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1.  Comparative Effectiveness of Audit-Feedback Versus Additional Physician Communication Training to Improve Cancer Screening for Patients with Limited Health Literacy 
Journal of General Internal Medicine  2014;29(8):1113-1121.
We designed a continuing medical education (CME) program to teach primary care physicians (PCP) how to engage in cancer risk communication and shared decision making with patients who have limited health literacy (HL).
We evaluated whether training PCPs, in addition to audit-feedback, improves their communication behaviors and increases cancer screening among patients with limited HL to a greater extent than only providing clinical performance feedback.
Four-year cluster randomized controlled trial.
Eighteen PCPs and 168 patients with limited HL who were overdue for colorectal/breast/cervical cancer screening.
Communication intervention PCPs received skills training that included standardized patient (SP) feedback on counseling behaviors. All PCPs underwent chart audits of patients’ screening status semiannually up to 24 months and received two annual performance feedback reports.
PCPs experienced three unannounced SP encounters during which SPs rated PCP communication behaviors. We examined between-group differences in changes in SP ratings and patient knowledge of cancer screening guidelines over 12 months; and changes in patient cancer screening rates over 24 months.
There were no group differences in SP ratings of physician communication at baseline. At follow-up, communication intervention PCPs were rated higher in general communication about cancer risks and shared decision making related to colorectal cancer screening compared to PCPs who only received performance feedback. Screening rates increased among patients of PCPs in both groups; however, there were no between-group differences in screening rates except for mammography. The communication intervention did not improve patient cancer screening knowledge.
Compared to audit and feedback alone, including PCP communication training increases PCP patient-centered counseling behaviors, but not cancer screening among patients with limited HL. Larger studies must be conducted to determine whether lack of changes in cancer screening were due to clinic/patient sample size versus ineffectiveness of communication training to change outcomes.
PMCID: PMC4099465  PMID: 24590734
communication; shared decision making; health literacy; cancer screening; standardized patients
2.  Physicians’ Anxiety Due to Uncertainty and Use of Race in Medical Decision-Making 
Medical care  2014;52(8):728-733.
The explicit use of race in medical decision-making is contested. Researchers have hypothesized that physicians use race in care when they are uncertain.
To investigate whether physician anxiety due to uncertainty is associated with a higher propensity to use race in medical decision-making.
Research Design
A national cross-sectional survey of general internists
A national sample of 1738 clinically active general internists drawn from the SK&A physician database
Anxiety Due to Uncertainty (ADU) is a 5-item measure of emotional reactions to clinical uncertainty. Bonham and Sellers Racial Attributes in Clinical Evaluation (RACE) scale includes 7 items that measure self-reported use of race in medical decision-making. We used bivariate regression to test for associations between physician characteristics, ADU and RACE. Multivariate linear regression was performed to test for associations between ADU and RACE while adjusting for potential confounders.
The mean score on ADU was 19.9 (SD=5.6). Mean score on RACE was 13.5 (SD=5.6). After adjusting for physician demographics, physicians with higher levels of ADU scored higher on RACE (+β=0.08 in RACE, p=0.04, for each 1-point increase in ADU), as did physicians who understand “race” to mean biological or genetic ancestral, rather than sociocultural, group. Physicians who graduated from a US medical school, completed fellowship, and had more white patients, scored lower on RACE.
This study demonstrates positive associations between physicians’ anxiety due to uncertainty, meanings attributed to race, and self-reported use of race in medical decision-making. Future research should examine the potential impact of these associations on patient outcomes and healthcare disparities.
PMCID: PMC4214364  PMID: 25025871
Medical Decision-Making; Race & Ethnicity; Uncertainty
3.  Improving Urban African Americans’ Blood Pressure Control through Multi-level Interventions in the Achieving Blood Pressure Control Together (ACT) Study: A Randomized Clinical Trial 
Contemporary clinical trials  2014;38(2):370-382.
Given their high rates of uncontrolled blood pressure, urban African Americans comprise a particularly vulnerable subgroup of persons with hypertension. Substantial evidence has demonstrated the important role of family and community support in improving patients’ management of a variety of chronic illnesses. However, studies of multilevel interventions designed specifically to improve urban African American patients’ blood pressure self-management by simultaneously leveraging patient, family, and community strengths are lacking.
We report the protocol of the Achieving Blood Pressure Control Together (ACT) study, a randomized controlled trial designed to study the effectiveness of interventions that engage patient, family, and community-level resources to facilitate urban African American hypertensive patients’ improved hypertension self-management and subsequent hypertension control. African American patients with uncontrolled hypertension receiving health care in an urban primary care clinic will be randomly assigned to receive 1) an educational intervention led by a community health worker alone, 2) the community health worker intervention plus a patient and family communication activation intervention, or 3) the community health worker intervention plus a problem-solving intervention. All participants enrolled in the study will receive and be trained to use a digital home blood pressure machine. The primary outcome of the randomized controlled trial will be patients’ blood pressure control at 12 months.
Results from the ACT study will provide needed evidence on the effectiveness of comprehensive multi-level interventions to improve urban African American patients’ hypertension control.
PMCID: PMC4169070  PMID: 24956323
hypertension; self-management; community health worker
4.  Perceived judgment about weight can negatively influence weight loss: A cross-sectional study of overweight and obese patients 
Preventive medicine  2014;62:103-107.
To examine the association between patient-perceived judgments about weight by primary care providers (PCP) and self-reported weight loss.
We conducted a national internet-based survey of 600 adults engaged in primary care with a BMI≥25kg/m2 in 2012. Our weight loss outcomes included attempted weight loss and achieved ≥10% weight loss in the last 12 months. Our independent variable was “feeling judged about my weight by my PCP.” We created an interaction between perceiving judgment and PCP discussing weight loss as an independent variable. We conducted a multivariate logistic regression model adjusted for patient and PCP factors using survey weights.
Overall, 21% perceived that their PCP judged them about their weight. Respondents who perceived judgment were significantly more likely to attempt weight loss [OR 4.67, 95%CI 1.96-11.14]. They were not more likely to achieve ≥10% weight loss [OR 0.87, 95%CI 0.42-1.76]. Among patients whose PCPs discussed weight loss, 20.1% achieved ≥10% weight loss if they did not perceive judgment by their PCP as compared to 13.5% who perceived judgment.
Weight loss discussions between patients and PCPs may lead to greater weight loss in relationships where patients do not perceive judgment about their weight.
PMCID: PMC4006987  PMID: 24521530
Obesity; patient-provider; primary care; psychosocial research
5.  Adapting Hypertension Self-Management Interventions to Enhance their Sustained Effectiveness among Urban African Americans 
Family & community health  2014;37(2):119-133.
African Americans suffer disproportionately poor hypertension control despite the availability of efficacious interventions. Using principles of community-based participatory research and implementation science, we adapted established hypertension self-management interventions to enhance interventions’ cultural relevance and potential for sustained effectiveness among urban African Americans. We obtained input from patients and their family members, their health care providers, and community members. The process required substantial time and resources, and the adapted interventions will be tested in a randomized controlled trial.
PMCID: PMC4002996  PMID: 24569158
hypertension; health disparities; implementation science; community-based participatory research; program translation
6.  Quality of Patient-Physician Discussions About CKD in Primary Care: A Cross-sectional Study 
The quality of patient-physician discussions about chronic kidney disease (CKD) in primary care has not been studied previously.
Study Design
Cross-sectional study.
Settings & Participants
We audiotaped encounters between 236 patients with hypertension and their primary care physicians (n = 40).
Patient, physician, and encounter characteristics.
Outcomes & Measurements
We described the occurrence and characteristics (content, use of technical terms, and physician assessment of patient comprehension of new concepts) of CKD discussions. We assessed patient and physician characteristics associated with CKD discussion occurrence.
Many patients (mean age, 59 years) had uncontrolled hypertension (51%), diabetes (44%), and/or 3 or more comorbid conditions (51%). Most primary care physicians practiced (52%) fewer than 10 years. CKD discussions occurred in few (26%; n = 61) encounters, with content focused on laboratory assessment (89%), risk-factor treatment (28%), and causes (26%) of CKD. In encounters that included a CKD discussion, physicians used technical terms (28%; n = 17) and rarely assessed patients’ comprehension (2%; n = 1). CKD discussions were statistically significantly less common in visits of patients with some (vs no) college education (OR, 0.23; 95% CI, 0.09–0.56), with 3 or more (vs fewer) comorbid conditions (OR, 0.49; 95% CI, 0.25–0.96), and who saw physicians with more (vs fewer) than 10 years of practice experience (OR, 0.41; 95% CI, 0.21–0.80). CKD discussions were more common during longer encounters (OR, 1.31; 95% CI, 1.04–1.65) and encounters in which diabetes was (vs was not) discussed (OR, 2.87; 95% CI, 1.22–6.77).
Generalizability of our findings may be limited.
Patient-physician discussions about CKD in high-risk primary care patients were infrequent. Physicians used technical terms and infrequently assessed patients’ understanding of new CKD concepts. Efforts to improve the frequency and content of patient-physician CKD discussions in primary care could improve patients’ clinical outcomes.
PMCID: PMC4374349  PMID: 21131116
Chronic kidney disease; primary care; patient-physician communication; patient awareness
7.  Biosynthesis of a Thiamin Antivitamin in Clostridium botulinum 
Biochemistry  2014;53(14):2215-2217.
Bacimethrin-derived 2′-methoxythiamin pyrophosphate inhibits microbial growth by disrupting metabolic pathways dependent on thiamin-utilizing enzymes. This study describes the discovery of the bacimethrin biosynthetic gene cluster of Clostridium botulinum A ATCC 19397 and in vitro reconstitution of bacimethrin biosynthesis from cytidine 5′-monophosphate.
PMCID: PMC4004229  PMID: 24654570
8.  Association of Race Consciousness With the Patient–Physician Relationship, Medication Adherence, and Blood Pressure in Urban Primary Care Patients 
American Journal of Hypertension  2013;26(11):1346-1352.
Race consciousness (the frequency with which one thinks about his or her own race) is a measure that may be useful in assessing whether racial discrimination negatively impacts blood pressure (BP). However, the relation between race consciousness and BP has yet to be empirically tested, especially within the context of the patient–physician relationship and medication adherence.
Race-stratified generalized estimating equations were used to assess the relationship of race consciousness on BP, measures of the patient–physician relationship, and self-reported medication adherence, controlling for patients being nested within physicians and for patient age and sex.
The mean age of the patients was 61.3 years, 62% were black, and 65% were women. Black patients were more likely to ever think about race than were white patients (49% vs. 21%; P < 0.001). Race-conscious blacks had significantly higher diastolic BP (79.4 vs. 74.5mm Hg; P = 0.004) and somewhat higher systolic BP (138.8 vs. 134.7mm Hg; P = 0.13) than blacks who were not race conscious. Race-conscious whites were more likely to perceive respect from their physician (57.1% vs. 25.8%; P = 0.01) but had lower medication adherence (62.4% vs. 82.9%; P = 0.05) than whites who were not race-conscious.
Among blacks, race consciousness was associated with higher diastolic BP. In contrast, among whites, there was no association between race consciousness and BP, but race consciousness was associated with poor ratings of adherence, despite more favorable ratings of the patient–physician relationship. Future work should explore disparities in race consciousness and its impact on health and health-care disparities.
PMCID: PMC3790452  PMID: 23864583
adherence; blood pressure; blood pressure discrimination; disparities; hypertension; perceived quality of care; race; racism.
9.  The Impact of Health Literacy on Desire for Participation in Healthcare, Medical Visit Communication, and Patient Reported Outcomes among Patients with Hypertension 
Journal of General Internal Medicine  2013;28(11):1469-1476.
Low health literacy (HL) is associated with poor healthcare outcomes; mechanisms for these associations remain unclear.
To elucidate how HL influences patients’ interest in participating in healthcare, medical visit communication, and patient reported visit outcomes.
Cross-sectional study of enrollment data from a randomized controlled trial of interventions to improve patient adherence to hypertension treatments. Participants were 41 primary care physicians and 275 of their patients. Prior to the enrollment visit, physicians received a minimal intervention or communication skills training and patients received a minimal intervention or a pre-visit coaching session. This resulted in four intervention groups (minimal patient/minimal physician; minimal patient/intensive physician; intensive patient/minimal physician; and intensive patient/intensive physician).
Rapid Estimate of Adult Literacy in Medicine; patients’ desire for involvement in decision making; communication behaviors; patient ratings of participatory decision making (PDM), trust, and satisfaction.
A lower percentage of patients with low versus adequate literacy had controlled blood pressure. Both groups were similarly interested in participating in medical decision making. Communication behaviors did not differ based on HL except for medical question asking by patients, which was lower among low literacy patients. This was particularly true in the intensive patient /intensive physician group (3.85 vs. 6.42 questions; p = 0.002). Overall, ratings of care didn’t differ based on HL; however, in analyses stratified by intervention assignment, patients with low literacy in minimal physician intervention groups reported significantly lower PDM scores than adequate literacy patients.
Patients with low and adequate literacy were similarly interested in participating in medical decision making. However, low literacy patients were less likely to experience PDM in their visits. Low literacy patients in the intensive physician intervention groups asked fewer medical questions. Patients with low literacy may be less able to respond to physicians’ use of patient-centered communication approaches than adequate literacy patients.
PMCID: PMC3797328  PMID: 23690237
health literacy;  participatory decision making; patient–physician relationship; communication
10.  Anthracobunids from the Middle Eocene of India and Pakistan Are Stem Perissodactyls 
PLoS ONE  2014;9(10):e109232.
Anthracobunidae is an Eocene family of large mammals from south Asia that is commonly considered to be part of the radiation that gave rise to elephants (proboscideans) and sea cows (sirenians). We describe a new collection of anthracobunid fossils from Middle Eocene rocks of Indo-Pakistan that more than doubles the number of known anthracobunid fossils and challenges their putative relationships, instead implying that they are stem perissodactyls. Cranial, dental, and postcranial elements allow a revision of species and the recognition of a new anthracobunid genus. Analyses of stable isotopes and long bone geometry together suggest that most anthracobunids fed on land, but spent a considerable amount of time near water. This new evidence expands our understanding of stem perissodactyl diversity and sheds new light on perissodactyl origins.
PMCID: PMC4189980  PMID: 25295875
11.  Racial Patterns of Cardiovascular Disease Risk Factors in Serious Mental Illness and the Overall U.S. Population 
Schizophrenia research  2013;150(1):10.1016/j.schres.2013.07.022.
Serious mental illness (SMI) and minority race are each associated with elevated cardiovascular disease (CVD) mortality. However, little is known about racial variation in CVD risk factors in individuals with SMI. This study aimed to determine racial patterns of CVD risk factors in individuals with SMI and to compare these patterns to those of the general population.
Overweight/obese adults with SMI (163 whites; 111 African Americans) examined from 2008 to 2011 during a weight loss trial were compared at study baseline to overweight/obese adults (1103 whites; 550 African Americans) of similar age, sex, and race in the 2007 to 2010 National Health and Nutrition Examination Survey.
All CVD risk factors except cholesterol were higher in SMI than the overall U.S. population. After adjusting for age and sex, both racial groups with SMI had similarly high risks of smoking, obesity, diabetes, and hypertension, while African Americans with SMI had lower risks of high cholesterol (RR 0.73; 95% CI 0.57–0.94) and metabolic syndrome (RR 0.75; 95% CI 0.63–0.91) than whites with SMI. In the U.S. population sample, African Americans compared to whites had higher risks of obesity (RR 1.23; 95% CI 1.14–1.34), diabetes (RR 1.68; 95% CI 1.21–2.34), and hypertension (RR 1.44; 95% CI 1.31–1.60) but no significant difference in smoking, high cholesterol, and metabolic syndrome.
Compared to the general population, the greater burden and dissimilar racial pattern of CVD risk factors in SMI underscore the need for CVD prevention programs targeting the SMI population.
PMCID: PMC3821976  PMID: 23916188
cardiovascular disease risk factors; serious mental illness; racial disparities; obesity; diabetes; hypertension
13.  The impact of depressive symptoms on patient–provider communication in HIV care 
AIDS care  2013;25(9):1185-1192.
Persons with HIV who develop depression have worse medical adherence and outcomes. Poor patient–provider communication may play a role in these outcomes. This cross-sectional study evaluated the influence of patient depression on the quality of patient–provider communication. Patient–provider visits (n = 406) at four HIV care sites were audio-recorded and coded with the Roter Interaction Analysis System (RIAS). Negative binomial and linear regressions using generalized estimating equations tested the association of depressive symptoms, as measured by the Center for Epidemiology Studies Depression scale (CES-D), with RIAS measures and postvisit patient-rated quality of care and provider-reported regard for his or her patient. The patients, averaged 45 years of age (range = 20–77), were predominately male (n = 286, 68.5%), of black race (n = 250, 60%), and on antiretroviral medications (n = 334, 80%). Women had greater mean CES-D depression scores (12.0) than men (10.6; p = 0.03). There were no age, race, or education differences in depression scores. Visits with patients reporting severe depressive symptoms compared to those reporting none/mild depressive symptoms were longer and speech speed was slower. Patients with severe depressive symptoms did more emotional rapport building but less social rapport building, and their providers did more data gathering/counseling (ps < 0.05). In postvisit questionnaires, providers reported lower levels of positive regard for, and rated more negatively patients reporting more depressive symptoms (p < 0.01). In turn, patients reporting more depressive symptoms felt less respected and were less likely to report that their provider knows them as a person than none/mild depressive symptoms patients (ps < 0.05). Greater psychosocial needs of patients presenting with depressive symptoms and limited time/resources to address these needs may partially contribute to providers’ negative attitudes regarding their patients with depressive symptoms. These negative attitudes may ultimately serve to adversely impact patient–provider communication and quality of HIV care.
PMCID: PMC4090599  PMID: 23320529
depression; communication; quality of health care; patient satisfaction; HIV
14.  In vitro reconstitution of the radical SAM enzyme MqnC involved in the biosynthesis of futalosine-derived menaquinone 
Biochemistry  2013;52(27):10.1021/bi400498d.
The radical S-adenosylmethionine (SAM) enzyme MqnC catalyzes conversion of dehypoxanthine futalosine (DHFL) to the unique spiro-compound cyclic DHFL in the futalosine pathway for menaquinone biosynthesis. This study describes the in vitro reconstitution of [4Fe-4S]-cluster-dependent MqnC activity and identifies the site of hydrogen atom abstraction from DHFL by the adenosyl radical.
PMCID: PMC3855634  PMID: 23763543
Menaquinone; futalosine; radical SAM enzyme
16.  Reversal of Substrate Specificity of CMP N-glycosidase to dCMP†,‡ 
Biochemistry  2013;52(23):4037-4047.
MilB is a CMP hydrolase involved in the early steps of biosynthesis of the antifungal compound mildiomycin. An enzyme from the bacimethrin biosynthetic pathway, BcmB, is closely related in both sequence and function to MilB. These two enzymes belong to the nucleoside 2′-deoxyribosyltransferase (NDT) superfamily. NDTs catalyze N-glycosidic bond cleavage of 2′-deoxynucleosides via a covalent 2-deoxyribosyl-enzyme intermediate. Conservation of key active site residues suggests that members of the NDT superfamily share a common mechanism; however, the enzymes differ in their substrate preferences. Substrates vary in the type of nucleobase, the presence or absence of a 2′-hydroxyl group, and the presence or absence of a 5′-phosphate group. We have determined the structures of MilB and BcmB and compared them to previously determined structures of NDT superfamily members. The comparisons reveal how these enzymes differentiate between ribosyl and deoxyribosyl nucleotides or nucleosides, and among different nucleobases. The 1.6 Å structure of the MilB-CMP complex reveals an active site feature that is not obvious from sequence comparisons alone. MilB and BcmB that prefer substrates containing 2′-ribosyl groups have a phenylalanine positioned in the active site whereas NDT family members with preference for 2′-deoxyribosyl groups have a tyrosine residue. Further studies show that the phenylalanine is critical for MilB and BcmB specificity towards CMP, and mutation of this phenylalanine residue to tyrosine results in a 1000-fold reversal of substrate specificity from CMP to dCMP.
PMCID: PMC3750073  PMID: 23659472
17.  Disparities in trauma care and outcomes in the United States: A systematic review and meta-analysis 
Race and socioeconomic disparities are pervasive and persist throughout our health care system. Inequities have also been identified in outcomes after trauma despite its immediate nature and the perceived equal access to emergent care.
Our objective was to systematically evaluate the current literature on the association between trauma mortality and race, insurance status, and socioeconomic status. Our secondary objective was to assess data investigating potential mechanisms underlying these outcome disparities.
We performed a systematic review and random effects meta-analysis to examine the relationship between trauma and race, insurance, and socioeconomic disparities published between April 1990 and October 2011. The Cochrane Review Handbook and the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) statement were used as guides.
Thirty-five studies were included in the final review. The current body of literature indicates that uninsured status is an independent negative predictor of trauma outcomes. Our meta-analysis corroborated this by demonstrating that uninsured patients were more likely to die than privately insured patients (OR 2.17 95% CI 1.51–3.11). Racial disparities in trauma outcomes are shown to be present and independent for black patients compared to whites. Our meta-analysis demonstrated that black race was associated with higher odds of death when compared with white race (OR 1.19 95% CI 1.09 – 1.31). Studies comparing Hispanic and white non-Hispanic patients’ post-trauma mortality outcomes, however, have provided conflicting results. Our meta-analysis found no significant difference in mortality comparing Hispanic patients with white patients (OR 1.08 95% CI 0.99–1.18)
Both race/ethnicity and insurance are clearly associated with disparate outcomes following trauma. These disparities are likely due to myriad factors across the trauma continuum of care: host factors, prehospital factors, hospital/provider factors, and factors associated with postacute care and rehabilitation. While there are many proposed mechanisms, we believe that there are several interventions that could be particularly effective in combatting trauma disparities. These include trauma prevention programs targeting vulnerable populations, expansion of healthcare coverage, relocation of trauma centers to better provide for vulnerable populations, and restructuring clinical training to address implicit biases. While much work still remains to fully elucidate the mechanisms underlying trauma disparities, we can and should now act to begin to reduce or eliminate these disparities that still plague our healthcare system.
Level of Evidence
PMCID: PMC3641534  PMID: 23609267
18.  Insurance Coverage for Weight Loss 
Given the prevalence of obesity and associated chronic conditions among U.S. adults, wellness benefits are an increasingly popular approach to promoting weight loss.
The goal of the study was to assess overweight and obese adults’ beliefs about the helpfulness of insurance coverage of weight loss–related benefits, their willingness to pay for such benefits, and whether these opinions differ by individuals’ weight or health insurance type.
A national survey was fielded in 2012 am ong non-pregnant, overweight and obese adults who had seen a primary care provider in the past year (n=600). Descriptive statistics summarized beliefs about which weight loss–related benefits would be helpful, willingness to pay for such benefits, and agreement about whether health insurers should be able to charge more to obese individuals. Multivariable logistic regression was employed to determine whether beliefs differed by weight category or health insurance type. Analyses were conducted in July 2012.
The majority (83%) of respondents cited a specific benefit as helpful. Those with private health insurance had a higher probability (89%, 95% CI=86%, 93%) of endorsing any benefit as helpful relative to those with other types of health insurance. Being obese relative to overweight was associated with greater support (57% vs 39%, p<0.05) for preventing health insurers from charging higher premiums to obese individuals.
In this sample of overweight adults, a large proportion endorsed the value of weight loss–related benefits offered by health plans. However, only about one third were willing to pay extra for them, and half disagreed with the notion that health plans should charge more to obese individuals. Given evidence of their effectiveness, wellness benefits should be offered to all individuals.
PMCID: PMC3671931  PMID: 23597807
19.  Physicians build less rapport with obese patients 
Obesity (Silver Spring, Md.)  2013;21(10):2146-2152.
Physicians’ negative attitudes towards patients with obesity are well documented. Whether or how these beliefs may affect patient-physician communication is unknown. We aimed to describe the relationship between patient BMI and physician communication behaviors (biomedical, psychosocial/lifestyle, and rapport building) during typical outpatient primary care visits.
Design and Methods
Using audio-recorded outpatient encounters from 39 urban PCPs and 208 of their patients, we examined the frequency of communication behaviors using the Roter Interaction Analysis System. The independent variable was measured patient BMI and dependent variables were communication behaviors by the PCP within the biomedical, psychosocial/lifestyle, and rapport building domains. We performed a cross-sectional analysis using multilevel Poisson regression models to evaluate the association between BMI and physician communication.
PCPs demonstrated less emotional rapport with overweight and obese patients (IRR 0.65, 95%CI 0.48–0.88, p=0.01; IRR 0.69, 95%CI 0.58–0.82, p<0.01, respectively) than for normal weight patients. We found no differences in PCPs’ biomedical or psychosocial/lifestyle communication by patient BMI.
Our findings raise the concern that low levels of emotional rapport in primary care visits with overweight and obese patients may weaken the patient-physician relationship, diminish patients’ adherence to recommendations, and decrease the effectiveness of behavior change counseling.
PMCID: PMC3694993  PMID: 23512862
Obesity; patient-provider; primary care; psychosocial research
20.  Physician Communication Behaviors and Trust among Black and White Patients with Hypertension 
Medical care  2013;51(2):151-157.
Racial differences in patient trust have been observed, but it is unclear which physician communication behaviors are related to trust, and whether the relationship of communication and trust differs among black and white patients.
We sought to determine whether there were associations between physician communication behaviors, visit process measures and patient trust, particularly within racial groups.
Study participants included 39 primary care physicians and 227 black and white hypertensive patients from community-based practices in Baltimore, Maryland. Physician informational and affective communication behaviors and visit process measures were coded from visit audiotapes using the Roter Interaction Analysis System. Patient trust was measured using items from the Trust in Physician Scale, and dichotomized (high/low). Logistic regression analysis using generalized estimating equations was used to assess the association of each physician communication behavior and visit process measure with patient trust, among the entire sample and then stratified by patient race.
Positive physician affect and longer visits were significantly associated with high patient trust in unadjusted analyses. After adjustment for covariates, positive physician affect remained a significant predictor of high patient trust in the overall sample (OR 1.26; 95%CI 1.08, 1.48; p=0.004) and after stratification by race, among black patients (OR 1.35; 95%CI 1.09, 1.67; p=0.006).
Physician communication behaviors may have a varying effect on patient trust, depending on patient race. Communication skills training programs targeting emotion-handling and rapport-building behaviors are promising strategies to reduce disparities in healthcare and to enhance trust among ethnic minority patients.
PMCID: PMC3552122  PMID: 23132201
patient-physician communication; trust; African Americans
21.  Patient Trust in Physicians and Adoption of Lifestyle Behaviors to Control High Blood Pressure 
To assess the relationship between patients’ trust in their physician and self-reported adoption of lifestyle modification behaviors and medication adherence for control of hypertension.
Longitudinal analysis of data from a randomized controlled trial of interventions to enhance hypertensive patients’ adherence to medications and recommended lifestyle modifications. Two hundred patients were seen by 41 physicians at 14 urban primary care practices in Baltimore, Maryland, and followed for 12 months.
Seventy percent of patients reported complete trust in their physician. In adjusted analyses, patients with complete trust had higher odds of reporting that they were trying to lose weight (OR=2.27, 95% CI=1.38–3.74) than did patients with less than complete trust in their physician. Though not statistically significant, the odds of reporting trying to cut back on salt and engaging in regular exercise were greater in patients with complete trust. We observed no association for reports of medication adherence.
Trust in one’s physician predicts attempts to lose weight among patients with hypertension, and may contribute to attempts to reduce salt and increase exercise.
Practice Implications
Strengthening patient-physician relationships through efforts to enhance trust may be a promising strategy to enhance patients’ engagement in healthy lifestyle behaviors for hypertension.
PMCID: PMC3462260  PMID: 22770676
adherence; African-Americans; blood pressure control; hypertension; lifestyle modification; trust
22.  Impact of Patient–Doctor Race Concordance on Rates of Weight-Related Counseling in Visits by Black and White Obese Individuals 
Obesity (Silver Spring, Md.)  2011;20(3):562-570.
The objective of this study was to assess the impact of patient-provider race concordance on weight-related counseling among visits by obese patients. We hypothesized that race concordance would be positively associated with weight-related counseling. We used clinical encounter data obtained from the 2005–2007 National Ambulatory Medical Care Surveys (NAMCS). The sample size included 2,231 visits of black and white obese individuals (ages 20 and older) to their black and white physicians from the specialties of general/family practice and general internal medicine. Three outcome measures of weight-related counseling were explored: weight reduction, diet/nutrition, and exercise. Logistic regression was used to model the outcome variables of interest. Wald tests were used to statistically compare whether physicians of each race provided counseling at different rates for obese patients of different races. We did not observe a positive association between patient–physician race concordance and weight-related counseling. We found that visits by black obese patients to white doctors had a lower odds of exercise counseling as compared to visits by white obese patients to white doctors (odds ratio (OR) = 0.54; 95% confidence interval (CI): 0.31, 0.95), and visits by black obese patients to black physicians had lower odds of receiving weight-reduction counseling than visits among white obese patients seeing black physicians (OR = 0.34; 95% CI: 0.13, 0.90). Black obese patients receive less exercise counseling than white obese patients in visits to white physicians and may be less likely than white obese patients to receive weight-reduction counseling in visits to black physicians.
PMCID: PMC3786341  PMID: 21233803
23.  Do physician beliefs about causes of obesity translate into actionable issues on which physicians counsel their patients? 
Preventive medicine  2013;56(5):326-328.
To describe the relationship between primary care physicians’ (PCPs’) beliefs about the causes of obesity with the frequency of nutritional counseling.
We analyzed a national cross-sectional internet-based survey of 500 US PCPs collected between February and March 2011.
PCPs that identified overconsumption of food as a very important cause of obesity had significantly greater odds of counseling patients to reduce portion sizes (OR 3.40; 95%CI: 1.73–6.68) and to avoid high calorie ingredients when cooking (OR 2.16; 95%CI: 1.07–4.33). Physicians who believed that restaurant/fast food eating was a very important cause of obesity had significantly greater odds of counseling patients to avoid high calorie menu items outside the home (OR 1.93; 95%CI: 1.20–3.11). Physicians who reported that sugar-sweetened beverages were a very important cause of obesity had significantly greater odds of counseling their obese patients to reduce consumption (OR 5.99; 95%CI: 3.53–10.17).
PCP beliefs about the diet-related causes of obesity may translate into actionable nutritional counseling topics for physicians to use with their patients.
PMCID: PMC3745015  PMID: 23399006
Obesity; Physician beliefs; Nutrition counseling
24.  How does physician BMI impact patient trust and perceived stigma? 
Preventive medicine  2013;57(2):120-124.
The objective is to evaluate whether physician body mass index (BMI) impacts their patients’ trust or perceptions of weight-related stigma.
We used a national cross-sectional survey of 600 non-pregnant overweight and obese patients conducted between April 5 and April 13, 2012. The outcome variables were patient trust (overall and by type of advice) and patient perceptions of weight-related stigma. The independent variable of interest was primary care physician (PCP) BMI. We conducted multivariate regression analyses to determine whether trust or perceived stigma differed by physician BMI, adjusting for covariates.
Patients reported high levels of trust in their PCPs, regardless of the PCPs body weight (normal BMI = 8.6; overweight = 8.3; obese = 8.2; where 10 is the highest). Trust in diet advice was significantly higher among patients seeing overweight PCPs as compared to normal BMI PCPs (87% vs. 77%, p = 0.04). Reports of feeling judged by their PCP were significantly higher among patients seeing obese PCPs (32%; 95% confidence interval (CI): 23–41) as compared to patients seeing normal BMI PCPs (14%; 95% CI: 7–20).
Overweight and obese patients generally trust their PCP, but they more strongly trust diet advice from overweight PCPs as compared to normal BMI PCPs.
PMCID: PMC3745018  PMID: 23743418
Physician BMI; Patient trust; Weight stigma; Weight-related advice
25.  Facilitators and barriers to hypertension self-management in urban African Americans: perspectives of patients and family members 
We aimed to inform the design of behavioral interventions by identifying patients’ and their family members’ perceived facilitators and barriers to hypertension self-management.
Materials and methods
We conducted focus groups of African American patients with hypertension and their family members to elicit their views about factors influencing patients’ hypertension self-management. We recruited African American patients with hypertension (n = 18) and their family members (n = 12) from an urban, community-based clinical practice in Baltimore, Maryland. We conducted four separate 90-minute focus groups among patients with controlled (one group) and uncontrolled (one group) hypertension, as well as their family members (two groups). Trained moderators used open-ended questions to assess participants’ perceptions regarding patient, family, clinic, and community-level factors influencing patients’ effective hypertension self-management.
Patient participants identified several facilitators (including family members’ support and positive relationships with doctors) and barriers (including competing health priorities, lack of knowledge about hypertension, and poor access to community resources) that influence their hypertension self-management. Family members also identified several facilitators (including their participation in patients’ doctor’s visits and discussions with patients’ doctors outside of visits) and barriers (including their own limited health knowledge and patients’ lack of motivation to sustain hypertension self-management behaviors) that affect their efforts to support patients’ hypertension self-management.
African American patients with hypertension and their family members reported numerous patient, family, clinic, and community-level facilitators and barriers to patients’ hypertension self-management. Patients’ and their family members’ views may help guide efforts to tailor behavioral interventions designed to improve hypertension self-management behaviors and hypertension control in minority populations.
PMCID: PMC3743518  PMID: 23966772
hypertension; patient perspective; qualitative research; health disparities

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