Family Medicine Residency Clinic Research Articles

Perspectives From Patients Using a Food Pantry in a Family Medicine Residency Clinic: A Qualitative Study.

Food insecurity is common in patients receiving care in primary care offices. Some health systems and primary care offices provide food directly to food insecure patients. Our family medicine residency clinic started a food pantry to directly address this social determinant of health. We aimed to understand the reasons patients in primary care visited our food pantry and their impressions of food available directly in a primary care office. We conducted semistructured interviews with 21 patients obtaining food from our food pantry. We recorded and transcribed the interviews, and analyzed them with an editing organizing style to highlight noteworthy segments, recognize patterns, and understand important themes. Patients reported numerous barriers to obtaining healthy food, including cost, transportation, and time. Life-changing events often led a patient to a food pantry, and patients often prioritized family members when addressing food insecurity. Food pantry users appreciated the convenience of obtaining food at a medical visit and felt supported by healthy food that aligned with a message received from their physician. Food insecure patients face many barriers to obtaining healthy food. A colocated food pantry in a primary care office helps address barriers, is convenient, and is appreciated by patients using the service.

Expanding Access to Contraceptive Services in a Family Medicine Residency Clinic:The Rapid Access to Contraception Clinic Model.

Learning to provide long-acting reversible contraception (LARC) during family medicine residency is an important step in building capacity for the primary care workforce to meet the reproductive health care needs of communities. We aimed to measure the impact of adding a contraceptive visit type (CVT) allowing for rapid access to contraception (RAC) on family medicine resident LARC procedure numbers. Our program created a CVT in which patients were seen only for contraceptive services. We added the CVT to third-year family medicine resident continuity clinic schedules and a block of CVTs (the RAC clinic) to the third-year gynecology rotation. Residents self-reported LARC procedure numbers performed throughout residency, and the totals were compared for graduating residents from 2023 (post-RAC cohort) to 2022 graduates and 2018-2022 graduates (pre-RAC cohort). Post-RAC cohort residents reported a statistically significant increase in intrauterine device (IUD; P=.015) and contraceptive implant (P=.010) removals compared to the 2022 pre-RAC cohort. Insertions of IUDs and contraceptive implants were unchanged when compared to the pre-RAC cohort. IUD removals (P=.004) and insertions (P=.034), and contraceptive implant removals (P=.028) were significantly increased for post-RAC compared to 2022 graduates, with no difference in contraceptive implant insertions (P=.211). The addition of the CVT and RAC clinic contributed to an increase in LARC removals in both comparisons, and IUD insertions between 2022 and 2023. This clinic model offers an opportunity for other family medicine residency programs to improve access to contraceptive services and increase resident training in LARC management.

Barriers to Fresh Fruit and Vegetable Access in Adult Patients in the Mayo-La Crosse Family Medicine Residency Clinic.

Food insecurity remains a pressing issue in the United States, with approximately 12.8% of American households experiencing this challenge in 2023, as reported by the USDepartment of Agriculture (USDA). In Wisconsin, a state with a notable agricultural heritage, the prevalence of food insecurity averaged 9.9% between 2019 and 2023. A growing body of research underscores the importance of consuming diets rich in fruits and vegetables for maintaining optimal health and mitigating the risk of various chronic diseases, including cardiovascular disease (CVD) and obesity. Fruits and vegetables are reservoirs of essential nutrients such as vitamins, minerals, antioxidants, and dietary fiber, which collectively contribute to overall well-being.Despite the well-documented health benefits of fruits and vegetables, a considerable proportion of the population fails to meet the recommended daily intake of at least five servings. This disparity underscores the importance of exploring factors influencing dietary behaviors and identifying strategies to promote adherence to dietary guidelines. Surveys were distributed by staff at the family medicine residency clinic in La Crosse, Wisconsin, during routine visits in April and May 2023. Any patients ≥18 years old presenting to the Family Health Clinic (FHC) were eligible for inclusion. Patients were excluded if they were unable to read/answer survey questions due to intellectual/language/other barriers. Surveys included demographic data such as the participant's age, gender, race, income bracket, and primary mode of transportation. A total of 122 participants were then asked how many servings in a day they ate of 100% juice, fruits, beans, green vegetables, yellow/orange vegetables, and other vegetables, as well as about barriers to more fruit and vegetable consumption and a Likert scale about their attitudes toward fruit and vegetable consumption and interest in discussing it with a healthcare provider. Demographic characteristics were analyzed through graphical representation to elucidate trends and patterns among the surveyed population. We compared different demographics with the barriers to fruits and vegetables using bar graphs. The primary barrier to fruit and vegetable intake varied by age group: "cost" for 18-30, "other" for 31-50, "cost" and "none" for 51-70, and "none" for over 70. For gender, "none" was most frequent for maleswhile "cost" was for females. By income, "cost" was common for $0-20k and $20-50k, "none" for $50-100k, and "other" for >$100k. A Likert scale assessed interest in discussing healthy foods with healthcare providers. Most responses were "neutral,"with "strongly agree" highest in 18-30 and "agree" in 31-50, 51-70, and over 70 age groups. The purpose of this study was to ascertain barriers to fruit and vegetable access and identify patients' attitudes toward discussing healthy food choices with healthcare providers. There appears to be a correlation between decreasing income and increasing age and the likelihood of identifying cost as a barrier to fruit/vegetable intake. Barriers identified in our clinic included convenience/time constraints and cost. Many people in our survey also identified the lack of quality or good variety of fruits and vegetables at the store (availability) as a significant barrier to eating them.

Disparities in the Timeliness of Addressing Patient-Initiated Telephone Calls in a Primary Care Clinic: The Impact of Quality Improvement Interventions

ABSTRACT A timely response to patient-initiated telephone calls can affect many aspects of patient health, including quality of care and health equity. Historically, at a family medicine residency clinic, at least 1 out of 4 patient calls remained unresolved three days after the call was placed. We sought to explore whether there were differential delays in resolution of patient concerns for certain groups and how these were affected by quality improvement interventions to increase responsiveness to patient calls. A multidisciplinary team at a primary care residency clinic applied Lean education and tools to improve the timeliness of addressing telephone encounters. Telephone encounter data were obtained for one year before and nine months after the intervention. Data were stratified by race, ethnicity, preferred language, sex, online portal activation status, age category, zip code, patient risk category, and reason for call. Stratified data revealed consistently worse performance on telephone encounter closure by 72 hours for Black/African American patients compared to Hispanic and non-Hispanic White patients pre-intervention. Interventions resulted in statistically significant overall improvement, with an OR of 2.9 (95% CI: 2.62 to 3.21). Though interventions did not target a specific population, pre-intervention differences based on race and ethnicity resolved post-intervention. Telephone calls serve as an important means of patient communication with care teams. General interventions to improve the timeliness of addressing telephone encounters can lead to sustainable improvement in a primary care academic clinic and may also alleviate disparities.

A Retrospective Chart Review Evaluating the Changes in Depressive Symptoms in Adult Patients With Attention-Deficit/Hyperactivity Disorder (ADHD) With the Treatment of the Underlying ADHD.

Adult attention-deficit/hyperactivity disorder (ADHD) represents a significant public health burden. ADHD is often comorbid with many other psychiatric disorders, with a high co-occurrence with depression. However, there is a paucity in our understanding of the potential impact of treating patients' ADHD on their depressive symptoms. The primary objective of this study was to assess the effect of treating adult ADHD on comorbid depressive symptoms without directly administering treatment for depression in an integrated behavioral health clinic in the primary care setting. We performed a retrospective chart review between April 2021 and May 2022 on adult patients treated in the Primary Care Adult Integrated Behavioral Health Clinic at an urban family medicine residency clinic. For patients with ADHD, we administered the Adult ADHD Self-Report Scale (ASRS-v1.1) to serve as a marker of ADHD symptom burden and the nine-item Patient Health Questionnaire(PHQ-9) to serve as a marker of depressive symptom burden. We administered the questionnaires prior to initiating ADHD treatment and again at the three-month follow-up visit. The ADHD treatment included pharmacotherapy and brief psychological interventions targeted at ADHD. We compared the ASRS scores and PHQ-9 scores at baseline and after three months to determine whether ADHD treatment had any impact on PHQ-9 scores. At baseline, the average ASRS score was 11.3 and the average PHQ-9 score was 8.25. Comparing scores after three months of intervention to the initial scores, our preliminary results demonstrated a trend of improvement in both ASRS and PHQ-9 scores. A total of 75% (n=24/32) of the patients had an improvement in ASRS scores, and 56.7% (n=17/30) of the patients had an improvement in PHQ-9 scores at three months. At three months, there was a decline in PHQ-9 scores with a decrease in ASRS scores following treatment. Our preliminary results suggest that integrated behavioral health treatment of ADHD using a combination of pharmacological and non-pharmacological interventions may play a role in improving comorbid depressive symptoms.

Enhanced Scheduling to Improve Resident Continuity in a Family Medicine Teaching Clinic.

Continuity of care is a core concept at the heart of primary care practices. Increased patient-provider continuity of care is associated with better satisfaction scores, better clinical outcomes, decreased hospitalizations and emergency department utilization, improved completion of preventive health services, adherence to medical treatment plans, and improved show rates. Compared to traditional outpatient practices, resident teaching clinics traditionally have lower rates of continuity and face unique challenges in improving continuity given the curricular demands, complex scheduling, and high turnover of providers. The objective of our study was to assess the impact of front office training and new electronic medical record (EMR) scheduling protocols on resident continuity in a family medicine teaching clinic. From July 2021 through May 2022, optimized scheduling through a provider search function in the EMR was implemented in a family medicine teaching clinic. We compared the monthly continuity rates between corresponding months in the prior year and the intervention year. Over an 11-month implementation process, continuity for resident physicians increased from 36.4% to 64.6% (χ2=675.41, P<.001) using EMR tools and scheduling search functions to improve and sustain continuity over the study period. This intervention to enhance continuity in a family medicine residency clinic led to rapid and sustained improvement in provider continuity. This result demonstrates that optimization of EMR scheduling with tools and protocols can improve overall continuity. This scheduling process can likely be applied to clinical sites for residency programs across disciplines.

Impact of Set-Day Clinic on Physician Continuity in a Family Medicine Residency Clinic.

Continuity of care between patients and their primary care providers is associated with improved patient outcomes and experience, decreased health care costs, and improved provider well-being. Strategies to enhance continuity of care in residency programs involve electronic health record, scheduling, and panel management methods. Our study compared physician-patient continuity rates (pre and post) for one family medicine residency's implementation of a set-day clinic (SDC) scheduling model. In July 2019, Bethesda Clinic switched from a rotation-driven scheduling (RDS) model to SDC. Physicians were divided into two scheduling groups: Monday, Thursday, or Friday; or Tuesday, Wednesday, or Friday. We used visit data from two 6-month periods, October 2018 to March 2019 (RDS) and October 2021 to March 2022 (SDC), to calculate continuity using the continuity for physician formula. We used t tests to compare mean continuity rates between the RDS and SDC periods. In June 2022, faculty and residents were emailed a nine-question survey about SDC. Adherence to the SDC model ranged from 65% to 76%. Postgraduate year (PGY) 3 residents' continuity increased significantly (P<.001) from 44% (RDS) to 56% (SDC), while PGY2 residents' continuity increased, nonsignificantly, from 38% to 43%. Among those that completed the survey, 94% of residents and 78% of faculty were in favor of SDC. We demonstrated that SDC is feasible and well received by residents and faculty alike. Continuity was highest for PGY2 and PGY3 residents during the SDC period. Predictable clinic schedules have the potential to improve continuity in family medicine residency clinics and may improve physician well-being.

Implementation of a Multidisciplinary Medication Refill Protocol.

Primary care clinicians spend significant time managing nonvisit activities, including processing of requests for prescription renewal. Delays in processing refills may lead to patient dissatisfaction and impact provider productivity. Having nonclinicians process refills can be more efficient and time-saving. We aimed to evaluate the use of a multidisciplinary medication refill protocol to decrease the time to complete refill requests. We implemented nursing-driven management of refill requests within two family medicine residency clinics in Milwaukee, Wisconsin (Phase 1: single clinic implementation [March 2017-June 2019]; Phase 2: added second clinic prepandemic [June 2019-March 2020] and postpandemic [April 2020-December 2020]). The multidisciplinary refill protocol was created by faculty, residents, pharmacy, and nursing. Data were collected using electronic health record time stamps to determine when refill requests were initiated and filled by faculty, residents, and nurses. We used Mood's median test to compare the median time for medication refill completion. We used Levene's test to test for equal variance surrounding the median of each caregiver group. We used Fisher's exact test or χ2 test with Yates' correction for 2×2 contingency tables. In both phases, we identified a significant reduction in median time to refill completion ( P<.001) and variability of time to refill completion ( P<.001). Notably, in Phase 1, reduction in median refill time was most apparent among residents (383 vs 79 min postimplementation); and in Phase 2, the percentage of refills completed within 48 hours significantly increased between the pre-COVID-19 and COVID-19 pandemic among faculty and nursing in Clinic 1 and residents and faculty in Clinic 2 (all P's<.001). Implementation of a multidisciplinary refill protocol significantly improved time and predictability of refill completion in both phases.

Integrating osteopathic manipulative treatment into prenatal care visits in a family medicine resident clinic.

Literature describing the integration of osteopathic manipulative treatment (OMT) during prenatal care visits in a resident clinic setting are scarce. Concise and readily accessible resources reviewing OMT in pregnancy are limited. We sought to integrate OMT into routine prenatal care appointments in a family medicine resident clinic setting and create a concise resource for those performing OMT in pregnancy. Musculoskeletal (MSK) pain in pregnancy is common. Specifically, low back pain (LBP) often accompanies pregnancy and may negatively impact sleep, the ability to work, and the ability to complete daily tasks. Treatment options for LBP in pregnancy are limited due to the concern for fetal or maternal harm associated with pharmacologic options or invasive procedures. OMT is a low-risk intervention that has been demonstrated to improve back pain and reduce deterioration of back-specific function in pregnancy. Over a 12-month period, one resident physician offered OMT during routine prenatal care visits in a family medicine resident clinic. During the study period, we identified barriers to integrating OMT along with solutions. Barriers to integrating OMT were noted in three areas: clinic setup and logistics, attending physician awareness of OMT in pregnancy, and treating physician knowledge of OMT in pregnancy. OMT provides pregnant patients withadditional treatment options and relief from MSK pain. This may reduce the number of patients with untreated MSKpain and benefit those who are unable to attend additional appointments outside of prenatal care due to financial or logistic barriers. OMT can be integrated intoroutine prenatal care visits in a training setting by providing complaint-specific OMT and determining how treatments can be performed for each unique examination room and table. Reviewing OMT in pregnancy with the attending physician prior to treatment, contraindications to OMT in pregnancy, and visualizing how treatments will be altered in pregnancy allows for smooth integration.

Self-care Perception in Physicians and Patients With Type 2 Diabetes.

We sought to assess self-care perception consistency between patients with type 2 diabetes mellitus and their physicians and characterize the psychosocial parameters influencing their respective perceptions. We conducted a study of 627 patients with type 2 diabetes and their physicians throughout 12 family medicine residency clinics in Texas to analyze their respective perceptions of patient self-care. We utilized linear regression testing. There was a lack of consistency in self-care perception between patients and physicians 31.2% of the time. Patient self-care perception was best predicted by the patients' diabetes distress scores (P<.001) and last HbA1c (P<.001). Measuring a patient's diabetes distress may help physicians better understand a patient's self-care perception. By understanding a patient's self-care perception, the physician may be able to explore these notions of positive or negative self-care perception and even gently correct them when necessary. This may allow physicians to better align themselves with the patient, provide behavioral health interventions, and better target and communicate effective plans. We suggest periodic assessment of diabetes distress and self-care perception to inform the need for education to improve self-efficacy.

959-P: Hands-On Continuous Glucose Monitor Training for Primary Care Providers in a Rural Family Medicine Residency Clinic

Continuous glucose monitors (CGMs) are helpful tools in managing diabetes, and it is important that primary care providers (PCPs) receive adequate training on how to use them. There are various on-demand lectures about CGMs that are available for clinicians, but these programs lack a hands-on component. In a rural Family Medicine residency clinic, two clinical pharmacists created a training program for PCPs which included an educational module, a hands-on experience wearing an intermittently-scanned CGM for 2 weeks, and a debriefing module. This study describes and evaluates this training program. The investigators created a questionnaire aimed to measure PCPs confidence and knowledge of CGMs. PCPs were given the identical questionnaire at baseline, after the educational module (midpoint), and after the debriefing module (final). Descriptive statistical analysis was performed to assess differences in confidence and knowledge levels throughout the program. A total of 21 PCPs completed the program, including 13 medical residents, six physician faculty, and two nurse practitioners. On a scale from 1 to 10, PCP’s rated their average baseline knowledge of CGMs at 3.8. This increased to 5.3 at midpoint, and 7.9 at final. For the knowledge-based portion of the questionnaire, PCPs scored an average of 20.35% at baseline, and this increased to 75.32% at midpoint, and 90.48% at final. After completion of the training program, all 21 participants either agreed or strongly agreed that having the opportunity to wear a CGM provided them with more confidence in working with patients with CGMs, compared to a lecture-based training program alone. This study demonstrates that a training program including a hands-on experiential component can improve PCPs confidence and knowledge levels regarding CGMs. Disclosure J.Prudencio: None. M.Kim: None. C.Chan: None. Funding Abbott Medical Education (2182022)

Association Between Patient Demographics and No-Show Rates at a Family Medicine Residency Clinic in Downtown Omaha

Association Between Patient Demographics and No-Show Rates at a Family Medicine Residency Clinic in Downtown Omaha

The Value of Qualitative Methods in Cross Cultural Education: A Case Study from a First Person Perspective

This paper presents a first-person account of using qualitative research methods to address medical residency education. The results of this project have been published. However, the study's process and its educational impact on the participants have not been well-described. The purpose of this article is to describe the background and conduct of the study itself. A family medicine residency program, the setting for this project, had recently begun accepting international medical graduates (IMGs) who had lived and received medical school education outside of the United States. The author, a faculty member in the residency and a clinical psychologist, and the physician faculty observed residents as they saw patients in the family medicine residency clinic. Concern was expressed about some of the IMG resident physicians’ knowledge base and their ability to develop rapport with patients. In providing instruction in behavioral science, the author and a psychologist colleague noted that some of the IMG residents were confused by aspects of U.S. family life and the educational system. The relationship with clinical instructors and expectations of faculty also differed from the pedagogical norms in U.S. medical education. As a result, a qualitative interview project was undertaken to understand better how these IMG residents were experiencing and interpreting faculty-learner and resident physician-patient interactions. The results were beneficial in multiple ways. First, recognizing that faculty members were interested in their experiences helped develop rapport and trust between the faculty and residents. Providing the project results to the residents helped open discussion about cultural differences in medical education and patient care. For educators who may have difficulty understanding the perspective that learners bring to their education, the process described could be of potential benefit.

The Association Between Family Medicine Appointment Cancellations and Hospital Utilization in 2019 and 2020.

The COVID-19 pandemic caused a disruption in the usual primary care services offered and received by patients. The objective of this study was to compare the impact of family medicine appointment cancellations on hospital utilization metrics both before and during the COVID-19 pandemic within a family medicine residency clinic. This study is a retrospective chart review of cohorts of patients with a family medicine clinic cancellation who presented to the emergency department during a similar time period before and during the pandemic (March-May of 2019 vs March-May 2020). The patient population studied has multiple chronic diagnoses and prescriptions. Hospital admission, hospital readmission, and length of stay for hospitalizations during these periods were compared. The impacts of appointment cancellations on the emergency department presentation with subsequent inpatient admission, readmission, and length of stay were examined using generalized estimating equation (GEE) logistic or Poisson regression models to account for the lack of independence between patient outcomes. A total of 1878 patients were included in the final cohorts. Of these patients, 101 (5.7%) presented to the emergency department and/or hospital in both 2019 and 2020. An increased odds of readmission was associated with family medicine appointment cancellation regardless of year. The effects of appointment cancellations were not associated with admissions or length of stay between 2019 and 2020. Between the 2019 and 2020 cohorts, appointment cancellations were not associated with significant differences in likelihood of admission, readmission, or length of stay. A higher risk of readmission was associated with patients with a recent family medicine appointment cancellation.

Utilizing the Modified OMP Model for Health Equity in a Family Medicine Residency Clinic

Background Racial and ethnically diverse communities have higher mortality rates from chronic diseases. One approach to address health disparities and systemic racism in health care is through alterations in primary care workforce development via the One-Minute Preceptor (OMP) Teaching Method. The University of North Carolina at Chapel Hill created a modified OMP Model for Health Equity to address racial health disparities while teaching. This quality improvement (QI) project focuses on faculty confidence in discussing racial health disparities with learners using the modified OMP Model. Methods The QI project used a Plan-Do-Study-Act (PDSA) framework. Faculty participated in the Awareness, Reflection/Empowerment, and Action (AREA) survey, to assess level of engagement in addressing health disparities. Family Medicine (FM) residents completed a survey on current precepting practices of ethno-racial health disparities. Faculty were introduced to the modified OMP, followed by a two-month intervention period. Post-intervention surveys assessed the impact and identified faculty development opportunities. The intervention took place within a Family Medicine Residency Program, specifically during outpatient continuity clinics and the inpatient Family Medicine Hospital Service. Results Faculty engagement increased in areas of awareness and action and decreased in reflection/empowerment. Residents reported higher satisfaction with Ethno-Racial health disparities clinical teaching after the intervention. Qualitative data suggests discussions are not occurring as often as residents desire and depend on different factors; race/ethnicity of the patient, clinical situation, social determinants of health impacting care, time, and preceptor. Discussion The modified OMP for Health Equity intervention can be used to increase awareness and promote self-reflection and change. Conclusion The PDSA cycle framework for an intervention can improve faculty engagement addressing Ethnic-Racial health disparities.

Utilizing the Modified OMP Model for Health Equity in a Family Medicine Residency Clinic

Background Racial and ethnically diverse communities have higher mortality rates from chronic diseases. One approach to address health disparities and systemic racism in health care is through alterations in primary care workforce development via the One-Minute Preceptor (OMP) Teaching Method. The University of North Carolina at Chapel Hill created a modified OMP Model for Health Equity to address racial health disparities while teaching. This quality improvement (QI) project focuses on faculty confidence in discussing racial health disparities with learners using the modified OMP Model. Methods The QI project used a Plan-Do-Study-Act (PDSA) framework. Faculty participated in the Awareness, Reflection/Empowerment, and Action (AREA) survey, to assess level of engagement in addressing health disparities. Family Medicine (FM) residents completed a survey on current precepting practices of ethno-racial health disparities. Faculty were introduced to the modified OMP, followed by a two-month intervention period. Post-intervention surveys assessed the impact and identified faculty development opportunities. The intervention took place within a Family Medicine Residency Program, specifically during outpatient continuity clinics and the inpatient Family Medicine Hospital Service. Results Faculty engagement increased in areas of awareness and action and decreased in reflection/empowerment. Residents reported higher satisfaction with Ethno-Racial health disparities clinical teaching after the intervention. Qualitative data suggests discussions are not occurring as often as residents desire and depend on different factors; race/ethnicity of the patient, clinical situation, social determinants of health impacting care, time, and preceptor. Discussion The modified OMP for Health Equity intervention can be used to increase awareness and promote self-reflection and change. Conclusion The PDSA cycle framework for an intervention can improve faculty engagement addressing Ethnic-Racial health disparities.

Actual vs Documented Advance Care Planning in a Primary Care Clinic.

Advance care planning (ACP) is a complex and multifaceted entity that has significant impact on patient care. ACP takes many forms, may be underbilled, and can have significant ramifications on quality care metrics. We performed a retrospective chart review for patients over 70 years in age in our family medicine resident clinic to evaluate the ways in which ACP is charted and the gap between billed and nonbilled ACP. The first 50 patients over 70 years in age seen between August 25, 2020 and September 25, 2020 were selected for standardized chart review. Billing for ACP was defined as Current Procedural Terminology codes=-10 codes 99497 or 99498. Primary outcomes were the percentage of patients with ACP and incidence of ACP documents. Secondary outcome was the proportion of documented ACP conversations in office visits which had billing for ACP. Forty-eight patients over 70 years in age were identified with an average age of 80.9 years old. Forty-one of 48 patients (85.4%) had some form of ACP and 12 (25%) had formal ACP documents. Of 25 patients with documented ACP conversations in office visits, eleven patients (44%) had ACP which had been formally billed. The majority of our patients had some form of ACP ranging from inpatient discussions of code status to outpatient visits regarding end-of-life care. However, ACP was underbilled in our practice. Physicians are often evaluated based on quality care metrics such as billed ACP which may not accurately reflect the work physicians are doing.

Group B Streptococcus Screening and Treatment Adherence in Pregnancy: A Retrospective Cohort Study and Opportunities for Improvement

Pregnancy is a time of increased healthcare screening, and past adherence to evolving guidelines informs best practices. Although studies of Group B Streptococcus guideline adherence have focused primarily on treatment of Group B Streptococcus carriers, this study broadly evaluated long-term adherence to both Group B Streptococcus screening and treatment guidelines. Adherence was evaluated across provider types (obstetrics and gynecology, certified nurse midwives, and family medicine). We conducted a retrospective cohort study. Demographic and clinical information were extracted from all prenatal care and delivery patients at a single institution in a single year. Vancomycin prescriptions in pregnancy were tracked for 10 years to determine long-term adherence. Adherence was defined as no deviation from 2010 Group B Streptococcus screening and treatment guidelines. Adherence occurred in 89% (1,610/1,810) of patients. Reasons for deviations from guidelines could not always be determined. There was no significant difference in maternal age, race, prenatal provider type, provider type at delivery, gestational age at delivery, delivery mode, or whether antibiotic sensitivities were performed between compliant and noncompliant groups. Significant differences in adherence were found between obstetric clinics (high-risk obstetrics clinic, maternal‒fetal medicine fellows clinic, continuity of care clinic, and faculty private clinic) (p<0.0001) and between the faculty family medicine clinic and resident family medicine clinic (p=0.001). Vancomycin prescription practice did not change significantly over the10-year period. High rates of adherence to Group B Streptococcus screening and treatment guidelines in pregnancy have positive implications for reducing antibiotic resistance. Given evolving guidelines, there is a need to periodically evaluate adherence and to re-educate providers about standard practices and best documentation practices.

Evidence based opioid weaning with behavioral support – Forum for Behavioral Science Edition

Nationally published guidelines state that many patients prescribed chronic opioids would benefit from gradually reducing and/or eliminating their use of these medications. This is easier said than done. Patients are often resistant or fearful, physicians are often uncomfortable prescribing an opioid taper, and patients often do not get the needed behavioral health support in this process. It is critical to develop a comprehensive behavioral and medical plan, however the field lacks practical approaches to guide physicians (and patients) through this challenge. In this manuscript our team of primary care providers and behaviorists walk through a case involving complex opioid weaning in a Family Medicine residency clinic environment. Through the lens of our patient's case, we will discuss best practices for getting patient buy-in, opioid weaning strategies, behavioral support during the wean, identifying co-morbid opioid use disorders, and deciding on acceptable end points for the taper.

Implementation of a Well-Male Examination in a Family Medicine Residency Clinic

Implementation of a Well-Male Examination in a Family Medicine Residency Clinic