Factors affecting clinician educator encouragement of routine HIV testing among trainees.

BACKGROUND: Adoption of CDC recommendations for routine, voluntary HIV screening of all Americans age 13­64 years has been slow. One method to increase adherence to clinical practice guidelines is through medical school and residency training. OBJECTIVE: To explore the attitudes, barriers, and behaviors of clinician educators (CEs) regarding advocating routine HIV testing to their trainees. DESIGN/PARTICIPANTS: We analyzed CE responses to a 2009 survey of Society of General Internal Medicine members from community, VA, and university-affiliated clinics regarding HIV testing practices. MAIN MEASURES: Clinician educators were asked about their outpatient practices, knowledge and attitudes regarding the revised CDC recommendations and whether they encouraged trainees to perform routine HIV testing. Associations between HIV testing knowledge and attitudes and encouraging trainees to perform routine HIV testing were estimated using bivariate and multivariable logistic regression. RESULTS: Of 515 respondents, 367 (71.3%) indicated they supervised trainees in an outpatient general internal medicine clinic. These CEs demonstrated suboptimal knowledge of CDC guidelines and over a third reported continued risk-based testing. Among CEs, 196 (53.4%) reported that they encourage trainees to perform routine HIV testing. Higher knowledge scores (aOR 5.10 (2.16, 12.0)) and more positive attitudes toward testing (aOR 8.83 (4.21, 18.5)) were independently associated with encouraging trainees to screen for HIV. Reasons for not encouraging trainees to screen included perceived low local prevalence (37.2%), competing teaching priorities (34.6%), and a busy clinic environment (34.0%). CONCLUSIONS: Clinician educators have a special role in the dissemination of the CDC recommendations as they impact the knowledge and attitudes of newly practicing physicians. Despite awareness of CDC recommendations, many CEs do not recommend universal HIV testing to trainees. Interventions that improve faculty knowledge of HIV testing recommendations and address barriers in resident clinics may enhance adoption of routine HIV testing.

Provider and practice characteristics associated with use of rapid HIV Testing by general internists.

BACKGROUND: Rapid HIV testing could increase routine HIV testing. Most previous studies of rapid testing were conducted in acute care settings, and few described the primary care providers' perspective. OBJECTIVE: To identify characteristics of general internal medicine physicians with access to rapid HIV testing, and to determine whether such access is associated with differences in HIV-testing practices or perceived HIV-testing barriers. DESIGN: Web-based cross-sectional survey conducted in 2009. PARTICIPANTS: A total of 406 physician members of the Society of General Internal Medicine who supervise residents or provide care in outpatient settings. MAIN MEASURES: Surveys assessed provider and practice characteristics, HIV-testing types, HIV-testing behavior, and potential barriers to HIV testing. RESULTS: Among respondents, 15% had access to rapid HIV testing. In multivariable analysis, physicians were more likely to report access to rapid testing if they were non-white (OR 0.45, 95% CI 0.22, 0.91), had more years since completing training (OR 1.06, 95% CI 1.02, 1.10), practiced in the northeastern US (OR 2.35; 95% CI 1.28, 4.32), or their practice included a higher percentage of uninsured patients (OR 1.03; 95% CI 1.01, 1.04). Internists with access to rapid testing reported fewer barriers to HIV testing. More respondents with rapid than standard testing reported at least 25% of their patients received HIV testing (51% versus 35%, p = 0.02). However, access to rapid HIV testing was not significantly associated with the estimated proportion of patients receiving HIV testing within the previous 30 days (7.24% vs. 4.58%, p = 0.06). CONCLUSION: Relatively few internists have access to rapid HIV testing in outpatient settings, with greater availability of rapid testing in community-based clinics and in the northeastern US. Future research may determine whether access to rapid testing in primary care settings will impact routinizing HIV testing.

General internists' beliefs, behaviors, and perceived barriers to routine HIV screening in primary care.

The Centers for Disease Control and Prevention (CDC) recommends routine HIV screening in primary care but little is known about general internists' views of this practice. We conducted a national, cross-sectional, Internet-based survey of 446 general internists in 2009 regarding their HIV screening behaviors, beliefs, and perceived barriers to routine HIV screening in outpatient internal medicine practices. Internists' awareness of revised CDC guidelines was high (88%), but only 52% had increased HIV testing, 61% offered HIV screening regardless of risk, and a median 2% (range 0-67%) of their patients were tested in the past month. Internists practicing in perceived higher risk communities reported greater HIV screening. Consent requirements were a barrier to screening, particularly for VA providers and those practicing in states with HIV consent statutes inconsistent with CDC guidelines. Interventions that promote HIV screening regardless of risk and streamlined consent requirements will likely increase adoption of routine HIV screening in general medicine practices.

Conceptual frameworks in the study of duty hours changes in graduate medical education: a review.

PURPOSE: Conceptual frameworks are approaches to a research problem that specify key entities and their relationships. The 2009 Institute of Medicine (IOM) report on resident duty hours, subsequent studies, and published responses to the report present a variety of conceptual frameworks for the study of the impact of duty hours regulations. The authors sought to identify and describe these conceptual frameworks and their implications. METHOD: The authors reviewed the IOM report and articles in both peer-reviewed and non-peer-reviewed literature for the period January 2008 through April 2010, identified using multiple electronic databases including PubMed, EMBASE, CINAHL, BEME, and PsycInfo. Studies that explicitly described or argued for the effect of resident duty hours on any other outcome, as judged by consensus of multiple reviewers, were included. The authors selected 239 of 858 studies reviewed. Several of the authors reviewed articles to identify conceptual frameworks used implicitly or explicitly to describe the relationship between duty hours (or duty hours regulations) and outcomes. Identification was by consensus. RESULTS: Twenty-three conceptual frameworks were identified. Several made contradictory predictions about the impact of duty hours regulations on patient outcomes, resident education, and other key outcomes. CONCLUSIONS: The concept of duty hours itself is contested, and little attention has been paid to the nature and intensity of the activities that occupy residents' hours. Much research focuses on isolated outcomes of duty hours changes without considering mediation or moderation. More studies are needed to define trade-offs between outcomes and the value society places on these trade-offs.

Outcomes of AIDS Education and Training Center HIV/AIDS skill-building workshops on provider practices.

The Midwest AIDS Training and Education Center (MATEC) implemented a Web-based survey method to measure impact on practitioners of HIV/AIDS skill-building workshops offered in seven midwestern states. Surveys were sent to 2,949 participants from 230 workshops 4-6 weeks after each workshop. Of those surveyed, 631 respondents provided usable data (22.4%). Self-reported narrative responses described practice changes attributed to training. Changes were categorized as (a) practitioner attitude/knowledge, (b) practitioner practice behavior, (c) planning system change, and (d) implemented adaptations to the clinical care system. Other outcome measures were attending more programs and consulting with colleagues. Change was reported by 341 (54.0%) individuals, with a total of 411 change events/activities documented. Of the change events, 302 (73%) related to changes in health provider practices and 109 (27%) related to the care systems. Findings from this evaluation project provide evidence that MATEC workshops do impact practitioners' behaviors and care systems consistent with the literature about translating research into practice.

A randomized trial of pictorial versus prose-based medication information pamphlets.

OBJECTIVE: The goal of this study was to compare prose and pictorial-based information pamphlets about the medication methotrexate in the domains of free recall, cued recall, comprehension and utility. METHODS: A single blind, randomized trial of picture versus prose-based information pamphlets including 100 participants aged 18-65 years of age, who had not completed high school, could read English, and had no prior knowledge about methotrexate. Superiority of pamphlet type was assessed using immediate free recall, cued recall and comprehension. RESULTS: There were no differences between picture and prose pamphlets in free recall, cued recall, and comprehension either immediately or after a 1-week interval. Immediate free recall of important information was 17-26%; free recall fell even lower to 7-16% after 1 week. The pictorial pamphlet was preferred over the prose-based pamphlet. CONCLUSION: This study found no benefit in free recall, cued recall, or comprehension through the addition of pictograms to a simple prose-based medication pamphlet. PRACTICE IMPLICATIONS: In order for them to be effective in clinical practice, even simple medication information pamphlets that have been assessed for patients' ability to comprehend them cannot be used as the sole means for conveying important medication-related information to patients.

Impact of student reflective e-portfolio on medical student advisors.

BACKGROUND: Little is published about the role of faculty advisors and use of students' e-portfolios. PURPOSE: This article reports advisors' observations and understanding about 1st-year students based on information from students' journaling as part of an e-portfolio. METHODS: Data were collected on Blackboard survey module for 8 volunteer advisors at two medical school campuses. Responses were hand coded, verified by two authors, tallied, with example comments recorded. RESULTS: The four male and four female advisors are all mid-career, mixed between clinical and nonclinical faculty. The students' responses in the portfolio gave advisors greater insight into students' thinking, maturity, and reflective ability, and they helped advisors identify early warnings about problems. The e-portfolio enhanced meaningful interactions and more focused discussions with students. Advisors reported no improvements in efficiency of communications and had technical difficulties with Blackboard (version 6.0). CONCLUSIONS: Advisors reported students' reflective responses to focused questions in an e-portfolio contribute valuable understanding about students' thinking and attitudes. Advisors are enthusiastic about the value of the e-portfolio for this purpose. We anticipate benefits will generalize when fully implemented.

Relationship between candidate communication ability and oral certification examination scores.

CONTEXT: Structured case-based oral examinations are widely used in medical certifying examinations in the USA. These orals assess the candidate's decision-making skills using real or realistic patient cases. Frequently mentioned but not empirically evaluated is the potential bias introduced by the candidate's communication ability. OBJECTIVE: This study aimed to assess the relationship between candidate communication ability and medical certification oral examination scores. METHODS: Non-doctor communication observers rated a random sample of 90 candidates on communication ability during a medical oral certification examination. The multi-facet Rasch model was used to analyse the communication survey and the oral examination data. The multi-facet model accounts for observer and examiner severity bias. anova was used to measure differences in communication ability between passing and failing candidates and candidates grouped by level of communication ability. Pearson's correlations were used to compare candidate communication ability and oral certification examination performance. RESULTS: Candidate separation reliability values for the communication survey and the oral examination were 0.85 and 0.97, respectively, suggesting accurate candidate measurement. The correlation between communication scores and oral examination scores was 0.10. No significant difference was found between passing and failing candidates for measured communication ability. When candidates were grouped by high, moderate and low communication ability, there was no significant difference in their oral certification examination performance. CONCLUSIONS: Candidates' communication ability has little relationship to candidate performance on high-stakes, case-based oral examinations. Examiners for this certifying examination focused on assessing candidate decision-making ability and were not influenced by candidate communication ability.

Assessment of faculty perception of content validity of PerioSim, a haptic-3D virtual reality dental training simulator.

Haptic technology (sense of touch) along with 3D-virtual reality (VR) graphics, creating lifelike training simulations, was used to develop a dental training simulator system (PerioSim). This preliminary study was designed to evaluate whether faculty considered PerioSim realistic and useful for training and evaluating basic procedural skills of students. The haptic device employed was a PHANToM and the simulator a Dell Xeon 530 workstation with 3D, VR oral models and instruments viewed on a stereoscopic monitor. An onscreen VR periodontal probe or explorer was manipulated by operating the PHANToM for sensing lifelike contact and interactions with the teeth and gingiva. Thirty experienced clinical dental and dental hygiene faculty judged the realism of the system. A PowerPoint presentation on one screen provided instructions for the simulator use with the 3D, VR simulator on a second stereoscopic monitor viewed with 3D goggles. Faculty/practitioners found the images very realistic for teeth and instruments, but less so for gingiva. Tactile sensation was realistic for teeth but not so for gingiva. The onscreen instructions were very useful with high potential for teaching. Faculty members anticipated incorporating this device into teaching and were enthusiastic about its potential for evaluating students' basic procedural skills. This study suggests that the preliminary "evidence-of-concept" was successful and PerioSim may aid students in developing necessary dental tactile skills.

Best practices for assessing competence and performance of the behavioral health workforce.

The need for mechanisms to assess the competence and performance of the behavioral health workforce has received increasing attention. This article reviews strategies used in general medicine and other disciplines for assessing trainees and practitioners. The possibilities and limitations of various approaches are reviewed, and the implications for behavioral health are addressed. A conceptual model of competence is presented, and practical applications of this model are reviewed. Finally, guidelines are proposed for building competency assessment protocols for behavioral health.

Specialty board certification and clinical outcomes: the missing link.

PURPOSE: Specialty board certification status is often used as a standard of excellence, but no systematic review has examined the link between certification and clinical outcomes. The authors evaluated published studies tracking clinical outcomes and certification status. METHOD: Data sources consisted of studies cited between 1966 and July 1999 in OVID-Medline, psychological abstracts (PsycLit), and the Educational Research Information Clearinghouse (ERIC). Screening criteria included: only U.S. patients and physicians used as subjects; verified specialty board certification status by an American Board of Medical Specialties' (ABMS') member board using the ABMS database or derivative sources; described selection criteria for patients and physicians; selected nationally recognized standards of care for outcomes; and nested patient data by individual physician. The computerized searches that were conducted in 1999 identified 1,204 papers; one author and a research assistant selected 237 papers based on subject relevance, and reduced the list to 56 based on study quality. The authors independently applied inclusion and exclusion criteria to identify 13 of the 56 papers containing 33 separable relevant findings. RESULTS: Of the 33 findings, 16 demonstrated a significant positive association between certification status and positive clinical outcomes, three revealed worse outcomes for certified physicians, and 14 showed no association. Three negative findings and one finding of no association were identified in two papers with insufficient case-mix adjustments in the analyses. Meta-analytic statistics were not feasible due to variability in outcome measures across studies. CONCLUSIONS: Few published studies (5%) used research methods appropriate for the research question, and among the screened studies more than half support an association between board certification status and positive clinical outcomes.