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Biomedical subjects

R M Frankel

Publications and source records attributed to R M Frankel.

At least 19 recordsLinked to original sources
PubMed2001

One year's experience with a program to facilitate personal and professional development in medical students using reflection groups.

PURPOSE: (1) to integrate sociobehavioral science concepts into the early curriculum through a continuity ambulatory clinical experience in primary care, and (2) to expose students to a learning environment in which self-awareness and emotional development are nurtured in the context of dealing with the stresses of an early clinical experience. METHODS: Second-year students spent half a day twice monthly in a primary care community practice, kept a journal of their experiences, and attended biweekly 60-minute Reflection Groups designed to foster personal awareness and empathic witnessing. Analysis of journal entries and Reflection Group field notes identified stressors occurring during the students' clinical encounters. RESULTS: Three sources of stress are illustrated: the role and responsibility of the physician, death and dying, and racial issues. Reflection Groups provided students with opportunities to identify and describe stressors, to feel less isolated, to begin the process of self-awareness development, and to integrate behavioral and social science concepts into clinical practice. Our program incorporates students' early clinical experience with facilitated opportunities to reflect on the emotional challenges of becoming a physician.

Journal Article↗
PubMed2001

Getting qualitative research published.

Translating research findings in health education into a publishable manuscript is challenging regardless of whether qualitative or quantitative methods are used. In this paper, we offer practical advice about how to successfully prepare and guide manuscripts based on qualitative research methods, in particular through the peer-reviewed journal publication process. Researchers trying to publish qualitative findings may face some unique challenges, given the field's current knowledge of qualitative methods, evaluation criteria, and conventional manuscript styles and length.

Journal Article↗
PubMed2000

Qualitative research: a consumer's guide.

Qualitative research is best characterized as a family of approaches whose goal is understanding the lived experience of persons who share time, space and culture. Although they are often judged as a single entity, the approaches actually vary in their theoretical assumptions and canons of evidence. Four qualitative research domains that are currently used in studying education for health are reviewed here. They are ethnographic/field work approaches, use of interviews and surveys, audiovisual records, and the study of documents. Characteristics of each domain and brief examples are provided. In addition to introducing the four research domains, we offer some general guidelines on how to be a good consumer of qualitative research. We pose a series of questions about the importance of the research question, study design, and trustworthiness of qualitative research results. In addition, we focus on how research results are presented and discussed. We conclude with the observation that qualitative research approaches are only as good as the questions they set out to illuminate. In the arena of education for health a number of good and important questions remain unaddressed and would benefit by being studied using qualitative research approaches.

Journal Article↗
PubMed2000

Study design in qualitative research--1: Developing questions and assessing resource needs.

This is the second in a series of four papers on understanding and doing qualitative research [Frankel & Devers (2000) Qualitative research: a consumer's guide, Education for Health, 13, 113-123; Devers & Frankel (2000) Study design in qualitative research--2: sampling and data collection strategies, Education for Health, 13, 263-271]. Here, we focus on problems of study design, including question development, literature review, identifying a target audience and resource needs assessment. We provide a step-by-step description of major issues and choice points in the process. There are three key differences between qualitative and quantitative research designs. First, the logic of qualitative research is often inductive, rather than deductive, and consists of describing people's and groups' particular situations, meanings and experiences. Second, qualitative research designs are often emergent and flexible, and the research itself is quite dynamic. Third, the qualitative research process is non-linear and non-sequential. There is agreement that good qualitative studies answer clearly stated, important research questions. How qualitative research questions are formulated has implications for conducting a literature review. Some scholars believe that literature should be reviewed prior to beginning a study; others argue that this may impede the researcher from truly listening, observing and remaining open to new concepts and ideas. We offer suggestions about formulating research questions and how and when to conduct a literature review. Another important issue in conducting qualitative research is determining the resources that will be needed to conduct a study. These include internal resources, such as research skills, and external resources, such as personnel (expertise and time), equipment, supplies and travel. A description of typical resource and management issues in conducting a qualitative research study is included.

Journal Article↗
PubMed2000

Study design in qualitative research--2: Sampling and data collection strategies.

In two prior papers in our series on qualitative research [Frankel & Devers (2000a, 2000b) Qualitative research: a consumer's guide, Education for Health, 13, 113-123; Frankel & Devers (2000) Study design in qualitative research-1: developing research questions and assessing research needs, Education for Health, 13, 251-261], we examine two critical issues in qualitative research design: sampling, including identifying and negotiating access to research sites and subjects, and data collection and management. We describe these two key steps in the qualitative research design process, discuss challenges that often emerge when pursuing these steps, and provide guidelines for addressing them. Qualitative research most often uses "purposive," rather than random, sampling strategies. A good understanding of these sampling strategies and why they are used is central to designing a credible qualitative study. In addition, given the real-world context in which most qualitative research is carried out, identifying and negotiating access to research sites and subjects are critical parts of the process. We also provide suggestions for developing and maintaining productive and mutually satisfying research relationships with sites and subjects. Finally, data collection and management are often neglected subjects in qualitative research. We offer practical advice on how to collect and manage qualitative data, including factors to consider when deciding how structured the data collection process should be, the pros and cons of audio- and/or videotaping compared with note-taking, and tips for writing up field notes and document management. A forthcoming, final paper in the series will focus on qualitative data analysis and the publication of qualitative research results.

Journal Article↗
PubMed2000

The path to professionalism: cultivating humanistic values and attitudes in residency training.

Though few question the importance of incorporating professionalism and humanism in the training of physicians, traditional residency programs have given little direct attention to the processes by which professional and humanistic values, attitudes, and behaviors are cultivated. The authors discuss the underlying philosophy of their primary care internal medicine residency program, in which the development of professionalism and humanism is an explicit educational goal. They also describe the specific components of the program designed to create a learner-centered environment that supports the acquisition of professional values; these components include a communication-skills training program, challenging-case conferences, home visits with patients, a resident support group, and a mentoring program. The successful ten-year history of the program shows how a residency program can enable its trainees to develop not only the requisite excellent diagnostic and technical tools and skills but also the humane and professional attributes of the fully competent physician.

Attitude of Health Personnel↗
PubMed1999

Teaching self-awareness enhances learning about patient-centered interviewing.

PURPOSE: To evaluate the effect of intensive attitudinal training on residents' learning the patient-centered interviewing skills required to establish a healthy provider-patient relationship and to communicate effectively. METHOD: While teaching 53 residents patient-centered interviewing skills, the authors also trained them to recognize previously unrecognized, negative attitudes that interfered with learning the skills. The authors, using an iterative, consensus-building process based on the residents' performances and personality data, identified a spectrum of responses to the educational intervention. Barriers to and facilitators of mastery of skills were analyzed and this information was used to help residents overcome skill deficits. RESULTS: To varying degrees, 44 residents became aware of previously unrecognized attitudes to the extent that they improved their patient-centered interviewing skills. Six residents failed to develop awareness of negative attitudes and showed little learning and clinical use of the interviewing skills being taught. Three residents who rapidly developed superb interviewing skills showed no negative attitude towards using them. CONCLUSIONS: Pending a confirmatory hypothesis-testing study, the authors believe that, as residents learn how to conduct patient-centered interviews, training in awareness of interfering attitudes should accompany training in skills.

Attitude of Health Personnel↗
PubMed1998

Awkward moments in patient-physician communication about HIV risk.

BACKGROUND: Physicians frequently encounter patients who are at risk for HIV infection, but they often evaluate risk behaviors ineffectively. OBJECTIVE: To describe the barriers to and facilitators of comprehensive HIV risk evaluation in primary care office visits. DESIGN: Qualitative thematic and sequential analysis of videotaped patient-physician discussions about HIV risk. Tapes were reviewed independently by physician and patient and were coded by the research team. SETTING: Physicians' offices. PARTICIPANTS: Convenience sample of 17 family physicians and general internists. Twenty-six consenting patients 18 to 45 years of age who indicated concern about or risks for HIV infection on a 10-item questionnaire administered before the physician visit were included. MEASUREMENTS: A thematic coding scheme and a five-level description of the depth of HIV-related discussion. RESULTS: In 73% of the encounters, physicians did not elicit enough information to characterize patients' HIV risk status. The outcome of HIV-related discussions was substantially influenced by the manner in which the physician introduced the topic, handled awkward moments, and dealt with problematic language and the extent to which the physician sought the patient's perspective. Feelings of ineffectiveness and strong emotions interfered with some physicians' ability to assess HIV risk. Physicians easily recognized problematic communication during reviews of their own videotapes. CONCLUSIONS: Comprehensive HIV risk discussions included providing a rationale for discussion, effectively negotiating awkward moments, repairing problematic language, persevering with the topic, eliciting the patient's perspective, responding to fears and expectations, and being empathic. Educational programs should use videotape review and should concentrate on physicians' personal reactions to discussing emotionally charged topics.

Adolescent↗
PubMed1998

Recruiting physicians for office-based research.

OBJECTIVES: Research conducted in community outpatient offices can provide insight into the common experiences of patients and physicians. However, recruiting physicians to participate in office-based research is challenging and few descriptions of methods that have been used to successfully recruit random samples of physicians are available. This article describes recruitment strategies utilized in a project that achieved high rates of participation from community-based primary care physicians and surgeons. METHODS: Recruitment methods included the use of advisory boards to identify potential barriers to participation, use of respected members of the medical community as recruiters, and obtaining endorsements from physician organizations and prominent members of the medical community. RESULTS: Overall, 81% of physicians contacted from a sample frame agreed to participate in the project. Participating physicians most frequently reported that they participated because the project could provide them with feedback about their interviewing style. CONCLUSIONS: The recruitment methods described here can be generalized to other types of investigations.

Colorado↗
PubMed1997

Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons.

OBJECTIVE: To identify specific communication behaviors associated with malpractice history in primary care physicians and surgeons. DESIGN: Comparison of communication behaviors of "claims" vs "no-claims" physicians using audiotapes of 10 routine office visits per physician. SETTINGS: One hundred twenty-four physician offices in Oregon and Colorado. PARTICIPANTS: Fifty-nine primary care physicians (general internists and family practitioners) and 65 general and orthopedic surgeons and their patients. Physicians were classified into no-claims or claims (> or =2 lifetime claims) groups based on insurance company records and were stratified by years in practice and specialty. MAIN OUTCOME MEASURES: Audiotape analysis using the Roter Interaction Analysis System. RESULTS: Significant differences in communication behaviors of no-claims and claims physicians were identified in primary care physicians but not in surgeons. Compared with claims primary care physicians, no-claims primary care physicians used more statements of orientation (educating patients about what to expect and the flow of a visit), laughed and used humor more, and tended to use more facilitation (soliciting patients' opinions, checking understanding, and encouraging patients to talk). No-claims primary care physicians spent longer in routine visits than claims primary care physicians (mean, 18.3 vs 15.0 minutes), and the length of the visit had an independent effect in predicting claims status. The multivariable model for primary care improved the prediction of claims status by 57% above chance (90% confidence interval, 33%-73%). Multivariable models did not significantly improve prediction of claims status for surgeons. CONCLUSIONS: Routine physician-patient communication differs in primary care physicians with vs without prior malpractice claims. In contrast, the study did not find communication behaviors to distinguish between claims vs no-claims surgeons. The study identifies specific and teachable communication behaviors associated with fewer malpractice claims for primary care physicians. Physicians can use these findings as they seek to improve communication and decrease malpractice risk. Malpractice insurers can use this information to guide malpractice risk prevention and education for primary care physicians but should not assume that it is appropriate to teach similar behaviors to other specialty groups.

Colorado↗
PubMed1996

Ethnography: a stepwise approach for primary care researchers.

Ethnography is a research method borrowed from cultural anthropology and a disciplined method for understanding human conduct. It is a valid alternative to quantitative methods for primary care researchers. This article reviews the defining principles of ethnographic research, which uses principally observational methods to study actions and events that exist in natural situations. It is the job of ethnographic researchers to establish and frame their observations from the point of view of the people under observation. We present five steps fundamental to the development of an ethnographic research plan and a research case study that demonstrates the use of ethnography by a family physician.

Anthropology, Cultural↗
PubMed1994

The doctor-patient relationship and malpractice. Lessons from plaintiff depositions.

BACKGROUND: The current literature does not provide an answer to the question, "What prompts patients to sue doctors or hospitals?" Not all adverse outcomes result in suits, and threatened suits do not always involve adverse outcomes. The exploration of other factors has been hampered by the lack of a methodology to contact plaintiffs and elicit their views about their experience in delivered health care. This study employed the transcripts of discovery depositions of plaintiffs as a source of insight into the issues that prompted individuals to file a malpractice claim. METHODS: This study is a descriptive series review of a convenience sample of 45 plaintiffs' depositions selected randomly from 67 depositions made available from settled malpractice suits filed between 1985 and 1987 against a large metropolitan medical center. Information extracted from each deposition included the alleged injury; the presence of the question, "Why are you suing?" and, if present, the answer; the presence of problematic relationship issues between providers and patients and/or families and, if present, the discourse supporting it; the presence of the question, "Did a health professional suggest maloccurrence?" and, if yes, who. Using a process of consensual validation, relationship issues were organized into groups of more generalized categories suggested by the data. Answers to the questions, "Why are you suing?" and "Who suggested maloccurrence?" are described. RESULTS: Problematic relationship issues were identified in 71% of the depositions with an interrater reliability of 93.3%. Four themes emerged from the descriptive review of the 3787 pages of transcript: deserting the patient (32%), devaluing patient and/or family views (29%), delivering information poorly (26%), and failing to understand the patient and/or family perspective (13%). Thirty-one plaintiffs were asked if health professionals suggested maloccurrence. Fifty-four percent (n = 17) responded affirmatively. The postoutcome-consulting specialist was named in 71% (n = 12) of the depositions in which maloccurrence was allegedly suggested. CONCLUSIONS: In our sample, the decision to litigate was often associated with a perceived lack of caring and/or collaboration in the delivery of health care. The issues identified included perceived unavailability, discounting patient and/or family concerns, poor delivery of information, and lack of understanding the patient and/or family perspective. Particular attention should be paid to the postadverse-event consultant-patient interaction.

Adult↗
PubMed1994

The use of videotape in internal medicine training.

By paying attention to the power of the medium and the method of feedback, videotaping programs can be a remarkably successful teaching and research tool. Learners can view their performance, review feedback on their own behavior, knowledge, and displayed attitudes, and develop plans to change behavior that can be followed up on subsequent tappings. In addition, trainees can share important experiences with each other and valued teachers. Interviewing skills can be documented and preserved, creating a video library that allows trainees to actually visualize improvements in their own performances over time. An archive of many such performances allows trainees, faculty, and researchers alike comparative access to the complex challenges of the medical interview.

Decision Making↗
PubMed1994

Detection of the new tuberculosis: ocular examination as a diagnostic imperative.

BACKGROUND: Until recently, tuberculosis in the U.S. had been considered a public health concern of the past, largely conquered by therapy devised in the 1950s. However, in the past several years, the incidence of tuberculosis has increased steeply and unexpectedly, owing to a conspiracy of new factors. These include: the epidemic of acquired immune deficiency, the emergence of drug-resistant strains, the confinement of susceptibles in crowded shelters, and the premature demolition of public health programs. METHODS: A dynamic interplay exists between the tubercle bacillus and the declining immune system in AIDS patients. Because of this, many atypical, clinical presentations of tuberculosis have emerged. RESULTS: The detection of ocular manifestations of tuberculosis has thus assumed increased importance. It can allow not only for an earlier diagnosis of TB, but an earlier diagnosis of AIDS, preventing spread of both diseases within the population. CONCLUSIONS: Evaluation of ocular signs of tuberculosis should now be a diagnostic imperative.

AIDS-Related Opportunistic Infections↗
PubMed1984

The effect of physician behavior on the collection of data.

Determining the patient's major reasons for seeking care is of critical importance in a successful medical encounter. To study the physician's role in soliciting and developing the patient's concerns at the outset of a clinical encounter, 74 office visits were recorded. In only 17 (23%) of the visits was the patient provided the opportunity to complete his or her opening statement of concerns. In 51 (69%) of the visits the physician interrupted the patient's statement and directed questions toward a specific concern; in only 1 of these 51 visits was the patient afforded the opportunity to complete the opening statement. In six (8%) return visits, no solicitation whatever was made. Physicians play an active role in regulating the quantity of information elicited at the beginning of the clinical encounter, and use closed-ended questioning to control the discourse. The consequence of this controlled style is the premature interruption of patients, resulting in the potential loss of relevant information.

Communication Barriers↗