing problems.

Medical student beliefs: spirituality's relationship to health and place in the medical school curriculum.

The relationship between spirituality and health is receiving increased attention; consequently medical schools have begun asking how and in what manner these issues should be addressed in medical education. Unfortunately, student beliefs concerning spirituality and health have not been adequately assessed. This study examined medical student beliefs regarding the relationship between spirituality and health and the level of instruction spirituality should receive in the curriculum. Questionnaire results from 254 medical students indicated that religiousness and spirituality are important, with spirituality more important than religiousness. Spiritual practices were seen as more helpful for acute and mental health conditions than for chronic or terminal conditions and believed to be more helpful for coping with a health condition than healing tissue. Students believed that patients could benefit from spiritual practices more than they could for their own health conditions. Most students endorsed a lecture or one- to two-week seminar with instruction in the first or second year of medical school. Student spirituality was the only predictor of required level of instruction in the medical school curriculum.

Depression and congestive heart failure.

The prevalence rates of depression in congestive heart failure patients range from 24%-42%. Depression is a graded, independent risk factor for readmission to the hospital, functional decline, and mortality in patients with congestive heart failure. Physicians can assess depression by using the SIG E CAPS + mood mnemonic, or any of a number of easily administered and scored self-report inventories. Cognitive-behavior therapy is the preferred psychological treatment. Cognitive-behavior therapy emphasizes the reciprocal interactions among physiology, environmental events, thoughts, and behaviors, and how these may be altered to produce changes in mood and behavior. Pharmacologically, the selective serotonin reuptake inhibitors are recommended, whereas the tricyclic antidepressants are not recommended for depression in congestive heart failure patients. The combination of a selective serotonin reuptake inhibitor with cognitive-behavior therapy is often the most effective treatment.

Multidisciplinary pain center follow-up study: evaluation with a no-treatment control group.

The long-term efficacy of a multidisciplinary pain management center was evaluated by comparing 20 treated patients with 20 no-treatment control patients who met the program's entrance criteria, wanted to participate, but could not because they did not have insurance coverage. At 1-5 years follow-up, 60% of the treated patients met all of the criteria for success established by Roberts and Reinhardt, while none of the untreated patients did so. Treated patients reported less interference with activities, more uptime, lower pain levels, less depression, and fewer hospitalizations than untreated patients. Also, more treated patients reported being employed, while fewer used either narcotic or psychotropic medications at follow-up compared to untreated patients. Pretreatment-to-follow-up changes are reported for both the treated and untreated groups.