When should learning about hospitalized patients end? Providing housestaff with post-discharge follow-up information.

PURPOSE: As hospital stays grow shorter, many patients are discharged to follow up with their primary care physicians before their diagnoses and responses to treatment are clear. The authors studied the value and feasibility of providing housestaff with follow-up information about their former inpatients. METHOD: Patients included in the study (1) had been admitted to the housestaff service during the study period (January to March 1997), (2) had received follow-up care from a primary care physician in the Johns Hopkins Bayview Physicians' Professional Association, and (3) had been hospitalized for at least three days. The primary care physician completed a single-page follow-up form four to six weeks after the patient's discharge from the hospital; that form was given to the house officers who had cared for that patient. RESULTS: Responses to a preintervention questionnaire completed by 28 of 39 house officers (72%) showed that 92% felt it to be important or extremely important to get follow-up information about inpatients; 86% indicated that they rarely or never receive such information. During the study period, house officers were sent follow-up information for 65 of 76 eligible patients (85%). In their responses to a post-intervention questionnaire (response rate 73%), the house officers most valued learning about the accuracy of the discharge diagnosis, the results of additional diagnostic tests, and information about the patient's quality of life since discharge. Housestaff's satisfaction with the follow-up information received about inpatients improved (p = .001). CONCLUSIONS: Providing follow-up information was a feasible intervention that was valued by housestaff.

Recent trans-European initiatives in general practice.

Recently, several initiatives have addressed the situation of general practice in Europe. These trans-European developments in medicine have paralleled the continuing emergence of geopolitical Europe. Most of these initiatives have emanated from 2 events in that occurred in 1995: the mandatory implementation of the European Union's directive governing the duration of postgraduate training in general practice and the founding of the European Society of General Practice/Family Practice.

Adherence to the JNC VI guidelines for the treatment of hypertension in the resident clinic.

The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) provided guidelines for the treatment of hypertension. This study examined the adherence to the JNC VI guidelines by a retrospective chart review of patients treated for hypertension in the internal medicine house staff practice at a university teaching hospital in the year after publication of the JNC VI.

Improving physicians' interviewing skills and reducing patients' emotional distress. A randomized clinical trial.

BACKGROUND: Despite high prevalence, emotional distress among primary care patients often goes unrecognized during routine medical encounters. OBJECTIVE: To explore the effect of communication-skills training on the process and outcome of care associated with patients' emotional distress. METHODS: A randomized, controlled field trial was conducted with 69 primary care physicians and 648 of their patients. Physicians were randomized to a no-training control group or one of two communication-skills training courses designed to help physicians address patients' emotional distress. The two training courses addressed communication through problem-defining skills or emotion-handling skills. All office visits of study physicians were audiotaped until five emotionally distressed and five nondistressed patients were enrolled based on patient response to the General Health Questionnaire. Physicians were also audiotaped interviewing a simulated patient to evaluate clinical proficiency. Telephone monitoring of distressed patients for utilization of medical services and General Health Questionnaire scores was conducted 2 weeks, 3 months, and 6 months after their audiotaped office visits. RESULTS: Audiotape analysis of actual and simulated patients showed that trained physicians used significantly more problem-defining and emotion-handling skills than did untrained physicians, without increasing the length of the visit. Trained physicians also reported more psychosocial problems, engaged in more strategies for managing emotional problems with actual patients, and scored higher in clinical proficiency with simulated patients. Patients of trained physicians reported reduction in emotional distress for as long as 6 months. CONCLUSIONS: Important changes in physicians' communication skills were evident after an 8-hour program. The training improved the process and outcome of care without lengthening the visits.

An evaluation of residency training in interviewing skills and the psychosocial domain of medical practice.

Competent use of interviewing skills is important for the care of all patients but is especially critical, and frequently deficient, in meeting the needs of patients experiencing emotional distress. This study presents an evaluation of a curriculum in communication and psychosocial skills taught to first-year medical residents. A randomized experimental design compared trained and untrained residents' (n = 48) performances with a simulated patient presenting with atypical chest pain and psychosocial distress. Evaluation was based on analysis of videotapes, simulated patient report of residents' behaviors, and chart notation. Trained compared with untrained residents asked more open-ended questions and fewer leading questions, summarized main points more frequently, did more psychosocial counseling, and were rated as having better communication skills by the simulated patient. The use of more focused and psychosocially directed questions, and fewer leading and grab-bag questions, was associated with more accurate diagnoses and management recorded in the medical chart. However, no significant difference was found in the charting practices of trained versus untrained residents.

Use of an outpatient medical record audit to achieve educational objectives: changes in residents' performances over six years.

OBJECTIVE: To evaluate the effectiveness of a process whereby a faculty-resident committee annually audits outpatient record keeping and preventive care practices and provides feedback to resident physicians. DESIGN: Pre- and postfeedback audits with interventions and observations repeated over six consecutive academic years. SETTING: The adult primary care practice of housestaff in a university-affiliated hospital. SUBJECTS: All 139 physicians in an internal medicine residency program from 1981-82 through 1986-87, of whom 37 were present for three consecutive years. INTERVENTION: Each year, residents were given individualized, detailed, typewritten feedback based on audits of their outpatient records. MEASUREMENTS AND MAIN RESULTS: Each resident physician had a minimum of four (mean 5.2) outpatient records per year audited against standards for record-keeping practices and the provision of preventive care. Overall performance scores for each resident audit improved from a mean of 39.7 +/- 12.3 (SD) in 1981-82 to a mean of 58.5 +/- 14.1 (SD) in 1986-87 (possible range 0 to 100, observed range 9.4 to 86.6). The overall performance scores of individual residents, who received two cycles of feedback, improved an average of 11.5 (95% confidence limits 7.6, 15.3), from a mean of 48.4 +/- 11.4 (SD) during their first year of residency to 59.8 +/- 13.9 (SD) during their third year. General (primary care) and traditional-track residents improved at similar rates, although mean performance scores were consistently higher for general than for traditional-track residents. Analysis of variance revealed that all changes and differences were statistically significant. CONCLUSIONS: An ongoing chart audit and feedback system can be associated with improvements both in the performance of individual residents and in the long-term performance of a residency program.

Curriculum for ambulatory care training in medical residency: rationale, attitudes, and generic proficiencies.

This paper provides a foundation for establishing curricula to train medical residents in ambulatory care. To do so, it first presents reasons that curricula are needed in this area. It then delineates attitudes and proficiencies (knowledge and skills) that such curricula should be designed to instill. Finally, it briefly discusses implications for curriculum development. Extensive tables are provided, including detailed lists of generic proficiencies that residents should attain. Among realms in which these proficiencies lie are organizing the ambulatory care encounter, using interpersonal skills, gathering information through physical examination and other means, obtaining and employing clinically useful knowledge, documenting the encounter, and planning and coordinating care. The paper notes that planning for the discharge of patients from the hospital can contribute to obtaining proficiencies important in ambulatory care.

Hypertension: spectrum of problems and guidelines for management.

Hypertensive patients may present to the emergency department with one of three general problems: high blood pressure due to labile hypertension, chronic hypertension, accelerated hypertension, or a hypertensive emergency; side effects from antihypertensive drugs; or acute medical or surgical illness whose management may be affected by hypertension or by drugs taken for hypertension. We describe these problems and recommend an approach to each that is appropriate in the emergency department.