Study Protocol for Investigating Physician Communication Behaviours that Link Physician Implicit Racial Bias and Patient Outcomes in Black Patients with Type 2 Diabetes Using an Exploratory Sequential Mixed Methods Design

Introduction Patient-physician racial discordance is associated with Black patient reports of dissatisfaction and mistrust, which in turn are associated with poor adherence to treatment recommendations and underutilisation of healthcare. Research further has shown that patient dissatisfaction and mistrust are magnified particularly when physicians hold high levels of implicit racial bias. This suggests that physician implicit racial bias manifests in their communication behaviours during medical interactions. The overall goal of this research is to identify physician communication behaviours that link physician implicit racial bias and Black patient immediate (patient-reported satisfaction and trust) and long-term outcomes (eg, medication adherence, self-management and healthcare utilisation) as well as clinical indicators of diabetes control (eg, blood pressure, HbA1c and history of diabetes complication). Methods and analysis Using an exploratory sequential mixed methods research design, we will collect data from approximately 30 family medicine physicians and 300 Black patients with type 2 diabetes mellitus. The data sources will include one physician survey, three patient surveys, medical interaction videos, video elicitation interviews and medical chart reviews. Physician implicit racial bias will be assessed with the physician survey, and patient outcomes will be assessed with the patient surveys and medical chart reviews. In video elicitation interviews, a subset of patients (approximately 20–40) will watch their own interactions while being monitored physiologically to identify evocative physician behaviours. Information from the interview will determine which physician communication behaviours will be coded from medical interactions videos. Coding will be done independently by two trained coders. A series of statistical analyses (zero-order correlations, partial correlations, regressions) will be conducted to identify physician behaviours that are associated significantly with both physician implicit racial bias and patient outcomes

Achieving Integration in Mixed Methods Designs—Principles and Practices

Mixed methods research offers powerful tools for investigating complex processes and systems in health and health care. This article describes integration principles and practices at three levels in mixed methods research and provides illustrative examples. Integration at the study design level occurs through three basic mixed method designs—exploratory sequential, explanatory sequential, and convergent—and through four advanced frameworks—multistage, intervention, case study, and participatory. Integration at the methods level occurs through four approaches. In connecting, one database links to the other through sampling. With building, one database informs the data collection approach of the other. When merging, the two databases are brought together for analysis. With embedding, data collection and analysis link at multiple points. Integration at the interpretation and reporting level occurs through narrative, data transformation, and joint display. The fit of integration describes the extent the qualitative and quantitative findings cohere. Understanding these principles and practices of integration can help health services researchers leverage the strengths of mixed methods.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/101791/1/hesr12117.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/101791/2/hesr12117-sup-0001-AuthorMatrix.pd

Women’s impressions of their inpatient birth care as provided by family physicians in the Shizuoka Family Medicine Training Program in Japan

Abstract Background Even though Japan faces serious challenges in women’s health care such as a rapidly aging population, attrition of obstetrical providers, and a harsh legal climate, few family medicine residency training programs in Japan include training in obstetrics, and the literature lacks research on women’s views of intra-partum pregnancy care by family physicians. Findings In this exploratory study, we conducted semi-structured qualitative interviews with five women who received their admission, intrapartum, delivery and discharge care from family medicine residents in the obstetrics ward of a community training hospital. Four women had vaginal births, and one had a Cesarean section. Three were primiparous, and two multiparous. Their ages ranged from 22–33. They found value in family physician medical knowledge and easy communication style, though despite explanation, some had trouble understanding the family physician’s scope of work. These women identified negative aspects of the hospital environment, and wanted more anticipatory guidance about what to expect physically after birth, but were enthusiastic about seeing a family doctor after discharge. Conclusions These results demonstrate the feasibility of family medicine residents providing inpatient birth care in a community hospital, and that patients are receptive to family physicians providing that care as well after discharge. Women’s primary concerns relate mostly to hospital environment issues, and better understanding the care family physicians provide. This illustrates-areas for family physicians to work for improvements.http://deepblue.lib.umich.edu/bitstream/2027.42/112408/1/12930_2012_Article_51.pd

Perspectives about and approaches to weight gain in pregnancy: a qualitative study of physicians and nurse midwives

Abstract Background Over one third of reproductive age women in the US are obese. Pregnancy is a strong risk factor for obesity, with excess weight gain as the greatest predictor of long term obesity. The majority of pregnant women gain more weight than recommended by the Institute of Medicine guidelines. The objective of this study was to understand prenatal care providers’ perspectives on weight gain during pregnancy. Methods Semi-structured qualitative interviews of 10 prenatal care providers (three family physicians, three obstetricians, and four nurse midwives) at a University Hospital in the Midwest, that included the ranking of important prenatal issues, and open-ended questions addressing: 1) general perceptions; 2) approach with patients; and 3) clinical care challenges. Results Providers felt that appropriate weight gain during pregnancy was not a high priority. Many providers waited until patients had gained excess weight before addressing the issue, were not familiar with established guidelines, and lacked resources for patients. Providers also believed that their counseling had low impact on patients, avoided counseling due to sensitivity of the topic, and believed that patients were more influenced by other factors, such as their family, habits, and culture. Conclusions Both providers and patients may benefit from increased awareness of the morbidity of excess weight gain during pregnancy. Practice-level policies that support the monitoring and management of weight gain during pregnancy could also improve care. Research that further investigates the barriers to appropriate weight gain is warranted.http://deepblue.lib.umich.edu/bitstream/2027.42/112570/1/12884_2012_Article_736.pd

How men view genetic testing for prostate cancer risk: findings from focus groups

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/65567/1/j.1399-0004.2000.580303.x.pd

Lifestyle changes of Japanese people on overseas assignment in Michigan, USA

<p>Abstract</p> <p>Background</p> <p>Temporary work assignments in the United States (US) are widely considered to have negative health outcomes on Asians mostly due to adverse changes in diet and exercise, though there is little research on this phenomenon. This study investigated the impact of lifestyle changes on the biological and psychological health and health behaviours of Japanese people on temporary assignments in the US.</p> <p>Methods</p> <p>In this cross sectional survey, we distributed a 38 item self-administered questionnaire addressing health habits, mental health function, lifestyle changes and dietary habits to adult Japanese patients presenting for general physicals at a family medicine clinic serving Japanese patients. We conducted simple statistics and regression analysis between length of stay and other health outcomes to determine whether length of residence in the US was predictive of negative lifestyle changes.</p> <p>Results</p> <p>Most participants reported increased caloric intake, weight gain, and less exercise. They also reported increased time with family. More women than men reported physical symptoms and anxiety related to stress. Smoking and alcohol intake were essentially unchanged. No associations were identified between length of residence in the US and health lifestyle habits or other health outcomes.</p> <p>Conclusion</p> <p>Negative lifestyle changes occur in diet and exercise for overseas Japanese people, but a positive change in increased family time was found. Women appear to be at a greater risk for somatic disorders than men. As duration of stay does not appear predictive of adverse changes, clinicians should advise patients going abroad of these risks regardless of the term of the work assignment.</p

Truth or fallacy? Three hour wait for three minutes with the doctor: Findings from a private clinic in rural Japan

<p>Abstract</p> <p>Introduction</p> <p>While previous reports examine various aspects of Family Medicine in Japan, there is sparse research on consultation lengths. A common phrase permeates throughout Japan, <it>sanjikan machi, sanpun shinsatsu </it>that means, "Three hour wait, three minute visit." The purpose of this study is to examine consultation length in Japan, and how it is affected by patient variables.</p> <p>Case Description</p> <p>We conducted a case study of consultation length and how it varies in relation to the demographics, presenting illness, and diagnoses at a rural clinic in central Japan. Data were coded according to the standards of the International Classification of Primary Care. Descriptive statistics were obtained to identify features of the data. Further, regression analysis was performed to characterize and to quantify the association between length of consultation and various subject level characteristics.</p> <p>Discussion and Evaluation</p> <p>A total of 263 patients aged 0 - 93 years old had consultations during the 8-day study period. The mean consultation duration was 6.12 minutes. Of all consultations, 11.8% lasted 3 minutes or less. The mean (median) consultation time among males was 6.29 (5.2) minutes and among females was 6.03 (5.4) minutes. The duration of visits increased with age. Among different International Classification of Primary Care categories, psychological issues required the most time (mean = 10.75 min, median = 10.9 min) while urological issues required the least (mean = 5.08 min, median = 4.9 min). The majority of cases seen in the clinic were stable, chronic conditions and required shorter consultation times.</p> <p>Conclusions</p> <p>While the mean and median consultation length in this study extends beyond the anecdotal three minutes, the average length of consultation is still remarkably short. Trends affecting consultation length were similar to other international studies. These data present only one aspect of primary care delivery in Japan. To better understand the significance of consultation length relative to the delivery of primary care, future research should examine issues such as continuity, frequency of consultations over time and comprehensiveness of care.</p

Partial and Incremental PCMH Practice Transformation: Implications for Quality and Costs

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/102699/1/hesr12085.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/102699/2/hesr12085-sup-0002-AuthorMatrix.pd

A community-based intervention in middle schools to improve HPV vaccination and cervical cancer screening in Japan

Abstract Aim Japan has low rates of cervical cancer screening and Human papilloma virus (HPV) vaccination. This research examines the effectiveness of a family medicine resident-led, intervention in increasing knowledge about HPV and cervical cancer in middle school-girls and increasing knowledge and intention to have cervical cancer screening in their mothers. Methods We utilized a pre-test/post-test intervention design in three rural middle schools with 7th grade middle school-girls and their mothers. A school-based activity educated girls about HPV and cervical cancer. A home-based activity utilized a homework assignment for girls and their mothers. Pre/post intervention surveys were completed by the girls and their mothers. Major outcomes included changes in knowledge among girls and mothers and barriers to be screened for cervical cancer among mothers. Results Sixty-five students and sixty-three mothers completed the study. Two out five mothers were not in compliance with current screening recommendations. Identified barriers included: embarrassment (79%), poor access (56%), fear of having cancer (52%), and cervical cancer screening being an unknown procedure (46%). Forty-four percent of mothers deemed their daughters to be at risk for cervical cancer. Trusted sources of information included: doctors (97%), newspapers/television (89%), government (79%), the Internet (78%), and friends (62%). Student knowledge scores (7-point scale) improved significantly from pre- to post-intervention (4.8 vs. 5.9, p < 0.001). Knowledge scores (14-point scale) among mothers also significantly improved (11.7 vs. 12.0, p = 0.024). Conclusions These data suggest a community-based intervention on a sensitive topic by family medicine residents can be implemented in middle schools, can improve school-girls’ knowledge about HPV and cervical cancer, and can reach their mothers. Additional research could examine whether those intending to be screened receive screening and how to reach women who still resist screening.http://deepblue.lib.umich.edu/bitstream/2027.42/109452/1/12930_2014_Article_13.pd