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PubMed2003

Development of geriatrics-oriented faculty in general internal medicine.

The need for adequate geriatrics training for the physician workforce has been recognized for decades. However, there are not enough academic geriatricians to provide for the educational needs of trainees, and this situation is not expected to change in the future. General internists are often responsible for teaching medical students and internal medicine residents to care for elderly patients in inpatient and ambulatory settings. These academic general internists could play a pivotal role in providing geriatrics instruction. To characterize what is being done to develop geriatrics-oriented general internal medicine faculty, we identified current practices, "best practices," goals and targets, and barriers to achieving those goals and targets. We reviewed the literature on faculty-development programs for general internal medicine faculty, and we held focus groups and structured interviews with general internal medicine unit chiefs and directors of Geriatric Centers of Excellence at 46 medical schools throughout the United States. We found a need for programs to develop geriatrics-oriented academic general internists. Although general internal medicine faculties seem receptive to further geriatrics training, important obstacles exist. These include inadequate time and resources as well as motivational and attitudinal challenges. We discuss potential solutions for overcoming these barriers and the implications of these solutions for stakeholders.

Faculty, Medical↗
PubMed2006

Current guidelines produce competent endovascular surgeons.

OBJECTIVE: This study was conducted to evaluate the safety of percutaneous endovascular procedures (PEPs) during integration of endovascular skills into an urban academic vascular surgery practice and assess the hypothesis that currently accepted guidelines are a valid benchmark for endovascular competency. METHODS: From 2000 through 2004, an endovascular training paradigm was instituted to integrate endovascular procedures into an academic endovascular practice. The paradigm involved individual mentoring of vascular surgery faculty by a partner with mature endovascular skills. Mentoring continued until each surgeon achieved a procedural experience of 100 diagnostic angiograms and 50 percutaneous endovascular interventions. Once achieved, privileges were granted for independent endovascular practice. To assess the effectiveness of the training process and competency of the newly trained endovascular practitioner, the surgeon-specific 30-day incidence of major complications and deaths for all PEPs performed during and after the mentoring process was determined. Complications and deaths were assigned to the mentor during the training process and to the individual surgeon once endovascular privileges were granted. Complications were classified as local vascular, local nonvascular, or systemic/remote. RESULTS: From 2000 through 2004, 1208 PEPs were performed. During this time, three faculty surgeons achieved sufficient endovascular procedural experience and were granted endovascular privileges. Major complications consisted of 17 local vascular, three local nonvascular, and four systemic/remote. Three deaths occurred. Renal percutaneous transluminal angioplasty/stent procedures had the highest complication and death rate at 9%. The major complication and death rate per year was 1.8% to 4.9% (P = .32) and did not significantly vary. The major complication and death rate for all 1208 PEPs was 2.2%. The surgeon-specific complication and death rate was 1.9% to 3.6% (P = .14) and did not vary between surgeons. CONCLUSION: Endovascular skills can be safely transferred using a vascular surgeon-based training paradigm. When the training paradigm is directed at satisfying currently recommended guidelines for endovascular privileging, competent endovascular surgeons are the result.

Adolescent↗
PubMed1997

Effects of sinus surgery on speech.

OBJECTIVE: To determine the effects of sinus surgery on the production and perception of speech. DESIGN: Vocal recordings were performed before, 1 week after, and at least 1 month after sinus surgery. Acoustic spectra were analyzed for nasal consonants /m/ and /n/, nasalized vowels, and nonnasalized vowels. Results for nasal consonants were compared with similar recordings obtained from a group of normal subjects with no history of sinus disease. Perceptual analysis of nasalized vowels was conducted by trained phoneticians. SETTING: Private practice at an academic medical center. SUBJECTS: Five patients who underwent endoscopic sinus surgery and 3 normal subjects. MAIN OUTCOME MEASURES: The spectral characteristics and perceptual attributes of nasal sounds. RESULTS: Significant differences in spectral properties were observed for the consonants and nasalized vowels recorded before and after surgery (P < .001). Perceptual experiments for nasalized vowels demonstrated a postoperative decrease in nasality for the high vowel /i/, as in "beep," and an increase in nasality for the non-high vowel /ae/, as in "bad." These perceived changes correlated well with acoustic measures of nasal peak amplitudes and the lowest resonance peak amplitude of the vocal tract. CONCLUSIONS: Sinus surgery results in measurable effects on the produced acoustic signal and the perceived nasality of a patient's speech. The identified acoustic correlates may be useful for preoperative counseling of patients concerning expected changes in speech quality following surgery.

Adult↗
PubMed1999

The effect of patient reassignment on future continuity in a pediatric resident continuity practice.

BACKGROUND: When residents complete their pediatric training, patients from their continuity practices in academic settings must be reassigned to either a known resident of their selection or an unknown, incoming intern. OBJECTIVES: To determine what antecedent factors were associated with patient reassignment to a known resident of their selection, whether such reassignment was associated with increased health care use, and what factors were associated with continuity with the new resident provider. DESIGN: Nonconcurrent cohort study. SETTING: Hospital-based resident continuity clinic practice. PARTICIPANTS: Patients of residents graduating in June 1993. RESULTS: Seven hundred fifty-eight patients of 18 graduating residents required reassignment: 86 patients (11%) were assigned to a resident colleague, defined as the study group. From the remaining 673 patients who were assigned to unknown, incoming interns, a control group was randomly selected (n = 160), with approximately 2 patients for each study group subject. Looking at antecedent factors, study group patients were more likely to have chronic medical problems and to have seen their graduating resident more often and more recently. Univariate analysis explored the consequent factors of health care use and found that study group patients were more likely to return for a visit and to make more visits with the new provider. Multiple logistic regression analysis demonstrated that being in the study group, younger age at the original encounter with the graduating resident, and a shorter interval since the last visit with the graduating resident were all associated with increased continuity with the new resident. CONCLUSIONS: The method of patient reassignment at a continuity clinic was associated with chronic disease of the patient and regularity of visits with the graduating resident. Increased continuity with a new resident, as determined by multivariate analysis, was associated with the method of reassignment, a younger age at first encounter with the graduating resident, and a shorter interval since the last visit with the graduating resident. This study has implications at ambulatory sites where transitions occur.

Academic Medical Centers↗
PubMed1990

The next generation of surgical residencies. What are the challenges and the opportunities?

I suggest restructuring general surgical residencies to facilitate training of surgical specialists and subspecialists. Basic surgical education for 1 or 2 years should provide a foundation of fundamental cognitive, technical, and patient management skills useful for all surgery residents, regardless of discipline. Intermediate surgical education for an additional 2 or 3 years should amplify cognitive, technical, and clinical skills and senior responsibility in general surgery for individuals entering a general surgical subspecialty or for advanced general surgery training. Residents seeking a career in advanced general surgery would take 2 additional years of training in advanced surgery. Such individuals could pursue additional subspecialty training and research experience to qualify as academic surgical scientists. Implementation of such innovations in general surgical education awaits the cooperative joint efforts of appropriate accrediting and certifying organizations, specialty societies, and surgical program directors.

General Surgery↗
PubMed1999

Rheological Behavior of Suspensions Flocculated by Weak Bridging of Polymer Coils.

A polymer coil with weak affinity for the solid surface makes a flexible bridge between particles by reversible adsorption. When the coil size is comparable to particle diameter in solution, the suspensions flocculated by reversible bridging show shear-thickening flow in a narrow range of shear rates. The force generated by the rapid extension of bridges within the lifetime is responsible for the shear thickening. Although it is expected that the bridges become more flexible with increasing coil size, the polymers with high molecular weights do not necessarily give rise to shear thickening. The striking shear thickening is induced by polymers with molecular weights, Mw, of 2.5 x 10(5) and 4.5 x 10(5). The viscosity enhancement in the shear-thickening region is considerably suppressed for polymers with Mw = 7.5 x 10(5). From the sedimentation experiments, a large portion of the segments of a coil with Mw = 7.5 x 10(5) is adsorbed in train on the particle surface. The addition of small amounts of surfactant leads to an increase in the fraction of loops at the expense of trains and the bridges become more flexible. As a result, the flow of suspensions in the presence of surfactant becomes shear thickening. The rheology of suspensions flocculated by reversible bridging can be modified by a balance between loop and train fractions in a bridge. Copyright 1999 Academic Press.

Journal Article↗
PubMed2003

Postgraduate musculoskeletal fellowship training in the United States: current trends and future direction.

OBJECTIVE: To document current postgraduate musculoskeletal training program (accredited and unaccredited) curricula and approaches to education. DESIGN AND PATIENTS: Questionnaires were sent to all musculoskeletal training programs. Responses regarding radiology residency and fellowship program sizes, types of imaging and invasive procedures included, and other program parameters were solicited. Features of accredited and unaccredited programs were compared. Teaching approaches, including the use of web-based or distance learning were evaluated. RESULTS: Twenty-nine (73%) of 40 musculoskeletal programs responded to the questionnaire. Twenty-eight percent of programs were accredited and 72% unaccredited. Radiology residencies were also present at all responding institutions (the majority had a class size of 4-8/year). Residency programs in related specialties included pathology 96%, orthopedics and rheumatology 90%, oncology 83% and pain management 69%. The majority (93-100%) provided training in radiography, MRI and CT. Spine MRI was included in 69% of programs, ultrasonography in 62% and positron emission tomography in 24%. Arthrography and diagnostic and therapeutic injections (100%) were included in all programs. Other invasive procedures, including spine and radiofrequency ablation, were offered less frequently. Teaching approaches included conferences (100%), journal clubs (62%), multidisciplinary conferences (45-90%), web-based learning (30%) and distance learning (7%). Forty-one percent of programs offered off-site rotations. CONCLUSIONS: The majority of musculoskeletal training programs prepared trainees for private or academic practice. There are inconsistencies that could be improved to better prepare trainees for careers in musculoskeletal imaging.

Accreditation↗
PubMed1999

Recent changes in occupational medicine in The Netherlands.

In some respects, the Dutch seem to be forerunners in Europe. Occupational health care for all workers can be considered as a substantial progress. Nonetheless, The Netherlands has taken the lead in Europe regarding high work pressure, sickness absence and disability for work. The resulting focus on sickness absence management in many companies is associated with changes in the tasks and position of the occupational physician. Quality of occupational health care is not always as high as it should be, partly as a result of the commercial approach occupational health services have to adopt nowadays. However, the post-academic education programme, with special attention for training of skills, is increasingly adapted to occupational physicians working in a commercial environment. Moreover, a basis has been laid for a better infrastructure and occupational physicians show an increase in professional enthusiasm. Furthermore, co-operation between different professionals has become increasingly common, resulting in a more comprehensive support for companies. Efforts are being made for better co-operation with general practitioners and medical specialists. Finally, the priorities for future research have been clearly outlined by a programming study. Experts are in demand for studies regarding implementation and evaluation of interventions, especially cost-benefit analysis. Furthermore, work stress and musculoskeletal disorders remain on the research agenda.

Absenteeism↗
PubMed2003

[Set up in plastic and aesthetic surgery: personal experience].

The set up in liberal practice represents a real turning point in the professional life of a medical doctor. After more than 10 years under the hospital protection the objective is to create a structure, which is a real small company and the academic program does not offer any particular training corresponding to this important step. The author proposes to briefly relate his own experience and add few advice that will help the younger ones in their enterprise. It is necessary to properly reflect on several subjects before any decisions: location's choice, setup's mode (alone, with an associate or acquisition of existing clientele) and the choice of the surgical establishments. Other decisions are more personal as the decoration of the office, the computerizing, the assistant's recruitment and the orientation of the surgical activity. Our specialty presents several specificity that have to be properly evaluated and some choices do not have to necessarily correspond to an economic or demographic logic. The aesthetic surgery is democratizing itself and the request of surgery is in constant increase. We must then have a strong preparation and look forward to the future with serenity giving to ourselves every means for professional success.

Decision Making↗
PubMed2006

Clinically important drug-disease interactions and their prevalence in older adults.

BACKGROUND: Older adults may have decreased homeostatic reserve, have multiple chronic diseases, and take multiple medications. Therefore, they are at risk for adverse outcomes after receiving a drug that exacerbates a chronic disease. OBJECTIVES: The aims of this study were to compile a list of clinically important drug-disease interactions in older adults, obtain the consensus of a multidisciplinary panel of geriatric health care professionals on these interactions, and determine the prevalence of these interactions in a sample of outpatients. METHODS: This analysis included a 2-round modified Delphi survey and cross-sectional study. Possible drug-disease interactions in patients aged > or =65 years were identified through a search of the English-language literature indexed on MEDLINE and International Pharmaceutical Abstracts (1966-July 2004) using terms that included drug-disease interaction, medication errors, and inappropriate prescribing. Nine health care professionals with expertise in geriatrics (2 geriatricians, 7 geriatric clinical pharmacist specialists) were selected based on specialty training and continuing clinical work in geriatrics, academic appointments, and geographic location. The panel rated the importance of the potential drug-disease interactions using a 5-point Likert scale (from 1 = definitely not serious to 5 = definitely serious). Consensus on a drug-disease interaction was defined as a lower bound of the 95% CI > or =4.0. The prevalence of drug-disease interactions was determined by applying the consensus criteria to a convenience sample of frail older veterans at hospital discharge who were enrolled in a health services intervention trial. RESULTS: The panel reached consensus on 28 individual drug-disease interactions involving 14 diseases or conditions. Overall, 205 (15.3%) of the 1340 veterans in the sample had > or =1 drug-disease interaction. The 2 most common drug-disease interactions were use of first-generation calcium channel blockers in patients with congestive heart failure and use of aspirin in patients with peptic ulcer disease (both, 3.7%). CONCLUSIONS: A survey of multidisciplinary geriatric health care professionals resulted in a concise consensus list of clinically important drug-disease interactions in older adults. Further research is needed to examine the impact of these drug-disease interactions on health outcomes and their applicability as national measures for the prevention of drug-related problems.

Aged↗
PubMed2004

Nurses' self-assessment of their nursing competencies, job demands and job performance in the Taiwan hospital system.

This exploratory study investigated nurses' self-assessment of their own nursing competencies, job demands and job performance in Taiwan. Nurses' self-evaluation on their own job performance was conceptualized as an indicator of nursing care quality. A total of 21 competencies were clustered into three groups: basic-level patient care skills, intermediate-level patient care and fundamental management skills, and advanced-level patient care and supervision skills. Nurse subjects were randomly selected from the member roster of Kaohsiung Nurse Association; 850 nurses were invited to participate and questionnaire packets were sent to their homes. The overall response rate was 35.8%. Multiple regression analyses found that nurses' self-assessment of intermediate patient care skills, the difference between nurses' self-assessment and job demands for basic patient care skills, and nurses' overall satisfaction with their own nursing competencies were three significant predictors of overall satisfaction with nurses' own job performance. Nurses' self-assessment on basic patient care skills and advanced patient care skills contributed to nurses' levels of overall satisfaction with their own nursing competencies. These results suggest a relationship between competency and performance. These findings may serve as a guide to amend academic nursing courses and on-job training programs as appropriate to place a greater emphasis on the competencies desired for providing high quality of nursing services.

Adult↗
PubMed2006

Patient perceptions of emergency physicians: the gender gap still exists.

This study examines whether female emergency physicians are less likely than male emergency physicians to be recognized by patients as physicians. A convenience sample of adult patients seen while a trained observer was on duty in an academic Emergency Department constituted the study population. After the first physician contact, the observer asked the patient if a physician had seen the patient yet. The observer recorded the physician's sex, the patient's response, sex, age, and race. The frequencies that male and female physicians were recognized as physicians were compared. For the 184 physician-patient contacts evaluated, 98/105 (93.3%) of males were recognized as physicians and 62/79 (78.5%) of females were recognized as physicians. Females were significantly less likely than males to be recognized as physicians (chi-square, p = 0.003). Female emergency physicians are less likely than male emergency physicians to be recognized by patients as physicians.

Adult↗
PubMed2005

Chemosensory anxiety signals augment the startle reflex in humans.

The aim of the present study was to investigate whether chemosensory anxiety signals can activate behavioral withdrawal systems in humans. Twelve male university students donated their axillary sweat in two situations: right before an oral academic examination (anxiety condition) and during ergometric training (exercise condition). Subjective ratings revealed that the odor donors experienced significantly more anxiety and less pleasure during the anxiety condition than during the exercise condition. Seven subjects (three females) participated in the psychophysiological experiment. The chemosensory stimuli from pooled sweat samples of the donors, and from unused cotton pads (pad condition) were presented via a constant-flow olfactometer. Acoustic startle probes (100 dB (A)) were delivered during and between the presentations of the chemosensory stimuli. Only three subjects were able to discriminate the chemosensory stimuli of the human sweat samples from room air. However, the startle reflex amplitude (EMG of the eyeblink response) recorded in the context of chemosensory anxiety signals was increased, as compared to the amplitude recorded in the context of chemosensory stimuli from either exercise (p = 0.018) or cotton pad (p = 0.012). It is concluded that chemosensory anxiety signals may pre-attentively prime defensive behavior.

Acoustic Stimulation↗
PubMed2006

The influence of the surgeon's and the hospital's caseload on survival and local recurrence after colorectal cancer surgery.

BACKGROUND: Past studies have identified surgeon- and institution- related characteristics as prognostic factors in colorectal cancer surgery. The present work assesses the influence of the surgeon's and the hospital's caseload on long-term results of colorectal cancer surgery. METHODS: The data on 2706 patients from 2, randomized, colorectal cancer trials (Swiss Group for Clinical Cancer Research [SAKK] 40/81, SAKK 40/87) investigating adjuvant intraportal and systemic chemotherapy and 1 concurrent registration study (SAKK 40/88) were reviewed. A first analysis included 1809 eligible, nonmetastatic patients from all 3 studies. A subsequent subgroup analysis included 915 eligible patients from both randomized trials. Overall survival (OS), disease-free survival (DFS), and local recurrence (LR) were analyzed in multivariate models taking into account the possible effect of clustering. The main potential covariates were surgeon's annual caseload (>5 operations/year vs < or =5 operations/year), hospital's annual caseload (>26 operations/year vs < or =26 operations/year), tumor site, T stage, and nodal status. RESULTS: Primary analysis of all 3 studies combined found a high surgeon's caseload to be positively associated with OS (P = .025) and marginally with DFS (P = .058). Separate analysis for each trial, however, showed that a high surgeon's caseload was beneficial for outcome in both randomized trials but not in the registration study. A subgroup analysis of 915 patients with 376 rectal and 539 colonic primaries from both randomized trials, therefore, was performed. Neither age, gender, year of operation, adjuvant chemotherapy (intraportal vs systemic vs operation alone), hospital academic status (university vs non-university), training status of the surgeon (certified surgeon vs surgeon-in-training), nor inclusion in 1 of the 2 randomized trials (SAKK 40/81 vs SAKK 40/87) was a significant predictor of outcome. However, both high surgeon's and high hospital's annual caseloads were independent, beneficial prognostic factors for OS (P = .0003, P = .044) and DFS (P = .0008, P = .020), and marginally significant factors for LR (P = .057, P = .055). CONCLUSIONS: High surgeon's and hospital's annual caseloads are strong, independent prognostic factors for extending overall and disease-free survival and reducing the rate of local recurrence in 2 randomized colorectal cancer trials.

Chemotherapy, Adjuvant↗
PubMed1993

Overtraining affects male reproductive status.

OBJECTIVE: To substantiate the hypothesis that strenuous exercise disrupts the hypothalamic-pituitary-gonadal axis in men. DESIGN: Longitudinal study. SETTING: Normal human volunteers in an academic research environment. PATIENTS: Five endurance-trained men (maximum oxygen consumption 65.4 +/- 3.6 mL/kg per minute [means +/- SEM]) with normal spermatogenic and hormonal profiles. INTERVENTIONS: Semen and blood samples were collected bimonthly before, immediately after, and 3 months after overtraining, which was defined as twice the previous average weekly training volume with unchanged intensity. MAIN OUTCOME MEASURE: Testosterone, cortisol, and sperm concentration. RESULTS: Basal T levels decreased to 5.37 +/- 67 ng/mL from 8.68 +/- 93 ng/mL (conversion factor to SI unit, 3.47) immediately after overtraining and basal cortisol levels increased to 215.3 +/- 31 ng/mL from 145.7 +/- 27 ng/mL (conversion factor to SI unit, 2.76). This inverse relationship was highly correlated (r = -0.92). Both cortisol and T levels returned to pretraining values 3 months after resumption of previous training volume. Sperm count (91 +/- 23.3 x 10(6)) decreased significantly by 43% immediately after overtraining (52 +/- 6.8 x 10(6)) and by 52% 3 months after overtraining (44.5 +/- 20 x 10(6)). However, all values remained within normal range and would not be expected to affect fertility. CONCLUSIONS: Our results indicate that overtraining reduces T levels, which is highly correlated with an increase in levels of cortisol and possibly a subsequent decrease in sperm concentration 74 days later.

Adult↗
PubMed2000

Attitudes toward mental illness in medical students: does personal and professional experience with mental illness make a difference?

PURPOSE: Medical students may be susceptible to emotional difficulties because of the high levels of both academic and interpersonal stress associated with their training. This study examined attitudes toward mental illness in medical students. It was expected that people who had experience of mental illness, either in their personal lives or through their professional experience, would have more positive attitudes toward students with mental health problems than would people who had not had such experience. METHOD: Faculty and staff employed by a large American university medical centre completed a questionnaire package including several measures designed to assess specific attitudes toward medical students with emotional problems. Data were also collected on the degree to which specific mental disorders were thought to interfere with the performance of medical students. RESULTS: In general, prior experience with mental illness, either through personal or professional activities, was associated with more positive attitudes about students with mental illness. However, the pattern of findings was complex. CONCLUSION: Future research should examine the extent to which specific mental illnesses actually affect the performance of medical students.

Adult↗
PubMed2002

The learning curve revisited: stapedotomy.

OBJECTIVE: To determine whether the outcome of stapedotomy changes with experience. STUDY DESIGN AND SETTING: Retrospective case review of an academic otologic practice of a fellowship-trained otologist that consisted of 50 consecutive patients who underwent primary stapedotomy. The main outcome measures were preoperative and postoperative audiograms for both the operated ear and the opposite ear (control). RESULTS: There were no major complications or loss of hearing among the 50 patients. Minor complications included 1 middle ear infection, 2 torn flaps, and 1 tympanic membrane perforation. One patient had worse conductive hearing loss after surgery. The hearing of 2 patients was unchanged. Hearing for the entire group improved (P > 0.001) from a speech reception threshold of 55 dB (SD, 17 dB) to 30 dB (SD, 19 dB). Complete closure of the air-bone gap was achieved in 20% of the first 10 patients and 30% of the last 10 patients. CONCLUSIONS: The results of stapedotomy improve with experience, although the learning curve seems less steep than has been reported for total or near-total footplate removal. SIGNIFICANCE: Stapedotomy can be successfully performed early in surgical experience, but the learning curve should be acknowledged and discussed with the patient.

Adolescent↗
PubMed1993

A case study of a successful health advocate program.

This case study describes the health advocate program of Olin Health Center at Michigan State University. The health advocates are the peer branch of the university's health education/public health service. Since initiation of the program in January 1986, more than 125 students have participated in the training and service, for which they receive academic credit. This case study describes the background, development, and evaluation strategies of the health advocate program and offers recommendations to those who are interested in developing a similar program.

Health Education↗