Health care risks and access within the community of Michigan over-the-road truckers.

This mixed methods study explored health care access problems faced by long-distance truck drivers. Thirty trucking professionals were interviewed at truck-stops in Michigan about health status and health care access. Thirty of the 88 drivers approached participated. The most common illnesses they reported concerned the eye, back, excessive stress at work and painful joints or arthritis. Most respondents had a family doctor; for those who did not, cost was a major contributing factor. More than one third stated their health is "not excellent" because of poor accessibility to healthcare on the road. Almost unanimously, drivers desired to have access to health care clinics in truck-stop areas and described particular access problems; the solution may be as simple as making the existing health care system more amenable to those driving large truck rigs.

Racial and marital status influences on 10 year survival from breast cancer.

The association of race and marital status with survival during a 10 year period after a breast cancer diagnosis is described. The data for this study were obtained from the Metropolitan Detroit Cancer Surveillance System, a participant in the National Cancer Institute's SEER program. The study sample was 10,778 women (85.6% white and 14.4% black) diagnosed with incident invasive breast cancer between 1973 and 1978. Marital status was significantly associated with race, but had only a weak relationship with length of survival in a multivariate model predicting 10 year survival. However, race was strongly related to survival. African American women were significantly more likely than white women to die from breast cancer after controlling for age at diagnosis, marital status, tumor stage, histologic type, treatment status, and the interaction of age with stage. Ten years after being diagnosed with breast cancer, 38.2% of whites, compared with 33.3% of blacks were still living. These data confirm a body of literature which finds that blacks experience a shorter survival period following a cancer diagnosis than do whites. However, the relationship of marital status to cancer survival is still unclear and needs further study.

Serum cholesterol and colorectal polyps.

Colorectal cancer and hypocholesterolemia have recently been associated, and colorectal polyps have a known relationship with colorectal cancer. In order to establish further evidence regarding the nature of the serum cholesterol-colorectal cancer relationship, this study investigated the hypothesis that men with colorectal polyps would have lower serum cholesterol levels than men without polyps. Of the 1380 men screened by sigmoidoscopy for colorectal polyps, 246 had at least one polyp. The men with polyps were older than those without, and also had higher cholesterol levels, but after controlling for age, there were no serum cholesterol differences. These data suggest that low serum cholesterol is not etiologically linked to cancer. Analyses of potentially confounding variables showed smoking to be strongly related to the presence of polyps.

The effect of stress on glycemic control in patients with type II diabetes during glyburide and glipizide therapy.

Stress adversely affects glycemic control in patients with type II diabetes mellitus. In addition, stress reduction with relaxation techniques or medication use in the management of hyperglycemia has been recommended. This study examined the relationship of glycemic control to self-reported stress in 19 patients with type II diabetes mellitus who were randomly allocated to receive either glyburide or glipizide for 16 weeks in a double-blind crossover design. Each treatment phase was preceded by a 2-week washout period. A previously designed and validated nine-item stress questionnaire was used to assess areas such as safety, financial wellbeing, energy level, health, etc. These areas were evaluated as more/less, better/worse, or no change. The stress questionnaire, fasting blood glucose (FBG), and glycosylated hemoglobin (GHb) concentrations were completed or measured at the end of glyburide and glipizide treatment periods. By assigning a value of 1, 2, or 3 to a positive, no change, or negative response, respectively, a composite stress score was computed and compared with glycemic control as assessed by FBG and GHb. Regression analysis showed highly significant correlations (P < .05) between stress scores and FBG (r = .70) as well as GHb (r = 0.84) with glipizide therapy. No such correlation was noted with glyburide (FBG: r = 0.29; GHb: r = 0.29). These findings suggest that during glyburide treatment, in contrast to glipizide, an increase in stress was not associated with a corresponding rise in blood glucose or worsening of metabolic control.(ABSTRACT TRUNCATED AT 250 WORDS)

A consortium-based research education program for residents.

With growing pressures to consolidate and reorganize health care delivery systems, graduate medical education (GME) consortia can draw faculty from affiliated members to assemble educational programs. The authors report on consortium-based research education seminars of a quality that many residency programs would be unable to develop and support on their own. Drawing a diverse faculty from consortium members and area universities, the OHEP Center for Medical Education's annual Research Workshop Series focuses on the design of research projects; data analysis and hypothesis testing; and written and oral presentation of scientific research. Each spring, OHEP sponsors a research forum in which the best research projects from consortium members are presented by the resident-researchers, who compete for recognition and prize money. Further, of the 128 presentations made thus far at the annual OHEP Research Forum, 25% were subsequently published. The consortium's research education program has been well received by residents, is cost-effective, and is an integral component of the research curricula of many area residency programs. Including research training in GME provides residents an opportunity to become more competitive for fellowship, faculty, and leadership positions.

Environmental medicine content in medical school curricula.

BACKGROUND: The Institute of Medicine has recommended basic clinical competence in environmental medicine (EM) for all physicians. However, the amount and content of instruction in EM currently offered in U.S. medical schools is unknown. METHOD: This cross-sectional study was based on responses to a questionnaire regarding the EM curriculum content of U.S. medical schools, mailed in June 1994 with the Association of American Medical Colleges curriculum survey. RESULTS: Of the 126 schools, 119 (94%) responded. Of these, 29 (24%) reported no required EM content in the curriculum. Schools with EM content averaged seven hours of instruction. Eighty-one schools (68%) had faculty with environmental and occupational medicine expertise, primarily within the departments of medicine, preventive medicine, and family medicine. CONCLUSION: There is a need for increased instruction in EM in medical school curricula for students to acquire the knowledge and skills to prevent, diagnose, and treat health problems with an environmental exposure component. For those schools without EM content in the curriculum, the necessary expertise to develop EM curriculum may be available in current faculty.

Marital status, delay in seeking treatment and survival from breast cancer.

This study examined 10-year survival following a breast cancer diagnosis among 910 married and 351 widowed white women after adjusting for the effects of age, socio-economic status (SES), stage of disease and delay in seeking treatment for symptoms. All breast cancer patients were treated at M.D. Anderson Hospital and Tumor Institute in Houston, Texas between 1949 and 1968. Marital status, age, SES, delay and stage were all univariate predictors of survival. Widowed patients were less likely to survive than married patients. Multivariate analyses using a Cox regression technique did not detect an effect of delay on survival when stage and the other variables were included. However, marital status differences in survival remained when all the other variables were included in the model. These data suggest that marital status differences in survival cannot be accounted for by patient delay in seeking treatment for breast cancer symptoms.

Incongruence between self-reported symptoms and objective evidence of respiratory disease among construction workers.

In clinical settings, self-reported symptoms and objective evidence of disease may be poorly correlated. In the present study, symptoms and objective evidence of pulmonary disease were compared in a community sample of construction workers with occupational exposure to asbestos. Symptoms of dyspnea and cough were assessed by a standardized questionnaire. The clinical examination included a chest X-ray, pulmonary function testing (PFT), and a physical examination. Both symptoms and objective clinical findings were strongly related to years in these trades. However, less than 1% of workers reported symptoms in the absence of any clinical evidence of disease. A similar low percentage of workers denied any symptoms yet produced clear evidence of pulmonary disease on clinical examination. Results were interpreted in terms of the variety of factors which have been associated with patients' readiness, and conversely, reluctance to report symptoms. The comparatively low frequency of incongruence between symptoms and objective clinical findings in this study suggests over emphasis of malingering by other authors. Health care might be improved if more attention is given by clinicians and researchers to patients who fail to report symptoms in the presence of disease.

Evaluation of the two-step tuberculin skin test in health care workers at an inner-city medical center.

The increased rate of tuberculosis (TB) infection and transmission from patients to health care workers (HCWs) has brought awareness of the need for better surveillance programs. The two-step purified protein derivative (PPD) skin test decreases the misinterpretation of a "boosted reaction" as a recent infection with Mycobacterium tuberculosis in HCWs. We reviewed the medical records of 4082 HCWs at an inner-city medical center who had PPD skin-testing performed as a component of the TB medical surveillance program during the years 1994 and 1995. Of those HCWs tested, 3896 (95.4%) returned for the PPD skin-test evaluation. Of those 3896 HCWs, 3659 (93.9%) had a negative baseline PPD skin test, and 237 (6.1%) had a positive skin test. Of those HCWs with a negative baseline skin test, 252 (6.9%) were eligible for the second PPD skin test. Of the 241 who returned for their second PPD skin-test reading, six (2.5%) had positive results. All six cases were foreign-born physician residents with a previous history of Bacille bilié de Calmette-Guérin (BCG) vaccination. We conclude that the two-step PPD skin test method is not indicted for HCWs at this urban medical facility.

Consistency of occupational exposure history from pattern and model makers.

This study investigates the consistency of occupational histories reported by the same men in 1985 and again in 1988. Detroit-area pattern and model makers participating in a colorectal cancer screening program that was offered at 3-year intervals completed a career length occupational exposure questionnaire at each screening. Analysis of the data from the 243 men who participated in both screening programs provided the opportunity to examine the consistency with which these workers reported the extent of their exposure to 13 substances commonly found in their work environment. Workers were asked to provide a work history, and for each different pattern or model maker job they had held, to estimate the percentage of time they were exposed to the 13 substances. The data indicated that over the 3-year study period, pattern and model makers were highly consistent in reporting whether or not they were exposed to the 13 substances. In addition, their first estimates of the percentage of time they were exposed to each substance were within 10% of their second estimates more than 70% of the time. This concordance was somewhat diminished after excluding those who reported no exposure. These findings suggest that skilled tradesman can provide occupational exposure information that is likely to be useful for physicians in considering an occupational cause for a presenting health concern.

The association of elder abuse and substance abuse in the Illinois Elder Abuse System.

This article explores the role of abuser substance abuse in 552 cases of substantiated elder abuse in Illinois. When the abuser was identified as having a substance abuse (SA) problem, the type of elder abuse substantiated was more likely to involve either physical or emotional abuse than neglect or financial exploitation. Abusers with SA problems were more frequently men and children of their victims, and less likely to be caregivers. Abuser SA was associated with victim SA. Cases involving abusers with SA problems were more likely to be evaluated by case workers as having a high potential risk for future abuse. Elder abuser case workers should be trained to identify both victim and abuser SA and appropriate intervention strategies.

The Illinois elder abuse system: program description and administrative findings.

In this article we describe the Illinois statewide elder abuse social service program, which is unusual in its comprehensive approach to the assessment and documentation of reported cases of abuse and its extensive data monitoring system. Descriptive information on the number and types of cases of elder abuse reported to the system are presented, along with information on the amount of social work time and administrative effort spent on substantiating abuse reports and providing services. Financial exploitation, emotional abuse, and neglect were the most common types of abuse reported, although emotional abuse was the type most frequently substantiated. The most frequent reasons for case closure were (a) victim entered long-term care, and (b) the workers' assessment that the victim was not at risk for future abuse. A detailed description of the comprehensive assessment and substantiation process is provided.

The use of behavioral contracting to increase exercise activity.

Abstract A cardiovascular risk reduction program used a submaximal treadmill stress test to evaluate physical fitness. Of the 179 individuals who participated in the health education counseling activities which followed testing, 96 signed a behavioral contract to engage in a 12-week aerobic exercise program. Forty-one contractors fully met contract goals, and 21 reported increased activity levels. Analyses examined demographic, risk factor, and attitudinal predictors of contract signing and contract adherence. Contract signing was related to education, smoking, and women's mean body weight. Only women's body weight was related to contract adherence. Attitudes toward exercise were related to neither. Level of contract adherence was significantly related to a decrease in exercising heart rate at the six-month follow-up assessment. These data suggest that contract signing may be a useful device for assessing client motivation and predicting program participation and behavioral change outcomes.

Answering funding preferences for medical school graduates in underserved areas.

We describe here a feasible and data-based approach for obtaining important information about the percentage of our medical school graduates who primarily provide health care to the medically underserved. The logic and data used in our methodology have been acceptable to funding agencies. After making the initial investment in developing this approach, we can execute it at low cost to respond to relevant inquiries about the practice activities of our graduates. Other programs that can produce a computerized listing of post-residency graduates' practice locations can follow the procedure outlined above to demonstrate qualification for funding preferences.

The home visit in resident education: program description and evaluation.

A home visit rotation was developed to provide family practice residents with a more comprehensive understanding of the effect of patient life-style on health status. The rotation emphasizes geriatric, community, and rehabilitative medicine. In addition, the curriculum addresses issues related to patient compliance, assessment of activities of daily living, patient psychosocial needs, community services, and exposure to medical equipment of potential use to homebound individuals. Over a three-year period, 209 home visits were made. Program evaluation data suggest that at the end of the three-month rotation, residents were less concerned with personal safety and more likely to agree that home visits were an important part of residency training. A comparison of pre- and post-test knowledge scores indicated significant increases in geriatric medicine, patient compliance issues, patient functional status, and community services. A follow-up telephone interview with patients found that some patients experienced anxiety when the home visit was scheduled, but the majority were positive about the experience.

Teaching practice management during residency.

BACKGROUND AND OBJECTIVES: Practice management is a required component in family practice residency education. A few studies have reported that recently graduated primary care physicians indicated that their practice management training was inadequate. Our study describes the current nature of practice management education in family practice residencies and the perceptions of residency directors about the effectiveness of their program's practice management curriculum. METHODS: Surveys were mailed to 421 family practice residency directors, who were asked about their program's curriculum approach to teaching practice management, as well as their evaluation of the effectiveness of the curriculum. After two mailings, 213 surveys (51%) were returned. RESULTS: Eighteen percent of the respondents provided less than the required 60 hours of practice management curricular time. Residency directors indicated that managed care has had a significant effect on their curriculum. Directors' ratings of the effectiveness of their curriculum were associated with more curricular time and specifically with active learning activities. Although directors reported that managed care had affected how they teach practice management, managed care penetration was not associated with perceived curriculum effectiveness. CONCLUSIONS: Family practice residency program directors described a variety of approaches to teaching practice management. Active learning strategies seem to be important curricular components, although further study is needed about the most-effective methods to prepare physicians for post-residency practice.

Estimating cancer screening indicators in the primary care setting.

The software "Profile: A Cancer Risk Profile of Your Patient Practice" was used to estimate cancer screening activities in a primary care practice. "Profile" is a public health tool that does not track the screening histories of individual patients, but rather, using a sampling strategy, provides estimates for the entire practice of the age and sex specific number of screening eligible patients, the number screened, and the number that should have been screened, based on National Cancer Institute/American Cancer Society (NCI/A CS) guidelines. This report describes "Profile," and the results it generated from a sample of medical records. Primary care providers who seek to integrate primary and secondary cancer prevention activities into their routine practices will find it useful to have an objective estimate of their current level of such activities.

Glycosylated hemoglobin levels and self-reported stress in adults with diabetes.

This study examined the relationship between glycosylated hemoglobin and self-reported stress in a sample of adult Type II diabetics. The study sample was drawn from participants in a randomized clinical trial of the comparative effectiveness of two oral antihyperglycemic drugs in the treatment of non-insulin-dependent diabetes. The 19 study participants were asked to complete a brief questionnaire on recent stress. Stress scores were then compared with levels of glycosylated hemoglobin. Correlations between glycosylated hemoglobin and stress scores were highly significant, a finding of particular clinical relevance in view of the relatively small number of participants. These findings suggest that sustained stress may contribute to poor glucose control in diabetics. Individuals interested in stress-related research may find glycosylated hemoglobin a useful marker of physiological stress.

Tracking and interviewing clients at risk for HIV and substance abuse in a Latino community.

Latino Family Services' (LFS) Outreach and Pre-Treatment Program (OPT) has a mission to increase access of high-risk individuals to substance abuse treatment and HIV/AIDS and related services, and to decrease high-risk behaviors related to HIV/AIDS, TB and/or substance abuse. This mission is addressed through three program components: (1) outreach to high-risk individuals; (2) assessment and referral to needed services; and (3) facilitation of substance abuse pre-treatment didactic and support groups. Part of the OPT's evaluation involved tracking and interviewing clients three and six months after the intake assessment. This paper discusses methodological challenges faced by the evaluator in longitudinal tracking and interviewing a bicultural high-risk population. Recognizing the diversity of the target client population, we developed a culturally sensitive approach to tracking and interviewing Hispanic clients. This included: locating a bilingual/bicultural research interviewer; translating the questionnaire into Spanish; conducting the interviews in Spanish when preferred by the client; identifying effective incentives for participants; and tracking clients in a culturally-sensitive manner. We also describe the approach taken to maintain the methodological rigor of the evaluation. This included: maintaining the objectivity of the interviewer; maintaining the independence of the research interviewer from job roles of program staff; and protecting client confidentiality. Finally, the problems associated with tracking and following-up with this high risk client group are described, as well as the outcomes of such efforts.

The impact of physicians' brief smoking cessation counseling: a MIRNET study.

Although many family physicians may discuss smoking cessation with their patients, few do so consistently. A common belief among many physicians is that such efforts will not deter their patients from smoking. Others believe the time commitment required for a successful intervention is excessive. The present study addressed the above issues by examining the effect of a 3- to 5-minute unstructured physician discussion encouraging smoking cessation with family practice patients. Cigarette-smoking patients of two busy family practices in southeast Michigan were randomly assigned to either a control group receiving routine care or an intervention group receiving, in addition to routine care, smoking cessation counseling from their physician. A third comparison group was drawn from smokers in practices not involved in delivering the intervention. Two hundred thirty-eight patients from the intervention group, 178 from the control group, and 47 from the comparison group were followed up with a telephone interview at 6 months. Intervention group patients made significantly more quit attempts than did those in the control group (P less than .001), which was similar to the comparison group. At the 6-month follow-up, 8% of intervention group members, and 4% of both the comparison and control groups reportedly were abstinent from smoking. Among those contacted at the 1-year follow-up, the respective percentages abstinent were 8%, 3%, and 4%. Although these differences in quit rates were not statistically significant, the findings suggest that physicians can positively affect patient smoking cessation. This intervention was feasible in busy family practices, highlighting its generalizability and applicability to other family practice settings in the United States.