Emily M. Mader

The temporal decline of idealism in two cohorts of medical students at one institution

BackgroundA number of studies have indicated that students lose idealistic motivations over the course of medical education, with some identifying the initiation of this decline as occurring as early as the second year of the traditional US curricula. This study builds on prior work testing the hypothesis that a decline in medical student idealism is detectable in the first two years of medical school.MethodsThe original study sought to identify differences in survey responses between first-year (MS1) and second-year (MS2) medical students at the beginning and end of academic year 2010, on three proxies for idealism. The current study extends that work by administering the same survey items to the same student cohorts at the end of their third and fourth years (MS3 and MS4), respectively. Survey topics included questions on: (a) motivations for pursuing a medical career; (b) specialty choice; and (c) attitudes toward primary care. Principle component analysis was used to extract linear composite variables (LCVs) from responses to each group of questions. Linear regression was then used to test the effect of the six cohort/time-points on each composite variable, controlling for demographic characteristics.ResultsIdealism in medicine decreased (β = -.113, p < .001) while emphasis on employment and job security increased (β = .146, p < .001) as motivators of pursuing a career in medicine at each medical school stage and time period. Students were more likely to be motivated by student debt over interest in content in specialty choice (β = .077, p = .004) across medical school stages. Negative attitudes towards primary care were most sensitive to MS group and time effects. Both negative/antagonistic views (β = .142, p < .001) and negative/sympathetic views (β = .091, p < .001) of primary care increased over each stage.ConclusionsOur results provide further evidence that declines in medical student idealism may occur as early as the second year of medical education. Additionally, as students make choices in their medical careers, such as specialty choice or consideration of primary care, the influences of job security, student debt and social status increasingly outweigh idealistic motivations.

A Practice Facilitation and Academic Detailing Intervention Can Improve Cancer Screening Rates in Primary Care Safety Net Clinics

Background: Despite the current evidence of preventive screening effectiveness, rates of breast, cervical, and colorectal cancer in the United States fall below national targets. We evaluated the efficacy and feasibility of combining practice facilitation and academic detailing quality improvement (QI) strategies to help primary care practices increase breast, cervical, and colorectal cancer screening among patients. Methods: Practices received a 1-hour academic detailing session addressing current cancer screening guidelines and best practices, followed by 6 months of practice facilitation to implement evidence-based interventions aimed at increasing patient screening. One-way repeated measures analysis of variance compared screening rates before and after the intervention, provider surveys, and TRANSLATE model scores. Qualitative data were gathered via participant focus groups and interviews. Results: Twenty-three practices enrolled in the project: 4 federally qualified health centers, 10 practices affiliated with larger health systems, 4 physician-owned practices, 4 university hospital clinics, and 1 nonprofit clinic. Average screening rates for breast cancer increased by 13% (P = .001), and rates for colorectal cancer increased by 5.6% (P = .001). Practices implemented a mix of electronic health record data cleaning workflows, provider audits and feedback, reminder systems streamlining, and patient education and outreach interventions. Practice facilitators assisted practices in tailoring interventions to practice-specific priorities and constraints and in connecting with community resources. Practices with resource constraints benefited from the engagement of all levels of staff in the quality improvement processes and from team-based adaptations to office workflows and policies. Many practices aligned quality improvement interventions in this project with patient-centered medical home and other regulatory reporting targets. Conclusions: Combining practice facilitation and academic detailing is 1 method through which primary care practices can achieve systems-level changes to better manage patient population health.

Update on Performance in Tobacco Control: A Longitudinal Analysis of the Impact of Tobacco Control Policy and the US Adult Smoking Rate, 2011-2013

This study aims at gaining an updated understanding of how recent efforts in tobacco control have impacted tobacco use across the United States, using yearly State of Tobacco Control tobacco control measure assessments.

Active transportation: Do current traffic safety policies protect non-motorists?

OBJECTIVE This study investigated the impact that state traffic safety regulations have on non-motorist fatality rates. METHODS Data obtained from the National Highway Traffic Safety Administration (NHTSA), the Federal Highway Administration (FHWA), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) were analyzed through a pooled time series cross-sectional model using fixed effects regression for all 50 states from 1999 to 2009. Two dependent variables were used in separate models measuring annual state non-motorist fatalities per million population, and the natural log of state non-motorist fatalities. Independent variables measuring traffic policies included state expenditures for highway law enforcement and safety per capita; driver cell phone use regulations; graduated driver license regulations; driver blood alcohol concentration regulations; bike helmet regulations; and seat belt regulations. Other control variables included percent of all vehicle miles driven that are urban and mean per capita alcohol consumption per year. RESULTS Non-motorist traffic safety was positively impacted by state highway law enforcement and safety expenditures per capita, with a decrease in non-motorist fatalities occurring with increased spending. Per capita consumption of alcohol also influenced non-motorist fatalities, with higher non-motorist fatalities occurring with higher per capita consumption of alcohol. Other traffic safety covariates did not appear to have a significant impact on non-motorist fatality rates in the models. CONCLUSION Our research suggests that increased expenditures on state highway and traffic safety and the initiation/expansion of programs targeted at curbing both driver and non-motorist intoxication are a starting point for the implementation of traffic safety policies that reduce risks for non-motorists.

Cognitive and Affective Representations of Active Surveillance as a Treatment Option for Low-Risk Prostate Cancer

Benefits of early diagnosis and treatment remain debatable for men with low-risk prostate cancer. Active surveillance (AS) is an alternative to treatment. The goal of AS is to identify patients whose cancer is progressing rapidly while avoiding treatment in the majority of patients. The purpose of this study was to explore cognitive and affective representations of AS within a clinical environment that promotes AS a viable option for men with low-risk prostate cancer. Participants included patients for whom AS and active treatment were equally viable options, as well as practitioners who were involved in consultations for prostate cancer. Data were generated from semistructured interviews and audits of consultation notes and were analyzed using thematic analysis. Nineteen patients and 16 practitioners completed a semistructured interview. Patients generally viewed AS as a temporary strategy that was largely equated with inaction. There was variation in the degree to which inaction was viewed as warranted or favorable. Patient perceptions of AS were generally malleable and able to be influenced by information from trusted sources. Encouraging slow deliberation and multiple consultations may facilitate greater understanding and acceptance of AS as a viable treatment option for low-risk prostate cancer.

Emerging Practice Concerning Vitamin D in Primary Care

The establishment of practice patterns concerning the diagnosis and management of hypovitaminosis D seems to be heterogeneous among primary care physicians. We conducted a qualitative study to explore the emerging practices among primary care providers regarding screening and treatment for hypovitaminosis D, as well as factors that influence practice patterns. Trained researchers facilitated focus groups among primary care providers. We followed a grounded theory approach to transcript coding and analysis using ATLAS.ti analysis software. Testing or screening for hypovitaminosis D and subsequent replacement or supplementation practices varied among participants. Emerging practice concerning vitamin D appears to be constructed and reinforced by patient demand; incidental reading; brief, purposeful research; conversations with colleagues; results of consultations by specialists; and more patient demand. A multifaceted approach to promoting guideline adherence will be required to influence this practice.

Qualitative insights into how men with low-risk prostate cancer choosing active surveillance negotiate stress and uncertainty.

BackgroundActive surveillance is a management strategy for men diagnosed with early-stage, low-risk prostate cancer in which their cancer is monitored and treatment is delayed. This study investigated the primary coping mechanisms for men following the active surveillance treatment plan, with a specific focus on how these men interact with their social network as they negotiate the stress and uncertainty of their diagnosis and treatment approach.MethodsThematic analysis of semi-structured interviews at two academic institutions located in the northeastern US. Participants include 15 men diagnosed with low-risk prostate cancer following active surveillance.ResultsThe decision to follow active surveillance reflects the desire to avoid potentially life-altering side effects associated with active treatment options. Men on active surveillance cope with their prostate cancer diagnosis by both maintaining a sense of control over their daily lives, as well as relying on the support provided them by their social networks and the medical community. Social networks support men on active surveillance by encouraging lifestyle changes and serving as a resource to discuss and ease cancer-related stress.ConclusionsSupport systems for men with low-risk prostate cancer do not always interface directly with the medical community. Spousal and social support play important roles in helping men understand and accept their prostate cancer diagnosis and chosen care plan. It may be beneficial to highlight the role of social support in interventions targeting the psychosocial health of men on active surveillance.

Status of Underrepresented Minority and Female Faculty at Medical Schools Located within Historically Black Colleges and in Puerto Rico.

Background and objectives To assess the impact of medical school location in Historically Black Colleges and Universities (HBCU) and Puerto Rico (PR) on the proportion of underrepresented minorities in medicine (URMM) and women hired in faculty and leadership positions at academic medical institutions. Method AAMC 2013 faculty roster data for allopathic medical schools were used to compare the racial/ethnic and gender composition of faculty and chair positions at medical schools located within HBCU and PR to that of other medical schools in the United States. Data were compared using independent sample t-tests. Results Women were more highly represented in HBCU faculty (mean HBCU 43.5% vs. non-HBCU 36.5%, p=0.024) and chair (mean HBCU 30.1% vs. non-HBCU 15.6%, p=0.005) positions and in PR chair positions (mean PR 38.23% vs. non-PR 15.38%, p=0.016) compared with other allopathic institutions. HBCU were associated with increased African American representation in faculty (mean HBCU 59.5% vs. non-HBCU 2.6%, p=0.011) and chair (mean HBCU 73.1% vs. non-HBCU 2.2%, p≤0.001) positions. PR designation was associated with increased faculty (mean PR 75.40% vs. non-PR 3.72%, p≤0.001) and chair (mean PR 75.00% vs. non-PR 3.54%, p≤0.001) positions filled by Latinos/Hispanics. Conclusions Women and African Americans are better represented in faculty and leadership positions at HBCU, and women and Latino/Hispanics at PR medical schools, than they are at allopathic peer institutions.Background and objectives To assess the impact of medical school location in Historically Black Colleges and Universities (HBCU) and Puerto Rico (PR) on the proportion of underrepresented minorities in medicine (URMM) and women hired in faculty and leadership positions at academic medical institutions. Method AAMC 2013 faculty roster data for allopathic medical schools were used to compare the racial/ethnic and gender composition of faculty and chair positions at medical schools located within HBCU and PR to that of other medical schools in the United States. Data were compared using independent sample t-tests. Results Women were more highly represented in HBCU faculty (mean HBCU 43.5% vs. non-HBCU 36.5%, p=0.024) and chair (mean HBCU 30.1% vs. non-HBCU 15.6%, p=0.005) positions and in PR chair positions (mean PR 38.23% vs. non-PR 15.38%, p=0.016) compared with other allopathic institutions. HBCU were associated with increased African American representation in faculty (mean HBCU 59.5% vs. non-HBCU 2.6%, p=0.011) and chair (mean HBCU 73.1% vs. non-HBCU 2.2%, p≤0.001) positions. PR designation was associated with increased faculty (mean PR 75.40% vs. non-PR 3.72%, p≤0.001) and chair (mean PR 75.00% vs. non-PR 3.54%, p≤0.001) positions filled by Latinos/Hispanics. Conclusions Women and African Americans are better represented in faculty and leadership positions at HBCU, and women and Latino/Hispanics at PR medical schools, than they are at allopathic peer institutions.

Practice facilitation and academic detailing improves colorectal cancer screening rates in safety net primary care clinics

Objective SUNY Upstate Medical University entered a contract with Health Research, Inc. and the New York State Department of Health to implement an intervention using academic detailing and practice facilitation to increase colorectal cancer screening rates within primary care practices, and to assess the outcomes and barriers to intervention success. The project was conducted within a large multiorganizational framework, led by the Studying-ActingLearning-Teaching Network (SALT-Net, SUNY Upstate Medical University) in partnership with the Upstate New York Network (UNYNET -University at Buffalo) and the Greater Rochester PBRN (GR-PBRN -University of Rochester Medical Center), under the auspices of the Upstate New York Translational Research Network (UNYTE).

Immunization Mandates, Vaccination Coverage, and Exemption Rates in the United States

Abstract Background Vaccination coverage among children entering kindergarten in the United States is high, but interstate variations exist. The relationship between state immunization laws and vaccination coverage has not been fully assessed. We evaluated associations of state laws on both measles, mumps, and rubella (MMR) and diphtheria, tetanus, and pertussis (DTaP) vaccination coverage and exemptions to school immunization requirements. Methods We conducted a retrospective, longitudinal analysis of the effect of state immunization laws on vaccination coverage and exemptions among US kindergarteners from SY 2008 to SY 2014. The primary outcome measures were state-level kindergarten entry vaccination coverage rates for 2-dose MMR and 4-dose DTaP vaccines. Secondary outcome measures included rates of state-level exemptions (ie, medical, religious, philosophical) to school immunization requirements. Results We found that state policies that refer to Advisory Committee on Immunization Practices recommendations were associated with 3.5% and 2.8% increases in MMR and DTaP vaccination rates. Health Department–led parental education was associated with 5.1% and 4.5% increases in vaccination rates. Permission of religious and philosophical exemptions was associated with 2.3% and 1.9% decreases in MMR and DTaP coverage, respectively, and a 1.5% increase in both total exemptions and nonmedical exemptions, respectively. Conclusions We found higher vaccination coverage and lower nonmedical exemption rates for MMR and DTaP vaccines in states adopting Advisory Committee on Immunization Practices guidelines for school entry. Adherence to these best practices was a successful strategy to increase vaccination coverage and reduce vaccination exemptions.