Background and Objectives: The Papanicolaou (Pap) smear is a widely accepted tool for the detection and prevention of cervical cancer. Under the Bethesda Scoring System, the key internal control for adequacy of the smear is the presence of endocervical cells. Over the past several decades, much effort has been undertaken to maximize the adequacy of this acquisition. The present study determined if Pap smear sample adequacy is related to clinician experience.

Methods: This study includes a retrospective analysis of 1,356 Pap smears acquired between January 1992 and January 1995. The procedures were performed by family practice residents and faculty physicians. Cervical smears were obtained with a combination of a cytobrush and an Ayre spatula and were placed on two slides. Adequacy was subsequently determined by a cytotechnologist. Chi-square analysis was used to determine if the adequacy rates for faculty and for PGY-1, PGY-2, and PGY-3 residents were significantly different.

Results: The adequacy rates for PGY-l, PGY-2, and PGY-3 residents and faculty physicians were 80%, 89%, 89%, and 93%, respectively. The adequacy rates for the first-year residents were significantly different from that of all other studied groups.

Conclusions: This study demonstrates the relationship between clinician experience and the ability to perform an adequate Pap smear. Considering the cost and potential medical risk of an inadequate Pap smear, family practice residency programs should increase the degree of PGY-1 education and experience in performing Pap smears.

Background and Objectives: The influence of capitation versus fee-for-service reimbursement for services provided by primary care physicians is an important topic as capitation becomes increasingly prevalent. This study ascertained whether family physicians perceive an economic incentive to perform flexible sigmoidoscopy, colposcopy, and vasectomy under capitated versus fee-for-service payment structures.

Methods: In May 1995, questionnaires were mailed to 592 randomly selected physicians of the American Board of Family Practice in California, Florida, Texas, Virginia, and Minnesota. Nonrespondents received an additional mailing in July 1995.

Results: The return rate was 62%. Of 336 responses: 1) 177 (52%) provide flexible sigmoidoscopy; 68 (20%) think capitation and 173 (51%) think fee for service provide sufficient reimbursement to make this procedure profitable. 2) 69 (20%) provide colposcopy; 50 (16%) think capitation and 99 (30%) think fee for service provide sufficient reimbursement to make this procedure profitable. 3) 91 (27%) provide flexible sigmoidoscopy; 36 (11%) think capitation and 84 (25%) think fee for service provide sufficient reimbursement to make this procedure profitable.

Conclusions: A significant number of family physicians provide these three procedures in their offices. Most physicians view fee-for-service payment as providing an economic incentive to provide these procedures. Capitation was less frequently perceived as providing sufficient reimbursement to make the provision of these procedures profitable.

Background and Objectives: Although patients with prostate disorders are frequently referred to urologists for diagnosis and management, primary care physicians (PCPs) are beginning to take a more active role. However, there is concern that PCPs are not optimally educated in the diagnosis and management of these disorders. This survey determined PCP practice patterns in evaluating and treating benign prostatic hyperplasia (BPH) and screening for prostate cancer.

Methods: A 10-question survey was completed by 344 physicians attending various scientific meetings in 1995.

Results: Most PCPs (89%) indicated that up to 30% of their patients have symptomatic BPH, and a significant proportion of these are treated initially by the PCP. Although 61% of PCPs are aware of the American Urological Association (AUA) symptom score and its recommended role in clinical practice guidelines, only 38% currently use it. Indications for using the AUA score include men with BPH symptoms (80%), men >50 years (55%), and men with an abnormal digital rectal examination (DRE) (42%). The most popular BPH therapies are long-acting alpha blockers and watchful waiting. DRE is performed routinely by 84% of PCPs in men >50 years, and annual serum prostate-specific antigen is routinely requested by 69% of PCPs.

Conclusions: Although PCPs play an increasing role in the diagnosis and management of prostate disorders, they are not taking full advantage of published clinical practice guidelines.

Background and Objectives: This study sought to determine whether the number of alcohol-containing beverages consumed by adolescents attending a "typical" high school weekend party was planned or spontaneous. A second objective was to understand the role of the designated driver and whether he or she honored a pledge of sobriety.

Methods: A printed, anonymous survey with signed informed consent was distributed to 52 high school students from three different suburban high schools during three weekend high school parties. In addition, subjects underwent breath alcohol testing using the Intoximeter breath alcohol instrument. Salivary alcohol measurements were also obtained using Alco-Screen. Levels were measured in volunteers on entry and exit from the party.

Results: Fifty-two students volunteered to participate in the survey. Eleven participants volunteered to be designated drivers, nine of whom did not drink alcohol at this party. By the end of each party, the 26 boys had consumed a mean of 10 drinks, and the 16 girls had consumed 4.1 drinks, almost exactly what they had predicted at the time of arrival. By departure time, 22 (54%) of the drinkers had a breath alcohol value of .10 g/dL or greater, while only three (7%), had alcohol values of .02 g/dL or less. Blackouts were common and had been experienced by 73% of all the students surveyed. Twenty-seven percent of those surveyed had been involved in some form of physical violence while drinking. Eleven percent of the female participants reported being sexually assaulted while they or their attacker were drunk. Most of the 42 drinkers believed that it was acceptable for designated drivers to drink at least two beers. Two intoxicated designated drivers were driven home by sober friends.

Conclusions: High school students in this study knew before attending a party the quantity of beer they would consume. Survey participants believed that it is acceptable practice for designated drivers to drink alcohol at parties; 13% of those who intended to drive after these parties were intoxicated.

Background and Objectives: Alcoholism is a common problem in primary care. Although the four-question CAGE screening tool was developed for use by primary care physicians, studies show that the questionnaire is still not widely used in clinical practice. This study tested the effectiveness of an intervention to increase physicians' use of the CAGE questions.

Methods: We reviewed medical records charts completed by 15 family practice residents for documented alcoholism screening, both before and after an educational intervention. The intervention included modification of examination forms to include the CAGE questions, as well as written feedback from faculty members regarding residents' documentation of alcohol screening.

Results: We reviewed a total of 170 pre- and 227 post-intervention charts. Following educational intervention, documentation of quantity/frequency of alcohol beverage consumption increased from 26.5% to 93%. The use of CAGE screening increased from 5.9% to 76.7%. For post-intervention charts that documented using the four CAGE questions, 12.6% showed one or more positive responses. Of these charts, 27% documented physician intervention such as a warning or referral for treatment of alcohol-related problems.

Conclusions: Our educational intervention was a successful way to improve physicians' use of CAGE questions to screen for alcoholism.

Background and Objectives: Hand washing prevents communicable illness. We evaluated the effect of a mandatory, scheduled hand-washing program in elementary school children on absenteeism due to acute communicable illness.

Methods: The study was conducted at Trombley Elementary School in Grosse Pointe Park, Mich. The intervention group, approximately half of the school children (n=143, including all grades 1-5), washed their hands a minimum of four scheduled times a day. The control group (n=162) continued hand-washing practices as usual. Results: Of the 37 school days examined, children in the hand-washing group were absent fewer days than the control group due to all acute communicable illness (relative risk = .75). There were less days of absence due to gastrointestinal symptoms (relative risk = .43). The difference in absence due to respiratory symptoms was not statistically significant.

Conclusions: A scheduled hand-washing program will reduce acute communicable (gastrointestinal) illnesses in elementary school-age children.

Background and Objectives: Violence directed at general practitioners (GPs) is on the increase in urban areas of Ireland. However, little information has been available on the incidence, effects, or precipitants of this violence. This study documents the frequency of the problem in Ireland's capital city, Dublin.

Methods: A survey was sent to all 634 GPs in the Eastern Health Board region of Ireland. The survey asked each GP to report any incident of violence or aggression using standardized definitions and reporting forms. The survey also requested that participants provide information on their practice and its staff and setting.

Results: We collected information from 622 of 634 doctors (98%). The overall incidence of violence or aggression in the sample was 21%. Of the 131 incidents reported, only 7% resulted in injury to the doctor; the remainder all involved verbal abuse and/or threats. The most frequent assailant characteristics identified were alcohol or opiate abuse.

Conclusions: Violence and aggression against GPs are common. Several interventions are discussed.

Background and Objectives: Prior research indicates that up to 5% of hypertensive subjects can be successfully withdrawn from antihypertensive medications. This study determined if, in a family practice setting, greater than 5% of patients with mild essential hypertension could be withdrawn from their antihypertensive medication for more than 1 year and remain normotensive.

Methods: We enrolled 116 randomly chosen volunteer patients. Of these, 96% were white, and 58% were female. The mean age was 57, and the mean history of hypertension was 10.1 years.

Results: A total of 81 subjects completed the study; 46.9% of those 81 remained normotensive for 1 year after stopping medication. Females tended to do better than males at withdrawing from antihypertensives (58% versus 33%).

Conclusions: The proportion of patients who successfully withdrew from antihypertensive medication for 1 year and remained normotensive was significantly greater than expected. Further studies are needed to identify factors that predict which patients will remain normotensive without medication.

Background: The system of paying for graduate medical education is undergoing reform. As financing changes, understanding the costs of training family practice residents in the outpatient setting will be critical.

Methods: A financial model was used to analyze retrospective data from an existing residency and community health center linkage in Utah. Data from 1994 were used to estimate fixed and variable costs and income associated with the training program. The net cost of training residents was determined, as well as the cost of replacing their services with staff physicians.

Results: This outpatient program generated an average of $1,933 per resident in annual revenues above expenses. If staff physicians replaced residents in providing the same services, the health center would have generated an additional $5,033 per resident in income. If precepting faculty were paid rather than volunteer, the program would cost $7,912 per resident per year. Under baseline assumptions, an educational supplement of $9.52 per patient would be required for the residents to break even relative to staff physicians.

Conclusions: Graduate medical education reform will need to include provisions for reimbursing host facilities for the increased cost of outpatient care provided by residents.

Background and Objectives: As part of an initiative to promote the education of generalist physicians at the University of North Carolina, a series of meetings were held over a 12-month period between generalist senior faculty and faculty from a range of departments in the School of Medicine and other health professions schools. Through open discussion about generalist initiatives, we hoped to understand their issues, attitudes, and opinions regarding generalists and generalist education. The major themes arising from these dialogues were 1) uncertainty about the definition of the generalist physician, 2) beliefs about the poor clinical reputations of generalists, 3) lack of a scientific basis for generalist practice, and 4) beliefs that few new resources are needed to undertake and expand generalist education. We comment on the validity and possible reasons for these perceptions and suggest strategies that can enhance generalist culture in the medical school.