Cultural competency in medical education: demographic differences associated with medical student communication styles and clinical clerkship feedback.

PURPOSE: We tested the significance of associations among students' demographics, communication styles, and feedback received during clerkships. METHODS: US medical students who completed at least one required clinical clerkship were invited between April and July 2006 to complete an anonymous, online survey inquiring about demographics, communication styles (assertiveness and reticence), feedback (positive and negative), and clerkship grades. The effects of self-identified race/ethnicity, gender, and generation (immigrant, first- or second-generation American) and their 2-way interactions on assertiveness, reticence, total positive and total negative feedback comments were tested using factorial analysis of covariance, controlling for age, clerkship grades, and mother's and father's education; pairwise comparisons used simple contrasts. Two-sided P values < .05 were considered significant. RESULTS: Medical students from 105 schools responded (N = 2395: 55% women; 57% white). Men reported more assertiveness than women (P = .001). Reticence (P < .001) and total positive comments (P = .006) differed by race/ethnicity; in pairwise contrasts, black, East Asian, and Native American/ Alaskan students reported greater reticence than white students (P < .001), and white students reported receiving more positive comments than black, and South and East Asian students. Race/ethnicity-by-generation (P = .022) and gender-by-generation (P = .025) interaction effects were observed for total negative comments; white first-generation Americans reported receiving the fewest and male immigrants reported receiving the most negative comments. CONCLUSIONS: Demographic differences in students' communication styles and feedback they received highlight a need for cultural competency training to improve medical student-teacher interactions, analogous to training currently advocated to improve physician-patient interactions.

Components of a successful intervention for monthly skin self-examination for early detection of melanoma: the "Check It Out" trial.

BACKGROUND: Multicomponent Check-It-Out project interventions were found to be effective at increasing thorough skin self-examinations (TSSE). Application of this research will benefit from determining the most important interventions for promoting TSSE. OBJECTIVE: Identification of the most important Check-It-Out intervention components for promoting TSSE. METHODS: This study analyzed the responses of the 567 participants who were randomized into the skin examination intervention group and who did not report performing TSSE at their baseline interview. RESULTS: Watching the video, using the hand mirror, shower card, American Cancer Society brochure, sample photographs, and finding the health educator helpful were associated with performing TSSE at 2 months, 12 months, or both. LIMITATIONS: Use of the materials within the skin group was not randomly assigned. All data were based on participant self-report. CONCLUSIONS: As future interventions to increase TSSE are developed, the identified useful components will be important to include.

Diphenyl difluoroketone: a curcumin derivative with potent in vivo anticancer activity.

Diphenyl difluoroketone (EF24), a molecule having structural similarity to curcumin, was reported to inhibit proliferation of a variety of cancer cells in vitro. However, the efficacy and in vivo mechanism of action of EF24 in gastrointestinal cancer cells have not been investigated. Here, we assessed the in vivo therapeutic effects of EF24 on colon cancer cells. Using hexosaminidase assay, we determined that EF24 inhibits proliferation of HCT-116 and HT-29 colon and AGS gastric adenocarcinoma cells but not of mouse embryo fibroblasts. Furthermore, the cancer cells showed increased levels of activated caspase-3 and increased Bax to Bcl-2 and Bax to Bcl-xL ratios, suggesting that the cells were undergoing apoptosis. At the same time, cell cycle analysis showed that there was an increased number of cells in the G(2)-M phase. To determine the effects of EF24 in vivo, HCT-116 colon cancer xenografts were established in nude mice and EF24 was given i.p. EF24 significantly suppressed the growth of colon cancer tumor xenografts. Immunostaining for CD31 showed that there was a lower number of microvessels in the EF24-treated animals coupled with decreased cyclooxygenase-2, interleukin-8, and vascular endothelial growth factor mRNA and protein expression. Western blot analyses also showed decreased AKT and extracellular signal-regulated kinase activation in the tumors. Taken together, these data suggest that the novel curcumin-related compound EF24 is a potent antitumor agent that induces caspase-mediated apoptosis during mitosis and has significant therapeutic potential for gastrointestinal cancers.

"Making the grade:" noncognitive predictors of medical students' clinical clerkship grades.

OBJECTIVES: Because clinical clerkship grades are associated with resident selection and performance and are largely based on residents'/attendings' subjective ratings, it is important to identify variables associated with clinical clerkship grades. METHODS: U.S. medical students who completed > or =1 of the following required clinical clerkships--internal medicine, surgery, obstetrics/gynecology, pediatrics, neurology and psychiatry--were invited to participate in an anonymous online survey, which inquired about demographics, degree program, perceived quality of clerkship experiences, assertiveness, reticence and clerkship grades. RESULTS: A total of 2395 medical students (55% women; 57% whites) from 105 schools responded. Multivariable logistic regression models identified factors independently associated with receiving lower clerkship grades (high pass/pass or B/C) compared with the highest grade (honors or A). Students reporting higher quality of clerkship experiences were less likely to report lower grades in all clerkships. Older students more likely reported lower grades in internal medicine (P = 0.02) and neurology (P < 0.001). Underrepresented minorities more likely reported lower grades in all clerkships (P < 0.001); Asians more likely reported lower grades in obstetrics/gynecology (P = 0.007), pediatrics (P = 0.01) and neurology (P = 0.01). Men more likely reported lower grades in obstetrics/gynecology (P < 0.001) and psychiatry (P = 0.004). Students reporting greater reticence more likely reported lower grades in internal medicine (P = 0.02), pediatrics (P = 0.02) and psychiatry (P < 0.05). Students reporting greater assertiveness less likely reported lower grades in all clerkships (P < 0.03) except IM. CONCLUSIONS: The independent associations between lower clerkship grades and nonwhite race, male gender, older age, lower quality of clerkship experiences, and being less assertive and more reticent are concerning and merit further investigation.

Identification of breast cancer in patients with pathologic nipple discharge: does ductoscopy predict malignancy?

OBJECTIVE: The purpose of the current study was to review characteristics of patients with nipple discharge who underwent ductoscopy-assisted excisional biopsy who had a final diagnosis of carcinoma. METHODS: A retrospective review was performed of patients presenting with pathologic nipple discharge (PND) who underwent ductoscopy-assisted excisional biopsy and had a final diagnosis of carcinoma. RESULTS: A total of 14 (7%) of 188 patients who underwent ductoscopy-assisted excision had a final pathology of ductal carcinoma-in-situ (DCIS) (12/14, 86%) or invasive breast cancer with DCIS (2/14, 14%). Duct wall irregularities or intraluminal growths were visualized during ductoscopy in 8 of the 14 (57%) breast cancer patients. There were no visual abnormalities noted during ductoscopy that accurately predicted a final diagnosis of malignancy. CONCLUSIONS: Although occult malignancies can be identified in patients undergoing ductoscopy-assisted biopsy for PND, no clear morphologic changes visualized during ductoscopy definitively indicated the presence of malignancy.

Race is a fundamental prognostic indicator for 2325 northeastern Ohio women with infiltrating breast cancer.

The goal of this research was to determine if race, independent of socioeconomic status, is a prognostic indicator for women diagnosed with infiltrating breast cancer. We hypothesized that black patients would present with breast cancers having less favorable prognostic indicators relative to white patients, regardless of socioeconomic status. Using data collected prospectively in our institutional review board approved breast center patient registry and 2000 Census Tract data for northeastern Ohio, we compared tumor size, node status, hormone receptor status, clinical outcomes, and socioeconomic status for patients who were self-described as either black or white and who had been diagnosed with infiltrating breast cancer. The chi-square test, t-test, log-rank test, and Cox proportional hazards analysis were used to analyze the data. Kaplan-Meier outcome curves were generated. Data were available for 2325 women, including 313 who were black and 2012 who were white. Compared to white patients, black patients were more likely to have positive axillary nodes and to have hormone receptor-negative tumors. Black patients were also more likely to have positive axillary nodes associated with smaller tumors. Independent of socioeconomic status, black patients were more likely to have poorer overall survival and disease-free survival rates for breast cancer relative to white patients. The prognostic significance of race was not dependent on a concomitant relationship with socioeconomic status.

Does core needle breast biopsy accurately reflect breast pathology?

BACKGROUND: Core needle breast biopsy (CB) has replaced excisional biopsy as the initial diagnostic biopsy procedure for many suspicious breast lesions; however, CB remains a sampling procedure. The purpose of this study was to determine the degree of agreement between histology obtained at CB and that obtained at a subsequent excisional procedure (EP). We hypothesized a high degree of agreement. METHODS: Data were collected prospectively for 3035 CBs performed by breast radiologists using either ultrasound or stereotactic guidance between January 1995 and July 2002, 1410 (46%) of which had a subsequent EP within 1 year. Histologic categories were defined as invasive breast cancer, duct carcinoma in-situ, atypia/lobular carcinoma in-situ, and benign. The principal histology (PH) from CB and EP was identified and compared. RESULTS: Overall, there was moderate agreement (kappa=0.669) between CB and EP histology. Complete agreement occurred in 1168 (83%) procedures. For the remaining 242, the PH was identified only at CB for 78 (5%) procedures, and only after EP for 164 (12%) procedures. CONCLUSIONS: Although the majority (83%) of CB and EP demonstrated exact histologic agreement, CB was diagnostic for 1246 (88%) procedures.

Does ultrasound core breast biopsy predict histologic finding on excisional biopsy?

BACKGROUND: The purpose of this study was to determine whether ultrasound-guided core breast biopsy accurately predicts the histologic finding of a subsequent excisional procedure. METHODS: Data were collected prospectively from 1997 to 2001 for 832 ultrasound-guided core breast biopsies (USB) that were followed by excisional breast procedure (EP) within 1 year at our institution. The principal histologic finding obtained at USB and EP was identified for each procedure and the degree of agreement was assessed. RESULTS: The USB histology predicted EP histology in 90% (n = 746) of the procedures. The USB histology was more significant than EP histology in 3% (n = 22) of procedures; USB histology underdetermined EP histology in 7% (n = 64) of procedures. Overall, our results indicate moderate agreement between the principal histology identified at USB relative to that identified at EP. CONCLUSIONS: Ultrasound-guided core breast biopsy is an effective diagnostic method, but sampling limitations do exist.