Inginia Genao

A prescription for cultural competence in medical education.

Cultural competence programs have proliferated in U.S. medical schools in response to increasing national diversity, as well as mandates from accrediting bodies. Although such training programs share common goals of improving physician-patient communication and reducing health disparities, they often differ in their content, emphasis, setting, and duration. Moreover, training in cross-cultural medicine may be absent from students’ clinical rotations, when it might be most relevant and memorable. In this article, the authors recommend a number of elements to strengthen cultural competency education in medical schools. This “prescription for cultural competence” is intended to promote an active and integrated approach to multicultural issues throughout medical school training.

Repaving the road to academic success: the IMeRGE approach to peer mentoring.

In recent years, academic health centers have made a considerable effort to encourage medical students and physicians-in-training to consider academic medicine as a career choice. For physicians, selecting a career in academic medicine may be the first hurdle, but the challenge of successfully maintaining an academic career is perhaps a more formidable task. Mentoring is a much-needed response to this challenge. But the success of traditional mentoring programs at academic institutions is often limited by, among other things, the availability of senior faculty who can serve as mentors. The authors describe the formation and organization of the Internal Medicine Research Group at Emory (IMeRGE), an innovative peer mentoring group within the Division of General Medicine at Emory University. This group, born partially out of the mentoring needs of our women and minority faculty, shared the primary goal of fostering a collaborative atmosphere among junior faculty, while simultaneously acquiring experience through advanced faculty development. The authors present our methods of garnering division support for designated time and financial resources, defining member responsibilities, developing a curriculum, providing peer support, and seeking advisors with expertise in the areas on which we wished to focus. In addition to the development of IMeRGE, the authors provide an overview of the pros and cons of traditional mentoring versus peer mentoring; discuss the challenges faced by IMeRGE and strategies for addressing these issues; and present the paradigm of IMeRGE as a template for alternative forms of academic mentorship.

Complementary and Alternative Medicine Use by Primary Care Patients with Chronic Pain

OBJECTIVES To describe the characteristics and attitudes toward complementary and alternative medicine (CAM) use among primary care patients with chronic pain disorders and to determine if CAM use is associated with better pain control. DESIGN Cross-sectional survey. SUBJECTS Four hundred sixty-three patients suffering from chronic, nonmalignant pain receiving primary care at 12 U.S. academic medical centers. OUTCOME MEASURE Self-reported current CAM usage by patients with chronic pain disorders. RESULTS The survey had an 81% response rate. Fifty-two percent reported current use of CAM for relief of chronic pain. Of the patients that used CAM, 54% agreed that nontraditional remedies helped their pain and 14% indicated that their individual alternative remedy entirely relieved their pain. Vitamin and mineral supplements were the most frequently used CAM modalities. There was no association between reported use of CAM and pain severity, functional status, or perceived self-efficacy. Patients who reported having at least a high school education (odds ratio [OR] 1.1, 95% confidence interval [CI] 1.02-1.19, P = 0.016) and high levels of satisfaction with their health care (OR 1.47, 95% CI 1.13-1.91, P = 0.004) were significantly more likely to report using CAM. CONCLUSIONS Complementary and alternative therapies were popular among patients with chronic pain disorders surveyed in academic primary care settings. When asked to choose between traditional therapies or CAM, most patients still preferred traditional therapies for pain relief. We found no association between reported CAM usage and pain severity, functional status, or self-efficacy.

Physicians' comfort in caring for patients with chronic nonmalignant pain

Background:More than 100 million U.S. adults experience chronic nonmalignant pain. Many physicians are uncomfortable managing such patients. We sought to determine the timing and intensity of training that primary care physicians receive in chronic pain treatment, and the effect of training on their comfort in managing patients. Methods:The 4P Study was a cross-sectional study conducted at 12 academic medical centers in the United States. More than 500 primary care physicians completed a survey regarding their attitudes toward patients with chronic nonmalignant pain and their education in chronic pain management. Results:We received 572 surveys out of 753 distributed. The respondents’ mean age was 35 years; 64% were white, non-Hispanic and 41% were women. Eighty-eight percent were internists, and mean years spent in practice were 7.6. Fifty-seven percent of the physicians felt that they should serve as the principal doctor managing patients with chronic nonmalignant pain. Only 34% of physicians felt comfortable in managing patients with chronic pain. More intensive education after entry into practice was associated with the highest comfort level. Conclusions:Most primary care physicians are not comfortable treating patients with chronic nonmalignant pain. Education increases primary care physicians’ comfort in managing these patients. Increased comfort was associated with the willingness of primary care physicians to take charge of managing chronic pain. In addition, physician comfort is greatest when pain management skills are taught after residency training.

Building the case for cultural competence

&NA; Cultural competence in the provision of health care is a very important area of investigation and is receiving recognition at multiple levels. Minority groups constitute a significant and growing percentage of our population. However, there has been no commensurate increase in the number of minority physicians. There is a tremendous need for medical professional schools and health care organizations to implement formal cultural competence training for current and future health professionals. In this article, we present the findings of an extensive literature review that describes how several factors have brought the need for cultural competence to the forefront. These factors include a greater appreciation for the impact of culture on health, changes in U.S. demographics, increased awareness in health care disparities, and modifications in legislative and accreditation mandates.

Reasons for readmission in an underserved high-risk population: a qualitative analysis of a series of inpatient interviews

Objective To gather qualitative data to elucidate the reasons for readmissions in a high-risk population of underserved patients. Design We created an instrument with 27 open-ended questions based on current interventions. Setting Yale-New Haven Hospital. Patients Patients at the Yale Adult Primary Care Center (PCC). Measurements We conducted semi-structured qualitative interviews of patients who had four or more admissions in the previous 6 months and were currently readmitted to the hospital. Results We completed 17 interviews and identified themes relating to risk of readmission. We found that patients went directly to the emergency department (ED) when they experienced a change in health status without contacting their primary provider. Reasons for this included poor telephone or urgent care access and the belief that the PCC could not treat acute illness. Many patients could not name their primary provider. Conversely, every patient except one reported being able to obtain medications without undue financial burden, and every patient reported receiving adequate home care services. Conclusions These high-risk patients were receiving the formal services that they needed, but were making the decision to go to the ED because of inadequate access to care and fragmented primary care relationships. Formal transitional care services are unlikely to be adequate in reducing readmissions without also addressing primary care access and continuity.

Metabolic Syndrome in Obese Patients With Binge-Eating Disorder in Primary Care Clinics: A Cross-Sectional Study

BACKGROUND The distribution and nature of metabolic syndrome in obese patients with binge-eating disorder (BED) are largely unknown and require investigation, particularly in general internal medicine settings. The objectives of this study were to (1) examine the frequency of metabolic syndrome and (2) explore its eating- and weight-related correlates in obese patients with BED. METHOD This was a cross-sectional analysis of 81 consecutive treatment-seeking obese (body mass index ≥ 30 kg/m(2)) patients (21 men, 60 women) who met DSM-IV-TR research criteria for BED (either subthreshold criteria: ≥ 1 binge weekly, n = 19 or full criteria: ≥ 2 binges weekly, n = 62). Participants were from 2 primary care facilities in a large university-based medical center in an urban setting. Patients with and without metabolic syndrome were compared on demographic features and current and historical eating- and weight-related variables. Data were collected from December 2007 through March 2009. RESULTS Forty-three percent of patients met criteria for metabolic syndrome. A significantly higher proportion of men (66%) than women (35%) met criteria for metabolic syndrome (P = .012). Patients with versus without metabolic syndrome did not differ significantly in ethnicity or body mass index. Patients with versus without metabolic syndrome did not differ significantly in binge-eating frequency, severity of eating disorder psychopathology, or depression. Analyses of covariance controlling for gender revealed that patients without metabolic syndrome started dieting at a significantly younger age (P = .037), spent more of their adult lives dieting (P = .017), and reported more current dietary restriction (P = .018) than patients with metabolic syndrome. CONCLUSIONS Metabolic syndrome is common in obese patients with BED in primary care settings and is associated with fewer dieting behaviors. These findings suggest that certain lifestyle behaviors, such as increased dietary restriction, may be potential targets for intervention with metabolic syndrome.

Age-based and sex-based disparities in screening colonoscopy use among medicare beneficiaries.

Background: The use of screening colonoscopy among older persons is controversial due to variability in life expectancy and sex-based differences in colorectal cancer incidence. We assessed the relation between sex, age, and receipt of screening colonoscopy overall and within strata of life expectancy. Methods: We used Medicare data to identify beneficiaries during the years 2001 to 2005 who had not undergone a colonoscopy in the prior 3 years. Medicare claims were used to identify screening colonoscopy use; life expectancy was estimated using a life table approach. We used Poisson regression to examine sex and age differences in screening colonoscopy, adjusted for patient demographic characteristics. Results: Our sample consisted of 161,229 patients (61.9% female; mean age 76.9 y). The screening colonoscopy rates for females and males were 16.9 and 24.4 screening colonoscopies per 1000 person-years, respectively (P<0.001). The screening colonoscopy rate was highest for patients with the longest life expectancy (10 to 15 y: 27.2 screening colonoscopies per 1000 person-years) compared with 3.4 per 1000 person-years in the life expectancy <5-year group. Within specific life expectancy categories, older patients had significantly lower screening rates; in the 10- to 15-year life expectancy category, patients 75 to 79 years old had a lower rate (21.9 screening colonoscopies per 1000 person-years) than patients 68 to 69 years old (34.1 screening colonoscopies per 1000 person-years; P<0.001). Conclusions: In a large cohort of Medicare beneficiaries, there was evidence of screening colonoscopy use even among patients with a short life expectancy. After accounting for life expectancy, females and older persons were less likely to undergo screening colonoscopy.

Clinical Decisions Made in Primary Care Clinics Before and After Choosing Wisely

Background: The Choosing Wisely™ campaign encourages physicians to avoid low-value care. Although widely lauded, no study has examined its impact on clinical decisions made in primary care settings. Methods: We compared clinical decisions made for 5 Choosing Wisely recommendations over two 6-month time periods before and after the campaign launch and an educational intervention to promote it at 3 primary care residency clinics. Results: The rate of recommendations adherence was high (93.2%) at baseline but did significantly increase to 96.5% after the launch. These findings suggest primary care physicians respond to training and publicity in low-value care, though further research is needed. Conclusion: Given that even small decreases of physician test ordering can produce large cost savings, the Choosing Wisely project may help achieve the health care triple aim.

Biopsychosocial Correlates of Binge Eating Disorder in Caucasian and African American Women with Obesity in Primary Care Settings

This study examined racial differences in eating-disorder psychopathology, eating/weight-related histories, and biopsychosocial correlates in women (n = 53 Caucasian and n = 56 African American) with comorbid binge eating disorder (BED) and obesity seeking treatment in primary care settings. Caucasians reported significantly earlier onset of binge eating, dieting, and overweight, and greater number of times dieting than African American. The rate of metabolic syndrome did not differ by race. Caucasians had significantly elevated triglycerides whereas African Americans showed poorer glycaemic control (higher glycated haemoglobin A1c [HbA1c]), and significantly higher diastolic blood pressure. There were no significant racial differences in features of eating disorders, depressive symptoms, or mental and physical health functioning. The clinical presentation of eating-disorder psychopathology and associated psychosocial functioning differed little by race among obese women with BED seeking treatment in primary care settings. Clinicians should assess for and institute appropriate interventions for comorbid BED and obesity in both African American and Caucasian patients.