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Background: Although resident physicians often teach, few trials have tested interventions to improve residents' teaching skills. A pilot trial in 2001-2002 found that 13 trained resident teachers taught better than did untrained control residents. Objective: To determine whether a longitudinal residents-as-teachers curriculum improves residents' teaching skills. Design: Randomized, controlled trial from May 2001 to February 2002 (pilot trial) and March 2002 to April 2003. Setting: 4 generalist residencies affiliated with an urban academic medical center. Participants: 62 second-year residents: 23 in the 2001-2002 pilot trial and 39 more in 2002-2003; 27 of the 39 participants were medicine residents required to learn teaching skills. Intervention: A 13-hour curriculum in which residents practiced teaching and received feedback during 1-hour small-group sessions taught twice monthly for 6 months. Measurements: A 3.5-hour, 8-station, objective structured teaching examination that was enacted and rated by 50 medical students before and after the intervention. Two trained, blinded raters independently assessed each station (inter-rater reliability, 0.75). Results: In the combined results for 2001-2003, the intervention group (n = 33) and control group (n = 29) were similar in sex, specialty, and academic performance. On a 1 to 5 Likert scale, intervention residents outscored controls on overall improvement score (post-test--pretest difference, 0.74 vs. 0.07; difference between intervention and control groups, 0.68 [95% Cl, 0.55 to 0.81]; P < 0.001) by a magnitude of 2.8 standard deviations and on all 8 individual stations. The intervention residents improved 28.5% overall, whereas the scores of control residents did not increase significantly (2.7%). In 2002-2003, 19 intervention residents similarly outscored 19 controls (post-test-pretest difference, 0.83 vs. 0.14; difference between intervention and control groups, 0.69 [Cl, 0.53 to 0.84]; P < 0.001). Twenty-seven medicine residents required to learn teaching skills achieved scores similar to those of volunteers. Limitations: The study was conducted at a single institution. No 'real life' assessment with which to compare the results of the objective structured teaching examination was available. Conclusions: Generalist residents randomly assigned to receive a 13-hour longitudinal residents-as-teachers curriculum consistently showed improved teaching skills, as judged by medical student raters. Residents required to participate improved as much as volunteers did.

Chronic fatigue syndrome (CFS) has been of considerable interest to the public, and has been a point of controversy within orthodox medicine. Recently the Centers for Disease Control have proposed clinical criteria which allows some uniformity in diagnosing the condition. A group of patients who met these assessment criteria were asked to participate in an experiment to test the clinical value of an injection of beef liver extract, which is rich in folic acid, and cyanocobalamin - a regimen that has become a popular treatment for CFS in southern California. Fifteen patients were recruited and randomly assigned to receive either liver extract or a placebo. Patients were given instructions on administration of intramuscular injections of the medication and they received a one-week supply of pre-filled syringes. Patients in both groups reported increased vitality, but there was no measurable difference in response between the groups. Patients with CFS seem to have a strong response to a placebo and physicians who study or treat this condition should consider this finding before accepting claims for treatments that are not rigorously investigated.

Access to medical care in the United States is deteriorating, particularly for the poor. The authors evaluated patients who could not aiford medical care recommended by physicians in a university-affiliated clinic that serves a predominately indigent population. The authors determined the patients’ demographic characteristics, their medical problems, and the types of care for which financial barriers existed. In addition, the authors compared the patients’ demographic characteristics and medical illnesses with those of a control group of patients from the clinic who did not experience financial barriers to medical care. Of the 1,950 patients evaluated, 94 (4.8%) were unable to aiford care recommended by their physicians. Sixty-seven percent were US citizens, 73% were unemployed, 63% had monthly family incomes of less than $500, and only 33% had health insurance. The patients had a variety of medical problems, ranging from hearing loss, for which they could not obtain hearing aids, to breast masses, for which they could not obtain mammographies or biopsies. When compared to patients who did not experience financial barriers to recommended care, the study patients tended to be poorer, more likely to be undocumented, more likely to be uninsured, and less likely to have acute, self-limited illnesses. Our findings support the argument that the nation’s current piecemeal approach to providing indigent health care may lead to serious financial barriers to access in some localities.

We evaluated the usefulness of commonly ordered routine admission laboratory tests in 301 patients admitted consecutively to the internal medicine wards of a university teaching hospital. Using a consensus analysis approach, three Department of Medicine faculty members reviewed the charts of admitted patients to determine the impact of the test results on patient care. The evaluated tests were the urinalysis, hematocrit, white blood cell count, platelet count, six-factor automated multiple analysis (serum sodium, potassium, chloride, bicarbonate, glucose, and blood urea nitrogen), prothrombin time, partial thromboplastin time, chest x-ray, and electrocardiogram. Forty-five percent of the 3,684 tests were ordered for patients without recognizable medical indications. Twelve percent of these routine tests were abnormal, 5 led to additional laboratory testing, but only 0.5 led to change in the treatment of patients. We conclude that the impact of routine admission laboratory testing on patient care is very small and that there is little justification for ordering tests solely because of hospital admission.

Access to health care for the medically indigent has emerged as a major policy issue throughout the United States. Because no national health program assures entitlement to basic services, practitioners and patients must cope with barriers to access on the local level. The authors report several separate but integrated strategies that a community-based coalition has used to achieve improvements in indigent care within a single county. Research strategies have involved short-term investigations of barriers to needed services, so that local awareness of the problem would increase rapidly. Political strategies have attempted to improve the county government's administrative procedures and financial support of services for the poor, to modify the practices of local health care institutions, and to influence statewide and national policies affecting local conditions. Legal strategies have involved the participation of attorneys who represent clients unable to receive care and who could initiate litigation as appropriate. Each of these strategies contains weaknesses as well as strengths. Although such advocacy efforts do not achieve a coherent system guaranteeing access, they can substantially improve the availability of local services.

Abstract: The usefulness of three components of the routine admission complete blood cell count (leukocyte count, hematocrit, and platelet count) was evaluated in 301 patients consecutively admitted to the internal medicine wards of a university teaching hospital. Using a consensus analysis approach, three faculty members reviewed the patients’ charts to determine which tests were performed routinely, which tests were abnormal, and which routine tests led to diagnostic or therapeutic changes. Overall, 55.3% of the tests were considered routine admission tests. Abnormalities were detected in 13.6% of the routine leukocyte counts, in 8.2% of the routine hematocrit levels, and in 12.4% of the routine platelet counts. However, treatment was changed for only three patients, all of whom had low hematocrits; this amounted to 0.6% of all tests. Furthermore, only one of the three patients received appropriate treatment that might have been withheld if a routine hematocrit determination had not been ordered. The authors conclude that the impact of routine admission complete blood cell counts on patient management is small and that the practice of ordering this test for all hospitalized patients could be eliminated with little adverse effect on patient care.

Abstract: Objective:To determine the prevalence of domestic violence among patients seen in three university-affiliated ambulatory care internal medicine clinics and to assess the personal characteristics of those patients affected by domestic violence. Design:Survey using a self-administered, anonymous questionnaire. Setting:Three university-affiliated internal medicine clinics at the University of California Irvine Medical Center. Participants:We asked all patients on randomly selected days during the three-month study to participate. 453 (72%) of the 629 eligible English- and Spanish-speaking patients completed the questionnaire. Measurements and main results:28% of participants had experienced domestic violence at some time in their lives, and 14% were currently experiencing domestic violence. Logistic regression analysis showed that female gender, unmarried status, and poverty were important predictors of domestic violence. However, domestic violence occurred in all groups regardless of sex, ethnicity, age, or socioeconomic status. Conclusions:The study found an unexpectedly high prevalence of domestic violence in the three internal medicine clinics. Physicians should ask their patients routinely about domestic violence and, when domestic violence is present, should offer emotional support, information about social service agencies, and psychological care.

OBJECTIVE:To determine whether there are differences in the methods and criteria used by primary care and traditional internal medicine programs to select first-year residents. DESIGN:A questionnaire was sent to primary care and traditional internal medicine program directors, who were asked to rank in importance ten documents of an applicant’s file and to score the relative importance, on a scale of −5 to +5, of 21 candidate traits of four types: academic, demographic, personal, and career goal. SETTING:Programs at institutions (n=54) that have categorical residency programs in both traditional and primary care internal medicine. PARTICIPANTS:Of 108 questionnaires, the overall response rate was 81%, with 40 pairs (74%) of matched respondents. Seventy-two percent of the responding institutions were university- administered. RESULTS:Primary care and traditional programs use similar methods to process applicants, rank similarly ten documents in an applicant’s file, and value academic success during the clinical years as the most important candidate trait. Compared with traditional tracks, primary care tracks place greater emphasis on a candidate’s career goals and select for candidates planning to pursue primary care careers (3.9±1.4 vs 0.9±1.5, p<0.001), enter practice (1.4±1.5 vs 0.1±1.2, p<0.001), or serve medically indigent populations (2.7±1.5 vs 1.2±1.2, p<0.001). Primary care programs rate negatively candidates who intend to subspecialize, whereas traditional programs view them almost neutrally (−1.8±2.2 vs 0.5±1.5, p<0.001). CONCLUSION:Primary care and traditional track internal medicine programs use similar methods to select residents and both rank academic achievement during the clinical years as a candidate’s most important attribute. However, only primary care programs strongly select for candidates on the basis of their career plans and in particular prefer candidates who are committed to pursuing primary care careers and serving the medically indigent.

Objective:To study the nature and extent of barriers to access to medical care in a single county and to define the nature of the illnesses in a population affected by those barriers.

• Depression is common in medical outpatients, but the diagnosis is frequently missed. We introduced the Beck Depression Index into our clinic as a screening tool to determine the feasibility of depression screening, the prevalence of depression in our patients, and the clinical usefulness of the depression index. The questionnaire was easily implemented and well accepted by the 375 patients screened. Moderate or severe depression was identified in 32% of our patients. By several measures, the Beck Depression Index proved to be a highly useful clinical tool. It provided information significant enough to change the plan in 20% of the entire population of patients screened. The severity or presence of depression would probably have been missed without the screening. Depression screening should be considered in all primary care settings.(Arch Intern Med 1986;146:729-731)

We proposed that clinical criteria could define a group of patients very unlikely to have abnormal preoperative chest roentgenograms. Nine hundred five surgical admissions were screened for the presence of clinical factors we thought would make those patients more likely to have abnormal preoperative chest roentgenograms. Of these, 368 had no risk factors. One patient (0.3%) of the 368 had an abnormal x-ray film, which did not affect the surgery. No material abnormalities were found in the remainder of the group without risk factors. Five hundred four patients had identifiable risk factors. Of these, 114 (22%) were found to have serious abnormalities on preoperative chest roentgenogram.(JAMA 1983;250:3209-3211)