[show abstract][hide abstract] ABSTRACT: BACKGROUND: Shared decision making improves value-concordant decision-making around prostate cancer screening (PrCS). Yet, PrCS discussions remain complex, challenging and often emotional for physicians and average-risk men. OBJECTIVE: In July 2011, the Centers for Disease Control and Prevention convened a multidisciplinary expert panel to identify priorities for funding agencies and development groups to promote evidence-based, value-concordant decisions between men at average risk for prostate cancer and their physicians. DESIGN: Two-day multidisciplinary expert panel in Atlanta, Georgia, with structured discussions and formal consensus processes. PARTICIPANTS: Sixteen panelists represented diverse specialties (primary care, medical oncology, urology), disciplines (sociology, communication, medical education, clinical epidemiology) and market sectors (patient advocacy groups, Federal funding agencies, guideline-development organizations). MAIN MEASURES: Panelists used guiding interactional and evaluation models to identify and rate strategies that might improve PrCS discussions and decisions for physicians, patients and health systems/society. Efficacy was defined as the likelihood of each strategy to impact outcomes. Effort was defined as the relative amount of effort to develop, implement and sustain the strategy. Each strategy was rated (1-7 scale; 7 = maximum) using group process software (ThinkTank(TM)). For each group, intervention strategies were grouped as financial/regulatory, educational, communication or attitudinal levers. For each strategy, barriers were identified. KEY RESULTS: Highly ranked strategies to improve value-concordant shared decision-making (SDM) included: changing outpatient clinic visit reimbursement to reward SDM; development of evidence-based, technology-assisted, point-of-service tools for physicians and patients; reframing confusing prostate cancer screening messages; providing pre-visit decision support interventions; utilizing electronic health records to promote benchmarking/best practices; providing additional training for physicians around value-concordant decision-making; and using re-accreditation to promote training. CONCLUSIONS: Conference outcomes present an expert consensus of strategies likely to improve value-concordant prostate cancer screening decisions. In addition, the methodology used to obtain agreement provides a model of successful collaboration around this and future controversial cancer screening issues, which may be of interest to funding agencies, educators and policy makers.
Journal of General Internal Medicine 05/2013; · 3.28 Impact Factor
[show abstract][hide abstract] ABSTRACT: INTRODUCTION: The information provided by pharmaceutical sales representatives has been shown to influence prescribing. To enable safe prescribing, medicines information must include harm as well as benefits. Regulation supports this aim, but relative effectiveness of different approaches is not known. The United States (US) and France directly regulate drug promotion; Canada relies on industry self-regulation. France has the strictest information standards. METHODS: This is a prospective cohort study in Montreal, Vancouver, Sacramento and Toulouse. We recruited random samples of primary care physicians from May 2009 to June 2010 to report on consecutive sales visits. The primary outcome measure was "minimally adequate safety information" (mention of at least one indication, serious adverse event, common adverse event, and contraindication, and no unqualified safety claims or unapproved indications). RESULTS: Two hundred and fifty-five physicians reported on 1,692 drug-specific promotions. "Minimally adequate safety information" did not differ: 1.7 % of promotions; range 0.9-3.0 % per site. Sales representatives provided some vs. no information on harm more often in Toulouse than in Montreal and Vancouver: 61 % vs. 34 %, OR = 4.0; 95 % CI 2.8-5.6, or Sacramento (39 %), OR = 2.4; 95 % CI 1.7-3.6. Serious adverse events were rarely mentioned (5-6 % of promotions in all four sites), although 45 % of promotions were for drugs with US Food and Drug Administration (FDA) "black box" warnings of serious risks. Nevertheless, physicians judged the quality of scientific information to be good or excellent in 901 (54 %) of promotions, and indicated readiness to prescribe 64 % of the time. DISCUSSION: "Minimally adequate safety information" did not differ in the US and Canadian sites, despite regulatory differences. In Toulouse, consistent with stricter standards, more harm information was provided. However, in all sites, physicians were rarely informed about serious adverse events, raising questions about whether current approaches to regulation of sales representatives adequately protect patient health.
Journal of General Internal Medicine 04/2013; · 3.28 Impact Factor
[show abstract][hide abstract] ABSTRACT: The authors reflect on the creation of the Doctoring program at the UCLA School of Medicine two decades ago. Although Doctoring-at UCLA and other institutions where it has been implemented-has successfully taught large numbers of students psychosocial content and communications skills that are often overlooked in traditional medical school curricula and has had an impact on the larger culture of medical education, the authors believe that its full promise remains unfulfilled. Of the many practical difficulties they encountered in creating and implementing this comprehensive program, the greatest barriers, by far, were cultural. The authors argue that the impact of programs like Doctoring-programs that attempt not only to change the content of what students learn but also to encourage students to think critically and to question fundamental aspects of the way medicine is taught, learned, and practiced-cannot grow unless and until the larger culture of medicine also changes. They offer recommendations for overcoming barriers to improve the next generation of Doctoring and similar programs; these include changing the philosophy behind the selection of medical students, providing far greater resources and support for course faculty, and altering incentives for medical school faculty. They conclude that until major cultural and structural barriers are overcome and the values that Doctoring and like programs attempt to engender become the primary values of the larger culture they seek to change, these programs will continue in fundamental ways to function outside the dominant culture of medicine.
Academic medicine: journal of the Association of American Medical Colleges 04/2013; 88(4):438-441. · 2.34 Impact Factor
[show abstract][hide abstract] ABSTRACT: Over the past decade there has been an enormous increase in the availability of and demand for genetic tests. The appropriateuse ofgenetic tests has the potentialtoenhance both the quality and length of human life. Not surprisingly, numerous stakeholder groups have emerged seeking to influence the medical profession and the public in an attempt to guide genetic test use. Some of these groups offer advice based on their expertise and scientific evidence; others are driven by profit. When ordering genetic tests, we need to remember that the screening tests are similar to other screening tests we often order, same basic principles should apply as to other screening tests (PSA, colonoscopy, etc.). Clear criteria are already established for appropriate use of screening tests. 1 Readers of JGIM need only a reminder that genetic testing is most useful when 1) a person has a personal or family history that increases their risk for a genetic syndrome; 2) the results of the test can be interpreted, and 3) the testing will influence medical management. Certainly issues unique to genetic testing include ethical dilemmas involving families, discrimination, and stigma. The public often is confused by genetics, and some people hold beliefs that are not consistent with accepted medical understanding. As a result, our patients may make clinical choices based on erroneous assumptions. All of this suggests a vital role for patient education and makes the case for careful shared decision-making between physicians and patients. Haga 2 and colleagues present a cross sectional study of 356 primary care physicians with a 44% response rate. The study examines several issues related to genetic profiling (a statistical process of looking for “risk patterns” of complex diseases such as obesity and diabetes). It is important to understand that genetic profiling is not susceptibility testing (e.g., BRCA testing) which is intended to look for specific gene mutations associated with specific diseases. Instead, genetic profiling looks at single nucleotide polymorphisms (SNPs) in an attempt to identify potential risk information only by statistical association. In theory, the benefit of genetic profiling (as opposed to susceptibility testing) is to encourage disease prevention by encouraging healthy behavior change. However, to date there have been no proven direct benefits from genetic profiling. Haga’s research design was to survey a national practice group of primary care physicians (MDVIP) that started offering genomic risk profiling as a part of their routine practice. This national practice group had recently announced a “collaboration” with the for-profit company Navigenics which heavily markets genetic tests to physicians and the public. Part of this “collaboration” involved an offer by Navigenics to provide as a gift, a personalized genetic profile to all MDVIP physicians. 2 Is it possible that this offer of free genetic testing to doctors had as the primary goal of helping to promote the test and increase company profits? One important finding from Haga’s study was that one third of physicians offered a free genetic profile (cost=$999) accepted the offer. Not surprisingly, those who accepted the free offer were eight times more likely to order the genetic test on their patients compared to those who did not accept the free offer. The low response rate in Haga’s study precludes us from making any broad assumptions of physician behavior; although, hidden in her study are two important social issues that deserve comment. Our patients trust us, and need to trust us, to provide them advice based on what we believe is in their best interest and not influenced by other considerations such as gifts or perks that the doctor receives. Did the MDVIP leadership not consider a $999 offer of a free laboratory test a gift intended to influence the doctor’s practice behaviors? Did they naively believe that Navigenics was offering this free testing based on an altruistic concern over the health of MDVIP doctors? Could it be that Navigenetics knew that an offer of free tests to doctors would increase test ordering for patients? Could it be that this was the basis of their promotional campaign—getting doctors to agree to genetic testing by offering it to them for free?” An offer of an incentive (in this case a free genetic test) from a
Journal of General Internal Medicine 06/2011; 26(8):824-5. · 3.28 Impact Factor
[show abstract][hide abstract] ABSTRACT: Medical genetics lends itself to disseminated teaching methods because of mismatches between numbers of physicians having patients with genetic disorders and availability of genetic specialists.
During 3 years, we implemented an interactive, web-based curriculum on ethical, legal, and social implications in medical genetics for primary care residents in three specialties at three institutions. Residents took five (of 10) cases and three (of five) tutorials that varied by specialty. We assessed changes in self-efficacy (primary outcome), knowledge, application, and viewpoints.
Overall enrollment was 69% (279/403). One institution did not complete implementation and was dropped from pre-post comparisons. We developed a six-factor ethical, legal, and social implications self-efficacy scale (Cronbach α = 0.95). Baseline self-efficacy was moderate (71/115; range: 23-115) and increased 15% after participation. Pre-post knowledge scores were high and unchanged. Residents reported that this curriculum covered ethical, legal, and social implications/genetics better than their usual curricula. Most (68-91%) identified advantages, especially in providing flexibility and stimulating self-directed learning. After participation, residents reported creating learning goals (66%) and acting on those goals (62%).
Ethical, legal, and social implications genetics curricular participation led to modest self-efficacy gains. Residents reported that the curriculum covered unique content areas, had advantages over traditional curriculum, and that they applied ethical, legal, and social implications content clinically. We share lessons from developing and implementing this complex web-based curriculum across multiple institutions.
Genetics in medicine: official journal of the American College of Medical Genetics 06/2011; 13(6):553-62. · 3.92 Impact Factor
[show abstract][hide abstract] ABSTRACT: Worldwide, health care providers use strikes and job actions to influence policy. For health care providers, especially physicians, strikes create an ethical tension between an obligation to care for current patients (e.g., to provide care and avoid abandonment) and an obligation to better care for future patients by seeking system improvements (e.g., improvements in safety, to access, and in the composition and strength of the health care workforce). This tension is further intensified when the potential benefit of a strike involves professional self-interest and the potential risk involves patient harm or death. By definition, trainees are still forming their professional identities and values, including their opinions on fair wages, health policy, employee benefits, professionalism, and strikes. In this article, the authors explore these ethical tensions, beginning with a discussion of reactions to a potential 2005 nursing strike at the University of California, Davis, Medical Center. The authors then propose a conceptual model describing factors that may influence health care providers' decisions to strike (including personal ethics, personal agency, and strike-related context). In particular, the authors explore the relationship between training level and attitudes toward taking a job action, such as going on strike. Because trainees' attitudes toward strikes continue to evolve during training, the authors maintain that open discussion around the ethics of health care professionals' strikes and other methods of conflict resolution should be included in medical education to enhance professionalism and systems-based practice training. The authors include sample case vignettes to help initiate these important discussions.
Academic medicine: journal of the Association of American Medical Colleges 03/2011; 86(5):580-5. · 2.34 Impact Factor
[show abstract][hide abstract] ABSTRACT: The authors describe in detail the 3-year model of the Doctoring curriculum plus an elective fourth-year Doctoring course at University of California, Davis School of Medicine (UCDSOM) and University of California, Los Angeles (UCLA) School of Medicine and the critical role for psychiatry faculty leadership and participation.
The authors present a review of curricular materials and course operations for the different Doctoring courses for first-, second-, third-, and fourth-year curriculum. The authors describe the role of psychiatry faculty in both leadership and in group facilitation.
The Doctoring curriculum offers case-based, small-group learning that relies heavily on standardized patients to teach core content around doctor-patient communication, ethics, behavioral medicine, and counseling approaches. There are frequent psychosocial issues woven in to these encounters. Psychiatry faculty members and other mental health professionals are well-prepared by virtue of their training to lead small group discussions and facilitate the supportive elements of the small groups in medical education.
The Doctoring curriculum is both a biopsychosocial educational endeavor and a high-visibility leadership opportunity for the Department of Psychiatry. Other medical schools and departments of psychiatry may wish to pursue similar roles in their didactic programs.
[show abstract][hide abstract] ABSTRACT: Achieving competence in 'practice-based learning' implies that doctors can accurately self- assess their clinical skills to identify behaviours that need improvement. This study examines the impact of receiving feedback via performance benchmarks on medical students' self-assessment after a clinical performance examination (CPX).
The authors developed a practice-based learning exercise at 3 institutions following a required 8-station CPX for medical students at the end of Year 3. Standardised patients (SPs) scored students after each station using checklists developed by experts. Students assessed their own performance immediately after the CPX (Phase 1). One month later, students watched their videotaped performance and reassessed (Phase 2). Some students received performance benchmarks (their scores, plus normative class data) before the video review. Pearson's correlations between self-ratings and SP ratings were calculated for overall performance and specific skill areas (history taking, physical examination, doctor-patient communication) for Phase 1 and Phase 2. The 2 correlations were then compared for each student group (i.e. those who received and those who did not receive feedback).
A total of 280 students completed both study phases. Mean CPX scores ranged from 51% to 71% of items correct overall and for each skill area. Phase 1 self-assessment correlated weakly with SP ratings of student performance (r = 0.01-0.16). Without feedback, Phase 2 correlations remained weak (r = 0.13-0.18; n = 109). With feedback, Phase 2 correlations improved significantly (r = 0.26-0.47; n = 171). Low-performing students showed the greatest improvement after receiving feedback.
The accuracy of student self-assessment was poor after a CPX, but improved significantly with performance feedback (scores and benchmarks). Videotape review alone (without feedback) did not improve self-assessment accuracy. Practice-based learning exercises that incorporate feedback to medical students hold promise to improve self-assessment skills.
Medical Education 10/2007; 41(9):857-65. · 3.55 Impact Factor
[show abstract][hide abstract] ABSTRACT: Although the concept of altruism in medicine has a long tradition in Western thought, little empirical research has been carried out recently in this area. This study compares the altruistic attitudes of medical, legal and business students.
We used a cross-sectional survey to compare the altruistic attitudes of 3 types of contemporary 'professional' students, those in medicine, law and business.
The results suggest that medical students report more altruistic attitudes than legal students, but not than business students. Overall, female students reported stronger attitudes consistent with altruism compared with males; African-American and Hispanic students reported more altruistic attitudes compared with White students.
Our results suggest that the recent trend in recruiting more women and under-represented minority group members into medicine may have a positive impact on altruism in the profession, if we can assume that attitudes correlate with behaviours.
Medical Education 05/2007; 41(4):341-5. · 3.55 Impact Factor
[show abstract][hide abstract] ABSTRACT: Problem-based learning (PBL) is now used at many medical schools to promote lifelong learning, open inquiry, teamwork, and critical thinking. PBL has not been compared with other forms of discussion-based small-group learning. Case-based learning (CBL) uses a guided inquiry method and provides more structure during small-group sessions. In this study, we compared faculty and medical students' perceptions of traditional PBL with CBL after a curricular shift at two institutions.
Over periods of three years, the medical schools at the University of California, Los Angeles (UCLA) and the University of California, Davis (UCD) changed first-, second-, and third-year Doctoring courses from PBL to CBL formats. Ten months after the shift (2001 at UCLA and 2004 at UCD), students and faculty who had participated in both curricula completed a 24-item questionnaire about their PBL and CBL perceptions and the perceived advantages of each format
A total of 286 students (86%-97%) and 31 faculty (92%-100%) completed questionnaires. CBL was preferred by students (255; 89%) and faculty (26; 84%) across schools and learner levels. The few students preferring PBL (11%) felt it encouraged self-directed learning (26%) and valued its greater opportunities for participation (32%). From logistic regression, students preferred CBL because of fewer unfocused tangents (59%, odds ration [OR] 4.10, P = .01), less busy-work (80%, OR 3.97, P = .01), and more opportunities for clinical skills application (52%, OR 25.6, P = .002).
Learners and faculty at two major academic medical centers overwhelmingly preferred CBL (guided inquiry) over PBL (open inquiry). Given the dense medical curriculum and need for efficient use of student and faculty time, CBL offers an alternative model to traditional PBL small-group teaching. This study could not assess which method produces better practicing physicians.
Academic Medicine 02/2007; 82(1):74-82. · 3.29 Impact Factor
[show abstract][hide abstract] ABSTRACT: We undertook this investigation to characterize conflict of interest (COI) policies of biomedical journals with respect to authors, peer-reviewers, and editors, and to ascertain what information about COI disclosures is publicly available.
We performed a cross-sectional survey of a convenience sample of 135 editors of peer-reviewed biomedical journals that publish original research. We chose an international selection of general and specialty medical journals that publish in English. Selection was based on journal impact factor, and the recommendations of experts in the field. We developed and pilot tested a 3-part web-based survey. The survey included questions about the presence of specific policies for authors, peer-reviewers, and editors, specific restrictions on authors, peer-reviewers, and editors based on COI, and the public availability of these disclosures. Editors were contacted a minimum of 3 times.
The response rate for the survey was 91 (67%) of 135, and 85 (93%) of 91 journals reported having an author COI policy. Ten (11%) journals reported that they restrict author submissions based on COI (e.g., drug company authors' papers on their products are not accepted). While 77% report collecting COI information on all author submissions, only 57% publish all author disclosures. A minority of journals report having a specific policy on peer-reviewer 46% (42/91) or editor COI 40% (36/91); among these, 25% and 31% of journals state that they require recusal of peer-reviewers and editors if they report a COI. Only 3% of respondents publish COI disclosures of peer-reviewers, and 12% publish editor COI disclosures, while 11% and 24%, respectively, reported that this information is available upon request.
Many more journals have a policy regarding COI for authors than they do for peer-reviewers or editors. Even author COI policies are variable, depending on the type of manuscript submitted. The COI information that is collected by journals is often not published; the extent to which such "secret disclosure" may impact the integrity of the journal or the published work is not known.
Journal of General Internal Medicine 01/2007; 21(12):1248-52. · 3.28 Impact Factor
[show abstract][hide abstract] ABSTRACT: At the University of California, Davis (UCD), the authors sought to develop an institutional network of reflective educational leaders. The authors wanted to enhance faculty understanding of medical education's complexity, and improve educators' effectiveness as regional/national leaders.
The UCD Teaching Scholars Program is a half-year course, comprised of 24 weekly half-day small group sessions, for faculty in the School of Medicine and Veterinary Medicine. The program's philosophical framework was centered on personal reflection to enhance change: 1) understanding educational theory to build metacognitive bridges, 2) diversity of perspectives to broaden horizons, 3) colleagues as peer teachers to improve interactive experiences, and 4) reciprocal process of testing theory and examining practice to reinforce learning. The authors describe the program development (environmental analysis, marketing, teaching techniques), specific challenges, and failed experiments. The authors provide examples of interactive exercises used to enhance curricular content. The authors enrolled 7-10 faculty per year, from a diverse pool of current and near-future educational leaders.
Four years of Teaching Scholars participants were surveyed about program experiences and short/longer term outcomes. Twenty-six (76%) respondents reported that they were very satisfied with the course (4.6/5), individual curricular blocks (4.2-4.6), and other faculty (4.7). They described participation barriers/facilitators. Participants reported positive impact on their effectiveness as educators (100%), course directors (84%), leaders (72%), and educational researchers (52%). They described specific acquired attitudes, knowledge, and skills. They described changes in their approach to education/career changed based on program participation. Combining faculty from different educational backgrounds significantly broadened perspectives, leading to greater/new collaboration.
Developing a cadre of master educators requires careful program planning, implementation, and program/participant evaluation. Based on participant feedback, our program was a success at stimulating change. This open assessment of programmatic strengths and weaknesses may provide a template for other medical institutions that seek to enhance their institutional educational mission.
[show abstract][hide abstract] ABSTRACT: Although the benefits of prostate cancer screening are uncertain and guidelines recommend that physicians share the screening decision with their patients, most U.S. men over age 50 are routinely screened, often without counseling.
To develop an instrument for assessing physicians' knowledge related to the U.S. Preventive Services Task Force recommendations on prostate cancer screening.
Seventy internists, family physicians, and general practitioners in the Los Angeles area who deliver primary care to adult men.
We assessed knowledge related to prostate cancer screening (natural history, test characteristics, treatment effects, and guideline recommendations), beliefs about the net benefits of screening, and prostate cancer screening practices for men in different age groups, using an online survey. We constructed a knowledge scale having 15 multiple-choice items.
Participants' mean knowledge score was 7.4 (range 3 to 12) of 15 (Cronbach's alpha=0.71). Higher knowledge scores were associated with less belief in a mortality benefit from prostate-specific antigen (PSA) testing (r=-.49, P<.001). Participants could be categorized as low, age-selective, and high users of routine PSA screening. High users had lower knowledge scores than age-selective or low users, and they believed much more in mortality benefits from PSA screening.
Based on its internal consistency and its correlations with measures of physicians' net beliefs and self-reported practices, the knowledge scale developed in this study holds promise for measuring the effects of professional education on prostate cancer screening. The scale deserves further evaluation in broader populations.
Journal of General Internal Medicine 05/2006; 21(4):310-4. · 3.28 Impact Factor
[show abstract][hide abstract] ABSTRACT: Medical students currently interface more and more with community-based physicians, many of whom have little training or experience as educators. They also start their ambulatory experiences from the beginning of their medical school training, not just at the clerkship year. This has prompted substantial literature on the need for improved faculty development for community preceptors, which is widely believed to be inadequate at present. The authors describe a novel program, designed to augment community preceptor teaching skills and practice behaviors, focusing on topics relating to humanism, communication, and psychosocial issues common in primary care. The program was conducted for four years beginning in 1999 and organized around acknowledged attributes of successful adult learning, and used case-based, small-group sessions, where individual community preceptors were each asked to "teach" a series of standardized students, in front of the group, regarding issues raised by a number of hypothetical patient cases. The standardized students had in turn been trained by the authors to interact with the participating faculty in a defined manner. The small-group sessions were led by community "opinion leaders" who had been chosen for this role by the participants, and who themselves first underwent training by the authors to familiarize them with core concepts felt to be essential to the program. At the conclusion of the entire process, surveys of the opinion leaders, the other community preceptor participants, and the standardized students suggested that the program did stimulate significant changes in attitude and behavior, although further research is needed to confirm this.
Academic Medicine 05/2006; 81(4):332-41. · 3.29 Impact Factor
[show abstract][hide abstract] ABSTRACT: This article describes two complementary technology systems used in academic medicine to 1) improve the quality of learning and teaching, and 2) describe the barriers and obstacles encountered in implementing these systems.
The literature was integrated with in-depth, case-based experience with technology related to student progression, faculty promotion and school administration.
Academic medicine concerns itself with data and outcomes. Psychiatrists need to attend to their learning and teaching paths as much as to developing the knowledge and skills to manage their patients.
Technology enables us to track, manage, and report these data with increasing ease, making transparency and accuracy more achievable.
[show abstract][hide abstract] ABSTRACT: This article provides a framework for understanding the nature, role, functioning, design, and effects of organizational oversight systems. Using a case study with elements recognizable to an academic audience, the authors explore how a dean of a fictitious School of Medicine might use organizational control structures to develop effective solutions to global disarray within the academic medical center. Organizational control systems are intended to help influence the behavior of people as members of a formal organization. They are necessary to motivate people toward organizational goals, to coordinate diverse efforts, and to provide feedback about problems. The authors present a model of control to make this process more visible within organizations. They explore the overlap among academic medical centers and large businesses-for instance, each is a billion-dollar enterprise with complex internal and external demands and multiple audiences. The authors identify and describe how to use the key components of an organization's control system: environment, culture, structure, and core control system. Elements of the core control system are identified, described, and explored. These closely articulating elements include planning, operations, measurement, evaluation, and feedback systems. Use of control portfolios is explored to achieve goal-outcome congruence. Additionally, the authors describe how the components of the control system can be used synergistically by academic leadership to create organizational change, congruent with larger organizational goals. The enterprise of medicine is quickly learning from the enterprise of business. Achieving goal-action congruence will better position academic medicine to meet its multiple missions.
Academic Medicine 12/2005; 80(11):1054-63. · 3.29 Impact Factor
[show abstract][hide abstract] ABSTRACT: The clinical performances of physicians have come under scrutiny as greater public attention is paid to the quality of health care. However, determinants of physician performance have not been well elucidated. The authors sought to develop a theoretical model of physician performance, and explored the literature about factors affecting resident performance.
Using expert consensus panel, in 2002-03 the authors developed a hypothesis-generating model of resident performance. The developed model had three input factors (individual resident factors, health care infrastructure, and medical education infrastructure), intermediate process measures (knowledge, skills, attitudes, habits), and final health outcomes (affecting patient, community and population). The authors used factors from the model to focus a PubMed search (1967-2002) for all original articles related to the factors of individual resident performance.
The authors found 52 original studies that examined factors of an individual resident's performance. They describe each study's measurement instrument, study design, major findings, and limitations. Studies were categorized into five domains: learning styles/personality, social/financial factors, practice preferences, personal health, and response to job environment. Few studies examined intermediate or final performance outcomes. Most were single-institution, cross-sectional, and survey-based studies.
Attempting to understand resident performance without understanding factors that influence performance is analogous to examining patient adherence to medication regimens without understanding the individual patient and his or her environment. Based on a systematic review of the literature, the authors found few discrete associations between the factors of individual resident and the resident's actual job performance. Additionally, they identify and discuss major gaps in the educational literature.
Academic Medicine 05/2005; 80(4):376-89. · 3.29 Impact Factor
[show abstract][hide abstract] ABSTRACT: Direct-to-consumer (DTC) advertising of prescription drugs in the United States is both ubiquitous and controversial. Critics charge that it leads to overprescribing, while proponents counter that it helps avert underuse of effective treatments, especially for conditions that are poorly recognized or stigmatized.
To ascertain the effects of patients' DTC-related requests on physicians' initial treatment decisions in patients with depressive symptoms.
Randomized trial using standardized patients (SPs). Six SP roles were created by crossing 2 conditions (major depression or adjustment disorder with depressed mood) with 3 request types (brand-specific, general, or none).
Offices of primary care physicians in Sacramento, Calif; San Francisco, Calif; and Rochester, NY, between May 2003 and May 2004.
One hundred fifty-two family physicians and general internists recruited from solo and group practices and health maintenance organizations; cooperation rates ranged from 53% to 61%.
The SPs were randomly assigned to make 298 unannounced visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder. The SPs made a brand-specific drug request, a general drug request, or no request (control condition) in approximately one third of visits.
Data on prescribing, mental health referral, and primary care follow-up obtained from SP written reports, visit audiorecordings, chart review, and analysis of written prescriptions and drug samples. The effects of request type on prescribing were evaluated using contingency tables and confirmed in generalized linear mixed models that accounted for clustering and adjusted for site, physician, and visit characteristics.
Standardized patient role fidelity was excellent, and the suspicion rate that physicians had seen an SP was 13%. In major depression, rates of antidepressant prescribing were 53%, 76%, and 31% for SPs making brand-specific, general, and no requests, respectively (P<.001). In adjustment disorder, antidepressant prescribing rates were 55%, 39%, and 10%, respectively (P<.001). The results were confirmed in multivariate models. Minimally acceptable initial care (any combination of an antidepressant, mental health referral, or follow-up within 2 weeks) was offered to 98% of SPs in the major depression role making a general request, 90% of those making a brand-specific request, and 56% of those making no request (P<.001).
Patients' requests have a profound effect on physician prescribing in major depression and adjustment disorder. Direct-to-consumer advertising may have competing effects on quality, potentially both averting underuse and promoting overuse.
JAMA The Journal of the American Medical Association 05/2005; 293(16):1995-2002. · 29.98 Impact Factor