Diane S. Morse

Physician Responses to Ambiguous Patient Symptoms

AbstractOBJECTIVE: To examine how primary care physicians respond to ambiguous patient symptom presentations. DESIGN: Observational study, using thematic analysis within a large cross-sectional study employing standardized patients (SPs), to describe physician responses to ambiguous patient symptoms and patterns of physician-patient interaction. SETTING: Community-based primary care offices within a metropolitan area. PARTICIPANTS: Twenty-three primary care physicians (internists and family physicians). METHOD: Participating physicians had 2 unannounced SP visits randomly inserted into their daily practice schedules and the visits were audiotaped and transcribed. A coding system focusing on physician responses to concerned patients presenting with ambiguous symptoms was developed through an inductive process. Thematic analyses were then applied to coded data. RESULTS: Physicians’ responses to ambiguous symptoms were categorized into 2 primary patterns: high partnering (HP) and usual care (UC). HP was characterized by greater responsiveness to patients’ expression of concern, positivity, sensitivity to patients’ clues about life circumstances, greater acknowledgment of symptom ambiguity, and solicitation of patients’ perspectives on their problems. UC was characterized by denial of ambiguity and less inclusion of patients’ perspectives on their symptoms. Neither HP physicians nor UC physicians actively included patients in treatment planning. CONCLUSIONS: Primary care physicians respond to ambiguity by either ignoring the ambiguity and becoming more directive (UC) or, less often, by acknowledging the ambiguity and attempting to explore symptoms and patient concerns in more detail (HP). Future areas of study could address whether physicians can learn HP behaviors and whether HP behaviors positively affect health outcomes.

They told me to leave: how health care providers address intimate partner violence.

Background: Intimate partner violence (IPV) victims frequently seek medical treatment, though rarely for IPV. Recommendations for health care providers (HCPs) include IPV screening, counseling, and safety referral. The objective of this study was to report womens experiences discussing IPV with HCPs. Methods: This study used structured interviews with women reporting IPV discussions with their HCP; descriptive analyses and bivariate and multivariate analyses were performed, and association with patient demographics and substance abuse was reviewed. We included women from family court; a community-based, inner-city primary care practice; and a tertiary care-based, outpatient psychiatric practice. Results: A total of 142 women participated: 44 from family court (31%), 62 from a primary care practice (43.7%), and 36 from a psychiatric practice (25.4%). Fifty-one percent (n = 72) of patients reported that HCPs knew of their IPV. Of those, 85% (n = 61) told a primary care provider. Regarding IPV attitudes, 85% (n = 61) found their HCP open, and 74% (n = 53) found their HCP knowledgeable. Regarding approaches, 71% (n = 51) believed their HCP advocated leaving the relationship. Whereas 31% (n = 22) received safety information, only 8% (n = 6) received safety information and perceived their HCP as not advocating leaving the abusive relationship. Conclusions: Half of participants disclosed IPV to their HCPs, and most perceived their provider advocated them leaving the relationship. Only 31% reported that HCPs provided safety planning despite increased risks associated with leaving. We suggest HCPs improve safety planning with patients who disclose IPV.

An effect that is deeper than beating: family violence in Jordanian women.

This study informs health care approaches to gender-based family violence through focus groups with Jordanian women. The authors conducted a thematic qualitative analysis of 12 focus groups among 70 married, divorced, or widowed women about their experiences and beliefs regarding family violence. Five themes relevant to health care providers were identified. Three of the themes addressed participant-perceived causes of gender-based family violence: (1) unmet gender role expectations; (2) stigma and social norms; and (3) extended family roles. The fourth theme reflected effects on victims. The fifth theme reflected protective qualities and help-seeking behaviors. The themes identified in the analysis revealed multiple ways that gender-based family violence can contribute to health problems and that it can be kept secret by Jordanian women as patients. Potential clues are described for the violence which may not be typically explored in a medical encounter. Additional ways that Jordanian families may seek help from other family or clergy instead of police and family violence agencies are described. Implications of these results for health care providers who care both for Jordanians and Arab immigrants in Western cultures are discussed.

Intimate Partner Violence Resource Materials Assessment of Information Distribution

Objective: To determine the educational impact of placing partner violence resource information in a medical setting. Method: A cross-sectional study with a structured interview. Setting: Emergency department (ED) in an urban academic medical center. Participants: adult patients and visitors. Interventions: Educational materials and community resource information. Results: 51 patients and 71 visitors (N = 122) met the inclusion criteria and consented to enrollment during a 2-week study period. Of the participants, 71% were female and 29% were male. Sixty-five (53%) of the participants noticed the literature or cards. Ten (8%) read the materials. Seven (6%) retained a copy of the literature. Nineteen (16%) of the participants acknowledged knowing someone who could benefit from the information. Nine (7%) revealed that some of the information was new to them. Conclusions: Placing intimate partner violence resource pamphlets and cards in a medical setting is one means of educating the community and promoting violence prevention.

Structured practice opportunities with a mnemonic affect medical student interviewing skills for intimate partner violence.

Background: Low rates of partner violence inquiry and detection are reported in the medical setting. Purpose: To determine if a teaching module with a mnemonic improves interviewing skills. Method: Prospective randomized trial. A total of 43 medical students were assigned to either the intervention group (teaching module with guided discussion and practice highlighting use of a mnemonic) or the control group (general discussion and provision of the mnemonic at the end of the session). These students subsequently interviewed simulated patients. Results: A total of 75% of the intervention group and 62% of the control group reported the mnemonic was helpful. A total of 68% of the intervention group and 45% of the control group asked a direct question about partner violence. Students who obtained a history of abuse consistently asked direct, nonjudgmental question(s). Conclusions: Students learn to perform desired interviewing skills more frequently when they have the benefit of guided discussion, practice, and memory aids.

Finding the loopholes: a cross-sectional qualitative study of systemic barriers to treatment access for women drug court participants

BackgroundTherapeutic diversion courts seek to address justice-involved participants’ underlying problems leading to their legal system involvement, including substance use disorder, psychiatric illness, and intimate partner violence. The courts have not addressed systemic hurdles, which can contribute to a cycle of substance use disorder and recidivism, which in turn hinder health and wellness. The study purpose is to explore the systemic issues faced by women participants in drug treatment court from multiple perspectives to understand how these issues may relate to health and wellness in their lives.MethodsQualitative thematic framework analysis of five separate focus groups consisting of female drug treatment court participants, community providers, and court staff (n = 25). Themes were mapped across the socio-ecological framework and contextualized according to social determinants of health.ResultsNumerous systemic factors impacted women’s access to treatment. Laws and legal policies (governance) excluded those who could potentially have benefitted from therapeutic court and did not allow consideration of parenting issues. Macroeconomic policies limit housing options for those with convictions. Social policies limited transportation, education, and employment options. Public policies limited healthcare and social protection and ability to access available resources. Culture and societal values, including stigma, limited treatment options.ConclusionsBy understanding the social determinant of health for women in drug treatment court and stakeholder’s perceptions, the legal system can implement public policy to better address the health needs of women drug court participants.

Humoral Dysregulation Associated with Increased Systemic Inflammation among Injection Heroin Users

Background Injection drug use is a growing major public health concern. Injection drug users (IDUs) have a higher incidence of co-morbidities including HIV, Hepatitis, and other infections. An effective humoral response is critical for optimal homeostasis and protection from infection; however, the impact of injection heroin use on humoral immunity is poorly understood. We hypothesized that IDUs have altered B cell and antibody profiles. Methods and Findings A comprehensive systems biology-based cross-sectional assessment of 130 peripheral blood B cell flow cytometry- and plasma- based features was performed on HIV-/Hepatitis C-, active heroin IDUs who participated in a syringe exchange program (n = 19) and healthy control subjects (n = 19). The IDU group had substantial polydrug use, with 89% reporting cocaine injection within the preceding month. IDUs exhibited a significant, 2-fold increase in total B cells compared to healthy subjects, which was associated with increased activated B cell subsets. Although plasma total IgG titers were similar between groups, IDUs had significantly higher IgG3 and IgG4, suggestive of chronic B cell activation. Total IgM was also increased in IDUs, as well as HIV Envelope-specific IgM, suggestive of increased HIV exposure. IDUs exhibited numerous features suggestive of systemic inflammation, including significantly increased plasma sCD40L, TNF-α, TGF-α, IL-8, and ceramide metabolites. Machine learning multivariate analysis distilled a set of 10 features that classified samples based on group with absolute accuracy. Conclusions These results demonstrate broad alterations in the steady-state humoral profile of IDUs that are associated with increased systemic inflammation. Such dysregulation may impact the ability of IDUs to generate optimal responses to vaccination and infection, or lead to increased risk for inflammation-related co-morbidities, and should be considered when developing immune-based interventions for this growing population.

Our commonality is our past: a qualitative analysis of re-entry community health workers' meaningful experiences.

BackgroundRe-entry community health workers (CHWs) are individuals who connect diverse community residents at risk for chronic health issues such as Hepatitis C virus and cardiovascular disease with post-prison healthcare and re-entry services. While the utilization of CHWs has been documented in other marginalized populations, there is little knowledge surrounding the work of re-entry CHWs with individuals released from incarceration. Specifically, CHWs’ experiences and perceptions of the uniqueness of their efforts to link individuals to healthcare have not been documented systematically. This study explored what is meaningful to formerly incarcerated CHWs as they work with released individuals.MethodsThe authors conducted a qualitative thematic analysis of twelve meaningful experiences written by re-entry CHWs employed by the Transitions Clinic Network who attended a CHW training program during a conference in San Francisco, CA. Study participants were encouraged to recount meaningful CHW experiences and motivations for working with re-entry populations in a manner consistent with journal-based qualitative analysis techniques. Narratives were coded using an iterative process and subsequently organized according to themes in ATLAS.ti. Study personnel came to consensus with coding and major themes.ResultsThe narratives highlighted thought processes and meaning related to re-entry CHWs’ work helping patients navigate complex social services for successful re-integration. Six major themes emerged from the analysis: advocacy and support, empathy relating to a personal history of incarceration, giving back, professional satisfaction and responsibilities, resiliency and educational advancement, and experiences of social inequities related to race. Re-entry CHWs described former incarceration, employment, and social justice as sources of meaning for assisting justice-involved individuals receive effective, efficient, and high-quality healthcare.ConclusionsHealth clinics for individuals released from incarceration provide a unique setting that links high risk patients to needed care and professionalizes career opportunities for formerly incarcerated re-entry CHWs. The commonality of past correctional involvement is a strong indicator of the meaning and perceived effectiveness re-entry CHWs find in working with individuals leaving prison. Expansion of reimbursable visits with re-entry CHWs in transitions clinics designed for re-entering individuals is worthy of further consideration.

A Pilot Training Program for a Motivational Enhancement Approach to Hepatitis C Virus Treatment Among Individuals in Israeli Methadone Treatment Centers

Although hepatitis C virus (HCV) can be cleared, very few infected persons complete the treatment, resulting in disease progression and transmission. Motivational interventions effectively address health and substance-use-related conditions in many cultures. The research team piloted an HCV treatment motivational enhancement training and supervision for four counselors treating four patients in one (of 11) large methadone programs in Israel between 2007 and 2008. The counselors received a 3-day training followed by seven supervision sessions. Training included cultural and language adaptation from the original United States version to practice in Israel. Feasibility was assessed and demonstrated through training field notes and questionnaire feedback, review of taped intervention sessions for counselor proficiency and patient engagement, and patient completion of intervention sessions and piloted measures. While positive feasibility outcomes were noted, future studies should employ larger numbers of counselors and patients to assess the effectiveness of motivational enhancement in promoting HCV treatment in methadone patients.

Bridging Prevention and Health: Exploring Community Perceptions of Intimate Partner Violence in Rural Honduras

This qualitative study rooted in community-based participatory research principles utilized semi-structured interviews with 2 focus groups (n = 9) with female healthcare volunteers (FCVs) and 3 male key informants who were community leaders (MCLs). The study aimed to examine how a rural Honduran community defines and responds to intimate partner violence (IPV) in order to lay the foundation for future interventions. Based on grounded theory, the authors assessed for common themes across transcripts. Authors found that a number of participants denied the existence of IPV. Perspectives on the causes and definitions of IPV varied between FCVs and MCLs. All participants affirmed the need for intervention and many participants mentioned healthcare and legal systems as potential venues to ameliorate IPV. The results highlight potentially important differences between FCV and MCL perspectives that may inform future interventions. Findings suggest healthcare workers can play a role in IPV prevention and intervention in rural Honduras.