Faculty Bibliography

AIM: To assess and teach cultural competency skills at the fellowship training level through the use of objective structured clinical examinations (OSCEs). METHODS: We revised four scenarios to infuse a specific focus on cross-cultural care, and to render them appropriate for gastroenterology fellows. Three are discussed here: (1) Poor Health Literacy; (2) Disclosing/Apologizing for a Complication to a Patient Who Mistrusts the Healthcare System; and (3) Breaking Bad News to a Fatalistic Patient. A fourth case emphasizing shared decision-making will be described elsewhere. Four stations were completed by fellows and observed live by four faculty members, and the fellows' performance was assessed. RESULTS: Eleven fellows from four programs participated in the four OSCE. In the "Poor Health Literacy" case, 18% (2/11) of participants recognized that the standardized patient (SP) had below-basic health literacy. None successfully evaluated the SP's reading skills in a culturally-sensitive manner. In "Disclosing/Apologizing for a Complication", 4/11 (36%) personally apologized for the complication. 1/11 recognized the SP's mistrust of the medical system. With "Breaking Bad News", 27% (3/11) explored the patient's values to identify her fatalistic beliefs. CONCLUSION: OSCEs can be used to assess deficiencies in culturally-competent care at the fellowship level. OSCEs also afford fellowships the opportunity to inform future training curricula.

OBJECTIVES: Despite the increased focus on health care consumers' active choice, not enough is known about how to best facilitate the choice process. We sought to assess methods of improving this process for vulnerable consumers in the United States by testing alternatives that emphasize insights from behavioral economics, or 'nudges'. METHODS: We performed a hypothetical choice experiment where subjects were randomized to one of five experimental conditions and asked to choose a health center (location where they would receive all their care). The conditions presented the same information about health centers in different ways, including graphically as a chart, via written summary and using behavioral economics, 'nudging' consumers toward particular choices. We hypothesized that these 'nudges' might help simplify the choice process. Our primary outcomes focused on the health center chosen and whether consumers were willing to accept 'nudges'. RESULTS: We found that consumer choice was influenced by the method of presentation and the majority of consumers accepted the health center they were 'nudged' towards. CONCLUSIONS: Consumers were accepting of choices grounded in insights from behavioral economics and further consideration should be given to their role in patient choice.

OBJECTIVE:: In 2011, 15.8% of eligible patients in the United States were vaccinated against herpes zoster (HZ). To increase the usage of the HZ vaccine by studying physicians' knowledge, attitudes, practices, and perceived obstacles after interventions to overcome barriers. METHODS:: General internal medicine physicians were surveyed with a cross-sectional internet survey from October to December 2011 before interventions to increase the use of the HZ vaccine and 1 year later. Interventions included education, increasing availability at the medical center pharmacy, and electronic medical record reminders. Outcome measures included changes in knowledge, attitudes, and practices, and perceived barriers. McNemar chi-square tests were used to compare the changes from the baseline survey for physicians who completed the follow-up survey. RESULTS:: Response rate for the baseline study was 33.5% (89/266) and for the follow-up was 29.8% (75/252). Fifty-five completed both surveys. There was a decrease from 57% at baseline to 40% at follow-up in the proportion of physicians who reported that less than 10% of their patients were vaccinated. They were more likely to know the HZ annual incidence (30% baseline; 70% follow-up; P=0.02), and report having educational information for physicians (7% baseline; 27% follow-up; P=0.003). The top helpful intervention was nursing administration of the vaccine. Average monthly HZ vaccine usage in the affiliated outpatient pharmacy increased in 10 months between surveys by 156% compared with the 3 months before the baseline survey. CONCLUSIONS:: Interventions implemented during the study led to an increase in physicians' basic knowledge of the HZ vaccine and an increase in usage at the affiliated pharmacy.

BACKGROUND: Standardized Patients (SPs) are actors trained to portray health care patients during the training and assessment of health care providers. This paper describes the methods and costs associated with using SPs to evaluate the skills of telephone counselors working on a clinical trial that evaluated a telephone smoking cessation program tailored for smokers using Department of Veterans Affairs mental health clinics. FINDINGS: Conducting the SP exercises required five main steps: (1) Write a SP case description detailing patient demographics, demeanor, clinical symptoms and history, and instructions on how to respond to counseling, (2) Identify, select and train actors to portray the SP cases; (3) Conduct audio-taped counseling encounters between the SPs and counselors, (4) Rate the counselors on their core counseling competencies, (5) Provide feedback to counselors. The SPs and study supervisors reported that the checklist was easy to use when rating the counselors. Counselors reported that the SP encounters were realistic and helpful for practicing their clinical work and for building self-efficacy for working with real patients. The labor costs of developing two SP cases and training two SP actors was approximately $1,475. The per-session labor cost of conducting a 1-hour counseling session between one SP and one counselor was approximately $314. CONCLUSIONS: Using SPs to train telephone counselors working on a clinical trial was feasible and offered training benefits beyond those provided by didactic instruction and role plays. Our research group is now routinely using SPs for the training of incoming telephone counselors.