Medical Practice Settings Research Articles

Estimated cost per HIV infection diagnosed through routine HIV testing offered in acute general medical admission units and general practice settings in England.

Following national guidelines to expand HIV testing in high-prevalence areas in England, a number of pilot studies were conducted in acute general medical admission units (ACUs) and general practices (GPs) to assess the feasibility and acceptability of testing in these settings. The aim of this study was to estimate the cost per HIV infection diagnosed through routine HIV testing in these settings. Resource use data from four 2009/2010 Department of Health pilot studies (two ACUs; two GPs) were analysed. Data from the pilots were validated and supplemented with information from other sources. We constructed possible scenarios to estimate the cost per test carried out through expanded HIV testing in ACUs and GPs, and the cost per diagnosis. In the pilots, cost per test ranged from £8.55 to £13.50, and offer time and patient uptake were 2 minutes and 90% in ACUs, and 5 minutes and 60% in GPs, respectively. In scenario analyses we fixed offer time, diagnostic test cost and uptake rate at 2 minutes, £6 and 80% for ACUs, and 5 minutes, £9.60 and 40% for GPs, respectively. The cost per new HIV diagnosis at a positivity of 2/1000 tests conducted was £3230 in ACUs and £7930 in GPs for tests performed by a Band 3 staff member, and £5940 in ACUs and £18 800 in GPs for tests performed by either hospital consultants or GPs. Expanded HIV testing may be more cost-efficient in ACUs than in GPs as a consequence of a shorter offer time, higher patient uptake, higher HIV positivity and lower diagnostic test costs. As cost per new HIV diagnosis reduces at higher HIV positivity, expanded HIV testing should be promoted in high HIV prevalence areas.

Functional neuroimaging correlates of thinking flexibility and knowledge structure in memory: Exploring the relationships between clinical reasoning and diagnostic thinking

Background: Diagnostic reasoning involves the thinking steps up to and including arrival at a diagnosis. Dual process theory posits that a physician’s thinking is based on both non-analytic or fast, subconscious thinking and analytic thinking that is slower, more conscious, effortful and characterized by comparing and contrasting alternatives. Expertise in clinical reasoning may relate to the two dimensions measured by the diagnostic thinking inventory (DTI): memory structure and flexibility in thinking.Aim: Explored the functional magnetic resonance imaging (fMRI) correlates of these two aspects of the DTI: memory structure and flexibility of thinking.Methods: Participants answered and reflected upon multiple-choice questions (MCQs) during fMRI. A DTI was completed shortly after the scan. The brain processes associated with the two dimensions of the DTI were correlated with fMRI phases – assessing flexibility in thinking during analytical clinical reasoning, memory structure during non-analytical clinical reasoning and the total DTI during both non-analytical and analytical reasoning in experienced physicians.Results: Each DTI component was associated with distinct functional neuroanatomic activation patterns, particularly in the prefrontal cortex.Conclusion: Our findings support diagnostic thinking conceptual models and indicate mechanisms through which cognitive demands may induce functional adaptation within the prefrontal cortex. This provides additional objective validity evidence for the use of the DTI in medical education and practice settings.

ANÁLISE HERMENÊUTICA DA ORTOTANÁSIA: APLICAÇÃO DOS MÉTODOS DE INTERPRETAÇÃO DA NORMA CONSTITUCIONAL À MORTE DIGNA

When one is facing cases of terminally ill patients, to which there are no skilled therapeutic resources to contain or bring healing to the disease, orthothanasia is presented as a set of medical practices aimed at leading to such patients entitled death with dignity. This article aims to analyze how orthothanasia must be assimilated before the different acting techniques applicable to constitutional rule, basedon the principles of human dignity, freedom and the right to life. It was used the deductive method, analytical, dogmatic philosophical-legal approach and also zeteticthrough indirect documentation to arrive at the conclusions found by the study ofhermeneutical methods applied to the Federal Constitution of 1988, which allowedthe consideration that orthothanasia is legally compatible with the Brazilian constitutional system in place.

Prevalence of Drug Testing Among Family Medicine Residents and Students: Much Needed Data.

Prevalence of Drug Testing Among Family Medicine Residents and Students: Much Needed Data.

Report of consultation as psychological practice in medical settings

Report of consultation as psychological practice in medical settings

Global Health Care-seeking Discourses Facing Local Clinical Realities: Exploring the Case of Cancer.

Using cancer as an example and drawing on Pierre Bourdieu's concepts of field and on prolonged fieldwork in Danish general medical practice settings, we examine how discourses about what counts as legitimate help-seeking practices are negotiated in local clinical encounters. Overall, we identify competition between two discourses on help-seeking practices. This competition is present most when people seek help with unspecific, vague, or diffuse illness complaints, voicing uncertainty as to what counts as signs of illness, characteristic of proactive discourses emanating from global, scientific biomedicine. Such indistinct help-seeking conflicts with the dominant discourse in the local clinical setting and is characterized by an overt focus on identification of the chief complaint. The analysis illustrates how competing discourses may result in conflicting expectations to the clinical encounter and prove counterproductive to ensuring early diagnosis of cancer.

Use of SBI, an Oral Medical Food as an Option for Various Gastrointestinal Disorders

Introduction: Oral medical foods have been used for decades for nutritional support, primarily in institutional settings. It is now possible to utilize prescription medical foods for gastrointestinal (GI) disorders in medical practice. Oral serum-derived bovine immunoglobulin/protein isolate (SBI) has been shown to reduce loose stools, improve stool consistency as well as other symptoms (i.e., abdominal pain, bloating, urgency) in patients with diarrhea predominant irritable bowel syndrome (IBS-D) syndrome and HIV-associated enteropathy. This current assessment followed 18 difficult to treat patients in outpatient medical practice setting using SBI as an addition to standard of care. The population consisted of 18 patients: 14 IBS (2 constipation predominant IBS (IBS-C), 7 IBS-D, 2 Mixed IBS (IBS-M), 3 IBS), 2 Crohn’s disease, 1 J-pouch, and 1 chronic ischemic bowel, and ranged in age from 22-92 years. SBI was added to their current care at a daily dose of either 5 or 10 g and followed for several weeks to determine if treatment helped to address and manage their symptoms. Primary symptoms included abdominal pain, diarrhea, bloating, distention and incontinence. Overall, 16 of the 18 patients showed improved symptoms while 2 patients discontinued therapy. One IBS patient was non-compliant during 8 weeks of therapy and 1 IBS-C patient showed improved bowel movements, but felt the therapy was ineffective and chose to discontinue after 11 weeks of therapy. Of the remaining 16 patients who remained on therapy, they reported an overall improvement in symptoms with improved stool consistency, decreased frequency as well as improvements in abdominal pain, bloating, distention, incontinence, nausea and some reports of improved appetites. Two patients reported a resolution or near resolution of symptoms. In most cases, therapeutic effects of SBI were seen within the first 4 weeks of therapy with continued improvements at subsequent visits. In some cases, the removal of other medications was made given patient response with SBI. GI disorders that result in severe chronic changes in motility can be difficult to treat and many patients fail on conventional drug therapies. The multifaceted mechanism of action and specificity of SBI may help to manage chronic motility problems and other symptoms in these difficult to treat patients. Evidence in animal models has shown that SBI can reduce intra-luminal bacterial products, bind with bacterial lipopolysaccharides, and enhance tight junctions between intestinal epithelial cells. Medical foods are a safe treatment option for patients with IBS and other gastrointestinal disorders. Disclosure - Bryon Petschow, PhD - employee of Entera Health, Inc.

Two decades of using the combination of tetracycline derivatives and niacinamide as steroid-sparing agents in the management of pemphigus: Defining a niche for these low toxicity agents

The twin goals of long-term disease control and minimizing toxicities related to immunosuppression necessitate efforts to find effective steroid-sparing agents in the management of patients with autoimmune bullous diseases. Pemphigus especially requires a long view, because the disease can persist throughout a patient's lifetime, yet few clinical trial reports exist to guide the practitioner. We review the response of pemphigus patients to tetracycline, doxycycline, or minocycline plus niacinamide (TCN/NAM) as steroid-sparing therapy and to determine the effects of TCN/NAM on autoantibody levels during the long-term treatment of pemphigus. This was a retrospective chart review in a private medical dermatology practice setting of all pemphigus patients treated between 1993 and 2013. Clinical responses to TCN/NAM therapy after initial high-dose steroid induction therapy and pemphigus antibody levels were recorded over the course of disease flares and treatment cycles along with any related side effects. Anti-desmoglein 1 and 3 titers were compared in a subset of patients over time, and a statistical analysis was performed to correlate the clinical response with antibody levels. Fifty-one pemphigus patients (43 with pemphigus vulgaris, 7 with pemphigus foliaceous, and 1 with pemphigus erythematosus) received at least 3 months of TCN/NAM, and 16 patients with pemphigus vulgaris had 1 set of pemphigus antibody titers correlating to a baseline/flare and clinical remission. TCN/NAM was associated with disease control in 43 of 51 patients, with a duration of response ranging from 1 to 13 years (mean, 3.14 ± 2.97 years). Thirteen of 51 patients needed no additional treatment for complete disease control, while 33 of 51 needed intermittent topical clobetasol or short courses of oral steroids for long-term management. There were 5 nonresponders. Antidesmoglein titers trended lower in TCN/NAM responders, but only desmoglein 3 approached statistical significance (anti-desmoglein 1, P= .21; anti-desmoglein 3, P= .02). This is a retrospective analysis from a single practice. A lack of serial autoantibody titers limited statistical analyses. TCN/NAM may be useful as a steroid-sparing therapy for pemphigus.

Use of ibuprofen sustained release for treating osteoarthritic pain: findings from 15 general medical practices in Egypt.

PurposeIbuprofen sustained release (SR) has been shown to provide effective symptomatic pain relief in chronic arthritic conditions such as osteoarthritis in European and US patient populations. Few studies have been conducted in other patient populations. A 4-week prospective multicenter open-label observational study was designed to explore and describe the combined effect of ibuprofen SR and standard medical care in patients suffering from osteoarthritis in 15 general medical practices in Egypt.Patients and methodsIn total, 519 patients were prescribed ibuprofen SR 2 ×800 mg once daily for 4 weeks.ResultsIbuprofen SR combined with standard medical care significantly improved day and night pain, with 99.4% of the patients reporting improvement. The treatment reduced the symptom severity of joint tenderness/stiffness and the duration of morning stiffness, and allowed more patients to carry out normal activities. Overall compliance with the prescribed ibuprofen SR regimen was 98.6%. Ibuprofen SR was generally well tolerated with no serious adverse events reported during the study. There was no increase in blood pressure or heart rate.ConclusionThe combined treatment provided effective relief of pain in patients with osteoarthritis in a large real-life general medical practice setting in Egypt. Owing to its convenient once-daily dosing regimen, ibuprofen SR may enhance patient compliance.

An observational study evaluating tacrolimus dose, exposure, and medication adherence after conversion from twice- to once-daily tacrolimus in liver and kidney transplant recipients

Immunosuppression regimens in transplantation medicine are complex. Drugs with extended release action have simplified medication dosing without affecting efficacy. This prospective, observational, multicenter study, conducted in a routine medical practice setting, evaluated changes in tacrolimus daily dose and trough levels and patient-reported medication adherence at day 90 after 1:1 (mg: mg) conversion to once-daily tacrolimus in adult liver and kidney transplant recipients. Data from 224 recipients of a liver (n=19) or kidney (n=205) transplant, average age 51±14.5 years, were evaluated. The mean change in tacrolimus daily dose was +0.04 mg/day. Dose remained stable after conversion in 62.5%, was lower in 15.6%, and higher in 22% of patients. Trough level after conversion was lower in 62.6% and higher in 36.5%; generally, levels were 12.8% lower than pre-conversion levels. No acute rejection, graft loss, or serious safety events were observed. Two deaths occurred due to myocardial infarction. Conversion helped 19% to less frequently forget medications and 55% reported no difference in remembering to take the once-daily dose after conversion. The change in dosing frequency was identified as "better" for 55%. Tacrolimus daily dose remained stable while trough levels were significantly lower after conversion to once-daily dosing. Safety and efficacy were maintained; reduced dosing frequency had no apparent influence on patient-reported medication adherence.

Sequential Decisions for Location and Service Intensity by Professional Service Firms with Geographically Dispersed Clients

The issues of inseparability, the difficulty of knowledge transfer, and the limited number of service providers requires professional service firms(PSFs) to develop unique service delivery systems to serve geographically dispersed clients. This study examined service location and intensity decisions for a multi-location service delivery system. in other words, this study examined two inter-related questions; 1) how they chose locations in which to practice that lay outside the urban areas where their home offices resided, and 2) how much resources they allocated to the selected location. These two sequential questions are investigated with a generalized Tobit model. This research tested hypotheses using a unique data set of medical oncology specialty group practices in the state of Iowa in the U.S. for the period 1989–2001. This study focused on the service delivery decisions made by these specialized physicians regarding practicing in rural areas near the urban center where they are located. Specifically, this study examined their decisions regarding the locations and intensity of service via visiting consulting clinics(VCC) in rural hospitals. This study found that the practice locations in a given year were determined by the benefits of the location as well as the opportunity costs to serve that location. Furthermore, past experience played an important role in the choices made by these professional service firms. However, the data showed that the number of incumbent competitors does not affect PSF’s location decision. With respect to the level of resource allocation(service intensity) to these locations, the decisions by the PSFs in the sample of this study were driven by many of the same factors as their choices to practice there in the first place. Locations with larger client bases and lower opportunity costs enjoyed higher levels of service intensity. The PSFs also allocated more resources to locations that were not overly attracted to competitors. Although the number of competitors did not affect the choice decision, the service intensity of the incumbent competitors affects the focal PSF’s service intensity. In other words, once a PSF decides to enter the market the PSF tends to provides high level of service intensity when the competitors are allocating more resources.

The effectiveness of health education using the teach-back method on adherence and self-management in chronic disease: a systematic review protocol

Review question/objective What is the effect of using the teach-back method for health education to improve adherence to treatment regimen and self-management in chronic disease? Inclusion criteria Types of participants This review will consider all studies that include adult patients (aged 18 years and over) in any healthcare setting, either as inpatients (eg acute care, medical and surgical wards) or those who attend primary health care, family medical practice, general medical practice, clinics, outpatient departments, rehabilitation or community settings. Participants need to have been diagnosed as having one or more chronic diseases including heart failure, diabetes, cardiovascular disease, cancer, respiratory disease, asthma, chronic obstructive pulmonary disease, chronic kidney disease, arthritis, epilepsy or a mental health condition. Studies that include seriously ill patients, and/or those who have impairments in verbal communication and cognitive function will be excluded. Types of intervention This review will consider studies that investigate the use of the teach-back method alone or in combination with other supporting education, either in routine or research intervention education programs; regardless of how long the programs were and whether or not a follow-up was conducted. The intervention could be delivered by any healthcare professional. The comparator will be any health education for chronic disease that does not include the teach-back method. Types of outcomes Primary outcomes of interest are disease-specific knowledge, adherence, and self-management knowledge, behavior and skills measured using patient report, nursing observation or validated measurement scales. Secondary outcomes include knowledge retention, self-efficacy, hospital readmission, hospitalization, and quality of life, also measured using patient report, nursing observation, hospital records or validated measurement scales.

A review of research on the prevalence, antecedents, consequences and prevention of workplace aggression in clinical medical practice

A broad-ranging review of the published research literature was undertaken on workplace aggression in clinical medical practice. Prevalence studies have found that 15–75% of survey respondents reported verbal aggression and 2–29% reported physical aggression in medical practice settings in the previous 6–24 months. In comparison, there was limited published research on the antecedents and consequences of clinician exposure to workplace aggression, and a dearth of published research on the prevention and minimization of workplace aggression in medical practice settings. Future research efforts need to investigate workplace aggression from all sources and across all medical clinician sub-populations in the diverse settings in which they work. Specific attention needs to be given to identifying key risk and protective factors for workplace aggression exposure, including in relation to clinician profiles, the settings and conditions of medical work, and the presence of key aggression prevention and minimization efforts, both individually and in combination. The impact of workplace aggression on clinician health, well-being, performance and work participation remains under-researched. Overall, a more extensive and robust evidence base is required to enable informed decision-making on reducing the likelihood and consequences of workplace aggression in clinical medical practice.

Use of electronic medical records differs by specialty and office settings.

To assess differences in the use of electronic medical records (EMRs) among medical specialties and practice settings. A cross-sectional retrospective study using nationally representative data from the National Ambulatory Medical Care Survey for the period 2003-2010 was performed. Bivariate and multivariate analyzes compared EMR use among physicians of 14 specialties and assessed variation by practice setting. Differences in EMR use by geographic region, patient characteristics, and physician office settings were also assessed. Bivariate and multivariate analysis demonstrated increased EMR use from 2003 to 2010, with 16% reporting at least partial use in 2003, rising to 52% in 2010 (p<0.001). Cardiologists, orthopedic surgeons, urologists, and family/general practitioners had higher frequencies of EMR use whereas psychiatrists, ophthalmologists, and dermatologists had the lowest EMR use. Employed physicians had higher EMR uptake than physicians who owned their practice (48% vs 31%, p<0.001). EMR uptake was lower among solo practitioners (23%) than non-solo practitioners (42%, p<0.001). Practices owned by Health Maintenance Organizations had higher frequencies of EMR use (83%) than practices owned by physicians, community health centers, or academic centers (all <45%, p<0.001). Patient demographics did not affect EMR use (p>0.05). Uptake of EMR is increasing, although it is significantly slower in dermatology, ophthalmology, and psychiatry. Solo practitioners and owners of a practice have low frequencies of EMR use compared with non-solo practitioners and those who do not own their practice. Despite incentives for EMR adoption, physicians should carefully weigh which, if any, EMR to adopt in their practices.

Workplace aggression prevention and minimisation in Australian clinical medical practice settings – a national study

This report describes the extent to which 12 workplace aggression prevention and minimisation actions have been implemented in Australian clinical medical practice settings. Using a cross-sectional, self-report survey conducted as part of a national longitudinal study of the Australian medical workforce, differences in the proportions of medical clinicians reporting the implementation of 12 aggression prevention and minimisation actions in their main workplace were determined. Only one-third of aggression prevention and minimisation actions achieved point-prevalence rates of greater than 60%, including aggression policies and protocols (65.7%) and incident reporting systems (68.2%). Overall, lower point-prevalence rates were detected for general practitioners and specialists compared with hospital non-specialists and specialists in training, largely reflecting those for doctors mainly working in private rooms compared with public hospitals. Key environmental interventions had relatively low point-prevalence overall, including duress alarms and optimised clinician escape in consulting and treatment areas, and after-hours and off-site safety strategies. More widespread adoption of aggression prevention and minimisation measures in medical practice settings is required. Specific legislative and accreditation provisions and funding support may provide the necessary impetus for reform. Further studies can enhance the evidence base on the most effective approaches to the prevention and minimisation of workplace aggression in medical practice settings.

Ethics Commentary: Ethical Issues in Psychosomatic Medicine (Consultation-Liaison Psychiatry)

Psychiatrists who practice in medical settings are often called on to provide their recommendations in medical situations with challenging ethical dilemmas. Although not necessarily trained ethicists, psychiatric consultants are often expected to be expertly versed in the field of medical ethics. It is thus imperative for psychiatrists working in medical hospitals to be familiar with important ethical concepts and questions and have a framework within which they can conceptualize their cases. In this paper, we review the “Four Topics Method,” which provides a framework to help with ethical decision-making strategies for patients in a medical setting. We then discuss three cases using this framework, outlining the ethical dilemmas in question and highlighting important themes.

Corrigendum to: Prevalence and prevention of workplace aggression in Australian clinical medical practice

Objective. To determine the extent of aggression directed towards Australian doctors and the implementation of aggression prevention and minimisation strategies in medical workplaces. Methods. Data were obtained from the pilot phase (n = 321) of the Medicine in Australia: Balancing Employment and Life survey of the clinical medical workforce in 2010. Descriptive statistics were generated in relation to doctors' experiences of aggression at work in the previous 12 months, and the implementation of workplace aggression prevention and minimisation strategies. Distributions of the outcome variables were evaluated by doctor type and sex. Results. More than 70% of doctors experienced verbal or written aggression and almost a third experienced physical aggression. Higher proportions of hospital non-specialists and specialists-in-training experienced aggression from patients, patient relatives or carers and co-workers. Higher proportions of female doctors experienced verbal or written aggression from patient relatives or carers and co-workers. Overall, the more basic aggression prevention and minimisation strategies had been implemented in approximately two-thirds of clinical settings, with lower rates for more extended strategies. Conclusions. Many Australian doctors experience workplace aggression. The more widespread adoption of measures that support the prevention and minimisation of aggression in medical practice settings appears necessary. What is known about the topic? The limited research on workplace aggression in Australian medical practice primarily focusses on the prevalence of patient aggression in General Practice. What does this paper add? Current evidence is provided on the extent of workplace aggression directed towards Australian doctors from multiple sources and the implementation of workplace aggression prevention and minimisation strategies in diverse clinical settings. What are the implications for practitioners? More concerted efforts need to be undertaken to ensure that effective aggression prevention and minimisation strategies are implemented in medical practice.

Counseling in Primary Care Improves Depression and Quality of Life

Introduction:To measure the effectiveness on Quality of Life of adjunctive cognitive behavioral counseling in the setting of General Practitioners (GPs) along with the treatment as usual (TAU;) for the treatment of depression.Methods:Six month-controlled trial of patients who were referred to randomly assigned GPs (four for experimental group of patients and ten for the control) was done. Experimental sample had 34 patients with DSM-IV diagnosis of Depression (Depressed Episode, Dysthymia, or Adjustment Disorder with Depressed Mood) receiving the TAU supplemented with counseling. Control group had 30 patients with diagnosis of Depression receiving only the TAU. Results:The Beck Depression Inventory (BDI) score improved in both groups. Patients in the experimental group showed greater improvement compared to the control group at T2. The World Health Organization Quality OF Life Questionnaire (WHOQOL) score also improved in the experimental group but not in the control group. The improvement in the experimental group was statistically significant in terms of both BDI and WHOQOL scores.Conclusions:Adding counseling to TAU in general medical practice settings is more effective in controlling the symptoms of depression and improving the quality of life as measured over a period of six months, than TAU alone. These results while encouraging, also calls for a larger study involving a largersample size and a longer period of time.

Surveillance for Hepatocellular Carcinoma: Long Way to Achieve Effectiveness

Surveillance for hepatocellular carcinoma (HCC) in high risk groups including those with cirrhosis as well as with chronic HBV infection is recommended by several practice guidelines including those by the Asian Pacific Association for the Study of Liver (APASL) [1], the American Association for the Study of Liver Disease (AASLD) and the European Association for Study of The Liver (EASL). The evidence supporting the surveillance recommendations in these guidelines is based on evidence of intermediate strength, although arguably the evidence is strongest for HCC surveillance in individuals infected with HBV in Southeast Asia. For example, two randomized controlled trials were conducted in China among individuals with chronic HBV infection with and without cirrhosis. In one placebo-controlled randomized study of nearly 19,000 HBV-infected patients, it was shown that HCC surveillance with both abdominal ultrasound and serum AFP repeated at 6-month intervals resulted in a 37 % reduction in HCCrelated mortality [2]. However, the other randomized controlled trial of 5,581 HBV-infected patients reported that serum AFP repeated at 6-month intervals did not result in a significant reduction in overall mortality [3]. The latter study was smaller and had detected HCC less frequently than the first study and therefore could have suffered from a lack of adequate statistical power. In addition to these two randomized trials, a population-based surveillance program using serum AFP every 6-months among HBVinfected patients in Alaska reported that, during a 16-year follow-up period, patients with HCC who received surveillance had significantly longer 5-year survival compared with historical controls (42 vs. 0 %, respectively) [4]. Last in the evidence hierarchy, several nonrandomized trials and observational cohort and case–control studies have reported that patients who undergo HCC surveillance are diagnosed at an earlier stage of HCC, are more likely to receive potentially curative therapy, and have a significant reduction in cancer-specific mortality compared with patients detected with symptomatic HCC [5, 6]. The ‘‘efficacy’’ of HCC surveillance reflects the degree to which surveillance produces the expected result under controlled conditions chosen to maximize the likelihood of observing an effect if it exists. By contrast, ‘‘effectiveness’’ addresses the extent to which HCC surveillance is beneficial when deployed in medical practice settings [7]. Effectiveness takes into account external factors such as individual patient characteristics, health system features, and societal influences. For HCC surveillance to be effective, several steps need to be enacted. These include (1) identification of high risk patients who are appropriate for surveillance (HBV and HCV with advanced fibrosis/ cirrhosis), (2) availability and accessibility of HCC surveillance to patients at risk in appropriate health care settings, (3) recommendation of the intervention by health care providers, (4) acceptance of HCC surveillance by patients, (5) adherence to surveillance, recall and follow-up at the recommended intervals, the benefits of therapy, (6) availability of appropriate diagnostic test follow-up for abnormal surveillance, and (7) availability of efficacious curative or palliative treatment once HCC is diagnosed. Given the multiplicity of components involved with determining HCC surveillance effectiveness, one could assess the interactions between these factors to arrive with an estimate of how one particular intervention would H. B. El-Serag (&) Dan L Duncan Professor of Medicine, Michael E DeBakey VA Medical Center, Houston Center for Quality of Care and Utilization Studies, Baylor College of Medicine, Houston, TX, USA e-mail: hasheme@bcm.edu

Training for Collaboration: Collaborative Practice Skills for Mental Health Professionals

The purpose of the study was to identify skills that mental health practitioners need for successful collaborative practice in medical settings. Known experts in the field of collaborative health care completed a survey designed to elicit their suggestions about what is needed for successful collaborative care practice. Through qualitative analysis, a set of 56 skills was developed. These skills are organized into three general categories of competency: (a) skills for working in a medical setting; (b) skills for working with patients; and (c) skills for collaborating with healthcare providers.