Biomedical subjects
S W Fletcher
Publications and source records attributed to S W Fletcher.
Physicians' abilities to detect lumps in silicone breast models.
Little is known about how well physicians detect breast lumps in clinical breast examinations. We studied 80 general medicine, family medicine, general surgery, and obstetrics/gynecology physicians to determine their abilities to detect lumps in manufactured breast models. The mean number of lumps detected was 8.0 (44%), with a range of three (17%) to 15 (83%). Detection varied significantly by size (87% of 1.0-cm and 14% of 0.3-cm lumps) and hardness (56% of hard and 40% of soft lumps), but not depth; by specialty (from 50% for general internists to 40% for obstetricians), but not by level of training or experience; and by search duration (r = .59). On multiple regression analysis, only search duration was consistently associated with increased detection. Modest detection rates and wide variation suggest breast lump detection can be improved among physicians. Adequate search duration may be important for high detection rates.
Physicians and the teaching of breast self-examination: implications from a survey at a university teaching hospital.
We surveyed 80 physicians from four specialties (Family Medicine, General Medicine, General Surgery, Ob-Gyn) to investigate how they taught breast self-examination (BSE). Only half reported personally teaching BSE. Few MDs reported routinely using techniques to assess BSE competency. Most (72 per cent) claimed no formal training in teaching BSE; 10 per cent claimed no training at all. Techniques used to teach BSE may vary, and physicians may lack the training to teach BSE.
Performance of women candidates on the American Board of Internal Medicine Certifying Examination, 1973-1982.
Trends in the performances of female and male candidates taking the American Board of Internal Medicine Certifying Examination from 1973 through 1982 were examined. The mean scores of female candidates who graduated from medical schools in the United States or Canada and who were taking the examination for the first time improved from 428 to 470, and the percentage of those passing improved from 59% to 76%. The number of women taking the examination also increased markedly, by over 500%. Performance of female candidates remained slightly lower than that of male candidates, regardless of the quality of the residency training program or the medical school from which a candidate had graduated or the rating given a candidate by the director of the candidate's residency program. Except for the oldest candidates, age followed this pattern as well. Our findings suggest that the gender gap in scores on the Certifying Examination in Internal Medicine is narrowing.
House staff pregnancy in internal medicine residencies.
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Measuring the continuity and coordination of medical care in a system involving multiple providers.
Patients often receive medical care from many different providers. Consequently, the various episodes of care may not be integrated into a meaningful whole, and the quality of care may suffer. Before this possibility can be evaluated, it is necessary to develop a measure of the integrating process. The authors studied the continuity and coordination of care for 197 patients attending the General Medicine Practice within a large teaching hospital. Each patient had one internist as primary physician; however, a broad array of special services were available at the hospital and were often required. Of 1,768 total visits to the hospital, 62.2% were scheduled to the practice, whereas 92.9% were with the primary physician. For visits outside the practice, coordination (defined as the percent of visits for which the primary and other physicians were aware of each other's contact with shared patients) was 35.2%. Only 74.4% of all visits were either continuous or coordinated. Continuity with a single provider may be determined by patients' needs for services by others. A combined measure of continuity with coordination, such as the one used in this study, is more appropriate for a setting with multiple providers.
The periodic health examination and internal medicine: 1984.
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A nurse-initiated reminder system for the periodic health examination. Implementation and evaluation.
Implementation of specific health maintenance recommendations into practice settings has been difficult. We introduced a nurse-initiated health maintenance reminder system into a university-based internal medicine practice setting. We then compared performance of selected items (Papanicolaou smear, stool examination for occult blood, breast examination, and influenza immunization) in the practice before and after institution of the system. The system required no additional personnel and was quickly learned by the nursing staff. There were significant increases in the performance of stool examination for occult blood (32% to 47%), breast examination (29% to 46%), and influenza immunization (18% to 40%) after the reminder system was introduced. A nurse-initiated health maintenance reminder system is a feasible and effective method for implementing periodic health examination procedures into a practice setting.
Attitudes of internal medicine subspecialty fellows toward primary care.
Subspecialists deliver a substantial proportion of primary care but little is known about how their training affects their attitudes toward this role. We surveyed a department of medicine to determine fellows' (N = 34) attitudes toward primary care and how these compared with the attitudes of house staff (N = 45) and faculty (N = 66). Continuous, coordinated, and accessible care as departmental policy was almost unanimously endorsed by all physicians. In contrast, fellows less often supported the provision of such care for their own patients in actual clinical situations. Fellows were also less likely than either house staff or faculty to endorse primary care attributes for their own patients. Departments of medicine should examine how negative attitudes toward primary care develop in subspecialty fellows and whether these attitudes persist after fellowship.
Measuring patient waiting time in a practice setting: a comparison of methods.
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Patients' priorities for medical care.
Relatively little research has been done on the importance patients attach to various aspects of their medical care when their options are constrained. We studied priorities for care among 225 patients attending the medical clinics of a university teaching hospital. Eight attributes of medical care were considered: continuity, coordination, comprehensiveness, availability, convenience, cost, expertise, and compassion. Priorities were established by the method of paired comparisons. Continuity of care was the highest priority for these patients, while cost and convenience were lowest. Priorities varied in subgroups of patients defined by demographic, illness, and utilization characteristics. Patients with acute problems preferred coordination and expertise, while those with chronic problems ranked continuity higher. Patients younger than 30 years old valued coordination most; older patients preferred continuity and comprehensiveness. Since all aspects of medical care cannot be provided to all people, and choices are necessary, patients' priorities should be considered when planning health services.
Clinical epidemiology: a new discipline for an old art.
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Multi-class health care.
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Women physicians: old times or a new era?
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Primary health care: perspective of the faculty of a department of medicine.
A full-time faculty in one dependent of medicine, 66 (85%) of whom are subspecialists, were surveyed to determine standards for provision and attitudes toward the teaching and practice of primary health care (PHC). A 40-item questionnaire on specific attributes of PHC provision was given to 70 eligible faculty members; 66 (94%) responded. Of 17 standards, nine were supported by 50 (75%) or more of the faculty and eight by from 24 (44%) to 48 (73%) faculty members. However, 51 faculty members (77%) indicated some discomfort with primary responsibility for the complete, ongoing care of their patients. Most frequent reasons for this discomfort were clinic inefficiency (31 votes [47%]) and competing commitments (29 votes [44%]). Few faculty indicated they did not enjoy PHC (eight [12%] of the faculty) or considered PHC inappropriate for academic physicians (ten [15%] of the faculty). These results indicate the complexity of faculty attitudes toward PHC and point to a need for departments of medicine to examine thier teaching and practice of PHC.
The periodic health examination: comparison of recommendations and internists' performance.
In this paper we bring together recommendations from three expert sources for preventive care by periodic health examination of adults. We compare these recommendations with care items considered essential for such examinations, and those actually performed by a panel of practicing internists. We found substantial differences among the expert groups and between the experts and the practicing internists in their perceptions of essential care items. Overall, 59% of items recommended by any of the expert groups were found in the internists' records. We suggest that the periodic examination serves a purpose in addition to screening for disease; that the screening function need not be performed annually; that awareness and practice of proven beneficial components of such examinations be increased among practitioners; and that a better consensus on recommendations for preventive care be developed.
Research needed on preventive health services.
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Prevention in clinical practice. Problems and challenges.
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