Representational abilities and the hearing status of child/mother dyads.

Two representational abilities, expressive and receptive language and symbolic play, were assessed in multiple formats in hearing and deaf 2-year-old children of hearing and deaf mothers. Based on maternal report, hearing children of hearing and deaf mothers produced more words than deaf children of hearing mothers, hearing children of hearing mothers more words than deaf children of deaf mothers, and deaf children of deaf mothers more words than deaf children of hearing mothers. Based on experimenter assessments, hearing children in both groups produced and comprehended more words than deaf children in both groups. By contrast, no differences emerged among these groups in child solitary symbolic play or in child-initiated or mother-initiated child collaborative symbolic play; all groups also increased equivalently in symbolic play between solitary and collaborative play. Representational language and symbolic play were unrelated in hearing children of hearing mothers and in deaf children of deaf mothers, but the 2 abilities were associated in children in the 2 child/mother mismatched hearing status groups. These findings are placed in the context of a proposed developing modularity of verbal and nonverbal symbol systems, and the implications of hearing status in communicative exchanges between children and their mothers in diverse hearing and deaf dyads are explored.

The preparedness of students to discuss end-of-life issues with patients.

PURPOSE: To explore how well medical schools prepare students to address end-of-life issues with their patients. METHOD: In 1997, the authors surveyed 226 fourth-year students at Georgetown University School of Medicine and Mayo Medical School, assessing relevant knowledge, experiences, and attitudes, and the students' sense of preparedness to address end-of-life issues. RESULTS: Seventy-two percent (162) of the eligible students responded. Almost all (99%) recognized the importance of advance directives and anticipated discussing end-of-life issues with patients in their practices (84%). However, only 41% thought their education regarding end-of-life issues had been adequate, only 27% had ever discussed end-of-life issues with a patient themselves, and only 35% thought they had had adequate exposure and education regarding advance directives. Eighty percent favored more education about end-of-life issues. Educational exposure to end-of-life issues and to role models, ability to correctly define an advance directive, number of end-of-life discussions witnessed, and age all were associated the students' sense of preparedness to discuss advance directives with patients. CONCLUSION: Most of the students felt unprepared to discuss end-of-life issues with their patients, but wanted to learn more. The factors associated with a sense of preparedness suggest several possible, easily made, educational interventions, but further research is required to understand the scope of the problem and to implement curricular modifications.

Ethics education for medical house officers: long-term improvements in knowledge and confidence.

OBJECTIVE: To examine the long-term effects of an innovative curriculum on medical house officers' (HOs') knowledge, confidence, and attitudes regarding medical ethics. DESIGN: Long term cohort study. The two-year curriculum, implemented by a single physician ethicist with assistance from other faculty, was fully integrated into the programme. It consisted of monthly sessions: ethics morning report alternating with didactic conferences. The content included topics such as ethics vocabulary and principles, withdrawing life support, informed consent, and justice. Identical content was offered simultaneously at the largest affiliated community hospital. SETTING: A multi-hospital university training programme from July, 1992 to June, 1994. PARTICIPANTS: Thirty-nine HOs responded in 92. Thirty HOs from the same cohort responded in 94 (response rates = 83% v 71%; P = 0.19). RESULTS: The curriculum was well received, with 96% of HOs finding the sessions stimulating. Previously validated scales of knowledge and confidence were administered at baseline and at follow-up. The average knowledge score improved 14% (P < 0.001). Confidence also improved, rising from 3.3 to 3.8 on a 5-point Likert scale (P < 0.001). These findings were independent of age, gender, religion, and prior education. The only attitudinal change was an increase in the proportion of residents who thought that ethics should be a required part of residency training (57% v 80%, P = 0.05). CONCLUSION: This curriculum appears practical, popular, and effective. It should be readily transferable to other institutions.

Strategies to promote the use of advance directives in a residency outpatient practice.

OBJECTIVE: To evaluate patient education and resident education strategies to promote advance directives in the outpatient setting, and to assess barriers to implementation. DESIGN: Controlled clinical trial. SETTING: The internal medicine residents' practice of an urban, university medical center. PATIENTS/PARTICIPANTS: Medical residents and 250 patients seen at least twice in the 3 months prior to the study. INTERVENTIONS: We randomized practice days: one to patient education, one to resident education, and three controls. Resident education consisted of a lecture, a videotape of a model advance directives discussion, and videotaping of an actual discussion by each resident, followed by individual review. Patient education consisted of distributing pamphlets in the waiting room and offering all patients an opportunity to discuss advance directives. MEASUREMENTS AND MAIN RESULTS: We interviewed 187 of these patients (response rate 75%) and surveyed 62 residents (response rate 70%). After 18 months, there were no significant differences in the number of advance directives in charts among the three groups. Documented advance directives discussions with patients in the resident education group increased from 3% to 17% (p < .001), more than those in the patient education (5%) or control group (10%, p = .04). Residents in the resident education group were more likely to report discussing advance directives than those in the patient education or control groups (p = .05). Lack of time (95%) and lack of continuity (76%) were the most frequently cited barriers. In multivariate logistic regression, nonwhite race and non-U.S. birth were negatively associated with patient interest in advance directives. Patient race and birthplace were not associated with actual discussions of advance directives. CONCLUSIONS: Even with intensive efforts to educate outpatients and residents about advance directives, important barriers remain, raising questions about how best to promote advance directives among outpatients.

Improving office-based physician's prevention practices for sexually transmitted diseases.

OBJECTIVE: To determine whether office-based interventions increase primary care physicians' risk assessment of and counseling practices for patients regarding sexually transmitted diseases and the human immunodeficiency virus (HIV). DESIGN: Randomized controlled clinical trial. SETTING: Washington, D.C., Metropolitan Statistical Area. STUDY PARTICIPANTS: Office-based primary care physicians (family or general practice, internal medicine, and obstetrics-gynecology). INTERVENTION: Mailed educational materials alone or coupled with a simulated patient instructor office visit. MEASUREMENTS: Self-reported and observed frequency of assessing and counseling patients regarding their risk factors for sexually transmitted diseases and HIV infection. Participants were interviewed by telephone before and after the intervention (n = 757). A subset of participants (n = 194) was also observed after the intervention by simulated patient evaluators in blinded office visits. RESULTS: 89% of physicians who received both educational materials and a simulated patient instructor visit reported that they reviewed the educational materials compared with 53% of those who only received the educational materials (P < or = 0.001). Physicians in the combined intervention group had higher self-reported and observed rates for several risk assessment questions and counseling recommendations than did physicians in the control group or the group that only received educational materials. Seventy-three percent of physicians of the combined intervention group reported an increase in counseling patients about reducing risky sexual behavior compared with 53% of the group receiving only educational materials and 42% of the control group (P < or = 0.001). CONCLUSIONS: Mailed educational materials combined with an office visit by a simulated patient instructor for role-play and feedback on clinical performance increased the frequency of office-based physicians' risk assessment and risk reduction counseling of patients for sexually transmitted diseases and HIV infection.

Black-white differences in mortality in idiopathic dilated cardiomyopathy: the Washington, DC, dilated cardiomyopathy study.

Racial, socioeconomic, and clinical factors were examined as predictors of survival in idiopathic dilated cardiomyopathy using cases from five Washington, DC-area hospitals. One hundred three (80.5%) of the patients were black and 25 (19.5%) were white. The black patients were less likely to have private health insurance, less educated on average, and more likely to have a household income of $15,000 or less (P < or = .05). No racial differences were found in cardiac medication usage, with the exception of beta blockers and antiarrhythmics. The cumulative survival among black patients at 12 and 24 months was 71.5% and 63.6%, respectively, as compared with 92.0% and 86.3% among whites. The 12-month survival of black patients with ventricular arrhythmias or an ejection fraction of less than 25% was particularly poor. Age, ventricular arrhythmias, ejection fraction, and cigarette usage were significant predictors of survival in univariate analysis using the proportional hazards model. The univariate association with black race was of borderline significance (P < or = .07). In multivariate analysis, age and race were statistically significant independent predictors of survival. A strong association with black race was observed with an estimated relative risk of mortality of 5.41 (P < or = .02) after adjustment for age, ejection fraction, ventricular arrhythmias, and educational attainment. Poorer survival among blacks may be caused by a greater severity of disease at the time of diagnosis or by racial differences in cardiac care, comorbid conditions, or biologic factors affecting survival.

What technologies for health care in developing countries?

In order to decide whether a health technology is suitable for introduction into a developing country it is first necessary to assess both it and the infrastructural conditions in which it would have to function. The present article examines the rationale for establishing national health technology assessment programmes and outlines how they might be conducted.

PIP: The article examines the rationale for establishing national health technology assessment programs, offers a structure for such programs, discusses the phases of assessment, and outlines how they might be conducted. The transfer of health technologies from developed to developing countries has often been disappointing, mostly because of failure to recognize factors or other deficiencies in advance. In one country in the Americas it was discovered that 44% of the technological research institutions did not have a maintenance engineer or technician. In North America, Western Europe, and Japan, noncommunicable diseases are more prevalent than communicable diseases as causes of mortality, whereas in the developing world the reverse is true. In the developing world more emphasis on disease control is desirable and could prove economically beneficial in the long run. For many illnesses, life- saving treatment costs twice as much per patient as do individual preventive measures. In developing countries there are seldom adequate funds for the creation of a separate entity for health technology. However, by relying on personnel and material resources already present in government and private institutions, a national program for health technology can be established. The creation of a clearing-house is also essential for information on both the state of the national health system and the use of technology. The data collected by the technology planning group is compiled. A procedure is needed for obtaining information from care sites and research institutions. Information is shared with other governments through the setting up of a regional clearing-house. Once the structure and mechanism for health technology assessment are in place, and basic information on the status of the national health system has been gathered, individual health technologies can be assessed. The cost of operating and maintaining equipment is often much higher in developing countries than in the industrialized world.

Frequency and thoroughness of STD/HIV risk assessment by physicians in a high-risk metropolitan area.

The US Preventive Services Task Force recommends that all primary care physicians assess the sexually transmitted disease/human immunodeficiency virus (STD/HIV) risk of all adolescent and adult patients. To determine whether factors amenable to change through continuing medical education are associated with frequent and thorough STD/HIV risk assessment, a telephone survey of primary care physicians in the Washington, DC metropolitan area was conducted (n = 961). Thirty-seven percent of physicians reported regularly asking new adult patients about their sexual practices; 60% asked new adolescent patients. STD/HIV risk questioning was associated with physicians' confidence in their ability to help prevent HIV, comfort with discussing patients' sexual practices, and perception of a large STD/HIV problem in their practice. These findings suggest that continuing medical education should target improvement in physicians' sexual practice questioning skills.