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1.
Saitz R Friedmann PD Sullivan LM Winter MR Lloyd-Travaglini C Moskowitz MA Samet JH 《Journal of general internal medicine》2002,17(5):373-376
This survey aimed to describe and compare resident and faculty physician satisfaction, attitudes, and practices regarding
patients with addictions. Of 144 primary care physicians, 40% used formal screening tools; 24% asked patients’ family history.
Physicians were less likely (P<.05) to experience at least a moderate amount of professional satisfaction caring for patients with alcohol (32% of residents,
49% of faculty) or drug (residents 30%, faculty 31%) problems than when managing hypertension (residents 76%, faculty 79%).
Interpersonal experience with addictions was common (85% of faculty, 72% of residents) but not associated with attitudes,
practices, or satisfaction. Positive attitudes toward addiction treatment (adjusted odds ratio [AOR], 4.60; 95% confidence
interval [95% CI], 1.59 to 13.29), confidence in assessment and intervention (AOR, 2.49; 95% CI, 1.09 to 5.69), and perceived
responsibility for addressing substance problems (AOR, 5.59; CI, 2.07 to 15.12) were associated with greater satisfaction.
Professional satisfaction caring for patients with substance problems is lower than that for other illnesses. Addressing physician
satisfaction may improve care for patients with addictions.
This work was presented in part at the annual meeting of the Robert Wood Johnson Foundation Generalist Physician Faculty Scholars
Program, Tucson, Ariz, December 4, 1998, the annual meeting of the Society of General Internal Medicine, San Francisco, Calif,
April 29, 1999, and at the annual meeting of the Association of Medical Education and Research on Substance Abuse, Alexandria,
Va, November 5, 1999.
Deceased.
Dr. Saitz received support from the Robert Wood Johnson Foundation as a Generalist Physician Faculty Scholar (Grant No. 031489)
for this work. He and Dr. Samet were also supported in this work by the Center for Substance Abuse Prevention (Faculty Development
Grant T26-SP08355). Drs. Samet, Saitz, and Sullivan, and Mr. Winter and Ms. Lloyd-travaglini receive support from the National
Institute on Alcohol Abuse and Alcoholism (R01-AA10870). Dr. Friedmann was supported by a Mentored Clinical Scientist Career
Development Award (K08-DA 00320). 相似文献
2.
Dr. J. Randall Curtis MD MPH Douglas S. Paauw MD Marjorie D. Wenrich MPH Jan D. Carline PhD Dr. Paul G. Ramsey MD 《Journal of general internal medicine》1995,10(7):395-399
This study assesses the ability of primary care physicians to diagnose and managePneumocystis carinii pneumonia (PCP) in a standardized patient (SP) with unidentified HIV infection. One hundred thirty-four primary care physicians
from five Northwest states saw an SP with unidentified HIV infection who presented with symptoms, chest radiograph, and arterial
blood gas results classic for PCP. Seventy-seven percent of the physicians included PCP in their differential diagnoses and
71% identified the SP’s HIV risk. However, only a minority of the physicians indicated that they would initiate an appropriate
diagnostic evaluation or appropriate therapy: 47% ordered a diagnostic test for PCP, 31% initiated an antibiotic appropriate
for PCP, and 12% initiated an adequate dose of trimethoprim— sulfamethoxazole. Only 6% of the physicians initiated adjunctive
prednisone therapy, even though prednisone was indicated because of the blood gas result. These findings suggest significant
delay in diagnosis and treatment had these physicians been treating an actual patient with PCP.
Presented at the International Conference on AIDS, Berlin, Germany, June 6 –11, 1993.
Supported by grant number HS 06454-03 from the Agency for Health Care Policy and Research. Dr. Curtis is funded by the Robert
Wood Johnson Clinical Scholars Program.
The views expressed herein are those of the authors and are not necessarily the views of the Agency for Health Care Policy
and Research or the Robert Wood Johnson Foundation. 相似文献
3.
Halpern J 《Journal of general internal medicine》2007,22(5):696-700
Physicians associate empathy with benevolent emotions and with developing a shared understanding with patients. While there
have been many articles on managing “difficult” patients, little attention has been paid to the challenges physicians face
during conflicts with patients, especially when both parties are angry and yet empathy is still needed. This topic is especially
important in light of recent studies showing that practicing medicine increasingly requires physicians to manage their own
feelings of anger and frustration. This article seeks to describe how physicians can learn to empathize with patients even
when they are both subject to emotions that lead to interpersonal distancing. Empathy is defined as engaged curiosity about
another’s particular emotional perspective. Five specific ways for physicians to foster empathy during conflict are described:
recognizing one’s own emotions, attending to negative emotions over time, attuning to patients’ verbal and nonverbal emotional
messages, and becoming receptive to negative feedback. Importantly, physicians who learn to empathize with patients during
emotionally charged interactions can reduce anger and frustration and also increase their therapeutic impact.
This work was supported by the Greenwall Foundation and the Berkeley Consortium on Population Health and Human Development,
with funding from the National Institute of Mental Health (R21MH70950) and the Robert Wood Johnson Foundation Health & Society
Scholars Program. 相似文献
4.
Bruce M. Psaty MD PhD Thomas D. Koepsell MD MPH James P. LoGerfo MD MPH Edward H. Wagner MD MPH Thomas S. Inui MD ScM 《Journal of general internal medicine》1987,2(6):381-387
The authors conducted a population-based case-control study to determine the risk of myocardial infarction in patients who
reported angina-like symptoms. The cases studied were those of patients who had high blood pressure and had sought treatment
in 1984 with myocardial infarction as the first manifestation of coronary artery disease. Controls, a random sample of patients
who had hypertension, were frequency-matched to cases by age and gender. Blind to case-control status, the authors reviewed
the medical records of the 32 cases and 64 controls for reports of angina-like symptoms. While controls reported such symptoms
at a constant rate, the events for the cases clustered near their infarctions. When a patient with hypertension sought medical
advice for angina-like symptoms, the risk of infarction within 30 days was 14.2 (95% confidence interval, 2.8 to 71), and
after 30 days it fell to 1.03. Among patients who have high blood pressure but no history of angina, presentations with prodromal
symptoms in the primary care setting are so common that only about one in 100 such visits actually heralds myocardial infarction.
Presented at the National Meeting of the Robert Wood Johnson Clinical Scholars Program, Scottsdale, AZ (October 1986) and
the National Meeting of the American Federation for Clinical Research, San Diego, CA (May 1987).
Supported in part by a grant from the Robert Wood Johnson Foundation, Princeton, NJ, and by the Health Services Research and
Development Program, Veterans Administration Medical Center, Seattle, WA. The opinions, conclusions, and proposals in the
text are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation or the VA Medical
Center. 相似文献
5.
Saha S Christakis DA Saint S Whooley MA Simon SR 《Journal of general internal medicine》1999,14(12):745-749
Summary Generalist physicians pursuing fellowship training should develop an early strategic plan to guide them through their fellowship
years. Though each fellow’s plan must be individualized, fellows should get started on independent projects early, decide
how much time to allocate to various activities, strike an individualized balance between course work and independent projects,
and learn how to choose and maintain relationships with mentors. Early decision making with regard to these aspects of fellowship
will allow trainees to maximize their learning, development, and progress toward career goals.
Presented in part as a precourse at the National Meeting of the Society of General Internal Medicine, San Francisco, Calif,
April 1999.
Dr. Whooley is supported by a Research Career Development Award from the Department of Veterans Affairs, Health Services Research
and Development Service. Dr. Saha was a fellow in the Robert Wood Johnson Clinical Scholars Program, University of Washington,
and Health Services Research and Development, VA Puget Sound Health Care System. Drs. Christakis and Saint were fellows in
the Robert Wood Johnson Clinical Scholars Program, University of Washington, Dr. Whooley was a fellow in the Clinical Epidemiology
Fellowship, San Francisco VA Medical Center and University of California, San Francisco, Dr. Simon was a fellow in the Harvard
General Internal Medicine Fellowship and Faculty Development Program, and the Thomas O. Pyle Fellowship in Ambulatory Care
and Prevention, Harvard Medical School and Harvard Pilgrim Health Care. 相似文献
6.
Merrill JO 《Journal of general internal medicine》2002,17(5):361-368
Medical treatment of heroin addiction with methadone and other pharmacotherapies has important benefits for individuals and
society. However, regulatory policies have separated this treatment from the medical care system, limiting access to care
and contributing to the social stigma of even effective addiction pharmacotherapy. Increasing problems caused by heroin addiction
have added urgency to the search for policies and programs that improve the access to and quality of opiate addiction treatment.
Recent initiatives aiming to reintegrate methadone maintenance and other addiction pharmacotherapies into medical practice
may promote both expanded treatment capacity and increased physician expertise in addiction medicine. These initiatives include
changes in federal oversight of the opiate addiction treatment system, the approval of physician office-based methadone maintenance
programs for stabilized patients, and federal legislation that could enable physicians to treat opiate addiction with new
medications in regular medical practice.
This work was assisted by a grant from the Robert Wood Johnson Foundation Substance Abuse Policy Research Program. 相似文献
7.
Managed care, time pressure, and physician job satisfaction: Results from the physician worklife study 总被引:3,自引:0,他引:3
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Linzer M Konrad TR Douglas J McMurray JE Pathman DE Williams ES Schwartz MD Gerrity M Scheckler W Bigby JA Rhodes E 《Journal of general internal medicine》2000,15(7):441-450
OBJECTIVE: To assess the association between HMO practice, time pressure, and physician job satisfaction.
DESIGN: National random stratified sample of 5,704 primary care and specialty physicians in the United States. Surveys contained
150 items reflecting 10 facets (components) of satisfaction in addition to global satisfaction with current job, one’s career
and one’s specialty. Linear regression-modeled satisfaction (on 1–5 scale) as a function of specialty, practice setting (solo,
small group, large group, academic, or HMO), gender, ethnicity, full-time versus part-time status, and time pressure during
office visits. “HMO physicians” (9% of total) were those in group or staff model HMOs with >50% of patients capitated or in
managed care.
RESULTS: Of the 2,326 respondents, 735 (32%) were female, 607 (26%) were minority (adjusted response rate 52%). HMO physicians reported
significantly higher satisfaction with autonomy and administrative issues when compared with other practice types (moderate
to large effect sizes). However, physicians in many other practice settings averaged higher satisfaction than HMO physicians
with resources and relationships with staff and community (small to moderate effect sizes). Small and large group practice
and academic physicians had higher global job satisfaction scores than HMO physicians (P<.05), and private practice physicians had quarter to half the odds of HMO physicians of intending to leave their current
practice within 2 years (P<.05). Time pressure detracted from satisfaction in 7 of 10 satisfaction facets (P<.05) and from job, career, and specialty satisfaction (P<.01). Time allotted for new patients in HMOs (31 min) was less than that allotted in solo (39 min) and academic practices
(44 min), while 83% of family physicians in HMOs felt they needed more time than allotted for new patients versus 54% of family
physicians in small group practices (P<.05 after Bonferroni’s correction).
CONCLUSIONS: HMO physicians are generally less satisfied with their jobs and more likely to intend to leave their practices than physicians
in many other practice settings. Our data suggest that HMO physicians’ satisfaction with staff, community, resources, and
the duration of new patients visits should be assessed and optimized. Whether providing more time for patient encounters would
improve job satisfaction in HMOs or other practice settings remains to be determined.
Presented in part at the 21st Annual Meeting of the Society of General Internal Medicine, Chicago Ill, April 1998.
Other members of the CSSG include John Frey, MD, Department of Family Medicine, University of Wisconsin, Madison, Wis; Kathleen
Nelson, MD, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Ala, Richard Shugerman, MD, Department
of Pediatrics, University of Washington, Seattle, Wash; and David Karlson, PhD, SGIM, Washington DC.
This work was supported by grant 27069 from the Robert Wood Johnson Foundation. 相似文献
8.
Dr. Bruce M. Psaty MD PhD William M. Tierney MD Douglas K. Martin MD Clement J. McDonald MD 《Journal of general internal medicine》1987,2(3):160-167
To evaluate the performance of serum iron studies as a diagnostic test for iron-deficiency anemia in a county hospital, the
authors identified retrospectively all general medicine patients who had had bone-marrow aspirates for the work-up of non-macrocytic
anemias from 1978 through 1983. Re-reading a sample of aspirates from the 254 study patients (42 with iron deficiency) verified
the presence of absence of iron. Analysis with logistic regression, likelihood ratios, and receiver operating characteristic
curves demonstrated that the total iron-binding capacity (TIBC) performed markedly better as a diagnostic test than did the
transferrin saturation test. While no single TIBC level was diagnostic, the TIBC provided a good estimate of the probability
of iron-deficiency anemia.
Presented at the national meeting of the American Federation for Clinical Research, Washington, D.C., May 4, 1985.
Supported in part by a grant from the Robert Wood Johnson Foundation, Princeton, N.J.; and by the Health Services Research
and Development Program, VA Medical Center, Seattle, and by the National Center for Health Services Research, DHHS, under
research grant numbers HS-04080 HS-04996. The opinions, conclusions, and proposals in the text are those of the authors and
do not necessarily represent the views of the Robert Wood Johnson Foundation, the VA Medical Center, or the National Center
for Health Services Research. 相似文献
9.
Dr. Michael S. Wilkes MD MPH R. Nathan Link MD MPH Troy A. Jacobs MPH August H. Fortin MD Juan C. Felix MD 《Journal of general internal medicine》1990,5(2):122-125
Study Objective:To assess the attitudes of house officers in internal medicine and pathology about the value and use of the autopsy.
Design:Self-administered multiple-choice questionnaire.
Setting:Two New York City urban teaching hospitals.
Subjects:112 internal medicine and 37 pathology house officers who were on site during the survey period.
Main results:Most internal medicine house officers (86%) felt that the autopsy rate was too low and needed to be increased. The most common
reason the residents cited for the low rate was the reluctance of families to grant permission. A majority of medicine housestaff
(78%) felt they needed more instruction on how to ask for an autopsy, and 34% had never received feedback from the pathology
department on autopsy results. Most pathology residents (94%) felt the autopsy rate was too low; the most common reasons they
cited for the low rate were reluctance of clinicians to request permission and clinicians’ fears of being sued for malpractice.
Conclusions:House officers in internal medicine and pathology agreed that autopsies should be performed more frequently, and identified
problems in obtaining autopsies that should be addressed by educational, organizational, and regulatory strategies.
Supported in part by a grant from the Robert Wood Johnson Foundation. The opinions and conclusions herein are those of the
authors and do not necessarily represent the views of the Robert Wood Johnson Foundation. 相似文献
10.
Fisher EB Brownson CA O'Toole ML Shetty G Anwuri VV Fazzone P Housemann RA Hampton AD Kamerow DB McCormack LA Burton JA Orleans CT Bazzarre TL 《The Diabetes educator》2007,33(1):83-4, 86-8, 91-2, passim
PURPOSE: The purpose of the Diabetes Initiative of the Robert Wood Johnson Foundation is to demonstrate feasible and sustainable approaches to promoting diabetes self-management in primary care and community settings. METHODS: The Diabetes Initiative of the Robert Wood Johnson Foundation includes 14 demonstration projects in primary care settings and in community-clinical partnerships. Projects serve predominantly indigent populations from varied cultural and linguistic backgrounds in urban, rural, and frontier settings around the United States. This report describes the Initiative, its ecological perspective on self-management, and implications for program development, sustainability, and dissemination. RESULTS: Ecological perspectives stress varied levels of influence ranging from individuals to communities and policies. Based on this, the Initiative has identified key resources and supports for self-management (individualized assessment, collaborative goal setting, enhancing skills, follow-up and support, community resources, and continuity of quality clinical care). Lessons learned include the central roles of community health workers, integration of healthy coping and attention to negative emotion and depression in self-management, community partnerships, approaches to ongoing follow-up and support, organizational factors in sustaining programs, and the utility of a collaborative learning network for program development. Sustainability stresses organizational and policy supports for the program. Dissemination of lessons learned will stress collaboration among interested parties, stimulating consumer understanding and demand for self-management services as central to diabetes care. CONCLUSIONS: The Diabetes Initiative demonstrates that effective self-management programs and supports can be implemented in real-world clinical and community settings, providing models of worthwhile, sustainable programs. 相似文献
11.
Dr. David R. Calkins MD MPP Lisa V. Rubenstein MD MSPH Paul D. Cleary PhD Allyson R. Davies PhD Alan M. Jette PhD Arlene Fink PhD Jacqueline Kosecoff PhD Roy T. Young MD Robert H. Brook MD ScD Thomas L. Delbanco MD 《Journal of general internal medicine》1994,9(10):590-592
The authors conducted a randomized controlled trial of functional disability screening in a hospital-based internal medicine
group practice. They assigned 60 physicians and 497 of their patients to either an experimental or a control group. Every
four months the patients in both groups completed a self-administered questionnaire measuring physical, psychological, and
social function. The experimental group physicians received reports summarizing their patients’ responses; the control group
physicians received no report. At the end of one year the authors found no significant difference between the patients of
the experimental and control group physicians on any measure of functional status. Functional disability screening alone does
not improve patient function.
Supported by a grant from the Robert Wood Johnson Foundation, Princeton, New Jersey. 相似文献
12.
Improving patient quality of life with feedback to physicians about functional status 总被引:14,自引:0,他引:14
Dr. Lisa V. Rubenstein MD J. Michael McCoy MD Dennis W. Cope MD Pamela Anne Barrett BA Susan H. Hirsch MPH Karen S. Messer PhD Roy T. Young MD 《Journal of general internal medicine》1995,10(11):607-614
OBJECTIVE: To improve functional status among primary care patients.
INTERVENTION: 1) Computer-generated feedback to physicians about the patient’s functional status, the patient’s self-reported “chief complaint,”
and problem-specific resource and management suggestions; and 2) two brief interactive educational sessions for physicians.
DESIGN: Randomized controlled trial.
SETTING: University primary care clinic.
PARTICIPANTS: All 73 internal medicine houseofficers and 557 of their new primary care patients.
MEASURES: 1) Change in patient functional status from enrollment until six months later, using the Functional Status Questionnaire
(FSQ); 2) management plans and additional information about functional status abstracted from the medical record; and 3) physician
attitude about whether internists should address functional status problems.
RESULTS: Emotional well-being scores improved significantly for the patients of the experimental group physicians compared with those
of the control group physicians (p<0.03). Limitations in social activities indicated as “due to health” decreased among the
elderly (>70 years of age) individuals in the experimental group compared with the control group (p<0.03). The experimental
group physicians diagnosed more symptoms of stress or anxiety than did the control group physicians (p<0.001) and took more
actions recommended by the feedback form (p<0.02).
CONCLUSIONS: Computer-generated feedback of functional status screening results accompanied by resource and management suggestions can
increase physician diagnoses of impaired emotional well-being, can influence physician management of functional status problems,
and can assist physicians in improving emotional well-being and social functioning among their patients.
Supported by the Robert Wood Johnson Foundation. The opinions and conclusions herein are those of the authors and do not necessarily
represent the views of the Sepulveda VA, UCLA, CSUF, Rand, or the Robert Wood Johnson Foundation. 相似文献
13.
Dr. Charles E. Lewis MD ScD Kenneth B. Wells MD John Ware PhD 《Journal of general internal medicine》1986,1(1):14-19
The authors present a conceptual model of the determinants of the counseling practices of physicians and an empirical test
of the model. Seventy-six per cent of a 50% random sample of physicians in a western county medical society completed a questionnaire
(n=151). This instrument measures the aggressiveness, the indications and techniques used by physicians in counseling patients
about smoking, exercise, weight control and alcohol use. The independent variables assessed by this instrument are motivations,
perceived skills and barriers, medical specialty, and personal health habits. Significant associations were found between
the counseling practices reported and physicians’ personal health habits, attitudes and specialties. Non-surgeons counseled
more patients, counseled more intensively, and used a greater variety of techniques than surgeons and obstetrician-gynecologists.
In general, physicians who had poor health habits did not fully counsel patients about those habits; however, physicians attempting
to improve poor habits counseled patients significantly more often than physicians who were not trying to change their own
behavior. Health maintenance efforts among physicians may have a multiplier effect.
Received from the Departments of Medicine and Psychiatry, UCLA School of Medicine, and the Rand Corporation, Santa Monica,
California.
Supported in part by a grant from the Robert Wood Johnson Foundation. The opinions and conclusions expressed in the text are
those of the authors and do not necessarily represent the views of the Foundation. 相似文献
14.
Etzioni DA Yano EM Rubenstein LV Lee ML Ko CY Brook RH Parkerton PH Asch SM 《Diseases of the colon and rectum》2006,49(7):1002-1010
Purpose As evidence mounts for effectiveness, an increasing proportion of the United States population undergoes colorectal cancer
screening. However, relatively little is known about rates of follow-up after abnormal results from initial screening tests.
This study examines patterns of colorectal cancer screening and follow-up within the nation's largest integrated health care
system: the Veterans Health Administration.
Methods We obtained information about patients who received colorectal cancer screening in the Veterans Health Administration from
an existing quality improvement program and from the Veterans Health Administration's electronic medical record. Linking these
data, we analyzed receipt of screening and follow-up testing after a positive fecal occult blood test.
Results A total of 39,870 patients met criteria for colorectal cancer screening; of these 61 percent were screened. Screening was
more likely in patients aged 70 to 80 years than in those younger or older. Female gender (relative risk, 0.92; 95 percent
confidence interval, 0.9–0.95), Black race (relative risk, 0.92; 95 percent confidence interval, 0.89–0.96), lower income,
and infrequent primary care visits were associated with lower likelihood of screening. Of those patients with a positive fecal
occult blood test (n = 313), 59 percent received a follow-up barium enema or colonoscopy. Patient-level factors did not predict
receipt of a follow-up test.
Conclusions The Veterans Health Administration rates for colorectal cancer screening are significantly higher than the national average.
However, 41 percent of patients with positive fecal occult blood tests failed to receive follow-up testing. Efforts to measure
the quality of colorectal cancer screening programs should focus on the entire diagnostic process.
Supported by the Robert Wood Johnson Foundation Clinical Scholars Program (Etzioni), Department of Veterans Affairs (VA) Health
Services Research and Development (HSR&D), and National Cancer Institute Colorectal Cancer (CRC) Quality Enhancement Research
Initiative (QUERI) Service Directed Research (Project # CRS 02-163).
The views expressed in this article are those of the authors and do not necessarily represent the views of the Robert Wood
Johnson Foundation or the Department of Veterans Affairs. 相似文献
15.
Saint S Christakis DA Saha S Elmore JG Welsh DE Baker P Koepsell TD 《Journal of general internal medicine》2000,15(12):881-884
We assessed the reading habits of internists with and without epidemiological training because such information may help guide
medical journals as they make changes in how articles are edited and formatted. In a 1998 national self-administered mailed
survey of 143 internists with fellowship training in epidemiology and study design and a random sample of 121 internists from
the American Medical Association physician master file, we asked about the number of hours spent reading medical journals
per week and the percentage of articles for which only the abstract is read. Respondents also were asked which of nine medical
journals they subscribe to and read regularly. Of the 399 eligible participants, 264 returned surveys (response rate 66%).
Respondents reported spending 4.4 hours per week reading medical journal articles and reported reading only the abstract for
63% of the articles; these findings were similar for internists with and without epidemiology training. Respondents admitted
to a reliance on journal editors to provide rigorous and useful information, given the limited time available for critical
reading. We conclude that internists, regardless of training in epidemiology, rely heavily on abstracts and prescreening of
articles by editors.
This study was supported by the University of Washington Robert Wood Johnson Clinical Scholars Program and the Department
of Veterans Affairs. Drs. Christakis and Elmore are supported by Robert Wood Johnson Generalist Faculty Awards. Drs. Saint,
Christakis, and Saha were Robert Wood Johnson Clinical Scholars at the time this work was conducted. 相似文献
16.
Little is known about the prevalence of focused expertise (special areas of expertise within a clinical field) among physicians,
yet such expertise may influence how care is delivered. We surveyed general internists, pediatricians, cardiologists, infectious
disease specialists, and orthopedic surgeons to describe the prevalence of focused expertise and identify associated physician
and practice characteristics. About one quarter of generalists and three quarters of specialists reported a focused expertise
within their primary specialty. Hospital-based physicians more often reported such expertise, and physicians reimbursed by
capitation less often reported expertise. Learning how focused expertise affects processes and outcomes of care will contribute
to decisions about physician training and staffing of medical groups.
Dr. Keating was the recipient of a National Research Service Award from the Agency for Healthcare Research and Quality, Rockville,
MD, Dr. Ayanian was a Generalist Physician Faculty Scholar of the Robert Wood Johnson Foundation, Princeton, NJ. This study
was supported by the Primary Care Research and Education Fund of Brigham and Women’s Hospital. 相似文献
17.
Dr. Lisa V. Rubenstein MD Nancy C. Ward BA Sheldon Greenfield MD 《Journal of general internal medicine》1986,1(1):38-43
The serum alkaline phosphatase (ALP) is often included among the tests used for case-finding among ambulatory patients. To
determine the positive predictive value of the ALP, test results for all adults screened by a health maintenance organization
between March and December 1969 were obtained by computer. The authors reviewed the charts of all 661 patients with abnormal
tests whose primary source of medical care was at this facility. Complete two-year follow-up data were available for 91% of
these patients. There were 56 patients (9%) with a diagnosis that could have explained an abnormal ALP. Of those cases in
which ALP would have been clinically useful all but one could have been diagnosed by a simple, noninvasive work-up, and in
that one case, no management change would have occurred. The authors conclude that in the absence of a small number of specific
indications, extensive testing need not be performed to evaluate an isolated abnormal ALP obtained from a screening examination.
Received from the Department of Medicine and the School of Public Health, University of California, Los Angeles, Los Angeles,
California.
Supported in part by the Robert Wood Johnson Clinical Scholars Program. The views expressed herein do not necessarily represent
those of the Robert Wood Johnson Foundation. 相似文献
18.
Dr. Adina Kalet MD MPH John C. Roberts MD Robert Fletcher MD 《Journal of general internal medicine》1994,9(7):402-404
To describe the communication about risk between community-based physicians and their patients, the authors audiotaped 160
physician-patient encounters in the private practices of 19 physicians. Coding was done using a structured scheme to identify
the presence of talk about risk of future illness, and to describe its characteristics. Patient understanding and satisfaction
were assessed through an interview. Risk discussion occurred in 26% (95% CI 19%–33%) of the visits, quantitatively in two
cases and specifically with respect to outcome in 48% (95% CI 40%–56%) of the visits. The patients initiated only 16% of this
discussion but were, in general, satisfied with their care and the information they had received, but they had poor recall
of the specifics of the discussion.
This work was carried out while Drs. Kalet and Roberts were fellows in the Robert Wood Johnson Clinical Scholars Program at
the University of North Carolina at Chapel Hill.
Presented at the annual meeting of the Society of General Internal Medicine, Seattle, Washington, May 1–3, 1991. 相似文献
19.
Debra K. Litzelman MD MA Dr. William M. Tierney MD 《Journal of general internal medicine》1996,11(8):497-499
The objective of this study was to assess reasons for physicians’ noncompliance with computer-generated preventive care reminders.
In an academic general internal medicine practice, a survey of physicians’ reasons for noncompliance found that 55% of reminders
were not complied with. Reasons included “not applicable” in 22.6% (test done elsewhere, patient too ill, no uterus), “next
visit” in 22.5% (physician too busy, patient too ill), and “patient refuses” in 9.9% (test not necessary or too costly, patient
too busy or fears result). We conclude that although noncompliance with reminders is sometimes appropriate, making time for
prevention and patient education may augment preventive care.
Received from the Department of Medicine, Wishard Memorial Hospital, and the Indiana University School of Medicine, the Regenstrief
Institute for Health Care, and the Health Services Research and Development Service, Richard L. Roudebush VA Medical Center,
Indianapolis, Ind.
Supported in part by grants HS07632, HS07763, and HS07719 from the Agency for Health Care Policy and Research (AHCPR). Dr.
Litzelman was supported in part by a Robert Wood Johnson Generalist Physician Faculty Scholar Award (022318).
The opinions expressed herein are solely those of the authors and do not necessarily represent the authors’ institutions,
AHCPR, or the Robert Wood Johnson Foundation. 相似文献
20.
Objective: Since inordinately long or short lengths of stay at hospice can create problems for patients, providers, and payers, the
author sought to identify predictors of timing of patient referral.
Methods: A retrospective cohort of 405 hospice outpatients was analyzed with Cox regression to evaluate the effect on length of stay
of patient age, gender, race, diagnosis, activity level, mental status, dyspnea, insurance, income, religion, and home support,
and of referring physician specialty.
Results: Median survival time at the hospice was 29 days; 15% of the patients died within seven days and 12% lived longer than 180
days. A one-unit increment in a six-unit activity-level scale was associated with a 19% reduction in the rate of death. Compared
with reference groups, oriented patients and depressed patients had 57% and 35% lower death rates; patients with prostate
cancer and cardiovascular disease had 50% and 58% lower death rates. There was no significant gender, race, religion, insurance,
or income difference among the patient groups.
Conclusions: Inappropriately early or late referral occurs in a substantial minority of patients referred to the hospice under study.
Closer attention to accurate prognostication in different types of terminally ill patients and more timely referral to hospice
might help to optimize the use of this health care resource from both patient and societal perspectives.
Received from the Division of General Internal Medicine, Leonard Davis Institute of Health Economics, Department of Sociology,
University of Pennsylvania, Philadelphia, Pennsylvania.
Supported by the Robert Wood Johnson Foundation Clinical Scholars Program and by the Warren-Whitman-Richardson Fellowship
from Harvard Medical School. Dr. Christakis is the recipient of a NRSA Fellowship from the Agency for Health Care Policy and
Research. Computer facilities were provided by the Department of Sociology, University of Pennsylvania.
The opinions and conclusions herein are the author’s and do not necessarily represent the views of the Robert Wood Johnson
Foundation. 相似文献