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Future practice risks: obstacles with opportunities.

The encouragement of a consumer-directed insurance market and the involvement of corporate America have led to a transformation of the healthcare system that will redefine patient expectations and the role of the physician. The expectation of a higher level of customer service, the role of electronic media, and an earnest regard for healthcare by the patient will impact the physician. Consumer-directed healthcare will call for a reprioritization, focusing on service, convenience, competency, quality, and low cost. Indifference to patient courtesies or failure to become involved in modern technology may cause the physician to be bypassed from this new healthcare system. As the business world integrates the business model into the medical profession, healthcare organizations will restructure themselves into well-organized business enterprises employing physicians. The singular physician may no longer be competitive with such business enterprises, leading to consolidation of organizations and a significant decision for the physician. The physician will have the unusual opportunity to either remain exclusively a medical professional or to also venture into the business world as an equity investor, participating in financial growth possibilities of those medical practice organizations that are for-profit. With the emergence of these new equity models of healthcare, the primary focus will be on profit, production, and service efficiencies. It is the responsibility of the physician to maintain professionalism and the commitment to quality and appropriateness of patient care. However, at the same time, the physician has the unique opportunity to participate in the distribution, economics, and subsequent financial profit of healthcare. The medical experience of the physician, coupled with business acumen, will be an unbeatable combination.

Humans↗

Incentives and obstacles to the routine use of outcomes measures by clinicians.

OBJECTIVE: Unless clinicians are forced by funds providers to use outcomes measures, clinicians will choose to use them only if the value they provide is commensurate with the administration time required. This study was designed to determine which aspects of outcomes measures encouraged clinicians to use them and which aspects discouraged clinicians from using them. DESIGN: Clinicians who had used one or more outcomes measures were surveyed using a reasonably open-ended survey. Comments were analyzed by categorising them and counting the number of comments within each category. RESULTS: Aspects that were most valued included determining the clients' goals and expectations at the outset of the rehabilitation program, as well as measures of improvement and of residual hearing difficulties at the end of the program. Aspects that most discouraged the use of outcomes measures included collection or recording of information that the clinician would prefer to collect and record in other ways, and an excessive amount of time to administer. CONCLUSION: To maximize the adoption of outcomes measures by clinicians, the tools should provide information in addition to a simple quantification of benefit. For example, this might comprise information about clients' initial goals and/or expectations.

Attitude↗

Obstacles encountered in the development of the low vision enhancement system.

The Johns Hopkins Wilmer Eye Institute and the NASA Stennis Space Center are collaborating on the development of a new high technology low vision aid called the Low Vision Enhancement System (LVES). The LVES consists of a binocular head-mounted video display system, video cameras mounted on the head-mounted display, and real-time video image processing in a system package that is battery powered and portable. Through a phased development approach, several generations of the LVES can be made available to the patient in a timely fashion. This paper describes the LVES project with major emphasis on technical problems encountered or anticipated during the development process.

Audiovisual Aids↗

Visual correlates of obstacle avoidance in adults with low vision.

This study examined how mobility performance in a heterogeneous sample of visually impaired adults relates to measures of visual sensory and perceptual function. We found that the best predictors of mobility performance under photopic and scotopic lighting conditions were models that incorporated visual field extent (VFE) and scanning ability. Together with measures of contrast sensitivity and spatial resolution, these models accounted for approximately 50% of the variance in mobility performance. We also found that VFE and scanning ability were the dominant predictor variables when the sample was broken down by subjects' type of vision loss into an acuity loss, a visual field restriction, and a combination loss group.

Adaptation, Ocular↗

Managing device infections: are we progressing or is infection an insurmountable obstacle?

This article reviews infections that occur in patients with implanted mechanical circulatory support devices and presents recent data for signs of progress in controlling the incidence and impact of these infections. Two types of comparisons are used to examine this question. First, the outcomes of patients with HeartMate vented electric left ventricular assist devices (VADs) (Thoratec Corp, Pleasanton, CA) implanted during the REMATCH Trial are compared with the outcome of more recent patients who received this pump as destination therapy. Second, the outcome of patients who received a smaller left VAD (e.g., an axial flow VAD) or a fully implanted left VAD are reported and contrasted with results from the REMATCH era. Data are presented to support the hypothesis that improvements in patient selection, patient management, device durability, and device design have resulted in lower rates of infection and infection-related death for patients who require mechanical circulatory support.

Bacterial Infections↗

Obstacles to the early detection of endocervical adenocarcinoma.

We observed that the ratio of in situ to invasive carcinomas of the cervix is significantly greater for squamous than for glandular lesions. We wondered whether Pap smears were less effective for the identification of in situ glandular lesions. The purpose of this study was to determine if the location, extent of disease, and growth patterns of endocervical adenocarcinomas influence the ability to detect malignant cells by Pap smears. Medical records, doctor's office records, and all pathology materials (reports and slides) including Pap smears, biopsies, LEEP/cone biopsies, and hysterectomy specimens from 53 consecutive patients diagnosed with endocervical adenocarcinomas were examined at New York University Medical Center (a total of 654 pathology slides and 51 Pap smears were reviewed). Findings were correlated for each patient using gross descriptions and histopathology and stratified by location/extent of disease and growth pattern (exophytic or endophytic or both). Ten patients had in situ disease, seven (70%) of which involved the transformation zone (TZ); all seven of these were identified by Pap smears. In contrast, of the other three cases that did not involve the TZ but were confined to the endocervix, only one was identified by Pap smear. Forty-three patients had invasive disease. Twenty involved the TZ, and 23 involved the endocervix but spared the TZ. Of the 20 tumors involving the TZ, 11 (55%) were identified by Pap smears, whereas of the 23 sparing the TZ, 11 (47.8%) were diagnosed by Pap smear. Among the 23 patients with invasive disease that spared the TZ, 6 (26%) had a documented history of negative Pap smears at New York University within 3 years of diagnosis. Conversely only 1 of the 20 patients with TZ involvement had a history of negative Pap smears, and 3 patients in this group denied having had Pap smears for several years. Including all 53 patients, a significantly higher proportion were not detectable by Pap smear if the TZ was spared (54% versus 25%, p = 0.036). Of the 23 invasive cancers that spared the TZ, 6 (14%) had verified negative Pap smears. These lesions did not shed malignant cells onto Pap smears. Noteworthy was the finding that two of these six lesions extended from the endocervix upward, through the stroma, and into the endomyometrium of the lower uterine segment. Four extended downward into the exocervix through the stroma, sparing the surface mucosa; one reached the upper vagina. All six displayed an endophytic growth pattern.

Adenocarcinoma↗