Diary of a Family Physician Hayashi, Seiji
American family physician,
12/2021, Volume:
104, Issue:
6
Journal Article
Peer reviewed
After discussing the case, I wrote a letter stating that my patient has diabetes and end-stage renal disease, and that without the help of his wife, my patient would not be able to get to medical ...appointments or take care of himself at home. The patient looked at me nervously and showed me his discolored and thickened nails on two fingers and seven toes. Pointing to the procedure tray, he said, “I thought you were going to rip off all of my nails!” 3:30 p.m. I reviewed laboratory results between patients and saw an A1C of 6.7 for a patient whose A1C was 11 when I met her one year ago.
CONTEXT Primary care physicians report high levels of distress, which is linked to burnout, attrition, and poorer quality of care. Programs to reduce burnout before it results in impairment are rare; ...data on these programs are scarce. OBJECTIVE To determine whether an intensive educational program in mindfulness, communication, and self-awareness is associated with improvement in primary care physicians' well-being, psychological distress, burnout, and capacity for relating to patients. DESIGN, SETTING, AND PARTICIPANTS Before-and-after study of 70 primary care physicians in Rochester, New York, in a continuing medical education (CME) course in 2007-2008. The course included mindfulness meditation, self-awareness exercises, narratives about meaningful clinical experiences, appreciative interviews, didactic material, and discussion. An 8-week intensive phase (2.5 h/wk, 7-hour retreat) was followed by a 10-month maintenance phase (2.5 h/mo). MAIN OUTCOME MEASURES Mindfulness (2 subscales), burnout (3 subscales), empathy (3 subscales), psychosocial orientation, personality (5 factors), and mood (6 subscales) measured at baseline and at 2, 12, and 15 months. RESULTS Over the course of the program and follow-up, participants demonstrated improvements in mindfulness (raw score, 45.2 to 54.1; raw score change Δ, 8.9; 95% confidence interval CI, 7.0 to 10.8); burnout (emotional exhaustion, 26.8 to 20.0; Δ = −6.8; 95% CI, −4.8 to −8.8; depersonalization, 8.4 to 5.9; Δ = −2.5; 95% CI, −1.4 to −3.6; and personal accomplishment, 40.2 to 42.6; Δ = 2.4; 95% CI, 1.2 to 3.6); empathy (116.6 to 121.2; Δ = 4.6; 95% CI, 2.2 to 7.0); physician belief scale (76.7 to 72.6; Δ = −4.1; 95% CI, −1.8 to −6.4); total mood disturbance (33.2 to 16.1; Δ = −17.1; 95% CI, −11 to −23.2), and personality (conscientiousness, 6.5 to 6.8; Δ = 0.3; 95% CI, 0.1 to 5 and emotional stability, 6.1 to 6.6; Δ = 0.5; 95% CI, 0.3 to 0.7). Improvements in mindfulness were correlated with improvements in total mood disturbance (r = −0.39, P < .001), perspective taking subscale of physician empathy (r = 0.31, P < .001), burnout (emotional exhaustion and personal accomplishment subscales, r = −0.32 and 0.33, respectively; P < .001), and personality factors (conscientiousness and emotional stability, r = 0.29 and 0.25, respectively; P < .001). CONCLUSIONS Participation in a mindful communication program was associated with short-term and sustained improvements in well-being and attitudes associated with patient-centered care. Because before-and-after designs limit inferences about intervention effects, these findings warrant randomized trials involving a variety of practicing physicians.
Abstract Purpose Family physicians report some of the highest levels of burnout, but no published work has considered whether burnout is correlated with the broad scope of care that family physicians ...may provide. We examined the associations between family physician scope of practice and self-reported burnout. Methods Secondary analysis of the 2016 National Family Medicine Graduate Survey respondents who provided outpatient continuity care (N = 1,617). We used bivariate analyses and logistic regression to compare self-report of burnout and measures of scope of practice including: inpatient medicine, obstetrics, pediatric ambulatory care, number of procedures and/or clinical content areas, and providing care outside the principal practice site. Results Forty-two percent of respondents reported feeling burned out from their work once a week or more. In bivariate analysis, elements of scope of practice associated with higher burnout rates included providing more procedures/clinical content areas (mean procedures/clinical areas: 7.49 vs 7.02; P = .02) and working in more settings than the principal practice site (1+ additional settings: 57.6% vs 48.4%: P = .001); specifically in the hospital (31.4% vs 24.2%; P = .002) and patient homes (3.3% vs 1.5%; P = .02). In adjusted analysis, practice characteristics significantly associated with lower odds of burnout were practicing inpatient medicine (OR = 0.70; 95% CI, 0.56–0.87; P = .0017) and obstetrics (OR = 0.64; 95% CI, 0.47–0.88; P = .0058). Conclusions Early career family physicians who provide a broader scope of practice, specifically, inpatient medicine, obstetrics, or home visits, reported significantly lower rates of burnout. Our findings suggest that comprehensiveness is associated with less burnout, which is critical in the context of improving access to good quality, affordable care while maintaining physician wellness.
Purpose
Childhood cancer survivors are at risk for long-term morbidity and early mortality. Since most adult and some adolescent survivors of childhood cancer will receive their long-term care from a ...primary care physician, we sought to determine family physicians’ comfort with caring for this population.
Methods
A survey was mailed to 2,520 United States (US) and Canadian family physicians to assess their attitudes and knowledge regarding the care of adolescent and young adult survivors of childhood cancer.
Results
One thousand one hundred twenty-four family physicians responded (704 US, 420 Canadian). Median age was 53 years; 63 % were men; 81 % had cared for ≤2 childhood cancer survivors in the past 5 years. Of those who had cared for a survivor, 48 % had never or almost never received a treatment summary from the referring cancer center; 85 % preferred to care for survivors in consultation with a cancer center-based physician or long-term follow-up program. Only 33, 27, and 23 % of respondents were very comfortable caring for survivors of childhood Hodgkin lymphoma, acute lymphoblastic leukemia or osteosarcoma, respectively. Only 16, 10, and 74 % of respondents correctly identified the guideline recommended surveillance for secondary breast cancer, cardiac dysfunction and hypothyroidism in response to a vignette describing a Hodgkin lymphoma survivor. Respondents rated access to clinical care guidelines and receipt of a patient-specific letter from specialists with surveillance recommendations as the modalities most likely to assist them in caring for survivors.
Conclusions
Most family physicians are willing to care for childhood cancer survivors in consultation with a cancer center, and with specific tools to facilitate this care.
Implications for Cancer Survivors
Adult and adolescent survivors of childhood cancer who receive their follow-up care from a family physician must be empowered to choose a physician who is comfortable with caring for survivors. Further, the survivor must ensure that their physician has access to a treatment summary as well as to patient-specific recommendations for surveillance for late effects of cancer therapy.
Diary of a Family Physician Bradley, Megan; Humpherys, Dwight
American family physician,
02/2023, Volume:
107, Issue:
2
Journal Article
Peer reviewed
I am prerounding on patients in the hospital. One was admitted with a possible large pleural effusion. He is sent to interventional radiology for thoracentesis. I am concerned about the fluid because ...he was recently diagnosed with a rare cancer.
Diary of a Family Physician Knox, James D; Silk, Hugh
American family physician,
12/2022, Volume:
106, Issue:
6
Journal Article
Peer reviewed
My first patient is a 16-year-old girl with a massive skin lesion down the right side of her body that has been there since birth. This week the plaques started to cause pain and felt warm in one ...location. Suspecting a superinfection, I start her on antibiotics and hydrocortisone cream. I send my dermatologist friend in the United States pictures of the plaques, and she diagnoses epidermal nevus syndrome.
Noncommunicable diseases (NCDs) are a major threat to population health worldwide. In Shanghai, China, a new pattern of NCD management-self-management-has been developed in community health service ...centres (CHSCs).
To clarify how contracting with CHSC-based family doctors (FDs) influences the engagement in and effectiveness of self-management behaviour among NCD patients.
We conducted two waves of a questionnaire survey (in 2013 and 2016) to collect data on patients with NCDs. Separate logistic regression models and longitudinal analysis were performed to examine the effect of contracting with an FD on NCD self-management and the effectiveness of this self-management.
Nearly all contracted patients (80.79%) had implemented NCD self-management, while only 55.57% of non-contracted patients did so. The self-management effectiveness rate was also higher among contracted patients than among non-contracted ones (86.66% vs. 54.79%). In the population-averaged models, contracted patients had 2.25 and 2.91 times greater odds of implementing self-management and reporting that the self-management was effective, respectively, after controlling for all related variables. Additionally, awareness of FD-contracted services, satisfaction with CHSCs, and experiencing first contact at CHSCs had positive impacts on the implementation and effectiveness of self-management.
FDs were important for ensuring that NCD patients engaged in self-management behaviour, the most common form of which was focus group. Participation in NCD focus groups may be key for attaining the effects of self-management, including improved health knowledge, greater health awareness, more frequent engagement in health behaviour, and, most importantly, greater practice of self-monitoring. Self-management might help to achieve greater NCD control.
After the Ebola outbreaks in Africa, the WHO has declared the novel coronavirus, spreading from Wuhan city in China since December, another public health emergency of international concern. Since ...that 2003 fatal outbreak, the role of family doctors in risk reduction and preparedness to medical emergency has gained recognition both locally and globally. Family doctors empower the systems through training and new modes of practice In order to gain the trust of the public and other professionals, family doctors must demonstrate competency through continuous training and professional development.
Few interventions have proven effective in reducing the overuse of antibiotics for acute respiratory infections. We evaluated the effect of DECISION+2, a shared decision-making training program, on ...the percentage of patients who decided to take antibiotics after consultation with a physician or resident.
We performed a randomized trial, clustered at the level of family practice teaching unit, with 2 study arms: DECISION+2 and control. The DECISION+2 training program included a 2-hour online tutorial followed by a 2-hour interactive seminar about shared decision-making. The primary outcome was the proportion of patients who decided to use antibiotics immediately after consultation. We also recorded patients' perception that shared decision-making had occurred. Two weeks after the initial consultation, we assessed patients' adherence to the decision, repeat consultation, decisional regret and quality of life.
We compared outcomes among 181 patients who consulted 77 physicians in 5 family practice teaching units in the DECISION+2 group, and 178 patients who consulted 72 physicians in 4 family practice teaching units in the control group. The percentage of patients who decided to use antibiotics after consultation was 52.2% in the control group and 27.2% in the DECISION+2 group (absolute difference 25.0%, adjusted relative risk 0.48, 95% confidence interval 0.34-0.68). DECISION+2 was associated with patients taking a more active role in decision-making (Z = 3.9, p < 0.001). Patient outcomes 2 weeks after consultation were similar in both groups.
The shared decision-making program DECISION+2 enhanced patient participation in decision-making and led to fewer patients deciding to use antibiotics for acute respiratory infections. This reduction did not have a negative effect on patient outcomes 2 weeks after consultation. ClinicalTrials.gov trial register no. NCT01116076.
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