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Biomedical subjects

William L Miller

Publications and source records attributed to William L Miller.

27 records · Page 2Linked to original sources
PubMed2002

The nature of FSH induction by GnRH.

Follicle-stimulating hormone (FSH), a major regulator of mammalian gonadal function, is induced by gonadotropin-releasing hormone (GnRH), but it is unclear how much induction is direct or indirect and what relevance each has in vivo. Two advances now make it possible to address these issues, which are central to understanding FSH regulation. The first is the use of transformed L beta T2 gonadotropes to define key promoter sequences of FSHB (the gene encoding the FSH-beta subunit) that are needed for induction by GnRH and/or other factors; and the second is the ability to express FSHB promoter-reporter constructs in transgenic mouse gonadotropes to test the physiological relevance of promoter elements identified by using L beta T2 cells. Here, we summarize past studies on GnRH induction of FSH, and propose questions and approaches for the future.

Animals↗
PubMed2002

Evidence for anterior cingulate cortex involvement in monitoring preparatory attentional set.

An important cognitive function underlying unified, voluntary behavior is attentional control. Two frontal regions, anterior cingulate cortex (ACC) and dorsolateral prefrontal cortex (DLPFC), appear to be particularly involved in attentional control and monitoring. In this study, we investigated whether ACC is involved in monitoring the preparatory allocation of attention during task switching, or whether ACC is active only when subjects are processing target stimuli and selecting a response, via a cued-attention design. Event-related BOLD fMRI activity was examined using a cue-target paradigm in which subjects performed task switches that selectively required reallocation of attention when tasks changed. There were three cue conditions: informative switch, informative repeat, and neutral. There were four target conditions: informatively cued switch, informatively cued repeat, neutrally cued switch, and neutrally cued repeat. Significant ACC activity was observed following both informative switch and informative repeat cues, but not after neutral cues. No significant ACC activity was observed following any of the target conditions. Significant DLPFC activity was observed following all three cue conditions and following neutrally cued switch targets. Overall, our results suggest that ACC is involved in monitoring the preparatory allocation of attention for conflict at the level of activation of competing attentional sets. The results also support the role of DLPFC in holding cognitive goals in working memory and allocating attention to the appropriate processing systems to meet those goals.

Adult↗
PubMed2002

Relationships between physician practice style, patient satisfaction, and attributes of primary care.

OBJECTIVES: Style of physician-patient interaction has been shown to have an impact on patient outcomes. Although many different interaction styles have been proposed, few have been empirically tested. This study was conducted to empirically derive physician interaction styles and to explore the association of style with patient reports of specific attributes of primary care, satisfaction with care received, and duration of the visit. STUDY DESIGN: A cross-sectional observational study. POPULATION: We observed 2881 patients visiting 138 family physicians for outpatient care in 84 community family practice offices in northeast Ohio. OUTCOMES MEASURED: Components of Primary Care Instrument (CPCI), patient satisfaction, and duration of the visit. RESULTS: A cluster analysis of variables derived from qualitative field notes identified 4 physician interaction styles: person focused, biopsychosocial, biomedical, and high physician control. Physicians with the person-focused style rated highest on 4 of 5 measures of the quality of the physician-patient relationship and patient satisfaction. In contrast, physicians with the high-control style were lowest or next to lowest on the outcomes. Physicians with a person-focused style granted the longest visits, while high-control physicians held the shortest visits-a difference of 2 minutes per visit on average. The associations were not explained away by patient and physician age and gender. CONCLUSIONS: In community-based practices, we found that the person-focused interaction style appears to be the most congruent with patient reported quality of primary care. Further investigation is needed to identify ways to support and encourage person-focused approaches and the time needed to provide such care.

Adult↗
PubMedDate not supplied

New knowledge for and about primary care: a view through the looking glass of the Annals of Family Medicine.

PURPOSE: At this second anniversary of the Annals of Family Medicine, we sought to characterize primary care research and to identify opportunities for new directions by analyzing the content of the first and second volumes of the Annals. METHODS: Using an a priori classification scheme, 2 editors independently categorized each research article and essay published in 2003 and 2004, excluding supplements. We categorized the domain of knowledge, methods, topical content, whether articles represented core values of primary care, and looked for articles that studied health/illness/symptoms from a uniquely primary care experience. We reconciled differences by discussion. RESULTS: Among 110 articles, knowledge domains reflected the 4 quadrants of the clinician (n = 6), patient, family, or community (10), health care system (32), disease (22), or the interface (39) between these quadrants. The most frequent methods were cross-sectional studies (23), cohorts (15), randomized clinical trials (13), qualitative interviews (11), analyses of secondary data (11), systematic reviews (11), methods/theory development (10), self-reflections (8), and mixed methods (5). The most common topical areas were chronic disease and prevention. Core primary care values were represented in 75% of articles. Only 2 articles represented an integrative illness/healing perspective. CONCLUSIONS: Despite contemporary forces driving a reductionistic approach, primary care research, as reflected by articles published in the Annals of Family Medicine, addresses the domains of knowledge that contribute to comprehensive, relationship-centered health care. More work is needed to understand the nature of health and illness in whole people and ways to integrate diverse knowledge, methods and fragmented health care.

Health Knowledge, Attitudes, Practice↗
PubMedDate not supplied

Delivery of clinical preventive services in family medicine offices.

BACKGROUND: This study aimed to elucidate how clinical preventive services are delivered in family practices and how this information might inform improvement efforts. METHODS: We used a comparative case study design to observe clinical preventive service delivery in 18 purposefully selected Midwestern family medicine offices from 1997 to 1999. Medical records, observation of outpatient encounters, and patient exit cards were used to calculate practice-level rates of delivery of clinical preventive services. Field notes from direct observation of clinical encounters and prolonged observation of the practice and transcripts from in-depth interviews of practice staff and physicians were systematically examined to identify approaches to delivering clinical preventive services recommended by the US Preventive Services Task Force. RESULTS: Practices developed individualized approaches for delivering clinical preventive services, with no one approach being successful across practices. Clinicians acknowledged a 3-fold mission of providing acute care, managing chronic problems, and prevention, but only some made prevention a priority. The clinical encounter was a central focus for preventive service delivery in all practices. Preventive services delivery rates often appeared to be influenced by competing demands within the clinical encounter (including between different preventive services), having a physician champion who prioritized prevention, and economic concerns. CONCLUSIONS: Practice quality improvement efforts that assume there is an optimal approach for delivering clinical preventive services fail to account for practices' propensity to optimize care processes to meet local contexts. Interventions to enhance clinical preventive service delivery should be tailored to meet the local needs of practices and their patient populations.

Family Practice↗
PubMedDate not supplied

Understanding organizational designs of primary care practices.

During the past decade, many hospitals experienced difficulty integrating primary care practices into their health systems. We hypothesized that this difficulty may be, in part, a result of limited understanding of practice organizational designs. The structure and function of practices have not been well studied. In this article, we answer the following questions: Are practices all the same, or do variations in their organizational design exist? Do hospital designs predict the designs of affiliated practices? If variation exists, what are the management implications? Eighteen family practices, including nine affiliated with five separate hospital systems, were studied using an in-depth comparative case study design. A content analysis of the rich descriptive data from these cases indicates that a great variety exists in the organizational design of primary care practices, and this variety appears to be influenced by the initial conditions under which the practice was organized. Hospital system design in and of itself did not predict the design of affiliated practices. In fact, both affiliated and independent practices exhibited a range of design characteristics, some of which did not fit traditional models. Hospital systems that allowed greater flexibility of practice organizational designs were more effective at integrating and managing practices. Practices response to environmental change was greater when practice autonomy was highest. These findings suggest that a science of practice organizational design separate from that of hospitals is needed to help explain the success and failure of practices within health systems and to provide information for planning practice change.

Delivery of Health Care, Integrated↗
PubMedDate not supplied

Research guidelines for assessing the impact of healing relationships in clinical medicine.

This paper charts a course for assessing the impact of healing relationships in clinical medicine. The system of healing relationships is multidimensional, longitudinal, contextual, and emergent. In a new conceptual model, healing relationships are identified in terms of the conditions of healing intention, motivation, and information transfer, and in terms of the attributes of emotional engagement, mindfulness, and trust. Five components of quality in healing relationships--adaptability, cohesion, growth, caring-in-relation, and commitment--are noted, and the importance of timing, attunement, and cultural meaning systems are described. Communication, clinical method, caring, competence, and treatment characteristics are differentiated as mediating processes; expectancy and conditioning are positioned as antecedents of healing relationships. Multiple personal and contextual outcomes are addressed with a recommendation for assessing a minimal set of each, including symptom resolution, health status, sense of coherence, patient enablement, cost effectiveness, quality of care, efficiency, access, and healer satisfaction. A wheel of knowledge connects 3 ways of knowing--personal, connected, and objective--with appropriate methodology and research designs. Applying this wheel to the issue of assessing impact in healing relationships reveals the need for multiple methods, perspectives, and triangulations. A critical multiplist strategy is one means for advancing this area of research. A double-helix trial design is introduced, in which one strand consists of a standard quantitative approach and the other consists of qualitative methods. The 2 strands are bonded by the questions addressed and by the participants in the study.

Biomedical Research↗
PubMedDate not supplied

A practice change model for quality improvement in primary care practice.

Faced with a rapidly changing healthcare environment, primary care practices often have to change how they practice medicine. Yet change is difficult, and the process by which practice improvement can be understood and facilitated has not been well elucidated. Therefore, we developed a model of practice change using data from a quality improvement intervention that was successful in creating a sustainable practice improvement. A multidisciplinary team evaluated data from the Study To Enhance Prevention by Understanding Practice (STEP-UP), a randomized clinical trial conducted to improve the delivery of evidence-based preventive services in 79 northeastern Ohio practices. The team conducted comparative case-study analyses of high- and low-improvement practices to identify variables that are critical to the change process and to create a conceptual model for the change. The model depicts the critical elements for understanding and guiding practice change and emphasizes the importance of these elements' evolving interrelationships. These elements are (1) motivation of key stakeholders to achieve the target for change; (2) instrumental, personal, and interactive resources for change; (3) motivators outside the practice, including the larger healthcare environment and community; and (4) opportunities for change--that is, how key stakeholders understand the change options. Change is influenced by the complex interaction of factors inside and outside the practice. Interventions that are based on understanding the four key elements and their interrelationships can yield sustainable quality improvements in primary care practice.

Female↗