Contributions of general internal medicine teaching units: a national survey.

OBJECTIVE: To identify and describe general internal medicine teaching units and their educational activities. DESIGN: A cross-sectional mailed survey of heads of general internal medicine teaching units affiliated with U.S. internal medicine training programs who responded between December 1996 and December 1997. MEASUREMENTS AND MAIN RESULTS: Responses were received from 249 (61%) of 409 eligible programs. Responding and nonresponding programs were similar in terms of university affiliation, geographic region, and size of residency program. Fifty percent of faculty received no funding from teaching units, 37% received full-time (50% or more time), and 13% received part-time (under 50% time) funding from units. Only 23% of faculty were primarily located at universities or medical schools. The majority of faculty were classified as clinicians (15% or less time spent in teaching) or clinician-educators (more than 15% time spent in teaching), and few were clinician-researchers (30% or more time spent in research). Thirty-six percent of faculty were internal medicine subspecialists. All units were involved in training internal medicine residents and medical students, and 21% trained fellows of various types. Half of the units had teaching clinics located in underserved areas, and one fourth had teaching clinics serving more than 50% managed care patients. Heads of teaching units reported that 54% of recent graduating residents chose careers in general internal medicine. CONCLUSIONS: General internal medicine teaching units surveyed contributed substantial faculty effort, much of it unfunded and located off-campus, to training medical students, residents, and fellows. A majority of their graduating residents chose generalist careers.

Do general internal medicine fellows find jobs that match their training?

We surveyed employers of general internists at teaching hospitals to determine whether they prefer that new hires are graduates of general internal medicine (GIM) fellowships. We surveyed former GIM fellows who graduated between 1988 and 1994 to determine whether they found jobs with protected research time and whether the positions they found matched their expectations. Employers rated a GIM fellowship, among other criteria, as important for clinician-researchers, but not for clinician-educators. For graduates categorized as clinician-researchers (with more than 33% of their time protected for research), there was a good match between their actual time allocations for research and clinical work and what they recalled their expectations were when looking for a job. Clinician-educators had a marked discordance between actual time allocations for research and clinical work and their recollection of their expectations when looking for a job.

Managed care, attitudes, and career choices of internal medicine residents.

The influence of managed care on internal medicine residents' attitudes and career choices has not yet been determined and could be substantial. In a survey of 1,390 third-year internal medicine residents, 21% believed that managed care was the best model of health care for the United States, and 31% stated they would be satisfied working in a managed care system. Those from high managed care communities (>30% penetration) were only slightly more accepting of managed care, but were more likely to choose general internal medicine as a career (54%, p = .0009) than those from communities with lower managed care penetration.

The feasibility of consortia for internal medicine graduate medical education: perspectives from a survey of residency directors.

PURPOSE: To assess the perspectives of internal medicine (IM) residency directors on issues that might determine the feasibility of consortia for IM graduate medical education (GME). METHOD: A self-administered questionnaire was mailed to all 413 U.S. IM program directors in June 1994. Of the 413 IM programs, 215 were located in community hospitals; 123 in university hospitals; and 75 in municipal, Veterans Administration, or military hospitals, or hospitals associated with multispecialty clinics ("other"). The questionnaire elicited responses concerning (1) perspectives on the quality of academic affiliations, (2) experience with formal institutional collaboration on GME issues and projection of consortium success, and (3) possible barriers to the success of consortia. Data were analyzed by comparing responses from the three program categories. RESULTS: In all, 330 (80%) program directors responded. Two-thirds reported ongoing academic affiliations. A larger percentage of university program directors considered these ties to be strong and advantageous than did their colleagues in community or other hospitals, who also considered their affiliations to be less equitable and less mutually trusting. Only 31% of community and university programs and 40% of other programs reported any prior experience with institutional collaboration on GME issues. A high percentage of those respondents considered these collaborative experiences to be successful and were optimistic about the projected success of consortia. Of seven possible barriers to consortium success, competition, governance, bureaucracy, and mistrust were most often perceived as major barriers. CONCLUSION: The data appear to indicate some optimism for the prospects of GME consortia, thereby supporting their feasibility for IM GME. Although many respondents perceived barriers to success, such perceptions were less common among program directors who had had direct experience with previous collaborative efforts. Nevertheless, these barriers may require attention if consortia are to succeed in achieving their many possible advantages.

Headaches.

Headaches are a common problem that can be disabling. The clinical features and treatment of migraine, cluster, and tension headaches are presented in this article. Emphasis is placed on the newer drugs available for acute and prophylactic treatment of these headaches. Features of headaches associated with intracranial aneurysms, temporal arteritis, cerebrovascular accidents, brain tumors, and temporomandibular disorders are also discussed.

The effect of house officer rotation on inpatient satisfaction and ward atmosphere: preliminary findings.

Continual rotation of house officers builds discontinuity into the physician-patient relationship in teaching hospitals. This has led to speculation about the problem of residents and interns leaving their patients in the midst of hospital treatment. This article uses prospective data to assess the effect of house officer turnover on levels of patient satisfaction with hospital care and on patient perception of the hospital environment. Two inpatient cohorts defined by whether or not they had undergone a house officer change were matched by age and diagnostic category. Although survey instruments were significantly correlated, there was no significant difference between the two inpatient cohorts overall or on any of the survey subscales. The survey showed good satisfaction with the hospital, doctors, and nurses in both test groups. The authors draw a preliminary conclusion that patient satisfaction with medical care and with the hospital atmosphere remains constant, independent of termination of the doctor-patient relationship. Results from other reports linking patient satisfaction with continuity of care have been mixed. In discussing the limitations of their study, the authors point out that their findings are based on single-site data.

A model for faculty practice teaching clinics developed at the Oregon Health Sciences University.

In 1988 the Oregon Health Sciences University established its first faculty practice teaching clinic wherein physicians in training were incorporated into a faculty private practice clinic; this pilot project proved very successful and has been subsequently adopted as the model for essentially all outpatient clinics (both medical and surgery) in the university system. The model encourages efficiency, overhead control, and appropriate staffing; it also compensates faculty members for their additional time spent teaching. The authors conclude this model may help other academic training centers adapt to the changing demands of medical education.

Clinical management of the complications of HIV infection.

Patients with advancing HIV infection are subject to a broad range of complications that may challenge the primary care physician. The presence of more than one complication at a time is common. Selected, common complications are discussed, including a discussion of the approach to diagnosis and management. Areas covered include pulmonary, gastrointestinal, ocular, and mucocutaneous complications, as well as lymphadenopathy, the HIV wasting syndrome, and Kaposi's sarcoma.

Controversies in the management of HIV-related illnesses.

The care of patients who have HIV infection requires technical competence, skill in clinical decision making, a commitment to continuing self-education, the ability to collaborate with medical and community-based service providers, and attention to the psychological and ethical aspects of patient care. General internists bring these attributes to their work and will be increasingly involved in meeting the challenges presented by the AIDS epidemic. Controversial issues in the management of HIV illness include: assessment and management of latent syphilis in patients with intercurrent HIV infection; risk assessment and postexposure zidovudine prophylaxis of health care workers after occupational accidents; determination of the risk of reactivation tuberculosis in HIV-infected individuals; and treatment or nontreatment of infections with the Mycobacterium avium complex in symptomatic patients. Patients illustrating these management problems are presented by progressive disclosure; the points made in discussion by a panel of general internists and AIDS specialists are presented.

Parasitic infections in asymptomatic homosexual men: cost-effective screening.

The purpose of this study was to develop a cost-effective strategy for screening for enteric protozoan infections in homosexual men without gastrointestinal symptoms suggesting infection. One hundred and one homosexual men in Portland, Oregon, each submitted at least one unpurged stool sample; 91% submitted three samples each. Of these, 27% had Entamoeba histolytica, 61% had nonpathogenic protozoa with or without E. histolytica, 36% had a nonpathogen alone, and 3% had Giardia lamblia. Protozoan infection was highly associated with the practice of anilingus (p less than 0.005). Infection with E. histolytica correlated significantly with the presence of nonpathogenic protozoa (p less than 0.005). The following screening strategy was judged to be the most cost-effective: examine one sample first; if E. histolytica is found or if the sample is negative, no further investigation is required; if a nonpathogen is found, one additional sample should be obtained. This strategy had a sensitivity for E. histolytica of 85% and a cost of $136 per case detected.