Academic health centers can bridge the gulf between medicine and public health.

The authors review why the gulf between clinical medicine and public health has existed since the first schools of public health were established in 1916. They emphasize that academic health centers (AHCs) have the potential to bring together these two perspectives--as well as the health services perspective--to clarify what they offer and to find creative ways to build upon their combined strengths. The authors describe institutional approaches that can be taken to narrow the gulf, with examples from the initiatives of this type that are under way at The George Washington University Medical Center in Washington, D.C. For example, the authors state and discuss in detail that an AHC's medical, public health, and health services institutions should be physically and institutionally close; that collaboration between them requires well-structured interaction; that institutional structures are needed to ensure cooperation when internal competition is likely; and that collaboration is fostered by new opportunities and the potential for new resources. The authors conclude by stating that the future will require that the health education and prevention perspective of public health, the treatment perspective of medicine, and the financial and management perspective of health services be developed and integrated into the work of AHCs, and give examples of specific activities that would be possible with such integration.

Implementing the Association of Teachers of Preventive Medicine's recommendations into the undergraduate medical school curriculum.

In 1989, an expert panel appointed by the Association of Teachers of Preventive Medicine proposed minimum curricular content requirements for health promotion-disease prevention, including recommendations for timing, duration, and course sequencing during medical school. Making clinical preventive medicine an integral part of a primary care rotation is a central feature of the proposal. The panel presents recommendations for using the Guide to Clinical Preventive Services, which assesses the effectiveness of 169 types of prevention interventions, in both undergraduate and postgraduate medical education. Recommendations for incorporating the guide into the undergraduate medical school curriculum are outlined. The recommendations include options for using the guide as part of a curriculum in quantitative skills, in clinical preventive medicine, in a primary care rotation, as a health services and community dimension curriculum, and as part of continuing self-education. Recognizing that teaching methods and curriculum structures are varied in preventive medicine, the panel designed the recommendations to be adaptable to all medical schools' programs. The recommendations are aimed at achieving the goal of making preventive medicine an integral part of the education, training, and practice of physicians.

Effects of teaching first-year medical students skills to read medical literature.

A required first-year course at George Washington University School of Medicine and Health Sciences, entitled Studying a Study: Methods for Reading the Medical Literature, was evaluated by the author to determine the students' perception of the course's effectiveness, changes in the students' perception of their competence in reading medical literature, the students' knowledge of research study design and statistics, and the effect of the course on the students' journal reading. Students who took the course were questioned before and after the course and as fourth-year students and were compared with fourth-year students in a prior class that had not been offered the course. Students rated the course as effective. The students who took the course rated themselves as more competent and had greater knowledge than did the class that did not take the course. These students' ratings and scores declined, however, from the first to the fourth year. A required preclinical course in study design and statistics can be well received and can affect students' knowledge and perceptions of their competence. Reinforcement is necessary to maintain the results.

Cost effectiveness of vaccination against pneumococcal pneumonia: an update.

We updated a 1978 cost-effectiveness analysis of vaccination against pneumococcal pneumonia in light of the introduction in 1983 of a 23-valent vaccine, recent medical literature, and different relative prices of medical services. Although other base-case assumptions have remained reasonable, the low estimates of 10% of pneumonia as pneumococcal and a 3-year duration of immunity now appear more likely. Vaccination of a person age 65 or older could gain a year of healthy life for about $6000 in 1983 dollars. Medicare has covered pneumococcal vaccination since 1981. With the revised assumptions, net Medicare expenditures ranged from about $5.50 to $10.50 per vaccination, or from $4400 to $8300 per year of healthy life gained. Vaccination of an elderly person would almost break even, if duration of immunity were 8 years and would be cost saving if the vaccine were administered under a public program. Current levels of vaccination appear too low considering the potential health benefits and cost-effectiveness.

Medical students' skills, attitudes, and behavior needed for literature reading.

Skills, attitudes, confidence, and behavior needed for literature reading were studied in first- versus fourth-year medical students at George Washington University in Washington, D.C. Questions on diagnostic test skills were used for comparison. Anonymous questionnaires were completed by 114 first-year and 84 fourth-year students. Fourth-year students read considerably more literature than first-year students, valued reviews over original research, and placed more value on the journal's reputation. They had greater confidence and objective knowledge than first-year students on diagnostic test skills but not greater confidence or objective knowledge on literature reading skills. Most dramatic was their "lower" willingness to admit uncertainty, even when taking into account their level of knowledge. Less willingness to admit uncertainty on the part of fourth-year medical students than first-year students may reflect medical education's emphasis on specific answers and its failure to teach students how to analyze data and draw conclusions. A need exists for specific training in literature reading skills with preevaluations and postevaluations of skills, attitudes, and behavior.

What to do until the FDA arrives.

The need for clinical monitoring to assure drug safety despite reliance on Food and Drug Administration testing is illustrated. The need to temper theory with clinical experience is exemplified by the recent examples of swine flu, resistant gonorrhea, and resistant pneumococcal infection. The potential for adverse effects to escape detection in animal studies and small-scale human trials is illustrated by the examples of ticrynafen, chloramphenicol, and diethylstilbestrol. The potential for unexpected side effects when established drugs are used in new ways is demonstrated by the examples of retrolental fibroplasia and vitamin D toxicity. The responsibilities of the medical profession and the individual practitioner include a healthy skepticism of newly introduced treatments, active participation in clinical monitoring, and maintenance of a system for chart retrieval when drugs are recalled or new effects reported.

Dethroning the detective theory of diagnosis.

The physician diagnosing disease is often compared with the detective solving a crime. Eight operating principles of fictional detectives are presented and applied to diagnosis in modern medical practice. None holds up under scrutiny. In medicine, every problem does not require a diagnosis and every possibility does not have to be pursued. Time itself may be a diagnostic tool. All the facts may not be available for definitive diagnosis, or a diagnosis may not explain the patient's symptoms. Physicians, unlike fictional detectives, cannot ignore the obvious. They can and should recognize and diagnose diseases they initially failed to suspect.

The hidden holes in history.

History taking can be viewed as a diagnostic test. Identification of the purpose, accuracy, reproducibility, and diagnostic discrimination of the history assists in reliable history taking. An appreciation of the strengths and limitations of history taking helps physicians effectively utilize this important diagnostic tool.

The dogged physical examination in the era of the C.A.T.

In attempting to evaluate the usefulness of the screening physical examination, it is necessary to remember that these recommendations are for asymptomatic individuals. When specific symptoms are present they need to be evaluated using physical examination and laboratory techniques that are appropriate to diagnosis. Although some of the same examination techniques are applicable for diagnostic evaluation, the goals, techniques, and interpretation of results are frequently different. One must also be aware of the past history of the patient, which may suggest specific risk factors even in the absence of current symptoms. A past history of breast cancer, for instance, might increase the intensity and scope of the physical examination. A history of alcohol consumption might turn an optimal mouth and throat examination into a diligent search. Additional elements of the physical examination may be pertinent to special high-risk groups. For instance, a mental status examination might be part of the routine examination for the elderly. Finally, it is important to remember that the findings on routine physical examination may themselves alter what should be done during the rest of the examination. For example, the finding of high blood pressure requires a search for arterial narrowing, coarctation, and renal bruits. Positive findings on a screening physical examination must always be supplemented by physical examination techniques designed for specific diagnosis. The recommended elements for a screening physical examination are an attempt to assemble reasonable conclusions based on current clinical use. They do not deal with the question of how frequently routine screening should be done. These recommendations need to be adjusted to the needs and views of each individual physician. One cannot help but be impressed by the medical, social, economic, and technical advantages of the physical examination. Although not a perfect technology, it serves important clinical functions in diagnosis and screening for the 1980s. The physical examination, like the human memory, will not be displaced easily even in this era of the C.A.T. scan, the radioimmunoassay, or the nuclear angiogram.