Confidence of academic general internists and family physicians to teach ambulatory procedures

OBJECTIVE

To evaluate and compare the readiness of academic general internal medicine physicians and academic family medicine physicians to perform and teach 13 common ambulatory procedures.

DESIGN

Mailed survey.

SETTING

Internal medicine and family medicine residency training programs associated with 35 medical schools in 9 eastern states.

PARTICIPANTS

Convenience sample of full-time teaching faculty.

MEASUREMENTS AND MAIN RESULTS

A total of 331 general internists and 271 family physicians returned completed questionnaires, with response rates of 57% and 65%, respectively. Academic generalists ranked most of the ambulatory procedures as important for primary care physicians to perform; however, they infrequently performed or taught many of the procedures. Overall, compared with family physicians, general internists performed and taught fewer procedures, received less training, and were less confident in their ability to teach these procedures. Physicians' confidence to teach a procedure was strongly associated with training to perform the procedure and performing or precepting a procedure at least 10 times per year.

CONCLUSIONS

Many academic general internists do not perform or precept common adult ambulatory procedures. To ensure that residents have the opportunity to learn routine ambulatory procedures, training programs may need to recruit qualified faculty, train current faculty, or arrange for academic specialists or community physicians to teach these skills.

Patient preferences for care by general internists and specialists in the ambulatory setting

OBJECTIVE

To investigate patients' preferences for care by general internists and specialists for common medical conditions.

DESIGN

Telephone interview.

SETTING

A convenience sample of general internal medicine practices at 10 eastern academic medical centers.

PATIENT/PARTICIPANTS

A probability sample of 314 participants who had at least one visit with their primary care physician during the preceding 2 years.

MEASUREMENTS AND MAIN RESULTS

Items addressed patients' attitudes concerning continuity of care, preferences for care by general internists or specialists for common medical problems, and perceptions about the competency of general internists and specialists to manage these problems. Continuity was important to participants, with 63% reporting they preferred having one doctor. Respondents were willing to wait 3 or 4 days to see their regular doctor (85%) and wanted their doctor to see them in the emergency department (77%) and monitor their care while in the hospital (94%). A majority (>60%) preferred care from their regular doctor for a variety of new conditions. Though respondents valued continuity, 84% felt it was important to be able to seek medical care from any type of physician without a referral, and 74% responded that if they needed to see a specialist, they were willing to pay out-of-pocket to do so. Although most participants (98%) thought their regular doctor was able to take care of usual medical problems, the majority thought that specialists were better able to care for allergies (79%) and better able to prescribe medications for depression (65%) and low-back pain (72%).

CONCLUSIONS

Participants preferred to see their general internist despite their perceptions that specialists were more competent in caring for the conditions we examined. However, they wanted unrestricted access to specialists to supplement care provided by general internists.

Help wanted. Nurse or health educator?

Although health education may be considered a component of nursing, trained professionals exist whose sole focus is health education. For optimal results, these health education specialists, not nurses, are the ones hospitals and healthcare organizations should seek out when staffing their departments of health education.

Perceptions of cancer and its causes among "Industrial Corridor" residents: the LMRICS Planning Project. Lower Mississippi River Interagency Cancer Study

The Industrial Corridor is composed of 11 parishes heavily concentrated with petrochemical facilities along the Mississippi River from Baton Rouge to the mouth of the river. There exists a generalized belief that the proximity of these waste-emitting industries to residential areas has adversely impacted the health of the residents including increasing the rates of cancer. At the same time, Louisiana Tumor Registry data do not support the widely held belief of excess cancer rates in the corridor. A community in the corridor was chosen to explore the issues of health beliefs, health-seeking behavior, and perceived quality of life. An extensive questionnaire was developed and administered to a sample of community residents. The results of the questionnaire suggest there may be multiple factors that influence the perceived well-being and preventive health practices of corridor residents.

The career outcomes for doctors completing general practice vocational training 1990-1995

BACKGROUND

While much has been published about the career outcomes of doctors who completed general practice vocational training prior to 1990, no evidence is currently available about those who have qualified since that time.

AIM

To obtain information about the career paths of doctors who had completed general practice vocational training since 1990, and to compare the results with previously published data.

METHOD

Postal questionnaire survey of all doctors completing vocational training during the period 1990-1995 in three regions of the United Kingdom. The study examined current work status, career path since completion of training, desire for and experience of part-time training, degree of difficulty in choosing and following a career, and the degree to which certain factors impeded career choice.

RESULTS

The overall response rate was 64.8%, although there was a significant difference between the response rates for men and women. While virtually all responders were employed, with the majority working in general practice, women were significantly less likely than men to be working as principals in general practice, for all cohorts. These results were very similar to those cohorts described in earlier studies. The career paths of doctors only became stable after about four years. Of those working in general practice, about 20% found it difficult to choose their career, and about 10% found it difficult to follow their career. Out-of-hours work was the major factor impeding career choice.

CONCLUSION

Although they are taking longer to reach, the final career destinations of doctors completing vocational training since 1990 are no different from those of earlier cohorts.

Changing cancer outcome: the role of LSUMC Minority-Based Clinical Community Oncology Program

The National Cancer Institute has recognized the need for minority participation in clinical trials as a means to enhance cancer outcomes in minority populations and to validate the outcomes of clinical research. In 1994, Louisiana State University Medical Center in New Orleans was granted an award by the National Cancer Institute to establish a Minority-Based Clinical Community Oncology Program. This article outlines the Louisiana State University's Minority Based Clinical Community Oncology Program. During the initial funding period, the Program has established a regional network of cancer physicians and healthcare professionals to provide state-of-the-art cancer treatment and prevention trials to South Louisiana for indigent and minority populations who otherwise would have little access to this care. Because of the success of the Program in patient accrual to both cancer treatment and cancer prevention and control protocol trials, Louisiana State University Medical Center has applied for a continuation of funding for the Program for the next five years.

Growth plate pathology in feline mucopolysaccharidosis VI

The mucopolysaccharidoses (MPS) are a family of lysosomal storage diseases that result from the accumulation of partially catabolized glycosaminoglycans (GAGs) within lysosomes. A characteristic of most affected individuals is radiographic evidence of symmetrical epiphyseal dysplasia, with short stature and degenerative joint disease. Although there is evidence of epiphyseal dysfunction, little is known of the changes that occur at the morphological level. The growth plate of the femoral head was studied by light and electron microscopy in five cats with MPS VI (Maroteaux-Lamy syndrome, arylsulfatase B deficiency) and 12 normal cats. Compared with the normals, the MPS VI cat growth plates exhibited poorly organized proliferative zones, an almost total loss of column formation in the hypertrophic zone, an uneven chondro-osseous junction, a disorganized calcifying cartilage zone, and abnormal or reduced numbers of osteoclasts. By electron microscopy, the cytoplasm of affected cat chondrocytes was filled with membrane-bound vacuoles. Together these findings indicate that the MPS diseases cause major changes in growth plate structure and function.

Audit as part of summative assessment of vocational training

Written evidence of the ability to carry out audit and performance review looks likely to be one of the four components of a summative assessment package for the end of vocational training. This paper seeks to raise the issues involved in this process. The features of audit which lend themselves to assessment of the attributes of a general practitioner are discussed. The criteria which might be used to assess a written submission are presented. A possible mechanism for marking and grading is suggested, and strategies for optimizing the validity and reliability of that assessment discussed. A timescale for implementation is also suggested. These issues need to be discussed and a process piloted if a credible mechanism is to be in place by August 1996.

Craniofacial abnormalities in animal models of mucopolysaccharidoses I, VI, and VII

The genetic mucopolysaccharidoses (MPS) are a family of lysosomal storage diseases resulting from the partial catabolism of several glycosaminoglycans (GAGs). Depending on the particular enzyme deficient in activity, the MPS syndromes are defined into groups MPS I through VII, with several subgroups for a total of 10 disorders. In humans, clinical features include dysostosis multiplex, hepatosplenomegaly, hypertelorism, macroglossia, hypoplastic and irregularly shaped teeth, hyperplastic lips and gingiva, facial dysmorphia, corneal clouding, and mental retardation. MPS I (alpha-L-iduronidase deficiency) and VI (arylsulfatase B deficiency) have been described in cats, MPS VII (beta-glucuronidase deficiency) in dogs. Biochemically, these syndromes appear the same as their human counterparts and have similar clinical characteristics. All are inherited as autosomal recessive traits. The purpose of this study was to analyze the craniofacial aspects of these diseases in the animal models and compare these data with descriptions of the human syndromes. A total of 28 live animals were examined. Thirty-one skulls prepared from postmortem specimens were measured directly and radiographed. Controls were closely related family members of the same sex and similar age without the disease, clinically or biochemically. The data indicated that, as in the human syndromes, each is distinct, and the skull bones most severely affected are those of endochondral origin.

The condom race

The condom race is a hands-on activity that can help teach young people condom use as part of safer sex practices. Although it is well documented that students know about condom use, they often do not do what they know they should. One possible explanation for this is that the students may lack the skills and confidence they need to have when they use condoms. The condom race offers students a chance to gain skills and confidence in a humorous, nonthreatening way. During the exercise, which is based on the concept of a relay race, students touch, feel, and practice putting condoms on penis models. After participating in the activity, students reported increased confidence in their ability to use, discuss, and carry condoms. The condom race is a quick, amusing, and easy activity.

Intravenous sedation for MR imaging of the brain and spine in children: pentobarbital versus propofol

The authors present a prospective study of single-agent pediatric sedation regimens for patients older than 2 years of age undergoing magnetic resonance (MR) imaging of the brain and spine. Thirty patients underwent MR imaging after intravenous administration of pentobarbital in successive boluses of 2.5 mg/kg to a maximum of 7.5 mg/kg. Thirty-one patients received an intravenous bolus followed by continuous infusion of propofol. The dosage schedule for propofol was 2 mg/kg (with supplemental 1 mg/kg boluses) followed by continuous infusion of 6 mg/kg per hour. There was no significant difference in the physiologic response to sedation between the two groups, although the magnitude of the drop in pulse was significantly greater in the group receiving propofol. Three patients receiving propofol experienced transient decreases in oxygen saturation, at variable times over the course of the procedure. However, patients recovered significantly faster from sedation with propofol. While propofol may represent a viable alternative to pentobarbital in selected patients, propofol requires constant physician supervision and meticulous technique.

Managing change in primary care. Strategies for success

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Brucellosis: an unusual cause of fever in Kentucky

Human infection with brucellosis appears to be very uncommon in Kentucky. Only three cases have been reported to the Kentucky Department of Health, Frankfort, in the last 4 years. It is suspected, however, that brucellosis is severely underdiagnosed and under-reported in the United States. A patient recently diagnosed with acute systemic brucellosis reminds us that this illness may still be seen in the Commonwealth.

The epidemiology of methicillin-resistant Staphylococcus aureus in a burn center

The emergence of methicillin-resistant Staphylococcus aureus (MRSA) in a critical care facility creates a multifaceted epidemiological problem in uncovering the source of infection. This study was undertaken to determine the true etiology of MRSA burn wound infections. Patients with a 30% or greater TBSA burn had both burned and unburned skin surface cultured upon admission, using RODAC plates. All other body fluids were cultured when sepsis was suspected. Admission cultures of 14 patients who developed MRSA wound infections were examined for methicillin-resistant organisms. Both admission isolates and infection isolates were compared by antibiogram analysis. Of the 14 patients admitted who developed MRSA infections, 57.1% of these had methicillin-resistant staphylococci present on admission. However, the remaining 42.9% of the patients had methicillin-sensitive, B-lactamase positive staphylococci present on admission. Isolates of group D streptococci resistant to methicillin were isolated in 35.7% of the patients. This data suggests that burn wound infections caused by MRSA very likely arise from the endogenous flora present at the time of injury through conferring the resistant plasmid by conjugational transfer.

Effect of epidermal growth factor on growth and postnatal development of the rabbit liver

The effect of epidermal growth factor (EGF) on the postnatal development of the liver was examined. New Zealand White rabbits received 40 micrograms.kg-1.day-1 EGF from days 3 to 17 of age either intraperitoneally or orogastrically, whereas controls received saline. At days 18-20, animals underwent cannulation of the common duct using halothane anesthetic. Biliary output was measured directly for three 1-h periods: under basal conditions and in response to intravenous infusion of exogenous glycodeoxycholic acid at 0.75 and 1.5 mumol.min-1.kg-1, respectively. The bile salt pool size was measured by isotope dilution. Final mean body weight of intraperitoneal and orogastric groups did not differ from controls. Liver we weight, DNA, and protein content were significantly increased in intraperitoneally treated animals without morphological or biochemical evidence of fat deposition. Both intraperitoneal and orogastric EGF significantly increased bile salt secretion in the basal period and as a response to exogenous bile acid infusion. Bile flow was significantly increased in response to 1.5 mumol.min-1.kg-1 infusion of glycodeoxycholic acid. The bile salt pool was increased by both intraperitoneal and orogastric EGF. Administration of EGF resulted in a precocious development of glucokinase (EC 2.7.1.2) activity in the liver. EGF had no effect on serum cortisol, corticosterone, triiodothyronine, thyroxine, or free thyroxine levels. These findings suggest that in the neonatal period EGF can promote hepatic growth and maturation.