abilities? In the current study, we examined the abilities of internal medicine residents to identify and care for a victim of domestic abuse. METHODS: Seventy-one internal medicine residents in four programs participated in a tenstation standardized patient-based Clinical Skills Assessment. One standardized patient (SP) portrayed a woman, complaining of headaches, who was a victim of domestic abuse. The SP assessed residents' elicitation of information and counseling interventions on a fifteen-item checklist. After the encounter, residents documented the patient's problems, etiologies, work-up and treatment recommendations. RESULTS: Forty (56%) residents correctly diagnosed domestic violence and discussed the diagnosis with the patient. Eighteen residents (25%) asked about immediate safety concerns. Twenty-three (32%) asked about concomitant child abuse. Forty-one (58%) did not refer the patient for DV counseling. Forty-eight (68%) made one or more incorrect recommendations. Some of these recommendations could be dangerous: recommending marital therapy (n=19, 27%), prescribing potentially addictive medicines (n=9, 12%), or suggesting that the patient bring her abusive partner in to the doctor (n=23, 32%). To work-up the patient's headache, 36 (52%) ordered unnecessary tests which would have cost $32,500. CONCLUSION: In our sample there were many deficiencies in the residents' abilities to diagnose and manage DV. The majority of residents provided inappropriate care that in some cases would be dangerous. In addition, the residents' ordering of unnecessary and costly tests is a drain to already-limited health care resources. There appears to be a need for more intensive training in DV at the undergraduate and residency levels. METHODS: Groups of 4 to 5 residents participate in 10 to 12 weekly 1-hour sessions during the rotation. After 2 didactic sessions to review basic biostatistics, clinical epidemiology, and other core EBM topics, the sessions follow a journal club format. One resident searches for, selects, and distributes an article relevant to the clinical question chosen for that session. They present a summary and initial evaluation of the article, which is followed by participatory discussion facilitated by the instructor. The Users' Guides to the Medical Literature series from JAMA is used to guide topic selection and as supplementary reading. Group discussions focus on the Users' Guides core concepts and evaluative criteria. The residents also do a more intensive final presentation in a similar format. Changes in EBM knowledge and skills were evaluated with a 38-item test given before and after the course, with blinding of participants and the instructor to the results. Participants also self-evaluated changes in their knowledge, skills, and practice on an anonymous evaluation form. . Pairwise comparisons revealed that the three categories within each teaching setting were all significantly different from one another (p < .04). Regression analysis revealed that time spent teaching in the IP setting was a significant negative predictor (p < .001) in the LC and CG ratings for IP teaching, while total years of teaching experience was a significant positive predictor (p < .001) in the SDL ratings for IP teaching. For the OP teaching ratings, time spent teaching in the OP setting was a significant negative predictor (p < .002) for CG and SDL, while LC ratings were unaffected by any of these variables. CONCLUSION: Our results suggest the need for focused faculty development programs to enhance CG skills-particularly for teachers who spend more clinical time in either the IP or OP setting, SDL skills for less experienced IP teachers and teachers who spend more clinical time in the OP settings, and LC skills for faculty with more inpatient clinical time. Internal Medicine residents at one urban, multi-center residency program were asked to complete a 71-item questionnaire. The survey was self-administered at conferences, on wards, and by e-mail. It was piloted on faculty, fellows, and chief residents for clarity of the questions and content validity. We solicited residents' observations of the impact of crosscultural issues on clinical care. Attitudes and self-perceived knowledge and skills were assessed with 6-point Likert scales. RESULTS: 71 of 133 residents (53%) responded. There were 35 PGY-1, 16 PGY-2, and 20 PGY-3. The mean age was 28 years, 52% were women, 60% white, 39% were fluent in a language other than English, and 49% had non-U.S. born parents. Residents reported experiencing a situation where a patient's care was negatively impacted due to sexual orientation (28%), gender (29%), ethnicity (38%), race (44%), socioeconomic status (56%), or a language barrier (90%). 76% of residents responded that cultural issues are``very''/``extremely'' important to patient care, but only 50% thought training in cross-cultural medicine could substantially improve health delivery. Residents viewed the following as major barriers to integrating cross-cultural issues in residency training: time constraints (60%), lack of experts (30%), lack of interest among learners (19%), lack of interest among faculty (16%), perception that these issues are already adequately addressed (12%), belief that these issues might offend some people (12%). Most residents rated themselves as being overall``somewhat'' tò`m oderately'' knowledgeable (69%) and skilled (81%) about cultural issues and medicine. A significant association was found between PGY level and perception of overall knowledge (p < 0.04%). Interestingly, 16 ± 18% of PGY-1 and 2 residents felt very knowledgeable about cultural issues and medicine, while no PGY-3 did. CONCLUSION: Successful development of curricula in cross-cultural medicine requires an understanding of trainees' attitudes and observations. Residents regard cultural issues as important to patient care and many report observing a direct impact. Despite diverse backgrounds, they do not consider themselves to be highly knowledgeable or skilled in this area. Based on these observations, a need for cross-cultural curricula exists. PURPOSE: Mentors are regarded as important for the academic success of junior faculty, but the availability and impact of mentors on the careers of junior faculty has not been well studied. The purpose of this study was to evaluate junior faculty perceptions of senior faculty mentors at one large academic medical center. METHODS: We surveyed all 154 physicians in the clinician ± educator (CE) and clinician ± scientist (CS) tracks from the Departments of Medicine, Surgery and Obstetrics/Gynecology who held the rank of Instructor or Assistant Professor at the University of Washington. We collected demographic information and asked respondents to describe their academic productivity and rate the adequacy of their mentors. RESULTS: Among 122 (79%) junior faculty who responded the mean age was 38.7 years (SD=4.3); 56 (46%) were women; 52 (43%) were in the CE track; and the mean years in rank was 2.5 (SD= 1.5). CEs reported authoring 2.6 (SD=3.7) book chapters and 4.5 (SD=8.1) original manuscripts whereas the means for CSs were 3.5 (SD=12.1) and 10.9 (SD=12.6), respectively. CEs and CSs had a mean of 1.1 (SD=1.8) and 3.1 (SD=2.6) funded grants, respectively. When asked if they had access to a senior faculty member in their department whom they trusted and who supported them in achieving their career goals, similar percentages of CEs and CSs answered affirmatively (75% and 74%, respectively). On the other hand, when asked if they had adequate mentoring, 36% of all respondents``strongly agreed'' or``agreed,'' (mentored faculty) versus 64% whom``neither agreed nor disagreed'',``disagreed'' or``strongly disagreed'' (nonmentored faculty). In bivariate analyses, mentored faculty were more likely to be men (44% vs. 27%, p=0.049), have completed fellowship training (41% vs. 21%, p=0.048) and to be CSs (51% vs. 15.4%, p < 0.0001). 93% of mentored respondents``agreed'' or``strongly agreed'' that they would achieve their short-term career goals vs. 65% of the non-mentored faculty (p = 0.0006). Gender (OR=3.6, p=0.02) and academic track (OR=9.9, p=0.0002) were independently associated with junior faculty perception of adequate mentoring in logistic regression adjusting for age, years at current rank, department affiliation and fellowship training. Mentored faculty reported more publications than non-mentored faculty. This difference did not reach statistical significance in linear regression (p = 0.1) adjusting for all independent variables entered in the logistic multivariate analysis. CONCLUSION: Over half of the junior faculty in this study did not feel that they were being adequately mentored. Women and CEs were more likely to perceive not being adequately mentored. Strategies to improve mentoring need to be developed and evaluated. Little is known about the quality of Pap smears obtained by internists. The presence of endocervical cells increases the quality of pap smears and has been previously evaluated in family physicians and ob-gyn. We examined the influence of gender, status (faculty vs. resident) and practice site (university vs. community) on rates of satisfactory smears as defined by the presence of endocervical cells. METHODS: Retrospective review of Pap smears evaluated by one cytology department over a 2 year period that were performed by internal medicine faculty and residents from 1 academic department at three clinic sites: two university-based clinics(one staffed by faculty and one staffed by residents) and one community-based clinic(staffed by both faculty and residents). Vaginal smears were excluded. RESULTS: 1086 smears were evaluated. 56% of smears were obtained at the faculty university clinic (FC), 18% at the resident university clinic (RC), 26% at the community clinic (CC). FC patients were older than RC or CC (mean age 56,40,42). 86 Internists were included: 65% males, 17% faculty (60% FC), 83% residents (52% CC). 75% of smears were satisfactory, 19% satisfactory but limited by no endocervical cells, 5.6% limited for other reasons, 0.18% unsatisfactory. Males and female internists had similar satisfactory rates (78% vs. 71%). Physicians at the university clinics had higher satisfactory rates (83%) compared to the community clinic (53%). University faculty had higher satisfactory rates than community faculty (83% vs. 43%). University residents had satisfactory rates similar to university faculty (83%) but higher rates than community residents (56%). Community residents had higher satisfactory rates than community faculty (56% vs.43%). Using the generalized estimating equations approach to control for volume of smears done by each physician we found that younger patient age (p = 0.02), faculty status (p = 0.03), and community clinic site (p = 0.0001) were all associated with lower satisfactory rates. The odds of a satisfactory reading were 1.13 for each additional decade of age, 2.04 for residents vs. faculty, and 6.22 for FC vs. CC, 3.49 for RC vs. CC, and 1.78 for FC vs. RC. CONCLUSION: Satisfactory rates among this sample of Internists were 11 ± 18% lower than published reports for family physicians and ob-gyn. Rates of satisfactory smears did not differ by gender. We did find higher satisfactory rates in older patients, residents and at university-based sites. These results suggest that academic institutions should place more emphasis on teaching Pap smear sampling technique to internists. METHODS: Mailed and web-based surveys were conducted of all 395 internal medicine residency programs regarding 45 procedural skills. We asked directors which methods of procedural skills training they used, which procedures residency graduates should master, and the amount of training needed to attain and maintain competency in each procedure. This paper reports analysis of responses of 269 (68%) program directors or their designees. RESULTS: As in the 1987 survey, the proportion of program directors who said all residents should master these procedures differed from the proportion who said that all residents do master them. For 21 of the 45 procedures in the survey, at least 30% more respondents said residents should master the procedure than said all their residents do master the procedure. This gap is larger in the new survey. For the 35 procedures that appeared in both surveys the new survey found 12% fewer reporting that all residents mastered those procedures. For example, although more than 90% of respondents in both surveys thought thoracentesis should be mastered by all residents, 79% in the 1987 survey vs.58% in the new survey thought it was mastered by all. In addition, estimates of the amount of training needed to master the procedures were lower in 31 of 35 procedures and were 30% lower overall. Some procedures were less strongly recommended, as might be expected from changes in practice or new regulations (e.g. bone marrow aspiration, gram stain). For 4 of 6 procedures required by both the ABIM and RRC, fewer than 60% of directors said that all of their graduates master them. CONCLUSION: Compared with 1987, similar numbers of IM program directors consider procedural skills' training necessary, but fewer think that their residents are mastering the skills. Program directors' estimates of the amount of training needed are 30% lower. Although residents appear to be getting less training in procedural skills, these skills remain important for internists to learn. Given the implications for patient care, this apparent mismatch between expectations and actual practice requires careful review and intervention by medical educators and policy makers alike. PURPOSE: Managed care curricula are being developed and implemented in graduate health professions education programs throughout the country. The purpose of our study was to measure the attitudes of resident physicians in three departments at a large academic medical center during 1999 and 2000. Specifically, we wished to compare the attitudes of incoming interns and graduating seniors, since differences between these groups could indicate effects of graduate medical education on physicians' attitudes towards managed care. METHODS: A 35-item questionnaire was administered to all first-and third-year residents in Family Medicine, Internal Medicine, and Pediatrics at a large midwest academic medical center through two cross-sectional surveys in 1999 and 2000 (n=320). Topics included the effects of managed care on physician autonomy, costs, and quality of care (7 items); practice guidelines (3 items); capitation (3 items); Medicaid managed care (4 items); factors necessary for success under managed care (7 items); and expected practice payor mix (4 items), geographic setting (6 items), and practice type (1 item). All items were 4-or 5-point Likerttype scales. RESULTS: Over 60% of residents agreed that managed care has restrictive effects on physician autonomy, compensation, referrals, and test ordering. Residents were relatively neutral regarding managed care's effects on quality and costs of care. Residents recognized ( > 60% of residents rated as important) several``non-traditional'' areas as important for success under managed care, including patient outcomes, assessing the needs of populations, and team building. First-and third-year residents' attitudes towards managed care were largely similar, though first-year residents were more positive about managed care's effectiveness in controlling costs (64% vs. 46% agreed, p < .04), and more likely to expect to care for underserved (79% vs. 66%, p < .005) and Medicaid patients (98% vs. 88%, p < .04). CONCLUSION: Resident physicians are concerned about managed care's threat to professional autonomy, are relatively neutral regarding other aspects of managed care such as quality of care or cost control. Differences between first-and third-year residents were consistent with greater idealism among interns than seniors. Residency curricula should directly address issues of autonomy under managed care and provide accurate information on the effects of managed care on quality and costs. Recognition of the importance of several``new'' physician competencies suggests a positive effect of recent changes in medical school and residency curricula. Future research should be directed towards whether differences in idealism between interns and seniors are due to the effects of training, or secular trends in attitudes towards managed care and practice intentions, or both. This questionnaire was sent to all US medical schools in May and the results tabulated at the national CDIM office. Questions asked 1) whether formalized courses on student professionalism existed at the school, 2) whether white coat ceremonies were held, 3) what percentage of third year students had been counseled by the CD concerning professionalism issues, 4) what percentage of students received unsatisfactory clerkship grades because of these deficiencies in professionalism and 5) whether separate forms or mechanisms existed to document and deal specifically with issues of misconduct. RESULTS: 74% (92 of 124) of US medical schools completed the survey. 25% of respondents stated that a formalized course for professionalism existed at their institution. 84% of schools hold a white coat ceremony or similar event. During the past year CDs counseled almost 4% (range 0 ± 15%) of third year students and 1% of all students received an unsatisfactory clerkship grade because of these deficiencies. Only 32% of medical schools reported a separate form or mechanism to document breeches of professionalism. CONCLUSION: The results of this national survey of Internal Medicine CDs confirm the increasing interest in professionalism in medical education. The vast majority of institutions have established white coat ceremonies to foster the values of the profession. CDs are counseling students for unprofessional behavior and for a small minority this has significantly impacted the grade they received. However, formalized courses and effective policies to evaluate and document student misconduct still need broader implementation. This study sought to examine and understand how highly respected physician role models think about role modeling. METHODS: In-depth semi-structured 30-minute interviews were conducted by the primary investigator in the offices of 29 of the 30 most highly regarded role models, as judged by the house officers, at two large teaching hospitals in Baltimore. Interview transcripts were independently coded by two readers and compared for agreement. Content analysis identified several major categories of themes, which were examined and conceptually organized. RESULTS: The analyses revealed that role models have identifiable characteristics. Subcategories under the domain of personal qualities include a commitment to excellence and seeking continual improvement, integrity, a positive outlook, leadership, and being interpersonally skilled. Under the domain of teaching, the subcategories were establishing rapport with learners, being committed to their growth, and developing specific teaching philosophies and approaches. Subjects thought there was some overlap between teaching and role modeling, but role modeling was felt to be more implicit, more intimate, and more encompassing. In the clinical domain, a recurrent theme was that being a strong clinician was necessary but not sufficient for being considered a role model for medical learners. The informants identified barriers to effective role modeling and they included being over-extended, being passive, and being impatient, inflexible and overly opinionated. Although any given role model might embody a range of talents, subjects believed it was valuable for each medical learner to have multiple role models. CONCLUSION: Highly regarded role models shared their opinions about the critical components of role modeling in medicine and the barriers that can make it difficult. The identification of personal qualities and features of teaching and clinical work associated with effective role modeling by physicians advances our understanding in this area. PURPOSE: Due to the dwindling numbers of generalists available to teach interviewing and physical exam skills to small groups of medical students in the first and second year, all clinical departments at the University of Wisconsin Medical School agreed to supply faculty for small group teaching in the Patient, Doctor, and Society Course (PDS.) Much concern remained, however, as to whether specialist and generalists could teach pre-clinical students with equal effectiveness. METHODS: Specialists and generalists were randomly assigned to the third semester of PDS to teach groups of four students. All leaders were provided with the same verbal and written orientation materials. The specialists from nine clinical specialties were assigned to lead 18 groups of students and the generalists from general internal medicine and family medicine were assigned to lead 16 groups. To determine from the students' point of view, whether specialists and generalists teach with equal effectiveness, students were asked to evaluate their small group leaders on a seven point Likert scale on nine items that included: enthusiasm for teaching; fosters discussion; prepared/ knowledgeable; availability; constructive feedback; timely return of work; good role model; treats students with respect; and an overall rating of the group leader. Scores for leaders were compared using a chi square test. In addition, a questionnaire was distributed to the leaders to determine whether specialists and generalists were equally confident in teaching basic history and examination skills. The questionnaire asked leaders to evaluate their confidence in their ability to teach the abdomen, neurology, cardiovascular, pulmonary exams, and in providing feedback to students in the complete history and physical exam skills. Confidence ratings for leaders were compared using a chi square test.