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Purpose: Asian and Latinx individuals have a high burden of untreated depression. Under-recognition of depressive symptoms may contribute to existing disparities in depression treatment. The objective of this cross-sectional study was to determine whether physicians recognize and treat depressive symptoms for Chinese and Latinx patients during routine primary care visits. Methods: We analyzed data from 1171 Chinese and Latinx patients who were interviewed within 1 week after a primary care visit in a large academic practice, which had not yet implemented universal depression screening. We included participants with depressive symptoms (defined as a Patient Health Questionaire-2 score ≥3) and no prior history of depression (N=118). We investigated whether patients perceived having a mental health need in the prior year and conducted chart reviews to assess provider recognition of depressive symptoms, defined as documentation of symptoms, antidepressant initiation, or mental health referral within 30 days of the visit. We further examined differences by race/ethnicity and language preference. Results: Among the 118 patients with depressive symptoms and no prior depression diagnosis (mean age 68), 71 (61%) reported a mental health need in the prior 12 months; however, providers recognized depressive symptoms in only 8/118 patients (7%). The number of patients with recognized symptoms was small across race/ethnicity and language preference groups and we found no significant differences. Conclusion: Physicians recognized and documented depressive symptoms for 1 in 10 Chinese and Latinx patients during routine primary care visits. Targeted efforts are needed to address under-recognition of symptoms and improve depression care for these populations.

This Perspective presents a case study of multidimensional clinical transformation in an academic general internal medicine practice. In the face of increasing internal and external pressures, health systems and individual medical practices have pursued multiple strategies to improve quality, patient experience, and efficiency, while reducing staff and provider stress and burnout. We describe a Lean-informed approach that emphasizes the importance of organizational alignment in goals, evidence-based problem solving, and leadership behaviors to support a culture of continuous improvement. Our aim in this Perspective is to provide a real-world example of a feasible process for the planning, preparation, and execution of effective transformation, and to present lessons that may be useful to other academic health center practices seeking to develop innovative models to achieve the quadruple aim.

In order to evaluate mortality predictions based on boosted trees, this retrospective study uses electronic medical record data from three academic health centers for inpatients 18 years or older with at least one observation of each vital sign. Predictions were made 12, 24, and 48 hours before death. Models fit to training data from each institution were evaluated using hold-out test data from the same institution, and from the other institutions. Gradient-boosted trees (GBT) were compared to regularized logistic regression (LR) predictions, support vector machine (SVM) predictions, quick Sepsis-Related Organ Failure Assessment (qSOFA), and Modified Early Warning Score (MEWS) using area under the receiver operating characteristic curve (AUROC). For training and testing GBT on data from the same institution, the average AUROCs were 0.96, 0.95, and 0.94 across institutional test sets for 12-, 24-, and 48-hour predictions, respectively. When trained and tested on data from different hospitals, GBT AUROCs achieved up to 0.98, 0.96, and 0.96, for 12-, 24-, and 48-hour predictions, respectively. Average AUROC for 48-hour predictions for LR, SVM, MEWS, and qSOFA were 0.85, 0.79, 0.86 and 0.82, respectively. GBT predictions may help identify patients who would benefit from increased clinical care.

The current longitudinal study consisted of baseline and follow-up surveys among older adults living with HIV (OALHIV) in Thailand. The health-related quality of life (HRQoL) was assessed using the Medical Outcomes Study HIV (MOS-HIV) questionnaire. We performed multiple linear regression analysis to document correlates of HRQoL at baseline and the predictors of the changes in HRQoL at follow-up. Of the 364 participants recruited at baseline; 327 (89.9%) completed the follow-up survey. The mean (SD) Physical Health Summary (PHS) and Mental Health Summary (MHS) scores were respectively 49.8 (7.3) and 53.2 (6.4). There was a significant increase in the mean score of most of the MOS-HIV domains, ranging between 1.3 for the PHS and 26.9 for the energy/fatigue dimension. In contrast, the mean score significantly decreased by 4.1 and 10.3 points, respectively for the cognitive and social functioning. Female gender was a predictor of the decline in social (

Author(s): Tateyama, Yukiko; Musumari, Patou Masika; Techasrivichien, Teeranee; Suguimoto, S Pilar; Zulu, Richard; Dube, Christopher; Feldman, Mitchell D; Ono-Kihara, Masako; Kihara, Masahiro | Abstract: BackgroundCardiovascular diseases are among the leading causes of mortality and morbidity in sub-Saharan Africa, including Zambia, where cardiovascular diseases account for 8% of the mortality rates. Despite an increasing number of cardiovascular disease-related studies in Zambia, qualitative studies exploring how cardiovascular diseases and their risk factors are understood in the socioeconomic and cultural contexts are still few. This study, therefore, aimed to analyze the beliefs, perceptions, and behaviors related to cardiovascular diseases and their risk factors among the local residents of Zambia.MethodsThis qualitative study was conducted from August to September 2014 among healthy residents aged 40 years and above in a rural community in Mumbwa District. We investigated the beliefs, perceptions, and behaviors related to cardiovascular diseases and their potential risk factors in the sociocultural context of Zambia by conducting in-depth interviews and focus group interviews. Audio-recorded interviews were transcribed and analyzed using thematic analysis with investigator triangulation.ResultsWe conducted 34 in-depth interviews and 6 focus group interviews with 27 males and 40 females. Most participants were aware of the prevalence of cardiovascular diseases around them and correctly identified hypertension, excessive salt, sugar, and cooking oil intakes, poor quality cooking oil, consumption of meat or vegetables contaminated with chemicals, obesity, stress ["thinking too much"], lack of physical exercise, and heredity as potential risk factors of cardiovascular diseases, while smoking and alcohol were mentioned by only a few participants. However, they claimed that many of these risk factors were difficult to avoid due to ingrained taste preferences for high salt and sugar, increasingly busy lives that force them to use cooking oil to reduce preparation time, cultural preference for big body size or fatness, especially for women, stigmatized body image attached to HIV, stressful life or life events related to poverty, and financial barriers to affording quality foods and healthcare services. Limited health screening opportunities and the negative impact of HIV-related stigma on health-seeking behavior also emerged as important risk factors for cardiovascular diseases.ConclusionsThis study revealed that participants are relatively well aware of cardiovascular diseases and their risk factors. However, they engage in high-risk health behaviors, due to ingrained taste preferences, limited knowledge, and unavoidable socioeconomic and cultural circumstances. Results suggest that prevention interventions addressing cardiovascular diseases in rural Zambia should target gaps in knowledge and socioeconomic and cultural barriers.

S cientific peer review is imperfect, and efforts to improve the process have had limited impact. For example, concealing reviewer or author identity, using a statistical checklist, or training referees has yielded mixed results at best. However, until new approaches (e.g. post-publication review) are tried and evaluated, peer review remains the scientific community’s primarymechanism for ensuring editorial quality and principal bulwark against error. JGIM’s approach to editorial review is not dissimilar from that employed by our peer publications. We use a three-stage process, and at each stage we ask of the research, Bis it new, is it true, and will it change practice.^ First, the co-editors in chief and senior associate editor evaluate manuscripts for fit and potential impact. Manuscripts that pass this initial bar are sent to a deputy editor for a secondary, in-depth review. A subset of these manuscripts are sent on for peer review. We ask peer reviewers to do three things: first, identify scientific strengths and deficiencies; second, assess impact on the field of general internal medicine; and third, help authors convey their ideas with greater clarity. We are biased, of course, but we think that as a group, JGIM peer reviewers are exceptionally conscientious at accomplishing these tasks. While we ask reviewers to make recommendations regarding acceptance, we are mindful of the unreliability of this process and use these recommendations as only one element in what is ultimately an editorial decision. Many good papers are returned to authors with regrets, and no doubt we reject some potentially important and impactful work. Peer reviewers, editors, and the editorial process are all fallible.We are grateful to authors who continue to submit to the journal, hoping that we finally get it right. JGIM would like to thank the many talented people who have volunteered their time to serve as peer reviewers for the journal over the past 12 months. In 2015–2016, 795 reviewers provided a total of 957 reviews with a mean quality score of 4.4 on a scale of 1–6 (as judged by our JGIM deputy editors). Of these, 154 provided at least two reviews, and 8 provided three or more. We are indebted to them for their service. Among this group of dedicated peer reviewers, there is a group that stands out. These top peer reviewers performed at least two reviews between July 2015 and June 2016, returned all reviews within 30 days, and received a quality score of 4 or greater (out of a maximum score of 6) on all reviews. An asterisk identifies the 88 reviewers who meet these criteria. We congratulate them on their service to the academic community and thank them for their efforts on behalf of the journal.

Author(s): Yukawa, Michi; Gansky, Stuart A; O'Sullivan, Patricia; Teherani, Arianne; Feldman, Mitchell D | Abstract: BackgroundMentorship plays an essential role in enhancing the success of junior faculty. Previous evaluation tools focused on specific types of mentors or mentees. The main objective was to develop and provide validity evidence for a Mentor Evaluation Tool (MET) to assess the effectiveness of one-on-one mentoring for faculty in the academic health sciences.MethodsEvidence was collected for the validity domains of content, internal structure and relationship to other variables. The 13 item MET was tested for internal structure evidence with 185 junior faculty from Schools of Dentistry, Medicine, Nursing, and Pharmacy. Finally, the MET was studied for additional validity evidence by prospectively enrolling mentees of three different groups of faculty (faculty nominated for, or winners of, a lifetime achievement in mentoring award; faculty graduates of a mentor training program; and faculty mentors not in either of the other two groups) at the University of California San Francisco (UCSF) and asking them to rate their mentors using the MET. Mentors and mentees were clinicians, educators and/or researchers.ResultsThe 13 MET items mapped well to the five mentoring domains and six competencies described in the literature. The standardized Cronbach's coefficient alpha was 0.96. Confirmatory factor analysis supported a single factor (CFI = 0.89, SRMR = 0.05). The three mentor groups did not differ in the single overall assessment item (P = 0.054) or mean MET score (P = 0.288), before or after adjusting for years of mentoring. The mentorship score means were relatively high for all three groups.ConclusionsThe Mentor Evaluation Tool demonstrates evidence of validity for research, clinical, educational or career mentors in academic health science careers. However, MET did not distinguish individuals nominated as outstanding mentors from other mentors. MET validity evidence can be studied further with mentor-mentee pairs and to follow prospectively the rating of mentors before and after a mentorship training program.

PurposeThis study evaluates a machine-learning-based mortality prediction tool.Materials and MethodsWe conducted a retrospective study with data drawn from three academic health centers. Inpatients of at least 18 years of age and with at least one observation of each vital sign were included. Predictions were made at 12, 24, and 48 hours before death. Models fit to training data from each institution were evaluated on hold-out test data from the same institution and data from the remaining institutions. Predictions were compared to those of qSOFA and MEWS using area under the receiver operating characteristic curve (AUROC).ResultsFor training and testing on data from a single institution, machine learning predictions averaged AUROCs of 0.97, 0.96, and 0.95 across institutional test sets for 12-, 24-, and 48-hour predictions, respectively. When trained and tested on data from different hospitals, the algorithm achieved AUROC up to 0.95, 0.93, and 0.91, for 12-, 24-, and 48-hour predictions, respectively. MEWS and qSOFA had average 48-hour AUROCs of 0.86 and 0.82, respectively.ConclusionThis algorithm may help identify patients in need of increased levels of clinical care.

Thailand has undergone rapid modernization with implications for changes in sexual norms. We investigated sexual behavior and attitudes across generations and gender among a probability sample of the general population of Nonthaburi province located near Bangkok in 2012. A tablet-based survey was performed among 2,138 men and women aged 15-59 years identified through a three-stage, stratified, probability proportional to size, clustered sampling. Descriptive statistical analysis was carried out accounting for the effects of multistage sampling. Relationship of age and gender to sexual behavior and attitudes was analyzed by bivariate analysis followed by multivariate logistic regression analysis to adjust for possible confounding. Patterns of sexual behavior and attitudes varied substantially across generations and gender. We found strong evidence for a decline in the age of sexual initiation, a shift in the type of the first sexual partner, and a greater rate of acceptance of adolescent premarital sex among younger generations. The study highlighted profound changes among young women as evidenced by a higher number of lifetime sexual partners as compared to older women. In contrast to the significant gender gap in older generations, sexual profiles of Thai young women have evolved to resemble those of young men with attitudes gradually converging to similar sexual standards. Our data suggest that higher education, being never-married, and an urban lifestyle may have been associated with these changes. Our study found that Thai sexual norms are changing dramatically. It is vital to continue monitoring such changes, considering the potential impact on the HIV/STIs epidemic and unintended pregnancies.

Introduction Several methods have been developed to electronically monitor patients for severe sepsis, but few provide predictive capabilities to enable early intervention; furthermore, no severe sepsis prediction systems have been previously validated in a randomised study. We tested the use of a machine learning-based severe sepsis prediction system for reductions in average length of stay and in-hospital mortality rate. Methods We conducted a randomised controlled clinical trial at two medical-surgical intensive care units at the University of California, San Francisco Medical Center, evaluating the primary outcome of average length of stay, and secondary outcome of in-hospital mortality rate from December 2016 to February 2017. Adult patients (18+) admitted to participating units were eligible for this factorial, open-label study. Enrolled patients were assigned to a trial arm by a random allocation sequence. In the control group, only the current severe sepsis detector was used; in the experimental group, the machine learning algorithm (MLA) was also used. On receiving an alert, the care team evaluated the patient and initiated the severe sepsis bundle, if appropriate. Although participants were randomly assigned to a trial arm, group assignments were automatically revealed for any patients who received MLA alerts. Results Outcomes from 75 patients in the control and 67 patients in the experimental group were analysed. Average length of stay decreased from 13.0 days in the control to 10.3 days in the experimental group (p=0.042). In-hospital mortality decreased by 12.4 percentage points when using the MLA (p=0.018), a relative reduction of 58.0%. No adverse events were reported during this trial. Conclusion The MLA was associated with improved patient outcomes. This is the first randomised controlled trial of a sepsis surveillance system to demonstrate statistically significant differences in length of stay and in-hospital mortality. Trial registration NCT03015454.

As another year at JGIM draws to a close, we want to thank and acknowledge the many talented people who have served as peer reviewers for JGIM over the past 12 months. Peer review remains an imperfect process, just okay at detecting error and abysmal at detecting fraud. Nevertheless, traditional peer review seems here to stay: few leading journals or editors are currently pushing for its demise. So while the idea of open source review appeals to our sense of transparency and fairness, for now we will continue to rely on our large panel of expert volunteer peer reviewers (and outstanding Deputy Editors) to help ensure the quality and fidelity of what we publish.

The global response to the HIV/AIDS epidemic has improved access to antiretroviral therapy (ART) and has contributed to decreased HIV/AIDS morbidity and mortality in sub-Saharan Africa. Patient adherence to ART is crucial to the success of HIV/AIDS treatment. However, little is known about the determinants of adherence to ART among people living with HIV/AIDS (PLWHA) in the Democratic Republic of Congo (DRC). This qualitative study used in-depth semi-structured patient interviews, a purposive sampling strategy and thematic analysis scheme to identify barriers and facilitators of adherence to ART in the DRC. We recruited three categories of participants from the Centre Hospitalier Monkole and the NGO ACS/Amo-Congo including participants on antiretroviral (ARV) treatment (n=19), on ARV re-treatment (n=13) and lost to follow-up (n=6). Among 38 participants interviewed, 24 were female and the median age was 41 years. Food insecurity as a barrier to adherence emerged as a dominant theme across the three categories of participants. Other barriers included financial constraints, forgetfulness and fear of disclosure/stigma. Religious beliefs were both a barrier and a facilitator to ART adherence. We found that food insecurity was a common and an important barrier to ART adherence among patients in the DRC. Our findings suggest that food insecurity should be appropriately addressed and incorporated into ARV treatment programs to ensure patient adherence and ultimately the long-term success of HIV treatment in the region

ObjectiveTo develop high-performance early sepsis prediction technology for the general patient population. MethodsRetrospective analysis of adult patients admitted to the intensive care unit (from the MIMIC II dataset) who were not septic at the time of admission. ResultsA sepsis early warning algorithm, InSight, was developed and applied to the prediction of sepsis up to three hours prior to a patient's first five hour Systemic Inflammatory Response Syndrome (SIRS) episode. When applied to a never-before-seen set of test patients, InSight predictions demonstrated a sensitivity of 0.90 (95% CI: 0.89-0.91) and a specificity of 0.81 (95% CI: 0.80-0.82), exceeding or rivaling that of existing biomarker detection methods. Across predictive times up to three hours before a sustained SIRS event, InSight maintained an average area under the ROC curve of 0.83 (95% CI: 0.80-0.86). Analysis of patient sepsis risk showed that contributions from the coevolution of multiple risk factors were more important than the contributions from isolated individual risk factors when making predictions further in advance. ConclusionsSepsis can be predicted at least three hours in advance of onset of the first five hour SIRS episode, using only nine commonly available vital signs, with better performance than methods in standard practice today. High-order correlations of vital sign measurements are key to this prediction, which improves the likelihood of early identification of at-risk patients.

Background: Due to the clinical challenges of treatment-resistant depression (TRD), we evaluated the efficacy of mindfulness-based cognitive therapy (MBCT) relative to a structurally equivalent active comparison condition as adjuncts to treatment-as-usual (TAU) pharmacotherapy in TRD. Methods: This single-site, randomized controlled trial compared 8-week courses of MBCT and the Health Enhancement Program (HEP), comprising physical fitness, music therapy and nutritional education, as adjuncts to TAU pharmacotherapy for outpatient adults with TRD. The primary outcome was change in depression severity, measured by percent reduction in the total score on the 17-item Hamilton Depression Rating Scale (HAM-D17), with secondary depression indicators of treatment response and remission. Results: We enrolled 173 adults; mean length of a current depressive episode was 6.8 years (SD = 8.9). At the end of 8 weeks of treatment, a multivariate analysis showed that relative to the HEP condition, the MBCT condition was associated with a significantly greater mean percent reduction in the HAM-D17 (36.6 vs. 25.3%; p = 0.01) and a significantly higher rate of treatment responders (30.3 vs. 15.3%; p = 0.03). Although numerically superior for MBCT than for HEP, the rates of remission did not significantly differ between treatments (22.4 vs. 13.9%; p = 0.15). In these models, state anxiety, perceived stress and the presence of personality disorder had adverse effects on outcomes. Conclusions: MBCT significantly decreased depression severity and improved treatment response rates at 8 weeks but not remission rates. MBCT appears to be a viable adjunct in the management of TRD.

The United States has the most expensive, technologically advanced, and sub-specialized healthcare system in the world, yet it has worse population health status than any other high-income country. Rising healthcare costs, high rates of waste, the continued trend towards chronic non-communicable disease, and the growth of new market entrants that compete with primary care services have set the stage for fundamental change in all of healthcare, driven by a revolution in primary care. We believe that the coming primary care revolution ought to be guided by the following design principles: 1) Payment must adequately support primary care and reward value, including non-visit-based care. 2) Relationships will serve as the bedrock of value in primary care, and will increasingly be fostered by teams, improved clinical operations, and technology, with patients and non-physicians assuming an ever-increasing role in most aspects of healthcare. 3) Generalist physicians will increasingly focus on high-acuity and high-complexity presentations, and primary care teams will increasingly manage conditions that specialists managed in the past. 4) Primary care will refocus on whole-person care, and address health behaviors as well as vision, hearing, dental, and social services. Design based on these principles should lead to higher-value healthcare, but will require new approaches to workforce training.

PURPOSE Depression symptoms are underreported by patients. We thus assessed individuals' reasons for not disclosing depression to their primary care physician. METHODS We conducted a follow-up telephone survey of 1,054 adults who had participated in the California Behavioral Risk Factor Survey System. Respondents were asked about reasons for nondisclosure of depressive symptoms to their pri- mary care physician, depression-related beliefs, and demographic characteristics. Descriptive and inferential statistical procedures were used to characterize per- ceived obstacles to disclosure. RESULTS Of the respondents, 43% reported 1 or more reasons for nondisclosure. The most frequent reason was the concern that the physician would recommend antidepressants (22.9%; 95% confi dence interval, 18.8%-27.5%). Reported rea- sons for nondisclosure of depression varied based on whether the respondent had a history of depression. For example, respondents with no depression history were more likely to believe that depression falls outside the purview of primary care (P = .040) and more likely to fret about being referred to a psychiatrist (P = .036). Respondents with clinically signifi cant depressive symptoms rated 10 of 11 barriers to disclosure as more personally applicable than did those without symptoms (all P values ≤.014). Number of reported disclosure barriers was pre- dicted by demographic characteristics (being female, Hispanic, of low socioeco- nomic status), depression beliefs (depression is stigmatizing and should be under one's control), symptom severity, and absence of a family history of depression. CONCLUSIONS Many adults subscribe to beliefs likely to inhibit explicit requests for help from their primary care physician during a depressive episode. Interven- tions should be developed to encourage patients to disclose their depression symptoms and physicians to ask about depression.

Objective To identify attitudinal and interpersonal barriers to depression care-seeking and disclosure in primary care and in so doing, evaluate the primary care paradigm for depression care in the United States. Methods Fifteen qualitative focus group interviews in three cities. Study participants were English-speaking men and women aged 25–64 with first-hand knowledge of depression. Transcripts were analyzed iteratively for recurring themes. Results Participants expressed reservations about the ability of primary care physicians (PCPs) to meet their mental health needs. Specific barriers included problems with PCP competence and openness as well as patient–physician trust. While many reflected positively on their primary care experiences, some doubted PCPs’ knowledge of mental health disorders and believed mental health concerns fell outside the bounds of primary care. Low-income participants in particular shared stories about the essentiality, and ultimate fragility, of patient-PCP trust. Conclusion Patients with depression may be deterred from care-seeking or disclosure by relational barriers including perceptions of PCPs’ mental health-related capabilities and interests. Practice implications PCPs should continue to develop their depression management skills while supporting vigorous efforts to inform the public that primary care is a safe and appropriate venue for treatment of common mental health conditions.

Diagnostic and treatment delay in depression are due to physician and patient factors. Patients vary in awareness of their depressive symptoms and ability to bring depression-related concerns to medical attention.To inform interventions to improve recognition and management of depression in primary care by understanding patients' inner experiences prior to and during the process of seeking treatment.Focus groups, analyzed qualitatively.One hundred and sixteen adults (79% response) with personal or vicarious history of depression in Rochester NY, Austin TX and Sacramento CA. Neighborhood recruitment strategies achieved sociodemographic diversity.Open-ended questions developed by a multidisciplinary team and refined in three pilot focus groups explored participants' "lived experiences" of depression, depression-related beliefs, influences of significant others, and facilitators and barriers to care-seeking. Then, 12 focus groups stratified by gender and income were conducted, audio-recorded, and analyzed qualitatively using coding/editing methods.Participants described three stages leading to engaging in care for depression - "knowing" (recognizing that something was wrong), "naming" (finding words to describe their distress) and "explaining" (seeking meaningful attributions). "Knowing" is influenced by patient personality and social attitudes. "Naming" is affected by incongruity between the personal experience of depression and its narrow clinical conceptualizations, colloquial use of the word depression, and stigma. "Explaining" is influenced by the media, socialization processes and social relations. Physical/medical explanations can appear to facilitate care-seeking, but may also have detrimental consequences. Other explanations (characterological, situational) are common, and can serve to either enhance or reduce blame of oneself or others.To improve recognition of depression, primary care physicians should be alert to patients' ill-defined distress and heterogeneous symptoms, help patients name their distress, and promote explanations that comport with patients' lived experience, reduce blame and stigma, and facilitate care-seeking.

Older adults have high rates of suicide and typically seek care in primary medical practices. Older adults often do not directly or spontaneously report thoughts of suicide, which can impede suicide prevention efforts. Therefore, the use of additional approaches to suicide risk detection is needed, including the use of screening tools. The objective of this study was to assess whether brief screens for depression have acceptable operating characteristics in identifying suicide ideation among older primary care patients and to examine potential sex differences in the screen's accuracy.We administered the 15-item Geriatric Depression Scale (GDS), which includes a 5-item GDS subscale (GDS-SI) designed to screen for suicide ideation, to a cross-sectional cohort of 626 primary care patients (235 men, 391 women) 65 years of age or older in the Northeastern United States. We assessed presence of suicide ideation with items from the Hamilton Rating Scale for Depression and the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.Patients expressing suicide ideation (n = 69) scored higher on the GDS and GDS-SI than those who did not (n = 557). A GDS cut score of 4 maximized sensitivity (0.754) and specificity (0.815), producing an area under the curve of 0.844 (P.001) and positive and negative predictive values of 0.335 and 0.964, respectively. Optimal cut scores were 5 for men and 3 for women. A GDS-SI cut score of 1 was optimal for the total sample and for both men and women.The GDS and GDS-SI accurately identify older patients with suicide ideation. Research is needed to examine their acceptability and barriers to routine use in primary care.

In the right hands, ultrasound is a safe and helpful diagnostic imaging tool. However, evidence supporting the use of hand-carried ultrasound (HCU) by hospitalist physicians has not kept pace with expanding application of these devices. In spite of its strategic point-of-care benefit, use of this technology by hospitalists may not ultimately translate into improved efficiency and better clinical outcomes. Optimal levels of training in image acquisition and interpretation remain to be established. Novelty, availability, and the results of a few small studies lacking patient-centered outcomes remain insufficient grounds to justify the expanded clinical utilization of these medical imaging devices by nonspecialists.

[This corrects the article DOI: 10.1371/journal.pone.0188088.].

Breast cancer is the most common malignancy and second most common cause of cancer death in women in the US [1]. To date, screen-film mammography (SFM) has been considered the gold standard for breast cancer screening and detection [1]. Over 70% of women in the US over the age of 40 have had a mammogram within the past 2 years [2]. Prior research has investigated the efficacy of SFM at reducing mortality from breast cancer [3–17]. While the interpretation of these results has been hotly debated [18–25], the consensus in recent systematic reviews and practice guidelines is that SFM reduces breast cancer mortality among women who are 50–75 years of age, and may reduce mortality among women aged 40 years and older [26–30]. A series of complex models supports the hypothesis that SFM has contributed to a reduction in breast cancer mortality in the US [31]. Although film mammography is the established diagnostic tool, it has a number of limitations. Breast cancer screening is less effective in younger women than in older women, most likely because younger women have a higher proportion of mammographically dense breast tissue [32– 35]. Up to a third of breast cancers are missed, even though as many as 20 women are called back due to false-positive results for every one cancer identified; this increases patient anxiety and leads to additional breast imaging, radiation exposure, and biopsies. Furthermore, with SFM, image acquisition, storage, and comparison can be cumbersome. As a result, much attention has been devoted to developing improved radiographic techniques for breast cancer screening and evaluation. Full-field digital mammography (FFDM) addresses some of the limitations seen with SFM. It has a wider range of contrast resolution, which holds particular promise for improving the detection of low-contrast lesions in radiographically dense breasts. FFDM allows for the separation of image acquisition, presentation, and storage, thus enabling these tasks to be independently optimized. The implementation of computer-aided detection methods is potentially simplified with FFDM, as there is no longer the separate step of digitizing film mammograms [36]. Computer-aided enhancement of images at computer workstations may also improve the accuracy of mammographic interpretation [37]. FFDM also has the potential to improve workflow by allowing for electronic transmission, storage, and retrieval of the images. Use of this modality may facilitate the interpretation of mammograms, as the images can be obtained locally, but sent to a central location for interpretation by experts at centers that specialize in mammographic interpretation. Digital storage and retrieval may increase the likelihood that comparison images from prior mammograms would be available to aid the radiologist in the interpretation of a new mammogram. Digital images can either be printed on film for review (hard copy) or read on computer monitors (soft copy). Digital image acquisition may improve the signal-to-noise ratio of X-ray detection over a wider range of intensities, as compared to that of film acquisition over the same range [38–40]. There is also the possibility of lower radiation exposure than that required for SFM. In spite of these potential advantages, adoption of a digital approach to mammography has been slow, in part due to the high spatial resolution required by J. A. Tice (&) M. D. Feldman Division of General Internal Medicine, Department of Medicine, University of California, 1701 Divisadero Street, Suite 554, San Francisco, CA 94143-1732, USA e-mail: jtice@medicine.ucsf.edu

BP eer review is faith-based (not evidence-based), slow, wasteful, ineffective, largely a lottery, easily abused, prone to bias, doesn’t detect fraud and irrelevant.^ —Richard Smith, former BMJ editor, remarks to the Royal Society, 20 April 2015 Peer review in academic publishing has come under increasing scrutiny. Richard Smith’s accusations of haplessness and irrelevancy are not universally embraced; however, a growing number of scholars and thought leaders have increasingly questioned accepted practices and supported alternatives, some of which call into question the basic assumptions of the current peer review process. For example, ArXiv now has over 1 million research papers in Mathematics, Physics, Computer Science and similar subjects stored in an electronic archive. There is no peer review process; it is up to the reader to assess the integrity of the methods and conclusions. Other projects have emphasized so-called Bobjective^ peer review focusing on technical soundness rather than importance or originality; community peer review conducted via a preprint depository; an open collaborative process in which a group of peer reviewers share critiques and sign the final review jointly; and granting authors Bownership^ of peer reviews, which can then be shared with subsequent journals to which the paper is submitted. At JGIM, our take on peer review mirrors Churchill’s view of democracy: it is the worst form of scientific quality assurance except for all the others that have been tried. We are fully aware that our review process is not flawless (and in fact we have shown using our own data that it is not), nor are we averse to experimentation (our cooperative venture with the Annals of Internal Medicine is one example: articles reviewed and rejected by Annals can, at the authors’ discretion, be sent directly to JGIM along with the Annals peer reviews). However, we continue to believe that our outstanding group of JGIM reviewers and deputy editors add value to the process of selecting and preparing manuscripts for publication. In 2014–2015, JGIM reviewers volunteered their time and expertise to review about one-third of the approximately 1,500 manuscripts JGIM receives each year. During this period, 845 reviewers provided a total of 1061 reviews with a mean quality score of 4.35 on a scale of 1–6 (as judged by JGIM Deputy Editors). Of these, 191 (25 more than last year) provided at least two reviews and 24 provided three or more. We are indebted to them for their service. Among this group of dedicated peer reviewers, there is a group of top performers who stand out. Reviewers included in this group performed at least two reviews between July 2014 and June 2015, returned all reviews within 30 days, and received a quality score of four or greater on all reviews. An asterisk identifies the 101 reviewers who met these criteria. We congratulate them on their service to the academic community and thank them for their efforts on behalf of the journal. In our first BFrom the Editor’s Desk^ in January 2010, we wrote: BIn steering the journal forward...we will be guided by the principle that JGIM is a journal for generalists committed to improving the world in which they practice and teach. Thus, we will seek to publish data derived from settings where real patients live and real doctors practice, as well as reviews and tools that clinicians and educators can use to do their jobs more effectively, efficiently, and humanely.^ We remain committed to this vision and hope that you, our readers, will join us by continuing to submit to, review for, read, and respond to JGIM. Whether in print or on-line, JGIM is your journal and we need to hear from you. Send us an e-mail and share your thoughts on the future of peer review, medical journalism, and general internal medicine. 30(12):17 – 17 21

Objective To identify factors associated with participant consent to record visits; to estimate effects of recording on patient–clinician interactions. Methods Secondary analysis of data from a randomized trial studying communication about depression; participants were asked for optional consent to audio record study visits. Multiple logistic regression was used to model likelihood of patient and clinician consent. Multivariable regression and propensity score analyses were used to estimate effects of audio recording on 6 dependent variables: discussion of depressive symptoms, preventive health, and depression diagnosis; depression treatment recommendations; visit length; visit difficulty. Results Of 867 visits involving 135 primary care clinicians, 39% were recorded. For clinicians, only working in academic settings (P = 0.003) and having worked longer at their current practice (P = 0.02) were associated with increased likelihood of consent. For patients, white race (P = 0.002) and diabetes (P = 0.03) were associated with increased likelihood of consent. Neither multivariable regression nor propensity score analyses revealed any significant effects of recording on the variables examined. Conclusion Few clinician or patient characteristics were significantly associated with consent. Audio recording had no significant effect on any of the 6 dependent variables examined. Practice implications Benefits of recording clinic visits likely outweigh the risks of bias in this setting.

I saw a T-shirt the other day that said, “Don’t believe everything you think.” Funny, and ironically thought-provoking. If we can’t believe what we think, what can we believe? That afternoon I had seen a 72-year-old patient, Mr. B., who recounted to me that the day prior to his visit he had confused night with day. Up to that point (and subsequently), Mr. B. had been doing well, with no overt symptoms of cognitive impairment. The day before our visit, however, he reported that he had taken his usual evening shower around 6 p.m. (his second of the day per his routine); when he went into the shower, he knew it was evening—when he emerged 10 min later, toweled off, got dressed and went downstairs, he had shifted forward 12 h and thought it was actually morning. As he told us, the evening and morning light were similar, so there were no obvious external clues to orient him. He went downstairs, poured himself his morning cereal and turned on the BBC news. It was only when the phone rang and his friends informed him he was late for his weekly card game that he realized it was actually 8 p.m. and not 8 a.m. In less dramatic fashion, we in general medicine are increasingly questioning some long-held beliefs about how to deliver high-quality care to patients. Deeply held assumptions (for example, that quality care depends on a robust relationship between one doctor and his or her patients) are giving way to new and transformational experiments in delivery of care. This issue of JGIM features several such examples. Schwartz et al.1 report on a cluster-randomized controlled trial incorporating panel management assistants into primary care teams, with and without panel management education, in the context of a VA Patient Aligned Care Team, or PACT (the VA equivalent of a patient-centered medical home [PCMH]). The goal was to improve management of hypertension and smoking cessation. The panel management assistants were college-educated non-clinicians, and they were given responsibility for communicating with patients for referrals, sending mail reminders, and conducting motivational interviews by phone to reinforce behavior change. In the end, the intervention did not improve clinical outcomes, but there will no doubt be an increasing focus on population health and away from reliance on the doctor–patient dyad to improve health. Another study in this issue of JGIM examined the impact of the PCMH on outcomes in primary care. In a qualitative study, Fontaine et al.2 interviewed physicians and others at nine primary care practices in Minnesota in order to explore the facilitators and barriers to establishing a successful PCMH that these diverse practices had encountered. Among other themes, they found that increasing patient involvement in care through mechanisms such as patient and family advisory councils was key to successful implementation of a PCMH. Now considered essential, inviting patients and families to participate in measures to improve clinic policies and procedures would have been considered strange not long ago. Another model for improving population health, not dissimilar to panel management assistants, involves the use of “patient navigators.” Balaban et al.3 report on a randomized controlled trial that used patient navigators to reduce readmissions among high-risk, low-socioeconomic-status patients. Language-concordant panel managers provided coaching and other assistance to help patients manage the transition from hospital to home, with the main outcome being 30-day hospital readmissions. As in the Schwartz study, this study failed to demonstrate an overall improvement in the primary outcome, but did decrease readmissions in older patients while increasing them in younger patients. Like many of these early interventions in population health, there are more questions raised than answered, but undoubtedly, a new paradigm is emerging for how best to care for primary care patients. Unlike Mr. B., who only temporarily lost his orientation, this new paradigm will require a permanent change not only in what we think, but also in what we believe.

In the film Cool Hand Luke, Paul Newman stars as BLuke,^ a rebellious prisoner in a southern prison camp. Unable to tolerate the confinement of prison, Luke attempts an escape but is soon captured, returned to the prison and put in chains by the captain who aims to make an example of him in front of the others. Even in this vulnerable position, Luke refuses to give in and talks back to the captain, who, enraged, beats him and utters one of the most oft quoted lines in movie history

Background"Difficult visits" are common in primary care and may contribute to primary care provider (PCP) career dissatisfaction and burnout. Patient requests occur in approximately half of primary care visits and may be a source of clinician-patient miscommunication or conflict, contributing to perceived visit difficulty.ObjectiveWe aimed to determine associations between types of patient requests and PCP-perceived visit difficulty.DesignThis was an observational study, nested in a multicenter randomized trial of depression engagement interventions.SubjectsWe included 824 patient visits within 135 PCP practices in Northern California occurring from June 2010 to March 2012.Main measuresPCP-perceived visit difficulty was quantified using a three-item scale (relative visit difficulty, amount of effort required, and amount of time required; Cronbach's α = 0.81). Using linear regression, the difficulty scale (score range 0-2 from least to most difficult) was modeled as a function of: patient requests for diagnostics tests, pain medications, and specialist referrals; PCP perception of likely depression or likely substance abuse; patient sociodemographics, comorbidity, depression; PCP characteristics and practice setting.ResultsPatients requested diagnostic tests, pain medications, and specialist referrals in 37.2, 20.0 and 30.0% of visits, respectively. After adjustment for patient medical and psychiatric complexity, perceived difficulty was significantly higher when patients requested diagnostic tests [parameter estimate (PE) 0.11, (95% CI: 0.03, 0.20)] but not when patients requested pain medications [PE -0.04 (95% CI: -0.15, 0.08)] or referrals [PE 0.04 (95% CI: -0.07, 0.25)].ConclusionsPCP-perceived visit difficulty is associated with patient requests for diagnostic tests, but not requests for pain medications or specialist referrals. In this era of "choosing wisely," PCPs may be challenged to respond to diagnostic test requests in an evidence-based manner, while maintaining the provider-patient relationship and PCP career satisfaction.

Providing antidepressant information to patients may foster greater adherence to therapy.To assess physician information-giving while prescribing antidepressants, and to identify factors that influence the provision of information.Randomized experiment using standardized patients (SPs). Standardized patients roles were generated by crossing 2 clinical conditions (major depression or adjustment disorder) with 3 medication request types (brand-specific, general, or none).One hundred and fifty-two general internists and family physicians recruited from solo and group practices and health maintenance organizations; cooperation rates ranged from 53% to 61%.We assessed physician information-giving by analyzing audio-recordings of interactions between physicians and SPs, and collected physician background information by survey. Generalized estimating equations were used to examine the influence of patient and physician factors on physicians' provision of information.One hundred and one physicians prescribed antidepressants, accounting for 131 interactions. The mean age of physicians was 46.3 years; 69% were males. Physicians mentioned an average of 5.7 specific topics of antidepressant-related information (of a possible maximum of 11). The most frequently mentioned topic was purpose (96.1%). Physicians infrequently provided information about the duration of therapy (34.9%) and costs (21.4%). Standardized patients who presented with major depression received less information than those with adjustment disorder, and older and solo/private practice physicians provided significantly less information to SPs.Physicians provide limited information to patients while prescribing antidepressants, often omitting critical information that may promote adherence. Mechanisms are needed to ensure that patients receive pertinent antidepressant information.

Behavioral health carve-out arrangements create financial disincentives for primary care providers (PCPs) to treat depression. A novel collaboration between a primary care practice, a health insurer, and a managed behavioral health organization (MBHO) allows PCPs to receive reimbursement and schedule longer appointments to care for depressed patients. This article describes the details of the arrangement, and early results of this collaboration. Early results find that financial incentives are critical for implementation, but that time incentives do not appear to motivate PCPs. Sustainability of this model will require participation of multiple primary care practices, health insurers, and MBHOs.

Communication skills and the psychosocial dimensions of patient care are increasingly taught in medical schools and generalist residency programs. Evidence suggests they are not reinforced or optimally implemented in clinical training. The authors present the product of an iterative process that was part of a national faculty development program and involved both experts and generalist teachers concerning teaching psychosocial medicine while precepting medical students and residents in clinical settings. Using scientific evidence, educational theory, and experience, the authors developed recommendations, presented them in workshops, and revised them based on input from other experts and teachers, who gave feedback and added suggestions. The results are practical, expert consensus recommendations for clinical preceptors on how to teach and reinforce learning in this area. General skills to use in preparing the trainee for improved psychosocial care are organized into the mnemonic "CAARE MORE": Connect personally with the trainee; Ask psychosocial questions and Assess the trainee's knowledge/attitudes/skills/behaviors; Role model desired attitudes/skills/behaviors; create a safe, supportive, enjoyable learning Environment; formulate specific Management strategies regarding psychosocial issues; Observe the trainee's affect and behavior; Reflect and provide feedback on doctor-patient and preceptor-trainee interactions; and provide Educational resources and best Evidence. The preceptor-trainee teaching skills that are recommended parallel good doctor-patient interaction skills. They can be used during both preceptor-trainee and preceptor-trainee-patient encounters. Important common psychosocial situations that need to be managed in patients include substance abuse, depression, anxiety, somatoform disorder, physical and sexual abuse, and posttraumatic stress disorder. For these problems, where high-level evidence exists, specific psychosocial questions for screening and case finding are provided.

I n his book Start with Why: How Great Leaders Inspire Everyone to Take Action and in his well known TED talk, Simon Sinek, leadership author and consultant, argues that what distinguishes great leaders and organizations is their focus on the ‘why’ of the work and not just on the ‘what’ and the ‘how’. In fact, great leaders and organizations start with the ‘why’ and then move to the how and the what—while more conventional organizations move the other way; they start with the ‘what’ and then move to the ‘how’ and may never get around to the ‘why’. Sinek gives the example of Martin Luther King, Jr., who has inspired millions with his words. Dr. King’s ‘what’ was to eliminate race-based disparities and discrimination; others shared the same goal. His ‘how’ was through non-violent protests, a tactic he borrowed from Gandhi and others. However, It was Dr. King’s articulation of the ‘why’ that made him one of the great leaders of the twentieth century as illustrated by his Bdream^ that some day his four children would be judged not by the color of their skin, but Bby the content of their character.^ Sinek points to Apple as a company that built its success by starting with the ‘why’. Apple products fundamentally perform the same functions as their competitors (the ‘what’), and while Apple may pay particular attention to the design (the ‘how’), these features do not distinguish Apple products from those of Microsoft, Samsung or others. What distinguishes Apple, in Sinek’s view, is their attention to the ‘why’. He argues that Apple starts with the premise that to use their products is to challenge the status quo. He puts it this way in an imaginary ad from Apple: BWith everything we do, we aim to challenge the status quo. We aim to think differently. Our products are user friendly, beautifully designed, and easy to use. We just happen to make great computers. Want to buy one?^ So what are the lessons for the work we do in general internal medicine? In this issue of JGIM, several papers describe different approaches to working with patients around behavior change. To be effective, each must help patients imagine a future that is different and generally better than what they are currently experiencing or they will not be inspired to change. In this issue, Palacio et al. report on a systematic review of the effectiveness of motivational interviewing (MI) on medication adherence. They point out that lack of adherence to medication is a major problem in the US causing excess morbidity and mortality and contributing over $1 billion to health care costs. Motivational interviewing is a non-judgmental technique that helps patients to change destructive behavior by facilitating and engaging their intrinsic motivation. In a sense, it helps patients imagine what change would be like by allowing them to get in touch with their own personal motivations (their ‘why’) and to consider what would be different with change. Overall, Palacio et al. found that MI improves medication adherence, especially in minority populations, although there was significant variation in mode of delivery and adherence measures that may limit the generalizability of their findings. Danan et al. report on a randomized trial of 3006 current smokers at four Veterans Affairs Medical Centers (VA). The intervention arm included proactive outreach consisting of a mailed invitation followed by telephone outreach to participate in smoking cessation services as well as access to pharmacotherapy. The usual care arm had access to the usual VA smoking cessation services as well as telephone quitlines. They were interested in the relationship between the baseline stage of change treatment use and smoking cessation. Perhaps not surprisingly, the uptake of smoking cessation treatments increased with higher baseline stage of change (smokers in contemplation were more likely to engage in treatment than pre-contemplators) as were smokers in the ‘proactive’ (intervention) arm regardless of the stage of change. They conclude that proactive outreach to smokers, even those not planning to quit, is an effective strategy to enhance smoking cessation. In spite of significant technological advances over the past decade, organ transplantation continues to be stymied by low rates of organ donation. As Thornton et al. point out in this issue, many patients die while waiting for a transplant. The decision to donate is deeply personal and driven by values as well as by more pragmatic factors such as accurate information to address generally unfounded fears. The authors report on a randomized trial of an organ donation video conducted just prior to a primary care visit. Published online May 26, 2016

The HIV/AIDS surveillance system in Japan, which began collecting data on the number of AIDS patients in 1984 and the number of HIV-infected persons in 1987, has played an important role in monitoring the trend and magnitude of Japan's HIV/AIDS epidemic and its distribution across various population subgroups. However, the system lacks any personal identifiers, making it impossible to eliminate duplication or to track cases for disease progression. It also does not permit the identification of the residence of HIV-infected persons because the residence of only the reporting physician is documented under the New Infectious Diseases Control Law, effective since April 1, 1999. The number of people with HIV/AIDS in Japan continues to grow. Among youth, sexually transmitted diseases, induced abortion, and sexual activities have shown a marked increase since the mid-1990s. Behavioral risk of infection for both injection drug users (IDUs) and men who have sex with men (MSM) remains alarmingly high. Accurate monitoring of infection rates is critical to the planning and evaluation of treatment, care and prevention programs. Japan should restructure its HIV/AIDS surveillance system to more accurately monitor the HIV/AIDS epidemic and related risk behaviors.

Background: Use of brief depression symptom measures for identifying or screening cases may help to address depression undertreatment, but whether it also leads to diagnosis and treatment of patients with few or no symptoms- a group unlikely to have major depression or benefit from antidepressants-is unknown. We examined the associations of use of a brief depression symptom measure with depression diagnosis and antidepressant recommendation and prescription among patients with few or no depression symptoms.Methods: We conducted exploratory observational analyses of data from a randomized trial of depression engagement interventions conducted in primary care offices in California. Analyses focused on participants scoring