The Virginia generalist initiative: lessons learned in a statewide consortium.

In response to Virginia's need for an increased supply of generalist physicians, the state's three medical schools--Eastern Virginia Medical School, Virginia Commonwealth University School of Medicine, and the University of Virginia School of Medicine--have formed a partnership with key governmental stakeholders in the Virginia Generalist Initiative funded by The Robert Wood Johnson Foundation's Generalist Physician Initiative. These state-supported medical schools historically have functioned independently, with little cooperative effort. This paper describes the consortium, its activities, its successes, and its unmet objectives, and uses a series of cases in point to illustrate relevant lessons learned. Some of these lessons are that (1) stakeholders must be involved from the beginning of planning to identify mutual goals and establish consortium protocols; (2) all partners must share a philosophical commitment to the consortium's mission, as well as the time and resources needed; (3) an atmosphere that enables risk-taking behavior must be created; (4) stakeholders must be willing to revise goals and sustain an environment conductive to change; and (5) trust is essential and must be vigilantly maintained. The paper concludes that the Virginia Generalist Initiative has dramatically altered the goals, objectives and programs of the three schools and has succeeded in aligning the schools' strategic objectives with the state's priorities.

A combined residency in family medicine and internal medicine at Eastern Virginia Medical School.

This paper describes the first operational four-year combined family medicine/internal medicine residency designed to qualify residents for board examination in both disciplines, which began at Eastern Virginia Medical School in 1995. The authors describe key program features, including their block rotation schedule, interdisciplinary ambulatory precepting, and plans for achieving 50% ambulatory training experience, as well as their difficulties in implementing a collaborative core didactic experience. The authors present faculty survey data indicating that internal medicine faculty members are more likely to view the combined residency as a resource, while family medicine faculty members would like to concentrate on the categorical residency. A recent survey of combined residents indicates that they are satisfied with their choice of combined training and optimistic about the opportunity of garnering additional skills relative to their internal medicine and family medicine counterparts. The authors suggest that successfully implementing this interdisciplinary effort requires an atmosphere of mutual respect and an effort to find opportunities to positively affect the training experiences of both combined residents and their resident partners in family medicine and internal medicine.

Two-generation programs: design, cost, and short-term effectiveness.

Two-generation programs are relatively new attempts to deal with the nation's social ills. In two-generation programs, services such as early childhood educational programs are offered to children to help them get the best possible start in life, while, at the same time, parents are offered training to help enhance their parenting skills, and education, literacy, or job training to help them become economically self-sufficient. These multistrategy programs are relatively new additions to the broad array of programs designed to serve children and families, but many have already been the subjects of fairly sophisticated evaluations. This article describes two-generation programs and how they differ from earlier single-focus approaches to serve children and families. In-depth descriptions of six premier two-generation programs are used to illustrate the variability in content and costs of these programs. The short-term results of these six programs are reviewed and indicate mixed and modest results in promoting the development of children and improving the parenting skills and economic self-sufficiency of parents. The results suggest several lessons, and the article concludes with recommendations for program improvement and future research.

Operation Desert Shield and Storm: impact on undergraduate and graduate internal medicine education.

We evaluated the impact of mobilization during Operation Desert Shield and Storm on undergraduate and graduate internal medicine education. Surveys were sent to the 425 residency program directors and 128 chairs of departments of medicine of U.S. medical schools in February 1991. Among graduate programs (46% response), 1.6% of full-time faculty, 0.2% of voluntary faculty, and 0.1% of residents were mobilized. No full-time faculty, voluntary faculty, and residents were mobilized at 77%, 90%, and 93% of programs, respectively. Negative impact ranged from none (68%) to significant (2%). For undergraduate education (51% response), 1.2% of full-time faculty, 0.1% of voluntary faculty, and 0.3% of residents were activated. Sixty-three percent reported no full-time faculty, 97% no voluntary faculty, and 86% no residents activated. Negative impact ranged from none (53%) to significant (4%). The effect of mobilization was small, and program directors and chairs should feel comfortable supporting participation in reserve activities.

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.

Potential influences of residencies' health risk policies on their rankings by Ohio applicants.

Residents' health risks constitute an area of increasing concern for hospitals and residencies. This study examined the importance of health risk policies in the context of students' selection of residencies. In 1991, all 836 fourth-year students in six Ohio medical schools were surveyed about their attitudes regarding residencies' policies on drug screening, HIV (human immunodeficiency virus) testing, and smoke-free workplaces. Of 763 surveys able to be delivered, 341 (45%) were returned. Substantial subsets of the students indicated that they would rank lower or not at all a program that required pre-residency drug screening (22%) or HIV testing (31%). Conversely, almost half the students (48%) responded that they would rank a program higher whose institution has a smoke-free policy. A discussion of potential factors affecting these findings is presented, with recommendations for hospitals, residencies, and residency applicants.

Hypothyroidism and acquired von Willebrand disease.

A 15-year-old female with acquired von Willebrand disease associated with hypothyroidism is presented and discussed. The patient was initially seen for right lower quadrant abdominal pain and menorrhagia. Once hypothyroidism was diagnosed and treated her coagulation abnormality resolved.

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.

Medical student, resident, and faculty use of a computerized literature searching system.

The experiences of medical students, residents, and faculty with a computerized literature searching system were evaluated. Third-year medical students, internal medicine and family practice residents, and full-time and voluntary faculty at one medical school had the opportunity to use a full-text and bibliographic medical literature retrieval system free of charge for an eleven-month period. Subjects conducted nearly nine thousand literature searches over a period of 942 system hours. Questionnaire data showed that participants could learn to use and would use an electronic information system, felt capable of using the system, utilized the system for a variety of purposes and in a number of different ways, and viewed the system as a valuable tool in searching the medical literature. The results are discussed in the context of the educational needs of the four user-groups and medical education planning by institutions.

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.

Informed consent: the use of inpatients as teaching-patients for sophomore medical students.

The preservation of patient's rights is an important issue in medical education that has not been addressed adequately in relation to informed consent for the teaching of history and physical examination skills to beginning medical students who are not yet functioning as a part of the health care team. In an attempt to assure informed consent and basic patients' rights and to instruct patient volunteers about the teaching-patient role and its importance to effective medical education, the authors developed a nonphysician patient-advocate-interviewer (PAI) model. The usefulness of the model was evaluated by comparing the perceptions of two groups of volunteer patients and the students for whom they served as teaching patients. Members of volunteer patient group I had a PAI, while group II volunteers were selected and interviewed only by a medical resident. Group I patients were significantly better informed about the teaching-patient's role for which they were volunteering and its importance to medical education and were more comfortable in their student history and physical examination session than were group II patients.

Antithyroid drug therapy for toxic diffuse goiter (Graves disease): thirty years experience in children and adolescents.

Since 1946 104 children and adolescents with toxic diffuse goiter have been treated. Sixty-seven were treated with a thioamide for more than 12 months. Remission occurred in 61%. Twenty-five patients had a 12-hour perchlorate discharge test to determine the least frequent dose schedule required for disease control: 68% could be controlled on a single daily dose and an additional 25% on an every 12-hour schedule. A one-hour radioiodine uptake on combined therapy and change in thyroid gland size during treatment were found to be highly correlated with the presence of a spontaneous remission. Thirty-six patients have been treated by subtotal thyroidectomy. To date 65% have developed permanent hypothyroidism. In the author's opinion, thoamides are the treatment of choice for the majority of children and adolescents.

Medical management of Crohn's disease in adolescence.

The therapy of Crohn's disease in adolescence must balance the natural disease history of growth suppression, debilitation, and progression against possible drug-related adverse effects on growth and development. In contrast to published guidelines which usually suggest episodic and symptomatic treatment of relapses, we have attempted to suppress disease activity throughout adolescence. Sixteen consecutive adolescent patients treated with continuous medical therapy for a mean duration of 3.5 years are presented. Fourteen received long term prednisone therapy for maintenance of disease suppression. All 16 have been asymptomatic or have had only mild symptoms which did not interfere with regular activities. Only 1 subject had to be rehospitalized. He subsequently underwent bowel surgery. Aternate day corticosteroid administration has been attained in 11 patients; 10 are growing and developing at a normal rate. In total, 13 of 16 have achieved pubertal development appropriate for age. The 8 patients with distal ileal disease have had a consistently excellent response to medical therapy. There have been no major adverse effects from drug therapy. It is concluded that an effort to suppress disease activity continuously in adolsecents with Crohn's disease is warranted. Excellent symptomatic control and normal rate of growth can be expected in patients with primarily ileal disease.