Internal Medicine Residents' Ambulatory Management of Core Geriatric Conditions.

BACKGROUND: Adults aged 65 years and older account for more than 33% of annual visits to internal medicine (IM) generalists and specialists. Geriatrics experiences are not standardized for IM residents. Data are lacking on IM residents' continuity experiences with older adults and competencies relevant to their care. OBJECTIVE: To explore patient demographics and the prevalence of common geriatric conditions in IM residents' continuity clinics. METHODS: We collected data on age and sex for all IM residents' active clinic patients during 2011-2012. Academic site continuity panels for 351 IM residents were drawn from 4 academic medical center sites. Common geriatric conditions, defined by Assessing Care of Vulnerable Elders measures and the American Geriatrics Society IM geriatrics competencies, were identified through International Classification of Disease, ninth edition, coded electronic problem lists for residents' patients aged 65 years and older and cross-checked by audit of 20% of patients' charts across 1 year. RESULTS: Patient panels for 351 IM residents (of a possible 411, 85%) were reviewed. Older adults made up 21% of patients in IM residents' panels (range, 14%-28%); patients ≥ 75 (8%) or 85 (2%) years old were relatively rare. Concordance between electronic problem lists and chart audit was poor for most core geriatric conditions. On chart audit, active management of core geriatric conditions was variable: for example, memory loss (10%-25%), falls/gait abnormality (26%-42%), and osteoporosis (11%-35%). CONCLUSIONS: The IM residents' exposure to core geriatric conditions and management of older adults was variable across 4 academic medical center sites and often lower than anticipated in community practice.

Intern Boot Camp: Feasibility and impact of a 1-hour session to ensure graduating medical student competency in falls risk assessment.

The authors evaluated the feasibility of a 1-hour session to ensure competency in gait and falls risk assessment for medical students at their institution. The session included a history and exam with faculty and staff as standardized patients, gait recognition videos, and case evaluation for falls risk assessment and prevention. Student perceptions were evaluated using a retrospective pre-post survey, scored on a 5-point Likert-type scale. Wilcoxon signed-rank tests were used to assess change and Kruskal-Wallis tests were used to analyze differences by residency choice. A range of five to 11 faculty and staff certified 238 medical students during eight 1-hour sessions. Overall self-perception of competence in falls risk assessment and prevention improved (p ≤ .001), and did not differ by residency choice, both before and after the training program (p = .73 and p = .25). Feedback was positive. This session is a feasible way to teach and assess the competency for falls risk assessment with modest time commitment.

Teaching medical student geriatrics competencies in 1 week: an efficient model to teach and document selected competencies using clinical and community resources.

The Association of American Medical Colleges (AAMC) and the John A. Hartford Foundation published geriatrics competencies for medical students in 2008 defining specific knowledge and skills that medical students should be able to demonstrate before graduation. Medical schools, often with limited geriatrics faculty resources, face challenges in teaching and assessing these competencies. As an initial step to facilitate more-efficient implementation of the competencies, a 1-week geriatrics rotation was developed for the third year using clinical, community, and self-directed learning resources. The Wake Forest University School of Medicine Acute Care for the Elderly Unit serves as home base, and each student selects a half-day outpatient or long-term care experience. Students also perform a home-based falls-risk assessment with a Meals-on-Wheels client. The objectives for the rotation include 20 of the 26 individual AAMC competencies and specific measurable tracking tasks for seven individual competencies. In the evaluation phase, 118 students completed the rotation. Feedback was positive, with an average rating of 7.1 (1 = worst, 10 = best). Students completed a 23-item pre- and post-knowledge test, and average percentage correct improved by 15% (P < .001); this improvement persisted at graduation (2 years after the pretest). On a 12-item survey of attitudes toward older adults, improvement was observed immediately after the rotation that did not persist at graduation. Ninety-seven percent of students documented completion of the competency-based tasks. This article provides details of development, structure, evaluation, and lessons learned that will be useful for other institutions considering a brief, concentrated geriatrics experience in the third year of medical school.

Patient reactions to confidentiality, liability, and financial aspects of informed consent in cardiology research.

BACKGROUND: Although the informed consent process is supposed to help potential research participants make informed and voluntary decisions about participating in research, little is known about how participants react to language in the informed consent document and whether their reactions are related to their willingness to enroll in clinical trials. We examined the relationship between patients' reactions to standard informed consent language and their willingness to participate in a hypothetical clinical trial. METHODS AND RESULTS: We simulated the consent process for a hypothetical cardiology clinical trial with 470 patients in an outpatient cardiovascular medicine clinic at a large academic medical center. We analyzed the spontaneous comments and questions that participants made during the interviews about each section of the informed consent document. Few participants made positive comments. Participants made the most negative comments about the sections on risks, study purpose or protocol, and payment for injury. Having a negative reaction to any section was associated with a lower likelihood of participating in the clinical trial. Using a multivariable model, we found that negative reactions in the patient rights, financial disclosure, and confidentiality sections predicted willingness to participate (P<0.001). CONCLUSIONS: Recognizing elements of informed consent that elicit questions and concerns from potential research participants may help investigators design clinical research trials and model language in a way that reduces concerns or increases participant understanding, thereby enhancing informed consent for research.

Effects of disclosing financial interests on participation in medical research: a randomized vignette trial.

BACKGROUND: Little is known about the effects of investigators' financial disclosures on potential research participants. METHODS: We conducted a vignette trial in which 470 participants in a telephone survey were randomly assigned to receive a simulated informed consent document that contained 1 of 2 financial disclosures (per capita payments to the research institution or equity ownership by the investigator) or no disclosure. The main outcome measures were trust in medical research and willingness to participate in a hypothetical clinical trial. RESULTS: Participants in the equity group reported less willingness to participate than participants in the per capita payments group (P = .01) and the no disclosure group (P = .03). Trust in the investigator was highest in the per capita payments group and lowest in the equity group (P < .001). Trust among participants who received no disclosure was also greater than trust among participants in the equity group (P = .04) but did not differ significantly from trust among participants in the per capita payments group (P = .15). Participants in the equity group made 3 times as many negative comments as participants in the per capita payments group; and 10 participants in the equity group spontaneously said they would not participate in the hypothetical trial because of the financial interest, compared with only 1 such participant from the other groups. CONCLUSIONS: Although investigators' financial disclosures in research do not substantially affect willingness to participate, potential research participants are more troubled by equity interests than by per capita payments.

Measuring trust in medical researchers.

BACKGROUND: Concern is widespread that the public's and participants' trust in medical research is threatened, but few empirical measures of research trust exist. This project aims to enable more rigorous study of researcher trust by developing and testing appropriate survey measures. METHODS: Survey items were developed based on a conceptual model of the primary domains of researcher trust (safety, fidelity, honesty, global trust). Pilot testing was conducted on a regional convenience sample of adults (n = 124). Exploratory factor analyses of the data were performed, and an item selection procedure reduced the number of survey questions. A final set of 12 items was validated, and a 4-item short version of the researcher trust scale was selected and tested in a national web-based survey of asthma and diabetes patients (n = 3623). Further factor analysis and validation were performed on this larger sample. RESULTS: Both the full and short scales have a single-factor structure with acceptable internal reliability (alphas of 0.87 [12 items] and 0.72 [4 items]). Trust in physician researchers and trust in medical researchers generally were found not to be separate constructs. In the national sample, the short scale was positively associated with better health status, prior participation in medical research, and willingness to participate in a hypothetical medical research study, and negatively associated with African-American race and higher education. CONCLUSIONS: Trust in medical researchers is a measurable single-factor construct including trust in safety, researcher fidelity, and honesty. This new scale provides an empirical tool for informing the ethics and public policy of medical research.

Do employers voluntarily include patient protections in self-insured managed care plans?

Managed care patient protection laws passed by states do not apply to health plans sponsored by self-insured employers, although 54% of workers who receive health insurance coverage through their employer are in self-insured plans. In-depth interviews conducted in five states with employers offering self-insured health benefits and with other knowledgeable market informants provide evidence that self-insured managed care plans nonetheless include important features that strengthen subscribers' access to medical providers. Less common in these plans were features providing for independent external appeal of coverage denials and for protecting network providers from undue influence by plan administrators.