Chaperone use by residents during pelvic, breast, testicular, and rectal exams.
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We designed a questionnaire survey to study internal medicine residents' plans to use a chaperone during the pelvic, breast, rectal, and testicular examinations. We found chaperone use by male and female residents differed markedly, and neither group planned to use chaperones universally. When examining female patients, male residents overall were very likely to use a chaperone during a pelvic exam, but less likely for the breast exam and rectal exam. For the female resident, there was a significantly lower likelihood of using chaperones during the pelvic, breast, or rectal exams. There was a much lower rate of chaperone use during the sensitive portions of the male physical examination compared with the female examination, with somewhat higher use by female residents. We concluded that male and female residents differ significantly in their patterns of chaperone use. It would be valuable to develop guidelines for chaperone use to help residents understand the issues involved in the choices, and to protect the residents from the possible medico-legal consequences of forgoing chaperones. (+info)
Liability and validity of the Appropriateness Evaluation Protocol in Turkey.
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OBJECTIVE: To assess the inter-rater reliability between nurses and the convergent validity of the Appropriateness Evaluation Protocol (AEP) in the Turkish context. METHODS: Two nurses applied the original AEP concurrently to a random subsample of 335 patient-days in internal medicine, general surgery, and gynaecology departments at a university hospital and a government teaching hospital, as a part of a larger study. Inter-rater reliability was tested by calculating overall agreement and specific agreements between nurse reviewers' AEP assessments. Validity was tested by comparing the assessments of the nurses based on the AEP with the implicit judgements of five expert physicians on a random subsample of 818 patient-days. Sensitivity, specificity, positive and negative predictive values of the AEP were calculated. Reliability and validity were also evaluated by the K statistic. RESULTS: In the reliability test, there was a high level of agreement between the two independent raters applying the AEP in the three departments studied: overall agreement = 90.7-97.6%; specific inappropriate agreement = 69.1-92.3%; specific appropriate agreement = 88.3-96.6%. In validity testing, the AEP had a sensitivity of 0.83-0.97, specificity of 0.62-0.80, and positive and negative predictive values of 0.84-0.88 and 0.73-0.95 respectively. Kappa coefficients in internal medicine and gynaecology indicated almost perfect agreement in reliability testing and moderate agreement in validity testing. In general surgery, the K coefficients showed substantial agreement in both tests. CONCLUSION: These results indicate that the AEP is a reliable and valid instrument to assess appropriateness of patient-days in Turkey. (+info)
Cause-specific mortality risks of anesthesiologists.
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BACKGROUND: The health-related effects of the operating room environment are unclear. The authors compared mortality risks of anesthesiologists to those of internal medicine physicians between 1979 and 1995. METHODS: The Physician Master File database, a listing of all US physicians, was used to identify anesthesiologists and general internists. The cohort of internists (n = 40,211) was a stratified random sample of all internists, frequency-matched to the cohort of anesthesiologists (n = 40,242) by gender, decade of birth, and US citizenship. The National Death Index was used to confirm death status and to determine specific causes of death. Mortality risks, adjusted for age, gender, and race, were compared using the Cox proportional hazards regression model. RESULTS: The standardized mortality ratios for all physicians were well below 1.0, except for suicide. The all-cause mortality ratios, and the risks of death caused by cancer and heart disease, did not differ between anesthesiologists and internists. Anesthesiologists had an increased risk of death from suicide (rate ratio [RR] = 1.45, 95% confidence interval [CI] = 1.07 - 1.97), drug-related death (RR = 2.79, 95% CI = 1.87 - 4.15), death from other external causes (RR = 1.53, 95% CI = 1.05 - 2.22), and death from cerebrovascular disease (RR = 1.39, 95% CI = 1.08 - 1.79). Male anesthesiologists had an increased risk of death from HIV (RR = 1.82, 95% CI = 1.09 - 3.02) and viral hepatitis (RR = 7.98, 95% CI = 1.0 - 63.84). Although the risk to anesthesiologists of drug-related deaths was highest in the first 5 years after medical school graduation, it remained increased over that of internists throughout the career. CONCLUSIONS: Substance abuse and suicide represent significant occupational hazards for anesthesiologists. New methods to combat substance abuse among anesthesiologists should be developed. (+info)
Factors influencing the selection of general internal medicine fellowship programs: a national survey.
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Although criteria are available to guide the selection of general internal medicine (GIM) fellowship programs, the factors actually used in this process are unclear. Using a survey of current GIM fellows, we determined that most received information from their residency advisors, and many viewed them as the most important source of fellowship information. Program location was the top selection factor for fellows, followed by research opportunities, availability of a mentor, and the reputation of the program. This information may be useful to both fellowship candidates as an additional selection guide and to program directors seeking to best structure and market their fellowships. (+info)
Primary care physicians' knowledge and attitudes towards genetic testing for breast-ovarian cancer predisposition.
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BACKGROUND: Primary health care providers are expected to be directly involved in the genetic testing for cancer susceptibility. This study assessed physicians' knowledge, attitude and perception of their role towards testing for hereditary breast ovarian cancer. DESIGN: A mail-in survey was sent to all general practitioners, internists, obstetrician-gynecologists and oncologists in private practice in Geneva county, Switzerland. Questions included socio-demographic variables, knowledge about hereditary breast ovarian cancer, attitude towards testing and assessment of their role in the pre- and post-test procedure. RESULTS: Two hundred fifty-nine (65%) of four hundred questionnaires were returned of which two hundred forty-three (61%) were analysed. Response rates were similar between specialties; women answered more frequently. The majority of the respondents (87%) approved of genetic susceptibility testing. The most common objection to testing was the absence of approved strategies for the prevention and detection of early breast cancer. Most physicians felt they had an active part to play in the pre-test procedure, the disclosure of results, and especially the consultants' long-term care and support (99%). Physicians correctly answered a third (32%) of the knowledge questions. The abstention rate for individual items ranged from 13% to 60%. Scores varied by specialty. Oncologists were more knowledgeable than gynecologists, internists and general practitioners. CONCLUSIONS: The majority of the primary care physicians in this study have a favourable attitude and are ready to play a prominent role in genetic counseling and testing for breast ovarian cancer predisposition. Defective knowledge scores, however, underline the need for targeted educational programs. (+info)
Use of an open-ended question to supplement a patient satisfaction questionnaire in a medical residents' clinic.
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OBJECTIVES: To determine (1) the proportion of responses to an open-ended question related to patient satisfaction that could be categorized into 1 or more of 9 previously developed domains of out-patient care and (2) whether any other important aspects of care could be identified by adding the open-ended question to a satisfaction questionnaire. STUDY DESIGN: A 3-month observational study was done at the internal medicine clinic of an urban teaching hospital. PATIENTS AND METHODS: As part of a patient satisfaction study, 511 visitors were asked after their visit, "What are the 1 or 2 things that are most important to you when you see a doctor?" The responses were categorized independently by 2 raters into 1 or more of the 9 domains. When these 2 raters disagreed, the responses were read to a third rater. When either all 3 raters disagreed, or at least 1 rater thought a new domain was mentioned, those responses were categorized by consensus. Interobserver reliability between raters 1 and 2 was calculated by using Cohen's kappa statistic. RESULTS: The 355 responses were categorized as follows: 303 (85.4%) identified one or more domains that were part of the previously developed taxonomy, 9 (2.5%) identified a new domain, 11 (3.1%) identified both old and new domains, and 32 (9.0%) could not be categorized. Cohen's kappa was 0.57 (P < .001). Cultural sensitivity and physician honesty were the additional domains identified, by 1.1% and 4.5% of respondents, respectively. CONCLUSIONS: The previously developed taxonomy of domains can be used in this setting to categorize the large majority of open-ended responses. Such responses can identify important aspects of care that were either previously unidentified or were already identified but given low ratings. This information then can help improve quality of care. (+info)
Update in internal medicine.
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More than 500,000 new medical articles are published every year and available time to keep updated is scarcer every day. Nowadays, the task of selecting useful, consistent, and relevant information for clinicians is a priority in many major medical journals. This review has the aim of gathering the results of the most important findings in clinical medicine in the last few years. It is focused on results from randomized clinical trials and well-designed observational research. Findings were included preferentially if they showed solid results, and we avoided as much as possible including only preliminary data, or results that included only non-clinical outcomes. Some of the most relevant findings reported here include the significant benefit of statins in patients with coronary artery disease even with mean cholesterol level. It also provides a substantial review of the most significant trials assessing the effectiveness of IIb/IIIa receptor blockers. In gastroenterology many advances have been made in the H. pylori eradication, and the finding that the cure of H. pylori infection may be followed by gastroesophageal reflux disease. Some new antivirals have shown encouraging results in patients with chronic hepatitis. In the infectious disease arena, the late breaking trials in anti-retroviral disease are discussed, as well as the new trends regarding antibiotic resistance. This review approaches also the role of leukotriene modifiers in the treatment of asthma and discusses the benefit of using methylprednisolone in patients with adult respiratory distress syndrome, among many other advances in internal medicine. (+info)
Design and analysis of a Web-based guideline tutorial system that emphasizes clinical trial evidence.
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OBJECTIVE: To describe a Web-based guideline tutorial system and evaluate its features. METHODS: A Web-based tutorial system called SAGE (Self-study Acceleration with Graphic Evidence) was constructed to teach knowledge important for care after myocardial infarction. SAGE features a pretest, followed by an overview that coordinates studying resources for a set of learning objectives. Resources include pretest answers, guideline passages, and graphical presentations of clinical trial results. Data on the use of SAGE was obtained from 79 residents participating in a larger trial. Linear regression was used to correlate the amount learned with resource-use, and resource-use with user characteristics. RESULTS: On average, users accessed less than half of the guideline passages and very little of the graphic evidence. Greater use of guideline passages was correlated with greater immediate learning, but use of graphic evidence was not. CONCLUSIONS: Further research is needed to motivate more thorough self-study and to integrate clinical trial evidence with guideline-based education. (+info)