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To determine if additional burn-care facilities or educational programs for burn care were needed within Florida, 73 of the state's 220 hospitals were studied. Data were collected on hospital statistics for a one-year period, as well as on 1656 patients admitted for burns to these hospitals during that year. When results were adjusted for severity of the injury, there was no evidence that outcomes of patients were better in any one or group of the State's eight regions, or in hospitals that had special burn units. Considerable evidence, however, indicated the need for additional educational programs in burn care. Many records were poor, admissions were inappropriate, patients with minor burns stayed too long, and burn shock was too frequent.

The aim was to determine the effects of stress on immune status and surgical outcome in 24 healthy men undergoing hernia repair. Stressful life events over the prior 6 mo and social support was assessed at time of admission. Physiological response to a cold pressor test was measured the day before surgery. Lymphocyte blastogenesis and neutrophil chemotaxis were measured before and 3 and 30 days after surgery in patients and controls. Surgical outcomes were assessed by length of stay, narcotics used, and complications. Data were analyzed in 2 x 2 factorial designs for multivariate analysis of covariance where one factor was life stress and the other was response to the cold pressor. Age and social support were covaried in comparing immune responses before surgery. High responders to life stress had significantly less response to PHA, and high responders to cold pressor stress had lower PWM responses. With preoperative immune status covaried, high responders to cold pressor stress had significantly lower PWM response after surgery, indicating some T-B cell interaction defect and more narcotics and complications. Data suggest that high psychological and physiological stress responses before surgery (that is itself an additional psychophysiologic stressor) lead to poorer outcomes even in otherwise healthy men undergoing relatively simple elective surgical procedures.

Attitudes, personality, and career preferences of Anglo and Hispanic (Cuban) male and female junior students at the University of Miami School of Medicine were studied when they entered their surgical clerkship, and their performance in seven areas was measured 12 weeks later. Cuban females had more intolerance of ambiguity, felt less in control of their lives, anticipated more from the clerkship, preferred pediatrics, scored lower on written and verbal examinations, but performed higher on ward behaviors than other groups. Anglo females had the best written and verbal performance of any group and higher overall grades. Anglo and Cuban males preferred a surgical career more than other students did. Most differences observed were a result of the Hispanic females who, because of their role in the Cuban family, may not as yet be as assimilated into the core culture as the Cuban male.

The aims were twofold: to determine differences between the very old and younger patients in ambulatory care and to examine their self-assessments of health and whether these related to: subjective data such as symptoms and attitudes, objective data such as utilization of health services, and physician assessments of the patient's health. Although they had about one more diagnosis, the very old were similar in most respects to younger patients. Variables that discriminated the groups were physician ratings. About two-thirds of the older and younger patients regarded their health as good. Good health perceptions were associated with fewer symptoms, outpatient visits, and hospitalizations in both groups. Physician assessments were only lowly correlated with patient assessments of health. Patient perceptions of health were highly stable over a two month follow up. The subjective belief that one is healthy or ill may be more important than actual medical condition in maintaining good emotional and behavioral functioning.

The physician plays a central role in the emotional as well as the physical care of the dying patient. The concerns of the terminally ill cancer patient include (1) emotional response to the physical limitations of illness, (2) communication with significant others, (3) self-concept, and (4) resolution regarding impending death. Although a busy physician would not be able to spend much time talking with the patient about these concerns, the physician could communicate to the patient in just a few minutes an empathic understanding of the emotional crises the patient faces. Sometimes only a word or touch of the hand can covey the physician's support and understanding which are so meaningful for a terminally ill patient.

In 1973 a survey was done in Florida to identify needs throughout the state’s eight regions for improvement in burn patient care [l]. It was found that no specific regional needs existed and, furthermore, that gross mortality rates in Florida seemed, at worst, to be the same as elsewhere in the country. In a sense, therefore, this satisfied the initial purpose of the survey. The question arose, however, as to whether or not results might not be equally bad (rather than equally good) all over the country and therefore subject to improvement by upgrading the facilities for burn care. In reviewing the literature, there was no difficulty in finding uniform agreement among leading authorities that special burn care facilities, such as burn units, burn programs, or bum centers, represent the way in which optimal management can be provided and optimal results can be obtained. Unfortunately, not a single reference was found comparing outcomes of bum patients treated in institutions with such special care facilities to those of patients treated in institutions without such facilities. Since the Florida Burn Survey contained a substantial pool of clinical and institutional data, it was decided to use this information to provide at

This study tests the effects of nursing home staff training in care for the dying on the quality of life of terminally ill patients. Ten matched community nursing homes were assigned randomly to experimental (training) or control (no training) conditions. Patients ( N = 306) admitted to the homes were assessed at admission, one month, and three months concerning quality of life as measured by depression, alienation, self-esteem, and locus of control. Satisfaction with care was also measured at one and three months. Patients in trained homes had less depression and greater satisfaction with care than patients in control homes at one and three months. Training effects were similar in all of the five homes. The study shows that a favorable impact on patient care can be achieved when staff in nursing homes are trained to work with dying patients.

The role of the surgical clerkship in the curriculum has often been debated. This study highlights its function in the students' decision making process. Junior students (N = 164) were measured on interest in surgery before and after the clerkship and divided into groups that changed significantly in a positive or negative direction, or that remained essentially unchanged. Background factors, learning styles of the students, and their evaluations of the clerkship showed that students who changed negatively (12%), compared with those who changed positively (44%), did not learn as well from clinical experiences and evaluated certain aspects of the clerkship, related to time and clinical demands, less positively. The unchanged group resembled the positive change students. Performance in the clerkship did not differ significantly among the three groups. The group that changed positively had none interested in surgery as a career before the clerkship, 15% who chose surgery afterward, and who later entered a surgical residency. The negative change group entered with high, perhaps unrealistic, levels of interest, left with none selecting surgery, and a third entering nonclinical type residencies. The surgical clerkship appears to have a unique role to help students make decisions about future careers based on their underlying personalities and learning styles.

The authors compared the attitudes of men and women junior medical students at one medical school before and after completing the surgery clerkship. The attitudes surveyed pertained to the students' confidence in dealing with problems in the doctor-patient relationship, concerns about future practice, and attitudes about preventive care. The women and men differed in only one career preference, with more women than men choosing obstetrics-gynecology. The class as a whole had more positive attitudes in all three areas after the clerkship. The men and women did not differ before or after the clerkship in their confidence in handling problems in the doctor-patient relationship. The women, however, had higher levels of concern than the men about preventive care after the clerkship. Although the men and women overall entered the clerkship with similar attitudes, the women left the surgical clerkship with more positive attitudes overall but also with more concerns about future practice than the men. Because of the demands made on students' time during the surgery clerkship, some women students may become concerned about conflicts that could arise from balancing career roles and homemaker roles, and they may need support at this time in dealing with these concerns.

A revised version of the Rapid Disability Rating Scale (RDRS-2) is presented. Item definitions have been sharpened and directions expanded to indicate that ratings are based upon the patient's performance in regard to behavior, and that prosthesis normally used by the patient should be included in the assessment. Three items have been added to increase the breadth of the scale. Response items have been changed from three-point to four-point ratings in order to increase group discrimination amd make the scale more sensitive to changes in treatment. The new appraisals of reliability, factor structure, and validity are reported, along with the potential uses of the scale.

Older and younger malnourished and well-nourished head and neck cancer patients scheduled for surgery were studied. More of the young (75%) compared with the old (58%) underwent curative surgery, and only the old with lower clinical states of cancer were selected. When data on those undergoing surgery were analyzed in regard to older and younger malnourished and well-nourished men, the malnourished old had the poorest surgical outcomes of any group, with significantly more complications and morbidity rates. The well-nourished old had outcomes that did not differ from younger patients. On further examination, 60% of the young malnourished and only 20% of the old malnourished received preoperative enteral or parenteral nutritional support. Findings suggest that more attention to the needs of the older malnourished patients could improve surgical outcomes.

The purpose of this research was to determine whether a specialized telephone service could cut down on unscheduled visits to ambulatory care and improve satisfaction with care. Patients who were to receive care (N = 561) were assigned randomly to a specialized telephone service or a control group. They were measured with regard to satisfaction with care before being assigned and 6 months later. The number of scheduled and unscheduled visits also were monitored for a 1-year follow-up period. The telephone service, which provided a triage system for referrals as well as a source of central contact for scheduling or for complaints, helped to improve satisfaction and reduce the number of unscheduled visits within 6 months. Such a service also may have application in other problem areas in the delivery of quality ambulatory care.

The development of a 54-item, multidimensional, self-report scale to measure physical, emotional, and social function is described in regard to reliability, validity, and factor structure. The scale appears to measure the following dimensions: physical disability, symptoms of aging, self-esteem, social satisfaction, depression, and personal control. The scale was derived from two studies of 826 persons age 60 and older. The scale is recommended when a comprehensive, relatively short, self-report assessment is needed for screening or research purposes.

Although emphasis has been placed on including content on treating the elderly in the medical school curriculum, little attention has been given to whether content on surgical management of the elderly should be provided in the surgical clerkship. The purpose of this paper is to describe geriatric principles emphasized in a surgical clerkship and changes in attitudes of students. Junior students (N = 175) were tested on attitudes before and after the clerkship. Attitudes about treating the elderly and surgery in the elderly changed significantly and positively. Attitudes about emergency surgery in the elderly became more realistic, particularly in those selecting surgery as a career. This study differs from others that found that students became more negative about treating the elderly as they progressed through medical school. The surgical clerkship provides a different perspective of the older patient from that seen on medicine or in long-term care, in that the elderly are usually admitted and treated successfully in a short time. The fact that the surgical clerkship, in contrast to other medical school experiences, can positively influence attitudes about aging for all students, regardless of career choice, is encouraging and suggests that including content on surgical management of the elderly can help students become more favorable about treating older patients.

Concern has been expressed regarding the extensive use of psychotropic drugs in ambulatory care. The aim of this study was to examine the relationship between age and use of these drugs in terms of differences in personal characteristics, medical histories, use of medical services and symptoms. Male veterans (N = 992), randomly selected from ambulatory care, were divided into five age groups (44 years and younger, 45 through 54, 55 through 64, 65 through 74, 75 years and older) as well as according to whether or not they were currently taking psychoactive medication. Psychotropic medications were used most frequently by the two middle-aged groups (45-54 and 55-64) and least frequently by the older age group, with significantly less use by blacks in all age groups. Regardless of age, drug users had more diagnoses, more outpatient visits, and considered their health to be better than did nonusers. Other medications, such as antispasmodics and sleeping, pain and heart medications, were also associated with use of psychotropic drugs. Furthermore, users in all groups had more symptoms of anxiety, depression, interpersonal problems, obsessiveness-compulsiveness and concern with their bodies. These findings allow the physician to recognize the clinical profile of patients who are more likely to rely on psychotropic medications and to treat them accordingly.

This article examines perceptions of stress and career choice. One hundred sixty-nine junior students specified what they thought were the two most and two least stressful careers, as well as their own career preferences before and after a 12-week surgical clerkship. The class was divided for analysis into three groups: those who selected careers that they said were A) most stressful (42%), B) least stressful (10%), and C) neither most nor least stressful (48%). Surgery was cited as one of the two most stressful choices by 99% of the class before and 93% after the clerkship. The next most stressful career was internal medicine, cited by 43% before and 35% after the clerkship. The two least stressful careers were dermatology and radiology, cited by approximately 50% of the class before and after the clerkship. Those who chose careers that they said were most stressful had significantly higher self-esteem (p less than 0.05), experienced less unfavorable stress themselves as measured by a 31-item stress scale before and after the clerkship (p less than 0.01), and experienced more favorable (in their view) stress (p less than 0.05) than did the other two groups. Reanalysis of data comparing those who selected surgery with those who did not confirmed findings similar to that of the matched high-stress career group. The study suggests that some students may be able to tolerate stress better and in fact, tend to thrive in an environment that they perceive as stressful, and that such students are more likely to go into a surgical career, which they foresee as one of the most stressful that they can enter.

This study examined the degree of liver damage, reflected by standard laboratory tests, in a group of male veterans in regard to their self-reported histories and diagnosis of alcoholism. Fifty-two percent of the patients were diagnosed as alcoholic. The correlation between liver damage, judged by a physician reviewing the tests, and diagnosis of alcoholism was r =.33. Although liver damage does not develop in some alcoholics, this minimal correlation suggests the need to look for other nutritional and genetic factors that may interact with alcoholism in development of liver damage.

The purpose was to determine if students could identify their own strengths and weaknesses as viewed by their peers and whether peer or self ratings of knowledge and interpersonal skills could predict scores on National Board Medical Examinations and final grades in surgery. Ninety-eight juniors rated themselves on a 13-item scale; 830 peer ratings (about eight per student) were also obtained and averaged to provide a peer score for each student. There were low but significant correlations between the two sets of ratings. Peer scores were excellent predictors of both National Boards and final grade. Self scores were only weakly associated with these outcomes. Interpersonal skill ratings were inversely related to grades. Peer ratings seem to be a valuable addition to evaluation of student performance. Self ratings may be more useful as a means of helping students learn to accurately assess their strengths and weaknesses.

Some of the problems facing evaluators of medical care have been dealt with by individuals examining mental health programs. Mental health research has focused more on outcome studies that include a multidimensional approach in evaluation. Techniques have been devised in that field that make the evaluative process patient specific and goal oriented. Borrowing some of these methods to make medical care evaluation include a problem-oriented outcome, which incorporates patient satisfaction, compliance with medical therapy, and relief of symptoms, could lead to more accurate data on the health delivery system.

In light of limited health care funds, there is a need for reliable information relating costs to clinical outcomes. Distinction should be made between diseases for which improved outcomes relate to intensity of care and those for which limits of current knowledge preclude improved results. A survey of 1,656 burn admissions to 73 hospitals over a one-year period showed that length of stay, unpaid bills, and the proportion of unpaid bills to total bills were two to six times greater than for nonburn admissions to the same hospitals. Three hospitals had special burn facilities, and even when adjustments were made for severity of injury, these hospitals had poorer outcomes and higher costs when all their burn patients were studied. When only those patients with greater than 30 per cent burn were compared between hospitals with and without special burn programs, or when patients were matched for degree of burn the hospitals with the special programs still had no better patient outcomes than those without such facilities. The crucial question, then, is whether mortality and complications were lower in special facilities. Although there was no evidence in this survey that they were, the final answer must come from a prospective study of outcome. If these survey results are confirmed, burns might be identified as an illness for which current limits in management abilities limit the ultimate proportion of successful outcomes.

The aim of this study is to test a multiple choice test generated by the computer (CGE) with the National Board Examination (NBE) used for evaluation of surgical clerks. The CGE was developed and tested over a 2-year period prior to the study. It resembles the NBE in length and format but is geared to content covered in the 12-week surgical rotation. The research question concerned whether the CGE could replace the NBE. One hundred seventy-two students were randomly assigned to four groups at the end of each quarter of the year. They were tested twice, 1 day apart as follows: 1. NBE-NBE; 2. CGE-CGE; 3. NBE-CGE; 4. CGE-NBE. Correlations between NBE and CGE were in the moderate range. Analysis of variance between scores on CGE and NBE showed differences that were almost of borderline significance ( P

Much has been written about working with dying patients. To evaluate counseling, 120 terminally ill cancer patients were randomly assigned to counseling or no counseling and studied before random assignment and at 1, 3, 6, 9, and 12 months on quality of life variables (alienation, depression, locus of control, life satisfaction, self-esteem) as well as functional status and survival. Counseled patients changed significantly in comparison to controls and in a favorable direction by 3 months. The purpose here was to see if older and younger cancer patients differed at baseline and if outcomes of counseling differed by age. Patients under age 60 were compared with those 60 and over. There was no multivariate difference at baseline but univariate differences of more disability and less life satisfaction in the older group. Overall, response to therapy was similar in old and young, with both improving.

In a review of 292 hospital patients who had cardiac arrests over a period of two and a half years patients aged 60 and over were contrasted with those under 60, based on a 50-item clinical questionary completed at the time of the episode. Survival rates were identical (23%) in these two groups. On contrasting patients who survived with those who did not it was again found that age did not influence outcome. Patients with multiple arrests or without cardiographic evidence of ventricular standstill were much more likely to recover. Whether or not a doctor initiated therapy did not affect survival.

The purpose was to see if students changed their attitudes about medical care during the surgical clerkship and whether those who selected surgery as a career differed from other students at the end of the clerkship and time of entrance into a residency. Students were assessed before and after the clerkship in regard to confidence about handling problems in the doctor-patient relationship, concerns about future practice, and attitudes about preventive aspects of care. In general, the class changed positively in dealing with patients, had more concerns about future practice, and were more negative about preventive aspects of care. Potential surgeons had concerns about future practices similar to those of other students but differed from the rest of the class by having more confidence in dealing with patients and more positive attitudes about preventive aspects of care. When they entered the clerkship, would-be surgeons had more favorable ratings than did other students on ego strength and acceptance of people. The study suggests that attention may need to be given to the experiences of students in the clerkship that lead to their increased concerns about future practice and, for those not selecting surgery as a career, their increased negative attitudes about preventive care.

Authorities are not in full agreement in regard to risk of surgery in the elderly. One hundred eight studies of surgery in the elderly over the past 40 years were reviewed. The purpose was not merely to tabulate results, but to identify differences existing between reports with regard to data reported that could affect results independent of the surgical management itself. Sources of variance that need to be taken into account in comparing mortality rates between studies, such as whether mortality was computed by number of patients or operations, differing lengths of follow-up for recording mortality, proportions of emergency versus elective operations, and types of surgical procedures, were documented. A nine-item confidence in results scale was used to classify studies into high and low confidence groups. Surgical specialties scored substantially higher than general surgical studies. More recent studies received higher scores than earlier studies. Although mortality rates varied widely depending on methods of their calculation, there appeared to be a trend toward increases in elective, but not emergency, mortality rates in general surgery since 1941 that should be examined more closely. One thing that cannot be answered clearly from these studies is the relative risk of surgery with age. Some control of variations between studies and standardization of reporting surgical deaths are required before risk of surgery in the elderly can be assessed more accurately.

This study measured depressive symptoms in 98 men of whom 49 had and 49 had not had a recent experience of family death or serious family illness. The relationships of depression and occurrence of the stressful event to immune function was explored. Persons with higher scores on depression in both groups showed less responsiveness of their lymphocytes to phytohemagglutinin and to allogeneic cells. Data indicate that not all persons react the same way to stressful events and that those with high and low depressive features can be differentiated by their immune responses.

Surgery has sometimes been studied as a stressful event. The aim here was to determine the relationship between degrees of anxiety before surgery and postoperative outcomes in healthy old and young men. Old and young men were selected if they had no illnesses or prior surgery and were scheduled for elective hernia repair. Levels of anxiety were measured preoperatively along with other physiologic, psychologic, and immunologic modalities. Operative data and follow-up data for 30 days were obtained. Old and young men did not differ significantly before surgery. When age groups were divided by preoperative anxiety and their postoperative outcomes compared, more anxiety was associated with more pain-relieving medications and more disability days in each age group. Furthermore, the old anxious had even more disability days and complications than did other groups. The study points to the need to prepare the old, even those essentially in very good health, for even a minor surgical stress in order to improve their overall health outcomes.

The extent to which medical records supply reliable and valid data about a patient's condition is unknown. Recent emphasis on evaluation of quality of care by record review makes this an important issue. One hundred and three male patients (mean age 65) discharged from hospital to extended care were studied. At hospital discharge, the patient was rated by his physician on a 13-item impairment scale. Another physician, using only medical records, rated the same patients on the same scale. Similarity between ratings was found to be low. Validity was studied by following patients six months later to classify them as living (75) or dead (28). Each set of ratings was then used to predict death, on the assumption that degree of impairment would be related to subsequent death. Both sources predicted death at a highly significant level; however, slightly different predictors were elicited depending on whether records or personal knowledge were used. Common predictors were respiratory, hepatic, and neurologic impairment, with in person ratings adding upper gastrointestinal and record ratings adding vascular and psychiatric impairment. What might be concluded is that both sources were valid, but both incomplete. Records had missing data, and physicians using personal knowledge tended to think only of the patient's treated condition.

Predictors of satisfaction with ambulatory care and compliance in 267 older and 581 younger patients were determined. Each patient rated a 45-item satisfaction-with-care-scale. Race, SES, marital status, distance from clinic, severity of illness (as measured by physician ratings, self-health assessment, number of medications, number of diagnoses, and number of clinic visits and hospitalizations in the prior year), and physician expectations of improvement were entered as predictors into stepwise multiple regression analyses for the elderly and the young. Predictors of better satisfaction in the young were less severe conditions, being nearer to the clinic and having fewer prior clinic visits over the year. In the elderly, having fewer visits to the clinic, more expectation of improvement by the physician and less severe conditions were associated with better satisfaction. Severity and clinic visits were predictors in each age group. The young, however, were also influenced by distance from the clinic. The elderly were influenced separately by the physician's prognosis. Thus, when the more impaired elderly are seen frequently without expecting a benefit, their satisfaction with care is poor. Further, satisfaction with care was correlated significantly with compliance in the elderly but not in the young. Findings suggest that improving satisfaction with care might also improve rates of compliance with the medical regimen in older patients.

More stress from hospitalization, measured by level of anxiety at time of admission, in 75 males without cancer, infection, or autoimmune disease was associated with depressed immunological response of lymphocytes in vitro but positive reactions to skin tests of more delayed hypersensitivity. Findings suggest that psychological states of perceived stress and anxiety influence functioning of the immune system and could lead to greater vulnerability to infections and disease.

The aim was to determine which students had debilitating anxiety associated with oral examinations and whether their performance differed significantly from performance in other cognitive and behavioral evaluations obtained in a junior clerkship. Students with debilitating anxiety had lower interest in the clerkship, less favorable attitudes, less internal locus of control, lower self-esteem, and less favorable evaluations by peers.

Individuals with diabetes on insulin for at least one year, were studied in regard to styles of coping with stress and metabolic control of their disease. Those in good control used self-con trolling and avoiding styles of coping; whereas, those in poor control more often used fight/anger reactions to stress. Findings suggest self-controlling behaviors might be enhanced and anger/fight reactions to stress reduced through self-management programs. Such programs would be designed to increase self-efficacy through setting of achievable short-term goals with rein forcement of positive behaviors, modeling of successful coping styles, and attention to relaxation and stress reduction techniques.

Summary.-Junior medical students choosing surgery, internal medicine. or family practice as careers were studied in regard to whether their concepts of themselves as physicians were correlated wich their attitudes toward professionals in these three careers. Those who chose surgery and family practice had significant correlations between Me-As-A-Doctor and attitudes about professionals in those fields. This was not true for students choosing internal medicine and may reflect a diversity of roles in that profession. There has been considerable research on prediction of career preference or choice in medical education. Some of the correlates of choice have included sex ( 1 ) , premedical scientific orientation ( 2 ) , personalicy patterns ( 6), tolerance of ambiguity (3), research and education experience (7), self-perception (8), and learning styles (4). The hypothesis explored in this study of junior medical students was that their concepts of Me-As-A-Doctor would be closer to their evaluations of professionals in their chosen area of practice than their attitudes toward professionals in other medical specialties. Only students who said they had made a definire choice were selected for study (N = 67), and the three specialities wich large enough numbers of students were included: family practice, internal medicine, and surgery. Attirudes toward Family Practitioner, Surgeon, Internist, Psychiatrist, Pathologist, and MeAs-A-Doctor were measured with Osgood's Semantic Differential technique ( 5 ) . Ten bipolar adjectives (intelligent-unintelligent, egotistic-altruistic, friendly-unfriendly, bungling-skillful, influential-uninfluential, candid-deceitful, intolerant-tolerant, likeable-not I~keable, anxious-calm, and lucid-obscure) were selecred from the evaluative factor, raced on 7-point scales, and summed to represent attitudes toward these specialties. Ratings on Me-As-A-Doctor were correlated with ratings on each of the five specialty groups. These analyses were done separately for students who chose family practice, internal medicine, or surgery. Table 1 shows means and standard deviations For the three career preference groups as well as correlations for Me-As-A-Doctor with the five specialties. As seen, the hypothesis holds for those students selecting surgery and family practice but does not for those students preferring internal medicine. 'Requests for reprints should be sent to Bernard S. Linn, M.D., Veterans Administration Medical Center, 1201 N.W. 16th Street, Miami, Florida 33125.

Correlations of responses to a 31-item stress scale were factor analysed to determine areas of stress for 169 junior medical students. Factors describe Overwork, Learning, Future Concerns, Pressure from Self, Pressure from Others, Outside Pressures, and Interpersonal stresses rated in that order of magnitude. Most of the stresses diminished significantly after three months, except for Overwork which increased. Since this type of pressure is representative of demands which will be encountered in future practice, the junior year seems an appropriate time to help students learn to cope more effectively with pressures related to time constraints.

The aim was to determine if different doctors prescribed differently for older patients with the same diagnoses as patients who were younger. Five ambulatory-care physicians were selected randomly from a staff of 15. Over age 65 male patients ( N = 329) were compared with 889 younger patients in regard to symptoms and medications. Patient-rated symptoms differed by age of patients but not by the five physicians. Comparison of 20 types of medications showed seven differed by patient age but none by physician. Analysis of data in an age × physician grouping, however, showed that certain physicians treated older patients differently in regard to use of digitalis, tranquilizers and pain medications. The findings suggest remarkable similarity in symptoms for older patients seen by different physicians. While use of the medications did not differ between physicians for patients as a total group, they did differ when age of the patient was taken into account. The inconsistent use of certain medications for the old without support of symptoms and diagnoses raises questions about how the old are viewed as a group by some physicians.

There is increasing support for the concept that persons who live into extreme old age are biologically elite. In this study, self-health assessments and eight objective health indices were studied in 286 elderly living in the community. Self-health was measured on a 5-point scale ranging from very poor to excellent. Objective health measures included impairment and disability rating; number of physician visits, days in bed, and days hospitalized for the prior six months; diagnoses; medications; and operations. The sample was divided by good (70%) and poor (30%) self-health assessments and by old (age 65–74, 66%) and very old (75 and over, 34%). The objective health measures were compared between these groups in a multivariate analysis of variance. Number of medications was less and surgical operations more for the very old than old. All but two of the eight objective measures of health (surgery and days in bed) differentiated significantly between self-assessed health groups. It therefore seems that age, by itself, is a poor indicator of health among the elderly; however, how the elderly view their own health may be an extremely useful clinical guide as to their overall health status.

The purpose was to compare psychological status between high and low stress groups in Anglo, Black, and Cuban cultures. High and low stress groups were significantly different particularly in regard to symptoms of somatization, depression, and anxiety. Cultural groups differed significantly on social participation and social dysfunction. Controlling for locus of control decreased some of the differences between high and low stress and controlling for social class diminished some of the differences in adjustment between cultures. The fact that symptoms differentiated high and low stress groups similarly in each culture suggests that reactions to such stresses as death and illness, which occurred frequently among these older persons, may be a common response that transcends cultural differences.

Split-thickness grafts of skin of satisfactory quality were found to be more difficult to obtain from rabbits than from animals of other genera. An explanation for this was sought in the histology of the skins of the various experimental animals. Density of hair was judged to be the factor most critical for ease or difficulty in procuring satisfactory split-thickness grafts of skin, and a cluster of histologic characteristics of skin seemed to have meaning for taxonomic classification. Silver's dermatome was found to be the best instrument for taking grafts from all subjects.

Beliefs about causes of cancer were studied in 120 patients with late-stage cancer and compared with beliefs of non-cancer patients matched for age, sex, and hospitalization. Cancer patients consistently had less strong beliefs about causes of cancer than did the other groups, even when causes such as smoking and having pulmonary cancer were probably associated with the development of their disease. Although some correlates of beliefs were found in cancer patients' personal and social background, these were generally of minimal levels of statistical significance. Those who had been diagnosed longer believed cancer was more often inherited. The non-cancer patients' beliefs were similar to those found in a large survey of the general population. It is likely that cancer patients need to defend themselves against self-blame as a means of coping with a terminal illness.

Self-assessed health and physician-rated impairment were compared for 174 Anglo, black, and Cuban elderly medical outpatients. Level of disability was also recorded by the interviewer. A minimal correlation was found between patient and physician-rated health. Self-assessed health and level of functioning were associated significantly in each of the 3 cultures. The way patients perceived their health and functioned differed by culture, but impairment ratings of the physician did not discriminate among cultures. It seems likely that nonmedical factors may explain cultural differences in perception of health as well as how these perceptions influence ability to perform everyday activities of living. The patients' estimates of health appear to be an important factor in their overall health status, which physicians could use to augment their assessments of impairment. Since self-assessed health relates to level of functioning and to the way the elderly react to an illness, it can be seen as a useful component in evaluating health and predicting patient behavior.

Little attention has been given to selecting a set of variables that define the dimensions of health or illness as a totality. This could have utility, particularly in the field of aging, for better assessment of the person's residual capacity and proper selection of treatments or services. Generally, scales are assembled to measure discrete areas of physical, mental, and social functioning without regard to any overlap between scales or items in the over-all association with some dependent variable. Reducing these to the ones that uniquely contribute to outcome is a desirable research goal. Even within the area of physical health, there are dimensions such as impairment and disability (functional status). Impairment is usually defined as organic pathology judged by a physician, whereas disability or functional status can be determined through observation of the person's self-care ability in such areas as eating, dressing, toileting, bathing, and ambulation. However, some people who are quite impaired continue to function at rather high levels and some nor so organically impaired may exhibit poor functional states. Most medical research has relied on measurement of functional status (since these ratings are based on more objective observation) rather than on estimates of degree of impairment to organ systems. Yet, there seems to be justification for both types of assessment. The purpose of this study was to determine the relationship between these two areas in the prediction of mortality. Males (n = 714) averaging 67 yr. were rated by their physicians in the hospital on a 13-item impairment scale (1) and by a ward nurse on a 16-item functional status scale (2), just before their transfer to community nursing homes. Follow-up 6 mo. later showed that 221 patients (31%) had died. Both stepwise multiple regression and stepdown discriminant function analyses were used to identify the predictors in terms of unique contribution and accuracy in classification. Scales were first analysed separately and then all 29 items were combined. Although 8 functional items discriminated between living and dead at a univariate level. only 5 uniquely predicted mortality. All 16 functional scores had an accuracy in classification of 68%. Five of the 13 impairment items were statistically significant at a univariate level and also contributed significantly as predictors. All 13 impairment items had an accuracy in classification of 74%. Using the combined 29 items, 6 variables (4 impairment and 2 function) emerged as accounting significantly for 80% of the predictable variance in mortality and achieving an accuracy in classification of 77%. At the .O1 level, vascular, respiratory, and neurological impairment and need for assistance with earing were identified. Degree of mental depression and impairment ratings on hepatic system were associated with mortality (P < .05). Our data suggest that combining selected functional status ratings with estimates of impairment led to better classification of clinical condition and predictors of outcome.

We examined satisfaction with burn care in 1,418 patients treated in 20 community hospital emergency departments. Lower levels of satisfaction correlated with a poorer process of care measured by number of physician deviations from burn care algorithms. The less severely burned and older patients had higher degrees of satisfaction. The more satisfied the patient, the greater the compliance with medical regimens and the better the patient outcomes as measured by days lost from work and perceived disability. If better patient attitudes relate to process of care and in turn to increased compliance and better outcome, then patient satisfaction is an important part of an overall evaluation of emergency department care.

The role of self-assessment of health was compared in 150 diabetic and nondiabetic male outpatients matched for age and race. Data were collected (1) directly from the patient at intake into the study and then again in 2 mo, (2) from the medical record, and (3) from the physician. Variables included background information, symptomatology, satisfaction with care, attitudes, use of medical facilities, medications, diagnoses, compliance arid physician's estimate of patient's compliance, current health, and whether improvement was expected. A 2 × 2 factorial design was used to compare diabetic and nondiabetic patients with good and poor perceptions of health. Diabetic patients who viewed their health as poor had significantly more clinic visits, greater symptomatology, and were less satisfied with the doctor-patient relationship. The physician's rating of health did not confirm that this group actually had poorer health than the diabetic patients who perceived their health as good, and there was no difference in number of diagnoses between these groups. Data suggest that self-health perception is an important variable in diabetic patients. For those who see their health as poor, there may be a lack of concordance between patient and physician, which may result from these patients being more negativistic and difficult to treat. This may represent a group for whom a different type of treatment approach is needed.

This study concerns the relationship between age and injury in 1,297 patients with recent burns who were admitted variously to 73 hospitals. Older patients showed a significantly higher proportion of severe injuries than did middle-aged and younger groups. Even after adjusting for the severity of injury, the morbidity and mortality were higher in the over-65 group. These poorer results did not seem to be entirely accounted for by older age and greater severity of the burn. Surgical treatment such as debridement and grafting was used no more frequently in older patients than in younger ones, even though the greater severity of the burns would normally be expected to require more operations. The fact that older patients had more complications could have influenced physicians in their surgical decisions. Also, the attitude that the elderly are less able to tolerate surgical procedures may have played a role in the use of less aggressive treatment in relation to the severity of the burn.

Third year medical students (N=179) were tested on attitudes about the elderly and treating the old. Other variables such as age, sex, career preference of the students, knowledge about aging in the curriculum, experience with the elderly, and age definition of old were used to predict attitudes about the elderly and about their care. The best predictor of both attitudes was a more favorable view of geriatrics as a profession. Attitudes toward pediatrics was also a predictor. Those who selected family medicine as a career preference had more favorable attitudes about the elderly. Greater knowledge about aging was a predictor of positive attitudes toward the elderly and their care. Increasing knowledge about aging may be a practical way to shape more positive attitudes in medical students. The best way to increase knowledge may be through exposing of students to healthy elderly or those with short-term health problems rather than long-term care only. Attitudes about geriatrics also could be influenced by f...