Warren G. Thompson

Web-based learning in residents' continuity clinics: a randomized, controlled trial.

Purpose To determine whether internal medicine residents prefer learning from Web-based (WB) modules or printed material, and to compare the effect of these teaching formats on knowledge. Method The authors conducted a randomized, controlled, crossover study in the internal medicine resident continuity clinics of the Mayo School of Graduate Medical Education during the 2002–03 academic year. Participants studied two topics of ambulatory medicine using WB modules and two topics using paper practice guidelines in randomly assigned sequences. Primary outcomes were format preference (assessed by an end-of-course questionnaire) and score changes from pre- to postintervention tests of knowledge. Results A total of 109 consented and 75 (69%) completed the postintervention test. Fifty-seven of 73 (78% “95% CI, 67–86%”) preferred the WB format (p < .001). Test scores improved for both formats (67.7% to 75.0% for WB, 66.0% to 73.3% for paper), but score change was not different between formats both before (p = .718) and after (p = .080) adjusting for topic, clinic site, study group, postgraduate year, and gender. Residents spent less time on WB modules (mean = 47 ± 26 minutes) than paper (mean = 59 ± 35, p = .024). Difficulties with passwords limited their use of WB modules for 71% (59–80%) of residents. Conclusion No difference was found between WB and paper-based formats in knowledge-test score change, but residents preferred learning with WB modules and spent less time doing so. Passwords appeared to impede use of WB modules. WB learning is effective, well accepted, and efficient. Research should focus on aspects of WB instruction that will enhance its power as a learning tool and better define its role in specific settings.

Effects of Resistance versus Aerobic Training on Coronary Artery Disease Risk Factors

Individuals exhibiting “the metabolic syndrome” have multiple coronary artery disease risk factors, including insulin resistance, hyperlipidemia, hypertension, and android obesity. We performed a randomized trial to compare the effects of aerobic and resistance training regimens on coronary risk factors. Twenty-six volunteers who exhibited android obesity and at least one other risk factor for coronary artery disease were randomized to aerobic or resistance training groups. Body mass index, waist-to-hip ratio, glucose, insulin, body composition, 24-hr urinary albumin, fibrinogen, blood pressure, and lipid profile were measured at baseline and after 10 weeks of exercise training. Both groups showed a significant reduction in waist-to-hip ratio and the resistance training group also showed a reduction in total body fat. There was no significant change in mean arterial blood pressure in either group. Fasting plasma glucose, insulin, total cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides were unchanged in both groups. High-density lipoprotein (HDL) cholesterol increased (13%) with aerobic training only. Plasma fibrinogen was increased (28% and 34%, P < 0.02) in both groups and both groups showed a significant decrease (34% and 28%, P < 0.03) in microalbuminuria after their respective training regimen. In conclusion, resistance training was effective in improving body composition of middle-aged obese sedentary males. Only aerobic training was effective in raising HDL cholesterol. More studies are warranted to assess the effects of exercise on plasma fibrinogen and microalbuminuria.

Diagnosis of Obesity by Primary Care Physicians and Impact on Obesity Management

OBJECTIVE To evaluate whether primary care physicians document obesity as a diagnosis and formulate a management plan. PATIENTS AND METHODS The Mayo Clinic primary care database was used to identify general medical examinations performed from November 1, 2004, to October 31, 2005, in a primary care clinic for obese patients (body mass index [BMI] equals 30). Data on demographic variables, BMI, comorbidities, documentation of obesity, and obesity management strategy were obtained through the database. Multivariate logistic regression analyses were conducted to estimate multivariate odds ratios (ORs) and 95 percent confidence intervals (CIs). RESULTS A total of 9827 patients were seen for a general medical examination. Of the 2543 obese patients, 505 (19.9 percent) had a diagnosis of obesity documented, and 574 (22.6 percent) had an obesity management plan documented. Older patients (OR, 0.97 per year; 95 percent CI, 0.96-0.98) and men (OR, 0.60; 95% CI, 0.47-0.76) were significantly less likely to be diagnosed as having obesity, whereas those with a BMI greater than 35 (OR, 2.54; 95 percent CI, 2.10-3.16), diabetes mellitus (OR, 1.40; 95 percent CI, 1.09-1.78), and obstructive sleep apnea (OR, 2.34; 95 percent CI, 1.79 to 3.07) were significantly more likely to have the diagnosis made. Staff physicians were less likely than residents to document obesity as a diagnosis (OR, 0.55; 95 percent CI, 0.44 to 0.69). Diagnosis of obesity was the strongest predictor of formulation of an obesity plan (OR, 2.39; 95 percent CI, 1.90 to 3.02). CONCLUSION Most obese patients did not have a diagnosis of obesity or an obesity management plan made by their primary care physician. Diagnosis of obesity results in a higher chance of formulation of an obesity plan.

Impact of Self-Assessment Questions and Learning Styles in Web-Based Learning: A Randomized, Controlled, Crossover Trial

Purpose To determine the effect of self-assessment questions on learners’ knowledge and format preference in a Web-based course, and investigate associations between learning styles and outcomes. Method The authors conducted a randomized, controlled, crossover trial in the continuity clinics of the Mayo-Rochester internal medicine residency program during the 2003–04 academic year. Case-based self-assessment questions were added to Web-based modules covering topics in ambulatory internal medicine. Participants completed two modules with questions and two modules without questions, with sequence randomly assigned. Outcomes included knowledge assessed after each module, format preference, and learning style assessed using the Index of Learning Styles. Results A total of 121 of 146 residents (83%) consented. Residents had higher test scores when using the question format (mean ± standard error, 78.9% ± 1.0) than when using the standard format (76.2% ± 1.0, p = .006). Residents preferring the question format scored higher (79.7% ± 1.1) than those preferring standard (69.5% ± 2.3, p < .001). Learning styles did not affect scores except that visual-verbal “intermediate” learners (80.6% ± 1.4) and visual learners (77.5% ± 1.3) did better than verbal learners (70.9% ± 3.0, p = .003 and p = .033, respectively). Sixty-five of 78 residents (83.3%, 95% CI 73.2–90.8%) preferred the question format. Learning styles were not associated with preference (p > .384). Although the question format took longer than the standard format (60.4 ± 3.6 versus 44.3 ± 3.3 minutes, p < .001), 55 of 77 residents (71.4%, 60.0–81.2%) reported that it was more efficient. Conclusions Instructional methods that actively engage learners improve learning outcomes. These findings hold implications for both Web-based learning and “traditional” educational activities. Future research, in both Web-based learning and other teaching modalities, should focus on further defining the effectiveness of selected instructional methods in specific learning contexts.

Feasibility of a walking workstation to increase daily walking

Objective: The number of calories expended in the workplace has declined significantly in the past 75 years. A walking workstation that allows workers to walk while they work has the potential to increase caloric expenditure. We evaluated whether employees can and will use walking workstations while performing their jobs. Methods and procedures: We studied nurses, clinical assistants, secretaries and appointment secretaries using the StepWatch Activity Monitor System (which accurately measures steps taken at slow speeds) while performing their job functions in their usual fashion and while using the walking workstation. Results: Subjects increased the number of steps taken during the workday by 2000 steps per day (p<0.05). This was equivalent to an increase in caloric expenditure of 100 kcal/day. Subjects reported that they enjoyed using the workstation, that it could be used in the actual work arena and that, if available, they would use it. Discussion: Walking workstations have the potential for promoting physical activity and facilitating weight loss. Several subjects in this study expended more than 200 extra calories daily using such a system. Further trials are indicated.

Evaluating evaluation: assessment of the American Board of Internal Medicine Resident Evaluation Form.

The American Board of Internal Medicine suggests use of a standard form to rate residents on nine dimensions (such as clinical judgment and overall clinical competence) on a scale of 1 to 9. The authors examined the psychometric evidence for reliability and validity of 1,039 ratings of 85 residents by 135 attendings in a single internal medicine residency program. Of these ratings, 95.6% were from 6 to 9. Factor analysis revealed that high correlations among the nine dimensions (r ranged from 0.72 to 0.92) resulted from a single global factor accounting for 86% of the variance. The study also examined whether the form reliably distinguishes among residents scoring between 6 and 9. Agreement among attendings rating the same individual was weak (average reliability=0.64, by the method of James). The rating method fails to discriminate dimensions of clinical care and has low reliability for distinguishing among competent residents.

Treatment of obesity

For primary care physicians, obesity is one of the most challenging problems confronted in office practice. The disorder is Increasing in prevalence despite the efforts of both patients and physicians. Treatment requires a multimodality approach that addresses diet, physical activity, and behavioral issues. Medication and surgical approaches may be appropriate as well. This review outlines the evidence for each approach, suggests how primary care physicians can best help obese patients, and provides practical tips for weight loss.

Productivity of transcriptionists using a treadmill desk.

OBJECTIVE Time spent sitting increases all-cause mortality. Sedentary occupations are a major contributor to the obesity epidemic. A treadmill desk offers the potential to increase activity while working; however, it is important to make sure that productivity does not decline. The purpose of this study is to evaluate productivity while using a treadmill desk. PARTICIPANTS Eleven experienced medical transcriptionists participated in the study. METHODS Transcriptionists were given 4 hours training in the use of a treadmill desk. They were asked to transcribe tapes for 8 hours both while sitting and while using the treadmill desk. Speed and accuracy of transcription were compared as were the average expended calories per hour. RESULTS The accuracy of transcription did not differ between sitting and walking transcriptions. The speed of transcription was 16% slower while walking than while sitting (p < 0.001). The transcriptionists expended 100 calories per hour more when they transcribed while walking than when they transcribed while sitting (p < 0.001). CONCLUSION The treadmill desk offers a way to reduce sedentariness in the workplace and has potential to reduce employee obesity and health care costs. However, more than 4 hours of training will be necessary to prevent a significant drop in employee productivity.

''Go4Life'' exercise counseling, accelerometer feedback, and activity levels in older people §

Older people are more sedentary than other age groups. We sought to determine if providing an accelerometer with feedback about activity and counseling older subjects using Go4Life educational material would increase activity levels. Participants were recruited from independent living areas within assisted living facilities and the general public in the Rochester, MN area. 49 persons aged 65-95 (79.5±7.0 years) who were ambulatory but sedentary and overweight participated in this randomized controlled crossover trial for one year. After a baseline period of 2 weeks, group 1 received an accelerometer and counseling using Go4Life educational material (www.Go4Life.nia.nih.gov) for 24 weeks and accelerometer alone for the next 24 weeks. Group 2 had no intervention for the first 24 weeks and then received an accelerometer and Go4Life based counseling for 24 weeks. There were no significant baseline differences between the two groups. The intervention was not associated with a significant change in activity, body weight, % body fat, or blood parameters (p>0.05). Older (80-93) subjects were less active than younger (65-79) subjects (p=0.003). Over the course of the 48 week study, an increase in activity level was associated with a decline in % body fat (p=0.008). Increasing activity levels benefits older patients. However, providing an accelerometer and a Go4Life based exercise counseling program did not result in a 15% improvement in activity levels in this elderly population. Alternate approaches to exercise counseling may be needed in elderly people of this age range.

A Summary and Critical Assessment of the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Disease Risk in Adults: Filling the Gaps

The American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines has recently released the new cholesterol treatment guideline. This update was based on a systematic review of the evidence and replaces the previous guidelines from 2002 that were widely accepted and implemented in clinical practice. The new cholesterol treatment guideline emphasizes matching the intensity of statin treatment to the level of atherosclerotic cardiovascular disease (ASCVD) risk and replaces the old paradigm of pursuing low-density lipoprotein cholesterol targets. The new guideline also emphasizes the primacy of the evidence base for statin therapy for ASCVD risk reduction and lists several patient groups that will not benefit from statin treatment despite their high cardiovascular risk, such as those with heart failure (New York Heart Association class II-IV) and patients undergoing hemodialysis. The guideline has been received with mixed reviews and significant controversy. Because of the evidence-based nature of the guideline, there is room for several questions and uncertainties on when and how to use lipid-lowering therapy in clinical practice. The goal of the Mayo Clinic Task Force in the assessment, interpretation, and expansion of the ACC/AHA cholesterol treatment guideline is to address gaps in information and some of the controversial aspects of the newly released cholesterol management guideline using additional sources of evidence and expert opinion as needed to guide clinicians on key aspects of ASCVD risk reduction.