Perception of opioids among medical students: unveiling the complexities and implications

CONTEXT

From 2000 to 2019, drug overdoses, combined intentional and unintentional, were the number one cause of death for Americans under 50 years old,with the number of overdoses increasing every year. Between 2012 and 2018, approximately 85 % of all opioid users obtained their opioids through prescriptions from healthcare providers, predominantly physicians. Increased education about the severity of this issue may increase the likelihood of physicians integrating alternative forms of care such as cognitive behavioral approaches, nonopioid therapies, and nonpharmacologic therapies into treatment plans for chronic pain.

OBJECTIVES

This study investigates medical students' beliefs, experiences, and perceived impact of opioids at Ohio University Heritage College of Osteopathic Medicine (OU-HCOM) and University of Toledo College of Medicine and Life Sciences (UT).

METHODS

A total of 377 students from OU-HCOM (years 1-4, n=312) and UT (years 1-2, n=65) were surveyed on their beliefs, experiences, and perceived impact of opioids. Multiple t tests were conducted to compare the difference in perceived severity and stigma between participants who were impacted by the epidemic and those who were not. A Kendall rank test was performed to analyze the relationship between the county drug overdose rate and perceived severity for medical students. p <0.05 defined statistical significance for all statistical tests performed in this study.

RESULTS

In comparing medical students' personal experiences with the opioid crisis, it was found that many more participants had experiences with an affected classmate or patient (4.1; 95 % CI, 4.0-4.2), as opposed to direct experiences within their family or group of friends (1.9; 95 % CI, 1.8-2.0). However, this group of participants who directly experienced the opioid crisis were found to be more likely to view the crisis as more severe in Ohio's adult population than those without that direct experience (p=0.03, α=0.05). The difference in experience and severity outlook did not make one group of medical students more likely to hold a stigma toward those struggling with opioid addiction (p=0.3, α=0.05). The study did not find a significant relationship between the county drug overdose rate and the perceived severity among medical students (R=0.05, p=0.6, α=0.05).

CONCLUSIONS

This study gave an insight into the beliefs, experiences, and perceived impact of opioids within a group of 377 medical students. It was shown that differences in background can lead to differences in perception of the crisis. Knowing these differences can lead to beneficial changes in education and curriculum design in medical education.

Assessing Priorities in a Statewide Cardiovascular and Diabetes Health Collaborative Based on the Results of a Needs Assessment: Cross-Sectional Survey Study

BACKGROUND

The Ohio Cardiovascular and Diabetes Health Collaborative (Cardi-OH) unites general and subspecialty medical staff at the 7 medical schools in Ohio with community and public health partnerships to improve cardiovascular and diabetes health outcomes and eliminate disparities in Ohio's Medicaid population. Although statewide collaboratives exist to address health improvements, few deploy needs assessments to inform their work.

OBJECTIVE

Cardi-OH conducts an annual needs assessment to identify high-priority clinical topics, screening practices, policy changes for home monitoring devices and referrals, and preferences for the dissemination and implementation of evidence-based best practices. The results of the statewide needs assessment could also be used by others interested in disseminating best practices to primary care teams.

METHODS

A cross-sectional survey was distributed electronically via REDCap (Research Electronic Data Capture; Vanderbilt University) to both Cardi-OH grant-funded and non-grant-funded members (ie, people who have engaged with Cardi-OH but are not funded by the grant).

RESULTS

In total, 88% (103/117) of Cardi-OH grant-funded members and 8.14% (98/1204) of non-grant-funded members completed the needs assessment survey. Of these, 51.5% (53/103) of Cardi-OH grant-funded members and 47% (46/98) of non-grant-funded members provided direct clinical care. The top cardiovascular medicine and diabetes clinical topics for Cardi-OH grant-funded members (clinical and nonclinical) were lifestyle prescriptions (50/103, 48.5%), atypical diabetes (38/103, 36.9%), COVID-19 and cardiovascular disease (CVD; 38/103, 36.9%), and mental health and CVD (38/103, 36.9%). For non-grant-funded members, the top topics were lifestyle prescriptions (53/98, 54%), mental health and CVD (39/98, 40%), alcohol and CVD (27/98, 28%), and cardiovascular complications (27/98, 28%). Regarding social determinants of health, Cardi-OH grant-funded members prioritized 3 topics: weight bias and stigma (44/103, 42.7%), family-focused interventions (40/103, 38.8%), and adverse childhood events (37/103, 35.9%). Non-grant-funded members' choices were family-focused interventions (51/98, 52%), implicit bias (43/98, 44%), and adverse childhood events (39/98, 40%). Assessment of other risk factors for CVD and diabetes across grant- and non-grant-funded members revealed screening for social determinants of health in approximately 50% of patients in each practice, whereas some frequency of depression and substance abuse screening occurred in 80% to 90% of the patients. Access to best practice home monitoring devices was challenging, with 30% (16/53) and 41% (19/46) of clinical grant-funded and non-grant-funded members reporting challenges in obtaining home blood pressure monitoring devices and 68% (36/53) and 43% (20/46) reporting challenges with continuous glucose monitors.

CONCLUSIONS

Cardi-OH grant- and non-grant-funded members shared the following high-priority topics: lifestyle prescriptions, CVD and mental health, family-focused interventions, alcohol and CVD, and adverse childhood experiences. Identifying high-priority educational topics and preferred delivery modalities for evidence-based materials is essential for ensuring that the dissemination of resources is practical and useful for providers.

Stunt performers' reluctance to self-report head trauma: a qualitative study

BACKGROUND

Mild traumatic brain injuries receive voluminous attention in the research literature, but this is confined almost entirely to sports and military contexts. As an occupation, performing stunts in film, television, and entertainment places the head at high risk of repetitive impact and whiplash, but stunt performers do not enjoy the same level of healthcare supervision and access as that provided to sports participants. Therefore, the aim of this study was to evaluate stunt performers' qualitative perceptions of reporting and management of head trauma in their industry.

METHODS

After giving their informed consent, 87 motion picture and television stunt performers responded to a query about their views of ways to improve how stunt performers' occupational head trauma-specifically head impacts and head whips that could cause a concussion-are reported and managed. We analyzed their responses via content and thematic analyses. Two researchers independently marked and categorized key words, phrases, and texts to identify codes that described participants' comments. They then revised, discussed, and resolved coding discrepancies through consensus to establish inter-coder reliability. Next, we identified thematic patterns that described participants' understanding of the stunt performer industry and what must change to facilitate reporting of head trauma. We derived themes from data that occurred multiple times, both within and across short answer responses.

RESULTS

We identified three primary themes cited by the stunt performers as needs in their industry: (1) Need to Reduce the Stigma of Reporting a Stunt-Related Injury, (2) Need to Eliminate the "Cowboy Culture," and (3) Need to Improve the Quality of the Work Environment.

CONCLUSIONS

Stunt performers are crucial members of a global entertainment industry valued at approximately US$100 billion annually. A large segment of the world's population consumes their work in motion pictures, television, and live entertainment. When they are given an anonymous opportunity to speak, stunt performers offer insight into and recommendations for industry changes-primarily cultural and educational in nature-that could improve their physical and mental health, career longevity, and employability when they are confronted with head trauma.

5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

A Medicaid-Funded Statewide Diabetes Quality Improvement Collaborative: Ohio 2020‒2022

We used a collective impact model to form a statewide diabetes quality improvement collaborative to improve diabetes outcomes and advance diabetes health equity. Between 2020 and 2022, in collaboration with the Ohio Department of Medicaid, Medicaid Managed Care Plans, and Ohio's seven medical schools, we recruited 20 primary care practices across the state. The percentage of patients with hemoglobin A1c greater than 9% improved from 25% to 20% over two years. Applying our model more broadly could accelerate improvement in diabetes outcomes. (Am J Public Health. 2023;113(12):1254-1257. https://doi.org/10.2105/AJPH.2023.307410).

Cinematic Virtual Reality for Educating Health Care Providers About Type 2 Diabetes, Disability, and Elder Abuse and Neglect: A Pilot Study

BACKGROUND

Diabetes care for older adults is complex and must consider geriatric syndromes, disability, and elder abuse and neglect. Health care providers would benefit from professional training programs that emphasize these risks. One new educational approach is cinematic virtual reality (cine-VR). We conducted a pilot study to evaluate a cine-VR training program based on an older patient with type 2 diabetes and multiple geriatric syndromes who is at risk for elder abuse and neglect.

METHODS

We employed a single-arm, pre-post-test study to assess changes in attitudes to disability and self-efficacy in identifying and managing elder abuse and neglect.

RESULTS

Thirty health care providers completed the pilot study (83.3% women, 86.7% white, 56.7% physicians, 43.4% practiced in outpatient clinics). We observed change in attitudes toward discrimination (Z = -2.628, P = .009, Cohen's d = .62). In addition, we observed changes in six of the eight self-efficacy items, including how participants would ask questions about abuse (Z = -3.221, P = .001, Cohen's d = .59) and helping an older patient make a report to the police or social services (Z = -2.087, P = .037, Cohen's d = .52). In addition, we observed positive changes in understanding the documentation needed to complete whether a patient reports abuse (Z = -3.598, P < .001) as well as the legal knowledge for how to report elder abuse and neglect (Z = -2.556, P = .011).

CONCLUSION

Findings from this pilot study suggest that cine-VR training may increase health care providers' awareness of discrimination and improve self-efficacy toward identifying and managing elder abuse and neglect. Research with a proper control condition is needed to confirm its effectiveness.

Feasibility of a Cinematic-Virtual Reality Training Program for Health Professional Students: A Single-Arm Pre-Post Study

BACKGROUND

Cinematic-virtual reality (cine-VR) has demonstrated improvements in cultural self-efficacy, diabetes attitudes, and empathy among healthcare providers, but its impact on health professional students is unknown. The purpose of the single-arm pre-post study was to examine the feasibility of this cine-VR diabetes training program as well as to assess changes in cultural self-efficacy, diabetes attitudes, and empathy among health professional students.

METHOD

Participants viewed 12 cine-VR 12 simulations about a 72-year-old patient with type 2 diabetes. Pre-training and post-training, they completed the Transcultural Self-Efficacy Tool, Diabetes Attitude Scale-3, and Jefferson Scale of Empathy.

RESULTS

All 92 participants completed the full training. No participants reported technological difficulties or adverse events. For the assessment, 66 participants completed the pre-post measures for a response rate of 71.7% (mean age = 21.1 ± 1.9 years, 82.6% [n = 57] women; 84.1% [n = 58] white). We observed positive improvements in all three cultural self-efficacy subscales: "Cognitive" (t value = -4.705, P < .001), "Practical" (mean change = -.99, t value = -4.240, P < .001), and "Affective" (t value = -2.763, P = .008). Similarly, we observed positive improvements in four of the five diabetes attitude subscales: "Need for special training" (Z = -4.281, P < .001), "Seriousness of type 2 diabetes" (Z = -3.951, P < .001), "Value of tight glucose control" (Z = -1.676, P = .094), "Psychosocial impact of diabetes" (Z = -5.892, P < .001), and "Attitude toward patient autonomy" (Z = -2.889, P = .005). Finally, we observed a positive improvement in empathy (t value = -5.151, P < .001).

CONCLUSIONS

Findings suggest that the cine-VR diabetes training program has the potential to improve cultural self-efficacy, diabetes attitudes, and empathy among health professional students. A randomized controlled trial is needed to confirm its effectiveness.

Measuring grit, self-efficacy, curiosity, and intolerance of uncertainty in first-generation college and first-generation osteopathic medical students

BACKGROUND

Medical school is a challenging time, with many medical students reporting symptoms of burnout, depression, anxiety, suicidal ideation, and psychological distress during pre-clinical and clinical years. First-generation college and first-generation medical students may be two groups of students at increased risk for the negative psychosocial effects of medical school. Importantly, grit, self-efficacy, and curiosity are protective factors against the negative psychosocial effects of medical school, whereas intolerance of uncertainty is a risk factor. Thus, research examining the associations among grit, self-efficacy, curiosity, and intolerance of uncertainty in first-generation college and first-generation medical students is needed.

METHODS

We conducted a cross-sectional, descriptive study to assess medical students' grit, self-efficacy, curiosity, and intolerance of uncertainty. We conducted independent samples t-tests and regression analyses using SPSS statistical software version 28.0.

RESULTS

A total of 420 students participated in the study for a response rate of 51.5%. One-fifth of participants (21.2%, n = 89) identified as first-generation students, 38.6% (n = 162) participants reporting having a physician relative, and 16.2% (n = 68) reported having a physician parent. Grit, self-efficacy, and curiosity and exploration scores did not differ by first-generation college status, physician relative(s), or physician parent(s). However, total intolerance of uncertainty scores differed by physician relative(s) (t= -2.830, p = 0.005), but not by first-generation status, or physician parent(s). Further, subscale scores for prospective intolerance of uncertainty differed by physician relative(s) (t= -3.379, p = 0.001) and physician parent(s) (t= -2.077, p = 0.038), but not by first-generation college student status. In the hierarchical regression models, first-generation college student status and first-generation medical student status were not predictive of grit, self-efficacy, curiosity and exploration, or intolerance of uncertainty, although statistical trends were observed with students with physician relative(s) predicting lower intolerance of uncertainty scores (B= -2.171, t= -2138, p = 0.033) and lower prospective intolerance of uncertainty (B= -1.666, t= -2.689, p = 0.007).

CONCLUSIONS

These findings suggest that first-generation college students did not differ by grit, self-efficacy, curiosity, or intolerance of uncertainty. Similarly, first-generation medical students did not differ by grit, self-efficacy, or curiosity; however, first-generation medical students showed statistical trends in higher total intolerance of uncertainty and higher prospective intolerance of uncertainty. Additional research needs to confirm these findings in first-generation medical students.

Differences and similarities in the experience of living with diabetes distress: A qualitative study of adults with type 1 and type 2 diabetes

AIMS

To explore the lived experiences of diabetes distress (DD) in adults with type 1 and type 2 diabetes, and to identify similarities and differences in these experiences.

METHODS

We conducted in-depth interviews with people with type 1 (n = 19) and type 2 diabetes (n = 29). We conducted thematic analysis using NVivo 12 software.

RESULTS

We identified three themes: (1) Experiencing Diabetes Distress as a Lack of Control - Similarities: All participants voiced a perceived lack of control with their glucose levels and other peoples' misconceptions about diabetes. Differences: Nearly all type 1 participants described a "lack of control" over emotional reactions to hypo- and hyperglycaemia as opposed to only one type 2 participant. (2) Experiencing Diabetes Distress as a Burden of Constant Management - Similarities: All participants emphasized the nonstop, relentless nature of diabetes management. Differences: type 1 participants described self-care as vital, with life-threatening consequences if not performed, while type 2 participants did not perceive such dangerous consequences. (3) Understanding the Value of Social Support in Diabetes Distress - Similarities: All participants acknowledged the importance of having others recognize the difficulties of living with diabetes. Differences: type 1 participants noted actual experiences where peers and health care professionals acknowledged that burden, whereas type 2 participants expressed a desire for this support that was not present in their lives.

CONCLUSIONS

Findings revealed subtle differences in perceptions of DD among adults with type 1 and type 2 diabetes, which suggest a need to tailor treatment for people with each type of diabetes.

Forming Cardi-OH: A Statewide Collaborative to Improve Cardiovascular Health in Ohio

Background

Cardiovascular risk factor control is challenging, especially in disadvantaged populations. However, few statewide efforts exist to tackle this challenge. Therefore, our objective is to describe the formation of a unique statewide cardiovascular health collaborative so others may learn from this approach.

Methodology

With funding from the Ohio Department of Medicaid’s Ohio Medicaid Technical Assistance and Policy Program, we used a collective impact model to link the seven medical schools in Ohio, primary care clinics across the state, the Ohio Department of Medicaid, and Ohio’s Medicaid Managed Care Plans in a statewide health improvement collaborative for expanding primary care capacity to improve cardiovascular health in Ohio.

Results

Initial dissemination activities for primary care teams included a virtual case-based learning series focused on hypertension and social determinants of health, website resources, a monthly newsletter with clinical tips, webinars, and in-person conferences. The collaborative is aligned with a separately funded hypertension quality improvement project for paired implementation.

Conclusions

The collective impact model is a useful framework for developing a statewide collaborative focused on the dissemination and implementation of evidence-based best practices for cardiovascular health improvement and disparity reduction. Statewide collaboratives bringing payers, clinicians, and academic partners together have the potential to substantially impact cardiovascular health.

Osteopathic medical students' understanding of race-based medicine

CONTEXT

Race is a social construct, not a biological or genetic construct, utilized to categorize people based on observable traits, behaviors, and geographic location. Findings from the Human Genome Project demonstrated that humans share 99.9% of their DNA; despite this evidence, race is frequently utilized as a risk factor for diagnosis and prescribing practices. Diagnosing and treating people based on race is known as race-based medicine. Race-based medicine perpetuates biases and diverts attention and resources from the social determinants of health that cause racial health inequities. Minimal research has examined medical students' understanding of race-based medicine.

OBJECTIVES

The purpose of this study was to assess osteopathic medical students' knowledge, beliefs, and experiences with race-based medicine.

METHODS

We conducted a descriptive, cross-sectional survey study to assess osteopathic medical students' knowledge, beliefs, and experiences with race-based medicine. An electronic, anonymous survey was distributed to all osteopathic medical students enrolled at a medical school in the Midwest with three campuses during the 2019-2020 academic year. Participants completed a brief demographic questionnaire and the Race-Based Medicine Questionnaire. Descriptive and inferential statistics were conducted utilizing SPSS statistical software version 28.0, and statistical significance was defined as a p<0.05. Open-ended questions were analyzed utilizing content and thematic analyses.

RESULTS

A total of 438 of the 995 osteopathic medical students consented to participate in the study, for a response rate of 44.0%. Among those participants, 221 (52.0%) reported that they had heard of the term "race-based medicine." Familiarity with the term differed by racial background (χ [2] = 24.598, p<0.001), with Black or African American participants indicating greater familiarity with the term compared to all other races. Of the participants familiar with race-based medicine, 79 (44.4%) provided the correct definition for the term; this finding did not differ by any sociodemographic variable. Part of the way through the questionnaire, all participants were provided the correct definition of "race-based medicine" and asked if they thought medical schools should teach race-based medicine. The majority of participants (n=231, 61.4%) supported the teaching of race-based medicine. Qualitative findings elaborated on participants' support or opposition for teaching race-based medicine in medical school. Those in support explained the importance of teaching historical perspectives of race-based medicine as well as race as a data point in epidemiology and its presence on board examinations, whereas those in opposition believed it contradicted osteopathic principles and practice.

CONCLUSIONS

Findings showed half of the participants were familiar with race-based medicine, and among those, less than half knew the definition of the term. Highlighting osteopathic philosophy and its focus on the whole person may be one approach to educating osteopathic medical students about race-based medicine.

Assessing utility of a lifestyle-based tool in the clinical setting as a primordial prevention strategy: The Healthy Heart Score

OBJECTIVE

To evaluate the opinions of primary health-care providers and patients regarding the use of the Healthy Heart Score 20-year cardiovascular disease risk assessment tool in the clinical setting.

METHODS

Semi-structured in person or phone interviews among 20 patients with no self-reported cardiovascular disease diagnoses and 20 health-care providers in Central (Columbus) and Southeastern (Athens) regions of Ohio. The researchers independently coded transcribed interviews, discussed codes to resolve discrepancies, and agreed on common themes.

RESULTS

Participants suggested ways to best utilize and improve the tool, including adding graphics for visual reference of serving size. Patients showed interest in cardiovascular disease primordial prevention and expressed willingness to take the assessment prior to seeing a health-care provider. Health-care providers said that they would recommend the assessment to their patients and would be willing to use the tool in their practice. Health-care providers stated few barriers to using the tool, yet discussed numerous challenges to successful primordial prevention.

CONCLUSIONS

Our findings support the utilization of the Healthy Heart Score as a cardiovascular disease primordial prevention tool in the clinical setting. Additional research implementing the tool into the clinical setting will provide deeper insight into how the tool can impact behavior change and cardiovascular disease prevention.

Examination of Health Care Providers' Use of Language in Diabetes Care: A Secondary Qualitative Data Analysis

The purpose of this secondary qualitative data analysis was to assess the frequency and context of stigmatizing language used by health care providers (HCPs). The authors conducted content and thematic analysis of in-depth face-to-face and telephone interviews with HCPs in southeastern Ohio. Participants frequently used labeling language, such as "diabetic" and "noncompliant," as well as language with negative connotations, such as "control," "testing," and "regimen." These findings offer a real-world glimpse of how HCPs communicate about people with diabetes in this region of the country.

Clinically significant depressive symptoms and high diabetes distress in adults with type 1 and type 2 diabetes in Appalachian Ohio

CONTEXT

In rural southeastern Ohio, the prevalence of diabetes is 19.9%, nearly double the national average of 10.5%. Despite the high rate of diabetes, its impact on the region is understudied; one such understudied topic is psychosocial difficulties. People with diabetes experience disproportionately higher rates of major depressive disorder (MDD), clinically significant depressive symptoms, and diabetes distress. Diabetes distress refers to the negative emotional experience of living with diabetes. It reflects an individual's worries, concerns, and fears about living a chronic and progressive disease.

OBJECTIVES

To assess the prevalence of diabetes distress as well as comorbid, clinically significant depressive symptoms and diabetes distress among patients in southeastern Ohio; and to assess impact of depressive symptoms and diabetes distress on A_1C levels, diabetes self care behaviors, and diabetes quality of life (DQOL).

METHODS

In this cross sectional survey study, individuals aged 18 years and older, diagnosed with type 1 (T1D) or type 2 (T2D) diabetes, who were able to read and speak English, and living in southeastern Ohio were invited to participate. Participants completed the Diabetes Distress Scale for T2D or T1D, the Patient Health Questionnaire-9, the Self Care Inventory-Revised, and the DQOL Scale as part of the study survey. Participants completed the survey via an online questionnaire service or mailed packets. Chi square tests determined the comorbidity of clinically significant depressive symptoms and high diabetes distress levels by type of diabetes. Multiple regression models examined the relationships among clinically significant depressive symptoms, diabetes distress scores, A_1C levels, self care behaviors, and DQOL scores. Statistical significance was defined as a p<0.05.

RESULTS

A total of 325 adults participated (mean ± standard deviation [SD] age, 41.6 ± 19.2 years; 131 (40.7%) with T1D; 194 (59.7%) with T2D; mean ± SD A_1C, 7.5 ± 1.6%; mean ± SD duration, 12.4 ± 9.6 years). Of the 325 participants, 70 (21.5%) indicated clinically significant depressive symptoms, with 29 (22.3%) T1D participants and 41 (21.0%) T2D participants reporting clinically significant depressive symptoms. A total of 92 (28.3%) participants reported high diabetes distress (39 (30.5%) T1D participants and 53 (27.5%) T2D participants). Forty-eight participants (15.0%) screened positive for both clinically significant depressive symptoms and high diabetes distress. Regression models showed that higher diabetes distress scores were associated with fewer self care behaviors (T1D, b=-0.268, p=0.030; T2D, b=-0.312, p<0.001) and lower DQOL (T1D, b=0.726, p<0.001; T2D, b=0.501, p<0.001). Further, more depressive symptoms were associated with lower DQOL in participants with T2D (b=0.363, p<0.001). Higher diabetes distress scores were not associated with higher A_1C levels in participants with T1D or T2D; however, increased depressive symptoms were associated with higher A_1C levels in participants with T2D (b=0.390, p<0.001).

CONCLUSIONS

Findings showed that adults in southeastern Ohio experienced high levels of diabetes distress and co-occurring clinically significant depressive symptoms that were within range of data from previous studies. These findings highlight the importance of routine screening for both clinically significant depressive symptoms and diabetes distress. Future longitudinal research is needed to confirm these findings and examine the evolution of these relationships over time.

The buffering effect of social support on diabetes distress and depressive symptoms in adults with Type 1 and Type 2 diabetes

BACKGROUND

Social support may buffer or decrease the negative effects of diabetes distress (DD) and depressive symptoms on diabetes outcomes. We assessed the buffering role of social support in the relationship between DD and self-care and depressive symptoms and self-care in adults with Type 1 (T1D) and Type 2 (T2D) diabetes.

METHODS

Participants completed the Diabetes Distress Scale for T2D or T1D, the Patient Health Questionnaire-9, the Medical Outcomes Study Social Support Survey and the Self-Care Inventory-Revised. We conducted hierarchical multiple regression models using SPSS version 26.0.

RESULTS

A total of 325 adults (median age = 40.5 years, 62.2% women, 86.5% White; 59.7% T2D, A1C = 59 ± 6 mmol/mol or 7.5 ± 1.6%; median duration = 11.0 years) participated. Greater social support buffered the negative effects of DD on self-care (R² Δ = 0.015, p = 0.024) as well as depressive symptoms on self-care (R² Δ = 0.024, p = 0.004) in participants with T1D and T2D. Both regression models recorded medium effect sizes (F²  = 0.220, F²  = 0.234 respectively). Social support subscale analyses showed tangible support (R² Δ = 0.016, p = 0.018) and affectionate support (R² Δ = 0.016, p = 0.020) buffered DD and self-care, and emotional support (R² Δ = 0.015, p = 0.022), tangible support (R² Δ = 0.020, p = 0.009), affectionate support (R² Δ = 0.025, p = 0.004) and positive interaction support (R² Δ = 0.017, p = 0.018) buffered depressive symptoms and self-care.

CONCLUSIONS

Findings suggest that social support buffers the impact of DD and depressive symptoms on self-care in adults with T1D and T2D. Additional research is needed to confirm the buffering role of social support on DD and depressive symptoms. Greater understanding of these interactions may help improve clinical care and outcomes.

Focus on the Positive: A Qualitative Study of Positive Experiences Living With Type 1 or Type 2 Diabetes

The purpose of this study was to identify positive experiences associated with diabetes from the perspective of adults diagnosed with type 1 or type 2 diabetes. We conducted in-depth face-to-face and telephone interviews with adults with diabetes. Participants focused on positive and supportive experiences with their peers and community, improved health behaviors, personal growth, and engagement in diabetes advocacy. Communicating positive experiences about diabetes may help clinicians and educators reframe the negative messages commonly shared with people with diabetes.

Using contact-based education to destigmatize opioid use disorder among medical students

All first- and second-year (i.e., pre-clinical) medical students at a large, Midwestern medical school with three campuses were invited to participate in a two-arm, parallel educational study comparing the efficacy of two types of curricular interventions. Students at the main campus attended the modified contact-based education panel or the didactic lecture in person, while students at the two distance campuses attended the modified contact-based education or lecture remotely using the University's videoconferencing system. Impact: A total of 109 students participated in the study (average age 24.2 years (SD = 2.6), 64.2% female, 79.8% white, 56.0% second-year students, 67.9% attended on main campus, lecture = 52 participants, modified contact-based = 57 participants). Baseline responses were similar across groups. Following the session, participants in both interventions rated drug abuse (percent increase = 21.2%, p < .001) and prescription drug diversion (percent increase = 7.6%, p = .004) as more serious problems. Participants from both interventions expressed increased confidence in caring for patients with OUD (percent increase = 45.5%, p < .001) and increased interest in pursuing MAT training (percent increase = 21.5%, p = .04). Both curricular interventions were equally effective at reducing OUD stigma with a significant 8.2% decrease in total stigma scores and a large effect size (p < .001, η_p² = .34). Lastly, participants with lower post-assessment OUD stigma scores were more likely to indicate that they would pursue additional training to provide MAT (p = .02). Lessons learned: Exposure to opioid-specific education with a focus on MAT and recovery, regardless of education type, positively affected opioid-related postgraduate intentions and reduced OUD stigma. Notably, these findings suggest that there are multiple efficacious techniques to reduce OUD stigma during preclinical training.

A brief intervention to reduce burnout and improve sleep quality in medical students

BACKGROUND

Perceived stress, burnout, and poor sleep quality are high among medical students. Interventions designed to target these issues are necessary to promote the health and well-being of medical students. The purpose of this study was twofold: 1) to assess the feasibility of implementing a sunrise alarm clock intervention with medical students and 2) to evaluate the impact of the intervention on perceived stress, burnout scores, and sleep quality.

METHODS

We conducted a feasibility study to evaluate the efficacy of a two-week, sunrise alarm clock intervention in combination with electronic device removal at bedtime. We assessed first- and second-year medical students' perceived stress, burnout scores, including Emotional Exhaustion, Depersonalization, and Low Sense of Personal Achievement, and sleep quality before and after the intervention. In addition, we measured smartphone addiction prior to the intervention.

RESULTS

A total of 57 students consented to participate, of which 55 completed both the pre- and post-assessments (3.5% attrition). The mean age of the participants was 24.8 ± 1.9 years, 50.9% (n = 29) identified as women, and 68.4% (n = 39) identified as white. Pre-intervention, 42.1% (n = 24) of students met criteria for smartphone addiction and 77.2% (n = 44) met criteria for poor sleep quality. In addition, 22.8% (n = 13) of participants had high emotional exhaustion, 64.9% (n = 31) high depersonalization, and 42.1% (n = 24) low sense of personal accomplishment prior to the intervention. Following the two-week intervention, participants showed improvements in emotional exhaustion (p = 0.001, Cohen's d = 0.353), depersonalization (p = 0.001, Cohen's d = 0.411) low sense of personal accomplishment (p = 0.023, Cohen's d = 0.275), perceived stress (p < .001, Cohen's d = .334), and sleep quality (p < 0.001, Cohen's d = 0.925). The number of participants who reported poor sleep quality decreased to 41.8% (n = 23), demonstrating a significant decline (p = 0.026). Participants also improved subjective sleep quality (p < 0.001, Cohen's d = 1.033), sleep duration (p = 0.001, Cohen's d = 0.431), sleep latency (p < 0.001, Cohen's d = 0.433), and sleep efficiency (p = 0.021, Cohen's d = 0.673).

CONCLUSIONS

These findings suggest that the two-week sunrise alarm clock protocol with electronic device removal was effective in improving sleep quality and reducing burnout scores, and perceived stress. However, additional research comparing this intervention to a proper control group is needed to draw meaningful conclusions about the effectiveness of this intervention.

Diabetes in Appalachia: providers' perspectives

BACKGROUND

Southeastern Appalachian Ohio has more than double the national average of diabetes and a critical shortage of healthcare providers. Paradoxically, there is limited research focused on primary care providers' experiences treating people with diabetes in this region. This study explored providers' perceived barriers to and facilitators for treating patients with diabetes in southeastern Appalachian Ohio.

METHODS

We conducted in-depth interviews with healthcare providers who treat people with diabetes in rural southeastern Ohio. Interviews were transcribed, coded, and analyzed via content and thematic analyses using NVivo 12 software (QSR International, Chadstone, VIC, Australia).

RESULTS

Qualitative analysis revealed four themes: (1) patients' diabetes fatalism and helplessness: providers recounted story after story of patients believing that their diabetes was inevitable and that they were helpless to prevent or delay diabetes complications. (2) Comorbid psychosocial issues: providers described high rates of depression, anxiety, incest, abuse, and post-traumatic stress disorder among people with diabetes in this region. (3) Inter-connected social determinants interfering with diabetes care: providers identified major barriers including lack of access to providers, lack of access to transportation, food insecurity, housing insecurity, and financial insecurity. (4) Providers' cultural understanding and recommendations: providers emphasized the importance of understanding of the values central to Appalachian culture and gave culturally attuned clinical suggestions for how to use these values when working with this population.

CONCLUSIONS

Evidence-based interventions tailored to Appalachian culture and training designed to increase the cultural competency and cultural humility of primary care providers may be effective approaches to reduce barriers to diabetes care in Appalachian Ohio.

Burnout, Perceived Stress, Sleep Quality, and Smartphone Use: A Survey of Osteopathic Medical Students

Context

Burnout is a psychological syndrome that results from prolonged exposure to stressful work activities and includes 3 dimensions: emotional exhaustion (EE), depersonalization (DP), and low sense of personal accomplishment (PA). Burnout is a widespread problem in numerous professions but is particularly high among medical students, residents, and early-career physicians compared with college graduates of similar age. However, minimal research has addressed burnout in osteopathic medical students.

Objective

To assess levels of burnout in osteopathic medical students and to examine the relationship among burnout, perceived stress, sleep quality, and smartphone use.

Methods

This study used a cross-sectional study design and an anonymous, electronic questionnaire service to administer the Maslach Burnout Inventory, the Perceived Stress Scale-4, the Pittsburgh Sleep Quality index, and the Smartphone Addiction Scale Short Version.

Results

A total of 385 participants (mean [SD] age, 25 [2.4] years; 208 [54.0%] women; 286 [74.3%] white; 138 [35.8%] second-year osteopathic medical students [OMSs]) completed the survey. Of the 385 participants, 9 (2.3%) reported high EE, 67 (17.4) reported high DP, and 310 (80.5) reported a high level of low PA. When comparing dimensions of burnout by gender, only levels of PA differed by gender, with men reporting higher levels of burnout compared with women (χ1 2=5.2, P=.022). Further, levels of DP differed by year in medical school (χ2=17.3, P=.008), with post-hoc comparisons showing differences between OMS I and OMS III (F=4.530, df=3, P=.004). Linear regression models showed that higher perceived stress (standardized β=0.5, P<.001), poorer sleep quality (standardized β=0.2, P=.001), and higher smartphone addiction scores (standardized β=0.1, P<.001) were associated with higher EE. Similarly, higher perceived stress (standardized β=0.2, P<.001), poorer sleep quality (standardized β=0.2, P=.001), and higher smartphone addiction scores (standardized β=0.2, P=.001) were associated with higher DP. Only higher perceived stress was associated with higher levels of low PA (standardized β=−0.4, P<.001).

Conclusions

These findings suggest independent associations with EE, DP, perceived stress, sleep quality, and smartphone use. Additional research with a larger, more diverse sample is needed to confirm these findings. If confirmed, wellness interventions can be designed to target 2 modifiable factors: sleep quality and smartphone use.

Influence of Future Prescribers' Personal and Clinical Experiences With Opioids on Plans to Treat Patients With Opioid Use Disorder

CONTEXT

Recreational use of opioids is a growing problem in the United States, particularly in the Midwest. Educators have called for inclusion of pain- and opioid-specific courses in health professional school curricula, yet more research is needed to address future prescribers' beliefs, experiences, and postgraduate plans related to opioids.

OBJECTIVE

To examine health professional students' perceived severity of the opioid crisis and opioid-related beliefs, experiences, and postgraduate plans.

METHODS

Using a descriptive, cross-sectional design, researchers evaluated health professional students from 3 academic programs (nurse practitioner [NP], physician assistant [PA], and doctor of osteopathic medicine [DO]) using a 25-item survey that assessed perceived opioid crisis severity and opioid-related beliefs, experiences, and postgraduate plans. Demographics of respondents were assessed using descriptive statistics and frequencies. Responses were compared between academic programs with 1-way analysis of variance or Kruskal-Wallis tests, and relationships between students' experiences and postgraduate plans were assessed.

RESULTS

A total of 491 students (mean [SD] age, 27.2 [5.4] years; 62.7% female; 68.2% DO students) participated in the survey (response rate, 40.4%). The opioid crisis was perceived to be severely impacting the health care system (mean [SD] score, 79.7 [16.8] out of 100), and most respondents (415 [84.5%]) reported that opioid use affected their communities. Clinical experience varied by program, with NP students (75 [81.5%]) reporting the most experience treating acute overdose. Most respondents (317 [64.6%]) agreed that their postgraduate practice would involve caring for patients addicted to opioids; however, only 232 students (47.3%) felt confident in their ability to treat patients with addiction. Experiences managing acute overdose and handling drug-seeking behavior were positively associated with a belief that postgraduate work would involve working with patients with addiction (U=38,275.5, Z=5.92, P<.001; U=25,346.0, Z=4.94, P<.001) and confidence in treating patients with opioid addictions (U=36,806.5, Z=4.96, P<.001; U=23,765.5, Z=3.66, P<.001).

CONCLUSION

Although health professional students had similar beliefs and perceptions regarding the opioid crisis, there were notable differences between academic programs. Students with clinical opioid experiences were more likely to plan on working with patients addicted to opioids and be confident in treating these patients. Thus, the inclusion of experiential learning in the medical curricula may be beneficial for both students and their future patients.

Foundational knowledge regarding childhood obesity: a cross-sectional study of medical students

Background

Documentation and diagnosis of childhood obesity in primary care is poor and providers are often unfamiliar with guidelines. This lack of knowledge may be attributed to insufficient training in medical school and residency; however, no studies have evaluated medical students’ knowledge of recommendations.

Methods

We distributed a modified version of the Physician Survey of Practice on Diet, Physical Activity, and Weight Control to medical students at a single university. Descriptive analyses assessed knowledge and attitudes of childhood obesity and diabetes.

Results

Of the 213 participating students, 74% indicated being unfamiliar with obesity screening recommendations. Few correctly identified BMI percentile cut-points for child overweight (21.2%), obesity (23.7%), and normal weight (29.4%). They reported screening glucose 4.5 years earlier in patients with risk factors compared to those without (p < 0.001).

Conclusions

Although students recognized the need for earlier diabetes screening in children with risk factors, we determined that overall, student knowledge of obesity-related preventative care was inadequate.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7499-1) contains supplementary material, which is available to authorized users.

High Prevalence of Diabetes Distress in a University Population

Context

Diabetes distress is an affective condition that addresses an individual's frustrations, worries, and concerns about living with diabetes. It is associated with fewer self-care behaviors, suboptimal glycemic control, and lower quality of life (QOL). For these reasons, diabetes care guidelines recommend routine assessment of diabetes distress.

Objective

To assess diabetes distress in a university population.

Methods

This study was conducted using a descriptive, cross-sectional design. Researchers assessed diabetes distress and other psychosocial factors via an electronic anonymous survey among students, faculty, and staff at a large university in the Midwest.

Results

A total of 173 participants completed the survey (mean [SD] age, 35.1 [16.7] years), with 108 [62.4%] female and 142 [82.1%] white participants). Eighty-five participants had type 1 diabetes mellitus (T1DM), and 88 had type 2 diabetes mellitus (T2DM). Of the 85 T1DM participants, 23 (27.4%) reported high diabetes distress, and 27 (30.7%) T2DM participants reported high diabetes distress. Sixteen T1DM (18.8%) and 15 T2DM (17.0%) participants screened positive for severe depression. Severe depression was associated with high distress for both T1DM and T2DM participants (T1DM: χ2=28.845, P<.001; T2DM: χ2=20.679, P<.001). Participants with T1DM reported more frequent self-care behaviors (mean [SD], 62.3 [17.1] vs 52.2 [19.2]; P<.001), but lower diabetes QOL (63.3 [14.1] vs 68.5 [15.5]; P=.021) compared with T2DM participants. No differences were observed in depressive symptoms, diabetes self-efficacy, and coping styles. Linear regression models showed that high diabetes distress scores (standardized β=.323, P=.025; standardized β=.604, P<.001) were independently associated with higher hemoglobin A1C levels and lower diabetes QOL after controlling for depressive symptoms, age, and gender in T1DM participants. Similarly, high diabetes distress scores (standardized β=.434, P<.001) were associated with lower diabetes QOL in T2DM participants after controlling for the same variables.

Conclusion

High diabetes distress levels were associated with lower diabetes QOL for both T1DM and T2DM participants. These findings suggest that attending or working at a university may be associated with high diabetes distress scores and lower diabetes QOL. Additional research with a larger, more diverse sample from multiple universities is needed to confirm these findings.

Influence of Osteopathic Medical Students' Personal Health on Attitudes Toward Counseling Obese Pediatric Patients

Context

Research has shown that physicians with positive health and lifestyle behaviors have more positive attitudes toward effective counseling, but little is known about how personal health behaviors of medical students influence their attitudes regarding pediatric obesity counseling before entering practice.

Objective

To determine whether the personal health status and habits of osteopathic medical students influence their attitudes toward counseling obese pediatric patients regarding lifestyle behaviors.

Methods

A cross-sectional survey was distributed electronically to first- through fourth-year osteopathic medical students. The survey assessed students' personal lifestyle habits and their top anticipated barriers to providing pediatric weight counseling.

Results

A total of 200 participants completed the survey. National physical activity recommendations were met by 81 participants (40.5%). These 81 participants had significantly more positive attitudes toward pediatric physical activity counseling than participants who did not meet the recommendations (H=-35.06, P=.001) or those who only met resistance training recommendations (H=40.63, P=.021). Participants with obesity had significantly lower pediatric weight management counseling scores than overweight participants (H=40.77, P=.028). Thirty-one participants (15.5%) consumed a healthy amount of both vegetables and fruit. These 31 participants had significantly higher dietary mean item counseling scores than those who did not (H=-30.40, P=.048). Participants identified the barriers "Time" (137 [68.5%]) and "Difficult for patients to change behavior" (99 [49.5%]) most frequently. Clinical participants identified "Poor or lacking reimbursement" (21 [28.0%]) more frequently than preclinical participants (12 [9.6]).

Conclusion

Medical students who exhibited healthier lifestyle habits were more likely to positively view pediatric obesity management counseling.

Medical Students' Knowledge, Attitudes, and Behaviors With Regard to Skin Cancer and Sun-Protective Behaviors

Background

Skin cancer is the most prevalent cancer in the United States. Training medical students about the importance of sun-protective behaviors is critical to reducing skin cancer rates. However, minimal research has explored osteopathic medical students' knowledge and behaviors with regard to the sun's effect on skin health.

Objective

To assess first-year osteopathic medical students' knowledge about skin cancer and UV radiation, attitudes toward tanning, and sun-protective behaviors to establish baseline values.

Methods

Using a descriptive, cross-sectional study design, the authors evaluated students' knowledge, attitudes, and behaviors through a quiz.

Results

A total of 121 first-year osteopathic medical students completed the quiz. The mean (SD) score was 74.6% (11.5%). Two-thirds of participants (n=82) correctly identified basal cell carcinoma as the most common skin cancer, and the majority identified the ABCDs (asymmetry, border irregularity, color, and diameter) of melanoma detection (96 [79.3%], 106 [87.6%], 108 [89.3%], and 94 [77.7%], respectively). Most participants were aware that cloud cover and swimming underwater do not provide UV ray protection (121 [100%] and 109 [90.1%], respectively), a fact that is often misconceived. Forty participants (33.1%) usually or always used some form of sun protection when outdoors. Forty-seven participants (38.8%) believed that a tan makes one look healthy, and 43 participants (35.6%) sunbathed with the intention of tanning.

Conclusion

Physicians are uniquely positioned to counsel patients regarding sun-protective behaviors. Thus, a medical school curriculum that includes education about the sun's effect on health is needed for the prevention and early recognition of skin cancer in future patients.

A brief interactive training with medical students improves their diabetes knowledge about hypoglycemia

BACKGROUND

Hypoglycemia is a severe clinical problem with physical and psychosocial implications for people with type 1 and type 2 diabetes. Medical students would benefit from formal education on how to treat hypoglycemia as well as how to administer glucagon in case of a severe hypoglycemic emergency. The purpose of this study was to assess the effectiveness of a brief training to improve medical students' knowledge and attitudes about diabetes, hypoglycemia, and glucagon administration.

METHODS

We conducted a feasibility study to assess the effectiveness of an interactive training session on diabetes education with an emphasis on hypoglycemia. We measured medical students' knowledge and attitudes toward diabetes, hypoglycemia, and glucagon before and after the training. We performed Chi-Square tests, paired t-tests, determined effect sizes using Cohen's d, and analyzed short answer responses via content and thematic analyses.

RESULTS

Two hundred and seventeen participants (age = 25.1 ± 2.3 years, 45.2% female, 78.3% white, 36.4% planned to pursue primary care, response rate of 94.3%) completed surveys. Following the training, participants' total knowledge scores improved by five percentage points to 82.6 ± 11.0% (t-value = 7.119, p < 0.001). We also observed positive improvements in the General Test scores to 82.3 ± 12.6% (t-value = 5.844, p < 0.001) and Insulin Use Test scores to 82.4 ± 17.4% (t-value = 4.103, p < 0.001). For the hypoglycemia test, participants averaged 55.7 ± 24.8% pre-training and 83.0 ± 22.4% post-training (t-value = 14.258, p < 0.001). Lastly, participants scored 87.6 ± 18.5% on the glucagon test after the training session. In addition, we observed positive improvements in all five diabetes attitudes subscales after the training, with the largest magnitude of change in the "Psychosocial impact of diabetes" subscale (t-value = 9.249, p < 0.001, Cohen's d = 0.60). Qualitatively, more participants recognized the severity of hypoglycemia after the training. They also learned how to approach diabetes from the patient's perspective and valued the clinically relevant and practical information provided during the training session, such as the "15-15 Rule."

CONCLUSIONS

Medical students need to learn about patients' everyday experiences of diabetes in order to have an understanding of and confidence to assess and treat hypoglycemia. These findings underscore the importance of training medical students on how to actively assess and manage the risk of hypoglycemia in people with diabetes.

First-Year Osteopathic Medical Students' Knowledge of and Attitudes Toward Physical Activity

Context

Current guidelines recommend that primary care physicians provide physical activity counseling as part of routine preventive health care. However, education regarding physical activity counseling often is not included or is inadequately covered in medical school curriculum, and it is unclear whether future physicians are prepared to offer effective counseling in this area.

Objective

To examine first-year medical students' knowledge of and attitudes toward physical activity and the importance of physical activity in patient counseling.

Methods

An anonymous electronic survey was distributed to all first-year students enrolled at the Ohio University Heritage College of Osteopathic Medicine. The survey assessed students' knowledge, beliefs, and behavior regarding physical activity and physical activity counseling for patients. The frequencies of students' weekly physical activity were computed to assess students' physical activity behaviors. Attitudes toward personal importance of physical activity and physical activity counseling in primary care were also assessed by response frequency. The relationship between students' knowledge of and participation in physical activity and the priority placed on exercise for future patients were assessed by correlation.

Results

Of 243 potential participants, 144 students (59.3%) returned the survey. The majority of students (131 of 144 [91.0%]) indicated that living a healthy lifestyle was very or extremely important to them, and 125 of 144 (86.9%) prioritized physical activity as moderately, very, or extremely important. Of 122 students, 81 (66.4%) exercised for at least 30 minutes on 3 or more of the past 7 days, and 36 (29.5%) reported doing so on 5 or more of the past 7 days. Nearly all of the students (127 of 133 [95.5%]) indicated that exercise is important for their future patients, 97 of 133 (72.9%) indicated feeling moderately or extremely comfortable counseling patients on exercise, and 113 of 134 (84.3%) desired to include physical activity counseling in their practice. Fifty of 134 students (40.3%) indicated that they were aware of current physical activity recommendations for adults in the United States; however, of these 50 students, 1 (2.0%) provided a correct definition of the national recommendations.

Conclusion

Although students prioritized healthy lifestyles for themselves and their future patients and indicated a desire to include physical activity counseling as part of routine clinical care, the majority were unaware of the current physical activity recommendations. Thus, there is a need to address physical activity recommendations in the medical school curriculum.

Reducing the Stigma of Diabetes in Medical Education: A Contact-Based Educational Approach

IN BRIEF In this feasibility study, we evaluated the impact of a contact-based education patient panel in an Endocrine and Metabolism course on second-year medical students' diabetes attitudes and diabetes stigma. Prior to the patient panel, some medical students harbored stigma toward people with diabetes, thus confirming patients' reports in the literature of diabetes stigma on the part of health care professionals. Importantly, the one-time contact-based educational approach improved students' diabetes attitudes and reduced diabetes stigma.

A qualitative process evaluation of a diabetes navigation program embedded in an endocrine specialty center in rural Appalachian Ohio

BACKGROUND

Diabetes in the United States has reached epidemic proportions and the people of Appalachia have been disproportionately affected by this disease. Strategies that complement standard diabetes care are critically important to mitigate the risk of complications, reduce health expenditures, and improve the quality of life of patients living in rural Appalachia. The purpose of this study was to conduct a qualitative process evaluation of a patient navigation program for diabetes after its first year of implementation.

METHODS

The process evaluation assessed how the Diabetes Navigation Program was delivered as well as how it was experienced by the navigators, providers, health administrators, and office staff at an endocrine specialty center in rural Appalachian Ohio. We employed total population sampling to conduct in-depth, face-to-face interviews with all providers, health administrators, staff, and navigators at a Diabetes Endocrine Center. Interviews were transcribed, coded, and analyzed via content and thematic analyses using NVivo 11 software.

RESULTS

Seventeen individuals (providers n = 5, health administrators n = 4, office staff members n = 3, and navigators n = 5) participated in in-depth, face-to-face interviews (age = 44.7 ± 11.6 years, 82.4% female, 94.1% white, 13.3 ± 9.6 years work experience). Fidelity of implementation: The navigation team carried out most of the activities denoted in the Work Plan, therefore the program was implemented somewhat successfully. Qualitative analysis revealed three themes: 1) The navigator addresses sources of health disparities: All participants described the role of the diabetes navigator as someone who is knowledgeable about diabetes and able to identify and address health disparities. 2) The navigators are the eyes in the community and the patients' homes: Navigators offered providers and clinic staff a rare glimpse into the personal lives of patients, which led to the identification of unrecognized barriers. 3) Difficulties with cross-system integration of services: Differences in the organizational culture and vision of the specialty center and navigation office contributed to systemic barriers.

CONCLUSIONS

Overall, this process evaluation highlights the importance of coordinating providers, health administrators, medical office staff, and navigators to address barriers to diabetes care. Forthcoming research is needed to document the clinical effectiveness and sustainability of the Diabetes Navigation Program in rural Appalachia.

What can family medicine providers learn about concussion non-disclosure from former collegiate athletes?

BACKGROUND

Despite the risks, concussion symptoms often go underreported by athletes, leading to delayed or forgone treatment and increased potential for concussion recurrence. One of the most serious long-term consequences of sports-related concussions is Chronic Traumatic Encephelopathy (CTE), a disorder associated with progressive neurological deterioration. The purpose of this study was to explore former collegiate athletes' understanding of concussions and motivations behind concussion non-disclosure in order to better assist family medicine providers in screening for and managing a history of concussions.

METHODS

Informed by the theoretical framework Social Cognitive Theory, we conducted focus groups with former collegiate athletes using a field-tested discussion guide. Discussions were transcribed, coded, and analyzed via content and thematic analyses using NVivo 10 software.

RESULTS

Thirty-two former collegiate athletes (24.5 ± 2.9 years old, 59.4% female, 87.5% white) participated in 7 focus groups. Three predominant themes emerged: 1) Concussions are Part of the Game: Participants believed that concussions were part of sports, and that by agreeing to play a sport they were accepting the inherent risk of concussions. Importantly, many were not familiar with concussion symptoms and what constituted a concussion; 2) Hiding Concussion Symptoms: Participants said they often hid concussion symptoms from coaches and trainers in order to avoid being taken out of or missing games. Participants were able to hide their concussions because most symptoms were indiscernible to others; and 3) Misconceptions about Concussions in Low Contact Sports: Several participants did not understand that concussions could occur in all sports including low contact or noncontact sports. The former athletes who participated in low contact sports and experienced concussions attributed their concussions to personal clumsiness rather than their sport.

CONCLUSIONS

Family medicine providers as well as coaches, athletic trainers, teachers, and parents/guardians should reinforce the message that concussions can occur in all sports and inform patients about the signs and symptoms of concussions. Further, providers should ask all patients if they engaged in high school or collegiate athletics; and if yes, to describe their hardest hit to their head in order to obtain a complete medical history.

Assessment of Nutrition Knowledge and Attitudes in Preclinical Osteopathic Medical Students

Background

Nutrition is often overlooked in everyday health care despite the definitive connection between diet and health. Many practicing physicians and medical students feel unqualified to discuss specific dietary recommendations with patients, which may be attributed to inadequate nutrition education during medical school.

Objective

To assess the nutrition knowledge of osteopathic medical students and their attitudes regarding the importance of nutrition counseling in their future role as practicing physicians.

Methods

Using a descriptive, cross-sectional study design, the authors evaluated first- and second-year osteopathic medical students' nutrition knowledge and attitudes toward nutrition counseling. A questionnaire that assessed attitudes toward nutrition counseling and a quiz that tested nutrition knowledge were used.

Results

A total of 257 first-year (n=139) and second-year (n=118) medical students (mean [SD] age, 24.8 [3.4] years; 52.8% female and 78.2% white) completed the quiz and survey. The average score of the nutrition knowledge quiz was 69.5%, with 130 participants (50.6%) scoring below the school's passing rate of 72.5%. Second-year students performed better than first-year students on the quiz (mean, 74.2% vs 65.9%; t=-5.17; P<.001). The majority of participants (143 [55.6%]) felt comfortable counseling patients on nutrition recommendations; however, only 30 (11.9%) were aware of the current dietary reference intakes. Qualitatively, most participants acknowledged the importance of providing patient education, promoting overall health and wellness, and preventing and treating disease.

Conclusion

The majority of participants felt comfortable counseling future patients on nutrition recommendations; however, most participants lacked knowledge of dietary reference intakes and medical nutrition therapy. Because half of osteopathic medical students typically enter primary care, students and their future patients would benefit from the integration of more nutrition education in medical school.

Understanding the Meaning of Food in People With Type 2 Diabetes Living in Northern Appalachia

PURPOSE

Food and eating convey memories and feelings and serve important functions in creating and maintaining relationships. Given the increasing rate of diabetes in the United States, research understanding the meaning of food may shed light on how patients negotiate everyday food choices while managing type 2 diabetes. The purpose of this qualitative study was to explore the meaning of food among adults with type 2 diabetes living in Northern Appalachia.

METHODS

In-depth, face-to-face interviews were conducted with type 2 diabetes patients. Interviews were coded and analyzed via thematic analysis.

RESULTS

Nineteen adults with type 2 diabetes (mean age 68.7 ± 10.6 years, mean A1C 7.4 ± 1.4%, mean diabetes duration 10.9 ± 11.9 years, 52.6% female, 100% white) participated in the study. Qualitative analysis revealed three themes: 1) "Sustaining Life:" Food and the Demands of Diabetes Management, in which participants described the role of food as operational and said that eating was dictated by time rather than hunger or pleasure; 2) "Diabetes Feels Like a Yield Sign:" Diabetes Changes Perceptions of Food, Enjoyment, and Social Relationships, in which most participants described a negative or ambivalent relationship with food after their diabetes diagnosis; and 3) "Food is Everywhere; It's Seducing:" Struggling With Diabetes Management in a Fast-Food Culture, in which participants discussed how the American fast-food culture was in direct conflict with the demands of diabetes and described how they struggled to follow a healthful diet in a culture that advertised the opposite in many venues.

CONCLUSION

Adults with diabetes may benefit from education that addresses both the personal and sociocultural factors that guide food choices.

Students' Perceptions of Trigger Warnings in Medical Education

Phenomenon: Trigger warnings are verbal statements or written warnings that alert students in advance to potentially distressing material. Medical education includes numerous subjects frequently identified as triggers, such as abuse, rape, self-injurious behaviors, eating disorders, drug and alcohol addiction, and suicide. Thus, exploring medical students' perceptions of trigger warnings may provide a valuable perspective on the use of these warnings in higher education.

APPROACH

As part of a larger descriptive, cross-sectional survey study on medical education, we assessed 1st- and 2nd-year medical students' perceptions of trigger warnings in the preclinical curriculum. Five questions specific to trigger warnings explored students' knowledge, prior experience, and perceptions of trigger warnings in medical education. Frequencies of individual question responses were calculated, and qualitative data were analyzed via content and thematic analyses.

FINDINGS

Of the 424 medical students invited to participate, 259 completed the survey (M = 24.8 years, SD + 3.4, 51.4% female, 76.1% White, 53.7% 1st-year students). Few students (11.2%) were aware of the term trigger warning and its definition. However, after being presented with a formal definition on the online survey, 38.6% reported having had a professor use one. When asked whether they supported the use of trigger warnings in medical education, respondents were distributed fairly equally by response (yes = 31.0%, maybe = 39.2%, no = 29.7%). Qualitative analysis revealed three themes: (a) Trigger Warnings Allow Students to Know What is Coming and Prepare Themselves: Respondents believed that trigger warnings would benefit students with a history of trauma by providing them additional time to prepare for the material and, if appropriate, seek professional help; (b) Students Need to Learn How to Handle Distressing Information: Respondents agreed that they needed to learn and cope with highly sensitive material because they would be confronted with difficult and unexpected situations in clinical practice; and (c) Trigger Warnings Help Students Understand the Severity of the Material: Respondents felt that trigger warnings may help students understand the severity of the material being covered and increase awareness about trauma and its effects on health and well-being. Insights: Findings did not reach consensus for or against the use of trigger warnings in medical school; however, students emphasized the importance of learning how to cope with distressing material. Trigger warnings may represent a teaching tool to facilitate classroom discussions about the severity of trauma-related material and problem-focused coping strategies.

Neurobiology of Sexual Assault and Osteopathic Considerations for Trauma-Informed Care and Practice

Sexual assault is a traumatic event with potentially devastating lifelong effects on physical and emotional health. Sexual assault is associated with gastrointestinal, neurologic, and reproductive symptoms, as well as obesity, diabetes, and chronic pain. With 1 in 3 women and 1 in 6 men experiencing some form of unwanted sexual violence in their lifetime, sexual assault is a significant public health problem that necessitates attention in the medical community. This review discusses relevant literature on the neurobiologic changes that occur as a consequence of sexual assault, such as how the brain responds during a traumatic experience and the impact of trauma on memory. Osteopathic considerations for trauma-informed care and practice and how all physicians can better serve patients with a history of sexual assault are also discussed.

Premedical Students' Attitudes Toward Primary Care Medicine

BACKGROUND

Expanded insurance coverage will likely increase the demand for primary care physicians in the United States. Despite this demand, the number of medical students planning to specialize in primary care is decreasing.

OBJECTIVE

To explore premedical students' attitudes toward the primary care specialty.

METHODS

Students enrolled in premedicine at a large Midwestern university were invited to complete the Primary Care Attitudes Survey (Cronbach α=.76). This 25-item survey measures attitudes about primary care on a 5-point Likert scale, ranging from 1, "strongly disagree" to 5, "strongly agree." Basic sociodemographic characteristics were assessed using descriptive statistics, and frequencies of individual survey responses were calculated using SPSS statistical software version 21.0.

RESULTS

A total of 100 premedical students (mean [SD] age, 19.8 [1.5] years; 59 female, 82 white non-Hispanic, and 33 freshman) completed the survey. Of 100 students, 33 planned to pursue primary care; 66 thought that primary care physicians would always have a job; 25 thought that primary care may become obsolete as medicine becomes more specialized; 48 thought that physician assistants and nurse practitioners would take over many primary care duties in the future; 91 thought that primary care physicians make important contributions to medicine; and 84 agreed that primary care focuses on the whole patient.

CONCLUSIONS

Premedical students held positive views about the importance of primary care; however, many expressed uncertainty about the stability of primary care careers in the future. Further, a substantial number of students believed common misconceptions about the scope and practice of primary care, such as primary care doctors are gatekeepers and mostly diagnose colds and ear infections.

Is diabetes distress on your radar screen?

Diabetes distress, which affects almost half of those with diabetes, contributes to worsening glycemic control. Recognizing and responding to it is essential.

The Psychosocial Challenges and Care of Older Adults with Diabetes: "Can't Do What I Used To Do; Can't Be Who I Once Was"

The prevalence of diabetes is increasing in older populations worldwide. Older adults with diabetes have unique psychosocial and medical challenges that impact self-care and glycemic control. These challenges may include psychological factors such as depression or anxiety, social factors such loss of independence and removal from home environment/placement in a facility, and medical factors such as multiple comorbidities and polypharmacy. Importantly, these challenges interact and complicate the everyday life of the older adult with diabetes. Thus, timely identification and interventions for psychosocial and medical challenges are a necessary component of diabetes care. This review summarizes the current literature, research findings, and clinical recommendations for psychosocial care in older adults with diabetes.

The Value of Clinical Jazz: Teaching Critical Reflection on, in, and Toward Action

BACKGROUND AND OBJECTIVES

Clinical Jazz is a small-group strategy in medical education designed to develop interpersonal skills and improve doctor-patient and interprofessional relationships. The purpose of this study was to explore medical students' and faculty facilitators' perceived value of Clinical Jazz.

METHODS

We conducted a modified Nominal Group Process with participating medical students (n=21), faculty facilitators (n=5), and research team members (n=3). Students and faculty facilitators independently answered the question, "What do you value about Clinical Jazz?" We then conducted content and thematic analyses on the resulting data.

RESULTS

Three themes emerged during analysis: (1) students and faculty appreciated the opportunity to learn and practice a thoughtful and structured process for problem solving, (2) students and faculty valued the safety of the group process in sharing a diversity of perspectives on topics in medicine, and (3) students and faculty acknowledged the importance of addressing real and challenging problems that are rarely addressed in formal lectures and other planned small-group settings.

CONCLUSIONS

Clinical Jazz provides students and faculty with the opportunity to address the hidden and/or informal curriculum in medical education, while providing a safe space and time to solve important clinical and interprofessional problems.

Impact of traditional Chinese medicine on age trajectories of health: evidence from the Taiwan Longitudinal Study on Aging

Although traditional Chinese medicine (TCM) is widely used, its effect on health outcomes is not well understood. This study employed a cohort sequential design to investigate levels and rates of change in health from midlife to older adulthood in TCM users and nonusers. A sample of 1,302 community-dwelling adults aged 53 to 80 was selected from individuals interviewed in the 1999 Taiwan Longitudinal Study on Aging (TLSA) and reinterviewed in 2003 and 2007. TCM users were identified as participants who reported visiting a Chinese medicine clinic in the year before each of the three interviews. Health outcomes included physical function, self-rated health, cognitive function, and depressive symptoms. Approximately one in five adults reported that they used TCM in at least one wave of the 3 interview years, but less than one in twenty across all waves. Controlling for time-varying sociodemographic and health conditions, levels and rates of change in physical and cognitive function did not differ according to TCM use. Although adults who reported using TCM had higher depressive symptoms (βTCM = 0.979, 95% confidence interval (CI) = 0.200-1.758) and poorer self-rated health (βTCM = -0.267, 95% CI = -0.267 to -0.081) at baseline, their rates of change in these outcomes did not differ from those who did not use TCM. Subgroup analyses revealed that TCM use benefited adults with higher depressive symptoms by attenuating worsening depressive symptoms (βTCM ×Age = -0.221, 95% CI = -0.434 to -0.007). Further research aimed at understanding the specific mechanisms by which TCM affects health outcomes is warranted.

Barriers and facilitators to self-care communication during medical appointments in the United States for adults with type 2 diabetes

OBJECTIVE

Diabetes self-care is challenging and requires effective patient-provider communication to achieve optimal treatment outcomes. This study explored perceptions of barriers and facilitators to diabetes self-care communication during medical appointments.

DESIGN

Qualitative study using in-depth interviews with a semistructured interview guide.

PARTICIPANTS

Thirty-four patients with type 2 diabetes and 19 physicians who treat type 2 diabetes.

RESULTS

Physicians described some patients as reluctant to discuss their self-care behaviors primarily because of fear of being judged, guilt, and shame. Similarly, patients described reluctant communication resulting from fear of being judged and shame, particularly shame surrounding food intake and weight. Physicians and patients recommended trust, nonjudgmental acceptance, open/honest communication, and providing patients hope for living with diabetes as important factors for improving self-care communication. Further, patients stressed the clinical benefits of physicians directly addressing poor self-care behaviors while physicians described having few strategies to address these difficulties.

CONCLUSIONS

Physician-patient self-care communication barriers included patients' reluctance to discuss self-care behaviors and physicians' perceptions of few options to address this reluctance. Treatment recommendations stressed the importance of establishing trusting, nonjudgmental and open patient-provider communication for optimal diabetes treatment. Medical education is needed to improve physicians' strategies for addressing self-care communication during medical appointments.

Achieving glycemic control in elderly patients with type 2 diabetes: a critical comparison of current options

The prevalence of type 2 diabetes mellitus (T2DM) is increasing in the elderly. Because of the unique characteristics of elderly people with T2DM, therapeutic strategy and focus should be tailored to suit this population. This article reviews the guidelines and studies related to older people with T2DM worldwide. A few important themes are generalized: 1) the functional and cognitive status is critical for older people with T2DM considering their life expectancy compared to younger counterparts; 2) both severe hypoglycemia and persistent hyperglycemia are deleterious to older adults with T2DM, and both conditions should be avoided when determining therapeutic goals; 3) recently developed guidelines emphasize the avoidance of hypoglycemic episodes in older people, even in the absence of symptoms. In addition, we raise the concern of glycemic variability, and discuss the rationale for the selection of current options in managing this patient population.

Changing first-year medical students' attitudes toward primary care

BACKGROUND AND OBJECTIVES

With the passing of the Patient Protection and Affordable Care Act, an additional 34 million people will gain access to health care. Combined with population growth and aging adults, expanded insurance coverage will dramatically increase the demand for primary care services. To encourage medical students to pursue primary care, medical schools are integrating courses that will expose students to primary care medicine early in their education.

METHODS

We used a descriptive, cross-sectional study design to evaluate the impact of a week-long intensive course in primary care on first-year medical students' attitudes toward primary care. We developed a 25-item survey to assess medical students' knowledge, perception, and attitudes about primary care; the survey was administered before and after the course.

RESULTS

A total of 125 first-year medical students (mean age=23.7 ± 2.9 years, 52.4% female, 75.8% Non-Hispanic white, 11.2% rural) completed the pre-course survey, and 117 completed the post-course survey. We observed positive improvements in attitudes toward primary care in 20 of the 25 survey questions (with effect sizes ranging from 0.16--0.33). Further, students stated that the course improved their understanding of the scope of primary care and emphasized the importance and complexity of primary care medicine.

CONCLUSIONS

A week-long intensive course in primary care can influence medical students' attitudes toward primary care; however, the long-term impact on students' decision to pursue primary care is not known and needs to be evaluated. These findings provide empirical support for the integration of primary care courses into medical school curricula.