O'Laughlin, Danielle J

AIMS: Evidence-based medicine (EBM) is a necessary attribute required for quality medical practice. Despite being integral in advancing medicine and improving patient outcomes, research and quality improvement (QI) rarely integrate into medical education. We present our curricular course design and reveal students' perceptions of the implementation of this course. In addition, we compared physician assistant (PA) student perceptions from the first two traditional cohorts (4 years undergraduate before entry to PA program) to the accelerated 3+2 pathway cohorts (3 years pre-PA coursework followed by 2 years PA program). METHODS: Faculty developed an EBM course taught through student participation in QI projects and assessed students' perceptions of discovery, collaboration, cognitive ownership, and global sense toward general outcomes through the implementation and analysis of validated survey instruments. RESULTS: All students contributed to QI projects, achieved Quality Academy Bronze certification and Silver assessment and disseminated their work at peer-reviewed conferences. Over 56.4% earned Silver certification, and 36.2% of students had their project published in a journal. Student perception of experiential impact was positive overall, with 83.3% of students minimally responding 'true' to the prompts. All students indicated that after the experience, they possessed a basic understanding of QI approaches. The accelerated students selected 'true' for all other prompts more frequently than the traditional student population. DISCUSSION: This manuscript presents vital educational strategies, highlighting an approach and plan to extrapolate EBM principles beyond PA students and to generalize to other healthcare professionals and students. Through course completion, students met educational objectives and reaped additional benefits that positively impacted their resume building and future job prospects. By honing these skills, students are better prepared to contribute to patient care and advance the field of medicine. The accelerated students perceived greater course benefit likely due to the life-experience differences between the two cohorts, whereby the traditional students matriculated into the program with a breadth of prior knowledge obtained through years of contributions to education and careers.

Menopause marks a significant transition in a woman’s life, typically occurring between the ages of 46 and 55 years, characterized by the cessation of menstruation and a decline in ovarian function. This article provides a comprehensive overview of menopause, examining its physiological, psychological, and social dimensions. It explores the hormonal changes, including decreased levels of estrogen and progesterone, and how these changes contribute to common symptoms such as hot flashes, sleep disturbances, and mood fluctuations. Additionally, it highlights contemporary approaches to management, including lifestyle modifications and hormonal and non-hormonal therapies. By synthesizing current research and clinical insights, this overview aims to enhance understanding and support for women navigating menopause and the healthcare professionals assisting them.

Background: Proper diagnosis in primary care is crucial due to the large number of skin cancer diagnoses each year and its associated growing economic burden. Understanding how primary care providers can be best trained in dermoscopy is instrumental in helping primary care providers differentiate benign and malignant cutaneous lesions so that appropriate action can be taken (eg, biopsy/referral to dermatology or reassurance). Objective: To assess the success of concise dermoscopy training among primary care providers. Design: A cohort study was conducted in primary care at Mayo Clinic, Rochester, including primary care physicians, nurse practitioners, and physician assistants in internal medicine and family medicine. Diagnostic accuracy was measured on standardized testing through image-based recognition and in clinical practice through observation of referral and biopsy patterns both before and after dermoscopy education, focused on the TADA plus method. Results: Forty-three primary care providers completed the image-based recognition tests, with significant improvement in mean score measured after dermoscopy training workshop (20%). Among the thirteen primary care providers who continued to use dermoscopy in clinical practice, a significant improvement (31%) in mean clinical diagnostic accuracy was observed comparing 1 year of practice data before versus after dermoscopy training. Conclusion: Improvement in diagnostic accuracy with utilization of the TADA plus method translates into clinical practice. Therefore, training primary care providers in dermoscopy may improve the dermatologic care patients receive in primary care, especially in rural or medically underserved areas where access to dermatology is limited.

Background The Medicare Annual Wellness Visit (AWV) allows providers to acquire critical information about patients’ health through a review of vitals, environmental risks, and medical and family history. These visits are free to those enrolled in Medicare and prioritize patient–provider relationship building and preventative care. Despite this, AWV completion rates are suboptimal. Methods A quality improvement project was aimed to increase the percentage of AWVs among Medicare patients in a primary care internal medicine practice from a baseline of 1.7% completion to 2.7% in 3 months from January to April 2023. Intervention With eligible patients identified, a standardized approach was created where an AWV appointment was ordered, and a patient message explaining the benefit of the appointment was sent by the patient portal. Results Our AWV intervention resulted in 72 patients being seen for an AWV, which increased the percentage of completed AWVs in the division by 2.1% from 1.7% to 3.8% in 3 months. Conclusion This intervention will continue to improve AWV rates and improve patient care for Medicare patients in internal medicine. It could be applied to other areas of primary care and within other health systems.

Background: Gestational diabetes mellitus (GDM) is a common complication of pregnancy that carries lasting risks. For women who have a history of GDM, the risk of developing type 2 diabetes mellitus (T2DM) increases by 50 to 60%. To monitor and prevent the development of T2DM, guidelines suggest screening those with a history of GDM at 6-weeks and 3-years post-delivery. For patients with abnormal lab results at the 6-week mark, it is advised to complete lab work sooner, at the 1-year mark. Data suggests that these guidelines are not being followed globally, and most do not receive adequate screening for T2DM. Methods: A retroactive chart review of 203 women between 18 and 55 years old with a past medical history significant for GDM was conducted to determine if patients with GDM completed screening for T2DM at 6-week, 1-year, and 3-year timestamps post-delivery. Patient demographics (age, race, ethnicity, language), clinical characteristics (body mass index), provider gender, and whether prediabetes or T2DM developed were recorded. Patients who did not complete the required follow-up received educational materials via the online portal system, and hemoglobin A1c (HbA1c) screening tests were ordered. Results: Ninety days post-intervention, 38 patients (50%) completed the HbA1c screening test, which exceeded our goal of a 5% improvement. Age and BMI 1-year postpartum were found to be significant factors in whether a patient completed HbA1c screening, with 16/18 (89%) completing screening with a healthy BMI 1-year postpartum (18.5 ≤ BMI < 25.0) but only 11/41 (27%) completing screening for patients under 40 years with an unhealthy BMI 1-year postpartum. Of the 38 patients who completed HbA1c screening, 9 (23.7%) had abnormal screening results. Conclusion: Follow-up surveillance for T2DM among women with a history of GDM is poor. Electronic health records can be used to identify and rectify gaps in care. Dissemination of standardized educational materials and electronic order entry for patients improved screening between the handoff from obstetrics to primary care.

Background: Cotesting with the Papanicolaou (Pap) and human papillomavirus tests detects most precancerous and cancerous lesions and increases the sensitivity for detecting high-grade precancerous and invasive cervical cancers compared with human papillomavirus testing alone. Objective: To compare the use of the Papette brush (hereafter Papette) to the traditional spatula with endocervical brush (cytobrush) for cervical cancer screening. Design: Pragmatic observational study. Methods: Adult women aged 21–64 years who were eligible for a Papanicolaou test at a Midwest Community Internal Medicine practice underwent cervical cancer screening using the Papette or spatula with cytobrush from 18 August 2021 through 1 February 2022. Cluster sampling was used across the practice. Pathology reports were then analyzed to compare the number of satisfactory versus unsatisfactory results between the two collection techniques. Results: We collected results for 756 Pap tests. The test results were satisfactory with the Papette 93.8% of the time compared with 93.0% for the spatula with cytobrush. Conclusion: The Papette is not inferior to a spatula with cytobrush as a collection method for Pap tests.

Objectives Lupron 11.25 mg has both a narrow indication and a high cost compared to other Lupron presentations. Prior to our study initiation there was no clear distinction between presentations when ordering within the health-system’s Electronic Health Record (EHR). This resulted in inappropriate product selection, payment and billing errors that negatively impact our healthcare system. To reinforce prior education efforts, a new approach was considered leveraging the EHR with information to steer prescribers to the proper Lupron presentation based on indication. This study aimed to reduce off-label prescribing for Lupron 11.25 mg (NDC 00074-3663-03) by 25% by 02/28/2022 without negatively impacting the insurance collection rate. Methods Baseline Lupron 11.25 mg adult kit administrations one year prior to intervention and off-label prescribing was found to account for 22.7% of administrations. In December 2021 intervention order questions were added to Lupron 11.25 mg in the EHR. One and two-month data was obtained after implementing order questions within the EHR. Lupron 11.25 mg administrations were classified into one of four categories to determine impact on off-label prescribing. Results In the one- and two-month post-implementation periods off-label prescribing was 0% and 15.3% respectively, a reduction of 22.7% to and 7.4% respectively from the baseline assessment. There were no clinical denials found in either post-implementation reporting period. Conclusion This report adds to the body of evidence that leveraging the EHR can lead to healthcare savings and illustrates how patient and healthcare system burden can be reduced by prompting thought and direction when a medication has indication specific dose requirements.

To review the anxiety and fear risk factors, pathophysiology, symptoms, screening and diagnosis while highlighting treatment considerations for women undergoing a pelvic examination. Methods: We reviewed the literature pertaining to anxiety and fear surrounding the pelvic examination to help guide health care providers’ on available screening options and to review options for individualized patient management. Results: Anxiety and fear are common before and during the pelvic examination. In fact, the pelvic exam is one of the most common anxiety-provoking medical procedures. This exam can provoke negative physical and emotional symptoms such as pain, discomfort, anxiety, fear, embarrassment, and irritability. These negative symptoms can interfere with preventative health screening compliance resulting in delayed or avoided care and significant health consequences. Conclusion: Assessing women for anxiety related to pelvic examinations may help decrease a delay or avoidance of examinations. Risk factor and symptom identification is also a key component in this. General anxiety questionnaires can help identify women with anxiety related to pelvic examinations. Strategies to reduce anxiety, fear and pain during a pelvic examination should routinely be implemented, particularly in women with high-risk factors or those identified with screening techniques as having anxiety, fear or pain with examinations. Treatment options should be targeted at understanding the patient’s concerns, starting conversations about pelvic examinations early, educating patient’s about the examination and offering the presence of a chaperone or support person. During an examination providers should ensure the patient is comfortable, negative phrases are avoided, the correct speculum size is utilized and proper lubrication, draping, dressing and positioning are performed. Treating underlying gynecologic or mental health conditions, consideration of cognitive behavioral therapy and complementary techniques such as lavender aromatherapy and music therapy should also be considered when appropriate.