Strategies for efficient and effective teaching in the ambulatory care setting.

Medical education in the ambulatory care setting is characterized in part by the question of how to ensure educational effectiveness while simultaneously providing high-quality, cost-effective patient care. The constraints associated with managed care have only served to escalate the intensity of this dilemma. However, in spite of the difficulties faced by ambulatory care preceptors, there are educationally sound and time-efficient strategies clinical teachers may employ to improve ambulatory care education. Emphasizing the basic three-step process of planning, teaching, and reflection, the authors describe five such strategies: "wave" scheduling, orienting learners to patients, having learners do their case presentations in the examination room, employing the microskills of the "one-minute preceptor," and effectively reflecting on one's teaching in order to develop effective teaching scripts. Research in ambulatory care learning has indicated that learners must be given significant roles in patient care and that preceptors must observe trainees as they care for patients so that they can provide trainees with helpful feedback. Employing these strategies in the ambulatory care setting will help educators to accomplish these two objectives while minimizing disruption to cost-effective, high-quality clinical practice.

Ambulatory teaching "lite": less clinic time, more educationally fulfilling.

Typically, the primary instructional method for ambulatory care education is direct interaction between a preceptor and a learner during a patient encounter. This paper describes instructional strategies teachers and learners can use in ambulatory care training that can occur before or after scheduled clinic hours, thus providing instruction without disrupting a preceptor's busy clinic. First, they describe how preceptors and clerkship or residency-program directors can orient learners prior to their arrival at assigned sites, so that learners are better prepared to assume their patient-care responsibilities. Then they discuss strategies for making use of various types of conferences and independent learning activities to enhance learners' clinical experiences. Conferences and independent study projects that occur before clinic hours can help learners bring a higher level of thinking and clinical sophistication to their role in the ambulatory care site; conferences and independent study activities that occur after clinic hours give learners an opportunity to reinforce and expand on what they have learned during clinic. In this way, learners' educational experiences are enhanced, the best use is made of preceptors' time and expertise, and clinic efficiency is not disrupted.

Medical problems of homeless and nonhomeless persons attending an inner-city clinic: a comparative study.

The identification of homelessness as a national problem has focused attention on defining the needs of this sizable population. Existing studies on the medical problems of the homeless are largely descriptive and are limited by lack of comparison to nonhomeless persons. To help fill this gap in knowledge, we conducted a retrospective study of the medical problems of homeless and nonhomeless persons cared for in an outpatient clinic serving the medically indigent. Homeless persons (n = 150) were more likely to be identified as alcoholic and to be seen for cuts and gynecologic problems than nonhomeless persons (n = 154) (p less than .01). There were no significant differences in the occurrence of other illnesses considered to be prevalent in the homeless. This study is among the first that validates descriptive data on the health problems of homeless persons by using concurrent nonhomeless controls. It may help in designing programs to meet the medical needs of the homeless.

Hepatitis and hematemesis complicating nicotinic acid use.

Nicotinic acid has a proven efficacy in the treatment of hypercholesterolemia. Therapeutic use of this water-soluble B vitamin has resulted in a survival benefit among patients enrolled in the Coronary Drug Project. Conversely, nicotinic acid has been associated with a high side-effect profile when used at therapeutic doses. Nevertheless, there are no previously reported cases of hematemesis temporally associated with nicotinic acid use. The authors report the case of a previously healthy 20-year-old man who developed hematemesis and hepatitis 1 week after self-initiating the daily consumption of 6 g of nicotinic acid. Supportive therapy and discontinuing nicotinic acid resulted in rapid clinical improvement in this patient. The clinical circumstances suggest a possible causal relationship between nicotinic acid consumption and his presenting problems. The use of large doses of nicotinic acid may be rapidly complicated by hematemesis and hepatitis.

Androgenic-anabolic steroid abuse and platelet aggregation: a pilot study in weight lifters.

The abuse of anabolic-androgenic steroids by athletes has recently been associated with the development of myocardial infarction and stroke. Because platelets play a pathogenic role in these disorders, the authors hypothesized that androgenic steroid abuse among weight lifters was associated with increased platelet aggregation as measured in vitro. Twenty-eight study participants were recruited. Twelve denied current androgen use. However, 8 of these 12 tested positive for urinary androgens. Nonsignificant trends toward increased platelet counts and increased platelet aggregation to adenosine diphosphate were noted when androgen users were compared to nonusers. However, when stratified by age, older (greater than 22 years) androgen users required lower concentrations of collagen to produce 50% aggregation of test platelets than did younger (less than or equal to 22 years) androgen users (1.47 versus 3.35 micrograms/ml; p = .01). Further subgroup analysis revealed nonsignificant trends toward increased adenosine diphosphate-induced aggregability and nonsignificant trends in the platelet count in older weight lifters. Subsequent studies using collagen threshold aggregometry revealed no age-dependent effect in 17 other men (aged 18 to 46 years) not specifically selected for activity (r = .17). This study suggests an association between androgen use, age, and increased platelet sensitivity to collagen in weight lifters and may be helpful in explaining recent thrombotic disease in androgen users. It additionally calls into question the validity of subjective reporting when assessing androgen use among weight lifters.

Anabolic/androgenic steroid abuse and thrombosis: is there a connection?

Anabolic/androgenic steroid abuse is an increasing medical and public health problem. The uncontrolled use of these agents has been associated with numerous toxic side-effects including deleterious cardiovascular changes. The most widely reported to these latter changes include the development of adverse lipid profiles and hypertension. Acute thrombosis has only recently been linked to androgen abuse. Such a causative link has been proposed in reports of acute myocardial infarction and stroke in several athletes using androgens. Unfortunately, there exists no direct evidence that androgens are thrombogenic in humans. However, indirect experimental data suggests that androgens affect platelet aggregation, coagulation proteins and the vascular system in ways that facilitate thrombosis. Androgens also increase several anticoagulant and fibrinolytic proteins. However, they have not been shown to protect from thrombosis in high risk patients. Existing data supports a possible thrombogenic effect of exogenous androgens. Further studies are needed to clarify the hemostatic influence associated with androgen abuse in weightlifters. The abuse of these agents may diminish if acute thrombosis becomes clearly and scientifically associated with their uncontrolled use.

Bronchopulmonary sequestration. Unusual cause of a lung mass in an adult.

Bronchopulmonary sequestration is a relatively rare, albeit important, cause of pulmonary disease in the adult. It is characterized by a segment of non-functioning lung parenchyma that receives its blood supply from an anomalous systemic artery. Although chest roentgenography and arteriography are useful in detecting this condition, the most crucial element in diagnosis is a high index of suspicion. Bronchopulmonary sequestration is clinically significant because of its potential for medical and surgical complications. Surgery continues to be the appropriate treatment for symptomatic patients, but experts disagree on the most appropriate management for patients who are asymptomatic.

Validity of self-report in identifying anabolic steroid use among weightlifters.

To determine the validity of self-report in the detection of anabolic steroid use among weightlifters, self-report was compared with assay results of simultaneous urine samples from 48 male weightlifters. The sensitivity of self-report in the detection of urinary anabolic steroids was 74%, and specificity was 82%. In addition, 22 of 23 participants who declared current use had at least one undeclared anabolic steroid identified in their urine. However, 15 participants reported at least one drug that was not detected in the urine. Furthermore, 3 of 17 declared nonusers had objective evidence of steroids in their urine. The validity of self-report may be inadequate to differentiate reliably between users and nonusers.

The medical problems of homeless clinic patients: a comparative study.

OBJECTIVE: To compare the prevalence of major medical problems in homeless and nonhomeless patients. PATIENTS: All 475 persons seeking care at an ambulatory clinic serving the medically indigent for one calendar year. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Demographic and clinical data were collected by structured interviews and medical record reviews for all patients seeking care at the clinic between March 1989 and April 1990. Comparisons were made between homeless patients, those patients with unstable housing, and those with stable housing. There was no significant between-group difference in age, gender, ethnicity, and health insurance coverage. Homeless patients were more likely to be unemployed (p less than 0.001) and were found to have higher prevalence of alcohol abuse, injuries/fractures, and dental and gynecologic problems (p less than 0.05). CONCLUSIONS: There were more similarities than differences in the prevalences of major medical problems in homeless vs. nonhomeless community clinic patients. Where differences did exist, homeless persons consistently had a higher prevalence of illness than did the nonhomeless.

Anabolic-androgenic steroid abuse in weight lifters: evidence for activation of the hemostatic system.

Anabolic-androgenic steroid abuse has recently been linked with acute vascular events in athletes. To date, the relationship between steroid abuse and the potential for cardiovascular disease has been considered almost exclusively in terms of lipid metabolism. However, recent reports of thrombosis in androgen abusing athletes with no evidence of atherosclerosis suggests the hypothesis that thrombosis risk in such athletes could be mediated through androgen induced abnormalities of coagulation. To determine if anabolic-androgenic steroid abuse in weight lifters is associated with an activation of the hemostatic system we studied forty-nine weight lifters recruited through advertisements. History of androgen use or abstinence was confirmed via urine assays. Plasma was assayed for clotting and fibrinolytic activity by measuring thrombin/antithrombin complexes (TAT), prothrombin fragment 1 + 1 (F1 + 2), and D-dimers (D-di); markers of the endothelial based fibrinolytic components were assayed by measuring tissue plasminogen activator antigen (t-PA Ag) and its inhibitor (PAI-1); finally, the activity of antithrombin III, protein C, and protein S were measured. Abnormally high concentrations of TAT complexes were noted in 16% of our confirmed steroid using weight lifters compared to 6% of our confirmed nonusers (P = .01). Steroid users also demonstrated abnormally high concentrations of F1 + 2 and D-dimers when compared to nonusers (44 vs. 24%, P < .001, and 9 vs. 0%, respectively). Non-steroid users were more likely to have elevated levels of t-PA Ag and PAI-1 than our steroid using weight lifters (both P < .001). The activities of antithrombin III and protein S were more likely to be higher in users compared to nonusers (22 vs. 6%, P = .005; 19 vs. 0%, respectively). Some anabolic-androgenic steroid using weight lifters have an accelerated activation of their hemostatic system as evidence by increased generation of both thrombin and plasmin. These changes could reflect a thrombotic diatheses that may contribute to vascular occlusion reported in young athletes using these drugs. The predictive value of these coagulation abnormalities in terms of risk of thrombosis to individual steroid using weight lifters or the population as a whole remains to be studied.

The effect of testing time on students' performance for the subject examination for internal medicine.

The authors tested the hypothesis that increasing the allotted testing time from two to four hours for the National Board of Medical Examiners medicine subject examination would increase the score on this examination when given as part of the clerkship evaluation. One-hundred six students who completed their medicine clerkships between September 1991 and August 1992 (group 1) were compared with 96 students who completed their clerkships between September 1992 and August 1993 (group 2). The mean medicine subject examination score for group 1 was 462 +/- 86, vs 518 +/- 108 for group 2 (p = 0.0003). Regression analysis using the medicine subject examination score as the dependent variable and all baseline characteristics, group assignment, and time of year the test was taken as independent variables demonstrated significant interactions only for United States Medical Licensing Examination (USMLE) Step 1 score (R2 = 0.48, beta weight = 0.68, p = 0.0000) and group assignment (R2 = 0.05, beta weight = 0.18, p = 0.002). The authors conclude that increased testing time for the medicine subject examination from two to four hours is associated with a significant increase in scores; however, scores on the preclinical USMLE Step 1 showed a stronger association.

Obesity, adiposity, and lengthening of the QT interval: improvement after weight loss.

OBJECTIVES: To determine the prevalence of QT interval prolongation in patients referred to an outpatient clinic for treatment of obesity; and to describe the change in the QT interval during rapid weight loss with a very-low-calorie diet. DESIGN: Retrospective and prospective review of charts and electrocardiograms. SUBJECTS: Five hundred twenty-two obese patients (411 female, 112 males) with a mean age 44 (18-78 y) and a mean initial weight of 116 kg (63-285 kg) completing 26 weeks of treatment between September, 1989 through to December, 1993. MEASUREMENTS: We reviewed the EKGs of all patients and serially monitored the QTc if greater than 0.44 s or if more than 23 kg was lost during treatment. The QTc interval was calculated with Bazzett's formula using both a manual method and an automated software program. In some patients, body composition was measured by hydrodensitometry. RESULTS: The QTc interval before treatment was 0.42 +/- 0.026 s by manual measurement and 0.41 +/- 0.021 s by automated measurement. Forty-one to 53% of patients showed a QTc interval of greater than 0.42 s and 10-24% demonstrated moderate prolongation (> 0.44 s). In those patients for whom repeat EKG were performed, QTc showed shortening with weight loss by both methods (mean +/- s.e. of 0.42 +/- 0.003 to 0.41 +/- 0.003 s, P < 0.01 manually and 0.41 +/- 0.003 to 0.40 +/- 0.003 s, p < 0.005 by automated program). Analyses were repeated excluding 179 patients with a cardiovascular-related diagnosis or intraventricular block and the results were similar. By regression analysis, gender and fat mass (FM) percentage above normal predicted the QTc. CONCLUSIONS: QT Interval prolongation is common in obesity. For each 50% increase in FM% above normal, there is a 5 ms increase in the QTc above a 'normal' upper limit of 0.40 and 0.38 s in women and men, respectively. Moreover, the QT interval shortens with weight loss. This change may represent an additional benefit of weight loss along with the improvement in other cardiovascular risk factors.