David C. Dugdale

Relationship, Communication, and Efficiency in the Medical Encounter Creating a Clinical Model From a Literature Review

BACKGROUND While there is consensus about the value of communication skills, many physicians complain that there is not enough time to use these skills. Little is known about how to combine effective relationship development and communication skills with time management to maximize efficiency. Our objective was to examine what physician-patient relationship and communication skills enhance efficiency. DATA SOURCES We conducted searches of PubMed, EMBASE, and PsychINFO for the date range January 1973 to October 2006. We reviewed the reference lists of identified publications and the bibliographies of experts in physician-patient communication for additional publications. STUDY SELECTION From our initial group of citations (n = 1146), we included only studies written in English that reported original data on the use of communication or relationship skills and their effect on time use or visit length. Study inclusion was determined by independent review by 2 authors (L.B.M. and D.C.D.). This yielded 9 publications for our analysis. DATA EXTRACTION The 2 reviewers independently read and classified the 9 publications and cataloged them by type of study, results, and limitations. Differences were resolved by consensus. RESULTS Three domains emerged that may enhance communication efficiency: rapport building, up-front agenda setting, and acknowledging social or emotional clues. CONCLUSIONS Building on these findings, we offer a model blending the quality-enhancing and time management features of selected communication and relationship skills. There is a need for additional research about communication skills that enhance quality and efficiency.

Staphylococcus aureus bacteremia in patients with Hickman catheters

PURPOSE Determination of outcome and prognostic variables associated with Staphylococcus aureus bacteremia in patients with Hickman catheters. PATIENTS AND METHODS At the University of Washington Medical Center, 37 patients with Hickman catheters and S. aureus bacteremia were studied by retrospective chart review. Clinical features associated with each episode of infection were determined, and the relationships among clinical features, therapy, and outcomes were explored. RESULTS Only 18% of all Hickman catheter-associated S. aureus bacteremias and only 10% of those cases with exit site infections were cured without catheter removal. In seven of 41 episodes (17%), death or bacteremic relapse occurred. The best prognosis was found in infections with a low blood culture colony count (less than 1 colony/mL). CONCLUSION Hickman catheter-associated bacteremia due to S. aureus has a worse prognosis than other Hickman catheter-associated bacteremias. Early catheter removal should be considered except in cases with a remote, noncatheter focus of infection or in infections with no catheter-related physical signs and blood culture colony counts of less than 1/mL.

Redesigning the practice model for general internal medicine. A proposal for coordinated care: A policy monograph of the Society of General Internal Medicine

General Internal Medicine (GIM) faces a burgeoning crisis in the United States, while patients with chronic illness confront a disintegrating health care system. Reimbursement that rewards using procedures and devices rather than thoughtful examination and management, plus onerous administrative burdens, are prompting physicians to pursue specialties other than GIM. This monograph promotes 9 principles supporting the concept of Coordinated Care—a strategy to sustain quality and enhance the attractiveness and viability of care delivered by highly trained General Internists who specialize in the longitudinal care of adult patients with acute and chronic illness. This approach supplements and extends the concept of the Advanced Medical Home set forth by the American College of Physicians. Specific components of Coordinated Care include clinical support, information management, and access and scheduling. Success of the model will require changes in the payment system that fairly reimburse physicians who provide leadership to teams that deliver high quality, coordinated care.General Internal Medicine (GIM) faces a burgeoning crisis in the United States, while patients with chronic illness confront a disintegrating health care system. Reimbursement that rewards using procedures and devices rather than thoughtful examination and management, plus onerous administrative burdens, are prompting physicians to pursue specialties other than GIM. This monograph promotes 9 principles supporting the concept of Coordinated Care—a strategy to sustain quality and enhance the attractiveness and viability of care delivered by highly trained General Internists who specialize in the longitudinal care of adult patients with acute and chronic illness. This approach supplements and extends the concept of the Advanced Medical Home set forth by the American College of Physicians. Specific components of Coordinated Care include clinical support, information management, and access and scheduling. Success of the model will require changes in the payment system that fairly reimburse physicians who provide leadership to teams that deliver high quality, coordinated care.

Integrating Behavioral Health into Primary Care

Abstract Depression is one of the more common diagnoses encountered in primary care, and primary care in turn provides the majority of care for patients with depression. Many approaches have been tried in efforts to improve the outcomes of depression management. This article outlines the partnership between the University of Washington (UW) Neighborhood Clinics and the UW Department of Psychiatry in implementing a collaborative care approach to integrating the management of anxiety and depression in the ambulatory primary care setting. This program was built on the chronic care model, which utilizes a team approach to caring for the patient. In addition to the patient and the primary care provider (PCP), the team included a medical social worker (MSW) as care manager and a psychiatrist as team consultant. The MSW would manage a registry of patients with depression at a clinic with several PCPs, contacting the patients on a regular basis to assess their status, and consulting with the psychiatrist on a weekly basis to discuss patients who were not achieving the goals of care. Any recommendation (eg, a change in medication dose or class) made by the psychiatrist was communicated to the PCP, who in turn would work with the patient on the new recommendation. This collaborative care approach resulted in a significant improvement in the number of patients who achieved care plan goals. The authors believe this is an effective method for health systems to integrate mental health services into primary care. (Population Health Management 2016;19:81–87)

The Efficacy of Screening Colonoscopy—Reply

was also no evidence of inferiority of colonoscopy, I felt I should try to be a “good patient” that one time, since it is not easy to be my physician. One should not underestimate the difficulty that even an educated, informed patient may encounter in attempting to choose less instead of more. Finally, I should note that I received a letter 3 years after my first colonoscopy telling me it was time to schedule a follow-up procedure. Consulting the guidelines applicable to follow-up of a single, 6-mm adenomatous polyp, I chose to ignore the letter for 2 years.

Common problems in outpatient management of patients with diabetes in the age of insulin analogues

Most patients with diabetes are managed in an outpatient primary care setting. This article reviews common dilemmas in outpatient insulin therapy and presents the evidence regarding the rational use of insulin therapy and combination oral agent-insulin therapy.