NSAIDs: a clinical approach to the problems of gastrointestinal side-effects.

Despite the fact that non-steroidal anti-inflammatory drugs (NSAIDs) are among the most widely used drugs in medicine today, 2-10% of patients must discontinue their use primarily due to gastrointestinal (GI) side-effects. While the development of non-aspirin NSAIDs (NA-NSAIDs) has significantly reduced GI side-effects, major problems persist. A practical clinical approach to these problems includes informing the patient about the risks and benefits of NSAIDs, risk management during treatment with NSAIDs and investigation of symptomatic side-effects during treatment. Prophylaxis of GI side-effects is feasible in selected populations, but it has not been studied widely and may not be cost-effective. At present, costs of prophylaxis in all but selected populations with multiple risks probably outweight the benefits.

Faculty attitudes and opinions about problem-based learning.

BACKGROUND: Systematic research on faculty attitudes toward problem-based learning (PBL) has focused exclusively on the opinions of tutors. The purpose of the present study was to examine the attitudes of faculty at a single medical school who either (1) did not participate in the first year of a new PBL curriculum or (2) participated in ways other than as PBL tutors. METHOD: In 1993-94, at the end of the first year of a new PBL curriculum, a questionnaire used in an earlier, larger study of PBL tutors was sent to all 494 faculty at the University of Missouri-Columbia School of Medicine. RESULTS: The response rate was better for participants (76%, 115 of 151) than for non-participants (28%, 96 of 343). Overall, nonparticipants judged the new curriculum to be approximately equal to the "old" curriculum that preceded it. In contrast, participants were significantly more positive and judged the new PBL curriculum to be superior in most respects. For both groups the new curriculum received its highest ratings in the areas of student interest, clinical preparation, and medical reasoning and its lowest ratings in the teaching of factual knowledge in the basic sciences and efficiency of learning. The attitudes of participating faculty varied with their teaching roles in the new curriculum. Those whose primary roles were as PBL tutors or as leaders of other small discussion groups were more favorable to the new curriculum than those who primarily served as lecturers. Faculty who served in several different roles were more positive than faculty who served in only one role. There were also plausible qualitative differences among the teaching-role groups in what they liked and disliked about the new curriculum. CONCLUSION: In general, the attitudes and opinions of the faculty varied with the degrees and types of participation in the new curriculum. The attitudes and opinions of faculty with different teaching roles were plausibly related to differences in these roles. The opinions of the faculty about the strengths and weaknesses of PBL that emerged in this survey are much like those found in prior research. In addition, student performances on Step 1 of the United States Medical Licensing Examination suggest that the faculty may have underestimated the value of the new PBL curriculum for helping students acquire factual knowledge in the basic sciences.

Student performances on Step 1 and Step 2 of the United States Medical Licensing Examination following implementation of a problem-based learning curriculum.

PURPOSE: To examine students' performances on Step 1 and Step 2 of the United States Medical Licensing Examination (USMLE) following the implementation of a problem-based learning curriculum. METHOD: Performances on Step 1 of the USMLE for four classes at the University of Missouri-Columbia School of Medicine that completed a new problem-based learning curriculum (1997, 1998, 1999, and 2000) were compared with those of the last two classes to learn in the traditional curriculum (1995 and 1996). Performances on Step 2 of the USMLE for the classes of 1997, 1998, and 1999 were also compared with those of the classes of 1995 and 1996. The authors analyzed matriculation data (GPAs and MCAT scores) for all six classes. They compared all data with those of U.S. and Canadian first-time USMLE takers. RESULTS: The mean scores were higher on USMLE Step 1 for classes in the problem-based learning curriculum than for classes in the traditional curriculum. The mean scores for Step 2 were above the national mean for classes in the revised curriculum and below the national mean for classes in the traditional curriculum. The admission profiles of these classes were essentially the same before and after the change in curriculum. CONCLUSIONS: Major PBL revisions of the curriculum did not compromise the performances of medical students on the licensing examinations; in fact, they may have contributed to higher scores.

Collaborative practice and provider styles of delivering health care.

The delivery of primary health care involves complex interactive communication between the provider and patient. Describing the manner or style of this communication is important to more completely understand the delivery of primary health care. The purpose of this study was to examine provider's style of interaction with the patient and to compare the styles of nurse practitioners and physicians in joint practice. A total of 412 provider/patient clinic visits including 276 with physicians and 136 with nurse practitioners were videotaped and analyzed using a content-based interactive analysis system. Five provider style dimension indices were constructed including affiliation, control, somatic, psychosocial, and information indices. The results of this study show that the development of a content-based interactional analysis system which focuses on clinician activities can be useful in describing important aspects of the provider/patient encounter. Overall, there was little difference between nurse practitioner and physician style of interaction. Nurse practitioners, however, exhibited significantly more concern with psychosocial issues than physicians. Type of visit and visit history were also factors associated with provider style. Using the style dimension indices constructed for this study a typology of provider styles was developed.

Efficacy of an intervention to promote use of hearing protection devices by firefighters.

Numerous cases of hearing loss consistent with noise-induced damage were noted among firefighters in the city of Columbia, MO. A survey of firefighting vehicles in operation showed that the firefighters were exposed to excessive noise levels and put at risk for noise-induced hearing loss (NIHL). Audiologic evaluation showed that 36 percent of the firefighters had moderate or severe hearing loss (a threshold of 40 decibels (dB) or more at 3,000, 4,000, or 6,000 hertz (Hz) in either ear). An educational program on NIHL was then carried out to increase the use of hearing protection devices (HPDs) by firefighters, followed by an evaluation of the intervention. The educational intervention successfully increased knowledge of NIHL, positive attitudes toward HPDs, and resulted in more frequent use of HPDs. After the intervention, 85 percent of firefighters regularly used HPDs compared with 20 percent before the intervention. Recommendations are made for fire departments to reduce the risk of NIHL.

High-frequency hearing loss in male farmers of Missouri.

Farmers are exposed to noise that is potentially hazardous to hearing. We measured the hearing of 161 male farmers and 75 male nonfarmers at the 1979 Missouri Farmers Association Agri-Fair and compared it with the hearing of 129 office workers from central Missouri. Fixed-level screening tests were conducted in both ears at three stimulus frequencies: 1000 and 2000 hertz at 20 decibels hearing level and 4000 hertz at 25 decibels hearing level. Audiometers were calibrated in accordance with the ANSI-1969 standard. The results show that farmers are at risk for hearing loss at 2000 and 4000 hertz when compared with office workers. The prevalence of hearing loss was greater for farmers at both frequencies in every decade age group from 25 to 64 years. Using screening failure at 2000 and 4000 hertz in both ears as a criterion for a loss that would affect communication ability, we found that the failure rate was 16.8 percent for farmers and 6.2 percent for office workers. As other investigators have found, the prevalence of high-frequency hearing loss in male nonfarmers who associate with farmers was nearly as great as for farmers.

Medical students' attitudes toward pharmaceutical marketing: possibilities for change.

BACKGROUND: Concerns have been expressed about physicians' acceptance of gifts from pharmaceutical companies, but few studies have examined or attempted to change medical students' attitudes about accepting such gifts. METHODS: We used a questionnaire survey to measure attitudes about accepting such gifts. We then carried out a field experiment to compare changes in second-year medical students' attitudes, seven weeks after a one-hour lecture and discussion about the appropriateness of pharmaceutical gifts, to changes in first-year students who were not exposed to the program. RESULTS: Following the intervention, second-year students became less accepting of these marketing practices; first-year students showed no significant change. The difference between the groups after the intervention was statistically significant (P < .0001). CONCLUSIONS: If medical students' attitudes about accepting gifts from pharmaceutical companies need to be changed, this study suggests that the process may be fostered with little investment of curricular time.

Physician-related influences on use of health resources by primary care physicians.

With the increasing supply of physicians, speculation has focused on possible actions physicians might take to increase use of services (e.g., office visits, laboratory use, prescriptions, or referrals), thus adding to spiraling health care costs. A survey of primary care physicians--pediatricians, internists, and family physicians--was conducted to assess physician-related factors associated with health resource use. The most consistent factors found to explain the variance among physicians in use of these health resources were the number of years in practice, whether they graduated from a foreign medical school, government employment, self-assessed practice style, whether they were family physicians, and sex. There was no evidence that physician income, desire for income, or pace of practice had any effect on the amount of services physicians used in the "care" of the patients in the hypothetical cases. These findings suggest that if physicians induce demand for services in primary care, it is a minor factor in the increase of health care costs.

A process evaluation of a required primary care clerkship.

A process evaluation was implemented to guide faculty in developing a new required primary care clerkship. During the first eight months of the clerkship, 23 medical students were observed in a time and motion analysis and a study of the verbal content of the precepting interactions as students presented their patients to a preceptor. Students spent an average of 44% of their clinic time in examination rooms with patients, 21% interacting with preceptors and 13% waiting without interaction. The verbal behaviors accounting for 80% of the student-preceptor interaction time were case presentations (50%), direct or indirect questioning (16%), and making recommendations for management (13%).

Medical school application essays and specialty choice.

OBJECTIVE: To identify factors that could be used to predict physician specialty selection at the level of admissions to medical school. METHODS: Content analysis was performed on 161 personal statements from the American Medical College Admission Service application form. Randomly selected graduates analyzed were from the classes of 1985-1987 from a Midwestern public medical school. RESULTS: Fifty percent of those who stated that they had contact with a medical specialty entered either that specialty or a closely related specialty. Of the 11 applicants who stated a goal of entering family practice, one entered family practice. CONCLUSIONS: Contact with a specialty prior to entering medical school may be a significant predictor of the prospective student's eventual specialty selection. However, goals mentioned in the statements are not predictors of specialty choice.

Evaluation of standards of practice for primary care physicians using 12 hypothetical cases.

Concerns about the quality of medical care are increasing. As quality of medical care is difficult to measure, physicians have relied on standards based on research, consensus, or personal experience. The authors surveyed primary care physicians in Missouri to determine the presence and extent of standards of care for 12 hypothetical cases. The results demonstrate that within and between diagnoses there is both consensus and disagreement in case management. A standard of practice can be inferred for those management options achieving consensus. Further research is indicated for those options generating considerable disagreement to resolve the discrepancies in standards of care.

Development of a psychosocial concern index from videotaped interviews of nurse practitioners and family physicians.

The delivery of primary health care involves a complex interactive process between the provider and patient. One important feature of this interaction is provider concern for psychosocial issues. A study was undertaken to examine provider's actions with the patient and to describe the factors influencing the provider's concern with psychosocial issues. A total of 412 provider-patient clinic visits, including 276 with physicians and 136 with nurse practitioners, were videotaped and analyzed using a provider psychosocial concern index developed specifically for this study. Data from exit and follow-up interviews with patients plus a provider questionnaire were analyzed to identify factors associated with a provider's psychosocial concern. The results show that an interactional analysis focusing on clinician activities can be useful in describing important process-outcome relationships such as psychosocial concern. Factors such as type of visit, visit history, type of provider, and sex of patient and provider were associated with the amount of psychosocial concern displayed by providers and perceived by patients.

Analysis of resident and attending physician interactions in family medicine.

Clinical teaching does not fit neatly into traditional teaching-learning models. The interaction between a resident and an attending physician is of particular interest because it has several functions including education, supervision, socialization, and quality control. The purpose of this study was to observe, classify, and record verbal teaching and learning behaviors in the resident-attending physician interaction. During a 12-month period, 125 observations of resident-attending physician interactions were recorded; the average length of the interactions was 4.27 minutes. The six most frequent resident verbal behaviors compared by postgraduate year level did not vary significantly. Only one of the six most frequent attending physician verbal behaviors varied significantly. In the average interaction of about 4 minutes, three fourths of the interaction was on patient care issues, leaving little time for teaching. There are many unanswered questions about the resident-attending physician interaction and its contribution to the training of a physician.

An educational improvement project to track patient encounters: toward a more complete understanding of third-year medical students' experiences.

BACKGROUND: At the University of Missouri School of Medicine (MUSOM), "commitment to improving quality and safety in healthcare" is one of eight key characteristics set as goals for our graduates. As educators, we have modelled our commitment to continuous improvement in the educational experiences through the creation of a method to monitor and analyse patient encounters in the third year of medical school. This educational improvement project allowed course directors to (1) confirm adequate clinical exposure, (2) obtain prompt information on student experiences, (3) adjust individual student rotations to meet requirements and (4) ascertain the range of clinical experiences available to students. DISCUSSION: Data illustrate high levels of use and satisfaction with the educational innovation. We are in our second year using the new Patient Log (PLOG) process and are now considering expanding the use of PLOG into the fourth year of medical school.

The relationship between utilization and referral for family physicians.

Little is known about the relationship between use of referral by primary care physicians and their overall utilization of medical resources. Valid arguments can be made for both direct and inverse relationships. We analyzed data from a survey of Missouri family physicians using hypothetical cases to test for significant relationships between resource utilization, access to referral, and use of referral. No significant association between these variables was found using Pearson correlation coefficients. To determine whether physician characteristics other than utilization could explain referral behavior, multiple and logistic regressions were used with several physician personal and professional background factors as independent variables. No dominant factor emerged to explain differences in referral use by physicians. We conclude that the decision to initiate the referral process is complex and not easily explained, even with the aid of sophisticated statistical techniques.

Integration of neuroscience and endocrinology in hybrid PBL curriculum.

At the University of Missouri-Columbia, the medical school employs a problem-based learning curriculum that began in 1993. Since the curriculum was changed, student performance on step 1 of the United States Medical Licensing Examination has significantly increased from slightly below the national average to almost one-half a standard deviation above the national mean. In the first and second years, classes for students are organized in classes or blocks that are 8 wk long, followed by 1 wk for evaluation. Initially, basic science endocrinology was taught in the fourth block of the first year with immunology and molecular biology. Student and faculty evaluations of the curriculum indicated that endocrinology did not integrate well with the rest of the material taught in that block. To address these issues, basic science endocrinology was moved into another block with neurosciences. We integrate endocrinology with neurosciences by using the hypothalamus and its role in neuroendocrinology as a springboard for endocrinology. This is accomplished by using clinical cases with clear neuroscience and endocrinology aspects such as Cushing's disease and multiple endocrine neoplastic syndrome type 1.