A comparison of smoking cessation efforts in African Americans by resident physicians in a traditional and primary care internal medicine residency

Tobacco use causes significant morbidity and mortality among African Americans. Physicians may inconsistently counsel patients against smoking. This retrospective chart review evaluated smoking cessation efforts in African Americans by internal medicine resident physicians in a traditional and a primary care residency program. One hundred twenty-nine African-American patients were evaluated by resident physicians in the traditional internal medicine residency. A tobacco use history was obtained in 84 patients. Twenty-eight patients smoked and two patients were counseled against smoking. Fifty-two African-American patients were evaluated by resident physicians in the primary care residency. A tobacco use history was obtained in 47 patients. Twenty patients smoked and 12 patients were counseled against smoking. There was a statistically significant difference in the rate at which smoking histories were obtained (p = 0.0011) and frequency of counseling against smoking (p < 0.0001). Gender analysis revealed that African-American women were less frequently asked about their smoking history (p = 0.0058) and counseled against smoking (p = 0.0016) by resident physicians in the traditional residency. African-American men received less counseling against smoking (p = 0.055) by resident physicians in the traditional residency. Resident physicians in the primary care residency program demonstrated greater smoking cessation efforts for African American patients. Smoking cessation should be emphasized in all internal medicine residency training programs.     

Publications and extramural activities of general internal medicine and medicine subspecialty clinician-educators: a multicenter study.

PURPOSE: Generalist clinician-educators may have more difficulty than specialists satisfying common promotion criteria (peer-reviewed publication and extramural reputation). This study compared publication rates and participation in extramural activities among subspecialist and generalist clinician-educators, and sought to determine the views of clinician-educators on the use of publication and reputation in determining their promotion. METHOD: A cross-sectional questionnaire was delivered to 526 clinician-educators identified by the chairs at ten randomly selected U.S. medical schools in 2002. RESULTS: A total of 270 clinician-educators responded. Medicine subspecialist clinician-educators reported more peer-reviewed publications than did general internal medicine (GIM) faculty (mean 26.4 versus 10.2, p < .003). Independent predictors of having a greater number of peer-reviewed publications were subspecialty membership (p < .01), less time spent in clinic (p < .01), focus of scholarship (p = .01), academic rank (p < .01), higher quartile of National Institutes of Health funding received by respondent's department (p < .01), and years on faculty (p = .03). A greater proportion of GIM faculty reported spending most of their protected time on scholarly activities less amenable to publication (p = .05). A greater proportion of subspecialists felt peer-reviewed publication should be required for promotion (p < .01), but a minority of both groups felt this should necessarily entail original research. CONCLUSION: Subspecialist clinician-educators generate significantly more peer-reviewed publications than do their GIM colleagues. clinician-educators hold diverse views on the role of publication and reputation in determining their promotion.     

Colorectal cancer screening of African Americans by internal medicine resident physicians can be improved with focused educational efforts

Colorectal cancer causes significant morbidity and mortality in the United States. African Americans are disproportionately affected by this malignancy. There is evidence to suggest that resident physicians inconsistently screen for colorectal cancer in African Americans, perhaps because of a deficiency in knowledge and limited resources. This study evaluated internal medicine resident physicians' colorectal screening practices in African Americans prior to and following a focused educational intervention. A medical record review of internal medicine resident physicians' adherence to colorectal cancer screening recommendations was conducted. Physicians' performance of rectal exams, fecal occult blood testing, flexible sigmoidoscopy and colonoscopy was evaluated for six months prior to and six months following an educational intervention that focused upon issues related to racial disparities in colorectal cancer. Statistical significance was assessed using Fischer's exact test. There were 116 patients included in the preintervention assessment and 132 patients included in the postintervention assessment. There was no statistical significance in the rate at which rectal exams (p=0.6605) and fecal occult blood testing (p=0.7748) were performed prior to and following the educational initiative. However, there was a statistically significant difference in the rate at which endoscopic assessments (p<0.0001) were performed. Educational interventions that are focused upon racial disparity in colorectal cancer may improve resident physicians' performance of endoscopic exams in African Americans. Continued effort to enhance resident physicians' colorectal cancer screening practices in African Americans is important.     

Prevalence of enteric parasites in homosexual patients attending an outpatient clinic.

A total of 372 pooled stool specimens from 274 homosexual men with diarrhea were submitted for parasitologic examination over a 2.5-year period. Each two-vial pooled specimen set contained portions of stool from 3 consecutive days in Formalin and polyvinyl alcohol. Of the 274 patients, 133 (48.5%) harbored one or more intestinal protozoa, with 161 (43.3%) of the 372 specimens submitted being positive for one or more organisms. The parasites identified included Entamoeba histolytica (71 patients), Giardia lamblia (22 patients), Endolimax nana (106 patients), Entamoeba coli (39 patients), Entamoeba hartmanni (25 patients), Dientamoeba fragilis (3 patients), Iodamoeba bütschlii (2 patients), and Chilomastix mesnili (2 patients). Cryptosporidium sp. (2 patients) and Isospora belli (1 patient) were also detected. Results of this study support the experience of other workers regarding high rates of infection with intestinal parasites in the homosexual population and also indicate that symptomatic individuals belonging to this acquired immunodeficiency syndrome risk group be screened for both common and uncommon intestinal pathogens.     

综合医院内科门诊神经症的临床研究

神经症约占内科普通门诊的12%,其中神经衰弱比例在我国仍是显著的,他们多以躯体不适就诊。通过对神经症病人自身认识,求治过程及转诊问题和劳动能力损伤等问题评定的调查提示在综合医院设立精神科,对医务人员普及加强精神病学训练,在神经症病人中普及精神卫生知识是很必要的。     

The responsibilities and activities of internal medicine clerkship directors.

PURPOSE: To characterize the responsibilities, activities, and scholarly productivity of internal medicine clerkship directors (CDs). METHODS: In 1999, internal medicine CDs from 122 U.S. medical schools and one Canadian medical school were surveyed. The instrument asked about the CDs' demo-graphics, workloads, clerkship characteristics, and scholarly productivity. RESULTS: The response rate was 89%; 72% of the respondents were men. Mean age was 45 years, mean time as CD was 6.5 years, and 58% of the CDs had completed fellowship training. The CDs spent 28% of their professional time on the clerkship, three half days weekly in clinic, and three months on inpatient services. The CDs had published a mean of 2.2 (range 0-20) articles and received a mean of 0.7 (range 0-4) grants. Similar factors were associated with publishing articles and receiving grants; gender (men), < or = three clinic half days weekly, fellowship training, having a faculty development program, teaching other courses, and discussing expectations with their department chairs. In a multivariate analysis, fellowship training, clinic half days, teaching other courses, and discussing expectations explained 22% of the variance for papers published. For grants received, a model with gender, clinic half days, a faculty development program, discussing expectations, and teaching other courses explained 35% of the variance. CONCLUSIONS: An internal medicine CD invests significant effort administering the clerkship and contributing to clinical and educational activities. The factors associated with successful scholarship may be useful for fostering CDs' academic careers.     

A survey of subjective sleepiness and consequences in attending physicians

This article surveyed attending physicians on their work hours, sleep schedule, daytime sleepiness, and the perceived relation of these factors to patient safety, quality of care, and personal well-being. Physicians answered demographic and workload questions and attitudinal questions regarding work-hour limitations; the Epworth Sleepiness Scale (ESS) was used to measure subjective sleepiness, and an 18-item Impact Questionnaire was also used. Of 180 participants, 41 (23%) attending physicians manifested abnormal ESS scores (11 or greater). Private practice- and surgically-based subspecialties had higher ESS scores. Reduced sleep, but not hours worked, was associated with increased sleepiness. Sleepy physicians were more likely to associate sleep loss with medical errors and driving impairment. Sleepiness may be attenuated by education regarding consequences of insufficient sleep and institution of effective countermeasures.     

An assessment of mood in males attending an infertility clinic

This study was undertaken to assess the mood profile in men seeking treatment for infertility and also to investigate if aetiological factors of infertility have any impact on mood. This was a prospective questionnaire study and the setting was the Human Assisted Reproduction Ireland (H.A.R.I.) unit in the Rotunda Hospital. Fifty men participated in the study and were required to complete the Hospital Anxiety and Depression Scale (HADS) questionnaire. The results were analysed using an ordered logit regression analysis on the statistical software package DATA DESK 5.0.1. There were no cases of depression in the study population. However, detectable anxiety levels were displayed in 31.9% of men. Those with severe oligospermia had a higher mean anxiety score (8.5) compared with other patient subgroups. Clinically significant anxiety was found in 8.5%; all of these men had a male-factor problem. The study population was relatively small but some interesting trends were observed. A larger trial is warranted to assess if genuine at-risk groups exist.     

Examination room presentations in general internal medicine clinic: patients' and students' perceptions.

PURPOSE: To determine if patients are more satisfied with their health care when medical students present in the exam room to both the attending physician and patient than they are when medical students present outside the exam room to only the attending. To determine medical students' preference for location of presentation and the reasons for their preference. To determine if exam-room presentations promote the education of medical students to a greater degree than presentations outside of the exam room. METHOD: In 2001, 108 patients and 142 fourth-year medical students at internal medicine (IM) clinics affiliated with the University of Washington School of Medicine were asked to complete an 11-point ordinal scale questionnaire on their attitudes toward medical student presentations. RESULTS: One hundred patients (93%) and 68 medical students (48%) responded. Patients with in-room presentations enjoyed working with the medical student more than did patients with out-of-room presentations. Both groups expressed a preference for in-room presentations on future visits and a high level of comfort with student and physician discussing their health. Medical students reported a slight preference for presenting out of the room. When presenting in the room, students reported learning more about physical diagnosis and bedside manner and less about mechanism of disease than when presenting out-of-room. CONCLUSIONS: Patients preferred in-room case presentations and were comfortable with medical students and physicians discussing their health in their presence. In-room presentations also foster instruction on bedside manner and physical diagnosis. These data suggest that both patients and students would benefit from participating in more in-room presentations.     

Discussing care decisions at the internal medicine outpatient clinic: A conversation analysis

ObjectiveExplore how often, when and how care decisions are discussed during consultations at an internal medicine outpatient clinic, and what we can learn from these observations.MethodsQualitative analysis of 150 video-taped consultations. Consultations involving a discussion of care decisions were analyzed using conversation analysis.Results1) Only 21 of the 150 consultations involved a discussion of care decisions; 2) As there is no destined phase for the introduction of the topic of care decisions, the topic is most often introduced at the end of the phase ‘treatment and course of the disease’; 3) A lot of interactional effort is needed to create common ground and make relevance clear with extensive justification. Hesitation markers, repairs and hypothetical talk show the precariousness of the topic.ConclusionsThree dilemma’s need to be addressed: 1) a slot has to be created to introduce the topic of care decisions; 2) common ground has to be created, possibly over time; 3) the paradox of framing the topic as relevant ‘in the future’ but ‘needs to be discussed now’ needs to be attended to.Practice implicationsWe recommend that physician training should address the three dilemmas. Future research should focus on how to do so.     

Training in childhood obesity management in the United States: a survey of pediatric,internal medicine-pediatrics and family medicine residency program directors

Background  

Information about the availability and effectiveness of childhood obesity training during residency is limited.     

Teaching and improving quality of care in a primary care internal medicine residency clinic.

Purpose Learning and applying quality of care principles are essential to practice-based learning and improvement. The authors investigated the feasibility and effects of a self-directed curriculum in quality of care for residents. Method In 2001-02, 13 second-year residents at two community-based outpatient clinics in the Yale University primary care internal medicine residency program were asked to participate in a trial of a quality improvement curriculum (intervention group). Thirteen third-year residents in the same residency program served as the comparison group. The curriculum consisted of readings in quality of care, weekly self-reflection with a faculty member, completion of a commitment to change survey, and medical record audits. Study outcome measures were patient level quality of care measures for diabetes, satisfaction with the curriculum, and self-reported behavioral changes. Results In the follow-up, patients of the intervention group were significantly more likely to have received a monofilament foot examination and baseline electrocardiogram than were patients of the comparison group. When comparing the change between baseline and follow-up, patients for the second-year residents showed significantly more improvement in hemoglobin A1c and LDL cholesterol levels and Pneumovax administration than did patients of the comparison group. All residents in the intervention group were highly satisfied with the curriculum. Thirty-five of 54 residents' personal commitments to change were either partially or fully implemented six months after the curriculum. Conclusions A multifaceted curriculum in quality improvement led to modest improvements in the care of diabetic patients and meaningful changes in self-reported practice behaviors. Future research should include more focus on the microsystems of residency outpatient experiences.     

The risks and implications of excessive daytime sleepiness in resident physicians.

PURPOSE: To assess the levels of physiologic and subjective sleepiness in residents in three conditions: (1) during a normal (baseline) work schedule, (2) after an in-hospital 24-hour on-call period, and (3) following a period of extended sleep. METHOD: In 1996, a within-subjects, repeated-measures study was performed with a volunteer sample of 11 anesthesia residents from the Stanford University School of Medicine using three separate experimental conditions. Sixteen residents were recruited and 11 of the 16 completed the three separate experimental conditions. Daytime sleepiness was assessed using the Multiple Sleep Latency Test (MSLT). RESULTS: MSLT scores were shorter in the baseline (6.7 min) and post-call (4.9 min) conditions, compared with the extended-sleep condition (12 min, p =.0001) and there was no significant difference between the baseline and post-call conditions (p =.07). There was a significant main effect for both condition (p =.0001) and time of day (p =.0003). Subjects were inaccurate in subjectively identifying sleep onset compared with EEG measures (incorrect on 49% of EEG-determined sleep episodes). CONCLUSION: Residents' daytime sleepiness in both baseline and post-call conditions was near or below levels associated with clinical sleep disorders. Extending sleep time resulted in normal levels of daytime sleepiness. The residents were subjectively inaccurate determining EEG-defined sleep onset. Based on the findings from this and other studies, reforms of residents' work and duty hours are justified.     

Effects of gender and marital status on somatic symptoms of patients attending a mind/body medicine clinic.

To clarify the mechanisms of gender-related mind/body relationships, the authors analyzed the characteristics of 1,132 outpatients (848 women and 284 men) attending a mind/body medicine clinic. At entry in the program, the patients completed the Medical Symptom Checklist, Symptom Checklist-90 revised (SCL-90R), and Stress Perception Scale. Women reported 9 out of 12 symptoms (fatigue, insomnia, headache, back pain, joint or limb pain, palpitations, constipation, nausea, and dizziness) more frequently than the men did. Being a woman was a predictor of the total number of somatic symptoms endorsed. SCL-90R somatization scores were significantly higher in nonmarried women than in married women. Perceived stress ratings of family and health were higher in women than in men, despite the lower degree of perceived stress concerning work. Women, especially nonmarried women, were more likely to report somatic discomfort. Gender appears to be an important factor in relation to the report of somatic symptoms in stress-related conditions.     

Sexual victimization of boys: an ongoing study of an adolescent medicine clinic population

An ongoing clinical research project on sexual victimization of boys was begun in 1982. The study population is boys aged 12 to 21 years attending an adolescent medicine clinic for reasons other than having been sexually abused. More recently, comparison populations have been obtained from a sexual abuse clinic, from an adolescent medicine clinic for girls, and from a group of adolescent sexual offenders.