Effects of time-in-clinic, clinic setting, and faculty supervision on the continuity clinic experience

STUDY OBJECTIVE: To evaluate the effects of setting, type of supervision, and time in clinic on the resident continuity clinic experience. DESIGN: Prospective cohort with preintervention and postintervention measures. SETTINGS: Pediatric residents selected one of three clinic settings for their continuity clinic experience. These included a traditional, university-based clinic, private practice offices, and publicly funded community-based clinics. SUBJECTS: All pediatric residents at the University of Utah Health Sciences Center, July 1985 through June 1991. INTERVENTIONS: Using varied clinic sites, matching residents one or two to one with preceptors for their continuity clinic, increasing continuity clinic from 1 to 2 half-days per week. MEASUREMENTS AND MAIN RESULTS: Residents in private offices had the most varied experience, seeing more patients, more acute care, and a broader age range of patients than residents at other sites. They were more likely both to be observed by their preceptors during patient visits and to observe their preceptors delivering care. Because the number of patients seen per session rose, increasing continuity clinic time from one to two half-days per week more than doubled the number of patients seen per week. Increased time away from hospital did not affect scores on the Pediatric In-Training Examination. While test scores were similar for incoming residents, those in private offices scored higher on the final Behavioral Pediatrics Examination (P < .05). CONCLUSIONS: Clinic setting, time in clinic, and faculty supervision affect the quality of the continuity clinic experience. Increased time in clinic resulted in a broader exposure to patients. Residents placed in private offices had a more varied patient mix, were more closely supervised, and seemed to gain primary care skills more rapidly than residents at other sites.     

Spindle cell (Kaposiform) hemangioendothelioma with Kasabach-Merritt syndrome in an infant: successful treatment with alpha-2A interferon

Typically, the primary instructional method for ambulatory care education is direct interaction between a preceptor and a learner during a patient encounter. This paper describes instructional strategies teachers and learners can use in ambulatory care training that can occur before or after scheduled clinic hours, thus providing instruction without disrupting a preceptor's busy clinic. First, they describe how preceptors and clerkship or residency-program directors can orient learners prior to their arrival at assigned sites, so that learners are better prepared to assume their patient-care responsibilities. Then they discuss strategies for making use of various types of conferences and independent learning activities to enhance learners' clinical experiences. Conferences and independent study projects that occur before clinic hours can help learners bring a higher level of thinking and clinical sophistication to their role in the ambulatory care site; conferences and independent study activities that occur after clinic hours give learners an opportunity to reinforce and expand on what they have learned during clinic. In this way, learners' educational experiences are enhanced, the best use is made of preceptors' time and expertise, and clinic efficiency is not disrupted.     

Family planning program activity and patient enrollment rates in the United States, 1969 and 1971

The effects of demographic characteristics, socioeconomic conditions, health care, and family planning program activity on patient enrollment rates are estimated for 1969 and 1971. Two program activity variables (agencies and clinic locations) have significant, positive net effects in both years. The effect of agencies changed little between 1969 and 1971, and it is the strongest effect in both years. The effect of clinic locations more than doubled between 1969 and 1971, partly due to increased demand. The direct effects of the demographic, socioeconomic, and health care variables are not large, but many of the demographic and socioeconomic variables have substantial indirect effects via health care program activity.     

Nurse-physician communication in home care and hospice: a physician's point of view

As economic pressure continues to mount within the medical system, more and more patient contact is shifting away from expensive inpatient care. Initially, the shift in patient visits was away from the hospital and into clinics and the physicians offices. With the growth of capitated medical groups and prepaid care, not just inpatient days are declining. With efforts to control costs, the numbers of physician office and clinic visits are declining also.     

Risk of cerebral angiography in patients with subarachnoid hemorrhage, cerebral aneurysm, and arteriovenous malformation: a meta-analysis

OBJECTIVE: To evaluate the utility of "clinic room" case presentation in the ambulatory care setting. BACKGROUND: Neurology is increasingly an outpatient specialty. The transition from ward to clinic presents challenges for student and resident education. Interaction between attending physician and trainee is limited by busy patient schedules. New educational strategies must be developed to address the particular challenges of the outpatient clinic. One strategy to increase the quality and length of attending-trainee interaction is case presentation in the patient's presence. METHODS: The authors randomized 100 patients seen in an academic neuromuscular clinic to presentation in a conference room or clinic room. In the latter, all interaction between the trainee and attending occurred in the patient's presence. The attending recorded the time spent with the trainee and patient. The patient was asked to complete a survey and provide certain demographic information. RESULTS: The two groups were similar demographically. Time spent by the attending physician was similar between the two settings. Although there was no difference in patient satisfaction, those randomized to clinic room presentation were significantly more likely (p < 0.002) to feel their questions were answered adequately. There were trends toward these patients feeling less embarrassed, feeling that they were treated respectfully, and feeling that adequate time was spent with them. CONCLUSIONS: Although clinic room presentation does not save attending time, it allows for a more dynamic and intensive interaction among teacher, student, and patient.     

The use of nurse practitioners in the acute care setting

A collaborative practice model was initiated in a university hospital to assist resident physicians to coordinate patient care on specialty services. Nurse practitioner (NP) data were collected on daily work activities and categorized as direct care, indirect care, administration, education, and research. Satisfaction surveys were collected from patients, physicians and nursing staff. Data on clinic evaluation and management service provided by the NPs were reported. The study supported the appropriateness of NPs in the acute care setting.     

The Medical Polyclinic: an approach to conflicting needs in a teaching hospital

University teaching hospitals have become increasingly aware of their responsibility to improve both the teaching of ambulatory care and the quality of care provided in their clinics. This paper describes how one department of medicine met this challenge by forming a "Medical Polyclinic." The majority of the department's faculty and house staff, at all academic and training levels, participate in a system of ambulatory care with the following objectives: each patient has a single physician whom he sees by appointment and who coordinates his care; all medical subspecialties are available in the same clinic session; the clinic is attractive and efficient. While these goals are not infrequently met in private group practices, they are unusual in a university teaching hospital, where faculty, house staff, students, and patients each have unique needs, not always compatible. The success and problems of the polyclinic approach are discussed.     

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.     

Intrapreneurial nursing: the Comprehensive Lower Extremity Assessment Form

The Comprehensive Lower Extremity Assessment Form was developed in response to the need for a screening tool in a nurse-managed foot care clinic. It differs from other such tools because it includes clinical measures that identify the potential for foot pathology. The Comprehensive Lower Extremity Assessment Form also serves as an assessment teaching guide in a foot care course and is included as part of a home-study program. The authors demonstrate how the Comprehensive Lower Extremity Assessment Form has generated revenue as part of an intrapreneurial outgrowth of their foot clinic and provides a comprehensive approach to lower extremity assessment. The form can be tailored to meet the needs of the advanced practice nurse, the clinical setting, or patient population.     

Chronic disease management: an outpatient approach

The current climate of managed care has sparked efforts to reduce costs in patient care. In many cases, this has resulted in more efficient methods of patient management: chronic disease management in an outpatient setting appears to be one such success story. For critical care nurses interested in working beyond the boundaries of a traditional ICU, chronic disease management clinics represent an alternative environment in which they may apply their skills. Nancy Brass-Mynderse, RN, MSN, CCRN, a clinical nurse specialist (CNS) with 18 years of experience in critical care, was instrumental in development of the Scripps Health Chronic Disease Clinic at Green Hospital of Scripps Clinic, San Diego, Calif. Brass-Mynderse currently supervises the operation of the clinic, along with Omana Kaliangara, RN, MSN, CFNP, a nurse practitioner. Brass-Mynderse received her bachelor's degree from the University of Arizona, Tucson, Ariz, and her master's degree from San Diego State University. She recently obtained her family nurse practitioner certificate from California State University, Dominguez Hills, Calif. Kaliangara received her bachelor's degree from San Jose State University, San Jose, Calif, and her nurse practitioner certificate from the University of California, San Francisco, Calif. After working in family medicine and a diabetic clinic, Kaliangara developed an interest in the management of chronic diseases. In an interview with CRITICAL CARE NURSE in September, Brass-Mynderse and Kaliangara took time to discuss the development and operation of the clinic, and to recount some of their success stories.     

Contemplating a university clinical department

University clinics combine teaching, research and patient care. Some think that no single person (head of department) can perform all three tasks. Also, the head has to have the political skills necessary to manage the faculty society. The guidelines for university clinics, and for their heads in particular, are: (a) conscious pursuit of optimal quality, (b) giving the highest priority to training house staff and teaching students, (c) providing patient care and (d) ensuring that clinical research should serve the purpose of inspiring scientific attitudes in house staff. The 'product' of a university clinic is neither the sum of its publications nor the cured patient, but the medical specialist delivered to society.     

Exploratory eye movement dysfunctions in patients with schizophrenia: possibility as a discriminator for schizophrenia

Emergency oral health care, as conceived in Tanzania, is an on-demand service provided at a rural health center or dispensary by a Rural Medical Aide. The service includes: simple tooth extraction under local anesthesia, draining of abscesses, control of acute oral infection with appropriate drug therapy, first aid for maxillo-facial trauma, and recognition of oral conditions requiring patient referral for further care at the district or regional hospital dental clinic. The objective of the present study was to describe patient satisfaction with emergency oral health care services in rural Tanzania and determine the relative importance of factors influencing patient satisfaction. The study was carried out as a cross-sectional interview survey between April 1993 and May 1994 using a patient satisfaction questionnaire in rural villages in the Rungwe district of Tanzania. It included 206 patients aged 18 years or more who had received emergency oral health care between April 1993 and March 1994. Overall, 92.7% of the respondents reported that they were satisfied with the service. Patients who were married, had no formal education and lived more than 3 km from the dispensary were more likely to be satisfied with treatment. In a logistic regression model, a good working atmosphere at the dispensary, a good relationship between care provider and patients (art of care) and absence of post-treatment complications significantly influenced patient satisfaction with odds ratios of 10.3, 17.4 and 6.2, respectively.     

Cost effectiveness of community leg ulcer clinics: randomised controlled trial

OBJECTIVES: To establish the relative cost effectiveness of community leg ulcer clinics that use four layer compression bandaging versus usual care provided by district nurses. DESIGN: Randomised controlled trial with 1 year of follow up. SETTING: Eight community based research clinics in four trusts in Trent. SUBJECTS: 233 patients with venous leg ulcers allocated at random to intervention (120) or control (113) group. INTERVENTIONS: Weekly treatment with four layer bandaging in a leg ulcer clinic (clinic group) or usual care at home by the district nursing service (control group). MAIN OUTCOME MEASURES: Time to complete ulcer healing, patient health status, and recurrence of ulcers. Satisfaction with care, use of services, and personal costs were also monitored. RESULTS: The ulcers of patients in the clinic group tended to heal sooner than those in the control group over the whole 12 month follow up (log rank P=0.03). At 12 weeks, 34% of patients in the clinic group were healed compared with 24% in the control. The crude initial healing rate of ulcers in intervention compared with control patients was 1.45 (95% confidence interval 1.04 to 2. 03). No significant differences were found between the groups in health status. Mean total NHS costs were 878.06 pounds per year for the clinic group and 859.34 pounds for the control (P=0.89). CONCLUSIONS: Community based leg ulcer clinics with trained nurses using four layer bandaging is more effective than traditional home based treatment. This benefit is achieved at a small additional cost and could be delivered at reduced cost if certain service configurations were used.     

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.     

An approach to reducing the adverse effects of broken appointments in primary care systems: development of a decision rule based on estimated conditional probabilities

A method is presented for adjusting the scheduling of appointments in ambulatory health care centers to reduce the deleterious effects of broken appointments. The essence of the methodology calls for scheduling and "expected number" of patients for a given clinic session. This "expected number" is calculated from estimated probabilities of appointment breaking, conditioned on patient characteristics which are deemed to be related to appointment-breaking rates, and on which number appointment within a specified time period is being made for the patient. The two ill effects of appointment breaking that are considered here are the diminution of efficiency of operation and interference with continuity of patient care. Ways of using this methodology to ameliorate each of these effects are outlined, with one of these way serving to alleviate both effects. This method is meant to be of quite general applicability, although its development was motivated by the problems of a localized particular situation.     

Patient exposition and provider explanation in routine interviews and hypertensive patients' blood pressure control.

Studied the effects of verbal behavior by the patient and the health care provider on the subsequent control of hypertension in a sample of 217 Ss and 9 health care providers. It was hypothesized that both exposition of symptoms by the patient and explanation of illness and treatment by the provider would enhance subsequent control. Patient exposition was significantly correlated with a reduction in blood pressure from the initial to the subsequent home visit, but not with clinic or home interview pressures themselves. Provider explanation was significantly correlated with lower blood pressure at home interview, but not with a change in blood pressure between interviews. The hypothesis was partially confirmed, with implications for hypertension treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The integration of psychology into primary care: Personal perspectives and lessons learned.

The purpose of this article is to discuss the integration of psychology into a Veterans Affairs Medical Center Primary Care clinic, as experienced by the authors. There has been an evolving need for psychology's presence in primary care, due in part to the increasing number of primary care patients who present with complex physical and psychological issues, as well as institutional procedures for first-line treatment of more common mental health concerns (e.g., depression). Concurrent with the expansion of Medical Center services and patient population, an increasing demand has been placed upon psychology in primary care. To better accommodate the workload, a consultation-oriented model of treatment has been implemented. Within this integrated model, primary care providers and psychologists collaborate to provide multidisciplinary care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Hepatitis C virus infection in health care workers referred to a hepatitis clinic

OBJECTIVES: To assess method of acquisition, presence of liver disease, potential infectivity and the effect on work practices in health care workers with hepatitis C virus (HCV) infection referred to a hepatitis clinic. PATIENTS and METHODS: All 33 health care workers referred to a hepatitis clinic for management of HCV infection because of a positive test for HCV (enzyme-linked immunosorbent assay) between 1 January 1990 and 31 December 1994 (comprising six medical practitioners, 18 nurses, two scientists and seven others) were retrospectively assessed for most likely method of infection, alanine aminotransferase levels, results of liver biopsy and measurement of HCV-RNA. RESULTS: 30 health care workers (12 men and 18 women; age range, 27-68 years) had HCV infection confirmed on further testing. Only seven were believed to have acquired their infection occupationally (one with documented needlestick injury). Twenty-eight patients had elevated alanine aminotransferase levels and, of 23 patients who underwent liver biopsy, one had cirrhosis and 12 had chronic hepatitis and fibrosis. Of the 24 health care workers with direct patient contact, four had retired, eight had stopped or modified their work practices and 12 continued to practise normally. CONCLUSIONS: Few health care workers with chronic HCV infection have acquired it occupationally. We recommend that guidelines be set up for institutional expert committees to advise health care workers with HCV infection about modifying their work practice.