Robert Wood Johnson Clinical Scholars Research Articles

Editorial introductions.

Current Opinion in Pediatrics was launched in 1989. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The fields of pediatrics are divided into 18 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Editor in Chief and Section Editors for this issue. EDITOR-IN-CHIEF Margaret Kendrick HostetterMargaret Kendrick HostetterMargaret Kendrick Hostetter, MD, was born in Toledo, Ohio, USA and graduated from Denison University in Granville, Ohio, USA, summa cum laude and Phi Beta Kappa as a National Merit Scholar. After graduate school in English literature at Rice University in Houston, Texas, USA, she matriculated at Houston's Baylor College of Medicine, Texas, USA and graduated AOA in 1975, ranked first in the class. She completed her internship and residency in pediatrics at Boston Children's Hospital, USA (1975-1978) and a combined fellowship in infectious diseases at Boston Children's, the Peter Bent Brigham Hospital, USA and the Beth Israel, USA (1978-1980). After two years as instructor at Boston Children's, she moved to the University of Minnesota, USA, where over 16 years she rose to become the American Legion Heart Research Professor (endowed chair), Chief of the Division of Pediatric Infectious Diseases, and Vice Chair for Research in the Department of Pediatrics. In 1998, she was recruited to the Department of Pediatrics at Yale, USA, as head of the Yale Child Health Research Center. In 2002, she became Chair of the Department of Pediatrics and the Jean McLean Wallace Professor (endowed chair), the first woman to hold that position at Yale. She served as chair at Yale until 2010, when she was recruited to Cincinnati Children's Hospital, USA, and became the first female chair of the Department of Pediatrics and Director of the Cincinnati Children's Research Foundation. She retired from her position at Cincinnati Children's in February 2020 and now serves as Editor-in-Chief of Current Opinion in Pediatrics. In the national arena, she has been elected President of the Society for Pediatric Research and the American Pediatric Society. Peer recognition includes several awards for her research on Streptococcus pneumoniae and Candida albicans from the Society for Pediatric Research, the American Academy of Pediatrics, and private foundations. Other memberships include the American Society for Clinical Investigation, the Association for American Physicians, and the National Academy of Medicine. She has been principal investigator of NIH grants from 1985 to 2020 and served as program director for the NICHD-funded Pediatric Scientist Development Program for more than 22 years, where she fostered the research career development of more than 200 pediatric physician-scientists across the US and Canada. Graduates of the PSDP now hold leadership positions in research and academic medicine throughout North America. She lives in New York City, where her two children and four grandchildren reside. SECTION EDITORS Kara Odom WalkerKara Odom WalkerKara Odom Walker, MD, MPH, MSHS is Executive Vice President and Chief Population Health Officer (CPHO), Nemours Children's Health System, USA, as of September 2020. At Nemours, Dr Walker leads the Nemours National Office, Delaware Valley primary care, the Value Based Services Organization and related advocacy and public policy, as well as all aspects of population health strategy, research, innovation, and implementation. Her scope of responsibility includes advancement of the overall health and well-being of children, both broadly and among the populations served by Nemours. Dr Walker will collaborate with operational leaders and share accountability for managed care initiatives, to include medically complex case management, school-based wellness programs, and other services for specific populations. Working closely with the Executive Cabinet, Dr Walker and her team will develop and implement the organization's national and state-specific advocacy strategies to help achieve outcomes tied to health and value while also leading Nemours's federal policy agenda. Previously she was sworn in as Secretary of the Delaware Department of Health and Services (DHSS) and served in Governor Carney's first elected term from February 2017 through 2020. As Secretary, she led the principal agency charged with keeping Delawareans healthy, ensuring they get the health care they need in a fast-changing world, and providing children, families and seniors with essential social services including food benefits, disability-related services, and mental health and addiction treatment. She oversaw one of the largest departments in Delaware's government with an annual budget of more than $2 billion. Dr Walker's many accomplishments at DHSS include developing first-in-the-nation health care spending and quality benchmarks in Delaware, USA; creating a state reinsurance program that reduced premiums in its first year and increased the number of people covered; and shaping new Medicaid managed care contracts that include quality metrics and embed paying for value – not volume – in health care. Secretary Walker previously worked as the Deputy Chief Science Officer at the Patient Centered Outcomes Research Institute (PCORI), a non-profit, nongovernment organization in Washington that is authorized by Congress to improve evidence available to help patients, caregivers, employers, insurers, and policymakers make informed health care decisions. She managed the Institute's research investments, which totalled $1.6 billion in 2016, toward a planned total of $2.5 billion by 2019. She is a board-certified practicing family physician and is a Fellow of the American Academy of Family Physicians. Prior to joining PCORI, she was a faculty member of Family and Community Medicine at the University of California, San Francisco, USA. She has worked with several national organizations to advocate for health equity and for access to quality health care in minority and underserved populations, including the National Medical Association, the Student National Medical Association and the American Medical Association. Dr Walker has been recognized for leadership by Harvard Business School's Program for Leadership Development, the American Medical Association and the National Medical Association. A respected leader, innovator, and clinician, she was elected to the National Academy of Medicine (NAM) in 2018. Election to the NAM is considered one of the highest honours in the fields of health and medicine, recognizing individuals who have demonstrated outstanding professional achievement. Dr Walker completed her family medicine residency at the University of California, San Francisco, USA, graduated with a Masters’ of Public Health from Johns Hopkins School of Public Health and Masters’ of Health Services Research from the University of California, Los Angeles, USA, School of Public Health, where she also completed her fellowship in the Robert Wood Johnson Clinical Scholars program. Allison Gertel-RosenbergAllison Gertel-RosenbergAllison Gertel-Rosenberg, MS, has spent her career addressing some of the most important and challenging issues in public health. As Vice President, National Prevention and Practice for Nemours Children's Health's National Office of Policy and Prevention, USA, she is responsible for leading the Office's efforts to spread and scale promising practices and strategic prevention initiatives designed at the intersections of early childhood and health and population health and clinical care on a national scale. These efforts have included the highly successful Moving Health Care Upstream, Let's Move! Child Care, Healthy Kids, Healthy Future and the National Early Care and Education Learning Collaborative initiative. Allison's involvement has run the gamut from securing funding for these collaborations, as she has leveraged more than $50 million in grants over the course of her career, to playing a critical role in planning and implementing the strategic and operational measures necessary to make them successful. Allison is widely recognized as an expert on public health and population health and has presented at numerous national conferences on the value of investment in childhood health, patterns of drug abuse, assessments of the efficacy of prevention programs, youth smoking cessation, and the development of state-wide anti-tobacco media campaigns. In addition, she has published several articles on children's health issues. Before joining Nemours in 2006, Allison was the Program Manager for the Office of Policy Development for the Division of Addiction Services at the New Jersey Department of Human Services, USA. In that position, she was responsible for supervising a staff of researchers engaged in addiction-related research and overseeing treatment-related data collection and analysis. Allison received her M.S. in Health Policy and Management from the Harvard School of Public Health, USA, and her B.S. in Public Health from Rutgers College, USA. Brigitte WidemannBrigitte WidemannAs chief of National Cancer Institute's Pediatric Oncology Branch, Dr Widemann oversees and active basic, translational and clinical research program for children and young adults with hematologic and solid malignancies. Dr Widemann joined the NCI in 1992 as a pediatric hematology oncology fellow after having obtained her MD and completed pediatric residency at the University of Cologne in Germany. Her research has been focused on drug development and early clinical trials for children with refractory solid tumours or genetic tumour predisposition syndromes, in particular neurofibromatosis type 1 (NF1). The work of her research team on NF1 resulted in the first U.S. Food and Drug Administration approved medical therapy, the MEK inhibitor selumetinib, for children with NF1 and inoperable, symptomatic plexiform neurofibroma. She received tenure at the NIH in 2009 and became the Chief of the POB in 2016. Dr Widemann is a member of the Association of American Physicians and recipient of the AACR-Joseph H. Burchenal Award for Outstanding Achievement in Clinical Cancer Research. She serves as special advisor to the NCI Director for childhood cancer and has authored more than 200 original scientific papers, reviews, and book chapters, and has conducted many clinical trials. Daniel W. GreenDaniel W. GreenDr Daniel W. Green has been practicing at the Hospital for Special Surgery in New York, USA, since 1998 and is currently the Director of the Pediatric Sports Program for the Division of Pediatric Orthopedic Surgery. He has over 200 published papers with his research focusing on pediatric knee surgery, cartilage repair, pediatric ACL surgery, pediatric growth plate surgery, pediatric fracture care, and osteogenesis imperfecta. Dr Daniel Green is the Associate Director of the Hospital for Special Surgery Orthopedic Surgery Residency Program and Clinical Professor of Orthopedic Surgery at Weill Cornell Medical College, USA. Henry H. BernsteinHenry H. BernsteinDr Bernstein is a Professor of Pediatrics at Zucker School of Medicine at Hofstra/Northwell in New York, USA. He taps into his extensive 36–year experience as a general pediatrician in private practice, the National Health Service Corps, and as Chief of General Academic Pediatrics at urban, suburban, and rural children's hospitals to promote the health and well-being of children, their families, and their communities. His private, community-based primary care (generalist) experiences in combination with academic leadership responsibilities have provided him with a value-added, translational science perspective, unique from many others in academia. This tacit knowledge enables him to fulfil a lifelong passion of communicating, educating, and translating science into clinical settings, educational venues, policy-making, and media interactions to advance the health of children. Research is consistently woven into the fabric of Dr Bernstein's clinical practice, which has served as a “laboratory” for his active studies. His research and quality improvement initiatives focus on issues important to Academic General Pediatrics and community-based practice, including immunizations, infectious diseases, postpartum newborn discharge, childhood obesity, breastfeeding, health promotion, preventive health screening in primary care, technology and medical education. His commitment, innovative spirit, and enthusiasm also encompass many facets of medical education along the continuum from training and mentoring future physicians to fostering lifelong learning and supporting the continuous professional development of practicing pediatricians. Dr Bernstein is Associate Editor of the American Academy of Pediatrics’ (AAP) Red Book Online (www.aapredbook.org) and a former voting member of the Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practice (ACIP). He serves as a consultant on the ACIP COVID-19, Influenza, and Immunization Schedules for Adults and Children workgroups. He also is an ex-officio member of the AAP's Committee on Infectious Diseases (Red Book Committee). In addition, he is Editor-in-Chief Emeritus of PediaLink (www.pedialink.aap.org), the AAP's online home for lifelong learning, and Chair of the interdisciplinary Bright Futures Health Promotion Workgroup, which created a distinctive health promotion curriculum, videos, and a companion educational website (www.pediatricsinpractice.org). Dr Bernstein has been Editor of the Office Pediatrics Series in Current Opinion in Pediatrics since 1995 and was Senior Editor of Pediatrics on the public website of Harvard Medical School's Health Publications Division for 17 years. He regularly shares his knowledge and expertise by educating the public, writing for health information websites and often participating in media interviews on a variety of pediatric health care issues including immunizations, diagnosis and treatment of common childhood infectious diseases and conditions, and practical information for parents, teachers and caregivers. In the spirit of lifelong learning, Dr Bernstein earned a masters in healthcare management (MHCM) at Harvard T. H. Chan School of Public Health, USA in 2013 and has been a faculty member in this Executive Education Masters degree program since. He actively maintains his certification by the American Board of Pediatrics. He completed his residency training in pediatrics at St. Christopher's Hospital for Children in Philadelphia, USA after earning his medical degree from the University of Medicine and Dentistry of New Jersey - School of Osteopathic Medicine, USA. Hank and his wife, Sophie, have been married for 41 years, are extremely proud of their 36-year-old daughter, Lauren, and 30-year-old son, David, and are “over the moon” with their first grandchild Eva.

The Challenges, Joys, and Career Satisfaction of Women Graduates of the Robert Wood Johnson Clinical Scholars Program 1973–2011

To ensure a next generation of female leaders in academia, we need to understand challenges they face and factors that enable fellowship-prepared women to thrive. We surveyed woman graduates of the Robert Wood Johnson Clinical Scholars Program (CSP) from 1976 to 2011 regarding their experiences, insights, and advice to women entering the field. We surveyed every CSP woman graduate through 2012 (n = 360) by email and post. The survey, 12 prompts requiring open text responses, explored current work situation, personal definitions of success, job negotiations, career regrets, feelings about work, and advice for others. Four independent reviewers read overlapping subsets of the de-identified data, iteratively created coding categories, and defined and refined emergent themes. Of the 360 cohort, 108 (30%) responded. The mean age of respondents was 45 (range 32 to 65), 85% are partnered, and 87% have children (average number of children 2.15, range 1 to 5). We identified 11 major code categories and conducted a thematic analysis. Factors common to very satisfied respondents include personally meaningful work, schedule flexibility, spousal support, and collaborative team research. Managing professional-personal balance depended on career stage, clinical specialty, and children's age. Unique to women who completed the CSP prior to 1995 were descriptions of "atypical" paths with career transitions motivated by discord between work and personal ambitions and the emphasis on the importance of maintaining relevance and remaining open to opportunities in later life. Women CSP graduates who stayed in academic medicine are proud to have pursued meaningful work despite challenges and uncertain futures. They thrived by remaining flexible and managing change while remaining true to their values. We likely captured the voices of long-term survivors in academic medicine. Although transferability of these findings is uncertain, these voices add to the national discussion about retaining clinical researchers and keeping women academics productive and engaged.

The Familias Saludables partnership: Engaging the Latino community to address early childhood obesity.

Darcy A Thompson is an Associate Professor of pediatrics at the University of Colorado School of Medicine.Her main research seeks to address early childhood obesity in low-income children. She works in the Lifestyle Medicine clinic at Children's Hospital Colorado, a clinic focused on caring for children with obesity and related comorbidities. She is also an Associate Medical Director for the Research Institute at Children's Hospital Colorado. Her training includes a Master of Public Health degree, a medical degree (Yale University) and the Robert Wood Johnson Clinical Scholars Fellowship (University of Washington). Deborah (Deb) A Federspiel has been leading child health advocacy and community health improvement initiatives in support of Children's Hospital Colorado's mission for the past 15years. Her professional background includes experience developing and managing teams, programs and operations, as well as building partnerships and coalitions to drive key strategic initiatives and advance positive change on behalf of children and families. An active member of a number of community advisory committees and nonprofit boards, she has worked in the Colorado nonprofit sector since 1999. She has a Bachelor of Science in business administration from the University of Dayton.

Tamera Coyne-Beasley

In 2018, the Society for Adolescent Health and Medicine (SAHM) will be entering its 50th year, and who better to lead it into its sixth decade than President Tamera Coyne-Beasley (University of North Carolina [UNC], Chapel Hill, NC, USA). “Adolescents make up 25% of the population—that's 1·8 billion adolescents worldwide—and it's a critical time to invest in them”, she told The Lancet Child & Adolescent Health. “Adolescents are innovative and creative—more globally connected [than most adults]—so we look to them to assist and to lead us into a sustainable future.” Despite growing up in a low-wealth community in Boston (MA, USA), “my mother and my grandmother instilled in me that I could do anything and should strive to be anything that I wanted to be despite the obstacles”, she remembers. In order to get a quality education, she was bused to a school over an hour away from her home, which was difficult in many respects. “I began my education in the 60s so things were still relatively segregated; if they weren't segregated by law, they were segregated by community.” Coyne-Beasley's observations of how health and disease affected her family and community—including problems with access to health care and premature death due to preventable conditions—kindled her passion for medicine. She graduated from Brown University (Providence, RI, USA) and earned a scholarship to medical school at Duke University (Durham, NC, USA), where she became the first African-American to complete the Duke Medicine-Pediatrics residency. She chose to combine internal medicine and paediatrics so that she could “provide the best service to the greatest number of people” on returning to Boston. But opportunities during her training would expand her horizons. During her residency, she moonlighted with Robert Wood Johnson Clinical Scholars from UNC, who encouraged her to apply for this prestigious programme. As part of the scholarship, she received additional training in research, public health, and preventive medicine and honed her interest in adolescent medicine. She chose to focus on sexual and reproductive health and injury prevention—particularly firearm injury—because they were associated with the greatest morbidity and mortality in adolescents. These two areas remain relevant to adolescent health globally and are still at the forefront of Coyne-Beasley's work. Having completed a Masters in Epidemiology, an internship at the Office of Disease Prevention and Health Promotion (US Department of Health and Human Services), and a Medical Management programme at the UNC Business School, she took a tenured faculty position at UNC. Here, she was able to combine all her passions—adolescent health, community medicine, research, policy, and education, including working with local schools to help create pipeline programmes to encourage students to pursue careers in science and medicine. While Coyne-Beasley was regional chapter president for the Virginias/Carolinas Chapter of SAHM, she met Renée Jenkins (Howard University College of Medicine, Washington, DC, USA), the first African-American President of SAHM (1989–90). It was obvious to Jenkins that Coyne-Beasley had the skills and capacity to succeed in leadership. “Tamera listens to people and seeks out people who will be helpful”, comments Jenkins. Although SAHM is US based, 35 countries are represented in the Society. “Our 2018 focus is on global health equity”, Coyne-Beasley explains. “While we don't mean to suggest that any of our members abandon the unique challenges in their respective communities or countries, or that there is one solution that fits all, there are clear commonalities on which to collaborate.” These commonalities were highlighted in Our future: a Lancet Commission on adolescent health and wellbeing, and include sexual and reproductive health, accidental death, violence, mental health issues such as self-harm and suicide, and non-communicable diseases. “This is an important time for SAHM, which has been extending its commitment to global adolescent health”, comments Susan Sawyer (University of Melbourne, Melbourne, VIC, Australia), President of the International Association for Adolescent Health and co-author of the Lancet Commission, who worked with Coyne-Beasley on the board of SAHM. “Tamera is very strongly committed to embracing the global community.” But when asked what her proudest achievement is, Coyne-Beasley's answer couldn't be clearer: her children, aged 17 and 19. “I am most proud that I've been able to prioritise and raise healthy, gifted, and kind children who are confident and capable of making significant contributions to this world”, she replies. She recognises that she has been able to provide a level of resources for her children that she never experienced herself. But at the same time, “while my children have those benefits, they still live in a world where they are vulnerable and often judged by the colour of their skin and not the content of their character”. As someone who has provided health care and been engaged in public health efforts in Africa, Central and South America, and the Caribbean, Coyne-Beasley is inspired and motivated by her faith and passion to ensure that current and future generations of adolescents will have equity. “I want to make life better for all adolescents and young adults to ensure that they have the confidence, competency, and opportunity to achieve their dreams.”

Unintended Consequences of Expanded Mandatory Reporting Laws.

The Penn State child sex abuse case highlighted failures to act among numerous adults in positions of responsibility, as chilling details of football coach Gerald Sandusky’s sexual abuse of children over the course of decades came to light.1 Although it is unclear whether adults who chose to ignore ongoing child sexual abuse and rape would have acted differently had there been a legal requirement in place, it would have at least enabled their prosecution after the fact. In the aftermath, Pennsylvania adopted extensive new legislation to prevent and detect child abuse. In particular, Pennsylvania expanded its definitions of mandatory reporters, requiring child abuse awareness training for any licensed health care professional in the state and significantly expanding mandatory lay reporters to include essentially any individual in contact with children, rather than specifically those in contact with children by virtue of their profession. In Philadelphia, these new reporting requirements have flooded the reporting hotline, contributing to excessive waiting times, unanswered calls, spurious calls, and unnecessary reports, leading to the inability to pursue many of these reports.2 Although the Pennsylvania Department of Human Services has acted to address these flaws, few have questioned the wisdom of this expansion of mandatory reporting. There is no indication that the increase in reporting has improved the safety of Philadelphia’s children, and there is reason to believe it may detract. How is it possible that the expansion of mandatory reporting, a step designed to protect vulnerable children from harm, may have had the opposite effect? Mandatory reporting of suspected child abuse and neglect has a history of … Address correspondence to Mical Raz, MD, PhD, Robert Wood Johnson Clinical Scholars Program/Philadelphia VA Medical Center, 1310 Blockley Hall, 423 Guardian Dr, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, E-mail: micalraz{at}mail.med.upenn.edu

Arrived: the crisis of unaccompanied children at our southern border.

For me as a pediatrician, the rapid influx of unaccompanied minors at our southern border simultaneously raises eyebrows and clinical concerns. While our elected leaders continue to battle about immigration issues and refugee status, I have had many conversations with fellow pediatricians around the country who are asking the same 2 questions: “What is this situation at the border about?” and “How can I help?” Over the past few years, US Customs and Border Protection agents have seen increasing numbers of unaccompanied children and young families crossing into the United States. Most of these young immigrants come from the Central American countries of Guatemala, El Salvador, and Honduras. Contrary to media portrayal, this is not a new issue. These 3 countries are plagued by poverty, complicated by a growing culture of violence bolstered by an illegal drug trade.1 Although these children have diverse backgrounds, >90% of the children arriving at the border as unaccompanied minors have contact information for a family member living in the United States. Social workers work to contact this person or relative, and if he or she agrees to serve as a “Sponsor,” will conduct a background check of the person. If there are no issues with the background check (which does not include verification of citizenship), the child can be placed with the Sponsor while awaiting a deportation hearing. At this hearing, a child will often be represented by pro bono legal advocates. Some children will qualify for asylum as refugees; others will not, and will be deported. More information about this process is available from the Office of Refugee Resettlement. Some media sources have argued that the unaccompanied children pose an imminent public health threat, and even some elected officials have asserted that these children threaten our communities. These claims range from the … Address correspondence to Loren Robinson, MD, University of Pennsylvania, Robert Wood Johnson Clinical Scholars Program, 423 Guardian Dr, 13th Floor, Blockley Hall, Philadelphia, PA 19104. E-mail: lorenr{at}upenn.edu

Newest AMA Section Council Member Brings Focus on LGBT Health

Back to table of contents Previous article Next article Full AccessNewest AMA Section Council Member Brings Focus on LGBT HealthMark MoranMark MoranSearch for more papers by this authorPublished Online:17 Dec 2014https://doi.org/10.1176/appi.pn.2014.12b14AbstractAt the June 2015 Annual Meeting of the House of Delegates, the GLMA will be sponsoring a resolution to end the exclusion of transgender individuals from service in the military.Brian Hurley, M.D., an addiction psychiatrist and newest member of AMA Section Council on Psychiatry, is one example of how the 167-year-old physician group is no longer “your father’s AMA.”Brian Hurley, M.D., a delegate to the Section Council on Psychiatry representing the Gay and Lesbian Medical Association, says there is a confluence of interests between the section council and the GLMA.Mark MoranA delegate to the section council from the Gay and Lesbian Medical Association (GLMA), Hurley’s presence is evidence of the widening diversity of the organization and its growing attractiveness to a younger generation of physicians. “I have always felt very welcome here at the AMA,” Hurley told Psychiatric News. “There is a network of people who have a progressive vision for American medicine with whom I have a found a home at the AMA. I believe the AMA has made great strides in incorporating diverse voices, though there is still progress to be made. I see lots of potential for the AMA becoming even stronger through enriching our diversity.”When asked what he hopes to bring to the section council, Hurley pointed to a sharing of interest and concerns between APA and the GLMA. “At the very least, I bring a vote and energy,” he said. “More broadly, the GLMA has decades of experience working at combatting stigma—just as the Section Council on Psychiatry works to combat stigma against our profession and our patients. So I think there is a clear resonance.” AMA Addresses Confidentiality, Public-Health IssuesThe following are items of interest to psychiatrists that the AMA House of Delegates addressed at its November meeting:The Council on Medical Service report “Privacy Issues Regarding Insurance Company Explanation of Benefits” calls on the AMA to advocate for insurance company processes that maintain privacy for adults and dependents who are insured through another entity. Specifically, it asks the AMA to advocate that electronic medical record vendors be required to create user-triggered mechanisms that alert health care professionals of confidential medical information that should be safeguarded. Further, it calls on the AMA to advocate that health insurers be required to develop a method of listing health care services on Explanation of Benefits statements that would preserve confidentiality for all insured individuals. The Council on Ethical and Judicial Affairs Report “Physician Exercise of Conscience” examines implications for patients, physicians, and the medical profession when conflict arises between a physician’s professional commitments and his or her personal moral beliefs. It offers guidance on when a physician’s professional commitments should outweigh personal beliefs and when physicians should have freedom to act according to the dictates of conscience while still protecting patients’ interests.The resolution on “Legal Protection and Social Services for Commercially Sexually Exploited Youth” asks the AMA to work with state medical and specialty societies to advocate for legal protection and alternatives to incarceration for commercially sexually exploited youth as an alternative to prosecution for crimes related to their sexual or criminal exploitation. It also urges development of comprehensive, trauma-informed services as an alternative to criminal detention.The resolution on “Ensuring Access to Health and Mental Health Care, and Legal and Social Services for Unaccompanied Minors and Other Recently Migrated Children” asks the AMA to work with state and local medical societies and clinicians to ensure that new immigrant children receive timely and age-appropriate services that support their health and well-being and secure federal, state, and other funding sources to support those services.The Board of Trustees report “Facilitating State Licensure for Telemedicine Services” reviews the Federation of State Medical Board’s Interstate Compact for Medical Licensure and its application to facilitating state licensure for telemedicine services. The report recommends that the AMA support the Federation of State Medical Board’s Interstate Compact for Medical Licensure and work with interested medical associations, the Federation of State Medical Boards, and other stakeholders to ensure that states adopt the Interstate Compact for Medical Licensure and creation of the Interstate Medical Licensure Compact Commission.The Council on Science and Public Health report “Electronic Cigarettes, Vaping, and Health” reviews regulatory and health information related to electronic cigarettes and amends AMA policy to state that the organization supports a proposed rule that would extend FDA regulatory authority to pipes, cigars, hookahs, e-cigarettes, and all other nonpharmaceutical tobacco/nicotine products.A list of reports and resolutions approved by the AMA House of Delegates at its November meeting can be accessed here.This year, Hurley became the 11th voting delegate in the section council, which includes seven delegates from APA; one delegate each from the American Academy of Child and Adolescent Psychiatry, American Academy of Psychiatry and the Law, and the GLMA; and one sectional delegate from the Resident and Fellow Section. Next June, the American Association of Geriatric Psychiatry will add a delegate, bringing the voting membership to 12. That growing strength translates into influence in the House of Delegates. And Hurley is already having an impact. At the June 2015 Annual Meeting of the House of Delegates, Hurley said that the GLMA will be sponsoring a resolution to end the exclusion of transgender individuals from service in the military. “The Department of Defense prohibits transgender people from enlisting and also has policies that prohibit someone who is transitioning while enlisted from receiving any kind of gender-related treatment,” he said. “There are treatments for gender dysphoria that TriCare doesn’t cover.”He noted as well that the GLMA has joined the AMA in calling for an end to the lifetime deferral on blood donation by men who have had sex with men. “There is no real scientific rationale for that policy, so we support the call for the FDA and HHS to review this policy.” Also of note, for the past three years, Hurley has been one of nine members of the Association of American Medical Colleges (AAMC) Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development. That committee has developed competencies, a resource guide, and a video series designed to help educators implement curricular changes in medical schools and to ultimately improve the health care of individuals with diverse sexual orientations, gender identities, and sex anatomies. The guide, including the competencies, was published on the AAMC website and released at the 2014 AAMC annual meeting and is available as a free pdf download here.The GLMA had its origins as the Bay Area Physicians for Human Rights in the 1980s, later as the American Physicians for Human Rights. “We have over 30 years of experience advancing LGBT equality,” Hurley said. “Our mission is to support health professionals in all aspects of promoting LGBT health care and to see that all physicians are equipped to treat patients of every sexual orientation and gender identity with competence and respect.” Professionally, Hurley is working on a research fellowship at the University of California, Los Angeles, and next year will begin a Robert Wood Johnson Clinical Scholars fellowship. He has a private practice and also works in emergency psychiatry at a community hospital in Los Angeles. Hurley encourages APA members to pay attention to the AMA. “I think APA members would be well served to recognize how important APA’s voice is at the AMA in advancing the interests of psychiatry and our patients and making sure that American medicine is inclusive of our issues,” he said. “I hope APA members will also be aware that there is a Gay and Lesbian Medical Association in addition to the Association of Gay and Lesbian Psychiatrists, and that we are the voice for health professionals advancing LGBT health.” ■ ISSUES NewArchived

The Robert Wood Johnson Clinical Scholars Program: Four Decades of Training Physicians as Agents of Change

The Robert Wood Johnson Clinical Scholars Program has trained 1,200 physicians over 45 years to be agents of change in their communities, medical education, research, and politics.

The Robert Wood Johnson Clinical Scholars Program: Four decades of training physicians as agents of change.

The Robert Wood Johnson Clinical Scholars Program has trained 1,200 physicians over 45 years to be agents of change in their communities, medical education, research, and politics.

A Life Course Perspective on Stress and Health Among Caregivers of Children With Asthma in Detroit

Low-income caregivers raising children with asthma experience many obstacles to their own health, including stress. To understand and describe their daily experiences, researchers conducted 40 qualitative interviews supplemented with descriptive quantitative surveys in Detroit, Michigan, as part of a community-based participatory research partnership of Community Action Against Asthma. Prevalence of chronic illness is noticeably higher among participants than the general US population. Caregivers identified stress processes that may influence disproportionate health outcomes and risk-related behaviors over their lifetime. Applying a life course perspective, findings suggest that public health interventions should address family-level comorbidities, increase instrumental social support, and acknowledge practical coping mechanisms.

Circulation: Cardiovascular Quality and Outcomes Annual Report, 2012

HomeCirculation: Cardiovascular Quality and OutcomesVol. 5, No. 4Circulation: Cardiovascular Quality and Outcomes Annual Report, 2012 Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBCirculation: Cardiovascular Quality and Outcomes Annual Report, 2012 Harlan M. Krumholz, MD, SM and John A. Spertus, MD, MPH Harlan M. KrumholzHarlan M. Krumholz From the Section of Cardiovascular Medicine and the Robert Wood Johnson Clinical Scholars Program, Department of Medicine, Yale University School of Medicine (H.M.K.); Section of Health Policy and Administration, Yale School of Public Health (H.M.K.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.) and St. Luke’s Mid America Heart Institute (H.M.K.)/University of Missouri Kansas City, Kansas City, MO (J.A.S.). Search for more papers by this author and John A. SpertusJohn A. Spertus From the Section of Cardiovascular Medicine and the Robert Wood Johnson Clinical Scholars Program, Department of Medicine, Yale University School of Medicine (H.M.K.); Section of Health Policy and Administration, Yale School of Public Health (H.M.K.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.) and St. Luke’s Mid America Heart Institute (H.M.K.)/University of Missouri Kansas City, Kansas City, MO (J.A.S.). Search for more papers by this author Originally published1 Jul 2012https://doi.org/10.1161/CIRCOUTCOMES.112.967653Circulation: Cardiovascular Quality and Outcomes. 2012;5:e28–e32IntroductionWith this issue, we mark 4 complete years of publication of Circulation: Cardiovascular Quality and Outcomes (CQO). Thank you to our editors, readers, authors, reviewers, and supporters—and especially to Emily Picillo, Katie Sullivan, Karen Barry, and the rest of the outstanding Circulation staff—for helping CQO to mature as a publication with impact.Earlier this year, we submitted a report to the Scientific Publishing Committee of the American Heart Association. We would like to share the key aspects of the report.MissionThe mission of CQO is to improve clinical care and healthcare delivery for patients with, or at risk for, cardiovascular disease and stroke. We pursue this mission through a format that promotes scholarship, education, and constructive debate. The audience includes researchers, clinicians, policymakers, administrators, health plan executives, and government agency professionals. In addition to serving as a venue for high-quality scholarship, we seek to be a catalyst for good science, a vehicle for strengthening and expanding the community that is committed to improving clinical care and population health, and a means to inspire junior investigators to engage in scholarly activities of consequence.CQO ContentCQO has included original research, methods (describing studies that have been implemented) and methodological (describing specific research methods) articles, commentaries, data reports, quality improvement articles, and editorial perspectives. Our original articles span a broad set of disciplines. We consider the journal to be a home for high-quality epidemiology studies that have relevance for patient outcomes and public health. In a word cloud from the titles of 100 articles published in CQO earlier in the year (Figure 1), with word size proportionate to frequency of use, it is most heartening that the largest word is patients.Download figureDownload PowerPointFigure 1. Word cloud created from text contained in a sample of 100 articles published in CQO in 2012.Impact FactorAlthough the impact factor, defined as the average number of citations received per paper published in the 2 preceding years, is an imperfect method of assessing the performance of a journal, it is the most common measure of performance and thus deserves mention. With its first impact factor of 4.84 received last summer, CQO ranked 15th among cardiovascular journals, although several journals were tightly clustered around that level.CitationsAs of February, the 360 articles that had been published since CQO was launched were cited 1744 times (1415 of which were in journals other than CQO). There were 1311 articles that cited CQO articles, 1205 of which were published in journals other than CQO. The h-index indicates that ‘h’ articles have at least ‘h’ citations. A younger journal will necessarily tend to have a lower h-index, and the h-index for CQO was 18. Although there is no benchmark, this indicates that 18 of our articles have at least 18 citations and we are on track to exceed the number of citations from last year.The top 10 articles published in 2008, 2009, and 2010, on the basis of the number of citations, include a qualitative research study, a systematic review, a methods article, a descriptive study, and quantitative studies.1–10 They span preventive cardiology and acute cardiovascular care, with relevance to patient care and to national policy.SubmissionsSubmissions indicate the level of interest in submitting to the journal. Until 2010, there was a steady increase in the number of submissions to CQO (Figure 2).Download figureDownload PowerPointFigure 2. Total submissions from 2008 to 2011.Acceptance RateAcceptance rate is an indication of a journal’s competitiveness. The acceptance rate at CQO remained 30% in 2008 and 2009, followed by substantial decline to around 20% in 2010 (Figure 3).Download figureDownload PowerPointFigure 3. Acceptance rate of submissions from 2008 to 2011.DecisionsOver the past year, the editors have sought to make earlier decisions about papers that are unlikely to be competitive. We believe that authors appreciate the rapid response and the approach saves time and effort on the part of reviewers. As a result, there has been a steady growth in the Rejected Without Review category. We have sought to use the Reject De Novo category sparingly (Figure 4).Download figureDownload PowerPointFigure 4. Designation of final decisions for original research articles from 2008 to 2011 (rejected without review, rejected de novo, rejected, accepted).Time to First DecisionTimeliness of our decisions is an important metric for CQO. The time to first decision for original research articles has steadily improved over the past 3 years and has dropped nearly 25% since 2009 (Figure 5).Download figureDownload PowerPointFigure 5. Time from submission to first decision for original research articles from 2008 to 2011.Time from Submission to AcceptanceThe time from submission to acceptance for original research articles dropped by 37 days compared with 2010 (Figure 6).Download figureDownload PowerPointFigure 6. Time from submission to ­acceptance for original research articles from 2008 to 2011.Submissions from International AuthorsCQO has a particular interest in serving as a destination for international submissions. Last year, we identified submissions from 28 countries in addition to the United States. We show the top 10 countries (including a 3-way tie) from which we received international submissions in the Table.Guest EditorsIn 2011, 22% of the CQO submissions were handled by guest editors. We added a senior guest editor, Peter Groeneveld, to share this responsibility with Paul Heidenreich, our sole senior guest editor since 2008.Quality InitiativesOngoing initiatives to improve CQO include:Better Editorials. We are seeking earlier identification of articles that are suitable for accompanying editorials in order to provide more time and direction to the editorialists. We have assigned an associate editor to work with the editorialists and continue efforts to ensure that editorials are submitted on time for the internal review process.More Media Attention. We are seeking to expand promotional efforts on behalf of our accepted articles. At manuscript acceptance, we identify articles that may generate media interest and ensure their consideration by the American Heart Association press team.Stronger Connection with the Quality of Care and Outcomes Research (QCOR) Council. Our intent to strengthen our relationship with our home Council has resulted in the creation of 4 goals, which we will pursue directly through Council activities and the annual QCOR conference. Goal-directed efforts will build on our established integration with the conference through the Young Investigator Award, abstracts, and support for page charge waivers for highly rated articles that result from abstracts presented by trainees at the conference. QCOR has provided additional support for page charge waivers for 2 series of articles over the next 24 months.Goals are set to:provide all QCOR Council members with electronic Tables of Contents;raise awareness of CQO and its relationship with QCOR;increase submissions and reviewers from our QCOR community;achieve 100% participation of CQO members who are associated with nonsubscribing educational organizations in petitioning their organizations to subscribe to CQO.Better Engagement with American Heart Association Communities. We are reaching out to other Councils, eg, Epidemiology; Nutrition, Physical Activity, and Metabolism; and Nursing, to express our interest in a connection and we include members of those Councils on our Editorial Board. The effort with Epidemiology is most advanced, with one of our associate editors specifically designated as a liaison between our Councils. We continue to seek ways of making CQO more attractive to other communities while retaining our original focus.Better Engagement with the International Community. We have identified an International Advisor, Simon Stewart from Australia, who is assisting us with global dissemination efforts. Although we actively encourage submissions with international relevance, we continue to adhere to our high standards for all submissions.Better and More Submissions. The editorial team proactively identifies and assesses high-quality science at national meetings for suitability for CQO. We continue to extend the reach of our promotional activities through networking among outcomes research centers. In addition, we are seeking methods articles from outcomes research studies. Although we show no special preference, we have encouraged American Heart Association projects to submit their outcomes research papers in an effort to increase the number and diversity of potential papers for review.More Timely Reviews. The focus on reducing the time to decisions and publication for all submissions is particularly relevant to processes related to statistical reviews. Toward this overall aim, we are using e-mail to achieve rapid decisions between editorial meetings for those submissions that involve minimal variation in opinion among the team.More Timely Assessments. We have worked with the Circulation team to obtain monthly feedback for our metrics. In this way, we can be more accountable for our performance and more responsive to changes that require our attention.Future DirectionAs a firmly established journal, CQO is entering its next phase. Supported by the exceptional staff at Circulation, the journal will achieve its promise by adhering to its commitment to serve as a venue for top science while also featuring content that adds to the national dialogue about how best to practice medicine and produce constructive health policy.Sources of FundingDr Krumholz is supported by grant U01 HL105270-02 (Center for Cardiovascular Outcomes Research at Yale University) from the National Heart, Lung, and Blood Institute.DisclosuresDr Krumholz discloses that he is the recipient of a research grant from Medtronic, Inc, through Yale University and is chair of a cardiac scientific advisory board for UnitedHealth. Dr Spertus reports receiving financial support from the American Heart Association to serve as Deputy Editor of Circulation: Cardiovascular Quality and Outcomes and grant support from an American Heart Association Pharmaceutical Roundtable/David and Stevie Spina Outcomes Research Center Award.Table. Top 10 Contributors of International SubmissionsCountryNumber of SubmissionsCanada23Australia17United Kingdom15Netherlands13Unknown10Japan9Italy9Germany9China8Denmark7Taiwan5Iran, Islamic Republic of4FootnotesThe opinions expressed in this article are not necessarily those of the American Heart Association.Correspondence to Harlan M. Krumholz, MD, SM, 1 Church Street, Suite 200, New Haven, CT 06510. E-mail [email protected]

Vision and Persistence: Changing the Education of Physicians is Possible

More than 40 years ago, Margaret (Maggie) Mahoney*, who was at that time a staff member at the Carnegie Corporation, had a series of meetings with distinguished professors of medicine, including John Beck of McGill, Julie Krevans of Johns Hopkins, James Wyngaarden of Duke, Austin Weinberger of Case, Hal Holman of Stanford, and Oliver Cope of Harvard. The purpose of these meetings was to address fundamental issues regarding the training of the future physician leaders of the United States. In the early 1960s, the emphasis on basic science training for physicians was entering a period of heightened intensity. The future of medicine was seen as tied directly to success in the wet laboratory. However, at the same time these stalwarts of American medicine and a young program officer at the Carnegie Corporation were discussing the need to produce a different kind of physician leader. These leaders would be trained in an emerging set of skills, including health policy analysis and health services research. These leaders entertained concepts that clearly were not part of wet bench medicine—for example, perhaps the purpose of treating patients should be to improve their functional status or health status, and thus physicians needed to be leaders in measuring health status and function. Perhaps measuring and improving quality of care was important. Perhaps one should explore and develop a host of new statistical and epidemiologic techniques to assess how they might be used in clinical medicine.1,2,3 The truly revolutionary aspect of these meetings was the desire to integrate population health and personal health. Before the meetings occurred, a physician interested in improving the health of a population or understanding something about how culture affected patient care and how that, in turn, affected health would normally depart for a school of public health after completing clinical training.4 At places like Hopkins, the street that separated the School of Public Health from the School of Medicine was as broad as the DMZ separating North and South Korea. Everything one learned in clinical medicine, as well as the symbolic white coat and the stethoscope, was simply not acceptable in the School of Public Health. These leaders had a different vision. They believed that physicians could work in both clinical medicine and population health. To make this vision a reality meant defining a new field. Margaret Mahoney convinced the Carnegie Corporation and the Commonwealth Foundation to fund what would become the Clinical Scholars Program, thereby changing the face of medicine forever. She subsequently moved with the program to the Robert Wood Johnson Foundation, where she was the visionary who persuaded the foundation and each of its presidents to sustain funding of the Robert Wood Johnson Clinical Scholars Program. It may be the longest ongoing training program ever funded by a foundation. The Foundation’s support has continued without interruptions to this day, and the more than 1200 physicians who have gone through the Clinical Scholars Program have become the leaders of American medicine. They have held positions in government ranging from Surgeon General to Assistant Secretary. Some head state health departments or lead organizations such as the Joint Commission on Accreditation of Healthcare Organizations. Many are in academic departments including deans of both schools of medicine and schools of public health. The scope of their presence and influence cannot be overestimated. Indeed, it is hard to imagine modern American medicine without the leaders produced by the Clinical Scholars Program. Due to the efforts of this new kind of physician, fields were redefined and new fields, such as measuring health status and quality of care and understanding how healthcare policies affect patient outcomes, were opened up. But the vision also included having these physicians remain active clinicians, and graduates of these programs, who assumed jobs ranging from foundation presidents to assistant secretaries in HHS, still manage to provide patient care in free clinics or make hospital rounds. In essence, Maggie Mahoney and the leaders with whom she met and who shared her vision, changed the culture of medicine. The walls between schools of public health and medical schools were torn down. Population health and the delivery of clinical services were no longer incompatible. Methodologies used in the social science became methodologies used in the clinical sciences. These new physician leaders who became accepted in both camps actually helped to merge the camps into one vision of health and health care for all. But changing physician education requires more than a vision. For many of the past 40 years, Annie Lee Shuster, a program officer at The Robert Wood Johnson Foundation, used every skill in her armamentarium to convince the RWJ Foundation—its staff, its board, and its presidents as well as leaders of the Veterans Administration—to maintain the vitality of the Clinical Scholars Program. As a consequence, over those decades an extraordinarily diverse group of people has continued to allocate both financial and intellectual support for the Program. The results of this happy marriage of vision and persistence are many of the physician leaders of American medicine today. Is there now an equally important change in physician education that needs to occur? The Internet and smartphones have changed the way we purchase consumer goods; crowd sourcing has changed the way ideas are vetted; and people organize to improve our products and services and even bring down governments. Social media has changed the way we find mates, choose hotels, and decide whether to try that new, pricy, restaurant. Communication has become 24/7. However, to a large degree, medicine both does not take advantage of and has not kept up with this instant feedback, always connected world. Medical education still focuses on what a physician does in face-to-face contact with the patient. Office visits and hospital rounds still dominate the culture of American medicine. Indeed, physicians still ask if it is acceptable for patients to contact their physician by e-mail, if a physician who is covering for another physician should provide the same quality of care for patients who are not hers as she does for her own, or whether physicians have any responsibility for following up on patients after they are out of sight—e.g., after they have been discharged from a hospital or been seen in the outpatient setting. Perhaps it is time to ask a different set of questions. Should main-stream medical care be expanded beyond bankers’ hours, following the basic pattern of retail stores and internet sites? Should patients play a more prominent role in managing their health? For example, instead of requiring patients to ask for their x-ray or lab results, perhaps they should be responsible for maintaining these records, producing them as needed for care. Should patients have more control of their health care? For example, why can’t they get their blood pressure checked by using a machine in any drug store and then refill their prescription without contacting any doctor? Should patients be able to have blood drawn and have the results sent directly to them so that they can monitor their own illness? In short, how do we transform the vision of medicine from one in which physicians control the process, regulations dominate the playing field, and care is delivered at the convenience of health professionals to one in which patients are truly at the center? Many small companies and physician entrepreneurs are tinkering with or investing seriously in producing a paradigm shift in the way care is delivered. In the new paradigm, the patient, not the physician, would be at the center of the universe. That shift would have enormous consequences, system-wide. For example, if the patient, not the doctor, were at the center of the universe, patients would not leave the hospital without an electronic copy of their records and all test results, written or printed in a manner they could understand and use to ensure that continuity of care became a reality. No patient who was discharged from the hospital and urgently needed physical therapy would need to wait days or weeks, watching themselves deteriorate, if they could arrange therapy immediately without waiting for somebody in authority to approve it. The doctor of the future will need to partner with the patient in facilitating care and maintaining health. In this new world, a visit to a physician might be seen as a failure just as Internet providers believe that a visit to a store is a failure.5 Perhaps in 20 years, seeing a physician will represent a failure rather than a revenue-generating event. Wouldn’t it be nice if the education of physicians were guided not by how many hours need to be spent in the hospital or in outpatient care, but rather by what physicians need to do to reduce dramatically these activities by helping people improve and maintain health? The need to prepare doctors for this paradigm shift is urgent. Forty years ago, nobody thought the Clinical Scholars Program would succeed; paradigms, as Maggie Mahoney demonstrated, can be changed. * Maggie Mahoney died on December 22, 2011.

Open Science and Data Sharing in Clinical Research

HomeCirculation: Cardiovascular Quality and OutcomesVol. 5, No. 2Open Science and Data Sharing in Clinical Research Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBOpen Science and Data Sharing in Clinical ResearchBasing Informed Decisions on the Totality of the Evidence Harlan M. Krumholz, MD, SM Harlan M. KrumholzHarlan M. Krumholz From the Section of Cardiovascular Medicine and the Robert Wood Johnson Clinical Scholars Program, Department of Medicine, Yale University School of Medicine; Section of Health Policy and Administration, Yale School of Public Health; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn. Search for more papers by this author Originally published1 Mar 2012https://doi.org/10.1161/CIRCOUTCOMES.112.965848Circulation: Cardiovascular Quality and Outcomes. 2012;5:141–142A patient tentatively enters the examination room. A decision looms, and the patient waits with some trepidation. A doctor soon appears and pulls up a chair, prepared for the discussion by having conscientiously reviewed the medical literature, examined the evidence-based systematic reviews, and highlighted the relevant information. The ensuing conversation reflects on the patient's treatment goals and the published information about the benefits and harms of the available options. The tension breaks with a decision, and plans for the next steps are put in place.Every day, patients and their caregivers are faced with difficult decisions about treatment. They turn to physicians and other healthcare professionals to interpret the medical evidence and assist them in making individualized decisions.Unfortunately, we are learning that what is published in the medical literature represents only a portion of the evidence that is relevant to the risks and benefits of available treatments. In a profession that seeks to rely on evidence, it is ironic that we tolerate a system that enables evidence to be outside of public view. Those who own data, usually scientists or industry, have the choice of what, where, and when to publish. As a result, our medical literature portrays only a partial picture of the evidence about clinical strategies, including drugs and devices. Experts have recently drawn attention to this issue, including contributions in this issue of our journal, but there is resistance to change.1–5Studies document that a remarkable percentage of trials are not published within a reasonable period after they are completed. Ross and colleagues reported that fewer than half of trials were published within 2 years of completion.4 Although industry-sponsored studies tended to have the lowest publication rates, the problem spans all study sponsors. A subsequent study found that only 46% of clinical trials funded by the National Institutes of Health were published within 30 months of completion.6 Lee and colleagues found that fewer than half of the new drug trials submitted to the US Food and Drug Administration were published within 5 years of drug approval.7 Although pivotal trials were more likely to be published, 24% remained unpublished at 5 years. Negative trials were less likely to be published, yet 34% of the positive trials were also unpublished at 5 years.We tout systematic reviews, the linchpin of evidence-based medicine, as a method to distill and interpret the medical literature. The Institute of Medicine recently produced standards for these reviews and noted that, “Healthcare decision makers, including clinicians and other healthcare providers, increasingly turn to systematic reviews for reliable, evidence-based comparisons of health interventions.”8 Others have published checklists to promote high-quality methods9; however, the elegance of the methods cannot overcome the undermining effect of missing studies.Missing studies are unlikely to be missing at random, and the effect of the missing data on inferences about an intervention is not easy to predict. Hart and colleagues investigated the effect of unpublished data on the results of meta-analyses of drug trials.10 They showed that the unpublished data influenced the summary estimates such that the drug efficacy was lower in 46% of the meta-analyses and greater in 46%. The result was essentially unchanged in only 7% of the studies. Readers of meta-analyses, without the benefit of these types of analyses, are left to wonder how many missing trials might be relevant to the clinical question and what their effect might be.In some cases, the missing clinical research data may hold important information about risk. A classic example occurred with Vioxx (rofecoxib). Merck had data, mostly unpublished and obtained several years before the drug was withdrawn from the market,11 demonstrating that Vioxx likely increased the risk of an acute myocardial infarction. No systematic analysis could have detected this harm because most of the data were beyond public view. Similarly, GlaxoSmithKline had data, much of it unpublished, which indicated that Avandia (rosiglitazone) increased the risk of an acute myocardial infarction. Nissen and colleagues, accessing the data made available through litigation, revealed the concern that ultimately led to US Food and Drug Administration restrictions on the use of the drug.12,13Selective publication similarly skews the evidence base. For example, Psaty and Kronmal, using information obtained during litigation, reported that Merck and its consultants employed selective reporting in representing mortality results in trials of Vioxx in patients with Alzheimer disease or cognitive impairment.14 The published studies failed to report that an intention-to-treat analysis showed Vioxx to be associated with a significant increase in all-cause mortality. Turner and colleagues showed that trials of antidepressant drugs highlighted positive results as if they were the primary outcomes, contrary to the original study protocols.15 They concluded that, “By altering the apparent risk-benefit ratio of drugs, selective publication can lead doctors to make inappropriate prescribing decisions that may not be in the best interest of their patients and, thus, the public health.”The myriad of reasons why trials are selectively or never published include professional bias, profit, journal bias against negative studies, loss of interest, lack of funding, and competing interests. For example, when results do not confirm the beliefs of investigators, the motivation for their dissemination may weaken, as may the willingness of the investigator to devote time and resources to the publication. Companies may also lose interest when the findings are counter to embedded beliefs about a product. The end result is a scientific culture in which many experiments performed on patients are absent from the medical literature.Another issue relevant to selective and nonpublication is that access to a research database is commonly restricted to the principal investigator or the funders. For many trials, there is no opportunity for independent replication of the analyses or evaluation of the raw data. The US Food and Drug Administration has access to these data, but other experts do not.The sharing of trial data, as of yet uncommon except through mechanisms by some funders such as the National Heart, Lung, and Blood Institute,16 could provide an opportunity to leverage the strength of the global community of investigators. Many trials yield only a fraction of the knowledge that could be produced with more resources and creativity.Now is the time to bring data sharing and open science into the mainstream of clinical research, particularly with respect to trials that contain information about the risks and benefits of treatments in current use. This could be accomplished through the following steps:Post, in the public domain, the study protocol for each published trial. The protocol should be comprehensive and include policies and procedures relevant to actions taken in the trial.Develop mechanisms for those who own trial data to share their raw data and individual patient data.Encourage industry to commit to place all its clinical research data relevant to approved products in the public domain. This action would acknowledge that the privilege of selling products is accompanied by a responsibility to share all the clinical research data relevant to the products' benefits and harms.Develop a culture within academics that values data sharing and open science. After a period in which the original investigators can complete their funded studies, the data should be de-identified and made available for investigators globally.Identify, within all systematic reviews, trials that are not published, using sources such as clinicaltrials.gov and regulatory postings to determine what is missing.Share data.The path is not easy. We lack an infrastructure and funding, and incentives in the system run counter to sharing. Those who share may be giving advantage to “competitors.” The imperative, however, derives from what is best for society and our obligation to respect the contributions made by the subjects who agreed to participate in the research studies.Patients facing a decision deserve information that is based on all of the evidence. A new era of data sharing and open science would allow us to leverage existing investments to provide more and better evidence that will increase the possibility that patients' decisions will help them obtain the results they desire.Sources of FundingDr Krumholz is supported by grant U01 HL105270-02 (Center for Cardiovascular Outcomes Research at Yale University) from the National Heart, Lung, and Blood Institute.DisclosuresDr Krumholz discloses that he is the recipient of a research grant from Medtronic, Inc, through Yale University and is chair of a cardiac scientific advisory board for UnitedHealth.FootnotesThe opinions expressed in this article are not necessarily those of the American Heart Association.Correspondence to Harlan Krumholz, 1 Church St, Suite 200, New Haven, CT 06510. E-mail harlan.[email protected]edu

Interview: AcademyHealth and the future of comparative effectiveness research: making sure evidence matters

Dr Lisa Simpson is the president and CEO of AcademyHealth, and its advocacy arm, the Coalition for Health Services Research. A nationally recognized health policy researcher and pediatrician, Dr Simpson is a passionate advocate for the translation of research into policy and practice. Before joining AcademyHealth, Dr Simpson was director of the Child Policy Research Center at Cincinnati Children's Hospital Medical Center and Professor of Pediatrics in the Division of Health Policy and Clinical Effectiveness, Department of Pediatrics, University of Cincinnati (OH, USA). She served as the Deputy Director of the Agency for Healthcare Research and Quality (AHRQ) from 1996 to 2002. She previously served on the Institute of Medicine's Committee on Comparative Effectiveness Research Priorities and the Committee on Highly Effective Clinical Services. Dr Simpson is a member of the Robert Wood Johnson Clinical Scholars Program National Advisory Council and the AHRQ Healthcare Cost and Utilization Project (HCUP) Steering Committee. Dr Simpson's research focuses on improving the performance of the healthcare system and includes studies of the quality and safety of care, the role of health information technology in improving the quality of care, health and healthcare disparities, and the health policy and system response to childhood obesity. Dr Simpson earned her undergraduate and medical degrees at Trinity College (Dublin, Ireland), a master's in public health at the University of Hawaii (HI, USA), and completed a post-doctoral fellowship in health services research and health policy at the University of California, San Francisco (CA, USA).

Health Services Research Resources for Surgeons

Health services research examines how people get access to health care, how much care costs, and what happens to patients as a result of this care. Some of the challenges to conducting methodologically rigorous health services research as a surgeon are support, training, funding, acquisition of data, and resources. A review of support, training, funding, data, and organizational resources useful for surgeons interested in health services research, with a focus on existing online resources relevant to surgical health services researchers. Opportunities for research collaboration and mentoring are available through the Association for Academic Surgery, Society of University Surgeons, American College of Surgeons and surgical specialty societies. Advanced training is essential to performing high-impact health services research and is available through private foundations such as the Robert Wood Johnson Clinical Scholars program, the American College of Surgeons Fellowship, government funded fellowships, and institution hosted fellowships. Funding sources for health services research exist through academic surgical societies, private sector, and government sources. A variety of data sources for health services research are available, with different limitations, strengths, and ease of accessibility. Organizational resources in health services research include AcademyHealth, the Health Services Research Projects in Progress database, and the National Library of Medicine's Health Services Research Resources. The resources highlighted describe some of the opportunities available to surgeons pursuing health services research. It is valuable for surgeons to tap into the available resources and collaborate with existing expertise to facilitate methodologically rigorous surgical health services research.

What We Can and Cannot See Coming

HomeRadiologyVol. 257, No. 2 PreviousNext Reviews and CommentaryEditorialWhat We Can and Cannot See ComingChristoph I. Lee, Howard P. Forman Christoph I. Lee, Howard P. Forman Author Affiliations1From the Departments of Medicine and Radiology, Robert Wood Johnson Clinical Scholars Program, UCLA School of Medicine, Los Angeles, Calif (C.I.L.); and Department of Diagnostic Radiology, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510 (H.P.F.).Address correspondence to H.P.F. (e-mail: [email protected]).Christoph I. LeeHoward P. Forman Published Online:Nov 1 2010https://doi.org/10.1148/radiol.10101437MoreSectionsFull textPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In AbstractWhile radiology traditionally has been focused on reporting what we can see, can it be that a growing and fruitful component of our future profession will be based on reporting what we cannot see?References1 Budoff MJ, Hamirani YS, Gao YLet al.. Measurement of thoracic bone mineral density with quantitative CT. Radiology 2010;257(2):434–440. Link, Google Scholar2 Shemesh J, Henschke CI, Shaham Det al.. Ordinal scoring of coronary artery calcifications on low-dose CT scans of the chest is predictive of death from cardiovascular disease. Radiology 2010;257(2):541–548. Link, Google Scholar3 Gondrie MJ, Mali WP, Jacobs PC, Oen AL, van der Graaf Y; PROVIDI Study Group. Cardiovascular disease: prediction with ancillary aortic findings on chest CT scans in routine practice. Radiology 2010;257(2):549–559. Link, Google Scholar4 Lee CI, Tsai EB, Sigal BM, Plevritis SK, Garber AM, Rubin GD. Incidental extracardiac findings at coronary CT: clinical and economic impact. AJR Am J Roentgenol 2010;194(6):1531–1538. Crossref, Medline, Google Scholar5 Shortell SM, Casalino LP, Fisher ES. How the Center for Medicare and Medicaid Innovation should test accountable care organizations. Health Aff (Millwood) 2010;29(7):1293–1298. Crossref, Medline, Google Scholar6 Hendee WR. An opportunity for radiology. Radiology 2006;238(2):389–394. Link, Google ScholarArticle HistoryReceived July 19, 2010; revision requested July 20; revision received July 21; final version accepted July 21.Published online: Nov 2010Published in print: Nov 2010 FiguresReferencesRelatedDetailsCited ByClinical Imaging, Vol. 80JACC: Cardiovascular Imaging, Vol. 14, No. 2Clinical Imaging, Vol. 63American Journal of Roentgenology, Vol. 213, No. 3American Journal of Roentgenology, Vol. 212, No. 1Clinical Imaging, Vol. 50Clinical Imaging, Vol. 39, No. 6Breast Density: Comparison of Chest CT with MammographyMary Salvatore, Laurie Margolies, Minal Kale, Juan Wisnivesky, Sean Kotkin, Claudia I. Henschke, David F. Yankelevitz, 1 January 2014 | Radiology, Vol. 270, No. 1The British Journal of Radiology, Vol. 87, No. 1044Academic Radiology, Vol. 20, No. 12Academic Radiology, Vol. 19, No. 2Journal of the American College of Radiology, Vol. 9, No. 10Current Rheumatology Reports, Vol. 13, No. 3Recommended Articles Value-added Opportunistic CT Screening: State of the ArtRadiology2022Volume: 303Issue: 2pp. 241-254Invited Commentary: Coronary Artery Calcium Scoring—Simple Tool, Big ImpactRadioGraphics2022Volume: 42Issue: 4pp. E117-E118Opportunistic Osteoporosis Screening with Cardiac CT: Can We Predict Future Fractures?Radiology2020Volume: 296Issue: 3pp. 509-510Deep Learning for Automatic Calcium Scoring in CT: Validation Using Multiple Cardiac CT and Chest CT ProtocolsRadiology2020Volume: 295Issue: 1pp. 66-79Barriers to Lung Cancer Screening Engagement from the Patient and Provider PerspectiveRadiology2019Volume: 290Issue: 2pp. 278-287See More RSNA Education Exhibits Coronary Artery Calcium Scoring: Past, Present and FutureDigital Posters2020Shared Decision Making: A Primer for the Busy RadiologistDigital Posters2018Automated CT Biomarkers for Opportunistic Cardiometabolic Screening: Adding Value Beyond the Clinical Indication Digital Posters2019 RSNA Case Collection Small cell lung carcinomaRSNA Case Collection2020Diffuse idiopathic pulmonary neuroendocrine cell hyperplasiaRSNA Case Collection2020Pulmonary SequestrationRSNA Case Collection2022 Vol. 257, No. 2 Supplemental MaterialMetrics Altmetric Score PDF download

Consequences of Receipt of a Psychiatric Diagnosis for Completion of College

Back to table of contents Previous article Next article ArticleFull AccessConsequences of Receipt of a Psychiatric Diagnosis for Completion of CollegeJustin Hunt M.D., M.S.Daniel Eisenberg Ph.D.Amy M. Kilbourne Ph.D., M.P.H.Justin Hunt M.D., M.S.Search for more papers by this authorDaniel Eisenberg Ph.D.Search for more papers by this authorAmy M. Kilbourne Ph.D., M.P.H.Search for more papers by this authorPublished Online:1 Apr 2010https://doi.org/10.1176/ps.2010.61.4.399AboutSectionsView articleView PDFView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View article Mental disorders among college students appear to be increasing and may lead to substantial economic and functional impairment over time. About 90% of campus directors of counseling centers report an increase in psychological problems among their students ( 1 ), and the proportion of students with a previous diagnosis of depression increased from 10% to 15% between 2000 and 2005 ( 2 ). The first onset of most mental disorders occurs before or during the typical college ages of 18 to 24 ( 3 ), and the many social, economic, and academic pressures of college may further exacerbate these mental problems ( 4 ). Despite increased awareness about the prevalence of psychiatric disorders among college students, little is known about the impact of these disorders on the central educational mission of colleges: to provide knowledge and skills. The link between mental health and academic success in college is important to understand not only from the perspective of the institutions' objectives but also from a broader societal perspective. Over two-thirds of high school graduates attend postsecondary education ( 5 ), but only about half of college enrollees complete their degree ( 6 ). College completion has a beneficial effect on economic well-being through increased future earnings ( 7 , 8 ) and on physical health through lower mortality rates and better self-reported health ( 9 , 10 ). Mental illness may play an important role in this poor overall graduation rate and the resulting loss of societal human capital. Much of the evidence regarding the connection between mental health and academic outcomes for college students is based on small clinical samples. These studies primarily focused on depression ( 11 , 12 , 13 ) and indicate that measures of poor mental health are associated with worse academic outcomes. Two other studies examined nationally representative data from the National Comorbidity Survey (NCS) and the NCS-Replication (NCS-R), respectively. Using the NCS, Kessler and colleagues ( 14 ) found that failure to graduate from college was positively associated with several categories of mental disorders, but they did not examine specific DSM disorders. Breslau and colleagues ( 15 ) examined the impact of specific disorders on educational attainment but were unable to determine whether co-occurring disorders, such as substance use disorders, explained the impact of mood and anxiety disorders on outcomes. Improving our understanding of how co-occurring conditions affect educational attainment among students may help in prioritizing strategies in college mental health to improve care for the student population. In this study we evaluated the association between psychiatric disorders, such as bipolar I disorder, and the failure to complete college among college entrants. We analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), which were collected by the National Institute on Alcohol Abuse and Alcoholism in 2001–2002. The sample we derived from the NESARC data included 15,800 adults, aged 22 years and older, who had at least entered college.To our knowledge, this analysis used the largest available sample to analyze the relationship between psychiatric diagnoses and attainment of college education among college entrants. This large sample permitted the first analysis of a sample with multiple psychiatric disorders in the same regression models. Given the frequent comorbidity of the disorders included in this study, this approach is an important step toward disentangling the independent roles of disorders in educational outcomes.MethodsSample and data source The NESARC is a population-based survey providing data on the U.S. population regarding alcohol use as well as psychiatric and medical comorbidities. A total of 43,093 Americans participated in the first wave of the survey. The target population of the NESARC is the noninstitutionalized population that is aged 18 and older. Further information regarding the NESARC and its methodology can be found in the literature ( 16 , 17 ). To focus the analysis on the outcome of whether someone completed or dropped out of college, we limited the sample to people who at least entered college. We also limited the analysis to adults aged 22 years and older, given that few individuals obtain a college degree before age 22 ( 5 ). We excluded college students who were actively pursuing their degrees at the time of their interview because we could not code them as "successes" or "failures." Finally, we dropped adults who completed a two-year degree because we were focused primarily on the failure to graduate with a bachelor's degree, and we were unable to identify whether dropouts were attending a two-year or four-year institution. After applying these criteria, 15,800 persons remained in our primary analysis. Variables The primary outcome variable was coded as a binary variable, with 0 representing graduation from college with a bachelor's degree and 1 representing no graduation from college (in other words, some college but no bachelor's degree). The primary predictor variables were binary lifetime diagnoses, which were coded 0 for no diagnosis before age 22 and 1 for having that specific diagnosis before age 22. These diagnoses were made by using the NESARC survey instrument, the Alcohol Use Disorder and Associated Disability Interview Schedule—DSM-IV Version (AUDADIS-IV). The reliability and validity of this instrument are supported by multiple studies ( 16 , 17 ). Six lifetime psychiatric diagnoses were included in our model: mania (bipolar I), major depression, panic disorder with agoraphobia, social anxiety disorder, generalized anxiety disorder, and antisocial personality disorder. Four substance use disorders were included in our model, to cover alcohol, marijuana, stimulant (amphetamine), and cocaine abuse or dependence. These diagnoses were selected because they represent some of the most common diagnoses among adolescents and young adults, and their symptoms have plausible effects on academic success ( 18 ). They include the most severe diagnosis in each diagnostic category. For example, mania (bipolar I) was selected instead of hypomania (bipolar II), major depression was chosen over dysthymia, and panic disorder with agoraphobia was selected instead of agoraphobia or panic disorder alone. Sociodemographic covariates included age at time of interview, gender, race and ethnicity, family income, being raised in a female-headed household or not, country of birth (United States or not), urbanicity (rural, suburban, or urban), and region of residence (east, south, midwest, or west). Race and ethnicity included the following categories: white, non-Hispanic black, American Indian or Alaska Native, Asian, and Hispanic or Latino. These variables were selected on the basis of a large education literature that demonstrates their importance in postsecondary educational attainment ( 5 , 19 , 20 , 21 , 22 , 23 , 24 ). AnalysesWe completed our analyses in four stages. First, we conducted bivariate analyses to examine the relationship between the outcome variable of failure to graduate from college and the predictor variables, which were the diagnoses. Second, we performed separate regressions to examine the association between each diagnosis and educational attainment, controlling only for sociodemographic variables. Third, we looked at all of the clinical diagnoses in the same multivariable logistic regression model without controlling for sociodemographic variables. Fourth, we created our final model, which included all of the diagnoses as well as the sociodemographic variables. The final model discriminated reasonably well with a c statistic of .697. The p value for the likelihood ratio from the chi square test of the model was less than .001. Analyses were conducted with Stata version 10, and the study was classified as exempt by the University of Michigan Institutional Review Board.Results Of the 15,800 adults in our sample, 56% were women, 16% were non-Hispanic black, and 14% were of Hispanic or Latino ethnicity. Fifty-seven percent of the sample completed college, and 43% did not. Five percent of the sample met criteria for a diagnosis of major depression before age 22, and 26% of the sample met criteria for alcohol use disorder before age 22, indicating a high prevalence of heavy drinking in this population. The sociodemographic and clinical characteristics of the population are presented in Table 1 . Table 1 Sociodemographic and clinical characteristics of 15,800 adults who reported at least some college education, 2001–2002Table 1 Sociodemographic and clinical characteristics of 15,800 adults who reported at least some college education, 2001–2002Enlarge tableAmong the sociodemographic variables, being raised in a female-headed household was a strong predictor of failure to graduate from college (odds ratio [OR]=1.67, 95% confidence interval [CI]=1.48–1.88). Compared with the white reference group, non-Hispanic blacks (OR=1.48, CI=1.34–1.63), American Indians and Alaska Natives (OR=1.39, CI=1.04–1.86), and Hispanic and Latino adults (OR=1.80, CI=1.61–2.01) were significantly more likely to leave college without a degree. Adults in the midwest (OR=1.25, CI=1.12–1.39), south (OR=1.22, CI=1.11–1.35), and west (OR=1.37, CI=1.24–1.53) were more likely than college entrants in the northeast to leave college. In our final multivariable logistic regression model, which controlled for individuals' sociodemographic characteristics and diagnoses, we found five diagnoses to be significantly and positively associated with failure to graduate from college: bipolar I disorder, antisocial personality disorder, and marijuana, amphetamine, and cocaine use disorder ( Table 2 ). In the fourth model, cocaine abuse or dependence (OR=1.69) and bipolar I disorder (OR=1.70) had the strongest relationships with the dropping out of college. Major depression, social anxiety, and generalized anxiety all had significant unadjusted associations with failure to graduate from college (model 1) but insignificant associations when the sociodemographic variables were included (model 2). Antisocial personality disorder had a positive and significant relationship with failure to complete college in the final model (OR=1.31). Alcohol use disorder surprisingly had a very slight negative and insignificant association with completion of college (OR=.99). Marijuana, amphetamine, and cocaine use disorders were all positively related to dropout (OR=1.26, 1.50, and 1.69, respectively). Table 2 Logistic regressions of association between DSM-IV diagnosis and failure to graduate from college Table 2 Logistic regressions of association between DSM-IV diagnosis and failure to graduate from college Enlarge tableDiscussionMain findingsWe used a large, nationally representative sample to evaluate the independent associations between specific psychiatric disorders and postsecondary educational attainment. We found five diagnoses to be positively and significantly associated with the failure to graduate from college among college entrants: bipolar I disorder; marijuana, amphetamine, and cocaine use disorder; and antisocial personality disorder. Of particular interest is the finding that bipolar I disorder had a strong positive relationship with failure to graduate from college. Given the disabling nature of this disorder ( 25 , 26 , 27 ), it makes sense that it would have a strong relationship with educational failure, but why did it have a stronger relationship than other disabling conditions such as major depression, panic disorder with agoraphobia, or generalized anxiety disorder? All of these disorders consist of harmful symptoms that have the potential to affect academic functioning ( 28 , 29 ). Perhaps, underdetection of bipolar I disorder among adolescents ( 30 , 31 , 32 , 33 ) led to poor subsequent educational outcomes in college. Bipolar I disorder might be further exacerbated by the stressful lifestyle and workload of college, which often consists of poor sleeping habits, binge drinking, and relationship issues ( 4 ) that might trigger affective episodes. Considering the strong association between bipolar I disorder and educational attainment, further longitudinal investigation of possible mechanisms would be valuable. The other axis I disorders that demonstrated a significant, positive relationship with failure to graduate from college were all substance use disorders, including abuse of or dependence on marijuana, amphetamine, and cocaine. This finding is consistent with previous research analyzing the links between drug abuse and disability ( 34 , 35 ). One perhaps surprising finding was the slight negative and insignificant relationship of alcohol use disorder with the failure to graduate. Given the known detrimental effects of alcohol use disorders ( 36 , 37 , 38 ), this finding is difficult to explain, but similar findings have been reported in the past, especially in the white population ( 39 , 40 ). In the college population, it may be difficult to sort out recreational drinking from true problem drinking with DSM-IV diagnostic criteria alone. Antisocial personality disorder had a positive relationship with failure to graduate. Given that this disorder's criteria include irreverent behavior, criminal activity, and general disregard for societal rules ( 28 , 29 ), the college students with this diagnosis likely had legal difficulty that would be a definite barrier to completion of a degree ( 28 ). It is important to understand why several disorders, including major depression, panic disorder with agoraphobia, social anxiety, and generalized anxiety, had weak, insignificant associations in our model with failure to graduate. This finding could be due to a variety of factors that are not mutually exclusive. First, these conditions may not be as detrimental to academic productivity as commonly assumed. Second, students with these conditions may have benefited from more effective treatment and support than students with the conditions that are significantly associated with failure to graduate. Third, the estimated effects of these conditions may be confounded by unmeasured factors that differ among individuals with the conditions compared with individuals without those conditions. For example, to a certain extent young people with generalized anxiety disorder may be more likely to strive for perfection in their studies ( 41 ), which could enhance their educational performance. Fourth, respondents who were able to attend college despite having a previous diagnosis demonstrated resiliency—a trait that might be an important unmeasured factor in college graduation. Studies analyzing the link between mental health and education outcomes have primarily focused on primary and secondary education. Most noteworthy evidence for the college student population derives from small, clinical samples of counseling service clients at a single institution. These studies found that depression was negatively associated with academic success ( 11 , 13 , 42 ). These studies also suggest an important connection between mental health and college outcomes, but it is difficult to know how the results generalize to the broader populations of college students, including the large proportion of students with mental disorders who do not seek treatment ( 43 ). Kessler and colleagues ( 14 ) used data from the NCS to look at the association between categories of mental disorders and college graduation in the general population of college entrants. More recently, Breslau and colleagues ( 15 ) used NCS-R data to analyze associations between specific mental disorders (with childhood onset) and educational attainment. Although Breslau and colleagues ( 15 ) investigated the association between the number of co-occurring conditions and educational attainment, they noted that they did not have an adequate sample size to analyze multiple comorbid conditions simultaneously. The large NESARC sample we used allowed us to complement these earlier studies by analyzing multiple clinical diagnoses in the same model, taking into account their frequent comorbidity. We found results similar to those found by Breslau and colleagues ( 15 ) with respect to behavioral disorders. Among people who at least entered college, antisocial personality disorder was associated with failure to complete college (OR=1.31, p=.027). Breslau and colleagues analyzed conduct disorder (OR=1.3, p=.166) but not antisocial personality disorder. Similar to their results, our results showed that most anxiety and mood disorders were not significantly associated with failure to complete college, with the major exception of bipolar I disorder (OR=1.70, p=.004). After taking into account illness comorbidity in our model, we found that bipolar I disorder actually had a stronger relationship with failure to complete college than Breslau and colleagues found (OR=1.4 for bipolar I and II combined). Unlike Breslau and colleagues, we did not find that panic disorder (with agoraphobia) had a significant relationship with college completion. Although our results generally agree with those of Breslau and colleagues with respect to illicit drug abuse or dependence, we did not find a significant association between alcohol use disorder and failure to complete college after we controlled for the other DSM-IV diagnoses (OR=.99). Breslau and colleagues found a significant association for alcohol abuse (OR=1.3) ( 15 ). Finally, our findings suggest that simultaneously analyzing disorders affected the estimated magnitudes but did not substantially affect the main conclusions. In general, there was a consistent but modest reduction in the strength of the associations across all diagnoses when the other diagnoses were added into the model.Limitations Our study had some notable limitations. First, like the studies by Kessler and colleagues ( 14 ) and Breslau and colleagues ( 15 ), our study was retrospective in nature and likely subject to problems with recall bias. Also, similar to these other studies, in our study the NESARC's large sample made finding statistically significant ORs more likely, but it is critical to emphasize that our results were not only statistically significant but the point estimates were of magnitudes that were also clinically significant. Second, we controlled for multiple disorders simultaneously in our final model, but we did not examine patterns of comorbidity by analyzing interactions among disorders. In a sensitivity analysis, we looked at two potentially important interactions (between depression and alcohol and between depression and anxiety), and neither interaction reached statistical significance. Third, some of the NESARC respondents who reported dropping out of college before degree completion might return (or have returned) to complete their education in the future. Most of the respondents were well above the traditional college age range of 18 to 24, however, and the odds of completing college are only 12% for those who have ever stopped their college education ( 44 ). Fourth, NESARC did not evaluate respondents for attention-deficit hyperactivity disorder, obsessive-compulsive disorder, and psychotic disorders such as schizophrenia. It would be interesting to see how psychosis relates to the association of bipolar disorder with educational attainment, given that psychosis can be disabling and frequently occurs during manic or depressive episodes of bipolar I disorder.A fifth limitation in using data from NESARC for this analysis was that the lifetime diagnoses were nonhierarchical in nature, meaning that they were made before ruling out possible general medical causes and substance-induced symptoms. We addressed this limitation to a large extent by placing substance use disorders into the multivariable model, in effect controlling for substance abuse and dependence. Given the typical young age range of college students, it is unlikely that general medical conditions played a large role in causing psychiatric symptoms.A sixth limitation of our study is the fact that we investigated college graduation and not other measures of educational performance, such as number of years in college and grade point average. These outcomes are likely to be more sensitive and perhaps more affected by many of the psychiatric diagnoses, but they are not available in the NESARC data. Another limitation brought forth by the scope of the NESARC data was the inability to determine whether the respondents had active psychiatric symptoms during college. In sensitivity analysis, we focused only on disorders with an age of onset between 18 and 21, and our main results did not change. A final limitation was imposed by the scope of educational and sociodemographic variables available in the NESARC data. For example, there is no information on study skills or parents' educational attainment. In addition, we could not control for some of the "early life adversities" that Breslau and colleagues controlled for in their analysis ( 15 ). We note, however, that to the extent that these early life adversities cause childhood disorders (rather than affect educational outcomes directly), controlling for them could eliminate some of the effect that we aimed to estimate. Conclusions In our analysis of a large NESARC sample of college entrants, we found that four axis I disorders and one axis II disorder had significant and positive relationships with the failure to graduate from college among college entrants. Our study provides new data on which DSM-IV diagnoses are most associated with the failure to complete postsecondary education. Overall, our findings suggest that psychiatric factors play a significant role in college graduation, and the benefits of prevention, detection, and treatment may therefore include higher graduation rates. Acknowledgments and disclosuresThe Robert Wood Johnson Foundation provided salary support (two-year research fellowship for Dr. Hunt) through its Clinical Scholars Program.The authors report no competing interests.Dr. Hunt is affiliated with the Department of Psychiatry and Behavioral Sciences, University of Arkansas for Medical Sciences, 4301 W. Markham St., no. 755, Little Rock, AR 72205 (e-mail: [email protected]). Dr. Eisenberg is with the Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor. Dr. Kilbourne is with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor, and with the Serious Mental Illness Treatment Research and Evaluation Center, Health Services Research and Development, U.S. Department of Veterans Affairs, Ann Arbor. Results of this study were presented in part at the Robert Wood Johnson Clinical Scholars National Meeting, Washington, D.C., November 18–21, 2008.

Teaching Health Policy to Residents

Authors Reply:—We are delighted to see additional opportunities identified by Goetz et al. for both residents as well as students to learn about and engage in health policy. It is our hope that as interest in such experiences continues to rise, health policy will receive more attention in medical school and residency curricula across the country. Some schools and programs may even be able to coordinate their on-site education with intensive Washington-based initiatives, such as the ACEP Leadership Day. Furthermore, beyond residency, many internal medicine departments offer more in-depth training in health policy education and research through general internal medicine fellowships,1 and graduates of any specialty are eligible for similar training through the Robert Wood Johnson Clinical Scholars Program.2 We also agree that greater engagement by physicians in the political process is a laudable goal for health policy education, which is underscored by current health reform efforts. Indeed, low civic engagement by physicians3 might even be partially explained by missed opportunities to address gaps in health policy knowledge starting at medical school.4 Thus, the future challenge to JGIM readers as both educators and researchers is to seek better ways to teach health policy to physicians in training and to show that such training can make a difference in practice. Towards that end, we can think of few more gratifying rewards for our own efforts than to see students such as Ms. Goetz already engaged in this challenge along with her faculty!

A Physician Team's Experiences in Community-Based Participatory Research: Insights into Effective Group Collaborations

Postdoctoral fellows from the Robert Wood Johnson Clinical Scholars Program are among a growing number of physician-researchers training in community-based participatory research (CBPR). These fellows are uniquely positioned to observe and evaluate CBPR training needs and the experience of collaboratively conducting a CBPR project. To describe, from the perspective of physician-researchers, experiences in intragroup and intergroup collaborations while conducting CBPR. During a 2-year fellowship, a group of seven fellows received 6 months of didactic training and then spent 18 months conducting a mentored CBPR project. The CBPR project was complemented by a 2-year facilitated leadership seminar, which allowed for reflection on intragroup (among fellows) and intergroup (fellows/community members) relationships throughout the CBPR process. Seven core principles of CBPR were found to apply to not only intergroup but also intragroup relationships: (1) building trust, (2) finding a shared interest, (3) power-sharing, (4) fostering co-learning and capacity building among partners, (5) building on existing strengths, (6) employing an iterative process, and (7) finding a balance between research and action for the mutual benefit of all partners. Establishing and maintaining relationships is at the core of CBPR. The development of intragroup relationships paralleled the development of intergroup relationships with community members. Applying the core principles of CBPR to the development of intragroup relationships provided experience that may have enhanced relationships with community partners. An a priori acknowledgement of the importance of relationships and the time needed to develop and manage those relationships may add to the CBPR training experience and assist in successfully executing collaborative projects.

Patient Education to Reduce Prehospital Delay Time in Acute Coronary Syndrome

HomeCirculation: Cardiovascular Quality and OutcomesVol. 2, No. 6Patient Education to Reduce Prehospital Delay Time in Acute Coronary Syndrome Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBPatient Education to Reduce Prehospital Delay Time in Acute Coronary SyndromeNecessary But Not Sufficient Henry H. Ting, MD, MBA and Elizabeth H. Bradley, PhD Henry H. TingHenry H. Ting From the Knowledge and Encounter Research Unit, Division of Cardiovascular Diseases (H.H.T.), Mayo Clinic College of Medicine, Rochester, Minn; and the Division of Health Policy and Administration (E.H.B.), Yale School of Public Health, and Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, New Haven, Conn. Search for more papers by this author and Elizabeth H. BradleyElizabeth H. Bradley From the Knowledge and Encounter Research Unit, Division of Cardiovascular Diseases (H.H.T.), Mayo Clinic College of Medicine, Rochester, Minn; and the Division of Health Policy and Administration (E.H.B.), Yale School of Public Health, and Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, New Haven, Conn. Search for more papers by this author Originally published1 Nov 2009https://doi.org/10.1161/CIRCOUTCOMES.109.912188Circulation: Cardiovascular Quality and Outcomes. 2009;2:522–523Reducing time from symptom onset to reperfusion therapy decreases infarct size and improves survival in patients with ST-elevation myocardial infarction (STEMI). National quality improvement initiatives, including the Door-to-Balloon (D2B) Quality Alliance, have successfully disseminated evidence-based strategies to reduce door-to-balloon time.1,2 Many hospital systems have achieved the targeted door-to-balloon time <90 minutes for 75% of patients with STEMI presenting directly to a hospital with percutaneous coronary intervention capability.3 However, prehospital delay from time of symptom onset to hospital arrival remains the largest portion of the total delay time and has been refractory to interventions aimed at improving patient responsiveness.Article see p 524For patients with STEMI, longer prehospital delay is associated with higher in-hospital mortality even after adjusting for patient-, hospital-, and system-level variables including door-to-balloon or door-to-needle time.4,5 In the past 15 years, 2 randomized controlled trials have tested whether educational interventions to improve patient knowledge about acute coronary syndrome (ACS) symptoms and to promote patient action to call 9-1-1 would reduce prehospital delay time. Luepker and colleagues randomized 20 US cities to serve as controls or to receive 18 months of education targeting mass media, community and professional organizations, and patients and clinicians in the Rapid Early Action for Coronary Treatment (REACT) trial.6 The median prehospital delay time was 2.3 hours at baseline and decreased slightly (4.7% per year) during the 18 months in the intervention group; however, this trend was not significantly different to that observed in the control group (P=0.54). The use of emergency medical services (EMS) increased modestly in the intervention group from a baseline rate of 33% to 39% (P<0.005) and did not change in the control group.Since the disappointing findings from the REACT trial, there have been few insights or interventions to further our understanding of how to reduce prehospital delay. In this issue of Circulation: Cardiovascular Quality and Outcomes, Dracup et al7 randomized 3522 patients with documented coronary heart disease to receive an educational intervention or usual care in the Patient Response to Myocardial Infarction following a Teaching Intervention Offered by Nurses (PROMOTION) trial.7 The PROMOTION trial intervention consisted of a face-to-face encounter with a research nurse with cardiology expertise and telephone reinforcement at 1 month with the same nurse to improve patient knowledge about the symptoms and signs of heart attacks and to mitigate emotional and psychosocial reasons to delay. The primary outcomes, median prehospital delay time and use of EMS, were similar between intervention and control groups over 24 months follow-up (2.20 versus 2.25 hours, P=0.40, and 64% versus 67%, P=0.89, respectively).Despite these negative findings, the study was well-designed and conducted and provides important insights about prehospital delay. First, the marked variation in use of EMS between U.S. hospitals (33.3%) as compared to Australian hospitals (66.7%) was intriguing and provocative. Although variations in prehospital delay time at the country level were not reported, the substantial variation in use of EMS between the United States and Australia suggests that factors such as insurance coverage, psychosocial factors, and cultural beliefs may be important in understanding the outcomes of interest. Would universal healthcare insurance that provided coverage for EMS transport influence patients’ decision to immediately seek medical care or call 9-1-1? Previous studies have documented that uninsured and underinsured patients are associated with reluctance to seek medical care and to comply with prescribed medications.8 Furthermore, any observed variability in impact of education on prehospital delay time and use of EMS at the hospital-level would be particularly informative of contextual requirements for education to be an effective intervention.Second, subgroup analysis revealed that patients receiving the educational intervention were more likely than patients in the control group to use EMS if their ACS symptoms occurred within the first 6 months after the intervention, and, unlike other outcomes, this difference was statistically significant (P=0.036). Although it is not possible to draw conclusions from subgroup analyses because the variables affecting the outcomes of interest may not be balanced by randomization, this finding suggests that patient knowledge resulting from education may decay over time. The pattern of knowledge retention and the effectiveness of repeated educational interventions require additional investigation. The magnitude of effect in the higher use of EMS and any difference in prehospital delay time for patients within 6 months of the educational intervention were not reported.There are several implications of the PROMOTION trial for future studies seeking to understand and reduce prehospital delay. First, educational interventions are unlikely to have a major impact on prehospital delay time or use of EMS in patients with ACS. For educational interventions to be effective, there must be evidence that a knowledge gap exists in the targeted group, accounts for the observed defect, and can be corrected and sustained with an educational intervention.9 REACT and PROMOTION suggest that educational interventions to improve patient knowledge of ACS symptoms and promote patient responsiveness to seek medical care have failed to reduce prehospital delay time. Although patient education and knowledge transfer are important and necessary domains of clinical care, they are not sufficient to reduce prehospital delay time or increase use of EMS. Moreover, an ideal system of care should strive to normalize education interventions to be delivered and reinforced by the entire clinical team (including physicians) as a part of routine usual care.10 For instance, at the time of hospital discharge, a patient is required to uptake instructions from the physician and clinical team about diet, exercise, prescribed medications, and smoking cessation; consequently, will the patient be receptive to education about prehospital delay delivered solely by a nurse? Opportunities and teachable moments to normalize educational interventions include the time of hospital discharge, reconciliation of outpatient medications, stress testing, or cardiac rehabilitation.Second, researchers should seek causal factors for delay that may be amenable to intervention. Although previous studies have consistently shown that female gender, older age, and minority race are associated with longer prehospital delay, these variables are not modifiable with quality improvement interventions. However, a recent study exploring attachment theory has found that patients who had lower trustworthiness of others to provide needed care reported greater intention to delay to seek care for a heart attack.11 This low trustworthiness of others may be concentrated in patient sociodemographic characteristics associated with longer prehospital delay (ie, female gender, older age, minority race). Hence, although gender, age, and race may not be modifiable, the psychosocial and cultural beliefs of these vulnerable groups must be understood if we desire to effectively impact prehospital delay time. Furthermore, the patient’s ability to pay for healthcare costs, including the hospital admission and EMS transport, are structural factors likely associated with a patient’s decision to seek care. Differences in health insurance coverage and prehospital delay time would help illuminate the importance and magnitude of this variable.The cornerstone of treatment in patients with STEMI is to minimize the time from symptom onset to reperfusion therapy. Although much has been learned and disseminated on improving access to primary percutaneous coronary intervention, timeliness of primary percutaneous coronary intervention, and in-hospital mortality, prehospital delay time remains the longest portion of the total delay time and much work remains to be undertaken to understand why patients delay, and what structural and psychosocial factors could be modified to reduce prehospital delay time. Educational interventions have not been successful to date, although studies regarding the timing, intensity, decay, and who delivers the education would be informative. Perhaps, this field needs more innovative and disruptive strategies such as those used by marketing firms to understand and influence customer behavior to change the inertia in patient responsiveness.The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Guest Editor for this article was Paul A. Heidenreich, MD.DisclosuresNone.FootnotesCorrespondence to Henry H. Ting, MD, MBA, Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905. E-mail [email protected] References 1 Krumholz HM, Bradley EH, Nallamothu BK, Ting HH, Batchelor WB, Kline-Rogers E, Stern AF, Byrd JR, Brush JE. A campaign to improve the timeliness of primary percutaneous coronary intervention: Door-to-Balloon an alliance for quality. J Am Coll Cardiol Intv. 2008; 1: 97–104.CrossrefGoogle Scholar2 Nallamothu BK, Krumholz HM, Peterson ED, Pan W, Bradley E, Stern AF, Masoudi FA, Janicke DM, Hernandez AF, Cannon CP, Fonarow GC. Door-to-balloon times in hospitals within the Get-With-The-Guidelines registry after initiation of the Door-to-Balloon (D2B) Alliance. Am J Cardiol. 2009; 103: 1051–1055.CrossrefMedlineGoogle Scholar3 Nestler DM, Noheria A, Haro LH, Stead LG, Decker WW, Scanlan-Hanson LN, Lennon RJ, Lim C-C, Holmes DR Jr, Rihal CS, Bell MR, Ting HH. Sustaining improvement in door-to-balloon time over 4 years: The Mayo Clinic ST-elevation myocardial infarction protocol. Circ Cardiovasc Qual Outcomes. 2009; 2: 508–513.LinkGoogle Scholar4 Ting HH, Bradley EH, Wang Y, Lichtman JH, Nallamothu BK, Sullivan MD, Gersh BJ, Roger VL, Curtis JP, Krumholz HM. Factors associated with longer time from symptom onset to hospital presentation for patients with ST-elevation myocardial infarction. Arch Intern Med. 2008; 168: 959–968.CrossrefMedlineGoogle Scholar5 Ting HH, Bradley EH, Wang Y, Nallamothu BK, Gersh BJ, Roger VL, Lichtman JH, Curtis JP, Krumholz HM. Delay in presentation and reperfusion therapy in ST-elevation myocardial infarction. Am J Med. 2008; 121: 316–323.CrossrefMedlineGoogle Scholar6 Luepker RV, Raczynski JM, Osganian S, Goldberg RJ, Finnegan JR Jr, Hedges JR, Goff DC Jr, Eisenberg MS, Zapka JG, Feldman HA, Labarthe DR, McGovern PG, Cornell CE, Proschan MA, Simons-Morton DG. for the REACT Study Group. Effect of a community intervention on patient delay and emergency medical service use in acute coronary heart disease: The Rapid Early Action for Coronary Treatment (REACT) trial. JAMA. 2000; 284: 60–67.CrossrefMedlineGoogle Scholar7 Dracup K, McKinley S, Riegel B, Moser DK, Meischke H, Doering LV, Davidson P, Paul SM, Baker H, Pelter M. A randomized clinical trial to reduce patient prehospital delay to treatment in acute coronary syndrome. 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Farquharson B, Johnston M and Bugge C (2012) Appraisal and illness delay with symptoms of ACS: A questionnaire study of illness representations, British Journal of Cardiac Nursing, 10.12968/bjca.2012.7.10.493, 7:10, (493-499), Online publication date: 1-Oct-2012. November 2009Vol 2, Issue 6 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCOUTCOMES.109.912188PMID: 20031888 Originally publishedNovember 1, 2009 Keywordsmyocardial infarctionprehospital emergency carepatient educationPDF download Advertisement SubjectsAcute Coronary SyndromesEthics and PolicyMyocardial Infarction