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Biomedical subjects

Alan Schwartz

Publications and source records attributed to Alan Schwartz.

15 recordsLinked to original sources
PubMed2006

A web-based library consult service for evidence-based medicine: Technical development.

BACKGROUND: Incorporating evidence based medicine (EBM) into clinical practice requires clinicians to learn to efficiently gain access to clinical evidence and effectively appraise its validity. Even using current electronic systems, selecting literature-based data to solve a single patient-related problem can require more time than practicing physicians or residents can spare. Clinical librarians, as informationists, are uniquely suited to assist physicians in this endeavor. RESULTS: To improve support for evidence-based practice, we have developed a web-based EBM library consult service application (LCS). Librarians use the LCS system to provide full text evidence-based literature with critical appraisal in response to a clinical question asked by a remote physician. LCS uses an entirely Free/Open Source Software platform and will be released under a Free Software license. In the first year of the LCS project, the software was successfully developed and a reference implementation put into active use. Two years of evaluation of the clinical, educational, and attitudinal impact on physician-users and librarian staff are underway, and expected to lead to refinement and wide dissemination of the system. CONCLUSION: A web-based EBM library consult model may provide a useful way for informationists to assist clinicians, and is feasible to implement.

Chicago↗
PubMed2006

A chairside aid for shared decision making in dentistry: a randomized controlled trial.

The concept of shared decision making (SDM) is an important emerging trend in clinical medicine but has received little or no attention in the dental literature. Decision aids can play a useful role in SDM by helping patients and clinicians choose among reasonable alternative treatment options. The purpose of this study was to develop and test an Endodontic Decision Board (EndoDB) for chairside use to help clarify treatment alternatives, benefits, risks, prognosis, and costs when root canal therapy or extraction of a tooth was indicated. The hypothesis was that the use of the EndoDB would lead to improved patient knowledge, greater satisfaction with the decision-making process, and no difference in anxiety when compared to the standard discussion and informed consent process (usual care). The EndoDB was tested in a randomized controlled trial in a postgraduate endodontics clinic. After treatment discussion, a brief questionnaire was completed by the patient to measure knowledge, satisfaction, and anxiety. Patients in the EndoDB group (n=32) demonstrated a small, but statistically significant, increase in knowledge (t-test; difference=+0.37; p=0.03) compared to the usual care group (n=35). There was no difference between groups in the measures of satisfaction or anxiety (Mann-Whitney U-test; p>0.05). Decision aids may emerge as a useful tool to facilitate SDM and evidence-based clinical practice.

Analysis of Variance↗
PubMed2005

Gastric electrical stimulation: an alternative surgical therapy for patients with gastroparesis.

HYPOTHESIS: Gastric electrical stimulation is an alternative to gastrectomy in patients with refractory gastroparesis. DESIGN: Retrospective case series with a median follow-up of 20 months. SETTINGS: A tertiary care university hospital and a university-affiliated community hospital. PATIENTS: Twenty-nine patients (22 women, 7 men; median age, 39 years; age range, 20-87 years) with debilitating gastroparesis who were referred for gastrectomy from December 10, 2001, through October 1, 2004. Twenty-four patients had type 1 diabetic gastroparesis and 5 patients had idiopathic gastroparesis. INTERVENTIONS: Placement of a gastric stimulator device laparoscopically in 24 patients and by laparotomy in 5 patients. MAIN OUTCOME MEASURES: Morbidity and mortality of the procedure, symptom control, hospital readmissions, need for supplemental nutritional support, body mass index (calculated as weight in kilograms divided by the square of height in meters), and gastric emptying. RESULTS: Follow-up results were available in 27 patients. There was no 30-day mortality or morbidity in 4 patients. The median hospital stay was 3 days. All of the patients tolerated an oral diet at discharge. Symptom control was excellent to good in 19 patients. Nutritional support was discontinued in the 19 patients who were dependent on supplemental feeding before the procedure (P<.001). The median body mass index improved significantly (22.9 preoperatively vs 25.1 postoperatively; P = .006). The median gastric emptying rate (percentage per minute) was measured in 15 of the 27 patients postoperatively and showed significant improvement (0.17% per minute preoperatively vs 0.38% per minute postoperatively; P<.001). Additional procedures were required in 4 patients (owing to poor outcome in 3 patients). CONCLUSIONS: Gastric electrical stimulation ameliorated symptoms, returned patients to normal oral nutritional intake, increased body mass index, improved gastric emptying rates, and is an alternative to gastrectomy in patients with end-stage gastric disease.

Adult↗
PubMed2005

A decision making approach to assessing critical appraisal skills.

Critical appraisal is an important skill for practicing evidence-based medicine. Most assessments of critical appraisal focus either on knowledge about research design or evaluate a written critique of an article. This paper presents a Bayesian framework for assessing critical appraisal through measuring how clinical decisions and judgments change with the introduction of new research evidence. In a skilled clinician-appraiser, new evidence is predicted to cause the clinician to revise beliefs in the appropriateness of a decision, in proportion to both the strength of the findings and the methodological soundness of the research which produced the findings. The framework is illustrated by two studies using different items, respondents, and designs.

Bayes Theorem↗
PubMed2004

A survey of individual preference for colorectal cancer screening technique.

BACKGROUND: Due to the low participation in colorectal cancer screening, public preference for colorectal cancer screening modality was determined. METHODS: A cross-sectional survey was performed of healthy ambulatory adults in a pediatrics primary care office and neighboring church. Overall preference was ranked for each of four colorectal cancer screening modalities: Faecal Occult Blood, Fiberoptic Sigmoidoscopy, Barium Enema and Colonoscopy. Four additional domains of preference also were ranked: suspected discomfort, embarrassment, inconvenience and danger of each exam. RESULTS: 80 surveys were analyzed, 57 of which were received from participants who had experienced none of the screening tests. Fecal Occult Blood Testing is significantly preferred over each other screening modality in overall preference and every domain of preference, among all subjects and those who had experienced none of the tests. CONCLUSIONS: Efforts to increase public participation in colorectal cancer screening may be more effective if undertaken in the context of public perceptions of screening choices.

Adolescent↗
PubMed2004

Phenotypic variation in cardiovascular responses to acute hypoxic and hypercapnic exposure in mice.

The impact of genetic variation on cardiovascular responses to hypoxia and hypercapnia is not well understood. Therefore, we determined the acute changes in systemic arterial blood pressure (P(SA)) and heart rate (HR) in seven strains of commonly used inbred mice exposed to acute periods of hypoxia (10% O(2)), hypercapnia (5% CO(2)), and hypoxia/hypercapnia (10% O(2) + 5% CO(2)) during wakefulness. Hypercapnia induced an essentially homogeneous response across strains, with P(SA) maintained at or slightly above baseline and with HR exhibiting a typical baroreceptor-mediated bradycardia. In contrast, exposure to hypoxia elicited a marked heterogeneity in cardiovascular responses between strains. The change in P(SA) during hypoxia ranged from maintenance of normotension in the FVB/J strain to profound hypotension of approximately 30 mmHg in the DBA/2J strain. HR responses were highly variable between strains during hypoxia, and with the exception of the DBA/2J strain that exhibited significant bradyarrhythmias and consequent hypotension, the HR responses were unrelated to changes in P(SA). The P(SA) response to combined hypoxia/hypercapnia represented a balance of the hypertension of hypercapnia and the hypotension of hypoxia in six of the seven strains. In the FVB/J strain, combined hypoxia/hypercapnia produced a hypertensive response that was greater than that of hypercapnia alone. These results suggest that genetic background affects the cardiovascular response to hypoxia, but not hypercapnia.

Analysis of Variance↗
PubMed2004

Study habits of surgery residents and performance on American Board of Surgery In-Training examinations.

BACKGROUND: The purpose of this study was to evaluate the study habits (SHs) of surgery residents preparing for the annual American Board of Surgery In-Training Examination (ABSITE). METHODS: A validated instrument developed to assess SHs in college students, the Survey of Study Habits and Attitudes (SSHA), was modified slightly for use with residents. The modified SSHA contains 2 subscale scores, work methods and delay avoidance, and a combined overall study habit score. A total of 59 residents from 2 academic general surgical residency programs were administered the modified SSHA. The SSHA scores were correlated to performance on the in-training examination. RESULTS: There was a small but significant correlation between scores on the modified SSHA instrument and performance on the ABSITE overall (r = 0.29; P < .05; r2 = 0.0841). Linear-regression analysis showed that the clinical component and overall performance on the ABSITE were significantly predicted by the total SH scores. Overall total ABSITE percent correct scores were significantly predicted by residency levels of training and the overall SSHA scales (delay avoidance and work methods). Together they predicted 63% of the total variance in the overall performance scores. Residency level was the strongest predictor. SH performance accounted for 5.9% of the total variance beyond that contributed by residency level of training. CONCLUSIONS: The correlations of surgical resident ABSITE performance with SSHA scores were on the same order of magnitude as those of college students and academic performance with the original SSHA. Although SH in this study accounted for a measurable yet small contribution to ABSITE performance, this contribution was not enough to consider using the SSHA instrument in its current modified form as a diagnostic and counseling tool. Published instruments not specifically designed for residents may not be tailored enough to measure residents' unique SH.

Data Collection↗
PubMed2003

Medical students' application of published evidence: randomised trial.

OBJECTIVES: To determine how medical students apply research evidence that varies in validity of methods and importance of results to a clinical decision. DESIGN: Students examined a standardised patient with a whiplash injury, decided whether to order a cervical spine radiograph, and rated their confidence in their decision. They then read one of four randomly assigned variants of a structured abstract from a study of a decision rule that argued against such a procedure in this patient. Variants factorially combined two levels of validity of methods (prospective cohort or chart review) with two levels of importance of results (high sensitivity or high specificity rule). After reading the abstract, students repeated their choice and rated their confidence. SETTING: Academic medical centre in the United States. PARTICIPANTS: 164 graduating medical students. MAIN OUTCOME MEASURES: Proportion of students in each group whose beliefs shifted or stayed the same. RESULTS: When abstracts were of low importance students were more likely to shift their beliefs in favour of radiography, which was not supported by the evidence (odds ratio 3.42, 95% confidence interval 1.10 to 10.66). Neither methodological validity nor the interaction between validity and importance influenced decision shift. Few students acquired all necessary clinical data from the patient. CONCLUSIONS: Although the students could apply concepts of diagnostic testing, greater focus is needed on appraisal of validity and application of evidence to a particular patient.

Clinical Competence↗
PubMed2003

SCI health care provider attitudes about pressure ulcer management.

BACKGROUND/OBJECTIVE: To evaluate the variability in clinical decisions about pressure ulcer management for persons with spinal cord injury (SCI) and expand understanding of the various factors influencing variability. METHODS: Eighty-one SCI physicians and nurses completed a survey on pressure ulcer management. Patient scenarios were used to assess the effect of patient characteristics on provider decisions regarding inpatient treatment of severe pressure ulcers, surgery vs medical management, and amount of healing before discharge. RESULTS: The availability of social support to facilitate bed rest appears to be a more important factor in deciding whether the patient is managed at home vs in the hospital than is the level of injury. Medical condition does not appear to influence surgical vs medical management of severe pressure ulcers. For patients with poor social support, more healing was required before discharge, regardless of their medical condition. Providers were queried about other issues that influence management, including inpatient resource availability, patient preferences, the availability and quality of local home care, and the availability and use of formal care protocols. Respondents were virtually unanimous in their agreement that patients who are compliant with prevention measures can avoid ulcer development. CONCLUSION: Like many health care providers, those who provide care to people with SCI are struggling to provide quality care to improve their patients' lives in the absence of good evidence to guide their treatment decisions. The results of the present study indicate that in situations in which there is no strong empirical evidence, variation in care provided is extensive.

Attitude of Health Personnel↗
PubMed2002

Two perspectives on the indicators of quality in psychiatry residencies: program directors' and residents'.

PURPOSE: To determine whether psychiatry program directors and residents agree on the characteristics most important in determining the quality of a residency program. METHOD: The authors carried out factor analyses of the results of two national surveys that asked participants to rate the importance of 41 items in determining the quality of residency programs: a 1997 survey completed by 180 psychiatry residents and a 1998 survey completed by 234 psychiatry program directors and rotation heads. RESULTS: Residents' factors determining program quality were the interpersonal culture in the program, the curriculum, academic resources and opportunities, clinical resources and opportunities, and outcomes. Program directors' factors were program administration, curriculum and clinical resources, the quality of the institution, the supportiveness of the program, and individual preferences. CONCLUSIONS: Program directors and residents focus on different indicators of the quality of residency programs, differences that can be conceptualized as those between the "producer" and the "consumer" of the program. Four domains appear to underlie the results of the resident and faculty factor analyses: the context, content, culture, and consequences of the program. Multidimensional evaluations by multiple stakeholders may be the most appropriate way to evaluate the quality of residency programs. These results also strongly suggest that the interpersonal culture of a program should be assessed as part of its evaluation process.

Attitude of Health Personnel↗
PubMedDate not supplied

Work-family balance and academic advancement in medical schools.

OBJECTIVE: This study examines various options that a faculty member might exercise to achieve work-family balance in academic medicine and their consequences for academic advancement. METHOD: Three data sets were analyzed: an anonymous web-administered survey of part-time tenure track-eligible University of Illinois College of Medicine (UI-COM) faculty members conducted in 2003; exogenous data regarding the entire UI-COM faculty; and tenure rollback ("stop-the-clock") usage by all tenure track-eligible UI-COM faculty from 1994 to 2003. RESULTS: The data reveal a gender split in career-family balance priorities that affect academic advancement among part-time faculty. Women select part-time status for child care; men choose part-time to moonlight. Similarly, among all faculty members seeking tenure rollbacks, women request rollback for child care; men request rollback for other reasons. Among all faculty members, full-time men were more likely to be on the tenure track than any other group. Needs identified by the part-time faculty survey include improved mentoring in track selection, heightened awareness of options, such as tenure rollback, and provision of equitable benefits and opportunities. CONCLUSIONS: Policy changes, such as a prorated tenure track, are needed to support a family-friendly culture with flexibility throughout the career lifespan for both men and women medical faculty.

Academic Medical Centers↗
PubMedDate not supplied

Patient-physician fit: an exploratory study of a multidimensional instrument.

BACKGROUND: Patients face difficulty selecting physicians because they have little knowledge of how physicians' behaviors fit with their own preferences. OBJECTIVE: To develop scales of patient and physician behavior preferences and determine whether patient-physician fit is associated with patient satisfaction. DESIGN: Two cross-sectional surveys of patients and providers. SETTING: Ambulatory clinics at a university medical center. Participants. Eight general internists, 14 family physicians, and 193 patients. MEASUREMENTS: Two instruments were developed to measure 6 preferences for physician behaviors: 1) considering nonmedical aspects of the patient's life, 2) familiarity with herbal medicine, 3) physician decision making, 4) providing information, 5) considering the patient's religion, and 6) treating what the patient perceives as his or her problem. Patients reported how they would prefer physicians to behave, and physicians reported how they preferred to behave. Patients also rated satisfaction with their physician. RESULTS: Post hoc tests found that as a group, patients scored higher than physicians in preference for the physician to provide information and lower in preference for considering nonmedical aspects of the patient's life and religious beliefs. As hypothesized, preference differences accounted for significant variance in satisfaction in overall tests (19% in the family medicine patients and 25% in internal medicine patients). Greater satisfaction was associated with fit between patient and physician preferences for physician decision making (in the internal medicine patients) and with fit in providing information and consideration of religion (in family medicine patients) CONCLUSIONS: Patients often prefer behaviors other than how their physicians prefer to behave. Preference fit is associated with enhanced patient satisfaction. Physicians should attend to whether patients want religion and other nonmedical aspects of their lives considered. Health plans may wish to provide tools to help patients choose physicians by fit.

Academic Medical Centers↗