The residency interview is still paramount: results of a retrospective cohort study on concordance of dermatology residency applicant evaluators and influence of the applicant interview.

Application to dermatology residency is a highly competitive process. Although factors associated with successfully matching have been studied, less is known regarding the ability of admissions committees to screen applicants in a uniform manner or the importance of the interview in ranking applicants. Our goal was to retrospectively measure our admission committee evaluators' concordance regarding residency application credentials and interview performance, and ultimately the effects on final applicant ranking.

Factors associated with presence of pharmacies and pharmacies that sell syringes over-the-counter in Los Angeles County.

Community pharmacies serve as key locations for public health services including interventions to enhance the availability of syringes sold over-the-counter (OTC), an important strategy to prevent injection-mediated HIV transmission. Little is known about the community characteristics associated with the availability of pharmacies and pharmacies that sell syringes OTC. We conducted multivariable regression analyses to determine whether the sociodemographic characteristics of census tract residents were associated with pharmacy presence in Los Angeles (LA) County during 2008. Using a geographic information system, we conducted hot-spot analyses to identify clusters of pharmacies, OTC syringe-selling pharmacies, sociodemographic variables, and their relationships. For LA County census tracts (N = 2,054), population size (adjusted odds ratio [AOR], 1.22; 95 % confidence interval [CI], 1.16, 1.28), median age of residents (AOR, 1.03; 95 % CI, 1.01, 1.05), and the percent of households receiving public assistance (AOR, 0.97; 95 % CI, 0.94, 0.99) were independently associated with the presence of all pharmacies. Only 12 % of census tracts had at least one OTC syringe-selling pharmacy and sociodemographic variables were not independently associated with the presence of OTC syringe-selling pharmacies. Clusters of pharmacies (p < 0.01) were located proximally to clusters of older populations and were distant from clusters of poorer populations. Our combined statistical and spatial analyses provided an innovative approach to assess the sociodemographic and geographic factors associated with the presence of community pharmacies and pharmacies that participate in OTC syringe sales.

A Review of Potential Electrochemical Applications in Buildings for Energy Capture and Storage.

The integration of distributed renewable energy technologies (such as building-integrated photovoltaics (BIPV)) into buildings, especially in space-constrained urban areas, offers sustainable energy and helps offset fossil-fuel-related carbon emissions. However, the intermittent nature of these distributed renewable energy sources can negatively impact the larger power grids. Efficient onsite energy storage solutions capable of providing energy continuously can address this challenge. Traditional large-scale energy storage methods like pumped hydro and compressed air energy have limitations due to geography and the need for significant space to be economically viable. In contrast, electrochemical storage methods like batteries offer more space-efficient options, making them well suited for urban contexts. This literature review aims to explore potential substitutes for batteries in the context of solar energy. This review article presents insights and case studies on the integration of electrochemical energy harvesting and storage into buildings. The seamless integration can provide a space-efficient source of renewable energy for new buildings or existing structures that often have limited physical space for retrofitting. This work offers a comprehensive examination of existing research by reviewing the strengths and drawbacks of various technologies for electrochemical energy harvesting and storage, identifying those with the potential to integrate into building skins, and highlighting areas for future research and development.

Gold-like activity copper-like selectivity of heteroatomic transition metal carbides for electrocatalytic carbon dioxide reduction reaction.

An overarching challenge of the electrochemical carbon dioxide reduction reaction (eCO2RR) is finding an earth-abundant, highly active catalyst that selectively produces hydrocarbons at relatively low overpotentials. Here, we report the eCO2RR performance of two-dimensional transition metal carbide class of materials. Our results indicate a maximum methane (CH4) current density of -421.63 mA/cm2 and a CH4 faradic efficiency of 82.7% ± 2% for di-tungsten carbide (W2C) nanoflakes in a hybrid electrolyte of 3 M potassium hydroxide and 2 M choline-chloride. Powered by a triple junction photovoltaic cell, we demonstrate a flow electrolyzer that uses humidified CO2 to produce CH4 in a 700-h process under one sun illumination with a CO2RR energy efficiency of about 62.3% and a solar-to-fuel efficiency of 20.7%. Density functional theory calculations reveal that dissociation of water, chemisorption of CO2 and cleavage of the C-O bond-the most energy consuming elementary steps in other catalysts such as copper-become nearly spontaneous at the W2C surface. This results in instantaneous formation of adsorbed CO-an important reaction intermediate-and an unlimited source of protons near the tungsten surface sites that are the main reasons for the observed superior activity, selectivity, and small potential.

Treatment of dermatosis papulosa nigra in 10 patients: a comparison trial of electrodesiccation, pulsed dye laser, and curettage.

BACKGROUND: Dermatosis papulosa nigra (DPN) is a common variant of seborrheic keratoses in darkly pigmented individuals. Treatment options include cryosurgery, curettage, electrosurgery, and shave removal. OBJECTIVE: To compare the efficacy and complications of pulsed dye laser (PDL) therapy for the treatment of DPN with those of curettage and electrodesiccation. METHODS AND MATERIALS: Randomized, controlled, single-center, evaluator-blinded trial of 10 patients with at least four clinically diagnosed lesions. RESULTS: All 10 patients completed the study. Mean lesion clearance was 96% for curettage, 92.5% for electrodesiccation, and 88% for laser. There was no significant difference between the three treatment modalities. All three techniques had an overall cosmetic outcome of good for most patients. Five of the 10 patients preferred electrodesiccation. Patients rated the laser as the most painful treatment method. The most common adverse outcome was hyperpigmentation. There were no significant differences between the treatment groups for any of the measured outcomes. CONCLUSION: The efficacy of PDL in the treatment of DPN is not significantly different from the already established treatment modalities of electrodesiccation and curettage. The authors have indicated no significant interest with commercial supporters.

Training residents to employ self-efficacy-enhancing interviewing techniques: randomized controlled trial of a standardized patient intervention.

BACKGROUND: Current interventions to enhance patient self-efficacy, a key mediator of health behavior, have limited primary care application. OBJECTIVE: To explore the effectiveness of an office-based intervention for training resident physicians to use self-efficacy-enhancing interviewing techniques (SEE IT). DESIGN: Randomized controlled trial. PARTICIPANTS: Family medicine and internal medicine resident physicians (N = 64) at an academic medical center. MEASUREMENTS: Resident use of SEE IT (a count of ten possible behaviors) was coded from audio recordings of the physician-patient portion of two standardized patient (SP) instructor training visits and two unannounced post-training SP visits, all involving common physical and mental health conditions and behavior change issues. One post-training SP visit involved health conditions similar to those experienced in training, while the other involved new conditions. RESULTS: Experimental group residents demonstrated significantly greater use of SEE IT than controls, starting after the first training visit and sustained through the final post-training visit. The mean effect of the intervention was significant [adjusted incidence rate ratio for increased use of SEE IT = 1.94 (95% confidence interval = 1.34, 2.79; p < 0.001)]. There were no significant effects of resident gender, race/ethnicity, specialty, training level, or SP health conditions. CONCLUSIONS: SP instructors can teach resident physicians to apply SEE IT during SP office visits, and the effects extend to health conditions beyond those used for training. Future studies should explore the effects of the intervention on practicing physicians, physician use of SEE IT during actual patient visits, and its influence on patient health behaviors and outcomes.

A procedure to characterize geographic distributions of rare disorders in cohorts.

BACKGROUND: Individual point data can be analyzed against an entire cohort instead of only sampled controls to accurately picture the geographic distribution of populations at risk for low prevalence diseases. Analyzed as individual points, many smaller clusters with high relative risks (RR) and low empirical p values are indistinguishable from a random distribution. When points are aggregated into areal units, small clusters may result in a larger cluster with a low RR or be lost if divided into pieces included in units of larger populations that show no increased prevalence. Previous simulation studies showed lowered validity of spatial scan tests for true clusters with low RR. Using simulations, this study explored the effects of low cluster RR and areal unit size on local area clustering test (LACT) results, proposing a procedure to improve accuracy of cohort spatial analysis for rare events. RESULTS: Our simulations demonstrated the relationship of true RR to observed RR and p values with various, randomly located, cluster shapes, areal unit sizes and scanning window shapes in a diverse population distribution. Clusters with RR < 1.7 had elevated observed RRs and high p values. We propose a cluster identification procedure that applies parallel multiple LACTs, one on point data and three on two distinct sets of areal units created with varying population parameters that minimize the range of population sizes among units. By accepting only clusters identified by all LACTs, having a minimum population size, a minimum relative risk and a maximum p value, this procedure improves the specificity achieved by any one of these tests alone on a cohort study of low prevalence data while retaining sensitivity for small clusters. The procedure is demonstrated on two study regions, each with a five-year cohort of births and cases of a rare developmental disorder. CONCLUSION: For truly exploratory research on a rare disorder, false positive clusters can cause costly diverted research efforts. By limiting false positives, this procedure identifies 'crude' clusters that can then be analyzed for known demographic risk factors to focus exploration for geographically-based environmental exposure on areas of otherwise unexplained raised incidence.

Patient gender and physician practice style.

BACKGROUND: Patient and physician gender may impact the process of medical care and its outcomes. Our objective was to investigate the influence of patient gender on what takes place during initial primary care visits while controlling for other variables previously demonstrated to affect the physician-patient interaction, such as physician gender and specialty, patient health status, pain, depression, obesity, age, education, and income. METHODS: New patients (315 women, 194 men) were randomized for care by 105 primary care physicians. Sociodemographic information, self-reported health status and pain measures, a depression evaluation, screening for alcoholism, history of tobacco use, and measured body mass index (BMI) were collected during a previsit interview. The entire medical visit was videotaped, and then analyzed using the Davis Observation Code (DOC) system. RESULTS: There was no significant difference in the visit length or work intensity (number of behavioral codes) for female patients compared with male patients; however, women's visits had more discussions regarding the results of the therapeutic interventions, more preventive services, less physical examination, and fewer discussions about tobacco, alcohol, and other substance abuse. CONCLUSIONS: There are significant differences in the process of care between female and male patients. Physicians may be making medical decisions based on gender-related considerations. Strategies for implementing knowledge about these gender differences are crucial for the delivery of gender-sensitive care.

The Palliative Care in Assisted Living (PCAL) pilot study: successes, shortfalls, and methodological implications.

Troubling deficits exist in palliative care (PC) of older adults under the prevailing "terminal care"-oriented model. We previously described a PC model--TLC--that provides a blueprint for remedying these shortfalls. In this model, PC is envisioned as Timely and Team-oriented, Longitudinal, and Collaborative and Comprehensive. We present results of the Palliative Care in Assisted Living pilot, comparing two TLC model-based, facility delivered interventions for improving the PC of elderly assisted living residents in Sacramento, California, a growing and under-researched population. The less intensive intervention involved one assessment followed by a PC improvement recommendation letter to the resident, family member, primary provider, and facility staff, while the more intensive intervention involved assessments and letters every three months. Primary outcomes were SF-36 Physical (PCS) and Mental (MCS) Component scores and recommendation adherence. Eighty-one subjects enrolled (mean age 85), 58 in the more and 23 in the less intensive group. A loved one attended 56% of baseline assessments. Most subjects expressed a preference for maintaining current quality of life over prolonging life at reduced quality. None were eligible for hospice care. A total of 418 recommendations (mean 5.1 per subject) were generated concerning symptoms, mood, functional impairments, and advance directives. We found no significant differences in recommendation adherence between more (42%) and less (44%) intensive groups, and no significant changes in PCS and MCS scores within or between groups. However, a loved one's attendance of the baseline assessment was associated with improved PCS scores (p=0.04). Our pilot study had methodological limitations that could account for the lack of significant outcome effects. In this context, and given the myriad unmet PC needs we detected, interventions based on the TLC model might allow delivery of timely PC to assisted living residents not eligible for hospice care. Further studies exploring the TLC model appear warranted.

Body mass index is not a good predictor of bone density: results from WHI, CHS, and EPIDOS.

Body mass index (BMI) is often used to predict bone mineral density (BMD). This may be flawed. Large epidemiologic studies with BMI and BMD data were analyzed. Weight alone is a better predictor of BMD than BMI. Thus, when selecting individuals for dual-energy X-ray absorptiometry, weight should be used instead of BMI. Low body mass index (BMI) is frequently suggested as one of the factors that indicates the need for bone mineral density (BMD) screening for osteoporosis. The inclusion of the height-squared term in the denominator of this predictive factor is taken on faith or from other data, but it may not be reasonable in this case. We used data from three large epidemiologic studies to test the BMI, height, and weight as predictors of BMD: (1) the Women's Health Initiative (WHI) with 11,390 women; (2) the Cardiovascular Health Study (CHS) with 1,578 men and women; (3) and EPIDOS with 7,598 women. Dual-energy X-ray absorptiometry data on one or more BMD sites, the total hip, the femoral neck, and the lumbar spine from the three studies, as well as height and weight were examined. Correlation coefficients for BMI and weight with BMD were compared. Log transformed models were evaluated to compare the strengths of the models. The result of weight alone was a much better predictor of BMD for all sites in the three studies than BMI. Taller participants had larger BMDs than would have been predicted by BMI. In conclusion, BMIs should not be used to select individuals for BMD screening. A regression model using weight alone or weight and height is a better predictor of BMD in all three populations.

The influence of obesity, alcohol abuse, and smoking on utilization of health care services.

BACKGROUND AND OBJECTIVES: There is extensive evidence relating individual behavioral risk factors to adverse health outcomes and associated costs; however, more-comprehensive assessments have been limited. Our objective was to examine the relative effects of obesity, alcohol abuse, and smoking on health care use and associated charges. METHODS: New adult patients (n=509) were randomly assigned to primary care physicians, and their utilization of medical services was monitored for 1 year. Variables measured included sociodemographics, self-reported health status, Beck Depression Index, measured body mass index, Michigan Alcohol Screening Test results, and smoking history. RESULTS: Controlling for health status, depression, age, education, income, and gender, obesity was associated with the mean number of primary care visits, diagnostic services, and primary care clinic charges. Alcohol abuse was related to the mean number of emergency department visits and diagnostic services. Smoking was associated with the mean number of specialty clinic visits and hospitalizations. Smoking also predicted charges for emergency department visits, hospitalizations, and total health care charges. CONCLUSIONS: The economic burden of smoking is significant, even after only 1 year. Health care providers should focus attention on smoking prevention and cessation programs as an approach for managing medical costs.

Use of conventional and complementary health care during the transition to menopause: longitudinal results from the Study of Women's Health Across the Nation (SWAN).

OBJECTIVE: Women beginning the transition to menopause now have access to complementary and alternative therapies (CAM) that were not universally available in the past. Little is known about the association between CAM use and the use of conventional health care during menopause. We investigated the longitudinal association between use of CAM therapies and utilization of conventional health care in a large, multiethnic sample of midlife women who were enrolled in the cohort phase of the Study of Women's Health Across the Nation (SWAN). DESIGN: We used generalized estimating equations, repeated measures modeling to examine the association between CAM use and the yearly number of conventional health-care contacts, adjusting for relevant covariates, during a two-year period. CAM use was evaluated longitudinally as continuous, incident (no CAM use at baseline), sporadic, or no use during the study period. RESULTS: Relative to nonusers, continuous CAM users had more conventional health-care contacts (beta 0.14, 95% CI 0.06, 0.21). Incident users and sporadic users also showed an excess in conventional health-care contacts (beta 0.14, CI 0.06, 0.22) and (beta 0.09, CI 0.01, 0.16), respectively. Ethnicity was independently associated with health-care contacts. Relative to white women, Japanese women had fewer contacts (beta -0.18, CI -0.31, -0.05). CONCLUSIONS: Despite being a generally healthy, well-educated and high-income population with good access to health care, CAM users were using more of both conventional and alternative health-care resources than women who did not use CAM. These findings have practical implications for conventional health-care practitioners, allied health professionals and CAM practitioners.

Direct observation of requests for clinical services in office practice: what do patients want and do they get it?

BACKGROUND: Requests can influence the conduct and content of the medical visit. However, little is known about the nature, frequency, and impact of such requests. We performed this study to ascertain the prevalence, antecedents, and consequences of patients' requests for clinical services in ambulatory practice. METHODS: This observational study combined patient and physician surveys with audiotaping of 559 visits to 45 physicians in 2 health care systems between January and November 1999. All patients had a new problem or significant health concern. Main outcome measures included prevalence of 8 categories of requests for physician action; odds of patients' requesting tests, referrals, or new prescriptions; odds of physicians' ordering diagnostic tests, making specialty referrals, or writing new prescriptions; patient satisfaction; and physicians' perceptions of the visit. RESULTS: The 559 patients made 545 audiocoded requests for physician action; 23% requested at least 1 diagnostic test, specialty referral, or new prescription medication. Requests for diagnostic tests were more common among new patients (P<.001). Requests for any clinical service were more common among patients experiencing greater health-related distress (P<.05) and less common among patients of cardiologists (P<.001). After adjusting for predisposing, need, and contextual factors, referral requests were associated with higher odds of receiving specialty referrals (adjusted odds ratio [AOR], 4.1; 95% confidence interval [CI], 1.6-10.7) and prescription requests were associated with higher odds of receiving new prescription medications (AOR, 2.8; 95% CI, 1.2-6.3). Physicians reported that visits during which patients requested diagnostic tests were more demanding than visits in which no such requests were made (P =.02). CONCLUSIONS: Though more common in primary care than in cardiology, patients' requests for clinical services are both pervasive and influential. The results support placing greater emphasis on understanding and addressing the patient's role in determining health care utilization.

Recruitment strategies for minority participation: challenges and cost lessons from the POWER interview.

BACKGROUND: The importance of recruiting and retaining women from diverse populations is well recognized; however, the recruitment process often presents greater challenges at higher costs than initially anticipated. OBJECTIVES: To describe recruitment strategies and costs from a study evaluating women's preferences regarding tamoxifen use for primary prevention of breast cancer. DESIGN: Description and analysis of recruitment strategies, outcomes, and costs for a cross-sectional interview study. SETTING: University hospital and community sites. PARTICIPANTS: 932 racially and ethnically diverse women respondents, of whom 771 completed the screening process (aged 27-87). INTERVENTION: Women were recruited and screened by using the Breast Cancer Risk Assessment Program (BCRA version 1, National Cancer Institute). Eligibility required an estimated five-year breast cancer risk of at least 1.7%. Recruitment goals targeted a high percentage of ethnic minorities. METHODS: Recruitment strategies included direct mail, flyers, newspapers, media advertising, and community outreach. RESULTS: Of the 771 screened women, 341 (44%) met eligibility criteria and 255 (33%) completed interviews (76.9% White, 10.6% Latina, 7.0% Asian, 3.9% African American, 1.6% Native American). Recruitment costs averaged US $113/screened participant. Direct mail and community contact yielded the largest number of participants (312 screened, 205 eligible). Radio advertising provided few participants (one screened, one eligible) at high cost. CONCLUSIONS: Recruiting an ethnically diverse sample presented multiple challenges. We recommend that future studies budget adequately for recruitment time and costs, develop ongoing relationships with key community leaders, evaluate recruitment strategies closely, and report detailed recruitment findings to the research community.

Influence of patients' requests for direct-to-consumer advertised antidepressants: a randomized controlled trial.

CONTEXT: Direct-to-consumer (DTC) advertising of prescription drugs in the United States is both ubiquitous and controversial. Critics charge that it leads to overprescribing, while proponents counter that it helps avert underuse of effective treatments, especially for conditions that are poorly recognized or stigmatized. OBJECTIVE: To ascertain the effects of patients' DTC-related requests on physicians' initial treatment decisions in patients with depressive symptoms. DESIGN: Randomized trial using standardized patients (SPs). Six SP roles were created by crossing 2 conditions (major depression or adjustment disorder with depressed mood) with 3 request types (brand-specific, general, or none). SETTING: Offices of primary care physicians in Sacramento, Calif; San Francisco, Calif; and Rochester, NY, between May 2003 and May 2004. PARTICIPANTS: One hundred fifty-two family physicians and general internists recruited from solo and group practices and health maintenance organizations; cooperation rates ranged from 53% to 61%. INTERVENTIONS: The SPs were randomly assigned to make 298 unannounced visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder. The SPs made a brand-specific drug request, a general drug request, or no request (control condition) in approximately one third of visits. MAIN OUTCOME MEASURES: Data on prescribing, mental health referral, and primary care follow-up obtained from SP written reports, visit audiorecordings, chart review, and analysis of written prescriptions and drug samples. The effects of request type on prescribing were evaluated using contingency tables and confirmed in generalized linear mixed models that accounted for clustering and adjusted for site, physician, and visit characteristics. RESULTS: Standardized patient role fidelity was excellent, and the suspicion rate that physicians had seen an SP was 13%. In major depression, rates of antidepressant prescribing were 53%, 76%, and 31% for SPs making brand-specific, general, and no requests, respectively (P<.001). In adjustment disorder, antidepressant prescribing rates were 55%, 39%, and 10%, respectively (P<.001). The results were confirmed in multivariate models. Minimally acceptable initial care (any combination of an antidepressant, mental health referral, or follow-up within 2 weeks) was offered to 98% of SPs in the major depression role making a general request, 90% of those making a brand-specific request, and 56% of those making no request (P<.001). CONCLUSIONS: Patients' requests have a profound effect on physician prescribing in major depression and adjustment disorder. Direct-to-consumer advertising may have competing effects on quality, potentially both averting underuse and promoting overuse.

Impact of environmental tobacco smoke on children with sickle cell disease.

BACKGROUND: Parallels between the biological effects of exposure to environmental tobacco smoke (ETS) on nonsmokers and the pathophysiology of sickle cell disease (SCD) suggest that complications of SCD could be exacerbated by ETS exposure. OBJECTIVE: To determine whether children with SCD who are exposed to ETS at home have more sickle cell crises than do those who live in nonsmoking households. DESIGN: A retrospective cohort study in which ETS exposure was measured by using a survey of caretakers and patients. SETTING: A university-based pediatric sickle cell center. PARTICIPANTS: Fifty-two of 66 eligible children aged 2 to 18 years with SCD. OUTCOME MEASURES: The number of sickle cell vaso-occlusive crises requiring hospitalization per patient during the 2-year study (inpatient sickle cell crises). Total hospital days and hospital costs were secondary outcome measures. RESULTS: Patients exposed to ETS had more inpatient sickle cell crises than did unexposed patients (mean +/- SD, 3.7 +/- 5.7 vs 1.7 +/- 3.5; P =.02), and this association retained significance after adjustment for important covariates (risk ratio, 1.9; 95% confidence interval, 1.3-2.7). Hospital costs were greater in the exposed group than in the unexposed group (mean +/- SD, 21,671 US dollars +/- 41,809 US dollars vs 9705 US dollars +/- 19 146 US dollars; effect estimate, 11.4; 95% confidence interval, 1.0-129.5). CONCLUSIONS: Children with SCD who are exposed to ETS have a higher risk of sickle cell crises requiring hospitalization than do those not exposed, independent of other factors known to increase the frequency of sickle cell crises. Decreasing the exposure of these children to ETS could reduce morbidity and may provide cost savings.

Validity of scores generated by a web-based multimedia simulated patient case software: a pilot study.

PURPOSE: The value of multimedia simulated patient cases (MSPCs) in medical education remains unclear. The authors conducted a pilot study to assess the validity of automated scores of diagnostic reasoning ability provided by DxR Clinician, a widely available Web-based MSPC software. METHOD: In 2002-03, all 89 students enrolled in a required third-year primary care clerkship at the University of California, Davis, School of Medicine were assigned to complete four MSPCs. The authors determined the degree of correlation between the Clinical Reasoning Score (CRS) and Level of Diagnostic Performance (LDP) generated by the MSPC software and subscale scores from a validated measure of diagnostic reasoning sophistication, the Diagnostic Thinking Inventory (DTI). RESULTS: Of 356 completed case events, instructor override of automated scoring was required in 206 (58%) to obtain an accurate LDP and CRS. Mean DTI subscale scores improved significantly from the beginning to the end of the year (p <.0001, Wilcoxon signed rank test). However, there were no significant correlations between CRS or LDP scores on any of the four cases and either of the two DTI subscale scores. CONCLUSION: Automated diagnostic reasoning scores generated by one widely available MSPC software appear to lack criterion validity. The validity of automated diagnostic reasoning scores generated by MSPCs should be established before such cases can be confidently employed as educational tools.

Patient pain: its influence on primary care physician-patient interaction.

BACKGROUND AND OBJECTIVES: Heightened awareness of the importance of appropriate pain management in health care delivery has stimulated researchers to examine the impact of patient pain on medical encounters. In this study, we explored how patient pain might influence the physician-patient interaction during medical visits. METHODS: New adult patients (n = 509) were randomized to see primary care physicians in videotaped visits at a university medical center Self-reported patient pain was measured before the visit using the Visual Analog Scale and the Medical Outcomes Study Short Form-36 (MOS SF-36) pain scale; patient sociodemographics were also measured. Physician practice style during the visit was analyzed with the Davis Observation Code (DOC). RESULTS: Regression analyses revealed that patient pain during the medical visit was associated with the physician spending a greater portion of the visit on technical tasks and a smaller portion on preventive services and other activities designed to encourage the patients' active participation in their own health care. CONCLUSIONS: Patient pain may influence the physician-patient interaction and its outcomes. Primary care physicians should be aware that there may be less focus on patients' active involvement in their own care and less emphasis on providing disease prevention when treating patients who are experiencing pain.

Does time use in outpatient residency training reflect community practice?

BACKGROUND: The degree to which the ideals practiced during residency training persist amidst the pressures of community practice is unknown. Therefore, this paper compares time use during outpatient visits to family practice residents and experienced family physicians. METHODS: Visits of 244 new adult outpatients to 33 second- and third-year residents in a university clinic in Northern California were compared to 277 new adult outpatient visits to 92 community family physicians in Northeast Ohio, using the Davis Observation Code (DOC). The DOC uses observation to classify visit time into 20 different behavioral categories, reflecting different physician styles of interaction with patients. RESULTS: Controlling for patient mix, residents had longer visits, a less technical focus, and spent a greater percent of the visit on efforts to promote health behavior change, patient activation, preventive services, discussion of substance abuse, and counseling. CONCLUSIONS: Experienced family physicians provide more technical and less preventive and psychosocially oriented care than residents. This may reflect differences in patient mix, practice setting, physician experience, and the time and financial pressures of community practice. These findings may be used to modify residency training to better reflect actual community practice and to guide future studies of the effects of experience and different practice environments on physician style with patients.

Association of higher costs with symptoms and diagnosis of depression.

OBJECTIVES: We examined the relationships among depressive symptoms, physician diagnosis of depression, and charges for care. STUDY DESIGN: We used a prospective observational design. POPULATION: Five hundred eight new adult patients were randomly assigned to senior residents in family practice and internal medicine. OUTCOMES MEASURED: Self-reports of health status assessment (Medical Outcomes Study Short Form-36) and depressive symptoms (Beck Depression Inventory) were determined at study entry and at 1-year follow-up. Physician diagnosis of depression was determined by chart audit; charges for care were monitored electronically. RESULTS: Symptoms of depression and the diagnosis of depression were associated with charges for care. Statistical models were developed to identify predictors for the occurrence and magnitude of medical charges. Neither depressive symptoms nor diagnosis of depression significantly predicted the occurrence of charges in the areas studied, but physician diagnosis of depression predicted the magnitude of primary care and total charges. CONCLUSIONS: A complex relationship exists among depressive symptoms, the diagnosis of depression, and charges for medical care. Understanding these relationships may help primary care physicians diagnose depression and deliver primary care to depressed patients more effectively while managing health care expenditures.