Letters to the editor.
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Journal Article↗
Biomedical subjects
G Whelan
Publications and source records attributed to G Whelan.
The approaches to learning of specialist physicians.
Recent studies have provided information about the approaches to studying and learning used by medical students. However, no published work is available on the approaches of practising doctors. The Adelaide Diagnostic Learning Inventory for Medical Students (ADLIMS) was modified and administered to a random sample of 308 physicians (internists). Generally speaking, physicians seem to have lower scores on surface approach and higher scores on deep approach than students. Level of clinical experience did not appear to influence this finding. However, marked differences were apparent between the approaches adopted by physicians with additional postgraduate academic training and those without. The former had a much stronger tendency to use the more desirable deep approach. The latter seemed to rely more on the less desirable surface approach. Further longitudinal studies will be required to determine whether this difference is attributable to self-selection of those who have already developed a deep approach or is causally related to a training in research. Although these findings must be interpreted with caution, some implications are clear. Physicians should become more aware of the way they learn and about the way they teach. Inappropriate patterns of learning may be entrenched during the undergraduate and immediate postgraduate years. If validated, these findings may provide support for the inclusion of research projects in medical school and during specialist training.
Australia↗
Physicians' approaches to continuing education.
A questionnaire survey was conducted of a random sample of 308 physicians to determine their actual and preferred approach to continuing education. Demographic data raised questions about the possible influence of the undergraduate institution attended, the future impact of the growing proportion of women physicians and the effect of increasing subspecialisation. The average physician spends eight-nine hours a week on educational activities and 2.5-4.0 hours a week teaching. Unstructured ad hoc reading and postgraduate activities predominate over methods based on specific, individual needs or on current patient problems. The educational desirability of this is questioned. Physicians are avid attenders at conferences with 10-15% being at a national or international meeting in any one survey week. It appears physicians would prefer to use a wider range of educational activities including more refresher courses and innovative methods. By comparison, Canadian physicians showed similar, but more strongly evident, preferences. These findings have important implications for the College. It appears physicians need to be better informed about potentially more effective learning methods and account ought to be taken of their preference for methods which are not currently widely available.
Education, Medical, Continuing↗
Some phenomena of medical students' diagnostic problem-solving.
This paper introduces a perspective on medical problem-solving that derives from recent studies of content-related learning. Results from a study of fourth-year medical students' approaches to understanding a data base of significant facts about a patient (a problem synthesis) are presented. By analysing data collected in interviews, we obtain categories of description that portray the qualitatively different ways in which the information in diagnostic problems is handled by these students. Two major categories describe the variability in approach: 'ordering' and 'structuring'. The latter category contains elements that most clinical teachers would regard as desirable; the former represents a less satisfactory approach. We provisionally identify two diagnostic strategies within each of these categories. The perspective has implications for improving instruction and assessment.
Clinical Clerkship↗
Towards the identification of student learning problems: the development of a diagnostic inventory.
An understanding of how students approach their learning has important implications for medical education. Of particular interest is the fact that the approach students use in their study has a significant impact on both the quality of the learning and their academic success. It would clearly be of value to identify students whose approach to learning was predictive of unsatisfactory performance. This paper describes the initial development of two versions of an inventory (questionnaire) which was designed to aid in the diagnosis of student learning problems. Preliminary information is given on the reliability and validity of these instruments. Factor analyses support the underlying design. Correlation of subscales with academic performance has provided encouraging evidence of the potential of these inventories in identifying students with specific learning or study problems.
Education, Medical, Undergraduate↗
Relative incidence of Crohn's disease and ulcerative colitis in six Melbourne hospitals.
Information on the relative incidence of Crohn's disease and ulcerative colitis was obtained by a prospective investigation at six Melbourne teaching hospitals. One hundred and eleven patients who presented with chronic inflammatory bowel diseases between 1980-1981 were admitted to the study. Forty (36%) patients were diagnosed as having Crohn's disease and 63 (57%) patients as having ulcerative colitis. The type of chronic inflammatory bowel disease could not be determined in eight (7%) patients. These findings suggest that the relative frequency of Crohn's disease and ulcerative colitis in Melbourne hospitals is within the range that is reported for northern Europe and the United States.
Adolescent↗
Oesophageal manometry: how well does it predict oesophageal function.
The variability in manometric measurements of oesophageal peristalsis was assessed in 10 volunteers. The amplitude, velocity and duration of the peristaltic waves resulting from 10 separate 10 ml boluses of water were measured at fixed distances above the lower oesophageal sphincter (LOS). After a 10 minute rest period with the manometry catheter still in situ peristaltic values in response to a second group of 10 10 ml boluses were measured. The measurement of peristaltic amplitude at a fixed distance above the LOS showed wide interindividual variation--for example, at 8 cm above the LOS the variation between individuals was marked (p less than 0.001). At the same site, however, there was only a small intra individual variation noted with time (p greater than 0.25). Similar differences were noted at 16 and 4 cm above the LOS. For the first group of swallows, while the interindividual variation remained high (p less than 0.025), the measurement variation from site to site was of lesser magnitude (p greater than 0.1). Similar findings were noted for interindividual variation and site to site variation at the second group of swallows. The values for velocity showed a similar pattern of variation. From this study we conclude that manometric measurements can be used as a valid method for assessing the effects of drugs on peristalsis in individuals provided all measurements are made at the exact same level in the oesophagus and 'normal' subjects with a large inherent variation are excluded. Any studies comparing peristaltic values in different population groups - for example, normal v reflux patients, may not detect any significant difference even with large sample numbers. Any differences detected may be of no clinical importance because of the large normal variation.
Adult↗
Hepatic vein occlusion (Budd-Chiari syndrome): problems in diagnosis and management.
Seven patients demonstrating the difficulties in diagnosis and management of hepatic vein occlusion are presented. The syndrome may present in an acute form with upper abdominal pain, abdominal swelling, ascites and tender hepatomegaly or in a chronic form, mimicking cirrhotic ascites. The clinical features, predisposing factors, liver scan and liver biopsy may all suggest the condition, but hepatic venography is essential for diagnosis and as a preliminary to treatment. It is suggested that early side to side portacaval anastomosis is the current treatment of choice.
Aged↗
Ultrasound in the diagnosis of jaundice--a review.
A retrospective study of 92 jaundiced patients undergoing ultrasound examination was undertaken to assess the clinical utility of this test. The patients were graded according to the likelihood of biliary obstruction. In those in whom biliary obstruction was proven to be present, the sensitivity of ultrasound to detect the obstruction was 91% and the test specificity was 100%. In patients who had undergone cholecystectomy no increase in the diameter of the common duct was observed. Liver function tests proved to be unreliable in discriminating between extrahepatic obstructive jaundice and other forms of jaundice. Ultrasound scanning is a useful screening test in the diagnosis of the jaundiced patient. However, follow-up is suggested for those with a negative result of this test but in whom biliary obstruction is suspected. An approach to the investigation of the jaundiced patient should include early ultrasound examination in those with possible biliary obstruction.
Adolescent↗
Long-term follow-up of patients with Crohn's disease. Relationship between the clinical pattern and prognosis.
In a study of 615 new patients with Crohn's disease consecutively diagnosed at the Cleveland Clinic between 1966 and 1969, 592 patients were observed (mean greater than 13 yr, minimum 7 yr), giving a follow-up rate of 96.3%. The original hypothesis was that initial anatomic involvement (the clinical pattern) bears directly on clinical course and prognosis. Disease sites were as follows: 246 ileocolic, 165 small intestine, and 181 colon/anorectal. Among patients with ileocolic disease, 225 (91.5%) had surgery. For the small intestine pattern, the operative incidence was 65.5%; for the colon/anorectal pattern, it was 58%. Operations were for specific reasons: internal fistula with abscess or intestinal obstruction for ileocolic pattern; intestinal obstruction for small intestine pattern; and severe perianal disease or toxic megacolon for colon/anorectal pattern. Complications among nonoperated patients included perianal fistulas and extraintestinal manifestations. No statistical correlation existed between type and duration of medical treatment and prognosis. Seventy-five deaths occurred (12.8%), 36 of which related directly to Crohn's disease. Even after many years, symptoms continued and quality of life tended to be suboptimal among operated patients. For nonoperated patients, the most favorable quality of life was experienced by those with segmental involvement of the colon or ileum. Poor prognosis correlated with ileocolic disease and presence of sepsis because of an internal fistula.
Adult↗
Recurrence after surgery in Crohn's disease. Relationship to location of disease (clinical pattern) and surgical indication.
Among 615 patients with Crohn's disease originally diagnosed at the Cleveland Clinic Foundation from 1966 to 1969, 592 have been followed (96%) for a mean of 13 yr. Of these, 438 had undergone operation. The purpose of this study was to determine how many of these patients had developed recurrences requiring another operation and to relate recurrences to the original anatomic location of disease (the clinical pattern) and surgical indication. Those patients with ileocolic disease had the highest recurrence: 53% compared with 45% for colonic and 44% for small intestinal patterns. Second recurrences were ileocolic pattern 35%, colon 34%, small intestine 38%. The estimated median time of recurrence was similar among these three groups. The presence of internal fistula or perianal disease as an indicator for surgery were associated with a higher likelihood of recurrence and a shortened estimated median time to recurrence. This study supports the concept of conservatism with regard to the management of these two complications for patients with Crohn's disease.
Adult↗
Treatment of reflux oesophagitis. A randomized, controlled evaluation of cimetidine.
Twenty-five patients were studied in an eight-week randomized controlled comparison of cimetidine and placebo in the treatment of reflux oesophagitis. Therapy with cimetidine (1.0 g/day), compared with placebo, did not produce a statistically significant beneficial effect as assessed by relief of heartburn, reduction in antacid use, endoscopic evidence of healing, histological signs of improvement, or response to the acid perfusion (Bernstein) test.
Adult↗
Intensive bedside teaching of physical examination to medical undergraduates: evaluation including the effect of group size.
The effectiveness of intensive bedside teaching of techniques of physical examination of the alimentary system to students commencing their clinical training was assessed. All students viewed a videotape demonstrating these techniques and then participated in a morning practice examination session but only half of the class received afternoon bedside teaching of physical examination in addition. Teaching in history taking was used as a 'placebo' for the control group, and half the students in each of the study and control groups were taught in units of four, the other half in units of eight. Thus the effect of group size could also be estimated. After 1 week, the students' performance of a physical examination was assessed using a standardized scoring chart which demonstrated good reliability. The study group performed significantly better than the control and within the study group there was a trend for the students taught in smaller units to perform better.
Australia↗
Nursing on the high seas. Interview by Judith Banning.
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Canada↗
Epidemiology of ulcerative colitis.
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Colitis, Ulcerative↗
Paracetamol self-poisoning: diagnosis, management, and outcome.
Over a four-year period, 103 patients presented to St Vincent's Hospital, Melbourne, after poisoning themselves with paracetamol. Most of them were young adults who suffered temporary emotional or social distress. There was severe liver damage in four patients who presented, or were recognised, 24 hours or more after the ingestion of paracetamol. The absence of severe liver damage in the remaining 99 patients was attributed to early intervention with specific therapy with orally administered methionine or intravenously administered N-acetylcysteine. We describe a rapid plasma paracetamol assay which can aid in the diagnosis and management of this problem. All physicians should be aware that paracetamol-induced hepatic necrosis is not clinically apparent for two to three days, and that it can be prevented by early specific treatment.
Acetaminophen↗
Videotape demonstration of physical examination: evaluation of its use in medical undergraduate teaching.
A videotape demonstration of the physical examination of the alimentary system was used, in place of a traditional lecture, in the first week of a teaching programme for half of a group of commencing, clinical students. At the end of the week, these students obtained higher scores than the matched controls in a clinical assessment which utilized an objective scoring-chart especially for this study.
Australia↗
Alcohol unrelated hepato-biliary disorders in the alcoholic: the role of liver biopsy in determining the aetiology of liver disease.
Alcoholics with abnormal liver function tests are generally assumed to have one of the recognised patterns of alcoholic liver injury. This report described a group of nine patients who were initially thought to have alcoholic liver disease but were found on liver biopsy to have a variety of liver disorders unrelated to alcohol. Liver biopsy showed granulomatous hepatitis in three, primary biliary cirrhosis in two, and cholestasis of unknown cause, large duct biliary obstruction, haemochromatosis with secondary carcinoma and Budd-Chiari syndrome in one each. The histological changes observed in liver biopsy samples are believed to represent a chance occurrence of liver disease due to some agent other than alcohol and illustrates that forms of hepatic disease that affect the population at large can and do occur in heavy alcohol consumers.
Aged↗