Hypertension management in minority communities: a clinician survey.

BACKGROUND: Rates of blood pressure (BP) control are lower in minority populations compared to whites. OBJECTIVE: As part of a project to decrease health-related disparities among ethnic groups, we sought to evaluate the knowledge, attitudes, and management practices of clinicians caring for hypertensive patients in a predominantly minority community. DESIGN/PARTICIPANTS: We developed clinical vignettes of hypertensive patients that varied by comorbidity (type II diabetes mellitus, chronic renal insufficiency, coronary artery disease, or isolated systolic hypertension alone). We randomly assigned patient characteristics, e.g., gender, age, race/ethnicity, to each vignette. We surveyed clinicians in ambulatory clinics of the 4 hospitals in East/Central Harlem, NY. MEASUREMENTS: The analysis used national guidelines to assess the appropriateness of clinicians' stated target BP levels. We also assessed clinicians' attitudes about the likelihood of each patient to achieve adequate BP control, adhere to medications, and return for follow-up. RESULTS: Clinicians' target BPs were within 2 mm Hg of the recommendations 9% of the time for renal disease patients, 86% for diabetes, 94% for isolated systolic hypertension, and 99% for coronary disease. BP targets did not vary by patient or clinician characteristics. Clinicians rated African-American patients 8.4% (p = .004) less likely and non-English speaking Hispanic patients 8.1% (p = .051) less likely than white patients to achieve/maintain BP control. CONCLUSIONS: Clinicians demonstrated adequate knowledge of recommended BP targets, except for patients with renal disease. Clinicians did not vary management by patients' sociodemographics but thought African-American, non-English-speaking Hispanic and unemployed patients were less likely to achieve BP control than their white counterparts.

Using structured debate to teach a controversial topic: mammography for women in their 40s.

BACKGROUND: Screening mammography for women in their 40s is controversial, and counseling patients about it can be challenging. Debate is an educational tool that lends itself to teaching about controversial topics and improving communication skills but is underused in medical education. PURPOSE: The purpose of this intervention was to improve residents' willingness to discuss mammography with patients. METHODS: Second-year internal medicine residents participated in a 3-hr structured debate on screening mammography for women in their 40s. The intervention's effect was measured using pretest and posttest questionnaires. RESULTS: A total of 33 residents participated in 6 debates between January and June of 2003. Comparison of pretest and posttest questionnaires showed that participants became more comfortable discussing mammography screening and were more likely to discuss it with their patients after the debate. CONCLUSIONS: A structured debate resulted in residents reporting increased comfort level and willingness to discuss mammography with women in their 40s.

Internists training medical residents in pelvic examination: impact of an educational program.

BACKGROUND: Pelvic examination is an important component of the primary care of women by internists, but training beyond medical school is rare. DESCRIPTION: We created an internist-run educational program for 1st-year medical residents in pelvic examination. The program consisted of 4 weekly patient-care sessions with 2 to 3 patients seen by each resident each session. Internists supervised each exam and gave real-time feedback and utilized a skills-assessment checklist during the first and last exams of the program to give comprehensive, formative feedback. EVALUATION: We evaluated the program using a self-assessment questionnaire concerning pelvic examination competency and attitudes, which utilized a 5-point Likert scale and was administered prior to, and 3 months after, the program. A total of 37 participants completed the program and reported improvements in competency and a trend toward an increased likelihood of performing exams. CONCLUSIONS: This program, in which internists trained medical residents in pelvic examination, utilized real patients, improved participants self-assessed competency, and may increase the likelihood of residents performing pelvic examination in primary care.