Firearm-related personal and clinical characteristics of US medical students

BACKGROUND: Firearm injuries are the second leading cause of fatal injury in the US, and several medical specialty societies encourage patient counseling about firearm injury prevention. Because personal choices. influence physicians' willingness to counsel, it would be valuable to know how frequently guns are kept in the homes of physicians-in-training, as well as their perceptions and current rates of counseling about firearm injury prevention. METHODS: At a nationally representative sample of 16 medical schools, we surveyed the class of 2003 at freshman orientation, entrance to wards, and during senior year. RESULTS: A total of 2,316 students provided data (response rate = 80.3%). Among freshmen, 16% reported living in a home with a firearm, 13% did so at entry to wards, as did 14% of seniors (14% overall, women = 9%, men = 19%). Only 34% of seniors reported counseling their patients more often than "never/rarely" about firearm possession and storage. CONCLUSIONS: US medical students reported substantially lower rates of household gun ownership than the general population, but their participation in firearm-related counseling is also low.     

Firearm counseling by physicians: coverage under medical liability insurance policies

BACKGROUND: Physicians who offer firearms counseling may increase their legal liability, depending on the attitudes of their medical malpractice insurance carriers. METHODS: A survey was mailed to the 100 largest medical malpractice insurers. Requested data included their experience with claims involving allegations of negligent firearm counseling by physicians, their opinion regarding whether firearm counseling by physicians would be covered under their medical malpractice policies, and their prediction of how their insurance group or company would handle such claims. RESULTS: Fourteen surveys were returned. No respondents reported having dealt with a case involving an allegation of negligent firearm counseling by a physician. Eight respondents (57%) thought that such counseling would not be covered under their medical malpractice policy, whereas six respondents (43%) said that it would. CONCLUSION: A majority of responding insurers thought that physician firearm counseling would not be covered under their medical malpractice policies. Physicians wishing to counsel their patients about the risks and benefits of owning and using firearms are advised to seek assurance of medical malpractice insurance coverage from their insurers or the annexation of a rider to their current policies.     

Patients' perceptions of primary care physicians' participatory decision-making style and communication about complementary and alternative medicine for arthritis

OBJECTIVE: The purpose of this study was to examine: (1) which patient demographics were related to whether patients rated their family physicians as using a participatory decision-making style, and (2) whether arthritis patients who reported using complementary and alternative medicine (CAM) were more likely to report discussing CAM use with their providers if they saw family physicians rated with participatory decision-making styles. METHODS: A survey that asked about health status, demographics, physician use of a participatory decision-making style, and medical skepticism was sent to 2178 patients with arthritis who attended 16 different family practice sites that were part of a research network in rural and urban North Carolina. Generalized estimating equations were used to analyze the data. RESULTS: Younger and more educated patients were more likely to rate their family physicians as using participatory styles. In all, 71% of patients who reported having used one or more CAM strategy reported having discussed it with their physicians. Patients who rated their health as worse, reported using more categories of CAM, and rated their physicians as being using participatory styles were more likely to tell their physicians about their CAM use. CONCLUSION: Our findings suggest that if providers use more participatory styles with patients and involve them when making treatment decisions; patients will tell providers more about what they are doing for their health.     

Physician gender and psychosocial care for children: attitudes, practice characteristics, identification, and treatment

OBJECTIVE: To examine differences by physician gender in the identification and treatment of childhood psychosocial problems. DESIGN: Survey of patients (n = 19,963) and physicians (n = 366) in primary care offices in 2 large, practice-based research networks. Multivariate regressions were used to control for patient, physician, and visit characteristics, with a correction for the clustered sample. SUBJECTS: Children ages 4 to 15 years seen consecutively for nonemergent care. MEASURES: Physician report of attitudes, training, practice factors, and identification and treatment of psychosocial problems. Parental report of demographics and behavioral symptoms. RESULTS: Compared with male physicians, female physicians were less likely to view care for psychosocial problems as burdensome. They were more likely to see children who were female, younger, black or Hispanic, in single-parent households, enrolled in public or managed health plans, and with physical health limitations. Children seen by male physicians had higher symptom counts. Male physicians were more likely to report having primary care responsibility for their patient and that parents agree with their care plan. Female physicians spent more time with patients. After controlling for these differences, female physicians did not differ from male physicians in identification or treatment of childhood psychosocial problems. CONCLUSIONS: Male and female physicians see different kinds of children for different visit purposes and have different kinds of relationships with their patients. After controlling for these factors, management of childhood psychosocial problems does not differ by physician gender. Improving management of psychosocial conditions depends on identifying modifiable factors that affect diagnosis and treatment; our work suggests that characteristics of the practice environment, physician-patient relationship, and patient self-selection deserve more research.     

Reporting of child abuse: influence of characteristics of physician, practice, and community

This survey of 120 Alabama pediatricians, family physicians, and general practitioners investigated the relationship between physician, practice, and community characteristics and the factors that impede reporting of detected child abuse. Solo practitioners and rural physicians were most concerned about the effect of reporting on their relationship with their patients. Small town physicians, recent medical school graduates, and physicians who had attended child abuse workshops were most likely, and urban physicians least likely, to endorse an ethical or legal responsibility to report. Attendees of workshops were more confident in their ability to recognize abuse and less likely to think they could best handle the case themselves. Male physicians were reluctant to report because of the likelihood of having to appear in court. All physicians were reluctant to report cases about which they were uncertain and were concerned about the lack of prompt action after their reports; general practitioners expressed reluctance to report due to a wide variety of factors.     

Parents' beliefs about children and gun safety

This study sought to determine parents' beliefs about children and gun safety. A survey was sent to 230 parents of elementary age children addressing their beliefs about firearm storage, firearm safety training for children, and whether or not their child would handle a gun. Findings are based on the 82 returned surveys. Parents believed safe firearm storage was important to protect children. Only 22% of parents reported having a firearm in their home. However, of those reporting a firearm in the home, 85% did not practice safe gun storage despite reporting they believed it was important. These findings are supported by other studies that have found that parents have unrealistic perceptions about how their child will respond when a firearm is encountered. The only predictor of parents' incorrect perceptions about firearm safety training was the item "children will be safe if taught." This parental misperception provides further evidence that parents have unrealistic attitudes about children and guns.     

Correlates of HIV risk in a random sample of street youths in San Francisco.

In a random sample of 203 street youths recruited in the Haight-Ashbury neighborhood of San Francisco, the authors found significant differences between those who reported that they could go home if they wanted to compared to those who perceived that they could not go back home. Those who could not go home were significantly more likely to report having been away from home for more than 3 years, having run away before age 13, having been kicked out of their home, and not being in touch with their parents compared to the other group. Those who could not go home reported significantly more-injection drug use, which puts them at high risk for HIV. Health care providers can identify street youths at highest risk by asking the question "Could you go back home today if you wanted to do so?"     

Smoking Cessation Counseling by Emergency Physicians: Opinions, Knowledge, and Training Needs

Objectives: To determine: 1) the extent of emergency physicians' (EPs') training in smoking cessation counseling; 2) their understanding of counseling and pharmacologic treatment techniques; 3) their current practices in screening, counseling, and referring patients who smoke; and 4) perceived barriers to routine smoking cessation counseling in emergency medical practice.
Methods: A 26-item questionnaire addressing the above issues was mailed to all 256 members of the Colorado Chapter of the American College of Emergency Physicians.
Results: Completed questionnaires were returned by 196 physicians (77% response rate). The majority of respondents were men (80%), practiced in urban settings (87%), and were board-certified in emergency medicine (82%). Most EPs lacked formal smoking cessation training (55%) and felt poorly prepared to counsel patients about smoking cessation (65%). A minority (27%) of the physicians reported routinely asking patients to quit smoking. The physicians with formal smoking cessation training were more likely to counsel and refer patients routinely (34% vs 20%, p = 0.03). The physicians cited the following barriers to routine smoking cessation counseling: a lack of time; a perception that patients are not interested; a belief that the ED setting is inappropriate for counseling; and a sense that counseling is ineffective. Lack of reimbursement was cited by only 13% of the respondents. The physicians who had formal smoking cessation training perceived fewer barriers to ED-based counseling.
Conclusions: Emergency physicians have received little training in smoking cessation and perceive many barriers to ED-based smoking cessation interventions. Not surprisingly, they infrequently take action to encourage or assist their patients to quit smoking.     

Counseling medical patients about cigarette smoking: a comparison of the impact of training on nurse practitioners and physicians

Health providers believe that eliminating smoking is an important health promotion goal, but physicians and nurse practitioners may differ in the implementation of that belief. To determine whether nurse practitioners or physicians were more likely to counsel smokers to quit smoking, 12 internal medicine nurse practitioners (100 percent female) and 40 internal medicine physicians (30 percent female) were studied at four San Francisco Bay-area Kaiser Permanente Medical Centers, both before and after training in smoking-cessation counseling. In addition, exit phone surveys of at least 15 smokers per participant were completed as soon as possible following an office visit to the participant (269 nurse practitioner patients; 948 physician patients). It was found that nurse practitioners discussed smoking with patients more often than did physicians (64 percent vs. 50 percent; p less than 0.001), asked patients more often whether they were interested in quitting (49 percent vs. 40 percent; p less than 0.01), distributed more smoking-cessation literature to patients (37 percent vs. 25 percent; p less than 0.001) and made more follow-up appointments about smoking (36 percent vs. 19 percent; p less than 0.001). These differences in counseling behavior between the two groups were not explained by differences in patient characteristics of the two groups. The authors concluded that, given the same training, nurse practitioners are more likely to counsel smokers about quitting than are physicians.     

Factors related to the involvement of nurses in medical end-of-life decisions in Belgium: a death certificate study

BACKGROUND: Although nurses play an important role in end-of-life care for patients, they are not systematically involved in end-of-life decisions with a possible or certain life-shortening effect (ELDs). Until now we know little about factors relating to the involvement of nurses in these decisions. OBJECTIVE: To explore which patient- and decision-characteristics are related to the consultation of nurses and to the administering of life-ending drugs by nurses in actual ELDs in institutions and home care, as reported by physicians. METHOD: We sampled at random 5005 of all registered deaths in the second half of 2001--before euthanasia was legalized--in Flanders, Belgium. We mailed anonymous questionnaires to physicians who signed the death certificates and asked them to report on ELDs, including nurses' involvement. RESULTS: Response rate was 59% (n=2950). Physicians reported nurses involved in decision making more often in institutions than at home, and more often in care homes for the elderly than in hospitals (OR 1.70, 95% CI 1.15, 2.52). This involvement was more frequently when physicians intended to hasten the patient's death than when they had no such intention (institutions: OR 2.05, 95% CI 1.41, 2.99; home: OR 2.04, 95% CI 1.19, 3.49). In institutions, this involvement was also more likely where patients were of lower rather than higher education (OR 2.95, 95% CI 1.49, 5.84). The administering of life-ending drugs by nurses, as reported by physicians was also found more frequently in institutions than at home, and in institutions more frequently with lower rather than higher educated patients (p=.037). CONCLUSIONS: These findings raise questions about physicians' perception of the nurse's role in ELDs, but also about physicians' skills in interacting with all patients. Education and guidelines for physicians and nurses are needed to optimize good communication and to promote a clearer assignment of responsibilities concerning the execution of those decisions.     

Patterns and correlates of illicit drug selling among youth in the USA

PURPOSE: Despite the high rates of drug selling among youth in juvenile justice and youth residing in disadvantage neighborhoods, relatively little is known about the patterns of illicit drug selling among youth in the general population. METHODS: Using the public-use data file from the adolescent sample (N = 17 842) in the 2008 National Survey on Drug Use and Health (NSDUH), this study employed multiple logistic regression to compare the behavioral, parental involvement, and prevention experiences of youth who sold and did not sell illicit drugs in the past year. RESULTS: Findings from a series of logistic regression models indicated youth who sold drugs were far more likely to use a wide variety of drugs and engage in delinquent acts. Drug-selling youth were significantly less likely to report having a parent involved in their life and have someone to talk to about serious problems but were more likely to report exposure to drug prevention programming. CONCLUSION: Selling of drugs by youth appears to be a byproduct of substance abuse and deviance proneness, and the prevention programs these youth experience are likely a result of mandated exposure derived from contact with the criminal justice system. Assuming no major drug supply side reductions, policies, and practices associated with increasing drug abuse treatment, parental involvement and supervision, and school engagement are suggested.     

Use of and attitudes about alternative and complementary therapies among outpatients and physicians at a municipal hospital

OBJECTIVES: To survey outpatients and physicians about their use of, knowledge of, and interest in alternative therapies. DESIGN: Anonymous self-administered survey. SETTINGS/LOCATION: Outpatient clinics at a major municipal medical center. SUBJECTS: Outpatients visiting clinics and staff physicians. INTERVENTIONS: Patient survey about overall use of 7 categories and 19 types of alternative therapies, and their desire to have specific therapies offered at the institution. Survey to physicians about whether their patients used the same categories and types of alternative therapies, whether they provided or recommended their use, and their interest in having them available at the institution. OUTCOME MEASURES: Frequency of use of different alternative therapies by gender and race. Frequency of patient use of alternative therapies according to their physicians and frequency of physicians who provide or recommend alternative therapies. RESULTS: A total of 567 outpatients completed questionnaires during the survey week. When given a list of alternative therapies, 85% of patients acknowledged use of one or more alternative therapies. When Diet/Nutrition was excluded, 42% reported use of alternative therapies. No differences in overall use were seen by age, sex, or race; but when Diet/Nutrition was excluded, women were more likely to use alternative therapies, and use of Manual Healing and Herbal Medicine differed by race. Of the 85 responding physicians, 86% reported that their ambulatory patients used alternative therapies. Similar proportions (35%-38%) of patients and physicians wanted Manual Healing and Mind/Body Control therapies to be available. CONCLUSIONS: Frequency of use of alternative therapies was high, and similar according to patients and physicians. Overall use did not differ by gender and race, except when Diet/Nutrition was excluded. Patients and physicians had similar interests in having alternative therapies provided, and both were hampered by lack of information about many therapies.     

Self-reported weapon ownership, use, and violence experience among clients accessing an inner-city sexually transmitted disease clinic

Little is known about the extent to which people who access public health care settings own/carry weapons and experience/perpetrate acts of violence. The purpose of this study was to describe weapon ownership and violence experiences of persons attending an inner-city sexually transmitted disease clinic. Face-to-face interviews were administered to 245 clients to assess weapon ownership, types of weapons carried, and experiences as victims or perpetrators of violent acts. Overall, 43.7% reported experience of carrying a weapon at some point in their lives. More men chose to carry guns; more women chose to carry knives or mace. Participants reported experiencing alarming levels of violence in the previous year: 30.5% experienced beatings, 23.9% reported being threatened with a gun, and 18.9% reported forced, unwanted sex. Persons with a history of carrying weapons were significantly more likely to report being both victims and perpetrators of violence. Persons who experienced violence in the previous month were significantly more likely to be diagnosed with an STD. Results show that STD clinics represent yet another setting wherein interventions to curb the extent of violence might be appropriate, and strategies to assist and protect those experiencing violence are needed. Copyright John Wiley & Sons, Inc.     

Rediscovering the patient's role in receiving health promotion services

OBJECTIVE: This study examined differences in the odds of receiving health promotion/disease prevention services recommended by the US Preventive Services Task Force among three subgroups of patients. It tested the hypotheses that those most uninvolved in their own health (as exemplified by the lack of knowledge of blood pressure and cholesterol levels despite having been tested) would receive the least other health promotion services, and those being treated for both high blood pressure and hyperlipidemia would receive the most additional services. METHODS: A mail survey was sent to a random sample of 68,422 veterans who had obtained primary care from any of the 153 Veterans Health Administration facilities in 1996. The adjusted response rate was 68%. Subgroup analyses were performed on three subgroups who reported having been tested for both hypertension and hyperlipidemia in the previous year (n = 5,113). RESULTS: Both hypotheses were supported. Uninvolved patients were the least likely subgroup to report obtaining other recommended health promotion services, and the dually treated were most likely. The uninvolved subgroup was significantly more likely to report being female, physically inactive, current smokers, and heavy alcohol drinkers, and to report having a problem with alcohol, and significantly less likely to report being > or =50 years of age and overweight, to almost always wear seat belts, and to obtain at least 90% of their health care at the Veterans Health Administration. CONCLUSIONS: Clinicians need to encourage all patients to receive health promotion services, but in particular they should be aware that those who do not know their last hypertension and cholesterol levels despite having been tested are particularly in need of attention.     

Elective Rotations and Their Impact on Resident and Faculty Decision Making

Background: Restrictions on resident-duty work hours have led to fewer opportunities to participate in elective rotations. Purpose: To investigate the potential impact of elective rotations on resident and faculty physicians using allergy/immunology (A/I) as a model. Methods: A questionnaire was sent to 375 primary care physicians. It assessed demographic information, training background, A/I-referral history and intentions, and perceived knowledge of A/I-specific issues. Results: A total of 228 surveys were returned. Resident physicians who were more senior in their training or who had taken an A/I rotation were more likely to have referred a patient to A/I in the past, more likely to refer a patient to A/I for chronic sinusitis, and more likely to report a greater knowledge of A/I topics. Faculty physicians with a history of an A/I rotation were more likely to feel knowledgeable about A/I topics. Conclusion: Elective rotations are positively correlated with perceived knowledge, referral intentions, and past history of referrals.     

Children's participation in vaccine research: parents' views

AIM: Vaccine studies that evaluate the persistence of protection following immunisation require subjects to continue participation in a research protocol over many years. As parents' attitudes and opinions may change over time, and with experience of research, it is important to consider the factors influencing parents' decision-making about their child's continued participation in such prolonged vaccine studies. METHOD: Parental views about participation of their child in a one-year follow-up vaccine study were explored by means of a self-administered questionnaire. Of the 254 eligible parents, 187 took part (74 per cent). RESULTS: Parents who provided consent were more likely to agree that having a home visit to take blood was very helpful (p=0.005) and that information obtained during the earlier part of the study influenced their decision to take part in a follow-up study (p<0.0001). Parents who did not consent to their child's participation were more likely to report the presence of personal reasons as a variable influencing their decision (p<0.0001). CONCLUSIONS: The relationship between study staff and parents is the cornerstone for success in performing studies involving vaccines and children. Provision of clear study information (oral and written) and offering the convenience of home visits are important in retaining participants in paediatric vaccine trials.     

Office counseling for the adolescent

Physicians can and do influence adolescents' health-related behaviors. A recent study of low-income adolescents found that most adolescents report they are not receiving sufficient counseling about risk and risky behaviors from their physicians [8]. The results of this study and the author's personal experience (teaching physicians how to counsel and interview adolescents) support the need for physicians to learn more about office-based counseling with adolescents. Physicians who care for teens should learn how to meet the unique needs of individuals at varying stages of development and be prepared to offer counseling services tailored to the special needs of this population. Awareness of counseling techniques and knowledge of how to use those techniques effectively should help family medicine physicians to provide effective comprehensive health care to adolescent patients.     

Perceived Roles of Emergency Department Physicians Regarding Anticipatory Guidance on Firearm Safety

Background

Several professional medical societies advocate for firearm safety counseling with patients. Little is known about Emergency Physicians' practices and perceptions of firearm safety counseling.

Objective

To assess Emergency Physicians' beliefs regarding firearm control and their confidence in counseling patients on firearm safety.

Methods

A national random sample (n = 500) of the members of the American College of Emergency Physicians was sent a valid and reliable questionnaire on firearm safety counseling.

Results

Of the 278 (56.8%) responding physicians, those who were non-white and those who were not members of the National Rifle Association (NRA) perceived firearm violence to be more of a problem than white physicians and those who were members of the NRA. The majority did not believe that patients would view them as a good source of information on firearm safety (63.3%) or that patients would accept them providing anticipatory firearm safety guidance (56.5%). The majority of the Emergency Department physicians did not believe firearm safety counseling would impact firearm-related homicides (75.2%) or suicides (70%).

Conclusions

The vast majority of Emergency Physicians had never been formally trained regarding firearm safety counseling, did not believe patients would see them as credible sources, and did not believe that anticipatory guidance on firearm safety would have any impact. These data may help inform Emergency Medicine residency programs on the training needs of residents regarding anticipatory guidance on firearm safety.     

Differences in the Annual Incomes of Emergency Physicians Related to Gender

Objectives To examine the association between physician gender and income for emergency physicians (EPs) after correcting for factors likely to influence income.
Methods The authors used survey responses collected during the 1990s from 392 actively practicing white EPs. Linear regression modeling was used to determine the association between provider gender and annual income after controlling for workload, provider characteristics, and practice characteristics.
Results White female EPs reported seeing 7% fewer visits but worked 3% more annual hours than their white male counterparts. White female EPs had practiced medicine for fewer years than white male EPs, although the distribution of respondents across categories of years practicing medicine was not dramatically different. Female EPs were more likely to be employees, as opposed to having an ownership interest in the practice. Female EPs were less likely than their male counterparts to be board certified. After adjustment for work effort, provider characteristics, and practice characteristics, the mean annual income of white female EPs was 193,570, or 47,854 (20%) lower than that for white male EPs (95% confidence interval =−82,710 to −12,997; p = 0.007).
Conclusions During the 1990s, female gender was associated with lower annual income among EPs. These findings warrant further exploration to determine what factors might cause the gender-based differences in income that were found.     

End-of-life care for nursing home residents dying from cancer in Nova Scotia,Canada, 2000–2003

INTRODUCTION: With our population aging, an increasing proportion of cancer deaths will occur in nursing homes, yet little is known about their end-of-life care. This paper identifies associations between residing in a nursing home and end-of-life palliative cancer care, controlling for demographic factors. METHODS: For this population-based study, a data file was created by linking individual-level data from the Nova Scotia Cancer Centre Oncology Patient Information System, Vital Statistics, and the Halifax and Cape Breton Palliative Care Programs for all persons 65 years and over dying of cancer from 2000 to 2003. Multivariate logistic regression was used to compare nursing home residents to nonresidents. RESULTS: Among the 7,587 subjects, 1,008 (13.3%) were nursing home residents. Nursing home residents were more likely to be female [adjusted odds ratio (OR) 1.4, 95% confidence interval (CI) 1.2-1.7], older (for > or = 90 vs 65-69 years OR 5.4, CI 4.1-7.0), rural (OR 1.5, CI 1.2-1.8), have only a death certificate cancer diagnosis (OR 4.2, CI 2.8-6.3), and die out of hospital (OR 8.5, CI 7.2-10.0). Nursing home residents were less likely to receive palliative radiation (OR 0.6, CI 0.4-0.7), medical oncology consultation (OR 0.2, CI 0.1-0.4), and palliative care program enrollment (Halifax OR 0.2, CI 0.2-0.3; Cape Breton OR 0.4, CI 0.3-0.7). CONCLUSION: Demographic characteristics and end-of-life services differ between those residing and those not residing in nursing homes. These inequalities may or may not reflect inequities in access to quality end-of-life care.