Patty Carney, PhD

Dear Family Medicine Faculty and Staff,

We are thrilled to be releasing our first Research Newsletter, which is designed to provide more detail about ongoing research activities in Family Medicine. As you will see by the list of funded and unfunded projects, our work spans research in clinical phenomena, health services, health policy, and undergraduate and graduate educational research. The Research Section meets weekly on Wednesday mornings as part of the WORC (working on research collaboratively) group, where we assist faculty and project managers on everything from formulating research ideas to providing feedback on grants and manuscripts. This meeting is open to all family medicine faculty and we often have

Contact OHSU Family Medicine Research

visitors from the National College of Naturopathic Medicine as well as other OHSU departments. In addition, we hold an annual research retreat; this year's retreat is on June 17th. We are committed to activities that will advance the science of health and healthcare, and we hope that this newsletter will help stimulate research ideas, encourage you to become more involved in research or identify possible collaborators for you. In this edition, Rick Deyo, MD, MPH, the Kaiser Professor of Evidence-based Medicine, reflects on the concept of EBM and its relevance as a research topic for family medicine. We also highlight recent publications and feature projects that we think are especially exciting.

We hope you enjoy this newsletter and look forward to future editions!! ☼

Spring 2008 Volume 1, Issue 1

ME S SA GE FR OM THE R E S E AR CH DIR E CTOR :

FAMILY MEDICINE’S RESEARCH NEWSLETTER

Phone: 503-494-9861 Fax: 503-494-2746

Email: fmresch@ohsu.edu

Administrative Staff: Patty Carney, PhD, Research Director; Rick Deyo, MD, MPH, Kaiser EBM Professor; Connie Yu, MHA, Director,

Research Services; Janice Hohnstein; Scharlean Prevalle; Rebecca Rdesinski

Inside this Issue

Evidence-Based Family Medicine 2

Recent Publications 2

In the News 3

Upcoming Events 3

My Life. My Research 4

Featured Project 5

Current Research Projects 7

Collaborations 7

MESSAGE FROM THE KAISER PROFESSOR OF EVIDENCE-BASED FAMILY MEDICINE:

Rick Deyo, MD, MPH

Haven’t We Always Practiced Evidence-Based Medicine? Supposing is good, but finding out is better.

–Mark Twain

Faced with the new jargon of “Evidence-Based Medicine” (EBM), many physicians are confused. “Haven’t we always practiced evidence-based medicine?” they ask. They point to basic science studies, animal experiments, physiologic knowledge, and blood tests, and conclude that we’ve always had a good evidence base. But consider a litany of standard treatments that have now been debunked: pulmonary artery catheters in high risk surgical patients; encainide for cardiac arrhythmias; bone marrow transplants for late stage breast cancer; routine episiotomy after childbirth; radical mastectomies for breast cancer, and many more. These treatments have proved useless, wasteful, and sometimes harmful, so how did they get started in the first place? The answers may often lie in some of the alternatives to evidence-based medicine to which we all fall prey. These have been summarized by two Australian docs1 as including:

Eminence-based medicine: Grey hair and years of experience are the basis for recommendations.

Vehemence-based medicine: loud or strident advice is used to browbeat us.

Eloquence-based medicine: wherein the Armani suit and verbal eloquence supersede evidence.

Nervousness-based medicine: fear of lawsuits drives unnecessary testing and treatment

Confidence-based medicine: said to be especially common among surgeons

Diffidence-based medicine: doing nothing from a sense of despair.

Of course, we might add to the list things like marketing-based medicine, in which drug representatives substitute for scientific evidence; wishful-thinking based medicine, and other cognitive biases that affect us all. In my simple-minded definition, the EBM approach argues it isn’t enough to know if a treatment ought to work, that we’ve always done it that way, that it’s common practice, that we learned it in medical school, that an expert vouches for it, or that it works in mice. Furthermore, it’s not enough to know that a treatment lowers blood sugar, improves cholesterol, normalizes heart rhythms, improves range of motion, or has other physiological benefits. One of more of these reasons explains why the inappropriate treatments listed above became so popular. Instead, we need to ask: what’s the best evidence that a new treatment actually extends lives or improves quality of life, and what are the risks?2 These issues have a major impact on costs of care, and hence the affordability of insurance. Improving the evidence base for what we do is therefore a key to health care reform in general. This seems to be a perfect research agenda for Family Medicine. ☼

1. Isaacs D, Fitzgerald D. Seven

alternatives to evidence-based medicine. Br Med J 1999; 319: 1618.

2. Deyo RA, Patrick DL. Hope or Hype: the obsession with medical advances and the high cost of false promises. New York: Amacom, 2005, p 230.

Spring 2008 FM Research Express

Volume 1, Issue 1 Page 2

RECENT

PUBLICATIONS Calvert J. Is there a better way to ask patients whether there is “anything else”? J Fam Pract. 2008 Mar; 57(3):149. DeVoe JE, Krois L, Edlund C, Smith J, Carlson NE. Uninsured but eligible children: are their parents insured? Recent findings from Oregon. Med Care. 2008 Jan; 46(1):3-8. DeVoe JE, Krois L, Edlund T, Smith J, Carlson NE. Uninsurance among children whose parents are losing Medicaid coverage: Results from a statewide survey of Oregon families. Health Serv Res. 2008 Feb; 43(1 Pt 2):401-18. DeVoe JE, Graham A, Krois L, Smith J, Fairbrother GL. “Mind the Gap” in Children’s Health Insurance Coverage: Does the Length of a Child’s Coverage Gap Matter? Ambul Pediatr. 2008 Mar 17; 8(2):129-134.

Lawrence RC, Felson DT, Helmick CG, Arnold LM, Choi N, Deyo RA, Gabriel S, Hirsch R, Hochberg MC, Hunder GG, Jordan JM, Karz JN, Kremers HM, Wolfe F; National Arthritis Data Workgroup. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum. 2008 Jan; 58(1):26-35.

Roelofs PD, Deyo RA, Koes BW, Scholten RJ, van Tulder MW. Non-steroidal anti-inflammatory drugs for low back pain. Cochrane Database Syst Rev. 2008 Jan 23 ;( 1):CD000396. Martin BI, Deyo RA, Mirza SK, Turner JA, Comstock BA, Hollingsworth W, Sullivan SD. Expenditures and health status among adults with back and neck problems. JAMA. 2008 Feb 13; 299(6):656-64. Cherkin DC, Sherman KJ, Hogeboom CJ, Erro JH, Barlow WE, Deyo RA, Avins AL. Efficacy of acupuncture for chronic low back pain: protocol for a randomized controlled trial. Trials. 2008 Feb 28; 9(1):10.

IN THE NEWS

Visiting Professor Kurt Stange, M.D., Ph.D. Comes to OHSU

Dr. Kurt C. Stange, Professor of Family Medicine, Epidemiology & Biostatistics, Oncology, and Sociology at Case Western Reserve University was at OHSU May 7 & 8, 2008 as the OCTRI Visiting Professor. This visit was jointly hosted by Dr. Patricia Carney of the OHSU Cancer Institute and Dr. Mark Hornbrook of Kaiser Permanente’s Center for Health Research. During his visit, Dr. Stange lectured on “A Science of Practice” and “Practice-Based Research, Preventive Care and Qualitative Methods”.

John Saultz, MD Gives Health Reform Talk in Hawaii Dr. John Saultz presented at the Nineteenth National Conference on Primary Health Care Access at the Grand Hyatt Kaua’i from April 7 to April 10, 2008. Dr. Saultz had been designated as the Eighteenth G. Gayle Stephens Lecturer and gave his talk on “Health Reform in America: Lessons Learned from the Oregon Health Plan.”

David Buckley, MD Gives Research Results in Denver

Dr. David Buckley presented at the AAFP 2008 Convocation of Practices and Networks in Colorado Springs, CO from March 7 – 9, 2008. Dr. Buckley presented Research Results -“Chronic Opioid Therapy and Receipt of Preventive Services in Rural Primary Care.”

Family Medicine Research Retreat Scheduled The Annual Research Retreat for the Department of Family Medicine will be held on Tuesday, June 17, 2008 at the Kennedy School in NE Portland. Research faculty will be discussing development strategies for increased evidence based and educational research in Family Medicine.

Rick Deyo, MD, MPH Delivers Keynote Address at the 2008 ORPRN Convocation

Dr. Rick Deyo, Kaiser Permanente Professor of Evidence-Based Family Medicine, gave a presentation on Evidence Based Medicine and Practice Based Research on April 11, 2008 in the Center for Health and Healing. Dr. Deyo’s keynote address focused on the growing challenge of how to translate the best evidence from traditional randomized trials into routine practice, where there are many differences from the typical academic clinical trial environment. Dr. Deyo discussed the role of Practice-Based Research Networks (PBRNs) in contributing to research by posing different questions than those posed in academic or industry-funded settings; by incorporating more diverse patient populations; by focusing on access, convenience, and communication; and by improving the relevance of clinical trials and practice guidelines.

New NIH Public Access Policy Announced

The National Institutes of Health recently announced that effective April 7, 2008, all investigators funded by the NIH are now required to submit or have submitted for them to the National Library of Medicine’s PubMed Central an electronic version of their final, peer-reviewed manuscripts upon acceptance for publication, to be made publicly available no later than 12 months after the official date of publication: Provided, that the NIH shall implement the public access policy in a manner consistent with copyright law. ☼

For more information: Refer to the OHSU NIH Public Access Policy Guide at: http://www.ohsu.edu/library/scholarlycomm/nihpolicylong.shtml

Spring 2008 FM Research Express

Volume 1, Issue 1 Page 3

9th Annual Hilde and Bill Birnbaum Endowed Lecturer: Rick Deyo, MD, MPH Kaiser Professor of Evidence-Based Family Medicine “Hope or Hype – the Conflict between Science and Profit in Health Care”. Tuesday, June 10, 2008 Group Health Center for Health Studies and Group Health Community Foundation, Seattle, WA

UPCOMING EVENTS

Grants 101: Professional Grant Proposal Writing Workshop June 18 -20, 2008 8:00 AM – 5:00 PM The Grant Institute Seattle, WA For more information and registration, call (888) 824-4424 or visit The Grant Institute at: www.thegrantinstitute.com

Evidence-Based Medicine Grand Rounds Lecturer: Rick Deyo, MD, MPH Kaiser Professor of Evidence-Based Family Medicine Thursday, July 17, 2008 12:30 – 1:30 PM Bay Area Hospital Coos Bay, OR

National

My Name is:

Childhood Ambition:

Wildest dream:

Proudest moment:

Biggest Challenge:

First job:

Indulgence:

Favorite movie:

Inspiration:

My Life:

My Research:

Spring 2008 FM Research Express

Volume 1, Issue 1 Page 4

UPCOMING EVENTS (C O N ’T )

OHSU

“Universal access to healthcare” Speaker: Paul Gorman, MD Associate Professor Department of Medical Informatics Tuesday, May 27, 2008 UHS, 8B60, 12:00 PM – 1:00 PM “Advancing your academic career-unlocking the secrets of P&T” Speaker: Sharon Anderson, MD Professor of Medicine Wednesday, May 28, 2008 MacHall Cafeteria, Marquam Rm. 1116 12:00 PM – 1:00 PM “Treating Chronic Back Pain: Too Much of a Good Thing?” Speaker: Rick Deyo, MD, MPH Kaiser Permanente Professor of Evidence-Based Family Medicine Monday, June 2, 2008 CROET, Room 3524, 12:00 PM – 1:00 PM

M Y L I F E . M Y R E S E A R C H .

Reading thesis proposal at Jefferson Park, Oregon

Rebecca Rdesinski, MSW

Helping to install a gravity-fed water system in

Agua Buena village in Honduras

Rebecca Rdesinski is a Research Associate in the Department of Family Medicine. She works on several projects including the evaluation of the K07 Behavioral and Social Science Core Curriculum at OHSU and for the consortium of nine schools, the Post Occupancy Review of the Center for Health & Healing, a study of the association between acupuncture and opioid usage, and a study of the safety net clinic referral patterns to the emergency department. In addition, Rebecca manages the labor distribution and grant effort certification for the Family Medicine Department.

Written by E. Dawn Creach, MS, P4 Project Director

The OHSU Family Medicine Research Program houses the evaluation core for the national residency redesign project called “Preparing the Personal Physician for Practice” (P4). The OHSU P4 Evaluation Team includes Patty Carney, PhD, Pat Eiff, MD, John Saultz, MD, and E. Dawn Creach, MS. Dr. Saultz is also a member of the Steering Committee for P4. The project began in 2007 and continues through 2012, and will evaluate 14 Family Medicine residencies across the United States in search of the most effective ways to educate outstanding personal physicians. The results of the P4

evaluation are expected to guide future revisions to accreditation and content for Family Medicine residency training nationwide. Evaluation is the central task of P4. Since July, the OHSU P4 Evaluation Team has been busy establishing core variable data elements, collecting year one data, and completing Collaborative Visits to each P4 residency program. The evaluation includes both quantitative and qualitative data and is considered an observational case series research design. A common set of data is collected from each program P4

annually. This data includes surveys of residency program characteristics, clinic attributes, and nationally available data. Residents’ voices are captured with a P4 survey at In-Training Exams. About 320 residents comprise the first cohort of P4

learners who will be tracked over time through completion of residency training and into practice. Each program also

Preparing the Personal Physician for Practice (P4) Sponsor: TransforMed Principal Investigator: Patricia Carney, Ph.D.

Spring 2008 FM Research Express

FEATURED PROJECT

generates research questions specific to their own innovations and measures outcomes they expect to change over time. Qualitative data will be gathered using on-line diaries, set to launch in April, to obtain rich information from residents and faculty about their experiences undergoing substantive residency redesign.

The OHSU Evaluation Team has visited seven P4

programs to date, and will visit the remaining sites by November 2008. The visits have accomplished a great deal:

Understand & document individual curricular

innovations. (What are their residents doing that is

different?)

Provide consultation for site-specific hypotheses and measurement development. (What changes do they

A panel of P4 Innovators share their experiences

expect to see and how will they measure it over the

next five years?)

Facilitate customized faculty development and enrichment sessions. (How can we help faculty with the change process?)

Conduct focus groups with faculty and residents to

understand how physicians develop a “Family Medicine

Identity” throughout residency training and their

professional career.

Tour the clinics and the learning environments in

which P4 residents are trained.

Educate residents, faculty, staff, and hospital

administrators about the national P4 project, the

evaluation effort, and the importance of innovation in

graduate medical education for family physicians.

Establish face-to-face rapport and positive,

collaborative working relationships.

John Saultz and Erica Bliss

Volume 1, Issue 1 Page 5

Patty Carney and Jay Fetter

Steve Schultz, Colleen Fogarty, and Pat Eiff

Recently, the Evaluation Team traveled to Austin, TX for the national P4 Innovators’ Learning Collaborative. The meeting was a huge success! All 14 P4 programs had representatives in attendance to report on their first year successes. All programs have completed their respective IRB reviews and the core set of baseline survey data for the Evaluation Team. In addition, each program began to implement a variety of curriculum and practice changes for their residents. The P4 Learning Collaborative fostered shared problem-solving, networking, and inspired group ownership of the P4 change effort. The Evaluation Team shared some early discoveries from data collected from the P4 programs.

Next Steps for the P4 Evaluation Team

Visit the remaining seven residency programs by

November 2008.

Once first year data is analyzed, write reports and grants

to obtain additional funding for the evaluation effort.

Next P4 Learning Collaborative is scheduled for

September 2008.

Continue collecting core variable data bi-annually (2007 –

2011).

Intense data analysis and reporting occurs in 2011 – 2012, and is expected to guide revisions in accreditation and content for Family Medicine residency training. ☼

Spring 2008 FM Research Express

Volume 1, Issue 1 Page 6

P4 Selected Residency Programs

Baylor HCHD Family Medicine Residency Program Houston, Texas

Cedar Rapids Medical Education Foundation Cedar Rapids, Iowa

Christiana Care Health System Family Medicine Residency Program, Wilmington, Delaware

Hendersonville Family Practice Residency Program Hendersonville, North Carolina

John Peter Smith Hospital Family Medicine Residency Program, Fort Worth, Texas

Lehigh Valley Family Medicine Program Allentown, Pennsylvania

Loma Linda Family Medicine Residency Loma Linda, California.

Middlesex Hospital Family Medicine Residency Program, Middletown, Connecticut

Tufts University Family Medicine Residency Malden, Massachusetts

University of Colorado Family Medicine Residency Denver, Colorado

University of Missouri–Columbia Family Medicine Residency, Columbia, Missouri

University of Rochester Family Medicine Residency Program, Rochester, New York

Waukesha Family Medicine Residency Program Waukesha, Wisconsin

West Virginia University Rural Family Medicine Program, Harpers Ferry, West Virginia

Be sure to visit the P4 website for descriptions of each program’s educational innovations at http://www.transformed.com/p4.cfm

If you have more questions about P4, please feel free to contact E. Dawn Creach, MS, P4 Evaluation Team Project Director at creache@ohsu.edu.

David I. Buckley, MD, PI American Cancer Society Cancer Prevention and Screening for Disabled Adults in Rural Primary Care 1/1/08-12/31/12

Patricia A. Carney, PhD, PI

DHHS, NIH Understanding Variability in Community Mammography 12/1/05-6/30/08

DHHS, NIH Strategic Studies in Breast Cancer Surveillance 12/1/05-7/31/08

TransforMed Preparing the Personal Physician for Practice (P4) 6/1/07-5/31/12

American Cancer Society Assessing and Improving Mammography Interpretive Skills 8/1/07-7/31/09

American Cancer Society Health Insurance and Cancer Screening in Rural Oregon 7/1/07-6/30/11

DHHS, NIH National Cancer Inst. Behavioral & Social Sciences as Core Elements of the Medical School Curriculum 5/1/07-4/30/08

Jennifer E. DeVoe, MD, DPhil, PI DHHS Does Parental Health Insurance Loss Affect Children’s Access to Care? 7/1/06-6/30/11

Richard A. Deyo, MD, MPH, PI Washington State Department of Labor and Industries SCS for Injured Workers with Low Back and Leg Pain after Lumbar Surgery 10/1/07-7/31/08

Spring 2008 FM Research Express

CURRENT PROJECTS

Richard A. Deyo, MD, MPH, PI Public Health Trust Attorney General Consumer and Prescriber Grant Program Drug Reps in the Attic: Smoking out the influence of the pharmaceutical industry on providers prescribing practices 10/1/07-12/31/08

Scott A. Fields, MD/Ann O’Connell, PI CareOregon The Whole System Primary Care Delivery 1/1/08-12/31/08

Teresa Gipson, MD, PI Anonymous Sponsor Abortion and Reproductive Health Education 3/19/07-3/18/09

Tanya Page, MD, PI Unfunded Homeless Health Access and Utilization Survey: Pilot Project 6/25/07-6/24/08

Unfunded Outside In Referral Patterns to the ED 3/1/07- 12/31/08

Rebecca R. Rdesinski, MSW, PI Portland State University Post Occupancy Review at OHSU, CHH 7/25/07-6/30/08

Robert G. Ross, MD, PI DHHS, HRSA Residency Training in Primary Care 7/1/05-6/30/08

Elizabeth Steiner, MD, PI The Susan G. Komen Breast Cancer Foundation Enhancing Clinical Breast Exams 4/1/07-3/31/08

Anita D. Taylor, PI Girls In of NW Oregon Go Onward Program at Girls Inc of NW Oregon 7/1/06-6/30/08

William L. Toffler, MD, PI DHHS, NIH Curriculum Behavior & Social Sciences as Core Elements of the Medical School 5/1/06-4/30/11

Joanne Wu, MD, PI Unfunded Integration of Acupuncture into Family Medicine Teaching Clinics 12/12/07-12/11/09

Unfunded Association Between Acupuncture and Narcotics Usage 10/1/07-9/30/09

RESEARCH COLLABORATORS WANTED

PI: Agatha P. Colbert, MD Helfgott Research Institute

National College of Natural Medicine acolbert@ncnm.edu

Multichannel System for Measuring

Skin Inpedance at Acupuncture Points – NIH/NCCAM

Goal: Build an electrical impedance instrument that will allow for the beginning investigation for the bioelectromagnetic bases of acupuncture. Dr. Colbert would like feedback from FM faculty who are interested in acupuncture, to help her make a decision on which acupuncture points to study first. Carpal Tunnel Syndrome and Static

Magnetic Field Therapy – NIH/NCAAM

Goal: To access three difference magnet strengths for treating carpal tunnel syndrome. Participants are currently being enrolled. Dr. Colbert would like feedback from FM faculty when she starts writing up the results in a few months.

Volume 1, Issue 1 Page 7