The future of medical education: areas that should receive increased focus in the 21st Century

What is fundamental for medical students to learn in the 21st Century? Many medical educators understandably focus on the explosion of new medical knowledge and technology that will be essential for medical students to master in the 21st Century. These include advances in molecular medicine, genomics, a plethora of new pharmacological approaches, among other stunning discoveries in medicine. Moreover, there will be a continued need to ensure that medical students acquire the highest level of professional ethics, leadership skills, empathy, and communication and patient-centered counseling skills. All of these have been a core focus of medical educators over the past decade and will continue to be a priority. In thinking about the 21st Century, there are several key additional areas of content knowledge and skills that will be essential for future physicians that to date have not received sufficient attention in medical skill curricula.[...

Developing and Testing Interventions to Improve Obesity‐Related Outcomes in Underserved Rural Communities: Lessons from EMPOWER

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/137768/1/oby21905_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/137768/2/oby21905.pd

Re‐purposing anticoagulation clinics: expanding access to opioid agonist therapy in primary care settings

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/136313/1/add13531.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/136313/2/add13531_am.pd

Formative evaluation and adaptation of pre-and early implementation of diabetes shared medical appointments to maximize sustainability and adoption

Abstract Background Understanding the many factors that influence implementation of new programs, in addition to their success or failure, is extraordinarily complex. This qualitative study examines the implementation and adaptation process of two linked clinical programs within Primary Care, diabetes shared medical appointments (SMAs) and a reciprocal Peer-to-Peer (P2P) support program for patients with poorly controlled diabetes, through the lens of the Consolidated Framework for Implementation Research (CFIR). We illustrate the role and importance of pre-implementation interviews for guiding ongoing adaptations to improve implementation of a clinical program, achieve optimal change, and avoid type III errors. Methods We conducted 28 semi-structured phone interviews between September of 2013 and May of 2016, four to seven interviewees at each site. The interviewees were physician champions, chiefs of primary care, pharmacists, dieticians, nurses, health psychologists, peer facilitators, and research coordinators. Modifiable barriers and facilitators to implementation were identified and adaptations documented. Data analysis started with immersion in the data to obtain a sense of the whole and then by cataloging principal themes per CFIR constructs. An iterative consensus-building process was used to code. CFIR constructs were then ranked and compared by the researchers. Results We identified a subset of CFIR constructs that are most likely to play a role in the effectiveness of the diabetes SMAs and P2P program based on our work with the participating sites to date. Through the identification of barriers and facilitators, a subset of CFIR constructs arose, including evidence strength and quality, relative advantage, adaptability, complexity, patient needs and resources, compatibility, leadership engagement, available resources, knowledge and beliefs, and champions. Conclusions We described our method for identification of contextual factors that influenced implementation of complex diabetes clinical programs - SMAs and P2P. The qualitative phone interviews aided implementation through the identification of modifiable barriers or conversely, actionable findings. Implementation projects, and certainly clinical programs, do not have unlimited resources and these interviews allowed us to determine which facets to target and act on for each site. As the study progresses, these findings will be compared and correlated to outcome measures. This comprehensive adaptation data collection will also facilitate and enhance understanding of the future success or lack of success of implementation and inform potential for translation and public health impact. The approach of using the CFIR to guide us to actionable findings and help us better understand barriers and facilitators has broad applicability and can be used by other projects to guide, adapt, and improve implementation of research into practice. Trial registration ClinicalTrials.gov ID: NCT02132676 .https://deepblue.lib.umich.edu/bitstream/2027.42/144538/1/12875_2018_Article_797.pd

Neither Safety nor Health: How Title 42 Expulsions Harm Health and Violate Rights

Toward the beginning of the COVID-19 pandemic in March 2020, the Trump administration overrode the objections of public health experts at the U.S. Centers for Disease Control and Prevention (CDC) and compelled the CDC to issue an order under Title 42 U.S.C. section 265 of the 1944 Public Health and Service Act that closed the border to migrants and asylum seekers. The government used public health as a pretext to summarily expel children and adults seeking refuge at the U.S. border more than 980,000 times, while at the same time allowing other types of travelers to continue to cross the border with no testing or quarantine requirements. Public health experts strenuously objected to the ban, pointing out the lack of epidemiological evidence for only banning this category of entrants to the United States while keeping the borders open to other travelers.Nevertheless, six months into the Biden administration, the U.S. government continues to expel families and adults to countries where they face severe harm and persecution, violating their rights and failing to safeguard public health. The Biden administration also continues to carry out chaotic border expulsions that perpetuate family separation and further traumatize an already vulnerable population.In May 2021, a Physicians for Human Rights (PHR) research team conducted interviews in Tijuana and Ciudad Juárez, Mexico with 28 asylum seekers who had been expelled under the Title 42 order, and with six health care workers providing services to migrants. The team sought to document people's experiences during expulsion, including family separation, the actions of U.S. and Mexican government officials during the expulsion process, and the physical and mental health impacts of expulsion and family separation.People described an impossible situation, where they were unsafe in their own country, unsafe in Mexico, and yet unable to seek safety at the U.S. border. Every day that the Title 42 order continues to expel asylum seekers is another day that the U.S. government is harming people's health and violating their human rights

Physician assessments of medication adherence and decisions to intensify medications for patients with uncontrolled blood pressure: still no better than a coin toss

Abstract Background Many patients have uncontrolled blood pressure (BP) because they are not taking medications as prescribed. Providers may have difficulty accurately assessing adherence. Providers need to assess medication adherence to decide whether to address uncontrolled BP by improving adherence to the current prescribed regimen or by intensifying the BP treatment regimen by increasing doses or adding more medications. Methods We examined how provider assessments of adherence with antihypertensive medications compared with refill records, and how providers’ assessments were associated with decisions to intensify medications for uncontrolled BP. We studied a cross-sectional cohort of 1169 veterans with diabetes presenting with BP ≥140/90 to 92 primary care providers at 9 Veterans Affairs (VA) facilities from February 2005 to March 2006. Using VA pharmacy records, we utilized a continuous multiple-interval measure of medication gaps (CMG) to assess the proportion of time in prior year that patient did not possess the prescribed medications; CMG ≥20% is considered clinically significant non-adherence. Providers answered post-visit Likert-scale questions regarding their assessment of patient adherence to BP medications. The BP regimen was considered intensified if medication was added or increased without stopping or decreasing another medication. Results 1064 patients were receiving antihypertensive medication regularly from the VA; the mean CMG was 11.3%. Adherence assessments by providers correlated poorly with refill history. 211 (20%) patients did not have BP medication available for ≥ 20% of days; providers characterized 79 (37%) of these 211 patients as having significant non-adherence, and intensified medications for 97 (46%). Providers intensified BP medications for 451 (42%) patients, similarly whether assessed by provider as having significant non-adherence (44%) or not (43%). Conclusions Providers recognized non-adherence for less than half of patients whose pharmacy records indicated significant refill gaps, and often intensified BP medications even when suspected serious non-adherence. Making an objective measure of adherence such as the CMG available during visits may help providers recognize non-adherence to inform prescribing decisions.http://deepblue.lib.umich.edu/bitstream/2027.42/112850/1/12913_2012_Article_2450.pd

Study protocol: The Adherence and Intensification of Medications (AIM) study - a cluster randomized controlled effectiveness study

Abstract Background Many patients with diabetes have poor blood pressure (BP) control. Pharmacological therapy is the cornerstone of effective BP treatment, yet there are high rates both of poor medication adherence and failure to intensify medications. Successful medication management requires an effective partnership between providers who initiate and increase doses of effective medications and patients who adhere to the regimen. Methods In this cluster-randomized controlled effectiveness study, primary care teams within sites were randomized to a program led by a clinical pharmacist trained in motivational interviewing-based behavioral counseling approaches and authorized to make BP medication changes or to usual care. This study involved the collection of data during a 14-month intervention period in three Department of Veterans Affairs facilities and two Kaiser Permanente Northern California facilities. The clinical pharmacist was supported by clinical information systems that enabled proactive identification of, and outreach to, eligible patients identified on the basis of poor BP control and either medication refill gaps or lack of recent medication intensification. The primary outcome is the relative change in systolic blood pressure (SBP) measurements over time. Secondary outcomes are changes in Hemoglobin A1c, low-density lipoprotein cholesterol (LDL), medication adherence determined from pharmacy refill data, and medication intensification rates. Discussion Integration of the three intervention elements - proactive identification, adherence counseling and medication intensification - is essential to achieve optimal levels of control for high-risk patients. Testing the effectiveness of this intervention at the team level allows us to study the program as it would typically be implemented within a clinic setting, including how it integrates with other elements of care. Trial Registration The ClinicalTrials.gov registration number is NCT00495794.http://deepblue.lib.umich.edu/bitstream/2027.42/78258/1/1745-6215-11-95.xmlhttp://deepblue.lib.umich.edu/bitstream/2027.42/78258/2/1745-6215-11-95.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/78258/3/1745-6215-11-95-S1.DOCPeer Reviewe

Engaging family supporters of adult patients with diabetes to improve clinical and patient-centered outcomes: study protocol for a randomized controlled trial

Abstract Background Most adults with diabetes who are at high risk for complications have family or friends who are involved in their medical and self-care (“family supporters”). These family supporters are an important resource who could be leveraged to improve patients’ engagement in their care and patient health outcomes. However, healthcare teams lack structured and feasible approaches to effectively engage family supporters in patient self-management support. This trial tests a strategy to strengthen the capacity of family supporters to help adults with high-risk diabetes engage in healthcare, successfully enact care plans, and lower risk of diabetes complications. Methods/design We will conduct a randomized trial evaluating the CO-IMPACT (Caring Others Increasing EnageMent in Patient Aligned Care Teams) intervention. Two hunded forty adults with diabetes who are at high risk for diabetes complications due to poor glycemic control or high blood pressure will be randomized, along with a family supporter (living either with the patient or remotely), to CO-IMPACT or enhanced usual primary care for 12 months. CO-IMPACT provides patient-supporter dyads: it provides one coaching session addressing supporter techniques for helping patients with behavior change motivation, action planning, and proactive communication with healthcare providers; biweekly automated phone calls to prompt dyad action on new patient health concerns; phone calls to prompt preparation for patients’ primary care visits; and primary care visit summaries sent to both patient and supporter. Primary outcomes are changes in patient activation, as measured by the Patient Activation Measure-13, and change in 5-year cardiac event risk, as measured by the United Kingdom Prospective Diabetes Study cardiac risk score for people with diabetes. Secondary outcomes include patients’ diabetes self-management behaviors, diabetes distress, and glycemic and blood pressure control. Measures among supporters will include use of effective support techniques, burden, and distress about patient’s diabetes care. Discussion If effective in improving patient activation and diabetes management, CO-IMPACT will provide healthcare teams with evidence-based tools and techniques to engage patients’ available family or friends in supporting patient self-management, even if they live remotely. The core skills addressed by CO-IMPACT can be used by patients and their supporters over time to respond to changing patient health needs and priorities. Trial registration ClinicalTrials.gov, NCT02328326 . Registered on 31 December 2014.https://deepblue.lib.umich.edu/bitstream/2027.42/145179/1/13063_2018_Article_2785.pd

Engaging family supporters of adult patients with diabetes to improve clinical and patient-centered outcomes: study protocol for a randomized controlled trial

Abstract Background Most adults with diabetes who are at high risk for complications have family or friends who are involved in their medical and self-care (“family supporters”). These family supporters are an important resource who could be leveraged to improve patients’ engagement in their care and patient health outcomes. However, healthcare teams lack structured and feasible approaches to effectively engage family supporters in patient self-management support. This trial tests a strategy to strengthen the capacity of family supporters to help adults with high-risk diabetes engage in healthcare, successfully enact care plans, and lower risk of diabetes complications. Methods/design We will conduct a randomized trial evaluating the CO-IMPACT (Caring Others Increasing EnageMent in Patient Aligned Care Teams) intervention. Two hunded forty adults with diabetes who are at high risk for diabetes complications due to poor glycemic control or high blood pressure will be randomized, along with a family supporter (living either with the patient or remotely), to CO-IMPACT or enhanced usual primary care for 12 months. CO-IMPACT provides patient-supporter dyads: it provides one coaching session addressing supporter techniques for helping patients with behavior change motivation, action planning, and proactive communication with healthcare providers; biweekly automated phone calls to prompt dyad action on new patient health concerns; phone calls to prompt preparation for patients’ primary care visits; and primary care visit summaries sent to both patient and supporter. Primary outcomes are changes in patient activation, as measured by the Patient Activation Measure-13, and change in 5-year cardiac event risk, as measured by the United Kingdom Prospective Diabetes Study cardiac risk score for people with diabetes. Secondary outcomes include patients’ diabetes self-management behaviors, diabetes distress, and glycemic and blood pressure control. Measures among supporters will include use of effective support techniques, burden, and distress about patient’s diabetes care. Discussion If effective in improving patient activation and diabetes management, CO-IMPACT will provide healthcare teams with evidence-based tools and techniques to engage patients’ available family or friends in supporting patient self-management, even if they live remotely. The core skills addressed by CO-IMPACT can be used by patients and their supporters over time to respond to changing patient health needs and priorities. Trial registration ClinicalTrials.gov, NCT02328326 . Registered on 31 December 2014.https://deepblue.lib.umich.edu/bitstream/2027.42/145179/1/13063_2018_Article_2785.pd

Implicações biológicas da plasticidade fenotípica no modelo Schistosoma mansoni - Nectomys squamipes

The water-rat Nectomys squamipes is mostly important non-human host in schistosomiasis mansoni transmission in Brazil, due to its susceptibility, high abundance and water-contact pattern. During experimental infection of N. squamipes with Schistosoma mansoni, adult worms show phenotypic plasticity. This finding led us to investigate whether biological behavior is also affected. This was assessed comparing the biological characteristics of four S. mansoni strains: BE (State of Belém do Pará), CE (State of Pernambuco), CMO (State of Rio Grande do Norte) and SJ (State of São Paulo) using laboratory-bred N. squamipes. The infection was monitored by determination of the pre-patent period, fecal egg output, egg viability, intestinal egg count and, infectivity rate. No biological modification was observed in these parameters. Overall results highlight that N. squamipes was susceptible to several S. mansoni strains, suggesting that it might contribute to the maintenance of schistosomiasis mansoni in Brazil.O rato d´água Nectomys squamipes é importante transmissor não-humano da esquistossomose. Durante a infecção experimental em N. squamipes, os vermes adultos apresentam plasticidade fenotípica. Esses achados levaram-nos a investigar se os aspectos biológicos também são afetados. Foram comparadas as características biológicas de quatro cepas de S. mansoni: BE (Estado de Belém do Pará), CM (Estado de Pernambuco), CMO (Estado do Rio Grande do Norte) e SJ (Estado de São Paulo), utilizando como modelo experimental N. squamipes criados e mantidos em laboratório. A infecção foi monitorada para a determinação do período pré-patente, eliminação de ovos nas fezes, viabilidade dos ovos, contagem de ovos retidos no intestino e infectividade. Nenhuma modificação biológica foi observada nesses parâmetros. Os resultados sugerem que o N. squamipes é susceptível a várias cepas de S. mansoni, contribuindo para a manutenção da esquistossomose no Brasil