Kim Goldenberg

PERIODIC HEALTH EXAMINATION

Health maintenance and disease prevention guidelines of primary care internal medicine residency (PCIM) programs were investigated and compared with recommendations of major national organizations. Preventive screening data were requested from 134 PCIM programs; 120 (90%) responded. Methods included seminars/lectures by 73 (61%), health maintenance flow sheets by 58 (48%), and a variety of other formats by 25 (21%) programs. A comparison of recommended flow sheet items (n=33) from five major studies and 48 PCIM programs showed concordances (±SE) of 62% (±5) with high-priority items (n=15) and 33% (±4) with low-priority items (n=18). When an item’s frequency or age range was examined, however, concordances were much lower. From our analysis, fewer than half the programs routinely used prompting systems, such as flow sheets, in their ambulatory clinics, and there was little uniformity in the frequencies and age ranges for those items employed. The data suggest that major study recommendations were underused and underemphasized.Health maintenance and disease prevention guidelines of primary care internal medicine residency (PCIM) programs were investigated and compared with recommendations of major national organizations. Preventive screening data were requested from 134 PCIM programs; 120 (90%) responded. Methods included seminars/lectures by 73 (61%), health maintenance flow sheets by 58 (48%), and a variety of other formats by 25 (21%) programs. A comparison of recommended flow sheet items (n=33) from five major studies and 48 PCIM programs showed concordances (±SE) of 62% (±5) with high-priority items (n=15) and 33% (±4) with low-priority items (n=18). When an item’s frequency or age range was examined, however, concordances were much lower. From our analysis, fewer than half the programs routinely used prompting systems, such as flow sheets, in their ambulatory clinics, and there was little uniformity in the frequencies and age ranges for those items employed. The data suggest that major study recommendations were underused and underemphasized.

A successful academic-community partnership to improve the public's health.

As academic health center seek to address the changes in the health care system and in medical education, several approaches have been tried, some successfully, others not. The authors describe a successful approach that involves a close partnership between the health professions schools at two academic institutions, and agencies from the surrounding community. Specifically, the Center for Healthy Communities, begun in 1991 and formally institutionalized in 1994 in Dayton, Ohio, is a partnership among the schools of medicine, nursing, and professional psychology at Wright State University (WSU); the department of social work at WSU; the Allied Health Division of Sinclair Community College; more than 200 individuals (from grassroots neighborhood people to civic leaders); and 50 health and human services organizations in the Dayton area. The Center is recognized as a force for change in health professions education and health care delivery both in the community and in the academic settings. The authors explain how the Center was formed, list its goals (such as establishing strong partnerships among community educators and providers and educating students in the delivery of primary health care in the community), explain three principles that have been followed and that were crucial to the success of the Center (for example, individuals in the community must become empowered to capitalize on their strengths), and discuss the major difficulties that the community and the academic institutions encountered and strategies for meeting them (such as the importance of building trust and the importance of learning the needs identified by the community partners, not just those identified by the academic partners). The authors maintain that a successful community-academic partnership must be built on the foundation of community health development, a concept analogous to economic development, and that such a partnership can be a powerful tool for making a difference in the communitys health.

Impact of therapeutic guidelines on antibiotic use by residents in primary care clinics

Inappropriate use of antibiotics has been well documented for inpatient settings, but there are few studies in ambulatory patients. In a prospective study, the authors monitored the outpatient prescribing patterns of internal medicine residents and evaluated the effect of placing a one-page set of antibiotic guidelines in each patient examining room. Appropriateness of antibiotic choices was scored periodically. A 12-month pre-intervention survey of antibiotic use showed that 50% of the choices were inappropriate. Comparison of a four-month post-intervention analysis with the same four-month interval in the pre-intervention period showed no significant difference between the percentages of inappropriate prescriptions. The most common reasons for inappropriate use were: 1) failure to document a clinically significant bronchial infection, and 2) inadequate evaluation of nonspecific urinary tract complaints. The authors conclude that the ready availability of information about appropriate antibiotic use is not effective in changing antibiotic choices, and that educational strategies regarding antibiotic use must also address diagnostic evaluation.

Screening for primary aldosteronism: hypokalemia in hypertensive patients.

A serum potassium determination is usually recommended for new hypertensive patients as a screening test for primary aldosteronism and as a baseline for drug therapy. Since hypokalemia is not specific for aldosteronism, the authors assessed its use and limitations as a screening test in nine reported studies of 303 patients with aldosterone-producing adenomas (n=252) or adrenal hyperplasia (n=51). The optimal potassium cutoff level and the predictive ability of hypokalemia to detect aldosteronism were analyzed in a primary care setting with different diseases, test characteristics, and prevalences. Optimal screening for primary aldosteronism occurred at serum potassium <3.2 mEq/l in a primary care, low-prevalence population, and at higher potassium levels in higher-prevalence populations. Other screening tests, such as urinary aldoster-one levels and plasma renin activity, showed lower individual test performance characteristics, but when combined were similar in performance to serum potassium measurement.

Computerized literature searching on a core internal medicine clerkship

The use, acceptance, and benefits of computerized literature searching by medical students during an internal medicine clerkship were evaluated. A year‐long prospective comparison of two student groups was performed in a community‐based medical school with five clinical sites. All third‐year medical students were required to supply two nontextbook references for each assigned patient evaluation during their core medicine clerkship. All 37 students enrolled in the second and fourth quarters of the academic year (Group 1) used the computer bibliographic retrieval service BRS Colleague® through five local modern‐equipped terminals to obtain their references. The 40 students in the first and third quarters (Group 2, controls) obtained their references without doing computer searches themselves. All Group 1 students felt capable of using the system, and 96% felt the service was helpful to their clinical learning. When compared with the control group, students using the computer search spent less time looking f...

Tracking patient demographics and disease categories in a primary care residency

The residency training of primary care physicians must include experiences with multiple types of ambulatory patients and disease processes. Most residency programs, however, do not accurately monitor or quantify these experiences. We developed a simple computerized system, using a relational data base, to record and track patient demographics and disease categories. This system maintains a profile for each resident physician which is used to guide the assignment of future patients. The system can be simply modified to meet the specific patient and/or disease characteristics needed.