Daniel G. Tobin

Nonmedical Use of Opioid Analgesics Obtained Directly From Physicians: Prevalence and Correlates

Koestner, Torres, Thompson, Shintani, Han, Schnelle, Fick, Ely, and Kripalani. Statistical analysis: Torres, Thompson, and Shintani. Obtained funding: Ely. Administrative, technical, and material support: Morandi, Neal, and Fick. Study supervision: Morandi, Vasilevskis, Pandharipande, Girard, Solberg, Han, Schnelle, Ely, and Kripalani. Financial Disclosure: Dr Ely has received honoraria from GlaxoSmithKline, Pfizer, Lilly, Hospira, and Aspect. Dr Kripalani is a consultant to and holds equity in PictureRx LLC and has received honoraria from Pfizer Inc. Funding/Support: Dr Pandharipande is supported by the VA Clinical Science Research and Development Service (VA Career Development Award). Dr Ely is supported by the VA Clinical Science Research and Development Service (VA Merit Review Award) and the National Institutes of Health (NIH) (grant AG027472). Dr Girard is supported by the NIH (grant AG034257). Drs Ely and Girard are both supported by the GRECC, VA Medical Center, Tennessee Valley Healthcare System. Dr Fick acknowledges partial support for this work by Award No. R01 NR011042 from the National Institute of Nursing Research (NINR). Dr Kripalani was supported by the NIH (grant K23 HL077597). Role of the Sponsors: The funding sources did not participate in the planning, collection, analysis, or interpretation of data or in the decision to submit for publication. Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the NINR or NIH.

Continuity of Care as an Educational Goal but Failed Reality in Resident Training: Time to Innovate

C ontinuity of care between a patient and a physician is a core aspiration. However, we rarely achieve it in residency training, even though benefits of care continuity accrue in several realms, including preventive services, clinical outcomes in chronic disease, patient trust and satisfaction, and economic efficiencies. For trainees, benefits include participatory learning about the clinical courses of diseases and their patients’ experience of illness, understanding the value of a continuous relationships with patients, and developing professional responsibility. In the 1990s, threats to continuity of care included closed managed care programs with restrictive physician panels, exacerbated by frequent changes in employee insurance. Contemporary factors pose new disruptions to care continuity, including the hospitalist movement, resident duty hour limits, team coverage in the patient-centered medical home, and retail clinics. In this article, we explore the impact of these disruptions in continuity on resident education, and we propose strategies for improvement in the ambulatory, hospital, and transitional and alternate care settings.

Prescribing opioids in primary care: Safely starting, monitoring, and stopping.

Chronic noncancer pain is common and often managed in the outpatient setting with chronic opioid therapy, even though the efficacy of this approach is uncertain and adverse effects are common. Some patients report meaningful benefit from opioids, but prescription drug abuse has reached epidemic proportions, and many suffer harm from opioid misuse, abuse, and diversion. Primary care providers and their care teams often struggle to balance these risks and benefits with little outside support. The authors review common challenges when starting, monitoring, and discontinuing opioids, and offer strategies for risk-reduction and patient communication. Prescription drug abuse has reached epidemic proportions. Some patients benefi t from opioids, but many suffer harm.

Pain and Addiction in Specialty and Primary Care: The Bookends of a Crisis

Specialists and primary care physicians play an integral role in treating the twin epidemics of pain and addiction. But inadequate access to specialists causes much of the treatment burden to fall on primary physicians. This article chronicles the differences between treatment contexts for both pain and addiction — in the specialty and primary care contexts — and derives a series of reforms that would empower primary care physicians and better leverage specialists.

Breaking the pain contract: A better controlled-substance agreement for patients on chronic opioid therapy

“Pain contracts” for patients receiving long-term opioid therapy, though well-intentioned, often stigmatize the patient and erode trust between patient and physician. This article discusses how to improve these agreements to promote adherence, safety, trust, and shared decision-making. Common limitations of current pain treatment “contracts,” and strategies to improve them.

Implementing the patient-centered medical home in residency education.

Background: In recent years, physician groups, government agencies and third party payers in the United States of America have promoted a Patient-centered Medical Home (PCMH) model that fosters a team-based approach to primary care. Advocates highlight the model′s collaborative approach where physicians, mid-level providers, nurses and other health care personnel coordinate their efforts with an aim for high-quality, efficient care. Early studies show improvement in quality measures, reduction in emergency room visits and cost savings. However, implementing the PCMH presents particular challenges to physician training programs, including institutional commitment, infrastructure expenditures and faculty training. Discussion: Teaching programs must consider how the objectives of the PCMH model align with recent innovations in resident evaluation now required by the Accreditation Council of Graduate Medical Education (ACGME) in the US. This article addresses these challenges, assesses the preliminary success of a pilot project, and proposes a viable, realistic model for implementation at other institutions.

A rational approach to opioid use disorder in primary care

Treating addiction is quickly becoming part of primary care. Clinicians can no longer turn a blind eye toward this problem.

Pharmacotherapy for Alcohol Use Disorder

Alcohol use disorder is a common, destructive, and undertreated disease. As understanding of alcohol use disorder has evolved, so has our ability to manage patients with pharmacotherapeutic agents in addition to nondrug therapy, including various counseling strategies. Providers now have a myriad of medications, both approved and not approved by the US Food and Drug Administration, to choose from and can personalize care based on treatment goals, comorbidities, drug interactions, and drug availability. This review explores these treatment options and offers the prescriber practical advice regarding when each option may or may not be appropriate for a specific patient.

Factors Affecting Resident Satisfaction in Continuity Clinic—a Systematic Review

PurposeIn recent years, with an increasing emphasis on time spent in ambulatory training, educators have focused attention on improving the residents’ experience in continuity clinic. The authors sought to review the factors associated with physician trainee satisfaction with outpatient ambulatory training.MethodsA systematic literature review was conducted for all English language articles published between January 1980 and December 2016 in relevant databases, including Medline (medicine), CINAHL (nursing), PSYCHinfo (psychology), and the Cochrane Central Register of Controlled Clinical Trials. Search terms included internship and residency, satisfaction, quality of life, continuity of care, ambulatory care, and medical education. We included studies that directly addressed resident satisfaction in the ambulatory setting through interventions that we considered reproducible.ResultsThree hundred fifty-seven studies were reviewed; 346 studies were removed based on exclusion criteria with 11 papers included in the final review. Seven studies emphasized aspects of organizational structure such as block schedules, working in teams, and impact on resident-patient continuity (continuity between resident provider and patient as viewed from the provider’s perspective). Four studies emphasized the importance of a dedicated faculty for satisfaction. The heterogeneity of the studies precluded aggregate analysis.ConclusionsClinic structures that limit inpatient and outpatient conflict and enhance continuity, along with a dedicated outpatient faculty, are associated with greater resident satisfaction. Implications for further research are discussed.

Modifying the Primary Care Exception Rule to Require Competency-Based Assessment.

Teaching residents to practice independently is a core objective of graduate medical education (GME). However, billing rules established by the Centers for Medicare and Medicaid Services (CMS) require that teaching physicians physically be present in the examination room for the care they bill, unless the training program qualifies for the Primary Care Exception Rule (PCER). Teaching physicians in programs that use this exception can bill for indirectly supervised ambulatory care once the resident who provides that care has completed six months of training. However, CMS does not mandate that programs assess or attest to residents’ clinical competence before using this rule. By requiring this six-month probationary period, the implication is that residents are adequately prepared for indirectly supervised practice by this time. As residents’ skill development varies, this may or may not be true. The PCER makes no attempt to delineate how residents’ competence should be assessed, nor does the GME community have a standard for how and when to make this assessment specifically for the purpose of determining residents’ readiness for indirectly supervised primary care practice. In this Perspective, the authors review the history and current requirements of the PCER, explore its limitations, and offer suggestions for how to modify the teaching physician billing requirements to mandate the evaluation of residents’ competence using the existing milestones framework. They also recommend strategies to standardize this process of evaluation and to develop benchmarks across training programs.