"I was not able to keep myself away from tending to her immediate needs": Primary Care Physicians' Perspectives of Serious Illness Conversations at Community Health Centers
PURPOSE/OBJECTIVE:Seriously ill patients in low-income and minority populations have lower rates of advance care planning. Initiatives that promote serious illness (SI) conversations in community health centers (CHCs) can reach broad, diverse patient populations. This qualitative study explored the experiences of primary care physicians in conducting SI conversations at CHCs in order to understand challenges and needs in this setting. METHODS:An initiative to increase SI conversations was implemented at two CHCs in the Bronx, NY. Eleven participating family physicians who together conducted 37 SI conversations underwent semi-structured in-depth interviews. The 11 interviews were analyzed using inductive thematic analysis. RESULTS:Eight themes emerged: (1) Structured approaches to SI conversations are useful even in longstanding patient-doctor relationships; (2) Discussion of prognosis is meaningful but difficult; (3) Emotional work is humanizing but draining; (4) Poverty and underinsurance are high priorities; (5) Social context affects patient readiness; (6) Communication barriers take multiple forms; (7) Patient characteristics make it "easier" or "harder" to initiate the SI conversation; (8) Time constraints limit the ability to meet multiple patient needs. CONCLUSIONS:Physicians at CHCs identified challenges in SI conversations at personal, interpersonal, organizational, and societal levels. These challenges should be addressed by initiatives that aim to increase SI conversations in primary care, and especially at CHCs.
Roux-en-Y Gastric Bypass Is Associated With Hyperinsulinemia But Not Increased Maximal Î²-Cell Function
Context/UNASSIGNED:Roux-en-Y gastric bypass (RYGB) is associated with postprandial hyperinsulinemia. Objective/UNASSIGNED:-cell function. Design Setting and Participants/UNASSIGNED:We performed a cross-sectional study at Columbia University Medical Center, New York, New York. Subjects without a history of diabetes were studied after surgery (n = 12) and were compared with nonsurgical controls (n = 10) who were mean matched for body mass index, insulin sensitivity, and hemoglobin A1c and with nonobese controls (n = 8). Methods/UNASSIGNED:Subjects underwent a mixed-meal tolerance test and on a separate day an intravenous glucose tolerance test followed by a hyperglycemic clamp (450 mg/dL; 25 mM blood glucose) and arginine stimulation. The main outcome measure was maximal insulin secretion quantified after arginine stimulation (AinsRmax). Results/UNASSIGNED:The RYGB group exhibited greater peak postprandial glucose levels and fourfold greater peak insulin levels than control groups; however, there were no significant differences in insulinogenic index or AinsRmax. Another finding was significantly greater postprandial glucagon levels in the RYGB group compared with controls. Conclusions/UNASSIGNED:-cell function but appear to be an appropriate response to altered nutrient flow and absorption.