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PubMed2006

Physicians' decisions to withhold and withdraw life-sustaining treatment.

BACKGROUND: Few data are available about physicians' decisions in regard to withholding or withdrawing life-sustaining measures. We therefore studied internists' views on this subject. METHODS: We surveyed 1000 generalist and subspecialist internists about their views on withholding or withdrawing life-sustaining treatment. Thirty-two hypothetical cases were included. The effect of the demographic data on withholding or withdrawing treatment was analyzed via analysis of covariance and multiple logistic regression. RESULTS: Of 1000 internists, 407 (41%) completed and returned surveys. A majority of respondents (51%) were willing to withhold or withdraw treatment in all 32 scenarios; 49% were unwilling to withhold or withdraw in at least 1 scenario. Respondents were likely to withhold treatment in 14 of 16 scenarios compared with 13.7 of 16 scenarios for withdrawing treatments (P<.001). Respondents withheld or withdrew feeding tubes in 6.6 of 8 scenarios (P<.001) and antibiotics in 6.7 of 8 scenarios (P = .001) compared with ventilators (7.1 of 8 scenarios) and dialysis (7.3 of 8 scenarios). Respondents were less likely to withhold or withdraw treatments in nonterminally ill (12.9 of 16 scenarios) (P = .02) and alert patients (13.2 of 16 scenarios) (P<.001) compared with terminally ill patients (14.9 of 16 scenarios) and patients with dementia (14.5 of 16 scenarios). CONCLUSIONS: A large percentage of internists would be unwilling to adhere to some of patients' wishes to withhold or withdraw life-sustaining treatment. The clinical scenario and type of treatment affect internists' decisions about whether they would withhold or withdraw such treatment.

Advance Directives↗
PubMed1998

General pediatricians, pediatric subspecialists, and pediatric primary care.

OBJECTIVE: To assess the respective roles of general pediatricians and pediatric subspecialists in the provision of primary pediatric care. DESIGN AND METHODS: A practice characteristics questionnaire that included questions about primary care was sent to a random sample of 1616 board-certified and board-eligible active Fellows of the American Academy of Pediatrics; 1145 (70.9%) responded. Analyses pertain to those pediatricians who provided ambulatory patient care and were not in graduate medical education training at the time of the survey. Respondents were divided into 2 groups for purposes of analysis: the 527 pediatricians whose practice was primarily in general pediatrics (defined as 80% of time spent in general pediatrics or any time spent in adolescent medicine) and the 213 pediatricians whose practice was subspecialty focused (all others). These groups were then further stratified according to whether they provided primary care. The resultant subgroups contained 518 general pediatricians and 98 subspecialists who provided primary care. RESULTS: Among the entire sample, general pediatricians indicated that general pediatricians provide 93% of the primary care delivered by their practice and that pediatric subspecialists provide 2% of the primary care. In contrast, pediatric subspecialists reported that general pediatricians provide 53% of the primary care delivered by their practice and that subspecialists provide 32% of such care (P<.001). Among the subsample of pediatricians who provide primary care, general pediatricians reported delivering 88% of the primary care received by their patients and subspecialists reported delivering 74% of the primary care received by their patients (P<.001). CONCLUSION: Perspectives on the degree to which pediatric subspecialists provide primary pediatric care vary depending on generalist vs subspecialist self-identification.

Adult↗
PubMed2002

Antibiotic prescribing by primary care physicians for children with upper respiratory tract infections.

OBJECTIVES: To determine if the rate of appropriate antibiotic use in the treatment of children with bronchitis, viral upper respiratory tract infections, sinusitis, otitis media, and pharyngitis has changed in recent years and to identify factors that are associated with the use of inappropriate antibiotic therapy. DESIGN: The National Ambulatory Medical Care Survey was used to examine the antimicrobial prescribing habits of physicians who provide primary care for children. Data were analyzed from 1995-1998. SETTING: Office-based physician practices. PARTICIPANTS: Pediatricians, family physicians, and generalists completing survey forms for patients younger than 18 years. MAIN OUTCOME MEASURE: The appropriate use of antibiotics for upper respiratory tract infections. RESULTS: Multivariate analyses were used to examine factors associated with the use of inappropriate antibiotics to treat either upper respiratory tract infections or bronchitis. Patients seen in 1998 and diagnosed as having upper respiratory tract infections were 0.69 (95% confidence interval, 0.59-0.81) times less likely to be treated with antibiotics compared with patients seen in 1995. Multivariate analyses were also used to assess factors associated with the use of antibiotics with a suboptimal therapeutic profile for the treatment of either sinusitis or otitis media. Children diagnosed as having either sinusitis or otitis media were 0.3 (95% confidence interval [CI], 0.16-0.48) times less likely to receive antibiotics with a suboptimal therapeutic effect in 1998 compared with 1995. CONCLUSIONS: Physicians are slowly improving their antibiotic prescribing patterns but the use of inappropriate antibiotics is still common. Almost half of patients with upper respiratory tract infections receive antibiotics.

Adolescent↗
PubMed2002

Effects of removing gatekeeping on specialist utilization by children in a health maintenance organization.

BACKGROUND: The "gatekeeping" model of access to specialty care has been an essential managed care tool, intended to control costs of care and promote coordination between generalists and specialists. OBJECTIVE: To investigate the impact of removing gatekeeping on specialist utilization. METHODS: A capitated multispecialty group discontinued a gatekeeping system on April 1, 1998. We assessed the overall number and distribution of patient visits to primary care physicians and specialists and initial patient visits to specialists before and after the removal of gatekeeping. We performed focused analyses for specific specialties, children with chronic conditions, and children with specific diagnoses. RESULTS: Elimination of gatekeeping was not associated with changes in the mean number of visits to specialists (0.28 visits per 6 months before and after gatekeeping was removed) or the percentage of all child visits to specialists (11.6% vs 12.1%; 95% confidence interval, 11.3%-11.9% vs 11.8%-12.4%). The proportion of all specialist visits that were initial consultations increased after gatekeeping was removed, from 30.6% (95% CI, 29.4%-31.8%) to 34.8% (95% CI, 33.6%-36.1%). Visits to any specialist by children with chronic conditions increased from 18.6% (95% CI, 17.7%-19.1%) to 19.8% (95% CI, 19.0%-20.7%). New patient visits to specialists by children with chronic conditions as a proportion of all specialist visits increased from 28.1% (95% CI, 25.9%-30.2%) to 32.3% (95% CI, 30.1%-34.5%). CONCLUSIONS: Replacing a gatekeeping system with open access to all specialty physicians in a managed care organization resulted in minimal changes on the utilization of specialists. Visits to specialists by children with chronic conditions increased after the removal of gatekeeping.

Allergy and Immunology↗
PubMed1991

School health training during pediatric residency.

Pediatricians are becoming increasingly concerned about reaching beyond the office or clinic to help solve problems of child and family health. The physician's ability to interact with school personnel and communities is one important approach to this outreach effort. School health training has been a required 6-month component of the pediatric residency curriculum at the University of Texas Medical Branch, Galveston, since 1979, with second-year residents providing weekly on-site consultations to public school districts and participating in a weekly school health seminar series. In this study, graduates from this program were surveyed to determine their evaluations of the training and extent of current school involvement and to use their evaluations for curriculum evaluation. Residents who participated in the school consultation from 1979 through 1988 were surveyed. Seventy-eight pediatricians responded, a 79% return rate. Ratings by the graduates reveal that both pediatric generalists and subspecialists highly value their training experiences. Ratings were not related to the specific site to which the resident consultant had been assigned. Of these pediatricians, 41% are currently consulting with school personnel. These findings are discussed as they relate to other reports of physician involvement in schools and provide clues to curriculum design for school health training in pediatric residency.

Attitude of Health Personnel↗
PubMed1984

Utilization of health and mental health services. Three Epidemiologic Catchment Area sites.

Utilization of health and mental health services by non-institutionalized persons aged 18 years and older is examined based on interviews with probability samples of 3,000 to 3,500 persons in each of three sites of the National Institute of Mental Health Epidemiologic Catchment Area (ECA) program: New Haven, Conn, Baltimore, and St Louis. In all three ECAs, 6% to 7% of the adults made a visit during the prior six months for mental health reasons; proportions were considerably higher among persons with recent DSM-III disorders covered by the Diagnostic Interview Schedule (DIS) or severe cognitive impairment. Between 24% and 38% of all ambulatory visits by persons with DIS disorders were to mental health specialists. In seeking mental health services, men were more likely to turn to the specialty sector than to the generalist; women used both sectors about equally. The aged infrequently received care from mental health specialists. Visits for mental health reasons varied considerably depending on specific types of DIS disorder.

Adolescent↗
PubMed1994

Development of the city-county (public) hospital.

Prior to 1966, the United States had a two-tiered system of health care. Those patients who could afford the cost of medical care were treated by private physicians in their offices and in private hospitals. For patients who could not afford care, ie, the indigent and retirees over 65 years of age who developed catastrophic illnesses, the city and county (public) hospitals provided the only health care available. All counties assumed responsibility for their indigent patients, and all but the smallest counties had their local hospital. In the larger cities, these hospitals developed teaching programs and affiliations with medical schools that provided a volunteer teaching faculty (Table) (John G. Raffensperger, unpublished data, 1991; John E. Salvaggio, unpublished data, 1989). The smaller county hospitals relied on a few full-time generalists, but primarily they depended on volunteer physicians from the community to provide patient care.

Emergency Service, Hospital↗
PubMed1995

Medical migration and the physician workforce. International medical graduates and American medicine.

OBJECTIVE: Because of the size and growth of the international medical graduate (IMG) contribution to graduate medical education (GME) in the United States, and subsequently to the US physician workforce, it is essential to understand the demographics and patterns of IMG training and practice as well as the routes of entry into the United States. DATA SOURCES: Published data from the American Medical Association, the American Osteopathic Association, and the Association of American Medical Colleges; tabular runs of county-level data contained on the Bureau of Health Professions' Area Resource File. RESULTS: The majority of IMGs who participate in GME in the United States ultimately enter US practices. A significant proportion of exchange visitors eventually enter into permanent practice in the United States, contrary to the intent of the J-1 visa-based GME training as an international educational exchange program. International medical graduates gravitate toward initial residency programs in internal medicine and pediatrics, many of which have unfilled positions; however, IMGs subspecialize at a disproportionately high rate, reducing their net contribution to the generalist pool. Patterns of ultimate practice location of IMGs parallel the patterns of US medical graduates (USMGs). CONCLUSIONS: In recent years, participation of IMGs in GME and practice has increased significantly. Most IMGs in GME are not exchange visitors, but are either permanent residents or US citizens. Patterns of specialization and location of IMGs ultimately mirror those of USMGs. National IMG policy must be examined in light of the projected surplus of physicians in the United States. The best option for long-term control of the number of physicians in practice, USMG or IMG, is a system of specifying the number of GME positions nationally.

Education, Medical, Graduate↗
PubMed1998

Striking against managed care: the last gasp of la médicine libérale?

The French health care system combines a strong tradition of autonomous private practice with nearly universal health care coverage through the social security system. The French state's responses to rising health care expenditures have included limitation of the number of medical students, control over physician fees, rules to prohibit certain clinical practices, experiments with generalist physicians coordinating care and access to specialists, and collective physician responsibility for expenditures beyond the health care budget. The failure of physicians' protests, including a strike of French residents and fellows in 1997, may signify the end of traditional private practice in the face of France's statist version of managed care.

Delivery of Health Care↗
PubMed1999

Simulation technology for health care professional skills training and assessment.

Changes in medical practice that limit instruction time and patient availability, the expanding options for diagnosis and management, and advances in technology are contributing to greater use of simulation technology in medical education. Four areas of high-technology simulations currently being used are laparoscopic techniques, which provide surgeons with an opportunity to enhance their motor skills without risk to patients; a cardiovascular disease simulator, which can be used to simulate cardiac conditions; multimedia computer systems, which includes patient-centered, case-based programs that constitute a generalist curriculum in cardiology; and anesthesia simulators, which have controlled responses that vary according to numerous possible scenarios. Some benefits of simulation technology include improvements in certain surgical technical skills, in cardiovascular examination skills, and in acquisition and retention of knowledge compared with traditional lectures. These systems help to address the problem of poor skills training and proficiency and may provide a method for physicians to become self-directed lifelong learners.

Anesthesiology↗
PubMed2001

Self-referral in point-of-service health plans.

CONTEXT: Most health maintenance organizations offer products with loosened restrictions on patients' access to specialty care. One such product is the point-of-service (POS) plan, which combines "gatekeeping" arrangements with the ability to self-refer at increased out-of-pocket costs. Few data are available from formal evaluations of this new type of plan. OBJECTIVES: To comprehensively describe the self-referral process in POS plans by quantifying rates of self-referral, identifying patients most likely to self-refer, characterizing patients' reasons for self-referral, and assessing satisfaction with specialty care. DESIGN: Retrospective cohort analysis using administrative databases composed of members aged 0 to 64 years who were enrolled in 3 POS health plans in the Midwest (n = 265 843), Northeast (n = 80 292), and mid-Atlantic (n = 39 888) regions for 6 to 12 months in 1996, and a 1997 telephone survey of specialty care users (n = 606) in the midwestern plan. MAIN OUTCOME MEASURES: Self-referred service use and charges, reasons for self-referral, and satisfaction with specialty care. RESULTS: Overall, 8.8% of enrollees in the midwestern POS plan, 16.7% in the northeastern plan, and 17.3% in the mid-Atlantic plan self-referred for at least 1 physician or nonphysician clinician visit. The proportions of enrollees self-referring to generalists (4.7%-8.5%) were slightly higher than the proportions self-referring to specialists (3.7%-7.2%) across all 3 plans. Nine percent to 16% of total charges were due to self-referral. The chances of self-referral to a specialist were increased for patients with chronic and orthopedic conditions, higher cost sharing for physician-approved services, and less continuity with their regular physician. Patients who self-referred to specialists preferred to access specialty care directly (38%), reported relationship problems with their regular physicians (28%), had an ongoing relationship with a specialist (23%), were confused about insurance rules (8%), and did not have a regular physician (3%). Compared with those referred to specialists by a physician, patients who self-referred were more satisfied with the specialty care they received. CONCLUSIONS: Having the option to self-refer is enough for most POS plan enrollees; 93% to 96% of enrollees did not exercise their POS option to obtain specialty care via self-referral during a 1-year interval. The potential downside of uncoordinated, self-referred service use in POS health plans is limited and counterbalanced by higher patient satisfaction with specialist services.

Adolescent↗
PubMed2003

Trends in career choice by US medical school graduates.

CONTEXT: Trends in career choice among specialties have varied greatly. Most notable is the recent decrease in the percentage of US medical student graduates choosing a primary care career, which has important implications for the US physician workforce. OBJECTIVE: To review temporal trends in career choice by graduates of allopathic US medical schools, focusing on US medical doctors entering residencies since 1987. DATA SOURCES: Three databases, the Association of American Medical Colleges Graduation Questionnaire (AAMC GQ), the National Resident Matching Program, and the national Graduate Medical Education census, were used to review temporal trends in the number of US medical doctors entering residencies in primary care, general or subspecialty surgical, and non-primary care and nonsurgical specialties from 1987 to 2002. DATA SYNTHESIS: In 1987, 49.2% of all medical school graduates matched to one of the generalist residencies (internal medicine, pediatrics, or family medicine). The percentage of students matching to primary care specialties declined in the early 1990s, peaked at 53.2% in 1998, and declined to 44.2% in 2002. Concurrent with the latter decline, AAMC GQ data showed a decrease in medical student interest in primary care careers (35.6% in 1999 to 21.5% in 2002). The total percentage of US medical doctors matching to general or subspecialty surgical residencies remained stable at 11% to 12% from 1987 to 2002. During this same period, emergency medicine and plastic surgery increased as a match choice, while anesthesiology, pathology, and psychiatry were more variable over time. CONCLUSIONS: Distribution of medical students' career choices among specialties varied considerably from 1987 to 2002. The debate will continue regarding the appropriate specialty mix within the physician workforce.

Career Choice↗
PubMed1996

Antennal lobe interneurons in the desert locust Schistocerca gregaria (Forskal): processing of aggregation pheromones in adult males and females.

Physiological and morphological characteristics of antennal lobe interneurons in male and female Schistocerca gregaria were studied by using intracellular recording and staining techniques. For the first time, the responses of projection neurons to behaviourally active and potential aggregation pheromone compounds and plant odour compounds were recorded in young adult locusts. Excitatory, inhibitory, or combined excitatory/inhibitory responses to the presented odours were detected. The stained neurons had their cell bodies in the frontal cell group, arborized in 10 to 25 glomeruli at equal distances from the central fibre core, and sent their axons to the calyces of the mushroom body and to the lateral protocerebrum. The projection neurons responded to the set of different stimuli with varying specificity. In females, more neurons responded specifically to single plant or aggregation pheromone compounds than in males, where more generalist responses were found. "Blend specialist" neurons, responding only to mixtures of behaviourally active aggregation pheromone compounds, but not to the single compounds, were present in both males and females. Most neurons responded to the behaviourally active aggregation pheromone mixtures and to single compounds present in these mixtures, as well as to plant odours. Fewer neurons responded to the potential aggregation pheromone compounds tested. In several experiments, two spike sizes in the recording were correlated with two stained neurons in the antennal lobe, suggesting electrical coupling of the neurons. No response to any of the stimuli was found in antennal lobe interneurons in old adults. The morphological and physiological features of the projection neurons in S. gregaria are compared with projection neuron characteristics in other insects.

Animals↗
PubMed2000

Midbrain acoustic circuitry in a vocalizing fish.

The mapping of auditory circuitry and its interface with vocal motor systems is essential to the investigation of the neural processing of acoustic signals and its relationship to sound production. Here we delineate the circuitry of a midbrain auditory center in a vocal fish, the plainfin midshipman. Biotin injections into physiologically identified auditory sites in nucleus centralis (NC) in the torus semicircularis show a medial column of retrogradely filled neurons in the medulla mainly in a dorsomedial division of a descending octaval nucleus (DO), dorsal and ventral divisions of a secondary octaval nucleus (SO), and the reticular formation (RF) near the lateral lemniscus. Biotin-filled neurons are also located at midbrain-pretectal levels in a medial pretoral nucleus. Terminal fields are identified in the medulla (ventral SO, RF), isthmus (nucleus praeeminentialis), midbrain (nucleus of the lateral lemniscus, medial pretoral nucleus, contralateral NC, tectum), diencephalon (lateral preglomerular, central posterior, and anterior tuber nuclei), and telencephalon (area ventralis). The medial column of toral afferent neurons is adjacent to and overlapping the positions of DO and SO neurons shown previously to be linked to the vocal pacemaker circuitry of the medulla. Midshipman are considered "hearing generalists" because they lack the peripheral adaptations of "specialists" that enhance the detection of the pressure component of acoustic signals. Whereas the results indicate a general pattern of acoustic circuitry similar to that of specialists, they also show central adaptations, namely, a vocal-acoustic interface in DO and SO related to this species' vocal abilities.

Animals↗
PubMed2000

Food chemical discriminations by an herbivorous lizard, Corucia zebrata.

Adjustment of chemosensory response to diet should be apparent in evolutionary changes corresponding to dietary shifts. Because most lizards are generalist predators of small animals, relationships between chemosensory behavior and diet are difficult to detect. Nevertheless, the evolution of herbivory by a small number of lizards provides an opportunity to detect any corresponding change in response to plant chemicals. I studied tongue-flicking and biting by the large, herbivorous scincid lizard Corucia zebrata in response to chemical cues from crickets, romaine lettuce, and control stimuli presented on cotton swabs. The skinks exhibited significantly stronger response to plant and animal chemicals than to controls for several variables: greater number of individuals that bit swabs, shorter latency to bite, greater rate of tongue-flicks, and greater tongue-flick attack score. The clearest differences were observed for tongue-flick attack score, a composite variable that combines the effects of tongue-flicking and biting. An insectivorous member of the same subfamily, Scincella lateralis, shows strong tongue-flicking and biting response to chemical prey cues, but not to plant chemicals. This suggests that response to plant chemicals by C. zebrata may have evolved in tandem with the incorporation of plants into the diet and that response to cricket chemicals has been retained, perhaps due to similarities between plant and animal food. The findings support the hypothesis that dietary shifts induce corresponding changes in chemosensory response, but provide only a single independent contrast for a study of correlated evolution between plant diet and chemosensory response to plants. J. Exp. Zool. 286:372-378, 2000.

Adaptation, Physiological↗
PubMed2000

Morphology and function of the feeding apparatus of Pelusios castaneus (Chelonia; Pleurodira).

Feeding mechanics of vertebrates depend on physical constraints of the surrounding media, water or air. Such functions are inseparably combined with form. The aim of this study is to show this linkage for the pleurodiran freshwater turtle Pelusios castaneus and, additionally, to point out the major functional and biomechanical distinctions between aquatic and terrestrial feeding turtles as well as several intermediate forms. Gross morphological investigations of skull, hyoid, tongue, and connected musculature, as well as scanning electron microscopy of the tongue surface, show typical features of an aquatic feeder, e.g., strongly developed hyoid apparatus vs. a small tongue with only moderate papillae, and massive jaw and hyoid musculature. Additionally, the special function of the esophagus during feeding is investigated to elucidate the problems of a bidirectional feeder. The esophagus is highly distensible in order to store the excess water sucked in during feeding until the prey is fixed by the jaws. The distension is probably achieved by a coincidence of active (branchial horn) as well as passive (water) components. P. castaneus is a feeding generalist, and is well adapted to the aquatic medium in terms of its functional as well as morphological features.

Adaptation, Physiological↗
PubMed1997

Seasonal variation in the feeding behavior and diet of Japanese macaques (Macaca fuscata yakui) in lowland forest of Yakushima.

The feeding behavior of the southern subspecies of Japanese macaque (Macaca fuscata yakui) was studied over a period of 18 months in warm temperate broad-leaved forest on the island of Yakushima, Japan. Focal animal data were collected for the eight adults in the troop. Over a full annual cycle, 35.0% of foraging on identified foods was on leaves and shoots, 30.2% on fleshy fruit, 13.2% on seeds, and 5.5% on flowers. Invertebrates and other animal matter accounted for 10.3% of foraging and fungi for 4.6%. There was marked seasonal variation in the use of different food categories, and seeds, leaves, fleshy fruit, and animal matter were each predominant at different times of year. There was also evidence of annual cyclicity in patterns of foraging on all major food types. The monkeys spent less time moving and ate a greater variety of foods when feeding on leaves than when feeding on fruit and seeds, or on insects. Time spent foraging was positively correlated with diversity of the diet, but there was no simple relationship between time spent foraging and the predominant food type. This suggests that a wide variety of foods takes longer to harvest and process, irrespective of the food type. The diet of the study troop was flexible and could not be assigned to a simple dietary category, such as frugivorous or folivorous. If these data are representative of the subspecies, the Yakushima macaque is much more of a dietary generalist than most primates for which there are adequate data.

Animals↗
PubMed1998

Primate diversity, habitat preferences, and population density estimates in Noel Kempff Mercado National Park, Santa Cruz Department, Bolivia.

This report documents primate communities at two sites within Noel Kempff Mercado National Park in northeastern Santa Cruz Department, Bolivia. Diurnal line transects and incidental observations were employed to survey two field sites, Lago Caiman and Las Gamas, providing information on primate diversity, habitat preferences, relative abundance, and population density. Primate diversity at both sites was not particularly high, with six observed species: Callithrix argentata melanura, Aotus azarae, Cebus apella, Alouatta caraya, A. seniculus, and Ateles paniscus chamek. Cebus showed no significant habitat preferences at Lago Caiman and was also more generalist in use of forest strata, whereas Ateles clearly preferred the upper levels of structurally tall forest. Callithrix argentata melanura was rarely encountered during surveys at Lago Caiman, where it preferred low vine forest. Both species of Alouatta showed restricted habitat use and were sympatric in Igapo forest in the Lago Caiman area. The most abundant primate at both field sites was Ateles, with density estimates reaching 32.1 individuals/km2 in the lowland forest at Lago Caiman, compared to 14.1 individuals/km2 for Cebus. Both Ateles and Cebus were absent from smaller patches of gallery forest at Las Gamas. These densities are compared with estimates from other Neotropical sites. The diversity of habitats and their different floristic composition may account for the numerical dominance of Ateles within the primate communities at both sites.

Alouatta↗