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PubMed1999

Internal medicine-pediatrics combined residency graduates: what are they doing now? Results of a survey.

BACKGROUND: While the number of internal medicine-pediatrics (med/peds) residency training programs has increased considerably in the past decade, questions continue to be raised about career paths of the graduates of these programs. It is uncertain whether med/peds graduates follow a generalist career path and whether they continue to practice both specialties. OBJECTIVE: To determine the career outcomes of graduates of med/peds residency programs. DESIGN: A survey questionnaire of graduates of med/peds residency programs. METHODS: The computer databases of the American Board of Pediatrics and the American Board of Internal Medicine were used to identify 1482 individuals who had completed training in combined med/peds residency programs between 1986 and 1995 and who had applied to either board for certification. The survey questionnaire was mailed to all graduates identified. MAIN OUTCOME MEASURES: Time spent in professional activity (patient care, teaching, administration, and research), site of principal clinical activity, ages of the patient population, types of hospital privileges, practice organization, subspecialty activity, night and weekend coverage arrangements, community size of practice, involvement in teaching, and membership in professional organizations. RESULTS: Of the total group of 1482 graduates, 87.3% are certified by the American Board of Internal Medicine, 91.3% by the American Board of Pediatrics, and 81.6% by both boards. The survey was completed by 1005 graduates (67.8%). The principal activity of almost 70% of the graduates was direct patient care. Most graduates cared for patients of all ages. More than half of all respondents noted that their principal clinical site is a community office practice. Eighty-five percent managed patients who require hospitalization. Approximately 50% of respondents had a medical school appointment. CONCLUSIONS: This study, the largest survey to date of med/peds graduates, provides strong evidence that most med/peds graduates are practicing generalists who care for adults and children. In addition, the fact that 80% of graduates achieve dual board certification suggests that these physicians are well qualified to care for the spectrum of health care needs of children and adults. Because the changing US health care system mandates a strong primary care base, these physicians will play a small but important role in providing high-quality generalist care.

Adult↗
PubMed2007

Diverting multi-problem youth from juvenile justice: investigating the importance of community influence on placement and recidivism.

In the U.S., diversion has increasingly become one of the most utilized alternatives to detention of delinquent youth. Programs providing diversion can vary greatly. Variations in program design make it difficult to evaluate the effectiveness of program outcomes. Utilizing hierarchical linear modeling, this study examines variations in outcome for ten program sites of the New York State MH/JJ Diversion Project. Program and youth predictors were evaluated on two outcomes: out-of- community placement and recidivism. At the individual level, significant mental health and substance abuse problems, age, prior placements, and use of wraparound funds were predictive of youth placements, while significant substance abuse problems were predictive of recidivism. Program variations were found to have a significant impact on youth outcomes. Specifically, sites providing direct (or "in house") care had significantly reduced rates of placement. Study results and implications for future research are discussed.

Adolescent↗
PubMed2004

Effects of a physical activity program on postural stability in older people.

BACKGROUND AND AIMS: The objective of this non-randomized study was to determine the influence of a specific physical activity program on the postural stability of older people. METHODS: Seventy-four subjects (72.4 +/- 0.7 yrs) participated in an individualized three-month physical activity program designed to improve posture, balance and mobility--the PBM program. Sessions were held twice weekly. Postural stability was assessed using a force platform, subjects being in static and dynamic conditions, and with open and closed eyes. Changes in stabilometric parameters (Sway area, ML mean, AP mean, Total length, ML length and AP length) of the intervention group were compared to those of 14 control subjects (71.8 +/- 1.5 years). RESULTS: A two-way analysis of variance with repeated measures did not show any significant post-program change in postural stability in the hard floor condition. In contrast, Sway area (p < 0.0005), Total length (p < 0.001) and AP length (p < 0.01) were significantly reduced after the training program in the foam floor condition, with open and closed eyes. In addition, in the medio-lateral axis condition and with closed eyes, AP length in the intervention group was significantly reduced (p < 0.01), and in the antero-posterior axis condition with both open and closed eyes, Sway area (p < 0.0005), Total length (p < 0.0005) and AP length (p < 0.05) decreased significantly. CONCLUSIONS: As shown by the results in the foam floor and dynamic conditions, our individualized physical activity program improved the postural stability of older people when the standing position was challenged. However, the lack of significant results for the hard floor condition suggests that three months is not sufficient to improve static balance. The PBM physical activity program can be used for balance training in older people, but further studies are required to determine the time needed to effect improvements in static balance in this population.

Aged↗
PubMed1985

A pocket computer program for common calculations in clinical pediatrics.

This paper describes the use of a short computer program designed for use in a pediatric hospital ward. The program performs metric conversions, obviates the need for nomograms for body surface area and base excess determinations, and rapidly and accurately computes parenteral fluid mixtures, medication dosages, creatinine clearance, erythrocyte sedimentation rate corrections, and serum osmolality.

Computers↗
PubMedDate not supplied

Food safety beliefs and barriers to safe food handling among WIC program clients, Miami, Florida.

OBJECTIVE: To determine beliefs about and barriers to good food safety practices among clients of a Special Supplemental Nutrition Program for Women, Infants, and Children (WIC Program). DESIGN: Five audiotaped focus groups. SETTING: A large WIC Program clinic in Miami, Florida. PARTICIPANTS: Thirty-two women attending the clinic who were demographically similar to clinic clients. PHENOMENON OF INTEREST: Beliefs about, barriers to, and motivators for good food safety practices. ANALYSIS: Focus groups were audiotaped and transcribed. Transcripts were independently analyzed by three researchers to identify recurring ideas within and between groups. RESULTS: Participants did not perceive foodborne illnesses as a major problem or believe that foodborne illnesses usually resulted from poor food handling practices at home. The hardest practice to follow was using a cooking thermometer. Leaving perishable foods and baby bottles outside the refrigerator for longer than 2 hours were additional problems reported. Participants reported that their babies' health was the most important motivator to good food safety practices and that women may be most receptive to food safety education during their first pregnancy. CONCLUSIONS AND IMPLICATIONS: WIC clients in this clinic have several deficiencies in their food safety knowledge and practices. The WIC Program may be well positioned to help its clients, particularly pregnant women, improve food safety practices.

Adult↗
PubMed1999

Reproductive physician-scientists for the twenty-first century.

As we enter a new century, departments of obstetrics and gynecology in American medical schools face a number of challenges. A primary concern is the relative dearth of physician-scientists to explore basic mechanisms of cell function and relate these to the diseases of women. The question arises, what can we do to revitalize the spirit of investigation in many of our academic departments? This report reviews three programs designed to develop academic investigators: the Reproductive Scientist Development Program, the American Gynecological and Obstetrical Society/American Association of Obstetricians and Gynecologists Foundation Fellowship Program, and the Women's Reproductive Health Research Career Development Centers. On the basis of a decade of experience with the first two of these programs, the prospects for the third are promising. Clearly, the opportunities for obstetrician-gynecologist basic and clinical scientists are considerable. The question remains: Will leaders in the specialty work together to meet the challenge?

Education, Medical↗
PubMed2003

American ophthalmology graduate medical education and the web: current state of internet resource utilization.

PURPOSE: To evaluate the presence and accessibility of ophthalmology graduate medical education (GME) programs on the internet and the degree to which web-based resources are currently being utilized by American Ophthalmology training programs. DESIGN: Prospective sampling of internet postings of ophthalmology GME programs. METHODS: Ophthalmology residency programs listed in the American Medical Association Fellowship and Residency Electronic Interactive Database (FREIDA) online website (http://www.ama-assn.org/ama/pub/category/2997. html) were evaluated. Departmental websites were accessed either directly from the FREIDA website or from one of eight search engines or four metacrawlers utilized in the study. Each site was evaluated for the presence, extent, and type of postings in the following categories: residency, medical student resources, faculty, patient care, video utilization, and links. RESULTS: Departments with websites numbered 102 (83%). Specific posting rates were residency 84%; medical student resource 12%; faculty 72%; patient care 69%; video 2%; links 70%. CONCLUSIONS: Most departments have websites, but only a small number have postings in all categories.

Education, Medical, Graduate↗
PubMed1999

Psychological impact of childhood sexual abuse on male inmates: the importance of perception.

OBJECTIVE: The current study examined the association between childhood sexual victimization and adult psychiatric disorders among male inmates. It further assessed the association between the perception of an event (as sexual abuse or not) and psychiatric diagnoses. METHOD: A sample of 211 randomly-selected male inmates were interviewed. The Diagnostic Interview Schedule (Version III-R) was used to assess psychiatric diagnoses. An additional questionnaire assessing childhood sexual abuse and perception of childhood sexual abuse was also administered. RESULTS: Forty percent of the inmates met standard criteria for childhood sexual abuse, which far exceeded rates found in the general population. Significant differences were found between inmates who had a history of childhood sexual abuse and those who did not for a variety of psychiatric diagnoses. Forty-one percent of those who met criteria for childhood sexual abuse did not consider themselves to have been abused. Those who did not consider themselves to have been abused had higher rates of alcohol abuse/dependence, while those who considered themselves to have been abused had higher rates of posttraumatic stress and obsessive-compulsive disorder. CONCLUSIONS: This study emphasizes the importance of perception or "cognitive appraisal" of the sexual experience (as abusive or not) and the need for further study regarding the potential mediating role of cognitive appraisal. Other implications of these findings include the need for primary prevention programs designed to reduce childhood sexual abuse, and inmate rehabilitation programs with an emphasis on the connection between victimization and criminality.

Adolescent↗
PubMed2002

Statistical comparison of consumer drug expenditures and discretionary purchases to assess drug affordability.

BACKGROUND: Affordability may be defined as the absence of economic barriers to a good or service. There are 2 frequently observed measures of affordability: a consumer's ability to pay and his or her physical access to a good or service. Thus, most programs designed to subsidize consumers' health care costs, especially state programs that address prescription drug expenditures for people aged > or =65 years, base eligibility on measures of income as a proxy for a consumer's ability to pay. These measures do not explicitly include a consumer's willingness to pay for medications. For example, it is possible that some Medicare beneficiaries may be resistant to paying for medication because other major health care expenditures are typically covered by insurance. This resistance could be exacerbated by the keen awareness among the general population of the rising costs of medications. Because medications are considered a necessity, expenditure levels are usually compared with expenditures for other necessities, such as housing and medical services. OBJECTIVE: In an attempt to assess consumers' potential willingness to pay for medications, this article draws on data from the US Bureau of Labor Statistics' Consumer Expenditure Surveys to compare pharmaceutical expenditures with out-of-pocket expenditures for discretionary purchases, such as dining outside the home. RESULTS: Personal out-of-pocket expenditures for medications have ranged from 0.8% to 1.0% of consumer unit income since 1985. These expenditures are relatively small compared with those for necessities, such as housing (33%) and food (13.5%). They are also less than the share of income dedicated to many nonessentials. CONCLUSION: Assessing inability versus unwillingness to pay for medication remains a problem for both researchers and health care policy makers attempting to determine the affordability of medications.

Aged↗
PubMed1993

Social work technician program.

The increasing use of US emergency departments has resulted in increased patient delays and resultant dissatisfaction on the part of the patients and their families. Furthermore, recent studies have indicated that these delays may jeopardize the health of the ED patient. We describe a program designed to address these concerns. The Social Work Technician Program employs social work students nearing graduation as liaisons between medical personnel and ED patients and their families. This program has been found to promote patient satisfaction and welfare while providing the students with a valuable educational experience.

Clinical Clerkship↗
PubMed1996

Changing the relationship among nurses' knowledge, self-reported behavior, and documented behavior in pain management: does education make a difference?

An educational program designed to change knowledge in order to change pain management practices and patient outcomes was offered to nurses who provide day-to-day care to patients with cancer in communities in a predominantly rural state. A quasi-experimental time-series design was used to measure the effectiveness of the program in changing nurse knowledge, attitude and behavior, and to evaluate the relationships between the outcomes. Data were collected from nurses (N = 29) and patient charts before (N = 209) and after (N = 163) the program. Nurses' knowledge increased, but the change was not statistically significant; the mean percent of correct answers on the three subtests were different and differences persisted throughout the study. Nurses believed that patients should be "pain free." Documentation of behaviors, for example, practice activities, occurred infrequently and showed little change until 6 months after the program. Increase in documentation of pain-intensity ratings, pain location, number of sites of pain, presence of confusion, anxious or depressed mood, sleep, nausea and vomiting, constipation, and general activity were noted. Documentation of the use of a propoxyphene-containing analgesic decreased; increase in the use of hydromorphone methadone and transdermal fentanyl was noted. Analysis of the relationships between correct responses to nurse knowledge questions and documentation of behavior provided interesting, statistically insignificant results that need to be reexamined in future research. Future programs should emphasize analgesic dosing and calculation of equianalgesic doses. Current practices in chart documentation may provide incomplete information regarding change in practice behaviors; more detailed documentation of pain management practices is needed. Nurses who participated in the program anecdotally reported feelings of increased credibility and effectiveness. Although change in behavior is slow to occur, education does make a difference.

Adult↗
PubMed2003

Evidence-based care for depression in Maine: dissemination of the Kaiser Permanente Nurse Telecare Program.

This paper describes the program model, implementation and preliminary results from a dissemination of a nurse case management program for treating depression in primary care. The program design was modeled after the Kaiser Permanente Nurse TeleCare program, which in a randomized clinical trial had previously demonstrated significant improvement in depression outcomes and patient satisfaction over usual care. As illustrated in this pilot by patient outcomes measured using the Hamilton Depression Rating Scale, the SF-12 Mental Health Composite Score, and the Work Role, Household and Leisure Time Functioning, the authors believe that it is possible to implement successful interventions in smaller primary care practices in community-based settings.

Adult↗
PubMed2004

Interparental conflict and adolescent dating relationships: integrating cognitive, emotional, and peer influences.

This study investigated the ways in which exposure to interparental conflict may affect adolescent dating relationships in a sample of 391 adolescents ages 14 to 18 years. Boys exposed to greater parental discord were more likely to view aggression as justifiable in a romantic relationship, had more difficulty managing anger, and believed that aggressive behavior was more common in their peers' dating relationships. Each of these variables in turn linked witnessing interparental conflict to higher levels of verbal and physical aggression toward their own romantic partners. Interparental conflict was not related to girls' aggressive behavior. These data support the value of targeting cognitive and emotional processes in prevention programs designed to reduce dating violence and suggest that such programs will be strengthened by focusing on peer influences as well.

Adolescent↗
PubMed2006

Relationship between sex of parent and child on weight loss and maintenance in a family-based obesity treatment program.

OBJECTIVE: To determine if the sex of the participating parent/child pair is a contributing factor in initial weight loss and maintenance within a family-based obesity treatment program. DESIGN: A 2-year family-based obesity treatment program targeting one overweight parent and one overweight child. SUBJECTS: One overweight parent (body mass index (BMI) > or = 25) and child (> or = 85th BMI percentile) from 164 families. MEASUREMENTS: Parameters of body weight, including height, weight, BMI, z-BMI, percent overweight (BOV) at baseline and at 6-, 12- and 24-month follow-up time points. RESULTS: Children within the opposite-sex dyads had greater weight loss (P < 0.01) at 6- and 12-month time points compared with children in the same-sex dyads. Parents within opposite-sex dyads had significantly greater weight loss at 24 months (P < 0.05) compared with those in the same-sex dyads. When individual dyads were examined, the change in child z-BMI after 6 months was greater for the mother-son dyad as compared to the mother-daughter and father-son (P < 0.05). For parent z-BMI, the mother-daughter dyad consistently exhibited the poorest results. At 6- and 12-month time points, parents in the mother-daughter dyad lost significantly less weight than parents in all other dyads (P < 0.05), and at 24 months, parents in the mother-daughter dyad lost less weight than parents in the opposite-sex dyads (P < 0.05). CONCLUSION: These data reveal that child-parent sex interactions can strongly influence the outcome of obesity treatment when both parent and child are the target for weight loss. The reasons that underlie this effect remain to be determined.

Adult↗
PubMed2006

Obesity prevention programs for children and youth: why are their results so modest?

The purpose of this paper is to critically reflect upon the mixed/modest results of the primary studies related to the effectiveness of physical activity enhancement and improving nutritional intake in obesity prevention programs for children and youth. The results of a recent review of this topic that included 57 randomized controlled trials provide the basis for this discussion. Only four primary studies reported both statistically and clinically significant outcome differences between intervention and comparison groups. Although there are some similarities, there are differences among the four studies. These differences relate to program duration, frequency and intensity, targeted age of participants and level of involvement of students, the school as a community/institution and parents. Frequent methodological limitations of the studies included inadequate sample selection, lack of masking of outcome assessors, inappropriate data analysis and lack of important sub-analyses. Program design and implementation issues included lack of monitoring of program integrity and 'dose' received by participants. Theoretical basis for interventions were rarely stated and never used to explain the results. The effectiveness of parental involvement is unclear. The question of statistical versus clinical significance needs to be addressed by clinical experts. Based on this reflection, several potential future directions are outlined.

Adolescent↗
PubMed1983

Introducing preclinical students to primary care through a community preceptorship program.

In the 1980-81 academic year, the Morehouse School of Medicine implemented a preceptorship program designed to introduce preclinical students to primary care. The program is unique in that it is required for all first- and second-year students; it is continuous throughout the first two years of medical school; it exposes students to a variety of primary care specialties, settings, and practice modes; and it enables students to follow a family for one to two years. A preliminary evaluation of the program's first year indicates that it has had an impact on the students' attitudes, knowledge, and career plans. The objectives and operation of the program are described.

Attitude↗
PubMed2002

Health status and functional status in relationship to nursing home subacute rehabilitation program outcomes.

OBJECTIVE: To assess the relationship of health status and functional status to key nursing home subacute rehabilitation program outcomes: motor function at discharge, discharge destination, and length of stay in the program. DESIGN: Using a prospective cohort study design, 164 patients were assessed on entering the rehabilitation program for the first time after discharge from an acute hospital. Their median length of stay was 40 days. RESULTS: The patients' motor function improved over time (P < 0.0001), and a large majority were discharged to the community. At admission, health status was positively associated with motor function (P < 0.05) and cognitive function (P < 0.01). Higher cognitive function and higher motor function at admission were correlated with higher motor function at discharge (rs = 0.386, P < 0.0001; rs = 0.563, P < 0.0001 respectively). Better health status was independently associated with discharge to the community (P < 0.01). Only motor function at admission was independently associated with length of stay (P < 0.01). CONCLUSION: Health status and functional status are related, and both are independently associated with nursing home subacute rehabilitation program outcomes. Therefore, an improvement in one may result in an improvement in the other, and both aid in the attainment of positive subacute rehabilitation outcomes.

Activities of Daily Living↗
PubMed2006

Influence of total hip design on dislocation: a computer model and clinical analysis.

Dislocation following hip arthroplasty remains problematic. While the etiology of dislocation may be multifactorial, implant system design may play a role. Using a computer aided design program, virtual range of motion of several commonly implanted designs was performed with prosthetic interference representing impingement used as an endpoint. Implants with small diameter head size (22 mm) and a larger trunion geometry (type II taper) demonstrated impingement in flexion at less than 90 degrees , suggesting an increased risk for dislocation. To investigate this clinically, we performed a review of a consecutive series of 254 primary hip arthroplasties performed by a single surgeon using an implant with a type II taper (Biomet, Warsaw, IN). At a minimum 2 year followup, 12 patients with 12 hips (4.8%) had at least one episode of dislocation. Stratified by head size, the dislocation rates were 3.6% for 28 mm, 4.8% for 26 mm, and 18.8% for 22 mm bearings. These findings support the notion that computer aided design modeling of implant systems is useful in evaluating range of motion and this technique could be employed during the design of any new implant system.

Arthroplasty, Replacement, Hip↗