A professional virtues-based ethical framework for medical missions.

BACKGROUND: More than 1.6 million physicians participate in medical missions each year. This effort is part of a long history of volunteerism and service to those in need in the form of medical missions to low-income countries. The Children's Health International Medical Project of Seattle has provided the following 7 guiding principles of sustainable short-term international medical missions: "mission, collaboration, education, service, teamwork, sustainability, and evaluation." The role of professional virtues in grounding these principles and thus guiding medical missions is underappreciated. OBJECTIVE: To provide a professional virtues-based ethical framework for medical missions, this article addressed the question, "How should physicians design and implement a medical mission in a professionally responsible way?" Reference is made to one of the authors' experiences as a point of reference. STUDY DESIGN: The authors addressed the questions on how to design and implement a medical mission based on 5 professional virtues: compassion, integrity, humility, self-effacement, and self-sacrifice. A concise, historically based explanation of each virtue was provided, and the implications of the aforementioned principles for medical missions were identified. RESULTS: Compassion motivates the mission and its team members, whereas integrity, humility, self-effacement, and self-sacrifice guide team members as they act on the professional virtue of compassion. CONCLUSION: These 5 professional virtues can be used to provide a practical framework for the professionally responsible design and implementation of medical missions.

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.

Eye Conditions in Older Adults: Open-Angle Glaucoma.

Glaucoma is the leading cause of irreversible vision loss in the United States, affecting 1.9% of individuals older than 40 years. The prevalence of the most common form, open-angle glaucoma, increases with age and is higher in non-Hispanic minorities. The progressive loss of peripheral vision in glaucoma often leads to difficulty with driving, particularly at night, and can increase the risk of falls and subsequent fractures. Although glaucoma usually is characterized by chronically elevated intraocular pressure, it is more accurately defined as an optic neuropathy. Typically, there are no warning signs or symptoms, and extensive and permanent optic nerve damage can occur before the patient is aware of visual field loss. A cup to disc ratio greater than 0.6 on ophthalmoscopy is suspicious for glaucoma, and visual field testing results show a characteristic peripheral loss. Medical and surgical treatments are aimed at decreasing intraocular pressure by decreasing production of aqueous humor and increasing its outflow. Drugs for glaucoma treatment include prostaglandin analogs, beta blockers, alpha2-adrenergic agonists, and carbonic anhydrase inhibitors. Surgical or laser treatment is indicated if medical management is unsuccessful. Alternative therapies are less effective and have more adverse effects than standard treatments.

Eye Conditions in Older Adults: Cataracts.

A clinically significant cataract is defined as an opacification of the eye lens causing a significant decrease in visual acuity or a functional visual impairment. Age-related cataracts are the leading cause of blindness in the world and one of the most common etiologies of visual impairment in the United States. Consequences can include loss of driving privileges, inability to read or watch television, inability to participate in social activities, and an increased risk of falls. In the United States, cataract surgery is the most commonly performed surgical procedure among older patients. There are three main types of cataracts: nuclear, cortical, and subcapsular. Age is the strongest predictor of cataract development. Other major risk factors include a family history of cataracts, diabetes, smoking, obesity, poor nutrition, lower socioeconomic status, and alcohol use. Surgery is the definitive treatment. Phacoemulsification and implantation of a posterior chamber intraocular lens is the most common method used for managing cataracts in the United States. Glasses or contact lenses then are prescribed to correct any residual refractive errors. Cataract surgery is a low-risk procedure and routine preoperative testing typically is not needed.

Eye Conditions in Older Adults: Age-Related Macular Degeneration.

Age-related macular degeneration (AMD) causes a progressive loss of photoreceptors in the macula. It is the most common cause of legal blindness in the United States, and some form of AMD is thought to affect more than 9 million individuals. Risk factors include older age, smoking, dyslipidemia, obesity, white race, female sex, and a family history of AMD. There are two types of advanced AMD: nonexudative (dry or geographic atrophy) and exudative (wet or neovascular). Both cause progressive central vision loss with intact peripheral vision. Nonexudative AMD accounts for 80% to 90% of all advanced cases, and more than 90% of patients with severe vision loss have exudative AMD. On ophthalmoscopic examination, early findings include drusen (ie, yellow deposits in the retina). Prominent choroidal vessels, subretinal edema, and/or hemorrhage are seen in wet AMD. Regular eye examinations, visual field testing, fluorescein angiography, and optical coherence tomography are used for diagnosis and to guide management. There is no specific therapy for dry AMD, but antioxidant supplementation may be helpful. Intravitreal injection of a vascular endothelial growth factor inhibitor is the treatment of choice for wet AMD. Optical aids and devices can help to maximize function for patients with AMD.

Eye Conditions in Older Adults: Diabetic Retinopathy.

Diabetic retinopathy is related to neovascularization of the retina stimulated by an elevated blood glucose level. This can lead to macular edema, vascular hemorrhage, retinal detachment, and neovascular glaucoma. Diabetic retinopathy is a leading cause of blindness in the United States, and is estimated to affect between 28% and 40% of patients older than 40 years. Significant visual deficit from diabetic retinopathy can lead to social isolation of older individuals by limiting driving, the ability to leave the home or remain in the home safely, and the ability to watch television or read. Primary and secondary prevention includes adequate control of A1c levels. Screening is important for early detection of ocular damage and intervention. Retinal benefits of therapy may predict cardiovascular benefits over a longer period.