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PubMed2006

Training medical students to manage a chronic pain patient: both knowledge and communication skills are needed.

Most studies concerning pain education of undergraduate medical students focus on knowledge, but little is known about the interviewing skills and pain evaluation. At the end of the fifth study year and at the beginning of the sixth year the students were asked to answer an electronical questionnaire to evaluate how the IASP curriculum on pain had been covered during the studies. In addition, the interviewing skills of the fifth year medical students were assessed using an objective structured clinical examination (OSCE). The students met a standardized patient suffering from postherpetic neuralgia, who was instructed to express depressive and exhausted feelings. A total of 97 students received the questionnaire and 35% responded with identification. All students answering the IASP questionnaire evaluated teaching of postherpetic pain and antidepressant treatment as sufficient. OSCE appeared as a feasible instrument in the assessment of chronic pain education. Eighty-eight percent of the students made the correct diagnosis. However, only 35% asked about sleep disturbances and 16% about depression. When developing a curriculum on pain education, attention should be paid to pedagogic methods about helping the students to implement the learned knowledge in their practice. Formative assessment of both knowledge and skills is essential for the development of a functional pain curriculum.

Acute Disease↗
PubMedDate not supplied

General performance on a numeracy scale among highly educated samples.

BACKGROUND: Numeracy, how facile people are with basic probability and mathematical concepts, is associated with how people perceive health risks. Performance on simple numeracy problems has been poor among populations with little as well as more formal education. Here, we examine how highly educated participants performed on a general and an expanded numeracy scale. The latter was designed within the context of health risks. METHOD: A total of 463 men and women aged 40 and older completed a 3-item general and an expanded 7-item numeracy scale. The expanded scale assessed how well people 1) differentiate and perform simple mathematical operations on risk magnitudes using percentages and proportions, 2) convert percentages to proportions, 3) convert proportions to percentages, and 4) convert probabilities to proportions. RESULTS: On average, 18% and 32% of participants correctly answered all of the general and expanded numeracy scale items, respectively. Approximately 16% to 20% incorrectly answered the most straightforward questions pertaining to risk magnitudes (e.g., Which represents the larger risk: 1%, 5%, or 10%?). A factor analysis revealed that the general and expanded risk numeracy items tapped the construct of global numeracy. CONCLUSIONS: These results suggest that even highly educated participants have difficulty with relatively simple numeracy questions, thus replicating in part earlier studies. The implication is that usual strategies for communicating numerical risk may be flawed. Methods and consequences of communicating health risk information tailored to a person's level of numeracy should be explored further.

Adult↗
PubMed2003

Doctor-patient communication: a comparison of the USA and Japan.

BACKGROUND: Little is known about the differences and similarities between doctor-patient communication patterns in different cultures. OBJECTIVES: The aim of this study was to examine communication patterns of doctor-patient consultations in two different cultures, namely the USA and Japan, and to elucidate linguistic differences and similarities in communication. METHODS: This cross-sectional study used quantitative discourse analysis from linguistics to compare 40 doctor-patient consultations: 20 out-patient consultations of five physicians in the USA and 20 out-patient consultations of four physicians in Japan. The main outcomes measured were time spent in each phase of the encounter, number of categorized speech acts, distribution of question types and frequencies of back-channel responses and interruptions. RESULTS: The average length of doctor-patient encounters was 668.7 s in the USA and 505 s in Japan. US physicians spent relatively more time on treatment and follow-up talk (31%) and social talk (12%), whereas the Japanese had longer physical examinations (28%) and diagnosis or consideration talk (15%). Japanese doctor-patient conversations included more silence (30%) than those in the USA (8.2%). The doctor-patient ratios of total speech acts were similar (USA 55% versus 45%; Japan 59% versus 41%). Physicians in both countries controlled communication during encounters by asking more questions than the patients (75% in the USA; 78% in Japan). The Japanese physicians and patients used back-channel responses and interruptions more often than those in the USA. CONCLUSIONS: While doctor-patient communication differed between the USA and Japan in the proportion of time spent in each phase of the encounter, length of pauses and the use of back-channel responses and interruptions, physician versus patient ratios of questions and other speech acts were similar. The variations may reflect cultural differences, whereas the similarities may reflect professional specificity stemming from the shared needs to fill the information gap between physician and patient. Adequate awareness of these differences and similarities could be used to educate clinicians about the best approaches to patients from particular cultural backgrounds.

Adult↗
PubMed1994

The expression, phosphorylation, and localization of connexin 43 and gap-junctional intercellular communication during the establishment of a synchronized contraction of cultured neonatal rat cardiac myocytes.

We analyzed the expression, phosphorylation, and localization of the major cardiac gap-junction protein connexin 43 (Cx43) during the establishment of a synchronized contraction in confluent monolayers of primary cultured neonatal rat cardiac myocytes, combined with a functional assay of gap junctions by the microinjection-dye transfer method. Monitoring of the beating rate and synchronization by Fotonic Sensor showed that at Day 1 of culture cardiac myocytes contracted spontaneously but irregularly, that the contractile rate increased with culture time, and that a synchronized contraction was gradually formed. At Day 7, the confluent cells exhibited synchronous contraction with a relatively constant rate (125 +/- 20 beats/min). Cardiac myocytes expressed a large amount of Cx43 mRNA even at Day 1 and maintained the expression until at least Day 7. Immunofluorescence of Cx43 showed that the localization of Cx43-positive spots was mostly restricted to cell-cell contacts between myocytes and that few Cx43-positive spots were present between myocytes and fibroblasts or between fibroblasts. The amount of Cx43 protein, the proportion of phosphorylated forms to the nonphosphorylated one, and the number and total area of Cx43-positive spots increased with culture time. Gap-junctional intercellular communication measured by dye transfer assay was also increased with culture time and correlated well with the number and total area of Cx43-positive spots. Our systematic study suggests that a concerted action of the expression, phosphorylation, and localization of Cx43 and gap-junctional intercellular communication plays a major role in the reestablishment of synchronous beating of cultured neonatal rat cardiac myocytes.

Animals↗
PubMed1998

Collaboration in improving care for patients: how can we find out what we haven't been able to figure out yet?

BACKGROUND: Questions, or what the physicist and learning expert Reginald Revans called "insightful inquiry," are essential to learning. People remember and use what they discover themselves. But many habits and activities in front-line workplaces of patient care have not promoted frank discussions of what we haven't figured out yet about improving care for patients. Leaders are no longer defined by having the right answers. Leaders will be the ones who have the right questions and who promote local learning with the right questions. SUGGESTIONS FOR GETTING STARTED IN COLLABORATION. The authors suggest questions to ask to get collaborative inquiry going and cite examples they have collected. The questions and examples are grouped in seven thematic categories: Listening to and appreciating others; Thinking across disciplines and roles; Sharing ideas and linking those shared ideas to execution and deployment of change; Appreciating systems and interdependencies; Using research (including local research) to inform our practices; Using methods, skills, and techniques as facilitators of collaboration; and Working across organizational boundaries.

Communication↗
PubMed1992

High-tech home care with a homemade twist.

Usher's syndrome is a rare genetic condition involving hearing loss and gradual progressive blindness due to retinitis pigmentosa--a situation in which self-care at home would seem impossible. Yet innovative methods developed by a creative home care team have allowed a deaf-blind patient to self-administer infusion therapy and chemotherapy in the home setting.

Aged↗
PubMed1992

Metabolic fate of the new angiotensin-converting enzyme inhibitor imidapril in animals. 4th communication: placental transfer and secretion into milk in rats.

Imidapril hydrochloride ((-)-(4S)-3-[(2S)-2-[[(1S)-1-ethoxycarbonyl-3- phenylproply]amino]propionyl]-1-methyl-2-oxoimidazolidine-4-car box ylic acid hydrochloride, imidapril, TA-6366, CAS 89396-94-1) labeled with 14C was administered orally or intravenously to pregnant rats on the 13th or 19th day of pregnancy, and lactating rats on the 7th or 13th day after delivery at a dose of 1 or 5 mg/kg. The placental transfer and the secretion into milk were studied using whole-body autoradiographic methods and/or quantitative determination of total radioactivity after autopsy. Irrespective of the stages of pregnancy, the placental transfer of imidapril was low in the rats after oral administration. The transfer of total radioactivity per fetus on the 13th and 19th day of pregnancy was below 0.001 and 0.07%, respectively, of the dose to their dams during the observation periods. This indicates that the substance-associated radioactivity penetrates the placental barrier to a low extent. After oral administration of [N-methyl-14C]-imidapril to lactating rats on the 7th day after delivery, the concentration of radioactivity in the milk attained a peak at 4 h after administration (0.05 microgram equivalents of imidapril/g), which was about 1/3 of Cmax in the blood. The transfer of imidapril and/or its radioactive metabolites to each suckling via milk after oral dosing was only below 0.03% of the dose to the dams on the 13th day after delivery during the observation periods. The present autoradiographic findings confirmed the above results of tissue distribution studies.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed2003

Evaluation of the National Resident Matching Program (NRMP) radiation oncology data (1993-2003).

PURPOSE: Radiation oncology continues to evolve as a specialty. In the early 1990s, issues of manpower oversupply, resource allocation, development of academic radiation oncology, and residency training curricula were fervently considered and evaluated. Much of this effort continues. This communication endeavors to examine the National Residency Matching Program (NRMP) results as they pertain to radiation oncology to identify and document applicant trends over the last decade. METHODS AND MATERIALS: The NRMP database tables for inclusive dates 1993-2003 were evaluated. The database figures were supplied directly from the executive staff at the AAMC/NRMP. Data were reviewed for radiation oncology, and the following variables were evaluated for the study period (1993-2003): Training program participation, positions offered, applicant totals, proportion of US senior applicants, US seniors as a percentage of those who successfully matched, ratio of applicants to positions, and percentage of training program positions filled. Trends over the study period were analyzed. Data were also analyzed for all specialties collectively as a comparison group. RESULTS: The number of training programs has remained relatively stable between 1993 and 2003. In 2003, each radiation oncology program in the NRMP on average accepted two new candidates. The number of positions offered has fluctuated over time. There appeared to be a downward trend until 2003, during which 107 positions were offered. The number of applicants continues to rise with totals of 209 and 214 in 2003 and 2001, respectively. Percentage of US senior applicants compared with the total pool has remained relatively stable, but raw numbers are rising. The number of US seniors as a percentage of those who successfully matched escalated during 2001 compared with previous years. This value has been consistent over the past 3 years, at a level of approximately 94%. The ratio of applicants to positions, which is a broad indicator of level of competition for entrance, began to rise significantly in 2000 to a level of 1.9. It peaked at 2.6 in 2001, and the ratio for 2003 was approximately 2.0. For the first time, all positions offered were filled (100%) through the NRMP match process in 2003. Such positive trends have not been realized to the same degree for all specialties analyzed as a cohort. CONCLUSION: Acceptance into radiation oncology training programs through the NRMP has become very competitive. The explanation for this trend is likely complex with many variables. These data may be helpful in training program development and will certainly be of service to advisors of medical students seeking entrance into the field in the near future.

Career Choice↗
PubMed2003

Assessing medical students' training in end-of-life communication: a survey of interns at one urban teaching hospital.

PURPOSE: Although interns are responsible for caring for dying patients, little is known about end-of-life education and training, including communication skills, in U.S. medical schools. This study of three consecutive cohorts of new interns assessed their perceptions of the amount and types of classroom and clinical instructional strategies used during medical school, their self-rated skill and comfort levels in different aspects of end-of-life communication, and the associations between these measures. METHOD: A self-administered questionnaire was given to three consecutive cohorts (1996-1998) of incoming interns (n = 162). Measures were self-reported amount and type of education and clinical experience with four end-of-life communication domains (giving bad news, discussing advance directives, discussing prognosis with the patient, and discussing with the patient's family) and self-perceived comfort and skill levels in relation to different types of end-of-life communication. RESULTS: A total of 157 interns completed the questionnaire. They reported very little classroom teaching, clinical observation, or clinical experience with end-of-life communication during medical school. They lacked comfort and skill in the end-of-life communication domains that were studied. More reported clinical observation and experience with caring for and communicating with dying patients was associated with greater perceived comfort and skill, while classroom teaching was not. CONCLUSIONS: These interns, mostly U.S. medical school graduates (98.7%, n = 155) reported little training and low self-perceived comfort and skill with important elements of end-of-life communication that might contribute to a lack of preparedness to address these issues during their internship. Further research that confirms and explains the underlying reasons for these findings seems warranted.

Adult↗
PubMed1997

Clinical skills assessment with standardized patients.

Previous projects (Combell I & II) to assess clinical skills were conducted in medical schools in Catalonia, in order to introduce a model of such an assessment using standardized patients (SP). The aim of this study (Combell III) was to measure selected characteristics of our model. Seventy-three medical students in the final year at the Bellvitge teaching unit of the University of Barcelona participated in a clinical skills assessment (CSA) project that used 10 SP cases. The mean group scores for the four components of clinical skills for each day of testing were studied, and ratings for each student in the 10 sequential encounters were checked. The study also compared the clinical skills scores with their academic grades. The total case mean score (mean score of history-taking, physical examination and patient notes scores) was 51.9%, and the mean score for communication skills was 63.6%. The clinical skills scores over the 8 testing days showed no day-to-day differences. The study did not find differences among the sequential encounters for each student (training effect). There was a lack of correlation between clinical skills scores and academic grades. The project demonstrated the feasibility of the method for assessing clinical skills, confirmed its reliability, and showed that there is no correlation between scores with this method and academic examinations that mainly reflect knowledge.

Clinical Competence↗
PubMed2004

A systematic review of the research on communication between patients and health care professionals about medicines: the consequences for concordance.

OBJECTIVES: We draw on a systematic review of research on two-way communication between patients and health practitioners about medicines in order to determine the extent to which concordance is, or is not, being put into practice. DATA SOURCES: Six electronic databases were searched using the following categories of search terms: health care professionals, patients/consumers, medicine-taking/prescribing and communication. Articles were also identified from handsearches of journals, article reference lists and the Concordance website. REVIEW METHODS: Studies published between 1991 and 2000 were included. Studies were not excluded on the basis of design, methods or language employed. Abstracts of identified articles were assessed by at least two reviewers and the full articles were assessed by one reviewer and checked by at least one other reviewer. Data on the design, analysis and relevant findings were extracted. RESULTS: A total of 11 801 abstracts were reviewed and 470 full articles were retrieved. Of the 134 articles subsequently included, 116 were descriptive studies. All but 10 of the papers were written in English. There were mixed findings about the extent to which patients feel that their beliefs, experience and preferences about medicines can be shared. Doctors tend to dominate discussions in consultations, although patient participation is associated with positive outcomes. Health care professionals' behaviour can impede as well as enhance patient involvement. CONCLUSIONS: There is little research that examines fundamental issues for concordance such as whether an exchange of views takes place. It is possible that interventions are needed to facilitate the development of concordance in practice.

Drug Therapy↗
PubMed2002

Patterns of illness and injury encountered in amateur ocean yacht racing: an analysis of the British Telecom Round the World Yacht Race 1996-1997.

OBJECTIVES: To quantify the incidence and type of medical problem arising during an amateur circumnavigation yacht race, the BT Global Challenge. METHODS: All cases from 14 participating yachts in a confidential medical log completed by an appointed medic were reported. RESULTS: A total of 685 cases were reported, of which 299 (43.6%) were injuries and 386 (56.4%) illnesses. The subtype of injury, illness, and three evacuations at sea are described. CONCLUSION: Injury and other forms of medical problem are relatively common in an amateur long distance ocean yacht race. Most can be adequately managed at sea, provided that optimal communication, training, and equipment are provided and maintained.

Adult↗
PubMed2001

Improving access to specialist care for remote Aboriginal communities: evaluation of a specialist outreach service.

OBJECTIVE: To identify barriers faced by Aboriginal people from remote communities in the Northern Territory (NT) when accessing hospital-based specialist medical services, and to evaluate the impact of the Specialist Outreach Service (SOS) on these barriers. DESIGN: Combined quantitative and qualitative study. SETTING: Remote Aboriginal communities in the "Top End" of the NT, 1993-1999 (spanning the introduction of the SOS in 1997). PARTICIPANTS: 25 remote health practitioners, patients and SOS specialists. MAIN OUTCOME MEASURES: Numbers of consultations with specialists; average cost per consultation; perceived barriers to accessing hospital-based outpatient care; and perceived impact of specialist outreach on these barriers. RESULTS: Perceived barriers included geographic remoteness, poor doctor-patient communication, poverty, cultural differences, and the structure of the health service. Between 1993 and 1999, there were 5,184 SOS and non-SOS outreach consultations in surgical specialties. Intensive outreach practice (as in gynaecology and ophthalmology) increased total consultations by up to 441% and significantly reduced the number of transfers to hospital outpatient clinics (P< 0.001). Average cost per consultation was $277 for SOS consultations, compared with $450 at Royal Darwin Hospital and $357 at the closest regional hospital. Outreach has reduced barriers relating to distance, communication and cultural differences, and potentially bolsters existing primary healthcare services. CONCLUSIONS: When compared with hospital-based outpatient services alone, outreach is a more accessible, appropriate and efficient method of providing specialist medical services to remote Aboriginal communities in the NT.

Attitude of Health Personnel↗
PubMed2001

Early diagnosis of prostate cancer in the Western Cape.

BACKGROUND: Early stage prostate cancer does not cause symptoms, and even metastatic disease may exist for years without causing symptoms or signs. Whereas early stage prostate cancer can be cured with radical prostatectomy or radiotherapy, the prognosis of patients with locally advanced or metastatic cancer is significantly poorer. OBJECTIVES: In view of the high incidence of advanced and therefore incurable prostate cancer seen at the oncology clinic of the Department of Urology, Tygerberg Hospital, we started a prostate clinic with the aim of detecting early stage prostate cancer which is potentially curable. A secondary objective was to investigate the question whether there is a higher incidence of prostate cancer among black African men. PATIENTS AND METHODS: Men aged 50-70 years were invited by means of media communications (newspaper and radio) to attend our prostate clinic for a free physical examination, including a digital rectal examination (DRE) and serum prostate specific antigen (PSA) assay. If the DRE was clinically suspicious of malignancy and/or the serum PSA was > 4 ng/ml, the patient was appropriately counselled and referred for transrectal ultrasound (TRUS)-guided sextant prostate biopsy. RESULTS: In the period June 1997-September 1999 a total of 1,056 men attended the prostate clinic. Biopsies were indicated in 160 cases, and were obtained in 114 (71.3%, i.e. 10.8% of the entire cohort). Prostate cancer was detected on first biopsy in 3.5% of the entire group of men (in 35.9% of those with a clinically abnormal DRE, in 41.3% of those with a serum PSA > 4 ng/ml and in 88.6% of those with an abnormal DRE and serum PSA > 4 ng/ml. In the 37 men with prostate cancer, the clinical tumour stage was T1-2 in 83.8% and T3-4 in 16.2%. In the group of patients with clinical stage T1-2 tumours, the treatment was watchful waiting in 62.5% of cases, radiotherapy in 20.8% and radical prostatectomy in 16.7%. Analysis of the data according to race showed that in the group of 47 black men there was a higher percentage of clinically abnormal DRE, PSA > 4.0 ng/ml and biopsies showing malignancy, and a higher overall prostate cancer detection rate (8.5%). CONCLUSIONS: Our prostate cancer detection rate of 3.5% is slightly lower than that reported in larger studies (4.7%), which may be due to the fact that prostate biopsy was performed in only 71% of those who had an indication for biopsy. In the men diagnosed with clinically localised prostate cancer, potentially curative treatment was given in only 37.5% of cases. This compares unfavourably with the historical cohort of men seen at our oncology clinic, where 53% received potentially curative treatment, and a large European study where potentially curative treatment was given in 89% of cases. Our finding that black men had a higher percentage of clinically abnormal DRE, PSA > 4.0 ng/ml and biopsies showing malignancy and a higher overall detection rate of prostate cancer should be interpreted with caution, since black men comprised only 4.5% of our overall study cohort.

Aged↗
PubMed2004

Use of pedicled buccal fat pad in the closure of oroantral communication: analysis of 75 cases.

OBJECTIVE: This report evaluates the use of pedicled buccal fat pad for closure of oroantral communications. METHOD AND MATERIALS: Seventy-five patients were treated with pedicled buccal fat pad. Fifty-two were treated immediately after tooth extractions. The remaining 23 had chronic oroantral communication and were treated similarly after irrigation of the maxillary sinus with saline for 7 days. RESULTS: The 6-month follow-up revealed uneventful healing in all of the patients. Though partial necrosis of the flap was observed in three patients, this did not effect the final healing. Total necrosis of the flap was not noted. CONCLUSION: The use of pedicled buccal fat pad is an acceptable and reliable alternative in acute or chronic oroantral communications management and may even be used as a first treatment choice by experienced surgeons.

Acute Disease↗
PubMed1992

Structural design of hidden Markov model speech recognizer using multivalued phonetic features: comparison with segmental speech units.

A novel approach to speech recognition, on the basis of a multidimensional multivalued phonetic-feature description of speech signals, is presented and evaluated. The hidden Markov model (HMM) framework is used to provide the recognition algorithm, which assumes that the underlying Markov chain tracks the temporal evolution of the features. It is shown that this approach can naturally accommodate such coarticulatory effects as feature spreading and formant transition in the functionality of the recognizer, and can provide a high degree of acoustic data sharing that makes effective use of training data. Use of phonetic features as the basic speech units creates a framework where the Markov model's state topology in the recognizer can be designed with guidance of detailed speech knowledge. Details of such a design for a stop consonant-vowel vocabulary are described. Experimental results on the task of speaker-dependent stop consonant discrimination, evaluated from speech data from a total of ten male and five female speakers, demonstrate effectiveness of this feature-based recognizer. Over the 15 speakers, the error rates were shown to be reduced by 23%, 37%, 42%, and 38%, respectively, compared with the conventional HMM-based recognition methods using words, phonemes, allophones, and microsegments as the primary speech units.

Communication↗
PubMed1999

Statistical thinking applied to everyday data.

Despite all the talk about "improvement" and "statistical thinking," our everyday work environments are horribly contaminated with poor statistical practice (even if it is not formally called "statistics"). The statistical methods our work requires are quite simple ... but initially quite counter-intuitive. Once grasped, however, they can provide a deeper understanding that will ensure better analysis, communication and decision-making.

Benchmarking↗
PubMed2002

The image pyramid system--an unbiased, inexpensive and broadly accessible method of telepathology.

Although computerised information technology, including the Internet is broadly used and globally accessible it is still not a significant form of professional communications in diagnostic histopathology. The high cost of interactive dynamic telepathology systems makes their use limited outside the richest economies. In contrast static telepathology systems are relatively cheap but in practice their information content can be heavily biased by the choice of images sent by the consulting pathologist. The degree of this bias may be regarded simply as the amount of information transferred to a remote location expressed as a percentage of the total information present in the histological sample. We refer to this as the percentage of explicit versus implicit information. Another major source of bias may be found in the information transmitted in written or verbal discussion with a remote consultant. We have developed a system of static telepathology, the image pyramid, which attempts to minimise bias by transferring all of the information in a section to the consultant. It is inexpensive and should prove to be widely accessible.

Data Display↗