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OBJECTIVES: To compare the effects of resident physician motivational interviewing (MI), resident physician MI plus registered nurse (RN), and the standard of care counseling approach--ask, advise, assess, assist, and arrange follow-up (5 As)--on current smokers' behaviors (readiness to quit, cigarettes smoked per day, current smoking rates), self-efficacy to quit smoking, and nicotine dependence. METHODS: The study design was quasi-experimental pretest/posttest with a comparison group. Pencil/paper measures were completed in the clinic setting at baseline and via telephone approximately 1 and 2 months after the clinic visit. RESULTS: There were no differences among the three groups in the proportion of participants who quit smoking, and the stages of change did not differ among the groups or over time. There was a significant time effect and a decrease in the number of cigarettes smoked per day (F2,160 = 41.04, P < 0.001). Significant group × time interactions were present for self-efficacy (F4,140 = 8.20, P < 0.001), nicotine dependence (F4,140 = 6.22, P < 0.001) and satisfaction with clinician (F4,160 = 3.81, P = 0.006). Post hoc analyses showed that participants in the MI groups smoked fewer cigarettes, had higher self-efficacy, and had lower nicotine dependence scores. Only participants in the MD-plus-RN follow-up group had significant positive changes in satisfaction scores. CONCLUSIONS: Resident physicians who use MI techniques have a tremendous effect on patients' smoking behaviors. When the resident physician and the RN worked together, participants achieved better outcomes.

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BACKGROUND: As medical students become more active in online social networking (OSN), there are increasing concerns regarding violations of patient privacy and a lack of professionalism. PURPOSE: Students need to be mentored, but who is best suited to the task? We hypothesized that residents are closer to students in usage and attitudes toward online communication than are faculty. If so, they would be more credible as mentors. METHODS: We surveyed faculty (N = 16), 1st-year residents (N = 120), and 3rd-year medical students (N = 130) to compare attitudes about OSN and the online usage patterns. RESULTS: We found residents to be more like students in usage patterns of personal electronic media and in their choice of the mentoring techniques that should be used. CONCLUSION: Residents say they were not prepared to mentor students without additional guidance but were more confident than faculty members that they had the knowledge to do so.

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PURPOSE: We surveyed residents and fellows at the University of Louisville School of Medicine (N  =  600) to (1) explore their perceptions and knowledge of issues related to health care business and health care reforms, and (2) seek their input on what instructional content concerning health care business and health care reform they would like to receive and what instruction venue they would prefer. We will use the findings to make decisions about curriculum content and delivery. METHODS: All residents were invited to complete a 4-part, web-based survey that included questions on demographics, attitudes, and perceptions; a baseline-knowledge quiz about health care costs; and 2 open-ended questions about what they wanted to learn and how they preferred to be taught. RESULTS: The survey response rate was 24%. Residents' agreement was stronger for statements relating to the role of physicians as "gatekeepers," patient-centered care, and the value of learning to work as a team than it was for statements about the benefits of government intervention in health care. International medical graduates, when compared with US medical graduates, had statistically significant differences in perceptions (P ≤ .004) on 3 questions related to government impact on health care. There was a slight decrease in overall knowledge about health care cost issues by residents in later postgraduate years. CONCLUSION: Residents are aware of gaps in their knowledge on business aspects of health care and health care reform. Their narrative responses identified coding and billing, legal issues, and comparative health systems as topics of interest, and the best venues for teaching included grand rounds and noon conferences. Residents indicated a preference for brief, highly focused, interactive sessions with knowledgeable guest speakers.

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BACKGROUND: The role of residents as teachers is recognized as an important part of medical education. However, residents may not possess the practical skills needed to teach medical students effectively. AIM: In response to a Liaison Committee on Medical Education citation concerning surgery residents' teaching skills, the University of Louisville School of Medicine instituted a campus-wide residents as teachers program based on the bringing education and service together curriculum. METHODS: This evaluation plan is grounded on Kirkpatrick's four levels model. Levels 1 and 2 data included post-session learner questionnaires (2007 and 2008) and open-ended facilitator questionnaires (2008). Levels 3 and 4 data included third year medical students' responses to CourseEval questions on residents as teachers (2005-2006 and 2007-2008) and data from third year medical student focus groups (2008). RESULTS: Levels 1 and 2 data analysis showed statistically significant improvements from session to session in Year I and significant improvements between Years I and II. Levels 3 and 4 data analysis showed third year students' perceptions of most residents as teachers remained high and improved significantly in the surgery clerkship. CONCLUSION: Short-term and long-term measures show this curriculum to be successful for an interdisciplinary group of residents.

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Community-acquired pneumonia is one of the most common serious infections in children, with an annual incidence of 34 to 40 cases per 1,000 children in Europe and North America. When diagnosing community-acquired pneumonia, physicians should rely mainly on the patient's history and physical examination, supplemented by judicious use of chest radiographs and laboratory tests as needed. The child's age is important in making the diagnosis. Pneumonia in neonates younger than three weeks of age most often is caused by an infection obtained from the mother at birth. Streptococcus pneumoniae and viruses are the most common causes in infants three weeks to three months of age. Viruses are the most frequent cause of pneumonia in preschool-aged children; Streptococcus pneumoniae is the most common bacterial pathogen. Mycoplasma pneumoniae and Chlamydia pneumoniae often are the etiologic agents in children older than five years and in adolescents. In very young children who appear toxic, hospitalization and intravenous antibiotics are needed. The symptoms in outpatients who present with community-acquired pneumonia can help determine the treatment. Knowing the age-specific causes of bacterial pneumonia will help guide antibiotic therapy. Childhood immunization has helped decrease the incidence of invasive Haemophilus influenzae type B infection, and the newly introduced heptavalent pneumococcal vaccine may do the same for Streptococcus pneumoniae infections.

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Infantile colic can be distressing to parents whose infant is inconsolable during crying episodes. Colic is often defined by the "rule of three": crying for more than three hours per day, for more than three days per week, and for longer than three weeks in an infant who is well-fed and otherwise healthy. The physician's role is to ensure that there is no organic cause for the crying, offer balanced advice on treatments, and provide support to the family. Colic is a diagnosis of exclusion that is made after performing a careful history and physical examination to rule out less common organic causes. Treatment is limited. Feeding changes usually are not advised. Medications available in the United States have not been proved effective in the treatment of colic, and most behavior interventions have not been proved to be more effective than placebo. Families may turn to untested resources for help, and the physician should offer sound advice about these treatments. Above all, parents need reassurance that their baby is healthy and that colic is self-limited with no long-term adverse effects. Physicians should watch for signs of continuing distress in the child and family, particularly in families whose resources are strained already.

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BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) recommends integrating improvement activities into residency training. A curricular change was designed at the Department of Family and Community Medicine, University of Louisville, to address selected ACGME competencies by incorporating practice-based improvement activities into the routine clinical work of family medicine residents. METHODS: Teams of residents, faculty, and office staff completed clinical improvement projects at three ambulatory care training sites. Residents were given academic credit for participation in team meetings. After 6 months, residents presented results to faculty, medical students, other residents, and staff from all three training sites. Residents, staff, and faculty were recognized for their participation. PROGRAM EVALUATION: Resident teams demonstrated ACGME competencies in practice-based improvement: Chart audits indicated improvement in clinical projects; quality improvement tools demonstrated analysis of root causes and understanding of the process; plan-do-study-act cycle worksheets demonstrated the change process. CONCLUSIONS: Improvement activities that affect patient care and demonstrate selected ACGME competencies can be successfully incorporated into the daily work of family medicine residents.

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Histoplasmosis is an endemic infection in most of the United States and can be found worldwide. The spectrum of this illness ranges from asymptomatic infection to severe disseminated disease. Life-threatening illness is usually associated with an immunocompromised state; however, 20 percent of severe illnesses result from a heavy inoculum in healthy persons. Culture remains the gold standard for diagnosis but requires a lengthy incubation period. Fungal staining produces quicker results than culture but is less sensitive. Testing for antigen and antibodies is rapid and sensitive when used for particular disease presentations. An advantage of antigen detection is its usefulness in monitoring disease therapy. Antifungal therapy is indicated in chronic or disseminated disease and severe, acute infection. Amphotericin B is the agent of choice in severe cases; however, patients must be monitored for nephrotoxicity and hypokalemia. Itraconazole is effective in moderate disease and is well tolerated, even with long-term use. Hepatotoxicity, the most severe adverse effect of itraconazole, is uncommon and usually transient.

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