Education in family and community health: the challenge faced by a new medical school

This paper describes the efforts of the Department of Family and Community Health at Sultan Qaboos University in providing opportunities for the development of 'hands-on' problem-solving skills appropriate for Oman. The curriculum of the Department is discussed, highlighting the unusual emphasis of this discipline in both the preclinical and clinical curriculum of the College of Medicine. The importance of continuous assessment and supervision of students is discussed. Course-work in the preclinical curriculum of the Department is kept to a minimum. Field-work forms an important part of preclinical training, where application and problem-based learning are emphasized. During the clinical years the students are exposed to an integrated series of lectures and practicals covering core knowledge in clinical medicine. Practical clinical training, over a total period of 15 weeks, takes place at a variety of sites where common problems in primary health care in Oman are handled by students under supervision.     

The workload of trainees in general practice

During their first training period in general practice the authors felt that they did not encounter the balanced workload which is the foundation for learning to be a GP. Previous studies confirmed the existence of differences in overall and specific workload between trainees and trainers. From their own experience and from the relevant literature they addressed several factors which might affect the workload of trainees. A study was undertaken to determine differences in workload between trainees and trainers, and to investigate whether certain characteristics of practice and of trainees affect the workload of trainees. Details of surgery consultations with 34 trainee-trainer partnerships were recorded in the north of the Netherlands over 2 weeks. Questionnaires were filled in by trainers, trainees and practice assistants from these 34 general practices. The total number of contacts recorded was 10,103. It was found that trainees see fewer elderly and female patients, less chronic and oncological conditions, but more minor illnesses. They see only 30% of patients with problem behaviour. Factors that influence the trainees' workload, as compared to their trainers' are: list size; selection in the allocation of patients; trainee's experience prior to starting the training stage, and the trainee's sex. Except for problem behaviour, trainees generally see a cross-section of their trainer's practice population. Selection would provide a more balanced workload for trainees.     

Augmentation strategies in geriatric depression

Approximately 30–40% of elderly patients with major depression have inadequate response to an initial therapeutic trial of antidepressant medication. In these cases augmentation of the antidepressant has been recommended as one way of improving the rate of response. This article reviews the literature on augmentation strategies in treatment-resistant geriatric depression. Successful augmentation with lithium, triiodothyronine, stimulants, carbamazepine, valproate and a tricyclic–serotonin reuptake inhibitor combination have been described. However, there have been no controlled trials and, with the exception of two open prospective studies of lithium potentiation, the literature consists entirely of case reports and retrospective case series. As a result, it is difficult to draw conclusions about the efficacy of these strategies in late life, especially since treatment failures seldom get reported. Side-effects may limit the usefulness of some augmentation regimens in old age—up to 25% of patients treated with lithium or carbamazepine discontinued these medications because of adverse events. There is a need for controlled studies to better determine the clinical utility of augmentation strategies in physically well depressed elderly, as well as those with depression complicating medical illness, dementia and other neurological disorders.     

Systemic lupus erythematosus, 2nd ed. Edited by Robert G. Lahita. New York Churchill Livingstone, 1992, 1,022 pp. $189

Linkage disequilibrium (LD) analysis provides a powerful means for screening the genome to map the location of disease genes, such as those for bipolar disorder (BP). As described in this paper, the population of the Central Valley of Costa Rica, which is descended from a small number of founders, should be suitable for LD mapping; this assertion is supported by reconstruction of extended haplotypes shared by distantly related individuals in this population suffering low-frequency hearing loss (LFHL1), which has previously been mapped by linkage analysis. A sampling strategy is described for applying LD methods to map genes for BP, and clinical and demographic characteristics of an initially collected sample are discussed. This sample will provide a complement to a previously collected set of Costa Rican BP families which is under investigation using standard linkage analysis. © 1996 Wiley-Liss, Inc.     

不同剂量加味保元汤对束缚应激小鼠非特异性免疫功能的影响

目的 :研究不同剂量加味保元汤对束缚应激小鼠非特异性免疫功能的影响。方法 :80只小鼠随机等分为加味保元汤 5g/kg体重、 10g/kg体重、15g/kg体重和应激组 ,用巨噬细胞体内吞噬法 ,测其吞噬率及吞噬指数。结果 :吞噬指数 :10g/kg体重组明显高于 15g/kg体重组 (P <0 0 5 ) ,10g/kg体重组与 5g/kg体重组比较虽P >0 0 5 ,但均值高于 5g/kg体重组 ;吞噬率 :10g/kg体重组最高。结论 :10g/kg体重剂量加味保元汤对束缚应激小鼠非特异性免疫功能保护作用效果最佳。     

Cross-national study of perceived parental rearing behaviour in healthy subjects from Australia, Denmark, Italy, The Netherlands and Sweden: pattern and level comparisons

Samples of healthy subjects from Australia, Denmark, Italy, The Netherlands and Sweden completed the EMBU, a Swedish questionnaire aimed at assessing the experience of parental rearing practices. For the purpose of comparison three factors - "emotional warmth", "rejection" and "overprotection" - obtained in a previous factor analytic study, have been used. The most pronounced differences occurred between the Dutch and the Swedish sample on the one hand, and the Italian and Australian sample on the other, with the Danish sample in between. Differences in perceived parental rearing should be considered when comparing personality characteristics and/or psychopathological conditions in subjects from different countries.     

不同时期在押罪犯司法精神病学鉴定案例的对比分析

目的 探讨近年来在押犯罪司法精神病学鉴定的特点和发展趋势。方法 对1994年后经该院鉴定的87例与1993年前鉴定的33例在押罪犯案例进行对比分析。结果 1994年后组在押罪犯鉴定的案例明显增加（P＜0．01）。服刑能力的鉴定,1994年后组较多（P＜0．01）,服教能力的鉴定,1993年前组较多（P＜0．05）。1994年后组经济类案件有上升趋势（P＜0．05）,诊断为精神分裂症的有明显下降（P＜0．01）,诊断为拘禁性精神障碍的有明显上升（P＜0．05）。结论 在押罪犯司法精神病学鉴定已成为司法精神病学鉴定的重要组成部分,对其法定能力的评定需进一步入研究。     

Patient,Provider, and Treatment Factors Associated with Poor-Quality Care for Schizophrenia

Interventions are needed to improve the quality of care for schizophrenia. However, in designing these interventions it would be helpful to understand better which patients are at highest risk for poor-quality care and why care for this disorder is often of poor quality. We study the extent to which patient and treatment factors are associated with poor-quality care in 224 patients randomly sampled from two mental health clinics. Quality of medication management is evaluated using an established method based on national treatment recommendations. Multivariate regression is used to study the effect of patient and treatment factors on treatment quality, controlling for provider. Risk for poor-quality care was greater for patients who were more severely ill, older, and less compliant with treatment recommendations. There were trends toward poor management of symptoms in men and substance abusers, and poor management of side effects in Black patients. Provision of poor-quality care was associated with failure to document symptoms and side effects in the medical record. Interventions to improve care for schizophrenia should attend to the need for accurate clinical assessment and strategies for managing challenging clinical situations.     

A factor analytic study of teaching in off-campus general practice clerkships

The Preceptor-evaluation questionnaire (PEQ) was developed at the University of Mississippi Medical Center to evaluate the clinical teaching behaviour of general practice doctors in private practice who have one or more third-year medical students per year in their offices for a required general practice clerkship. The PEQ was designed to provide feedback to these doctors and the sponsoring department in an effort to improve teaching in this setting. Developed from the input of family practice doctors who have supervised students in their offices and from a review of related literature, the instrument was given to students to determine the level of importance they attributed to each teaching characteristic. A principle components factor analysis and subsequent varimax rotation produced six significant teaching factors in this setting. These six factors were:

• 1 demonstrates a humanistic orientation toward patients and staff;
• 2 demonstrates a humanistic orientation toward student;
• 3 provides opportunity for practice;
• 4 motivates and stimulates student's thinking;
• 5 communicates effectively with student; and
• 6 demonstrates comfort and confidence in the roles of doctor and teacher.

The factor relating to the humanistic orientation toward student has not appeared as a separate factor in other studies of clinical teaching. This may be due to the unique aspects of the relationship between student and doctor in this setting which may not occur in other settings. The PEQ and similar reliable and valid instruments can provide valuable information for the doctors in these off-campus teaching situations as well as provide useful programme planning information for the sponsoring academic departments. This information may also be valuable for off-campus residency training.