Serologic evidence of chlamydial and mycoplasmal pharyngitis in adults.

In a study of 763 adult patients we found serologic evidence of infection (a fourfold increase in antibodies) with Chlamydia trachomatis in 20.5 percent of the patients and with Mycoplasma pneumoniae in 10.6 percent, but with group A streptococcus (by culture) in only 9.1 percent. Pharyngitis, the most common problem for which patients seek medical care in the United States, may be caused by nonviral, potentially treatable organisms more often than had been suspected.

Analysis of the differential diagnosis and assessment of pleuritic chest pain in young adults.

The most important problem in the approach to young patients with acute pleurisy is distinguishing those with idiopathic or viral pleurisy from patients with pulmonary embolism. Three clinical features are helpful in making this distinction: (1) pleural effusion(s) present on chest roentgenography, (2) history of predisposing factors for or past history of veno-occlusive disease, and (3) physical signs indicative of phlebitis. Lung scanning should be performed in patients with these findings. If results of scanning are highly characteristic of pulmonary embolism (segmental or lobar defect with ventilation/perfusion mismatch) in such a patient, anticoagulation may be considered immediately. Patients in whom scanning reveals indeterminate characteristics or abnormalities not characteristic of pulmonary embolism should undergo pulmonary angiography if other clinical features suggest that the probability of pulmonary embolism remains at least moderately high.

Measures of clinical efficacy. III. The value of the lung scan in the evaluation of young patients with pleuritic chest pain.

The usefulness of various modalities in evaluating pleuritic pain in young patients and in isolating cases of pulmonary embolism was assessed using likelihood ratios and the receiver operating characteristic (ROC) curve. History and physical, laboratory, and radiographic finding were used disjunctively to establish an ROC curve. The percentage of patients found to have pulmonary embolism increased monotonically with certain critical pieces of diagnostic data. For example, a history and physical examination alone detected 80% of patients with pulmonary embolism; a chest radiograph raised the percentage to 95%; and the addition of a lung scan increased the percentage to 100%. Thus, with proper interpretation of clinical and radiographic data, the lung scan has only a marginal impact upon the sensitivity with which pulmonary embolism is detected. Its major value is an increased specificity in the diagnosis of pulmonary embolism.

Aortic aneurysm with retroperitoneal fibrosis and ureteral obstruction.

Arteriosclerotic aneurysms of the abdominal aorta constitute a common clinical entity. Rarely are they associated with retroperitoneal fibrosis and ureteral obstruction requiring ureterolysis. Fifteen such cases have been reported, with resection successful in 5 of 7. A sixteenth case is presented complicated by the presence of a persistent left cardinal vein. It is the third aneurysm resected with such an anomaly, and to our knowledge the first to be associated with retroperitoneal fibrosis and ureteral obstruction. Ureterolysis with resection of the aneurysm was performed. The difficulties presented by these pathologic entities, as well as the anomalous venous pattern, are reviewed. Complete preoperative evaluation, including intravenous pyelogram, retrograde pyelography, aortography, and venacavography, for the definition of anatomic relationships and planning of the surgical approach is stressed.

The ethics of caring and medical education.

The ethics of caring, though the subject of much recent discussion by philosophers, has hardly been applied to medical ethics and medical education. Based on receptivity (that is, empathy and compassion) toward and taking responsibility for other persons, the ethics of caring has particular relevance to medicine. Caring guides the physician always to remain the patient's advocate and to maintain the therapeutic relationship when dealing with and resolving ethical dilemmas. This article discusses the philosophy behind the ethics of caring and then explores three issues that arise within its context: receptivity, taking responsibility, and creating an educational environment that fosters caring.

Clinical evaluation of vertigo.

In attempting to outline the clinical evaluation of these patients with vertigo we have discussed examples which range in order from benign self-limited disease to those requiring emergency surgery or extensive diagnostic evaluation. We sought also to illustrate how the logic of hypothesis testing is generally employed by clinicians in approaching this or other diagnostic problems. The examples were chosen to illustrate the indications for, as well as the limitations of, the various diagnostic modalities--caloric testing, electronystagmography, audiometric testing, roentgenographic and nuclear medicine procedures--which may be employed by the clinician. Most of the skills discussed in our paper, though traditionally accorded to the fields of neurology and otolaryngology, would seem to be fundamental for any general physician, while the problem of vertigo is an example of how common ambulatory problems may require knowledgeable approach to sort self-limited from more serious illnesses as well as to utilize procedures with purpose and efficiency.

Supporting the moral development of medical students.

Philosophers who studied moral development have found that individuals normally progress rapidly in early adulthood from a conventional stage in which they base behavior on the norms and values of those around them to a more principled stage where they identify and attempt to live by personal moral values. Available data suggest that many medical students, who should be in this transition, show little change in their moral development. Possibly, this relates to perceived pressures to conform to the informal culture of the medical wards. Many students experience considerable internal dissidence as they struggle to accommodate personal values related to empathy, care, and compassion to their clinical training. Educational interventions that positively influence this process have established regular opportunities for critical reflection by the students in small groups. Other interventions include faculty development to enhance role modeling and feedback by clinical faculty. The author espouses more widespread adoption of these educational interventions.

Teaching models in an ambulatory training program.

Ambulatory care training is increasingly important in internal medicine. Such training centers on the practice where residents and faculty see their patients; thus, features of the practice model influence what residents learn. A resident-faculty group practice affiliated with a division of general internal medicine has many advantages. In such a practice, learning centers on resident-patient interactions, around which a comprehensive teaching program must be built. Major features of such a program include the mentoring of residents by faculty who work with them longitudinally and the presence of a well-balanced structured curriculum addressing clinical and nonclinical topics related to patient care. Teaching residents to interact and communicate with patients is crucial; approaches include role-modeling by faculty, use of videotaping, and role-playing and other innovative methods. Feedback is integral to learning and helps shape the attitudes and values that permeate residents' practices.

Dermatologic practice: implications for a primary care residency curriculum.

The problems encountered, diagnostic procedures performed, and treatments prescribed in dermatology were studied in a primary care practice and in a dermatology clinic. Referrals from a primary care practice to a dermatology practice were analyzed. It was determined that nine disease categories accounted for more than 75 percent of the problems encountered in both settings. Only one diagnostic procedure was performed commonly in both the primary care and dermatology practices--skin scraping for fungal infection. Approximately 90 percent of the treatments prescribed in both settings fell within 13 categories. It is proposed that these findings be the basis for designing the curriculum in dermatology for residents in primary care medicine. The curriculum also should provide practical experience in dermatology and familiarity with selected, rarely encountered dermatologic conditions that have important therapeutic implications.

Making "connexions": enhancing the therapeutic potential of patient-clinician relationships.

Healers must try to understand what the illness means to the patient and create a therapeutic sense of connection in the patient-clinician relationship. A favorable climate for "connexional" experiences can be created through the use of various interviewing techniques. Attending to rapport, silencing internal talk, accessing unconscious processes, and communicating understanding can help clinicians enhance their sensitivity to the subtle clues on which issues of meaning and connection often depend. Several risks are associated with the establishment of closer patient-clinician relationships, including dependence and power issues, sexual attraction, and deeper exposure of the clinician to the patient's pain. Prepared with an awareness of these risks and techniques to address them, clinicians are encouraged to deepen their level of dialogue with patients, to compare their experiences with those of other clinicians, and to thereby develop a more systematic understanding of therapeutic relationships.

Clinician-educators in academic medical centers: a two-part challenge.

As academic medical centers increasingly deliver care in primary care settings, a new category of faculty-clinician-educators-has emerged. Although the shift of education and patient care to outpatient settings makes the expanded role of clinician-educators necessary, it also presents challenges to clinician-educators themselves and to the institutions for which they work. This article examines these contemporary challenges (including financial constraints, undefined processes of promotion, and limited opportunities for professional development) and suggests strategies for meeting them. The number of clinician-educators joining the ranks of medical school faculties will probably continue to increase. As clinician-educators seek to provide the highest-quality education and patient care in the new medical marketplace, their success will be critical to the viability of the academic centers of the future.

The patient-physician relationship. Teaching the human dimensions of care in clinical settings.

Despite repeated calls to emphasize the humanistic dimensions of care during medical education, these are few known techniques for effective teaching of humanism. We describe the barriers that inhibit humanistic teaching and suggest pragmatic teaching methods to overcome such barriers and teach humanistic care in clinical settings. We began by asking participants at a conference on patient-physician communications sponsored by the American Academy on Physician and Patient in June 1998, "What can we do in the patient's presence to improve and teach the human dimensions of care? Please provide one or more examples of approaches you found to be effective." We augmented this information with suggestions from a number of colleagues in other settings. In a series of iterations, we analyzed all their suggestions to identify key teaching methods. We found that barriers to teaching humanism largely consist of elements of the informal and hidden curricula in medical schools. We then defined methods to help teachers overcome these barriers. Specific methods fall into the 3 categories of taking advantage of seminal events, role modeling, and using active learning skills. We believe that formal courses and other well-motivated endeavors that take place away from patients fail to foster humanistic care. In contrast, we present pragmatic teaching methods that can be used in the fast-paced setting of the clinical environment.

Teaching medicine as a human experience: a patient-doctor relationship course for faculty and first-year medical students.

We developed a required, longitudinal course for first-year medical students that addressed the patient-doctor relationship. Our course linked understanding patients' experiences and perspectives on illness with listening to, talking with, and establishing a rapport with patients while obtaining their medical histories. Learning was enhanced by use of an interdisciplinary faculty and by small-group continuity and faculty mentoring. Our curriculum adapted problem-based, self-directed educational methods to convey medical humanism. We focused on bedside interviewing as the means for exploring patients' social, emotional, and ethical concerns.