Reflective impressions of a precepted clinical experience caring for people with disabilities.

There is evidence that early and frequent encounters with people with disabilities can improve medical students' knowledge, skills, and attitudes about disability. As part of a 4-year integrated curriculum in caring for patients with disabilities, third-year medical students (n = 144) in a Family Medicine clerkship participated in a day-long precepted clinical experience at a medical facility serving people with disabilities, predominantly developmental disabilities, where they met patients and worked with clinicians. At the conclusion of the program, students completed a reflective survey about their experience. These data were analyzed qualitatively using a constructivist grounded-theory approach. Students' responses indicated that the experience improved their comfort levels in working with people with disabilities and increased their awareness of attitudinal factors that influence patient care. Responses also demonstrated that students achieved an awareness of technical accommodations and organizational adaptations that improve patient care.

Diabetes self-management in a low-income population: impacts of social support and relationships with the health care system.

OBJECTIVES: This article reports on results of a qualitative study of social supports and institutional resources utilized by individuals living with diabetes in a high-poverty urban setting. The goal was to examine how access to social capital among low-income populations facilitates and impedes their self-efficacy in diabetes self-management. METHODS: Semi-structured interviews were conducted with 34 patients with diabetes from a safety net primary care practice in Buffalo, New York. RESULTS: Facilitators and barriers to successful self-management were identified in three broad areas: (1) the influence of social support networks; (2) the nature of the doctor-patient relationship; and (3) the nature of patient-health care system relationship. Patients' unmet needs were also highlighted across these three areas. DISCUSSION: Participants identified barriers to effective diabetes self-management directly related to their low-income status, such as inadequate insurance, and mistrust of the medical system. It may be necessary for patients to activate social capital from multiple social spheres to achieve the most effective diabetes management.

Experiences with a novel policy for managing conflicts of interest of guideline developers: a descriptive qualitative study.

BACKGROUND: The executive committee of the Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (AT9) developed a novel policy for managing conflicts of interest (COIs): Methodologists bore primary responsibility for each chapter, there was equal emphasis on intellectual and financial COI, and content experts with COIs participated, but with restrictions for recommendations on which they had conflicts. The objective of this study was to explore the experiences of the methodologists and content experts with the COI policy after its implementation. METHODS: One investigator conducted two rounds of semistructured interviews with the methodologist and the leading content expert of each chapter until data saturation was achieved. Two investigators analyzed the transcripts of the interviews in duplicate using an immersion-crystallization approach. We also conducted member checking. RESULTS: We interviewed 15 participants and presented the results to the remaining four for verification. In comparison with their views expressed prior to AT9 development, methodologists remained more positive about the policy than content experts. Six of 10 content experts expressed a more positive view than prior to participation in the AT9 process. The other four content experts remained skeptical, especially regarding the emphasis on intellectual COI. The restrictions of the policy on conflicted individuals were not fully implemented. CONCLUSIONS: After its implementation, some content experts were more favorable to the policy, but some retained major reservations. The influence of the policy on recommendations may have been more through the leading role of the methodologists than exclusion of conflicted participants in making recommendations.

Living with diabetes on Buffalo, New York's culturally diverse West Side.

OBJECTIVES: This study explores the perceptions, attitudes, and beliefs that inform how people live with diabetes in a high poverty, ethnically diverse neighborhood with a growing population of refugees. The specific research objective was to examine participants' explanations of how their diabetes began, understandings about the illness, description of symptoms, as well as physical and emotional reactions to the diagnosis. METHODS: Qualitative design using semi-structured interviews. The transcripts were analyzed using an immersion-crystallization approach. RESULTS: Thirty four individuals diagnosed with diabetes for at least 1 year participated. The sample included 14 refugees (from Somalia, Sudan, Burma, or Cuba), eight Puerto Ricans, six non-Hispanic Caucasians, six African-Americans, and two Native Americans. Three broad themes were identified across ethnic groups: (a) the diagnosis of diabetes was unexpected; (b) emotional responses to diabetes were similar to Kubler-Ross's stages of grief; (c) patients' understanding of diabetes focused on symptoms and diet. CONCLUSIONS: Patients were frequently stunned by the diagnosis of diabetes, and expressed emotions associated with the stages of grief including denial, anger, bargaining, depression, and acceptance. Our findings suggest that clinicians might consider addressing the patients' emotions or grief reaction as an early priority to promote acceptance as a first step to self-management.

Methodologists and context experts disagreed regarding managing conflicts of interest of clinical practice guidelines panels.

OBJECTIVE: A new strategy to manage conflicts of interests (COIs) of a clinical guideline's panelists gives primary responsibility to a methodologist, puts equal emphasis on intellectual and financial COIs, and excludes panelists with primary conflicts from drafting or voting on recommendations. We explored the views of the methodologists and content experts regarding the new strategy. STUDY DESIGN AND SETTING: Before the guidelines chapter panels initiated their work, we conducted semi-structured personal interviews with the methodologists and the lead content experts. We analyzed the data qualitatively. RESULTS: Twenty-four panelists participated. The methodologists thought that the new strategy increased their responsibility and authority. The lead content experts perceived their role label as unfair and reflecting a demotion. Whereas methodologists were concerned about potential conflicts with content experts, the lead content experts were uncomfortable with the "extra surveillance" by the methodologists. Whereas methodologists believed that the changes ensure more rigorous evidence-based guidelines, some lead content experts were worried that methodologists' lack of content expertise and content expert attrition could hurt the quality of the guidelines. CONCLUSIONS: The methodologists and lead content experts were uneasy regarding their counterpart's role. They disagreed about the potential effect of the new strategy on the quality of the guideline.