Injury-prevention counseling among residents of internal medicine

Pediatrician-Reported Injury Prevention Anticipatory Guidance by Patient Age Group

OBJECTIVE

Unintentional injuries remain a leading cause of death for children and adolescents older than 1 year. Injury prevention has long been a cornerstone of anticipatory guidance. Previous studies have established the sustained efficacy of injury prevention anticipatory guidance in pediatric primary care. This study examines the topical emphasis of injury prevention anticipatory guidance by patient age, with special attention given to the rate of water safety anticipatory guidance across 4 patient age groups.

METHODS

A nationwide, random sample of AAP member pediatricians was surveyed on their experiences, attitudes, and practices related to injury prevention anticipatory guidance, including barriers to delivering anticipatory guidance.

RESULTS

Of the respondents who reported providing direct patient care, 92% considered injury prevention anticipatory guidance a priority issue. The content of that injury prevention guidance varied considerably by patient age. Roughly half (53%) reported counseling families with adolescents on water safety/drowning prevention, which represents a statistically significant decrease relative to other patient age groups.

CONCLUSIONS

Reported injury prevention anticipatory guidance is high across different mechanisms of injury. However, fewer pediatricians deliver drowning prevention anticipatory guidance to adolescents than to younger patients. Targeted outreach and education to increase injury prevention anticipatory guidance, especially for adolescent patients, should be part of a multipronged approach to decrease drowning and other injury deaths.

Implementation of a firearm safety guidance training program for pediatric providers

PURPOSE

Pediatric unintentional firearm injuries are potentially preventable with firearm safety guidance (FSG). In baseline assessment, we learned that providers feel uncomfortable delivering FSG due to lack of training, but are inclined to learn. Here we present the development and concept testing of an FSG training program.

METHODS

Using Kern's 6 rules of curriculum development, a training template was developed: 1. Program development, 2. Review by multidisciplinary expert team, 3. Concept testing, and 4. Modifications. Foundations included: raising awareness, increasing provider knowledge of safe storage methods, introducing a visual aide (American Academy of Pediatrics [AAP] infographic), and providing examples of guidance delivery. In-person training was provided and modifications made until there was uniform provider satisfaction. Program effectiveness and satisfaction were evaluated through surveys and focus groups. Descriptive statistics and univariate analyses were utilized.

RESULTS

Over one year, in-person training was provided to 44 pediatric providers (residents and practicing pediatricians) at 8 clinics. Modifications included: addition of a Spanish-version visual aide, instruction on safety device use, simulation scenarios, making the handout more child-friendly, and development of a home safety video to include firearm safety with other topics. Following training, routine FSG by pediatricians increased from 34% to 71% (p = 0.001). Focus groups revealed provider satisfaction with the AAP infographic and increased comfort of FSG delivery.

CONCLUSION

Following development and quality improvement, our FSG training model received positive feedback and increased provider delivery by pediatric providers. This model could be used for development of FSG training programs in other settings.

Clinician Attitudes, Screening Practices, and Interventions to Reduce Firearm-Related Injury

Firearm injury is a leading cause of injury-related morbidity and mortality in the United States. We sought to systematically identify and summarize existing literature on clinical firearm injury prevention screening and interventions. We conducted a systematic search of PubMed, Web of Science, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsycInfo, and ClinicalTrials.gov for English-language original research (published 1992-2014) on clinical screening methods, patient-level firearm interventions, or patient/provider attitudes on the same. Unrelated studies were excluded through title, abstract, and full-text review, and the remaining articles underwent data abstraction and quality scoring. Of a total of 3,260 unique titles identified, 72 were included in the final review. Fifty-three articles examined clinician attitudes/practice patterns; prior training, experience, and expectations correlated with clinicians' regularity of firearm screening. Twelve articles assessed patient interventions, of which 6 were randomized controlled trials. Seven articles described patient attitudes; all were of low methodological quality. According to these articles, providers rarely screen or counsel their patients-even high-risk patients-about firearm safety. Health-care-based interventions may increase rates of safe storage of firearms for pediatric patients, suicidal patients, and other high-risk groups. Some studies show that training clinicians can increase rates of effective firearm safety screening and counseling. Patients and families are, for the most part, accepting of such screening and counseling. However, the current literature is, by and large, not high quality. Rigorous, large-scale, adequately funded studies are needed.

Patient Counseling for Unintentional Injury Prevention

Injury prevention counseling (IPC) by health care providers is one strategy to reduce injury risk by encouraging people to modify their environment or their personal behaviors to protect themselves or their loved ones. National surveys indicate that few patients are receiving IPC. The evidence of IPC being effective at increasing safety practices is inconsistent. This may be explained partially because counseling recommendations for some injury issues may involve more effort, cost, or inconvenience by the patient. IPC that is based on behavior change theories is more likely to be effective. Physicians and other health care providers can play a critical role in efforts to prevent injuries, but barriers for delivering IPC need to be overcome.

Injury prevention counseling for adults: have we made progress?

Injuries are a leading cause of morbidity and mortality in the United States. Physicians are a trusted source that can disseminate information about the prevention of injury and violence. This study used the second Injury Control and Risk Survey to report the national prevalence of healthcare provider injury prevention counseling to adults. Results indicate that overall 1 in 5 adults who visited a healthcare provider received some counseling on injury prevention. Counseling prevalence varied by injury topic and patient demographic characteristics. Many people who could benefit from counseling are not receiving it, even among those who had visited a healthcare provider.

A national survey of medical students' beliefs and knowledge in screening for prostate cancer

BACKGROUND

Today's medical students are being educated at a time when there are no evidence-based guidelines for prostate cancer screening.

OBJECTIVE

To examine medical students' knowledge and beliefs concerning prostate cancer screening and specific determinants for their beliefs.

DESIGN, SETTING, AND PARTICIPANTS

One thousand six hundred and forty four students were sampled at 20 medical schools using a web-based, cross-sectional survey.

MAIN OUTCOME MEASURES

Basic knowledge and beliefs about prostate cancer testing, epidemiology, and therapy were ascertained.

RESULTS

Four of 8 knowledge items were answered incorrectly by 50% or more of students. Seven of 8 students believe that early diagnosis from screening can improve survival from prostate cancer. Second- and third-year students were more likely than fourth-year students to believe that the digital rectal exam (DRE) and the prostate-specific antigen test were accurate, adjusted odds ratio (AOR) 1.8; 95% confidence interval (CI), 1.2 to 2.7 and 1.7; 1.3 to 2.2 for second and third years, respectively, for the DRE. Black and Hispanic students were no more likely than white students to agree that early screening diagnosis improves survival, but blacks were more likely to agree with screening black or Hispanic men (AOR 7.8; 95% CI, 5.3 to 11.4 and 3.2; 2.2 to 4.7, respectively). More knowledgeable students were less likely to believe in the benefit of early detection and the accuracy of the prostate-specific antigen (AOR 0.3; 95%CI, 0.2 to 0.5).

CONCLUSIONS

Medical students generally are very optimistic about the benefits of screening for prostate cancer. Increased knowledge about prostate cancer is associated with a more conservative view of screening. Other predictors are independent of this knowledge.

Firearm-related personal and clinical characteristics of US medical students

BACKGROUND

Firearm injuries are the second leading cause of fatal injury in the US, and several medical specialty societies encourage patient counseling about firearm injury prevention. Because personal choices. influence physicians' willingness to counsel, it would be valuable to know how frequently guns are kept in the homes of physicians-in-training, as well as their perceptions and current rates of counseling about firearm injury prevention.

METHODS

At a nationally representative sample of 16 medical schools, we surveyed the class of 2003 at freshman orientation, entrance to wards, and during senior year.

RESULTS

A total of 2,316 students provided data (response rate = 80.3%). Among freshmen, 16% reported living in a home with a firearm, 13% did so at entry to wards, as did 14% of seniors (14% overall, women = 9%, men = 19%). Only 34% of seniors reported counseling their patients more often than "never/rarely" about firearm possession and storage.

CONCLUSIONS

US medical students reported substantially lower rates of household gun ownership than the general population, but their participation in firearm-related counseling is also low.

Changing habits of practice. Transforming internal medicine residency education in ambulatory settings

PURPOSE

The majority of health care, both for acute and chronic conditions, is delivered in the ambulatory setting. Despite repeated proposals for change, the majority of internal medicine residency training still occurs in the inpatient setting. Substantial changes in ambulatory education are needed to correct the current imbalance. To assist educators and policy makers in this process, this paper reviews the literature on ambulatory education and makes recommendations for change.

METHODS

The authors searched the Medline, Psychlit, and ERIC databases from 2000 to 2004 for studies that focused specifically on curriculum, teaching, and evaluation of internal medicine residents in the ambulatory setting to update previous reviews. Studies had to contain primary data and were reviewed for methodological rigor and relevance.

RESULTS

Fifty-five studies met criteria for review. Thirty-five of the studies focused on specific curricular areas and 11 on ambulatory teaching methods. Five involved evaluating performance and 4 focused on structural issues. No study evaluated the overall effectiveness of ambulatory training or investigated the effects of current resident continuity clinic microsystems on education.

CONCLUSION

This updated review continues to identify key deficiencies in ambulatory training curriculum and faculty skills. The authors make several recommendations: (1) Make training in the ambulatory setting a priority. (2) Address systems problems in practice environments. (3) Create learning experiences appropriate to the resident's level of development. (4) Teach and evaluate in the examination room. (5) Expand subspecialty-based training to the ambulatory setting. (6) Make faculty development a priority. (7) Create and fund multiinstitutional educational research consortia.