Are some subjects better taught in block rotation? A geriatric experience.

BACKGROUND AND OBJECTIVES: This study characterizes the progress in and effectiveness of learning geriatric medicine during longitudinal and block phases of a family practice residency program. METHODS: A structured second-year geriatric block rotation was added to a residency longitudinal curriculum. To assess learning, a Geriatric Assessment Instrument (GAI) consisting of 50 multiple choice questions was administered to three classes offamily practice residents (n=33)five times during training: entry into the program, beginning of the second year, pre- andpost-geriatric block rotation, and at graduation. Improvement between individual residentfirst- and third-year in-training exam scores in geriatrics of the intervention classes were compared with the four classes that preceded the introduction of the block rotation (n=38). RESULTS: Scores on the GAI improved significantly before and after the rotation but not during any other interval of training during the residency. In-training exam scores improved significantlyfor the classes taught with the block rotation over those without it. CONCLUSIONS: Most of the geriatric learning occurred during the 1-month geriatric block rotation during the residency. In-training geriatric exam scores improved significantly with a geriatric block rotation. The use of structured repetitive learning experiences during the rotation to emphasize the common clinical issues and the skewed exposure to geriatric patients in the random nature of residency clinic and inpatient encounters accountfor this result.

The impact on a health care system of a program to facilitate self-care.

BACKGROUND: High utilization for self-limiting conditions has challenged health care systems to be innovative. The facilitation of self-care has been identified as a viable concept to control demand and encourage efficient use of resources. A Self-Care Intervention Program (SCIP) coupled with a Health Promotion Pharmacy (HPP) was implemented in an Army health care system to determine the impact on the use of self-care. METHODS: A questionnaire was mailed to 283 SCIP participants at the 6-month interval to assess achievement of program objectives. Use of the HPP was documented during the same interval. The response rate was 67.5% (n = 191). RESULTS: A positive response was obtained for all six program OBJECTIVES: Increased knowledge of personal health issues (84.3%); increased confidence to treat minor illnesses (77%); improved opinion of the health care system (74.9%); increased practice of healthy behaviors (64.9%); and an increased commitment to seek preventive medicine (62.8%). Seventy-two percent of the respondents reported avoiding at least one clinic visit, and 39.8% reported avoiding at least one visit to the emergency room. The calculated return on investment was 11:1. CONCLUSION: A formal self-care program supported by a pharmacy can have a positive effect on participants' health and health care, resulting in cost-effective demand management.

The changing approach to falls in the elderly.

The annual incidence of falls is approximately 30 percent in persons over the age of 65 years. The risk of falls is greater in older persons, with the annual incidence increasing to 50 percent in those over age 80. Because of the significant incidence of falls in the elderly, physicians should have an organized approach to fall assessment and prevention. Most falls in the elderly are caused by complex interactions of intrinsic and extrinsic factors. A thorough history is essential to identifying the intrinsic or extrinsic factors involved. Approximately one half of falls in the elderly can be attributed to accidents and extrinsic causes such as slippery floors, and the remainder from intrinsic causes such as lower extremity weakness, gait disorders, effects of medications or acute illness. Extrinsic and intrinsic factors that are identified may be amenable to one of three management approaches: treating acute or reversible deficits, reducing the cumulative burdens of deficits, or using adaptive devices for irreversible deficits. A careful and focused evaluation can identify factors that can be corrected or therapeutic interventions that will lessen the risk of a subsequent fall.

Retention rates and retention predictors among graduates of Army Family Practice residency programs.

Accurate career retention rates for the 688 graduates of Army Family Practice residency programs over the period from 1973-1990 were determined by retrospective cohort analysis. Eight characteristics of these graduates were tested by chi-square analysis to determine if they had a predictive effect on retention: United States Military Academy attendance (USMA), Uniform Services University of the Health Science (USUHS) attendance, fellowship training, prior service, gender, first assignment, site of residency training, and spouse with history of active duty service. Overall retention was 21%. Significant predictors of retention at the p < 0.01 level (chi-square) were (1) USMA attendance, (2) USUHS attendance, (3) fellowship training, and (4) prior service. Gender, first assignment, and spouse history of active duty service were not factors. The 22% of the graduates who had at least one of the four positive predictors form two-thirds of the present career Family Physician force.

Mobile surgical hospital design: lessons from 5th MASH surgical packages for Operations Desert Shield/Desert Storm.

Operations Desert Shield/Desert Storm defined and tested a number of assumptions about the abilities of the Mobile Army Surgical Hospital. These assumptions involved the adequacies of mobility, both strategic and tactical, the number of hospital beds, surgical capability, and set-up time. This article reviews the characteristics, staffing, and surgical abilities of the four types of surgical packages deployed by the 5th Mobile Army Surgical Hospital in response to the changing patient care and tactical situation. These packages were the Forward Surgical Team, Forward Surgical Element, Mobile Army Surgical Hospital(-), and Mobile Army Surgical Hospital. Seven variables as they relate to hospital weight and cubic space are introduced. Mobility and surgical ability are emphasized as the first and second highest priority to consider in a proposed methodology when developing Mobile Army Surgical Hospitals.

Natural history and prognostic significance of purulent rhinitis.

Purulent rhinitis, or nasopharyngitis, is a common outpatient problem in children, although the recommended course of action varies and includes all modalities from observation to antibiotics. This study compared complications and duration of illness between children with clear rhinorrhea and those with purulent rhinorrhea. Nasopharyngeal and throat cultures were compared between these groups and well children. No significant difference was found between rhinorrhea groups with respect to complications or duration of illness. Children with purulent rhinorrhea did have a significant higher level of middle ear pathogens (P less than .01) isolated from nasopharyngeal cultures. Observation with throat culture is the desired method of treatment.

The disgruntled patient: how family practice residency programs handle requests for a physician change.

The purpose of this study was to investigate the alternatives available in family practice residency programs for handling patients who expressed dissatisfaction with their physician. Letters were sent to 150 family practice residency programs asking how they handled this problem. Of those who replied, it was determined that this problem is generally handled in one of three ways: (1) patient automatically transferred to another physician, (2) patient referred to original physician for discussion, or (3) patient referred to a designated authority. The rationale and implications of each method are discussed.