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Fischer KA, Anand S, Walling A, Larson SM, Glaspy J. Cost-Health Literacy as an Educational Objective in Fellowship Training. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2022; 37:1479-1485. [PMID: 33761118 DOI: 10.1007/s13187-021-01987-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 06/12/2023]
Abstract
Physicians are encouraged to communicate with their patients about financial concerns, but are infrequently taught skills necessary to do so. This study describes a curriculum for oncology fellows aimed to improve skills of cost-health literacy, and provides assessment of the curriculum impact on self-perceived cost communication practices. Oncology fellows at a large academic program in 2019 participated in a cost-health literacy curriculum over 3 months. The curriculum consisted of a didactic on financial toxicity (45 min), a problem-based learning case highlighting financial toxicity risk factors and areas for intervention (30 min), and a group discussion (30 min) to review and consolidate strategies to navigate financial toxicity in direct patient care. A cost-health literacy survey was administered at baseline and at the conclusion of the curriculum to evaluate the impact of the program. Of 19 participants, 16 completed both the pre-survey and post-survey and were included in the analysis. After the intervention, participants were more likely to report comfort discussing out-of-pocket costs (50% vs. 19%, p = 0.002) and to feel they could help a patient experiencing financial toxicity (62% vs. 6%, p = 0.005). There was no improvement in the subjective assessment of patient financial distress (57% v 50%, p = 0.759). Oncology fellows can improve self-reported cost-health literacy skills through participation in a targeted, brief curriculum. Further studies are warranted to determine how this approach can be applied in other settings and if it objectively impacts cost communication practices.
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Affiliation(s)
- Katrina A Fischer
- Department of Medicine (Hematology & Oncology), UCLA School of Medicine, Los Angeles, CA, USA.
- 200 UCLA Medical Plaza, Suite 120, Los Angeles, CA, 90095, USA.
| | - Sidharth Anand
- Department of Medicine (Hematology & Oncology), UCLA School of Medicine, Los Angeles, CA, USA
| | - Anne Walling
- Department of Medicine (Division of General Internal Medicine & Health Services Research), UCLA School of Medicine, Los Angeles, CA, USA
| | - Sarah M Larson
- Department of Medicine (Hematology & Oncology), UCLA School of Medicine, Los Angeles, CA, USA
| | - John Glaspy
- Department of Medicine (Hematology & Oncology), UCLA School of Medicine, Los Angeles, CA, USA
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Castillo EG, Isom J, DeBonis KL, Jordan A, Braslow JT, Rohrbaugh R. Reconsidering Systems-Based Practice: Advancing Structural Competency, Health Equity, and Social Responsibility in Graduate Medical Education. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:1817-1822. [PMID: 32590465 PMCID: PMC8279228 DOI: 10.1097/acm.0000000000003559] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Health inequities stem from systematic, pervasive social and structural forces. These forces marginalize populations and create the circumstances that disadvantage these groups, as reflected in differences in outcomes like life expectancy and infant mortality and in inequitable access to and delivery of health care resources. To help eradicate these inequities, physicians must understand racism, sexism, oppression, historical marginalization, power, privilege, and other sociopolitical and economic forces that sustain and create inequities. A new educational paradigm emphasizing the knowledge, skills, and attitudes to achieve health equity is needed.Systems-based practice is the graduate medical education core competency that focuses on complex systems and physicians' roles within them; it includes topics like multidisciplinary team-based care, patient safety, cost containment, end-of-life goals, and quality improvement. This competency, however, is largely health care centric and does not train physicians to engage with the complexities of the social and structural determinants of health or to partner with systems and communities that are outside health care.The authors propose a new core competency centered on health equity, social responsibility, and structural competency to address this gap in graduate medical education. For the development of this new competency, the authors draw on existing, innovative undergraduate and graduate medical pedagogy and public health, health services research, and social medicine frameworks. They describe how this new competency would inform graduate medical education and clinical care and encourage future physicians to engage in the work of health equity.
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Affiliation(s)
- Enrico G Castillo
- E.G. Castillo is a psychiatrist, Los Angeles County Department of Mental Health, and assistant professor, Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Center for Social Medicine and Humanities, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; ORCID: https://orcid.org/0000-0002-3807-1125
| | - Jessica Isom
- J. Isom is a community psychiatrist, Codman Square Health Center, Dorchester, Massachusetts
| | - Katrina L DeBonis
- K.L. DeBonis is assistant professor, Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Ayana Jordan
- A. Jordan is assistant professor, Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, and addiction psychiatrist, Community Mental Health Center, New Haven, Connecticut; ORCID: https://orcid.org/0000-0002-7850-8096
| | - Joel T Braslow
- J.T. Braslow is professor, Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Center for Social Medicine and Humanities, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Robert Rohrbaugh
- R. Rohrbaugh is professor, Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut; ORCID: https://orcid.org/0000-0002-4969-4352
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Kulkarni K, Shepherd S. Do we know the cost of orthopaedic care? Int J Health Plann Manage 2018; 34:71-86. [PMID: 30052283 DOI: 10.1002/hpm.2571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION The increasingly complex care needs of an expanding and ageing population leave a growing dichotomy between demand and supply. With sustainable cost-efficiency gains paramount, this study explored awareness of trauma and orthopaedic (T&O) care costs among patients and health care providers, alongside the impact of greater cost awareness on care quality, experience, and equality. MATERIALS AND METHODS Surveys were distributed over a 2-week period, at a single site, to in/outpatients and health care professionals allied to T&O. They evaluated (1) awareness of the costs of several common aspects of T&O care and (2) opinions on improved cost education. RESULTS Most professionals and patients had limited and markedly variable awareness of costs. Expensive items (>£200) were commonly underestimated, and cheap items (≤£200) were overestimated. The majority reported greater cost awareness might influence their approach to care decisions. DISCUSSION Cost ignorance restricts cost-efficiency and provision of equitable care. Given the widespread lack of cost education, there is unsurprisingly a lack of cost awareness among patients and professionals alike. Cost savings through "reduced waste" were a commonly highlighted potential benefit of greater cost awareness. Patients and professionals alike must become increasingly accountable for ensuring effective and efficient use of resources.
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Affiliation(s)
- Kunal Kulkarni
- Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW
| | - Sophie Shepherd
- Department of Surgery, East and North Herts NHS Trust, Stevenage, UK
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Truesdale MD, Elmer-Dewitt M, Sandri M, Schmidt B, Metzler I, Gadzinski A, Stoller ML, Chi T. Methylene Blue Injection as an Alternative to Antegrade Nephrostography to Assess Urinary Obstruction After Percutaneous Nephrolithotomy. J Endourol 2016; 30:476-82. [PMID: 26732844 DOI: 10.1089/end.2015.0594] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
AIMS AND OBJECTIVES Percutaneous nephrolithotomy (PCNL) remains an effective treatment for large stones. When nephrostomy tube (NT) is left post operation, antegrade urine flow is often confirmed with antegrade nephrostography (ANG) before tube removal. We compare methylene blue (MB) test combined with NT capping trial against ANG to assess antegrade urine flow after PCNL. MATERIALS AND METHODS One hundred one consecutive patients undergoing PCNL were prospectively enrolled between 7/2014 and 4/2015. An NT cap was placed the morning of postoperative day 1 (POD1). Failure was defined as need to uncap the NT for any reason. Two hours after capping, 7cc MB was injected into the NT. Positive MB test was defined as presence of blue per bladder Foley. ANG was then performed to assess antegrade urine flow. NTs were removed before discharge home when antegrade flow was documented. Primary outcomes included presence of antegrade flow on ANG and NT removal before discharge home. Receiver operating characteristic (ROC) and areas (Area under the ROC [AUC]), as well as Cohen's kappa coefficient (κ), were calculated comparing agreement of capping trial, MB, and ANG with NT removal. RESULTS One hundred one subjects were included in this analysis. 52.9% were left-sided surgeries and 60.4% utilized lower pole punctures. On ROC areas evaluating tests for agreement with NT removal before discharge, MB AUC 0.71 (95% CI 0.60-0.83), capping trial AUC 0.66 (95% CI 0.57-0.75), combed capping trial and MB AUC 0.72 (95% CI 0.61-0.84), and ANG AUC 0.78 (95% CI 0.68-0.88). In predicting NT removal, ANG performed better than capping trial alone (p = 0.042), but no differences were seen between MB and ANG (p = 0.229), combining the capping trial with MB test and ANG (p = 0.266) or combined testing and MB alone (p = 0.972). CONCLUSIONS Combining capping trial with MB injection is similarly accurate for predicting NT removal after PCNL compared to ANG. Capping trial and MB may be used in combination to obviate the need for ANG.
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Affiliation(s)
- Matthew D Truesdale
- 1 Department of Urology, University of California , San Francisco, California
| | - Molly Elmer-Dewitt
- 1 Department of Urology, University of California , San Francisco, California
| | - Marco Sandri
- 2 DMS StatLab, Data Methods and Systems Statistical Laboratory, University of Brescia , Brescia, Italy
| | - Bogdana Schmidt
- 1 Department of Urology, University of California , San Francisco, California
| | - Ian Metzler
- 1 Department of Urology, University of California , San Francisco, California
| | - Adam Gadzinski
- 1 Department of Urology, University of California , San Francisco, California
| | - Marshall L Stoller
- 1 Department of Urology, University of California , San Francisco, California
| | - Thomas Chi
- 1 Department of Urology, University of California , San Francisco, California
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Roy B, Chheda SG, Bates C, Dunn K, Karani R, Willett LL. For the General Internist: A Summary of Key Innovations in Medical Education. J Gen Intern Med 2016; 31:941-6. [PMID: 27084757 PMCID: PMC4945558 DOI: 10.1007/s11606-016-3669-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 02/19/2016] [Accepted: 03/08/2016] [Indexed: 10/21/2022]
Abstract
We conducted a review of published medical education articles to identify high-quality research and innovation relevant to educators in general medicine. Our review team consisted of six general internists with expertise in medical education and a professional medical librarian. We manually searched 15 journals in pairs (a total of 3062 citations) for original research articles in medical education published in 2014. Each pair of reviewers independently rated the relevance, importance, and generalizability of articles on medical education in their assigned journals using a 27-point scale (maximum of 9 points for each characteristic). From this list, each team member independently reviewed the 22 articles that received a score of 20 or higher from both initial reviewers, and for each selected article rated the quality and global relevance for the generalist educator. We included the seven top-rated articles for presentation in this review, and categorized the studies into four general themes: continuity clinic scheduling, remediation, interprofessional education, and quality improvement and patient safety. We summarized key findings and identified significant limitations of each study. Further studies assessing patient outcomes are needed to strengthen the literature in medical education. This summary of relevant medical education articles can inform future research, teaching, and practice.
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Affiliation(s)
- Brita Roy
- Section of General Internal Medicine, Yale University School of Medicine, PO Box 208025, New Haven, CT, 06520-8025, USA.
| | - Shobhina G Chheda
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Carol Bates
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Kathel Dunn
- National Library of Medicine, Bethesda, MD, USA
| | - Reena Karani
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lisa L Willett
- University of Alabama at Birmingham, Birmingham, AL, USA
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Long T, Bongiovanni T, Dashevsky M, Halim A, Ross JS, Fogerty RL, Silvestri MT. Impact of laboratory cost display on resident attitudes and knowledge about costs. Postgrad Med J 2016; 92:592-6. [DOI: 10.1136/postgradmedj-2015-133851] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 02/25/2016] [Indexed: 11/04/2022]
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Resident Self-Assessment and Learning Goal Development: Evaluation of Resident-Reported Competence and Future Goals. Acad Pediatr 2015; 15:367-73. [PMID: 26142068 DOI: 10.1016/j.acap.2015.01.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 12/20/2014] [Accepted: 01/03/2015] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To determine incidence of learning goals by competency area and to assess which goals fall into competency areas with lower self-assessment scores. METHODS Cross-sectional analysis of existing deidentified American Academy of Pediatrics' PediaLink individualized learning plan data for the academic year 2009-2010. Residents self-assessed competencies in the 6 Accreditation Council for Graduate Medical Education (ACGME) competency areas and wrote learning goals. Textual responses for goals were mapped to 6 ACGME competency areas, future practice, or personal attributes. Adjusted mean differences and associations were estimated using multiple linear and logistic regression. RESULTS A total of 2254 residents reported 6078 goals. Residents self-assessed their systems-based practice (51.8) and medical knowledge (53.0) competencies lowest and professionalism (68.9) and interpersonal and communication skills (62.2) highest. Residents were most likely to identify goals involving medical knowledge (70.5%) and patient care (50.5%) and least likely to write goals on systems-based practice (11.0%) and professionalism (6.9%). In logistic regression analysis adjusting for postgraduate year (PGY), gender, and degree type (MD/DO), resident-reported goal area showed no association with the learner's relative self-assessment score for that competency area. In the conditional logistic regression analysis, with each learner serving as his or her own control, senior residents (PGY2/3+s) who rated themselves relatively lower in a competency area were more likely to write a learning goal in that area than were PGY1s. CONCLUSIONS Senior residents appear to develop better skills and/or motivation to explicitly turn self-assessed learning gaps into learning goals, suggesting that individualized learning plans may help improve self-regulated learning during residency.
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Shah N, Levy AE, Moriates C, Arora VM. Wisdom of the crowd: bright ideas and innovations from the teaching value and choosing wisely challenge. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2015; 90:624-8. [PMID: 25565262 DOI: 10.1097/acm.0000000000000631] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
PROBLEM Medical education has been cited as both part of the problems facing, and part of the solution to reforming, the increasingly challenging U.S. health care system which is fraught with concerns regarding the quality and affordability of care. To teach value in ways that are impactful, sustainable, and scalable, the best and brightest ideas need to be shared such that educators can build on successful existing innovations. APPROACH To identify the most promising innovations and bright ideas for teaching value to clinical trainees, the authors hosted the "Teaching Value and Choosing Wisely Challenge." The challenge used crowdsourcing methods to solicit scalable, pedagogical approaches from across North America, and then draw generalizable lessons. OUTCOMES The authors received 74 submissions (28 innovations; 46 bright ideas) from 14 students, 20 residents/fellows, 38 faculty members (ranging from instructors to full professors), and 2 nonclinical administrators. Submissions represented 14 clinical disciplines including internal medicine, emergency medicine, surgery, pediatrics, obstetrics-gynecology, laboratory medicine, and pharmacy. Thirty-nine abstracts focused on graduate medical education, 15 addressed undergraduate medical education, and 20 applied to both. NEXT STEPS The authors have solicited, shared, and described solutions for teaching high-value care to medical trainees. Challenge participants demonstrated commitment to improving value and ingenuity in addressing professional barriers to change. Further success requires strong local faculty champions and willing trainee participants. Additionally, the use of data to demonstrate the collective positive impact of these ideas and programs will be critical for sustaining pedagogical changes in the health professions.
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Affiliation(s)
- Neel Shah
- N. Shah is founder and executive director, Costs of Care, Inc., and assistant professor of obstetrics, gynecology, and reproductive biology, Harvard Medical School, Boston, Massachusetts. A.E. Levy is resident advisor, Teaching Value Project, Costs of Care, Inc., Boston, Massachusetts, and resident in internal medicine, The University of Chicago Medical Center, Chicago, Illinois. C. Moriates is director of implementation initiatives, Costs of Care, Inc., Boston, Massachusetts, and assistant professor of medicine, University of California, San Francisco, San Francisco, California. V.M. Arora is director of education initiatives, Costs of Care, Inc., Boston, Massachusetts, and associate professor of medicine and director, Graduate Medical Education Clinical Learning Environment Innovation, The University of Chicago, Chicago, Illinois
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