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BACKGROUND: Medication-assisted treatment (MAT) for opioid use disorder (MAT) is encouraged for primary care use, but evidence for effectiveness when fully integrated with primary care versus provided separately is limited. METHOD: We conducted a retrospective cohort study of 257 MAT patients in our family medicine clinic to assess retention in treatment for patients receiving MAT integrated with primary care compared with our MAT patients who received their primary care elsewhere. RESULTS: At 1 year after enrollment, 60% of patients receiving MAT integrated with primary care remained in treatment versus 43% of patients who received their primary care separately. In multivariate analysis, the patients receiving integrated MAT had a significantly lower risk of dropout (hazard ratio 0.49, 95% CI, 0.33-0.72). CONCLUSION: In this rural family medicine clinic, MAT integrated with primary care was associated with higher retention in treatment. Providing MAT as a component of comprehensive primary care may be superior to referring patients to an outside source.

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INTRODUCTION: Recent changes to the Accreditation Council for Graduate Medical Education (ACGME) requirements eliminated minimum standards for protected nonclinical time for core faculty. Faculty perform many nonclinical tasks to maintain family medicine residencies. The objective of this study is to describe the landscape of nonclinical time for family medicine residency faculty. METHODS: Program directors at ACGME-accredited family medicine residencies were electronically surveyed in August 2019 to describe nonclinical time of their faculty. Survey information requested included program demographics, the amount of nonclinical time allocated, and the estimated amount of nonclinical time spent per year completing their faculty duties. RESULTS: A total 156 of 635 program directors (24.6%) returned the survey and 58 (9.1%) completed the entire survey for analysis inclusion. An average of 3,394 hours per year, per program were estimated to be spent on nonclinical activities. The greatest amount of time was spent on program administration (39%) and the least amount of time on curriculum development (5%). There was variation in the use of nonphysician faculty to complete these tasks. Allocated faculty time was comparable to estimated time spent performing nonclinical tasks. On average, a 24-resident program devoted 1.9 full-time equivalent faculty salary support to complete nonclinical activities. CONCLUSIONS: Family medicine residency faculty spend significant time completing nonclinical tasks required to meet ACGME requirements and need the protected time to complete these necessary tasks. Direct data on the use of faculty nonclinical time is needed to more accurately define its use.

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BACKGROUND AND OBJECTIVES: Medication-assisted treatment (MAT) for opioid use disorder with buprenorphine in primary care is effective and patient-accessible yet remains underutilized, including among residency training programs. One concern in residency programs is that MAT patients must be seen at least monthly and will overwhelm residents' clinic schedules and dilute their clinical experience. Our family medicine residency initiated an MAT program integrated into residents' continuity clinic schedules. After 2 years we assessed the chronic medical comorbidities we were managing in our MAT population. METHODS: We performed a retrospective review of all active patients receiving MAT. We collected basic demographic data and whether we were the patient's primary care provider (PCP) or were only providing MAT. For the patients for whom we were the PCP we recorded the chronic comorbidities that required medical management. RESULTS: One hundred fifty-seven active patients were 52% male and 48% female. The mean age was 38 years (SD=10) with a range of 22 to 77 years, with nine patients over age 60 years (6%). One hundred three patients used us as their PCP (66%). For these patients the mean number of chronic comorbidities was 2.3; only 10 patients reported no comorbidities. Psychiatric comorbidities were the most common with 69% of patients with a mood disorder, although nonpsychiatric comorbidities still averaged 1.5 per patient. CONCLUSIONS: MAT integrated into family medicine resident continuity clinics provides a broad and substantial primary care clinical experience for residents.

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BACKGROUND AND OBJECTIVES: Screening for depression in primary care can be effective, but ensuring that appropriate care is available and engaging patients in treatment are major challenges. Even when follow-up care is available, patient engagement often relies on the primary care provider initiating care. In this study we wanted to assess the effectiveness of a depression screening program in an academic family practice. RESULTS: Depression screening occurred in 98.4% of all adult encounters (n=3,341). Of these patients, 7.3% screened positive for depression and were not presenting for mood problems. Only 33.7% of patients with positive screens had their results addressed. Patients who had their results addressed were twice as likely to return for follow-up as those who did not (34.1% versus 17.4%). Patients with severe depression were more likely to follow-up than patients with mild depression (53% versus 15%). RESULTS: Depression screening occurred in 98.4% of all adult encounters (n=3341). Of these patients 7.3% screened positive for depression and were not presenting for mood problems. Only 33.7% of patients with positive screens had their results addressed. Patients who had their results addressed were twice as likely to return for follow-up as those who did not (34.1% vs. 17.4%, P<.01). Patients with severe depression were more likely to follow-up than patients with mild depression (53% vs. 15%, P<.01). CONCLUSIONS: Depression screening can be efficiently incorporated into primary care practice, but engaging providers and patients in diagnosis and treatment is challenging. We recommend a systems-based approach that emphasizes immediate access to treatment when implementing depression screening in a primary care practice.

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BACKGROUND AND OBJECTIVES: Application of the patient-centered medical home (PCMH) practice model requires managing patients with chronic diseases, such as asthma, with patient-centered approaches that ensure appropriate ongoing assessment and treatment for all patients. The Asthma Control Score (ACS) and the Asthma Action Plan (AAP) are validated tools for assessment and management of asthma. ACS use by phone has been shown to accurately assess patients' asthma control; however, no studies to date demonstrate the utility of AAP implementation by phone to improve asthma control. This study tested the effectiveness of AAP implementation by phone to improve asthma control. METHODS: Adult patients with asthma (n=48) participating in a managed care insurance plan at a university-based family medicine residency clinic were enrolled in the study. Patients were contacted by phone, and an initial ACS was assessed. Patients with an ACS <20 (uncontrolled asthma) had their medication adjusted and a new AAP implemented by phone. Uncontrolled patients were reassessed by phone monthly and management was adjusted until control was achieved. RESULTS: Of 48 patients, 42 (87.5%) were reached by phone. On initial assessment, 33 (69%) were controlled. After implementation of the new AAP by phone, seven of nine (78%) initially uncontrolled patients were controlled, for a total of 40 (83%) patients controlled by the end of the study. CONCLUSIONS: Asthma management using the ACS and AAP by phone is a feasible strategy that is acceptable to patients and can improve asthma control without the need for an office visit.

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Ankle sprains are a common problem seen by primary care physicians, especially among teenagers and young adults. Most ankle sprains are inversion injuries to the lateral ankle ligaments, although high sprains representing damage to the tibiofibular syndesmosis are becoming increasingly recognized. Physicians should apply the Ottawa ankle rules to determine whether radiography is needed. According to the Ottawa criteria, radiography is indicated if there is pain in the malleolar or midfoot zone, and either bone tenderness over an area of potential fracture (i.e., lateral malleolus, medial malleolus, base of fifth metatarsal, or navicular bone) or an inability to bear weight for four steps immediately after the injury and in the emergency department or physician's office. Patients with ankle sprain should use cryotherapy for the first three to seven days to reduce pain and improve recovery time. Patients should wear a lace-up ankle support or an air stirrup brace combined with an elastic compression wrap to reduce swelling and pain, speed recovery, and protect the injured ligaments as they become more mobile. Early mobilization speeds healing and reduces pain more effectively than prolonged rest. Pain control options for patients with ankle sprain include nonsteroidal anti-inflammatory drugs, acetaminophen, and mild opioids. Because a previous ankle sprain is the greatest risk factor for an acute ankle sprain, recovering patients should be counseled on prevention strategies. Ankle braces and supports, ankle taping, a focused neuromuscular training program, and regular sport-specific warm-up exercises can protect against ankle injuries, and should be considered for patients returning to sports or other high-risk activities.

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PURPOSE: To determine if urinary symptoms are more common in women during the 4 weeks after a routine pelvic examination. METHODS: This was a 4-week, prospective, observational cohort study in a Family Medicine residency clinic at an urban university. Participants included women ages 18 to 40 years who identified themselves as sexually active and who presented for a routine pelvic examination. Controls were women presenting for other health maintenance with no pelvic examination. Independent variables included age, pelvic examination/no pelvic examination, intercourse frequency, and condom use. Dependent variables included dysuria and urinary frequency. Relative rates of dysuria and frequency were compared using χ(2) analysis. Mean rates of dysuria, frequency, intercourse, and condom use were compared using 2-tailed t tests. RESULTS: Sixty-three subjects and 87 controls completed the study. More subjects had days with dysuria (17% vs 7%; P < .01), days with frequency (27% vs 14%; P < .01), days with both dysuria and frequency (13% vs 3%; P < .01), and days with either dysuria or frequency (32% vs 17%; P < .01). Subjects had less intercourse than controls (1.6 times per week vs 2.2 times per week; P < .01) and used condoms less frequently (33% vs 41%; P < .01). CONCLUSIONS: Dysuria and urinary frequency are more common among sexually active women during the month after a routine pelvic examination.

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PURPOSE: To determine if genitourinary problems are more common in women in the first 1 to 2 months after a routine pelvic examination. METHODS: This was a historical cohort study in 2 family medicine teaching clinics at an urban university. Participants included all women who received a Papanicolaou smear during calendar year 2006. Subjects included all participants for weeks 1 to 7 after their Papanicolaou smear. Controls were all participants in weeks 8 to 52 after their Papanicolaou smear. The independent variable was time after Papanicolaou smear, and dependent variables included frequency of visits for urinary complaints, diagnosed urinary tract infections (UTIs), vaginal complaints, diagnosed vaginitis, and sexually transmitted diseases. Relative frequencies compared using 2-tailed t tests. RESULTS: UTIs and urinary complaints were significantly more frequent during the first 7 weeks after a Papanicolaou smear compared with weeks 8 to 14, 8 to 48, and 8 to 52. The overall rate of UTIs was 7.33 per 100 person-years; the attributable risk during the first 7 weeks was 0.82 per 100 person-years, or 11% of observed UTIs. Combined Candidal and bacterial vaginitis was marginally more frequent during the first 7 weeks compared with weeks 8 to 48 and 8 to 52 only. The incidence of sexually transmitted diseases combined was 1.13 per 100 person-years, distributed evenly over the study period unrelated to time. CONCLUSIONS: The risk of UTI is increased in the 7 weeks after a Papanicolaou smear.

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Scrotal masses can represent a wide range of medical issues, from benign congenital conditions to life-threatening malignancies and acute surgical emergencies. Having a clear understanding of scrotal anatomy allows the examiner to accurately identify most lesions. Benign lesions such as hydroceles and varicoceles are often found incidentally by the patient or physician on routine examination. Epididymitis is bacterial in origin, readily diagnosed on physical examination, and treated with antibiotics. Indirect inguinal hernias usually are palpable separate from the normal scrotal contents and are a surgical emergency if strangulation is suspected based on symptoms of abdominal pain, tenderness, and nonreducibility. Testicular swelling may be caused by orchitis, cancer, or testicular torsion. Orchitis is usually viral in origin, subacute in onset, and may be accompanied by systemic illness. Testicular carcinomas are more gradual in onset; the testis will be nontender on examination. Testicular torsion has an acute onset, often with no antecedent trauma; the involved testis may be retracted and palpably rotated, and will be tender on examination. The swollen testis is always a true emergency. Although history and examination may suggest the diagnosis, testicular torsion can be reliably confirmed only with color Doppler ultrasonography, which must be obtained immediately. If torsion is suspected, surgical consultation should be obtained concurrently with ultrasonography, because the ability to successfully salvage the affected testis declines dramatically after six hours of torsion.

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Bell's palsy is a peripheral palsy of the facial nerve that results in muscle weakness on one side of the face. Affected patients develop unilateral facial paralysis over one to three days with forehead involvement and no other neurologic abnormalities. Symptoms typically peak in the first week and then gradually resolve over three weeks to three months. Bell's palsy is more common in patients with diabetes, and although it can affect persons of any age, incidence peaks in the 40s. Bell's palsy has been traditionally defined as idiopathic; however, one possible etiology is infection with herpes simplex virus type 1. Laboratory evaluation, when indicated by history or risk factors, may include testing for diabetes mellitus and Lyme disease. A common short-term complication of Bell's palsy is incomplete eyelid closure with resultant dry eye. A less common long-term complication is permanent facial weakness with muscle contractures. Approximately 70 to 80 percent of patients will recover spontaneously; however, treatment with a seven-day course of acyclovir or valacyclovir and a tapering course of prednisone, initiated within three days of the onset of symptoms, is recommended to reduce the time to full recovery and increase the likelihood of complete recuperation.

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The number of US medical students entering family medicine continues to decline. Despite the increased presence of family physicians on medical school faculty and increased exposure to family medicine during training, students still cite lack of respect and excessive knowledge base to master as reasons for not choosing our specialty. Specific changes must be made to family medicine residency training to make it more attractive to students and more compatible with the realities of practice today. These changes include eliminating maternity care as a requirement, lengthening training to 4 years, and reducing the number of residency slots available. These changes will ensure that graduating family physicians will be better prepared for practice, better qualified to obtain privileges in the hospital and clinic, and more respected by their colleagues and the public.

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BACKGROUND: Rosacea is a common skin disorder affecting middle-aged and older adults. Many patients mistakenly assume that early rosacea is normally aging skin and are not aware that effective treatments exist to prevent progression to permanent disfiguring skin changes. METHODS: The medical literature was reviewed on the pathophysiology, diagnosis, and treatment of rosacea. MEDLINE was searched using the key search terms "rosacea," "rhinophyma," "metronidazole," "Helicobacter pylori," and "facial redness." RESULTS AND CONCLUSIONS: Rosacea is easily diagnosed by physician observation, and physicians should initiate discussion of rosacea treatment with patients. Effective treatment of rosacea includes avoidance of triggers, topical and oral antibiotic therapy, both topical and oral retinoid therapy, topical vitamin C therapy, and cosmetic surgery.

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