INTRODUCTION:Despite the growing importance of quality improvement (QI) training in medical education, there is a lack of faculty with expertise in QI at many academic medical centers. In this report, we describe the design, implementation, and evaluation of a QI training program for faculty in hospital medicine at an academic medical center aimed at increasing faculty capacity in QI.METHODS:With input from an initial focus group of hospital medicine faculty, we developed a 12-session, active-learning curriculum incorporating core concepts in QI applied to a real-life QI problem. We used a survey instrument to assess changes in self-reported confidence, the Quality Improvement Knowledge Application Tool-Revised to assess changes in applied knowledge, and a second focus group to obtain qualitative feedback regarding the curriculum.RESULTS:Self-reported confidence in numerous QI skills increased after completion of the curriculum; however, concurrent improvement in applied knowledge was not observed. Qualitatively, participants not only described improved understanding of QI methodology and greater confidence contributing to QI initiatives but also a sense they were not prepared to lead a QI project independently.DISCUSSION:An active-learning faculty training program is feasible with limited resources and was associated with increased faculty confidence in QI skills.

Introduction: The role of opioids in managing chronic pain has evolved in light of the opioid misuse epidemic and new evidence regarding risks and benefits of long-term opioid therapy. With mounting national guidelines and local regulations, providers need interventions to standardize and improve safe, responsible prescribing. This article summarizes the evolution of an opioid management toolkit using a quality improvement (QI) approach to improve prescribing. Methods: The authors developed a list of opioid-prescribing best practices and offered in-office, team-based QI projects to ambulatory clinics, updated and tested over 3 trials in the form of a toolkit. Outcome measures included pre- and postproject surveys on provider and staff satisfaction, toolkit completion, and process measures. The toolkit supports workflow planning, redesign, and implementation. Results: Ten clinics participated in trial 1, completing the QI project on average in 3 months, with a mean of 9.1 hours of team time. Provider satisfaction with prescribing increased from 42% to 96% and staff satisfaction from 54% to 81%. The most common strategies in trials 1 and 2 focused on regulatory compliance (35% to 36%), whereas in Trial 3 there was a strong move toward peer support (81%). Discussion: Clinics responded to implementation of opioid-related best practices using QI with improved provider and staff satisfaction. Once the goals of regulatory compliance and workflow improvements were met, clinics focused on strategies supporting providers in the lead role of managing chronic pain, building on strategies that provide peer support. Using QI methods, primary care clinics can improve opioid-prescribing best practices for patients.

"Teaching" services usually incorporate a cadre of learners such as resident physicians and medical students as part of the care team, led by a faculty physician. "Nonteaching" services, in contrast, are usually defined by the absence of resident physicians on the care team. The care for patients on a nonteaching service is frequently managed directly by a faculty or nonfaculty physician. Nonteaching services have grown in number and size at academic medical centers (AMCs) in response to regulatory requirements, operational demands, and efforts to improve clinical education. The allocation of patients to teaching and nonteaching services is frequently based on perceived teaching value of hospitalized patients, which can potentially lead to a number of unintended consequences for medical education, professional satisfaction, and patient care. Through a series of four lessons, the authors describe how the structure of nonteaching services can result in curricular gaps, devalue attending physicians, and undermine the educational and clinical missions of AMCs. Anticipating the continued expansion and evolution of nonteaching services, the authors propose seven design principles for nonteaching services to ensure robust education for students and resident physicians, advance quality of care, and enhance attending physician and patient experience.

Guillain-Barré syndrome (GBS) represents a family of acute, inflammatory polyneuropathies . The classic presentation is of progressive limb weakness with absent or decreased tendon reflexes , although there are several subtypes with different signs and symptoms. The onset of neurologic symptoms is often preceded by an acute diarrheal or respiratory infection. Patients with suspected GBS should undergo lumbar puncture and nerve conduction studies to help confirm the diagnosis. All patients should be hospitalized for ongoing supportive care and close observation. Mortality is 3% to 4% and as many as 20% of patients have long-term disability.

Important considerations for constipation include: 1. Initial evaluation should evaluate for fecal incontinence, fecal impaction, medication side effects, concerning symptoms, underlying medical or metabolic issues and irritable bowel syndrome. 2. History and examination should be used to determine if a defecatory disorder is most likely. a. If defecatory disorder is likely, testing with balloon expulsion or anal manometry can be considered and, if confirmed, treatment with biofeedback (if testing not available, it is reasonable to trial fiber and laxatives because many patients have a mixed disorder). b. If it is unlikely, proceed with trial of fiber and/or osmotic laxatives. 3. If continued symptoms, consider trial of newer agent (lubiprostone or linaclotide). 4. If ineffective, consider testing for colon transit time and referral to gastroenterology.

OBJECTIVESTo describe the characteristics and attitudes toward complementary and alternative medicine (CAM) use among primary care patients with chronic pain disorders and to determine if CAM use is associated with better pain control.DESIGNCross-sectional survey.SUBJECTSFour hundred sixty-three patients suffering from chronic, nonmalignant pain receiving primary care at 12 U.S. academic medical centers.OUTCOME MEASURESelf-reported current CAM usage by patients with chronic pain disorders.RESULTSThe survey had an 81% response rate. Fifty-two percent reported current use of CAM for relief of chronic pain. Of the patients that used CAM, 54% agreed that nontraditional remedies helped their pain and 14% indicated that their individual alternative remedy entirely relieved their pain. Vitamin and mineral supplements were the most frequently used CAM modalities. There was no association between reported use of CAM and pain severity, functional status, or perceived self-efficacy. Patients who reported having at least a high school education (odds ratio [OR] 1.1, 95% confidence interval [CI] 1.02-1.19, P = 0.016) and high levels of satisfaction with their health care (OR 1.47, 95% CI 1.13-1.91, P = 0.004) were significantly more likely to report using CAM.CONCLUSIONSComplementary and alternative therapies were popular among patients with chronic pain disorders surveyed in academic primary care settings. When asked to choose between traditional therapies or CAM, most patients still preferred traditional therapies for pain relief. We found no association between reported CAM usage and pain severity, functional status, or self-efficacy.

Patients and physicians often disagree in their assessment of pain intensity. This study explores the impact of patient factors on underestimation of pain intensity in chronic noncancer pain. We surveyed patients and their physicians in 12 primary care centers. To measure pain intensity, patients completed an 11-point numeric rating scale for which pain scores range from 0 (no pain) to 10 (unbearable pain). Physicians rated patients' pain on the same scale. We defined disagreement of pain intensity as underestimation or overestimation by 22 points. Of 601 patients approached, 463 (77%) completed the survey. The majority of participants were black (39%) or white (47%), 67% were female, and the mean age was 53 years. Physicians underestimated pain intensity relative to their patients 39% of the time. Forty-six percent agreed with their patients' pain perception, and 15% of physicians overestimated their patients' pain levels by > or =2 points. In both the bivariate and multivariable models, black race was a significant variable associated with underestimation of pain by physicians (p < 0.05; OR = 1.92; 95% CI: 1.31-2.81). This study finds that physicians are twice as likely to underestimate pain in blacks patients compared to all other ethnicities combined. A qualitative study exploring why physicians rate blacks patients' pain low is warranted.