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Biomedical subjects

R S Wigton

Publications and source records attributed to R S Wigton.

At least 19 recordsLinked to original sources
PubMed1992

Training internists in procedural skills.

The procedural skills of internists have been scrutinized recently because of concern for quality of care and because of economic and liability issues. The findings of recent surveys of program directors and practicing internists about procedural skills are reviewed. The results of these surveys in relation to the American Board of Internal Medicine's (ABIM) new training requirements and New York State's new policy requiring credentialing of residents in training are also discussed. Surveys show that internists do a large number and variety of procedures, that the number of procedures varies with the nature and location of practice, and that internists who more recently completed training do more procedures. Many graduates do not master the procedures their program directors think they should, and many learn procedures, often without supervision, after they have entered practice. The ABIM has recently ruled that residents must have documented experience and competence in specific core procedures to become eligible for certification. Also, New York State, in the wake of the Libby Zion case, now requires that all residents be credentialed in the procedures they do during training. Programs in internal medicine need to decide which procedures their residents will master and assure that their residents receive the training and testing necessary for competency and for formal certification of mastery in each procedure. Programs may restructure rotations to assure adequate experience. In the new era of accountability, certification of training and of competence in procedural skills will be an important function of training programs.

Certification↗
PubMed1992

Controlled trial using computerized feedback to improve physicians' diagnostic judgments.

The goal of this study was to test an innovative method to improve physicians' diagnostic judgments by integrating the use of a computer program (employing cognitive feedback to teach a clinical rule that predicts the probability of streptococcal pharyngitis), a traditional lecture, and periodic disease-prevalence reports. In a controlled trial using pre- and postintervention measures involving 885 patients, the authors compared the effects of the integrated method on the diagnostic judgments of seven experienced physicians at a university health service (from 1982 to 1985) with the effects of the lecture alone on the judgments of seven experienced physicians at a different university health service (1986 to 1987). The integrated method significantly improved the quality of the physicians' judgments as measured by calibration curves and Brier scores, and increased the level of agreement between the physicians' judgments and those made by the clinical prediction rule. The lecture alone produced less improvement in the quality of the physicians' judgments, and decreased the level of agreement with the rule. The authors conclude that this method, based on cognitive psychology, is a promising educational tool.

Computer-Assisted Instruction↗
PubMed1992

The influence of treatment descriptions on advance medical directive decisions.

OBJECTIVE: To determine whether the wording of the descriptions of life-sustaining interventions would affect the choices elderly patients make when completing advance directives. METHODS: Survey. SETTING: General community in Omaha, Nebraska. PATIENTS: Two hundred one community-dwelling elderly were selected from a population-based sample. MAIN OUTCOME MEASURES: Subjects were asked whether they would accept or reject three life-sustaining interventions: cardiopulmonary resuscitation, mechanical ventilation, or tube feeding in three separate hypothetical case scenarios. The three life-sustaining interventions were each described positively, negatively, and exactly as they are worded in a widely used advance directive. Subjects reviewed each scenario three times with three different descriptions of the three interventions. RESULTS: For the three interventions presented in three scenarios, subjects opted for the intervention 12 percent of the time when it was presented negatively, 18 percent of the time when it was phrased as in an advance directive already in use and 30 percent of the time it was phrased positively. One hundred fifty-five of the 201 subjects (77 percent) changed their minds at least once when given the same scenario but a different description of the intervention. Of these 155, 33 percent changed decisions one to three times, 33 percent changed decisions four to seven times, and another 34 percent changed decisions eight to seventeen times based solely on the description of the intervention. CONCLUSION: The decisions patients make about whether to accept or reject life-sustaining treatments are affected by the descriptions of the treatments. These findings emphasize the critical importance of doctor-patient consultation when patients execute advance directives.

Advance Directives↗
PubMed1991

Significant efficiency findings while controlling for the frequent confounders of CAI research in the PlanAlyzer project's computer-based, self-paced, case-based programs in anemia and chest pain diagnosis.

Richard E. Clark in his widely published comprehensive studies and meta-analyses of the literature on computer assisted instruction (CAI) has decried the lack of carefully controlled research, challenging almost every study which shows the computer-based intervention to result in significant post-test proficiency gains over a non-computer-based intervention. We report on a randomized study in a medical school setting where the usual confounders found by Clark to plague most research, were carefully controlled. PlanAlyzer is a microcomputer-based, self-paced, case-based, event-driven system for medical education which was developed and used in carefully controlled trials in a second year medical school curriculum to test the hypothesis that students with access to the interactive programs could integrate their didactic knowledge more effectively and/or efficiently than with access only to traditional textual "nonintelligent" materials. PlanAlyzer presents cases, elicits and critiques a student's approach to the diagnosis of two common medical disorders: anemias and chest pain. PlanAlyzer uses text, hypertext, images and critiquing theory. Students were randomized, one half becoming the experimental group who received the interactive PlanAlyzer cases in anemia, the other half becoming the controls who received the exact same content material in a text format. Later in each year there was a crossover, the controls becoming the experimentals for a similar intervention with the cardiology PlanAlyzer cases. Preliminary results at the end of the first two full trials shows that the programs have achieved most of the proposed instructional objectives, plus some significant efficiency and economy gains. 96 faculty hours of classroom time were saved by using PlanAlyzer in their place, while maintaining high student achievement. In terms of student proficiency and efficiency, the 328 students in the trials over two years were able to accomplish the project's instructional objectives, and the experimentals accomplished this in 43% less time than the controls, achieving the same level of mastery. However, in spite of these significant efficiency findings, there have been no significant proficiency differences (as measured by current factual and higher order multiple choice post-tests) between the experimental and control groups. Very careful controls were used to avoid what Clark has found to be the most common confounders of CAI research. Accordingly, this research proved Clark's rival hypothesis, that the computer, in itself, does not appear to contribute to proficiency gains, at least as measured by our limited post-testing. Clark's position is that the computer is primarily a vehicle--as is either a pill or a hypodermic needle for delivering a drug.(ABSTRACT TRUNCATED AT 400 WORDS)

Anemia↗
PubMed1991

Addition of peripheral blood stem cells collected without mobilization techniques to transplanted autologous bone marrow did not hasten marrow recovery following myeloablative therapy.

A randomized prospective trial was conducted to determine if the addition of cryopreserved autologous peripheral blood stem cells (PBSC) collected without mobilization techniques to autologous cryopreserved bone marrow for patients receiving an autologous bone marrow transplant (ABMT) affected the time to marrow function recovery. Thirty-five evaluable patients with various malignancies were studied. Sixteen received PBSC + ABMT and 19 received ABMT alone. The PBSC were collected with 4 h leukapheresis procedures on 3 consecutive days. No manipulations to increase the number of circulating stem cells were used during the collections. The median time to recover 0.5 x 10(9)/l circulating granulocytes was 20 days after transplantation in the ABMT group and 27 days in the PBSC + ABMT group (p = 0.12). The median time to recover 20 x 10(9)/l platelets was 22 days after transplantation in the ABMT group and more than 27 days in the PBSC + ABMT group (p = 0.29). The day of discharge from the hospital was earlier for the ABMT group (median 29 days) than the PBSC + ABMT group (median 35 days, p = 0.03). We did not find that the addition of non-mobilized PBSC to infused autologous marrow accelerates marrow recovery.

Adolescent↗
PubMed1991

Findings from an evaluation of PlanAlyzer's double cross-over trials of computer-based, self-paced, case-based programs in anemia and chest pain diagnosis.

We report on three years of research trials of the PlanAlyzer I Project--a carefully controlled research study using a microcomputer-based, self-paced, case-based, event-driven system for medical education. PlanAlyzer presents cases, elicits and critiques a second year student's approach to the diagnosis of anemias and chest pain. PlanAlyzer uses text, hypertext, images and critiquing theory. Students were randomized, one half becoming the experimental group who received the interactive PlanAlyzer cases in anemia, the other half becoming the controls who received the exact same content material in a text format. Later in each year there was a crossover, the controls becoming the experimentals for a similar intervention with the cardiology PlanAlyzer cases. Results at the end of the first two years of trials show that the programs have achieved some significant efficiency and economy gains. 96 faculty hours of classroom time were saved by using PlanAlyzer in their place, with no loss in student achievement. In terms of student proficiency and efficiency, combining the anemia and cardiology trials, the 328 students in the two years of full scale trials were able to accomplish the project's instructional objectives. The experimentals accomplished this in 43% less time than the controls. On the average, for both the anemia and chest pain programs, this amounted to students spending 7.5 hours longer on the 30 text cases than on the same 30 computer cases to achieve the same level of mastery. There have been no significant proficiency differences (as measured by current post-tests) between the experimental and control groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Anemia↗
PubMed1990

Clinical prediction rule for pulmonary infiltrates.

OBJECTIVE: To derive and validate a clinical rule for predicting pneumonic infiltrates in adult patients with acute respiratory illness. DESIGN: Prevalence studies in three settings. SETTING: Emergency departments of the University of Illinois Hospital at Chicago, the University of Nebraska Medical Center at Omaha, and the Medical College of Virginia at Richmond. PATIENTS: Symptoms, signs, comorbidity data, and chest roentgenogram results were recorded for 1134 patients from Illinois (the derivation set), 150 patients from Nebraska, and 152 patients from Virginia (the validation sets). All patients presented to the emergency department and had a chest roentgenogram to evaluate fever or respiratory complaints. MEASUREMENTS AND MAIN RESULTS: Within the training set, temperature greater than 37.8 degrees C, pulse greater than 100 beats/min, rales, decreased breath sounds, and the absence of asthma were identified as significant predictors of radiographically proved pneumonia in a stepwise logistic regression model (P = 0.001). The logistic rule discriminated patients with and without pneumonia in the training set with a receiver operating characteristic (ROC) area of 0.82. In the validation sets, the rule discriminated pneumonia and nonpneumonia with ROC areas of 0.82 and 0.76 after adjusting for differences in disease prevalence (P greater than 0.2 compared with the training set). The predicted probability of having pneumonia for patients with different clinical findings corresponded closely with the incidence of pneumonia among patients with such findings in the three settings. CONCLUSIONS: Among adults presenting with acute respiratory illness, a prediction rule based on clinical findings accurately discriminated patients with and without radiographic pneumonia, and was used in two other samples of patients without significant decrement in discriminatory ability. This rule can be used by physicians to develop more effective strategies for detecting pneumonia and for helping to determine the need for radiologic study among patients with acute respiratory disease.

Acute Disease↗
PubMed1990

Procedural skills of practicing gastroenterologists. A national survey of 700 members of the American College of Physicians.

OBJECTIVE: To find which procedures gastroenterologists do in their practice, where they learned the procedures, and what training they recommend to achieve and maintain competence in each. DESIGN: Mailed survey. PARTICIPANTS: A random sample of 700 gastroenterologists who were members of the American College of Physicians, of whom 510 (73%) responded. RESULTS: Gastroenterologists did a median of 27 of the 40 gastroenterology procedures and 3 of the 16 general medicine procedures. A larger number of different procedures was done by those who were board certified in gastroenterology, spent more than 60 hours per week in patient care, graduated after 1969, or practiced in a university setting, a hospital with 250 to 500 beds, or a group limited to gastroenterologists. The majority of respondents had done each of the three most commonly done procedures 200 or more times in the previous year. For 10 procedures studied in detail, the majority had done 9 of the 10 in the past year at least as often as the median recommendation for maintaining competence. The number of procedures recommended to achieve and maintain competence differed little by the age, type of practice, and gastroenterology board certification status of the respondent. For most procedures, the range of recommendations was broad, but the median numbers agreed with other published recommendations. Respondents learned 31% of procedures after they had completed training. The earlier their training, the more likely they had learned the procedure in practice. CONCLUSIONS: Gastroenterologists do many different procedures, and this number is influenced by how recently they were trained and the nature of their practice. Respondents learned nearly one third of the procedures they do after they had completed training. It is an important and continuing challenge for the profession to assure that physicians learn and maintain these procedural skills at the highest level of proficiency.

Clinical Competence↗
PubMed1990

Procedural skills of practicing nephrologists. A national survey of 700 members of the American College of Physicians.

OBJECTIVE: To determine which procedures nephrologists do in practice, where they learned the procedures, and how much training they recommend to achieve and maintain clinical competence in each. DESIGN: Mailed survey. PARTICIPANTS: A random sample of 700 members of the American College of Physicians who were identified as practicing nephrologists; 516 (74%) responded. RESULTS: Acute peritoneal dialysis, acute hemodialysis, continuous arteriovenous hemofiltration, and percutaneous renal biopsy were done by 95%, 97%, 87%, and 91% of the respondents, respectively. Except for hemofiltration, procedures were learned by most respondents during fellowship training. Compared with general internists, fewer nephrologists did most of the 19 general procedures included in the survey. The number of nephrology procedures done during the past year varied considerably among respondents, as did the minimum number of procedures they recommended for achieving and maintaining competence. Neither the variation in number of procedures done nor recommendations regarding certification were explained by differences in practice characteristics. Median recommendations remained relatively constant among subgroups. CONCLUSIONS: Nearly all nephrologists do the four nephrology procedures included in the survey. Their opinions about the training needed for competence help to better define requirements for training programs. More attention should be focused on training and certifying practicing nephrologists in procedures learned after formal fellowship training.

Biopsy, Needle↗
PubMed1990

Counterflow centrifugation apheresis for the collection of autologous peripheral blood stem cells from patients with malignancies: a comparison with a standard centrifugation apheresis procedure.

Two apheresis methods used to collect hematopoietic stem cells from peripheral blood were compared in eight patients with a variety of malignancies. The standard lymphocyte collection method was alternated with the counterflow centrifugation or lymphocyte surge protocol. The number of clonogenic cells (CFU-GM and BFU-E), the red cell volume, and the number of mononuclear cells in each collection were assessed as well as the changes in circulating leukocytes, platelets, and blood hemoglobin produced by each apheresis procedure. There was no statistically significant difference found in the number of clonogenic cells collected with either method, but the number of mononuclear cells collected with the standard procedure was significantly higher (P = 0.001). The red cell volume collected with the standard procedure was significantly higher, (P = 0.0001), but corrected for the number of mononuclear cells the difference was not significant. The counterflow centrifugation apheresis produced significantly less thrombocytopenia (P = 0.005). The counterflow centrifugation apheresis procedure used collected fewer mononuclear cells than the standard procedure, however, with less red cell contamination but a comparable number of CFU-GM and BFU-E in four hour apheresis procedures. Each collection method resulted in a comparable amount of anaemia and leukopenia but the lymphocyte surge method produced less thrombocytopenia following the collection.

Adult↗
PubMed1989

Procedural skills of the general internist. A survey of 2500 physicians.

STUDY OBJECTIVE: To determine which of 40 clinical procedures general internists do in their practice, how often these procedures are done, and what training is needed to develop and maintain competence in each. DESIGN: Mailed survey. PARTICIPANTS: A random sample of 2500 American College of Physicians (ACP) members identified as general internists; 1806 (72%) responded. Of these, we excluded 398 who were board eligible or board certified in a subspecialty and 143 with unknown status. The resulting sample of 1179 was augmented in selected analyses by an additional sample of 199 rural internists. RESULTS: General internists did, on average, 16 of the 40 procedures. Practice characteristics markedly affected the number and variety of procedures done. A larger number of different procedures was independently associated with smaller cities, smaller hospitals, younger age, increased hours in patient care, and certain regions of the country. Practice characteristics varied considerably by practice type and location. Many procedures were done infrequently. There was reasonable agreement on the experience needed to attain and maintain competency in each procedure. The majority of respondents favored hospital credentialing for 22 of the 40 procedures. CONCLUSIONS: General internists do a wide variety of procedures, the number and frequency of which are affected by the characteristics and location of their practice. Despite opinion to the contrary, more recently trained general internists do a wider variety of procedures than older colleagues. These results provide data to help define standards for training and credentialing and suggest that we should reexamine general internists' training in procedural skills.

Attitude of Health Personnel↗
PubMed1989

Procedural skills training in internal medicine residencies. A survey of program directors.

STUDY OBJECTIVE: To obtain the opinions of internal medicine residency program directors about which procedural skills residents master during training and the amount of training needed to attain and maintain competence in each procedure. DESIGN: A mailed survey to all program directors in the United States. RESPONDENTS: Program directors or their designees from 389 of 431 (90%) internal medicine residency programs. RESULTS: For several procedures, 40% more respondents said all residents should master the procedure than said all their residents do master the procedure. Some procedures commonly done in practice were perceived as mastered by all residents in fewer than half of the programs. There were few differences in procedures learned by size or type of program. A fellowship program did affect exposure to some procedures in the field covered by the program. Median recommendations of training needed to master each procedure were similar to those of practicing internists for most procedures. CONCLUSIONS: Current residency training does not assure competency in all of the procedures the general internist does in practice. Program directors should examine which skills are adequately taught, test competence, and ways to improve residents' skills. Practicing general internists should have access to supervised training in procedural skills.

Clinical Competence↗
PubMed1988

Self-service computerized bibliographic retrieval: a comparison of Colleague and PaperChase, programs that search the MEDLINE data base.

Colleague and PaperChase are the two most widely used computer systems designed specifically for clinicians and scientists who wish to search the National Library of Medicine's MEDLINE data base of references to the biomedical literature. The present study compares the performance of these two systems. Two matched groups of second-year medical students each received 3 hr of instruction, one group in Colleague, the other in PaperChase. Each student then attempted 10 test searches. The next day the groups were reversed, and each student attempted 5 additional searches. During 3 1/2 hr allocated for searching, users of Colleague attempted 64 test searches and retrieved 326 target references; users of PaperChase attempted 78 searches and retrieved 496. Users of Colleague took a mean of 2.2 min and spent a mean of $1.20 to find each target reference; users of PaperChase took 1.6 min and spent $0.92. We conclude that after limited training, medical students find more references faster and at lower cost with PaperChase than with Colleague.

Computer User Training↗
PubMed1988

Changes in the inpatient and outpatient cancer patient population at a teaching institution over a three-year period.

Admission and outpatient clinic records of cancer patients seen by members of the University of Nebraska Medical Center Section of Oncology/Hematology in that section's clinic and on that section's hospital service were studied over a three-year period to determine if the tumor types of patients differed importantly from year to year. Cancer patients seen in other clinics or on other clinical services in the medical center were not included in this study. Some striking variations were found. The percentage of cancer patients with lymphoma admitted to the hospital increased significantly, from 23% to 41% (p less than .00001), and the percentage of those patients seen in the outpatient area increased correspondingly. In contrast, the percentage of colorectal cancer patients fell from 11% in 1984 to 4% in 1985 and to 3% in 1986 (p less than .00001). A similar decrease was found in the outpatient clinics as well. In addition, the percentage of breast cancer patients admitted to the hospital fell from 17% in 1984 to 12% in 1985 and to 11% in 1986 (p = .003); there was also a similar decline in the outpatient clinic (p = .00001). Other tumor types were equally represented in all three years in the inpatient and outpatient setting. The patient mix can vary markedly from year to year and should be monitored, so that changes in the teaching program can be made to assure the desired emphasis of all tumor types.

Curriculum↗
PubMed1987

Intracavitary bleomycin and tetracycline in the management of malignant pleural effusions: a randomized study.

Both bleomycin and tetracycline have been suggested as the sclerosing agent of choice in the management of malignant pleural effusions. To determine if one drug is superior to the other in this role, patients with malignant pleural effusions were randomly assigned to receive either bleomycin or tetracycline in the previously evacuated pleural space through a thoracostomy tube. Following instillation of the assigned agent, the tube was clamped for 8 hours and then reattached to suction. When the chest tube drainage had slowed to less than 40 ml in a 24-hour period or if 7 days had passed, the tube was removed. Pleural sclerosis was attempted 42 times in 34 patients. No statistically significant differences were found between the two treatment groups when prevention of effusion reaccumulation and time to removal of the chest tube (efficiency) were compared. Side effects including pleural pain and fever, occurred with both agents, but were manageable. Since one drug was not clearly superior to the other, and bleomycin is more costly, we suggest that tetracycline rather than bleomycin be used when pleural sclerosis is needed to manage malignant pleural effusions.

Bleomycin↗