Spring 2014 - Volume 18 Number 2

Original Research and ContributionsKaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical Group

Introducing Healing Circles and Talking Circles into Primary Care
Lewis Mehl-Madrona, MD, PhD, MPhil; Barbara Mainguy, MA

The authors report on the incorporation of "the talking circle" (or peacemaking or healing circle) into primary care. Communication is regulated through the passing of a talking piece. Only the person holding the piece may speak. Twelve hundred people participated: 415 attended 4 sessions and completed pre- and postquestionnaires. Participation in at least 4 talking circles resulted in a statistically significant improvement in reported symptoms and overall quality of life (p < 0.001).

Electrocardiograms of Adult Outpatients Followed-Up in Basic Health Care Units in the Community of the South Region of São Paulo City
Alice T Yamada, MD, PhD; Renata X Baldow, MD; Carla Ribeiro, MD; Wilma N Ribeiro, MD; Carolina Peruzzi, MD; Nilce M Matsuda, MD, PhD; Alfredo J Mansur, MD, PhD

The authors evaluated all elective electrocardiograms (ECGs) obtained in 3567 adult outpatients (63% women), from January 2009 to January 2010, at a municipal hospital in the city of São Paulo, Brazil, with results interpreted by a cardiologist. Of the 1918 patients whose ECGs showed abnormalities (mean age = 56 years, 59% women), 62% were major. There were more ECGs obtained from women; however, men and elderly patients more frequently had abnormal ECG results.

Using Simulation to Address Hierarchy-Related Errors in Medical Practice
Aaron William Calhoun, MD; Megan C Boone, RN, MSN, CCRN; Melissa B Porter, MD; Karen H Miller, PhD

Hierarchy, the unavoidable authority gradients that exist within and between clinical disciplines, can lead to significant patient harm in high-risk situations. Five sessions were conducted (pediatric intensive care unit and Emergency Department). The team was unsuccessful at addressing the error in 4 (80%) of 5 cases. Trends toward lower communication scores (3.4/5 vs 2.3/5), as well as poor team self-assessment of communicative ability, were noted in unsuccessful sessions.

Online Cognitive Behavioral Therapy for Depressed Primary Care Patients: A Pilot Feasibility ProjectKaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical Group
Ursula Whiteside, PhD; Julie Richards, MPH; Bradley Steinfeld, MD; Gregory Simon, MD, MPH; Selin Caka, MA; Chris Tachibana, PhD; Sarah Stuckey, MS; Evette Ludman, PhD

Cognitive behavioral therapy (CBT) is a goal-oriented treatment that guides patients to healthy thoughts and behaviors. Internet-delivered CBT with supportive coaching can be as effective as in-person psychotherapy treatment of depression. Of 196 eligible patients who were sent an invitation, 39 (20%) enrolled in the Internet-delivered CBT program. At follow-up, enrolled patients experienced a clinically significant decrease (average = 46%) in depressive symptoms. Suicidal thoughts also decreased both overall and in severity.

Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupUse of a Modified Reproductive Life Plan to Improve Awareness of Preconception Health in Women with Chronic Disease
Pooja Mittal, DO; Aparna Dandekar, MD; Danielle Hessler, MD

Preconception health results in improved reproductive outcomes. Primarily underserved, English- and Spanish-speaking women, aged 18 to 40 years, participated in reproductive-plan counseling. Twenty-seven women (average age = 31 years) were surveyed. Of the subjects, 85% were obese, 30% had hypertension, and 7% had diabetes. Significant increases (p < 0.001) were reported in understanding risks of pregnancy associated with diabetes, hypertension, and obesity, and most improvement occurred in women with the lowest precounseling test scores.

Toward a Trustworthy Voice: Increasing the Effectiveness of Automated Outreach Calls to Promote Colorectal Cancer Screening among African Americans
Karen Albright, PhD; Terri Richardson, MD; Karin L Kempe, MD, MPH; Kristin Wallace, MPH

This study evaluated the use of a linguistically congruent voice in interactive voice-response outreach calls about colorectal cancer screening as a strategy to increase call completion and response. Participants strongly preferred the African-American voices, because the sense of familiarity engendered trust among listeners. Effective messages should provide immediate clarity of purpose; explain why the issue is relevant to African Americans; avoid sounding scripted; emphasize that the call is for the listener's benefit only; sound personable, warm, and positive; and not create fear among listeners.

Prospects and Problems of Transferring Quality-Improvement Methods from Health Care to Social Services: Two Case Studies
Truls Neubeck, MSc; Mattias Elg, PhD; Thomas Schneider, PhD; Boel Andersson-Gäre, MD

This is a mixed-method case study. The two cases were analyzed through documented results and qualitative interviews with participants one year after the end of the quality-improvement (QI) projects. The social service QI projects led to measurable improvements when they used standard methods and tools for QI in health care. When one forms QI teams, the focus should be on functions instead of professions.

Special Report
RISQy Business (Relationships, Incentives, Supports, and Quality): Evolution of the British Columbia Model of Primary Care (Patient-Centered Medical Home)
Dan MacCarthy, MB, BCh, BAO; Marcus J Hollander, MA, MSc, PhD

The British Columbia General Practice Services Committee, in response to a decline in family practice, introduced a RISQ model: focus on Relationships; provide Incentives for general practitioners to spend more time with their patients and provide guidelines-based care; Support general practitioners by developing learning modules to improve their practices; and, through the incentive payments and learning modules, provide better Quality care to patients and improved satisfaction to physicians.

Special Report
Creating a Longitudinal Integrated Clerkship with Mutual Benefits for an Academic Medical Center and a Community Health System
Ann Noelle Poncelet, MD; Lindsay A Mazotti, MD; Bruce Blumberg, MD; Maria A Wamsley, MD; Tim Grennan, MD; William B Shore, MD

A successful one-year longitudinal integrated clerkship was created in partnership between an academic medical center and an integrated community health system. Compared with traditional clerkship students, students in the longitudinal integrated clerkship had better scores on clinical performance examinations, internal medicine examinations, and higher perceptions of direct observation of clinical skills.

Special Report
Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupPhysician Update: Total Health
Phillip Tuso, MD

Because of an increase in the incidence of preventable disease, and the potential long-term and short-term costs associated with the treatment of preventable disease, Kaiser Permanente has developed a new strategy called Total Health (healthy people in healthy communities) to meet the current and future needs of its patients by: 1) measuring vital signs of health, 2) promoting healthy behaviors, 3) monitoring disease incidence, 4) spreading leading practices, and 5) creating healthy environments with our community partners.

Special Report
Medical Missions—Overrated or Undervalued? A Single Program Experience
Randi Smith, MD, MPH; Samuel C Schecter, MBBS; Rhiana Menen, MD; Michael Cripps, MD; Richard Godfrey, MD

Surgical residents desire the opportunity to enhance their clinical training by working internationally, particularly, in resource-constrained environments. The authors' experiences confirm the potential of developing more well-versed, flexible, altruistic, and confident trainees. These experiences are only successful, however, through established, longstanding sustainable relationships with international institutions that prove mutually beneficial. The authors believe medical missions are a vital component of soft diplomacy and must be highly valued for their achievements in higher education and their service to patients in need.

Special Report
Leveraging Geographic Information Systems in an Integrated Health Care Delivery Organization
Kathryn Clift; Luther Scott, MS; Michael Johnson, PhD, MS; Carlos Gonzalez

Health exchanges require that health provider networks are geographically accessible to underserved populations. Nonprofit hospitals nationwide are required to conduct community health needs assessments every three years. Kaiser Permanente (KP) is applying geographic information systems, with spatial analytics and map-based visualizations,
to data sourced from its electronic medical records and from publicly and commercially available datasets. The results are helping to shape an understanding of the health needs of KP members in the context of their communities.

Review Article

Kaiser Permanente, The Permanente Medical Group, Southern California Permanente Medical GroupPalliative Care in the Emergency Department
Susanne M Mierendorf, MD, MS; Vinita Gidvani, MD

For patients living with chronic disease or malignancy who may be in a crisis, an Emergency Department (ED) visit may be pivotal in determining the patients' trajectory. This article summarizes the following: identification of patients who may need palliation, discussing prognosis, eliciting goals of care and directives, symptom management in the ED, and making plans for further care. These efforts have been shown to improve outcomes and to decrease length of stay and cost, assisting in transition to a noncurative approach and placement where this may be accomplished

Case Studies

The Coccidioidomycosis Conundrum: A Rare Parotid Mass
Christopher G Tang, MD; Brian A Nuyen; Balaram Puligandla, MD; Barry Rasgon, MD

A man, age 62 years, presented to the clinic with a 2-week history of increased nontender, nonerythematous, indurated right-sided parotid swelling. Cultures from an aspirate revealed Coccidioides immitis confirmed by DNA probe. The patient was treated with 800 mg of fluconazole every day for 3 months with resolution of the parotid swelling. However, persistent cervical adenopathy remains.

Medullary Sponge Kidney
Talha H Imam, MD; Alan S Taur, MD; Hassan Patail

Medullary sponge kidney is a congenital disorder that involves malformation of the terminal collecting ducts of renal tubules, which leads to formation of microscopic to large cysts in the medullary portion of both kidneys. Most patients are asymptomatic. If patients do have clinical manifestations, they are caused by kidney stones, hematuria, and urinary tract infections. These typically start presenting in the second and third decade of life.

Clinical Medicine

Image Diagnosis: Sister Mary Joseph Nodule
Alka Sharma, MD; Vishal Sharma, MD

A 44-year-old man presented to the Outpatient Department with a 2-month history of upper abdominal discomfort associated with loss of appetite and weight loss. An umbilical nodule was noted on physical exam. The Sister Mary Joseph nodule is a manifestation of umbilical metastasis of malignancy typically arising from the gastrointestinal or genitourinary tract.

ECG Diagnosis: ST-Elevation Myocardial Infarction
Calvin Hwang, MD; Joel T Levis, MD, PhD, FACEP, FAAEM

ST-elevation is the single best immediately available surrogate marker for detecting acute complete coronary artery occlusion without collateral circulation, signifying a significant region of injured myocardium at imminent risk of irreversible infarction, requiring immediate reperfusion therapy.

ECG Diagnosis: Type I Atrial Flutter
Steven Foy, MD; Joel T Levis, MD, PhD, FACEP, FAAEM

Atrial flutter is a cardiac dysrhythmia characterized by rapid and regular depolarization of the atria. It is most commonly caused by the presence of a macro-reentrant circuit in the right atrium that includes a small strip of tissue between the inferior vena cava and the tricuspid annulus known as the cavotricuspid isthmus.

Commentary

A Conversation on the Future of Health Care: Integrating Lifestyle Medicine—Part One: Understanding the Concepts
Herbert J Sorensen, MD

In response to personal and institutional history and articles published in The Permanente Journal, this article begins a conversation based on the premise that health care will only reach its full potential with the integration of traditional medical care (which relies on the application of pharmacologic and surgical intervention after the development of illness) and lifestyle medicine, the use of optimal nutrition, and exercise.

Narrative Medicine

What Can We Learn From Narratives in Medical Education?
Samir Johna, MD; Brandon Woodward, MD; Sunal Patel, MD

Medical literature has demonstrated the effectiveness of narrative writing in enhancing self-reflection and empathy, which opens the door for deeper understanding of patients' experiences of illness. Thirty-three narratives were collected over the course of 2 years. Each narrative analysis took 10 to 15 minutes to complete; narrative discussion with each learner took a similar length of time. The median for "collective number of core competencies" per single reflection was 4 (4 to 6). The learners perceived that reflective writing through narratives was a useful educational intervention for learning Accreditation Council for Graduate Medical Education core competencies through daily encounters.

Book Review

Ghosts from the Nursery: Tracing the Roots of Violence
Review by Anna Luise Kirkengen, MD, PhD

Nursing Research & Practice

Implemetation Study
Improving Alcohol Withdrawal Outcomes in Acute Care
Jo Melson, MSN, RN, FNP-BC; Michelle Kane, RN, MSN; Ruth Mooney, PhD, MN, RN-BC; James McWilliams, MSN, RN, NP-C; Terry Horton, MD

The authors instituted a care management guideline and assessed data for three months before and after implementation. There was a decreased percentage of patients who experienced delirium tremens (DT), and in those with DT, restraint use and transfers to the intensive care unit decreased. Early identification of patients for potential alcohol withdrawal followed by a standardized treatment protocol using symptom-triggered dosing improved alcohol withdrawal management and outcomes.

Nurse Practitioner Management of Type 2 Diabetes
Gail Carr Richardson, DNP, RN, CNP, CDE; Anne L Derouin, DNP, RN, CPNP; Allison A Vorderstrasse, DNSc, APRN, CNP; James Hipkens, MD, PhD; Julie A Thompson, PhD

Multifactorial barriers prevent primary care clinicians from helping their adult patients with type 2 diabetes achieve good control of hemoglobin A1C levels. Patient depression and low self-efficacy can complicate diabetes management by impairing tasks needed for effective disease self-management. Integrating nurse practitioners into primary care teams to provide innovative methods of support to adults with uncontrolled hyperglycemia improves clinical outcomes and self-efficacy for patients with type 2 diabetes.

Letter to the Editor

The Professional Practice of Registered Nurses

Soul of the Healer

Original Visual Art

"Serenity"
Brad Christian McDowell, MD

"Mont Saint-Michel, Normandy, France"
J Richard Gaskill, MD

"Groundwater Nitrogen in Clallam County"
Dwight Barry, PhD, and Brandon Massey

"I Dream of Living in a House with White Curtains Like One Sees in Old Prints" from Alone/Together: Meditations on Alienation.
Eric Blau, MD, and Lee Huai

On the Cover

"Dream Lake"
Brad Christian McDowell, MD

Circulation

25,000 print readers per quarter, 6900 eTOC readers, and in 2015, 1.4 million page views on TPJ articles in PubMed from a broad international readership

Subscriptions

The Permanente Journal (ISSN 1552-5767) is published quarterly by The Permanente Press. The Permanente Journal is available online (ISSN 1552-5775) at www.thepermanentejournal.org.

Letters

Articles, editorials, letters to the editor, and other material represent the opinion of the authors. Send your comments to permanente.journal@kp.org.


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