Data Source. Survey of a sample of primary care physicians in MA.

Study Design. Cross-sectional survey of a sample of physicians who provide care to MassHealth (MA Medicaid) enrolled-children. Dependent variables: history of completed preventive dental skills training, and FV provision. Independent variables: oral health knowledge, FV-attitudes, and physician and practice characteristics.

Principal Findings. Overall, 19 percent of respondents had completed the training required to be eligible to bill for FV provision. Only 5 percent of physicians were providing FV. Most respondents (63 percent) were not familiar with the new policy, and only 25 percent felt that FV should be provided during well-child visits. Most physicians (60 percent) did not feel that the reimbursement rate of U.S.$26/application was sufficient; 17 percent said that they would not provide FV, regardless of payment. Most common barriers to FV provision were a lack of time and logistical challenges.

Conclusions. Our findings suggest that simply reimbursing physicians for FV provision is insufficient to ensure provider participation. Success of this policy will likely require addressing several barriers identified.

Objective: This study was designed to examine student and facilitator perceptions of effective case-based small group teaching in the pre-clinical years and compare results in order to identify similarities and differences and identify key areas of disconnect so that the small group learning experience can be improved.

Methods: An 18-item survey was emailed to all 388 students who had started the second year of medical school at the University of Massachusetts between August 2008 and August 2010 and to 146 of 161 facilitators who had facilitated a case-based small group session during that same time. Chi-square tests of equality of proportions were used to compare the answers of students and small group facilitators.

Results: 79 (54%) small group facilitators and 195 (50%) students responded. Student and facilitator responses were similar in the areas regarding goals of small group sessions and responsibilities of the facilitator. Significant difference was noted between cohorts about the most important roles of the facilitator, whether facilitators and/or students should attend training prior to sessions, whether groups should follow a consistent format, how students should be expected to prepare for small groups, how student knowledge and performance should be assessed, and whether the small group leader should be a skilled facilitator or content expert.

Conclusions: This study demonstrates that there are areas where perceptions of effectiveness differ between students and facilitators. Identifying these areas presents an opportunity to make small group sessions more effective by allowing for more informed facilitator development and better communication of session expectations to students. The lack of a substantive body of literature on this important trend in medical education, coupled with our findings, suggests that further study is needed to identify characteristics of case-based small group learning that are mutually valued by students and facilitators. This will encourage the development of small group sessions that are deemed effective and maximize learning and teaching time.

Objectives: The objectives of this study were to evaluate if prenatal patient satisfaction and knowledge about pregnancy improves if a structured prenatal education plan is implemented throughout a family medicine health center. Also, we sought to evaluate if a structured prenatal education plan for expectant mothers will improve specific clinical outcomes.

Methods: Focus groups were held in which prenatal patients were asked about their level of satisfaction with current prenatal care practices at the Hahnemann Family Health Center. Advice for improvement was also elicited. The data gathered from the focus group, the input of physicians at the health center, and information gathered from a review of current prenatal education materials around the country was used to create a new prenatal health education plan.

In addition, data collection tools (three surveys) were specifically created for this study (partially based on previously validated tools). Surveys were specific for the first trimester, third trimester, and postnatal period. Currently in year one, pregnant women have been, and will continue to be, surveyed regarding their prenatal knowledge and satisfaction given the current state of prenatal care at the health center. During this year approximately 50 patients in their first trimester will be enrolled and surveyed throughout the pre and postnatal period. At the beginning of year two, the new prenatal education plan will be implemented. A new cohort of about 50 patients at the health center, who receive the new prenatal health education, will be assessed on their level of prenatal knowledge and satisfaction using the same survey tools. Knowledge/satisfaction will be compared between the two groups. In addition, clinical measures (such as number of phone calls regarding prenatal issues between scheduled visits, number of trips to the emergency room, preterm labor, smoking cessation rates, and breast feeding) will be compared, via a chart review, between the two groups.

Results: Focus groups, with women who currently receive prenatal care at the health center, revealed that women were inconsistently counseled about ways to combat stress during pregnancy, expectations for the mother and baby while in the hospital during labor and delivery, the reason the health center collects a urine sample during each prenatal visit, as well as dental care and preterm labor precautions. In addition, at least one woman reported never discussing with her physician topics such as nutrition during pregnancy, weight gain, breastfeeding, stages of pregnancy, and development of the baby.

Initial survey results indicate that women in their first trimester of pregnancy most often feel they have “some knowledge” about pregnancy and prenatal-related issues but patients vary widely on their confidence in making decisions regarding basic pregnancy issues without having to talk to a doctor. About 50% believe they have added stress in their life due to pregnancy. Worries regarding pregnancy and child care topics vary widely. About 78% of the time, women answered knowledge-based questions concerning pregnancy-related topics correctly.

Conclusion: Initial results indicate that there are currently gaps in prenatal education and knowledge throughout prenatal care at the health center. Based on our findings and those of previously published studies, it can be hypothesized that by closing these gaps, as with a structured health education plan, clinical outcomes will improve. We will be better able to assess this hypothesis after year two of this study. While patient satisfaction cannot be assessed at this time, our early survey results indicate that first trimester women seem to subjectively and objectively have some accurate prenatal knowledge.

Method: Surveys were mailed to the 833 members of the Massachusetts Academy of Family Physicians in 2007 eliciting information about screening practices. Factors associated with routine or targeted screening among adult primary care patients were evaluated.

Results: Less than one-third of providers reported usually or always screening for childhood trauma and correctly estimated childhood abuse prevalence rates; 25% of providers reported that they rarely or never screen patients. Confidence in screening, perceived role, and knowledge of trauma prevalence were associated with routine and targeted screening. Women and physicians reporting fewer barriers were more likely to routinely screen adult patients.

Conclusions: Despite the 20%–50% prevalence of child abuse exposure among adult primary care patients, screening for childhood abuse is not routine practice for most physicians surveyed; a large subgroup of physicians never screen patients. Study findings draw attention to a largely unexplored experience associated with considerable health care costs and morbidity. Results highlight the need to develop training programs about when to suspect trauma histories and how to approach adult patients.

Methods: Mental health directors in all 51 state and federal prison systems were invited to respond to a 30-item questionnaire available online or in hard copy. Univariate statistics were used to describe significant aspects of the national experience with self-injurious behavior, and bivariate statistics were used to examine relationships between variables.

Results: Thirty-nine systems (77%) responded to the survey. Responses indicated that <2% of inmates per year engage in self-injurious behavior, but such events were reported to occur at least weekly in 85% of systems, with occurrences more than once daily in some systems, thus causing substantial disruptions to operations and draining resources. The highest rates of occurrence of these behaviors were in maximum-security and lockdown units and most often involved inmates with axis II disorders. Despite the seriousness of the problem, systems typically collect few, if any, data on self-injurious behaviors, and management approaches to dealing with them lack consistency within and across systems. Eighty-four percent of respondents expressed interest in participating in further studies on this topic.

Conclusions: The survey responses indicated the disruptive effects of self-injurious behavior in the nation's prisons, a need for better epidemiologic monitoring and data on such behavior, and the importance of developing and widely using effective interventions. The high response rate and expressed interest in follow-up projects suggest that state and federal correctional mental health directors see a need for better information and management in this area. (Psychiatric Services 62:285-290, 2011).

METHOD: An extensive on-line three-part survey was conducted in 2006-2007 assessing sociodemographic characteristics, practice descriptors, coding and billing practices, productivity goals and perceived pressures among Society for Developmental and Behavioral Pediatric's 438 physician members.

RESULTS: Of the pediatricians responding, representing all regions of the United States, 93% were DB pediatrics subspecialty board certified or eligible. The majority was practicing DB pediatrics full-time (73%); and 67% were exclusively in academic settings. All reported seeing patients, 84% reported teaching, 76% reported having administrative responsibilities, and 46% reported conducting research. Despite having non-clinical responsibilities, full-time equivalent positions included an average of 25 hours per week in direct patient care and 14.5 hours per week (37% of clinical time) in indirect patient care. Only 42% reported working with multidisciplinary teams. Salaries varied widely within and across regions. Deficits in billing/coding practices, awareness of personal clinical productivity, and familiarity with national productivity benchmarks were identified.

CONCLUSIONS: DB pediatricians work in diverse settings nationwide. They provide considerable time in indirect patient care, which is poorly reimbursed in general and relative to direct patient care. The results of this survey offer opportunities for provider, institutional and payer education.

METHOD: In 2009, the authors sent a 22-question online survey to the deans of education of 126 MD-granting and 28 DO-granting U.S. medical schools to determine the extent to which these schools have an oral health curriculum.

RESULTS: Eighty-eight schools (57.1%) responded. Of these, 61 (69.3%) reported offering less than five hours of oral health curriculum; 9 (10.2%) offered no curriculum. Schools with greater than 150 students per class were more likely to offer five or more hours of oral health curriculum compared with small or midsize schools (P = .022). School location and having a dental school and/or residency were not significantly related to the number of hours of oral health curriculum (P = .728 and .271, respectively). Awareness of oral questions on the United States Medical Licensing Examination board exams and/or the Association of American Medical Colleges report on oral health education was also not associated with curriculum volume. In schools with an oral health curriculum, topics being covered ranged from 10.0% teaching hands-on skills training to 81.7% covering oral cancers. Only 29.9% reported evaluating students around oral health topics.

CONCLUSIONS: The majority of the responding U.S. medical schools offer very little oral health education. There are few meaningful correlations as to what contributes to schools having a more robust curriculum. Further study is needed to explore how to improve this educational void.

Given these known issues, the Association of American Medical Colleges (AAMC) published Report IX: Contemporary Issues in Medicine: Oral Health Education for Medical and Dental Students in 2008, which challenged medical schools to revise their curricula to include oral health education. The report outlined the necessary changes to a school’s curriculum to provide students with adequate OH training. This report was in response to the 2000 Surgeon General’s Oral Health in America Report and the 2003 A National Call to Action to Promote Oral Health which helped to make the medical and dental communities aware of the fact that they should be trained to provide adequate oral health care.

In addition, the USMLE Step 2CK and Step 3 exams include oral health topics, also making it evident that medical students should be learning oral health subjects during their training. There are some existing oral health curricula, such as the Academy of Pediatrics (AAP) modules on pediatric oral health and care and the Society of Teachers in Family Medicine’s (STFM) Smiles for Life comprehensive oral health curriculum, of which some schools are taking advantage. However, it is unclear to what extent medical schools have actually integrated oral health topics into their curricula to adequate train their students.

Objective: The objective of our survey was to determine the extent to which U.S. allopathic and osteopathic schools are including oral health in their curricula. We specifically were interested in finding out how much time is dedicated to oral health and which topics are being covered, as well as finding out if schools who have not implemented OH are aware of the current guidelines. We also wanted to determine what the level of interest for developing stronger OH curricula is at the schools with no or little OH curriculum.

Methods: Via web search and phone contacts, the ‘Dean of Education’ at all U.S. allopathic and osteopathic schools was identified. A 22-question survey was constructed to elicit demographic information about the school and information about its oral health curriculum (e.g., hours of oral health education, topics covered, and student evaluations about oral health). Other questions included: awareness of USMLE topics in oral health, the existence of the AAMC’s report encouraging OH curriculum development, awareness of existing oral health curriculum, current use of existing curriculum and plans to develop or expand curriculum at their institution. The survey was put into SurveyMonkey format to be sent to schools via e-mail.

The survey was pilot tested with 10 New England schools to gauge implementation issues, response rates and ease of completing the 15-minute survey. Once revisions were made for clarity, the survey was emailed to the remaining 154 Deans of Education (at 126 allopathic and 28 osteopathic schools) with an email explaining the purpose of the study. One week prior to the distribution of the survey link, an email announcing the upcoming survey was sent to all schools. We sent a reminder email to non-respondents (with the survey link) every 2 weeks for a total of 3 reminders. A final phone call was made to each non-responding school to encourage participation.

Descriptive univariate analyses were done using SPSS statistical software. This data was then assessed using chi-square tests and t-tests to examine relationships with school size, school location and the presence of an established affiliation with either a dental school or dental residency using an alpha of .05 to denote statistical significance.

Results: A total of 88 schools replied to the survey out of the 154 schools contacted (response rate: 57.1%). Of the 88 schools, 72 Allopathic schools and 13 Osteopathic schools replied; the remaining 3 were unknown. All regions of the country were represented with slightly higher responses from the Midwest region (29.6%) and lower responses from the Western region (12.5%). Response rates increased with increasing class size; the majority (55.7%) of respondents being from schools with more than 150 students. Most of the responding schools did not have an affiliated dental school (70.5%) nor a dental residency (62.5%). Finally, most schools offered either 1-2 hours (28.4%) or 3-4 hours (30.7%) of oral health curriculum over a student’s four years; one in 10 schools (10.2%) offered no oral health curriculum hours.

An analysis of the relationship between demographic information and the number of current hours of oral health curriculum (less than 5 hours or greater than 5 hours) found that hours of curriculum was statistically significantly related to matriculating class size (p=.022). Schools with greater than 150 students were more likely to offer 5 or more hours of oral health curriculum than small or mid-size schools. School location and having a dental residency and/or school were not found to be statistically significantly related to number of hours of oral health curriculum (p=.728 and p=.271, respectively).

Awareness of oral health questions on the USMLE board exams and/or the AAMC Report on Oral Health Education was also not associated with curriculum volume. In schools with an OH curriculum, topics being covered ranged from 10.0% teaching hands-on skills training to 81.7% covering oral cancers. Only 29.9% reported evaluating students around OH topics.

Conclusions: Few medical and osteopathic schools are currently providing more than 4 hours of oral health curriculum. Only large school size seems to have a positive association with more oral health curriculum. Fewer still are conducting rigorous evaluations of such education. Being aware of the AAMC Report on oral health education or that the USMLE has test questions on oral health, or being affiliated with a dental school or residency did not have a positive effect on the quantity of oral health curriculum. Future educational efforts should utilize these results to create a strategy aimed at promoting an awareness of oral health education requirements, training materials and potential oral health educational champions.

Presented as part of the Senior Scholars Program at the University of Massachusetts Medical School, May 3, 2010.

DESIGN: A 4-year prospective study.

SETTING: Public schools in 6 Massachusetts communities.

PARTICIPANTS: A cohort of 1246 sixth-grade students.

INTERVENTIONS: Eleven interviews.

MAIN OUTCOME MEASURES: Loss of autonomy over tobacco as measured by the Hooked on Nicotine Checklist, and tobacco dependence as defined in International Classification of Diseases, 10th Revision (ICD-10).

RESULTS: Among the 217 inhalers, 127 lost autonomy over their tobacco use, 10% having done so within 2 days and 25% having done so within 30 days of first inhaling from a cigarette; half had lost autonomy by the time they were smoking 7 cigarettes per month. Among the 83 inhalers who developed ICD-10-defined dependence, half had done so by the time they were smoking 46 cigarettes per month. At the interview following the onset of ICD-10-defined dependence, the median salivary cotinine concentration of current smokers was 5.35 ng/mL, a level that falls well below the cutoff used to distinguish active from passive smokers.

CONCLUSIONS: The most susceptible youths lose autonomy over tobacco within a day or 2 of first inhaling from a cigarette. The appearance of tobacco withdrawal symptoms and failed attempts at cessation can precede daily smoking; ICD-10-defined dependence can precede daily smoking and typically appears before consumption reaches 2 cigarettes per day.

METHODS: We developed systems to promote, coordinate, and lead the visits. Residents' responsibilities were delegated through a preparation checklist. A standardized progress note was developed to encourage patient goal setting and to track relevant laboratory test results. To evaluate our program, we conducted surveys to determine patients' behavioral changes and satisfaction levels and assessed the effect on group visit participants' glycated hemoglobin (HbA1c) and low-density lipoprotein (LDL) levels.

RESULTS: Group visit patient survey results showed that 72% of the patients in the group visit cohort reported making a lifestyle change; 88% felt that the group visit helped them achieve better control of their diabetes, and 100% stated that they would come to a group visit again. However, no significant changes were noted in HbA1c or LDL levels.

CONCLUSIONS: Residents can overcome challenges and implement, organize, and run effective group visits that increase patients' self-reported self-management abilities, but we could demonstrate no statistically significant improvement on measurable biochemical parameters of glucose or lipid control.

METHODS: Workers completed a mailed, self-report survey about their pre- and post-injury health and functioning, work environment, and retirement plans. Bivariate and multivariate analyses determined those factors associated with retirement-related job lock.

RESULTS: Over half of the respondents wanted to retire but could not because they needed job-related income or benefits. Factors associated with retirement-related job lock were indicative of poorer health and mental function and dissatisfaction with the workplace social environment. No injury-related factors were significant.

CONCLUSIONS: Retirement-related job lock was common in older workers with occupational injuries, and appears to be primarily due to difficulties at work, combined with health conditions that may impair work abilities. Workers wishing to retire but unable to do so may be at risk for work-related injuries, as well as decrements in work function and premature retirement resulting in insufficient income and health benefits.

PURPOSE: To examine factors contributing to physician satisfaction and retention in largely rural areas in Massachusetts, a state with rural pockets and small towns.

METHODS: A survey mailed in 2004-2005 to primary care physicians, practicing in areas designated by the state as rural, queried respondents about personal and practice characteristics as well as workforce concerns. Predictors of satisfaction and likelihood of remaining in current or rural practice somewhere were assessed.

FINDINGS: Of 227 eligible physicians, 160 returned their surveys (response rate, 70.5%). Approximately one third (34.0%) reported they had grown up in communities of 100,000 or larger. Factors associated with higher overall practice satisfaction included not feeling overworked (P = .043) or professionally isolated (P = .004), and being involved in their practice (P = .045) and home communities (P = .036) as well as ease of seeking additional physicians for practice and obtaining CME credits (P = .014 and P = .017, respectively). Female physicians were more likely to report an intention to remain in rural practice somewhere for the next decade (P = .034). In rating their satisfaction with various aspects of the rural practice environment, physicians reported greatest satisfaction with their practice overall (67%) and their call group size (66%). They were least satisfied with their current (30%) and likely future income (40%). In multivariate analyses, larger practice community size was positively related to the dependent variable of overall satisfaction and negatively related to likelihood of staying in current practice or in rural practice somewhere.

CONCLUSIONS: Our findings reaffirm the importance of rural medical education opportunities in physician recruitment, retention, and practice satisfaction. They also indicate that in a small New England state, a major source of physicians for rural and small town communities is physicians who have been raised in urban/suburban communities and who were trained outside of the region but who were prepared to live and to practice in rural and small town communities.

METHODS: All 347 graduates of the University of Massachusetts Family Medicine Residency were surveyed about practice location and type, involvement and training in community work, confidence in community-related skills, and sociodemographic characteristics. Analyses were conducted by residency graduation decade (1976-1985, 1986-1995, and 1996-2005).

RESULTS: Earlier graduates (19761985) were significantly more likely to engage in an array of community-related activities, but recent graduates (1996-2005) were more likely to report having been trained in these skills. There was a significant positive association between practice in an underserved area and confidence in issues related to sociocultural aspects of care. While recent graduates were more likely to locate both initial and current practices in a Health Professions Shortage Area (HPSA), 20.6% of all graduates reported an initial practice in a HPSA.

CONCLUSIONS: While family physician involvement in community-related activities increases with years out of residency, a higher proportion of recent graduates report having learned community-related skills while in medical school. Physician relocation tends to be away from HPSA toward non-HPSA sites.

METHODS: We sent a mail survey to all graduates of one family medicine residency about practice locations, types, and populations; influences on practice choice; and sociodemographic characteristics.

RESULTS: Training in a CHC had a statistically significant association with the likelihood of practice in an HPSA for both initial and current practice. Training in a rural residency site was associated with initial and current rural practice. Logistic regression analysis showed that physicians who completed ambulatory training in the CHC were nearly six times more likely to report having practiced initially and four times more likely to cite current practice in an HPSA.

CONCLUSIONS: Outpatient CHC residency training increases the likelihood of practice in an underserved setting. This finding has policy implications for supporting workforce training in practice settings that care for underserved populations.

METHODS: Family Advocates of Central Massachusetts (FACM) is a medical-legal collaboration that assists low-income families with legal issues that affect child health. A convenience sample of parents seen at each of 5 medical practices associated with FACM was recruited to complete the MASQ prior to a routine child health care visit. Physicians blinded to the result assessed family need for referral to FACM after their usual clinical encounter. The sensitivity and specificity of both the MASQ and provider assessment were calculated.

RESULTS: Two hundred fifty-five parents from 5 practices participated in the study. The MASQ identified 85 patients in need of legal services. Prior to reviewing the MASQ, the primary care providers identified 35 families in need of referral to the FACM. After completion of both the MASQ and the medical encounter, 37 families agreed to referral. The MASQ had sensitivity of 0.81 and specificity of 0.75 in predicting program referral. Provider assessment had sensitivity of 0.65 and specificity of 0.95 of predicting program referral.

CONCLUSIONS: Routine use of the MASQ would likely identify more patients in pediatric practices who would accept referral to legal assistance than reliance on provider impression alone after a routine clinical encounter.

METHODS: A total of 104 first-year medical students and 40 second-year nursing students were randomly assigned to participate in a 1-week regimen of mock prescriptions or to read a description of the regimen and make predictions about what the experience would be like had they participated.

RESULTS: Quantitative results in combination with qualitative information suggest that the students taking the mock prescriptions gained important insights into the difficulty of managing a complicated medication regimen.

DISCUSSION: This mock prescription exercise, well accepted by students and faculty, was easily incorporated into the curriculum and provided an experiential opportunity for students to learn of the difficulties of medication adherence.

METHODS: Data on tobacco use were obtained from a nationally representative sample of 16,244 adolescents from the 2003 Monitoring the Future survey. The association between merchant compliance with the law from 1997-2003 and current daily smoking was examined using logistic regression while controlling for cigarette prices, state restaurant smoking policies, anti-tobacco media, and demographic variables.

RESULTS: Higher average state merchant compliance from 1997-2003 predicted lower levels of current daily smoking among adolescents when controlled for all other factors. The odds ratio for daily smoking was reduced by 2% for each 1% increase in merchant compliance. After controlling for price changes, media campaigns and smoking restrictions, a 20.8% reduction in the odds of smoking among 10th graders in 2003 was attributed to the observed improvement in merchant compliance between 1997 and 2003. A 47% reduction in the odds of daily smoking could be attributed to price increases over this period.

CONCLUSION: Federally mandated enforcement efforts by states to prevent the sale of tobacco to minors appear to have made an important contribution to the observed decline in smoking among youth in the U.S. Given similar results from long-term enforcement efforts in Australia, other countries should be encouraged to adopt the World Health Organization Framework on Tobacco Control strategies to reduce the sale of tobacco to minors.