Do we practice what we preach? Comparing the patients of faculty and residents.

BACKGROUND AND OBJECTIVES: In academic family practice centers, the distribution of patients between faculty and residents influences the educational milieu. The medical literature has rarely addressed the differential case mix within the ambulatory medical educational setting. The goal of this study was to compare the characteristics of patient visits to resident and faculty physicians in seven community-based, university-affiliated family practice programs. METHODS: Using the National Ambulatory Care Survey instrument and protocol, 98 faculty and resident physicians recorded their ambulatory patient visits for one randomly selected week between July 1991 and June 1992 (n = 1,498). RESULTS: Patients of resident physicians were younger, more likely to be nonwhite (21.7% vs 9.8%, P < .001), and more likely to be reimbursed by Medicaid (34.2% vs 14.3%, P < .001) than patients of faculty physicians. Despite these patient differences, the spectrum of clinical problems was similar. There were minimal differences in the delivery of diagnostic services and therapeutic services. CONCLUSIONS: The patients seen by residents and faculty differ in important demographic characteristics. These differences could adversely affect the education of resident physicians. Academic family practice centers should actively monitor the age/gender/payment profile of resident and faculty patient panels and assign patients to achieve a desirable case mix for resident education. The differential racial distribution of faculty and resident visits suggests an unidentified systematic bias in patient assignment that warrants further investigation.

Does family practice at residency teaching sites reflect community practice?

BACKGROUND: Family medicine has aspired to train residents and conduct research in settings that closely resemble community practice. The purpose of this study was to compare the patient characteristics of the ambulatory teaching centers of a consortium of seven community-based university-affiliated family practice residency programs in northeast Ohio with the National Ambulatory Medical Care Survey (NAMCS) results for family physicians (FPs) and general practitioners (GPs). METHODS: Ninety-eight faculty and resident physicians at the residency training site of the Northeastern Ohio Universities College of Medicine collected data on all ambulatory patient visits (N = 1498) for one randomly chosen week between July 1, 1991, and June 30, 1992. We compared these data with patient visits reported in the 1990 NAMCS for FPs and GPs. RESULTS: The residency training sites saw slightly more children, women, blacks, and Medicare and Medicaid patients. The most common reason for an office visit in both populations was an undifferentiated symptom. Fifteen of the top 20 "reason for visit" codes were identical, as were 14 of the top 20 diagnoses. More preventive and therapeutic services were offered or performed at our residency training sites but fewer diagnostic services were performed. There were fewer consultations requested at our residency training sites but similar hospitalization rates for patients. The mean duration of visit differed by only 1 minute. CONCLUSIONS: The residency training sites of the Northeastern Ohio Universities College of Medicine provide patient care opportunities similar to those found in a national survey of family and general practitioners.

Effect of aminophylline on hindlimb blood flow autoregulation during increased metabolism in dogs.

The contribution of adenosine to hindlimb blood flow autoregulation during treadmill exercise or the administration of 2,4-dinitrophenol (DNP) was evaluated in 9 conscious dogs by determining hindlimb vascular bed pressure-flow relationships in the presence and absence of the adenosine receptor site antagonist, aminophylline. Hindlimb pressure-flow relationships were obtained by measuring blood flow during stepwise reductions in perfusion pressure produced with an occlusion cuff located distal to a flow probe on the external iliac artery. The efficiency of autoregulation was quantitated by calculating the closed-loop gain of flow regulation (Gc) at each pressure decrement utilizing the equation Gc = 1 - (% delta flow/% delta pressure). A Gc of one represents perfect autoregulation of flow, and a Gc of zero is indicative of a rigid system. During exercise, Gc averaged 0.44 +/- 0.07. Aminophylline reduced the Gc during exercise to -0.07 +/- 0.06 (P less than 0.05). During DNP administration, Gc averaged 0.54 +/- 0.09 and declined to -0.09 +/- 0.10 in the presence of aminophylline (P less than 0.05). These results support the hypothesis that adenosine is a primary mediator of hindlimb blood flow autoregulation during conditions that increase hindlimb metabolism.

Autoregulation of hind-limb blood flow in conscious dogs.

We evaluated the efficiency of blood flow autoregulation of the hind-limb vascular bed of eleven conscious dogs during: resting conditions; graded levels of treadmill exercise; and increases in oxygen consumption produced by the administration of 2,4-dinitrophenol (DNP). Blood flow to the left hind limb was measured with an electromagnetic flow probe on the left external iliac artery. Hind-limb perfusion pressure was measured from a catheter in the deep femoral artery and was controlled via an externally inflatable occlusion cuff positioned just distal to the flow probe. Arterial pressure was measured in the abdominal aorta. Experiments were performed 5-16 days after instrumentation. Hind-limb pressure-flow (P-F) relationships were evaluated by decreasing hind-limb perfusion pressure in 4-5 small sequential 'square-wave' steps of 10-15 mmHg each while measuring flow. Each step decrease in perfusion pressure was maintained for 2 min. The efficiency of autoregulation was quantified by calculating the closed-loop gain of flow regulation (Gc) at each decrement in perfusion pressure utilizing the equation: Gc = 1-[(F0-Fn/F0)/(P0-Pn/P0)] where F0 and P0 are the starting (control) flows and pressures prevailing prior to decreasing perfusion pressure, and Fn and Pn are the new flows and pressures at each decrement in perfusion pressure. A Gc value less than 0 indicates a predominantly passive P-F relationship, while a Gc of 1 is perfect autoregulation of flow. When the dogs were at rest, decrements in hind-limb perfusion pressure were accompanied by almost equivalent decreases in flow, i.e. no autoregulation occurred, and Gc averaged -0.177 +/- 0.044 over the pressure range from 100-40 mmHg. During all levels of treadmill exercise (on gradients of 0, 7, or 21%), however, positive Gc values were found that averaged from 0.258 +/- 0.046 at a gradient of 0% to 0.392 +/- 0.041 at a gradient of 21% and were significantly different from Gc values found during rest at perfusion pressure ranges from 90-40 mmHg. The administration of DNP directly into the hind-limb circulation increased hind-limb blood flow from 199 to 481 ml/min. In the presence of DNP, Gc values were positive over perfusion pressure ranges from 100-40 mmHg and averaged 0.473 +/- 0.054. These data demonstrate that hind-limb blood flow is not autoregulated in resting dogs, but that significant autoregulation is manifest during conditions that increase oxygen consumption.(ABSTRACT TRUNCATED AT 400 WORDS)