Recall-promoting physician behaviors in primary care.

BACKGROUND: Effective treatments can be rendered useless by poor patient recall of treatment instructions. Studies suggest that patients forget a great deal of important information and that recall can be increased through recall-promoting behaviors (RPBs) like repetition or summarization. OBJECTIVE: To assess how frequently RPBs are used in primary care, and to reveal how they might be applied more effectively. DESIGN: Recordings of 49 unannounced standardized patient (SP) visits were obtained using hidden audiorecorders. All SPs presented with typical gastroesophageal reflux disease symptoms. Transcripts were coded for treatment recommendations and RPBs. PARTICIPANTS: Forty-nine primary care physicians. RESULTS: Of 1,140 RPBs, 53.7% were repetitions, 28.2% were communication of the rationale for a treatment, 11.7% were categorizations of treatments (i.e., stating that a treatment could be placed into a treatment category, such as medication-related or lifestyle-related categories), and 3.8% were emphasis of a recommendation's importance. Physicians varied substantially in their use of most RPBs, although no physicians summarized or asked patients to restate recommendations. The number of RPBs was positively correlated with visit length. CONCLUSIONS: Primary care physicians apply most RPBs inconsistently, do not utilize several RPBs that are particularly helpful, and may use RPBs inefficiently. Simple principles guiding RPB use may help physicians apply these communication tools more effectively.

Factors affecting physicians' responses to patients' requests for antidepressants: focus group study.

BACKGROUND: The ways in which patients' requests for antidepressants affect physicians' prescribing behavior are poorly understood. OBJECTIVE: To describe physicians' affective and cognitive responses to standardized patients' (SPs) requests for antidepressants, as well as the attitudinal and contextual factors influencing prescribing behavior. DESIGN: Focus group interviews and brief demographic questionnaires. PARTICIPANTS: Twenty-two primary care physicians in 6 focus groups; all had participated in a prior RCT of the influence of patients' requests on physicians' prescribing. MEASUREMENTS: Iterative review of interview transcripts, involving qualitative coding and thematic analysis. RESULTS: Physicians participating in the focus groups were frequently unaware of and denied the degree to which their thinking was biased by patient requests, but were able to recognize such biases after facilitated reflection. Common affective responses included annoyance and empathy. Common cognitive reactions resulted in further diagnostic inquiry or in acquiescing to the patient's demands to save time or build the patient-clinician relationship. Patients' requests for medication prompted the participants to err on the side of overtreating versus careful review of clinical indications. Lack of time and participants' attitudes--toward the role of the patient and the pharmaceutical ads--also influenced their responses, prompting them to interpret patient requests as diagnostic clues or opportunities for efficiency. CONCLUSIONS: This study provides a taxonomy of affective and cognitive responses to patients' requests for medications and the underlying attitudes and contextual factors influencing them. Improved capacity for moment-to-moment self-awareness during clinical reasoning processes may increase the appropriateness of prescribing.

Home monitoring using wearable radio frequency transmitters.

BACKGROUND: Location tracking of a wearable radio frequency (RF) transmitter in a wireless network is a potentially useful tool for the home monitoring of patients in clinical applications. However, the problem of converting RF signals into accurate estimates of transmitter location remains a significant challenge. OBJECTIVES: We wish to demonstrate that long-term home monitoring using RF transmitters is feasible. Additionally, we conjecture that human motion within familiar environments is confined to relatively small regions of high occupancy. Hence, human motion can be modelled as movement along a network of such high occupancy regions. METHODS AND MATERIALS: Our methodology uses a signal processing technique developed by one of the authors (Almudevar). The technique converts longitudinal RF data into an estimated trajectory which does not depend on explicit location estimates. This approach eliminates the need for a location-signal calibration procedure. Given a long-term trajectory, Gaussian mixture models are used to identify high occupancy regions. The methodology was evaluated using data collected under a study funded by an Everyday Technologies for Alzheimer Care (ETAC) research grant from the Alzheimer's Association. A home monitoring system provided by Home Free Systems was used. RESULTS: The proposed methodology was able to reliably reconstruct trajectories using study data. Regions of high occupancy were identified, and the observed transitions between these regions were found to be spatially and serially coherent. In addition, the trajectory was compared to output from a parallel home sensor network, and a high degree a conformity was evident. CONCLUSION: Long-term home monitoring of human motion is feasible using readily available and easily installable technology. Furthermore, by using suitable signal processing algorithms, the often difficult location-signal calibration process can be bypassed.

Integrating a Resident-Driven Longitudinal Quality Improvement Curriculum Within an Ambulatory Block Schedule.

BACKGROUND: Quality improvement (QI) is essential in clinical practice, requiring effective teaching in residency. Barriers include lack of structure, mentorship, and time. OBJECTIVE: To develop a longitudinal QI curriculum for an internal medicine residency program with limited faculty resources and evaluate its effectiveness. METHODS: All medicine residents were provided with dedicated research time every 8 weeks during their ambulatory blocks. Groups of 3 to 5 residents across all postgraduate year levels were formed. Two faculty members and 1 chief resident advised all groups, meeting with each group every 8 weeks, with concrete expectations for each meeting. Residents were required to complete didactic modules from the Institute for Healthcare Improvement. Current residents and alumni were surveyed for feedback. RESULTS: Over 3 years, all eligible residents (92 residents per year in 2012-2014, 102 in 2014-2015) participated in the curriculum. Residents worked on 54 quality assessment and 18 QI projects, with 6 QI projects showing statistically significant indicator improvements. About 50 mentoring hours per year were contributed by 2 faculty advisors and a chief resident. No other staff or IT support was needed. A total of 69 posters/abstracts were produced, with 13 projects presented at national or regional conferences. Survey respondents found the program useful; most (75% residents, 63% alumni) reported it changed their practice, and 71% of alumni found it useful after residency. CONCLUSIONS: Our longitudinal QI curriculum requires minimal faculty time and resulted in increased QI-related publications and measurable improvements in quality indicators. Alumni reported a positive effect on practice after graduation.

Changing the P300 brain computer interface.

Brain-computer interfaces (BCIs) are now feasible for use as an alternative control option for those with severe motor impairments. The P300 component of the evoked potential has proven useful as a control signal. Individuals do not need to be trained to produce the signal, and it is fairly stable and has a large evoked potential. Even with recent signal classification advances, on-line experiments with P300-based BCIs remain far from perfect. We present two potential methods for improving control accuracy. Experimental results in an evoked potential BCI, used to control items in a virtual apartment, show a reduced response exists when items are accidentally controlled. The presence of a P300-like signal in response to goal items means that it can be used for automatic error correction. Preliminary results from an interface experiment using three different button configurations for a yes/no BCI task show that the configuration of buttons may affect on-line signal classification. These results will be discussed in light of the special considerations needed when working with an amyotrophic lateral sclerosis (ALS) patient.

Managing cardiovascular disease risk in patients treated with antipsychotics: a multidisciplinary approach.

BACKGROUND: The use of antipsychotic medication in the United States and throughout the world has greatly increased over the last fifteen years. These drugs have significant side effect burdens, many of them relating to cardiovascular health. OBJECTIVE: To review the available evidence on the major cardiovascular issues that arise in patients taking antipsychotic medication. METHOD: A PubMed literature review was performed to identify recent meta-analyses, review articles, and large studies. Further articles were identified through cited papers and based on expert consultation when necessary. RESULTS: CLINICAL GUIDANCE ON THE FOLLOWING ADVERSE EFFECTS AND ANTIPSYCHOTICS WAS REVIEWED: electrocardiogram (ECG) changes, (specifically, prolonged QT and risk of torsades de pointes), weight gain, dyslipidemia, metabolic syndrome, and myocarditis. Specific attention was paid to monitoring guidelines and treatment options in the event of adverse events, including dose change, medication switch, or adjuvant therapy.