A senior-year experience similar to an internship.

A senior year experience similar to an internship was initiated in community hospitals. It is designed to shorten the overall length of training and to restore a broad-based clinical experience to the period of "intermediate patient care responsibility" in the training of new physicians. The program provides students with an opportunity to observe and practice in a primary care setting and expands the clinical resources of the medical school. Analysis of the performance of students in the class of 1974 indicates that they perform on a level comparable with first-year house officers. This program provides a general clinical experience for those students who have not yet decided on future training plans or who are going into primary care fields.     

Handbooks, learning contracts, and senior house officers: a collaborative enterprise.

Efforts to bring about improvements in hospital-based education and training for senior house officers over the last few years have raised issues which are gradually being addressed. One of these is the lack of understanding by many clinical teachers of educational principles and their application to senior house officer training. This study describes how volunteer consultants in five specialties in a North West District General Hospital worked together to develop an educational structure for senior house officers. An audit of education and training was carried out across the hospital to help identify problem areas. An education specialist worked with consultants to develop, implement and evaluate a handbook based on adult learning principles. The handbook incorporated a learning contract, formal review process and a curriculum of learning objectives for each specialty. In parallel, consultants created in-house videos which were used to raise awareness of clinical teachers in the hospital about these educational issues. Preliminary evaluation showed positive responses by both senior house officers and consultants to both the study and its outcomes.     

Do emergency tests help in the management of acute medical admissions?

A two year combined retrospective and prospective study of 555 acute medical admissions to a district general hospital was carried out to assess the value of emergency biochemical, haematological, radiological, and electrocardiographic tests in diagnosis and treatment. For the study the tests were considered helpful only if they disclosed an abnormality and resulted in a definite diagnosis or change of treatment which would not have been possible from the history and examination alone. A total of 2372 emergency tests were carried out in the 555 patients who presented with 579 acute medical problems. Only 403 (17%) of the test results were abnormal and, of these, only one third helped in treatment and less than one third helped in diagnosis. The most useful diagnostic tests were serum amylase activity in abdominal pain, the electrocardiogram in chest pain, the chest radiograph in respiratory problems, and cerebrospinal fluid analysis in suspected meningitis or subarachnoid haemorrhage. The most useful tests in treatment were blood sugar value in diabetes, PCO2 in obstructive airways disease, and haemoglobin concentration in gastrointestinal haemorrhage. Of the tests requested by far the most often--blood urea and serum electrolyte concentrations--only 7% gave abnormal results and were rarely of any help in either diagnosis or treatment. Analysis of the reasons for the uncritical use of emergency tests by house officers suggested that better undergraduate training, regular audit by senior members of medical units, abolition of routine investigational procedures, and more selective laboratory reports would help to build up the house officer's confidence in his own skills of history taking and physical examination without recourse to indiscriminate use of laboratory and other investigations.     

Patient and house officer attitudes on physician attire and etiquette

To study patient preferences on physician attire and etiquette, we interviewed 200 patients on the general medical services of teaching hospitals in Boston and San Francisco. Of these 200 patients, 65% believed physicians should wear a white coat, 27% believed physicians should not wear tennis shoes, 52% believed physicians should not wear blue jeans, 37% believed male physicians should wear neckties, and 34% believed female physicians should wear dresses or skirts. Forty percent of patients wanted physicians to address them by first name, but only 10% of patients wanted to address their physicians by first name. A concurrent mailed survey of 74 medical house staff members at the two hospitals revealed wide variability in physicians' attire and in how patients were addressed at each institution. Thus, many house officers had habits that were less formal than a substantial portion of their patients preferred.     

Part-time medical training: 15 years' experience in the Oxford region

Part-time training of doctors with domestic commitments has taken place successfully in the Oxford region since 1966; 249 doctors have now passed through such training schemes and a further 120 are currently training part-time. Two training schemes are now offered for doctors at senior house officer and registrar level: one of six to eight sessions a week for those undertaking recognised training aiming for consultant or principal in general practice posts, the other of one to two sessions a week providing ad hoc training for those unable for personal reasons to follow a recognised training programme. For doctors at senior registrar level, part-time training entails five to eight sessions a week. Of the 115 doctors who have left the schemes and are now in career posts in the United Kingdom, 19% are now consultants, 30% in other hospital posts, 27% in general practice, and 18% are clinical medical officers; overall, 71% of those in career posts are working part-time. This experience shows that part-time training can be successful and that there is a continuing need for part-time career posts.     

Do house officers learn from their mistakes?

Mistakes are inevitable in medicine. To learn how medical mistakes relate to subsequent changes in practice, we surveyed 254 internal medicine house officers. One hundred fourteen house officers (45%) completed an anonymous questionnaire describing their most significant mistake and their response to it. Mistakes included errors in diagnosis (33%), prescribing (29%), evaluation (21%), and communication (5%) and procedural complications (11%). Patients had serious adverse outcomes in 90% of the cases, including death in 31% of cases. Only 54% of house officers discussed the mistake with their attending physicians, and only 24% told the patients or families. House officers who accepted responsibility for the mistake and discussed it were more likely to report constructive changes in practice. Residents were less likely to make constructive changes if they attributed the mistake to job overload. They were more likely to report defensive changes if they felt the institution was judgmental. Decreasing the work load and closer supervision may help prevent mistakes. To promote learning, faculty should encourage house officers to accept responsibility and to discuss their mistakes.     

Types of medical writing and teaching of writing in U.S. medical schools

U.S. medical schools were surveyed to determine which types of medical writing are most important for physicians, house officers, and medical students to learn and whether such types are formally taught. According to the responding schools, the five most important types were: write-up of the patient history and physical examination, progress note and discharge summary (tied), peer-reviewed published paper (of either clinical or laboratory research), and grant proposal. Certain types, however, were considered more important for some categories of physicians and trainees than others. Although these major types of writing represent complex and diverse writing tasks, they are not taught extensively in medical schools or thoroughly explained in the literature on medical writing.     

Survey of women physicians on issues relating to pregnancy during a medical career

Many women in medical training want to combine a family life and a career. Of major interest to these women is determining the most desirable time for pregnancy during their medical education and career. The results of a study on women physicians' timing of pregnancy are reported. A 53 percent response rate was obtained in a randomized national survey of women physicians who had completed residency training and were less than 50 years of age. Their first pregnancies (of which 77 percent were planned) occurred as follows: prior to medical school, 4 percent; during medical school, 7 percent; in first year as house officer, 11 percent; in other residency year, 32 percent; in fellowship year(s), 13 percent; in practice, 28 percent, on leave or other, 5 percent. Seventy percent of the respondents considered "after completion of residency" to be the best time to become pregnant. Sixty percent of the respondents' maternity leaves were six weeks or less in duration. Seventeen percent required some medical leave before delivery, although only 5 percent required more than eight weeks of medical leave. Only a third reported that their training or work sites had maternity leave policies. Ninety-one percent of the respondents reported satisfaction in their careers.     

Laboratory test analysis near the patient. Opportunities for improved clinical diagnosis and management

New developments in laboratory technology have produced complex analytic systems that are simple to operate, relatively reliable, and inexpensive. These systems allow the office practitioner to perform test analyses in an office laboratory and can provide timely information useful for diagnostic and clinical management decisions. This article reviews the clinical applications and analytic systems available for use in urine analysis, blood cell analysis, determination of the sedimentation rate, coagulation testing, biochemical analysis, and bacteriologic and virologic testing. Although these analytic systems are generally designed to be used by nonprofessional laboratory staff, there is only limited information available about their reliability when used in this manner. Physicians, in bringing this technology into their office laboratories, must be cognizant of a new area of medical practice because they will now be the professionals responsible for the laboratory's function. It will be important that they develop new skills as the office laboratory directors and develop consultative relationships with laboratory professionals to ensure that the information used in patient care is both timely and reliable.     

Training appropriate laboratory workers for rural health centres in Papua New Guinea

Many rural health centres in developing countries continue to treat patients without the help of any laboratory tests. The result is often inaccurate diagnosis, wasteful use of multiple drugs, and increasing drug resistance of pathogens. It is unlikely that there will ever be sufficient funds to employ a full-time laboratory worker at each of the many small remote health centres in Papua New Guinea. It is also doubtful whether staff and health extension officers who run such centres have the appropriate knowledge to adequately utilize full-time laboratory personnel. It is feasible, however, to train selected health workers in courses of three to four months' duration to perform a few simple laboratory tests part-time, in addition to their clinical duties. Suitable tests are those where the result does not require skilled interpretation. For most such tests, the result is the diagnosis. After the clinical staff have received the laboratory diagnosis, they are free to decide whether it fits the clinical picture. If so, they can then find the appropriate treatment to prescribe in standard treatment books. The present paper describes the experience in setting up and operating laboratory training for health centre staff in Milne Bay Province, Papua New Guinea. Costs and initial results of the program are discussed.     

Effect of student loan indebtedness and repayment on resident physicians' cash flow. An analytic model

Cumulative figures of "average medical student indebtedness," although meaningful, do not convey the effect of loan repayments on residents' cash flow, effect on a resident's value system and residency performance, and effect on trends in health care manpower allocation. Using a computer-based cash flow model, a "typical" house officer with $20,000 in undergraduate indebtedness who is training in a less expensive city will realize a $2390 deficit during internship and negative cash flow throughout a 5-year residency. House officers with extreme indebtedness (greater than $80,000) who are training in an expensive metropolitan area would accumulate an overall deficit approaching $75,000 or more, in excess of their undergraduate indebtedness, during a 5-year residency program. Effects of these findings on residency education and health care manpower issues, along with potential solutions for alleviating residents' cash flow problems, are discussed.     

Improving the interpretation of electrocardiographs in an accident and emergency department.

In this study we have examined the ability of senior house officers in the Accident and Emergency (A&E) Department to interpret electrocardiographs (ECGs) and tested the value of a single seminar and guidelines on interpretation. We prospectively audited ECG interpretation taken from notes over a two-month period and repeated this audit following a single seminar by a consultant cardiologist and after the issue of guidelines. A formal test of interpretation of a set of 20 ECGs by senior house officers in A&E was also carried out. 245 case notes were reviewed and in one third the ECG was interpreted incorrectly by senior house officers in A&E but incorrect clinical management followed in only 3.2% of cases. Following the intervention, 242 case notes were reviewed and serious misinterpretations were halved as was the number of patients mismanaged as a result (1.7%). In conclusion, formal training in ECG interpretation can reduce serious errors.     

Do the ward notes reflect the quality of end-of-life care?

OBJECTIVES: To study the accuracy of reviewing ward notes (chart review) as a measure of the quality of care rendered to patients with "Do Not Resuscitate" (DNR) orders. DESIGN: We reviewed the charts of 19 consecutive, competent inpatients with DNR orders for evidence that the staff addressed a broad range of patient care needs called Concurrent Care Concerns (CCCs), such as withholding treatments other than resuscitation itself, and attention to patient comfort needs. We then interviewed the patient, consultant physician, house officer, and primary nurse and compared the ward notes with the understandings of these staff members. SETTING: The medical service of an urban university medical centre. RESULTS: The average number of documented CCCs addressed per DNR order was 1.1. The ward notes generally agreed with the perceptions of patients, house officers, and nurses (% agreement with notes = 79%, 77%, and 82%; kappa = 0.43, 0.40, 0.50). Consultant physicians' understandings were poorly reflected in the ward notes (% agreement = 59%; kappa = 0.18). They overestimated attention to CCCs compared with the notes (P < 0.0001) and with other observers (P < 0.0001). CONCLUSION: Chart review for attention to CCCs accurately reflects the understandings of patients, house officers, and nurses, but consultant physicians report more attention to CCCs than is recorded in the ward notes or understood by other observers. Better communication regarding end-of-life care plans should be encouraged.     

Self-evaluation by house officers in a primary care training program

Expertise in ambulatory care requires a broad range of knowledge and skills. A modified Delphi survey technique was used to delineate diagnoses, management techniques, and procedural skills in seven subspecialty areas necessary for house officers in a primary care internal medicine training program. Self-evaluation instruments were developed, and residents were asked to rate their abilities in the seven areas. At entry, the house officers generally had more confidence in their diagnostic abilities than in their management techniques and procedural skills. Progression through the training program was accompanied by increases in confidence in all areas except the behavioral sciences. The self-evaluation approach provided a longitudinal assessment of changes in the confidence of house officers throughout their training and an indication of the effectiveness of the educational program.     

Regulation of physicians' office laboratories. The Idaho experience

Timely availability of reliable test results enhances the office practitioner's ability to provide high-quality care that is personally satisfying to patients. Modern technology allows physicians to have such timely information available through test analyses performed in an office laboratory. Studies of physicians' office laboratories in Idaho found the performance, initially, to be unacceptably variable for many hematology, urinalysis, clinical chemistry, and microbiology tests. State regulation, requiring each office laboratory to comply with quality assurance guidelines and to participate in a proficiency testing program, resulted in a marked improvement in the proficiency level of office laboratory testing in Idaho. With the increasing dispersion of clinical laboratory technology, it is essential that standards of practice for the office laboratory be developed that ensure, within reasonable limits, the reliability of test information used in patient care. If widespread acceptance of such standards cannot be developed with a voluntary approach, states should consider regulation of office laboratories within their jurisdiction. Compliance with standards of practice, voluntarily or as a result of regulation, should promote quality performance in the office laboratory and allow the physician to use confidently the timely test information in dealing with diagnostic and management problems in patient care.     

Avoiding laboratory pitfalls in infectious diseases

In today's medical care environment, clinicians are challenged to order clinically relevant, cost effective laboratory tests and antibiotic therapy. Together, physicians and laboratories must have guidelines and strategies that can provide quality patient care, while minimising costs and preventing further emergence of antimicrobial drug resistance. Five clinical vignettes that demonstrate these principles are presented.     

Skills of medical students and house officers in prescribing narcotic medications

Eighty-eight medical students and house officers were given patient management questions to assess their ability to convert from one narcotic regimen to an approximately equal analgesic dose of a second regimen. Only 8 percent of their answers were within the correct range, even though commonly used reference material was supplied to assist them in answering the questions. There were no significant differences in the responses of house officers from different medical specialties or among all the individuals at different educational levels. Correct answers to the patient management questions markedly increased after instruction on the use of a narcotic equivalency table. More emphasis on the importance of adequate pain control, better teaching of the pharmacology of narcotic analgesic drugs, and additional instruction on the use of narcotic equivalency tables are needed in medical school and house staff training programs.     

Fifth pathway in New Jersey. House officer preparatory course for US foreign medical graduates.

The Fifth Channel in New Jersey is a Fifth Pathway program for US foreign medical graduates. In its third year, 83 percent of its 81 graduates are house officers at 18 US medical school-affiliated hospitals. Performance as house officers is characterized as competitive with peers, including US graduates. Positive attitudes toward work load, fellow workers, and patients compared with those of fellow house staff are noted. Quality of performance as house officers correlates most strongly with the change in mean scores of two batteries of clinical National Board examinations taken during the Fifth Pathway and less strongly with mean scores of single batteries of National Boards, Intelligence quotient, Educational Council for Foreign Medical Graduates (ECFMG) examination, ang age. Recommendations concerning the implementing of similar programs in other states are presented.     

Sources of resistance to an intern support group

When senior house officers were observed to be resistant to an intern support group, they were surveyed in order to identify the sources of their resistance. Sixty-nine percent of house officers in postgraduate year two (PGY-2) and PGY-3 responded to an anonymous seven-item survey. Although their attitudes toward supportive programs were generally favorable, a minority of the house officers felt that residents expressing the need for support were less competent than other residents or needed to change to a less rigorous specialty. A majority felt that it was unfair to require senior house officers to provide coverage for interns attending a support group. They felt that support should be made available to all house officers rather than interns only and that stress would be reduced by eliminating the sources of stress as well as by providing supportive programs. Training program directors need to be aware of and anticipate these attitudes before designing supportive programs.     

Discrepancies between knowledge and use of diagnostic studies in asymptomatic patients.

The value of educational programs designed to promote optimal use of laboratory tests by physicians remains unsolved. To assess the effects of level of training and knowledge of test characteristics in determining laboratory ordering habits, physicians' use of laboratory tests as applied to asymptomatic patients was surveyed and their knowledge of four specific procedures was tested. The survey included 148 physicians both in training and in practice in Rochester, New York. Increased selectivity in the use of tests occurred during residency training, but selectivity correlated poorly with knowledge of test characteristics. These data underline the need for additional studies to determine the role of factors other than knowledge which contribute to the use of laboratory tests. Planners of cost containment programs and educational strategies will need to direct attention to these factors.