Michael J. Yedidia

Realizing the promise of breast cancer screening: clinical follow-up after abnormal screening among Black women

BACKGROUND Delayed or incomplete follow-up after abnormal screening results may compromise the effectiveness of breast cancer screening programs, particularly in medically underserved and minority populations. This study examined the role of socioeconomic status, breast cancer risk factors, health care system barriers, and patient cognitive-attitudinal factors in the timing of diagnostic resolution after abnormal breast cancer screening exams among Black women receiving breast cancer screening at three New York city clinics. METHODS We identified 184 Black women as having an abnormal mammogram or clinical breast exam requiring immediate follow-up and they were interviewed and their medical records examined. Bivariate and multivariate logistic regression analyses were used to assess the association between patient and health care system factors and diagnostic resolution within 3 months of the abnormal finding. RESULTS Within 3 months, 39% of women were without diagnostic resolution and 28% within 6 months. Neither socioeconomic status nor system barriers were associated with timely diagnostic resolution. Timely resolution was associated with mammogram severity, patients asking questions (OR, 2.73; 95% CI, 1.25-5.96), or receiving next step information (OR, 2.6; 95% CI, 1.08-6.21) at the initial mammogram. Women with prior breast abnormalities were less likely to complete timely diagnostic resolution (OR, 0.42; 95% CI, 0.20-0.85), as were women with higher levels of cancer anxiety (OR, 0.50; 95% CI, 0.27-0.92). CONCLUSIONS Interventions that address a womans prior experience with abnormal findings and improve patient/provider communication may improve timely and appropriate follow-up.

The Emotional Consequences of False Positive Mammography: African-American Women's Reactions in Their Own Words

ABSTRACT High false positive rates associated with screening for breast cancer in the United States have an unintended psychological consequence for women (Lerman et al., 1991) that has raised concerns in recent years (Sox, 1998). This study uses inductive qualitative analysis of open-ended interviews with 45 African American women living in New York City who were part of a larger study of women and their experiences after receiving an abnormal mammogram. Themes resulting from the analyses included: inadequate provider-patient communication, anxieties exacerbated by waiting and wondering, and fears of iatrogenic effects of follow-up tests such as biopsies and repeat mammograms. While more research is needed on message-framing strategies for women entering mammographic testing and follow-up, modest changes in service de livery such as improved medical communication can help to alleviate fears and enhance trust.

Learners as teachers : the conflicting roles of medical residents

OBJECTIVE: To explore the impact of internal medicine residents’ roles as learners, teachers, and physicians on their performance in teaching and supervising interns; to generate insights for educational policy and research.DESIGN: Qualitative analysis of in-depth, semistructured, recorded interviews with a cohort of second-postgraduate-year (PGY-2) residents. Questions elicited their accounts of differences in the learning process between the first and second residency years, their responses to situations in which they lacked sufficient clinical knowledge, their views of their supervisory relationship with interns, and their assessments of changes in their role in patient care since their internships. Transcripts were independently analyzed by the interdisciplinary team of authors.SETTING: New York University/Bellevue Hospital Center’s internal medicine residency (New York City), a highly competitive program in a major public hospital and a university medical center, emphasizing housestaff autonomy and self-reliance.PARTICIPANTS: A cohort of 18 of 21 medical residents at Bellevue Hospital Center during the last rotation of PGY-2.RESULTS: Intense conflicts confound residents’ roles as teachers. These conflicts fall into three categories: 1) as learners, residents’ own needs frequently coincide with those of interns in ways that may undermine their teaching—they are expected to nurture others despite their own considerable needs for emotional support, teach material that they barely grasp, and exert authority while feeling ignorant; 2) as team leaders, residents must ensure that interns get the hospital’s work done, sometimes at the expense of teaching them; and 3) as clinicians, residents’ first priority is to address the medical needs of patients—the learning needs of interns are secondary.CONCLUSION: Second-year internal medicine residents experience conflicts inherent in their simultaneous commitment to learning, teaching, and service that may undermine both their effectiveness in supervising interns and their own professional development. Potential remedies are to restructure residency programs so as to equip residents with training and support for their role as teachers, reduce the tension between training and service by delegating tasks to nonphysician personnel, and provide graded responsibility to house-staff as physicians and teachers.

Doctors as workers

Objective: To study residents’ perceptions of their responsibility for patients, the quality of patient care, and their learning experiences in light of new work-hour regulations.Design: Inductive analysis of in-depth, semistructured, recorded interviews with a cohort of interns in internal medicine in the last month of their first postgraduate year. Questions were grounded in an examination of issues related to going off duty and delegating tasks to colleagues. Transcripts were independently analyzed by an interdisciplinary team.Setting: New York University/Bellevue Hospital Center’s residency program in internal medicine (in New York City).Participants: A cohort of 21 of a possible 24 interns in medicine on rotation at Bellevue Hospital Center.Results: The interviews revealed: 1) intense concern harbored by interns for their patients with resulting difficulty in maintaining realistic boundaries between work and personal lives; 2) an open-ended workday and competing considerations confronting interns when deciding to leave the hospital — including concerns about leaving patients at critical junctures in their care, confidence in the colleague to whom they were signing out, regard for the workload of this colleague, and uneasiness about the educational consequences; 3) deterrents to acknowledging and acting on one’s limits in performing medical work; and 4) a recurrent conflict between delegating responsibility and retaining control over patient care.Conclusion: Values traditionally learned in training emphasize autonomy and individual accountability. They may conflict with the shared decision making and collective responsibility among peers necessitated by work-hour limitations and associated changes in program structure.

Improving data accuracy of commercial food outlet databases.

Purpose. Assessing food environments often requires using commercially available data. Disparate methods used for classifying food outlets in these databases call for creating a classification approach using common definitions. A systematic strategy for reclassifying food stores and restaurants, as they appear in commercial databases, into categories that differentiate the availability of healthy options is described here. Design and Setting. Commercially available data on food outlets including names, addresses, North American Industry Classification System codes, and associated characteristics was obtained for five New Jersey communities. Analysis. A reclassification methodology was developed using criteria and definitions from the literature to categorize food outlets based on availability of healthy options. Information in the database was supplemented by systematic Internet and key word searches, and from phone calls to food outlets. Results. The methodology resulted in 622 supermarket/grocery stores, 183 convenience stores, and 148 specialty stores in the original data to be reclassified into 58 supermarkets, 30 grocery stores, 692 convenience stores, and 115 specialty stores. Outlets from the original list of 1485 full-service restaurants and 506 limited-service restaurants were reclassified as 563 full-service restaurants and 1247 limited-service restaurants. Reclassification resulted in less than one-seventh the number of supermarkets and grocery stores, more than three times the number of convenience stores, and twice as many limited-service restaurants—a much less healthy profile than the one generated by using exclusively the commercial databases. Conclusion. An explicit and replicable strategy is proposed for reclassifying food outlets in commercial databases into categories that differentiate on the basis of healthy food availability. The intent is to contribute towards building a consensus among researchers on definitions used in public health research for characterizing different types of food outlets.

Association of Faculty Perceptions of Work–Life With Emotional Exhaustion and Intent to Leave Academic Nursing: Report on a National Survey of Nurse Faculty

The current and projected nurse faculty shortage threatens the capacity to educate sufficient numbers of nurses for meeting demand. As part of an initiative to foster strategies for expanding educational capacity, a survey of a nationally representative sample of 3,120 full-time nurse faculty members in 269 schools and programs that offered at least one prelicensure degree program was conducted. Nearly 4 of 10 participants reported high levels of emotional exhaustion, and one third expressed an intent to leave academic nursing within 5 years. Major contributors to burnout were dissatisfaction with workload and perceived inflexibility to balance work and family life. Intent to leave was explained not only by age but by several potentially modifiable aspects of work, including dissatisfaction with workload, salary, and availability of teaching support. Preparing sufficient numbers of nurses to meet future health needs will require addressing those aspects of work-life that undermine faculty teaching capacity.

The relative contribution of layers of the Social Ecological Model to childhood obesity

OBJECTIVE The Social Ecological Model (SEM) has been used to describe the aetiology of childhood obesity and to develop a framework for prevention. The current paper applies the SEM to data collected at multiple levels, representing different layers of the SEM, and examines the unique and relative contribution of each layer to childrens weight status. DESIGN Cross-sectional survey of randomly selected households with children living in low-income diverse communities. SETTING A telephone survey conducted in 2009-2010 collected information on parental perceptions of their neighbourhoods, and household, parent and child demographic characteristics. Parents provided measured height and weight data for their children. Geocoded data were used to calculate proximity of a childs residence to food and physical activity outlets. SUBJECTS Analysis based on 560 children whose parents participated in the survey and provided measured heights and weights. RESULTS Multiple logistic regression models were estimated to determine the joint contribution of elements within each layer of the SEM as well as the relative contribution of each layer. Layers of the SEM representing parental perceptions of their neighbourhoods, parent demographics and neighbourhood characteristics made the strongest contributions to predicting whether a child was overweight or obese. Layers of the SEM representing food and physical activity environments made smaller, but still significant, contributions to predicting childrens weight status. CONCLUSIONS The approach used herein supports using the SEM for predicting child weight status and uncovers some of the most promising domains and strategies for childhood obesity prevention that can be used for designing interventions.

Challenges to Effective Medical School Leadership: Perspectives of 22 Current and Former Deans.

A persistent decline in the average tenure of medical school deans and a concern about the implications for medical school leadership led the Council of Deans of the Association of American Medical Colleges to commission the 1996-1997 study reported here. The author conducted open-ended interviews with a broad spectrum of 22 current and former deans, selected to achieve an appropriate distribution with regard to key characteristics of their schools and to assure the relevance of the findings to a broad range of settings. His in-depth analysis of the transcribed interviews, using standard qualitative techniques, was designed to illuminate the challenges confronting deans and suggest strategies to address them. The respondents consistently identified two forces in the health care environment that had had profound impacts on their role as deans and that frequently posed conflicts between the clinical and educational enterprises: a decline in the resources available to medical schools following an era of abundance, and unprecedented competition in the clinical arena. Analysis of their accounts of the problems they encountered in managing in this changed environment revealed several underlying sources: imbalance between the breadth of their responsibilities and their authority to manage; lack of clarity in the deans mandate; inadequate institutional support for pursuing the missions of the school; insufficient attention to identifying requisite expertise and abilities for effective performance on the job as dean; and an anachronistic search process. The respondents offered numerous recommendations for addressing these problems, reflecting optimism about the prospects for purposeful change. While medical schools have unique features among educational institutions, the author concludes that the challenges that deans face and the strategies proposed for addressing them promise to have substantial relevance for academic leadership in other settings.

A closer examination of the relationship between children's weight status and the food and physical activity environment.

OBJECTIVES Conflicting findings on associations between food and physical activity (PA) environments and childrens weight status demand attention in order to inform effective interventions. We assess relationships between the food and PA environments in inner-city neighborhoods and childrens weight status and address sources of conflicting results of prior research. METHODS Weight status of children ages 3-18 was assessed using parent-measured heights and weights. Data were collected from 702 children living in four low-income cities in New Jersey between 2009 and 2010. Proximity of a childs residence to a variety of food and PA outlets was measured in multiple ways using geo-coded data. Multivariate analyses assessed the association between measures of proximity and weight status. RESULTS Significant associations were observed between childrens weight status and proximity to convenience stores in the 1/4 mile radius (OR = 1.9) and with presence of a large park in the 1/2 mile radius (OR = 0.41). No associations were observed for other types of food and PA outlets. CONCLUSIONS Specific aspects of the food and PA environments are predictors of overweight and obese status among children, but the relationships and their detection are dependent upon aspects of the geospatial landscape of each community.

The impact of implementing a chronic care residency training initiative on asthma outcomes.

Purpose To examine the impact of a chronic care residency training intervention on continuity clinic patients’ asthma-related emergency department use and primary care residents’ application of key elements of the Chronic Care Model (CCM). Method In 2002 and 2003, the authors conducted a pre- and posttraining survey of 41 intervention residents at Maine Medical Center to assess residents’ implementation of the CCM. The change in implementation for intervention residents was compared with that of 77 primary care residents not receiving CCM training. Asthma-related emergency department (ED) use by 441 patients cared for by intervention residents was compared with that of other asthma patients at Maine Medical Center using hospital billing records. Results At baseline, residents in both groups reported sporadic application of key elements of the CCM. At posttest, Maine Medical Center residents reported significantly greater increases in CCM implementation than the comparison group for 4 out of the 12 items. The greatest increases were in residents’ access to asthma guidelines, the proportion of patients receiving written asthma management plans, and residents’ access to information on community asthma programs. The number of asthma-related ED visits dropped significantly among patients treated by intervention residents (pediatric patients 42%, adults 44%). There was a slight increase in asthma ED use for nonintervention pediatric patients at the hospital (8%) and a very small decrease for adults (3%). Conclusions Chronic care training programs for residents may influence the health outcomes of patients treated in their continuity clinics while simultaneously offering an important educational experience in an underemphasized area of medicine.