Drew A. Helmer

Not the same everywhere: Patient-centered learning environments at nine medical schools

BACKGROUND: Learning environments overtly or implicitly address patient-centered values and have been the focus of research for more than 40 years, often in studies about the “hidden curriculum.” However, many of these studies occurred at single medical schools and used time-intensive ethnographic methods. This field of inquiry lacks survey methods and information about how learning environments differ across medical schools.OBJECTIVE: To examine patient-centered characteristics of learning environments at 9 U.S. medical schools.DESIGN: Cross-sectional internet-based survey.PARTICIPANTS: Eight-hundred and twenty-three third- and fourth-year medical students in the classes of 2002 and 2003.MEASUREMENTS: We measured the patient-centeredness of learning environments with the Communication, Curriculum, and Culture (C3) Instrument, a 29-item validated measure that characterizes the degree to which a medical school’s environment fosters patient-centered care. The C3 Instrument contains 3 content areas (role modeling, students’ experiences, and support for students’ patient-centered behaviors), and is designed to measure these areas independent of respondents’ attitudes about patient-centered care. We also collected demographic and attitudinal information from respondents.RESULTS: The variability of C3 scores across schools in each of the 3 content areas of the instrument was striking and statistically significant (P values ranged from .001 to .004). In addition, the patterns of scores on the 3 content areas differed from school to school.CONCLUSIONS: The 9 schools demonstrated unique and different learning environments both in terms of magnitude and patterns of characteristics. Further multiinstitutional study of hidden curricula is needed to further establish the degree of variability that exists, and to assist educators in making informed choices about how to intervene at their own schools.

Trust is the Basis for Effective Suicide Risk Screening and Assessment in Veterans

ABSTRACTBACKGROUNDTo reduce suicides among Veterans, the Department of Veterans Affairs (VA) has designated suicide risk assessments for Veterans who screen positive for depression or post-traumatic stress disorder as a national performance goal. Many VA Medical Centers (VAMCs) are using brief suicidal ideation screens, administered in non-mental health ambulatory care settings, as the first step in the assessment process.OBJECTIVETo explore Veterans’ perceptions of the suicide screening and risk assessment process, the barriers and facilitators to disclosing suicidal thoughts, and perceptions of possible consequences of revealing suicidal thoughts.DESIGNInvestigators recorded one semi-structured interview with each Veteran. Transcripts were analyzed using a modified grounded theory approach.PARTICIPANTSThirty-four Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans who screened positive for suicidal ideation in non-mental health ambulatory care settings in 2009 and 2010.KEY RESULTSVeterans accepted the need to assess suicide risk. They increasingly experienced attempts to suppress and avoid thoughts of suicide as burdensome and exhausting. Despite this, Veterans often failed to disclose severe and pervasive suicidal thoughts when screened because: (1) they considered suicidal thoughts as shameful and a sign of weakness; (2) they believed suicidal thoughts were private and not to be divulged to strangers; (3) they worried that disclosure would lead to unwanted hospitalization or medication recommendations; and (4) the templated computer reminder process was perceived as perfunctory and disrespectful. In contrast, admitting and discussing thoughts of suicide with a health provider who focused on building a relationship, demonstrated genuineness and empathy, offered information on the rationale for suicide risk assessment, and used straightforward and understandable language, all promoted trust that resulted in more honest disclosure of suicidal thoughts.CONCLUSIONIn ambulatory care settings, both provider behaviors and system modifications may lead to more honest disclosure of suicidal thoughts.

Sexual Dysfunction among Male Veterans Returning from Iraq and Afghanistan: Prevalence and Correlates

INTRODUCTION Sexual dysfunction (SD) is not well described in the Iraq/Afghanistan veteran population despite high prevalence of multiple risk factors for this issue. AIM To estimate the prevalence and examine the association of various sociodemographic, mental health, comorbid conditions and life style factors with sexual dysfunction in Iraq/Afghanistan veterans. METHODS This exploratory cross-sectional study was conducted using data from the VA administrative database. A total of 4,755 Iraq/Afghanistan veterans were identified who sought treatment from the Michael E. DeBakey Veterans Affairs Medical Center inpatient and outpatient clinic between September 2007 and August 2009. MAIN OUTCOME MEASURES Sexual dysfunction was determined by ICD9-CM codes related to sexual health issues and/or by specific medications, primarily phosphodiesterase-5 inhibitors (PDE5i), prescribed for erectile dysfunction. RESULTS The overall prevalence of sexual dysfunction was 5.5% (N = 265). By age category, it was 3.6% (N = 145) for Iraq/Afghanistan veterans aged 18-40 years and 15.7% (N = 120) for Iraq/Afghanistan veterans aged > 40 years, respectively. A multivariate logistic-regression model revealed that annual income, marital status, post-traumatic stress disorder, and hypertension were significant risk factors of SD (all P < 0.05) among younger Iraq/Afghanistan veterans, whereas among the older Iraq/Afghanistan veterans, being African American and having PTSD and hypertension were significant risk factors of SD (all P < 0.05). There was marked discrepancy between documented erectile dysfunction and prescription of a PDE5i. CONCLUSIONS These data demonstrate that a significant proportion of Iraq/Afghanistan veterans have SD and that the risk factors differ between younger and older veterans. Our findings also suggest that SD is likely under-coded. To better identify the scope of the problem, systematic screening for sexual dysfunction may be appropriate perhaps as part of an initial post-deployment health evaluation.

Opting out of an integrated healthcare system: Dual-system use is associated with poorer glycemic control in veterans with diabetes

AIMS To test for an association between quality of care and patient choice to obtain care outside an integrated healthcare delivery system. METHODS We used administrative data to define dual-system use (Veterans Health Administration (VHA) and Medicare) in 1999 for VHA users with diabetes over 65 years old. Quality of diabetes care was determined by the last hemoglobin A1c (HA1c) value in 2000. The distance to nearest VHA facility minus the distance to nearest non-federal hospital was the instrumental variable in a two-part regression model which controlled for observed and unobserved factors. RESULTS In 1999, 57.4% of subjects received care from both VHA and Medicare providers; their mean proportion of visits to Medicare providers was 0.41 (median 0.38). After controlling for observed and unobserved factors, higher proportions of Medicare visits were significantly associated with higher HA1c values; a 40% increase in the proportion of Medicare visits by those who did not use Medicare was associated with a 0.23% point increase in HA1c value. CONCLUSIONS Dual-system use was associated with higher HA1c values, suggesting that veterans who chose to receive care outside the integrated VHA may have worse intermediate clinical outcomes than those who received care exclusively within the system.

Airborne Hazards Exposure and Respiratory Health of Iraq and Afghanistan Veterans

More than 2.6 million military personnel have been deployed to recent conflicts in Iraq and Afghanistan and were likely exposed to a variety of airborne hazards during deployment. Despite several epidemiologic reports of increased respiratory symptoms, whether or not these respiratory illnesses lead to reductions in lung function and/or specific pulmonary disease is unclear. We reviewed data published from 2001 to 2014 pertaining to respiratory health in military personnel deployed to Iraq and Afghanistan and found 19 unique studies. Study designs were primarily retrospective and observational in nature with patient symptom reporting and medical encounter data as primary outcome measures. Two case series reported on rare respiratory diseases, and one performed a standardized evaluation of new-onset respiratory symptoms. Respiratory outcomes in relation to proximity to a specific air pollution source (i.e., smoke from burning trash and sulfur mine fire) were described in 2 separate studies. Only 2 longitudinal investigations were identified comparing pre- and postdeployment measurement of exercise capacity. In summary, published data based on case reports and retrospective cohort studies suggest a higher prevalence of respiratory symptoms and respiratory illness consistent with airway obstruction. However, the association between chronic lung disease and airborne hazards exposure requires further longitudinal research studies with objective pulmonary assessments.

Prescription Pain Medication Dependence

466 ajp.psychiatryonline.org Am J Psychiatry 168:5, May 2011 istration (FDA) initiated work in 2009 to establish a risk evaluation and mitigation strategy for opioids (9), which may require prescribers to periodically train and recertify using an opioid medication guide. Other requirements may include physician-patient agreement forms, patient counseling about individual opioid medications, and documentation of distribution by pharmacies.

The war-related illness and injury study centers : A resource for deployment-related health concerns

Combat veterans often return from deployment having experienced a wide range of exposures, symptoms, and medical conditions. The Department of Veterans Affairs established war-related illness and injury study centers to serve combat veterans with unexplained illnesses. We report the exposures, clinical status, and utilization of 53 combat veterans who participated in the National Referral Program (NRP) from January 2002 until March 2004. Participants were primarily male (81%) and served in the Persian Gulf War (79%). Common diagnoses were chronic fatigue syndrome (n = 23, 43%), neurotic depression (n = 21, 40%), and post-traumatic stress disorder (n = 20, 38%). Self-reported exposures related to weaponry, disease prophylaxis, environmental hazards, stress, and poor hygiene. A small increase in mean SF-36V mental component scores (2.8 points, p = 0.009) and use of rehabilitation therapies (1.6 additional visits, p = 0.018) followed the NRP referral. The small gain in mental function suggests that the NRP may benefit combat veterans with long and complex medical histories.

Assessment and Documentation of Sexual Health Issues of Recent Combat Veterans Seeking VHA Care

INTRODUCTION Sexual health is an important aspect of human existence associated with disease and overall health. Despite these associations and the existence of medical treatments to improve sexual function, sexual health is often overlooked in health care. Recent combat veterans may be particularly vulnerable to sexual health issues due to their deployment-related health issues such as mental health conditions, prescription medications use, and psychosocial challenges. AIM This study assesses the sexual health issues of recent combat veterans seeking care at a Veterans Affairs Medical Center (VAMC) documented in the primary care and mental health notes from the first 6 months of care. MAIN OUTCOME MEASURES Documentation of sexual health issues in the progress notes (coded into categories), primary care vs. mental health care visit note, initial vs. follow-up visit notes, and templated vs. non-templated text. METHODS This is a retrospective chart review of the first 158 consecutive patients seen for an initial assessment in the VAMC post-deployment clinic. Medical records were reviewed and text of sexual health issues and relevant patient and care characteristics were abstracted and coded into variables. RESULTS Almost 25% of patients had documented sexual health issues in the first 6 months of care. We coded 52 separate sexual health issues into 13 distinct categories. Overall, most sexual health issues were documented in mental health care notes, in non-templated text, and at follow-up visits. The use of templated text appeared to drive the documentation of low libido (the most common sexual health issue) in mental health care notes. CONCLUSIONS Sexual health issues are prevalent in recent combat veterans seeking care at a VAMC, but patterns of documentation suggest that they may be under-reported or incompletely addressed. A more systematic and provider-initiated approach to assessment of sexual health may promote fuller discussion of sexual health issues and optimize management.

Mild traumatic brain injury and pain in Operation Iraqi Freedom/Operation Enduring Freedom veterans.

The purpose of this study was to describe the pain experience in Operation Iraqi Freedom/Operation Enduring Freedom veterans with and without a history of mild traumatic brain injury (mTBI) who present to polytrauma clinics for evaluation and management. We sought to evaluate the relationship between a veterans history of mTBI and posttraumatic stress (PTS) on axial pain, head/headache pain, and pain interference. We performed retrospective chart reviews of 529 Iraq/Afghanistan veterans referred for evaluation at two Department of Veterans Affairs medical centers. Problems with head/headache, low back, and neck pain were frequently endorsed. Subjective pain interference was reported in 21% of patients without a history of mTBI, 31.9% of patients with a history of mTBI with disorientation only, and 36.1% of patients with a history of mTBI with loss of consciousness. Statistically significant differences existed between the mTBI groups on PTS symptom endorsement, and PTS was predictive of pain experience and interference. A history of mTBI with loss of consciousness predicted head/headache pain, but otherwise did not predict pain or pain interference. PTS was strongly related to the pain experience. Pain is common in polytrauma patients. PTS severity is strongly associated with both pain report and pain interference, with head/headache pain showing a unique association with a history of mTBI. Implications for evaluation and management of pain in this complex population are discussed.

Iraq and Afghanistan Veterans report symptoms consistent with chronic multisymptom illness one year after deployment

Many Veterans returning from service in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) experience chronic pain. What is not known is whether for some OIF/OEF Veterans this pain is part of a larger condition of diffuse multisystem symptoms consistent with chronic multisymptom illness (CMI). We use data from a prospective longitudinal study of OIF/OEF Veterans to determine the frequency of CMI. We found that 1 yr after deployment, 49.5% of OIF/OEF Veterans met criteria for mild to moderate CMI and 10.8% met criteria for severe CMI. Over 90% of Veterans with chronic pain met criteria for CMI. CMI was not completely accounted for either by posttraumatic stress disorder or by predeployment levels of physical symptoms. Veterans with symptoms consistent with CMI reported significantly worse physical health function than Veterans who did not report symptoms consistent with CMI. This study suggests that the presence of CMI should be considered in the evaluation of OIF/OEF Veterans. Further, it suggests the pain management for these Veterans may need to be tailored to take CMI into consideration.