Biomedical subjects
Publications and source records attributed to W M Rodney.
A three-year diagnostic ultrasound training project for generalists is described. Specific applications and a rationale for the use of ultrasound by general physicians are presented. The current status of training programmes, credentialing strategies, and desirable equipment characteristics are also discussed. Finally, benefits, liabilities and controversies in diagnostic ultrasound imaging are reviewed.
A randomized prospective study examined the impact of bowel gas introduced by 65-cm flexible sigmoidoscopy (FS) on the ability to perform air-contrast barium enema (ACBE) on the same day. Seventy-five patients at risk for colorectal cancer were randomly assigned to two groups. Of these, 28 patients in each group completed the protocol. The study group received flexible sigmoidoscopy and air-contrast barium enema on the same day, whereas the control group had their air-contrast barium enema on a different day. Bowel gas observed on an abdominal scout film prior to air-contrast barium enema was quantified on a scale of 1 (excessive gas) to 5 (no gas). The cancellation rate for the air-contrast barium enema was measured in each of the groups. The study group had significantly more bowel gas compared with the control group (p = 0.000003). The air-contrast barium enema cancellation rate was also higher in the study group (36%) than in the control group (14%) (p = 0.06). Greater than 60% of the study group patients were successfully examined. Same-day scheduling would reduce the number of bowel preparations required in the evaluation of patients at risk for colorectal cancer. Although retrospective studies have suggested no impact of same-day FS on ACBE quality, radiologists in this study canceled approximately one-third of scheduled patients due to perceived excessive bowel gas.
Procedural skills in flexible sigmoidoscopy and colonoscopy are widely accepted as diagnostic and therapeutic tools that assist physicians as they attempt to understand the biological and behavioral elements of undifferentiated gastrointestinal illness. Data support the ability of family physicians to perform and teach some of these endoscopic skills. Although one major contribution of these procedures is in the prevention of premature colorectal cancer mortality, other important patient care benefits are emerging for the office-based physician. Breadth of care enhances our most important therapeutic tool--the doctor/patient relationship. Unnecessary referral contributes to fragmentation and depersonalization of the health care system. Family physicians are urged to examine and acquire new procedural skills appropriate for their community. The process of privileges is discussed.
Medical students frequently have questions about the specialty of family practice. Responses to 30 questions commonly asked about family practice are presented with a review of recent literature. These responses may assist medical students and their advisors in considering the choice of family practice as a career.
A practical program to train family physicians in obstetric ultrasound was tested with 13 family physicians. Each physician completed 6.5 days of course work and ultrasound laboratory apprenticeship prior to beginning a clinical preceptorship of approximately 14 months' duration. During the clinical preceptorship the physicians performed ultrasound studies in their own offices. All studies were reviewed by a local consultant radiologist utilizing examination data sheets and videotapes. At the conclusion of the training program, the physicians took a combined practical and written proficiency examination administered by an independent sonographer. Eight physicians completed the training, performing during the preceptorship an average of 78 examinations. The rated performance of the physicians improved markedly over the course of the preceptorship. During the last segment of the preceptorship the radiologist preceptors rated 94 percent of the ultrasound studies as acceptable, compared with 79 percent rated acceptable at the beginning of the preceptorship. Seven of the eight physicians completing the protocol took the proficiency examination: all passed. This study can provide a blueprint for an individual family physician to design his own training, or it can guide an academic department of family medicine in developing and evaluating ultrasound training programs for residents and practicing physicians.
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Despite the availability of a procedure room equipped for the performance of common surgery procedures, physicians in a family medicine training programme have reported that minor surgery training objectives are not being accomplished. To examine this issue, the frequency of minor surgery procedures was audited among 357 randomly selected medical records. The frequency of documented sigmoidoscopy in this group of active patients over the age of 50 years was 4.8%. A similar low frequency for the performance of skin biopsy was also observed. All 15 senior residents participated in an attitude survey and a timed exercise in which they sought to find the necessary items for performance of a skin biopsy. In a questionnaire the group agreed that sigmoidoscopy and skin biopsies were procedures appropriate for their family practice goals. In their offices, these residents required over nine minutes to partially locate equipment chosen for skin biopsy. The attitude survey revealed few constraints other than insufficient time to perform indicated elective procedures. Further study of procedure room utilization and family physicians' office surgery skills is recommended.
Ninety-four out of 114 physicians who took part in a continuing medical education course on flexible sigmoidoscopy were contacted 12 to 18 months later. Ninety per cent (85) were now using flexible sigmoidoscopy in their office practice. Complete demographic and procedure-outcome information (number of procedures performed, average depth of insertion, time required for procedure, complications) was acquired from 78 of these physicians. Using a randomly chosen comparison group of 87 physicians matched for sex and specialty, the likelihood of similar continuing medical education during the study period was obtained. Thirty-two physicians had obtained this training and 69% (22 of 32) currently used flexible sigmoidoscopy. Utilization of the method was 9% (four of 45) among physicians who had not obtained this continuing education. Continuing medical education was significantly associated (P less than 0.05) with the acquisition and utilization of flexible sigmoidoscopy. The study group reported 5467 procedures, resulting in one bowel perforation. The utilization of sigmoidoscopy in primary care was significantly greater (P less than 0.05) in the post-continuing education period. After 10 to 20 procedures, insertion depths and procedure times were similar to those reported in other published primary care series.
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The 1982 US Festival, a three-day outdoor rock music festival, attracted close to 410,000 people. Through a private contractor, a group of physicians participated in the design, administration, and implementation of medical care for this event. Basic ambulatory care was provided by a multitiered approach, using emergency medical technicians, registered nurses, medical health counselors, and physicians. A total of 2,623 encounters required examination and evaluation by health professionals. Thirty-eight percent (1,014 cases) involved minor surgical trauma. Extreme environmental conditions, including temperatures exceeding 114 F, high winds, and unusually high dust concentrations, were thought to be responsible for 361 (13.6%) cases of reactive airway disease and 184 (7%) cases of heat exhaustion. There were 91 transports, of which 12 were classified as major casualties; there were no deaths.
Sixty-three consecutive fourth-year medical students applying for a family medicine training programme based in a county hospital questioned about their anticipated practice style and the projected cost of malpractice insurance premiums during their first year of practice. Those who felt committed to providing obstetric services within their family practice estimated a much lower first-year dollar cost for malpractice insurance than those who were not committed to obstetric services. The difference in estimates was greater than $10 000 per year. Both groups far exceeded the actual quoted first year cost by three separate malpractice insurance companies. This study suggests that medical students may be influenced by unrealistic estimates of malpractice insurance costs prior to real world experiences. Furthermore, these estimates may indicate widespread ignorance and/or misinformation among medical students considering a family medicine career. malpractice suits and the fear of them remain, however, an important distraction from the provision of patient care services in the United States.
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Patient satisfaction with resident physicians and patient satisfaction with faculty physicians was investigated in three clinical centers of a county hospital-based family medicine residency. Only patients in a continuity relationship (minimum 5 visits) were studied. Utilizing a previously validated Patient Satisfaction Questionnaire (PSQ), the dimensions of access, availability, continuity, finances, physician humaneness, and physician quality/competence were measured. Although there was little discriminant power between the measures of physician humaneness and quality/competence of care, overall internal validity was high. Availability and finances created the most dissatisfaction. Residents' care was reported to be as satisfying as that delivered by faculty physicians. Differentiation between system dependent factors and physician-dependent factors may be difficult among patients with a demonstrated continuity relationship. Nevertheless this study demonstrated a high internal validity for the short form of the PSQ in yet another practice setting. This instrument is available for further investigation in clinical settings.
The first multidisciplinary course developed jointly by the American Academy of Family Physicians and the American Society for Gastrointestinal Endoscopy is described. This prototype program was designed to teach the skills of 35 cm flexible sigmoidoscopy (FS) to twenty family physicians. Gastroenterologist preceptors determined that all 20 family physicians could perform this procedural skill within ten supervised cases. A control group of family physicians was studied to determine flexible sigmoidoscope acquisition frequencies in separate cohorts (Continuing Medical Education (CME) versus no CME on flexible sigmoidoscopy). The study group acquired instruments more frequently (18/19 = 95%) (p less than or equal to .05) than those with previous CME on FS (8/14 = 57%) or without previous CME on FS (2/19 = 11%). Two-thirds of these physicians purchased 60-65 cm flexible instruments rather than the 35 cm instrument. Longitudinal studies will be required to determine whether or not this intervention will have a meaningful impact upon colorectal cancer screening behaviors by primary care physicians.
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The office impact of two types of continuing medical education on flexible sigmoidoscopy were compared. Measured office outcomes included sigmoidoscopy utilization rates, depth of insertion, time required to perform the procedure, biopsy rates, acquisition of further training, use of electrocautery, performance of polypectomy, complication rates, and general satisfaction with office flexible sigmoidoscopy. A matched control group was randomly selected and polled for previous flexible sigmoidoscopy continuing medical education and current flexible sigmoidoscopy utilization. Outcomes as they relate to different types of course design were discussed and compared. Procedure times and depth of insertion were comparable to published studies from tertiary care centers. In the faculty intensive course, trainees utilized less procedure time for their initial 10-20 procedures. Attitudes in practice were positive with 68% of all physicians performing biopsy. A 60-cm scope length was chosen by 87% of physicians. Physicians in faculty intensive courses were more likely to obtain additional training and less likely to initiate higher risk procedures such as electrocautery, polypectomy, and colonoscopy.
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