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Maksutova M, Kemp MT, Sharma SB, Shen M, Leininger L, Singer AA, Krueger M, Kim GJ, Kwakye G, Alam HB, Sandhu G. "You've Got Gratitude!"- A Multispecialty and Multi-institution Program Encouraging Expressions of Gratitude. J Surg Educ 2023; 80:1741-1744. [PMID: 37723013 DOI: 10.1016/j.jsurg.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 08/11/2023] [Accepted: 08/14/2023] [Indexed: 09/20/2023]
Abstract
OBJECTIVE Efforts to improve physician well-being have focused on gratitude, which predicts health and happiness. Despite reported benefits, expressions of gratitude in healthcare can seem infrequent. Here, we describe Gratitude-Grams, an intervention to cultivate expressions of gratitude throughout a department. METHODS/APPROACH Piloted in our Department of Surgery and adopted by others, Gratitude-Grams employs a web-based platform (Qualtrics). Program feedback was solicited during teaching conferences using an anonymous department survey. RESULTS Gratitude-Grams streamlines and encourages expressions of gratitude while minimizing maintenance, cost, and time. The platform has been highly utilized and well-received in our Department of Surgery. CONCLUSION Expressing and receiving gratitude has been shown to be critical for well-being. Gratitude-Grams is a highly utilized, simple, and attainable system to support expressions of gratitude and is ready for rapid implementation.
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Affiliation(s)
- Mariam Maksutova
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Michael T Kemp
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Mary Shen
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Lisa Leininger
- Department of Surgery, Graduate Medical Education Program Administrator, University of Michigan, Ann Arbor, Michigan
| | - Andrew A Singer
- Department of Surgery, Surgical Education Administrative Manager, Northwestern University, Chicago, Illinois
| | - Mackenzie Krueger
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of Michigan, Ann Arbor, Michigan
| | - Grace J Kim
- Department of Surgery, Section of Minimally Invasive Surgery, University of Michigan, Ann Arbor, Michigan
| | - Gifty Kwakye
- Department of Surgery, Section of Colorectal Surgery, University of Michigan, Ann Arbor, Michigan
| | - Hasan B Alam
- Department of Surgery, Northwestern University, Chicago, Illinois
| | - Gurjit Sandhu
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Helleman A, Rubin RT, Gardner W, Lourie A, Taylor AN, Cochran J, Dorn LD, Susman E, Barrowman N, Bijelić V, Leininger L, Pajer K. Circadian cortisol secretion in adolescent girls with conduct disorder. Psychoneuroendocrinology 2023; 148:105972. [PMID: 36462295 PMCID: PMC10038075 DOI: 10.1016/j.psyneuen.2022.105972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 11/16/2022]
Abstract
Severe antisocial behavior in girls, best exemplified by conduct disorder (CD), is a serious clinical and public health problem. Treatment is difficult, particularly in girls with comorbid internalizing disorders. Identifying biological correlates may help to develop new treatments or diagnostic, prognostic, or treatment response biomarkers. Based on our earlier work and research from others occurring primarily in boys with severe antisocial behavior, it is possible that abnormalities in the hypothalamic pituitary adrenal (HPA) axis circadian cortisol cycle may be associated with female CD. Additionally, research suggests that the presence of comorbid internalizing disorders may be related to differences in cortisol secretion, compared to subjects who only have CD. Our study aimed: 1) to compare the circadian cortisol cycle in 98 girls with CD, 15-16 years of age to 47 girls without any psychiatric disorder (ND) and 2) to compare the cycle in girls with CD and comorbid internalizing disorders (CD + INT) to those without such comorbidity (CD Only). Salivary cortisol was collected over 24 h during weekdays at scheduled times, with protocol adherence measures in place. Unstructured covariance pattern modeling, controlling for effects of age, social class, IQ, and awakening time was used to analyze cortisol data. CD was associated with overall lower cortisol secretion (p = 0.03), but this difference was due to a lower volume of cortisol secreted 30 min after awakening (area under the curve with respect to ground, p = 0.01). Circadian cortisol secretion was no different in the CD+INT group compared to the CD Only group (p = 0.52). Our findings need to be replicated using current consensus guidelines for the assessment of the CAR. We also suggest two new avenues of research in this field.
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Affiliation(s)
| | - Robert T Rubin
- David Geffen School of Medicine at UCLA, Department of Psychiatry and Biobehavioral Sciences, Los Angeles, CA, USA
| | - William Gardner
- CHEO Research Institute, Ottawa, Ontario, Canada; The Research Institute at Nationwide Children's Hospital, The Ohio State University, Department of Pediatrics, Columbus, OH, USA
| | - Andrea Lourie
- The Research Institute at Nationwide Children's Hospital, The Ohio State University, Department of Pediatrics, Columbus, OH, USA
| | - Anna N Taylor
- David Geffen School of Medicine at UCLA, Department of Neurobiology, Los Angeles, CA, USA
| | - Justinn Cochran
- The Research Institute at Nationwide Children's Hospital, The Ohio State University, Department of Pediatrics, Columbus, OH, USA
| | - Lorah D Dorn
- Cincinnati Children's Hospital Medical Center, Division of Adolescent Medicine, Cincinnati, OH, USA
| | - Elizabeth Susman
- College of Health and Human Development, The Pennsylvania State University, University Park, PA, USA
| | | | - Vid Bijelić
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Lisa Leininger
- The Research Institute at Nationwide Children's Hospital, The Ohio State University, Department of Pediatrics, Columbus, OH, USA
| | - Kathleen Pajer
- CHEO Research Institute, Ottawa, Ontario, Canada; The Research Institute at Nationwide Children's Hospital, The Ohio State University, Department of Pediatrics, Columbus, OH, USA.
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Tagle L, Shen M, Leininger L, Kim GJ. Flipping the feedback script: Using a bottom-up feedback tool in surgical education. Am J Surg 2021; 222:1178-1179. [PMID: 34030868 DOI: 10.1016/j.amjsurg.2021.04.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 04/12/2021] [Accepted: 04/27/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Lorena Tagle
- University of Michigan Medical School, 1301 Catherine St, Ann Arbor, MI, 48109, USA
| | - Mary Shen
- Department of Surgery, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Lisa Leininger
- Graduate Medical Education, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Grace J Kim
- Department of Surgery, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.
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Ji S, Hwang C, Karmakar M, Matusko N, Thompson-Burdine J, Williams AM, Leininger L, Minter RM, Sandhu G. Association of intraoperative entrustment with clinical competency amongst general surgery residents. Am J Surg 2019; 219:245-252. [PMID: 31870532 DOI: 10.1016/j.amjsurg.2019.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 11/06/2019] [Accepted: 12/05/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Lack of transparency and meaningful assessment in surgical residency has led to inconsistent intraoperative entrustment and highly variable trainee competence at graduation. The relationship between faculty entrustment and resident entrustability on clinical competency remains unclear. We sought to evaluate the dynamic between entrustment/entrustability and clinical competency in general surgery residency. METHODS Intraoperative observations were conducted across a 22-month period at an academic tertiary center. Entrustment/entrustability were measured using OpTrust. Clinical competencies were appraised via ACGME Milestones and Objective Structured Assessment of Technical Skill (OSATS) scores. Mixed effects linear regression was used to investigate the relationship among overall ACGME Milestone scores, OSATS domain scores, and overall OpTrust scores. RESULTS Overall OpTrust scores significantly correlated with overall Milestone scores and multiple OSATS score domains. CONCLUSIONS OpTrust demonstrated a positive association between ACGME general surgery Milestones and OSATS scores. Overall, OpTrust may help optimize intraoperative faculty entrustment and resident entrustability, facilitating surgical trainee success during residency.
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Affiliation(s)
- Sunjong Ji
- University of Michigan Medical School, 7300 Medical Science Building I - A Wing, 1301 Catherine Street, Ann Arbor, MI, 48109, USA
| | - Charles Hwang
- University of Michigan Medical School, 7300 Medical Science Building I - A Wing, 1301 Catherine Street, Ann Arbor, MI, 48109, USA
| | - Monita Karmakar
- Department of Surgery, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Niki Matusko
- Department of Surgery, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Julie Thompson-Burdine
- Department of Surgery, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Aaron M Williams
- Department of Surgery, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Lisa Leininger
- Department of Surgery, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Rebecca M Minter
- Department of Surgery, University of Wisconsin, 600 Highland Avenue, Madison, WI, 53792, USA
| | - Gurjit Sandhu
- Department of Surgery, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA; Department of Learning Health Sciences, Michigan Medicine, 209 Victor Vaughan Building, 1111 E. Catherine Street, Ann Arbor, MI, 48109, USA.
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Barrett M, Holt K, Haley A, Leininger L, Sonnenday CJ, Sandhu G, Gauger PG. Needs assessment can guide creation of a "resident-optimized clinic" in surgery. Am J Surg 2019; 218:648-652. [PMID: 30826007 DOI: 10.1016/j.amjsurg.2019.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 01/21/2019] [Accepted: 02/02/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND There is limited data on deliberate teaching of residents in the clinic setting; we sought to investigate the clinic experience at our institution and improve education through creation of a novel "Resident-Optimized Clinic" (ROC). METHODS An online survey was sent separately to residents and faculty. Based on the results of this survey a modified ROC was developed to try to improve the obstacles to learning in clinic. RESULTS Qualitative analysis revealed the barriers in clinic were inconsistencies in expectations, lack of autonomy, time, and facility limitations. The modified ROC was rated positively with 100% of participants expressing they had sufficient time and autonomy; and 90% felt the environment was optimized for teaching. CONCLUSIONS Multiple themes have been identified as problematic for the clinic education experience. The ROC was rated positively by trainees suggesting thoughtful intervention to improve clinic results in a better clinic experience and more educational gain from the clinic environment.
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Affiliation(s)
- M Barrett
- Department of Surgery, Ann Arbor, MI, 48109, USA.
| | - K Holt
- Department of Surgery, Ann Arbor, MI, 48109, USA.
| | - A Haley
- Department of Surgery, Ann Arbor, MI, 48109, USA.
| | - L Leininger
- Department of Surgery, Ann Arbor, MI, 48109, USA.
| | | | - G Sandhu
- Department of Surgery, Ann Arbor, MI, 48109, USA; Department of Learning Health Sciences, Ann Arbor, MI, 48109, USA.
| | - P G Gauger
- Department of Surgery, Ann Arbor, MI, 48109, USA.
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6
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Barrett M, Georgoff P, Matusko N, Leininger L, Reddy RM, Sandhu G, Hughes DT. The Effects of Feedback Fatigue and Sex Disparities in Medical Student Feedback Assessed Using a Minute Feedback System. J Surg Educ 2018; 75:1245-1249. [PMID: 29674108 DOI: 10.1016/j.jsurg.2018.02.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 02/25/2018] [Accepted: 02/25/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Feedback is critical to the development of medical students. To enhance feedback, we created a web application, the Minute Feedback System (MFS). This app allows students to request precise, timely, written feedback from residents and staff without the burden of vague, end-of-rotation surveys. In this study, we investigate variations in response rates and feedback fatigue based on sex and rank (resident/fellow vs. faculty). DESIGN Data were collected from May 2015-October 2016. The MFS stores student requests for feedback along with faculty responses allowing for analysis of feedback response rate as well as sex and rank identification. Variation in response rate was analyzed using Chi-square and log-rank testing. Feedback fatigue was assessed using Cox regression modeling. SETTING University Affiliated, Tertiary Care Center. PARTICIPANTS Medical Students, Residents and Faculty. RESULTS About 98.6% of students (138 women, 140 men) used the MFS on their surgery clerkship. They requested feedback from 159 trainees (residents or fellows) and 114 surgical faculty. Feedback was requested more from faculty (26.3 requests per individual) compared to trainees (16.4 requests per individual). The overall evaluator response rate was 60%. Male students were 13% less likely to receive feedback than female students. There was a higher prevalence of feedback fatigue among female faculty (11% less likely to respond) and residents (23% less likely to respond). Regression analysis showed that the overall hazard of nonresponse over time was 1.05, indicative of overall feedback fatigue among all respondents. CONCLUSIONS The MFS is a novel tool for feedback used by nearly all M3 students during their surgery clerkship at our institution. Evaluation of response rates demonstrated feedback fatigue, especially among women faculty and residents. Feedback fatigue was more likely to affect male students, although the reason for this is unclear. Further analysis is necessary to understand this sex-associated response disparity and its effect on student feedback in the learning environment.
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Affiliation(s)
- Meredith Barrett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan.
| | - Patrick Georgoff
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Niki Matusko
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Lisa Leininger
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Gurjit Sandhu
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan
| | - David T Hughes
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
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7
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Georgoff PE, Shaughness G, Leininger L, Nikolian VC, Sandhu G, Reddy R, Hughes DT. Evaluating the performance of the Minute Feedback System : A web-based feedback tool for medical students. Am J Surg 2018; 215:293-297. [DOI: 10.1016/j.amjsurg.2017.08.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/11/2017] [Accepted: 08/22/2017] [Indexed: 10/18/2022]
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8
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Shaughness G, Georgoff PE, Sandhu G, Leininger L, Nikolian VC, Reddy R, Hughes DT. Assessment of clinical feedback given to medical students via an electronic feedback system. J Surg Res 2017; 218:174-179. [DOI: 10.1016/j.jss.2017.05.055] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/31/2017] [Accepted: 05/17/2017] [Indexed: 10/19/2022]
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9
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Cook B, Leininger L. The ethics of exercise in eating disorders: Can an ethical principles approach guide the next generation of research and clinical practice? J Sport Health Sci 2017; 6:295-298. [PMID: 30356587 PMCID: PMC6189014 DOI: 10.1016/j.jshs.2017.03.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 01/09/2017] [Accepted: 01/27/2017] [Indexed: 06/08/2023]
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10
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Hughes DT, Leininger L, Reddy RM, Sandhu G, Ryszawa S, Englesbe M. A novel Minute Feedback System for medical students. Am J Surg 2017; 213:330-335. [DOI: 10.1016/j.amjsurg.2016.11.042] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 10/17/2016] [Accepted: 11/29/2016] [Indexed: 11/30/2022]
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11
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DeBeliso M, Boham M, Carson C, Leininger L, Berning J, Sevene T, Harris C, Adams KJ. Grip Strength as a Measure of Body Strength in Older Adults. Med Sci Sports Exerc 2015. [DOI: 10.1249/01.mss.0000477326.88956.5c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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12
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Margolis PA, Lannon CM, Stevens R, Harlan C, Bordley WC, Carey T, Leininger L, Keyes LL, Earp JL. Linking clinical and public health approaches to improve access to health care for socially disadvantaged mothers and children. A feasibility study. Arch Pediatr Adolesc Med 1996; 150:815-21. [PMID: 8704887 DOI: 10.1001/archpedi.1996.02170330041007] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To test the feasibility of combining home- and office-based interventions to improve access to health care and health outcomes of Medicaid-eligible mothers and infants. DESIGN Randomized trial in 2 counties in North Carolina (1 rural, 1 urban). Information on health and developmental outcomes was obtained by face-to-face interviews, medical chart abstractions, hospital medical records, and state data tapes. PARTICIPANTS Ninety-three Medicaid-eligible first-time pregnant women in their third trimester and their subsequently born infants, who were followed up until they were 6 months old, and 3 pediatric practices and 1 family practice. INTERVENTIONS Coordinated home visit and office intervention, office intervention, and usual care. Home visits by 3 public health nurses provided parental education and social support and linked families with needed community resources. Women in the office intervention group were encouraged to seek health care for their infants from one of the primary care practices. Participating offices received assistance with Medicaid billing, help developing a system to improve preventive care, and customized patient education materials. RESULTS Mothers reported that the nurses helped them in areas related to the content of the program. An office system for prevention was developed and implemented in all 4 practices for study patients. Families in the intervention groups were more likely than control families to have had a prenatal visit with a pediatrician (P = .01, chi 2), a primary care office as the regular source of sick care (P = .02, chi 2), and less waiting time (P = .02, Student t test). They were also more likely to recall receiving patient education materials (P = .007, chi 2). CONCLUSIONS It is feasible to link clinical and public health approaches to improve the quality and effectiveness of care for socially disadvantaged children. Such interventions should be tested in defined populations.
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Affiliation(s)
- P A Margolis
- Department of Pediatrics, University of North Carolina at Chapel Hill, USA
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13
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Klein JD, Portilla M, Goldstein A, Leininger L. Training pediatric residents to prevent tobacco use. Pediatrics 1995; 96:326-30. [PMID: 7630693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE To assess the effectiveness and acceptability of incorporating the National Cancer Institute (NCI) Guide to Preventing Tobacco Use During Childhood and Adolescence into pediatric training. DESIGN Preintervention and postintervention self-reported surveys for residents receiving training and postintervention baseline surveys for those residents not receiving training. Measures include: (1) a self-reported knowledge, attitude, and behavior survey of residents; and (2) physician behavior reports from parent exit interviews. SETTING A hospital-based pediatric residency program and continuity clinic. SUBJECTS Pediatric residents and parents of pediatric patients seen for well child examinations. INTERVENTIONS Structured NCI smoking cessation curriculum modified for delivery during scheduled teaching activities. RESULTS The NCI training was acceptable and perceived as important by residents. Many did not recall receiving the materials or training. Trained residents who remembered the intervention improved their smoking cessation counseling effectiveness. Most patients' parents think it appropriate for physicians to ask; however, most reported not having been asked about smoking or environmental smoke exposure. CONCLUSIONS For residents to learn effective prevention counseling strategies, systematic, reinforced preventive educational curricula must become an institutionalized part of residency training.
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Affiliation(s)
- J D Klein
- Department of Pediatrics, University of Rochester School of Medicine, NY 14642, USA
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14
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Abstract
Asperger syndrome (AS) is a pervasive developmental disorder generally regarded as a variant of autism. While it has been included in the ICD-10 and DSM-IV as a distinct diagnostic entity, it is still unclear to what extent it differs from high-functioning autism (HFA). Persons with HFA have been reported to show a variety of deficits of thought processes. Abnormalities such as poor reality testing, perceptual distortions, and areas of cognitive slippage have been described using the Rorschach inkblot test (Dykens, Volkmar, & Glick, 1991). Since AS has been conceptualized as a mild variant of autism, we hypothesized that persons with AS will have fewer abnormalities on the Rorschach test compared to persons with HFA. To test this hypothesis, we compared 12 subjects with AS (ICD-10, 10 male, mean age = 12.2 +/- 3.3 years, mean full-scale IQ = 99.6) with 8 subjects with HFA (ICD-10/DSM-III-R, 7 male, mean age = 12.2 +/- 3.8 years, mean full-scale IQ = 83.4) on the Rorschach test. AS subjects demonstrated a trend towards greater levels of disorganized thinking than the HFA group. They were also more likely to be classified as "Introversive" suggesting that AS subjects may have more complex inner lives involving elaborate fantasies, Also, AS subjects tended to be more focused on their internal experiences. However, overall, the Rorschach test was not found to differentiate the two diagnostic groups on the majority of structural variables. Implications of these findings are discussed with regard to the diagnostic validity of Asperger syndrome.
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Affiliation(s)
- M Ghaziuddin
- Division of Child and Adolescent Psychiatry, University of Michigan Hospitals, Ann Arbor 48109-3290, USA
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15
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Margolis PA, Carey T, Lannon CM, Earp JL, Leininger L. The rest of the access-to-care puzzle. Addressing structural and personal barriers to health care for socially disadvantaged children. Arch Pediatr Adolesc Med 1995; 149:541-5. [PMID: 7735408 DOI: 10.1001/archpedi.1995.02170180071011] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A mother brings her 2-year-old child to the office at 4:30 Friday afternoon. The child has been seen only once in the practice for an episode of otitis media. The child missed her follow-up appointment. When the receptionist asks why the child is here, the mother responds that she was able to get a ride today with a neighbor who has an appointment with another physician in the practice. The child is not covered by health insurance. The mother did not bring her immunization record and is not certain what preventive care the child has received in the past.
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Affiliation(s)
- P A Margolis
- Department of Pediatrics, University of North Carolina, Chapel Hill, USA
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Abstract
When balancing the benefits of screening women for breast cancer against the harms and costs of such screening, one needs to consider the risk for dying of breast cancer, the relative reduction in that risk that will result from screening women in different age groups, and the harms and costs associated with screening. Seven randomized controlled trials provide evidence of the relative risk reduction that results from screening women in different age groups; other studies estimate the harms and costs of screening. These studies indicate that the benefit of screening, expressed as the absolute number of lives extended per 1000 women screened, increases with age and that the harm of screening, expressed as the number of follow-up procedures per cancer detected, decreases with age. Thus, the tradeoff between the benefits and the harms and costs of screening is better for older than for younger women. Because there is no clear cut-point for determining when benefits outweigh harms and costs, it is important to involve women in discussions of breast cancer screening. The women who most need to be involved are those for whom the benefits of screening clearly outweigh the harms and costs and those for whom the benefits and the harms and costs constitute a "close call." For women in both groups, the physician should routinely raise the issue of screening, first eliciting the patient's perceptions and then providing information and discussion about the risk for breast cancer and about the benefits and the harms and costs of screening. Furthermore, the physician should encourage the patient to use her own values to weigh the benefits against the harms and costs, pointing out biases in reasoning and minimizing socioeconomic barriers. Finally, when the benefits obviously outweigh the harms and costs, the physician should make a clear recommendation for screening.
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Affiliation(s)
- R Harris
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill
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17
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Abstract
Delivering preventive care in a primary care practice is often more difficult for rural than for urban practices. First, rural compared with urban patients tend to be older, poorer, and less well insured, all characteristics associated with lower levels of preventive care. Second, there are many more patients per physician in rural than urban settings. Third, the distance from sources of preventive care is much greater for rural than for urban people. Fourth, rural practices tend to be smaller, with fewer resources to perform high-quality preventive care. Long-term programs to increase recruitment and retention of primary care physicians and improve insurance coverage for rural people may eventually improve preventive care utilization. A more immediate approach is to change the organization of medical practice, including developing satellite clinics, redefining the roles of nurses and nurse practitioners, and using organized systems within practices to reach and follow-up underserved groups. Initial impressions from the North Carolina Prescribe for Health project indicate that an organized approach to preventive care within physicians' offices may improve utilization of carefully designed packages of preventive care. More information is needed to understand the differences among rural, urban, and suburban areas in delivering preventive care to primary care patients.
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Affiliation(s)
- R Harris
- Cancer Prevention Program, University of North Carolina School of Medicine, Chapel Hill 27599-7300
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