Faculty Bibliography

BACKGROUND: Latino immigrants face a higher burden of colorectal cancer (CRC) and screening rates are low. OBJECTIVE: To assess the effectiveness of a multilevel intervention in increasing the rate of CRC screening among Latino immigrants. DESIGN: A randomized controlled trial, with randomization at the physician level. PARTICIPANTS: Pairs of 65 primary care physicians and 65 Latino immigrant patients participated, 31 in the intervention and 34 in the control group. INTERVENTION: CRC educational video in Spanish on a portable personal digital video display device accompanied by a brochure with key information for the patient, and a patient-delivered paper-based reminder for their physician. MEASUREMENTS: Completed CRC screening, physician recommendation for CRC screening, and patient adherence to physician recommended CRC screening. RESULTS: The overall rate of completed screening for CRC was 55% for the intervention and 18% for the control group (p = 0.002). Physicians recommended CRC screening for 61% of patients in the intervention group versus 41% in the control group (p = 0.08). Of those that received a recommendation, 90% in the intervention group adhered to it versus 26% in the control group (p = 0.007). CONCLUSIONS: The intervention was successful in increasing rates of completed CRC screening primarily through increasing adherence after screening was recommended. Additional efforts should focus on developing new strategies to increase physician recommendation for CRC screening, while employing effective patient adherence interventions

Researchers lack the rich evidence base and benchmark patient outcomes needed to evaluate the effectiveness of medical education practice and guide policy. The authors offer a framework for medical education research that focuses on physician-influenced patient outcomes that are potentially sensitive to medical education. Adapting the concept of ambulatory care sensitive conditions, which provided traction to health services research by defining benchmark patient outcomes to measure health system performance, the authors introduce the concept and propose the adoption of educationally sensitive patient outcomes and suggest two measures: patient activation and clinical microsystem activation. They assert that the ultimate goal of medical education is to ensure that measurement of future physicians' competence and skills is based not only on biomedical knowledge and critical clinical skills but also on the ability to translate these competencies into effective patient- and systems-level outcomes. The authors consider methodological approaches and challenges to measuring such outcomes and argue for large, multiinstitutional, prospective cohort studies and the development of a national Database for Research in Education in Academic Medicine to provide the needed infrastructure. They advocate taking the next steps to establish an educational evidence base to guide the academic medical centers of the 21st century in aligning medical education practice with health care delivery that meets the needs of individuals and populations

New applications of evolutionary biology in medicine are being discovered at an accelerating rate, but few physicians have sufficient educational background to use them fully. This article summarizes suggestions from several groups that have considered how evolutionary biology can be useful in medicine, what physicians should learn about it, and when and how they should learn it. Our general conclusion is that evolutionary biology is a crucial basic science for medicine. In addition to looking at established evolutionary methods and topics, such as population genetics and pathogen evolution, we highlight questions about why natural selection leaves bodies vulnerable to disease. Knowledge about evolution provides physicians with an integrative framework that links otherwise disparate bits of knowledge. It replaces the prevalent view of bodies as machines with a biological view of bodies shaped by evolutionary processes. Like other basic sciences, evolutionary biology needs to be taught both before and during medical school. Most introductory biology courses are insufficient to establish competency in evolutionary biology. Premedical students need evolution courses, possibly ones that emphasize medically relevant aspects. In medical school, evolutionary biology should be taught as one of the basic medical sciences. This will require a course that reviews basic principles and specific medical applications, followed by an integrated presentation of evolutionary aspects that apply to each disease and organ system. Evolutionary biology is not just another topic vying for inclusion in the curriculum; it is an essential foundation for a biological understanding of health and disease

BACKGROUND: Beta-blockers reduce mortality among patients with systolic heart failure (HF), yet primary care provider prescription rates remain low. OBJECTIVE: To examine the association between primary care physician characteristics and both self-reported and actual prescription of beta-blockers among patients with systolic HF. DESIGN: Cross-sectional survey with supplementary retrospective chart review. PARTICIPANTS: Primary care providers at three New York City Veterans Affairs medical centers. MEASUREMENTS: MAIN OUTCOMES WERE: 1) self-reported prescribing of beta-blockers, and 2) actual prescribing of beta-blockers among HF patients. Physician HF practice patterns and confidence levels, as well as socio-demographic and clinical characteristics, were also assessed. RESULTS: Sixty-nine of 101 physicians (68%) completed the survey examining self-reported prescribing of beta-blockers. Physicians who served as inpatient ward attendings self-reported significantly higher rates of beta-blocker prescribing among their HF patients when compared with physicians who did not attend (78% vs. 58%; p = 0.002), as did physicians who were very confident in managing HF patients when compared with physicians who were not (82% vs. 68%; p = 0.009). Fifty-one of these 69 surveyed physicians (74%) were successfully matched to 287 HF patients for whom beta-blocker prescribing data was available. Physicians with greater self-reported rates of prescribing beta-blockers were significantly more likely to actually prescribe beta-blockers (p = 0.02); however, no other physician characteristics were significantly associated with actual prescribing of beta-blockers among HF patients. CONCLUSIONS: Physician teaching responsibilities and confidence levels were associated with self-reported beta-blocker prescribing among their HF patients. Educational efforts focused on improving confidence levels in HF care and increasing exposure to teaching may improve beta-blocker presciption in HF patients managed in primary care

Background: Adverse primary care work conditions could lead to a reduction in the primary care workforce and lower-quality patient care. Objective: To assess the relationship among adverse primary care work conditions, adverse physician reactions (stress, burnout, and intent to leave), and patient care. Design: Cross-sectional analysis. Setting: 119 ambulatory clinics in New York, New York, and in the upper Midwest. Participants: 422 family practitioners and general internists and 1795 of their adult patients with diabetes, hypertension, or heart failure. Measurements: Physician perception of clinic workflow (time pressure and pace), work control, and organizational culture (assessed survey); physician satisfaction, stress, burnout, and intent to leave practice (assessed by survey); and health care quality and errors (assessed by chart audits). Results: More than one half of the physicians (53.1%) reported time pressure during office visits, 48.1% said their work pace was chaotic, 78.4% noted low control over their work, and 26.5% reported burnout. Adverse workflow (time pressure and chaotic environments), low work control, and unfavorable organizational culture were strongly associated with low physician satisfaction, high stress, burnout, and intent to leave. Some work conditions were associated with lower quality and more errors, but findings were inconsistent across work conditions and diagnoses. No association was found between adverse physician reactions, such as stress and burnout, and care quality or errors. Limitation: The analyses were cross-sectional, the measures were self-reported, and the sample contained an average of 4 patients per physician. Conclusion: Adverse work conditions are associated with adverse physician reactions, but no consistent associations were found between adverse work conditions and the quality of patient care, and no associations were seen between adverse physician reactions and the quality of patient care. Primary Funding Source: Agency for Healthcare Research and Quality

BACKGROUND:Adverse primary care work conditions could lead to a reduction in the primary care workforce and lower-quality patient care. OBJECTIVE:To assess the relationship among adverse primary care work conditions, adverse physician reactions (stress, burnout, and intent to leave), and patient care. DESIGN/METHODS:Cross-sectional analysis. SETTING/METHODS:119 ambulatory clinics in New York, New York, and in the upper Midwest. PARTICIPANTS/METHODS:422 family practitioners and general internists and 1795 of their adult patients with diabetes, hypertension, or heart failure. MEASUREMENTS/METHODS:Physician perception of clinic workflow (time pressure and pace), work control, and organizational culture (assessed survey); physician satisfaction, stress, burnout, and intent to leave practice (assessed by survey); and health care quality and errors (assessed by chart audits). RESULTS:More than one half of the physicians (53.1%) reported time pressure during office visits, 48.1% said their work pace was chaotic, 78.4% noted low control over their work, and 26.5% reported burnout. Adverse workflow (time pressure and chaotic environments), low work control, and unfavorable organizational culture were strongly associated with low physician satisfaction, high stress, burnout, and intent to leave. Some work conditions were associated with lower quality and more errors, but findings were inconsistent across work conditions and diagnoses. No association was found between adverse physician reactions, such as stress and burnout, and care quality or errors. LIMITATION/CONCLUSIONS:The analyses were cross-sectional, the measures were self-reported, and the sample contained an average of 4 patients per physician. CONCLUSION/CONCLUSIONS:Adverse work conditions are associated with adverse physician reactions, but no consistent associations were found between adverse work conditions and the quality of patient care, and no associations were seen between adverse physician reactions and the quality of patient care.