Medical students' education in the ambulatory care setting: background paper 1 of the Medical School Objectives Project.

The present article is the first MSOP Background Paper. In planning the Medical School Objectives Project (MSOP), the Association recognized that certain changes in medical students' education were occurring already in some schools, and that it would be important to gain insight into and monitor these changes to provide ideas and information to help schools design curricular changes to foster students' achievements of the objectives and recommendations set forth in the MSOP Reports published in 1998 and reprinted in Academic Medicine. This background paper provides an overview of the strategies being developed by medical schools to carry out education in the ambulatory care setting. This report is based on site visits in 1997 to 26 U.S. medical schools conducted by two of the authors (CEH and GAK), who also used information from 12 additional schools that were not visited and consulted individuals responsible for the evaluation of five grant programs dedicated to national curriculum reform. The authors define and discuss in detail the use of the three main strategies that their research uncovered: (1) longitudinal preceptorships, (2) multispecialty clerkships, and (3) activities that are community oriented and population based to provide medical students the kinds of educational experiences they need to understand and practice in the ambulatory care setting. The authors then discuss issues and challenges related to the implementation of these curricular changes: curricular management issues; developing and maintaining a network of practicing physicians willing to serve as preceptors; evaluating curricular innovations; and assessing students' performances. The authors conclude with general observations about the need for ambulatory care education, the difficulties that have been--and continue to be--met and overcome to implement it, and the recommendation that relevant learning experiences should be incorporated into existing course work or clinical experiences.

Trends in clinical education of medical students: implications for pediatrics.

OBJECTIVES: To describe current educational imperatives and trends for curricular changes in the clinical education of medical students and to delineate the nature and extent of participation in these curricular trends by departments of pediatrics. METHODS: Site visits to 26 representative US medical schools and a review of detailed information from 12 additional schools. Evaluation of the core curriculum was developed by the Council on Medical Student Education in Pediatrics within the context of the major curricular trends observed. RESULTS: The major observed curricular trends emphasized community-based ambulatory experiences, continuity of care, integration, and population-based experiences. Supporting educational principles included student-directed learning and performance-based assessments. The 3 major curricular changes were early clinical experiences (longitudinal preceptorships), community-oriented/ population-based experiences, and multispecialty clerkships. The focus of the Council on Medical Student Education in Pediatrics objectives was the year 3 clerkship, and substantive participation by pediatric faculty in the overall curriculum was primarily related to the pediatric clerkship. CONCLUSIONS: Revising the clerkship-based Council on Medical Student Education in Pediatrics guidelines according to the new educational trends will extend clinical curricular opportunities for pediatrics beyond the traditional boundaries of the clerkship. The discipline of pediatrics will, as a consequence, be able to achieve enhanced partnership in the planning, conduct, and evaluation of a clinical curriculum for medical students that is relevant to child health issues and that extends across all 4 years.

The clinical utility of META: an analysis for hypertension.

To evaluate the clinical completeness of the National Library of Medicine Metathesaurus(META), we coded the conceptual information found in 2000 problem oriented (SOAP) notes for hypertension from one COSTAR site. To minimize the effects of practice idiosyncracy, we analyzed an additional 500 notes from a second, geographically remote site. Concepts occurring at either site numbered 1337. We classified concepts occurring at both sites as core concepts and these numbered 121. We attempted to find a matching concept of the proper semantic type in META for each of the items. All matching was done by program with a manual review by a physician. The overall success rate for matching was: [table: see text] We observed the greatest frequency of unmatched concepts in physical examination, medications, symptoms, personal behavior, non-medical therapies and counselling. We conclude that the current release of META is not sufficiently rich to describe the process of care in the ambulatory management of hypertension. However, the construction and breadth of the current scheme holds promise for medical knowledge representation and translation.

Report of an association between race and thyroid stimulating hormone level.

We examined the association between race and thyroid stimulating hormone (TSH) level in 809 consecutive Black or White adults tested for mild suspicion of hypothyroidism with a normal TSH result. The mean TSH level of Blacks was 0.4 (SE .053) mU/L lower than that for Whites after age and sex adjustment, race explaining 6.5 percent of the variation in TSH levels. A validation sample yield similar results. This finding supports the possibility that differences in thyroid function and/or regulation may be associated with race.

Ectopic hyperprolactinemia resulting from an ovarian teratoma.

Detection of an elevated prolactin level in the nonpregnant patient usually directs attention to the investigation of the pituitary gland. We describe a patient with secondary amenorrhea and galactorrhea in whom such an elevated prolactin level did initially lead to the discovery of a pituitary mass that was treated first unsuccessfully with surgery, and then successfully with medical therapy. After medical therapy normal menstruation continued, galactorrhea recurred intermittently, and the prolactin level rose again and remained in the approximately 36-micrograms/L range. However, 2 years later an ovarian teratoma was discovered incidentally and was removed surgically. On pathological evaluation the teratoma was noted to include prolactin-containing tissue, and immediately after surgery the patient's prolactin level and responsiveness to stimulatory testing returned to normal. To our knowledge this is the first case report of the association of clinically evident hyperprolactinemia with an ovarian cystic teratoma that contained prolactin-producing tissue.

Yield of hypothyroidism in symptomatic primary care patients.

Symptoms suggestive of hypothyroidism are common in primary care practice, but the yield of this disorder from symptom-based testing has not been adequately evaluated. We attempted to determine this yield and examine the effect of various patient factors on its magnitude. The records of 982 consecutive primary care health maintenance organization patients who had a thyroid-stimulating hormone (TSH) determination for suspicion of hypothyroidism were reviewed. Forty-two (4.3%) had an increased TSH concentration on initial testing, but only 17 (1.7%) had a TSH level 5 mU/L or more above normal. Abnormal thyroid examination results and white vs black race were independently associated with a TSH concentration 5 mU/L or more above normal. Female sex and age did not significantly affect the odds of an elevated TSH concentration. The yield of hypothyroidism from symptom-based testing in this setting was quite low. Although increasing age and female sex are both strong determinants of the risk of hypothyroidism in the general population, neither factor permitted risk stratification in symptom-based testing. The strong racial association noted was not anticipated and requires confirmation.