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Biomedical subjects

A J Dietrich

Publications and source records attributed to A J Dietrich.

At least 19 recordsLinked to original sources
PubMed2001

Identifying physicians likely to benefit from depression education: a challenge for health care organizations.

BACKGROUND: Few methods exist to identify physicians who might benefit from depression education. OBJECTIVES: To develop a measure of physicians' confidence or self-efficacy in caring for depressed patients and assess it's reliability and validity. RESEARCH DESIGN: A national sample of primary care physicians were surveyed and exploratory factor analysis (EFA) was used to identify factors underlying physicians' responses to 26 items. We named the factors, selected items with factor loadings > or = 0.50 for final scales, and tested a priori hypotheses about self-efficacy. SUBJECTS: 1) Random cross-sectional sample of family physicians, internists, obstetrician-gynecologists, and pediatricians (n = 5,369) and 2) 49 general internists and family physicians participating in a prepost evaluation of a depression workshop. RESULTS: In the national sample, 3,712 physicians were eligible and 2,104 responded. Forty-six percent were female, and 51% were family physicians and general internists. EFA identified 5 factors, the first of which was called Self-Efficacy (4 items, alpha = 0.86). More family physicians (64%) had confidence (self-efficacy) in caring for depressed patients compared with general internists (33%), obstetrician-gynecologists (16%), and pediatricians (6%) (P < 0.001). Few physicians intended to change their care of depressed patients (10%) or take CME on depression (24%). Of the 49 physicians attending a depression workshop, 76% reported high self-efficacy after the workshop versus 50% before it (P = 0.013). CONCLUSIONS: This study supports the reliability and validity of the Self-Efficacy scale as one method to identify physicians who might benefit from interventions. New approaches are needed because physicians are unlikely to change.

Cross-Sectional Studies↗
PubMed2000

Sun protection counseling for children: primary care practice patterns and effect of an intervention on clinicians.

OBJECTIVES: To describe current primary care sun protection advice for children and assess the effect on clinicians of an intervention to enhance their sun protection advocacy. SETTING: Primary care practices caring for children in New Hampshire with special attention to clinicians serving 10 towns that were involved in a randomized controlled trial of the multicomponent SunSafe intervention involving schools, recreation areas, and primary care practices. DESIGN/INTERVENTION: A statewide survey of all primary care clinicians serving children addressed their self-reported sun protection advocacy practices. Clinicians in 10 systematically selected rural towns were involved in the subsequent intervention study. The primary care intervention provided assistance to practices in establishing an office system that promoted sun protection advice to children and their parents during office visits. MAIN OUTCOME MEASURES: Sun protection promotion activities of primary care clinicians as determined by their self report, research assistant observation, and parent interviews. RESULTS: Of 261 eligible clinicians responding to the statewide survey, about half provide sun protection counseling "most of the time" or "almost always" during summer well care visits. Pediatricians do so more often than family physicians. Clinicians involved in the intervention increased their use of handouts, waiting room educational materials, and sunscreen samples. Compared with control town parents, parents in intervention towns reported an increase in clinician sun protection advice. CONCLUSIONS: The SunSafe primary care intervention increased sun protection counseling activities of participating clinicians. A single-focus preventive service office system is feasible to include in community interventions to promote sun protection.

Adolescent↗
PubMed2000

Persistent increase in children's sun protection in a randomized controlled community trial.

BACKGROUND: Reducing sun exposure during childhood may prevent skin cancer later in life. Sun protection increased immediately following implementation of the SunSafe multicomponent, community-based intervention delivered in 1996 through schools, day care centers, primary care offices, and beach recreation areas. Whether sun protection levels would remain higher than preintervention levels the following summer was unknown. METHODS: A randomized controlled trial based in 10 New Hampshire towns addressed children's use of protective clothing, shade, and sunscreen at freshwater beach areas. The intervention was provided initially between March and May 1996. A brief project follow-up contact was provided to schools, day care centers, beaches, and primary care offices between March and May 1997 to restock intervention materials and to answer questions. Observations of 1490 children during June through August of 1997 were compared with observations made prior to any intervention between June and August of 1995. RESULTS: In intervention towns, the proportion of children using at least some sun protection increased by 0.15 from 0.58 in 1995 to 0.73 in 1997 while the proportion in control towns increased by 0.03 (P = 0.033). This increase was due to more use of sunscreen, but not more use of protective clothing or shade. In 1997, care-givers of children in intervention towns reported receiving more sun protection information from school and health care sources than control town caregivers (62% versus 33%, P < 0.006). CONCLUSIONS: In intervention communities, a higher proportion of children used sun protection in 1997 than at baseline. Increases from 1995 to 1997 were similar in magnitude to short-term increases between 1995 and 1996 that we have been previously reported.

Child↗
PubMed2000

Office systems intervention to improve diethylstilbestrol screening in managed care.

OBJECTIVE: To examine the effectiveness of a comprehensive office systems intervention for improving identification of diethylstilbestrol (DES) exposure, a low-incidence condition with potentially severe consequences. METHODS: We developed a comprehensive office systems intervention to facilitate screening and follow-up for women exposed to DES in utero, consisting of a DES toolkit and the clinical and administrative education necessary to use the tools effectively. The intervention was implemented in the internal medicine and obstetrics-gynecology departments at six free-standing health centers in a Boston-area staff-model health maintenance organization. Intervention sites were matched and paired with a comparison group of centers. Intervention effectiveness was assessed through pretest and posttest surveys of clinicians, medical record review of 3900 women, and review of a computerized medical records data base. RESULTS: There was significantly higher DES awareness and knowledge among clinical staff at intervention sites. Documentation of DES exposure in the medical record ranged from 1.14 to 2.31 times greater at intervention sites than in matched comparison sites, and rates of DES code use in pregnancy were 1.91 to 3.61 times greater. CONCLUSIONS: The office systems intervention improved documentation of DES exposure in a managed care environment. Because this approach was designed to accommodate the limited time allotted for each patient visit, it not only improved DES screening but could also serve as a model for integrating screening for other low-prevalence but potentially serious conditions into routine care.

Adult↗
PubMed2000

An encounter-based analysis of the nature of teaching and learning in a 3rd-year medical school clerkship.

BACKGROUND: Much of medical education has shifted from the hospital to ambulatory settings where each student works with a preceptor. PURPOSE: Our objectives were to describe the nature of community-based learning and to explore how learning experiences vary by type of health care visit. METHODS: This prospective study used both paper- and computer-based documentation systems to collect information on student-patient-preceptor encounters. A consecutive sample of 3rd-year medical students contributed data on 1 full clinical day each week as they rotated through a required 8-week family medicine clerkship. The main measures of interest included patient age, gender, health care visit type (acute, acute exacerbation of chronic, chronic, and health maintenance), method of learning in history taking and physical examinations (observing preceptor, being observed by preceptor, performing unobserved, or working jointly with preceptor), content of physical examinations, amount of preceptor feedback, and preceptor teaching content. RESULTS: Sixty-three students contributed data on 4,083 patient encounters. The majority of visits concerned acute complaints (37.7%) or health maintenance (26.4%). Many encounters involved students conducting the cardiovascular and pulmonary exams (33.2% each); fewer encounters involved neurologic (6.9%), gynecological (4.5%), and genitourinary (2.2%) exams. Students reported being observed performing histories and physical exams in 4% and 6% of encounters respectively. The most common student experiences were performing histories and performing physical exams unobserved during acute visits, which accounted for 65.8% and 52.4% of encounters overall. CONCLUSIONS: This system is useful for determining educational content and processes that occur in ambulatory settings. Important differences were found in teaching and learning by type of health care visit. This factor can and should be used when considering how students meet educational objectives in community-based ambulatory settings.

Adult↗
PubMed2000

The depression in primary care tool kit.

OBJECTIVE: A tool kit was developed to help primary care physicians overcome some of the barriers to recognition and management of depression. METHOD: Tools were collected from a variety of sources, categorized by function, and evaluated on the basis of previously established criteria, with the best tools selected for inclusion in the tool kit. New tools were developed when an adequate tool for a desired function was not available. The tool kit was reviewed and then revised based on the feedback from eleven experts on depression in primary care, five medical directors from health care systems or managed care companies, and eighteen primary care physicians. All eighteen primary care physicians completed a questionnaire after reviewing the tool kit as part of the evaluation process. RESULTS: Only five of the eighteen physicians were using any kind of tool for depression prior to reviewing the tool kit. All eighteen physicians indicated that they were likely to use one or more of the components of the tool kit. On average, physicians indicated they were likely to use 6.5 of the ten types of tools included in the kit. CONCLUSIONS: A depression tool kit containing screening, diagnostic, management planning, and outcomes assessment questionnaires as well as treatment and counseling guidelines, information tables, flow charts, and patient education materials is likely to be well received by primary care physicians. However, its effectiveness may have as much to do with how its use is organized and implemented as it does with the intrinsic value of its components.

Algorithms↗
PubMed2000

Differences in ambulatory teaching and learning by gender match of preceptors and students.

BACKGROUND AND OBJECTIVES: Important differences exist in traditional medical education by gender of the teachers and learners. Much less is known about how gender influences educational experiences in community-based ambulatory settings. In this study, we explored how community-based teaching and learning varies by gender of the students and preceptors. METHODS: This prospective study used both paper- and computer-based documentation systems to collect information on student-patient-preceptor encounters. A consecutive sample of third-year medical students contributed data on one full clinical day each week as they rotated through a required 8-week family medicine clerkship. The main measures of interest included patient age and gender, health care visit type (acute, acute exacerbation of chronic, chronic, and health maintenance), method of learning in history taking and physical examinations (observing preceptor, being observed by preceptor, performing unobserved, or working jointly with preceptor), content of physical examinations, amount of preceptor feedback, preceptor teaching content, and gender of the students and their preceptors. RESULTS: Ninety-three students contributed data on 5,017 patient encounters. The distribution of encounters by student-preceptor dyad included: 1,926 (38%) female students with male preceptors. 1,716 (34%) male students with male preceptors, 841 (17%) female students with female preceptors, and 534 (11%) male students with female preceptors. We found that female preceptors conduct more complete physical exams with students than do male preceptors (28% versus 23%). Female students with male preceptors devoted more encounters to observation only than any other dyad (20% versus 12%), and female preceptors are more likely than male preceptors to allow students to perform unobserved (70% versus 59%). Patient gender played little if any role in how students and their preceptors worked together. CONCLUSIONS: Differences of potential importance were found in teaching and learning by gender of the student-preceptor dyad. This factor can and should be considered when determining how students can best meet educational objectives in community-based ambulatory settings.

Clinical Clerkship↗
PubMed1999

CART: a controlled algebraic reconstruction technique for electron microscope tomography of embedded, sectioned specimen.

Reconstruction of thick, embedded, sectioned material has to cope with the restricted tilt view of the electron microscope, with information not stemming from the object of interest in the projections, with aberrations of the objective lens and with a distorted relationship between the projected densities in the micrographs and the specimen mass densities due to incoherent electron interactions within the specimen. Micrograph densities over a full tilt-range show in general an averaged mass increase which is more than should be expected from the cosine dependency of the tilt-angles of the projections. The hereby presented reconstruction technique finds a solution for the under-determined system by a controlled algebraic iteration procedure. For this solution the procedure stabilises the region of interest by dynamically scaling the input data during the procedure. A model for the electron transport through thick specimens is proposed and microscope projection simulations are carried out to test the algorithms.

Algorithms↗
PubMed1999

Improved access to women's health services for Alaska natives through community health aide training.

This project demonstrates the effect of increasing the skills of Community Health Aides (CHAs) on the use of specific preventive health services by women in remote Alaska villages. Eight CHAs were trained in specimen collection for Pap and sexually transmitted disease testing, and in clinical breast examination. Skill competency was monitored. Computerized medical records of all women between the ages of 18 and 75 in the four villages with trained CHAs and in four comparison villages (n = 1093) were checked for Pap status prior to CHA training and again 12 months later. All eight CHAs achieved competency and provided services in their village clinics with telephone support from an experienced clinician. The post-training year Pap test rate of women who were overdue for a Pap test was 0.44 in the villages with trained CHAs; the rate among the women in the comparison villages was 0.32 (p = .079).

Adolescent↗
PubMed1999

Promoting sun protection in elementary schools and child care settings: the SunSafe Project.

Elementary schools and child care settings in rural New Hampshire participated in a sun protection program that reached more than 4,200 children. The program was part of a successful multifaceted community intervention targeting children ages 2-9. Program components included curricular materials, training and support for school/child care staff, and parent outreach. Evaluation showed good uptake of the curriculum by teachers and child care providers, improvements in sun protection policy in participating schools and child care settings, and significant knowledge and attitude improvements in fourth grade children tested, as well as actual behavior change. The study highlighted the importance of flexible, developmentally appropriate curricular materials and active engagement of principals and directors in policy review. In addition, for parent outreach programs to be successful, children needed to participate.

Child↗
PubMed1999

Improving the recognition and management of depression: is there a role for physician education?

BACKGROUND: Many patients who visit primary care physicians suffer from depression, but physicians may miss the diagnosis or undertreat these patients. Improving physicians' communication skills pertaining to diagnosing and managing depression may lead to better outcomes. METHODS: We performed a randomized controlled trial involving 49 primary care physicians to determine the effect of the Depression Education Program on their knowledge of depression and their behavior toward depressed patients. After randomization, physicians in the intervention group completed the Depression Education Program, which consists of 2 4-hour interactive workshops that combine lectures, discussion, audiotape review, and role-playing. Between sessions, physicians audiotaped an interview with one of their patients. Two to 6 weeks following the intervention program, physicians completed a knowledge test and received office visits from 2 unannounced people acting as standardized patients with major depression. These "patients" completed a checklist and scales. Logistic and linear regression were used to control for sex, specialty, and suspicion that the patient was a standardized patient. RESULTS: For both standardized patients, more intervention physicians than control physicians asked about stresses at home, and they also scored higher on the Participatory Decision-Making scale. During the office visits of one of the standardized patients, more intervention physicians asked about at least 5 criteria for major depression (82% and 38%, P = .006), discussed the possibility of depression (96% and 65%, P = .049), scheduled a return visit within 2 weeks (67% and 33%, P = .004), and scored higher than control physicians on the Patient Satisfaction scale (40.3 and 35.5, P = .014). CONCLUSIONS: The Depression Education Program changed physicians' behavior and may be an important component in the efforts to improve the care of depressed patients.

Communication↗
PubMed1999

How physician communication influences recognition of depression in primary care.

BACKGROUND: The relationship between physician communication patterns and the successful recognition of depression is poorly understood. METHODS: We used unannounced visits by actors playing standardized patients to evaluate verbal communication between primary care physicians and a patient presenting with a minor depression scenario. Participants (n = 77) were assigned to receive 2 visits from a man or woman portraying a 26-year-old patient with chronic headaches who meets the criteria for minor depression. The standardized patients carried hidden audiotape recorders and high-fidelity microphones to document the encounters. The audiotapes were coded at 2-second intervals. These data were linked to information gathered from standardized patient checklists, medical records, and debriefing telephone calls with participants. RESULTS: We obtained complete data on 59 (77%) of the physician-patient encounters; of those, 43 (73%) of the physicians recognized depression. Physicians who recognized depression asked twice as many questions about feelings and affect compared with those who did not (for feelings: 1.9% of total physician activity vs. 0.9%, P = .017; for affect: composite score of 2.7% of total physician activity vs 1.3%, P = .003). We found no differences in the proportion or timing of broad to narrow questioning between those who did and did not recognize depression. Physicians who successfully recognized depression later in the interview showed an increase in questions about feelings in the quartile just before recognition occurred. CONCLUSIONS: Physicians who recognized depression differed significantly in the percentage of questions about feeling and affect, and an increase in questions about feelings may precede a diagnosis of depression, though more research is needed to establish this as an important finding.

Adult↗
PubMed1999

Recognizing and managing depression in primary care: a standardized patient study.

BACKGROUND: Guidelines for recognition and management of depression in primary care provide a framework for detailed exploration of physician practice patterns. METHODS: Our objective was to explore physician diagnosis and management approaches to depressive disorders according to type (major vs. minor) and presenting complaint (difficulty sleeping and concentrating vs. headache). The participants were community primary care internists and family physicians in northern New England, Washington, and Alabama (N = 149) who were randomly assigned to receive a visit from an unannounced actor portraying a standardized patient in 1 of 2 depression scenarios: (A) insomnia and poor concentration meeting Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) criteria for major depressive disorder; or (B) tension headaches meeting the criteria for minor depression. RESULTS: All physicians who were assigned to the standardized patients presenting with scenario A recognized depression, and 49% (38 of 78) of those assigned to scenario B patients diagnosed depression. Of those recognizing depression, 72% and 42% queried patients about anhedonia and mood, respectively. For both scenarios, if fewer than 2 DSM-III-R criteria were explored, depression was not diagnosed. Management for scenario A was compatible with Agency for Health Care Policy and Research guidelines, including the prescription of an antidepressant (94%), scheduling of a follow-up visit within 2 weeks (61%), and exploration of suicidal ideation (69.4%). For scenario B, management included over-the-counter analgesics for the headache (84%), exercise (63%), prescription for an antidepressant (53%), recommendation for ongoing counseling (100%), and follow-up within 2 weeks (42%). CONCLUSIONS: Major depression is recognized in primary care at a very high rate. Guidelines for recognizing and managing depression are often followed in primary care. Patients' presentations of depression influence its recognition and management.

Adult↗
PubMed1998

SCP2: a major protein component of the axial elements of synaptonemal complexes of the rat.

In the axial elements of synaptonemal complexes (SCs) of the rat, major protein components have been identified, with relative electrophoretic mobilities (M rs) of 30 000-33 000 and 190 000. Using monoclonal anti-SC antibodies, we isolated cDNA fragments which encode the 190 000 M r component of rat SCs. The translation product predicted from the nucleotide sequence of the cDNA, called SCP2 (for synaptonemal complex protein 2), is a basic protein (pI = 8.0) with a molecular mass of 173 kDa. At the C-terminus, a stretch of approximately 50 amino acid residues is predicted to be capable of forming coiled-coil structures. SCP2 contains two clusters of S/T-P motifs, which are common in DNA-binding proteins. These clusters flank the central, most basic part of the protein (pI = 9.5). Three of the S/T-P motifs are potential target sites for p34(cdc2) protein kinase. In addition, SCP2 has eight potential cAMP/cGMP-dependent protein kinase target sites. The gene encoding SCP2 is transcribed specifically in the testis, in meiotic prophase cells. At the amino acid sequence and secondary structural level, SCP2 shows some similarity to the Red1 protein, which is involved in meiotic recombination and the assembly of axial elements of SCs in yeast. We speculate that SCP2 is a DNA-binding protein involved in the structural organization of meiotic prophase chromosomes.

Amino Acid Sequence↗