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This article focuses on how cancer site, age and comorbid conditions of elderly women cancer patients influence their reporting of symptoms; how these variables in turn impact their physical functioning and mental health; and whether there are differences according to the site of the cancer. For the study, a sample of 299 women, age 65 and above, was selected from an on-going longitudinal study of cancer patients recruited from six cancer treatment centers in Michigan and who were recently diagnosed with breast, colon or lung cancer. Age, comorbidity and cancer site were predictors of symptom severity. Age, comorbidity, symptom severity and cancer site were significant predictors of physical functioning, while mental health scores were only predicted by symptom severity. Lung cancer patients reported greater losses in physical functioning than either breast or colon cancer patients, however there were no significant differences in average mental health scores among the three cancer sites. A systematic and comprehensive approach to self-care management of symptom distress provided by oncologists and other health care professionals may enable patients, especially elderly patients with comorbid conditions, to successfully alleviate or reduce the impact of symptoms on their lives. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: getinfo@haworthpressinc.com] KEYWORDS. Women, geriatric, cancer, physical functioning, mental health

Background: Lung cancer is a major health problem throughout the world. It is the leading cause of cancer-related death in men and women in the USA, with a 5-year survival rate of only 14%. It has been hypothesized that variables such as physical and social functioning, cancer-related symptomatology, comorbid conditions, cell type, and treatment are valid predictors of the psychological response to a diagnosis of lung cancer. Methods: As part of a larger longitudinal study, 211 patients, 65 years of age or older, with an incident diagnosis of lung cancer, were recruited from 23 sites within a midwestern state. Repeated measures analysis of variance techniques were used to analyse how age, gender, comorbid conditions, stage of disease, cell type, as well as the time-dependent variables symptoms, physical functioning, social functioning, and treatment predict depressive symptomatology at four assessments over the first year following diagnosis. Results: Social functioning (p <0.0001), symptoms severity (p <0.0001) and radiation treatment (p =0.017) were significant predictors of depressive symptomatology, with more symptoms and more restricted social functioning generally corresponding to higher levels of depressive symptomatology. Patients who had not received radiation treatment were more depressed than those who had received treatment at least 40 days prior to the interview. Conclusions: At a clinical level of patient care, these findings mandate early identification of psychosocial difficulties experienced, an individualized symptom management plan and the application of other interventions, such as information giving, reassurance and referral to other resources. Copyright © 2002 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

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The present study investigated two aspects of the sequelae of recent bereavement among family caregivers following the death of their cancer patient: (1) the extent to which depressive symptomatology among family caregivers measured following the death of their patient could be predicted by their levels of depressive symptomatology in the months prior to death, their physical health, the setting in which the patient's death occurred, patient age, gender of the caregiver, consanguinity, financial stress, social support from family and friends during the terminal stage, impact of caregiving activities on caregiver's daily schedule, caregiver optimism, perceived esteem attributed to caregiving, the time between the prebereavement assessment and death, and the time between death and the postbereavement assessment; and (2) whether these same explanatory variables could successfully differentiate those bereaved caregivers whose psychological health improved during the first 3 months following bereavement from those who did not improve. A sample of 114 family caregivers of cancer patients were surveyed for approximately 3 months before and 3 months after the death of their patient. A multivariate analysis of variance using the regression approach was undertaken to determine the primary predictors of postbereavement depressive symptomatology. In addition, a logistic regression analysis was used to attempt to predict those caregivers whose depressive symptomatology would improve during the postbereavement period. Critical factors in determining levels of postbereavement depressive symptomatology were caregiver optimism, prebereavement depressive symptomatology, and levels of social support from friends. Caregiver optimism and prebereavement depressive symptomatology were important in predicting whether caregivers' depressive symptomatology would improve or not. Physicians must be aware that if the social history of a patient reveals that he/ she is anticipating or has recently experienced the loss of a family member for whom they were the primary caregiver, this information may be critical in determining whether the illness behavior exhibited by the patient has medical or psychosocial origins. [ABSTRACT FROM AUTHOR]

Colorectal cancer constitutes a major health problem for elderly patients. The disease and its stage, treatment, and attendant symptoms can have significant negative impact on the mental functioning of these patients. As part of a larger longitudinal study, 158 patients 65 years of age or older with an incident diagnosis of colorectal cancer were recruited from 23 sites within a Midwestern state. Random effects regression analysis techniques were used to analyze how age, gender, race, presence of a family caregiver, co-morbid conditions, stage of disease at diagnosis, and the time-dependent variables marital status, employment status, symptoms, physical functioning, social functioning, and treatment predict depressive symptomatology at four assessments over the 1st year following diagnosis. Gender, race, co-morbid conditions, physical functioning, social functioning, and symptoms were significant predictors of depressive symptomatology over the four waves of the study. Female patients, African Americans, and patients with two or more co-morbid conditions exhibited more depressive symptomatology. Both more symptoms and more restricted physical and social functioning corresponded to higher levels of depressive symptomatology. At a clinical level of patient care, these findings mandate early identification of psychosocial difficulties experienced, an individualized symptom management plan and the application of other interventions, such as information giving, reassurance and referral to other resources, with particular attention to African American and female patients.

Purpose: To determine whether osteopathic manipulative treatment (OMT), a key identifiable feature of osteopathic medicine, is becoming a "lost art" in the profession, and whether the long-term evolution of osteopathic medicine into mainstream medicine and particularly specialization has had a similar impact on the use of OMT by family practitioners and specialists., Method: In April 1998, a two-page questionnaire was mailed to 3,000 randomly selected osteopathic physicians in the United States to assess factors affecting their use of OMT. Descriptive statistics, linear regression analyses, and analysis of variance techniques were used to test for differences., Results: The response rate was 33.2%. Over 50% of the responding osteopathic physicians used OMT on less than 5% of their patients, and analysis of variance revealed OMT use was significantly affected by practice type, graduation date, and family physicians versus specialists. For specialists, 58% of the variance regression was attributed to barriers to use, practice protocol, attitudes, and training, whereas for family physicians, 43% of the variance regression was attributed to barriers to use, practice protocol, and attitudes. More important, the eventual level of OMT use was related to whether postgraduate training had been undertaken in osteopathic, allopathic, or mixed staff facilities, particularly for osteopathic specialists., Conclusions: The evidence supports the assertion that OMT is becoming a lost art among osteopathic practitioners. Osteopathic as well as allopathic medical educators and policymakers should address the impact of the diminished use of OMT on both U.S. health care and the unique identifying practices associated with the osteopathic profession.

Purpose: The purpose of this study was to help identify factors to assess which elderly patients are likely to experience problems with physical and psychological functioning in association with cancer or its treatment., Description of Study: A study was undertaken with a sample of 420 patients with cancer who were between the ages of 65 and 98 years and had received an incident diagnosis of breast, colon, lung, or prostate cancer. An analysis of covariance technique was used to determine how cancer site, treatment type, stage of disease, gender, age, comorbidity, symptom severity, and pre-diagnosis levels of physical functioning were related to physical functioning deficit, and how all of these in turn influenced patient depressive symptomatology., Results: Pre-diagnosis physical functioning, symptom severity, and days since surgery were significant predictors of physical functioning deficit. Patients who had been treated only with surgery experienced greater physical functioning deficits than did patients who had received both surgery and adjuvant therapy. This apparent anomaly was partly explained by the time interval from surgery to interview. Higher levels of symptom severity, lower levels of prior physical functioning, and greater physical functioning deficits all predicted higher levels of depressive symptomatology., Clinical Implications: In the care of elderly patients with cancer, it is important for healthcare providers to consider the pre-diagnosis levels of physical functioning of patients with cancer to understand and anticipate the physical and psychological consequences of cancer and its treatment. Equally important is the proper management of patient symptoms in maximizing both the physical and psychological quality of life.

A questionnaire was mailed to 2000 randomly selected osteopathic physicians to assess use of osteopathic manipulative treatment (OMT). In all, 1055 responses were summarized for the study. The contention is supported that OMT is being used less and less by practicing physicians. Only 6% of the respondents treated more than 50% of their patients with OMT, and nearly one third used OMT on less than 5% of their patients. A progressive de-emphasis of OMT use correlated with more recent graduation from osteopathic medical colleges. Thirty-eight percent of the variance regarding OMT use was attributed to two factors: barriers to use, and OMT protocol used. Perceptions by physicians of insufficient OMT training were not predictive of decreased use of OMT. Significantly more OMT was used in solo practice as opposed to other settings. The results present a wake-up call for the osteopathic medical profession. The profession must strive to remove barriers that preclude OMT use by justifying to policymakers, health professionals, and the public the cost-benefits of OMT in holistic healthcare.

The purpose of this study was to develop a quality of life instrument for long-term female cancer survivors. A factor analysis (n = 188) of 34 items resulted in the Long-Term Quality of Life (LTQL) instrument. Internal consistency was high for the four subscales: somatic concerns (alpha = .86), spiritual/philosophical views of life (alpha = .87) fitness (alpha = .92) and social support (alpha = .88). These four factors are congruent with Ferrell's four theoretical domains of quality of life developed for women with breast cancer. Content validity was supported through interrater agreement of subscale items. Significant correlations between the LTQL and the CaRES, an established measure of quality of life, support the concurrent validity of the LTQL. Construct validity was supported by differential subscale scores according to demographic and health status data. Although the LTQL retained all of Ferrell's four domains of quality of life (physical, psychological, social, and spiritual) within one instrument, individual items reconfigured to suggest an overlapping of domains for the long-term female cancer survivor. This research suggests that the LTQL warrants further testing and may be a useful measure of quality of life in long-term female cancer survivors.

Purpose: This study investigated whether family caregiver reports of cancer patients' symptoms (specifically: nausea, pain, poor appetite, insomnia, fatigue, cough, constipation, and diarrhea) were in concordance with patient reports, and whether variables such as patient depression, caregiver depression, caregiver optimism, and perceived impact of caring on caregiver health would explain discrepancies in patients' and caregivers' reports., Description of Study: A sample of 216 patients and their family caregivers was recruited through six community-based cancer treatment centers located in lower Michigan. Data on the study variables were obtained from two separate, multifaceted survey instruments completed by the patients and their family caregivers, respectively., Results: The rate of agreement between patient and caregiver was highest for fatigue and lowest for insomnia, whether the entire sample, male caregivers, or female caregivers were considered. Female caregivers had a higher percentage agreement with their patients, and a higher level of association between patient and caregiver responses than male caregivers, uniformly for all symptoms. The overall accuracy of caregiver reports was approximately 71% and seemed to be relatively independent of the number of symptoms reported by the patient., Clinical Implications: Health professionals caring for patients with cancer must recognize that patient and caregiver reports of patient symptoms may not always be in agreement. Awareness of variables that may cloud family caregivers' observations is needed, so that accurate symptom reporting occurs, and appropriate management can be initiated to enhance quality of life for the patient as much as possible. It is also important for health professionals to educate family caregivers about the nuances of symptom distress presentation and to teach caregivers techniques to elicit accurate information so that timely, appropriate palliative management can be initiated.

Background: A study was designed to investigate the knowledge, attitudes, and preventive efforts with regard to exposure to environmental tobacco smoke (ETS) among a sample of urban African American children and adolescents., Methods: A sample of 675 students enrolled in grades 5 through 12 in an urban public school district located in the greater metropolitan area of Detroit, Michigan, was surveyed., Results: Smoking rates among students were higher if someone else in the home was a smoker and lower if there were no other smokers in the home. Forty-eight percent of the students reported that their fathers smoked, while 46% reported mothers who smoked. In each of the areas knowledge, attitudes, and preventive efforts, elementary students scored highest and middle school students scored lowest. Attitude scores were higher if the mother or father was a nonsmoker, and nonsmokers scored higher than smokers on knowledge, attitudes, and preventive efforts. Students' preventive efforts were significantly predicted by their knowledge, attitudes, and gender, while their attitudes were in turn predicted by their knowledge, gender, school level, and smoking status and by the proportion of their friends who were smokers. Students' knowledge was significantly predicted by their gender and school level and by the proportion of their siblings who were smokers., Conclusions: It is apparent that many of the African American students surveyed in this study experience significant exposure to ETS, particularly in the home. As is evident from the literature, this has implications for the long term health of these youngsters. Health education and promotion efforts should be directed not only toward the students themselves, but should also address the smoking behavior of parents and others in the home environment.

The results of a survey on various aspects of quality of life for 191 women who were long-term cancer survivors are presented. We explored six areas--somatic concerns, health habits, psychological state, sexual satisfaction, social/emotional support giving, and philosophical/spiritual view--and whether differences existed in them among the women on the basis of age, educational level, income level, length of survival, location of residence (urban, suburban, or rural), cancer site, and whether a recurrence of the cancer had been experienced. Generally, the women reported good psychological states and relative satisfaction with their sexual lives. However, women who had experienced a recurrence of their cancer, were longer term survivors, or suffered from breast cancer all reported higher levels of somatic concerns. Women with higher levels of education or income and those who had had a recurrence of their cancer indicated a greater willingness to provide social and emotional support to other women newly diagnosed with cancer. Women who had a positive philosophical/spiritual outlook were more likely to have good health habits and be supportive of others. There was no statistically significant variation among the women in either health habits or psychological state for any of the factors considered.

This research examined, in a sample of N = 150 cancer patients and caregivers, the relationships among patient's physical functioning, depression and symptomatology, impact on caregivers' schedule and health, and caregiver depression, as well as the changes in these variables over time. A measure of caregivers' optimism was also included in the analyses. The disposition of caregiver optimism was a strong predictor of caregiver reactions to the burdens of caring, and seemed to play the role of a personality characteristic which was for the most part independent of patient variables. Levels of patient symptoms and their change over time were both strongly linked to change in patient immobility over time. Patient symptoms, and to a lesser degree patient immobility, were strong predictors of patient depression which in turn predicted caregiver depression. In general, as patients' needs subsided, caregivers perceived fewer reactions to the burdens of caring. Caregivers' reactions were clearly distinct, and were influenced differently by different patient variables. However, all three types of caregivers' reactions were influenced by caregivers' optimism. Oncologists, nurses and other health care professionals involved in the care of patients with cancer should consider this potentially important personal characteristic in the assessment of need for and the development of interventions designed to assist patients with cancer and their family caregivers.

Background: During the course of cancer treatment and as the disease progresses, symptoms may worsen and physical status may deteriorate. The interaction of age, symptoms, and nearness to death on the physical and mental health of patients and family members has not been examined. The research questions in this paper focus on how age and survival status influence the frequency and severity of patients' symptoms and dependencies in functioning. The impact of patient age and survival status on family depression, schedule, and health also are explored., Methods: Cancer patients in treatment and their caregiver dyads (n = 208) were followed for 12 months. Survival status was measured by those who survived the year, those who died within 6 months, and those who died between 6 and 12 months. Measures used included frequency and severity counts of patient symptoms, functioning (activities of daily living [ADL] and immobility), depression, frequency of others' assistance to caregivers, and caregiver reactions to care. Analysis of variance was applied to test for significant differences according to age and survival status., Results: Symptoms did vary significantly by survival status; however, age demonstrated no independent effect on patient variables including: symptom severity, patient depression, and ADL or immobility. When controlling for symptom severity and age, survival group had no effect on ADL status. For immobility, survival status continued to have a direct impact. Survival status does not influence dependencies in ADL but is related directly to losses in mobility. Significant differences occurred by survival groups for caregiver depression, caregiver reactions, and patient assistance., Conclusions: Strategies for assisting patients and families to deal with immobility are important. Family members require assistance for their distress as patient status deteriorates.

We investigated whether attitudes, intentions, and practices regarding breast cancer screening by mammography and clinical breast examination could be positively influenced through a brief educational intervention administered to women employees at diverse work sites. The educational intervention involved the mailing of American Cancer Society brochures that discussed breast cancer screening and contained guidelines on the recommended frequency for each screening modality according to age. Effects of the intervention were measured through pre/post questionnaires. The results were positive for the entire group of women who participated, as evidenced by their increased perception of the importance of mammography and clinical breast examination and of the priority of getting a mammogram regularly, their decreased perception of mammography as an uncomfortable procedure, and the increased frequency of discussions of breast cancer screening at work. Employers, particularly large corporations and agencies, must realize that by introducing effective work site cancer screening programs they not only fulfill their social responsibility to contribute to their employees' health, but also achieve reductions in health care costs.

This article explores long-term survivorship (5 years or longer) through focus group discussions with women who have experienced breast cancer. The data revealed four major themes; integration of the disease process into current life, change in perspective, and unresolved issues. These data begin to shed light on the issues of breast cancer survivors and can provide a basis for development of a quantitative instrument to be tested with larger populations.

This study investigated, in a convenience sample of 279 patients with cancer, the trajectories of symptoms and loss of physical functioning over time, the relationships of these variables to age and co-morbidity, and differences existing according to cancer site (breast, lung, colorectal/gastrointestinal, urinary/reproductive, lymphoma, and "other"). The patients were surveyed twice; at intake (wave I, n = 279) and 6 months later (wave II, n = 160). Findings indicated, at wave I, that age and co-morbidity were significantly correlated, and loss of physical functioning was associated primarily with symptoms and, to a lesser degree, with age. Loss of function scores varied significantly according to cancer site, with higher levels for patients with lung cancer and lower levels for patients with breast or colorectal/gastrointestinal cancer. The most frequently occurring symptoms were fatigue, insomnia, pain, and nausea. Average levels of symptoms and loss of physical functioning were lower at wave II, indicative of a possible treatment-related effect (at wave II, a smaller percentage of patients had recently undergone treatment). Although co-morbidity was only modestly correlated with symptoms and loss of function for the total sample, it was highly correlated with both symptoms and loss of physical functioning for the younger patients (those younger than 60 years of age). The significant link that was identified between symptoms and loss of physical functioning has important implications for physicians, nurses, and other healthcare providers caring for patients with cancer as they deal with symptom management and quality-of-life issues.

The American Cancer Society recommends a regimen for breast cancer screening that includes mammograms, clinical breast examination, and breast self-examination. Compliance with breast cancer screening guidelines has been linked to a number of barriers and facilitators. These barriers and facilitators seem to lie within the cognitive framework and generalized beliefs of women, and in the situational contexts in which they lead their lives. A comprehensive study was designed to investigate variables related to breast cancer screening behaviors (breast self-examination, mammography, and clinical breast examination) of working women > or = 35 years of age at their worksite environments. A factor analysis identified similar sets of composite variables related to each of the screening modalities, and a discriminant analysis was performed for each screening technique to identify those variables that were most significant in predicting compliance with screening guidelines. The variables discomfort, perceived efficacy, and desire for control over health were significant for all three screening behaviors. Perceived importance was identified as a fourth variable for mammography and clinical breast examination, and lack of knowledge was a fourth variable for breast self-examination. Effective breast cancer screening programs involve all three screening techniques. In the design of education and intervention programs at worksites, it is critical to emphasize the commonalities of the variables that emerged in this study as important for each screening technique. Health-care professionals who implement such intervention programs need to explore and bring into the open these common barriers and facilitators to maximize working women's compliance with breast screening guidelines.

In this article the paths among cancer patients' physical and mental health and the reactions and mental health of their family caregivers were examined. Data for these analyses came from a cross-sectional sample of cancer patients who were recruited through ambulatory outpatient chemotherapy units, and their family caregivers. Patients' depression was explained largely by their symptomatology and, to a lesser extent, by loss of mobility. Patients' physical limitations impacted caregivers' daily schedules but not their physical health. Patients' levels of depression were related to those of their caregivers. However, caregivers' optimism proved to be a significant predictor of their mental health and reactions to caregiving.

We investigated urban, married Nigerian women's knowledge of the health risks associated with secondary tobacco smoke, their attitudes toward this problem, and the preventive efforts they took when they or their children were exposed involuntarily to secondary tobacco smoke. Two hundred forty-nine women were surveyed with a structured, written questionnaire. The results indicated that these predominantly well-educated and professionally employed Nigerian women had only a fair knowledge of the adverse health effects of exposure to secondary tobacco smoke. Although their attitudes toward exposure to secondary tobacco smoke were generally quite good, they were reluctant to take preventive measures in public. The most prominent factors relating to knowledge and attitudes were age, educational level, and smoking status. Attitudes proved to be a stronger predictor of preventive efforts than knowledge.

The following article on group practice governance is followed by four short commentaries from various MGMA members across the country as well as the director of the MGMA Consulting Service. This article, and the commentaries that follow it, are intended to stimulate your thinking regarding the governance structure in your group.

This study investigated knowledge, attitudes, and preventive efforts of Malaysian college students regarding health risks associated with passive smoking, as well as possible directions for intervention and health education programs. Students responded anonymously to a structured written questionnaire. Statistical analyses were conducted to examine (1) differences in knowledge, attitudes, and preventive efforts between smokers and nonsmokers and between men and women; (2) the relationship between smoking by parents, siblings, and friends, and students' knowledge, attitudes, and preventive efforts; and (3) relationships between knowledge, attitudes, and preventive efforts. Peer groups and siblings had a substantial influence on students' attitudes toward passive smoking and their preventive efforts when exposed to passive smoke. A regression analysis revealed a statistically significant linear dependence of preventive efforts on knowledge and attitudes, with the attitude component playing the dominant role. This research suggests that educational efforts on passive smoking, directed toward young college students in developing countries such as Malaysia, should concentrate heavily on changing attitudes and reducing the effects of peer group and sibling influences.

The purpose of this work was to elucidate the genetic fine structure of the central portion of mouse chromosome (Chr) 2. Seven Chr 2 congenic mouse strains [B10.PA(L)-pa we un at, B10.PA(L)-pa Aw, B10.PA(L)-we un at, B10.PA(J)-pa a, B10.FS-we Aw, B10.C-we Aw, and B10.YBR-a] were produced. Breeding studies were carried out using strains B10.PA(L)-pa we un at and B10.LP-H-13b to accurately determine the recombination frequencies between marker genes pa and we (1.9% +/- 0.3), we and un (8.8% +/- 0.5), and un and at (4.5% +/- 0.4) of strain B10.PA(L)-pa we un at. These strains and other Chr 2 congenic strains were typed for immunologically defined loci using monoclonal antibody (mAb) C23 reactive with the gene product of B2mb T-lymphocyte clone C1 reactive with the gene product of H-3a and H-3c, and lymphocyte clone H1.8 reactive with the gene product of Hd-1a. B2m and H-3 typing located a recombinational event separating [pa B2m H-3] from we (the order of bracketed genes is not known). Hd-1 typing indicated that Hd-1 maps distal to [H-42, H-44] and proximal to un. The gene order [pa, B2m, H-3], we, [H-42, H-45], Hd-1, un, H-13, at, with H-44 mapping centromeric to Hd-1, is indicated by the data.

This study investigated whether knowledge and attitudes of Malay college students regarding smoking can be positively influenced by educational intervention. The experiment included a pretest to assess the students knowledge and attitudes regarding smoking, a lecture on the health risks associated with smoking, and a posttest given six weeks later to assess whether any changes had occurred. A profile of the typical Malay student smoker was also elicited. Twenty-seven percent of the study population were smokers. Of the men in the sample, 44% were smokers, while less than 4% of the women were smokers. T-tests indicated that knowledge of the health risks associated with smoking was significantly improved for most groups, while attitudes towards smoking were essentially unchanged.

Medical education has been described as an extremely intense and stressful experience. First- and second-year osteopathic medical students (N = 225) were surveyed to assess their perceptions of their own physical and psychological well-being, mechanisms they use to combat daily stress, their leisure activities, and the health-promoting behaviors in which they engage. This study found perceived physical and psychological well-being to be quite good, with more than 82% of respondents reporting "good" or "excellent" in both areas. Only 11% of students reported using tobacco, and the mean number of alcoholic drinks consumed per day was less than one. Most of the students reported that they exercised regularly and that they did not view sleep deprivation as a significant problem; however, the students did perceive the stress attributed to the demands of medical school as quite high. The primary coping behaviors they used in response to stress included humor, leisure, exercise, and social activity. Smoking, using medication, and using illicit drugs were infrequently indicated as coping strategies. From a comprehensive perspective, student perceptions indicate that they are effectively coping with the stresses of medical education.

As part of an introductory course on the doctor/patient relationship, a teaching unit was designed which emphasized to students that values, biases and prejudices may affect their behaviors when interacting with patients. The unit included lectures on values, specific readings and a survey component which challenged students' value systems and provided them with the opportunity for exploration of hidden biases and prejudices. The survey component involved a series of trigger vignettes depicting five patients interacting with the same (actor) physician. On a rating instrument, students were asked to rate each patient on ten positive and ten negative characteristics, identify the characteristic which best described each patient and select the patient they would most like to treat. The survey was administered to an incoming class of medical students at the orientation session to a course on the doctor/patient relationship. Students were asked to keep a copy of their ratings and bring it to the small group discussion session on physician values. The data were collected, and a class composite developed and submitted to the course instructors prior to the discussion and processing sessions on values. Specific instructions on how to utilize the materials were provided. The class composite, which revealed that students have biases, served as a focus for discussion and facilitated students awareness that unconscious stereotypes exist in their value systems. This teaching approach provided students with a beginning insight that biases and prejudices affect the doctor/patient relationship and the quality of care patients receive.

Ear pain is a common patient complaint in the practice of the primary care physician. Acute otitis media can affect a person of any age, although it is more often seen in children than in adults. The disease is usually caused by Streptococcus pneumoniae (Diplococcus pneumoniae) or Haemophilus influenzae. The differential diagnosis and subsequent treatment of otitis media is approximately the same for children and adults. First-line therapy usually consists of an antibiotic regimen of amoxicillin in combination with autoinflation exercises. In the case presented, a pharmacologic regimen was combined with osteopathic manipulation.

Effective recruitment and selection of physicians for a medical group practice depends on an objective assessment of the group's needs, philosophy, and organizational style, and an objective assessment of all candidates in relation to these factors. While emphasis in the hiring process is traditionally placed on a candidate's medical skills, there are other considerations which should be of equal concern in order to get the best possible organizational "fit": personality, family situation, behavioral style, and organizational philosophy and orientation. The utilization of behavior assessment methods borrowed from the applied management and behavioral sciences can enhance recruitment objectivity, member satisfaction, and retention.