Reducing obesity prejudice in medical education.

BACKGROUND: Healthcare worker attitudes toward obese individuals facilitate discrimination and contribute to poor health outcomes. Previous studies have demonstrated medical student bias toward obese individuals, but few have examined effects of the educational environment on these prejudicial beliefs. We sought to determine whether an innovative educational intervention (reading a play about obesity) could diminish obesity prejudice relative to a standard medical lecture. METHODS: We conducted a randomized, controlled trial enrolling medical students (n = 129) from three universities. Students were assigned to play-reading or a standard lecture. Explicit attitudes and implicit bias toward obese individuals were assessed prior to intervention and after four months. RESULTS: At baseline, students demonstrated moderate explicit and implicit bias toward obese people despite high scores on empathy. Students randomized to the play-reading group had significantly decreased explicit fat bias (P = 0.01) at follow-up, while students in the lecture group showed increased endorsement of a prescriptive model of care at the expense of a patient-centered approach (P = 0.03). There was a significant increase in empathy for those in both the theater (P = 0.007) and lecture group (P = 0.02). The intervention had no significant effect on implicit bias or regard for obesity as a civil rights issue. DISCUSSION: Dramatic reading may be superior to traditional medical lectures for showcasing patient rights and preferences. The present study demonstrates for the first time that play-reading diminishes conscious obesity bias. Further research should determine whether nontraditional methods of instruction promote improved understanding of and care for obese patients.

When physicians and patients think alike: patient-centered beliefs and their impact on satisfaction and trust.

OBJECTIVE: Our goal was to identify physician and patient characteristics associated with patient-centered beliefs about the sharing of information and power, and to determine how these beliefs and the congruence of beliefs between patients and physicians affect patients' evaluations. STUDY DESIGN: Physicians completed a scale assessing their beliefs about sharing information and power, and provided demographic information. A sample of their patients filled out the same scale and made evaluations of their physicians before and after a target visit. POPULATION: Physicians and patients in a large multispecialty group practice and a group model health maintenance organization were included. Forty-five physicians in internal medicine, family practice, and cardiology participated, as well as 909 of their patients who had a significant concern. OUTCOMES MEASURED: Trust in the physician was measured previsit, and visit satisfaction and physician endorsement were measured immediately postvisit. RESULTS: Among patients, patient-centered beliefs (a preference for information and control) were associated with being women, white, younger, more educated, and having a higher income; among physicians these beliefs were unrelated to sex, ethnicity, or experience. The patients of patient-centered physicians were no more trusting or endorsing of their physicians, and they were not more satisfied with the target visit. However, patients whose beliefs were congruent with their physicians' beliefs were more likely to trust and endorse their physicians, even though they were not more satisfied with the target visit. CONCLUSIONS: The extent of congruence between physicians' and patients' beliefs plays an important role in determining how patients evaluate their physicians, although satisfaction with a specific visit and overall trust may be determined differently.

Vaginal birth after cesarean in California.

OBJECTIVE: To estimate rates at which women were offered and consented to trial of labor in California hospitals with high and low risk-adjusted cesarean delivery rates. METHODS: From 267 nonfederal acute-care hospitals in California that performed more than 678 deliveries in 1992-1993, 51 hospitals were selected in a stratified sample. Hospitals in the sample were categorized as having high, medium, and low risk-adjusted cesarean rates using a logistic regression model based on data from the California Patient Discharge Data System. We reviewed medical records of women with previous cesareans for evidence of counseling regarding trial of labor, other clinical variables, and method of delivery. Differences in proportions between the three groups of hospitals were compared. RESULTS: According to records of 369 women with previous cesareans, after excluding contraindications, 312 were potentially eligible for trial of labor. Hospitals with low risk-adjusted cesarean rates documented counseling women for trial of labor in over 99% of records reviewed, compared with 85% and 79%, respectively, of hospitals with intermediate and high rates (P <.001). Rates of completed vaginal births after cesarean were 71% in hospitals with low risk-adjusted cesarean rates, compared with 39% and 31% in hospitals with intermediate and high rates (P <.05). CONCLUSIONS: California hospitals with high cesarean rates in 1992-1993 had markedly higher rates of repeat elective cesarean delivery without evidence of counseling regarding trial of labor. Informed patient choice is a critical element of the decision for trial of labor or elective repeat cesarean, and lack of documented counseling is cause for concern.

Unsaid but not forgotten: patients' unvoiced desires in office visits.

OBJECTIVES: To examine patient, physician, and health care system characteristics associated with unvoiced desires for action, as well as the consequences of these unspoken requests. PATIENTS AND METHODS: Patient surveys were administered before, immediately after, and 2 weeks after outpatient visits in the practices of 45 family practice, internal medicine, and cardiology physicians working in a multispecialty group practice or group model health maintenance organization. Data were collected at the index visit from 909 patients, of whom 97.6% were surveyed 2 weeks after the outpatient visit. Before the visit, patients rated their trust in the physician, health concerns, and health status. After the visit, patients reported on various types of unexpressed desires and rated their visit satisfaction. At follow-up, patients rated their satisfaction, health concerns, and health status, and also described their postvisit health care use. Evaluations of the visit were also obtained from physicians. RESULTS: Approximately 9% of the patients had 1 or more unvoiced desire(s). Desires for referrals (16.5% of desiring patients) and physical therapy (8.2%) were least likely to be communicated. Patients with unexpressed desires tended to be young, undereducated, and unmarried and were less likely to trust their physician. Patients with unvoiced desires evaluated the physician and visit less positively; these encounters were evaluated by physicians as requiring more effort. Holding an unvoiced desire was associated with less symptom improvement, but did not affect postvisit health care use. CONCLUSIONS: Patients' unvoiced needs affect patients' and physicians' visit evaluations and patients' subjective perceptions of improvement. Implications of these findings for clinical practice are examined.

Parent expectations for antibiotics, physician-parent communication, and satisfaction.

OBJECTIVES: To explore how parents communicate their preferences for antibiotics to their child's physician and to examine whether physicians can communicate why antibiotics are not being prescribed in a way that maintains satisfaction with the visit. DESIGN: Previsit survey of parents, audiotaping of the study encounters, and a postvisit survey of parents and physicians. SETTING: Two private pediatric practices. PARTICIPANTS: Ten physicians (response rate = 77%) and a consecutive sample of 295 eligible parents (response rate = 86%) who attended acute care visits for their children between October 1996 and March 1997. MAIN OUTCOME MEASURES: Physician-perceived pressure to prescribe antibiotics and parental visit-specific satisfaction. RESULTS: Fifty percent of parents expressed a previsit expectation for antibiotics. Among these parents, only 1% made a direct verbal request for them. Even when no direct requests for antibiotics were made, physicians still perceived an expectation for antibiotics 34% of the time. Among parents who did not receive expected antibiotics, those offered a contingency plan from the physician (i.e., the possibility of receiving antibiotics in the future if their child did not get better) had a higher mean satisfaction score than parents not receiving a contingency plan (76 vs. 58.9; P<.05). CONCLUSION: Physicians should consider providing a contingency plan to parents who expect antibiotics for their children when there is no clinical indication. Further study is needed to determine how parents indirectly communicate their desire for antibiotics and what additional communication techniques physicians can use to resist the overprescribing of antibiotics.

Does "mainstreaming" guarantee access to care for medicaid recipients with asthma?

OBJECTIVE: Recent reforms in the federal Medicaid program have attempted to integrate beneficiaries into the mainstream by providing them with managed care options. However, the effects of mainstreaming have not been systematically evaluated. DESIGN: Cross-sectional survey. SETTING/PARTICIPANTS: A sample of 478 adult, nonelderly asthmatics followed by a large Northern California medical group. MEASUREMENTS AND MAIN RESULTS: We examined differences in self-reported access by insurance status. Compared to patients with other forms of insurance, patients covered by the state's Medicaid program (Medi-Cal) were more likely to report access problems for asthma-related care, including difficulties in reaching a health care provider by telephone, obtaining a clinic appointment, and obtaining asthma medication. Adjusting for relevant clinical and sociodemographic variables, Medi-Cal patients were more likely to report at least one access problem compared to non-Medi-Cal patients (adjusted odds ratio [AOR], 3.34; 95% confidence interval [CI], 1.43 to 7.80). Patients reporting at least one access problem were also more likely to have made at least one asthma-related emergency department visit within the past year (AOR, 4.84; 95% CI, 2.41 to 9.72). Reported barriers to care did not translate into reduced patient satisfaction. CONCLUSIONS: Within this population of Medicaid patients, the provision of health insurance and care within the mainstream of an integrated health system was no guarantee of equal access as perceived by the patients themselves.

Health information on the Internet: accessibility, quality, and readability in English and Spanish.

CONTEXT: Despite the substantial amount of health-related information available on the Internet, little is known about the accessibility, quality, and reading grade level of that health information. OBJECTIVE: To evaluate health information on breast cancer, depression, obesity, and childhood asthma available through English- and Spanish-language search engines and Web sites. DESIGN AND SETTING: Three unique studies were performed from July 2000 through December 2000. Accessibility of 14 search engines was assessed using a structured search experiment. Quality of 25 health Web sites and content provided by 1 search engine was evaluated by 34 physicians using structured implicit review (interrater reliability >0.90). The reading grade level of text selected for structured implicit review was established using the Fry Readability Graph method. MAIN OUTCOME MEASURES: For the accessibility study, proportion of links leading to relevant content; for quality, coverage and accuracy of key clinical elements; and grade level reading formulas. RESULTS: Less than one quarter of the search engine's first pages of links led to relevant content (20% of English and 12% of Spanish). On average, 45% of the clinical elements on English- and 22% on Spanish-language Web sites were more than minimally covered and completely accurate and 24% of the clinical elements on English- and 53% on Spanish-language Web sites were not covered at all. All English and 86% of Spanish Web sites required high school level or greater reading ability. CONCLUSION: Accessing health information using search engines and simple search terms is not efficient. Coverage of key information on English- and Spanish-language Web sites is poor and inconsistent, although the accuracy of the information provided is generally good. High reading levels are required to comprehend Web-based health information.

Posttraumatic concerns: a patient-centered approach to outcome assessment after traumatic physical injury.

BACKGROUND: Approximately 2.5 million Americans are admitted to the hospital after traumatic physical injury each year. Few investigations have elicited patients' perspectives regarding posttraumatic outcomes. OBJECTIVE: To identify and categorize physically injured trauma survivors' posttraumatic concerns. RESEARCH DESIGN: Prospective longitudinal investigation; trauma survivors were interviewed during the post-injury hospitalization and again 1, 4, and 12 months after the trauma. SUBJECTS: Ninety-seven, randomly selected, English speaking, hospitalized survivors of motor vehicle-crashes or assaults. MEASURES: At the end of each interview patients were asked, "Of all the things that have happened to you since you were injured, what concerns you the most?" Using an iterative process and working by consensus, investigators categorized patient concerns in content domains. Concern domains were then compared with established measures of posttraumatic stress disorder (PTSD) symptoms and limitations in physical functioning. RESULTS: Seven categories of posttraumatic concerns were identified. During the course of the year, 73% of patients expressed physical health concerns, 58% psychological concerns, 53% work and finance concerns, 40% social concerns, 10% legal concerns, 10% medical concerns, and 20% uncodable concerns. Rater agreement on concern categorization was substantial (kappa = 0.72). The mean number of concerns expressed per patient gradually decreased over time (1 month mean = 1.51; 12 month mean = 1.26) and resembled the trajectories of PTSD symptoms and functional limitations. CONCLUSIONS: The concerns of physically injured trauma survivors are readily elicited and followed up during the course of the year after injury. Open-ended inquiry regarding posttraumatic concerns may complement standardized outcome assessments by identifying and contextualizing the outcomes of greatest importance to patients.

Measuring patients' expectations and requests.

Patients seeking help for symptoms frequently worry about the underlying causes of their symptoms; have specific expectations for care; and request (or demand) time, information, and services. Understanding patients' concerns, expectations, and requests is important for clinicians, health care policymakers, and researchers. One obstacle to progress in this area has been disagreement over the most appropriate methods for identifying, monitoring, and classifying these phenomena. This article reviews the conceptual relationships linking patients' expectations, requests, and satisfaction with care; surveys contemporary approaches to the measurement of expectations and requests; and highlights recent empirical findings. The literature reviewed supports the conclusion that patients' expectations are wide ranging, can be measured, and have potentially important clinical consequences. For clinicians and policymakers alike, learning to elicit, evaluate, and understand patients' expectations will be a major task for the early part of the new century.

Individualized patient education and coaching to improve pain control among cancer outpatients.

PURPOSE: An estimated 42% of cancer patients suffer from poorly controlled pain, in part because of patient-related barriers to pain control. The objective of this study was to evaluate the effect of an individualized education and coaching intervention on pain outcomes and pain-related knowledge among outpatients with cancer-related pain. PATIENTS AND METHODS: English-speaking cancer patients (18 to 75 years old) with moderate pain over the past 2 weeks were randomly assigned to the experimental (n = 34) or control group (n = 33). Experimental patients received a 20-minute individualized education and coaching session to increase knowledge of pain self-management, to redress personal misconceptions about pain treatment, and to rehearse an individually scripted patient-physician dialog about pain control. The control group received standardized instruction on controlling pain. Data on average pain, functional impairment as a result of pain, pain frequency, and pain-related knowledge were collected at enrollment and 2-week follow-up. RESULTS: At baseline, there were no significant differences between experimental and control groups in terms of average pain, functional impairment as a result of pain, pain frequency, or pain-related knowledge. At follow-up, average pain severity improved significantly more among experimental group patients than among control patients (P =.014). The intervention had no statistically significant impact on functional impairment as a result of pain, pain frequency, or pain-related knowledge. CONCLUSION: Compared with provision of standard educational materials and counseling, a brief individualized education and coaching intervention for outpatients with cancer-related pain was associated with improvement in average pain levels. Larger studies are needed to validate these effects and elucidate their mechanisms.

Evaluating large and complex demonstrations: the CHAMPUS reform initiative experience. Civilian Health and Medical Program of the Uniformed Services.

OBJECTIVE: To examine the evaluation process for the CHAMPUS Reform Initiative (CRI) both to highlight issues that evaluators must consider when undertaking such projects and to provide policymakers with tools to better assess demonstration project evaluations. DATA SOURCES: The CRI evaluation. STUDY DESIGN: Case study. DATA COLLECTION: Review of CRI evaluation reports. PRINCIPAL FINDINGS: Although policymakers increasingly rely on the evaluations of demonstration projects to determine whether to extend the scope and funding of many public programs, the results of these evaluations are often difficult to assess. Despite its analytical sophistication, the CRI evaluation was no exception. The somewhat artificial time constraints imposed by policymakers made projection of the CRI's performance beyond the demonstration period particularly difficult. CONCLUSIONS: Much uncertainty generally remains even after well-planned and well-executed evaluations of demonstration projects.

How much explanation is enough? A study of parent requests for information and physician responses.

OBJECTIVE: To examine the relationship between doctor-parent communication patterns and parents' perceptions that they were listened to by the doctor. DESIGN: Cross-sectional, clinic-based survey. Before the visit, parents were asked about the strength of their desires/preferences for being listened to; after the visit, they were asked if their desires were fulfilled and to rate their satisfaction with care. Encounters were audiotaped, transcribed, and coded for parent requests for information and action and physician responses to those requests. Coding was performed using an adapted version of the Taxonomy of Requests by Patients (TORP). Physician responses to parental requests for information were coded as brief, moderate, or prolonged fulfillment or as partially fulfilled, ignored, or denied. SETTING: Two private pediatric practices, 1 community based and 1 university based. PARTICIPANTS: Ten of 13 eligible physicians (participation rate, 77%) and 306 of 356 eligible parents (participation rate, 86%) who sought care for their children's respiratory illnesses. Parents were invited to participate if they spoke and read English and if their child was 2-10 years old, had a chief complaint of cold symptoms, and was seeing one of the participating physicians. Complete data were obtained for 287 doctor-parent encounters (94%). RESULTS: Before the visit, 74% of parents reported that they considered it necessary for the physician to listen to their ideas about their child's illness. Among these parents, 62% (n = 130) reported after the visit that the physician had listened to their ideas. As the proportion of moderate-length responses to parent requests for information increased, parents were significantly more likely to report being listened to (P <.05). Multivariate results indicated a 59% probability of parents reporting that they were listened to when given moderate-length responses, 45% when given brief responses, 39% when given prolonged responses, and 12% when requests for information were only partially fulfilled, ignored, or denied. The length of response to parent requests for information was not related to overall parent satisfaction. CONCLUSIONS: Parents who received moderate-length answers to their questions were most likely to report that they were listened to. Although it is assumed that lengthier, in-depth explanations result in higher satisfaction, this study suggests that more doctor talk does not necessarily constitute better communication.

The educational value of consumer-targeted prescription drug print advertising.

BACKGROUND: The case for direct-to-consumer (DTC) prescription drug advertising has often been based on the argument that such promotions can educate the public about medical conditions and associated treatments. Our content analysis of DTC advertising assessed the extent to which such educational efforts have been attempted. METHODS: We collected advertisements appearing in 18 popular magazines from 1989 through 1998. Two coders independently evaluated 320 advertisements encompassing 101 drug brands to determine if information appeared about specific aspects of the medical conditions for which the drug was promoted and about the treatment (mean kappa reliability=0.91). We employed basic descriptive statistics using the advertisement as the unit of analysis and cross-tabulations using the brand as the unit of analysis. RESULTS: Virtually all the advertisements gave the name of the condition treated by the promoted drug, and a majority provided information about the symptoms of that condition. However, few reported details about the condition's precursors or its prevalence; attempts to clarify misconceptions about the condition were also rare. The advertisements seldom provided information about the drug's mechanism of action, its success rate, treatment duration, alternative treatments, and behavioral changes that could enhance the health of affected patients. CONCLUSIONS: Informative advertisements were identified, but most of the promotions provided only a minimal amount of information. Strategies for improving the educational value of DTC advertisements are considered.

A survey of physician attitudes and practices concerning cost-effectiveness in patient care.

OBJECTIVE: To identify physicians' views regarding cost-containment and cost-effectiveness and their attitudes and experience using cost-effectiveness in clinical decision making. DESIGN: A close-ended 30-item written survey. SUBJECTS: 1,000 randomly selected physicians whose practices currently encompass direct patient care and who work in the California counties of Sacramento, Yolo, Placer, Nevada, and El Dorado. OUTCOME MEASURES: Physician attitudes about the role of cost and cost-effectiveness in treatment decisions, perceived barriers to cost-effective medical practice, and response of physicians and patients if there are conflicts about treatment that physicians consider either not indicated or not cost-effective. RESULTS: Most physicians regard cost-effectiveness as an appropriate component of clinical decisions and think that only the treating physician and patient should decide what is cost-worthy. However, physicians are divided on whether they have a duty to offer medical interventions with remote chances of benefit regardless of cost, and they vary considerably in their interactions with patients when cost-effectiveness is an issue. CONCLUSION: Although physicians in the Sacramento region accept cost-effectiveness as important and appropriate in clinical practice, there is little uniformity in how cost-effectiveness decisions are implemented.

Measuring underuse of necessary care among elderly Medicare beneficiaries using inpatient and outpatient claims.

CONTEXT: Continuing changes in the health care delivery system make it essential to monitor underuse of needed care, even for relatively well-insured populations. Traditional approaches to measuring underuse have relied on patient surveys and chart reviews, which are expensive, or simple single-condition claims-based indicators, which are not clinically convincing. OBJECTIVE: To develop a comprehensive, low-cost system for measuring underuse of necessary care among elderly patients using inpatient and outpatient Medicare claims. DESIGN: A 7-member, multispecialty expert physician panel was assembled and used a modified Delphi method to develop clinically detailed underuse indicators likely to be associated with avoidable poor outcomes for 15 common acute and chronic medical and surgical conditions. An automated system was developed to calculate the indicators using administrative data. SETTING AND SUBJECTS: A total of 345,253 randomly selected elderly US Medicare beneficiaries in 1994-1996. MAIN OUTCOME MEASURES: Proportion of beneficiaries receiving care, stratified by indicators of necessary care (n = 40, including 3 for preventive care), and avoidable outcomes (n = 6). RESULTS: For 16 of 40 necessary care indicators (including preventive care indicators), beneficiaries received the indicated care less than two thirds of the time. Of all indicators, African Americans scored significantly worse than whites on 16 and better on 2; residents of poverty areas scored significantly lower than nonresidents on 17 and higher on 1; residents of federally defined Health Professional Shortage Areas scored significantly lower than nonresidents on 16 and higher on none (P<.05 for all). CONCLUSIONS: This claims-based method detected substantial underuse problems likely to result in negative outcomes in elderly populations. Significantly more underuse problems were detected in populations known to receive less-than-average medical care. The method can serve as a reliable, valid tool for monitoring trends in underuse of needed care for older patients and for comparing care across health care plans and geographic areas based on claims data. JAMA. 2000;284:2325-2333.