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author:("haider, Paul")
1.  The Role of Patients’ Explanatory Models and Daily-Lived Experience in Hypertension Self-Management 
Journal of General Internal Medicine  2012;27(12):1626-1634.
ABSTRACT
BACKGROUND
Uncontrolled hypertension remains a significant problem for many patients. Few interventions to improve patients’ hypertension self-management have had lasting effects. Previous work has focused largely on patients’ beliefs as predictors of behavior, but little is understood about beliefs as they are embedded in patients’ social contexts.
OBJECTIVE
This study aims to explore how patients’ “explanatory models” of hypertension (understandings of the causes, mechanisms or pathophysiology, course of illness, symptoms and effects of treatment) and social context relate to their reported daily hypertension self-management behaviors.
DESIGN
Semi-structured qualitative interviews with a diverse group of patients at two large urban Veterans Administration Medical centers.
PARTICIPANTS (OR PATIENTS OR SUBJECTS)
African-American, white and Latino Veterans Affairs (VA) primary care patients with uncontrolled blood pressure.
APPROACH
We conducted thematic analysis using tools of grounded theory to identify key themes surrounding patients’ explanatory models, social context and hypertension management behaviors.
RESULTS
Patients’ perceptions of the cause and course of hypertension, experiences of hypertension symptoms, and beliefs about the effectiveness of treatment were related to different hypertension self-management behaviors. Moreover, patients’ daily-lived experiences, such as an isolated lifestyle, serious competing health problems, a lack of habits and routines, barriers to exercise and prioritizing lifestyle choices, also interfered with optimal hypertension self-management.
CONCLUSIONS
Designing interventions to improve patients’ hypertension self-management requires consideration of patients’ explanatory models and their daily-lived experience. We propose a new conceptual model — the dynamic model of hypertension self-management behavior — which incorporates these key elements of patients’ experiences.
doi:10.1007/s11606-012-2141-2
PMCID: PMC3509311  PMID: 22821569
hypertension; medication adherence; qualitative methods; health behavior; self-management
2.  Recruiting clinical personnel as research participants: a framework for assessing feasibility 
Increasing numbers of research studies test interventions for clinicians in addition to or instead of interventions for patients. Although previous studies have enumerated barriers to patient enrolment in clinical trials, corresponding barriers have not been identified for enrolling clinicians as subjects. We propose a framework of metrics for evidence-based estimation of time and resources required for recruiting clinicians as research participants, and present an example from a federally funded study. Our framework proposes metrics for tracking five steps in the recruitment process: gaining entry into facilities, obtaining accurate eligibility and contact information, reaching busy clinicians, assessing willingness to participate, and scheduling participants for data collection. We analyzed recruitment records from a qualitative study exploring performance feedback at US Department of Veterans Affairs Medical Centers (VAMCs); five recruiters sought to reach two clinicians at 16 facilities for a one-hour interview. Objective metrics were calculable for all five steps; metric values varied considerably across facilities. Obtaining accurate contact information slowed down recruiting the most. We conclude that successfully recruiting even small numbers of employees requires considerable resourcefulness and more calendar time than anticipated. Our proposed framework provides an empirical basis for estimating research-recruitment timelines, planning subject-recruitment strategies, and assessing the research accessibility of clinical sites.
doi:10.1186/1748-5908-8-125
PMCID: PMC4015152  PMID: 24153049
3.  Measuring the quality of Patients’ goals and action plans: development and validation of a novel tool 
Background
The purpose of this study is to develop and test reliability, validity, and utility of the Goal-Setting Evaluation Tool for Diabetes (GET-D). The effectiveness of diabetes self-management is predicated on goal-setting and action planning strategies. Evaluation of self-management interventions is hampered by the absence of tools to assess quality of goals and action plans. To address this gap, we developed the GET-D, a criteria-based, observer rating scale that measures the quality of patients’ diabetes goals and action plans.
Methods
We conducted 3-stage development of GET-D, including identification of criteria for observer ratings of goals and action plans, rater training and pilot testing; and then performed psychometric testing of the GET-D.
Results
Trained raters could effectively rate the quality of patient-generated goals and action plans using the GET-D. Ratings performed by trained evaluators demonstrated good raw agreement (94.4%) and inter-rater reliability (Kappa = 0.66). Scores on the GET-D correlated well with measures theoretically associated with goal-setting, including patient activation (r=.252, P<.05), diabetes specific self-efficacy (r=.376, P<.001) and inverse relationship with depression (r= −.376, P<.01). Significant between group differences (P<.01) in GET-D scores between goal-setting intervention (mean = 7.33, standard deviation = 4.4) and education groups (mean = 4.93, standard deviation = 3.9) confirmed construct validity of the GET-D.
Conclusions
The GET-D can reliably and validly rate the quality of goals and action plans. It holds promise as a measure of intervention fidelity for clinical interventions that promote diabetes self-management behaviors to improve clinical outcomes.
Trial registration
Clinicaltrials.gov Identifier: NCT00481286
doi:10.1186/1472-6947-12-152
PMCID: PMC3544573  PMID: 23270422
Goal-setting; Diabetes; Self-management; Goals; Action plans; Measurement
4.  Knowing the ABCs: A Comparative Effectiveness Study of Two Methods of Diabetes Education 
Patient education and counseling  2011;85(3):383-389.
Objective
To test an active-learning, empowerment approach to teaching patients about the “diabetes ABCs” (hemoglobin A1C, systolic blood pressure, and low density lipoprotein cholesterol).
Methods
84 (97%) diabetic patients who participated in a randomized effectiveness trial of two clinic-based group educational methods and completed a post-intervention assessment. The empowerment arm participated in a group session that incorporated two educational innovations (a conceptual metaphor to foster understanding, and team-based learning methods to foster active learning). The traditional diabetes education arm received a didactic group session focused on self-management and educational materials about the diabetes ABCs. Participants in both arms received individual review of their current ABC values.
Results
A questionnaire evaluated knowledge, understanding, and recall of the diabetes ABCs was administered three months after enrollment in the study. At three months, participants in the empowerment group demonstrated greater understanding of the diabetes ABCs (P<.0001), greater knowledge of their own values (P<.0001), and greater knowledge of guideline-derived target goals for the ABCs compared with participants in the traditional arm (P<.0001).
Conclusion
An active-learning, empowerment-based approach applied to diabetes education can lead to greater understanding and knowledge retention.
Practice Implications
An empowerment approach to education can facilitate informed, activated patients and increase performance of self-management behaviors.
doi:10.1016/j.pec.2011.01.010
PMCID: PMC3116090  PMID: 21300516
Diabetes Education; Self-Management; Patient Empowerment; Team-Based Learning; Group Clinics
5.  Improving quality of care through improved audit and feedback 
Background
The Department of Veterans Affairs (VA) has led the industry in measuring facility performance as a critical element in improving quality of care, investing substantial resources to develop and maintain valid and cost-effective measures. The External Peer Review Program (EPRP) of the VA is the official data source for monitoring facility performance, used to prioritize the quality areas needing most attention. Facility performance measurement has significantly improved preventive and chronic care, as well as overall quality; however, much variability still exists in levels of performance across measures and facilities. Audit and feedback (A&F), an important component of effective performance measurement, can help reduce this variability and improve overall performance. Previous research suggests that VA Medical Centers (VAMCs) with high EPRP performance scores tend to use EPRP data as a feedback source. However, the manner in which EPRP data are used as a feedback source by individual providers as well as service line, facility, and network leadership is not well understood. An in-depth understanding of mental models, strategies, and specific feedback process characteristics adopted by high-performing facilities is thus urgently needed.
This research compares how leaders of high, low, and moderately performing VAMCs use clinical performance data from the EPRP as a feedback tool to maintain and improve quality of care.
Methods
We will conduct a qualitative, grounded theory analysis of up to 64 interviews using a novel method of sampling primary care, facility, and Veterans Integrated Service Network (VISN) leadership at high-, moderate-, and low-performing facilities. We will analyze interviews for evidence of cross-facility differences in perceptions of performance data usefulness and strategies for disseminating performance data evaluating performance, with particular attention to timeliness, individualization, and punitiveness of feedback delivery.
Discussion
Most research examining feedback to improve provider and facility performance lacks a detailed understanding of the elements of effective feedback. This research will highlight the elements most commonly used at high-performing facilities and identify additional features of their successful feedback strategies not previously identified. Armed with this information, practices can implement more effective A&F interventions to improve quality of care.
doi:10.1186/1748-5908-7-45
PMCID: PMC3462705  PMID: 22607640
6.  Comparative Effectiveness of Goal Setting in Diabetes Mellitus Group Clinics:Randomized Clinical Trial 
Archives of internal medicine  2011;171(5):453-459.
Background
Diabetes group clinics can effectively control hypertension, but data to support glycemic control is equivocal. This study evaluated the comparative effectiveness of two diabetes group clinic interventions on glycosolated hemoglobin (HbA1c) levels in primary care.
Methods
Participants (n = 87) were recruited from a diabetes registry of a single regional VA medical center to participate in an open, randomized comparative effectiveness study. Two primary care based diabetes group interventions of three months duration were compared. Empowering Patients in Care (EPIC) was a clinician-led, patient-centered group clinic consisting of four sessions on setting self-management action plans (diet, exercise, home monitoring, medications, etc.) and communicating about progress with action plans. The comparison intervention consisted of group education sessions with a diabetes educator and dietician followed by an additional visit with one’s primary care provider. HbA1c levels were compared post-intervention and at one-year follow-up.
Results
Participants in the EPIC intervention had significantly greater improvements in HbA1c levels immediately following the active intervention (8.86 to 8.04 vs. 8.74 to 8.70, mean [SD] between-group difference 0.67±1.3, P=.03) and these differences persisted at 1 year follow-up (.59±1.4, P=.05). A repeated measures analysis using all study time points found a significant time-by-treatment interaction effect on HbA1c levels favoring the EPIC intervention (F(2,85) =3.55, P= .03). The effect of the time-by-treatment interaction appears to be partially mediated by diabetes self-efficacy (F(1,85) =10.39, P= .002).
Conclusions
Primary care based diabetes group clinics that include structured goal-setting approaches to self-management can significantly improve HbA1c levels post-intervention and maintain improvements for 1-year.
Trial registration
ClinicalTrials.gov Identifier: NCT00481286
doi:10.1001/archinternmed.2011.70
PMCID: PMC3132209  PMID: 21403042
diabetes; group clinics intervention; goal-setting; HbA1c; self-efficacy
7.  How Well Do Doctors Know their Patients? Factors Affecting Physician Understanding of Patients’ Health Beliefs 
BACKGROUND
An important feature of patient-centered care is physician understanding of their patients’ health beliefs and values.
OBJECTIVE
Determine physicians’ awareness of patients’ health beliefs as well as communication, relationship, and demographic factors associated with better physician understanding of patients’ illness perspectives.
DESIGN
Cross-sectional, observational study.
RESEARCH PARTICIPANTS
A convenience sample of 207 patients and 29 primary care physicians from 10 outpatient clinics.
APPROACH AND MEASURES
After their consultation, patients and physicians independently completed the CONNECT instrument, a measure that assesses beliefs about the degree to which the patient’s condition has a biological cause, is the patient’s fault, is one the patient can control, has meaning for the patient, can be treated with natural remedies, and patient preferences for a partnership with the physician. Physicians completed the measure again on how they thought the patient responded. Active patient participation (frequency of questions, concerns, acts of assertiveness) was coded from audio-recordings of the consultations. Physicians’ answers for how they thought the patient responded to the health belief measure were compared to their patients’ actual responses. Degree of physician understanding of patients’ health beliefs was computed as the absolute difference between patients’ health beliefs and physicians’ perception of patients’ health beliefs.
KEY RESULTS
Physicians’ perceptions of their patients’ health beliefs differed significantly (P < 0.001) from patients’ actual beliefs. Physicians also thought patients’ beliefs were more aligned with their own. Physicians had a better understanding of the degree to which patients believed their health conditions had personal meaning (p = 0.001), would benefit from natural remedies (p = 0.049), were conditions the patient could control (p = 0.001), and wanted a partnership with the doctor (p = 0.014) when patients more often asked questions, expressed concerns, and stated their opinions. Physicians were poorer judges of patients’ beliefs when patients were African-American (desire for partnership) (p = 0.013), Hispanic (meaning) (p = 0.075), or of a different race (sense of control) (p = 0.024).
CONCLUSIONS
Physicians were not good judges of patient’s health beliefs, but had a substantially better understanding when patients more actively participated in the consultation. Strategies for increasing physicians’ awareness of patients’ health beliefs include preconsultation assessment of patients’ beliefs, implementing culturally appropriate patient activation programs, and greater use of partnership-building to encourage active patient participation.
doi:10.1007/s11606-010-1453-3
PMCID: PMC3024116  PMID: 20652759
physician-patient relationship; racial concordance; patient-centered communication; patient participation; disparities
8.  The role of cultural distance between patient and provider in explaining racial/ethnic disparities in HIV care* 
Patient education and counseling  2011;85(3):e278-e284.
Objective
We sought to evaluate whether cultural distance between patients and providers was associated with quality of care for people living with HIV/AIDS, and whether cultural distance helped explain racial/ethnic disparities in HIV care.
Methods
We surveyed 437 patients and 45 providers at 4 HIV clinics in the U.S. We examined the association of patients' perceived cultural distance from their providers with patient ratings of healthcare quality, trust in provider, receipt of antiretroviral therapy, medication adherence, and viral suppression. We also examined whether racial/ethnic disparities in these aspects of HIV care were mediated by cultural distance.
Results
Greater cultural distance was associated with lower patient ratings of healthcare quality and less trust in providers. Compared to white patients, nonwhites had significantly lower levels of trust, adherence, and viral suppression. Adjusting for patient-provider cultural distance did not significantly affect any of these disparities (p-values for mediation >.10).
Conclusion
Patient-provider cultural distance was negatively associated with perceived quality of care and trust but did not explain racial/ethnic disparities in HIV care.
Practice implications
Bridging cultural differences may improve patient–provider relationships but may have limited impact in reducing racial/ethnic disparities, unless coupled with efforts to address other sources of unequal care.
doi:10.1016/j.pec.2011.01.012
PMCID: PMC3193890  PMID: 21310581
Physician–patient relations; Culture; HIV
9.  Following the Clues: Teaching Medical Students to Explore Patients’ Contexts 
Patient education and counseling  2010;80(3):345-350.
Objective
Physicians often overlook important contextual clues that patients give during an encounter. The objective of our study was to increase medical students’ knowledge and skills in identifying contextual issues.
Methods
Six consecutive learning experiences, including a standardized patient (SP) encounter and activities designed to trigger reflection, were implemented within a first year Introduction to Clinical Medicine course. Evaluation of the intervention was measured through self-confidence, attitudes, SP history checklist, and student and small group facilitator evaluations.
Results
Standardized patient encounters, coupled with activities designed to trigger reflection, can help students identify patients’ contextual clues. Students’ confidence in eliciting patient clues significantly increased after the intervention. Our results suggest that some contextual clues were more difficult for students to elicit.
Conclusion
Multi-faceted approaches that include activities to trigger reflection are effective in teaching students to recognize and respond to contextual clues, however, more research is needed.
Practice Implications
While students elicited most clues in this study, they struggled with identifying some clues. These results suggest the need for additional research and educational development in this area.
doi:10.1016/j.pec.2010.06.035
PMCID: PMC3049898  PMID: 20674240
10.  Medical Students’ Perceptions of Their Teachers’ and Their Own Cultural Competency: Implications for Education 
Journal of General Internal Medicine  2010;25(Suppl 2):91-94.
BACKGROUND
Enhancing the cultural competency of students is emerging as a key issue in medical education; however, students may perceive that they are more able to function within cross-cultural situations than their teachers, reducing the effectiveness of cultural competency educational efforts.
OBJECTIVE
The purpose of our study was to compare medical students’ perceptions of their residents, attendings, and their own cultural competency.
DESIGN
Cross-sectional study.
MAIN MEASURES
A questionnaire containing previously validated instruments was administered to end-of-third-year medical students at four institutions throughout the US. Repeated measures multivariate analysis was used to determine differences in student ratings.
PARTICIPANTS
Three hundred fifty-eight medical students from four schools participated, for an overall response rate of 65%.
RESULTS
Analysis indicated overall statistically significant differences in students’ ratings (p < 0.001, η2 = 0.33). Students rated their own cultural competency as statistically significantly higher than their residents, but similar to their attendings. For reference, students rated the patient care competency of themselves, their residents, and their attendings; they rated their attendings’ skills as statistically significantly higher than residents, and residents as statistically significantly higher than themselves. There were differences between cultural competency and patient care ratings.
CONCLUSIONS
Our results indicate that students perceive the cultural competency of their attendings and residents to be the same or lower than themselves. These findings indicate that this is an important area for future research and curricular reform, considering the vital role that attendings and residents play in the education of medical students.
doi:10.1007/s11606-009-1245-9
PMCID: PMC2847104  PMID: 20352500
cultural competency; medical education; medical education-undergraduate
11.  When Best Intentions Aren’t Enough: Helping Medical Students Develop Strategies for Managing Bias about Patients 
Journal of General Internal Medicine  2010;25(Suppl 2):115-118.
Introduction/Aims
Implicit bias can impact physician–patient interactions, alter treatment recommendations, and perpetuate health disparities. Medical educators need methods for raising student awareness about the impact of bias on medical care.
Setting
Seventy-two third-year medical student volunteers participated in facilitated small group discussions about bias.
Program Description
We tested an educational intervention to promote group-based reflection among medical students about implicit bias.
Program Evaluation
We assessed how the reflective discussion influenced students’ identification of strategies for identifying and managing their potential biases regarding patients. 67% of the students (n = 48) identified alternate strategies at post-session. A chi-square analysis demonstrated that the distribution of these strategies changed significantly from pre-session to post-session \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \left( {{X^2}\left( {11} \right) = 27.93,\,p < 0.01} \right) $$\end{document}, including reductions in the use of internal feedback and humanism and corresponding increases in the use of reflection, debriefing and other strategies.
Discussion
Group-based reflection sessions, with a provocative trigger to foster engagement, may be effective educational tools for fostering shifts in student reflection about bias in encounters and willingness to discuss potential biases with colleagues, with implications for reducing health disparities.
doi:10.1007/s11606-009-1243-y
PMCID: PMC2847119  PMID: 20352504
bias; physician–patient interactions; medical students
12.  Associations between subspecialty fellowship interest and knowledge of internal medicine: A hypothesis-generating study of internal medicine residents 
Background
Little is known about whether and how medical knowledge relates to interest in subspecialty fellowship training. The purpose of this study was to examine the relationships between residents' interest in subspecialty fellowship training and their knowledge of internal medicine (IM).
Methods
A questionnaire was emailed to 48 categorical postgraduate-year (PGY) two and three residents at a New York university-affiliated IM residency program in 2007 using the Survey Monkey online survey instrument. Overall and content area-specific percentile scores from the IM in-training examination (IM-ITE) for the same year was used to determine objective knowledge.
Results
Forty-five of 48 residents (response rate was 93.8%) completed the survey. Twenty-two (49%) were PG2 residents and 23(51%) were PGY3 residents. Sixty percent of respondents were male. Six (13%) residents were graduates of U.S. medical schools. Eight (18%) reported formal clinical training prior to starting internal medicine residency in the U.S. Of this latter group, 6 (75%) had training in IM and 6 (75) % reported a training length of 3 years or less. Thirty-seven of 45 (82%) residents had a subspecialty fellowship interest. Residents with a fellowship interest had a greater mean overall objective knowledge percentile score (56.44 vs. 31.67; p = 0.04) as well as greater mean percentile scores in all content areas of IM. The adjusted mean difference was statistically significant (p < 0.02) across three content areas.
Conclusions
More than half of surveyed residents indicated interest in pursuing a subspecialty fellowship. Fellowship interest appears positively associated with general medical knowledge in this study population. Further work is needed to explore motivation and study patterns among internal medicine residents.
doi:10.1186/1472-6920-11-5
PMCID: PMC3038163  PMID: 21281500
13.  RECONSIDERING THE TEAM CONCEPT: EDUCATIONAL IMPLICATIONS FOR PATIENT-CENTERED CANCER CARE 
Patient education and counseling  2009;77(3):450-455.
Patient-centered cancer care has become a priority in the oncology field. Increasing efforts to train oncologists in communication skills have led to a growing literature on patient-centered cancer education. In addition, systems approaches have led to an increased emphasis on the concept of teams as an organizing framework for cancer care. In this essay, we examine issues involved in educating teams to provide patient-centered cancer care. In the process, we question the applicability of a tightly coordinated ‘team’ concept, and suggest the concept of a ‘care community’ as a more achievable ideal for the way that cancer care is commonly delivered. We discuss the implications that this has for cancer communication education, and propose three principles to guide the development of educational interventions aimed at increasing patient-centeredness in cancer care delivery systems.
doi:10.1016/j.pec.2009.09.020
PMCID: PMC2787698  PMID: 19850437
Physician-Patient Relations; Patient-Centered Care; Medical Oncology; Radiation Oncology; Oncology Service
14.  Behind Closed Doors: Physician-Patient Discussions About Colorectal Cancer Screening 
Journal of General Internal Medicine  2009;24(11):1228-1235.
BACKGROUND
Despite the availability of multiple effective screening tests for colorectal cancer, screening rates remain suboptimal. The literature documents patient preferences for different test types and recommends a shared decision-making approach for physician-patient colorectal cancer screening (CRCS) discussions, but it is unknown whether such communication about CRCS preferences and options actually occurs in busy primary-care settings.
OBJECTIVE
Describe physician-patient CRCS discussions during a wellness visit.
DESIGN
Cross-sectional; patients audio-recorded with physicians.
PARTICIPANTS
A subset of patients (N = 64) participating in a behavioral intervention trial designed to increase CRCS who completed a wellness visit during the trial with a participating physician (N = 8).
APPROACH
Transcripts were analyzed using qualitative methods.
RESULTS
Physicians in this sample consistently recommended CRCS, but focused on colonoscopy. Physicians did not offer a fecal occult blood test alone as a screening choice, which may have created missed opportunities for some patients to get screened. In this single visit, physicians’ communication processes generally precluded discussion of patients’ test preferences and did not facilitate shared decision-making. Patients’ questions indicated their interest in different CRCS test types and appeared to elicit more information from physicians. Some patients remained resistant to CRCS after discussing it with a physician.
CONCLUSION
If a preference for colonoscopy is widespread among primary-care physicians, the implications for intervention are either to prepare patients for this preference or to train physicians to offer options when recommending screening to patients.
doi:10.1007/s11606-009-1108-4
PMCID: PMC2771240  PMID: 19763699
colorectal cancer screening; physician-patient communication; shared decision-making; qualitative research; interventions
15.  Does Reducing Physician Uncertainty Improve Hypertension Control? Rationale and Methods 
Background
Hypertension affects nearly one-third of the U.S. population overall, and the prevalence rises sharply with age. In spite of public educational campaigns and professional education programs to encourage blood pressure measurement and control of both systolic and diastolic control to < 140/90 mmHg (or 130/80 mmHg if diabetic), 43% of treated hypertensives do not achieve the recommended JNC VII target. Among African-Americans, 48% are uncontrolled on treatment. The majority of persons classified as poorly controlled hypertensives have mild systolic blood pressure elevation (in the range of 140–160 mmHg). We hypothesized that physician uncertainty regarding the patient’s usual blood pressure, as well as uncertainty regarding the extent of medication non-adherence represent an important barrier to further reductions in the proportion of uncontrolled hypertensives in the U.S.
Methods
Using cluster randomization, ten primary care clinics (six from a public health care system and four from a private clinic system) were randomized to either the uncertainty reduction intervention condition or to usual care. An average of 68 patients per clinic were recruited to serve as units of observation. Physicians in the five intervention clinics were provided with a specially designed study form that included a graph of recent blood pressure measurements in their study patients, a check box to indicate their assessment of the adequacy of the patient’s blood pressure control, and a menu of services they could order to aid in patient management. These menu options included: 24-hour ambulatory blood pressure monitoring (ABPM); electronic bottle cap assessment of medication adherence, followed by medication adherence counseling in patients found to be non-adherent; and lifestyle assessment and counseling followed by 24-hour ABPM. Physicians in the five usual practice clinics did not have access to these services, but were informed of which patients had been enrolled in the study. Substudies carried out to further characterize the study population and interpret intervention results included ABPM and electronic bottle cap monitoring in a random subsample of patients at baseline, and audio recording of patient-physician encounters after intervention implementation.
Results
The primary study endpoint was defined as the proportion of patients with controlled blood pressure (BP < 140/90 mmHg or < 130/80 mmHg if diabetic). Secondary endpoints include actual measured clinic systolic and diastolic blood pressure, patient physician communication patterns, physician prescribing patient self-reported lifestyle and medication adherence, physician knowledge, attitude and beliefs regarding the utility of intervention tools to achieve blood pressure control, and the cost-effectiveness of the intervention. Six-hundred eighty patients have been randomized, and 675 remain in active follow-up after 1.5 years. Patient closeout will be complete in March of 2009. Analysis of the baseline data is in progress.
Conclusions
Office-based blood pressure measurement error and bias, as well as physician and patient beliefs about the need for treatment intensification may be important factors that limit further progress in blood pressure control. This trial will provide data on the extent to which available technologies not widely used in primary care will change physician prescribing behavior and patient adherence to prescribed treatment.
doi:10.1161/CIRCOUTCOMES.109.849984
PMCID: PMC2780342  PMID: 20031846
Hypertension Control; African-Americans; Cluster-randomized Trial; 24-hour Ambulatory Blood Pressure Monitoring; electronic bottle cap monitoring
16.  Details for Manuscript Number SSM-D-06-01956R1 “Physicians” Communication and Perceptions of Patients: Is it How They Look, How They Talk, or is it Just the Doctor?” 
Social science & medicine (1982)  2007;65(3):586-598.
Although physicians’ communication style and perceptions affect outcomes, few studies have examined how these perceptions relate to the way physicians communicate with patients. Moreover, while any number of factors may affect the communication process, few studies have analyzed these effects collectively in order to identify the most powerful influences on physician communication and perceptions. Adopting an ecological approach, this investigation examined: (a) the relationships of physicians’ patient-centered communication (informative, supportive, partnership-building) and affect (positive, contentious) on their perceptions of the patient, and (b) the degree to which communication and perceptions were affected by the physicians’ characteristics, patients’ demographic characteristics, physician-patient concordance, and the patient’s communication. Physicians (N = 29) and patients (N = 207) from 10 outpatient settings in the United States participated in the study. From audio-recordings of these visits, coders rated the physicians’ communication and affect as well as the patients’ participation and affect. Doctors were more patient-centered with patients they perceived as better communicators, more satisfied, and more likely to adhere. Physicians displayed more patient-centered communication and more favorably perceived patients who expressed positive affect, were more involved, and who were less contentious. Physicians were more contentious with black patients, whom they also perceived as less effective communicators and less satisfied. Finally, physicians who reported a patient-centered orientation to the doctor-patient relationship also were more patient-centered in their communication. The results suggest that reciprocity and mutual influence have a strong effect on these interactions in that more positive (or negative) communication from one participant leads to similar responses from the other. Physicians’ encounters with black patients revealed communicative difficulties that may lower quality of care for these patients.
doi:10.1016/j.socscimed.2007.03.036
PMCID: PMC2811428  PMID: 17462801
USA; physician-patient communication; physician perceptions; racial inequalities; patient participation
17.  Integrating Diabetes Self-Management with the Health Goals of Older Adults: A Qualitative Exploration 
Patient education and counseling  2008;72(3):418-423.
Objective
This study investigates the life and health goals of older adults with diabetes, and explores the factors that influence their diabetes self-management.
Methods
Qualitative in-depth interviews were conducted with 24 older adults with diabetes and other morbid conditions and/or their caregivers, when appropriate.
Results
Participants’ provided a consistent set of responses when describing life and health goals. Participants described goals for longevity, better physical functioning, spending time with family, or maintaining independence. Diabetes discordant conditions, but not diabetes, were seen as barriers to life goals for participants with functional impairments. Functionally independent participants described additional health goals that related to diabetes self-management as diabetes was seen often a barrier to life goals. Caregivers, co-morbid conditions, denial and retirement were among the factors that influenced initiation of diabetes self-management.
Conclusion
Participants endorsed health goals and diabetes self-management practices that they believed would help them accomplish their life goals. Functional capabilities and social support were key factors in the relationship between diabetes self-management and their broader goals.
Practice Implications
When planning diabetes treatments, clinicians, patients and caregivers should discuss the relationship between diabetes self-management and health and life goals as well as the affects of functional limitations and caregiver support.
doi:10.1016/j.pec.2008.05.017
PMCID: PMC2613855  PMID: 18621501
diabetes; co-morbidity; self-management; goals
18.  Caring Attitudes in Medical Education: Perceptions of Deans and Curriculum Leaders 
Journal of General Internal Medicine  2007;22(11):1514-1522.
BACKGROUND
Systems of undergraduate medical education and patient care can create barriers to fostering caring attitudes.
OBJECTIVE
The aim of this study is to survey associate deans and curriculum leaders about teaching and assessment of caring attitudes in their medical schools.
PARTICIPANTS
The participants of this study include 134 leaders of medical education in the USA and Canada.
METHODS
We developed a survey with 26 quantitative questions and 1 open-ended question. In September to October 2005, the Association of American Medical Colleges distributed it electronically to curricular leaders. We used descriptive statistics to analyze quantitative data, and the constant comparison technique for qualitative analysis.
RESULTS
We received 73 responses from 134 medical schools. Most respondents believed that their schools strongly emphasized caring attitudes. At the same time, 35% thought caring attitudes were emphasized less than scientific knowledge. Frequently used methods to teach caring attitudes included small-group discussion and didactics in the preclinical years, role modeling and mentoring in the clinical years, and skills training with feedback throughout all years. Barriers to fostering caring attitudes included time and productivity pressures and lack of faculty development. Respondents with supportive learning environments were more likely to screen applicants’ caring attitudes, encourage collaborative learning, give humanism awards to faculty, and provide faculty development that emphasized teaching of caring attitudes.
CONCLUSIONS
The majority of educational leaders value caring attitudes, but overall, educational systems inconsistently foster them. Schools may facilitate caring learning environments by providing faculty development and support, by assessing students and applicants for caring attitudes, and by encouraging collaboration.
doi:10.1007/s11606-007-0318-x
PMCID: PMC2219796  PMID: 17786522
caring attitudes; medical education; hidden curriculum; professionalism
19.  Where We’re Headed: A New Wave of Scholarship on Educating Medical Professionalism 
Journal of General Internal Medicine  2008;23(7):1118-1119.
doi:10.1007/s11606-008-0670-5
PMCID: PMC2517922  PMID: 18612756
education, medical; physician’s role; education, medical, undergraduate; education, medical, graduate; social environment; organizational culture; schools, medical; internship and residency; professional practice; ethics, professional; professional–patient relations; learning; teaching; psychology, educational
20.  Personal Growth During Internship: A Qualitative Analysis of Interns' Responses to Key Questions 
BACKGROUND
During clinical training, house officers frequently encounter intense experiences that may affect their personal growth. The purpose of this study was to explore processes related to personal growth during internship.
DESIGN
Prospective qualitative study conducted over the course of internship.
PARTICIPANTS
Thirty-two postgraduate year (PGY)-1 residents from 9 U.S. internal medicine training programs.
APPROACH
Every 8 weeks, interns responded by e-mail to an open-ended question related to personal growth. Content analysis methods were used to analyze the interns' writings to identify triggers, facilitators, and barriers related to personal growth.
RESULTS
Triggers for personal growth included caring for critically ill or dying patients, receiving feedback, witnessing unprofessional behavior, experiencing personal problems, and dealing with the increased responsibility of internship. Facilitators of personal growth included supportive relationships, reflection, and commitment to core values. Fatigue, lack of personal time, and overwhelming work were barriers to personal growth. The balance between facilitators and barriers may dictate the extent to which personal growth occurs.
CONCLUSIONS
Efforts to support personal growth during residency training include fostering supportive relationships, encouraging reflection, and recognizing interns' core values especially in association with powerful triggers.
doi:10.1111/j.1525-1497.2006.00383.x
PMCID: PMC1924625  PMID: 16808737
graduate medical education; personal growth; qualitative research
21.  Not the Same Everywhere 
BACKGROUND
Learning environments overtly or implicitly address patient-centered values and have been the focus of research for more than 40 years, often in studies about the “hidden curriculum.” However, many of these studies occurred at single medical schools and used time-intensive ethnographic methods. This field of inquiry lacks survey methods and information about how learning environments differ across medical schools.
OBJECTIVE
To examine patient-centered characteristics of learning environments at 9 U.S. medical schools.
DESIGN
Cross-sectional internet-based survey.
PARTICIPANTS
Eight-hundred and twenty-three third- and fourth-year medical students in the classes of 2002 and 2003.
MEASUREMENTS
We measured the patient-centeredness of learning environments with the Communication, Curriculum, and Culture (C3) Instrument, a 29-item validated measure that characterizes the degree to which a medical school's environment fosters patient-centered care. The C3 Instrument contains 3 content areas (role modeling, students' experiences, and support for students' patient-centered behaviors), and is designed to measure these areas independent of respondents' attitudes about patient-centered care. We also collected demographic and attitudinal information from respondents.
RESULTS
The variability of C3 scores across schools in each of the 3 content areas of the instrument was striking and statistically significant (P values ranged from .001 to .004). In addition, the patterns of scores on the 3 content areas differed from school to school.
CONCLUSIONS
The 9 schools demonstrated unique and different learning environments both in terms of magnitude and patterns of characteristics. Further multiinstitutional study of hidden curricula is needed to further establish the degree of variability that exists, and to assist educators in making informed choices about how to intervene at their own schools.
doi:10.1111/j.1525-1497.2006.00417.x
PMCID: PMC1484792  PMID: 16704378
physician-patient relations; patient-centered care; schools, medical; students, medical; culture; organizational culture; education, medical, undergraduate; curriculum
22.  A quasi-experimental test of an intervention to increase the use of thiazide-based treatment regimens for people with hypertension 
Background
Despite recent high-quality evidence for their cost-effectiveness, thiazides are underused for controlling hypertension. The goal of this study was to design and test a practice-based intervention aimed at increasing the use of thiazide-based antihypertensive regimens.
Methods
This quasi-experimental study was carried out in general medicine ambulatory practices of a large, academically-affiliated Veterans Affairs hospital. The intervention group consisted of the practitioners (13 staff and 215 trainees), nurses, and patients (3,502) of the teaching practice; non-randomized concurrent controls were the practitioners (31 providers) and patients (18,292) of the non-teaching practices. Design of the implementation intervention was based on Rogers' Diffusion of Innovations model. Over 10.5 months, intervention teams met weekly or biweekly and developed and disseminated informational materials among themselves and to trainees, patients, and administrators. These teams also reviewed summary electronic-medical-record data on thiazide use and blood pressure (BP) goal attainment. Outcome measures were the proportion of hypertensive patients prescribed a thiazide-based regimen, and the proportion of hypertensive patients attaining BP goals regardless of regimen. Thirty-three months of time-series data were available; statistical process control charts, change point analyses, and before-after analyses were used to estimate the intervention's effects.
Results
Baseline use of thiazides and rates of BP control were higher in the intervention group than controls. During the intervention, thiazide use and BP control increased in both groups, but changes occurred earlier in the intervention group, and primary change points were observed only in the intervention group. Overall, the pre-post intervention difference in proportion of patients prescribed thiazides was greater in intervention patients (0.091 vs. 0.058; p = 0.0092), as was the proportion achieving BP goals (0.092 vs. 0.044; p = 0.0005). At the end of the implementation period, 41.4% of intervention patients were prescribed thiazides vs. 30.6% of controls (p < 0.001); 51.6% of intervention patients had achieved BP goals vs. 44.3% of controls (p < 0.001).
Conclusion
This multi-faceted intervention appears to have resulted in modest improvements in thiazide prescribing and BP control. The study also demonstrates the value of electronic medical records for implementation research, how Rogers' model can be used to design and launch an implementation strategy, and how all members of a clinical microsystem can be involved in an implementation effort.
doi:10.1186/1748-5908-2-5
PMCID: PMC1803001  PMID: 17298669
23.  The “New Revolution” in Medical Education 
Journal of General Internal Medicine  2004;19(5 Pt 2):610-611.
doi:10.1111/j.1525-1497.2004.45003.x
PMCID: PMC1492312  PMID: 15109334
24.  Beliefs About Control in the Physician-patient Relationship 
OBJECTIVES
Effective communication is a critical component of quality health care, and to improve it we must understand its dynamics. This investigation examined the extent to which physicians' and patients' preferences for control in their relationship (e.g., shared control vs doctor control) were related to their communications styles and adaptations (i.e., how they responded to the communication of the other participant).
DESIGN
Stratified case-controlled study.
PATIENTS/PARTICIPANTS
Twenty family medicine and internal medicine physicians and 135 patients.
MEASUREMENTS
Based on scores from the Patient-Practitioner Orientation Scale, 10 patient-centered physicians (5 male, 5 female) and 10 doctor-centered physicians (5 male, 5 female) each interacted with 5 to 8 patients, roughly half of whom preferred shared control and the other half of whom were oriented toward doctor control. Audiotapes of 135 consultations were coded for behaviors indicative of physician partnership building and active patient participation.
MAIN RESULTS
Patients who preferred shared control were more active participants (i.e., expressed more opinions, concerns, and questions) than were patients oriented toward doctor control. Physicians' beliefs about control were not related to their use of partnership building. However, physicians did use more partnership building with male patients. Not only were active patient participation and physician partnership building mutually predictive of each other, but also approximately 14% of patient participation was prompted by physician partnership building and 33% of physician partnership building was in response to active patient participation.
CONCLUSIONS
Communication in medical encounters is influenced by the physician's and patient's beliefs about control in their relationship as well as by one another's behavior. The relationship between physicians' partnership building and active patient participation is one of mutual influence such that increases in one often lead to increases in the other.
doi:10.1046/j.1525-1497.2003.20749.x
PMCID: PMC1494906  PMID: 12911642
physician-patient communication; patient participation; control; gender
25.  Racial and Ethnic Disparities in the Use of Health Services 
African Americans and Latinos use services that require a doctor's order at lower rates than do whites. Racial bias and patient preferences contribute to disparities, but their effects appear small. Communication during the medical interaction plays a central role in decision making about subsequent interventions and health behaviors. Research has shown that doctors have poorer communication with minority patients than with others, but problems in doctor-patient communication have received little attention as a potential cause, a remediable one, of health disparities. We evaluate the evidence that poor communication is a cause of disparities and propose some remedies drawn from the communication sciences.
doi:10.1046/j.1525-1497.2003.20532.x
PMCID: PMC1494820  PMID: 12542590
communication; recial disparities; race; health care utilization

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