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Background: Successful management of chronic pain with opioid medications requires balancing opioid dependence and addiction with pain relief and restoration of function. Evaluating these risks and benefits is difficult among patients with chronic pain and pre-existing addiction, and the ambiguity is increased for patients on methadone maintenance therapy for opioid dependence. Providers treating both chronic pain and addiction routinely make diagnostic and therapeutic decisions, but decision-making strategies in this context have not been well described.Objective: Our objective was twofold. We sought first to explore providers' perceptions of ambiguity, and then to examine their strategies for making diagnostic and treatment decisions to manage chronic pain among patients on methadone maintenance therapy.Design: Qualitative semi-structured interviews.Setting and Participants: We interviewed health-care providers delivering integrated medical care and substance abuse treatment to patients in a methadone maintenance program.Results: Providers treating pain and co-morbid addiction described ambiguity in all diagnostic and therapeutic decisions. To cope with this inherent ambiguity, most providers adopted one of two decision-making frameworks, which determined clinical behavior. One framework prioritized addiction treatment by emphasizing the destructive consequences of abusing illicit drugs or prescription medications; the other prioritized pain management by focusing on the destructive consequences of untreated pain. Identification with a decision-making framework shaped providers' experiences, including their treatment goals, perceptions of treatment risks, pain management strategies, and tolerance of ambiguity. Adherence to one of these two frameworks led to wide variation in pain management practices, which created tension among providers.Conclusions: Providers delivering integrated medical care and substance abuse treatment to patients in a methadone maintenance program found tremendous ambiguity in the management of chronic pain. Most providers adopted one of the two divergent heuristic frameworks we identified, which resulted in significant variations in pain management. To reduce variation and determine best practices, studies should examine clinically relevant endpoints, including pain, illicit drug use, prescription drug abuse, and functional status. Until then, providers managing chronic pain in patients with co-morbid addiction should attempt to reduce tension by acknowledging ambiguity and engaging in open discourse. [ABSTRACT FROM AUTHOR]

Introduction: Despite the 1984 United Nations's Convention Against Torture calling to train doctors to work with torture survivors, many physicians are unaware of their obligation and few are taught the requisite clinical skills.Aim: To describe the development, implementation, and evaluation of a curriculum to teach residents to work with torture survivors.Participants: Medicine residents in New York CityProgram Description: A 2-component curriculum consisting of a series of workshops and clinical experiences, which provide content, skills, and practices regarding the medical, psychological, ethical, and legal aspects of evaluating and caring for torture survivors. CURRICULUM EVALUATION: All 22 trainees received surveys before and after training. Surveys assessed residents' relevant prior experience, beliefs, skills, and attitudes regarding working with torture survivors. At baseline, 23% of residents described previous human rights trainings and 17% had work experiences with torture survivors. Before the curriculum, 81% of residents reported doctors should know how to evaluate survivors, although only 5% routinely screened patients for torture. After the curriculum, residents reported significant improvements in 3 educational domains-general knowledge, sequelae, and self-efficacy to evaluate torture survivors.Discussion: This curriculum addresses the disparity between doctors' obligations, and training to work with torture survivors. It is likely to achieve its educational goals, and can potentially be adapted to other residencies. [ABSTRACT FROM AUTHOR]

Introduction: Few curricula train medical students to engage in health system reform.Aim: To develop physician activists by teaching medical students the skills necessary to advocate for socially equitable health policies in the U.S. health system.Setting: Montefiore Medical Center, the University Hospital of the Albert Einstein College of Medicine, Bronx, NY.Program Description: We designed a 1-month curriculum in research-based health activism to develop physician activists. The annual curriculum includes a student project and 4 course sections;health policy, research methods, advocacy, and physician activists as role models; taught by core faculty and volunteers from academic institutions, government, and nongovernmental organizations.Program Evaluation: From 2002 to 2005, 47 students from across the country have participated. Students reported improved capabilities to generate a research question, design a research proposal,and create an advocacy plan.Discussion: Our curriculum demonstrates a model for training physician activists to engage in health systems reform. [ABSTRACT FROM AUTHOR]

Although depression and anxiety syndromes are common in primary care, many depressed and anxious patients fail to receive effective treatment. Little attention has been given to the role of illness beliefs in shaping these patients' treatment preferences and decisions. Using semistructured interviews, this study examined conceptual models of depressive symptoms among patients in an inner-city clinic. A theoretical taxonomy of patients' conceptual models of distress was developed: each category was associated with a unique pattern of treatment preferences. We conclude that patients' models of distress may play an important role in treatment-seeking decisions, and deserve further investigation. [ABSTRACT FROM AUTHOR]