A conceptional model integrating geographic information systems (GIS) and social media data for disease exposure assessment.

Although previous studies have acknowledged the potential of geographic information systems (GIS) and social media data (SMD) in assessment of exposure to various environmental risks, none has presented a simple, effective and user-friendly tool. This study introduces a conceptual model that integrates individual mobility patterns extracted from social media, with the geographic footprints of infectious diseases and other environmental agents utilizing GIS. The efficacy of the model was independently evaluated for selected case studies involving lead in the ground; particulate matter in the air; and an infectious, viral disease (COVID- 19). A graphical user interface (GUI) was developed as the final output of this study. Overall, the evaluation of the model demonstrated feasibility in successfully extracting individual mobility patterns, identifying potential exposure sites and quantifying the frequency and magnitude of exposure. Importantly, the novelty of the developed model lies not merely in its efficiency in integrating GIS and SMD for exposure assessment, but also in considering the practical requirements of health practitioners. Although the conceptual model, developed together with its associated GUI, presents a promising and practical approach to assessment of the exposure to environmental risks discussed here, its applicability, versatility and efficacy extends beyond the case studies presented in this study.

Toward the fabrication of a 5-µm-resolution Wolter microscope for the National Ignition Facility (invited).

Advancements in computer-controlled polishing, metrology, and replication have led to an x-ray mirror fabrication process that is capable of producing high-resolution Wolter microscopes. We present the fabrication and test of a nickel-cobalt replicated full-shell x-ray mirror that was electroformed from a finely figured and polished mandrel. This mandrel was designed for an 8-m source-to-detector-distance microscope, with 10× magnification, and was optimized to reduce shell distortions that occur within 20 mm of the shell ends. This, in combination with an improved replication tooling design and refined bath parameters informed by a detailed COMSOL Multiphysics® model, has led to reductions in replication errors in the mirrors. Mandrel surface fabrication was improved by implementing a computer-controlled polishing process that corrected the low-frequency mandrel figure error and achieved <2.0 nm RMS convergence error. X-ray tests performed on a pair of mirror shells replicated from the mandrel have demonstrated <10 µm full-width at half-maximum (FWHM) spatial resolution. Here, we discuss the development process, highlight results from metrology and x-ray testing, and define a path for achieving a program goal of 5 µm FWHM resolution.

Addressing Kentucky's Physician Shortage While Securing a Network for a Research-Intensive, Referral Academic Medical Center: Where Public Policy Meets Effective Clinical Strategic Planning.

A critical shortage of physicians is looming in the United States. The situation in Kentucky is especially dire, especially in rural areas. Class size constraints have resulted in the University of Kentucky College of Medicine (UK COM) unable to admit over 100 qualified Kentuckians each year. This article describes how leadership at University of Kentucky committed to addressing the state physician shortage while simultaneously strengthening relationships with critical partners through the establishment of two 4-year UK COM regional medical campuses. Based on criteria (such as a commitment to educating physicians, ample patients, sufficient willing physician preceptors, etc.), partners selected were Med Center Health, the leading health care system in southwestern Kentucky, and St. Elizabeth Healthcare, the predominant health care system in northern Kentucky. These regional campuses allow UK COM to expand its class size to 201 and total enrollment to 804, increasing from historically 70 to currently 120 graduates per year expected to practice in Kentucky. Critical to the success of this expansion is the buy-in of leadership and the Admissions Committee to consider students with a wider range of Medical College Admission Test scores. The regional clinical partners have substantially increased their teaching opportunities, with a greater ability to attract physicians. Both partners have made substantial financial contributions in support of the regional campuses. These relationships have energized UK COM engagement with its area alumni and have resulted in fewer Kentuckians referred out of state for advanced specialty care. Partnerships are also occurring with UK COM to increase graduate medical education offerings at the regional sites, fulfilling the vision of "training Kentuckians in Kentucky to practice in Kentucky."

A complementary and alternative medicine workshop using standardized patients improves knowledge and clinical skills of medical students.

OBJECTIVES: As the use of complementary and alternative medicine (CAM) has increased in the general population, so has the interest in CAM education among medical students and medical educators. The purpose of this study is to determine the impact of a CAM workshop using standardized patients (SP) on knowledge and clinical skills of third-year medical students. DESIGN: A 4-hour CAM workshop was developed as part of a new curriculum for a required third-year 4-week primary care internal medicine clerkship. The CAM workshop and 3 other novel workshops were randomized for delivery to half of the rotational groups. The CAM workshop incorporates 4 SP cases representing different clinical challenges. All students in every rotation group are assigned CAM readings. At the end of the rotation, all students take a 100-item written exam (7 CAM items) and 9-station SP exam (1 CAM station) including a post-SP encounter open-ended written exercise. Scores on the written exam CAM items, CAM SP checklist, and CAM open-ended written exercise of workshop participants and nonparticipants were analyzed with simple means, standard deviations, and multiple regression approaches. RESULTS: The CAM workshop was delivered to 12 of the 24 rotation groups during the 2004-2005 and 2005-2006 academic years. Ninety-two students participated in the workshop, and 94 did not. Workshop participants performed significantly better than nonparticipants on the CAM-specific SP checklist items (58 vs 36.6%, P<.0001), post-SP encounter written exercise (76.9 vs 63.3%, P<.0001), and 7 CAM written exam items (84.8 vs 76.3%, P<.0001). CONCLUSIONS: Students participating in a 4-hour SP workshop exhibit superior CAM knowledge as assessed by SP checklist, open-ended exercises, and multiple choice items. It appears that practice with SPs assists in acqusition and application of CAM knowledge and deferential counseling skills.

Attitudes of Kentucky women regarding mandatory reporting of intimate partner violence.

BACKGROUND: Kentucky is one of only six states with laws mandating that intimate partner violence be reported to authorities. The purpose of this project was to understand the attitudes of women clinic patients in Kentucky regarding mandatory reporting of intimate partner violence and how these attitudes may differ by abuse status. METHODS: Women presenting to an internal medicine clinic in the summer of 2003 were asked to complete an anonymous 30-item questionnaire, including personal history of abuse and their opinions about mandatory reporting of intimate partner violence to the police. RESULTS: Surveys were completed by 238 women, of which 29% reported a history of intimate partner violence. Of abused women, 49% supported mandatory reporting of intimate partner violence to the police, compared to 61% of women without an abuse history (p = 0.05) CONCLUSION: Women with a history of abuse are more ambivalent about mandatory reporting of intimate partner violence to the police than women without a history of abuse.

The association of student examination performance with faculty and resident ratings using a modified RIME process.

BACKGROUND: RIME is a descriptive framework in which students and their teachers can gauge progress throughout a clerkship from R (reporter) to I (interpreter) to M (manager) to E (educator). RIME, as described in the literature, is complemented by residents and attending physicians meeting with a clerkship director to discuss individual student progress, with group discussion resulting in assignment of a RIME stage. OBJECTIVE: 1) to determine whether a student's RIME rating is associated with end-of-clerkship examination performance; and 2) to determine whose independent RIME rating is most predictive of a student's examination performance: attendings, residents, or interns. DESIGN: Prospective cohort study. PARTICIPANTS: Third year medical students from academic years 2004-2005 and early 2005-2006 at 1 medical school. MEASUREMENTS AND MAIN RESULTS: Each attending, resident, and intern independently assessed the student's final RIME stage attained. For the purpose of analysis, R stage=1, I=2, M=3, and E=4. Regression analyses were performed with examination scores as dependent variables (National Board of Medical Examiners [NBME] medicine subject examination and a clinical performance examination [CPE]), with independent variables of mean attending RIME score, mean resident score, and mean intern score. For the 122 students, significant predictors of NBME subject exam score were resident RIME rating (p = .008) and intern RIME rating (p = .02). Significant predictor of CPE performance was resident RIME rating (p = .01). CONCLUSION: House staff RIME ratings of students are associated with student performance on written and clinical skills examinations.

Communication and decision making about life-sustaining treatment: examining the experiences of resident physicians and seriously-ill hospitalized patients.

BACKGROUND: Despite evidence-based recommendations for communication and decision making about life-sustaining treatment, resident physicians' actual practice may vary. Few prior studies have examined these conversations qualitatively to uncover why ineffective communication styles may persist. OBJECTIVE: To explore how discussions about life-sustaining treatment occur and examine the factors that influence physicians' communicative practices in hopes of providing novel insight into how these processes can be improved. PARTICIPANTS AND APPROACH: We conducted and recorded 56 qualitative semi-structured interviews with participants from 28 matched dyads of a resident physician and a hospitalized patient or their surrogate decision maker with whom cardiopulmonary resuscitation was discussed. Transcripts were analyzed and coded using the constant comparative method to develop themes. MAIN RESULTS: Resident physicians introduced decisions about resuscitation in a scripted, depersonalized and procedure-focused manner. Decision makers exhibited a poor understanding of the decision they were being asked to make and resident physicians often disagreed with the decision. Residents did not advocate for a particular course of action; however, the discussions of resuscitation were framed in ways that may have implicitly influenced decision making. CONCLUSIONS: Residents' communication practices may stem from their attempt to balance an informed choice model of decision making with their interest in providing appropriate care for the patient. Physicians' beliefs about mandatory autonomy may be an impediment to improving communication about patients' choices for life-sustaining treatment. Redefining the role of the physician will be necessary if a shared decision making model is to be adopted.

The effect of physician continuity on diabetic outcomes in a resident continuity clinic.

BACKGROUND: Conflicting data exists regarding the effect of continuity on diabetes care. Resident physicians frequently treat patients with diabetes in their continuity clinics; however, maintaining continuity in a resident clinic can be very challenging. OBJECTIVE: To determine if resident continuity is associated with improvement in diabetic outcomes (HgA1c, LDL, blood pressure) in a resident clinic. DESIGN AND SETTING: Retrospective analysis of data obtained from a medical record review of diabetic patients seen in a resident physician clinic. MEASUREMENTS: We measured continuity, using the Usual Provider of Continuity Index (UPC) for residents and faculty preceptors. We measured changes in HgA1c, LDL, and blood pressure over a 3-year period. Using repeated measures analysis of variance (ANOVA), we assessed the relationship between UPC and change in these diabetic outcomes. RESULTS: The resident UPC was 0.43, and the faculty preceptor UPC was 0.76. The overall change in HgA1c was -0.3. There was a statistically significant relationship between improvement in HgA1c and resident UPC (p = 0.02), but not faculty preceptor UPC. There was no association between resident or faculty preceptor continuity and change in LDL or blood pressure. CONCLUSION: This study showed a link between resident continuity and improvement in glycemic control in diabetic patients. Resident physicians have a greater opportunity to develop a personal relationship with their patients. This interpersonal continuity may be of benefit in patients with illnesses that requires a significant amount of self-management behaviors. Medical training programs should focus efforts on improving continuity in resident primary care clinics.

Discussing preferences for cardiopulmonary resuscitation: what do resident physicians and their hospitalized patients think was decided?

OBJECTIVE: To explore the ways in which seriously ill hospitalized patients, their family members and physicians interpret the discussion of the patient's preferences for cardiopulmonary resuscitation (CPR). METHODS: Resident physicians, their patients, and family members were interviewed following a discussion regarding preferences for CPR. We sought the participants' perceptions of the resulting decision, examined how often these interpretations differed, and explored the communicative factors underlying discrepancies when they occurred. RESULTS: Fifty-six interviews with 28 matched dyads were completed. In six dyads (21%), the participants reported differing results of the discussion. Two patients had orders to limit their care based on the physician's interpretation of their discussion. Another two patients who did not want resuscitation lacked a DNR order. Two patients did not recall having the conversation. These discrepancies could be attributed to the physician misconstruing the patient's wishes, interference of a family member, and fluctuating preferences. CONCLUSIONS: Discrepant interpretations of a DNR discussion occur with a concerning frequency between resident physicians and their hospitalized patients. PRACTICE IMPLICATIONS: Educational efforts should focus on training physicians to clarify the language used in these discussions, remain vigilant about discerning the patient's preferences, and be aware that these preferences may be contextually fluid.

Sexual history inquiry and HIV counseling: improving clinical skills and medical knowledge through an interactive workshop utilizing standardized patients.

BACKGROUND: Sexual history and HIV counseling (SHHIVC) are essential clinical skills. Our project's purpose was to evaluate a standardized patient educational intervention teaching third-year medical students SHHIVC. METHODS: A four-hour standardized patient workshop was delivered to one-half of the class each of three consecutive years at one medical school. Approximately 3.5 weeks later, all students engaged in a standardized patient examination including one station assessing SHHIVC, answered an open-ended written exercise following the standardized patient encounter, and completed a written examination including sexual history and HIV-related questions. RESULTS: Workshop participants scored higher than non-participants on SHHIVC items on the standardized patient station (P < .0001), written exam (P < .0001), and open-ended written exercise after the standardized patient encounter (P = .024). CONCLUSIONS: Our SHHIVC curriculum was associated with students demonstrating better clinical skills on a SHHIVC standardized patient examination station and more SHHIVC knowledge on two measures of medical knowledge than students not participating in the SHHIVC educational intervention.

The hidden curriculum: medical students' changing opinions toward the pharmaceutical industry.

BACKGROUND: Authorities suggest academic medical centers eliminate conflicts of interest. The authors evaluated medical students' opinions and knowledge of the pharmaceutical industry. METHOD: An anonymous 20-item questionnaire was administered to medical students from four different medical schools; 15 items addressed opinions, and five items were free-response knowledge questions. Results were analyzed by Fisher exact test. RESULTS: Authors received 667 responses from the schools. Sixty-five percent of clinical students believed accepting gifts was appropriate; 28% of preclinical students believed it was appropriate (P < .001). Knowledge was the same for clinical and preclinical students. CONCLUSIONS: Clinical students were more favorable toward receiving gifts than were preclinical students, yet there was no difference in their knowledge of the industry. Increased formal and informal education about the pharmaceutical industry is necessary during the clinical years.

Student involvement on teaching rounds.

BACKGROUND: Inpatient internal medicine education occurs in a fragile learning environment. The authors hypothesized that when medical students are involved in teaching rounds, residents may perceive a decrease in value of attending teaching. METHOD: During two summer periods, trained research assistants shadowed teaching rounds, tracking patient census and team call status, recording basic content of rounds, and delivering a survey instrument to the learners, asking them to rate the quality of the attending's teaching that day. RESULTS: One hundred sixty-six rounds were analyzed. Attending teaching ratings peaked when students were highly involved. In fact, high student involvement was an independent predictor of higher resident evaluation of teaching rounds (P < .0001). CONCLUSIONS: The best teaching occurred when involvement of medical students was greatest and their involvement was not necessarily a zero-sum game. The authors conclude that attending investment in medical student education during teaching rounds benefits all members of the inpatient team.

Medical residents' perspectives on discussions of advanced directives: can prior experience affect how they approach patients?

INTRODUCTION: Resident physicians are inadequately taught how to communicate with patients about end-of-life decision making. Their beliefs about resuscitation and prior experiences with end-of-life care may impact the manner in which they approach patients. OBJECTIVE: To explore residents' perceptions of end-of-life discussions, determine the features they find most important, and discern the challenges they face in this process. METHODS: Internal medicine residents were surveyed about their experiences discussing resuscitation with patients including perceptions of patient understanding, outcomes of resuscitation, and regret about attempting to resuscitate patients. They were asked what features of these discussions are most important and which are the most challenging. Qualitative content analysis was used to examine the responses to open-ended questions. RESULTS: Fifty-five residents completed the survey. Residents reported rarely feeling satisfied with the results of these discussions and disagreed with the decision for resuscitation numerous times. They perceive that few patients and families understand resuscitation. In their description of important features, they focus on the content of the discussion rather than the process, with the most common responses centering on a description of resuscitation. In contrast, the greatest challenge they identify is dealing with the emotional aspects of the discussion. CONCLUSIONS: Residents report internal conflict about their experiences discussing resuscitation with patients. Their approach to these discussions focuses on resuscitation itself with less attention paid to processes that might improve patient decision making. The challenges they describe may be overcome with improved education about end-of-life communication.

Do pressure and fatigue influence resident job performance?

BACKGROUND: Global surveys of residents have consistently identified stress variables as important factors in resident job performance. AIMS: Determine whether an association exists between resident stress and job performance. METHOD: Over a three month period, interns on our inpatient ward services were surveyed regarding their current call schedule, whether their prior night's sleep was sufficient, whether they felt pressed by other commitments, whether they spent enough time teaching medical students and whether they had completed all patient care issues on a given day. Multiple logistic regression was used to assess the association between call status, pressure and sleep adequacy with reported omissions in patient care and adequacy of teaching. RESULTS: In the regression analysis, ratings of high pressure and insufficient sleep but not call status independently predicted outcomes. For example, if an intern felt both pressed and tired, they were over eight times more likely to omit a patient care issue and over four times more likely to report inadequate teaching. CONCLUSIONS: Subjective ratings of high pressure and insufficient sleep are associated with poor job performance in medical residents.

Are continuity clinic patients less satisfied when residents have a heavy inpatient workload?

The purpose of this study was to assess the influence of resident non-clinic workload on the satisfaction of continuity clinic patients. Over a 2-month period in 2002, residents and patients were surveyed at the University of Kentucky internal medicine continuity clinic. Residents provided a self-report of their non-clinic workload as light or medium versus heavy or extremely heavy. Patient satisfaction was assessed with a 7-item, 10-point scale with items derived from commonly used patient satisfaction instruments. In 168 patient encounters, patients were significantly less satisfied with their clinic visit if they were seen by a resident who had a heavier workload. In addition, these patients gave significantly lower ratings with regard to the amount of time spent with the patient during the visit, and how well the resident listened and paid attention. Although alternative explanations exist, we propose that heavy hospital workload is associated with decreased patient satisfaction in resident continuity clinic.

Can physicians improve patient satisfaction with long waiting times?

The purpose of our study was to determine how time spent with the physician might be related to patient dissatisfaction with their waiting time. During a 2-month period, patients in our internal medicine resident continuity clinic completed a survey assessing their satisfaction with their waiting time and their estimates of their waiting time and time spent with the resident physician. For patients with long waiting times (more than 15 min in the waiting room or more than 10 min in the exam room), patient dissatisfaction with waiting time was associated with a shorter physician visit (48% were dissatisfied if the physician spent less than 15 min vs. 18% if the physician spent more than 15 min with them, p = .03). These data suggest that physicians can mediate the negative effects of long waiting times by spending more time with their patients. Future studies on patient satisfaction should consider this interaction.

Quality of life and social outcomes in adults with congenital heart disease living in rural areas of Kentucky.

As revealed by a quality-of-life survey done in a small rural Kentucky cohort, adults who live in rural areas who have congenital heart disease have a relatively poor health-related quality of life and face unique challenges in gaining employment, maintaining health insurance, and overcoming the perceived childhood stigma of being "different."

Residents' ability to identify patients with poor literacy skills.

PURPOSE: To determine whether residents could identify patients with poor literacy skills based on clinical interactions during a continuity clinic visit. The authors hypothesized residents would overestimate patients' literacy abilities and fail to recognize many patients at risk for poor literacy. METHOD: The Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) was administered to screen patients for potential literacy problems. Residents were asked "Do you feel this patient has a literacy problem?" and answered yes or no. Continuity adjusted chi-square was used to test for overestimation of literacy abilities by residents. RESULTS: REALM-R scores and residents' evaluations of literacy were available for 182 patients. The residents believed 10% of patients (18) had literacy problems based on their clinical interactions. Only three patients passing the literacy screen were incorrectly identified as at risk for literacy. Of the 90% of patients (164) the residents perceived to have no literacy problem, 36% (59) failed the literacy screen. CONCLUSION: Resident physicians overestimated the literacy abilities of their patients. A significant portion of these residents' patients may not have the skills to effectively interact with the health care system and are at increased risk for adverse outcomes.