An evaluation of a positive youth development program for adolescents with chronic illness.

PURPOSE: Youth with chronic illness often struggle transitioning to adulthood and adult medical care. This article examines the outcomes of a group mentoring program called The Adolescent Leadership Council (TALC) that brings together high school participants and college mentors, all with chronic illness. TALC uses a positive youth development (PYD) approach, emphasizing strong relationships between youth and adults in an environment where youth can learn important life skills and take a leadership role. METHODS: A pre-/postprogram participant survey was conducted for high school participants using a loneliness scale and a transition readiness survey. An alumni survey was conducted with all high school and college mentor graduates to assess educational-, vocational-, and health care-related outcomes. RESULTS: Program records review and the alumni survey indicated that TALC was consistent with the PYD program model. Twenty high school students participated in the pre-/postprogram outcomes evaluation, which demonstrated a decrease in loneliness from 46 to 38.5 (p < .001) and an increase in health care self-advocacy from 3.8 to 4.2 (p < .001). Thirty-four alumni participated in the alumni survey. All high school and college mentor alumni had graduated from high school and college, respectively, and all were either currently in school or working. The majority of alumni were seeing adult providers for medical care. CONCLUSIONS: The TALC program applies the principles of PYD to support positive educational, vocational, and health care outcomes for youth with chronic illness. Program development using the PYD perspective is an important new approach for supporting adult development of youth with chronic illness.

Teaching Advanced Leadership Skills in Community Service (ALSCS) to medical students.

Inadequate access to health care, lack of health insurance, and significant health disparities reflect crises in health care affecting all of society. Training U.S. physicians to possess not only clinical expertise but also sufficient leadership skills is essential to solve these problems and to effectively improve health care systems. Few models in the undergraduate medical curriculum exist for teaching students how to combine needed leadership competencies with actual service opportunities.The Advanced Leadership Skills in Community Service (ALSCS) selective developed in response to the shortage of leadership models and leadership training for medical students. The ALSCS selective is designed specifically to increase students' leadership skills, with an emphasis on community service. The selective integrates classroom-based learning, hands-on application of learned skills, and service learning. More than 60 medical students have participated in the selective since inception. Short-term outcomes demonstrate an increase in students' self-efficacy around multiple dimensions of leadership skills (e.g., fundraising, networking, motivating others). Students have also successfully completed more than a dozen leadership and community service projects. The selective offers an innovative model of a leadership-skills-based course that can have a positive impact on leadership skill development among medical school students and that can be incorporated into the medical school curriculum.

Complementary and alternative medicine use by primary care patients with chronic pain.

OBJECTIVES: To describe the characteristics and attitudes toward complementary and alternative medicine (CAM) use among primary care patients with chronic pain disorders and to determine if CAM use is associated with better pain control. DESIGN: Cross-sectional survey. SUBJECTS: Four hundred sixty-three patients suffering from chronic, nonmalignant pain receiving primary care at 12 U.S. academic medical centers. OUTCOME MEASURE: Self-reported current CAM usage by patients with chronic pain disorders. RESULTS: The survey had an 81% response rate. Fifty-two percent reported current use of CAM for relief of chronic pain. Of the patients that used CAM, 54% agreed that nontraditional remedies helped their pain and 14% indicated that their individual alternative remedy entirely relieved their pain. Vitamin and mineral supplements were the most frequently used CAM modalities. There was no association between reported use of CAM and pain severity, functional status, or perceived self-efficacy. Patients who reported having at least a high school education (odds ratio [OR] 1.1, 95% confidence interval [CI] 1.02-1.19, P = 0.016) and high levels of satisfaction with their health care (OR 1.47, 95% CI 1.13-1.91, P = 0.004) were significantly more likely to report using CAM. CONCLUSIONS: Complementary and alternative therapies were popular among patients with chronic pain disorders surveyed in academic primary care settings. When asked to choose between traditional therapies or CAM, most patients still preferred traditional therapies for pain relief. We found no association between reported CAM usage and pain severity, functional status, or self-efficacy.

An innovative home-based interdisciplinary service-learning experience.

The University of North Carolina Mobile Student Health Action Coalition (UNC MSHAC) at Chapel Hill, North Carolina is a voluntary service-learning program in which interdisciplinary teams of graduate level health professional students provide monthly home visits to isolated, community-dwelling elders with complex medical and social issues. Students are mentored by UNC clinical faculty and retirees from the local community. Together, mentors and students generate action plans to improve the health and well-being of the participating elders. We report here the qualitative and quantitative results from our program evaluation demonstrating UNC MSHAC as an effective, service-learning model that compliments curricula, is satisfactory to students, and is a vehicle for academic institutions to serve elders in the local community.

When race matters: disagreement in pain perception between patients and their physicians in primary care.

Patients and physicians often disagree in their assessment of pain intensity. This study explores the impact of patient factors on underestimation of pain intensity in chronic noncancer pain. We surveyed patients and their physicians in 12 primary care centers. To measure pain intensity, patients completed an 11-point numeric rating scale for which pain scores range from 0 (no pain) to 10 (unbearable pain). Physicians rated patients' pain on the same scale. We defined disagreement of pain intensity as underestimation or overestimation by 22 points. Of 601 patients approached, 463 (77%) completed the survey. The majority of participants were black (39%) or white (47%), 67% were female, and the mean age was 53 years. Physicians underestimated pain intensity relative to their patients 39% of the time. Forty-six percent agreed with their patients' pain perception, and 15% of physicians overestimated their patients' pain levels by > or =2 points. In both the bivariate and multivariable models, black race was a significant variable associated with underestimation of pain by physicians (p < 0.05; OR = 1.92; 95% CI: 1.31-2.81). This study finds that physicians are twice as likely to underestimate pain in blacks patients compared to all other ethnicities combined. A qualitative study exploring why physicians rate blacks patients' pain low is warranted.

The impact of alternating dissection on student performance in a medical anatomy course: are dissection videos an effective substitute for actual dissection?

The way in which anatomy is taught to first year medical students at the University of North Carolina at Chapel Hill was recently changed, so that first year students are now divided into two groups that dissect alternately. The effect of this change on both written and practical test performance was analyzed by comparing grades from 2004 with those from the previous year (2003), when students performed all the dissections. A statistically significant decrease (P < or = 0.05) from 2003 was noted on three of the four written test scores in 2004, while practical examination scores in 2004 fluctuated from lower to higher than those in 2003, depending on the unit of material being covered. However, the number of students failing each of the examinations (written and practical combined) was statistically greater on only one of the four examinations in 2004. Scores of the two groups dissecting alternately in 2004 were essentially the same on the practical examinations. There was no difference in the number of questions answered incorrectly between these two groups in the two practical examinations where comparisons were made. Furthermore, students who dissected a particular structure did not score significantly better on practical questions concerning that structure than students who had not dissected it. The effect of the availability of step-by-step dissection videos on student practical examination scores is also discussed. We conclude that the change in the curriculum had a significant impact on the students' written examination performance, given the same material in the course. The reasons for this include student course load, increased need for self-study, and a loss of a learning opportunity in the dissection laboratory, all of which affect student comprehension and retention of the material and their ability to use it in problem solving.

Effectiveness of mailing "Bathing Without a Battle" to all US nursing homes.

An educational CD-ROM/video program was developed to educate nursing home staff about two research-based techniques for reducing agitation and aggression during bathing of persons with Alzheimer's disease, including person-centered showering and the towel bath. This educational program was distributed free of charge to all 15,453 US nursing homes in the Centers for Medicare and Medicaid Services database. The dissemination, use, and short-term outcomes were evaluated by extrapolating data collected by long-term care surveyors in three states; usage was further assessed by tracking the number of nursing home staff who registered for the continuing education credits associated with the program. The program's quality and content was evaluated by actual program users, who rated the program after completion. Short-term learning outcomes were assessed by examinations built into the CD-ROM. Evaluating a national innovation presented a set of unique challenges; yet, to date, our findings have revealed mostly favorable short-term outcomes in terms of its dissemination, usage, and educational value. The long-term outcomes of this educational program continue to be monitored.

Use of Web-based materials to enhance anatomy instruction in the health sciences.

Teaching anatomy by dissection is under considerable pressure to evolve and/or even be eliminated, and curricular hours in the dissection laboratory are decreasing. As a possible means of easing this pressure, an online interactive anatomy program has been created to enhance the dissection experience, observational learning, and three-dimensional comprehension of human anatomy. An assessment was made of the utility of the program in preparing students for dissection laboratories and for examinations. The efficacy of the application was evaluated by first-year students and faculty with pre- and post-use surveys in anatomy courses at three medical schools. It was found that students felt better prepared if they utilized the Web site prior to their dissection laboratory, and faculty reported spending less time explaining basic concepts or techniques. It is concluded that a comprehensive online program significantly enhances the quality and efficiency of instruction in human anatomy in the dissection laboratory and could prove to be a useful tool at other institutions.

The influence of discordance in pain assessment on the functional status of patients with chronic nonmalignant pain.

BACKGROUND: Chronic pain is a frequent cause of suffering and disability that seriously affects patients' quality of life and imposes a staggering socioeconomic toll on society. Little is known about the impact of patient-physician disagreement (discordance) regarding the assessment of chronic pain on patients' quality of life in primary care settings. This study evaluates the role of discordance and other potentially modifiable factors that affect the quality of life and functional status of chronic pain patients. METHODS: We evaluated 436 patient-physician encounters at 12 academic medical centers in the United States. We surveyed chronic nonmalignant pain patients to understand their pain perceptions. We concurrently surveyed their physicians about their perceptions of their patient's pain in primary care settings. RESULTS: More than 50% of physicians disagreed with their patient's pain. Thirty-nine percent of primary care physicians underestimated their patient's pain. In the multivariate analysis, this discordance was associated with poor physical functioning and worse bodily pain (P < 0.018 and P < 0.001 respectively). Patients with chronic, nonmalignant pain have reductions in physical function and bodily pain domains of the SF-36 compared to age-matched populations. Depression and obesity represented other associations. CONCLUSION: Patients with chronic nonmalignant pain have poor physical functioning and worse bodily pain. Discordance, obesity, and depression are other modifiable factors. Prospective studies are needed to design interventions. However, a multifaceted approach appears to represent the best opportunity to reduce the pain and suffering of this challenging population.

Racial differences in opioid use for chronic nonmalignant pain.

BACKGROUND: Chronic pain is a frequent cause of suffering and disability that negatively affects patients' quality of life. There is growing evidence that disparities in the treatment of pain occur because of differences in race. OBJECTIVE: To determine whether race plays a role in treatment decisions involving patients with chronic nonmalignant pain in a primary care population. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional survey was administered to patients with chronic nonmalignant pain and their treating physicians at 12 academic medical centers. We enrolled 463 patients with nonmalignant pain persisting for more than 3 consecutive months and the primary care physicians participating in their care. RESULTS: Analysis of the 397 black and white patients showed that blacks had significantly higher pain scores (6.7 on a scale of 0 to 10, 95% confidence interval (CI) 6.4 to 7.0) compared with whites (5.6, 95% CI 5.3 to 5.9); however, white patients were more likely to be taking opioid analgesics compared with blacks (45.7% vs 32.2%, P<.006). Even after controlling for potentially confounding variables, white patients were significantly more likely (odds ratio (OR) 2.67, 95% CI 1.71 to 4.15) to be taking opioid analgesics than black patients. There were no differences by race in the use of other treatment modalities such as physical therapy and nonsteroidal anti-inflammatories or in the use of specialty referral. CONCLUSION: Equal treatment by race occurs in nonopioid-related therapies, but white patients are more likely than black patients to be treated with opioids. Further studies are needed to better explain this racial difference and define its effect on patient outcomes.

Community-engaged scholarship: is faculty work in communities a true academic enterprise?

Since Ernest Boyer's landmark 1990 report, Scholarship Reconsidered: Priorities of the Professoriate, leaders in higher education, including academic medicine, have advocated that faculty members apply their expertise in new and creative ways in partnership with communities. Such community engagement can take many forms, including community-based teaching, research, clinical care, and service. There continues to be a gap, however, between the rhetoric of this idea and the reality of how promotion and tenure actually work in health professions schools. The Commission on Community-Engaged Scholarship in the Health Professions was established in October 2003 with funding from the W.K. Kellogg Foundation to take a leadership role in creating a more supportive culture and reward system for community-engaged faculty in the nation's health professions schools. The authors prepared this article to inform the commission's deliberations and to stimulate discussion among educators in the health professions. The authors define the work that faculty engage in with communities, consider whether all work by faculty in community-based settings is actually scholarship, and propose a framework for documenting and assessing community-engaged scholarship for promotion and tenure decisions. They conclude with recommendations for change in academic health centers and health professions schools.

Recognizing the value of community involvement by AHC faculty: a case study.

Physicians seek connections to their communities. Some health care and academic leaders believe that facilitating the creation of more such community connections is one way to reverse the trend of waning social and political legitimacy for the U.S. medical profession. For academic health centers (AHCs), such connections can maintain local and state support crucial to their long-term success. Multiple barriers exist to such involvement, especially for physicians in AHCs, where work done beyond direct patient care, administration, and research rarely contributes to the tenure and promotion process. The authors present a case study to show how one department in an AHC, beginning in the late 1990s, has been overcoming these barriers to incorporate the scholarship of community engagement into its mission and structure. The case study incorporates theoretical underpinnings to crystallize the following lessons that the department has learned so far: (1) If academic departments wish community service to be a central part of their mission, they need ways to institutionalize community engagement within organizational structures. (2) Community engagement can be scholarly. (3) If faculty members are to be recognized for their service activities, measures are necessary to determine what constitutes "excellence" and "scholarship" in community service. (4) Scholarship of community engagement goes beyond performing service activities in the community.

Community service by North Carolina family physicians.

BACKGROUND: Community service is an integral part of American society. Although Family Medicine advocates community service through community medicine, few data exist on family physicians' involvement in voluntary community service activities or roles as community advocates. METHODS: A questionnaire was mailed to 489 North Carolina family physicians, including a 20% random sample of those in community practice and all statewide faculty physicians. The survey assessed types and amount of volunteer activity, attitudes toward volunteer work, and factors that support or inhibit participation in community service. RESULTS: The overall response rate was 54%. Most respondents reported strong interests in community service before medical school and residency, yet few reported any relevant training during medical education. More than 85% of faculty and community practice family physicians reported participating in volunteer service in the previous year (70.8 mean hours for faculty vs 45.5 mean hours for community practice; P = .06). Family physicians also reported a wide variety of lifetime volunteer activities (mean number of different faculty physician activities 20.8 vs mean number of different community practice physician activities 16.7, P = .00). Less than 50% of both physician groups reported that their practice or program publicly supports those performing community service. CONCLUSIONS: The great majority of family physicians in North Carolina regularly participate in one or more volunteer community service activities, frequently without organizational recognition. Data about the scope of service expected by communities and provided by physicians may assist the discipline in clarifying the place of volunteer community service in medical education, promotion guidelines and practice.

Finding support for educational projects in anatomy: tips, tools, and lessons learned.

This article is based on a presentation of the same name given on 20 April 2004 at a symposium entitled "Faculty Development: Funding Resources for Education Projects" at the annual meeting of the American Association of Anatomists in Washington, DC. It discusses various lessons learned by the authors from their own work on the development of an educational tool and the assessment of its use with funding from an educational research grant, as well as tips and tools gathered from other education researchers. The material is organized into two sections. The first provides information and suggestions useful in the development of an educational project in anatomy and the preparation of the grant application. The second consists of insights that may help ensure that the funded grant is successful.

Institutional collaboration and competition in community-based education.

We sought to determine whether competition for community-based training sites exists among health professions schools, and to examine faculty and senior administrators' perspectives on institutional collaboration for community-based education. Eight academic health centers (AHCs) in the USA were selected by objective criteria for their significant community involvement. Chief executive officers, vice chancellors, deans, and the individuals responsible for community-based education, research and community service responded to written surveys. The overall response rate was 79% (n = 91). Responses were subjected to quantitative and qualitative analyses. Leaders of community-based education reported that "competition for community-based training sites" is a barrier to community involvement. "Competition for community-based training sites"was positively related to 'call for increasing percentage of graduates to enter primary care careers' (0.30, p < 0.01) and negative related to "collaboration exists between the community and your school/AHC" ( - 0.28, p < 0.05). Respondents reported that a moderate level of collaboration across schools exists. While medical school respondents reported having collaborative relationships with other health professions schools and with the community, nursing respondents reported medicine's performance at a significantly lower level. Public health and nursing faculty reported that they are competing with medical schools for sites they had traditionally used for their students. Competition for sites is an unintended outcome of the increased emphasis on community-based education in health professions curricula. We recommend AHCs form joint committees across schools to effectively address community-based sites as a limited resource, and to consider a wider range of community-based organizations as training partners.

Health professional faculty perspectives on community-based research: implications for policy and practice.

Community-based research (CBR) has become central to the understanding and elimination of health disparities within the USA and across the globe. The authors sought to determine the perspectives of health professional faculty on the factors affecting their involvement in CBR and the extent of community participation in that research. Faculty from 18 health professional schools in the USA identified by their deans as being leaders in CBR completed a written survey. Respondents reported that between 5-10% of faculty in their schools were involved in CBR. Public perception of the university, familiarity with community-based organization leaders and institutional leadership were cited as the most significant factors contributing to a school's involvement in CBR. Long-term community relationships, recognition in tenure and promotion policies and access to funding were cited as factors that support faculty in conducting CBR. The authors conclude that a more significant investment of public and private funds, the development of interdisciplinary institutional structures for community partnerships and a more inclusive definition of scholarship are needed to achieve a central role for CBR in efforts to understand and eliminate health disparities.

Structure and culture of schools of public health to support academic public health practice.

Schools of public health have been cautioned about producing graduates and research that were disconnected from public interest. Although institutions may implement a variety of strategies to rectify the situation, institutional structural and cultural barriers impede progress. Public health practice coordinators in accredited schools of public health were surveyed to describe the presence of structural and cultural barriers to academic public health practice using the Stevens model. Administrative leadership and faculty reward systems are described as critical to advance academic public health practice.

Forces affecting community involvement of AHCs: perspectives of institutional and faculty leaders.

PURPOSE: To understand the external and internal factors that either facilitated or were barriers to an academic health center's (AHC's) involvement in community-based education, research, and clinical care; community service; and community or economic development activities. METHOD: Eight AHCs in the United States were selected by objective criteria for their significant community involvement. Chief executive officers, vice chancellors, deans, and the individuals responsible for community-based education, research, and community service responded to written surveys. Responses were subjected to quantitative and qualitative analyses. RESULTS: The overall response rate was 79% (n = 91). Public perception, an increased focus on a population health perspective, and an increased call for AHCs to be accountable to local and statewide constituents were cited as the most significant external factors contributing to an AHC's community involvement. Institutional leadership, familiarity with community-based organizations, institutional climate, faculty and student interest, and institutional structures were cited as the most significant internal facilitators of community involvement. Fiscal concerns, competition for community-based training sites, lack of collaboration across health professions schools, and inadequate faculty roles and rewards were viewed as the most significant barriers to community involvement. All respondents reported that their AHCs' orientations towards community service, and community-based teaching, research, and clinical care would increase in the next five years. CONCLUSION: Development of a strategic plan may increase the effectiveness of an institution's community involvement. Central to this plan should be a restructuring of faculty roles and reward polices and an increase in faculty release time to promote community involvement. The importance of involving the community in the planning and implementation of community-campus partnerships should not be underestimated.