A Comparative Case Study Analysis of Cultural Competence Training at 15 U.S. Medical Schools.

PURPOSE: Twenty years have passed since the Liaison Committee on Medical Education (LCME) mandated cultural competence training at U.S. medical schools. There remain multiple challenges to implementation of this training, including curricular constraints, varying interpretations of cultural competence, and evidence supporting the efficacy of such training. This study explored how medical schools have worked to implement cultural competence training. METHOD: Fifteen regionally diverse public and private U.S. medical schools participated in the study. In 2012-2014, the authors conducted 125 interviews with 52 administrators, 51 faculty or staff members, and 22 third- and fourth-year medical students, along with 29 focus groups with an additional 196 medical students. Interviews were recorded, transcribed, and imported into NVivo 10 software for qualitative data analysis. Queries captured topics related to students' preparedness to work with diverse patients, engagement with sociocultural issues, and general perception of preclinical and clinical curricula. RESULTS: Three thematic areas emerged regarding cultural competence training: formal curriculum, conditions of teaching, and institutional commitment. At the formal curricular level, schools offered a range of courses collectively emphasizing communication skills, patient-centered care, and community-based projects. Conditions of teaching emphasized integration of cultural competence into the preclinical years and reflection on the delivery of content. At the institutional level, commitment to institutional diversity, development of programs, and degree of prioritization of cultural competence varied. CONCLUSIONS: There is variation in how medical schools approach cultural competence. Among the 15 participating schools, longitudinal and experiential learning emerged as important, highlighting the needs beyond mere integration of cultural competence content into the formal curriculum. To determine efficacy of cultural competence programming, it is critical to conduct systematic assessment to identify and address gaps. While LCME standards have transformed aspects of medical education, further research is needed to clarify evidence-based, effective approaches to this training.

Racial/Gender Biases in Student Clinical Decision-Making: a Mixed-Method Study of Medical School Attributes Associated with Lower Incidence of Biases.

BACKGROUND: Accumulating evidence suggests that clinician racial/gender decision-making biases in some instances contribute to health disparities. Previous work has produced evidence of such biases in medical students. OBJECTIVE: To identify contextual attributes in medical schools associated on average with low levels of racial/gender clinical decision-making biases. DESIGN: A mixed-method design using comparison case studies of 15 medical schools selected based on results of a previous survey of student decision-making bias: 7 schools whose students collectively had, and 8 schools whose students had not shown evidence of such biases. PARTICIPANTS: Purposively sampled faculty, staff, underrepresented minority medical students, and clinical-level medical students at each school. MAIN MEASURES: Quantitative descriptive data and qualitative interview and focus group data assessing 32 school attributes theorized in the literature to be associated with formation of decision-making and biases. We used a mixed-method analytic design with standard qualitative analysis and fuzzy set qualitative comparative analysis. KEY RESULTS: Across the 15 schools, a total of 104 faculty, administrators and staff and 21 students participated in individual interviews, and 196 students participated in 29 focus groups. While no single attribute or group of attributes distinguished the two clusters of schools, analysis showed some contextual attributes were seen more commonly in schools whose students had not demonstrated biases: longitudinal reflective small group sessions; non-accusatory approach to training in diversity; longitudinal, integrated diversity curriculum; admissions priorities and action steps toward a diverse student body; and school service orientation to the community. CONCLUSIONS: We identified several potentially modifiable elements of the training environment that are more common in schools whose students do not show evidence of racial and gender biases.

Successful Utilization of Mechanical Thrombectomy in a Presentation of Pediatric Acute Ischemic Stroke.

Guidelines regarding the management of acute ischemic stroke (AIS) in the pediatric population using mechanical recanalization procedures are lacking. We present a case of a 14-year-old male diagnosed in the Emergency Department with an acute onset stroke who underwent successful mechanical clot removal by interventional radiology.

Moving Away from the Tip of the Pyramid: Screening and Brief Intervention for Risky Alcohol and Opioid Use in Underserved Patients.

PURPOSE: Rates of risky substance use and substance use disorders are high in primary-care practices, yet the adoption of universal screening and brief intervention (SBI) has been slow and uneven. This study aimed to describe SBI-related attitudes, practices, and perspectives regarding practice change among medical providers in a minority-majority state. METHODS: We conducted a cross-sectional, on-line survey of a practice-based research network of medical providers serving predominantly Hispanic/Latinx and Native American patients in rural and urban settings. The main variables were clinician 1) perspectives on the need to address substance use problems in primary care, 2) current screening and intervention practices, and 3) satisfaction with and willingness to make changes to their practices. RESULTS: Although providers endorsed alcohol and opiate misuse to be significant problems in their practices, only 25% conducted universal screening. Providers reported focusing most of their screening efforts on those with substance use dependence. In general, providers rated importance of and ability to make practice changes moderately high. There was high interest in practice coordination with the community followed by interest in a collaborative care approach. CONCLUSIONS: Providers mainly focus efforts on the relatively few patients at the tip of the pyramid (substance use dependence) rather than on the majority of patients who comprise the middle of the pyramid (risky substance use). Practice change strategies are needed to increase universal screening with a focus on risky substance use, particularly in practices serving racial/ethnic communities.

Costs and inconsistencies in US IRB review of low-risk medical education research.

CONTEXT: Advances in communication technologies over the last two decades have transformed the way medical education research is conducted, creating opportunities for multi-institution national and international studies. Although these studies enable researchers to gain broader understandings of educational processes across institutions, they increase the need for multiple institutional review board (IRB) reviews to ensure the protection of human subjects. OBJECTIVES: This study describes the process of obtaining multiple IRB approvals of the same protocol for a multi-site, low-risk, medical education research project in the USA. The burden of obtaining those reviews and their consistency are assessed. The associated time and costs, and implications for the research process are detailed. METHODS: Following review by the investigators' parent institution IRB, the project team circulated a uniform protocol for conduct of a low-risk, medical education survey to the IRBs of 89 US medical schools for review. The processes and time required to obtain approvals were recorded to estimate associated research team personnel costs. RESULTS: Approval could not be obtained from five IRBs as a result of insurmountable procedural barriers. A total of 67 IRBs eventually deferred to the parent IRB determination. The remaining IRBs required a variety of additional procedural processes before ultimately agreeing with the original determination. The personnel costs associated with obtaining the 84 approvals amounted to US$121,344. CONCLUSIONS: Considering the value of multi-site designs to address a range of research questions, enhance participant diversity and develop representative findings, solutions must be found to counter inefficiencies of current IRB review processes for low-risk research, such as that usually conducted in medical education. Although we acknowledge that local review is an essential protective measure for research involving identifiable communities that are uniquely susceptible to social or economic harm, this report suggests that proposals to modernise and streamline IRB review processes for low-risk research are timely and relevant.

Racial, gender, and socioeconomic status bias in senior medical student clinical decision-making: a national survey.

BACKGROUND: Research suggests stereotyping by clinicians as one contributor to racial and gender-based health disparities. It is necessary to understand the origins of such biases before interventions can be developed to eliminate them. As a first step toward this understanding, we tested for the presence of bias in senior medical students. OBJECTIVE: The purpose of the study was to determine whether bias based on race, gender, or socioeconomic status influenced clinical decision-making among medical students. DESIGN: We surveyed seniors at 84 medical schools, who were required to choose between two clinically equivalent management options for a set of cardiac patient vignettes. We examined variations in student recommendations based on patient race, gender, and socioeconomic status. PARTICIPANTS: The study included senior medical students. MAIN MEASURES: We investigated the percentage of students selecting cardiac procedural options for vignette patients, analyzed by patient race, gender, and socioeconomic status. KEY RESULTS: Among 4,603 returned surveys, we found no evidence in the overall sample supporting racial or gender bias in student clinical decision-making. Students were slightly more likely to recommend cardiac procedural options for black (43.9 %) vs. white (42 %, p = .03) patients; there was no difference by patient gender. Patient socioeconomic status was the strongest predictor of student recommendations, with patients described as having the highest socioeconomic status most likely to receive procedural care recommendations (50.3 % vs. 43.2 % for those in the lowest socioeconomic status group, p < .001). Analysis by subgroup, however, showed significant regional geographic variation in the influence of patient race and gender on decision-making. Multilevel analysis showed that white female patients were least likely to receive procedural recommendations. CONCLUSIONS: In the sample as a whole, we found no evidence of racial or gender bias in student clinical decision-making. However, we did find evidence of bias with regard to the influence of patient socioeconomic status, geographic variations, and the influence of interactions between patient race and gender on student recommendations.

Student specialty plans, clinical decision making, and health care reform.

BACKGROUND AND OBJECTIVES: Health care reform aims to increase evidence-based, cost-conscious, and patient-centered care. Family medicine is seen as central to these aims in part due to evidence of lower cost and comparable quality care compared with other specialties. We sought evidence that senior medical students planning family medicine residency differ from peers entering other fields in decision-making patterns relevant to these health care reform aims. METHODS: We conducted a national, anonymous, internet-based survey of senior medical students. Students chose one of two equivalent management options for a set of patient vignettes based on preventive care, medication selection, or initial chronic disease management scenarios, representing in turn evidence-based care, cost-conscious care, and patient-centered care. We examined differences in student recommendations, comparing those planning to enter family medicine with all others using bivariate and weighted, multilevel, multivariable analyses. RESULTS: Among 4,656 surveys received from seniors at 84 participating medical schools, students entering family medicine were significantly more likely to recommend patient management options that were more cost conscious and more patient centered. We did not find a significant difference between the student groups in recommendations for evidence-based care vignettes. CONCLUSIONS: This study provides preliminary evidence suggesting that students planning to enter family medicine may already have clinical decision-making patterns that support health care reform goals to a greater extent than their peers. If confirmed by additional studies, this could have implications for medical school admission and training processes.

Cultivating a cycle of trust with diverse communities in practice-based research: a report from PRIME Net.

PURPOSE: Practice-based research networks (PBRNs) are increasingly seen as important vehicles to translate research into practice, although less is known about the process of engaging diverse communities in PBRN research. The objective of this study was to identify strategies for successfully recruiting and retaining diverse racial/ethnic communities into PBRN research studies. METHODS: This collaborative, multisite study engaged 5 of the 8 networks of the PRImary care MultiEthnic Network (PRIME Net) consortium that conducts research with traditionally underrepresented/underserved populations. We used a sequential, qualitative research design. We first conducted 1 key informant interview with each of 24 researchers experienced in recruiting research participants from 5 racial/ethnic communities (African American, Arab/Chaldean, Chinese, Hispanic, and Native American). Subsequently, we conducted 18 focus groups with 172 persons from these communities. RESULTS: Participants' comments indicated that successful recruitment and retention of underrepresented populations in PBRN studies is linked to the overall research process. This process, which we termed the cycle of trust, entailed developing and sustaining relationships of trust during 4 interrelated stages: before the study, during study recruitment, throughout study conduct, and after study completion. Participants identified a set of flexible strategies within each stage and called for close engagement with clinic and community partners. CONCLUSIONS: Our participants suggest that approaches to research that lay a foundation of trust, demonstrate respect for community members, and extend beyond the enrollment and data collection phases are essential to enhance the participation of diverse populations in PBRN research. These findings offer the PBRN community a guide toward achieving this important goal.

The robotic lumbar spine: dynamics and feedback linearization control.

The robotic lumbar spine (RLS) is a 15 degree-of-freedom, fully cable-actuated robotic lumbar spine which can mimic in vivo human lumbar spine movements to provide better hands-on training for medical students. The design incorporates five active lumbar vertebrae and the sacrum, with dimensions of an average adult human spine. It is actuated by 20 cables connected to electric motors. Every vertebra is connected to the neighboring vertebrae by spherical joints. Medical schools can benefit from a tool, system, or method that will help instructors train students and assess their tactile proficiency throughout their education. The robotic lumbar spine has the potential to satisfy these needs in palpatory diagnosis. Medical students will be given the opportunity to examine their own patient that can be programmed with many dysfunctions related to the lumbar spine before they start their professional lives as doctors. The robotic lumbar spine can be used to teach and test medical students in their capacity to be able to recognize normal and abnormal movement patterns of the human lumbar spine under flexion-extension, lateral bending, and axial torsion. This paper presents the dynamics and nonlinear control of the RLS. A new approach to solve for positive and nonzero cable tensions that are also continuous in time is introduced.

Three-dimensional static modeling of the lumbar spine.

This paper presents three-dimensional static modeling of the human lumbar spine to be used in the formation of anatomically-correct movement patterns for a fully cable-actuated robotic lumbar spine which can mimic in vivo human lumbar spine movements to provide better hands-on training for medical students. The mathematical model incorporates five lumbar vertebrae between the first lumbar vertebra and the sacrum, with dimensions of an average adult human spine. The vertebrae are connected to each other by elastic elements, torsional springs and a spherical joint located at the inferoposterior corner in the mid-sagittal plane of the vertebral body. Elastic elements represent the ligaments that surround the facet joints and the torsional springs represent the collective effect of intervertebral disc which plays a major role in balancing torsional load during upper body motion and the remaining ligaments that support the spinal column. The elastic elements and torsional springs are considered to be nonlinear. The nonlinear stiffness constants for six motion types were solved using a multiobjective optimization technique. The quantitative comparison between the angles of rotations predicted by the proposed model and in the experimental data confirmed that the model yields angles of rotation close to the experimental data. The main contribution is that the new model can be used for all motions while the experimental data was only obtained at discrete measurement points.

Primary care providers' needs and preferences for information about colorectal cancer survivorship care.

BACKGROUND: The Institute of Medicine (IOM) proposed that cancer survivors and their primary care providers (PCPs) should receive survivorship care plans to inform ongoing care. We aimed to determine PCPs' preferences for the content of survivorship care plans for colorectal cancer (CRC) survivors. METHODS: PCPs in 3 practice-based research networks completed a survey regarding 45 topics of CRC information based on the IOM's survivorship care plan framework. RESULTS: One hundred fifty-six PCPs completed the survey. For 35 topics (78%), at least half of respondents felt the topic was very important. Most PCPs reported receiving too little information about problems with chemotherapy (68%) or radiation (60%) and whether the oncologist intended to monitor for other cancers (71%). PCPs widely agreed that they do not have enough information about increased risk of second CRCs, other cancers, and other diseases (78%); long-term effects of chemotherapy (73%) and radiation (67%); and genetic counseling (83%). CONCLUSIONS: PCPs endorse the IOM's survivorship care plan framework as relevant and often report needing more information. Survivorship care plans may provide important information to PCPs by communicating patients' cancer histories and making recommendations regarding which aspects of care should be provided by the oncologist or the PCP.

Climate change and population growth in Timor Leste: implications for food security.

The climate in Timor Leste (East Timor) is predicted to become about 1.5 °C warmer and about 10 % wetter on average by 2050. By the same year, the population is expected to triple from 1 to 2.5-3 million. This article maps the predicted changes in temperature and rainfall and reviews the implications of climate change and population growth on agricultural systems. Improved cultivars of maize, rice, cassava, sweet potato and peanuts with high yield performance have been introduced, but these will need to be augmented in the future with better adapted cultivars and new crops, such as food and fodder legumes and new management practices. The requirements for fertilizers to boost yields and terracing and/or contour hedgerows to prevent soil erosion of steeply sloping terrain are discussed. Contour hedges can also be used for fodder for improved animal production to provide protein to reduce malnutrition.

No longer simply a Practice-based Research Network (PBRN) health improvement networks.

While primary care Practice-based Research Networks are best known for their original, research purpose, evidence accumulating over the last several years is demonstrating broader values of these collaborations. Studies have demonstrated their role in quality improvement and practice change, in continuing professional education, in clinician retention in medically underserved areas, and in facilitating transition of primary care organization. A role in informing and facilitating health policy development is also suggested. Taking into account this more robust potential, we propose a new title, the Health Improvement Network, and a new vision for Practice-based Research Networks.

Reports of persistent change in the clinical encounter following research participation: a report from the Primary Care Multiethnic Network (PRIME Net).

PURPOSE: Following anecdotal reports of unexpected patient and/or clinician behavior change in the primary care encounter in a previous study, we conducted this study to learn more about the short- and long-term effects on clinician and/or patient behavior from participation in a practice-based research network (PBRN) study. METHODS: Clinicians in two PBRN studies of Acanthosis nigricans were surveyed and interviewed 3 to 6 months following one study and surveyed 3 to 5 years following a second study. We gathered data on clinicians' reports of behavior change in the encounter, the persistence of those changes, and the likely causes of reported changes. RESULTS: Eighty-six percent of clinicians in the short-term and 79% in the long-term samples reported more frequent diagnostic efforts, and 68% and 54%, respectively, reported more frequent preventive counseling after participation in the studies. Interview data suggested that several factors contributed to this reported behavior change: increased clinician knowledge, availability of a feasible tool to support counseling, change in patient receptivity/motivation, and creation of a new context for counseling. CONCLUSIONS: Reports of behavior change in the primary care encounter associated with a PBRN study suggest that PBRNs may be effective vehicles for education, translation, and practice change in addition to their value in research.

Chronic non-cancer pain: a siren for primary care--a report from the PRImary Care MultiEthnic Network (PRIME Net).

INTRODUCTION: Patients with chronic non-cancer pain (CNCP) are common and have a high degree of morbidity. Previous studies document clinician frustration and variability in CNCP management. We conducted this study to gather in-depth clinicians' views about factors that affect management of CNCP. METHODS: We conducted a survey in the Primary Care MultiEthnic Network, a consortium of PBRNs of primary care clinicians practicing in low-income, medically underserved communities, and in a network of private primary care offices. RESULTS: Of 792 clinicians surveyed, 497 (63%) participated. Responses and accompanying narrative comments clustered around 5 themes: (1) barriers to and uncertainties in optimal management; (2) the complex biopsychosocial nature of CNCP; (3) seriousness of prescription opioid abuse; (4) effort and burden required to properly manage CNCP; and (5) clinician commitment to provide care for CNCP patients and benefits of expanded care model for CNCP. One-third reported a severe outcome (death or life-threatening event) in a CNCP patient for whom they had prescribed opioids. Roughly one-third do not initiate prescribing of opioids. CONCLUSIONS: Guidelines and increased continuing medical education alone are unlikely to be the solutions to the challenges of CNCP management. Increased evidence for recommendations and resources for more comprehensive care management are needed.

Ethics of health research in communities: perspectives from the southwestern United States.

PURPOSE: The increasing attention paid to community-based research highlights the question of whether human research protections focused on the individual are adequate to safeguard communities. We conducted a study to explore how community members perceive low-risk health research, the adequacy of human research protection processes, and the ethical conduct of community-based research. METHODS: Eighteen focus groups were conducted among rural and urban Hispanic and Native American communities in New Mexico using a semistructured guide. Group transcriptions were analyzed using iterative readings and coding, with review of the analytic summary by group members. RESULTS: Although participants recognized the value of health research, many also identified several adverse effects of research in their communities, including social (community and individual labeling, stigmatization, and discrimination) and economic (community job losses, increased insurance rates, and loss of community income). A lack of community beneficence was emphasized by participants who spoke of researchers who fail to communicate results adequately or assist with follow-through. Many group members did not believe current human research and data privacy processes were adequate to protect or assist communities. CONCLUSIONS: Ethical review of community-based health research should apply the Belmont principles to communities. Researchers should adopt additional approaches to community-based research by engaging communities as active partners throughout the research process, focusing on community priorities, and taking extra precautions to assure individual and community privacy. Plans for meaningful dissemination of results to communities should be part of the research design.

Acanthosis Nigricans: high prevalence and association with diabetes in a practice-based research network consortium--a PRImary care Multi-Ethnic network (PRIME Net) study.

BACKGROUND: Previous work has established a surprisingly high prevalence of acanthosis nigricans (AN) and its association with increased risk of type 2 diabetes in a Southwestern practice-based research network (PBRN). Our objective was to establish whether this high prevalence of AN would be present in other areas. METHODS: We examined the prevalence of type 2 diabetes and its risk factors and the prevalence of AN among patients aged 7 to 65 years who had been seen by one of 86 participating clinicians in a national PBRN consortium during a 1-week data collection period. In a subsample of nondiabetic matched pairs who had or did not have AN, we compared fasting glucose, insulin, and lipid levels. RESULTS: AN was present in 19.4% of 1730 patients from among all age ranges studied. AN was most prevalent among persons with more risk factors for diabetes. Patients with AN were twice as likely as those without AN to have type 2 diabetes (35.4% vs 17.6%; P < .001). In multivariable analysis, the prevalence ratio for diabetes was 2.1 (95% CI, 1.3-3.5) among non-Hispanic whites with AN and 1.4 (95% CI, 1.1-1.7) among minority patients with AN. In a subsample of 11 matched pairs, those with AN had higher levels of insulin and insulin resistance. CONCLUSIONS: We found high rates of AN among patients in primary care practices across the country. Patients with AN likely have multiple diabetes risk factors and are more likely to have diabetes.

Can we rapidly identify traditional, complementary and alternative medicine users in the primary care encounter? A RIOS Net study.

OBJECTIVE: Pressed for time to address competing clinical demands within the brief clinical encounter, primary care clinicians often rely on observations of patients to select topics to address. Use of traditional, complementary, or alternative medicine (TM/CAM) may be an important topic for discussion with a patient, but identification of patients using TM/CAM is problematic. We conducted this study to determine if observable characteristics--among southwestern Hispanic and Native American persons--might suggest to the clinician that a patient is likely to use TM/CAM. DESIGN: A combination of clinic staff focus groups, patient and clinician interviews, and a clinician focus group was used to explore possible predictors of TM/CAM use among primary care patients in practices serving predominantly Hispanic and Native American communities. RESULTS: No easily observable characteristics were identified that clinicians might use to predict TM/CAM use in their patients. Less readily observable characteristics--identification with culture, family of origin, health condition--were more likely to be associated with TM/CAM use, but not infallibly so. CONCLUSIONS: Rather than attempt to predict TM/CAM use by an individual patient, clinicians may be better served by assuming its use by all, by applying strategies for rapid and effective communications with patients about the topic, by selecting which patients to discuss TM/CAM use with based on clinical circumstances, and/or by gathering information about TM/CAM use as part of routine initial database development.