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Background Shadow coaching, a type of one-on-one provider counseling by trained peers, is an effective strategy for improving provider behaviors and patient interactions, but its effects on improving patient experience for English- and Spanish-preferring patients is unknown. Objective Assess effects of shadow coaching on patient experience for English- and for Spanish-preferring patients. Design We analyzed 2012–2019 Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) data (n=46,089) from an urban Federally Qualified Health Center with 44 primary care practices and 320 providers. One-third (n=14,631) were Spanish-preferring patients. We fit mixed-effects regression models with random effects for provider (the level of treatment assignment) and fixed effects for time (a linear spline for time with a knot and “jump” at coaching date), patient characteristics, and site indicators, stratified by preferred language. Participants The 74 providers who had a 6-month average top-box score on the CAHPS overall provider rating below 90 (on a 100-point scale) were shadow coached. Similar percentages of English-preferring (45%) and Spanish-preferring patients (43%) were seen by coached providers. Intervention Trained providers observed patient care by colleagues and provided suggestions for improvement. Verbal feedback was provided immediately after the observation and the participant received a written report summarizing the comments and recommendations from the coaching session. Main Measures CG-CAHPS Visit Survey 2.0 provider communication composite and overall provider rating (0–100 scoring). Key Results We found a statistically significant 2-point (small) jump in CAHPS provider communication and overall provider rating among English-preferring patients of coached providers. There was no evidence of a coaching effect on patient experience for Spanish-preferring patients. Conclusions Coaching improved care experiences for English-preferring patients but may not have improved patient experience for Spanish-preferring patients. Selection and training of providers to communicate effectively with Spanish-preferring patients is needed to extend the benefits of shadow coaching to Spanish-preferring patients.

IntroductionShadow coaching improves provider-patient interactions, asmeasured by CG-CAHPS® overall provider rating (OPR) and provider communication (PC). However, these improvements erode over time.AimExamine whether a second coaching session (re-coaching) improves and sustains patient experience.SettingLarge, urban Federally Qualified Health Center PROGRAM: Trained providers observed patient care by colleagues and provided suggestions for improvement. Providers with OPRs

Author(s): Quigley, Denise D; Qureshi, Nabeel; Slaughter, Mary E; Kim, Scott; Talamantes, Efrain; Hays, Ron D | Abstract: BackgroundHealthcare organizations want to improve patient care experiences. Some use 'shadow coaching' to improve interactions between providers and patients. A Federally Qualified Health Center (FQHC) implemented a half-day observation of individual primary-care providers by a 'shadow coach' during real-time patient visits, including an in-person verbal debrief afterwards and a written report with specific recommendations. Shadow coaching identified areas for improvement. We aimed to characterize lessons and barriers to implementing shadow coaching as a mechanism to improve interactions with patients and change organizational culture.MethodsWe examined provider and coach perceptions of shadow coaching through interviewing coached providers, stratified by provider type and Consumer Assessment of Healthcare Providers and Systems (CAHPS) performance, and the coaches who coached the most providers. We interviewed 19 coached providers and 2 coaches in a large, urban FQHC. Content analysis identified implementation barriers, facilitators and themes.ResultsCoaches reported needing 'buy-in' throughout the organization and the need to be credible and empathize with the providers being coached. Most providers reported behaviour changes based on recommendations. Almost all providers recalled at least one coaching recommendation that was actionable. Providers and coaches highlighted patient-level and practise-level barriers that impeded their ability to implement recommended improvements. CAHPS data was reported as an effective performance management metric for measuring change, counselling providers, and evaluating provider-level efforts but was not always specific enough to yield tangible recommendations.ConclusionsRegular messaging by leadership about the priority and purpose of shadow coaching was essential for both physician engagement and its mature implementation across the organization. Coaching could be embedded into a long-term strategy of professional development with periodic re-coaching. Re-coaching sessions could target issues raised by providers, such as dealing with difficult patients or specific populations. Research on the timing and content of re-coaching is needed.

Background Health care organizations strive to improve patient care experiences. Some use one-on-one provider counseling (shadow coaching) to identify and target modifiable provider behaviors. Objective We examined whether shadow coaching improves patient experience across 44 primary care practices in a large urban Federally Qualified Health Center. Research design Seventy-four providers with "medium" (ie, slightly below average) overall provider ratings received coaching and were compared with 246 uncoached providers. We fit mixed-effects regression models with random effects for provider (level of treatment assignment) and fixed effects for time (linear spline with a knot and "jump" at coaching date), patient characteristics and site indicators. By design, coached providers performed worse at selection; models account for the very small (0.2 point) regression-to-the-mean effects. We assessed differential effects by coach. Subjects A total of 46,452 patients (from 320 providers) who completed the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) Visit Survey 2.0. Measures CAHPS overall provider rating and provider communication composite (scaled 0-100). Results Providers not chosen for coaching had a nonsignificant change in performance during the period when selected providers were coached. We observed a statistically significant 2-point (small-to-medium) jump among coached providers after coaching on the CAHPS overall provider rating and provider communication score. However, these gains disappeared after 2.5 years; effects differed by coach. Conclusions Shadow coaching improved providers' overall performance and communication immediately after being coached. Regularly planned shadow coaching "booster" sessions might maintain or even increase the improvement gained in patient experience scores, but research examining additional coaching and optimal implementation is needed.

The termination of the Deferred Action for Childhood Arrivals (DACA) immigration policy poses unique challenges for medical education and healthcare. A survey on DACA was administered online using Qualtrics Software System to 121 unique U.S.-MD granting medical school admissions leadership using e-mails between January 2018 and April 2018. A total of 39 individuals out of 121 (32%) responded to the survey; 23 (59%) of respondents identified as medical school admissions deans, 11 (28%) identified as directors and 5 (13%) as staff/officers. During the past 4 years, 19 (49%) reported having accepted DACA students. The majority either incorrectly answered or were otherwise unsure about the effect of DACA on medical education. The correlation between perception of understanding DACA and mean knowledge composite score was 0.38, P

PurposeMedical students who attend community college are more likely to express intention to train in family medicine. This study examined whether community college attendance is associated with family medicine residency training in a national sample of US medical school graduates.MethodsWe performed a cross-sectional analysis using the Association of American Medical Colleges matriculant files of residency trainees who graduated from medical school between 2010 to 2012. Residency specialty (family medicine vs other) was modeled using logistic regression analysis; the key independent variable was community college attendance, with categories of non-community college (reference); community college while in high school; community college after graduating from high school, then transfer to 4-year university; and community college after graduating from a 4-year university or as a postbaccalaureate. The logistic model adjusted for age, sex, race/ethnicity, years in medical school, parental education (a marker of socioeconomic status), and high school US region.ResultsOf the 43,382 medical school graduates studied, 25.9% attended community college and 8.7% trained in family medicine. In unadjusted analysis, graduates attending community college while in high school, after graduating from high school with transfer to 4-year university, or after graduating from a 4-year university or as a postbaccalaureate (12.0%, 12.7%, and 10.8%, respectively) were more likely to train in family medicine compared with their peers who did not attend community college (7.7%). Respective adjusted odds ratios were 1.47 (95% CI, 1.33-1.63; P

Multiple Mini-Interviews (MMIs) are increasingly used in medical school admissions. We previously reported that while under-represented minority (URM) status was not associated with MMI scores, self-designated disadvantaged applicants had lower MMI scores, possibly affecting their matriculation prospects. No studies have examined how URM status or socioeconomic disadvantage (SED) are associated with academic performance following admission through an MMI. We examined the adjusted associations of MMI scores, SED, and URM status with U.S. Medical Licensing Examination Steps 1 and 2 performance and third-year clerkship Honors, measures affecting residency matching. While URM status was not associated with the measures, students with greater SED had lower Step 1 scores and fewer Honors. Students with higher MMI scores had more Step 1 failures, but more Honors. The findings identify areas to address in medical school admissions, student support, and evaluation processes, which is important given the need for a more representative physician workforce.

© 2017 by the American Society of Nephrology. Background and objectives Waitlist inactivity is a barrier to transplantation, because inactive candidates cannot receive deceased donor organ offers. We hypothesized that temporarily inactive kidney transplant candidates living in linguistically isolated communities would be less likely to achieve active waitlist status. Design, setting, participants, & measurements We merged Organ Procurement and Transplantation Network/ United Network for Organ Sharing data with five-digit zip code socioeconomic data from the 2000 US Census. The cumulative incidence of conversion to active waitlist status, death, and delisting before conversion among 84,783 temporarily inactive adult kidney candidates from 2004 to 2012 was determined using competing risks methods. Competing risks regression was performed to characterize the association between linguistic isolation, incomplete transplantation evaluation, and conversion to active status. A household was determined to be linguistically isolated if all members ≥14 years old speak a non-English language and also, speak English less than very well. ResultsA total of 59,147 candidates (70% of the studypopulation) achieved active status over the studyperiod of 9.8 years. Median follow-up was 110 days (interquartile range, 42–276 days) for activated patients and 815 days (interquartile range, 361–1244 days) for candidates not activated. The cumulative incidence of activation over the studyperiod was 74%, the cumulative incidence of death before conversion was 10%, and the cumulative incidence of delisting was 13%. After adjusting for other relevant covariates, living in a zip code with higher percentages of linguistically isolated households was associated with progressively lower subhazards of activation both in the overall population (reference

Making Medical School Admissions More Equitable The growing gap between the racial, ethnic, and socioeconomic makeup of medical school classes and that of the general population means medical educa...

Cooking programs are one avenue to promote healthy eating. However, many cooking programs are a one size-fits-all approach and do not consider costs, time, accessibility, or cultural barriers to the recipes being taught. Healthy Bites is a cooking program developed by medical students, physician assistant students, and chefs to remedy this by redesigning recipes to be less than $3 per meal, fewer than 30 minutes to cook, inclusive of accessible ingredients, and tailored for Latin American dishes. In this descriptive work, we implemented the Healthy Bites (HB) program by recruiting Latino participants from free clinics and community centers in Sacramento County to measure their changes in confidence in various aspects of food preparation. We also assessed the utility of a collaborative, community-based student initiative to increase confidence and skills for medical and physician assistant students. Although we are limited by the number of participants, we report an increase in confidence for cooking cost effective foods, accessing healthy ingredients, cooking dishes that participants culturally identify with, and cooking in a timely manner. Our findings suggest that culturally tailored cooking courses can positively influence cooking behavior and training for healthcare professionals.

One-third of all medical students attend a community college (CC) on their path to medical school. The objective of this study was to examine the association between CC participation and initial specialty of interest among US allopathic medical students.We performed a national cross-sectional study of allopathic medical students who completed the 2012 Association of American Medical Colleges' Matriculating Student Questionnaire. Bivariate and logistic regression analyses were conducted.A total of 9,885 medical student respondents were included in the study sample, consisting of 7,035 (71%) non-CC pathway, and 2,850 (29%) CC pathway participants. CC pathway participants were more likely to express intent to specialize in family medicine (272/2,850 [10%] vs 463/7,035 [7%], P.001), compared to those on the non-CC path. CC pathway participants had higher odds of intent to specialize in family medicine (adjusted odds ratio [AOR]=1.32; 95% CI 1.13-1.56, P0.001), compared to those on the non-CC path. Women, independent of college pathway, were nearly two times more likely to express an intention to specialize in family medicine, and three times more likely to express an intention to specialize in pediatrics than men.Medical students who used a CC pathway are more likely to have intentions to specialize in family medicine, compared to those on the non-CC path.

The United States, under new executive orders proposed by its 45th president, may quickly lose its greatness in serving Emma Lazarus’ untimely portrait of immigrants and refugees as “the tired, poor and huddled masses yearning to breathe free.” After years of progress in improving health care access to underserved populations, new executive orders threaten our nation’s advancements in health equity. Within this perspective, we offer examples on how these actions may result in damaging impacts on patients, families, communities and the health care workforce. We add our voices to a myriad of national leaders who are advocating for the preservation of the Affordable Care Act (ACA) and the protection of immigrants, including Deferred Action for Childhood Arrivals (DACA).Ethn Dis. 2017;27(2):121-124; doi:10.18865/ed.27.2.121

The authors conducted a systematic review of the medical literature to determine the factors most strongly associated with localizing primary care physicians (PCPs) in underserved urban or rural areas of the United States.In November 2015, the authors searched databases (MEDLINE, ERIC, SCOPUS) and Google Scholar to identify published peer-reviewed studies that focused on PCPs and reported practice location outcomes that included U.S. underserved urban or rural areas. Studies focusing on practice intentions, nonphysicians, patient panel composition, or retention/turnover were excluded. They screened 4,130 titles and reviewed 284 full-text articles.Seventy-two observational or case-control studies met inclusion criteria. These were categorized into four broad themes aligned with prior literature: 19 studies focused on physician characteristics, 13 on financial factors, 20 on medical school curricula/programs, and 20 on graduate medical education (GME) programs. Studies found significant relationships between physician race/ethnicity and language and practice in underserved areas. Multiple studies demonstrated significant associations between financial factors (e.g., debt or incentives) and underserved or rural practice, independent of preexisting trainee characteristics. There was also evidence that medical school and GME programs were effective in training PCPs who locate in underserved areas.Both financial incentives and special training programs could be used to support trainees with the personal characteristics associated with practicing in underserved or rural areas. Expanding and replicating medical school curricula and programs proven to produce clinicians who practice in underserved urban or rural areas should be a strategic investment for medical education and future research.

Objectives: To understand the health care access issues faced by Los Angeles (LA) County’s uninsured and residually unin­sured after implementation of the Afford­able Care Act (ACA) and to identify poten­tial solutions using a community-partnered dialogue.Design: Qualitative study using a com­munity-partnered participatory research framework.Setting: Community forum breakout discus­sion.Discussants: Representatives from LA County health care agencies, community health care provider organizations, local community advocacy and service organiza­tions including uninsured individuals, and the county school district.Main Outcome Measures: Key structural and overarching value themes identified through community-partnered pile sort, c-coefficients measuring overlap between themes.Results: Five overarching value themes were identified – knowledge, trust, quality, partnership, and solutions. Lack of knowl­edge and misinformation were identified as barriers to successful enrollment of the eligible uninsured and providing health care to undocumented individuals. Discussants noted dissatisfaction with the quality of tra­ditional sources of health care and a broken cycle of trust and disengagement. They also described inherent trust by the uninsured in “outsider” community-based providers not related to quality.Conclusions: Improving health care for the residually uninsured after ACA implementa­tion will require addressing dissatisfaction in safety-net providers, disseminating knowl­edge and providing health care through trusted nontraditional sources, and using effective and trusted partnerships between community and health care agencies with mutual respect. Community-academic part­nerships can be a trusted conduit to discuss issues related to the health care of vulner­able populations. Ethn Dis. 2015; 25(4)487- 494; doi:10.18865/ed.25.4.487

Efrain Talamantes,1 Gerardo Moreno,2 Lourdes R Guerrero,3 Carol M Mangione,3,4 Leo S Morales5,6 1US Department of Veterans Affairs and Division of General Internal Medicine, Division of General Internal Medicine and Health Services Research, University of California Los Angeles, CA, 2Department of Family Medicine, University of California Los Angeles, Los Angeles, CA, 3Department of Medicine, Division of General Internal Medicine and Health Services, University of California Los Angeles, Los Angeles, CA, 4School of Public Health, University of California Los Angeles, Los Angeles, CA, 5Group Health Research Institute, Seattle, WA, 6Center for Health Equity, Diversity and Inclusion, School of Medicine, University of Washington, Seattle, WA, USA Purpose: This study evaluates the psychometric properties of three newly developed items assessing the quality of interpretation from the patient's perspective among Spanish-speaking limited English proficient Latino patients. Patients and methods: The authors examined the psychometric properties of a patient-reported measure of quality of interpretation using a cross-sectional survey study of 1,590 adult Spanish-speaking limited English proficient Latinos in the United States. Quality of interpretation, doctor communication, and satisfaction with care were assessed using a three survey-item, an independent multiple-item measure, and a single-item measure, respectively. Results: Sixty-nine percent (1,104) of patients surveyed used interpreters. Cronbach’s alpha for the three items assessing interpreter quality was 0.31, while dropping item three resulted in an alpha of 0.56. Items one and two were moderately correlated with doctor communication (r=0.39) and satisfaction with care scores (r=0.21) supporting construct validity. Conclusion: Two out of three survey items can be scaled to measure quality of interpretation from the patient's perspective. Quality of interpretation reported by patients is moderately associated with doctor communication and satisfaction with care. Keywords: interpreters, Latinos, doctor–patient communication, satisfaction with care

Diversity in the physician workforce increases health care access for underserved populations, improves culturally and linguistically appropriate care, and better positions the workforce to serve the needs of a diverse population.1–9 How to achieve that diversity, however, is not well understood. To our knowledge, no prior research has clarified how or if the undergraduate pathway contributes to a diverse physician workforce that is interested in serving underserved communities. Furthermore, we are not aware of any studies that have explored the community college (CC) as a pathway to medical school. Since CCs (2-year post-secondary educational institutions) serve as a principal higher education attainment pathway for many low-income and underrepresented minority (URM) students10, we chose to investigate the CC pathways to medical school in this study. In 2010, approximately 8 million or 44% of all the undergraduate students in the United States were enrolled at one of the 1,600 CCs throughout the country.11 The percentage of Latinos attending CC’s has nearly doubled since 1992,12 and the majority of CC students come from low-income families.13 CC enrollment in 2010 was as follows: 57% women, 52% White, 17% Latino, 15% Black, 5% Asian, and 11% other race or not reported.11 These data indicate that CC students potentially represent the type of student being targeted by national efforts to encourage URM students to pursue careers in medicine. However, achieving diversity in our future physician workforce is challenged by rising tuition costs that have outpaced family income growth. Although numerous factors influence URM interest in medicine, financial barriers can considerably widen the privilege gap, resulting in a socially stratified higher education system.14 In the United States, the majority of medical students have parents with graduate levels of education and incomes in the top quintile of all American families.15,16 The median student-reported parental income among matriculating medical students in 2012 was $115,000.17 Although cost is a strong deterrent for potential applicants with lower parental income, other determinants, such as disparities in educational attainment and academic preparedness, may explain some of the demographic trends among medical school applicants.18 From 1977 to 2012, the racial-ethnic composition of medical school applicants has changed as follows: Asians increased from 2.6% to 23%, Latinos increased from 2.6% to 8.7%, Blacks increased from 6.4% to 8.1%, American Indians and Alaska Natives decreased from 0.33% to 0.25%, and Whites decreased from 88% to 60%.19 Today, Blacks and Latinos make up 13% and 17% of the U.S. population, and comprise 6% and 5.5% of the physician workforce, respectively.20,21 We describe the characteristics of pre-medical students who use CC pathways and the association of those characteristics with acceptance to medical school, intentions to serve underserved communities, and intentions to work primarily with minority populations. Given the diversity in the CC student body and prior studies identifying factors that support students’ intent to practice in underserved and minority communities2,5,22–24, we hypothesized that CC pathways are used differently by medical school applicants and matriculants with different characteristics, and that students who use CC pathways may be more likely to practice in underserved communities than those who did not use a CC pathway.