John M. Wiecha

Can medical students afford to choose primary care? An economic analysis of physician education debt repayment.

Purpose Some discussions of physician specialty choice imply that indebted medical students avoid choosing primary care because education debt repayment seems economically unfeasible. The authors analyzed whether a physician earning a typical primary care salary can repay the current median level of education debt and meet standard household expenses without incurring additional debt. Method In 2010–2011, the authors used comprehensive financial planning software to model the annual finances for a fictional physician’s household to compare the impact of various debt levels, repayment plans, and living expenses across three specialties. To accurately develop this spending model, they used published data from federal and local agencies, real estate sources, and national organizations. Results Despite growing debt levels, the authors found that physicians in all specialties can repay the current level of education debt without incurring more debt. However, some scenarios, typically those with higher borrowing levels, required trade-offs and compromises. For example, extended repayment plans require large increases in the total amount of interest repaid and the number of repayment years required, and the use of a federal loan forgiveness/repayment program requires a service obligation such as working at a nonprofit or practicing in a medically underserved area. Conclusions A primary care career remains financially viable for medical school graduates with median levels of education debt. Graduates pursuing primary care with higher debt levels need to consider additional strategies to support repayment such as extended repayment terms, use of a federal loan forgiveness/repayment program, or not living in the highest-cost areas.

Evaluation of a web-based asthma self-management system: a randomised controlled pilot trial.

BackgroundAsthma is the most common chronic condition of childhood and disproportionately affects inner-city minority children. Low rates of asthma preventer medication adherence is a major contributor to poor asthma control in these patients. Web-based methods have potential to improve patient knowledge and medication adherence by providing interactive patient education, monitoring of symptoms and medication use, and by facilitation of communication and teamwork among patients and health care providers. Few studies have evaluated web-based asthma support environments using all of these potentially beneficial interventions. The multidimensional website created for this study, BostonBreathes, was designed to intervene on multiple levels, and was evaluated in a pilot trial.MethodsAn interactive, engaging website for children with asthma was developed to promote adherence to asthma medications, provide a platform for teamwork between caregivers and patients, and to provide primary care providers with up-to-date symptom information and data on medication use. Fifty-eight (58) children primarily from inner city Boston with persistent-level asthma were randomised to either usual care or use of BostonBreathes. Subjects completed asthma education activities, and reported their symptoms and medication use. Primary care providers used a separate interface to monitor their patients’ website use, their reported symptoms and medication use, and were able to communicate online via a discussion board with their patients and with an asthma specialist.ResultsAfter 6-months, reported wheezing improved significantly in both intervention and control groups, and there were significant improvements in the intervention group only in night-time awakening and parental loss of sleep, but there were no significant differences between intervention and control groups in these measures. Emergency room or acute visits to a physician for asthma did not significantly change in either group. Among the subgroup of subjects with low controller medication adherence at baseline, adherence improved significantly only in the intervention group. Knowledge of the purpose of controller medicine increased significantly in the intervention group, a statistically significant improvement over the control group.ConclusionsThis pilot study suggests that a multidimensional web-based educational, monitoring, and communication platform may have positive influences on pediatric patients’ asthma-related knowledge and use of asthma preventer medications.

A Virtual World Versus Face-to-Face Intervention Format to Promote Diabetes Self-Management Among African American Women: A Pilot Randomized Clinical Trial

Background Virtual world environments have the potential to increase access to diabetes self-management interventions and may lower cost. Objective We tested the feasibility and comparative effectiveness of a virtual world versus a face-to-face diabetes self-management group intervention. Methods We recruited African American women with type 2 diabetes to participate in an 8-week diabetes self-management program adapted from Power to Prevent, a behavior-change in-person group program for African Americans with diabetes or pre-diabetes. The program is social cognitive theory–guided, evidence-based, and culturally tailored. Participants were randomized to participate in the program via virtual world (Second Life) or face-to-face, both delivered by a single intervention team. Blinded assessors conducted in-person clinical (HbA1c), behavioral, and psychosocial measurements at baseline and 4-month follow-up. Pre-post differences within and between intervention groups were assessed using t tests and chi-square tests (two-sided and intention-to-treat analyses for all comparisons). Results Participants (N=89) were an average of 52 years old (SD 10), 60% had ≤high school, 82% had household incomes <US

Utilization of a Free Fitness Center-Based Exercise Referral Program Among Women with Chronic Disease Risk Factors

30,000, and computer experience was variable. Overall session attendance was similar across the groups (6.8/8 sessions, P=.90). Compared to face-to-face, virtual world was slightly superior for total activity, light activity, and inactivity (P=.05, P=.07, and P=.025, respectively). HbA1c reduction was significant within face-to-face (−0.46, P=02) but not within virtual world (−0.31, P=.19), although there were no significant between group differences in HbA1c (P=.52). In both groups, 14% fewer patients had post-intervention HbA1c ≥9% (virtual world P=.014; face-to-face P=.002), with no significant between group difference (P=.493). Compared to virtual world, face-to-face was marginally superior for reducing depression symptoms (P=.051). The virtual world intervention costs were US

Use of a virtual world computer environment for international distance education: lessons from a pilot project using Second Life

1117 versus US

Design and Methods for a Comparative Effectiveness Pilot Study: Virtual World vs. Face-to-Face Diabetes Self-Management

931 for face-to-face. Conclusions It is feasible to deliver diabetes self-management interventions to inner city African American women via virtual worlds, and outcomes may be comparable to those of face-to-face interventions. Further effectiveness research is warranted. Trial Registration ClinicalTrials.gov NCT01340079; http://clinicaltrials.gov/show/NCT01340079 (Archived by WebCite at http://www.webcitation.org/6T2aSvmka).

Diet measurement in VietNamese youth: Concurrent reliability of a self-administered food frequency questionnaire

Abstract Physical activity (PA) reduces the risk for a number of chronic diseases including heart disease, hypertension, hyperlipidemia, and diabetes mellitus type 2. However, most Americans do not meet expert recommendations for exercise, and minorities and low-income persons are the most inactive. Community-based approaches to promoting PA include primaryxa0care exercise referral programs. This study examines patient characteristics associated with utilization of axa0community health center-based exercise referral program. Adult female patients of a community health center with an affiliated fitness center, in Boston, MA, were included in the study if they received a referral to the fitness center from their primary care provider. Demographic and medical information was abstracted from the medical chart, and fitness records were abstracted to measure activation of a fitness center membership (creation of an account denoting at least an initial visit) and utilization over time. Overall, 503 (40xa0%) of the 1,254 referred women in the study sample activated their membership. Black women were almost 60xa0% more likely to activate their membership (adjusted OR 1.6, 95xa0% CI 1.2–2.2), and women with higher co-morbidity counts were almost 45xa0% more likely to activate (adjusted OR 1.4, 95xa0% CI 1.0–2.0). Once activated, a minority of women participated at levels likely to improve cardiometabolic fitness. Of the 503 activations, 96 (19xa0%) had no participation, 359 (71xa0%) had low participation, and only 48 (10xa0%) had high participation. No independent predictors of participation were identified. These findings suggest that program design may benefit from developing activation, initial participation, and retention strategies that address population-specific barriers.

Use of an Online Curriculum to Teach Delirium to Fourth‐Year Medical Students: A Comparison with Lecture Format

Virtual worlds (VWs), in which participants navigate as avatars through three-dimensional, computer-generated, realistic-looking environments, are emerging as important new technologies for distance health education. However, there is relatively little documented experience using VWs for international healthcare training. The Geneva Foundation for Medical Education and Research (GFMER) conducted a VW training for healthcare professionals enrolled in a GFMER training course. This paper describes the development, delivery, and results of a pilot project undertaken to explore the potential of VWs as an environment for distance healthcare education for an international audience that has generally limited access to conventionally delivered education.

The Comparative Experiences of Women in Control: Diabetes Self-Management Education in a Virtual World

Background Type 2 diabetes (diabetes) is a serious threat to public health in the United States and disproportionally affects many racial/ethnic minority groups, including African Americans. Limited access to treatment and high attrition rates further contribute to health disparities in diabetes-related morbidity and mortality among minorities. Greater opportunities for increasing access and decreasing barriers to treatment are needed. Technology-based interventions have potential for accomplishing this goal but evidence of feasibility and potential effectiveness is lacking, especially for populations that traditionally have limited educational attainment and low computer literacy. Objective This paper describes the design and methods of a pilot randomized clinical trial that will compare the feasibility and potential efficacy of delivering a diabetes self-management intervention via a virtual world vs. a face-to-face format. Methods Study participants (n=100) will be African American women with uncontrolled type 2 diabetes recruited from primary care practices and affiliated health centers at a large safety net hospital in Massachusetts. Participants will be randomized into a virtual world-based (VW) intervention condition or a face-to-face control condition. Both conditions provide the same theory-based curriculum and equivalent exposure to the self-management program (eight group sessions), and both will be delivered by a single intervention team (a dietitian and a diabetes educator). Assessments will be conducted at baseline and 4 months. Feasibility will be determined by evaluating the degree to which participants engage in the VW-based intervention compared to face to face (number of sessions completed). Potential efficacy will be determined by comparing change in physiological (glycemic control) and behavioral (self-reported dietary intake, physical activity, blood glucose self-monitoring, and medication adherence) outcomes between the experimental and control groups. Results The primary outcomes of interest are feasibility of the VW intervention and its potential efficacy on glucose control and diabetes self-management behaviors, compared to the face-to-face condition. Analysis will use a two-sample Kolmogorov-Smirnov test for changes in variable distribution. P values will be calculated using binomial tests for proportions and t tests for continuous variables. Conclusions If the intervention is found to be feasible and promising, it will be tested in a larger RCT.

The perceived effects of faculty presence vs. absence on small-group learning and group dynamics: a quasi-experimental study

Dietary patterns of Asian Americans change with increasing acculturation, leading to increased consumption of Western foods including those high in fat. Strategies to preserve the healthy aspects of traditional diets need to be developed and dietary assessment methods evaluated. Little is known about reliability of brief dietary measures in the general population or among minority youth. The concurrent reliability of a brief food frequency questionnaire (FFQ) was determined among Vietnamese youth using diet reports.Students in a bilingual high school program were given a FFQ. Students then completed daily diet reports one day each week over seven weeks. The data from the FFQ were compared to the daily food reports.The reliability of the FFQ was highest for frequently eaten food types like rice (r=0.626, P<0.01), fruit (r=0.513, P<0.01), meat (r=0.525, P<0.01) and vegetables (r=0.474, P<0.01) and was lower for less commonly eaten types including fish/shellfish (r=0.227, P=0.20) and fried foods (r=0.310, P=0.07).These results suggest that a few simple FFQ items, particularly for indicator foods such as rice, are reliable for dietary assessment in this population.Dietary patterns of Asian Americans change with increasing acculturation, leading to increased consumption of Western foods including those high in fat. Strategies to preserve the healthy aspects of traditional diets need to be developed and dietary assessment methods evaluated. Little is known about reliability of brief dietary measures in the general population or among minority youth. The concurrent reliability of a brief food frequency questionnaire (FFQ) was determined among Vietnamese youth using diet reports. Students in a bilingual high school program were given a FFQ. Students then completed daily diet reports one day each week over seven weeks. The data from the FFQ were compared to the daily food reports. The reliability of the FFQ was highest for frequently eaten food types like rice (r=0.626, P<0.01), fruit (r=0.513, P<0.01), meat (r=0.525, P<0.01) and vegetables (r=0.474, P<0.01) and was lower for less commonly eaten types including fish/shellfish (r=0.227, P=0.20) and fried foods (r=0.310, P=0.07). These results suggest that a few simple FFQ items, particularly for indicator foods such as rice, are reliable for dietary assessment in this population.