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Year of Publication
1.  Socioeconomic Position and Cardiovascular Disease in Adults with and Without Diabetes: United States Trends, 1997–2005 
Journal of General Internal Medicine  2008;23(10):1634-1641.
Background
Diabetes and its cardiovascular complications are more common in adults of low socioeconomic position (SEP). In the US, the past decade has seen the establishment of many programs to reduce cardiovascular risk in persons with diabetes, but their effect on socioeconomic disparities is uncertain.
Objective
We sought to investigate recent time trends in socioeconomic disparities in cardiovascular disease (CVD) among persons with and without diabetes.
Participants and Design
Two hundred fifty-five thousand nine hundred sixty-six individuals aged 25 years or older included in the National Health Interview Survey between 1997 and 2005.
Measurements
Educational attainment was used as a marker for SEP and self-reported history of CVD as the main outcome. Educational disparities were measured using prevalence rate ratios (PRR) and the relative index of inequalities (RII).
Main Results
Among adults with diabetes, CVD prevalence was persistently higher in those who did not complete high school (HS) than in college graduates (adjusted PRR [aPRR] 1.20, 95% confidence interval [95%CI] 1.05–1.38 in 1997–1999, and aPRR 1.12, 95% CI 1.00–1.25 in 2003–2005). However, the HS vs. college graduates disparity in CVD declined from 1997–1999 (aPRR 1.20, 95% CI 1.04–1.37) to 2003–2005 (aPRR 1.01, 95% CI 0.90–1.12). Among adults without diabetes educational disparities in CVD widened markedly over time.
Conclusions
Concurrently with improvements in diabetes management, the widening of socioeconomic health disparities has remained limited in the diabetic population during the past decade. This provides evidence for the potential impact of improvements in disparities in health care access and process, such as experienced among persons with diabetes, in limiting socioeconomic health disparities.
doi:10.1007/s11606-008-0727-5
PMCID: PMC2533376  PMID: 18668297
diabetes mellitus; cardiovascular diseases; socioeconomic factors; health disparities
2.  Preferences for Human Papillomavirus Testing with Routine Cervical Cancer Screening in Diverse Older Women 
Journal of General Internal Medicine  2008;23(9):1324-1329.
Background
Human papillomavirus (HPV) testing is increasingly being used to determine the optimal cervical cancer screening interval in older women. Little is known about women’s attitudes toward HPV testing or how these attitudes may influence medical discussions about cervical cancer screening.
Methods
Preferences for HPV and concomitant Papanicolaou (Pap) testing were assessed through in-person interviews with diverse women aged 50 to 80 years recruited from community and university-based practices.
Results
Eight hundred and sixty-five women (257 White, 87 African American, 149 Latina, and 372 Asian) were interviewed. Approximately 60% of participants wanted to be tested for HPV and another 15% would undergo testing if recommended by their physician. Among those wanting HPV testing, 94% would want more frequent than annual Pap tests if they had a positive HPV test and a normal Pap test. Two thirds of those under age 65 would be willing to switch to triennial Pap testing, and half of those aged 65 and older would be willing to discontinue Pap testing, if they had a negative HPV test and normal Pap test. Preferences for testing varied by ethnicity, age, place of birth, and cancer history.
Conclusions
The majority of older women were willing to use HPV testing to make decisions about frequency and duration of cervical cancer screening, but up to one third would want at least annual, ongoing screening regardless of HPV test results. Efforts should be made to ensure that HPV testing is used to reinforce appropriate utilization of screening tests.
doi:10.1007/s11606-008-0633-x
PMCID: PMC2518007  PMID: 18506546
human papillomavirus; cervical cancer screening; ethnicity; Papanicolaou test
3.  A New Age for Cancer Information Seeking: Are We Better Off Now? 
Abstract
A decade after the dawn of the Internet Age, are people who seek health information better off than they used to be? The current study by Arora and colleagues examines a small slice of the massive Health Information National Trends Survey dataset and attempts to understand the experiences of those US adults who have sought cancer information at any point in their lives from any source. One third reported that the information they encountered was hard to understand, and one half questioned the quality of the information they found. Several research questions regarding how individuals successfully find information on the Internet remain to be answered.
doi:10.1007/s11606-007-0496-6
PMCID: PMC2245996  PMID: 18200452
internet; health information seeking; cancer information
4.  Socioeconomic position and cardiovascular disease in adults with and without diabetes: United States trends, 1997-2005 
Journal of General Internal Medicine  2008;23(10):1634-1641.
Background
Diabetes and its cardiovascular complications are more common in adults of low socioeconomic position (SEP). In the US, the past decade saw the establishment of many programs to reduce cardiovascular risk in persons with diabetes, but their effect on socioeconomic disparities is uncertain.
Objective
We sought to investigate recent time trends in socioeconomic disparities in cardiovascular disease (CVD) among persons with and without diabetes.
Participants and Design
255,966 individuals aged 25 years or older included in the National Health Interview Survey between 1997 and 2005.
Measurements
Educational attainment was used as a marker for SEP and self-reported history of CVD as the main outcome. Educational disparities were measured using prevalence rate ratios (PRR) and relative index of inequalities (RII).
Results
Among adults with diabetes, CVD prevalence was persistently higher in those who did not complete high school (HS) than in college graduates (adjusted PRR [aPRR] 1.20, 95% confidence interval [95%CI] 1.05–1.38 in 1997–1999, and aPRR 1.12, 95%CI 1.00–1.25 in 2003–2005). However, the HS vs. college graduates disparity in CVD declined from 1997–1999 (aPRR 1.20, 95%CI 1.04–1.37) to 2003–2005 (aPRR 1.01, 95%CI 0.90–1.12). Among adults without diabetes educational disparities in CVD widened markedly over time.
Conclusions
Concurrently with improvements in diabetes management, the widening of socioeconomic health disparities has remained limited in the diabetic population during the past decade. This provides evidence for the potential impact of improvements in disparities in health care access and process, such as experienced among persons with diabetes, in limiting socioeconomic health disparities.
doi:10.1007/s11606-008-0727-5
PMCID: PMC2533376  PMID: 18668297
Diabetes mellitus; Cardiovascular diseases; Socioeconomic factors; Health disparities
5.  Preferences for Human Papillomavirus Testing with Routine Cervical Cancer Screening in Diverse Older Women 
BACKGROUND
Human papillomavirus (HPV) testing is increasingly being used to determine the optimal cervical cancer screening interval in older women. Little is known about women’s attitudes toward HPV testing or how these attitudes may influence medical discussions about cervical cancer screening.
METHODS
Preferences for HPV and concomitant Papanicolaou (Pap) testing were assessed through in-person interviews with diverse women aged 50 to 80 years recruited from community and university-based practices.
RESULTS
865 women (257 White, 87 African American, 149 Latina, and 372 Asian) were interviewed. Approximately 60% of participants wanted to be tested for HPV and another 15% would undergo testing if recommended by their physician. Among those wanting HPV testing, 94% would want more frequent than annual Pap tests if they had a positive HPV test and a normal Pap test. Two thirds of those under age 65 would be willing to switch to triennial Pap testing, and half of those aged 65 and older would be willing to discontinue Pap testing, if they had a negative HPV test and normal Pap test. Preferences for testing varied by ethnicity, age, place of birth, and cancer history.
CONCLUSIONS
The majority of older women were willing to use HPV testing to make decisions about frequency and duration of cervical cancer screening, but up to one third would want at least annual, ongoing screening regardless of HPV test results. Efforts should be made to ensure that HPV testing is used to reinforce appropriate utilization of screening tests.
doi:10.1007/s11606-008-0633-x
PMCID: PMC2518007  PMID: 18506546
Human papillomavirus; cervical cancer screening; ethnicity; Papanicolaou test
6.  Refusal of Medical and Surgical Interventions by Older Persons with Advanced Chronic Disease 
BACKGROUND
Patients with advanced chronic disease are frequently offered medical and surgical interventions with potentially large trade-offs between benefits and burdens. Little is known about the frequency or outcomes of treatment refusal among these patients.
OBJECTIVE
To assess the frequency of, reasons for, factors associated with, and outcomes of treatment refusal among older persons with advanced chronic disease.
DESIGN
Observational cohort study.
PARTICIPANTS
Two hundred twenty-six community-dwelling persons with advanced cancer, chronic obstructive pulmonary disease, or congestive heart failure, interviewed at least every 4 months for up to 2 years.
MEASUREMENTS
Participants were asked if they had refused any treatments recommended by their physicians, and why.
RESULTS
Thirty-six of 226 patients (16%) reported refusing 1 or more medical or surgical treatments recommended by their physician. The most frequently refused interventions were cardiac catheterization and surgery. The most common reason for refusal was fear of side effects (41%). Treatment refusal was more frequent among patients who wanted prognostic information (10% vs 2%, p = .02) or estimated their own longevity at 2 years or less (18% vs 5%, p = .02). There was an increased risk of mortality among refusers compared with non-refusers (HR 1.98, 95% CI 1.02–3.86).
CONCLUSIONS
Refusal of medical and surgical interventions other than medications is common among persons with advanced chronic disease, and is associated with a greater desire for, and understanding of, prognostic information.
doi:10.1007/s11606-007-0222-4
PMCID: PMC1948844  PMID: 17483977
chronic disease; decision making; refusal
7.  Awareness of Hepatitis C Diagnosis is Associated with Less Alcohol Use Among Persons Co-Infected with HIV 
BACKGROUND AND OBJECTIVE
It is unknown whether testing HIV-infected individuals for hepatitis C virus (HCV) and informing them of their HCV status impacts subsequent alcohol use. We hypothesized that HIV-infected individuals with current or past alcohol problems who reported being told they had HCV were more likely to 1) abstain from alcohol and 2) not drink unhealthy amounts compared to individuals who had not been told.
DESIGN, PARTICIPANTS, AND MEASUREMENTS
Data from a prospective, observational cohort study (HIV-Longitudinal Interrelationships of Viruses and Ethanol) were used to assess the association between awareness of having HCV at baseline and subsequent abstinence and not drinking unhealthy amounts as reported at 6-month follow-up intervals. General estimating equations logistic regression was used to account for the correlation from using repeated observations from the same subject over time. We adjusted for age, sex, race, homelessness, injection drug use, depressive symptoms, and having abnormal liver tests.
RESULTS
Participants who reported being told they had HCV were more likely to report abstaining from alcohol (AOR = 1.60; 95% CI: 1.13 to 2.27) and not drinking unhealthy amounts (AOR = 1.46; 95% CI: 1.01 to 2.11).
CONCLUSIONS
Among patients infected with HIV who had a history of alcohol problems, reporting being told one had HCV was associated with greater abstinence from alcohol and less unhealthy amounts of drinking.
doi:10.1007/s11606-007-0147-y
PMCID: PMC2048689  PMID: 17503108
alcohol; hepatitis C; HIV; awareness of diagnosis
8.  Why do General Practitioners Decline Training to Improve Management of Medically Unexplained Symptoms? 
Background
General practitioners’ (GPs) communication with patients presenting medically unexplained symptoms (MUS) has the potential to somatize patients’ problems and intensify dependence on medical care. Several reports indicate that GPs have negative attitudes about patients with MUS. If these attitudes deter participation in training or other methods to improve communication, practitioners who most need help will not receive it.
Objective
To identify how GPs’ attitudes to patients with MUS might inhibit their participation with training to improve management.
Design
Qualitative study.
Participants
GPs (N = 33) who had declined or accepted training in reattribution techniques in the context of a research trial.
Approach
GPs were interviewed and their accounts analysed qualitatively.
Results
Although attitudes that devalued patients with MUS were common in practitioners who had declined training, these coexisted, in the same practitioners, with evidence of intuitive and elaborate psychological work with these patients. However, these practitioners devalued their psychological skills. GPs who had accepted training also described working psychologically with MUS but devalued neither patients with MUS nor their own psychological skills.
Conclusions
GPs’ attitudes that suggested disengagement from patients with MUS belied their pursuit of psychological objectives. We therefore suggest that, whereas negative attitudes to patients have previously been regarded as the main barrier to involvement in measures to improve patient management, GPs devaluing of their own psychological skills with these patients may be more important.
doi:10.1007/s11606-006-0094-z
PMCID: PMC1855690  PMID: 17443362
medically unexplained symptoms; general practitioners; management; psychological skills; attitudes
9.  Stress from Uncertainty from Graduation to Retirement—A Population-Based Study of Swiss Physicians 
BACKGROUND
Uncertainty shapes many decisions made by physicians everyday. Uncertainty and physicians’ inability to handle it may result in substandard care and unexplained variations in patterns of care.
OBJECTIVE
To describe socio-demographic and professional characteristics of reactions to uncertainty among physicians from all specialties, including physicians in training.
DESIGN
Cross-sectional postal survey.
PARTICIPANT
All physicians practicing in Geneva, Switzerland (n = 1,994).
MEASUREMENT
Reaction to medical care uncertainty was measured with the Anxiety Due to Uncertainty and Concern About Bad Outcomes scales. The questionnaire also included items about professional characteristics and work-related satisfaction scales.
RESULTS
After the first mailing and two reminders, 1,184 physicians responded to the survey. In univariate analysis, women, junior physicians, surgical specialists, generalist physicians, and physicians with lower workloads had higher scores in both scales. In multivariate models, sex, medical specialty, and workload remained significantly associated with both scales, whereas clinical experience remained associated only with concern about bad outcomes. Higher levels of anxiety due to uncertainty were associated with lower scores of work-related satisfaction, while higher levels of concern about bad outcomes were associated with lower satisfaction scores for patient care, personal rewards, professional relations, and general satisfaction, but not for work-related burden or satisfaction with income-prestige. The negative effect of anxiety due to uncertainty on work-related satisfaction was more important for physicians in training.
CONCLUSION
Physicians’ reactions to uncertainty in medical care were associated with several dimensions of work-related satisfaction. Physicians in training experienced the greatest impact of anxiety due to uncertainty on their work-related satisfaction. Incorporating strategies to deal with uncertainty into residency training may be useful.
doi:10.1007/s11606-007-0159-7
PMCID: PMC1855273  PMID: 17443371
uncertainty; quality of care; medical training; work-related satisfaction
10.  Mortality in Peripheral Arterial Disease: A Comparison of Patients Managed by Vascular Specialists and General Practitioners 
BACKGROUND
Peripheral arterial disease (PAD) is undertreated by general practitioners (GPs). However, the impact of the suboptimal clinical management is unknown.
OBJECTIVE
To assess the mortality rate of PAD patients in relation to the type of physician who provides their care (GP or vascular specialist).
DESIGN
Prospective study.
SETTING
Primary care practice and academic vascular laboratory.
PARTICIPANTS
GP patients (n = 60) were those of the Peripheral Arteriopathy and Cardiovascular Events study (PACE). Patients managed by specialists (n = 82) were consecutive subjects with established PAD who were referred to our vascular laboratory during the enrolment period of the PACE study.
MEASUREMENTS
All-cause and cardiovascular mortality.
RESULTS
After 32 months of follow-up, specialist management was associated with a lower rate of all-cause mortality (RR = 0.04; 95% CI 0.01–0.34; p = .003) and cardiovascular mortality (RR = 0.07; 95% CI 0.01–0.65; p = .020), after adjustment for patients’ characteristics. Specialists were more likely to use antiplatelet agents (93% vs 73%, p < .001), statins (62% vs 25%, p < .001) and beta blockers (28% vs 3%, p < .001). Survival differences between specialists and GPs disappeared once the use of pharmacotherapies was added to the proportional hazard model. The fully adjusted model showed that the use of statins was significantly associated with a reduced risk of all-cause mortality (RR = 0.02; 95% CI 0.01–0.73, p = .034) and cardiovascular mortality (RR = 0.02; 95% CI 0.01–0.71, p = .033).
CONCLUSIONS
Specialist management of patients with symptomatic PAD resulted in better survival than generalist management. This effect appears to be mainly caused by the more frequent use of effective medicines by specialists.
doi:10.1007/s11606-007-0162-z
PMCID: PMC1852923  PMID: 17354043
peripheral arterial disease; mortality; vascular specialists; general practitioners
11.  Characteristics of Nondisabled Older Patients Developing New Disability Associated with Medical Illnesses and Hospitalization 
OBJECTIVE
To identify demographic, clinical, and biological characteristics of older nondisabled patients who develop new disability in basic activities of daily living (BADL) during medical illnesses requiring hospitalization.
DESIGN
Longitudinal observational study.
SETTING
Geriatric and Internal Medicine acute care units.
PARTICIPANTS
Data are from 1,686 patients aged 65 and older who independent in BADL 2 weeks before hospital admission, enrolled in the 1998 survey of the Italian Group of Pharmacoepidemiology in the Elderly Study.
MEASUREMENTS
Study outcome was new BADL disability at time of hospital discharge. Sociodemographic, functional status, and clinical characteristics were collected at hospital admission; acute and chronic conditions were classified according to the International Classification of Disease, ninth revision; fasting blood samples were obtained and processed with standard methods.
RESULTS
At the time of hospital discharge 113 patients (6.7%) presented new BADL disability. Functional decline was strongly related to patients’ age and preadmission instrumental activities of daily living status. In a multivariate analysis, older age, nursing home residency, low body mass index, elevated erythrocyte sedimentation rate, acute stroke, high level of comorbidity expressed as Cumulative Illness Rating Scale score, polypharmacotherapy, cognitive decline, and history of fall in the previous year were independent and significant predictors of BADL disability.
CONCLUSION
Several factors might contribute to loss of physical independence in hospitalized older persons. Preexisting conditions associated with the frailty syndrome, including physical and cognitive function, comorbidity, body composition, and inflammatory markers, characterize patients at high risk of functional decline.
doi:10.1007/s11606-007-0152-1
PMCID: PMC1852921  PMID: 17443376
hospitalization; frailty; disability; functional status; aging
12.  Comparison of Hospital Costs and Length of Stay for Community Internists, Hospitalists, and Academicians 
BACKGROUND
The model of inpatient medical management has evolved toward Hospitalists because of greater cost efficiency compared to traditional practice. The optimal model of inpatient care is not known.
OBJECTIVE
To compare three models of inpatient Internal Medicine (traditional private practice Internists, private Hospitalist Internists, and Academic Internists with resident teams) for cost efficiency and quality at a community teaching hospital.
DESIGN
Single-institution retrospective cohort study.
MEASUREMENTS AND MAIN RESULTS
Measurements were hospital cost, length of stay (LOS), mortality, and 30-day readmission rate adjusted for severity, demographics, and case mix. Academic Internist teams had 30% lower cost and 40% lower LOS compared to traditional private Internists and 24% lower cost and 30% lower LOS compared to private Hospitalists. Hospital mortality was equivalent for all groups. Academic teams had 2.3–2.6% more 30-day readmissions than the other groups.
CONCLUSIONS
Academic teams compare favorably to private Hospitalists and traditional Internists for hospital cost efficiency and quality.
doi:10.1007/s11606-007-0148-x
PMCID: PMC1852918  PMID: 17443375
hospitalist; medical care costs; academic medicine
13.  Living Alone, Patient Sex and Mortality After Acute Myocardial Infarction 
BACKGROUND
Psychosocial factors, including social support, affect outcomes of cardiovascular disease, but can be difficult to measure. Whether these factors have different effects on mortality post-acute myocardial infarction (AMI) in men and women is not clear.
OBJECTIVE
To examine the association between living alone, a proxy for social support, and mortality postdischarge AMI and to explore whether this association is modified by patient sex.
DESIGN
Historical cohort study.
PARTICIPANTS/SETTING
All patients discharged with a primary diagnosis of AMI in a major urban center during the 1998–1999 fiscal year.
MEASUREMENTS
Patients’ sociodemographic and clinical characteristics were obtained by standardized chart review and linked to vital statistics data through December 2001.
RESULTS
Of 880 patients, 164 (18.6%) were living alone at admission and they were significantly more likely to be older and female than those living with others. Living alone was independently associated with mortality [adjusted hazard ratio (HR) 1.6, 95% confidence interval (CI) 1.0–2.5], but interacted with patient sex. Men living alone had the highest mortality risk (adjusted HR 2.0, 95% CI 1.1–3.7), followed by women living alone (adjusted HR 1.2, 95% CI 0.7–2.2), men living with others (reference, HR 1.0), and women living with others (adjusted HR 0.9, 95% CI 0.5–1.5).
CONCLUSIONS
Living alone, an easily measured psychosocial factor, is associated with significantly increased longer-term mortality for men following AMI. Further prospective studies are needed to confirm the usefulness of living alone as a prognostic factor and to identify the potentially modifiable mechanisms underlying this increased risk.
doi:10.1007/s11606-007-0106-7
PMCID: PMC1852915  PMID: 17443363
social environment; sex factors; cardiovascular disease
14.  Do Doctors Vote? 
BACKGROUND
Organizational leaders and scholars have issued calls for the medical profession to refocus its efforts on fulfilling the core tenets of professionalism. A key element of professionalism is participation in community affairs.
OBJECTIVE
To measure physician voting rates as an indicator of civic participation.
DESIGN
Cross-sectional survey of a subgroup of physicians from a nationally representative household survey of civilian, noninstitutionalized adult citizens.
PARTICIPANTS
A total of 350,870 participants in the Current Population Survey (CPS) November Voter Supplement from 1996–2002, including 1,274 physicians and 1,886 lawyers; 414,989 participants in the CPS survey from 1976–1982, including 2,033 health professionals.
MEASUREMENTS
Multivariate logistic regression models were used to compare adjusted physician voting rates in the 1996–2002 congressional and presidential elections with those of lawyers and the general population and to compare voting rates of health professionals in 1996–2002 with those in 1976–1992.
RESULTS
After multivariate adjustment for characteristics known to be associated with voting rates, physicians were less likely to vote than the general population in 1998 (odds ratio 0.76; 95% confidence interval [CI] 0.59–0.99), 2000 (odds ratio 0.64; 95% CI 0.44–0.93), and 2002 (odds ratio 0.62; 95% CI 0.48–0.80) but not 1996 (odds ratio 0.83; 95% CI 0.59–1.17). Lawyers voted at higher rates than the general population and doctors in all four elections (P < .001). The pooled adjusted odds ratio for physician voting across the four elections was 0.70 (CI 0.61–0.81). No substantial changes in voting rates for health professionals were observed between 1976–1982 and 1996–2002.
CONCLUSIONS
Physicians have lower adjusted voting rates than lawyers and the general population, suggesting reduced civic participation.
doi:10.1007/s11606-007-0105-8
PMCID: PMC1852914  PMID: 17443365
professionalism; social science; community health; health policy
15.  A Ten-Month Program in Curriculum Development for Medical Educators: 16 Years of Experience 
BACKGROUND
Despite increased demand for new curricula in medical education, most academic medical centers have few faculty with training in curriculum development.
OBJECTIVE
To describe and evaluate a longitudinal mentored faculty development program in curriculum development.
DESIGN
A 10-month curriculum development program operating one half-day per week of each academic year from 1987 through 2003. The program was designed to provide participants with the knowledge, attitudes, skills, and experience to design, implement, evaluate, and disseminate curricula in medical education using a 6-step model.
PARTICIPANTS
One-hundred thirty-eight faculty and fellows from Johns Hopkins and other institutions and 63 matched nonparticipants.
MEASUREMENTS
Pre- and post-surveys from participants and nonparticipants assessed skills in curriculum development, implementation, and evaluation, as well as enjoyment in curriculum development and evaluation. Participants rated program quality, educational methods, and facilitation in a post-program survey.
RESULTS
Sixty-four curricula were produced addressing gaps in undergraduate, graduate, or postgraduate medical education. At least 54 curricula (84%) were implemented. Participant self-reported skills in curricular development, implementation, and evaluation improved from baseline (p < .0001), whereas no improvement occurred in the comparison group. In multivariable analyses, participants rated their skills and enjoyment at the end of the program significantly higher than nonparticipants (all p < .05). Eighty percent of participants felt that they would use the 6-step model again, and 80% would recommend the program highly to others.
CONCLUSIONS
This model for training in curriculum development has long-term sustainability and is associated with participant satisfaction, improvement in self-rated skills, and implementation of curricula on important topics.
doi:10.1007/s11606-007-0103-x
PMCID: PMC1852913  PMID: 17443374
curriculum development; faculty development
16.  A Shot in the Dark: Failing to Recognize the Link Between Physical and Mental Illness 
A 74-year-old widowed white man with chronic rheumatoid arthritis presented with nausea and weight loss. He was diagnosed with failure to thrive and admitted for hydration. Misoprostol was determined to be the etiology of his symptoms and he was discharged home. Three days later, he killed himself with a gunshot to the head. Clinicians often fail to recognize those at high risk for suicide. Suicidal risk is increased in both psychiatric and physical illness, and particularly when both are present. Psychiatric illness, particularly depression, often underlies chronic medical illness. The purpose of this case report is to remind health care providers of the strong association between depression and chronic medical illness, and to consider this in all patients, including those who present solely with physical symptoms. Recognizing this association and screening for it, as recommended by the U.S. Preventive Services Task Force, may prevent the unnecessary tragedy of suicide.
doi:10.1007/s11606-006-0089-9
PMCID: PMC1852910  PMID: 17443378
depression; chronic disease; risk assessment; screening
17.  Recognition of Depression in Older Medical Inpatients 
Background
Studies of recognition of depression in older (aged 65 or more) medical inpatients show low rates of recognition of depression by attending physicians. However, few studies have compared different measures of recognition of depression.
Objectives
(1) To compare the validity of four indicators of recognition of depression and a global measure of recognition against a diagnosis of depression and (2) to explore the effect of patient characteristics on recognition of depression.
Methods
In a cohort of 264 medical inpatients 65 years and older (115 with major or minor depression, 78 with no depression), sensitivities, specificities, and diagnostic odds ratios (DOR) of 4 indicators of recognition (symptoms, diagnosis, treatment, and referral) and a global measure of recognition (any of the 4 indicators) were calculated. The associations between patient characteristics (age, sex, history of depression, antidepressant use before admission, severity of depression, comorbidity, duration of hospitalization, disability, and hospital of admission) and recognition were explored using multiple logistic regression.
Results
Less than half of the depressed patients were recognized. The indicator with the highest sensitivity was treatment (27.8%, 95% confidence interval [CI] 20.0–37.0), whereas the indicator with the best specificity was diagnosis (96.6%, 95% CI 91.9–98.7). The unadjusted DOR of global recognition was 2.6 (95% CI 1.5, 4.4). Less comorbidity, more severe depression symptoms, a history of depression, longer hospital stay, and antidepressant use before admission were significantly associated with better global recognition.
Conclusion
Recognition of depression in elderly medical inpatients depends upon the indicator of recognition used.
doi:10.1007/s11606-006-0085-0
PMCID: PMC1852909  PMID: 17443361
recognition; depression; inpatients
18.  Breast Cancer Presenting as Unilateral Arm Edema 
Context
Symptomatic arm lymphedema as the presenting symptom of invasive breast carcinoma is a rare occurrence.
Design
We report a case of invasive breast cancer presenting with unilateral arm swelling. The patient was initially thought to have venous thrombosis. A thorough physical examination and a mammogram revealed the presence of breast cancer and associated subclinical axillary lymphadenopathy.
Conclusion
Failure to recognize this presentation can lead to misdiagnosis or a significant delay in diagnosis and treatment.
doi:10.1007/s11606-006-0077-0
PMCID: PMC1852908  PMID: 17443377
breast cancer; lymphedema; diagnosis
19.  What Does ‘Respect’ Mean? Exploring the Moral Obligation of Health Professionals to Respect Patients 
Respect is frequently invoked as an integral aspect of ethics and professionalism in medicine, yet it is often unclear what respect means in this setting. While we recognize that there are many reasonable ways to think about and use the term ‘respect’, in this paper, we develop a conception of respect that imposes a distinct moral duty on physicians. We are concerned mainly with the idea of respect for persons, or more specifically, respect for patients as persons. We develop an account of respect as recognition of the unconditional value of patients as persons. Such respect involves respecting the autonomy of patients, but we challenge the idea that respect for autonomy is a complete or self-sufficient expression of respect for persons. Furthermore, we suggest that the type of respect that physicians owe to patients is independent of a patient’s personal characteristics, and therefore, ought to be accorded equally to all. Finally, the respect that we promote has both a cognitive dimension (believing that patients have value) and a behavioral dimension (acting in accordance with this belief).
doi:10.1007/s11606-006-0054-7
PMCID: PMC1852905  PMID: 17443381
ethics; respect for persons; respect for autonomy; professionalism
20.  Empathy and Patient–Physician Conflicts 
Physicians associate empathy with benevolent emotions and with developing a shared understanding with patients. While there have been many articles on managing “difficult” patients, little attention has been paid to the challenges physicians face during conflicts with patients, especially when both parties are angry and yet empathy is still needed. This topic is especially important in light of recent studies showing that practicing medicine increasingly requires physicians to manage their own feelings of anger and frustration. This article seeks to describe how physicians can learn to empathize with patients even when they are both subject to emotions that lead to interpersonal distancing. Empathy is defined as engaged curiosity about another’s particular emotional perspective. Five specific ways for physicians to foster empathy during conflict are described: recognizing one’s own emotions, attending to negative emotions over time, attuning to patients’ verbal and nonverbal emotional messages, and becoming receptive to negative feedback. Importantly, physicians who learn to empathize with patients during emotionally charged interactions can reduce anger and frustration and also increase their therapeutic impact.
doi:10.1007/s11606-006-0102-3
PMCID: PMC1852904  PMID: 17443382
doctor-patient relationships; communications skills; professionalism; patient-centered care; empathy
21.  Acute Kawasaki Disease: Not Just for Kids 
Kawasaki Disease is a small-to-medium-vessel vasculitis that preferentially affects children. Kawasaki Disease can occur in adults, but the presentation may differ from that observed in children. Typical findings in both adults and children include fever, conjunctivitis, pharyngitis, and skin erythema progressing to a desquamating rash on the palms and soles. Adults more frequently present with cervical adenopathy (93% of adults vs. 15% of children), hepatitis (65% vs. 10%), and arthralgia (61% vs. 24–38%). In contrast, adults are less frequently affected by meningitis (10% vs. 34%), thrombocytosis (55% vs. 100%), and coronary artery aneurysms (5% vs. 18–25%). We report a case of acute Kawasaki Disease in a 24-year-old man who presented with rash, fever, and arthritis. He was successfully treated with high-dose aspirin and intravenous immunoglobulin (IVIG). Our case highlights the importance of considering Kawasaki Disease in adults presenting with symptoms commonly encountered in a general medical practice.
doi:10.1007/s11606-006-0100-5
PMCID: PMC1852903  PMID: 17443379
Kawasaki Disease; adult; coronary artery aneurysms; vasculitis; adenopathy; arthritis; mucocutaneous lymph node syndrome
22.  What are the Essential Elements to Enable Patient Participation in Medical Decision Making? 
BACKGROUND
Patient participation in shared decision making (SDM) results in increased patient knowledge, adherence, and improved outcomes. Despite the benefits of the SDM model, many patients do not attain the level of participation they desire.
OBJECTIVE
To gain a more complete understanding of the essential elements, or the prerequisites, critical to active patient participation in medical decision making from the patient’s perspective.
DESIGN
Qualitative study.
SETTING
Individual, in-depth patient interviews were conducted until thematic saturation was reached. Two analysts independently read the transcripts and jointly developed a list of codes.
PATIENTS
Twenty-six consecutive subjects drawn from community dwelling subjects undergoing bone density measurements.
MEASUREMENTS
Respondents’ experiences and beliefs related to patient participation in SDM.
RESULTS
Five elements were repeatedly described by respondents as being essential to enable patient participation in medical decision making: (1) patient knowledge, (2) explicit encouragement of patient participation by physicians, (3) appreciation of the patient’s responsibility/rights to play an active role in decision making, (4) awareness of choice, and (5) time.
LIMITATIONS
The generalizability of the results is limited by the homogeneity of the study sample.
CONCLUSIONS
Our findings have important clinical implications and suggest that several needs must be met before patients can become active participants in decisions related to their health care. These needs include ensuring that patients (1) appreciate that there is uncertainty in medicine and “buy in” to the importance of active patient participation in decisions related to their health care, (2) understand the trade-offs related to available options, and (3) have the opportunity to discuss these options with their physician to arrive at a decision concordant with their values.
doi:10.1007/s11606-007-0149-9
PMCID: PMC1855272  PMID: 17443368
patient participation; medical decision making; shared decision making; health care
23.  Are Good Intentions Good Enough?: Informed Consent Without Trained Interpreters 
Objective
To examine the informed consent process when trained language interpreters are unavailable.
Background
Ensuring sufficient patient understanding for informed consent is especially challenging for patients with Limited English Proficiency (LEP). While US law requires provision of competent translation for LEP patients, such services are commonly unavailable.
Design and Participants
Qualitative data was collected in 8 prenatal genetics clinics in Texas, including interviews and observations with 16 clinicians, and 30 Latina patients. Using content analysis techniques, we examined whether the basic criteria for informed consent (voluntariness, discussion of alternatives, adequate information, and competence) were evident for each of these patients, contrasting LEP patients with patients not needing an interpreter. We present case examples of difficulties related to each of these criteria, and compare informed consent scores for consultations requiring interpretation and those which did not.
Results
We describe multiple communication problems related to the use of untrained interpreters, or reliance on clinicians’ own limited Spanish. These LEP patients appear to be consistently disadvantaged in each of the criteria we examined, and informed consent scores were notably lower for consultations which occurred across a language barrier.
Conclusions
In the absence of adequate Spanish interpretation, it was uncertain whether these LEP patients were provided the quality and content of information needed to assure that they are genuinely informed. We offer some low-cost practice suggestions that might mitigate these problems, and improve the quality of language interpretation, which is essential to assuring informed choice in health care for LEP patients.
doi:10.1007/s11606-007-0136-1
PMCID: PMC1855271  PMID: 17443367
informed consent; language barriers; genetic counseling; Latinas
24.  The Role of Medical Education in Reducing Health Care Disparities: The First Ten Years of the UCLA/Drew Medical Education Program 
BACKGROUND
The University of California, Los Angeles (UCLA)/Charles R. Drew University Medical Education Program was developed to train physicians for practice in underserved areas. The UCLA/Drew Medical Education Program students receive basic science instruction at UCLA and complete their required clinical rotations in South Los Angeles, an impoverished urban community. We have previously shown that, in comparison to their UCLA counterparts, students in the Drew program had greater odds of maintaining their commitment to medically disadvantaged populations over the course of medical education.
OBJECTIVE
To examine the independent association of graduation from the UCLA/Drew program with subsequent choice of physician practice location. We hypothesized that participation in the UCLA/Drew program predicts future practice in medically disadvantaged areas, controlling for student demographics such as race/ethnicity and gender, indicators of socioeconomic status, and specialty choice.
DESIGN
Retrospective cohort study.
PARTICIPANTS
Graduates (1,071) of the UCLA School of Medicine and the UCLA/Drew Medical Education Program from 1985–1995, practicing in California in 2003 based on the address listed in the American Medical Association (AMA) Physician Masterfile.
MEASUREMENTS
Physician address was geocoded to a California Medical Service Study Area (MSSA). A medically disadvantaged community was defined as meeting any one of the following criteria: (a) federally designated HPSA or MUA; (b) rural area; (c) high minority area; or (d) high poverty area.
RESULTS
Fifty-three percent of UCLA/Drew graduates are located in medically disadvantaged areas, in contrast to 26.1% of UCLA graduates. In multivariate analyses, underrepresented minority race/ethnicity (OR: 1.57; 95% CI: 1.10–2.25) and participation in the Drew program (OR: 2.47; 95% CI: 1.59–3.83) were independent predictors of future practice in disadvantaged areas.
CONCLUSIONS
Physicians who graduated from the UCLA/Drew Medical Education Program have higher odds of practicing in underserved areas than those who completed the traditional UCLA curriculum, even after controlling for other factors such as race/ethnicity. The association between participation in the UCLA/Drew Medical Education Program and physician practice location suggests that medical education programs may reinforce student goals to practice in disadvantaged communities.
doi:10.1007/s11606-007-0154-z
PMCID: PMC1852922  PMID: 17443370
medical education; health care disparities; UCLA/Drew program
25.  Group Visits: Promoting Adherence to Diabetes Guidelines 
BACKGROUND
Current diabetes management guidelines offer blueprints for providers, yet type 2 diabetes control is often poor in disadvantaged populations. The group visit is a new treatment modality originating in managed care for efficient service delivery to patients with chronic health problems. Group visits offer promise for delivering care to diabetic patients, as visits are lengthier and can be more frequent, more organized, and more educational.
OBJECTIVE
To evaluate the effect of group visits on clinical outcomes, concordance with 10 American Diabetes Association (ADA) guidelines [American Diabetes Association, Diabetes Care, 28:S4–36, 2004] and 3 United States Preventive Services Task Force (USPSTF) cancer screens [U.S. Preventive Services Task Force, http://www.ahrq.gov/clinic/uspstf/resource.htm, 2003].
RESEARCH DESIGN AND METHODS
A 12-month randomized controlled trial of 186 diabetic patients comparing care in group visits with care in the traditional patient–physician dyad. Clinical outcomes (HbA1c, blood pressure [BP], lipid profiles) were assessed at 6 and 12 months and quality of care measures (adherence to 10 ADA guidelines and 3 USPSTF cancer screens) at 12 months.
RESULTS
At both measurement points, HbA1c, BP, and lipid levels did not differ significantly for patients attending group visits versus those in usual care. At 12 months, however, patients receiving care in group visits exhibited greater concordance with ADA process-of-care indicators (p < .0001) and higher screening rates for cancers of the breast (80 vs. 68%, p = .006) and cervix (80 vs 68%, p = .019).
CONCLUSIONS
Group visits can improve the quality of care for diabetic patients, but modifications to the content and style of group visits may be necessary to achieve improved clinical outcomes.
doi:10.1007/s11606-007-0150-3
PMCID: PMC1852919  PMID: 17443369
group visits; guideline concordance; type 2 diabetes control

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