PURPOSE Primary care physicians play unique roles caring for complex patients, often acting as the hub for their care and coordinating care among specialists. To inform the clinical application of new models of care for complex patients, we sought to understand how these physicians conceptualize patient complexity and to develop a corresponding typology. METHODSWe conducted qualitative in-depth interviews with internal medicine primary care physicians from 5 clinics associated with a university hospital and a community health hospital. We used systematic nonprobabilistic sampling to achieve an even distribution of sex, years in practice, and type of practice. The interviews were analyzed using a team-based participatory general inductive approach. RESULTSThe 15 physicians in this study endorsed a multidimensional concept of patient complexity. The physicians perceived patients to be complex if they had an exacerbating factor-a medical illness, mental illness, socioeconomic challenge, or behavior or trait (or some combination thereof)-that complicated care for chronic medical illnesses.CONCLUSION This perspective of primary care physicians caring for complex patients can help refine models of complexity to design interventions or models of care that improve outcomes for these patients. INTRODUCTIONP rimary care physicians (PCPs) play unique roles caring for complex patients, often acting as the hub for their care and coordinating care among specialists. Algorithms that focus on numbers of conditions, medications, or both, however, may not align with clinicians' definitions of complexity.1,2 Early definitions of patient complexity focused on those factors.2,3 Newer models of complexity have been developed that incorporate mental health, social influences, and economic factors that substantially affect chronic disease outcomes. [4][5][6][7][8][9][10][11][12][13][14] For example, building on the work of Stiefel et al 10 with the INTERMED instrument, Peek et al 4 developed the Minnesota Complexity Assessment Method, which assesses 5 domains: illness (both medical and mental illness), readiness to engage, social, health system, and resources for care. It is unclear, however, whether PCPs' perceptions of complexity are aligned with these newer models.If endorsed by PCPs, newer models of complexity could potentially contribute to improving algorithms for risk adjustment for primary care patient panels, controlling for complexity in secondary database analysis, and designing interventions for complex patients. To inform the clinical application of new models of care for complex patients, we sought to understand how PCPs conceptualize patient complexity and to develop a corresponding typology. METHODSWe used a qualitative study design to conduct in-depth, open-ended interviews with PCPs. Using systematic nonprobabilistic sampling to achieve a 452balanced distribution of sex, years in practice, and type of practice, we recruited physicians from 2 university clinics and 3 community health clinics. 15 We limited o...

BackgroundComplex patients are increasingly common in primary care and often have poor clinical outcomes. Healthcare system barriers to effective care for complex patients have been previously described, but less is known about the potential impact and meaning of caring for complex patients on a daily basis for primary care providers (PCPs). Our objective was to describe PCPs’ experiences providing care for complex patients, including their experiences of health system barriers and facilitators and their strategies to enhance provision of effective care.MethodsUsing a general inductive approach, our qualitative research study was guided by an interpretive epistemology, or way of knowing. Our method for understanding included semi-structured in-depth interviews with internal medicine PCPs from two university-based and three community health clinics. We developed an interview guide, which included questions on PCPs’ experiences, perceived system barriers and facilitators, and strategies to improve their ability to effectively treat complex patients. To focus interviews on real cases, providers were asked to bring de-identified clinical notes from patients they considered complex to the interview. Interview transcripts were coded and analyzed to develop categories from the raw data, which were then conceptualized into broad themes after team-based discussion.ResultsPCPs (N = 15) described complex patients with multidimensional needs, such as socio-economic, medical, and mental health. A vision of optimal care emerged from the data, which included coordinating care, preventing hospitalizations, and developing patient trust. PCPs relied on professional values and individual care strategies to overcome local and system barriers. Team based approaches were endorsed to improve the management of complex patients.ConclusionsGiven the barriers to effective care described by PCPs, individual PCP efforts alone are unlikely to meet the needs of complex patients. To fulfill PCP’s expressed concepts of optimal care, implementation of effective systemic approaches should be considered.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-016-0433-z) contains supplementary material, which is available to authorized users.

No abstract

BACKGROUND: Providers need an accurate sexual history for appropriate screening and counseling, but data on the patient, visit, and physician factors associated with sexual history-taking are limited. OBJECTIVES: To assess patient, resident physician, and visit factors associated with documentation of a sexual history at health care maintenance (HCM) visits. DESIGN: Retrospective cross-sectional chart review. PARTICIPANTS: Review of all HCM clinic notes (n=360) by 26 internal medicine residents from February to August of 2007 at two university-based outpatient clinics. MEASUREMENTS: Documentation of sexual history and patient, resident, and visit factors were abstracted using structured tools. We employed a generalized estimating equations method to control for correlation between patients within residents. We performed multivariate analysis of the factors significantly associated with the outcome of documentation of at least one component of a sexual history. KEY RESULTS: Among 360 charts reviewed, 25% documented at least one component of a sexual history with a mean percent by resident of 23% (SD=18%). Factors positively associated with documentation were: concern about sexually transmitted infection (referent: no concern; OR=4. Factors negatively associated with documentation were: age groups [46][47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62][63][64][65] ORs=0.1, 0.1,, and 0.1-0.6]), and no specified marital status (referent: married; OR= 0.5 [0.3-0.8]). CONCLUSIONS: Our findings highlight the need for an emphasis on documentation of a sexual history by internal medicine residents during routine HCM visits, especially in older and asymptomatic patients, to ensure adequate screening and counseling.

Introduction Providers need an accurate sexual history for appropriate screening and counseling. While curricula on sexual history taking have been described, the impact of such interventions on resident physician performance of the sexual history remains unknown. Aims Our aims were to assess the rates of documentation of sexual histories, the rates of documentation of specific components of the sexual history, and the impact of a teaching intervention on this documentation by Internal Medicine residents. Methods The study design was a teaching intervention with a pre- and postintervention chart review. Participants included postgraduate years two (PGY-2) and three (PGY-3) Internal Medicine residents (N=25) at two university-based outpatient continuity clinics. Residents received an educational intervention consisting of three 30-minute, case-based sessions in the fall of 2007. Main Outcome Measures We reviewed charts from health-care maintenance visits pre- and postintervention. We analyzed within resident pre- and postrates of sexual history taking and the number of sexual history components documented using paired t-tests. Results In total, we reviewed 369 pre- and 260 postintervention charts. The mean number of charts per resident was 14.8 (range 8–29) pre-intervention and 10.4 (range 3–25) postintervention. The mean documentation rate per resident for one or more components of sexual history pre- and postintervention were 22.5% (standard deviation [SD]=18.1%) and 31.7% (SD=20.4%), respectively, P <0.01. The most frequently documented components of sexual history were current sexual activity, number of current sexual partners, and gender of current sexual partner. The least documented components were history of specific sexually transmitted infections, gender of sexual partners over lifetime, and sexual behaviors. Conclusion An educational intervention modestly improved documentation of sexual histories by Internal Medicine residents. Future studies should examine the effects of more comprehensive educational interventions and the impact of such interventions on physician behavior or patient care outcomes.

Systematic approaches to depression identification and management are effective though not consistently implemented. The research team implemented a depression protocol, preceded by training, in 2 faculty-resident practices. Medical assistants used the Patient Health Questionnaire (PHQ)-2 for initial screening; providers performed the PHQ-9. These were documented in the electronic medical record. Logistic regression was performed to assess the association of provider type, clinic site, and training attendance with documentation of PHQ-9 after positive PHQ-2s, and with repeat PHQ-9s after positive PHQ-9s. In logistic regression analysis, training attendance was positively associated with documentation of PHQ-9 after a positive PHQ-2 (odds ratio [OR] = 2.4 [confidence interval (CI) = 1.3–4.3]) and repeated documentation of a PHQ-9 after a positive PHQ-9 (OR = 2.5 [CI = 1.1–5.3]). This study describes the successful implementation of a stepped-care approach to depression care. The positive association of training with compliance with protocol procedures indicates the importance of training in the implementation of practice change.

This sexual history taking module engages medical students in discussion and practice with standardized patients in taking an inclusive (orientation-and gender-neutral) sexual history. An inclusive sexual history is critical to providing comprehensive patient care and an environment supportive of lesbian, gay, bisexual, and transgender (LGBT) patients. This case was developed for first-and second-year medical students who have had basic communication skills training. This session was designed to be delivered in one 40-minute large-group session followed by three 1hour-long small-group sessions (with one third of the class participating in each session) with standardized patients. Four students per group is optimal. Faculty training should take approximately 30 minutes prior to the session as well as participation in the large-group session. The materials associated with this publication include guidelines for faculty facilitators and students to prepare them for the large-group discussion and small-group practice sessions with standardized patients. Also included are four standardized patient cases, a slide presentation using an audience response system for the large-group session, and an evaluation form. The average response to "Overall, this session was effective in improving my sexual history taking skills" has been out of 5. Our communication needs assessment has shown a statistically significant improvement in those reporting increased importance, confidence, and performance of a sexual history between the first and second year of medical school (before and after the curriculum). In addition, students reported performing more components of the sexual history after the session. This sexual history taking module has been incorporated into our Foundations of Doctoring communications curriculum and has been rated as highly effective by learners. Performing an inclusive sexual history is critical to providing comprehensive patient care as well as providing an environment supportive of LGBT patients. Educational Objectives By the end of this module, the learner will be able to: 1. Describe the rationale and steps for performing a gender-and orientation-neutral sexual history. 2. Recognize the breadth of expression of sexuality and gender identity. 3. Practice performing a gender-and orientation-neutral sexual history.

Introduction Benzodiazepines are prescribed inappropriately in up to 40% of outpatients. The purpose of this study is to describe a collaborative team-based care model in which clinical pharmacists work with primary care providers (PCPs) to improve the safe use of benzodiazepines for anxiety and sleep disorders and to assess the preliminary results of the impact of the clinical service on patient outcomes. Methods Adult patients were eligible if they received care from the academic primary care clinic, were prescribed a benzodiazepine chronically, and were not pregnant or managed by psychiatry. Outcomes included baseline PCP confidence and knowledge of appropriate benzodiazepine use, patient symptom severity, and medication changes. Results Twenty-five of 57 PCPs responded to the survey. PCPs reported greater confidence in diagnosing and treating generalized anxiety and panic disorders than sleep disorder and had variable knowledge of appropriate benzodiazepine prescribing. Twenty-nine patients had at least 1 visit. Over 44 total patient visits, 59% resulted in the addition or optimization of a nonbenzodiazepine medication and 46% resulted in the discontinuation or optimization of a benzodiazepine. Generalized anxiety symptom severity scores significantly improved (–2.0; 95% confidence interval (CI): –3.57 to –0.43). Conclusion Collaborative team-based models that include clinical pharmacists in primary care can assist in optimizing high-risk benzodiazepine use. Although these findings suggest improvements in safe medication use and symptoms, additional studies are needed to confirm these preliminary results.