Kirsten Austad

Conflict of Interest Disclosure in Early Education of Medical Students

MEDICAL EDUCATION HAS EMBRACED THE transparency movement by shining the light of disclosure on physician-industry interactions. Many medical journals mandate that authors report potential conflicts of interest and publish detailed financial relationship lists with their articles. Likewise, the Accreditation Council for Continuing Medical Education requires disclosure of lecturers’ conflicts before lectures qualifying for continuing medical education (CME) credits. Despite these changes in physician education, disclosure norms have not yet trickled down to the very start of medical education—the preclinical years. Are firstand second-year students justified in expecting conflicts of interest disclosure in their education? The clinicians and researchers who lead preclinical medical education at US medical schools are usually drawn from affiliated medical centers and therefore are likely to have financial ties to industry. In the context of physician education, financial relationships to the subject matter have been shown to induce selective presentation of data or biased interpretations. Nonetheless, the typical rationales for conflict of interest disclosure do not apply in the context of preclinical education. The ultimate justification for disclosure is that biased statements can influence the care patients receive. Because medical students do not prescribe medications and have little patient care responsibility, there is less direct potential for harm. In addition, the first 2 years of medical education are largely spent studying basic biological sciences and pathophysiology. In the context of a CME event, it is easy to see how a speaker’s financial relationship to a specific pharmaceutical company could be relevant to the therapeutic recommendations, such as the best choice for treatment-refractory depression. In an analogous lecture to medical students on the neurobiochemical basis for depression, the mention of specific therapies may only serve as examples to illustrate the underlying scientific concepts. However, these perspectives miss the essential role that disclosure can have in early medical education. For example, as students learn details about anatomy and physiology, they also are beginning to construct a framework for analysis of data and application of data to clinical reasoning they will use as practicing physicians. In this light, a policy that requires disclosure of financial conflicts of interest before the start of any lecture would serve as a powerful reminder to a medical student audience about the potential for bias in the presentation of scientific information and therefore the need to be critical evaluators of the material being taught. Such lessons will be particularly useful when these students later need to weigh the risks and benefits of a new, heavily promoted therapeutic product or analyze the design of clinical trials that led to treatment recommendations. Promoting critical thinking in medical professionals may be easier to accomplish at a time when students’ clinical reasoning skills are just beginning to be developed than trying to create this skill after the students graduate, enter residency training, and subsequently practice. The mere existence of a disclosure policy can also affect students’ professional development. In addition to lessons in the formal curriculum, students are deeply influenced by the behavior of role models, institutional policies, or other characteristics of the learning environment cumulatively known as the “hidden curriculum.” Most students do not enter medical school having reflected on the scope and influence of interactions between physicians and the pharmaceutical and medical device industries; however, the acculturation process can occur rapidly. For example, surveys reveal that students further along in training have more positive attitudes regarding issues such as the appropriateness of accepting gifts from pharmaceutical representatives. The existence of a disclosure policy would communicate that an institution values the integrity of medical education. The practice of disclosure also provides a stimulus for students to begin dialogues with peers and advisers and consider their own ethical views on the controversial topic of

A Patient Navigation System to Minimize Barriers for Peritoneal Dialysis in Rural, Low-Resource Settings: Case Study From Guatemala

BACKGROUND: CHRONIC KIDNEY DISEASE IN GUATEMALA Guatemala is a lowerto middle-income, Latin American nation with a population of 16 million people and a growing need for rural dialysis services due to a confluence of factors. First, although the epidemiology and risk factors for chronic kidney disease (CKD) in Guatemala are not well understood, there is evidence that CKD mortality is among the highest in the Americas. The emerging entity “chronic kidney disease of nontraditional causes” may be a CKD risk factor in rural Guatemala, and regional data show that diabetic renal disease is a significant driver of population mortality. Second, approximately 40% of the population are rural indigenous Maya, a group that faces significant socioeconomic, geographic, and language barriers in accessing specialty nephrology care that is available only in urban tertiary centers. Finally, Guatemala’s population is growing and aging rapidly, greatly increasing the absolute number of people at risk for CKD.

Case reportAccompanying indigenous Maya patients with complex medical needs: A patient navigation system in rural Guatemala

a Wuqu’ Kawoq | Maya Health Alliance, Guatemala b Department of Emergency Medicine, Massachusetts General Hospital, United States c Departments of Internal Medicine and Pediatrics, University of Minnesota, United States d Division of Women’s Health, Department of Medicine, Brigham and Women’s Hospital, United States e University of California, San Francisco, United States f Burrell College of Osteopathic Medicine, United States g Division of Global Health Equity, Brigham and Women’s Hospital, United States

Insights into Global Health Practice from the Agile Software Development Movement

Global health practitioners may feel frustration that current models of global health research, delivery, and implementation are overly focused on specific interventions, slow to provide health services in the field, and relatively ill-equipped to adapt to local contexts. Adapting design principles from the agile software development movement, we propose an analogous approach to designing global health programs that emphasizes tight integration between research and implementation, early involvement of ground-level health workers and program beneficiaries, and rapid cycles of iterative program improvement. Using examples from our own fieldwork, we illustrate the potential of ‘agile global health’ and reflect on the limitations, trade-offs, and implications of this approach.

Residents: Workers or Students in the Eyes of the Law?

On January 11, 2011, in the case of Mayo Foundation for Medical Education and Research, et al. v. United States, the Supreme Court added its weighty voice to the question of whether residents are workers or students.

Fertility Awareness Methods Are Not Modern Contraceptives: Defining Contraception to Reflect Our Priorities

A recent article in GHSP calls for classifying fertility awareness methods as “modern contraceptives” despite their inferiority. We believe in a rights-based approach, which considers the real-world conditions that many women face, including constrained sexual agency and low baseline reproductive health literacy. We must demonstrate true commitment to increasing access to the most effective and reliable contraceptive methods. A recent article in GHSP calls for classifying fertility awareness methods as “modern contraceptives” despite their inferiority. We believe in a rights-based approach, which considers the real-world conditions that many women face, including constrained sexual agency and low baseline reproductive health literacy. We must demonstrate true commitment to increasing access to the most effective and reliable contraceptive methods.

Erratum to: Changing Interactions Between Physician Trainees and the Pharmaceutical Industry: A National Survey

reported receiving gifts when they attended medical schools that received higher levels of NIH funding (odds ratio (OR) 0.51, 95 % confidence interval (CI) 0.38-0.67, p<0.001). However, there was also a non-significant negative correlation between receiving gifts and a school’s AMSA score (OR 0.83, 95 % CI 0.61-1.12, p=0.21). Since medical students’ exposure to pharmaceutical marketing is more strongly related to the school’s NIH funding level, policymakers seeking to further insulate students from industry marketing could focus their resources on less research-intensive medical schools. Students in more research-intensive schools (OR 1.36, 95 % CI 1.00-1.85, p=0.052) and in schools with high AMSA scores (OR 1.29, 95 % CI 0.92-1.80, p=0.14) were more likely to report that receiving gifts would affect their prescribing practices, although neither association was statistically significant. Neither NIH funding level (OR 0.87, 95 % CI 0.51-1.48, p=0.60) nor AMSA score (OR 1.14, 95 % CI 0.70-1.85, p=0.24) was correlated with students’ report of “adequate separation” between school faculty and the pharmaceutical industry. We apologize for the erroneous rows in the Figure.

Correlates of long-acting reversible contraception uptake among rural women in Guatemala

Objective In many low-resource settings around the world utilization of long-acting reversible contraception (LARC) is low, in part due to access barriers. We sought to explore LARC utilization patterns as well as factors associated with LARC initiation by women seeking contraception in rural Guatemala from a program working to reduce contraception access barriers. Study design We analyzed data from a program that provides family planning in six remote, primarily indigenous, villages in Guatemala with limited access to alternative health services. Methods are free and delivered directly within villages by culturally competent providers. We conducted a retrospective chart review of all 288 women who initiated a contraceptive method over a 16-month period and conducted a logistic regression to obtain adjusted odds ratios (OR) for predictors of LARC uptake. Results Overall 79.2% of women elected a LARC method. More than half of women (49.8%) switched to LARC from short-acting hormonal methods. In the univariate analysis prior use of short-acting method (p = 0.014), number of prior methods (p = 0.049), and current contraceptive use (p<0.01) were significantly associated with choosing a LARC. In the logistic regression model current use of contraception remained significant (OR 3.29, 95% CI 1.67–8.04). Report of abnormal bleeding or other side effects from prior short-acting method use did not predict LARC uptake (p = 0.82 and p = 0.079). Conclusions Most women in this marginalized population opted for a LARC method. Implications Low utilization of LARCs may be related to service delivery factors. Further research is needed to validate these conclusions prospectively and in less selected populations.

Barriers to Cervical Cancer Screening and the Cervical Cancer Care Continuum in Rural Guatemala: A Mixed-Method Analysis

Purpose Cervical cancer is an important cause of mortality in low- and middle-income countries. Although screening technologies continue to improve, systems of care remain fragmented. It is important to better understand factors that affect use of screening services and loss to follow-up along the care continuum. Methods We conducted a mixed-methods study of a cytology-based screening program in rural Guatemala. A retrospective electronic chart review was performed on data from all patients from 2013 to 2014. We analyzed progression through care and calculated loss–to–follow-up rates. We also analyzed the prior experiences of patients with cervical cancer screening on the basis of self-reported historical data available in the chart review. Structured interviews with a subset of individuals to explore social supports and barriers to screening and engagement in care were conducted at the time of screening. Results The analysis included 515 women (median age, 36 years). Cytologic screening showed concern for neoplastic changes in 0.83%; half resulted in biopsy-proven cervical intraepithelial neoplasia. An additional 9.9% showed severe inflammation. The rate of loss to follow–up was 11.3%. All losses to follow-up occurred for severe inflammation, not for cervical intraepithelial neoplasia. Historical data showed that 73% of the cohort had previously been screened and had high levels of loss to follow-up (57.4%). Qualitative interviews revealed factors that promoted loss to follow-up; these included cost, lack of social supports, transportation, distrust in public facilities, long turn-around times, and failure to return test results or offer follow-up treatments. Conclusions Taken together, these quantitative and qualitative results highlight the need for cervical cancer screening programs in Guatemala to improve uptake of screening services by eligible women and to improve follow-up after a first abnormal screen.

Patient Navigation and Access to Cancer Care in Guatemala

Cancer epidemiology in Guatemala is an emerging field. Although one hospital-based cancer registry has existed for years, recent efforts to develop a population-based cancer registry in Guatemala City for pediatric and adult cancers would make population data available for the first time.2 Despite these limitations, in 2013 it was estimated that there were approximately 13,000 incident cases of cancer each year, the most common of which were cancers of the stomach, prostate, and cervix.3 For the majority of the adult population without private insurance or social security, the primary cancer referral centers in Guatemala are two large public referral hospitals (Roosevelt and San Juan de Dios) and the private, not-for-profit Instituto de Cancerología (National Cancer Institute [INCAN]), all in Guatemala City. Most elements of care at Roosevelt and San Juan de Dios are free of charge, and the Guatemalan government partially subsidizes cancer care for public-sector patients at INCAN. However, standard medications are sometimes unavailable, radiation therapy infrastructure is insufficient, and direct costs incurred by patients still can be significant.4