Internet health ratings systems: knowledge vs Babel.
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Computer Communication Networks↗
Biomedical subjects
R G Badgett
Publications and source records attributed to R G Badgett.
Can the clinical examination diagnose left-sided heart failure in adults?
We systematically reviewed the literature to ascertain how well clinicians determine the probability and type of left-sided heart failure in their patients. Left-sided heart failure is characterized by decreased left ventricular ejection fraction or increased filling pressure. The type of heart failure determines optimal treatment. Systolic dysfunction exists when ejection fraction is reduced. Diastolic dysfunction is presumed to be present when filling pressure is increased with a normal ejection fraction and without another explanatory diagnosis. Many findings are associated with heart failure, and wide variation exists in clinicians' ability to detect these findings. The best findings for detecting increased filling pressure are jugular venous distention and radiographic redistribution. The best findings for detecting systolic dysfunction are abnormal apical impulse, radiographic cardiomegaly, and q waves or left bundle branch block on an electrocardiogram. Diastolic dysfunction is especially difficult to diagnose, but is associated with an elevated blood pressure during heart failure.
Clinical Competence↗
Using systematic reviews in clinical education.
Traditional educational methods change clinical practice only with considerable effort and difficulty. In particular, the teaching of critical appraisal in the setting of journal clubs does not increase the amount of medical research read by trainees. Experiential learning theory, corroborated by the success of problem-based learning, encourages us to link learning to the numerous medical questions that physicians generate while providing patient care. Systematic reviews can link these questions with the results of research that would otherwise be difficult to locate, read, and appraise. Systematic reviews are a uniquely powerful mechanism for teaching, and they offer teachers a new opportunity to model rational and effective use of information. Systematic reviews should be made available at clinical sites for use during "teachable moments." Resistance to the use of systematic reviews can be reduced by using existing journal clubs to teach about the strengths and limitations of these reviews. The point that systematic reviews are meant to assist, not replace, clinical decision making deserves emphasis in such teaching.
Education, Medical↗
Knowledge and attitudes about depression among non-generalists and generalists.
BACKGROUND: The purpose of this study was to learn more about barriers to managing depression by comparing knowledge and attitudes about depression among physicians, internists, obstetrician-gynecologists, and a reference group of psychiatrists. Among the non-psychiatrists, we hypothesized that generalist physicians would have more favorable attitudes and greater knowledge about depression than non-generalists. METHODS: Survey questionnaires were sent to resident and faculty physicians (N = 375) of two university-affiliated medical centers. The physicians were classified as non-generalists (medicine subspecialists, transitional year interns, and obstetrician-gynecologists), generalists (general internists and family physicians), and psychiatrists. A 33-item written questionnaire assessed knowledge and three attitudinal dimensions: attitudes attributed by physicians to patients; physicians' confidence in managing depression; and physicians' psychosocial orientation. A knowledge scale and an attitudes scale were scored by adding the number of knowledge items answered correctly and the more favorable attitudinal responses. Multivariable regression was used to identify physician characteristics among non-generalists and generalists associated with higher knowledge and attitudinal scores. RESULTS: Response rate was 82%. Sixty percent of the respondents were male, 63% were resident physicians, and 14% had advanced psychosocial training. Non-generalists and generalists had similar demographic characteristics, but psychiatrists were significantly more experienced. Psychiatrists had the most favorable attitudes, followed by generalists and non-generalists. Compared with non-generalists, generalists were more confident in prescribing antidepressants (62% vs 25%), more likely to report that treating depression is rewarding (71% vs 39%), and less likely to refer to a psychiatrist (58% vs 79%). Generalist classification, increased experience, and higher levels of psychosocial training were associated with more favorable attitudes. Knowledge scores were significantly higher for psychiatrists than for non-generalists and generalists. Among non-psychiatrists, correct responses for knowledge items were: treatment efficacy (61%), treatment duration (59%), > or = 5 DSM-III-R criteria (52%), and prevalence of depression (30%). Among those with incorrect responses, both non-generalists and generalists overestimated the prevalence (52%) and underestimated the efficacy of drug therapy (30%). CONCLUSIONS: Generalists and non-generalists have similar and relatively good basic knowledge about depression. Misperceptions about treatment efficacy, and attitudinal barriers, particularly among non-generalists, may compromise the physician's ability to diagnose and manage depression.
Depression↗
How well can the chest radiograph diagnose left ventricular dysfunction?
OBJECTIVES: To review the diagnostic utility of the chest radiograph for left ventricular dysfunction. DATA SOURCES: Structured MEDLINE searches, citation reviews of relevant primary research, review articles, and textbooks, personal files, and data from experts. STUDY SELECTION: Studies of patients without valvular disease that allowed calculation of the sensitivity and specificity of selected radiographic signs compared with a criterion standard of increased left ventricular preload or reduced ejection fraction. DATA EXTRACTION: Two independent readers reviewed 29 studies. Studies were pooled after stratification by radiographic finding, criterion standard, and clinical setting. MAIN RESULTS: Redistribution best diagnosed increased preload with a sensitivity of 65% (95% confidence interval [CI] 55%, 75%) and specificity 67% (95% CI 53%, 79%). Cardiomegaly best diagnosed decreased ejection fraction with a sensitivity of of 51% (95% CI 43%, 60%) and specificity of 79% (95% CI 71%, 85%). Interrater reliability was fair to moderate for redistribution and moderate for cardiomegaly. The clinical setting affected results by decreasing the specificity of cardiomegaly to 8% in detecting increased preload in patients with severe systolic dysfunction. The absence of redistribution could only exclude increased preload in situations in which the suspicion (pretest probability) of disease was less than 9%, whereas redistribution could confirm increased preload when the pretest probability was greater than 91%. The absence of cardiomegaly could only exclude a reduced ejection fraction if the pretest probability was less than 8%, whereas cardiomegaly could confirm a reduced ejection fraction if the pretest probability was greater than 87%. CONCLUSIONS: Redistribution and cardiomegaly are the best chest radiographic findings for diagnosing increased preload and reduced ejection fraction, respectively. Unfortunately, neither finding alone can adequately exclude or confirm left ventricular dysfunction in usual clinical settings. Redistribution is not always reliably interpreted.
Confidence Intervals↗
Safety belt nonuse by internal medicine patients: a missed opportunity in clinical preventive medicine.
BACKGROUND: The United States Preventive Services Task Force recommends that physicians routinely counsel all patients to wear safety belts. We undertook this study to determine the prevalence of the nonuse of safety belts among internal medicine patients, to measure the association of nonuse with other health risk factors, and to ascertain the safety belt counseling practices of physicians. PATIENTS AND METHODS: A total of 492 consecutive patients attending a university-based general medicine clinic were given a validated, self-administered questionnaire, and 94% responded. A medical chart review was performed in a blinded fashion on 94% of the eligible charts. RESULTS: Of the 454 patients who provided safety belt information, 243 (54%) did not wear safety belts. Nonusers were more likely to be problem drinkers, inactive, obese, and to have a low income (adjusted odds ratios 1.8 to 2.0). Of patients with all four of these characteristics, 91% did not use safety belts. The leading reasons for safety belt nonuse were discomfort (35%), short driving distances (24%), and forgetfulness (13%). Obese patients were more likely to report discomfort as their reason for nonuse (odds ratio 2.4; 95% confidence limit 1.4 to 4.3). Eighteen patients (3.9%) reported that a physician had ever counseled them about safety belt use. Only two of 314 medical records (0.6%) noted physician questioning or counseling about safety belt use. CONCLUSIONS: The majority of patients attending an internal medicine clinic do not wear safety belts. Nonusers are more likely to be problem drinkers, inactive, obese, and to have a low income. Patients with multiple health risk factors are at significant risk of nonuse. The most common reason for nonuse is physical discomfort, especially among obese patients. Finally, physicians rarely counsel patients to use safety belts.
Alcoholism↗
Medical student career choice: do physical diagnosis preceptors influence decisions?
The authors attempted to measure the influence of a physical diagnosis course and its preceptors on the career decisions of second-year medical students. They designed pre- and post-course questionnaires for 204 second-year medical students in a University of Texas Health Science Center at San Antonio Advanced Physical Diagnosis course. They found that 48% of students changed their career choice during the study period, 75% believed their preceptor was a very good role model, and 39% thought their preceptor influenced their career choice. Students who believed their preceptor was a good role model were 31 times more likely to consider their preceptors' career (confidence interval [CI] 95, 4.1-236). In results from students precepted by primary care physicians, there was a nonsignificant trend toward choosing a primary care career (Odds Ratio [OR]) 1.6 [CI95, 0.7-3.3]). Factors associated with a final career choice of primary care were a primary care career choice at baseline (OR 8.5 [CI95, 3.8-19.0]) and a belief that physical diagnosis skills would be important to a future career (OR 4.7 [CI95, 1.1-20.0]). By multivariable analysis, only a primary care career choice at baseline remained significant (OR 8.7 [CI95, 3.5-21.3]). The authors concluded that good role models can influence students to consider alternative career choices, but this effect is still overshadowed by a student's baseline career choice.(ABSTRACT TRUNCATED AT 250 WORDS)
Career Choice↗
Screening for prostate cancer.
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American Cancer Society↗
The clinical evaluation for diagnosing obstructive airways disease in high-risk patients.
OBJECTIVE: We measured the ability of the medical history, physical examination, and peak flowmeter in diagnosing any degree of obstructive airways disease (OAD). DESIGN: Prospective comparison of historical and physical findings with independently measured spirometry. SETTING: University outpatient clinic. PATIENTS: Ninety-two adult consecutive outpatient volunteers with a self-reported history of smoking, asthma, chronic bronchitis, or emphysema. MEASUREMENTS: All subjects completed a pulmonary history questionnaire and received peak flow (PF) and spirometric testing. The subjects were independently examined for 12 pulmonary physical signs by four internists blinded to all other results. Multivariable analysis was used to create a diagnostic model to predict OAD as diagnosed by spirometry (FEV1 < 80 percent of predicted not secondary to restrictive disease, or FEV1/FVC less than 0.7). RESULTS: The best model diagnosed OAD when any of three variables were present--a history of smoking more than 30 pack-years, diminished breath sounds, or peak flow less than 350 L/min. This model had a sensitivity of 98 percent and specificity of 46 percent. In addition, the model detected all subjects with probable restrictive lung disease. Thirty-one percent of subjects had none of these variables and were at very low (3 percent) risk of OAD. Fifty percent of subjects with one or more abnormal variables had OAD. CONCLUSIONS: The history, physical examination, and peak flowmeter can be used to screen high-risk patients for OAD. Using this diagnostic model, 31 percent of subjects could be classified at very low risk of OAD while half of those referred for spirometry would have abnormal results.
Airway Obstruction↗
Can moderate chronic obstructive pulmonary disease be diagnosed by historical and physical findings alone?
BACKGROUND: The value of the history and physical examination in diagnosing chronic obstructive pulmonary disease (COPD) is uncertain. This study was undertaken to determine the best clinical predictors of COPD and to define the incremental changes in the ability to diagnose COPD that occur when the physical examination findings and then the peak flowmeter results are added to the pulmonary history. SUBJECTS AND METHODS: Ninety-two outpatients with a self-reported history of cigarette smoking or COPD completed a pulmonary history questionnaire and received peak flow and spirometric testing. The subjects were independently examined for 12 physical signs by 4 internists blinded to all other results. Multivariate analyses identified independent predictors of clinically significant, moderate COPD, defined as a forced expiratory volume in 1 second (FEV1) less than 60% of the predicted value or a FEV1/FVC (forced vital capacity) less than 60%. RESULTS: Fifteen subjects (16%) had moderate COPD. Two historical variables from the questionnaire--previous diagnosis of COPD and smoking (70 or more pack-years)--significantly entered a logistic regression model that diagnosed COPD with a sensitivity of 40% and a specificity of 100%. Only the physical sign of diminished breath sounds significantly added to the historical model to yield a mean sensitivity of 67% and a mean specificity of 98%. The peak flow result (best cutoff value was less than 200 L/min) significantly added to the models of only one of the four physicians for a mean final sensitivity of 77% and a specificity of 95%. Subjects with none of the three historical and physical variables had a 3% prevalence of COPD; this prevalence was unchanged by adding the peak flow results. CONCLUSIONS: Diminished breath sounds were the best predictor of moderate COPD. A sequential increase in sensitivity and a minimal decrease in specificity occurred when the quality of breath sounds was added first to the medical history, followed by the peak flow result. The chance of COPD was very unlikely with a normal history and physical examination.
Adult↗
Concordance versus correlation.
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Evaluation Studies as Topic↗
Clinical and sociocultural determinants of gallstone treatment.
Cholecystectomy remains the principal treatment for gallstones. Many gallstone patients do not undergo surgery within 6 months of diagnosis. To determine factors associated with cholecystectomy, treated and untreated patients were compared with respect to clinical and sociodemographic factors. The study population was comprised of outpatients of a public system evaluated in an emergency room or at a community health center. All were interviewed in English or Spanish before completing imaging studies. Of 121 found to have gallstones, 75 underwent early cholecystectomy. Patients reporting episodes of prolonged abdominal pain more often had surgery (p < 0.003). Patients evaluated in the emergency room underwent surgery more often than those from the community health center (p < 0.04). Patient ethnicity was unrelated to treatment, but Mexican Americans who requested interviews in Spanish were less likely to undergo cholecystectomy (p < 0.05). After logistic regression, prolonged abdominal pain was the only significant predictor of surgical management, although relationships with language use and site of diagnosis persisted. It was concluded that clinical presentation largely determines surgical treatment for gallstones but site of diagnosis is also a factor. Patients with poor English language skills undergo cholecystectomy less often. This may be due to poor doctor-patient communication, or it may be a reflection of cultural factors linked to language use.
Cholecystectomy↗
Is screening for chronic obstructive pulmonary disease justified?
BACKGROUND: Many experts recommend spirometry to screen for chronic obstructive pulmonary disease (COPD) in asymptomatic patients; however, evidence for this recommendation has not been systematically reviewed. METHODS: We examined whether screening spirometry meets standard criteria for effective screening. We performed structured searches of MEDLINE, followed by a selective search of the CITATION index, to locate randomized trials of interventions for asymptomatic patients with COPD. In regard to smoking cessation, we included all controlled trials of smoking cessation programs that used spirometry. We also included all studies that assessed the ability of spirometry to predict successful smoking cessation by comparing baseline lung function in smokers who subsequently quit versus those who did not. RESULTS: With the exception of smoking cessation, all interventions for COPD have only been proven effective in symptomatic patients. Two studies found that multifaceted smoking cessation programs that included spirometry were efficacious. There was no effect in a third study that isolated the role of spirometry. Smokers with abnormal spirometric results are less likely than other smokers to quit over the ensuing year. CONCLUSIONS: There is no evidence that spirometry, as an isolated intervention, aids smoking cessation.
Cost of Illness↗
Detection of injury-prone behaviors among internal medicine patients.
OBJECTIVES: 1) To describe the prevalence of eight injury-prone behaviors (IPBs) and the associations of these behaviors with ten standard chronic disease and sociodemographic risk factors (CDSRFs) among internal medicine patients and 2) to identify a subset of patients with multiple IPBs who might be at particularly high risk of injury. DESIGN: Cross-sectional survey. SETTING: The University of Colorado Health Sciences Center general internal medicine clinic. PATIENTS: Four hundred ninety-two consecutive continuity care patients were eligible. The response rate was 94.3% (464/492). INSTRUMENT: A validated, self-administered questionnaire. MAIN RESULTS: Thirty-four percent of patients did not wear safety belts regularly and 32% had no smoke detector in their homes. Nearly 26% of patients had firearms at home and 6% had a loaded and unlocked gun at home. Fourteen percent of patients had seriously thought about suicide and 6% had attempted suicide. In the prior month, 10% had ridden with a drunk driver, and 4% had driven after drinking too much. Of patients aged 65 years or older, 50% had had recent falls. After adjustment for other CDSRFs, problem drinking was the CDSRF most frequently associated with IPBs. Among men, problem drinking was significantly associated with drinking and driving (OR = 35.3), safety belt non-use (OR = 4.3), and previous thoughts of or attempts at suicide (OR = 6.2). Among women, problem drinking was significantly associated with drinking and driving (OR = 8.7). Among men, being unmarried was the demographic risk factor associated with the most IPBs. Of all IPBs, safety belt non-use was most frequently associated with CDSRFs (ORs ranged from 2.8 to 4.4). Men with three or more IPBs were more likely to be problem drinkers (OR = 9.6), smokers (OR = 15.8), obese (OR = 6.3), and unmarried (OR = 67.1). CONCLUSIONS: 1) Injury-prone behaviors are common among patients attending a university-based internal medicine clinic; 2) men and women have substantially different patterns of risk factor associations; 3) CDSRFs, such as problem drinking smoking, and being unmarried, are associated with many IPBs; 4) safety belt non-use is the IPB associated with the most CDSRFs; and 5) CDSRFs appear to cluster in men with multiple IPBs, suggesting that screening for high-risk individuals may be feasible in clinical practice.
Accident Proneness↗
Clinical usage of the leukocyte count in emergency room decision making.
Leukocyte (WBC) and differential counts are commonly used, but their clinical characteristics are poorly understood. To understand how the clinician interprets the WBC count in the presence of these uncertainties, the authors used a case vignette with a questionnaire to isolate physician reaction to an abnormal WBC count as compared with a normal control WBC count. In response to a case vignette of a urinary tract infection in the emergency room, physicians altered their diagnostic and therapeutic plans based solely on the WBC count. The results of the study also suggest that the cost of the WBC is not limited to the test cost, but also includes the cost of the physician reaction to the abnormal WBC count.
Attitude of Health Personnel↗