Showing papers in "Journal of General Internal Medicine in 1997"

Case-Finding Instruments for Depression: Two Questions Are as Good as Many

Abstract: Objective To determine the validity of a two-question case-finding instrument for depression as compared with six previously validated instruments.

Meta-analysis of Randomized Control Trials Addressing Brief Interventions in Heavy Alcohol Drinkers

Abstract: OBJECTIVE: To assess the effectiveness of brief interventions in heavy drinkers by analyzing the outcome data and methodologic quality. DESIGN: (1) Qualitative analysis of randomized control trials (RCTs) using criteria from Chalmers' scoring system; (2) calculating and combining odds ratios (ORs) of RCTs using the One-Step (Peto) and the Mantel-Haenszel methods. STUDY SELECTION AND DATA ANALYSIS: A MEDLINE and PsycLIT search identified RCTs testing brief interventions in heavy alcohol drinkers. Brief interventions were less than 1 hour and incorporated simple motivational counseling techniques much like outpatient smoking cessation programs. By a single-reviewer, nonblinded format, eligible studies were selected for adult subjects, sample sizes greater than 30, a randomized control design, and incorporation of brief alcohol interventions. Methodologic quality was assessed using an established scoring system developed by Chalmers and colleagues. Outcome data were combined by the One-Step (Peto) method; confidence limits and test for heterogeneity were calculated. RESULTS: Twelve RCTs met all inclusion criteria, with an average quality score of 0.49 +/- 0.17. This was comparable to published average scores in other areas of research (0.42 +/- 0.16). Outcome data from RCTs were pooled, and a combined OR was close to 2 (1.91; 95% confidence interval 1.61-2.27) in favor of brief alcohol interventions over no intervention. This was consistent across gender, intensity of intervention, type of clinical setting, and higher-quality clinical trials. CONCLUSIONS: Heavy drinkers who received a brief intervention were twice as likely to moderate their drinking 6 to 12 months after an intervention when compared with heavy drinkers who received no intervention. Brief intervention is a low-cost, effective preventive measure for heavy drinkers in outpatient settings.

To tell the truth : Ethical and practical issues in disclosing medical mistakes to patients

Abstract: While moonlighting in an emergency room, a resident physician evaluated a 35-year-old woman who was 6 months pregnant and complaining of a headache. The physician diagnosed a “mixed tension/sinus headache.” The patient returned to the ER 3 days later with an intracerebral bleed, presumably related to eclampsia, and died.

Identification of Patient Attitudes and Preferences Regarding Treatment of Depression

Abstract: To identify attitudes that influence patient help-seeking behavior and aspects of treatment that influence patient preferences for management of depression. Three focus group discussions (two patient groups stratified by race and one professional group). Questions addressed experience with depression, help-seeking behaviors, treatment preferences, and perceived barriers to mental health care. Academic medical, center. Eight black patients and eight white patients with depression; seven health care professionals (four physicians and three social workers). Discussions were audiotaped, transcribed, and reviewed independently by two investigators to identify and group distinct comments into categories with specific themes. Differences were adjudicated by a third investigator. Comments within categories were then checked for relevance and consistency by a health services researcher and a psychiatrist. More than 90% of the 806 comments could be grouped into one of 16 categories. Black patients raised more concerns than white patients regarding spirituality and stigma. Patients made more comments than professionals regarding the impact of spirituality, social support systems, coping strategies, life experiences, patient-provider relationships, and attributes of specific treatments. They discussed the role these factors played in their helpseeking behavior and adherence to treatment. In-depth focus group discussions with depressed patients can provide valuable and unique information about patient experiences and concerns regarding treatment for depression. Clinicians, researchers, and policymakers need to incorporate the range of factors identified by patients into their decision making for individuals with depression.

The Impact of Role Models on Medical Students

Abstract: To explore the relationship between exposure to clinical role models during medical school and the students' choice of clinical field for residency training, and to estimate the strength of this association. Cross-section study. McGill University School of Medicine, Montreal, Canada. Of the 146 graduating medical students in the class of 1995, 136 participated. Clinical field chosen by students for residency training and the students' assessment of their exposure to and interaction with physician role models were the main measurements. Ninety percent of graduating students had identified a role model or models during medical school. Personality, clinical skills and competence, and teaching ability were most important in the selection of a role model, while research achievements and academic position were least important. Odds ratios between interacting with "sufficient" role models in a given clinical field and choosing that same clinical field for residency were 12.8 for pediatrics, 5.1 for family medicine, 4.7 for internal medicine, and 3.6 for surgery. Most students (63%) received career counseling and advice from their role models. Exposure to role models in a particular clinical field is strongly associated with medical students' choice of clinical field for residency training. Knowing which characteristics students look for in their role models should help identify the physicians who may be most influential in medical students' career choice.

How Doctors and Patients Discuss Routine Clinical Decisions: Informed Decision Making in the Outpatient Setting

Abstract: OBJECTIVE: To characterize the informed consent process in routine, primary care office practice. DESIGN: Cross-sectional, descriptive evaluation of audiotaped encounters. SETTING: Offices of primary care physicians in Portland, Oregon. PARTICIPANTS: Internists (54%) and family physicians (46%), and their patients. MEASUREMENTS AND MAIN RESULTS: Audiotapes of primary care office visits from a previous study of doctor-patient communication were coded for the number and type of clinical decisions made. The discussion between doctor and patient was scored according to six criteria for informed decision making: description of the nature of the decision, discussion of alternatives, discussion of risks and benefits, discussion of related uncertainties, assessment of the patient's understanding and elicitation of the patient's preference. Discussions leading to decisions included fewer than two of the six described elements of informed decision making (mean 1.23, median 1.0), most frequent of these was description of the nature of the decision (83% of discussion). Discussion of risks and benefits was less frequent (9%), and assessment of understanding was rare (2%). Discussions of management decisions were generally more substantive than discussions of diagnostic decisions (p = .05). CONCLUSIONS: Discussions leading to clinical decisions in these primary care settings did not fulfill the criteria considered integral to informed decision making. Physicians frequently described the nature of the decision, less frequently discussed risks and benefits, and rarely assessed the patient's understanding of the decision.

Is language a barrier to the use of preventive services

Abstract: Objective To isolate the effect of spoken language from financial barriers to care, we examined the relation of language to use of preventive services in a system with universal access.

Measuring Prognosis and Case Mix in Hospitalized Elders: The Importance of Functional Status

Abstract: OBJECTIVE: Although physical function is believed to be an important predictor of outcomes in older people, it has seldom been used to adjust for prognosis or case mix in evaluating mortality rates or resource use. The goal of this study was to determine whether patients' activity of daily living (ADL) function on admission provided information useful in adjusting for prognosis and case mix after accounting for routine physiologic measures and comorbid diagnoses. SETTING: The general medical service of a teaching hospital. PARTICIPANTS: Medical inpatients (n = 823) over age 70 (mean age 80.7, 68% women). MEASUREMENTS: Independence in ADL function on admission was assessed by interviewing each patient's primary nurse. We determined the APACHE II Acute Physiology Score (APS) and the Charlson comorbidity score from chart review. Outcome measures were hospital and 1-year mortality, nursing home use in the 90 days following discharge, and cost of hospitalization. Patients were divided into four quartiles according to the number of ADLs in which they were dependent. MAIN RESULTS: ADL category stratified patients into groups that were at markedly different risks of mortality and higher resource use. For example, hospital mortality varied from 0.9% in patients dependent in no ADL on admission, to 17.4% in patients dependent in all ADLs. One-year mortality ranged from 17.5% to 54.9%, nursing home use from 3% to 33%, and hospital costs varied by 53%. In multivariate analyses controlling for APS, Charlson scores, and demographic characteristics, compared with patients dependent in no ADL, patients dependent in all ADLs were at greater risk of hospital mortality (odds ratio [OR] 13.7; 95% confidence interval [CI] 3.1-58.8), 1-year mortality (OR 4.4; 2.7-7.4), and 90-day nursing home use (OR 14.9; 6.0-37.0). The DRG-adjusted hospital cost was 50% higher for patients dependent in all ADLs. ADL function also improved the discrimination of hospital and 1-year mortality models that considered APS, or Charlson scores, or both. CONCLUSIONS: ADL function contains important information about prognosis and case mix beyond that provided by routine physiologic data and comorbidities in hospitalized elders. Prognostic and case-mix adjustment methods may be improved if they include measures of function, as well as routine physiologic measures and comorbidity.

Why do patients of female physicians have higher rates of breast and cervical cancer screening

Abstract: Women are more likely to receive breast and cervical cancer screening if they see female physicians. We studied whether this is due to differences between male and female physicians, or to differences in their patients. Large midwestern, independent practice association style of health plan. We surveyed male and female primary care physicians matched for age and specialty and a stratified random sample of three of each physician's women patients. Physicians reported on their practice setting, their attitudes and practices regarding prevention, and their comfort and skill with various examinations. Patients reported on their sociodemographic characteristics, their attitudes and practices regarding prevention, and their preferences for physician gender. Claims data were used to calculate mammography and Pap smear screening rates for the physicians We studied 154 female and 190 male internists and family physicians and 794 of their patients. We compared the responses of male and female physicians and their patients and used multivariable analysis to identify the patient and physician factors that accounted for the differences in screening rates between male and female physicians. Female physicians were more likely to ask new patients about components of prevention, to believe in the effectiveness of mammography, to feel more personal responsibility for ensuring that their patients received screening, and to report more comfort in performing Pap smears and breast examinations. Patients of female physicians were more educated and less likely to be married, but did not differ in other sociodemographic characteristics. They had similar attitudes and practices regarding prevention, except that patients of male physicians were more likely to smoke. Significantly more patients of female physicians preferred a female for some component of care. In multivariable analyses, practice organization, patient preference for a female physician, and prevention orientation of female physicians accounted for up to 40% of screening rate differences between female and male physicians for Pap smears, and 33% for mammography. Differences in beliefs of male and female physicians and patient preference for a female provider contribute independently to the higher rate of breast and cervical cancer screening by female physicians.

Impact of an Evidence-Based Medicine Curriculum Based on Adult Learning Theory

Abstract: To develop and implement an evidence-based medicine (EBM) curriculum and determine its effectiveness in improving residents’ EBM behaviors and skills. Description of the curriculum and a multifaceted evaluation, including a pretest-posttest controlled trial. University-based primary care internal medicine residency program. Second-and third-year internal medicine residents (N=34). A 7-week EBM curriculum in which residents work through the steps of evidence-based decisions for their own patients. Based on adult learning theory, the educational strategy included a resident-directed tutorial format, use of real clinical encounters, and specific EBM facilitating techniques for faculty. Behaviors and self-assessed competencies in EBM were measured with questionnaires. Evidence-based medicine skills were assessed with a 17-point test, which required free text responses to questions based on a clinical vignette and a test article. After the intervention, residents participating in the curriculum (case subjects) increased their use of original studies to answer clinical questions, their examination of methods and results sections of articles, and their self-assessed EBM competence in three of five domains of EBM, while the control subjects did not. The case subjects significantly improved their scores on the EBM skills test (8.5 to 11.0, p=.001), while the control subjects did not (8.5 to 7.1, p=.09). The difference in the posttest scores of the two groups was 3.9 points (p=.001, 95% confidence interval 1.9, 5.9). An EBM curriculum based on adult learning theory improves residents’ EBM skills and certain EBM behaviors. The description and multifaceted evaluation can guide medical educators involved in EBM training.

Atherosclerotic Risk Factors Are Less Intensively Treated in Patients with Peripheral Arterial Disease Than in Patients with Coronary Artery Disease

Abstract: OBJECTIVE: To compare rates of therapy for atherosclerotic risk factors between patients with lower extremity peripheral arterial disease (PAD) and patients with coronary artery disease (CAD). DESIGN: Cross-sectional. SETTING: Academic medical center. PATIENTS/PARTICIPANTS: Three hundred forty-nine consecutive patients diagnosed with PAD or CAD identified from the blood flow and cardiac catheterization laboratories, respectively. MEASUREMENTS AND MAIN RESULTS: Participants were interviewed by telephone for medical history as well as therapies prescribed and recommended by their physicians. Among patients with hypercholesterolemia, more CAD patients were taking cholesterol-lowering drugs (58% vs 46%, p = .08) and more CAD patients recalled a physician's instruction to follow a low-fat, low-cholesterol diet (94% vs 83%, p = .01). CAD patients were more likely to exercise regularly (71% vs 50%, p < .01). Among patients not exercising, more CAD patients recalled a physician's advice to exercise (74% vs 47%, p < .01). In logistic regression analysis, hypercholesterolemic patients with exclusive CAD were more likely to be treated with drug therapy (odds ratio [OR] 2.3, p = .05). CAD patients were more likely to recall advice to exercise (OR 4.0, p < .001), and more likely to be taking aspirin or warfarin (OR 4.8, p = .01). CONCLUSIONS: Atherosclerotic risk factors are less intensively treated among PAD patients than CAD patients. A number of possible explanations could account for these disparities in therapeutic intensity.

Medical information on the Internet : A study of an electronic bulletin board

Abstract: Objective To assess medical information provided in a medically oriented Internet discussion group, in terms of the professional status of the individuals providing information, the consistency of the information with standard medical practice, and the nature of the evidence cited in support of specific claims or recommendations.

Health-related quality of life after elective surgery: measurement of longitudinal changes.

Abstract: Objective: To examine the responsiveness of the 36-Item Short Form Health Survey (SF-36) to clinical changes in three surgical groups and to study how health-related quality of life (HRQL) changes with time among patients who undergo total hip arthroplasty, thoracic surgery for treatment of non-small-cell lung cancer, or abdominal aortic aneurysm (AAA) repair.

The treatment of chronic constipation in adults. A systematic review.

Abstract: OBJECTIVE To evaluate whether laxatives and fiber therapies improve symptoms and bowel movement frequency in adults with chronic constipation.

The Seasons of a Woman's Life

Abstract: As a 40 i s h w o m a n genera l i n t e r n i s t feeKng the compet ing tugs of fantily and profess ion, I w a s de l ighted at the p rospec t of r ead ing The Seasons o f a Woman's Ifffe. ~eVritten by Daniel J. Levinson in co l labora t ion w i t h h i s wife, J u d y D. Levinson, t h i s book s t ud i e s w o m e n in midlife in order to a dd r e s s the ques t i on of w h e t h e r the re is a s ingle adu l t deve lopmenta l life cycle ana logous to the ear l ier p rocess of child development . The Levinsons p r e s e n t s tor ies of w o m e n f rom th ree w a l k s of life h o m e m a k e r s , b u s i n e s s execut ives , and academics s tor ies t h a t r e m a i n wi th me long a f te r r ead ing the book. This book h a s p a r t i c u l a r appea l to r e ade r s in t e res t ed in qual i ta t ive me thods , gender i s s ue s , or s t ud i e s of na r ra t ive and biography. The S e a s o n s o f a Woman's Life is a seque l to Danie l Levinson 's 1978 The Seasons o f a Man's LtJ~, in w h i c h the populax t e r m \"midlife crisis\" origklated, Fk-ofessor E m e r i t u s of Psychol ogy in the D e p a r t m e n t of Psych ia t iy a t the Yale Univers i ty School of Medicine, Levinson h a d come to identify h im s e l f over the course of h i s career a s a hybr id a t the m a r g i n s of p s y c h d o g y , sociology, and psych ia t i y . He developed m u l t t m e t h o d a p p r o a c h e s to s t u d y ind iv idua l l ives over t ime, s u c h as h i s tec t~l ique of \" in ten sive b iograph ica l in te iv iewmg.\" In The Seasons o f a Man's IJfe, Levinson add re s sed the ques t ions : Is there an u n d e r l y i n g order i n the adul t life cou r se? Do men ' s l ives evolve in accord w i t h bas ic u n i v e r s a l p ~ n e i p l e s ? Levinson conc luded tha t , in h i s adu l t development , every m a n goes t h rough a predic table order of age-related \"seasons\" or eras, In h i s preface to The Seasons o f a Woman's Life, Levinson exp la ins tha t , h a d he s tud ied m e n and w o m e n toge ther from the outse t , he would have done a disservice to each group and r u n the r i s k of genera l i zk lg f rom the f ind ings of the ma le cohort. He u n d e r t o o k the s t u d y of m e n first, he s t a t e s , largely ou t of in t e res t in h i s own p e r s o n a l adu l t deve lopment , ye t w i t h the i n t en t i on of doing a second s t u d y of w o m e n ' s lives, In 1979, r eady to e m b a r k on the women ' s project, he w a s app roached by the F inanc ia l Women ' s Assoc ia t ion of New York w i t h an offer to s ponso r h i s w o r k on s t u d y i n g w o m e n ' s lives. In 1981, Teacher s I n s u r a n c e and Annu i ty Assoc ia t ion became a cosponsor . Thus , two p o p u l a t ions he s t ud i e s in the book are w o m e n f rom corporate f inanc ia l b u s i n e s s e s in the New York City a rea a nd facul ty in colleges and un ive r s i t i e s located a long the New York Bos ton con-idor, His th i rd cohor t compr i ses h o m e m a k e r s d r a w n raxldolifly f rom the grea te r New Haven t e l ephone directory. All of the w o m e n s tud ied are d r a w n from a p o d of severa l h u n d r e d r e s p o n d e n t s to a quest ionnai re , deta i ls of w h i c h are no t inc luded in the book.

Do traditional symptoms of hypothyroidism correlate with biochemical disease

Abstract: Objective Hypothyroidism often remains undetected because of the difficulty associating symptoms with disease. To determine the relation between symptoms and biochemical disease, we assessed symptoms and serum thyroid function tests, concurrently, for patients with and without hypothyroidism.

Patients’ Perspectives on the Management of Emotional Distress in Primary Care Settings

Abstract: Objective To investigate how important treatment for emotional distress is to primary care patients in general and to primary care patients with depression, and to evaluate the types of mental health interventions they desire.

Do Patient Preferences Contribute to Racial Differences in Cardiovascular Procedure Use

Abstract: OBJECTIVE: To determine whether patient preferences for the use of coronary revascularization procedures differ between white and black Americans. DESIGN: Cross-sectional survey. SETTING: Tertiary care Department of Veterans Affairs hospital. PATIENTS: Outpatients with and without known coronary artery disease were interviewed while awaiting appointments (n = 272). Inpatients awaiting catheterization were approached the day before the scheduled procedure (n = 80). Overall, 118 blacks and 234 whites were included in the study. MEASUREMENTS AND MAIN RESULTS: Patient responses to questions regarding (1) willingness to undergo angioplasty or coronary artery bypass surgery if recommended by their physician and (2) whether they would elect bypass surgery if they were in either of two hypothetical scenarios, one in which bypass surgery would improve symptoms but not survival and one in which it would improve both symptoms and survival. Blacks were less likely to say they would undergo revascularization procedures than whites. However, questions dealing with familiarity with the procedure were much stronger predictors of a positive attitude toward procedure use. Patients who were not working or over 65 years of age were also less interested in procedure use. In multivariable analysis race was not a significant predictor of attitudes toward revascularization except for angioplasty recommended by their physician. CONCLUSIONS: Racial differences in revascularization rates may be due in part to differences in patient preferences. However, preferences were more closely related to questions assessing various aspects of familiarity with the procedure. Patients of all races may benefit from improved communication regarding proposed revascularization. Further research should address this issue in patients contemplating actual revascularization.

The Treatment of Chronic Constipation in Adults

Abstract: To evaluate whether laxatives and fiber therapies improve symptoms and bowel movement frequency in adults with chronic constipation. English language studies were identified from computerized MEDLINE (1966-1995), Biological Abstracts (1990-1995), and Micromedex searches; bibliographies; textbooks; laxative manufacturers; and experts. Randomized trials of laxative or fiber therapies lasting more than 1 week that evaluated clinical outcomes in adults with chronic constipation Two independent reviewers appraised each trial's characteristics including methodologic quality. There were 36 trials involving 1,815 persons from a variety of settings including clinics, hospitals and nursing homes. Twenty-three trials were 1 month or less in duration. Several laxative and fiber preparations were evaluated. Twenty trials had a placebo, usual care, or discontinuation of laxative control group, and 16 directly compared different agents. Laxatives and fiber increased bowel movement frequency by an overall weighted average of 1.4 (95% confidence interval [CI] 1.1-1.8) bowel movements per week. Fiber and bulk laxatives decreased abdominal pain and improved stool consistency compared with placebo. Most nonbulk laxative data concerning abdominal pain and stool consistency were inconclusive, though cisapride, lactulose, and lactitol improved consistency. Data concerning superiority of various treatments were inconclusive. No severe side effects for any of the therapies were reported. Both fiber and laxatives modestly improved bowel movement frequency in adults with chronic constipation. There was inadequate evidence to establish whether fiber was superior to laxatives or one laxative class was superior to another.

The efficacy of selective serotonin reuptake inhibitors for the management of chronic pain.

Abstract: OBJECTIVE: To assess the effectiveness of selective serotonin reuptake inhibitors (SSRIs) in the management of chronic pain. METHODS: Randomized, controlled trials of SSRIs in the management of chronic pain were identified by searching MEDLINE from 1966 to 1997 and by contacting the manufacturers of SSRIs available in the United States. MAIN RESULTS: Nineteen studies were identified, including 10 on the treatment of headache, 3 on diabetic neuropathy, 3 on fibromyalgia, and 3 on mixed-chronic pain. SSRIs were consistently helpful for mixed-chronic pain. Results were conflicting for migraine headache, tension headache, diabetic neuropathy, and fibromyalgia. CONCLUSIONS: SSRIs appear to be beneficial for mixed-chronic pain. It is unclear, from the available evidence, whether SSRIs are beneficial for migraine headaches, tension headaches, diabetic neuropathy, or fibromyalgia. For those patients it may be reasonable to reserve SSRIs for those who fail to respond to other medications or who are intolerant of their side effects. KEY WORDS: chronic pain, management of; selective serotonin reuptake inhibitors.

Patients' preferences for risk disclosure and role in decision making for invasive medical procedures.

Abstract: To assess the level of involvement patients want in decision making related to the acceptance or rejection of an invasive medical intervention and whether their preference for decision making is related to their preference for qualitative (verbal) or quantitative (numeric) information about the risks of the procedure. Cross-sectional study using structured interviews of consecutive patients seen for continuity care visits in a general medicine clinic. A university-based Department of Veterans Affairs Medical Center. Four hundred and sixty-seven consecutive patients with a mean age of 65.2 years (SD 10.70 years, range 31-88 years) and with a mean of 12.6 years (SD 2.96 years, range 0-24 years) of formal education. In the context of an invasive diagnostic or therapeutic intervention, patients were asked whether they preferred patient-based, physician-based, or shared patient-physician decision making. Patients were asked to give the ratio of patient-to-physician decision making they preferred, and whether they preferred discussions using words, numbers, or both. Of 467 subjects, 318 (68%) preferred shared decision making; 100 (21.4%) preferred physician-based decision making; and 49 (10.5%) preferred patient-based decision making. In terms of risk disclosure, 436 (93.4%) preferred that their physician disclose risk information to them. Of these 436 patients, 42.7% preferred disclosure of information about the probability of adverse outcomes using qualitative (verbal) expressions of probability; 35.7% preferred disclosure in terms of quantitative (numeric) expressions of probability; and 9.8% preferred disclosure in both qualitative and quantitative terms. Younger patients (odds ratio [OR] 0.96; confidence interval [CI] 0.93, 0.99), patients who had at least one stroke (OR 3.03; CI 1.03, 8.90), and patients who preferred to discuss risk information with their physicians in terms of numbers (OR 2.39; CI 1.40, 4.06) tended to prefer patient-based or shared decision making. Male veterans consistently preferred shared patient-physician decision making in the context of invasive medical interventions.

Faculty development. A resource for clinical teachers.

Abstract: Clinical teachers have the challenging and profound responsibility to convey the art and science of current medical practice. Fortunately, over the past four decades, a variety of programs have been developed to help them play this difficult role. Starting with the initial work of Miller and colleagues in the mid 1950s,1 faculty-development programs to enhance instructional skills have been created for the large cadre of clinician-educators in this country. Since 1978, the Department of Health and Human Services and foundations such as the Kaiser Family Foundation, the Macy Foundation, and the Robert Wood Johnson Foundation have supported programs that emphasize teaching. Such initiatives have resulted in a wide variety of faculty-development programs operating at the institutional, regional, and national levels. The rationale for providing support for clinician-educators can be found in both the task of clinical teaching itself and the empirical studies of faculty-development programs. The task of teaching in general is complex and difficult.2 Clinical teaching can be especially difficult. First, its intended outcome—the effective training of medical practitioners—imposes a ponderous responsibility on the clinical teacher. In the short term, effective clinical teaching is necessary to provide society with excellent care for patients currently in teaching hospitals. Over the long term, effective clinical teaching provides the underpinnings for the high quality of care given patients away from the academic center, who are treated long after physicians finish their formal training. Second, clinical teaching is laden with many educational challenges requiring a breadth of skills. Clinical teachers are expected to address a wide range of educational goals (knowledge, attitudes, and skills); to work with learners who vary greatly in their experience and abilities (students through fellows); to use a variety of teaching methods (lecturing, small–group discussion, and one-on-one teaching); and to teach in different settings (inpatient, outpatient, and lecture hall).3–5 Moreover, clinical teaching is commonly compounded by the simultaneous requirement to deliver patient care. Given this complexity, clinical teachers need to be prepared with as many teaching skills as possible. Empirical studies provide further evidence for the value of faculty development. First, in evaluating many faculty-development programs, clinical teachers rate the experience as useful, and they recommend their experience to colleagues.6,7 Second, evaluation measures show that such programs can improve teachers’ knowledge, skills, and attitudes. These measures include improvements in the following: self–reported knowledge and the use of educational terms before and after training,8 retrospective ratings of knowledge and skills,9,10 teacher ratings of self-efficacy in teaching specific content,11 teacher behavior during problem-based tutorials,12 teacher beliefs regarding problem-based methods,13 ratings from videotapes of participants’ teaching,3 and attitudes toward collaboration between community faculty and university programs.14 Other unpublished data describe improvements in student ratings,15 participants’ self-report 3 to 6 months after training regarding the concepts and skills taught in the program (T. A. DeWitt and M. Quirk, unpublished results),16 and participants’ ability to use educational concepts when analyzing videotaped teaching scenarios (K. M. Skeff and G. A. Stratos, unpublished results).17 In summary, the difficulty of clinical teaching coupled with the evidence that clinician-educators can improve in this role indicates the value of faculty-development programs. Although this rationale for using faculty-development methods is forceful, most medical faculty still have not participated in programs to improve teaching skills. Possible reasons include barriers to faculty participation and lack of knowledge about resources. To help more faculty benefit from available methods, we shall discuss potential barriers to participation in faculty-development programs, provide a summary of the types of available programs in primary care fields, describe characteristics of effective teaching-improvement methods, and recommend how to choose among teaching-improvement methods.

Predictors of recovery in activities of daily living among disabled older persons living in the community

Abstract: Objective To identify the factors that predict recovery in activities of daily living (ADLs) among disabled older persons living in the community.

Measuring Symptomatic and Functional Recovery in Patients with Community‐Acquired Pneumonia

Abstract: OBJECTIVE To determine the rates of resolution of symptoms and return to premorbid health status and assess the association of these outcomes with health care utilization in patients with community-acquired pneumonia.

Physician job satisfaction : Developing a model using qualitative data.

Abstract: 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.

Presentations of acute myocardial infarction in men and women

Abstract: To assess the influence of gender on the likelihood of acute myocardial infarction (AMI) among emergency department (ED) patients with symptoms suggestive of acute cardiac ischemia, and to determine whether any specific presenting signs or symptoms are associated more strongly with AMI in women than in men. Analysis of cohort data from a prospective clinical trial. Emergency departments of 10 hospitals of varying sizes and types in the United States. Patients 30 years of age or older (n = 10,525) who presented to the ED with chest pain or other symptoms suggestive of acute cardiac ischemia. The prevalence of AMI was determined for men and women, and a multivariable logistic regression model predicting AMI was developed to adjust for patients' demographic and clinical characteristics. AMI was almost twice as common in men as in women (10% vs 6%). Controlling for demographics, presenting signs and symptoms, electrocardiogram features, and hospital, male gender was a significant predictor of AMI (odds ratio [OR] 1.7; 95% confidence interval [CI] 1.4, 2.0). The gender effect was eliminated, however, among patients with ST-segment elevations on electrocardiogram (OR 1.1; 95% CI 0.7, 1.7) and among patients with signs of congestive heart failure (CHF) (OR 1.1; 95% CI 0.8, 1.5). Signs of CHF were associated with AMI among women (OR 1.9; 95% CI 1.4, 2.6) but not men (OR 1.0; 95% CI 0.8, 1.3). Among patients who presented to EDs with chest pain or other symptoms suggestive of acute cardiac ischemia, AMI was more likely in men than in women. Among women with ST-segment elevation or signs of CHF, however, AMI likelihood was similar to that in men with these characteristics.

Childhood Sexual Abuse Among Homosexual Men: Prevalence and Association with Unsafe Sex

Abstract: Of 327 homosexual and bisexual men participating in an ongoing cohort study pertaining to risk factors for HIV infection who completed a survey regarding history of sexual abuse, 116 (35.5%) reported being sexually abused as children. Those abused were more likely to have more lifetime male partners, to report more childhood stress, to have lied in the past in order to have sex, and to have had unprotected receptive anal intercourse in the past 6 months (odds ratio 2.13; 95% confidence interval 1.15–3.95). Sexual abuse remained a significant predictor of unprotected receptive anal intercourse in a logistic model adjusting for potential confounding variables.

Differences in Generalist and Specialist Physicians’ Knowledge and Use of Angiotensin-Converting Enzyme Inhibitors for Congestive Heart Failure

Abstract: To quantify the extent and determinants of underutilization of angiotensin-converting enzyme (ACE) inhibitors for patients with congestive heart failure, especially with respect to physician specialty and clinical indication. Survey of a national systematic sample of physicians. Five hundred family practitioners, 500 general internists, and 500 cardiologists. Physicians’ choice of medications were determined for four hypothetical patients with left ventricular systolic dysfunction: (1) new-onset, symptomatic; (2) asymptomatic; (3) chronic heart failure, on digitalis and diuretic; and (4) asymptomatic, post-myocardial infarction. For each patient, randomized controlled trials have demonstrated that ACE inhibitors decrease mortality or the progression of symptoms. Among the 727 eligible physicians returning surveys (adjusted response rate 58%), approximately 90% used ACE inhibitors for patients with chronic heart failure who were already taking digitalis and a diuretic. However, family practitioners and general internists chose ACE inhibitors less frequently (p≤.01) than cardiologists for the other indications. Respective rates of ACE inhibitor use for each simulated patient were new-onset, symptomatic (family practitioners 72%, general internists 76%, cardiologists 86%); asymptomatic (family practitioners 68%, general internists 78%, cardiologists 93%); and asymptomatic, post-myocardial infarction (family practitioners 58%, general internists 70%, cardiologists 94%). Compared with generalists, cardiologists were more likely (p≤.05) to increase ACE inhibitors to a target dosage (45% vs 26%) and to tolerate systolic blood pressures of 90 mm Hg or less (43% vs 15%). Compared with cardiologists, family practitioners and general internists probably underutilize ACE inhibitors, particularly among patients with decreased ejection fraction who are either asymptomatic or post-myocardial infarction. Educational efforts should focus on these indications and emphasize the dosages demonstrated to lower mortality and morbidity in the trials.

Assessing the effectiveness of health interventions for cost-effectiveness analysis

Abstract: Cost-effectiveness analysis (CEA) is an analytic tool in which the costs and effects of an intervention designed to prevent, diagnose, or treat disease are calculated and compared with an alternative strategy to achieve the same goals. The results of a CEA are presented as a ratio of costs to effects, where the effects are health outcomes such as cases of disease prevented, years of life gained, or quality-adjusted life years gained, rather than monetary measures, as in cost-benefit analysis. Conducting a CEA requires a framework for portraying the cascade of events that occur as a consequence of the decision to intervene, for describing the probability that each event will occur, for accounting how long each event will last, and describing how much each event costs and is valued by the population or individuals targeted by the intervention. Mathematical models are well suited to these purposes. The purpose of this article is to provide an overview of modeling to estimate net effectiveness in a CEA (the difference in effectiveness between an intervention and the alternative to which it is being compared). Many of the principles described for estimating effectiveness apply equally to determining costs in a CEA. The main difference is that health events are weighted by costs in the numerator of the cost-effectiveness ratio, while they are often weighted by preference values in the denominator. Preference values, or utilities, reflect the fact that individuals or populations with similar ability (or disability) to function may regard that level of functioning differently. When preferences are incorporated into CEAs, the results are generally expressed as costs per quality-adjusted life years.1,2 A discussion of measurement of costs and valuing outcomes is beyond the scope of this article; for further information on these, and other components of a CEA, the reader is referred elsewhere.3–5 Following some definitions of terms, this article is organized into two sections describing the process of estimating effectiveness in a CEA: the first presents a review of the sources of event probabilities, and the second describes the use of modeling to estimate effectiveness.