A successful academic-community partnership to improve the public's health.

As academic health center seek to address the changes in the health care system and in medical education, several approaches have been tried, some successfully, others not. The authors describe a successful approach that involves a close partnership between the health professions schools at two academic institutions, and agencies from the surrounding community. Specifically, the Center for Healthy Communities, begun in 1991 and formally institutionalized in 1994 in Dayton, Ohio, is a partnership among the schools of medicine, nursing, and professional psychology at Wright State University (WSU); the department of social work at WSU; the Allied Health Division of Sinclair Community College; more than 200 individuals (from grassroots neighborhood people to civic leaders); and 50 health and human services organizations in the Dayton area. The Center is recognized as a force for change in health professions education and health care delivery both in the community and in the academic settings. The authors explain how the Center was formed, list its goals (such as establishing strong partnerships among community educators and providers and educating students in the delivery of primary health care in the community), explain three principles that have been followed and that were crucial to the success of the Center (for example, individuals in the community must become empowered to capitalize on their strengths), and discuss the major difficulties that the community and the academic institutions encountered and strategies for meeting them (such as the importance of building trust and the importance of learning the needs identified by the community partners, not just those identified by the academic partners). The authors maintain that a successful community-academic partnership must be built on the foundation of community health development, a concept analogous to economic development, and that such a partnership can be a powerful tool for making a difference in the community's health.

The Association of Teachers of Preventive Medicine's recommendations for postgraduate education in prevention.

The Guide to Clinical Preventive Services, prepared in 1989 by the U.S. Preventive Services Task Force, assesses the effectiveness of 169 types of preventive interventions. In 1990, the Association of Teachers of Preventive Medicine formed a panel to review the guide and recommend ways it could be used to enhance both undergraduate and postgraduate medical education. This paper outlines the panel's recommendations of the types of knowledge and attitudes on which postgraduate medical education in prevention should be built. Detailed recommendations are presented, based on the summary findings of the guide, for residency education in prevention. Implementation of these recommendations will integrate preventive services into the continuum of medical care. These recommendations are presented to achieve the goal of educating physicians to approach the total patient, putting the patient's health rather than the disease process in the forefront of primary medical care.

Implementing the Association of Teachers of Preventive Medicine's recommendations into the undergraduate medical school curriculum.

In 1989, an expert panel appointed by the Association of Teachers of Preventive Medicine proposed minimum curricular content requirements for health promotion-disease prevention, including recommendations for timing, duration, and course sequencing during medical school. Making clinical preventive medicine an integral part of a primary care rotation is a central feature of the proposal. The panel presents recommendations for using the Guide to Clinical Preventive Services, which assesses the effectiveness of 169 types of prevention interventions, in both undergraduate and postgraduate medical education. Recommendations for incorporating the guide into the undergraduate medical school curriculum are outlined. The recommendations include options for using the guide as part of a curriculum in quantitative skills, in clinical preventive medicine, in a primary care rotation, as a health services and community dimension curriculum, and as part of continuing self-education. Recognizing that teaching methods and curriculum structures are varied in preventive medicine, the panel designed the recommendations to be adaptable to all medical schools' programs. The recommendations are aimed at achieving the goal of making preventive medicine an integral part of the education, training, and practice of physicians.

A combined primary care residency in internal medicine and pediatrics.

The authors describe the development and evaluation of a primary care residency program encompassing both internal medicine and pediatrics. The combined residency is a four-year program of alternating six-month rotations in the two disciplines. One-fourth of the program is ambulatory medicine and includes training in a clinic for children and adults. Patient demographics are maintained for each resident, and an ambulatory-medicine-focused curriculum consisting of weekly conferences and self-directed independent study is used. The program is routinely evaluated and is highly rated by patients and residents. Factors critical to its success include emphasizing goals and experiences in outpatient versus inpatient care, developing an ambulatory practice to help support resident salaries, adequately preparing residents to take the board examinations in both disciplines, and providing a comprehensive primary care curriculum.

Comparing clerkship sites in a community-based medical school by evaluating students' undergraduate and postgraduate performances.

BACKGROUND: Studies have generally found clinical training sites within the same clerkship to be comparable regarding students' performances--by using undergraduate measures in individual clerkships at medical schools with university hospitals. The present study examined performance comparability among sites within two clerkships in a community-based medical school and used both undergraduate and postgraduate measures. METHOD: The participants were the 349 graduates from the classes of 1988-1991 at Wright State University School of Medicine who took an internal medicine clerkship (332 of the graduates, in five principal combinations of sites) and a general surgery clerkship (349 at six sites). The undergraduate measures were final percent scores for the clerkships and subtest and total scores on the National Board of Medical Examiners (NBME) Part II examination. The postgraduate measures were supervisors' ratings from the first year of residency (210 graduates) and total score on the NBME Part III (212). Univariate analysis of variance and Tukey's multiple-range test were used for the comparisons. RESULTS: The only statistically significant difference among sites was for the medicine clerkship and involved only one undergraduate measure, the clerkship score (and the differences were slight, less than four percentage points). CONCLUSION: Virtually no differences in the students' performances on the undergraduate and postgraduate measures were found among sites for the two clerkships.

Molecular interactions in biomedicine: modulation of regulatory behavior by cross reactivity: relevance to analysis of receptor function.

The influence of cross reactivity on biomolecular regulation is not frequently incorporated into theoretical analysis and is often eliminated by experimental design. Nonetheless, cross reactive molecules produce effects on binding which may considerably modulate their behavior in quite diverse systems, i.e., drug-tissue receptor, antigen-antibody, substrate-enzyme, protein-DNA and hormone-tumor receptor interactions. In particular, certain effects vary at different concentrations suggesting a simple control mechanism.

Dermatomyositis and nasopharyngeal carcinoma.

A nasopharyngeal carcinoma was diagnosed in a 37-year-old man with a two year history of dermatomyositis. The physical and laboratory examinations excluded further medical problems. To our knowledge, this is the first case of dermatomyositis associated with nasopharyngeal carcinoma in a white Israeli Jewish patient.

Metastatic renal cell carcinoma (RCC): spontaneous regression, long-term survival and late recurrence.

We report 4 cases of metastatic renal cell carcinoma (RCC) with long-term survival either following radical nephrectomy alone or in combination with radio- or hormonal therapy. Two patients with lymph node metastases showed a long-term survival of 12 or more years following radical tumour nephrectomy (with lymphadenectomy) and radiotherapy. One of them exhibited a histologically proven tumour recurrence nearly 12 years after primary surgical treatment and died shortly later; the other one is still without any evidence of metastatic disease. Two other patients exhibited spontaneous regression of pulmonary metastases: one regression occurred after radical tumour nephrectomy alone, the other one after successful primary hormonal treatment and subsequent radical tumour nephrectomy. The following important aspects are emphasized: 1. Renal cell carcinoma is a very unpredictable tumour. Once the diagnosis of renal cell carcinoma is proved, a patient can never be considered cured. 2. Although adjuvant palliative nephrectomy has produced contradictory results in several reports, radical tumour nephrectomy either alone or in combination with other adjuvant therapies such as radiotherapy, hormonal or immunological treatment, can be worthwhile. Cases with long-term survival and spontaneous regression of distant metastases are proof of this. Besides, if carefully selected, the mortality rate of different adjuvant therapies is not significantly higher in patients with metastatic disease than in patients without metastases. The world literature on this subject is reviewed.

Periodic health examination: comparison of residency programs and national recommendations.

Health maintenance and disease prevention guidelines of primary care internal medicine residency (PCIM) programs were investigated and compared with recommendations of major national organizations. Preventive screening data were requested from 134 PCIM programs; 120 (90%) responded. Methods included seminars/lectures by 73 (61%), health maintenance flow sheets by 58 (48%), and a variety of other formats by 25 (21%) programs. A comparison of recommended flow sheet items (n = 33) from five major studies and 48 PCIM programs showed concordances (+/- SE) of 62% (+/- 5) with high-priority items (n = 15) and 33% (+/- 4) with low-priority items (n = 18). When an item's frequency or age range was examined, however, concordances were much lower. From our analysis, fewer than half the programs routinely used prompting systems, such as flow sheets, in their ambulatory clinics, and there was little uniformity in the frequencies and age ranges for those items employed. The data suggest that major study recommendations were underused and underemphasized.

Community occupational therapy associates.

This article describes the creation and evolution of an occupational therapy practice agency in Canada. It explains how the agency has grown to meet the needs of both patients and therapists, and gives case examples as illustrations of successful intervention.

An elective in primary care internal medicine for students in the preclinical years.

A two-week elective to introduce first- and second-year medical students to primary care internal medicine was developed and evaluated. Course time is divided between conference sessions (25 percent) provided by full-time clinical faculty members and office experience (75 percent) provided by volunteer clinical faculty members (general internists in private practice and in prepaid health plans). Evaluations by the students (n = 58) who took the elective consisted of a questionnaire assessment of the conference session topics, the student's ability to carry out course objectives, and the preceptor's teaching activities. The conference topics were highly rated, with a mean score of 4.1 on a rating scale ranging from 1 (unfavorable) to 5 (favorable). The course objectives and teaching activities were also well rated, with a mean score of 4.1 and 3.9, respectively, on a rating scale ranging from 1 (none) to 5 (outstanding).

Survey of combined residency programs in internal medicine and pediatrics on curricula.

Combined residency programs in internal medicine and pediatrics began to emerge during the past decade. Combined programs provide four years of training that leads to board eligibility in both disciplines. To learn more about the curricula of these programs, the authors sent a questionnaire to the directors of the 81 known combined programs. Sixty-eight such programs were active as of July 1986. Of these, 54 had been active in the 1985-86 academic year and had a total enrollment of 390 residents, an average of 7.2 residents per program. Fourteen new programs were activated in July 1986 and enrolled 46 residents, with an average of 3.3 residents per program. Virtually all the programs emphasized training in primary care and included the use of outpatient clinics where residents often work with nonphysician health-care providers. Many programs provided instruction in the use of community resources, preceptorships, and outpatient-oriented conferences and emphasized data-gathering skills. Areas that need to be addressed by program directors and the accrediting organizations are discussed by the authors.

A home visiting program for adolescents.

This article describes the origin and evolution of an occupational therapy home visiting program for adolescents in Toronto, a large metropolitan area. It explains community occupational therapy as it applies to a specific patient population, and then gives case examples demonstrating successful intervention.

Screening for primary aldosteronism: hypokalemia in hypertensive patients.

A serum potassium determination is usually recommended for new hypertensive patients as a screening test for primary aldosteronism and as a baseline for drug therapy. Since hypokalemia is not specific for aldosteronism, the authors assessed its use and limitations as a screening test in nine reported studies of 303 patients with aldosterone-producing adenomas (n = 252) or adrenal hyperplasia (n = 51). The optimal potassium cutoff level and the predictive ability of hypokalemia to detect aldosteronism were analyzed in a primary care setting with different diseases, test characteristics, and prevalences. Optimal screening for primary aldosteronism occurred at serum potassium less than 3.2 mEq/l in a primary care, low-prevalence population, and at higher potassium levels in higher-prevalence populations. Other screening tests, such as urinary aldosterone levels and plasma renin activity, showed lower individual test performance characteristics, but when combined were similar in performance to serum potassium measurement.

Use of a predictor for total body potassium content: application to nutrition and hypertension.

Total body potassium (TBK), measured at different institutions, has no reference standard for comparison. A useful reference formula, however, based on body size and age, has been derived at the Brookhaven National Laboratory. This formula was used to help calibrate a simple whole body counter for measuring total potassium and applied to nutrition and hypertension studies. A sodium iodide detector was used for counting gamma rays emitted by potassium-40 to estimate TBK. The mean ratio (+/- S.D.) of adjusted TBK measurements to predicted values was 1.002 +/- 0.047. The ratio of lean body mass estimated by the TBK measurement to that derived from skin fold thickness was 1.069 +/- 0.056. In hypertensives on low dose thiazide, the ratio of TBK measurements to predicted values was 0.994 +/- 0.052. Thus, our TBK measurements were adjusted in close agreement with a predictor formula, provided higher estimates of lean body mass than did skin fold thickness, and showed no change in thiazide treated hypertensives.

Tracking patient demographics and disease categories in a primary care residency.

The residency training of primary care physicians must include experiences with multiple types of ambulatory patients and disease processes. Most residency programs, however, do not accurately monitor or quantify these experiences. We developed a simple computerized system, using a relational data base, to record and track patient demographics and disease categories. This system maintains a profile for each resident physician which is used to guide the assignment of future patients. The system can be simply modified to meet the specific patient and/or disease characteristics needed.

Impact of therapeutic guidelines on antibiotic use by residents in primary care clinics.

Inappropriate use of antibiotics has been well documented for inpatient settings, but there are few studies in ambulatory patients. In a prospective study, the authors monitored the outpatient prescribing patterns of internal medicine residents and evaluated the effect of placing a one-page set of antibiotic guidelines in each patient examining room. Appropriateness of antibiotic choices was scored periodically. A 12-month pre-intervention survey of antibiotic use showed that 50% of the choices were inappropriate. Comparison of a four-month post-intervention analysis with the same four-month interval in the pre-intervention period showed no significant difference between the percentages of inappropriate prescriptions. The most common reasons for inappropriate use were: 1) failure to document a clinically significant bronchial infection, and 2) inadequate evaluation of nonspecific urinary tract complaints. The authors conclude that the ready availability of information about appropriate antibiotic use is not effective in changing antibiotic choices, and that educational strategies regarding antibiotic use must also address diagnostic evaluation.