Gender Differences and Influencing Factors in Specialty Choices: Findings From One Medical School in China.

Background: Gender plays a significant role in the selection of medical specialty. Few studies have been conducted to explore the impact of gender differences on specialty choosing among Chinese medical students. Methods: The specialty choices of 648 students from six consecutive classes in an 8-year MD program were collected and compared between male and female students. A total of 110 students from one graduating class were surveyed by a questionnaire covering 22 career influencing factors. Each factor has a scale of zero to three (zero = no influence, one = mild influence, two = moderate influence, and three = strong influence). Results: Statistically significant gender differences were observed in 10 out of 16 specialties. Most male students limited their specialty choices to surgery (64%), internal medicine (12%), and orthopedics (12%), compared with a relatively diversified pattern in female students. For male students, the top three influencing factors were personal interest, future job prospects for the chosen specialty, and job opportunity in academic medicine. The strongest influencing factors of females were personal interest, specialty-specific knowledge and skills, and the sense of achievement. The expected salary was ranked among the top 10 influencing factors in male but not in females, while the work-life balance was ranked among the top 10 factors in females but not in males. Conclusion: There is a significant gender difference regarding specialty choices among Chinese medical students. Career coaching is needed to help students in their specialty choosing process.

A framework to understand the needs of the medical students of the future.

Purpose: Medical education is undergoing curricular reform driven by internal needs and external pressures. Concurrently, medical students are changing. More diverse student bodies, particularly those from underrepresented minorities, bring different skill sets, needs and priorities to their medical school education. Here we present their voices.Methods: In order to explore the stories, needs and motivations of future physicians, we conducted a small-scale study of students from diverse backgrounds in US medical schools. Our interviews revealed two core themes about medical school: (1) that medical school is an extreme physical and emotional challenge for all students, and (2) that medical school education consists of multiple conflicting goals. Combining the two themes provides a descriptive topology of student's motivations and strategies for getting through medical school. Using this framework, we deconstruct the experience of medical school to reveal the gaps and misalignments between the traditional system of medical education and what medical students want, expect and need to be successful.Conclusions: We discuss the implications of our research and this framework for curricula and the learning environment with a particular focus on (1) cooperative learning and social interdependence theory and (2) an expanded understanding of diversity and the needs of under-represented students.

Self-care habits among people who inject drugs with skin and soft tissue infections: a qualitative analysis.

BACKGROUND: Injection drug use is on the rise in the USA, and skin and soft tissue infections (SSTI) are a common complication, resulting in significant morbidity and mortality. Due to structural barriers to care-seeking, many people who inject drugs avoid formal care and resort to self-care techniques, but little is known about the nature of these techniques, or more generally about the accuracy or breadth of this population's knowledge of SSTIs. METHODS: Semi-structured qualitative interviews were conducted with 12 people who inject heroin in two metropolitan areas: Sacramento and Boston, USA. RESULTS: These interviews reveal a robust and accurate knowledge base regarding skin infections, including the progression from simple cellulitis to an abscess, and acknowledgment of the possibility of serious infections. Nonetheless, there remains a reticence to seek care secondary to past traumatic experiences. A step-wise approach to self-care of SSTI infections was identified, which included themes of whole-body health, topical applications, use of non-prescribed antibiotics, and incision and drainage by non-medical providers. CONCLUSIONS: The reported SSTI self-care strategies demonstrate resilience and ingenuity, but also raise serious concerns about inappropriate antibiotic consumption and complications of invasive surgical procedures performed without proper training, technique, or materials. Harm reduction agencies and health care providers should work to obviate the need for these potentially dangerous practices by improving healthcare access for this population. In the absence of robust solutions to meet the needs of this population, education materials should be developed to optimize the efficacy and minimize the harms of these practices, while empowering and supporting the autonomy of people who use drugs and providing clear guidance on when self-care should be abandoned in favor of formal medical care.

Adverse Childhood Experiences in Medical Students: Implications for Wellness.

OBJECTIVE: The primary purpose of the study was to assess the prevalence of adverse childhood experiences (ACEs) in a cohort of third-year medical students and characterize their childhood protective factors. METHODS: The authors developed a web-based anonymous survey distributed to all third-year medical students in one school (N = 98). The survey included the 10-item ACE Study questionnaire, a list of childhood protective factors (CPF) and questions to assess students' perception of the impact of ACEs on their physical and mental health. The medical school's IRB approved the student survey as an exempt study. The authors computed descriptive and comparative statistical analyses. RESULTS: Eighty-six of 98 students responded (88% response rate). Forty-four students (51%) reported at least one ACE exposure and 10 (12%) reported ≥ 4 exposures. The latter were all female. The average difference in the ACE score between male and female medical students was - 1.1 (independent t test with unequal variances t(57.7) = - 2.82, P = .007). Students with an ACE score of ≥ 4 were significantly more likely to report a moderate or significant effect on their mental health, compared with students with scores ≤ 3 (chi-square test, P = < .0001). Most students reported high levels of CPF (median score = 13 of a maximum score = 14). ACEs and CPF were inversely associated (Pearson correlation = - 0.32, P = .003). CONCLUSIONS: A sizeable minority of medical students reported exposure to multiple ACEs. If replicated, findings suggest a significant vulnerability of these medical students to health risk behaviors and physical and mental health problems during training and future medical practice.

One Health-One Education: Medical and Veterinary Inter-Professional Training.

Physicians and veterinarians are increasingly expected to collaborate across disciplines; however, in most cases their education and training remain isolated within their respective professions. Medical and veterinary students are rarely provided with opportunities for inter-professional learning during their coursework and clinical training. One Health serves as an ideal framework for developing problem-focused curricula that promote inter-professional teamwork. One Health issues (e.g., zoonotic diseases, water pollution, toxic waste, impact of climate change, and food safety and security) not only engage students across disciplines, but require faculty and senior leadership across various health-related fields to share knowledge and balance perspectives throughout curriculum development and implementation. In this article, we report on one of several interactive, small-group, case-based One Health curricular exercises developed collaboratively by students and faculty in our Schools of Medicine and Veterinary Medicine to ensure that all students, regardless of background or intended specialty, would receive a basic introduction to inter-professional collaboration in the context of a One Health clinical problem of the sort they might encounter in their future practice. Toxoplasmosis ( Toxoplasma gondii infection) was selected as the first case because of the potentially different perspectives that medical and veterinary practitioners may have on advising a pregnant woman with regard to risk factors, prevention, testing, and treatment. Our goal was to develop an evidence-based approach to this clinical case that could be used by both professions to assess environmental and zoonotic risk factors for T. gondii in human pregnancies.

Negative experiences of pain and withdrawal create barriers to abscess care for people who inject heroin. A mixed methods analysis.

BACKGROUND: Skin and soft tissue infections (SSTIs) are prevalent among people who inject heroin (PWIH). Delays in seeking health care lead to increased costs and potential mortality, yet the barriers to accessing care among PWIHs are poorly understood. METHODS: We administered a quantitative survey (N = 145) and conducted qualitative interviews (N = 12) with PWIH seeking syringe exchange services in two U.S. cities. RESULTS: 66% of participants had experienced at least one SSTI. 38% reported waiting two weeks or more to seek care, and 57% reported leaving the hospital against medical advice. 54% reported undergoing a drainage procedure performed by a non-medical professional, and 32% reported taking antibiotics that were not prescribed to them. Two of the most common reasons for these behaviors were fear of withdrawal symptoms and inadequate pain control, and these reasons emerged as prominent themes in the qualitative findings. These issues are often predicated on previous negative experiences and exacerbated by stigma and an asymmetrical power dynamic with providers, resulting in perceived barriers to seeking and completing care for SSTIs. CONCLUSIONS: For PWIH, unaddressed pain and withdrawal symptoms contribute to profoundly negative health care experiences, which then generate motivation for delaying care SSTI seeking and for discharge against medical advice. Health care providers and hospitals should develop policies to improve pain control, manage opioid withdrawal, minimize prejudice and stigma, and optimize communication with PWIH. These barriers should also be addressed by providing medical care in accessible and acceptable venues, such as safe injection facilities, street outreach, and other harm reduction venues.

Reconciling a "pleasant exchange" with evidence of information bias: A three-country study on pharmaceutical sales visits in primary care.

OBJECTIVES: To examine and compare the experiences and attitudes of primary care physicians in three different regulatory environments (United States, Canada, and France) towards interactions with pharmaceutical sales representatives, particularly their perspectives on safety information provision and self-reported influences on prescribing. METHODS: We recruited primary care physicians for 12 focus groups in Montreal, Sacramento, Toulouse and Vancouver. A thematic analysis of the interview data followed a five-stage framework analysis approach. RESULTS: Fifty-seven family physicians (19 women, 38 men) participated. Physicians expected a commercial bias and generally considered themselves to be immune from influence. They also appreciated the exchange and the information on new drugs. Across all sites, physicians expressed concern about missing harm information; however, attitudes to increased regulation of sales visits in France and the US were generally negative. A common solution to inadequate harm information was to seek further commercially sourced information. Physicians at all sites also expressed sensitivity to critiques from medical students and residents about promotional interactions. CONCLUSIONS: Physicians have contradictory views on the inadequate harm information received from sales representatives, linked to their lack of awareness of the drugs' safety profiles. Commonly used strategies to mitigate information bias are unlikely to be effective. Alternate information sources to inform prescribing decisions, and changes in the way that physicians and sales representatives interact are needed.

Increasing confidence and changing behaviors in primary care providers engaged in genetic counselling.

BACKGROUND: Screening and counseling for genetic conditions is an increasingly important part of primary care practice, particularly given the paucity of genetic counselors in the United States. However, primary care physicians (PCPs) often have an inadequate understanding of evidence-based screening; communication approaches that encourage shared decision-making; ethical, legal, and social implication (ELSI) issues related to screening for genetic mutations; and the basics of clinical genetics. This study explored whether an interactive, web-based genetics curriculum directed at PCPs in non-academic primary care settings was superior at changing practice knowledge, attitudes, and behaviors when compared to a traditional educational approach, particularly when discussing common genetic conditions. METHODS: One hundred twenty one PCPs in California and Pennsylvania physician practices were randomized to either an Intervention Group (IG) or Control Group (CG). IG physicians completed a 6 h interactive web-based curriculum covering communication skills, basics of genetic testing, risk assessment, ELSI issues and practice behaviors. CG physicians were provided with a traditional approach to Continuing Medical Education (CME) (clinical review articles) offering equivalent information. RESULTS: PCPs in the Intervention Group showed greater increases in knowledge compared to the Control Group. Intervention PCPs were also more satisfied with the educational materials, and more confident in their genetics knowledge and skills compared to those receiving traditional CME materials. Intervention PCPs felt that the web-based curriculum covered medical management, genetics, and ELSI issues significantly better than did the Control Group, and in comparison with traditional curricula. The Intervention Group felt the online tools offered several advantages, and engaged in better shared decision making with standardized patients, however, there was no difference in behavior change between groups with regard to increases in ELSI discussions between PCPs and patients. CONCLUSION: While our intervention was deemed more enjoyable, demonstrated significant factual learning and retention, and increased shared decision making practices, there were few differences in behavior changes around ELSI discussions. Unfortunately, barriers to implementing behavior change in clinical genetics is not unique to our intervention. Perhaps the missing element is that busy physicians need systems-level support to engage in meaningful discussions around genetics issues. The next step in promoting active engagement between doctors and patients may be to put into place the tools needed for PCPs to easily access the materials they need at the point-of-care to engage in joint discussions around clinical genetics.

Injection-site vein loss and soft tissue abscesses associated with black tar heroin injection: A cross-sectional study of two distinct populations in USA.

BACKGROUND: Injection-site vein loss and skin abscesses impose significant morbidity on people who inject drugs (PWID). The two common forms of street heroin available in the USA include black tar and powder heroin. Little research has investigated these different forms of heroin and their potential implications for health outcomes. METHODS: A multiple-choice survey was administered to a sample of 145 participants seeking services at reduction facilities in both Sacramento, CA and greater Boston, MA, USA. Multivariate regression models for reporting one or more abscesses in one year, injection-site veins lost in six months, and soft tissue injection. RESULTS: Participants in Sacramento exclusively used black tar (99%), while those in Boston used powder heroin (96%). Those who used black tar heroin lost more injection-site veins (ß=2.34, 95% CI: 0.66-4.03) and were more likely to report abscesses (AOR=7.68, 95% CI: 3.01-19.60). Soft tissue injection was also associated with abscesses (AOR=4.68, 95% CI: 1.84-11.93). Consistent venous access (AOR: 0.088, 95% CI: 0.011-0.74) and losing more injection sites (AOR: 1.22, 95% CI: 1.03-1.45) were associated with soft tissue injection. CONCLUSION: Use of black tar heroin is associated with more frequent abscesses and more extensive vein loss. Poor venous access predisposes people who inject drugs to soft tissue injection, which may constitute a causal pathway between black tar heroin injection and abscess formation. The mechanisms by which black tar heroin contributes to vein loss and abscess formation must be further elucidated in order to develop actionable interventions for maintaining vein health and decreasing the abscess burden. Potential interventions include increased access to clean injection equipment and education, supervised injection facilities, opioid substitution therapy, and supply chain interventions targeting cutting agents.

Organizational and Teamwork Factors of Tele-Intensive Care Units.

BACKGROUND: Use of tele-intensive care involves organizational and teamwork factors across geographic locations. This situation adds to the complexity of collaboration in providing quality patient-centered care. OBJECTIVE: To evaluate cross-agency teamwork of health care professionals caring for patients in tele-intensive care units in rural and urban regions. METHODS: A national qualitative study was conducted in 3 US geographic regions with tele-intensive care programs. Discussions and interviews were held with key participants during site visits at 3 hub sites (specialist services location) and 8 rural spoke sites (patient location). The effects of communication and culture between the hub team and the spoke team on use of the services and effectiveness of care were evaluated. RESULTS: A total of 34 participants were interviewed. Specific organizational and teamwork factors significantly affect the functionality of a tele-intensive care unit. Key operational and cultural barriers that limit the benefits of the units include unrealistic expectations about operational capabilities, lack of trust, poorly defined leadership, and a lack of communication policies. Potential solutions include education on spoke facility resources, clearly defined expectations and role reversal education, team-building activities, and feedback mechanisms to share concerns, successes, and suggestions. CONCLUSION: Proper administration and attention to important cultural and teamwork factors are essential to making tele-intensive care units effective, practical, and sustainable.

One Health profile of a community at the wildlife-domestic animal interface, Mpumalanga, South Africa.

We used a community engagement approach to develop a One Health profile of an agro-pastoralist population at the interface of wildlife areas in eastern South Africa. Representatives from 262 randomly-selected households participated in an in-person, cross-sectional survey. Questions were designed to ascertain the participants' knowledge, attitudes, and practices with regard to human health, domestic animal health, and natural resources including wildlife and water. Surveys were conducted within four selected villages by a team of trained surveyors and translators over four weeks in July-August 2013. Questions were a combination of multiple choice (single answer), multiple selection, open-ended, and Likert scale. The study found that nearly three-quarters of all households surveyed reported owning at least one animal (55% owned chickens, 31% dogs, 25% cattle, 16% goats, 9% cats, and 5% pigs). Among the animal-owning respondents, health concerns identified included dissatisfaction with government-run cattle dip facilities (97%) and frequent morbidity and mortality of chickens that had clinical signs consistent with Newcastle disease (49%). Sixty-one percent of participants believed that diseases of animals could be transmitted to humans. Ninety-six percent of respondents desired greater knowledge about animal diseases. With regard to human health issues, the primary barrier to health care access was related to transportation to/from the community health clinics. Environmental health issues revealed by the survey included disparities by village in drinking water reliability and frequent domiciliary rodent sightings positively associated with increased household size and chicken ownership. Attitudes towards conservation were generally favorable; however, the community demonstrated a strong preference for a dichotomous approach to wildlife management, one that separated wildlife from humans. Due to the location of the community, which neighbors the Great Limpopo Transfrontier Conservation Area, and the livestock-dependent lifestyle of the resource-poor inhabitants, a One Health approach that takes into consideration the interconnectedness of human, animal, and environmental health is necessary. The community profile described in this study provides a foundation for health research and planning initiatives that are driven by community engagement and consider the multitude of factors affecting health at the human-domestic animal-wildlife interface. Furthermore, it allows for the determination and quantification of the linkages between human, animal, and environmental health.

Não se limite a fazer algo, esteja lá / Don't just do something, stand there / No se limite a hacer algo, esté allí

Imagine a (hypothetical) screening test which, done in a population of average risk, saves one person from dying from cancer out of every 10,000 people screened. Imagine as well that every one of those 10,000 pays a price in terms of time and money spent, as well as discomfort, and that some or even many of them will also have to deal with increased anxiety, repeat testing, biopsies, and in a few cases, surgery. Finally, a few will have serious adverse effects like infection or organ failure. Presented with this information, some people would undoubtedly decline to have the test ("You mean only one out of 10,000 who get the test will benefit?!"), while others would choose to have it ("I'll put up with all that if it could save my life"). That is to say, informed patients would understand that they are making a choice between a very rare but very important benefit, that would however accrue to almost none of the people getting the test, and very frequent, but far more manageable, harms, that would have to be dealt with by almost everyone getting the test. Now imagine a patient with osteoarthritis offered treatment with a (hypothetical) non-steroidal anti-inflammatory drug (NSAID), where the doctor notes that most patients would get a fairly small degree of benefit (more pain relief than with an analgesic with fewer side effects), but that perhaps one in 10,000 would suffer terrible harm (from GI bleeding, or renal failure). In this case, an informed patient would understand that this is a choice between a very small benefit that would apply to many people, and a terrible harm that would nevertheless be very rare. The two situations are comparable, such that it would make sense that after a shared decision-making discussion with an informed physician, almost all informed patients would choose both to forgo the screening test and to take the NSAID, or to do just the opposite in both instances. The first combination should be the choice of individuals who are not terribly concerned about extremely rare events, no matter how important they might be, and are more interested in very common effects (harms in the case of screening, and benefits in the case of the NSAID), even if they are relatively less important. The opposite choice would be made by those who are greatly concerned about a critical problem (a hidden disease that a screening test might detect, or a terrible drug side effect), no matter how rare. There could be occasional exceptions to this pattern, but one would expect the large majority of people to make similar choices consistent with the same set of underlying values and preferences. So how is it that in today's world most patients ­ and most of their doctors ­ automatically choose both a series of screening tests that have an extremely high number-needed-to-screen for one person to benefit, and drugs that offer only a very small additive benefit while occasionally producing life-threatening harm? (One could argue, in fact, that the two scenarios presented are both overly optimistic, since few if any screening tests actually affect overall, rather than disease-specific, mortality, and because there are very few conditions where an NSAID actually provides any advantage over acetaminophen.) Physicians are taught, right from the start of medical school, that medical care is a powerful weapon to be used in fighting disease. This is of course in some ways true. They are also taught that harm can occur with all sorts of individual treatments. But this is typically little more than an afterthought; medical thinking generally precedes along the lines of "what shall we do (as safely as possible, of course"), rather than "should we do something?" That is to say, while we acknowledge the possibility of harm, we viscerally believe ­ and have taught patients also to believe ­ that doing something should be the default choice whenever a patient is sick … and often even before they are actually sick. We rely on concepts of "disease" that are in fact only risk factors, and find reassurance in "successful" treatment of surrogate markers, even when (as is the rule, rather than the exception) such success is unassociated with any change in patient-oriented outcomes. We have internalized ­ and again, led patients to believe almost as a matter of faith ­ a number of truly dangerous myths about healthcare, such as "earlier is better" (and more is always better), "technology will solve all our problems," "miracles are right around the corner," "once we identify genetic risk factors there will be a perfect tailored treatment for each of us," and ultimately ­ if we're only clever enough … and spend enough ­ death will soon be optional. Quaternary prevention, or P4, offers a new paradigm, by insisting that medical harm is far from a trivial, or secondary, concern. It tells us that preventing harm from medical interventions ­ which has been proven to be a major cause of death and disability in "advanced" societies ­ deserves equal consideration as does preventing harm from disease. This is different than the commonly cited "first do no harm," which is commonly misunderstood to mean "don't do anything that could cause harm." P4, on the other hand, acknowledges the critical fact that everything we do in health care can cause harm ­ so refusing to do anything that isn't perfectly safe would mean never doing anything! That would be a terrible mistake, as medicine does indeed have a great deal to offer. But in helping patients make decisions we, and they, must consider the potential for harm every bit as prominently as we consider the potential for benefit. Furthermore, by asking, "should we do something," we don't actually mean "do nothing." We can always offer support, and comfort, and symptomatic care ­ for all of which the number needed to treat to benefit one patient … approaches one. (Compare that to most chronic disease treatments, where the NNT is at least 100 … which means that with such "treatment" the likelihood that any given individual will benefit is in fact remote.) Acknowledging this in our heads is only a tiny first step; if we want to reverse a milieu where "medicine's much hailed ability to help the sick is fast being challenged by its propensity to harm the healthy,"1 we must incorporate, into the very DNA of medical education, and practice, P4's simple and obvious, but also revolutionary, admonishment ­ that doing what we can to prevent medical harm must become one of the pillars of modern healthcare. Only when we viscerally incorporate this into our practice will we become worthy contributors to truly rational shared decision-making with our patients.

Impact of a randomized controlled educational trial to improve physician practice behaviors around screening for inherited breast cancer.

BACKGROUND: Many primary care physicians (PCPs) are ill-equipped to provide screening and counseling for inherited breast cancer. OBJECTIVE: To evaluate the outcomes of an interactive web-based genetics curriculum versus text curriculum for primary care physicians. DESIGN: Randomized two-group design. PARTICIPANTS: 121 California and Pennsylvania community physicians. INTERVENTION: Web-based interactive genetics curriculum, evaluated against a control group of physicians who studied genetics review articles. After education, physicians interacted with an announced standardized patient (SP) at risk for inherited breast cancer. MAIN MEASURES: Transcripts of visit discussions were coded for presence or absence of 69 topics relevant to inherited breast cancer. KEY RESULTS: Across all physicians, history-taking, discussions of test result implications, and exploration of ethical and legal issues were incomplete. Approximately half of physicians offered a genetic counseling referral (54.6%), and fewer (43.8%) recommended testing. Intervention physicians were more likely than controls to explore genetic counseling benefits (78.3% versus 60.7%, P = 0.048), encourage genetic counseling before testing (38.3% versus 21.3%, P = 0.048), ask about a family history of prostate cancer (25.0% versus 6.6%, P = 0.006), and report that a positive result indicated an increased risk of prostate cancer for male relatives (20.0% versus 1.6%, P = 0.001). Intervention-group physicians were less likely than controls to ask about Ashkenazi heritage (13.3% versus 34.4%, P = 0.01) or to reply that they would get tested when asked, "What would you do?" (33.3% versus 54.1%, P = 0.03). CONCLUSIONS: Physicians infrequently performed key counseling behaviors, and this was true regardless of whether they had completed the web-based interactive training or read clinical reviews.

A comparison of Web-based and small-group palliative and end-of-life care curricula: a quasi-randomized controlled study at one institution.

PURPOSE: Few studies have compared the effect of Web-based eLearning versus small-group learning on medical student outcomes. Palliative and end-of-life (PEOL) education is ideal for this comparison, given uneven access to PEOL experts and content nationally. METHOD: In 2010, the authors enrolled all third-year medical students at the University of California, Davis School of Medicine into a quasi-randomized controlled trial of Web-based interactive education (eDoctoring) compared with small-group education (Doctoring) on PEOL clinical content over two months. Students participated in three 3-hour PEOL sessions with similar content. Outcomes included a 24-item PEOL-specific self-efficacy scale with three domains (diagnosis/treatment [Cronbach alpha=0.92; CI: 0.91-0.93], communication/prognosis [alpha=0.95; CI: 0.93-0.96], and social impact/self-care [alpha=0.91; CI: 0.88-0.92]); 8 knowledge items; 10 curricular advantage/disadvantages; and curricular satisfaction (both students and faculty). RESULTS: Students were randomly assigned to Web-based eDoctoring (n=48) or small-group Doctoring (n=71) curricula. Self-efficacy and knowledge improved equivalently between groups (e.g., prognosis self-efficacy, 19%; knowledge, 10%-42%). Student and faculty ratings of the Web-based eDoctoring curriculum and the small-group Doctoring curriculum were equivalent for most goals, and overall satisfaction was equivalent for each, with a trend toward decreased eDoctoring student satisfaction. CONCLUSIONS: Findings showed equivalent gains in self-efficacy and knowledge between students participating in a Web-based PEOL curriculum in comparison with students learning similar content in a small-group format. Web-based curricula can standardize content presentation when local teaching expertise is limited, but it may lead to decreased user satisfaction.

Physician communication regarding prostate cancer screening: analysis of unannounced standardized patient visits.

PURPOSE: Prostate cancer screening with prostate-specific antigen (PSA) is a controversial issue. The present study aimed to explore physician behaviors during an unannounced standardized patient encounter that was part of a randomized controlled trial to educate physicians using a prostate cancer screening, interactive, Web-based module. METHODS: Participants included 118 internal medicine and family medicine physicians from 5 health systems in California, in 2007-2008. Control physicians received usual education about prostate cancer screening (brochures from the Center for Disease Control and Prevention). Intervention physicians participated in the prostate cancer screening module. Within 3 months, all physicians saw unannounced standardized patients who prompted prostate cancer screening discussions in clinic. The encounter was audio-recorded, and the recordings were transcribed. Authors analyzed physician behaviors around screening: (1) engagement after prompting, (2) degree of shared decision making, and (3) final recommendations for prostate cancer screening. RESULTS: After prompting, 90% of physicians discussed prostate cancer screening. In comparison with control physicians, intervention physicians showed somewhat more shared decision making behaviors (intervention 14 items vs control 11 items, P <.05), were more likely to mention no screening as an option (intervention 63% vs control 26%, P <.05), to encourage patients to consider different screening options (intervention 62% vs control 39%, P <.05) and seeking input from others (intervention 25% vs control 7%, P<.05). CONCLUSIONS: A brief Web-based interactive educational intervention can improve shared decision making, neutrality in recommendation, and reduce PSA test ordering. Engaging patients in discussion of the uses and limitations of tests with uncertain value can decrease utilization of the tests.

Pairing physician education with patient activation to improve shared decisions in prostate cancer screening: a cluster randomized controlled trial.

BACKGROUND: Most expert groups recommend shared decision making for prostate cancer screening. Most primary care physicians, however, routinely order a prostate-specific antigen (PSA) test with little or no discussion about whether they believe the potential benefits justify the risk of harm. We sought to assess whether educating primary care physicians and activating their patients to ask about prostate cancer screening had a synergistic effect on shared decision making, rates and types of discussions about prostate cancer screening, and the physician's final recommendations. METHODS: Our study was a cluster randomized controlled trial among primary care physicians and their patients, comparing usual education (control), with physician education alone (MD-Ed), and with physician education and patient activation (MD-Ed+A). Participants included 120 physicians in 5 group practices, and 712 male patients aged 50 to 75 years. The interventions comprised a Web-based educational program for all intervention physicians and MD-Ed+A patients compared with usual education (brochures from the Centers for Disease Control and Prevention). The primary outcome measure was patients' reported postvisit shared decision making regarding prostate cancer screening; secondary measures included unannounced standardized patients' reported shared decision making and the physician's recommendation for prostate cancer screening. RESULTS: Patients' ratings of shared decision making were moderate and did not differ between groups. MD-Ed+A patients reported that physicians had higher prostate cancer screening discussion rates (MD-Ed+A = 65%, MD-Ed = 41%, control=38%; P <.01). Standardized patients reported that physicians seeing MD-Ed+A patients were more neutral during prostate cancer screening recommendations (MD-Ed+A=50%, MD-Ed=33%, control=15%; P <.05). Of the male patients, 80% had had previous PSA tests. CONCLUSIONS: Although activating physicians and patients did not lead to significant changes in all aspects of physician attitudes and behaviors that we studied, interventions that involved physicians did have a large effect on their attitudes toward screening and in the discussions they had with patients, including their being more likely than control physicians to engage in prostate cancer screening discussions and more likely to be neutral in their final recommendations.

Pharmaceutical sales representatives and patient safety: a comparative prospective study of information quality in Canada, France and the United States.

INTRODUCTION: The information provided by pharmaceutical sales representatives has been shown to influence prescribing. To enable safe prescribing, medicines information must include harm as well as benefits. Regulation supports this aim, but relative effectiveness of different approaches is not known. The United States (US) and France directly regulate drug promotion; Canada relies on industry self-regulation. France has the strictest information standards. METHODS: This is a prospective cohort study in Montreal, Vancouver, Sacramento and Toulouse. We recruited random samples of primary care physicians from May 2009 to June 2010 to report on consecutive sales visits. The primary outcome measure was "minimally adequate safety information" (mention of at least one indication, serious adverse event, common adverse event, and contraindication, and no unqualified safety claims or unapproved indications). RESULTS: Two hundred and fifty-five physicians reported on 1,692 drug-specific promotions. "Minimally adequate safety information" did not differ: 1.7 % of promotions; range 0.9-3.0 % per site. Sales representatives provided some vs. no information on harm more often in Toulouse than in Montreal and Vancouver: 61 % vs. 34 %, OR = 4.0; 95 % CI 2.8-5.6, or Sacramento (39 %), OR = 2.4; 95 % CI 1.7-3.6. Serious adverse events were rarely mentioned (5-6 % of promotions in all four sites), although 45 % of promotions were for drugs with US Food and Drug Administration (FDA) "black box" warnings of serious risks. Nevertheless, physicians judged the quality of scientific information to be good or excellent in 901 (54 %) of promotions, and indicated readiness to prescribe 64 % of the time. DISCUSSION: "Minimally adequate safety information" did not differ in the US and Canadian sites, despite regulatory differences. In Toulouse, consistent with stricter standards, more harm information was provided. However, in all sites, physicians were rarely informed about serious adverse events, raising questions about whether current approaches to regulation of sales representatives adequately protect patient health.