General practice and the care of children with HIV infection: 6 month prospective interview study.
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OBJECTIVES: To describe the use of primary care services by children infected with HIV and to explore the attitudes of their parents to the role of general practitioners in their children's care. DESIGN: A 6 month prospective study. Quantitative analysis of "contact diaries" kept by parents; qualitative analysis of face to face interviews with parents. PARTICIPANTS: Parents of children receiving care at a regional referral centre in London. RESULTS: Twenty four families (80% response rate) were recruited to the study. In 19 families the mother was black African. Half the children had been diagnosed with symptomatic HIV infection, half with AIDS. All the children were registered with a general practitioner who knew of the child's HIV infection. In five families there had initially been tensions in their relationship with their general practitioner but by the time of the study all but one family had established at least an "acceptable" relationship. Children with symptomatic HIV infection saw their general practitioner a mean of 7.5 times per patient year; for children with AIDS the figure was 5.8. Parents regarded the paediatric HIV team at the hospital as their primary source of medical care. Three factors constrained their use of general practice: their own anxieties about distinguishing "normal" symptoms from those related to HIV infection; their view that their general practitioner did not feel competent to treat HIV infected children; and their concerns about maintaining confidentiality in the surgery. CONCLUSIONS: Parents remain oriented towards the paediatric HIV team as their primary source of medical care and use general practice largely for routine prescriptions for their children. Any further development of the general practitioner's role will need to build on existing relationships with specialist providers and take account of parents' concerns. (+info)
Practice guidelines and late-life depression assessment in long-term care.
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To determine how well nursing home physicians believe they can detect and treat depression, we conducted a national survey, eliciting a 63% response rate. More than 75% of respondents believed they detected and treated depression well. Excellent depression training (vs "good," "fair," "poor/none") was associated with better self-reported recognition (odds ratio [OR] 14.25; 95% confidence interval [CI] 1.81, 111.93) and treatment skills (OR 6.72; 95% CI 1. 91, 23.64). Screening tool use predicted greater self-assessed detection (OR 1.89; 95% CI 0.92, 3.87) and treatment competency (OR 2.00; 95% CI 1.14, 3.50). Practice guideline awareness was associated with greater self-reported treatment competency (OR 2.47; 95% CI 1.56, 3.91). (+info)
Should UK emergency physicians undertake diagnostic ultrasound examinations?
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From the published evidence there is no doubt that emergency physicians in America can undertake focused ultrasound examinations and that, by extrapolation, this would also be the case for UK emergency physicians. If this skill is to become part of the diagnostic armamentarium of the emergency physician, however, it needs to be demonstrated to be cost effective compared with the alternatives already available to the hospital. Trials to test for this benefit should adopt a hospital and not an emergency department perspective if the results are to influence health policy and specialty training. (+info)
Consistency, inter-rater reliability, and validity of 441 consecutive mock oral examinations in anesthesiology: implications for use as a tool for assessment of residents.
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BACKGROUND: Oral practice examinations (OPEs) are used extensively in many anesthesiology programs for various reasons, including assessment of clinical judgment. Yet oral examinations have been criticized for their subjectivity. The authors studied the reliability, consistency, and validity of their OPE program to determine if it was a useful assessment tool. METHODS: From 1989 through 1993, we prospectively studied 441 OPEs given to 190 residents. The examination format closely approximated that used by the American Board of Anesthesiology. Pass-fail grade and an overall numerical score were the OPE results of interest. Internal consistency and inter-rater reliability were determined using agreement measures. To assess their validity in describing competence, OPE results were correlated with in-training examination results and faculty evaluations. Furthermore, we analyzed the relationship of OPE with implicit indicators of resident preparation such as length of training. RESULTS: The internal consistency coefficient for the overall numerical score was 0.82, indicating good correlation among component scores. The interexaminer agreement was 0.68, indicating moderate or good agreement beyond that expected by chance. The actual agreement among examiners on pass-fail was 84%. Correlation of overall numerical score with in-training examination scores and faculty evaluations was moderate (r = 0.47 and 0.41, respectively; P < 0.01). OPE results were significantly (P < 0.01) associated with training duration, previous OPE experience, trainee preparedness, and trainee anxiety. CONCLUSION: Our results show the substantial internal consistency and reliability of OPE results at a single institution. The positive correlation of OPE scores with in-training examination scores, faculty evaluations, and other indicators of preparation suggest that OPEs are a reasonably valid tool for assessment of resident performance. (+info)
Counselling on breastfeeding: assessing knowledge and skills.
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Reported are the results of a randomized controlled trial to assess the effectiveness of the WHO/UNICEF 40-hour course "Breastfeeding counselling: a training course". The course was conducted in a maternity hospital which provides care to a low-income population in a metropolitan area in Sao Paulo, Brazil. Health workers from 60 health units were randomly assigned to be either participants (20) or controls (40), and their breastfeeding knowledge and skills were assessed before and immediately after the course, as well as 3 months later. Immediately after the course the participants' knowledge of breastfeeding had increased significantly compared to controls. Both their clinical and counselling skills also improved significantly. When assessed 3 months later, the scores remained high with only a small decrease. The implementation of the course was also evaluated. The methods used were participatory observation, key interviews and focus group discussion. In the 33 sessions of the course, the average score was 8.43 out of 10. Scores were highest for content and methodology of the theory sessions, and lowest for "use of time", "clinical management of lactation", and "discussion of clinical practice". "Breastfeeding counselling: a training course" therefore effectively increases health workers' knowledge and their clinical and counselling skills for the support of breastfeeding. The course can be conducted adequately using the material and methodology proposed, but could be more satisfactory if the time allocated to exercises and clinical practice sessions were increased. (+info)
Cuffed oropharyngeal airway (COPA) as an adjunct to fibreoptic tracheal intubation.
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The cuffed oropharyngeal airway (COPA) was evaluated as an adjunct to oral and nasal fibreoptic tracheal intubation in 40 adult patients during general anaesthesia. Time from start to completion of intubation decreased rapidly with experience (median time 138 s). We conclude that the COPA may be a useful adjunct to fibreoptic tracheal intubation, allowing control and support of the airway during the procedure, using various anaesthetic techniques, in an acceptable amount of time. The ability to perform fibreoptic tracheal intubation while effectively supporting the airway using the COPA may be advantageous in managing the difficult airway and in trainee education. (+info)
Criteria, performance and diagnostic problems in diagnosing acute otitis media.
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OBJECTIVE: We aimed to assess criteria when diagnosing acute otitis media and related performance in general practice in Denmark. Furthermore, we aimed to identify the scale of and the reasons for diagnostic uncertainty. METHODS: We conducted: (i) a survey among GPs assessing criteria; and (ii) prospective registration of acute otitis-media-related consultations performed by GPs assessing performance. The survey was sent to all 790 GPs in Funen, North Jutland and Ringkobing counties, Denmark. A total of 568 (72%) of all GPs in the three counties responded. A total of 368 children with acute otitis media or previous acute otitis media visiting 151 GPs were studied. The main outcome measures were: (i) criteria for symptoms and findings suggesting the diagnosis acute otitis media, criteria for use of equipment and reasons for diagnostic uncertainty; and (ii) prevalence of symptoms and findings in diagnosed cases, equipment used and multivariate analysis of factors predicting diagnostic certainty. RESULTS: The symptoms of earache, fever, reduced hearing, findings of bulging eardrum, red eardrum and purulent otorrhea were important criteria used during both diagnosis of acute otitis media by the GPs and assessment of performance. In the prospective study, diagnostic certainty of acute otitis media was 67% (95% CI 58-76) in children under 2 years and 75% (95% CI 69-81) in older children. Diagnostic certainty was statistically related (P < 0.05) to a good view of the eardrum and the findings of purulent otorrhea or a bulging eardrum. Logistic regression revealed that the two most important factors predicting diagnostic certainty were a satisfactory view of the eardrum, with an odds ratio (OR) 11.0 (95% CI 4.1-29.5), and purulent otorrhea OR 10.1 (95% CI 3.1-32.9). Main reasons for diagnostic uncertainty given by GPs were differential diagnostic doubts, insufficient view of the eardrum and lack of knowledge. CONCLUSION: Danish GPs' criteria for the diagnosis of acute otitis media were stricter than criteria used internationally. The discrepancy between diagnostic criteria and performance was small. Diagnostic accuracy and certainty could be substantially improved by cleaning the ear canal when needed and by widespread use of pneumatic otoscopy. (+info)
The importance of intuition in the occupational medicine clinical consultation.
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Clinical consultation involves unspoken elements which flow between doctor and patient. They are vital ingredients of successful patient management but are not easily measured, objective or evidence-based. These elements include empathy and intuition for what the patient is experiencing and trying to express, or indeed suppressing. Time is needed to explore the instinctive feeling for what is important, particularly in present day society which increasingly recognizes the worth of psychosocial factors. This time should be available in the occupational health consultation. In this paper the importance of intuition and its essential value in the clinical interview are traced through history. Differences between intuition and empathy are explored and the use of intuition as a clinical tool is examined. (+info)