Motor vehicle crash fatalities by race/ethnicity in Arizona, 1990-96.

OBJECTIVE: To compare rates of motor vehicle crash (MVC) fatalities among different race/ethnic groups in urban and rural Arizona. METHOD: Using the Fatality Analysis Reporting System and the National Center for Health Statistics Multiple Cause of Death file, MVC fatalities in Arizona from 1990-96 inclusive were classified by gender, race/ethnicity, and urban or rural residence. Age adjusted rates of total, occupant, pedestrian, and alcohol related fatalities were calculated. The total MVC fatality rate for each race/ethnic group was then adjusted for proportion of rural residence. RESULTS: Compared with non-Hispanic whites (NHWs), American Indians had raised relative risks for MVC fatality in all gender and residence subgroups. Hispanic females and rural Hispanic males had lower relative risks, as did rural African-American men. Raised relative risks for American Indian men and women included all subgroups: total, occupant, pedestrian, and alcohol related. Hispanic and African-American men both had raised relative risks of pedestrian related fatalities, and Hispanic men had a slightly higher relative risk while Hispanic women had a lower relative risks, for alcohol related fatality. Hispanic men and women and African-American men had lower occupant fatality rates. Close to half (45%) of the excess MVC fatality among American Indians can be attributed to residence in rural areas, where MVC fatality rates are higher. There were 1.85 occupants in crashes involving NHW deaths compared with 2.51 for Hispanics and 2.71 for American Indians (p<0.001). The proportion of occupants not using a seatbelt was higher in Hispanics and American Indians in both urban and rural areas. CONCLUSION: The major disparity in MVC fatality in Arizona is among American Indians. The higher MVC fatality rates among American Indians occur in all age groups, in both urban and rural areas, and among occupants and pedestrians. Rural residence, lower rates of seatbelt use, higher rates of alcohol related crashes, a greater number of occupants, and higher rates of pedestrian deaths all contribute to the American Indian MVC fatality disparity. High rates of pedestrian fatality occur in men in all three race/ethnic minorities in Arizona and among American Indian women. In contrast to other studies, African-Americans and Hispanics did not have raised total MVC fatality rates and compared to NHWs actually had lower rates in the rural areas of the state.

Family medicine research funding.

BACKGROUND AND OBJECTIVES: While the specialty of family practice has achieved parity with other specialties in many areas, it lags behind in research productivity. This article explores current and historical funding levels of family medicine research from the National Institutes of Health (NIH) and the Agency for Health Care Policy and Research (AHCPR). METHODS: Funding amounts from NIH to medical schools and family medicine departments were obtained for the years 1984-1997. Funding amounts from AHCPR awarded to family physicians and the total AHCPR research budget were obtained for 1991-1995. RESULTS: In 1997, family medicine departments were awarded $18.6 million from the NIH, .4% of the NIH research awards. The amount from NIH has increased progressively since 1984, but the proportion of the total NIH budget has increased only marginally (from .3% to .4%). In 1995, family medicine researchers obtained $6.7 million from AHCPR, 4.0% of the AHCPR research budget. Since 1991, this amount has increased slightly, but as a proportion of the AHCPR budget, it has declined (from 4.4% to 4.0%). DISCUSSION: The NIH is an increasingly important source of support for family medicine researchers, while AHCPR support has plateaued. Even though NIH support of family physician researchers is increasing, the proportion of NIH funding awarded to family medicine departments remains below the proportion of US medical school faculty who are family physicians. One possible cause of this discrepancy is a lack of a locus of primary care and family medicine research funding.

A longitudinal, national study of the effect of implementing a required third-year family practice clerkship or a department of family medicine on the selection of family medicine by medical students.

PURPOSE: To conduct a longitudinal study of the effect of implementing a required third-year family practice clerkship or a department of family medicine on the proportion of graduating medical students choosing family practice as a specialty. METHOD: Using national data sets, the authors studied the proportion of students who chose family practice as a specialty at each medical school that implemented a required third-year family practice clerkship or a department of family medicine between 1984 and 1993. They compared the mean proportions of students choosing family practice for the three years before and three years after implementation of the required clerkship or the department. They controlled for national trends by comparing study schools with schools that did not have required family practice clerkships. RESULTS: The mean proportions of students who chose family practice increased 2.36% above control schools (95% CI = 1.06, 3.65) in public schools and 2.07% (95% CI = -2.58, 6.73) in private schools after a required third-year clerkship was implemented. The proportion of students choosing family practice declined by 0.84% (95% CI = -4.05, 2.47) after a department of family medicine was established. CONCLUSION: Implementing a required third-year family practice clerkship led to an immediate, significant increase in the proportion of students choosing family practice. Implementing a department of family medicine had no noticeable effect on the proportion of students choosing family practice in the first three years after implementation.

Correlations of family medicine clerkship evaluations and Objective Structured Clinical Examination scores and residency directors' ratings.

BACKGROUND AND OBJECTIVES: This study validated the evaluation methods used in a family medicine clerkship by comparing students' scores to how students are rated in their first year of residency by residency directors. The clerkship evaluations consisted of three components: problem solving in small groups, clinical evaluations, and a final examination. These components were combined to form a composite clerkship score. Residency director ratings consisted of 20 individual scores and an overall average. METHODS: Scores received by students in the clerkship were correlated with ratings by residency directors given toward the end of the first year of residency. The correlations between Objective Structured Clinical Examination (OSCE) scores and residency directors' ratings were used as comparison. RESULTS: The composite clerkship score correlated with the director's rating, overall average, at r = .278. The highest individual component correlation was achieved by the clerkship final exam (r = .269). The total OSCE score correlated with the director's rating overall average at r = .304. CONCLUSIONS: This study provides evidence that, while not perfect, the family medicine clerkship evaluations perform nearly as well as the OSCE as a predictor of how students will be rated by their residency directors in their first year of residency.

A hypothetical model of the effect of medical education on specialty choice.

BACKGROUND AND OBJECTIVES: Using the Theory of Reasoned Action, we propose a model that diagrams medical school characteristics known or hypothesized to influence the process of specialty choice. The medical school characteristics we consider are administrative support, special programs, primary care funding, number and quality of primary care faculty, faculty influence, primary care residencies, committee representation, primary care environment, required time, and student contact. This model provides explicit hypotheses to be tested in future research on specialty choice.

A systematic analysis of how medical school characteristics relate to graduates' choices of primary care specialties.

PURPOSE: To examine medical school characteristics, in particular federal funding for biomedical research, as they relate to the graduates' choices of family medicine, general internal medicine, general pediatrics, or all three specialties. METHOD: Data were collected for 121 U.S. medical schools, including information on funding, faculty, curricula, and other school characteristics. In addition, a questionnaire was mailed to the schools requesting information about non-federal funding for primary care, primary care department characteristics, and primary care representation on the admission, curriculum, and promotion and tenure committees. Analyses were carried out separately for each specialty and for all three combined. The first multiple regression analysis was done to predict specialty choice (proximate predictors), the second to predict the predictors of specialty choice (intermediate predictors), and the third to predict those predictors (distal predictors). RESULTS: Prediction was best for family medicine practice. Interest at matriculation and required third-year and fourth-year time in primary care were the two best proximate predictors. The best predictors of initial interest were the percentage of rural students and special programs for primary care, while the best predictors of required time in primary care were funding for family medicine and the percentage of faculty in family medicine (intermediate predictors). The best predictor of the percentage of faculty in family medicine was funding for family medicine (distal predictor). CONCLUSION: The results suggest that the most effective way to increase the number of physicians with generalist practices is to increase the number of students interested in a family medicine career at matriculation.

Incidence of infectious disease and the licensure of immunobiologics in the United States.

INTRODUCTION: Our objective was to investigate the relationship of vaccine or toxoid licensure with the incidence of the target disease in the United States. METHODS: We used a historical correlational study design with outcome measures of the national incidence and elimination rate of polio, pertussis, diphtheria, and measles as well as the New York City incidence and elimination rate of mumps, rubella, and tetanus. RESULTS: The licensure of pertussis, measles, polio, mumps, and rubella vaccine was followed by an increase in the elimination rate of disease. The elimination rates of diphtheria and tetanus apparently worsened following the licensure of the respective toxoids. CONCLUSIONS: Historical data provide evidence of proof of efficacy of mass immunization for measles, polio, rubella, mumps, and pertussis, but not for diphtheria or tetanus.

Motor-vehicle crash fatalities among American Indians and non-Indians in Arizona, 1979 through 1988.

OBJECTIVES: This study evaluated the contributions of rural residence, alcohol use, and pedestrian fatalities to the high American Indian motor-vehicle crash mortality rate in Arizona. METHODS: Records from the Fatal Accident Reporting System were used to examine mortality rates between 1979 and 1988. RESULTS: American Indians had increased relative risks in all motor-vehicle crash categories in all residence-gender groups. The percentage of excess mortality associated with alcohol varied from 36.8% to 66.7%, and the percentage associated with pedestrian deaths ranged from 27.2% to 55.4%. CONCLUSIONS: Efforts to reduce excess motor-vehicle crash mortality among American Indians should concentrate on preventing pedestrian and alcohol-related fatalities.

Commitment to the underserved: evaluating the effect of an extracurricular medical student program on career choice.

BACKGROUND: This study was conducted to compare the practice locations and characteristics of physicians who participated as medical students in an extracurricular program to foster interest in careers of service to medically underserved populations with those of their classmates who did not participate in the program. METHODS: Using a mailed questionnaire, we conducted a cross-sectional study of graduates from the classes of 1983-1987 at one southwestern, public medical school. All Commitment to Underserved People (CUP) participants (n = 94) and a random sample of nonparticipating classmates (n = 188) were surveyed. CUP is an extracurricular project with components in each of 4 years of medical school that provides peer and faculty support, curriculum enrichment, and direct service to medically underserved populations. Outcome measures included the size of community of practice, practice type, and practice patient characteristics. RESULTS: Sixty seven (71%) of CUP participants and 126 (67%) of nonparticipants responded. CUP participants were more likely to be women, to specialize in family practice, to practice in the Indian Health Service (IHS) or overseas, to be located in a community of 25,000 or less, and to have participated in the state, service-payback loan program. In multiple regression, the specialty of family practice was associated with practice in a small community, the IHS, and a community health center; CUP participation was correlated with practice in small communities, the IHS, and a foreign country. CONCLUSIONS: Participation in the CUP program was associated with the specialty choice of family practice and with practice in settings associated with medically underserved populations. The CUP program has been successful in sustaining entering medical students' interests in underserved practice.

Prevalence of cardiovascular disease risk factors in a southwestern Native American tribe.

A cross-sectional study was conducted among the Pascua Yaqui Indian tribe in Tucson, AZ, in 1990 to document the prevalence of cardiovascular disease risk factors. Cardiovascular disease is the leading cause of mortality for Native Americans and for members of the Pascua Yaqui tribe specifically. A total of 230 randomly selected adults, ages 25-65 years, who were listed as members on the tribal roll, participated, resulting in a 73-percent participation rate for those contacted. The five risk factors studied included diabetes, hypertension, hypercholesterolemia, obesity, and smoking. Only 14 percent of participants had none of the risk factors; 52 percent had two or more factors. Obesity was the most prevalent, being present in 69 percent of the women and 40 percent of the men, followed by diabetes, 35 percent of men and 39 percent of women. Twenty-six percent of the population had hypertension, and 43 percent of men were smokers, compared with 24 percent of women. Hypercholesterolemia was present in 19 percent of men and 14 percent of women. The rates of diabetes, obesity, hypertension, and smoking documented in this tribe are relatively high and can serve as a baseline for evaluating future prevention efforts.

Accuracy of Pap smear and mammogram self-reports in a southwestern Native American tribe.

The use of Pap smears and mammograms in the Native American population is not well documented and the validity of women's self-reports is unknown. The purpose of this study was to examine the agreement between women's self-reports of their Pap smear and mammogram histories with their medical records in one Native American tribe. Two hundred fifty-one women between the ages of 35 and 65 answered questions regarding their Pap smear and mammogram histories. These women then underwent an education program and one year later they again answered questions about their Pap smear and mammogram histories. Two hundred four of the original 251 women completed the education program and the second questionnaire. On the first questionnaire, 51.0% of women's claims to have received a Pap smear within the past 12 months were verified by the record audit and 69.2% of claims of receiving a mammogram within the past 12 months were verified. On the second questionnaire, 46.7% of women who said they had received a Pap smear within the past 12 months had their claims verified by their records, and 45.2% of women's claims of receiving a mammogram within the past 12 months were verified. These results suggest that patient recall alone should not be used to determine date of last procedure.

The effects of medical school curricula, faculty role models, and biomedical research support on choice of generalist physician careers: a review and quality assessment of the literature.

The authors evaluated and reviewed the literature on the effects of medical school curricula, faculty role models, and federal biomedical research support on the specialty choices of U.S. medical students. All 275 articles on these subjects published from 1984 through 1993 were considered. An instrument was developed to assess the quality of the articles. A total of 85 articles met study criteria and were reviewed. The mean score achieved was 42.7% of the total possible points. Major educational reforms emphasizing primary care have resulted in significant increases in the percentages of graduates choosing generalist careers. Except for required clinical training in family practice, individual curriculum components have generally not been successful. Students and physicians often stated that faculty role models influenced specialty choices, and there is some evidence that faculty composition is related to students' career choices. There was a consistent inverse correlation between the amount of federal biomedical research support received and the percentage of a school's graduates choosing generalist careers. It is unknown whether this relationship is causative and, if so, how research funds affect specialty choices. The best strategies to enlarge the proportion of medical students choosing generalist careers include institutional reform to emphasize generalist training, increasing the size of generalist faculty, and requiring clinical training in family practice. The relationship of federal biomedical research support to the specialty choices of medical students needs to be studied further. Research on specialty choice could be improved by including a larger number of schools and students, studying trends over several years, and using validated measures and outcomes, control groups, and multivariate analyses.(ABSTRACT TRUNCATED AT 250 WORDS)

Decentralization of health services in Western Highlands Province, Papua New Guinea: an attempt to administer health service at the subdistrict level.

In 1990, Western Highlands Province in Papua New Guinea, decentralized the administration of health services from the province (population 264,000) to 14 districts (equivalent to subdistricts elsewhere). Two years later interviews were conducted with health workers and district and provincial heads. Productivity data were obtained from the provincial health information system and financial data from the provincial and national budgetary report. Health workers had a predominately negative opinion of the results of the decentralization. The most common complaints listed were lack of qualifications of District Assistant Secretaries, a diversion of funds to other programs, unavailability of transportation, a lack of equity in personnel between districts and a lack of adequate professional supervision. The problems which developed in this attempt at further decentralization related to a lack of professional support and oversight of health professionals, a lack of role definition for provincial and district administrators, lack of management training for district officials, inadequate oversight by local elected officials and inadequate budgets.

Prevalence of sexually transmitted diseases in Mexican-American pregnant women by country of birth and length of time in the United States.

BACKGROUND AND OBJECTIVES: The prevalence of sexually transmitted diseases in Hispanic prenatal patients has not been well documented. Studies of disease prevalence in Hispanic patients often are complicated by multiple countries of origin and the combining of foreign-born and U.S.-born Hispanics into a single category. GOAL OF THE STUDY: The purpose of this study was to document the prevalences of sexually transmitted diseases in low-income, pregnant Mexican-American women and to compare the prevalences of those born in the United States with those born in Mexico. We also compared the prevalence of those who recently arrived from Mexico with those who had been in the United States a longer time. STUDY DESIGN: Three-hundred-forty-seven pregnant women attending a clinic for low-income populations were screened for syphilis, gonorrhea, chlamydia, and hepatitis B virus on their first perinatal visit. RESULTS: Thirty-five women (10.1%) were positive for chlamydia, four (1.2%) for gonorrhea, one (0.3%) for syphilis, and none for hepatitis B virus. Women born in Mexico reported fewer past chlamydia and total sexually transmitted disease infections than Mexican-Americans and non-Hispanic whites born in the United States However, the prevalence of chlamydia and total sexually transmitted diseases did not differ by ethnicity, country of birth, or length of time in the United States The only variable correlated with chlamydia infection was the presence of vaginal discharge, but the sensitivity of this symptom was too low to be clinically useful as a means of selective screening. CONCLUSION: Low-income women of Mexican ancestry should be routinely screened for syphilis, gonorrhea, and chlamydia as part of their prenatal care in the United States. The value of hepatitis B virus screening in this population was neither supported nor refuted by this study.

The effect of a required third-year family medicine clerkship on medical students' attitudes: value indoctrination and value clarification.

BACKGROUND: The effect of a required six-week third-year family medicine clerkship was examined within a framework of professional socialization. Socialization was considered to consist of an institutional process, i.e., value indoctrination, and a learner process, i.e., value clarification. METHOD: Pre- and postclerkship data from 1,095 students (classes of 1981-1993) at the University of Arizona College of Medicine were analyzed. In addition, specialty match data were obtained. Factor analysis of 19 items on the pre- and postclerkship questionnaires was used to derive four scales measuring attitudes related to family medicine. The students were first grouped into four groups: those who preferred family medicine before and after the clerkship, those who preferred other specialties both times, those who switched to family medicine, and those who switched away from family medicine. Then the students were grouped into eight groups by dividing each of the specialty-preference groups into two sections: those who matched to family medicine and those who did not. Statistical comparisons involved the use of the t and F statistics. RESULTS: Usable data were available for a maximum of 997 students (91%). The students' attitudes about family medicine changed during the clerkship to become more consistent with their postclerkship specialty preferences. In addition, more students preferred family medicine after the clerkship than before it. When each group was further divided into those matching and not matching into family medicine, no significant difference in attitudes was found between those matching and those not matching. CONCLUSION: These results reflect both a value clarification process and a value indoctrination effect. The discrepancy between postclerkship specialty preferences and later match data indicates that the indoctrination effect and clarification process continue into the fourth year.

Cardiovascular disease risk factors in native Americans: a literature review.

Cardiovascular disease (CVD) has become the leading cause of death for Native Americans and Alaska Natives. CVD risk factors (diabetes, hypertension, obesity, hypercholesterolemia, smoking, and sedentary lifestyle) have been studied in a number of Native American tribes, and such studies are increasing as the CVD mortality rate rises. This article reviews the literature between 1980 and 1991 concerning the prevalence of CVD risk factors in this population. In addition to summarizing the data, we describe limitations inherent in comparison and address the need for standardization of methodology in future studies.

Performances of underrepresented-minority students at the University of Arizona College of Medicine, 1987-1991.

PURPOSE: To compare the academic performances of underrepresented-minority (African American, Native American, and Hispanic) students and all other students at the University of Arizona College of Medicine. METHOD: The performances of 42 underrepresented-minority and 368 other students who graduated between 1987 and 1991 were compared using the following variables: undergraduate science, non-science, and overall grade-point average (GPA); scores on the Medical College Admission Test (MCAT); subtest and total scores on the National Board of Medical Examiners (NBME) Part I and Part II examinations; and three types of evaluations from a required family practice clerkship. In addition, a comparison was made of scores on an objective structured clinical examination (OSCE) taken in the fourth year by 25 underrepresented-minority and 165 other students. Data were analyzed using a three-way analysis of variance and Pearson correlation analysis. RESULTS: The underrepresented-minority students earned significantly lower GPAs and scored significantly lower on all standardized paper-and-pencil tests and the family practice clerkship final examination. There was no significant group difference in the family practice clerkship clinical evaluations or the majority of the OSCE scores. For both groups, overall GPAs and MCAT scores correlated equally well with NBME total scores but were not significantly corrected with OSCE scores or family practice clerkship clinical evaluations. CONCLUSION: While the underrepresented-minority students entered medical school with significant educational disadvantages and continued to score lower than the other students on paper-and-pencil tests, their clinical performances on the OSCE and family practice clerkship were nearly equivalent to those of the other students.

Occupational health epidemiology and objectives for the year 2000.

This article summarizes epidemiologic data available on work-related morbidity and mortality and describes the occupational health surveillance systems currently in use. The NIOSH top 10 priority occupational illnesses and injuries and the year 2000 objectives for occupational health are described. Finally, statistics regarding occupational medicine specialists are presented.

Correlations of family medicine clerkship evaluations with scores on standard measures of academic achievement.

BACKGROUND: The family medicine clerkship at the University of Arizona uses three methods to evaluate students. The purpose of this study is to 1) look for possible sources of bias in each method, 2) validate the evaluation methods by correlating with other measures of academic achievement, and 3) measure the amount of correlation between the three evaluation methods. METHODS: The three clerkship evaluation methods include a final exam, clinical evaluations, and problem-solving scores. The clerkship evaluations received by 482 students were correlated with undergraduate grade point averages, MCAT scores, National Board of Medical Examiners parts I and II subtests and total scores, gender, age, race, college major, and timing of the clerkship. RESULTS: Females and older students scored higher on problem solving and minority students scored lower on the final exam. Students in the second half of the year scored higher on the final exam. There were significant correlations found between the final exam score and all the scores on standard measures of academic performance except the MCAT quantitative subtest. Problem-solving scores correlated only with NBME part II. The clinical evaluations correlated with five NBME part I subtest scores, three NBME part II subtest scores, and both parts I and II total scores. All three evaluation methods correlated significantly with each other. CONCLUSIONS: These analyses highlight the need to examine all evaluation methods used in order to improve their validity and reliability and to find potential biases. In addition, more work is needed to document the predictive validity of clerkship evaluations by correlating them with future clinical performance.