Jumana Antoun

Involving the health care system in domestic violence: What women want.

PURPOSE Domestic violence is prevalent among women using primary health care services in Lebanon and has a negative effect on their health, yet physicians are not inquiring about it. In this study, we explored the attitudes of these women regarding involving the health care system in domestic violence management. METHODS We undertook a qualitative focus group study. Health care professionals in 6 primary health care centers routinely screened women for domestic violence using the HITS (Hurt, Insult, Threaten, Scream) instrument. At each center, 12 women who were screened (regardless of the result) were recruited to participate in a focus group discussion. RESULTS Most of the 72 women encouraged involvement of the health care system in the management of domestic violence and considered it to be a “socially accepted way to break the silence.” Women expected health care professionals to have an “active conscience”; to be open minded, ready to listen, and unhurried; and to respect confidentiality. Additionally, they recommended mass media and community awareness campaigns focusing on family relationships to address domestic violence. CONCLUSIONS Addressing domestic violence through the health care system, if done properly, may be socially acceptable and nonoffensive even to women living in conservative societies such as Lebanon. The women in this study described characteristics of health professionals that would be conducive to screening and that could be extrapolated to the health care of immigrant Arab women.

Theranostics in primary care: pharmacogenomics tests and beyond

Theranostics represents a broadening in the scope of personalized medicine to include companion diagnostics for health interventions ranging from drugs to vaccines, as well as individual susceptibility to disease. Surprisingly, in the course of this broadening of personalized medicine discourse, relatively little attention has been paid to primary care (as compared with tertiary healthcare settings) despite its vast patient population and being a crucial entry point to health services. Recent advances in pharmacogenomics (PGx), a classical theranostics application whereby genotyping and/or gene expression-based tests are used for targeted or optimal therapy, revealed new opportunities to characterize more precisely human genomic variation and the ways in which it contributes to person-to-person and population variations in drug response. In the immediate foreseeable future, the primary-care physicians are expected to play an ever increasing crucial role in PGx-based prescribing in order to reduce the rates of adverse drug events and improve drug efficacy, yet PGx testing in primary care remains limited. In this article, the authors review the advances in PGx applications, the barriers for their adoption in the clinic from a primary care point of view and the efforts that are being undertaken to move PGx forward in this hitherto neglected application context of theranostic medicine. Finally, the authors propose several salient recommendations, including a 5-year forecast, to accelerate the current convergence between PGx and primary care.

Effect of computer use on physician-patient communication using a validated instrument: Patient perspective

BACKGROUND Physician-patient communication is essential in the physician-patient relationship. Concerns were raised about the impact of the computer on this relationship with the increase in use of electronic medical records (EMR). Most studies addressed the physicians perspective and only few explored the patients perspective. AIM This study aims to assess the patients perspective of the effect of the physicians computer use during the clinical encounter on the interpersonal and communication skills of the physician using a validated communication assessment tool (CAT). DESIGN AND SETTINGS This is a cross-sectional survey of three hundred eighty-two patients who visited the family medicine clinics (FMC) at the American University of Beirut Medical Center (AUBMC). MATERIAL AND METHODS At the end of the visit with the physician, the patients were approached by the clinical assistant to fill a paper-based questionnaire privately in the waiting room to measure communication skills of physicians using CAT. RESULTS Nearly two-thirds of the patients (62%) did not consider that using the computer by their physician during the visit would negatively affect the patient-doctor communication. Patients rated their physician with a higher communication score when there was an ongoing relationship between the physician and the patient. Higher communication scores were reported for extensive use of the computer by the physician to check results (p<0.001), to retrieve patient record information (p<0.001) and to educate patients (p<0.001) as compared to less use. CONCLUSIONS Physician-patient communication was not negatively affected by the physician use of the computer as rated by patients. An ongoing relationship with the physician remains a significant predictor of better physician-patient communication even in the presence of the computer.

Mapping the Balint groups to the Accreditation Council for Graduate Medical Education family medicine competencies

Introduction Balint group discussions provide learning opportunities for many of the competencies and milestones put forward by the Accreditation Council for Graduate Medical Education. The current literature is mixed concerning the effect of Balint groups on communication skills and professionalism. Aim To map the content of the Balint discussion to the competencies and milestones put forward by the Accreditation Council for Graduate Medical Education. Methodology: A group who were both experts in Balint and members of the clinical competency committee of residency programs rated narratives that summarized Balint group discussions. Credentialed Leaders of the American Balint Society were invited via email to submit narratives (250 words) about Balint groups that they have led, or were leading, with residents. Results Only four narratives were submitted. Additional cases were recruited through literature review of published Balint discussion cases. A total of 25 cases were rated by the committee. There was agreement between three out of four raters on at least one core milestone in every case. The most frequent milestones were C1 (develops meaningful therapeutic relationships with patients and families), C2 (communicated effectively with patients, families, and public), Prof1 (completes a process of professionalization), and Prof3 (demonstrates humanism and cultural proficiency). Balint groups provided a learning opportunity for a subset of milestones in at least 36% of the cases. Conclusion This pilot research suggests that Balint groups and the discussions of complex and challenging cases provide learning opportunities for multiple family medicine milestones, mainly communication skills and professionalism. Further research is needed to refine the methodology and the rating system.

Doctors at times of national instability: What Balint seminars reveal

Background It is not known in what ways is the doctor whose practice is secure in a clinic challenged to maintain a therapeutic doctor–patient relationship when confronting a flood of immigrants within a country that is politically volatile, internally fractionalized, and surrounded by sporadic military incursions? Methods During Balint seminars, a family medicine resident presents a troubling case which all group members reflect upon from the perspective of the doctor, the patient, and their relationship. Balint leaders later debrief and review the work of the group. Lebanon has passed through many political, social, and religious conflicts and was affected by the onset of the Syrian Civil War in 2010. The Balint leaders had begun to see in resident case presentations reflections of war’s disruption of the doctor–patient relationship. Two Balint leaders reviewed a log of all the cases between 2013 and 2016. Results In our observations, the discussion of the presented cases mirrored the cultural, social, religious, and political context of the country. First, the political situation was reflected in the dynamics of the group: agitation, conflicts, hopelessness, and a search for norms. Second, the residents subconsciously chose words in their discussion that reflect the country’s situation. Third, the presented case was stirred by a tragic war-related event. Conclusions The social/political/religious context in which the physician is practicing distracts the doctor from fulfilling his/her professional role. Balint seminars are an example of direct, experiential learning that provide an excellent opportunity for the special training of primary care physicians who deal with refugees and citizens to self-reflect on war’s impact on them and their profession.

Problematic smartphone use among Lebanese adults aged 18–65 years using MPPUS-10

Abstract Background While substance abuse and other forms of addiction are well established in the medical literature, problematic smartphone use is still under-diagnosed and potentially a widespread and serious form of addiction. Most of the literature is focused on adolescents and university students. We aimed to determine the extent of problematic smartphone use among adults aged 18 to 65. Methodology This study is a cross-sectional study among Lebanese adults (18-65y) using a phone-based survey. The questionnaire included basic demographics, types of smartphone use, the validated MPPUS-10, and questions screening for depression and obsessive-compulsive disorder. Results A total of 207 adults participated with a response rate of 69%. The mean score on the MPPUS-10 questionnaire was 44.3 ± 17.3. The prevalence of problematic smartphone use among Lebanese adults was found to be 20.2% with 95% CI [14.7,25.7]. Chatting was the most used smartphone function on a typical day. Higher MPPUS score was associated with people who were younger (mainly 18–34 years), unmarried, and had mobile data subscription. The internal reliability and consistency of the MPPUS-10 in our sample was acceptable. Exploratory factor analysis revealed three components that explained 59.3% of the total variance with intrinsic value above 1. Conclusion This eye-opening study reveals that smartphone problematic use among older adults is considerable and warrants further exploration. Smartphones are turning into essential accessible communication tools of daily life. Adults should be aware when to draw the line to avoid problematic use of their smartphones.

Email communication in a developing country: different family physician and patient perspectives

Background Email communication between physicians and patients could improve access to and delivery of health care. Most of the literature studies about email communication between physicians and patients have been conducted in developing countries. Therefore, this study aims to analyze the practices, attitudes, and barriers of both physicians’ and patients’ use of email within the same health care setting of a developing country. Methods A cross-sectional paper-based survey was conducted among 39 physicians and 500 patients at the Family Medicine clinics of the American University of Beirut, a tertiary academic medical center. Results Most of the surveyed patients and physicians reported that they would like to communicate through email and agreed that it is useful. However, only 19% of the patients have ever communicated with their physicians via email, and only 5.1% of physicians have often communicated with their patients via email. Almost half of the patients surveyed were unaware of the possibility of this form of communication, and only 17% reported that their physician offered them his or her email address. In addition, physicians and patients did not agree on the services to be provided by email communication. For instance, almost half of the patients indicated consultation for an urgent medical matter as suitable for email communication. Conclusion The use of email communication in health care is still scarce. Patients and physicians have different perspectives of its use and importance. Further rigorous research is needed to clarify the advantages and disadvantages of this form of communication, especially in the developing world. Interested physicians are encouraged to establish appropriate personal policies for email communication with adequate announcement and patient education plans.

Interactive and Collaborative Learning in the Classroom at the Medical School : Automated Response Systems and Team-Based Learning

There has been a pedagogic shift in higher education from the traditional teacher centered to the student centered approach in teaching, necessitating a change in the role of the teacher from a supplier of information to passive receptive students into a more facilitative role. Active learning activities are based on various learning theories such as self-directed learning, cooperative learning and adult learning. There exist many instructional activities that enhance active and collaborative learning. The aim of this manuscript is to describe two methods of interactive and collaborative learning in the classroom, automated response systems (ARS) and team-based learning (TBL), and to list some of their applications and advantages. The success of these innovative teaching and learning methods at a large scale depends on few elements, probably the most important of which is the support of the higher administration and leadership in addition to the availability of “champions” who are committed to lead the change.

What matters in the patients' decision to revisit the same primary care physician?

OBJECTIVE To assess the priority of various aspects of the patient-primary care physician relationship in the decision to visit again that same physician. STUDY SETTINGS: A total of 400 community residents in Ras Beirut, Lebanon. STUDY DESIGN A cross-sectional community based study sampled by a nonrandom sex-education quota-based procedure. DATA COLLECTION Participants were asked to fill a survey where they indicated the ranking of nine items by importance in their decision to revisit the same physician. The nine items were chosen from three categories of factors: professional expertise of the physician; characteristics of the patient-physician relationship, office organization. RESULTS Having a physician that gives the patient adequate time for discussion prevailed as rank 1 and luxurious clinic ranked as 9th. Affordability was one of the main concerns among men, those with poor health and those of lower socioeconomic status. Accessibility of the physicians phone was considered highly important among women and those of lesser education status. CONCLUSIONS This study emphasizes the importance of adequate time with the patient, accessibility and affordability of the physician in maintaining continuity of care and patient satisfaction, beyond mere medical expertise.

Telemedicine in Primary Care

I receive a call from a parent telling me that his 4 year old has developed a rash. Despite all the questions about its shape and consistency, I was not confident to reassure the parent. Suddenly, he sends me a photo of the rash on my blackberry. Another parent audio recorded his child’s cough that was bothering them all night. On daily basis, I see patients who present to the office for checkup from close adjacent countries. They are in a hurry and leave before the results of the tests are out, or they might do the tests when they go back to their own country. So I use email correspondence to comment on the results or receive the results. I have a depressed patient who still corresponds with me about her medical condition as she had to leave the country to continue her education. Every now and then, I am challenged with patients who want to discuss sensitive issues by emails like impotence or unusual obsessions. Definitely, you have encountered that meticulous patients who has jotted his blood pressure readings on an excel sheet, printed it and brought it to the clinic. The above scenarios are some aspects of telemedicine and they pose some questions to answer concerning the appropriateness of this way of communication; safety and assurance of confidentiality and privacy in communications, effectiveness, preference of patients.