BACKGROUND: The factors influencing medication adherence have not been fully elucidated. Inadequate health literacy skills may impair comprehension of medical care instructions, and thereby reduce medication adherence.
OBJECTIVES: To examine the relationship between health literacy and medication refill adherence among Medicare managed care enrollees with cardiovascular-related conditions.
RESEARCH DESIGN: Prospective cohort study.
SUBJECTS: New Medicare enrollees from 4 managed care plans who completed an in-person survey and were identified through administrative data as having coronary heart disease, hypertension, diabetes mellitus, and/or hyperlipidemia (n=1,549).
MEASURES: Health literacy was determined using the short form of the Test of Functional Health Literacy in Adults (S-TOFHLA). Prospective administrative data were used to calculate the cumulative medication gap (CMG), a valid measure of medication refill adherence, over a 1-year period. Low adherence was defined as CMG≥20%.
RESULTS: Overall, 40% of the enrollees had low refill adherence. Bivariate analyses indicated that health literacy, race/ethnicity, education, and regimen complexity were each related to medication refill adherence (P<.05). In unadjusted analysis, those with inadequate health literacy skills had increased odds (odds ratio [OR]=1.37, 95% confidence interval [CI]: 1.08 to 1.74) of low refill adherence compared with those with adequate health literacy skills. However, the OR for inadequate health literacy and low refill adherence was not statistically significant in multivariate analyses (OR=1.23, 95% CI: 0.92 to 1.64).
CONCLUSIONS: The present study suggests, but did not conclusively demonstrate, that low health literacy predicts poor refill adherence. Given the prevalence of both conditions, future research should continue to examine this important potential association.
OBJECTIVES: To review systematically the evidence about what factors influence the decision to choose or not choose a career in academic medicine.
DESIGN: A systematic review of relevant literature from 1990 to May 2005.
DATA SOURCES: Searches of The Cochrane Library, Medline (using Ovid and PubMed) from 1990 to May 2005, and EMBASE from 1990 to May 2005 were completed to identify relevant studies that explored the influential factors. Additional articles were identified from searching the bibliographies of retrieved articles.
SELECTION OF STUDIES: We attempted to identify studies that included residents, fellows, or staff physicians. No restrictions were placed on the study methodologies identified and all articles presenting empirical evidence were retrieved. For cohort, case-control, and cross-sectional studies, minimum inclusion criteria were the presence of defined groups, and the ability to extract relevant data. For surveys that involved case series, minimum inclusion criteria were a description of the population, and the availability of extractable data. Minimum inclusion criteria for qualitative studies were descriptions of the sampling strategy and methods.
RESULTS: The search identified 251 abstracts; 25 articles were included in this review. Completion of an MD with a graduate degree or fellowship program is associated with a career in academic medicine. Of the articles identified in this review, this finding is supported by the highest quality of evidence. Similarly, the completion of research and publication of this research in medical school and residency are associated with a career in academic medicine. The desire to teach, conduct research, and the intellectual stimulation and challenge provided in academia may also persuade people to choose this career path. The influence of a role model or a mentor was reported by physicians to impact their decision making. Trainees' interest in academic medicine wanes as they progress through their residency.
CONCLUSIONS: In order to revitalize academic medicine, we must engage trainees and retain their interest throughout their training. Research opportunities for medical students, and fellowships or graduate training can meet this challenge and influence career choice. Initiatives to stimulate and maintain interest in academic medicine should be evaluated in prospective studies across multiple sites.
CONTEXT: Traditional methods of setting curricular guidelines using experts or consensus panels may miss important areas of knowledge, skills, and attitudes that need to be addressed in the training of medical students and residents.
OBJECTIVE: To seek input from medical students and internal medicine residents (“trainees”) on their perception of their needs for training in Geriatrics.
DESIGN: Two assessment methods were used (1) focus groups with students and residents were conducted by professional facilitators and the transcripts analyzed for areas of agreement and divergence and (2) geriatric medicine experts and ward attendings were surveyed to examine training gaps raised by trainees during Geriatric Guest Attending Rounds.
RESULTS: Trainees perceived training gaps in caring for elderly patients in the areas of (1) recognizing and addressing the complex, multifactorial nature of illness; (2) setting priorities and goals for work-up and intervention; (3) communication with families and with patients with cognitive disorders; (4) assessment of a patient for discharge from the hospital and the services at different sites in which patients may receive care. They recounted feeling overwhelmed by complex patients and social situations while acknowledging the special aspects of connecting with older patients. The gaps identified by trainees differ from and complement the curriculum guidelines set by expert recommendations.
CONCLUSION: Trainees identified gaps in skills and knowledge leading to trainee frustration and potentially adverse outcomes in caring for elderly patients. Development of curriculum guidelines should include assessment of trainees' perceived learning needs.
BACKGROUND: Receipt of highly active antiretroviral therapy (HAART) differs by gender and racial/ethnic group and may reflect an effect of mood disorders.
OBJECTIVE: We examined the effects of dysthymia and major depression on HAART use by 6 groups defined by gender and race/ethnicity (white, black, Hispanic).
MAIN OUTCOME MEASURE: Self-reported HAART use in the past 6 months.
DATA SOURCE: Interview data from the HIV Cost and Services Utilization Study (HCSUS). Independent variables measured in or before the first half of 1997, and HAART use measured in the second half of 1997.
ANALYSES: Multivariate logistic regression of depression and dysthymia on HAART use by 6 patient groups.
PARTICIPANTS: One thousand nine hundred and eighty-two HIV-infected adults in HIV care in 1996 and with a CD4 count <500 in 1997.
RESULTS: Highly active antiretroviral therapy receipt was the highest for white men (68.6%) and the lowest for Hispanic women (52.7%) and black women (55.4%). Dysthymia was more prevalent in women (Hispanic, 46%; black, 27%; white, 31%) than men (Hispanic, 23%; black, 18%; white, 15%). The prevalence of major depression was greater in whites (women, 35%; men, 31%) than minorities (women, 26%; men, 21%). Compared with white men without dysthymia, the adjusted odds ratios (AORs) of HAART were significantly lower for black women (0.50 [95% confidence interval [95% CI] 0.29 to 0.87]) and Hispanic women (0.45 [95% CI 0.25, 0.79]). Among patients with depression and no dysthymia, minority women had HAART use (AOR=1.28 [95% CI 0.48 to 3.43]) similar to white men.
LIMITATIONS: Self-report data from the early era of HAART use; causation cannot be proven; mental health diagnoses may not meet full DSM IV criteria.
CONCLUSIONS: Dysthymia is highly prevalent in minority women and associated with a 50% reduction in the odds of receiving HAART. This underrecognized condition may contribute more than depression to the “gender disparity” in HAART use.
BACKGROUND: Angiotensin converting enzyme-inhibitors (ACEI) and angiotensin-II-receptor blockers (ARB) are equally efficacious in reducing mortality after MI, although the latter are far more costly. Little is known about their relative use after MI in typical care settings, and about their relative effectiveness outside the clinical trial setting.
OBJECTIVES: To assess temporal trends in the relative use of ACEI and ARB after myocardial infarction, and to test for differences in 1-year survival between users of these drug classes.
DESIGN: Retrospective closed cohort study.
PATIENTS: Medicare beneficiaries who survived >90 days after myocardial infarction, had full prescription drug coverage, and who filled a prescription for either ACEI or ARB within 90 days of myocardial infarction.
MEASUREMENTS: Relative use of ACEI versus ARB over time. Adjusted relative 1-year mortality between ACEI and ARB users.
RESULTS: Between 1995 and 2004, 14,190 patients met inclusion criteria. Mean age was 80 years, 75% were female, and 90% were white. Overall, 88% received an ACEI, and 12% an ARB, with the proportion receiving an ARB increasing from 2% (1995) to 25% (2004; P<.001). Multivariate-adjusted 1-year mortality did not differ between ARB and ACEI users (HR: 1.04; 95% confidence interval: 0.88 to 1.22). The findings were similar for new users of ACEI/ARB, and for those with preexisting heart failure.
CONCLUSIONS: ARB users had the same 1-year mortality after myocardial infarction as ACEI users in routine care. Use of more costly ARB has increased dramatically over time, to a quarter of ACEI/ARB users, despite the lack of a therapeutic advantage for most patients.
OBJECTIVE: We undertook this investigation to characterize conflict of interest (COI) policies of biomedical journals with respect to authors, peer-reviewers, and editors, and to ascertain what information about COI disclosures is publicly available.
METHODS: We performed a cross-sectional survey of a convenience sample of 135 editors of peer-reviewed biomedical journals that publish original research. We chose an international selection of general and specialty medical journals that publish in English. Selection was based on journal impact factor, and the recommendations of experts in the field. We developed and pilot tested a 3-part web-based survey. The survey included questions about the presence of specific policies for authors, peer-reviewers, and editors, specific restrictions on authors, peer-reviewers, and editors based on COI, and the public availability of these disclosures. Editors were contacted a minimum of 3 times.
RESULTS: The response rate for the survey was 91 (67%) of 135, and 85 (93%) of 91 journals reported having an author COI policy. Ten (11%) journals reported that they restrict author submissions based on COI (e.g., drug company authors' papers on their products are not accepted). While 77% report collecting COI information on all author submissions, only 57% publish all author disclosures. A minority of journals report having a specific policy on peer-reviewer 46% (42/91) or editor COI 40% (36/91); among these, 25% and 31% of journals state that they require recusal of peer-reviewers and editors if they report a COI. Only 3% of respondents publish COI disclosures of peer-reviewers, and 12% publish editor COI disclosures, while 11% and 24%, respectively, reported that this information is available upon request.
CONCLUSION: Many more journals have a policy regarding COI for authors than they do for peer-reviewers or editors. Even author COI policies are variable, depending on the type of manuscript submitted. The COI information that is collected by journals is often not published; the extent to which such “secret disclosure” may impact the integrity of the journal or the published work is not known.
BACKGROUND: Black, older, and less affluent women are less likely to receive adjuvant breast cancer therapy than their counterparts. Whereas preference contributes to disparities in other health care scenarios, it is unclear if preference explains differential rates of breast cancer care.
OBJECTIVE: To ascertain utilities from women of diverse backgrounds for the different stages of, and treatments for, breast cancer and to determine whether a treatment decision modeled from utilities is associated with socio-demographic characteristics.
PARTICIPANTS: A stratified sample (by age and race) of 156 English-speaking women over 25 years old not currently undergoing breast cancer treatment.
DESIGN AND MEASUREMENTS: We assessed utilities using standard gamble for 5 breast cancer stages, and time-tradeoff for 3 therapeutic modalities. We incorporated each subject's utilities into a Markov model to determine whether her quality-adjusted life expectancy would be maximized with chemotherapy for a hypothetical, current diagnosis of stage II breast cancer. We used logistic regression to determine whether socio-demographic variables were associated with this optimal strategy.
RESULTS: Median utilities for the 8 health states were: stage I disease, 0.91 (interquartile range 0.50 to 1.00); stage II, 0.75 (0.26 to 0.99); stage III, 0.51 (0.25 to 0.94); stage IV (estrogen receptor positive), 0.36 (0 to 0.75); stage IV (estrogen receptor negative), 0.40 (0 to 0.79); chemotherapy 0.50 (0 to 0.92); hormonal therapy 0.58 (0 to 1); and radiation therapy 0.83 (0.10 to 1). Utilities for early stage disease and treatment modalities, but not metastatic disease, varied with socio-demographic characteristics. One hundred and twenty-two of 156 subjects had utilities that maximized quality-adjusted life expectancy given stage II breast cancer with chemotherapy. Age over 50, black race, and low household income were associated with at least 5-fold lower odds of maximizing quality-adjusted life expectancy with chemotherapy, whereas women who were married or had a significant other were 4-fold more likely to maximize quality-adjusted life expectancy with chemotherapy.
CONCLUSIONS: Differences in utility for breast cancer health states may partially explain the lower rate of adjuvant therapy for black, older, and less affluent women. Further work must clarify whether these differences result from health preference alone or reflect women's perceptions of sources of disparity, such as access to care, poor communication with providers, limitations in health knowledge or in obtaining social and workplace support during therapy.
BACKGROUND: Some institutions require patients and families to give signed consent for Do Not Resuscitate (DNR) orders, especially in New York State. As this may be a barrier to discussions about DNR orders, we changed a signed consent policy to a witnessed verbal consent policy, simplified and modified the DNR order forms, and educated the staff at 1 hospital, comparing the effects with an affiliated hospital where the policy was not changed.
DESIGN: Prospective natural experiment with intervention and comparison sites.
SUBJECTS AND MEASUREMENTS: Pre- and postintervention, we surveyed house officers' confidence and attitudes, reviewed charts to assess the number of concurrent care concerns (CCCs) addressed per DNR order (e.g., limits on intubation or blood products or need for hospice), and at the intervention hospital, measured the stress levels of surrogates consenting for DNR orders using the Horowitz Impact of Event Scale. We also surveyed staff perceptions about the policy following the change.
RESULTS: At the intervention hospital, the percentage of house officers reporting low confidence in their ability to obtain consent for DNR orders declined postintervention (24% to 7%, P=.002), while there was no significant change at the comparison hospital (20% vs 15%, P=.45). Among intervention hospital house officers, there were declines in percent reporting difficulty talking to patients and families about DNR orders, but no significant changes at the comparison hospital. At the intervention hospital, the mean number of CCCs/DNR order increased (1.0 pre to 4.2 post, P<.001), but did not change significantly (1.2 pre to 1.4 post) at the comparison hospital. The mean total stress score for intervention hospital surrogates declined postintervention (23.6 to 17.3, P=.02), indicating lower stress. House officers (98%), attendings (59%), and nurses (79%) thought the new policy was better for families.
CONCLUSIONS: The policy change was well received and associated with improved house officer attitudes, more attention to patients' concurrent care concerns, and decreased surrogate stress. The results suggest that DNR orders can be made simpler and clearer, and raise questions about policies requiring signed consent for DNR orders.
OBJECTIVE: To evaluate whether training primary care clinicians in maintenance care for patients who have changed their drinking influences practice behavior.
DESIGN: We randomized 15 physician and 3 mid-level clinicians in 2 primary care offices in a 2:1 design. The 12 intervention clinicians received a total of 2 ¼ hours of training in the maintenance care of alcohol problems in remission, a booster session, study materials and chart-based prompts at eligible patients' visits. Six controls provided usual care. Screening forms in the waiting rooms identified eligible patients, defined as those who endorsed: 1 or more items on the CAGE questionnaire or that they had an alcohol problem in the past; that they have “made a change in their drinking and are trying to keep it that way”; and that they drank <15 (men) or <10 (women) drinks per week in the past month. Exit interviews with patients evaluated the clinician's actions during the visit.
RESULTS: Of the 164 patients, 62% saw intervention clinicians. Compared with patients of control clinicians, intervention patients were more likely to report that their clinician asked about their alcohol history (odds ratio, 2.8; 95% confidence interval, 1.3, 5.8). Intervention clinicians who asked about the alcohol history were more likely to assess prior and planned alcohol treatment, assist through offers for prescriptions and treatment referral, and receive higher satisfaction ratings for the visit.
CONCLUSIONS: Systemic prompts and training in the maintenance care of alcohol use disorders in remission might increase primary care clinicians' inquiries about the alcohol history as well as appropriate assessment and intervention after an initial inquiry.
BACKGROUND: While acute illness and hospitalization represent pivotal events for older persons, their contribution to recoverable cognitive dysfunction (RCD) has not been well examined.
OBJECTIVE: Our goals were to estimate the frequency and degree of RCD in an older hospitalized cohort; to examine the relationship of RCD with delirium and dementia; and to determine 1-year cognitive outcomes.
DESIGN: Prospective cohort study.
PARTICIPANTS: Four hundred and sixty patients aged ≥70 years drawn from consecutive admissions to an academic hospital.
MEASUREMENTS: Patients underwent interviews daily during hospitalization and at 1 year. The primary outcome was RCD, defined as an admission Mini-Mental State Examination (MMSE) score that improved by 3 or more points by discharge.
RESULTS: Recoverable cognitive dysfunction occurred in 179 of 460 (39%) patients, with MMSE impairment at baseline ranging from 3 to 13 points (median=5.0 points). The majority of cases were not characteristic of either delirium or dementia, as 144 of 179 (80%) cases did not meet criteria for delirium, and 133 of 164 (81%) cases did not meet criteria for dementia at baseline. In multivariable analysis controlling for baseline MMSE level, 3 factors were predictive of RCD: higher educational level, preadmission functional impairment, and higher illness severity. At 1 year, further improvement in MMSE score occurred in 38 of 92 (41%) patients with RCD. Recoverable cognitive dysfunction was independently predictive of 1-year mortality with an adjusted odds ratio of 1.82 (95% confidence interval [95% CI] 1.03 to 3.20).
CONCLUSIONS: Acute illness is accompanied by a high rate of RCD that is neither characteristic of delirium or dementia. Our observations underscore the reversible nature of this cognitive dysfunction with continued improvement over the ensuing year, and highlight the potential clinical implications of this under-recognized phenomenon.
BACKGROUND: Graduated compression stockings (GCS) are often used for deep vein thrombosis prophylaxis in nonsurgical patients, although evidence on their effectiveness is lacking in this setting.
OBJECTIVE: To determine whether prophylaxis with GCS is associated with a decrease in the rate of deep vein thrombosis in nonsurgical elderly patients.
METHODS: Using original data from 2 multicenter nonrandomized studies, we performed multivariable and propensity score analyses to determine whether prophylaxis with GCS reduced the rate of deep vein thrombosis among 1,310 postacute care patients 65 years or older. The primary outcome was proximal deep vein thrombosis detected by routine compression ultrasonography performed by registered vascular physicians.
RESULTS: Proximal deep vein thrombosis was found in 5.7% (21/371) of the GCS users and in 5.2% (49/939) of the GCS nonusers (odds ratio [OR], 1.09; 95% confidence interval [CI], 0.64–1.84). Although adjusting for propensity score eliminated all differences in baseline characteristics between users and nonusers, the OR for proximal deep vein thrombosis associated with GCS remained nonsignificant in propensity-stratified (adjusted OR, 1.11; 95% CI, 0.59–2.10) and propensity-matched (conditional OR, 0.92; 95% CI, 0.42–2.02) analysis. Similar figures were observed for distal and any deep vein thrombosis. The rates of deep vein thrombosis did not differ according to the length of stockings.
CONCLUSIONS: Prophylaxis with GCS is not associated with a lower rate of deep vein thrombosis in nonsurgical elderly patients in routine practice. Randomized studies are needed to assess the efficacy of GCS when properly used in this setting.
BACKGROUND: Little is known about how interventions motivate individuals to change multiple health risk behaviors. Self-determination theory (SDT) proposes that patient autonomy is an essential factor for motivating change.
OBJECTIVE: An SDT-based intervention to enhance autonomous motivation for tobacco abstinence and improving cholesterol was tested.
DESIGN: The Smokers' Health Study is a randomized multiple risk behavior change intervention trial.
SETTING: Smokers were recruited to a tobacco treatment center.
PATIENTS: A total of 1,006 adult smokers were recruited between 1999 and 2002 from physician offices and by newspaper advertisements.
INTERVENTIONS: A 6-month clinical intervention (4 contacts) to facilitate internalization of autonomy and perceived competence for tobacco abstinence and reduced percent calories from fat was compared with community care. Clinicians elicited patient perspectives and life strivings, provided absolute coronary artery disease risk estimates, enumerated effective treatment options, supported patient initiatives, minimized clinician control, assessed motivation for change, and developed a plan for change.
MAIN OUTCOME MEASURES: Twelve-month prolonged tobacco abstinence, and change in percent calories from fat and low-density lipoprotein-cholesterol (LDL-C) from baseline to 18 months.
RESULTS: Intention to treat analyses revealed that the intervention significantly increased 12-month prolonged tobacco abstinence (6.2% vs 2.4%; odds ratio [OR]=2.7, P=.01, number needed to treat [NNT]=26), and reduced LDL-C (−8.9 vs −4.1 mg/dL; P=.05). There was no effect on percent calories from fat.
CONCLUSIONS: An intervention focused on supporting smokers' autonomy was effective in increasing prolonged tobacco abstinence and lowering LDL-C. Clinical interventions for behavior change may be improved by increasing patient autonomy and perceived competence.
BACKGROUND: Understanding how and when patients use nonphysician sources of health information is important to facilitate shared decision making within provider outpatient visits. However, little is known about which older adults seek health information on the internet or when.
OBJECTIVE: To determine how patient characteristics are related to seeking health information online and to the timing of these searches in relation to doctor visits.
PARTICIPANTS: Six thousand two hundred and seventy-nine respondents (aged 63 to 66 years) who completed the 2004 round of phone and mail surveys (70% response) as part of the Wisconsin Longitudinal Study Graduate Sample.
MEASUREMENTS: Self-reported use of the internet to search for health information and timing of use.
RESULTS: One-third of respondents had searched online for information about their own health or health care. Half of these searched for health information unrelated to their last doctor visit, while 1/3 searched after a visit, and 1/6 searched before. Among respondents with internet access at home or work, years of education (odds ratio [OR]=1.09, confidence interval [CI]=1.06 to 1.13) and openness-to-experience (OR=1.26, CI=1.16 to 1.36) were positively associated with searching online for health information irrespective of timing in relation to doctor visits. Compared with those who had never sought health information online, sicker individuals (especially those with cancer, OR=1.51, CI=1.14 to 1.99) were more likely to seek information online after a doctor visit. Attitudinal and personality factors were related to seeking health information online before or unrelated to a visit.
CONCLUSIONS: There are important differences in the timing of online health information searches by psychological and health characteristics among older adults with internet access.
BACKGROUND: Clinical experience, features of data collection process, or both, affect diagnostic accuracy, but their respective role is unclear.
OBJECTIVE, DESIGN: Prospective, observational study, to determine the respective contribution of clinical experience and data collection features to diagnostic accuracy.
METHODS: Six Internists, 6 second year internal medicine residents, and 6 senior medical students worked up the same 7 cases with a standardized patient. Each encounter was audiotaped and immediately assessed by the subjects who indicated the reasons underlying their data collection. We analyzed the encounters according to diagnostic accuracy, information collected, organ systems explored, diagnoses evaluated, and final decisions made, and we determined predictors of diagnostic accuracy by logistic regression models.
RESULTS: Several features significantly predicted diagnostic accuracy after correction for clinical experience: early exploration of correct diagnosis (odds ratio [OR] 24.35) or of relevant diagnostic hypotheses (OR 2.22) to frame clinical data collection, larger number of diagnostic hypotheses evaluated (OR 1.08), and collection of relevant clinical data (OR 1.19).
CONCLUSION: Some features of data collection and interpretation are related to diagnostic accuracy beyond clinical experience and should be explicitly included in clinical training and modeled by clinical teachers. Thoroughness in data collection should not be considered a privileged way to diagnostic success.
BACKGROUND: β-Blockers reduce mortality in patients with systolic chronic heart failure (CHF), yet prescription rates have remained low among primary care providers.
OBJECTIVE: To determine the β-blocker prescription rate among patients with systolic CHF at primary care Veterans Affairs (VA) clinics, its change over time; and to determine factors associated with nonprescription.
DESIGN: Retrospective chart review.
SUBJECTS: Seven hundred and forty-five patients with diagnostic codes for CHF followed in primary care clinics at 3 urban VA Medical Centers.
MEASUREMENTS: Rate of β-blocker prescription and comparison of patient characteristics between those prescribed versus those not prescribed β-blockers.
RESULTS: Only 368 (49%) had documented systolic CHF. Eighty-two percent (303/368) of these patients were prescribed a β-blocker. The prescription rate rose steadily over 3 consecutive 2-year time periods. Patients with more severely depressed ejection fractions were more likely to be on a β-blocker than patients with less severe disease. Independent predictors of nonprescription included chronic obstructive pulmonary disease, asthma, depression, and age. Patients under 65 years old were 12 times more likely to receive β-blockers than those over 85.
CONCLUSION: Primary care providers at VA Medical Centers achieved high rates of β-blocker prescription for CHF patients. Subgroups with relative contraindications had lower prescription rates and should be targeted for quality improvement initiatives.
BACKGROUND: Who provides health care to resident physicians is not well studied.
OBJECTIVE: To determine whether residency program directors (PDs) provide health care to their own residents and residents' families.
DESIGN: An anonymous survey mailed to 1,345 PDs in Emergency Medicine, Family Medicine, Internal Medicine, Medicine-Pediatrics, and Obstetrics-Gynecology in the United States in 2003.
RESULTS: Six hundred nineteen PDs (46%) responded. Half had taken care of their own residents for acute conditions. Less commonly, directors had written prescriptions for acute (40%) or chronic needs (15%) or provided ongoing care (22%). Only 3% believed this conflicted with their ability to be effective directors. Responders more likely to provide future care to residents considered this kind of care generally appropriate (P<.001), or appropriate under certain circumstances (P<.001). Most of these spent ≥31% of their time seeing patients. There was no difference among types of programs, gender of the director, or the years as director. Twenty-five percent of directors provided care to their residents' families.
CONCLUSIONS: Substantial numbers of directors provided health care to their own residents. Few believed this conflicted with their director role. We believe organizations of PDs should develop positions about this practice.
BACKGROUND: Websites offering drug information vary in coverage and quality, and most health care consumers are poorly equipped to assess the quality of internet medication information.
OBJECTIVE: To establish a webliography of recommended prescription medication information websites for health care consumers and providers.
DESIGN AND METHODS: Drug information websites were systematically identified based on recommendations from health professionals and text-word searches of MEDLINE and Google. The resulting sample of websites was evaluated in a 2-step process. Candidate websites were first screened using inclusion/exclusion criteria representing minimum information requirements. Websites that passed the inclusion/exclusion criteria were then rated on 16 quality criteria using a 5-point scale by 3 trained judges. Website ratings were averaged, then multiplied by the corresponding importance weight of each criterion and summed to generate a total score. Websites with the highest total scores were included in the webliography.
RESULTS: Ten websites were selected for inclusion in the webliography. The 3 highest-scoring websites were Anthem Blue Cross and Blue Shield (http://home.anthemhealth.com/topic/drugcenter), U.S. National Library of Medicine (http://www.nlm.nih.gov/medlineplus/druginformation.html), and Healthvision (http://www.yourhealthinformation.com/library/healthguide/en-us/drugguide/default.htm).
CONCLUSION: Medication information websites vary widely in quality and content. The online webliography is a valuable and easily accessed tool that can be recommended by health care professionals to patients who request referral to reliable websites.
BACKGROUND: The gap in asthma prevalence, morbidity, and mortality is increasing in low-income racial/ethnic minority groups as compared with Caucasians. In order to address these disparities, alternative beliefs and behaviors need to be identified.
OBJECTIVE: To identify causal models of asthma and the context of conventional prescription versus complementary and alternative medicine (CAM) use in low-income African-American (AA) adults with severe asthma.
DESIGN: Qualitative analysis of 28 in-depth interviews.
PARTICIPANTS: Twenty-six women and 2 men, aged 21 to 48, who self-identified as being AA, low-income, and an inner-city resident.
APPROACH: Transcripts of semi-structured in-depth qualitative interviews were inductively analyzed using the constant comparison approach.
RESULTS: Sixty-four percent of participants held biologically correct causal models of asthma although 100% reported the use of at least 1 CAM for asthma. Biologically based therapies, humoral balance, and prayer were the most popular CAM. While most subjects trusted prescription asthma medicine, there was a preference for integration of CAM with conventional asthma treatment. Complementary and alternative medicine was considered natural, effective, and potentially curative. Sixty-three percent of participants reported nonadherence to conventional therapies in the 2 weeks before the research interview. Neither CAM nor nonmedical causal models altered most individuals (93%) willingness to use prescription medication. Three possibly dangerous CAM were identified.
CONCLUSIONS: Clinicians should be aware of patient-generated causal models of asthma and use of CAM in this population. Discussing patients' desire for an integrated approach to asthma management and involving social networks are 2 strategies that may enhance patient-provider partnerships and treatment fidelity.
INTRODUCTION: Few curricula train medical students to engage in health system reform.
AIM: To develop physician activists by teaching medical students the skills necessary to advocate for socially equitable health policies in the U.S. health system.
SETTING: Montefiore Medical Center, the University Hospital of the Albert Einstein College of Medicine, Bronx, NY.
PROGRAM DESCRIPTION: We designed a 1-month curriculum in research-based health activism to develop physician activists. The annual curriculum includes a student project and 4 course sections; health policy, research methods, advocacy, and physician activists as role models; taught by core faculty and volunteers from academic institutions, government, and nongovernmental organizations.
PROGRAM EVALUATION: From 2002 to 2005, 47 students from across the country have participated. Students reported improved capabilities to generate a research question, design a research proposal, and create an advocacy plan.
DISCUSSION: Our curriculum demonstrates a model for training physician activists to engage in health systems reform.
Restless legs syndrome (RLS) is a common condition characterized by an unpleasant urge to move the legs that usually occurs at night and may interfere with sleep. The medications used most commonly to treat RLS include dopaminergic drugs (levodopa, dopamine agonists), benzodiazepines, and narcotic analgesics. We report the cases of 2 patients with RLS who illustrate the problems of tolerance (declining response over time) and augmentation (a worsening of symptoms due to ongoing treatment) that can complicate the pharmacotherapy of RLS. We discuss the optimal management of RLS and propose strategies to overcome tolerance and augmentation such as a rotational approach among agents from different classes.
]]>Extra-articular symptoms could be the first manifestation of gouty arthritis (GA); polyarticular GA can mimic an infectious arthritis; infection can complicate GA. A 66-year-old male with a history of gout presented with high fever and excruciating bilateral calf pain for 1 day. Examination revealed chronic knee effusions; range of motion in both knees was limited by calf pain. Joint aspiration showed negatively birefringent intracellular crystals and normal gram stain. While receiving empiric antibiotics fever continued and he developed bilateral knee, right ankle, and shoulder pain. After demonstration of urate crystals and exclusion of infection, antibiotics were discontinued and steroids initiated. Fever, calf pain, and polyarthritis quickly resolved. Polyarticular gouty attack is an uncommon presentation of gout, and can mimic several other conditions. An exceptional presentation of this entity is excruciating calf pain, probably caused by tenosynovitis or referred pain preceding an acute polyarticular gouty attack.
]]>Clinically, we most often associate Wernicke's encephalopathy (WE) with an alcohol abusing population. However, it is important to consider other causes of malnutrition and vitamin deficiency as risk factors for the development of this disorder. We present a case of a 51-year-old man with schizophrenia and malnutrition who presented with delirium, ophthalmoplegia, and seizures. He responded rapidly to the administration of IV thiamine. Because of the high rate of mortality and morbidity, WE should be high on the differential of any patient at risk for malnutrition or with ophthalmoplegia, regardless of alcohol history. This is particularly important in psychiatric patients where the syndrome may be masked and thus treatment delayed.
]]>We describe the case of a 43-year-old woman with transient ischemic neurologic deficits and recurrent systemic and pulmonary emboli in whom infectious work-up and extensive thrombophilic evaluation were unremarkable. Transesophageal echocardiography (TEE) established the diagnosis of nonbacterial thrombotic endocarditis (NBTE). This is a rare condition often associated with hypercoagulable states or advanced malignancy such as adenocarcinomas, characterized by cardiac vegetations along valvular coaptation lines without destruction of leaflets. In our patient, we diagnosed an ovarian clear cell adenocarcinoma, a malignant disorder that has been rarely reported in association with NBTE. This case illustrates that NBTE can present as an atypical manifestation of malignancy and must be distinguished from infective endocarditis which implies a different therapeutic strategy. When confronted with findings of NBTE without a clear etiology, an occult neoplasm must be excluded. Anticoagulant therapy is the mainstay of treatment. However, cardiac vegetations may require surgical intervention in rare instances.
]]>Restless legs syndrome (RLS) is a common condition characterized by an unpleasant urge to move the legs that usually occurs at night and may interfere with sleep. The medications used most commonly to treat RLS include dopaminergic drugs (levodopa, dopamine agonists), benzodiazepines, and narcotic analgesics. We report the cases of 2 patients with RLS who illustrate the problems of tolerance (declining response over time) and augmentation (a worsening of symptoms due to ongoing treatment) that can complicate the pharmacotherapy of RLS. We discuss the optimal management of RLS and propose strategies to overcome tolerance and augmentation such as a rotational approach among agents from different classes.
]]>LEARNING OBJECTIVES: Extra-articular symptoms could be the first manifestation of gouty arthritis (GA); polyarticular GA can mimic an infectious arthritis; infection can complicate GA.
CASE: A 66-year-old male with a history of gout presented with high fever and excruciating bilateral calf pain for 1 day. Examination revealed chronic knee effusions; range of motion in both knees was limited by calf pain. Joint aspiration showed negatively birefringent intracellular crystals and normal gram stain.
HOSPITAL COURSE: While receiving empiric antibiotics fever continued and he developed bilateral knee, right ankle, and shoulder pain. After demonstration of urate crystals and exclusion of infection, antibiotics were discontinued and steroids initiated. Fever, calf pain, and polyarthritis quickly resolved.
DISCUSSION: Polyarticular gouty attack is an uncommon presentation of gout, and can mimic several other conditions. An exceptional presentation of this entity is excruciating calf pain, probably caused by tenosynovitis or referred pain preceding an acute polyarticular gouty attack.
Clinically, we most often associate Wernicke's encephalopathy (WE) with an alcohol abusing population. However, it is important to consider other causes of malnutrition and vitamin deficiency as risk factors for the development of this disorder. We present a case of a 51-year-old man with schizophrenia and malnutrition who presented with delirium, ophthalmoplegia, and seizures. He responded rapidly to the administration of IV thiamine. Because of the high rate of mortality and morbidity, WE should be high on the differential of any patient at risk for malnutrition or with ophthalmoplegia, regardless of alcohol history. This is particularly important in psychiatric patients where the syndrome may be masked and thus treatment delayed.
]]>We describe the case of a 43-year-old woman with transient ischemic neurologic deficits and recurrent systemic and pulmonary emboli in whom infectious work-up and extensive thrombophilic evaluation were unremarkable. Transesophageal echocardiography (TEE) established the diagnosis of nonbacterial thrombotic endocarditis (NBTE). This is a rare condition often associated with hypercoagulable states or advanced malignancy such as adenocarcinomas, characterized by cardiac vegetations along valvular coaptation lines without destruction of leaflets. In our patient, we diagnosed an ovarian clear cell adenocarcinoma, a malignant disorder that has been rarely reported in association with NBTE. This case illustrates that NBTE can present as an atypical manifestation of malignancy and must be distinguished from infective endocarditis, which implies a different therapeutic strategy. When confronted with findings of NBTE without a clear etiology, an occult neoplasm must be excluded. Anticoagulant therapy is the mainstay of treatment. However, cardiac vegetations may require surgical intervention in rare instances.
]]>Academic medicine is in crisis. Contributing factors include the failure to engage stakeholders in developing the research and education agendas and the declining interest in academic careers. To reinvigorate academic medicine, it is necessary to understand what factors influence career choice. Exposure of trainees to research opportunities and graduate programs stimulate interest in academia. The desire to teach, conduct research, and the intellectual stimulation provided in academia also influence people. Several disincentives were found to careers in academic medicine including lack of financial rewards, lack of autonomy, and the pressure to be a “triple threat” requiring productivity in clinical work, research, and education.
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