Use of Internet technology by obstetricians and family physicians.
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Family Practice↗
Biomedical subjects
J W Ely
Publications and source records attributed to J W Ely.
Identifying left lower lobe pneumonia at chest radiography: performance of family practice residents before and after a didactic session.
RATIONALE AND OBJECTIVES: The authors sought to determine whether the lateral chest radiograph is helpful in identifying left lower lobe pneumonia among inexperienced readers. MATERIALS AND METHODS: The authors selected all patients who presented to a family practice training program with radiologic and clinical evidence of left lower lobe pneumonia (n = 65). They then selected an equal number of patients in whom chest radiographs were taken to "rule out pneumonia" and were found to be normal. Eight 1st-year family practice residents were asked to read the radiographs before and after a didactic session that emphasized lateral chest radiograph interpretation. The radiographs were presented under two viewing conditions: posteroanterior (PA) only versus PA and lateral. Receiver operating characteristic (ROC) curve methods were used to compare the effect of both the didactic session and the viewing condition on diagnostic accuracy. RESULTS: There were no significant differences in performance before and after the didactic session and no differences between the two viewing conditions. After including only abnormal radiographs that demonstrated the "spine sign" (an apparent increased opacification of the lower vertebral bodies on the lateral view), the residents performed better when presented with both PA and lateral radiographs than when presented with the PA radiograph only (area under ROC curve, .8158 vs .7418, respectively; P = 0.24). CONCLUSION: In patients with left lower lobe pneumonia whose radiographs demonstrated the spine sign, diagnostic accuracy improved when the lateral chest radiograph was viewed.
Case-Control Studies↗
The effect of physician characteristics on compliance with adult preventive care guidelines.
BACKGROUND AND OBJECTIVES: This study identified physician characteristics and attitudes related to self-reported compliance with adult prevention guidelines. METHODS: A questionnaire was mailed to family practice and internal medicine residents and faculty at the University of Iowa (n = 209). The questionnaire's 78 items fell into seven categories, including physician demographics, history-taking practices, counseling practices, self-perceived effectiveness in changing patient behavior, beliefs about preventive care, knowledge about preventive care, and perceived barriers to the delivery of preventive care. RESULTS: Compliance with history-taking recommendations was independently associated with high knowledge scores, female physician gender, and high self-perceived effectiveness in changing patient behavior. The only factor that was independently associated with counseling efforts was self-perceived effectiveness in changing patient behavior. CONCLUSIONS: Factors that were independently associated with self-reported preventive care efforts include female physician gender, knowledge about preventive care guidelines, and perceived effectiveness in changing patient behavior. After controlling for these factors, other variables such as lack of time, lack of reminder systems, attitudes about preventive care, and amount of formal preventive care education were not related to self-reported compliance with counseling and history-taking recommendations.
Adult↗
Legal implications of birth videos.
There is little information available in the peer-reviewed literature on the medical and legal aspects of videotaping obstetric procedures. To manage legal risks, some large medical centers do not allow families to videotape the birth. One liability insurer is now attempting to limit video cameras in labor and delivery suites throughout its state. These policies can have significant implications for physicians and their patients. In an effort to examine approaches to the problem, we gathered the experiences of physician and attorney members of the American College of Legal Medicine through letters and telephone conversations, and we performed a review of the available medical and legal literature. Based on this research and review, we present the benefits and risks of permitting families to videotape the birth process, and we make recommendations for reducing potential liability.
Delivery, Obstetric↗
Neonatal respiratory distress in the community hospital: when to transport, when to keep.
Neonatal respiratory distress is a common problem confronting family physicians. Although respiratory distress may represent a benign, self-limited process, it may also be the first sign of sepsis or serious cardiopulmonary disease. Because it is crucial to differentiate the two, we offer a practical approach to the treatment of neonatal respiratory distress at community hospitals. Our method, the Rule of 2 Hours, is based on readily accessible clinical findings. We believe it will help physicians detect babies at risk for serious problems, but will not result in unnecessary referral of neonates that are simply adapting to extrauterine life.
Clinical Protocols↗
Russian family practice training program: a single step on a long journey.
BACKGROUND AND OBJECTIVES: Since 1992, when the Russian government recognized family practice as a medical specialty, efforts have begun to progress from the idea stage to the delivery of patient care via family practice methods. We describe an educational effort to help teach Russian physicians family practice skills. METHODS: Five young Russian physicians were selected from an initial pool of 15 candidates on the basis of standardized testing, English language skills, and their potential to teach future Russian family physicians. Clinical, teaching, and business curricula were developed and used during the 6-month training period for the five selected physicians. Trainees were evaluated by mentors' and preceptors' written evaluations and by the American Board of Family Practice In-training Examination before, during, and at completion of the training. Subsequently, a fully equipped family practice office was opened in St Petersburg to serve as an on-site training facility. RESULTS: The trainees' self-perceived knowledge in community medicine, geriatrics, medical decision making, patient education, behavioral science, preventive medicine, and general family practice topics improved over the course of training. The composite scores on the in-training examinations improved from baseline (30 versus 308). Preceptors noted the greatest improvements in the use of clinical instruments, proficiency in physical exams, accessing medical information, and formulating differential diagnoses. The St Petersburg family practice office opened on October 1, 1996. The trainees now participate in the care of patients in this office and teach a new class of family medicine interns. CONCLUSION: The training program we describe has allowed Russian physicians to acquire new skills and knowledge that they can use and adapt to training future Russian family physicians.
Curriculum↗
An introduction to time-trend analysis.
Healthcare professionals often are presented with data that appear to indicate an upward or downward trend over time. For example, admissions of acquired immunodeficiency syndrome (AIDS) patients appear to be increasing, cesarean section rates appear to be decreasing, or nosocomial pneumonia rates appear to be increasing. Critical decisions sometimes are based on such trends, which often are presented without a statistical analysis. Those responsible for decision making may be left wondering whether these apparent trends represent only chance variation. Graphs showing trends over time generally present one of three kinds of outcome data: counts (eg, three AIDS admissions), proportions (eg, 10 cesarean sections per 100 total deliveries), or person-time data (eg, 13 cases of nosocomial pneumonia per 10,000 patient days). Using familiar examples and a minimum of technical language, we illustrate the analysis of time trends.
Data Interpretation, Statistical↗
Home visit program for teaching elder abuse evaluations.
BACKGROUND AND OBJECTIVES: A home visit program was designed to teach family practice residents how to evaluate patients for elder abuse and capacity (the ability to make one's own decisions). METHODS: Residents assessed potential abuse victims reported to Arizona's Adult Protective Service (APS) in their homes. Written evaluations prepared immediately following each home visit were abstracted for diagnoses (including abuse), recommendations, and patient demographics. Follow-up surveys by APS case workers determined whether the home visit recommendations were accomplished. Graduates of the residency were surveyed about their perceptions of the educational value of the program and their practice characteristics. RESULTS: The residents evaluated 201 patients. The mean age was 77, and 73% of patients were female. Seventy-five percent were incapacitated, 65% of these because of dementia. Ninety-one percent were abused, and the types of abuse included neglect (69%), exploitation (20%), physical abuse (8%), and unknown (3%). Recommendations were accomplished in the majority of cases: medical advice (68%), services (65%), medical evaluations (58%), guardian (53%), and conservator (52%). Graduates who participated in this program (1985-1992) rated their ability to diagnose elder abuse and to assess the patient's home environment significantly higher than earlier graduates who did not participate in the program (1977-1984). Earlier graduates made more home visits and provided more statements for guardianship than later graduates. CONCLUSIONS: The home visit program gave residents exposure to a population of elderly who were abused, demented, and living at home. This program provided clinical substance to build an effective teaching experience and furnished APS with a needed service.
Adult↗
Lifelong self-directed learning using a computer database of clinical questions.
Physicians often have self-perceived knowledge gaps when they are seeing patients. Traditional continuing medical education is designed to meet the knowledge gaps of groups rather than individual physicians with specific patient problems. Physicians with clinical information needs are advised to critically evaluate high-quality original research in order to practice "evidence-based medicine." But this advice may be unrealistic for busy clinicians. We propose a system for documenting self-perceived information needs using a computer database. Concise answers to these needs are included in the database along with reference citations supporting the answers. The system tracks continuing education efforts, directs patient care decisions, and focuses lifelong learning on relevant topics. We emphasize the importance of being sensitive to personal information needs and the benefits of maintaining a record of these needs.
Clinical Medicine↗
Physicians' mistakes: will your colleagues offer support?
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Decision Making↗
Differences in practice patterns between obstetricians and family physicians: use of serum screening.
OBJECTIVE: Our purpose was to compare the use of the Iowa Expanded Serum Screening program (maternal serum alpha-fetoprotein, human chorionic gonadotropin, and unconjugated estriol) by obstetricians and family physicians. STUDY DESIGN: A registry was used to identify all obstetricians (160) and family physicians (404) who practice obstetrics in Iowa. A questionnaire exploring attitudes and practice patterns related to serum screening was mailed to these physicians. RESULTS: The response rate was 80.3% overall. There were significant differences in the offering of serum screening (p < 0.001) for following three responses: obstetricians were more likely to offer screening through the Iowa Expanded Serum Screening Program than were family physicians (89.3% vs 57.2%) and less likely to offer screening outside the state program (9.9% vs 39.0%), whereas family physicians were more likely to not offer screening (0.8% vs 3.8%). When the responses of the physicians who offer screening were analyzed, several differences emerged: (1) obstetricians were more likely than family physicians to offer screening to all obstetric patients (99.2% vs 92.1%, p < 0.05), whereas family physicians were more likely to offer testing to patients with perceived risks for neural tube defects or chromosomal abnormalities and to those patients who requested it, (2) obstetricians were more likely to recommend screening than family physicians (39.0% vs 25.7%, p < 0.05), who more often discouraged testing, although the latter did not reach statistical significance, (3) family physicians more than obstetricians felt that screening was not necessary if the patient would not terminate the pregnancy for neural tube defects (41.6% vs 19.1%, p < 0.001) or chromosomal abnormalities (39.7% vs 21.4%, p < 0.01), and (4) obstetricians used nurses to counsel patients to a much greater extent than family physicians did (44.6% vs 14.0%, p < 0.001). CONCLUSION: There is a significant difference in practice patterns between obstetricians and family physicians in their reported use and presentation of maternal serum screening. Guidelines based on outcome studies should be developed and followed by obstetricians and family physicians.
Chorionic Gonadotropin↗
Benign fever following vaginal delivery.
BACKGROUND: In patients with fever following vaginal delivery, physicians must differentiate benign self-resolving fevers from fevers with more serious causes, especially endometritis. To help differentiate these clinical entities, we explored the characteristics and risk factors for benign "single-day" postpartum fever. METHODS: We conducted a retrospective cohort study of 2137 vaginal deliveries. Patients were randomly selected from the 25,687 vaginal deliveries that took place between 1979 and 1992 at The University of Iowa Hospitals and Clinics. The data were analyzed using odds ratios and multiple logistic regression. RESULTS: Benign fevers occurred in 3.3% of patients, while endometritis was diagnosed in 1.6%. After controlling for confounding variables, two clinical factors were independently associated with single-day fever: primiparity (odds ratio [OR], 3.4; 95% confidence interval [CI], 2.0 to 5.7) and use of a uterine pressure catheter (OR, 2.4; 95% CI, 1.5 to 3.7). These factors were not associated with endometritis. The first postpartum temperature elevation ( > or = 38.0 degrees C) occurred earlier in patients with single-day fever than in patients with endometritis (4.0 +/- 4.6 hours postpartum vs 30.2 +/- 27.0 hours postpartum, P < .001). The maximum temperature elevation was lower, on average, in patients with single-day fever than in patients with endometritis (38.2 degrees +/- 0.2 degrees C vs 38.9 degrees +/- 0.6 degrees C, P < .001). CONCLUSIONS: Single-day fever was more likely to occur in primiparous women and in women who were monitored with a uterine pressure catheter. Most women with benign single-day fevers had early low-grade fevers, whereas women with endometritis had higher fevers that occurred later in the postpartum period.
Adult↗
Diagnosing left lower lobe pneumonia: usefulness of the 'spine sign' on lateral chest radiographs.
BACKGROUND: Left lower lobe pneumonia may be obscured by the heart on the postero-anterior (PA) chest radiograph. In such cases, the lateral projection may be helpful, especially if it exhibits the "spine sign", which is an interruption in the progressive increase in lucency of the vertebral bodies from superior to inferior. We investigated whether the spine sign would help family physicians diagnose left lower lobe pneumonia on chest radiographs. METHODS: We selected the chest radiographs of all patients with left lower lobe pneumonia who were seen between 1983 and 1995 at a family practice training program (N = 78) and an equal number of chest radiographs of patients without pneumonia. Six family physicians read these radiographs under two viewing conditions: PA only vs PA and lateral. We used receiver operating characteristic (ROC) curve methodology to compare the two viewing conditions. RESULTS: There was no significant difference in performance between the two viewing conditions. The lateral view was helpful in some patients but misleading in others. Among patients with pneumonia, the lateral view was helpful when the spine sign was present, but it was misleading when the spine sign was absent. CONCLUSIONS: In this study of family physicians, the lateral chest radiograph did not improve overall diagnostic accuracy in patients with left lower lobe pneumonia. Among pneumonia patients with the spine sign, however, the lateral view was often helpful.
Adolescent↗
Understanding logistic regression analysis through example.
Logistic regression is a valuable statistical tool that is often used in primary care research. When researchers explore the association between a possible risk factor and a disease, they attempt to control the effects of extraneous factors (confounders) that can obscure the true association. Using logistic regression, researchers can simultaneously control for the effects of multiple confounders. When investigators use logistic regression, they make subjective decisions about which factors to include in the analysis and in the final predictive model. Critical readers must understand basic concepts of logistic regression and potential problems with its use before they can accurately interpret study results. This article uses a familiar example to explain the principles of logistic regression to make it understandable to nonstatisticians.
Coffee↗
Practice patterns during the third stage of labor: the effect of physician age and specialty.
BACKGROUND: Elective manual removal of the placenta and routine uterine exploration following vaginal delivery are controversial procedures. Although advocated in the past, little is known about current attitudes and practices related to these procedures. METHODS: Using a mailed questionnaire, we surveyed all 178 Iowa obstetrician-gynecologists and a random sample of 163 Iowa family physicians to determine their practice patterns related to selected aspects of the third stage of labor. The data were analyzed using odds ratios and multiple logistic regression. RESULTS: The analysis was based on answers from 302 physicians. Physicians in the oldest age quartile were three times more likely than physicians in the youngest age quartile to routinely explore the uterus after a vaginal delivery (P < .01). After controlling for specialty, younger physicians were more likely to believe that manual removal of the placenta is a risk factor for endometritis (adjusted odds ratio [OR] 0.7 for each 10-year increase in age, 95% confidence interval [CI] 0.6 to 1.0). Controlling for age, family physicians were more likely than obstetrician-gynecologists to routinely order prophylactic antibiotics after manually removing the placenta (adjusted OR 2.0, 95% CI 1.1 to 3.7). CONCLUSIONS: Both physician age and specialty were associated with selected practice patterns involving the third stage of labor. Older physicians were less likely to believe that manually removing a placenta increases the risk of postpartum endometritis, and they were more likely to routinely explore the uterus after a vaginal delivery.
Adult↗
The association between manual removal of the placenta and postpartum endometritis following vaginal delivery.
OBJECTIVE: To determine whether manual removal of the placenta after vaginal delivery is a risk factor for postpartum endometritis. METHODS: A retrospective cohort study of vaginal deliveries compared 1052 patients who had manual removal of the placenta with 1085 patients whose placentas delivered spontaneously. Subjects were selected randomly from the 25,687 vaginal deliveries at the University of Iowa Hospitals during 1979-1992. The presence of endometritis was determined using information in medical records. The data were analyzed using odds ratios (OR) and multiple logistic regression. RESULTS: After controlling for confounding variables, manual removal of the placenta was associated with postpartum endometritis (adjusted OR 2.9, 95% confidence interval [CI] 1.7-4.9). Other risk factors for endometritis included maternal age less than 17 years (OR 3.3, 95% CI 1.5-7.2), postpartum anemia (OR 2.9, 95% CI 1.9-4.5), and membranes ruptured longer than 24 hours (OR 2.5, 95% CI 1.4-4.3). CONCLUSION: Manual removal of the placenta is a risk factor for postpartum endometritis after vaginal delivery.
Adult↗
Perceived causes of family physicians' errors.
BACKGROUND: Competent physicians occasionally make critical errors in patient care that can lead to long-lasting remorse and guilt. The perceived causes of self-admitted physician errors have not been previously explored. METHODS: Fifty-three family physicians were interviewed in depth and asked to describe their most memorable errors and the perceived causes. The authors analyzed transcripts of the audiotaped interviews to determine the frequencies of the different causes. Errors were classified according to four general categories. RESULTS: Family physicians collectively reported a mean of 8 different causes for each case in which an error was made (range, 1 to 16). In 47% of the cases, the patient died following the error, whereas in 26% of the cases, there was no adverse outcome. Only 4 of the 53 errors led to malpractice suits, and none were addressed by peer review organizations. Seven (10%) of the 70 physicians who were invited to participate could not recall having made any errors. Family physicians attributed their most memorable errors to 34 different causes, which fit into the following categories: physician stressors (eg, bing hurried or distracted), process-of-care factors (eg, premature closure of the diagnostic process), patient-related factors (eg, misleading normal findings), and physician characteristics (eg, lack of knowledge). CONCLUSIONS: Family physicians attribute their memorable errors to a wide variety of causes, but most commonly to hurry, distraction, lack of knowledge, premature closure of the diagnostic process, and inadequately aggressive patient management. Physicians who understand common causes of errors may be better prepared to prevent them.
Adult↗
The physician's decision to use tube feedings: the role of the family, the living will, and the Cruzan decision.
OBJECTIVE: To determine the relative importance of factors influencing physicians to use tube feedings in patients lacking decision-making capacity. DESIGN: Survey. SETTING AND PARTICIPANTS: Four hundred thirty-nine members of the Missouri Academy of Family Physicians. MEASUREMENTS: Using a mailed questionnaire, physicians were asked for a decision about feeding tube placement in an 89-year-old man who was unable to swallow or communicate after a stroke. Changing the conditions of the scenario, we then evaluated the influence of patient age, duration of disability, a living will, the Cruzan decision, and family preferences on the physician's decision. RESULTS: After reading the initial case history, 47% of physicians opposed tube feedings. Physicians who were told that the patient signed a living will specifically excluding tube feedings were more likely to oppose tube feedings than those who were told that he signed only a standard living will (53% vs 42%; P = 0.02). Forty-two percent of physicians who initially suggested a feeding tube changed their recommendation if the family opposed it. Sixty-six percent of physicians who initially opposed a feeding tube changed their recommendation if the family "pushed" for it. Thirty-three percent of physicians who initially opposed tube feedings under the living will scenario would favor tube feedings if the patient had not signed a living will. Twenty-two percent of physicians who initially opposed tube feedings would change to favor them if the issue had arisen before the Cruzan decision. CONCLUSIONS: Among this group of physicians, there was no consensus on whether tube feedings should be initiated. However, it was found that the family's opinion was the most influential factor affecting the physician's recommendation about tube feedings. Most physicians endorsed family preferences for tube feedings even when this intervention was specifically opposed in the patient's living will.
Brain Diseases↗