Residency Program Directors' Views on Research Conducted During Medical School: A National Survey.

PURPOSE: With the United States Medical Licensing Examination Step 1 transition to pass/fail in 2022, uncertainty exists regarding how other residency application components, including research conducted during medical school, will inform interview and ranking decisions. The authors explore program director (PD) views on medical student research, the importance of disseminating that work, and the translatable skill set of research participation. METHOD: Surveys were distributed to all U.S. residency PDs and remained open from August to November 2021 to query the importance of research participation in assessing applicants, whether certain types of research were more valued, productivity measures that reflect meaningful research participation, and traits for which research serves as a proxy. The survey also queried whether research would be more important without a numeric Step 1 score and the importance of research vs other application components. RESULTS: A total of 885 responses from 393 institutions were received. Ten PDs indicated that research is not considered when reviewing applicants, leaving 875 responses for analysis. Among 873 PDs (2 nonrespondents), 358 (41.0%) replied that meaningful research participation will be more important in offering interviews. A total of 164 of 304 most competitive specialties (53.9%) reported increased research importance compared with 99 of 282 competitive (35.1%) and 95 of 287 least competitive (33.1%) specialties. PDs reported that meaningful research participation demonstrated intellectual curiosity (545 [62.3%]), critical and analytical thinking skills (482 [55.1%]), and self-directed learning skills (455 [52.0%]). PDs from the most competitive specialties were significantly more likely to indicate that they value basic science research vs PDs from the least competitive specialties. CONCLUSIONS: This study demonstrates how PDs value research in their review of applicants, what they perceive research represents in an applicant, and how these views are shifting as the Step 1 exam transitions to pass/fail.

Provider and Staff Morale, Job Satisfaction, and Burnout over a 4-Year Medical Home Intervention.

BACKGROUND: The patient-centered medical home (PCMH) is a widely adopted primary care model. However, it is unclear whether changes in provider and staff perceptions of clinic PCMH capability are associated with changes in provider and staff morale, job satisfaction, and burnout in safety net clinics. OBJECTIVE: To determine how provider and staff PCMH ratings changed under a multi-year PCMH transformation initiative and assess whether changes in provider and staff PCMH ratings were associated with changes in morale, job satisfaction, and burnout. DESIGN: Comparison of baseline (2010) and post-intervention (2013-2014) surveys. SETTING: Sixty clinics in five states. PARTICIPANTS: Five hundred thirty-six (78.2%) providers and staff at baseline and 589 (78.3%) post-intervention. INTERVENTION: Collaborative learning sessions and on-site coaching to implement PCMH over 4 years. MEASUREMENTS: Provider and staff PCMH ratings on 0 (worst) to 100 (best) scales; percent of providers and staff reporting good or better morale, job satisfaction, and freedom from burnout. RESULTS: Almost half of safety net clinics improved PCMH capabilities from the perspective of providers (28 out of 59, 47%) and staff (25 out of 59, 42%). Over the same period, clinics saw a decrease in the percentage of providers reporting high job satisfaction (- 12.3% points, p = .009) and freedom from burnout (- 10.4% points, p = .006). Worsened satisfaction was concentrated among clinics that had decreased PCMH rating, with those clinics seeing far fewer providers report high job satisfaction (- 38.1% points, p < 0.001). LIMITATIONS: Control clinics were not used. Individual-level longitudinal survey administration was not feasible. CONCLUSION: If clinics pursue PCMH transformation and providers do not perceive improvement, they may risk significantly worsened job satisfaction. Clinics should be aware of this potential risk of PCMH transformation and ensure that providers are aware of PCMH improvements.

Activity Tracking Devices in Group Prenatal Care: A Feasibility Study.

To evaluate the feasibility (adherence to the study protocol and satisfaction) of using an activity tracking device (ATD) in group prenatal care. Women participated if they (1) were in group prenatal care, (2) owned a smartphone, and (3) had no activity restrictions. Women were instructed to wear and sync the ATD daily. Protocol adherence and satisfaction were assessed via surveys. Mixed models assessed the relationship between gestational age and ATD data. Self-reported energy expenditure from the Pregnancy Physical Activity Questionnaire (PPAQ) was compared with ATD-calculated energy expenditure. The baseline characteristics of the 49 women were as follows: 24 years old, prepregnancy body mass index 28, 80% Hispanic, 86% nulliparas, and 21 weeks of gestation. Of the 30 women who completed the follow-up survey, 47% self-reported wearing the ATD daily, 27% reported a lost or broken ATD, and 22% reported technical problems; however, 97% enjoyed wearing it, 100% would recommend it to a pregnant friend, and 77% thought it helped them reach activity goals. According to ATD data, the median active days were 47 (interquartile range [IQR] 21-79) and the median proportion of active days of potential days was 43.7% (IQR 15.4-77.1). For women who wore the ATD for the first 7 days, mean steps/day were 7574 (range 3076-15,828), active minutes/day were 277 (range 145-475), and sedentary hours/day were 12 (range 7.8-16.2). As gestational age increased, mean log steps decreased, mean active minutes decreased, and mean sedentary hours increased in unadjusted and adjusted models (p < 0.001 all comparisons). There were no differences in mean energy expenditure (MET-h/week) by PPAQ or ATD data at 28 weeks of gestation [231 (62-927 range) vs. 238 (212-290 range), p = 0.74] and at 36 weeks of gestation [145 (35-581 range) vs. 222 (196-272 range), p = 0.27]. Most women reported high satisfaction with an ATD in group prenatal care, yet adherence to the study protocol was low and ATD technical problems were common. As gestational age increased, activity decreased while sedentary time increased, suggesting that additional research is needed to find ways to engage women in physical activity during pregnancy.

Patients' Future Expectations for Diabetes and Hypertension Treatments: "Through the Diet I Think This is Going to Go Away."

BACKGROUND: Diabetes and hypertension are chronic conditions for which over 90 % of patients require medication regimens that must be intensified over time. However, delays in intensification are common, and may be partially due to unrealistic patient expectations. OBJECTIVE: To explore whether patient expectations regarding their diabetes and hypertension are congruent with the natural history of these conditions. DESIGN: Qualitative analysis of semi-structured interviews. PARTICIPANTS: Sixty adults from an urban academic primary care clinic taking oral medications for both diabetes (duration <10 years) and hypertension (any duration) MAIN MEASURES: (1) Expectations for their a) current diabetes and hypertension medications, b) need for additional medications, c) likelihood of cure (not requiring medications); (2) preferences for receiving information on expected duration of treatments KEY RESULTS: The average patient age was 60 years, and 65 % were women. Nearly half (48 %) of participants expected to discontinue current diabetes medications in 6 years or less, whereas only one-fifth (22 %) expected to take medications for life. For blood pressure medications, one-third (37 %) expected to stop medicines in 6 years or less, and one-third expected to take medicines for life. The vast majority did not expect that they would need additional medications in the future (oral diabetes medications: 85 %; insulin: 87 %; hypertension medications: 93 %). A majority expected that their diabetes (65 %) and hypertension (58 %) would be cured. Most participants believed that intensifying lifestyle changes would allow them to discontinue medications, avoid additional medications, or cure their diabetes and hypertension. Nearly all participants (97 %) wanted to hear information on the expected duration of their diabetes and hypertension treatments from their healthcare provider. CONCLUSIONS: Providers should educate patients on the natural history of diabetes and hypertension in order to manage patient expectations for current and future medications. Future research should assess whether education can increase the adoption of and adherence to medications, without diminishing enthusiasm for lifestyle changes.

How information about the time requirements and legacy effects of treatments influence decision-making in patients with diabetes and hypertension.

OBJECTIVE: When deciding about diabetes treatments, patients are typically uninformed about how much time is required before (time requirements), or for how long treatments change outcomes (legacy effects). However, patients may be motivated to adopt treatments with time-related treatment information. We explored whether this information alters a patients' likelihood of starting medications. RESEARCH DESIGN AND METHODS: We conducted semistructured interviews with 60 adults with type 2 diabetes for <10 years and hypertension on oral medications. We measured change in likelihood of starting medications after receiving time requirement (diabetes, 10 years; hypertension, 3 years) and legacy effect (diabetes, 10 additional years; hypertension, none) information. Responses were analyzed for themes about time-related treatment information. RESULTS: At baseline, 70% of participants reported being very likely to start a recommended medication. Nearly half (40%) were less likely to start a diabetes medication after being informed of time requirements; but after being informed of legacy effects, 32% reported being more likely. Fewer participants changed likelihoods of starting antihypertensives with time-related information. Many participants expressed that medications' benefits were important to them regardless of time-related information. Participants considered time requirements for diabetes medications too long and compared them to their life expectancy. Many participants were interested in legacy effects of diabetes medications because they looked forward to discontinuing medications, although some expressed doubt that benefits could persist after stopping medications. CONCLUSIONS: While prolonged time requirements may dissuade patients from adopting treatments, the promise of legacy effects may motivate patients to commit to diabetes treatments.

Revisiting Disparities in Quality of Care Among US Adults With Diabetes in the Era of Individualized Care, NHANES 2007-2010.

BACKGROUND: Diabetes quality of care standards promote uniform goals and are used routinely for performance measurement and reimbursement. Diabetes health disparities have been characterized using these universal goals. However, guidelines emphasize individualized goals. OBJECTIVES: To assess diabetes care disparities using individualized goals to (1) determine their racial/ethnic distribution and (2) compare disparities using individualized versus uniform goals. RESEARCH DESIGN, SUBJECTS, AND MEASURES: A nationally representative sample of non-Hispanic white, non-Hispanic black, and Hispanic adults with self-reported diabetes aged 20 years or more in the National Health and Nutrition Examination Survey, 2007-2010. Individualized glycemic goals (A1C<6.5%, <7.0%, or <8.0%) assigned based on age, duration, complications, and comorbidity, and cholesterol goals [low-density lipoprotein cholesterol (LDL) <70 or <100 mg/dL] assigned based on cardiovascular history. RESULTS: More Hispanics were recommended an individualized A1C<7.0% compared with whites (54% vs. 42%, P=0.008). Fewer blacks and Hispanics were recommended an individualized LDL<70 mg/dL than whites (21% and 19% vs. 28%, P=0.02 and 0.001). Fewer Hispanics had adequate individualized A1C control (56% vs. 68%, P<0.001), and fewer blacks and Hispanics had adequate individualized LDL control (31% and 36% vs. 51%, P≤0.001 and P=0.004). A uniform A1C<7% goal did not reveal disparities in glycemic control; individualized A1C and LDL, blood pressure <140/90 mm Hg, and nonsmoking was achieved by few adults (18%), and fewer blacks and Hispanics than whites (6% and 11% vs. 22%, P<0.001 and P=0.005). CONCLUSIONS: Individualized goals for diabetes care may unearth greater racial/ethnic disparities in clinical performance compared with uniform goals. Diabetes performance measures should include individualized goals to prevent worsening disparities in diabetes outcomes.

Medical home characteristics and the pediatric patient experience.

BACKGROUND: The patient-centered medical home (PCMH) has roots in pediatrics, yet we know little about the experience of pediatric patients in PCMH settings. OBJECTIVE: To examine the association between clinic PCMH characteristics and pediatric patient experience as reported by parents. RESEARCH DESIGN: We assessed the cross-sectional correlation between clinic PCMH characteristics and pediatric patient experience in 24 clinics randomly selected from the Safety Net Medical Home Initiative, a 5-state PCMH demonstration project. PCMH characteristics were measured with surveys of randomly selected providers and staff; surveys generated 0 (worst) to 100 (best) scores for 5 subscales, and a total score. Patient experience was measured through surveying parents of pediatric patients. Questions from the Consumer Assessment of Healthcare Providers and Systems-Clinician and Group instrument produced 4 patient experience measures: timeliness, physician communication, staff helpfulness, and overall rating. To investigate the relationship between PCMH characteristics and patient experience, we used generalized estimating equations with an exchangeable correlation structure. RESULTS: We included 440 parents and 214 providers and staff in the analysis. Total PCMH score was not associated with parents' assessment of patient experience; however, PCMH subscales were associated with patient experience in different directions. In particular, quality improvement activities undertaken by clinics were strongly associated with positive ratings of patient experience, whereas patient care management activities were associated with more negative reports of patient experience. CONCLUSIONS: Future work should bolster features of the PCMH that work well for patients while investigating which PCMH features negatively impact patient experience, to yield a better patient experience overall.