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Teaching and learning clinical skills, Part 1--Development of a multidisciplinary skills centre.

A critical review of current nursing, midwifery and medical education programmes in the context of a changing health service, had led staff at the nursing and medical colleges at St Bartholomew's Hospital in London to conclude that radical approaches to teaching and learning are needed. This is particularly the case for the teaching and assessment of competence in clinical skills. Increased emphasis on community care, day care and outpatient teaching with the concomitant increase in dependency and throughput of inpatients, makes it increasingly difficult for students to observe and practice communication and clinical skills. To meet this major challenge, a joint initiative between the College of Nursing & Midwifery, the Medical College and the St Bartholomew's NHS Group to develop a clinical skills learning facility has been established. The Skills Centre will provide a focus for the learning and assessment of clinical and communication skills in a multidisciplinary environment. In a series of two papers the aims and development of the joint initiative will be explored together with four key outcomes, a Clinical Skills Matrix, a staged approach to skills teaching, a schedule for teaching and assessing clinical skills and the Integrated Skills Teaching Model.

Clinical Competence↗

The prediction of treatment outcome at a multidisciplinary pain center.

The purpose of this study was to determine if some commonly used admission variables could predict treatment outcome on a multidisciplinary pain center. Specifically, it was designed as a prospective study of an index proposed by Maruta et al. The subjects were 104 patients. The 4 outcome measures used were staff judgment, patient judgment, change in pain scores and change in mood. With the exception of a negative correlation with age, none of the other variables predicted outcome. The index of Maruta did not predict outcome.

Adult↗

Treatment outcome and compliance with therapeutic regimens: long-term follow-up of a multidisciplinary pain program.

Fifty-seven patients (74%) who had completed a multidisciplinary pain program returned mailed questionnaires assessing both outcome and compliance measures. Significant treatment gains were observed at follow-up. Compliance with prescribed therapeutic regimens was low, averaging around 42% for individual regimens. Compliance with any one therapeutic regimen was generally unrelated to rate of compliance with other therapeutic regimens. Discriminant relationships were observed between the various therapeutic regimens and outcome measures.

Adult↗

Multidisciplinary pain center follow-up study: evaluation with a no-treatment control group.

The long-term efficacy of a multidisciplinary pain management center was evaluated by comparing 20 treated patients with 20 no-treatment control patients who met the program's entrance criteria, wanted to participate, but could not because they did not have insurance coverage. At 1-5 years follow-up, 60% of the treated patients met all of the criteria for success established by Roberts and Reinhardt, while none of the untreated patients did so. Treated patients reported less interference with activities, more uptime, lower pain levels, less depression, and fewer hospitalizations than untreated patients. Also, more treated patients reported being employed, while fewer used either narcotic or psychotropic medications at follow-up compared to untreated patients. Pretreatment-to-follow-up changes are reported for both the treated and untreated groups.

Adult↗

Factors for predicting premature termination from a multidisciplinary inpatient chronic pain program.

Forty-eight chronic pain patients who were discharged from or left the 21-day inpatient component of a multidisciplinary pain program prior to completion were compared with a randomly selected matched group of program patients who stayed the entire 21 days. The purpose of the study was to determine if pre-admission factors are useful in predicting whether a chronic pain patient will complete an inpatient pain program. The results of pre-admission MMPI, POMS, MPQ, and information obtained from a questionnaire specially created for the program were studied. On the tests, the non-completers admitted to less psychopathology than those who did complete the program. The non-completers also had a higher number of pain-related surgeries and were more likely to be college graduates; limited social support from their families and lower MMPI premature termination scale scores were also found. Implications of these findings for the management of chronic pain patients are discussed.

Adult↗

Three year follow-up of patients with chronic pain who were treated in a multidisciplinary pain management center.

Between September 1979 and October 1982, 408 patients with chronic benign pain were evaluated for admission to a pain management program. Of the 408 patients, 249 completed the program; the success rate at the time of dismissal was 70% among these 249 patients. Of the 239 patients who entered the follow-up study, 87% responded to either a mailed questionnaire or a follow-up telephone call by an independent reviewer at the time of 3 year follow-up; the improvement had been maintained by 46.6% of the successfully treated patients (or a third of the original participants). The present finding is strikingly similar to that in a previous study from this institution - an indication of the long-term efficacy of the multidisciplinary pain management program. Further search for modifications for the existing program is indicated to accommodate the needs of patients who fail initially or cannot maintain the improvement.

Adolescent↗

Factors associated with early discharge from a multidisciplinary work rehabilitation program for chronic low back pain.

The need to document cost-benefit of comprehensive work rehabilitation services represents a critical requirement for its long-term viability as a treatment option for injured workers. One approach to improving cost-benefit is to identify patients who experience difficulty completing a rigorous goal-oriented treatment approach. This study examined a set of psychological, pain, perceived work environment, and patient expectation measures in order to determine whether such factors were associated with failure to complete rehabilitation. Patients (n = 168) presenting with low back pain who participated in a multidisciplinary work rehabilitation program (physical conditioning, work conditioning, work-related pain and stress management, ergonomic consultation, and vocational counseling) were categorized into 2 groups based upon whether they completed the 4 week, 5 day per week program (n = 84) or were discharged prior to program completion (n = 84). T tests were computed for return to work expectation, pain (average pain intensity, fear of re-injury), psychological measures (somatization, dysthymia), perceived work environment (work pressure, control, supervisor support), and disability (duration of work disability, physical disability, perceived disability) variables found in previous studies to affect successful rehabilitation and return to work. The discharged group was marked by lower return to work expectations, and heightened somatization, pain intensity, and perceived disability. In addition, this group was significantly younger and had been out of work longer. The groups did not differ on gender, marital status, ICD-9 diagnoses or perceived work environment. These findings indicate that patients displaying the pattern of low return to work expectations, heightened perceived disability, pain and somatic focus experience compliance problems in an intensive work rehabilitation program.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

Quality assurance in radiation therapy: multidisciplinary considerations--European experience.

The organization of a multidisciplinary cancer treatment center is very heterogeneous in Europe. In Eastern Europe, there are written concepts of cancer treatment with advanced plans and an acceptable position for radiotherapy. In the future, there will be no principal differences between Eastern and Western Europe. In the development of radiotherapy in Europe, a determining factor seems to be that radiotherapy has been an independent clinical speciality. The problem in Germany can be explained on the basis that only now is radiotherapy separate from diagnostic radiology. In other countries radiotherapy has long been a strong independent speciality, often working with other cancer specialties. Great Britain, France, Belgium, The Netherlands and Italy are the leading countries in the development of radiotherapy. In the Scandanavian countries, radiotherapy has always had a strong position and has been able to develop further by integration with medical oncology. Cooperation between radiotherapists, radiophysicists, surgeons, pathologists, cytologists, etc., has given the cancer patient an opportunity for better overall treatment. The quality assurance in cancer therapy is the teamwork between different specialists before the treatment plan for the patient is decided.

Cancer Care Facilities↗

Multidisciplinary consideration of cancer therapy in Latin America.

A multidisciplinary approach to cancer control, diagnosis, pretreatment evaluation and particularly treatment requires cooperation among surgeons, internists, chemotherapists and radiotherapists. The best sequence of radiotherapy and chemotherapy in patients who need both treatments is essential to avoid interference between treatments or potentiation of the adverse toxic effects. Several features may interfere in the detection and delivery of the best treatment combination in patients with cancer in Latin American countries, compared to patients in more developed countries: (1) There are differences among countries in the percentages for certain cancer sites and stages of disease. (2) Most of the cancer incidence figures are originated in hospital-based registries and not population-based registries. (3) On many occasions the modality of treatment of an individual patient depends on which doctor the patient sees first--the physician, the surgeon, or the radiotherapist. (4) In many radiotherapy services the treatment capacity is outweighed by the great amount of cancer patients, and radiotherapy is used primarily for curative purposes. (5) A higher percentage of patients arrive with advanced incurable disease because of lack of the awareness of the significance of early signs and symptoms on the part of patients, relatives and even doctors. (6) Another frequent problem is the lack of communication, transportation and accommodations near the treatment center. Many patients come from long distances; these factors make adequate follow-up of patients difficult. (7) There is a lack of radiotherapy services and there are numerous non-functioning units due to break-downs. A collaborative cancer treatment research program was initiated in 1977 between Latin American cancer centers and U.S. centers. This program is coordinated by the Pan American Health Organization and U.S. National Cancer Institute. Most of the protocols include multiple modality treatment (surgery, radiotherapy, chemotherapy and immunotherapy). This program has shown that, good control clinical trials can be performed in multiple cancer centers in Latin America in spite of the problems mentioned above.

Combined Modality Therapy↗

How can free radicals cause damage to hepatic cells. A multidisciplinary approach.

Excessive alcohol intake is a factor in a significant percentage of all deaths. Hepatoprotective drugs aim to prevent alcoholic liver damage. Our experiments with antioxidant free radical scavengers also proved that such chemicals are hepatoprotectives. Free radical reactions play a significant role in many biological phenomena such as aging and toxic liver cell damage. Different disciplines support theories to interpret their effects. In this paper, theories are summarized as a multidisciplinary approach which can provide further explanation and challenge further investigation on alcoholic liver damage and hepatoprotection.

Animals↗

A multidisciplinary overview of intoxicating snuff rituals in the western hemisphere.

Part one of the paper discusses ethnobotanical, chemical and general pharmacological aspects of intoxicating snuff rituals in the western hemisphere. Four categories of ritual snuff ingredients arise from this multidisciplinary approach: It is well established that the plant contains one or more psychoactive principles and the Indian use of the plant as a ritual snuff ingredient is confirmed or quite probable: Anadenanthera, Erythroxylum, Nicotiana, Virola; It is well established that the plant contains one or more psychoactive principles, but the Indian use of the plant as a ritual snuff ingredient is not well recorded or even unlikely: Banisteriopsis, Cannabis, Datura, Ilex guayusa; The Indian use of the plant as a ritual snuff ingredient is confirmed or quite probable, but it is not well established that the plant contains one or more psychoactive principles: Justicia pectoralis, Pagamea macrophylla, Tanaecium nocturnum; The Indian use of the plant as a ritual snuff ingredient is not well recorded, and it is not well established that the plant contains one or more psychoactive principles: Acorus calamus, Capsicum, Macquira sclerophylla, Piper interitum. Part two of the paper discusses the nasal pharmacokinetics and efficacy of possible ritual snuff constituents. The literature yields convincing clinical evidence that atropine, cocaine, nicotine and scopolamine are effective following nasal application, but experimental confirmation of the efficacy of nasal tryptamine alkaloids is still awaited. In self-experiments, 6.4 mg/kg of caffeine produced substantial plasma levels via the nasal route, but 0.5 mg/kg of harmine did not produce measurable plasma levels, when taken as a nasal powder. Without additional experiments, it is difficult to give a definite explanation for this negative result.

Atropine↗

A multidisciplinary patient education workshop to integrate staff training with program development.

A four session multidisciplinary workshop was held to teach Veterans Administration (VA) Medical Center staff basic patient education design principles. During the sessions, staff, working in teams, designed patient education programs on a wide variety of health care topics. Guidance to teams was provided at each step of program development so that at the end of the workshop, programs were ready for implementation. Medical Center standards for patient education and documentation were integrated into program designs.

California↗

Neoadjuvant and adjuvant chemotherapy in the multidisciplinary treatment of oral cancer stage III or IV.

We performed a retrospective analysis on the effect of initial induction chemotherapy with two courses of cisplatin (each course 120 mg/m2 cisplatin on day 1, then 20 mg/m2 bleomycin (alone) per day for 5 days with 4 weeks between courses) in 75 consecutive patients with advanced cancer of the oral cavity or lip. Further local therapy consisted of surgery or radiation, depending on tumour location. In 18 resected patients adjuvant chemotherapy was added. This consisted of carboplatin, 400 mg/m2 on day 1 then ftorafur alone, 500 mg/m2/day for 30 consecutive days, repeated every month for 4 consecutive months. Among the patients treated in the neoadjuvant setting, complete response was observed in 10 out of 75 patients (13%), and partial response in a further 50 patients (67%) (partial plus complete rate 80%). Of all the patients, 43% in stage III and 26% in stage IV were long-term survivors. Improved survival was observed in surgical patients where adjuvant postoperative chemotherapy was added (P < 0.025). The main toxic effect was vomiting, observed in 71 patients. We noted a low rate of stomatitis (4%) and an important hearing loss (12%). Neoadjuvant and adjuvant cisplatin-based chemotherapy as part of a multidisciplinary approach have a high overall response rate and low toxicity, and should increase survival in cancer of the oral cavity or lip.

Adult↗

Pilot study to determine the impact of a multidisciplinary educational intervention in patients hospitalized with heart failure.

BACKGROUND: Patients with heart failure (HF) face challenges complying with multidrug regimens. OBJECTIVES: To examine the impact of a compliance enhancing intervention on medication compliance and morbidity in HF. DESIGN: Patients were randomized to either usual care or an inhospital educational intervention delivered by a multidisciplinary team (Intervention). SETTING: Acute medical and surgical units at a teaching hospital. PATIENTS: One hundred thirty four patients with a clinical diagnosis of HF and a left ventricular ejection fraction of < 40% requiring long-term medical treatment. MAIN OUTCOME MEASURES: A validated HF-specific instrument provided a measure of knowledge. We characterized patients as noncompliant if pharmacy refill data suggested they had taken < or = 0.80 of their medication. We measured quality of life using the Minnesota Living with Heart Failure Questionnaire and the Short Form 36 and conducted a time to first event analysis of a composite end point including mortality, readmissions, and emergency department visits. RESULTS: The Intervention group showed higher knowledge scores at discharge and 1 year (P = .05). The risk of noncompliance in Intervention patients varied from 0.78 (95% CI 0.33-1.89) for ACE-I (13% Intervention, 17% Control) to 1.02 (0.49-2.12) for diuretics (23% Intervention, 23% Control). Quality of life improved in both groups over time; the only difference between groups favored the Intervention (Minnesota Living with Heart Failure Questionnaire, P = .04). The composite end point occurred in 67% of control and 60% of Intervention patients (hazard ratio 0.85, 95% CI 0.55-1.30). CONCLUSIONS: An inhospital educational intervention improved knowledge and, possibly, quality of life and may be useful as part of a comprehensive compliance enhancing strategy in patients with HF.

Aged↗

Coronary artery imaging with multidetector computed tomography: a call for an evidence-based, multidisciplinary approach.

Modern multidetector computed tomography systems are capable of a comprehensive assessment of the cardiovascular system, including noninvasive assessment of coronary anatomy. Multidetector computed tomography is expected to advance the role of noninvasive imaging for coronary artery disease, but clinical experience is still limited. Clinical guidelines are necessary to standardize scanner technology and appropriate clinical applications for coronary computed tomographic angiography. Further evaluation of this evolving technology will benefit from cooperation between different medical specialties, imaging scientists, and manufacturers of multidetector computed tomography systems, supporting multidisciplinary teams focused on the diagnosis and treatment of early and advanced stages of coronary artery disease. This cooperation will provide the necessary education, training, and guidelines for physicians and technologists assuring standard of care for their patients.

Coronary Angiography↗

Clinical anatomy and surgical skills training (CASST): development of a multicenter, multidisciplinary program.

OBJECTIVE: The aim of this program was to develop a multicenter, multidisciplinary anatomy and surgical skills training program for junior residents in obstetrics and gynecology and urology. STUDY DESIGN: After administering a needs assessment, we developed a collaborative clinical anatomy and surgical skills training program for junior residents in obstetrics and gynecology and urology at 3 academic medical centers in Chicago. RESULTS: Thirty-two residents participated in the program. Needs assessment results indicated that all residents felt they could benefit by more formal training in basic surgical skills. Learning objectives were developed for each of the 5 3-hour sessions that dealt with basic surgical skills, anterior abdominal wall anatomy, opening and closing the abdomen, female pelvic anatomy, and perineal anatomy and laceration repair. The cost of training each of the residents was approximately 600 dollars. Forty-five percent of the costs were one-time "start-up" costs for abdominal trainers and surgical instruments. CONCLUSION: By including multiple centers and disciplines, we were able to reduce costs of teaching basic surgical skills and anatomy and maximize faculty teaching time and effort.

Abdomen↗