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To reduce suicides among Veterans, the Department of Veterans Affairs (VA) has designated suicide risk assessments for Veterans who screen positive for depression or post-traumatic stress disorder as a national performance goal. Many VA Medical Centers (VAMCs) are using brief suicidal ideation screens, administered in non-mental health ambulatory care settings, as the first step in the assessment process.To explore Veterans' perceptions of the suicide screening and risk assessment process, the barriers and facilitators to disclosing suicidal thoughts, and perceptions of possible consequences of revealing suicidal thoughts.Investigators recorded one semi-structured interview with each Veteran. Transcripts were analyzed using a modified grounded theory approach.Thirty-four Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans who screened positive for suicidal ideation in non-mental health ambulatory care settings in 2009 and 2010.Veterans accepted the need to assess suicide risk. They increasingly experienced attempts to suppress and avoid thoughts of suicide as burdensome and exhausting. Despite this, Veterans often failed to disclose severe and pervasive suicidal thoughts when screened because: (1) they considered suicidal thoughts as shameful and a sign of weakness; (2) they believed suicidal thoughts were private and not to be divulged to strangers; (3) they worried that disclosure would lead to unwanted hospitalization or medication recommendations; and (4) the templated computer reminder process was perceived as perfunctory and disrespectful. In contrast, admitting and discussing thoughts of suicide with a health provider who focused on building a relationship, demonstrated genuineness and empathy, offered information on the rationale for suicide risk assessment, and used straightforward and understandable language, all promoted trust that resulted in more honest disclosure of suicidal thoughts.In ambulatory care settings, both provider behaviors and system modifications may lead to more honest disclosure of suicidal thoughts.

Objective Sales visits, or detailing, by pharmaceutical industry representatives at academic institutions has been increasingly criticized. The authors surveyed psychiatric residents and faculty members on their views and interactions with representatives of the pharmaceutical industry.

Hundreds of thousands of incidental pulmonary nodules are detected annually in the United States, and this number will increase with the implementation of lung cancer screening. The lengthy period for active pulmonary nodule surveillance, often several years, is unique among cancer regimens. The psychosocial impact of longitudinal incidental nodule follow-up, however, has not been described. We sought to evaluate the psychosocial impact of longitudinal follow-up of incidental nodule detection on patients. Veterans who participated in our previous study had yearly follow-up qualitative interviews coinciding with repeat chest imaging. We used conventional content analysis to explore their knowledge of nodules and the follow-up plan, and their distress. Seventeen and six veterans completed the year one and year two interviews, respectively. Over time, most patients continued to have inadequate knowledge of pulmonary nodules and the nodule follow-up plan. They desired and appreciated more information directly from their primary care provider, particularly about their lung cancer risk. Distress diminished over time for most patients, but it increased around the time of follow-up imaging for some, and a small number reported severe distress. In settings in which pulmonary nodules are commonly detected, including lung cancer screening programmes, resources to optimise patient-centred communication strategies that improve patients’ knowledge and reduce distress should be developed. Renewed efforts are needed to alleviate patient stress and keep them informed following the diagnosis of small growths on the lungs. The discovery of so-called ‘pulmonary nodules’ during routine chest screening can cause considerable distress to patients. The nodules, though often benign, require monitoring via follow-up scans, leading to a period of uncertainty which potentially affects patients’ well-being. In a longitudinal study involving interviews with 17 patients with newly diagnosed nodules, Donald Sullivan at Oregon Health and Science University, USA, and co-workers found that stress was often exacerbated by ineffective communication from medical staff. This led to patient misunderstandings about lung cancer risk, for example, which were compounded by the complex information in letters they received. Patients much preferred to speak to their primary care providers. The researchers call for improved staff training and education resources.

To improve pain management, the Veterans Health Administration launched the "Pain as the 5th Vital Sign" initiative in 1999, requiring a pain intensity rating (0 to 10) at all clinical encounters.To measure the initiative's impact on the quality of pain management.We retrospectively reviewed medical records at a single medical center to compare providers' pain management before and after implementing the initiative and performed a subgroup analysis of patients reporting substantial pain (or =4) during a postimplementation visit.Unique patient visits selected from all 15 primary care providers of a general medicine outpatient clinic.We used 7 process indicators of quality pain management, based on appropriately evaluating and treating pain, to assess 300 randomly selected visits before and 300 visits after implementing the pain initiative.The quality of pain care was unchanged between visits before and after the pain initiative (P.05 for all comparisons): subjective provider assessment (49.3% before, 48.7% after), pain exam (26.3%, 26.0%), orders to assess pain (11.7%, 8.3%), new analgesic (8.7%, 11.0%), change in existing analgesics (6.7%, 4.3%), other pain treatment (11.7%, 13.7%), or follow-up plans (10.0%, 8.7%). Patients (n=79) who reported substantial pain often did not receive recommended care: 22% had no attention to pain documented in the medical record, 27% had no further assessment documented, and 52% received no new therapy for pain at that visit.Routinely measuring pain by the 5th vital sign did not increase the quality of pain management. Patients with substantial pain documented by the 5th vital sign often had inadequate pain management.

To determine if a psychiatry-primary medical care (PPMC) training track impacts comfort and behaviors related to addressing general medical issues after residency.Thirty five psychiatry resident graduates completed mailed surveys; nine of them had completed the PPMC track.Compared to non-PPMC participants, PPMC participants felt better prepared to address medical issues and tended to perform more consultations and feel more comfortable referring patients to general medical providers. They were not more likely to perform routine health screenings.Integrated training tracks may impact resident preparedness and career choice but may be insufficient to influence practice behaviors related to delivering general medical care.

Since 1991, the Patient Self-Determination Act (PSDA) has required all health care institutions that receive Federal funds to inform patients upon admission of their rights to make decisions about medical care and to execute advance directives. Implementation of the PSDA presents a special challenge for state mental hospitals. The relevance and possible negative therapeutic impact of discussing end of life decisions at the time of an acute psychiatric admission has recently been raised in the literature. Other ethical dilemmas arising from the interplay between mental illness and informed consent for medical treatment, particularly for older patients committed to state mental hospitals, have been highlighted by the PSDA. In this article we discuss some of the issues raised by implementation of the PSDA in this setting.