Amy Cunningham

Organisational strategies to cultivate professional values and behaviours

Background In recent years, there has been increased focus on the importance of professionalism among medical students, residents and practising physicians, as well as the interaction between individual behaviours and the practice environment. Methods Recognising the need to better understand how organisations advance professional behaviours, the authors undertook an exploratory, qualitative study. This study consisted of screening interviews with 30 organisations. Staff and an expert advisory committee developed criteria to select 10 organisations for further study. The authors then conducted in-depth interviews with two leaders from each of the 10 organisations. Results and discussion Qualitative analysis revealed several key findings, including diversity in the language that organisations used regarding professionalism, and the professional behaviours that they chose to promote. Despite this diversity, all organisations shared a common strategy of clearly articulating their values and reinforcing these values. This reinforcement occurred through the provision of aligned organisational systems and structures, and the cultivation of strong interpersonal relationships. To better illustrate these findings, the authors provide several examples that demonstrate how organisational leaders use values to cultivate professional behaviour in their organisations.

Cancer screening, prevention, and treatment in people with mental illness.

Answer questions and earn CME/CNE

How Multidimensional Health Locus of Control predicts utilization of emergency and inpatient hospital services

Health locus of control may be an important predictor of health care utilization. We analyzed associations between health locus of control and frequency of emergency department visits and hospital admissions, and investigated self-rated health as a potential mediator. Overall, 863 patients in an urban emergency department completed the Multidimensional Health Locus of Control instrument, and self-reported emergency department use and hospital admissions in the last year. We found small but significant associations between Multidimensional Health Locus of Control and utilization, all of which were mediated by self-rated health. We conclude that interventions to shift health locus of control may change patients’ perceptions of their own health, thereby impacting utilization.

Systems model of physician professionalism in practice

RATIONALE This article proposes a systems level conceptualization of physician professionalism that is embedded in and results from the characteristics of the organizations in which doctors work such as hospitals, group practices and physician organizations. AIMS AND OBJECTIVES The goal of this study was to develop and test the systems model of professionalism. METHODS In total, 25 interviews were conducted in Minneapolis and Miami. Job titles of the subjects included hospital presidents, medical directors, chairs of hospital departments, quality and safety directors, chief of quality improvement and practising physicians. The data from the interviews were coded and then sorted by members of the study team into major and minor themes. RESULTS Virtually, all of the subjects were readily able to confirm aspects of the model by providing real-life examples of factors at the practice, hospital and market levels that they believed strongly influenced the extent to which physicians adhere, or fail to adhere, to the professional norms. CONCLUSIONS The systems model of professionalism was consistent with the views and experiences of physicians and administrators in two different geographic regions of the USA. If born out by further research, this model has implications for interventions aimed at improving professionalism as well as for professionalism as a field of study.

Concept Mapping as a Method to Engage Patients in Clinical Quality Improvement

Patient engagement has become a primary care research and practice priority. Little guidance exists, however, on how best to engage patients in primary care practice improvement, or how to measure the impact of their engagement. We present an overview of group concept mapping as a method for engaging patients in primary care practice improvement. We detail the group concept mapping process as a tool for use in primary care practice improvement, research, and evaluation, and we present resources to enable researchers and practice leaders to use this tool in practice improvement. To illustrate the method, we present a practice-based quality improvement project conducted with patients and staff at a large urban academic primary care practice.

Race as a Predictor of Palliative Care Referral Time, Hospice Utilization, and Hospital Length of Stay: A Retrospective Noncomparative Analysis:

Background: Palliative care is associated with significant benefits, including reduced pain and suffering, an increased likelihood of patients dying in their preferred location, and decreased health-care expenditures. Racial and ethnic disparities are well-documented in hospice use and referral patterns; however, it is unclear whether these disparities apply to inpatient palliative care services. Objective: To determine if race is a significant predictor of time to inpatient palliative care consult, patient enrollment in hospice, and patients’ overall hospital length of stay among patients of an inpatient palliative care service. Design: Retrospective noncomparative analysis. Setting: Urban academic medical center in the United States. Patients: 3207 patients referred to an inpatient palliative care service between March 2006 and April 2015. Measurements: Time to palliative care consult, disposition of hospice/not hospice (excluding patients who died), and hospital length of stay among patients by racial (Asian, black, Native American/Eskimo, Hispanic, white, Unknown) and ethnic (Hispanic/Latino, non-Hispanic, Unknown) background. Results: Race was not a significant predictor of time to inpatient palliative care consult, discharge to hospice, or hospital length of stay. Similarly, black/white, Hispanic/white, and Asian/white variables were not significant predictors of hospice enrollment (Ps > .05). Limitations: Study was conducted at 1 urban academic medical center, limiting generalizability; hospital race and ethnicity categorizations may also limit interpretation of results. Conclusions: In this urban hospital, race was not a predictor of time to inpatient palliative care service consult, discharge to hospice, or hospital length of stay. Confirmatory studies of inpatient palliative care services in other institutions are needed.

Response: Re: Evaluation of an Ongoing Diabetes Group Medical Visit in a Family Medicine Practice

To the Editor: We thank Steven Kaufman, MD; and Valerie S. Ganetsky, PharmD, BCPS and for their response to our article[1][1] evaluating a diabetes group medical visit (GMV) and for sharing their experience implementing a diabetes shared medical appointment (SMA). We applaud their implementation of

Evaluation of an Ongoing Diabetes Group Medical Visit in a Family Medicine Practice

Purpose: Group medical visits (GMVs), which combine 1-on-1 clinical consultations and group self-management education, have emerged as a promising vehicle for supporting type 2 diabetes management in primary care. However, few evaluations exist of ongoing diabetes GMVs embedded in medical practices. Methods: This study used a quasi-experimental design to evaluate diabetes GMV at a large family medicine practice. We examined program attendance and attrition, used propensity score matching to create a matched comparison group, and compared participants and the matched group on clinical, process of care, and utilization outcomes. Results: GMV participants (n = 230) attended an average of 1 session. Participants did not differ significantly from the matched comparison group (n = 230) on clinical, process of care or utilization outcomes. Conclusions: The diabetes GMV was not associated with improvements in outcomes. Further studies should examine diabetes GMV implementation challenges to enhance their effectiveness in everyday practice.

Schonberg: Overutilization of Breast Cancer Screening in the US

T o the Editors, We read with great interest Dr. Mara Schonberg’s editorial, BOverutilization of Breast Cancer Screening in the US: Awareness of a Growing Problem.^ 1 As primary care and geriatrics clinicians and researchers, we fully agree that there is wide variation in primary care provider recommendations regarding breast cancer screening in older women. Furthermore, the discussions between PCPs and patients regarding the harms and benefits of breast cancer screening are complex and involve potentially sensitive topics such as life expectancy. Therefore, useful shared decision-making tools for breast cancer screening in older women are vital. 1

Capsule Commentary on Njeru et al., Diabetes Mellitus Management Among Patients with Limited English Proficiency: a Systematic Review and Meta-analysis

L imited English proficiency (LEP) is associated with numerous health disparities, including poorer glycemic control in LEP patients with diabetes. In this issue, Njeru et al. 2 report findings from a systematic review and meta-analysis of diabetes self-management education (DSME) interventions in LEP populations. In their meta-analysis, DSME interventions were associated with a significant lower hemoglobin A1c (− 0.84% [95% CI, − 0.97 to − 0.71]) than usual care. Interventions lasting less than 6 months and using in-person delivery were more likely to demonstrate improvements in hemoglobin A1c. Improvements in selfefficacy, quality of life, and several other measures were also reported. This systematic review and meta-analysis is the first to examine the impact of DSME in LEP populations, and includes a sizable number of articles. The clinically significant reduction in hemoglobin A1c and positive effects on selfefficacy and quality of life are encouraging findings that are consistent with prior meta-analyses of DSME’s effect in the general population 3 and in racial and ethnic minority groups. The study also has several notable limitations. Nearly half of the included studies were non-randomized designs. Additionally, none of the interventions enrolled exclusively LEP participants, and for nearly half of included studies, LEP participation rates were Binferred^ from demographics tables or the article text. Furthermore, nearly all studies (94%) offered LEP accommodations, such as language-concordant staff or translated materials, but it was unclear which accommodations were most helpful to participants. Finally, the overall heterogeneity of the interventions, including delivery methods and intensity, precludes conclusions about the most effective DSME designs for LEP populations. The findings from Njeru et al. 2 suggest fruitful avenues for future research. Overall, the LEP population in the USA is very linguistically and culturally heterogeneous with substantial variations in country of origin, education level, and socioeconomic status. Development and evaluation of DSME for specific LEP sub-populations would strengthen the evidence for DSME’s impact on LEP participants and clarify the most effective intervention components for different groups. For clinicians and health educators, understanding their local LEP populations and working with community partners is critical to designing linguistically and culturally appropriate DSME to meet the needs of this vulnerable population.L imited English proficiency (LEP) is associated with numerous health disparities, including poorer glycemic control in LEP patients with diabetes. In this issue, Njeru et al. 2 report findings from a systematic review and meta-analysis of diabetes self-management education (DSME) interventions in LEP populations. In their meta-analysis, DSME interventions were associated with a significant lower hemoglobin A1c (− 0.84% [95% CI, − 0.97 to − 0.71]) than usual care. Interventions lasting less than 6 months and using in-person delivery were more likely to demonstrate improvements in hemoglobin A1c. Improvements in selfefficacy, quality of life, and several other measures were also reported. This systematic review and meta-analysis is the first to examine the impact of DSME in LEP populations, and includes a sizable number of articles. The clinically significant reduction in hemoglobin A1c and positive effects on selfefficacy and quality of life are encouraging findings that are consistent with prior meta-analyses of DSME’s effect in the general population 3 and in racial and ethnic minority groups. The study also has several notable limitations. Nearly half of the included studies were non-randomized designs. Additionally, none of the interventions enrolled exclusively LEP participants, and for nearly half of included studies, LEP participation rates were Binferred^ from demographics tables or the article text. Furthermore, nearly all studies (94%) offered LEP accommodations, such as language-concordant staff or translated materials, but it was unclear which accommodations were most helpful to participants. Finally, the overall heterogeneity of the interventions, including delivery methods and intensity, precludes conclusions about the most effective DSME designs for LEP populations. The findings from Njeru et al. 2 suggest fruitful avenues for future research. Overall, the LEP population in the USA is very linguistically and culturally heterogeneous with substantial variations in country of origin, education level, and socioeconomic status. Development and evaluation of DSME for specific LEP sub-populations would strengthen the evidence for DSME’s impact on LEP participants and clarify the most effective intervention components for different groups. For clinicians and health educators, understanding their local LEP populations and working with community partners is critical to designing linguistically and culturally appropriate DSME to meet the needs of this vulnerable population.