Eugene C. Rich

Specialty differences in the 'July Phenomenon' for Twin Cities teaching hospitals.

This study evaluated changes over the academic year in the cost and the outcome of inpatient care to investigate the effect of housestaff experience in teaching hospitals. Patients with 25 preselected discharge diagnoses, admitted between January 1,1983 and December 31,1987 to acute-care, nonfederal, nonpediatric hospitals in the Minneapolis/St. Paul metropolitan area (total number available for analysis 240,467) were examined. Level of housestaff experience was measured as the number of days (1 to 365) into the academic year when the patient was admitted. Linear and logistic regression analyses were used to evaluate the different effects of experience on patient care in teaching hospitals compared with nonteaching hospitals. For the subset of patients with internal medicine diagnoses, the expected “July Phenomenon” was observed, with significant relative declines in diagnostic and pharmaceutical charges in teaching hospitals over the academic year. In contrast, surgery patients showed an increase in length of stay and various charges over the academic year in teaching hospitals. There were no meaningful effects of housestaff experience on mortality, operative complications, or nursing home discharge. These results indicate that housestaff training is significantly related to the use of hospital resources for inpatients, but that the degree and direction of the effects differ by specialty. These findings may reflect important differences among training programs in the process of physician education and its effects on patient care.

Call nights and patient care: Effects on inpatients at one teaching hospital

OBJECTIVE To determine whether the timing and number of patients admitted by internal medicine housestaff under a traditional call schedule affect the resource utilization and outcome of care for those patients. DESIGN Retrospective cohort study, using existing computerized records. SETTING University-affiliated 340-bed city/county teaching hospital. PATIENTS/PARTICIPANTS 22,112 patients discharged from the internal medicine service who had been admitted by an on-call first-year resident between January 1, 1980, and December 31, 1987. MEASUREMENTS AND MAIN RESULTS Admission after 5:00 PM was associated with decreased hospital length of stay (8.1%, p less than 0.0001), but increased total charges (3.1%, p = 0.007). The relative risk of inpatient mortality for patients admitted at night was 1.21 (p = 0.03). Patients of busier housestaff, as indicated by a larger number of on-call admissions, had lower total charges (1.7% decreased per admission) and no change in risk of inpatient mortality. While no linear relation was found between number of admissions and length of stay, analysis of nonlinear effects revealed that length of stay first rises, then falls as interns receive more on-call admissions. CONCLUSIONS The number and timing of admissions by on-call internal medicine housestaff are significantly related to length of hospital stay, total charges, and likelihood of inpatient mortality at one teaching hospital. These variations should be considered in planning the reform of residency training programs.

Call nights and patient care

Objective:To determine whether the timing and number of patients admitted by internal medicine housestaff under a traditional call schedule affect the resource utilization and outcome of care for those patients.Design:Retrospective cohort study, using existing computerized records.Setting:University-affiliated 340-bed city/county teaching hospital.Patients/participants:22,112 patients discharged from the internal medicine service who had been admitted by an on-call first-year resident between January 1, 1980, and December 31, 1987.Measurements and main results:Admission after 5:00 PM was associated with decreased hospital length of stay (8.1%, p<0.0001), but increased total charges (3.1%, p=0.007). The relative risk of inpatient mortality for patients admitted at night was 1.21 (p=0.03). Patients of busier housestaff, as indicated by a larger number of on-call admissions, had lower total charges (1.7% decreased per admission) and no change in risk of inpatient mortality. While no linear relation was found between number of admissions and length of stay, analysis of nonlinear effects revealed that length of stay first rises, then falls as interns receive more on-call admissions.Conclusions:The number and timing of admissions by oncall internal medicine housestaff are significantly related to length of hospital stay, total charges, and likelihood of inpatient mortality at one teaching hospital. These variations should be considered in planning the reform of residency training programs.

Housestaff Experience, Workload, and Test Ordering in a Neonatal Intensive Care Unit.

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.

The Effects of Scheduled Intern Rotation on the Cost and Quality of Teaching Hospital Care

We studied the effect of scheduled intern rotations on the cost and quality of inpatient care at one teaching hospital. For all discharges from the internal medicine service between 1980 and 1986, we identified 1,705 rotation patients and 3,141 no-rotation patients. Using linear or logistic regression analysis to controlfor baseline differences, we evaluatedfor the effect of rotation. We found that rotation was significantly related to longer length of hospital stay, b = 0.341 days, p = 0.C001, and higher hospital charges (for log charges, b = 0.053, p = 0.016. Hospital deaths, nursing home placements, and 30-day readmissions were not significantly related to rotation, p > 0.1. These results suggest that the systematic discontinuity induced by scheduled intern rotations may be another source of increased health care costs experienced at teaching hospitals.

Nursing Staff Perceptions of Quality of Life of Cognitively Impaired Elders: Instrumental Development:

This article describes the development and testing of the Cognitively Impaired Life Quality (CILQ) Scale to quantify differences in quality of life of severely cognitively impaired elderly patients as perceived by nursing caregivers. Two studies are reported. In study 1, focus groups with long-term care nurses were conducted using a vignette to elicit items most relevant to quality of life in cognitively impaired elders. These data were used to generate a 29-item version of the CILQ Scale. An exploratory factor analysis revealed a four-factor structure that included items related to social interaction, basic physical care, appearance of patient to others, and nutrition. In study 2, 67 nursing caregivers completed a shortened 14-item CILQ Scale using two actual patients as their reference. With these patients, the factor structure best resembled a three-factor solution including items related to social interaction, nutrition/comfort, and basic physical care.

Preparing generalist physicians: the organizational and policy context

A combination of financial, regulatory, and professional factors have led to a gradual but pronounced decline in generalist training and practice in the United States. This trend is likely to undergo dramatic reversal, however, as reflected by the diverse range of health care reform proposals incorporating incentives to promote generalist education and primary care practice. Considerable consensus has been reached by a number of professional organizations and public policy groups regarding the broad details of reform of generalist physician training, but key areas of controversy remain with important implications for academic medical centers. In addition, the generalist professional organizations, particularly those of family practice, general internal medicine, and general pediatrics, are being challenged to reconcile historic differences in the definitions and training of generalist competence. In this, the call for “retraining subspecialists” will both offer an opportunity and entail a risk. Finally, academic medical centers will need new organizational structures that can combine the distinctive intellectual traditions and the expertise of the generalist medical disciplines to develop new approaches to the education and practice of primary care.

Call nights and mortality

coupled with the complexion, focus, and training of the individual provider. However, data generated from an ongoing study of 270 consecutively evaluated patients to determine the incidence of shoulder pain disorders in my practice reveal the complaint of shoulder pain is third (14%), exceeded only by cardiopulmonary/vascular-related disorders (41%) and osteoarthritis (18%). This is in keeping with other investigators who note over 5% of our populat ion has significant shoulder pain each year and European studies showing that about 14% of the population developed significant shoulder pain.9-x Lastly, Chard attempted to discover the prevalence of symptomatic shoulder disorders in both a hospital and community-based study sample of 744 persons. 12, 13 He found a prevalence of 21%, corresponding to the observation that shoulder tendon pathology is found in 20% of persons examined postmortem, t4 I appreciate and, in part, agree with the keen observation of Dr. Feagin, but most importantly our prime goal of this extensive review is to help primary care providers sort out common shoulder complaints in a logical sequence and provide a current, well-referenced discussion on various available treatment methods.--DAVID L. SMITH, MD, StaffPhys# clan, Section o f General Medicine, Associate Professor o f Medicine, Oregon Health Sciences University, Portland, OR 97201

Teaching in a Physical Diagnosis Course: Identifying Faculty Characteristics and Motivational Factors.

It is often difficult to recruit faculty to teach in medical school courses. Faculty in one Department of Medicine were surveyed regarding their participation in the second‐year Physical Diagnosis course. Faculty most commonly cited enthusiasm for teaching students and personal satisfaction as reasons for participation. Faculty who did not choose to teach indicated they were too busy with other responsibilities. Release time from clinical duties was the most common motivating factor enhancing enthusiasm for teaching. Faculty who wanted to teach in the Physical Diagnosis course were more likely to be generalists, to be assigned to a teaching tenure track, to have spent less time at other institutions, and to value workshops on instructional methodologies. Understanding characteristics of faculty who are likely to teach and providing appropriate motivational support may assist course directors in recruiting preceptors.

Resident recognition of open-angle glaucoma: effects of an educational intervention

To test an educational intervention’s effect on improving detection of glaucoma by direct ophthalmoscopy, 14 medicine residents examined five patients, two with ophthalmoscopic changes of glaucoma and three with normal fundi. The residents observed a standardized slide/narrative educational intervention reviewing glaucomatous ophthalmoscopic changes and then re-examined the same patients eight to 12 weeks later. The intervention’s odds of improving residents’ diagnostic impression were significant (OR=2.2; 95% CI=1.3–36), with significant improvement in sensitivity (p=0.02) and a trend toward improved specificity. These findings confirm that the diagnosis of glaucomatous ocular changes on eye examinations by medicine residents can be improved with a brief educational intervention.