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C Christopher Smith

Publications and source records attributed to C Christopher Smith.

6 recordsLinked to original sources
PubMed2006

Beyond the comfort zone: residents assess their comfort performing inpatient medical procedures.

PURPOSE: Resident physicians learn to perform inpatient bedside procedures in a manner that is neither standardized nor rigorous. As a result, residents may be unskilled and uncomfortable performing procedures. This study characterizes residents' comfort performing medical procedures and identifies factors associated with lack of comfort. SUBJECTS: Study subjects were internal medicine resident physicians who performed one of four medical procedures (central line, lumbar puncture, paracentesis, or thoracentesis) on adult medical inpatients between July 1, 2003, and June 30, 2004. METHODS: This prospective cohort study was conducted at a 556-bed Boston teaching hospital. Resident physicians evaluated their comfort with 9 aspects of 4 medical procedures, recording this information in an electronic log. We also abstracted operator characteristics and patient demographic data. We analyzed residents' comfort with each aspect of the procedure and defined "overall comfort" as comfort with each of the 9 aspects. RESULTS: A majority of resident physicians reported lack of comfort with at least one aspect of the procedure. Residents reported lack of comfort with 37% of unsupervised procedures. They also reported lack of comfort with the prospect of managing complications in 35% of procedures. In the multivariable analysis, overall comfort was associated with the use of a dedicated medical procedure service (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.1-3.4) and inversely associated with postgraduate year 1 status (OR 0.3, CI 0.1-0.5), first time performing the procedure (OR 0.4, CI 0.2-0.8), thoracenteses (OR 0.4, CI 0.2-0.8), and emergent procedures (OR 0.6, CI 0.3-1.0). CONCLUSIONS: Many resident physicians are uncomfortable performing common bedside procedures. Experience and supervision mitigate some, but not all, discomfort.

Adult↗
PubMed2006

Moderate alcohol consumption and safety of lovastatin and warfarin among men: the post-coronary artery bypass graft trial.

PURPOSE: Although moderate drinking has been associated with lower mortality among patients with coronary heart disease, its safety among patients taking common cardiac medications is unknown. SUBJECTS AND METHODS: We studied 1244 men enrolled in the Post-Coronary Artery Bypass Graft (CABG) Trial who had undergone previous coronary bypass surgery. Participants were randomly assigned to lovastatin in low (mean 4 mg) or high (mean 76 mg) doses and to low-dose warfarin (mean international normalized ratio [INR] 1.4, goal INR <2.0) or placebo in a factorial design. Participants underwent routine measurement of alanine aminotransferase (ALT) and INR levels every 6 to 12 weeks for 4 to 5 years. We categorized weekly alcohol intake as abstention (<1 drink), light (1-6 drinks), moderate (7-13 drinks), and heavier (> or =14 drinks). RESULTS: During follow-up, 66% of men taking warfarin had an INR of 2.0 or higher, and 7% of men had an ALT of 80 IU/L or higher. Maximum INR (P = .72) and ALT (P = .51) levels did not differ across categories of alcohol intake. The risks of an INR of 2.0 or higher were 67%, 66%, 68%, and 61% among non-, light, moderate, and heavier drinkers (P = .86), respectively. The corresponding risks of an ALT of 80 IU/L or more were 8%, 10%, 9%, and 6% (P = .70), respectively. CONCLUSION: Moderate drinking did not adversely influence the safety of low-dose warfarin or even high-dose lovastatin among men in this randomized trial, as measured by INR and ALT levels.

Adult↗
PubMed2005

A comprehensive new curriculum to teach and assess resident knowledge and diagnostic evaluation of musculoskeletal complaints.

Musculoskeletal complaints are a common reason for primary care visits; however, many essential physical examination, diagnostic and treatment skills are not adequately taught. The objectives of the study were to create and implement a comprehensive clinical skills teaching model, and to evaluate its effects on residents' knowledge and diagnostic skills. A comparison of cohorts who participated and did not participate in a musculoskeletal curriculum was undertaken. Second and third year medical residents participated in comprehensive curricula to teach and evaluate musculoskeletal skills. Sixty-seven attended the first of three lectures on the painful shoulder; 61 attended all three lectures and completed pre- and post-self assessment forms and tests. Three months later 26 of these residents and 10 controls participated in an OSCE examination. Thirty-nine medical residents attended the first of three lectures on the painful knee; 32 attended all three lectures and completed pre- and post-self assessment forms and tests. Seven of these residents and eight controls participated in an OSCE examination three months later. Both the shoulder and knee curricula were associated with a significant improvement in test scores (p < 0.0001), in self-assessment of physical examination, diagnostic and procedural skills (p < 0.0001), and in OSCE results (p < 0.005). It was concluded that the skills required for the diagnosis and treatment of common musculoskeletal complaints can be effectively taught and assessed using inexpensive and simple methods.

Boston↗
PubMed2004

Creation of an innovative inpatient medical procedure service and a method to evaluate house staff competency.

INTRODUCTION: Training residents in medical procedures is an area of growing interest. Studies demonstrate that internal medicine residents are inadequately trained to perform common medical procedures, and program directors report residents do not master these essential skills. The American Board of Internal Medicine requires substantiation of competence in procedure skills for all internal medicine residents; however, for most procedures, standards of competence do not exist. OBJECTIVE: 1) Create a new and standardized approach to teaching, performing, and evaluating inpatient medical procedures; 2) Determine the number of procedures required until trainees develop competence, by assessing both clinical knowledge and psychomotor skills; 3) Improve patient safety. DESIGN: A Medical Procedure Service (MPS), consisting of select faculty who are experts at common inpatient procedures, was established to supervise residents performing medical procedures. Faculty monitor residents' psychomotor performance, while clinical knowledge is taught through a complementary, comprehensive curriculum. After the completion of each procedure, the trainee and supervising faculty member independently complete online questionnaires. RESULTS: During this pilot program, 246 procedures were supervised, with a pooled major complication rate of 3.7%. 123 thoracenteses were supervised, with a pneumothorax rate of 3.3%; this compares favorably with a pooled analysis of the literature. 87% of surveyed house staff felt the procedure service helped in their education of medical procedures. CONCLUSIONS: The "see one, do one, teach one" model of procedure education is dangerously inadequate. Through the development of a Medical Procedure Service, and an associated procedure curriculum and a mechanism of evaluation, we hope to reduce the rate of complications and errors related to medical procedures and to determine at what point competency is achieved for these procedures.

Boston↗
PubMed2003

Screening for statin-related toxicity: the yield of transaminase and creatine kinase measurements in a primary care setting.

BACKGROUND: Recommendations for monitoring levels of transaminases (alanine aminotransferase and aspartate aminotransferase) and of creatine kinase (CK) in patients taking 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) vary and are not based on data from clinical practice. We performed a study to determine the yield of routine screening of aminotransferase and CK levels among patients taking statins. METHODS: We performed a retrospective review of a primary care practice's computerized medical record. A computerized search identified all patients with a statin on their medication list and gave their alanine aminotransferase, aspartate aminotransferase, and CK values for 1998. We reviewed the records of all patients for whom these values were significantly or moderately abnormal to determine the values' relationship to statin therapy and outcomes. RESULTS: During the year of the study, 1014 (85%) of the 1194 patients who had a statin on their medication list had at least 1 monitoring test performed. Of these 1014 patients, 10 (1.0%) had a significant elevation and 5 (0.5%) a moderate elevation of transaminase levels, but none of these abnormalities appeared to be related to statin use. Moreover, 6 (0.9%) patients had at least 1 significantly abnormal CK value but it did not appear to be attributable to a statin; and of the 14 (2.1%) patients who had a moderate CK elevation, it was potentially due to a statin in only 2. There were no documented adverse sequelae associated with these abnormal results. CONCLUSIONS: In this study of statin use in a primary care practice, routine monitoring revealed no cases of significantly or moderately abnormal transaminase values attributable to statins. No significantly abnormal and only 2 moderately abnormal CK values were potentially attributable to statin use. This study questions the usefulness of routine measurement of transaminase and CK levels in all patients taking statins.

Alanine Transaminase↗