Teaching culturally effective diabetes care: results of a randomized controlled trial.

BACKGROUND AND OBJECTIVES: Increased cultural competence is a tool in the fight to eliminate health disparities in people with diabetes. However, questions remain regarding the best cultural competence teaching, evaluation, and dissemination methods. An Internet-based approach requires less facilitator time and provides greater ease of dissemination. We developed and tested a skills-focused, Internet-based course on cultural competence in the context of type 2 diabetes. METHODS: To test the effectiveness of the course, a randomized controlled trial was conducted on a national sample of 122 family medicine residents. The primary outcome was measured by changes in score on the Cultural Competence Assessment Tool (CCAT), a new self-assessment tool developed for this study. RESULTS: Total CCAT score increased significantly after the completion of the Internet course for 58 residents in the experimental group (83.55 before the course, 192.09 after the course) but did not change for the 64 residents in the control group (177.58 at baseline, 177.84 at end of study). On multivariate analysis, the only significant predictor of total CCAT score change was having taken the online course. CONCLUSIONS: A skills-based course on cultural competence, delivered via the Internet, is an effective educational strategy. It has potential for dissemination of standardized content.

The variable response of women with menopausal hot flashes when treated with sertraline.

OBJECTIVE: To evaluate the variable response of women when treated with a selective serotonin reuptake inhibitor (sertraline) to decrease hot flashes. DESIGN: A double-blind, placebo-controlled, crossover trial was conducted in 102 women aged 40 to 65 years who were experiencing hot flashes and not taking any hormone therapy. The original purpose of the study was to evaluate the effectiveness of sertraline for the treatment of hot flashes. After 1 week of baseline hot flash data collection, study participants were randomized to receive placebo or active drug (sertraline 50 mg) for 4 weeks. This intervention was followed by a 1-week washout and crossover to the opposite treatment for 4 weeks. The number and severity of hot flashes were measured. RESULTS: One hundred two women were enrolled in the study, and 87 completed the study. The average response was a statistically significant but clinically modest reduction in hot flash frequency and hot flash index (frequency x severity). These data on the average response have been previously published. Although the average response was modest, some women responded vigorously, others modestly, and some women actually worsened. This is a post hoc analysis of those data. Percentage of change was divided into three categories of clinical response: women with a clinically significant reduction (>or=30%, n=27), women with a nonsignificant reduction (<30% to none, n=28), and women with an increase (1%-100%, n=32). A vigorous response to sertraline for the treatment of hot flashes was related to activity level, education, and menopausal status. CONCLUSIONS: Women have markedly variable responses when treated with antidepressants for their hot flashes. We have begun to describe the characteristics of those most likely to respond to treatment with a selective serotonin reuptake inhibitor.

Literacy education as treatment for depression in patients with limited literacy and depression: a randomized controlled trial.

BACKGROUND: Individuals with limited literacy and those with depression share many characteristics, including low self-esteem, feelings of worthlessness, and shame. OBJECTIVE: To determine whether literacy education, provided along with standard depression treatment to adults with depression and limited literacy, would result in greater improvement in depression than would standard depression treatment alone. DESIGN: Randomized clinical trial with patients assigned either to an intervention group that received standard depression treatment plus literacy education, or a control group that received only standard depression treatment. PARTICIPANTS: Seventy adult patients of a community health center who tested positive for depression using the 9-question Patient Health Questionnaire (PHQ-9) and had limited literacy based on the Rapid Estimate of Adult Literacy in Medicine (REALM). MEASUREMENTS: Depression severity was assessed with PHQ-9 scores at baseline and at 3 follow-up evaluations that took place up to 1 year after study enrollment. Changes in PHQ-9 scores between baseline and follow-up evaluations were compared between the intervention and control groups. RESULTS: The median PHQ-9 scores were similar in both the intervention and control groups at baseline (12.5 and 14, respectively). Nine-question Patient Health Questionnaire scores improved in both groups, but the improvement was significantly larger in the intervention group. The final follow-up PHQ-9 scores declined to 6 in the intervention group but only to 10 in the control group. CONCLUSIONS: There may be benefit to assessing the literacy skills of patients who are depressed, and recommending that patients with both depression and limited literacy consider enrolling in adult education classes as an adjuvant treatment for depression.

The diverse functions of role models across primary care specialties.

BACKGROUND AND OBJECTIVES: This study investigated the relationship of role models to primary care specialty and gathered information on the attributes and functions of role models. METHODS: A questionnaire on medical school experiences and attitudes was administered to primary care graduates from 24 US medical schools. RESULTS: Questionnaires were completed by 1,457 physicians. Sixty-three percent of primary care respondents had a role model. Having a role model was significantly related to current specialty and ethnicity. Respondents most valued their role models' patient relationships. For family medicine and internal medicine graduates, having a role model was related to more contact and more-positive views of faculty in their specialty. Those with a role model reported that primary care was encouraged at their medical school and were more satisfied with their specialty choice. CONCLUSIONS: Role models may be more important to students who are not well represented among medical school faculty, namely women, underrepresented ethnic minorities, and those interested in family medicine. For family medicine graduates, role models function to moderate negative stereotypes. Role models may also make explicit the values of physicians in that specialty, making students more informed when choosing a specialty and as a consequence more satisfied with the decision.

Family medicine specialty choice and interest in research.

BACKGROUND AND OBJECTIVES: This study investigated interest in research related to declining interest in family medicine by US medical school graduates. METHODS: Twenty-four schools were selected for study based on American Academy of Family Physicians data on the number of their graduates entering family medicine. Data for all graduates in 1997, 1998, and 1999 were obtained from the Association of American Medical Schools matriculation and graduation questionnaires for 23 of 24 schools. RESULTS: Measures of research activity or interest were available on matriculation during medical school and at graduation. All were inversely related to interest in family medicine. Students interested in family medicine were less likely to have selected the field of medicine because of research interests, were less likely to have participated in a research project during medical school, and at graduation were less likely to plan on a career involving research. CONCLUSIONS: Given this pervasive negative relationship between interest in research and interest in family medicine, initiatives intended to increase research within the specialty of family medicine should be evaluated for their effects on student career choices. These initiatives may decrease interest in family medicine among students who don't want to do research but who otherwise might have been interested in family medicine. Conversely, they may increase interest in family medicine among students with research interest, or they may do both.

Lessons not learned from the generalist initiatives.

The grouping of the primary care specialties (general internal medicine, general pediatrics, and family medicine) for research purposes is at best limiting the value of the information that is found and, at worst, leading researchers to erroneous conclusions. For example, three large studies each showed differences in abilities to predict students' specialty choices in primary care (e.g., in one study, the investigators correctly predicted 3% of those choosing general internal medicine, 29% considering general pediatrics, and 51% considering family medicine). These and related findings suggest that medical students entering the three primary care specialties are not a homogeneous group. While there were some factors predictive for all primary care specialties, there were more factors that were unique to the individual specialties Grouping the specialties may not reveal factors that are significantly related to only one of the specialties. In addition, when a variable operates in different ways for different specialties, findings where the specialties are combined can show a reduced effect of that variable or even no effect, because the directions of effects cancel each other. Researchers can fruitfully examine the primary care specialties as a group but at the same time report their data for the individual specialties, which would greatly increase our knowledge both of primary care and also about the similarities and dissimilarities of its component specialties. However, the best models continue to be either research in which the sample size is large enough to compare specialty groups statistically or research with a focus on just one of the primary care specialties.

Which primary care specialty? Factors that relate to a choice of family medicine, internal medicine, combined internal medicine-pediatrics, or pediatrics.

BACKGROUND AND OBJECTIVES: This study was conducted to examine factors used by medical students to select a primary care specialty that may differentiate students who choose the primary care specialties of family medicine, internal medicine, pediatrics, and combined internal medicine-pediatrics. METHODS: A questionnaire was sent to all family physicians and an equal number of other primary care physicians graduating from one of 24 medical schools in 1997-1999. Twelve schools had increasing proportions of graduates choosing family medicine in this study period, and 12 had decreasing proportions. The questionnaire asked about factors related to choice of specialty, which could be grouped into the specialty domains of type of patients, process, content, and setting. RESULTS: For family physicians, the most important factor was patient relationships, and the second most important was wanting an approach to the practice of medicine similar to that of family physicians. Internists indicated as most important wanting to work with adults and as the next most important an "internal medicine approach" to the practice of medicine. Most important for pediatricians was working with children and next most important was having patient relationships like other pediatricians. Those in combined internal medicine-pediatrics most often indicated a desire to work with children and next most important was an approach to medicine like others in their specialty. CONCLUSIONS: The most important reasons for choice of specialty were similar for all primary care specialties and related to congruence between the graduate and the physicians in the specialty or the process of providing care within that specialty. The factors that differentiated the four specialties related to the content of the specialty.

Declining interest in family medicine: perspectives of department heads and faculty.

BACKGROUND AND OBJECTIVES: In 2003, US seniors filled 42% of family practice residency positions, the lowest percentage in the specialty's recent history. We hypothesized that institutional support, contact with family medicine faculty, and faculty satisfaction would be positively related to choice of family practice and that faculty satisfaction would be negatively affected by increasing pressure for clinical productivity. METHODS: We surveyed department heads and faculty at 24 US allopathic medical schools, selected by their rate of family medicine graduates from 1997 to 1999 and the size of the school. Twelve of these schools had an increase in rates of graduates selecting family practice, and 12 showed decreases. RESULTS: Department heads and faculty from schools with an increase in student entry into family practice residencies were significantly more likely to report financial and philosophical support from their state legislature or medical school administration. Faculty ranked patient care as most valued at their institutions, followed by teaching, research, and service. A common theme emerging from both the faculty and department head surveys was an inverse relationship between research activity and graduates choosing family practice. CONCLUSIONS: This study demonstrates the importance of upper-level institutional support on family practice specialty choice. It also highlights a need for further examination of the specialty's relationship to research.

Concurrent and longitudinal predictors of self-esteem in elementary and middle school girls.

BACKGROUND: The purpose of this study was to analyze the effects of factors related to self-esteem, both cross-sectionally and longitudinally, among 2 cohorts of girls over a period of 4 years, from elementary through middle school. METHODS: A multiethnic sample of 656 elementary school girls recruited from 13 schools in Hayward, CA, and Tucson, AZ, was evaluated annually over a 4-year period. The McKnight Risk Factor Survey IV was administered, which consists of 103 questions that assess self-esteem, appearance appraisal, effect of body changes, depressed mood, teasing, school performance, and other factors. In addition, participants' heights and weights were measured. RESULTS: The most important predictor of self-esteem in each grade was appearance appraisal, and, in all grades but the eighth, weight-related teasing by either boys or girls was also a predictor of self-esteem. Teasing about weight was more important than body weight itself in predicting self-esteem. Self-esteem was lower in girls who were teased about their weight, even if they believed that it had no effect on how they felt about themselves. School performance predicted self-esteem in grades 6 and 8. In longitudinal analyses, the participant's current perception of her appearance was more important than her previous level of self-esteem in predicting current self-esteem. CONCLUSIONS: The results of this study support the need to allocate funding to address the issue of teasing as 1 of the stressors in the school environment, and to explore further the important relationship between school performance and self-esteem.

Does literacy education improve symptoms of depression and self-efficacy in individuals with low literacy and depressive symptoms? A preliminary investigation.

BACKGROUND AND OBJECTIVES: Individuals with low literacy and symptoms of depression have greater improvement of depression symptoms when their treatment includes education to enhance literacy skills. The reason why literacy enhancement helps depression symptoms is unknown, but we hypothesize that it might be due to improved self-efficacy. We studied whether providing literacy education to individuals with both depression symptoms and limited literacy might improve their self-efficacy. METHODS: We studied 39 individuals enrolled in an adult literacy program and who, on further testing with the Patient Health Questionnaire (PHQ-9) had symptoms of depression. While they participated in the literacy program, we monitored their self-efficacy using the General Self Efficacy (GSE) scale, and also monitored the severity of depression symptoms with the PHQ-9. Changes in GSE and PHQ-9 scores from baseline were assessed with the Wilcoxon Signed Ranks Test. RESULTS: Thirty-one (79.5%) subjects participated for 1 year. There was a significant increase in their self-efficacy (P = .019) and a significant decrease in depression symptoms (P < .002). CONCLUSION: The results of this preliminary study suggest that among persons with low literacy and symptoms of depression, depression symptoms lessen as self-efficacy scores improve during participation in adult basic literacy education.

Food cravings, ethnicity and other factors related to eating out.

OBJECTIVE: Our objective was to study factors related to eating patterns, specifically whether certain food cravings were associated with frequency of meals eaten away from home. METHODS: Data were collected from 277 patients from a family medicine residency office in Arizona. The survey questionnaire included information about the respondents' demographics, socioeconomic status, food cravings, as well as, number of meals eaten away from home. The food craving inventory included foods in four categories identified by factor analysis: fast foods, carbohydrates, sweets and snacks. Data on food cravings were factor analyzed and scale scores were derived. RESULTS: Being a Hispanic adult, working outside the home, and cravings for individual food items were related to eating more meals away from home. If the mother was working outside the home, the youngest child ate an average of two additional meals away from home each week. In general respondent's cravings for some specific food items were also related to higher numbers of meals their child ate away from home. Cravings for both fast food and snacks were positively correlated with adult eating out. None of the respondents' scale scores were related to child's eating away from home. Adults with Arizona Health Care Cost Containment System insurance (AHCCCS--a form of Medicaid) and older adults were less likely to eat away from home compared to patients with other types of insurance. CONCLUSIONS: Socioeconomic status, ethnicity, and food cravings are related to adult and child patterns of eating meals away from home.

Does dieting lead to weight gain? A four-year longitudinal study of middle school girls.

OBJECTIVE: A majority of the published longitudinal research on children has reported that dieting is related to weight gain at a later point in time. The purpose of this study was to look at weight control behaviors and patterns of weight gain and loss, specifically whether dieting is related to weight gain. RESEARCH METHODS AND PROCEDURES: Baseline data were collected from 1358 female students in grades 6 to 9 from schools in Hayward, CA, and Tucson, AZ. Data were obtained annually over a 4-year period. Paper-and-pencil questionnaires and height and weight were obtained during the students' regular classroom periods. Dieting was measured both with the single item, "In the past year, how often have you been on a diet to lose weight?" scored from "never" to "always," and with a Dieting Behavior Scale including five items on weight control behaviors. Changes in BMI z-scores were analyzed. RESULTS: On average, girls who reported "never" dieting were most likely to have an increased BMI z-score at the next measurement, and those who reported "always" dieting were most likely to have a decreased BMI z-score. The same pattern was true for the Dieting Behavior Scale. DISCUSSION: Our finding that dieting and weight gain were not related, independently of initial BMI, does not mean that dieting to lose weight is appropriate, especially among young girls. Additional research is needed both to examine this relationship and to determine exactly what behaviors children are engaging in when they report that they are dieting.

Factors related to the choice of family medicine: a reassessment and literature review.

BACKGROUND: Recent decreases in the number of students entering family medicine has prompted reconsideration of what is known about the factors affecting specialty choice. METHODS: Thirty-six articles on family medicine specialty choice published since 1993 were reviewed and rated for quality. RESULTS: Rural background related positively and parents' socioeconomic status relates negatively to choice of family medicine. Career intentions at entry to medical school predict specialty choice. Students who believe primary care is important, have low income expectations, and do not plan a research career are more likely to choose family medicine. The school characteristic related to choice of family medicine is public ownership. Large programs to increase numbers entering primary care seem effective. Required family medicine time in clinical years is related to higher numbers selecting family medicine. Faculty role models serve both as positive and negative influences. Students rejecting family medicine are concerned about prestige, low income, and breadth of knowledge required. Students planning on a career in a disadvantaged or rural area are more likely to enter family medicine. CONCLUSIONS: Multiple factors are consistently shown to be related to the choice of the specialty of family medicine.