Tinkering or real reform? The choice is ours.
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Curriculum↗
Biomedical subjects
T S Inui
Publications and source records attributed to T S Inui.
Do we still need primary care tracks?
Primary care tracks in internal medicine residency programs were initiated in the late 1970s in response to the need for more primary care physicians. These programs have shown that internists can be trained effectively in ambulatory settings. Graduates of primary care tracks are more likely to choose careers in general internal medicine than are other internal medicine graduates. Primary care internist training has been accompanied by the growth of academic general internal medicine divisions and by the enhancement of the scientific base for ambulatory care practice and medical education. Expanded ambulatory training opportunities, modeled after current primary care tracks, should be offered to all residents in internal medicine. At the same time, primary care tracks should be revised to address deficiencies in current ambulatory training. These tracks should be designed to commit most resident time to ambulatory care settings, to involve residents in community-based and interdisciplinary health care, and to expose residents to conditions outside of the medical sector that affect health. Revised primary care tracks can serve as pathfinder programs for ongoing reform in internal medicine residency training. Three models for organizing and funding such reform are presented.
Curriculum↗
A 1992 manifesto for primary physicians.
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Curriculum↗
Geriatric preventive care. Counseling techniques in practice settings.
Counseling patients in preventive health measures may be considerably more difficult for the clinician than managing acute illnesses. It requires medical knowledge and assiduousness on the part of both patient and physician, facilitative systems, the cooperation of significant others, and longitudinal good communication between all of these persons to facilitate the kind of objective-setting necessary to make preventive medicine work. The spectrum of clinical preventive care for the elderly is considerable, and the breadth of communication competencies required for optimal effectiveness somewhat daunting. All are within the scope of activities of the active clinician, however, given time and reflective experience. In this broad domain, what is most important to elderly patients may not be primary prevention (avoidance of onset of new diseases) but tertiary prevention (avoidance of impaired function from diseases already in existence) and avoidance of iatrogenesis. Ironically, the final acts of geriatric clinical prevention are those designed to assure appropriate end-of-life care.
Aged↗
Changes over time in the knowledge base of practicing internists.
OBJECTIVE: To determine factors affecting the knowledge base of practicing internists. DESIGN: An 82-item multiple-choice examination with questions from the 1988 American Board of Internal Medicine (ABIM) certifying examination was used to assess the knowledge base of 289 internists. SETTING AND PARTICIPANTS: Participants were selected from among practicing internists in New York, New Jersey, and Pennsylvania who had received ABIM certification 5 to 15 years previously. RESULTS: significant inverse correlation (r = -.30) was found between examination scores and the number of years elapsed since certification. Knowledge declined sharply within 15 years of certification. In addition, procedure-oriented subspecialists (cardiologists and gastroenterologists) had lower scores than other internists in this examination of general medical knowledge. Multivariate analyses showed that independent variables that predicted test performance were initial ABIM certifying examination score, time elapsed since certification, subspecialty classification, medical school type, and residency type. CONCLUSIONS: These results support the recent decision for time-limited certification of internists and raise questions related to content and standard setting for recertification examinations.
Certification↗
An approach to several problems in using large databases for population-based case-control studies of the therapeutic efficacy and safety of anti-hypertensive medicines.
In this paper we discuss approaches to two distinct problems in using large computerized databases to conduct population-based case-control studies. The first topic, concerning case ascertainment, is a methodologic problem, and the second, concerning confounding by indication, is an analytic problem. The first involves attempting to ascertain all incident cases of coronary disease among enrollees of Group Health Cooperative of Puget Sound (GHC), a large health-maintenance organization. Methodologic studies reported here have helped us improve the efficiency of using the large computerized databases for case ascertainment at GHC. The second problem involves the issue of confounding by drug indication. Drugs such as beta-blockers have multiple indications, including the treatment of both high blood pressure and angina. These two indications may make it difficult in an observational study to determine whether beta-blockers may prevent coronary disease in patients with high blood pressure. We discuss here our current thinking about the best analytic approach to this problem.
Adrenergic beta-Antagonists↗
The place of human values in the language of science: Kuhn, Saussure, and structuralism.
The current paradigm in medicine generally distinguishes between genetic and environmental causes of disease. Although the word "paradigm" has become a commonplace, the theories of Thomas Kuhn have not received much attention in the journals of medicine. Kuhn's structuralist method differs radically from the daily activities of the scientific method itself. Using linguistic theory, this essay offers a structuralist reading of Thomas Kuhn's The Structure of Scientific Revolutions. Our purpose is to highlight the similarities between these structuralist models of science and language. In part, we focus on the logic that enables Kuhn to assert the priority of perception over interpretation in the history of science. To illustrate some of these issues, we refer to the distinction between environmental and genetic causes of disease. While the activity of scientific research results in the revision of concepts in science, the production of significant differences that shape our knowledge is in part a social and linguistic process.
Disease↗
Factors associated with participation in a randomized trial of adult day health care.
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Aged↗
Indeterminate human immunodeficiency virus type 1 western blots: seroconversion risk, specificity of supplemental tests, and an algorithm for evaluation.
The human immunodeficiency virus type 1 (HIV-1) Western blot is indeterminate in 10%-20% of sera reactive by EIA. Eighty-nine individuals with prior repeatedly reactive EIA and indeterminate Western blots were followed prospectively to study the risk of seroconversion and specificity of supplemental tests. Four high-risk cases seroconverted within 10 months after enrollment (seroconversion risk, 4.5%, 95% confidence interval, 1.2%-11.1%). Among cases with p24 bands initially, 4 (18.2%) of 22 high-risk individuals seroconverted compared with 0 of 33 low-risk cases (P = .03). Specificities of HIV-1 culture, serum p24 antigen, polymerase chain reaction, and recombinant ENV 9 EIA were 100%, 100%, 98.6%, and 94.4%, respectively. An expedited evaluation protocol is proposed. Low-risk individuals with nonreactive EIAs upon repeat testing do not need further follow-up; high-risk individuals should be followed serologically for at least 6 months, especially those with p24 bands on Western blot.
AIDS Serodiagnosis↗
The Health of the Public Program at the University of Washington: a new role for academic medical centers.
The University of Washington Health of the Public Program has convened a consortium composed of the region's academic medical center, the two largest managed care plans in Washington, and representatives of the state's major private and public purchasers of health care. The consortium's purpose is to test the feasibility of collaboratively collecting cross-system data, assessing variations in practice, and implementing site-specific interventions to improve the management of common illnesses and encourage preventive care. Changes under way in the ambulatory training environment and in the undergraduate curriculum as a result of the consortium's initial efforts are described. In today's climate of cost consciousness and concerns about quality, academic medical centers can play an important role in helping to improve community-wide outcomes of care.
Academic Medical Centers↗
Adult day health care evaluation study: methodology and implementation. Adult Day Health Care Evaluation Development Group.
The Adult Day Health Care Evaluation Study was developed in response to a congressional mandate to study the medical efficacy and cost effectiveness of the Adult Day Health Care (ADHC) effort in the Department of Veterans Affairs (VA). Four sites providing ADHC in VA facilities are participating in an ongoing randomized controlled trial. Three years of developmental work prior to the study addressed methodological issues that were problematic in previous studies. This developmental work resulted in the methodological approaches described here: (1) a patient recruitment process that actively recruits and screens all potential candidates using empirically developed admission criteria based on predictors of nursing home placement in VA; (2) the selection and development of measures of medical efficacy that assess a wide range of patient and caregiver outcomes with sufficient sensitivity to detect small but clinically important changes; and (3) methods for detailed, accurate, and efficient measurement of utilization and costs of health care within and outside VA. These approaches may be helpful to other researchers and may advance the methodological sophistication of long-term care program evaluation.
Aged↗
Beta blockers and the primary prevention of nonfatal myocardial infarction in patients with high blood pressure.
A population-based, case-control study was conducted to determine whether beta blockers, used for the treatment of high blood pressure, prevent first events of coronary heart disease. All study subjects were health-maintenance organization enrollees with pharmacologically treated hypertension. Patients presented in 1982 to 1984 with new coronary heart disease, and control subjects were a probability sample of eligible hypertensive enrollees free of coronary heart disease. With the investigators blind to case-control status, the subjects' medical records were reviewed for other coronary risk factors, and the health-maintenance organization's computerized pharmacy database was used to ascertain the use of beta blockers. A larger proportion of controls than cases were using beta blockers. This difference was confined to the subgroup with nonfatal myocardial infarctions. For current use, the estimated relative risk for nonfatal myocardial infarction was 0.62 (95% confidence interval, 0.39 to 0.99). Among current users of beta blockers, higher doses conferred greater protection. Past use and total lifetime intake of beta blockers were only weakly associated with case-control status. The current use of beta blockers may prevent first events of nonfatal myocardial infarction in patients with high blood pressure.
Adrenergic beta-Antagonists↗
Predictive validity of certification by the American Board of Internal Medicine.
STUDY OBJECTIVE: To determine the predictive validity of the American Board of Internal Medicine (ABIM) certification process. DESIGN: Prospective measurement of the knowledge, skills, and attitudes of 185 ABIM-certified and 74 noncertified internists by a written examination; evaluation by professional associates; a patient questionnaire assessing satisfaction with care, physician's counseling role, and preventive care; and review of records of patients with common illnesses. SUBJECTS: Practicing internists who completed training or received ABIM certification 5 to 10 years previously. SETTING: Office-based practices in six western states. RESULTS OF DATA ANALYSIS: Physicians certified by the ABIM had significantly higher scores on the written examination than the noncertified physicians, and scores on our examination correlated highly with the ABIM certification examination (r = 0.73). Ratings of clinical skills by professional associates were significantly higher for certified internists and also correlated highly with ABIM examination scores (r = 0.53 to 0.59). Regression analysis showed that ABIM certification status was the major variable affecting performance on these measures of clinical competence. Results from other measures did not show many differences between certified and noncertified physicians in the care of patients with common illnesses, but modest differences in preventive care and a few differences in outcome favored the certified physicians. CONCLUSIONS: Comparison of findings from the written examination and the professional associate ratings with certification status and original ABIM certification examination scores shows predictive validity of ABIM certification. Further studies are needed to determine if certification status predicts important differences in the care of patients with complex illnesses.
Certification↗
Beta-blockers and primary prevention of coronary heart disease in patients with high blood pressure.
We conducted a population-based, case-control study to determine whether beta-blockers, used for the treatment of hypertension, prevent first events of coronary heart disease. Cases were patients who had high blood pressure treated with medicines and who presented in 1982 to 1984 with angina or fatal or nonfatal myocardial infarction. Controls were a probability sample of health maintenance organization patients with pharmacologically treated hypertension and free of coronary heart disease. Blinded to case-control status, we reviewed the medical records of the 248 cases and 737 controls. The health maintenance organization's computerized pharmacy database was used to ascertain the use of beta-blockers. Fewer cases than controls were taking beta-blockers. This difference was confined to those with nonfatal infarctions. After adjustment for confounding, the estimated relative risk was 0.62 (95% confidence interval, 0.39 to 0.99). Higher doses of beta-blockers conferred greater protection. We conclude that beta-blockers may prevent first events of nonfatal myocardial infarction in patients with high blood pressure.
Adrenergic beta-Antagonists↗
Coffee and alcohol use and the risk of ulcerative colitis.
We performed a population-based, case-control study of the risk of ulcerative colitis associated with coffee and alcohol use among the 304,000 members of a prepaid health plan. We compared coffee and alcohol use histories before ulcerative colitis onset in 209 cases and an equal number of age- and sex-matched controls selected from the enrollment file of the prepaid health plan. Neither coffee use, amount of coffee consumed daily, or cumulative coffee consumption before disease onset altered the risk of developing ulcerative colitis. A decreased risk of ulcerative colitis was associated with alcohol consumption before disease onset among never-smokers only. This risk declined as daily alcohol consumption increased. These results suggest that alcohol consumption may lower ulcerative colitis incidence.
Coffee↗
The knowledge base of certified internists. Relationships to training, practice type, and other physician characteristics.
A written examination was used to assess the knowledge base of 183 practicing certified internists. Analyses of the examination scores showed that performance on the initial American Board of Internal Medicine certification examination taken 7.6 years previously was the major factor predicting current knowledge base. By developing regression models, the unique contribution of different variables to prediction of current examination scores was determined. Prior American Board of Internal Medicine certification examination performance accounted for 70.9% of the explained variance, and demographic and practice variables were responsible for 17.8%. Among the demographic and practice variables studied, community size and subspecialty practice were the only variables that contributed significantly to the regression equations. Examination scores were highest for certified internists practicing in smaller communities. General internists received higher scores than subspecialists. Although statistically significant, the apparent adverse influence of subspecialty practice and larger community size on examination performance was modest. Further study is needed to determine if longer periods in practice might produce different relationships between variables such as these and examination performance.
Certification↗
Screening for occupational disease among workers in a high-risk trade: examination of cost, yield, and potential for increased efficiency.
We evaluated the cost and yield of a general health surveillance program emphasizing the identification of occupationally related diseases among workers in a high-risk trade. Of approximately 4,000 eligible members of two local plumbers and pipefitters unions, 639 were screened in this program. Screening tests indicated either by specific occupational exposures (eg, chest X-ray, spirometry, and audiometry) or general clinical risk factors (urine analysis for those with a positive urine dipstick, and stool heme occult testing for those over 45 years of age) proved to be far less costly for each positive finding than those procedures (physical examination, complete blood count, and blood chemistry panel) that were not specifically indicated. A discriminant analysis revealed predictor variables (age, years in the trade, and presence of respiratory symptoms) that, in subsequent screening efforts, could be used in the unscreened population either to identify individuals who are more likely to have any positive test result or to "tailor" the content of the initial screening program for a single individual. Increasing the yield and decreasing the direct costs of screening activities may make programs like these more affordable. In addition, this program assisted workers in filing for compensation and thus served to promote the appropriate transfer of cost for the identification and management of occupational diseases from traditional forms of payment to workers' compensation insurance programs.
Adolescent↗
A general method of compliance assessment using centralized pharmacy records. Description and validation.
The prescription refill records of centralized pharmacies are a potential source of information about patient compliance with long-term medications. We developed a method for assessing compliance in such settings and validated our measures using pharmacy data and clinical information from patients with seizure disorders and hypertension. For patients taking the anticonvulsant medication phenytoin, compliance with the drug correlated significantly with mean plasma phenytoin level. For patients on antihypertensive medications, compliance with the treatment regimen correlated with control of diastolic blood pressure. Many patients (15% in the phenytoin validation, and 33% in the blood pressure validation) obtained substantial oversupplies of medications; for these patients, the direct relationship between compliance and drug effect was not evident. A majority of seizure patients with "subtherapeutic" mean plasma phenytoin levels were identified as noncompliant using our measures. We conclude that our method of assessing compliance in obtaining medications is feasible in "managed care" settings, appears to be a valid correlate of drug effects, and may be useful in research and patient care.
Computers↗