Teaching residents to care for vulnerable populations in the outpatient setting.

Residency programs have an obligation to teach house officers to care for vulnerable populations. Such populations consist of those whom physicians tend to consider undersirable as patients, and thus who often lack adequate care, because they cannot pay for medical services, because they have medical problems that are difficult to manage, or because they have characteristics giving them low social status. The authors identify and discuss key aspects of learning to care for such populations. These aspects include obtaining appropriate experience caring for disadvantaged patients, developing sensitivity to pertinent sociocultural issues, exploring biases, acquiring relevant special skills, studying epidemiology of diseases in specific vulnerable groups, and learning about health care financing and health policy. Measures to help residents obtain more satisfaction from caring for vulnerable patients are among additional topics discussed.

Treatment modality and quality differences for black and white breast-cancer patients treated in community hospitals.

This study assessed the relationship of race and patterns of care, defined by an expert NCI-appointed committee, for 7,781 patients with breast cancer treated in 107 hospitals in 45 communities between 1982 and 1985. After control for age and stage of disease, black patients had significantly different care from white patients for four of the ten patterns examined. They were less likely to have a progesterone receptor assay or to be referred for postmastectomy rehabilitation, two patterns deemed desirable for all patients. Black patients were also more likely to receive liver scans and radiation therapy in situations in which these procedures were labeled "less appropriate (as defined in the text)." Black patients differed significantly from whites on their health insurance, hospital, and physician characteristics; these factors were also significantly associated with the patterns of care. However, after controlling for these variables, the association between race and care persisted for three patterns. The patterns that showed racial differences were not the most clinically significant of the ten studied. Different treatment for black and white patients may help to explain differences in survival rates of black and white women with breast cancer.

Types of problem students encountered by clinical teachers on clerkships.

The teachers who play the all-important role of enabling students to learn on clinical clerkships must balance the two essential skills of being a good role model and maintaining objectivity in order to identify students with a variety of problems. This study describes the findings of a survey that identifies both the type of the problems that most bother teachers and the relative frequency of those problems. Non-cognitive problems (poor interpersonal skills and non-assertive, shy students) were identified by teachers as being seen at the same relative frequency but posing greater difficulty than cognitive problems (poor integration skills, disorganization, poor fund of knowledge, etc.). A variety of the types of interventions to these problems are discussed.

Medical education for minorities at a US medical school.

The University of Washington School of Medicine (UWSM) has initiated new efforts to build a regional minority applicant pool and to expand its educational programmes to accommodate students from disadvantaged backgrounds. Specific interventions include: establishment of medical career planner position to coordinate region-wide outreach; pre-entry education; and support activities once enrolled. This study describes specific services and presents sociodemographic and performance data on 56 minority and 280 majority students entering the UWSM between 1981 and 1985. Economic status and educational background of minority students were significantly below that of majority students, several flexible academic policies enabled most students to achieve mastery in courses and to progress through the curriculum. The educational data base utilized in this study, and those at other institutions, can assume important roles in the identification of problem areas in the education of disadvantaged students and in evaluation of the interventions attempted.

Relationship between patient race and the intensity of hospital services.

This study reviews evidence on whether services in United States hospitals vary by racial groupings of patients. The focus is on both equity and quality of hospital services. Patients with the diagnosis of pneumonia were studied at 16 randomly selected hospitals. The services and outcomes studied include five measures of the intensity of diagnostic and therapeutic services received by patients, and death rates during hospitalization. Multiple regression was used to control for patient health status at the time of entry into the hospital. Results are presented both before and after controlling for the effects of differences in the services offered between hospitals and patient payment sources. Our findings suggest that nonwhite pneumonia patients received fewer hospital services than expected on the basis of their health characteristics, and that their hospital lengths of stay were longer than expected. These findings were apparent when the hospitals were examined in aggregate and within individual institutions. No consistent differences in death rates were apparent. Possible explanations for these results are discussed. From our data, we conclude that patient race remains a potentially significant characteristic in determining the intensity of care provided to patients in hospitals, which is not explained by differences among racial groups in health status, source of payment, or site of hospitalization.

Performance of residents who had academic difficulties in medical school.

An assessment of how well graduates of one medical school performed in residency training was undertaken to assess the school's monitoring of students' performances. The minutes of the school's student progress committee for four years were reviewed to identify all students who had had academic difficulty. Seven students had been recommended for dismissal but ultimately graduated, 22 students were on academic probation for longer than one year, and 22 students were on academic probation for less than one year. The residency performance of 43 of these 51 students were compared with the performances of a randomly selected group of students who had had no academic difficulties and had graduated during the same period. Of 12 performance and knowledge items assessed by the residency directors for the studied graduates, the one dealing with quality of interaction with patients showed significant differences among the residents. The residents who had had academic difficulty had lower ratings on this item than the residents who had not had academic trouble. On all other items, those residents who had had academic difficulties received generally lower scores than the other residents, but the differences were not statistically significant. Of the seven students considered for dismissal, one had been dismissed and one had withdrawn from the residencies; the other five generally received positive ratings from their residency directors. The findings suggest that the medical school's overall monitoring of students' performance was working and confirmed the authors' opinion that each decision concerning a student with academic difficulties should be based on the student's individual situation.

Health status as a measure of need for medical care: a critique.

At the national level there has been a desire to assure that individuals have access to effective personal medical care services. Accordingly, there has been an interest in linking policies on access to care to the health needs of diverse population groups. This article critiques three measures of access linked to health status: the Use-Disability Ratio, the Symptoms-Response Ratio, and the Episode of Illness Analysis. Their utility in determining whether a given level of health-service utilization is appropriate for the optimization of health status in a population is considered. As part of this task, we review the concept of health, its measurement, and data on the relationship between changes in utilization and changes in health status. Although the Use-Disability ratio may be a useful instrument to measure access equity, it appears less suited for the purpose stated above. Elements of both the Symptoms-Response Ratio and the Episode of Illness Analysis appear better suited for this purpose. Recommendations are provided on 1) the scope of services that should be included in a comprehensive construct designed to assess access related to health status, and 2) the required research to develop such a construct.