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Biomedical subjects

R Tamblyn

Publications and source records attributed to R Tamblyn.

31 records · Page 2Linked to original sources
PubMed1994

Faculty ratings of resident humanism predict patient satisfaction ratings in ambulatory medical clinics.

OBJECTIVE: To determine whether patient satisfaction ratings can be predicted by faculty ratings or self-ratings of resident humanism. DESIGN: A prospective three-month collection of patient satisfaction ratings in two ambulatory care clinics and simultaneous acquisition of faculty ratings and self-ratings of resident humanism using ABIM questionnaires. SETTING: Two teaching hospital ambulatory care internal medicine clinics. PARTICIPANTS: Forty-seven internal medicine residents and 17 faculty internists were sent questionnaires for evaluation of humanism of individual residents. One thousand one hundred ninety-four consecutive outpatients cared for by the residents were eligible for patient satisfaction questionnaires. MEASUREMENTS AND MAIN RESULTS: Thirty-three residents and 13 faculty completed evaluations of resident humanism while 792 patients completed satisfaction questionnaires, which were used for analysis. The faculty ratings of resident humanism correlated strongly with patient satisfaction ratings, while the resident self-ratings did not. CONCLUSIONS: Faculty ratings of resident humanism were highly predictive of patient satisfaction with the care rendered by internal medicine residents in two ambulatory care clinics. This suggests that ambulatory care settings are useful for evaluation of noncognitive behavioral features of resident performance.

Ambulatory Care↗
PubMed1994

The feasibility and value of using patient satisfaction ratings to evaluate internal medicine residents.

OBJECTIVE: To determine the feasibility and value of using patient satisfaction ratings to evaluate the physician-patient relationship skills of medical residents. DESIGN: A cross-sectional survey was used to collect patient satisfaction information for medical residents from all patients attending the out-patient teaching clinics over a three-month period. The feasibility of patient rating was assessed by evaluating the reliability of resident satisfaction scores and potential sources of bias in rating. The value of using this method was assessed by evaluating the proportion of variance in ratings attributable to residents, the prevalence of residents with ratings substantially below average, and the effect of training on patient satisfaction. SETTING: The medical clinics of two teaching hospitals at McGill University. PARTICIPANTS: 91 medical residents and clinical clerks, 1,003 patients, and 1,219 visit ratings. RESULTS: An average of 12.2 satisfaction ratings were collected per resident, providing a reliability of 0.56 (intraclass correlation) for resident satisfaction score. Adjustment for differences in patient populations would be necessary to obtain comparable scores among residents. Fifteen percent of the residents had a substantially greater proportion of poor and fair satisfaction ratings than the study average. Residents were responsible for a substantial proportion of the variance in clinic waiting time and patient satisfaction rating. Training appeared to have no effect on improving satisfaction scores, except among women residents. CONCLUSIONS: Patient satisfaction ratings provide valuable information about a resident's ability to establish an effective physician-patient relationship. However, the number of ratings required to obtain a reliable estimate of resident skill may limit the feasibility of using patient ratings as part of residency evaluation.

Adolescent↗
PubMed1994

Evaluation of consultative skills in respiratory medicine using a structured medical consultation.

An essential component of competency in respiratory medicine is the acquisition of consultative skills. The American Board of Internal Medicine (ABIM) and other certification bodies have recommended a greater emphasis on the evaluation of clinical skills by direct observation. In this study, consultative abilities are assessed using the format of an objective structured clinical examination (OSCE). A six-case, 160-min-long, examination was administered to three groups of physicians: faculty members, respiratory residents, and junior residents in internal medicine. The overall quality of the consultations was significantly better for the attending physicians when compared with the junior residents, and there was a systematic trend for the quality to improve with increased training. The educational value of the consultation improved significantly with the level of training. There was a tendency for physicians with greater experience to report less of the findings from the history and physical on their consultations. Patient satisfaction, as measured by the standardized patients using an ABIM patient satisfaction questionnaire, did not differ between groups of examinees. The test reliability for the overall quality of consultation score was 0.65. The reliability of a 14-station exam was estimated to be 0.81. This exam proved to be a useful, valid, and moderately reliable tool for assessing the consultative skills of physicians and could prove to be of benefit to clinical training programs.

Clinical Competence↗
PubMed1994

Is the public being protected? Prevention of suboptimal medical practice through training programs and credentialing examinations.

Governments have traditionally looked to the medical profession for leadership in health planning and have charged the profession with the responsibility of establishing and monitoring standards of medical practice. Training program accreditation and licensure/certification exams have been used as the primary methods of preventing unqualified individuals from entering medical practice. Despite the critical nature of the decision made at the time of licensure/certification, there is no information about the validity of these examinations for predicting subsequent practice and health outcome. In this article, the assumptions implicit in the current use of licensing/certifying examinations are identified, the relevant evidence is reviewed, and the implications of this evidence for current methods of measurement are discussed.

Canada↗
PubMed1993

The effect of varying levels of outdoor-air supply on the symptoms of sick building syndrome.

BACKGROUND: The sick building syndrome is the term given to a constellation of symptoms reported by workers in modern office buildings, hypothesized to occur when the supply of outdoor air is reduced, because of the accumulation of contaminants arising from within the building. We undertook this study to determine the effect of changing the supply of outdoor air in four office buildings on the symptoms reported by workers and their perception of the indoor environment. METHODS: Within each of three consecutive two-week blocks, the ventilation systems in each building were manipulated, in random order, to deliver to the indoor environment an intended 20 or 50 ft3 (0.57 or 1.4 m3) of outdoor air per minute per person for one week at a time. Each week, the participants, unaware of the experimental intervention, reported symptoms and the indoor environment was thoroughly evaluated. RESULTS: Of 1838 eligible workers in the four buildings, 1546 (84 percent) participated in the study. The supply of outdoor air averaged 7 percent and 32 percent in the ventilation systems and 30 and 64 ft3 (0.85 and 1.8 m3) per minute per person in the work sites at the lower and higher ventilation levels, respectively. These changes in the supply of outdoor air were not associated with changes in the participants' ratings of the office environment or in symptom frequency (crude odds ratio, 1.0; 95 percent confidence interval, 0.9 to 1.1). After work-site measures of ventilation, temperature, humidity, and air velocity were included in the regression analysis, the adjusted odds ratio was also 1.0 (95 percent confidence interval, 0.8 to 1.2). CONCLUSIONS: Increases in the supply of outdoor air did not appear to affect workers' perceptions of their office environment or their reporting of symptoms considered typical of the sick building syndrome.

Adult↗
PubMed1988

How standardized are standardized patients?

The accuracy and reproducibility of the standardized patient's presentation of a clinical problem was evaluated in 15 cases used in the evaluation of fourth year medical students in two universities. There were differences in the quality of standardized patient presentation between institutions and among the cases presented.

Clinical Competence↗
PubMed1988

Methylmercury and the health of autochthons in northwest Quebec.

We conducted a cross-sectional epidemiologic and clinical study to evaluate the nature, magnitude, and frequency of unfavourable health states among residents of northwest Quebec. Of particular interest were the possible occurrence of Minamata disease and any other neurological abnormalities. We also sought to determine whether industrial or naturally-occurring mercury in the region's environment were causally associated with any disorders that might be detected. A total of 321 subjects were studied in four groups with contrasting exposure to point-source mercury from a chlor-alkali plant in the area. Methylmercury in hair served as the marker of subject's ingestion of any organic mercury (natural or industrial). Ten pre-chosen target variables, seven clinical and three neurophysiological, were assessed in all subjects. Relationships between mercury in hair and each target variable were calculated. We determined whether gradients in target variables corresponded to gradients in potential exposure of the subjects to the aquatic emissions of the chlor-alkali plant. Minamata disease was not found. Diabetes and alcohol-related health problems assessed as important clinically plausible confounders, were common. Differences in frequency or magnitude of clinical, toxicological, and physiological findings among the contrast groups were small and not of clinical or statistical significance. There were definite relationships between mercury in hair and four target variables despite the low values of mercury measured and the mild nature of the health problems observed. This would suggest that verifiable biological threshold levels for clinical effects, if such exist, may be substantially lower among Canadians than those currently adopted as policy for adults elsewhere. A gradient was found only for two of the ten target variables. Clinically meaningful alternate hypotheses for observed health effects emerge in the data and agree with observations in the field made by consulting clinical experts.

Animals↗
PubMed1987

A model to guide development and application of multiple nursing theories.

Over the past decade there has been an explosion of interest and activity in the nursing profession directed toward the development of a theory base for nursing education and practice. Although we support the overall thrust of nursing theory development, we have concerns about its utility, scope and stated purposes. We are especially sensitive to the plight of the practising nurse who might attempt to use the current nursing theories to guide and explain choices made in daily practice. In this paper we examine current use of the word 'theory' and describe problems inherent in nursing's efforts to apply educationally derived conceptual frameworks to nursing practice. We identify a need for the development and use of many theories for nursing and argue that there is a logical need for a 'meta-model' which will guide the use of multiple theories in practice. A model is presented which allows the practising nurse to examine the various theories in terms of their applicability to a given client situation. We believe the model is also useful to nurse educators and researchers who may be attempting to use nursing theories for educational purposes or develop nursing's knowledge base through empirical work.

Humans↗
PubMedDate not supplied

Adverse events associated with prescription drug cost-sharing among poor and elderly persons.

CONTEXT: Rising costs of medications and inequities in access have sparked calls for drug policy reform in the United States and Canada. Control of drug expenditures by prescription cost-sharing for elderly persons and poor persons is a contentious issue because little is known about the health impact in these subgroups. OBJECTIVES: To determine (1) the impact of introducing prescription drug cost-sharing on use of essential and less essential drugs among elderly persons and welfare recipients and (2) rates of emergency department (ED) visits and serious adverse events associated with reductions in drug use before and after policy implementation. DESIGN AND SETTING: Interrupted time-series analysis of data from 32 months before and 17 months after introduction of a prescription coinsurance and deductible cost-sharing policy in Quebec in 1996. Separate 10-month prepolicy control and postpolicy cohort studies were conducted to estimate the impact of the drug reform on adverse events. PARTICIPANTS: A random sample of 93 950 elderly persons and 55 333 adult welfare medication recipients. MAIN OUTCOME MEASURES: Mean daily number of essential and less essential drugs used per month, ED visits, and serious adverse events (hospitalization, nursing home admission, and mortality) before and after policy introduction. RESULTS: After cost-sharing was introduced, use of essential drugs decreased by 9.12% (95% confidence interval [CI], 8.7%-9.6%) in elderly persons and by 14.42% (95% CI, 13.3%-15.6%) in welfare recipients; use of less essential drugs decreased by 15.14% (95% CI, 14.4%-15.9%) and 22.39% (95% CI, 20.9%-23.9%), respectively. The rate (per 10 000 person-months) of serious adverse events associated with reductions in use of essential drugs increased from 5.8 in the prepolicy control cohort to 12.6 in the postpolicy cohort in elderly persons (a net increase of 6.8 [95% CI, 5.6-8.0]) and from 14.7 to 27.6 in welfare recipients (a net increase of 12.9 [95% CI, 10.2-15.5]). Emergency department visit rates related to reductions in the use of essential drugs also increased by 14.2 (95% CI, 8.5-19.9) per 10 000 person-months in elderly persons (prepolicy control cohort, 32.9; postpolicy cohort, 47.1) and by 54.2 (95% CI, 33.5-74.8) among welfare recipients (prepolicy control cohort, 69.6; postpolicy cohort, 123.8). These increases were primarily due to an increase in the proportion of recipients who reduced their use of essential drugs. Reductions in the use of less essential drugs were not associated with an increase in risk of adverse events or ED visits. CONCLUSIONS: In our study, increased cost-sharing for prescription drugs in elderly persons and welfare recipients was followed by reductions in use of essential drugs and a higher rate of serious adverse events and ED visits associated with these reductions.

Adult↗
PubMedDate not supplied

Medication use in seniors: challenges and solutions.

Use of prescribed and over-the-counter medication increases with age. Although drug therapy often results in beneficial effects and improve functional status, drug related illness is a significant health problem, accounting for 5 to 23 per cent of hospitalization, 1.75 per cent of ambulatory visits and one in 1000 deaths. In most studies, drug-related illness is more common in the elderly. Four factors influence the likelihood that a patient will experience adverse effects from a drug: the type of drug prescribed, the characteristics of patients receiving the drug, the characteristics of physicians who are prescribing the medication, and health care system policy and practice. Cardiovascular drugs, psychotropic drugs and NSAIDs are the three groups of drugs that are most commonly implicated in drug related illness, probably because they are the three groups of drugs that are most commonly prescribed in the elderly. The risk of an adverse effect with drug increases with the number of drugs prescribed. Several mechanisms may account for this phenomenon including (1) increased sensitivity of diseased tissue to drug toxicity (2) potential drug interactions, and (3) difficulties in patient compliance with an increasing number of drugs. Physician prescribing habits can increase the risk of adverse drug effects through two mechanisms: (1) the prescription of drugs that are unnecessary for the treatment of ailments that might be better managed through non-pharmacologic management and (2) the inappropriate prescription of drugs that are either contraindicated or prescribed in combination with other drugs that produce potential drug interaction. Errors in prescribing accounting for 19 to 36 per cent of hospital admissions due to drug-related events and up to 72 per cent of drug related events occurring in the hospital setting. Health care system policies influence the list of drugs that are included in the formulary, the conditions under which they are accessible and payment policy, all of which strongly influence the likelihood that a drug will be utilized. Physician payment policy may also influence drug prescribing and the success of initiatives to discontinue drugs. Interventions to improve the optimal use of medication will need to target policy, patients and physicians. Better information needs to be provided to physicians and patients about the risks and benefits of drug therapy, and the problems of patient compliance and inappropriate and unnecessary prescribing need to be addressed.

Aged↗