Primary care by desire or default? Specialty choices of minority graduates of US medical schools in 1983.

This study was undertaken to determine if US medical school students of different racial/ethnic backgrounds demonstrate similar patterns of evolution of specialty choice between their senior year of medical school and their third postgraduate year. The study identified the specialty choices of US medical school seniors in 1983 through their responses to the Association of American Medical Colleges Graduating Medical Student Questionnaire (GQ). The cohort was classified into three groups: underrepresented minorities, non-underrepresented minorities, and whites. Using these AAMC data as baseline, each racial/ethnic background group was tracked through their third residency year. Comparisons were made between anticipated specialty choices as senior medical students and actual specialties as revealed through residency tracking. The study found that more than 95% of the cohort began residencies in specialties compatible with their GQ choices. Unexpectedly, almost 20% of blacks, Commonwealth Puerto Ricans, and other Hispanics were not in graduate medical education in their third postgraduate year. This group needs to be studied further in order to learn the proportion of these physicians who subsequently completed residency training and the reason(s) for attrition in physicians who did not fulfill minimum training requirements for board certification.

Advising parents to stop smoking: pediatricians' and parents' attitudes.

Pediatricians are in a unique position to address the issues of smoking cessation with parents. Vermont pediatricians and parents of their patients were surveyed to assess attitudes about giving and receiving smoking cessation advice. A questionnaire was mailed to all pediatricians in Vermont, and 72 valid responses were received, for a response rate of 91%. Forty percent of pediatricians routinely took a smoking history from parents and 11% recorded this information in the child's chart. Most pediatricians (94%) reported advising at least 60% of smoking parents to quit, and they spent an average of 4.4 minutes doing this. Barriers to giving advice were lack of time (42%), feeling that parents did not expect advice (25%), and feeling ill at ease giving the advice (25%). Only 8.5% of pediatricians had received training in how to give smoking cessation advice, but 87% were willing to learn methods to give advice briefly. Six hundred seventy-six parents from randomly selected pediatric practices were interviewed. The average parental age was 32, and 84% were women; 49% had never smoked, 30% were former smokers, and 21% were current smokers. Current smokers were less likely to agree with statements about the adverse effects of passive smoke on children. Most parents (56%) felt that pediatricians should give quit-smoking advice to parents, and 52% of smoking parents reported that they would welcome advice. Only 30% of current smokers said advice would bother them somewhat, and 15% had more negative reactions. Parents and pediatricians agreed on the best opportunities to give quit-smoking advice.(ABSTRACT TRUNCATED AT 250 WORDS)

Predictors of cardiac rehabilitation participation in older coronary patients.

BACKGROUND: While older coronary patients have a lower exercise capacity than younger coronary patients and have been demonstrated to improve exercise capacity to a degree similar to younger coronary patients, they are less likely to be referred to an outpatient cardiac rehabilitation program. The goal of this study was to determine demographic, medical, and psychosocial predictors of outpatient cardiac rehabilitation participation in hospitalized older post--coronary event patients. METHODS: An in-hospital-guided interview was performed by the clinical research nurse of the cardiac rehabilitation program with 226 hospitalized patients, aged 62 years and older, who had recently suffered a myocardial infarction or coronary bypass surgery. Demographic, medical, and psychosocial data were analyzed. RESULTS: Overall cardiac rehabilitation participation rate in a population with a mean age of 70.4 +/- 6 years (range, 62 to 92 years) was 21%. By multivariate analysis, the strength of the primary physician's recommendation for participation was the most powerful predictor of cardiac rehabilitation entry. Also, significant predictors of participation included commute time, patient "denial" of severity of illness, and history of depression. Medical factors such as cardiac diagnosis and left ventricular ejection fraction did not predict participation. CONCLUSIONS: Demographic, medical, and psychosocial data, collected in hospitalized post-coronary event patients are powerful predictors of subsequent participation in cardiac rehabilitation.

Cardiac rehabilitation participation predicts lower rehospitalization costs.

The effect of participation in cardiac rehabilitation on medical costs was determined by measuring hospitalization charges for cardiac admissions over a 3-year period in 580 post-coronary event patients (58% after coronary bypass surgery, 42% after myocardial infarction), of whom 230 entered a cardiac rehabilitation program and 350 did not. Baseline left ventricular ejection fraction was similar in entrants and nonentrants (59.9% vs 59.5%). Over the 1 to 46-month follow-up period (mean 21 months), per capita hospitalization charges for participants in cardiac rehabilitation were $739 lower than charges for nonparticipants ($1197 +/- 3911 vs $1936 +/- 5459, p = 0.022). This was due to both a lower incidence of hospitalizations and lower charges per hospitalization. Inasmuch as groups differed with regard to age, sex, diagnostic category, and smoking status, data were adjusted for these baseline differences by means of analysis of covariance. Rehospitalization charges remained significantly higher in nonparticipants (p = 0.015). Because physician charges were not measured, the cost differential between groups is underestimated. Results of this study show an association between participation in comprehensive cardiac rehabilitation and lowered cardiac rehospitalization costs in the years after an acute coronary event.

Bronchiolar inflammation and fibrosis associated with smoking. A morphologic cross-sectional population analysis.

The lungs of 42 smokers and 13 nonsmoking males of various ages who died suddenly and unexpectedly were examined grossly using Gough-Wentworth whole-lung sections and by microscopic planimetry to assess the severity and prevalence of emphysema. The bronchioles in representative histologic sections were evaluated for inflammation and epithelial metaplasia as well as for fibrosis and muscular hypertrophy. Postmortem interviews with next of kin established a history of cigarette smoking and excluded possible occupational exposures to toxic or particulate inhalants. Emphysematous changes were not prominent in members of the study group, but they tended to be more severe in smokers (p = 0.059) and increased in severity with age (p less than 0.001). Inflammatory changes (so-called smoker's bronchiolitis) were evident in smokers of all ages, although they were significantly less prominent in the lungs of older smokers. On the other hand, respiratory and membranous bronchiolar wall fibrosis was increasingly evident in older smokers (p less than 0.05). Muscular hypertrophy in the bronchiolar walls was significantly greater in smokers, but a change with age was not observed. These findings strongly suggest that bronchiolar fibrosis is associated with chronic cigarette use. These lesions occur independently of emphysema and may account for some of the subtle physiologic alterations observed in smokers.

Medical student attitudes about internal medicine: a study of U.S. medical school seniors in 1988.

OBJECTIVE: To determine the attitudes of medical students toward careers in internal medicine. DESIGN: Cross-sectional national survey of U.S. medical school seniors. PARTICIPANTS: The 10,379 respondents to the 1988 Medical Student Graduation Questionnaire from the Association of American Medical Colleges. MEASUREMENTS AND MAIN RESULTS: Most men and women selecting internal medicine (n = 1931) as well as those switching from earlier preferences for internal medicine (n = 1606) made their final decisions about specialty during the third and fourth years of medical school. Almost 50% of students planning to be internists cited "intellectual content" as the most important factor in their choice of specialty. "Diagnostic challenge" was next most frequently cited. "Type of patient seen" and "role models" were more frequently cited as the most important factors in specialty choice for all other specialties than for internal medicine. Students who switched away from earlier preferences for general internal medicine cited the following most important factors in descending order of frequency: "too demanding of time and effort," "inconsistent with personality," "negative clerkship experiences," "don't like the type of patient," and "specialty chosen more fulfilling." The same five factors, in a different order of frequency, were given for switching from the subspecialties of internal medicine. CONCLUSIONS: Most medical students make their final choices about specialty during or after their clerkship year. Knowledge of these students' attitudes toward internal medicine could form the basis for the development of strategies to enhance the attractiveness of internal medicine among these students while they are making their final decisions about specialty.

A community-wide program in breast self-examination training and maintenance.

This study reports on the effects of innovative community-wide breast self-examination education approaches in increasing breast self-examination frequency and quality, and ability to detect breast lumps during a 1-year training program and a second-year maintenance program. Four Vermont communities were randomly assigned to receive breast self-examination training plus maintenance, training alone, control (with full measurement), and low-measurement control. Random digit dialing telephone surveys were conducted at baseline and at 1- and 2-year follow-up with a panel of 637 women representing all adult women in the first three communities. The low-measurement control community received only baseline and second-year follow-up surveys with a panel of 238 women. Home interviews to determine breast self-examination palpation skills and lump detection on silicone breast models were conducted in first- and second-year follow-up surveys. Results of the first-year follow-up survey indicated significant increases in breast self-examination frequency, quality, and number of lumps detected for women in communities receiving the training program compared with controls; in the second year, women in the community also receiving breast self-examination maintenance showed greater improvement in reported breast self-examination quality and detected more breast lumps than did women in other communities.

Racial-ethnic background and specialty choice: a study of U.S. medical school graduates in 1987.

This study used two Association of American Medical Colleges' questionnaires to determine whether there was a relationship between the racial-ethnic backgrounds and the specialty choices of a 1987 cohort of 11,136 U.S. medical school seniors, both prior to entering medical school and as they prepared for residency training. Their specialty preferences as premedical students were shown by their responses to the Premedical Student Questionnaire, administered when they registered for the Medical College Admission Test; their specialty choices at the end of their medical school training were shown by their responses to the Medical Student Graduation Questionnaire, which they completed shortly before graduation. Racial-ethnic backgrounds, self-recorded, were classified into black, other underrepresented minorities, Asian, other non-underrepresented minorities, and white. Specialties were clustered into primary care, medical specialties, surgical specialties, and supporting services. Before entering medical school, the students had similar specialty preferences regardless of background. As seniors in medical school, there was even greater convergence of specialty choices among the students of all backgrounds. Racial-ethnic background in itself appears not to have been a major factor influencing the senior medical students' specialty choices.

Trends in evolution of specialty choice. Comparison of US medical school graduates in 1983 and 1987.

This study describes the evolution of specialty choices among US medical school seniors in 1983 and 1987. Its purposes were to determine the specialty interests of the 1987 cohort as these 11,264 students proceeded through medical school and to compare their evolving specialty plans with those of the 10,321 US medical school seniors in 1983. As the 1987 cohort advanced through medical school, they became increasingly interested in general and subspecialty internal medicine, psychiatry, obstetrics and gynecology, anesthesia, radiology and rehabilitation medicine and less interested in family practice, general surgery, pathology, and public health. Compared with the 1983 cohort, 1987 seniors were significantly less likely to choose general internal medicine and more likely to choose internal medicine and pediatric subspecialties. Similar proportions of each cohort of seniors chose family practice. Between 1983 and 1987, men's interest in pediatrics, general surgery, and obstetrics and gynecology declined, while their interest in the surgical subspecialties, anesthesia, and rehabilitation medicine increased.

Personal characteristics, career plans, and specialty choices of medical students elected to Alpha Omega Alpha.

Among US medical graduates in 1983, personal characteristics, career plans, and specialty choices of men and women elected to Alpha Omega Alpha (AOA), the honor medical society, differed in a number of ways from those of their non-AOA classmates. Students in AOA scored significantly higher on each subtest of the Medical College Admission Test, were disproportionately white, and had a higher proportion of parents achieving a post-high school education. Members of AOA participated in undergraduate medical research and authored papers during medical school significantly more frequently than those who were not members of AOA, planned a major career commitment to research, and planned careers in academic medicine significantly more frequently than those who did not belong to AOA. In contrast, neither religious preference, among students from Catholic, Jewish, or Protestant backgrounds, nor gender differentiated members of AOA from non-AOA members. Among the 15 specialties studied, internal medicine subspecialties and internal medicine attracted the highest proportion of students elected to AOA.

Impact of commercial eating on nutrient adequacy.

The purpose of this study was to investigate the impact of eating away from home (at commercial establishments) on nutrient adequacy by examining frequency of eating away from home, the nutritional value of foods eaten both away and at home, and the nutritional adequacy of the daily diets of individuals. Data from 3,500 individuals, 15 years of age or older, interviewed in the fall quarter of the 1977-78 Nationwide Food Consumption Survey were used. Results indicate that although the nutrient density of food eaten away from home was lower than that of food eaten at home, the persons studied did not eat out frequently enough to influence the adequacy of their diets significantly. The low nutrient density of food eaten away from home does suggest, however, that individuals could be putting themselves at risk of some nutrient inadequacies (particularly of calcium and vitamins A, B-6, and C) or of caloric excess if they substantially increase their frequency of eating away from home. Teenagers and senior citizens seem most vulnerable to potential nutritional inadequacies.