Innovative approaches to educating medical students for practice in a changing health care environment: the National UME-21 Project.

In today's continually changing health care environment, there is serious concern that medical students are not being adequately prepared to provide optimal health care in the system where they will eventually practice. To address this problem, the Health Resources and Services Administration (HRSA) developed a $7.6 million national demonstration project, Undergraduate Medical Education for the 21st Century (UME-21). This project funded 18 U.S. medical schools, both public and private, for a three-year period (1998-2001) to implement innovative educational strategies. To accomplish their goals, the 18 UME-21 schools worked with more than 50 organizations external to the medical school (e.g., managed care organizations, integrated health systems, Area Health Education Centers, community health centers). The authors describe the major curricular changes that have been implemented through the UME-21 project, discuss the challenges that occurred in carrying out those changes, and outline the strategies for evaluating the project. The participating schools have developed curricular changes that focus on the core primary care clinical clerkships, take place in ambulatory settings, include learning objectives and competencies identified as important to providing care in the future health care system, and have faculty development and internal evaluation components. Curricular changes implemented at the 18 schools include having students work directly with managed care organizations, as well as special demonstration projects to teach students the knowledge, skills, and attitudes necessary for successfully managing care. It is already clear that the UME-21 project has catalyzed important curricular changes within 12.5% of U.S. medical schools. The ongoing national evaluation of this project, which will be completed in 2002, will provide further information about the project's impact and effectiveness.

Correlates of maternal depressive symptoms in a national Head Start program sample.

OBJECTIVE: To examine correlates of maternal depressive symptoms in a diverse, national sample of mothers whose kindergarten-aged children attended a Head Start program. DESIGN AND PARTICIPANTS: A cross-sectional study of 5820 mothers was conducted during their child's kindergarten year. MAIN OUTCOME MEASURE: Rates of maternal depressive symptoms were assessed by a validated 3-item depression screen. RESULTS: The ethnic makeup of the group of mothers was non-Hispanic white, 46%; African American, 30%; Hispanic, 13%; American Indian, 6%; Asian American, 1%; and other, 4%. The mean (SD) age of the mothers was 30.1 (5.55) years, 57% were unemployed, and 68% had at least a high school diploma or had earned a high school equivalency diploma. More than 40% of the mothers screened positive for depressive symptoms. The strongest associations after controlling for several biological and demographic variables were maternal chronic health problem (adjusted odds ratio, 2.77; 95% confidence interval, 1.98-3.87), homelessness (adjusted odds ratio, 2.00; 95% confidence interval, 1.45-2.77), and lowest income level (adjusted odds ratio, 1.56; 95% confidence interval, 1.30-1.88). CONCLUSIONS: Depressive symptoms were common among mothers of young children in this national sample. Interventions must be targeted at alleviating maternal depressive symptoms by decreasing poverty, providing support programs for single parents, and establishing accessible and affordable medical care for all parents and their children. Primary care physicians can play a key role in early identification and intervention.

Essential concepts in clinical epidemiology for pediatric practice.

Providing the best possible health care requires the integration of individual clinical experience with external clinical information, often derived from published research papers. This article reviews several important concepts in clinical epidemiology that should help the pediatric clinician become a more active and critical reader. Among the basic concepts reviewed are measurement of disease occurrence, relative risk, and screening within the context of the pediatric practice.

Temperament of preterm infants at 4 months of age: maternal ratings and perceptions.

The purpose of this study was to compare temperament of preterm infants born at 34 weeks gestation or earlier with that of healthy, term infants at 4 months of age by maternal ratings and maternal perceptions and to examine the role of social support on maternal assessments of infant temperament. The mothers of preterm infants completed the Early Infancy Temperament Questionnaire (EITQ) and the Maternal Social Support Index when the child reached 4 months adjusted age. The EITQ assesses infant temperament by maternal ratings of specific infant behaviors and by mothers' global perceptions of infant temperament. Mothers of healthy term infants completed the same instruments when they brought their 4-month-old infant for a pediatric visit. Mothers rated preterm infants as having more negative mood (p = .01) and being less adaptable (p = .03) than term infants. However, mothers perceived that preterm infants were more difficult overall (p = .00001), had more negative mood (p < .005), were less regular (p = .02), and were less adaptable (p = .03). Mothers perceive preterm infant temperament to be more difficult than that of term infants and to be more difficult than is indicated by ratings of individual infant behaviors.

The Wisconsin Primary Care Organizations Consortium: a forum for the primary care medical specialties.

The Wisconsin Primary Care Organizations Consortium (WI-PCOC) is composed of the leadership of Wisconsin's primary care medical specialties whose four professional societies have a combined membership of about 3,900 physicians. Since 1992, WI-PCOC has explored the priorities and issues of importance of each organization, and has reviewed organizational resources to synchronize agendas and to avoid conflict. WIPCOC articulates policy supported by its member societies with a common voice; it does not set policy. WI-PCOC has worked with legislators, medical school deans, other specialty societies and other groups interested in primary care service and education. WI-PCOC member organizations aspire to work together to improve the level of health of Wisconsin citizens and their communities.

Pediatric residency training in the normal newborn nursery. A national survey.

OBJECTIVE: To determine how and what pediatric residency programs are teaching residents about normal newborn care in the nursery. DESIGN: A mailed survey distributed in 1994. PARTICIPANTS: All 237 known pediatric residency programs in the United States, Canada, and Puerto Rico. RESULTS: Survey response rate was 77% (184 of 237 questionnaires were returned and completed). In 40% of the programs, neonatologists were primarily responsible or co-responsible for teaching residents about management of normal newborns. A normal newborn nursery curriculum had been developed and implemented in 56% of the programs, 30% of programs were developing one, and 13% reported no curriculum. Specific instruction about breast-feeding was not offered in 16% of programs. Circumcisions were most commonly performed by obstetricians; anesthetic use was low (overall median use, 10%) but was more common (P < .002) when circumcisions were performed by pediatricians. The hospital environment and lack of faculty time were cited as the main barriers to teaching residents about normal newborn care. CONCLUSIONS: Although general pediatricians spend a substantial amount of practice time on newborn care, neonatologists were responsible for this teaching in almost half of the pediatric residency programs. Many programs have not developed a curriculum. Instruction about breast-feeding was not universal. Most pediatric residents do not learn to perform circumcisions. General pediatricians should be more involved in the development, implementation, and evaluation of comprehensive newborn nursery curricula to improve training in this important aspect of general pediatric practice.

Correlates of multigravida women's binge drinking during pregnancy. A longitudinal study.

OBJECTIVE: To refine our understanding of prenatal psychosocial factors associated with binge drinking during pregnancy and the contribution of binge drinking during pregnancy to the duration of newborn hospitalization. DESIGN: Prospective cohort. SETTING: A large urban medical center in Wisconsin. PARTICIPANTS: One hundred thirty-nine women (106 multigravida) who were invited to participate during a prenatal clinic visit early in their third trimester. MEASURES: Prenatal measures included social support (Maternal Social Support Index), depression (Center for Epidemiologic Studies Depression Scale), stress (Difficult Life Circumstances), substance use (Monitoring the Future Substance Use Questionnaire and T-ACE Scale [a screen with questions about tolerance, annoyance, cutting down, and using alcohol as an eye-opener), and maternal-fetal attachment (Maternal-Fetal Attachment Scale). After delivery, a mothers' and infants' medical record review form was used. RESULTS: Multigravida pregnant women (n = 106) were older than primigravida pregnant women (n = 33) (25.8 +/- 0.6 vs. 20.5 +/- 0.5 years; P = .001), with more children at home (2.3 +/- 0.2 vs 1.3 +/- 0.3; P = .01) and less social support (Maternal Social Support Index, 20.1 +/- 0.6 vs 22.9 +/- 1.0; P = .03). All of the binge-drinking women in this sample were in the unmarried multigravida subgroup (17/101 [17%]). Compared with multigravida pregnant women who did not binge drink during pregnancy, binge-drinking pregnant women were older (28.1 +/- 1.3 vs 25.1 +/- 0.6 years; P = .03) and more socially isolated (Maternal Social Support Index, 17.2 +/- 1.3 vs 20.7 +/- 0.7; P = .04) and were more likely to smoke during the pregnancy (82% vs 39%; P = .001). Even after controlling for a number of other important biologic and psychosocial factors (duration of pregnancy, maternal gravidity, racial heritage, education, social support at second trimester, and birth weight), by hierarchical multiple linear regression, binge drinking within the last 2 weeks before the late second-trimester interview continued to explain a significant amount of variance in duration of newborn hospitalization (total R2 = .48, partial R2 = .04; P = .01). CONCLUSIONS: This study suggests that binge drinking during pregnancy is related to longer newborn hospitalizations. Effective prenatal interventions to improve the outcome of pregnancies for women who abuse alcohol during pregnancy should use early screening and provide augmentation of mothers' social support.

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.

Prenatal correlates of indigent mothers' attitudes about spoiling their young infants: a longitudinal study.

The purpose of this study was to investigate factors associated with indigent mothers' attitudes about spoiling their young infants. Mothers who believe that young infants can be spoiled may be more likely to misperceive their infants' basic needs for nurturing and thus undermine their infants' sense of security and trust. One hundred twenty-nine consecutive pregnant women who were at approximately 15 weeks' gestation completed measures to assess depressive symptoms (Center for Epidemiologic Studies Depression Scale) and social support (Maternal Social Support Index). One hundred seventeen mothers (91%) completed a simple three-question Spoiling Index when their infants were about 1 month old. Fifty-eight percent were single, never married, 73% multiparous, 66% Euro-American, 28% African-American, and 84% at least 20 years old. Fifty-eight percent of mothers believed infants younger than 5 months old could be spoiled. After including maternal age, race, marital status, prenatal social support, and number of prenatal clinic visits in the hierarchical logistic regression model, "spoilers" were more likely to be primigravida mothers (odds ratio = 2.71; 95% confidence interval, 1.05 to 7.06) and more likely to be depressed during pregnancy (odds ratio = 2.83; 95% confidence interval, 1.29 to 6.19). Primigravida indigent mothers and mothers with higher levels of prenatal depressive symptoms are more likely to believe they can spoil their young infants.

Social support during labor and duration of labor: a community-based study.

The effect of a birth companion on duration of labor was examined in a sample of 66 nulliparous women in Michigan. Two-thirds of the sample were single, 66% received Medicaid, and 88% were white. Using simple linear regression, support during labor explained a significant amount of variance in duration of labor. Duration of labor for 8 unsupported mothers was significantly longer (965 +/- 206 min) than that for 58 supported mothers. Using hierarchic regression and including maternal education, marital status, race, amniotomy, and labor induction in the model before support, support during labor continued to explain a significant amount of variance in duration of labor. These findings are similar to those reported from earlier randomized trials of social support during labor. Evidence continues to accumulate that confirms the proposition that labor duration is affected by environmental as well as biologic factors.

Third-trimester maternal psychosocial factors and infants' home stimulation. A prospective study.

OBJECTIVE: To examine prospectively the association between mothers' third trimester maternal social support, depression, and satisfaction with a male support figure and their infants' home stimulation 4 months after birth. DESIGN: Prospective cohort. SETTING: Prenatal clinics in three private obstetric offices and two public clinics in western Michigan, a postpartum ward in a community hospital, and subjects' homes at follow-up. PATIENTS OR OTHER PARTICIPANTS: Nulliparous mothers who made at least one visit to a participating prenatal clinic during the third trimester who experienced vaginal deliveries, and whose infants were discharged from normal newborn nurseries between July 1988 and September 1989. One hundred thirty-five mothers agreed to participate, and 101 were available for follow-up home visits. MAIN OUTCOME MEASURES: Home Observation for Measurement of the Environment, a measure of home stimulation. RESULTS: Mothers' third-trimester social support explained 20% of the variance (P = .0001) in infants' home stimulation scores at age 4 months. Third-trimester social support was a stronger predictor of postnatal home stimulation than socioeconomic status, race, depressive symptoms, and satisfaction with a male support figure. Third-trimester social support continued to explain a significant amount of variance in home stimulation scores (R2 = .06, P = .01) even after marital status was included in the model. CONCLUSIONS: Mothers who report higher levels of social support during the third trimester of pregnancy provide higher levels of home stimulation for their infants. These findings suggest that primary care health providers may facilitate early child development by encouraging pregnant mothers to identify and make use of their social resources.

The effects of a multimodal intervention with attention-deficit hyperactivity disorder children: a 9-month follow-up.

Using a double-blind, placebo design, we evaluated 96 attention-deficit hyperactivity disordered children for the effects of methylphenidate alone and in combination with behavioral parent training plus child self-control instruction. Seventy one of the children completed the treatment protocol. As reported previously, main effects were found for medication at posttest; however, there was no evidence of additive effects. Nine months after the termination of the behavioral interventions and the withdrawal of the stimulant medication, we found limited support for the hypothesis that the combined conditions would produce greater maintenance of treatment gains than would medication alone.

The effect of a medical journal club on residents' knowledge of clinical epidemiology and biostatistics.

BACKGROUND: We performed a prospective controlled trial of a monthly journal club to determine if it would increase pediatric residents' knowledge of clinical epidemiology and biostatistics. METHODS: Intervention residents received two didactic sessions before the journal club started. Eight monthly journal club sessions followed. Pediatric residents at another institution served as controls. Intervention and control residents completed a pre- and post-test on clinical epidemiology and biostatistics. RESULTS: Neither the intervention nor the control group showed a significant change in test scores over the 9-month period. CONCLUSION: A more intensive and more structured approach is needed to effectively teach clinical epidemiology and biostatistics to residents.

Additive effects of psychostimulants, parent training, and self-control therapy with ADHD children.

Utilizing a double-blind, placebo design, the effects of a high (0.8 mg/kg) and a low (0.4 mg/kg) dose of methylphenidate alone and in combination with behavioral parent training plus child self-control instruction were evaluated with 96 attention deficit hyperactivity disorder children. No evidence of the superiority of the combined conditions relative to medication alone was found. Some limited support was found for the hypothesis that the effects of a high dose of psychostimulant medication could be achieved by combining the low dose with a behavioral intervention. The importance of the latter finding is highlighted by the fact that both the benefits and untoward effects of the psychostimulants appear to increase with the dose.

The reliability and validity of the Maternal Social Support Index for primiparous mothers: a brief report.

The Maternal Social Support Index (MSSI) is an 18-item questionnaire designed to quickly assess qualitative and quantitative aspects of a mother's social support. This study examines a sample of primiparous mothers during the first nine months following delivery. Mothers were interviewed within 72 hours after delivery and again at six weeks and nine months. Using Spearman coefficients, the correlation for total MSSI scores between birth and nine months was .75. The correlations for individual items between birth and nine months ranged from .22 to .76. The MSSI at birth was strongly correlated with the Dyadic Adjustment Scale at nine months (r = .41, P = .001). Scores on the Center for Epidemiologic Studies Depression Scale at birth were inversely and significantly associated with the MSSI at six weeks postpartum (r = .50, P = .004). The MSSI assesses important elements of a new mother's environment which are related to her satisfaction with an intimate other, as well as depressive symptoms. These findings are similar to those in earlier reports.