[Show abstract][Hide abstract] ABSTRACT: Medical educators need proven curriculum innovations that prepare trainees for the expanding number of patients with chronic illnesses.
We describe and evaluate the effectiveness of a chronic illness training program, Chronic Illness Needs Educated Doctors (CINED).
Forty-seven trainees completed four instructional components: (1) measurements of the health-related quality of life of patients with chronic illnesses; (2) didactic sessions in which they described chronically ill patients and their care; (3) written narratives describing the trainees' reactions for these patients; and (4) portfolios offering evidence of chronic illness learning. We measured the accuracy of the trainees' clinical skills at the end of CINED with an objective standardized clinical exercise (OSCE).
Forty-seven trainees scored the perceptions of mental and physical health of 414 chronic illnesses patients. In 47 didactic sessions and 93 written narratives, the trainees explained the relationship between the scores and their clinical observations. Accurate differential diagnoses of and communications with chronically ill patients were observed in an OSCE by standardized patients. The trainers rated 13 of the trainees' chronic illness portfolios as excellent and the remainder satisfactory.
Initial evaluations suggest that the CINED is an effective curriculum for promoting chronic illness learning among trainees.
Medical Teacher 06/2011; 33(6):e340-8. · 2.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The objectives of the current study were to examine the trends in incidence rates of subsite-specific colorectal cancer at all stages in a large US population and to explore the impact of age and sex on colorectal cancer incidence.
Data were obtained from the Surveillance, Epidemiology, and End Results (SEER) 9 registries. Colorectal cancer incidence was divided into 3 anatomic subsite groupings: proximal colon, distal colon, and rectum. Incidence rates and relative risk were calculated using the SEER*Stat software provided by the National Cancer Institute.
From 1976 to 2005, age-adjusted incidence of proximal colon, distal colon, and rectal cancers per 100,000 population have steadily decreased from 22.5, 18.8, and 19.2 to 21.1, 11.7, and 13.6, respectively, contributing to the overall decline in the incidence of colorectal cancer from 60.5 to 46.4. Distal colon cancer had the greatest incidence decline (-37.79%), whereas the most minimal change in the incidence rates occurred for proximal colon cancer (-6.37%) because of increased incidence rates of ascending colon (24.8%) and hepatic flexure (21.3%) over 30 years. The steadily increased proportion of proximal colorectal cancer subsites was observed in both men and women starting at age 50 although women experienced a greater increase than did men.
Overall incidence rate of colorectal cancer decreased over the past 3 decades. The percent of ascending colon and hepatic flexure cancers diagnosed at early stages (localized and regional) increased. The finding on sex difference over years suggests that great attention should be paid in the future studies to male and female disparities.
American journal of clinical oncology 01/2011; 34(6):573-80. · 2.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Our objective was to describe and evaluate an educational intervention for teaching preclinical medical students enrolled in a family medicine preceptorship to use evidence-based medicine (EBM) techniques.
In a brief workshop, 94 preclinical students, enrolled in a 4?week family medicine preceptorship, learned an EBM approach to clinical decision making. Students were responsible for completing four patient case summaries to document that they had searched selected databases and obtained feedback from their preceptors. We then evaluated (1) the percent of students documenting EBM processes, (2) the students' perceived self-efficacy, (3) the level of the students' EBM learning, and (4) preceptors' attitudes toward using the EBM project as the focus of their feedback.
All students succeeded in identifying the factual knowledge that they had used to convert information from patient encounters into searchable clinical questions. The preceptors provided case-specific, written feedback to all students. Students gave lesser ratings of importance to EBM and self-efficacy in using EBM after the preceptorship as compared to after the brief introductory workshop. Preceptors acknowledged that the project helped them to focus their feedback and to reconsider patient management practices.
Students learned to use an EBM process and became more familiar with and more realistic about their self-efficacy in using EBM. Preceptors and preclinical medical students can learn and hone EBM skills together.
Family medicine 06/2009; 41(5):332-6. · 0.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: RATIONAL, AIMS AND OBJECTIVES: Previous studies found that the increasing number of paediatricians in the United States was associated with improved childhood immunization coverage, while the increasing poverty level and the lack of health insurance reduced access to health care. We evaluated whether changes in the number of paediatricians, poverty level and health insurance affected national childhood immunization coverage in the state levels of the United States.
Data were collected primarily from the US National Immunization Surveys, series 4:3:1:3:3 from years 1995 and 2003. Ordinal logistic regression analysis was used to analyse the relationships among variables.
Over 8 years studied, immunization coverage increased for children aged 19-35 months from 52.3% to 79.8% in the 50 states. The average number of paediatricians per 1000 births increased 28.7% while the percentage of children without health insurance declined 15.6%, and the percentage of children who lived in poverty level declined 17.3%. In 1995, the states with higher immunization coverage were associated with higher numbers of paediatricians [odds ratio (OR), 32.73; 95% confidence interval (CI), 5.96-179.77]. In 2003, the higher numbers of paediatricians still played a role in the increased immunization coverage (OR, 4.69; 95% CI, 1.01-21.78); however, the higher rate of uninsured children in 2003 had an even greater effect upon immunization coverage. Compared with states with lower rates of uninsured children, states with intermediate and higher rates of uninsured children had sixfold (OR, 0.16; 95% CI, 0.03-0.81) and 16-fold (OR, 0.06; 95% CI, 0.01-0.40) decreased childhood immunization coverage, respectively.
Between 1995 and 2003 in the United States, the lack of health insurance became more prominent than the supply of paediatricians in affecting immunization coverage for children aged 19-35 months. Future improvements in insurance coverage for children will likely lead to greater immunization coverage.
Journal of Evaluation in Clinical Practice 05/2008; 14(2):248-53. · 1.58 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Portfolios are used to summarize and communicate the academic accomplishments of faculty seeking career development and promotion.
We assessed knowledge and use of the portfolio in a cross sectional survey of 435 academic chairpersons of family medicine and division directors of general internal medicine and general pediatrics.
Of the 241 respondents (55% response rate), 69% reported knowledge of portfolios and 55% used portfolios. Satisfaction with the source of information on a faculty candidate was greater when portfolios were used (85.5% of respondents) than when they were not used (67.3% of respondents; p = .01). Increased knowledge and use of portfolios was associated with respondents working at institutions with academic fellowships/advanced education programs or who had fellowship training (ps = .01).
Results suggest that leaders of primary care departments use portfolios to promote the career development of their faculty and that portfolio use is influenced by attitudes and training.
Teaching and Learning in Medicine 04/2008; 20(2):127-30. · 1.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Evidence suggests that when doctors use systematically developed clinical practice guidelines they have the potential to improve the safety, quality and value of health care. The purpose of this study was to evaluate recent changes in the perceptions of practice guidelines among US primary care doctors.
Data were collected from the Community Tracking Survey 1996-97 and 2000-01. All results were weighted and adjusted to reflect the complex survey design.
Over the 5 years, the proportion of primary care doctors who said that practice guidelines had at least a moderate effect on their practice of medicine increased from 45.8% to 60.7%. This increase was nearly equal among primary care doctors of family medicine, internal medicine and paediatrics. In the 2001 survey, a higher perceived effect of practice guidelines was described by female doctors (OR = 1.39, 95% CI 1.19-1.63) and doctors who were practising in a large model group (OR = 1.73; 95% CI 1.04-2.89). Doctors who graduated from medical school within 10 years of the survey were more likely to report that practice guidelines had a positive effect on their practice of medicine than doctors who graduated 10 or more years before the survey.
The perceived effect of practice guidelines on primary care doctors increased over time. Improved dissemination of guidelines and curriculum changes may have led recent primary care graduates to view practice guidelines as more important.
Journal of Evaluation in Clinical Practice 09/2007; 13(4):621-6. · 1.58 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Chronic illnesses are not only major health threats for half of the world's population, but these diseases are also increasing rapidly. Medical training, however, has not kept pace with this increase in chronic illness.
I describe two instructional modules whose goals were to teach preclinical medical students to (1) screen for diabetic neuropathies and provide counseling for improved diabetic foot care, and (2) screen for tobacco use and provide counseling for smoking cessation. All educational activities took place during an orientation to the modules or during ambulatory patient encounters. Preclinical students (n = 280), who were supervised by 157 family physicians, screened and counseled a total of 3,640 patients. Program outcomes were assessed by analyzing student's responses to attitudinal questionnaires, student's documentation of the diabetic foot and tobacco use screenings, and postcards on which patients wrote their reactions to screening and counseling. In addition, the physician supervisors evaluated the impact of the modules on their practices.
Analysis of data indicated that medical students, supervising physicians and patients benefited from the screening and counseling activities.
We believe that these successful educational modules offer a training model for teaching medical students to intervene in chronic illnesses.
Medical Teacher 06/2007; 29(4):391-3. · 2.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To learn whether preclinical primary care preceptorships resulted in demonstrable clinical performance benefits to medical students.
This was a retrospective cohort study of 267 medical students who elected and 310 students who did not elect to take a four-week primary care preceptorship following the first year of training at the University of Texas Medical School at Houston in 2001-2003. Outcome variables were the students' performances on a written examination testing their integration of basic science and fundamentals of clinical medicine and performances on a comprehensive objective structured clinical examination (OSCE). After adjusting for factors that might have explained differences in the students' performances, logistic regression models were used to assess the association of the outcome variables with participation in a preceptorship.
Students who participated in any one of the preceptorships performed better on the OSCE and on the fundamentals of clinical medicine examination than students who did not participate (p < .01). Students who participated in the family medicine or pediatric preceptorship scored higher on an OSCE (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.01-2.78 and OR, 2.26; 95% CI, 1.18-4.36, respectively) than those students who did not participate in a preceptorship. Students who participated in the internal medicine preceptorship scored higher on the fundamentals of clinical medicine examination (OR, 3.18; 95% CI, 1.92-5.23).
Preliminary evidence indicates that a short preclinical primary care preceptorship can help medical students to consolidate and integrate the fundamental cognitive and clinical skills they will apply during the clinical years of medical training.
Academic Medicine 04/2006; 81(4):342-6. · 3.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Family medicine preceptorships are underused opportunities for learning smoking cessation counseling skills. To prepare students for their future roles in preventing health problems in patients who use tobacco, we implemented a patient-centered instructional module within the elective Texas Statewide Family Practice Preceptorship Program.
Seventy-eight preclinical medical students learned to screen for tobacco use and perform smoking cessation counseling using brief motivational methods. Students practiced these skills under the supervision of community preceptors. Program evaluation included measurement of the percentage of students who documented that they could screen for tobacco use, their increase in knowledge and sense of self efficacy in conducting smoking cessation counseling, and performance of appropriate and time-efficient interventions.
Fifty-four of 78 students screened 1,891 patients and documented 593 current tobacco users. The students provided appropriate smoking cessation intervention for 539 (91%) of these patients. Each intervention session took approximately 5 to 10 minutes. There was a more than 50% increase in the proportion of students who "agreed" or "strongly agreed" to having increased their knowledge and confidence in conducting smoking cessation counseling between the orientation and the end of their summer preceptorship.
With focused training, preclinical medical students can successfully learn and practice patient-centered screening and smoking cessation counseling skills in a community preceptorship setting that fits the needs of busy preceptors and prepares students for their future roles in tobacco control.
Family medicine 03/2005; 37(2):105-11. · 0.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Academic physicians must master the elements of curriculum development and evaluation specific to defined competencies in postgraduate medical education. Six fellows in primary care medicine, working as a peer group with a faculty mentor, designed and evaluated a distance-learning project that included resident physicians. Professionalism, interpersonal skills and systems-based medical practice skills were measured with original instruments designed by the peer group. By the process of evaluation and revision in a peer-group setting and with mentorship from program faculty, experiential learning enhanced the training of future academic physicians. This paper describes the background, process and statistical results of their work.
Medical Teacher 12/2004; 26(7):615-20. · 2.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Since 1979, the Texas Statewide Family Practice Preceptorship Program (TSFPPP) has conducted ambulatory preceptorships to increase the number of medical students selecting family practice residencies. The authors describe the evaluation of the TSFPPP's efficacy in terms of four evaluation questions and outcome measures identified by program users from eight Texas medical schools.
The authors compared the proportion of 10,081 Texas medical school students graduating from 1992-2000 who chose family practice or other primary care residencies following participation or nonparticipation in the TSFPPP's preclinical and clinical programs.
The proportion of students choosing family practice residencies among TSFPPP participants was significantly greater than among nonparticipants. Participation in the TSFPPP was associated with an increased choice of a family practice residency for students who were involved in the TSFPPP at the preclinical level (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.41-1.87); the clinical level (OR, 2.31; 95% CI, 1.99-2.68); and both levels (OR, 4.98; 95% CI, 3.75-6.68) compared to non-TSFPPP participation. There was a 44% increase in preceptors willing to teach medical students.
Participation in the TSFPPP is associated with a greater likelihood of students selecting a family practice residency. The interinstitutional approach to analyzing effects of the preceptorship on students' specialty choices focuses attention on primary care issues that, in the long run, may affect an entire state's health care delivery system.
Academic Medicine 02/2004; 79(1):62-8. · 3.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: HIV-related morbidity and mortality have declined in recent years in the United States. Relative to their male counterparts, however, HIV-infected women tend to have less reduced morbidity and mortality. The purpose of this study was to investigate if the reported small decreases in HIV-related morbidity and mortality in women could be due to their receiving a lesser standard of care from public health clinics.
One hundred sixteen female and 131 male patients who were diagnosed with HIV infection were drawn consecutively from a county-owned health clinical database in Houston, Texas. Physicians from the two local medical schools staffed the clinic. Information on patients' demographic characteristics, screening tests, clinical care, and prophylaxis care was abstracted for comparison.
The data showed that there were no statistically significant sex-based differences in getting access to antiretroviral treatment or for prophylaxis of opportunistic infections in the clinic. Sex-based differences, however, were found in the initial CD4 cell count and HIV load. Women had higher CD4 cell counts and HIV RNA levels at the initial stage and during the time of treatment.
Journal of Women's Health 12/2003; 12(9):897-902. · 1.90 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Understanding health-related quality of life (HRQOL) leads to more effective and focused healthcare. America's growing health disparities makes it is increasingly necessary to understand the HRQOL of pregeriatric individuals who are now 55-64 years old, i.e. before they are eligible for federally mandated health care at age 65. Our study measured the self-perceived HRQOL of pregeriatric, poor patients with multiple chronic diseases treated at 2 public clinics.
Consecutive patients aged 55-64 years, many with multiple chronic diseases, responded in an interview to the 36-Item Short-Form Health Survey (SF-36) as a general measure of HRQOL during a regular visit to one of two university-staffed urban public clinics.
The perceived physical and mental functioning of 316 pregeriatric patients was tabulated from SF-36 scores to yield their HRQOL. Their scores were statistically significantly lower than those of the general US pregeriatric population and lower than averages for US patients with multiple chronic diseases. All eight subscale scores of SF-36 were 16% to 36% lower compared with the averages of the general US pregeriatric population. Further, as the number of chronic diseases increased, the lower was the HRQOL. Lower physical and mental scores were associated with a lower income, unemployment, and higher numbers of multiple chronic diseases.
Chronic diseases have a powerful negative impact on perceived mental and physical functioning in pregeriatric patients. HRQOL information can assist health care providers to gain a more complete picture of their pregeriatric patients' health.
Health and Quality of Life Outcomes 02/2003; 1:63. · 2.10 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: "Family Medicine Month," a rotation forfirst-year residents, was developed to clarifyfirst-year residents'new roles as family physicians. The rotation explored the meaning and history of the specialty, as well as teaching core family medicine clinical and behavioral skills. Twenty residents who participated in the rotation in 1999 and 2000 indicated satisfaction with the rotation and endorsed its usefulness. They also reported greater self efficacy in performing family practice skills after the rotation, compared with before the rotation. Results suggest that a curriculum based on the context of family medicine as a specialty enhances resident satisfaction and self efficacy.
Family medicine 04/2002; 34(3):164-6. · 0.85 Impact Factor