Evaluation of a web-based asthma self-management system: a randomised controlled pilot trial.

BACKGROUND: Asthma is the most common chronic condition of childhood and disproportionately affects inner-city minority children. Low rates of asthma preventer medication adherence is a major contributor to poor asthma control in these patients. Web-based methods have potential to improve patient knowledge and medication adherence by providing interactive patient education, monitoring of symptoms and medication use, and by facilitation of communication and teamwork among patients and health care providers. Few studies have evaluated web-based asthma support environments using all of these potentially beneficial interventions. The multidimensional website created for this study, BostonBreathes, was designed to intervene on multiple levels, and was evaluated in a pilot trial. METHODS: An interactive, engaging website for children with asthma was developed to promote adherence to asthma medications, provide a platform for teamwork between caregivers and patients, and to provide primary care providers with up-to-date symptom information and data on medication use. Fifty-eight (58) children primarily from inner city Boston with persistent-level asthma were randomised to either usual care or use of BostonBreathes. Subjects completed asthma education activities, and reported their symptoms and medication use. Primary care providers used a separate interface to monitor their patients' website use, their reported symptoms and medication use, and were able to communicate online via a discussion board with their patients and with an asthma specialist. RESULTS: After 6-months, reported wheezing improved significantly in both intervention and control groups, and there were significant improvements in the intervention group only in night-time awakening and parental loss of sleep, but there were no significant differences between intervention and control groups in these measures. Emergency room or acute visits to a physician for asthma did not significantly change in either group. Among the subgroup of subjects with low controller medication adherence at baseline, adherence improved significantly only in the intervention group. Knowledge of the purpose of controller medicine increased significantly in the intervention group, a statistically significant improvement over the control group. CONCLUSIONS: This pilot study suggests that a multidimensional web-based educational, monitoring, and communication platform may have positive influences on pediatric patients' asthma-related knowledge and use of asthma preventer medications.

A Virtual World Versus Face-to-Face Intervention Format to Promote Diabetes Self-Management Among African American Women: A Pilot Randomized Clinical Trial.

BACKGROUND: Virtual world environments have the potential to increase access to diabetes self-management interventions and may lower cost. OBJECTIVE: We tested the feasibility and comparative effectiveness of a virtual world versus a face-to-face diabetes self-management group intervention. METHODS: We recruited African American women with type 2 diabetes to participate in an 8-week diabetes self-management program adapted from Power to Prevent, a behavior-change in-person group program for African Americans with diabetes or pre-diabetes. The program is social cognitive theory-guided, evidence-based, and culturally tailored. Participants were randomized to participate in the program via virtual world (Second Life) or face-to-face, both delivered by a single intervention team. Blinded assessors conducted in-person clinical (HbA1c), behavioral, and psychosocial measurements at baseline and 4-month follow-up. Pre-post differences within and between intervention groups were assessed using t tests and chi-square tests (two-sided and intention-to-treat analyses for all comparisons). RESULTS: Participants (N=89) were an average of 52 years old (SD 10), 60% had ≤high school, 82% had household incomes

Utilization of a free fitness center-based exercise referral program among women with chronic disease risk factors.

Physical activity (PA) reduces the risk for a number of chronic diseases including heart disease, hypertension, hyperlipidemia, and diabetes mellitus type 2. However, most Americans do not meet expert recommendations for exercise, and minorities and low-income persons are the most inactive. Community-based approaches to promoting PA include primary care exercise referral programs. This study examines patient characteristics associated with utilization of a community health center-based exercise referral program. Adult female patients of a community health center with an affiliated fitness center, in Boston, MA, were included in the study if they received a referral to the fitness center from their primary care provider. Demographic and medical information was abstracted from the medical chart, and fitness records were abstracted to measure activation of a fitness center membership (creation of an account denoting at least an initial visit) and utilization over time. Overall, 503 (40%) of the 1,254 referred women in the study sample activated their membership. Black women were almost 60% more likely to activate their membership (adjusted OR 1.6, 95% CI 1.2-2.2), and women with higher co-morbidity counts were almost 45% more likely to activate (adjusted OR 1.4, 95% CI 1.0-2.0). Once activated, a minority of women participated at levels likely to improve cardiometabolic fitness. Of the 503 activations, 96 (19%) had no participation, 359 (71%) had low participation, and only 48 (10%) had high participation. No independent predictors of participation were identified. These findings suggest that program design may benefit from developing activation, initial participation, and retention strategies that address population-specific barriers.

Use of a virtual world computer environment for international distance education: lessons from a pilot project using Second Life.

Virtual worlds (VWs), in which participants navigate as avatars through three-dimensional, computer-generated, realistic-looking environments, are emerging as important new technologies for distance health education. However, there is relatively little documented experience using VWs for international healthcare training. The Geneva Foundation for Medical Education and Research (GFMER) conducted a VW training for healthcare professionals enrolled in a GFMER training course. This paper describes the development, delivery, and results of a pilot project undertaken to explore the potential of VWs as an environment for distance healthcare education for an international audience that has generally limited access to conventionally delivered education.

Can medical students afford to choose primary care? An economic analysis of physician education debt repayment.

PURPOSE: Some discussions of physician specialty choice imply that indebted medical students avoid choosing primary care because education debt repayment seems economically unfeasible. The authors analyzed whether a physician earning a typical primary care salary can repay the current median level of education debt and meet standard household expenses without incurring additional debt. METHOD: In 2010-2011, the authors used comprehensive financial planning software to model the annual finances for a fictional physician's household to compare the impact of various debt levels, repayment plans, and living expenses across three specialties. To accurately develop this spending model, they used published data from federal and local agencies, real estate sources, and national organizations. RESULTS: Despite growing debt levels, the authors found that physicians in all specialties can repay the current level of education debt without incurring more debt. However, some scenarios, typically those with higher borrowing levels, required trade-offs and compromises. For example, extended repayment plans require large increases in the total amount of interest repaid and the number of repayment years required, and the use of a federal loan forgiveness/repayment program requires a service obligation such as working at a nonprofit or practicing in a medically underserved area. CONCLUSIONS: A primary care career remains financially viable for medical school graduates with median levels of education debt. Graduates pursuing primary care with higher debt levels need to consider additional strategies to support repayment such as extended repayment terms, use of a federal loan forgiveness/repayment program, or not living in the highest-cost areas.

Use of an online curriculum to teach delirium to fourth-year medical students: a comparison with lecture format.

Web-based learning methods are being used increasingly to teach core curriculum in medical school clerkships, but few studies have compared the effectiveness of online methods with that of live lectures in teaching the same topics to students. Boston University School of Medicine has implemented an online, case-based, interactive curriculum using videos and text to teach delirium to fourth-year medical students during their required 1-month Geriatrics and Home Medical Care clerkship. A control group of 56 students who received a 1-hour live delirium lecture only was compared with 111 intervention group students who completed the online delirium curriculum only. Evaluation consisted of a short-answer test with two cases given as a pre- and posttest to both groups. The total possible maximum test score was 34 points, and the lowest possible score was -8 points. Mean pre- and posttest scores were 10.5 ± 4.0 and 12.7 ± 4.4, respectively, in the intervention group and 9.9 ± 3.5 and 11.2 ± 4.5, respectively, in the control group. The intervention group had statistically significant improvement between the pre- and posttest scores (2.21-point difference; P < .001), as did the control group (1.36-point difference; P = .03); the difference in test score improvement between the two groups was not statistically significant. An interactive case-based online curriculum in delirium is as effective as a live lecture in teaching delirium, although neither of these educational methods alone produces robust increases in knowledge.

Design and Methods for a Comparative Effectiveness Pilot Study: Virtual World vs. Face-to-Face Diabetes Self-Management.

BACKGROUND: Type 2 diabetes (diabetes) is a serious threat to public health in the United States and disproportionally affects many racial/ethnic minority groups, including African Americans. Limited access to treatment and high attrition rates further contribute to health disparities in diabetes-related morbidity and mortality among minorities. Greater opportunities for increasing access and decreasing barriers to treatment are needed. Technology-based interventions have potential for accomplishing this goal but evidence of feasibility and potential effectiveness is lacking, especially for populations that traditionally have limited educational attainment and low computer literacy. OBJECTIVE: This paper describes the design and methods of a pilot randomized clinical trial that will compare the feasibility and potential efficacy of delivering a diabetes self-management intervention via a virtual world vs. a face-to-face format. METHODS: Study participants (n=100) will be African American women with uncontrolled type 2 diabetes recruited from primary care practices and affiliated health centers at a large safety net hospital in Massachusetts. Participants will be randomized into a virtual world-based (VW) intervention condition or a face-to-face control condition. Both conditions provide the same theory-based curriculum and equivalent exposure to the self-management program (eight group sessions), and both will be delivered by a single intervention team (a dietitian and a diabetes educator). Assessments will be conducted at baseline and 4 months. Feasibility will be determined by evaluating the degree to which participants engage in the VW-based intervention compared to face to face (number of sessions completed). Potential efficacy will be determined by comparing change in physiological (glycemic control) and behavioral (self-reported dietary intake, physical activity, blood glucose self-monitoring, and medication adherence) outcomes between the experimental and control groups. RESULTS: The primary outcomes of interest are feasibility of the VW intervention and its potential efficacy on glucose control and diabetes self-management behaviors, compared to the face-to-face condition. Analysis will use a two-sample Kolmogorov-Smirnov test for changes in variable distribution. P values will be calculated using binomial tests for proportions and t tests for continuous variables. CONCLUSIONS: If the intervention is found to be feasible and promising, it will be tested in a larger RCT.

Promoting medical humanism: design and evaluation of an online curriculum.

To provide patient-centered care, physicians must be well trained in the concepts and methods of humanistic practice. Educational efforts to promote humanism may help to overcome the counter-training of the hidden medical school curriculum, responsible for a decline in empathy and idealism over the course of medical training. The online component of the clerkship in family medicine at Boston University introduced activities founded on reflection, self-awareness, collaborative learning, and applied practice to successfully promote student confidence in three key areas of humanistic practice.

BostonBreathes: an RCT to improve pediatric asthma care with a home-based interactive website for patient education, monitoring, and clinical teamwork.

The BostonBreathes (BB) system is an interactive website enabling physician-physician and physician-patient communication, monitoring (peak-flow, medication use, symptoms) of asthma patients in the home, and patient and family asthma education. The system helps primary care physicians to function in team relationships with asthma specialists and nurses. Patients and families can interact with their health professionals online as members of the care team. BB uniquely combines patient education, monitoring, and clinical teamwork functions into one integrated web environment.

Web-based versus face-to-face learning of diabetes management: the results of a comparative trial of educational methods.

BACKGROUND AND OBJECTIVES: Relatively little is known about the effectiveness of Web-based learning (WBL) in medical education and how it compares to conventional methods. This study examined the influence of an interactive, online curriculum in a third-year medical school family medicine clerkship on students' ability to create a management plan for a patient newly diagnosed with type 2 diabetes. We also evaluated how the online curriculum compared to a conventionally taught curriculum. METHODS: The online course included three integrated activities: (1) self-study modules, (2) a patient case study, and (3) a moderated discussion board for posting and discussing patient care plans. The WBL curriculum was compared to small-group case-based sessions with a faculty facilitator. Students completed a test case before and after the clerkship. RESULTS: Among standard-of-care diabetic management interventions not ordered on the pretest, 38% were subsequently correctly ordered by WBL students on the posttest, versus 33% by students in the comparison group. For four out of five subgroups assessed on the case write-ups, the gain from before to after the clerkship favored the WBL group. CONCLUSIONS: Improvement among students learning online exceeded that of students learning face to face. This suggests superiority of the online method, a finding consistent with other recently published, well-controlled studies.

BostonBreathes: improving pediatric asthma care with a home-based interactive website for patient education, monitoring, and clinical teamwork.

The BostonBreathes (BB) system is an interactive website enabling physician-physician and physician-patient communication, monitoring (peak-flow, medication use, symptoms) of asthma patients in the home, and patient and family asthma education. The system helps primary care physicians to function in team relationships with asthma specialists and nurses. Patients and families can interact with their health professionals online as members of the care team. BB uniquely combines patient education, monitoring, and clinical teamwork functions into one integrated web environment.

Collaborative e-learning using streaming video and asynchronous discussion boards to teach the cognitive foundation of medical interviewing: a case study.

BACKGROUND: Advances in electronic technology have created opportunities for new instructional designs of medical curricula. OBJECTIVE: We created and evaluated a 4-week online elective course for medical students to teach the cognitive basis for interviewing skills. METHODS: Ten students, from 2 medical schools, studied online modules on interviewing concepts and viewed videos illustrating the concepts. They then participated in asynchronous discussion groups designed to reinforce course concepts, stimulate reflective learning, and promote peer learning. RESULTS: In qualitative evaluations, learners reported improvements in self-awareness; increased understanding of interviewing concepts; and benefits of online learning vs face to face learning. Participants reported high levels of satisfaction with online learning and with achievement of course objectives. Self-reported knowledge scores increased significantly from pre-course completion to post-course completion. CONCLUSIONS: Online education has significant potential to augment curriculum on the medical interview, particularly among students trained in community settings geographically distant from their academic medical center.

HEAL: an instructional design model applied to an online clerkship in family medicine.

OBJECTIVE: The potential of distance learning technology to deliver educational programs in which instruction and evaluation are of a consistent and high standard across multiple settings is hampered by a lack of instructional design models. In response, we developed the HEAL (Heuristic for Electronic Asynchronous Learning) model for designing online curricula. DESCRIPTION: HEAL is based on the theories that learning is facilitated by independent problem solving, investigation, and discovery (heuristics); collaboration between students fosters learning; and the proven educational cycle of practice, feedback, and reflection is integral to the interrelated domains of skill development and personal awareness.(1) The HEAL model is defined by synergistic online learning activities integrated with real patient care. It is applicable to all medical education levels. We applied this innovative design template to an online curriculum that augments our conventional six-week third-year clerkship. Our students, who were placed in distant family physician offices, needed more interaction and learning from peers and faculty. The three elements of HEAL, and implementation in the "online clerkship," are: (1) Didactic modules teach and illustrate concepts. Students study modules (HTML pages) on management of diabetes (DM), and complete five modules on evidence-based medicine (EBM). They do EBM literature searches reviewed online by peers, faculty, and librarians, who provide feedback. (2) A problem-based case discussion promotes application of concepts from modules (horizontal curricular integration). Students view streamed video of a patient with a history suggestive of diabetes, review her medical chart online, and suggest evidence-based management in an asynchronous discussion group. The case progresses weekly to mimic 12 months of continuity of care. (3) A collaborative journal activity explores the results of applying elements one and two to real patients (vertical integration). Additional elements advance reflection, professionalism, and medical humanism. Participation in the journal discussion group, stimulated by online readings, enhances self-awareness, informs psychosocial aspects of element 2, and promotes generalization of learning objectives to real patients. We use BlackBoard software. Students log in two to three times per week. Faculty who are trained in online moderation facilitate the threaded discussion groups and provide feedback. DISCUSSION: Students in alternating clerkship blocks complete the online clerkship. Their performance is compared with that of students who complete a face-to-face diabetes curriculum, but no curriculum on EBM or medical humanism. After nearly a year (105 students), compared with the non-online group, students completing the online clerkship demonstrated greater gains in reported EBM skills from preto post-clerkship, larger increases in mean score (from pre to post) on a medical-humanism aptitude scale, and higher scores on a post-clerkship diabetes management assessment (all comparisons p <.05). The online clerkship will become a permanent part of our clerkship and we have begun to use HEAL to design other online courses, including continuing education courses.

Ethics in medicine: are we blind? In support of teaching medical ethics at the bedside.

The ability to recognize and respond to the ethical dimension of medicine is integral to providing health care that is comprehensive and humane. However, this aspect of medical practice is underemphasized in clinical and academic medicine, despite attempts to devise curricula in this field. This paper examines the origins and consequences of this deficiency through a case history of a Jehovah's Witness who reluctantly accepted a blood transfusion. It emphasizes the ubiquity of the ethical context in medicine and argues that blindness to this context stems from the prevailing scientific and technological paradigm in medicine. Innovations in medical education are called for to enhance health care providers' abilities to appreciate and cope with these complex situations.