The ability of first-year medical students to correctly identify and directly respond to patients' observed behaviors.

PURPOSE: To determine whether first-year medical students could correctly identify and directly respond to patients' observed behaviors. METHOD: In January 1995, 166 first-year students at the University of Illinois College of Medicine were shown a videotape of six patients vignettes illustrating three types of patient behaviors (anger, seduction, and hypochondriasis) by pairs of men and women. After each vignette the tape was stopped, and in an open-ended format the students were asked to identify each patient's behavior and to write their verbal response to that patient. The students were prompted with the question, "What would you say now?" They were then asked to select their comfort level with each patient on a scale ranging from 1 (very comfortable) to 5 (very uncomfortable). The students' responses were analyzed with several statistical tools. RESULTS: The students correctly identified anger in both the man and the woman over 90% of the time. Forty percent of the students identified seductive behavior from the woman, but only 5% identified it from the man. Hypochondriacal behavior was identified 65% of the time in the woman and 49% of the time in the man. Identification of behavior did not correlate with the formation of a direct response. The students' gender did not predict the ability to correctly identify or directly respond to patients. However, student responses as a whole differed significantly based on the patient's gender. CONCLUSION: These findings underscore the complexity of physician-patient communications and the need to address the subtleties of these interactions as part of the medical school curriculum.

Ambulatory health services provided to low-income and homeless adult patients in a major community health center.

OBJECTIVE: The homeless are more likely than other poor and vulnerable populations to manifest serious health problems. Early research focused on needs assessments of this population; current work has shifted to examine issues of access, use of health services, and barriers to care. However, current research has not examined whether model clinics designed for the homeless have created parity with their low-income domiciled peers in terms of provision of ambulatory services. Such data are increasingly in demand as managed care looms just over the political horizon as a means of providing services to low-income patients. SETTING: A major community ambulatory health center in West Los Angeles. PATIENTS: Homeless (N = 210) and low-income domiciled (N = 250) patients. DESIGN: A medical record review of care provided over a one-year period to homeless and low-income domiciled adult patients in a major community ambulatory health center in West Lost Angeles was conducted. Data were collected on length of visits, laboratory tests, procedures, and services, immunizations, specialty clinic referrals, medications, and travel vouchers. RESULTS: On average, homeless patients were provided with as many outside laboratory tests per patient as low-income domiciled patients (1.1 vs 1.3). Further, they returned for more visits (3.4 vs 2.9), were more likely to have had longer visits (88% vs 61%), and were provided with more laboratory tests (2.3 vs 1.7), procedures and services (3.1 vs 1.1), referrals (1.3 vs 0.7), medications (4.4 vs 3.3), and travel vouchers (0.6 vs 0.2) (all p < .01). Many of the procedures and services received by the homeless were for nonmedical assistance. Preventive health services such as tuberculosis skin tests, sexually transmitted disease (STD) screening, and Pap tests were provided to both homeless and domiciled patients at low rates. CONCLUSIONS: Findings from this study on the provision of care in a major West Los Angeles community health center indicate that homeless patients receiving care from a model program designed to address their special needs will return for follow-up visits and will utilize services at least as much as low-income domiciled patients.

Effect of an educational program on medical students' conversations with patients about advance directives: a randomized trial.

Advance directives, such as the durable power of attorney for health care (DPAHC), help patients and physicians make end-of-life health care decisions. Medical education should prepare student physicians to be knowledgeable about and comfortable with discussing advance directives. The authors developed an educational module for the third-year medical school curriculum and conducted a randomized trial to evaluate in students its effect on various outcome measures regarding the DPAHC. Over a six-week period, students who received written material about the DPAHC and a two-hour seminar significantly increased knowledge about and reported increased skill, comfort, and experience with the DPAHC.

Pharmaceutical advertisements in leading medical journals: experts' assessments.

OBJECTIVE: To assess both the accuracy of scientific data presented in print pharmaceutical advertisements and the compliance of these advertisements with current Food and Drug Administration (FDA) standards. DESIGN: Cross-sectional survey. MEASUREMENTS: Each full-page pharmaceutical advertisement (n = 109) appearing in 10 leading medical journals, along with all available references cited in the advertisement (82% of the references cited were available) were sent to three reviewers: two physicians in the relevant clinical area who were experienced in peer review and one academic clinical pharmacist. Reviewers, 95% of whom responded, were asked to evaluate the advertisements using criteria based on FDA guidelines, to judge the educational value and overall quality of the advertisements, and to make a recommendation regarding publication. RESULTS: In 30% of cases, two or more reviewers disagreed with the advertisers' claim that the drug was the "drug of choice." Reviewers felt that information on efficacy was balanced with that on side effects and contraindications in 49% of advertisements but was not balanced in 40%. Reviewers agreed with advertisements' claims that the drug was safe in 86% of the cases but judged that headlines in 32% of the advertisements containing headlines misled the reader about efficacy. In 44% of cases, reviewers felt that the advertisement would lead to improper prescribing if a physician had no other information about the drug other than that contained in the advertisement. Fifty-seven percent of advertisements were judged by two or more reviewers to have little or no educational value. Overall, reviewers would not have recommended publication of 28% of the advertisements and would have required major revisions in 34% before publication. CONCLUSION: In the opinion of the reviewers, many advertisements contained deficiencies in areas in which the FDA has established explicit standards of quality. New strategies are needed to ensure that advertisements comply with standards intended to promote proper use of the products and to protect the consumer.

Patient care and professional staffing patterns in McKinney Act clinics providing primary care to the homeless.

OBJECTIVE: To describe the patient care and staffing patterns of the 157 clinics that receive federal funding to provide health care to the homeless. DATA SOURCES: Telephone interviews with clinic medical directors. RESULTS: Clinics treated a mean of 96 homeless patients per week, approximately 50% of the estimated homeless population. Three quarters treated homeless patients only, the others integrated homeless patients into an existing setting. One third of the clinics had no physician more than 5 hours per week, 10% had no physician staff at all, and 80% employed a nurse practitioner. The proportion of patients initially examined by a nurse practitioner and the proportion subsequently referred to a physician ranged between 10% and 100%. Clinic directors reported that in over 50% of clinics, physician recruitment was hampered by poor working conditions, inadequate salaries, physician biases against working with the homeless, and the lack of respect this work receives from the medical profession. CONCLUSIONS: Current financial constraints may be impeding the ability of clinics serving the homeless to ensure adequate access to high quality care. Additional research should evaluate the impact various staffing patterns have on access and quality of care and develop methods to improve physician recruitment.