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BACKGROUND: Barriers to pain management include physicians' lack of knowledge and attitudes. Our aim was to investigate future physicians' knowledge and attitudes toward pain and the use of opioid analgesics. METHODS: We tested a medical school class during their freshman and senior years. Stepwise regression analysis was used to identify the personal traits that predicted opiophobia. RESULTS: The professionalization process of medical training may reinforce negative attitudes. Psychologic characteristics were associated with reluctance to prescribe opioids, and fears of patient addiction and drug regulatory agency sanctions. CONCLUSIONS: Consistent attitudes were found in senior medical students with preferences for certain specialty areas and the practitioners of their future specialties, suggesting a "preselection" effect. Higher scores on reliance on high technology, external locus of control, and intolerance of clinical uncertainty were associated with higher scores on one or more of the three dimensions of opiophobia. Implications for medical education are discussed.

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BACKGROUND: Despite extensive progress in the scientific understanding of pain in humans, serious mismanagement and undermedication in treating acute and chronic pain is a continuing problem. This study was designed to examine the barriers to adequate pain management, especially as they might be associated with community size and medical discipline. METHODS: A 59-item survey was used to measure physicians' attitudes, knowledge, and psychologic factors that contribute to pain management practices. RESULTS: Overall, a significant number of physicians in this survey revealed opiophobia (prejudice against the use of opioid analgesics), displayed lack of knowledge about pain and its treatment, and had negative views about patients with chronic pain. There were significant differences among groups of physicians based on size of geographic practice area and medical discipline. CONCLUSIONS: New educational strategies are needed to overcome these barriers and to improve pain treatment in routine medical practice. The effect of practice milieu must be taken into consideration.

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BACKGROUND: Because good interpersonal skills are essential for successful careers in primary care, we investigated senior medical students' (SMS) perceptions of the impression they leave with patients. METHODS: To assess the key elements that define the impression we make on others, we developed measures for self monitoring/social desirability, sensitivity, and Machiavellianism. These scales were used to predict SMS' attitudes toward various patient problems and their residency choices. RESULTS: Lower sensitivity scores and higher Machiavellianism scores predicted negative attitudes toward patients with psychologic problems. Positive attitudes toward elderly patients were predicted by higher self-monitoring/social desirability scores and lower Machiavellianism scores. Overall, women scored higher than men on self-monitoring/social desirability and sensitivity and lower on Machiavellianism. CONCLUSIONS: Among SMS, impression management's dimensions are readily measured and the students with the best scores tend to choose primary care careers.

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To gain a better understanding of senior medical students who perceive high-technology medicine as the desirable form of medical practice, we developed and evaluated a structural equation model. Intolerance to clinical uncertainty, Machiavellianism, and authoritarianism characterized students who scored higher on reliance on high-technology medicine. High scorers also tended to have a negative orientation toward patients' psychological problems and were unlikely to choose careers in primary care medicine. Students who perceive high technology as a panacea in clinical medicine share personal traits and attitudes toward patients that are not conducive to achieving the national goal of a 50:50 ratio between primary and non-primary care physicians.

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PURPOSE: When the goal of treatment is palliative, the most important outcome is improving patient quality of life. The authors describe the major concerns of terminally ill cancer patients with a prognosis of 6 months of less. OVERVIEW: In phase I of this three-part study, 74 terminally ill patients were interviewed to identify their major concerns. In phase II, interviews with 120 terminally ill cancer patients showed that their most important concerns encompass existential, spiritual, familial, physical, and emotional issues. Phase III will determine the validity and reliability of a quality-of-life scale based on these patients' most important concerns. The information presented here summarizes the results of interviews from phases I and II. CLINICAL IMPLICATIONS: Patients were receptive to being interviewed and remarked on the relevance and importance of these issues to their own experience. Several patients commented that although their disease was assessed and reassessed throughout their care, the existential, spiritual, familial, and emotional aspects of their illness rarely were a focus of their care. Healthcare professionals can create an atmosphere in which these patients feel comfortable exploring the quality-of-life issues that are most important to them. The systematic assessment of patient concerns about quality of life may complement disease assessment and facilitate referrals to appropriate members of the healthcare team. The wide range of concerns reported suggests that a team approach, including physicians, nurses, social workers, psychiatrists, psychologists, and chaplains, is the most effective way to meet the needs of terminally ill patients.

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To assess participants' perceptions of a phase I colon cancer chemoprevention trial using a calcium intervention, questionnaires were mailed to trial participants at the conclusion of the study. Responses to questionnaire items reported here include (1) perceived benefits and barriers of participation, (2) interest in participating in future trials, (3) willingness to pay trial expenses out of pocket, and (4) posttrial continuation of the calcium regimen. The study found that the most highly rated trial benefit was the perception of potential colon cancer prevention; the trial barrier reported to be the most troublesome was inappropriate or mistaken billing for study visits. Three fourths of the subjects expressed an interest in future trials of the same duration. For trials of longer duration, this percentage decreased to 66%. Approximately half did not object to participation in future trials involving placebos, and just over one third indicated that they would either definitely (8%) or probably (27%) have joined the calcium trial even if they had to pay some study expenses out of pocket. Over 90% indicated they would continue taking the calcium pills if calcium is shown to be effective. The level of perceived benefits was positively associated with reported interest in participating in future trials of the same and longer durations, and the level of reported difficulty with trial pills and procedures was inversely related to interest in future placebo-controlled trials. The results of this study, in conjunction with results of prospective studies of trial participation, may be applied in future chemoprevention trials to facilitate recruitment, reduce attrition, and promote positive trial experiences for participants by emphasizing frequently reported benefits and minimizing frequently reported barriers.

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A scale identifying 141 medical students who responded positively to geriatric patients was based on Rosenberg's Self-esteem Scale modified by adding a phrase about geriatric care. Personal and professional role traits that predicted a positive therapeutic attitude were high scores on social desirability or self-monitoring and low scores on thanatophobia and depression. Senior medical students who expressed the highest self-esteem toward caring for elderly people indicated family medicine as their first choice of residency.

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The purpose of the study was to assess the role of medical students' social desirability scores on influencing their attitudes toward either a geriatric or hypochondriac patient. To carry out this investigation, we developed a social desirability scale that was domain-specific for medicine. Students' medical social desirability scores predicted negative attitudes and beliefs toward the geriatric but not the hypochondriac patient. This difference suggests that medical students find it acceptable to dislike the hypochondriac as a patient but not the elderly person. Social desirability scores were inversely related to Machiavellan scores, suggesting that medical students with a Machivellian response pattern tended to view their role as a physician in a less idealized way. Students who scored highest on social desirability tended to choose obstetrics-gynecology for their future career and those with the lowest scores either pathology or surgical subspecialties. Research with this scale should help access social desirability's role in medical students' in managing the impression they leave with patients.

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Children are becoming an increasingly important focus for exposure and risk assessments because they are more sensitive than adults to environmental contaminants. A necessary step in measuring the extent of children's exposure and in calculating risk assessments is to document how and where children spend their time. This 1990-1991 survey of 1000 households was designed for this purpose, targeting children between 5 and 12 years of age, in six states in varied geographic regions. The behavior of children was sampled on both weekdays and weekends over all four seasons of the year using a retrospective time diary to allocate time to activities during the previous 24 h. Information was obtained on the kinds and locations of activities, the nature of the microenvironments of the locations, and the time spent in the different environments. Measures of variability in addition to mean hours per day are reported. Results of this study closely match those of earlier research on California children's activities done by the California Air Resources Board. One important finding of the survey was that 5- to 12-year-old children in all geographic regions spend most of their time indoors at home, indicating that risk assessments should focus on indoor, onsite hazards.

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OBJECTIVE: To define the test characteristics of four methods of screening for diabetic retinopathy. RESEARCH DESIGN AND METHODS: Four screening methods (an exam by an ophthalmologist through dilated pupils using direct and indirect ophthalmoscopy, an exam by a physician's assistant through dilated pupils using direct ophthalmoscopy, a single 45 degrees retinal photograph without pharmacological dilation, and a set of three dilated 45 degrees retinal photographs) were compared with a reference standard of stereoscopic 30 degrees retinal photographs of seven standard fields read by a central reading center. Sensitivity, specificity, and positive and negative likelihood ratios were calculated after dichotomizing the retinopathy levels into none and mild nonproliferative versus moderate to severe nonproliferative and proliferative. Two sites were used. All patients with diabetes in a VA hospital outpatient clinic between June 1988 and May 1989 were asked to participate. Patients with diabetes identified from a laboratory list of elevated serum glucose values were recruited from a DOD medical center. RESULTS: The subjects (352) had complete exams excluding the exam by the physician's assistant that was added later. The sensitivities, specificities, and positive and negative likelihood ratios are as follows: ophthalmologist 0.33, 0.99, 72, 0.67; photographs without pharmacological dilation 0.61, 0.85, 4.1, 0.46; dilated photographs 0.81, 0.97, 24, 0.19; and physician's assistant 0.14, 0.99, 12, 0.87. CONCLUSIONS: Fundus photographs taken by the 45 degrees camera through pharmacologically dilated pupils and read by trained readers perform as well as ophthalmologists for detecting diabetic retinopathy. Physician extenders can effectively perform the photography with minimal training but would require more training to perform adequate eye exams. In this older population, many patients did not obtain adequate nonpharmacological dilation for use of the 45 degrees camera.

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OBJECTIVE: To assess from the perspectives of a government delivery system and patients, the cost-effectiveness of the 45-degrees retinal camera compared to the standard ophthalmologist's exam and an ophthalmic exam by a physician's assistant or nurse practitioner technician, for detecting nonproliferative and proliferative diabetic retinopathy. RESEARCH DESIGN AND METHODS: Comparison of 45-degrees fundus photographs with and without pharmacological pupil dilation taken by technicians and interpreted by experts, direct and indirect ophthalmoscopy by ophthalmologists, and direct ophthalmoscopy by technicians with seven-field stereoscopic fundus photography (reference standard). Costs were estimated from market prices and actual resource use. The study included 352 patients attending outpatient diabetes and general-medicine clinics at VA and DOD facilities. RESULTS: Medical system costs per true positive were: 45-degrees photos with dilation, $295; 45-degrees photos without dilation, $378; ophthalmologist, $390; and technician, $794. Patient costs per true positive were: 45-degrees photos with dilation, $139; 45-degrees photos without dilation, $171; ophthalmologist, $306; and technician, $1009. Cost-effectiveness is sensitive to program size due to high fixed cost of the camera methods but not to prevalence. Cost-effectiveness of the technician exam is strongly affected by its sensitivity. CONCLUSIONS: Primary-care screening with retinal photographs through pharmacologically dilated pupils for diabetic retinopathy is an appropriate and cost-effective alternative to screening by an ophthalmologist in this setting. Ophthalmologists are scarce, primary-care physicians are extremely busy, and large clinics allow fixed equipment costs to be spread across many patients.

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The authors assessed the symptoms and role performance of a group of psychiatric inpatients 1 year after their discharge to determine their level of adjustment in the community. Level of self-derogation at the time of discharge was consistently found to predict the level of adjustment. The occurrence of stressful life events was also predictive of symptoms but was not found to be significantly related to role performance. The chronicity of the disease was unrelated to adjustment. The change in self-derogation level and its ability to predict community adjustment is interpreted in terms of reestablishing the patient's belief in his or her own worth and efficacy.

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The objective of this study was to determine whether the much-repeated finding of a relationship between socioeconomic status and health status is explained by individuals' health practices. The investigation was carried out using data tapes from the 1977 Health Interview Survey in which a one-third subsample of adults was asked a series of questions related to the seven nonmedical health practices identified in the Alameda County Study. The group selected for analysis comprised 15,892 white, responding adults. With age controlled statistically, perceived health status was found to be associated with socioeconomic status, whether the indicator was educational level, family income, or occupation, and to number of positive health practices. When number of health practices, in addition to age and other socioeconomic indicators was controlled for, the association was still positive and significant. The finding of an independent contribution by socioeconomic status to health status emphasizes that individual health habits are not the only influence on health status.

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Of 400 patients followed up for 1 year after release from the hospital, 34% were readmitted during that year. For schizophrenic patients the readmission rate was 49%, and for nonschizophrenic patients it was 21%. Rate of rehospitalization was positively related to number of prior hospitalizations, cumulative months of prior hospitalization, and duration of illness, but the relationship varied between the schizophrenic and nonschizophrenic groups. In contrast to the findings of Linn and associates, in this study prior hospitalization of nonschizophrenic patients markedly increased the likelihood of rehospitalization.

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Data from the first National Health and Nutrition Examination Survey were examined for individual 24-h dietary intakes of protein, vitamin A, thiamin, riboflavin, and iron, and for laboratory indices of the same nutrients in blood and urine. Mean intake values were close to or above reference standards for all nutrients except iron. Substandard laboratory values were recorded for: serum albumin and vitamin A--less than 3% of subjects; urinary thiamin/creatinine excretion--3 and 8% of white and Black subjects, respectively; Hb, hematocrit, and percentage transferrin saturation--5 to 15% of whites and 18 to 27% of Black subjects; serum iron--less than 6% of subjects. Individual dietary recall data were of limited value in predicting the laboratory indices; regression analyses indicated that sociodemographic variables may be of greater predictive value.

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The stature of children, relative to that of a reference population, is often used as a measure of the nutritional status of a population. But while undernourished children are often small in stature, all small-statured children cannot be assumed to be undernourished as a wide range of hereditary, socioeconomic and health factors also influence growth processes. The distribution of heights of 3850 "healthy" U.S. children 1-11 years of age who participated in the first National Health and Nutrition Examination Survey, a probability sample of the U.S. population, have been examined in relation to age- and sex-specific reference medians, and in relation to race, family income, and height of their parents. The distribution of heights of black children was shifted to the right (i.e., taller) of that of white children (Index of Dissimilarity = 7.9%). The distribution of heights of children of above poverty level income families was shifted to the right of that of children of below poverty level income families (Index of Dissimilarity = 8.4%). In both races, and with family incomes both above and below the poverty income level, the distribution of heights of children of tall parents was shifted to the right of that of children of short parents (Index of Dissimilarity = 20.25%). We concluded that parental stature, economic conditions and race must be considered in interpreting the growth of children in all societies, and before concluding that nutritional factors are the major determinants of short stature.

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Alcoholics participated in fewer leisure activities than did nonalcoholics except that white-collar alcoholics participated in more leisure activities than did white-collar nonalcoholics. Alcoholics viewed leisure less positively than did nonalcoholics.

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This survey determined the job-related activities being carried out by graduates of the University of Texas School of Public Health (UTSPH), whether the graduates received preparation for each activity in their academic program, and what continuing education was needed in each job-related activity. It was found that there was a difference between job activities of UTSPH graduates and their perceptions of their preparation at UTSPH for these activities. Further study is planned.

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