House Staff Physicians Research Articles

An educational program to modify laboratory use by house staff.

An earlier study showed that the prothrombin time determination is overutilized as a routine admission laboratory test. In the present study the investigator evaluated the effectiveness of an educational program in decreasing utilization of the prothrombin time determination by house staff physicians at a teaching hospital. Six months after the educational program, use of the prothrombin time determination as a routine admission test had decreased significantly from 87 percent to 55 percent. Eighteen months after the educational program, the use of this test by the study group had returned to initial levels. These results emphasize the need to measure the long-term outcome of educational programs aimed at modifying the clinical behavior of physicians and to institute follow-up programs to ensure that an educational effort will have a lasting effect.

Diagnosing potential noncompliance. Physicians' ability in a behavioral dimension of medical care.

Predictions by housestaff physicians of whether or not patients would return for follow-up visits and of the amount of prescribed medication they would take were compared to measured compliance for 187 patients discharged from the medical service. Although physicians were able to predict visit compliance better than by chance alone, at best they could accurately predict only 35% of the noncompliers and one half of their predictions of noncompliance were incorrect. In predicting medication compliance, less than one half of physician predictions correctly discriminated between compliant and noncompliant patients and three fourths of their predictions of noncompliance were inaccurate. Because of physician limitations in this important clinical area, medical education should expand efforts to develop physician skills in diagnosing and managing sociobehavioral aspects of illness, and efforts to improve quality of care cannot ignore these "nontechnical" factors.

Diagnosing Potential Noncompliance

Predictions by housestaff physicians of whether or not patients would return for follow-up visits and of the amount of prescribed medication they would take were compared to measured compliance for 187 patients discharged from the medical service. Although physicians were able to predict visit compliance better than by chance alone, at best they could accurately predict only 35% of the noncompliers and one half of their predictions of noncompliance were incorrect. In predicting medication compliance, less than one half of physician predictions correctly discriminated between compliant and noncompliant patients and three fourths of their predictions of noncompliance were inaccurate. Because of physician limitations in this important clinical area, medical education should expand efforts to develop physician skills in diagnosing and managing sociobehavioral aspects of illness, and efforts to improve quality of care cannot ignore these "nontechnical" factors. (<i>Arch Intern Med</i>137:318-321, 1977)

Effectiveness of certified nurse-midwives: A prospective evaluation study

A prospective evaluation study of the effectiveness of the services of certified nurse-midwives demonstrated that in a hospital setting the care of low-risk maternity patients provided by nurse-midwives was as effective as the provided by house staff physicians. A total of 438 low-risk maternity patients were studied. Selected outcomes pertaining to the prenatal period, labor and delivery, and early infancy demonstrated, with two exceptions, no significant differences. The two exceptions were: (1) overcompliance with appointment attendance was more common among the nurse-midwifery group of patients; (2) a higher rate of forceps delivery was reported among the house staff group of patients.

Medical diagnosis: Comparison of human and computer logic

Questionnaires describing four logical methods by which a patient's signs and symptoms can be translated into a diagnostic impression were administered to medical students and housestaff physicians. Two of the methods have been successfully used by diagnostic computer programs; two have not. Ninety per cent of the responders to the survey indicated that they used one or both of the logical systems which have not been successfully adapted to computer diagnosis.

Acceptability of an expanded nurse role to nurses and physicians.

A questionnaire was developed to measure the acceptance by physician.1; and nurses of an expanded nurse role. The questionnaire was administered to a total of 218 persons: 93 nurses, 86 house staff physicians, and 39 senior medical students. Duplicate questionnaires were filled out by the medical students at the beginning and end of the academic year. The results of the survey indicate that the questionnaire is a good measure of attitude. Nurses found the expanded role more acceptable than the medical students, whose attitudes did not change after a year of clinical experience. House staff physicians found the expanded nurse role least acceptable. Intra-group variations were great. Implications of the study are discussed.

How to get a clean colon--with less effort.

The examination of the colon by the radiologist is one of the most difficult of all examinations. A major problem for the hospital patient is the preparation of the colon for radiologic study: a “clean colon” is preferred. In order to conserve time in the hospital, we employ a procedure that does not entail several days of dietary preparation, is not exhausting for a sick or weak patient, and does not produce or increase irritability of the colon. Our observations are being reported because we feel that we are doing a better examination for the patient, and it is our hope that others will elect to use the procedure and, if possible, develop a more effective method. Until eighteen months ago, the preparation employed in our hospital was castor oil at 4:00 p.m., a liquid supper, and cleansing enemas the following morning before the barium study. Although that method has been used for years, a preliminary survey of 129 randomly selected inpatients so prepared showed that they had received from 2 to 18 enemas, with an average of 5. In general, the procedure was distasteful and exhausting for the patient, time-consuming for the hospital personnel, and inadequate for clear visualization of the colon in about half the cases. Too often, repeat preparation and examinations were required. Materials and Methods We investigated other methods of preparation which did not include cleansing enemas and selected a procedure which, with slight modifications, was similar to one described by Garland Brown (1). The procedure involved good hydration of the patient, purging with magnesium citrate, and final cleansing of the colon with a contact laxative (bisacodyl) (2–4) given both orally and rectally. The program included 540 patients scheduled for barium examination over a period of about eight months. A group of 152 patients received castor oil and cleansing enemas, and 388 had the “clean colon” procedure. The patients ranged in age from fifteen to eighty-five years, with the great majority over forty-five years old. There were about 20 per cent more females than males, and the distribution of age and sex in the two groups was comparable. Initially, all referring and house staff physicians were advised of the new bowel preparation program to be used in the hospital. We issued a printed procedural form provided with an adhesive and sized to fit the doctor's order sheet of the hospital chart. This form requires the physician's signature. All necessary medications are obtainable in one laxative kit available at the hospital pharmacy. Outpatients receive a printed form listing foods to be eaten for lunch and supper, while the hospital dietary department furnishes the same foods to inpatients. In addition, each step in the preparation concerned with the timing of the special diet, the liquid intake, and the medication is itemized. With the “clean colon” method, preparation of the patient begins eighteen hours before the scheduled barium enema study.

Diseases of Metabolism.

The fifth edition of Diseases of Metabolism is, like its predecessors, a well-written, easily readable book that will be cordially welcomed and extensively used by students, house staff, and other physicians interested in metabolism and endocrinology. It continues the fine tradition of previous editions and will no doubt enjoy a healthy demand due to its unique treatment of the biochemical aspects of clinical disease. A few chapters have been rewritten by new authors, but the major changes in the present edition (1,513 pages vs 1,073 pages for the

Principles of Clinical Electrocardiography

Dr. Goldman, in his fifth edition ofPrinciples of Clinical Electrocardiography, has ably accomplished his objective of presenting the basic concepts of electrocardiography and their clinical application. Written in clear, crisp, concise language, this book details the simpler and some of the more complex theoretical and practical aspects of electrocardiography. For the medical student and house staff physician in particular, as well as practitioners of medicine, the volume will serve as an excellent introductory guide and future reference. The book is profusely illustrated with simplified drawings which permit excellent correlation of electrocardiographic patterns with electrophysiologic principles. For the sake of clarity, Dr. Goldman has purposefully avoided controversial theoretical discussions. For example, he emphasizes the unitarian concept of accelerated conduction and atrial arrhythmias as the theories most widely accepted today. Emphasis also has been placed on the unipolar leads; there is, however, an introductory section on vector cardiography as well. Other