Family Medicine Update

Lesson in a pill box: teaching about the challenges of medication adherence.

Fam Med. 2009 Feb;41(2):99-104

Authors: O’Connor DM, Savageau JA, Centerbar DB, Wamback KN, Ingle JS, Lomerson NJ

BACKGROUND AND OBJECTIVES: Medication mismanagement is a serious health issue affecting elders and people with disabilities, who often manage multiple medications. This project’s goal was to educate medical and nursing students about the challenges patients face when managing complex medication regimens. METHODS: A total of 104 first-year medical students and 40 second-year nursing students were randomly assigned to participate in a 1-week regimen of mock prescriptions or to read a description of the regimen and make predictions about what the experience would be like had they participated. RESULTS: Quantitative results in combination with qualitative information suggest that the students taking the mock prescriptions gained important insights into the difficulty of managing a complicated medication regimen. Discussion: This mock prescription exercise, well accepted by students and faculty, was easily incorporated into the curriculum and provided an experiential opportunity for students to learn of the difficulties of medication adherence.

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Primary Care Physicians’ Use of an Electronic Medical Record System: A Cognitive Task Analysis.

J Gen Intern Med. 2009 Jan 7;

Authors: Shachak A, Hadas-Dayagi M, Ziv A, Reis S

OBJECTIVE: To describe physicians’ patterns of using an Electronic Medical Record (EMR) system; to reveal the underlying cognitive elements involved in EMR use, possible resulting errors, and influences on patient-doctor communication; to gain insight into the role of expertise in incorporating EMRs into clinical practice in general and communicative behavior in particular. DESIGN: Cognitive task analysis using semi-structured interviews and field observations. PARTICIPANTS: Twenty-five primary care physicians from the northern district of the largest health maintenance organization (HMO) in Israel. RESULTS: The comprehensiveness, organization, and readability of data in the EMR system reduced physicians’ need to recall information from memory and the difficulty of reading handwriting. Physicians perceived EMR use as reducing the cognitive load associated with clinical tasks. Automaticity of EMR use contributed to efficiency, but sometimes resulted in errors, such as the selection of incorrect medication or the input of data into the wrong patient’s chart. EMR use interfered with patient-doctor communication. The main strategy for overcoming this problem involved separating EMR use from time spent communicating with patients. Computer mastery and enhanced physicians’ communication skills also helped. CONCLUSIONS: There is a fine balance between the benefits and risks of EMR use. Automaticity, especially in combination with interruptions, emerged as the main cognitive factor contributing to errors. EMR use had a negative influence on communication, a problem that can be partially addressed by improving the spatial organization of physicians’ offices and by enhancing physicians’ computer and communication skills.

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Enhancing family physician capacity to deliver quality palliative home care: an end-of-life, shared-care model.

Can Fam Physician. 2008 Dec;54(12):1703-1703.e7

Authors: Marshall D, Howell D, Brazil K, Howard M, Taniguchi A

PROBLEM BEING ADDRESSED: Family physicians face innumerable challenges to delivering quality palliative home care to meet the complex needs of end-of-life patients and their families. OBJECTIVE OF PROGRAM: To implement a model of shared care to enhance family physicians’ ability to deliver quality palliative home care, particularly in a community-based setting. PROGRAM DESCRIPTION: Family physicians in 3 group practices (N = 21) in Ontario’s Niagara West region collaborated with an interprofessional palliative care team(including a palliative care advanced practice nurse, a palliative medicine physician, a bereavement counselor, a psychosocial-spiritual advisor, and a case manager) in a shared-care partnership to provide comprehensive palliative home care. Key features of the program included systematic and timely identification of end-of-life patients, needs assessments, symptom and psychosocial support interventions, regular communication between team members, and coordinated care guided by outcome-based assessment in the home. In addition, educational initiatives were provided to enhance family physicians’ knowledge and skills. CONCLUSION: Because of the program, participants reported improved communication, effective interprofessional collaboration, and the capacity to deliver palliative home care, 24 hours a day, 7 days a week, to end-of-life patients in the community.

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