Development of physical examination skills in a third-year surgical clerkship.

BACKGROUND: Previous studies have revealed deficiencies in physical examination (PE) skills of third-year medical students. The purpose of this study was to determine if formal teaching of PE skills and more supervised experiences with clinical faculty would increase the competency of these skills. METHODS: Forty-nine third-year medical students were assigned to one of two groups: group A was given formal instruction on PE skills at the beginning of the clerkship, and group B received the same instruction at the midpoint of the clerkship. The two groups received an assessment of the PE skills before, in the middle, and at the end of clerkship, utilizing a physician-developed checklist. RESULTS: Group A had a pretest score of 57.7%. Group B scored 59.8% on the pretest. Independent groups t tests were used to compare the two groups. At the midterm examination, group A increased their score to 71.0%, while group B decreased their score to 55.6%. From beginning to final, both groups had significant improvements in all areas, with group A scoring an overall mean of 75.1% (P = 0.0001), and group B scoring 75.5% (P = 0.0001). CONCLUSION: These findings show the effectiveness of structured learning situations for improving third-year surgery students' PE skills. There is also an indication that usual clerkship activities may not enhance learning of PE skills.

Physical therapy management of pelvi/perineal and perianal pain syndromes.

Pelvic floor physical therapy is considered to be effective in the management of functional urogenital and anorectal disorders. A functioning pelvic floor is integral to increases in intra-abdominal pressure, provides rectal support during defecation, has an inhibitory effect on bladder activity, helps support pelvic organs, and assists in lumbopelvic stability. Coordinated release of the sphincters within a supporting extensible levator ani allows complete and effortless emptying. A major feature of pelvi/perineal and perianal pain syndromes commonly encountered by multidisciplinary clinicians is pelvic floor imbalance and incoordination. Precise pelvic floor and abdominal muscle coactivity, based on research, is used clinically. Motor and cognitive learning which can alter peripheral and central pain mechanisms and produce physical changes in the CNS, viscera, smooth and musculoskeletal tissues is the basis of physical therapy in pelvic floor and pelvic organ pain management.

Co-activation of the abdominal and pelvic floor muscles during voluntary exercises.

The response of the abdominal muscles to voluntary contraction of the pelvic floor (PF) muscles was investigated in women with no history of symptoms of stress urinary incontinence to determine whether there is co-activation of the muscles surrounding the abdominal cavity during exercises for the PF muscles. Electromyographic (EMG) activity of each of the abdominal muscles was recorded with fine-wire electrodes in seven parous females. Subjects contracted the PF muscles maximally in three lumbar spine positions while lying supine. In all subjects, the EMG activity of the abdominal muscles was increased above the baseline level during contractions of the PF muscles in at least one of the spinal positions. The amplitude of the increase in EMG activity of obliquus externus abdominis was greatest when the spine was positioned in flexion and the increase in activity of transversus abdominis was greater than that of rectus abdominis and obliquus externus abdominis when the spine was positioned in extension. In an additional pilot experiment, EMG recordings were made from the pubococcygeus and the abdominal muscles with fine-wire electrodes in two subjects during the performance of three different sub-maximal isometric abdominal muscle maneuvers. Both subjects showed an increase in EMG activity of the pubococcygeus with each abdominal muscle contraction. The results of these experiments indicate that abdominal muscle activity is a normal response to PF exercise in subjects with no symptoms of PF muscle dysfunction and provide preliminary evidence that specific abdominal exercises activate the PF muscles.

Factors affecting the diagnosis of peripheral vascular disease before vascular surgery referral.

OBJECTIVE: Many new patients evaluated by vascular surgeons are referred by internal medicine physicians (IMPs). Objectives shared by vascular surgeons and IMPs include early identification of peripheral arterial disease (PAD), improved referral relationships, and reduction of health care costs. The approach to PAD by IMPs and identification of deficiencies that might contribute to suboptimal care form the basis for this report. METHODS: An anonymous survey was mailed to all IMPs (n = 843) in the central and southern parts of Illinois. Questions concerned IMP demographics, approach to diagnostic testing, referral patterns, perception of adequacy of education of PAD, and how often parts of the history and physical examination for PAD would be performed on the initial office visit of a hypothetical 65-year-old male with hypertension (each answer measured as 0%-25%, 25%-50%, 50%-75%, and 75%-100% of the time completed). RESULTS: There was a response from 360 IMPs: 230 IMPs (27.3%) returned the questionnaire, and 130 IMPs (15.4%) declined to participate. Practice locations for IMPs returning the questionnaire included rural (36%), suburban (22%), and urban (40%). Practice types included academic (7%), solo private (29%), group private (53%), and other (14%). A history of cardiac disease was obtained most of the time by 92% of IMPs (75%-100% answer category). Histories for pulmonary disease, diabetes mellitus, stroke, and smoking were obtained most of the time with similar frequencies (85%, 86%, 73%, and 96%, respectively). In contrast, only 37% obtained a history for claudication, and 26% obtained a history for foot ulceration 75% to 100% of the time (P <.05, all comparisons). Examination of the heart (95%) and lungs (96%) occurred most of the time (75%-100% answer category) compared with each part of the pulse examination (range, 34%-60%; P <.05, all comparisons) and aortic aneurysm palpation (39%; P <.05). If pedal pulses were absent, examination by IMPs with Doppler scan and ankle-arm indices were mostly distributed in the 0% to 25% answer category (79% and 79%, respectively). After suspecting PAD, most IMPs obtained diagnostic tests first compared with specialist referral: carotid disease (91% vs 9%), aortic aneurysm (91% vs 9%), and lower extremity PAD (86% vs 14%). Initial referral patterns were made to vascular surgeons (49%), general surgeons (33%), cardiothoracic surgeons (13%), cardiologists (4%), and radiologists (1%). Most IMPs believed medical school (70%) and residency (73%) provided adequate training for PAD diagnosis. CONCLUSIONS: Deficiencies may exist in the identification of PAD by IMPs that could adversely affect diagnosis, time to referral, health care costs, and ultimately, patient outcome. Improvements in medical school education and IMP training in the diagnosis of PAD are needed.

Assessment of a surgery clerkship's performance evaluation system.

BACKGROUND: This study was designed to examine the validity of a surgery clerkship's performance evaluation system. The study also assessed faculty members' confidence in how clerks are evaluated and promotion decisions made. METHODS: Student files from five classes (n = 339) were analyzed. A 25-item published survey designed to study faculty perceptions of a student evaluation system was distributed. Chi-square tests of independence and descriptive statistics were used. RESULTS: Faculty survey results showed faculty perceptions of strengths and weaknesses in the evaluation system. Significant relationships were found with prior performance indicators and clerkship performance yielding evidence of concurrent and predictive validity. CONCLUSIONS: Findings provide guidance for enhancing how clerks are evaluated as well as specific profiles of students who may need special attention or additional challenges during the surgery clerkship. This study provides a model for other clerkships to assess their student evaluations systems.

Evaluation of students' physical examination skills during their surgery clerkship.

BACKGROUND: Faculty often presume that students possess adequate physical examination skills upon graduation. Yet assessments of their performance with these skills often reveal deficiencies. This study was designed to determine if students' physical examination skills improved during their clerkship year. METHODS: Sixty-six students performed four specific physical examinations on patients during the first and last week of their surgery clerkship. Four consecutive clerkship rotations were examined. Encounters were videotaped and evaluated by faculty members. RESULTS: Posttest mean percent correct scores significantly improved for three examinations (P <0.01). Analysis of variance found no significant differences between clerkship mean percent correct scores. CONCLUSIONS: Students' physical examination skills improved slightly during their clerkship, however, no relationship was found between clerkship rotation and performance. These findings suggest unsupervised experiences during the third year do not positively influence student performance with physical examination skill proficiency.

Effects of metrifonate on cognitive decline in Alzheimer disease: a double-blind, placebo-controlled, 6-month study.

Forty-seven patients with probable Alzheimer disease (AD) completed a 6-month double-blind study to compare metrifonate with placebo. The Alzheimer Disease Assessment Scale cognitive subscale score of the metrifonate group treated to a 50-70% inhibition of red blood cell acetylcholinesterase activity differed significantly from the placebo group score by 1.8 points (p < 0.03) due to a deterioration in cognitive performance in the placebo group (p < 0.01). Statistically significant deterioration also occurred in the Mini-Mental State Examination scores (p < 0.01) in the placebo-treated group. Adverse effects were uncommon and did not require adjustment of the dose of metrifonate or discontinuation of treatment. These findings extend our previous report of a favorable effect of metrifonate on cognitive symptoms in AD by showing clinical, not only statistical, significance.

Is test security a concern when OSCE stations are repeated across clerkship rotations?

PURPOSE: To examine the issue of test security when the same stations on an objective structured clinical examination (OSCE) are repeated across clerkship rotations. Specifically, is there a significant difference in students' scores on stations repeated in three or four rotations within a single academic year? METHOD: The sample consisted of 15 stations in the OSCE given at the end of the third-year surgery clerkship at the Southern Illinois University School of Medicine from 1989-90 through 1993-94. Each station was administered three or four times a year. One-way analyses of variance with contrast coding to test for linear trends were used. Results were considered significant at or below the .05 level. RESULTS: Only three of the 15 stations showed significant linear trends. A two-part couplet orthopedic station showed a significant decreasing linear trend (p=.0001). Two stations showed significant increasing linear trends: a general surgery couplet station (p=.0004) and a plastic surgery station with an essay question (p=.0253). CONCLUSION: There was no consistent evidence that students scored increasingly higher on OSCE stations repeated throughout the year. Thus, it would appear that a clerkship can repeat OSCE stations within an academic year without risk of a trend toward increasing scores.

Double-blind, placebo-controlled study of metrifonate, an acetylcholinesterase inhibitor, for Alzheimer disease.

Fifty patients with probable Alzheimer disease (AD) completed a 3-month double-blind study to compare metrifonate to placebo. We dosed metrifonate to achieve a 40-60% inhibition of red blood cell acetylcholinesterase activity. The Alzheimer Disease Assessment Scale cognitive subscale score (ADAS-C) served as the primary outcome measure. At the completion of 3 months of treatment, the metrifonate group ADAS-C score differed significantly from the placebo group score by 2.6 points (p < 0.01). A 0.75-point trend toward improvement occurred during treatment in the ADAS cognitive performance of the metrifonate group (p = 0.15), and a 1.10-point deterioration in cognitive performance was found in the placebo group (p < 0.02). On the Global Improvement Scale (GIS), the two groups differed significantly on their changes from baseline to treatment phase (p < 0.02). Significant deterioration occurred in GIS scores (p < 0.01) and in Mini Mental State Examination (MMSE) scores (p < 0.03) in the placebo-treated group. Adverse effects were uncommon and did not require adjustment of the dose of metrifonate or discontinuation of treatment. We achieved a mean of 52.3% decrease in red blood cell acetylcholinesterase activity. During up to 18 months of subsequent open metrifonate treatment of patients, we found a deterioration of 1.68 points per year in MMSE performance. These findings support further study of the effects of metrifonate on deterioration rate in AD.

Patients' attitudes toward the involvement of medical students in their care.

BACKGROUND: Research has shown that medical students are generally accepted by patients, but specific details that elucidate patient perceptions of the advantages and disadvantages to student involvement have not been documented. This study was designed to determine variables that influence patient satisfaction with students. PATIENTS AND METHODS: Patients were interviewed by one of two faculty members using a questionnaire-style format that covered 12 variables regarding patient care. Patients were asked to rate the extent to which medical students helped or hindered their hospital stay, with regard to the 12 variables. RESULTS: Patients' attitudes were favorable regardless of the students' extent of clinical experience or clinical abilities or the patients' age or length of hospital stay. Patients reported that students spent time with them and answered their questions. Most patients stated that they would allow students to participate in their future hospital care. CONCLUSION: Positive patient-student interactions can have important effects on patients' expectations and their acceptance of future encounters with students. This fact is becoming increasingly important due to the changes in health care and the decreasing incidence of inpatient surgical encounters.

A highly successful and novel model for treatment of chronic painful diabetic peripheral neuropathy.

OBJECTIVE: To investigate why, in spite of a vast variety of treatment agents, the alleviation of pain in patients with diabetic neuropathy is difficult. Previous studies have not used a treatment algorithm based on anatomic site and neuropathophysiological source of the neuropathic pain. RESEARCH DESIGN AND METHODS: A model that categorizes the types of pain into three groups (superficial, deep, and muscular) was applied in 75 diabetic patients with chronic (> 12 mo) painful distal symmetrical polyneuropathy in a controlled case series. Twenty-two patients were untreated and 53 patients were treated with imipramine +/- mexiletine for deep pain, capsaicin for superficial pain, and stretching exercises and metaxalone +/- piroxican for muscular pain. Each type of pain was scored separately on a scale of 0 (none) to 19 (worst), and the total of all three types was used as an index of overall pain. Ability to sleep through the night was scored by a scale of 1 (never) to 5 (always). RESULTS: No significant differences were observed in initial pain scores, sleep scores, demographics, biochemistries, or physical findings between the two groups. After 3 mo a significant improvement in scores was noted in the treated but not the untreated patients. In addition, a significant difference was found in the change of scores between the treated and untreated patients: total pain (-18 +/- 2 vs. 0 +/- 2), deep pain (-7 +/- 1 vs. 0 +/- 1), superficial pain (-5 +/- 1 vs. 0 +/- 1), muscular pain (-6 +/- 1 vs. 0 +/- 1), and sleep (1.2 +/- 0.2 vs. 0.2 +/- 0.2), all P < 0.0001. In treated patients 21% became pain-free (total pain < 2), 66% had improvement (decrease in total pain > 5, but not total elimination of painful symptoms), and 13% were considered treatment failures (a decrease in total pain of < or = 5). This compares with 0 (P < 0.02), 10 (P < 0.0001), and 90% (P < 0.0001), respectively, in the untreated patients. CONCLUSIONS: This study presents a new rationale and hypothesis for the successful treatment of chronic painful diabetic peripheral neuropathy. It uniquely bases the treatment algorithm on the types and sources of the pain.

Reliability and efficiency of components of clinical competence assessed with five performance-based examinations using standardized patients.

The present study was conducted to provide in-depth information on the reliabilities of measures of the separate components of clinical competence (e.g. data collection, test interpretation, diagnosis, etc.) assessed by a performance-based examination consisting of standardized-patient cases administered to five classes of senior medical students at Southern Illinois University School of Medicine. In general, the reliabilities of the competencies as they were actually measured on the examination (using the number of cases on which each competency was actually measured) were small, with 54% less than 0.30 and 75% less than 0.40. For generalizability coefficients pooled across the five classes and projected to a common number of k = 10 cases, two of the nine competencies had reliabilities in the 40s, a third was close to 0.40, and the remaining six were in the low 20s. The number of cases needed for the competencies to achieve the recommended reliability of 0.80 ranged from 45 to 170 cases, with six of the nine competencies requiring over 100 cases to reach the 0.80 level. The low reliabilities of these measures of the components of clinical competence raise serious questions about using the scores as indicators of student performance.

Determinants of hospital charges for coronary artery bypass surgery: the economic consequences of postoperative complications.

This is a prospective study of 500 consecutive patients having coronary artery bypass surgery; mean hospital charge from time of surgery to discharge was +11,900 +/- 12,700. Multiple regression analysis was performed using preoperative variables and postoperative complications. No preoperative clinical feature was a significant predictor of higher average charge. Sternal wound infection (p = 0.0001), respiratory failure (p = 0.0001) and left ventricular failure (p = 0.017) were associated with higher average hospital charge. The absence of any complication predicted a lower average charge, and postoperative death (4.4 +/- 4.5 days after surgery) was also associated with lower average charge. A cost equation was developed: hospital charge equalled $11,217 + $41,559 of sternal wound infection, + $28,756 for respiratory failure, + $5,186 for left ventricular failure, - $1,798 for no complication and - $6,019 for death. Recognition of the influence of complications on charges suggests that low average charges can only be achieved by surgical programs with a low complication rate.

Evaluation and comparison of the distributions of gastric pH and hydrogen ion concentration.

The shapes of the distributions of gastric pH and hydrogen ion concentration [H+] were determined for each of 68 groups of patients scheduled for elective surgery under general anesthesia. The 68 groups comprised a total of 1,326 patients who had served as subjects in 13 of the authors' previously published studies. In general, the results showed that neither pH nor H+ was normally distributed; most of the pH distributions (47 of 68 = 69%) and most of the H+ distributions (53 of 68 = 78%) showed significant departure from the normal distribution. Moreover, the shapes of the distributions varied, depending upon the conditions under which gastric acidity was assessed. Groups receiving no medication for gastric acidity had positively skewed pH distributions (nonsymmetrical distribution with tail pointing to right and majority of cases in lower range), and groups receiving medications for the reduction of acidity had negatively skewed pH distributions (nonsymmetrical with tail pointing to left and majority of cases in upper range). The medications produced an inverse relationship between mean pH and skewness such that the skewness of the groups decreased from positive to negative as mean pH increased. For H+, all groups had positively skewed distributions, but the distributions were more positively skewed for groups receiving medications for gastric acidity. Again, the medication conditions produced an inverse relationship between mean acidity and skewness such that the groups became more positively skewed as the mean H+ decreased.(ABSTRACT TRUNCATED AT 250 WORDS)