Annals of Family Medicine最新文献

As a primary care pediatrician trained before work hour restrictions were enacted, I spent hours mastering procedures that trainees today rarely perform. The changing landscape of health care clinician roles, technology, and work hour restrictions have all contributed to a remarkable decline in trainees' procedural competence which has significant negative effects for patients, health care systems, and physicians themselves. I suggest simulation, live training, mentoring, and scheduled opportunities as ways to reemphasize the importance of learning these technical skills.

Purpose: This study aimed to examine the approaches general practitioners (GPs) use to respond to the treatment burden faced by people with type 2 diabetes.

Methods: We retrospectively analyzed 29 videos of GP-patient consultations in an academic general practice clinic in China. Thematic analysis and a framework matrix approach were used to identify patterns in GPs' responses to the identified issues.

Results: The median length of the 29 video-recorded consultations was 23 minutes 54 seconds. We identified 77 segments focusing on discussions about treatment burden. In 37.7% of these segments, the GP elicited and responded to discussions about treatment burden, whereas in 23.4%, the patient initiated the discussion and the GP responded to it, leaving 39.0% in which the patient initiated the discussion but the GP did not respond. In thematic analysis, medication was the component of treatment burden most frequently identified by both patients and GPs, followed by personal resources, medical information, and administrative burden. General practitioners used 12 response approaches to address patients' treatment burden. The most frequently used included active listening and nonverbal skills, shared decision making, and confidence and self-efficacy support, which were broadly applied across various issues. In contrast, GPs typically reserved health record management, motivational interviewing, and awareness of the patient's background for specific issues.

Conclusions: In clinical encounters, GPs used a wide variety of approaches to respond to different aspects of the treatment burden of type 2 diabetes. Our findings emphasize the need to improve GPs' response strategies through increased responsiveness and more rapid surfacing of issues during visits.

Purpose: We performed a pragmatic, cluster randomized controlled trial of a comprehensive practice-level, multistage practice transformation intervention aiming to increase behavioral health integration in primary care practices and improve patient outcomes. We examined associations between completion of intervention stages and patient outcomes across a heterogeneous national sample of primary care practices.

Methods: Forty-two primary care practices across the United States with colocated behavioral health and 2,945 patients with multiple chronic medical and behavioral health conditions completed surveys at baseline, midpoint, and 2-year follow-up. We examined effects of intervention on patient health and primary care integration outcomes using multilevel mixed-effects models, controlling for baseline outcome measurements.

Results: No differences were found associated with the number of intervention stages completed and patient health outcomes including depression, anxiety, fatigue, sleep disturbance, pain, pain interference, social participation, and physical function. However, the completion of each intervention stage was associated with increases in Practice Integration Profile domain scores and confirmed with modeling using multiple imputation for the following: workflow 3.5 (95% CI, 0.9 to 6.1), integration methods 4.6 (95% CI, 1.5 to 7.6), patient identification 2.9 (95% CI, 0.9 to 5.0), and total integration 2.7 (95% CI, 0.7 to 4.7).

Conclusion: A practice-centric flexible practice transformation intervention improved integration of behavioral health in primary care across heterogeneous primary care practices treating patients with multiple chronic conditions when accounting for completion of intervention stages. Interventions that allow practices to flexibly improve care have the potential to help complex patient populations. Future research is needed to determine how to best target patient health outcomes at the population level.

Purpose: Adoption has lifelong health implications for 7.8 million adopted people and their families in the United States. The majority of adoptees have limited family medical history (LFMH). Primary care physicians (PCPs) rarely receive training about adoptees including their mental health needs and increased suicide risk. The growing availability and popularity of direct-to-consumer genetic testing kits amplifies the need for PCPs to be prepared to address genetic testing for adoptees with LFMH. This study explores PCP training and approaches to adult adopted patients with LFMH.

Methods: We used critical adoption studies as a theoretical framework for this study to understand how adoptive identity might shape clinical experiences. We recruited PCPs from Minnesota and Rhode Island via purposive, criteria-based, reputational sampling. We conducted hour-long semistructured qualitative interviews incorporating hypothetical clinical vignettes. Transcripts were coded via template organizing method and analyzed via Immersion-Crystallization.

Results: We interviewed 23 PCPs. They reported receiving little training or resources on adult adoptees with LFMH and showed substantial knowledge gaps regarding mental health and genetic testing for this population. Many failed to adjust history-taking and primary care approaches, which they recognized as potentially resulting in inaccuracies, inappropriate clinical care, and microaggressions while inadvertently triggering anxiety, shame, and distrust among patients. A mismatch between adopted patients' and physicians' understandings of family medical history could strain the therapeutic relationship. Nearly all interviewees viewed additional training to care for adult adoptees with LFMH as beneficial.

Conclusion: Future research should expand education and training for PCPs on adult adoptees with LFMH.

There is a hum and drum to the clinical day, sounds and rhythms that pervade physician and patient's soundscape. We hear but we do not listen. The soundtrack of the daily grind is experienced as an audio blanket of white noise. Often taken for granted, we suggest the sounds of practice form an important role in our daily lives as family doctors. Masked in these sounds are tacit skills and auditory expertise that speak louder than words. In this essay, as 2 family doctors, we reflect on the sounds of a single day in the clinic.

Annals Early Access article.