Early detection and evaluation of professionalism deficiencies in medical students: one school's approach.

Since 1995, the University of California, San Francisco, School of Medicine has monitored students' professional behaviors in their third and fourth years. The authors recognized that several students with professionalism deficiencies during their clerkships had manifested problematic behaviors earlier in medical school. They also observed behaviors of concern--such as inappropriate behavior in small groups--in some first- and second-year students who could have been helped by early remediation. The authors describe the modifications to the evaluation system to bring professionalism issues to a student's attention in a new, earlier, and heightened way. In this new system for first- and second-year students, the course director of a student who has professionalism deficiencies submits a Physicianship Evaluation Form to the associate dean for student affairs, who then meets with the student to identify the problematic issues, to counsel, and to remediate. The student's behavior is monitored throughout the academic years. If the student receives two or more forms during the first two years and a subsequent form in the third or fourth year, this indicates a persistent pattern of inappropriate behavior. Then the physicianship problem is described in the dean's letter of recommendation for residency and the student is placed on academic probation. The student may be eligible for academic dismissal from school even if he or she has passing grades in all courses. The authors describe their experience with this system, discuss lessons learned, and review future plans to expand the system to deal with residents' mistreatment of students.

A strategy for the detection and evaluation of unprofessional behavior in medical students. University of California, San Francisco School of Medicine Clinical Clerkships Operation Committee.

The authors describe the first four years (1995-1998) in which the University of California, San Francisco School of Medicine operated an evaluation system to monitor students' professional behaviors longitudinally through their clinical rotations. The goals of this system are to help "turn around" students found to have behaved unprofessionally, to demonstrate the priority placed by the school on the attainment of professional behavior, and to give the school "muscle" to deal with issues of professionalism. A student whose professional skills are rated less than solid at the end of the clerkship receives a "physicianship report" of unprofessional behavior. If the student receives such a report from two or more clerkships, he or she is placed on academic probation that can lead to dismissal even if passing grades are attained in all rotations. Counseling services and mentoring by faculty are provided to such students to improve their professional behaviors. From 1995 to 1998, 29 reports of unprofessional behavior on the part of 24 students were submitted to the dean's office; five students received two reports. The clerkship that submitted the most reports was obstetrics-gynecology. The most common complaint for the five students who received two reports was a poor relationship with the health care team. Four of these students had their difficulties cited in their dean's letters and went on to residency; the fifth voluntarily withdrew from medical school. The authors describe the students' and faculty members' responses to the system, discus lessons learned, difficulties, and continuing issues, review future plans (e.g., the system will be expanded to the first two years of medical school), and reflect on dealing with issues of professionalism in medical school and the importance of a longitudinal (i.e., not course-by-course) approach to monitoring students' behaviors. The authors plan to compare the long-range performances of students identified by the evaluation system with those of their classmates.

Occupational exposures to body fluids among medical students. A seven-year longitudinal study.

BACKGROUND: Medical students may be at high risk for occupational exposures to blood. OBJECTIVE: To measure the frequency of medical students' exposure to infectious body substances, to identify factors that affect the probability of such exposure, and to suggest targets for the prevention of such exposure. DESIGN: Review of all exposures reported by medical students at the University of California, San Francisco, School of Medicine. SETTING: Teaching hospitals affiliated with the University of California, San Francisco. PARTICIPANTS: Third- and fourth-year medical students from the classes of 1990 through 1996 at the University of California, San Francisco, School of Medicine. INTERVENTIONS: A needlestick hotline service was instituted at teaching hospitals affiliated with the University of California, San Francisco, and a required course was created to train students in universal precautions and clinical skills before the beginning of the third-year clerkship. MEASUREMENTS: Reports of exposures made to the needlestick hotline service, including type of exposure, training site, clerkship, and time of year. RESULTS: 119 of 1022 medical students sustained 129 exposures. Of these exposures, 82% occurred on four services: obstetrics-gynecology, surgery, medicine, and emergency medicine. The probability of exposure was not related to graduation year, clerkship location, previous clerkship experience, or training site. Surveys of two graduating classes at the beginning and end of the study showed that the percentage of exposures reported increased from 45% to 65% over the 7-year study period. Thus, the reported injury rates represent minimum estimates of actual occurrences. Human immunodeficiency virus infection and hepatitis were not reported, although follow-up was limited. CONCLUSIONS: Instruction in universal precautions and clinical procedures is not sufficient to prevent exposures to blood during medical training. Medical schools must assume greater responsibility for ensuring that students are proficient in the safe conduct of clinical procedures and must develop systems that protect students so that they can report and learn from their mistakes.

A comparison of two methods to teach smoking-cessation techniques to medical students.

PURPOSE: To evaluate two smoking-cessation practice exercises, one using standardized patients (SPs), the other using role playing by medical students. METHOD: In the spring of 1994 all 120 first-year University of California, San Francisco, School of Medicine Students were given lectures on the health effects of smoking and how physicians can help patients quit. Afterward some of the students were randomly assigned to two groups in which to practice counseling patients: Group 1 (n = 35) used SPs, Group 2 (n = 37) used role playing. Each of the Group 1 students practiced smoking-cessation techniques with an SP; the SP evaluated the student on cognitive and communication skills, assigned an overall rating, and provide feedback using a standardized form. The Group 2 students (as well as the 48 students not assigned to a group) role-played in pairs and used the same form to provide feedback. All the students evaluated their respective practice practices. Two weeks later 24 Group 1 and 31 Group 2 students participated in a clinic-skills-assessment exercise using SPs. As in the Group 1 practice exercise, each student was evaluated by an SP on cognitive and communication skills and assigned an overall rating. Data were analyzed through a number of statistical methods. The cost of the SP program was determined. RESULTS: The Group 1 students rated their practice exercise much more favorably than did the Group 2 students. However, there was no significant difference between the groups in their ratings by the SPs on the clinical-skills-assessment exercise. The use of SPs cost a great deal more than did the use of role playing. CONCLUSION: Although the students rated the SPs higher than they did the role playing, the two tools produced similar levels of skills attainment. The data suggest that having students practice smoking-cessation techniques through role playing may be as effective as using the more extensive SPs.

Effect of growth hormone replacement on wound healing in healthy older men.

The secretion of growth hormone, an important anabolic agent, declines with aging. We hypothesize that growth hormone levels (measured as insulin-like growth factor-1) correlate with postoperative tissue repair in otherwise healthy, elderly persons. The goal was to determine whether growth hormone supplementation can improve wound healing in this circumstance. We conducted a randomized controlled double-blind trial of 6 months of growth hormone replacement or placebo in 28 healthy older men (>69 years of age) with low baseline plasma insulin-like growth factor-1. Growth hormone doses were adjusted to elevate insulin-like growth factor-1 to levels expected in younger adults. Wound healing was tested by implanting 10 cm expanded polytetrafluoroethylene porous tubes for 10 days, then measuring the content of collagen (as hydroxyproline), DNA, and total protein. Hydroxyproline content was 15% greater in the wounds of the growth hormone group (n = 13) compared with the placebo group (n = 15), (4.52 +/- 0.94 versus 3.92 +/- 0.78 microg/cm; p = 0.04). Therefore, healthy older men who took growth hormone had enhanced reparative collagen deposition during the wound healing process. This action may be clinically useful after selected surgery or trauma in the elderly.

Growth hormone replacement in healthy older men improves body composition but not functional ability.

OBJECTIVE: To determine whether growth hormone replacement in older men improves functional ability. DESIGN: Randomized, controlled, double-blind trial. SETTING: General community. PATIENTS: 52 healthy men older than 69 years of age with well-preserved functional ability but low baseline insulin-like growth factor 1 levels. INTERVENTION: Growth hormone (0.03 mg/kg of body weight) or placebo given three times a week for 6 months. MEASUREMENTS: Body composition, knee and hand grip muscle strength, systemic endurance, and cognitive function. RESULTS: The participants' mean age was 75.0 years (range, 70 to 85 years). At 6 months, lean mass had increased on average by 4.3% in the growth hormone group and had decreased by 0.1% in the placebo group, a difference of 4.4 percentage points (95% CI, 2.1 to 6.8 percentage points). Fat mass decreased by an average of 13.1% in the growth hormone group and by 0.3% in the placebo group, a difference of 12.8 percentage points (CI, 8.6 to 17.0 percentage points). No statistically or clinically significant differences were seen between the groups in knee or hand grip strength or in systemic endurance. The mean Trails B score in the growth hormone group improved by 8.5 seconds, whereas scores in the placebo group deteriorated by 5.0 seconds, a difference of 13.5 seconds (CI, 3.1 seconds to 23.9 seconds; P = 0.01). However, the growth hormone group's score on the Mini-Mental Status Examination deteriorated by 0.4, whereas the placebo group's score improved by 0.2, a difference of 0.6 (P = 0.11). The two treatment groups had almost identical scores on the Digit Symbol Substitution Test (P > 0.2). Twenty-six men in the growth hormone group had 48 incidents of side effects, and 26 placebo recipients had 14 incidents of side effects (P = 0.002). Dose reduction was required in 26% of the growth hormone recipients and in none of the placebo recipients (P < 0.001). CONCLUSIONS: Physiologic doses of growth hormone given for 6 months to healthy older men with well-preserved functional abilities increased lean tissue mass and decreased fat mass. Although body composition improved with growth hormone use, functional ability did not improve. Side effects occurred frequently.

Insulin-like growth factor 1 and functional status in healthy older men.

OBJECTIVE: To determine if insulin-like growth factor 1 (IGF-1) is associated with strength and functional ability in healthy older men. DESIGN: Cross-sectional study. SETTING: San Francisco Department of Veterans Affairs Medical Center. PARTICIPANTS: One hundred four ambulatory community-dwelling men. MEASUREMENTS: Serum IGF-1 levels were obtained. Measured variables included strength of the knee flexors and extensors, handgrip, score on the Physical Performance Test, body composition, and three tests of cognitive function. RESULTS: The subjects' mean age was 75.5 +/- 4.9 (SD) years (range 70-94 years), and their mean IGF-1 level was 134.7 +/- 43.6 ng/mL. The univariate association of age with the variables was much stronger than the univariate association of IGF-1 with the same variables. In multivariable models, age, but not IGF-1, was associated with the variables. CONCLUSION: In this study of healthy older men, age is the most important variable in predicting functional decline. There was no association of IGF-1 levels to functional status independent of age.

Categorical medicine residents' experiential curriculum.

PURPOSE: To assess the case mix or experiential curriculum of a university-based categorical medicine residency program and compare the residents' continuity clinic case mix with the outpatients seen by practicing internists. PATIENTS AND METHODS: Descriptive study during the 1991-1992 academic year of 24,218 inpatients and outpatients from the University of California, San Francisco, Department of Medicine's three core hospitals: the University of California, San Francisco Hospital; the Department of Veterans Affairs Medical Center; and the San Francisco General Hospital. The diagnoses and ages of patients who made office visits to practicing internists from the National Ambulatory Medical Care Survey (NAMCS) were compared with corresponding data from the categorical medicine residents' continuity clinic patients. RESULTS: Seventy percent of the general medicine inpatients at the three core hospitals had one of the 25 most common principal diagnoses for inpatients. Eighty-seven percent of the patients seen by the residents in their continuity clinic had one of the 20 most common diagnoses seen by practicing internists in the NAMCS. The age distribution was similar in both groups. CONCLUSIONS: A systematic assessment of clinical training at one university-based hospital program shows that common internal medicine problems represent the case mix of the great majority of patients, both inpatients and outpatients, seen by categorical medicine residents. Residents' continuity clinic patients are similar to patients seen by practicing internists. The program's challenge is to ensure that residents have adequate time with general medicine experiences, both in the inpatient setting and in the ambulatory and longitudinal care settings, while balancing and integrating these activities.

Influence of ambulatory care rotations on gatekeeping referral patterns of categorical medical residents.

PURPOSE: To determine whether a required ambulatory care block rotation for categorical medicine residents improved their ambulatory care skills and altered their outpatient gatekeeping referral patterns. METHOD: In 1991-92 a prospective cohort study was conducted of 39 categorical medicine residents at the University of California, San Francisco, and their continuity clinic patients. Before and after the residents participated in an ambulatory care block rotation, the residents were surveyed about their ambulatory care skills, and the frequencies and indications for referral of their continuity clinic patients were obtained. Statistical methods consisted of Student's t-test, the Wilcoxon rank-sum test, and Mantel-Haenszel analysis. RESULTS: The 39 residents reported significant improvement in ambulatory care skills. Yet the proportions of the residents' 4,276 patients referred before and after the intervention were 14.2% and 12.4%, respectively (adjusted odds ratio 1.02, p > .9). One-fourth of the referrals were for procedures both before and after the intervention (adjusted odds ratio 1.06, p > .5). CONCLUSION: Despite improvements in the ambulatory care skills of the categorical medicine residents, the residents' gatekeeping referral patterns remained unchanged. Ambulatory care curriculum changes need to be evaluated from the perspective of the trainee and from the perspective of whether these changes influence patient care.

Prevention training and medical residency.

We developed a questionnaire to assess training and perceived competence in prevention skills during medical residency. We asked residents at a university training program about 20 prevention interventions recommended by the U.S. Preventive Services Task Force. Primary care and categorical medicine residents rated the adequacy of training and the perceived relevance to clinical practice of these interventions as well as basic skill and knowledge areas (such as patient education) on five-point Likert-type scales (1 = very inadequate or very unimportant and 5 = very adequate or very important). Fifty-eight residents (n = 19 primary care and 39 categorical medicine) completed the questionnaire (response rate = 63%). Primary care residents felt significantly (P < .05) more competent than categorical medicine residents in 14 of the 20 prevention interventions. Primary care residents rated the adequacy of training in eight of 10 basic skill and knowledge areas significantly (P < .05) higher than did categorical medicine residents. For both groups of residents, mean relevance scores significantly exceeded mean perceived competence scores in 18 of 20 prevention interventions and in all 10 skill and knowledge areas. Primary care residents felt more competent than categorical medicine residents in performing most prevention interventions. However, residents in both training programs rate the relevance of several basic skill and knowledge areas as higher than their perceived competence, suggesting training underemphasis. Both primary care and categorical medicine training programs could use this instrument to assess the adequacy of their training in these areas.

Prognosis of mechanically ventilated patients.

In this Department of Veterans Affairs cooperative study, we examined predictors of in-hospital and 1-year mortality of 612 mechanically ventilated patients from 6 medical intensive care units in a retrospective cohort design. The outcome variable was vital status at hospital discharge and after 1 year. The results showed that 97% of patients were men, the mean age was 63 +/- 11 years (SD), and hospital mortality was 64% (95% confidence interval, 60% to 68%). Within the next year, an additional 38% of hospital survivors died, for a total 1-year mortality of 77% (95% confidence interval, 73% to 80%). Hospital and 1-year mortality, respectively, for patients older than 70 years was 76% and 94%, for those with serum albumin levels below 20 grams per liter it was 92% and 96%, for those with an Acute Physiology and Chronic Health Evaluation II (APACHE II) score greater than 35 it was 91% and 98%, and for patients who were being mechanically ventilated after cardiopulmonary resuscitation it was 86% and 90%. The mortality ratio (actual mortality versus APACHE II-predicted mortality) was 1.15. Conclusions are that patient age, APACHE II score, serum albumin levels, or the use of cardiopulmonary resuscitation may identify a subset of mechanically ventilated veterans for whom mechanical ventilation provides little or no benefit.

A randomized, controlled pilot study of placing third-year medical clerks in a continuity clinic.

BACKGROUND: Because of the great interest in developing ambulatory care components within medical school curricula, there is a need for outcome data concerning such changes. METHOD: In 1991-92, 40 third-year students at the University of California, San Francisco, School of Medicine were assigned to the San Francisco Veterans Affairs Medical Center for their core medicine clerkships; ten of these students were exposed to ambulatory care by being assigned to medical residents who worked in a general medicine continuity clinic. The ten students in the continuity clinic and the 30 who were not were evaluated by means of their (1) final clerkship evaluation scores for overall competence, (2) performances on a standardized-patient exercise where the majority of the simulations were of ambulatory care problems, and (3) self-assessment of clinical skills and knowledge and attitudes about primary care. Student's t-test was used to determine whether there were statistically significant differences between the performances of the two groups. In addition, the students in the clinic kept diaries about their clinic experiences. RESULTS: No significant difference was found between the two groups of students on the objective or subjective measures of evaluation, although the diary narratives of the clinic students revealed that they were extremely enthusiastic about the clinic experience. CONCLUSION: Because there was no significant difference between the performances of the two student groups, the ambulatory care model in this study, despite its feasibility to implement, was not adequate to teach the students the different problem-solving and therapeutic skills necessary in the ambulatory care setting.

Treatable abdominal pathologic conditions and unsuspected malignant neoplasms at autopsy in veterans who received mechanical ventilation.

STUDY OBJECTIVE: To determine, in medical patients who received mechanical ventilation, the frequency and types of major unexpected diagnoses at autopsy that, if known before death, would probably have led to improved survival (class I errors) or substantively changed management but not survival (class IIB errors). DESIGN: Retrospective cohort study. SETTING: Six medical intensive care units in a Department of Veterans Affairs Cooperative Study. PATIENTS: One hundred seventy-two autopsied patients of the 401 veterans who received mechanical ventilation and died in the hospital. RESULTS: The class I error rate was 12%. Abdominal pathologic conditions--abscesses, bowel perforations, or infarction--were as frequent as pulmonary emboli as a cause of class I errors. While patients with abdominal pathologic conditions generally complained of abdominal pain, results of examination of the abdomen were considered unremarkable in most patients, and the symptom was not pursued. Six percent of patients had extensive malignant neoplasms (class IIB errors). CONCLUSIONS: Atypical presentation of potentially treatable abdominal pathologic conditions is a common cause of class I errors in veterans who receive mechanical ventilation. Conversely, several patients with unrecognized terminal conditions underwent intensive intervention. If the information gained at autopsy had been known before death, management would have probably changed substantively in 18% of patients.

Hyponatraemia in patients with cirrhosis.

Hyponatraemia occurs in nearly half of patients in hospital with cirrhosis and ascites, and is due to the excessive retention of free water which results from the kidney's inability to excrete it normally. The morbidity and mortality associated with hyponatraemia is largely attributable to central nervous system disturbances. The degree to which brain water content increases depends on the duration of hyponatraemia and on compensatory mechanisms. Altered steroid and peptide hormones in cirrhotic patients may contribute to the development of hyponatraemic encephalopathy, symptoms of which overlap with hepatic encephalopathy and uraemia. The occurrence of central pontine myelinolysis is unrelated to the rate of correction of hyponatraemia. The appearance of hyponatraemia in cirrhotic patients, long regarded as a poor prognostic sign, may be a function of unrecognized underlying impaired renal function. Therapy for hyponatraemia remains suboptimal.

Appropriateness of digoxin use in medical outpatients.

PURPOSE: Digoxin is the third most commonly prescribed drug, yet limited information exists about its use in outpatients. Therefore, 242 medical outpatients receiving digoxin at our hospital were studied to evaluate the appropriateness of its use, defined by: (1) current or past supraventricular arrhythmias and/or (2) left ventricular systolic dysfunction (ejection fraction less than 45 percent). PATIENTS AND METHODS: Charts of 242 patients receiving digoxin were obtained. The patients were divided into groups based upon their physician's stated indication for digoxin therapy. Patients with only a clinical diagnosis of congestive heart failure (CHF) underwent echocardiography or radionuclide angiography to quantify left ventricular systolic function. Those with documented supraventricular arrhythmias and/or those with confirmed left ventricular systolic dysfunction were classified as appropriate candidates for digoxin. RESULTS: Ninety-five percent of patients received digoxin for appropriate indications; 75 percent had confirmed supraventricular arrhythmias (27 percent also had CHF) and 20 percent with normal sinus rhythm had documented systolic dysfunction. However, physicians had difficulty in the clinical assessment of left ventricular function; 18 percent of patients with sinus rhythm and CHF by the Framingham scoring system and 20 percent of those with supraventricular arrhythmias and CHF had preserved systolic function. An S3 was present in 15 percent of patients with preserved ejection fraction and CHF and in 69 percent with low ejection fraction; hypertension was significantly more common in the former group. Noninvasive assessment of systolic function was obtained in 97 percent of patients independent of this study, yet some patients without supraventricular arrhythmias and with documented preservation of systolic function continued to receive the drug. CONCLUSION: Noninvasive assessment of left ventricular function, which appears to have become routine, is of value in the appropriate utilization of digoxin, since clinicians' assessment of left ventricular function may be inaccurate. Physicians also do not always discontinue digoxin therapy when indicated.

Prognosis of noncardiac medical patients receiving mechanical ventilation in a veterans hospital.

In order to determine prognostic factors in noncardiac medical patients treated by mechanical ventilation in a Veterans Administration hospital, 78 patient records were reviewed. Disease severity was scored by the Acute Physiology and Chronic Health Evaluation (APACHE) II system. Physicians' prior impressions of prognostic factors were compared with the actual results of this study. Most patients were middle-aged men with respiratory diseases. Fifty-nine patients (76 percent) died in the hospital. Survivors of hospitalization and nonsurvivors had similar age, diagnoses, emergency intubations, duration of ventilation, and pH and oxygen tension after 24 hours of ventilation. However, only one of 31 patients with a serum albumin level of 2.5 g/dl or less at the initiation of mechanical ventilation survived (p less than 0.001). Of 24 patients requiring a fractional inspired oxygen concentration greater than 50 percent at 24 hours, none survived (p less than 0.005). At all APACHE II scores, the mortality rates documented in this study were higher than predicted. Physicians overestimated the impact of several variables, including age and presence of pneumonia, on mortality. At the San Francisco Veterans Administration Medical Center, a low serum albumin level may aid in the decision whether to begin mechanical ventilation, and a high fractional inspired oxygen concentration at 24 hours may aid in the decision regarding further aggressive care. These findings need to be validated in other patients before being applied. Conversely, certain older patients, and those undergoing emergency intubation or intubation for a prolonged time, may have as good a prognosis as patients without these factors.

Unpredictability of clinical evaluation of renal function in cirrhosis. Prospective study.

The natural course of renal function in patients with cirrhosis and ascites but without azotemia is unclear. Therefore, a prospective evaluation of 23 non-azotemic cirrhotic patients with ascites was carried out over a three-year interval. Assessment included evaluation of serum electrolyte values, liver function tests, plasma renin levels, and parathyroid hormone levels. Renal function was determined by measurement of clearances of water and solute excretion, and simultaneous clearances of para-amino hippurate, inulin, and creatinine. The initial mean glomerular filtration rate was 66 ml/minute, serum creatinine level was 1.1 mg/dl, and blood urea nitrogen value was 13 mg/dl. The glomerular filtration rate showed marked variability among patients. On the basis of initial glomerular filtration rate, the patients were divided into three groups. Group I consisted of patients with supranormal filtration rates (mean 183 ml/minute), Group II constituted patients with normal filtration rates (mean 92 ml/minute), and Group III comprised patients with severely impaired filtration rates (mean 32 ml/minute). The serum creatinine level was below 1.5 mg/dl in all three groups. Serial measurement of renal function was performed in 18 patients over a mean of 310 days (range four to 1,176 days). Eighty-six percent of patients studied from Groups I and II maintained a normal or supranormal glomerular filtration rate over one year. However, most patients in Group III showed a progressive decline in filtration rate, despite no change in serum creatinine value. Sixty-seven percent of Group III patients died over a mean of one year. The mean 24-hour solute excretion among Group III patients was only 263 mOsm per day, significantly less than the control value of 874 mOsm per day in other hospitalized non-cirrhotic patients. The serum creatinine level frequently failed to rise above normal even when the glomerular filtration rate was very low (less than 25 ml/minute), and creatinine clearance overestimated inulin clearance by a factor of two in Group III patients. However, the creatinine index was an aid in determining true glomerular filtration rate and may be a useful clinical test in the evaluation of renal insufficiency in cirrhotic patients with normal serum creatinine values. Many patients with cirrhosis and ascites will have a glomerular filtration rate of less than 60 ml/minute but a normal serum creatinine level. These patients may constitute a previously unrecognized large group.