Physician job satisfaction: developing a model using qualitative data. SGIM Career Satisfaction Study Group

The purpose of this study was to develop a current and comprehensive model of physician job satisfaction. Information was gathered by (1) analysis of open-ended responses from a large group practice physician survey in 1988, and (2) analysis of focus group data of diverse physician subgroups from 1995. Participants were 302 physicians from large-group practices and 26 participants in six focus groups of HMO, women, minority, and inner-city physicians. Data were used to develop a comprehensive model of physician job satisfaction. The large group practice survey data supported the key importance of day-to-day practice environment and relationships with patients and physician peers. Future concerns focused on the effect of managed care on the physician-patient relationship and the ability of physicians to provide quality care. Focus groups provided contemporary data on physician job satisfaction, reinforcing the centrality of relationships as well as special issues for diverse physician subgroups of practicing physicians. New variables that relate to physician job satisfaction have emerged from economic and organizational changes in medicine and from increasing heterogeneity of physicians with respect to gender, ethnicity, and type of practice. A more comprehensive model of physician job satisfaction may enable individual physicians and health care organizations to better understand and improve physician work life.

The HIV-1 matrix domain of Gag is required for Vpu responsiveness during particle release

HIV-1 viral protein U (Vpu) facilitates virus particle release. To determine whether Gag is sufficient for generation of a target for Vpu-mediated particle release, we expressed HIV-1 Gag protein in the absence of the other viral genes. The resulting particles were still Vpu responsive. Mutational analysis of Gag indicated that the matrix domain (MA) is required for Vpu responsiveness. However, additional mutations in other domains of Gag, which affect the formation of stable virus particles, also abrogate Vpu responsiveness on total Gag release. Coexpression of the wild-type gag gene and a gag mutant lacking the MA domain renders the MA- mutant Vpu responsive. This indicates that Gag molecules lacking MA are still incorporated into particles through association with wild-type Gag molecules and that the resulting composite particles are sufficient for Vpu-mediated exit.

The influence of psychological distress on use of genetic testing for cancer risk

The recent identification of BRCA1, a breast cancer susceptibility gene, offers an unprecedented opportunity for high-risk individuals to learn whether they are genetically predisposed to develop breast or ovarian cancer. This study examined the relationships between psychological distress and use of BRCA1 testing by 149 high-risk individuals from hereditary cancer families. After a baseline assessment of demographics, objective risk, cancer-specific distress, and global distress (depressive symptoms), study participants were offered the opportunity to receive genetic counseling and to learn whether they carry a mutation in the BRCA1 gene. Overall, 58% of study participants requested BRCA1 test results, and 42% declined to learn their genetic status. After controlling for demographic factors and risk status, cancer-specific distress was significantly and positively related to BRCA1 test use, whereas global distress was unrelated to test use.

The influence of psychological distress on use of genetic testing for cancer risk

The recent identification of BRCA1, a breast cancer susceptibility gene, offers an unprecedented opportunity for high-risk individuals to learn whether they are genetically predisposed to develop breast or ovarian cancer. This study examined the relationships between psychological distress and use of BRCA1 testing by 149 high-risk individuals from hereditary cancer families. After a baseline assessment of demographics, objective risk, cancer-specific distress, and global distress (depressive symptoms), study participants were offered the opportunity to receive genetic counseling and to learn whether they carry a mutation in the BRCA1 gene. Overall, 58% of study participants requested BRCA1 test results, and 42% declined to learn their genetic status. After controlling for demographic factors and risk status, cancer-specific distress was significantly and positively related to BRCA1 test use, whereas global distress was unrelated to test use.

Efficient encapsidation of human immunodeficiency virus type 1 vectors and further characterization of cis elements required for encapsidation

To determine whether there is a cis-acting effect of translational expression of gag on RNA encapsidation, we compared the encapsidation of wild-type RNA with that of a mutant in which the translation of gag was ablated. This comparison indicated that there is not such a cis effect. To determine what is necessary and sufficient for encapsidation, we measured the relative encapsidation efficiencies of human immunodeficiency virus type 1 vector RNAs containing mutations in domains proximal to the canonical encapsidation signal or containing large deletions in the remainder of the genome. These data indicate that TAR and two additional regions are required for encapsidation and that the 5' end of the genome is sufficient for encapsidation. The Rev-responsive element is required mainly for efficient RNA transport from the nucleus to the cytoplasm. A foreign sequence was found to have a negative effect on encapsidation upon placement within the parental vector. Interestingly, this negative effect was compounded by multiple copies of the sequence.

HIV-1 particle release mediated by Vpu is distinct from that mediated by p6

Vpu and the C-terminal peptide of Gag (p6) are both HIV-1-encoded proteins that augment the release of virus particles from cells. We examined the functional relationship between these proteins and their activities during particle release. Our results indicate that efficient HIV-1 particle release from HeLa and Jurkat cells depends on the presence of Vpu. However, Vpu is dispensable for efficient release from Cos cells. In contrast, p6 is required for efficient release from Cos cells but not from Jurkat or HeLa cells. These data suggest that Vpu and p6 have distinct activities in virus exit from different cell lines. Intracellular proteolytic processing of Gag precursor protein is more complete in Cos cells than in HeLa cells. However, this processing has little or no effect on Vpu- or p6-mediated particle release. p6 is required for incorporation of yet another virus protein (Vpr) into cells but our data suggest that Vpr plays no role in p6-dependent particle release. Vpu also facilitates the degradation of CD4 in virus producing cells but, in contrast to particle release, the ability of Vpu to facilitate the degradation of CD4 is not cell line-dependent.

A randomized trial of breast cancer risk counseling: interacting effects of counseling, educational level, and coping style

The authors evaluated the impact of individualized breast cancer risk counseling (BCRC) on breast-cancer-specific distress and general distress in 239 women with a family history of breast cancer. Following a baseline assessment of demographics, risk factors, coping styles, and distress, participants were assigned randomly to receive either BCRC or general health education (GHE; i.e., control group). After controlling for education level, women who received BCRC had significantly less breast-cancer-specific distress at 3-month follow-up compared with women who received GHE. A significant Education Level x Treatment Group interaction indicated that the psychological benefits of BCRC were greater for women with less formal education. In both the BCRC and GHE groups, participants who had monitoring coping styles exhibited increases in general distress from baseline to follow-up.

Nuclear factor-kappa B is activated in alveolar macrophages from patients with acute respiratory distress syndrome

OBJECTIVE

The expression of proinflammatory cytokines is rapidly increased in experimental models of the acute respiratory distress syndrome (ARDS), in patients at risk for ARDS, and in patients with established ARDS. Because multiple cytokines are present in bronchoalveolar lavage fluid, a common, proximal activation mechanism may operate in these settings. The proinflammatory cytokines whose expression is increased in the lungs of patients with ARDS have binding sequences in their enhancer/promoter regions for transcriptional regulatory proteins, such as nuclear factor-kappa B (NF-kappa B), nuclear factor-IL6 (NF-IL6), cyclic adenosine monophosphate responsive element binding protein, serum protein-1, and activating protein-1. To test the hypothesis that activation of one or more of these nuclear transcriptional regulatory factors might provide a common mechanism for the simultaneous expression of multiple cytokine genes in the setting of ARDS, we measured activation of these factors in alveolar macrophages from patients with ARDS and from controls.

DESIGN

Prospective, clinical study.

SETTING

Medical and surgical intensive care units at a university hospital and a county hospital.

PATIENTS

Twelve patients, six with established ARDS and six control patients without lung injury.

INTERVENTIONS

Patients with ARDS and controls underwent fiberoptic bronchoscopy and bronchoalveolar lavage. Alveolar macrophages were isolated from lavage fluid and the nuclear proteins were extracted. Activation of transcriptional factors NF-kappa B, NF-IL6, cyclic adenosine monophosphate responsive element binding protein, activating protein-1, and serum protein-1 was determined using an electrophoretic mobility shift assay, followed by densitometry of the autoradiographed gels.

MEASUREMENTS AND MAIN RESULTS

There were no significant differences in gender, age, tobacco smoking, Acute Physiology and Chronic Health Evaluation II score, quantity of lavage fluid, or number of alveolar macrophages in lavage specimens in the patient groups. Acute Lung Injury score and the Pao2/Fio2 ratio differed significantly between controls and ARDS patients: 0.46 +/- 0.17 vs. 2.74 +/- 0.14 (p < .0001) and 310 +/- 45 torr (41.3 +/- 6.0 kPa) vs. 150 +/- 11 torr (21.3 +/- 1.5 kPa) (p < .006), respectively. The mean Fio2 of the control patients was not significantly different from the mean Fio2 of ARDS patients: 0.47 +/- 0.11 vs. 0.55 +/- 0.6 (p = .53). Patients with ARDS had significantly (p < .02) increased activation of NF-kappa B in alveolar macrophages compared with patients without the syndrome. There was no evidence of increased activation of the transcriptional factors activating protein-1, serum protein-1, NF-IL6, or cyclic adenosine monophosphate responsive element binding protein in alveolar macrophages from ARDS vs. control patients.

CONCLUSIONS

These experiments demonstrated increased in vivo activation of the nuclear transcriptional regulatory factor NF-kappa B (but not NF-IL6, cyclic adenosine monophosphate responsive element binding protein, activating protein-1, or serum protein-1) in alveolar macrophages from patients with ARDS. Because binding sequences for NF-kappa B are present in the enhancer/promoter sequences of multiple proinflammatory cytokines, activation of NF-kappa B may contribute to the increased expression of multiple cytokines in the lung in the setting of established ARDS.

Hemorrhage activates NF-kappa B in murine lung mononuclear cells in vivo

Hemorrhage rapidly increases the expression of proinflammatory and immunoregulatory cytokines in the lungs. Binding elements for the nuclear transcriptional regulatory factors (NF)-kappa B and NF-IL6 (C/EBP beta) are present in the promoter regions of multiple cytokine genes, including those whose expression is increased after blood loss. In the present experiments, we found increased activation in vivo of NF-kappa B in lung mononuclear cells, but not in splenocytes, taken from mice 1 h after hemorrhage. In contrast, hemorrhage did not activate NF-IL6 in lung cells or splenocytes. Inhibition of xanthine oxidase by prior feeding of a tungsten-enriched diet prevented hemorrhage-induced activation in lung cells of NF-kappa B. Incubating splenocytes in vitro with xanthine oxidase activated NF-kappa B but not NF-IL6. Xanthine oxidase-induced activation of NF-kappa B was inhibited by manganese superoxide dismutase, but not by catalase. These results suggest that xanthine oxidase-mediated superoxide anion-dependent activation of NF-kappa B occurs in vivo and in vitro. This mechanism may contribute to increased lung cytokine responses after hemorrhage.

Role of nausea in the development of aversions to a beverage paired with chemotherapy treatment in cancer patients

Previous experimental research has demonstrated that patients can develop conditioned aversions to foods and beverages after a single pairing with chemotherapy administration for cancer. The present study used a prospective longitudinal design to examine the role of posttreatment nausea in the development of learned food aversions in these patients. Chemotherapy patients sampled a distinctive beverage immediately prior to their first and second chemotherapy infusions. We assessed nausea, and other chemotherapy side effects, for the 24-h period following chemotherapy administration. Food aversion, at the second infusion, was assessed in terms of behavior (decreased consumption) and affect (decreased hedonic rating). Consistent with previous research, patients showed both decreased consumption and decreased hedonic rating after a single chemotherapy infusion. Nausea was found to be related to decreases in hedonic rating, but not to decreases in consumption. No other treatment side effects predicted either decreased consumption or hedonic rating. These results are consistent with the hypothesis that there is a special link between nausea and changes in affective response to food items. These results also highlight the unique opportunities for studying food aversion formation in the oncology setting.

A randomized trial of breast cancer risk counseling: interacting effects of counseling, educational level, and coping style

The authors evaluated the impact of individualized breast cancer risk counseling (BCRC) on breast-cancer-specific distress and general distress in 239 women with a family history of breast cancer. Following a baseline assessment of demographics, risk factors, coping styles, and distress, participants were assigned randomly to receive either BCRC or general health education (GHE; i.e., control group). After controlling for education level, women who received BCRC had significantly less breast-cancer-specific distress at 3-month follow-up compared with women who received GHE. A significant Education Level x Treatment Group interaction indicated that the psychological benefits of BCRC were greater for women with less formal education. In both the BCRC and GHE groups, participants who had monitoring coping styles exhibited increases in general distress from baseline to follow-up.

Gail model breast cancer risk components are poor predictors of risk perception and screening behavior

The Gail model is being used increasingly to determine individual breast cancer risk and to tailor preventive health recommendations accordingly. Although widely known to the medical and biostatistical communities, the risk factors included in the model may not be salient to the women to whom the model is being applied. This study explored the relationship of the individual Gail model risk factors to perceived risk of breast cancer and prior breast cancer screening among women with a family history of breast cancer. Data from baseline interviews with 969 women found a striking disparity between the objective risk factors included in the model and the accuracy of perceived risk and screening behaviors of this population, particularly among women over the age of 50 years. Risk perception accuracy was unrelated to all of the Gail model risk factors for all age groups. Reported mammography adherence was only associated with having had a breast biopsy in both age groups. Breast self examination (BSE) practice was independent of all measured factors for both age groups. These findings support the need for further research to identify additional determinants of risk perception and motivators of screening behavior.

Learners as teachers: the conflicting roles of medical residents

OBJECTIVE

To explore the impact of internal medicine residents' roles as learners, teachers, and physicians on their performance in teaching and supervising interns; to generate insights for educational policy and research.

DESIGN

Qualitative analysis of in-depth, semistructured, recorded interviews with a cohort of second-postgraduate-year (PGY-2) residents. Questions elicited their accounts of differences in the learning process between the first and second residency years, their responses to situations in which they lacked sufficient clinical knowledge, their views of their supervisory relationship with interns, and their assessments of changes in their role in patient care since their internships. Transcripts were independently analyzed by the interdisciplinary team of authors.

SETTING

New York University/Bellevue Hospital Center's internal medicine residency (New York City), a highly competitive program in a major public hospital and a university medical center, emphasizing housestaff autonomy and self-reliance.

PARTICIPANTS

A cohort of 18 of 21 medical residents at Bellevue Hospital Center during the last rotation of PGY-2.

RESULTS

Intense conflicts confound residents' roles as teachers. These conflicts fall into three categories: 1) as learners, residents' own needs frequently coincide with those of interns in ways that may undermine their teaching--they are expected to nurture others despite their own considerable needs for emotional support, teach material that they barely grasp, and exert authority while feeling ignorant; 2) as team leaders, residents must ensure that interns get the hospital's work done, sometimes at the expense of teaching them; and 3) as clinicians, residents' first priority is to address the medical needs of patients--the learning needs of interns are secondary.

CONCLUSION

Second-year internal medicine residents experience conflicts inherent in their simultaneous commitment to learning, teaching, and service that may undermine both their effectiveness in supervising interns and their own professional development. Potential remedies are to restructure residency programs so as to equip residents with training and support for their role as teachers, reduce the tension between training and service by delegating tasks to nonphysician personnel, and provide graded responsibility to housestaff as physicians and teachers.

The impact of an ambulatory rotation on medical student interest in internal medicine. The Society of General Internal Medicine Task Force on Career Choice in Internal Medicine

OBJECTIVE

To determine whether students who take ambulatory rotations in internal medicine are more likely to choose internal medicine careers.

DESIGN

National survey.

SETTING AND PARTICIPANTS

The intended sample was 1,650 senior U.S. medical students from 16 medical schools, of whom 1,244 (76%) responded. Representative schools nationwide were selected using a stratified, random-sampling method.

MEASUREMENTS

The questionnaire asked about characteristics of the ambulatory rotation, perceptions of internal medicine, and factors influencing students toward or away from an internal medicine career.

RESULTS

Ambulatory rotations were taken by 543 students (43%). Of these rotations, 73% were required, 74% were during the fourth year, 77% were in general internal medicine, 73% provided continuity of care, and 19% were during the medicine clerkship. Overall, 24% of the students chose careers in general (9%) or subspecialty internal medicine (15%). Thirty percent of the students who did ambulatory rotations planned internal medicine careers, compared with 19% of the students who had no rotation [odds ratio (OR) = 1.8, 95% confidence interval (CI) 1.3 to 2.4, p = 0.0001]. This association was of similar magnitudes for students completing required rotations (OR = 1.6, 95% CI 1.2 to 2.2, p = 0.002) and for students completing rotations before or in proximity to when they chose careers (OR = 1.7, 95% CI 1.1 to 2.4, p = 0.01). Ninety percent of the 543 students who had ambulatory rotations were satisfied with the experience. Thirty-eight percent of the highly satisfied students chose internal medicine careers, compared with 21% of the students who had low or moderate satisfaction (p = 0.0001).

CONCLUSIONS

An ambulatory rotation is strongly associated with positive perceptions of, attraction to, and choice of a career in internal medicine. Research is needed to determine specific components of an effective rotation. Further development of ambulatory rotations could help attract more students to internal medicine.

Coping disposition, perceived risk, and psychological distress among women at increased risk for ovarian cancer

The authors examined predictors of psychological distress among women who were at increased risk for ovarian cancer. Participants were 103 women who had at least 1 first degree relative with ovarian cancer. Specifically, the authors tested the relationship between the dispositional attentional style of monitoring (the tendency to scan for threat-relevant information), perceptions of risk for ovarian cancer, intrusive thoughts regarding ovarian cancer, and psychological distress. Overall, this sample exhibited moderately high levels of psychological distress. High scores on monitoring were associated with high perceived risk for ovarian cancer and elevated levels of intrusive thoughts and psychological distress. Finally, the authors proposed and tested a path model describing the interrelationships between these variables. The results of this study are discussed in terms of their implications for treating the psychological distress associated with being at increased risk for ovarian cancer.

Conditioned emotional distress in women receiving chemotherapy for breast cancer

This study investigated whether women undergoing outpatient chemotherapy for breast cancer can develop classically conditioned emotional distress. Women scheduled to begin chemotherapy were randomly assigned either to an experimental group (exposed to a distinctive stimulus before each chemotherapy infusion) or a control group. After repeated infusions of chemotherapy, patients' responses to the distinctive stimulus were assessed in a location not associated with chemotherapy administration. At the test trial, experimental group patients showed evidence of increased emotional distress (self-reported on a visual analog scale) after the presentation of the distinctive stimulus, whereas control group patients did not. Post hoc analyses indicated that these increases in distress were not secondary to other conditioned responses (e.g., nausea, taste aversion). Thus, results supported the hypothesis that the pairing of a distinctive stimulus with chemotherapy would result in the development of a conditioned emotional response.

Xanthine oxidase-derived oxygen radicals increase lung cytokine expression in mice subjected to hemorrhagic shock

Acute inflammatory lung injury often complicates hemorrhagic shock, a systemic ischemia-reperfusion syndrome. Because oxygen radicals are generated during ischemia-reperfusion, and oxygen radicals can activate nuclear regulatory factors that affect transcription of proinflammatory cytokines, we examined the premise that oxygen radicals increase interleukin-1 beta (IL-1 beta) and tumor necrosis factor-alpha (TNF-alpha) expression in lung mononuclear cells after hemorrhage. Intraparenchymal pulmonary mononuclear cells isolated 1 h after hemorrhage from control mice had increased levels of mRNA for IL-1 beta (P < 0.001) and TNF-alpha (P < 0.05) compared with cells from sham-hemorrhaged mice. Hemorrhaged mice treated with the oxygen radical scavenger dimethylthiourea (DMTU) had decreased levels of mRNA for IL-1 beta in pulmonary mononuclear cells, compared with hemorrhaged controls (P < 0.05). In hemorrhaged mice depleted of xanthine oxidase (XO) by a tungsten-enriched diet, pulmonary mononuclear cell mRNA levels for IL-1 beta and TNF-alpha were significantly decreased (P < 0.01 and 0.05, respectively), compared with cells from hemorrhaged control mice fed a normal diet. Similarly, mRNA transcripts for IL-1 beta and TNF-alpha among pulmonary mononuclear cells from hemorrhaged mice treated with allopurinol, an inhibitor of XO, were also significantly reduced (P < 0.05 and 0.001, respectively), compared with hemorrhaged control mice not treated with allopurinol. Our results indicate that XO-derived oxygen radicals contribute to the increased expression of mRNA for IL-1 beta and TNF-alpha, which occurs among pulmonary mononuclear cell populations immediately after hemorrhage.(ABSTRACT TRUNCATED AT 250 WORDS)

Conditioned emotional distress in women receiving chemotherapy for breast cancer

This study investigated whether women undergoing outpatient chemotherapy for breast cancer can develop classically conditioned emotional distress. Women scheduled to begin chemotherapy were randomly assigned either to an experimental group (exposed to a distinctive stimulus before each chemotherapy infusion) or a control group. After repeated infusions of chemotherapy, patients' responses to the distinctive stimulus were assessed in a location not associated with chemotherapy administration. At the test trial, experimental group patients showed evidence of increased emotional distress (self-reported on a visual analog scale) after the presentation of the distinctive stimulus, whereas control group patients did not. Post hoc analyses indicated that these increases in distress were not secondary to other conditioned responses (e.g., nausea, taste aversion). Thus, results supported the hypothesis that the pairing of a distinctive stimulus with chemotherapy would result in the development of a conditioned emotional response.

Effects of therapy with soluble tumour necrosis factor receptor fusion protein on pulmonary cytokine expression and lung injury following haemorrhage and resuscitation

Acute lung injury frequently develops following haemorrhage, and is characterized by increased proinflammatory cytokine levels and massive neutrophil accumulation in the lung. Blood loss produces rapid increases in tumour necrosis factor-alpha (TNF-alpha) mRNA expression among pulmonary cell populations which precede the development of lung injury. In order to examine the role of TNF-alpha in producing acute inflammatory lung injury, we treated mice following haemorrhage and resuscitation with a TNF antagonist, composed of soluble dimeric human p80 TNF receptor linked to the Fc region of human IgG1 (sTNFR:Fc). Therapy with sTNFR:Fc prevented the post-haemorrhage increases in circulating and pulmonary TNF-alpha levels normally found following blood loss. Administration of sTNFR:Fc also diminished the increase in IL-1 beta, IL-6, TNF-alpha and interferon-gamma (IFN-gamma) mRNA normally found in the lungs following haemorrhage. However, therapy with sTNFR:Fc was not associated with improvement in the histologic parameters of post-haemorrhage lung injury, such as neutrophil infiltration and interstitial oedema. In contrast to the effects of sTNFR:Fc on cytokine mRNA levels among intraparenchymal pulmonary mononuclear cells, such therapy following haemorrhage was associated with increased amounts of mRNA for TNF-alpha among peripheral blood mononuclear cells, as well as increased IFN-gamma titres in serum and bronchoalveolar lavage (BAL) specimens. These results indicate that therapy with sTNFR:Fc in the post-haemorrhage period, although capable of decreasing proinflammatory cytokine expression in the lungs, does not prevent the development of acute lung injury in this setting.

General internal medicine

Internists advanced toward a patient care model based on critical, qualitative, and quantitative assessment of clinical care processes and outcomes. The complete internist must consider social context as well as traditional risk factors in promoting the health of patients.

Effect of a simple ambulatory experience on career choice and attitudes of medical students

Students were allocated randomly to participate in a simple ambulatory experience during their third-year medicine clerkship. A convenience sample was surveyed by questionnaire in the fall of their fourth year, after decisions were made regarding future career plans. The questionnaire assessed medical student attitudes toward general internal medicine and career choice. Valuation of the effectiveness of the clerkship was associated with choosing a career in internal medicine (p = 0.007); having an ambulatory experience was not associated with subsequent career choice. Sixty-two percent of all students felt the clerkship affected their career choice a great deal or moderately; these students were likely to find a career in general internal medicine less attractive as a result of their clerkship (p = 0.008). When stratified, this association disappeared in those students who participated in the ambulatory experience (p = 0.39) but persisted in those who did not (p = 0.01). A simple experience in internal medicine clinics during a third-year clerkship was not associated with subsequent career choice, but had some positive effects on attitudes toward general internal medicine as a career.

Formation of food aversions in cancer patients receiving repeated infusions of chemotherapy

Patients receiving emetogenic chemotherapy for cancer have been found to develop aversions to normal dietary items consumed in close temporal relation to treatment administrations. These aversions are presumed to develop via conditioning processes as demonstrated in experimental studies of food aversion learning. The present study used a prospective, longitudinal design to evaluate the possible role of conditioning in the formation of aversions to normal dietary items in women receiving adjuvant chemotherapy for breast cancer. Patients were monitored for the development of aversions to foods and beverages consumed in the 24 hr periods before and after each of eight consecutive chemotherapy infusions beginning with the initial infusion. Data on the prevalence, course, and prediction of aversions to normal dietary items are reported. These results pointed to similarities and differences between aversions formed to normal dietary items during chemotherapy treatment and aversions formed to taste stimuli during experimental conditioning studies. In addition to their theoretical significance, results also suggest possible strategies for preventing the clinical problem of aversions to normal dietary items in chemotherapy patients.

The attractiveness of internal medicine: a qualitative analysis of the experiences of female and male medical students. Society of General Internal Medicine Task Force on Career Choice in Internal Medicine

OBJECTIVE

To understand better the decline in medical student interest in internal medicine.

DESIGN

Qualitative analysis of 500 essays from respondents who participated in a national survey of graduating medical students from the class of 1990 in 16 medical schools. Medical students were asked the open-ended question, "What suggestions do you have for improving the attractiveness of internal medicine?" A model of career choice was developed for the analysis that included the following factors: ambulatory care exposure and primary care (including relationships with patients); attending physician-student interactions and learning climate; stress and workload; income and prestige; and intellectual stimulation.

PARTICIPANTS

The original survey included 1650 fourth-year medical students; 500 essay respondents were stratified by sex and then randomly chosen for the analysis.

RESULTS

Students most frequently suggested that ambulatory care experiences be increased and that better relationships with patients be established during medical training (65% of women and 50% of men, P < 0.01). The second most frequent suggestion was to improve internal medicine attending physicians' interactions with students (51% and 48% of women and men, respectively). Students who had seriously considered a career in medicine but switched to other primary care careers (general pediatrics, family medicine) had few concerns about income and prestige, whereas those who chose internal medicine had reservations about expected workload and income. Women were more likely than men to reject internal medicine for other primary care fields (26% of women compared with 16% of men, P = 0.05).

CONCLUSIONS

Students, particularly female students, expressed a strong interest in establishing better relationships with patients. Lack of respect by medical attendings and negative teaching methods were important sources of dissatisfaction among both men and women. Attention to these relationship issues, in addition to housestaff stress and expected future income, may improve the attractiveness of internal medicine.

Doctors as workers: work-hour regulations and interns' perceptions of responsibility, quality of care, and training

OBJECTIVE

To study residents' perceptions of their responsibility for patients, the quality of patient care, and their learning experiences in light of new work-hour regulations.

DESIGN

Inductive analysis of in-depth, semistructured, recorded interviews with a cohort of interns in internal medicine in the last month of their first postgraduate year. Questions were grounded in an examination of issues related to going off duty and delegating tasks to colleagues. Transcripts were independently analyzed by an interdisciplinary team.

SETTING

New York University/Bellevue Hospital Center's residency program in internal medicine (in New York City).

PARTICIPANTS

A cohort of 21 of a possible 24 interns in medicine on rotation at Bellevue Hospital Center.

RESULTS

The interviews revealed: 1) intense concern harbored by interns for their patients with resulting difficulty in maintaining realistic boundaries between work and personal lives; 2) an open-ended workday and competing considerations confronting interns when deciding to leave the hospital--including concerns about leaving patients at critical junctures in their care, confidence in the colleague to whom they were signing out, regard for the workload of this colleague, and uneasiness about the educational consequences; 3) deterrents to acknowledging and acting on one's limits in performing medical work; and 4) a recurrent conflict between delegating responsibility and retaining control over patient care.

CONCLUSION

Values traditionally learned in training emphasize autonomy and individual accountability. They may conflict with the shared decision making and collective responsibility among peers necessitated by work-hour limitations and associated changes in program structure.

Referral patterns of primary care physicians for eye care

BACKGROUND

There is very little data regarding the referral rates of primary care physicians for eye care. We studied the extent to which primary care physicians follow guidelines and standards that have been set by professional organizations within eye care.

METHODS

Forty-eight patients over age 40 years seen during one day in the Primary Care Department of a large, metropolitan hospital were reviewed.

RESULTS

Only 12.5 percent of patients seen were referred for eye care. Only 8 percent of those who were diabetic and 13 percent of those with hypertension were referred for eye care, while of each group respectively, 25 percent and 34.8 percent had been seen for eye care in the previous year. Referrals tended to be for acute problems, not for routine monitoring of ocular signs associated with hypertension or diabetes. Only 33.3 percent of the patients had an ocular assessment in the physician's records within the year. In addition, most patients did not have ophthalmoscopy, glaucoma testing, or any other form of vision care during the year.

CONCLUSIONS

In this study, referrals for eye care seemed to be driven by acute, symptomatic problems, and to a lesser extent by a known ocular condition. The importance of routine eye care was not reflected in the referral patterns observed in this study.

Diabetic ketoacidosis in prisoners without access to insulin

OBJECTIVE

To assess the cause and clinical severity of diabetic ketoacidosis in male prisoners hospitalized in New York City.

DESIGN

Retrospective chart review.

SETTING

A municipal hospital in New York City.

PATIENTS

Forty-nine adult male prisoners with a total of 54 hospital admissions for diabetic ketoacidosis between January 1, 1989, and June 30, 1991.

MAIN OUTCOME MEASURES

Charts were reviewed for diabetic and medical history, time from arrest until hospitalization, cause of diabetic ketoacidosis, admission laboratory data, and hospital course.

RESULTS

Thirty-eight (70%) of the 54 admissions for diabetic ketoacidosis among prisoners occurred because prisoners had not received insulin during the period immediately following arrest (mean number of days from arrest until hospitalization was 2.5). All of these individuals had a history of insulin-dependent diabetes and were reportedly compliant with their insulin regimen at the time of arrest. Admission laboratory data for this group of prisoners included a mean serum glucose level of 27.4 mmol/L (495 mg/dL) and a mean serum bicarbonate level of 14.4 mmol/L. Mean number of days in the hospital was 3.4 including a mean of 1 day in an intensive care unit.

CONCLUSIONS

Inadequate access to medication results in serious sequelae for recently arrested prisoners in New York City with insulin-dependent diabetes. Access to health care for recently arrested prisoners needs to be improved.

Computerized, telephone-based stress management program

A stress management program that used computerized, telephone-based technology was offered to the public via a free, "800" telephone number. The program was intended to reach a very large number of persons, while requiring a minimum of staff time. The program used an interactive telephone system, employing natural sounding, digitized voice, and touch tone recognition of callers' responses. The program was available 24 hours a day. It composed each message to suit the individual needs and expectations of each caller. A controlled evaluation of the program was conducted to determine how the messages could be worded and presented most effectively. The results suggest that subjects were most likely to find the messages in the program helpful, to carry out the stress management instructions, and to continue calling when the messages were personalized and contained homework assignments.

Medical student interest in internal medicine. Initial report of the Society of General Internal Medicine Interest Group Survey on Factors Influencing Career Choice in Internal Medicine

OBJECTIVE

To determine the factors that attract students toward and push students away from a career in internal medicine.

DESIGN

National survey of senior U.S. medical students using a stratified random cluster sampling of medical schools.

PARTICIPANTS

The survey included 1650 U.S. senior students from 16 medical schools, of whom 1244 (76%) responded.

MEASUREMENTS AND MAIN RESULTS

A survey instrument was developed and pilot tested at 17 medical schools. Twenty-four percent of the respondents to the final survey chose a career in general internal medicine (9%) or subspecialty internal medicine (15%). A career in internal medicine had been "seriously considered" by 608 respondents (50%) who finally chose a career other than internal medicine (the "switchers"). Compared with other specialties, internal medicine was perceived as being more stressful to residents, more demanding of time and workload as a career and a residency, and as an easier residency to enter. Internal medicine was also seen as providing less satisfaction for residents, having lower income potential, and allowing less leisure time. For the 608 switchers, the most important influences leading to their decision to switch were the type of patient seen in internal medicine (for example, chronically ill, alcohol and drug abusing patients) as well as dissatisfaction and stress among internal medicine residents. Factor analysis showed that three factors, "intellectual challenge of internal medicine," "primary care interests," and "the medicine clerkship" attracted students toward internal medicine, whereas three others, "taking care of chronically ill patients," "level of satisfaction among internists and medical residents," and "workload and stress" pushed students away from internal medicine. Factors pushing students away from internal medicine were significantly more negative with regard to a career in general as opposed to subspecialty internal medicine (P less than 0.001).

CONCLUSION

Medical students have serious reservations about internal medicine as a career choice. Perceptions about the medical residency, the patients they expect to see, and the dissatisfaction among residents and internists are foremost in their thinking. Changes to improve the attractiveness of internal medicine should address these adverse perceptions while building on the positive influences identified by the respondents.

Information system for labor and delivery surveillance

An on-line information system has been developed and implemented at St. Mary Medical Center in Long Beach, California, to support a ten-bed labor and delivery suite. A Digital Equipment Corporation VAX 750 was programmed to provide on-line multi-terminal clinical surveillance. The reports implemented include an obstetrical summary report, labor record, obstetrical clinical record, and the birth certificate. Computer terminals and monitors are placed at the nursing station and other work areas, such as the anesthesia on-call room, obstetrical supervisor's office, on-call room, neonatal ICU, O.R., admission room, and M.D. conference room. The system includes computer databases used to store information for medical quality assurance, management reports, obligatory statutory reports, and research, and to provide comparison of patient data with data from other hospitals.

Analyze of hospital computer networks

Methods for the analysis of hospital computer networks have been developed without the need for a large-scale computer simulation of the queueing events in the problem. A table-driven methodology and a simple computer program are provided for an analysis of the computer utilization and channel utilization for a network of computers supporting hospital tasks. An example, using a DEC 11/780 VAX and six DEC 11/44's is given. The example network is also analyzed by large-scale computer simulation techniques, and the results are compared.

A computerized data management system

A low-cost, computerized data management system has been developed on a Digital Equipment Corporation PDP11V03 computer system with dual floppy discs using BASIC in a time-shared configuration. The system collects, updates, and stores patient information on floppy discs for later retrieval and statistical analysis. All application software is written in BASIC to simplify changes or expansion, and to reduce the software labor costs for transferring the system to other low-cost microprocessor systems currently on the market. This system has been used by several hospital departments for data management and has proven to be a useful tool.

Velopharyngeal function following maxillary advancement

In a series of 40 patients who had maxillary advancements, none developed velopharyngeal incompetence. Unlike the cleft palate patient who is more at risk, there are distinct anatomical characteristics in craniofacial dysostosis which favor maintenance of the integrity of the velopharyngeal mechanism. Hyponasality was eliminated in 5 patients with Crouzon's disease. On cephalometric study, it was observed that after maxillary advancement the nasopharyngeal volume was expanded and the angle formed by the hard and soft palates was increased. On phonating cephalograms, the velopharyngeal contact became more physiological after maxillary advancement in the craniofacial dysostosis patient. The only postoperative articulatory changes after maxillary advancement were in the production of the /s/ sound, which is particularly sensitive to changes in dentoalveolar relationships.

A low cost medical data handling system

A low-cost Medical Data Handling System (MDHS) has been developed on a Digital Equipment Corporation PDP 11V03 computer system with dual floppy discs using BASIC in a time-shared configuration. The MDHS can be called up by one or more users to collect, update, or store patient data on floppy discs. Various analysis options are available to generate reports for patient management or administrative purposes. All software is written in BASIC to facilitate changes or expansion, and to reduce the costs in transferring the software system to other low-cost microprocessor systems currently available. The MDHS can be used in a variety of hospital departments for data management by simple customization of the I/O software to take advantage of the general purpose routines. The system is currently in use for generating daily patient-summary clinical-laboratory reports for ICU and CCU patients. This is the first part of a two-part article. The second part will follow in the July-September issue of this Journal.