2014 NAPCRG Annual Meeting Presentations with DFM faculty members as presenters, co-presenters or co-authors

8 Sessions

PP21 Describing Emerging Practice Concerning Vitamin D in Primary Care

John W. Epling Jr, MD, MSEd; Emily Mader, MPH, MPP; Carrie A. Roseamelia, MA; Christopher P. Morley, PhD

Introduction: The establishment of practice patterns concerning the diagnosis and management of hypovitaminosis D seem to be heterogeneous among primary care physicians. In response to member interest within the SALT-Net practice-based research network, we conducted a qualitative study to explore the emerging practices among primary care providers regarding screening and treatment for hypovitaminosis D, as well as factors that influence practice patterns. Methods and Analysis: Five focus groups were facilitated by trained researchers; participants were primary care providers recruited from within SALT-Net. Transcripts from focus group recordings were independently coded by two authors, followed by subsequent review of these codes by all other authors. The coding and analysis used a grounded theory approach. Atlas.ti™ analysis software was used to perform open coding and thematic analysis of focus group transcript data. Results: The majority of the 42 participants were practicing physicians. Testing or screening for hypovitaminosis D and subsequent replacement or supplementation practices varied. Demand for vitamin D screening is largely patient-driven, with patients being heavily influenced by media attention to vitamin D. Physicians appear to respond to this demand through three approaches: reflexive acceptance of testing and treatment; incorporation of testing as a diagnostic tool; or with skeptical caution. Conclusion: The formation of emerging practice concerning vitamin D appears to be constructed and reinforced by: patient demand; incidental reading; brief, purposeful research; conversations with colleagues; consultations by specialists; and more patient demand. To influence this practice, clear, authoritative guidelines and a significant amount of accompanying social marketing will be required.

ET35 R U 4 PC? Texting to Quantify Feedback and its Relationship With Student Career Interest

Andrea E Wudyka, MD; Andrea L. Wendling, MD; Julie P. Phillips, MD, MPH; Diane Levine; Elie Mulhem, MD; Anne Victoria Neale, PhD, MPH; Christopher P. Morley, PhD

Context: Medical students are often asked about career preferences; faculty and residents routinely offer feedback on this complex decision. Feedback may influence career decisions, but influence has not been quantitatively evaluated. Objective: To report incidence of positive and negative comments about primary care heard by medical students and determine effect of comments on primary care career interest. Design: Multicenter observational cohort study. Text messaging at point of contact and online surveys were used to examine incidence and balance of positive and negative feedback about primary care, as reported by medical students between September 2012 and April 2013. Settings: Wayne State University School of Medicine; Michigan State University College of Human Medicine; College of Medicine at SUNY Upstate Medical University. Participants: 139 medical students recruited from all enrolled students at participating universities. Participants randomized into three cohorts; post-randomization adjustments balanced gender, university, and class year distribution. Outcome Measures: Number and balance of positive and negative comments regarding primary care; relationship between feedback and medical students’ commitment to primary care careers. Results: 120 students (86.3%) participated in at least one texting period; 87 (62.6%) all aspects of study. Positive comments (851) outnumbered negative (616). Total negative comments reported per student was associated with a significant decrease in primary care interest (β= -.04, p=.014). There was a correlation between students’ negative-to-positive comment ratios and decreased primary care interest which approached significance (β= -.145, p=.084), but only became significant (β= -.191, p=.028) when variables including institution were added to linear regression model, supporting hypothesis that improving institutional culture toward primary care can positively influence graduates’ primary care interest. Conclusions: Negatively perceived comments about primary care were associated with a significant decrease in medical student interest in primary care. Quantitative real-time data supports the association between hidden curriculum about primary care and students’ career choices.

ET36 Teaching Cross-Cultural Communication Skills Online: A Mixed Method Evaluation of a Novel Curricular Element

Emily Mader, MPH, MPP; Amy L. Lee, MD; Christopher P. Morley, PhD

Context: Cultural competency is recognized as an important yet under-incorporated curricular component in medical education. Objective: To evaluate a novel cross-cultural communication skills online module, delivered in a family medicine clerkship, to teach use of questions that elucidate patient perceptions of reason for visit: How patient defines problem; how problem affects life; what concerns patient most about problem; and what treatment patient believes should occur (Problem-Affect on life –Concerns-Treatment, or PACT). Design: Mixed methods study with case-control block design comparing students assigned the online module vs. those with routine instruction and qualitative phase. Participants: Third-year medical students completing a family medicine clerkship at a US medical school. Main Outcome Measures: PACT-usage scores received in a standardized patient case. Student perceptions regarding use of PACT were measured through qualitative analysis of self-reflective essays composed by students receiving the online module. Results: Students participating in the online module asked more PACT questions during a communication-focused standardized patient encounter than those who received routine instruction (P=.049). The majority of students reflected positively on the PACT exercise and acknowledged the value of the model. Four themes emerged through analysis of self-reflective essays: 1. Communication – PACT questions facilitate increased, constructive communication with patients; 2. Student Development –PACT questions guided students toward a more patient-centered focus to patient care; 3. Improved Patient Outcomes –PACT questions revealed important information regarding etiology, treatment barriers, and patient knowledge gaps and misconceptions; and 4. Improved Patient Experience – the gains in communication made possible through PACT questions established a positive relationship between patient and provider. Conclusions: The cross-cultural communication skills module utilizing PACT questions effectively increased use of PACT questions, which in turn are perceived by the students as improving their ability to communicate with patients cross-culturally, and understand patient perceptions regarding medical concerns and treatment.

ET37 Essential Public Health Competencies for Medical Trainees: Toward Establishing a Consensus

Christopher P. Morley, PhD; Jacob P. Prunuske, MD, MSPH; Ranit Mishori, MD, MHS; Yumi Shitama Jarris, MD; William B. Jordan, MD, MPH; Scott Rosas PhD

Context: The integration of Public Health (PH) competency training into medical education, and further integration of public health and primary care, has been urged by the U.S. Institute of Medicine. However, PH competencies are numerous, and no consensus exists over which competencies are most important for adoption by current trainees. Objective: To conduct a mixed-methods group concept mapping exercise with stakeholders regarding the most crucial PH skills to incorporate in medical and residency curricula. Design: Group concept mapping exercise, where stakeholders complete the phrase, “A key Public Health competency for physicians-in-training to learn is...” with 1-10 statements. The statement list is edited for duplication and other issues; stakeholders then sort the statements and rate them for importance, feasibility of integration, and timing over medical education. Multidimensional scaling and cluster analysis are then employed to create a two-dimensional point map of domains of PH training, with ratings incorporated, allowing visual comparison of groupings of related ideas and relative importance of these ideas. Setting: National data collection effort, by invitation. Participants: Family Medicine (FM) educators, identified through the Society of Teachers of Family Medicine Group on Public Health Education. Additional informants from PH education practice were identified via snowball sampling. Instruments: The Concept System™ Global Max ( Outcome Measures: Concept maps of PH competencies for medical education; ratings of importance, feasibility, and timing for each competency and domain. Results: A total of 116 non-duplicative statements (225 total) were suggested by 120 participants. “Health Disparities” and “Prevention” were the most important and feasibly-taught domains, with “Reporting Role” identified as feasible but of moderate importance. Maps generated using FM only and PH only were fairly different. Conclusions: Not all PH competencies are equally regarded. There may be disunity between how FM and PH communities group and rate PH competencies for medical learners.

ET38 An Exploration of Social Mission Content in the Public Mission Statements of U.S. Medical Schools

Timothy Smilnak; Emily Mader, MPH, MPP; Jose E. Rodriguez, MD; Andrew Bazemore, MD, MPH; Kendall M. Campbell, MD; Christopher P. Morley, PhD; Stephen Petterson, PhD

Context: Medical school mission statements are highly variable, but often reflect underlying values held by institutions as they produce new physicians. Objective: To explore the relationship between U.S. medical school mission statement content and outcomes in terms of faculty composition and graduate career choices. Design: A panel of expert raters completed a web-based instrument, scoring the degree to which medical school mission statements reflect a social mission of medical education to address inequities, to create a linear scale of social mission content (SMC). The relationship between social mission scale and targeted medical school outputs were analyzed via OLS regression, controlling for allopathic/osteopathic and public/private school designation. Participants: Faculty, administrators, and students at US medical schools and related organizations. Main Outcome Measures: Percent physician output in primary care specialties; percent physician output in designated Health Professional Shortage Areas (HPSA) and Medically Underserved Areas/Populations (MUAP); percent female faculty employed at each medical school; percent of faculty at each medical school of racial subgroups. Results: 37 raters contributed to social mission score survey; resulting SM scale had high internal consistency (Cronbach’s α= 0.972). SMC was a significant predictor for percentage of family medicine (β=1.936, p=0.003), and nearly significant for pediatrics (β=0.297, p=.066), but not of general internal medicine physician output. SMC was also a significant predictor for graduates working in MUAP (β=4.256, p≤0.001), HPSA (β=1.737, p=0.042), (combined HPSA-MUAP (β=3.627, p≤0.001), and rural (β=2.041, p≤0.001) locations. Finally, SMC was a predictor of a higher percentage of African American faculty (β=4.4, p≤0.001). Conclusions: Medical schools that include a higher degree of content reflecting a social mission of medical education within their mission statements appear to have increased output of physicians working in underserved areas and in primary care. These schools may also employ a relatively larger number of minority faculty.

WS33 Using Short Message Service (SMS) Text Messaging to Collect Real-Time Data: A Methodological Example From the RU4PC Study

Christopher P. Morley, PhD; Andrea E Wudyka, MD; Andrea L. Wendling, MD; Julie P. Phillips, MD, MPH; Diane Levine; Elie Mulhem, MD; Anne Victoria Neale, PhD, MPH

Objectives: To describe the methods employed to collect and analyze short message service (SMS), or “text messaging,” data, using the RU4PC study as an example. Content: Instruction on an inexpensive method for using SMS to collect data, using a recently-completed study as an example. Methods: Didactic presentation followed by guided activity. Prerequisite Knowledge: A background in basic research design and basic statistics will be helpful, but not required. Audience: Researchers exploring methods for economical real-time data collection; we expect 20-30 early-stage researchers and a more limited number of advanced researchers to attend. Rationale: Collecting data from research subjects in real-time (i.e. as a process is occurring) can be challenging, expensive, and methodologically complex. The RU4PC study recently used SMS text messaging to collect instances of primary care bashing in medical education observed by students. Although the example study was conducted in the context of medical education, the methods could be used with patients, community members, and a variety of other contexts. Schedule: The first ten minutes of the workshop will include an overall introduction to the objectives of the workshop and an outline of the example project. The next 30 minutes of the session will cover the basics of a) examples of research questions that can be addressed; b) use of free services to collect texting data (such as Google Voice); c) the aggregation of SMS data, and integration with other types of data, for analysis; d) potential analytic methods that can be employed; e) problems and solutions related to SMS data collection; and f) protection of subjects and their data. Participants will then take part in a 30-minute exercise to demonstrate rapid live data collection and preparation for analysis. The final 20 minutes will be devoted to open question/answer dialogue.

BP43 A Systematic Review of Ashwagandha as a Treatment for Anxiety and Stress

Morgan A Pratte; Kaushal B Nanavati, MD; Virginia Young, MLS; Christopher P. Morley, PhDContext: Ashwagandha (Withania somnifera-WS) is an Ayurvedic herb that has gained increasing recognition and use as an alternative treatment for anxiety and stress. Objectives: To determine the scope of clinical testing on Ashwagandha for anxiety and stress, and to examine the outcomes of these trials. Design: Systematic review of the literature, with searches conducted in PubMed, SCOPUS, CINHAL, and Google Scholar by a medical librarian. Search terms included “Ashwagandha” or “Withania somnifera” and mental health term combinations. Citation searching was performed by a research assistant, in addition to the database overview. Inclusion criteria: human randomized controlled trials (RCTs) with a treatment arm that included WS as a remedy for anxiety or stress. The study team members applied inclusion criteria while screening the records by abstract review. Intervention: Regimens of WS. Main Outcome Measures: Number and results of studies identified in the review. Results: 62 abstracts were screened; 5 human trials met inclusion criteria. Three studies compared several dosage levels of WS extract with placebos using versions of the Hamilton Anxiety Scale (HAM), with two demonstrating significant benefit of WS vs. placebo, and the third demonstrating beneficial effects that approached but did not achieve significance at p=.05. In a fourth study comparing naturopathic care with WS vs. psychotherapy using utilizing Beck Anxiety Inventory (BAI) scores as an outcome, BAI scores decreased by 56.5% in the WS group, compared with a 30.5% decrease for psychotherapy (p<.0001). A fifth study measured changes in Perceived Stress Scale (PSS) scores in WS group vs. placebo, and found a 44.0% reduction in the WS group, vs. 5.5% reduction in PSS scores for placebo (p<0.0001). Conclusions: All five studies concluded that WS intervention resulted in greater score improvements (significantly in most cases) than placebo when assessing scores on anxiety and/or stress scales.

HD45 The Effect of State-Level Tobacco Control Measures on Adult Smoking Rate: Analysis of Cross-Sectional Time Series Data of State Smoking Rates and ALA Graded Tobacco-Control Measures

Emily Mader, MPH, MPP; Morgan A Pratte; Emilija Postolovska, MPH; Thomas Carr; Christopher P. Morley, PhD

Context: Every state in the U.S. employs a variety of population-level tobacco controls measures (TCMs), including excise taxation, smoking restrictions, and cessation program funding, counter-advertising, and tobacco marketing restrictions. The level of TCM implementation varies across each state and by year, and is graded for each category of measures by the American Lung Association (ALA), using the “State of Tobacco Control” (SOTC) grading framework. Objective: To assess the effect of each SOTC-graded measure on adult smoking rate in each U.S. state. Design: Examination of relative effects of state TCMs on adult smoking rates from 2008-2012, using time-series cross-sectional linear regression of publicly available data. Setting and Participants: The 50 U.S. states, excluding territories, districts and possessions. Interventions: State smoking restrictions as measured through the ALA Smokefree Air Score; state cessation coverage through public and private insurance as measured through the ALA Cessation Coverage Score; state-level tobacco prevention and control spending, both as dollars spent and percent of CDC recommended funding level; and cigarette excise tax rates. Main Outcome Measures: Adult smoking rate in each state from 2008 to 2012. Results: Strongest predictors of state adult smoking rate are the level of state smoking restrictions (ALA Smokefree Air Score) (β = -0.447, p = 0.002) and state excise tax rates (β = -0.267, p = .051). For each of these variables, ALA grade moved inversely from adult smoking rate. Other tested state TCMs were not statistically significant predictors of the adult smoking rate. Conclusions: Results corroborate the findings of previous investigation into the impact of state TCMs on the adult smoking rate across 50 states. More expansive implementation of state smoking restrictions and increased cigarette excise tax rates have the strongest statewide impacts on the adult smoking rate.