Proficiency of internal medicine residents in outpatient care of patients with HIV infection

To determine internal medicine residents’ knowledge of HIV care, the authors conducted a survey of residents from four internal medicine programs in the San Francisco Bay area. On a knowledge test, the mean score was 42.4/55, 77% correct. The residents performed relatively worse on questions regarding didanosine and zalcitabine, tuberculosis prophylaxis, and risk of cervical neoplasia in HIV-infected women. Predictors of greater knowledge were specific residency program, higher postgraduate year, primary care residency track, and more extensive HIV experience. Primary care internal medicine residencies and programs with more exposure to HIV patients are most effective in producing knowledgeable residents. Supported by the AIDS Clinical Research Center, University of California San Francisco, VA Medical Center (141A), 4150 Clement Street, San Francisco, CA 94121; and National Institute of Mental Health Grant: MH44045 (Dr. Cooke). Dr. Bindman is a Robert Wood Johnson Generalist Physician Faculty Scholar. This research was conducted, in part, while Dr. Schultz was a fellow in general internal medicine and clinical epidemiology in the Division of General Internal Medicine, San Francisco General Hospital, San Francisco, California.     

The relative risk of myocardial infarction in patients who have high blood pressure and non-cardiac pain

The authors conducted a population-based case-control study to determine the risk of myocardial infarction in patients who reported angina-like symptoms. The cases studied were those of patients who had high blood pressure and had sought treatment in 1984 with myocardial infarction as the first manifestation of coronary artery disease. Controls, a random sample of patients who had hypertension, were frequency-matched to cases by age and gender. Blind to case-control status, the authors reviewed the medical records of the 32 cases and 64 controls for reports of angina-like symptoms. While controls reported such symptoms at a constant rate, the events for the cases clustered near their infarctions. When a patient with hypertension sought medical advice for angina-like symptoms, the risk of infarction within 30 days was 14.2 (95% confidence interval, 2.8 to 71), and after 30 days it fell to 1.03. Among patients who have high blood pressure but no history of angina, presentations with prodromal symptoms in the primary care setting are so common that only about one in 100 such visits actually heralds myocardial infarction. Presented at the National Meeting of the Robert Wood Johnson Clinical Scholars Program, Scottsdale, AZ (October 1986) and the National Meeting of the American Federation for Clinical Research, San Diego, CA (May 1987). Supported in part by a grant from the Robert Wood Johnson Foundation, Princeton, NJ, and by the Health Services Research and Development Program, Veterans Administration Medical Center, Seattle, WA. The opinions, conclusions, and proposals in the text are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation or the VA Medical Center.     

Timing of referral of terminally Ill patients to an outpatient hospice

Objective: Since inordinately long or short lengths of stay at hospice can create problems for patients, providers, and payers, the author sought to identify predictors of timing of patient referral. Methods: A retrospective cohort of 405 hospice outpatients was analyzed with Cox regression to evaluate the effect on length of stay of patient age, gender, race, diagnosis, activity level, mental status, dyspnea, insurance, income, religion, and home support, and of referring physician specialty. Results: Median survival time at the hospice was 29 days; 15% of the patients died within seven days and 12% lived longer than 180 days. A one-unit increment in a six-unit activity-level scale was associated with a 19% reduction in the rate of death. Compared with reference groups, oriented patients and depressed patients had 57% and 35% lower death rates; patients with prostate cancer and cardiovascular disease had 50% and 58% lower death rates. There was no significant gender, race, religion, insurance, or income difference among the patient groups. Conclusions: Inappropriately early or late referral occurs in a substantial minority of patients referred to the hospice under study. Closer attention to accurate prognostication in different types of terminally ill patients and more timely referral to hospice might help to optimize the use of this health care resource from both patient and societal perspectives. Received from the Division of General Internal Medicine, Leonard Davis Institute of Health Economics, Department of Sociology, University of Pennsylvania, Philadelphia, Pennsylvania. Supported by the Robert Wood Johnson Foundation Clinical Scholars Program and by the Warren-Whitman-Richardson Fellowship from Harvard Medical School. Dr. Christakis is the recipient of a NRSA Fellowship from the Agency for Health Care Policy and Research. Computer facilities were provided by the Department of Sociology, University of Pennsylvania. The opinions and conclusions herein are the author’s and do not necessarily represent the views of the Robert Wood Johnson Foundation.     

The value of serum iron studies as a test for iron-deficiency anemia in a county hospital

To evaluate the performance of serum iron studies as a diagnostic test for iron-deficiency anemia in a county hospital, the authors identified retrospectively all general medicine patients who had had bone-marrow aspirates for the work-up of non-macrocytic anemias from 1978 through 1983. Re-reading a sample of aspirates from the 254 study patients (42 with iron deficiency) verified the presence of absence of iron. Analysis with logistic regression, likelihood ratios, and receiver operating characteristic curves demonstrated that the total iron-binding capacity (TIBC) performed markedly better as a diagnostic test than did the transferrin saturation test. While no single TIBC level was diagnostic, the TIBC provided a good estimate of the probability of iron-deficiency anemia. Presented at the national meeting of the American Federation for Clinical Research, Washington, D.C., May 4, 1985. Supported in part by a grant from the Robert Wood Johnson Foundation, Princeton, N.J.; and by the Health Services Research and Development Program, VA Medical Center, Seattle, and by the National Center for Health Services Research, DHHS, under research grant numbers HS-04080 HS-04996. The opinions, conclusions, and proposals in the text are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation, the VA Medical Center, or the National Center for Health Services Research.     

Can a specialty society educate its members to think differently about clinical decisions?

OBJECTIVE: Measure the effect of specialty society-developed continuing medical education (CME) on clinical decision making. DESIGN: Randomized controlled trial. SETTING: National sample of neurologists. PARTICIPANTS: Of 492 neurologists randomly selected from an ongoing American Academy of Neurology CME program, 248 were randomized to receive a mailed CME course, and 244 did not receive it. INTERVENTION: A mailed educational course on movement disorders, developed by the specialty society, containing information on diseases and practice recommendations with illustrative case presentations. MEASUREMENTS AND MAIN RESULTS: We assessed adherence to 16 practice recommendations on disease detection, diagnostic test use, and treatments by mailed survey sent to all subjects 4.5 months after the intervention group received the course (73% response rate). The survey contained detailed clinical scenarios to measure self-reported clinical decision making and short open-ended questions to measure factual knowledge. More intervention participants (up to 2.6 times more) than control subjects reported clinical decision making adherent to 9 of the 16 recommendations (p<.05). For 4 of the other 7 recommendations, adherence exceeded 85% in both groups. Within the intervention group, neurologists who read the educational course were 2 to 6 times more likely to be adherent than neurologists who did not. The intervention group had better factual knowledge than control subjects in six of seven areas (p<.01). CONCLUSIONS: This educational course improved neurologists’ reported decision making. Specialty society-developed CME that utilizes a similar format may enhance the effectiveness of mailed CME information to improve physicians’ approach to clinical decisions. Presented at the Robert Wood Johnson Clinical Scholars annual meeting, November 1995, and VA Health Services Research and Development annual meeting, February 1996. Supported by an unrestricted grant from the American Academy of Neurology and by the Office of Research and Development, Health Services Research & Development Program, Center for the Study of Healthcare Provider Behavior. Dr. Gifford received additional support from the Robert Wood Johnson Clinical Scholars Program and from the Bureau of Health Professions, Mid-Career Faculty Training Program in Geriatric Medicine and Dentistry, grant 5D31AH99000-08. Dr. Vickrey received additional support from a Clinical Investigator Development Award from NINDS (K08NS0 1669-02). Opinions are those of the authors and do not necessarily reflect the views of the sponsoring institutions, the Department of Veterans Affairs, the University of California, Los Angeles, or RAND.     

Journal reading habits of internists

We assessed the reading habits of internists with and without epidemiological training because such information may help guide medical journals as they make changes in how articles are edited and formatted. In a 1998 national self-administered mailed survey of 143 internists with fellowship training in epidemiology and study design and a random sample of 121 internists from the American Medical Association physician master file, we asked about the number of hours spent reading medical journals per week and the percentage of articles for which only the abstract is read. Respondents also were asked which of nine medical journals they subscribe to and read regularly. Of the 399 eligible participants, 264 returned surveys (response rate 66%). Respondents reported spending 4.4 hours per week reading medical journal articles and reported reading only the abstract for 63% of the articles; these findings were similar for internists with and without epidemiology training. Respondents admitted to a reliance on journal editors to provide rigorous and useful information, given the limited time available for critical reading. We conclude that internists, regardless of training in epidemiology, rely heavily on abstracts and prescreening of articles by editors. This study was supported by the University of Washington Robert Wood Johnson Clinical Scholars Program and the Department of Veterans Affairs. Drs. Christakis and Elmore are supported by Robert Wood Johnson Generalist Faculty Awards. Drs. Saint, Christakis, and Saha were Robert Wood Johnson Clinical Scholars at the time this work was conducted.     

Ability of primary care physicians to diagnose and managePneumocystis carinii pneumonia

This study assesses the ability of primary care physicians to diagnose and managePneumocystis carinii pneumonia (PCP) in a standardized patient (SP) with unidentified HIV infection. One hundred thirty-four primary care physicians from five Northwest states saw an SP with unidentified HIV infection who presented with symptoms, chest radiograph, and arterial blood gas results classic for PCP. Seventy-seven percent of the physicians included PCP in their differential diagnoses and 71% identified the SP’s HIV risk. However, only a minority of the physicians indicated that they would initiate an appropriate diagnostic evaluation or appropriate therapy: 47% ordered a diagnostic test for PCP, 31% initiated an antibiotic appropriate for PCP, and 12% initiated an adequate dose of trimethoprim— sulfamethoxazole. Only 6% of the physicians initiated adjunctive prednisone therapy, even though prednisone was indicated because of the blood gas result. These findings suggest significant delay in diagnosis and treatment had these physicians been treating an actual patient with PCP. Presented at the International Conference on AIDS, Berlin, Germany, June 6 –11, 1993. Supported by grant number HS 06454-03 from the Agency for Health Care Policy and Research. Dr. Curtis is funded by the Robert Wood Johnson Clinical Scholars Program. The views expressed herein are those of the authors and are not necessarily the views of the Agency for Health Care Policy and Research or the Robert Wood Johnson Foundation.     

Physicians’ reasons for failing to comply with computerized preventive care guidelines

The objective of this study was to assess reasons for physicians’ noncompliance with computer-generated preventive care reminders. In an academic general internal medicine practice, a survey of physicians’ reasons for noncompliance found that 55% of reminders were not complied with. Reasons included “not applicable” in 22.6% (test done elsewhere, patient too ill, no uterus), “next visit” in 22.5% (physician too busy, patient too ill), and “patient refuses” in 9.9% (test not necessary or too costly, patient too busy or fears result). We conclude that although noncompliance with reminders is sometimes appropriate, making time for prevention and patient education may augment preventive care. Received from the Department of Medicine, Wishard Memorial Hospital, and the Indiana University School of Medicine, the Regenstrief Institute for Health Care, and the Health Services Research and Development Service, Richard L. Roudebush VA Medical Center, Indianapolis, Ind. Supported in part by grants HS07632, HS07763, and HS07719 from the Agency for Health Care Policy and Research (AHCPR). Dr. Litzelman was supported in part by a Robert Wood Johnson Generalist Physician Faculty Scholar Award (022318). The opinions expressed herein are solely those of the authors and do not necessarily represent the authors’ institutions, AHCPR, or the Robert Wood Johnson Foundation.     

Bridging cultural differences in medical practice

BACKGROUND: Cultural differences between doctors and their patients are common and may have important implications for the clinical encounter. For example, some Navajo patients may regard advance care planning discussions to be a violation of their traditional values. OBJECTIVE: To learn from Navajo informants a culturally competent approach for discussing negative information. DESIGN: Focused ethnography. SETTING: Navajo Indian reservation, northeast Arizona. PARTICIPANTS: Thirty-four Navajo informants, including patients, traditional healers, and biomedical health care providers. MEASUREMENT: In-depth interviews. MAIN RESULTS: Strategies for discussing negative information were identified and organized into four stages. Assessment of patients is important because some Navajo patients may be troubled by discussing negative information, and others may be unwilling to have such discussions at all. Preparation entails cultivating a trusting relationship with patients, involving family members, warning patients about the nature of the discussion as well as communicating that no harm is intended, and facilitating the involvement of traditional healers. Communication should proceed in a caring, kind, and respectful manner, consistent with the Navajo concept k’é. Reference to a third party is suggested when discussing negative information, as is respecting the power of language in Navajo culture by framing discussions in a positive way. Follow-through involves continuing to care for patients and fostering hope. CONCLUSIONS: In-depth interviews identified many strategies for discussing negative information with Navajo patients. Future research could evaluate these recommendations. The approach described could be used to facilitate the bridging of cultural differences in other settings. Presented at the annual meeting of the American Society for Bioethics and Humanities, Philadelphia, Penn, October 31, 1999. The views expressed in this paper do not necessarily reflect the views of the Robert Wood Johnson Foundation, the Indian Health Service, the Department of Veterans Affairs, or the Bioethics Institute of the Johns Hopkins University. This study was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (project IIR 93-131R). Dr. Carrese, who was a V.A. fellow in the Robert Wood Johnson Clinical Scholars Program (University of Washington) when this study was conducted, is a Robert Wood Johnson Generalist Physician Faculty Scholar.     

Long-term care preferences of hospitalized persons with AIDS

Objective:To determine in a cohort of hospitalized persons with AIDS: 1) their preferences for various postdischarge long-term care settings, 2) the postdischarge settings recommended by primary care providers (doctors, nurses, and social workers), and 3) the impact of these views on the resulting discharge dispositions. Design:Prospective cohort study. Setting:Medical wards of five Seattle tertiary care hospitals. Participants:120 consecutive hospitalized persons with AIDS and their primary care providers. Measurements and main results:Although 70 (58%) of the patients found care in an AIDS long-term care facility acceptable, 87 (73%) preferred home care. Thirty-eight (32%) of the cohort were appropriate for long-term care after hospitalization, according to primary care providers. Eleven of the 38 patients deemed appropriate for long-term care were discharged to long-term care settings; among these, three had preferred home care. Likelihood of discharge to long-term care settings increased if patients found it acceptable (OR=7.1; 95% CI=3.2, 15.5), if they did not prefer home care (OR=7.7; 95% CI=4.7, 13.5), and if providers judged them to be appropriate for long-term care (OR=29; 95% CI=13, 64). In unstructured interviews, availability of emotional and medical support and privacy emerged as important factors to persons with AIDS considering long-term care. Conclusions:Hospitalized persons with AIDS willingly express their desires for various postdischarge care settings. A majority find long-term care in AIDS facilities acceptable, although they generally prefer home care. Discharge disposition is associated with acceptability, preference, and appropriateness for long-term care. Presented in part at the Vth International Conference on AIDS, Montreal, Quebec, Canada, June 5, 1989. Also presented in part at the 14th annual meeting of the Society of General Internal Medicine, Seattle, Washington, May 1–3, 1991. Supported in part by the Northwest Health Services Research and Development Field Program (Seattle VA Medical Center) and the Seattle/King County Department of Public Health, AIDS Prevention Project. Dr. McCormick was a fellow in the Robert Wood Johnson Clinical Scholars Program during this project. The opinions stated herein are those of the authors and may not represent the views of the Robert Wood Johnson Foundation or the Department of Veterans Affairs.     

Professional satisfaction experienced when caring for substance-abusing patients

This survey aimed to describe and compare resident and faculty physician satisfaction, attitudes, and practices regarding patients with addictions. Of 144 primary care physicians, 40% used formal screening tools; 24% asked patients’ family history. Physicians were less likely (P<.05) to experience at least a moderate amount of professional satisfaction caring for patients with alcohol (32% of residents, 49% of faculty) or drug (residents 30%, faculty 31%) problems than when managing hypertension (residents 76%, faculty 79%). Interpersonal experience with addictions was common (85% of faculty, 72% of residents) but not associated with attitudes, practices, or satisfaction. Positive attitudes toward addiction treatment (adjusted odds ratio [AOR], 4.60; 95% confidence interval [95% CI], 1.59 to 13.29), confidence in assessment and intervention (AOR, 2.49; 95% CI, 1.09 to 5.69), and perceived responsibility for addressing substance problems (AOR, 5.59; CI, 2.07 to 15.12) were associated with greater satisfaction. Professional satisfaction caring for patients with substance problems is lower than that for other illnesses. Addressing physician satisfaction may improve care for patients with addictions. This work was presented in part at the annual meeting of the Robert Wood Johnson Foundation Generalist Physician Faculty Scholars Program, Tucson, Ariz, December 4, 1998, the annual meeting of the Society of General Internal Medicine, San Francisco, Calif, April 29, 1999, and at the annual meeting of the Association of Medical Education and Research on Substance Abuse, Alexandria, Va, November 5, 1999. Deceased. Dr. Saitz received support from the Robert Wood Johnson Foundation as a Generalist Physician Faculty Scholar (Grant No. 031489) for this work. He and Dr. Samet were also supported in this work by the Center for Substance Abuse Prevention (Faculty Development Grant T26-SP08355). Drs. Samet, Saitz, and Sullivan, and Mr. Winter and Ms. Lloyd-travaglini receive support from the National Institute on Alcohol Abuse and Alcoholism (R01-AA10870). Dr. Friedmann was supported by a Mentored Clinical Scientist Career Development Award (K08-DA 00320).     

Clinical predictors of treatment reduction in hypertensive patients

Objective:To demonstrate that some hypertensive patients under good blood pressure (BP) control can reduce medications, and to identify predictors of successful reduction. Design:Observational study with 11-month follow-up. Setting:Outpatient hypertension clinic at the Seattle Veterans Administration Hospital. Patients:59 males (51% of those eligible) with diastolic BP<95 mm Hg for ≥6 months; 57 patients (97%) completed the study. Intervention:Gradual reduction of medications unless diastolic BP rose above 95 mm Hg. Measurements and main results:Intensity of treatment with BP medications was assessed using a scale of their comparative “vigors.” 35 patients (59%) reduced medications successfully. By the end of the study, systolic BP had risen by 8.2±12.3 mm Hg (mean±SD) in successful patients, while diastolic BP did not change significantly. Two predictors of treatment reduction were statistically significant in both univariate and multivariate analyses: successful patients had been treated more intensively (2.7±1.7 vs. 1.3±0.5 “vigor units,” p=0.0001), and they had been enrolled in the clinic longer (5.5±3.0 vs. 3.1±2.3 years, p=0.003). Lower systolic BP, higher urinary sodium excretion, lower compliance, and younger age were significant predictors of treatment reduction on univariate analysis only. Age≤65 years had the highest sensitivity (86%) for treatment reduction, while treatment with two or more “vigor units” had the highest specificity (79%) and likelihood ratio (3.3). Conclusions:Treatment reduction is feasible in many well-controlled hypertensives, though systolic BP rises. Patients with high intensity and long duration of treatment are most likely to reduce medications successfully. Presented in part at the annual meeting of the Society of General Internal Medicine, Arlington, Virginia, April 1988, and the annual meeting of the Robert Wood Johnson Clinical Scholars Program, Miami, Florida, October 1988. This study was conducted while Dr. Steiner was a Robert Wood Johnson Clinical Scholar at the University of Washington. Support was provided by the Northwest Health Services Research and Development Program of the Veterans Administration. The opinions, conclusions, and proposals in this paper are those of the authors, and do not necessarily represent the views of the Robert Wood Johnson Foundation or the Veterans Administration.     

How do physicians talk with their patients about risks?

To describe the communication about risk between community-based physicians and their patients, the authors audiotaped 160 physician-patient encounters in the private practices of 19 physicians. Coding was done using a structured scheme to identify the presence of talk about risk of future illness, and to describe its characteristics. Patient understanding and satisfaction were assessed through an interview. Risk discussion occurred in 26% (95% CI 19%–33%) of the visits, quantitatively in two cases and specifically with respect to outcome in 48% (95% CI 40%–56%) of the visits. The patients initiated only 16% of this discussion but were, in general, satisfied with their care and the information they had received, but they had poor recall of the specifics of the discussion. This work was carried out while Drs. Kalet and Roberts were fellows in the Robert Wood Johnson Clinical Scholars Program at the University of North Carolina at Chapel Hill. Presented at the annual meeting of the Society of General Internal Medicine, Seattle, Washington, May 1–3, 1991.     

Measuring the Quality of Colorectal Cancer Screening: The Importance of Follow-Up

Purpose As evidence mounts for effectiveness, an increasing proportion of the United States population undergoes colorectal cancer screening. However, relatively little is known about rates of follow-up after abnormal results from initial screening tests. This study examines patterns of colorectal cancer screening and follow-up within the nation's largest integrated health care system: the Veterans Health Administration. Methods We obtained information about patients who received colorectal cancer screening in the Veterans Health Administration from an existing quality improvement program and from the Veterans Health Administration's electronic medical record. Linking these data, we analyzed receipt of screening and follow-up testing after a positive fecal occult blood test. Results A total of 39,870 patients met criteria for colorectal cancer screening; of these 61 percent were screened. Screening was more likely in patients aged 70 to 80 years than in those younger or older. Female gender (relative risk, 0.92; 95 percent confidence interval, 0.9–0.95), Black race (relative risk, 0.92; 95 percent confidence interval, 0.89–0.96), lower income, and infrequent primary care visits were associated with lower likelihood of screening. Of those patients with a positive fecal occult blood test (n = 313), 59 percent received a follow-up barium enema or colonoscopy. Patient-level factors did not predict receipt of a follow-up test. Conclusions The Veterans Health Administration rates for colorectal cancer screening are significantly higher than the national average. However, 41 percent of patients with positive fecal occult blood tests failed to receive follow-up testing. Efforts to measure the quality of colorectal cancer screening programs should focus on the entire diagnostic process. Supported by the Robert Wood Johnson Foundation Clinical Scholars Program (Etzioni), Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), and National Cancer Institute Colorectal Cancer (CRC) Quality Enhancement Research Initiative (QUERI) Service Directed Research (Project # CRS 02-163). The views expressed in this article are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation or the Department of Veterans Affairs.     

Hypertension, renal disease, and cardiovascular outcomes

During the meeting of the American Society of Hypertension in San Francisco, CA on May 17, 2005, a roundtable was convened to discuss the relationship between hypertension, renal disease, and cardiovascular outcomes. Dr. Marvin Moser, Clinical Professor at Yale University School of Medicine, New Haven, CT, chaired the session. Dr. Jan Basile, Professor of Medicine at the Ralph Johnson VA Medical Center and the Medical University of South Carolina in Charleston, SC and Dr. William Cushman, Professor of Preventive Medicine and Medicine at the University of Tennessee in Memphis, TN participated in the discussion.     

Alcohol-related discussions during general medicine appointments of male VA patients who screen positive for at-risk drinking

OBJECTIVE: This study describes primary care discussions with patients who screened positive for at-risk drinking. In addition, discussions about alcohol use from 2 clinic firms, one with a provider-prompting intervention, are compared. DESIGN: Cross-sectional analyses of audiotaped appointments collected over 6 months. PARTICIPANTS AND SETTING: Male patients in a VA general medicine clinic were eligible if they screened positive for at-risk drinking and had a general medicine appointment with a consenting provider during the study period. Participating patients (N=47) and providers (N=17) were enrolled in 1 of 2 firms in the clinic (Intervention or Control) and were blinded to the study focus. INTERVENTION: Intervention providers received patient-specific results of positive alcohol-screening tests at each visit. MEASURES AND MAIN RESULTS: Of 68 visits taped, 39 (57.4%) included any mention of alcohol. Patient and provider utterances during discussions about alcohol use were coded using Motivational Interviewing Skills Codes. Providers contributed 58% of utterances during alcohol-related discussions with most coded as questions (24%), information giving (23%), or facilitation (34%). Advice, reflective listening, and supportive or affirming statements occurred infrequently (5%, 3%, and 5%, of provider utterances respectively). Providers offered alcohol-related advice during 21% of visits. Sixteen percent of patient utterances reflected “resistance” to change and 12% reflected readiness to change. On average, Intervention providers were more likely to discuss alcohol use than Control providers (82.4% vs 39.6% of visits; P=.026). CONCLUSIONS: During discussions about alcohol, general medicine providers asked questions and offered information, but usually did not give explicit alcohol-related advice. Discussions about alcohol occurred more often when providers were prompted. This research was supported by grants from the University of Washington Royalty Research Fund, and the Department of Veterans Affairs, Health Services Research and Development Service (SDR 96-002). Dr. Bradley is an investigator at the VA Puget Sound Health Care System, and is currently supported by National Institute of Alcohol Abuse and Alcoholism grant no. K23AA00313) and is a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar. Views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs, the University of Washington, the National Institute of Alcohol Abuse and Alcoholism, or the Robert Wood Johnson Foundation.     

Performance of cancer screening in a university general internal medicine practice

The authors evaluated use of seven cancer screening tests by 52 providers in a university general internal medicine practice, using 1980 American Cancer Society (ACS) recommendations as standards for comparison. Performance rates were determined by retrospective medical record reviews of a stratified random sample of 525 patients. In addition, the 48 physicians and four nurse-practitioners in the practice were interviewed to determine their opinions, knowledge and perceived use of the tests. Performance rates were low, significantly below the ACS quidelines for all tests except Pap smear. Providers used the tests significantly more often to evaluate patients with cancer risk factors or for new patients. They significantly overestimated their own performances of six tests. More than a fourth of the providers disagreed with the use of mammography, sigmoidoscopy, pelvic or rectal examinations for screening asymptomatic adults. Their knowledge about cancer screening and the ACS recommendations was highly variable, and frequently quite limited. Providers offered four major reasons for not performing the screening tests: provider forgetfulness, lack of time, inconvenience and logistical difficulties, and patient discomfort or refusal. Received from the Division of General Internal Medicine, Department of Medicine, and Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California. Presented in part at the 111th annual meeting of the American Public Health Association, Dallas, Texas, November 1983, and at the 8th annual meeting of the Society for Research and Education in Primary Care Internal Medicine, Washington, D.C., May 1985. Supported by the Robert Wood Johnson Foundation and by PHS grant number 5 R01 CA37340, awarded by the National Cancer Institute, DHHS. Steven Schroeder, MD, Bernard Lo, MD, Steven Cummings, MD, Thomas Coates, PhD, Eliseo Perez-Stable, MD, Hal Luft, PhD, and Joyce Bird, PhD, provided helpful comments. The faculty and residents of the Division of General Internal Medicine and the General Internal Medicine Group Practice at the University of California, San Francisco, provided their interest and cooperation. Richard Meltzer, Matthew Boone, MD, and William Cunningham, MD, assisted in obtaining data.     

In pursuit of the abnormal serum alkaline phosphatase

The serum alkaline phosphatase (ALP) is often included among the tests used for case-finding among ambulatory patients. To determine the positive predictive value of the ALP, test results for all adults screened by a health maintenance organization between March and December 1969 were obtained by computer. The authors reviewed the charts of all 661 patients with abnormal tests whose primary source of medical care was at this facility. Complete two-year follow-up data were available for 91% of these patients. There were 56 patients (9%) with a diagnosis that could have explained an abnormal ALP. Of those cases in which ALP would have been clinically useful all but one could have been diagnosed by a simple, noninvasive work-up, and in that one case, no management change would have occurred. The authors conclude that in the absence of a small number of specific indications, extensive testing need not be performed to evaluate an isolated abnormal ALP obtained from a screening examination. Received from the Department of Medicine and the School of Public Health, University of California, Los Angeles, Los Angeles, California. Supported in part by the Robert Wood Johnson Clinical Scholars Program. The views expressed herein do not necessarily represent those of the Robert Wood Johnson Foundation.     

Cost effectiveness in the detection of renal artery stenosis

Cost effectivenesses of four tests for diagnosing renal artery stenosis were examined. Sensitivity, specificity, cost per patient, and cost per stenosis found for a variety of diagnostic strategies using these tests were retrospectively evaluated using clinical data from 605 hypertensive patients. Cost effectiveness of a given strategy was found to depend on the sequence in which the tests were performed, but to be relatively independent of the exact cost of the tests. Auscultation for a systolic/diastolic abdominal bruit was the most cost-effective test for beginning a diagnostic strategy and showed a 99.6% specificity for stenosis. When the patient has a systolic bruit only or no bruit, plasma renin activity measurement should guide the clinician’s choice of whether to test further with intravenous pyelography or renal arteriography. Diagnosis of renal artery stenosis using these tests is estimated to cost between $2,300 and $6,200 per stenosis found, depending on the prevalence of renal artery stenosis. Supported in part by USPHS grants HL-14159, Specialized Center of Research (SCOR) in Hypertension and RR-00750, General Clinical Research Center. Dr. England was supported by a Robert Wood Johnson Faculty Fellowship in Health Care Finance during the latter part of this project.     

A consumer/medical educator conference

The authors discuss the development and proceedings of a highly structured conference at which 17 representatives from diverse non-medical groups and 14 medical educators from one medical school identified objectives needing greater emphasis in the medical curriculum. The conference emulated industry’s use of consumer advisory panels. Using the nominal group technique, a group process used in business, the non-medical group developed independently a priority list of areas in which physicians might be better educated to serve society. The medical educators then joined the non-medical group to discuss and clarify the concerns given highest priority. The authors describe subsequent initiatives by the medical school to address aspects of the general concerns raised by the non-medical group. The conference represents an approach to seeking input from non-traditional sources in the development of the medical curriculum. Received from the University of Pennsylvania Robert Wood Johnson Clinical Scholars Program, the Philadelphia VA Medical Center, and the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania.