Linda N. Meurer

Determinants of primary care specialty choice: a non-statistical meta-analysis of the literature

This paper analyzes and synthesizes the literature on primary care specialty choice from 1987 through 1993. To improve the validity and usefulness of the conclusions drawn from the literature, the authors developed a model of medical student specialty choice to guide the synthesis, and used only high-quality research (a final total of 73 articles). They found that students predominantly enter medical school with a preference for primary care careers, but that this preference diminishes over time (particularly over the clinical clerkship years). Student characteristics associated with primary care career choice are: being female, older, and married; having a broad undergraduate background; having non-physician parents; having relatively low income expectations; being interested in diverse patients and health problems; and having less interest in prestige, high technology, and surgery. Other traits, such as value orientation, personality, or life situation, yet to be reliably measured, may actually be responsible for some of these associations. Two curricular experiences are associated with increases in the numbers of students choosing primary care: required family practice clerkships and longitudinal primary care experiences. Overall, the number of required weeks in family practice shows the strongest association. Students are influenced by the cultures of the institutions in which they train, and an important factor in this influence is the relative representation of academically credible, full-time primary care faculty within each institutions governance and everyday operation. In turn, the institutional culture and faculty composition are largely determined by each schools mission and funding sources–explaining, perhaps, the strong and consistent association frequently found between public schools and a greater output of primary care physicians. Factors that do not influence primary care specialty choice include early exposure to family practice faculty or to family practitioners in their own clinics, having a high family medicine faculty-to-student ratio, and student debt level, unless exceptionally high. Also, students view a lack of understanding of the specialties as a major impediment to their career decisions, and it appears they acquire distorted images of the primary care specialties as they learn within major academic settings. Strikingly few schools produce a majority of primary care graduates who enter family practice, general internal medicine, or general practice residencies or who actually practice as generalists. Even specially designed tracks seldom produce more than 60% primary care graduates. Twelve recommendations for strategies to increase the proportion of primary care physicians are provided.

A systematic approach to conducting a non-statistical meta-analysis of research literature

Literature analyses and syntheses are becoming increasingly important as a means of periodically bringing coherence to a research area, contributing new knowledge revealed by integrating single studies, and quickly informing scientists of the state of the field. As a result, there is a need for approaches that can provide replicable, reliable, and trustworthy results. Over the last decade many researchers have begun using the statistical meta-analysis approach to integrate studies. However, the single studies conducted in many areas are not of the type amenable to statistical meta-analysis but are more appropriate for non-statistical analysis and synthesis. The present paper describes (1) a rigorous approach to conducting a non-statistical meta-analysis of research literature and (2) an example of how this approach was applied to the literature of determinants of primary care specialty choice published between 1987 and 1993. This approach includes model development, literature retrieval, literature coding, rating references for quality, annotating high-quality references, and synthesizing only the subset of the literature found of sufficient quality to be considered. Also, the basic results of each included study are reported in the synthesis so that readers have before them all the “data points” used in the synthesis. Thus, readers can draw their own interpretations without having to re-collect the data, just as they would be able to do in any single study that presents original data as well as conclusions and discussion.

Influence of medical school curriculum on primary care specialty choice: analysis and synthesis of the literature.

There is a growing consensus that the proportion of primary care physicians in the United States is inadequate to meet health care needs. Many graduating medical students continue to choose to subspecialize. The literature on curriculum and specialty choice is fraught with confounders and a lack of randomized trials, and recommendations for strategies to increase the production of generalists have not been based on clear evidence that the interventions will be effective, thus making it difficult for medical schools to react responsibly to these recommendations. To assist educators and policymakers in their efforts to produce more generalists, the author critically reviewed the literature on curriculum and primary care specialty choice from 1982 through April 1993. A literature search was conducted using the MEDLINE, Educational Resources Information Center, and PsychInfo databases. Of more than 150 studies found in the search, 31 were determined to be relevant and to meet inclusion criteria. The results confirm that the determinants of specialty choice are multifactorial and that there are many weaknesses in the published literature, making interpretation difficult. Important trends did emerge, however, providing direction for intervention and recommendations for further investigation. The evidence suggests that three types of curricular experiences may increase interest in primary care: third-year required family medicine clerkships (especially those that are six, rather than four, weeks long), continuity experiences in primary care settings, and, most promising of all, primary care tracks.

Diabetes and Hypertension Prevalence in Homeless Adults in the United States: A Systematic Review and Meta-Analysis

We estimated hypertension and diabetes prevalence among US homeless adults compared with the general population, and investigated prevalence trends. We systematically searched 5 databases for published studies (1980-2014) that included hypertension or diabetes prevalence for US homeless adults, pooled disease prevalence, and explored heterogeneity sources. We used the National Health Interview Survey for comparison. We included data from 97366 homeless adults. The pooled prevalence of self-reported hypertension was 27.0% (95% confidence interval=23.8%, 29.9%; n=43 studies) and of diabetes was 8.0% (95% confidence interval=6.8%, 9.2%; n=39 studies). We found no difference in hypertension or diabetes prevalence between the homeless and general population. Additional health care and housing resources are needed to meet the significant, growing burden of chronic disease in the homeless population.

Salud de la Mujer: Using Fotonovelas to Increase Health Literacy Among Latinas

Background: There is an identified need for health literacy strategies to be culturally sensitive and linguistically appropriate.Objectives: The goal of our community-based participatory research (CBPR) project related to health and nutrition is to demonstrate that active community involvement in the creation of health education fotonovelas that are relevant to culture, ethnicity, gender, social class, and language can increase the health literacy of women in a disadvantaged community.Methods: We recruited 12 women to take part in our pilot fotonovela intervention about healthy eating and nutrition. Pre- and post-test assessments of knowledge, attitudes, and behavior around nutrition were given at baseline and will be collected after the completion of the project.Results: We hypothesize that post-test assessments of our participants will reveal increased nutrition knowledge as well as positive changes in attitudes and behavior toward healthy eating.Conclusions: We believe that our fotonovelas will represent experiences of community members and encourage good health practices by increasing knowledge and cooperation among community members.

Excess Mortality Caused by Medical Injury

PURPOSE We wanted to estimate excess risk of in-hospital mortality associated with medical injuries identified using an injury surveillance system, after controlling for risk of death resulting from comorbidities. METHODS The Wisconsin Medical Injuries Prevention Program (WMIPP) screening criteria were used to identify medical injuries, defined as “any untoward harm associated with a therapeutic or diagnostic healthcare intervention,” among discharge diagnoses for all 562,317 patients discharged from 134 acute care hospitals in Wisconsin in 2002. We then derived estimates for crude and adjusted relative risk of in-hospital mortality associated with the presence of a medical injury diagnosis. Logistic regression adjusted for baseline risk of mortality using a comorbidity index, age, sex, Diagnosis Related Groups, hospital characteristics, and clustering within hospital. RESULTS There were 77,666 discharges that met WMIPP criteria for at least 1 medical injury (13.8%). Crude risk ratios for death ranged from 1.27 to 2.4 for those with medical injuries within 1 of 4 categories: drugs/biologics; devices, implants, and grafts; procedures; and radiation. After adjustment, estimates of excess mortality decreased, and significance persisted only for injuries related to procedures (39%; 95% confidence interval [CI], 28%–52%) and devices, implants, and grafts (16%; 95% CI, 3%–30%). CONCLUSIONS Estimates of excess mortality that do not account for baseline mortality risk may be exaggerated. Findings have implications for the care family physicians provide in the hospital and for the advice they give their patients who are concerned about the risks of hospitalization.

Meeting the Scholarly Project Requirement—Application of Scholarship Criteria beyond Research

Maintaining an environment of scholarly inquiry is highlighted in the Accreditation Council for Graduate Medical Education’s (ACGME) common program requirements. Faculty and trainees are expected to participate in scholarly activities, and present those findings to peers for review. Faculty and residents/fellows often lack a conceptual yet practical framework for guiding scholarly activities when they occur in the context of health care systems, clinical practice, quality improvement, education, or community partnerships.

Integrating information technology training into an established faculty development program.

No abstract available.

Needs Assessment for Creating a Patient-Centered, Community-Engaged Health Program for Homeless Pregnant Women

Purpose Women who experience homelessness during pregnancy have poorer birth outcomes than the general population. This exploratory research describes the needs assessment of homeless women currently living at a shelter in Milwaukee, Wisconsin, to identify unmet needs related to maternal and infant perinatal health as the first step in designing a mutually beneficial patient-centered service-learning program for medical students to address these needs. Methods Two 1-hour focus groups were held at a shelter for women who are homeless and/or victims of domestic violence. A total of 13 women participated in each session; four medical students and a physician served as facilitators and scribes at each session. The facilitators alternated asking predetermined open- and close-ended questions, followed by discussion among participants. Questions elicited experiences during pregnancy, what went well, what women living in the shelter struggled with, and what support they wished for but did not have. Scribes captured the conversation through hand-written notes and used content analysis in order of frequency. Results Thirteen themes were identified. The 5 most frequently identified themes were a need for pregnancy education, access/transportation, baby care, advocacy, and material necessities. Participating shelter residents and the medical students expressed interest in working with one another and forming a long-term partnership with the shelter. Conclusions Results of this needs assessment will inform the creation of a new shelter-based medical education program that will meet homeless womens needs while preparing medical students for patient-centered, community-responsive care.