Teaching medical students about continuity of patient care.

This article reports on medical schools' longitudinal primary care ambulatory programs and five themes identified by educators as to why it is important for students to experience continuity of patient care. It briefly describes methods used to expose students to this concept, which is so basic to primary care practice.

The audition elective and its relation to success in the National Resident Matching Program.

BACKGROUND: Many medical students take audition electives in an effort to improve their chances of being selected by a residency program. PURPOSE: The study was to determine if audition electives improved student success in the National Resident Matching Program. METHOD: A questionnaire was mailed to graduates of the University of South Dakota School of Medicine from 1977 (the charter graduating class) through 1997. Comparisons were done between students who took audition electives and those who did not. Statistical analysis was performed by chi-square or Fisher Exact tests for smaller groups. RESULTS: The data show no statistically significant difference in first-choice matching for the total group (p = .35), primary care (p = .44), or nonprimary care subgroups (p = .38). Sample size is inadequate for sufficient analysis of individual specialties. CONCLUSIONS: The limited time available to provide students with a broad education and the disadvantages of taking audition electives should be considered when advising students about 4th-year schedules.

A case of Lactobacillus acidophilus endocarditis successfully treated with cefazolin and gentamicin.

Infective endocarditis secondary to Lactobacillus acidophilus is rare and difficult to treat. Management of patients allergic to penicillin is further complicated by resistance of Lactobacillus organisms to commonly substituted antibiotics. We report a case of a 46-year old woman successfully treated with a prolonged course of cefazolin and gentamicin.

Pine Ridge Indian Health Service Primary Care Resident Rotation: a summary.

The Pine Ridge Indian Health Service Primary Care Resident Rotation was officially established in January 1992 and operated through May 1996. Sponsored by an Indian Health Service grant, the rotation was conceived in an effort to help address the problem of recruitment and retention of physicians at Pin Ridge in the long term, while offering a unique educational experience for residents. Fifty-eight residents from 40 Family Practice, General Internal Medicine and General Pediatric Residency Programs in 18 states completed the rotation. Four of the rotation "graduates" are currently employed by the IHS at Pine Ridge and two other sites. A fifth physician provided short term service to a fourth site.

Pine Ridge Indian Health Service Primary Care Resident Rotation: an update.

The Pine Ridge Indian Health Service Primary Care Resident Rotation has been in existence for 2 years. It was conceived in an effort to help address the problem of recruitment and retention of physicians at Pine Ridge in the long term, while offering a unique educational experience for primary care residents. Twenty-five residents from family practice, general internal medicine, and general pediatric residency programs across the country have participated in calendar years 1992 and 1993. Three of the original 12 residents have returned following completion of their residency programs to join the Pine Ridge medical staff.

Pine Ridge IHS Primary Care Resident Rotation.

With the support of the Oglala Sioux Tribe and the Aberdeen Area Indian Health Service, the University of South Dakota School of Medicine initiated development of a primary care resident rotation at the Pine Ridge IHS provider site. The rotation was conceived in an effort to help address the problem of recruitment and retention of physicians at Pine Ridge in the long term, while offering a unique educational experience for residents. It is a cooperative effort of four neighboring medical schools in South Dakota, North Dakota and Nebraska. Similar relationships between tribes, the Indian Health Service, and medical schools are encouraged, with the belief that such endeavors will assist in stabilizing professional staffs at provider sites, and lead to improved health care of the Indian people.

Testicular cancer. Role of primary care physicians in screening and education.

Cure rates for testicular cancer have improved dramatically over the years, but early diagnosis is still essential. Primary care physicians have a responsibility to include testicular examination as part of cancer screening and to educate young male patients about the frequency of testicular cancer in their age-group and on how to perform self-examination. A high index of suspicion and careful bimanual palpation are crucial in evaluation of complaints referable to the scrotum. Prompt urologic consultation must be obtained if a tumor is suspected.

Hyperlipoproteinemias: part IV. Drug regimens.

The bile acid sequestrants and nicotinic acid are the agents of first choice for the treatment of hypercholesterolemia. Experts disagree as to the drug of choice for hypertriglyceridemia, although both nicotinic acid and gemfibrozil are effective. For combined hyperlipoproteinemia, single drug choices include nicotinic acid, lovastatin, and gemifibrozil. Patients with hypercholesterolemia not responding to single drug therapy in conjunction with diet can be treated with a number of drug combinations.

Hyperlipoproteinemias: Part III. When to treat.

The recommended treatment goals for patients with hypercholesterolemia who do not have coronary heart disease or two additional risk factors, are a total cholesterol of less than 240 mg/dL and an LDL-cholesterol of less than 160 mg/dL. For patients with coronary heart or two additional risk factors, the goals are 200 mg/dL and 130 mg/dL respectively. The step-one diet is the initial therapy for hypercholesterolemia, followed by the more rigid step-two diet if response has been inadequate. Drug treatment is indicated upon failure of adequate response to six months of dietary therapy, and an LDL-cholesterol of greater than or equal to 190 mg/dL in the patient without coronary heart disease or two additional risk factors, or greater than or equal to 160 mg/dL in the patient with coronary heart disease or two additional risk factors. The decision regarding when to treat patients with hypertriglyceridemia is controversial. Patients with levels greater than 500 mg/dL should at least be treated by diet. A consensus report on the management of children with hyperlipidemia is awaited. The approach to the elderly patient is debated.

Hyperlipoproteinemias: Part II. Screening and patient classification.

The National Cholesterol Education Program recommends measuring the total nonfasting serum cholesterol in all individuals 20 years of age or older. By definition, a desirable level is less than 200 mg/dL, borderline-high is 200-239 mg/dL, and high is greater than or equal to 240 mg/dl. Subsequent classification is based on the LDL-cholesterol level with a value of less than 130 mg/dL considered to be desirable. The appropriate approach to screening for hypercholesterolemia in children and the elderly is debated and awaits definitive recommendations.

Hyperlipoproteinemias: Part I. Lipoprotein classification and abnormalities.

The hyperlipoproteinemias are disturbances in the metabolism of lipoproteins. Elevated levels of total and low density lipoprotein-cholesterol, and low levels of high density lipoprotein-cholesterol are proven risk factors for atherosclerosis. The significance of hypertriglyceridemia as an independent risk factor for atherosclerosis is controversial, however, at high levels triglycerides are a major risk factor for pancreatitis. Lipoprotein abnormalities can be divided into dietary, primary (genetic), and secondary disorders. The major causes of moderate and severe hypercholesterolemia are familial hypercholesterolemia, familial combined hyperlipidemia, severe primary (polygenic) hypercholesterolemia, and familial dysbetalipoproteinemia. Causes of hypertriglyceridemia include familial hypertriglyceridemia, familial lipoprotein lipase deficiency, sporadic hypertriglyceridemia, and secondary causes.

Rhinitis.

While it is a common problem, the differential considerations and treatment options can make the appropriate diagnosis and management of rhinitis a challenge. Frequent causes include the viral URI, allergic rhinitis, and vasomotor rhinitis. Eosinophilic nonallergic rhinitis is an interesting syndrome that must be considered in the patient whose presentation is suggestive of allergy but whose laboratory investigation is unrewarding for the same. Rhinitis medicamentosa is a distressing problem that is best managed by prevention. A careful history, physical examination, prudent clinical testing, and appropriate consultation will be beneficial to the primary care physician and allow management of most of these diseases in the ambulatory setting.

The consultant family physician.

Family physicians frequently consult and refer to other specialists, both generalist and subspecialist. Less commonly has the family physician been used as a consultant. A randomized questionnaire survey of family physicians in five midwestern states was used to consider the frequency and reasons for other specialists collaborating with the family physician as a consultant. Fifty percent of the respondents consult and refer to as well as receive consultations/referrals from other family physicians. Thirty-five percent of the respondents receive consultations and referrals from other generalist specialists, and 28 percent receive theirs from subspecialists. Most often these occur because the patient has no family physician, but family physicians are also used for their procedural skills and coordination of patient evaluation and management, including preoperative evaluation of patients. This study confirms that the consultant family physician is an important part of the health care team.

Family physician consultation/referral patterns.

Family physicians, regardless of training, board certification, or practice setting, more commonly consult or refer to internal medicine subspecialists than to general internists. The primary reason is need for a consultant with technical (procedural) skill. In the case of pediatric referrals, family physicians more commonly refer to general pediatricians than to pediatric subspecialists. Physicians who use pediatric subspecialists more when both are available, however, do so because of the need for a consultant with technical skill. Large numbers of internal medicine and pediatric residents are choosing subspecialties, thereby increasing availability of these subspecialties. At the same time, there is a documented need for an increased number of primary care physicians. Family physicians, general internists, and general pediatricians all need to be trained; however, because the breadth of training of the family physician prepares this practitioner to provide comprehensive primary care in a broad variety of settings, there should be an emphasis on training this specialist.

Patient education in primary care practice. Tips on planning a workable in-office program.

Patient education is an integral part of primary care practice. Physicians provide most patient education in the office setting. Good communication skills are a prerequisite for establishing a physician-patient partnership, which is key to effective patient education. A formalized plan and use of ancillary personnel should never substitute for the physician's personal communication with the patient. The office environment--including the attitudes of all personnel--sets the tone for and emphasizes the importance of patient education. The use of quality educational materials and the assistance of office personnel and allied health professionals will help the physician provide effective patient education in the office setting. Such education is one component of a quality medical care program for the entire family.