Principles of clinical medicine: Oregon Health Sciences University School of Medicine.

In 1992, the School of Medicine at Oregon Health Sciences University inaugurated a Principles of Clinical Medicine (PCM) course as part of an overall curricular revision. The PCM course, which covers the first and second years of medical school, integrates material from ten separate courses in the previous curriculum. Students learn longitudinally over the two years, rather than "cramming" discrete areas of knowledge and then moving on. Course sessions are related to concurrently taken basic science classes. Meeting two afternoons per week, the PCM course offers preceptorships, health care issues sessions, and patient examination sessions. The PCM course aims to encompass the body of knowledge, skills, and attitudes necessary to become a competent physician. First- and second-year students have more opportunities than previously to interact with patients and practicing physicians in the community. Competition between learning areas, student perceptions of "soft" and "hard" courses, teacher recruitment, and administrative burnout are ongoing difficulties, while faculty recognition and development, administrative commitment and flexibility, and student and faculty feedback all contribute to the success of the course. The PCM course is now the backbone of the first two years of medical school and creates a solid foundation for the third and fourth years.

Use of a group objective structured clinical examination with first-year medical students.

PURPOSE: To evaluate the implementation of a quarterly group objective structured clinical examination (GOSCE) to assess the patient-evaluation abilities of a medical school class. METHOD: The study subjects were 94 first-year students participating in the Principles of Clinical Medicine course at the Oregon Health Sciences University School of Medicine in 1992-93. To create the GOSCE, the authors modified the format of the quarterly objective structured clinical examination by making each standardized-patient station the site of an interaction between a standardized patient and a group of four or five students. The GOSCE's reliability, content and face validity, and expense were evaluated. Student feedback was obtained using a structured questionnaire. RESULTS: Performances varied both among the five stations of the GOSCE and among the 23 student groups: the mean percentage of items performed correctly per station was 83%, with a range of 73-97%. The reliability of the GOSCE's stations was low, with intraclass correlations during the three consecutive quarters of .29, .05, and .12. Despite no prior experience with this type of testing, the students' mean rating of the GOSCE's appropriateness was 3.8 (on a Likert scale of 1, poor, to 5, excellent), compared with 2.5 for the appropriateness of the written examination also used for quarterly assessment. The expense of the GOSCE was much less than the costs reported for the OSCE format. CONCLUSION: The use of the quarterly GOSCE favorably influenced the students, faculty, and curriculum. The GOSCE format made possible the assessment of a large number of students' abilities, without the time and expense needed to evaluate students individually.

The use and compensation of community preceptors in U.S. medical schools.

PURPOSE: To better understand how U.S. medical schools are using and compensating community preceptors. METHOD: In 1995, the authors sent questionnaires to associate deans for education at all 125 U.S. medical schools. Each questionnaire asked whether that school used community preceptors to teach students and, if so, from what disciplines community preceptors came, at what sites community preceptors taught students, how community preceptors were compensated, and how these factors varied for each year of medical school. RESULTS: One hundred schools (80%) completed the questionnaire. Ninety-six reported using community preceptors. Primary care physicians were used most often, and private practices were the dominant teaching location. A clinical academic appointment was the most common compensation. Few schools compensated community preceptors monetarily. Community preceptors' involvement was substantial in all four years, but greatest in year three. CONCLUSION: Community preceptors are widely used in educating medical students, especially in year three. More recognition and better compensation of these important educators is necessary.

Using a sociomatrix to evaluate the effectiveness of small-group teaching to residents.

This article describes a 1988 pilot study in a family medicine residency program of the use of a sociomatrix to assess small-group teaching. A multidisciplinary team developed a sociomatrix coding sheet, which was used by a family physician-psychiatrist to classify behaviors seen on videotaped small-group teaching sessions, which were held at the conclusion of patient care activities. Although the sociomatrix appears to have the potential to relate specific leader behaviors to residents' feedback regarding subjective learning outcomes, the number of observations was too small to permit clear conclusions regarding optimal teaching behaviors and styles.

Comparative cytologic yield and quality of three Pap smear instruments.

BACKGROUND: Various sampling techniques of the cervix have established false negative rates ranging from 18% to 45%. A number of studies suggest that this false negative rate can be reduced by sampling techniques that are associated with higher yields of endocervical cells. METHOD: This study enrolled 301 women, each of whom had a Pap smear obtained using three different sampling instruments (a cervical brush, a plastic spatula, and a cotton swab) in random order. RESULTS: The cervical brush yielded a better endocervical sample than either of the other instruments (P < .001), and there was no difference between the swab and spatula. In addition, the recovery of endocervical cells increased with each additional sample taken, regardless of instrument used (P < .001), although the difference in yield between the second and third samples was not significant. CONCLUSIONS: To enhance the yield of endocervical cells in Pap smear sampling, consideration should be given to using the cervical brush routinely as a sampling instrument and to taking more than one sample per screening.

Failure of insulin treatment in obese patients with non-insulin-dependent diabetes mellitus.

A number of experts recommend the use of insulin for patients with non-insulin-dependent diabetes mellitus (NIDDM) who fail to respond to diet, exercise, and oral hypoglycemics, even when the patient is morbidly obese. This article describes the use of insulin in two obese patients with NIDDM whose obesity worsened following the institution of insulin therapy. In some cases the risk for increased obesity and its complications following the institution of insulin may offset the potential benefits of insulin therapy itself. There are two main drawbacks associated with insulin therapy in these patients. First, from a medical point of view, insulin has a lipogenic effect and may actually contribute to weight gain, hyperinsulinemia, and increased insulin resistance in obese patients with NIDDM. Second, from a behavioral point of view, the institution of insulin therapy may shift the patient's and physician's focus from the preferred lifestyle adjustments to the numerous details associated with insulin use and monitoring. Since weight gain and sedentary activity are themselves risk factors for coronary artery disease, the benefits of decreased blood glucose levels should be balanced against the risk of increased weight gain in these patients.

The relationship between assessed obstetric risk and maternal-perinatal outcome.

The relationship between antepartum risk assessment and subsequent maternal and perinatal outcome was examined in a retrospective study of 430 randomly selected deliveries at the Oregon Health Sciences University during the 1986 calendar year. Antepartum risk scores at the initial prenatal visit and at 37 weeks' gestation were positively correlated with each other. Antepartum risk scores were correlated with maternal length of stay and maternal hospital charges, but not with gestational age, birth weight, or Apgar scores. Increased intrapartum risk scores were strongly correlated with increasing length of stay for mother and baby, lower birth weight, and lower estimated gestational age at birth. The ability of the risk-scoring system to predict selected adverse outcomes was then assessed using a high-risk cutoff score of 5 or greater. Sensitivity and positive predictive value were found to be quite low while specificity and negative predictive value were reasonably high. The results suggest that the risk-scoring system used at this institution is effective in identifying low obstetrical risk and that prenatal care reduces the probability of poor neonatal outcome among infants of women at high obstetrical risk identified through antepartum multivariate assessment. Two antepartum risk assessments, each measuring different factors, may be redundant. Not yet known are which specific factors by their identification result in more effective prenatal care.

Characteristics and perceptions of nicotine patch users.

BACKGROUND: Although transdermal nicotine patches are frequently prescribed to aid in smoking cessation, little information exists about their use in general medical practice. In clinical studies, nicotine patches have been found to be effective when used in conjunction with nonpharmacologic interventions, such as physician counseling and follow-up visits. This study examines the characteristics and perceptions of patients regarding treatment with nicotine patches. METHODS: Patients filling or refilling prescriptions for a nicotine patch at 17 pharmacies were asked to complete a questionnaire. RESULTS: Seventy-six questionnaires were returned. Thirty-six percent of the respondents first learned about the nicotine patch from the media, 32% from friends, family, or co-workers, and 25% from their physicians. Most respondents (87%) had requested the patch, whereas only 9% had been asked by their prescriber to try the patch. Most of the surveyed smokers were highly motivated to quit, and 86% smoked at least one pack per day. Eighty percent indicated they had received a clear message from their physicians to quit, 56% said their physician had counseled them about relapse, and 55% had follow-up arranged. A quit date had been set by 37%, and only 24% reported the use of self-help materials. Approximately one half of smokers (54%) who had started using the patch indicated that they continued to smoke. CONCLUSIONS: Most respondents were good candidates for the nicotine patch based on how much they smoked and their motivation to quit. Direct-to-consumer advertising may have influenced many smokers to request treatment with the patch. Physicians should recognize that some persons may use the patch as a "quick fix," as very few respondents used the number of nonpharmacologic interventions that have proved useful in nicotine patch clinical trials. Physicians should follow the progress of patch users to ensure that they completely stop smoking during treatment.

The immunogenicity and safety of intradermal hepatitis B vaccine.

BACKGROUND: One of the chief barriers to a greater use of hepatitis B vaccine is the high cost of the vaccine itself. A number of small research trials have shown that an adequate immune response can be induced at a much lower cost by administering one tenth of the vaccine using an intradermal technique. The purpose of this study was to ascertain whether these results could be replicated in a larger clinical trial. METHODS: Vaccine recipients included health care providers, police officers, and firefighters. Recipients were given 0.1 mL of plasma-derived hepatitis B vaccine intradermally on days 1, 30, and 180. Antibody response was measured on day 210, with seroconversion defined as a sample-to-negative (S/N) ratio of greater than or equal to 10. Any local and systemic side effects were documented. RESULTS: Six hundred sixteen individuals completed the vaccination series, and seroconversion occurred in 534 (86.7%). The rate of seroconversion in those younger than 40 years was 91.2% and in those 40 years and older was 75.1%. The mean S/N ratio was 154.9 (range 0 to 620) and decreased with increasing age (r = -.25, P = .0001). Side effects were largely limited to local reactions. CONCLUSIONS: The results support the use of the intradermal technique as a cost-effective alternative to the intramuscular route in individuals younger than 40 years. The intradermal technique may be used in older individuals if titers are obtained to assure seroconversion. Because of the restricted availability of the plasma-derived vaccine used in this study, similar trials with recombinant vaccine should be undertaken.

Dorsal penile nerve block for newborn circumcision.

Dorsal penile nerve block with lidocaine is safe and effective for reducing the pain associated with newborn circumcision. Administering the anesthesia adds little time or expense to the overall routine. Complications are minor, limited to local bleeding and hematoma formation. Family physicians performing circumcision should be prepared to use penile nerve block and to advocate it to parents who choose newborn circumcision.

Hopes and concerns of a first-year medical school class.

To assess the hopes and concerns of first-year medical students, the 1991 Oregon Health Sciences University (OHSU) Medical School class was surveyed during orientation. Using qualitative research methods, student responses were grouped into general categories. The most common 'hopes' were to provide personal care and develop relationships with patients, to attain self-fulfillment, and to enjoy the personal challenge and variety of medicine. Common 'concerns' were family issues, outside intervention into medicine, and loss of self. The hopes and concerns of this class revolve primarily around personal issues, rather than issues relating to their local community or to society. This information may be useful in student counselling and curriculum development. Further research is necessary to evaluate changes in this class's attitudes over time. The methodology of this study may be useful in the evaluation of the attitudes of subsequent first-year medical school classes at OHSU, and at other institutions.