General internal medicine.

Internists advanced toward a patient care model based on critical, qualitative, and quantitative assessment of clinical care processes and outcomes. The complete internist must consider social context as well as traditional risk factors in promoting the health of patients.

Diabetic ketoacidosis in prisoners without access to insulin.

OBJECTIVE: To assess the cause and clinical severity of diabetic ketoacidosis in male prisoners hospitalized in New York City. DESIGN: Retrospective chart review. SETTING: A municipal hospital in New York City. PATIENTS: Forty-nine adult male prisoners with a total of 54 hospital admissions for diabetic ketoacidosis between January 1, 1989, and June 30, 1991. MAIN OUTCOME MEASURES: Charts were reviewed for diabetic and medical history, time from arrest until hospitalization, cause of diabetic ketoacidosis, admission laboratory data, and hospital course. RESULTS: Thirty-eight (70%) of the 54 admissions for diabetic ketoacidosis among prisoners occurred because prisoners had not received insulin during the period immediately following arrest (mean number of days from arrest until hospitalization was 2.5). All of these individuals had a history of insulin-dependent diabetes and were reportedly compliant with their insulin regimen at the time of arrest. Admission laboratory data for this group of prisoners included a mean serum glucose level of 27.4 mmol/L (495 mg/dL) and a mean serum bicarbonate level of 14.4 mmol/L. Mean number of days in the hospital was 3.4 including a mean of 1 day in an intensive care unit. CONCLUSIONS: Inadequate access to medication results in serious sequelae for recently arrested prisoners in New York City with insulin-dependent diabetes. Access to health care for recently arrested prisoners needs to be improved.

Physician-patient gender congruence and the physical examination.

To assess the hypothesis that breast, genitourinary (GU), and rectal examinations are performed more frequently when the physician and patient are of the same gender, the authors reviewed the records of 529 patients in a housestaff medical clinic. They found no significant difference between gender-congruent and gender-incongruent patient encounters in the rates of these examinations. However, higher rates of performance by primary care housestaff compared with those of internal medicine housestaff were noted in all categories. The authors conclude that performances of breast, GU, and rectal examinations were not related to gender congruence but may have been associated with the houseofficers' training program.

Attitudes of house officers toward the autopsy.

STUDY OBJECTIVE: To assess the attitudes of house officers in internal medicine and pathology about the value and use of the autopsy. DESIGN: Self-administered multiple-choice questionnaire. SETTING: Two New York City urban teaching hospitals. SUBJECTS: 112 internal medicine and 37 pathology house officers who were on site during the survey period. MAIN RESULTS: Most internal medicine house officers (86%) felt that the autopsy rate was too low and needed to be increased. The most common reason the residents cited for the low rate was the reluctance of families to grant permission. A majority of medicine housestaff (78%) felt they needed more instruction on how to ask for an autopsy, and 34% had never received feedback from the pathology department on autopsy results. Most pathology residents (94%) felt the autopsy rate was too low; the most common reasons they cited for the low rate were reluctance of clinicians to request permission and clinicians' fears of being sued for malpractice. CONCLUSIONS: House officers in internal medicine and pathology agreed that autopsies should be performed more frequently, and identified problems in obtaining autopsies that should be addressed by educational, organizational, and regulatory strategies.

Concerns of medical and pediatric house officers about acquiring AIDS from their patients.

To assess the degree of house officers' concerns about acquiring AIDS (acquired immunodeficiency syndrome) from their patients, we surveyed 263 medical and pediatric interns and residents in four housestaff training programs affiliated with seven New York City hospitals with large AIDS patient populations; 258 questionnaires (98 per cent) were returned. Thirty-six per cent of medical and 17 per cent of pediatric house officers reported percutaneous exposures to needles contaminated with blood of AIDS patients. Forty-eight per cent of medical and 30 per cent of pediatric house officers reported a moderate to major concern about acquiring AIDS from their patients. Greater concern about personal risk was noted in those house officers who were earlier in their residency training, who reported having treated a greater number of AIDS patients, and who were in medicine rather than pediatrics programs. Twenty-five per cent of all respondents reported that they would not continue to care for AIDS patients if given a choice. The results demonstrate a substantial degree of concern about acquiring AIDS among house officers caring for AIDS patients and suggest the need for housestaff program administrators for formally address these concerns.