Hypertension Guidelines and Interventions.

Hypertension remains one of the most prevalent conditions encountered in the primary care setting and is a major contributor to cardiovascular disease in the United States. This reality underscores the importance for primary care clinicians to have an understanding of hypertension guidelines, interventions, and population-based considerations. This article provides a succinct overview of hypertension guidelines, reviews guideline-informed approaches to hypertension screening, diagnosis, and treatment, and concludes with a thoughtful discussion of population-based considerations.

Development of a curriculum in cultural determinants of health and health disparities.

INTRODUCTION: Current sociopolitical events coupled with requirement modifications by the Liaison Committee on Medical Education have reinvigorated a need for training in cultural awareness and health disparities in undergraduate medical education. Many institutions, however, have not established longitudinal courses designed to address this content. Additionally, little is known about the change in learners' awareness of cultural determinants of health and health disparities after enrollment in such curricula. In 2016, the authors developed a yearlong required course entitled Cultural Determinants of Health and Health Disparities for first year medical students at a large university medical school in the United States. The course launched in the 2017 academic year. METHODS: Two cohorts participated in twelve 2.5 to 3-hour multi-modal sessions focused on various aspects of healthcare delivery for marginalized populations and factors that contribute to health disparities. The Multicultural Assessment Questionnaire was used pre and post course to assess students' self-evaluated changes in knowledge, skills, and awareness related to cultural competency in healthcare. RESULTS: Students' self-reported knowledge, skills, and awareness scores regarding cultural competence in health care increased from pre to post-course assessment. On the knowledge scale, students' mean score increased from 2.63 to 2.97 (P < .001), with 16% reporting a decreased score, 30% reporting no change, and 54% reporting growth. On the skills scale, students' mean score increased from 2.64 to 3.38 (P < .001), with 11% reporting a decreased score, 17% reporting no change, and 72% reporting growth. On the awareness scale, students' overall score increased from 3.76 to 3.97 (P < .05), with 16% reporting a decreased score, 50% reporting no change, and 34% reporting growth. There were no changes in KSA scores across cohorts pre and post course. CONCLUSION: Perceived knowledge, skills, and awareness related to the importance of cultural competence in healthcare delivery increased at the end of the academic year. This type of longitudinal course model could be broadly adopted at other institutions to enhance patient, peer, and future provider awareness regarding cultural impacts on care and health disparities among vulnerable populations.

Intrahepatic cholestasis in sickle cell disease: A review of diagnostic criteria, treatments, and case reports.

Objective To delineate the etiology, symptomatology, and treatment of sickle cell intrahepatic cholestasis (SCIC). Sickle cell disease (SCD) is the most frequently inherited hematologic disease, and SCIC is one rare and often fatal complication and comorbid disease. The literature contains only a small number of case reports involving SCIC and hence limited guidance can be obtained. Methods We reviewed the scientific literature to evaluate the science of SCIC to determine if there were consistencies in presentation, evaluation, treatment, and clinical outcomes. Results We reviewed 6 case reports and a limited number of clinical papers on SCIC. We reported consistencies in clinical presentation and treatment outcomes among cases as well as serological and hematological finding. Conclusions While there is some consistency in the symptom presentation of individuals with SCIC, reliable evaluation and clinical procedures were not demonstrated in what we reviewed. Further research is needed to delineate the attributes of this complicated disease that occurs within SCD.

Is One Lecture Enough? Self-Perception of Bias and Cultural Training in Medical Education.

INTRODUCTION: A recognition of the importance of the sociocultural determinants of health and well-being has increased within medical education; yet, there is variability in exposure and evidence of effect. The goal of this project was to assess contact with cultural humility or competency instruction prior to training, evaluate self-perception of bias, and test the effect of a single lecture on this perception. METHODS: A 17-item survey was administered to participants before and after a lecture "intervention." RESULTS: Analysis revealed that 54% (n = 93) of participants received formal instruction prior to medical/graduate school. Subsequently, significant changes ( p = 0.02) when comparing pretests, immediate posttests, and 8-week posttests were found in only one area, "ability to withhold judgment." While the majority of participants reported having "bias towards certain groups" (chi-square p <0.0001), there was no statistically significant difference in improvement of self-reflection. DISCUSSION: A single lecture may improve personal awareness of bias but likely does not significantly affect reflection on this bias or improve self-perception of cultural competency.

Neurological interest and career exploration among black medical students: Perceptions and solutions for the pipeline.

PURPOSE: The goal of this study was to identify factors that influence the selection of Neurology as a career choice for Black medical students. METHODS: Survey data was collected from attendees at a national educational conference and at a large academic medical school. Two proportion z-tests were used to assess responses among students of different racial/ethnic backgrounds. RESULTS: 199 students participated in the survey. Compared to their Asian and White counterparts, Black students were significantly less likely to choose or consider a career in Neurology. In addition, we found that these students relied more heavily on their pre-clinical experiences to make this determination, citing preference for another specialty, lack of exposure, a preference for a different patient population, and a lack of racial/ethnic diversity as key reasons to not choose a career in Neurology. CONCLUSIONS: Neurological disorders are important contributors to morbidity and mortality. It is imperative that the field attract medical students toward careers in Neurology, particularly those students from traditionally and persistently underrepresented backgrounds. Our findings suggest that Black medical students consider Neurology as a specialty choice less frequently than their counterparts do, and this decision may be made prior to training. We conclude that a multifaceted approach is best to improve the racial/ethnic diversity within the neurological workforce, which should include targeted interventions prior to and after matriculation to medical school.

The Impact of Racial Bias in Patient Care and Medical Education: Let's Focus on the Educator.

Introduction: Racial bias in health care is well documented. Research shows the presence of racial bias among health care providers. There is a paucity of workshops focused on racial bias effects in health professions educators. Method: Two to three workshops were delivered to a diverse group of clinical educators from three programs at a major academic institution. Each workshop included a brief multimedia presentation followed by a facilitated group discussion. Participants completed the online Implicit Association Test (IAT), a baseline demographic questionnaire, and a brief post-then-pre questionnaire. Results: Twenty-four faculty participated in the study (six physicians, eight nurse practitioners, 10 physician assistants). Nineteen (90%) were women, 18 (86%) were White, nine (43%) had more than 10 years of experience as educators, and seven (35%) had previously participated in a biases program. Seventeen completed the IAT. Sixteen educators agreed or strongly agreed that bias has a significant impact on patients' outcomes at the end of the workshop compared to 17 before the workshop. Seventeen educators agreed or strongly agreed that recognizing their own racial bias would positively alter their teaching practice after the workshop compared to 15 before the workshop. Discussion: This series of workshops was created to fill a gap regarding the impact of racial bias on patient outcomes, health disparities, and health professions education. The impact of racial bias in health professions education and the long-term impact of awareness and knowledge of racial bias in education are areas needing further evaluation.

Partnerships to Care for Our Patients and Communities During COVID-19.

The Coronavirus disease 2019 (COVID-19) pandemic forced not only rapid changes in how clinical care and educational programs are delivered but also challenged academic medical centers (AMCs) like never before. The pandemic made clear the need to have coordinated action based on shared data and shared resources to meet the needs of patients, learners, and communities. Family medicine departments across the country have been key partners in AMCs' responses. The Duke Department of Family Medicine and Community Health (FMCH) was involved in many aspects of Duke University's and Health System's responses, including leadership contributions in delivering employee health and student health services. The pandemic also surfaced the biological and social interactions that reveal underlying socioeconomic inequalities, for which family medicine has advocated since its inception. Key to success was the department's ability to integrate "horizontally" with the broader community, thereby accelerating the institution's response to the pandemic.

Reducing Reliance on Test Scores Reduces Racial Bias in Neurology Residency Recruitment.

PURPOSE: We sought to correct a low interview rate for racial groups underrepresented in medicine (URM) by analyzing our interview selection process, identifying sources of unintended bias, and developing a new process that would provide a more racially diverse interview pool. METHODS: We analyzed our review process to determine at which point we were eliminating URM candidates at a higher rate than those who are not from an underrepresented group. A point system was created incorporating clinical grades, extracurricular activities, research, letters of recommendation, board exam scores, and life experiences. We compared the rate at which interviews were offered to URM candidates and compared those rates to historical data. We then analyzed the new process by comparing groups who were offered interviews to those who were not. RESULTS: In 2016, 56% of URM applicants were screened out by a mandatory minimum United States Medical Licensing Examination (USMLE) test score, whereas only 39% of all other groups were disqualified by test scores. This led to 20% of the URM applicants receiving interview offers. By comparison, 30.6% of other groups were offered interviews. After removing the required minimum test score for application review and modifying the screening process to a more holistic one the following application cycle, 24.5% of URMs were offered interviews in 2017 compared to 28.1% of others. CONCLUSIONS: A comprehensive review of applications that minimizes emphasis on USMLE step 1 scores substantially reduced the difference between the percentages of URMs and those of other racial backgrounds who were offered interviews for a Neurology residency.

Are You SURE You Want to Send That? A Model for Email Professionalism in Medical Education.

Email is an essential method of communication within academic medical environments and elsewhere. There is a growing body of literature that focuses on provider-to-patient communication in addition to studies examining the intersection of social networking and professionalism. Relatively little research exists, however, regarding the components of professional email interactions or "best practices" for electronic correspondence among colleagues, faculty, and trainees. After reviewing the existing literature, the authors created a practical approach for skillful email construction; the SURE model proposes a simplified framework that teaching institutions can use to improve interdisciplinary interactions and enhance email professionalism.

Behavioral Health in Prevention and Chronic Illness Management: Motivational Interviewing.

This article reviews the history, methodology, and evidence related to the effective use of motivational interviewing (MI) in the primary care setting. MI has been shown to have a positive effect in promotion and modification of health habits and to increase treatment engagement. MI is also effective when used in conjunction with other treatment modalities, such as educational programs and cognitive behavioral therapy. Practical application of MI can be accomplished in a variety of primary care settings by a wide range of practitioners, incorporates nicely into new health care delivery models, and may improve the patient-provider relationship.

Enlisting New Teachers in Clinical Environments (ENTICE); novel ways to engage clinicians.

PURPOSE: To explore the barriers and incentives that affect primary care providers who precept students in outpatient clinics in the US. METHOD: In 2013, leadership of our large primary care group sent a 20-question survey via e-mail to all of the 180 providers within the network. The survey assessed provider demographics, precepting history, learner preferences, and other issues that might affect future decisions about teaching. RESULTS: The response rate was 50% (90 providers). The top reasons for precepting in the past were enjoyment for teaching and personal interaction with learners. The most commonly cited reason for not precepting previously was a perceived lack of time followed by increased productivity demands. When questioned about the future, 65% (59 respondents) indicated that they were likely to precept within the next 6 months. A desired reduction in productivity expectations was the most commonly cited motivator, followed by anticipated monetary compensation and adjusted appointment times. A top barrier to future precepting was a belief that teaching decreases productivity and requires large amounts of time. CONCLUSION: This survey represents an opportunity to study a change in focus for a cohort of busy clinicians who were mostly new to teaching but not new to clinical practice. The survey provides further insight into clinician educators' perceptions regarding the education of a variety of different learners. The results align with data from previous studies in that time pressures and productivity demands transcend specific programs and learner backgrounds. This information is critical for future clerkship directors and hospital administrators in order to understand how to increase support for potential preceptors in medical education.