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Biomedical subjects

E C Rich

Publications and source records attributed to E C Rich.

At least 19 recordsLinked to original sources
PubMed1992

The accelerated internal medicine program at the University of Kentucky.

Concern is growing about the ability of categorical medicine residency programs, structured within academic health centers, to provide balanced, progressive, postgraduate internal medicine education. Detrimental factors, including over-representation of critically ill patients, shortened length of hospitalization, stress, discontinuity between undergraduate and graduate training, rotational assignments driven by hospital service imperatives, and total costs, may all negatively affect internal medicine residency education. Therefore, an experimental accelerated internal medicine (AIM) curriculum combining 3 years of undergraduate with 3 years of graduate internal medicine education has been initiated by the Department of Medicine and the College of Medicine at the University of Kentucky. After completion of the third year and during the first 13 months of the AIM curriculum, selected students are rotated through an integrated series of educational experiences that incorporate all of the requirements for graduation from medical school and progressively advance the students' skills, knowledge, and responsibilities to that of a second-year resident. Thereafter, the curriculum is similar to that of the categorical residents, except that more ambulatory care and off-site rotations are interspersed to better provide the educational experiences representative of the practice of internal medicine. Evaluations of the first groups of AIM residents indicate that their performance has equaled that of the control residents who graduated after 4 years from the College of Medicine. Furthermore, the AIM residents report general acceptance by their fellow residents and attending physicians and report no undue stress in making the transition.

Costs and Cost Analysis↗
PubMed1990

Attitudes of internal medicine faculty and residents toward professional interaction with pharmaceutical sales representatives.

We surveyed faculty and residents from seven hospitals affiliated with three academic internal medicine training programs about their perceptions of the informational and service benefits vs the risks of ethical compromise involved in interactions with pharmaceutical sales representatives. Questionnaires were returned by 467 (81%) of 575 physicians surveyed. Residents and faculty generally had somewhat negative attitudes toward the educational and informational value of detailing activities at their institutions but indicated that representatives supported important conferences and speakers. Residents were more likely than faculty to perceive contacts with sales representatives as potentially influencing physician decision making. Sixty-seven percent of faculty and 77% of residents indicated that physicians could be compromised by accepting gifts. More than half of the physicians who suggested that such compromise was possible indicated that acceptance of gifts worth more than +100 from drug companies would be likely to compromise a physician's independence and objectivity. A majority of both faculty and house staff favored eliminating presentations by pharmaceutical representatives at their hospitals. Only 10% thought they had had sufficient training during medical school and residency regarding professional interaction with sales representatives.

Adult↗
PubMed1990

The relationship of house staff experience to the cost and quality of inpatient care.

The inexperience of house staff has been offered as one explanation for the increased cost of care at teaching hospitals, but conclusive evidence for this has been lacking. We studied the relationship of house staff experience to the cost and quality of inpatient care in a large series of internal medicine patients at one teaching hospital. We defined house staff experience by the month of academic year during which the patient received care. Our measures of cost were length of hospital stay and total hospital charges, while our measures of quality were hospital deaths, hospital readmissions, and nursing home placement. Multiple linear regression analysis on 21,679 hospital discharges revealed increasing house staff experience to be associated with a significant decline in length of stay (95% confidence interval for b, -0.006 to -0.066 days per discharge per month of house staff experience) and total hospital charges (95% confidence interval for b, -0.002 to -0.017 log dollars per discharge per month of house staff experience). These findings constitute an estimated average decline of 0.43 days per discharge and +370 per discharge over the academic year. Logistic regression analysis found no relationship of house staff experience to hospital deaths, readmissions, or nursing home placement. These findings suggest that the process of training inexperienced physicians may represent an important source of inefficiency for teaching hospitals struggling in a competitive environment.

Costs and Cost Analysis↗
PubMed1990

Two strategies for prophylaxis of fatal postoperative pulmonary embolism. Cost-effectiveness analysis.

While subcutaneous heparin is a standard prophylaxis for death from pulmonary embolism following general surgery, it has been suggested that adding the vasoconstricting drug dihydroergotamine would improve survival compared to heparin alone. Dihydroergotamine may be associated with rare but life-threatening side effects; thus, reduced mortality from pulmonary embolism could be offset by increased mortality from other causes. Because a clinical trial to examine this possibility would be impractical, we performed a cost-effectiveness analysis to evaluate the effects of prophylactic dihydroergotamine on mortality. Based on published data, despite its favorable effects on the prevention of deep vein thrombosis, the addition of dihydroergotamine did not appear to save lives when added to heparin as prophylaxis. Probabilistic sensitivity analysis demonstrated that even if published risk estimates are in error, substantial changes would still not support the conclusion that dihydroergotamine is life-saving. In the absence of clear potential for improved survival, the increased costs associated with dihydroergotamine provide reason to question its routine prophylactic use in general surgery.

Adult↗
PubMed1990

Knowledge resource preferences of family physicians.

Because of the pivotal role of medical knowledge in clinical problem solving, it is important to understand how clinicians decide to seek additional knowledge for patient care decisions and how they choose among the resources available to them. Using a self-administered questionnaire, 126 family physicians reported their use of 11 types of knowledge resources for answering patient-specific questions arising in clinical practice. They reported almost daily use of the Physicians' Desk Reference and more often than weekly use of colleagues. There was little use reported of Index Medicus or computer-based bibliographic retrieval systems. The research literature of medicine was used infrequently and rated among the lowest of resources in terms of credibility, availability, searchability, understandability, and applicability. In deciding among a subset of knowledge resources for answering a clinical practice question, resource cost variables related to clinical availability and applicability of the information to the problem at hand appeared to be more influential in the minds of physicians than factors related to quality of the resource. These findings have important implications for the development and deployment of knowledge resources intended to be useful and used in clinical practice.

Diagnosis↗
PubMed1989

Influence of a preventive care educational intervention on physician knowledge, attitudes, beliefs, and practice.

We evaluated the effect of a three-part intervention on knowledge, attitudes, beliefs, and practices relevant to preventive care. A group of 13 second-year internal medicine residents (Group I) were exposed to a lecture, chart-based reminder, and biweekly feedback during a 3-month ambulatory care rotation. The remaining two groups of residents (Group II, n = 12; Group III, n = 11) were not exposed to the intervention. We performed a chart review to assess preventive care practice at a clinical site separate from the intervention and surveyed residents to assess preventive care knowledge, self-reported practice, professional attitudes, and health beliefs. Chart reviews revealed the intervention to be associated with improved performance of preventive care (0.52 vs 0.35 and 0.42, P = 0.01). In addition, the intervention was associated with improved scores for preventive care knowledge (90 vs 74 and 77, P = 0.001) and self-reported practice (85 vs 65 and 72, P = 0.007). Although attitudes toward prevention and health locus of control were not measurably influenced by the intervention, stepwise multiple linear regression analysis demonstrated these factors to be independently related to preventive practice. Our data support the notion that physician preventive practice is subject to a variety of influences involving not only knowledge, and practice environment, but also training, professional attitudes, and health beliefs.

Ambulatory Care↗
PubMed1989

Open-angle glaucoma.

Open-angle glaucoma is a common cause of blindness and visual impairment, and is characterized by elevated intraocular pressure, optic nerve degeneration and visual field loss. Risk factors include increasing age, black race, positive family history and diabetes. Since many high risk individuals are seen periodically by primary care physicians, the office or clinic is a logical site for screening for open angle glaucoma. Tonometry is a useful screening maneuver, but is little used in the primary care setting. If primary care physicians can acquire the necessary skills, ophthalmoscopy may be a simple, safe and inexpensive alternative to tonometry.

Fundus Oculi↗
PubMed1988

Preparation for practice in internal medicine. A study of ten years of residency graduates.

To evaluate the adequacy of preparation for medical practice, we surveyed 320 internal medicine program graduates. The 210 respondents gave their perceptions regarding preparation in training and importance in practice of eight clinical practice skills and 27 clinical procedure skills. The skills with highest preparation scores were venipuncture, intravenous line placement, and arterial puncture for blood gases. The skills rated as the most important in practice were history taking, physical examination, and selection of diagnostic tests. For 13 of the 27 clinical procedure skills, mean preparation scores were significantly higher than mean importance scores, suggesting "overpreparation." In contrast, seven of the eight clinical practice skills had mean preparation scores significantly lower than mean importance scores, suggesting "underpreparation." Furthermore, greater preparation during training was reported by more recent graduates for five of the overprepared skills. We concluded that skills emphasized in internal medicine training are not necessarily those important for practice and that recent changes in the training and practice environments may be increasing these discrepancies.

Clinical Competence↗
PubMed1987

The diagnostic process in primary care: a comparison of general internists and family physicians.

This investigation examined the formulation of diagnostic hypotheses by general internists and family physicians in response to three patient cases (dyspnea, abdominal pain and syncope). The investigation was conducted in the United States. Physician responses to sequentially presented written clinical information were audiotaped. Each transcribed protocol was scored to enumerate and characterize the hypotheses considered by physicians in each specialty. Results of the analyses of variance of hypothesis measures revealed that internists generated more hypotheses than family physicians and that the internist's hypotheses were more specific and were less likely to be generated by other physicians. In addition, internists tended to consider hypotheses more closely related to the final diagnosis sooner in the case presentation than did family physicians. The findings of increased number, specificity, and uniqueness of hypothesis considered by internists are consistent with previously demonstrated differences in the amount and nature of diagnostic information collected by family physicians and internists.

Diagnosis, Differential↗
PubMed1987

The diagnostic value of the medical history. Perceptions of internal medicine physicians.

We investigated the perceptions of 71 internal medicine faculty and residents regarding the diagnostic value of the medical history and other attitudes toward the medical interview. Physicians perceive the medical history as having much higher value in diagnosis than either the physical examination or laboratory/radiography information (mean scores, 5.76, 2.41, and 2.49, respectively). The perceptions of the importance of the physician-patient relationship were significantly correlated with the diagnostic value of the history. There was also a strong relationship between the perceived value of the history and preferences for more skilled interviewing responses, as measured by the Helping Relationship Inventory. Contrary to expectations, the perceptions of residents toward the diagnostic value of the patient's history increased significantly over the course of training (5.00 to 6.00). We conclude that despite the increasing emphasis on diagnostic technology, internal medicine residents and faculty continue to view the patient's history as the preeminent source of diagnostic information. Physician attitudes toward the physician-patient relationship and toward the medical interview may contribute to the diagnostic value of the history.

Attitude of Health Personnel↗
PubMed1986

A comparison of locus of control between men and women in an internal medicine residency.

In this comparison of men and women PGY-1 residents, a significant difference in perceived locus of control, a personality variable, was detected. At the beginning and the end of PGY-1, women residents perceived a more external locus of control than men residents. These findings may be important in understanding the different responses of men and women to the stresses of medical training.

Female↗
PubMed1985

Alcohol-related acute atrial fibrillation. A case-control study and review of 40 patients.

Heavy alcohol use has been suspected to cause acute atrial fibrillation, but an association between these two common problems has never been demonstrated. We retrospectively reviewed 64 cases with idiopathic acute atrial fibrillation and 64 age- and sex-matched controls, randomly selected from among general medical admissions. Sixty-two percent of cases and 33% of controls had documentation as heavy users of alcohol. Furthermore, patients with alcohol-related atrial fibrillation were significantly more likely to manifest alcohol withdrawal syndrome than were other inpatients with heavy alcohol use. Patients with alcohol-related acute atrial fibrillation were not different from other patients with acute atrial fibrillation with respect to clinical evidence of congestive heart failure, electrocardiographic abnormalities, cardiomegaly, electrolyte disturbance, or response to therapy. Heavy alcohol use is an important potential etiology for acute atrial fibrillation; alcohol withdrawal may represent a particular risk for such alcohol-related atrial fibrillation.

Acute Disease↗
PubMed1985

Evidence for an informal clinical policy resulting in high use of a very-low-yield test.

The actual and self-reported practice regarding the use of cerebrospinal fluid cultures for Mycobacterium tuberculosis was examined. All neurology house staff members surveyed, 62 percent of internal medicine house staff members, and none of pediatric house staff members reported that they would order mycobacterial cultures of cerebrospinal fluid routinely. The actual practice was comparable, with 71 percent of cerebrospinal fluid specimens being subjected to culture for mycobacteria on the neurology service, 65 percent on the internal medicine service, and 6 percent on the pediatric service. In this practice, medicine and neurology house staff differ significantly from their pediatric colleagues (p less than 0.001) and from the stated practice of their respective faculties (p less than 0.01). For at least six years, most medicine and neurology house staff have commonly applied an informal clinical policy of routinely culturing cerebrospinal fluid specimens for mycobacteria, despite a low suspicion of disease, lack of faculty support for the practice, and a zero yield for the test. Informal clinical policies such as this may be an important contributor to the problem of technology overuse.

Bacteriological Techniques↗
PubMedDate not supplied

Cost effectiveness of HemoQuant versus Hemoccult for colorectal cancer screening.

Initial reports on HemoQuant, a new quantitative test for occult gastrointestinal bleeding, suggest it is more sensitive than Hemoccult. Increased detection of upper gastrointestinal tract bleeding and dietary hemoglobin may reduce HemoQuant's specificity in the screening setting. The authors performed a cost effectiveness analysis comparing Hemoccult and HemoQuant for colorectal cancer screening using assumptions based on probabilities and costs in the current literature, varying the specificity of HemoQuant. The analysis showed the marginal cost effectiveness of Hemoccult versus no test to be $43,000, and HemoQuant versus Hemoccult to be $296,000 if HemoQuant specificity is 0.95. The marginal cost effectiveness ratio increased to $601,000 if three HemoQuant tests were used. Survival benefit was small and highly dependent on Hemoccult sensitivity and mortality from colonoscopy if HemoQuant specificity was less than 0.9. The authors conclude that unless the high sensitivity reported for HemoQuant is accompanied by a specificity comparable to that of Hemoccult, HemoQuant may not be an acceptable alternative for colorectal cancer screening.

Colonic Neoplasms↗