-
Jed D Gonzalo,
Brian S Heist,
Briar L Duffy,
Liselotte Dyrbye,
Mark J Fagan,
Gary Ferenchick,
Heather Harrell,
Paul A Hemmer, Walter N Kernan,
Jennifer R Kogan,
Colleen Rafferty,
Raymond Wong,
D Michael Elnicki
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: Medical educators believe bedside rounds are effective for the delivery of patient-centered care, and are necessary in helping trainees acquire competence in clinical care. Although recommendations for bedside rounds have been reported, a recent, systematic assessment of strategies used by current-day bedside teachers was needed to advance knowledge of this teaching method. OBJECTIVE: To identify and understand bedside teachers' 1) preparatory steps, 2) patient selection, and 3) role allocation during the process of bedside rounds. DESIGN: A qualitative inductive thematic analysis using transcripts from audio-recorded, semi-structured telephone interviews. PARTICIPANTS: Internal medicine physicians (n = 34) who perform bedside rounds from ten academic US institutions (2010-2011). APPROACH: A purposive sampling strategy was utilized to identify physicians who were active inpatient attending physicians and met specific inclusion criteria for "bedside rounds." A total of 34 interviews were completed, and each was recorded and transcribed verbatim. A thematic analysis extracted key themes pertaining to the three objectives. KEY RESULTS: Most respondents (51 %) were associate or full professors, with an average of 14 years of academic experience. Attending physicians prepared using trainee-specific, patient-specific and disease-specific information, while also mentally preparing for bedside rounds. They sought trainee buy-in and learning objectives, reviewed expectations and methods to ensure patient comfort, and provided early guidance with bedside encounters. Patients were selected if they required immediate care, were new to the service, or had a high educational value, while patients were deferred if unavailable, unwilling, or unable to communicate. The team members' roles during bedside rounds varied, with trainees being given graduated autonomy with increased experience. CONCLUSIONS: Bedside teachers' methods for preparation, patient selection, and role allocation during bedside rounds enhance trainees' education within the workplace. Strategies used by experienced bedside teachers can be used for faculty development efforts aimed at promoting this activity.
Journal of General Internal Medicine 11/2012; · 2.83 Impact Factor
-
Stroke 10/2012; · 5.73 Impact Factor
-
Stroke 12/2011; 42(12):3333-5. · 5.73 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Medical students' career choices affect health care. To understand how to increase the number of students who choose careers in internal medicine (IM), students who seriously considered IM but chose another field ("Switchers") and those who rejected IM ("Never Considered") were compared with those who chose IM ("Choosers").
Fourth-year medical students from 11 U.S. institutions were surveyed about demographics, medical school educational experiences, and aspects of the specialty of IM. Univariate analysis and multivariate logistic regression models examined associations between student characteristics and classification as Switchers, Choosers, and Never Considered.
A total of 1,177 students completed the survey (82% response rate). There were 274 (23%) Choosers, 398 (34%) Switchers, and 499 (43%) Never Considered. The authors' models explained over 80% of variance in these three career choice classification groups. For most responses, an increasingly favorable gradient from Never Considered to Choosers was observed. Multivariate analysis revealed six items that were associated with higher probability of choosing IM: types of patients internists see, timing of career decision, interest groups, intellectual challenge, satisfaction among internists, and the core IM clerkship.
Several potentially modifiable educational experiences and aspects of IM distinguished Switchers from the other two groups. The percentage of variance explained by group suggests that these findings identify important underpinnings of career decisions. These items also suggest ways that educational experiences and aspects of the specialty could be redesigned by academicians and policy makers to improve the attractiveness of IM careers.
Academic medicine: journal of the Association of American Medical Colleges 02/2011; 86(2):194-200. · 2.34 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The control of stroke risk factors remains challenging. The "polypill" concept represents a novel approach for reducing stroke and cardiovascular risk factors in the entire population. The polypill would include several components and be provided without prescription to all adults of a certain age.
A polypill aimed at lowering blood pressure and cholesterol levels is estimated to potentially reduce the risk of a first ischemic stroke by 53%; this would translate to about 400 000 fewer strokes each year in the United States alone. Recommending a polypill for the entire older adult population would, however, include many individuals without the multiple risk factors targeted by its components, putting them at risk for drug-related side effects and responsible for the costs of a medication from which they would not derive benefit. Additional arguments for and against the polypill approach are discussed.
Only clinical trials can provide the evidence needed to determine the usefulness of the polypill approach. Issues related to defining the components of the polypill, evaluating the pharmacodynamics and pharmacokinetics of a multiple-component formulation, and establishing safety and cost-effectiveness when given to large populations, however, are not trivial.
Stroke 10/2010; 41(10 Suppl):S35-8. · 5.73 Impact Factor
-
Karen E Hauer,
Steven J Durning, Walter N Kernan,
Mark J Fagan,
Matthew Mintz,
Patricia S O'Sullivan,
Michael Battistone,
Thomas DeFer,
Michael Elnicki,
Heather Harrell,
Shalini Reddy,
Christy K Boscardin,
Mark D Schwartz
[show abstract]
[hide abstract]
ABSTRACT: Shortfalls in the US physician workforce are anticipated as the population ages and medical students' interest in careers in internal medicine (IM) has declined (particularly general IM, the primary specialty serving older adults). The factors influencing current students' career choices regarding IM are unclear.
To describe medical students' career decision making regarding IM and to identify modifiable factors related to this decision making.
Web-based cross-sectional survey of 1177 fourth-year medical students (82% response rate) at 11 US medical schools in spring 2007.
Demographics, debt, educational experiences, and number who chose or considered IM careers were measured. Factor analysis was performed to assess influences on career chosen. Logistic regression analysis was conducted to assess independent association of variables with IM career choice.
Of 1177 respondents, 274 (23.2%) planned careers in IM, including 24 (2.0%) in general IM. Only 228 (19.4%) responded that their core IM clerkship made a career in general IM seem more attractive, whereas 574 (48.8%) responded that it made a career in subspecialty IM more attractive. Three factors influenced career choice regarding IM: educational experiences in IM, the nature of patient care in IM, and lifestyle. Students were more likely to pursue careers in IM if they were male (odds ratio [OR] 1.75; 95% confidence interval [CI], 1.20-2.56), were attending a private school (OR, 1.88; 95% CI, 1.26-2.83), were favorably impressed with their educational experience in IM (OR, 4.57; 95% CI, 3.01-6.93), reported favorable feelings about caring for IM patients (OR, 8.72; 95% CI, 6.03-12.62), or reported a favorable impression of internists' lifestyle (OR, 2.00; 95% CI, 1.39-2.87).
Medical students valued the teaching during IM clerkships but expressed serious reservations about IM as a career. Students who reported more favorable impressions of the patients cared for by internists, the IM practice environment, and internists' lifestyle were more likely to pursue a career in IM.
JAMA The Journal of the American Medical Association 10/2008; 300(10):1154-64. · 30.03 Impact Factor
-
Walter N Kernan
The Lancet 02/2007; 369(9558):251-2. · 38.28 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Previous studies have suggested that the obstructive sleep apnea syndrome may be an important risk factor for stroke. It has not been determined, however, whether the syndrome is independently related to the risk of stroke or death from any cause after adjustment for other risk factors, including hypertension.
In this observational cohort study, consecutive patients underwent polysomnography, and subsequent events (strokes and deaths) were verified. The diagnosis of the obstructive sleep apnea syndrome was based on an apnea-hypopnea index of 5 or higher (five or more events per hour); patients with an apnea-hypopnea index of less than 5 served as the comparison group. Proportional-hazards analysis was used to determine the independent effect of the obstructive sleep apnea syndrome on the composite outcome of stroke or death from any cause.
Among 1022 enrolled patients, 697 (68 percent) had the obstructive sleep apnea syndrome. At baseline, the mean apnea-hypopnea index in the patients with the syndrome was 35, as compared with a mean apnea-hypopnea index of 2 in the comparison group. In an unadjusted analysis, the obstructive sleep apnea syndrome was associated with stroke or death from any cause (hazard ratio, 2.24; 95 percent confidence interval, 1.30 to 3.86; P=0.004). After adjustment for age, sex, race, smoking status, alcohol-consumption status, body-mass index, and the presence or absence of diabetes mellitus, hyperlipidemia, atrial fibrillation, and hypertension, the obstructive sleep apnea syndrome retained a statistically significant association with stroke or death (hazard ratio, 1.97; 95 percent confidence interval, 1.12 to 3.48; P=0.01). In a trend analysis, increased severity of sleep apnea at baseline was associated with an increased risk of the development of the composite end point (P=0.005).
The obstructive sleep apnea syndrome significantly increases the risk of stroke or death from any cause, and the increase is independent of other risk factors, including hypertension.
New England Journal of Medicine 12/2005; 353(19):2034-41. · 53.30 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To determine whether altruism as reason for participation in research is independently associated with adherence to a medical regimen in a clinical trial.
Participants were 475 participants in the Women's Estrogen for Stroke Trial. Before randomization to estrogen or placebo, all women were questioned about reason for participation and baseline features that may contribute to adherence. Adherence was defined as completion of at least 80% of expected pill intake during the trial.
Women who reported at least one altruistic reason for participation were more likely to be college educated, have a higher level of social support, and a better functional status. They were also more likely to be adherent to their study medication {155 of 212 (73%) vs. 158 of 253 (62.5%), P < .01}. On stratified analysis and multivariable regression, the relationship between altruism as reason for participation and adherence was independent of other sociodemographic, psychosocial, and clinical features (relative risk 1.17, Confidence interval 1.03-1.32).
Altruism may explain a small portion of the variation in adherence among research participants. This relationship may have implications for recruitment of participants in clinical research. The possible contribution of altruism to the relationship between adherence and outcomes in clinical trials is worthy of further investigation.
Journal of Clinical Epidemiology 11/2005; 58(11):1109-14. · 4.27 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To identify risk factors for intracerebral hemorrhage (ICH), we examined data from the Hemorrhagic Stroke Project (HSP), a case-control study of hemorrhagic stroke among men and women aged 18 to 49 years.
Case subjects for the HSP were recruited from 44 hospitals in the United States. Eligibility criteria included an ICH within 30 days preceding enrollment, no history of stroke or known brain lesion. For this report, we focused on patients with primary ICH, defined as not associated with an aneurysm, arteriovenous malformation or other structural lesion. Two control subjects were sought for each case subject. A multivariate regression analysis was performed to determine risk factors for primary ICH.
A total of 1714 patients with hemorrhagic stroke were identified for participation in the HSP. Of these, 217 cases met the criteria for primary ICH. Cases with primary ICH were matched to 419 controls. Independent risk factors for ICH included hypertension (adjusted odds ratio [OR], 5.71; 95% CI, 3.61 to 9.05), diabetes (adjusted OR, 2.40; 95% CI, 1.15 to 5.01), menopause (adjusted OR, 2.50; 95% CI, 1.06 to 5.88), current cigarette smoking (adjusted OR, 1.58; 95% CI, 1.02 to 2.44), alcoholic drinks> or =2/day (adjusted OR, 2.23; 95% CI, 1.16 to 4.32), caffeinated drinks> or =5/day (adjusted OR, 1.73; 95% CI, 1.08 to 2.79), and caffeine in drugs (adjusted OR, 3.55; 95% CI, 1.24 to 10.20).
Among young men and women, the major risk factors for primary ICH can be modified, suggesting that this type of stroke may be preventable. Our findings for caffeine and menopause warrant further study.
Stroke 09/2005; 36(9):1881-5. · 5.73 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: In the US, blacks have a higher incidence of stroke and more severe strokes than whites. Our objective was to determine if differences in income, education, and insurance, as well as differences in the prevalence of stroke risk factors, accounted for the association between ethnicity and stroke.
We used data from the Third National Health and Nutrition Survey (NHANES III), a cross-sectional sample of the noninstitutionalized US population (1988-1994), and included blacks and whites aged 40 years or older with a self-reported stroke history. Income was assessed using a ratio of income to US Census Bureau annual poverty threshold.
Among 11 163 participants, 2752 (25%) were black and 619 (6%) had a stroke history (blacks: 160/2752 [6%]; whites: 459/8411 [6%]; P=0.48). Blacks had a higher prevalence of 5 risk factors independently associated with stroke: hypertension, treated diabetes, claudication, higher C-reactive protein, and inactivity; whites had a higher prevalence of 3 risk factors: older age, myocardial infarction, and lower high-density lipoprotein cholesterol. Ethnicity was independently associated with stroke after adjusting for the 8 risk factors (adjusted odds ratio, 1.32; 95% CI, 1.04 to 1.67). Ethnicity was not independently associated with stroke after adjustment for income and income was independently associated with stroke (adjusted odds ratios for: ethnicity, 1.15; 95% CI, 0.88 to 1.49; income, 0.89; 95% CI, 0.82 to 0.95). Adjustment for neither education nor insurance altered the ethnicity-stroke association.
In this study of community-dwelling stroke survivors, ethnic differences exist in the prevalence of stroke risk factors and income may explain the association between ethnicity and stroke.
Stroke 08/2005; 36(7):1507-11. · 5.73 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Physical performance for walking, reaching, turning, and other common tasks is a major determinant of functional independence after stroke. Current strategies to preserve physical performance focus on prevention of recurrent stroke. Loss of physical performance, however, may occur in the absence of recurrence. To examine this possibility, we measured change in physical performance, independent of subsequent stroke, among women with a recent ischemic stroke or transient ischemic attack (TIA).
Among 664 postmenopausal women who participated in a clinical trial of estrogen therapy after stroke or TIA, we administered the Physical Performance Test (PPT) at baseline (mean 58 days from the cerebrovascular event) and annually. Women who died or had a stroke during follow-up were censored. Decline or improvement in physical performance was defined as a change in the PPT score from baseline of at least 3 points. Sustained decline or improvement was defined as 2 consecutive years during which the score had declined or improved, respectively, relative to the baseline score.
With each year of follow-up, a smaller proportion of the cohort demonstrated improvement (16% in year 1, 6% in year 5) and a larger proportion demonstrated decline (15% in year 1, 35% in year 5). In an analysis restricted to 259 women with 3 years of follow-up, 46 (18%) experienced a nonsustained decline in physical performance, and 39 (15%) experienced a sustained decline.
Decline in physical performance is common after an ischemic stroke or TIA even in the absence of a recurrent neurological event. Our findings suggest that specific interventions to maintain and improve physical performance may be important for reducing long-term disability.
Stroke 04/2005; 36(3):630-4. · 5.73 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Peer-mediated learning is an effective educational strategy that is rarely used during clinical training for medical students. We developed a peer-mediated learning conference, Student-Faculty Rounds (SFR), for the ambulatory component of a medicine clerkship. Designed to broaden students' exposure to common medical problems and provide practice in small-group teaching, the 30-minute conference is conducted by each student once during their clerkship. Students choose their topics and instructional formats, but they are advised to supply written learning objectives and employ interactive, problem solving opportunities. We analysed evaluations written by 280 students and 17 faculty supervisors during 1998-2001. Students presented over 150 topics. The most common were hypercholesterolemia, diabetes, headache, smoking cessation, hypertension management, and cancer screening (each presented in 3-4% of rounds). On a scale of 10 (outstanding) to 0 (lost cause), students gave SFR a score of 9.2 (95% confidence interval 9.0-9.3). In written comments, students indicated that topics were relevant and that peers provided instruction at an appropriate level of complexity, but that quality was variable. Faculty supervisors reported that 35% of students did not provide written learning objectives and 35% chose topics too broad for a 30-minute conference. SFR is a popular conference that accomplishes its educational objectives. It recognizes students' ability to educate themselves, and introduces variability and challenge into the classroom curriculum. Adequate faculty guidance is needed to assure students design conferences for maximum educational effectiveness.
Medical Teacher 04/2005; 27(2):140-4. · 1.22 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: This study was undertaken to assess whether estrogen therapy (ET) reduces the risk of cognitive decline in women with cerebrovascular disease.
We conducted a randomized, double-blind trial of estradiol 17beta versus placebo for secondary stroke prevention in 664 postmenopausal women with a recent stroke or transient ischemic attack. The Mini-Mental State Examination (MMSE) and 5 domain measures were obtained at baseline and exit.
Among 461 women withdrawn alive without stroke, ET did not have a significant effect on cognitive measures after an average of 3 years (relative risk of MMSE decline: 0.74, 95% CI, 0.49-1.13). In women with normal MMSE at entry, estrogen was associated with less decline (relative risk, 0.46, 95% CI, 0.24-0.87).
In this study, estradiol did not have significant effects on cognitive measures. However, in women with normal function at baseline, there may be a benefit for ET in reducing the risk for cognitive decline.
American Journal of Obstetrics and Gynecology 03/2005; 192(2):387-93. · 3.47 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Despite current preventive therapies, patients with transient ischemic attack (TIA) and ischemic stroke remain at high risk for recurrent brain disease and cardiovascular events. In an effort to develop new therapies, abnormal glucose tolerance has recently been proposed as an interventional target. Among persons not otherwise known to be diabetic, impaired glucose tolerance (IGT) and diabetic glucose tolerance (DGT) are each associated with an increased risk for incident vascular disease, vascular disease mortality, and all-cause mortality. We conducted this study to determine if IGT and DGT are sufficiently common among patients with TIA and ischemic stroke to warrant therapeutic trials of antihyperglycemic agents.
Men and women older than 45 years were recruited from 3 hospitals in south central Connecticut. Eligibility criteria included a recent TIA or nondisabling ischemic stroke, no history of physician-diagnosed diabetes mellitus, and a fasting plasma glucose level less than 126 mg/dL (<7.0 mmol / L). After an overnight fast, subjects were admitted to a clinical research center for a standard 75-g oral glucose tolerance test. Impaired glucose tolerance was defined by a 2-hour plasma glucose value of 140 to 199 mg/dL (7.8-11.0 mmol / L) and DGT by a value of 200 mg/dL or greater (> or =11.1 mmol/L).
Between June 2000 and August 2003, we enrolled 98 eligible patients. The average time from TIA or stroke to measurement of glucose tolerance was 105 days (range, 24-180 days) and the median age was 71 years. Twenty-seven subjects (28%) had IGT and 24 (24%) had diabetes. In a forward stepwise logistic regression model, only a fasting plasma glucose level of 110 mg/dL or greater (> or =6.1 mmol / L) and lower waist circumference were associated with an increased risk for IGT or DGT.
Impaired glucose tolerance and DGT are present in most persons with a recent TIA or ischemic stroke who have no history of diabetes and a fasting plasma glucose level less than 126 mg/dL (<7.0 mmol / L). Our findings bring new urgency to the initiation of research to examine the effectiveness of antihyperglycemic therapies among patients with cerebrovascular disease and abnormal glucose tolerance.
Archives of Internal Medicine 02/2005; 165(2):227-33. · 11.46 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Prior research has indicated an association between insulin resistance and stroke; we sought to determine if this association persists after adjusting for stroke risk factors, including glycemic control.
We used data from the Third National Health and Nutrition Survey (1988-1994), including participants aged > or =40 years. We assessed insulin sensitivity using the homeostasis model assessment (HOMA): HOMA = (FPGSI x FPI)/22.5, where FPGSI refers to fasting plasma glucose (mmol/l) and FPI refers to fasting plasma insulin (microU/l). Increasing HOMA indicates decreasing insulin sensitivity. We used glycosylated hemoglobin (HbA1c) to measure glycemic control. Multivariable logistic regression analysis was used to identify factors that were independently associated with stroke.
Among 3,844 participants, 168 (4%) reported a stroke history. Participants with stroke had lower insulin sensitivity than participants without stroke: HOMA mean +/- standard deviation, 4.0 +/- 4.0 vs. 3.3 +/- 3.0; p = 0.022. HOMA was independently associated with stroke (odds ratio 1.06, 95% CI: 1.01-1.12; adjusted for age, hypertension, myocardial infarction, claudication, activity, and HbA1c). The strength of the association between HOMA and stroke was similar to the association between claudication and stroke (index R(2): 0.0032 vs. 0.0036).
Impaired insulin sensitivity is independently associated with stroke, even after adjustment for glycemic control.
Neuroepidemiology 01/2005; 25(2):69-74. · 2.31 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Two methods for measuring insulin sensitivity, fasting plasma insulin (FPI) and homeostasis model assessment (HOMA) have been proposed for use in large epidemiological research and clinical practice. This project describes the range of observed values of the HOMA and FPI in a large sample of the U.S. population.
We used fasting plasma glucose and insulin values from the Third National Health and Nutrition Survey (NHANES III) to identify the FPI and HOMA values. For both FPI and HOMA, higher values indicate lower insulin sensitivity.
Among 6,511 participants without treated diabetes mellitus, FPI ranged from 1.8 to 175.8 microU/mL, with 25th percentile=6.7, median=9.3, 75th percentile=13.3, and mean+/-1 SD=11.2+/-7.5; HOMA ranged from 0.3 to 52.6 (mmol)(microU)/L(2), with 25th percentile=1.5, median=2.2, 75th percentile=3.3, and mean+/-SD=2.8+/-2.4.
These findings describe the spectrum of insulin sensitivity and may be useful in helping physicians develop a clinical understanding of the dynamic range of both FPI and HOMA measures.
Journal of Clinical Epidemiology 12/2004; 57(11):1214-7. · 4.27 Impact Factor
-
The American Journal of Medicine 12/2004; 117(9):713-7. · 5.43 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Medical educators are increasingly concerned about the quality of skills instruction at medical schools in the United States, yet few data exist to support quality assessment and faculty development. The purpose of this research was to (1) develop an instrument for measuring teaching behavior of ambulatory care preceptors (the Teaching Encounter Card), and (2) assess current teaching practices at one institution.
Based on published guidelines for teaching in the ambulatory setting, the authors identified nine teaching behaviors for inclusion on a Teaching Encounter Card. Students completed the card immediately after a supervised patient (teaching) encounter, indicating (yes/no) if they observed each behavior. Validation of the card was assessed using standardized patients and scripted teaching encounters. A field application of the card assessed behaviors for 17 preceptors and 270 teaching encounters in one ambulatory care clerkship.
Validation testing revealed the card was highly accurate. Specificity exceeded 75% for all behaviors and sensitivity exceeded 75% for eight. During the field application, preceptors used each of the behaviors except three in over 70% of encounters. The three exceptions were observing the student interviewing or counseling (68% of encounters), providing feedback (52% of encounters), and observing the student perform any part of the physical examination (24% of encounters). Interpreceptor variability was substantial for several behaviors.
The Teaching Encounter Card is valid and represents a new tool for quality assessment and faculty development. Preceptors and course directors will need guidelines or educational standards to help them interpret individual results.
Academic Medicine 12/2004; 79(11):1088-94. · 3.52 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Incorporating clinical content into medical education faculty development programs has been proposed as a strategy to consolidate faculty continuing medical education time and enhance learning. We developed a faculty development program for ambulatory internal medicine preceptors that integrated primary care genetics with ambulatory precepting. The instructional strategies addressed both areas simultaneously and included facilitated discussions, mini-lectures, trigger tapes, and role plays. To evaluate the program, we conducted a pre-post trial. Skills were measured by retrospective pre-post self-reported ratings and behaviors by self-reported implementation of commitment to change (CTC) statements. Participants' (N = 26) ambulatory precepting and primary care genetics skill ratings improved after the intervention. They listed an average of 2.4 clinical teaching CTC statements and 2.0 clinical practice CTC statements. By 3 months after the workshop, preceptors, as a group, fully implemented 32 (38%), partially implemented 35 (41%), and failed to implement 18 (21%) CTC statements. The most common barrier to clinical teaching change was insufficient skills (8 of 25; 32%) and to clinical practice change was lack of a suitable patient (15 of 25; 60%). Integrating clinical content with clinical teaching in a faculty development workshop is feasible, can improve clinical and teaching skills, and can facilitate behavior change.
Journal of General Internal Medicine 07/2003; 18(6):468-74. · 2.83 Impact Factor
