William Murdoch

Abuse, Outpatient Charges and Utilization, and Psychiatric Symptoms among Urban Women on Medicaid

Background: Adult and childhood sexual and physical abuse are common and intertwined. Our objectives were to assess (1) the relationship between different forms of abuse; (2) outpatient charges and hospital and emergency department use among women with and without childhood and adult abuse; (3) psychiatric symptoms of women with and without childhood and adult abuse; and (4) the relationship between psychiatric symptoms and outpatient charges and hospital and emergency department use among a group of Medicaid-insured women seeking outpatient services in a primary care setting. Methods: We recruited female primary care patients for this cross-sectional study. Women reported childhood and adult sexual and physical abuse and anxiety, depression, and posttraumatic stress symptoms. We assessed outpatient charges through reviews of clinic records. Patients reported hospital and emergency department use. Results: Childhood and adult sexual and physical abuse were highly interrelated. Adult sexual abuse showed a trend toward significantly greater outpatient charges. Women who had experienced physical abuse during childhood had more emergency department visits and women who experienced physical abuse as an adult had more days of hospitalization. Childhood and adult sexual abuse were both related to higher levels of anxiety, depression, and posttraumatic stress symptoms. Anxiety, depression, and posttraumatic stress symptoms were related to higher outpatient charges. Depression and posttraumatic stress symptoms were related to greater emergency department use. Conclusions: Women who experience abuse often have psychiatric symptoms. In our sample it was the severity of psychiatric symptoms rather than reported abuse alone that was related to outpatient charges and emergency department visits.

TRAINING FAMILY MEDICINE RESIDENTS TO PRACTICE COLLABORATIVELY WITH PSYCHOLOGY TRAINEES

Objective: This article will describe a training curriculum for family medicine residents to practice collaboratively with psychology (doctoral) trainees at the Wayne State University/Crittenton Family Medicine Residency program. Methods: The collaborative care curriculum involves a series of patient care and educational activities that require collaboration between family medicine residents and psychology trainees. Activities include: 1) clinic huddle, 2) shadowing, 3) pull-ins and warm handoffs, 4) co-counseling, 5) shared precepting, 6) feedback from psychology trainees to family medicine residents regarding consults, brief interventions, and psychological testing, 7) lectures, 8) video-observation and feedback, 9) home visits, and 10) research. The activities were designed to teach the participants to work together as a team and to provide a reciprocal learning experience. Results: In a brief three-item survey of residents at the end of their academic year, 83% indicated that they had learned new information or techniques from working with the psychology trainees for assessment and intervention purposes; 89% indicated that collaborating with psychology trainees enhanced their patient care; and 89% indicated that collaborating with psychology trainees enhanced their ability to work as part of a team. Informal interviews with the psychology trainees indicated that reciprocal learning had taken place. Conclusions: Family medicine residents can learn to work collaboratively with psychology trainees through a series of shared patient care and educational activities within a primary care clinic where an integrated approach to care is valued.

One Presentation, Two Continents: Left Wrist Myositis of Distinct Etiology in Genetically Similar Individuals

A 34-year-old man presented with a 5-day history of rapid onset weakness of the left wrist flexor muscles, associated with fever, sore throat, arthralgias, and myalgias. A literature review to answer the question, “What could cause focal muscle weakness, fever, and myalgias?” yielded several case reports describing initial presentations of polymyositis or unusual presentations of various infectious agents. Interestingly, the man in our case had a cousin in France, with whom he had no recent contact, who presented with the same symptoms approximately 3 months earlier. Because of our patients recent travel history, testing was performed for Lyme disease, confirming our diagnosis. The mans cousin, however, had been similarly tested and was found negative for Lyme disease.

Convergent Validity of the Early Memory Index in Two Primary Care Samples

ABSTRACT Karliner, Westrich, Shedler, and Mayman (1996) developed the Early Memory Index (EMI) to assess mental health, narrative coherence, and traumatic experiences in reports of early memories. We assessed the convergent validity of EMI scales with data from 103 women from an urban primary care clinic (Study 1) and data from 48 women and 24 men from a suburban primary care clinic (Study 2). Patients provided early memory narratives and completed self-report measures of psychopathology, trauma, and health care utilization. In both studies, lower scores on the Mental Health scale and higher scores on the Traumatic Experiences scale were related to higher scores on measures of psychopathology and childhood trauma. Less consistent associations were found between the Mental Health and Traumatic Experiences scores and measures of health care utilization. The Narrative Coherence scale showed inconsistent relationships across measures in both samples. In analyses assessing the overall fit between hypothesized and actual correlations between EMI scores and measures of psychopathology, severity of trauma symptoms, and health care utilization, the Mental Health scale of the EMI demonstrated stronger convergent validity than the EMI Traumatic Experiences scale. The results provide support for the convergent validity of the Mental Health scale of the EMI.

Multisystem Manifestations of Benign Ovarian Teratomas

A 26-year-old woman presented with acute onset of right-sided pelvic pain and had a medical history significant for migraine headaches and polycystic ovarian disease. Ultrasonography demonstrated bilateral ovarian tumors, and the patient underwent laparoscopic removal of bilateral cystic teratomas. A literature review focused on similar presentations of teratomas revealed isolated cases of migraines and polycystic ovarian disease associated with teratomas and an increased risk for ovarian torsion. Our patient experienced complete resolution of her acute abdominal pain, as well as her long-standing headaches and hormonal symptoms, after removal of the teratomas.

“I Fired My Last Doctor for Not Taking Me Seriously”: Collaborating With a Difficult Medical Patient in a Multidisciplinary Primary Care Facility

We present the case of a multidisciplinary primary care assessment of a 32-year-old woman with multiple medical and psychological complaints. Following the collaborative care model, this assessment was conducted by a team consisting of a clinical health psychologist, Dr. J. L. Skillings, and a family physician, Dr. W. J. Murdoch. We describe the primary care environment in which this referral was made including the methods that were utilized to insure a successful professional collaboration. We report the results and recommendations from a comprehensive biopsychosocial assessment; we place emphasis on the psychological diagnosis and pain symptoms. We also describe the feedback session in which the assessment results were provided to the patient and her spouse by both physician and psychologist. Multiperspective commentary about the assessment is offered by the patient and her husband as well as the physician and psychologist assessors.

The Use of the Social Cognition and Object Relations Scale in a Primary Care Setting

ABSTRACT Research has indicated that as many as 10% to 15% of primary care patients have symptoms that are not well explained medically. These patients could be labeled as “somatizers.” This study assessed the extent to which underlying psychological characteristics contribute to a persons level of somatization and service utilization. The Social Cognition and Object Relations Scale–Global Rating Method (SCORS–G; Stein, Hilsenroth, Slavin-Mulford, & Pinsker, 2011; Westen, 1995) was used to rate early memory narratives of 100 patients in a suburban primary care setting. Using principal axis factoring, the SCORS–G was divided into 2 components and these components (cognitive and affective) were used in subsequent analyses. The affective component was significantly negatively correlated with 2 measures of somatization and positively related to physician ratings of global health. The affective component also showed a trend toward significance on overnight hospital stays and patient-rated health. The cognitive component showed a trend toward significance with both measures of somatization, but it was not correlated with other measures of health. This study demonstrates the value of assessing underlying processes (via SCORS–G ratings of early memory narratives) that contribute to increased rates of somatization and health care utilization. Clinical implications for the relationship between affect and physical health are explored.

Behavioral Health Assessments and Interventions of Psychology Trainees and Residents During Dual Interviewing: Replication and Extension

The integration of psychologists and other behavioral health providers in primary care practice continues to evolve and reshape approaches to patient care. This study is a replication and extension of a 2013 study describing dual interviewing encounters involving psychology trainees and family medicine residents within an integrated primary care clinic as it relates to behavioral health assessments and interventions. Psychology trainees provided descriptions of 400 collaborative patient encounters involving 337 single and 63 repeat encounters. Psychology trainees coded the frequency of behavioral health assessments and interventions by the psychology trainee, family medicine resident, or both. Seventy-eight percent of encounters contained an assessment, and 20% contained interventions. Compared to the 2013 study, there were significantly fewer behavioral health interventions offered and a significantly greater number of psychoeducation/supportive interventions offered collaboratively. It was discovered that discussions between psychology trainees and family medicine residents immediately after patient encounters occurred 50% of the time and involved issues of case conceptualization. These informal discussions may be an important source of behavioral health education for family medicine residents. This study adds to efforts to better understand what occurs during these encounters.

Guest Family Physician Commentaries

The high prevalence and associated morbidity and mortality of type 2 diabetes mellitus (T2DM) present a significant challenge for today’s family physician at the individual, patient, and public health levels. It follows that the primary and secondary prevention of this disease are of keen interest to clinicians. Kong et al 1 present data about the correlations between acanthosis nigricans (AN) and T2DM, replicating the findings from earlier, limited studies within a multistate primary care research consortium. The study highlights 2 key points that should be of interest to family physicians. First, although AN was associated with a higher prevalence of T2DM, it did not relate well with the traditional screening modalities currently recommended for the disease. For example, AN showed no significant association with blood pressure, which is used by the US Preventive Services Task Force as the sole screening “trigger” for T2DM. 2 In addition, fasting blood glucose, currently the standard screening method, was also not correlated with AN. Several questions follow from these findings: Does the use of AN as a screening tool for T2DM present an opportunity to catch the disease process earlier? Would AN predict glycohemoglo