An ounce of prevention: how are we managing the early assessment of residents' clinical skills?: A CERA study.

BACKGROUND AND OBJECTIVES: Clinical skills deficits in residents are common but when identified early can result in decreased cost, faculty time, and stress related to remediation. There is currently no accepted best practice for early assessment of incoming residents' clinical skills. This study describes the current state of early PGY-1 clinical skills assessment in US family medicine residencies. METHODS: Eleven questions were embedded in the nationwide CERA survey to US family medicine residency directors regarding the processes, components, and barriers to early PGY-1 assessment. Responses are described, and bivariate analyses of the relationship between assessment variables and percentage of international medical graduates (IMGs), type of program, and barriers to implementation were performed using chi square testing. RESULTS: Almost four of five (78.4%) responding programs conduct formal early assessments to establish baseline clinical skills (89.6%), provide PGY-1 residents with a guide to focus their learning goals (71.6%), and less often, in response to resident performance problems (34.3%). Barriers to implementing PGY-1 early assessment programs include cost of faculty time (56.3%), cost of tools (42.1%), and time for the assessment during the PGY-1 resident's schedule (41.0%). Cost of faculty time and time for assessment from the PGY-1 resident's schedule were statistically significant major/insurmountable barriers for community-based, non-university-affiliated programs. CONCLUSIONS: Early PGY-1 assessments with locally developed tools for direct observation are commonly used in family medicine residency programs. Assessment program development should be targeted toward using existing, validated tools during the PGY-1 resident's patient care schedule.

Are unexplained vaginal symptoms associated with psychosocial distress? A pilot investigation.

AIM: Vaginal complaints cannot be definitively diagnosed in approximately one-third of women. We sought to determine if women without a diagnosis had higher levels of psychiatric disorders. METHODS: This was an observational study in an urban family practice clinic. Prior to seeing a clinician, women with vaginal complaints completed the Patient Health Questionnaire (PHQ); symptoms were measured by the Vaginal Complaints Scale (VCS). Patients were then examined and treated by a family physician. At one and two weeks' time patients were contacted by phone regarding symptom resolution and clinical outcomes. RESULTS: We enrolled 47 patients; one patient was excluded. A diagnosis was made in 36. Eighteen had bacterial vaginosis, 16 had candida, three trichomonas, two HSV, one chlamydia; there were eight dual diagnoses. PHQ diagnoses were slightly less common in women without an identified cause for their symptoms. We obtained follow-up data from 45 subjects at one week and 34 subjects at two weeks' time. At two weeks' follow-up, 97% of subjects had complete resolution or improvement of their symptoms. Symptom improvement was equivalent among women with a diagnosis and those without. We estimate 180 subjects would be needed to detect a clinically meaningful difference in PHQ diagnoses. DISCUSSION: Our pilot study did not find an association between psychiatric diagnoses made by the PHQ and unexplained vaginal symptoms. Nearly all patients experienced rapid resolution of symptoms irrespective of whether a diagnosis had been made or not. These findings are limited primarily by the small sample size.

Are a speculum examination and wet mount always necessary for patients with vaginal symptoms? A pilot randomized controlled trial.

PURPOSE: The suggested evaluation of vaginal symptoms is based on the wet mount diagnosis of candidiasis, trichomoniasis, and bacterial vaginosis. We wondered if patients with vaginal symptoms could be managed initially based solely on symptoms. METHODS: This pilot randomized controlled trial was conducted in 2 urban family practice clinics and enrolled 46 premenopausal, nonpregnant women with acute vaginal symptoms. In the control arm, women were managed based on a speculum examination and wet mount. In the intervention arm, women were managed based on symptoms. Women were tested for gonorrhea, chlamydia, and trichomoniasis and called 2 weeks later to assess symptom resolution, adverse medication effects, need for revisit, and satisfaction with care. RESULTS: Forty-one of 44 women (93%) felt better 2 weeks after the visit; 28 (64%) had complete resolution of symptoms. The intervention arm had slightly better resolution of symptoms (P=.046); there were other no differences between the 2 arms. Three women were diagnosed with sexually transmitted diseases (trichomoniasis, chlamydia, and gonorrhea). CONCLUSIONS: Our pilot study suggests that in selected women it may be reasonable to initially manage vaginal complaints based on symptoms. These results should be confirmed in other larger trials. Testing for sexually transmitted diseases is important in our population.

Probiotics.

Probiotics are microorganisms with potential health benefits. They may be used to prevent and treat antibiotic-associated diarrhea and acute infectious diarrhea. They may also be effective in relieving symptoms of irritable bowel syndrome, and in treating atopic dermatitis in children. Species commonly used include Lactobacillus sp., Bifidobacterium sp., Streptococcus thermophilus, and Saccharomyces boulardii. Typical dosages vary based on the product, but common dosages range from 5 to 10 billion colony-forming units per day for children, and from 10 to 20 billion colony-forming units per day for adults. Significant adverse effects are rare, and there are no known interactions with medications.

Probiotics in children.

The gastrointestinal flora plays a complex and important role in the development of healthy immunologic and digestive function in children. Probiotics are safe in healthy children and effective in reducing the risk of antibiotic-associated diarrhea and the duration of acute infectious diarrhea. Probiotics may also be effective in preventing community-acquired diarrheal infections, in reducing the risk of necrotizing enterocolitis in premature infants, and in the prevention and treatment of atopic dermatitis. The exact strain or combination of strains most effective for common clinical indications has yet to be determined, but the exact strain used seems less important than whether an adequate dose is used (typically 5 to 10 billion CFUs per day or higher). Clinicians should familiarize themselves with the products available because there is a wide range in their quality.

Demonstrating prescribing competence: a successful pilot of a prescription competency curriculum for family medicine residents.

BACKGROUND: Poor medication prescribing skills among residents have been widely reported. METHODS: We implemented a three-stage prescribing curriculum with eight interns in an urban family medicine residency. Clinical pharmacy faculty delivered two lectures, attended hospital rounds, and coprecepted in clinic. Evaluations were done by a written exam and clinical assessment. RESULTS: All eight interns made at least one prescribing error on the exam. One error was considered potentially fatal. All interns passed on the second attempt and gained prescribing privileges after 6 months. CONCLUSIONS: Our prescribing curriculum was practical and feasible. Further studies will determine whether the intervention improved prescribing habits and reduced clinical errors.

Evaluation of vaginal complaints.

CONTEXT: Vaginal symptoms are one of the most common reasons for gynecological consultation. Clinicians have traditionally diagnosed vaginal candidiasis, bacterial vaginosis, and vaginal trichomoniasis using some combination of physical examination, pH, the wet mount, and the whiff test. OBJECTIVES: To evaluate the role of the clinical examination and determine the positive and negative likelihood ratios (LRs) for the diagnosis of vaginal candidiasis, bacterial vaginosis, and vaginal trichomoniasis. DATA SOURCES: Using a structured literature review, we abstracted information on sensitivity and specificity for symptoms, signs, and office laboratory procedures. We chose published (1966 to April 2003) articles that appeared in the MEDLINE database and were indexed under the combined search terms of diagnosis with vaginitis, vaginal discharge, candidiasis, bacterial vaginosis, and trichomoniasis. STUDY SELECTION: Included studies of symptomatic premenopausal women seen in primary care settings. Tests were evaluated only if they would provide diagnostic information during the office visit and were compared with an acceptable criterion standard. DATA EXTRACTION: All 3 authors extracted the data and computed sensitivity and specificity from each article independently. The absence of standard definitions for symptoms and signs made it impossible to combine results across studies. DATA SYNTHESIS: Symptoms alone do not allow clinicians to distinguish confidently between the causes of vaginitis. However, a patient's lack of itching makes candidiasis less likely (range of LRs, 0.18 [95% confidence interval [CI], 0.05-0.70] to 0.79 [95% CI, 0.72-0.87]) and lack of perceived odor makes bacterial vaginosis unlikely (LR, 0.07 [95% CI, 0.01-0.51]). Similarly, physical examination signs are limited in their diagnostic power. The presence of inflammatory signs is associated with candidiasis (range of LRs, 2.1 [95% CI, 1.5-2.8] to 8.4 [95% CI, 2.3-31]). Presence of a "high cheese" odor on examination is predictive of bacterial vaginosis (LR, 3.2 [95% CI, 2.1-4.7]) while lack of odor is associated with candidiasis (LR, 2.9 [95% CI, 2.4-5.0]). Office laboratory tests, particularly microscopy of vaginal discharge, are the most useful way of diagnosing these 3 conditions. CONCLUSIONS: The cause of vaginal complaints may be easily diagnosed when typical findings appear in microscopy. However, the poor performance of individual symptoms, signs, and office laboratory tests often makes it problematic to identify the cause of vaginal symptoms.

Homeopathy.

Homeopathy, using the tenet of "like cures like," is one of the most popular of the complementary medicines. In conventional medicine, however, little is known about this modality. This article describes the field of homeopathy and its principles and philosophy. It also summarizes the current state of evidence and offers an outlook on future research options.