Treatment of obesity by behavior therapy and very low calorie diet: a pilot investigation.
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Adult↗
Biomedical subjects
S C Day
Publications and source records attributed to S C Day.
A learning-curve approach to the self-assessment of internal medicine training.
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Ambulatory Care↗
Evaluation and outcome of emergency room patients with transient loss of consciousness.
We identified 198 patients who presented to our emergency room with transient loss of consciousness. Seizures (29 percent of patients) and vasovagal/psychogenic episodes (40 percent of patients) were the most common presumptive causes of loss of consciousness, but the cause of loss of consciousness remained uncertain even at follow-up in 11 +/- 6 months in 13 percent of the patients. The history and physical examinations were sufficient for diagnosis in 85 percent of the patients in whom a diagnosis could be established. These data guided inpatient and outpatient with potentially dangerous causes of loss of consciousness except for one patient who had pulmonary embolism. In selected patient, diagnostic tests such as blood chemistries (three patients), electrocardiograms (four patients) electroencephalograms (three patients), and Holter monitoring (four patients) provided crucial information, and CT scans identified new brain tumors in four patients with focal neurologic presentations. At the time of follow-up, 7.5 percent of patients had suffered either major morbidity or death related to the cause of the index episode of loss of consciousness. Patients with cardiac causes represented a high risk (33 percent) group for such poor outcome, whereas patients who were under age 30, or who were under age 70 and had loss of consciousness on a vasovagal/psychogenic or unknown basis, constituted a low risk (1 percent) subgroup.
Adult↗
Long-term survival after transient loss of consciousness.
To determine the factors that influenced the long-term outcome of 198 patients who presented to the emergency ward with transient loss of consciousness, the authors followed them for a median of 83 months. Forty-one patients (21%) died, including nine patients who had out-of-hospital sudden cardiac arrest. Compared with age- and sex-adjusted mortality rates for the United States, long-term mortality was not increased among patients with benign causes of syncope. Multivariate analysis revealed that the long-term mortality rate was significantly increased in patients with a prior history of coronary or cerbrovascular disease (RR = 6.7), those who had cancer (RR = 7.3), and those who had drug or metabolic (RR = 5.9), central nervous system (RR = 5.7) or cardiac (RR = 9.2) causes of transient loss of consiousness. Among patients who experience transient losses of consciousness, the cause of the episode is significantly correlated with mortality for at least the next seven years.
Actuarial Analysis↗
Gender differences in the clinical competence of residents in internal medicine.
OBJECTIVE: To study the differences between cognitive and noncognitive skills of men and those of women entering internal medicine. DESIGN: Comparison of program directors' ratings of overall clinical competence and its specific components and pass rates for men and women taking the Certifying Examinations in Internal Medicine in 1984-1987. PARTICIPANTS: 14,340 U.S. and Canadian graduates taking the Certifying Examinations of the American Board of Internal Medicine for the first time in 1984-1987. MEASUREMENTS/RESULTS: Average program directors' ratings of overall competence were 6.70-6.78 for men and 6.60-6.71 for women. The greatest differences in ratings of specific components of competence were in the areas of medical knowledge and procedural skills, where men were rated higher than women, and humanistic qualities, where women were rated higher than men. Pass rates were stable over the four years of the study, and ranged from 85 to 86% for men and from 79 to 81% for women. Men consistently performed slightly better than women regardless of the type of residency or quality of medical school attended. CONCLUSIONS: Small but consistent differences were found in the performances of men and those of women completing training in Internal Medicine as measured by program directors' ratings and ABIM Certifying Examination performances.
Certification↗
A longitudinal description of patterns of certification in internal medicine and the subspecialties.
OBJECTIVE: To document the timings, frequencies, and outcomes of attempts at certification in internal medicine and the internal medicine subspecialties in the years following residency training for two cohorts of residents. DESIGN: Residents who had completed residency training and had been admitted to an American Board of Internal Medicine (ABIM) certifying examination in 1982 or 1983 were tracked through the ABIM database for five years. PARTICIPANTS: A total of 10,568 residents were studied. Of the cohort, 79% were men, 21% were women, 79% were graduates of U.S./Canadian medical schools (USMGs), and 21% were graduates of foreign medical schools (FMGs). MAIN RESULTS: Ultimately, 85% of the residents achieved certification in internal medicine. Cumulative pass rates were 87% for men, 81% for women, 92% for USMGs, and 60% for FMGs; rates increased minimally after the second attempt. Most (87%) residents first attempted the internal medicine examination in the year in which training had been completed. Delaying the first examination was associated with lower pass rates. Half of the candidates who had passed the internal medicine examination attempted subspecialty certification. Over all nine subspecialty examinations, the two-cycle cumulative pass rate was 87%. Higher percentages of FMGs than of any other subgroup attempted subspecialty certification. CONCLUSIONS: The detailed description extends the body of knowledge about certification in internal medicine and the nine internal medicine subspecialties. Questions are raised, such as why some candidates delay the first internal medicine examination and why some residents never seek certification. Future research could explore these issues as well as explanations for the observed differences in pass rates.
Certification↗
Residents' perception of evaluation procedures used by their training program.
OBJECTIVE: To determine the methods of evaluation used routinely by training programs and to obtain information concerning the frequencies with which various evaluation methods were used. DESIGN: Survey of residents who had recently completed internal medicine training. PARTICIPANTS: 5,693 respondents who completed residencies in 1987 and 1988 and were registered as first-time takers for the 1988 Certifying Examination in Internal Medicine. This constituted a 76% response rate. MAIN RESULTS: Virtually all residents were aware that routine evaluations were submitted on inpatient rotations, but were more uncertain about the evaluation process in the outpatient setting and the methods used to assess their humanistic qualities. Most residents had undergone a Clinical Evaluation Exercise (CEX); residents' clinical skills were less likely to be evaluated by direct observation of history or physical examination skills. Resident responses were aggregated within training programs to determine the pattern of evaluation across programs. The majority of programs used Advanced Cardiac Life Support (ACLS) certification, medical record audit, and the national In-Training Examination to assess most of their residents. Performance-based tests were used selectively by a third or more of the programs. Breast and pelvic examination skills and ability to perform sigmoidoscopy were thought not to be adequately assessed by the majority of residents in almost half of the programs. CONCLUSIONS: While most residents are receiving routine evaluation, including a CEX, increased efforts to educate residents about their evaluation system, to strengthen evaluation in the outpatient setting, and to evaluate certain procedural skills are recommended.
Attitude of Health Personnel↗
A controlled trial to improve delivery of preventive care: physician or patient reminders?
OBJECTIVE: To improve the delivery of preventive care in a medical clinic, a controlled trial was conducted of two interventions that were expected to influence delivery of preventive services differently, depending on level of initiative required of the physician or patient to complete a service. DESIGN: A prospective, controlled trial of five-months' duration. SETTING: A university hospital-based, general medical clinic. PARTICIPANTS: Thirty-nine junior and senior medical residents who saw patients in stable clinic teams throughout the study. INTERVENTION: A computerized reminder system for physicians and a patient questionnaire and educational hand-out on preventive care. MEASUREMENTS AND MAIN RESULTS: Delivery of five of six audited preventive services improved significantly after the interventions were introduced. The computerized reminder alone increased completion rates of services that relied primarily on physician initiative; the questionnaire alone increased completion rate of the service that depended more on patient compliance as well as on some physician-dependent services. Both interventions used together were slightly less effective in improving performance of physician-dependent services than the computerized reminder used alone. CONCLUSIONS: These interventions can improve the delivery of preventive care but they differ in their impacts on physician and patient behaviors. Overall, the computer reminder was the more effective intervention.
Ambulatory Care Information Systems↗