How do doctors use information in real-time? A qualitative study of internal medicine resident precepting

Background  Despite the importance of evidence-based medicine in medical education, little observational research exists on how doctors-in-training seek and use evidence from information resources in ambulatory care. Objective  To describe information exchange behaviour by internal medicine residents and attendings in ambulatory resident clinic precepting rooms. Design  We observed resident behaviour and audiotaped resident–attending doctor interactions during precepting sessions. Participants  Participating residents included 70 of an eligible 89 residents and 28 of 34 eligible attendings from one large academic internal medicine residency programme in the Midwestern USA. Residents were observed during 95 separate precepting interactions at four ambulatory sites. Approach  Using a qualitative approach, we analysed transcripts and field notes of observed behaviours and interactions looking for themes of information exchange. Coders discussed themes which were refined using feedback from an interdisciplinary panel. Results  Four themes of information exchange behaviour emerged: (i) questioning behaviours that were used as part of the communication process in which the resident and attending doctor could reason together; (ii) searching behaviour of non-human knowledge sources occurred in a minority of precepting interations; (iii) unsolicited knowledge offering and (iv) answering behaviours were important means of exchanging information. Conclusions  Most clinic interactions between resident and attending doctors relied heavily on spoken deliberation without resorting to the scientific literature or other published information resources. These observations suggest a range of factors that may moderate information exchange behaviour in the precepting context including relationships, space and efficiency. Future research should aim to more readily adapt information resources to the relationships and practice context of precepting.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/72879/1/j.1365-2753.2006.00752.x.pd

Do we practice what we preach? A qualitative assessment of resident–preceptor interactions for adherence to evidence‐based practice

Background  Evidence‐based medicine (EBM) is important in training doctors for high‐quality care. Yet little is known about whether ambulatory precepting incorporates the concepts and principles of EBM. Methods  The authors observed and audiotaped 95 internal medicine residency precepting interactions and rated interactions using a qualitative analytic template consisting of three criteria: (1) presence of clinical questions; (2) presence of an evidence‐based process; and (3) resident ability to articulate a clinical question. Results  Sixty‐seven of 95 audio tapes (71%) were of acceptable quality to allow template analysis. Thirty (45%) contained explicit clinical questions; 11 (16%) included an evidence‐based process. Resident ability to articulate a clinical question when prompted was rated as at least ‘fair’ in 59 of 67 interactions (88%). Conclusions  EBM was not optimally implemented in these clinics. Future research could explore more systematically what factors facilitate or impair the use of EBM in the real‐time ambulatory training context.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/99027/1/j.1365-2753.2008.00966.x.pd

Prescribing “placebo treatments”: results of national survey of US internists and rheumatologists

Objective To describe the attitudes and behaviours regarding placebo treatments, defined as a treatment whose benefits derive from positive patient expectations and not from the physiological mechanism of the treatment itself

Getting physicians to open the survey: little evidence that an envelope teaser increases response rates

BACKGROUND: Physician surveys are an important tool to assess attitudes, beliefs and self-reported behaviors of this policy relevant group. In order for a physician to respond to a mailed survey, they must first open the envelope. While there is some evidence that package elements can impact physician response rates, the impact of an envelope teaser is unknown. Here we assess this by testing the impact of adding a brightly colored "$25 incentive" sticker to the outside of an envelope on response rates and nonresponse bias in a survey of physicians. METHODS: In the second mailing of a survey assessing physicians' moral beliefs and views on controversial health care topics, initial nonrespondents were randomly assigned to receive a survey in an envelope with a colored "$25 incentive" sticker (teaser group) or an envelope without a sticker (control group). Response rates were compared between the teaser and control groups overall and by age, gender, region of the United States, specialty and years in practice. Nonresponse bias was assessed by comparing the demographic composition of the respondents to the nonrespondents in the experimental and control condition. RESULTS: No significant differences in response rates were observed between the experimental and control conditions overall (p = 0.38) or after stratifying by age, gender, region, or practice type. Within the teaser condition, there was some variation in response rate by years since graduation. There was no independent effect of the teaser on response when simultaneously controlling for demographic characteristics (OR = 0.875, p = 0.4112). CONCLUSIONS: Neither response rates nor nonresponse bias were impacted by the use of an envelope teaser in a survey of physicians in the United States

“Righteous Minds” in Health Care: Measurement and Explanatory Value of Social Intuitionism in Accounting for the Moral Judgments in a Sample of U.S. Physicians

The broad diversity in physicians’ judgments on controversial health care topics may reflect differences in religious characteristics, political ideologies, and moral intuitions. We tested an existing measure of moral intuitions in a new population (U.S. physicians) to assess its validity and to determine whether physicians’ moral intuitions correlate with their views on controversial health care topics as well as other known predictors of these intuitions such as political affiliation and religiosity. In 2009, we mailed an 8-page questionnaire to a random sample of 2000 practicing U.S. physicians from all specialties. The survey included the Moral Foundations Questionnaire (MFQ30), along with questions on physicians’ judgments about controversial health care topics including abortion and euthanasia (no moral objection, some moral objection, strong moral objection). A total of 1032 of 1895 (54%) physicians responded. Physicians’ overall mean moral foundations scores were 3.5 for harm, 3.3 for fairness, 2.8 for loyalty, 3.2 for authority, and 2.7 for sanctity on a 0–5 scale. Increasing levels of religious service attendance, having a more conservative political ideology, and higher sanctity scores remained the greatest positive predictors of respondents objecting to abortion (β = 0.12, 0.23, 0.14, respectively, each p<0.001) as well as euthanasia (β = 0.08, 0.17, and 0.17, respectively, each p<0.001), even after adjusting for demographics. Higher authority scores were also significantly negatively associated with objection to abortion (β = −0.12, p<0.01), but not euthanasia. These data suggest that the relative importance physicians place on the different categories of moral intuitions may predict differences in physicians’ judgments about morally controversial topics and may interrelate with ideology and religiosity. Further examination of the diversity in physicians’ moral intuitions may prove illustrative in describing and addressing moral differences that arise in medical practice.</p

Impact of the 2009 US Preventive Services Task Force Guidelines on Screening Mammography Rates on Women in Their 40s

Background: The 2009 US Preventive Services Task Force breast cancer screening update recommended against routine screening mammography for women aged 40–49; confusion and release of conflicting guidelines followed. We examined the impact of the USPSTF update on population-level screening mammography rates in women ages 40–49. Methods and Findings: We conducted a retrospective, interrupted time-series analysis using a nationally representative, privately-insured population from 1/1/2006-12/31/2011. Women ages 40–64 enrolled for ≥1 month were included. The primary outcome was receipt of screening mammography, identified using administrative claims-based algorithms. Time-series regression models were estimated to determine the effect of the guideline change on screening mammography rates. 5.5 million women ages 40–64 were included. A 1.8 per 1,000 women (p = 0.003) decrease in monthly screening mammography rates for 40–49 year-old women was observed two months following the guideline change; no initial effect was seen for 50–64 year-old women. However, two years following the guideline change, a slight increase in screening mammography rates above expected was observed in both age groups. Conclusions: We detected a modest initial drop in screening mammography rates in women ages 40–49 immediately after the 2009 USPSTF guideline followed by an increase in screening rates. Unfavorable public reactions and release of conflicting statements may have tempered the initial impact. Renewal of the screening debate may have brought mammography to the forefront of women's minds, contributing to the observed increase in mammography rates two years after the guideline change. This pattern is unlikely to reflect informed choice and underscores the need for improved translation of evidence-based care and guidelines into practice

Infectious Diseases Physicians’ Attitudes and Practices Related to Complementary and Integrative Medicine: Results of a National Survey

Background. Complementary and alternative medicine (CAM) and integrative medicine (IM) modalities are widely used by patients, including those with infectious diseases (ID). Methods. One thousand randomly selected ID practitioners were surveyed. The survey was divided into domains related to familiarity and recommendation, beliefs and attitudes, and use of CAM/IM modalities. Results. The response rate was 31%. ID physicians were most familiar with vitamin and mineral supplementation (83%), massage (80%), acupuncture (79%), chiropractic (77%), yoga (74%), and herbal medicine (72%). ID physicians most recommended vitamin and mineral supplementation (80%) and massage (62%). Yoga, meditation, and acupuncture were recommended by 52%, 45%, and 46%, respectively. Drug interactions, clinical research, and knowledge of CAM/IM modalities were factors that were considered a major influence. Almost 80% of respondents indicated an interest in IM versus 11% for CAM. Most respondents (75%) felt that IM modalities are useful, and more than 50% believed that they could directly affect the immune system or disease process. Conclusion. ID physicians expressed a markedly greater interest for IM versus CAM. They appear to be familiar and willing to recommend some CAM/IM modalities and see a role for these in the management of certain infectious diseases. Data regarding clinical efficacy and safety appear to be important factors

Ethical Issues in the Design and Implementation of Population Health Programs

Spurred on by recent health care reforms and the Triple Aim’s goals of improving population health outcomes, reducing health care costs, and improving the patient experience of care, emphasis on population health is increasing throughout medicine. Population health has the potential to improve patient care and health outcomes for individual patients. However, specific population health activities may not be in every patient’s best interest in every circumstance, which can create ethical tensions for individual physicians and other health care professionals. Because individual medical professionals remain committed primarily to the best interests of individual patients, physicians have a unique role to play in ensuring population health supports this ethical obligation. Using widely recognized principles of medical ethics—nonmaleficence/beneficence, respect for persons, and justice—this article describes the ethical issues that may arise in contemporary population health programs and how to manage them. Attending to these principles will improve the design and implementation of population health programs and help maintain trust in the medical profession

Potential Unintended Consequences Of Recent Shared Decision Making Policy Initiatives

Shared decision making (SDM)-when clinicians and patients make medical decisions together-is moving swiftly from an ethical ideal toward widespread clinical implementation affecting millions of patients through recent policy initiatives. We argue that policy initiatives to promote SDM implementation in clinical practice carry the risk of several unintended negative consequences if limitations in defining and measuring SDM are not addressed. We urge policy makers to include prespecified definitions of desired outcomes, offer guidance on the tools used to measure SDM in the multitude of contexts in which it occurs, evaluate the impact of SDM policy initiatives over time, review that impact at regular intervals, and revise SDM measurement tools as needed

What rheumatologists in the United States think of complementary and alternative medicine: results of a national survey

<p>Abstract</p> <p>Background</p> <p>We aimed to describe prevailing attitudes and practices of rheumatologists in the United States toward complementary and alternative medicine (CAM) treatments. We wanted to determine whether rheumatologists' perceptions of the efficacy of CAM therapies and their willingness to recommend them relate to their demographic characteristics, geographic location, or clinical practices.</p> <p>Methods</p> <p>A National Institutes of Health-sponsored cross-sectional survey of internists and rheumatologists was conducted regarding CAM for treatment of chronic back pain or joint pain. In this study we analyzed responses only from rheumatologists. Response items included participant characteristics and experience with 6 common CAM categories, as defined by the National Institutes of Health. Descriptive statistics were used to describe attitudes to CAM overall and to each CAM category. Composite responses were devised for respondents designating 4 or more of the 6 CAM therapies as "very" or "moderately" beneficial or "very likely" or "somewhat likely" to recommend.</p> <p>Results</p> <p>Of 600 rheumatologists who were sent the questionnaire, 345 responded (58%); 80 (23%) were women. Body work had the highest perceived benefit, with 70% of respondents indicating benefit. Acupuncture was perceived as beneficial by 54%. Most were willing to recommend most forms of CAM. Women had significantly higher composite benefit and recommend responses than men. Rheumatologists not born in North America were more likely to perceive benefit of select CAM therapies.</p> <p>Conclusions</p> <p>In this national survey of rheumatologists practicing in the United States, we found widespread favorable opinion toward many, but not all, types of CAM. Further research is required to determine to what extent CAM can or should be integrated into the practice of rheumatology in the United States.</p