Perspectives of internal medicine residency clinics: A national survey of US medical directors.

Background: Ambulatory training is an integral component of internal medicine residency programs, yet details regarding operational processes in resident continuity clinics remain limited. Methods: We surveyed a convenience sample of medical directors of residency practices between 2015 and 2019 (n = 222) to describe and share operational and scheduling processes in internal medicine resident continuity clinics in the US. Results: Among residency practices, support for the medical director role ranged substantially, but was most commonly reported at 11%-20% full-time-equivalent support. By the end of the survey period, the majority of programs (65.1%) reported obtaining patient-centered medical home (PCMH) certification (level 1-3). For new patient appointments, 34.9% of programs reported a 1-7 day wait and 25.8% reported an 8-14 day wait. Wait times for new appointments were generally shorter for PCMH certified practices (P = 0.029). No-show rates were most commonly 26%-50% for new patients and 11%-25% for established patients. Most programs reported that interns see 3-4 patients per ½-day and senior residents see 5-6 patients per ½-day. Most interns and residents maintain a panel size of 51-120 patients. Discussion: Creating high-performing residency clinics requires a focus on core building blocks and operational processes. Based on the survey results and consensus opinion, we provide five summary recommendations related to (1) support for the medical director leadership role, (2) patient-centered and coordinated models of care, (3) support for patient scheduling, (4) recommended visit lengths, and (5) ancillary support, such as social work.

Predictors of Suboptimal Follow-up in Pediatric Cancer Survivors.

Attendance to follow-up care after completion of cancer treatment is an understudied area. We examined demographic, clinical, and socioeconomic predictors of follow-up by pediatric cancer patients at a large center in 442 newly diagnosed patients using multivariable logistic regression analyses. Patients who did not return to clinic for at least 1000 days were considered lost to follow-up. Two hundred forty-two (54.8%) patients were lost. In multivariable analyses, the following variables were independent predictors of being lost to follow-up: treatment with surgery alone (odds ratio [OR]=6.7; 95% confidence interval [CI], 3.1-14.9), older age at diagnosis (reference, 0 to 4; ages, 5 to 9: OR=1.8, 95% CI, 1.1-3; ages, 10 to 14: OR=3.3; CI, 1.8-6.1; and ages, 15 and above: OR=4.8; CI, 2.1-11.7), lack of history of stem cell transplantation (OR=2, 95% CI, 1.04-3.7) and lack of insurance (OR=3.4; CI, 1.2-9.2). Hispanic patients had the best follow-up rates (53.7%) compared to whites and blacks (P=0.03). Attendance to long-term follow-up care is suboptimal in childhood cancer survivors. Predictors that were associated with nonattendance can be used to design targeted interventions to improve follow-up care for survivors of pediatric cancer.

Development and evaluation of two instruments for assessing screening, brief intervention, and referral to treatment (SBIRT) competency.

BACKGROUND: Screening, brief intervention, and referral to treatment (SBIRT) is shown to be effective in identifying, intervening with, and making appropriate referrals for patients with unhealthy alcohol use. SBIRT training consists of knowledge-based and skill-based components and has increased the use of screening and intervention skills in clinical settings. This article reports on the development and evaluation of 2 SBIRT proficiency checklists for use across institutions to assess SBIRT skills in both simulated and clinical encounters. METHODS: A national panel of 16 experts identified 137 discrete SBIRT skills items for the checklists. From this final list, 2 proficiency checklists were derived: the SBIRT Proficiency Checklist (SPC), composed of 22 questions for videotaped interviews, and the Clinical SBIRT Proficiency Checklist (CSPC), composed of 13 questions for direct clinical observation. An evaluation was conducted to test the reliability of the SPC and to assess the utility of the CSPC. RESULTS: Two checklists for assessing SBIRT proficiency were developed by a collaborative workgroup. Fleiss' kappa analyses indicated moderate agreement. In addition, faculty recorded satisfaction with the CSPC for assessing residents on their SBIRT performance during clinical encounters. CONCLUSIONS: The SPC and the CSPC are practical tools for assessing competence with SBIRT and are easily integrated as standard instruments in a wide range of training settings. Future advancements to the checklists and their evaluation include modification of the SPC rating scale to be consistent with the CSPC, developing a training program for using the checklists, and further testing to improve interrater reliability.

Baylor Pediatric SBIRT Medical Residency Training Program: model description and evaluation.

BACKGROUND: The Baylor College of Medicine SBIRT Medical Residency Training Program is a multilevel project that trains residents and faculty in evidenced-based screening, brief intervention, and referral to treatment methods for alcohol and substance use problems. METHODS: This paper describes the training program created for pediatric residents and provides an evaluation of the program. Ninety-five first-year pediatric residents participated in the training program. They were assessed on satisfaction with the program, self-rated skills, observed competency, and implementation into clinical practice. RESULTS: The program was successfully incorporated into the residency curricula in two pediatric residencies. Evaluations indicate a high degree of satisfaction with the program, self-reported improvement in SBIRT skills, observed proficiency in SBIRT skills, and utilization of SBIRT skills in clinical practice. CONCLUSIONS: SBIRT skills training can be incorporated into pediatric residency training, and residents are able to learn and implement the skills in clinical practice.

Baylor SBIRT Medical Residency Training Program: model description and initial evaluation.

The Baylor College of Medicine SBIRT Medical Residency Training Program is a multilevel project that trains residents and faculty in evidenced-based screening, brief intervention, and referral to treatment (SBIRT) methods for alcohol and substance use problems. This paper describes the training program and provides initial evaluation after the first year of the project. The program was successfully incorporated into the residency curricula in family medicine, internal medicine, and psychiatry. Initial evaluations indicate a high degree of satisfaction with the program and, despite a slight decrease in satisfaction scores, participants remained satisfied with the program after 30 days. Implementation barriers, solutions, and future directions of the program are discussed.

Factors associated with self-management independence and quality of life for adolescents and young adults with spina bifida engaged in a guideline-based transition clinic.

PURPOSE: To determine characteristics associated with self-management independence and quality of life (QOL) among adolescents and young adults with spina bifida (AYASB) engaged in a spina bifida (SB) health care transition clinic. METHODS: During SB transition visits, Eighty-eight AYASB ages 14-20 completed the Adolescent/Young Adult Self-management and Independence Scale II Self-Report/SB (AMIS II-SR/SB), scores ranging from 1-7 with 7 indicating full independence in activities, and the QUAlity of Life Assessment in Spina bifida for Teens (QUALAS-T), which has two subscales, family/independence (QFI) and bowel/bladder (QBB), with scores ranging from 0-100 with 100 indicating maximal QOL score. Demographic and clinical variables were collected from the electronic medical record. RESULTS: The baseline AMIS II-SR/SB score was 3.3 (SD 1.0). Baseline scores for QUALAS-T QFI and QBB subscales were 73.8 (SD 19.9) and 63.8 (SD 25.8). Older age was associated with a higher baseline AMIS II-SR/SB score (p = 0.017). Over time, AMIS II-SR/SB total significantly improved (p < 0.001), but QFI and QBB did not. AYASB not on chronic intermittent catheterization (CIC) and those using urethral CIC significantly improved in AMIS II-SR/SB total scores (p = 0.001), but those using abdominal channel CIC did not. CONCLUSION: Baseline bladder management method was associated with self-management improvement for AYASB engaged in a SB-specific transition clinic.

Multi-Community Cardiopulmonary Resuscitation Education by Medical Students.

Introduction One purpose of the hands-only cardiopulmonary resuscitation (HOCPR) program is to simplify CPR instruction to encourage more bystanders to take action during cardiac arrest. Although the program has been successfully implemented in traditional classroom settings, the utility of large-scale training events has not been well-explored. We hypothesized that CPR knowledge and comfort levels would increase through a large-scale, multi-community HOCPR training event. We also explored what effect this training event had on perceived barriers to bystander-performed CPR. Methods A convenience sample participated in HOCPR training on a single day across 10 Texas cities. A sub-sample completed training questionnaires, including a five-item CPR pre- and post-test. A follow-up questionnaire was conducted two years after the event. The primary outcome of interest was the difference in cardiopulmonary resuscitation (CPR) knowledge and comfort level between pre- and post-event questionnaires. Demographic contributions were also assessed. Results A total of 4,253 participants were trained, 1,416 were enrolled upon submitting matching pre- and post-event questionnaires, and 101 (14%) submitted follow-up questionnaires. Mean knowledge scores increased from pre-training (2.7 ± 1.6 standard deviation (SD)) to post-training (4.7 ± 0.76 SD) (p < 0.001). Follow-up test scores (3.8 ± 1.1 SD) remained higher than pre-test scores (p < 0.001). Comfort with HOCPR increased from 59% (95% confidence interval (CI) 56 - 61) to 96% (95% CI 95 - 97). Pre- and post-knowledge scores differed significantly by education level (p < 0.001), ethnicity (p < 0.001), and income (p < 0.001). Education contributed significantly to comfort at both pre- (p = 0.015) and post-training (p = 0.026), but ethnicity and income did not. Before training, the most common barrier to performing CPR was lack of knowledge 59% (95% CI 55 - 62); after training, the most common barrier was fear of causing harm 34% (95% CI 29 - 40). Conclusions This study demonstrated that medical students were successfully able to conduct large-scale HOCPR training that improved CPR knowledge and comfort levels among participants across multiple metropolitan areas. Knowledge retention remained higher at two-years for participants of a follow-up questionnaire. Medical students can use the experiences from this training event as a template to organize similar large-scale training events in the future.

Religious coping and caregiver well-being in Mexican-American families.

OBJECTIVE: We sought to explore the association of religious and spiritual coping with multiple measures of well-being in Latinos caring for older relatives with long-term or permanent disability, either with or without dementia. METHODS: Using a multi-dimensional survey instrument, we conducted in-home interviews with 66 predominantly Mexican-American Catholic family caregivers near the US-Mexico border. We assessed caregivers' intrinsic, organizational and non-organizational religiosity with the Duke Religiosity Index, as well as Pargament's brief positive and negative spiritual coping scale to determine the association of religiosity with caregivers' mental and physical health, depressive symptomatology and perceived burden. RESULTS: Using regression analysis, we controlled for sociocultural factors (e.g. familism, acculturation), other forms of formal and informal support, care recipients' functional status and characteristics of the caregiving dyad. Intrinsic and organizational religiosity was associated with lower perceived burden, while non-organizational religiosity was associated with poorer mental health. Negative religious coping (e.g. feelings that the caregiver burden is a punishment) predicted greater depression. CONCLUSION: Measures of well-being should be evaluated in relation to specific styles of religious and spiritual coping, given our range of findings. Further investigation is warranted regarding how knowledge of the positive and negative associations between religiosity and caregiving may assist healthcare providers in supporting Latino caregivers.

A Novel Interprofessional Mock Clinic Workshop for Medical Students With Orthotics and Prosthetics Students.

Introduction: Medical school education on orthotics and prosthetics (O&P) is limited, and O&P students receive limited education on performing comprehensive histories and physicals (H&Ps). This interprofessional workshop brings medical and O&P students together in a mock clinical setting. Students from one profession appraise the relationship of their scope/role to those of students of the other profession. Methods: Third-year medical students, second-year O&P students, and O&P patients participated in a 3-hour workshop. Students partnered into groups and rotated among stations performing patient history, physical exam, and O&P assessment. As a medical or O&P student completed the H&P, she or he explained the process to the student of the other profession. Each group assessed two patients and then presented one to a physical medicine and rehabilitation (PM&R) attending physician. The workshop concluded with a feedback session. Results: Immediate feedback was positive. Medical students, O&P students, PM&R physicians, and patients all commented favorably. In the workshop's first year, there were 19 responding students (10 medical, nine O&P); 68.4% said that the clinical session was better than expected, 73.7% were satisfied with the overall event, and 73.7% felt they were likely to use what they had learned in clinical practice. Feedback from learners included requesting more time for students to interact with each other after the mock clinic, sending preparation materials before the session, and focusing the medical student H&P on the musculoskeletal exam. Discussion: This workshop was well received by participants. Their feedback will help to continue and expand this collaboration.

Low-literacy interventions to promote discussion of prostate cancer: a randomized controlled trial.

BACKGROUND: Professional organizations recommend that physicians discuss prostate cancer with patients to make individual screening decisions. However, few studies have tested strategies to encourage such discussions, particularly among high-risk populations. We examined the effects of two low-literacy interventions on the frequency of prostate cancer discussion and screening. DESIGN: Randomized, blinded, controlled trial with concealed allocation. SETTING/PARTICIPANTS: Inner-city primary care clinic, serving a predominately African-American population. Participants were men aged 45-70 with no history of prostate cancer, presenting for a regular appointment. INTERVENTIONS: While waiting to see their physician, patients received a patient education handout on prostate cancer screening (PtEd), a handout simply encouraging patients to talk to their doctor about prostate cancer (Cue), or a control handout. The interventions did not advocate for or against screening. MEASURES: Patient-reported discussion of prostate cancer with the physician and chart reviews determine prostate-specific antigen (PSA) test orders and performance of digital rectal examination (DRE). Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were computed. Data were collected in 2003, and analyses were completed in 2006. RESULTS: Most of the 250 subjects (90.4%) were African American and 78.8% read below the ninth grade level. Overall, 48.4% reported discussing prostate cancer during the appointment. Compared to the control group (37.3%), discussions were significantly more common in the Cue group (58.0%, aOR=2.39 [1.26-4.52]), as well as in the PtEd group (50.0%, aOR=1.92 [1.01-3.65]). When prostate cancer was discussed, patients in the intervention groups more commonly initiated the conversation (47.6% PtEd and 40.0% Cue, vs 9.7% control, p<0.01 for each comparison to control). Compared to the control group (2.4%), PSA test orders increased in the PtEd group (14.1%, aOR=7.62 [1.62-35.83]) and in the Cue group (12.3%, aOR=5.86 [1.24-27.81]). Documentation of DRE did not change significantly (4.7% PtEd, 6.2% Cue, and 6.0% control). CONCLUSIONS: Two simple low-literacy interventions significantly increased discussion of prostate cancer and PSA test orders but not performance of DRE. Both interventions were effective in empowering low-literacy patients to initiate conversations about prostate cancer with their physician.

Improvement in provider immunization knowledge and behaviors following a peer education intervention.

Provider education programs that use academic detailing to improve childhood immunization have been implemented in several states. The purpose of this study was to evaluate the impact of these types of programs to improve immunization-related behaviors in private provider offices. The intervention included peer-based academic detailing in which teams of 1 physician, 1 nurse, and 1 office manager visited pediatric and family practices to deliver an educational presentation and develop practice-specific action plans. Comparison of pre-post intervention surveys showed that providers' willingness to give the maximum number of immunizations due at 1 visit (P < .001) increased. More providers reported routinely screening immunization records at sickness or injury visits (P < .05) and using minimum intervals (P < .001) postintervention. Mean change in baseline and postintervention overall scores was significant for pediatric practices (0.40, P < .05), small practices (0.64, P < .01), Vaccines for Children (VFC) practices (0.74, P < .05), and non-VFC provider practices (0.67, P < .01) but not for family or large practices.

Two educational interventions to improve pediatricians' knowledge and skills in performing ankle and knee physical examinations.

BACKGROUND: Methods are needed to improve pediatricians' skills for physical examination of the ankle and knee. OBJECTIVE: To compare the effect of 2 methods of teaching the physical examination of the ankle and knee on the knowledge and skills of pediatricians. DESIGN: Prospective intervention trial with preintervention and postintervention tests. SETTING: Pediatricians' offices. PARTICIPANTS: Twenty-three practice groups of community pediatricians, including 75 pediatricians (74% of the eligible sample). INTERVENTIONS: Practice groups were assigned by clustered randomization to 1 of 2 teaching interventions: (1) a videotape showing correct performance of the ankle and knee physical examinations (videotape only; 15 groups) and (2) the same videotape plus a skills building session (18 groups). The randomization was stratified by practice size. MAIN OUTCOME MEASURES: Knowledge of ankle and knee examinations and ankle and knee physical examination skills, assessed by means of a Clinical Skills Assessment Examination (CSAE), at 18 weeks. RESULTS: The pediatricians' baseline mean ankle CSAE score was 26% correct in both groups. These scores improved to 44% and 59% correct in the videotape and videotape plus skills instruction groups, respectively, at 18 weeks (P<.001 for both). The baseline mean knee CSAE score was 25% in both groups and improved to 30% (P =.02, videotape group) and 41% (P<.001, videotape plus skills instruction group) at 18 weeks. The change in CSAE scores was greater in the videotape plus skills instruction group. Written test scores improved significantly in both groups. CONCLUSIONS: Pediatricians' skills were lacking at baseline. Both teaching interventions were associated with improved skills and knowledge.

Determinants of low-fat eating behaviors among midlife African American women.

OBJECTIVE: The purpose of this study was to explore midlife African American women's low-fat eating habits in the context of health attitudes, social support, and food preferences. DESIGN: A cross-sectional design was used. SETTINGS: One Midwestern and 1 national African American women's organization were targeted for data collection. PARTICIPANTS: African American women between the ages of 45 and 64. MAIN OUTCOME MEASURES: Health Attitudes Scale, Social Support Scale, Eating Behaviors subscale, and Low-Fat Eating subscale. ANALYSIS: A hierarchical multiple regression analysis was performed. RESULTS: Highly educated women did not engage in better eating habits than women with less education. Family members provided more criticism and friends provided more encouragement for healthful eating. However, only family encouragement and criticism for healthful eating and food preferences remained predictive of low-fat eating habits in midlife African American women in the final regression model. CONCLUSIONS AND IMPLICATIONS: Changing attitudes may not influence changes in behaviors. Women experience family support as a significant influence to eating habits. Future nutrition interventions should be inclusive of women at every educational level and have a multidimensional focus that targets family involvement and changing behaviors.

Between and within: international perspectives on cancer and health disparities.

The purpose of this article is to compare reasons for cancer health disparities in developing and developed countries. By 2010, approximately 60% of new cancer cases will occur in the developing world, higher than rates developed countries. However, disparities exist not only between countries but also within countries. Cancer epidemiology in developing countries is paradoxical: Increased incidence is partially due to increased development resulting in longer life expectancy and unhealthy lifestyle behaviors. Reduced mortality from infectious diseases results in relatively greater mortality from chronic diseases. However, infectious diseases are also risk factors for the leading causes of cancer mortality in these countries. While health disparities in developing versus developed countries are quantitatively worlds apart, they are qualitatively rather similar. They share common causes, such as environmental pollution, the need for social justice, large gaps between the rich and the poor, lack of access to cancer resources, and health services that are available to some but not to all. While industrialization and urbanization elevate a country's economic base while contributing to cancer incidence and mortality. Strategies to reduce international cancer disparities include country- and regional-level interventions, utilizing nongovernmental organizations, and developing long-term inter-institutional partnerships. Although economic aid is undoubtedly necessary, it is not sufficient to control cancer in the developing world. To address these problems, it will be necessary to focus attention on what can be done locally-within countries, not only between countries.

Increasing mammography screening through inpatient education.

BACKGROUND: The reasons why women do not undergo regular screening mammograms have not been clearly defined. In this study, we addressed an educational intervention based on Health Belief Model constructs for 3 of the most common reasons why women do not participate in mammography screening: cost, fear, and lack of knowledge. The purpose of the project was to study whether an educational intervention addressing these factors could increase mammography screening among age-appropriate women who had not had a recommended mammogram within the previous 12 months. METHODS: The educational intervention consisted of providing a tailored brochure addressing either the barrier of (1) cost, (2) fear, or (3) lack of information. Participants were hospital inpatients admitted for noncancer diagnoses. They were followed up approximately 3 months after hospital discharge to ascertain subsequent mammography utilization either before or after leaving the hospital. RESULTS: Of the 272 women originally interviewed, 147 (54%) were reached for follow-up. Although there were no differences related to which mammography barrier was addressed, 42 (28.6%) reported that they had obtained a mammogram after the intervention. CONCLUSIONS: These data suggest that a fairly simple, low-cost patient education intervention of brochure distribution can produce substantially increased patient awareness and consequent mammography utilization.

Depressed mood and social support as predictors of quality of life in women receiving home health care.

We examined relationships among depressed mood, social support and quality of life in 58 medically ill low-income women 40 years and older receiving home health care. Analyses showed a negative relationship between depressed mood and quality of life (p's < or = 0.05). Positive relationships were found between number of people available for support and two of three quality of life domains as well as satisfaction with support and all three domains (p's < or = 0.05). Results also provided preliminary support that belonging to a church is related to emotional well-being (p = 0.039) and among those belonging to a church, recent increased activity was related to social/family well-being (p = 0.004). Mediational analyses revealed a cycle of depressed mood, dissatisfaction with social support, and loss of social support providers underlying the poor quality of life of many participants. This highlights the need to address the relationship between depression and social support when treating patients with chronic illness.