The in-training examination in internal medicine.

OBJECTIVE: The In-Training Examination in Internal Medicine (ITE-IM) has been offered to internal medicine trainees annually since 1988 as an instrument for self-assessment. This report outlines the manner in which the test is prepared, reviews the results of annual examinations, and analyzes trends during the past 6 years. DESIGN: Results of each examination were reviewed with regard to the demographic characteristics of persons taking the test, their previous medical training, and their present program affiliations. RESULTS: Then number of residents participating in the ITE-IM has increased steadily over the past 6 years. In 1993, more than 12,000 residents from more than 90% of internal medicine training programs in the United States participated in the examination; the percentage of international medical school graduates taking the examination increased from 27% in 1988 to 47% in 1993. Statistical analyses of each examination have shown it to be reliable, internally consistent, and discriminating. Over the past 6 years, graduates of U.S. medical schools have scored consistently higher than those of international medical schools and schools of osteopathic medicine on all annual examinations. However, in 1993, for residents at all levels of training, the differences in scores between graduates of U.S. medical schools and graduates of international medical schools narrowed substantially. From 1988 to 1993, there has been a trend toward lower scores by every cohort on each subsequent examination. The decreases in scores are most pronounced for graduates of U.S. medical school and those of schools of osteopathic medicine. The lower scores may be caused by either an increased level of difficulty in the examination or decreased knowledge among examinees. CONCLUSIONS: The ITE-IM is a useful instrument to assess the knowledge base of residents and program directors with a reliable evaluation of themselves and their programs in comparison to their national peer groups. It also provides objective data to monitor trends over time in residents' scores and relates them to the changing demographic characteristics of trainees and to innovations in the clinical curricula of internal medicine training programs.

Management of upper respiratory tract infections by telephone.

We surveyed Utah general internists (N = 134) regarding their attitudes toward and practices associated with telephone management of upper respiratory tract infections. The questionnaire contained 3 case vignettes--viral upper respiratory tract infection, streptococcal pharyngitis, and acute infectious epiglottitis--and a series of questions were asked about telephone diagnosis, management preferences (clinic versus telephone), and telephone management practices. The 53 respondents (40%) were able to make important diagnostic distinctions about upper respiratory tract infections from a written vignette. As the likelihood of a complicated or serious condition increased, patients would be appropriately triaged for clinical evaluation. Most internists would make a written record of the telephone conversation. Only 1 internist of the 53 would charge for telephone management.

Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses.

We report an attempt to quantitate the relative contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. In this prospective study of 80 medical outpatients with new or previously undiagnosed conditions, internists were asked to list their differential diagnoses and to estimate their confidence in each diagnostic possibility after the history, after the physical examination, and after the laboratory investigation. In 61 patients (76%), the history led to the final diagnosis. The physical examination led to the diagnosis in 10 patients (12%), and the laboratory investigation led to the diagnosis in 9 patients (11%). The internists' confidence in the correct diagnosis increased from 7.1 on a scale of 1 to 10 after the history to 8.2 after the physical examination and 9.3 after the laboratory investigation. These data support the concept that most diagnoses are made from the medical history. The results of physical examination and the laboratory investigation led to fewer diagnoses, but they were instrumental in excluding certain diagnostic possibilities and in increasing the physicians' confidence in their diagnoses.

Placebo-controlled trial of quinine therapy for nocturnal leg cramps.

A prospective, double-blind, placebo-controlled crossover study of the use of quinine for nocturnal leg cramps was carried out in 8 elderly volunteer patients. The patients were randomly assigned to receive either placebo or 200 mg of quinine sulfate by mouth at bedtime. After 4 weeks of treatment and after a one-week washout period, the group taking quinine switched to placebo and vice versa for another 4 weeks. The differences in the number, duration, and severity of cramps and the side effects were compared. All of the patients had fewer cramps and decreased severity and duration of attacks while receiving quinine. Mild side effects developed in only 2 patients, and these subsided without treatment or discontinuing the medication. We conclude that quinine was effective in relieving nocturnal leg cramps in a selected group of elderly patients.

Public policy on smoking and health: toward a smoke-free generation by the year 2000. A statement of a working group to the Subcommittee on Smoking of the American Heart Association.

On May 20, 1984, the Surgeon General challenged the health community to work toward attainment of a smoke-free society by the year 2000. The leadership of the nation's three major voluntary organizations joined numerous associations of health professionals in accepting the challenge. The Subcommittee on Smoking of the American Heart Association (AHA) has concluded that attaining this objective requires the development and implementation of public policies designed to facilitate the transition from a smoking to a nonsmoking society. To study the relevant issues and recommend appropriate policies, the subcommittee commissioned a working group of distinguished experts in the field of smoking and health to prepare a policy statement. The statement, published here, has received the enthusiastic endorsement of the Subcommittee on Smoking and the leadership of the AHA. The working group discusses and recommends four policies: Increase the federal cigarette excise tax. Eliminate or restrict tobacco advertising and other forms of promotion. Assure the rights of nonsmokers to clean air through legislative means. Identify mechanisms to ease and assist the transition of tobacco farmers to other crops or careers.

Promotion of tobacco products: issues and policy options.

During the past year, several prominent voluntary health organizations and professional medical associations have called for a ban on all forms of promotion of tobacco products. The proposal raises complex issues, ranging from determination of the effects of tobacco promotion to assessment of the constitutionality of banning advertising of a legal product. We identify the issues that underlie the concern of health professionals, review evidence addressing these issues, and describe and discuss frequently mentioned policy options, especially the ban proposal.

Personal health maintenance for adults.

The practice of adult medicine provides many opportunities to prolong life, prevent disease and disability and promote health. Essential steps in this process include establishing patient rapport, obtaining a comprehensive data base, providing periodic health examinations for both symptomatic and asymptomatic patients and helping patients change unhealthy behavior.

Ischemic colitis in a young adult due to inferior mesenteric vein thrombosis.

A thirty-two-year-old male presented with abdominal pain and rectal bleeding due to ischemic colitis. Inferior mesenteric vein thrombosis was documented angiographically. No predisposing factors for thrombosis were found. The natural course of the disease was documented with fiberoptic endoscopy. The pathological changes which account for the radiologic alterations were documented.