"Sharing in hopes and worries"-a qualitative analysis of the delivery of compassionate care in palliative care and oncology at end of life.

Purpose: To explore the methods through which physicians deliver compassionate care during end-of-life (EOL). Compassionate care provides benefits to patients and providers and is particularly important for patients with serious illnesses, yet its practice remains limited. We aim to qualitatively characterize methods utilized by physicians that facilitate the delivery of compassionate care at EOL. Methods: We conducted 13 semi-structured interviews with physicians from palliative care and medical oncology subspecialities at a rural academic medical centre in New Hampshire. Interviews were transcribed and analysed using a qualitative research design. Results: Participants described methods of compassionate care ranging from symptom control to less tangible, non-verbal methods. Primary barriers to the delivery of compassionate care were described as within the broader healthcare system and within the inherent emotional difficulty of EOL care. Physicians from both subspecialities emphasized the importance of successful inter-provider relationships. Conclusions: Methods for delivering compassionate care at EOL are wide ranging, but barriers on a systemic and individual level should be addressed to make its practice more widespread. This can be accomplished, in part, by the standardization of EOL conversations, training physicians how to have meaningful EOL conversations, and integration of such conversations into electronic medical records.

The effect of an extract of green and black tea on glucose control in adults with type 2 diabetes mellitus: double-blind randomized study.

Recent evidence suggests that tea from Camellia sinensis (eg, green, oolong, and black tea) may have a hypoglycemic effect. We evaluated the ability of an extract of green and black tea to improve glucose control over a 3-month period. A double-blind, placebo-controlled, randomized multiple-dose (0, 375, or 750 mg per day for 3 months) study in adults with type 2 diabetes mellitus not taking insulin was performed. The primary end point was change in glycosylated hemoglobin at 3 months. The 49 subjects who completed this study were predominantly white with an average age of 65 years and a median duration of diabetes of 6 years, and 80% of them reported using hypoglycemic medication. After 3 months, the mean changes in glycosylated hemoglobin were +0.4 (95% confidence interval, 0.2-0.6), +0.3 (0.1-0.5), and +0.5 (0.1-0.9) in the placebo, 375-mg, and 750-mg arms, respectively. The changes were not significantly different between study arms. We did not find a hypoglycemic effect of extract of green and black tea in adults with type 2 diabetes mellitus.

Obesity perceptions and documentation among primary care clinicians at a rural academic health center.

BACKGROUND: Obesity recognition in primary care is important to address the epidemic. We aimed to evaluate primary care clinician-reported documentation, management practices, beliefs and attitudes toward obesity compared to body mass index (BMI) calculation, obesity prevalence and actual documentation of obesity as an active problem in electronic health record in a rural academic center. METHODS: Our target population for previously validated clinician survey was 56 primary care providers working at 3 sites. We used calendar year 2012 data for assessment of baseline system performance for metrics of documentation of BMI in primary care visits, and proportion of visits in patients with obesity with obesity as a problem. Standard statistical methods assessed the data. RESULTS: Survey response rate was 91%. Average age of respondents was 48.9 years and 62.7% were females. 72.5% clinicians reported having normal BMI. The majority of clinicians reported regularly documenting obesity as an active problem, and utilized motivational interviewing and basic good nutrition and healthy exercise. Clinicians identified lack of discipline and exercise time, access to unhealthy food and psychosocial issues as major barriers. Most denied disliking weight loss discussion or patients taking up too much time. In 21,945 clinic visits and 11,208 annual preventive care visits in calendar year 2012, BMI was calculated in 93% visits but obesity documentation as an active problem only 27% of patients meeting BMI criteria for obesity. CONCLUSIONS: Despite high clinician-reported documentation of obesity as an active problem, actual obesity documentation rates remained low in a rural academic medical center.

Computer use among community-based primary care physician preceptors.

PURPOSE: Use of the Internet to access biomedical information in patient care has important implications in medical education. Little is known about how community-based clinical teachers use computers in their offices and what factors, such as age, may influence use. METHOD: A total of 178 active community-based primary care preceptors were mailed a 15-item questionnaire about their computer equipment; Internet use; and specific applications in patient care, patients' education, medical students' or residents' education, or accessing other clinical and/or research information. Data analysis used descriptive statistics, chi-square for comparisons of categorical data and analysis of variance (ANOVA) mixed model for comparisons of continuous variables. All tests were two-tailed with alpha set at.05 to determine statistical significance. RESULTS: In all, 129 preceptors responded (73%). Office computer availability was high (92%). The Internet as a clinical information resource was used most frequently (98%) and MD Consult and Medline-EBM were used less frequently (20% and 21%, respectively). No statistical differences were found in routine use by age of preceptor; frequency of use did differ. Preceptors 60 years or older were four times more likely to use the Internet to assist in students' and residents' education (p =.02) and at least twice as likely to use full text Medline articles for patient care decisions (p =.05) than their younger colleagues. Decreased computer use was related to lack of time (45%) or other logistical reasons (40%), such as the computer's distance from the patient care areas or slow connections. CONCLUSIONS: Rates of computer access and Internet connectivity were high among community-based preceptors of all ages. Uses of specific online clinical and/or educational resources varied by preceptors' age with more rather than less use among older preceptors, an unexpected finding.

A collaborative model for supporting community-based interdisciplinary education.

Development and support of community-based, interdisciplinary ambulatory medical education has achieved high priority due to on-site capacity and the unique educational experiences community sites contribute to the educational program. The authors describe the collaborative model their school developed and implemented in 2000 to integrate institution- and community-based interdisciplinary education through a centralized office, the strengths and challenges faced in applying it, the educational outcomes that are being tracked to evaluate its effectiveness, and estimates of funds needed to ensure its success. Core funding of $180,000 is available annually for a centralized office, the keystone of the model described here. With this funding, the office has (1) addressed recruitment, retention, and quality of educators for UME; (2) promoted innovation in education, evaluation, and research; (3) supported development of a comprehensive curriculum for medical school education; and (4) monitored the effectiveness of community-based education programs by tracking product yield and cost estimates needed to generate these programs. The model's Teaching and Learning Database contains information about more than 1,500 educational placements at 165 ambulatory teaching sites (80% in northern New England) involving 320 active preceptors. The centralized office facilitated 36 site visits, 22% of which were interdisciplinary, involving 122 preceptors. A total of 98 follow-up requests by community-based preceptors were fulfilled in 2000. The current submission-to-funding ratio for educational grants is 56%. Costs per educational activity have ranged from $811.50 to $1,938, with costs per preceptor ranging from $101.40 to $217.82. Cost per product (grants, manuscripts, presentations) in research and academic scholarship activities was $2,492. The model allows the medical school to balance institutional and departmental support for its educational programs, and to better position itself for the ongoing changes in the health care system.

Educational epidemiology: applying population-based design and analytic approaches to study medical education.

Conducting educational research in medical schools is challenging partly because interventional controlled research designs are difficult to apply. In addition, strict accreditation requirements and student/faculty concerns about educational inequality reduce the flexibility needed to plan and execute educational experiments. Consequently, there is a paucity of rigorous and generalizable educational research to provide an evidence-guided foundation to support educational effectiveness. "Educational epidemiology," ie, the application across the physician education continuum of observational designs (eg, cross-sectional, longitudinal, cohort, and case-control studies) and randomized experimental designs (eg, randomized controlled trials, randomized crossover designs), could revolutionize the conduct of research in medical education. Furthermore, the creation of a comprehensive national network of educational epidemiologists could enhance collaboration and the development of a strong educational research foundation.