Factors Influencing Physician Assistant Students' Attitudes Toward Deservingness of Care for Undocumented Mexicans.

PURPOSE: Attitudes regarding health-related deservingness of care for vulnerable patient populations can impact the quality of services provided. This study was aimed at identifying the influences that shape these attitudes among physician assistant (PA) students. METHODS: The study focused on PA students' perspectives toward care for a particularly vulnerable population, undocumented Mexican immigrants. An in-person survey was administered to first- and second-year PA students (n = 75). Multiple regression was used to assess whether familiarity, stereotyping, language skills, cultural preparedness, societal views, and background characteristics of PA students influenced attitudes toward deservingness of care. RESULTS: Results suggested that cultural preparedness among PA students was associated with positive views toward deservingness of both emergency services (ß = 0.38, p < .001) and primary care (ß = -0.211, p = .05) for undocumented Mexicans. Negative societal views toward this population predicted an unwillingness to endorse emergency care (ß = -0.43, p < .001) and primary care (ß = -0.45, p < .001). CONCLUSIONS: Demographic projections indicate continued trends toward increasingly diverse patient populations, with dramatic growth among Hispanics. The findings of this study suggest that greater cultural preparedness is needed for future PAs. Furthermore, strategies for increasing PA students' self-awareness of how their broader societal views shape service delivery are warranted to ensure equitable care.

Willingness to treat drug dependence and depression: comparisons of future health professionals.

PURPOSE: Stigma-related feelings, including degree of enthusiasm and willingness to work with alcohol, drug, and mental disorder (ADM) patients, as well as anticipated success in such work, will be required for the United States to be successful in its new initiatives for ADM screening, brief intervention, and effective referral to treatment and rehabilitation services (SBIRT). This study investigates students of medicine and social work with respect to their stigma-related feelings and degree of enthusiasm or willingness to treat patients affected by alcohol dependence, nicotine dependence, or major depression. Inference is strengthened by an anonymous online survey approach, with use of randomized reinforcers to gain at least partial experimental control of nonparticipation biases that otherwise are present in student survey data. MATERIAL AND METHODS: All students on required course rosters were asked to participate in a two-part in-class and online assessment; 222 participated, with a gradient of participation induced via randomly drawn reinforcers for online survey participation. Between-group comparisons were made with a multivariate generalized linear model and generalized estimating equations approach that adjusts for covariates. RESULTS: Medical and social work students did not differ from each other with respect to their willingness to treat patients affected by major depression, alcohol dependence, or nicotine dependence, but together were less willing to treat nicotine and alcohol dependence-affected patients as compared to depression-affected patients. Personal history was not associated with the students' willingness to treat, but men were less willing to treat. Drawing strength from the randomized reinforcer experimental design nested within this survey approach, the study evidence suggests potential nonparticipation bias in standard surveys on this topic. CONCLUSION: These results indicate that future health professionals may prefer to treat depression as opposed to drug dependence conditions. For SBIRT success, curriculum change with educational interventions may be needed to increase willingness to treat patients with neuropsychiatric conditions such as drug dependence. Future research requires attention to a possible problem of nonparticipation bias in surveys of this type.

How are the experiences and needs of families of individuals with mental illness reflected in medical education guidelines?

OBJECTIVE: This descriptive study explored the extent that medical education curriculum guidelines contained content about the experiences and needs of family members of people with serious mental illness. METHODS: Key family-focused-literature themes about the experiences and needs of families of individuals with mental illness were drawn from a review of over 6,000 sources in the mental health practice literature that were identified within a systematic search and thematic development process. The study identified the extent and nature of family-focused key literature themes as reflected in medical education curriculum guidelines for psychiatry and primary care practice specialties of family practice, internal medicine, and pediatrics. An iterative process was used to retrieve and analyze text data drawn from the curriculum guidelines of national accrediting organizations for undergraduate, graduate, and continuing medical education. RESULTS: The key family-focused themes, as drawn from the mental health practice research literature, were: mental illness stigma; family caregiver burden; information exchange and referral; family stress, coping, and adaptation; family support; crisis response; and family psychoeducation. Two of these seven themes appeared in medical education curriculum guidelines: information exchange and caregiver burden. The most frequently appearing family-focused key literature theme was information exchange. Psychiatry and undergraduate medical education reflected the most family content. CONCLUSION: It appears that medical education curriculum guidelines have insufficient content about families of people with mental illness. The educational experiences of psychiatrists and primary care physicians may not adequately prepare them for working with family members of their patients. It is recommended that medical education curriculum guidelines incorporate information about family stigma; family/caregiver burden; information exchange; family stress, coping, and adaptation; family support; crisis response; and multiple family group psychoeducation.

Attitudes, experiences, and interest in geriatrics of first-year allopathic and osteopathic medical students.

A cross-sectional survey was designed to assess interest in geriatric medicine of allopathic and osteopathic medical students and to determine whether their career interests were related to past experiences with and current attitudes toward older adults. The study was conducted at an allopathic and osteopathic medical school with 231 first-year medical students. Experiences with elderly people were measured using survey questions assessing amount and quality of experiences with grandparents, as well as experiences caring for, volunteering with, or having a paid position working with older adults. Attitudes were measured using the University of California at Los Angeles Geriatric Attitudes Scale, revised for applicability to medical students. Interest in geriatrics was measured using a 4-point scale. Overall, students expressed positive attitudes toward older adults. Past experiences, including positive relationships with older relatives (P<.001) and experiences providing care for older adults (P<.001), were related to more-positive attitude scores toward elderly people. Students had low interest in geriatric medicine, but those with more-positive attitudes were more likely to consider geriatrics as a career (odds ratio=8.18, P<.001). Furthermore, having prior experience caring for older persons increased interest in the field (P=.001). No significant differences were found between allopathic and osteopathic student interest in geriatrics or attitudes toward older adults. Efforts toward increasing the pool of future geriatricians and increasing positive attitudes toward older patients could be improved by providing quality experiences caring for and interacting with older adults before medical school training.

Home telecare for COPD/CHF patients: outcomes and perceptions.

We evaluated the use of home telehealth for patients with chronic obstructive pulmonary disease (COPD) and/or congestive heart failure (CHF). Patients diagnosed with COPD and/or CHF who were prescribed home health-care services were randomly assigned to an experimental group where they received home health care through a combination of traditional face-to-face and telemedicine visits (n = 83), and a control group where only conventional home care was employed (n = 78). Data were collected via the Short Form 36 (SF-36), Outcome and Assessment Information Set (OASIS) and patient charts. In the experimental group, patient perceptions of the home telecare services were collected via telephone interviews. Overall, the addition of telehealth to COPD/CHF patient care was not a significant predictor of health and wellbeing, either positively or negatively. Although those receiving telehealth had worse ratings on the SF-36 general health subscale after the intervention, this measure was only significant when controlling for a number of key variables in the model. In regard to patient perceptions of home telecare, patients were satisfied with the technology and the way that care was delivered via this modality.

An administrator's perspective on mental health in assisted living.

Administrators of 94 assisted living facilities in Michigan completed a 19-item survey about the extent of mental health problems of residents and how such problems were addressed. In 45 facilities more than half of the residents were reported to be cognitively impaired. The two most common problems were dementia and depression. The most common problematic behaviors were resistance to care and wandering. Two-thirds of the facilities conducted some type of mental health evaluation at admission, and two-thirds conducted evaluations as needed. The most common treatment barriers were patient refusal and family refusal. Results of the study suggest that there may be a significant need for mental health services in assisted living facilities.

Comparing clinical practice with guideline recommendations for the treatment of depression in geriatric patients: findings from the APA practice research network.

OBJECTIVE: The authors describe treatments provided for depressed geriatric patients (age 65+) treated by psychiatrists in the American Psychiatric Association's (APA) Practice Research Network (PRN) and compare treatments with recommended guidelines for treating late-life depression. METHODS: Detailed demographics, diagnoses, service utilization, and treatment information were collected on relevant patients treated by psychiatrists participating in the APA's PRN during 1997, sample-weighted to produce nationally representative estimates. Treatment data were qualitatively compared with existing depression treatment guidelines from the APA and the Expert Consensus Guideline Series on pharmacotherapy of depressive disorders in older patients. RESULTS: Of patients treated by psychiatrists in the PRN (N=152), just over 41% had a diagnosable depressive disorder, and, of those with depression, nearly 84% had major depression. Over 90% received a psychotropic medication, and over 75% received an antidepressant. Treatment intensity, as measured by visit frequency and duration of treatment, were more intense than typically found in primary care. Most patients received a combination of medication management and psychotherapy. Selective serotonin reuptake inhibitors were the most frequently prescribed antidepressant, although they were less frequently prescribed than in primary care and other national surveys. Just over 11% received a tertiary amine antidepressant, and nearly 43% received benzodiazepines, this frequency being inconsistent with existing guidelines. CONCLUSION: Depressed geriatric patients treated by psychiatrists in APA's PRN receive active treatments largely consistent with existing guidelines, which generally resulted in favorable patient outcomes.

Late-life depression and mental health services in primary care.

Mental health services in the treatment of late-life depression are critical in the primary care arena. A significant proportion of elderly patients experience depression, a problem causing a far-reaching impact on morbidity, mortality, and quality of life. A number of barriers may prevent effective depression treatment including negative physician and patient attitudes toward the stigma of depression, somatically focused clinical presentations, health care plan constraints, and competing medical demands, as well as gender and geographic isolation. Screening for depression in primary care settings is not always standard fare as physicians may feel confident in their diagnostic abilities. Research addressing effective depression treatment in the primary care setting has been limited to few clinical trials and physician-focused academic detailing. Future research should address real-world scenarios encountered by the primary care physician in their treatment of the "old-old" patient with complex medical comorbidities and functional decline.

Comparison of adult and geriatric psychiatric practice patterns: findings from the American Psychiatric Association's Practice Research Network.

OBJECTIVE: The authors explored diagnostic and treatment patterns for patients under and over age 65 seen by a nationally representative sample of psychiatrists participating in the American Psychiatric Association's Practice Research Network. METHODS: Detailed patient information, including demographic and financial characteristics, diagnoses, service utilization, and treatment, was collected by 383 psychiatrists on 1,026 patients to assess the impact of patient age on pharmacotherapy and psychotherapy service use as well as treatment outcomes. RESULTS: Approximately 15% of the patient sample was over age 65. Compared with patients ages 19-64, a lower percentage of geriatric patients had Axis I comorbidity, but a higher percentage had Axis III comorbidity. Geriatric patients were more often treated in hospital settings, and older patients were less likely to have their visits adversely affected by financial pressures of the healthcare system. Over 60% of patients in both age-groups received antidepressants, but there was a disproportionately increased use of antipsychotics and antianxiety/benzodiazepine medications among geriatric patients. Being age 65+ was a strong predictor for "improved" clinician rating on general assessment scores, but failed to be a predictor of receiving psychotherapy or pharmacotherapy. CONCLUSION: There were important differences between subject groups. Overall, American psychiatrists treat a complex group of geriatric patients suffering from major mental disorders complicated by medical comorbidity. Additional studies would further enhance our understanding of the delivery of mental health services to elderly patients and improve training of psychiatrists who help care for our aging population.

Ties to influential adults among black and white adolescents: culture, social class, and family networks.

Although prior research suggests the importance of nonparental adults to adolescents, the ecological context of those relationships has received little attention. This study examined ties to influential adults among 122 adolescents who varied by race, family structure, and gender The strongest effects were for race. Blacks reported stronger ties than Whites to the maternal grandmother as well as more supportive interactions with adult males. While race differences in grandparental ties were robust across social class (SES), ties to an influential adult male became nonsignificant upon controlling for SES. African American girls from divorced families consistently reported the strongest ties. Discussion considers the role of culture versus SES in explaining race differences. Implications for mentoring interventions are proposed, with special attention to the role of actualizing latent ties to already existing network members.