Getting Under the Skin of Clinical Inertia in Insulin Initiation: The Translating Research Into Action for Diabetes (TRIAD) Insulin Starts Project

Purpose The purpose of this cross-sectional study is to explore primary care providers’ (PCPs) perceptions about barriers to initiating insulin among patients. Studies suggest that many patients with poorly controlled type 2 diabetes do not receive insulin initiation by PCPs. Methods As part of the Translating Research Into Action for Diabetes study, the authors conducted structured interviews in health systems in Indiana, New Jersey, and California, asking PCPs about the importance of insulin initiation and factors affecting this decision. The authors calculated proportions choosing each multiple-choice response option and listed the most frequently offered open-ended response categories. Results Among 83 PCPs, 45% were women; 60% were white; and they averaged 13.4 years in practice. Four-fifths of PCPs endorsed guideline-concordant glycemic targets, but 54% individualized targets based on patient age, life expectancy, medical comorbidities, self-management capacity, and willingness. Most (64%) reported that many patients were resistant to new oral or insulin therapies due to fears about the therapy and what it meant about their disease progression. Two-thirds (64%) cited patient resistance as a barrier to insulin initiation, and 43% cited problems with patient self-management, including cognitive or mental health issues, dexterity, or ability to adhere. Eighty percent felt that patient nonadherence would dissuade them from initiating insulin at least some of the time. Conclusions PCPs perceived that patient resistance and poor self- management skills were significant barriers to initiating insulin. Future studies should investigate whether systems-level interventions to improve patient-provider communication about insulin and enhance providers’ perceptions of patient self-management capacity can increase guideline-concordant, patient-centered insulin initiation

When only the real thing will do: junior medical students’ learning from real patients

Bell, K., Boshuizen, H. P. A., Scherpbier, A. J. J. A., & Dornan, T. L. (2009). When only the real thing will do: junior medical students' learning from real patients. Medical Education, 43(11), 1036-1043. doi:10.1111/j.1365-2923.2009.03508.xOBJECTIVES This study aimed to explore how medical students experience contacts with real patients and what they learn from them. METHODS We carried out a post hoc, single-group study in one teaching sector of a 5-year, problem-based, horizontally integrated, outcome-based and community-oriented undergraduate programme, in which students lacked clinical exposure in the pre-clerkship phase. Subjects comprised five cohorts of students on their first clerkships. Data consisted of purposively selected, voluntary, self-report statements regarding real patient learning (RPL). Constant comparative analysis was performed by two independent researchers. RESULTS Respondents valued patients as an instructional resource that made learning more real. They reported learning through visual pattern recognition as well as through dialogue and physical examination. They more often used social than professional language to describe RPL. They reported affective outcomes including enhanced confidence, motivation, satisfaction and a sense of professional identity. They also reported cognitive outcomes including perspective, context, a temporal dimension, and an appreciation of complexity. Real patient learning helped respondents link theory learned earlier with reality as represented by verbal, visual and auditory experiences. It made learning easier, more meaningful and more focused. It helped respondents acquire complex skills and knowledge. Above all, RPL helped learners to remember subject matter. Most negative responses concerned the difficulty of acquiring appropriate experience, but RPL made a minority of respondents feel uncomfortable and incompetent. CONCLUSIONS Real patient learning led to a rich variety of learning outcomes, of which at least some medical students showed high metacognitive awareness. Sensitivity from clinical mentors towards the positive and negative outcomes of RPL reported here could support reflective clinical learning

Choice of outcomes and measurement instruments in randomised trials on eLearning in medical education: A systematic mapping review protocol

Background: There will be a lack of 18 million healthcare workers by 2030. Multiplying the number of well-trained healthcare workers through innovative ways such as eLearning is highly recommended in solving this shortage. However, high heterogeneity of learning outcomes in eLearning systematic reviews reveals a lack of consistency and agreement on core learning outcomes in eLearning for medical education. In addition, there seems to be a lack of validity evidence for measurement instruments used in these trials. This undermines the credibility of these outcome measures and affects the ability to draw accurate and meaningful conclusions. The aim of this research is to address this issue by determining the choice of outcomes, measurement instruments and the prevalence of measurement instruments with validity evidence in randomised trials on eLearning for pre-registration medical education. Methods: We will conduct a systematic mapping and review to identify the types of outcomes, the kinds of measurement instruments and the prevalence of validity evidence among measurement instruments in eLearning randomised controlled trials (RCTs) in pre-registration medical education. The search period will be from January 1990 until August 2017. We will consider studies on eLearning for health professionals' education. Two reviewers will extract and manage data independently from the included studies. Data will be analysed and synthesised according to the aim of the review. Discussion: Appropriate choice of outcomes and measurement tools is essential for ensuring high-quality research in the field of eLearning and eHealth. The results of this study could have positive implications for other eHealth interventions, including (1) improving quality and credibility of eLearning research, (2) enhancing the quality of digital medical education and (3) informing researchers, academics and curriculum developers about the types of outcomes and validity evidence for measurement instruments used in eLearning studies. The protocol aspires to assist in the advancement of the eLearning research field as well as in the development of high-quality healthcare professionals' digital education. Systematic review registration: PROSPERO CRD4201706842

Patient–Physician Role Relationships and Patient Activation among Individuals with Chronic Illness

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/91318/1/hesr1354.pd

The association of health literacy with adherence in older 2 adults, and its role in interventions: a systematic meta-review

Background: Low health literacy is a common problem among older adults. It is often suggested to be associated with poor adherence. This suggested association implies a need for effective adherence interventions in low health literate people. However, previous reviews show mixed results on the association between low health literacy and poor adherence. A systematic meta-review of systematic reviews was conducted to study the association between health literacy and adherence in adults above the age of 50. Evidence for the effectiveness of adherence interventions among adults in this older age group with low health literacy was also explored. Methods: Eight electronic databases (MEDLINE, ERIC, EMBASE, PsycINFO, CINAHL, DARE, the Cochrane Library, and Web of Knowledge) were searched using a variety of keywords regarding health literacy and adherence. Additionally, references of identified articles were checked. Systematic reviews were included if they assessed the association between health literacy and adherence or evaluated the effectiveness of interventions to improve adherence in adults with low health literacy. The AMSTAR tool was used to assess the quality of the included reviews. The selection procedure, data-extraction, and quality assessment were performed by two independent reviewers. Seventeen reviews were selected for inclusion. Results: Reviews varied widely in quality. Both reviews of high and low quality found only weak or mixed associations between health literacy and adherence among older adults. Reviews report on seven studies that assess the effectiveness of adherence interventions among low health literate older adults. The results suggest that some adherence interventions are effective for this group. The interventions described in the reviews focused mainly on education and on lowering the health literacy demands of adherence instructions. No conclusions could be drawn about which type of intervention could be most beneficial for this population. Conclusions: Evidence on the association between health literacy and adherence in older adults is relatively weak. Adherence interventions are potentially effective for the vulnerable population of older adults with low levels of health literacy, but the evidence on this topic is limited. Further research is needed on the association between health literacy and general health behavior, and on the effectiveness of interventions

Professional Development and the Informal Curriculum in End-of-Life Care

Although professionalism has emerged as a key competency for today’s physicians, there exists little insight into how best to teach medical students the relevant skills or instill in them the commitment required to practice according to the highest professional standards. Ten UCSF medical students were interviewed at three time points (second, third, and fourth years of school). Interviews focused on students’ learning and development regarding end-of-life care (EOLC). Students described varying steps in their professional development from their second to fourth years of school, including feeling confused about the definition of professionalism and integrating their personal and professional identities. In addition to professional development, four other themes contributed to the development of medical student understanding of how to provide EOLC as a professional: (1) curricular discordance, (2) role models, (3) the tightrope between trained versus human reactions, and (4) ethical dilemmas. These five themes represent dilemmas that students often learned how to respond to over the course of school. Professional development in EOLC required the acquisition of skills necessary to balance the tension between and navigate conflicting messages present in medical student training

The Next Frontier in Communication and the ECLIPPSE Study: Bridging the Linguistic Divide in Secure Messaging

Health systems are heavily promoting patient portals. However, limited health literacy (HL) can restrict online communication via secure messaging (SM) because patients’ literacy skills must be sufficient to convey and comprehend content while clinicians must encourage and elicit communication from patients and match patients’ literacy level. This paper describes the Employing Computational Linguistics to Improve Patient-Provider Secure Email (ECLIPPSE) study, an interdisciplinary effort bringing together scientists in communication, computational linguistics, and health services to employ computational linguistic methods to (1) create a novel Linguistic Complexity Profile (LCP) to characterize communications of patients and clinicians and demonstrate its validity and (2) examine whether providers accommodate communication needs of patients with limited HL by tailoring their SM responses. We will study >5 million SMs generated by >150,000 ethnically diverse type 2 diabetes patients and >9000 clinicians from two settings: an integrated delivery system and a public (safety net) system. Finally, we will then create an LCP-based automated aid that delivers real-time feedback to clinicians to reduce the linguistic complexity of their SMs. This research will support health systems’ journeys to become health literate healthcare organizations and reduce HL-related disparities in diabetes care

Motivation and job satisfaction among medical and nursing staff in a Cyprus public general hospital

<p>Abstract</p> <p>Background</p> <p>The objective of this study was to investigate how medical and nursing staff of the Nicosia General Hospital is affected by specific motivation factors, and the association between <it>job satisfaction </it>and <it>motivation</it>. Furthermore, to determine the motivational drive of socio-demographic and job related factors in terms of improving work performance.</p> <p>Methods</p> <p>A previously developed and validated instrument addressing four work-related motivators (<it>job attributes, remuneration, co-workers and achievements</it>) was used. Two categories of health care professionals, medical doctors and dentists (N = 67) and nurses (N = 219) participated and motivation and job satisfaction was compared across socio-demographic and occupational variables.</p> <p>Results</p> <p>The survey revealed that <it>achievements </it>was ranked first among the four main motivators, followed by <it>remuneration</it>, <it>co-workers </it>and <it>job attributes</it>. The factor <it>remuneration </it>revealed statistically significant differences according to gender, and hospital sector, with female doctors and nurses and accident and emergency (A+E) outpatient doctors reporting greater mean scores (p < 0.005). The medical staff showed statistically significantly lower job satisfaction compared to the nursing staff. Surgical sector nurses and those >55 years of age reported higher job satisfaction when compared to the other groups.</p> <p>Conclusions</p> <p>The results are in agreement with the literature which focuses attention to management approaches employing both monetary and non-monetary incentives to motivate health care professionals. Health care professionals tend to be motivated more by intrinsic factors, implying that this should be a target for effective employee motivation. Strategies based on the survey's results to enhance employee motivation are suggested.</p