Variables that may enhance medical students' perceived preparedness for computer-based testing.

OBJECTIVE: To identify variables that may enhance medical student's preparedness for computer-based administration of the United States Medical Licensing Examination (USMLE). DESIGN: A cross-sectional survey of 301 medical students who completed a self-administered questionnaire. MEASUREMENTS: The questionnaire was designed to obtain information about students' computer resources, personal experience with computers, computer expertise, opinions about computers, experience with computer-based testing, perceived preparedness for the computer-based USMLE, and demographic variables. Variables related to students' perceived preparedness for the computer-based USMLE were identified by ordinal logistic regression. RESULTS: A significant regression model yielded four significant predictors: perceived preparedness for USMLE content (P: < 0.0001), opinions about computers (P: < 0.0012), gender (P: < 0.0001), and a gender by computer-based testing experience interaction (P: < 0. 0004). Computer resources, personal experience with computers, computer expertise, age, race, and year of medical school were not significant predictors. CONCLUSION: Students' perceived preparedness for computer-based administration of high-stakes examinations may be facilitated by preparing them for examination content, by enhancing their opinions about computers, and by increasing their computer-based testing experiences.

Influence of medical school on medical students' opinions about primary care practice.

PURPOSE: To compare first- and fourth-year medical students' opinions about primary care practice. METHOD: A cross-sectional survey was made of medical students at New York Medical College (NYMC) and East Carolina University School of Medicine (ECUSOM) over three years (1993-94, 1994-95, and 1995-96). Three consecutive classes of first-year students from both schools (n = 807), two consecutive classes of fourth-year NYMC students (n = 373), and three consecutive classes of fourth-year ECUSOM students (n = 221) were given a self-administered questionnaire about professional aspects of primary care practice. Responses to ten items about primary care practice were the independent variables in a logistic regression analysis. Career choice, categorized as primary care or non-primary care, was the dependent variable. Independent, two-tailed t-tests were employed to compare the responses of the first-year students interested in primary care careers with those of the fourth-year students interested in primary care careers. RESULTS: In all, 639 (79%) of the first-year students and 396 (67%) of the fourth-year students returned completed questionnaires. The first-year students interested in primary care careers were significantly more likely to believe that primary care practice has more prestige, has more intellectual stimulation, needs a large knowledge base, and involves work that is more important than that of non-primary care physicians, and were significantly more likely to disagree with the assertion that in primary care practice, physicians have more control over their working hours. With one exception (prestige of primary care practice), all these independent variables were significant for the fourth-year students as well. The comparison of the first- and fourth-year students indicated that the fourth-year students were significantly more likely to believe that primary care practice has more intellectual stimulation, needs a large knowledge base, and requires knowledge that non-primary care practice may not; they were also significantly more likely to disagree with the assertions that primary care practice is adequately compensated, has more prestige, and allows more control over working hours. CONCLUSION: It appears that students' positive perceptions about primary care practice may change as realistic perceptions about the professional demands on primary care physicians develop during medical school.

What predicts medical student career choice?

The literature on medical student career choice has identified several influences that can be categorized as student demographics, medical school characteristics, students' perceptions of specialty characteristics, and student-held values. A logistic regression model that included demographics, medical school, and student-rated influences as a proxy for perceptions and values was used to determine their relative contribution to student career choice for three consecutive cohorts of senior medical students attending two schools (n = 649). This model identified a positive relation between choice of primary care career and both student-rated influences and one student demographic characteristic, but not between career choice and school attended. Variables positively correlated with primary care career choice were related to working with people and marital status. Negatively correlated variables were related to income and prestige.

Standardized examination performance and specialty choice.

BACKGROUND AND OBJECTIVES: It has been suggested that medical students who attend schools known for graduating prospective primary care physicians may enter primary care residencies, rather than non-primary care residencies, because they are unable to compete for subspecialty residencies due to poorer academic performance. This study determined if performance on standardized examinations conducted by the National Board of Medical Examiners (NBME) could differentiate between students who selected primary care and those who selected non-primary care specialties at a medical school in the southeastern United States committed to graduating primary care physicians. METHODS: We examined initial scores on NBME examinations and subsequent residency selections by 780 students over a 14-year period to determine if there were differences in the kind of residency placements of students who passed and those who failed the examinations. RESULTS: Data analysis indicated that medical students who entered primary care and non-primary care residencies were not distinguishable on the basis of standardized examination performance. CONCLUSIONS: These results may help to refute negative stereotypes about students who enter primary care residencies and about medical schools known for promoting careers in primary care.

Photograph documentation of motor vehicle damage by EMTs at the scene: a prospective multicenter study in the United States.

The purpose of this study was to determine if emergency medical service (EMS) personnel could take instant photographs of motor vehicle damage at crash scenes depicting the area and severity of damage of the crash under adverse weather conditions, in different lighting, and quickly enough so as not to interfere with patient care. This prospective multicenter trial involved 35 ambulances responding to motor vehicle crash scenes in rural, suburban, and urban areas in five centers in four states. Emergency medical technicians (EMTs) reported their experience implementing a protocol for use of an instant camera to photograph vehicle damage at crash scenes. Time reported by EMTs to take the photographs was 1 minute or less in 204 of 288 (70.9%) of motor vehicle crashes and 2 minutes or longer in 12 of 288 (4.2%) of motor vehicle crashes. From one EMS agency in the study, 48 scene times during which photographs were taken were, on average, 1.5 minutes shorter than 48 scene times immediately before implementation of on-scene crash photography. Photographs were taken in different weather and lighting conditions. EMTs reported they were able to determine both area and severity of damage in 260 of 290 (92.5%) crash photographs, but they were unable to determine area and severity of damage in only 2 of 290 (0.7%) crash photographs.

Patient and physician perception of need for emergency medical care: a prospective and retrospective analysis.

The purpose of this study was to examine patients' and physicians' perceptions of the urgency of need for emergency medical care, and why patients come to the emergency department (ED). Survey instruments were utilized at EDs at an academic tertiary care center and a community hospital. Physicians' prospective assessment indicated that 65.8% (921 of 1,400) of the patients seen needed attention within 12 hours, whereas the patients' perception was that 86.5% (957 of 1,106) needed care within 12 hours. Patients' and physicians' retrospective responses were compared; in 19.5% (152 of 781) of cases patients rated urgency of their condition lower than the physician. These results indicate that patients and the physicians who treat them, despite the passage of a decade since a previous report of a similar study and a vastly different patient and physician population, have similar perceptions of the need for emergency care. Additionally, patients presented to EDs for a multitude of reasons; however, in strikingly different patient populations, a number of reasons are identified consistently.

Does basic life support in a rural EMS system influence the outcome of patients with respiratory distress?

PURPOSE: The purpose of this study was to determine whether basic life support, prehospital emergency medical care in a rural area affects the hospital course of patients with respiratory distress. METHODS: Medical records for patients admitted from the emergency department with a discharge diagnosis related to respiratory disease were reviewed. Data collected included: 1) mode of arrival; 2) initial symptom; 3) vital signs; 4) prehospital interventions applied; 5) hospital days; 6) discharge status; and 7) principal diagnosis. Multiple logistic regression analysis was used to predict length of hospital stay. RESULTS: Charts for 603 patients were reviewed. Complete data for all variables included in the logistic regression analysis were available for 471 patients (78.1%). Because 55 patients died, only 416 (69.0%) were included in the multiple regression analysis conducted to predict length of hospital stay. Logistic regression analysis demonstrated that patients who arrived by ambulance and older patients were more likely to die; patients with higher systolic blood pressures were more likely to survive. Only patient age predicted length of hospital stay, with older patients having longer stays. CONCLUSIONS: Basic life support prehospital care in this rural emergency medical services system does not result in a lower mortality rate or a shorter hospital stay for a broad group of patients with respiratory distress who require hospital admission. Although this study is limited to a single population and a single emergency medical services system, it is one of only a few studies of outcome in basic life support systems.

First-year medical students' knowledge of and attitudes toward primary care careers.

BACKGROUND AND OBJECTIVES: This study compared the knowledge of and attitudes toward primary care in relation to anticipated career choices of first-year medical students at two medical schools that differ significantly in production of primary care physicians. METHODS: A cross-sectional survey was conducted at a private, urban school in the Northeast where only a small percentage of students enter family practice residencies and a public, rural school in the Southeast where entry into family practice is among the highest in the country. The survey was conducted during the first semester of medical school. RESULTS: Ninety-six percent of students correctly identified general internal medicine, general pediatrics, and family practice as primary care fields; 51.8% identified these fields as "specialties." Statistically significant differences were seen between the percentages of students at the two schools who planned careers in primary care, suggesting that selection processes may differ between the two schools. There were no significant differences between students at the two schools in correctly identifying the characteristics of primary care practice. Only minor differences between the schools were found in assessments of the need for or importance of primary care. CONCLUSIONS: Although a significant difference in student interest in becoming primary care physicians was detected at the two schools, a surprising similarity was shown in their knowledge and attitudes about primary care. New attitudinal markers will need to be developed to help admissions committees select students most likely to enter primary care careers.

Effect of acute ethanol ingestion on orthostatic vital signs.

STUDY OBJECTIVE: To determine the effect of acute ethanol intoxication on the results of orthostatic tilt testing. DESIGN: Prospective, randomized crossover study. Subjects received ethanol (1.1 gm/kg) or an equal volume of water added to nonalcoholic beer. Orthostatic vital signs, ethanol concentration, and relative volume status were checked initially and hourly for 8 hours. PARTICIPANTS: Twenty healthy human volunteers, 10 men, and 10 women. RESULTS: Peak ethanol concentration was 116 +/- 18 mg/dL (mean +/- SD) 1 hour after ingestion. ANOVA for repeated measures revealed a significant difference in orthostatic pulse change and relative volume deficit between the ethanol and placebo groups (P < .05). Post hoc testing revealed significant differences between the two groups at two, five, seven and eight hours post ingestion for pulse change, and two to eight hours for volume status (Bonferroni's corrected t test, P < .0055). At 2 and 5 to 8 hours, there were significantly more positive tilt tests (+/- 30 beat/minute increase) in the ethanol group than in the placebo group (P < .05). Starting at 2 hours, the ethanol group had a statistically significant relative fluid deficit averaging .5 L by 3 hours. There was no difference in postural blood pressure changes between the two groups. CONCLUSION: In healthy volunteers, ethanol intoxication resulted in exaggerated postural pulse changes and in a greater proportion of positive orthostatic tilt test results than in a placebo group. These changes were accompanied by significant relative fluid deficits.

Is ambulance transport time with lights and siren faster than that without?

STUDY OBJECTIVE: To determine whether ambulance transport time from the scene to the emergency department is faster with warning lights and siren than that without. DESIGN: In a convenience sample, transport times and routes of ambulances using lights and sirens were recorded by an observer. The time also was recorded by a paramedic who drove an ambulance without lights and siren over identical routes during simulated transports at the same time of day and on the same day of the week as the corresponding lights-and-siren transport. SETTING: An emergency medical service system in a city with a population of 46,000. PARTICIPANTS: Emergency medical technicians and paramedics. RESULTS: Fifty transport times with lights and siren averaged 43.5 seconds faster than the transport times without lights and siren [t = 4.21, P = .0001]. CONCLUSION: In this setting, the 43.5-second mean time savings does not warrant the use of lights and siren during ambulance transport, except in rare situations or clinical circumstances.

The extent and effects of abuse and harassment of emergency medicine residents. The SAEM In-service Survey Task Force.

OBJECTIVE: To determine the extent and effects of abuse and harassment, including sexual harassment and racial or ethnic discrimination, experienced by residents in emergency medicine (EM). METHOD: The study instrument was an anonymous, self-report survey administered to a national sample of EM residents. The survey was timed to coordinate with the American Board of Emergency Medicine's annual In-Service Examination in February 1993. The residents reported whether they had experienced nine types of abuse or harassment during their residency training, the sources of these incidents, the effects on the residents, and whether they chose to file a formal complaint regarding these events. RESULTS: Surveys were returned by 1,774 (80%) of the 2,229 residents who sat for the examination--74.4% men and 24.6% women. Overall, 98% reported at least one occurrence of abuse or harassment, with patients being the most frequent source. More than half of the more senior residents reported having been physically hit or pushed. Other health care professionals were a frequent source of verbal abuse and sexual harassment. Women were significantly more likely than men to report unwanted sexual advances (63% vs 32%, p < 0.001), discomfort from sexual humor (66% vs 27%, p < 0.001), and unfair treatment because of gender (71% vs 15%, p < 0.001). Non-Caucasians reported a higher rate of racial or ethnic discrimination than did Caucasians (51% vs 23%, p < 0.001). As a result of these episodes, 19% of the respondents had questioned their decision to become a physician, 20% had questioned entering the specialty of EM, 11% had experienced emotional effects lasting over one month, and 11% had experienced disruption of their family lives. Only 56 (3.2%) had filed formal complaints. CONCLUSIONS: Residents frequently encounter abuse or harassment, particularly from patients. They also report adverse consequences from these episodes.

Accuracy of fingerstick glucose values in shock patients.

BACKGROUND: Fingerstick blood glucose measurement has become widespread in both hospital and prehospital settings. OBJECTIVE: To determine the accuracy of fingerstick blood glucose measurement in patients with poor peripheral perfusion (shock). METHOD: Results obtained during three methods of glucose analysis (fingerstick blood glucose measurement; bedside and laboratory glucose analysis) were examined prospectively on 38 patients from inpatient medical and surgical critical care units or the emergency department of a large tertiary care referral center. RESULTS: The means of the three glucose measurements were significantly different. Univariate analysis of the mean laboratory glucose value versus the mean fingerstick glucose value was significantly different. The mean venipuncture glucose measured by the bedside glucose meter versus the mean venous laboratory glucose was not significantly different. CONCLUSION: These results suggest that fingerstick blood samples should not be used for bedside glucose analysis in patients who may have inadequate tissue perfusion.

Intravenous versus rectal prochlorperazine in the treatment of benign vascular or tension headache: a randomized, prospective, double-blind trial.

STUDY OBJECTIVE: To compare the effectiveness of i.v. and PR prochlorperazine for treatment of acute benign vascular or tension headache. DESIGN: Prospective, randomized, double-blind trial. SETTING: University emergency department with 50,000 annual census. PARTICIPANTS: Forty-five adult patients enrolled on 46 visits. INTERVENTIONS: Patients received 10 mg prochlorperazine i.v. and placebo suppository or 25 mg prochlorperazine PR and placebo injection. Pain assessment was made using a 10-cm visual-analog scale; scores were analyzed using Wilcoxon/Kruskal-Wallis rank-sum tests (alpha of .01). RESULTS: Mean 60-minute pain scores for i.v. and PR groups were 0.6 and 3.5, respectively (P = .0002). Two patients (8.7%) in the i.v. group and six patients (26.1%) in the PR group required rescue analgesia (P = .12). CONCLUSION: i.v. prochlorperazine appears to provide more effective relief than PR prochlorperazine for benign vascular or tension headaches.

Prehospital blood pressures: inaccuracies caused by ambulance noise?

Blood pressure measurements in a moving ambulance can be difficult to obtain. Sirens, engine noise, and road noise can all interfere with the accurate detection of a patient's blood pressure. This study was undertaken to determine the influence of ambulance noise and vibration on auscultated blood pressures. A model was developed that used dynamic pressures to simulate systolic Korotkoff sounds. Forty-nine emergency personnel were asked to obtain blood pressures using the model in both a quiet environment and in a moving ambulance. A total of 485 blood pressure measurements were obtained. Systolic pressures were randomized to two settings: 76 mm Hg and 138 mm Hg. Stationary readings were compared with moving readings using analysis of variance for repeated measures. Systolic blood pressure measurements obtained in the quiet environment averaged 133 +/- 5 mm Hg at the high setting, and 45 +/- 6 mm Hg at the low setting. Systolic blood pressure measurements obtained in a moving ambulance averaged 86 +/- 7 mm Hg at the high setting, and 41 +/- 7 mm Hg at the low setting. The average differences between quiet and moving measurements were 47 mm Hg at the "high" setting (P < .01) and 4 mm Hg at the "low" setting (P > .01). At physiological levels, blood pressures obtained in moving ambulances differ significantly from those obtained in a quiet environment, which may be caused by road noise and ambulance motion.

Adverse effect of helicopter flight on the ability to palpate carotid pulses.

STUDY OBJECTIVE: To determine if the air medical helicopter environment compromises the ability to palpate carotid pulses. DESIGN: Using a carotid pulse model, flight nurses were tested for their ability to palpate the simulated carotid pulse at normal (120/80 mm Hg) and low (80/60 mm Hg) blood pressures on the ground and during helicopter flight. SETTING: Palpation tests were performed during flight in an MBB BO-105 twin-turbine engine, single-rotor air medical helicopter; control palpation tests were performed on the ground. TYPE OF PARTICIPANTS: Ten flight nurses. MEASUREMENTS AND MAIN RESULTS: Tracings of pulsatile pressure from the carotid pulse model verified its ability to simulate a wide range of arterial pressures. Analyses of variance for repeated measures, including polynomial contrasts, were performed to compare the number of correct detections of the presence or absence of pulse pressures in flight with the number of correct detections in the two control conditions for both carotid pulse pressures. The mean in-flight number of correct detections was lower than both the preflight and postflight control tests, which were themselves nearly equal, at each simulated carotid pulse pressure. The quadratic terms for both the 120/80 mm Hg trial (F1,14 = 9.28; P = .0087) and the 80/60 mm Hg trial (F1,18 = 5.69; P = .0283) were statistically significant. CONCLUSION: Factors associated with transport of patients in an MBB BO-105 helicopter impair the ability of flight nurses to detect carotid pulses in a simulated physiologic model.

Work-related stress and depression among practicing emergency physicians: an international study.

STUDY OBJECTIVE: To compare the levels of work-related stress and depression reported by practicing emergency physicians in three survey sites and to determine the effects of gender and marital status on the stress and depression experienced by these physicians. DESIGN: Cross-sectional mail surveys. SETTING AND PARTICIPANTS: Seven hundred sixty-four practicing emergency physicians from the United States, 91 fellows in full-time practice from Australasia, and 154 consultants and 47 senior registrars from the United Kingdom. INTERVENTION: Administration of questionnaires requesting demographic information and including an inventory to assess work-related stress and a scale to measure depressive symptomatology. MEASUREMENTS AND MAIN RESULTS: A 3 x 2 x 2 multivariate analysis of variance performed to compare scores on the stress inventory and depression scale simultaneously by survey site, gender, and marital status revealed significant differences in stress and depression by survey site and marital status. Univariate analyses of variance revealed significant differences in both stress and depression among the three survey sites and in depression by marital status. Adjusted means indicated that physicians from the United Kingdom reported higher levels of stress and depression than physicians from the United States and Australasia. Physicians from the United States and Australasia did not differ with respect to stress or depression. Physicians who were not married reported higher levels of depression than married physicians. No large mean differences, actual or adjusted, were found for any of the grouping factors. CONCLUSION: Statistical differences among practicing emergency physicians from the United States, Australasia, and the United Kingdom were observed, but the actual levels of work-related stress and depression were similar and did not appear severe. Marriage was associated with lower levels of depressive symptomatology.

Interhospital transfer of cardiac patients: does air transport make a difference?

INTRODUCTION: The purpose of this study was to compare the outcome of interhospital transported cardiac patients for whom bias in selecting transport mode was removed due to helicopter unavailability. METHODS: Patients with the diagnosis of unstable angina or myocardial infarction who underwent transport by ground only because helicopter transport was not available, were compared to patients transported by helicopter. Patients were matched by gender and referring hospital. Ninety-six patients were studied and both groups were comparable in age, diagnosis, Killip classification, treatment with thrombolytics and post-transport procedures. RESULTS: There were no statistically significant differences between the groups for mean ICU days (5.3 air vs. 3.5 ground) and mean hospital days (9.9 vs. 8.2, respectively). No differences were detected in the proportions of deaths within 72 hours of arriving at the receiving institution (1/48 air vs. 0/48 ground), but air transportation was associated with more total deaths (9/48 vs. 1/48, respectively). CONCLUSION: It appears that the interhospital transport of cardiac patients by air offers no outcome advantage over ground transport.