Update on screening for type 2 diabetes. The why, who, how, and what of testing and diagnosing.

Type 2 diabetes can cause serious complications even as it remains undiagnosed. Screening is recommended only in people with risk factors for the disease. The ADA recommends FPG as the test of choice, but RPG is also a practical alternative because it is easier and more convenient. Frequency of rescreening if the first screen result is normal depends on the number of risk factors present. Physicians should realize the importance of a confirmatory test and not base a diagnosis of diabetes on a single value unless the value is so high that the diagnosis is unequivocal.

Barriers to control of blood glucose in diabetes mellitus.

The purpose of this study was to characterize the barriers to tight control of diabetes mellitus. The study collected data from multiple sources at a primary health care clinic in an academic teaching hospital serving an urban population, including patients' charts, structured interviews with patients, a survey of physicians' general perspectives and beliefs concerning diabetes mellitus, and a physician's structured review of barriers to tight control for individual patients. One hundred thirty-five patients with scheduled appointments were eligible for the study, of whom 94% had had a recent hemoglobin A1C (HbA1C). Seventy-seven of 88 patients (88%) who presented for their appointments consented to the interview, 48 of 50 providers (96%) returned useable surveys, and providers completed individual assessments for 96 patients (71%). Patients had a mean age of 61 years, an average of 7.60 diagnoses, and an average of 8.96 prescriptions. Their diabetes control was less than ideal, with less than 15% having normal or near normal control and almost a quarter having poor control. Correlations of HbA1C with age and show rate were seen. Physicians' assessments showed that motivation and understanding of diabetes and compliance with diet and medications correlated with diabetes control. Neither patient knowledge nor physician knowledge appeared to be a problem, nor did either correlate with diabetes control. The number of barriers to control were many, with over half of the patients having five or more barriers. Tight control of blood glucose is felt to be an important aspect of quality care for diabetic patients. In this study, a representative sample of diabetic patients had less than ideal diabetes control. This population was receiving their care in an urban setting and had many comorbid illnesses and many barriers to control. Age, motivation, understanding of the disease, show rate, and compliance with diet and medications had statistical correlations with diabetes control. In order to improve the quality of care for diabetic patients, barriers to care must be addressed.

The elderly psychiatric patient with positive syphilis serology: the problem of neurosyphilis.

OBJECTIVE: Older patients have a high prevalence of neurological and psychiatric disorders. They also have a baseline prevalence of late latent syphilis or positive syphilis serology. Thus the clinical question arises as to whether a neuropsychiatric disorder in a geriatric patient is neurosyphilis or if the positive serology is incidental. METHOD: An illustrative case example is used to illustrate this dilemma. The relevant literature is reviewed. RESULTS: The cerebrospinal fluid (CSF) protein is an important indicator of inflammatory activity in the central nervous system and is used as a clinical guide in the diagnosis. Elderly patients have higher values of normal CSF protein than younger patients. CONCLUSIONS: Given the importance of CSF protein in the diagnosis of neurosyphilis, physicians must include this knowledge, that elderly patients have higher CSF protein values, in their clinical decision making in the differentiation between neurosyphilis and late latent syphilis in the elderly patient.

Delivery of vaccines to adults: correlations with physician knowledge and patient variables.

Our objective was to explore reasons why vaccines are not provided to adult patients receiving primary health care. The study setting was a primary health care clinic in a urban hospital staffed primarily by residents and teaching faculty. The patients were identified as all continuity care patients with a scheduled visit to the clinic during the 4-week study period in April 1995. The providers were all primary care providers for the patients during the study period. The providers were given two surveys before the study: one to assess their knowledge of published preventive health care guidelines and one to assess their perspective of the guidelines. During the study period, the charts of the patients were reviewed for the services they had received. An assessment was placed in each patient's chart for the provider's completion during the visit. The assessment enabled the provider to explain why services had not been provided. The results showed that influenza, pneumococcal, and diphtheria-tetanus vaccines were provided at varying rates. Each vaccine had a different profile as to noncompliance with guidelines. Lack of provider knowledge of the guideline was most apparent with pneumococcal vaccine. Providers' ambivalence regarding the scientific basis and/or clinical importance was most apparent with influenza vaccine. Patient refusal was a prominent cause with influenza vaccine in the elderly. Patient appointment behavior (opportunity for care and compliance) also seemed to play an important role. We conclude that explanations for nondelivery of vaccines to adults seem to be multiple. Lack of physician knowledge and physician perception of the guidelines provide some explanations. Patient-related factors including refusal, decreased opportunity for care, and noncompliance also play important roles in why vaccinations are not provided. Improvement in the rates at which immunizations to adults are provided will require interventions in multiple areas.

Assessment of preventive health care: design considerations.

OBJECTIVE: To design an instrument to assess the performance of a clinic in the delivery of preventive health services to a general population. METHODS: The study utilized a chart review of services delivered, abstraction of data from electronic databases, and a standardized provider assessment of each eligible patient. The study was conducted in a primary care clinic staffed primarily by internal medicine residents in an urban academic medical center. Patients who were receiving continuity care in the clinic and who were scheduled for an appointment during the 2-week study period were eligible for inclusion. Patients were identified prospectively from the appointment schedule. Charts were reviewed for the delivery of preventive health services prior to the patient's visit. Assessment forms were provided to the primary providers for review and completion. Demographic and appointment information was electronically abstracted from current databases. RESULTS: The rate at which services were provided varied considerably by service and over time. The reasons for nondelivery included disagreement with guidelines, patient resistance/refusal, and lack of priority. CONCLUSIONS: It should be possible to assess a clinic's performance over a range of services over its entire population over time. There may be legitimate reasons for services not being provided to a sizable proportion of the population. These issues are complex and require sensitive detailed investigation.

Assessment of delivery of preventive health services.

Our objective was to design and evaluate an instrument to assess the performance of a clinic in the delivery of preventive health services to a general medical clinic population. The patients were identified prospectively; data were obtained retrospectively with review of the charts. The study was conducted in a primary care clinic staffed primarily by internal medicine residents in an urban academic medical center. Patients who were receiving continuity care in the clinic and who were scheduled for an appointment during the 4-week study period were eligible for inclusion. Patients were identified by the appointment schedule. Charts were reviewed for the delivery of preventive health services. Data were abstracted utilizing a standard instrument. We found that the rate at which services were provided varied considerably by service and over time. The techniques used provided some insight into methods for the evaluation of the delivery of preventive services. It should be possible to assess a clinic's performance over a range of services over its entire population over time. An understanding of this more global performance may provide a better tool for managers and researchers addressing these issues. There may be legitimate reasons for services not being provided. These issues are complex and require sensitive, detailed investigation.

Experience with community academic practice: strategies for the ambulatory education of residents.

The expectation that training programs will place more of their physician graduates into primary care has caused internal medicine programs to explore different educational experiences for their residents. One proposal is to transfer the ambulatory training site for residents from the hospital clinic to a community academic practice (CAP) site. We discuss the theoretical aspects, the practical considerations, and our experience with one CAP site, including the problems that have been solved and the problems remaining.

Enhancing physician adoption of practice guidelines. Dissemination of influenza vaccination guideline using a small-group consensus process.

BACKGROUND: A dissemination intervention to facilitate adoption of a preventive practice guideline (influenza vaccination for older adults) in group practices was developed and evaluated. The intervention, small-group consensus process, started with a physician expert presenting the guideline and followed with the group participating in a structured discussion of ways to implement the guideline that culminated in a public commitment (ie, "buy in") to adopt the guideline. METHODS: Thirteen group practices and their primary care physicians (mean size, 5) were assigned randomly to intervention or control arms. In each group practice, physicians in the intervention arm met for 1 hour. Control physicians participated in an unrelated discussion (non-steroidal drug use). Guideline adoption was determined by changes in physicians' vaccination rates that were obtained through prechart and postchart reviews of 51 physicians. Prequestionnaires and postquestionnaires measured influenza knowledge and prevention attitudes. RESULTS: Using analysis of covariance, the small-group consensus process was found to increase physician vaccination rates by 34% compared with the control arm (F (1,48) = 19.49). All intervention arm physicians increased vaccination rates from before to after compared with 54% of control arm physicians. Attitudes and knowledge did not change and were unrelated to increased vaccination rates. CONCLUSIONS: A case is made for the small-group consensus process as an effective utilization-focused dissemination method. Interventions based on group dynamics and sensitive to local practice contexts can be useful in facilitating adoption of guidelines by physicians in group practices.

Measuring physician mental workload: reliability and validity assessment of a brief instrument.

This study examined the reliability and validity of a brief six-item instrument to measure the mental workload experienced by residents for specific patient visits to an ambulatory care clinic. Participating in the study were twenty-two residents in postgraduate years 1 through 3 who were working in the general outpatient clinic of an inner city, private, nonprofit community hospital. Cronbach's alpha coefficient for the instrument was 0.80. Findings supported several theory-based hypotheses on determinants and performance consequences of mental workload. Mental workload was positively correlated with fatigue (r = 0.42, P = 0.03) and inversely correlated with residents' self-rated experience with patients' problems (r = -0.65, P less than 0.001). Residents' performance was measured through self-ratings and faculty physicians' ratings. Mental workload was inversely correlated with self-rated performance (r = -0.67, P less than 0.001). The correlation of mental workload with faculty physician ratings that reflected the technical dimension of patient care (physician examination, medications, and procedures) was r = -0.38 (P = 0.04). With mental workload squared, the correlation was r = -0.45 (P = 0.02) and the form of the relationship, consistent with the hypothesis, was a slightly downward sloping curve. Limitations of this research are discussed as well as suggestions for further research.

Postmortem management of patient affairs: the resident's perspective.

The role of residents continues to evolve, and they are finding themselves increasingly being asked to request an autopsy from a grieving family. Although much has been written previously concerning the need for residents to be more aggressive in obtaining autopsy, this article suggests that structural problems must be addressed if the current low autopsy rate is to be improved.

A measure of physician mental work load in internal medicine ambulatory care clinics.

Physician mental work load is an important variable intervening between work demands imposed on physicians and physician performance. A brief instrument was developed to measure the mental work load experienced during a clinic session in internal medicine ambulatory care hospital clinics. The instrument covered six dimensions of mental work load: performance, time load, mental effort, physical effort, psychologic stress, and difficulty. Cronbach's alpha reliability coefficient for the instrument was 0.83. The instrument exhibited construct validity. As hypothesized, mental work load was found to be positively associated with number of patients seen and with fatigue, and mental work load was inversely associated with physician satisfaction with the patient care they provided and with their self-rating of the quality of care they provided. The importance of measuring physician mental work load is discussed.

The new medical practice environment. Internists' view of the future.

There have been many changes in the environment in which internal medicine is practiced in recent years. This has been coupled with reports of internists becoming frustrated and of internists leaving primary care practice. We conducted a survey of 219 internists in academic and private practice in western New York. While internists were generally positive regarding the training of residents, there was a pervasive feeling of frustration and demoralization among practicing internists. This demoralization may affect recruitment of new physicians to internal medicine and cause early retirement of practicing internists. The study demonstrated some of the causes of the demoralization.

Assessing clinical experience in a residency training program.

Training programs are expected to provide experience to residents and students such that a reasonable spectrum of diseases and severity of illness are encountered. One approach is to have the resident or student keep a record of the cases encountered. A clinical experience is much more than the patients completely evaluated and treated by the resident or student. We propose a program approach in which all patients admitted to the medical service are categorized by several standard methods. This study describes an evaluation of a patient population seen by medical residents and students with specific demographic information and the spectrum and severity of their diseases. The numbers of patients and the severity of illness of the patients cared for during the ward experience affect the educational value of the program. This type of information has implications for the evaluation and design of training programs.

Round pneumonia in adults.

We recently evaluated three adult patients with rounded densities on their chest roentgenograms in whom the final diagnosis was presumed to be lower respiratory tract infection. In all cases, the circular infiltrates proved to be localized "round pneumonias." Round pneumonia has been well described in children but is less well known in adults. While uncommon, round pneumonia in adults may not be rare and deserves early diagnostic consideration to prevent unnecessary investigation.

Academic group practice. The physicians' view.

In order to evaluate physician response to the reorganization of a traditional medical clinic into a group practice model, a randomized controlled trial was conducted using equivalent groups of patients and physicians. The group practice model, unlike the traditional clinic, provided decentralized registration, 5 days/week clinic coverage, and night/weekend phone coverage. Residents worked in small groups with an attending physician, nurse practitioner, staff nurse, and receptionist. A panel of 50 medical residents was interviewed prior to the reorganization and 1 year later. Residents in the experimental groups perceived improvements in the ancillary staff, placed a higher value on informal discussion of patient management problems, and were more satisfied with the outpatient experience. Moreover, residents in the group practices were more likely to voluntarily schedule additional clinic sessions to accommodate their patients. No change was noted in their career choices. We conclude that reorganization of a traditional medical clinic into a group practice model can result in increased physician satisfaction although it may not have a major impact on long-term career goals.

A randomized controlled trial of academic group practice. Improving the operation of the medicine clinic.

We conducted a controlled trial of the adoption of a group-practice model within an academic department of medicine. Ongoing randomization yielded similar groups of patients and residents. To determine the effect of the intervention on medicine-clinic operation, we monitored the hospital outpatient activity of 28 residents and 2299 patients during an 11-month study period. The group-practice clinics generated 20% more patient encounters per month than did the traditional, control clinics (328 vs 273 encounters), primarily because twice as many voluntary, overflow clinic sessions were scheduled (20.2 vs 9.7 sessions). Yet, because group-practice registration was decentralized, patients spent 15% less time in completing scheduled visits (93.2 vs 109.9 minutes). Regular utilizers of the group practices made 7% more scheduled clinic visits on average (3.27 vs 3.05 visits), but 39% fewer walk-in visits (0.14 vs 0.23 visits). Hospital-wide, continuity of care was not affected. We conclude that adoption of a group-practice model at our institution improved clinic productivity, enhanced patient flow, and decreased unscheduled clinic visits.

Resident knowledge of charges: are we asking the right questions?

Physician knowledge of costs and charges for medical services is thought to have substantial relevance for cost containment. Unfortunately, numerous studies have demonstrated the difficulties in using educational techniques to improve knowledge and reduce charges. Furthermore, reductions in charges, when achieved, have not correlated with improved physician knowledge. The authors examined several methods of ascertaining physician knowledge of charges and they suggest that previous methods may have been too insensitive. Previous reports may have underestimated physician knowledge of costs and charges.

Effect of an academic group practice on patient show rates: a randomized controlled trial.

Ambulatory medical clinics at academic centers are reputed to be expensive, inefficient, and poorly regarded by the medical residents who staff them. In an effort to address these problems, some centers have reorganized their traditional clinics into group practices. These group practices are thought to be more effective for teaching and providing services than are the traditional clinics. This is a report on the results of a study in which the authors reorganized two of four firm clinics into group practices in order to test the influence of the organizational changes on the various aspects of ambulatory care. During this controlled prospective trial of the group practice model, higher show rates were observed for patients in the group practices than in the traditional clinics (70% vs 65%, P less than 0.0005). The possible reasons for the higher rates are discussed.