Professionalism: The Wrong Tool to Solve the Right Problem?

Medical schools and other higher education institutions across the United States are grappling with how to respond to racism on and off campus. Institutions and their faculty, administrators, and staff have examined their policies and practices, missions, curricula, and the representation of racial and ethnic minority groups among faculty, staff, and students. In addition, student-led groups, such as White Coats for Black Lives, have emerged to critically evaluate medical school curricula and advocate for change. Another approach to addressing racism has been a focus on the role of professionalism, which has been variably defined as values, traits, behaviors, morality, humanism, a role, an identity, and even a social contract.In this article, the authors consider the potential role that professionalism might play in responding to racism in medical education and at medical schools. They identify 3 concerns central to this idea. The first concern is differing definitions of what the problem being addressed really is. Is it isolated racist acts or institutional racism that is a reflection of white supremacy? The second concern is the notion that professionalism may be used as a tool of social control to maintain the interests of the social groups that dominate medicine. The third concern is that an overly simplistic application of professionalism, regardless of how the problem of racism is defined, may result in trainees practicing professionalism that is performative rather than internally motivated. The authors conclude that professionalism may complement a more systematic and holistic approach to addressing racism and white supremacy in medical education, but it is an insufficient stand-alone tool to address this core problem.

Preventing relapse to smoking with transcranial magnetic stimulation: Feasibility and potential efficacy

Many smokers attempt to quit every year, but 90% relapse within 12 months. Converging evidence suggests relapse is associated with insufficient activation of the prefrontal cortex. Delay discounting rate reflects relative activity in brain regions associated with relapse. High-frequency repetitive transcranial magnetic stimulation (rTMS) of the left dorsolateral prefrontal cortex (LDLPFC) increases cortical excitability and reduces delay discounting rates, but little is known about feasibility, tolerability, and potential efficacy for smoking cessation. We hypothesized that 8 sessions of 20Hz rTMS of the LDLPFC combined with an evidence-based self-help intervention will demonstrate feasibility, tolerability, and potential efficacy in a limited double-blind randomized control trial. Smokers (n=29), abstinent for 24h, motivated to quit, and not using cessation medications, were randomized to active 20Hz rTMS at 110% of Motor Threshold or sham stimulation that replicated the look and sound of active stimulation. Stimulation site was located using the 6cm rule and neuro-navigation. Multiple clinical, feasibility, tolerability, and efficacy measures were examined. Active rTMS decreased delay discounting of $100 (F (1, 25.3694)=4.14, p=.05) and $1000 (F (1, 25.169)=8.42, p<.01), reduced the relative risk of relapse 3-fold (RR 0.29, CI 0.10-0.76, Likelihood ratio χ2 with 1 df=6.40, p=.01), increased abstinence rates (active 50% vs. sham 15.4%, Χ² (df=1)=3.80, p=.05), and increased uptake of the self-help intervention. Clinical, feasibility, and tolerability assessments were favorable. Combining 20Hz rTMS of the LDLPFC with an evidence-based self-help intervention is feasible, well-tolerated, and demonstrates potential efficacy.

Proceedings of the inaugural International Summit for Medical Nutrition Education and Research

Medical Nutrition Education (MNE) has been identified as an area with potential public health impact. Despite countries having distinctive education systems, barriers and facilitators to effective MNE are consistent across borders, demanding a common platform to initiate global programmes. A shared approach to supporting greater MNE is ideal to support countries to work together. In an effort to initiate this process, the Need for Nutrition Education/Innovation Programme group, in association with their strategic partners, hosted the inaugural International Summit on Medical Nutrition Education and Research on August 8, 2015 in Cambridge, UK. Speakers from the UK, the USA, Canada, Australia, New Zealand, Italy, and India provided insights into their respective countries including their education systems, inherent challenges, and potential solutions across two main themes: (1) Medical Nutrition Education, focused on best practice examples in competencies and assessment; and (2) Medical Nutrition Research, discussing how to translate nutrition research into education opportunities. The Summit identified shared needs across regions, showcased examples of transferrable strategies and identified opportunities for collaboration in nutrition education for healthcare (including medical) professionals. These proceedings highlight the key messages presented at the Summit and showcase opportunities for working together towards a common goal of improvement in MNE to improve public health at large.

Response to a patient activation intervention among Spanish-speaking patients at a community health center in New York City

Patient activation describes an individual's readiness to participate in their health care. Lower levels of activation that may contribute to poor health outcomes have been documented in Latino patients. We administered a brief activating intervention directed at Spanish-speakers that sought to improve and encourage question-asking during a medical visit. We used quantitative measures of patient attitudes supplemented with open-ended questions to evaluate the effectiveness of the intervention at a community health center. Post-intervention changes in the Patient Activation Measure (PAM) and Decision Self-Efficacy (DSE) were measured. Both control and intervention group PAM scores changed significantly, but for those at lower levels of activation, only the intervention group showed significant gains. For the DSE the intervention group showed significant changes in scores. These findings, which are supported by the qualitative data, suggest that the intervention helped patients who may have difficulty asking questions during medical visits.

The impact of different modalities for activating patients in a community health center setting

OBJECTIVE

Decision aids are designed to assist patients in understanding their health care choices but lower SES populations are less activated and may not be prepared to benefit. Activating interventions may help prepare patients for using decision aids.

METHODS

We evaluated the impact of a decision aid video (DA) and the Patient Activation Intervention (PAI) on patient's level of activation measured by the Patient Activation Measure (PAM) and their decision-making confidence measured by the decision self-efficacy (DSE) scale. Patients were randomized into control, PAI alone, DA alone, and DA+PAI groups.

RESULTS

PAM and DSE scores increased significantly in all groups with repeated measures. Restricting analyses to those with pre-intervention PAM scores at stages 1 or 2, the change in PAM scores was significant only for the intervention groups. The change in DSE scores was significantly only in the DA group.

CONCLUSION

These findings provide support for the utility of the DA, the PAI, and the DA+PAI in activating lower SES individuals. The DA alone changed DSE scores in the least activated patients while the PAI and DA both changed PAM scores.

PRACTICE IMPLICATIONS

Interventions directed at increasing patient engagement in their care may be useful particularly for less activated patients from lower SES populations.

Asking questions: the effect of a brief intervention in community health centers on patient activation

OBJECTIVE

To evaluate the impact of a patient activation intervention (PAI) focused on building question formulation skills that was delivered to patients in community health centers prior to their physician visit.

METHODS

Level of patient activation and patient preferred role were examined using the patient activation measure (PAM) and the patient preference for control (PPC) measure.

RESULTS

More of the 252 patients evaluated were at lower levels of activation (PAM levels 1 or 2) than U.S. population norms before the intervention. Paired-samples t-test revealed a statistically significant increase from pre-intervention to post-visit PAM scores. One-third of participants moved from lower levels of activation to higher levels (PAM levels 3 or 4) post-intervention. Patients preferring a more passive role had lower initial PAM scores and greater increases in their post-intervention PAM scores than did those who preferred a more active role.

CONCLUSION

Patients exposed to the PAI demonstrated significant improvement on a measure of activation. The PAI may be useful in helping patients prepare for more effective encounters with their physicians.

PRACTICE IMPLICATIONS

The PAI was feasible to deliver in the health center setting and may be a useful method for activating low-income, racial/ethnic minority patient populations.

The influence of longitudinal mentoring on medical student selection of primary care residencies

BACKGROUND

The number of students selecting careers in primary care has declined by 41% in the last decade, resulting in anticipated shortages.

METHODS

First-year medical students interested in primary care were paired with primary care mentors. Mentors were trained, and mentors and students participated in focus groups at the end of each academic year. Quantitative and qualitative results are presented.

RESULTS

Students who remained in the mentoring program matched to primary care programs at 87.5% in the first year and 78.9% in the second year, compared to overall discipline-specific match rates of 55.8% and 35.9% respectively. Students reported a better understanding of primary care and appreciated a relationship with a mentor.

CONCLUSIONS

A longitudinal mentoring program can effectively support student interest in primary care if it focuses on the needs of the students and is supportive of the mentors.

Activating Community Health Center Patients in Developing Question-Formulation Skills

The authors developed and delivered a brief patient activation intervention (PAI) that sought to facilitate physician–patient communication. The intervention was designed to assist low-income, racial/ethnic minority users of community health centers in building skills and confidence asking questions. The PAI takes 8 to 10 minutes to deliver and consists of five steps that can be carried out by individuals with minimal formal medical training. A total of 252 patients waiting to see their physician participated in the intervention and completed the follow-up semistructured interview after their health care visit. The authors describe the intervention and the results of their qualitative evaluation of patient’s responses. Overall, the PAI was valued by patients, appeared to add to patients’ satisfaction with the health care they received, and was feasible to implement in the primary care setting. Furthermore, findings from this study provide indirect insight regarding factors that influence minority patient’s question-asking behavior that include patient’s attitudes, social factors, and patient’s self-efficacy in question formulation.

Specialized nutrition support

Specialized nutrition support should be offered to patients who are malnourished or at risk of becoming malnourished when it would benefit patient outcomes or quality of life. Improving the nutritional value of ingested food and tailoring intake to the patient's preferences, abilities, and schedule should be the first measures in addressing nutritional needs. When these interventions alone are insufficient to meet nutritional requirements, oral nutritional supplements should be considered. Nutritional status should be evaluated in patients before specialized nutrition sup- port is considered. Enteral nutrition is used when patients have a functional gastrointestinal tract but are unable to safely swallow. Although a variety of enteral formulas are available, evidence for choosing a specific formula is often lacking. Parenteral nutrition should be used only when enteral nutrition is not feasible. There are no known benefits of parenteral nutrition over the enteral route, and the risk of serious complications is much greater with parenteral nutrition. Even when the parenteral route is necessary, some enteral nutrition is beneficial when possible. Specialized nutrition support can provide an effective bridge until patients are able to return to normal food and, in rare cases, may be continued as long-term home enteral or parenteral nutrition. Specialized nutrition support is not obligatory and can be harmful in cases of futile care and at the end of life.

Implementation of a pilot primary care lifestyle change intervention for families of pre-school children: lessons learned

OBJECTIVE

We used Glasgow's RE-AIM framework to evaluate the feasibility of a primary care-based intervention to decrease behaviors that place urban children at risk for obesity.

METHODS

During preventive visits of 2-5-year olds between February 2006 and May 2007, parents completed a health behavior assessment. Primary care providers engaged parents in brief goal setting and referred them to a lifestyle counselor. Evaluation involved medical record review, interviews with staff and clinicians, and health behavior assessment via a pre- and post-intervention telephone survey.

RESULTS

Families reached by the intervention did not differ from families who were not. The intervention was adopted by 14 of 17 clinicians. The health assessment was implemented in 32% of preventive visits (N=354). Of those, goal setting by physicians occurred in 59%, with 55% referred to the lifestyle counselor. We were unable to demonstrate effectiveness to change adult or child nutrition or physical activity, as complete data were available for only 34 families.

CONCLUSION

Goal setting with referral for more intensive lifestyle counseling for obesity prevention in high risk families is feasible and acceptable in primary care.

PRACTICE IMPLICATIONS

Patient educators can be integrated into primary care to achieve preventive care goals.

Counseling to prevent obesity among preschool children: acceptability of a pilot urban primary care intervention

PURPOSE

To help design effective primary care-based interventions, we explored urban parents' reactions to a pilot and feasibility study designed to address risk behaviors for obesity among preschool children.

METHODS

We conducted 3 focus groups (2 in English, 1 in Spanish) to evaluate the pilot intervention. Focus group participants explored the acceptability of the pilot intervention components (completion of a new screening tool for risk assessment, discussion of risk behaviors and behavior change goal setting by physicians, and follow-up contacts with a lifestyle counselor) and the fidelity of the pilot intervention delivery.

RESULTS

Parents expressed a desire to change behaviors to achieve healthier families. They believed that doctors should increase their focus on healthy habits during visits. Parents were more accepting of nutrition discussions than increasing activity (citing a lack of safe outdoor space) or decreasing sedentary behaviors (citing many benefits of television viewing). Contacts with the lifestyle counselor were described as empowering, with parents noting her focus on strategies to achieve change for the whole family while recognizing that many food behaviors relate to cultural heritage. Parents expressed frustration with physicians for offering advice about changing behavior but not how to achieve it, for dismissing concerns about picky eating or undereating, and in some cases for labels of overweight that they believed were inappropriately applied.

CONCLUSIONS

Parents welcomed efforts to address family lifestyle change in pediatric visits. The model of physician goal setting with referral for behavior change counseling is highly acceptable to families. Future interventions should acknowledge parental concerns about undereating and perceived benefits of television viewing.

The bariatric surgery patient: a growing role for registered dietitians

Between 1998 and 2004, the total number of bariatric procedures increased almost 10-fold, from 13,386 procedures in 1998 to 121,055 in 2004. Current estimates suggest the number of bariatric operations will exceed 220,000 in 2010. Bariatric surgery encompasses several surgical techniques classified as restrictive or malabsorptive, based on the main mechanism of weight loss. Clinical studies and meta-analyses show that bariatric surgery decreases morbidity and mortality when compared with nonsurgical treatments. A successful long-term outcome of bariatric surgery is dependent on the patient's commitment to a lifetime of dietary and lifestyle changes. The registered dietitian (RD) is an important member of the bariatric team and provides critical instructions to help patients adhere to the dietary changes consistent with surgery. Referencing current literature, this article outlines the indications, contraindications, and types of bariatric surgery. The role of the RD for preoperative and postoperative nutrition assessment and medical nutrition therapy is highlighted. Management of long-term nutrition issues is also reviewed. The current recommendations include a multivitamin/mineral supplement plus vitamin B-12, calcium, vitamin D-3, iron, and folic acid. Given the increasing prevalence of obesity and bariatric surgery procedures, caring for patients who have undergone surgery will be an expanding role for the RD. Close postoperative follow-up and careful monitoring will improve the odds for successful surgical outcomes, and RDs play a very important part in this process.

How can nutrition education contribute to competency-based resident evaluation?

The Curriculum Committee of the Nutrition Academic Award (NAA) has created a consensus document of knowledge, skills, and attitude learning objectives for medical nutrition education. To evaluate the impact of nutrition education in residency training, it is necessary to specify the goals and objectives of that education in terms of specific learner outcomes. To make the NAA objectives more user friendly for graduate medical education faculty, they must be translated into measurable competencies. The Accreditation Council for Graduate Medical Education has proposed a schema for organizing resident competencies. This article illustrates one way that the NAA curriculum objectives can be translated into specific competencies to demonstrate medical knowledge, patient care, practice-based learning, interpersonal and communication skills, professionalism, and systems-based practice.

Metabolic syndrome: time for action

The constellation of dyslipidemia (hypertriglyceridemia and low levels of high-density lipoprotein cholesterol), elevated blood pressure, impaired glucose tolerance, and central obesity is identified now as metabolic syndrome, also called syndrome X. Soon, metabolic syndrome will overtake cigarette smoking as the number one risk factor for heart disease among the U.S. population. The National Cholesterol Education Program-Adult Treatment Panel III has identified metabolic syndrome as an indication for vigorous lifestyle intervention. Effective interventions include diet, exercise, and judicious use of pharmacologic agents to address specific risk factors. Weight loss significantly improves all aspects of metabolic syndrome. Increasing physical activity and decreasing caloric intake by reducing portion sizes will improve metabolic syndrome abnormalities, even in the absence of weight loss. Specific dietary changes that are appropriate for addressing different aspects of the syndrome include reducing saturated fat intake to lower insulin resistance, reducing sodium intake to lower blood pressure, and reducing high-glycemic-index carbohydrate intake to lower triglyceride levels. A diet that includes more fruits, vegetables, whole grains, monounsaturated fats, and low-fat dairy products will benefit most patients with metabolic syndrome. Family physicians can be more effective in helping patients to change their lifestyle behaviors by assessing each patient for the presence of specific risk factors, clearly communicating these risk factors to patients, identifying appropriate interventions to address specific risks, and assisting patients in identifying barriers to behavior change.

Nutrition education in family practice residency programs

BACKGROUND AND OBJECTIVES

Nutrition is a required part of family practice residency training. Unfortunately, little is known about the quality or effectiveness of this nutrition training. This study evaluated the current status of nutrition training in family practice residency training programs.

METHODS

We surveyed 100 randomly selected US family practice residencies about their nutrition education curriculum. Surveys were sent by e-mail, mail, fax, or administered by phone to individuals identified as responsible for nutrition teaching. A response rate of 66% was obtained.

RESULTS

Programs varied greatly in their emphasis on nutrition. Identified barriers were similar across most programs. The presence of at least a part-time faculty member dedicated to nutrition was correlated with perceived effectiveness of nutrition education efforts.

CONCLUSIONS

If family physicians are to be prepared to inform their patients regarding nutrition and to make appropriate referrals, improvements in the nutrition curriculum offered in many family practice residency programs will be required. Readers can evaluate their program's nutrition education efforts and see how they compare to our sample. Specific recommendations for potential changes are included.

A mini-fellowship in clinical nutrition for primary care physicians

When the Regional Nutrition Center's (RNC's) mini-fellowship was being developed, physicians teaching in medical schools and residency programs had little formal training in nutrition, so it was difficult to identify faculty to serve as role models and clinical preceptors. Using funds provided by an NIH/NCI R-25 grant, the mini-fellowship in clinical nutrition was developed as a model to meet the nutrition education needs of senior residents and junior faculty in primary care disciplines. It provided a brief but broad exposure to clinical nutrition topics, with a focus on issues relevant to the practice of primary care and teaching skills. In four weeks, fellows completed didactic course work, a clinical preceptorship, and a teaching project. Tracking of the 55 physicians who completed the program by questionnaires has shown significant improvement in their nutrition-related patient care activities.

Re-evaluating gadolinium(III) texaphyrin as a radiosensitizing agent

Gadolinium(III) texaphyrin (Gd-tex) was recently proposed as a radiosensitizing agent that combines preferential tumor uptake with detection of drug localization by magnetic resonance imaging (S. W. Young et al., Proc. Natl. Acad. Sci. USA, 93: 6610-6615, 1996). In view of the initial report on this compound, four radiobiology laboratories undertook independent efforts to further study radiosensitization by Gd-tex. In addition to repeating the previously reported studies on Gd-tex in HT-29 cells, we tested five other human tumor cell lines (U-87 MG, U251-NCI, SW480, A549, and MCF-7). These studies included a Gd-tex treatment period of 24 h before irradiation (as in the original publication), with concentrations of Gd-tex ranging from 20-500 microM. In neither the HT-29 cells nor any of the other five human cell lines did we see radiation sensitization by Gd-tex. Two cell lines (MCF-7 and U-87 MG) were further tested for radiosensitization by Gd-tex under hypoxic conditions. No radiosensitization was observed in either case. Finally, the radiation response of two tumor lines were assessed in vivo. Neither HT-29 xenografts in severe combined immunodeficient (SCID) mice nor RIF-1 tumors growing in C3H mice demonstrated radiosensitization after Gd-tex treatment before single or fractionated doses of radiation. Our results raise questions about the efficacy of Gd-tex as a radiosensitizing agent.

Taking a nutrition history: a practical approach for family physicians

The association between nutrition and health has been clearly documented. Primary care physicians are expected to address nutrition and dietary behavior issues with their patients in the context of a brief clinical encounter. This article proposes the use of a short interview form, with specific suggestions for behavior changes that family physicians can use to help their patients meet currently accepted dietary guidelines. Answers to the questions on the interview form provide the physician with an overall sense of the patient's daily eating habits and help to identify major sources of saturated fat in the patient's diet. The patient is asked about the number of meals and snacks eaten in a 24-hour period, dining-out habits and frequency of consumption of fruits, vegetables, meats, poultry, fish, dairy products and desserts. Documentation of dietary changes can be accomplished using the suggested nutrition history form, and improvements in nutritional status can be measured using weight, blood pressure and laboratory test data.

Pyrroxamide, a nonionic nitroxyl spin label contrast agent for magnetic resonance imaging. Mutagenesis and cell survival

Pyrroxamide [N-(1-hydroxymethyl-2,3-dihydroxypropyl)-2,2,5,5-tetramethyl pyrrolidine-1-oxyl-3-carboxyamide] is a newly tested nonionic monomeric nitroxyl compound with demonstrated effectiveness for MRI contrast enhancement at doses as low as 10(-3) M. Pyrroxamide and its hydroxylamine metabolic derivative were tested in concentrations from 10(-9) to 10(-2) M with a battery of cytotoxic and mutagenic assays using mammalian Chinese hamster ovary cells. Loci-specific mutation induction was examined at the hypoxanthine-guanine phosphoribosyltransferase (HGPRT) and the Na+/K+ ATPase loci, both in the presence and absence of a liver microsomal metabolic activating mixture (S-9 mix). Cell survival and induction of sister chromatid exchanges also were studied. All tests yielded negative results indicating that pyrroxamide and and hydroxylamine derivative were both noncytotoxic and nonmutagenic at the doses tested.

Mutagenesis studies on cultured mammalian cells. The sensitivity of the asparagine-requiring phenotype to several chemical agents

The effect of several chemical agents on the mutation frequency from asparagine dependence to asparagine independence has been studied in Jensen sarcoma cells. It was found that ethylmethanesulfonate brought about a dramatic exponential increase, while nitrosoguanidine was not lighly effective as a mutagen, causing only a modest increase in mutation frequency, and quinacrine HCl was ineffective. The results presented here are compared with those obtained in other systems and with our previous work on the effects of UV on mutation induction in the asparagine system. They suggest that the basis of the asparagine requirement of mammalian cell lines resides in a specific genetic alteration in nuclear DNA which is corrected by the mutagenic action of the agents tested here.