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Purpose The purpose of this study was to determine whether 'clinical inertia'--inadequate intensification of therapy by the provider--could contribute to high A1C levels in patients with type 2 diabetes managed [...]

I and my colleagues designed and implemented a longitudinal faculty development program to improve humanistic teaching and role modeling at 30 medical schools involving more than 1,000 faculty members and 50 local facilitators. Evaluation demonstrated that participating faculty members who completed our program were superior humanistic teachers compared to controls as rated by their learners on a validated questionnaire. Participants were also sufficiently engaged to attend 80% or more of the curricular sessions with few dropouts, indicating the feasibility and generalizability of the program. Preliminary analysis of participants' personal narratives at the beginning compared to the end of our program suggested advancement in professional identity formation. I provide examples of the narratives and discuss future studies addressing this topic. [ABSTRACT FROM AUTHOR]

Intercollegiate athletics has come under increasing scrutiny. Questions of leadership and the NCAA's Presidents' Commission reflect new levels of exposure and commitment to clean the athletic house. The problem of defining the academic/athletic balance in big-time college sports has polarized faculty, administrators, and athletic leaders at many colleges and universities. The purpose of this study was to examine athletic director and selected assistant perceptions of leader behavior to determine whether their perceptions contributed significantly to the prediction of intercollegiate organizational effectiveness. Findings indicate that effective athletic organizations have leaders who are more predisposed to goal and task accomplishment than to developing good interpersonal relationships with their subordinates. Contemporary leader- ship theory and management philosophy suggests that organizations that can accomplish both are most effective. Athletic directors may want to adjust their leadership behaviors to meet the managerial demands of today's inter- collegiate athletic program. [ABSTRACT FROM AUTHOR]

One way practitioners learn ethics is by reflecting on experience. They may reflect in the moment (reflection-in-action) or afterwards (reflection-on-action). We illustrate how a teaching clinician may transform relationships with patients and teach person-centered care through reflective learning. We discuss reflective learning pedagogies and present two case examples of our preferred method, guided group reflection using narratives. This method fosters moral development alongside professional identity formation in students and advanced learners. Our method for reflective learning addresses and enables processing of the most pressing ethical issues that learners encounter in practice. [ABSTRACT FROM AUTHOR]

Patients want to be treated humanely and as individuals by their care-providers. Many curricula, usually written by university faculty, have been developed to teach physicians such skills. Rarely are patients' actual preferences taken into account when designing curricula. This study was undertaken to identify what hospitalized patients most valued about their encounters with attending faculty physicians. In this study, medical residents (post-graduate medical trainees) identified faculty physicians as outstanding teachers of humanistic care. Patients receiving care from these outstanding physicians were interviewed, as were the students and residents on the care team and the study physicians. Using qualitative techniques, patients' comments were analyzed and common themes were identified. These findings were compared with qualities identified by medical residents and students and by the attending physicians themselves. Patients identified the following specific behaviors as those they most valued in their physicians: direct communication, understanding, direct involvement in care, adequate explanation, and overt expressions of respect, as highly valued. Outstanding teachers of humane care exhibited several discrete behaviors that patients described as valuable. Since these behaviors can be discretely identified, they can be taught as part of medical curricula. The content of medical education in communication and doctor-patient relationships should incorporate goals informed by the perspectives of patients. [ABSTRACT FROM AUTHOR]

Although traditional cardiovascular risk factors 'prime the soil' for atherogenesis systemically, atherosclerosis primarily occurs in a site-specific manner with a predilection towards the inner wall of curvatures and outer wall of bifurcations with sparing of flow-dividers. Wall shear stress is a frictional force exerted parallel to the vessel wall that leads to alteration of the endothelial phenotype, endothelial cell signaling, gene and protein expression leading to a proinflammatory phenotype, reduced nitric oxide availability and disruption of the extracellular matrix, which in turn leads to plaque development. Clinical and experimental data are emerging that suggest the pathobiology associated with abnormal wall shear stress results in atherosclerotic plaque development and progression. [ABSTRACT FROM AUTHOR]

Central cord syndrome (CCS) is the most common form of incomplete cervical spinal cord injury. This clinical syndrome marked by a disproportionate weakness in the upper extremities compared with the lower extremities was originally described by Richard Schneider in 1954. After poor initial surgical results, Schneider deemed surgery “contraindicated” in the setting of CCS as a majority of patients managed medically made predictable recoveries. Since his time, the role of surgery in traumatic CCS has remained controversial despite numerous reports of its successful application. Surgical intervention has been advocated for persistent or worsening neurologic deficits and evidence of spinal cord compression on imaging. Including Schneider's report, only 2 out of 352 patients in the literature have been reported as having a neurologic decline after surgery for CCS. Reported benefits of surgery include earlier rehabilitation and neurologic recovery, decreased hospital length of stay, decreased risks of delayed neurologic deterioration, and a decrease in the risks associated with prolonged convalescence. These potential benefits must be weighed against surgical and anesthetic risks in the face of an acute spinal cord injury. The purpose of this article was to review the role of surgery in traumatic CCS. [ABSTRACT FROM AUTHOR]

The article presents findings of a study on the views of presidents or chancellors on the challenges of collegiate sport in the U.S. It states that the respondents seem to be in a dilemma regarding the length of football and basketball seasons. According to the study, each of the issues of freshman ineligibility, football and men's basketball coaches' salaries and paying athletes for their services has financial implications for intercollegiate athletic programs.

Background: Although one goal of end-of-life care is to honor the wishes and needs of patients, little research has been done to characterize what is important to seriously ill African American patients at the end of life. Objective: To characterize the views of seriously ill African American patients toward endof- life care. Design: A qualitative study using semistructured, in-depth interviews. Setting and participants: Patients in a large, urban, public hospital who are facing a serious illness. Results: Twenty-three African American patients were interviewed. Although most acknowledged a point at which they would want to cease aggressive care, some equated this with giving up. Most subjects expressed that the end of life was in God's hands. Many expressed a concern to be free of pain and suffering. Few saw a significant role for the physician at the end of life. Some had expressed their wishes for care to a family member. Others thought such discussions were unnecessary because a family member would make decisions or because death was not imminent. Subjects raised concerns about trust in the physician and the burden of end-of-life discussions. Conclusions: African Americans in an urban, public hospital who are facing a severe illness have clear desires for care at the end of life and are willing to discuss their views at length. Such discussions should explore patients' desire for aggressive care, consider spiritual views and the importance of family in end-of-life decisions, and consider that some patients will not believe such discussions are necessary. [ABSTRACT FROM AUTHOR]

Background Context: In a large series of human patients undergoing open anterior lumbar interbody fusion with a tapered titanium fusion cage, recombinant human bone morphogenetic protein type 2 (rhBMP-2) on an absorbable collagen sponge carrier has been shown to decrease operative time and blood loss, to promote osteoinduction and fusion and to be a safe and effective substitute for iliac crest harvesting. Purpose: The purpose of the study was to determine the clinical and radiographic outcomes in patients treated for single-level degenerative lumbar disc disease with a posterior interbody fusion, using stand-alone cylindrical threaded titanium fusion cages with either autogenous bone graft or rhBMP-2 and an absorbable collagen sponge carrier. Study Design/setting: A prospective, randomized, nonblinded, 2-year pilot study at 14 investigational sites. Patient Sample: Between March 1999 and December 1999, 67 patients with symptomatic, single-level degenerative lumbar disc disease of at least 6 months' duration underwent a single-level posterior lumbar interbody fusion using two paired cylindrical threaded titanium fusion devices. Patients were randomly assigned to one of two groups: one (n=34 patients) received rhBMP-2 on a collagen sponge carrier; the other (n=33 patients) autogenous iliac crest bone graft. Outcome Measures: Clinical outcomes were measured using low back and leg pain numerical rating scales, the Short Form (SF)-36, Oswestry Low Back Pain Disability Questionnaire and work status. Plain radiographs and computed tomographic scans were used to evaluate fusion at 6, 12 and 24 months after surgery. Methods: In this prospective nonblinded study, 67 patients were randomly assigned to one of two groups who underwent interbody fusion using two cylindrical threaded fusion cages: the investigational group (34 patients), who received rhBMP-2 on an absorbable collagen sponge, and a control group (33 patients), who received autogenous iliac crest bone graft. Clinical data were collected and analyzed by a commercial entity. Results: The mean operative time and blood loss for the investigational rhBMP-2 group was 2.6 hours and 322.8 ml, respectively. For the autograft control group, these values were 3.0 hours and 372.7 ml. The differences were not significant. Although not statistically different, at 24 months, the investigational group's fusion rate of 92.3% was higher than the control's at 77.8%. At all postoperative intervals, the mean Oswestry, back and leg pain scores and physical components of the SF-36 improved in both treatment groups compared with preoperative scores, but no significant differences were found between groups. A statistically significant difference in the change in back pain was found at 24 months for the investigational group. In the control group, two adverse events related to harvesting of the iliac crest graft occurred in two patients (6.1%). Conclusions: This small multicenter, randomized, nonblinded trial showed few statistically significant differences between the study groups. Both groups showed comparable improvements on outcome scores. Overall results show that the use of rhBMP-2 can eliminate the need for harvesting iliac crest graft and may be an equivalent replacement for autograft for use in successful posterior lumbar interbody fusions. Further studies of the use of rhBMP-2 in posterior lumbar interbody fusion cage procedures are needed. [ABSTRACT FROM AUTHOR]

The article focuses on the emerging renaissance in medical education published in "Journal of General Internal Medicine." The Accreditation Council for Graduate Medical Education Outcome Project, which has identified six core competencies has created the need for increased accountability for documenting proficiency in each of the six competencies. This will require increased attention to the evaluation of house staff in general. The seven brief reports and one original article in this issue focus more on understanding or evaluating the efficacy of educational interventions than on their innovativeness per se.

We describe a half-day workshop to teach third-year medical students three focused end-of-life care skills: breaking bad news, discussing advance directives, and assessing and managing pain. Our workshop included a readers' theater exercise and three role-play exercises. In two of the workshops, faculty members played the role of patients. We used readers' theater to engage the students on an emotional level and set a reflective tone for the workshop. Evaluations reflected that most respondents felt that the workshop enhanced their understanding and ability to address these skills with patients. By 6 months, many students reported applying these skills to patient care in a way they thought was effective. [ABSTRACT FROM AUTHOR]

Background: The medical literature offers little information about how older African Americans view the medical decision-making process. We sought to describe the perspectives of older African American patients in a primary care clinic as they consider a medical decision. Methods: We interviewed 25 African American patients older than 50 years who had discussed flexible sigmoidoscopy with their primary care provider. Interviews were analyzed using qualitative methods. Results: Patients listed concerns about cancer and health, risks and benefits, their own understanding of the test, and the recommendation of the provider as the most important factors in their decision. Most patients wanted information about medical tests and procedures to increase their understanding and to provide reassurance rather than to guide decision making. Most patients explained that they wanted the provider to make medical decisions because of his or her training and experience. Despite this, many expressed a sense of ownership or control over one's own body. Patients thought trust was built by a health care provider's honesty, patience, kindness, interest, and continuity of care. Conclusions: Although traditional models of informed consent have emphasized providing patients with information to guide autonomous decision making, patients may want this information for other reasons. Fully informing patients about their medical condition increases understanding and provides reassurance. Because many of these patients want their provider to participate in making medical decisions, he or she should not only provide information but should also provide guidance to the patient. [ABSTRACT FROM AUTHOR]

To determine the prevalence, topics, methods, and intensity of ongoing faculty development (FD) in teaching skills. Mailed survey. Two hundred and seventy-seven of the 386 (72%) U.S. teaching hospitals with internal medicine residency programs. Prevalence and characteristics of ongoing FD. One hundred and eight teaching hospitals (39%) reported ongoing FD. Hospitals with a primary medical school affiliation (university hospitals) were more likely to have ongoing FD than nonuniversity hospitals. For nonuniversity hospitals, funding from the Health Resources Services Administration and >50 house staff were associated with ongoing FD. For university hospitals, >100 department of medicine faculty was associated. Ongoing programs included a mean of 10.4 topics (standard deviation, 5.4). Most offered half-day workshops (80%), but 22% offered ≥1-month programs. Evaluations were predominantly limited to postcourse evaluations forms. Only 14% of the hospitals with ongoing FD (5% of all hospitals) had “advanced” programs, defined as offering ≥10 topics, lasting >2 days, and using ≥3 experiential teaching methods. These were significantly more likely to be university hospitals and to offer salary support and/or protected time to their FD instructors. Generalists and hospital-based faculty were more likely to receive training than subspecialist and community-based faulty. Factors facilitating participation in FD activities were supervisor attitudes, FD expertise, and institutional culture. A minority of U.S. teaching hospitals offer ongoing faculty development in teaching skills. Continued progress will likely require increased institutional commitment, improved evaluations, and adequate resources, particularly FD instructors and funding. J GEN INTERN MED 2004;19:205–214. [ABSTRACT FROM AUTHOR]