Background: Over the past 30 years, patients' options for accessing information about prescription drugs have expanded dramatically. In this narrative review, we address four questions: (1) What information sources are patients exposed to, and are they paying attention? (2) Is the information they hear credible and accurate? (3) When patients ask for a prescription, what do they really want and need? Finally, (4) How can physicians reconcile what patients hear, want, and need?. Analysis. A critical synthesis of the literature is reported. Observations indicate that the public is generally aware of and attends to a growing body of health information resources, including traditional news media, advertising, and social networking. However, lay audiences often have no reliable way to assess the accuracy of health information found in the media, on the Internet, or in direct-to-consumer advertising. This inability to assess the information can lead to decision paralysis, with patients questioning what is known, what is knowable, and what their physicians know. Many patients have specific expectations for the care they wish to receive and have little difficulty making those expectations known. However, there are hazards in assuming that patients' expressed desires are direct reflections of their underlying wants or needs. In trying to reconcile patients' wants and needs for information about prescription medicines, a combination of policy and clinical initiatives may offer greater promise than either approach alone. Conclusions: Patients are bombarded by information about medicines. The problem is not a lack of information; rather, it is knowing what information to trust. Making sure patients get the medications they need and are prepared to take them safely requires a combination of policy and clinical interventions. © 2013 Kravitz and Bell; licensee BioMed Central Ltd.

Background. Specialty-specific data on career satisfaction may be useful for understanding physician workforce trends and for counseling medical students about career options. Methods. We analyzed cross-sectional data from 6,590 physicians (response rate, 53%) in Round 4 (2004-2005) of the Community Tracking Study Physician Survey. The dependent variable ranged from +1 to -1 and measured satisfaction and dissatisfaction with career. Forty-two specialties were analyzed with survey-adjusted linear regressions. Results. After adjusting for physician, practice, and community characteristics, the following specialties had significantly higher satisfaction levels than family medicine: pediatric emergency medicine (regression coefficient = 0.349); geriatric medicine (0.323); other pediatric subspecialties (0.270); neonatal/prenatal medicine (0.266); internal medicine and pediatrics (combined practice) (0.250); pediatrics (0.250); dermatology (0.249);and child and adolescent psychiatry (0.203). The following specialties had significantly lower satisfaction levels than family medicine: neurological surgery (-0.707); pulmonary critical care medicine (-0.273); nephrology (-0.206); and obstetrics and gynecology (-0.188). We also found satisfaction was significantly and positively related to income and employment in a medical school but negatively associated with more than 50 work-hours per-week, being a full-owner of the practice, greater reliance on managed care revenue, and uncontrollable lifestyle. We observed no statistically significant gender differences and no differences between African-Americans and whites. Conclusion. Career satisfaction varied across specialties. A number of stakeholders will likely be interested in these findings including physicians in specialties that rank high and low and students contemplating specialty. Our findings regarding "less satisfied" specialties should elicit concern from residency directors and policy makers since they appear to be in critical areas of medicine. © 2009 Leigh et al; licensee BioMed Central Ltd.

Background: Current interventions to enhance patient self-efficacy, a key mediator of health behavior, have limited primary care application. Objective: To explore the effectiveness of an office-based intervention for training resident physicians to use self-efficacy-enhancing interviewing techniques (SEE IT). Design: Randomized controlled trial. Participants: Family medicine and internal medicine resident physicians (N∈=∈64) at an academic medical center. Measurements: Resident use of SEE IT (a count of ten possible behaviors) was coded from audio recordings of the physician-patient portion of two standardized patient (SP) instructor training visits and two unannounced post-training SP visits, all involving common physical and mental health conditions and behavior change issues. One post-training SP visit involved health conditions similar to those experienced in training, while the other involved new conditions. Results: Experimental group residents demonstrated significantly greater use of SEE IT than controls, starting after the first training visit and sustained through the final post-training visit. The mean effect of the intervention was significant [adjusted incidence rate ratio for increased use of SEE IT∈=∈1.94 (95% confidence interval = 1.34, 2.79; p∈<∈0.001)]. There were no significant effects of resident gender, race/ethnicity, specialty, training level, or SP health conditions. Conclusions: SP instructors can teach resident physicians to apply SEE IT during SP office visits, and the effects extend to health conditions beyond those used for training. Future studies should explore the effects of the intervention on practicing physicians, physician use of SEE IT during actual patient visits, and its influence on patient health behaviors and outcomes.

Background: The appropriateness and cost-effectiveness of screening mammography (SM) for women younger than 50 and older than 74 years is debated in the clinical research community, among health care providers, and by the American public. This study explored primary care physicians' (PCPs) perceptions of the influence of clinical practice guidelines for SM; the recommendations for SM in response to hypothetical case scenarios; and the factors associated with perceived SM effectiveness and recommendations in the US from June to December 2009 before the United States Preventive Services Task Force (USPSTF) recently revised guidelines. Methods. A nationally representative sample of 11,922 PCPs was surveyed using a web-based questionnaire. The response rate was 5.7% (684); (41%) 271 family physicians (FP), (36%) 232 general internal medicine physicians (IM), (23%) 150 obstetrician-gynaecologists (OBG), and (0.2%) 31 others. Cross-sectional analysis examined PCPs perceived effectiveness of SM, and recommendation for SM in response to hypothetical case scenarios. PCPs responses were measured using 4-5 point adjectival scales. Differences in perceived effectiveness and recommendations for SM were examined after adjusting for PCPs specialty, race/ethnicity, and the US region. Results: Compared to IM and FP, OBG considered SM more effective in reducing breast cancer mortality among women aged 40-49 years (p = 0.003). Physicians consistently recommended mammography to women aged 50-69 years with no differences by specialty (p = 0.11). However, 94% of OBG "always recommended" SM to younger and 86% of older women compared to 81% and 67% for IM and 84% and 59% for FP respectively (p = <.001). In ordinal regression analysis, OBG specialty was a significant predictor for perceived higher SM effectiveness and recommendations for younger and older women. In evaluating hypothetical scenarios, overall PCPs would recommend SM for the 80 year woman with CHF with a significant variation by specialty (38% of OBG, 18% of FP, 17% of IM; p = <.001). Conclusions: A majority of physicians, especially OBG, favour aggressive breast cancer screening for women from 40 through 79 years of age, including women with short life expectancy. Policy interventions should focus on educating providers to provide tailored recommendations for mammography based on individualized cancer risk, health status, and preferences. © 2012 Yasmeen et al; licensee BioMed Central Ltd.

Background

Healthcare worker attitudes toward obese individuals facilitate discrimination and contribute to poor health outcomes. Previous studies have demonstrated medical student bias toward obese individuals, but few have examined effects of the educational environment on these prejudicial beliefs. We sought to determine whether an innovative educational intervention (reading a play about obesity) could diminish obesity prejudice relative to a standard medical lecture.

Methods

We conducted a randomized, controlled trial enrolling medical students (n = 129) from three universities. Students were assigned to play-reading or a standard lecture. Explicit attitudes and implicit bias toward obese individuals were assessed prior to intervention and after four months.

Results

At baseline, students demonstrated moderate explicit and implicit bias toward obese people despite high scores on empathy. Students randomized to the play-reading group had significantly decreased explicit fat bias (P = 0.01) at follow-up, while students in the lecture group showed increased endorsement of a prescriptive model of care at the expense of a patient-centered approach (P = 0.03). There was a significant increase in empathy for those in both the theater (P = 0.007) and lecture group (P = 0.02). The intervention had no significant effect on implicit bias or regard for obesity as a civil rights issue.

Discussion

Dramatic reading may be superior to traditional medical lectures for showcasing patient rights and preferences. The present study demonstrates for the first time that play-reading diminishes conscious obesity bias. Further research should determine whether nontraditional methods of instruction promote improved understanding of and care for obese patients.

Background: Cancer-related pain is common and under-treated. This article describes a study designed to test the effectiveness of a theory-driven, patient-centered coaching intervention to improve cancer pain processes and outcomes. Methods/Design: The Cancer Health Empowerment for Living without Pain (Ca-HELP) Study is an American Cancer Society sponsored randomized trial conducted in Sacramento, California. A total of 265 cancer patients with at least moderate pain severity (Worst Pain Numerical Analog Score >=4 out of 10) or pain-related impairment (Likert score >= 3 out of 5) were randomly assigned to receive tailored education and coaching (TEC) or educationally-enhanced usual care (EUC); 258 received at least one follow-up assessment. The TEC intervention is based on social-cognitive theory and consists of 6 components (assess, correct, teach, prepare, rehearse, portray). Both interventions were delivered over approximately 30 minutes just prior to a scheduled oncology visit. The majority of visits (56%) were audio-recorded for later communication coding. Follow-up data including outcomes related to pain severity and impairment, self-efficacy for pain control and for patient-physician communication, functional status and well-being, and anxiety were collected at 2, 6, and 12 weeks. Discussion: Building on social cognitive theory and pilot work, this study aims to test the hypothesis that a brief, tailored patient activation intervention will promote better cancer pain care and outcomes. Analyses will focus on the effects of the experimental intervention on pain severity and impairment (primary outcomes); self-efficacy and quality of life (secondary outcomes); and relationships among processes and outcomes of cancer pain care. If this model of coaching by lay health educators proves successful, it could potentially be implemented widely at modest cost. © 2009 Kravitz et al; licensee BioMed Central Ltd.

BACKGROUND: Chronic pain is prevalent, costly, and clinically vexatious. Clinicians typically use a trial-and-error approach to treatment selection. Repeated crossover trials in a single patient (n-of-1 trials) may provide greater therapeutic precision. N-of-1 trials are the most direct way to estimate individual treatment effects and are useful in comparing the effectiveness and toxicity of different analgesic regimens. The goal of the PREEMPT study is to test the 'Trialist' mobile health smartphone app, which has been developed to make n-of-1 trials easier to accomplish, and to provide patients and clinicians with tools for individualizing treatments for chronic pain. METHODS/DESIGN: A randomized controlled trial is being conducted to test the feasibility and effectiveness of the Trialist app. A total of 244 participants will be randomized to either the Trialist app intervention group (122 patients) or a usual care control group (122 patients). Patients assigned to the Trialist app will work with their clinicians to set up an n-of-1 trial comparing two pain regimens, selected from a menu of flexible options. The Trialist app provides treatment reminders and collects data entered daily by the patient on pain levels and treatment side effects. Upon completion of the n-of-1 trial, patients review results with their clinicians and develop a long-term treatment plan. The primary study outcome (comparing Trialist to usual care patients) is pain-related interference with daily functioning at 26 weeks. DISCUSSION: Trialist will allow patients and clinicians to conduct personalized n-of-1 trials. In prior studies, n-of-1 trials have been shown to encourage greater patient involvement with care, which has in turn been associated with better health outcomes. mHealth technology implemented using smartphones may offer an efficient means of facilitating n-of-1 trials so that more patients can benefit from this approach. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02116621 , first registered 15 April 2014.

Background: Communication about prognosis and treatment choices is essential for informed decision making in advanced cancer. This article describes an investigation designed to facilitate communication and decision making among oncologists, patients with advanced cancer, and their caregivers.Methods/design: The Values and Options in Cancer Care (VOICE) Study is a National Cancer Institute sponsored randomized controlled trial conducted in the Rochester/Buffalo, NY and Sacramento, CA regions. A total of 40 oncologists, approximately 400 patients with advanced cancer, and their family/friend caregivers (one per patient, when available) are expected to enroll in the study. Drawing upon ecological theory, the intervention uses a two-pronged approach: oncologists complete a multifaceted tailored educational intervention involving standardized patient instructors (SPIs), and patients and caregivers complete a coaching intervention to facilitate prioritizing and discussing questions and concerns. Follow-up data will be collected approximately quarterly for up to three years.Discussion: The intervention is hypothesized to enhance patient-centered communication, quality of care, and patient outcomes. Analyses will examine the effects of the intervention on key elements of physician-patient-caregiver communication (primary outcomes), the physician-patient relationship, shared understanding of prognosis, patient well-being, and health service utilization (secondary outcomes).Trial registration: Clinical Trials Identifier: NCT01485627. © 2013 Hoerger et al.; licensee BioMed Central Ltd.