Medical student and faculty perceptions of desirable primary care teaching site characteristics.

BACKGROUND: As the need to expand and improve primary care teaching experiences has mushroomed, the need to identify desirable preceptor and site characteristics has also grown. PURPOSE: The current study was designed to assess the relative importance students and preceptors place on site versus preceptor characteristics. METHODS: After a required year-long primary care experience, third-year medical students (n=39) and primary care preceptors (n=20) completed a Q-sort exercise. RESULTS: In all analyses preceptor characteristics were ranked highest. The highest ranked item for students and preceptors was 'The preceptor allows student to assume increasing levels of responsibility'. Seven of the highest ranked items appear on both groups' top 10 list. CONCLUSIONS: There is a high level of agreement between students and preceptors that preceptor rather than site characteristics make the vital difference in primary care educational experiences. When students and preceptors disagree, it is because preceptors see their role- modelling characteristics related to relationships with patients as important, while students are more interested in the hands-on learning opportunities afforded by the preceptor.

Diagnostic decision support systems.

Diagnostic decision support systems are ready for prime time. We used them in a general medical clinic and found that they could suggest new diagnostic possibilities, focus thinking about clinical problems, and serve as a tool for recertification preparation. In addition, we have found diagnostic decision support systems useful for the novice clinician (fourth-year medical students and interns). These tools serve as a reminder system for learners, suggesting questions to ask the patient, physical exam components to complete, and tests to order. The novice clinician may also use these systems in preparing case presentations. The systems reviewed vary in the ways we described earlier, and there is no one "best buy." Which program is right for you depends on how much detail you want, whether you prefer a CD or internet format, and in what setting you practice. Demos are available from most vendors: Try them out, make a choice, and get on with the business of enhanced diagnostic decision making.

Elevated levels of tumor necrosis factor alpha in postdialysis fatigue.

Postdialysis fatigue (PDF) has been ascribed to excessive ultrafiltration and decline in osmolality during hemodialysis. We evaluated the potential role for the sommogenic cytokines, interleukin-1 beta (IL-1beta) and tumor necrosis factor alpha (TNFalpha), in the genesis of PDF Patients dialyzing with cuprophane membrane were assigned to PDF (N=25) and non-PDF (N=25) groups based on a fatigue index questionnaire. Pre- and postdialysis samples were obtained from 3 consecutive treatments and later assayed for serum levels of IL-1beta and TNFalpha by ELISA. Our results show significant intradialytic elevation of TNFalpha in both non-PDF groups (non-PDF: pre- 3.36+/-0.80 pg/ml to post 3.75+/-0.88 pg/ml, p<0.04; PDF: pre- 5.95+/-0.80 pg/ml to post- 8.66-/+1.35 pg/ml, p<0.02). The degree of intradialytic augmentation was significantly greater for TNFalpha in the PDF group (46+/-18% vs 11+/-5%; p<0.03). There were no significant intradialytic changes in serum levels of IL-1beta in either the PDF or non-PDF groups. There also were no significant differences in dialysis-related body weights, systolic blood pressures, or osmolalities. These findings suggest that TNFalpha may be involved in the pathogenesis of PDF.

Predictors of hospital acquired heel pressure ulcers.

The purpose of this study was to evaluate predictors of hospital acquired heel pressure ulcers. A prospective cohort study of hospitalized patients was conducted (N = 291). Subjects were enrolled by one team and followed by another team that was blind to initial assessment information. Initial assessment included demographics, Braden scale, and other variables found in the first study to be statistically significant. Ongoing evaluation involved heel assessment only. Univariate analysis yielded 15 statistically significant variables. Using multivariate logistic regression, subject's with a potential problem on the Braden Friction and Shear item (p = 0.01) and who were more frequently moist on the Braden Moisture item (p = 0.007) were more likely to develop heel ulcers (chi-square 30.52, df 3, p = 0.00001). Receiver Operator Characteristic (ROC) curves were plotted for the Braden scale and multiple other scoring systems. ROC curves were virtually identical using all new scoring systems as compared to the original Braden scale. No new scoring system was identified that led to a clinically significant improvement in sensitivity/specificity over the total Braden scale. While not perfect, the Braden scale may currently be the best predictive tool for heel pressure ulcer development.

Postdialysis fatigue.

To clarify the demographic and clinicolaboratory features of postdialysis fatigue (PDF), we enrolled 85 patients on maintenance hemodialysis in a cross-sectional study using validated questionnaires and chart review. Forty-three patients complained of fatigue after dialysis. On formal testing using the Kidney Disease Questionnaire, the PDF group had statistically greater severity of fatigue and somatic complaints than the group of patients without subjective fatigue (P = 0.03 and 0.04, respectively). On a scale measuring intensity of fatigue (1 = least to 5 = worst), the PDF group average was 3.4 +/- 1.2. PDF subjects reported that 80% +/- 25% of dialysis treatments were followed by fatigue symptoms. In 28 (65%) of patients, the symptoms started with the first dialysis treatment. They reported needing an average of 4.8 hours of rest or sleep to overcome the fatigue symptoms (range, 0 to 24 hours). There were no significant differences between patients with and without PDF in the following parameters: age; sex; type of renal disease; presence of diabetes mellitus, heart disease (congestive, ischemic), or chronic obstructive lung disease; blood pressure response to dialysis; type or adequacy of dialysis regimen; hematocrit; electrolytes; blood urea nitrogen; creatinine; cholesterol; albumin; parathyroid hormone; ejection fraction; and use of antihistamines, benzodiazepines, and narcotics. In the fatigue group, there was significantly greater use of antihypertensive medications known to have fatigue as a side effect (P = 0.007). Depression was more common in the fatigue group by Beck Depression score (11.6 +/- 8.0 v 7.8 +/- 6.3; P = 0.02). We conclude that (1) postdialysis fatigue is a common, often incapacitating symptom in patients on chronic extracorporeal dialysis; (2) no routinely measured parameter of clinical or dialytic function appears to predict postdialysis fatigue; and (3) depression is highly associated with postdialysis fatigue, but the cause-effect relationship is unclear.

Medical students' perceptions of desirable characteristics of primary care teaching sites.

PURPOSE: With the increased need to establish primary care sites, we must identify the key characteristics of effective primary care training experiences. METHODS: After completing a required year-long primary care experience, third-year medical students participated in focus groups (n = 17) and completed a Q-sort exercise with three sets of items: preceptor characteristics, site characteristics, and a combination of preceptor and site characteristics (n = 59). RESULTS: Thirty-eight concepts were identified by content analysis, which were grouped into six major categories: patients, preceptors' teaching behaviors, characteristics of office and staff, preceptors' personal characteristics, programmatic issues, and educational opportunities. The focus groups clearly identified preceptor teaching characteristics (35%) as the major factor that determines a good primary care teaching site. Items with the highest rankings from the Q-sort exercises related to teaching characteristics of the preceptor. The preceptor's enthusiasm, genuine interest in students, and ability to involve the student in active learning experiences with increasing levels of student responsibility were rated high. CONCLUSIONS: The development of primary care experiences should focus on the selection and/or development of preceptors with the identified personal and teaching characteristics. Preceptor rather than site characteristics seem to make the vital difference in primary care educational experiences.

Prerenal azotemia: differentiation of hyperureagenesis from renal hypoperfusion using urinary urea nitrogen data.

Blood urea nitrogen (BUN) rises disproportionately to serum creatinine in patients with prerenal azotemia whether due to impaired hemodynamics or excessive ureagenesis. To determine whether urinary urea nitrogen excretion rates can distinguish between these caused of hyperuremia we performed a cross-sectional observational study to compare urinary urea nitrogen excretion rates in a highly selected group of patients with prerenal azotemia. Patients who had stable serum creatinine levels, BUN: serum creatinine ratios exceeding 20:1, and progressive azotemia were identified from the hospital laboratory data base. Using conventional clinicolaboratory criteria, 27 patients were diagnosed with either renal hypoperfusion (group I; n = 17) or hyperureagenesis ((group II; n = 10). Random urine sampling for electrolytes, osmolality, creatinine, and urea nitrogen was followed by 24 h collection for creatinine clearance and urinary urea nitrogen. There were no significant differences in age, gender, absolute levels of BUN, or BUN: serum creatinine ratios between the groups. Creatinine clearance (ml/min/1.73 m2) (ml/s/1.73 m2) was lower in group I than in group II (21 +/- 16 vs 36 +/- 13; p < 0.05) (0.35 +/- 0.27 vs 0.60 +/- 0.22; p < 0.05). Twenty-four hour urinary urea nitrogen levels were significantly different (group I, 4.8 +/- 2.9 vs. group II, 13.6 +/- 3.2 gm; p < 0.001) (group I, 171 +/- 300 vs. group II, 486 +/- 114 mmol; p < 0.001). Random urine urea excretion indices were less discriminating but nevertheless still capable of separating the groups. Timed as well as random urine urea nitrogen determinations may assist in differentiating prerenal azotemia due to renal hypoperfusion from hyperureagenesis. Differentiation of these causes of prerenal azotemia might prevent iatrogenic overhydration of patients with azotemia incorrectly attributed to hemodynamic disturbances.

Change in medical students' attitudes about primary care during the third year of medical school.

PURPOSE: This study explores how medical students' attitudes and career interests change over the third year, and it investigates the potential of an attitudinal instrument to predict specialty interest. METHOD: A total of 106 students in the classes of 1992-1994 at the Clinical Campus at Binghamton of the State University of New York Health Science Center at Syracuse College of Medicine were surveyed at the beginning and end of their third year about specialty interests and attitudes toward medical care practices. The students were divided into primary care, non-primary-care, and undecided groups based on end-of-year preferences. Statistical methods used were paired t-tests and one-way analysis of variance. RESULTS: Complete data were collected for 99 (93%) of the students: 23 (23%) in the primary care, 60 (61%) in the non-primary-care, and 16 (16%) in the undecided groups. Beginning-of-the-year differences were found among the groups on only four of 29 attitudinal items (p < .05). By the end of the year, the students in the non-primary-care group had changed on more items than those in the primary care and undecided groups. The students in the primary care and the non-primary-care groups diverged on statements relating to physician roles concerning control and treatment of patients. CONCLUSION: The results suggest that as students experience direct patient care, the attitudes of students preferring non-primary-care specialties diverge from those who prefer primary care specialties. Attitudinal changes relate primarily to the control of patient care and the role of specialists.

Changing knowledge and attitudes about skin cancer risk factors in adolescents.

We examined knowledge, attitudes, and behaviors related to skin cancer, sun exposure, sunscreen use, and use of tanning booths in 903 female and 800 male adolescents. The effectiveness of a brief, school-based intervention designed to increase teens' knowledge and preventive attitudes about skin cancer was also evaluated. Females, older students, and those with high-risk skin types were most likely to use sunscreen and to take precautions. However, overall level of protection was low. Intentions to take precautions were associated with levels of perceived susceptibility to skin cancer, attitudes about the benefits of sun exposure, skin type, and sex. Beyond intentions, sunscreen use was associated with perceived susceptibility and skin type. The one-session, school-based intervention significantly increased knowledge and perceived susceptibility to skin cancer but not behavioral intentions.