Management of laboratory test results in family practice. An OKPRN study. Oklahoma Physicians Resource/Research Network.

BACKGROUND: Ineffective management of laboratory test results can result in suboptimal care and malpractice liability. However, there is little information available on how to do this important task properly in primary care settings. METHODS: We used a questionnaire guided by a literature review to identify a conceptual model, current practices, and clinicians who reported having an effective method for at least one of 4 steps in the process of managing laboratory test results. Clinicians with differing methods were selected for each of the steps. Practice audits and patient surveys were used to determine actual performance. On the basis of these audits, we constructed a unified best method and conducted time-motion studies to determine its cost. RESULTS: After auditing only 4 practices we were able to identify effective methods for 3 of the 4 steps involved in the management of laboratory test results. The unified best method costs approximately $5.19 per set of tests for an individual patient. CONCLUSIONS: By identifying effective practices within a family practice research network, an effective method was identified for 3 of the 4 steps involved in the management of laboratory test results in primary care settings.

A longitudinal investigation of medical student attitudes toward the medically indigent.

BACKGROUND: Studies have shown that medical student attitudes decline as students progress through school. Controversy persists about the meaning and generalizability of these findings because studies have not been longitudinal and many were conducted prior to an influx of female students. Much of medical education occurs in academic medical center environments where disproportionate numbers of indigent (uninsured and underinsured) patients seek care. This study examined whether students' attitudes toward providing care to indigent clientele changed over time. PURPOSE: To track longitudinal changes in attitudes toward providing care for the medically indigent of 1 cohort of medical students and to determine if gender differences existed and persisted over time. METHODS: Students entering a Southwest medical school in 1989 participated in this study. Attitudes were compared using the Medical Students' Attitudes Toward the Underserved questionnaire, a self-report, attitudinal scale. RESULTS: Student attitudes declined during the 1st year of school, remained fairly stable during Years 2 and 3, and declined further during Year 4. Analyses comparing 1st- and 4th-year students showed a decline in attitudes for men and women for each scale except Basic Services. Although both women's and men's attitudes declined, women's attitudes remained more favorable across the 4 years. CONCLUSIONS: A clearer understanding of how female medical students sustain socially responsible attitudes throughout medical school may help educators develop support mechanisms for men and women that would promote an ethic of social responsibility and encourage students to work with indigent clientele.

Using audiotapes to monitor student-preceptor interactions in a decentralized clerkship.

BACKGROUND: Community-based preceptors are increasingly being used to provide clinical experiences for medical students; therefore, the issue of when and how to monitor the appropriateness of teacher-learner interactions in the clinical setting has become increasingly complex and urgent. This paper describes how an audiotaping program in a department of family medicine was designed to account for preceptor and student needs and what this audiotaping experience revealed about the teaching strengths and weaknesses of full-time and volunteer faculty. METHODS: Audiotaped case discussions between third-year students and preceptors were evaluated using a structured instrument that reflected important responsibilities of clerkship preceptors. Reviews were compared using chi-square to evaluate for significant differences between university and community preceptors in overall quality of interaction with students and in specific deficiency areas. Ninety-five percent confidence intervals were used to evaluate for significant differences in frequency of occurrence among deficiencies. RESULTS: A total of 376 audiotaped case discussions were reviewed between July 1992 and June 1994. University preceptors had significantly more "superior" interactions with students than their community peers (P < .05). However, university and community preceptors had nonsignificant differences when specific deficiency areas were compared. Deficiencies in students who were allowed to present cases and assessments occurred significantly less frequently, while deficiencies in preceptors using open-ended questions occurred significantly more frequently than deficiencies in other areas. CONCLUSIONS: This study shows that volunteer faculty performed comparably to full-time university faculty in both the frequency of deficiencies in teacher-learner interactions identified and in the types of deficiencies identified. Both university and volunteer faculty had the most deficiencies in higher-order teaching skills--those involving synthesizing and assessing student knowledge and selecting appropriate questions based on that information. Audiotaped case discussions have a potentially significant role in monitoring teacher-student interactions, particularly on decentralized clinical rotations.