Characteristics of patient visits to nurse practitioners and physician assistants in hospital outpatient departments

Amprolium was successfully used to induce cerebrocortical necrosis (CCN) in dromedary racing camels, only when they were fed on a barley diet. Camels which were fed on hay ad libitum did not suffer form CCN, although their thiamine pyrophosphate (TPP) reached similar levels as in camels fed on barley. The reason for this phenomenon is discussed. Five camels which suffered from CCN had TPP values of 80-115% and were euthanized on humane grounds when they were in lateral recumbency. Pathohistological investigations revealed a polioencephalomalacia of the dorsal cerebral cortex with oedema and status spongiosus. Cerebral autofluorescence was observed under ultraviolet light. The major clinicopathological changes were a slight anemia and a decreased potassium value whereas glucose, muscle enzymes, leucocyte counts and differential counts were elevated. A TPP effect of 12% was found during this study in healthy dromedary racing camels and symptoms were observed when TPP values reached 80-115%. The test is now being widely used during the camel racing season.     

Enhancing the relationship between physician and patient

We have studied the effects of zinc on the 51Cr survival of red blood cells (RBC) from patients with homozygous sickle cell anemia (SCA) using an animal model in which the RBC were transfused into specially prepared rats. The slope (lambdas) of a standard 51Cr RBC survival curve was used as a measure of the rate of RBC sequestration. The effects of intravenous zinc were of considerable therapeutic interest from the standpoint of setting guidelines for effective blood levels of zinc in patients. SCA RBC were transfused into rats whose plasma zinc levels had been raised 3-6 times above normal (300-600 mug/100 ml) by prior iv injection of zinc acetate; in three experiments the mean lambdas in zinc-treated animals breathing 15-16% oxygen was significantly lower (meaning lessened sequestration and greater survival) than saline-treated controls. A possible explanation for the requirement to lower ambient oxygen tension in order to see this zinc effect is discussed. We have further observed an increased mean lambdas for RBC from 10 SCA patients compared to 4 normal controls (0.134 vs 0.030; t = 2.8, p less than 0.01). The lambdas values are quite patient specific (4 patients studied; F = 18.2, P = 0.002). In vitro pretransfusion treatment of SCA RBC with 1.5 mM zinc resulted in a significant increase in hemoglobin oxygen affinity and a marked reduction in lambdas (0.073 vs 0.120; t = 4.5, p less than 0.01). The mean lambdas was not affected by in vitro 0.3 mM zinc treatment; this level did not change hemoglobin oxygen affinity. We conclude that systemic zinc therapy in the animal model described, at plasma levels only slightly higher than those presently obtained in patients, prolongs SCA RBC survival. This animal model is a sensitive measure of the sicklability of SCA RBC and is useful in the testing of in vitro and in vivo antisickling agents.     

Nursing staff between physician and patient

Departing from a report on today's understanding about nursing, the demanding duties nurses see themselves confronted with are featured in connection with the theme of this meeting. In a second part, difficulties in daily practise are treated. Furthermore, problematic aspects of collaboration within the nursing staff as well as between the disciplines burdening patients are covered. Possible improvements are proposed.     

Factors determining the quality of physician performance in patient care

The study determined the separate and joint effects of 1) physician specialty, 2) type of medical school attended, 3) time in practice, 4) type of ambulatory care setting, and 5) type of hospital on the quality of physician performance in patient care. The sample consisted of 454 physicians in 18 specialty categories. Multiple Classification Analysis was used to determine the effects of these predictors on the quality of physician performance. The study found that the organization of hospital care had a large independent effect, but that the other four predictors had relatively small effects on the quality of physician performance. The findings imply that the organization of the setting in which care is provided has more influence than the education and training that physicians had attained. All five predictors together explained 20 per cent of the variance. Methodological suggestions were made to improve the explanatory power of the variables, and various pragmatic for medical care administrators were presented.     

Nurses and physicians evaluate their intensive care experiences

PURPOSE: To evaluate quantitative analysis of dynamic breast MRI studies using a dedicated PC based diagnosis system (DS) providing parametric images and automatic ROI definition as compared to the standard subtraction image, manual-ROI based procedure. METHODS: We compared the diagnostic usefulness of parametric versus subtraction images in terms of visualisation of enhancement inhomogeneities and enhancement velocities. Quantitative analysis of enhancing lesions of 15 breast MRI studies was performed using both the DS and the system's console software (SC). We assessed the time needed for complete quantitative analysis and number of lesions evaluated. This was followed by assessment of within-reader and between-reader variability or within-case reproducibility of results of quantitative analysis. RESULTS: Parametric images are superior to subtraction images in visualizing enhancement inhomogeneities or ring enhancement in breast cancers. Mean time needed for analysis at DS and SC was 4 (3-5) min. and 23 (8-39) min., respectively. During this time period, significantly more lesions were evaluated per case using the DS as compared to the SC (2-14 vs. 1-6). Mean within-reader variability of enhancement velocities of the same lesions was 0% and 25% (DS and SC); between-reader variability of enhancement values obtained in the same lesions was 11% (DS) versus 41% (SC). CONCLUSION: The DS significantly cuts down the time needed for quantitative analysis. It significantly improves reproducibility of quantitative enhancement values due to standardization of ROI analysis.     

Evaluation of changes in primary health care availability and provision from the patient perspective

This study was designed to investigate changes in primary care following recent NHS reforms. The study was carried out by home interview of random samples of people aged 65 years and over in three district health authorities; 1500 in 1990 and 1500 in 1992, before and after the introduction of the reforms. The response rate was 94% (1413 in 1990 and 1405 in 1992). Few patients (6%) changed their general practitioner (GP) in 1990 or 1992. There was an increase in the provision of written practice information in 1992, but more than 60% of patients could not recall receiving leaflets. More practices included practice nurses and appointments systems and fewer used rotas of local practices or deputizing services for 'out of hours' calls. In 1992 more patients aged 75 years and over saw their GP within the previous year and significantly more were assessed for vision, hearing, continence, foot problems and blood pressure and had their urine tested, but most of these health assessments, except blood pressure (64%), were recalled by few patients. There have been small changes in the provision and use of primary health care by older people since the introduction of the new GP contract.     

The productivity of physician assistants and nurse practitioners and health work force policy in the era of managed health care

Managed care is spreading rapidly in the United States and creating incentives for physician practices to find the most efficient combination of health professionals to deliver care to an enrolled population. Given these trends, it is appropriate to reexamine the roles of physician assistants (PAs) and nurse practitioners (NPs) in the health care workforce. This paper briefly reviews the literature on PA and NP productivity, managed care plans' use of PAs and NPs, and the potential impact of PAs and NPs on the size and composition of the future physician workforce. In general, the literature supports the idea that PAs and NPs could have a major impact on the future health care workforce. Studies show significant opportunities for increased physician substitution and even conservative assumptions about physician task delegation imply a large increase in the number of PAs and NPs that can be effectively deployed. However, the current literature has certain limitations that make it difficult to quantify the future impact of PAs and NPs. Among these limitations is the fact that virtually all formal productivity studies were conducted in fee-for-service settings during the 1970s, rather than managed care settings. In addition, the vast majority of PA and NP productivity studies have viewed PAs and NPs as physician substitutes rather than as members of interdisciplinary health care teams, which may become the dominant health care delivery model over the next 10-20 years.     

Preferences of physicians and their patients for end-of-life care

OBJECTIVE: Both physicians and patients view advance directives as important, yet discussions occur infrequently. We assessed differences and correlations between physicians' and their patients' desires for end-of-life care for themselves. MEASUREMENTS AND MAIN RESULTS: Study physicians (n = 78) were residents and faculty practicing in an inner-city, academic primary care general internal medicine practice. Patients (n = 831) received primary care from these physicians and were either at least 75 or between 50 and 74 years of age, with selected morbid conditions. Physicians and patients completed identical questionnaires that included an assessment of their preferences for six specific treatments if they were terminally ill. There were significant differences between physicians' and patients' preferences for all six treatments (p < .0001), with physicians wanting less treatment than their patients for five of them. Patients desiring more care (p < .01) were more often male (odds ratio [OR] 1.7). African-American (OR 1.6), and older (OR 1.02 per year). There were no such correlates with physicians' preferences. A treatment preference score was calculated from respondents' desires to receive or refuse the six treatments. Physicians' scores were highly correlated with those of their enrolled primary care patients (r = .51, p < .0001). CONCLUSIONS: Although patients and physicians as groups differ substantially in their preferences for end-of-life care, there was significant correlation between individual academic physicians' preferences and those of their primary care patients. Reasons for this correlation are unknown.     

The relation between physician and patient age in family practice

A study of 100 selected Wisconsin family physicians demonstrated that younger physicians generally had more contact with younger patients, middle-aged physicians had an even distribution of patient age contacts, and older physicians had more contact with older patients. The increase in older patients became pronounced for 56 to 60-year-old physicians. Generally a ten-year increase in physician age was accompanied by a five-year increase in patient age. The rising average age of the American population, combined with the direct physician-patient age relationship demonstrated here suggest that geriatrics will become increasingly relevant not only in the continuum of medical education but also for the individual practicing physician.     

Interpreting educational concepts for the teaching family physician: some parallels between patient care and undergraduate clinical education

Three of the most widely used concepts in education, objectives, curriculum, and evaluation, have direct parallels in primary care. This parallelism suggests an approach which may help family physicians both in understanding these educational concepts and in applying them with judgment. By drawing specific attention to the parallels and by the use of examples drawn both from clinical practice and from teaching, the author hopes to encourage physicians to view their teaching as an analog of clinical skills that are already familiar to them. This approach is applied to the problem of accommodating to individual differences in students, the most difficult obstacle to the proper application of educational concepts.     

The impact of surgical physician assistants on the delivery of modern healthcare

In 15-day-old control and vehicle-treated rats, the evening rise of the pineal N-acetyltransferase occurred at the same time as in their mothers, whereas in 5-day-old pups, the rise occurred by 2-3 hr earlier. Four-day administration of melatonin in the late day phase advanced the N-acetyltransferase rise in 15-day-old rats as compared with the rise in the vehicle-treated animals; a slight melatonin induced phase advance in 5- and 27-day-old rats was not significant. The data indicate that the newborn rat's circadian pacemaker controlling the rhythmic N-acetyltransferase rise may be entrained by exogenous melatonin. It appears, however, that the maternal melatonin transferred via milk cannot entrain the pup's pacemaker by phase advancing it, since the N-acetyltransferase rise in the pups begins earlier or at the same time as maternal melatonin production driven by the N-acetyltransferase rhythm.     

Nurse practitioners, certified nurse midwives, and physician assistants in California

A monoclonal antibody (MAb) targeting human hepatocellular carcinoma (HCC) has been produced by immunizing BALC/c mice with HCC SMMC-7721 cells. Solid phase enzyme-linked immunoabsorbent assay (ELISA) analysis showed that this mAb (mAb 95) was reactive with human HCC cell lines and tumor biopsies, but not tumors of other origin or normal tissues tested. Immuno-gold labeling and flow cytometry indicated that mAb 95 bound specifically to HCC cell membrane protein. Western blot analysis showed mAb 95 reacts only with HCC cell lysates, but not with 10 different human normal tissue lysates. The approximate molecular size of the reactive proteins were 40,000 and 60,000 daltons. The specificity of mAb 95 indicates it may be a potential candidate for a targeting agent in HCC immunotherapy or immunodetection.     

Deliberation between physician and patient concerning active euthanasia at the patient's home

Three patients, one man aged 68 and two aged 67, with terminal incurable cancer, requested euthanasia. It was performed in two, the third patient eventually died without having repeated his request. There are three phases in euthanasia: orientation (the patient asks the physician whether he would be willing to assist should the need arise), organisation (the physician ensures that the necessary prerequisites are fulfilled, i.e. the patient's request must be voluntary, mature and longlasting, his suffering must be longlasting, unbearable and incurable, and another physician must have been consulted and must have prepared a written report), and the phase entered after the definitive decision to perform euthanasia has been taken. The physician should not be reluctant to bring up the subject at an early stage, as it may set the patient's mind at rest to have expressed a wish concerning suffering and the end of life.     

Understanding the provision of postretirement health care and pension benefits: which firm characteristics are most explanatory?

This article investigates the impact of firm work force characteristics, human resource practices, and external environmental attributes upon the likelihood that a company provides postretirement income and health care benefits. Using data from a national stratified random sample of 953 companies with 20 or more employees, logistic regression models were estimated to explore the impact of these three sets of variables on benefit provision. Results indicate that work force characteristics and human resources practices contribute considerably to the likelihood that these benefits are provided and that the impact of some of the more global characteristics, such as industry, diminishes in a fuller predictive model.     

Psychiatry and the primary care physician

Psychiatry makes an important contribution to the training and practice of primary care physicians by emphasizing a holistic approach to patient care, by teaching psychiatric skills and by providing knowledge that enables primary care physicians to give basic psychological care to the large numbers of their patients who need it. Consultation-liaison psychiatry and psychiatry education programs for medical students, both of which are given high priority for support by the Psychiatry Education Branch of National Institute of Mental Health (NIMH), are model settings in which to teach the psychiatric aspects of primary care.     

Physician recommendations and patient autonomy: finding a balance between physician power and patient choice

Medical care in the United States has rapidly moved away from a paternalistic approach to patients and toward an emphasis on patient autonomy. At one extreme end of this spectrum is the "independent choice" model of decision making, in which physicians objectively present patients with options and odds but withhold their own experience and recommendations to avoid overly influencing patients. This model confuses the concepts of independence and autonomy and assumes that the physician's exercise of power and influence inevitably diminishes the patient's ability to choose freely. It sacrifices competence for control, and it discourages active persuasion when differences of opinion exist between physician and patient. This paper proposes an "enhanced autonomy" model, which encourages patients and physicians to actively exchange ideas, explicitly negotiate differences, and share power and influence to serve the patient's best interests. Recommendations are offered that promote an intense collaboration between patient and physician so that patients can autonomously make choices that are informed by both the medical facts and the physician's experience.     

The relationship between patient income and physician discussion of health risk behaviors

CONTEXT: The US Preventive Services Task Force recommends that physicians assess patients' health risk behaviors, addressing those needing modification. OBJECTIVE: To examine the relationship between patient income, health risk behaviors, the prevalence of physician discussion of these behaviors, and the receptiveness of patients to their physicians' advice. DESIGN: Employee survey. PARTICIPANTS: A random sample of 6549 Massachusetts state employees in 12 health plans. MAIN OUTCOME MEASURES: Data were obtained using a patient-completed mail survey. Trend tests were used to discern differences in the prevalence of health risk behaviors, physician discussion of these behaviors, and patient receptiveness to discussions by patient income. RESULTS: Although unhealthy behaviors were common among all income groups, physician discussion of health risk behaviors fell far short of the universal risk assessment recommended by the US Preventive Services Task Force. Low-income patients were more likely to be obese and smoke than high-income patients and were less likely to wear seat belts and exercise. In contrast, stress and alcohol consumption increased with income, while the proportion of heavy drinkers did not vary significantly. Physicians were more likely to discuss diet and exercise with high-income patients in need of these discussions than with low-income patients, but were more likely to discuss smoking with low-income patients who smoked than with high-income patients who smoked. Among patients with whom discussions occurred, low-income patients were much more likely to report attempting to change their behavior based on physician advice. CONCLUSIONS: Physician counseling of patients regarding health risk behaviors should be greatly improved if the US Preventive Services Task Force recommendations are to be fulfilled. Improvement is especially needed in regard to alcohol consumption, safe sex, and seat belt use. Physicians also need to be more vigilant in properly identifying and counseling low-income patients at risk in regard to diet and exercise and high-income patients who smoke.