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Many children have diagnosed diabetes that must be safely managed at school. New laws have created the potential for school systems to rely more heavily on unlicensed assistive personnel (UAP) than on nurses to deliver health services, including administration of insulin injections. Using the theory of planned behavior as a framework, aims were to (1) determine the nature and extent to which health services related to diabetes were being delegated to UAP in Kentucky schools, (2) describe the attitudes of Kentucky school nurses regarding the delegation of diabetes health services to UAP, and (3) examine the relationship of selected variables to school nurses’ intentions to delegate diabetes health services. Survey results revealed that school nurses in Kentucky intended to delegate some diabetes-related tasks despite their lack of support for delegation of those tasks.

Summary Objective To examine the comfort level of medical students beginning their paediatric clerkships, and to identify students’ perceived concerns around interacting with children in a medical setting. Methods Prior to beginning required paediatric clerkships, third-year students in two south-eastern US medical schools completed an anonymous, 13-item questionnaire eliciting prior personal experiences with children, as well as comfort levels with selected aspects of paediatric care. Results Based on 237 responses (76.2% response rate), medical students’ total child-related experiences were significantly associated with self-assessed comfort delivering paediatric care. Female students reported more prior experiences than male medical students; however, gender was not associated with comfort working with children. A dose–response curve of experience shows a critical level of two types of experiences for comfort in working with children. Students reported significantly lower levels of comfort in performing a physical exam on a child versus obtaining a child’s medical history from a parent/caregiver. Students’ child-related experiences were significantly associated with self-assessed comfort delivering paediatric care Conclusions Medical students with little to no prior experience with children expressed significantly less comfort interacting with children in paediatric clerkships. A diversity of past experiences appeared to be a more meaningful correlate, as opposed to experience in a specific setting or context. Providing some general exposure to children during the preclinical years could instill in students greater comfort approaching their paediatric training.

An emphasis on competency-based curricula has led to the concept of Entrustable Professional Activities (EPAs), responsibilities that a trainee can perform with minimum to no supervision. Establishment of EPAs in medical education seeks to standardize clinical learning experiences and ensure that graduates can perform at the resident level. To date, no study has addressed the medical student perspective regarding EPA implementation. A pilot case-based survey examined student confidence of proposed EPAs. Clinical year students reported greater confidence (p < .01) for all EPAs, demonstrating progressive confidence during training. Case-based subjective assessment of EPAs could be used to evaluate curricula, identify the learning needs of students and target educational interventions.

Those with chronic diseases, including inflammatory bowel disease (IBD), often do not receive preventive care at the same rate as the general population. Attitudes of primary care providers could be key factors in the receipt of preventive care. We surveyed attendees of a family medicine review course. The survey contained nine demographic items, four items to assess exposure to and comfort level with IBD, and six clinical vignettes. Of surveys, 36% (61/169) were returned. The large majority were males practicing outpatient family medicine. Mean age was 51 years, and 48% reported a mostly rural practice. Of subjects, 10% reported either having IBD themselves or having a close associate or relative with IBD. Only 37% of subjects felt comfortable providing primary care across a range of illness severity. Forty-six percent reported moderate or high exposure to IBD. For the case vignettes, the overall highest rate of endorsement of the active role was 84% for a case related to stage I hypertension, while the lowest rate was 30% for an item relating to vaccination for immunosuppressed persons. We assessed the following predictors of comfort level and active role responses and found no significant associations: age, gender, years of medical practice, and close contact with IBD. Our study suggests that family medicine practitioners often do not feel comfortable providing care to IBD patients. Lack of familiarity with IBD medications may be a key factor.

Background Resident physicians' beliefs about cardiopulmonary resuscitation (CPR) may impact their communication with patients about end-of-life care. We sought to understand how these perceptions and experiences have changed in the past decade because both medical education and American society have focused more on this domain. Method We surveyed 2 internal medicine resident cohorts at a large academic medical center in 1995 and 2005. Residents were asked of their beliefs about survival after CPR, perceived patient understanding, and regret after attempted resuscitation. Residents in 2005 reported more numerical experience with CPR. Current internal medicine residents are more optimistic than the 1995 cohort about survival after an inpatient cardiac arrest. They believe that far fewer patients and families understand resuscitation but report less regret about attempting to resuscitate patients. Conclusions These pilot data reveal potential changes in the attitudes of resident physicians toward CPR. The perceived poor understanding among decision makers calls into question the standard of informed consent. Despite this, residents report less regret leading one to ask what factors may underlie this response.

Background: Persons with chronic diseases often do not receive preventive care at the same rate as the general population. Reasons for this are not clear. We conducted a cross-sectional survey of patients with inflammatory bowel disease (IBD) and controls to assess receipt of 10 preventive health services. Methods: From March through October 2006, IBD outpatients and primary care outpatients at the University of Kentucky (UK) were surveyed by trained clinicians, using chart data to augment patient response. A second sample of IBD patients from the University of Chicago was studied with a self-administered survey. Results: One hundred and seventeen IBD subjects were enrolled at UK, 125 IBD subjects were enrolled at UCH, and 100 control subjects were recruited from UK primary care clinics. The overall age-/sex-adjusted screening rate, as measured by the screening index, was significantly lower in UK IBD subjects than in UK controls (75.1% versus 83.9%, P = 0.0002). The UCH data showed a 67% overall age-/sex-adjusted screening rate. After adjusting for insurance status, the difference in screening rates was still lower for IBD patients than for controls (71% versus 78%; P = 0.022). Neither disease type nor disease control rating predicted screening rate. Conclusions: Our data suggest IBD patients do not receive preventive services at the same rate as general medical patients. Preventive care is a facet of global IBD management that deserves further study. (Inflamm Bowel Dis 2007)

Residents feel inadequately trained to treat domestic violence victims.The purpose was to assess clinical skills of residents participating in a domestic violence workshop.Twenty-seven internal medicine residents were randomized to receive one of two workshops (domestic violence or control workshop). Standardized patients were trained to two domestic violence cases (depressed; injured). The two cases were randomized and insinuated into each resident's continuity clinic at either 1 to 3 months or more than 3 months after the workshops.The domestic violence workshop residents did not identify the standardized patients as domestic violence victims any more often than residents participating in the control workshop; 16/25 (64%) versus 13/23 (56%), p=.86. However, domestic violence workshop residents were more likely to score 75% or higher on the domestic violence checklist items compared to control workshop residents; 9/25 (36%) versus 2/23 (9%), p=.04.Once a standardized patient was identified in clinic as a domestic violence victim, domestic violence workshop participating residents demonstrated better clinical skills than a control group.

Standardized patient (SP) exams are becoming an important part of testing clinical skills. The dynamics of this test format warrant exploration. This study is designed to measure the relationship between experience with SPs and performance on a SP examination. A general linear model is used to determine if a relationship exists and the pattern of that relationship as experience increases. There is a linear association between increased experience and better performance in technical domains. In interpersonal skill domains, there is a curvilinear association between experience and performance with improved performance with moderate levels of experience but not in the most experienced group. Different levels of experience with SPs are associated with differences in performance. The varied pattern of associations suggests a possible practice effect or test-taking behavior. Additional studies are needed to assess this potential effect on SP exam validity.

Sexual history and HIV counseling (SHHIVC) are essential clinical skills. Our project's purpose was to evaluate a standardized patient educational intervention teaching third-year medical students SHHIVC.A four-hour standardized patient workshop was delivered to one-half of the class each of three consecutive years at one medical school. Approximately 3.5 weeks later, all students engaged in a standardized patient examination including one station assessing SHHIVC, answered an open-ended written exercise following the standardized patient encounter, and completed a written examination including sexual history and HIV-related questions.Workshop participants scored higher than non-participants on SHHIVC items on the standardized patient station (P.0001), written exam (P.0001), and open-ended written exercise after the standardized patient encounter (P = .024).Our SHHIVC curriculum was associated with students demonstrating better clinical skills on a SHHIVC standardized patient examination station and more SHHIVC knowledge on two measures of medical knowledge than students not participating in the SHHIVC educational intervention.

Sexual history and HIV counseling are essential clinical skills. Our project's purpose was to evaluate a standardized patient (SP) educational intervention teaching third-year medical students sexual history taking and HIV counseling. A 4-hour SP workshop was delivered to one-half of the class. Four weeks later, all students engaged in an SP examination including one station on assessing sexual history taking and HIV counseling. Workshop participants scored one standard deviation higher on sexual history and HIV counseling items than nonparticipants. Our sexual history and HIV counseling curriculum was associated with students asking more thorough sexual histories and providing more HIV counseling.

Historical and contemporary discourses on American culture were applied to work stress for the purpose of identifying the cultural assumptions, values, and beliefs that may predispose Americans to certain types of distress and, by association, stress-related illnesses within the context of work. Six primary American (albeit democratic) values and beliefs were identified and applied to work stress. The findings suggest that for work stress to be addressed effectively, professionals who study and seek to ameliorate it should understand the cultural underpinnings and assumptions that drive American business specifically, and all democratic societies generally; influence worker behaviors; shape employee–employer cognitions; and bias work stress research. Suggestions for future research are provided.

Purpose: Determine whether gender predicted student performance on a clinical performance examination (CPX) when controlling for pre-matriculation and medical school performance. Method: A sixteen-station CPX, utilizing standardized patients (SPs), was administered to the fourth-year students three successive years at one United States medical school. Scores for each student by discipline and skills across stations were generated. Bivariate correlation and multiple regression analyses were performed to determine relationships between students' scores and pre-matriculation information (age, gender, MCAT, and undergraduate GPA) and medical school performance (first-, second- and third-year GPA, and USMLE Step 1). Results: The CPX mean score for all students was 65.1% (SD 6.2). The mean total score for men (n = 182) and women (n = 93) was 64.0% and 67.0%, respectively. Being a woman, positively affected a student's score in two models controlling for pre-matriculation and medical school performance by 2.8% or 0.47 standard deviations (SD) and 2.3% or 0.39 SD, respectively. Women scored numerically higher than men in all seven disciplines (internal medicine, obstetrics/gynecology, pediatrics and psychiatry, p < 0.05) and for nine skills across all stations (introduction, history, physical examination, counseling and interpersonal, p < 0.05). Conclusion: Women performed better than men on the University of Kentucky CPX. Being a woman was a positive and independent predictor of performance.

Peer and self-evaluation are crucial in the professional development of physicians. However, these skills must be learned, and there are barriers to their acceptance and successful utilization. To overcome these obstacles, it has been suggested that these concepts should be addressed longitudinally throughout medical education. Therefore, first-year medical students were introduced to peer and self-assessment as part of a videotape review during an interviewing course by having students complete written peer and self-assessments of the interviews. Students’self-assessments were compared with the assessments of peers and faculty. Written evaluations showed peers were more lenient than faculty and students were most critical of their own performances. Students could provide balanced assessments of their peers but were predominately negative regarding their own performances. It appears first-year students are capable of evaluating their peers but have difficulty accurately assessing their own performance. Further interventions are needed to foster self-assessment skills in first-year students.

Individuals with tension-type headache report significant anger, depression, anxiety, and stressors. However, it is not clear to what extent these variables are interrelated. The objective of the present study was to explore the role of anger in headaches, and to examine its relationship to anxiety, depression, and daily life stressors. Participants were 65 young adult women who suffered from recurrent headaches. The sample was obtained in a large-scale screening of young adult women using the Headache Symptoms List to identify those with recurrent headache. Those individuals reporting headaches completed a battery of assessment measures that included the State-Trait Anger Expression Inventory, the Mood and Anxiety Symptoms Questionnaire, and the Hassles Scale. Results revealed a significant relationship between anger suppression and depression (r = 0.40, P

Being able to predict medical school performance is essential to help ensure the supply of quality physicians. The purpose of our study was to examine the influence of gender and age on academic performance (AP) and on academic difficulty (AD). The study involved all matriculants of 3 classes at one medical school. Independent variables included gender, age (categorized into younger and older than 23 years) and the gender by age interaction. Dependent variables included an AP scale score, a clinically based performance examination and AD. The Wilson AP Scale score was developed to assess both excellent and poor performance. The Wilson AP Scale included first-, second-, and third-year medical school grade-point-averages, USMLE Step 1score and USMLE Step 2 score. Older women as a group had the highest mean Wilson AP Scale score. Women performed better than men on the clinically based performance examinations. Younger men were least likely to have AD and younger women were most likely to have AD. Five of 123 younger men versus 13/66 older men had AD. Also, 15/63 younger women had AD versus 2/27 older women. A significant gender by age interaction was present in predicting the Wilson AP Scale score (p = 0.009) and AD (p = 0.002). Older women performed better than both older men and younger women in 3 classes of medical students at one medical school. A significant gender by age interaction was predictive of AP and AD. These findings may have implications on admission decisions.

Background: Although combined internal medicine/pediatrics programs (med-peds) are increasing in popularity, little is known of the eventual practice patterns of med-peds graduates, and how well the med-peds curriculum prepares them for practice. Purpose: To characterize current practices of the med-peds graduates of 2 programs, and assess how well residency prepared them for practice. Method: Thirty-four graduates (81% response) of 2 med-peds residencies were surveyed regarding their current medical practices. These graduates were also asked to rate 23 procedure and 17 practice skills as to the importance the skills hold in their current practices, as well as their level of preparation from residency for each. Results: Most graduates (78%) practiced in an urban/suburban setting. Most (61%) provided primary care to adults and children. Respondents reported being overprepared for skills specific to an intensive care setting (i.e. neonatal and pediatric intensive care, delivery room resuscitation, Swan-Ganz...

Objective To investigate the association of clinical workload and the decision to perform procedures on infants in the neonatal intensive care unit (NICU). Design Prospective cohort study over one academic year, observing infants exposed to housestaff working under various levels of clinical workload. Subjects All 31 housestaff rotating on the NICU service during the academic year 1993 to 1994 were observed. A total of 785 infants were admitted to these housestaff. Setting One academic Level III intensive care nursery. Measurements and main results Clinical workload was operationalized as number of NICU infants cared for by the individual houseofficer on-call each night. The procedures of interest were number of umbilical artery catheters (UACs), intubations, lumbar punctures (LPs), and peripheral phlebotomy performed by the houseofficer on-call. Using multiple linear regression approaches, controlling for the average severity-of-illness of each of the NICU infants, the experience and residency program of the houseofficer on-call, and the individual attending, we found that increased clinical workload (number of NICU infants) resulted in a significantly greater probability that an admitted infant received an umbilical artery catheter (p = .02), but resulted in less probability that any NICU infant received a lumbar puncture (p = .0001) or peripheral phlebotomy (p = .0002). The decision to intubate an infant was not affected by the workload in the NICU. Conclusions The clinical workload of housestaff in the NICU can affect decisions to perform procedures on infants in the NICU. For equivalently severely ill infants, there is a greater chance of receiving a UAC and less chance of being phlebotomized or receiving an LP when workload is high. Attending neonatologists need to be sensitive to possible effects of workload on patient care in the NICU.

Inpatient internal medicine education occurs in a fragile learning environment. The authors hypothesized that when medical students are involved in teaching rounds, residents may perceive a decrease in value of attending teaching.During two summer periods, trained research assistants shadowed teaching rounds, tracking patient census and team call status, recording basic content of rounds, and delivering a survey instrument to the learners, asking them to rate the quality of the attending's teaching that day.One hundred sixty-six rounds were analyzed. Attending teaching ratings peaked when students were highly involved. In fact, high student involvement was an independent predictor of higher resident evaluation of teaching rounds (P.0001).The best teaching occurred when involvement of medical students was greatest and their involvement was not necessarily a zero-sum game. The authors conclude that attending investment in medical student education during teaching rounds benefits all members of the inpatient team.

Global surveys of residents have consistently identified stress variables as important factors in resident job performance.Determine whether an association exists between resident stress and job performance.Over a three month period, interns on our inpatient ward services were surveyed regarding their current call schedule, whether their prior night's sleep was sufficient, whether they felt pressed by other commitments, whether they spent enough time teaching medical students and whether they had completed all patient care issues on a given day. Multiple logistic regression was used to assess the association between call status, pressure and sleep adequacy with reported omissions in patient care and adequacy of teaching.In the regression analysis, ratings of high pressure and insufficient sleep but not call status independently predicted outcomes. For example, if an intern felt both pressed and tired, they were over eight times more likely to omit a patient care issue and over four times more likely to report inadequate teaching.Subjective ratings of high pressure and insufficient sleep are associated with poor job performance in medical residents.

To review the impact of the clinical education of internal medicine residents on patients' outcomes.English-language studies of the relation between internal medicine housestaff training and patients' outcomes were systematically identified by a MEDLINE search and from bibliographies and reference lists of recently published articles.We hypothesized that the primary impact of internal medicine residency training on patients' outcomes would be the result of: (1) the inexperience of the residents; (2) the heavy workload these inexperienced residents are expected to manage: or (3) some structural feature of the internal medicine teaching services, such as the discontinuity of patient care inherent in night float systems and the fact that residents rotate to different services each month. We also hypothesized that residents may in may ways provide superior care, and many actually improve certain patient outcomes. Housestaff inexperience, workload, and structural features that promote discontinuity have been shown to affect especially outcomes of resource utilization, length of stay, and patient satisfaction. No study has demonstrated that internal medicine residents contribute to excess patient morbidity or mortality. However, the published studies in this area are for the most part retrospective and were conducted 10 to 15 years ago. The full extent of the untoward (or the beneficial) effects of internal medicine residency training on patients' outcomes is unknown.Multisite, prospective studies would remedy the deficiencies in the published research in this area and would yield the most valid insight into the range and extent of the effects of housestaff training on patients' outcomes. In the absence of such studies and in a rapidly changing managed care environment, academic medical centers and departments of medicine need to be aware of those aspects of the clinical education of residents that are most likely to affect patients' outcomes.

To determine if fourth-year medical students are as effective as faculty in teaching the physical examination to first-year medical students.Stratified randomization of the first-year students.A public medical school.All 100 first-year medical students in one medical school class were randomly assigned (controlling for gender) to either a faculty or a fourth-year student preceptor for the Physical Examination Module.The first-year students of faculty preceptors scored no differently on the written examination than the students of the fourth-year medical student preceptors (82.8% vs 80.3%, p = .09) and no differently on a standardized patient practical examination (95.5% vs 95.4%, p = .92). Also, the first-year students rated the two groups of preceptors similarly on an evaluation form, with faculty rated higher on six items and the student preceptors rated higher on six items (all p.10). The fourth-year student preceptors rated the experience favorably.Fourth-year medical students were as successful as faculty in teaching first-year medical students the physical examination as measured by first-year student's performances on objective measures and ratings of teaching effectiveness.

A two-year longitudinal study of thirty-five children used data gathered from pulmonary function tests, clinical measurements and standardized tests of depression, self-esteem and family environment to illustrate homeostatic interactions among biological and psychosocial adaptation to cystic fibrosis. Despite physical deterioration over the course of the study, children with cystic fibrosis reported lower depression and higher self-esteem than population norms, and improvements in psychological functioning. Decline in biological indicators of health was associated with increases on an index based on Family Environmental Scales (FES), subscales of cohesion, expressiveness and organization, and maintenance of high self-esteem and low depression. Presence of additional major life stressors was associated with deterioration in pulmonary function, higher levels of depression and poorer scores on the FES. These findings suggest that homeostatic interactions between children's health status and family functioning may moderate the physical and psychological sequelae of cystic fibrosis.

The present study was designed to determine the role of endogenous opioid mechanisms in the circulatory effects of relaxation training. Opioid mechanisms were assessed by examination of the effects of opioid receptor blockade with naltrexone on acute cardiovascular reactivity to laboratory stress before and after relaxation training. Thirty-two young men with mildly elevated casual arterial pressure were recruited for placebo-controlled naltrexone stress tests and relaxation training. The results indicated that relaxation training significantly reduced the diastolic pressure response to mental arithmetic stress. Opioid receptor blockade with naltrexone antagonized the effects of relaxation training. These findings suggest that some of the physiological effects of relaxation training are mediated by augmentation of inhibitory opioid mechanisms.

BACKGROUND Previous studies suggest that 20% to 67% of patients would desire cardiopulmonary resuscitation (CPR) even if they had advanced Alzheimer's disease. These preferences were not affected by education about CPR. We hypothesized that CPR preferences in scenarios involving Alzheimer's disease are influenced more by knowledge of or experience with Alzheimer's disease than by knowledge of CPR and its outcomes. METHODS We performed a random digit-dialing telephone survey of adult Kentuckians in June 1993. A total of 661 persons responded. We asked respondents whether they have had a friend or family member with Alzheimer's disease and whether they had cared for that person at home. We then assessed basic knowledge of Alzheimer's disease and CPR. We read to one half of respondents an educational paragraph describing CPR and its outcomes. Finally, we asked respondents their CPR preference if they were to develop Alzheimer's disease. RESULTS Overall, 22% of respondents would probably or definitely want CPR if they had Alzheimer's disease. With the use of simultaneous multiple linear regression, predictors of refusing CPR in scenarios involving Alzheimer's disease included knowledge of or experience with Alzheimer's disease (P < .001), older age (P < .001), greater income (P < .004), female sex (P < .01), and nonwhite race (P < .04). Baseline knowledge of CPR did not affect CPR preferences, nor did being read the educational paragraph. CONCLUSIONS Cardiopulmonary resuscitation preferences in scenarios involving Alzheimer's disease are strongly associated with knowledge of or experience with Alzheimer's disease more so than with knowledge of CPR. These findings suggest that in eliciting patients' CPR preferences in an advanced directive, care must be taken that patients understand the condition presented in the scenario (eg, Alzheimer's disease).

PURPOSE: Domestic violence (DV) is common, yet physicians feel unprepared to address it. Educational interventions may improve the care provided to DV victims, yet the effectiveness of interventions is often unproven. METHOD: Written questions and DV-specific standardized patient (SP) checklist items from an end-of-clerkship and fourth-year comprehensive multispecialty (the Clinical Performance Examination or CPX) examinations of medical students participating in a DV workshop using SPs was compared with nonparticipants. RESULTS: DV workshop participants' and nonparticipants' written question mean scores were 93.2% and 85.8%, respectively, p =.02. End-of-clerkship SP examination DV-specific checklist scores for participants and nonparticipants was 76.3% and 60.0%, respectively, p =.002. Workshop participants scored 44.1% on the CPX DV-specific checklist items versus 35.6% for the nonparticipants, p =.01. CONCLUSION: A DV workshop improved knowledge and skills assessed four and an average of 27 weeks later. Language: en

To determine whether residents could identify patients with poor literacy skills based on clinical interactions during a continuity clinic visit. The authors hypothesized residents would overestimate patients' literacy abilities and fail to recognize many patients at risk for poor literacy.The Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) was administered to screen patients for potential literacy problems. Residents were asked "Do you feel this patient has a literacy problem?" and answered yes or no. Continuity adjusted chi-square was used to test for overestimation of literacy abilities by residents.REALM-R scores and residents' evaluations of literacy were available for 182 patients. The residents believed 10% of patients (18) had literacy problems based on their clinical interactions. Only three patients passing the literacy screen were incorrectly identified as at risk for literacy. Of the 90% of patients (164) the residents perceived to have no literacy problem, 36% (59) failed the literacy screen.Resident physicians overestimated the literacy abilities of their patients. A significant portion of these residents' patients may not have the skills to effectively interact with the health care system and are at increased risk for adverse outcomes.

Providing charge data to resident physicians has been shown to reduce the amounts spent on diagnostic testing. This pilot study sought to determine the influences of charge data and group decision making on diagnostic test ordering by internal medicine residents.In an interactive workshop, 23 internal medicine residents received a hypothetical case. They completed an 18-item questionnaire estimating charges for diagnostic tests and then "ordered" tests. The residents were then randomly divided into groups that either received charge data, received charge data after ordering tests, or received no charge data. The groups ordered tests by consensus. Tests were weighted for appropriateness (+1 to +6) and inappropriateness (-1 to -6). Analyses compared individual and group decisions and effect of availability of charge data.Residents with access to charge data spent less on tests, but also had lower appropriateness scores. The appropriateness of the diagnostic workup was better by groups than by individuals, but cost more.Cost-containment interventions targeted towards doctors in training need to address the effect on quality of care and the influence of the group process in clinical decision making. Group diagnostic decisions may be more costly, but more appropriate.

The effectiveness of a brief clinical and basic science seminar on pain for 1st year medical students was examined by comparing attitudes about pain prior to the seminar to attitudes 5 months after the seminar. The 6-h course combined written materials conveying facts about behavioral, social and biological aspects of pain with clinical observations of an acute and a chronic pain treatment team. Examination of responses to a questionnaire assessing attitudes toward pain patients revealed that medical students have limited personal experience with pain and medications for pain, and limited knowledge about pain. Pre-course attitudes toward pain patients were dominated by perceived negative characteristics of pain patients and the belief that working with such patients is difficult. Attitudes measured 5 months after the course reflected increased complexity, greater emphasis that pain is real and not imaginary, and stronger belief that working with pain patients is rewarding. Five months after the seminar, students reported more accurate estimates of the frequency of problems with addiction stemming from acute pain treatment and exaggerated the prevalence of pain problems in the society. The importance of integrating clinical and basic science experiences in order to influence long-term clinical attitudes and produce lasting changes in clinically relevant knowledge is discussed.

PURPOSE To determine which internal medicine (IM) clerkship characteristics are associated with better student examination performance. METHOD The authors collected data from 17 U.S. medical schools (1,817 students) regarding characteristics of their IM clerkships, including structural characteristics, pedagogical approaches, patient contact, and clinical teacher characteristics. Outcomes of interest were postclerkship National Board of Medical Examiners (NBME) subject examination score, United States Medical Licensing Examination (USMLE) 2 score, and change in score from USMLE 1 to 2. To examine how associations of various clerkship characteristics and examination performance may differ for students of different prior achievement, the authors categorized students into those who scored in the top (1/4) of the cohort on USMLE 1 and the bottom (1/4). The authors conducted analyses at both the school and the individual student levels. RESULTS In school-level analyses (using a reduced four-variable model), independent variables associated with higher NBME subject examination score were more small-group hours/week and use of community-based preceptors. Greater score increase from USMLE 1 to 2 was associated with students caring for more patients/day. Several variables were associated with enhanced student examination performance at the student level. The most consistent finding was that more patients cared for per day was associated with higher examination performance. More structured learning activities were associated with higher examination scores for students with lower baseline USMLE 1 achievement. CONCLUSION Certain clerkship characteristics are associated with better student examination performance, the most salient being caring for more patients per day.

This study assessed the impact of a classroom intervention designed to influence physician assistant (PA) students' attitudes toward the elderly. Twenty first semester PA students participated in a quasi-experimental study which assessed their attitudes before and after a lecture/discussion on normal- and disease-related age changes and a non-clinical interview with a health older adult. In general, students became more accurate in their knowledge of older adults activities and health status. Students' open-ended responses to a sentence completion task also revealed more favorable attitudes toward older patients at the end of the course. Exploratory analysis revealed that less experienced students demonstrated more attitude change than did students returning to school specifically for PA certification.

The understanding of psychiatric morbidity in the infertile population relies to a great extent upon the instruments used to measure psychopathology. The present study investigated the distinction between psychiatric morbidity and infertility strain reactions in a sample of 104 infertile couples using the SCL-90-R. Some symptoms ordinarily indicative of psychopathology can represent normal side effects or reactions to infertility treatment, thus causing spurious estimates of pathology. Alternately, item analyses revealed a profile of infertility strain reflecting tension, depressive symptoms, worry, and interpersonal alienation frequently occurring among both male and female infertility patients. The concept of infertility strain is suggested as a vehicle for understanding the functioning of infertile patients and to circumvent the stigmatizing effects of psychiatric labels while providing appropriate intervention.

To explore whether the amount of workload of first-year residents (interns) affects the satisfaction of their patients.The authors collected data from January through May 1995 for 145 patients admitted to Lexinton Veterans Affairs Medical Center with the primary diagnosis of chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF). Workload was measured as the number of other patients for whom the intern had primary responsibility on the day of the studied patient's admission. A questionnaire measured the patients' satisfaction on the day of discharge. The authors analyzed the data using Pearson correlation and multiple linear regression.For the 89 patients with COPD (controlling for patient age, severity of illness, and sex of intern), greater workloads for their interns was a significant predictor of decreased patients' satisfaction (p = .001). No association was found for the 56 patients with CHF.Interns' workloads on the day their patients are admitted can influence their patients' subsequent satisfaction.

To see whether fourth-year medical students can teach the physical examination to first-year students as effectively as can faculty preceptors.Ninety-three first-year students studying the physical examination were randomly assigned to one of ten fourth-year student preceptors or one of 15 faculty preceptors. Test results and course evaluations were compared by type of preceptor. Fourth-year student preceptors were surveyed regarding their experience.The mean test scores did not differ between the first-year students with fourth-year student preceptors and those with faculty preceptors. The first-year students rated the fourth-year student preceptors higher than they did the faculty preceptors. The fourth-year students rated their experience favorably.A select group of fourth-year medical students provides a successful alternative to faculty in the teaching of the physical examination to first-year students.

BACKGROUND: Little is known of how the inexperience or the clinical workload of housestaff affects the decisions they make in the neonatal intensive care unit (NICU). The authors hypothesized that less experienced interns would order more tests per infant than more experienced residents, especially under conditions of heavy workload. METHOD: The NICU at the University of Kentucky A. B. Chandler Medical Center has either an intern or a resident on call by himself or herself at night, a natural setting to compare test ordering by interns and residents. The authors counted the numbers of X rays, analyses of arterial blood gases (ABGs), and electrolyte determinations ordered by the house officers on call for 321 infants from July through November 1993. Data for nine interns and seven residents were compared using multivariate linear regression. RESULTS: When workload became heavier (about five NICU patients), the interns increased their ordering of ABGs per infant to a significantly greater degree than did the residents (p = .01), with the difference being even greater on weekends when the housestaff were under less supervision (p = .004). CONCLUSION: As workload becomes greater in the NICU, interns order more ABGs per infant than do more experienced residents, especially when the interns are less supervised.

To assess the extent to which house officers know the social histories of their hospital patients, and to examine the factors that influence social history knowledge.In October-November 1992, all 31 internal medicine housestaff rotating on the hospital inpatient services at the University of Kentucky A. B. Chandler Medical Center completed questionnaires regarding the social histories of up to three of their patients. Responses were analyzed using simultaneous multiple linear regression analysis.Standard questions about social history were answered correctly only 29% of the time (two of seven items). The overall knowledge of patients' social histories was significantly less for supervising residents than for interns (p = .03) and, independently, for housestaff with greater patient loads (p = .04). Knowledge of a patient's social history was not related to the particular inpatient service, time the patient was admitted, or other characteristics of the patients or residents.The internal medicine residents' knowledge of their hospital patients' social histories was limited, particularly when the residents had relatively heavy patient loads or supervisory roles in patient care. The data suggest that patients' social histories may have been underemphasized during the residents' training.

The purpose of this project was to understand how resident attitudes to specific types of patients change throughout their internship. Over a 3-year period all 1st-year internal medicine residents were asked to complete a 15-item survey regarding their attitudes toward certain patient types and the profession. The survey was administered the 1st day of the internship, again in mid-November, and in June in the last month of internship. Sixty-one of 80 interns (76% response) completed all three administrations of the survey. In general, there were statistically significant differences in attitudes from the first administration to the second in all categories (all changes reflecting less idealism), with attitudes remaining the same for the second to third administration. For example, interns believed significantly more patients requesting narcotics were drug seekers (19% vs. 33%/ 37%, p < .0001) and a lesser percentage of the elderly could care for themselves independently(62% vs. 50%/48%, p < .0001). We conclude interns become less idealistic toward patients and the profession throughout internship, with the greatest change within the first 5 months.

Medical school admission committees differ in their decision-making procedures. Some assign ratings to groups of application materials to devise rank order acceptance lists, whereas others deliberate and vote on each separate application.This study examined what the screening review and deliberative processes contribute to decision making in a medical school admission committee.We reviewed records of admission committee members' preliminary votes on applicants after initial screening, final votes after committee deliberation, and written comments regarding issues of concern influencing their votes cast. Descriptive univariate and bivariate analyses are presented.Approximately one in five votes cast after initial screening was changed following committee deliberation, resulting in majority vote shifts in roughly 10% of cases containing votes by the same committee members at both time periods. Factors cited as influencing vote changes (in declining order of frequency) included Medical College Admission Test scores, medical experience, comparison with other applicants, grades, letters of evaluation, interviews, individual attributes, residency status, service experience, expressed desire of committee members to discuss the applicant at the meeting, American Medical College Application Service personal statement, and diversity.Admission committee members' voting behaviors appear to be influenced by the deliberative process. Future studies should explore the extent to which committee group dynamics influences decision making and the relative contribution of particular academic and nonacademic factors to vote-changing behavior.

PURPOSE: To assess the skills of internal medicine-pediatrics (med-peds) residents in evaluating and counseling patients with complex psychosocial problems using a clinical performance exercise (CPE). METHOD: The authors designed a 13-station CPE [nine standardized-patient (SP) stations and four non-SP stations]. Eight of the SP stations focused on counseling or assessing complex psychosocial needs, and three were videotaped and analyzed for specific verbal and nonverbal communication skills. Residents completed a written task for each station and SPs completed a checklist on interviewing and communication skills and a 52-item patient's-satisfaction survey. All first- and third-year residents (n = 25) from two academic years participated. RESULTS: The range of the average scores on the nine SP stations was 43-75%. The residents performed better with common problems (newborn hospital discharge instructions and cardiac risk-factor counseling) than with more complex problems that are less often encountered in the institution (HIV counseling), or problems less often recognized (adult survivor of childhood sexual abuse). As expected, third-year residents scored better than did first-year residents on the written "plan" part of the SP stations and on the non-SP stations. Third-year and first-year residents had similar scores, however, on measures of verbal and nonverbal communication and patient's satisfaction, and for gathering data and providing information. CONCLUSION: This is the first performance-based evaluation of residents in a combined med-peds residency program. The stations addressed more complex clinical skills than those reported for objective structured clinical evaluations of residents.

The purpose of this study was to specify how student attitudes toward different types of patients and the profession change during clinical rotations. A questionnaire was given to all medical students prior to 3rd-year rotations regarding their attitudes toward the medical profession and patient types. It was given again after students completed their l6-week medicine-surgery clerkship. Eighty-eight of 96 students responded to preand posttests. Students became less idealistic toward two patient groups: the elderly and people with chronic pain. After clerkship, students believed a greater percentage of the elderly were demented (26% increasing to 35%, p = .09 and that a greater percentage of patients with chronic pain are drug seekers (l5% increasing to 24%, p = .004). The authors conclude that in the 3rd year of medical school students become less idealistic toward elderly patients, those with chronic pain, and the profession.

To determine the influence of the quality of attending physicians and residents on the specialty choices of excellent medical students, who actually have a broad choice of specialties.In 1993-94 and 1994-95, 169 third-year students at the University of Kentucky College of Medicine were randomly assigned to two one-month rotations on general medicine inpatient wards. At the end of each rotation, the students confidentially evaluated the attending physician and the supervising resident (different for each rotation) with whom they had worked. Data were collected for 62 attending physicians and 89 residents. The authors analyzed the influences of the "best" and "worst" clinical instructors (those rated in the top and the bottom 20% by all students with whom they had worked over the two years) on "excellent" medical students (the 52 students whose USMLE I scores were in the top 30% of their class).Using regression approaches from the general linear model, the authors found that independent predictors of internal medicine residency choice for excellent medical students were exposure to highly rated internal medicine attendings (p = .02) and residents (p = .03). Nine of 29 (30%) of the excellent students who worked with a "best" medicine clinical instructor chose an internal medicine residency, while none of the 23 excellent medical students who did not work with a "best" medicine clinical instructor did so. The authors found no correlation in students' ratings of their pairs of attendings and residents, suggesting that rater bias did not explain the results.Better medical students who work with the best internal medicine attending physicians and residents in their internal medicine clerkship are more likely to choose an internal medicine residency.

Background: This study examined the influence of the quality of faculty members’ teaching on student performance in a third-year surgery clerkship. Methods: Eighty-nine third-year students on a surgery clerkship completed preceptor evaluation forms. The faculty member’s overall score was the mean of ratings from all the third-year students for whom that faculty member served as preceptor during the year. We examined associations between these ratings and student performance on the National Board of Medical Examiners (NBME) surgery subject examination and clerkship Objective Structured Clinical Examination (OSCE) by using an analysis of covariance that controlled for prior academic achievement [United States Medical Licensure Examination (USMLE) Part I]. Results: The average mean teaching evaluation score was associated with the scores on the NBME surgery subject examination ( P = 0.0005). Students with attendings who received poor teaching evaluations performed more poorly on OSCE data-gathering stations than did students with attendings rated as average or good. Conclusions: The study results indicate that the teaching quality of surgery faculty appears to have an impact on student performance.

Our institution has instituted “short-call” and “nightfloat” systems to reduce the number of admissions to the traditional “long-call” housestaff. However, the nightfloat system introduces increased discontinuity to patient care, and interns may spend less time with short-call patients because they are not required to spend the night on-call. Discontinuity and less time spent with patients may result in decreased patient satisfaction. Over a 6-month period, data were collected on 145 consecutive patients admitted to a teaching Veterans Affairs Medical Center with the primary diagnoses of congestive heart failure and chronic obstructive pulmonary disease. We found that patients admitted to either short-call or nightfloat interns were significantly less satisfied with their care than patients admitted to long-call housestaff, controlling for intern gender, patient age, and patient severity of illness (p= .02). Residency program directors need to realize that changes in the structure of teaching environment may have an impact on patient satisfaction. KEY WORDS: interns; on-call systems; patient satisfaction.