Ralph A. Gillies

The Prevalence of Dysphagia in Primary Care Patients: A HamesNet Research Network Study

Purpose: A number of disorders cause dysphagia, which is the perception of an obstruction during swallowing. The purpose of this study was to determine the prevalence of dysphagia in primary care patients. Methods: Adults 18 years old and older were the subjects of an anonymous survey that was collected in the clinic waiting room before patients were seen by a physician. Twelve family medicine offices in HamesNet, a research network in Georgia, participated. Results: Of the 947 study participants, 214 (22.6%) reported dysphagia occurring several times per month or more frequently. Those reporting dysphagia were more likely to be women (80.8% women vs 19.2% men, P = .002) and older (mean age of 48.1 in patients with dysphagia vs mean age of 45.7 in patients without dysphagia, P = .001). Sixty-four percent of patients with dysphagia indicated that they were concerned about their symptoms, but 46.3% had not spoken with their doctor about their symptoms. Logistic regression analyses showed that increased frequency [odds ratio (OR) = 2.15, 95% CI 1.41–3.30], duration (OR = 1.91, CI 1.24–2.94), and concern (OR = 2.64, CI 1.36–5.12) of swallowing problems as well as increased problems eating out (OR = 1.72, CI 1.19–2.49) were associated with increased odds of having talked to a physician. Conclusions: This is the first report of the prevalence of dysphagia in an unselected adult primary care population. Dysphagia occurs commonly in primary care patients but often is not discussed with a physician.

Racial Disparities and Barriers to Colorectal Cancer Screening in Rural Areas

Introduction: This study examined barriers to colorectal cancer (CRC) screening in people living in rural areas. Methods: We identified 2 rural counties with high rates of CRC and randomly contacted county residents by telephone using a published listing. Results: Six hundred thirty-five of the 1839 eligible respondents (34.5%) between the ages of 50 and 79 years living in McDuffie and Screven counties, Georgia, agreed to complete the survey. The mean age was 62.2 years (SD, ±7.5 years); 72.4% were women, 79.4% were white, and 19.5% were African American. African-American respondents had lower CRC screening rates (50.4%) than whites (63.4%; P = .009). Significantly more African Americans compared with whites reported barriers to CRC screening. Based on logistic regression analyses, having a physician recommend CRC screening had the strongest association with having a current CRC screening, regardless of race. Conclusions: Important racial differences existed between African Americans and whites regarding the barriers to CRC screening and factors impacting current screening. However, endorsement of a small set of questionnaire items—not race—had the strongest association with being current with screening. Physician recommendation for CRC screening had the strongest association with being current with CRC screening.

Measuring psychological flexibility in medical students and residents: a psychometric analysis

Purpose Psychological flexibility involves mindful awareness of our thoughts and feelings without allowing them to prohibit acting consistently with our values and may have important implications for patient-centered clinical care. Although psychological flexibility appears quite relevant to the training and development of health care providers, prior research has not evaluated measures of psychological flexibility in medical learners. Therefore, we investigated the validity of our learners’ responses to three measures related to psychological flexibility. Methods Fourth-year medical students and residents (n=275) completed three measures of overlapping aspects of psychological flexibility: (1) Acceptance and Action Questionnaire-II (AAQ-II); (2) Cognitive Fusion Questionnaire (CFQ); and (3) Mindful Attention and Awareness Questionnaire (MAAS). We evaluated five aspects of construct validity: content, response process, internal structure, relationship with other variables, and consequences. Results We found good internal consistency for responses on the AAQ (α=0.93), MAAS (α=0.92), and CFQ (α=0.95). Factor analyses demonstrated a reasonable fit to previously published factor structures. As expected, scores on all three measures were moderately correlated with one another and with a measure of life satisfaction (p<0.01). Conclusion Our findings provide preliminary evidence supporting validity of the psychological flexibility construct in a medical education sample. As psychological flexibility is a central concept underlying self-awareness, this work may have important implications for clinical training and practice.

Office-Based Unsedated Ultrathin Esophagoscopy in a Primary Care Setting

PURPOSE Gastroesophageal reflux disease is common and with time may be complicated by Barrett’s esophagus and esophageal adenocarcinoma. Upper gastrointestinal endoscopy, including esophagoscopy, is the procedure of choice to diagnose Barrett’s esophagus and other esophageal disease. The use of unsedated ultrathin esophagoscopy (UUE) has been reported by gastroenterologists in specialized endoscopy units and otolaryngologists in outpatient otolaryngology offices, but UUE has not been previously described in a primary care setting. This study examines the feasibility of office-based UUE in primary care. METHODS This study is a retrospective chart review in a university-based family medicine clinic in the southeastern United States. Charts were reviewed of 56 adult outpatients who were referred for further evaluation of reflux symptoms that persisted after at least 4 weeks of therapy with histamine2 receptor agonists or proton pump inhibitors and who elected to undergo UUE in the primary care setting. Patient demographics, procedure indications and findings, changes in clinical management, and procedure times were recorded. RESULTS One hundred percent of patients asked to participate in UUE were willing to undergo the procedure (mean age 48.3 ± 1.6 y, 57.1% women); 95% of the patients tolerated UUE. Barrett’s esophagus was diagnosed in 5.7% (n = 3) of the patients. Mean procedure time was 5.5 ± 1.7 min. No complications were reported in this series. CONCLUSIONS Initial data suggest that UUE is feasible in primary care, with the majority of patients tolerating the procedure. UUE may be an efficient method of examining the distal esophagus.

Nasolaryngoscopy in a Family Medicine Clinic: Indications, Findings, and Economics

Background: Nasopharyngeal complaints are common among patients who present to primary care. Patients with these complaints are often referred for nasolaryngoscopy evaluation to exclude serious conditions such as laryngeal cancer. Methods: This study is a retrospective case series in which 276 charts of adult outpatients who were referred for nasolaryngoscopy were reviewed. We examined patient demographics, procedure indications and findings, complications, and changes in clinical management. Results: Nasolaryngoscopy was completed in 273 (98.9%) patients (mean age, 51.3 ± 14.6 years; 71.4% were women). The most common indications for nasolaryngoscopy were hoarseness (51.3%), globus sensation (32.0%), and chronic cough (17.1%); the most common findings included laryngopharyngeal reflux (42.5%), chronic rhinitis (32.2%), and vocal cord lesions (13.2%). Three patients (1.1%) were diagnosed with laryngeal cancer and this diagnosis was significantly associated with a history of smoking (P = .03). No major complications occurred. Conclusions: We found that nasolaryngoscopy was a safe procedure in the primary care setting, and no major complications occurred in our series. Patients who have ever smoked and complain of hoarseness are at higher risk for laryngeal cancer. An alarming 1% of patients in our series were diagnosed with laryngeal cancer. This is the first study to define the rates of laryngopharyngeal reflux, vocal cord lesions, and laryngeal cancer among primary care patients.

Introversion and Medical Student Education: Challenges for Both Students and Educators

Issue: Introversion is one of the personality factors that has been shown to be associated with performance in medical school. Prior cross-sectional studies highlight performance evaluation differences between introverted and extraverted medical students, though the mechanisms and implications of these differences remain relatively unexplained and understudied. This gap in the literature has become more salient as medical schools are employing more interactive learning strategies into their curricula which may disproportionately challenge introverted learners. Evidence: In this article, we provide an overview and working definition of introversion as a valid construct occurring on a continuum. We apply a goodness of fit model to explore how various medical training contexts may be more or less challenging for introverted students and the potential consequences of a poor fit. As preliminary support for these hypothesized challenges, we share observations from students self-identified as introverts. Examples include introverted students feeling at times like misfits, questioning a need to change their identity to succeed in medical school, and being judged as underperformers. We offer pragmatic suggestions for improving the fit between introverted students and their training contexts, such as teachers and students pausing between a question being asked and the initial response being offered and teachers differentiating between anxious and introverted behaviors. We conclude with suggested areas for future qualitative and quantitative research to examine how medical school curricula and the teaching environment may be differentially impacting the learning and health of introverted and extraverted students. Implications: Extraverted behaviors will continue to be an important part of medical training and practice, but the merits of introverted behaviors warrant further consideration as both medical training and practice evolve. Educators who make manageable adjustments to current teaching practices can improve the learning for both introverted and extraverted styles of academic engagement.