Suicide-related discussions with depressed primary care patients in the USA: gender and quality gaps. A mixed methods analysis

Objective: To characterise suicide-risk discussions in depressed primary-care patients. Design: Secondary analysis of recordings and self reports by physicians and patients. Descriptive statistics of depression and suicide-related discussion, with qualitative extraction of disclosure, enquiry and physician response. Setting: 12 primary-care clinics between July 2003 and March 2005. Participants: 48 primary-care physicians and 1776 adult patients. Measures: Presence of depression or suicide-related discussions during the encounter; patient and physician demographics; depression symptom severity and suicide ideation as measured by the Patient Health Questionnaire (PHQ9); physician’s decision-making style as measured by the Medical Outcomes Study Participatory Decision-Making Scale; support for autonomy as measured by the Health Care Climate Questionnaire; trust in their physician as measured by the Primary Care Assessment Survey; physician response to suicide-related enquiry or disclosure. Results: Of the 1776 encounters, 128 involved patients scoring \u3e14 on the PHQ9. These patients were seen by 43 of the 48 physicians. Suicide ideation was endorsed by 59% (n1⁄475). Depression was discussed in 52% of the encounters (n1⁄466). Suicide-related discussion occurred in only 11% (n1⁄413) of encounters. 92% (n1⁄412) of the suicide discussions occurred with patients scoring \u3c2 on PHQ9 item 9. Suicide was discussed in only one encounter with a male. Variation in elicitation and response styles demonstrated preferred and discouraged interviewing strategies. Conclusions: Suicide ideation is present in a significant proportion of depressed primary care patients but rarely discussed. Men, who carry the highest risk for suicide, are unlikely to disclose their ideation or be asked about it. Patient-centred communication and positive healthcare climate do not appear to increase the likelihood of suicide related discussion. Physicians should be encouraged to ask about suicide ideation in their depressed patients and, when disclosure occurs, facilitate discussion and develop targeted treatment plans

Confrontation and politeness strategies in physician-patient interactions

The therapeutic sucess of physician-patient interactions depends in large part on how physicians interpret and respond to patients' implicit and explicit messages. Using a hypothetical vignette, in which a patient refuses to comply with a recommended therapeutic regimen, we found that first-year medical students with no classroom training in medical interviewing implicity recognized that the situation called for face preserving or polite linguistic behavior. Ninety percent of them used culturally sanctioned politeness forms to repair the conversational breakdown depicted in the vignette. They responded to this clinical scenario, however, with linguistic behaviors borrowed from their everyday interactions, some of which were culturally appropriate, but not necessarily therapeutic. We suggest that students can learn to adapt their culturally appropriate behaviors and engage in therapeutic communication as physicians if they are given the necessary conceptual tools. We discuss how Brown and Levinson's theories of politeness and strategic language usage can (1) provide a framework for interpreting communication in general and physician-patient interaction in particular, (2) illuminate some of the problems inherent in doctor-patient encounters, and (3) be used prescriptively for teaching students and health professionals how to avoid some communication difficulties.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/27511/1/0000555.pd

Physical Activity Training for Functional Mobility in Older Persons

The effectiveness of low-intensity physical activity for improving functional ability and psycho logical well-being in chronically impaired older individuals was demonstrated in a pilot study. Participants who completed 6 weeks of structured low-intensity exercise (N = 77) improved in the time and number of steps required to walk a measured course, in self-assessments of mobility and flexibility, and in three measures of well-being. Those who continued to exercise in a peer-led program (n = 32) maintained improvements in mobility and optimism after 18 weeks.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/68101/2/10.1177_073346489501400401.pd

Twelve tips for developing, implementing, and sustaining medical education fellowship programs: Building on new trends and solid foundations

Medical education fellowship programs (MEFPs) are a form of faculty development contributing to an organization\u27s educational mission and participants\u27 career development. Building an MEFP requires a systematic design, implementation, and evaluation approach which aligns institutional and individual faculty goals. Implementing an MEFP requires a team of committed individuals who provide expertise, guidance, and mentoring. Qualified MEFP directors should utilize instructional methods that promote individual and institutional short and long term growth. Directors must balance the use of traditional design, implementation, and evaluation methodologies with advancing trends that may support or threaten the acceptability and sustainability of the program. Drawing on the expertise of 28 MEFP directors, we provide twelve tips as a guide to those implementing, sustaining, and/or growing a successful MEFP whose value is demonstrated by its impacts on participants, learners, patients, teaching faculty, institutions, the greater medical education community, and the population\u27s health