"Without handicap": issues of medical schools and physically disabled students.

The Americans with Disabilities Act of 1990 requires that access to education not be denied simply on the basis of disability. The law requires definition of "basic qualifications" required of all applicants, "essential elements" of the curriculum, and whether accommodation would alter the "fundamental nature" of the learning experience or impose "undue burden." Medical schools have a very low proportion of physically disabled students, which the author argues is largely a result of schools' conception of the "undifferentiated graduate" as being capable of performing the history, physical examination, and any medical procedure without an intermediary. But the author maintains that medical students need not be unblemished physically; medical educators' obligation is to educate those students who are qualified to become physicians by virtue of intelligence, professional attitude, and ability to effectively interact and communicate. With respect to clinical training, it is important to consider whether personal, hands-on experience is required for adequate learning to occur. Because most physicians limit the scopes of their practices and do not perform all procedures, because those physicians who develop physical disabilities are not precluded from continuing in some forms of medical practice, and because technologic advances allow for the substitution of imaging and diagnostic testing for the more conventional approach to the physical examination, the requirement for hands-on capability becomes less compelling. Yet not every physically disabled applicant should be admitted to medical school, and those admitted require coaching, guidance, and career advice in order to succeed with their physical limitations. The author suggests that one of the seminal concepts of medical education, "without handicap," should be seen not as referring to the pre-existing physical status of students but instead as the obligation of educators to provide all their students with the broadest possible learning experiences so that they will be without the handicap of inadequate education when they proceed to their chosen fields.

CaseLog: semantic network interface to a student computer-based patient record system.

We have developed a computer program called CaseLog, which serves as an exemplary, computer-based patient record (CPR) system. The program allows for the introduction of the students to issues unique to patient record systems. These include record security, unique patient identifiers, and the use of controlled vocabularies. A particularly challenging aspect of the development of this program was allowing for student entry of controlled vocabulary terms. There were four goals we wished to achieve: students should be able to find the terms they are looking for; once a term has been found, it should be easy to find contextually related terms; it should be easy to determine that a sought-for term is not in the vocabulary; and the structure of the vocabulary should be dynamically altered by contextual information to allow its use for a variety of purposes. We chose a semantic network for our vocabulary structure. Within the processing power of the equipment we were working with, we achieved our goals. This paper will describe the development of the vocabulary, the design of the CaseLog program, and the feedback from student users of the program.

Quality assurance for HIV-related care.

Now that models of care for numerous HIV-related conditions have been defined, a knowledge base exists for developing protocols of appropriate, high-quality care for HIV-infected patients. Bronx Municipal Hospital Center in New York City plans to implement a monitoring and evaluation program for HIV-related care that would establish protocols and indicators of quality and appropriateness, monitor compliance with protocols, and generate recommendations for improving care. At present, Bronx Municipal's AIDS consultation service has drafted guidelines for developing indicators of appropriate diagnosis, clinical course, and drug usage for HIV-infected patients, as well as guidelines for reviewing medical records.

Issues in the pharmacologic management of primary hypertension in adolescence.

Hypertension may occur in as many as 12% of adolescents and is usually of primary origin. There is an age-related increase of the blood pressure, making it difficult to define the limits of normal. True hypertension can be defined as blood pressure exceeding 140/90 mmHg regardless of age. Borderline blood pressure is said to exist when the blood pressure is above the 90th percentile for age. Blood pressure can be lowered with a wide variety of drugs, and adolescents are most often prescribed adult doses. There are specific concerns about the drugs' side effects in adolescents, particularly effects on growth and development, cognitive function, and metabolism. Diuretics are not the best first choice for therapy because of their metabolic effects. Cardiac hypertrophy and the morbidity of sustained hypertension are reduced by sympathetic inhibitors. Beta-blockers are the best currently available choice, although newer alpha-blocking agents may have some advantages. Even borderline pressure has been associated with evidence of cardiac hypertrophy, and there is substantial evidence that the adolescents with the highest blood pressures, even if still within normal limits, have the highest likelihood of developing sustained hypertension as adults. Yet there is no data establishing a beneficial effect on long-term risk of early treatment with drugs. For these reasons, nonpharmacologic intervention and close follow up are preferred as treatment for borderline blood pressure.

The nurse practitioner's role in complex patient management: hypertension.

The importance of hypertension as a risk factor and the size of the hypertensive population have created a demand for care of this problem. Nurse practitioners are effective managers of simple hypertension; however, high blood pressure often coexists with other chronic illnesses. Data are not yet available to support the role of the nurse practitioner in the management of more complex patients. The authors have examined the characteristics of patients and the processes and outcomes of care in a hypertension clinic in which physicians and nurse practitioners share responsibilities for patient care. The results show that the nurses are managing patients as complex as those seeing only physicians and are achieving better blood pressure control. The nurses successfully identify important problems and refer appropriately. Thus, nurse practitioners, with physician support, can serve as primary managers for even complex patients. Use of this model will significantly increase the resources available for care of hypertension.

Acceptance by private patients of resident involvement in their outpatient care.

The attitudes of private patients toward resident participation in their ambulatory care were evaluated. Of 195 patients (29 percent) responding to 667 mailed prospective questionnaires, 143 (73 percent) stated that they would allow resident participation in their care. Satisfactory prior experiences with trainees was the most important factor predicting acceptance (p less than .0001) of resident participation. A majority of "accepting" respondents would allow the following limited delegation of responsibility to residents: history-taking, physical examination, and visit scheduling. The majority (71 percent) desired faculty consultation at every visit. A small, retrospective survey of resident-treated private patients revealed that 70 percent were fully satisfied, 20 percent partially satisfied, and 10 percent dissatisfied. Dissatisfaction by the patients was associated with not knowing beforehand that a trainee would participate in the health care delivery. The private patients usually accepted trainees for outpatient care if: (a) they had been informed in advance, (b) they had not had a prior unsatisfactory resident experience, and (c) the responsibility of the residents had been carefully delegated and the residents closely supervised.

Strategies to improve patient compliance with antihypertensive therapy.

Compliance is a critical issue in the treatment of hypertension. Strategies designed for individual patients, based on an analysis of their specific personality characteristics, are probably the most productive. At present, however, necessary educational diagnoses cannot easily be made. Therefore, more general strategies involving simplification of the treatment regimen, stimuli to appropriate behavior, positive reinforcement, increased attention by providers, and open communications should be employed. These are of particular value for patients with inadequately controlled blood pressure who admit to noncompliance.

Minoxidil and pericardial effusion: an idiosyncratic reaction.

Minoxidil is a new potent antihypertensive vasodilator. Although highly effective, its use is limited by the association of the drug with pericardial effusion. We examined possible relationships in 37 patients. There was no significant effusions identified by echocardiography in 22 patients under active treatment. Retrospective review of 15 additional patients no longer under treatment identified seven who had had effusion and one who had had transient pericarditis. Resolution of effusion accompanied withdrawal in five patients; rechallenge was followed by effusion in one patient. Ninety-one episodes of pericardial disease have been reported in 1,869 experimental subjects (4.8%). Pericardial tamponade occurred in 21, with eight associated deaths. There are no specific patient characteristics that predict the likelihood of effusion. Since the reaction is both idiosyncratic and potentially fatal, it seems appropriate to continue to limit the use of minoxidil.

Patient compliance with antihypertensive medication.

Self-reported medication taking compliance behavior of 132 high blood pressure patients was analyzed using an expanded version of the health belief model. Subjects were selected through random sampling procedures from regular hypertension program sessions at a large urban hospital. A questionnaire was constructed to measure the model components, and interviews were conducted with each patient. Bivariate analysis showed that control over health matters, dependence on providers, perceived barriers, duration of treatment, and others' nonconfirming experience were significantly related to compliance (p < .05). Log-linear multivariate analysis revealed that three of these five variables--control over health matters, perceived barriers, and duration of treatment--contributed independently to patient compliance. Self-reported medication taking was significantly related to blood pressure control (p < .02). These data provide the basis for developing interventions for providers to facilitate the medication taking behavior of clinic patients.

Achievement of standards for quality care of hypertension by physicians and nurses.

The quality of care provided by physicians and nurses to a hypertension clinic population was studied using retrospective chart audit to compare control of blood pressure (physiologic outcome) and provider performance (process). Data was collected from 200 records, 36.4% of patients, in the program. Return visits were kept by 173 patients (86.5%) during the 6 month study period. Satisfactory point prevelance BP control (diastolic less than or equal to 90 mmHg) was achieved in 103 (59.5%). Adequate process was documented for 49 of 69 patients with unsatisfactory BP control. The records of 20 patients (11.5%) did not satisfy minumum quality of care criteria. Physicians and nurses saw similar patient groups and did not differ in process documentation or outcome results. The audit methodology was efficient, effective in evaluating management and useful in providing information about staff performance.

Should corticosteroids be used in shock?

PIP: This paper analyzes the available information on the possible mechanisms of corticosteroid action relevant to the correction of shock. Though shock may occur in a number of diseases, the pathophysiological common denominator is inadequate tissue perfusion, and its metabolic consequences: decreased pH, PO2, PCO2, and sodium, and increased lactic acid, potassium, magnesium, fatty acids, ketone bodies, and amino acids. The 4 proposed useful mechanisms of action of corticosteroid for shock treatment are: 1) Corticosteroids are required for normal cardiac function, and their cradiovascular effects are both intropic and vascular (i.e., enhance effects of catecholamines and provide an adrenergic blockade); 2) Corticosteroids stabilize membranes, enhancing the integrity of capillaries and affecting lysosomal membrane stability; 3) they improve tissue metabolism; and 4) catecholamines may also be useful in terms of their other mechanisms of action, which include the prevention of tissue breakdown and direct detoxification of endotoxin. The toxicity and administration of corticosteroids are discussed, and it is pointed out that the only benefit from corticosteroids demonstrated in experimental situations occurred when large doses (more than 300 mg, some up to 1-2 gm., of hydrocortisone or equivalent) were given at the earliest possible decision point and well before extremis, but the authors claim to be in no position to recommend specific agents or dosage regimens for clinical use.^ieng