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Biomedical subjects

Meldon Kahan

Publications and source records attributed to Meldon Kahan.

11 recordsLinked to original sources
PubMed2006

Effects of a distance learning program on physicians' opioid- and benzodiazepine-prescribing skills.

INTRODUCTION: Opioid misuse is common among patients with chronic nonmalignant pain. There is a pressing need for physicians to increase their confidence and competence in managing these patients. METHODS: A randomized controlled trial of family physicians (N = 88) attending 1 of 4 continuing medical education events helped to determine the effectiveness of e-mail case discussions in changing physician behavior. Before random assignment, participants completed a pretest and attended a 3-hour didactic session on prescribing opioids and benzodiazepines. The intervention group participated in 10 weeks of e-mail case discussions, with designated participants responding to questions on cases. An addictions physician facilitated the discussion. Several months after the e-mail discussion, participants took part in a mock telephone consultation; a blinded researcher posing as a medical colleague asked for advice about 2 cases involving opioid and benzodiazepine prescribing. Using a checklist, the researcher recorded the questions asked and advice given by the physician. RESULTS: On post-testing, both groups expressed greater optimism about treatment outcomes and were more likely to report using a treatment contract and providing advice about sleep hygiene. There were no significant differences between pretesting and post-testing between the groups on the survey. During the telephone consultation, the intervention group asked significantly more questions and offered more advice than the control group (odds ratio for question items, 1.27 [p = .03]; advice items, 1.33 [p = .01). DISCUSSION: Facilitated by electronic mail and a medical expert, case discussion is an effective means of improving physician performance. Telephone consultation holds promise as a method for evaluating physicians' assessment and management skills.

Adult↗
PubMed2006

Methadone induction doses: are our current practices safe?

PURPOSE: To review the literature on methadone deaths and propose evidence-based dosing guidelines. METHODS: A literature search was conducted on overdose deaths during the induction phase. Data on methadone deaths from the Ontario coroner's office, as well as prescribing guidelines from different countries and jurisdictions, were reviewed. The information was collectively considered and, using the best available evidence, translated into safe dosing guidelines for methadone induction. RESULTS: A literature review found high death rates during the methadone induction period. Data from the Ontario coroner's office revealed that of deaths that were felt to be attributable to methadone overdose, the majority occurred in those who had consumed diverted methadone: of those deaths within a registered program, the majority occurred during the initial dosing phase. Despite high death rates during induction onto methadone treatment, many jurisdictions do not have prescribing guidelines that take this evidence into account. CONCLUSIONS: Safer prescribing guidelines are needed to reduce deaths during induction onto methadone treatment. Recommendations are made for safe methadone induction doses.

Age Factors↗
PubMed2005

SARS: coping with the impact at a community hospital.

AIM: This paper presents the findings of a staff survey conducted at a 350-bed acute care facility located on the periphery of Toronto, Canada. BACKGROUND: Toronto's severe acute respiratory syndrome (SARS) crisis resulted in trauma-like effects at hospitals hardest hit by the disease. A systematic examination of the impact on staff working in hospitals that saw relatively few cases, while maintaining the precautions associated with elevated alert levels, has not been undertaken. METHODS: A questionnaire was distributed for 1 month commencing 17 April 2003 and 300 completed responses were obtained (approximately one in six staff members). The data collected included demographic and occupational information, in addition to perceptions of SARS' impact on patient care, factors contributing to adverse impacts on patient care, working conditions, decision-making, communication and relations, sources of support, and the impact on workers' lives outside work. Items for these sections were developed by a multi-disciplinary team of health care workers and hospital administrators. RESULTS: In the absence of pre-SARS normative data for the survey, demographic and occupational variables were used to look for patterns of differences between relevant subgroups of respondents. Statistically significant differences were found for gender (73.9% women), nurses (24.7%) vs. others, doctors (20.3%) vs. others, older (40 years or older, 60.0%) vs. younger persons, emergency or intensive care unit workers (8.0%) vs. others, and those employed fewer years at the hospital (less than 5 years: 46.2%) vs. five or more years. These differences varied across the following domains: factors adversely affecting patients, communications, support, working conditions, decision-making and, to a lesser extent, impact on life outside work. While all groups found SARS stressful, nurses reported a greater impact on morale and job satisfaction. Nurses relied more on peer support than doctors, felt less informed and less involved in decision-making than doctors felt, and were more likely to report that infection control procedures were not strict enough. CONCLUSIONS: The between-group differences and the pattern of these differences clearly illustrate the polarizing and stressful impact SARS had at a hospital with only a small number of probable or suspect cases. The clear differences between groups defined by demographics, professions and clinical roles suggest a subtle and pervasive secondary impact of the SARS outbreak, with repercussions health care facilities must contend with while maintaining increased levels of vigilance in the wake of SARS.

Adult↗
PubMed2004

Family medicine residents' beliefs, attitudes and performance with problem drinkers: a survey and simulated patient study.

Fifty-six second-year family medicine residents completed a survey on their knowledge and beliefs about problem drinkers. Most residents felt responsible for screening and counseling, were confident in their clinical skills in these areas, and scored well on related knowledge questions. However, only 18% felt that problem drinkers would often respond to brief counseling sessions with physicians while 36% felt that moderate drinking was a reasonable goal for patients with severe alcohol dependence. Residents were then visited by unannounced simulated patients (SPs) presenting with alcohol-induced hypertension or insomnia. Residents detected the SP in 45 out of 104 visits. In the 59 undetected SP visits, residents asked about alcohol consumption in 47 visits (80%), discussed the relationship between alcohol use and the presenting complaint in 37 visits (63%), and recommended a specific weekly consumption in 35 visits (59%). Only 31% offered reduced drinking strategies, and most did not ask about features of alcohol dependence. These results suggest that residents have the fundamental clinical skills required to manage the problem drinker who gives a clear history and is receptive to advice. Educational efforts with residents should focus on the importance of systematic screening, taking an alcohol history under more challenging conditions, identifying the subtler presentations of alcohol problems, counselling the less receptive patient at an earlier stage of change, distinguishing the problem drinker from the alcohol-dependent patient, and offering specific behavioral strategies for the problem drinker.

Adult↗
PubMed2003

Educating physicians to reduce benzodiazepine use by elderly patients: a randomized controlled trial.

BACKGROUND: Benzodiazepine use by elderly patients is associated with adverse outcomes including increased risk of falls and fractures, motor vehicle accidents and cognitive impairment. Recent studies suggest that individualized feedback and education to physicians may improve drug prescribing. In this study, we evaluated an intervention to address the inappropriate prescribing of benzodiazepines for elderly patients. METHODS: We identified 1624 primary care physicians who wrote at least 10 prescriptions for the target drugs in a 2-month period and randomly assigned these physicians to the intervention group or the control group. We obtained data from the Ontario Drug Benefit claims database, which covers all Ontario residents aged 65 years and over for drugs selected from a minimally restrictive formulary. Every 2 months for 6 months, confidential profiles of benzodiazepine prescription use coupled with evidence-based educational bulletins were mailed to the intervention group. The control group received feedback and educational bulletins about first-line antihypertension drug prescribing for elderly patients. Our main outcome measures were reductions in the proportion of each physician's total benzodiazepine prescriptions for long-acting agents, combinations of benzodiazepines with other psychoactive medications (including other benzodiazepines) and long-term benzodiazepine therapy. RESULTS: After randomization, 168 physicians agreed to be in the intervention group and 206 in the control group. Their demographic and prescribing characteristics were similar. Although the proportion of long-acting benzodiazepine prescriptions decreased by 0.7% in the intervention group between the baseline period and the end of the intervention period (from 20.3%, or a mean of 29.5 prescriptions, to 19.6%, or a mean of 27.7 prescriptions) and increased by 1.1% in the control group (from 19.8%, or a mean of 26.4 prescriptions, to 20.9%, or a mean of 27.7 prescriptions) (p = 0.036), this difference was not clinically significant. There was no significant difference over the study period in either combination prescribing of benzodiazepines or in prescriptions for long-term benzodiazepine therapy. INTERPRETATION: We did not find that a program of confidential feedback and educational material offered to Ontario primary care physicians had a clinically significant impact on their benzodiazepine prescribing.

Adult↗
PubMed2003

Randomized controlled trial on the effects of a skills-based workshop on medical students' management of problem drinking and alcohol dependence.

The purpose of this study was to determine whether a skills-based workshop will improve medical students' management of problem drinking and alcohol dependence in simulated patients. Seventy-six 3rd and 4th year Ontario medical students were randomized to receive a 3-h workshop on either problem drinking and alcohol dependence or depression (control condition). Students then completed eight simulated office visits (OSCE stations) with simulated patients presenting with depression, problem drinking or alcohol dependence. Examiners completed a checklist of the questions asked and advice given by the student, and simulated patients and examiners completed a global rating scale. Four months later, students were sent a survey on their knowledge, attitudes, and behavior towards patients with alcohol problems. The alcohol group received significantly higher assessment and management checklist scores and global rating scores than did the depression group (p < 0.01) and performed better on almost all aspects of clinical management of both problem drinking and alcohol dependence. On the follow-up survey (n = 55) the alcohol group showed a significant increase in beliefs about self-efficacy in managing alcohol problems (p < 0.05) and had greater knowledge of reduced drinking strategies, but the two groups did not differ on other measures. A skills-based workshop causes marked short-term improvements in medical students' management of problem drinking and alcohol dependence, an increase from baseline to postworkshop in self-efficacy beliefs that was sustained through to follow-up, and greater knowledge of reduced drinking strategies. Repeated reinforcement of clinical skills may be required for a long-term impact on clinical behavior.

Alcohol Drinking↗
PubMed2002

Physician behavior towards male and female problem drinkers: a controlled study using simulated patients.

BACKGROUND: Evidence suggests that physicians are less likely to identify alcohol problems in females than in males. PURPOSE: To compare the performance of family medicine residents with male and female simulated patients (SPs) posing as problem drinkers. METHODS: Fifty-six family medicine residents completed a baseline survey on knowledge and attitudes towards problem drinkers. Each resident was then visited by one male and female unannounced SP. The male and female roles were similar with respect to presenting complaint (in somnia or hypertension), age, social class, and drinking history. RESULTS: Residents expressed slightly more positive attitudes towards female than male patients (3.32 vs. 3.09, p < .001). Residents scored higher with undetected male than with undetected female SPs on the assessment checklist (5.1 vs. 3.2, p < .045), the management checklist (4.4 vs. 3.2, p = .032), and an interpersonal rating scale (the Alcohol Skills Rating Form; 5.5 vs. 4.7, p = .023). CONCLUSION: Educational programs should focus on improving physicians' clinical skills in the identification and treatment of alcohol problems in women.

Adult↗
PubMed2001

Faculty Rating of Learning Objectives for an Undergraduate Medical Curriculum in Substance Abuse.

The purpose of this study is to describe medical faculty's ratings of learning objectives related to substance abuse. A comprehensive set of learning objectives was drafted. The Associate Dean at each of Ontario's five medical schools was asked to select two faculty members from each clinical discipline who were involved in undergraduate medical education. The selected faculty were sent a survey asking them to rate 282 objectives according to their importance for undergraduate education in their discipline, using a 5-point scale. Sixty-eight out of 90 surveys were returned. For statistical analysis, disciplines were placed into two groups, Group 1 (internal medicine, surgery, emergency medicine, and anesthesia) and Group 2 (family medicine, psychiatry, and pediatrics). The mean ratings of Group 1 were significantly higher than Group 2 (p < 0.001) for five sets of objectives: attitudes, epidemiology, screening and assessment, nonmedical interventions, and specific populations (women, the elderly, and adolescents). Group 1 gave mean ratings above 4 to all themes except epidemiology, inpatient care, and medical complications. In contrast, Group 2 gave mean ratings above 4 to only three themes: physician substance abuse problems, withdrawal, and medical complications. The marked differences in learning objectives between disciplines suggest that a discipline-specific approach is needed for curricular development in substance abuse.

Journal Article↗