Evaluating residency applicants: stable values in a changing market.

BACKGROUND AND OBJECTIVES: A 1994 study found significant differences in the way family practice and OB-GYN residency directors ranked the importance of components of the residency application package. Family practice residency directors favored qualitative measures (dean's letter, personal statement), and OB-GYN residency directors favored quantitative measures (transcripts, National Board of Medical Examiners score). The authors of the 1994 study hypothesized that the differences could be attributed to specialty competitiveness and philosophy. Our study reexamined family practice rankings of these same application components to determine if the programs, with increased competition for residency positions, had changed their values. METHODS: We surveyed all Accreditation Council for Graduate Medical Education-approved residency directors, using the core questions from the 1994 study, plus 2 additional questions. RESULTS: The component rankings in 1997 were virtually identical to the rankings in 1994. The new variables, computed to identify competitiveness, failed to elicit any meaningful or consistent differences. CONCLUSIONS: Program directors have remained relatively stable in favoring the qualitative aspects of the application package, ranking the dean's letter and personal statement consistently in the top 3 positions. This stability is found across time and independent of success in the National Resident Matching Program and number of US graduate applicants. Residency directors have not increased their reliance on quantitative measures.

Catheter ablation for atrial flutter and fibrillation. An effective alternative to medical therapy.

Atrial flutter and atrial fibrillation are common arrhythmias that can be difficult to manage clinically. In many patients, these conditions are refractory to pharmacologic therapy because of drug failure or intolerance. Radiofrequency catheter ablation may be a reasonable alternative in patients with typical atrial flutter. The procedure has a high initial success rate and a low complication rate. However, recurrence after ablation is common, and a second treatment session may be needed. In selected patients with atrial fibrillation, radiofrequency ablation can be useful for rate control. However, its use in curing chronic fibrillation is still experimental. The procedure involves insertion of a pacemaker, anticoagulation therapy is still needed in most patients, and the need for antiarrhythmic medication may not be obviated.

Lifestyle modification: weight control, exercise, and smoking cessation.

Cigarette smoking, obesity, and sedentary lifestyle are known to increase risk of coronary and other vascular disease. Yet eliminating, or reducing, these risk factors through lifestyle modifications is a significant challenge to patients and their physicians. To help meet this challenge in patients with coronary and other vascular disease, physicians should use an approach similar to that followed in other treatment plans: First, help the patient understand the value of the therapy; second, discuss the way in which treatment will evolve and set appropriate goals; third, follow up by monitoring and encouraging the patient's progress and identifying any barriers or adverse effects. When applying this paradigm to exercise, physicians can motivate patients by making them aware of the benefit of even moderate levels of activity, outlining a specific exercise program and setting appropriate goals, and following up on their patients' progress. Studies show that physicians can have a major positive impact on smoking cessation merely by asking patients whether they smoke and advising smokers to quit. Physicians can further assist smokers by providing educational materials, referring patients to counseling groups when needed, and prescribing nicotine replacement therapy when appropriate. Again, follow-up is essential. Dietary intervention should be tailored to individual patients, their food preferences and ethnic backgrounds. Individuals should be encouraged to try a wide variety of nonfat and low-fat foods and incorporate those they find acceptable into their diet in place of higher-fat alternatives. Educational materials are helpful in motivating patients to modify their eating habits and in providing additional ideas for food substitutions.

The process of resident selection: a view from the residency director's desk.

In 1992, the Executive Council of the Association of American Medical Colleges recommended that a computerized application system be investigated. Under this system, the application package would include: 1) a standardized application form, 2) a personal statement, 3) a dean's letter, 4) transcripts, 5) a chairman's letter, and 6) United States Medical Licensing Examination (USMLE) scores. To investigate the value residency directors placed on these items, all directors from Accreditation Council for Graduate Medical Education--approved residency programs in obstetrics and gynecology and family practice residency programs were surveyed. The directors were asked to prioritize the usefulness of the proposed components of the Electronic Residency Application Service application package. Transcripts, the dean's letter, and USMLE scores ranked highest (in descending order) for the obstetrics and gynecology residency directors for making decisions about "inviting a student for an interview," whereas the dean's letter, personal statement, and transcripts ranked highest for the family practice residency directors. Both ranked the interview as most valuable in ranking a student in the residency match. Although these two disciplines do not represent all fields, our study indicates that residency programs are not homogeneous in their value systems and that certain characteristics may predict those values.

Residency directors' responses to the concept of a proposed electronic residency application service.

BACKGROUND: In 1992, the Executive Council of the Association of American Medical Colleges (AAMC) recommended that the feasibility of the proposed Electronic Residency Application Service (ERAS) be investigated. This action was based on concerns that the current system was inefficient, costly, and disruptive to students, medical schools, and residency programs. The purpose of this study was to explore residency directors' opinions about the benefits and barriers to the introduction of such a system. METHOD: All directors from family practice and obstetrics-gynecology residency programs were surveyed in early 1993. Three forced-choice and three open-ended questions elicited opinions concerning benefits and potential barriers to the implementation of ERAS. T-tests and chi-square tests for independence were used to examine differences for continuous and categorical variables. RESULTS: Overall, 544 residency directors (81%) responded to the questionnaire: 339 (86%) in family practice, and 205 (75%) in obstetrics-gynecology. Eighty percent of the respondents in family practice and 75% of those in obstetrics-gynecology were in favor of the initiation of ERAS. Perceived benefits included increased "efficiency," "simplicity," "standardization," and "completeness." Concerns included "technical problems," "loss of flexibility," "lack of a personal touch," "costs," and "lack of security." CONCLUSIONS: It is appropriate for the AAMC to take the lead in investigating the computerization of this important process. It is essential, however, to gather data from all three consumers of this potentially valuable service as an important step in the project's development.

Postvasectomy semen analysis: why patients don't follow-up.

Semen analysis following elective vasectomy is necessary to confirm that the procedure was successful. However, many patients fail to follow postoperative instructions to obtain semen analysis. One hundred forty-one patients who had undergone vasectomy at the Family Practice Center of the Medical College of Ohio were surveyed to assess reasons for a poor rate of follow-up after vasectomy. Only 26 percent of respondents had returned two or more semen samples following surgery. Forty-five percent had not returned any samples. The inconvenience and embarrassment of having to bring semen specimens to the laboratory were identified as factors that can affect patient adherence to instructions. Respondents who had not returned any semen specimens were more likely to answer that their spouse would not be very upset if the vasectomy failed and pregnancy resulted. Our survey results identify issues for improving patient care following vasectomy. These include patient education and postoperative protocols.

PIP: This survey of the 141 post-operative vasectomy patients at the Family Practice Center of the Medical College of Ohio resulted in suggestions for modifying postoperative patient care protocol and patient education. The concern centered on the poor response rate for post operative semen analysis, where 29% returned 1 specimen, 26% returned 2 or more samples following surgery, and 45% had not returned any samples. Patient education was repetitions with the 1st verbal instructions preoperative, the 2nd verbal instructions postoperative, and a typewritten instruction sheet postoperative; additional reinforcement was given at the 1 week followup visit. Masturbation, condom, or withdrawal were recommended method of collection. 2 sterile containers were provided and the request made for a 1st collection after 12 ejaculations and a 2nd 2 or more weeks after the first. The requirement was for 2 specimens completely sperm free. The results of the questionnaire analyzed with Pearson chi-square for nominal or ordinal data and the 2 tailed remembered all 3 methods of collection; remembering was not related to whether the specimen was returned. Of those returning specimens, 70% masturbated, 20% used condoms, and 17% withdrew. 99% knew the reason for collection. Convenience was an important factor. 68% found daytime drop off inconvenient and 77% agreed that refrigeration and a next day dropoff was better. 50% were embarrassed to bring the specimen in. 59% felt that a failure in vasectomy with pregnancy was upsetting. Those not returning specimens had wives less concerned about the failure of vasectomy. 69% had mutual agreement about the vasectomy decision. 58% did not return due to inconvenience, 38% embarrassment, 29% confidence in sterility, 17% forgot, 4% afraid of repeat surgery. Recommended protocol is for a 1st aspermic specimen or a fresh specimen that shows only few, nonmotile sperm turned in in a brown bag provided along with a separate handout on semen collection and joint signatures. Motility checks should be made monthly if sperm persist. Ambivalence about future pregnancy means reevaluation of suitability of couple for vasectomy.

Absenteeism certification: the physician's role.

Two hundred five family physicians and 135 personnel managers were surveyed to determine the physician's role in certifying absenteeism. Fifty-four percent of the managers returned the questionnaire and indicated that the physician's certificate reduced absenteeism. Even though they expressed dissatisfaction with the certificate's content, the personnel managers usually did not request additional information. Sixty-six percent of the physicians returned questionnaires, with 80 percent reporting one or more requests for certification per week, and 41 percent feeling pressured to write unwarranted excuses. The primary factor the physicians considered when writing an excuse was whether the illness could be verified. Requests for excuses when conditions lacked objective findings produced physician feelings of reluctance, of suspicion, and of being manipulated.

Clinical indications for calcium channel blockers.

Ca2+ channel blocking agents have proven to be one of the most exciting groups of drugs for management of many cardiovascular diseases and as potentially first-line agents for treatment of angina pectoris and hypertension. Unlike beta blockers, they can directly relax coronary and peripheral arteries and, therefore, reduce total peripheral resistance and improve tissue perfusion. Ca2+ channel blockers are drugs of choice for patients with Prinzmetal's angina and should be first-line drugs for mixed angina, and can be used alone or with beta blockers for classic angina. These drugs as a group have many potential clinical indications, especially in diseases in which vascular or smooth muscle spasm seems to cause the disease. Although all three Ca2+ channel blockers have a common mechanism of action, their cardiac and hemodynamic effects are different, nifedipine being the least depressant to cardiac function. In choosing the right agent, careful consideration should be given to the patient's characteristics in order to derive maximum benefit with minimal risks.

The behavioral implications of some old wives' tales.

A study was designed to gain information on the concerns, attitudes, beliefs, and knowledge that women have about reproduction to determine how these affect their health practices during pregnancy. A low-income multiethnic clinic population was studied in which the majority of the patients were in a high-risk category for pregnancy. They often failed to follow suggested regimens and/or engaged in negative health behaviors. Interviews with patients revealed that they too identified a number of risk factors in pregnancy, but that there was a disparity between their perceived risks and those of concern to the clinic staff. Many of the problems ascribed to patient noncompliance may be attributable to this differential perception of what constitutes a danger to pregnant women. In clinical settings where patients and professionals are divided by social class and cultural differences, it is suggested that physicians be aware of such beliefs so that patients may be reeducated to improve pregnancy outcomes.

Limited patient knowledge as a reproductive risk factor.

A study was designed to obtain information on the concerns, attitudes, beliefs, and knowledge that women have about reproduction in order to determine how these factors affect their ability to plan pregnancies. A clinical population was studied and in general found to be uninformed and misinformed about basic physiological facts relating to reproduction. Their lack of information or their misinformation about the menstrual cycle, safe time for intercourse, and contraception contributed to unwated pregnancies. They did not know enough to prevent pregnancy. The patients were aware of some deficits in their knowledge about reproduction and expressed a desire to learn more. This study suggests that individualized education may be necessary to break the pattern of unwanted pregnancies and the feelings of apathy and fatalism so common among low-income patients.