Working adeptly to diagnose and treat adult ADHD.

Rely on DSM-5 criteria and an appropriate rating scale to assess how an individual's inattention, hyperactivity, and impulsivity interfere with functioning in different settings.

Behavioral science education and the international medical graduate.

PURPOSE: International medical graduates (IMGs), many of whom are recent immigrants to the United States, are filling an increasing proportion of U.S. family medicine residency positions. Therefore, assumptions about the training experiences of first-year residents may no longer apply to a large percentage of incoming residents. The authors sought to improve the behavioral science education in their residency program by learning about IMGs' previous training and experience in behavioral science before coming to the United States. METHOD: Ten first-, second-, and third-year family medicine residents, representing medical school training from India, Macedonia, Bosnia-Herzegovina, The Philippines, Egypt, and Iraq, were individually interviewed using an inductive, qualitative approach. Transcripts were reviewed and double coded. Categories and story lines were identified, and member checking was employed. RESULTS: Segments were classified into seven categories: residents' behavioral medicine training prior to coming to the United States; reflections on the inclusion of mental health and psychosocial content in clinical family medicine; training in medical interviewing; reflections on the physician-patient relationship; perceptions of U.S. family life; recommendations for improving IMGs' understanding of psychosocial aspects of patient care; and specific challenges residents face as IMGs. CONCLUSIONS: The narrative data suggested several possible modifications to the family medicine curriculum, including expanding new resident orientation content about U.S. health care, introducing behavioral science content sooner, and having IMGs observe quality physician-patient interactions. Interview data also yielded concrete suggestions for improving residents' psychiatric interview knowledge and skills, such as instruction in specific wording of questions.

"It's like playing with your destiny": Bosnian immigrants' views of advance directives and end-of-life decision-making.

Patient autonomy is a primary value in US health care. It is assumed that patients want to be fully and directly informed about serious health conditions and want to engage in advance planning about medical care at the end-of-life. Written advance directives and proxy decision-makers are vehicles to promote autonomy when patients are no longer able to represent their wishes. Cross-cultural studies have raised questions about the universal acceptance of these health care values among all ethnicities. In the current investigation, Bosnian immigrants were interviewed about their views of physician-patient communication, advance directives, and locus of decision-making in serious illness. Many of the respondents indicated that they did not want to be directly informed of a serious illness. There was an expressed preference for physician- or family-based health care decisions. Advance directives and formally appointed proxies were typically seen as unnecessary and inconsistent with many respondents' personal values. The findings suggest that the value of individual autonomy and control over the health care decisions may not be applicable to cultures with a collectivist orientation.

Cultural diversity at the end of life: issues and guidelines for family physicians.

Ethnic minorities currently compose approximately one third of the population of the United States. The U.S. model of health care, which values autonomy in medical decision making, is not easily applied to members of some racial or ethnic groups. Cultural factors strongly influence patients' reactions to serious illness and decisions about end-of-life care. Research has identified three basic dimensions in end-of-life treatment that vary culturally: communication of "bad news"; locus of decision making; and attitudes toward advance directives and end-of-life care. In contrast to the emphasis on "truth telling" in the United States, it is not uncommon for health care professionals outside the United States to conceal serious diagnoses from patients, because disclosure of serious illness may be viewed as disrespectful, impolite, or even harmful to the patient. Similarly, with regard to decision making, the U.S. emphasis on patient autonomy may contrast with preferences for more family-based, physician-based, or shared physician- and family-based decision making among some cultures. Finally, survey data suggest lower rates of advance directive completion among patients of specific ethnic backgrounds, which may reflect distrust of the U.S. health care system, current health care disparities, cultural perspectives on death and suffering, and family dynamics. By paying attention to the patient's values, spirituality, and relationship dynamics, the family physician can elicit and follow cultural preferences.