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Background: The essence of humanism in medicine and health care is relationships-caring relationships between clinicians and patients. While raising concerns regarding professional-patient boundaries has positively contributed to our understanding and prevention of potentially harmful boundary violations, there is controversy about which types of relationships, caring acts, and practices are acceptable versus cross boundary lines.Objective: To examine primary care physicians' practices and attitudes regarding acts that have been questioned as potentially "inappropriate" or "unethical" crossing of professional-patient boundaries.Design: Surveys conducted via in-person polling or electronic and mailed paper submissions from April 2016 to July 2017. We calculated descriptive statistics and examined associations with practices and attitudes using logistic regression.Participants: Random sample of all US primary care physicians who treat adult patients; convenience sample of attendees at medicine grand rounds presentations.Main Measures: Outcomes were self-reported practices and attitudes related to giving patients rides home, paying for patients' medication, helping patients find jobs, employing patients, going to dinner with patients, and providing care to personal friends.Key Results: Among 1563 total respondents, 34% had given a ride home, 34% had paid for medications, 15% helped patients find a job, 7% had employed a patient, 10% had dinner with patients, and 59% provided care to personal friends. A majority disapproved of dinner with a patient (75%) but approved of or were neutral on all other scenarios (61-90%).Conclusions: The medical profession is quite divided on questions related to drawing lines about appropriate boundaries. Contrary to official and widespread proscriptions against such practices (with exception of dinner dates), many have actually engaged in such practices and the majority found them acceptable. [ABSTRACT FROM AUTHOR]

Background: Improving care coordination is a key priority for many healthcare systems. However, initiatives to improve care coordination are complex to implement and have produced mixed results. A better understanding of how to craft and support implementation of effective care coordination strategies is needed.Objective: To identify and understand the challenges and factors encountered by Patient-Aligned Care Team (PACT) staff in performing care coordination tasks in outpatient clinics in the Veterans Health Administration (VA).Design: Qualitative study using semi-structured formative evaluation interviews.Participants: Fourteen interviews with 18 clinical frontline managers and staff from 12 clinic sites across five VA health systems.Interventions: This paper reports on baseline data collected for the Coordination Toolkit and Coaching (CTAC) project. CTAC aims to improve patients' experience of care coordination within VA primary care and between PACT and other outpatient and community settings.Approach: We conducted pre-implementation telephone interviews with frontline managers and staff, primarily nurse managers.Key Results: PACT staff described challenges in aligning care coordination priorities across different levels of the VA system, including staff, patients, and leadership. Additionally, PACT staff noted challenges coordinating care both within and outside the VA, and identified resource barriers impeding their care coordination efforts. To address these challenges, staff made several recommendations for improvement, including (1) contingency staffing to address staff burnout; (2) additional PACT training for new staff; (3) clarification of care coordination roles and responsibilities; and (4) and care coordination initiatives that align both with centrally initiated care coordination programs and frontline needs.Conclusion: In the VA and similarly complex healthcare systems, our findings suggest the need for care coordination strategies that are buttressed by a system-level vision for care coordination, backed up by clear roles and responsibilities for information exchange between primary care staff and other settings, and multidimensional accountability metrics that encompass patient-, staff-, and system-level goals. [ABSTRACT FROM AUTHOR]

Background: Few studies examined specific mentoring needs and preferences of clinician educators (CEs). Further research on CEs' perceptions of mentoring adequacy, as related to educational development and career advancement, is needed.Objective: The study aims were to (1) explore general internal medicine CEs' experiences as mentees within various mentoring models; (2) examine the perceived quality, nature, and impact of mentoring on career development; and (3) determine whether specific models of mentoring impact their attitudes towards mentoring.Design: Sequential mixed methods study design answered the study questions.Participants: Society of General Internal Medicine members identifying themselves as CEs.Main Measures/approach: Participants completed an anonymous online survey and a subsample participated in two semi-structured focus group discussions. Outcomes of interest were perceptions of mentoring experiences, and perspectives on quality of mentoring as well as mentoring needs specific to clinician educators.Key Results: One hundred thirty-nine participants completed the survey (37% response rate) with 20 participants in focus group discussions. Among CEs with perceived high-quality mentor relationships (e.g., reporting strongly agree), peer mentorship was viewed as adequate mentorship (45% (n = 17) vs 24% (n = 24), p < 0.05), as beneficial for career development (77% (n = 40) vs 48% (n = 41), p < 0.01) and as being challenged to become a better CE (58% (n = 30) vs 35% (n = 29), p < 0.05), compared to reporting agree or lower. Qualitative analysis generated four themes: (1) A mentoring team promotes career advancement, (2) peer mentors are important at every stage of a CE's career, (3) there is inadequate mentoring specific to CE needs, and (4) mentoring needs protected time and skill development.Conclusions: The traditional dyadic mentoring relationship may not adequately address all professional needs of CEs. A mentoring team can provide valuable perspectives on career goals. Peer mentoring can be powerful for professional growth. Mentoring needs change at different career stages and training in mentoring skills is essential. [ABSTRACT FROM AUTHOR]

Background: African Americans have low engagement in advance care planning (ACP). This has been attributed to healthcare distrust and skepticism about ACP. A better understanding of these attitudes is needed to address health disparities related to end-of-life care. Objective: To explore the ACP-related values and beliefs of diverse African American communities across the USA and then the perceived value of an inexpensive end-of-life conversational game. Design: Prospective, convergent, mixed methods cohort study involving fifteen underserved, African American communities across the USA. Participants: Of the 428 who attended events at purposively sampled sites, 90% consented to the research; 37% participated in one of 15 focus groups (n = 141). Intervention: An end-of-life conversation game, played in groups of 4–6. Main Measures: The validated, 7-item ACP values and beliefs questionnaire (scaled 7 = least skeptical, 49 = most skeptical) was administered pre-game. Post-game focus groups explored perceptions about ACP and the intervention. Key Results: Participants had positive attitudes (low skepticism) about ACP with a median score of 12.00 (7.00, 20.00). Values and beliefs did not significantly differ by geographical region; however, rural areas were observed to be slightly more skeptical than urban areas (median score 14.00 vs. 11.00, p = 0.002). Themes from focus groups converged with survey data showing participants valued the ACP process and consider further engagement in ACP to be worthwhile. Subthemes emphasized the need for and value of ACP. Conclusions: Skepticism about ACP may contribute to low rates of ACP engagement in underserved African American communities. The positive attitudes uncovered in our study either negate previous findings or suggest reduced skepticism. Trial Registration: This study has been registered at clinicaltrials.gov (NCT03456921) [ABSTRACT FROM AUTHOR]

Background: Ineffective transitions of care continue to be a source of risk for patients. Although there has been widespread implementation of electronic medical record (EMR) systems, little is currently known about hospitalists' and primary care providers' (PCPs) direct communication preferences at discharge using messaging capabilities in a shared EMR system.Objective: We examined how hospitalists and PCPs with a shared EMR prefer to directly communicate at the time of hospital discharge by identifying preferred modes, information prioritization, challenges, facilitators, and proposed solutions.Design: A sequential, explanatory mixed methods study with surveys and semi-structured interviews.Participants: Thirty-eight academic hospitalists and 63 PCPs working in outpatient clinics in a single safety net hospital system with a shared EMR.Main Approach: Descriptive statistics were used to analyze survey responses. Interviews were analyzed using immersion/crystallization and a mixture of inductive and deductive thematic analysis.Key Results: PCPs preferred direct communication at discharge through a message within the EMR while hospitalists preferred a message within the EMR and email. Qualitative results identified key themes related to patient care and direct communication: value of direct communication, safety, social determinants of health, and clinical judgment. Both groups prioritized direct communication for high-risk medications, pending and follow-up studies, and high-risk patients that hospitalists were concerned about. Overall, both hospitalists and PCPs reported that ensuring patient safety, flagging patients with social challenges, and expressing concerns about patients based on clinical judgment were key communication priorities.Conclusions: Hospitalists and primary care providers report considerable overlap in preferences for direct communication at the time of hospital discharge through a shared EMR. Specifically, both groups reported similar concerns regarding patient safety and continuity during transitions. Direct messaging within the EMR could enable "closed loop" communication that helps ensure safe transitions of care for high-risk patients. [ABSTRACT FROM AUTHOR]

Background: As more health care organizations integrate social needs screening and navigation programs into clinical care delivery, the patient perspective is necessary to guide implementation and achieve patient-centered care.Objectives: To examine patients' perceptions of whether social needs affect health and attitudes toward healthcare system efforts to screen for and address social needs.Research Design: Multi-site, self-administered survey to assess (1) patient perceptions of the health impact of commonly identified social needs; (2) experience of social needs; (3) degree of support for a health system addressing social needs, including which social needs should be screened for and intervened upon; and (4) attitudes toward a health system utilizing resources to address social needs. Analyses were conducted using multivariable logistic regression models with clinic site cluster adjustment.Subjects: Adult patients at seven primary care clinics within a large, integrated health system in Southern California.Main Measures: Survey measures of experience with, acceptability of, and attitudes toward clinical social determinants of health screening and navigation.Key Results: A total of 1161 patients participated, representing a 79% response rate. Most respondents (69%) agreed that social needs impact health and agreed their health system should ask about social needs (85%) and help address social needs (88%). Patients with social needs in the last year were more likely to (1) agree social needs impact health (OR 10.2, p < 0.001), (2) support their health system asking patients about social needs (OR 3.7, p < 0.001), and (3) support addressing patient social needs (OR 3.5, p < 0.001). Differences by social need history, gender, age, race, ethnicity, and education were found.Conclusions: Most patients at a large integrated health system supported clinical social needs screening and intervention. Differences in attitudes by social need history, gender, age, race, ethnicity, and education may indicate opportunities to develop more equitable, patient-centered approaches to addressing social needs. [ABSTRACT FROM AUTHOR]

Background: Despite the importance of professionalism, little is known about how burnout relates to professionalism among practicing physicians.Objective: To evaluate the relationship between burnout and professional behaviors and cost-conscious attitudes.Design and Participants: Cross-sectional study in a national sample of physicians of whom a fourth received a sub-survey with items exploring professional behaviors and cost-conscious attitudes. Responders who were not in practice or in select specialties were excluded.Measures: Maslach Burnout Inventory and items on professional behaviors and cost-conscious attitudes.Key Results: Among those who received the sub-survey 1008/1224 (82.3%) responded, and 801 were eligible for inclusion. Up to one third of participants reported engaging in unprofessional behaviors related to administrative aspects of patient care in the last year, such as documenting something they did not do to close an encounter in the medical record (243/759, 32.0%). Fewer physicians reported other dishonest behavior (e.g., claiming unearned continuing medical education credit; 40/815, 4.9%). Most physicians endorsed cost-conscious attitudes with over 75% (618/821) agreeing physicians have a responsibility to try to control health-care costs and 62.9% (512/814) agreeing that cost to society is important in their care decisions regarding use of an intervention. On multivariable analysis adjusting for personal and professional characteristics, burnout was independently associated with reporting 1 or more unprofessional behaviors (OR 2.01, 95%CI 1.47-2.73, p < 0.0001) and having less favorable cost-conscious attitudes (difference on 6-24 scale - 0.90, 95%CI - 1.44 to - 0.35, p = 0.001).Conclusions: Professional burnout is associated with self-reported unprofessional behaviors and less favorable cost-conscious attitudes among physicians. [ABSTRACT FROM AUTHOR]

Background: Effective co-management of patients with chronic kidney disease (CKD) between primary care physicians (PCPs) and nephrologists is increasingly recognized as a key strategy to ensure the delivery of efficient and high-quality CKD care. However, the co-management of patients with CKD remains suboptimal.Objective: We aimed to identify PCPs' perceptions of key barriers and facilitators to effective co-management of patients with CKD at the PCP-nephrology interface.Study Design: Qualitative study SETTING AND PARTICIPANTS: Community-based PCPs in four US cities: Baltimore, MD; St. Louis, MO; Raleigh, NC; and San Francisco, CA APPROACH: We conducted four focus groups of PCPs. Two members of the research team coded transcribed audio-recorded interviews and identified major themes.Key Results: Most of the 32 PCPs (59% internists and 41% family physicians) had been in practice for > 10 years (97%), spent ≥ 80% of their time in clinical care (94%), and practiced in private (69%) or multispecialty group practice (16%) settings. PCPs most commonly identified barriers to effective co-management of patients with CKD focused on difficulty developing working partnerships with nephrologists, including (1) lack of timely adequate information exchange (e.g., consult note not received or CKD care plan unclear); (2) unclear roles and responsibilities between PCPs and nephrologists; and (3) limited access to nephrologists (e.g., unable to obtain timely consultations or easily contact nephrologists with concerns). PCPs expressed a desire for "better communication tools" (e.g., shared electronic medical record) and clear CKD care plans to facilitate improved PCP-nephrology collaboration.Conclusions: Interventions facilitating timely adequate information exchange, clear delineation of roles and responsibilities between PCPs and nephrologists, and greater access to specialist advice may improve the co-management of patients with CKD. [ABSTRACT FROM AUTHOR]

Background: For at least the past two decades, medical educators have worked to improve patient communication and health care delivery to diverse patient populations; despite efforts, patients continue to report prejudice and bias during their clinical encounters. Targeted instruction in implicit bias recognition and management may promote the delivery of equitable care, but students at times resist this instruction. Little guidance exists to overcome this resistance and to engage students in implicit bias instruction; instruction over time could lead to eventual skill development that is necessary to mitigate the influence of implicit bias on clinical practice behaviors.Objective: To explore student perceptions of challenges and opportunities when participating in implicit bias instruction.Approach: We conducted a qualitative study that involved 11 focus groups with medical students across each of the four class years to explore their perceptions of challenges and opportunities related to participating in such instruction. We analyzed transcripts for themes.Key Results: Our analysis suggests a range of attitudes toward implicit bias instruction and identifies contextual factors that may influence these attitudes. The themes were (1) resistance; (2) shame; (3) the negative role of the hidden curriculum; and (4) structural barriers to student engagement. Students expressed resistance to implicit bias instruction; some of these attitudes are fueled from concerns of anticipated shame within the learning environment. Participants also indicated that student engagement in implicit bias instruction was influenced by the hidden curriculum and structural barriers.Conclusions: These insights can inform future curriculum development efforts. Considerations related to instructional design and programmatic decision-making are highlighted. These considerations for implicit bias instruction may provide useful frameworks for educators looking for opportunities to minimize student resistance and maximize engagement in multi-session instruction in implicit bias recognition and management. [ABSTRACT FROM AUTHOR]

Background: The Veterans Access, Choice and Accountability Act (hereafter, Choice Program) seeks to improve access to care by enabling eligible Veterans to receive care from community providers. Veterans Affairs (VA) primary care providers (PCPs) play a key role in making referrals to community specialists, but their frontline experiences with referrals are not well understood.Objective: To understand VA PCPs' experiences referring patients to community specialists while VA works to expand and refine the implementation of the Choice Program.Design: Qualitative study using interview methods.Participants: Semi-structured telephone interviews were conducted with VA primary care providers (N = 72 out of 599 contacted) recruited nationally.Approach: Open-ended interview questions elicited PCP perceptions and experiences with referrals to community specialists via the Choice Program. Keywords were identified using automated coding features in ATLAS.ti and evaluated using conventional content analysis to inductively describe the qualitative data.Key Results: VA PCPs emphasized problems with care coordination and continuity between the VA and community specialists (e.g., "It is extremely difficult for us to obtain and continue continuity of care because there's not much communication with the community specialist"). They described difficulties with tracking the initial referral, coordinating care after receiving community specialty care, accessing community medical records, and aligning community specialists' prescriptions with the VA formulary.Conclusions: The VA Choice Program provides access to community specialists for VA patients; however, VA primary care providers face challenges tracking referrals to community specialists and in coordinating care. Strategies to improve care coordination between the VA and community providers should focus on providing PCPs with information to follow Veterans throughout the Choice referral process and follow-up. [ABSTRACT FROM AUTHOR]

Background: One widely cited study suggested a link between physician empathy and laboratory outcomes in patients with diabetes, but its findings have not been replicated. While empathy has a positive impact on patient experience, its impact on other outcomes remains unclear.Objective: To assess associations between physician empathy and glycosylated hemoglobin (HgbA1c) as well as low-density lipoprotein (LDL) levels in patients with diabetes.Design: Retrospective cross-sectional study.Participants: Patients with diabetes who received care at a large integrated health system in the USA between January 1, 2011, and May 31, 2014, and their primary care physicians.Main Measures: The main independent measure was physician empathy, as measured by the Jefferson Scale of Empathy (JSE). The JSE is scored on a scale of 20-140, with higher scores indicating greater empathy. Dependent measures included patient HgbA1c and LDL. Mixed-effects linear regression models adjusting for patient sociodemographic characteristics, comorbidity index, and physician characteristics were used to assess the association between physician JSE scores and their patients' HgbA1c and LDL.Key Results: The sample included 4176 primary care patients who received care with one of 51 primary care physicians. Mean physician JSE score was 118.4 (standard deviation (SD) = 12). Median patient HgbA1c was 6.7% (interquartile range (IQR) = 6.2-7.5) and median LDL concentration was 83 (IQR = 66-104). In adjusted analyses, there was no association between JSE scores and HgbA1c (β = - 0.01, 95%CI = - 0.04, 0.02, p = 0.47) or LDL (β = 0.41, 95%CI = - 0.47, 1.29, p = 0.35).Conclusion: Physician empathy was not associated with HgbA1c or LDL. While interventions to increase physician empathy may result in more patient-centered care, they may not improve clinical outcomes in patients with diabetes. [ABSTRACT FROM AUTHOR]

Background: Support for ongoing care management and coordination between office visits for patients with multiple chronic conditions has been inadequate. In January 2015, Medicare introduced the Chronic Care Management (CCM) payment policy, which reimburses providers for CCM activities for Medicare beneficiaries occurring outside of office visits.Objective: To explore the experiences, facilitators, and challenges of practices providing CCM services, and their implications going forward.Design: Semi-structured telephone interviews from January to April 2016 with 71 respondents.Participants: Sixty billing and non-billing providers and practice staff knowledgeable about their practices' CCM services, and 11 professional society representatives.Key Results: Practice respondents noted that most patients expressed positive views of CCM services. Practice respondents also perceived several patient benefits, including improved adherence to treatment, access to care team members, satisfaction, care continuity, and care coordination. Facilitators of CCM provision included having an in-practice care manager, patient-centered medical home recognition, experience developing care plans, patient trust in their provider, and supplemental insurance to cover CCM copayments. Most billing practices reported few problems obtaining patients' consent for CCM, though providers felt that CMS could better facilitate consent by marketing CCM's goals to beneficiaries. Barriers reported by professional society representatives and by billing and non-billing providers included inadequacy of CCM payments to cover upfront investments for staffing, workflow modification, and time needed to manage complex patients. Other barriers included inadequate infrastructure for health information exchange with other providers and limited electronic health record capabilities for documenting and updating care plans. Practices owned by hospital systems and large medical groups faced greater bureaucracy in implementing CCM than did smaller, independent practices.Conclusions: Improving providers' experiences with and uptake of CCM will require addressing several challenges, including the upfront investment for CCM set-up and the time required to provide CCM to more complex patients. [ABSTRACT FROM AUTHOR]

Background: Physicians in Argentina smoke at rates similar to the general population, and do not have a clear role in tobacco control strategies.Objective: To describe the attitudes and knowledge of medical students and recent graduates towards smoking behavior in Argentina.Design: Cross-sectional self-administered online survey conducted in 2011.Participants: Medical students and recent medical graduates from the University of Buenos Aires.Main Measures: Attitudes and knowledge were evaluated by responses to 16 statements regarding the effects of smoking cigarettes and the role of physicians in tobacco control. Rates of agreement with a full ban on indoor smoking in different public settings were assessed.Key Results: The sample included 1659 participants (response rate: 35.1 %), 453 of whom (27.3 %) were current smokers. Only 52 % of participants agreed that doctors should set an example for their patients by not smoking, 30.9 % thought that medical advice had little effect on patients' cessation behavior, and 19.4 % believed that physicians could decline to care for smoking patients who failed to quit. In adjusted logistic regression models, current smokers had less supportive attitudes about tobacco control and were less likely than non-smokers to agree with a full indoor smoking ban in hospitals (OR: 0.30; 95 % CI 0.16-0.58), universities (OR: 0.55; 95 % CI 0.41-0.73), workplaces (OR: 0.67; 95 % CI 0.50-0.88), restaurants (OR: 0.42; 95 % CI 0.33-0.53), cafes (OR: 0.41; 95 % CI 0.33-0.51), nightclubs (OR: 0.32; 95 % CI 0.25-0.40), and bars (0.35; 95 % CI 0.28-0.45). Recent medical graduates had more accurate knowledge about cessation and were more likely to agree with a full smoking ban in recreational venues.Conclusions: Although most participants reported a strong anti-tobacco attitude, a proportion still failed to recognize the importance of their role as physicians in tobacco control strategies. Current smokers and current students were less likely to support indoor smoking bans. Specific educational curricula could address these factors. [ABSTRACT FROM AUTHOR]

Background: Over the past two decades, state and local governments across the U.S. have been increasingly reforming marijuana laws. Despite growing support for marijuana as a medical treatment, little is known about medical students' perceptions of marijuana use.Objective: To assess Colorado medical students' personal and professional opinions on current and future marijuana use in a healthcare setting.Design: A voluntary, anonymous, online cross-sectional survey.Participants: Medical students (n = 624) at the University of Colorado School of Medicine between January and February 2014 were invited to participate.Main Measures: Numerical responses were quantified using counts and percentages, and Likert scale responses were collapsed for bivariate analysis. Items were gathered thematically and additively scored for each subscale. Internal consistency reliability statistics were calculated for each subscale to ensure that items were assessing similar constructs. Unadjusted t tests and one-way analysis of variance (ANOVA) were used to calculate mean differences in subscale scores between subgroups.Key Results: We received 236 responses (37%). Students indicated support for marijuana legalization (64%), and few believed that physicians should be penalized for recommending marijuana to patients (6%). Nearly all (97%) believed that further marijuana research should be conducted, and believed marijuana could play a role in the treatment of various medical conditions. Seventy-seven percent reported that they believed marijuana use had the potential for psychological harm, and 68% indicated concern for potential physical harm. Only a minority of students would recommend marijuana to a patient under current law (29%), or if it were legally available (45%). Acceptability of marijuana for treatment of approved conditions was not correlated with age or gender, but was positively correlated with living in Colorado prior to medical school (p < 0.001) and with prior marijuana use (p < 0.001).Conclusions: Medical students support marijuana legal reform, medicinal uses of marijuana, and increased research, but have concerns regarding risks of marijuana use, and appear hesitant to recommend marijuana to patients. [ABSTRACT FROM AUTHOR]

Background: Revised breast cancer screening guidelines have fueled debate about the effectiveness and frequency of screening mammography, encouraging discussion between women and their providers.Objective: To examine whether primary care providers' (PCPs') beliefs about the effectiveness and frequency of screening mammography are associated with utilization by their patients.Design: Cross-sectional survey data from PCPs (2014) from three primary care networks affiliated with the Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium, linked with data about their patients' mammography use (2011-2014).Participants: PCPs (n = 209) and their female patients age 40-89 years without breast cancer (n = 30,233).Main Measures: Outcomes included whether (1) women received a screening mammogram during a 2-year period; and (2) screened women had >1 mammogram during that period, reflecting annual screening. Principal independent variables were PCP beliefs about the effectiveness of mammography and their recommendations for screening frequency.Key Results: Overall 65.2% of women received >1 screening mammogram. For women 40-48 years, mammography use was modestly lower for those cared for by PCPs who believed that screening was ineffective compared with those who believed it was somewhat or very effective (59.1%, 62.3%, and 64.7%; p = 0.019 after controlling for patient characteristics). Of women with PCPs who reported they did not recommend screening before age 50, 48.1% were nonetheless screened. For women age 49-74 years, the vast majority were cared for by providers who believed that screening was effective. Provider recommendations were not associated with screening frequency. For women ≥75 years, those cared for by providers who were uncertain about effectiveness had higher screening use (50.7%) than those cared for by providers who believed it was somewhat effective (42.8%). Patients of providers who did not recommend screening were less likely to be screened than were those whose providers recommended annual screening, yet 37.1% of patients whose providers recommended against screening still received screening.Conclusions: PCP beliefs about mammography effectiveness and screening recommendations are only modestly associated with use, suggesting other likely influences on patient participation in mammography. [ABSTRACT FROM AUTHOR]

Background: The shortage of primary care providers and the provisions of the Affordable Care Act (ACA) have spurred discussion about expanding the number, scope of practice (SOP), and independence of primary care nurse practitioners (NPs). Such discussions in the media and among professional organizations may insinuate that changes to the laws governing NP practice will engender acrimony between practicing physicians and NPs. However, we lack empirical, descriptive data on how practicing professionals view NP independence in primary care.Objective: The aim of the present study was to explore and describe the attitudes about NP independence among physicians and NPs working in primary care.Design: A qualitative study based on the principles of grounded theory.Participants: Thirty primary care professionals in Missouri, USA, including 15 primary care physicians and 15 primary care NPs.Approach: Semi-structured, in-depth interviews, with data analysis guided by grounded theory.Key Results: Participants had perspectives that were not well represented by professional organizations or the media. Physicians were supportive of a wide variety of NP roles and comfortable with high levels of NP independence and autonomy. Physicians and NPs described prerequisites to NP independence that were complementary. Physicians generally believed that NPs needed some association with physicians for patient safety, and NPs preferred having a physician readily accessible as needed. The theme "knowing your limits" was important to both NPs and physicians regarding NP independence, and has not been described previously in the literature.Conclusions: NP and physician views about NP practice in primary care are not as divergent as their representative professional organizations and the news media would suggest. The significant agreement among NPs and physicians, and some of the nuances of their perspectives, supports recommendations that may reduce the perceived acrimony surrounding discussions of NP independent practice in primary care. [ABSTRACT FROM AUTHOR]

Background: Rationing is a controversial topic among US physicians. Understanding their attitudes and behaviors around rationing may be essential to a more open and sensible professional discourse on this important but controversial topic.Objective: To describe rationing behavior and associated factors among US physicians.Design: Survey mailed to US physicians in 2012 to evaluate self-reported rationing behavior and variables related to this behavior.Setting: US physicians across a full spectrum of practice settings.Participants: A total of 2541 respondents, representing 65.6 % of the original mailing list of 3872 US addresses.Interventions: The study was a cross-sectional analysis of physician attitudes and self-reported behaviors, with neutral language representations of the behaviors as well as an embedded experiment to test the influence of the word "ration" on perceived responsibility.Main Outcome Measures: Overall percentage of respondents reporting rationing behavior in various contexts and assessment of attitudes toward rationing.Key Results: In total, 1348 respondents (53.1 %) reported having personally refrained within the past 6 months from using specific clinical services that would have provided the best patient care, because of health system cost. Prescription drugs (n = 1073 [48.3 %]) and magnetic resonance imaging (n = 922 [44.5 %]) were most frequently rationed. Surgical and procedural specialists were less likely to report rationing behavior (adjusted odds ratio [OR] [95 % CI], 0.8 [0.9-0.9] and 0.5 [0.4-0.6], respectively) compared to primary care. Compared with small or solo practices, those in medical school settings reported less rationing (adjusted OR [95 % CI], 0.4 [0.2-0.7]). Physicians who self-identified as very or somewhat liberal were significantly less likely to report rationing (adjusted OR [95 % CI], 0.7 [0.6-0.9]) than those self-reporting being very or somewhat conservative. A more positive opinion about rationing tended to align with greater odds of rationing.Conclusions: More than one-half of respondents engaged in behavior consistent with rationing. Practicing physicians in specific subgroups were more likely to report rationing behavior. [ABSTRACT FROM AUTHOR]

Background: Workforce projections indicate a potential shortage of up to 31,000 adult primary care providers by the year 2025. Approximately 80 % of internal medicine residents and nearly two-thirds of primary care internal medicine residents do not plan to have a career in primary care or general internal medicine.Objective: We aimed to explore contextual and programmatic factors within primary care residency training environments that may influence career choices.Design: This was a qualitative study based on semi-structured, in-person interviews.Participants: Three primary care internal medicine residency programs were purposefully selected to represent a diversity of training environments. Second and third year residents were interviewed.Approach: We used a survey guide developed from pilot interviews and existing literature. Three members of the research team independently coded the transcripts and developed the code structure based on the constant comparative method. The research team identified emerging themes and refined codes. ATLAS.ti was used for the analysis.Key Results: We completed 24 interviews (12 second-year residents, and 12 third-year residents). The age range was 27-39 years. Four recurrent themes characterized contextual and programmatic factors contributing to residents' decision-making: resident expectations of a career in primary care, navigation of the boundary between social needs and medical needs, mentorship and perceptions of primary care, and structural features of the training program.Conclusions: Addressing aspects of training that may discourage residents from careers in primary care such as lack of diversity in outpatient experiences and resident frustration with their inability to address social needs of patients, and strengthening aspects of training that may encourage interests in careers in primary care such as mentorship and protected time away from inpatient responsibilities during primary care rotations, may increase the proportion of residents enrolled in primary care training programs who pursue a career in primary care. [ABSTRACT FROM AUTHOR]

Background: Primary care providers (PCPs) have few tools for enhancing patient self-efficacy, a key mediator of myriad health-influencing behaviors.Objective: To examine whether brief standardized patient instructor (SPI)-delivered training increases PCPs' use of self-efficacy-enhancing interviewing techniques (SEE IT).Design: Randomized controlled trial.Participants: Fifty-two family physicians and general internists from 12 primary care offices drawn from two health systems in Northern California.Interventions: Experimental arm PCPs received training in the use of SEE IT training during three outpatient SPI visits scheduled over a 1-month period. Control arm PCPs received a single SPI visit, during which they viewed a diabetes treatment video. All intervention visits (experimental and control) were timed to last 20 min. SPIs portrayed patients struggling with self-care of depression and diabetes in the first 7 min, then delivered the appropriate intervention content during the remaining 13 min.Main Measures: The primary outcome was provider use of SEE IT (a count of ten behaviors), coded from three audio-recorded standardized patient visits at 1-3 months, again involving depression and diabetes self-care. Two five-point scales measured physician responses to training: Value (7 items: quality, helpfulness, understandability, relevance, feasibility, planned use, care impact), and Hassle (2 items: personal hassle, flow disruption).Key Results: Pre-intervention, study PCPs used a mean of 0.7 behaviors/visit, with no significant between-arm difference (P = 0.23). Post-intervention, experimental arm PCPs used more of the behaviors than controls (mean 2.7 vs. 1.0 per visit; adjusted difference 1.7, 95 % CI 1.1-2.2; P < 0.001). Experimental arm PCPs had higher training Value scores than controls (mean difference 1.05, 95 % CI 0.68-1.42; P < 0.001), and similarly low Hassle scores.Conclusions: Primary care physicians receiving brief SPI-delivered training increased their use of SEE IT and found the training to be of value. Whether patients visiting SEE IT-trained physicians experience improved health behaviors and outcomes warrants study. CLINICALTRIALS.Gov Identifier: NCT01618552. [ABSTRACT FROM AUTHOR]

Background: Changes to national guidelines for breast and cervical cancer screening have created confusion and controversy for women and their primary care providers.Objective: To characterize women's primary health care provider attitudes towards screening and changes in practice in response to recent revisions in guidelines for breast and cervical cancer screening.Design, Setting, Participants: In 2014, we distributed a confidential web and mail survey to 668 women's health care providers affiliated with the four clinical care networks participating in the three PROSPR (Population-based Research Optimizing Screening through Personalized Regimens) consortium breast cancer research centers (385 respondents; response rate 57.6 %).Main Measures: We assessed self-reported attitudes toward breast and cervical cancer screening, as well as practice changes in response to the most recent revisions of the U.S. Preventive Services Task Force (USPSTF) recommendations.Key Results: The majority of providers believed that mammography screening was effective for reducing cancer mortality among women ages 40-74 years, and that Papanicolaou (Pap) testing was very effective for women ages 21-64 years. While the USPSTF breast and cervical cancer screening recommendations were widely perceived by the respondents as influential, 75.7 and 41.2 % of providers (for mammography and cervical cancer screening, respectively) reported screening practices in excess of those recommended by USPSTF. Provider-reported barriers to concordance with guideline recommendations included: patient concerns (74 and 36 % for breast and cervical, respectively), provider disagreement with the recommendations (50 and 14 %), health system measurement of a provider's screening practices that use conflicting measurement criteria (40 and 21 %), concern about malpractice risk (33 and 11 %), and lack of time to discuss the benefits and harms with their patients (17 and 8 %).Conclusions: Primary care providers do not consistently follow recent USPSTF breast and cervical cancer screening recommendations, despite noting that these guidelines are influential. [ABSTRACT FROM AUTHOR]

Background: Ethical challenges are common in end of life care; the uncertainty of prognosis and the ethically permissible boundaries of treatment create confusion and conflict about the balance between benefits and burdens experienced by patients.Objective: We asked physician trainees in internal medicine how they reacted and responded to ethical challenges arising in the context of perceived futile treatments at the end of life and how these challenges contribute to moral distress.Design: Semi-structured in-depth qualitative interviews.Participants: Twenty-two internal medicine residents and fellows across three American academic medical centers.Approach: This study uses systematic qualitative methods of data gathering, analysis and interpretation.Key Results: Physician trainees experienced significant moral distress when they felt obligated to provide treatments at or near the end of life that they believed to be futile. Some trainees developed detached and dehumanizing attitudes towards patients as a coping mechanism, which may contribute to a loss of empathy. Successful coping strategies included formal and informal conversations with colleagues and superiors about the emotional and ethical challenges of providing care at the end of life.Conclusions: Moral distress amongst physician trainees may occur when they feel obligated to provide treatments at the end of life that they believe to be futile or harmful. [ABSTRACT FROM AUTHOR]

Background: Traditional productivity-based compensation models do not align well with newer population-based approaches to primary care. There are few published examples of academic general internal medicine compensation models that explicitly reward population health management, including care for patients between visits.Objective: To describe the development and implementation of an academic general internal medicine compensation plan based upon actual work performed, compare satisfaction across primary care specialties, and evaluate work-related outcomes.Design: Observational study.Participants: Forty-seven general internists who practice in affiliated academic and community clinics.Main Measures: Clinician satisfaction with compensation plan, workforce stability, panel data, and productivity.Key Results: The compensation plan change was associated with higher provider satisfaction. Sixty-five percent (31/47) of participants within general internal medicine reported being satisfied or very satisfied, as compared to 24 % (22/90 participants) for family medicine and 22 % (5/23 participants) for general pediatrics (p < 0.05). In the first 4 years of the compensation plan change, no general internists left to join other local groups. General internal medicine increased its number of physicians by 19 %. The number of established general internists accepting new patients increased from 17 to 48 %, while the relative value units per full-time equivalent declined by 3 %.Conclusions: An equitable compensation model that aligns with population management goals and work performed outside the clinical visit can lead to improved satisfaction and retention of faculty in an academic general internal medicine division, along with improved access for the patient population. [ABSTRACT FROM AUTHOR]

Background: Research suggests stereotyping by clinicians as one contributor to racial and gender-based health disparities. It is necessary to understand the origins of such biases before interventions can be developed to eliminate them. As a first step toward this understanding, we tested for the presence of bias in senior medical students. Objective: The purpose of the study was to determine whether bias based on race, gender, or socioeconomic status influenced clinical decision-making among medical students. Design: We surveyed seniors at 84 medical schools, who were required to choose between two clinically equivalent management options for a set of cardiac patient vignettes. We examined variations in student recommendations based on patient race, gender, and socioeconomic status. Participants: The study included senior medical students. Main Measures: We investigated the percentage of students selecting cardiac procedural options for vignette patients, analyzed by patient race, gender, and socioeconomic status. Key Results: Among 4,603 returned surveys, we found no evidence in the overall sample supporting racial or gender bias in student clinical decision-making. Students were slightly more likely to recommend cardiac procedural options for black (43.9 %) vs. white (42 %, p = .03) patients; there was no difference by patient gender. Patient socioeconomic status was the strongest predictor of student recommendations, with patients described as having the highest socioeconomic status most likely to receive procedural care recommendations (50.3 % vs. 43.2 % for those in the lowest socioeconomic status group, p < .001). Analysis by subgroup, however, showed significant regional geographic variation in the influence of patient race and gender on decision-making. Multilevel analysis showed that white female patients were least likely to receive procedural recommendations. Conclusions: In the sample as a whole, we found no evidence of racial or gender bias in student clinical decision-making. However, we did find evidence of bias with regard to the influence of patient socioeconomic status, geographic variations, and the influence of interactions between patient race and gender on student recommendations. [ABSTRACT FROM AUTHOR]