Lessons from Detecting Cognitive Impairment Including Dementia (DetectCID) in Primary Care.

BACKGROUND: Cognitive impairment, including dementia, is frequently under-detected in primary care. The Consortium for Detecting Cognitive Impairment, including Dementia (DetectCID) convenes three multidisciplinary teams that are testing novel paradigms to improve the frequency and quality of patient evaluations for detecting cognitive impairment in primary care and appropriate follow-up. OBJECTIVE: Our objective was to characterize the three paradigms, including similarities and differences, and to identify common key lessons from implementation. METHODS: A qualitative evaluation study with dementia specialists who were implementing the detection paradigms. Data was analyzed using content analysis. RESULTS: We identified core components of each paradigm. Key lessons emphasized the importance of engaging primary care teams, enabling primary care providers to diagnose cognitive disorders and provide ongoing care support, integrating with the electronic health record, and ensuring that paradigms address the needs of diverse populations. CONCLUSION: Approaches are needed that address the arc of care from identifying a concern to post-diagnostic management, are efficient and adaptable to primary care workflows, and address a diverse aging population. Our work highlights approaches to partnering with primary care that could be useful across specialties and paves the way for developing future paradigms that improve differential diagnosis of symptomatic cognitive impairment, identifying not only its presence but also its specific syndrome or etiology.

A comparison of two methods of teaching reflective ability in Year 3 medical students.

CONTEXT: Little is known about best practices for teaching and learning reflection. We hypothesised that reflective ability scores on written reflections would be higher in students using critical reflection guidelines, or receiving feedback on reflective skill in addition to reflection content, or both, compared with those in students who received only a definition of reflection or feedback on reflection content alone. METHODS: Using a 2 (guidelines) × 2 (feedback) × 2 (time) design, we randomly assigned half of our sample of 149 Year 3 medical students to receive critical reflection guidelines and the other half to receive only a definition of critical reflection. We then randomly divided both groups in half again so that one half of each group received feedback on both the content and reflective ability in their reflections, and the other received content feedback alone. The learners' performance was measured on the first and third written reflections of the academic year using a previously validated scoring rubric. We calculated descriptive statistics for the reflection scores and conducted a repeated-measures analysis of variance with two between-groups factors, guidelines and feedback, and one within-group factor, occasion, using the measure of reflective ability as the dependent variable. RESULTS: We failed to find a significant interaction between guidelines and feedback (F = 0.51, d.f. = 1, 145, p = 0.48). However, the provision of critical reflection guidelines improved reflective ability compared with the provision of a definition of critical reflection only (F = 147.1, d.f. = 1, 145, p < 0.001). Feedback also improved reflective ability, but only when it covered reflective skill in addition to content (F = 6.5, d.f. = 1, 145, p = 0.012). CONCLUSIONS: We found that the provision of critical reflection guidelines improved performance and that feedback on both content and reflective ability also improved performance. Our study demonstrates that teaching learners the characteristics of deeper, more effective reflection and helping them to acquire the skills they need to reflect well improves their reflective ability as measured by performance on reflective exercises.

Medical assistants: the invisible "glue" of primary health care practices in the United States?

PURPOSE: Little attention has been given to the field of medical assisting in US health services to date. To explore the roles medical assistants (MAs) currently play in primary care settings, the paper aims to focus on the work scope and dynamics of these increasingly common healthcare personnel. DESIGN/METHODOLOGY/APPROACH: This is a multiple step, mixed methods study, combining a quantitative survey and qualitative semi-structured interviews: eight experts in the field of medical assisting; 12 MAs from diverse primary care practice settings in Northern California. FINDINGS: Survey results revealed great variation in the breadth of tasks that MAs performed. Five overarching themes describe the experience of medical assistants in primary care settings: ensuring patient flow and acting as a patient liaison, "making a difference"; diversity within the occupation and work relationships. RESEARCH IMPLICATIONS/LIMITATIONS: As the number of medical assistants working in primary care practices in the United States increases, more attention must be paid to how best to deploy this allied health workforce. This study suggests that MAs have an expertise in maintaining efficient clinic flow and promoting patient satisfaction. Future recommendations for changes in MA roles must address the diversity within this occupation in terms of workscope and quality assurance as well as MA relationships with other members of ambulatory care teams. ORIGINALITY/VALUE: This is the first study to explore perspectives of medical assistants in the USA. As this is a largely unregulated and understudied field, a qualitative study allowed the exploration of major themes in medical assisting and the establishment of a framework from which further study can occur.

A professional development course for the clinical clerkships: developing a student-centered curriculum.

INTRODUCTION: Although professional development is addressed throughout the medical school curriculum, it is particularly salient to third-year students as they become integral members of health care teams. AIM: We present a professional development curriculum for third-year medical students. SETTING: Urban medical school. PROGRAM DESCRIPTION: In 2005, our curriculum consisted of 3 large group panels, each followed by a small group, occurring after the first, third, and last clerkship. Before each small group, students prepared critical incident reports, which led to focused group reflection. The individual topics were, respectively: (1) transition to clerkship learning; (2) challenges to professional behavior; and (3) medical errors. In 2006, based on student feedback, we piloted a revised student-centered panel on professionalism that was based entirely on themes from students' critical incident reports. PROGRAM EVALUATION: Students rated the curriculum well overall. In 2005-2006, the small groups ranged from 3.95 to 3.98 (SD 0.88) on a 5-point Likert scale (1 = poor, 5 = excellent) and the panels ranged from 3.54 to 4.41 (SD 0.9). The pilot panel in 2006 was rated 4.38 (SD 0.80). The most common professionalism themes generated from 185 critical incident reports were communication, compassionate patient care, accountability, and team collaboration. DISCUSSION: A professional development curriculum, consisting of panels, small groups, and critical incident reports, can promote reflection among third-year medical students.

Complementary and alternative medicine for menopause: a qualitative analysis of women's decision making.

BACKGROUND: While almost half of women use complementary and alternative medicine (CAM) during their menopause, almost no literature explores why women choose CAM for menopausal symptoms. Clinician-patient conversations about CAM can be unsatisfactory, and exploration of women's choices may benefit communication. OBJECTIVE: The objective of this study was to describe women's choices to use CAM for menopausal health issues. DESIGN: This is a qualitative study utilizing semi-structured interviews. PARTICIPANTS: Convenience sample of 44 menopausal women ages 45 to 60 recruited in two primary care clinics. Both users and non-users of CAM were included. APPROACH: Transcripts of semi-structured interviews were analyzed for themes that were refined through comparison of labeled text. MAIN RESULTS: Four themes emerged in decisions to use CAM: (1) valuing CAM as "natural", although the meaning of "natural" varied greatly, (2) perceiving menopause as marking a change in life stage, (3) seeking information about menopause generated from personal intuition and other women's experiences, and (4) describing experiences before menopause of using CAM and allopathic medication in patterns similar to current use (patterned responses). CONCLUSION: Women's decisions about using CAM during menopause can be understood through their perspectives on menopause and overall health. Increased clinician awareness of these themes may promote supportive discussions about CAM during counseling for menopause.

Do required preclinical courses with family physicians encourage interest in family medicine?

BACKGROUND: Many medical schools, including the University of California, San Francisco (UCSF), added required preclinical course work with family physicians in the 1990s. We examined whether current UCSF students interested in family medicine noted more contact with family physicians and more faculty support of their interest than current Stanford students and 1993 UCSF students, neither of whom had required preclinical course work with family physicians. METHODS: A questionnaire was administered to students interested in family medicine at UCSF and Stanford in February 2001, with response rates of 84% and 90%, respectively. Previously published 1993 data from UCSF were also used for comparison. Data were analyzed using chi-square and t statistics as appropriate. RESULTS: UCSF students in 2001, despite exposure to required preclinical course work with family physicians, did not perceive greater contact with family physicians than Stanford students. Stanford students perceived greater encouragement from their family medicine faculty but less from faculty overall, compared with 2001 UCSF students. UCSF students in 2001 perceived no more overall faculty encouragement than did UCSF students in 1993. CONCLUSIONS: Required preclinical course work with family physicians was not consistently associated with greater student perception of faculty support for students' interest in family medicine, nor was it demonstrated to increase the amount or quality of interested students' interaction with family medicine faculty.