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Background: The essence of humanism in medicine and health care is relationships-caring relationships between clinicians and patients. While raising concerns regarding professional-patient boundaries has positively contributed to our understanding and prevention of potentially harmful boundary violations, there is controversy about which types of relationships, caring acts, and practices are acceptable versus cross boundary lines.Objective: To examine primary care physicians' practices and attitudes regarding acts that have been questioned as potentially "inappropriate" or "unethical" crossing of professional-patient boundaries.Design: Surveys conducted via in-person polling or electronic and mailed paper submissions from April 2016 to July 2017. We calculated descriptive statistics and examined associations with practices and attitudes using logistic regression.Participants: Random sample of all US primary care physicians who treat adult patients; convenience sample of attendees at medicine grand rounds presentations.Main Measures: Outcomes were self-reported practices and attitudes related to giving patients rides home, paying for patients' medication, helping patients find jobs, employing patients, going to dinner with patients, and providing care to personal friends.Key Results: Among 1563 total respondents, 34% had given a ride home, 34% had paid for medications, 15% helped patients find a job, 7% had employed a patient, 10% had dinner with patients, and 59% provided care to personal friends. A majority disapproved of dinner with a patient (75%) but approved of or were neutral on all other scenarios (61-90%).Conclusions: The medical profession is quite divided on questions related to drawing lines about appropriate boundaries. Contrary to official and widespread proscriptions against such practices (with exception of dinner dates), many have actually engaged in such practices and the majority found them acceptable. [ABSTRACT FROM AUTHOR]

Background: Improving care coordination is a key priority for many healthcare systems. However, initiatives to improve care coordination are complex to implement and have produced mixed results. A better understanding of how to craft and support implementation of effective care coordination strategies is needed.Objective: To identify and understand the challenges and factors encountered by Patient-Aligned Care Team (PACT) staff in performing care coordination tasks in outpatient clinics in the Veterans Health Administration (VA).Design: Qualitative study using semi-structured formative evaluation interviews.Participants: Fourteen interviews with 18 clinical frontline managers and staff from 12 clinic sites across five VA health systems.Interventions: This paper reports on baseline data collected for the Coordination Toolkit and Coaching (CTAC) project. CTAC aims to improve patients' experience of care coordination within VA primary care and between PACT and other outpatient and community settings.Approach: We conducted pre-implementation telephone interviews with frontline managers and staff, primarily nurse managers.Key Results: PACT staff described challenges in aligning care coordination priorities across different levels of the VA system, including staff, patients, and leadership. Additionally, PACT staff noted challenges coordinating care both within and outside the VA, and identified resource barriers impeding their care coordination efforts. To address these challenges, staff made several recommendations for improvement, including (1) contingency staffing to address staff burnout; (2) additional PACT training for new staff; (3) clarification of care coordination roles and responsibilities; and (4) and care coordination initiatives that align both with centrally initiated care coordination programs and frontline needs.Conclusion: In the VA and similarly complex healthcare systems, our findings suggest the need for care coordination strategies that are buttressed by a system-level vision for care coordination, backed up by clear roles and responsibilities for information exchange between primary care staff and other settings, and multidimensional accountability metrics that encompass patient-, staff-, and system-level goals. [ABSTRACT FROM AUTHOR]

Racial-ethnic minorities receive lower quality and intensity of health care compared with whites across a wide range of preventive, diagnostic, and therapeutic services and disease entities. These disparities in health care contribute to continuing racial-ethnic disparities in the burden of illness and death. Several national medical organizations and the Institute of Medicine have issued position papers and recommendations for the elimination of health care disparities. However, physicians in practice are often at a loss for how to translate these principles and recommendations into specific interventions in their own clinical practices. This paper serves as a blueprint for translating principles for the elimination of racial-ethnic disparities in health care into specific actions that are relevant for individual clinical practices. We describe what is known about reducing racial-ethnic disparities in clinical practice and make recommendations for how clinician leaders can apply this evidence to transform their own practices. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this paper was to describe primary care prescribers' perspectives on electronic prescribing drug alerts at the point of prescribing.Design: We used a mixed-method study which included clinician surveys (web-based and paper) and focus groups with prescribers and staff.Participants: Prescribers (n = 157) working in one of 64 practices using 1 of 6 e-prescribing technologies in 6 US states completed the quantitative survey and 276 prescribers and staff participated in focus groups.Measurements: The study measures self-reported frequency of overriding of drug alerts; open-ended responses to: "What do you think of the drug alerts your software generates for you?"Results: More than 40% of prescribers indicated they override drug-drug interactions most of the time or always (range by e-prescribing system, 25% to 50%). Participants indicated that the software and the interaction alerts were beneficial to patient safety and valued seeing drug-drug interactions for medications prescribed by others. However, they noted that alerts are too sensitive and often unnecessary. Participant suggestions included: (1) run drug alerts on an active medication list and (2) allow prescribers to set the threshold for severity of alerts.Conclusions: Primary care prescribers recognize the patient safety value of drug prescribing alerts embedded within electronic prescribing software. Improvements to increase specificity and reduce alert overload are needed. [ABSTRACT FROM AUTHOR]

Patients' experience of stereotype threat in clinical settings and encounters may be one contributor to health care disparities. Stereotype threat occurs when cues in the environment make negative stereotypes associated with an individual's group status salient, triggering physiological and psychological processes that have detrimental consequences for behavior. By recognizing and understanding the factors that can trigger stereotype threat and understanding its consequences in medical settings, providers can prevent it from occurring or ameliorate its consequences for patient behavior and outcomes. In this paper, we discuss the implications of stereotype threat for medical education and trainee performance and offer practical suggestions for how future providers might reduce stereotype threat in their exam rooms and clinics. [ABSTRACT FROM AUTHOR]

Objective: To determine if a clinically structured, paper-based prescription form can modify pharmaceutical prescribing behavior without restricting physician freedom to select the most appropriate medication for an individual patient.Design: Uncontrolled, nonrandomized, time series design.Setting: The urgent care clinic of a university-affiliated, county-supported hospital that provides care for underserved, vulnerable populations.Patients: Patients (N = 2189) who had a prescription written at the intervention site during the study.Intervention: Four-phase interventions lasting 2 weeks each, with a washout period between each phase, consisting of: (1). collection of baseline data utilizing the traditional prescription blank, (2). introduction of the pre-formatted prescription form, (3). use of the pre-formatted prescription form with medication cost added, and (4). pre-formatted prescription form with target drug (ranitidine) removed.Measurements and Main Results: Physicians were less likely to prescribe ranitidine compared to cimetidine after the introduction of the cost information (P <.01) and again after the removal of ranitidine from the pre-formatted prescription form (P <.001).Conclusions: A structured, paper-based prescription order form can shift prescribing practices without inhibiting physicians' ordering freedom. [ABSTRACT FROM AUTHOR]

The paper by Clever et al. published in this issue of the Journal characterizes students at the beginning of their rite of passage. The authors readminister a questionnaire developed by Feudtner and Christakis and seven years after their original publication, demonstrate that the majority of medical students continue to hear derogatory comments directed toward patients and to witness or do actions felt to be unethical. The authors determine that the most important reasons students fail to challenge these "unethical" events are "difficult personalities on the team," and "being too low in the hierarchy," reasons reflecting their rocky period of socialization into the current clinical climate. [ABSTRACT FROM AUTHOR]

Background: Many older adults in the U.S. do not receive appropriate colorectal cancer (CRC) screening. Although primary care physicians' recommendations to their patients are central to the screening process, little information is available about their recommendations in relation to guidelines for the menu of CRC screening modalities, including fecal occult blood testing (FOBT), flexible sigmoidoscopy (FS), colonoscopy, and double contrast barium enema (DCBE). The objective of this study was to explore potentially modifiable physician and practice factors associated with guideline-consistent recommendations for the menu of CRC screening modalities.Methods: We examined data from a nationally representative sample of 1266 physicians in the U.S. surveyed in 2007. The survey included questions about physician and practice characteristics, perceptions about screening, and recommendations for age of initiation and screening interval for FOBT, FS, colonoscopy and DCBE in average risk adults. Physicians' screening recommendations were classified as guideline consistent for all, some, or none of the CRC screening modalities recommended. Analyses used descriptive statistics and polytomous logit regression models.Results: Few (19.1%; 95% CI:16.9%, 21.5%) physicians made guideline-consistent recommendations across all CRC screening modalities that they recommended. In multivariate analysis, younger physician age, board certification, north central geographic region, single specialty or multi-specialty practice type, fewer patients per week, higher number of recommended modalities, use of electronic medical records, greater influence of patient preferences for screening, and published clinical evidence were associated with guideline-consistent screening recommendations (p < 0.05).Conclusions: Physicians' CRC screening recommendations reflect both overuse and underuse, and few made guideline-consistent CRC screening recommendations across all modalities they recommended. Interventions that focus on potentially modifiable physician and practice factors that influence overuse and underuse and address the menu of recommended screening modalities will be important for improving screening practice. [ABSTRACT FROM AUTHOR]

Background: Few studies examined specific mentoring needs and preferences of clinician educators (CEs). Further research on CEs' perceptions of mentoring adequacy, as related to educational development and career advancement, is needed.Objective: The study aims were to (1) explore general internal medicine CEs' experiences as mentees within various mentoring models; (2) examine the perceived quality, nature, and impact of mentoring on career development; and (3) determine whether specific models of mentoring impact their attitudes towards mentoring.Design: Sequential mixed methods study design answered the study questions.Participants: Society of General Internal Medicine members identifying themselves as CEs.Main Measures/approach: Participants completed an anonymous online survey and a subsample participated in two semi-structured focus group discussions. Outcomes of interest were perceptions of mentoring experiences, and perspectives on quality of mentoring as well as mentoring needs specific to clinician educators.Key Results: One hundred thirty-nine participants completed the survey (37% response rate) with 20 participants in focus group discussions. Among CEs with perceived high-quality mentor relationships (e.g., reporting strongly agree), peer mentorship was viewed as adequate mentorship (45% (n = 17) vs 24% (n = 24), p < 0.05), as beneficial for career development (77% (n = 40) vs 48% (n = 41), p < 0.01) and as being challenged to become a better CE (58% (n = 30) vs 35% (n = 29), p < 0.05), compared to reporting agree or lower. Qualitative analysis generated four themes: (1) A mentoring team promotes career advancement, (2) peer mentors are important at every stage of a CE's career, (3) there is inadequate mentoring specific to CE needs, and (4) mentoring needs protected time and skill development.Conclusions: The traditional dyadic mentoring relationship may not adequately address all professional needs of CEs. A mentoring team can provide valuable perspectives on career goals. Peer mentoring can be powerful for professional growth. Mentoring needs change at different career stages and training in mentoring skills is essential. [ABSTRACT FROM AUTHOR]

Preventive care is considered a benefit to the patient. Physicians express a positive attitude towards prevention, but their performance of recommended activities is low, as shown in a five-year trial at the Seattle VA Medical Center. The release of the U.S. Preventive Services Task Force's guide to clinical preventive services has provided physicians with authoritative prevention recommendations. While most physicians are specialists with little interest or skill in preventive care, primary care providers do accept an obligation to provide comprehensive care, including prevention. This paper examines the ethical basis for the idea of obligation. External pressures, legal, economic, and organizational, are affecting the physician-patient relationship in ways that encourage a contract mode of medical practice and limit physicians' ability to provide preventive care. As a profession, medicine needs to speak for the health needs of the public. As practitioners, physicians need to seek the welfare of their patients. [ABSTRACT FROM AUTHOR]

The article comments on a paper by John Song and colleagues about homeless persons' attitude toward death and dying. The authors note that the wishes of the homeless include a desire for death with dignity and freedom from pain. They mention the unique perspectives of the homeless including a high rate of exposure to loss, both early in life and while living on the streets. They stress that acknowledging the homeless patients' situation could help reduce their distrust of the health care system.

Background: African Americans have low engagement in advance care planning (ACP). This has been attributed to healthcare distrust and skepticism about ACP. A better understanding of these attitudes is needed to address health disparities related to end-of-life care. Objective: To explore the ACP-related values and beliefs of diverse African American communities across the USA and then the perceived value of an inexpensive end-of-life conversational game. Design: Prospective, convergent, mixed methods cohort study involving fifteen underserved, African American communities across the USA. Participants: Of the 428 who attended events at purposively sampled sites, 90% consented to the research; 37% participated in one of 15 focus groups (n = 141). Intervention: An end-of-life conversation game, played in groups of 4–6. Main Measures: The validated, 7-item ACP values and beliefs questionnaire (scaled 7 = least skeptical, 49 = most skeptical) was administered pre-game. Post-game focus groups explored perceptions about ACP and the intervention. Key Results: Participants had positive attitudes (low skepticism) about ACP with a median score of 12.00 (7.00, 20.00). Values and beliefs did not significantly differ by geographical region; however, rural areas were observed to be slightly more skeptical than urban areas (median score 14.00 vs. 11.00, p = 0.002). Themes from focus groups converged with survey data showing participants valued the ACP process and consider further engagement in ACP to be worthwhile. Subthemes emphasized the need for and value of ACP. Conclusions: Skepticism about ACP may contribute to low rates of ACP engagement in underserved African American communities. The positive attitudes uncovered in our study either negate previous findings or suggest reduced skepticism. Trial Registration: This study has been registered at clinicaltrials.gov (NCT03456921) [ABSTRACT FROM AUTHOR]

Background: Ineffective transitions of care continue to be a source of risk for patients. Although there has been widespread implementation of electronic medical record (EMR) systems, little is currently known about hospitalists' and primary care providers' (PCPs) direct communication preferences at discharge using messaging capabilities in a shared EMR system.Objective: We examined how hospitalists and PCPs with a shared EMR prefer to directly communicate at the time of hospital discharge by identifying preferred modes, information prioritization, challenges, facilitators, and proposed solutions.Design: A sequential, explanatory mixed methods study with surveys and semi-structured interviews.Participants: Thirty-eight academic hospitalists and 63 PCPs working in outpatient clinics in a single safety net hospital system with a shared EMR.Main Approach: Descriptive statistics were used to analyze survey responses. Interviews were analyzed using immersion/crystallization and a mixture of inductive and deductive thematic analysis.Key Results: PCPs preferred direct communication at discharge through a message within the EMR while hospitalists preferred a message within the EMR and email. Qualitative results identified key themes related to patient care and direct communication: value of direct communication, safety, social determinants of health, and clinical judgment. Both groups prioritized direct communication for high-risk medications, pending and follow-up studies, and high-risk patients that hospitalists were concerned about. Overall, both hospitalists and PCPs reported that ensuring patient safety, flagging patients with social challenges, and expressing concerns about patients based on clinical judgment were key communication priorities.Conclusions: Hospitalists and primary care providers report considerable overlap in preferences for direct communication at the time of hospital discharge through a shared EMR. Specifically, both groups reported similar concerns regarding patient safety and continuity during transitions. Direct messaging within the EMR could enable "closed loop" communication that helps ensure safe transitions of care for high-risk patients. [ABSTRACT FROM AUTHOR]

Background: As more health care organizations integrate social needs screening and navigation programs into clinical care delivery, the patient perspective is necessary to guide implementation and achieve patient-centered care.Objectives: To examine patients' perceptions of whether social needs affect health and attitudes toward healthcare system efforts to screen for and address social needs.Research Design: Multi-site, self-administered survey to assess (1) patient perceptions of the health impact of commonly identified social needs; (2) experience of social needs; (3) degree of support for a health system addressing social needs, including which social needs should be screened for and intervened upon; and (4) attitudes toward a health system utilizing resources to address social needs. Analyses were conducted using multivariable logistic regression models with clinic site cluster adjustment.Subjects: Adult patients at seven primary care clinics within a large, integrated health system in Southern California.Main Measures: Survey measures of experience with, acceptability of, and attitudes toward clinical social determinants of health screening and navigation.Key Results: A total of 1161 patients participated, representing a 79% response rate. Most respondents (69%) agreed that social needs impact health and agreed their health system should ask about social needs (85%) and help address social needs (88%). Patients with social needs in the last year were more likely to (1) agree social needs impact health (OR 10.2, p < 0.001), (2) support their health system asking patients about social needs (OR 3.7, p < 0.001), and (3) support addressing patient social needs (OR 3.5, p < 0.001). Differences by social need history, gender, age, race, ethnicity, and education were found.Conclusions: Most patients at a large integrated health system supported clinical social needs screening and intervention. Differences in attitudes by social need history, gender, age, race, ethnicity, and education may indicate opportunities to develop more equitable, patient-centered approaches to addressing social needs. [ABSTRACT FROM AUTHOR]

Background: Despite the importance of professionalism, little is known about how burnout relates to professionalism among practicing physicians.Objective: To evaluate the relationship between burnout and professional behaviors and cost-conscious attitudes.Design and Participants: Cross-sectional study in a national sample of physicians of whom a fourth received a sub-survey with items exploring professional behaviors and cost-conscious attitudes. Responders who were not in practice or in select specialties were excluded.Measures: Maslach Burnout Inventory and items on professional behaviors and cost-conscious attitudes.Key Results: Among those who received the sub-survey 1008/1224 (82.3%) responded, and 801 were eligible for inclusion. Up to one third of participants reported engaging in unprofessional behaviors related to administrative aspects of patient care in the last year, such as documenting something they did not do to close an encounter in the medical record (243/759, 32.0%). Fewer physicians reported other dishonest behavior (e.g., claiming unearned continuing medical education credit; 40/815, 4.9%). Most physicians endorsed cost-conscious attitudes with over 75% (618/821) agreeing physicians have a responsibility to try to control health-care costs and 62.9% (512/814) agreeing that cost to society is important in their care decisions regarding use of an intervention. On multivariable analysis adjusting for personal and professional characteristics, burnout was independently associated with reporting 1 or more unprofessional behaviors (OR 2.01, 95%CI 1.47-2.73, p < 0.0001) and having less favorable cost-conscious attitudes (difference on 6-24 scale - 0.90, 95%CI - 1.44 to - 0.35, p = 0.001).Conclusions: Professional burnout is associated with self-reported unprofessional behaviors and less favorable cost-conscious attitudes among physicians. [ABSTRACT FROM AUTHOR]

Background: Effective co-management of patients with chronic kidney disease (CKD) between primary care physicians (PCPs) and nephrologists is increasingly recognized as a key strategy to ensure the delivery of efficient and high-quality CKD care. However, the co-management of patients with CKD remains suboptimal.Objective: We aimed to identify PCPs' perceptions of key barriers and facilitators to effective co-management of patients with CKD at the PCP-nephrology interface.Study Design: Qualitative study SETTING AND PARTICIPANTS: Community-based PCPs in four US cities: Baltimore, MD; St. Louis, MO; Raleigh, NC; and San Francisco, CA APPROACH: We conducted four focus groups of PCPs. Two members of the research team coded transcribed audio-recorded interviews and identified major themes.Key Results: Most of the 32 PCPs (59% internists and 41% family physicians) had been in practice for > 10 years (97%), spent ≥ 80% of their time in clinical care (94%), and practiced in private (69%) or multispecialty group practice (16%) settings. PCPs most commonly identified barriers to effective co-management of patients with CKD focused on difficulty developing working partnerships with nephrologists, including (1) lack of timely adequate information exchange (e.g., consult note not received or CKD care plan unclear); (2) unclear roles and responsibilities between PCPs and nephrologists; and (3) limited access to nephrologists (e.g., unable to obtain timely consultations or easily contact nephrologists with concerns). PCPs expressed a desire for "better communication tools" (e.g., shared electronic medical record) and clear CKD care plans to facilitate improved PCP-nephrology collaboration.Conclusions: Interventions facilitating timely adequate information exchange, clear delineation of roles and responsibilities between PCPs and nephrologists, and greater access to specialist advice may improve the co-management of patients with CKD. [ABSTRACT FROM AUTHOR]

Background: For at least the past two decades, medical educators have worked to improve patient communication and health care delivery to diverse patient populations; despite efforts, patients continue to report prejudice and bias during their clinical encounters. Targeted instruction in implicit bias recognition and management may promote the delivery of equitable care, but students at times resist this instruction. Little guidance exists to overcome this resistance and to engage students in implicit bias instruction; instruction over time could lead to eventual skill development that is necessary to mitigate the influence of implicit bias on clinical practice behaviors.Objective: To explore student perceptions of challenges and opportunities when participating in implicit bias instruction.Approach: We conducted a qualitative study that involved 11 focus groups with medical students across each of the four class years to explore their perceptions of challenges and opportunities related to participating in such instruction. We analyzed transcripts for themes.Key Results: Our analysis suggests a range of attitudes toward implicit bias instruction and identifies contextual factors that may influence these attitudes. The themes were (1) resistance; (2) shame; (3) the negative role of the hidden curriculum; and (4) structural barriers to student engagement. Students expressed resistance to implicit bias instruction; some of these attitudes are fueled from concerns of anticipated shame within the learning environment. Participants also indicated that student engagement in implicit bias instruction was influenced by the hidden curriculum and structural barriers.Conclusions: These insights can inform future curriculum development efforts. Considerations related to instructional design and programmatic decision-making are highlighted. These considerations for implicit bias instruction may provide useful frameworks for educators looking for opportunities to minimize student resistance and maximize engagement in multi-session instruction in implicit bias recognition and management. [ABSTRACT FROM AUTHOR]

Background: The Veterans Access, Choice and Accountability Act (hereafter, Choice Program) seeks to improve access to care by enabling eligible Veterans to receive care from community providers. Veterans Affairs (VA) primary care providers (PCPs) play a key role in making referrals to community specialists, but their frontline experiences with referrals are not well understood.Objective: To understand VA PCPs' experiences referring patients to community specialists while VA works to expand and refine the implementation of the Choice Program.Design: Qualitative study using interview methods.Participants: Semi-structured telephone interviews were conducted with VA primary care providers (N = 72 out of 599 contacted) recruited nationally.Approach: Open-ended interview questions elicited PCP perceptions and experiences with referrals to community specialists via the Choice Program. Keywords were identified using automated coding features in ATLAS.ti and evaluated using conventional content analysis to inductively describe the qualitative data.Key Results: VA PCPs emphasized problems with care coordination and continuity between the VA and community specialists (e.g., "It is extremely difficult for us to obtain and continue continuity of care because there's not much communication with the community specialist"). They described difficulties with tracking the initial referral, coordinating care after receiving community specialty care, accessing community medical records, and aligning community specialists' prescriptions with the VA formulary.Conclusions: The VA Choice Program provides access to community specialists for VA patients; however, VA primary care providers face challenges tracking referrals to community specialists and in coordinating care. Strategies to improve care coordination between the VA and community providers should focus on providing PCPs with information to follow Veterans throughout the Choice referral process and follow-up. [ABSTRACT FROM AUTHOR]

Background: One widely cited study suggested a link between physician empathy and laboratory outcomes in patients with diabetes, but its findings have not been replicated. While empathy has a positive impact on patient experience, its impact on other outcomes remains unclear.Objective: To assess associations between physician empathy and glycosylated hemoglobin (HgbA1c) as well as low-density lipoprotein (LDL) levels in patients with diabetes.Design: Retrospective cross-sectional study.Participants: Patients with diabetes who received care at a large integrated health system in the USA between January 1, 2011, and May 31, 2014, and their primary care physicians.Main Measures: The main independent measure was physician empathy, as measured by the Jefferson Scale of Empathy (JSE). The JSE is scored on a scale of 20-140, with higher scores indicating greater empathy. Dependent measures included patient HgbA1c and LDL. Mixed-effects linear regression models adjusting for patient sociodemographic characteristics, comorbidity index, and physician characteristics were used to assess the association between physician JSE scores and their patients' HgbA1c and LDL.Key Results: The sample included 4176 primary care patients who received care with one of 51 primary care physicians. Mean physician JSE score was 118.4 (standard deviation (SD) = 12). Median patient HgbA1c was 6.7% (interquartile range (IQR) = 6.2-7.5) and median LDL concentration was 83 (IQR = 66-104). In adjusted analyses, there was no association between JSE scores and HgbA1c (β = - 0.01, 95%CI = - 0.04, 0.02, p = 0.47) or LDL (β = 0.41, 95%CI = - 0.47, 1.29, p = 0.35).Conclusion: Physician empathy was not associated with HgbA1c or LDL. While interventions to increase physician empathy may result in more patient-centered care, they may not improve clinical outcomes in patients with diabetes. [ABSTRACT FROM AUTHOR]

Background: Support for ongoing care management and coordination between office visits for patients with multiple chronic conditions has been inadequate. In January 2015, Medicare introduced the Chronic Care Management (CCM) payment policy, which reimburses providers for CCM activities for Medicare beneficiaries occurring outside of office visits.Objective: To explore the experiences, facilitators, and challenges of practices providing CCM services, and their implications going forward.Design: Semi-structured telephone interviews from January to April 2016 with 71 respondents.Participants: Sixty billing and non-billing providers and practice staff knowledgeable about their practices' CCM services, and 11 professional society representatives.Key Results: Practice respondents noted that most patients expressed positive views of CCM services. Practice respondents also perceived several patient benefits, including improved adherence to treatment, access to care team members, satisfaction, care continuity, and care coordination. Facilitators of CCM provision included having an in-practice care manager, patient-centered medical home recognition, experience developing care plans, patient trust in their provider, and supplemental insurance to cover CCM copayments. Most billing practices reported few problems obtaining patients' consent for CCM, though providers felt that CMS could better facilitate consent by marketing CCM's goals to beneficiaries. Barriers reported by professional society representatives and by billing and non-billing providers included inadequacy of CCM payments to cover upfront investments for staffing, workflow modification, and time needed to manage complex patients. Other barriers included inadequate infrastructure for health information exchange with other providers and limited electronic health record capabilities for documenting and updating care plans. Practices owned by hospital systems and large medical groups faced greater bureaucracy in implementing CCM than did smaller, independent practices.Conclusions: Improving providers' experiences with and uptake of CCM will require addressing several challenges, including the upfront investment for CCM set-up and the time required to provide CCM to more complex patients. [ABSTRACT FROM AUTHOR]

Background: Physicians in Argentina smoke at rates similar to the general population, and do not have a clear role in tobacco control strategies.Objective: To describe the attitudes and knowledge of medical students and recent graduates towards smoking behavior in Argentina.Design: Cross-sectional self-administered online survey conducted in 2011.Participants: Medical students and recent medical graduates from the University of Buenos Aires.Main Measures: Attitudes and knowledge were evaluated by responses to 16 statements regarding the effects of smoking cigarettes and the role of physicians in tobacco control. Rates of agreement with a full ban on indoor smoking in different public settings were assessed.Key Results: The sample included 1659 participants (response rate: 35.1 %), 453 of whom (27.3 %) were current smokers. Only 52 % of participants agreed that doctors should set an example for their patients by not smoking, 30.9 % thought that medical advice had little effect on patients' cessation behavior, and 19.4 % believed that physicians could decline to care for smoking patients who failed to quit. In adjusted logistic regression models, current smokers had less supportive attitudes about tobacco control and were less likely than non-smokers to agree with a full indoor smoking ban in hospitals (OR: 0.30; 95 % CI 0.16-0.58), universities (OR: 0.55; 95 % CI 0.41-0.73), workplaces (OR: 0.67; 95 % CI 0.50-0.88), restaurants (OR: 0.42; 95 % CI 0.33-0.53), cafes (OR: 0.41; 95 % CI 0.33-0.51), nightclubs (OR: 0.32; 95 % CI 0.25-0.40), and bars (0.35; 95 % CI 0.28-0.45). Recent medical graduates had more accurate knowledge about cessation and were more likely to agree with a full smoking ban in recreational venues.Conclusions: Although most participants reported a strong anti-tobacco attitude, a proportion still failed to recognize the importance of their role as physicians in tobacco control strategies. Current smokers and current students were less likely to support indoor smoking bans. Specific educational curricula could address these factors. [ABSTRACT FROM AUTHOR]

Background: Over the past two decades, state and local governments across the U.S. have been increasingly reforming marijuana laws. Despite growing support for marijuana as a medical treatment, little is known about medical students' perceptions of marijuana use.Objective: To assess Colorado medical students' personal and professional opinions on current and future marijuana use in a healthcare setting.Design: A voluntary, anonymous, online cross-sectional survey.Participants: Medical students (n = 624) at the University of Colorado School of Medicine between January and February 2014 were invited to participate.Main Measures: Numerical responses were quantified using counts and percentages, and Likert scale responses were collapsed for bivariate analysis. Items were gathered thematically and additively scored for each subscale. Internal consistency reliability statistics were calculated for each subscale to ensure that items were assessing similar constructs. Unadjusted t tests and one-way analysis of variance (ANOVA) were used to calculate mean differences in subscale scores between subgroups.Key Results: We received 236 responses (37%). Students indicated support for marijuana legalization (64%), and few believed that physicians should be penalized for recommending marijuana to patients (6%). Nearly all (97%) believed that further marijuana research should be conducted, and believed marijuana could play a role in the treatment of various medical conditions. Seventy-seven percent reported that they believed marijuana use had the potential for psychological harm, and 68% indicated concern for potential physical harm. Only a minority of students would recommend marijuana to a patient under current law (29%), or if it were legally available (45%). Acceptability of marijuana for treatment of approved conditions was not correlated with age or gender, but was positively correlated with living in Colorado prior to medical school (p < 0.001) and with prior marijuana use (p < 0.001).Conclusions: Medical students support marijuana legal reform, medicinal uses of marijuana, and increased research, but have concerns regarding risks of marijuana use, and appear hesitant to recommend marijuana to patients. [ABSTRACT FROM AUTHOR]

Background: Revised breast cancer screening guidelines have fueled debate about the effectiveness and frequency of screening mammography, encouraging discussion between women and their providers.Objective: To examine whether primary care providers' (PCPs') beliefs about the effectiveness and frequency of screening mammography are associated with utilization by their patients.Design: Cross-sectional survey data from PCPs (2014) from three primary care networks affiliated with the Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium, linked with data about their patients' mammography use (2011-2014).Participants: PCPs (n = 209) and their female patients age 40-89 years without breast cancer (n = 30,233).Main Measures: Outcomes included whether (1) women received a screening mammogram during a 2-year period; and (2) screened women had >1 mammogram during that period, reflecting annual screening. Principal independent variables were PCP beliefs about the effectiveness of mammography and their recommendations for screening frequency.Key Results: Overall 65.2% of women received >1 screening mammogram. For women 40-48 years, mammography use was modestly lower for those cared for by PCPs who believed that screening was ineffective compared with those who believed it was somewhat or very effective (59.1%, 62.3%, and 64.7%; p = 0.019 after controlling for patient characteristics). Of women with PCPs who reported they did not recommend screening before age 50, 48.1% were nonetheless screened. For women age 49-74 years, the vast majority were cared for by providers who believed that screening was effective. Provider recommendations were not associated with screening frequency. For women ≥75 years, those cared for by providers who were uncertain about effectiveness had higher screening use (50.7%) than those cared for by providers who believed it was somewhat effective (42.8%). Patients of providers who did not recommend screening were less likely to be screened than were those whose providers recommended annual screening, yet 37.1% of patients whose providers recommended against screening still received screening.Conclusions: PCP beliefs about mammography effectiveness and screening recommendations are only modestly associated with use, suggesting other likely influences on patient participation in mammography. [ABSTRACT FROM AUTHOR]

Background: The shortage of primary care providers and the provisions of the Affordable Care Act (ACA) have spurred discussion about expanding the number, scope of practice (SOP), and independence of primary care nurse practitioners (NPs). Such discussions in the media and among professional organizations may insinuate that changes to the laws governing NP practice will engender acrimony between practicing physicians and NPs. However, we lack empirical, descriptive data on how practicing professionals view NP independence in primary care.Objective: The aim of the present study was to explore and describe the attitudes about NP independence among physicians and NPs working in primary care.Design: A qualitative study based on the principles of grounded theory.Participants: Thirty primary care professionals in Missouri, USA, including 15 primary care physicians and 15 primary care NPs.Approach: Semi-structured, in-depth interviews, with data analysis guided by grounded theory.Key Results: Participants had perspectives that were not well represented by professional organizations or the media. Physicians were supportive of a wide variety of NP roles and comfortable with high levels of NP independence and autonomy. Physicians and NPs described prerequisites to NP independence that were complementary. Physicians generally believed that NPs needed some association with physicians for patient safety, and NPs preferred having a physician readily accessible as needed. The theme "knowing your limits" was important to both NPs and physicians regarding NP independence, and has not been described previously in the literature.Conclusions: NP and physician views about NP practice in primary care are not as divergent as their representative professional organizations and the news media would suggest. The significant agreement among NPs and physicians, and some of the nuances of their perspectives, supports recommendations that may reduce the perceived acrimony surrounding discussions of NP independent practice in primary care. [ABSTRACT FROM AUTHOR]

Background: Rationing is a controversial topic among US physicians. Understanding their attitudes and behaviors around rationing may be essential to a more open and sensible professional discourse on this important but controversial topic.Objective: To describe rationing behavior and associated factors among US physicians.Design: Survey mailed to US physicians in 2012 to evaluate self-reported rationing behavior and variables related to this behavior.Setting: US physicians across a full spectrum of practice settings.Participants: A total of 2541 respondents, representing 65.6 % of the original mailing list of 3872 US addresses.Interventions: The study was a cross-sectional analysis of physician attitudes and self-reported behaviors, with neutral language representations of the behaviors as well as an embedded experiment to test the influence of the word "ration" on perceived responsibility.Main Outcome Measures: Overall percentage of respondents reporting rationing behavior in various contexts and assessment of attitudes toward rationing.Key Results: In total, 1348 respondents (53.1 %) reported having personally refrained within the past 6 months from using specific clinical services that would have provided the best patient care, because of health system cost. Prescription drugs (n = 1073 [48.3 %]) and magnetic resonance imaging (n = 922 [44.5 %]) were most frequently rationed. Surgical and procedural specialists were less likely to report rationing behavior (adjusted odds ratio [OR] [95 % CI], 0.8 [0.9-0.9] and 0.5 [0.4-0.6], respectively) compared to primary care. Compared with small or solo practices, those in medical school settings reported less rationing (adjusted OR [95 % CI], 0.4 [0.2-0.7]). Physicians who self-identified as very or somewhat liberal were significantly less likely to report rationing (adjusted OR [95 % CI], 0.7 [0.6-0.9]) than those self-reporting being very or somewhat conservative. A more positive opinion about rationing tended to align with greater odds of rationing.Conclusions: More than one-half of respondents engaged in behavior consistent with rationing. Practicing physicians in specific subgroups were more likely to report rationing behavior. [ABSTRACT FROM AUTHOR]

Background: Workforce projections indicate a potential shortage of up to 31,000 adult primary care providers by the year 2025. Approximately 80 % of internal medicine residents and nearly two-thirds of primary care internal medicine residents do not plan to have a career in primary care or general internal medicine.Objective: We aimed to explore contextual and programmatic factors within primary care residency training environments that may influence career choices.Design: This was a qualitative study based on semi-structured, in-person interviews.Participants: Three primary care internal medicine residency programs were purposefully selected to represent a diversity of training environments. Second and third year residents were interviewed.Approach: We used a survey guide developed from pilot interviews and existing literature. Three members of the research team independently coded the transcripts and developed the code structure based on the constant comparative method. The research team identified emerging themes and refined codes. ATLAS.ti was used for the analysis.Key Results: We completed 24 interviews (12 second-year residents, and 12 third-year residents). The age range was 27-39 years. Four recurrent themes characterized contextual and programmatic factors contributing to residents' decision-making: resident expectations of a career in primary care, navigation of the boundary between social needs and medical needs, mentorship and perceptions of primary care, and structural features of the training program.Conclusions: Addressing aspects of training that may discourage residents from careers in primary care such as lack of diversity in outpatient experiences and resident frustration with their inability to address social needs of patients, and strengthening aspects of training that may encourage interests in careers in primary care such as mentorship and protected time away from inpatient responsibilities during primary care rotations, may increase the proportion of residents enrolled in primary care training programs who pursue a career in primary care. [ABSTRACT FROM AUTHOR]

Background: Primary care providers (PCPs) have few tools for enhancing patient self-efficacy, a key mediator of myriad health-influencing behaviors.Objective: To examine whether brief standardized patient instructor (SPI)-delivered training increases PCPs' use of self-efficacy-enhancing interviewing techniques (SEE IT).Design: Randomized controlled trial.Participants: Fifty-two family physicians and general internists from 12 primary care offices drawn from two health systems in Northern California.Interventions: Experimental arm PCPs received training in the use of SEE IT training during three outpatient SPI visits scheduled over a 1-month period. Control arm PCPs received a single SPI visit, during which they viewed a diabetes treatment video. All intervention visits (experimental and control) were timed to last 20 min. SPIs portrayed patients struggling with self-care of depression and diabetes in the first 7 min, then delivered the appropriate intervention content during the remaining 13 min.Main Measures: The primary outcome was provider use of SEE IT (a count of ten behaviors), coded from three audio-recorded standardized patient visits at 1-3 months, again involving depression and diabetes self-care. Two five-point scales measured physician responses to training: Value (7 items: quality, helpfulness, understandability, relevance, feasibility, planned use, care impact), and Hassle (2 items: personal hassle, flow disruption).Key Results: Pre-intervention, study PCPs used a mean of 0.7 behaviors/visit, with no significant between-arm difference (P = 0.23). Post-intervention, experimental arm PCPs used more of the behaviors than controls (mean 2.7 vs. 1.0 per visit; adjusted difference 1.7, 95 % CI 1.1-2.2; P < 0.001). Experimental arm PCPs had higher training Value scores than controls (mean difference 1.05, 95 % CI 0.68-1.42; P < 0.001), and similarly low Hassle scores.Conclusions: Primary care physicians receiving brief SPI-delivered training increased their use of SEE IT and found the training to be of value. Whether patients visiting SEE IT-trained physicians experience improved health behaviors and outcomes warrants study. CLINICALTRIALS.Gov Identifier: NCT01618552. [ABSTRACT FROM AUTHOR]

Background: Changes to national guidelines for breast and cervical cancer screening have created confusion and controversy for women and their primary care providers.Objective: To characterize women's primary health care provider attitudes towards screening and changes in practice in response to recent revisions in guidelines for breast and cervical cancer screening.Design, Setting, Participants: In 2014, we distributed a confidential web and mail survey to 668 women's health care providers affiliated with the four clinical care networks participating in the three PROSPR (Population-based Research Optimizing Screening through Personalized Regimens) consortium breast cancer research centers (385 respondents; response rate 57.6 %).Main Measures: We assessed self-reported attitudes toward breast and cervical cancer screening, as well as practice changes in response to the most recent revisions of the U.S. Preventive Services Task Force (USPSTF) recommendations.Key Results: The majority of providers believed that mammography screening was effective for reducing cancer mortality among women ages 40-74 years, and that Papanicolaou (Pap) testing was very effective for women ages 21-64 years. While the USPSTF breast and cervical cancer screening recommendations were widely perceived by the respondents as influential, 75.7 and 41.2 % of providers (for mammography and cervical cancer screening, respectively) reported screening practices in excess of those recommended by USPSTF. Provider-reported barriers to concordance with guideline recommendations included: patient concerns (74 and 36 % for breast and cervical, respectively), provider disagreement with the recommendations (50 and 14 %), health system measurement of a provider's screening practices that use conflicting measurement criteria (40 and 21 %), concern about malpractice risk (33 and 11 %), and lack of time to discuss the benefits and harms with their patients (17 and 8 %).Conclusions: Primary care providers do not consistently follow recent USPSTF breast and cervical cancer screening recommendations, despite noting that these guidelines are influential. [ABSTRACT FROM AUTHOR]

Background: Ethical challenges are common in end of life care; the uncertainty of prognosis and the ethically permissible boundaries of treatment create confusion and conflict about the balance between benefits and burdens experienced by patients.Objective: We asked physician trainees in internal medicine how they reacted and responded to ethical challenges arising in the context of perceived futile treatments at the end of life and how these challenges contribute to moral distress.Design: Semi-structured in-depth qualitative interviews.Participants: Twenty-two internal medicine residents and fellows across three American academic medical centers.Approach: This study uses systematic qualitative methods of data gathering, analysis and interpretation.Key Results: Physician trainees experienced significant moral distress when they felt obligated to provide treatments at or near the end of life that they believed to be futile. Some trainees developed detached and dehumanizing attitudes towards patients as a coping mechanism, which may contribute to a loss of empathy. Successful coping strategies included formal and informal conversations with colleagues and superiors about the emotional and ethical challenges of providing care at the end of life.Conclusions: Moral distress amongst physician trainees may occur when they feel obligated to provide treatments at the end of life that they believe to be futile or harmful. [ABSTRACT FROM AUTHOR]

Background: Traditional productivity-based compensation models do not align well with newer population-based approaches to primary care. There are few published examples of academic general internal medicine compensation models that explicitly reward population health management, including care for patients between visits.Objective: To describe the development and implementation of an academic general internal medicine compensation plan based upon actual work performed, compare satisfaction across primary care specialties, and evaluate work-related outcomes.Design: Observational study.Participants: Forty-seven general internists who practice in affiliated academic and community clinics.Main Measures: Clinician satisfaction with compensation plan, workforce stability, panel data, and productivity.Key Results: The compensation plan change was associated with higher provider satisfaction. Sixty-five percent (31/47) of participants within general internal medicine reported being satisfied or very satisfied, as compared to 24 % (22/90 participants) for family medicine and 22 % (5/23 participants) for general pediatrics (p < 0.05). In the first 4 years of the compensation plan change, no general internists left to join other local groups. General internal medicine increased its number of physicians by 19 %. The number of established general internists accepting new patients increased from 17 to 48 %, while the relative value units per full-time equivalent declined by 3 %.Conclusions: An equitable compensation model that aligns with population management goals and work performed outside the clinical visit can lead to improved satisfaction and retention of faculty in an academic general internal medicine division, along with improved access for the patient population. [ABSTRACT FROM AUTHOR]

Background: Research suggests stereotyping by clinicians as one contributor to racial and gender-based health disparities. It is necessary to understand the origins of such biases before interventions can be developed to eliminate them. As a first step toward this understanding, we tested for the presence of bias in senior medical students. Objective: The purpose of the study was to determine whether bias based on race, gender, or socioeconomic status influenced clinical decision-making among medical students. Design: We surveyed seniors at 84 medical schools, who were required to choose between two clinically equivalent management options for a set of cardiac patient vignettes. We examined variations in student recommendations based on patient race, gender, and socioeconomic status. Participants: The study included senior medical students. Main Measures: We investigated the percentage of students selecting cardiac procedural options for vignette patients, analyzed by patient race, gender, and socioeconomic status. Key Results: Among 4,603 returned surveys, we found no evidence in the overall sample supporting racial or gender bias in student clinical decision-making. Students were slightly more likely to recommend cardiac procedural options for black (43.9 %) vs. white (42 %, p = .03) patients; there was no difference by patient gender. Patient socioeconomic status was the strongest predictor of student recommendations, with patients described as having the highest socioeconomic status most likely to receive procedural care recommendations (50.3 % vs. 43.2 % for those in the lowest socioeconomic status group, p < .001). Analysis by subgroup, however, showed significant regional geographic variation in the influence of patient race and gender on decision-making. Multilevel analysis showed that white female patients were least likely to receive procedural recommendations. Conclusions: In the sample as a whole, we found no evidence of racial or gender bias in student clinical decision-making. However, we did find evidence of bias with regard to the influence of patient socioeconomic status, geographic variations, and the influence of interactions between patient race and gender on student recommendations. [ABSTRACT FROM AUTHOR]

Background: Many older adults who die by suicide have had recent contact with a primary care physician. As the risk-assessment and referral process for suicide is not readily comparable to procedures for other high-risk behaviors, it is important to identify areas in need of quality improvement (QI).Objective: Identify patterns in physician-patient communication regarding suicide to inform QI interventions.Design: Qualitative thematic analysis of video-taped clinical encounters in which suicide was discussed.Participants: Adult primary care patients (n = 385) 65 years and older and their primary care physicians.Results: Mental health was discussed in 22% of encounters (n = 85), with suicide content found in less than 2% (n = 6). Three patterns of conversation were characterized: (1) Arguing that "Life's Not That Bad." In this scenario, the physician strives to convince the patient that suicide is unwarranted, which results in mutual fatigue and discouragement. (2) "Engaging in Chitchat." Here the physician addresses psychosocial matters in a seemingly aimless manner with no clear therapeutic goal. This results in a superficial and misleading connection that buries meaningful risk assessment amidst small talk. (3) "Identify, assess, and…?" This pattern is characterized by acknowledging distress, communicating concern, eliciting information, and making treatment suggestions, but lacks clearly articulated treatment planning or structured follow-up.Conclusions: The physicians in this sample recognized and implicitly acknowledged suicide risk in their older patients, but all seemed unable to go beyond mere assessment. The absence of clearly articulated treatment plans may reflect a lack of a coherent framework for managing suicide risk, insufficient clinical skills, and availability of mental health specialty support required to address suicide risk effectively. To respond to suicide's numerous challenges to the primary care delivery system, QI strategies will require changes to physician education and may require enhancing practice support. [ABSTRACT FROM AUTHOR]

Background: Clinician attitudes toward patients are associated with variability in the quality of health care. Attitudes are typically considered difficult to change, and few interventions have attempted to do so. Negative attitudes toward adults with sickle cell disease have been identified as an important barrier to the receipt of appropriate pain management for this patient population.Objective: To test the effect of a video-intervention designed to improve clinician attitudes toward adults with sickle cell disease.Interventions: An 8-minute video depicting a clinician expert and patients discussing challenges in seeking treatment for sickle cell pain.Design and Participants: A randomized post-test only control group design was used to assess the impact of the intervention on the attitudes of 276 nurses and housestaff working at a large, urban, academic medical center.Main Measures: Attitudes toward adult sickle cell patients assessed using 5- and 6-point Likert-scale items. Exploratory factor analysis was used to identify underlying attitudinal domains and develop scales. Examples of the negative and positive attitudes assessed include clinician estimates of the percentage of SCD patients that exaggerate pain (negative) or make clinicians glad they went into medicine (positive).Key Results: Compared to the control group, the intervention group exhibited decreased negative attitudes (Difference in means = -8.9, 95%CI [-14.2, -3.6]; Cohen's d = 0.41), decreased endorsement of certain patient behaviors as "concern-raising" (Difference in means = -7.8, 95%CI [-13.1, -2.5]; Cohen's d = 0.36), and increased positive attitudes toward sickle cell patients (Difference in means = 6.6, 95% CI [0.6, 12.6]; Cohen's d = 0.27).Conclusions: Our results suggest that the attitudes of clinicians toward sickle cell patients may be improved through a short and relatively easy to implement intervention. Whether the attitudinal differences associated with our intervention are sustainable or are linked to clinical outcomes remains to be seen. [ABSTRACT FROM AUTHOR]

Background: Religiously affiliated hospitals provide nearly 20% of US beds, and many prohibit certain end-of-life and reproductive health treatments. Little is known about physician experiences in religious institutions.Objective: Assess primary care physicians' experiences and beliefs regarding conflict with religious hospital policies for patient care.Design: Cross-sectional survey.Participants: General internists, family physicians, and general practitioners from the AMA Masterfile.Main Measures: In a questionnaire mailed in 2007, we asked physicians whether they had worked in a religiously affiliated hospital or practice, whether they had experienced conflict with the institution over religiously based patient care policies and how they believed physicians should respond to such conflicts. We used chi-square and multivariate logistic regression to examine associations between physicians' demographic and religious characteristics and their responses.Key Results: Of 879 eligible physicians, 446 (51%) responded. In analyses adjusting for survey design, 43% had worked in a religiously affiliated institution. Among these, 19% had experienced conflict over religiously based policies. Most physicians (86%) believed when clinical judgment conflicts with religious hospital policy, physicians should refer patients to another institution. Compared with physicians ages 26-29 years, older physicians were less likely to have experienced conflict with religiously based policies [odds ratio (95% confidence interval) compared with 30-34 years: 0.02 (0.00-0.11); 35-46 years: 0.07 (0.01-0.72); 47-60 years: 0.02 (0.00-0.10)]. Compared with those who never attend religious services, those who do attend were less likely to have experienced conflict [attend once a month or less: odds ratio 0.06 (0.01-0.29); attend twice a month or more: 0.22 (0.05-0.98)]. Respondents with no religious affiliation were more likely than others to believe doctors should disregard religiously based policies that conflict with clinical judgment (13% vs. 3%; p = 0.005).Conclusions: Hospitals and policy-makers may need to balance the competing claims of physician autonomy and religiously based institutional policies. [ABSTRACT FROM AUTHOR]

Background: Enhancing the cultural competency of students is emerging as a key issue in medical education; however, students may perceive that they are more able to function within cross-cultural situations than their teachers, reducing the effectiveness of cultural competency educational efforts.Objective: The purpose of our study was to compare medical students' perceptions of their residents, attendings, and their own cultural competency.Design: Cross-sectional study.Main Measures: A questionnaire containing previously validated instruments was administered to end-of-third-year medical students at four institutions throughout the US. Repeated measures multivariate analysis was used to determine differences in student ratings.Participants: Three hundred fifty-eight medical students from four schools participated, for an overall response rate of 65%.Results: Analysis indicated overall statistically significant differences in students' ratings (p < 0.001, eta(2) = 0.33). Students rated their own cultural competency as statistically significantly higher than their residents, but similar to their attendings. For reference, students rated the patient care competency of themselves, their residents, and their attendings; they rated their attendings' skills as statistically significantly higher than residents, and residents as statistically significantly higher than themselves. There were differences between cultural competency and patient care ratings.Conclusions: Our results indicate that students perceive the cultural competency of their attendings and residents to be the same or lower than themselves. These findings indicate that this is an important area for future research and curricular reform, considering the vital role that attendings and residents play in the education of medical students. [ABSTRACT FROM AUTHOR]

Background: There is little to no information on whether race should be considered in the exam room by those who care for and treat patients. How primary care physicians understand the relationship between genes, race and drugs has the potential to influence both individual care and racial and ethnic health disparities.Objective: To describe physicians' use of race-based therapies, with specific attention to the case of BiDil (isosorbide dinitrate/hydralazine), the first drug approved by the FDA for a race-specific indication, and angiotensin-converting enzyme (ace) inhibitors in their black and white patients.Design: Qualitative study involving 10 focus groups with 90 general internists.Participants: Black and white general internists recruited from community and academic internal medicine practices participated in the focus groups.Of the participants 64% were less than 45 years of age, and 73% were male.Approach: The focus groups were transcribed verbatim, and the data were analyzed using template analysis.Results: There was a range of opinions relating to the practice of race-based therapies. Physicians who were supportive of race-based therapies cited several potential benefits including motivating patients to comply with medical therapy and promoting changes in health behaviors by creating the perception that the medication and therapies were tailored specifically for them. Physicians acknowledged that in clinical practice some medications vary in their effectiveness across different racial groups, with some physicians citing the example of ace inhibitors. However, physicians voiced concern that black patients who could benefit from ace inhibitors may not be receiving them. They were also wary that the category of race reflected meaningful differences on a genetic level. In the case of BiDil, physicians were vocal in their concern that commercial interests were the primary impetus behind its creation.Conclusions: Primary care physicians' opinions regarding race-based therapy reveal a nuanced understanding of race-based therapies and a wariness of their use by physicians. [ABSTRACT FROM AUTHOR]

Background: Energized, talented faculty are essential to achieving the missions of academic medical centers (AMCs) in education, research and health care. The alignment of individuals' values with workplace experiences are linked to meaningfulness of work and productivity.Objective: To determine faculty values and their alignment with institutional values.Design: A qualitative hypothesis-generating interview study to understand the professional experiences of faculty and organizational approach in five AMCs that were nationally representative in regional and organizational characteristics. Analysis was inductive and data driven.Participants: Using stratified, purposeful sampling, we interviewed 96 male and female faculty at different career stages (early career, plateaued, senior faculty and those who had left academic medicine) and diverse specialties (generalists, medical and surgical subspecialists, and research scientists).Approach: Dominant themes that emerged from the data.Results: Faculty described values relating to excellence in clinical care, community service (including care for the underserved and disadvantaged), teaching, intellectual rigor/freedom and discovery, all values that mirror the stated missions of AMCs. However, many faculty also described behaviors that led them to conclude that their AMCs, in practice, undervalued excellence in clinical care, and their social and educational missions. Themes were seen across gender, career stage, race and discipline, except that female leaders appeared more likely than male leaders to identify incongruence of individual values and organizational practices.Conclusions: In this study of five diverse medical schools, faculty values were well aligned with stated institutional missions; however, many perceived that institutional behaviors were not always aligned with individual faculty values. [ABSTRACT FROM AUTHOR]

Background: General practitioners (GP) play an important role in detecting cognitive impairment among their patients.Objectives: To explore factors associated with GPs' judgment of their elderly patients' cognitive status.Design: Cross-sectional data from an observational cohort study (AgeCoDe study); General practice surgeries in six German metropolitan study centers; home visits by interviewers.Participants: 138 GPs, 3,181 patients (80.13 +/- 3.61 years, 65.23% female).Measurements: General practitioner questionnaire for each patient: familiarity with the patient, patient morbidity, judgment of cognitive status. Home visits by trained interviewers: sociodemographic and clinical data, psychometric test performance. Multivariate regression analysis was used to identify independent associations with the GPs' judgment of "cognitively impaired" vs. "cognitively unimpaired."Results: Less familiar patients (adjusted odds ratio [aOR] 2.42, 95% CI 1.35-4.32, for poor vs. very high familiarity), less mobile patients (aOR 1.29, 95% CI 1.13-1.46), patients with impaired hearing (aOR 5.46, 95% CI 2.35-12.67 for serious vs. no problems), and patients with greater comorbidity (aOR 1.15, 95% CI 1.08-1.22) were more likely to be rated as "cognitively impaired" by their GPs.Conclusions: The associations between GPs' assessments of cognitive impairment and their familiarity with their patients and patients' mobility, hearing, and morbidity provide important insights into how GPs make their judgments. [ABSTRACT FROM AUTHOR]

Background: Previously, we reported a high level of comfort among Californians for collecting race/ethnicity information by health care providers (HCPs). However, minorities were less comfortable providing race/ethnicity information and were more worried than non-Hispanic whites about the potential misuse of this information.Objective: To determine if perceived experiences of discrimination (both in general and in medical care) were associated with comfort providing race/ethnicity information, and conversely, to worry about providing the information.Design and Participants: Telephone survey of 480 Californians, including 101 whites, 98 Asians, 173 Hispanics, 82 blacks, and 26 multiracial individuals.Measurements: Comfort level giving HCPs information about race/ethnicity (measured on a 1-10 scale, with text anchors of "very uncomfortable" at 1 and "very comfortable" at 10), worry that the information could be used to discriminate against patients, and worry that the information could be used to find undocumented immigrants. Worry was measured using a four-point Likert scale- not worried at all, a little worried, somewhat worried, and very worried. Respondents were also asked about perceived discrimination in general and perceived discrimination in medical care.Results: Compared to whites, Hispanics (Beta-coefficient (BC) = -1.16, SE = 0.51) and Mandarin/Cantonese-speaking Asians (BC = -1.40, SE = 0.65) reported significantly less comfort giving HCPs information about their race/ethnicity, while blacks (BC = 0.70, SE = 0.16), Hispanics (BC = 0.91, SE = 0.18), and multiracial individuals (BC = 0.63, SE = 0.24) were significantly more worried that race/ethnicity information could be used to discriminate against them. Adjusting for perceived experiences of discrimination in general and in medical care partially explained the higher discomfort and worry among minorities.Conclusions: Perceived experiences of discrimination are associated with greater discomfort and worry about providing race/ethnicity data. Health care institutions should consider how they can address the public's concerns about possible misuses of data. [ABSTRACT FROM AUTHOR]

Background: Experts suggest an individualized approach to colon cancer screening to take into account variation in older adults' life expectancies and potential to benefit from screening. However, little is known about how physicians make decisions about colon cancer screening in adults age 75 and older.Objective: To understand whether physicians employ individualized decision making for colon cancer screening in older adults, and, if so, to determine the individual factors they believed were important to consider in making such decisions.Design: Qualitative research using focus groups and individual interviewsParticipants: Fifteen primary care physicians practicing in community settings participated in three focus groups and two interviews.Approach: We used two clinical vignettes of 78-year-old women in fair and poor health states to stimulate discussions about clinical decision making for CRC screening in older adults.Results: Physicians considered a wide range of factors, including clinical factors, such as age, life expectancy, co-morbidities, and functional status, as well as individual factors, such as personality, previous screening behavior, family support, and the relationship with the patient. Physicians reported difficulty with these decisions because of their complexity and because they involve life expectancy estimates. Their approach and discussion with patients seemed to be dependent on the degree of certainty they perceived regarding their clinical assessment as to whether the patient had the potential to benefit from screening.Conclusions: Colorectal cancer screening decision making is complex. Physicians reported using a range of clinical and individual factors to decide about colorectal cancer screening in older adults. [ABSTRACT FROM AUTHOR]

Introduction: Morning report is a traditional core teaching session in most departments of internal medicine where learners present cases to a facilitator who uses the material to teach clinical reasoning. It instills fear in both learners and teachers because they may embarrassingly miss diagnostic possibilities including even the actual diagnosis.Aim: The two teaching tips described here enable the learner and the teacher to fall back on a routine approach to arriving at a differential diagnosis list.Description: The first tip describes how to elicit the ten "focal findings" in the case that best summarize the data used to derive a diagnosis list. The second tip describes a matrix of etiologies and systems that can be used to generate the diagnostic probabilities.Discussion: This approach is easy to teach and, where all else fails when coming up with a diagnosis, can be used to prompt the discussion of what is wrong with the patient. [ABSTRACT FROM AUTHOR]

Background: Clinician perceptions of a newly implemented electronic health record play an important role in its success or failure.Objective: To measure changes in primary care clinician attitudes toward an electronic health record during the first year following implementation.Design: Longitudinal survey.Participants: 86 primary care clinicians surveyed between December 2006 and January 2008.Measurements: Perceived impact on overall quality of care, patient safety, communication, and efficiency at 1, 3, 6, and 12 months following implementation.Results: Response rates for months 1, 3, 6, and 12 were 92%, 95%, 90%, and 82%, respectively. The proportion of clinicians agreeing that the EHR improved the overall quality of care (63% to 86%; p < 0.001), reduced medication-related errors (72% to 81%; p = 0.03), improved follow-up of test results (62% to 87%; p < 0.001), and improved communication among clinicians (72% to 93%; p < 0.001) increased from month 1 to month 12. During the same time period, a decreasing proportion of clinicians agreed that the EHR reduced the quality of patient interactions (49% to 33%; p = 0.001), resulted in longer patient visits (68% to 51%; p = 0.001), and increased time spent on medical documentation (78% to 68%; p = 0.006). Significant improvements in perceptions related to test result follow-up were first detected at 6 months, while those related to overall quality, efficiency, and communication were first identified at 12 months.Conclusions: Primary care clinicians report increasingly positive perceptions of a new electronic health record within 1 year of implementation across a spectrum of domains of care. [ABSTRACT FROM AUTHOR]

Objective: We evaluated the association between physicians' communication behavior and breast cancer patients' trust in their physicians.Design: Longitudinal survey conducted at baseline, 2-month, and 5-month follow-up during first year of diagnosis.Participants: Newly diagnosed breast cancer patients (N = 246).Measurements: We collected data on patient perceptions of the helpfulness of informational, emotional, and decision-making support provided by physicians and patients' trust. Linear regression models evaluated the association of concurrent and prior levels of physician support with patients' trust.Results: At baseline, patients who received helpful informational, emotional, and decision-making support from physicians reported greater trust (p < 0.05, p < 0.001, and p < 0.01, respectively). At the 2-month assessment, baseline informational support and informational and emotional support at 2-months were associated with greater trust (p < 0.05, p < 0.01, and p < 0.05, respectively). At the 5-month assessment, only helpful emotional support from physicians at 5 months was associated with greater trust (p < 0.01). Interestingly, while perceived helpfulness of all three types of physician support decreased significantly over time, patient trust remained high and unchanged.Conclusions: Findings suggest that while informational and decision-making support may be more important to patient trust early in the course of treatment, emotional support from physicians may be important to maintain trust throughout the initial year of diagnosis. [ABSTRACT FROM AUTHOR]

Objective: To identify and describe unintended adverse consequences related to clinical workflow when implementing or using computerized provider order entry (CPOE) systems.Methods: We analyzed qualitative data from field observations and formal interviews gathered over a three-year period at five hospitals in three organizations. Five multidisciplinary researchers worked together to identify themes related to the impacts of CPOE systems on clinical workflow.Results: CPOE systems can affect clinical work by 1) introducing or exposing human/computer interaction problems, 2) altering the pace, sequencing, and dynamics of clinical activities, 3) providing only partial support for the work activities of all types of clinical personnel, 4) reducing clinical situation awareness, and 5) poorly reflecting organizational policy and procedure.Conclusions: As CPOE systems evolve, those involved must take care to mitigate the many unintended adverse effects these systems have on clinical workflow. Workflow issues resulting from CPOE can be mitigated by iteratively altering both clinical workflow and the CPOE system until a satisfactory fit is achieved. [ABSTRACT FROM AUTHOR]

Background: Recent reports from the Institute of Medicine emphasize patient-centered care and cross-cultural training as a means of improving the quality of medical care and eliminating racial and ethnic disparities.Objective: To determine whether, controlling for training received in medical school or during residency, resident physician socio-cultural characteristics influence self-perceived preparedness and skill in delivering cross-cultural care.Design: National survey of resident physicians.Participants: A probability sample of residents in seven specialties in their final year of training at US academic health centers.Measurement: Nine resident characteristics were analyzed. Differences in preparedness and skill were assessed using the chi(2) statistic and multivariate logistic regression.Results: Fifty-eight percent (2047/3500) of residents responded. The most important factor associated with improved perceived skill level in performing selected tasks or services believed to be useful in treating culturally diverse patients was having received cross-cultural skills training during residency (OR range 1.71-4.22). Compared with white residents, African American physicians felt more prepared to deal with patients with distrust in the US healthcare system (OR 1.63) and with racial or ethnic minorities (OR 1.61), Latinos reported feeling more prepared to deal with new immigrants (OR 1.88) and Asians reported feeling more prepared to deal with patients with health beliefs at odds with Western medicine (1.43).Conclusions: Cross-cultural care skills training is associated with increased self-perceived preparedness to care for diverse patient populations providing support for the importance of such training in graduate medical education. In addition, selected resident characteristics are associated with being more or less prepared for different aspects of cross-cultural care. This underscores the need to both include medical residents from diverse backgrounds in all training programs and tailor such programs to individual resident needs in order to maximize the chances that such training is likely to have an impact on the quality of care. [ABSTRACT FROM AUTHOR]

Background: Pneumococcal vaccine (PPV) is recommended for adults >or=65 years and those with chronic illness, but there are potential advantages of universal vaccination of adults age 50-64 years.Objective: To assess reported (1) recommendations and administration practices of general internists for PPV, (2) barriers to vaccination, and (3) willingness to expand vaccination to all adults >or=50 years.Methods: National survey of general internists representative of the American College of Physicians.Results: Response rate was 74% (N = 326). Although 99% reported giving PPV, less than 20% used a computerized database to identify eligible patients by age or diagnoses and only 6% recalled patients. Major barriers included acute problems taking precedence over preventive care (39%), difficulty determining vaccination history (30%), not thinking of it/not a priority (20%), and inadequate reimbursement for vaccine (19%). If ACIP expanded recommendations, 60% would definitely and 37% would probably institute this change.Conclusions: Most general internists reported giving PPV, but delivery was hindered by competing demands, lack of systems to identify patients needing vaccination, and reimbursement issues. Barriers might be decreased by a policy of universal vaccination of adults >or=50 years, and the majority of physicians reported they would follow such a recommendation if it were made. [ABSTRACT FROM AUTHOR]

Background: Efforts to improve primary care depression treatment have assessed strategies across heterogeneous groups of patients, but few have examined clinician-level influences on depression treatment.Objective: To examine clinician characteristics that affect depression treatment in primary care settings, using multilevel ordinal regression modeling to disentangle patient- from clinician-level effects.Design: Secondary analysis from the Quality Improvement in Depression Study dataset.Participants: The participants were 1,023 primary care patients with depression who reported on treatment in the 6-month follow-up and whose clinicians (n = 158) had at least 4 patients in the study.Measurements: Primary outcome variable was depression treatment intensity, derived from assessment of concordance with AHCPR depression treatment guidelines based on patient-reported data on their treatment. Primary independent variable was clinical practice burden for treating depression, derived from patient- and clinician-reported composite measures tested for significant association with clinician-reported practice burden.Results: Clinicians who treat patients with more chronic medical comorbidities perceive less burden from treating depressed patients in their practice (Spearman's rho = -.30, p < .05). Clinicians who treat patients with more chronic medical comorbidities also provide greater intensity of depression treatment (adjusted OR = 1.44, p = .02), even after adjusting for the effects of patient-level chronic medical comorbidities (adjusted OR = 0.95, p = .45).Conclusions: Clinicians who provide more chronic care also provide greater depression treatment intensity, suggesting that clinicians who care for complex patients can integrate depression care into their practice. Targeting interventions to these clinicians to enhance their ability to provide guideline-concordant depression care is a worthwhile endeavor and deserves further investigation. [ABSTRACT FROM AUTHOR]

Background: Patient-centered access is a philosophy and a method that supports efforts to redesign health-care delivery systems to deliver higher quality care and to better meet the needs and preferences of patients. Since mid-2000, Group Health Cooperative has pursued an ensemble of strategic initiatives aimed at promoting patient-centered access, referred to as the Access Initiative. In support of this strategy, Group Health has also engaged in enterprise implementation of an electronic medical record and clinical information system that is integrated with their patient Web site, MyGroupHealth.Objective: To elicit, describe, and characterize providers' perceptions of the effects of the Access Initiative, an information technology-enabled organizational redesign initiative intended to promote patient-centered access.Design: Thematic analysis of semi-structured in-depth interviews.Participants: Twenty-two care providers representing 14 primary care, medical, and surgical specialties at Group Health Cooperative, an integrated health-care system based in Seattle, Washington.Findings: Analyses of the interview transcripts revealed nine emergent themes, five of which have particular relevance for health-care organizations pursuing patient-centered access: the Access Initiative improved patient satisfaction, improved the quality of encounter-based care, compromised providers' focus on population health, created additional work for providers, and decreased job satisfaction for primary care providers and some medical specialists.Conclusions: Providers like that the Access Initiative is mostly good for their patients, but dislike the negative effects on their own quality of life - especially in primary care. These reforms may not be sustainable under current models of organization and financing. [ABSTRACT FROM AUTHOR]

Background: As an increasing number of patients with chronic conditions of childhood survive to adulthood, experts recommend that young adults with chronic conditions transfer from child-focused to adult-focused primary care. Little, however, is known about how comfortable physicians are caring for this population.Objectives: To assess the comfort of general internists and general pediatricians in treating young adult patients with chronic illnesses originating in childhood as well as the factors associated with comfort.Participants: In a random sample, 1288 of 2434 eligible US general internists and pediatricians completed a mailed survey (response rate = 53%).Methods: We measured respondents' comfort level in providing primary care for a patient with sickle cell disease (SCD) or cystic fibrosis (CF). We also measured levels of disease familiarity, training and subspecialty support, as well as individual physician characteristics.Results: Fifteen percent of general internists reported being comfortable as the primary care provider for adults with CF and 32% reported being comfortable providing primary care for adults with SCD, compared with 38% of pediatricians for CF (p < .001) and 35% for SCD (p > 0.05). Less than half of general internists felt that their specialty should take primary care responsibility for adult patients with CF and SCD.Conclusions: A majority of general internists and pediatricians are not comfortable providing primary care for young adults with chronic illnesses of childhood origin, such as CF and SCD. Efforts to increase treatment comfort among providers may help with the transition to adult-focused care for the growing numbers of young adults with complex chronic conditions. [ABSTRACT FROM AUTHOR]

Background: Medical educators act on the belief that students benefit from formal and informal educational experiences that foster virtues such as compassion, altruism, and respect for patients.Objective: The purpose of this study is to examine fourth year medical students' perspectives on how, where, and by whom they believe the virtues associated with good physicianhood have been taught to them.Design: Fourth year students were assigned a two- to three-page essay that asked them to reflect on how their medical education had "fostered and hindered" their conceptions of compassion, altruism, and respect for patients.Participants: All 112 students completed this assignment, and 52 (46%) gave us permission to use their essays for this study.Approach: An inductive, qualitative approach was used to develop themes derived from students' essays.Results: Students' thoughts were organized around the idea of influences in three areas to which they consistently referred. Foundational influences included parents and "formative years," religious faith, and other experiences preceding medical school. Preclinical education influences comprised formal classroom experiences (both positive and negative effects). Clinical education influences included role modeling (both positive and negative) and the clinical environment (notable for emphasis on efficiency and conflicting cues). Students' essays drew most heavily on the effects of role modeling.Discussion: Medical students arrive at our doors as thoughtful, compassionate people. Positive role models and activities to promote critical self-reflection may help nurture these attitudes. [ABSTRACT FROM AUTHOR]