Urinary tract infections and estrogen use in older women.

OBJECTIVE: To examine the relationship between exogenous estrogen use and risk of clinically diagnosed urinary tract infection (UTI) in older women. DESIGN: A case-control study. SETTING: Two hundred seventy-six general practices. PATIENTS: Cases (n = 3,616) were women, age 50-69 years, with a first recorded UTI in the calendar years 1989 or 1990. Controls (n = 19,162) were matched for age and practice. MAIN OUTCOME MEASURE: Clinical diagnosis of UTI. RESULTS: Women using estrogens for greater than or equal to 1 year had an increased risk of being diagnosed with a UTI compared to non-users, crude odds ratio (OR) 1.9 (95% CI 1.5-2.2). All of this excess risk was observed in women with intact uteri, OR 2.1 (CI 1.7-2.7). Hysterectomized women had no increased risk, OR 1.1 (CI 0.8-1.5). Controlling for diabetes, neurologic deficit, atrophic vaginitis, incontinence, and age did not affect the observed associations. CONCLUSION: Estrogen use is associated with an increased risk of UTI in older women with intact uteri but not in hysterectomized women. This observed differential effect on women with or without uteri may be explained by prescribing biases between these two groups of women, but we lack any evidence to support this conclusion over several alternative possibilities.

The effect of a teaching skills course on interns' and students' evaluations of their resident--teachers.

PURPOSE: To determine the effect that a six-hour course on resident teaching and leadership skills had on residents' teaching evaluations. METHOD: The authors analyzed six years of teaching evaluations of second- and third-year internal medicine residents at the University of Washington: three years before and three years after a resident teaching skills course was introduced in 1992. Interns and students rated their resident-teachers using a nine-question standardized clinical teaching assessment form (CTAF). Evaluations at baseline (the three years before the course) were compared with evaluations for the three years after the intervention. RESULTS: The authors analyzed 3,946 evaluations of 235 second-year and 211 third-year residents. Despite already high baseline evaluations, mean ratings of the CTAF showed continuous and statistically significant improvement in each year after the introduction of the course (p < .001). There was no significant difference between evaluations from students and those from interns. CONCLUSION: A six-hour teaching skills course significantly improved residents' teacher ratings. Residents are important teachers of interns and medical students and serve as their primary ward supervisors; therefore, sessions on teaching skills should be part of required curricula for all residency programs.

Improving medical residents' attitudes toward HIV-infected persons through training in an HIV staging and triage clinic.

PURPOSE: To assess the effect of a weekly outpatient clinic for staging and triage of newly identified human-immunodeficiency-virus (HIV)-infected patients on medical residents' attitudes and knowledge regarding care of HIV-infected persons. METHOD: Twenty-one second- and third-year medical residents who participated in the Diagnostic Evaluation Unit (DEU) of Boston City Hospital's Clinical AIDS Program from July 1991 through December 1991 were matched with a control group of 20 residents. Both groups of residents were asked to anonymously complete self-administered questionnaires before, immediately after, and three months following the DEU rotation. Responses were compared using repeated measures analysis of variance, two-tailed t-tests, and chi-square analysis. RESULTS: Compared with the controls, the DEU residents showed an increased sense of feeling adequately trained to provide primary care to HIV-infected patients immediately after the rotation (p = .0002), which was sustained at the three-month follow-up (p < .001). Compared with the controls, the DEU residents also showed improved general attitudes toward treating persons with acquired immune deficiency syndrome, which persisted at the three-month follow-up, although these changes were not significant. CONCLUSION: The experience in an HIV staging and triage clinic had a positive effect on the confidence and attitudes of the medical residents. Similar training experiences may increase the willingness and capacity of physicians to provide primary care to HIV-infected persons.

Use of advance directives by health care workers and their families.

BACKGROUND: Advance directives (ADs) are advocated for many but executed by few. To ascertain the importance of education in the decision to execute an AD, I did this study to determine the rate at which health care workers (a medically educated group) and their families execute ADs. METHODS: All clinical staff at an urban tertiary care VA medical center were surveyed. RESULTS: Of 730 surveys mailed, 553 (76%) were returned, and 18% of respondents executed an AD. Age was the only variable that predicted execution of an AD. End-of-life medical decision-making discussions with family members were reported frequently (with spouses 74%, parents 50%). CONCLUSION: Health care workers do not appear to complete ADs at a rate any higher than the general population. Thus, education may be necessary, but alone it appears insufficient to increase use of ADs. Frequent family discussions occur among health care providers and their families. Such discussions may be an important outcome in their own right.

Soliciting feedback: on becoming an effective clinical teacher.

The art of teaching is difficult to master. When teaching in small groups, as often happens in clinical medicine, there is an opportunity to find out what works by speaking directly with students. The information they provide can serve as an invaluable guide, permitting refinement of skill over time. There are, however, significant barriers to this process. The art lies in finding an approach that is comfortable for both parties. The authors refer to this activity as soliciting feedback. They offer guidelines for soliciting feedback as an aid to improving teaching efforts.

Fellowship training in academic general internal medicine: a curriculum survey.

OBJECTIVE: To determine whether current fellowships in general internal medicine (FGIM) meet the perceived needs and objectives of physicians entering careers in academic internal medicine. DESIGN: A modified Delphi method yielded the 18 curricular elements included in the mailed survey. Participants outlined both actual and ideal fellowship experiences by rating the degree of emphasis of each curricular element on a Likert scale. Respondents then prioritized elements by rank-ordering them on perceived importance. Current job descriptions and opinions on related issues in FGIM were collected. PARTICIPANTS: Potential fellows, current fellows, and recent graduates were surveyed. Individuals were identified through the Society of General Internal Medicine associates' mailing list and solicitation of program directors. Nonfellow associates served as the proxy group for potential fellows. MEASUREMENTS AND MAIN RESULTS: 579 surveys were mailed; 348 (60%) responses were received, of which 288 (50%) were suitable for analysis. Of all respondents, 38% were current fellows and 40% were recent graduates. When asked to prioritize educational needs during fellowship training, respondents ranked research methodology, ambulatory medicine, critical review of the literature, epidemiology, biostatistics, teaching skills, medical consultation, grant writing, preventive medicine, and design of educational curriculum as the top ten. Only minor deviations in rank order were found between graduates and nongraduates. Mean Likert scale scores for degree of emphasis of each curricular element in graduates' actual fellowships were compared with mean scores for graduates' ideal fellowship descriptions. High-priority elements that were perceived as adequately emphasized included research methodology, critical analysis of the literature, epidemiology, and biostatistics. High-priority elements that were perceived as inadequately emphasized included ambulatory medicine, teaching skills, medical consultation, grant writing, preventive medicine, and design of educational curricula. CONCLUSIONS: FGIM largely meet the expectations of their fellows for preparation for research responsibilities. However, several curricular elements concerned with preparation for future clinical and teaching responsibilities are perceived by graduates as underemphasized. These areas deserve increased emphasis during fellowship training to better prepare fellows for their future roles in academic general internal medicine.

Co-teaching: a faculty development strategy.

It has been stated that faculty development programmes which are closely linked to particular teaching contexts are most likely to be effective. Over the past 10 years we have developed a model of 'co-teaching' for faculty development which is based upon this premise and which can be applied to any clinical rotation. In this paper we describe our model, in which paired physicians focus on developing their teaching skills while sharing the clinical supervision of residents and medical students. Through iterative phases of teaching, debriefing and planning, co-teachers gain experience in analysing teaching encounters and develop skills in self-evaluation. Teaching occurs in the usual clinical settings such as attending (consultant) teaching rounds, clinic precepting, and case conferences. We discuss our model in the context of educational theory and related literature. We support our positive assessment of the co-teaching model through the precepts of collaborative inquiry and case study methodology. Vignettes, taken from the experiences of the authors, are used to demonstrate how the model is used to develop effective solutions to problems and to help in the maturation of one's skill as an educator. Successful implementation of the model is predicated on the development of a truly collaborative process between co-teachers. We share lessons we have learned from our experience of implementing the model in different clinical venues, such as the contrast between teaching on a hospital ward or in the clinic. This collaborative process has been well received by junior and senior faculty participants in our institution for more than a decade.