Bimal H. Ashar

Evaluation of an audience response system for the continuing education of health professionals

Introduction: Continuing medical education (CME) for physicians and other health personnel is becoming increasingly important in light of recertification requirements. Interactive learning is more effective and may be useful in a continuing education setting. This study examines the use of an audience response system (ARS) as an interactive learning tool for health care providers. Method: We conducted a national randomized controlled trial to evaluate the utility of an ARS to enhance attention and learning. Speakers at 42 clinical round table (CRT) programs in five regions across the United States were randomized to “use” or “no use” of an ARS during their lectures. We surveyed participants to collect data regarding presentation and speaker quality, impressions of the ARS, and knowledge of the material presented. We collected information from speakers regarding ease of use and overall opinions of the ARS. Results: A total of 283 surveys were completed (164 from participants using the ARS and 119 from participants not using the ARS). ARS participants rated the quality of the presentation, the quality of the speaker, and their level of attention more highly than non‐ARS participants (p <.05). Knowledge scores (of material presented) were not significantly different between the two groups. Both participants and speakers felt that the ARS was easy to use and preferred to use the system in future CRTs. Discussion: Participants in CRTs with the ARS rated presentation and speaker quality more favorably than those participants in CRTs without the tool. Participant knowledge scores, however, were not significantly different. ARSs may provide easy‐to‐use tools to enhance attention and enthusiasm in CME learners.

The reported validity and reliability of methods for evaluating continuing medical education: A systematic review

Purpose To appraise the reported validity and reliability of evaluation methods used in high-quality trials of continuing medical education (CME). Method The authors conducted a systematic review (1981 to February 2006) by hand-searching key journals and searching electronic databases. Eligible articles studied CME effectiveness using randomized controlled trials or historic/concurrent comparison designs, were conducted in the United States or Canada, were written in English, and involved at least 15 physicians. Sequential double review was conducted for data abstraction, using a traditional approach to validity and reliability. Results Of 136 eligible articles, 47 (34.6%) reported the validity or reliability of at least one evaluation method, for a total of 62 methods; 31 methods were drawn from previous sources. The most common targeted outcome was practice behavior (21 methods). Validity was reported for 31 evaluation methods, including content (16), concurrent criterion (8), predictive criterion (1), and construct (5) validity. Reliability was reported for 44 evaluation methods, including internal consistency (20), interrater (16), intrarater (2), equivalence (4), and test–retest (5) reliability. When reported, statistical tests yielded modest evidence of validity and reliability. Translated to the contemporary classification approach, our data indicate that reporting about internal structure validity exceeded reporting about other categories of validity evidence. Conclusions The evidence for CME effectiveness is limited by weaknesses in the reported validity and reliability of evaluation methods. Educators should devote more attention to the development and reporting of high-quality CME evaluation methods and to emerging guidelines for establishing the validity of CME evaluation methods.

A critical evaluation of Internet marketing of products that contain ephedra.

OBJECTIVE To evaluate information contained within Internet sites that advertise and market dietary supplements containing ephedra. MATERIAL AND METHODS We conducted an Internet search to identify Web sites advertising weight-loss supplements that contained ephedra. Between July 7 and July 18, 2002, 4 search engines were used by entering the term herbal weight loss. Outcome measures included disclosure of potential adverse effects of or contraindications to ephedra-containing supplements, disclosure of ephedra alkaloid dosage, and presence of misleading or incorrect information. RESULTS Thirty-two products and advertisements were identified and systematically evaluated for deviance from truth-in-advertising standards. Of the 32 Web sites analyzed, 13 (41%) failed to disclose potential adverse effects or contraindications to supplement use. Seventeen (53%) did not reveal the dosage of ephedra alkaloids that was recommended. More importantly, 11 sites (34%) contained incorrect or misleading statements, some of which could directly result in serious harm to consumers. CONCLUSION If dietary supplements containing ephedra are to continue to be marketed freely, substantial reform in advertising regulation and enforcement is warranted.

Bisphosphonate-associated scleritis: a case report and review.

An 86-year-old female was treated for osteoporosis with alendronate, an aminobisphosphonate. Six weeks after alendronate therapy began, scleritis developed in the patient’s right eye. The alendronate was discontinued, and, with the administration of prednisone, the symptoms of scleritis fully resolved. Rechallenge resulted in recurrence of the symptoms. Bisphosphonates are commonly used in the management of osteoporosis and are generally safe agents. Rarely, they have been linked with ocular inflammation. This case report reviews the literature on the ocular effects of bisphosphonates and discusses a possible mechanism for the association.

Advising patients who use dietary supplements.

Public use of dietary supplements is quite prevalent, with an estimated 1 of 5 patients using such substances in an effort to maintain or promote their health. Despite their popularity, patients and physicians are often unaware of the limited regulation of these products as well as their potential risks and benefits. Lack of physician knowledge in these areas has the potential to strain the doctor-patient relationship. In this review, we present a 6-step approach to advising patients who are considering use of dietary supplements. Our framework includes a discussion of regulatory issues, efficacy and safety, potential supplement-drug interactions, and monitoring for adverse events and therapeutic effects.

Medical Residents' Knowledge of Dietary Supplements

Introduction: The widespread use of complementary and alternative medicine modalities such as dietary supplements has prompted many medical schools to offer courses covering such topics. To date, little is known about the impact of these courses on medical graduates’ knowledge. This study was designed to evaluate resident physicians’ level of understanding of popular dietary supplement regulation and to determine whether an interactive online curriculum could aid in improving such knowledge. Methods: A multicenter online educational intervention was developed and administered to physicians at 15 internal medicine residency programs throughout the United States, between March 1, 2006 and June 30, 2006. Pretest performance was used to measure baseline knowledge of commonly used dietary supplements. Posttest performance compared with pretest performance measured the effectiveness of the educational intervention. Results: A total of 335 physicians completed the module. Baseline knowledge of dietary supplements was low (average pretest score 59.7%). More than one-third of respondents were unaware of the reasons for use of saw palmetto and black cohosh. Results for questions on safety and drug-supplement interactions were similarly low. Only 57% of physicians knew that kava kava has been associated with hepatitis. Only 15% were aware that St. John’s Wort can lower cyclosporine levels. With regards to knowledge of efficacy, only 36% were aware that fish oil has been shown to lower triglyceride levels. After completion of the curriculum, scores improved significantly (P < 0.001) in all question/content areas. Conclusions: Residents’ knowledge of dietary supplements is poor. An online didactic module may improve knowledge and potentially enhance patient-physician communication regarding the use of such products.

Prevalence and determinants of physician participation in conducting pharmaceutical-sponsored clinical trials and lectures

AbstractBACKGROUND: The relationship between physicians and the pharmaceutical industry is controversial because of the potential for conflicts of interest. However, little empirical evidence exists on the extent of physician participation in activities sponsored by pharmaceutical companies. OBJECTIVES: To determine the prevalence of participation of internal medicine physicians in clinical trials and lectures sponsored by pharmaceutical companies and to describe factors that are associated with such participation. DESIGN, SETTING, AND PARTICIPANTS: We conducted a cross-sectional regional survey of 1,000 Maryland internal medicine physicians between February 2000 and January 2001 in order to measure the prevalence of physician participation in pharmaceutical-sponsored clinical trials and lectures. We also collected economic and demographic information to examine potential associations between physician characteristics and engagement in such activities. RESULTS: Of 835 eligible physicians 444 (53%) responded, of whom 37% reported engaging in pharmaceutical-sponsored clinical trials and/or lectures to supplement their incomes. In our multivariable analysis, subspecialists versus generalist physicians (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.14 to 2.99), physicians in private group-single specialty and academic practice versus physicians in solo practice (OR, 2.30; 95% CI, 1.19 to 4.44 and OR, 2.56; 95% CI, 1.17 to 5.61, respectively), and physicians with higher versus lower annual incomes (OR, 1.22; 95% CI, 1.04 to 1.44) had a greater odds of participation in these activities. Additionally, physicians dissatisfied with their income had a 140% greater odds of participation (OR, 2.36; 95% CI, 1.45 to 3.83) than those who were satisfied with their income. CONCLUSIONS: A substantial number of internists engage in pharmaceutical industry-sponsored clinical trials and/or lectures in an effort to supplement their incomes. Physician dissatisfaction with income appears to partially explain such participation.

Extent and determinants of physician participation in expert witness testimony.

Objectives: In the recent past, law firms have had difficulties in finding physicians to review malpractice cases and serve as expert witnesses. Over the last few years, however, many clinicians have had a decline in their income, causing some physicians to seek alternative sources of revenue such as the review of legal cases. The purpose of this study was to qualify and quantify the extent of physician participation in legal activities. Methods: We conducted a survey of 1,000 Maryland internal medicine physicians. The survey consisted of 24 items designed to collect information on demographics, practice patterns, income variables, and participation in legal review. Results: Twenty-four percent of our respondents reported engaging in expert witness testimony/review to supplement their incomes. Engagement was significantly associated with internal medicine subspecialty practice, academic practice, a self-perception that personal income was higher than the income of colleagues, and being in practice for 11 to 20 years. Economic factors were not found to be associated with engaging in these activities. Conclusions: Physician participation in legal review and expert witness activities is significant and appears not to be determined by economic factors. Both the positive effects of such participation on the legal system and the potential ethical concerns require further study.

Medical students’ perceptions of low-value care

Medical schools are creating high‐value care (HVC) curricula in undergraduate medical education; however, there are few studies identifying what are the most pressing low‐value care (LVC) practices, as observed by students. This study is a multicentre, targeted needs assessment comparing medical student perceptions of LVC at four institutions, after completion of their internal medicine clerkship, to identify areas of focus for future HVC curriculum development.

More than “Just Say No”

In 2001, the Joint Commission on the Accreditation of Healthcare Organizations issued standards for hospitals designed to draw attention to the underassessment and undertreatment of pain. Many organizations reacted by adopting the “5th vital sign” of pain assessment. The Wong-Baker FACES Pain Rating scale was used widely by practices to identify the pain status in all patients. Narcotic prescriptions, which had already been rising, increased even further as providers were “educated” by pharmaceutical companies as to the safety of opioids. Physicians welcomed having something “safe and effective” in their armamentarium to help relieve their patients’ suffering. It took more than a decade to realize the harms from chronic opioid use. The Centers for Disease Control and Prevention estimates that in 2016 more than 2 million Americans suffered from substance use disorders related to prescription opioid pain relievers and more than 60,000 people in the United States died of an opioid overdose. In October of 2017, President Trump directed the Department of Health and Human Services to declare the opioid crisis a “public health emergency.” He went on to say that the government would initiate “really tough, really big, really great advertising” aimed at persuading Americans not to start taking drugs. “This was an idea that I had, where if we can teach young people not to take drugs,” the President said, “it’s really, really easy not to take them.” Despite the recent focus on narcotic use and abuse, other substances continue to negatively impact health. It is estimated that 80% of the more than 21 million Americans suffering from a substance abuse disorder have an alcohol use disorder. Providers are often uncomfortable dealing with such disorders and/or feel limited in their ability to address the psychosocial issues surrounding the abuse. Physicians appear to be more comfortable assessing and addressing tobacco use. Despite this, tobacco use continues to be the leading cause of preventable death in the United States. Although it would be great if the entire population “just said no” to abusing substances, it seems unrealistic. Physicians need to know how to assist patients in dealing