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Biomedical subjects

M Linzer

Publications and source records attributed to M Linzer.

At least 37 records · Page 2Linked to original sources
PubMed1997

Diagnosing syncope. Part 2: Unexplained syncope. Clinical Efficacy Assessment Project of the American College of Physicians.

PURPOSE: To review the literature on diagnostic testing in syncope that remains unexplained after initial clinical assessment. DATA SOURCES: MEDLINE search. STUDY SELECTION: Published papers were selected if they addressed diagnostic testing in syncope, near syncope, or dizziness. DATA EXTRACTION: Studies were identified as population studies, referral studies, or case series. DATA SYNTHESIS: After a thorough history, physical examination, and electrocardiography, the cause of syncope remains undiagnosed in 50% of patients. In such patients, information may be derived from the results of carefully selected diagnostic tests, especially 1) electrophysiologic studies in patients with organic heart disease, 2) Holter monitoring or telemetry in patients known to have or suspected of having heart disease, 3) loop monitoring in patients with frequent events and normal hearts, 4) psychiatric evaluation in patients with frequent events and no injury, and 5) tilt-table testing in patients who have infrequent events or in whom vasovagal syncope is suspected. Hospitalization is indicated for high-risk patients, especially those with known heart disease and elderly patients. CONCLUSIONS: A flexible, focused approach is required to diagnose syncope. Features of the initial history and physical examination help guide diagnostic testing.

Aged↗
PubMed1997

Diagnosing syncope. Part 1: Value of history, physical examination, and electrocardiography. Clinical Efficacy Assessment Project of the American College of Physicians.

PURPOSE: To review the literature on diagnostic testing in syncope and provide recommendations for a comprehensive, cost-effective approach to establishing its cause. DATA SOURCES: Studies were identified through a MEDLINE search (1980 to present) and a manual review of bibliographies of identified articles. STUDY SELECTION: Papers were eligible if they addressed diagnostic testing in syncope or near syncope and reported results for at least 10 patients. DATA EXTRACTION: The usefulness of tests was assessed by calculating diagnostic yield: the number of patients with diagnostically positive test results divided by the number of patients tested or, in the case of monitoring studies, the sum of true-positive and true-negative test results divided by the number of patients tested. DATA SYNTHESIS: Despite the absence of a diagnostic gold standard and the paucity of data from randomized trials, several points emerge. First, history, physical examination, and electrocardiography are the core of the syncope workup (combined diagnostic yield, 50%). Second, neurologic testing is rarely helpful unless additional neurologic signs or symptoms are present (diagnostic yield of electroencephalography, computed tomography, and Doppler ultrasonography, 2% to 6%). Third, patients in whom heart disease is known or suspected or those with exertional syncope are at higher risk for adverse outcomes and should have cardiac testing, including echocardiography, stress testing. Holter monitoring, or intracardiac electrophysiologic studies, alone or in combination (diagnostic yields, 5% to 35%). Fourth, syncope in the elderly often results from polypharmacy and abnormal physiologic responses to daily events. Fifth, long-term loop electrocardiography (diagnostic yield, 25% to 35%) and tilt testing (diagnostic yield < or = 60%) are most useful in patients with recurrent syncope in whom heart disease is not suspected. Sixth, psychiatric evaluation can detect mental disorders associated with syncope in up to 25% of cases. Seventh, hospitalization may be indicated for patients at high risk for cardiac syncope (those with an abnormal electrocardiogram, organic heart disease, chest pain, history of arrhythmia, age > 70 years) or with acute neurologic signs. CONCLUSIONS: Many tests for syncope have a low diagnostic yield. A careful history, physical examination, and electrocardiography will provide a diagnosis or determine whether diagnostic testing is necessary in most patients.

Algorithms↗
PubMed1997

Multisomatoform disorder. An alternative to undifferentiated somatoform disorder for the somatizing patient in primary care.

BACKGROUND: For clinical or research use in primary care, the DSM-IV diagnostic criteria for somatization disorder are too restrictive, while the criteria for undifferentiated somatoform disorder are overly inclusive. In this article, we examine the validity of multisomatoform disorder, defined as 3 or more medically unexplained, currently bothersome physical symptoms plus a long (> or = 2 years) history of somatization. METHODS: Data from the Primary Care Evaluation of Mental Disorders Study of 1000 patients from 4 primary care sites were analyzed. The outcomes assessed were 6 domains of health-related quality of life, using the 20-item Short-Form General Health Survey; self-reported disability days and health care use; satisfaction with care; and physician-rated difficulty of the encounter. RESULTS: Multisomatoform disorder was diagnosed in 82 (8.2%) of the 1000 patients who were enrolled in the Primary Care Evaluation of Mental Disorders Study. Compared with mood and anxiety disorders, multisomatoform disorder was associated with comparable impairment in health-related quality of life, more self-reported disability days and clinic visits, and greater clinician-perceived patient difficulty. CONCLUSIONS: Multisomatoform disorder may be a valid diagnosis and potentially more useful than the DSM-IV diagnosis of undifferentiated somatoform disorder. Also, because multisomatoform disorder has a large and independent effect on impairment, its diagnosis should not be precluded simply because of a coexisting mood or anxiety disorder.

Adolescent↗
PubMed1997

Physician job satisfaction: developing a model using qualitative data. SGIM Career Satisfaction Study Group.

The purpose of this study was to develop a current and comprehensive model of physician job satisfaction. Information was gathered by (1) analysis of open-ended responses from a large group practice physician survey in 1988, and (2) analysis of focus group data of diverse physician subgroups from 1995. Participants were 302 physicians from large-group practices and 26 participants in six focus groups of HMO, women, minority, and inner-city physicians. Data were used to develop a comprehensive model of physician job satisfaction. The large group practice survey data supported the key importance of day-to-day practice environment and relationships with patients and physician peers. Future concerns focused on the effect of managed care on the physician-patient relationship and the ability of physicians to provide quality care. Focus groups provided contemporary data on physician job satisfaction, reinforcing the centrality of relationships as well as special issues for diverse physician subgroups of practicing physicians. New variables that relate to physician job satisfaction have emerged from economic and organizational changes in medicine and from increasing heterogeneity of physicians with respect to gender, ethnicity, and type of practice. A more comprehensive model of physician job satisfaction may enable individual physicians and health care organizations to better understand and improve physician work life.

Adult↗
PubMed1996

The difficult patient: prevalence, psychopathology, and functional impairment.

OBJECTIVE: To determine the proportion of primary care patients who are experienced by their physicians as "difficult," and to assess the association of difficulty with physical and mental disorders, functional impairment, health care utilization, and satisfaction with medical care. DESIGN: Survey. SETTING: Four primary care clinics. PATIENTS: Six-hundred twenty-seven adult patients. MEASUREMENTS: Physician perception of difficulty (Difficult Doctor-Patient Relationship Questionnaire), mental disorders and symptoms (Primary Care Evaluation of Mental Disorders, [PRIME-MDI]), functional status (Medical Outcomes Study Short-Form Health Survey [SF-20]), utilization of and satisfaction with medical care by patient self-report. RESULTS: Physicians rated 96 (15%) of their 627 patients as difficult (site range 11-20%). Difficult patients were much more likely than not-difficult patients to have a mental disorder (67% vs 35% [corrected], p < .0001). Six psychiatric disorders had particularly strong associations with difficulty: multisomatoform disorder (odds ratio [OR] = 12.3. 95% confidence interval [CI] = 5.9-26.8), panic disorder (OR = 6.9, 95% CI = 2.6-18.1), dysthymia (OR = 4.2, 95% CI = 2.0-8.7), generalized anxiety (OR = 3.4, 95% CI = 1.7-7.1), major depressive disorder (OR = 3.0, 95% CI = 1.8-5.3), and probable alcohol abuse or dependence (OR = 2.6, 95% CI = 1.01-6.7). Compared with not-difficult patients, difficult patients had more functional impairment, higher health care utilization, and lower satisfaction with care, whereas demographic characteristics and physical illnesses were not associated with difficulty. The presence of mental disorders accounted for a substantial proportion of the excess functional impairment and dissatisfaction in difficult patients. CONCLUSIONS: Difficult patients are prevalent in primary care settings and have more psychiatric disorders, functional impairment, health care utilization, and dissatisfaction with care. Future studies are needed to determine whether improved diagnosis and management of mental disorders in difficult patients could diminish their excess disability, health care costs, and dissatisfaction with medical care, as well as the physicians experience of difficulty.

Adult↗
PubMed1996

Gender, quality of life, and mental disorders in primary care: results from the PRIME-MD 1000 study.

BACKGROUND: Recently there has been increased interest in the special mental health needs of women. We used data from the PRIME-MD 1000 study to assess gender differences in the frequency of mental disorders in primary care settings, and to explore the potential impact of these differences on health-related quality of life (HRQL). SUBJECTS AND METHODS: One thousand primary care patients (559 women) were interviewed during the PRIME-MD study, which was conducted at four primary care clinics affiliated with university hospitals throughout the eastern United States. Patients completed a one-page questionnaire in the waiting room prior to being seen by the physician; patients and physicians then completed together a clinician evaluation guide that used DSM-III-R algorithms to diagnose mood, anxiety, somatoform, eating, and alcohol related disorders. Health-related quality of life was assessed with the Medical Outcomes Study SF-20 General Health Survey. RESULTS: Women were more likely than men to have at least one mental disorder (43% versus 33%, P < 0.05). Higher rates were particularly prominent for mood disorders (31% of women versus 19% of men, odds ratio [OR] = 1.9, 95% confidence interval [CI] 1.4 to 2.6), anxiety disorders (22% versus 13%, OR = 1.9, CI = 1.3 to 2.8), and somatoform disorders (18% versus 9%, OR = 2.2, CI = 1.5 to 3.4). Psychiatric comorbidity was also more common in women (26% of women had two or more mental disorders versus 15% of men, P < 0.05). Unadjusted HRQL scores, ranging from 0 to 100, with 100 = best health, were all significantly lower in women than in men (eg, physical function = 67 in women versus 76 in men, P < 0.0001; mental health = 69 in women versus 76 in men, P < 0.0001). Many HRQL differences persisted after controlling for age, education, ethnicity, marital status, and number of physical disorders; however, differences in HRQL were eliminated in 5 of 6 domains after controlling for number of mental disorders. When compared with female patients of male physicians, female patients of female physicians demonstrated similar satisfaction with care, health care utilization, HRQL, and recognition rate of mental disorders. CONCLUSIONS: In the 1,000 patients of the PRIME-MD study, mood, anxiety, and somatoform disorders and psychiatric comorbidity were all significantly more common in women than men. The HRQL scores were poorer in women than men, although most of this difference was accounted for by the difference in prevalence of mental disorders. These data suggest that one of the most important aspects of a primary care physician's care of female patients is to screen for and treat common mental disorders.

Adult↗
PubMed1995

Health-related quality of life in primary care patients with mental disorders. Results from the PRIME-MD 1000 Study.

OBJECTIVE: To determine if different mental disorders commonly seen in primary care are uniquely associated with distinctive patterns of impairment in the components of health-related quality of life (HRQL) and how this compares with the impairment seen in common medical disorders. DESIGN: Survey. SETTING: Four primary care clinics. SUBJECTS: A total of 1000 adult patients (369 selected by convenience and 631 selected by site-specific methods to avoid sampling bias) assessed by 31 primary care physicians using PRIME-MD (Primary Care Evaluation of Mental Disorders) to make diagnoses of mood, anxiety, alcohol, somatoform, and eating disorders. MAIN OUTCOME MEASURES: The six scales of the Short-Form General Health Survey and self-reported disability days, adjusting for demographic variables as well as psychiatric and medical comorbidity. RESULTS: Mood, anxiety, somatoform, and eating disorders were associated with substantial impairment in HRQL. Impairment was also present in patients who only had subthreshold mental disorder diagnoses, such as minor depression and anxiety disorder not otherwise specified. Mental disorders, particularly mood disorders, accounted for considerably more of the impairment on all domains of HRQL than did common medical disorders. Finally, we found marked differences in the pattern of impairment among different groups of mental disorders just as others have reported unique patterns associated with different medical disorders. Whereas mood disorders had a pervasive effect on all domains of HRQL, anxiety, somatoform, and eating disorders affected only selected domains. CONCLUSIONS: Mental disorders commonly seen in primary care are not only associated with more impairment in HRQL than common medical disorders, but also have distinct patterns of impairment. Primary care directed at improving HRQL needs to focus on the recognition and treatment of common mental disorders. Outcomes studies of mental disorders in both primary care and psychiatric settings should include multidimensional measures of HRQL.

Adult↗
PubMed1995

The impact of an ambulatory rotation on medical student interest in internal medicine. The Society of General Internal Medicine Task Force on Career Choice in Internal Medicine.

OBJECTIVE: To determine whether students who take ambulatory rotations in internal medicine are more likely to choose internal medicine careers. DESIGN: National survey. SETTING AND PARTICIPANTS: The intended sample was 1,650 senior U.S. medical students from 16 medical schools, of whom 1,244 (76%) responded. Representative schools nationwide were selected using a stratified, random-sampling method. MEASUREMENTS: The questionnaire asked about characteristics of the ambulatory rotation, perceptions of internal medicine, and factors influencing students toward or away from an internal medicine career. RESULTS: Ambulatory rotations were taken by 543 students (43%). Of these rotations, 73% were required, 74% were during the fourth year, 77% were in general internal medicine, 73% provided continuity of care, and 19% were during the medicine clerkship. Overall, 24% of the students chose careers in general (9%) or subspecialty internal medicine (15%). Thirty percent of the students who did ambulatory rotations planned internal medicine careers, compared with 19% of the students who had no rotation [odds ratio (OR) = 1.8, 95% confidence interval (CI) 1.3 to 2.4, p = 0.0001]. This association was of similar magnitudes for students completing required rotations (OR = 1.6, 95% CI 1.2 to 2.2, p = 0.002) and for students completing rotations before or in proximity to when they chose careers (OR = 1.7, 95% CI 1.1 to 2.4, p = 0.01). Ninety percent of the 543 students who had ambulatory rotations were satisfied with the experience. Thirty-eight percent of the highly satisfied students chose internal medicine careers, compared with 21% of the students who had low or moderate satisfaction (p = 0.0001). CONCLUSIONS: An ambulatory rotation is strongly associated with positive perceptions of, attraction to, and choice of a career in internal medicine. Research is needed to determine specific components of an effective rotation. Further development of ambulatory rotations could help attract more students to internal medicine.

Adult↗
PubMed1995

Gender differences in depression in primary care.

OBJECTIVES: To determine gender differences in the frequency and manifestation of depression in primary care. STUDY DESIGN: PRIME-MD, a new assessment tool, was tested in 1000 patients as an aid to diagnose depression in primary care patients. Answers to a self-assessment questionnaire completed by patients determined whether physicians administered the mood module in the Clinician Evaluation Guide to diagnose depression. Functional status was assessed with the Medical Outcomes Study Short Form (SF-20). RESULTS: More women than men were diagnosed as having a mood disorder (31% vs 19%; p < 0.01), and an antidepressant was newly prescribed only for women (p < 0.001). There were no gender differences in physician ratings of patients' health, but women rated their health significantly more poorly than did men. Similarly, functional impairment scores were significantly lower in women than in men. CONCLUSIONS: Women are much more likely than men to have depressive disorders, and when these disorders are diagnosed, to receive a prescription for antidepressant medication. Further research is needed to determine why women seem to suffer disproportionately from symptoms of depression and signs of functional impairment.

Antidepressive Agents↗
PubMed1995

Psychiatric comorbidity, health status, and functional impairment associated with alcohol abuse and dependence in primary care patients: findings of the PRIME MD-1000 study.

The psychiatric comorbidity, health, and functioning of primary care patients with alcohol abuse and dependence (AAD) were investigated in a sample of 1,000 patients. Psychiatric symptomatology was assessed with the Primary Care Evaluation of Mental Disorders (PRIME-MD) diagnostic system. Health and functional status was assessed with the Medical Outcomes Study Short Form General Health Survey (SF-20). Results indicated that use of the PRIME-MD system brought about a 71% increase in physician recognition of AAD. AAD patients were diagnosed with substantial psychiatric comorbidity, and they reported poorer health and functioning than did patients without any psychiatric disorders. However, they reported less impairment and psychiatric comorbidity than did patients with other psychiatric disorders. Results also indicated that AAD patients' health and functioning were associated with the presence or absence of psychiatric comorbidity.

Adolescent↗
PubMed1995

Evaluating medical residents' literature-appraisal skills.

BACKGROUND: Measuring critical-appraisal skills is a key step in assessing physicians' abilities to engage in self-directed learning. The authors developed an instrument to evaluate the abilities of residents to critically appraise a journal article. METHOD: In 1991, 62 residents in the categorical internal medicine program at the New England Medical Center were asked to respond to a questionnaire, evaluate a sample article, and complete a self-assessment of competence in evaluation of research. Critical-appraisal skill was determined by calculating the resident's deviations from a "gold standard" critique developed through a modified Delphi technique, using a panel of five physicians. Spearman correlation coefficients were used to compare the residents' actual and self-perceived abilities. RESULTS: Twenty-eight residents returned the questionnaire, for a response rate of 45%. The composite score for the residents' objective assessments was 63% of the gold standard, and was not significantly correlated with post-graduate year, prior journal club experience, or self-assessed critical-appraisal skill. CONCLUSION: After further validation in other settings, the assessment instrument in this study may be used to objectively assess critical-reading skills. It may also provide feedback and measure outcomes for interventions designed to improve critical reading.

Internal Medicine↗
PubMed1994

Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study.

OBJECTIVE: To assess the validity and utility of PRIME-MD (Primary Care Evaluation of Mental Disorders), a new rapid procedure for diagnosing mental disorders by primary care physicians. DESIGN: Survey; criterion standard. SETTING: Four primary care clinics. SUBJECTS: A total of 1000 adult patients (369 selected by convenience and 631 selected by site-specific methods to avoid sampling bias) assessed by 31 primary care physicians. MAIN OUTCOME MEASURES: PRIME-MD diagnoses, independent diagnoses made by mental health professionals, functional status measures (Short-Form General Health Survey), disability days, health care utilization, and treatment/referral decisions. RESULTS: Twenty-six percent of the patients had a PRIME-MD diagnosis that met full criteria for a specific disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition. The average time required of the primary care physician to complete the PRIME-MD evaluation was 8.4 minutes. There was good agreement between PRIME-MD diagnoses and those of independent mental health professionals (for the diagnosis of any PRIME-MD disorder, kappa = 0.71; overall accuracy rate = 88%). Patients with PRIME-MD diagnoses had lower functioning, more disability days, and higher rates of health care utilization than did patients without PRIME-MD diagnoses (for all measures, P < .005). Nearly half (48%) of 287 patients with a PRIME-MD diagnosis who were somewhat or fairly well-known to their physicians had not been recognized to have that diagnosis before the PRIME-MD evaluation. A new treatment or referral was initiated for 62% of the 125 patients with a PRIME-MD diagnosis who were not already being treated. CONCLUSION: PRIME-MD appears to be a useful tool for identifying mental disorders in primary care practice and research.

Adult↗
PubMed1994

Physical symptoms in primary care. Predictors of psychiatric disorders and functional impairment.

OBJECTIVE: To examine how the type and number of physical symptoms reported by primary care patients are related to psychiatric disorders and functional impairment. DESIGN: Outpatient mental health survey. SETTING: Four primary care clinics. PATIENTS: One thousand adult clinic patients, of whom 631 were selected randomly or consecutively and 369 by convenience. MAIN OUTCOME MEASURES: Psychiatric disorders as determined by the Primary Care Evaluation of Mental Disorders procedure; the presence or absence of 15 common physical symptoms and whether symptoms were somatoform (ie, lacked an adequate physical explanation); and functional status as determined by the Medical Outcomes Study Short-form General Health Survey. RESULTS: Each of the 15 common symptoms was frequently somatoform (range, 16% to 33%). The presence of any physical symptom increased the likelihood of a diagnosis of a mood or anxiety disorder by at least twofold to three-fold, and somatoform symptoms had a particularly strong association with psychiatric disorders. The likelihood of a psychiatric disorder increased dramatically with increasing numbers of physical symptoms. The prevalence of a mood disorder in patients with 0 to 1, 2 to 3, 4 to 5, 6 to 8, and 9 or more symptoms was 2%, 12%, 23%, 44%, and 60%, respectively, and the prevalence of an anxiety disorder was 1%, 7%, 13%, 30%, and 48%, respectively. Finally, each physical symptom was associated with significant functional impairment; indeed, the number of physical symptoms was a powerful correlate of functional status. CONCLUSIONS: The number of physical symptoms is highly predictive for psychiatric disorders and functional impairment. Multiple or unexplained symptoms may signify a potentially treatable mood or anxiety disorder.

Adult↗