Deodorising dressings for malodorous wounds

When patients don't understand how to care for their chronic illness, frequent hospitalization results. One example is the patient who is admitted to a medical nursing unit in end stage renal disease (ESRD), the common complications of which are hypervolemia, hypovolemia and associated electrolyte imbalances. To prevent further disease progression and frequent hospitalization, an accurate measurement of fluid intake and output is critical, as is the patient's ability to understand and take responsibility for his/her own care.     

Primary cerebral non-Hodgkin lymphoma in non-immunocompromised subjects

OBJECTIVES: To assess the percentage of adult patients presenting to an urban ED who have a written advance directive (AD) and to determine whether age, sex, a patient's perception of his or her health status, and having a regular physician are associated with the patient's having an AD. METHODS: This was a cross-sectional patient survey performed at a community teaching hospital ED. Surveys were completed by 511 adult ED patients during representative shifts over a 3-month period. The questions included age, sex, "self-reported" health status, whether the patient had a "regular" physician, a patient-generated list of medical problems, and whether the patient had a written AD. For this study, ADs included health care proxies, living wills, and do-not-attempt-resuscitation (DNAR) orders. RESULTS: Of the patients surveyed, 27% reported having an AD. Males and females were equally likely to have an AD. Factors associated with an increased likelihood of having an AD were older age, having a "regular" physician, and the patient's perception of his or her health status as ill. Most patients who had an AD (82%) discussed it with their families, but only 48% discussed it with their physicians. CONCLUSION: Only 27% of the adult patients presenting to the ED had an AD. Older age, the patient's perception of his or her health status as ill, and having a "regular" physician increased the likelihood of having an AD.     

Biomedical ethics and the biomedical engineer: a review

Biomedical engineering is responsible for many of the dramatic advances in modern medicine. This has resulted in improved medical care and better quality of life for patients. However, biomedical technology has also contributed to new ethical dilemmas and has challenged some of our moral values. Bioengineers often lack adequate training in facing these moral and ethical problems. These include conflicts of interest, allocation of scarce resources, research misconduct, animal experimentation, and clinical trials for new medical devices. This paper is a compilation of our previous published papers on these topics, and it summarizes many complex ethical issues that a bioengineer may face during his or her research career or professional practice. The need for ethics training in the education of a bioengineering student is emphasized. We also advocate the adoption of a code of ethics for bioengineers.     

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.     

The licensed physicians of Rhode Island in the year 1895

A brief demographic profile of the 466 physicians applying for licensure in Rhode Island in the year 1895, is presented here. The typical Rhode Island physician of a century ago was a New England-born 39-year-old white male general practitioner who had little undergraduate education, received his medical diploma from an allopathic medical school within 180 miles of his place of birth, typically a small town, had little or no supervised hospital training, professed to no specialty and established his office, often sharing space with his practitioner-father, within the same community in which he was born.     

Information and consent]

Informed consent is applied more and more in routine medical practice. It is the consequence of a long history during which patients' rights have been progressively better recognised. This process begins by the right to be informed about one's health or disease and about consecutive treatment. After this information is given the patient is free to give opinion, consent or refusal with regard to what the physician proposes to improve his/her health or to treat the disease, according to present medical knowledge. Medical science has a power which must not constrain excessively patients, who may refuse some medical intervention, particularly if they have received adequate information and if they have their faculties. The physician is responsible for affording consistent information and for respecting patient's right to self-determination.     

The primary care network--a new type of HMO for private practice physicians

A new type of health maintenance organization has been developed to encourage primary care physicians in private practice to become coordinators and financial managers for all medical care. Each patient chooses one internist, family or general physician, or pediatrician and must be referred by that physician for all hospital admissions and care by specialists. The primary care physician authorizes all payments from his own account for care provided to his patients. He shares any deficit or surplus remaining at the end of the year. Hospital admission rates and length of stay are lower than those of Blue Cross, with only one of three dollars paid to hospitals. The plan is providing care to 38,000 persons with 750 participating physicians in Northern California, Washington and Utah. This plan represents an attempt by physicians to control costs without government regulation.     

Withholding medical care as a physical injury--homicide from the viewpoint of the physician

Limitation and termination of intensive care and in particular life support in patients who do not have a chance to recover from their illness has become a widely accepted approach in intensive care medicine. In well defined situations, life support can be withheld or withdrawn without the risk of becoming a criminal case. Frequently, the physician must base his/her decision on the presumed will of the patient which can be difficult to assess. Existing guidelines of the Society of physicians of Germany, which are partly preliminary, are helpful for the decision process of the physicians as well as of the relatives of the patients.     

Treatment of child abuse

Standards of care have recently been established for the diagnosis and treatment of child abuse. This article addresses the key areas of treatment with which each primary care physician should be acquainted. As part of a community-based approach to this problem, the physician can positively impact the prognosis for the victimized child and his or her family.     

Psychiatric disorders and gynecological oncology: a review of the literature

The widespread use of complementary and alternative medicine techniques, often explored by patients without discussion with their primary care physician, is seen as a request from patients for care as well as cure. In this article, we discuss the reasons for the growth of and interest in complementary and alternative medicine in an era of rapidly advancing medical technology. There is, for instance, evidence of the efficacy of supportive techniques such as group psychotherapy in improving adjustment and increasing survival time of cancer patients. We describe current and developing complementary medicine programs as well as opportunities for integration of some complementary techniques into standard medical care.     

The teaching of clinical oncology in Italian medical schools. A survey among teachers and students

BACKGROUND: Oncologists, health care workers and health organizations consider well-performed teaching programs in clinical oncology a fundamental step in cancer control. The aim of our study was to assess the views of teachers and students on the present status of oncology teaching in Italian medical schools and on the most common shortcomings in cancer education. MATERIALS AND METHODS: A survey was carried out among teachers and students of 17 Italian medical schools using two different questionnaires. Six hundred forty-seven students of Northern, Central and Southern Italy in the final two years (5th and 6th) of their medical curriculum and 87 professors of pathology, surgery, internal medicine and medical oncology completed the questionnaires. RESULTS: Doctor/patient relationships and integration among disciplines were the most unsatisfactory aspects of oncology teaching, according to students. Biology, epidemiology, radiotherapy, and medical treatment were felt to be insufficiently treated, whilst diagnostic aspects, clinical management and surgery were rated sufficient. The median number of cancer patients to whom each student had access during his/her training was limited, averaging only 13 patients; however, a high degree of variability was noted. A larger number of patients was generally observed in smaller, less crowded medical schools, with notable exceptions. Although the majority of teachers had clinical practices related to their disciplines, only a small number of students underwent a period of clinical training. Traditional methods of teaching were preferred to innovative methods, while interaction among disciplines was uncommon. CONCLUSIONS: This survey emphasizes the dualism between students' expectations and teachers' ideas about cancer teaching. Doctor/patient relationships and poor attention to practical clinical problems seem the most critical issues for clinical oncology training in Italian medical schools.     

The physician and accidents. Legal and medical problems

German law requires that any physician at a place of accident is obliged to help according to his training and ability. As an emergency doctor on duty he works in a warrantee position. In cases with multiple accident victims triage may be necessary, corresponding to the priority of medical care. In criminal procedures against a physician due to omitted help, there is no probative charge against the accused. On the other hand, civil law sets up an objective standard: attention as required in communication. In giving initial medical assistance for unconscious patients or injured children, rules of "authorized management without commission" become valid. Basic first aid measures involve: securing, saving and rescue. Life-threatening situations such as severe bleeding, airway obstruction and cardiac arrest must be dealt with immediately. Following this, such measures as proper positioning, clearing of the respiratory tract, removal of dental prostheses, evaluation of multiple injuries, avoidance of hypothermia and initiating infusions are mandatory. The orientating examination of the accident victim is described, as is the "ABCD Rule" for treating respiratory insufficiency or circulatory arrest and shock, using heart massage and artificial respiration. Finally, medical first aid is described for special injuries, such as cerebral or thoracic trauma, fractures and burns. The psychological situation affecting the physician at the place of an accident is characterized.     

Do physicians discuss HIV and AIDS with patients? A survey of physician practices

HIV and AIDS continue to be major concerns to the health care community and the world around them. Preventive efforts and education have been the focus of the fight against AIDS thus far. By the year 2000, 75% of physicians are expected to conduct risk-reduction counseling for patients regularly. Previous studies show that a smaller percentage "routinely" follow this recommendation. The purpose of our study was to assess with what percentage of patients physicians discuss several HIV/ AIDS-related topics, what percentage of their patients are considered at risk for infection, and how comfortable the physicians are with their knowledge level and discussing the subject matter. We sent surveys to the last five graduating classes from St. Louis University School of Medicine and to 169 physician preceptors in the community. The survey asked about patients considered at risk, physician comfort level with HIV/ AIDS, the percentage of patients they discuss various HIV/AIDS topics with, and his or her preparedness for these discussions. Total responses were 464 (53.7%) representing all areas of medicine. Most of the physicians (72.9%) consider 0-25% of their patients at risk for HIV/AIDS. Eighty-one percent claim they are moderately or very comfortable discussing the material with patients and more than 90% feel they have at least adequate knowledge. Most of the respondents discuss the HIV/ AIDS topics with 0-25% of patients. Recent medical school graduates and primary care physicians are more comfortable with HIV/AIDS and discuss the surveyed topics with a higher percentage of patients.     

Nutrient Intake Report: a coordination of patient dietary assessment between physicians and registered dietitians

The Nutrient Intake Report (NIR) is based on a 7-day dietary recall questionnaire used previously in research for dietary assessment and adapted for clinical use. Used to provide information and counseling as part of total patient care, the NIR acts as a cornerstone for dietary education and interaction between physician, registered dietitian, and patient. The NIR is ordered by physicians or registered dietitians, scanned and assessed by a registered dietitian, and incorporated into the laboratory section of the medical record. It documents the patient's dietary intake in the context of his or her diagnosis and general health status. The NIR also opens a dialogue between physicians and registered dietitians. Incorporation of the NIR into the medical record makes the work of the registered dietitian available to other health practitioners, which is welcome in an era when licensing and reimbursement are contingent on systematic documentation of dietary assessment and its role in patient care.     

Factors associated with the use of flexible sigmoidoscopy as a screening test for the detection of colorectal carcinoma by primary care physicians

BACKGROUND: Despite current recommendations of flexible sigmoidoscopy as a screening test for the detection of colorectal carcinoma, relatively few asymptomatic patients undergo this procedure. To enhance the use of sigmoidoscopy, differences in the use of screening, as well as barriers to screening among specific physician groups, should be defined. METHODS: The authors surveyed 1762 practicing primary care physicians to determine their self-reported ability to perform sigmoidoscopy and perceived obstacles to either initiating or enhancing screening. RESULTS: A total of 884 physicians (50%) responded. Ninety percent of primary care physicians reported that they offered sigmoidoscopic screening to their patients, with 46% referring patients and 44% performing the procedure themselves. Physician characteristics were not associated with the overall use of sigmoidoscopy. In contrast, compared with physicians who referred patients for the procedure, physicians who performed sigmoidoscopy themselves were more often board certified, male, and graduated from medical school after 1970 (P < 0.001). In a multivariate analysis, these characteristics were also independently associated with the ability to perform sigmoidoscopy. The barrier to sigmoidoscopy cited most often was poor patient acceptance, whether or not the physician performed or referred patients for sigmoidoscopic screening. Other barriers cited were lack of training, lack of equipment, and time required, each of which was identified most often by physicians who did not screen at all. CONCLUSIONS: Most physicians surveyed reported using sigmoidoscopic screening to some degree in their practice, although many did not perform the procedure themselves. Population-based interventions to increase screening may benefit from targeting specific physician subgroups and attempting to improve patient acceptance of the procedure.     

Establishing a high-school-based training room clinic

Being a team physician can be a time-consuming commitment. The team physician is responsible for all aspects of the athlete's care and has the final say in all medical matters related to athletic participation. Primary care physicians are well suited to be team physicians. The training room is an outstanding way to increase physician availability to adolescents and underserved population. Setting up a training room must be planned in advance, including funding, supplies and liability. Most legal problems can be avoided with a contract and proper documentation. The school-based training room provides the physician with an excellent opportunity for community service and can be a very rewarding experience.     

Relationship of provider characteristics to outcomes, process, and costs of care for community-acquired pneumonia

OBJECTIVES: The authors describe the relation of provider characteristics to processes, costs, and outcomes of medical care for elderly patients hospitalized for community-acquired pneumonia. METHODS: Using Medicare claims data, Medicare beneficiaries discharged from Pennsylvania hospitals during 1990 with community-acquired pneumonia were identified. Claims data were used to ascertain mortality, readmissions, use of procedures and physician consultations, and the costs of care. The relationship of these measures to provider characteristics was analyzed using regression techniques to adjust for patient characteristics, including comorbidity and microbial etiology. RESULTS: Among 22,294 pneumonia episodes studied, 30-day mortality was 17.0%. After adjusting for patient characteristics, 30-day mortality and readmission rates were unrelated to hospital teaching status or urban location or to physician specialty. Use of procedures and physician consultations was more common and costs were 11% higher among patients discharged from teaching hospitals compared with nonteaching hospitals. Similarly, costs were 15% higher at urban hospitals compared with rural hospitals. General internists and medical subspecialists used more procedures and had higher costs than family practitioners. CONCLUSIONS: Processes and costs of care for community-acquired pneumonia varied by provider characteristics, but neither mortality nor readmission rates did. These differences cannot be explained by clinical variables in the database. Further studies should determine whether less costly patterns of care for pneumonia, and perhaps other conditions, could replace more costly ones without compromising patient outcomes.     

The physician executive and laboratory tests

Sera Central Hospital was founded in 1953 as Sera District Medical Center under the auspices of the neighboring five towns. At that time, the hospital had 3 doctors, 10 nurses, and 20 beds. But now in 1992, we have 12 doctors, 53 nurses and 110 beds. The present medical specialists are physician (4), surgeon (2), orthopedist (3), pediatrician (1), clinical laboratory physician (1), and dentist (1). Although the yearly income and expenditures were well balanced until 1989, thereafter the income began to decrease insidiously and expenditures began to increase year by year. In this symposium titled "Suggestions for Clinical Laboratory Medicine by Experienced Hospital Directors," I must refer to the issue of "Clinical Laboratory Medicine Administrator's Standpoint". Recently, the unaccustomed phrase "Physician Executive" is occasionally heard as the details of medical care become more numerous and more intricate and economic efficiency is strictly persued. From this perspective, the clinical laboratory physician is responsible for managing the laboratory department with well disciplined knowledge and technique. Therefore, training as "Physician Executive" has developed naturally within the field of Clinical Laboratory Medicine. So, I cannot help coming to the conclusion that the management of a hospital, as a matter of course, will be entrusted to a doctor including clinical laboratory physician who can do his best for the citizens, for the patients, and ultimately for ourselves.     

Osteogenesis of the fetal bovine skull

BACKGROUND: We wanted to validate reports that deaf persons have difficulty obtaining medical care by comparing physicians' attitudes towards these patients with physicians' attitudes toward their patients in general. METHODS: Two questionnaires were randomly distributed to physicians attending continuing medical education conferences at the University of Michigan during a 3-month period. The questionnaires were identical except that one asked about deaf patients and the other about patients in general. The questions assessed the respondent's perceptions of communication with patients, attitudes toward their patients, knowledge of current information about deaf people, and demographics. RESULTS: One hundred sixty-five physicians responded, 94 to the general questionnaire and 71 to the deaf questionnaire. The two physician groups were similar demographically, but 165 differed significantly in communication and attitude variables. Physicians receiving the questionnaire focusing on deaf patients reported greater difficulties in understanding (P < 0.001) and maintaining free-flowing conversations (P < 0.001), and that these patients had more difficulty understanding them (P < 0.001), trusted them less (P < 0.001), asked them to repeat statements more often (P < 0.001) and were less likely to understand the diagnosis and recommended treatments (P < 0.001). Physicians also reported feeling less comfortable with deaf patients (P < 0.001) and that they asked fewer questions (P < 0.001). Physicians were more likely to say that deaf patients rely on interpreters (P = 0.040), get frustrated easily (P < 0.001), and are harder to communicate with (P < 0.001). There were no significant differences between the two groups in knowledge about deaf people. All physicians, however, displayed ignorance about their legal obligations under the Americans with Disabilities Act to provide interpreters for their deaf patients. CONCLUSIONS: Physicians surveyed about deaf patients reported significantly greater difficulties communicating with and different attitudes toward these patients than physicians surveyed about their patients in general. All physicians were unaware of their obligations under the Americans with Disabilities Act to provide interpreters for deaf patients. Research is needed to determine whether physician attitudes and beliefs affect the actual quality of care they deliver to deaf patients.     

The Medical Polyclinic: an approach to conflicting needs in a teaching hospital

University teaching hospitals have become increasingly aware of their responsibility to improve both the teaching of ambulatory care and the quality of care provided in their clinics. This paper describes how one department of medicine met this challenge by forming a "Medical Polyclinic." The majority of the department's faculty and house staff, at all academic and training levels, participate in a system of ambulatory care with the following objectives: each patient has a single physician whom he sees by appointment and who coordinates his care; all medical subspecialties are available in the same clinic session; the clinic is attractive and efficient. While these goals are not infrequently met in private group practices, they are unusual in a university teaching hospital, where faculty, house staff, students, and patients each have unique needs, not always compatible. The success and problems of the polyclinic approach are discussed.