Correction to: Medical School Factors Associated with Changes in Implicit and Explicit Bias Against Gay and Lesbian People among 3492 Graduating Medical Students.

Due to a tagging error, two authors were incorrectly listed in indexing systems. Brook W. Cunningham should be B.A. Cunningham and Mark W. Yeazel should be M.W. Yeazel for indexing purposes.

Informal Training Experiences and Explicit Bias Against African Americans among Medical Students.

Despite the widespread inclusion of diversity-related curricula in US medical training, racial disparities in the quality of care and physician bias in medical treatment persist. The present study examined the effects of both formal and informal experiences on non-African American medical students' (N=2922) attitudes toward African Americans in a longitudinal study of 49 randomly selected US medical schools. We assessed the effects experiences related to medical training, accounting for prior experiences and attitudes. Contact with African Americans predicted positive attitudes toward African Americans relative to White people, even beyond the effects of prior attitudes. Furthermore, students who reported witnessing instructors making negative racial comments or jokes were significantly more willing to express racial bias themselves, even after accounting for the effects of contact. Examining the effects of informal experiences on racial attitudes may help develop a more effective medical training environment and reduce racial disparities in healthcare.

Medical students' learning orientation regarding interracial interactions affects preparedness to care for minority patients: a report from Medical Student CHANGES.

BACKGROUND: There is a paucity of evidence on how to train medical students to provide equitable, high quality care to racial and ethnic minority patients. We test the hypothesis that medical schools' ability to foster a learning orientation toward interracial interactions (i.e., that students can improve their ability to successfully interact with people of another race and learn from their mistakes), will contribute to white medical students' readiness to care for racial minority patients. We then test the hypothesis that white medical students who perceive their medical school environment as supporting a learning orientation will benefit more from disparities training. METHODS: Prospective observational study involving web-based questionnaires administered during first (2010) and last (2014) semesters of medical school to 2394 white medical students from a stratified, random sample of 49 U.S. medical schools. Analysis used data from students' last semester to build mixed effects hierarchical models in order to assess the effects of medical school interracial learning orientation, calculated at both the school and individual (student) level, on key dependent measures. RESULTS: School differences in learning orientation explained part of the school difference in readiness to care for minority patients. However, individual differences in learning orientation accounted for individual differences in readiness, even after controlling for school-level learning orientation. Individual differences in learning orientation significantly moderated the effect of disparities training on white students' readiness to care for minority patients. Specifically, white medical students who perceived a high level of learning orientation in their medical schools regarding interracial interactions benefited more from training to address disparities. CONCLUSIONS: Coursework aimed at reducing healthcare disparities and improving the care of racial minority patients was only effective when white medical students perceived their school as having a learning orientation toward interracial interactions. Results suggest that medical school faculty should present interracial encounters as opportunities to practice skills shown to reduce bias, and faculty and students should be encouraged to learn from one another about mistakes in interracial encounters. Future research should explore aspects of the medical school environment that contribute to an interracial learning orientation.

The mixed impact of medical school on medical students' implicit and explicit weight bias.

CONTEXT: Health care trainees demonstrate implicit (automatic, unconscious) and explicit (conscious) bias against people from stigmatised and marginalised social groups, which can negatively influence communication and decision making. Medical schools are well positioned to intervene and reduce bias in new physicians. OBJECTIVES: This study was designed to assess medical school factors that influence change in implicit and explicit bias against individuals from one stigmatised group: people with obesity. METHODS: This was a prospective cohort study of medical students enrolled at 49 US medical schools randomly selected from all US medical schools within the strata of public and private schools and region. Participants were 1795 medical students surveyed at the beginning of their first year and end of their fourth year. Web-based surveys included measures of weight bias, and medical school experiences and climate. Bias change was compared with changes in bias in the general public over the same period. Linear mixed models were used to assess the impact of curriculum, contact with people with obesity, and faculty role modelling on weight bias change. RESULTS: Increased implicit and explicit biases were associated with less positive contact with patients with obesity and more exposure to faculty role modelling of discriminatory behaviour or negative comments about patients with obesity. Increased implicit bias was associated with training in how to deal with difficult patients. On average, implicit weight bias decreased and explicit bias increased during medical school, over a period of time in which implicit weight bias in the general public increased and explicit bias remained stable. CONCLUSIONS: Medical schools may reduce students' weight biases by increasing positive contact between students and patients with obesity, eliminating unprofessional role modelling by faculty members and residents, and altering curricula focused on treating difficult patients.

The Effects of Racism in Medical Education on Students' Decisions to Practice in Underserved or Minority Communities.

PURPOSE: The purpose of this study was to examine the relationship between manifestations of racism in medical school and subsequent changes in graduating medical students' intentions to practice in underserved or minority communities, compared with their attitudes and intentions at matriculation. METHOD: The authors used repeated-measures data from a longitudinal study of 3,756 students at 49 U.S. medical schools that were collected from 2010 to 2014. They conducted generalized linear mixed models to estimate whether manifestations of racism in school curricula/policies, school culture/climate, or student attitudes/behaviors predicted first- to fourth-year changes in students' intentions to practice in underserved communities or primarily with minority populations. Analyses were stratified by students' practice intentions (no/undecided/yes) at matriculation. RESULTS: Students' more negative explicit racial attitudes were associated with decreased intention to practice with underserved or minority populations at graduation. Service learning experiences and a curriculum focused on improving minority health were associated with increased intention to practice in underserved communities. A curriculum focused on minority health/disparities, students' perceived skill at developing relationships with minority patients, the proportion of minority students at the school, and the perception of a tense interracial environment were all associated with increased intention to care for minority patients. CONCLUSIONS: This study provides evidence that racism manifested at multiple levels in medical schools was associated with graduating students' decisions to provide care in high-need communities. Strategies to identify and eliminate structural racism and its manifestations in medical school are needed.

Validity of four self-reported colorectal cancer screening modalities in a general population: differences over time and by intervention assignment.

Little is known about the validity of self-reported colorectal cancer screening. To date, few published studies have validated all four screening modalities per recommended guidelines or included a general population-based sample, and none has assessed validity over time and by intervention condition. To estimate the validity of self-reported screening, a random sample of 200 adults, ages > or =50 years, was selected from those completing annual surveys on screening behavior as part of an intervention study. Approximately 60% of the validation sample authorized medical record review. Sensitivity, specificity, and positive and negative predictive values were calculated for baseline and year 1 follow-up reports for each test and for overall screening adherence. Sensitivity at baseline ranged from 86.9% (flexible sigmoidoscopy) to 100% (colonoscopy). Sensitivity at follow-up was slightly lower. Adjusting for validity measures, the sample overreported screening prevalence at baseline for each of the four modalities. At follow-up, overreporting was greatest for fecal occult blood test (13.0%). Overreporting across intervention conditions was highest for fecal occult blood test (10.8% for control; 24.8% for the most intense intervention) and overall screening adherence (10.9% for control; 14.3% for the most intense intervention). Sensitivity and specificity of self-reported colorectal cancer screening compared with medical records were high; however, adjusting self-reported screening rates based on relative error rates reduced screening prevalence estimates. Those exposed to more intense interventions to modify screening behavior seemed more likely to overestimate their screening rates compared with those who were not exposed.

Beyond Generalized Sexual Prejudice: Need for Closure Predicts Negative Attitudes Toward Bisexual People Relative to Gay/Lesbian People.

Increasing evidence suggests that bisexual people are sometimes evaluated more negatively than heterosexual and gay/lesbian people. A common theoretical account for this discrepancy argues that bisexuality is perceived by some as introducing ambiguity into a binary model of sexuality. The present brief report tests a single key prediction of this theory, that evaluations of bisexual people have a unique relationship with Need for Closure (NFC), a dispositional preference for simple ways of structuring information. Participants (n=3406) were heterosexual medical students from a stratified random sample of 49 U.S. medical schools. As in prior research, bisexual targets were evaluated slightly more negatively than gay/lesbian targets overall. More importantly for the present investigation, higher levels of NFC predicted negative evaluations of bisexual people after accounting for negative evaluations of gay/lesbian people, and higher levels of NFC also predicted an explicit evaluative preference for gay/lesbian people over bisexual people. These results suggest that differences in evaluations of sexual minority groups partially reflect different psychological processes, and that NFC may have a special relevance for bisexual targets even beyond its general association with prejudice. The practical value of testing this theory on new physicians is also discussed.

Impact of an Electronic Health Record (EHR) Reminder on Human Papillomavirus (HPV) Vaccine Initiation and Timely Completion.

BACKGROUND: The initiation and timely completion of the human papillomavirus (HPV) vaccine in young women is critical. We compared the initiation and completion of the HPV vaccine among women in 2 community-based networks with electronic health records: 1 with a prompt and reminder system (prompted cohort) and 1 without (unprompted cohort). METHODS: Female patients aged 9 to 26 years seen between March 1, 2007, and January 25, 2010, were used as the retrospective cohort. Patient demographics and vaccination dates were extracted from the electronic health records. RESULTS: Patients eligible for the vaccine included 6019 from the prompted cohort and 9096 from the unprompted cohort. Mean age at initiation was 17.3 years in the prompted cohort and 18.1 years in the unprompted cohort. Significantly more (P < .001) patients initiated the vaccine in the prompted cohort (34.9%) compared with the unprompted cohort (21.5%). African Americans aged 9 to 18 years with ≥3 visits during the observation period were significantly more likely to initiate in the prompted cohort (P < .001). The prompted cohort was significantly more likely (P < .001) to complete the vaccine series in a timely manner compared with the unprompted cohort. CONCLUSION: More patients aged 9 to 26 years initiated and achieved timely completion of the HPV vaccine series in clinics using an electronic health record system with prompts compared with clinics without prompts.

Do Contact and Empathy Mitigate Bias Against Gay and Lesbian People Among Heterosexual First-Year Medical Students? A Report From the Medical Student CHANGE Study.

PURPOSE: A recent Institute of Medicine report concluded that lesbian and gay individuals face discrimination from health care providers and called for research on provider attitudes. Medical school is a critical juncture for improving future providers' treatment of sexual minorities. This study examined both explicit bias and implicit bias against lesbian women and gay men among first-year medical students, focusing on two predictors of such bias, contact and empathy. METHOD: This study included the 4,441 heterosexual first-year medical students who participated in the baseline survey of the Medical Student Cognitive Habits and Growth Evaluation Study, which employed a stratified random sample of 49 U.S. medical schools in fall 2010. The researchers measured explicit attitudes toward gay and lesbian people using feeling thermometer self-assessments, implicit attitudes using the Implicit Association Test, amount and favorability of contact using self-report items, and empathy using subscales of the Interpersonal Reactivity Index. RESULTS: Nearly half (45.79%; 956/2,088) of respondents with complete data on both bias measures expressed at least some explicit bias, and most (81.51%; 1,702/2,088) exhibited at least some implicit bias against gay and lesbian individuals. Both amount and favorability of contact predicted positive implicit and explicit attitudes. Both cognitive and emotional empathy predicted positive explicit attitudes, but not implicit attitudes. CONCLUSIONS: The prevalence of negative attitudes presents an important challenge for medical education, highlighting the need for more research on possible causes of bias. Findings on contact and empathy point to possible curriculum-based interventions aimed at ensuring high-quality care for sexual minorities.

A Comparison of the Mental Health and Well-Being of Sexual Minority and Heterosexual First-Year Medical Students: A Report From the Medical Student CHANGE Study.

PURPOSE: Research is lacking on psychological distress and disorder among sexual minority medical students (students who identify as nonheterosexual). If left unaddressed, distress may result in academic and professional difficulties and undermine workforce diversity goals. The authors compared depression, anxiety, and self-rated health among sexual minority and heterosexual medical students. METHOD: This study included 4,673 first-year students who self-reported sexual orientation in the fall 2010 baseline survey of the Medical Student Cognitive Habits and Growth Evaluation Study, a national longitudinal cohort study. The authors used items from published scales to measure depression, anxiety, self-rated health, and social stressors. They conducted bivariate and multivariate analyses to estimate the association between sexual identity and depression, anxiety, and self-rated health. RESULTS: Of 4,673 students, 232 (5.0%) identified as a sexual minority. Compared with heterosexual students, after adjusting for relevant covariates, sexual minority students had greater risk of depressive symptoms (adjusted relative risk [ARR] = 1.59 [95% confidence interval, 1.24-2.04]), anxiety symptoms (ARR = 1.64 [1.08-2.49]), and low self-rated health (ARR = 1.77 [1.15-2.60]). Sexual minority students were more likely to report social stressors, including harassment (22.7% versus 12.7%, P < .001) and isolation (53.7% versus 42.8%, P = .001). Exposure to social stressors attenuated but did not eliminate the observed associations between minority sexual identity and mental and self-reported health measures. CONCLUSIONS: First-year sexual minority students experience significantly greater risk of depression, anxiety, and low self-rated health than heterosexual students. Targeted interventions are needed to improve mental health and well-being.

Identifying Predictors of Longitudinal Decline in the Level of Medical Care Received by Adult Survivors of Childhood Cancer: A Report from the Childhood Cancer Survivor Study.

OBJECTIVES: Characterize longitudinal changes in the use of medical care in adult survivors of childhood cancer. DATA SOURCES: The Childhood Cancer Survivor Study, a retrospective cohort study of 5+ year survivors of childhood cancer. STUDY DESIGN: Medical care was assessed at entry into the cohort (baseline) and at most recent questionnaire completion. Care at each time point was classified as no care, general care, or survivor-focused care. DATA COLLECTION: There were 6,176 eligible survivors. Multivariable models evaluated risk factors for reporting survivor-focused care or general medical care at baseline and no care at follow-up; and survivor-focused care at baseline and general care at follow-up. PRINCIPAL FINDINGS: Males (RR, 2.3; 95 percent CI 1.8-2.9), earning <$20,000/year (RR, 1.6; 95 percent CI 1.2-2.3) or ≤ high school education (RR, 2.5; 95 percent CI 1.6-3.8 and RR 2.0; 95 percent CI 1.5-2.7 for

Colorectal cancer screening adherence in a general population.

BACKGROUND: This article describes the self-reported colorectal cancer (CRC) screening adherence rates of adults, aged 50 years and older, living in five nonurban Minnesota counties. METHODS: During the year 2000, 1693 eligible respondents, aged 50 years and older, from a randomly selected sample completed a survey assessing CRC screening adherence (approximately 86.3% response). The survey allowed differentiation between the four CRC screening modalities but did not differentiate between screening and diagnostic testing. Adjustment for nonresponse was performed using a version of Horvitz-Thompson weighting accounting for unknown eligibility. RESULTS: 24.5% of respondents had a fecal occult blood test within 1 year of the survey, 33.8% had flexible sigmoidoscopy within 5 years, 29.3% had a colonoscopy within 10 years, and 13.7% had a barium enema within the last 5 years. Overall, 55.3% of respondents reported testing by any modality; thus, 44.7% were not adherent to screening guidelines. CONCLUSIONS: This study improves on previous attempts to characterize CRC screening adherence by assessing all four modalities of screening as recommended by current screening guidelines, by focusing on nonadherence, and by rigorously accounting for nonresponse. This study confirms that nearly half of the population remains unscreened by any method.

Put prevention into practice (PPIP): evaluating PPIP in two family practice residency sites.

BACKGROUND AND OBJECTIVES: The Put Prevention Into Practice (PPIP) office system is a set of office tools designed to address physician, patient, and system barriers to the provision of clinical preventive services. This study evaluated the effect of using PPIP on the delivery of clinical preventive services at two family practice residency sites. METHODS: After a careful planning process at each clinic, a 1-year trial was conducted with implementation of PPIP at two residency sites compared to two control residency sites. The subjects included adults age 19 and older Data were collected via chart extraction on 300 randomly selected patients per clinic for the following three outcomes: health risk factor assessment (for limited physical activity, poor nutrition habits, and tobacco use), health promotion/counseling (for nutrition, physical activity, and tobacco use), and screening rates (clinical breast exam, cholesterol, fecal occult blood test, mammography, and Pap smear). RESULTS: Only inconsistent or sporadic differences in risk factor assessment, health promotion counseling, and screening were seen when comparing implementation and control sites. CONCLUSIONS: PPIP had little effect on the delivery of clinical preventive services. Future research should include a careful analysis of the users of PPIP and the environments in which they practice.

An examination of the dental utilization practices of adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study.

OBJECTIVES: This study characterized the self-reported dental utilization practice of long-term survivors of childhood cancer, a group at increased risk for treatment-induced dental abnormalities. METHODS: 9,434 survivors and a comparison group of 3,858 siblings completed a 289-item survey that included a question on when their last dental visit occurred. RESULTS: Within the last year 60.4 percent of survivors reported a dental visit. The groups less likely to report a recent dental visit include minority subjects, subjects with low levels of educational attainment, subjects with annual household incomes < dollar 20,000, and those without health insurance. No significant differences between survivors and siblings were seen. Male survivors exposed to cranial radiation were slightly more likely than other male survivors to report a recent dental visit (OR = 1.27, 95% CI = 1.12, 1.44). CONCLUSIONS: The dental utilization practices among survivors of childhood cancer are below recommended levels, even among those at highest risk for dental abnormalities.

Implicit and explicit weight bias in a national sample of 4,732 medical students: the medical student CHANGES study.

OBJECTIVE: To examine the magnitude of explicit and implicit weight biases compared to biases against other groups; and identify student factors predicting bias in a large national sample of medical students. METHODS: A web-based survey was completed by 4,732 1st year medical students from 49 medical schools as part of a longitudinal study of medical education. The survey included a validated measure of implicit weight bias, the implicit association test, and 2 measures of explicit bias: a feeling thermometer and the anti-fat attitudes test. RESULTS: A majority of students exhibited implicit (74%) and explicit (67%) weight bias. Implicit weight bias scores were comparable to reported bias against racial minorities. Explicit attitudes were more negative toward obese people than toward racial minorities, gays, lesbians, and poor people. In multivariate regression models, implicit and explicit weight bias was predicted by lower BMI, male sex, and non-Black race. Either implicit or explicit bias was also predicted by age, SES, country of birth, and specialty choice. CONCLUSIONS: Implicit and explicit weight bias is common among 1st year medical students, and varies across student factors. Future research should assess implications of biases and test interventions to reduce their impact.

Patient-reported quality of supportive care among patients with colorectal cancer in the Veterans Affairs Health Care System.

PURPOSE: High-quality supportive care is an essential component of comprehensive cancer care. We implemented a patient-centered quality of cancer care survey to examine and identify predictors of quality of supportive care for bowel problems, pain, fatigue, depression, and other symptoms among 1,109 patients with colorectal cancer. PATIENTS AND METHODS: Patients with new diagnosis of colorectal cancer at any Veterans Health Administration medical center nationwide in 2008 were ascertained through the Veterans Affairs Central Cancer Registry and sent questionnaires assessing a variety of aspects of patient-centered cancer care. We received questionnaires from 63% of eligible patients (N = 1,109). Descriptive analyses characterizing patient experiences with supportive care and binary logistic regression models were used to examine predictors of receipt of help wanted for each of the five symptom categories. RESULTS: There were significant gaps in patient-centered quality of supportive care, beginning with symptom assessment. In multivariable modeling, the impact of clinical factors and patient race on odds of receiving wanted help varied by symptom. Coordination of care quality predicted receipt of wanted help for all symptoms, independent of patient demographic or clinical characteristics. CONCLUSION: This study revealed substantial gaps in patient-centered quality of care, difficult to characterize through quality measurement relying on medical record review alone. It established the feasibility of collecting patient-reported quality measures. Improving quality measurement of supportive care and implementing patient-reported outcomes in quality-measurement systems are high priorities for improving the processes and outcomes of care for patients with cancer.

Predictors of risk-based medical follow-up: a report from the Childhood Cancer Survivor Study.

PURPOSE: The purpose of this study is to conduct an intervention study designed to assess the effectiveness of using a newsletter to increase medical follow-up in pediatric cancer survivors at risk of selected treatment complications. METHODS: Survivors participating in the Childhood Cancer Survivor Study who were at least 25 years of age and at risk of cardiovascular disease, breast cancer, or osteoporosis related to previous cancer treatment were randomly assigned to receive a newsletter featuring brief health risk information or a newsletter including an insert providing more comprehensive health risk information. A follow-up survey distributed 24 months after the newsletter intervention assessed predictors of medical follow-up. RESULTS: Overall, there were no differences found among the groups in terms of access to a treatment summary, medical follow-up, discussion of childhood cancer health risks, and medical screening for the targeted health behaviors. One exception, indicating borderline significance was that women at risk for osteoporosis who received the newsletter insert were more likely to have discussed their risk with a doctor than those who only received the brief information (10.1 % vs. 4.0 % p = 0.05). Discussion of breast cancer (OR = 2.15; 95 % CI = 1.74-2.66), heart disease (OR = 5.54; 95 % CI = 4.67-6.57) and osteoporosis (OR = 10.6; 95 % CI = 8.34-13.47) risk with physician significantly predicted report of undergoing screening for targeted behavior in previous 2 years as did physician access to treatment summary. CONCLUSIONS: More detailed content in a newsletter had minimal effect on recommended screening. However, survivor's discussion of cancer-related risks with one's doctor significantly influenced participation in health screening. These results highlight the integral role of communication in health behavior. IMPLICATIONS FOR CANCER SURVIVORS: This study is designed to assess communication strategies that increase medical follow-up in pediatric cancer survivors at risk of selected treatment complications. The results are of great importance not only to the pediatric oncology community but also the broad range of adult oncology medical specialties who are directly involved in the long-term medical care of this ever increasing population of cancer survivors.

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.

Cardiac outcomes in a cohort of adult survivors of childhood and adolescent cancer: retrospective analysis of the Childhood Cancer Survivor Study cohort.

OBJECTIVES: To assess the incidence of and risks for congestive heart failure, myocardial infarction, pericardial disease, and valvular abnormalities among adult survivors of childhood and adolescent cancers. DESIGN: Retrospective cohort study. SETTING: 26 institutions that participated in the Childhood Cancer Survivor Study. PARTICIPANTS: 14,358 five year survivors of cancer diagnosed under the age of 21 with leukaemia, brain cancer, Hodgkin's lymphoma, non-Hodgkin's lymphoma, kidney cancer, neuroblastoma, soft tissue sarcoma, or bone cancer between 1970 and 1986. Comparison group included 3899 siblings of cancer survivors. MAIN OUTCOME MEASURES: Participants or their parents (in participants aged less than 18 years) completed a questionnaire collecting information on demographic characteristics, height, weight, health habits, medical conditions, and surgical procedures occurring since diagnosis. The main outcome measures were the incidence of and risk factors for congestive heart failure, myocardial infarction, pericardial disease, and valvular abnormalities in survivors of cancer compared with siblings. RESULTS: Survivors of cancer were significantly more likely than siblings to report congestive heart failure (hazard ratio (HR) 5.9, 95% confidence interval 3.4 to 9.6; P<0.001), myocardial infarction (HR 5.0, 95% CI 2.3 to 10.4; P<0.001), pericardial disease (HR 6.3, 95% CI 3.3 to 11.9; P<0.001), or valvular abnormalities (HR 4.8, 95% CI 3.0 to 7.6; P<0.001). Exposure to 250 mg/m(2) or more of anthracyclines increased the relative hazard of congestive heart failure, pericardial disease, and valvular abnormalities by two to five times compared with survivors who had not been exposed to anthracyclines. Cardiac radiation exposure of 1500 centigray or more increased the relative hazard of congestive heart failure, myocardial infarction, pericardial disease, and valvular abnormalities by twofold to sixfold compared to non-irradiated survivors. The cumulative incidence of adverse cardiac outcomes in cancer survivors continued to increase up to 30 years after diagnosis. CONCLUSION: Survivors of childhood and adolescent cancer are at substantial risk for cardiovascular disease. Healthcare professionals must be aware of these risks when caring for this growing population.

A validated tool for gaining insight into clinicians' preventive medicine behaviors and beliefs: the preventive medicine attitudes and activities questionnaire (PMAAQ).

OBJECTIVE: This article describes the development, reliability, and validity of the Preventive Medicine Attitudes and Activities Questionnaire (PMAAQ). METHOD: From 1995 to 2003, the PMAAQ was administered to 353 residents at six primary care residency programs in the United States. Validity was demonstrated in four ways: content validity through an expert panel, calculation of internal consistency reliabilities, demonstration of divergent validity, and external validation using a pre-existent chart review dataset. Stability measures were also calculated. RESULTS: High internal consistency reliabilities among the eight scales were seen (Cronbach's alpha = 0.74 to 0.98). Divergent validity was demonstrated by low to moderate intercorrelations among scales (r = -0.23 to 0.54). Significant correlations were seen between several PMAAQ scales and scales created from chart review data. Two-month test-retest correlations ranged from r = 0.56 to 0.87. Results suggest that clinicians' attitudes alone are not directly responsible for behaviors. CONCLUSION: The PMAAQ can validly and reliably measure residents' prevention behaviors and provide insight into their preventive healthcare attitudes. This survey could be useful in targeting areas for interventions to improve delivery of clinical preventive services, as a means of evaluating the effectiveness of such interventions, or as a quality assurance tool to monitor physician prevention activities.