Needs assessment can guide creation of a "resident-optimized clinic" in surgery

BACKGROUND

There is limited data on deliberate teaching of residents in the clinic setting; we sought to investigate the clinic experience at our institution and improve education through creation of a novel "Resident-Optimized Clinic" (ROC).

METHODS

An online survey was sent separately to residents and faculty. Based on the results of this survey a modified ROC was developed to try to improve the obstacles to learning in clinic.

RESULTS

Qualitative analysis revealed the barriers in clinic were inconsistencies in expectations, lack of autonomy, time, and facility limitations. The modified ROC was rated positively with 100% of participants expressing they had sufficient time and autonomy; and 90% felt the environment was optimized for teaching.

CONCLUSIONS

Multiple themes have been identified as problematic for the clinic education experience. The ROC was rated positively by trainees suggesting thoughtful intervention to improve clinic results in a better clinic experience and more educational gain from the clinic environment.

Linking clinical and public health approaches to improve access to health care for socially disadvantaged mothers and children. A feasibility study

OBJECTIVE

To test the feasibility of combining home- and office-based interventions to improve access to health care and health outcomes of Medicaid-eligible mothers and infants.

DESIGN

Randomized trial in 2 counties in North Carolina (1 rural, 1 urban). Information on health and developmental outcomes was obtained by face-to-face interviews, medical chart abstractions, hospital medical records, and state data tapes.

PARTICIPANTS

Ninety-three Medicaid-eligible first-time pregnant women in their third trimester and their subsequently born infants, who were followed up until they were 6 months old, and 3 pediatric practices and 1 family practice.

INTERVENTIONS

Coordinated home visit and office intervention, office intervention, and usual care. Home visits by 3 public health nurses provided parental education and social support and linked families with needed community resources. Women in the office intervention group were encouraged to seek health care for their infants from one of the primary care practices. Participating offices received assistance with Medicaid billing, help developing a system to improve preventive care, and customized patient education materials.

RESULTS

Mothers reported that the nurses helped them in areas related to the content of the program. An office system for prevention was developed and implemented in all 4 practices for study patients. Families in the intervention groups were more likely than control families to have had a prenatal visit with a pediatrician (P = .01, chi 2), a primary care office as the regular source of sick care (P = .02, chi 2), and less waiting time (P = .02, Student t test). They were also more likely to recall receiving patient education materials (P = .007, chi 2).

CONCLUSIONS

It is feasible to link clinical and public health approaches to improve the quality and effectiveness of care for socially disadvantaged children. Such interventions should be tested in defined populations.

Training pediatric residents to prevent tobacco use

OBJECTIVE

To assess the effectiveness and acceptability of incorporating the National Cancer Institute (NCI) Guide to Preventing Tobacco Use During Childhood and Adolescence into pediatric training.

DESIGN

Preintervention and postintervention self-reported surveys for residents receiving training and postintervention baseline surveys for those residents not receiving training. Measures include: (1) a self-reported knowledge, attitude, and behavior survey of residents; and (2) physician behavior reports from parent exit interviews.

SETTING

A hospital-based pediatric residency program and continuity clinic.

SUBJECTS

Pediatric residents and parents of pediatric patients seen for well child examinations.

INTERVENTIONS

Structured NCI smoking cessation curriculum modified for delivery during scheduled teaching activities.

RESULTS

The NCI training was acceptable and perceived as important by residents. Many did not recall receiving the materials or training. Trained residents who remembered the intervention improved their smoking cessation counseling effectiveness. Most patients' parents think it appropriate for physicians to ask; however, most reported not having been asked about smoking or environmental smoke exposure.

CONCLUSIONS

For residents to learn effective prevention counseling strategies, systematic, reinforced preventive educational curricula must become an institutionalized part of residency training.

Brief report: thought disorder in Asperger syndrome: comparison with high-functioning autism

Asperger syndrome (AS) is a pervasive developmental disorder generally regarded as a variant of autism. While it has been included in the ICD-10 and DSM-IV as a distinct diagnostic entity, it is still unclear to what extent it differs from high-functioning autism (HFA). Persons with HFA have been reported to show a variety of deficits of thought processes. Abnormalities such as poor reality testing, perceptual distortions, and areas of cognitive slippage have been described using the Rorschach inkblot test (Dykens, Volkmar, & Glick, 1991). Since AS has been conceptualized as a mild variant of autism, we hypothesized that persons with AS will have fewer abnormalities on the Rorschach test compared to persons with HFA. To test this hypothesis, we compared 12 subjects with AS (ICD-10, 10 male, mean age = 12.2 +/- 3.3 years, mean full-scale IQ = 99.6) with 8 subjects with HFA (ICD-10/DSM-III-R, 7 male, mean age = 12.2 +/- 3.8 years, mean full-scale IQ = 83.4) on the Rorschach test. AS subjects demonstrated a trend towards greater levels of disorganized thinking than the HFA group. They were also more likely to be classified as "Introversive" suggesting that AS subjects may have more complex inner lives involving elaborate fantasies, Also, AS subjects tended to be more focused on their internal experiences. However, overall, the Rorschach test was not found to differentiate the two diagnostic groups on the majority of structural variables. Implications of these findings are discussed with regard to the diagnostic validity of Asperger syndrome.

The rest of the access-to-care puzzle. Addressing structural and personal barriers to health care for socially disadvantaged children

A mother brings her 2-year-old child to the office at 4:30 Friday afternoon. The child has been seen only once in the practice for an episode of otitis media. The child missed her follow-up appointment. When the receptionist asks why the child is here, the mother responds that she was able to get a ride today with a neighbor who has an appointment with another physician in the practice. The child is not covered by health insurance. The mother did not bring her immunization record and is not certain what preventive care the child has received in the past.

Clinical strategies for breast cancer screening: weighing and using the evidence

When balancing the benefits of screening women for breast cancer against the harms and costs of such screening, one needs to consider the risk for dying of breast cancer, the relative reduction in that risk that will result from screening women in different age groups, and the harms and costs associated with screening. Seven randomized controlled trials provide evidence of the relative risk reduction that results from screening women in different age groups; other studies estimate the harms and costs of screening. These studies indicate that the benefit of screening, expressed as the absolute number of lives extended per 1000 women screened, increases with age and that the harm of screening, expressed as the number of follow-up procedures per cancer detected, decreases with age. Thus, the tradeoff between the benefits and the harms and costs of screening is better for older than for younger women. Because there is no clear cut-point for determining when benefits outweigh harms and costs, it is important to involve women in discussions of breast cancer screening. The women who most need to be involved are those for whom the benefits of screening clearly outweigh the harms and costs and those for whom the benefits and the harms and costs constitute a "close call." For women in both groups, the physician should routinely raise the issue of screening, first eliciting the patient's perceptions and then providing information and discussion about the risk for breast cancer and about the benefits and the harms and costs of screening. Furthermore, the physician should encourage the patient to use her own values to weigh the benefits against the harms and costs, pointing out biases in reasoning and minimizing socioeconomic barriers. Finally, when the benefits obviously outweigh the harms and costs, the physician should make a clear recommendation for screening.

Preventive care in rural primary care practice

Delivering preventive care in a primary care practice is often more difficult for rural than for urban practices. First, rural compared with urban patients tend to be older, poorer, and less well insured, all characteristics associated with lower levels of preventive care. Second, there are many more patients per physician in rural than urban settings. Third, the distance from sources of preventive care is much greater for rural than for urban people. Fourth, rural practices tend to be smaller, with fewer resources to perform high-quality preventive care. Long-term programs to increase recruitment and retention of primary care physicians and improve insurance coverage for rural people may eventually improve preventive care utilization. A more immediate approach is to change the organization of medical practice, including developing satellite clinics, redefining the roles of nurses and nurse practitioners, and using organized systems within practices to reach and follow-up underserved groups. Initial impressions from the North Carolina Prescribe for Health project indicate that an organized approach to preventive care within physicians' offices may improve utilization of carefully designed packages of preventive care. More information is needed to understand the differences among rural, urban, and suburban areas in delivering preventive care to primary care patients.