Comparison of continuity clinic experience by practice setting and postgraduate level

OBJECTIVE: To compare continuity clinic experiences by practice setting and postgraduate level. DESIGN: Mailed questionnaire. SETTING: Baylor College of Medicine pediatric residents selected 1 of 3 continuity practice settings, including community-based private offices (n = 35) and university-based clinics in a private (n = 71) and a public (n = 12) hospital. SUBJECTS: One hundred eighteen pediatric residents, May 1993. OUTCOME MEASURES: Patient volume, continuity of care, type of patient visit, and faculty supervision. RESULTS: The response rate was 77% (91/118). Pediatric residents in community-based private offices reported seeing more patients per session than those in the university-based private and public clinics (88%, 10%, and 0% residents in the respective practice settings reported > or = 4 patients per session), but were less likely to see patients repeatedly (6%, 68%, and 40% residents in the respective practice settings had seen more than half their patients > 2 times). Residents in private offices provided a smaller percentage of well child care (16%, 61%, and 90% residents in the respective practice settings reported > 50% patients were well) and more acute care (68%, 15% and 0% residents in the respective practice settings reported > 25% patients were acutely ill). Residents in private offices reported a higher percentage of time spent observing only (33%, 0%, and 0% residents in the respective practice settings observed > 25% of the time) and less time managing patients independently (93%, 59%, and 40% residents, respectively, managed < or = 25% of the time). No significant differences among postgraduate levels were found for these variables. CONCLUSIONS: Patient volume, continuity of care, type of patient visit, and faculty supervision were significantly different among continuity practice settings. Postgraduate level of training did not affect significantly these measures of continuity clinic experience. These differences need to be considered in curriculum development.     

Teaching gastroenterology in a private outpatient clinic

In this essay I review how I have taught clinical gastroenterology to residents and fellows and medical students for the past 40 years in an academic private outpatient clinic. Private patients can serve as "teaching patients," even in an ambulatory setting, and even in a managed care environment that encourages productivity.     

Student and faculty collaboration in a clinic for the medically underserved

BACKGROUND AND OBJECTIVES: Growing numbers of uninsured and underinsured individuals in the United States have resulted in increased needs for health care for medically underserved populations. Educational strategies are needed that provide opportunities for students to develop the attitudes, knowledge, and skills necessary for providing quality health care for underserved patients. METHODS: Medical students, residents, and faculty of the University of Wisconsin-Madison Medical School worked together to establish extracurricular opportunities for first- and second-year students to participate in medical clinics serving the poor and homeless. The process for the development and operation of a volunteer clinic is described. RESULTS: In the last 2 years, 163 medical students, 27 residents, and 21 faculty have provided care to more than 1,000 patients. Patients, students, residents, and faculty reported high satisfaction with the experience. CONCLUSIONS: Medical students, residents, and faculty working in collaboration can provide increased access to care for the medically underserved. Engaging in community-oriented primary health care early in their medical education provided positive learning opportunities for medical students, especially those interested in generalist careers.     

Vladimir Mikha?lovich Smol''ianinov (on the centenary of his birth)

Continuity clinics are required for residents in obstetrics and gynecology in the U.S., but are costly and difficult to administer. Organizing them into group resident continuity clinic programs which emulate the group private practice most residents will join, creates a design that is parsimonious of clinic resources, while providing a type of continuity with which patients, nurses, and physicians are familiar and comfortable.     

Who needs an immunization in a pediatric subspecialty clinic?

BACKGROUND: The Standards for Pediatric Immunization Practices recommends that subspecialty clinics screen children's immunization status and ensure the receipt of needed immunizations. OBJECTIVES: To determine the proportion of children presenting to a pediatric subspecialty clinic in whom immunization status can be assessed, and which of those assessed are due an immunization (eligible to receive an immunization on the day of clinic visit). DESIGN: Standardized survey of 196 patients or accompanying children presenting to a pediatric cardiology clinic. Need for immunizations was determined by the Advisory Committee on Immunization Practices recommendations. RESULTS: The reason for visit included 58% return (enrolled in the clinic), 25% initial, and 17% accompanying another patient. Usual immunization provider included 51% health department, 42% primary care physician, and 7% military. We could assess the immunization status of 79 (40%) of 196, and 19 (24%) of these 79 were due an immunization. Logistic regression analysis revealed that children enrolled in the clinic were more likely to be due for immunization than those presenting for initial visits (38% vs 8%; adjusted odds ratio, 7.42; 95% confidence interval, 1.43 to 38.55). CONCLUSIONS: We could not assess the immunization status of most children presenting to this pediatric clinic. Patients enrolled in the clinic were at increased risk for being due immunization. Having a primary care physician as a provider of immunizations did not ensure the receipt of immunizations. Pediatric subspecialists should assess the immunization status of their patients and make sure that they receive needed immunizations.     

Aesthetic surgical training: the Lenox Hill model

This program enhances residency training in aesthetic surgery. It provides hands-on operating experience in a supervised hospital setting. Concerns of financial support and liability are addressed. Four chief residents from two university programs each spend 3 months conducting a "private" practice in a service population. A separate resident operative consent form unambiguously specifies the resident as the operating surgeon. Patients are derived from an advertised, free screening clinic every 3 months. The hospital has a special aesthetic surgical fee schedule for the residents. A resident operative fee is collected in support of resident salaries and insurance. An additional fee is collected on behalf of our anesthesiologists. During their 3 months the residents perform 30 to 40 operations as primary surgeon and 50 to 60 as the first assistant. Patient discontent, though rare, is resolved in conference with the patient, the resident, the attending surgeon, and the chief of section. Didactic training consists of monthly surgical conferences, journal club, and guest speaker presentations. Residents experience a practice setting by overseeing appointments to their clinic, booking operating room cases, and providing all paperwork for preadmission testing and certification, as well as fulfilling utilization and quality assurance requirements. They are responsible for their operative patients 24 hours a day, 7 days a week. The program is in its seventh year and its success is noted by continued full certification of the two participating university programs and absence of litigation.     

Involvement of different Ca2+ pools during the canine bronchial sustained contraction in Ca2+-free medium: lack of effect of PKC inhibition

OBJECTIVES: To: (1) develop a pharmaceutical care multicenter outcomes research project using clinical pharmacy residents and preceptors; (2) develop two research protocols to document pharmacists' impact on clinical, economic, and humanistic outcomes of therapy; (3) develop and implement a data collection process and methodology for outcomes research; (4) evaluate the effectiveness of the multicenter outcomes research process; and (5) prepare clinical pharmacy preceptors and residents to conduct outcomes research. DESIGN AND SETTING: Two research protocols were developed, each a randomized, parallel, open-label evaluation of patients at 10 Department of Veterans Affairs and 1 university medical center. One protocol focused on patients with chronic obstructive pulmonary disease (COPD) and the other on patients with hypertension. The study evaluated pharmacists' management of these two patient groups. PATIENTS AND OTHER PARTICIPANTS: 133 patients with hypertension and 98 patients with COPD; 33 pharmacy directors and preceptors; 45 pharmacy residents. MAIN OUTCOME MEASURES: Clinical, economic, and humanistic outcomes of pharmacists' interventions. The processes of developing a multicenter outcomes study were evaluated, including the data collection process. RESULTS: The two study protocols and an educational program for study participants were developed. A data collection process was developed and implemented, with the paper process being successful and the computer data collection process not implemented due to time constraints. Overall, the multicenter outcomes research process was successful. CONCLUSION: The study provides a framework of processes and sites for the future development of other outcomes research studies. Clinical, economic, and humanistic outcomes are reported in Parts 2 and 3.     

Late syndesmosis reconstruction: a case report

The purpose of this study was to determine the benefits and costs to community-based primary care physicians teaching medical students in their offices. Survey data were collected from 185 preceptors between 1990 and 1996. Respondents reported increases in their enjoyment of the practice of medicine (82%), time spent reviewing clinical medicine (66%), desire to keep up with recent developments in medicine (49%), and patients' perception of their stature (44%). However, 61% reported a decrease in the number of patients seen when a student was present. We conclude that despite the costs associated with teaching medical students in their offices, preceptors derived many benefits.     

Comparison of an anticoagulation clinic with usual medical care: anticoagulation control, patient outcomes, and health care costs

BACKGROUND: The outcomes of an inception cohort of patients seen at an anticoagulation clinic (AC) were published previously. The temporary closure of this clinic allowed the evaluation of 2 more inception cohorts: usual medical care and an AC. OBJECTIVE: To compare newly anticoagulated patients who were treated with usual medical care with those treated at an AC for patient characteristics, anticoagulation control, bleeding and thromboembolic events, and differences in costs for hospitalizations and emergency department visits. RESULTS: Rates are expressed as percentage per patient-year. Patients treated at an AC who received lower-range anticoagulation had fewer international normalized ratios greater than 5.0 (7.0% vs 14.7%), spent more time in range (40.0% vs 37.0%), and spent less time at an international normalized ratio greater than 5 (3.5% vs 9.8%). Patients treated at an AC who received higher-range anticoagulation had more international normalized ratios within range (50.4% vs 35.0%), had fewer international normalized ratios less than 2.0 (13.0% vs 23.8%), and spent more time within range (64.0% vs 51.0%). The AC group had lower rates (expressed as percentage per patient-year) of significant bleeding (8.1% vs 35.0%), major to fatal bleeding (1.6% vs 3.9%), and thromboembolic events (3.3% vs 11.8%); the AC group also demonstrated a trend toward a lower mortality rate (0% vs 2.9%; P= .09). Significantly lower annual rates of warfarin sodium-related hospitalizations (5% vs 19%) and emergency department visits (6% vs 22%) reduced annual health care costs by $132086 per 100 patients. Additionally, a lower rate of warfarin-unrelated emergency department visits (46.8% vs 168.0%) produced an additional annual savings in health care costs of $29 72 per 100 patients. CONCLUSIONS: A clinical pharmacist-run AC improved anticoagulation control, reduced bleeding and thromboembolic event rates, and saved $162058 per 100 patients annually in reduced hospitalizations and emergency department visits.     

Transition to a computer-based record using scannable, structured encounter forms

OBJECTIVE: To evaluate the quality of documentation and user satisfaction with a structured documentation system for pediatric health maintenance encounters, using scanned paper-based forms to generate an electronic medical record. DESIGN: (1) A retrospective medical record review comparing 16 structured (ST) records with 16 contemporaneously created unstructured records, (2) a questionnaire evaluation of user satisfaction, and (3) an electronic records review of patients seen 1 year following the full implementation of the system to evaluate persistence of the effect. SETTING: The Yale-New Haven Hospital Pediatric Primary Care Center, New Haven, Conn, an inner-city clinic in an academic center. PARTICIPANTS: (1) A random sample of 16 health maintenance records completed by first- and second-year residents in February 1996 matched for patient's age and provider training level with 16 contemporaneously documented visits, (2) 16 of 18 pediatric level 1 residents and 14 of 16 pediatric level 2 residents who completed questionnaires, and (3) all electronic records of health maintenance visits during February 1997. MAIN OUTCOME MEASURES: The number of data elements documented and the percentage of records that record specific components of the health maintenance encounter. User satisfaction was specified on a Likert scale. RESULTS: Overall, residents in the ST records group documented more data elements per visit than did those in the unstructured records group. The number of developmental items documented was 11.5 per visit in the ST records group and 4.8 per visit in the unstructured records group (P = .004). Likewise, anticipatory guidance was more thoroughly documented in the ST records group--8.3 items per visit vs 2.5 items per visit (P < .001). Ninety percent of the users preferred the ST records. One year after the adoption of the ST recording system, high levels of thoroughness persisted. CONCLUSIONS: Structured, scannable encounter forms can facilitate documentation of patient care and are well accepted by users. They can provide an effective mechanism to ease the transition to a computer-based patient record.     

Audit of casual patient attendance at a restorative dentistry clinic

The aim of this prospective study was to audit casual attendance at the Conservation clinic of the School of Clinical Dentistry, Belfast. Details of 500 consecutive casual patient attendances were collected over a four month period. There were 253 male and 247 female patients with a mean age of 43.4 years. Fifty-eight percent of patients lived within five miles of the clinic with 16% travelling more than 15 miles. Sixty-five per cent of patients were self-referred, 27% were referred from within the School and 3% were referred from their General Dental Practitioner. Pulpal or endodontic problems were diagnosed in 42% of cases, 25% presented with loss of a crown or bridge and 14% complained of a pain-free loss of the filling. Half the patients were given a further appointment to attend the Conservation clinic while only 33% were directed to the General Dental Services for further care. It was concluded that the majority of casual attendees to the Conservation clinic were local residents who referred themselves for treatment. A minority of patients were currently under treatment at the School of Clinical Dentistry but over 65% remained their immediate responsibility. Recommendations for improvements in the current service were also made.     

Do clinical and formal assessments of the capacity of patients in the intensive care unit to make decisions agree?

BACKGROUND: The complex environment and technology of intensive care unit (ICU) care may impair the ability of patients to participate in medical decision making or give informed consent. We studied the agreement of the intuitive assessments of residents and nurses of ICU patients' cognition, judgment, and decision-making capacity, and whether those assessments agreed with abbreviated formal mental status testing. METHODS: Using a prospective survey case study, we assessed 200 English-speaking patients within 24 hours of their ICU admission. Formal assessment of cognition, judgment, and insight was performed by a research assistant. We obtained independent intuitive ratings by nurses and residents of patient cognition, judgment, and ability to participate in medical decision making or give informed consent. RESULTS: Residents' and nurses' assessment of cognition and judgment showed a high degree of agreement with weighted ks of greater than 0.76. Assessments of cognition by residents and nurses agreed with Folstein Mini-Mental State Examination in 70% and 73.6% of cases, respectively. Forty percent of the population had an unimpaired Mini-Mental State Examination score of greater than 23, and an additional 12% of the subjects were mildly impaired with scores of 20 to 23. When asked whether they would approach patient or family for consent for an invasive procedure, nurses and physicians said they would request informed consent from 66% and 62% of the patients, respectively. CONCLUSIONS: Residents and nurses caring for patients newly admitted to the ICU agree in their assessment of cognition, judgment, and capacity to participate in medical decision making, and are not unduly influenced by ventilator status. Their assessments correlate highly with abbreviated formal mental status testing.     

Comparison of patient satisfaction with ambulatory visits in competing health care delivery settings in Geneva, Switzerland

OBJECTIVES: To measure satisfaction with medical visits in various health care settings and to assess the extent to which differences in satisfaction scores between health care settings can be attributed to patients' characteristics. DESIGN: This was a cross sectional survey to measure seven dimensions of patient satisfaction. SETTINGS: Ambulatory visits to 'gatekeepers' or specialists in a newly established managed care organisation, a private group practice, or a university hospital outpatient clinic in Geneva, Switzerland. PATIENTS: There were altogether 1027 adult patients (81% participation rate). RESULTS: Patients who consulted physicians in the private group practice reported higher levels of satisfaction (overall mean 83.2 on a scale between 0 and 100) than university clinic patients (79.7), patients of independent specialists within the managed plan (78.5), and patients of managed plan gatekeepers (69.8, intergroup differences p < 0.001). Differences between settings were reduced after adjustment for sex, age, country of origin, general practitioner versus specialist visit, and scheduled versus urgent visit (adjusted scores: 80.8, 78.8, 77.6, and 72.7 in the four settings, p < 0.001). Intergroup differences were largest for general satisfaction, but small and non-significant for satisfaction with explanations given by the physician and for time spent with the patient. CONCLUSIONS: Patient satisfaction varied widely between health care settings. Differences in satisfaction ratings could be ascribed only partly to disparities in patient populations. Patients of managed plan gatekeepers were least satisfied, presumably because they could not choose their physician freely. Comparison of patient satisfaction across health care settings can provide a basis for targeted quality improvement initiatives.     

Longitudinal weight changes, length of survival, and energy requirements of long-term care residents with dementia

OBJECTIVE: We hypothesized that institutionalized patients with dementia, who frequently have feeding problems and require supervised and assisted feeding, would lose more weight during their residency than nondemented, independently functioning residents and have compromised survival. To test this hypothesis, we examined the survival and longitudinal changes in weight of two cohorts of institutionalized residents with dementia and compared these cohorts with a cohort of nondemented residents. We also measured the resting energy expenditures of a subset of the subjects with dementia as an indicator of their energy needs. DESIGN: A longitudinal cohort study with retrospective baseline chart review and subsequent follow-up of monthly weights and mortality over 4 years. SETTING: A 725-bed long-term care institution with specified levels of care. SUBJECTS: Two cohorts of residents with dementia, one consisting of subjects who required total care throughout their institutional stay (n = 31) and another group who did not initially require total care (n = 48); these were compared with a cohort with normal mentation who were functionally independent in their daily activities (n = 26). The total number of subjects was 105. MEASUREMENTS: Demographics, medical problems, and medications by chart review; functional and mental status evaluations; longitudinal monthly weights and mortality for the 48-month study period; and resting energy expenditures by indirect calorimetry. MAIN RESULTS: Residents with dementia had lower weights on admission and throughout their stay than nondemented, independently functioning residents, and they were more likely to have a weight loss of 10 lbs or more at some point during the 4-year study period. However, their mean weights did not change during the study period. The mean survival from admission of those demented residents who died was more than 3 years. Resting energy expenditures of women residents with advanced dementia were 12% lower than predicted from the Harris Benedict equations. CONCLUSION: Dementia is not necessarily associated with unremitting weight loss during institutionalization despite the frequent occurrence of feeding difficulties and temporary weight loss. This may be caused partly by the lower than expected resting energy expenditures and, hence, energy needs of affected residents as their dementia progresses. Demented residents weighed significantly less than nondemented, independently functioning residents throughout their institutional stay. Nevertheless, nursing staff are able to maintain weight and survival for extended periods even in very impaired residents.     

Secretion of plasminogen activator by cultured rat endometrial stromal cells from uteri differentially sensitized for the decidual cell reaction

OBJECTIVE: We investigated whether patient-centered communication skills can be taught to residents in Internal Medicine by using a time-limited behaviorally oriented intervention. METHOD: Residents working at the Department of Internal Medicine were randomly assigned to an intervention group (IG; N = 19) or a control group (CG; N = 23). In addition to 6 hours of standard medical education per week, the IG received specific communication training of 22.5 hours duration within a 6-month period. Initially and 10 months later, participants performed interviews with simulated patients. Interviews were rated by blinded raters who used the Maastricht History and Advice Checklist-Revised. RESULTS: Compared with the CG, the IG improved substantially in many specific communication skills. Both groups improved in the "amount of medical information identified" and in the ability to "communicate about feasibility of treatment." CONCLUSION: Patient-centered communication skills such as those presented in this intervention study can be taught. The ability to gain medical information and the readiness to communicate about aspects of medical treatment seem to improve with more professional experience; however, they also profit from the intervention.     

Patients' experiences with a hospital outpatient clinic. Is lack of continuity in the physician-patient relationship an important quality problem?

The organization of a haematological out-patient clinic was evaluated. 52 patients completed a problem-oriented questionnaire with structured response alternatives. Patient satisfaction was generally high. The patients defined lack of continuity in the doctor-patient relationship as the main problem. Waiting time, information and poor premises were other areas where the chosen quality standard was not achieved. Possible causes of these deficiencies, and actions to improve the quality of care are discussed.     

The properties of simian coronavirus

OBJECTIVE: To determine the effect of a unique educational program in critical care medicine on the attitudes, knowledge, and skills of general internists who care for critically ill patients. DESIGN: Comparison of objective assessments and self-assessments obtained before and after the one-year educational program. SETTING/PARTICIPANTS: Eighteen general internists practicing in a 350-bed university-affiliated community teaching hospital. RESULTS: After the program, the internists felt significantly more competent in, knowledgeable about, comfortable with, and satisfied with caring for critically ill patients than they did when completing the precourse self-assessments (p < 0.05). Participants felt particularly more comfortable with managing ventilator patients and leading the advanced cardiac life-support team (p < 0.05). Comfort levels for other commonly performed critical care procedures did not vary. No significant change in knowledge test scores was noted from before to after the one-year program (61% vs 60%). Residents and nurses rated the internists' overall ability in critical care medicine to be the same as that of senior medical residents. They also favorably rated the internists on humanism, teaching skills, and interpersonal interactions. Residents also appreciated the decrease in their night call because of the program. CONCLUSIONS: This unique educational program increased comfort and satisfaction of general internists caring for critically ill patients. The program was well accepted by residents and nurses because of favorable interaction with the internists and a decrease in resident night-call responsibility. This curriculum is recommended to other teaching hospitals.