Practice Inquiry: Clinical Uncertainty as a Focus for Small-Group Learning and Practice Improvement

PROBLEM: Many primary care physicians in nonacademic settings lack a collegial forum for engaging the clinical uncertainties inherent in their work. PROGRAM DESCRIPTION: “Practice Inquiry” is proposed as a set of small-group, practice-based learning and improvement (PBLI) methods designed to help clinicians better manage case-based clinical uncertainty. Clinicians meet regularly at their offices/clinics to present dilemma cases, share clinical experience, review evidence for blending with experience, and draw implications for practice improvement. From 2001 through 2005, Practice Inquiry was introduced to sites in the San Francisco Bay Area as a demonstration effort. Meeting rosters, case logs, a feedback survey, and meeting field notes documented implementation and provided data for a formative, qualitative evaluation. PROGRAM EVALUATION: Of the 30 sites approached, 14 held introductory meetings. As of summer 2006, 98 clinicians in 11 sites continue to hold regularly scheduled group meetings. Of the 118 patient cases presented in the seven oldest groups, clinician–patient relationship and treatment dilemmas were most common. Clinician feedback and meeting transcript data provided insights into how busy practitioners shared cases, developed trust, and learned new knowledge/skills for moving forward with patients. DISCUSSION: Ongoing clinician involvement suggests that Practice Inquiry is a feasible, acceptable, and potentially useful set of PBLI methods. Two of the Practice Inquiry’s group learning tasks received comparatively less focus: integrating research evidence with clinical experience and tracking dilemma case outcomes. Future work should focus on reducing the methodological limitations of a demonstration effort and examining factors affecting clinician participation. Set-aside work time for clinicians, or other equally potent incentives, will be necessary for the further elaboration of these PBLI methods aimed at managing uncertainty

Adult memory and appraisal of maltreatment in childhood: Implications for problem substance use

Objective. Alcohol and drug abuse are major public health concerns. Child maltreatment has been identified as a risk factor that increases the likelihood of substance use problems in adulthood. However, most studies have used retrospective reports of maltreatment and the few studies that have used prospective measures of maltreatment have found a weaker association with adult substance use problems. This study examines whether adult memory and appraisal of maltreatment is the primary pathway through which substantiated child maltreatment effects adult substance use problems. Methods. Data are from the Rochester Youth Development Study (RYDS), a longitudinal study of youth and young adult development spanning almost 20 years. RYDS provides multiple interviews with the sample of 1,000 participants and their caregivers as well as information from official sources including Child Protective Services (CPS). Substantiated CPS reports of child maltreatment and adult retrospective recall of childhood maltreatment were used to predict illegal drug use, alcohol related problems, and driving under the influence of drugs or alcohol at two adult developmental stages. The effect of early adolescent attachment to parent was also examined, and analyses controlled for adolescent substance use problems, family poverty, parental substance use, and family instability. Multivariate path analyses were conducted using Mplus. Results. Memory of maltreatment was positively associated with all three substance use problems. Memory of maltreatment completely mediated any association between substantiated CPS reports and substance use problems in both early adulthood and adulthood. There was no direct association or other indirect association between prospectively measured CPS reports and adult substance use problems. Conclusion. These findings indicate that memory of maltreatment is the primary mediator between child and adolescent maltreatment and adult substance use problems. Thus, prospectively measured substantiated reports of maltreatment do not increase the likelihood of substance use problems in adulthood for the sizable proportion of persons who do not report memories of maltreatment. These results can inform our understanding of why abuse or neglect in childhood leads to substance use problems in adulthood for some people but not for others. This in turn has implications for prevention and treatment of substance use problems