Assessing the knowledge of future internists and gynecologists in caring for a woman with tetraplegia

OBJECTIVE: To assess the knowledge base and comfort level of potential physician "gatekeepers" when treating women with spinal cord injuries. Residents with at least 1 year of training in either internal medicine (IM) or obstetrics and gynecology (Ob/Gyn) from a large academic urban medical center were surveyed. STUDY DESIGN: This study used a written questionnaire that included a case scenario of a young woman with C6 tetraplegia who presented to her primary care physician for a routine visit. Information about the patient from her history and physical and laboratory exams was presented in stages, followed by open-ended queries to elicit information about the residents' problem-solving processes and management strategies. RESULTS: Thirty-eight percent (30 of 79) of the IM residents and 64% (14 of 22) of the Ob/Gyn residents completed the questionnaire. Significant deficits in knowledge about physical accessibility, spasticity management, and potential disability-related medical complications in pregnancy were found. More Ob/Gyn residents were aware of the risk of autonomic hyperreflexia than IM residents, whereas the IM residents demonstrated greater awareness of neurogenic bladder and skin problems. Both groups indicated they were not very comfortable in managing the patient's care. CONCLUSIONS: The results raise concern about the adequacy of the training of primary care physicians to meet the needs of people with severe disabilities.     

Misdiagnosis and labeling in psychiatry and their consequences: Part II

The complexity of arriving at a correct psychiatric diagnosis in cases in which physical and mental disorders are interrelated is discussed. A case is presented in which a psychiatric diagnosis had been made and malingering suspected, although the patient actually had a severe neurological disorder. The psychiatric diagnosis had not been changed despite recurrent medical and psychological examinations which clearly indicated a physical disorder. The difficulties that follow misdiagnosing organic disorders as psychiatric disorders are illustrated. Various aspects of the effects of psychiatric misdiagnosis on functional, legal and civil aspects of life are discussed. Emphasis is given to the problems facing those discharged from military service for medical reasons, especially mental disorders. Important measures are currently being applied to overcome some of these problems. It is strongly emphasized that there is need for greater openness and tolerance among psychiatrists when making psychiatric diagnoses.     

Letter: Random thoughts on abortion attitudes

Comments on a paper of physicians' attitudes toward abortion are presented. The reasons for approval of abortion which show about 80% citing medical or psychiatric and only 60% citing social reasons or a woman's right to do with her body what she wants support the belief in the sexist attitudes of physicians. Disbelief is voiced toward the 1 physician who feels a woman cannot become pregnant from incest or rape, and towards the physician who believes a woman's mental health is unthreatened by an unwanted pregnancy. The author wonders if there were differences between male and female physicians sampled.     

Inhibition of TNFalpha attenuates infarct volume and ICAM-1 expression in ischemic mouse brain

The family physician occupies a front-line position in the detection and treatment of emotional problems and psychiatric illnesses. The practice pattern of the family physician necessitates an efficient, effective model of psychotherapy The BATHE technique is a brief psychotherapeutic method that addresses the patient's background issues, affect and most troubling problem. The emphasis of the interview then shifts to how the patient is handling the problem and a demonstration of empathy by the physician. Some of the challenges in psychotherapy are presented, and cases in which the BATHE technique was used are described.     

The medical context of hypochondriacal traits

OBJECTIVE: This study examines the effects of two medical contexts on the relationship of hypochondriacal traits and their potential correlates. METHOD: Correlates of hypochondriacal traits were compared from a matched sample of fifty-five general medical inpatients with a sample of fifty-five medical inpatients referred for psychiatric evaluation. Patients completed questionnaires assessing emotional distress and health attitudes, beliefs, and behaviors, and their attending physician completed ratings of the patient's illness and illness behavior. RESULTS: Patients referred for psychiatric consultation exhibited significantly higher levels of hypochondriacal illness presentation than the matched nonreferred sample. Moderated regression analyses revealed three trends regarding the interactive effects of group status on the relationship of hypochondriacal traits to their potential correlates: 1) presence of angry feelings and interpersonal friction was positively associated with hypochondriacal concerns for the psychiatric referred patients only, 2) the tendency to deny life stresses and attribute all problems to the effects of illness was positively associated with a misinterpretation of the severity of their illness and hypochondriacal illness presentation for the psychiatric referred patients, whereas this association was negative for the nonreferred medical patients, and 3) the association of reports of emotional distress symptoms with hypochondriacal illness preparation was negative for the psychiatric referred patients and positive for the nonreferred medical patients. CONCLUSIONS: Study results suggest that hypochondriasis may not represent a uniform nosological disorder and that the context of its study can significantly influence etiologic findings.     

Chronic fatigue syndrome in young persons

The prevalence of chronic fatigue syndrome (CFS) in teenagers is 10-20 per 100,000 inhabitants in the Netherlands. The natural course of the disorder is not favourable according to the literature. Proposed criteria for the diagnosis 'CFS' in adolescence are: absence of a physical explanation for the complaints, a disabling fatigue for at least six months and prolonged school absenteeism or severe motor and social disabilities. Exclusion criterion should be a psychiatric disorder. Factors that attribute to the persistence of fatigue are somatic attributions, illness enhancing cognitions and behaviour of parents as well as physical inactivity. The role of the physician and the role of parents can enhance the problems. The treatment should focus on decreasing the somatic attributions, on reinforcement by the parents of healthy adolescent behaviour, on the gradual increase of physical activity and on decreasing attention (including medical attention) for the somatic complaints.     

Global physician budgets as common-property resources: some implications for physicians and medical associations

Since 1990 payment for physician services in the fee-for-service sector has shifted from an open-ended system to fixed global budgets. This shift has created a new economic context for practising medicine in Canada. A global cap creates a conflict between physicians' individual economic self-interest and their collective interest in constraining total billings within the capped budget. These types of incentive problems occur in managing what are known in economics as "common-property resources." Analysts studying common-property resources have documented several management principles associated with successful, long-run use of such resources in the face of these conflicting incentives. These management principles include early defining the boundaries of the common-property resource, explicitly specifying rules for using the resource, developing collective decision-making arrangements and monitoring mechanisms, and creating low-cost conflict-resolution mechanisms. The authors argue that global physician budgets can usefully be viewed as common-property-resources. They describe some of the key management principles and note some implications for physicians and the provincial and territorial medical associations as they adapt to global budgets.     

Elderly patients with altered mental status

Mental status changes in the elderly are a source of concern and a challenge for the emergency physician. A variety of medical conditions and psychiatric disturbances are potential causes of those symptoms. Acute changes must be differentiated from mental status alterations occurring as a result of chronic conditions. This article focuses on the emergency evaluation, treatment, and differential diagnosis of this symptom complex.     

Psychiatric symptom management in terminal care

During the terminal phase of illness, many geriatric patients develop psychiatric complications that subsequently have profound effects on their quality of life. Effective treatment requires the skills of a physician who is experienced in the recognition, assessment, and management of psychiatric complications of terminal care. Specialized knowledge is required, because even the most common psychiatric symptoms (anxiety, depression, and cognitive disorder) may be difficult to diagnose and treat. Recognition and management are complicated by the fact that these symptoms can arise as a consequence of other symptoms, for example, as a direct result of the disease and its treatment, or as a reflection of underlying psychosocial issues. In many instances, the use of pharmacologic agents, either alone or in combination with psychotherapeutic interventions, provides reasonable control of psychiatric symptoms. Here, too, specialized knowledge is required in order to know which regimens are likely to yield the most benefits with the least risk of toxicity. Fortunately, a considerable body of knowledge has accumulated over the last few years regarding the management of psychiatric symptoms in terminal care. The challenge for the future is to make sure that this information is applied in the routine clinical care of the terminally ill geriatric patient.     

Reducing conduct problems among children exposed to intimate partner violence: A randomized clinical trial examining effects of Project Support.

This study was a randomized clinical trial of Project Support, an intervention designed to reduce conduct problems among children exposed to intimate partner violence. Participants were 66 families (mothers and children) with at least 1 child exhibiting clinical levels of conduct problems. Families were recruited from domestic violence shelters. The Project Support intervention involves (a) teaching mothers child management skills and (b) providing instrumental and emotional support to mothers. Families were randomly assigned to the Project Support intervention condition or to an existing services comparison condition. They were assessed on 6 occasions over 20 months, following their departure from the shelter. Children in families in the Project Support condition, compared with those in the comparison condition, exhibited greater reductions in conduct problems. Mothers in the Project Support condition, compared with those in the comparison condition, displayed greater reductions in inconsistent and harsh parenting behaviors and psychiatric symptoms. Changes in mothers’ parenting and psychiatric symptoms accounted for a sizable proportion of Project Support’s effects on child conduct problems at the end of treatment. Clinical and policy implications are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Creatine phosphokinase in thyroid disease (author''s transl)]

The mere presence of uterine fibroids is not, since qua non, an indication for their surgical removal. Knowing when not to operate is probably more important for the physician than knowing when to operate. It is easy to fall into diagnostic and therapeutic traps when uterine fibroids are known to be present, especially when they occur concomitantly with a condition such as irregular uterine bleeding, infertility, or pregnancy. The contributions of such conditions to problems in diagnosing and managing fibroids must be kept in mind by the prudent physician; a decision in favor of medical rather than surgical management is often best.     

Factors affecting hemopoietic recovery after high-dose therapy and autologous peripheral blood progenitor cell transplantation: a single center experience

Major depression is one of the most common psychiatric problems complicating the treatment and prognosis of patients with active medical illness. Recognizing and treating major depressive conditions in this population can often be challenging, even for the most seasoned clinicians. This article reviews the medical and neurologic conditions that have been associated with the high prevalence rates of major depression. Highlights of the evaluation process that help confirm this suspected diagnosis are addressed, and management issues are discussed. Brief reviews of supportive psychotherapeutic tools that the clinician may find helpful are included, as well as current advances in pharmacologic interventions.     

The future supply of physicians

Many health services researchers point to a growing surplus of physicians by the end of the century. The author discusses in detail a variety of policy positions, from the Flexner Report onward, that have affected the present and projected supplies of U.S. physicians. These include the American Medical Association's decades of efforts to control the numbers and types of U.S. medical students; effects of Medicare and Medicaid; changes in immigration and naturalization laws that increased the number of international medical graduates (IMGs); the medical community's non-response to the 1981 GMENAC Report's forecasts on physician oversupply; growth in the numbers of specialists; the fall and subsequent rise in the numbers of applicants to medical schools; the changing composition of the physician workforce; the refusal of the medical profession to consider a shorter training period for physicians; and other events from the past that can inform today's policymakers. The author then evaluates four policy recommendations that have evolved to deal with the problem of physician oversupply, and concludes that (1) reliance on the market to contain physician supply is unwarranted; (2) there is little prospect that Congress will soon reduce the inflow of IMGs, and even if it did, such action would have a marginal effect; (3) there is no prospect that 20-25% of U.S. medical schools will be closed by 2005, since the forces militating against such action are overwhelming; and (4) it remains to be seen whether the new health care environment will have more than a marginal effect in altering the current ratio of primary care to specialist physicians in the years ahead. In fact, if future outlays for health care increase as predicted, there should be sufficient funds for physician supply to continue to grow and for specialists to continue to make good incomes.     

Medical emergencies in commercial air travel

There are physiologic and logistic concerns involved in caring for patients with inflight emergencies. This article presents the physiologic changes that occur at altitude, the types of medical problems that can be encountered, and management strategies. An overview is also presented of the medical training of flight attendants and the medical equipment that is available on commercial aircraft.     

An analysis of the nature and justification of treatment decisions in inpatient settings.

83 mental health professionals employed at 2 inpatient settings participated in a study on the nature and justification of assessment and treatment decision making. Clinical psychologists, psychiatrists, a psychiatric nursing service staff group, social workers, nonpsychiatric physicians, physician assistants, mental health workers/psychiatric technicians who had at least a high school diploma, rehabilitation specialists, and psychiatric administrators completed a treatment decision questionnaire. It addressed several specific content areas relating to the types of assessment procedures, treatment goals, and treatment methods mental health professionals usually use, as well as the usual reason(s) for such procedures. Results showed that inpatient mental health professionals mostly relied on past success as well as logistical-practical factors in the determination and justification of assessment and treatment methods. Analyses of differences among inpatient institutions and mental health professionals are also presented. The conclusion was that, regardless of the specific assessment and treatment methods relied on, mental health professionals did use systematic decision procedures in choosing such methods. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An analysis of physician resistance to psychiatric consultations

Although it has been estimated that between 30% and 60% of hospital patients have an emotional problem related to and sometimes affecting the course of their hospitalization, psychiatric consultations for such patients are rarely requested. We conducted chart rounds with house and nursing staffs to identify those patients with prominent psychiatric problems relating to hospitalization. It was found that physician resistance to consultation was involved in more than 50% of cases not referred, usually because the physicians believed that there was no psychiatric problem or that psychiatry could not help, and less often because the physician thought that the patient might become upset or the patient-doctor relationship would be destroyed. The basis of the physicians' resistance was found not justified in 26 of 29 patients seen, and 23 of these patients were judged to have been helped by the psychiatrist.     

Management of the patient with renovascular hypertension

Renal artery stenosis, either fibromuscular or atheromatous, is probably the most common cause of secondary hypertension in man. Both of these diseases are active, ongoing processes that may be ameliorated but not cured by medical or surgical treatment. The clinical history and examination of the patient with hypertension may help differentiate renovascular hypertension from essential hypertension. The presence of a systolic-diastolic or continuous bruit is often an indicator of severe renal artery stenosis. Systemic hypertension is the physiologic consequence of significant renal artery stenosis. Knowledge of the basic concepts of the renin-angiotensin-aldosterone system, as has evolved from experimental models of renovascular hypertension, forms the basis for understanding the process of evaluation and treatment of such patients. The treatment of choice for the patient with severe hypertension and a functionally significant renovascular lesion is surgical--both in terms of successful treatment of hypertension and improved long-term prognosis. Diligent periodic reevaluation of these patients as well as those with less severe hypertension who are receiving medical treatment enables the physician to select the proper management that offers optimal control of patient blood pressure and avoids target-organ damage to the kidneys, central nervous system, or cardiovascular system.     

Review of Psychophysiologic medicine.

Reviews the book, Psychophysiologic medicine by Eugene Ziskind (see record 1954-08809-000). Here is a book written for the general medical practitioner that will interest psychologists more by its purpose than by its content. Its premise is that one-third of the patients seeking medical aid have symptoms solely or primarily due to psychogenic pathology and another third combine psychogenic with physiogenic pathology. The requirement for psychodiagnosis and psychotherapy in the treatment of general medical disorders is clear indeed. The book consists of four parts. The first one provides background and orientation to the problem. The second part is concerned with diagnostic and psychotherapeutic technique. The third part consists of a review of familial and other social factors in psychopathology, plus a general treatment of psychiatric syndromes and common psychiatric emergencies with which the physician may be confronted. The fourth part includes a useful review of contemporary schools of psychiatric thought. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Precisely defining high-risk operable head and neck tumors based on RTOG #85-03 and #88-24: targets for postoperative radiochemotherapy?

OBJECTIVE: In the German physician-based emergency medical system (EMS) psychiatric emergency situations (PES) rank on third place contradictory to it's importance during emergency physician training program. The aim of our study was to examine the relevance of PES and the stress which PES imposes upon EMS physicians. Further, the interest of training programs on that issue was determined. Knowledge about PES was investigated by a short test. METHODS: 952 emergency physicians were sent a questionnaire about following: demographic data, frequency of PES, strain by PES, own knowledge, interest about training programs. Further five typical PES were presented for diagnostic and therapeutic judgement. RESULTS: 222 responded (183 men/37 women/2 without gender data, average age: 40.1 +/- 6.7, qualification as emergency physician: 9.6 +/- 5.1 years, most frequent subspeciality in-hospital physicians: anaesthesiology 67.5%, in-practice physicians: general medicine 72.1%). PES frequence was estimated at 9.4%, personal knowledge judged only by 13% as sufficient, 14.2 felt incapable by PES. 73% saw importance of training, especially expressed by the more experienced (P < 0.05). Test presented 65% correct diagnoses, 33% correct therapy, 26% incorrect decision of hospital admission. CONCLUSION: PES are a frequent problem of pre-hospital patient care for emergency physicians. As personal knowledge was estimated to be insufficient, the interest for courses concerning PES issues is high.