Tonya L. Fancher

Combined use of rapid d-dimer testing and estimation of clinical probability in the diagnosis of deep vein thrombosis: systematic review

Abstract Objective To summarise the evidence supporting the use of rapid D-dimer testing combined with estimation of clinical probability to exclude the diagnosis of deep venous thrombosis among outpatients. Data sources Medline (June 1993 to December 2003), the Database of Abstracts and Reviews (DARE), and reference lists of studies in English. Selection of studies We selected 12 studies from among 84 reviewed. The selected studies included more than 5000 patients and used a rapid D-dimer assay and explicit criteria to classify cases as having low, intermediate, or high clinical probability of deep vein thrombosis of the lower extremity among consecutive outpatients. Review methods Diagnosis required objective confirmation, and untreated patients had to have at least three months of follow up. The outcome was objectively documented venous thromboembolism. Two authors independently abstracted data by using a data collection form. Results When the less sensitive SimpliRED D-dimer assay was used the three month incidence of venous thromboembolism was 0.5% (95% confidence interval 0.07% to 1.1%) among patients with a low clinical probability of deep vein thrombosis and normal D-dimer concentrations. When a highly sensitive D-dimer assay was used, the three month incidence of venous thromboembolism was 0.4% (0.04% to 1.1%) among outpatients with low or moderate clinical probability of deep vein thrombosis and a normal D-dimer concentration. Conclusions The combination of low clinical probability for deep vein thrombosis and a normal result from the SimpliRED D-dimer test safely excludes a diagnosis of acute venous thrombosis A normal result from a highly sensitive D-dimer test effectively rules out deep vein thrombosis among patients classified as having either low or moderate clinical probability of deep vein thrombosis.

Getting to “No”: Strategies Primary Care Physicians Use to Deny Patient Requests

BACKGROUND Physicians need strategies for addressing patient requests for medically inappropriate tests and treatments. We examined communication processes that physicians use to deal with patient requests of questionable appropriateness. METHODS Data come from audio-recorded visits and postvisit questionnaires of standardized patient visits to primary care offices in Sacramento and San Francisco, California, and Rochester, New York, from May 2003 to May 2004. Investigators performed an iterative review of visit transcripts in which patients requested, but did not receive, an antidepressant prescription. Measurements include qualitative analysis of strategies for communicating request denial. The relationship between strategies and satisfaction reports in postvisit questionnaires was examined using the Fisher exact test. RESULTS Standardized patients requested antidepressants in 199 visits; the antidepressants were not prescribed in 88 visits (44%), 84 of which were available for analysis. In 53 of 84 visits (63%), physicians used 1 or more of the following 3 strategies that explicitly incorporated the patient perspective: (1) exploring the context of the request, (2) referring to a mental health professional, and (3) offering an alternative diagnosis. Twenty-six visits (31%) involved emphasis on biomedical approaches: prescribing a sleep aid or ordering a diagnostic workup. In 5 visits (6%), physicians rejected the request outright. Standardized patients reported significantly higher visit satisfaction when approaches relying on the patient perspective were used to deny the request (P = .001). CONCLUSIONS Strategies for saying no may be used to communicate appropriate care plans, to reduce provision of medically inappropriate services, and to preserve the physician-patient relationship. These findings should be considered in the context of physician education and training in light of increasing health care costs.

Suicide Inquiry in Primary Care: Creating Context, Inquiring, and Following Up

PURPOSE We wanted to describe the vocabulary and narrative context of primary care physicians’ inquiries about suicide. METHODS One hundred fifty-two primary care physicians (53% to 61% of those approached) were randomly recruited from 4 sites in Northern California and Rochester, New York, to participate in a study assessing the effect of a patient’s request for antidepressant medication on a physician’s prescribing behavior. Standardized patients portraying 2 conditions (carpal tunnel syndrome and major depression, or back pain and adjustment disorder with depressed mood) and 3 antidepressant request types (brand-specific, general, or none) made 298 unannounced visits to these physicians between May 2003 and May 2004. Standardized patients were instructed to deny suicidality if the physician asked. We identified the subset of transcripts that contained a distinct suicide inquiry (n = 91) for inductive analysis and review. Our qualitative analysis focused on elucidating the narrative context in which inquiries are made, how physicians construct their inquiries, and how they respond to a patient’s denial of suicidality. RESULTS Most suicide inquiries used clear terminology related to self-harm, suicide, or killing oneself. Three types of inquiry were identified: (1) straightforward (eg, “Are you feeling like hurting yourself?”); (2) supportive framing (eg, “Sometimes depression gets so bad that people feel that life is no longer worth living. Have you felt this way?”); and (3) no problem preferred (eg, “You’re not feeling suicidal, are you?”). Four inquiries were glaringly awkward, potentially inhibiting a patient’s disclosure. Most (79%) suicide inquiries were preceded by statements focusing on psychosocial concerns, and most (86%) physician responses to a standardized patient’s denial of ideation were followed up with relevant statements (eg, “I hope you would tell me if you did.”). CONCLUSION Although most suicide inquiries by primary care physicians are sensitive, clear, and supportive, some language is used that may inhibit suicide disclosure. Some physician responses may unintentionally reinforce patients for remaining silent about their risk. This study will inform future research in the development of quality improvement interventions to support primary care physicians in making clear, appropriate, and sensitive inquires about suicide.

Discussing Depression with Vietnamese American Patients

Background Asian patients preferentially seek mental health care from their primary care providers but are unlikely to receive it. Primary care providers need culturally-informed strategies for addressing stigmatizing illnesses. Methods 11 Vietnamese American community members participated in semi-structured interviews. Interviews were audio-taped and transcribed. The grounded theory approach was used for qualitative coding and thematic analysis. Results Vietnamese community members describe experiences with depression under four themes: (1) Stigma and face; (2) Social functioning and the role of the family; (3) Traditional healing and beliefs about medications; and (4) Language and culture. Based on this data, we offer suggestions for improving culturally-informed care for Vietnamese Americans. Disucssion Our study adds to the research aimed at improving communication and health care relationships between physicians and Vietnamese American patients. Physicians should learn to tailor their interviewing style to the increasingly diverse patient population.

Health Systems Science Curricula in Undergraduate Medical Education: Identifying and Defining a Potential Curricular Framework.

Purpose The authors performed a review of 30 Accelerating Change in Medical Education full grant submissions and an analysis of the health systems science (HSS)-related curricula at the 11 grant recipient schools to develop a potential comprehensive HSS curricular framework with domains and subcategories. Method In phase 1, to identify domains, grant submissions were analyzed and coded using constant comparative analysis. In phase 2, a detailed review of all existing and planned syllabi and curriculum documents at the grantee schools was performed, and content in the core curricular domains was coded into subcategories. The lead investigators reviewed and discussed drafts of the categorization scheme, collapsed and combined domains and subcategories, and resolved disagreements via group discussion. Results Analysis yielded three types of domains: core, cross-cutting, and linking. Core domains included health care structures and processes; health care policy, economics, and management; clinical informatics and health information technology; population and public health; value-based care; and health system improvement. Cross-cutting domains included leadership and change agency; teamwork and interprofessional education; evidence-based medicine and practice; professionalism and ethics; and scholarship. One linking domain was identified: systems thinking. Conclusions This broad framework aims to build on the traditional definition of systems-based practice and highlight the need for medical and other health professions schools to better align education programs with the anticipated needs of the systems in which students will practice. HSS will require a critical investigation into existing curricula to determine the most efficient methods for integration with the basic and clinical sciences.

Impact of a Randomized Controlled Educational Trial to Improve Physician Practice Behaviors Around Screening for Inherited Breast Cancer

ABSTRACTBACKGROUNDMany primary care physicians (PCPs) are ill-equipped to provide screening and counseling for inherited breast cancer.OBJECTIVETo evaluate the outcomes of an interactive web-based genetics curriculum versus text curriculum for primary care physicians.DESIGNRandomized two-group design.PARTICIPANTS121 California and Pennsylvania community physicians.INTERVENTIONWeb-based interactive genetics curriculum, evaluated against a control group of physicians who studied genetics review articles. After education, physicians interacted with an announced standardized patient (SP) at risk for inherited breast cancer.MAIN MEASURESTranscripts of visit discussions were coded for presence or absence of 69 topics relevant to inherited breast cancer.KEY RESULTSAcross all physicians, history-taking, discussions of test result implications, and exploration of ethical and legal issues were incomplete. Approximately half of physicians offered a genetic counseling referral (54.6 %), and fewer (43.8 %) recommended testing. Intervention physicians were more likely than controls to explore genetic counseling benefits (78.3 % versus 60.7 %, P = 0.048), encourage genetic counseling before testing (38.3 % versus 21.3 %, P = 0.048), ask about a family history of prostate cancer (25.0 % versus 6.6 %, P = 0.006), and report that a positive result indicated an increased risk of prostate cancer for male relatives (20.0 % versus 1.6 %, P = 0.001). Intervention-group physicians were less likely than controls to ask about Ashkenazi heritage (13.3 % versus 34.4 %, P = 0.01) or to reply that they would get tested when asked, “What would you do?” (33.3 % versus 54.1 %, P = 0.03).CONCLUSIONSPhysicians infrequently performed key counseling behaviors, and this was true regardless of whether they had completed the web-based interactive training or read clinical reviews.

An academic-community partnership to improve care for the underserved.

Despite the need for a robust primary care workforce, the number of students and residents choosing general internal medicine careers continues to decline. In this article, the authors describe their efforts at the University of California, Davis School of Medicine to bolster interest in internal medicine careers and improve the quality of care for medically underserved populations through a tailored third-year residency track developed in partnership with the Sacramento County Department of Health and Human Services. The Transforming Education and Community Health (TEACH) Program improves continuity of care between inpatient and outpatient settings, creates a new multidisciplinary teaching clinic in the Sacramento County health system, and prepares residents to provide coordinated care for vulnerable populations. Since its inception in 2005, 25 residents have graduated from the TEACH Program. Compared with national rates, TEACH graduates are more likely to practice general internal medicine and to practice in medically underserved settings. TEACH residents report high job satisfaction and provide equal or higher-quality diabetes care than that indicated by national benchmarks. The authors provide an overview of the TEACH Program, including curriculum details, preliminary outcomes, barriers to continued and expanded implementation, and thoughts about the future of the program.

How Medical School Applicant Race, Ethnicity, and Socioeconomic Status Relate to Multiple Mini-Interview-Based Admissions Outcomes: Findings From One Medical School.

Purpose To examine associations of medical school applicant underrepresented minority (URM) status and socioeconomic status (SES) with Multiple Mini-Interview (MMI) invitation and performance and acceptance recommendation. Method The authors conducted a correlational study of applicants submitting secondary applications to the University of California, Davis, School of Medicine, 2011–2013. URM applicants were black, Southeast Asian, Native American, Pacific Islander, and/or Hispanic. SES from eight application variables was modeled (0–1 score, higher score = lower SES). Regression analyses examined associations of URM status and SES with MMI invitation (yes/no), MMI score (mean of 10 station ratings, range 0–3), and admission committee recommendation (accept versus not), adjusting for age, sex, and academic performance. Results Of 7,964 secondary-application applicants, 19.7% were URM and 15.1% self-designated disadvantaged; 1,420 (17.8%) participated in the MMI and were evaluated for acceptance. URM status was not associated with MMI invitation (OR 1.14; 95% CI 0.98 to 1.33), MMI score (0.00-point difference, CI −0.08 to 0.08), or acceptance recommendation (OR 1.08; CI 0.69 to 1.68). Lower SES applicants were more likely to be invited to an MMI (OR 5.95; CI 4.76 to 7.44) and recommended for acceptance (OR 3.28; CI 1.79 to 6.00), but had lower MMI scores (−0.12 points, CI −0.23 to −0.01). Conclusions MMI-based admissions did not disfavor URM applicants. Lower SES applicants had lower MMI scores but were more likely to be invited to an MMI and recommended for acceptance. Multischool collaborations should examine how MMI-based admissions affect URM and lower SES applicants.

In the clinic. Generalized anxiety disorder.

Section Editors Deborah Cotton, MD, MPH Darren Taichman, MD, PhD Sankey Williams, MD The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP’s Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://www.acponline.org/products_services/ mksap/15/?pr31, and other resources referenced in each issue of In the Clinic.

Role Modeling and Regional Health Care Intensity: U.S. Medical Student Attitudes Toward and Experiences with Cost-Conscious Care

Purpose To examine medical student attitudes toward cost-conscious care and whether regional health care intensity is associated with reported exposure to physician role-modeling behaviors related to cost-conscious care. Method Students at 10 U.S. medical schools were surveyed in 2015. Thirty-five items assessed attitudes toward, perceived barriers to and consequences of, and observed physician role-modeling behaviors related to cost-conscious care (using scales for cost-conscious and potentially wasteful behaviors; Cronbach alphas of 0.82 and 0.81, respectively). Regional health care intensity was measured using Dartmouth Atlas End-of-Life Chronic Illness Care data: ratio of physician visits per decedent compared with the U.S. average, ratio of specialty to primary care physician visits per decedent, and hospital care intensity index. Results Of 5,992 students invited, 3,395 (57%) responded. Ninety percent (2,640/2,932) agreed physicians have a responsibility to contain costs. However, 48% (1,1416/2,960) thought ordering a test is easier than explaining why it is unnecessary, and 58% (1,685/2,928) agreed ordering fewer tests will increase the risk of malpractice litigation. In adjusted linear regression analyses, students in higher-health-care-intensity regions reported observing significantly fewer cost-conscious role-modeling behaviors: For each one-unit increase in the three health care intensity measures, scores on the 21-point cost-conscious role-modeling scale decreased by 4.4 (SE 0.7), 3.2 (0.6), and 3.9 (0.6) points, respectively (all P < .001). Conclusions Medical students endorse barriers to cost-conscious care and encounter conflicting role-modeling behaviors, which are related to regional health care intensity. Enhancing role modeling in the learning environment may help prepare future physicians to address health care costs.