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Biomedical subjects

P G Ramsey

Publications and source records attributed to P G Ramsey.

At least 19 recordsLinked to original sources
PubMed2001

Communicating with dying patients within the spectrum of medical care from terminal diagnosis to death.

BACKGROUND: Efforts to improve communication between physicians and dying patients have been unsuccessful, and guidelines for improving patient-physician communication about end-of-life care are based primarily on expert opinion. This study assessed which aspects of communication between patients and physicians are important in end-of-life care. METHODS: Twenty focus groups were held with 137 individuals, including patients with chronic and terminal illnesses, family members, health care professionals from hospice or acute care settings, and physicians with expertise in end-of-life care. Focus group analyses determined domains of physician skill at end-of-life care. Communication with patients was identified as one of the most important domains. Analyses of components important in communicating with dying patients and their families were performed. RESULTS: The following 6 areas were of central importance in communicating with dying patients: talking with patients in an honest and straightforward way, being willing to talk about dying, giving bad news in a sensitive way, listening to patients, encouraging questions from patients, and being sensitive to when patients are ready to talk about death. Within these components, subthemes emerged that provide guidelines for physicians and educators. Dying patients also identified the need to achieve a balance between being honest and straightforward and not discouraging hope. CONCLUSIONS: Several areas emerged for physicians to focus their attention on when communicating with dying patients. These findings provide guidance in how to improve this communication. They also highlight the need to approach communication about end-of-life care as a spectrum that requires attention from the time of a terminal diagnosis through death.

Clinical Competence↗
PubMed2001

From concept to culture: the WWAMI program at the University of Washington School of Medicine.

Shortages of primary care physicians have historically affected rural areas more severely than urban and suburban areas. In 1970, the University of Washington School of Medicine (UWSOM) administrators and faculty initiated a four-state, community-based program to increase the number of generalist physicians throughout a predominantly rural and underserved region in the U.S. Northwest. The program developed regional medical education for three neighboring states that lacked their own medical schools, and encouraged physicians in training to practice in the region. Now serving five Northwest states (Washington, Wyoming, Alaska, Montana, and Idaho), the WWAMI program has solidified and expanded throughout its 30-year history. Factors important to success include widespread participation in and ownership of the program by the participating physicians, faculty, institutions, legislatures, and associations; partnership among constituents; educational equivalency among training sites; and development of an educational continuum with recruitment and/or training at multiple levels, including K--12, undergraduate, graduate training, residency, and practice. The program's positive influences on the UWSOM have included historically early attention to primary care and community-based clinical training and development of an ethic of closely monitored innovation. The use of new information technologies promises to further expand the ability to organize and offer medical education in the WWAMI region.

Alaska↗
PubMed2001

Understanding physicians' skills at providing end-of-life care perspectives of patients, families, and health care workers.

BACKGROUND: A framework for understanding and evaluating physicians' skills at providing end of life care from the perspectives of patients, families, and health care workers will promote better quality of care at the end of life. OBJECTIVE: To develop a comprehensive understanding of the factors contributing to the quality of physicians' care for dying patients. DESIGN: Qualitative study using focus groups and content analysis based on grounded theory. SETTING: Seattle, Washington. PARTICIPANTS: Eleven focus groups of patients with chronic obstructive pulmonary disease, AIDS, or cancer (79 patients); 3 groups of family members who had a loved one die of chronic disease (20 family members); 4 groups of nurses and social workers from hospice or acute care settings (27 health care workers); and 2 groups of physicians with expertise in end-of-life care (11 physicians). RESULTS: We identified 12 domains of physicians' skills at providing end-of-life care: accessibility and continuity; team coordination and communication; communication with patients; patient education; inclusion and recognition of the family; competence; pain and symptom management; emotional support, personalization; attention to patient values; respect and humility; and support of patient decision making. within these domains, we identified 55 specific components of physicians' skills. Domains identified most frequently by patients and families were emotional support and communication with patients. Patients with the 3 disease groups, families, and health care workers identified all 12 domains. Investigators used transcript analyses to construct a conceptual model of physicians' skills at providing end-of-life care that grouped domains into 5 categories. CONCLUSIONS: The 12 domains encompass the major aspects of physicians' skills at providing high-quality end-of-life care from the perspectives of patients, their families, and health care workers, and provide a new framework for understanding, evaluating, and teaching these skills. Our findings should focus physicians, physician-educators, and researchers on communication, emotional support, and accessibility to improve the quality of end-of-life care.

Adult↗
PubMed1998

History-taking and preventive medicine skills among primary care physicians: an assessment using standardized patients.

BACKGROUND: The ability of primary care physicians to obtain important clinical information in initial encounters with new patients is a core competency that has received little attention in previous studies. This paper describes the history-taking and preventive screening skills of practicing primary care physicians in initial interactions with ambulatory patients, as determined by a large panel of standardized patients. METHODS: Standardized patient cases with diverse presentations were developed and used to assess the clinical skills of 134 primary care physicians from five Northwest states. Scoring categories for each case identified the percentage and content of essential history items and preventive screening items performed. Physicians' scores were compared by training and practice characteristics. RESULTS: Physicians asked 59% of essential history items. They frequently obtained appropriate information about presenting symptoms and medications, but they often missed important information about related symptoms and medical history. Physicians frequently screened for smoking and alcohol use, but rarely asked about recreational drug use. Although board-certified general internists performed more comprehensive histories than board-certified family practitioners in the same amount of time, both groups of providers missed a large number of items that should have been influential in developing diagnostic and treatment plans. CONCLUSIONS: Primary care physicians may miss important patient information in their initial interactions with patients. Medical intake questionnaires or other approaches should be considered to ensure that more complete and accurate information is available to guide diagnostic and treatment plans.

Clinical Competence↗
PubMed1998

The JIM interview. Paul G. Ramsey, MD.

While it is known around the world for its prestigious research, the University of Washington School of Medicine has played a pioneering role in medical education, particularly in the area of primary care. Long before country was cool, the school had established a highly regarded community based teaching program aimed at providing primary care for underserved rural areas and three decades ago was the first center to offer an additional year of training in general internal medicine. Even as other centers aspire to integrate health services research with clinical practice, Washington finds itself sitting in a hotbed of information management that naturally blends into its long-term mission. At the helm of the medical center is Paul G. Ramsey, MD. Ramsey, who first came to the school as a senior fellow in infectious diseases in 1978, was named vice president for medical affairs and dean of the School of Medicine in May 1997 after serving seven years as chair of the Department of Medicine. Interviewed in his office in Seattle, Ramsey reflected on the shape of medical education in the Pacific Northwest and the strong primary care component of this mission.

Education, Medical↗
PubMed1997

HIV risk screening in the primary care setting. Assessment of physicians skills.

OBJECTIVE: To assess the content and extent of HIV risk assessment by primary care physicians across a diverse panel of patients with unidentified HIV risk behaviors. DESIGN: Standardized patient examination to assess primary care physicians' skills at identifying and managing HIV infection and overall clinical skills. In a day of testing, physicians saw 13-16 standardized patients (SPs) with diverse case presentations. In analyses presented here, physician performance was examined with nine SPs who had unidentified risks for HIV, which they offered if asked. SETTING: An academic clinic. PARTICIPANTS: We randomly selected 134 paid volunteers (general internists and family/general practitioners) after stratifying by specialty, experience caring for patients with HIV infection, and year of medical school graduation. MEASUREMENTS AND MAIN RESULTS: Performance at initiating HIV risk screening and identifying patients' HIV risk behaviors were the main outcome measures. Physicians performed variably at HIV risk screening with different patients and across different HIV risk screening topics. Although physicians initiated screening with 60% of patients, they identified only 49% of risk behaviors and included HIV in the differential diagnosis for less than half of at-risk patients. Physicians performed better with cases in which there was a higher probability of HIV infection based on symptoms, but often did not screen at-risk patients without obvious symptoms suggestive of HIV. Board-certified general internists initiated screening and identified risk behaviors with more patients than board-certified family practitioners. Medical school graduation year also influenced performance. CONCLUSIONS: Our data suggest that primary care physicians do not routinely perform HIV risk assessments with patients who have risk behaviors for HIV infection. Methods are needed to develop, standardize, and disseminate better screening techniques to identify patients with or at risk of developing HIV infection, such as written HIV risk screening questions for use in medical intake forms.

Adult↗
PubMed1996

Feasibility of hospital-based use of peer ratings to evaluate the performances of practicing physicians.

PURPOSE: To address the feasibility of obtaining reliable evaluations of individual physicians from peer ratings undertaken at diverse hospitals. METHOD: Eleven hospitals in diverse locations in the United States were recruited to participate. With the aid of the hospitals' medical directors, up to 40 board-certified internists with admitting privileges were recruited per hospital. Participating physicians provided demographic data about themselves and nominated physician-associates to do peer ratings. Between April 1993 and January 1994, the physicians were rated by their peers, who received a single mailing with no follow-up. The raters used a nine-point Likert scale for 11 cognitive and noncognitive categories. Administrative procedures were coordinated from the American Board of Internal Medicine. Chi-square, Student's t-test, and factor analysis using varimax rotation were used to analyze the results. RESULTS: Of the 4,139 questionnaires that were mailed to peer raters, 3,005 (73%) were returned. Of the 228 physicians who were rated, 187 received ten or more usable ratings, which were used for further analysis. The findings confirmed the results of previous research. The highest mean rating was for the category of integrity, and the lowest was for the category of psychosocial aspects of care. Ten to 11 responses per physician were necessary to achieve a generalizability coefficient of .7. Nearly 90% of the variance in the ratings was accounted for by two factors, one representing cognitive and clinical management skills and the other, humanistic qualities. For 16 physicians (9%), the ratngs of overall clinical skills were less than 7 on a scale from 1 (low) to 9 (high); their ratings for all individual cognitive and noncognitive categories were below the ratings of the other physicians. CONCLUSION: The peer raters' response rate and the analysis of the ratings suggest that the rating process is acceptable to physicians and that it is feasible to obtain reliable, multidimensional peer evaluations of individual physicians practicing in diverse clinical settings.

Employee Performance Appraisal↗
PubMed1995

Ability of primary care physicians to recognize physical findings associated with HIV infection.

OBJECTIVE: To assess the ability of primary care physicians to identify physical findings associated with human immunodeficiency virus (HIV) infection. DESIGN: Standardized patient examination. PARTICIPANTS: A total of 134 general internists and family practitioners were randomly selected after stratifying by year of medical school graduation, specialty, and experience caring for patients with HIV infection. MAIN OUTCOME MEASURES: Recognition of physical findings of Kaposi's sarcoma, oral hairy leukoplakia, and diffuse lymphadenopathy. RESULTS: Despite being directed by presenting histories to sites of prominent physical abnormalities, only 23 (25.8%) of 89 physicians evaluating a patient with Kaposi's sarcoma and 22 (22.7%) of 97 physicians evaluating a patient with oral hairy leukoplakia detected and correctly diagnosed the abnormalities. Twenty-three (17%) of 133 physicians detected diffuse lymphadenopathy in a patient complaining of fatigue, fever, and arthralgias. Physicians with the most experience treating patients with HIV infection more frequently identified oral hairy leukoplakia, but HIV experience did not influence identification of Kaposi's sarcoma or detection of lymphadenopathy. There were no differences between general internists and family practitioners or among physicians by year of medical school graduation in identifying the three physical findings associated with HIV infection. CONCLUSIONS: Primary care physicians may frequently miss important physical findings related to HIV infection during patient examinations.

Clinical Competence↗
PubMed1995

Ability of primary care physicians to diagnose and manage Pneumocystis carinii pneumonia.

This study assesses the ability of primary care physicians to diagnose and manage Pneumocystis carinii pneumonia (PCP) in a standardized patient (SP) with unidentified HIV infection. One hundred thirty-four primary care physicians from five Northwest states saw an SP with unidentified HIV infection who presented with symptoms, chest radiograph, and arterial blood gas results classic for PCP. Seventy-seven percent of the physicians included PCP in their differential diagnoses and 71% identified the SP's HIV risk. However, only a minority of the physicians indicated that they would initiate an appropriate diagnostic evaluation or appropriate therapy: 47% ordered a diagnostic test for PCP, 31% initiated an antibiotic appropriate for PCP, and 12% initiated an adequate dose of trimethoprim - sulfamethoxazole. Only 6% of the physicians initiated adjunctive prednisone therapy, even though prednisone was indicated because of the blood gas result. These findings suggest significant delay in diagnosis and treatment had these physicians been treating an actual patient with PCP.

Clinical Competence↗
PubMed1995

Do primary care physicians screen patients about alcohol intake using the CAGE questions?

The performances of 134 primary care physicians at initial screening about alcohol use and screening with the CAGE questions were assessed using 17 standardized patients. For three-fourths of the standardized patients, more than 50% of the physicians asked an initial alcohol screening question. However, use of the CAGE questions with six patients who reported drinking more than one drink per day was less consistent; for most of these patients, few physicians asked any CAGE questions. Fewer than 50% of the physicians included alcohol abuse in the differential diagnosis for three of four patients who drank four or more drinks per day. Methods are needed to incorporate the CAGE questions into primary care practices in a more systematic manner.

Alcoholism↗
PubMed1994

A fourth year of training in ambulatory medicine: the University of Washington experience.

Postresidency training in ambulatory general internal medicine has been proposed as a means to enhance the generalist skills of internal medicine graduates. At the University of Washington, a fourth year of training in ambulatory medicine has been offered since 1967. The resident training year provides a core experience in general internal medicine as well as the opportunity for elective experiences in subspecialties and other allied specialties. Graduates of this year of experience in ambulatory training were surveyed to determine current practice patterns and retrospective evaluation of the program; responses were received from 36 of 52 graduates (69%). Among respondents, 50% are general internists, 39% subspecialists, and 11% in other practice specialties. Eight respondents (22%) are practicing in rural communities. Respondents identified the specialized training in outpatient medicine as the primary strength of the additional training year. Many reported using the year to gain additional training tailored to their future practice. The fourth year of ambulatory training thus represents an efficient means to provide additional training to internists planning careers in general internal medicine. It can serve a variety of purposes, including preparation for practice in rural and other settings with unique clinical demands, training of clinician educators, and retraining of subspecialists seeking to shift to generalist practice.

Ambulatory Care↗
PubMed1994

Evaluation of clinical teaching by general internal medicine faculty in outpatient and inpatient settings.

PURPOSE: To determine the measurement characteristics of a form used to evaluate teaching in outpatient settings, and to compare ratings received by general internists in outpatient and inpatient settings. METHOD: The physicians evaluated were 29 faculty who taught in both outpatient and inpatient settings affiliated with the Department of Medicine, University of Washington School of Medicine, over a five-year period (from 1985-86 through 1989-90). Residents completed 639 evaluations, using a six-point Likert-type scale (from 1, very poor, to 6, excellent) to rate instructors in eight categories and to provide an overall assessment of each instructor's teaching effectiveness. In addition, each evaluation contained an indication of the resident's perceived degree of involvement with the instructor. Statistical analysis involved two-tailed t-tests, analysis of variance and covariance, intraclass correlation coefficients, and the Spearman Brown prophecy formula. RESULTS: When more than ten raters of teaching in outpatient settings were available, the reliabilities ranged from .58 to .81. The outpatient-setting ratings were significantly lower than the inpatient-setting ratings for seven categories, overall teaching effectiveness (5.01 versus 5.35, p < .05), and perceived degree of involvement of the instructor with the resident. When controlled for perceived degree of involvement, differences remained in only two categories: demonstration of clinical skills, rated higher for outpatient settings, and instructor accessibility, rated lower. CONCLUSION: The evaluation form provides reliable ratings of teaching in outpatient settings when more than ten raters are available. The differences found in the ratings between the inpatient and outpatient settings may be explained by the factor of the resident's perceived degree of involvement with the instructor.

Evaluation Studies as Topic↗
PubMed1993

Use of peer ratings to evaluate physician performance.

OBJECTIVE: To assess the feasibility and measurement characteristics of ratings completed by professional associates to evaluate the performance of practicing physicians. DESIGN: The clinical performance of physicians was evaluated using written questionnaires mailed to professional associates (physicians and nurses). Physician-associates were randomly selected from lists provided by both the subjects and medical supervisors, and detailed information was collected concerning the professional and social relationships between the associate and the subject. Responses were analyzed to determine factors that affect ratings and measurement characteristics of peer ratings. SETTING AND PARTICIPANTS: Physician-subjects were selected from among practicing internists in New York, New Jersey, and Pennsylvania who received American Board of Internal Medicine certification 5 to 15 years previously. MAIN OUTCOME MEASURE: Physician performance as assessed by peers. RESULTS: Peer ratings are not biased substantially by the method of selection of the peers or the relationship between the rater and the subject. Factor analyses suggest a two-dimensional conceptualization of clinical skills: one factor represents cognitive and clinical management skills and the other factor represents humanistic qualities and management of psychosocial aspects of illness. Ratings from 11 peer physicians are needed to provide a reliable assessment in these two areas. CONCLUSIONS: These findings suggest that it is feasible to obtain assessments from professional associates of practicing physicians in areas such as clinical skills, humanistic qualities, and communication skills. Using a shorter version of the questionnaire used in this study, peer ratings provide a practical method to assess clinical performance in areas such as humanistic qualities and communication skills that are difficult to assess with other measures.

Clinical Competence↗