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Providing care for families under occupation has always been marked by scarce resources and too many patients. The current war in Gaza has dramatically worsened conditions in the Occupied Territories of Palestine (OTP). A family physician and her team in the southern West Bank describe their own challenges and give voice to the physicians in the OTP they interviewed to better understand the professional and personal challenges of living and working during the uncertainty of war., Primary care is the backbone of many health care systems around the world. (1) With 15 years of experience in primary care, 6 of those as a family physician, and [...]

Background: Geopolitical and socioeconomic challenges limit faculty development and clinical teaching in Palestine and many other developing countries. The first, and still only, Family Medicine (FM) residency program is a four-year program based out of An-Najah University in the West Bank. Training in primary care clinics occurs in the final two years and there are many challenges to adequate supervision in the clinical setting that were exacerbated during the pandemic. To improve the readiness for practice skills of 13 Palestinian FM residents a three-month tutorial program was organized in 2020. A nongovernmental organization (NGO) that has worked to support Family Medicine development in the region engaged experienced British and American General Practitioners trained as tutors to offer online tutorials. We examined the program as a case study to understand the factors that facilitated or impaired a positive virtual learning environment in a middle/low income country. Methods: The tutors and residents were divided into groups and met virtually between June and September 2020. Evaluations and session reports collected during the program, the text of an online chat, and responses to an online survey two years later were collected. Using thematic analysis techniques, we evaluated the value for the residents at the time and two years later and identified factors that facilitated or impaired a positive virtual learning environment. Results: Themes of knowledge, skills, attitudes, cultural disconnects, and tutorial logistics emerged. The group with the most stable tutor pairing, including one Arabic-speaker familiar with the context, was the most engaged. The all-female group formed a chat group to share real-time case questions during clinical practice and focused on skills (e.g. conducting a thorough medication review) and attitudes (e.g. open to sharing and discussing uncertainties). Other groups were less cohesive. Conclusions: Transnational tutorials that focused on clinical thinking and decision-making skills were most successful when the tutorial pair was stable, offered familiarity with the language and addressed cultural differences. Intrinsic factors such as lacking the motivation to participate and extrinsic factors such as unstable internet and rolling electric cuts, and clinical structures that made applying new skills challenging were more difficult to address but must be considered. [ABSTRACT FROM AUTHOR]

Teams have been important in primary care for almost 15 years, (1) and the recent National Academies of Sciences, Engineering, and Medicine (NASEM) report, Implementing High-Quality Primary Care: Rebuilding the [...]

Purpose: Resilience, the capacity to endure and overcome hardship, has been suggested as a basic competency for rural medical practice. Unfortunately for physician educators, the medical education literature offers only limited guidance for nurturing this adaptive capacity. We describe the process and subsequent analysis of a daylong curriculum development workshop conducted at the annual meeting of Rural Medical Educators in 2010. Methods: Fifty administrator, faculty and student attendees reflected individually and worked in groups to construct key curricular components and modalities for teaching this competency. Prior to the meeting, participants were asked to submit a personal story about resilience. The 22 narratives received were distributed across 8 groups and provided the grist for the small group discussions, in which each group identified key concepts for teaching and learning about resilience, constructed a concept map, and developed a curriculum that was presented to all session participants. Concept maps, curriculum outlines and notes taken during the presentations were analyzed using content analysis techniques. Findings: Data highlight the importance of (1) embracing hardship as an opportunity for growth, (2) viewing resilience as both an individual and community property, (3) pursuing adaptability more than hardiness, and (4) setting a lifelong pattern of learning this competency in practice. Specific teaching modalities are suggested including individual reflective time and group activities. Conclusions: To our knowledge this represents a first effort to define and develop a medical curriculum for teaching resiliency in rural predoctoral and residency education.

Purpose: The purpose of this study was to identify the organizational factors that influence electronic health information exchange (HIE) by medical group practices in rural areas. Methods: A purposive sample of 8 small medical group practices in 3 experimental HIE regions were interviewed to determine the extent of clinical information exchange with other health care providers and to identify the factors influencing those patterns. Findings: HIE was found to be largely limited to exchanging immunization data through the state health department and exchanging clinical information within owned provider systems. None of the clinics directly exchange clinical information with non-owned clinics or hospitals. Conclusions: While regional HIE networks may be a laudable goal, progress is slow and significant technical, political, and financial obstacles remain. Limiting factors include data protection concerns, competition among providers, costs, and lack of compatible electronic health record (EHR) systems.

A clinical sample of 995 community dwelling women aged 55 and older were surveyed by telephone about their experience with psychological/emotional, control, threat, physical, and sexual abuse. Nearly half of the women experienced at least one type of abuse since turning 55. Sizable proportions were victims of repeated abuse, and many experienced co-occurring abuse. Women who experienced any type of abuse were more likely to self-report negative health effects than those who were not abused. Health care and social service providers should routinely screen older women for psychological/emotional abuse at it often co-occurs with more severe forms of abuse. (Contains 3 tables.)

Childhood sexual abuse (CSA) is common and is associated with both mental and physical health problems in adulthood. Using data from an age- and sex-stratified population survey of 600 Olmsted County, Minnesota, residents, a Sexual Abuse Severity Score was developed. The abuse characteristics of 156 CSA respondents were associated with self-reported trauma, somatization, and alcohol use. Characteristics included age of first sexual abuse, more than one perpetrator, degree of coercion, severity of abuse (i.e., attempted intercourse is more severe than fondling), and the number of occurrences. This is one of the few reports to develop a risk summary that quantifies the severity of CSA. (Contains 3 tables.)

Context: Changes in health care and new theories of learning have prompted significant changes in medical education. Some US medical schools employ immersion learning in rural communities to increase the number of physicians who choose to practice in these areas. Founded in 1971, the rural physician associate program (RPAP) is a longitudinal immersion learning experience for students during their third year of medical school. Students are assigned to a primary care preceptor(s) in a rural community ranging in population from 1,000 to 30,000 for 36 weeks. Purpose: To describe students' perceived value of this immersion learning experience. Methods: Data from 3 classes (2004, 2005, 2006) of students (n = 95) were analyzed, including final essays that reflect on their experiences and logs of their patient encounters and procedures. Themes from students' essays related to the hands-on learning experience are presented. Frequencies of ambulatory encounters and procedures were calculated and compared with those of metropolitan area colleagues where possible. Findings: The continuity experience allows for one-to-one mentoring and long-term relationships. Students see physicians, clinic/hospital staff, and patients as their teachers. The environment is nurturing, but nudges them outside their comfort zone. Students gain increasing competence with their skills and do best if they are independent and seek out learning opportunities. They report more hands-on experience, more confidence and autonomy than their peers in the metropolitan area. Conclusions: The RPAP experience provides a nurturing, longitudinal, immersion learning experience that facilitates the gradual but steady development of clinical skills alongside a personal and professional mentor.

Little is known about how older women cope in long-term abusive intimate relationships. Understanding their coping strategies may give insight into how to further support their effective coping efforts. Interviews were conducted with 38 women older than age 55 years. Grounded theory analysis demonstrated that women who remained in their abusive relationships employed mainly cognitive (emotion-focused) strategies to find meaning in a situation that was perceived as unchangeable. By reappraising themselves, their spouses, and their relationships they refocused energies in certain roles, set limits with their abusers, and reached out to others (friends, family, and community organizations). Some women appeared to thrive, others merely survived, but all maintained the appearance of conjugal unity. (Contains 1 table and 1 figure.)

The past 20 years of research has exposed the profound cost of intimate partner violence (IPV) in health care problems and health care dollars for victims and bystanders. As a result, professional organizations encourage clinicians to identify IPV victims and to refer them to community resources. To date there is little evidence to show the value of these efforts, and many completed studies are criticized for methodological weaknesses. IPV studies are challenging to design, and the double-blind randomized controlled trial may be an impossible standard. To move forward, funders and study committees are encouraged to reassess the standards for IPV research methodologies.

Due to geopolitical and socioeconomic challenges, the Family Medicine (FM) speciality in Palestine is in early stages of development. Volunteer British General Practitioner (BGP) trainers worked with FM faculty to develop an online tutorial program (OTP) and a novel evaluation framework E-QUaL (Evaluation-Quality, Utilization and Learning) to enhance residents' patient-centered communication and clinical skills. Three OTP cycles were facilitated and evaluated at An Najah National University (ANNU) in Palestine between 2017–2020. Qualitative data were collected during focus groups and online chats and analysed. The development and joint facilitation of the OTP developed faculty skills and enhanced clinically oriented education. The collaborative (BGPs and ANNU faculty) approach and the use of the EQUaL framework helped to identify and address strengths and opportunities as well as the challenges and threats of the educational content and the virtual learning format with each iteration. The COVID pandemic provided a new and inexpensive platform which improved training quality. Issues such as the volunteer nature of BGPs, internet instability, and differing cultural approaches and expectations between physicians and patients were addressed in a continuous quality improvement approach and continues today. This may be a useful model in other low resourced settings. [ABSTRACT FROM AUTHOR]

Self-report information about mistreatment experiences and perpetrators were collected from a large sample of women over 55 years of age who sought care from Midwestern primary care offices. A significantly larger proportion of women had experienced sexual mistreatment since turning 55 that was perpetrated by an intimate partner than committed by an interpersonal perpetrator. The women experienced significantly more threats, physical mistreatment, and caregiver mistreatment since turning 55, and more threats and caregiver mistreatment within the last year by an interpersonal perpetrator than by an intimate partner. Several women described different types of perpetrators who had threatened or mistreated them. Few women reported the mistreatment to anyone. Implications for elder service providers and advocates are discussed, doi:10.1300/J084v18n01_04 KEYWORDS. Elder mistreatment, abuse, older women, intimate partner violence, interpersonal abuse

Over the last ten years, a growing body of literature has examined services for older women who are abused. This article describes the results from a statewide survey of Ohio's domestic violence (DV) centers' programs and services for older women. Surveys were mailed to all Ohio DV centers in spring 2002, with a follow-up mailing and phone calls, yielding a 73% response rate. Seventy-eight percent had sheltered as least one woman over 55 years old during 2001. Other programs were serving some older women as well. While less than half of the centers educated their staff and volunteers about the needs of older women, 57% had provided training to aging agencies about DV. More collaboration and cross training with aging agencies was recommended to better meet the needs of older women. KEYWORDS, Older women, domestic violence, elder abuse

Although intimate partner violence (IPV) is routinely encountered in health care, it often goes undetected. Medical organizations recommend routine screening of women alone without children or partner. Separating a mother from her children may not be feasible in busy practices. Therefore, screening may not occur. Little research has examined women's desires about IPV screening in front of their children. This study interviewed 32 mothers/survivors who were in either an IPV shelter or support group regarding their wishes about IPV screening and discussions in front of their children. Interviews were audio taped, transcribed, and analyzed using thematic analysis techniques. Major themes included mothers' comfort with the use of general IPV screening questions in front of children ages 3 to 12 years. In summary, most mothers/survivors were comfortable with physicians using general questions to screen for IPV but preferred in-depth discussions about the abuse and resource sharing in private. Keywords: domestic violence; screening; family violence; child abuse

Managed care organizations (MCOs) joined local and state public health agencies in a pilot effort to improve hepatitis B immunization rates of adolescents in an urban and a suburban/rural school district. The pilot also explored issues inherent in public and private collaboration on population health improvement Local public health agencies provided links to schools in their communities, took the lead in implementing school-based immunization programs, and provided health education materials. MCOs contributed financial support necessary for the project The final cost per fully vaccinated student, not taking into account the work group's planning and coordination time, was little more than the catalog price of the vaccine alone. Managed care organizations face challenges that complicate their participation and funding of school-based vaccinations: 1) Limited data on health plans of participating students complicate allocation of costs to each MCO; 2) Double-paying occurs for MCOs paying clinics a monthly, per-member rate that already includes adolescent immunizations; 3) When schools provide adolescent immunizations, MCOs lose the 'hook' that draws adolescents to clinics for comprehensive health services. When self-consenting is permitted, schools can achieve a high consent and completion rates for multi-dose adolescent immunizations such as hepatitis B. At the same time, MCOs have the responsibility to provide members with comprehensive care and should continue to examine both internal modifications and external partnerships as opportunities to improve their services to adolescents. (J Sch Health. 1997;67(7):286-289), Three legislative statutes laid the groundwork for collaboration between managed care organizations (MCOs) and public health agencies in Minnesota. MinnesotaCare legislation, which provided improved access to health care for Minnesotans, [...]