Reversal of morphine disruption of maternal behavior by concurrent treatment with the opiate antagonist naloxone.

Rats whose pregnancies were surgically terminated on day 17 of gestation were injected with morphine, morphine plus naloxone hydrochloride, or saline, and then tested for maternal responsiveness toward foster young. Morphine treatment alone significantly disrupted the rate of onset and quality of maternal responsiveness. Concurrent administration of naloxone to morphine-injected rats reinstated the rapid onset of behavioral responsiveness toward foster young, such that the responsiveness of the rats treated with both morphine and naloxone was indistinguishable from that shown by saline-injected controls. The disruptive effects of morphine did not appear to result from a general reduction in activity levels as measured in an open-field apparatus. These findings suggest that the normal onset and maintenance of maternal behavior in the rat may be regulated by endogenous opiates.

Preparing residents for managed care practice using an experience-based curriculum.

Many U.S. residency graduates will practice in various types of managed care organizations, where they will be expected to arrive skilled in managed care activities such as prescribing with formularies and adhering to preauthorization processes for procedures, referrals, and hospital admissions. Residency programs must prepare their trainees to negotiate for their patients' needs within such systems. This article describes a University of California, Los Angeles, UCLA School of Medicine curriculum that teaches managed care skills to residents in two internal medicine residency training programs. The residents in one program participate in a commercial health maintenance organization plan via a group-model faculty practice. Managed care activities for residents in this program were gradually introduced beginning in 1990. This reflected previous years' gradual yet enforced introduction of managed care activities that occurred for this program's faculty and most group practice physicians in California. Residents in the other program train at a public hospital where managed care practice is simulated. Managed care activities were not required by this program's institution but were voluntarily introduced for their educational value beginning in 1994. Responding to this program's trainee and faculty requests, these activities were rapidly implemented over two years with the goal of preparing residents for joining practices in a market with high managed care penetration. Since 1994, the centerpiece of the curriculum has been residents' participation in ambulatory utilization review and related activities. Residents learn managed care principles through problem-based learning, experiential exercises, and feedback on resource utilization. The curriculum has affected residents' attitudes toward managed care and changed their patterns of referrals and resource use. Residents trained with this curriculum perceive managed care practices as familiar and less intrusive. They submit fewer requests for referrals, perhaps with review in mind. However, precautions may be required to avoid undercare. The authors found that the reduction of referrals requested was greater than what they had expected. Residents may find scrutiny by colleagues intimidating. Also, this curriculum requires a substantial time commitment from residency training, with its already busy teaching agenda. The authors feel that initiating a managed care curriculum is an important investment in time for U.S. residency programs. Given that most graduates of residency programs will have their health care management decisions scrutinized while in practice, the authors feel it is important that residents' first exposure to managed care be while they are still in the supportive residency environment. They believe that early exposure will not only give residents the confidence to overcome the intimidation of colleague scrutiny, but may also give graduates the tools for involvement with the development of future managed care health policy.

Opiate regulation of maternal behavior in the rat.

The effects of the opiate agonist morphine, the opiate antagonist naloxone and the weak opiate nonanalgesic dextrorphan on the expression of maternal behavior were investigated in a series of three experiments. In the first experiment treatment of rats with morphine (5 mg/kg, subcutaneously) after ovariectomy and hysterectomy on day 17 of gestation resulted in a disruption in the onset and quality of maternal responsiveness in the homecage and in a T-maze test. The duration of morphine's acute disruptive action was 2-4 hours. In the second experiment concurrent treatment of morphine-injected rats with naloxone prevented the disruptive effects of morphine in both the homecage and T-maze tests. The effects of morphine did not appear to result from a severe alteration in activity levels as measured in an open-field test, although morphine did increase activity slightly by the fifth day of treatment. In the third experiment treatment of rats after ovariectomy plus hysterectomy on day 17 of gestation with dextrorphan failed to disrupt maternal behavior. These results indicate that morphine disrupts maternal behavior through an opiate receptor mechanism, and suggests to us that endogenous opiates may mediate the expression of maternal behavior under certain physiological conditions.

Effect of ambulatory utilization review on referrals from generalists to specialists.

We studied whether ambulatory utilization review (UR) alters how many patients internal medicine residents refer to sub-specialists, and whether the effect persists without reinforcement. We compared referral rates of residents from a firm that held UR meetings (intervention firm residents, n = 20) with those of residents from a firm that did not (control firm residents, n = 21). We then compared referral rates of 17 intervention firm residents while they were participating in UR with their rates after not participating for at least 4 weeks. Intervention firm residents submitted 30% fewer referrals than control firm residents (9% vs 13%, p = .05). However, the effect was short-lived; after 4 weeks without UR, intervention firm resident referral rates were similar to control firm referral rates.