Shifting plant phenology in response to global change

Plants are finely tuned to the seasonality of their environment, and shifts in the timing of plant activity (i.e. phenology) provide some of the most compelling evidence that species and ecosystems are being influenced by global environmental change. Researchers across disciplines have observed shifting phenology at multiple scales, including earlier spring flowering in individual plants and an earlier spring green-up' of the land surface revealed in satellite images. Experimental and modeling approaches have sought to identify the mechanisms causing these shifts, as well as to make predictions regarding the consequences. Here, we discuss recent advances in several fields that have enabled scaling between species responses to recent climatic changes and shifts in ecosystem productivity, with implications for global carbon cycling.

Working conditions in primary care: physician reactions and care quality

BACKGROUND

Adverse primary care work conditions could lead to a reduction in the primary care workforce and lower-quality patient care.

OBJECTIVE

To assess the relationship among adverse primary care work conditions, adverse physician reactions (stress, burnout, and intent to leave), and patient care.

DESIGN

Cross-sectional analysis.

SETTING

119 ambulatory clinics in New York, New York, and in the upper Midwest.

PARTICIPANTS

422 family practitioners and general internists and 1795 of their adult patients with diabetes, hypertension, or heart failure.

MEASUREMENTS

Physician perception of clinic workflow (time pressure and pace), work control, and organizational culture (assessed survey); physician satisfaction, stress, burnout, and intent to leave practice (assessed by survey); and health care quality and errors (assessed by chart audits).

RESULTS

More than one half of the physicians (53.1%) reported time pressure during office visits, 48.1% said their work pace was chaotic, 78.4% noted low control over their work, and 26.5% reported burnout. Adverse workflow (time pressure and chaotic environments), low work control, and unfavorable organizational culture were strongly associated with low physician satisfaction, high stress, burnout, and intent to leave. Some work conditions were associated with lower quality and more errors, but findings were inconsistent across work conditions and diagnoses. No association was found between adverse physician reactions, such as stress and burnout, and care quality or errors.

LIMITATION

The analyses were cross-sectional, the measures were self-reported, and the sample contained an average of 4 patients per physician.

CONCLUSION

Adverse work conditions are associated with adverse physician reactions, but no consistent associations were found between adverse work conditions and the quality of patient care, and no associations were seen between adverse physician reactions and the quality of patient care.

Effect of communications training on medical student performance

CONTEXT

Although physicians' communication skills have been found to be related to clinical outcomes and patient satisfaction, teaching of communication skills has not been fully integrated into many medical school curricula or adequately evaluated with large-scale controlled trials.

OBJECTIVE

To determine whether communications training for medical students improves specific competencies known to affect outcomes of care.

DESIGN AND SETTING

A communications curriculum instituted in 2000-2001 at 3 US medical schools was evaluated with objective structured clinical examinations (OSCEs). The same OSCEs were administered to a comparison cohort of students in the year before the intervention.

PARTICIPANTS

One hundred thirty-eight randomly selected medical students (38% of eligible students) in the comparison cohort, tested at the beginning and end of their third year (1999-2000), and 155 students in the intervention cohort (42% of eligible students), tested at the beginning and end of their third year (2000-2001).

INTERVENTION

Comprehensive communications curricula were developed at each school using an established educational model for teaching and practicing core communication skills and engaging students in self-reflection on their performance. Communications teaching was integrated with clinical material during the third year, required clerkships, and was supported by formal faculty development.

MAIN OUTCOME MEASURES

Standardized patients assessed student performance in OSCEs on 21 skills related to 5 key patient care tasks: relationship development and maintenance, patient assessment, education and counseling, negotiation and shared decision making, and organization and time management. Scores were calculated as percentage of maximum possible performance.

RESULTS

Adjusting for baseline differences, students exposed to the intervention significantly outperformed those in the comparison cohort on the overall OSCE (65.4% vs 60.4%; 5.1% difference; 95% confidence interval [CI], 3.9%-6.3%; P<.001), relationship development and maintenance (5.3% difference; 95% CI, 3.8%-6.7%; P<.001), organization and time management (1.8% difference; 95% CI, 1.0%-2.7%; P<.001), and subsets of cases addressing patient assessment (6.7% difference; 95% CI, 5.9%-7.8%; P<.001) and negotiation and shared decision making (5.7% difference; 95% CI, 4.5%-6.9%; P<.001). Similar effects were found at each of the 3 schools, though they differed in magnitude.

CONCLUSIONS

Communications curricula using an established educational model significantly improved third-year students' overall communications competence as well as their skills in relationship building, organization and time management, patient assessment, and negotiation and shared decision making-tasks that are important to positive patient outcomes. Improvements were observed at each of the 3 schools despite adaptation of the intervention to the local curriculum and culture.

Managed care, time pressure, and physician job satisfaction: results from the physician worklife study

OBJECTIVE

To assess the association between HMO practice, time pressure, and physician job satisfaction.

DESIGN

National random stratified sample of 5,704 primary care and specialty physicians in the United States. Surveys contained 150 items reflecting 10 facets (components) of satisfaction in addition to global satisfaction with current job, one's career and one's specialty. Linear regression-modeled satisfaction (on 1-5 scale) as a function of specialty, practice setting (solo, small group, large group, academic, or HMO), gender, ethnicity, full-time versus part-time status, and time pressure during office visits. "HMO physicians" (9% of total) were those in group or staff model HMOs with > 50% of patients capitated or in managed care.

RESULTS

Of the 2,326 respondents, 735 (32%) were female, 607 (26%) were minority (adjusted response rate 52%). HMO physicians reported significantly higher satisfaction with autonomy and administrative issues when compared with other practice types (moderate to large effect sizes). However, physicians in many other practice settings averaged higher satisfaction than HMO physicians with resources and relationships with staff and community (small to moderate effect sizes). Small and large group practice and academic physicians had higher global job satisfaction scores than HMO physicians (P <.05), and private practice physicians had quarter to half the odds of HMO physicians of intending to leave their current practice within 2 years (P <.05). Time pressure detracted from satisfaction in 7 of 10 satisfaction facets (P <.05) and from job, career, and specialty satisfaction (P <.01). Time allotted for new patients in HMOs (31 min) was less than that allotted in solo (39 min) and academic practices (44 min), while 83% of family physicians in HMOs felt they needed more time than allotted for new patients versus 54% of family physicians in small group practices (P <.05 after Bonferroni's correction).

CONCLUSIONS

HMO physicians are generally less satisfied with their jobs and more likely to intend to leave their practices than physicians in many other practice settings. Our data suggest that HMO physicians' satisfaction with staff, community, resources, and the duration of new patient visits should be assessed and optimized. Whether providing more time for patient encounters would improve job satisfaction in HMOs or other practice settings remains to be determined.

Factors associated with medical students' career choices regarding internal medicine

CONTEXT

Shortfalls in the US physician workforce are anticipated as the population ages and medical students' interest in careers in internal medicine (IM) has declined (particularly general IM, the primary specialty serving older adults). The factors influencing current students' career choices regarding IM are unclear.

OBJECTIVES

To describe medical students' career decision making regarding IM and to identify modifiable factors related to this decision making.

DESIGN, SETTING, AND PARTICIPANTS

Web-based cross-sectional survey of 1177 fourth-year medical students (82% response rate) at 11 US medical schools in spring 2007.

MAIN OUTCOME MEASURES

Demographics, debt, educational experiences, and number who chose or considered IM careers were measured. Factor analysis was performed to assess influences on career chosen. Logistic regression analysis was conducted to assess independent association of variables with IM career choice.

RESULTS

Of 1177 respondents, 274 (23.2%) planned careers in IM, including 24 (2.0%) in general IM. Only 228 (19.4%) responded that their core IM clerkship made a career in general IM seem more attractive, whereas 574 (48.8%) responded that it made a career in subspecialty IM more attractive. Three factors influenced career choice regarding IM: educational experiences in IM, the nature of patient care in IM, and lifestyle. Students were more likely to pursue careers in IM if they were male (odds ratio [OR] 1.75; 95% confidence interval [CI], 1.20-2.56), were attending a private school (OR, 1.88; 95% CI, 1.26-2.83), were favorably impressed with their educational experience in IM (OR, 4.57; 95% CI, 3.01-6.93), reported favorable feelings about caring for IM patients (OR, 8.72; 95% CI, 6.03-12.62), or reported a favorable impression of internists' lifestyle (OR, 2.00; 95% CI, 1.39-2.87).

CONCLUSIONS

Medical students valued the teaching during IM clerkships but expressed serious reservations about IM as a career. Students who reported more favorable impressions of the patients cared for by internists, the IM practice environment, and internists' lifestyle were more likely to pursue a career in IM.

Nuclear factor-kappa B is activated in alveolar macrophages from patients with acute respiratory distress syndrome

OBJECTIVE

The expression of proinflammatory cytokines is rapidly increased in experimental models of the acute respiratory distress syndrome (ARDS), in patients at risk for ARDS, and in patients with established ARDS. Because multiple cytokines are present in bronchoalveolar lavage fluid, a common, proximal activation mechanism may operate in these settings. The proinflammatory cytokines whose expression is increased in the lungs of patients with ARDS have binding sequences in their enhancer/promoter regions for transcriptional regulatory proteins, such as nuclear factor-kappa B (NF-kappa B), nuclear factor-IL6 (NF-IL6), cyclic adenosine monophosphate responsive element binding protein, serum protein-1, and activating protein-1. To test the hypothesis that activation of one or more of these nuclear transcriptional regulatory factors might provide a common mechanism for the simultaneous expression of multiple cytokine genes in the setting of ARDS, we measured activation of these factors in alveolar macrophages from patients with ARDS and from controls.

DESIGN

Prospective, clinical study.

SETTING

Medical and surgical intensive care units at a university hospital and a county hospital.

PATIENTS

Twelve patients, six with established ARDS and six control patients without lung injury.

INTERVENTIONS

Patients with ARDS and controls underwent fiberoptic bronchoscopy and bronchoalveolar lavage. Alveolar macrophages were isolated from lavage fluid and the nuclear proteins were extracted. Activation of transcriptional factors NF-kappa B, NF-IL6, cyclic adenosine monophosphate responsive element binding protein, activating protein-1, and serum protein-1 was determined using an electrophoretic mobility shift assay, followed by densitometry of the autoradiographed gels.

MEASUREMENTS AND MAIN RESULTS

There were no significant differences in gender, age, tobacco smoking, Acute Physiology and Chronic Health Evaluation II score, quantity of lavage fluid, or number of alveolar macrophages in lavage specimens in the patient groups. Acute Lung Injury score and the Pao2/Fio2 ratio differed significantly between controls and ARDS patients: 0.46 +/- 0.17 vs. 2.74 +/- 0.14 (p < .0001) and 310 +/- 45 torr (41.3 +/- 6.0 kPa) vs. 150 +/- 11 torr (21.3 +/- 1.5 kPa) (p < .006), respectively. The mean Fio2 of the control patients was not significantly different from the mean Fio2 of ARDS patients: 0.47 +/- 0.11 vs. 0.55 +/- 0.6 (p = .53). Patients with ARDS had significantly (p < .02) increased activation of NF-kappa B in alveolar macrophages compared with patients without the syndrome. There was no evidence of increased activation of the transcriptional factors activating protein-1, serum protein-1, NF-IL6, or cyclic adenosine monophosphate responsive element binding protein in alveolar macrophages from ARDS vs. control patients.

CONCLUSIONS

These experiments demonstrated increased in vivo activation of the nuclear transcriptional regulatory factor NF-kappa B (but not NF-IL6, cyclic adenosine monophosphate responsive element binding protein, activating protein-1, or serum protein-1) in alveolar macrophages from patients with ARDS. Because binding sequences for NF-kappa B are present in the enhancer/promoter sequences of multiple proinflammatory cytokines, activation of NF-kappa B may contribute to the increased expression of multiple cytokines in the lung in the setting of established ARDS.

Admissions to Veterans Affairs Hospitals for Emergency Conditions During the COVID-19 Pandemic

To assess the effect of COVID-19 on health care, this study compares admissions data from the Veterans Affairs system for overall admissions and for 6 common emergencies immediately before and for 6 weeks during the pandemic.

Refining the measurement of physician job satisfaction: results from the Physician Worklife Survey. SGIM Career Satisfaction Study Group. Society of General Internal Medicine

BACKGROUND

Physician job satisfaction has been linked to various patient care and health system outcomes. A survey instrument that concisely measures physicians' satisfaction with various job facets can help diverse stake-holders to better understand and manage these outcomes.

OBJECTIVE

To document the development and validation of a multidimensional physician job satisfaction measure and separate global satisfaction measures.

DESIGN

Self-administered questionnaire: Physician Worklife Survey (PWS).

SUBJECTS

A pilot study employed a national American Medical Association Masterfile sample of US primary care physicians and random samples from four states. Responses (n = 835; 55% return rate) were randomly assigned to developmental (n = 560) or cross-validation (n = 275) samples. A national sample (n = 2,325; 52% response rate) of physicians was used in a subsequent validation study.

RESULTS

A 38-item, 10-facet satisfaction measure resulting from factor and reliability analyses of 70 pilot items was further reduced to 36 items. Reliabilities of the 10 facets ranged from .65 to .77. Three scales measuring global job, career, and specialty satisfaction were also constructed with reliabilities from .84 to .88. Results supported face, content, convergent, and discriminant validity of the measures.

CONCLUSIONS

Physician job satisfaction is a complex phenomenon that can be measured using the PWS.

Flock house virus RNA replicates on outer mitochondrial membranes in Drosophila cells

The identification and characterization of host cell membranes essential for positive-strand RNA virus replication should provide insight into the mechanisms of viral replication and potentially identify novel targets for broadly effective antiviral agents. The alphanodavirus flock house virus (FHV) is a positive-strand RNA virus with one of the smallest known genomes among animal RNA viruses, and it can replicate in insect, plant, mammalian, and yeast cells. To investigate the localization of FHV RNA replication, we generated polyclonal antisera against protein A, the FHV RNA-dependent RNA polymerase, which is the sole viral protein required for FHV RNA replication. We detected protein A within 4 h after infection of Drosophila DL-1 cells and, by differential and isopycnic gradient centrifugation, found that protein A was tightly membrane associated, similar to integral membrane replicase proteins from other positive-strand RNA viruses. Confocal immunofluorescence microscopy and virus-specific, actinomycin D-resistant bromo-UTP incorporation identified mitochondria as the intracellular site of protein A localization and viral RNA synthesis. Selective membrane permeabilization and immunoelectron microscopy further localized protein A to outer mitochondrial membranes. Electron microscopy revealed 40- to 60-nm membrane-bound spherical structures in the mitochondrial intermembrane space of FHV-infected cells, similar in ultrastructural appearance to tombusvirus- and togavirus-induced membrane structures. We concluded that FHV RNA replication occurs on outer mitochondrial membranes and shares fundamental biochemical and ultrastructural features with RNA replication of positive-strand RNA viruses from other families.

Predictors and Outcomes of Burnout in Primary Care Physicians

OBJECTIVE

To assess relationships between primary care work conditions, physician burnout, quality of care, and medical errors.

METHODS

Cross-sectional and longitudinal analyses of data from the MEMO (Minimizing Error, Maximizing Outcome) Study. Two surveys of 422 family physicians and general internists, administered 1 year apart, queried physician job satisfaction, stress and burnout, organizational culture, and intent to leave within 2 years. A chart audit of 1795 of their adult patients with diabetes and/or hypertension assessed care quality and medical errors.

KEY RESULTS

Women physicians were almost twice as likely as men to report burnout (36% vs 19%, P < .001). Burned out clinicians reported less satisfaction (P < .001), more job stress (P < .001), more time pressure during visits (P < .01), more chaotic work conditions (P < .001), and less work control (P < .001). Their workplaces were less likely to emphasize work-life balance (P < .001) and they noted more intent to leave the practice (56% vs 21%, P < .001). There were no consistent relationships between burnout, care quality, and medical errors.

CONCLUSIONS

Burnout is highly associated with adverse work conditions and a greater intention to leave the practice, but not with adverse patient outcomes. Care quality thus appears to be preserved at great personal cost to primary care physicians. Efforts focused on workplace redesign and physician self-care are warranted to sustain the primary care workforce.

A randomized trial of breast cancer risk counseling: interacting effects of counseling, educational level, and coping style

The authors evaluated the impact of individualized breast cancer risk counseling (BCRC) on breast-cancer-specific distress and general distress in 239 women with a family history of breast cancer. Following a baseline assessment of demographics, risk factors, coping styles, and distress, participants were assigned randomly to receive either BCRC or general health education (GHE; i.e., control group). After controlling for education level, women who received BCRC had significantly less breast-cancer-specific distress at 3-month follow-up compared with women who received GHE. A significant Education Level x Treatment Group interaction indicated that the psychological benefits of BCRC were greater for women with less formal education. In both the BCRC and GHE groups, participants who had monitoring coping styles exhibited increases in general distress from baseline to follow-up.

Measuring physician job satisfaction in a changing workplace and a challenging environment. SGIM Career Satisfaction Study Group. Society of General Internal Medicine

BACKGROUND

Changes in the demographic, specialty, and employment sector composition of medicine have altered physicians' jobs, limiting autonomy and reducing morale. Because physician job satisfaction has been linked to clinical variables, better measurement might help to ameliorate conditions linked to medical disaffection, possibly improving health care.

OBJECTIVE

To document conceptual development, item construction, and use of content experts in designing multidimensional measures of physician job satisfaction and global satisfaction scales for assessing physicians' job perceptions across settings and specialties.

DESIGN

Using previous research, physician focus groups, secondary analysis of survey data, interviews with physician informants, and a multispecialty physician expert panel, distinct job facets and statements representing those facets were developed.

RESULTS

Facets from previously validated instruments included autonomy, relationships with colleagues, relationships with patients, relationships with staff, pay, resources, and status. New facets included intrinsic satisfaction, free time away from work, administrative support, and community involvement. Physician status items were reconfigured into relationships with peers, patients, staff, and community, yielding 10 hypothetical facets. Global scales and items were developed representing satisfaction with job, career, and specialty.

CONCLUSIONS

A comprehensive approach to assessing physician job satisfaction yielded 10 facets, some of which had not been previously identified, and generated a matching pool of items for subsequent use in field tests.

Coping disposition, perceived risk, and psychological distress among women at increased risk for ovarian cancer

The authors examined predictors of psychological distress among women who were at increased risk for ovarian cancer. Participants were 103 women who had at least 1 first degree relative with ovarian cancer. Specifically, the authors tested the relationship between the dispositional attentional style of monitoring (the tendency to scan for threat-relevant information), perceptions of risk for ovarian cancer, intrusive thoughts regarding ovarian cancer, and psychological distress. Overall, this sample exhibited moderately high levels of psychological distress. High scores on monitoring were associated with high perceived risk for ovarian cancer and elevated levels of intrusive thoughts and psychological distress. Finally, the authors proposed and tested a path model describing the interrelationships between these variables. The results of this study are discussed in terms of their implications for treating the psychological distress associated with being at increased risk for ovarian cancer.

NF-kappaB regulatory mechanisms in alveolar macrophages from patients with acute respiratory distress syndrome

Activation of the nuclear regulatory factor NF-kappaB occurs in the lungs of patients with the acute respiratory distress syndrome (ARDS) and may contribute to the increased expression of immunoregulatory cytokines and other proinflammatory mediators in this setting. Because of the important role that NF-kappaB activation appears to play in the development of acute lung injury, we examined cytoplasmic and nuclear NF-kapppaB counterregulatory mechanisms, involving IkappaB proteins, in alveolar macrophages obtained from 7 control patients without lung injury and 11 patients with established ARDS. Cytoplasmic levels of the NF-kappaB subunits p50, p65, and c-Rel were significantly decreased in alveolar macrophages from patients with ARDS, consistent with enhanced migration of liberated NF-kappaB dimers from the cytoplasm to the nucleus. Cytoplasmic and nuclear levels of IkappaBalpha were not significantly altered in alveolar macrophages from patients with established ARDS, compared with controls. In contrast, nuclear levels of Bcl-3 were significantly decreased in patients with ARDS compared with controls (P = 0.02). No IkappaBgamma, IkappaBbeta, or p105 proteins were detected in the cytoplasm of alveolar macrophages from control patients or patients with ARDS. The presence of activated NF-kappaB in alveolar macrophages from patients with established ARDS implies the presence of an ongoing stimulus for NF-kappaB activation. In this setting, appropriate counterregulatory mechanisms to normalize nuclear levels of NF-kappaB and to suppress NF-kappaB-mediated transcription, such as increased cytoplasmic and nuclear IkappaBalpha levels or decreased Bcl-3 levels, appeared to be induced. Nevertheless, even though counterregulatory mechanisms to NF-kappaB activation are activated in lung macrophages of patients with ARDS, NF-kappaB remains activated. These results suggest that fundamental abnormalities in transcriptional mechanisms involving NF-kappaB and important in the inflammatory response occur in the lungs of patients with ARDS.

Efficient encapsidation of human immunodeficiency virus type 1 vectors and further characterization of cis elements required for encapsidation

To determine whether there is a cis-acting effect of translational expression of gag on RNA encapsidation, we compared the encapsidation of wild-type RNA with that of a mutant in which the translation of gag was ablated. This comparison indicated that there is not such a cis effect. To determine what is necessary and sufficient for encapsidation, we measured the relative encapsidation efficiencies of human immunodeficiency virus type 1 vector RNAs containing mutations in domains proximal to the canonical encapsidation signal or containing large deletions in the remainder of the genome. These data indicate that TAR and two additional regions are required for encapsidation and that the 5' end of the genome is sufficient for encapsidation. The Rev-responsive element is required mainly for efficient RNA transport from the nucleus to the cytoplasm. A foreign sequence was found to have a negative effect on encapsidation upon placement within the parental vector. Interestingly, this negative effect was compounded by multiple copies of the sequence.

The influence of psychological distress on use of genetic testing for cancer risk

The recent identification of BRCA1, a breast cancer susceptibility gene, offers an unprecedented opportunity for high-risk individuals to learn whether they are genetically predisposed to develop breast or ovarian cancer. This study examined the relationships between psychological distress and use of BRCA1 testing by 149 high-risk individuals from hereditary cancer families. After a baseline assessment of demographics, objective risk, cancer-specific distress, and global distress (depressive symptoms), study participants were offered the opportunity to receive genetic counseling and to learn whether they carry a mutation in the BRCA1 gene. Overall, 58% of study participants requested BRCA1 test results, and 42% declined to learn their genetic status. After controlling for demographic factors and risk status, cancer-specific distress was significantly and positively related to BRCA1 test use, whereas global distress was unrelated to test use.

Evolution in health and medicine Sackler colloquium: Making evolutionary biology a basic science for medicine

New applications of evolutionary biology in medicine are being discovered at an accelerating rate, but few physicians have sufficient educational background to use them fully. This article summarizes suggestions from several groups that have considered how evolutionary biology can be useful in medicine, what physicians should learn about it, and when and how they should learn it. Our general conclusion is that evolutionary biology is a crucial basic science for medicine. In addition to looking at established evolutionary methods and topics, such as population genetics and pathogen evolution, we highlight questions about why natural selection leaves bodies vulnerable to disease. Knowledge about evolution provides physicians with an integrative framework that links otherwise disparate bits of knowledge. It replaces the prevalent view of bodies as machines with a biological view of bodies shaped by evolutionary processes. Like other basic sciences, evolutionary biology needs to be taught both before and during medical school. Most introductory biology courses are insufficient to establish competency in evolutionary biology. Premedical students need evolution courses, possibly ones that emphasize medically relevant aspects. In medical school, evolutionary biology should be taught as one of the basic medical sciences. This will require a course that reviews basic principles and specific medical applications, followed by an integrated presentation of evolutionary aspects that apply to each disease and organ system. Evolutionary biology is not just another topic vying for inclusion in the curriculum; it is an essential foundation for a biological understanding of health and disease.

Health Systems Science Curricula in Undergraduate Medical Education: Identifying and Defining a Potential Curricular Framework

PURPOSE

The authors performed a review of 30 Accelerating Change in Medical Education full grant submissions and an analysis of the health systems science (HSS)-related curricula at the 11 grant recipient schools to develop a potential comprehensive HSS curricular framework with domains and subcategories.

METHOD

In phase 1, to identify domains, grant submissions were analyzed and coded using constant comparative analysis. In phase 2, a detailed review of all existing and planned syllabi and curriculum documents at the grantee schools was performed, and content in the core curricular domains was coded into subcategories. The lead investigators reviewed and discussed drafts of the categorization scheme, collapsed and combined domains and subcategories, and resolved disagreements via group discussion.

RESULTS

Analysis yielded three types of domains: core, cross-cutting, and linking. Core domains included health care structures and processes; health care policy, economics, and management; clinical informatics and health information technology; population and public health; value-based care; and health system improvement. Cross-cutting domains included leadership and change agency; teamwork and interprofessional education; evidence-based medicine and practice; professionalism and ethics; and scholarship. One linking domain was identified: systems thinking.

CONCLUSIONS

This broad framework aims to build on the traditional definition of systems-based practice and highlight the need for medical and other health professions schools to better align education programs with the anticipated needs of the systems in which students will practice. HSS will require a critical investigation into existing curricula to determine the most efficient methods for integration with the basic and clinical sciences.

Psychological distress in women seeking genetic counseling for breast-ovarian cancer risk: the contributions of personality and appraisal

The purpose of the present study was two-fold: (a) to characterize the psychological status of women with a family history of breast or ovarian cancer who self-refer for genetic counseling and BRCA1 testing; and (b) to identify specific demographic, personality, and appraisal factors that contribute to cancer-specific distress and general distress in this group of women. Participants were 256 women ages 18 and older who had at least one first-degree relative (FDR) with breast and/or ovarian cancer. Participants were recruited through breast cancer clinics and obstetrics/gynecology departments at two medical centers by responding to program information described in a brochure. The results revealed moderate distress levels in this population. The results of a hierarchical regression of general distress indicated that women with higher levels of general distress were less likely to be married, less optimistic, and had heightened breast cancer risk perceptions accompanied by feelings of low perceptions of control over the development of breast cancer (R2 = .44, p = .0001). Women with higher levels of cancer-specific distress tended to be younger and non-White and had low perceptions of control over developing breast cancer (R2 = .15, p = .0002). These findings suggest that self-referred genetic counseling participants may be psychologically vulnerable and may benefit from interventions designed to decrease distress and the perceived absence of control over developing breast cancer.

Worklife and satisfaction of general internists

BACKGROUND

Prior studies have reported relatively low job satisfaction for general internists. We used data from a large US physician survey to assess correlates of satisfaction of general internists.

METHODS

The Physician Worklife Survey was mailed to a national random stratified sample of 5704 US physicians. General internists were assessed for their satisfaction, training, patient mix, work hours, the likelihood of recommending their specialty to medical students, and job stability. We then compared them with a specialist sample (internal medicine subspecialists [IMSSs]) and a primary care sample (family physicians [FPs]). Logistic regression was used to model predictors of satisfaction, stress, and medical student recruitment.

RESULTS

There were 2326 respondents (adjusted response rate, 52%): 450 (19%) were general internists; 502 (22%), FPs; and 438 (19%), IMSSs. General internists were less satisfied than were IMSSs with their relationships with colleagues and with patient care issues (P<.01 for both) and less satisfied than were FPs with community ties (P =.001). Global job, career, and specialty satisfaction were significantly lower for general internists vs FPs and IMSSs (P<.05). General internists spent proportionately more of their work week in the hospital than did FPs (20% vs 13%; P<.001) and more time providing outpatient care than did IMSSs (56% vs 42%; P<.001). General internists had more patients with complex medical and psychosocial problems than did FPs (P<.01) but fewer patients with complex medical problems than did IMSSs (P<.001). Higher satisfaction for general internists was associated with older physician age, less time pressure during office visits, fewer work hours, and fewer patients with complex psychosocial problems (P<.05 for all). General internists were less likely than were FPs to recommend their specialty to medical students (P<.001). Specialty satisfaction, female gender, and control of hassles predicted medical student recruitment by general internists.

CONCLUSIONS

General internists' role of caring for patients with complex problems is associated with lower levels of satisfaction than for IMSSs and FPs. Adjusting caseload for patient complexity, expanding time for office visits, and additional training in the care of patients with psychosocially complex problems may improve the job satisfaction of general internists and medical student recruitment into the specialty.

Teaching communication in clinical clerkships: models from the macy initiative in health communications

Medical educators have a responsibility to teach students to communicate effectively, yet ways to accomplish this are not well-defined. Sixty-five percent of medical schools teach communication skills, usually in the preclinical years; however, communication skills learned in the preclinical years may decline by graduation. To address these problems the New York University School of Medicine, Case Western Reserve University School of Medicine, and the University of Massachusetts Medical School collaborated to develop, establish, and evaluate a comprehensive communication skills curriculum. This work was funded by the Josiah P. Macy, Jr. Foundation and is therefore referred to as the Macy Initiative in Health Communication. The three schools use a variety of methods to teach third-year students in each school a set of effective clinical communication skills. In a controlled trial this cross-institutional curriculum project proved effective in improving communication skills of third-year students as measured by a comprehensive, multistation, objective structured clinical examination. In this paper the authors describe the development of this unique, collaborative initiative. Grounded in a three-school consensus on the core skills and critical components of a communication skills curriculum, this article illustrates how each school tailored the curriculum to its own needs. In addition, the authors discuss the lessons learned from conducting this collaborative project, which may provide guidance to others seeking to establish effective cross-disciplinary skills curricula.

Standardized phenology monitoring methods to track plant and animal activity for science and resource management applications

Phenology offers critical insights into the responses of species to climate change; shifts in species' phenologies can result in disruptions to the ecosystem processes and services upon which human livelihood depends. To better detect such shifts, scientists need long-term phenological records covering many taxa and across a broad geographic distribution. To date, phenological observation efforts across the USA have been geographically limited and have used different methods, making comparisons across sites and species difficult. To facilitate coordinated cross-site, cross-species, and geographically extensive phenological monitoring across the nation, the USA National Phenology Network has developed in situ monitoring protocols standardized across taxonomic groups and ecosystem types for terrestrial, freshwater, and marine plant and animal taxa. The protocols include elements that allow enhanced detection and description of phenological responses, including assessment of phenological "status", or the ability to track presence-absence of a particular phenophase, as well as standards for documenting the degree to which phenological activity is expressed in terms of intensity or abundance. Data collected by this method can be integrated with historical phenology data sets, enabling the development of databases for spatial and temporal assessment of changes in status and trends of disparate organisms. To build a common, spatially, and temporally extensive multi-taxa phenological data set available for a variety of research and science applications, we encourage scientists, resources managers, and others conducting ecological monitoring or research to consider utilization of these standardized protocols for tracking the seasonal activity of plants and animals.

Computers in the exam room: differences in physician-patient interaction may be due to physician experience

BACKGROUND

The use of electronic medical records can improve the technical quality of care, but requires a computer in the exam room. This could adversely affect interpersonal aspects of care, particularly when physicians are inexperienced users of exam room computers.

OBJECTIVE

To determine whether physician experience modifies the impact of exam room computers on the physician-patient interaction.

DESIGN

Cross-sectional surveys of patients and physicians.

SETTING AND PARTICIPANTS

One hundred fifty five adults seen for scheduled visits by 11 faculty internists and 12 internal medicine residents in a VA primary care clinic.

MEASUREMENTS

Physician and patient assessment of the effect of the computer on the clinical encounter.

MAIN RESULTS

Patients seeing residents, compared to those seeing faculty, were more likely to agree that the computer adversely affected the amount of time the physician spent talking to (34% vs 15%, P = 0.01), looking at (45% vs 24%, P = 0.02), and examining them (32% vs 13%, P = 0.009). Moreover, they were more likely to agree that the computer made the visit feel less personal (20% vs 5%, P = 0.017). Few patients thought the computer interfered with their relationship with their physicians (8% vs 8%). Residents were more likely than faculty to report these same adverse effects, but these differences were smaller and not statistically significant.

CONCLUSION

Patients seen by residents more often agreed that exam room computers decreased the amount of interpersonal contact. More research is needed to elucidate key tasks and behaviors that facilitate doctor-patient communication in such a setting.