Biomedical subjects
D G Federman
Publications and source records attributed to D G Federman.
Lack of correlation between internists' ability in dermatology and their patterns of treating patients with skin disease.
BACKGROUND AND DESIGN: We determine whether a subset of internists exist who are better at diagnosing skin disease and therefore select themselves to treat the majority of patients with dermatologic disorders. A survey was conducted in which internists reported their self-perception regarding their abilities in dermatology, the amount of dermatology training they had received, and the percentage of patients they encounter with and treat for skin diseases. This was correlated with results from an objective photographic (Kodachrome) examination assessing their diagnostic abilities in dermatology. The setting was university and private practices in Miami, Fla, and New Haven, Conn. The participants were general internists, medical subspecialists, and medical residents. After completing a self-administered questionnaire, each physician then participated in an examination where they were shown 20 color photographs of common skin disorders. We correlate the relationship between the survey variables and the results of the photographic examination. RESULTS: Eighty-four internists diagnosed 50.5% of the diseases correctly. Internists perceive themselves as mediocre in dermatology (2.6, on a scale of 1-5, 5 being the best), which correlated with their poor performance on the photographic evaluation (P = .04). Internists reported having limited education or training in dermatology (> 85% having < 1 month of training in or after medical school). There was a trend toward a correlation between the amount of training internists received and their ability in dermatology (P = .07). Notably , there was no correlation between internists' ability in dermatology and the percentage of patients they encounter with and treat for skin disease. CONCLUSIONS: Internists receive limited training and have resultant poor performance in diagnosing skin disease. Internists are aware of their limited ability in dermatology as demonstrated by their mediocre self-perceived ability. Notably, no correlation was found between internists' abilities in dermatology and the percentage of patients they encounter and treat for skin disease. Therefore, we did not demonstrate a subset of internists, superior at dermatology, who treat the majority of patients with skin disease. This suggests patients with skin disease may be better served by dermatologists.
The epidemiology of non-Hodgkin's lymphoma.
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Managed care: the dermatologist as a primary care provider.
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Syphilis presenting as the 'blue toe syndrome'.
The abrupt development of cyanotic and painful toes, "the blue toe syndrome," has been attributed to a number of medical conditions. We describe a patient in which the workup for this condition failed to elucidate a typical cause. Skin biopsy, serologic findings, and response to treatment led to the diagnosis of secondary syphilis. Our experience indicates that secondary syphilis should be included in the differential diagnosis of patients presenting with the blue toe syndrome.
Swelling of the ear in a patient with ulcerative colitis.
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Effect of hypercalcemia on the anion gap.
It has been assumed, but not documented, that hypercalcemia induces an appreciable reduction in the serum anion gap (AG) because it represents an increase in the level of unmeasured cations. To test this question, we retrospectively compared the data of 59 hypercalcemic patients with malignancy [group 1, serum Ca 13.3 +/- SE 0.3 mg/dl] with those of 108 patients whose hypercalcemia was of parathyroid origin (group 2, serum Ca 12.1 +/- 0.1 mg/dl), and those of 51 control subjects (group 3, serum Ca 9.5 +/- 0.1 mg/dl). The AG of group 2 subjects (8.7 +/- 0.3 mEq/l) was significantly lower than that of the other two groups (p less than 0.001 for both) despite their higher serum albumin and lower serum Ca in comparison to group 1. The AGs of group 1 (11.1 +/- 0.4 mEq/l) and group 3 (11.1 +/- 0.3 mEq/l) were identical. There was no statistically significant correlation between the AG and serum Ca in the hypercalcemic patients. The major finding that the association of hypercalcemia with reduced AG is seen in hyperparathyroidism, but not in malignancy-related hypercalcemia, is not explained by differences in serum albumin, renal function, or acid-base status. Overlap of values between groups limits the diagnostic usefulness of the AG in an individual patient. Nevertheless, in the absence of multiple myeloma, the finding of an AG of 5 mEq/l or less in a hypercalcemic patient may be a helpful clue suggesting that malignancy is not the etiology.
Comparison of dermatologic diagnoses by primary care practitioners and dermatologists. A review of the literature.
BACKGROUND: Cost-containment efforts in the United States have led to a greater emphasis on health care delivery by primary care physicians as opposed to specialists, who are assumed to be more costly. With this approach, it is incumbent on the primary care physician to be able to accurately diagnose and treat common maladies, including skin disease. OBJECTIVE: To ascertain whether differences in performance were detectable between groups of physicians when presented with color slides or high-quality transparencies. DESIGN: We performed a critical review of published studies. RESULTS: Overall, dermatologists (93% correct) performed better than nondermatologists (52% correct) (P < .001). No difference was appreciable between dermatology residents (91% correct) and practicing dermatologists (96% correct) or between internal medicine residents (45% correct) and family practice residents (48% correct). In addition, family medicine attending physicians (70% correct) performed better than internal medicine attending physicians (52% correct) (P < .001). CONCLUSION: Primary care physicians should receive more training in the diagnosis of skin disease.
Informed consent for PSA screening: does it happen?
CONTEXT: Screening for prostate cancer with serum prostate-specific antigen (PSA) is controversial. Ideally, patients should be aware of the potential benefits and risks related to testing. PURPOSE: To assess whether patients remembered having PSA screening and to determine whether they recalled having a discussion with their primary care provider about the pros and cons of such testing. METHODS: A questionnaire was sent to patients who had PSA screening ordered by a primary care practitioner during a 2-month period at a university-affiliated Veterans Affairs medical center. Approximately 3 months after the PSA test was done, patients were asked about their baseline health as well as their knowledge of and attitudes toward screening with PSA and treatment for prostate cancer. RESULTS: The overall response rate was 197 out of 421 (46%) patients. Among 173 eligible respondents without prostate cancer, 53 (31%) were unaware that their physician had ordered a PSA test. Among the 120 patients who were aware of receiving the test, only 56 (47%) recalled having a discussion with their primary care provider about the risks and benefits of screening. Support for the test was more common among patients who recalled having PSA screening than those who did not recall having the test (91% vs. 70%, respectively; P = 0.003). CONCLUSIONS: Patients who have PSA screening often are unable to recall relevant facts about the test and may have no knowledge of its associated risks and benefits. The role and effectiveness of obtaining verbal informed consent for PSA screening should be re-evaluated.
Serum sulfate concentration and the anion gap in hemodialysis patients.
First-of-the-month predialysis serum sulfate (SO4) and other blood chemistry values were measured prospectively for 5 to 7 months in 14 patients undergoing single pass chronic tri-weekly maintenance hemodialysis with bicarbonate dialysate. Blood was also obtained predialysis and again immediately postdialysis from seven patients (five of whom also participated in the chronic study). As expected, the patients manifested a high anion gap (AG) metabolic acidosis. Serum SO4 was only moderately stable from month to month (the average coefficient of variation was 0.30; correlation between the serum SO4 value of month one and months two and five were r = 0.59, p = 0.026; and r = 0.38, p = 0.182, respectively). The ratio of mean serum SO4 to mean AG (5.0 +/- 0.4 [SE] mEq/L divided by 19.1 +/- 0.5 mEq/L) was 0.26. Although there was a statistically significant correlation between the serum SO4 and the blood urea nitrogen (BUN), there was no such correlation between SO4 and AG. A single hemodialysis reduced serum SO4 by 54% (from 3.5 +/- 0.5 mEq/L to 1.6 +/- 0.1 mEq/L), but there was no correlation between the change in SO4 and the change in AG. The authors concluded that SO4 contributes importantly to the elevated AG in patients receiving chronic hemodialysis. Single pass bicarbonate hemodialysis temporarily reduces, but does not normalize, both the serum SO4 and the AG of such patients.