The importance of self-determination theory for medical education.

While some theories of human motivation focus exclusively on levels of motivation, self-determination theory argues that different types of motivators, even when the resulting motivation is high, will lead to very different outcomes. This theory differentiates between two primary kinds of motivation, controlled and autonomous. Controlled motivation depends either on explicit or implicit rewards or punishment or on people's internalized beliefs about what is expected of them. Learning in controlled situations, in which students act under pressure and anxiety, is likely to be rote, short-lived, and poorly integrated into students' long-term values and skills. In contrast, autonomous motivation, as its name implies, is personally endorsed and reflects what people find interesting and important. While controlled motivation involves compliance with pressures, autonomous motivation involves behaving with a sense of volition, agency, and choice. Autonomously motivated learning leads to better educational outcomes. There is evidence that medical students who learn in autonomy-supportive environments act in more autonomy-supportive ways in their interactions with patients. Because the reliable implementation of practice guidelines and physicians' use of an autonomy-supportive style have been associated with more positive health outcomes (particularly in the behavior-related areas of smoking cessation, weight loss, etc.), more autonomy-supportive medical education may result in more effective health care delivery.

Physician-delivered smoking intervention.

More Oklahomans smoke than the national average. Oklahoma ranks among the top 15 states for its smoking-attributable mortality rate and lung cancer death rate. Although physicians are strategically placed to influence smokers, most physicians fail to effectively promote smoking cessation. By developing the necessary knowledge, skills, and attitudes, the physician may successfully deliver smoking intervention within the context of routine office visits. The physician must identify all smokers and deliver a consistent unambiguous quit smoking message at every visit. Establishing the patient's readiness for change focuses the physician's efforts at the patient's specific stage of cessation which enhances likelihood of success and reduces physician frustration. For patients ready to quit, visits may be scheduled for evaluation, quitting, and maintenance. Utilizing these cost-effective office based strategies, a physician may realistically achieve a 15% to 25% success rate in smoking cessation.

Patient demographic characteristics and housestaff performance in the care of patients with human immunodeficiency virus disease.

A retrospective review of the medical records of 45 patients with human immunodeficiency virus (HIV) disease was conducted in an Oklahoma internal medicine teaching clinic. Demographics of this patient population and house staff performance in the care of these patients was evaluated. The study population demographics were similar to national findings with the exception of lower documented homosexual/bisexual transmission among males and higher heterosexual transmission among females. Deficiencies in documentation were noted in the areas of route of acquisition, mental status, and functional level. In several instances patients who were candidates for zidovudine and/or Pneumocystis prophylaxis were not receiving these treatments. The quality of care could be enhanced through the use of HIV evaluation and treatment protocols as well as specially designed, HIV-specific medical records to improve data collection. These HIV-specific medical records can be found in the appendices.

Managing cholesterol in children and adolescents.

Reduction of elevated cholesterol in adults decreases risk of coronary heart disease. Despite evidence of atherosclerosis development at early ages and studies confirming cholesterol tracking from childhood into adulthood, many physicians are reluctant to screen for hypercholesterolemia in children and adolescents. Targeting screening only to children of high-risk families fails to identify as many as two-thirds of at-risk children. Dietary modification and medical therapy appears safe and effective in this age group. Recommendations for screening of all children by age 5 are made, with guidelines for managing elevated cholesterol.