Barbara Gerbert

Residency Training in Internal Medicine: Time for a Change?

Internal medicine residencies risk becoming obsolete if they are not adjusted to changing patterns of medical practice. Declining length of hospital stay, increased intensity of hospital care, movement of critical management decisions to outpatient settings, increased proportions of admissions for specific diagnostic procedures, and increased needs for perioperative consultations all erode the foundation of traditional internal medicine training. Furthermore, demographic shifts, the move to prepaid care, and a projected oversupply of subspecialists warrant more exposure to generalism and geriatrics. To prepare internists for clinical practice, some training should shift from medical wards and intensive care units to outpatient settings and surgical consultation, additional process skills must be taught, and the epidemiologically important non-internal-medicine disciplines should be included in the curriculum. These shifts will require changes in methods to pay for residency training, accreditation procedures for residency programs, and the residency certifying process. Most importantly, the model and organization of internal medicine training need to be reconsidered.

Public Health Surveillance of Dental Pain via Twitter

On Twitter, people answer the question, “What are you doing right now?” in no more than 140 characters. We investigated the content of Twitter posts meeting search criteria relating to dental pain. A set of 1000 tweets was randomly selected from 4859 tweets over 7 non-consecutive days. The content was coded using pre-established, non-mutually-exclusive categories, including the experience of dental pain, actions taken or contemplated in response to a toothache, impact on daily life, and advice sought from the Twitter community. After excluding ambiguous tweets, spam, and repeat users, we analyzed 772 tweets and calculated frequencies. Of the sample of 772 tweets, 83% (n = 640) were primarily categorized as a general statement of dental pain, 22% (n = 170) as an action taken or contemplated, and 15% (n = 112) as describing an impact on daily activities. Among the actions taken or contemplated, 44% (n = 74) reported seeing a dentist, 43% (n = 73) took an analgesic or antibiotic medication, and 14% (n = 24) actively sought advice from the Twitter community. Twitter users extensively share health information relating to dental pain, including actions taken to relieve pain and the impact of pain. This new medium may provide an opportunity for dental professionals to disseminate health information.

Preventing excessive weight gain in pregnancy: how do prenatal care providers approach counseling?

BACKGROUND Excessive weight gain during pregnancy is becoming more common and is associated with many adverse maternal and infant outcomes. There is a paucity of data on how weight gain counseling is actually provided in prenatal care settings. Our objective was to study prenatal care providers and their knowledge, attitudes, and practices regarding prevention of excessive weight gain during pregnancy and, secondarily, their approach to nutrition and physical activity counseling during pregnancy. METHODS We conducted seven focus groups of general obstetrician/gynecologists, midwives, and nurse practitioners. We analyzed data using qualitative methods. RESULTS Providers agreed to participate because they were unsure of the effectiveness of their counseling efforts and wanted to learn new techniques for counseling patients about weight gain, nutrition, and physical activity. We identified several barriers to weight gain counseling, including insufficient training, concern about the sensitivity of the topic, and the perception that counseling is ineffective. Providers all agreed that weight gain was an important topic with short-term and long-term health consequences, but they described widely disparate counseling styles and approaches. CONCLUSIONS Prenatal care providers are deeply concerned about excessive weight gain and its sequelae in their patients but encounter barriers to effective counseling. Providers want new tools to help them address weight gain counseling during pregnancy.

Training physicians about smoking cessation

Study objective:To test the hypotheses that physicians in private practice who receive a continuing education program (entitled “Quit for Life”) about how to counsel smokers to quit would counsel smokers more effectively and have higher rates of long-term smoking cessation among their patients.Design:Randomized trial with blinded assessment of principal outcomes.Setting:Private practices of internal medicine and family practice.Subjects:Forty-four physicians randomly assigned to receive training (24) or serve as controls (20) and consecutive samples of smokers visiting each physician (19.6 patients per experimental and 22.3 per control physician).Interventions:Physicians received three hours of training about how to help smokers quit. Physicians and their office staffs were also given self-help booklets to distribute to smokers and were urged to use a system of stickers on charts as reminders to counsel smokers about quitting.Measurements and main results:Based on telephone interviews with patients, physicians in the experimental group were more likely to discuss smoking with patients who smoked (64% vs. 44%), spent more time counseling smokers about quitting (7.5 vs. 5.2 minutes), helped more smokers set dates to quit smoking (29% vs. 5% of smokers), gave out more self-help booklets (37% vs. 9%), and were more likely to make a follow-up appointment about quitting smoking (19% vs. 11% of those counseled) than physicians in the control group. One year later, the rates of biochemically confirmed, long-term (≥9 months) abstinence from smoking were similar among patients in the experimental (3.2%) and control (2.5%) groups (95% confidence interval for the 0.7% difference: −1.7 to +3.1%).Conclusions:The authors conclude that this continuing education program substantially changed the way physicians counseled smokers, but had little or no impact on rates of long-term smoking cessation among their patients. There is a need for more effective strategies to help physicians help their patients to quit smoking.

Interactive “Video Doctor” Counseling Reduces Drug and Sexual Risk Behaviors among HIV-Positive Patients in Diverse Outpatient Settings

Background Reducing substance use and unprotected sex by HIV-positive persons improves individual health status while decreasing the risk of HIV transmission. Despite recommendations that health care providers screen and counsel their HIV-positive patients for ongoing behavioral risks, it is unknown how to best provide “prevention with positives” in clinical settings. Positive Choice, an interactive, patient-tailored computer program, was developed in the United States to improve clinic-based assessment and counseling for risky behaviors. Methodology and Findings We conducted a parallel groups randomized controlled trial (December 2003–September 2006) at 5 San Francisco area outpatient HIV clinics. Eligible patients (HIV-positive English-speaking adults) completed an in-depth computerized risk assessment. Participants reporting substance use or sexual risks (n = 476) were randomized in stratified blocks. The intervention group received tailored risk-reduction counseling from a “Video Doctor” via laptop computer and a printed Educational Worksheet; providers received a Cueing Sheet on reported risks. Compared with control, fewer intervention participants reported continuing illicit drug use (RR 0.81, 95% CI: 0.689, 0.957, p = 0.014 at 3 months; and RR 0.65, 95% CI: 0.540, 0.785, p<0.001 at 6 months) and unprotected sex (RR 0.88, 95% CI: 0.773, 0.993, p = 0.039 at 3 months; and RR 0.80, 95% CI: 0.686, 0.941, p = 0.007 at 6 months). Intervention participants reported fewer mean days of ongoing illicit drug use (-4.0 days vs. -1.3 days, p = 0.346, at 3 months; and -4.7 days vs. -0.7 days, p = 0.130, at 6 months) than did controls, and had fewer casual sex partners at (−2.3 vs. −1.4, p = 0.461, at 3 months; and −2.7 vs. −0.6, p = 0.042, at 6 months). Conclusions The Positive Choice intervention achieved significant cessation of illicit drug use and unprotected sex at the group-level, and modest individual-level reductions in days of ongoing drug use and number of casual sex partners compared with the control group. Positive Choice, including Video Doctor counseling, is an efficacious and appropriate adjunct to risk-reduction efforts in outpatient settings, and holds promise as a public health HIV intervention. Trial Registration Clinicaltrials.gov NCT00447707

Improving diet and exercise in pregnancy with Video Doctor counseling: a randomized trial.

OBJECTIVE To determine if an interactive, computerized Video Doctor counseling tool improves self-reported diet and exercise in pregnant women. METHODS A randomized trial comparing a Video Doctor intervention to usual care in ethnically diverse, low-income, English-speaking pregnant women was conducted. Brief messages about diet, exercise, and weight gain were delivered by an actor-portrayed Video Doctor twice during pregnancy. RESULTS In the Video Doctor group (n=158), there were statistically significant increases from baseline in exercise (+28 min), intake of fruits and vegetables, whole grains, fish, avocado and nuts, and significant decreases in intake of sugary foods, refined grains, high fat meats, fried foods, solid fats, and fast food. In contrast, there were no changes from baseline for any of these outcomes in the usual care group (n=163). Nutrition knowledge improved significantly over time in both groups but more so in the Video Doctor group. Clinician-patient discussions about these topics occurred significantly more frequently in the Video Doctor group. There was no difference in weight gain between groups. CONCLUSION A brief Video Doctor intervention can improve exercise and dietary behaviors in pregnant women. PRACTICE IMPLICATIONS The Video Doctor can be integrated into prenatal care to assist clinicians with effective diet and exercise counseling.

Measuring physician behavior.

Reliable and valid information on physician behavior is required for measuring the adequacy of physician performance. We studied 4 methods of obtaining information on physician behavior in the ambulatory care of chronic obstructive pulmonary disease. Physician interview, patient interview, chart audit, and videotaped observation were used to record the performance of 63 physicians in office visits with 214 adult patients. High interrater agreement was attained. All methods are of reasonable cost and all are acceptable to physicians. The content validity of the 2 interview methods was reasonably good, but chart audit and videotaped observation had poor content validity. Our findings suggest that no one method provides an accurate picture of physician behavior and, therefore, that a combination of methods should be used.

Improving primary care residents' proficiency in the diagnosis of skin cancer.

OBJECTIVE: To determine whether a brief, multicomponent intervention could improve the skin cancer diagnosis and evaluation planning performance of primary care residents to a level equivalent to that of dermatologists.PARTICIPANTS: Fifty-two primary care residents (26 in the control group and 26 in the intervention group) and 13 dermatologists completed a pretest and posttest.DESIGN: A randomized, controlled trial with pretest and posttest measurements of residents’ ability to diagnose and make evaluation plans for lesions indicative of skin cancer.INTERVENTION: The intervention included face-to-face feedback sessions focusing on residents’s performance deficiencies; an interactive seminar including slide presentations, case examples, and live demonstrations; and the Melanoma Prevention Kit including a booklet, magnifying tool, measuring tool, and skin color guide.MEASUREMENTS AND MAIN RESULTS: We compared the abilities of a control and an intervention group of primary care residents, and a group of dermatologists to diagnose and make evaluation plans for six categories of skin lesions including three types of skin cancer—malignant melanoma, squamous cell carcinoma, and basal cell carcinoma. At posttest, both the intervention and control group demonstrated improved performance, with the intervention group revealing significantly larger gains. The intervention group showed greater improvement than the control group across all six diagnostic categories (a gain of 13 percentage points vs 5, p<.05), and in evaluation planning for malignant melanoma (a gain of 46 percentage points vs 36, p<.05) and squamous cell carcinoma (a gain of 42 percentage points vs 21, p<.01). The intervention group performed as well as the dermatologists on five of the six skin cancer diagnosis and evaluation planning scores with the exception of the diagnosis of basal cell carcinoma.CONCLUSIONS: Primary care residents can diagnose and make evaluation plans for cancerous skin lesions, including malignant melanoma, at a level equivalent to that of dermatologists if they receive relevant, targeted education.

Are patients talking to their physicians about AIDS

We conducted a nationwide telephone survey of a random sample of United States adults in summer 1988 (n = 2000, response rate = 75 percent) to find out if physicians were providing education and counseling to the public about AIDS and AIDS prevention. Within the previous five years, 94 percent had seen a physician but only 15 percent had discussed AIDS even though most said they would not object to discussing the topic. AIDS-related conversations are not commonplace in physicians offices and in most cases (72 percent) patients are the initiators of such conversations.

The impact of who you know and where you live on opinions about aids and health care

We hypothesized that public attitudes towards AIDS and the safety of health care in the era of HIV would be more positive for people who knew someone with AIDS. We believed, moreover, that living in areas with high AIDS prevalence would result in more favorable attitudes. To test these hypotheses, we conducted telephone interviews with a random sample of 2000 U.S. adults (response rate = 75%) in summer 1988. Overall 19.5% of respondents said that they knew someone with AIDS or the AIDS virus. Thirteen percent of people who lived in low prevalences areas reported knowing someone with AIDS, compared with 27% of those in areas of high prevalence. Of the total sample, 38% reported knowing someone they believed was at risk. People who knew someone with AIDS were less likely to say they would change physicians or dentists if their provider was HIV infected or was known to be treating people who were infected. Knowing someone with AIDS was also associated with greater tolerance for those with AIDS to continue to work if they were able and with lower perception of risk of transmission in health care settings. Multivariate regression analyses indicated that personal contact was related to more positive attitudes. Counter to our hypothesis, living in a high prevalence area had no independent effect on attitudes. This surprising finding suggests that, after controlling for personal contact with someone with AIDS, where one lives does not influence attitudes. Because bringing people with AIDS into contact with others may have positive outcomes, we suggest implementation of interventions using this strategy.