U-M Family Medicine at the 2019 North American Primary Care Research Group meeting

Context: The US currently has the highest ever recorded rates of sexually transmitted infections (STIs), with youth experiencing the highest rates. Likewise, HPV-related head and neck cancers are becoming more common than cervical cancer. Despite these alarming trends, less than 10% of youth report using protection during oral sex. Objective: To understand youth’s knowledge and perceptions regarding protection during oral sex in order to address these critical public health issues. Human Subjects Review: Approved by the IRB of the University of Michigan. Design: This study utilized MyVoice, a national mixed methods text message poll of youth that aims to gauge youth opinion on salient policy issues. Four open-ended survey questions were sent that asked about topics including why youth are not using protection during oral sex, what risks youth perceive are associated with not using protection, and suggestions for increasing rates of protection usage. Qualitative questions were analyzed inductively using thematic analysis, and quantitative data were analyzed using descriptive statistics. Setting: Participants were comprised of youth aged 14 to 24 years who were recruited through Instagram, Facebook, and in-person community events to meet national benchmarks based on the American Community Survey. Anticipated Results: Out of 1,095 youth, 908 responded to at least one question (RR= 83%). The average age was 18 years. The majority were female (58%), white (74%) and had a high school education or less (75%). Three main themes emerged regarding barriers to use of protection during oral sex: 1) Lack of knowledge (“[We] are not being educated about what can happen when you have unprotected oral sex.”) 2) Inadequate access (“Because it's easier and cheaper not to.”), 3) Cultural norms (“most people would think it was weird if they asked to do that.”). Conclusions: Youth report several modifiable barriers to increasing the use of protection during oral sex including more education regarding the risks, improving access to protection during oral sex, and adjusting cultural norms to make navigating the use of protection easier for youth. These findings suggest that youth-serving organizations, educators and medical professionals have the opportunity to reduce the risks of oral sex by engaging youth in conversations regarding safe oral sex practices.

Upon completion of this session, participants should be able to: 

1. Participants should be able to understand youth perceptions regarding using protection during oral sex.
2. Participants should be able to understand why it is critical to understand youth opinions in order to create effective interventions for this population.

Context: Active shooter drills are on the rise in the United States education system due to the rise in gun violence in school settings. While gauging adult public opinion on gun safety measures has been an ever increasing political pursuit, national surveying of the youngest individuals affected by gun violence has been less widespread. More research is needed to understand the impact of these drills on the emotional well being of youth. Objective: To understand youth opinion and experiences surrounding active shooter drills in the United States. Human Subjects Review: Approved by the Institutional Review Board of the University of Michigan Design: This study utilizes MyVoice, a national mixed methods text message poll of youth that aims to gauge youth opinion on salient policy issues. Five open-ended survey questions will be fielded in August 2019. They were designed by the research team through an iterative process and tested amongst a pilot group: Tell us about how gun violence affects you. Does/did your school have active shooter drills? What happens during an active shooter drill? How do active shooter drills make you feel? Do you think active shooter drills make schools safer? Why or why not? Demographic information was also collected. Qualitative questions will be analyzed inductively using thematic analysis, and quantitative questions will be analyzed using descriptive statistics. Setting: Participants are comprised of a diverse sample of over 1000 youth aged 14 to 24 years from across the nation who were recruited through Instagram/Facebook, and in-person community events to meet national benchmarks based on the American Community Survey. Anticipated Results: We expect youth responses to center around three themes: anxiety surrounding the possibility of gun violence, the ineffectiveness of active shooter drills, and mental distress associated from participating in drills. While active shooter drills may be implemented by school administrators with good intentions, we expect that students will not agree that they are the best solution to the threat of gun violence. Conclusions: We anticipate that the results of this study will be a useful contribution to the literature on active shooter drills, especially in the context of injury prevention and adolescent health. The current population of adolescents is the first to experience active shooter drills on a regular basis, making their opinions on the impact of such exercises invaluable.

Upon completion of this session, participants should be able to: 

1. Participants should be able to explain youth attitudes towards active shooter drills.
2. Participants should be able to apply youth attitudes on active shooter drills towards future research and policy solutions.

Context: Since 2011, the Chinese government has mandated that general practitioners receive standardized training, but previous research on General Practice (GP) residents’ views about training is limited. Objective: This study aims to understand GP residents’ attitudes about their residency training in China, and compare the opinions from two GP residencies in Beijing and Shenzhen. Human Subjects Review: The study was reviewed and approved by Peking University First Hospital Human Research Ethics Committee, Ethical review number: (2019) Scientific research number-89. Study Design: Cross-sectional mixed data collection survey. Setting: General Medicine Department of Peking University First Hospital in Beijing, and the General Medicine Department of Peking University Shenzhen Hospital in Shenzhen, China. Population studied: 35 residents in Beijing and 70 residents in Shenzhen. Results: Overall, residents felt discrimination because of specialty choice, and that they lacked competency as a GP. Many residents commented faculty had negative teaching attitudes. Beijing residents were more satisfied than Shenzhen residents with their training (p=0.001), and felt teaching faculty had sufficient knowledge (p<0.001) and appropriate attitudes towards teaching (p=0.004). Beijing residents more strongly agreed on five items about good future job prospects as GPs (all p<0.05). Conclusions: These Chinese GP residents identify strengths and areas for improvement in their training. Satisfaction with faculty teaching and job optimism in the Beijing program where GP residents receive training from specifically qualified faculty and can earn a special certification suggest educational innovations enhance GP training and promote optimism for future work prospects. Nurturing of respectful relationships between GPs and other specialists is a critical priority for alleviating many challenges in GP training. 

Upon completion of this session, participants should be able to: 

1. Appraise a mixed methods survey approach for assessing resident attitudes towards general practice residency training.
2. To recognize potential of comparing general practice residents’ attitudes in two GP residency programs in Beijing and Shenzhen.
3. To consider importance of factors that influence the education satisfaction of general practice residents.

Context: Type 2 Diabetes Mellitus (T2DM) is preventable, yet few patients with pre-diabetes participate in prevention programs. Use of new low-cost and user-friendly continuous glucose monitors (CGM) to support low carbohydrate eating is a novel strategy to prevent T2DM. Objective: Determine patient satisfaction and feasibility of using CGM in patients with pre-diabetes to drive dietary behavior change. Study design: Mixed methods single arm pilot and feasibility study Setting or Dataset: Suburban primary care clinic Population studied: Fifteen adults with pre-diabetes and BMI > 30 kg/m2 not on metformin. Intervention: The intervention and assessments took place during three in-person study visits and one qualitative phone interview. At visit 1, participants were asked to wear a continuous glucose monitor (CGM) and complete a food and craving log for ten days. At visit 2, they returned to review their food and craving log with CGM results and learn about low carbohydrate eating. A second CGM sensor was placed and participants again logged food and cravings as they tried to reduce their total carbohydrate intake using real-time CGM feedback to guide food choices. At visit 3, they again reviewed their CGM and log data. Outcome measures: Primary: satisfaction with use of CGM and low carbohydrate diet education. Secondary: feasibility, weight change, % time above glucose goal of 140 mg/dL, knowledge regarding low carbohydrate eating. Results: 93% satisfaction rate with intervention. Quantitative results significant for reduction in hemoglobin A1c (HbA1c) from final estimated HbA1c to enrollment HbA1c (-0.71 mmol/mol, p>.001) and weight change from second to final visit (-1.4 lb, p = .02). Percent time above glucose goal and average daily glucose were not significant but trended in the expected direction. Qualitative interview themes indicated: 1) Acceptance of low carbohydrate diet; 2) CGM helped to visualize food’s impact on the body inciting dietary changes; 3) No major barriers to CGM use. Conclusions: Use of CGMs to drive behavior change in patients with pre-diabetes is feasible and participants were satisfied with their experience. This novel method deserves further exploration as preliminary data indicates CGM supported dietary behavior change which may ultimately result in prevention of T2DM. 

Upon completion of this session, participants should be able to: 

1. Participants will be able to distinguish between interventions that use continuous glucose monitoring to adjust medication and those that use continuous glucose monitoring to change behaviors.
2. Participants will be able to identify eating patterns that correspond to glucose excursions on a continuous glucose monitoring report in a patient with pre-diabetes.

Context: There are over 1 million transgender (trans*) persons in the United States (US). Trans* persons continue to struggle with access to competent healthcare. Physicians and patients Further trans* education is needed. Objective: To identify the current state of trans* education in Family Medicine Clerkships (FMCs) and describe the characteristics of FMCs and Family Medicine Clerkship Directors (FMCDs) that include trans* education. Study Design: This was a cross-sectional survey of FMCDs from qualifying medical schools in North America. Questions regarding personal trans* practice and beliefs in addition to current trans* curricula were added to the 2018 annual Council of Academic Family Medicine Educational Research Alliance (CERA) survey. Setting: FMCDs in US and Canadian medical schools. Population studied: The FMCD or institutional representative for each qualifying medical school (n=144) received an email invite to participate. Outcome Measures: We aimed to determine the percentage of FMCs with a trans* curriculum and characteristics of that curriculum. We looked at characteristics of FMCDs with trans* education as a part of their curriculum, including the percentage who personally provide trans* care. Results: Ninety-nine of 144 (68.75%) FMCDs completed the survey. 60% personally treat trans* patients; only 6% believe their clinical staff and/or colleagues would prefer not to treat trans* patients. 24% indicated that they have no trans* education in their FMC. Specifically, 21% taught medical students how to communicate with trans* patients, 13% included trans*-specific preventive care and 5% covered trans* reassignment therapies. Medical school type (public vs private) and location (Canada vs US), and FMCD race and ethnicity were not correlated with the likelihood of having a trans* curriculum in the FMC. Personally treating trans* patients, having trans* acquaintances, and belief that trans*education should be a part of medical school curriculum was not correlated with the likelihood of having a trans* curriculum in the FMC. Conclusions: FMCs are a suitable place for integrating trans* education into the medical school curriculum. Just 24% of respondents indicated they do not have any trans* education in their FMC. The lack of trans* curriculum in FMCs is independent of all FMCD characteristics. Further exploration is warranted to determine factors that may increase the addition of trans* curriculum in FMCs. 

Upon completion of this session, participants should be able to: 

1. Define the current state of transgender education in Family Medicine Clerkships in North America.
2. Recognize that characteristics of Family Medicine Clerkship programs and Directors do not affect inclusion of a transgender curriculum.
3. Consider further factors that could be investigated for correlation with including a transgender curriculum in the Family Medicine Clerkship.

Context: While having only 209,000 general practitioners in 2016, the Chinese government has set a workforce goal of 700,000 general practitioners by 2030. Though medical students form the primary pool of future general practitioners, little previous research has addressed medical student perspectives in China, and most has focused on upper classmen and been published in Chinese. Research on the perspectives of entry-level medical students have been lacking. Objective: The purpose of this research was to elucidate first year medical students’ perspectives about general practice and provide suggestions about general practice education in medical schools. Study Design: Qualitative analysis of student perspectives expressed in a parent mixed methods survey. Setting: Peking University Health Science Center. Population studied: First-year Chinese and international students who attended the Introduction to Medicine Course. Outcome Measures: The analysis identified major themes and subthemes, and created a conceptual model interrelating the findings. Results: Five major themes address first-year students’ perspectives about general practice: 1) the need for general practice in China, 2) the value of general practice to society, 3) the breadth of care of general practice, 4) general practice training and whether general practitioners are specialists, 5) general practice development and need for social support. The resulting model formed by these perspectives indicate both confirmatory and contradictory impressions about general practice. Conclusions: Among entry level medical students, many lack knowledge and have misunderstandings about general practice. At the same time, these findings demonstrates that some students have a realistic understanding of many aspects of general practice. These results suggest medical educators in China need to provide accurate information about general practice and dispel misperceptions. As some entry level students have an interest and a good understanding about general practice, medical educators should also take steps to nurture and reinforce their interest.

Upon completion of this session, participants should be able to: 

1. Recognize the range of first year medical students' perspectives about GP in China
2. Interpret the interrelationships among the elucidated five major themes using a single model

 Rationale: Mixed method research involves collecting, analyzing and integrating qualitative and quantitative data. Mixed methods researchers face the challenge of planning, analyzing and presenting mixed methods findings. Joint displays have developed as a state-of-the-art approach for integrating the qualitative and quantitative strands in a single table or figure, yet many researchers are unaware of these innovative approaches. Participation: This workshop is highly interactive and participatory. After a brief review of mixed methods fundamentals, there will be a series of short presentations, one each on joint display planning, joint display analysis, and then joint display presentation. After each brief presentation, workshop participants will engage in applied activities by filling out a worksheet for each type of joint display. Content to be Presented: The workshop has four sections, fundamentals of mixed methods, joint display planning, joint display analysis, and joint display presentation. After each of the brief joint display presentations, participants will apply the material directly to their own work using templates and instructions for completing three worksheets, one each on joint display planning, joint display analysis, and joint display presentation. Participants who do not have their own project, will use a designated workshop mixed methods project. Method of Evaluation: Participants will complete three worksheets during the workshop so as to apply the presented concepts. For those participants already engaged in mixed methods studies, the completed worksheets can be used for the conduct, implementation and dissemination of their findings. Participants will evaluate the four brief didactic presentations, and the quality of the worksheet activities. Prerequisite Knowledge: No prerequisite knowledge is required, though participants with knowledge of qualitative and quantitative methods who have their own mixed data will be able to apply the content to their own work. Participants who desire to work on their own projects should have access to their original data.

Upon completion of this session, participants should be able to:

describe three types of joint displays for mixed methods project planning, analysis, and presentation of mixed methods findings.
apply the introduced mixed methods joint display development fundamentals by completing worksheets for each type of joint display, and for those with their own projects, using their own projects as the basis for their worksheets.
develop draft mixed methods joint displays suitable for use in actual research planning, analysis and presentation of mixed methods findings.

Context: Sexual health is a delicate yet important subject for youth and adolescents given its impact on long-term health and future care-seeking. The lack of standardized sexual education in schools means that there is wide variation in youth knowledge about sex and intimacy. Primary care physicians are in a position to provide accurate, personalized education regarding sex and intimacy, but youth preferences regarding these discussions are under-researched. Objective: Determine whether youth regularly discuss sexual health with their providers, and what they would want their doctors to cover when discussing sexual health and intimacy. Human Subjects Review: Approved by the Institutional Review Board of the University of Michigan Design: Five open-ended qualitative questions were sent via text message to a national sample of youth via MyVoice, a mixed method longitudinal poll of youth age 14-24 years (www.hearmyvoicenow.org). Questions assessed included: Do you think doctors should talk to youth about sex? Have you ever had a conversation with your doctor about sex and what was did you talk about? How should doctors talk to youth about sex? What should doctors NOT say to youth about sex? Qualitative data was analyzed inductively by two investigators using thematic analysis to identify major themes. Setting: Youth age 14-24 were recruited at community events and from Instagram and Facebook to meet benchmarks based on the American Community Survey. This resulted in a national group of 773 youth of diverse ethnic backgrounds and gender identities. Anticipated Results: Preliminary results suggest that many doctors pose the question “are you sexually active?” to youth, though youth do not find that question to sufficiently address their needs and questions about healthy sexuality. Further, a large proportion of youth surveyed reported wanting their doctor to discuss issues such as consent, healthy relationships, and emotional aspects of intimacy in addition to topics like sexually-transmitted infections and contraception. Youth felt strongly that their doctors should not express their own personal/religious views. Conclusion: Discussions of sexual health by doctors appears to be insufficient to address the needs of a large proportion of youth in our national sample. Youth are requesting more discussion about the emotional and interpersonal aspects of sex and intimacy.

Upon completion of this session, participants should be able to: 

1. understand that many youth view the question "are you sexually active?" as insufficient to address their needs regarding healthy sexuality
2. understand that a large proportion of youth want their doctors to discuss the emotional and interpersonal aspects of sex and intimacy, and participants should be able to use this knowledge to benefit their future interactions with youth

Rationale: Becoming an excellent reviewer is one step to becoming a better author. “Staying current” and learning relevant methods/data/studies within a field as broad as primary care research have become more challenging for clinicians and researchers. Reviewing for academic journals can improve understanding of the state of current research and enhances knowledge of others’ research. Reviewing stimulates ideas for our own work, as well. Becoming a skilled reviewer is also an important act of collegiality, service to the field, and is another way of teaching. High quality reviews from an array of scientific disciplines are critical to strengthening research, advancing primary care and assuring the effectiveness and relevance of our journals, including the Annals of Family Medicine). Participation: The workshop will open with a presentation on the purpose and process of reviewing. A discussion portion will include the benefits of reviewing, strategies for evaluating a variety of types of manuscripts, and potential ethical issues. The session will follow with time for questions and answers with the editors of the Annals of Family Medicine. Content to be Presented: The workshop will examine: A paper’s path from submission to publication; The roles and needs of authors, reviewers, readers, and editors; How to evaluate a manuscript being considered for publication; How to write a constructive review that is useful to authors and editors and that helps advance scholarship; Specific Do’s and Don’ts of reviewing manuscripts; Special topics, challenges and controversies in peer review (and the changing trends in peer review); Participants' helpful experiences, concerns and questions; How thinking like a reviewer can improve one’s own writing. Method of Evaluation: Attendees will be encouraged to fill out a paper evaluation at the end of the workshop. Prerequisite Knowledge: Readers, reviewers, and writers at all levels of experience and expertise are welcome. The diversity of the group is a strength of the workshop format. ***This workshop is submitted under my name, but will be presented by the Editors of the Annals of Family Medicine. At the time of submission the editorial team in November is uncertain, but both groups have agreed to present regardless of editorial team. 

Upon completion of this session, participants should be able to: 

1. To develop knowledge and skills for peer review of research reports.
2. To apply these skills to conducting effective reviews and improving one’s own writing for publication.
3. To better understand the changing landscape of “peer review.”

Context: Hypertension (HTN) affects about 78 million Americans and is a costly, major public health concern. Of those individuals with HTN, only about half achieve adequate blood pressure control through pharmacologic and behavior/lifestyle modification. Mobile health (mHealth) is increasingly used to support chronic disease self-management; however, most initiatives do not involve established clinical care processes. Moreover, evidence supporting its use in clinical settings is not well documented. Objective: To establish the feasibility and acceptability of a clinical pharmacist-led mHealth intervention, BPTrack, among primary care patients with uncontrolled HTN. Design: Single-arm pre-/post-design. Setting: A Family Medicine clinic affiliated with a large Midwestern academic medical center. Population studied: 15 patients, age 18-65 years, who had been diagnosed with HTN, taking at least one antihypertension medication, and had uncontrolled HTN (SBP > 140 mmHg and/or DBP > 90 mmHg on repeat measurements). Intervention: BPTrack is a patient-facing smartphone app for iOS/Android that supports home blood pressure monitoring, medication adherence, and communication with a clinical pharmacist who is managing patient HTN. The clinical pharmacist uses BPTrack Pharm, a mobile app for iPad that provides a color-coded dashboard view to quickly highlight all BP data, as well as a more detailed view for each individual patient. Outcome Measures: Primary outcome measure was patient blood pressure. Results: Baseline and 12-week follow up data were collected from 13 individuals (mean SBP=137.6 mmHg, SD=11.4 mmHg; mean DBP=88.2 mmHg, SD=7.2 mmHg). BPTrack participants had significantly lower blood pressures (SBP and DBP) at 12-week follow up compared to baseline (mean change SBP = -6.62 mmHg, t(12)=2.72, p=.02; mean change DBP = -5.65 mmHg, t(12)=4.13, p=.001). Participants found BPTrack to be acceptable, with the majority of agreeing / strongly agreeing that they would recommend it to others (100.0%), liked knowing someone was watching their BP in between visits with their primary care physician (100.0%), were satisfied with the program (92.3%), and felt the program was beneficial to their overall health (92.3%). Conclusions: Results suggest that clinical pharmacist management of HTN, supported by the use of patient home blood pressure monitoring, combined with a mobile app, may be a feasible and acceptable approach to managing HTN within primary care.

Upon completion of this session, participants should be able to: 

1. Describe how mobile technologies can be used to support pharmacists in hypertension management.
2. Describe the benefits of mobile technologies for hypertension management.

Context: Scribes are increasingly used in primary care to help mitigate burdens associated with electronic health record documentation. Although benefits of scribes have been established, little is known about how they may affect patient-physician communication within an encounter. Objective: To understand how patient-physician communication in clinical encounters differs with and without the use of scribes in primary care. Study Design: Mixed methods study integrating quantitative survey data and content analysis of video recordings of clinical encounters (randomized to either have a scribe present or absent). Setting: Two family medicine clinics in a large Midwestern academic medical center. Population Studied: Primary care physician-scribe pairs, as well as their adult patients age >18 years who were scheduled for a clinic visit. Patients seen for health maintenance exams, or those who refused to consent to be videotaped and complete a survey, were excluded. Outcome Measures: Primary outcome focused on measures of patient-physician communication from video recordings, as well as patient surveys. Results: Three physicians and their scribes, and 34 patients were recruited and had their exams videotaped (scribed = 19, un-scribed = 15). Patients were on average 51 years old (SD=19). The majority were male (68%), had at least a bachelor's degree (50%), and had an annual salary >$50,000 (74%). No significant difference in encounter duration were found in video recordings between scribed (mean (SD)=16.5 (1.8) minutes) and un-scribed encounters (mean (SD)=15.6 (1.3) minutes; p-value=0.70). Moreover, results from patient surveys yielded no significant differences between groups regarding perceptions of patient-physician communication, or quality of care received. There was little variability between the groups, and the majority of all participants reported very high patient-physician communication and satisfaction scores. Conclusion: This study found that scribes have little impact on observed and patient reported measures of patient-physician communication. Regardless of the presence of a scribe, patients were uniformly satisfied with physician communication and their care, suggesting that scribes are acceptable to patients. Although scribes have little impact on patient perceptions, as documented in the literature, their potential impact on other important issues such as physician productivity and satisfaction is great, and merits further investigation.

Upon completion of this session, participants should be able to: 

1. Describe the role of medical scribes in primary care.
2. Describe the effect of medical scribes on physician-patient communication in primary care encounters.

Context/Objective: Large scale US surveys monitor and guide efforts to maximize the health of the population. Cervical cancer screening is an effective preventive measure with consistent question constructs among US population surveys. The aims of this study are to compare the cervical cancer screening rates of older women across three national surveys, and to describe screening predictors. Study Design and Dataset: All of the surveys aggregated data at the national level, on behavioral risk factors within states, the Behavioral Risk Factor Surveillance System (BRFSS), on national cancer information (Health Information National Trends Survey (HINTS); the Health Center Patient Survey (HCPS) collected data from individuals in health center programs across the US. The surveys reported responses from women, without hysterectomy, 45-65 years old. Reported predictors of screening were age, race/ethnicity, geo-location, insurance and educational attainment. Screening was defined as cytology within the last 3 years. Results: Overall, Pap screening rates were 71% (BRFSS), 66% (HCPS), and 79% (HINTS); significant decreased screening was reported with increased age, rural location, and less educational attainment in BRFSS only. Race/ethnicity was associated with screening in two surveys. HCPS reported that, when screening occurred at the Health Center, rates exceeded 92% for black, Hispanic and ‘other’ women, significantly higher than for white women. By contrast, the BRFSS reported similar screening rates at about 70% across white, black and Hispanic women. Conclusions: Older women continue to be at risk for insufficient cervical cancer screening, although black and Hispanic women in HCPS are screening at the Healthy People 2020 goal. We are the first to identify a racial disparity in cervical cancer screening among older white women within the HCPS. 

Upon completion of this session, participants should be able to: 

1. evaluate reports of cervical cancer screening for older women in three federal databases— Behavioral Risk Factor Surveillance System (BRFSS), the Health Center Patient Survey (HCPS), and Health Information National Trends Survey (HINTS)
2. describe the predictors of cervical cancer screening participation rates by survey

Rationale: Over the past three decades health sciences researchers have increasingly adopted mixed methods approaches. However, the structuring, writing and revising of mixed methods manuscripts for publication additional challenges than qualitative or quantitative only, studies. Led by a Chief-Co Editor of the Journal of Mixed Methods Research, the purpose of this workshop is to enhance the writing skills of primary care researchers conducting mixed methods studies. Participation: This workshop is interactive and participatory. After presenter reviews three core mixed methods designs, participants will use a design template to appropriate to their own study to guide the structure of an outline of a mixed methods paper that will be reviewed with a peer-mentor/participant. The presenter will then review 10 essential elements for inclusion in a mixed methods empirical study, and participants will check for the presence of these elements in their own studies, and again review with a peer-mentor. The presenter will then review discuss best practices for peer review of mixed methods studies. Content to be Presented: The presenter will review three core mixed methods designs, exploratory sequential, explanatory sequential and convergent. Participants will choose among three templates for application in their individual projects. Having chosen a template structure, the presenter will then review a checklist of 10 essential elements for inclusion in a mixed methods study, and add these elements into their templates. The workshop presenter will discuss common errors seen in mixed methods research manuscripts and how to use the checklist of 10 essential elements as a peer-reviewer. This will follow with a discussion of strategies for for addressing the comments of reviewers. The workshop will close with an open discussion about any aspect of the publication process. At the completion of the workshop, participants will be prepared for the submission, review and acceptance process for empirical mixed methods research manuscripts. Method of Evaluation: Participants will complete templates and worksheets during the workshop so as to apply the presented concepts to their own study. Participants will evaluate the effectiveness of the presentation and workshop activities. Prerequisite Knowledge: Participants familiar with qualitative and quantitative methods and are planning a mixed methods publication will benefit most from the workshop. 

Upon completion of this session, participants should be able to: 

1. Recognize the three core mixed methods designs and select a mixed methods structure for participants to compose their own mixed methods manuscripts.
2. Reference a checklist of 10 essential elements of a mixed methods empirical paper and check for the presence of these elements in their own mixed methods manuscript.
3. Develop the skills to apply the 10 essential elements from the perspective of a reviewer and how to respond to comments of reviewers.

Context: Understanding factors that influence clinical decision-making in patients with dementia and comorbid conditions will provide insight to develop successful supports for primary care physicians (PCPs). Objective: The purpose of the overall study was to understand the decision-making processes of PCPs caring for patients with dementia and other chronic conditions. The goal of this research is to describe PCP perspectives on the role that caregivers play in the management of dementia. Study Design: Qualitative approach using semi-structured interviews with 24 primary care physicians. Semi-structured interviews were audio-recorded and transcribed verbatim. Transcripts were analyzed using thematic analysis, including line-by-line coding by four members of the research team. Following coding, codes were grouped into categories and categories were related to one another to develop themes. Themes were reviewed by team members to ensure that the data was adequately reflected. Setting: Community setting, including both rural, suburban, and urban primary care practices. Population studied: Participants included clinically active PCPs in Michigan, USA. The primary inclusion factors for the study were PCPs without specialty training in geriatrics who self-identified as practicing in a rural, suburban or urban area, providing longitudinal care, serving older adults (>=65), and not practicing within a VA primary care clinic or free clinic. Outcome Measures: Themes developed into a narrative depicting PCPs' perspectives on caring for patients with dementia and multiple comorbidities. Results: 12 PCPs were practicing in rural settings and 12 PCPs in suburban or urban settings. The analysis produced three primary themes from PCP perspectives: (1) caregivers play multiple key roles in the management of dementia, including providing accurate communication, supporting clinical management of the patient, helping to maintain patient safety and quality of life, and making decisions on behalf of the patient as their condition deteriorates; (2) caregivers experience significant stress, which becomes a focus of care provided by the PCP; (3) dementia management is strained when there is not an available or engaged caregiver. Conclusions: PCPs practicing in community settings rely on caregivers for the management of dementia. Resources targeted at helping PCPs support caregivers may enhance management of patients with both dementia and comorbid conditions. 

Upon completion of this session, participants should be able to: 

1. describe the purpose of using semi-structured interviews for data collection.
2. describe the role that caregivers play in management of patients with dementia.