Medical student attitudes toward older people and willingness to consider a career in geriatric medicine

OBJECTIVES: To evaluate the attitudes of first- and fourth-year medical students toward older people and the relationship between these attitudes and possible career choice. To examine the effects of an intensive geriatric medicine (GM) teaching program on these attitudes and career aspirations.
DESIGN: Observational study.
SETTING: University of Aberdeen.
PARTICIPANTS: Medical students.
MEASUREMENTS: In September 2005, first-year students (n=163) at the start of their undergraduate training completed a questionnaire based on the University of California at Los Angeles Geriatrics Attitudes Scale. Students were asked how likely they were to consider a career in GM in the future on a 5-point Likert scale. From the beginning of the academic year 2005/06, fourth-year students completed the same questionnaire before and after an intensive 8-day GM teaching program.
RESULTS: First-year medical students had a mean attitude score±standard deviation of 3.69±0.39. A more-positive attitude increased the likelihood of considering a career in GM ( P <.001). Fourth-year students had better attitude scores than first-year students (3.86±0.36, P =.002). The GM teaching program did not significantly affect attitude scores but significantly increased the willingness to consider a career in GM by a mean 0.52 points (95% confidence interval=0.35–0.70, P <.001).
CONCLUSION: Attitudes toward older people were better in fourth-year than first-year medical students. A more-positive attitude toward older people increased the likelihood of considering a career in GM. An intensive 8-day course in GM had no significant effect on attitudes but increased the likelihood of fourth-year students considering a career in GM.     

Factors enabling home death of the elderly in an institution specializing in home medical care: Analysis of apprehension of the bereaved family

Aim:   To determine the factors enabling home death despite caregiver apprehension about home medical care.
Methods:   This study was an anonymous mailed survey of bereaved family members (the caregiver) of patients who died in a home medical care setting provided by an institution specializing in home medical care in Japan (home death rate, ∼80%). We analyzed the relationships between caregiver apprehension about home medical care, overall satisfaction with home medical care and the place of death.
Results:   Higher caregiver apprehension about home medical care and lower overall satisfaction with home medical care were significantly associated with dying in a hospital. In addition, the home death group with apprehension about home medical care significantly rated higher overall satisfaction with home medical care than the hospital death group. Meanwhile, there was no difference in the overall satisfaction with home medical care between those with or without apprehension about home medical care in the home death group. Factors influencing overall satisfaction with home medical care in the home death group with apprehension about home medical care were: (i) being free from pain or symptoms (partial regression coefficient: 0.83); and (ii) fulfilled medical care service system (partial regression coefficient: 0.40).
Conclusion:   These results suggest that caregiver satisfaction with home medical care is an essential factor to enable home death of the patient despite the caregiver apprehension about home medical care.     

A controlled trial of a seminar to improve medical student attitudes toward,knowledge about,and use of the medical literature

Objective: To determine whether an interactive seminar could affect medical student knowledge of research design, basic critical appraisal skills, and attitudes toward and clinical use of the medical literature. Design: Controlled, nonrandomized clinical trial Participants: Third-year clinical clerks (n=146) during their core medicine clerkship. Interventions: Two 90 minute interactive seminars. Measurements and main results: Pre- and postquestionnaires were used to assess knowledge and attitudes regarding the use of the medical literature among 65 study and 81 control students. Blinded review of write-ups assessed actual use of the medical literature. Overall, 80% of the students subscribed to one or more journals and reported reading three or more journal articles per month. After the intervention, the study students were more likely than the control students to consider: 1) study design important in article selection and 2) use of medical literature critical to patient care decisions. Knowledge scores were significantly improved in the study group (p=0.0001). The intervention yielded no increase in the actual use of medical literature in patient write-ups over that encouraged by usual clerkship goals. 51% of the study and 48% of the control students cited literature at baseline, and 53% of all the students did so after the intervention. Of these citations, 50% were for journal articles and the remainder were for textbooks. The students infrequently mentioned the quality of the cited literature. Conclusions: An interactive seminar designed to introduce medical students to critical appraisal improved student knowledge and attitudes but did not increase the actual use of literature in patient writeups. Presented at the annual meeting of the Society of General Internal Medicine, May 1, 1992, Washington, DC. Supported by an Education Grant from the Uniformed Services University of Health Sciences, Bethesda, Maryland. The opinions or assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the Department of the Army or the Department of Defense.     

Similarities and differences in attitudes toward long-term care between Japanese Americans and Caucasian Americans

The purpose of this study was to compare attitudes toward the use of long-term care between older Japanese Americans (n = 1,244) and older Caucasian Americans (n = 1,354). When presented with a hypothetical situation in which they have dementia, 39% of older Japanese Americans and 42% of older Caucasians intended to be cared for at home, whereas 53% versus 38%, respectively, intended to use nursing home care (P <.001). If the hypothetical situation was hip fracture, 81% of older Japanese Americans and 72% of older Caucasians intended to be cared for at home, with 13% of both groups intending to use nursing home care (P = NS). The subjects' perceptions of what their families, friends, ministers, and communities would want them to choose differed, with more uncertainty among Caucasians (P <.001). For provision of home care, Japanese Americans were more likely to rely on loved ones than Caucasians, who were more likely to rely on paid providers. Multivariate logistic regression showed ethnicity to be independently related to intention to use nursing home care in the dementia scenario, controlling for demographic variables. Being married lowered the odds of intending to use nursing homes in any situation. We conclude that Caucasian Americans intend to use paid home health care at higher rates than Japanese Americans if they become disabled by dementia. Japanese Americans demonstrated more certainty about the influences of others on their opinions, suggesting a more stable cultural norm in this population, and intended to use more nursing home care in the event of permanent debility (dementia).     

Multidimensional attitudes of medical residents and geriatrics fellows toward older people

OBJECTIVES: To examine dimensions of a validated instrument measuring geriatric attitudes of primary care residents and performances on these dimensions between residents and fellows. DESIGN: Cross-sectional and longitudinal studies. SETTING: An academic medical center. PARTICIPANTS: Two hundred thirty-eight primary care residents (n=177) and geriatrics fellows (n=61) participated in the study from 1995 to 2000. MEASUREMENTS: A 14-item, 5-point Likert scale previously validated for measuring primary care residents' attitudes toward older people and geriatric patient care was used. RESULTS: Factor analysis showed four dimensions of the scale, labeled Social Value, Medical Care (MC), Compassion (CP), and Resource Distribution, which demonstrated acceptable reliability. Both groups of subjects showed significantly (P<.001) positive (mean>3) attitudes across the dimensions and times, except for residents, who had near-neutral (mean=3) attitudes on MC. Residents' mean attitude scores on the overall scale and the MC and CP subscales were significantly (P<.001) lower than those of fellows over time. Residents and fellows showed different change patterns in attitudes over time. Residents' attitudes generally improved during the first 2 years of training, whereas fellows' attitudes declined slightly. Personal experience was a strong predictor of residents' attitudes toward older patients. Ethnicity, academic specialty, professional experience, and career interest in geriatrics were also associated with residents' attitude scores. CONCLUSION: The multidimensional analysis of the scale contributes to better understanding of medical trainees' attitudes and sheds light on educational interventions.     

Physician attitudes regarding telephone medicine

OBJECTIVE: To measure physicians’ attitudes regarding telephone medicine and identify determinants of these attitudes. DESIGN: Cross-sectional survey. SETTING: Ten internal medicine residency programs in the United States. PARTICIPANTS: Graduates from 1988 through 1992. The response rate was 62% (n=356). MEASUREMENTS AND MAIN RESULTS: Survey items were assigned to one of four types of variables: demographic, attitude, training, or system variables. We used factor analysis to consolidate information from the individual questions about attitudes. Six scales describing attitudes toward telephone medicine were identified. Cronbach’s α was greater than 0.70 for all scales. One scale measured physicians’ satisfaction and confidence with the management of patient calls. Other attitude scales measured the helpfulness of personal experience or informal education and the importance of formal training in telephone medicine. Three of the scales measured how comfortable the physician felt prescribing over the telephone. We used regression analysis to predict physician attitudes towards telephone medicine using the demographic, training, and system variables. Availability of the patient’s chart, feeling prepared for telephone medicine by one’s residency training, and being comfortable prescribing narcotics by telephone predicted satisfaction and confidence with the management of patient calls (R ²=.25). CONCLUSIONS: Several physician attitudes regarding telephone medicine can be measured reliably. Our findings suggest that improving systems for managing patient calls and improving telephone training for physicians will improve physician satisfaction and confidence with the practice of telephone medicine. Received from the University of North Carolina, Chapel Hill Presented in part at the 17th annual meeting of the Society of General Internal Medicine, Washington, DC, April 27–29, 1994. Supported by grants from the General Internal Medicine Faculty Development Program at the University of North Carolina, Chapel Hill (PE54004, HRSA Bureau of Health Professions, Rockvtile, Md.), the Alliant Community Trust Fund Grant at Alliant Hospital, Louisville, Ky., the East Carolina University School of Medicine Research Trust Fund, Greenville, NC, the Moses H. Cone Memorial Hospital, Greensboro, NC, the Scott and White Brindley Foundation, Temple, Tex., and the Dean’s Office of the School of Medicine at Virginia Commonwealth University, Richmond.     

Improving health care student attitudes toward older adults through educational interventions: A systematic review

ABSTRACT

Educational institutions should aim to positively influence the attitudes of future health care practitioners toward older patients to ensure the provision of quality patient care. This systematic review of the literature aims to determine the effectiveness of educational interventions designed to improve health care student behaviors and/or attitudes toward older people. The 29 studies included in this review utilized a variety of interventions, methods, and measurement tools. The most common type of educational intervention incorporated interaction with real patients. Few studies evaluated the impact of interventions on behavior; therefore, more observational studies are required. Overall interventions incorporating interactions with real patients who are independently living had a positive impact on student attitudes toward older adults. Clinically focused placements with patients who are ill may still have a place in the development of the patient-centered interview and assessment skills, along with improving confidence and competence, despite not having a favorable impact on attitudes.     

Physician surveys to assess customary care in medical malpractice cases

OBJECTIVE: Physician experts hired and prepared by the litigants provide most information on standard of care for medical malpractice cases. Since this information may not be objective or accurate, we examined the feasibility and potential value of surveying community physicians to assess standard of care. DESIGN: Seven physician surveys of mutually exclusive groups of randomly selected physicians. SETTING: Iowa. PARTICIPANTS: Community and academic primary care physicians and relevant specialists. INTERVENTIONS: Included in each survey was a case vignette of a primary care malpractice case and key quotes from medical experts on each side of the case. Surveyed physicians were asked whether the patient should have been referred to a specialist for additional evaluation. The 7 case vignettes included 3 closed medical malpractice cases, 3 modifications of these cases, and 1 active case. MEASUREMENTS AND MAIN RESULTS: Sixty-three percent of 350 community primary care physicians and 51% of 216 community specialists completed the questionnaire. For 3 closed cases, 47%, 78%, and 88% of primary care physician respondents reported that they would have made a different referral decision than the defendant. Referral percentages were minimally affected by modifying patient outcome but substantially changed by modifying patient presentation. Most physicians, even those whose referral decisions were unusual, assumed that other physicians would make similar referral decisions. For each case, at least 65% of the primary care physicians disagreed with the testimony of one of the expert witnesses. In the active case, the response rate was high (71%), and the respondents did not withhold criticism of the defendant doctor. CONCLUSIONS: Randomly selected peer physicians are willing to participate in surveys of medical malpractice cases. The surveys can be used to construct the distribution of physician self-reported practice relevant to a particular malpractice case. This distribution may provide more information about customary practice or standard of care than the opinion of a single physician expert.     

Evaluation of geriatrics education at a Chinese University: A survey of attitudes and knowledge among undergraduate medical students

ABSTRACT

Despite widespread reforms in medical education across China, nationally there has been no mandate or movement toward systemically incorporating geriatrics into curricula. To what degree medical students are trained and have exposure to geriatric topics remains unclear. We surveyed 190 medical students during their final year of medical school at a Chinese medical university, graduating from reformed and also traditional curricula. The survey was comprised of a subjective assessment of attitudes and reported knowledge, as well as an objective assessment of knowledge via a multiple choice test. Student attitudes were favorable toward geriatrics, with 91% supporting the addition of specialized clinical experiences to the curriculum. Students generally reported low exposure to geriatrics, with no statistically significant differences between reform and traditional curricula. There was a statistically significant difference in performance on the multiple choice test between curricula but at a degree unlikely to be practically significant. Students had very favorable attitudes toward geriatrics as a field and specialty; however scored poorly on competency exams, with the lowest performance around diagnosis and treatment of specific geriatric conditions. Our results suggest that there is a need and desire for increased geriatric-oriented learning at Chinese medical schools.     

Associations of patient-centered medical home with quality of care,patient experience,and health expenditures: A STROBE-compliant cross-sectional study

In efforts to improve the delivery of quality primary care, patient-centered medical home (PCMH) model has been promoted. However, evidence on its association with health outcomes has been mixed. The aim of this study was to assess the performance of PCMH model on quality of care, patient experience, health expenditures.This was a cross-sectional study of the 2015–2016 Medical Expenditure Panel Survey-Medical Organization Survey linked data, including 5748 patient-provider pairs. We examined twenty-four quality of care measures (18 high-value and 6 low-value care services), health service utilization, patient experience (patient-provider communication, satisfaction), and health expenditure.Of 5748 patients, representing a weighted population of 56.2 million American adults aged 18 years and older, 44.2% were cared for by PCMH certified providers. 9.3% of those with PCMHs had at least one inpatient stay in the past year, which was comparable to the 11.4% among those with non-PCMHs. Similarly, 17.4% of respondents cared for by PCMH and 18.5% cared for by non-PCMH had at least one ED visit. Overall, we found no significant differences in quality of care measures (neither high-nor low-value of care) between the two groups. The overall satisfaction, the experience of access to care, and communication with providers were also comparable. Patients who were cared for by PCMHs had less total health expenditure (difference $217) and out-of-pocket spending (difference $91) than those cared for by non-PCMHs; however, none of these differences reached the statistical significance (adjusted P > 0.05 for all).This study found no meaningful difference in quality of care, patient experience, health care utilization, or health care expenditures between respondents cared for by PCMH and non-PCMH. Our findings suggest that the PCMH model is not superior in the quality of care delivered to non-PCMH providers.     

The status of medical education in end-of-life care

OBJECTIVE: To assess the status of medical education in end-of-life care and identify opportunities for improvement. DESIGN: Telephone survey. SETTING: U.S. academic medical centers. PARTICIPANTS: National probability sample of 1,455 students, 296 residents, and 287 faculty (response rates 62%, 56%, and 41%, respectively) affiliated with a random sample of 62 accredited U.S. medical schools. MEASUREMENTS AND MAIN RESULTS: Measurements assessed attitudes, quantity and quality of education, preparation to provide or teach care, and perceived value of care for dying patients. Ninety percent or more of respondents held positive views about physicians' responsibility and ability to help dying patients. However, fewer than 18% of students and residents received formal end-of-life care education, 39% of students reported being unprepared to address patients' fears, and nearly half felt unprepared to manage their feelings about patients' deaths or help bereaved families. More than 40% of residents felt unprepared to teach end-of-life care. More than 40% of respondents reported that dying patients were not considered good teaching cases, and that meeting psychosocial needs of dying patients was not considered a core competency. Forty-nine percent of students had told patients about the existence of a life-threatening illness, but only half received feedback from residents or attendings; nearly all residents had talked with patients about wishes for end-of-life care, and 33% received no feedback. CONCLUSIONS: Students and residents in the United States feel unprepared to provide, and faculty and residents unprepared to teach, many key components of good care for the dying. Current educational practices and institutional culture in U.S. medical schools do not support adequate end-of-life care, and attention to both curricular and cultural change are needed to improve end-of-life care education.     

Relationship of medical home quality with school engagement and after-school participation among children with asthma

Objectives: To examine the relationship between medical home quality and measures of daily life experiences among children with asthma. Methods: A nationally representative sample of children from the 2007 National Survey of Children's Health (NSCH), aged 6–17 years (n = 6357), who have asthma was used to assess the relationship of a quality medical home and its features with their daily life experiences. Five medical home features – access, continuity, comprehensiveness, family-centered care, and coordination of care – were examined individually and in total in relation to measures of school engagement (missed school days, parents contacted about problems with the child, repeating a grade since kindergarten) and after-school activity participation (physical activity, sports participation, and community service or volunteer work). Results: Before and after adjustment for personal characteristics, health insurance status, family environment, neighborhood variables, and asthma severity, total medical home score was associated with more days exercised [beta (B) = 0.10, p < .05] and a greater likelihood of having performed community service or volunteer work [odds ratio (OR) = 1.16, CI: 1.02–1.31]. Additionally, the medical home features of access, comprehensiveness, and family-centered care remained favorably associated with three of the six measures of school engagement and after-school activity participation, even after adjustment. Conclusion: Medical home quality – particularly the features of access, comprehensiveness, and family-centered care – is positively associated with the daily life experiences of children with asthma. Working to enhance these aspects of primary care might be one place to start in improving the management of children's chronic conditions and their quality of life.     

Toward developing care outcome quality indicators for home care for older people: A prospective cohort study in Japan

Introduction

Care quality in Japan's long-term care (LTC) agencies, including home care, is the responsibility primarily of individual agencies, and the evaluation of service processes and outcomes is minimal.

Objectives

To describe the development of quality indicators for LTC (QIs-LTC) in Japan.

Methods

QIs-LTC were developed through literature review and expert panel discussions and then were piloted and used in a 2-year longitudinal survey. The survey (launched in September 2019) targeted older people receiving home care (n = 1450), their family members (n = 880), their professional home care providers (n = 577), and managers of home care agencies (n = 122).

Results

Across eight domains (maintaining dignity, minimizing symptoms and disease deterioration, maintaining nutritional status, maintaining bladder/bowel control, encouraging physical activities, experiencing sound sleep, maintaining serenity and contentedness, and maintaining family's well-being), 24 care quality objectives were set with 24 outcome QIs-LTC and 144 process QIs-LTC. In the survey, 84.8% of clients were using home care nursing, 26.3% were living alone, and 39.5% had dementia. In the month preceding the data collection, 13.9% of clients had a new disease or worsening of an existing disease, 8.8% were hospitalized at least once, and 47.9% did not participate in activities of interest. About 20% of clients' families were unable to spend time peacefully, and 52.8% were exhausted from the client's care.

Conclusions

The QIs-LTC developed in the current study are generic and client- and family-centered. They encompass objective and subjective information and would facilitate standardized monitoring if adopted and comparison between LTC settings, including home care. In addition, future research directives are outlined. Geriatr Gerontol Int 2023; 23: 383–394 .     

A randomized trial of depression assessment intervention in home health care

OBJECTIVES: To determine whether an educational intervention would improve depression assessment and appropriate referral. Secondary analyses tested whether referral led to depression improvement. DESIGN: Training in the Assessment of Depression (TRIAD) was a three‐group, nurse‐randomized trial. Researchers interviewed randomly selected patients at baseline and 8 weeks. SETTING: Three certified home healthcare agencies in Westchester County, New York. PARTICIPANTS: Fifty‐three medical/surgical nurses were randomized within agency to three intervention groups: full, minimal, or control. Research contact with nurses' patients (aged >65; N=477) yielded 256 (53.7%) enrolled subjects, 84 (17.6%) ineligibles, and 120 (25.2%) refusals; 233 of the 256 (87.1%) enrolled patients completed follow‐up interviews. INTERVENTION: Nurse training in clinically meaningful use of depression sections of Medicare's mandatory Outcome and Assessment Information Set (OASIS). MEASUREMENTS: Nurse‐assessed mood or anhedonia (OASIS) versus research assessments using the Structured Clinical Interview for Axis I Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Disorders (SCID); referrals for mental health evaluation (agency records), and depression severity (24‐item Hamilton Depression Rating Scale; HDRS). RESULTS: Referral rates for patients with (SCID) depressed mood or anhedonia (n=75) varied according to nurse group: 50.0% full intervention, 18.5% minimal, 21.4% control (P=.047). Rates for nondepressed patients (n=180) did not differ (4.9%, 2.0%, 5.8%, respectively; P=.60). In patients with major or minor depression (n=37), referral was associated with symptom improvement. Change in HDRS was 5 points greater in referred patients than others (P=.04). Concordance between OASIS and SCID did not differ between intervention groups. CONCLUSION: TRIAD showed that training nurses to assess for depression using an approach developed in partnership with home healthcare agencies led to appropriate referral and care for depressed patients.