Debora A. Paterniti

Medical student attitudes toward the doctor–patient relationship

Context  Medical educators have emphasized the importance of teaching patient‐centred care.

Evaluation of Factors Affecting Awareness of and Willingness to Participate in Cancer Clinical Trials

PURPOSE Annually, only 3% of patients participate in cancer clinical trials (CCTs). Barriers to accrual include lack of CCT awareness and uncertain third-party payer coverage. In January 2002, a California law (Senate Bill 37 [SB37]) required all third-party payers to reimburse patient care costs related to CCTs. We evaluated the level of awareness of patients and/or their family members/friends regarding CCTs and SB37. METHODS We used both a written survey for patients and/or their family members and friends seen in oncology clinics, and a verbal telephone version for Cancer Information Service callers. We tested for correlations between CCT awareness and SB37 knowledge, and willingness to participate in CCTs. RESULTS Of 1,188 respondents, 59% were aware of CCTs, 19% knew of SB37, and 36% were very likely to consider a CCT. There were significant positive correlations between CCT awareness and willingness to participate (P < .001, Spearman), and between SB37 knowledge and willingness to participate (P = .001, Pearson chi2). Reduced awareness was seen in respondents who were either black or African American (odds ratio [OR], 0.44; P = .004), Hispanic (OR, 0.56; P = .03), had an annual income less than 25,000 dollars (OR, 0.38; P < .001), or had less than a college degree (OR, 0.12 to 0.53; P < .001 to .013). Reduced willingness to participate in CCTs was seen in black or African American participants (OR, 0.38; P < .001), Asians (OR, 0.44; P < .006), or respondents aged 18 to 24 years (OR, 0.35; P = .002). CONCLUSION These results support the hypothesis that improving CCT awareness and SB37 knowledge especially among lower income, less educated, and minority patients, may potentially overcome barriers to participation and subsequently increase accrual in California.

Barriers in Diagnosing and Treating Men With Depression: A Focus Group Report

This study reports on the experiences of 45 male focus group participants with a history of depression. Men responded to questions addressing the interaction between the male role, masculinity, depression, and experiences with treatment for depression. Using a qualitative, thematic-based coding strategy, three primary themes emerged. First, participants described aspects of the male gender as being in conflict or incongruent with their experiences of depression and beliefs about appropriate help-seeking behaviors. Second, men outlined alternative symptom profiles that could interfere with the recognition of depression and willingness to seek help. Finally, men expressed a range of positive and negative reactions toward depression treatment and treatment providers. Implications for health care providers are provided.

Preferences of Women Evaluating Risks of Tamoxifen (POWER) study of preferences for tamoxifen for breast cancer risk reduction.

The objective of this study was to understand the attitudes and preferences of risk‐eligible women regarding use of tamoxifen for breast cancer risk reduction.

The eHealth Enhanced Chronic Care Model: A Theory Derivation Approach

Background Chronic illnesses are significant to individuals and costly to society. When systematically implemented, the well-established and tested Chronic Care Model (CCM) is shown to improve health outcomes for people with chronic conditions. Since the development of the original CCM, tremendous information management, communication, and technology advancements have been established. An opportunity exists to improve the time-honored CCM with clinically efficacious eHealth tools. Objective The first goal of this paper was to review research on eHealth tools that support self-management of chronic disease using the CCM. The second goal was to present a revised model, the eHealth Enhanced Chronic Care Model (eCCM), to show how eHealth tools can be used to increase efficiency of how patients manage their own chronic illnesses. Methods Using Theory Derivation processes, we identified a “parent theory”, the Chronic Care Model, and conducted a thorough review of the literature using CINAHL, Medline, OVID, EMBASE PsychINFO, Science Direct, as well as government reports, industry reports, legislation using search terms “CCM or Chronic Care Model” AND “eHealth” or the specific identified components of eHealth. Additionally, “Chronic Illness Self-management support” AND “Technology” AND several identified eHealth tools were also used as search terms. We then used a review of the literature and specific components of the CCM to create the eCCM. Results We identified 260 papers at the intersection of technology, chronic disease self-management support, the CCM, and eHealth and organized a high-quality subset (n=95) using the components of CCM, self-management support, delivery system design, clinical decision support, and clinical information systems. In general, results showed that eHealth tools make important contributions to chronic care and the CCM but that the model requires modification in several key areas. Specifically, (1) eHealth education is critical for self-care, (2) eHealth support needs to be placed within the context of community and enhanced with the benefits of the eCommunity or virtual communities, and (3) a complete feedback loop is needed to assure productive technology-based interactions between the patient and provider. Conclusions The revised model, eCCM, offers insight into the role of eHealth tools in self-management support for people with chronic conditions. Additional research and testing of the eCCM are the logical next steps.

Twenty years post-NIH Revitalization Act: enhancing minority participation in clinical trials (EMPaCT): laying the groundwork for improving minority clinical trial accrual: renewing the case for enhancing minority participation in cancer clinical trials.

The National Institutes of Health (NIH) Revitalization Act of 1993 mandated the appropriate inclusion of minorities in all NIH‐funded research. Twenty years after this act, the proportion of minority patients enrolled in cancer clinical trials remains persistently low. Clinical trials are vehicles for the development and evaluation of therapeutic and preventive agents under scientifically rigorous conditions. Without representation in trials, it is projected that disparities in the cancer burden for minorities will increase.

Successful self-directed lifelong learning in medicine: A conceptual model derived from qualitative analysis of a national survey of pediatric residents

Purpose Self-directed lifelong learning is integral to medical professionalism, yet how best to encourage its development during clinically intensive training is unknown. The authors develop a model for successful self-directed learning by analyzing qualitative data from a national survey of residents. Method Pediatric and medicine/pediatric residents at 46 training programs completed a Web-based survey in 2008–2009. Self-reported barriers to and strategies for achieving self-directed learning goals were systematically analyzed through inductive iterative review. Results A total of 992 out of 1,739 (57%) residents responded. Barriers to achieving self-directed learning goals were categorized into difficulty with personal reflection, environmental strain, competing demands, difficulty with goal generation, and problems with plan development and implementation. Strategies for achieving learning goals included creating goals that were important (relevant to the learner and prioritized by the learner as important to achieve), specific (with broad goals broken down into incremental steps and a specific plan for each step), measurable, accountable (with reminder and tracking systems and building in internal and external accountability), realistic (achievable goals which utilize existing opportunities and constant self-adjustment), and included a timeline for completing the goal (and incorporating the goal into their daily routine). Conclusions On the basis of the data, the authors propose a conceptual model for self-directed lifelong learning involving creation of learning goals and plan development based on individual reflection and self-assessment, and continual revision of goals and/or plans based on degree of goal attainment. This model could be broadly applicable throughout medical education.

Not the same everywhere: Patient-centered learning environments at nine medical schools

BACKGROUND: Learning environments overtly or implicitly address patient-centered values and have been the focus of research for more than 40 years, often in studies about the “hidden curriculum.” However, many of these studies occurred at single medical schools and used time-intensive ethnographic methods. This field of inquiry lacks survey methods and information about how learning environments differ across medical schools.OBJECTIVE: To examine patient-centered characteristics of learning environments at 9 U.S. medical schools.DESIGN: Cross-sectional internet-based survey.PARTICIPANTS: Eight-hundred and twenty-three third- and fourth-year medical students in the classes of 2002 and 2003.MEASUREMENTS: We measured the patient-centeredness of learning environments with the Communication, Curriculum, and Culture (C3) Instrument, a 29-item validated measure that characterizes the degree to which a medical school’s environment fosters patient-centered care. The C3 Instrument contains 3 content areas (role modeling, students’ experiences, and support for students’ patient-centered behaviors), and is designed to measure these areas independent of respondents’ attitudes about patient-centered care. We also collected demographic and attitudinal information from respondents.RESULTS: The variability of C3 scores across schools in each of the 3 content areas of the instrument was striking and statistically significant (P values ranged from .001 to .004). In addition, the patterns of scores on the 3 content areas differed from school to school.CONCLUSIONS: The 9 schools demonstrated unique and different learning environments both in terms of magnitude and patterns of characteristics. Further multiinstitutional study of hidden curricula is needed to further establish the degree of variability that exists, and to assist educators in making informed choices about how to intervene at their own schools.

How much time does it take to prescribe a new medication

OBJECTIVE To measure the length of time spent discussing all aspects of new prescriptions and guideline-recommended aspects of counseling, and to evaluate factors associated with duration of discussion. METHODS We analyzed tape recordings in which 181 patients received 234 new medication prescriptions from 16 family physicians, 18 internists, and 11 cardiologists in 2 healthcare systems in Sacramento, California between January and November 1999. RESULTS Of the mean total visit time of 15.9min (S.D.=434s), a mean of 26s (S.D.=28s) was allocated to guideline-recommended components and a mean of 23s (S.D.=25s) was allocated to discussion of all other aspects of new prescription medications. The majority of time spent discussing individual new prescriptions was dedicated to: medication purpose or justification, directions and duration of use, and side effects. On average, more complete discussion of these components was associated with more time. More time was spent talking about guideline-recommended information if patients were in better health, if there was a third party in the room, and if the medication belonged to a psychiatric, compared to an ear, nose, throat medication class. Less time was spent discussing over-the-counter (OTC) medications and those prescribed to patients with a previous visit to the physician. CONCLUSION Higher quality information transmission between physicians and patients about new medications requires more time, and may be difficult to achieve in short office visits. PRACTICE IMPLICATIONS Time-compressed office visits may need to be redesigned to promote improved provider-patient communication about new medications.

Overcoming Barriers to Cancer Clinical Trial Accrual : Impact of a Mass Media Campaign

Annually, only 3% of adult patients participate in cancer clinical trials (CCT). Accrual barriers include lack of CCT awareness and uncertain third‐party coverage. In 2002, a California law (SB37) required all insurers to reimburse costs related to CCT. The objective of the current study was to increase awareness of CCT and SB37 through a mass multimedia campaign (MMC) in the University of California (UC) Davis (UCD) Cancer Center catchment area. The authors assessed willingness to participate in and accrual to CCT.