Jorge J. Gonzalez

Measuring the use of mammography: two methods compared.

Population studies often estimate mammography use using womens self-reports. In one North Carolina county, we compared self-report surveys with a second method--counting mammograms per population--for 1987 and 1989. Estimates from self-reports (35% in 1987, 55% in 1989) were considerably higher than those from mammogram counts (20% in 1987, 36% in 1989). We then confirmed 66% of self-reports in the past year. Self-reported use is more accurate regarding whether a woman has had a mammogram than when she had it, but self-reports accurately measure change over time.

Can Residents Be Trained to Counsel Patients about Quitting Smoking? Results from a Randomized Trial

Study objective:To evaluate the effectiveness of two teaching interventions to increase residents’ performance of smoking cessation counseling.Design:Randomized controlled factorial trial.Setting:Eleven residency programs, in internal medicine (six), family medicine (three), and pediatrics (two). Programs were located in three university medical centers and four university-affiliated community hospitals.Participants:261 residents who saw ambulatory care patients at least one half-day per week, and 937 returning patients aged 17 to 75 years who reported having smoked five or more cigarettes in the preceding seven days. Of the 937, 843 were eligible for follow-up, and 659 (78%) were interviewed by phone at six months.Interventions:Two interventions (tutorial and prompt) and four groups. The tutorial was a two-hour educational program in minimal-contact smoking cessation counseling for residents. The prompt was a chart-based reminder to assist physician counseling. One group of residents received the tutorial; one, the prompt; and one, both. A fourth group received no intervention.Measurement and results:Six months after the intervention, physician self-reports showed that residents in the tutorial + prompt and tutorial-only groups had used more counseling techniques (1.5–1.9) than had prompt-only or control residents (0.9). Residents in all three intervention groups advised more patients to quit smoking (76–79%) than did control group residents (69%). The tutorial had more effect on counseling practices than did the prompt. Physician confidence, perceived preparedness, and perceived success followed similar patterns. Exit interviews with 937 patients corroborated physician self-reports of counseling practices. Six months later, self-reported and biochemically verified patient quitting rates for residents in the three intervention groups (self-reported: 5.3–8.2%; biochemically verified: 3.4–5.7%) were higher than those for residents in the control group (self-reported: 5.2%; biochemically verified: 1.7%), though the differences were not statistically significant.Conclusion:A simple and feasible educational intervention can increase residents’ smoking cessation counseling.

Mammography and age: are we targeting the wrong women? A community survey of women and physicians.

To determine mammography use among women with a broad range of ages, the authors surveyed women aged 30 to 74 years and physicians practicing primary care in two eastern North Carolina counties. Twenty‐five percent of women in their 30s had ever had a mammogram, and 34% intended to have one in the coming year. From 45% to 52% of women in their 40s, 50s, and 60s had ever had a mammogram, and 55% to 57% intended to have one in the next year. Thirty‐seven percent of women aged 70 to 74 years had ever had a mammogram, and 40% intended to have one in the following year. Nineteen percent of physicians reported screening nearly all women aged 30 to 39 years, and 14% screened few women aged 50 to 74 years. Younger women were more worried about breast cancer than older women and assessed their risk as higher, attitudes that were generally associated with higher mammography utilization. These community surveys suggest that mammography use may be excessive among younger women; older women continue to be underscreened.

Clay Ingestion: A Rare Cause of Hypokalemia

Excerpt Hypokalemia induced by clay ingestion was reported in 1964 by Mengel and associates (1). They postulated that the potassium-trapping ability of some clays was responsible for the profound h...

How do women compare with internal medicine residents in breast lump detection? A study with silicone models.

Objective:Manufactured silicone breast models were used to compare the accuracy of breast examination by 300 women and 62 internal medicine residents.Design:The study design was cross-sectional.Setting:The study took place in two teaching-hospital general medicine clinics.Patients/Participants:Women were continuing care patients, ages 40 to 68, with no current breast complaint; 300 of 467 (66%) randomly selected women participated. Physicians were internal medicine residents with at least one-half day per week of ambulatory care practice; 62 of 64 (97%) participated.Measurements and Main Results:Sensitivity equalled the percentage of 18 lumps correctly detected in examination of six silicone breast models. Specificity equalled the percentage of six models examined without a false-positive detection. Women’s sensitivity was lower than physicians’ (40% vs. 58%), but their specificity was higher (66% vs. 52%). For both women and physicians, sensitivity varied according to lump size, hardness, and depth, with women’s sensitivity lower than physicians’ for each characteristic. Examination duration was the technique most strongly and consistently related to accuracy. Physicians spent more time examining models than did women (2.5 vs. 2.1 minutes per model). For both groups duration related positively to sensitivity (r=0.46, women; 0.55, physicians) and negatively to specificity (r=−0.35, women; −0.59, physicians). After adjusting for differences in technique, women’s sensitivity remained lower than physicians’, whereas specificity generally remained higher. The sensitivity of physicians with prior tactile experience with breast lumps was higher than that of physicians without such experience (60% vs. 51%, p=0.01). Too few women (2%) had prior tactile experience to permit analysis.Conclusions:Women’s and physicians’ breast examination accuracies differ, but for the two groups accuracies vary similary by lump characteristics and examination technique. Programs to improve breast examination should focus on specificity as well as sensitivity. Training that includes tactile experience may be important.

Iron Deficiency and Pica

Excerpt To the editor: We wish to address some of the points raised by Crosby (1) about iron deficiency and pica in the case we reported (2). After a full diagnostic work-up to exclude continued bl...