Why we need laws to protect patients from their health plan.
Explore the source record for details and available documents.
Hawaii↗
Biomedical subjects
R S Miller
Publications and source records attributed to R S Miller.
Graduate medical education, 1998-1999: a closer look.
Despite the ever-present risk of a critical imbalance in the physician workforce total numbers and specialty distribution, no systematic planning mechanism is in place. Furthermore, the length of training for graduate medical education (GME) precludes timely rectification of imbalances. We report GME activities collected in the American Medical Association Annual Survey of Graduate Medical Education Programs for 1998-1999, along with trends during the last 3 to 6 years. These data initially suggest that little has changed during the past several years; however, on closer examination, small but significant changes during the past 2 years may have serious consequences if continued. The total number of resident physicians, which has been constant during the last several years, decreased in 1998 by 760 from the previous year, while the number of programs continues to increase (6.1% since 1993). The number of US medical graduates entering GME programs remained stable during the last 6 years, the number of osteopathic graduates entering GME increased by 55.7%, and the number of international medical graduates (IMGs) entering GME continued to drop (down 13.2% since 1993). More IMGs tend to pursue additional training than do US graduates (in 1997, 32.9% vs 23.6%). Because IMGs are remaining in GME programs for longer periods, the total number of IMGs has not yet reflected significant change. About 62% of IMGs now entering GME training are either US citizens or permanent residents; ethnic minority residents are not decreasing in numbers as some predicted; and for the first time in the past 5 years, the primary care specialties have ceased their persistent growth. Toward the end of GME, the number of residents leaving programs before completion increased by 5.7% during the last 3 years. While some of these changes may be ascribed to reduced GME funding through the Balanced Budget Act of 1997, other factors clearly are at play. To anticipate future changes in the physician workforce, these factors should be identified to permit them to be monitored and modified as needed.
Education, Medical, Graduate↗
Size and age-sex distribution of pediatric practice: a study from Pediatric Research in Office Settings.
OBJECTIVES: To estimate (1) the average number of patients per practitioner in Pediatric Research in Office Settings, the national practice-based research network of the American Academy of Pediatrics; (2) the total number of active patients cared for in the network; and (3) the age-sex distribution of patients seen in pediatric practice. SETTING: Eighty-nine practices in 31 states with 373 Pediatric Research in Office Settings practitioners (59% of Pediatric Research in Office Settings members). METHODS: Practices were asked to enumerate the number of patients visiting the practice during the 2-year period from January 1, 1991, through December 31, 1992. Patients making multiple visits were counted only once, resulting in a patient count rather than a visit count. Age-sex registers were completed using computer billing records or medical record sampling. RESULTS: Study participants cared for 529513 active patients (50.7% male). Each practitioner cared for an average of 1546 patients. The number of patients per practitioner was significantly higher in less-populated areas and in solo practices. Children aged 12 years and younger comprised 81% of the patients seen by Pediatric Research in Office Settings practitioners, and more than half of the children were aged 6 years or younger. Before age 5 years, boys accounted for a slightly, but significantly, higher number of patients, whereas after age 14 years, girls comprised a significantly larger proportion of patients. CONCLUSIONS: The average number of 1546 patients per practitioner derived from these private practice data is in line with health maintenance organization-based estimates. Pediatric practitioners predominantly serve younger children. These data provide the only current national estimates of the size and age-sex distribution of independent pediatric practices, and can help pediatricians and health service researchers plan for the future provision of health care to children.
Adolescent↗
Prophylactic inferior vena cava filters in trauma patients at high risk: follow-up examination and risk/benefit assessment.
PURPOSE: The efficacy of prophylactic inferior vena cava filters in selected trauma patients at high risk has come into question in relation to risk/benefit assessment. To evaluate the usefulness of prophylactic inferior vena cava filters, we reviewed our experience and overall complication rate. METHODS: From February 1991 to April 1998, the trauma registry identified 7333 admissions. One hundred eighty-seven prophylactic inferior vena cava filters were inserted. After the exclusion of 27 trauma-related deaths (none caused by thromboembolism), 160 patients were eligible for the study. The eligible patients were contacted and asked to complete a survey and return for a follow-up examination to include physical examination, Doppler scan study, vena cava duplex scanning, and fluoroscopic examination. The patients' hospital charts were reviewed in detail. The indications for prophylactic inferior vena cava filter insertion included prolonged immobilization with multiple injuries, closed head injury, pelvic fracture, spine fracture, multiple long bone fracture, and attending discretion. RESULTS: Of the 160 eligible patients, 127 were men, the mean age was 40.3 years, and the mean injury severity score was 26.1. The mean day of insertion was hospital day 6. Seventy-five patients (47%) returned for evaluation, with a mean follow-up period of 19.4 months after implantation (range, 7 to 60 months). On survey, patients had leg swelling (n = 27), lower extremity numbness (n = 14), shortness of breath (n = 9), chest pain (n = 7), and skin changes (n = 4). All the survey symptoms appeared to be attributable to patient injuries and not related to prophylactic inferior vena cava filter. Physical examination results revealed edema (n = 12) and skin changes (n = 2). Ten Doppler scan studies had results that were suggestive of venous insufficiency, nine of which had histories of deep vein thrombosis. With duplex scanning, 93% (70 of 75) of the vena cavas were visualized, and all were patent. Only 52% (39 of 75) of the prophylactic inferior vena cava filters were visualized with duplex scanning. All the prophylactic inferior vena cava filters were visualized with fluoroscopy, with no evidence of filter migration. Of the total 187 patients, 24 (12.8%) had deep vein thrombosis develop after prophylactic inferior vena cava filter insertion, including 10 of 75 (13.3%) in the follow-up group, and one patient had a nonfatal pulmonary embolism despite filter placement. Filter insertion complications occurred in 1.6% (three of 187) of patients and included one groin hematoma, one arteriovenous fistula, and one misplacement in the common iliac vein. CONCLUSION: This study's results show that prophylactic inferior vena cava filters can be placed safely with low morbidity and no attributable long-term disabilities. In this patient population with a high risk of pulmonary embolism, prophylactic inferior vena cava filters offered a 99.5% protection rate, with only one of 187 patients having a nonfatal pulmonary embolism.
Adult↗
Comparison of tricortical screw fixation versus a modified suture construct for fixation of ankle syndesmosis injury: a biomechanical study.
OBJECTIVE: To assess the viability of using a modified flexible suture implant instead of a tricortical screw for fixation of ankle syndesmosis failures. DESIGN: Randomized biomechanical study. SETTING: Orthopaedic Research Laboratories at the University of North Carolina at Chapel Hill. INTERVENTION: Formalin-preserved cadaveric legs were used in pairs. Two holes, 2.5 millimeters in diameter and 7.0 to 10.0 millimeters apart horizontally, were drilled through the fibula and tibia 2.0 centimeters above the tibial plafond. Two strands of Number 5 suture were passed through the holes and tied. Similarly, a 3.5-millimeter tricortical screw was placed on the opposite leg of each pair at 2.0 centimeters. The ankles were tested to failure. This process was repeated at 5.0 centimeters above the tibial plafond. MAIN OUTCOME MEASUREMENTS: Maximum load and displacement at failure of the suture construct at 2.0 centimeters and at 5.0 centimeters were compared with a tricortical screw at 2.0 centimeters and at 5.0 centimeters. RESULTS: There was no significant difference in strength or displacement between the flexible suture implant and the tricortical screw at either 2.0 centimeters or 5.0 centimeters. The fixations at 5.0 centimeters had significantly increased holding strength over fixations at 2.0 centimeters, and the fixations had significantly greater displacement at 2.0 centimeters than at 5.0 centimeters. CONCLUSION: This study confirms that flexible syndesmosis repair is a viable option for internal fixation of ankle mortise instability due to syndesmosis rupture.
Ankle Injuries↗
Ehrlichial meningitis with cerebrospinal fluid morulae.
Explore the source record for details and available documents.
Child↗
Clinical impact of MR spectroscopy when MR imaging is indeterminate for pediatric brain tumors.
OBJECTIVE: We undertook this study to determine if single-voxel proton (hydrogen) MR spectroscopy could have clinical impact on the management of pediatric brain tumors when MR findings were indeterminate. SUBJECTS AND METHODS: Eleven children (mean age, 9 years) being examined for brain tumors underwent MR imaging that revealed indeterminate criteria of enhancement, mass effect, and prolonged T1 and T2 signal. MR spectroscopy was then used to distinguish radiation necrosis from tumor in one patient, differentiate residual tumor from scarring in two patients, document early treatment response in three patients, and discriminate benign from malignant masses in five patients. RESULTS: In 10 of the 11 patients, spectra were successfully acquired. Based on the chemical analysis of the indeterminate area shown on MR imaging, clinical impact was achieved in these 10 patients. Clinical impact included treatment modification in five patients, follow-up studies replacing further treatment in three patients, and tumor characterization in the remaining two patients. Confirmation was by histology in four patients and by follow-up MR imaging and MR spectroscopy for up to 30 months in the remaining six patients. CONCLUSION: When MR imaging is indeterminate in evaluating pediatric brain tumors, MR spectroscopy can provide objective neurochemical information, thereby altering treatment.
Adolescent↗
Use of a Web-based process model to implement security and data protection as an integral component of clinical information management.
Delivery of health care at Scott and White, a large integrated health care delivery system, is supported by an Electronic Medical Record (EMR) system repository of six million SGML-based documents. Control of document access is currently based on standard commercial security and confidentiality methodologies. Given the planned release in Fall 1999 of new federal security and confidentiality requirements, we have developed a web-based security process model that "wraps" existing EMR documents with HTML-compliant security attributes. Resulting logical documents are filtered regarding user queries by mapping the security attributes of the data to specific user role characteristics. A key virtue of our approach is that source EMR data do not undergo alteration by the imposition of the security process. It also places no additional work load or query pressure on the existing EMR system.
Computer Security↗
Increased efficiency and cost-effectiveness in the evaluation of the blunt abdominal trauma patient with the use of ultrasound.
The efficacy and effectiveness of ultrasound (US) in evaluating patients suspected of having blunt abdominal trauma are near that of computed tomography (CT) and diagnostic peritoneal lavage (DPL). Because no cost-effectiveness study has been reported, the purpose of this study was to demonstrate that US is more efficient and cost-effective than CT/DPL in evaluating blunt abdominal trauma. Over a 9-month period, 331 patients suspected of sustaining blunt abdominal trauma were evaluated at a Level I trauma center by US, CT, and/or DPL. Cost data and time to disposition were determined for analysis. The sensitivity, specificity, and accuracy of US were similar to those reported in previous studies. There was a significant difference in time to disposition with the US group being significantly lower (P = 0.001). The total procedural cost was 2.8 times greater for the CT/DPL group than for the US group. US is not only effective in diagnosing blunt abdominal trauma, but it is also more efficient and cost-effective than is CT/DPL.
Abdominal Injuries↗
Employment-seeking experiences of resident physicians completing training during 1996.
CONTEXT: Studies analyzing the physician workforce have concluded that the United States is verging on a physician oversupply, yet we lack persuasive evidence that this is resulting in physician underemployment and/or unemployment. OBJECTIVE: To determine the degree to which graduating residents have difficulty finding or are unable to find employment in their primary career choices. DESIGN: Two 1-page surveys sent separately to residents and to program directors to collect information on the employment status of residents who were completing a graduate medical education program at the end of the 1995-1996 academic year. SETTING: A total of 25 067 resident physicians scheduled in the spring of 1996 to complete a residency program accredited by the Accreditation Council on Graduate Medical Education, and 4569 program directors in 31 specialties and subspecialties. MAIN OUTCOME MEASURE: Both the graduates' employment status and the degree of difficulty they experienced securing a practice position, as reported by resident physicians and program directors. RESULTS: After 6 months of data collection, 12135 (48.4%) of 25 067 resident physicians responded to the survey. Of the respondents, 11 200 had completed their training, and 7628 (68.1%) were attempting to enter the workforce, 28.4% were seeking additional training, and 3.5% were fulfilling their military obligations. Of the 7628 resident physicians who sought employment, 67.3% obtained clinical practice positions in their specialties, 15.5% took academic positions, 5.0% found clinical positions in other specialties, 5.1% had other plans, and 7.1% did not yet have positions but were actively looking. In addition, 22.4% of resident physicians who found clinical positions reported significant difficulty finding them. The subgroup reporting greater difficulty finding clinical positions included international medical graduates (more than 40%),those completing programs in the Pacific or East North Central region, and those in several specialties. The 1996 graduating residents reported significantly higher rates of difficulty finding suitable employment than program directors reported for their graduates (22.4% vs 6.0%); however, the percentage of graduates reported by both groups as entering the workforce was the same (68.1%). Program directors reported an unemployment rate of only 1.2%, for their 1996 graduates, which was less than the rate reported by the resident physicians (7.1%). CONCLUSIONS: Resident physicians' direct reports of their employment-seeking experiences differ from what program directors report. Program directors accurately determined the number of residents pursuing further training; however, they did not have complete information about the employment difficulties experienced by their graduates. Based on graduates' reports, we conclude that employment difficulties are greatest among international medical graduates and vary by specialty and geographic region.
Career Choice↗
Graduate medical education, 1997-1998.
In response to growing concerns that continued unlimited governmental funding of graduate medical education (GME) would lead to a physician surplus, Congress enacted provisions in the Balanced Budget Act (BBA) of 1997 to limit further growth, as well as to encourage reductions in GME. The measures incorporated in this section of the BBA reflect recommendations made by a number of major professional associations. The question now is how effective these efforts will be and whether they will produce unintended or deleterious consequences. We report the changes occurring in GME from 1993 to 1997, focusing on changes prior to and since the enactment of the BBA. The total number of residents in GME programs has remained relatively constant from 1993 to 1997. The number of residents entering GME programs without prior GME experience has also remained constant; however, over the same period, the number entering a new program with some prior GME experience has fallen by 5.8%. The number of international medical graduates in all GME programs has increased 12.4% during this same period, while the number of US allopathic medical school graduates has decreased 4.4%. As federal and state initiatives are introduced to change the number and distribution of GME positions, it is critical that the American Medical Association and other professional organizations monitor GME tracking data more systematically and accurately than ever before.
Data Collection↗
Failure of amphotericin B lipid complex in the treatment of cutaneous leishmaniasis.
Explore the source record for details and available documents.
Adult↗
US graduate medical education, 1996-1997.
Workforce planners continue to be concerned that unlimited growth in graduate medical education (GME)-principally fueled by unrestrained federal support-will lead to a physician surplus. Because of this concern, in 1996 six major professional organizations called for a reduction in Medicare support of GME to bring residency training programs into more rational alignment with population needs. As of July 1, 1997, no final action had been taken by Congress to limit GME funding, although extensive discussions are under way. Even without governmental restrictions, the American Medical Association's annual survey of GME programs showed a reduction in the numbers of first-year residents in most major specialties and subspecialties. Minor reductions were initially noticed last year; now, the decreases are significant. Nearly all the specialties that had difficulty placing their graduates for 2 consecutive years also reported at least 10% fewer first-year residents than in 1994. More importantly, disciplines without employment difficulties also reported downsizing. The overall effect of these first-year reductions is easily masked by the addition of programs in new disciplines and some residents staying in the GME system longer. Entry-level reductions appear to be broader and more extensive than can be explained by market forces alone.
Education, Medical, Graduate↗
Initial employment status of resident physicians completing training in 1995.
OBJECTIVE: To assess the degree and type of difficulty encountered by resident physicians attempting to enter the workforce in 1995. DESIGN: Employment information derived from a 1-page descriptive survey completed by residency program directors from January 1, 1996, to June 15,1996, is described and compared with the results of a similar survey completed 1 year earlier. SETTING: Directors of 4568 residency programs in 31 specialties and subspecialties accredited by the Accreditation Council for Graduate Medical Education. MAIN OUTCOME MEASURE: The number of 1995 program graduates, their current professional status, and program directors' characterization of the experience of graduates who entered clinical practice, including the number who experienced major difficulties securing an acceptable practice position. Program directors reported actual and anticipated decreases in the number of residency positions and the likely availability of future professional opportunities. RESULTS: The 3819 program directors (83.6%) who completed the survey reported that 20065 resident physicians completed a residency program during 1995. Of those seeking employment (n = 13215), most entered clinical practice (80.1%) or took an academic position (15.6%); 2.2% were unemployed or had taken a position in a specialty or subspecialty different from the one in which they were last trained. A portion (6.3%) of graduates who entered clinical practice in their specialty or subspecialty experienced difficulty finding a suitable position; the percentage was lowest among graduates of general surgery, psychiatry, and primary care specialties. CONCLUSIONS: Survey results regarding the 1995 graduates are consistent with those obtained regarding the 1994 graduates and suggest that the market for physician services in some disciplines continues to be restrictive. We found that graduates of the specialties of anesthesiology and plastic surgery, whom we reported had the greatest difficulty finding acceptable positions in 1994, had less difficulty in 1995, suggesting a possible improvement in the market, less competition, a change in the respondents' perception of "acceptable," or a change in the resident physicians' willingness to pursue different opportunities. The general consistency of our results and their congruence with other published data suggest that this method is useful to identify and monitor trends in the physician market.
Employment↗
Effect of cardiopulmonary bypass on the plasma concentrations of fentanyl and alcuronium.
This study was conducted to examine the effect of cardiopulmonary bypass surgery on the total and unbound plasma concentrations of fentanyl and the total plasma concentrations of alcuronium. Total fentanyl concentrations were measured by gas chromatography, the plasma protein binding of fentanyl by ultrafiltration, and alcuronium concentrations by high-performance liquid chromatography. Sixteen patients were studied. On initiation of cardiopulmonary bypass (CPB), there were mean decreases of 58.8 +/- 7.1% and 47 +/- 3.2% for total concentrations of fentanyl in plasma and haemoglobin in blood, respectively. The magnitude of these reductions in individual patients was significantly related (Spearman p = 0.65, P < 0.05). The unbound fraction of fentanyl rose from 0.23 to 0.34 after the start of CPB. The total fentanyl concentration remained relatively stable during bypass until near the end of CPB when the mean total concentration increased, coinciding with rewarming. The size of the increase was related to the body mass index (BMI) of the patient (Spearman p = 0.85, P < 0.01). The estimated elimination half-life of fentanyl using the grouped data was 4.7 h. The total alcuronium concentration in plasma fell by 29% on initiation of CPB and there was no increase on rewarming. The estimated elimination half-life of alcuronium using the grouped data was 234 min. Despite marked declines in the plasma concentrations of both drugs on initiation of CPB, suitable levels of anaesthesia were maintained throughout the procedure.
Adjuvants, Anesthesia↗
Tissue prothrombin. Universal distribution in smooth muscle.
Immunohistochemical analysis of surgically obtained porcine tissue samples reveals ubiquitous staining for prothrombin in organs rich in smooth muscle content and universal staining of smooth muscle in tissue vasculature. The native character of tissue prothrombin is verified first by chromogenic substrate hydrolysis and hirudin inhibition after incubation of tissue extracts with taipan snake venom and phospholipid. Western analysis of tissue extracts confirms the native zymogen molecular weight. In addition, prothrombin purified in good yield from porcine uterus is activated by Echis carinatus venom which, like taipan venom, is 4-carboxyglutamic acid-sensitive. After correction for blood (gross heme) and interstitial fluid (albumin), excess functional prothrombin is observed in extracts of tissues having abundant smooth muscle. In contrast with factor X, the yield of prothrombin purified from porcine uterus greatly exceeds that attributable to contamination by whole blood. Northern blot analysis from selected bovine tissues extracted for polyadenylated messenger RNA is equivocal for prothrombin mRNA with the exception of liver, which is positive. It is concluded that functionally intact prothrombin is widely distributed among tissues owing to smooth muscle content, although the mechanism of emplacement and physiologic significance of prothrombin in these tissues remains unclear.
Animals↗
Sternal fracture: a benign entity?
A retrospective review of the Greenville Memorial Hospital trauma registry revealed 70 patients admitted with sternal fractures over a 38-month period. Localized sternal tenderness was present in 68 (97.1%), external signs of contusion/ecchymosis in 33 (47.1%), and dyspnea in 10 (14.3%) patients. The mechanism of injury was motor vehicle crash in 64 (91.4%) patients, with 46 of these restrained. Isolated sternal fractures were present in 34 (48.6%) patients. Only one death occurred. All sternal fractures were managed with analgesia and rest; surgery was required only when indicated for associated injuries. No patient was found to have an aortic injury or clinically significant cardiac dysrhythmia. Conclusions in this study that differ from those in previous studies can possibly be attributed to an evolving mechanism of sternal injury. This retrospective review shows no association between sternal fracture and clinically significant cardiac injury or injury to the thoracic aorta.
Adolescent↗
Comparison of IMG-dependent and non-IMG-dependent residencies in the National Resident Matching Program.
OBJECTIVE: To provide insight into the dynamics that determine the pattern of participation of international medical graduates (IMGs) in graduate medical education (GME). DESIGN: Data on IMG-dependent programs (ie., those having at least 50% of first-year positions filled by IMGs) and non-IMG-dependent programs in 6 core specialties (internal medicine, family practice, obstetrics and gynecology, surgery, pediatrics, and psychiatry) were matched with application data from the 1989 and 1995 National Resident Matching Program (NRMP). MAIN OUTCOME MEASURES: Participation of IMG-dependent and non-IMG-dependent programs in the 1995 NRMP and the pattern of US medical graduate (USMG) and IMG applications to these programs in 1989 and 1995. RESULTS: Of the 1634 programs in the 6 specialties, 93.5% participated in the 1995 NRMP. The 1165 non-IMG-dependent programs were significantly more likely to participate in the NRMP and were slightly more likely to fill their offered positions than were the 469 IMG-dependent programs. Specifically, IMGs constituted 76% of applicants to IMG-dependent programs and only 14% of applicants to non-IMG-dependent programs. Changes in NRMP data between 1989 and 1995 indicated that the number of IMG applications to IMG-dependent programs increased 88.7%, as did the number of applicants ranked. CONCLUSIONS: Persistent differences exist in the mix of USMGs and IMGs applying through the NRMP to IMG-dependent and non-IMG-dependent programs. Over time, programs that enroll large numbers of IMGs are likely to experience an increase in the number and proportion of applications from IMGs and a decrease in the number and proportion of applications from USMGs. If policies are adopted to limit IMG access to GME, IMG-dependent programs may be unable to recruit USMGs unless the total number of GME programs or the quality of existing programs fundamentally changes.
Foreign Medical Graduates↗