Skip to main content
Top

18-06-2015 | Psychosocial care | Review | Article

A Review of Adolescent Adherence in Type 1 Diabetes and the Untapped Potential of Diabetes Providers to Improve Outcomes

Journal: Current Diabetes Reports

Authors: Karishma A. Datye, Daniel J. Moore, William E. Russell, Sarah S. Jaser

Publisher: Springer US

Abstract

Only 21 % of adolescents with type 1 diabetes (T1D) meet glycemic goals set forth by the American Diabetes Association. Adherence to therapy is a particular concern in this population, and the association between poor adherence and worsening glycemic control indicates that there is a critical need to improve adherence to therapy in adolescents with T1D. In this article, we review barriers to adherence in adolescents with T1D and discuss interventions aimed at improving adherence to therapy and glycemic control. Interventions include technology-based applications, family-based therapies, motivational interviewing, and others. Notably, less than 10 % of the interventions reviewed are provider-led, clinic-based interventions, and few have focused on regimen-related aspects of adherence. This article also outlines the importance of provider communication and the role of providers in facilitating adherence behaviors in adolescents with T1D. Finally, we suggest future directions of research to improve adherence to therapy in adolescents with T1D.
Literature
1.••
Wood JR, Miller KM, Maahs DM, Beck RW, DiMeglio LA, Libman IM, et al. Most youth with type 1 diabetes in the T1D Exchange Clinic Registry do not meet American Diabetes Association or International Society for Pediatric and Adolescent Diabetes clinical guidelines. Diabetes Care. 2013;36(7):2035–7. doi:10.​2337/​dc12-1959. This article demonstrates that even before the pediatric glycemic goals of the ADA changed, most youth were not achieving recommended hemoglobin A1c levels.PubMedCentralPubMedCrossRef
2.
The American Diabetes Association. Standards of Medical Care in Diabetes-2015. Diabetes Care. 2015;38:S1–93.CrossRef
3.
The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977–86. doi:10.​1056/​nejm199309303291​401.CrossRef
4.
Hood KK, Peterson CM, Rohan JM, Drotar D. Association between adherence and glycemic control in pediatric type 1 diabetes: a meta-analysis. Pediatrics. 2009;124(6):e1171–9. doi:10.​1542/​peds.​2009-0207.​ PubMed.PubMedCrossRef
5.
Zolnierek KB, Dimatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care. 2009;47(8):826–34. doi:10.​1097/​MLR.​0b013e31819a5acc​.PubMedCrossRef
6.
Wong JC, Foster NC, Maahs DM, Raghinaru D, Bergenstal RM, Ahmann AJ, et al. Real-time continuous glucose monitoring among participants in the T1D Exchange clinic registry. Diabetes Care. 2014;37(10):2702–9. doi:10.​2337/​dc14-0303.​ PubMed.PubMedCrossRef
7.••
Rausch JR, Hood KK, Delamater A, Shroff Pendley J, Rohan JM, Reeves G, et al. Changes in treatment adherence and glycemic control during the transition to adolescence in type 1 diabetes. Diabetes Care. 2012;35(6):1219–24. doi:10.​2337/​dc11-2163. This article finds that blood glucose monitoring frequency can be used as a surrogate for treatment adherence and that declining adherence to therapy leads to worsening glycemic control. Notably, the article also demonstrates that glycemic control should not be used as a surrogate for adherence to therapy.PubMedCentralPubMedCrossRef
8.
Helgeson VS, Honcharuk E, Becker D, Escobar O, Siminerio L. A focus on blood glucose monitoring: relation to glycemic control and determinants of frequency. Pediatr Diabetes. 2011;12(1):25–30. doi:10.​1111/​j.​1399-5448.​2010.​00663.​x.PubMedCentralPubMedCrossRef
9.
Palmer DL, Osborn P, King PS, Berg CA, Butler J, Butner J, et al. The structure of parental involvement and relations to disease management for youth with type 1 diabetes. J Pediatr Psychol. 2011;36(5):596–605. doi:10.​1093/​jpepsy/​jsq019.PubMedCentralPubMedCrossRef
10.
Berg CA, Butler JM, Osborn P, King G, Palmer DL, Butner J, et al. Role of parental monitoring in understanding the benefits of parental acceptance on adolescent adherence and metabolic control of type 1 diabetes. Diabetes Care. 2008;31(4):678–83. doi:10.​2337/​dc07-1678.PubMedCrossRef
11.
Lloyd SM, Cantell M, Pacaud D, Crawford S, Dewey D. Brief report: hope, perceived maternal empathy, medical regimen adherence, and glycemic control in adolescents with type 1 diabetes. J Pediatr Psychol. 2009;34(9):1025–9. doi:10.​1093/​jpepsy/​jsn141.PubMedCrossRef
12.
Mlynarczyk SM. Adolescents’ perspectives of parental practices influence diabetic adherence and quality of life. Pediatr Nurs. 2013;39(4):181–9.PubMed
13.
Ingerski LM, Anderson BJ, Dolan LM, Hood KK. Blood glucose monitoring and glycemic control in adolescence: contribution of diabetes-specific responsibility and family conflict. J Adolesc Health. 2010;47(2):191–7. doi:10.​1016/​j.​jadohealth.​2010.​01.​012.PubMedCentralPubMedCrossRef
14.
Berg CA, King PS, Butler JM, Pham P, Palmer D, Wiebe DJ. Parental involvement and adolescents’ diabetes management: the mediating role of self-efficacy and externalizing and internalizing behaviors. J Pediatr Psychol. 2011;36(3):329–39. doi:10.​1093/​jpepsy/​jsq088.PubMedCentralPubMedCrossRef
15.
Horton D, Berg CA, Butner J, Wiebe DJ. The role of parental monitoring in metabolic control: effect on adherence and externalizing behaviors during adolescence. J Pediatr Psychol. 2009;34(9):1008–18. doi:10.​1093/​jpepsy/​jsp022.PubMedCentralPubMedCrossRef
16.
Hilliard ME, Holmes CS, Chen R, Maher K, Robinson E, Streisand R. Disentangling the roles of parental monitoring and family conflict in adolescents’ management of type 1 diabetes. Health Psychol. 2013;32(4):388–96. doi:10.​1037/​a0027811.PubMedCrossRef
17.
Wysocki T, Gavin L. Paternal involvement in the management of pediatric chronic diseases: associations with adherence, quality of life, and health status. J Pediatr Psychol. 2006;31(5):501–11. doi:10.​1093/​jpepsy/​jsj042.PubMedCrossRef
18.
Hood KK, Butler DA, Anderson BJ, Laffel LM. Updated and revised diabetes family conflict scale. Diabetes Care. 2007;30(7):1764–9. doi:10.​2337/​dc06-2358.PubMedCrossRef
19.
Lewin AB, Heidgerken AD, Geffken GR, Williams LB, Storch EA, Gelfand KM, et al. The relation between family factors and metabolic control: the role of diabetes adherence. J Pediatr Psychol. 2006;31(2):174–83. doi:10.​1093/​jpepsy/​jsj004.PubMedCrossRef
20.
Cameron FJ, Skinner TC, de Beaufort CE, Hoey H, Swift PG, Aanstoot H, et al. Are family factors universally related to metabolic outcomes in adolescents with type 1 diabetes? Diabet Med. 2008;25(4):463–8. doi:10.​1111/​j.​1464-5491.​2008.​02399.​x.PubMedCrossRef
21.
La Greca AM, Auslander WF, Greco P, Spetter D, Fisher Jr EB, Santiago JV. I get by with a little help from my family and friends: adolescents’ support for diabetes care. J Pediatr Psychol. 1995;20(4):449–76.PubMedCrossRef
22.
Palladino DK, Helgeson VS. Friends or foes? A review of peer influence on self-care and glycemic control in adolescents with type 1 diabetes. J Pediatr Psychol. 2012;37(5):591–603. doi:10.​1093/​jpepsy/​jss009.PubMedCentralPubMedCrossRef
23.
Helgeson VS, Mascatelli K, Reynolds KA, Becker D, Escobar O, Siminerio L. Friendship and romantic relationships among emerging adults with and without type 1 diabetes. J Pediatr Psychol. 2014. doi:10.​1093/​jpepsy/​jsu069.
24.
Saluja G, Iachan R, Scheidt PC, Overpeck MD, Sun W, Giedd JN. Prevalence of and risk factors for depressive symptoms among young adolescents. Arch Pediatr Adolesc Med. 2004;158(8):760–5. doi:10.​1001/​archpedi.​158.​8.​760.PubMedCrossRef
25.
Northam EA, Matthews LK, Anderson PJ, Cameron FJ, Werther GA. Psychiatric morbidity and health outcome in type 1 diabetes—perspectives from a prospective longitudinal study. Diabet Med. 2005;22(2):152–7. doi:10.​1111/​j.​1464-5491.​2004.​01370.​x.PubMedCrossRef
26.
McGrady ME, Hood KK. Depressive symptoms in adolescents with type 1 diabetes: associations with longitudinal outcomes. Diabetes Res Clin Pract. 2010;88(3):e35–7. doi:10.​1016/​j.​diabres.​2010.​03.​025.PubMedCentralPubMedCrossRef
27.
Herzer M, Hood KK. Anxiety symptoms in adolescents with type 1 diabetes: association with blood glucose monitoring and glycemic control. J Pediatr Psychol. 2010;35(4):415–25. doi:10.​1093/​jpepsy/​jsp063.PubMedCentralPubMedCrossRef
28.
Hanlan ME, Griffith J, Patel N, Jaser SS. Eating disorders and disordered eating in type 1 diabetes: prevalence, screening, and treatment options. Curr Diab Rep. 2013. doi:10.​1007/​s11892-013-0418-4.PubMedCentralPubMed
29.••
Valenzuela JM, Seid M, Waitzfelder B, Anderson AM, Beavers DP, Dabelea DM, et al. Prevalence of and disparities in barriers to care experienced by youth with type 1 diabetes. J Pediatr. 2014;164(6):1369–75.e1. doi:10.​1016/​j.​jpeds.​2014.​01.​035. The authors find that there are several barriers to care in youth with diabetes within the US and highlight the most prominent barriers to care.
30.
Burdick J, Chase HP, Slover RH, Knievel K, Scrimgeour L, Maniatis AK, et al. Missed insulin meal boluses and elevated hemoglobin A1c levels in children receiving insulin pump therapy. Pediatrics. 2004;113(3 Pt 1):e221–4.PubMedCrossRef
31.
Mulvaney SA, Rothman RL, Dietrich MS, Wallston KA, Grove E, Elasy TA, et al. Using mobile phones to measure adolescent diabetes adherence. Health Psychol. 2012;31(1):43–50. doi:10.​1037/​a0025543.PubMedCentralPubMedCrossRef
32.
Hood KK, Rohan JM, Peterson CM, Drotar D. Interventions with adherence-promoting components in pediatric type 1 diabetes: meta-analysis of their impact on glycemic control. Diabetes Care. 2010;33(7):1658–64. doi:10.​2337/​dc09-2268.PubMedCentralPubMedCrossRef
33.
Grey M, Boland EA, Davidson M, Li J, Tamborlane WV. Coping skills training for youth with diabetes mellitus has long-lasting effects on metabolic control and quality of life. J Pediatr. 2000;137(1):107–13. doi:10.​1067/​mpd.​2000.​106568.PubMedCrossRef
34.
Miller WR, Rollnick S. Motivational interviewing: helping people change. 3rd ed. New York: Guilford Press; 2013.
35.•
Gayes LA, Steele RG. A meta-analysis of motivational interviewing interventions for pediatric health behavior change. J Consult Clin Psychol. 2014;82(3):521–35. doi:10.​1037/​a0035917. This meta-analysis reviews the literature on motivational interviewing (MI) in pediatric medicine and finds that MI might be a helpful way to influence change in this population.PubMedCrossRef
36.
Robling M, McNamara R, Bennert K, Butler CC, Channon S, Cohen D, et al. The effect of the talking diabetes consulting skills intervention on glycaemic control and quality of life in children with type 1 diabetes: cluster randomised controlled trial (DEPICTED study). The effect of the talking diabetes consulting skills intervention on glycaemic control and quality of life in children with type 1 diabetes: cluster randomised controlled trial (DEPICTED study). BMJ. 2012;344:e2359. doi:10.​1136/​bmj.​e2359.PubMedCentralPubMedCrossRef
37.
Powell PW, Hilliard ME, Anderson BJ. Motivational interviewing to promote adherence behaviors in pediatric type 1 diabetes. Curr Diab Rep. 2014;14(10):531. doi:10.​1007/​s11892-014-0531-z.PubMedCentralPubMedCrossRef
38.
Jaser SS, Patel N, Rothman RL, Choi L, Whittemore R. Check it! A randomized pilot of a positive psychology intervention to improve adherence in adolescents with type 1 diabetes. Diabetes Educ. 2014;40(5):659–67. doi:10.​1177/​0145721714535990​.PubMedCrossRef
39.
Salamon KS, Hains AA, Fleischman KM, Davies WH, Kichler J. Improving adherence in social situations for adolescents with type 1 diabetes mellitus (T1DM): a pilot study. Prim Care Diabetes. 2010;4(1):47–55. doi:10.​1016/​j.​pcd.​2009.​10.​003.PubMedCrossRef
40.
Svoren BM, Butler D, Levine BS, Anderson BJ, Laffel LM. Reducing acute adverse outcomes in youths with type 1 diabetes: a randomized, controlled trial. Pediatrics. 2003;112(4):914–22.PubMedCrossRef
41.
Katz ML, Volkening LK, Butler DA, Anderson BJ, Laffel LM. Family-based psychoeducation and care ambassador intervention to improve glycemic control in youth with type 1 diabetes: a randomized trial. Pediatr Diabetes. 2014;15(2):142–50. doi:10.​1111/​pedi.​12065.PubMedCentralPubMedCrossRef
42.
Lenhart A. Pew Research Center. Teens, social media and technology overview 2015 [cited 2015 May 4th]. Available from: http://​www.​pewinternet.​org/​2015/​04/​09/​teens-social-media-technology-2015.
43.
Lenhart A. Pew Research Center. Cell phone ownership 2012 [cited 2015 February 11]. Available from: http://​www.​pewinternet.​org/​2012/​03/​19/​cell-phone-ownership/​.
44.
Smith A. Pew Research Center. U.S. Smartphone Use in 2015 [cited 2015 May 4th]. Available from: http://​www.​pewinternet.​org/​2015/​04/​01/​us-smartphone-use-in-2015/​.
45.
Mulvaney SA, Anders S, Smith AK, Pittel EJ, Johnson KB. A pilot test of a tailored mobile and web-based diabetes messaging system for adolescents. J Telemed Telecare. 2012;18(2):115–8. doi:10.​1258/​jtt.​2011.​111006.PubMedCentralPubMedCrossRef
46.
Hanauer DA, Wentzell K, Laffel N, Laffel LM. Computerized Automated Reminder Diabetes System (CARDS): e-mail and SMS cell phone text messaging reminders to support diabetes management. Diabetes Technol Ther. 2009;11(2):99–106. doi:10.​1089/​dia.​2008.​0022.PubMedCrossRef
47.•
Herbert L, Owen V, Pascarella L, Streisand R. Text message interventions for children and adolescents with type 1 diabetes: a systematic review. Diabetes Technol Ther. 2013;15(5):362–70. doi:10.​1089/​dia.​2012.​0291. This review outlines text messaging interventions that aim to improve glycemic control in pediatric patients with type 1 diabetes. While several interventions have been trialed, their effect on glycemic control is unclear.PubMedCrossRef
48.
Franklin VL, Waller A, Pagliari C, Greene SA. A randomized controlled trial of sweet talk, a text-messaging system to support young people with diabetes. Diabet Med. 2006;23(12):1332–8. doi:10.​1111/​j.​1464-5491.​2006.​01989.​x.PubMedCrossRef
49.
Brown SJ, Lieberman DA, Germeny BA, Fan YC, Wilson DM, Pasta DJ. Educational video game for juvenile diabetes: results of a controlled trial. Med Inform (Lond). 1997;22(1):77–89.CrossRef
50.
Kumar VS, Wentzell KJ, Mikkelsen T, Pentland A, Laffel LM. The DAILY (Daily Automated Intensive Log for Youth) trial: a wireless, portable system to improve adherence and glycemic control in youth with diabetes. Diabetes Technol Ther. 2004;6(4):445–53. doi:10.​1089/​1520915041705893​.PubMedCrossRef
51.
Marrero DG, Vandagriff JL, Kronz K, Fineberg NS, Golden MP, Gray D, et al. Using telecommunication technology to manage children with diabetes: the Computer-Linked Outpatient Clinic (CLOC) study. Diabetes Educ. 1995;21(4):313–9.PubMedCrossRef
52.
Raiff BR, Dallery J. Internet-based contingency management to improve adherence with blood glucose testing recommendations for teens with type 1 diabetes. J Appl Behav Anal. 2010;43(3):487–91. doi:10.​1901/​jaba.​2010.​43-487.PubMedCentralPubMedCrossRef
53.
Cafazzo JA, Casselman M, Hamming N, Katzman DK, Palmert MR. Design of an mHealth app for the self-management of adolescent type 1 diabetes: a pilot study. J Med Internet Res. 2012;14(3):e70. doi:10.​2196/​jmir.​2058.PubMedCentralPubMedCrossRef
54.
Anderson BJ, Brackett J, Ho J, Laffel LM. An office-based intervention to maintain parent-adolescent teamwork in diabetes management. Impact on parent involvement, family conflict, and subsequent glycemic control. Diabetes Care. 1999;22(5):713–21.PubMedCrossRef
55.
Laffel LM, Vangsness L, Connell A, Goebel-Fabbri A, Butler D, Anderson BJ. Impact of ambulatory, family-focused teamwork intervention on glycemic control in youth with type 1 diabetes. J Pediatr. 2003;142(4):409–16. doi:10.​1067/​mpd.​2003.​138.PubMedCrossRef
56.
Nansel TR, Iannotti RJ, Simons-Morton BG, Cox C, Plotnick LP, Clark LM, et al. Diabetes personal trainer outcomes: short-term and 1-year outcomes of a diabetes personal trainer intervention among youth with type 1 diabetes. Diabetes Care. 2007;30(10):2471–7. doi:10.​2337/​dc06-2621.PubMedCentralPubMedCrossRef
57.
Holmes CS, Chen R, Mackey E, Grey M, Streisand R. Randomized clinical trial of clinic-integrated, low-intensity treatment to prevent deterioration of disease care in adolescents with type 1 diabetes. Diabetes Care. 2014;37(6):1535–43. doi:10.​2337/​dc13-1053.PubMedCentralPubMedCrossRef
58.
Cook S, Herold K, Edidin DV, Briars R. Increasing problem solving in adolescents with type 1 diabetes: the choices diabetes program. Diabetes Educ. 2002;28(1):115–24.PubMedCrossRef
59.
Howe CJ, Jawad AF, Tuttle AK, Moser JT, Preis C, Buzby M, et al. Education and telephone case management for children with type 1 diabetes: a randomized controlled trial. J Pediatr Nurs. 2005;20(2):83–95. doi:10.​1016/​j.​pedn.​2004.​12.​010.PubMedCrossRef
60.
Wysocki T, Harris MA, Greco P, Bubb J, Danda CE, Harvey LM, et al. Randomized, controlled trial of behavior therapy for families of adolescents with insulin-dependent diabetes mellitus. J Pediatr Psychol. 2000;25(1):23–33.PubMedCrossRef
61.
Wysocki T, Harris MA, Buckloh LM, Mertlich D, Lochrie AS, Taylor A, et al. Effects of behavioral family systems therapy for diabetes on adolescents’ family relationships, treatment adherence, and metabolic control. J Pediatr Psychol. 2006;31(9):928–38. doi:10.​1093/​jpepsy/​jsj098.PubMedCrossRef
62.
Wang YC, Stewart SM, Mackenzie M, Nakonezny PA, Edwards D, White PC. A randomized controlled trial comparing motivational interviewing in education to structured diabetes education in teens with type 1 diabetes. Diabetes Care. 2010;33(8):1741–3. doi:10.​2337/​dc10-0019.PubMedCentralPubMedCrossRef
63.
Channon SJ, Huws-Thomas MV, Rollnick S, Hood K, Cannings-John RL, Rogers C, et al. A multicenter randomized controlled trial of motivational interviewing in teenagers with diabetes. Diabetes Care. 2007;30(6):1390–5. doi:10.​2337/​dc06-2260.PubMedCrossRef
64.
Husted GR, Thorsteinsson B, Esbensen BA, Gluud C, Winkel P, Hommel E, et al. Effect of guided self-determination youth intervention integrated into outpatient visits versus treatment as usual on glycemic control and life skills: a randomized clinical trial in adolescents with type 1 diabetes. Trials. 2014;15:321. doi:10.​1186/​1745-6215-15-321.PubMedCentralPubMedCrossRef
65.
Ellis DA, Naar-King S, Chen X, Moltz K, Cunningham PB, Idalski-Carcone A. Multisystemic therapy compared to telephone support for youth with poorly controlled diabetes: findings from a randomized controlled trial. Ann Behav Med. 2012;44(2):207–15. doi:10.​1007/​s12160-012-9378-1.PubMedCentralPubMedCrossRef
66.
Ellis DA, Frey MA, Naar-King S, Templin T, Cunningham P, Cakan N. Use of multisystemic therapy to improve regimen adherence among adolescents with type 1 diabetes in chronic poor metabolic control: a randomized controlled trial. Diabetes Care. 2005;28(7):1604–10.PubMedCrossRef
67.
Stanger C, Ryan SR, Delhey LM, Thrailkill K, Li Z, Li Z, et al. A multicomponent motivational intervention to improve adherence among adolescents with poorly controlled type 1 diabetes: a pilot study. J Pediatr Psychol. 2013;38(6):629–37. doi:10.​1093/​jpepsy/​jst032.PubMedCentralPubMedCrossRef
68.
Matam P, Kumaraiah V, Munichoodappa C, Kumar KM, Aravind S. Behavioural intervention in the management of compliance in young type-I diabetics. J Assoc Physicians India. 2000;48(10):967–71.PubMed
69.
McNabb WL, Quinn MT, Murphy DM, Thorp FK, Cook S. Increasing children’s responsibility for diabetes self-care: the in control study. Diabetes Educ. 1994;20(2):121–4.PubMedCrossRef
70.
Viner RM, Christie D, Taylor V, Hey S. Motivational/solution-focused intervention improves HbA1c in adolescents with type 1 diabetes: a pilot study. Diabet Med. 2003;20(9):739–42.PubMedCrossRef
71.
Murphy HR, Wadham C, Hassler-Hurst J, Rayman G, Skinner TC. Randomized trial of a diabetes self-management education and family teamwork intervention in adolescents with type 1 diabetes. Diabet Med. 2012;29(8):e249–54. doi:10.​1111/​j.​1464-5491.​2012.​03683.​x.PubMedCrossRef
72.•
de Wit M, Pulgaron ER, Pattino-Fernandez AM, Delamater AM. Psychological support for children with diabetes: are the guidelines being met? J Clin Psychol Med Settings. 2014;21(2):190–9. doi:10.​1007/​s10880-014-9395-2. This article finds that a large portion of pediatric diabetes treatment teams queried do not have access to a mental health specialist; this is an important finding given the several known psychosocial barriers to treatment adherence in this population.PubMedCrossRef
73.
Mann S. AAMC Approves new MCAT exam with increased focus on social, behavioral sciences 2012 [cited 2015 May 4th]. Available from: https://​www.​aamc.​org/​newsroom/​reporter/​march2012/​276588/​mcat2015.​html.
74.
Drotar D, Rohan J. Pediatric Adherence and Health Behavior Change. In: Martin L, DiMatteo R, editors. The Oxford handbook of health communication, behavior change, and treatment adherence. New York: Oxford University Press; 2014.
75.
Chae M, Reith DM, Tomlinson PA, Rayns J, Wheeler BJ. Accuracy of verbal self-reported blood glucose in teenagers with type I diabetes at diabetes ski camp. J Diabetes Metab Disord. 2014;13(1):14. doi:10.​1186/​2251-6581-13-14.PubMedCentralPubMedCrossRef
76.
Patrick K, Sallis JF, Prochaska JJ, Lydston DD, Calfas KJ, Zabinski MF, et al. A multicomponent program for nutrition and physical activity change in primary care: PACE+ for adolescents. Arch Pediatr Adolesc Med. 2001;155(8):940–6.

Be confident that your patient care is up to date

Medicine Matters is being incorporated into Springer Medicine, our new medical education platform. 

Alongside the news coverage and expert commentary you have come to expect from Medicine Matters diabetes, Springer Medicine's complimentary membership also provides access to articles from renowned journals and a broad range of Continuing Medical Education programs. Create your free account »