Biomedical subjects
Publications and source records attributed to M A Reinhart.
The American Board of Emergency Medicine gathers extensive background information on emergency medicine residents and the programs in which they train. We present the fourth annual report on the status of US emergency medicine residency programs.
STUDY OBJECTIVE: The American Board of Emergency Medicine (ABEM) Longitudinal Study of Emergency Physicians (LSEP) was initiated to describe the development of a new medical specialty through the continuing study of the lives of representative emergency physicians. The study is designed to gather data periodically over many years to come. The primary purpose of this article is to provide a baseline for the information obtained and the methods used to develop the ABEM LSEP. METHODS: Stratified, random sampling was used to select emergency physicians who represent different stages in the development of the specialty. Major data collections are conducted using a comprehensive questionnaire in 5-year intervals. Practice profiles were developed and analyzed. Homogeneous scales were created in 9 survey categories and analyzed. RESULTS: The survey was returned by 95% (958/1,008) of the emergency physicians. They are primarily middle-aged, family- and community-oriented, satisfied with their careers, and find that work stress is not a serious problem. Those who are trained in emergency medicine are the most likely to be involved in academic emergency medicine. CONCLUSION: The LSEP is a broad-reaching investigation of emergency physicians. Over time the study will describe (1) the individuals who move the specialty forward at different stages in the growth of the specialty, (2) the realities of practice in the specialty, (3) the relationship of the specialty to the personal lives and well-being of the specialty physicians, and (4) the changes seen in these factors over time.
We describe the development and validation of the Relationship Self Inventory (RSI), which assesses 2 general self-orientations, (a) the Separate Self (SS) and (b) the Connected Self (CS), as well as two manifestations of connection, (a) Primacy of Other Care and (b) Self and Other Care. The CS reflects the importance of interconnectedness with others and a "voice of caring," whereas the SS reflects autonomy, independence, and a "voice of justice." Adequate reliability was demonstrated for the RSI on samples consisting of 927 women and 218 men ranging in age from 26 to 78. Construct validity of the RSI was also explored in a subsample (n = 604) by comparing its scales with measures of personality, temperament, and psychological adjustment. Although mean scores of men and women differed minimally on the CS and SS scales, gender differences in patterns of correlation with validity measures suggested that the meanings of the scales differed for men and women. The RSI appears to be an adequate survey tool for assessing these self-orientations.
The heart of the specialty of emergency medicine, like all specialties and subspecialties, is training. The excellence in medical care that has accrued to the American public has proceeded from the belief that a well-defined and accredited program of education will produce the highest probability that a physician providing care will be competent. There is now a joint opportunity in emergency medicine to build a certification and recertification system that meets the criteria to provide the highest quality care for the public and to offer an efficient and effective system for the members of the specialty.
STUDY OBJECTIVE: To obtain current demographic data and information regarding the opinion of a stratified random sample of emergency physicians about the greatest current challenges facing emergency medicine. METHODS: An annual survey was conducted by the American Board of Emergency Medicine (ABEM) using a stratified random sample of 1,004 emergency physicians selected from four cohorts, 1979, 1984, 1988, and 1993. These samples were further divided between diplomates who had completed emergency medicine residency training and those who had not. The 1993 non-residency-trained panel was replaced by a random sample of American College of Emergency Physicians members who were full-time emergency physicians, were not ABEM diplomates, and had not completed a residency in emergency medicine. The interim survey instrument is a one-page collection of relevant demographic items selected from the comprehensive 5-year questionnaire with the addition of the open-ended question, "What are the greatest challenges facing emergency medicine today?" RESULTS: Of the interim surveys distributed, 95% (n = 956) were returned. Because the 1995 interim survey was the first distributed after the initial 1994 comprehensive survey, the demographic data had changed little. Such data will become increasingly important and useful as changes are reported over subsequent years. The main challenge identified by participants was the impact of managed care (31%), followed by economic and financial issues (23%). Personal impact issues, such as individual stress and malpractice, accounted for a smaller number of responses (18%). CONCLUSION: Overall, the ABEM Longitudinal Study participant responses to the 1995 interim survey describe a committed group of emergency physicians who are struggling and coping with the needs of a maturing specialty and with the crosscurrents and changes in American medicine.
Three cases of child abuse are described in which pelvic injuries were prominent findings on radiologic examination: Two patients had pelvic fractures, and one was found to have heterotopic ossification of the soft tissues of the pelvis and thighs corresponding to extensive bruising in the pubic, genital, buttock, and thigh areas, resulting from physical and sexual abuse. These represent uncommon radiographic findings. Skeletal survey in cases of suspected child abuse should include the entire pelvis, and special attention should be paid to the ischiopubic rami the most common site of these rare pelvic injuries.
A unique case of child abuse in a six-year-old Hispanic girl is reported. In this case, a tooth avulsed and swallowed during an episode of physical abuse and/or sexual abuse, caused an esophageal perforation resulting in a retropharyngeal abscess and mediastinal abscess containing the tooth. Although traumatic esophageal injuries in child abuse have occurred, the presence of a tooth within the mediastinal abscess is an unique manifestation of child abuse.
The objective of this study was to determine if gender differences exist when using the Manning criteria for diagnosis of irritable bowel syndrome. In an outpatient setting, 61 women and 36 men with entry complaints of abdominal pain, altered bowel habits, or both underwent full evaluation by board-certified/eligible gastroenterologists who also systematically rated the presence or absence of the six Manning criteria. Irritable bowel syndrome was defined as the absence of an organic disease explanation for the entry complaints. This determination was made by two other board-certified gastroenterologists after patients had been in the study for 9 months. These raters were independent of the study and rated the transcripts of patients' clinic visits, all other available clinical data from this and other clinics, all laboratory data obtained during the 9-month study period, and the results of a 9-month telephone follow-up to patients and their physicians. Sixty-five percent of the study population had no organic disease explanation for the entry symptoms, thereby representing irritable bowel syndrome for this study. A similar proportion and type of organic disease and irritable bowel syndrome were experienced by men and women. For the total sample of 97 subjects, the correlation of the Manning criteria with irritable bowel syndrome was 0.22 (P less than 0.01). In the 61 women, correlation between the Manning criteria and irritable bowel syndrome was significant (r = 0.47; P less than 0.01). In the 36 men, however, the correlation was in the opposite direction, although it was not significant (r = -0.16). It was concluded that significant gender differences exist when using the Manning criteria for the diagnosis of irritable bowel syndrome and that the Manning criteria were not of diagnostic value in men.
This paper reviews current knowledge of medical evaluations of young victims of alleged sexual abuse. The several purposes and the value of these examinations are discussed. The evaluation of physical findings is reviewed with emphasis on recent progress in improving the reliability and validity of such examinations. The complexities of the identification and interpretation of sexually transmitted diseases are reviewed. Areas in which additional progress is expected in the 1990s are identified.
A case of mediastinitis and mediastinal abscess due to cervical esophageal perforation in a 9/12 month old girl who was a victim of child abuse and possible sexual assault is reported. Injury to the hypopharynx or esophagus with child abuse as a possible etiology should be considered when an infant or young child presents with unexplained erythematous neck swelling, subcutaneous emphysema, pneumomediastinum and/or wide mediastinum.
The objective of this prospective study was to test the hypothesis that 6 reportedly important psychosocial factors were useful criteria for diagnosing the irritable bowel syndrome. Ninety-seven new patients with entry complaints of abdominal pain, altered bowel habits, or both underwent full evaluation by board-certified or -eligible gastroenterologists in an outpatient setting. The independent measures were 6 questionnaires concerning anxiety, depression, stress, lack of social support, somatization, and abnormal illness behavior. The dependent measure, irritable bowel syndrome, was defined as the absence of an organic disease explanation for patients' entry complaints. Two other board-certified gastroenterologists, independent of the study, made this determination. Their rating was based on full review of transcripts of patients' clinic visits, laboratory data, and the results of a 9-mo telephone follow-up to patients and their physicians. Sixty-five percent of the sample had no organic disease explanation for the entry symptoms, thereby representing irritable bowel syndrome. The psychosocial predictors did not show a significant association with irritable bowel syndrome; the power of the study was 0.86. Post hoc analysis revealed that patients with organic disease, as well as patients with irritable bowel syndrome, had significantly more (p less than 0.01) psychosocial abnormality than normal subjects, which likely contributed to the inability of the psychosocial predictors to distinguish irritable bowel syndrome from organic disease. It was concluded that psychosocial criteria were of limited value in differentiating irritable bowel syndrome from organic disease but that they were determinants of health care seeking for the entire study group.
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In the 1988 study reported here, Medical College Admissions test (MCAT) scores and grade point averages for undergraduate science courses (S-GPAs) were examined for predictive validity and differential prediction of National Board of Medical Examiners Part I scores. Data from 579 medical students from the classes of 1979-80 through 1983-84 attending a midwestern medical college were analyzed via moderated multiple regression. The findings indicated that using the S-GPA and a composite MCAT score based on the Biology Knowledge, Chemistry Knowledge, Physics Knowledge, Science Problems, and Reading subtests was valid and equally predictive for the minority and majority groups studied. These results are discussed in terms of past findings on cognitive tests in general, and the MCAT and the S-GPA specifically.
Many common genitourinary complaints may be related to sexual abuse. We report five patients referred to a Pediatric Nephrology Clinic who demonstrate some of the symptoms and signs caused by abuse, such as dysuria, genital and urinary tract infections, voiding dysfunction, and genital trauma. Difficulties in eliciting histories are described. Although these genitourinary complaints may be due to a variety of etiologies, sexual abuse should not be overlooked. Suggestions for a management approach are made.
Scores, ratings of score validity, and the precision of scores were compared for four methods of assessing clinical performance by case review that differ primarily in the communication allowed between physician and assessor. Results indicate that, at least for board-certified physicians, scores and ratings of score validity are significantly improved by increased communication.
Male victims of child sexual abuse have received inadequate attention in the literature. This article is a retrospective review of the reports of 189 boys evaluated during 1983-85. This population was younger than those previously reported. Comparison to an age- and race-matched group of girl victims seen during the same period revealed many similarities in patterns of disclosure and perpetrator characteristics. The acts perpetrated against the boys included a wide array of invasive acts at all ages, but sodomy was more frequently reported in the older victims. Abnormal anogenital findings were seen more often in younger children, but the findings were often nonspecific. An examiner experienced with young children and infants is essential.
Four cases of battered children, in whom concurrent sexual abuse was present in the patient or siblings, are presented. The occurrence of both physical and sexual abuse in the same child has not received adequate attention in the literature, yet diagnostic and intervention procedures change drastically when both are present. The possibility of sexual abuse must be considered early in the course of caring for a physically abused infant or young child.
Because urinary tract infections have been considered to be related to sexual abuse and proposed as an indicator of sexual abuse, a group of children reported as suspected victims of sexual abuse was studied. Clean-catch urine specimens were obtained at the time of their initial medical evaluations for sexual abuse. Results indicated that urinary tract infections were not present in this group of sexually abused children at rates substantially higher than the general population. The findings do not support routine screening of sexually abused children for urinary tract infection, and suggest that further study is indicated if urinary tract infection is to be considered an indicator of abuse.