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Biomedical subjects

J W Ely

Publications and source records attributed to J W Ely.

At least 19 recordsLinked to original sources
PubMed2000

Evaluation of pregnant women exposed to respiratory viruses.

Prenatal patients are often exposed to respiratory viruses at home and at work. Understandably, these patients may be concerned and want immediate answers and advice from their physicians. While most women who are exposed to chickenpox are immune, serologic testing can be performed and susceptible patients can be treated with varicella-zoster immune globulin. If the prenatal patient is infected with the varicella-zoster virus, the risk of fetal manifestations is less than 2 percent. Women who have been exposed to fifth disease can undergo serologic testing to determine the likelihood of infection. If the prenatal patient becomes infected with fifth disease during the first 20 weeks of gestation, the risk of fetal manifestations is about 9 percent and includes nonimmune hydrops and death. Cytomegalovirus, which is the most common congenital infection, is generally asymptomatic in the mother. Infected fetuses have a 25 percent chance of developing early or late neurologic manifestations. The evidence of harm from other common respiratory viruses is inconsistent.

Algorithms↗
PubMed2000

Videotaping obstetric procedures. Assessment of obstetricians and family physicians.

OBJECTIVE: To compare the attitudes and practice of Iowa obstetricians (OBs) and family physicians (FPs) regarding patients' desires to videotape obstetric procedures. DESIGN: All Iowa OBs (172) and FPs (438) who practice obstetrics received a questionnaire exploring their attitudes and practice patterns regarding videotaping obstetric procedures. Data were analyzed using chi 2, odds ratios with 95% confidence intervals, and multiple logistic regression. SETTING: The state of Iowa. MAIN OUTCOME MEASURES: Degree to which physicians allow videotaping and characteristics that contribute to any differences between OBs and FPs. RESULTS: The response rate was 87.8% (536 of 610 participants). Obstetricians were more likely than FPs to prevent patients from filming medical procedures (40.8% vs 19.1%, respectively, P < .001), modify their actions and conversation when video cameras were present (34.5% vs 25.5%, respectively, P = .046), and be tempted to turn off the camera when complications arose (35.1% vs 14.0%, respectively, P < .001). Younger OBs (aged, 25-40 years) were more likely than older OBs (aged, 41-80 years) to disallow videocameras (52.7% vs 33.3%, respectively, P = .02). Legal concerns were cited by more than 80% of OBs and FPs who disallowed videotaping. CONCLUSIONS: A significant difference was noted between OBs and FPs in their willingness to allow video recording of obstetric procedures. Legal concerns were cited by most OBs and FPs who had disallowed videotaping.

Adult↗
PubMed2000

Community characteristics associated with elder abuse.

OBJECTIVES: To help define the relationship between elder abuse rates and counties' demographics, healthcare resources, and social service characteristics. DESIGN: County-level data from Iowa were analyzed to test the association between county characteristics and rates of elder abuse between 1984 and 1993 using univariate correlation analysis and stagewise linear regression. SETTING: Ninety-nine counties in Iowa. PARTICIPANTS: Iowa residents aged 65 years and older. MEASUREMENTS: County-level population-adjusted numbers of abused elderly, abused children, children in poverty, high school dropouts, physicians and other healthcare providers, hospital beds, social workers and caseworkers in the Department of Human Services (DHS). RESULTS: Community characteristics that had a positive association with rates of reported or substantiated elder abuse at the P < .001 level were population density, children in poverty, and reported child abuse. Lower substantiated elder abuse rates were associated at P < .05 with higher community rates of high school dropouts, number of chiropractors, and number of nurse practitioners. After adjusting for number of DHS caseworkers and reported child abuse rates (a surrogate for workload) a district effect persists for substantiated elder abuse cases (P = .002). CONCLUSION: County demographics are risk factors for reported and substantiated elder abuse. The strongest risk factor for reported elder abuse was reported child abuse. The difference in districts may reflect differences in resources and/or differing characteristics of caseworkers who substantiate elder abuse. The risk factors may reflect conditions that influence the amount of elder abuse or the detection of existing elder abuse.

Aged↗
PubMed1999

Analysis of questions asked by family doctors regarding patient care.

OBJECTIVES: To characterise the information needs of family doctors by collecting the questions they asked about patient care during consultations and to classify these in ways that would be useful to developers of knowledge bases. DESIGN: Observational study in which investigators visited doctors for two half days and collected their questions. Taxonomies were developed to characterise the clinical topic and generic type of information sought for each question. SETTING: Eastern Iowa. PARTICIPANTS: Random sample of 103 family doctors. MAIN OUTCOME MEASURES: Number of questions posed, pursued, and answered; topic and generic type of information sought for each question; time spent pursuing answers; information resources used. RESULTS: Participants asked a total of 1101 questions. Questions about drug prescribing, obstetrics and gynaecology, and adult infectious disease were most common and comprised 36% of all questions. The taxonomy of generic questions included 69 categories; the three most common types, comprising 24% of all questions, were "What is the cause of symptom X?" "What is the dose of drug X?" and "How should I manage disease or finding X?" Answers to most questions (702, 64%) were not immediately pursued, but, of those pursued, most (318, 80%) were answered. Doctors spent an average of less than 2 minutes pursuing an answer, and they used readily available print and human resources. Only two questions led to a formal literature search. CONCLUSIONS: Family doctors in this study did not pursue answers to most of their questions. Questions about patient care can be organised into a limited number of generic types, which could help guide the efforts of knowledge base developers.

Adult↗
PubMed1999

Informed consent and general surgeons' attitudes toward the use of pain medication in the acute abdomen.

To determine general surgeons' attitudes about the use of pain medications in the acute abdomen, a questionnaire was mailed to all practicing general surgeons in Iowa. The questionnaire sought to determine the frequency with which pain medications were administered either before informed consent was obtained or before the patient with an acute abdomen was examined, and, in cases when pain medications were withheld, the reasons for withholding. The response rate was 72% (131 of 182). Seven percent of patients with an acute abdomen received pain medications by a general surgeon before being seen and 22% received pain medication by another physician in the emergency department (ED). Fifty-three percent of general surgeons responded that they believe pain medications preclude a patient from signing a valid informed consent; 78% reported that concerns about informed consent enter into their decision to withhold pain medications. Sixty-seven percent agreed that pain medications interfere with diagnostic accuracy, and 82% consider diagnostic accuracy when deciding to withhold pain medication.

Abdomen, Acute↗
PubMed1999

What clinical information resources are available in family physicians' offices?

BACKGROUND: When faced with questions about patient care, family physicians usually turn to books in their personal libraries for the answers. The resources in these libraries have not been adequately characterized. METHODS: We recorded the titles of all medical books in the personal libraries of 103 randomly selected family physicians in eastern Iowa. We also noted all clinical information that was posted on walls, bulletin boards, refrigerators, and so forth. Participants were asked to describe their use of other resources such as computers, MEDLINE, reprint files, and "peripheral brains" (personal notebooks of clinical information). For each physician, we recorded how often the resources were used to answer clinical questions during 2 half-day observation periods. RESULTS: The 103 participants owned a total of 5794 medical books, with 2836 different titles. Each physician kept an average of 56 books in the office. Prescribing references (especially the Physicians' Desk Reference) were most common (owned by 100% of the participants), followed by books on general internal medicine (99%), adult infectious disease (89%), and general pediatrics (83%). Books used to answer clinical questions were more likely to be up to date (copyright date within 5 years) than unused books (74% vs 27%, P <.001). Items posted on walls included drug dosage charts and pediatric immunization schedules. Only 26% of the physicians had computers in their offices. CONCLUSIONS: Drug-prescribing textbooks were the most common type of book in family physicians' offices, followed by books on general internal medicine and adult infectious diseases. Although many books were relatively old, those used to answer clinical questions were generally current.

Adult↗
PubMed1999

Malpractice claims against family physicians are the best doctors sued more?

BACKGROUND: Physicians who have been sued multiple times for malpractice are assumed to be less competent than those who have never been sued. However, there is a lack of data to support this assumption. Competence includes both knowledge and performance, and there are theoretical reasons to suspect that the most knowledgeable physicians may be sued the most. METHODS: We conducted a retrospective cohort study of family physicians who were included in the Florida section of the 1996 American Medical Association's Physician Masterfile and who practiced in Florida at any time between 1971 and 1994 (N = 3686). The main outcome was the number of malpractice claims per physician adjusted for time in practice. Using regression methods, we analyzed associations between malpractice claims and measures of physician knowledge. RESULTS: Risk factors for malpractice claims included graduation from a medical school in the United States or Canada (incidence rate ratio [IRR] 1.8; 95% confidence interval [CI], 1.6-2.1), specialty board certification (IRR 1.8; 95% CI, 1.6-2.1), holding the American Medical Association Physician's Recognition Award (IRR 1.4; 95% CI, 1.2-1.7), and Alpha Omega Alpha Honor Society membership (IRR 1.8; 95% CI, 1.1-3.0). Among board-certified family physicians, sued physicians who made no payments to a plaintiff had higher certification examination scores than nonsued physicians (53.48 vs 51.38, P < .01). The scores of sued physicians who made payments were similar to those of nonsued physicians (51.05 vs 51.38, P = .93). CONCLUSIONS: Among Florida family physicians, the frequency of malpractice claims increased with evidence of greater medical knowledge.

Family Practice↗
PubMed1998

Identifying left lower lobe pneumonia at chest radiography: performance of family practice residents before and after a didactic session.

RATIONALE AND OBJECTIVES: The authors sought to determine whether the lateral chest radiograph is helpful in identifying left lower lobe pneumonia among inexperienced readers. MATERIALS AND METHODS: The authors selected all patients who presented to a family practice training program with radiologic and clinical evidence of left lower lobe pneumonia (n = 65). They then selected an equal number of patients in whom chest radiographs were taken to "rule out pneumonia" and were found to be normal. Eight 1st-year family practice residents were asked to read the radiographs before and after a didactic session that emphasized lateral chest radiograph interpretation. The radiographs were presented under two viewing conditions: posteroanterior (PA) only versus PA and lateral. Receiver operating characteristic (ROC) curve methods were used to compare the effect of both the didactic session and the viewing condition on diagnostic accuracy. RESULTS: There were no significant differences in performance before and after the didactic session and no differences between the two viewing conditions. After including only abnormal radiographs that demonstrated the "spine sign" (an apparent increased opacification of the lower vertebral bodies on the lateral view), the residents performed better when presented with both PA and lateral radiographs than when presented with the PA radiograph only (area under ROC curve, .8158 vs .7418, respectively; P = 0.24). CONCLUSION: In patients with left lower lobe pneumonia whose radiographs demonstrated the spine sign, diagnostic accuracy improved when the lateral chest radiograph was viewed.

Case-Control Studies↗
PubMed1998

The effect of physician characteristics on compliance with adult preventive care guidelines.

BACKGROUND AND OBJECTIVES: This study identified physician characteristics and attitudes related to self-reported compliance with adult prevention guidelines. METHODS: A questionnaire was mailed to family practice and internal medicine residents and faculty at the University of Iowa (n = 209). The questionnaire's 78 items fell into seven categories, including physician demographics, history-taking practices, counseling practices, self-perceived effectiveness in changing patient behavior, beliefs about preventive care, knowledge about preventive care, and perceived barriers to the delivery of preventive care. RESULTS: Compliance with history-taking recommendations was independently associated with high knowledge scores, female physician gender, and high self-perceived effectiveness in changing patient behavior. The only factor that was independently associated with counseling efforts was self-perceived effectiveness in changing patient behavior. CONCLUSIONS: Factors that were independently associated with self-reported preventive care efforts include female physician gender, knowledge about preventive care guidelines, and perceived effectiveness in changing patient behavior. After controlling for these factors, other variables such as lack of time, lack of reminder systems, attitudes about preventive care, and amount of formal preventive care education were not related to self-reported compliance with counseling and history-taking recommendations.

Adult↗
PubMed1998

Legal implications of birth videos.

There is little information available in the peer-reviewed literature on the medical and legal aspects of videotaping obstetric procedures. To manage legal risks, some large medical centers do not allow families to videotape the birth. One liability insurer is now attempting to limit video cameras in labor and delivery suites throughout its state. These policies can have significant implications for physicians and their patients. In an effort to examine approaches to the problem, we gathered the experiences of physician and attorney members of the American College of Legal Medicine through letters and telephone conversations, and we performed a review of the available medical and legal literature. Based on this research and review, we present the benefits and risks of permitting families to videotape the birth process, and we make recommendations for reducing potential liability.

Delivery, Obstetric↗
PubMed1998

Neonatal respiratory distress in the community hospital: when to transport, when to keep.

Neonatal respiratory distress is a common problem confronting family physicians. Although respiratory distress may represent a benign, self-limited process, it may also be the first sign of sepsis or serious cardiopulmonary disease. Because it is crucial to differentiate the two, we offer a practical approach to the treatment of neonatal respiratory distress at community hospitals. Our method, the Rule of 2 Hours, is based on readily accessible clinical findings. We believe it will help physicians detect babies at risk for serious problems, but will not result in unnecessary referral of neonates that are simply adapting to extrauterine life.

Clinical Protocols↗
PubMed1998

Russian family practice training program: a single step on a long journey.

BACKGROUND AND OBJECTIVES: Since 1992, when the Russian government recognized family practice as a medical specialty, efforts have begun to progress from the idea stage to the delivery of patient care via family practice methods. We describe an educational effort to help teach Russian physicians family practice skills. METHODS: Five young Russian physicians were selected from an initial pool of 15 candidates on the basis of standardized testing, English language skills, and their potential to teach future Russian family physicians. Clinical, teaching, and business curricula were developed and used during the 6-month training period for the five selected physicians. Trainees were evaluated by mentors' and preceptors' written evaluations and by the American Board of Family Practice In-training Examination before, during, and at completion of the training. Subsequently, a fully equipped family practice office was opened in St Petersburg to serve as an on-site training facility. RESULTS: The trainees' self-perceived knowledge in community medicine, geriatrics, medical decision making, patient education, behavioral science, preventive medicine, and general family practice topics improved over the course of training. The composite scores on the in-training examinations improved from baseline (30 versus 308). Preceptors noted the greatest improvements in the use of clinical instruments, proficiency in physical exams, accessing medical information, and formulating differential diagnoses. The St Petersburg family practice office opened on October 1, 1996. The trainees now participate in the care of patients in this office and teach a new class of family medicine interns. CONCLUSION: The training program we describe has allowed Russian physicians to acquire new skills and knowledge that they can use and adapt to training future Russian family physicians.

Curriculum↗
PubMed1997

An introduction to time-trend analysis.

Healthcare professionals often are presented with data that appear to indicate an upward or downward trend over time. For example, admissions of acquired immunodeficiency syndrome (AIDS) patients appear to be increasing, cesarean section rates appear to be decreasing, or nosocomial pneumonia rates appear to be increasing. Critical decisions sometimes are based on such trends, which often are presented without a statistical analysis. Those responsible for decision making may be left wondering whether these apparent trends represent only chance variation. Graphs showing trends over time generally present one of three kinds of outcome data: counts (eg, three AIDS admissions), proportions (eg, 10 cesarean sections per 100 total deliveries), or person-time data (eg, 13 cases of nosocomial pneumonia per 10,000 patient days). Using familiar examples and a minimum of technical language, we illustrate the analysis of time trends.

Data Interpretation, Statistical↗
PubMed1997

Home visit program for teaching elder abuse evaluations.

BACKGROUND AND OBJECTIVES: A home visit program was designed to teach family practice residents how to evaluate patients for elder abuse and capacity (the ability to make one's own decisions). METHODS: Residents assessed potential abuse victims reported to Arizona's Adult Protective Service (APS) in their homes. Written evaluations prepared immediately following each home visit were abstracted for diagnoses (including abuse), recommendations, and patient demographics. Follow-up surveys by APS case workers determined whether the home visit recommendations were accomplished. Graduates of the residency were surveyed about their perceptions of the educational value of the program and their practice characteristics. RESULTS: The residents evaluated 201 patients. The mean age was 77, and 73% of patients were female. Seventy-five percent were incapacitated, 65% of these because of dementia. Ninety-one percent were abused, and the types of abuse included neglect (69%), exploitation (20%), physical abuse (8%), and unknown (3%). Recommendations were accomplished in the majority of cases: medical advice (68%), services (65%), medical evaluations (58%), guardian (53%), and conservator (52%). Graduates who participated in this program (1985-1992) rated their ability to diagnose elder abuse and to assess the patient's home environment significantly higher than earlier graduates who did not participate in the program (1977-1984). Earlier graduates made more home visits and provided more statements for guardianship than later graduates. CONCLUSIONS: The home visit program gave residents exposure to a population of elderly who were abused, demented, and living at home. This program provided clinical substance to build an effective teaching experience and furnished APS with a needed service.

Adult↗
PubMed1997

Lifelong self-directed learning using a computer database of clinical questions.

Physicians often have self-perceived knowledge gaps when they are seeing patients. Traditional continuing medical education is designed to meet the knowledge gaps of groups rather than individual physicians with specific patient problems. Physicians with clinical information needs are advised to critically evaluate high-quality original research in order to practice "evidence-based medicine." But this advice may be unrealistic for busy clinicians. We propose a system for documenting self-perceived information needs using a computer database. Concise answers to these needs are included in the database along with reference citations supporting the answers. The system tracks continuing education efforts, directs patient care decisions, and focuses lifelong learning on relevant topics. We emphasize the importance of being sensitive to personal information needs and the benefits of maintaining a record of these needs.

Clinical Medicine↗
PubMed1996

Differences in practice patterns between obstetricians and family physicians: use of serum screening.

OBJECTIVE: Our purpose was to compare the use of the Iowa Expanded Serum Screening program (maternal serum alpha-fetoprotein, human chorionic gonadotropin, and unconjugated estriol) by obstetricians and family physicians. STUDY DESIGN: A registry was used to identify all obstetricians (160) and family physicians (404) who practice obstetrics in Iowa. A questionnaire exploring attitudes and practice patterns related to serum screening was mailed to these physicians. RESULTS: The response rate was 80.3% overall. There were significant differences in the offering of serum screening (p < 0.001) for following three responses: obstetricians were more likely to offer screening through the Iowa Expanded Serum Screening Program than were family physicians (89.3% vs 57.2%) and less likely to offer screening outside the state program (9.9% vs 39.0%), whereas family physicians were more likely to not offer screening (0.8% vs 3.8%). When the responses of the physicians who offer screening were analyzed, several differences emerged: (1) obstetricians were more likely than family physicians to offer screening to all obstetric patients (99.2% vs 92.1%, p < 0.05), whereas family physicians were more likely to offer testing to patients with perceived risks for neural tube defects or chromosomal abnormalities and to those patients who requested it, (2) obstetricians were more likely to recommend screening than family physicians (39.0% vs 25.7%, p < 0.05), who more often discouraged testing, although the latter did not reach statistical significance, (3) family physicians more than obstetricians felt that screening was not necessary if the patient would not terminate the pregnancy for neural tube defects (41.6% vs 19.1%, p < 0.001) or chromosomal abnormalities (39.7% vs 21.4%, p < 0.01), and (4) obstetricians used nurses to counsel patients to a much greater extent than family physicians did (44.6% vs 14.0%, p < 0.001). CONCLUSION: There is a significant difference in practice patterns between obstetricians and family physicians in their reported use and presentation of maternal serum screening. Guidelines based on outcome studies should be developed and followed by obstetricians and family physicians.

Chorionic Gonadotropin↗