Health Policy and Advocacy for New Mexico Medical Students in the Family Medicine Clerkship.

BACKGROUND AND OBJECTIVES: Learners in medical education are often inadequately prepared to address the underlying social determinants of health and disease. The objective of this article is to describe the development, implementation, and evaluation of a Health Policy and Advocacy curriculum incorporated into our family medicine clerkship. METHODS: We developed a Health Policy and Advocacy course for medical students within our family medicine clerkship. We evaluated the curriculum using a survey of our own design administered to students before and after their clerkship year. We created a mean score for each subscale that measured (1) physician's role, (2) knowledge, and (3) confidence in ability and calculated differences between the pre-survey and the post-survey scores for four medical school classes. We also conducted a focus group to get student input on the new curriculum. RESULTS: Mean scores on the pre- and post-surveys were highest for the subscale regarding attitudes about a physician's role in health policy and advocacy and did not change over time. Scores for self-reported knowledge and confidence in abilities increased significantly from the beginning to the end of the clerkship year. Students were generally positive about the curriculum but had some concerns about finding time for advocacy in their future practices. CONCLUSIONS: Training in health care policy and advocacy can be successfully implemented into a medical school curriculum with positive outcomes in students' self-reported knowledge and confidence in their abilities. Work remains on providing advocacy role models for students.

Student peer assessment in evidence-based medicine (EBM) searching skills training: an experiment.

BACKGROUND: Student peer assessment (SPA) has been used intermittently in medical education for more than four decades, particularly in connection with skills training. SPA generally has not been rigorously tested, so medical educators have limited evidence about SPA effectiveness. EXPERIMENTAL DESIGN: Seventy-one first-year medical students were stratified by previous test scores into problem-based learning tutorial groups, and then these assigned groups were randomized further into intervention and control groups. All students received evidence-based medicine (EBM) training. Only the intervention group members received SPA training, practice with assessment rubrics, and then application of anonymous SPA to assignments submitted by other members of the intervention group. RESULTS: Students in the intervention group had higher mean scores on the formative test with a potential maximum score of 49 points than did students in the control group, 45.7 and 43.5, respectively (P = 0.06). CONCLUSIONS: SPA training and the application of these skills by the intervention group resulted in higher scores on formative tests compared to those in the control group, a difference approaching statistical significance. The extra effort expended by librarians, other personnel, and medical students must be factored into the decision to use SPA in any specific educational context. IMPLICATIONS: SPA has not been rigorously tested, particularly in medical education. Future, similarly rigorous studies could further validate use of SPA so that librarians can optimally make use of limited contact time for information skills training in medical school curricula.

Cause or effect? The relationship between student perception of the medical school learning environment and academic performance on USMLE Step 1.

BACKGROUND: A school's learning environment is believed to influence academic performance yet few studies have evaluated this association controlling for prior academic ability, an important factor since students who do well in school tend to rate their school's environment more highly than students who are less academically strong. AIM: To evaluate the effect of student perception of the learning environment on their performance on a standardized licensing test while controlling for prior academic ability. METHODS: We measured perception of the learning environment after the first year of medical school in 267 students from five consecutive classes and related that measure to performance on United States Medical Licensing Examination (USMLE) Step 1, taken approximately six months later. We controlled for prior academic performance by including Medical College Admission Test score and undergraduate grade point average in linear regression models. RESULTS: Three of the five learning environment subscales were statistically associated with Step 1 performance (p < 0.05): meaningful learning environment, emotional climate, and student-student interaction. A one-point increase in the rating of the subscales (scale of 1-4) was associated with increases of 6.8, 6.6, and 4.8 points on the Step 1 exam. CONCLUSION: Our findings provide some evidence for the widely held assumption that a positively perceived learning environment contributes to better academic performance.

Evaluating Medical Student Communication/Professionalism Skills from a Patient's Perspective.

OBJECTIVE: Evaluate medical students' communication and professionalism skills from the perspective of the ambulatory patient and later compare these skills in their first year of residency. METHODS: Students in third year neurology clerkship clinics see patients alone followed by a revisit with an attending neurologist. The patient is then asked to complete a voluntary, anonymous, Likert scale questionnaire rating the student on friendliness, listening to the patient, respecting the patient, using understandable language, and grooming. For students who had completed 1 year of residency these professionalism ratings were compared with those from their residency director. RESULTS: Seven hundred forty-two questionnaires for 165 clerkship students from 2007 to 2009 were analyzed. Eighty-three percent of forms were returned with an average of 5 per student. In 64% of questionnaires, patients rated students very good in all five categories; in 35% patients selected either very good or good ratings; and <1% rated any student fair. No students were rated poor or very poor. Sixty-two percent of patients wrote complimentary comments about the students. From the Class of 2008, 52% of students received "better than their peers" professionalism ratings from their PGY1 residency directors and only one student was rated "below their peers." CONCLUSION: This questionnaire allowed patient perceptions of their students' communication/professionalism skills to be evaluated in a systematic manner. Residency director ratings of professionalism of the same students at the end of their first year of residency confirms continued professional behavior.

A resident-led institutional patient safety and quality improvement process.

The authors used a multipronged approach to gain resident involvement in institutional quality improvement over a 3-year period; the initiative included a survey, a retreat, workgroups, a resurvey, and another retreat. Survey results (from 2007 compared with those of 2010) demonstrated significant improvement in almost all the top issues concerning patient safety for residents-emergency department boarding and crowding, adequacy of patient flow through the institution, adequacy of nursing and technical support staffing, and laboratory specimen handling (initial overall mean concern level was 2.87, and final concern level was 2.19; P < .01). This perceived improvement in patient safety concerns for residents was associated with observable improvements in areas of high concern for hospital leaders. By surveying residents and students, prioritizing concerns, convening a hospital-wide retreat with key leaders, and implementing accountable plans, the authors have demonstrated that resident perceptions of quality and safety can help drive quality improvement and engage residents in improvement efforts at an institutional level.

The association between intolerance of ambiguity and decline in medical students' attitudes toward the underserved.

PURPOSE: Little published research details the risk factors for the decline in students' attitudes toward underserved populations during medical school. The authors assessed the association between this attitude change and intolerance of ambiguity (the tendency to perceive novel or complex situations as sources of threat), since treating underserved populations often involves a high level of complexity. METHOD: The University of New Mexico School of Medicine administered a survey assessing attitudes toward underserved populations at matriculation and at graduation to seven consecutive medical school classes (matriculation years 1999 to 2005). The university also administered a survey measuring tolerance of ambiguity at matriculation. Five hundred twenty-nine students were eligible to complete both surveys between 1999 and 2009. RESULTS: Three hundred thirteen (59%) students completed the attitude survey at matriculation and graduation. Attitude scores for a majority of students (69%) decreased from matriculation to graduation. Changes in scores ranged from +25 to -35; the average change was -4.5. Linear regression analysis showed that those who were tolerant of ambiguity (top 20% of tolerance of ambiguity scores) were significantly less likely to have declines in attitudes toward the underserved; the coefficient was 3.69 (P = .003). Other factors independently associated with maintaining high attitude scores were being female and starting medical school at age 24 or younger. CONCLUSIONS: Attention to, and practice with, ambiguous situations may help moderate decreases in attitudes toward underserved populations. Medical education should address the fact that physicians face much ambiguity and should offer students tools to help them respond to ambiguous clinical situations.

Early predictors of physicians' practice in medically underserved communities: a 12-year follow-up study of University of New Mexico School of Medicine graduates.

BACKGROUND: Substantial numbers of people are medically underserved because of rural residence and/or economic circumstances. The mission of many medical schools is service to this group, so the ability to identify applicants likely to serve this population is valuable. METHOD: In 2009, the authors asked graduates from their medical school, class of 1997 and forward, if they practiced in a medically underserved community in the past year. Variables obtained from medical school applications and scores from a survey of attitudes toward the underserved measured at matriculation were analyzed using logistic regression. RESULTS: Of 244 practitioners, 35% reported working in an underserved community. Rural background, older age (25+) at matriculation, and being a member of an underrepresented minority were independent, statistically significant predictors of practice in an underserved community. CONCLUSIONS: Schools wanting to increase the number of practitioners caring for the underserved could consider older as well as rural and minority applicants.

Medical students' attitudes toward underserved populations: changing associations with choice of primary care versus non-primary care residency.

The number of medical students entering primary care residencies continues to decrease. The association between student attitudes toward underserved populations and residency choice has received little attention even though primary care physicians see a larger proportion of underserved patients than most other specialists. We evaluated attitudes toward underserved populations in 826 medical students using a standardized survey, and used logistic regression to assess the effect of attitudes, along with other variables, on selection of a primary care residency. We compared results between two groups defined by year of entry to medical school (1993-99 and 2000-05) to determine whether associations differed by time period. Students' attitudes regarding professional responsibility toward underserved populations remained high over the study period; however, there was a statistically. significant association between positive attitudes and primary care residency in the early cohort only. This association was not found in the more recent group.

Breast cancer survivors who use estrogenic botanical supplements have lower serum estrogen levels than non users.

To measure the association between use of estrogenic botanical supplements and serum sex hormones in postmenopausal breast cancer survivors, a total 502 postmenopausal women were queried 2-3 years after breast cancer diagnosis about their use of botanical supplements, and supplements were categorized according to their estrogenic properties. Concurrently, a fasting blood sample was obtained for assay of estrone, estradiol, free estradiol, testosterone, free testosterone, dehydroepiandrosterone sulfate (DHEAS), and sex hormone-binding globulin. Adjusted means of the serum hormones were calculated by use of estrogenic supplements. Women reporting use of any estrogenic botanical supplement had significantly lower levels of estrone (20.8 vs. 23.6 pg/ml), estradiol (12.8 vs. 14.7 pg/ml), free estradiol (0.29 vs. 0.35 pg/ml), and DHEAS (47.7 vs. 56.2 microg/dl) compared to women reporting no use. Data from this cross-sectional study suggest the use of estrogenic botanical supplements may be associated with sex hormone concentrations in breast cancer survivors. Considering the high use of these supplements among breast cancer patients, further research is needed to clarify the relative estrogenicity/antiestrogenicity of these compounds and their relation with prognosis.

Association between alcohol intake and serum sex hormones and peptides differs by tamoxifen use in breast cancer survivors.

OBJECTIVE: To measure the association between alcohol intake and 11 hormones and peptides in postmenopausal breast cancer survivors and to evaluate whether this association differs by tamoxifen use. METHODS: Self-reported alcohol intake was assessed via food frequency questionnaire on average 30 months post-breast cancer diagnosis in 490 postmenopausal women from three western states. Concurrently, a fasting blood sample was obtained for assay of estrone, estradiol, free estradiol, testosterone, free testosterone, dehydroepiandrosterone sulfate (DHEAS), sex hormone-binding globulin (SHBG), leptin, C-peptide, insulin-like growth factor-I (IGF-I), and IGF-binding protein-3. Adjusted means of these hormones and peptides were calculated for categories of alcohol intake, overall and stratified by tamoxifen use. RESULTS: The association between alcohol intake and serum hormone and peptide levels differed by tamoxifen use. We found statistically significant inverse associations between alcohol intake and both leptin and SHBG values but only among tamoxifen users. In women not using tamoxifen, we found a positive association between alcohol intake and DHEAS but no association in tamoxifen users. CONCLUSION: Tamoxifen may modify the association between alcohol intake and serum hormones and peptides. The significant associations found for DHEAS and SHBG are in a direction considered unfavorable for breast cancer prognosis. Postmenopausal breast cancer survivors may benefit from decreasing their alcohol intake.

Vitamin D insufficiency in a multiethnic cohort of breast cancer survivors.

BACKGROUND: Little is known about vitamin D status in breast cancer survivors. This issue is important because vitamin D influences pathways related to carcinogenesis. OBJECTIVE: The objective of this report was to describe and understand vitamin D status in a breast cancer survivor cohort. DESIGN: Data are from the Health, Eating, Activity, and Lifestyle study. With the use of a cross-sectional design, we examined serum concentrations of 25-hydroxyvitamin D [25(OH)D] in 790 breast cancer survivors from western Washington state, New Mexico, and Los Angeles County. Cancer treatment data were obtained from Surveillance, Epidemiology, and End Results registries and medical records. Fasting blood, anthropometry, and lifestyle habits were collected after diagnosis and treatment. We examined distributions of 25(OH)D by race-ethnicity, season, geography, and clinical characteristics. Multivariate regression tested associations between 25(OH)D and stage of disease. RESULTS: Five hundred ninety-seven (75.6%) of the women had low serum 25(OH)D, suggesting vitamin D insufficiency or frank deficiency. The overall mean (+/-SD) was 24.8 +/- 10.4 ng/mL, but it was lower for African Americans (18.1 +/- 8.7 ng/mL) and Hispanics (22.1 +/- 9.2 ng/mL). Women with localized (n = 424) or regional (n = 182) breast cancer had lower serum 25(OH)D than did women with in situ disease (n = 184) (P = 0.05 and P = 0.03, respectively). Multivariate regression models controlled for age, body mass index (in kg/m(2)), race-ethnicity, geography, season, physical activity, diet, and cancer treatments showed that stage of disease independently predicted serum 25(OH)D (P = 0.02). CONCLUSIONS: In these breast cancer survivors, the prevalence of vitamin D insufficiency was high. Clinicians might consider monitoring vitamin D status in breast cancer patients, together with appropriate treatments, if necessary.

Dietary fiber is associated with serum sex hormones and insulin-related peptides in postmenopausal breast cancer survivors.

OBJECTIVE: To measure the association between dietary fiber intake and eleven hormones and peptides in postmenopausal breast cancer survivors. METHODS: Intake of fiber from food and supplements was measured two to three years after breast cancer diagnosis in 493 postmenopausal women from three western states. Concurrently, a fasting blood sample was obtained for assay of estrone, estradiol, free estradiol, testosterone, free testosterone, dehydroepiandrosterone sulfate, sex hormone-binding globulin (SHBG), leptin, C-peptide, insulin-like growth factor-1 (IGF1), and IGF-binding protein-3. Adjusted means of these hormones and peptides were calculated for categories of fiber intake. RESULTS: High intake of dietary fiber was significantly (P

Diet quality is directly associated with quality of life in breast cancer survivors.

PURPOSE: To determine whether there is a direct relationship between diet quality and quality of life in breast cancer survivors. METHODS: Subjects (n = 714) were members of the Health, Eating, Activity, and Lifestyle study, a study of breast cancer prognosis conducted in three areas of the western United States. Approximately 2 years after entry to this study, diet data were collecting using food frequency questionnaires. These data were used to classify diet quality using the Diet Quality Index. Approximately 10 months later, data on quality of life were gathered using the Medical Outcomes Study 36-Item short form health survey. RESULTS: After controlling for age, education, race/ethnicity, body mass index, stage of disease, and time from diagnosis to quality of life measurement, women with excellent diet quality had significantly better scores than women with poor diet quality for overall mental health functioning and for 3 of 4 mental health subscale scores and 2 of 4 physical health subscale scores. CONCLUSION: Post-diagnosis diet quality is directly associated with subsequent mental and physical functioning in breast cancer survivors. This association is stronger for mental functioning than for physical functioning. The association remains strong after control for potential confounding variables.

Prevalence of depressive symptoms in new Mexico Hispanic and non-Hispanic white elderly.

OBJECTIVE: To evaluate the prevalence rates, risk factors, and pattern of depressive symptoms in elderly Hispanic and non-Hispanic Whites (NHWs). METHODS: This survey was a community-based, cross-sectional survey of randomly selected Medicare recipients living in Bernalillo County (Albuquerque, New Mexico). The survey's objective was to examine the health and health-related issues of Hispanic and NHW elderly persons (> or =65 years of age). As part of the survey, participants were administered the Geriatric Depression Scale-short form (GDS). RESULTS: Complete data were available on 798 subjects with a mean age of 73.7 years, age range 65-96. The prevalence of a GDS score > or =6 was: Hispanic males, 9.5%; Hispanic females, 19.2%; NHW males, 5.4%; and NHW females, 8.7%. Hispanics (P=.001) and women (P=.003) had higher prevalence rates. Sociodemographic variables, health, social support, and the activities of daily living (ADLs) were significantly related to symptoms. English skills (P<.0001) and birthplace (P=.011) were associated with symptoms in Hispanics. Significant differences were found in the response patterns between Hispanics and NHWs. Logistic regression analyses showed that ethnic differences were largely explained by differences in the level of education and income among Hispanics and NHWs. CONCLUSION: A difference was seen in the prevalence rates of depressive symptoms between Hispanic and NHW elderly persons and between men and women. In addition to the traditional risk factors for depressive symptoms, we found that ethnic differences in prevalence rates can be largely explained by education and income differences in the two groups.

Cognitive function in drinkers compared to abstainers in the New Mexico elder health survey.

BACKGROUND: Recent epidemiological studies have shown that individuals who ingest alcohol regularly have a higher level of cognitive function and are less likely to develop dementia than those who abstain. The purpose of this study was to compare nine measures of cognitive function in drinkers compared to abstainers. METHODS: A cross-sectional community survey was conducted of 883 randomly selected Hispanic and non-Hispanic white men and women, age >or=65 years of age, undergoing a paid home interview and 4-hour interview/examination in a senior health clinic (The New Mexico Elder Health Survey). The interviews included questions on frequency and quantity of alcohol ingested. RESULTS: Participants who consumed alcohol had significantly better mean scores on 7 of 9 cognitive function tests and less frequently had scores below selected "cut points" compared to those who abstained from all alcohol intake. Scoring used multivariate linear and logistic regression models adjusted for sex, ethnicity, age, level of education, and evidence of depression. CONCLUSIONS: Participants in the New Mexico Elder Health Survey (nearly equal numbers of Hispanic and non-Hispanic white men and women) who consumed alcohol had better scores on their cognitive tests than did those participants who abstained.

Apolipoprotein epsilon4 allele and problems with orientation are associated with a persistent decline in cognition in community-dwelling elderly persons.

BACKGROUND: A decline in cognitive test scores in elderly persons can signal the beginning of a descent into dementia or may indicate only a short-term cognitive disturbance. It would be clinically useful to distinguish between the two outcomes and to identify characteristics of each. METHODS: Four hundred thirty-seven community-dwelling elderly persons were given the Mini-Mental State Examination (MMSE) annually for an average of 7 years. A low score between baseline and final MMSE was identified. A low score 3 or more points lower than baseline score indicated cognitive decline. This decline was called persistent if the final MMSE score was also at least 3 points lower than baseline MMSE score; otherwise, the decline was considered transient. RESULTS: Twenty participants (4.6%) experienced a persistent cognitive decline, 67 participants (15.3%) experienced a transient cognitive decline. Presence of the apolipoprotein epsilon4 allele was significantly associated with persistent cognitive decline (age-adjusted odd ratio [OR] = 11.46, p < .0001) but not with transient cognitive decline (age-adjusted OR = 1.53, p = .219). Incorrect answers on the orientation part of the MMSE at the time of cognitive decline was associated with persistent decline compared to transient decline (age-adjusted OR = 3.58, p = .058). CONCLUSIONS: Persistent cognitive decline is an infrequent occurrence in community-dwelling elderly persons. Presence of the epsilon4 allele and errors made by the subject on questions of orientation may be useful in determining whether a cognitive decline is likely to be persistent.

Changes in dietary intake after diagnosis of breast cancer.

OBJECTIVE: To quantify change in intake of kilocalories, macronutrients, and fruit and vegetable servings after diagnosis of breast cancer, and to correlate these changes with subject characteristics and with self-reported global change in dietary patterns. DESIGN: Food frequency questionnaires were completed by women newly diagnosed with breast cancer shortly after diagnosis. They were asked to recall intake 1 year before diagnosis. Two years after the initial interview another food frequency questionnaire was completed recalling intake during the previous year. At the 2-year follow-up interview women were also asked if they had changed their intake of fruit, vegetables, and fat since diagnosis. SUBJECTS/SETTING: Two hundred sixty New Mexico women with newly diagnosed breast cancer between July 1997 and March 1999. ANALYSIS: Two-year change scores for kilocalories, macronutrients, and fruit and vegetable servings were calculated and tested for difference from zero using paired t tests or Wilcoxon signed rank tests. Subjects' characteristics were related to change in kilocalories and linear regression was used to determine the relative importance of these characteristics. Amount of change in fruit and vegetable servings and fat intake were calculated using food frequency data for women who reported increasing their intake of fruits and vegetables or decreasing their intake of fat after diagnosis. RESULTS: Small but significant decreases in intake of total energy and macronutrients were found 2 years postdiagnosis, with younger women reporting the greatest decreases. Fat as a percentage of diet increased over this period. There was no change in mean intake of fruit and vegetable servings. There is agreement between change as measured by food frequency questionnaire and change reported by more global questions on dietary habits; however, the amount of change measured was small. Women reporting an increase in fruit and vegetable intake postdiagnosis described an increase of one-quarter serving of fruit and one-third serving of vegetables per day. CONCLUSIONS: Breast cancer diagnosis results in modest dietary changes. Small changes in fruit and vegetable consumption suggest that efforts are needed to encourage increased consumption of these foods.

Sarcopenic obesity predicts instrumental activities of daily living disability in the elderly.

OBJECTIVE: To determine the association of sarcopenic obesity with the onset of Instrumental Activities of Daily Living (IADL) disability in a cohort of 451 elderly men and women followed for up to 8 years. RESEARCH METHODS AND PROCEDURES: Sarcopenic obesity was defined at study baseline as appendicular skeletal muscle mass divided by stature squared <7.26 kg/m2 in men and 5.45 kg/m2 in women and percentage body fat greater than the 60th percentile of the study sample (28% body fat in men and 40% in women). Incident disability was defined as a loss of two or more points from baseline score on the IADL. Subjects with disability at baseline (scores < 8) were excluded. Cox proportional hazards analysis was used to determine the association of baseline sarcopenic obesity with onset of IADL disability, controlling for potential confounders. RESULTS: Subjects with sarcopenic obesity at baseline were two to three times more likely to report onset of IADL disability during follow-up than lean sarcopenic or nonsarcopenic obese subjects and those with normal body composition. The relative risk for incident disability in sarcopenic obese subjects was 2.63 (95% confidence interval, 1.19 to 5.85), adjusting for age, sex, physical activity level, length of follow-up, and prevalent morbidity. DISCUSSION: This is the first study, to our knowledge, to indicate that sarcopenic obesity is independently associated with and precedes the onset of IADL disability in the community-dwelling elderly. The etiology of sarcopenic obesity is unknown but may include a combination of decreases in anabolic signals and obesity-associated increases in catabolic signals in old age.

Impact of subclinical hypothyroidism on serum total homocysteine concentrations, the prevalence of coronary heart disease (CHD), and CHD risk factors in the New Mexico Elder Health Survey.

The serum/plasma total homocysteine (tHcy) concentration, now recognized as an independent risk factor for accelerated atherosclerotic disease, is increased in overtly hypothyroid patients, and it decreases with thyroid replacement therapy. Whether or not individuals with subclinical hypothyroidism also increase their tHcy concentrations, and whether this elevation might help to explain the increased prevalence of the atherosclerotic diseases observed in this condition, remains unclear. If individuals with subclinical hypothyroidism have higher tHcy concentrations than euthyroid subjects, there would be added incentive to treat this condition earlier. In this cross-sectional study (New Mexico Elder Health Survey) of a randomly selected sample of Medicare recipients (age > or =65 years), no significant difference in serum tHcy concentrations could be detected between the 112 participants with subclinical hypothyroidism (Groups 2 and 3) and the 643 participants with thyrotropin (TSH) values < or =4.6 microU/mL (Group 1) after adjusting for differences in gender, ethnicity, age, and serum concentrations of folate, vitamin B(12), and creatinine. Only those participants with the highest TSH levels (>10 microU/mL) (Group 3) had a significantly higher prevalence of coronary heart disease (CHD) when compared against Group 1 participants (p = 0.007). No consistent significant differences in the prevalences of CHD or in the CHD risk factors examined were observed when all participants with subclinical hypothyroidism (Groups 2 and 3 combined) were compared against Group 1 participants.