Impact of an audiology clinic in one general practice.

There is a large demand for the provision of hearing aids. However, there are lengthy delays involved between referral and fitment of National Health Service (NHS) hearing aids. This report shows that a general practice based audiology clinic can lead to an increase in the number of patients referred and fitted with a hearing aid. The introduction of the clinic also led to reduced waiting times for patients to be fitted with hearing aids.     

Surveying graduates of one school to determine regional workforce demand.

PURPOSE: To study the demand for physician graduates from one school in one region of the country. The use of demand as a measure of potential regional variation should be of interest to medical educators and policymakers. METHOD: All residency graduates of the University of Washington School of Medicine between 1975 and 1995 (n = 3,824) were surveyed about their ability to gain employment in a timely manner and whether they were recruiting physicians for their practices. RESULTS: The response rate was 50.29%. A non-responder survey was done using a subsample (n = 200), with a 28% return. Over 95% of the graduates had found employment in their desired specialties and locations within two years of finishing their residencies. This was the same for graduates over all years. Approximately 30% of all practices of respondents within the Northwest region were recruiting for new physicians (26% of specialty practices and 34% of generalist practices were recruiting). There was no difference between recruitment in the urban and rural practices or between respondents to the initial survey and those responding to the follow up. CONCLUSIONS: Despite a significant oversupply of specialist physicians and at least a sufficient supply of generalist physicians nationally, there appears to be a strong demand for both specialists and generalists in the Northwest region of the country. This raises questions concerning the use of national averages to inform the education policies in specific regions of the country. More validated measures of demand are needed for future studies.     

Musculoskeletal clinic in general practice: study of one year''s referrals.

BACKGROUND. A musculoskeletal clinic, staffed by a general practitioner trained in osteopathy, medical acupuncture and intralesional injections, was set up in an inner London general practice in 1987. AIM. A retrospective study was undertaken of one year's referrals to the clinic in 1989-90 to determine how general practitioners were using the clinic in terms of problems referred; consultation patterns of patients attending the clinic and 12 months after initially being seen; and how access to the clinic influenced referrals to relevant hospital departments. METHOD. Day sheets were studied which recorded information on demographic characteristics of patients referred to the clinic and their problems, diagnoses made, duration of symptoms, number and range of treatments given, and recurrence of problems. Use of secondary referral sources was also examined. RESULTS. During the study year 154 of 3264 practice patients were referred to the musculoskeletal clinic, and attended a mean of 3.5 times each. Of all the attenders 64% were women and 52% were 30-54 years old. Eighty one patients (53%) presented with neck, back or sciatic pain. A specific traumatic, inflammatory or other pathological process could be ascribed to only 19% of patients. Regarding treatment, 88% of patients received osteopathic manual treatment or acupuncture, or a combination of these treatments and 4% received intralesional injections. Nine patients from the clinic (6%) were referred to an orthopaedic specialist during the year, two with acute back pain. Referrals to orthopaedic specialists by the practice as a whole were not significantly lower than the national average, although the practice made fewer referrals to physiotherapy and rheumatology departments than national figures would have predicted. Seventeen patients (11%) returned to the clinic with a recurrence of their main complaint within a year of their initial appointment; second courses of treatment were usually brief. CONCLUSION. The clinic encouraged a relatively low referral rate to musculoskeletal specialists outside the practice. However, a need was identified for better communication about the potential of the approaches used in order that referrals to secondary specialists, particularly orthopaedic specialists, could be further reduced.     

How reorganizing a general medicine clinic affected residents' and patients' satisfaction

The authors examined how satisfied patients and residents were before and after the restructuring of the general medicine clinic at a large urban teaching hospital in 1985; the change to a longitudinal care clinic was made to provide greater continuity of care, more consistent access of residents to attending physicians, and a more structured educational curriculum. Questionnaires to assess satisfaction were administered three weeks before and ten months after the change to all 80 of the second- and third-year residents. A convenience sample of 310 patients seen during a two-week period before the change and another such sample of 267 patients seen during a two-week period ten months after the change comprised the patients who completed a patients' satisfaction questionnaire. The residents were significantly more satisfied with the quality of care, functioning, and educational value of the new longitudinal care clinic. Their average overall rating of satisfaction (on a scale where 1 = completely dissatisfied and 5 = completely satisfied) increased from 2.3 to 3.7 (p less than .001). Unexpectedly, the patients were "very satisfied" with both clinic models and their overall ratings changed little (4.5 before, 4.4 after). In addition, the patients' and residents' before-and-after perceptions of the quality of care delivered in the clinic differed substantially. These findings show that the longitudinal care clinic significantly enhanced the satisfaction of the residents but not of the patients. Furthermore, the data suggest that results from standardized patients' satisfaction surveys may not accurately assess the quality of care being delivered.     

The rapid access proctology clinic: an appraisal of one year''s experience.

A walk-in, once-a-week clinic was established in May 1993. In the first year, 1268 patients (954 new and 314 follow up) were seen with a reduction in waiting time, high patient and general practitioner satisfaction, and raised awareness of colorectal disease.     

How completely internal medicine residents at a New York State teaching hospital met the expectations of a credentialing protocol

The authors conducted a two-year prospective study (1988-1990) to determine whether internal medicine residents at a multi-facility teaching hospital in New York State could meet the expectations of a formal credentialing protocol and receive independent privileges in a timely manner. The study group consisted of 38 first-year residents separated into two subgroups. Subgroup I, seven categorical and 11 preliminary residents, entered the residency program July 1, 1988; subgroup II, seven categorical and 13 preliminary residents, joined the residency July 1, 1989. During the first three months of the 1988-89 academic year, subgroup I showed minimal compliance, obtaining only 11% of the total privileges available. However, subgroup II, working under a protocol that underwent major revisions related to monitoring the credentialing process, showed significant improvement, with 90% of all required privileges credentialed within the first quarter of 1989-90. The findings suggest that a minimal rate of residents' compliance can be improved dramatically by the development of a structured protocol that includes stringent monitoring of the entire credentialing process and formal, regular feedback to the housestaff regarding their progress.     

Effectiveness of a psychiatric pain clinic.

Medical charts were reviewed for 101 consecutive outpatients seen between January 1, 1993 and July 1, 1996 at a unidisciplinary, psychiatric pain clinic, which exists within a hospital-based, university-run, outpatient service with primary and specialty care clinics. Mean duration of pain was 7 years. Multiple sites of pain were present in 69% of patients. Eighty-eight percent fulfilled DSM-IV criteria for pain disorder. The patients had significantly fewer medical visits and diagnostic tests 6 months after attending the pain clinic, compared with 6 months before (P < 0.0001). Interventions frequently included detoxification and reduction and substitution of medication, and always included psychotherapeutic approaches, particularly support and suggestions.     

Recurrence rates after treatment of breast cancer with standard radiotherapy with or without additional radiation.

BACKGROUND: Radiotherapy prevents local recurrence of breast cancer after breast-conserving surgery. We evaluated the effect of a supplementary dose of radiation to the tumor bed on the rates of local recurrence among patients who received radiotherapy after breast-conserving surgery for early breast cancer. METHODS: After lumpectomy and axillary dissection, patients with stage I or II breast cancer received 50 Gy of radiation to the whole breast in 2-Gy fractions over a five-week period. Patients with a microscopically complete excision were randomly assigned to receive either no further local treatment (2657 patients) or an additional localized dose of 16 Gy, usually given in eight fractions by means of an external electron beam (2661 patients). RESULTS: During a median follow-up period of 5.1 years, local recurrences were observed in 182 of the 2657 patients in the standard-treatment group and 109 of the 2661 patients in the additional-radiation group. The five-year actuarial rates of local recurrence were 7.3 percent (95 percent confidence interval, 6.8 to 7.6 percent) and 4.3 percent (95 percent confidence interval, 3.8 to 4.7 percent), respectively (P<0.001), yielding a hazard ratio for local recurrence of 0.59 (99 percent confidence interval, 0.43 to 0.81) associated with an additional dose. Patients 40 years old or younger benefited most; at five years, their rate of local recurrence was 19.5 percent with standard treatment and 10.2 percent with additional radiation (hazard ratio, 0.46 [99 percent confidence interval, 0.23 to 0.89]; P=0.002). At five years in the age group 41 to 50 years old, no differences were found in rates of metastasis or overall survival (which were 87 and 91 percent, respectively). CONCLUSIONS: In patients with early breast cancer who undergo breast-conserving surgery and receive 50 Gy of radiation to the whole breast, an additional dose of 16 Gy of radiation to the tumor bed reduces the risk of local recurrence, especially in patients younger than 50 years of age.     

Trunk muscle coordination in reaction to load-release in a position without vertical postural demand

The aim of this study was to investigate the coordination between the innermost muscle layer of the ventro-lateral abdominal wall, the transversus abdominis (TrA), and other trunk muscles, in reaction to a load-release without the postural demand of keeping the trunk upright. Eleven healthy male volunteers participated. Intramuscular fine-wire electromyography (EMG) was obtained bilaterally from the TrA, rectus abdominis (RA), obliquus externus (OE) and erector spinae (ES) muscles. The subjects lay on their right side on a horizontal swivel-table with immobilized pelvis and lower limbs and with the trunk strapped to a movable platform allowing for trunk flexion and extension. Subjects maintained trunk flexion or extension at different force levels against a static resistance, which was suddenly released. They were instructed to resume the start position as fast as possible. EMG signals were analysed with respect to amplitude and timing of muscle activation. Following released static flexion, TrA increased its activity in synergy with ES. Also in released static extension, TrA increased its activity, but now in synergy with RA and OE. The direction-independent activation of TrA indicates a role of this muscle in controlling inter-segmental movements of the lumbar spine. This function was not accompanied by an early activation of TrA as has been shown previously for trunk perturbations in standing, i.e. a situation with an additional demand of maintaining the trunk posture upright against gravity.     

How physicians experience patient consultations at an orthopaedic out-patient clinic: a qualitative study

The aim of this study is to describe physicians' experiences in their encounters with patients by allowing the physicians to observe and comment on their own video-recorded medical consultations. Eighteen orthopaedic surgeons took part in the study; they were informed that we were interested in studying what actually takes place during a consultation, the quality of communication between doctor and patient, and how the physicians themselves experience the consultation. Each time the physician wished to make a comment, the video film was stopped and the comments were taped on audiocassette. The results showed that when the physicians watched the video-recorded consultations they commented spontaneously on issues regarding, among others: (1) how they try to adapt their communication to the patient's situation; (2) the need to explain things to the patient; (3) perceptions of working under unfavourable conditions; (4) difficulties in helping certain patients.     

The nodular form of hepatic tuberculosis: a review with five additional new cases

BACKGROUND: Tuberculosis presenting as an isolated liver tumour, without active pulmonary or miliary tuberculosis, or other clinical evidence of tuberculosis, is distinctly rare. A greater awareness of this rare clinical entity may prevent needless surgical intervention. AIMS: To help characterise this distinctly rare presentation of tuberculosis, five new cases are presented, together with a review of the world literature. The clinical, laboratory, radiological, and pathological features of these patients are described. METHODS: Polymerase chain reaction (PCR) assay of the liver tissue was carried out in all cases to confirm an aetiological diagnosis of Mycobacterium tuberculosis infection. RESULTS: All five patients (44-71 years old; two women, three men) underwent surgery, and had a preoperative diagnosis of malignant hepatic neoplasm and a postoperative histological diagnosis of chronic granulomatous inflammation, suggestive of tuberculosis. None of them had a known previous history of tuberculosis. All of them were positive for M tuberculosis by PCR analysis of the liver tissue. CONCLUSIONS: This report illustrates the difficulty in reaching a correct preoperative diagnosis. It is usually unsuspected and confused with primary or metastatic carcinoma of the liver, especially when it coexists with other malignancies. A high index of suspicion is required for diagnosis, which can be made only by histological and bacteriological studies, and PCR analysis.     

The prevalence of psychiatric disorder among female new referrals to a migraine clinic

In a consecutive series of 46 female new referrals to a migraine clinic, 17 patients (37%) complained of increased irritability and/or depression in association with more than 50% of their migraine attacks. This was not related to the attack frequency or duration. Sixteen patients (33%) met DSM-III criteria for a current diagnosis of an affective syndrome and when present this was significantly associated with these complaints.     

Improving access to a primary care medical clinic.

Patients presenting to an episodic care walk-in clinic often warrant prompt but not necessarily emergency attention. Legitimate reasons often prohibit these patients from attending regularly scheduled daytime weekday clinics. Most patients interviewed thought that having a single primary care provider was important to ensure continuity of care. Access to primary care can be improved by scheduling clinics and ancillary services on nontraditional times and days. Enhanced communication can help patients differentiate routine from urgent from emergency conditions. Printed and audiovisual materials can be used to increase awareness of the benefits of comprehensive care.     

Managing resources in a better way: a new financial management approach for the University of Michigan Medical School.

Responding to changing trends in how the University of Michigan Medical School (UMMS) has been traditionally financed and anticipating that these trends will continue, in 2002 the executive leadership at the UMMS embarked upon a course designed to change not only the school's financial structure but its management culture as well. Changing traditional ways of thinking about budgets and developing a set of key performance indicators that demonstrate how certain activities shape the use of resources has brought greater understanding of how to optimize those resources to the greatest extent. Through internally developed Web-based software applications called M-STAT, M-DASH and M-ALERT (which are strategic reporting tools that the author describes), the UMMS now can manage resources in a completely different way. These tools are used to spot general financial trends or examine a more specific financial element (such as trends in grant funding or clinical activity), track the utilization of research space, calculate the break-even cost of research space, and most important, model various "what-if" scenarios to help plan effectively for the future needs of the UMMS. The strategic reporting system is still being integrated throughout the UMMS, so there has not yet been time to measure the system's efficacy or its shortcomings. Nevertheless, important lessons have already been learned, which the author presents.