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Biomedical subjects

P Adam Kelly

Publications and source records attributed to P Adam Kelly.

13 recordsLinked to original sources
PubMed2006

Physician overestimation of patient literacy: a potential source of health care disparities.

OBJECTIVE: To investigate physician overestimation of patient literacy level in a primary care setting. METHODS: The study sample consisted of 12 non-academic primary care physicians and 100 patients from a U.S. Department of Veterans Affairs Hospital in Houston, Texas. Patient literacy level was measured on a 1-4 scale using the Rapid Estimate of Adult Literacy in Medicine (REALM). Physicians rated each patient's literacy level on a corresponding scale. Chi-square was used to test for association of patient race/ethnicity and gender with: (1) patient REALM level and (2) discrepancy between patient REALM level and physician rating of patient literacy level. RESULTS: Patient REALM level was not statistically significantly associated with patient race/ethnicity or gender. Physicians overestimated the REALM level for 54% of African American, 11% of white non-Hispanic, and 36% of other race/ethnicity patients (p<.01). CONCLUSION: Physicians commonly overestimate patients' literacy levels, and this apparently occurs more often with minority patients, and particularly with African Americans, than with white non-Hispanic patients. This discordance in estimation of patient's literacy level may be a source of disparities in health care.

Black or African American↗
PubMed2006

Racial differences in trust and lung cancer patients' perceptions of physician communication.

PURPOSE: Black patients report lower trust in physicians than white patients, but this difference is poorly studied. We examined whether racial differences in patient trust are associated with physician-patient communication about lung cancer treatment. PATIENTS AND METHODS: Data were obtained for 103 patients (22% black and 78% white) visiting thoracic surgery or oncology clinics in a large Southern Veterans Affairs hospital for initial treatment recommendation for suspicious pulmonary nodules or lung cancer. Questionnaires were used to determine patients' perceptions of the quality of the physicians' communication and were used to assess patients' previsit and postvisit trust in physician and trust in health care system. Patients responded on a 10-point scale. RESULTS: Previsit trust in physician was statistically similar in black and white patients (mean score, 8.2 v 8.3, respectively; P = .80), but black patients had lower postvisit trust in physician than white patients (8.0 v 9.3, respectively; P = .02). Black patients, compared with white patients, judged the physicians' communication as less informative (7.3 v 8.5, respectively; P = .03), less supportive (8.1 v 9.3, respectively; P = .03), and less partnering (6.4 v 8.2, respectively; P = .001). In mixed linear regression analysis, controlling for clustering of patients by physician, patients' perceptions of physicians' communication were statistically significant (P < .005) predictors of postvisit trust, although patient race, previsit trust, and patient and visit characteristics were not significant (P > .05) predictors. CONCLUSION: Perceptions that physician communication was less supportive, less partnering, and less informative accounted for black patients' lower trust in physicians. Our findings raise concern that black patients may have lower trust in their physicians in part because of poorer physician-patient communication.

Adult↗
PubMed2006

Nutritional status is altered in the self-neglecting elderly.

Elder self-neglect is the most common form of elder mistreatment. Individuals who cannot provide basic needs for themselves may develop social, functional, and physical deficits. The systematic characterization of self-neglecting individuals is the goal of the Consortium for Research in Elder Self-Neglect of Texas project. This study reports on the nutritional status of self-neglecting elderly. Self-neglectors (SN) were recruited based on referrals along with matched control (CN) subjects. Data are for 40 SN subjects (age 76 +/- 7 y) and 40 CN subjects (76 +/- 7 y). Blood samples were collected and analyzed for indices of nutritional status. SN subjects had a greater serum concentration of total homocysteine than CN subjects (13.6 +/- 4.5 vs. 11.6 +/- 5.6 micromol/L, P < 0.05) and a lower concentration of red blood cell folate (1380 +/- 514 vs. 1792 +/- 793 nmol/L, P < 0.05). Plasma beta-carotene and alpha-tocopherol were lower in SN subjects (0.28 +/- 0.2 vs. 0.43 +/- 0.33 micromol/L; 23.2 +/- 9.3 vs. 27.8 +/- 9.3 micromol/L, P < 0.05). SN subjects had a lower serum concentration of 25-hydroxyvitamin D than CN subjects (33.7 +/- 16.4 vs. 44.1 +/- 19.6 nmol/L, P < 0.05). These differences in markers of nutritional status show that the self-neglecting elderly are at risk for altered nutritional status, particularly of folate, antioxidants, and vitamin D. Evaluation of these data in relation to other functional and cognitive assessments are critical for evaluating the relation between nutrition and self-neglect.

Aged↗
PubMed2006

Not the same everywhere. Patient-centered learning environments at nine medical schools.

BACKGROUND: Learning environments overtly or implicitly address patient-centered values and have been the focus of research for more than 40 years, often in studies about the "hidden curriculum." However, many of these studies occurred at single medical schools and used time-intensive ethnographic methods. This field of inquiry lacks survey methods and information about how learning environments differ across medical schools. OBJECTIVE: To examine patient-centered characteristics of learning environments at 9 U.S. medical schools. DESIGN: Cross-sectional internet-based survey. PARTICIPANTS: Eight-hundred and twenty-three third- and fourth-year medical students in the classes of 2002 and 2003. MEASUREMENTS: We measured the patient-centeredness of learning environments with the Communication, Curriculum, and Culture (C3) Instrument, a 29-item validated measure that characterizes the degree to which a medical school's environment fosters patient-centered care. The C3 Instrument contains 3 content areas (role modeling, students' experiences, and support for students' patient-centered behaviors), and is designed to measure these areas independent of respondents' attitudes about patient-centered care. We also collected demographic and attitudinal information from respondents. RESULTS: The variability of C3 scores across schools in each of the 3 content areas of the instrument was striking and statistically significant (P values ranged from .001 to .004). In addition, the patterns of scores on the 3 content areas differed from school to school. CONCLUSIONS: The 9 schools demonstrated unique and different learning environments both in terms of magnitude and patterns of characteristics. Further multiinstitutional study of hidden curricula is needed to further establish the degree of variability that exists, and to assist educators in making informed choices about how to intervene at their own schools.

Adult↗
PubMed2005

Ethnic variation in knee replacement: patient preferences or uninformed disparity?

BACKGROUND: Despite the efficacy and cost-effectiveness of total knee replacement (TKR), minority patients with knee osteoarthritis (OA) are half as likely as their white counterparts to undergo this procedure. Patient preferences may play a large role in the variations in utilization of TKR. We evaluated the preferences and beliefs of patients with knee OA from diverse ethnic backgrounds in relation to TKR. METHODS: The 198 patients with knee OA surveyed were of different ethnicities. Patients were asked about physician recommendations of TKR and whether they had considered having the procedure, their perceptions about the benefits and risks of TKR, their expectations if they were to undergo the procedure, and their trust in physicians and the health system. Bivariate and multivariate analyses were performed. RESULTS: A physician had discussed TKR with 27% of African Americans, 15% of whites, and 11% of Hispanics (P = .04). White patients were more likely than minority patients to have considered undergoing TKR (P = .04), more likely to consider TKR if their OA worsened and the procedure were recommended by their physician (P = .002), and more likely to consider TKR as a beneficial procedure (P = .02). Ethnic differences in preferences remained after controlling for severity of OA. CONCLUSIONS: Ethnic minority patients with knee OA are less likely to consider TKR. In our study, these differences were not related to physician recommendation biases. The ethnic variation in preferences was associated with differences in perception of benefit, lack of personal experiences with TKR, and trust.

Black or African American↗
PubMed2005

Physician-patient communication following invasive procedures: an analysis of post-angiogram consultations.

Although rarely studied, physician-patient interactions immediately following diagnostic tests are significant medical events because during these encounters the physician and patient often make decisions about major and sometimes invasive treatment. This investigation analyzed patterns of physician-patient communication following coronary angiography with particular attention to behaviors important to decision-making: physician information-giving, physician use of partnership-building, and active forms of patient participation (e.g., asking questions, being assertive, expressing concerns). We were particularly interested in effects related to the patient's race in light of documented evidence of racial disparities in cardiac care and outcomes. From audiotape recordings, 93 physician-patient interactions after coronary angiogram in a catheterization laboratory in a large US Veterans Affairs Medical Center were coded to measure the frequency of physicians' information-giving and partnership-building and the frequency of active patient participation. We also stratified these behaviors according to whether the behavior was prompted (e.g., physician information in response to a patient's question; a patient's opinion solicited by the doctor) or self-initiated. Several findings were noteworthy. First, these interactions were very brief and dominated by the physician. Second, although physician information-giving increased with more active patient participation, which in turn was correlated with physicians' use of partnership-building, proportionally little of the physicians' information (8%) and active patient participation (9%) was directly prompted by the other interactant. Finally, there was a tendency for physicians to self-initiate less information giving to black patients and for black patients to self-initiate less active participation than white patients. Although these differences were attenuated when other variables (e.g., the physician's training, disease severity) were included in the analysis, the pattern suggests a potential cycle of passivity where certain patients tend to receive fewer informational resources and these patients in turn do less to prompt the doctor for more.

Assertiveness↗
PubMed2005

Characterizing the patient-centeredness of hidden curricula in medical schools: development and validation of a new measure.

PURPOSE: The "hidden curriculum" has a powerful influence in shaping medical students' attitudes and behaviors toward patient care. The purpose of this project was to develop and test a tool (the C(3) Instrument) to help educators characterize and understand the hidden curriculum at their own institutions. METHOD: In 2000, the authors developed survey items to measure three content areas of the hidden curriculum with respect to patient-centered care. These content areas include role modeling, students' patient-care experiences, and perceived support for students' own patient-centered behaviors. The survey was distributed to third- and fourth-year students at ten medical schools in the United States. Using factor analysis, the authors selected items for the final version of the C(3) Instrument. To examine validity, they compared instrument scores to results of a poll of members of two organizations devoted to teaching patient-centered care. RESULTS: A total of 890 students completed the survey. The mean age of students was 27 (SD 3). Fifty-two percent of students were women, and 70% were white. Twenty-nine items were selected for the C(3) Instrument, with internal consistency measures ranging from .67 to .93 for instrument subdimensions. In the validation analysis, summary scores for all three content areas of the C(3) Instrument were consistent with results of the poll of patient-centered organizations. CONCLUSION: Despite some issues that still need to be resolved, the C(3) Instrument proved to be a reliable and valid tool that characterizes a medical school's hidden curriculum with respect to patient-centered care. It can be used to guide educational interventions by addressing the context that exists around formal teaching activities. It also makes possible the study of hidden curricula across multiple medical schools. Further research on the hidden curriculum should be aimed at developing a greater understanding of the dynamics between formal teaching activities and school culture.

Clinical Competence↗
PubMed2005

Integrating validity theory with use of measurement instruments in clinical settings.

OBJECTIVE: To present validity concepts in a conceptual framework useful for research in clinical settings. PRINCIPAL FINDINGS: We present a three-level decision rubric for validating measurement instruments, to guide health services researchers step-by-step in gathering and evaluating validity evidence within their specific situation. We address construct precision, the capacity of an instrument to measure constructs it purports to measure and differentiate from other, unrelated constructs; quantification precision, the reliability of the instrument; and translation precision, the ability to generalize scores from an instrument across subjects from the same or similar populations. We illustrate with specific examples, such as an approach to validating a measurement instrument for veterans when prior evidence of instrument validity for this population does not exist. CONCLUSIONS: Validity should be viewed as a property of the interpretations and uses of scores from an instrument, not of the instrument itself: how scores are used and the consequences of this use are integral to validity. Our advice is to liken validation to building a court case, including discovering evidence, weighing the evidence, and recognizing when the evidence is weak and more evidence is needed.

Data Collection↗
PubMed2005

Conceptualizing and categorizing race and ethnicity in health services research.

OBJECTIVES: Veterans Affairs (VA) patient populations are becoming increasingly diverse in race and ethnicity. The purpose of this paper is to (1) document the importance of using consistent standards of conceptualizing and categorizing race and ethnicity in health services research, (2) provide an overview of different methods currently used to assess race and ethnicity in health services research, and (3) suggest assessment methods that could be incorporated into health services research to ensure accurate assessment of disease prevalence and incidence, as well as accounts of appropriate health services use, in patients with different racial and ethnic backgrounds. DESIGN: A critical review of published literature was used. PRINCIPAL FINDINGS: Race is a complex, multidimensional construct. For some individuals, institutionalized racism and internalized racism are intertwined in the effects of race on health outcomes and health services use. Ethnicity is most commonly used as a social-political construct and includes shared origin, shared language, and shared cultural traditions. Acculturation appears to affect the strength of the relationships among ethnicity, health outcomes, and health services use. CONCLUSIONS: Improved and consistent methods of data collection need to be developed for use by VA researchers across the country. VA research sites with patients representing specific population groups could use a core set of demographic items in addition to expanded modules designed to assess the ethnic diversity within these population groups. Improved and consistent methods of data collection could result in the collection of higher-quality data, which could lead to the identification of race- and ethnic-specific health services needs. These investigations could in turn lead to the development of interventions designed to reduce or eliminate these disparities.

Acculturation↗
PubMed2005

A comparison of in-class learner engagement across lecture, problem-based learning, and team learning using the STROBE classroom observation tool.

BACKGROUND: Having recently introduced team learning into the preclinical medical curriculum, evidence of the relative impact of this instructional method on in-class learner engagement was sought. PURPOSE: To compare patterns of engagement behaviors among learners in class sessions across 3 distinct instructional methods: lecture, problem-based learning (PBL), and team learning. METHODS: Trained observers used the STROBE classroom observation tool to measure learner engagement in 7 lecture, 4 PBL, and 3 team learning classrooms over a 12-month period. Proportions of different types of engagement behaviors were compared using chi-square. RESULTS: In PBL and team learning, the amount of learner-to-learner engagement was similar and much greater than in lecture, where most engagement was of the learner-to-instructor and self-engagement types. Also, learner-to-instructor engagement appeared greater in team learning than in PBL. CONCLUSIONS: Observed engagement behaviors confirm the potential of team learning to foster engagement similar to PBL, but with greater faculty input.

Behavior↗
PubMed2003

Team learning in medical education: initial experiences at ten institutions.

PURPOSE: In the midst of curricular reforms that frequently call for reducing lectures and increasing small-group teaching, there is a crisis in faculty time for teaching. This paper describes the initial experiences of ten institutions with team learning (TL), a teaching method which fosters small-group learning in a large-class setting. METHOD: After initial pilot studies at one institution, nine additional institutions implemented TL in one or more courses. RESULTS: Within 18 months, TL has been used in 40 courses (from.5% to 100% of the time) and all ten institutions will increase its use next year. CONCLUSIONS: We surmise that this relatively rapid spread of TL into the medical curriculum is due to the sound pedagogy and efficiency of TL as well as the modest financial resources and support we have provided to partner institutions.

Curriculum↗
PubMed2003

Validation of an observation instrument for measuring student engagement in health professions settings.

Documenting student engagement has received increased emphasis in medical schools, as teaching strategies are changing to include more student-to-student interactions. The purpose of this study was to develop and evaluate a measure of student engagement completed by independent observers that would not interfere with student learning time. Data from 3,182 observations completed by nine observers in 32 educational classroom settings with 23 different instructors were used to evaluate the interobserver reliability and gather validity evidence for our observational instrument, named the STROBE. Results indicated that interobserver agreement was good to excellent when observations were conducted simultaneously on randomly selected students in the same classroom (84% average agreement and 0.79 average kappa coefficient) and when observations were conducted on different randomly selected students (79% average agreement). Results also provided strong evidence for validity. Overall, findings indicate that the STROBE demonstrates promise for educational research and evaluation by documenting student engagement in medical education settings.

Health Occupations↗