Policies and Procedures

Trident GMEC Handbook

Curriculum

Trident Family Medicine Residency Program
Clinical Scholars Program 2001

• Fitness Level and Health Risk Appraisal Status of Family Medicine Residents. Kirt Caton MD; Paul Rubinton, MD; James Tomsic, MS; Peter J.Carek, MS, MD.
• The Electronic Medical Record as a Tool to Improve the Diagnosis and Management of Osteoporosis in Post-Menopausal Women-A Continuous Quality Improvement Project. Stephen Burke, MD; Keith Lobel, MD; Brian Dewhirst, MD.
• Measuring Patient Satisfaction: The Resident Physician's Role.
  Robert L. Hetzel, MD; Alan Armstrong, MD.
• The Direct Medical Translator: A Multilingual .Luis Insignares, MD
• Application of a Case Management Model to Patients with Congestive Heart Failure. Choyah N, Mazyck P.
• Documentation of Occupational and Environmental Medicine Histories. Philip Scheel, MD, William Simpson, MD.
• Identifying Drug-Seeking Patients by Evaluating Prescribing Practices. Alden K, Teets, R, Tumblin M, Dickerson, L.
• Quality Assessment: Use of Thin Prep versus Routine Cytology and Samples Limited by Lack of Endocervical Component at University Family Medicine.P.H. Gordon Thompson, M.D., Sean B. Halligan, M.D.
• Are the Resident Physicians at Trident Family Medicine Effectively Educating Adolescent Patients about Sexually Transmitted Diseases? Tara N Vandegrift, MD
• Development and Implementation of protocol for inpatient/outpatient treatment of Deep Vein Thrombosis using Low-molecular weight Heparin John A. von Lehe, M.D.
• Prednisone for the Treatment of Acute Bronchitis
  King DE, Wells BJ

OBJECTIVES:To examine the fitness level and health risk appraisal status for the family medicine residents and to examine whether these levels remained stable or change as physician progress through residency training.

METHODS: Males and females between the ages of 18 and 65 involved in residency training at the family medicine program were asked to participate in study. Each participant completed a battery of measures of selected cardiovascular and all cause mortality risk factors: Maximum oxygen consumption (i.e., VO2 max), Body mass index (BMI), and hip-to-waist ratio (WHR). The participants completed the tests twice; baseline and then after 11 months of residency training.

RESULTS: Based upon the results of the initial test, the participants compared favorably with the national averages. In terms of cardiovascular endurance (i.e. VO2 max); the average VO2 max for female residents was 35.0 ml O2/kg/min while the VO2 max for male residents was 45.8 ml O2/kg/min. The average BMI for females was 22.4 and the average for males was 24.8. The average WHR for both females and males was 0.8.
Upon further analysis, these variables were compared between females and males in the first and second year of residency training. No statistical difference was noted between PGY-1 and PGY-2 residents for females and, males in VO2 max, BMI, or WHR.

DISCUSSION: These findings indicate that individuals in the family medicine residency program compare favorably to the normal population in measures of selected cardiovascular and all cause mortality risk factors. Furthermore, these measures did not differ between first and second year residents, implying that these risk factors are comparable between residents at differing levels of training.

Measuring Patient Satisfaction: The Resident Physician's Role.
Robert L. Hetzel, MD; Alan Armstrong, MD.

INTRODUCTION: One of the keys to expand a practice and then maintain current patient levels would be to provide patient satisfaction with health care and office experiences. In a growing residency-based practice, where patient and physician turnover is significant, this becomes even more important. Through evaluation of patient satisfaction, the focus of this study was to provide feedback for resident physicians at University Family Medicine (UFM) to assist in improvement of provision of health care.

METHODS: Patients of the two investigating resident physicians at UFM were surveyed between January 3, 2001 and March 12, 2001. A simple survey with four open-ended questions was handed by the resident physician to randomly selected patients at the conclusion office visits. Patients were then asked to complete the survey in order to assist the resident physician in improving both patient satisfaction and the quality of care provided. The surveys were packaged in plain white envelopes without patient-identifying information and were collected from the patient at the check-out desk. The following four questions comprised the survey: 1) What did you like best about the time spent with your doctor today? 2) What about your office visit was less than ideal? 3) What could your doctor do to improve your next office visit? 4) Would you refer your family and friends to our office?

RESULTS: 108 surveys were distributed over the survey period; survey procedure ended once 100 surveys were returned. (response rate of 93%). Although patients used multiple ways to record opinions, responses to all four questions were overwhelmingly positive. 24 responses identified areas for improvement.

DISCUSSION: Patients at UFM are satisfied with their medical care. However, several areas for improvement were identified.

The Direct Medical Translator: A Multilingual
Luis Insignares, MD

PURPOSE: The current study is a test of the feasibility of using a direct paper translator system (DMT),
from Spanish to English in actual emergency department practice in acute care settings.
The purpose of this study is to:
1. measure physician perceptions of usefulness of Direct Medical Translator tool in this setting, and
2. use the feedback from study participants to refine the DMT.

METHODS: A pilot study was conducted in the Trident Emergency Department with the participation of Trident Emergency Physicians, Trident ER Staff, and Residents of Trident Family Medicine.
The Direct Medical Translator tool was used for doctor patient encounters where Spanish/English is the communication barrier in non trauma cases. Trident ER Staff routinely assess patients coming to the emergency room, and determine the need for Spanish to English translation. Beginning April 1,2001 the staff will gave the DMT to Spanish only speaking non trauma patients who could not communicate in English. The patients completed the DMT and returned it to the ER staff nurse. The English copy was reviewed by the nurse and ER physician or Resident Physician, and placed with Spanish copy in patients' chart. The ER or Resident Physician, then took the history form, identified the location of pain, and chief complaint, and proceeded with a physical exam. Once a diagnosis was reached, treatment was given, and the Plan conveyed to the patient via a patient education handout in Spanish.
Upon discharging the patient, the physician filled out a 4 question survey, and gave it to the secretary to be held for the Principal Investigator to enter into database.

RESULTS: In an 8 week period, the DMT was used 10 times in the Trident ER to assist in Spanish to English Translation. 10 different ER Physicians used the DMT, but only 3 filled out the survey . Of those that did fill out the survey, all gave a 5/5 rating and/or favorable results as for the usefulness of this tool in the ER setting. One MD requested adding a question regarding LMP. The ages of the patients who were assisted in Spanish to English Translation ranged from 6 weeks to 55 years old. Actual Diagnoses included a full spectrum from childhood to adult illnesses. In addition, in an earlier trial, (Ecuador), The DMT tool was found to be a more sensitive tool for localizing symptoms of depression, than direct doctor-patient conversation in the patients native language, Spanish.

CONCLUSIONS: The DMT may be a useful tool in the ER and primary care settings, but further refinement is needed. Information obtained from this study will be used to improve the DMT, and make it more effective in medical translation.

Application of a Case Management Model to Patients with Congestive Heart Failure.
Choyah N, Mazyck P.

INTRODUCTION: Congestive heart failure (CHF) is one of the leading causes for hospitalization on the Family Medicine (FM) inpatient service. The objectives of this study were to: 1) use a multidisciplinary team (physician and pharmacist) to ensure that FM patients with frequent admissions are being managed according to the Consensus Recommendations for CHF and 2) evaluate the effect of case management on objective (emergency room (ER) visits, hospitalizations, office visits) and subjective (symptom relief, quality of life) measures.

METHODS: Family Medicine patients hospitalized for CHF in the past year were identified. Six patients with the most frequent admissions (N=11) and ER visits (N=14) were targeted for intervention. The team reviewed patient charts to evaluate guideline compliance, and contacted the patients weekly to evaluate the following parameters: daily weights, dietary and medication compliance, activity level, and CHF symptoms. A modified quality of life questionnaire was given at baseline and six month follow-up. Patients were withdrawn if they were unavailable for weekly follow-up.

RESULTS: Of the initial 6 patients, 2 died and 2 were withdrawn due to lack of follow-up. Two patients were replaced for a total of 4 patients, followed from December 2000-May 2001. All patients had a decrease in hospitalizations (N=0) and ER visits (N=3). Patients reported a subjective improvement in symptoms and quality of life.

CONCLUSION: This study demonstrates the effectiveness of the case management model in improving objective and subjective measures in patients with CHF. Case management may provide economic benefits in a managed care environment. Case management of a broader population of CHF patients should be considered. Limitations of this study include patient selection bias and difficulty in patient follow-up.

Documentation of Occupational and Environmental Medicine Histories. Philip Scheel, MD, William Simpson, MD.

INTRODUCTION: Increase in the taking of concise, uniformly informative occupational and environmental medicine (OEM) histories has been the goal of faculty at Medical University of South Carolina's (MUSC) OEM Program since 1993. Numerous interventions have been implemented, subsequent to a baseline study of approximately 50 charts at each of seven residency sites in South Carolina. Grant funding for the original SC statewide OEM initiative was discontinued in 1998, yet the MUSC OEM Program has continued its OEM educational efforts without outside funding.

METHODS: A follow-up review of both MUSC DFM (faculty) and UFM (resident) clinic charts, using the original criteria, was undertaken to guage educational effectiveness, and guide further interventions. The following questions were posed: 1. Is occupation listed? 2. Is patient's job function or workplace described? 3. Was an OEM concern documented? 4. Was an OEM-related treatment documented? 104 charts were examined, and the interval confined to the past three years. Exclusion criteria were; Patient: seen less than three times, unemployed or working at home, less than 20 or greater than 65 years old at any time in past three years, on staff.

RESULTS: Corresponding to the above numbered questions, results, respectively, of: 29, 12, 10, and 16 percent were initially obtained. This follow-up study revealed results of: 74, 21, 40, and 29 percent.

DISCUSSION: Educational efforts, and inclusion of specific prompts in EMR social history section, have yielded significant improvements in OEM history collection, both quantitatively and qualitatively over the last eight years at MUSC clinics.

Identifying Drug-Seeking Patients by Evaluating Prescribing Practices. Alden K, Teets, R, Tumblin M, Dickerson, L.

INTRODUCTION: Prescription drug abuse is increasing and becoming a significant problem in both the medical and legal fields. The negative stigma of addiction and the frustration of dealing with drug-seeking behavior lead to difficulty in effectively managing patients with prescription drug abuse. On the other hand, pressures to adequately treat pain in patients as well as genuine mental health disorders demands the judicious use of controlled and addictive medications. The purpose of this study is see whether inappropriate prescribing practices occur in our practice, a surrogate measure for the possibility of prescription drug abuse.

METHODS: All prescriptions for addictive medications, including all controlled substances, were retrieved from July, September, and October 2000, using the electronic medical record (N = 244). Patients were from either Calhoun Street DFM or Trident UFM clinics. The patient record was then examined looking for appropriate documentation and rationale for addictive medicines prescribed. Prescriptions were deemed inappropriate for any one of the following reasons: (1) inadequate documentation, (2) refills without exams, (3) indications that are inappropriate, or (4) prescriptions to patients with history of addiction.

RESULTS: 244 prescriptions for addictive/controlled substances were identified for the 3 months mentioned above in 2000. 33% of these were deemed inappropriate.

DISCUSSION: Inappropriate addictive drug-prescribing occurs at a significant rate in our combined practices. This brings up a strong possibility of that prescription drug abuse is occurring in our practice as well, as a drug-seeker is likely to push the doctor into using such medicines improperly. A further direction we could take would be to educate our colleagues on the signs of drug-seeking behavior, as well as review appropriate indications for addictive medications. In addition, a survey designed to elicit both attitudes and beliefs of our colleagues regarding drug-seeking behavior and addictive medications may illuminate further reasons for the prescribing practices identified above.

Quality Assessment: Use of Thin Prep versus Routine Cytology and Samples Limited by Lack of Endocervical Component at University Family Medicine.
P.H. Gordon Thompson, M.D., Sean B. Halligan, M.D.

INTRODUCTION: The recent introduction of the Thin Prep method of preserving cells collected during Pap smear for cytological evaluation has increased the reporting of LGSIL and HGSIL, and decreased the number of samples yielding ASCUS. The objective of this QA study was to determine whether Thin Prep performed by University Family Medicine (UFM) caused more unsatisfactory samples than the traditional method and decide whether improvement in method of collection of Thin Prep samples, or return to the traditional method, was indicated.

METHODS: A database was constructed using three years of Pap smear cytology reports performed at UFM. 698 tests were done with Thin Prep and 268 using the traditional method, those individuals with total hysterectomy having been eliminated. A comparison was made between the two groups with regard to the numbers of unsatisfactory samples and numbers of samples with abnormal pathology.

RESULTS: There was a significantly higher percentage of unsatisfactory samples in the Thin Prep group compared with the traditional method (13.43% vs. 22.78%, p<0.001). However, Thin Prep yielded more abnormal pathology overall (20.62% vs. 12.96%, p<0.004). Interestingly, in the traditional group, there was no significant difference in regards to abnormal pathology whether the sample was unsatisfactory or not (p <0.5). However, this difference was significant in the Thin Prep group (p<0.03).

DISCUSSION: While this study does show that UFM is demonstrating a higher percentage of unsatisfactory samples since beginning use of Thin Prep, the percentage of abnormal pathology has also increased. This is in keeping with the advantages of this method and the reasons for initially switching to it. The differences between the group with regards to abnormal pathology and unsatisfactory samples may be due to study size, but further investigation with different collection equipment, inservice seminars, and separating by year level of training may demonstrate verifiable causes.

Are the Resident Physicians at Trident Family Medicine Effectively Educating Adolescent Patients about Sexually Transmitted Diseases? Tara N Vandegrift, MD

INTRODUCTION: More than 12 million cases of sexually transmitted diseases are reported annually. Of those, approximately 3 million occur in adolescents. Sexually transmitted diseases not only cause primary symptoms, but also may lead to long term complications. One must consider the reasons behind the rising number of adolescents becoming infected. A consideration is that adolescents are not receiving adequate information about how to protect themselves against STDs. This study is designed to determine if there is a lack of knowledge among teenagers, and if so, whether the resident physicians at Trident Family Medicine are effectively providing this information.

METHODS: The study groups consists of patients between the ages of 13 and 19 presenting for annual physical exams or pre-participation sports physical examinations who agree to participate. A brief questionnaire regarding knowledge of STDs is used to measure baseline knowledge as well as post appointment knowledge of the adolescent patients. Participants receive the questionnaires from their nurse during collection of the vital signs. Subjects complete the first questionnaire prior to the encounter with the physician. The second questionnaire is completed after the visit. Both are returned to the receptionist at check out. Any change in score of these questionnaires is analyzed to determine if 1) adolescents need to be educated regarding STDs and 2) whether residents are effectively providing this education.

RESULTS: Results are available currently for 5 patients collected over 3 months. An additional 2 pre-appointment surveys were collected. Prior to the visit, respondents answered an average of 81% correctly. Percentage of responses answered correctly did not change significantly after the appointment. Deficits in knowledge include modes of transmission and protection against STDs as well as which diseases are sexually transmitted.

DISCUSSION: As the number of participants is currently low, continued collection of data is necessary. Increased discussion with adolescents about the transmission of and protection against contracting STDs is needed.

Development and Implementation of protocol for inpatient/outpatient treatment of Deep Vein Thrombosis using Low-molecular weight Heparin John A. von Lehe, M.D.

Introduction: Patients with Deep Vein Thrombosis (DVT) have traditionally treated in an inpatient setting using weight based protocols for Heparin. Patients were started on Coumadin at the same time and they were hospitalized until the INR reached therapeutic levels. The purpose of the development of this protocol was to identify those patients that were being seen for treatment of Deep Vein Thrombosis and start those eligible patients on Low-molecular Weight Heparin (LMWH) while in the hospital. While in the hospital the patient would then be educated on home use and self-administration of LMWH with the goal being early discharge and cost savings.

Methods: Protocols from several resources were obtained and reviewed and a new protocol was developed for Trident Regional Medical Center. The protocol was then introduced to the hospital committee for therapeutics. Once approved for review, the protocol was submitted to the members of the committee for individual review and comments. Simultaneously, the protocol was sent to the general staff for their review and comments. Once adequate time has been given for review, the protocol will be put to a final vote for approval and implementation. In one year, the DRG for DVT will be reviewed by TRMC for determination of use and cost-effectiveness.

Results: Currently, the protocol is under review and will be changed as necessary as a result of the suggestions from the various members of the hospital general staff.

Discussion: Studies have shown that Low-molecular Weight Heparin is as effective as Standard Heparin in treatment in DVT and may be more cost-effective. Implementation and follow-up will show if this is true on a local level.

Prednisone for the Treatment of Acute Bronchitis
King DE, Wells BJ

INTRODUCTION: Many studies have demonstrated that antibiotics do not effectively treat acute bronchitis. Some studies show a modest improvement of cough with treatment with albuterol. This study was designed to test the effectiveness of prednisone in treating acute bronchitis.

METHODS: Adult patients diagnosed with acute bronchitis were enrolled at MUH and UFM. The patients were randomized to either the control group or the treatment group. The control group received an albuterol metered dose inhaler plus placebo. The treatment group received prednisone 20 milligrams by mouth twice a day for five days plus an albuterol metered dose inhaler. Patients were asked to rate their nighttime cough on days one and 14. The nightime cough was graded on a scale from 0-4. Zero represents the absence of a cough, while four is the worst cough that the patient has ever experienced.

RESULTS: Thus far, 20 patients have been enrolled in the study. The initial results illustrate a trend towards better peak flows and nighttime cough in the group treated with prednisone. The peak flows in the placebo group improved 55 points from day one to day 7. In contrast, the peak flows in the treatment group improved 98 points. In addition, the placebo group went from a mean nighttime cough on day one of 3.1 to 1.5 on day 14. The prednisone group's mean nighttime cough improved from 2.67 on day one to 1.16 on day 14.

DISCUSSION: These results show a modest trend towards improved symptoms and objective data in patients with acute bronchitis who were treated with prednisone. More subjects will need to be enrolled to determine if prednisone is statistically better than placebo in treating acute bronchitis.