Integrating Oral Health into Health Professions School Curricula

Oral health is essential to human health. Conditions associated with poor oral health involve all organ systems and many major disease categories including infectious disease, cardiovascular disease, chronic pain, cancer, and mental health. Outcomes are also associated with health equity. Medical education organizations including the Association of American Medical Colleges and National Academy of Medicine recommend that oral health be part of medical education. However, oral health is not traditionally included in many medical school, physician assistant, or nurse practitioner curricula. Several challenges explain this exclusion including lack of time, expertise, and prioritization; we therefore provide suggestions for integrating oral health education into the health professions school curriculum. These recommendations offer guidance for enhancing the oral health curriculum across institutions. We include key organizational and foundational steps, strategies to link oral health with existing content, and approaches to achieve curricular sustainability.

The impact of family physicians in rural maternity care

BACKGROUND

Reduced access to maternity care in rural areas of the United States presents a significant burden to pregnant persons and infants. The objective of this study was to estimate the impact of family physicians (FPs) on access to maternity care in rural United States hospitals, especially where other providers may not be available.

METHODS

We administered a survey to 216 rural hospitals in 10 US states inquiring about the number of babies delivered from 2013 to 2017, the types of delivering physicians, and the maternity services offered. We calculated the percentage of rural hospitals in our sample where FPs performed vaginal deliveries, cesareans, and vaginal births after cesarean (VBACs), and the percentage of all babies delivered by FPs. We estimated the distance patients would have to travel for care if FPs were not providing care locally.

RESULTS

The final study population consisted of 185 rural hospitals. FPs delivered babies in 67% of these hospitals and were the only physicians who delivered babies in 27% of these hospitals. FPs provided VBAC at 18% and cesarean birth services at 46% of the rural hospitals, but with wide geographic differences. Many patients would have to drive an average of 86 miles round-trip to access care if those FPs were to stop delivering.

CONCLUSIONS

Family physicians are essential providers of maternity care in the rural United States. Family Medicine residency programs should ensure that trainees who intend to practice in rural locations have adequate maternity care training to maintain and expand access to maternity care for rural patients and their families.

Eight Ways to Mitigate US Rural Health Inequity

Rural residents in the United States are less likely to have dental insurance and more likely to face environmental and geographic barriers to oral health and dental care. This article discusses oral health inequity, evidence of oral health's influence on overall health, and why the primary care workforce is well positioned to provide prevention, screening, and referrals for oral health and dental care. Six strategies by which oral health and dental care are integrated into primary care delivery streams can help mitigate rural health inequity.

Contributions of US Medical Schools to Primary Care (2003-2014): Determining and Predicting Who Really Goes Into Primary Care

BACKGROUND AND OBJECTIVES

Schools of medicine in the United States may overstate the placement of their graduates in primary care. The purpose of this project was to determine the magnitude by which primary care output is overestimated by commonly used metrics and identify a more accurate method for predicting actual primary care output.

METHODS

We used a retrospective cohort study with a convenience sample of graduates from US medical schools granting the MD degree. We determined the actual practicing specialty of those graduates considered primary care based on the Residency Match Method by using a variety of online sources. Analyses compared the percentage of graduates actually practicing primary care between the Residency Match Method and the Intent to Practice Primary Care Method.

RESULTS

The final study population included 17,509 graduates from 20 campuses across 14 university systems widely distributed across the United States and widely varying in published ranking for producing primary care graduates. The commonly used Residency Match Method predicted a 41.2% primary care output rate. The actual primary care output rate was 22.3%. The proposed new method, the Intent to Practice Primary Care Method, predicted a 17.1% primary care output rate, which was closer to the actual primary care rate.

CONCLUSIONS

A valid, reliable method of predicting primary care output is essential for workforce training and planning. Medical schools, administrators, policy makers, and popular press should adopt this new, more reliable primary care reporting method.

An Assessment of Participant-Described Interprofessional Oral Health Referral Systems Across Rurality

PURPOSE

As a means to identify and quantify oral health interprofessional collaborative practice (IPP), we examined participant-described medical-to-dental (M2D) referral networks and how they function across rurality.

METHODS

We conducted a cross-sectional survey on the appraisal of IPP referral systems in 2016. Secondarily, we examined if rural health clinics (RHCs) have different experiences with M2D referrals compared to other practice types. Independent variables included geographic and organizational indicators, referral system attributes, and respondent characteristics. Data were coded by Census region and state Medicaid expansion status. Bivariable and multivariable analyses were conducted using SAS.

FINDINGS

A convenience cohort (n = 559) from 44 states was examined. Nearly, half (48.7%) reported dependable M2D referral systems. In bivariate analysis, all independent variables were significant except for state Medicaid expansion status. In multivariable analysis, Census region retained significance (P = .0093). Organization type and practice issues with no shows/missed appointments continued to have significance (P < .001 and .002, respectively). Accountable care organizations were over 5 times (5.72, P = .001) more likely than RHCs to report dependable M2D referral systems. Federally qualified health clinics were slightly over 3 times more likely than RHCs to report dependable M2D referral (3.04, P < .001). No differences between RHCs and other private practices were observed.

CONCLUSIONS

The importance of IPP continues to be promoted in the current health care environment. Our study demonstrates that, in this motivated study population, M2D referrals can work well, even in rural areas. Organization type, directionality of referral, broken appointment rates, and electronic health information management were all found to significantly impact the respondents' rating on the dependability of an M2D referral process.

Using Ultrasound to Enhance Medical Students' Femoral Vascular Physical Examination Skills

OBJECTIVES

To determine whether the addition of ultrasound to traditional physical examination instruction improves junior medical students' abilities to locate the femoral pulse.

METHODS

Initially, 150 second-year medical students were taught the femoral pulse examination using traditional bedside teaching on standardized patients and online didactic videos. Students were then randomized into 2 groups: group 1 received ultrasound training first and then completed the standardized examination; and group 2 performed the standardized examination first and then received ultrasound training. On the standardized patients, the femoral artery was marked with invisible ink before the sessions using ultrasound. Compared to these markers, students were then evaluated on the accuracy of femoral artery pulse palpation and the estimated location of the femoral vein. All students completed a self-assessment survey after the ultrasound sessions.

RESULTS

Ultrasound training improved the students' ability to palpate the femoral pulse (P= .02). However, ultrasound did not facilitate correct estimation of the femoral vein's anatomic location (P = .09). Confidence levels in localizing the femoral artery and vein were equal between groups at baseline, and both increased after the ultrasound sessions.

CONCLUSIONS

The addition of ultrasound teaching to traditional physical examination instruction enhanced medical student competency and confidence with the femoral vascular examination. However, understanding of anatomy may require emphasis on precourse didactic material, but further study is required.

The impact of Advanced Life Support in Obstetrics (ALSO) training in low-resource countries

OBJECTIVE

To examine the effects of the Advanced Life Support in Obstetrics (ALSO) program on maternal outcomes in four low-income countries.

METHODS

Data were obtained from single-center, longitudinal cohort studies in Colombia, Guatemala, and Honduras, and from an uncontrolled prospective trial in Tanzania.

RESULTS

In Colombia, maternal morbidity and the number of near misses increased after ALSO training, but maternal mortality decreased. In Guatemala, sustained reductions in overall maternal mortality and mortality from postpartum hemorrhage (PPH) were recorded after ALSO implementation. In Honduras, there was a significant decrease in episiotomy rates, and increases in active management of the third stage of labor (AMTSL), vacuum-assisted delivery, and reported comfort managing obstetric emergencies. In Tanzania, the frequency of PPH and severe PPH decreased after training, while management improved.

CONCLUSION

In low-income countries, ALSO training was associated with decreased in-hospital maternal mortality, episiotomy use, and PPH. AMTSL and vacuum-assisted vaginal delivery increased in frequency after ALSO training.

Endoscopy training in primary care: innovative training program to increase access to endoscopy in primary care

BACKGROUND AND OBJECTIVES

Colorectal cancer (CRC) is a significant source of morbidity and mortality in the United States. Colonoscopy can be an extension of the care provided by a family physician to help substantially reduce CRC morbidity and mortality. Family physicians trained in colonoscopy can provide access to care in rural and medically underserved areas.

METHODS

The Department of Family Medicine and the Colorado Area Health Education Center (AHEC) developed the Endoscopy Training for Primary Care (ETPC) program to teach primary care physicians to perform colonoscopy. The program included online didactic education, a formal endoscopy simulator experience, and proctoring by a current endoscopist. Participants completed a baseline and follow-up survey assessing CRC screening knowledge and the effectiveness of the endoscopy training for ongoing screening activities.

RESULTS

To date, 94 practitioners and health professional students have participated in the study. Ninety-one (97%) completed the online didactic portion of the training. Sixty-five participants (77%) were physicians or medical students, and the majority (64%) was in the field of family medicine. The year 4 (2011) follow-up cohort was comprised of 62% respondents working in an urban background and 26% in rural communities. Many participants remain in a queue for proctoring by a trained endoscopist. Several participants are successfully performing a significant number of colonoscopies.

CONCLUSIONS

ETPC program showed success in recruiting a large number of physicians and students to participate in training. The program enhanced perceptions about the value of colon cancer screening and providing screening endoscopy in primary care practice. Providing sites for simulation training throughout Colorado provided opportunity for providers in rural regions to participate. As a result of this training, thousands of patients underwent testing to prevent colon cancer. Future research relating to colonoscopy training by family physicians should focus on quality assurance and determining best methods for procedural competence.

Tiered maternity care training in family medicine

BACKGROUND AND OBJECTIVES

Maternity care training in family medicine is a major component of our specialty. The Association of Family Medicine Residency Directors (AFMRD) issued a position paper calling for a two-tiered system of training for family physicians based on concern that some residency programs are unable to meet the current Residency Committee-Family Medicine (RC-FM) requirements for maternity care training. This two-tiered system was also endorsed by other family medicine organizations, including the AAFP, ADFM, NAPCRG, and STFM. Despite this support of the new system, there remains concern among some family medicine educators about this two-tiered approach. The Society of Teachers of Family Medicine Group on Hospital Medicine and Procedural Training met in 2009 and 2010 to develop an alternative tiered system for the training of family medicine residents in maternity care.

METHODS

Working from previous requirements for maternity care training and the AFMRD document, the group used a multi-voting process to identify the tiers and their elements.

RESULTS

The group generated a three-tier system for maternity care training in family medicine residencies. These included curriculum, patient volume, faculty expectations, and institutional requirements.

CONCLUSIONS

The three tiers we propose address the importance of maternity care, the limitations that some residencies face in providing adequate patient volumes, and the need to teach more advanced skills to those family medicine residents who will work in rural and underserved areas upon graduation. We urge family medicine governing bodies to adopt this system and believe that it will help preserve the essential role that family physicians serve in the care of pregnant women starting with basic maternity care and extending to advanced roles including care of complicated pregnancies and cesarean delivery.

First trimester bleeding

Vaginal bleeding in the first trimester occurs in about one fourth of pregnancies. About one half of those who bleed will miscarry. Guarded reassurance and watchful waiting are appropriate if fetal heart sounds are detected, if the patient is medically stable, and if there is no adnexal mass or clinical sign of intraperitoneal bleeding. Discriminatory criteria using transvaginal ultrasonography and beta subunit of human chorionic gonadotropin testing aid in distinguishing among the many conditions of first trimester bleeding. Possible causes of bleeding include subchorionic hemorrhage, embryonic demise, anembryonic pregnancy, incomplete abortion, ectopic pregnancy, and gestational trophoblastic disease. When beta subunit of human chorionic gonadotropin reaches levels of 1,500 to 2,000 mIU per mL (1,500 to 2,000 IU per L), a normal pregnancy should exhibit a gestational sac by transvaginal ultrasonography. When the gestational sac is greater than 10 mm in diameter, a yolk sac must be present. A live embryo must exhibit cardiac activity when the crown-rump length is greater than 5 mm. In a normal pregnancy, beta subunit of human chorionic gonadotropin levels increase by 80 percent every 48 hours. The absence of any normal discriminatory findings is consistent with early pregnancy failure, but does not distinguish between ectopic pregnancy and failed intrauterine pregnancy. The presence of an adnexal mass or free pelvic fluid represents ectopic pregnancy until proven otherwise. Medical management with misoprostol is highly effective for early intrauterine pregnancy failure with the exception of gestational trophoblastic disease, which must be surgically evacuated. Expectant treatment is effective for many patients with incomplete abortion. Medical management with methotrexate is highly effective for properly selected patients with ectopic pregnancy. Follow-up after early pregnancy loss should include attention to future pregnancy planning, contraception, and psychological aspects of care.

Changing policies on vaginal birth after cesarean: impact on access

BACKGROUND

The issue of vaginal birth after cesarean (VBAC) has become highly visible and contentious. In 1999, the American College of Obstetricians and Gynecologists advocated a policy that surgical capability be "immediately available" for women in labor attempting VBAC.

METHODS

Every hospital in Colorado, Montana, Oregon, and Wisconsin was contacted by telephone at least once during the period 2003 to 2005. Using a semistructured interview, respondent hospitals were asked whether and when their policies for VBAC had changed and what was the availability of VBAC services before and after the 1999 policy was issued.

RESULTS

Of 314 hospitals contacted, 312 responded to the survey (response rate 99.4%). Babies were delivered at 230 (74%) respondent hospitals. Almost one-third, 68 of 222 (30.6%), of responding delivery hospitals that previously offered VBAC services had stopped doing so; seven hospitals had never allowed VBAC. Of the hospitals that still allowed VBAC, 68 percent had changed their VBAC policies since 1999, with the most frequent changes requiring the in-house presence of surgery (53%) and anesthesia (44%) personnel when women desiring VBAC presented in labor. Compared with hospitals that stopped allowing VBAC, those that currently permit VBAC were larger (156.6 vs 58.1 beds, t = 7.02, p < 0.001), closer to other delivery hospitals (20.9 vs 39.2 miles, t = 4.33, p < 0.001), annually delivered more babies (1009.9 vs 458.3, t = 4.41, p < 0.001), and annually had more cesarean deliveries (226.7 vs 105.7, t = 3.91, p < 0.001).

CONCLUSIONS

In the years following advocacy of the 1999 policy, the availability of VBAC services significantly decreased, especially among smaller or more isolated hospitals.

Advanced life support in obstetrics (ALSO) international development

BACKGROUND

The Advanced Life Support in Obstetrics (ALSO) program helps pregnancy care providers learn the information and skills necessary to deal with urgent and emergent conditions that arise during pregnancy and delivery by using mannequins, mnemonics, and evidence-based approaches. Since its origin, the program has been disseminated internationally. Outside of North America, more than 18,000 clinicians have taken the ALSO course, and more than 1,200 ALSO individuals have been approved as ALSO instructors. Some of the international programs have become self-sustaining, others have not.

METHODS

Features of ALSO programs were analyzed in all countries in which ALSO has been introduced to identify characteristics associated with the program becoming self-sustaining.

RESULTS

Characteristics of self-sustaining ALSO programs include a strong organizational structure, use of a train-the-trainer model to introduce the course, and encouragement of competing groups to work together. Overall, the program has been sustained by drawing on the expertise of international collaborators for medical content and by balancing customization of content against preservation of core information and skills.

CONCLUSIONS

When the ALSO program is introduced to a new country or region, methods that have resulted in programs becoming self-sustaining should be used.

Stress urinary incontinence in women: diagnosis and medical management

Stress urinary incontinence (SUI) is the most common form of urinary incontinence in women and is associated with high financial, social, and emotional costs. The history and physical examination can identify most patients with a significant stress incontinence component without the need for urodynamic testing. A variety of pharmacologic agents have been used off-label, but an evidence-based pharmacologic treatment has not been readily available. The development of a selective serotonin and norepinephrine reuptake inhibitor will add a potentially useful drug to the primary care physician's practice for treating female patients with SUI. In August 2004, a selective serotonin and norepinephrine reuptake inhibitor, duloxetine, became the first medication approved for the treatment of women with moderate to severe SUI throughout the European Union. As of November 2005, however, duloxetine has not been approved for the treatment of SUI in the United States.

Is reimbursement for childhood immunizations adequate? evidence from two rural areas in colorado

OBJECTIVE

To assess adequacy of reimbursement for childhood vaccinations in two rural regions in Colorado, the authors measured medical practice costs of providing childhood vaccinations and compared them with reimbursement.

METHODS

A "time-motion" method was used to measure labor costs of providing vaccinations in 13 private and public practices. Practices reported non-labor costs. The authors determined reimbursement by record review.

RESULTS

The average vaccine delivery cost per dose (excluding vaccine cost) ranged from $4.69 for community health centers to $5.60 for private practices. Average reimbursement exceeded average delivery costs for all vaccines and contributed to overhead in private practices. Average reimbursement was less than total cost (vaccine-delivery costs + overhead) in private practices for most vaccines in one region with significant managed care penetration. Reimbursement to public providers was less than the average vaccine delivery costs.

CONCLUSIONS

Current reimbursement may not be adequate to induce private practices to provide childhood vaccinations, particularly in areas with substantial managed care penetration.

Is reimbursement for childhood immunizations adequate? evidence from two rural areas in colorado

OBJECTIVE

To assess adequacy of reimbursement for childhood vaccinations in two rural regions in Colorado, the authors measured medical practice costs of providing childhood vaccinations and compared them with reimbursement.

METHODS

A "time-motion" method was used to measure labor costs of providing vaccinations in 13 private and public practices. Practices reported non-labor costs. The authors determined reimbursement by record review.

RESULTS

The average vaccine delivery cost per dose (excluding vaccine cost) ranged from $4.69 for community health centers to $5.60 for private practices. Average reimbursement exceeded average delivery costs for all vaccines and contributed to overhead in private practices. Average reimbursement was less than total cost (vaccine-delivery costs + overhead) in private practices for most vaccines in one region with significant managed care penetration. Reimbursement to public providers was less than the average vaccine delivery costs.

CONCLUSIONS

Current reimbursement may not be adequate to induce private practices to provide childhood vaccinations, particularly in areas with substantial managed care penetration.

Outcomes from use of an evidence-based practice guideline

The aim of evidence-based guidelines is primarily to improve patient outcomes without adding to the existing cost of care because both payers and policymakers want to identify health care costs that do not result in benefit to the patient. The purpose of the reported project was to generate a practice guideline for the treatment of uncomplicated acute cystitis in a female population, to determine the extent to which the guideline would be used by providers and to measure the cost and quality of outcomes from its use. A retrospective chart review was used to gather pre-guideline practice and cost data. Measurements included the type, frequency, and duration of antibiotic therapy and the use of urine cultures and both complications and routine followup visits. The implementation of an outpatient practice guideline resulted in a significant change in antibiotic prescribing and a trend toward a change in ordering cultures and clinic followup. There was also a significant decrease in treatment costs.

Outcomes of cesarean sections performed by family physicians and the training they received: a 15-year retrospective study

BACKGROUND

Family physicians are the major or sole providers of Cesarean section services in many communities. Approximately 2800 family physicians provide Cesarean section services in communities of all sizes across the country.

METHODS

The outcomes of all Cesarean sections performed at two rural hospitals during a 10- to 15-year period were examined and compared with standard quality-outcome criteria published in the medical literature. Outcome criteria included rates of various surgical complications, use of blood transfusion, infant Apgar scores, and length of postoperative hospital stay. Other descriptive data were examined including patient demographics, operating time, anesthesia type, and choice of incision. Statistical analysis consisted of chi-squares, odds ratios, and stepwise multiple regression.

RESULTS

Five hundred sixty-three Cesarean sections were performed by 12 residency-trained family physicians, 68 by general practitioners, 70 by general surgeons, and 9 by obstetrician-gynecologists. Family physicians met or surpassed the referenced standards in all measures examined. The number of Cesarean sections each physician performed while in residency training was also examined. The average number of in-training Cesarean sections was 46, ranging from 25 to 100.

CONCLUSIONS

The results of this study support the ability of family physicians to provide Cesarean section services based on a wide range of training backgrounds and variable numbers of procedures done in training.

Advances in the diagnosis of first-trimester pregnancy problems

Prompt diagnosis of problems in the first trimester of pregnancy is facilitated by ultrasound scanning and quantitative serum human chorionic gonadotropin and progesterone testing. When used appropriately, these tests can determine whether a patient has a normal early pregnancy, a miscarriage, a missed abortion, an ectopic pregnancy or a hydatidiform mole.

The problematic first-trimester pregnancy

The first-trimester obstetric patient who is experiencing pain or bleeding may have a normal intrauterine pregnancy, a threatened miscarriage, an ectopic pregnancy, a blighted ovum or trophoblastic disease. Correlation of clinical findings, quantitative human chorionic gonadotropin levels and diagnostic ultrasound findings can maximize the efficiency of the work-up, provide a definitive prognosis and identify early ectopic pregnancy.

The effects of 1% pyrophosphate and 0.02% sodium fluoride on artificial caries lesions in vivo

We evaluated the potential of a pyrophosphate-fluoride solution to affect the remineralizing-demineralizing equilibrium, i.e., caries-inhibiting/-promoting effects on enamel in vivo. Fifteen subjects carried dentin blocks and enamel thin sections with artificial caries lesions in removable partial dentures for periods of two weeks, during which time they rinsed twice daily in a double-blind, randomized cross-over design with solutions containing (a) 90 ppm F, (b) 90 ppm F and 1% pyrophosphate, or (c) no active agents (placebo). A severe cariogenic challenge provided to the lesions by plaque under a stainless steel mesh cover resulted in the placebo-treated lesions losing 70.2% +/- 72.1% mineral. The pyrophosphate rinse with fluoride held the mineral loss to only 28.1 +/- 52.8%, while the fluoride rinse without pyrophosphate held the loss to 24.2 +/- 50.1%. The differences between the fluoride and placebo results were significant (p less than 0.01), but the difference between the two fluoride groups was not. A large amount of fluoride was deposited in the dentin lesions. In the surface layer, the concentration was increased from 1000 ppm F to more than 2300 ppm F by both fluoride treatments. The concentration of fluoride in both groups of fluoride-treated lesions further increased to more than 3500 ppm F in the approximate center of the lesion before declining in deeper layers toward the level found in the placebo-treated group. The findings from both mineral change and fluoride uptake phases of this study show that in the presence of 90 ppm F, 1% pyrophosphate did not promote demineralization of artificial caries lesions.

Effects of two fluoride gels on fluoride uptake and phosphorus loss during artificial caries formation

Blocks of human enamel were cycled through a demineralization--F-treatment-remineralization procedure and then analyzed for fluoride and the presence of caries-like lesions. Treatments with a sodium fluoride gel (5000 ppm F) increased the enamel fluoride concentration to 6500 ppm F, whereas a stannous fluoride gel (1000 ppm F) increased enamel fluoride to about 1200 ppm F. Although a control treatment (water) allowed caries-like lesions to form, as observed by microradiography, no lesions were found in either of the fluoride-treated groups. When the experiment was repeated with radioactive teeth, mineral loss, as determined by release of 32P, was again greatest in the water-treated control group, but some loss was observed in the fluoride treatment groups. The least loss was found in the sodium fluoride group. It was concluded that the fluoride treatments not only increased enamel resistance but also enhanced remineralization so that calcium phosphate was replaced during the subsequent remineralization phase. Because of the probability that stannous ions were deposited during the stannous fluoride treatments, some of the apparent calcium phosphate re-deposition in this group was probably stannous compounds.