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1.
Eboni G. Price-Haywood Katherine G. Roth Kit Shelby Lisa A. Cooper 《Journal of general internal medicine》2010,25(2):126-129
BACKGROUND
Low health literacy (HL) is an important risk factor for cancer health disparities.OBJECTIVE
Describe a continuing medical education (CME) program to teach primary care physicians (PCP) cancer risk communication and shared decision-making (SDM) with low HL patients and baseline skills assessment.DESIGN
Cluster randomized controlled trial in five primary care clinics in New Orleans, LA.PARTICIPANTS
Eighteen PCPs and 73 low HL patients overdue for cancer screening.INTERVENTION
Primary care physicians completed unannounced standardized patient (SP) encounters at baseline. Intervention physicians received SP verbal feedback; academic detailing to review cancer screening guidelines, red flags for identifying low HL, and strategies for effective counseling; and web-based tutorial of SP comments and checklist items hyperlinked to reference articles/websites.MAIN MEASURES
Baseline PCP self-rated proficiency, SP ratings of physician general cancer risk communication and SDM skills, patient perceived involvement in care.RESULTS
Baseline assessments show physicians rated their proficiency in discussing cancer risks and eliciting patient preference for treatment/decision-making as “very good”. SPs rated physician exploration of perceived cancer susceptibility, screening barriers/motivators, checking understanding, explaining screening options and associated risks/benefits, and eliciting preferences for screening as “satisfactory”. Clinic patients rated their doctor’s facilitation of involvement in care and information exchange as “good”. However, they rated their participation in decision-making as “poor”.DISCUSSION
The baseline skills assessment suggests a need for physician training in cancer risk communication and shared decision making for patients with low HL. We are determining the effectiveness of teaching methods, required resources and long-term feasibility for a CME program.2.
Shoshana J. Herzig Jeffrey L. Schnipper Lauren Doctoroff Christopher S. Kim Scott A. Flanders Edmondo J. Robinson Gregory W. Ruhnke Larissa Thomas Sunil Kripalani Peter K. Lindenauer Mark V. Williams Joshua P. Metlay Andrew D. Auerbach 《Journal of general internal medicine》2016,31(11):1287-1293
Background
The transition out of the hospital is a vulnerable time for patients, relying heavily on communication and coordination of resources across care settings. Understanding the perspectives of inpatient and outpatient physicians regarding factors contributing to readmission and potential preventive strategies is crucial in designing appropriately targeted readmission prevention efforts.Objective
To examine and compare inpatient and outpatient physician opinions regarding reasons for readmission and interventions that might have prevented readmission.Design
Cross-sectional multicenter study.Participants
We identified patients readmitted to general medicine services within 30 days of discharge at 12 US academic medical centers, and surveyed the primary care physician (PCP), discharging physician from the index admission, and admitting physician from the readmission regarding their endorsement of pre-specified factors contributing to the readmission and potential preventive strategies.Main Measures
We calculated kappa statistics to gauge agreement between physician dyads (PCP-discharging physician, PCP-admitting physician, and admitting-discharging physician).Key Results
We evaluated 993 readmission events, which generated responses from 356 PCPs (36 % of readmissions), 675 discharging physicians (68 % of readmissions), and 737 admitting physicians (74 % of readmissions). The most commonly endorsed contributing factors by both PCPs and inpatient physicians related to patient understanding and ability to self-manage. The most commonly endorsed preventive strategies involved providing patients with enhanced post-discharge instructions and/or support. Although PCPs and inpatient physicians endorsed contributing factors and potential preventive strategies with similar frequencies, agreement among the three physicians on the specific factors and/or strategies that applied to individual readmission events was poor (maximum kappa 0.30).Conclusions
Differing opinions among physicians on factors contributing to individual readmissions highlights the importance of communication between inpatient and outpatient providers at discharge to share their different perspectives, and suggests that multi-faceted, broadly applied interventions may be more successful than those that rely on individual providers choosing specific services based on perceived risk factors.3.
Justin P. Lafreniere Rebeca Rios Hillary Packer Sharon Ghazarian Scott M. Wright Rachel B. Levine 《Journal of general internal medicine》2016,31(2):203-208
Background
Burnout is high among resident physicians and may be associated with suboptimal patient care and reduced empathy.Objective
To investigate the relationship between patient perceptions of empathy and enablement and physician burnout in internal medicine residents.Design
Cross-sectional, survey-based observational study between December 2012 and March 2013 in a resident continuity clinic located within a large urban academic primary care practice in Baltimore, Maryland.Participants
Study participants were 44 PGY1-3 residents and a convenience sample of their English-speaking adult primary care patients (N?=?244).Main Measures
Patients rated their resident physicians using the Consultation and Relational Empathy Measure (CARE) and the Patient Enablement Instrument (PEI). Residents completed the Maslach Burnout Inventory (MBI). We tested for associations between resident burnout and patients’ perceptions of resident empathy (CARE) and enablement (PEI) using multilevel regression analysis.Key Results
Multilevel regression analyses indicated significant positive associations between physician depersonalization scores on the MBI and patient ratings of empathy (B?=?0.28, SE?=?0.17, p?<?0.001) and enablement (B?=?0.11, SE?=?0.11, p?=?0.02). Emotional exhaustion scores on the MBI were not significantly related to either patient outcome.Conclusions
Patients perceived residents who reported higher levels of depersonalization as more empathic and enabling during their patient care encounters. The relationship between physician distress and patient perceptions of care has important implications for medical education and requires further study.4.
Mariposa Garth Alexandra Millet Emily Shearer Sara Stafford Sylvia Bereknyei Merrell Janine Bruce Erika Schillinger Alistair Aaronson David Svec 《Journal of general internal medicine》2018,33(4):487-492
Background
The Association of American Medical Colleges (AAMC) includes the ability to collaborate in an interprofessional team as a core professional activity that trainees should be able to complete on day 1 of residency (Med Sci Educ. 26:797–800, 2016). The training that medical students require in order to achieve this competency, however, is not well established (Med Sci Educ. 26:457–61, 2016), and few studies have examined non-physician healthcare professionals’ perspectives regarding resident physicians’ interprofessional skills.Objective
This study aims to describe non-physicians’ views on barriers to collaboration with physicians, as well as factors that contribute to good collaborative relationships.Participants
Nurses, social workers, case managers, dietitians, rehabilitation therapists, and pharmacists at one academic medical center, largely working in the inpatient setting.Approach
A qualitative study design was employed. Data were collected from individual interviews and focus groups comprising non-physician healthcare professionals.Key Results
Knowledge gaps identified as impeding interprofessional collaboration included inadequate understanding of current roles, potential roles, and processes for non-physician healthcare professionals. Specific physician behaviors that were identified as contributing to good collaborative relationships included mutual support such as backing up other team members and prioritizing multidisciplinary rounds, and communication including keeping team members informed, asking for their input, physicians explaining their rationale, and practicing joint problem-solving with non-physicians.Conclusions
Discussion of how physician trainees can best learn to collaborate as members of an interprofessional team must include non-physician perspectives. Training designed to provide medical students and residents with a better understanding of non-physician roles and to enhance mutual support and communication skills may be critical in achieving the AAMC’s goals of making physicians effective members of interprofessional teams, and thus improving patient-centered care. We hope that medical educators will include these areas identified as important by non-physicians in targeted team training for their learners.5.
Elizabeth A. Jacobs Laura S. Sadowski Paul J. Rathouz 《Journal of general internal medicine》2007,22(2):306-311
BACKGROUND
Many health care providers do not provide adequate language access services for their patients who are limited English-speaking because they view the costs of these services as prohibitive. However, little is known about the costs they might bear because of unaddressed language barriers or the costs of providing language access services.OBJECTIVE
To investigate how language barriers and the provision of enhanced interpreter services impact the costs of a hospital stay.DESIGN
Prospective intervention study.SETTING
Public hospital inpatient medicine service.PARTICIPANTS
Three hundred twenty-three adult inpatients: 124 Spanish-speakers whose physicians had access to the enhanced interpreter intervention, 99 Spanish-speakers whose physicians only had access to usual interpreter services, and 100 English-speakers matched to Spanish-speaking participants on age, gender, and admission firm.MEASUREMENTS
Patient satisfaction, hospital length of stay, number of inpatient consultations and radiology tests conducted in the hospital, adherence with follow-up appointments, use of emergency department (ED) services and hospitalizations in the 3 months after discharge, and the costs associated with provision of the intervention and any resulting change in health care utilization.RESULTS
The enhanced interpreter service intervention did not significantly impact any of the measured outcomes or their associated costs. The cost of the enhanced interpreter service was $234 per Spanish-speaking intervention patient and represented 1.5% of the average hospital cost. Having a Spanish-speaking attending physician significantly increased Spanish-speaking patient satisfaction with physician, overall hospital experience, and reduced ED visits, thereby reducing costs by $92 per Spanish-speaking patient over the study period.CONCLUSION
The enhanced interpreter service intervention did not significantly increase or decrease hospital costs. Physician–patient language concordance reduced return ED visit and costs. Health care providers need to examine all the cost implications of different language access services before they deem them too costly.6.
Richard L. StreetJr Lin Liu Neil J. Farber Yunan Chen Alan Calvitti Nadir Weibel Mark T. Gabuzda Kristin Bell Barbara Gray Steven Rick Shazia Ashfaq Zia Agha 《Journal of general internal medicine》2018,33(4):423-428
Background
Evidence is mixed regarding how physicians' use of the electronic health record (EHR) affects communication in medical encounters.Objective
To investigate whether the different ways physicians interact with the computer (mouse clicks, key strokes, and gaze) vary in their effects on patient participation in the consultation, physicians’ efforts to facilitate patient involvement, and silence.Design
Cross-sectional, observational study of video and event recordings of primary care and specialty consultations.Participants
Thirty-two physicians and 217 patients.Main Measures
Predictor variables included measures of physician interaction with the EHR (mouse clicks, key strokes, gaze). Outcome measures included active patient participation (asking questions, stating preferences, expressing concerns), physician facilitation of patient involvement (partnership-building and supportive talk), and silence.Key Results
Patients were less active participants in consultations in which physicians engaged in more keyboard activity (b?=??0.002, SE?=?0.001, p?=?0.02). More physician gaze at the computer was associated with more silence in the encounter (b?=?0.21, SE?=?0.09, p?=?0.02). Physicians’ facilitative communication, which predicted more active patient participation (b?=?0.65, SE?=?0.14, p?<?0.001), was not related to EHR activity measures.Conclusions
Patients may be more reluctant to actively participate in medical encounters when physicians are more physically engaged with the computer (e.g., keyboard activity) than when their behavior is less demonstrative (e.g., gazing at EHR). Using easy to deploy communication tactics (e.g., asking about a patient’s thoughts and concerns, social conversation) while working on the computer can help physicians engage patients as well as maintain conversational flow.7.
Salvatore Mangione Chayan Chakraborti Giuseppe Staltari Rebecca Harrison Allan R. Tunkel Kevin T. Liou Elizabeth Cerceo Megan Voeller Wendy L. Bedwell Keaton Fletcher Marc J. Kahn 《Journal of general internal medicine》2018,33(5):628-634
Background
Literature, music, theater, and visual arts play an uncertain and limited role in medical education. One of the arguments often advanced in favor of teaching the humanities refers to their capacity to foster traits that not only improve practice, but might also reduce physician burnout—an increasing scourge in today’s medicine. Yet, research remains limited.Objective
To test the hypothesis that medical students with higher exposure to the humanities would report higher levels of positive physician qualities (e.g., wisdom, empathy, self-efficacy, emotional appraisal, spatial skills), while reporting lower levels of negative qualities that are detrimental to physician well-being (e.g., intolerance of ambiguity, physical fatigue, emotional exhaustion, and cognitive weariness).Design
An online survey.Participants
All students enrolled at five U.S. medical schools during the 2014–2015 academic year were invited by email to take part in our online survey.Main Measures
Students reported their exposure to the humanities (e.g., music, literature, theater, visual arts) and completed rating scales measuring selected personal qualities.Key Results
In all, 739/3107 medical students completed the survey (23.8%). Regression analyses revealed that exposure to the humanities was significantly correlated with positive personal qualities, including empathy (p?<?0.001), tolerance for ambiguity (p?<?0.001), wisdom (p?<?0.001), emotional appraisal (p?=?0.01), self-efficacy (p?=?0.02), and spatial skills (p?=?0.02), while it was significantly and inversely correlated with some components of burnout (p?=?0.01). Thus, all hypotheses were statistically significant, with effect sizes ranging from 0.2 to 0.59.Conclusions
This study confirms the association between exposure to the humanities and both a higher level of students’ positive qualities and a lower level of adverse traits. These findings may carry implications for medical school recruitment and curriculum design.“[Science and humanities are] twin berries on one stem, grievous damage has been done to both in regarding [them]... in any other light than complemental.” (William Osler, Br Med J. 1919;2:1–7).8.
Christina Nicolaidis Dora Raymaker Katherine McDonald Steven Kapp Michael Weiner Martha Gerrity Clarissa Kripke Laura Platt Amelia Baggs 《Journal of general internal medicine》2016,31(10):1180-1189
Background
The healthcare system is ill-equipped to meet the needs of adults on the autism spectrum.Objective
Our goal was to use a community-based participatory research (CBPR) approach to develop and evaluate tools to facilitate the primary healthcare of autistic adults.Design
Toolkit development included cognitive interviewing and test–retest reliability studies. Evaluation consisted of a mixed-methods, single-arm pre/post-intervention comparison.Participants
A total of 259 autistic adults and 51 primary care providers (PCPs) residing in the United States.Interventions
The AASPIRE Healthcare toolkit includes the Autism Healthcare Accommodations Tool (AHAT)—a tool that allows patients to create a personalized accommodations report for their PCP—and general healthcare- and autism-related information, worksheets, checklists, and resources for patients and healthcare providers.Main Measures
Satisfaction with patient–provider communication, healthcare self-efficacy, barriers to healthcare, and satisfaction with the toolkit’s usability and utility; responses to open-ended questions.Key Results
Preliminary testing of the AHAT demonstrated strong content validity and adequate test–retest stability. Almost all patient participants (>94 %) felt that the AHAT and the toolkit were easy to use, important, and useful. In pre/post-intervention comparisons, the mean number of barriers decreased (from 4.07 to 2.82, p?<?0.0001), healthcare self-efficacy increased (from 37.9 to 39.4, p?=?0.02), and satisfaction with PCP communication improved (from 30.9 to 32.6, p?=?0.03). Patients stated that the toolkit helped clarify their needs, enabled them to self-advocate and prepare for visits more effectively, and positively influenced provider behavior. Most of the PCPs surveyed read the AHAT (97 %), rated it as moderately or very useful (82 %), and would recommend it to other patients (87 %).Conclusions
The CBPR process resulted in a reliable healthcare accommodation tool and a highly accessible healthcare toolkit. Patients and providers indicated that the tools positively impacted healthcare interactions. The toolkit has the potential to reduce barriers to healthcare and improve healthcare self-efficacy and patient–provider communication.9.
Liselotte N. Dyrbye Daniel Satele Jeff Sloan Tait D. Shanafelt 《Journal of general internal medicine》2013,28(3):421-427
BACKGROUND
Despite a high prevalence of distress, few physicians seek help. Earlier identification of physicians in distress has been hampered by the lack of a brief screening instrument to assess the common forms of distress.OBJECTIVE
To evaluate the ability of the seven-item Physician Well-Being Index (PWBI) to i) stratify physician well-being in several important dimensions (mental quality of life [QOL], fatigue, suicidal ideation); and ii) identify physicians whose degree of distress may negatively impact their practice (career satisfaction, intent to leave current position, medical errors).DESIGN
Cross-sectional study.PARTICIPANTS
National sample of 6,994 U.S. physicians.MAIN MEASURES
PWBI, Mental QOL, fatigue, suicidal ideation, career satisfaction,and clinical practice measures.KEY RESULTS
Physicians with low mental QOL, high fatigue, or recent (< 12 months) suicidal ideation were more likely to endorse each of the seven PWBI items and a greater number of total items (all P?< 0?.001). Assuming a prevalence of 19 %, the PWBI could reduce the post-test probability of a physician having low mental QOL to < 1 % or raise it to > 75 %. The likelihood ratio for low mental QOL among physicians with PWBI scores ≥ 4 was 3.85 in comparison to 0.33 for those with scores < 4. At a threshold score of >4, the PWBI’s specificity for identifying physicians with low mental QOL, high fatigue, or recent suicidal ideation were 85.8 %. PWBI score also stratified physicians’ career satisfaction, reported intent to leave current practice, and self-reported medical errors.CONCLUSIONS
The seven-item PWBI appears to be a useful screening index to identify physicians with distress in a variety of dimensions and whose degree of distress may negatively impact their practice.10.
Francesca Gany Jennifer Leng Ephraim Shapiro David Abramson Ivette Motola David C. Shield Jyotsna Changrani 《Journal of general internal medicine》2007,22(2):312-318
Background
Growth of the foreign-born population in the U.S. has led to increasing numbers of limited-English-proficient (LEP) patients. Innovative medical interpreting strategies, including remote simultaneous medical interpreting (RSMI), have arisen to address the language barrier. This study evaluates the impact of interpreting method on patient satisfaction.Methods
1,276 English-, Spanish-, Mandarin-, and Cantonese-speaking patients attending the primary care clinic and emergency department of a large New York City municipal hospital were screened for enrollment in a randomized controlled trial. Language-discordant patients were randomized to RSMI or usual and customary (U&C) interpreting. Patients with language-concordant providers received usual care. Demographic and patient satisfaction questionnaires were administered to all participants.Results
541 patients were language-concordant with their providers and not randomized; 371 were randomized to RSMI, 167 of whom were exposed to RSMI; and 364 were randomized to U&C, 198 of whom were exposed to U&C. Patients randomized to RSMI were more likely than those with U&C to think doctors treated them with respect (RSMI 71%, U&C 64%, p?<?0.05), but they did not differ in other measures of physician communication/care. In a linear regression analysis, exposure to RSMI was significantly associated with an increase in overall satisfaction with physician communication/care (β 0.10, 95% CI 0.02–0.18, scale 0–1.0). Patients randomized to RSMI were more likely to think the interpreting method protected their privacy (RSMI 51%, U&C 38%, p?<?0.05). Patients randomized to either arm of interpretation reported less comprehension and satisfaction than patients in language-concordant encounters.Conclusions
While not a substitute for language-concordant providers, RSMI can improve patient satisfaction and privacy among LEP patients. Implementing RSMI should be considered an important component of a multipronged approach to addressing language barriers in health care.11.
Quyen Ngo-Metzger Dara H. Sorkin Russell S. Phillips Sheldon Greenfield Michael P. Massagli Brian Clarridge Sherrie H. Kaplan 《Journal of general internal medicine》2007,22(2):324-330
Background
Provider–patient language discordance is related to worse quality care for limited English proficient (LEP) patients who speak Spanish. However, little is known about language barriers among LEP Asian-American patients.Objective
We examined the effects of language discordance on the degree of health education and the quality of interpersonal care that patients received, and examined its effect on patient satisfaction. We also evaluated how the presence/absence of a clinic interpreter affected these outcomes.Design
Cross-sectional survey, response rate 74%.Participants
A total of 2,746 Chinese and Vietnamese patients receiving care at 11 health centers in 8 cities.Measurements
Provider–patient language concordance, health education received, quality of interpersonal care, patient ratings of providers, and the presence/absence of a clinic interpreter. Regression analyses were used to adjust for potential confounding.Results
Patients with language-discordant providers reported receiving less health education (β?=?0.17, p?<?0.05) compared to those with language-concordant providers. This effect was mitigated with the use of a clinic interpreter. Patients with language-discordant providers also reported worse interpersonal care (β?=?0.28, p?<?0.05), and were more likely to give low ratings to their providers (odds ratio [OR]?=?1.61; CI?=?0.97–2.67). Using a clinic interpreter did not mitigate these effects and in fact exacerbated disparities in patients’ perceptions of their providers.Conclusion
Language barriers are associated with less health education, worse interpersonal care, and lower patient satisfaction. Having access to a clinic interpreter can facilitate the transmission of health education. However, in terms of patients’ ratings of their providers and the quality of interpersonal care, having an interpreter present does not serve as a substitute for language concordance between patient and provider.12.
Adam Wright Skye Aaron Diane L. Seger Lipika Samal Gordon D. Schiff David W. Bates 《Journal of general internal medicine》2018,33(11):1868-1876
Background
Drug-drug interaction (DDI) alerts in electronic health records (EHRs) can help prevent adverse drug events, but such alerts are frequently overridden, raising concerns about their clinical usefulness and contribution to alert fatigue.Objective
To study the effect of conversion to a commercial EHR on DDI alert and acceptance rates.Design
Two before-and-after studies.Participants
3277 clinicians who received a DDI alert in the outpatient setting.Intervention
Introduction of a new, commercial EHR and subsequent adjustment of DDI alerting criteria.Main Measures
Alert burden and proportion of alerts accepted.Key Results
Overall interruptive DDI alert burden increased by a factor of 6 from the legacy EHR to the commercial EHR. The acceptance rate for the most severe alerts fell from 100 to 8.4%, and from 29.3 to 7.5% for medium severity alerts (P?<?0.001). After disabling the least severe alerts, total DDI alert burden fell by 50.5%, and acceptance of Tier 1 alerts rose from 9.1 to 12.7% (P?<?0.01).Conclusions
Changing from a highly tailored DDI alerting system to a more general one as part of an EHR conversion decreased acceptance of DDI alerts and increased alert burden on users. The decrease in acceptance rates cannot be fully explained by differences in the clinical knowledge base, nor can it be fully explained by alert fatigue associated with increased alert burden. Instead, workflow factors probably predominate, including timing of alerts in the prescribing process, lack of differentiation of more and less severe alerts, and features of how users interact with alerts.13.
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15.
David A. Haggstrom Paul Helft Ingrid Oakley-Girvan 《Journal of general internal medicine》2009,24(2):472
Background
The Institute of Medicine has identified patients as a key source of information for assessing the quality of care.Objective
To evaluate the association of physician specialty with the content and quality of follow-up cancer care.Design and Participants
Three hundred three colorectal cancer (CRC) survivors in Northern California were surveyed 2–5 years post-diagnosis.Measurements
Specialty of physician seen most often [primary care physician (PCP), oncologist, surgeon, or gastroenterologist]; other physician specialties seen; patient characteristics; content of visits; patient-centered quality of follow-up care (communication, coordination, nursing, and staff interactions).Main Results
A minority (16%) of CRC survivors reported that the doctor they most often saw for follow-up cancer care was a PCP, while 60% saw an oncologist. Many CRC survivors (40%) saw >1 physician for follow-up cancer care. Survivors most often seen by PCPs were more likely to have three or more medical comorbidities (70% vs. 51%, p?=?0.012) than survivors seen by subspecialty physicians. Survivors seen by PCPs were less likely to report seeing a doctor for medical tests and more likely to report discussing disease prevention (82% vs. 64%, p?=?0.012) or diet (70% vs. 48%, p?=?0.005) with their doctor. There were no significant specialty differences in patient-centered quality of follow-up cancer care.Conclusions
Cancer survivors’ assessment of the quality of care was similar across specialties, while the content of follow-up cancer care varied by physician specialty. These findings provide important information about the potential value of primary care and the need for coordination when delivering care to CRC survivors.16.
Teo Soleymani Soumya M. Reddy Jeffrey M. Cohen Andrea L. Neimann 《Current rheumatology reports》2018,20(1):1
Purpose of Review
Diagnosis and treatment of psoriatic arthritis (PsA) can be challenging and require a multidisciplinary approach. This review provides an overview of combined dermatology–rheumatology clinics.Recent Findings
Combined dermatology–rheumatology clinics have emerged to optimize integrated care for patients with psoriasis and PsA. There are over 20 such clinics across the USA. These clinics facilitate multidisciplinary care for patients with psoriasis and PsA and have been found to improve outcomes and enhance both patient and physician satisfaction and knowledge. Challenges presented by these clinics include appropriate scheduling for both dermatologists and rheumatologists and proving the benefits of the clinics to obtain institutional support.Summary
Combined dermatology–rheumatology clinics are a novel model of care for patients with psoriasis and PsA. They improve outcomes, patient and physician satisfaction, and efficiency. As more of these clinics are established, we must further understand their impact on outcomes and care processes.17.
Judith K. Ockene Rashelle B. Hayes Linda C. Churchill Sybil L. Crawford Denise G. Jolicoeur David M. Murray Abigail B. Shoben Sean P. David Kristi J. Ferguson Kathryn N. Huggett Michael Adams Catherine A. Okuliar Robin L. Gross Pat F. BassIII Ruth B. Greenberg Frank T. Leone Kola S. Okuyemi David W. Rudy Jonathan B. Waugh Alan C. Geller 《Journal of general internal medicine》2016,31(2):172-181
Background
Early in medical education, physicians must develop competencies needed for tobacco dependence treatment.Objective
To assess the effect of a multi-modal tobacco dependence treatment curriculum on medical students’ counseling skills.Design
A group-randomized controlled trial (2010–2014) included ten U.S. medical schools that were randomized to receive either multi-modal tobacco treatment education (MME) or traditional tobacco treatment education (TE).Setting/Participants
Students from the classes of 2012 and 2014 at ten medical schools participated. Students from the class of 2012 (N?=?1345) completed objective structured clinical examinations (OSCEs), and 50 % (N?=?660) were randomly selected for pre-intervention evaluation. A total of 72.9 % of eligible students (N?=?1096) from the class of 2014 completed an OSCE and 69.7 % (N?=?1047) completed pre and post surveys.Interventions
The MME included a Web-based course, a role-play classroom demonstration, and a clerkship booster session. Clerkship preceptors in MME schools participated in an academic detailing module and were encouraged to be role models for third-year students.Measurements
The primary outcome was student tobacco treatment skills using the 5As measured by an objective structured clinical examination (OSCE) scored on a 33-item behavior checklist. Secondary outcomes were student self-reported skills for performing 5As and pharmacotherapy counseling.Results
Although the difference was not statistically significant, MME students completed more tobacco counseling behaviors on the OSCE checklist (mean 8.7 [SE 0.6] vs. mean?8.0 [SE 0.6], p?=?0.52) than TE students. Several of the individual Assist and Arrange items were significantly more likely to have been completed by MME students, including suggesting behavioral strategies (11.8 % vs. 4.5 %, p?<?0.001) and providing information regarding quitline (21.0 % vs. 3.8 %, p?<?0.001). MME students reported higher self-efficacy for Assist, Arrange, and Pharmacotherapy counseling items (ps?≤0.05).Limitations
Inclusion of only ten schools limits generalizability.Conclusions
Subsequent interventions should incorporate lessons learned from this first randomized controlled trial of a multi-modal longitudinal tobacco treatment curriculum in multiple U.S. medical schools.NIH Trial Registry Number: NCT0190561818.
Gail L. Rose Gary J. Badger Joan M. Skelly Tonya A. Ferraro Charles D. MacLean John E. Helzer 《Journal of general internal medicine》2016,31(9):996-1003
BACKGROUND
Brief interventions for unhealthy drinking in primary care settings are efficacious, but underutilized. Efforts to improve rates of brief intervention though provider education and office systems redesign have had limited impact. Our novel brief intervention uses interactive voice response (IVR) to provide information and advice directly to unhealthy drinkers before a physician office visit, with the goals of stimulating in-office dialogue about drinking and decreasing unhealthy drinking. This automated approach is potentially scalable for wide application.OBJECTIVE
We aimed to examine the effect of a pre-visit IVR-delivered brief alcohol intervention (IVR-BI) on patient–provider discussions of alcohol during the visit.DESIGN
This was a parallel group randomized controlled trial with two treatment arms: 1) IVR-BI or 2) usual care (no IVR-BI).PARTICIPANTS
In all, 1,567 patients were recruited from eight university medical center-affiliated internal medicine and family medicine clinics.INTERVENTIONS
IVR-BI is a brief alcohol intervention delivered by automated telephone. It has four components, based on the intervention steps outlined in the National Institute of Alcohol Abuse and Alcoholism guidelines for clinicians: 1) ask about alcohol use, 2) assess for alcohol use disorders, 3) advise patient to cut down or quit drinking, and 4) follow up at subsequent visits.MAIN MEASURES
Outcomes were patient reported: patient–provider discussion of alcohol during the visit; patient initiation of the discussion; and provider’s recommendation about the patient’s alcohol use.KEY RESULTS
Patients randomized to IVR-BI were more likely to have reported discussing alcohol with their provider (52 % vs. 44 %, p?=?0.003), bringing up the topic themselves (20 % vs. 12 %, p?<?0.001), and receiving a recommendation (20 % vs. 14 %, p?<?0.001). Other predictors of outcome included baseline consumption, education, age, and alcohol use disorder diagnosis.CONCLUSIONS
Providing automated brief interventions to patients prior to a primary care visit promotes discussion about unhealthy drinking and increases specific professional advice regarding changing drinking behavior.19.
Jennifer L. Wolff Debra L. Roter Cynthia M. Boyd David L. Roth Diane M. Echavarria Jennifer Aufill Judith B. Vick Laura N. Gitlin 《Journal of general internal medicine》2018,33(9):1478-1486
Background
Establishing priorities for discussion during time-limited primary care visits is challenging in the care of patients with cognitive impairment. These patients commonly attend primary care visits with a family companion.Objective
To examine whether a patient–family agenda setting intervention improves primary care visit communication for patients with cognitive impairmentDesign
Two-group pilot randomized controlled studyParticipants
Patients aged 65?+ with cognitive impairment and family companions (n?=?93 dyads) and clinicians (n?=?14) from two general and one geriatrics primary care clinicIntervention
A self-administered paper-pencil checklist to clarify the role of the companion and establish a shared visit agendaMeasurements
Patient-centered communication (primary); verbal activity, information disclosure including discussion of memory, and visit duration (secondary), from audio recordings of visit discussionResults
Dyads were randomized to usual care (n?=?44) or intervention (n?=?49). Intervention participants endorsed an active communication role for companions to help patients understand what the clinician says or means (90% of dyads), remind patients to ask questions or ask clinicians questions directly (84% of dyads), or listen and take notes (82% of dyads). Intervention dyads identified 4.4 health issues for the agenda on average: patients more often identified memory (59.2 versus 38.8%; p?=?0.012) and mood (42.9 versus 24.5%; p?=?0.013) whereas companions more often identified safety (36.7 versus 18.4%; p?=?0.039) and personality/behavior change (32.7 versus 16.3%; p?=?0.011). Communication was significantly more patient-centered in intervention than in control visits at general clinics (p?<?0.001) and in pooled analyses (ratio of 0.86 versus 0.68; p?=?0.046). At general clinics, intervention (versus control) dyads contributed more lifestyle and psychosocial talk (p?<?0.001) and less biomedical talk (p?<?0.001) and companions were more verbally active (p?<?0.005). No intervention effects were found at the geriatrics clinic. No effect on memory discussions or visit duration was observed.Conclusion
Patient–family agenda setting may improve primary care visit communication for patients with cognitive impairment.Trial Registration
ClinicalTrials.gov: NCT0298695820.