Implementing community-based education: essential elements and recommendations.

Two elements are essential for implementing community-based educational programs: a vision of how community experiences fit into the training of the health professionals of the future and a local environment that will support innovation, change, and growth. Change cannot occur unless very basic assumptions regarding medical education are challenged. What is "quality education"? Can programs oriented toward tertiary and specialty care adequately provide the training that should be the core of a 3-year general training program? Do schools and programs select and train physicians to function within the microcosm of the academic center, or do they prepare physicians to manage the country's health care needs? National consensus has had little influence over local environments. Each medical school, training program, and teaching facility must reexamine its values and its culture. Each must have a vision of the physicians of the future and a commitment to train them appropriately. The role of vision and culture in creating successful programs has been clearly described. Several key elements have been found to be consistent with success, the first being vision. Four basic principles will bring the vision to fruition: (1) preserving core values while still stimulating progress; (2) emphasizing the process by which programs are created, implemented, and changed rather than the product; (3) avoiding the "tyranny of the or," learning to be inclusive with a broad vision rather than limited to an "either-or" approach; and (4) aligning the process, management, and values in working toward envisioned progress for the future. Effective leadership is essential for a group or organization to accomplish its mission, as is an organizational structure that aligns responsibility, authority, resources, and accountability.

Clinical estimation of liver size in newborn infants.

Liver size was measured in 100 healthy newborn infants of gestational ages 35 to 44 weeks. A mean liver span of 5.9 +/- 0.8 cm was determined in these infants by measuring the distance between the percussed upper and palpated lower liver borders along the midclavicular line. This value correlated well with measurements derived from percussing both borders (r = .8) and correlated poorly with measurements of liver projection below the costal margin (r = .55). The practice of reporting liver projection below the costal margin as a single indicator of liver size should be discouraged.

Use of groups in well child care.

A controlled study was conducted to examine the use of groups for well child care in the office setting. Group visits were compared to traditional visits by assessing the efficiency, efficacy, content, and process of visits as well as patient satisfaction. The group method was efficient and required no more provider time per pair than individual visits. The group method effectively changed the process and content of the well child visits and was acceptable to the sample population. Few changes in health care utilization were found, but mothers in the experimental group completed more well child visits and sought less advice between visits than mothers in the control group. The group method offers an alternative method of care that is worthy of further investigation and implementation.

Organizational responses to managed care: issues for academic health centers and implications for pediatric programs.

The health care market dynamics that supported and directed the growth and development of Academic Health Centers (AHCs) have changed dramatically in the last 10 years. AHCs are struggling to adapt to new reimbursement mechanisms and to compete effectively for limited dollars, but are constrained by administrative and governance structures that are slow to evolve. Their multiple missions, including education, research, and care for complex patients and underserved populations, are at risk. Although most recognize the need for substantive reorganization, available resources and market specifics vary dramatically from one AHC to another. The current approaches to adaptation by four AHCs are described, along with some of the unique challenges confronted by academic pediatric programs.

Jaundice in the full-term neonate.

Hyperbilirubinemia is the most common problem experienced by the full-term infant in the immediate neonatal period. The development of jaundice was prospectively investigated in 866 newborns. Significant correlations were found between the serum bilirubin level and the method of birth, perinatal complications, blood group incompatibilities, birth weight, and method of feeding. Breast-feeding was highly related to the development of exaggerated jaundice. The most common occurrence of jaundice requiring phototherapy was in breast-feeding infants in whom no cause for the jaundice could be determined. Study findings were most compatible with a theory of relative caloric deprivation as an explanation of the increased incidence of hyperbilirubinemia found in breast-fed newborns.

Effects of time-in-clinic, clinic setting, and faculty supervision on the continuity clinic experience.

STUDY OBJECTIVE: To evaluate the effects of setting, type of supervision, and time in clinic on the resident continuity clinic experience. DESIGN: Prospective cohort with preintervention and postintervention measures. SETTINGS: Pediatric residents selected one of three clinic settings for their continuity clinic experience. These included a traditional, university-based clinic, private practice offices, and publicly funded community-based clinics. SUBJECTS: All pediatric residents at the University of Utah Health Sciences Center, July 1985 through June 1991. INTERVENTIONS: Using varied clinic sites, matching residents one or two to one with preceptors for their continuity clinic, increasing continuity clinic from 1 to 2 half-days per week. MEASUREMENTS AND MAIN RESULTS: Residents in private offices had the most varied experience, seeing more patients, more acute care, and a broader age range of patients than residents at other sites. They were more likely both to be observed by their preceptors during patient visits and to observe their preceptors delivering care. Because the number of patients seen per session rose, increasing continuity clinic time from one to two half-days per week more than doubled the number of patients seen per week. Increased time away from hospital did not affect scores on the Pediatric In-Training Examination. While test scores were similar for incoming residents, those in private offices scored higher on the final Behavioral Pediatrics Examination (P < .05). CONCLUSIONS: Clinic setting, time in clinic, and faculty supervision affect the quality of the continuity clinic experience. Increased time in clinic resulted in a broader exposure to patients. Residents placed in private offices had a more varied patient mix, were more closely supervised, and seemed to gain primary care skills more rapidly than residents at other sites.

Hygienic care in uncircumcised infants.

A written questionnaire was used to determine the advice pediatricians give concerning hygienic care of uncircumcised infants. A telephone survey was conducted in which new mothers were asked what they had been told about genital hygiene and how they were caring for their infants. Pediatricians' advice concerning hygiene in uncircumcised infants varied greatly. Most counseled mothers to retract the foreskin and clean the child, but few (22%) knew when this could be readily accomplished. None of the mothers of uncircumcised children had been told when the foreskin could be expected to retract, and only half had been given any advice concerning hygiene. Mothers of infants whose foreskins had been manipulated by physicians felt this practice was traumatic. Both this and the stress of caring for their infants without adequate instruction caused 40% of the mothers to state they would choose to have the next child circumcised. Recommendations for hygienic care of uncircumcised infants are given.

Phototherapy in full-term infants with hemolytic disease secondary to ABO incompatibility.

Current guidelines for treatment of hemolytic disease of the newborn make no differentiation between ABO and Rh incompatibility. A protocol that prolonged the observation period in full-term, ABO-incompatible infants with positive Coombs' tests who were otherwise healthy was tested. Postponement of treatment made it possible to determine more accurately which infants needed phototherapy. This dramatically decreased the number of infants treated without increasing their risk of requiring exchange transfusion.

Stimulus configuration and context effects in perceptual organization in schizophrenia.

Two studies assessed perceptual organization in schizophrenia to determine (a) whether inpatient and outpatient groups with poor premorbid schizophrenia have comparable levels of perceptual organization deficit; and (b) whether the deficit could be eliminated by task manipulations. In Study 1, inpatients demonstrated clear evidence of a perceptual organization deficit, whereas outpatients performed similarly to the control groups. In Study 2, a performance pattern that operationally defined a perceptual organization deficit was eliminated by a task manipulation thought to aid in context processing. The perceptual organization deficit is most pronounced in actively symptomatic patients with poor premorbid schizophrenia, and the deficit reflects, in part, deficient top-down influences to basic perceptual processes.

Group well-child care offers unique opportunities for patient education.

By using a group process, health educators can greatly increase the cost effectiveness of well-child care. Benefits of group care, compared with traditional well-child care, include increased time for patient education, prolonged observation of parent-child interactions, the ability to observe children with their peers, and the opportunity to employ a broad variety of teaching techniques, such as role-modeling. This paper describes the author's 15 years of experience using this model, illustrating with examples the advantages of group well-child care.

Group well-child care.

Well-child care can be a positive influence on parent-child relationships when social, psychological, and emotional health are stressed. Because of its brevity, the traditional well-child visit does not offer adequate opportunities to address these issues. A group format, in which four to six parent-infant pairs meet, changes the character of the child health maintenance visit. Advantages of group visits include increased time for patient education, more active parental participation, greater time for the physician to observe parents and their children, and more reassurance for parents that they and their children are normal. Problems of group visits are those of space and scheduling. Few pediatric offices have ideal space for group visits, so many visits take place in cramped quarters. Siblings can be disruptive to the group and should be excluded. A dedicated receptionist and an efficient nurse are essential if the groups are to run smoothly. Because the visits last one to one-and-one-half hours, only one group visit can be scheduled during a half day. Although parents of varied socioeconomic and cultural backgrounds benefit from group visits, this format appears to be most acceptable to white, middle-class families. The content of group visits is somewhat dependent upon parental questions and concerns; however, the physician must be careful to include important issues that do not usually arise spontaneously. These topics usually include safety, disease prevention, and anticipatory guidance. Although group visits may not fit every practice, the format does offer to both obstetricians and pediatricians some exciting possibilities. The increased patient-provider contact and the increased patient participation help establish better rapport, better educate families about health, and hopefully, will produce better babies.

Family psychosocial screening: should we focus on high-risk settings?

The objective of this study was to address the question of whether or not psychosocial screening should be focused on "high-risk" populations. A cross-sectional survey of mothers of young children was conducted in various clinics: 758 in teaching clinics, 444 in private practices, and 202 at a military clinic. The self-administered questionnaire covered demographic factors, problems in mothers family of origin, maternal depression, and substance abuse. Mothers in the teaching clinics were younger and had less education and lower incomes than mothers in private practices, with intermediate levels in the military clinic. However, a substantial proportion of mothers seen in all sites reported psychosocial problems. Approximately 20% of mothers in all sites reported a family history of alcoholism. Positive screens for maternal depression ranged from about 15% to 35%. Binge drinking was reported by 10% to 20% at different sites. Psychosocial problems were common even among families seen in "low-risk" settings. Focusing screening only on high-risk clinics would miss many families with psychosocial problems.

The Winnecott "set situation". A useful tool for the pediatrician.

D.W. Winnecott devised a short, simple test which he used to evaluate normal infants. In this study, we compared 9-month-old infants' behaviors elicited during the Winnecott Test (WSS), both with historical data and with their behavior during a structured separation from their mothers. We found significant correlations between the WSS, the structured separation, and historical data. This simple test can provide the practitioner with invaluable information regarding the infant, his temperamental style, and his relationship with others.

Teaching well child care.

Despite recommendations that the emphasis of the well child visit be on behavior and development, some studies indicate that pediatricians continue to spend a relatively small percentage of each well baby visit on these subjects. One factor contributing to the discrepancy between current recommendations and practice may be the way we teach residents to perform this task. In this study, we investigated and evaluated current methods for teaching well child care. Our data indicate that the content of well child care is being taught, but that problems with teaching setting, methods and frequency of supervision, and lack of formal evaluation may be among the factors which contribute to our continued inability to change the focus of well child visits.

Preventive health care utilization. Prenatal and the first 3 years in a Utah population.

The utilization of preventive health care services prenatally and for children up to 3 years old was determined by mailed questionnaire. The parents surveyed were randomly chosen from birth records provided by the Utah Bureau of Vital Records. "Adequate use of preventive services" was defined as six prenatal visits for a full-term pregnancy and as seven well-child visits during the first 3 years of life. Responses, received from 219 (36.5%) parents, indicated only 1 percent did not utilize adequate prenatal care. Women made an average of 11.3 visits during their pregnancies; 83 percent saw their prenatal health care provider at least 10 times. Well-child visits were less adequately utilized, an average of 6.3 visits per child. Fifty-six percent made fewer than seven visits; only 23 percent made all of the nine visits recommended by the American Academy of Pediatrics. Patients who made seven or more well-child visits were more likely to have received their fourth diphtheria, pertussis, tetanus (DTP) immunization and to have health insurance policies that paid for preventive health care services. Results indicate that families use preventive services more consistently before the birth of their children than after. Use of preventive services is associated with adequate insurance coverage and results in more thorough immunization.

Circumcision. A study of current practices.

The purpose of this study was to investigate the current incidence of circumcision, the reasons governing parental decisions regarding circumcision, the immediate and later complications from the procedure, as well as genital problems occurring in uncircumcised boys. The incidence of circumcision was found not to have changed over the past five years despite the recommendations of the American Academy of Pediatrics Task Force on Circumcision. The reasons given for circumcision reflected mostly the strength of tradition, rather than a medical approach. Four per cent of newborns experienced early complications from the procedure, whereas 13 per cent experienced later, minor complications. Problems reported in uncircumcised infants were probably variants of normal. While the results of this study and evidence for discontinuing neonatal circumcision, we strongly recommend that, if physicians dissuade parents from having their infants circumcised, they must give adequate information concerning hygiene and the slow, natural separation of the foreskin from the glans.

Temperature and fever in the full-term newborn.

In order to establish temperature norms during the first nine days of life, a retrospective analysis of 501 neonates was completed. After norms were derived, charts of all infants born at the UCLA Medical Center in 1979 were reviewed. Data were analyzed on every infant who had a recorded temperature greater than two standard deviations above the mean high. Sustained fever was unusual but highly predictive of infection. Infants rarely had fever, however, as the only sign of infection. Single elevated temperature readings were not associated with infection.

Breast feeding and jaundice in the first week of life.

Infants who most commonly receive treatment for neonatal hyperbilirubinemia are breast-fed babies in whom no cause for the jaundice can be determined. Hyperbilirubinemia in these newborns may not be caused by the breast feeding as such, but rather by inadequate nursing. This paper reports attempts to decrease readmissions for phototherapy at the UCLA Medical Center by inducing earlier and more functional lactation in the entire nursery population and by formula feeding infants whose bilirubins approached recommended treatment levels. Nursing was interrupted for 24 to 48 hours in 87 newborns; six still required readmission, while 81 were successfully treated at home. At the two-week well-baby visit, no differences in the incidence of breast feeding were found when comparing nonjaundiced breast-fed babies with infants who were taken off the breast or who were readmitted for phototherapy. Differences in the cost of care were significant with an average cost per patient of $126 for those treated at home compared with $1,440 for those readmitted. Policies designed to induce earlier lactation did nothing to decrease the incidence of exaggerated jaundice in the study's breast-fed population. It was concluded that supervised setting with careful counseling and follow-up, can provide an effective alternative to readmission and phototherapy in the treatment of jaundice.

Outcome of pregnancies experienced during residency.

To investigate potential adverse effects of residency training on pregnancy outcome, a cohort study was conducted among 45 university-affiliated residency programs. Outcomes of the first pregnancy experienced during residency were compared between 92 female residents and 144 spouses of male residents. Despite long hours, sleep deprivation, and an increase in perceived stress, the female residents were as likely to give birth to a live, full-term newborn as the spouses of male residents. For white cohort members, an increased risk of premature labor without delivery was identified (RR = 12.3, 95% confidence interval 2.4-61.6). No significant differences were found in prematurity, spontaneous and therapeutic abortions, or presence of congenital abnormalities in the infants. Method of delivery and use of anesthetics and of other medications were similar in both groups. Pregnancy outcomes between the two groups were similar; however, the increased risk for premature labor among female residents is a cause for concern and should be further investigated.

Management of neonatal jaundice.

Jaundice is the most commonly encountered neonatal clinical problem; 80 percent of neonates become clinically jaundiced, while 5 percent develop serum bilirubin levels above currently recommended treatment standards. This article outlines theories about the pathophysiology of neonatal jaundice and presents a logical approach to its management. First, the health care provider must distinguish between physiologic, exaggerated and pathologic jaundice. The treatment modalities of exchange transfusion, phototherapy and cessation of nursing are discussed.