A survival guide for generalist physicians in academic fellowships part 1: getting started.
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Adult↗
Biomedical subjects
D A Christakis
Publications and source records attributed to D A Christakis.
A survival guide for generalist physicians in academic fellowships part 2: preparing for the transition to junior faculty.
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Adult↗
Is greater continuity of care associated with less emergency department utilization?
BACKGROUND: The benefits of continuity of care (COC) have not been firmly established for pediatric patients. OBJECTIVE: To assess whether greater COC is associated with lower emergency department (ED) utilization. SETTING: Outpatient teaching clinic at Children's Hospital and Regional Medical Center, Seattle, WA. PATIENTS: All 785 Medicaid managed care children ages 0 to 19 years followed at Children's Hospital and Regional Medical Center between 1993 to 1997 who had at least four outpatient visits. METHODS: Retrospective claims-based analysis. COC was quantified based on the number of different care providers in relation to the number of clinic visits. RESULTS: Attending COC was significantly greater than resident COC. In a multiple event survival analysis, compared with those patients in the lowest tertile of attending COC, those in the middle tertile had 30% lower ED utilization (hazard ratio 0.70 [0.53-0.93]) and those in the highest tertile had 35% lower ED use (hazard ratio 0.65 [0.50-0.80]). Resident COC was not significantly associated with ED use. CONCLUSION: Greater COC with attending physicians in outpatient teaching clinics is associated with lower ED utilization.
Adolescent↗
Pediatricians' awareness of and attitudes about four clinical practice guidelines.
BACKGROUND: The increasing complexity of medical care and a desire to increase quality and control costs have led to growing use of clinical practice guidelines (CPGs). It is unclear how helpful these guidelines are to the practitioners expected to use them. We surveyed pediatricians about their knowledge and impressions of four well-publicized CPGs: the American Academy of Pediatrics' "Practice Parameter for Hyperbilirubinemia in Newborns" (hyperbilirubinemia), "A Guideline for the Management of Febrile Infants" (fever), the Agency for Health Care Policy and Research's "Guideline for Otitis Media With Effusion" (otitis), and the US Preventive Services Task Force Guide to Clinical Preventive Services (preventive care). OBJECTIVES: 1) What percentage of practicing pediatricians are aware of these guidelines? 2) How helpful do they find them? 3) What are practitioners' perceived limitations of these guidelines? 4) Have these guidelines affected provider behavior? 5) Are there features of a provider's training or practice that are associated with changing practice as a result of guidelines? DESIGN: A national survey of 600 pediatricians selected at random from the American Medical Association master file. RESULTS: A total of 300 of 555 eligible participants (54%) returned surveys. Of the respondents, 66% were aware of the hyperbilirubinemia guideline, 64% of the fever guideline, 50% of the otitis guideline, but only 16% knew of the preventive care guidelines. Mean helpfulness scores (1 to 10 scale, where 1 = "not at all helpful" and 10 = "extremely helpful") ranged from 3.67 to 6.67 for the different guidelines. In terms of limitations, 15% to 33% of respondents reported that CPGs were "too cookbook," 6% to 19% reported that they were "too time-consuming," and 4% to 16% reported that they were "too cumbersome." Additional reported limitations were believing that a guideline left no room for personal experience and judgment, concern of increased liability risk, and poor parental acceptance of CPG recommendations. The proportions reporting change in management as a result of a CPG were 28% for the hyperbilirubinemia guideline, 36% for the fever guideline, 19% for the preventive care guidelines, and 28% for the otitis guideline. Mean helpfulness scores reported by nonuniversity-affiliated physicians were significantly higher than those reported by university-affiliated physicians. In a regression model of respondents aware of a particular guideline, more recent graduation from medical school and increased helpfulness scores were associated with guideline-related behavior change. CONCLUSION: In their present form, CPGs are not perceived as very helpful by most practitioners. More recent medical school graduates and nonuniversity-affiliated physicians are more likely to find them helpful and more likely to change their behavior because of them.
Attitude of Health Personnel↗
Temporary matters. The ethical consequences of transient social relationships in medical training.
Medical students and resident physicians spend much of their training engaged in transient, time-limited relationships with patients, families, and other care providers. This article offers a partial catalog of the problems that the evanescent nature of trainees' relationships with others creates in their lives, the strategies they often use to address these problems, and the deleterious consequences these strategies may have on their behavior and ethical development.
Clinical Clerkship↗
Do clinical clerks suffer ethical erosion? Students' perceptions of their ethical environment and personal development.
BACKGROUND: Little is known about the ethical dilemmas that medical students believe they encounter while working in hospitals or how students feel these dilemmas affect them. The authors examine how clinical students perceive their ethical environment, their feelings about their dilemmas, and whether these dilemmas erode students' ethical principles. METHOD: An anonymous mail survey was sent in 1992-93 to the 1,853 third- and fourth-year medical students enrolled at six Pennsylvania medical schools. The survey addressed whether students had encountered situations they felt were ethically problematic, their attitudes toward these situations, and their perceptions of their personal ethical development. Data were analyzed with logistic regression; respondents' comments were analyzed qualitatively. RESULTS: Of the 665 students (36%) who responded, 58% reported having done something they believed was unethical, and 52% reported having misled a patient; 80% reported at least one of these two behaviors. In addition, 98% had heard physicians refer derogatorily to patients; 61% had witnessed what they believed to be unethical behavior by other medical team members, and of these students, 54% felt like accomplices. Many students reported dissatisfaction with their actions and ethical development: 67% had felt bad or guilty about something they had done as clinical clerks; 62% believed that at least some of their ethical principles had been eroded or lost. Controlling for other factors, students who had witnessed an episode of unethical behavior were more likely to have acted improperly themselves for fear of poor evaluation [odds ratio, OR, 1.37 (95% CI, 1.18-1.60)] or to fit in with the team [OR 1.45 (1.25-1.69)]. Moreover, students were twice as likely to report erosion of their ethical principles if they had behaved unethically for fear of poor evaluation [OR 2.25 (1.47-3.45)] or to fit in with the team [OR 1.78 (1.18-2.71)]. CONCLUSION: The ethical dilemmas that medical students perceive as affecting them while serving as clinical clerks are apparently common and often detrimental, and warrant the attention of physicians, educators, and ethicists.
Adult↗
Ethics in a short white coat: the ethical dilemmas that medical students confront.
Many existing ethics curricula fail to address the subtle yet critical ethical issues that medical students confront daily. The authors report on the kinds of dilemmas students face as clinical clerks, using cases that students submitted in 1991-92 during an innovative and well-received ethics class given at a tertiary care hospital as part of the internal medicine clerkship. Analysis of these cases reveals that many dilemmas are intimately tied to the student's unique role on the medical health care team. Recurring themes included the student's pursuit of experience, differing degrees of knowledge and ignorance among team members, and dealing with disagreement within the hierarchical authority structure of the medical team. The authors conclude that some components of ethical education must be participant-driven and developmentally stage-specific, focusing more attention on the kinds of ethical decisions made by medical students as opposed to those made by residents or practicing physicians.
Aged↗
Oxygen extraction in lamb skeletal muscle.
Past studies have found that total-body O2 extraction during hypoxia was less in 1-wk-old lambs than in older animals. It was proposed that reduced O2 extraction was secondary to suppression of growth-related oxygen consumption (VO2) in tissues such as skeletal muscle, bone, kidney, and skin, rather than a defect in peripheral O2 use. To determine the capacity of immature skeletal muscle to extract O2, we isolated the hind limb circulation of eight ketamine-anesthetized, 7- to 18-d-old lambs exposed to stagnant hypoxia by inflation of a right atrial balloon catheter. Femoral arterial and venous PO2, PCO2, pH, Hb concentration, O2 saturation, and femoral arterial blood flow (Q) were measured and hind limb O2 delivery (DO2), extraction ratio, and VO2 calculated. Individual critical levels of DO2 below which VO2 was dependent on O2 supply were determined by dual-line best-fit regression analysis. In six of eight animals, VO2 was clearly independent of supply until DO2 reached critically low levels. However, O2 extraction during extreme hypoxia appeared submaximal (baseline O2 extraction ratio, 0.22 +/- 0.06; at critical levels of DO2, 0.51 +/- 0.11; at the lowest level of Q, 0.64 +/- 0.15). When 2,4-dinitrophenol, an uncoupler of oxidative phosphorylation, was administered to four additional lambs exposed to stagnant hypoxia, O2 extraction below critical levels of DO2 increased from 0.48 +/- 0.15 to 0.79 +/- 0.10 (p less than 0.001, unpaired t test). These data suggest that initial limitations in O2 extraction were a result of the suspension of O2-consuming processes, not an irreversible defect in peripheral O2 use.
2,4-Dinitrophenol↗
Metabolic stability of hippocampal slice preparations during prolonged incubation.
Hippocampal slices were prepared under three conditions: (1) in medium containing glucose and oxygen at 4 degrees C; (2) as in (1), but at 37 degrees C; (3) in medium devoid of glucose and oxygen at 37 degrees C. The rates of recovery to roughly steady-state levels and through 8 h of incubation were monitored for energy metabolite levels and related parameters. In vitro stable values are compared with in situ hippocampal levels. Regardless of the conditions under which slices were prepared, metabolite levels required up to 3 h to stabilize, and these levels were maintained or improved through 8 h of incubation. Further, the maximal concentrations of metabolites were independent of the conditions of slice preparation. Total adenylates and total creatine levels reached 55% of those in vivo. Lactate decreased from the decapitation-induced high levels, but stabilized at concentrations about twice those in rapidly frozen brain. Cyclic AMP and cyclic GMP exhibited peak levels at 30 min of incubation, and cyclic GMP remained elevated for 3 h. Although all three methods of slice preparation resulted in similar metabolite profiles on incubation, the initial decreases in high energy phosphates were delayed by chilling. Most striking, the slices prepared in the absence of glucose and oxygen exhibited much smaller orthodromic evoked potentials in the dentate gyrus. The presence of glucose and oxygen during preparation of the slices appears to be critical to the electrophysiological response of the tissue.
Adenosine Triphosphate↗
Posttrauma symptoms in childhood leukemia survivors and their parents.
This study used a self-report measure of posttraumatic stress (the Posttraumatic Stress Disorder Reaction Index) to evaluate 64 pediatric leukemia survivors age 7-19 years and their parents (mothers n = 63, fathers n = 42). Based upon normative data for the Reaction Index, 12.5% of the survivors, 39.7% of the mothers, and 33.3% of the fathers reported symptoms consistent with a severe level of posttraumatic stress. The data indicate that a substantial subset of pediatric cancer survivors and their parents experience severe symptoms that can be understood within a posttraumatic stress model. The data are discussed with regard to pediatric follow-up care for cancer survivors, as well as in terms of preventive steps that could be taken to lessen the traumatic aspects of pediatric cancer treatment.
Adolescent↗
Methodologic issues in pediatric outcomes research.
Clinicians, health services researchers, and third-party payers, among others, are justifiably interested in the outcomes of pediatric medical care and are, therefore, supportive of research in this area. Pediatric populations pose some unique methodologic challenges for health services researchers. To date, however, many of the approaches, models, and techniques used in pediatric outcomes research have been imported uncritically from experience with adult populations. As a result, some of the most interesting and salient aspects of pediatric outcomes research have yet to be fully developed. These include the following: 1) the problems posed by the dynamics of childhood development, 2) an emphasis on health supervision, 3) the need to see children within the context of a family system and to appreciate the interrelatedness of child health domains, 4) the measurement of the effects of interventions that span sectors, and 5) the paucity of available data sources. This article reviews these problematic areas and argues for a broad conceptual definition of pediatric health, a systems approach to assessing outcomes, and increased interdisciplinary collaboration.
Child↗
Continuity and quality of care for children with diabetes who are covered by medicaid.
BACKGROUND: Poor and minority children with Type 1 diabetes mellitus are at increased risk of severe adverse outcomes as a result of their disease. However, little is known about the quality of care that these children receive and which factors are associated with better quality of care. OBJECTIVES: Our objectives were as follows: 1) to describe the utilization of services associated with quality of care for children with Type 1 diabetes mellitus who are covered by Medicaid and 2) to test the hypothesis that increased continuity of primary care is associated with better care for these children. DESIGN: Retrospective cohort study. METHODS: Washington State Medicaid claims data for 1997 were used to determine what proportion of children with diabetes had 1) an inpatient or outpatient diagnosis of diabetic ketoacidosis (DKA), 2) a glycosylated hemoglobin (HgA1c) level that had been checked, 3) a retinal examination, and 4) thyroid function studies. Continuity of care was quantified using a pre-established index. RESULTS: Two hundred fifty-two eligible patients were identified. During the observation year, 20% had an outpatient diagnosis of DKA, 6% were admitted with DKA, 43% visited an ophthalmologist, 54% had their HgA1c checked, and 21% had their thyroid function assessed. Children with high continuity of care were less likely to have DKA as an outpatient (0.30 [0.13-0.71]). Children with medium continuity of care and high continuity of care were less likely to be hospitalized for DKA (0.22 [0.05-0.87] and 0.14 [0.03-0.67], respectively). For preventive services utilization, high continuity of care was associated only with an increased likelihood of visiting an ophthalmologist (2.80 [1.08-3.88]). CONCLUSIONS: The quality of care for Medicaid children with diabetes can be substantially improved. Low continuity of primary care is an identifiable risk factor for DKA.
Adolescent↗
Is hospitalism new? An analysis of medicare data from Washington State in 1994.
CONTEXT: Managed care, increased disease severity, and more complex treatment options may be reasons for the recent enthusiasm for "hospitalists"--physicians who specialize in the care of inpatients. It is not clear, however, whether hospitalism is a new model for caring for inpatients or merely a new description for previously existing practice patterns. PRACTICE PATTERNS EXAMINED: The proportion of physician visits occurring in the hospital before the introduction of the term hospitalists. Five specialties were examined: family/general practice, general internal medicine, cardiology, gastroenterology, and pulmonology. DATA SOURCE: 1994 Medicare Part B claims data for beneficiaries 65 years of age and older who received all of their care in Washington State. RESULTS: For the average family/general practitioner, 10% of all Medicare visits occurred in the hospital. Corresponding figures for the other specialties were 20% for general internists, 36% for cardiologists, 38% for gastroenterologists, and 45% for pulmonologists. A substantial number of physicians devoted most of their Medicare effort to inpatient care (i.e., hospital visits > 50% of total visits). If this definition were used as a proxy for hospitalism, 4% of family/general practitioners, 10% of general internists, 20% of gastroenterologists, 29% of cardiologists, and 37% of pulmonologists would have been considered hospitalists in Washington State during 1994. On the other hand, 35% of family/general practitioners, 18% of general internists, 7% of both gastroenterologists and pulmonologists, and 4% of cardiologists did not bill Medicare for any inpatient visits and could reasonably be categorized as "officists." CONCLUSION: Physicians vary considerably in the proportion of their workload that occurs in the hospital or outpatient setting. Even before the term was coined, a considerable number of physicians were de facto "hospitalists."
Aged↗
First do no harm--to err is human.
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Evaluation Studies as Topic↗
Informational errors.
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Child, Preschool↗
Making the rounds. The ethical development of medical students in the context of clinical rotations.
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Attitude of Health Personnel↗