Teaching behavioral science to family medicine residents: integrating training into the family practice unit

INTRODUCTION: Physicians need to be well trained in HIV risk assessment interview skills. Little has been written in the literature concerning training methods for this specialized interview. METHODS: One model to teach the HIV risk assessment interview has been developed and has been used to teach third-year medical students. We compared this interactive model, which uses simulated patients to teach HIV Risk Assessment, to a didactic one. Twelve medical residents were taken through either the interactive session or the didactic session. Pre-post changes from questionnaires were calculated to determine any differences in sessions. Also, Objective Structured Clinical Examinations (OSCEs) were used to grade all residents 2 weeks after their sessions. RESULTS: All pre-post changes were calculated and no statistically significant differences were seen (P > 0.50). OSCE interpersonal skills scores and content scores were calculated. The interactive group had statistically significantly higher scores (P < 0.05). CONCLUSION: The data supports the conclusion that an interactive method is more effective to use to train HIV risk assessment interview skills to medical residents when compared to the didactic method.     

Direct observation of community-based ambulatory encounters involving medical students

CONTEXT: The current shift of predoctoral medical education from inpatient tertiary settings to community-based, ambulatory practice has raised questions about the effect of the medical student on the process of patient care. OBJECTIVE: To determine how the presence of a medical student during the ambulatory medical encounter affects the use of clinical time and patient satisfaction. DESIGN: Cross-sectional, multimethod study using direct observation of ambulatory care by research-trained nurses. SETTING: A total of 16 community-based family practice offices accepting family practice clerkship students. PATIENTS: A total of 452 outpatient visits with and without student involvement. MAIN OUTCOME MEASURES: Clinical time use as measured by the Davis Observation Code; patient satisfaction was assessed with the Medical Outcomes Study 9-item visit rating scale. RESULTS: When students were involved, physicians spent more time discussing visit expectations (P=.03) and less time in history taking (P=.007), providing assessment (P=.01), and answering questions (P=.04). Despite these differences, patients were equally satisfied with explanations received, and there was no change in the rank order of the 5 most commonly observed physician behaviors. There was no difference in time spent in treatment planning, physical examination, health education, or social chatting. The physician spent equal time with the patient with (10.3 minutes) and without (9.9 minutes, P=.6) student involvement. There was no decrease in patient satisfaction when students were involved. Physicians were more likely to discuss another family member's problems when a student was present (P=.001). Students were directed to care for minority patients at a disproportionate rate (P=.001), controlling for confounding variables. CONCLUSIONS: Medical student involvement alters the content but not the duration of the ambulatory medical encounter. Application of validated measures indicate that students did not impair patient satisfaction or hinder the physicians' ability to ensure that patient expectations for the visit were met.     

Attitudes of medical students to HIV and AIDS

OBJECTIVE--To assess the knowledge and attitudes of medical students to HIV/AIDS and whether attitudes correlate with knowledge and clinical experience. To determine if students felt adequately prepared to deal with medical and psychological aspects of HIV/AIDS. SUBJECTS AND METHODS--The subjects consisted of 190 London and 99 Cambridge medical students at the end of their genitourinary medicine attachment, plus 230 Cambridge medical students at the end of their second pre-clinical year. Between March 1991 and February 1992 all were asked to complete an anonymous questionnaire, covering factual knowledge and attitudes towards HIV/AIDS. MAIN RESULTS--Cambridge genitourinary medicine students, despite spending less time studying HIV infection than their London counterparts gave more correct answers to the factual questions, although this difference did not reach significance (52.4% vs. 47.5%, p = 0.14). One third of students believed that many health care workers were at high risk of acquiring HIV at work and one fifth thought doctors should have the right to refuse to treat people with HIV. Fourteen percent of Cambridge genitourinary medicine students indicated that most British people with HIV have only themselves to blame, by comparison with 4% of London students (p = 0.003). Thirty-nine per cent of Cambridge genitourinary medicine students expressed reluctance to care for someone with AIDS by comparison with 10% of London students (p = 0.0001). CONCLUSIONS--It is important that medical educators convey accurate information about HIV, including the actual risks posed by occupational exposure and try to ensure that medical students spend sufficient time seeing patients with HIV/AIDS during their training.     

Oral mucosal changes and nicotine disposition in users of Swedish smokeless tobacco products: a comparative study

A survey was conducted to assess the knowledge of 30 oral hygiene (OH I & II) and 79 dental students (BCHD III & VI) on HIV infection and AIDS. A questionnaire consisting of twenty-nine questions based on the 'agree-disagree' format was prepared for this study. Clinical slides were projected to assess students' ability to identify oral manifestations of HIV infection. Most students agreed that HIV-sero-positive people were entitled to the same dignity and respect as those who were suffering from other illnesses. Students were concerned about treating sero-positive patients. They would preferably receive training in the management of these patients in a controlled environment. They had a poor perception of the risk of infection following needle-stick injury and whether HIV could be transmitted through contact with saliva. Most students felt that they had insufficient lectures on HIV/AIDS and had practically no clinical exposure to HIV-sero-positive patients.     

Regulation of reproductive tract immunoglobulins by oestradiol-17beta in the European Red Fox

This article reports the findings from the second part of a two-stage study that used both qualitative and quantitative methods to investigate the communication context of school-based HIV-AIDS education in state secondary schools in metropolitan and rural areas of New South Wales. The quantitative data are here described, focusing on a sample of 1005 Year 12 students' responses to a self-administered questionnaire. The data suggest that the students strongly supported the general idea of school-based HIV-AIDS education, but found current offerings lacking in several respects. Students identified a strong need for information about how HIV and AIDS affect the body, for more information about sexually transmissible diseases other than HIV-AIDS, for people with HIV themselves and experts in the field to provide education sessions, and for more small-group discussions. Rural students and those students from schools located in the outer western suburbs of Sydney in particular reported that they had insufficient access to the modes of information that they most preferred. There were some important differences between the responses of female and male students and between the responses of students from different ethnic groups, suggesting that these factors also need acknowledgment when school-based programs are designed for young people.     

Teaching gastroenterology in a private outpatient clinic

In this essay I review how I have taught clinical gastroenterology to residents and fellows and medical students for the past 40 years in an academic private outpatient clinic. Private patients can serve as "teaching patients," even in an ambulatory setting, and even in a managed care environment that encourages productivity.     

Mental health pathways from interpersonal violence to health-related outcomes in HIV-positive sexual minority men.

Objective: We examined mental health pathways between interpersonal violence (IPV) and health-related outcomes in HIV-positive sexual minority men engaged with medical care. Method: HIV-positive gay and bisexual men (N = 178) were recruited for this cross-sectional study from 2 public HIV primary care clinics that treated outpatients in an urban setting. Participants (M age = 44.1 years, 36% non-White) filled out a computer-assisted survey and had health-related data extracted from their electronic medical records. We used structural equation modeling to test associations among the latent factors of adult abuse and partner violence (each comprising indicators of physical, sexual, and psychological abuse) and the measured variables: viral load, health-related quality of life (HRQOL), HIV medication adherence, and emergency room (ER) visits. Mediation was tested for the latent construct mental health problems, comprising depression, anxiety, symptomatology of posttraumatic stress disorder, and suicidal ideation. Results: The final model demonstrated acceptable fit, χ2(123) = 157.05, p = .02, CFI = .95, TLI = .94, RMSEA = .04, SRMR = .06, accounting for significant portions of the variance in viral load (13%), HRQOL (41%), adherence (7%), and ER visits (9%), as well as the latent variable mental health problems (24%). Only 1 direct link emerged: a positive association between adult abuse and ER visits. Conclusions: Findings indicate a significant role of IPV and mental health problems in the health of people living with HIV/AIDS. HIV care providers should assess for IPV history and mental health problems in all patients and refer for evidence-based psychosocial treatments that include a focus on health behaviors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Determinants of delayed diagnosis of HIV infection in France, 1993-1995

OBJECTIVE: To describe the circumstances of the first HIV-positive test and to study the determinants of a delayed diagnosis of HIV infection. METHODS: In a retrospective study among adult AIDS patients diagnosed between July 1993 and May 1995 in two French districts, data on socioeconomic characteristics, circumstances of first HIV-positive test and attitudes and behaviours regarding medical care were collected in a confidential interview and analysed for potential association with a late test, defined as a first HIV-positive test within 6 months of AIDS diagnosis. RESULTS: Of the 359 AIDS patients studied, 69 (19.2%) had a late test. Late testers were more likely than other patients to have had an HIV-positive test because of clinical symptoms (89.7 versus 38.9%, P < 0.001) and not to perceive themselves as being at risk of infection with HIV (53.6 versus 39.3%, P < 0.05). The proportion of late testers was 34.6% among heterosexually infected patients, 12.7% among homo-/ bisexual men and 9.6% among injecting drug users. Factors independently associated with a late test were male gender [adjusted odds ratio (aOR), 5.6; 95% confidence interval (CI), 1.7-18.9] and absence of earned income (aOR, 5.2; 95% CI, 1.4-19) among heterosexually infected patients; high education (aOR, 3.1; 95% CI, 1.0-9.6) and having consulted a person practising alternative medicine (aOR, 3.4; 95% CI, 1.2-10) in homo-/bisexual men. CONCLUSIONS: Despite incentives to be tested for HIV, many individuals in France are still tested too late, even if they are in known high-risk groups. Efforts to test HIV-infected people as early as possible should be made by increasing the perception of HIV risk and decreasing the level of missed opportunities for testing. Current case management approaches make this recommendation critically important from both public health and an individual perspective.     

Computerized monitoring protocols as a pharmaceutical care practice enhancement: a conceptual illustration using diabetes mellitus

OBJECTIVE: To illustrate how a computer system used in an ambulatory care pharmacy setting might enhance care of patients with diabetes by prospectively monitoring and prompting them to seek routine medical care. DATA SOURCES: A MEDLINE search to identify existing works on informatics was conducted. An epidemiology and general medical literature review of diabetes mellitus was also performed via MEDLINE. Additionally, known textbooks on the disease were consulted. CONCLUSIONS: Programming a computer system to prompt pharmacists to remind their patients of necessary medical interventions could save medical resources by warning chronically ill patients not to ignore routine medical care. Also, this would allow the pharmacist to prospectively monitor patient outcomes. By knowing when medical interventions are due and obtaining feedback from patients on the results of the medical contact, pharmacists increase their knowledge about patient outcomes and the rationale behind changes in pharmacotherapy. It is expected that such a system would prevent the inconspicuous development of chronic complications.     

Congenital toxoplasmosis and seroconversion at the end of pregnancy: clinical observations

OBJECTIVE: To determine the knowledge of HIV-disease management and the adherence to contemporary guidelines among British Columbia physicians whose practices focused on HIV/AIDS. DESIGN: Self-administered mail survey. PARTICIPANTS: All 659 physicians registered in a province-wide HIV/AIDS drug treatment program. OUTCOME MEASURES: Data on demographic and personal characteristics of respondents, level of HIV-related experience, use of preventive vaccinations and tests, and preferred approaches to the prophylaxis and treatment of common opportunistic infections. Knowledge scores in 4 areas of patient care, as well as an overall score, were computed by comparing respondents' answers with the therapeutic strategies recommended at the time of the survey. Associations between physician characteristics and knowledge scores were identified by linear regression analysis. RESULTS: Of the 659 physicians surveyed, 65% returned responses: only 38% returned completed surveys while a further 27% returned a follow-up survey that asked nonrespondents about their demographic characteristics and HIV-related experience. Scores for specific areas of patient management ranged from 29% for the treatment of opportunistic infections to 62% for preventive measures, with a mean overall score of 47%. Physician knowledge in all areas of patient care was associated with the number of HIV-positive patients in the practice (p = 0.003 to p < 0.001). Physicians who were younger were more knowledgeable regarding preventive measures (p = 0.001); those whose practice location was in Vancouver had a greater knowledge of prophylaxis (p = 0.047); and those who had medical specialty training were more knowledgeable about the treatment of opportunistic infections (p = 0.009). CONCLUSIONS: There is substantial disparity in how physicians approach the management of HIV and related conditions. Deviations from therapeutic guidelines are common and may be associated with physician characteristics, particularly lack of experience in managing HIV.     

Effect of pharmacist interventions on medication use and cost in hospitalized patients with or without HIV infection

Pharmacotherapeutic interventions and drug acquisition costs in HIV-positive and HIV-negative patients on a hospital medical service were studied. In November and December 1995, HIV-positive and HIV-negative patients were randomly selected and matched on the basis of admission date. Pharmacotherapeutic interventions were recorded by a pharmacist until the time of discharge. Drug acquisition costs were obtained through records of medications ordered. The two patient groups were compared with respect to length of stay (LOS), number and cost of medications, and number of interventions. HIV-positive patients had significantly more medication orders and required more interventions than HIV-negative patients. Mean LOS was not significantly different. HIV status and number of medications were significantly associated with requiring five or more interventions. Drug acquisition costs were significantly higher in the HIV-positive group. The mean pharmacist-attributed cost saving per patient was $134 for HIV-positive patients and $27 for HIV-negative patients. HIV-positive patients required more interventions and consumed more medication resources than HIV-negative patients. Pharmacist interventions produced drug acquisition cost savings for both groups, with more savings being realized for positive patients.     

Implementation and evaluation of a primary care preceptorship

As part of overall curricular reform, the University of Michigan Medical School developed and implemented a required primary care clerkship for third-year students in July 1993. The clerkship was intended to help students develop an understanding of the principles of comprehensive health care and of disease prevention and the knowledge and skills to manage common problems in primary care. The successful implementation of the program was based on agreement across primary care specialties on a common set of goals and objectives, which were developed with the involvement of community practitioners; frequent communication with preceptors to identify problems and students at risk; active feedback to preceptors; and thorough formal and informal evaluations of students and preceptors. Students and preceptors felt the program was beneficial to them; still, the medical school must in the future address concerns about more accurately grading students, retaining preceptors, and ensuring that students be exposed to the broadest possible range of primary care patients and services.     

Long-term peritoneal dialysis before transplantation and intra-abdominal infection after simultaneous pancreas-kidney transplantations

OBJECTIVE: To examine the attitudes and knowledge of health care professionals regarding human immunodeficiency virus (HIV) infection in countries with a varying prevalence of HIV infection to assist in the development of acquired immunodeficiency syndrome (AIDS) educational programs. DESIGN: Anonymous questionnaire with four sections: demographics, attitudes, knowledge, and an open-ended question investigating feelings about the potential impact that HIV infection may have on respondents' practices. PARTICIPANTS: Final-year medical students, house staff, and attending physicians at teaching hospitals in India, Thailand, Canada, and the United States. RESULTS: From January to October 1992, 819 health care professionals completed the questionnaire: 340 from India, 196 from Canada, 155 from the United States, and 128 from Thailand. The percentage of respondents who had previous contact with patients with HIV/AIDS varied from 30% to 98%; it was lowest in India, followed by Thailand and then Canada, and highest in the United States. Percentages of respondents uncomfortable performing a physical examination on a patient with HIV/AIDS were 24%, 25%, 9%, and 4%, respectively. Mean HIV/AIDS knowledge scores were 83%, 84%, 92%, and 93%, respectively. Most respondents correctly identified modes of transmission of HIV infection. Only 67% of Indian health care professionals understood the concept of a false-negative screening serologic test, compared with 98% of Canadian health care professionals. In Canada and the United States, only 78% and 76%, respectively, understood the concept of a false-positive screening serologic test. Awareness of an asymptomatic stage of HIV infection ranged from 32% in India to 74% in Canada. Despite their concerns of becoming infected, health care professionals in countries with a lower prevalence of HIV infection reported a strong ethical duty to care for these patients. CONCLUSIONS: Level of comfort in caring for HIV-infected patients and HIV/AIDS knowledge scores varied directly with the amount of previous contact with these patients. Disturbing numbers of health care professionals from all four countries did not understand the potential problems of the enzyme-linked immunosorbent assay serologic test and a significant percentage were unaware of the asymptomatic stage of HIV infection. There is a universal need for increased education of health care professionals about HIV infection and AIDS.     

Smoked cocaine self-administration in females and voucher incentives for abstinence

Although some individuals are able to cope well with the challenges posed by HIV and AIDS, others experience psychological difficulties. This article reviews factors that facilitate or hinder successful coping with HIV including preexisting psychological functioning, medical health status, quality and adequacy of social support, stress-and-coping style, and perceived expected benefits of treatment. The article reviews studies evaluating the effects of group psychotherapy intervention for persons living with HIV. The article then describes clinical issues encountered in therapy groups for persons with HIV. These clinical issues include the presence of coexisting problems unrelated to HIV/AIDS, disclosure of HIV-positive serostatus to others, making changes in transmission-risk-behavior practices, AIDS-related bereavement and caregiving stress, establishing social supports, adhering to medical care regimens, and developing a positive self-identity as a person living with HIV. Practical considerations of group therapy for HIV-positive clients are also described.     

Assessment at one school of students' abilities and confidence in diabetic patients' education

PURPOSE: To determine medical students' experiences in working with diabetic patients, their cognitive competence and their confidence in meeting diabetic patients' educational needs, and changes in their expertise with advancing education. METHOD: The study was conducted in March 1994 at the University of Illinois College of Medicine, where students work with ambulatory patients in a longitudinal primary care experience from their second year through graduation. A combined questionnaire and objective quiz was developed and distributed to 138 second-, third-, and fourth-year students. The students were asked whether they had had experience in seeing a newly diagnosed diabetic patient, in what setting, and whether they felt confident in educating such patients on various common topics. They were also asked about their interests in and preferences for learning about diabetic patients' education. A 50-item objective quiz on the management of diabetes followed the questionnaire. Data were analyzed with several statistical methods. RESULTS: In all, 65 of the students (47%) responded; the majority were third- or fourth-year students. The percentages of students who felt confident ranged from 83% who felt confident about counseling about exercise to only 16% who felt confident about pre-conception counseling. All of the students but one felt that diabetic patients' education was an important topic, and all but two were interested in it. The students' quiz scores showed no significant difference by year of training; for all the students the average score was 39.6% correct, with no increase in score for increased training. Also, the students who were more confident about their abilities to provide patient education on a certain topic were no more likely to have accurate information about that topic than were those who were not confident. CONCLUSION: Although they were clearly interested in diabetic patients' education, the students did not feel confident in providing it, nor did they have the cognitive competence to do so. Medical schools have a responsibility to students and to their patients to formally address the issues of patient education.     

Patient attitudes toward rooming with persons with HIV infection

BACKGROUND: Early in the HIV epidemic, hospitals developed strict isolation policies for patients with HIV infection, some of which have not been revised. The objectives of this study were to examine patient attitudes about rooming with persons with various medical conditions, including HIV, and to assess their knowledge about the transmission of HIV. METHODS: One hundred four inpatients at a university hospital were surveyed by means of a structured interviewer-administered questionnaire. Patients were asked about preference for a single or double room, and about their objections to rooming with patients with HIV infection and other medical conditions. The questionnaire also examined subject's knowledge about the transmission of HIV. RESULTS: Of 104 inpatients surveyed, 55% objected to rooming with an HIV-seropositive patient. Patients who objected to rooming with an HIV-seropositive patient were also more likely to object to rooming with a disfigured patient (relative risk = 1.5; 95% CI, 1.1 to 2.2), or with a demented patient (relative risk = 1.7; 95% CI, 1.0 to 2.9). Also, patients who objected to rooming with an HIV-seropositive patient had greater misconceptions about the transmissibility of HIV infection. CONCLUSIONS: A significant proportion of patients reported an unwillingness to room with patients with HIV infection, but also had misconceptions about the transmissibility of HIV. Current rooming policies may perpetuate misconceptions about the possibility of causal transmission of HIV.     

Undergraduate education in primary care: the Rockford experience

Four years of experience with an undergraduate program in primary care in a new community-based medical school are described. Students are intimately involved over a two-and-a-half-year period in the delivery of primary care in rural and semi-rural community health centers. Despite problems of financing and, especially, faculty recruitment and development, the program has been enthusiastically endorsed by students and patients and appears to represent a viable new model for medical education.     

The Medical Polyclinic: an approach to conflicting needs in a teaching hospital

University teaching hospitals have become increasingly aware of their responsibility to improve both the teaching of ambulatory care and the quality of care provided in their clinics. This paper describes how one department of medicine met this challenge by forming a "Medical Polyclinic." The majority of the department's faculty and house staff, at all academic and training levels, participate in a system of ambulatory care with the following objectives: each patient has a single physician whom he sees by appointment and who coordinates his care; all medical subspecialties are available in the same clinic session; the clinic is attractive and efficient. While these goals are not infrequently met in private group practices, they are unusual in a university teaching hospital, where faculty, house staff, students, and patients each have unique needs, not always compatible. The success and problems of the polyclinic approach are discussed.     

Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. Project RESPECT Study Group

CONTEXT: The efficacy of counseling to prevent infection with the human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs) has not been definitively shown. OBJECTIVE: To compare the effects of 2 interactive HIV/STD counseling interventions with didactic prevention messages typical of current practice. DESIGN: Multicenter randomized controlled trial (Project RESPECT), with participants assigned to 1 of 3 individual face-to-face interventions. SETTING: Five public STD clinics (Baltimore, Md; Denver, Colo; Long Beach, Calif; Newark, NJ; and San Francisco, Calif) between July 1993 and September 1996. PARTICIPANTS: A total of 5758 heterosexual, HIV-negative patients aged 14 years or older who came for STD examinations. INTERVENTIONS: Arm 1 received enhanced counseling, 4 interactive theory-based sessions. Arm 2 received brief counseling, 2 interactive risk-reduction sessions. Arms 3 and 4 each received 2 brief didactic messages typical of current care. Arms 1, 2, and 3 were actively followed up after enrollment with questionnaires at 3, 6, 9, and 12 months and STD tests at 6 and 12 months. An intent-to-treat analysis was used to compare interventions. MAIN OUTCOME MEASURES: Self-reported condom use and new diagnoses of STDs (gonorrhea, chlamydia, syphilis, HIV) defined by laboratory tests. RESULTS: At the 3- and 6-month follow-up visits, self-reported 100% condom use was higher (P<.05) in both the enhanced counseling and brief counseling arms compared with participants in the didactic messages arm. Through the 6-month interval, 30% fewer participants had new STDs in both the enhanced counseling (7.2%; P= .002) and brief counseling (7.3%; P= .005) arms compared with those in the didactic messages arm (10.4%). Through the 12-month study, 20% fewer participants in each counseling intervention had new STDs compared with those in the didactic messages arm (P = .008). Consistently at each of the 5 study sites, STD incidence was lower in the counseling intervention arms than in the didactic messages intervention arm. Reduction of STD was similar for men and women and greater for adolescents and persons with an STD diagnosed at enrollment. CONCLUSIONS: Short counseling interventions using personalized risk reduction plans can increase condom use and prevent new STDs. Effective counseling can be conducted even in busy public clinics.