Internal Medicine Doctors Research Articles

Thyroid diseases and pregnancy

BACKGROUND Thyroid diseases and diabetes mellitus are the most common endocrine diseases during pregnancy. Internal Medicine doctors could be involved in the management of pregnant women affected by thyroid diseases, in particular if an Endocrine Unit lacks in the hospital; it is mandatory that they have the skills to cope with these diseases. METHODS In this work authors describe the most common thyroid abnormalities that can occur during pregnancy: hypothyroidism (clinical and subclinical), hyperthyroidism (clinical and sub-clinical), autoimmune thyroiditis (in particular the so called post-partum thyroiditis), nodular diseases and cancer. They discuss moreover the peculiar pathophysiologic mechanisms by which these diseases appear, the diagnostic tools and the therapies, according to their own experience and the more recent international guidelines. RESULTS AND CONCLUSIONS It is important to evaluate thyroid function tests before and during pregnancy, at 16th and 28th gestational week; it is mandatory to cure also the “sub-clinical” hypothyroidism during pregnancy, when TSH level are higher than 5 μIU/mL; the optimal dose of levo-thyroxine during pregnancy is, average, 30-50% higher than that used before pregnancy; it is not correct to treat mild or sub-clinical hyperthyroidism; propylthyouracil is the best drug to treat hyperthyroidism during pregnancy; the post-partum thyroiditis is generally transient, so that a careful monitoring of thyroid function is advisable, in particular after 9-12 months of therapy; thyroid cancer, if discovered during pregnancy, generally has no negative effects on the outcome of the pregnancy; it would be better to treat surgically thyroid cancer during the last trimester of the pregnancy.

GRP-116 Medicines Reconciliation: An Innovative Computer-Based Use of the Medicines List

BackgroundMedicines reconciliation is as an important approach to prevent medicines errors and adverse health outcomes. However, the implementation of these interventions is frequently unsuccessful especially due to difficulties in information...

An attitude of doctors in internal medicine for soft tissue tumors

An attitude of doctors in internal medicine for soft tissue tumors

345 NEW DIAGNOSIS OF HYPERTENSION IN PATIENTS WITH OBSTRUCTIVE SLEEP APNEA SYNDROME

Introduction: Over 50% of patients diagnosed of ASA have hypertension. A third of patients with hypertension have ASA. 56% of patients with resistant hypertension have ASA. Objective: To detect hypertensive patients among patient without diagnosis of hypertension but with suspected sleep apnea syndrome (SAS). Design and methods: A non-interventional, cross-sectional and descriptive study which includes the 100 first patients with suspected sleep apnea syndrome send to the Internal Medicine doctor's office of two Valencian (Spanish) hospitals. We determined the clinic blood pressure (BP) following the Spanish Society of Hypertension recommendations, the 24-hour ambulatory blood pressure monitoring (ABPM) (with a Sapcelabs 90207) and a nocturnal polysomnography. Results: Mean age 50 years, 84% men, boy mass index (BMI) 29,6 ±4,7 kg/m2. Comorbidity: 42% obesity (IMC ≥ 30 kg/m2), 51.1% smokers. High blood pressure prevalence: clinic hypertension: 38.2% hypertensive 24-hour ABPM (35.9%): masked hypertension: 12.2%, white-coast hypertension: 14.5%. Polysomnography results: Normal: 65%, snorer: 26%, SAS: 9%. Hypertension prevalence in SAS: clinic hypertension 39.1%, hypertensive 24h-ABPM 39.1%, hypertensive daytime-ABPM 38.4%, hypertensive night-time-ABPM 56.3%. Hypertension prevalence in snorer: clinic hypertension 28.2%, hypertensive 24h-ABPM 28.2%, hypertensive daytime-ABPM 327.9%, hypertensive night-time-ABPM 40.7%. Circadian rhythm of BP: non-dippers 46%, dippers 36%, risers 11%, extreme-dippers 7%. Conclusions: There is a high prevalence of undiagnosed hypertension in patients with suspected sleep apnea syndrome. The BP and prevalence of hypertension is higher in SAS than in snorers without SAS. Only 1 of 3 patients with suspected SAS has a normal circadian BP rhythm.

Use of non-vitamin, non-mineral (NVNM) supplements by hospitalized internal medicine patients and doctor–patient communication

ObjectiveTo study non-vitamin, non-mineral (NVNM) supplements use and disclosure of among hospitalized internal medicine patients. MethodsA convenience sample of patients completed an interviewer-administered questionnaire examining use of and perceptions regarding NVNM supplements, and disclosure to medical personnel. Results280 patients were interviewed (54% female), 15.4% reporting NVNM supplement use. This practice was more prevalent among female patients (p=0.045), more educated (p<0.001) and patients with more impaired quality-of-life, measured by the SF-12 tool (p<0.020). The most common factor influencing NVNM supplement use was a physician's recommendation. Most (74%) patients using NVNM supplements reported having disclosed this practice to community-based physicians, with only 23.7% disclosing to hospital staff. Six patients reported using supplements at the exclusion of conventional medication, with potentially serious implications. ConclusionWhile the majority of patients using NVNM supplements are sharing this information with their primary-care physicians, there is little disclosure of this practice to hospital staff. This may be due to a perceived negative attitude of medical professionals to complementary medicine, and a lack of awareness by hospital staff regarding such practices. Practice implicationsHospital-based medical professionals need to be aware of the use of NVNM supplements and the resulting implications by their internal medicine patients.

Who gets a referral to oncologists and subsequent treatments for stages III and IV non-small cell lung cancer (NSCLC)?

6007 Background: We identified the physicians initially involved in the management of stages III and IV NSCLC, and explored associations of patient and their initial physician factors with referrals to oncologists and subsequent receipt of guideline-based therapies (GBTs) endorsed by the National Comprehensive Cancer Network. Methods: Using a retrospective cohort design, we identified patients with a new diagnosis of stages III and IV NSCLC from 01/01/2000 to 12/31/2005 included in the Surveillance, Epidemiology, and End Results-Medicare database. After collecting patient sociodemographic, tumor, and treatment data, we linked Unique Physician Identifier Numbers (UPINs) from Medicare claims to the American Medical Association Masterfile database to identify the initial physicians and subsequent referrals to cancer specialists, defined as surgeons, radiation oncologists and oncologists. We used logistic regression to explore associations between: 1) patient and initial physician independent variables with referrals to oncologists; 2) referrals to different combinations of cancer specialists with receipt of stage-specific GBTs, adjusted for confounders. The follow-up period was 12 months or up to 12/31/2006. Results: For 28,977 patients, mean age was 75 years, 53% were male, 83% were white, 51% had stage IV, 37% initially saw an internal medicine doctor, 84% saw at least an oncologist, 31% saw all 3 types of cancer specialists, and 44% received GBTs. Younger age, white race, stage IV, higher income, lower co-morbidity index, initial physicians other than family practice doctors, and referral to pulmonologists were associated with higher likelihood of referral to oncologists (P&lt;0.01 for all factors). Compared to those who saw only an oncologist, those who saw only a surgeon and/or a radiation specialist were less likely to receive GBTs (OR=0.3; 95%CI=0.3-0.4). Among patients who had no referrals or who saw specialties other than oncology, 14% received GBTs. Conclusions: Seeing an oncologist is a critical step in the standard treatment of advanced NSCLC. Yet, race, income, and the type of initial physician may constitute barriers of access to oncologists, which can result in substandard care.

Defining and measuring the effort needed for inpatient medicine work

Current metrics for assessing physician workload are inadequate. Understanding the effort associated with work tasks could make workload assessments more robust. To assess the physical, mental, and psychological effort needed for the tasks performed by internal medicine doctors while admitting a patient to the hospital. Cross-sectional survey. A single Midwest academic institution. Internal medicine housestaff, hospitalists, and nonhospitalist internal medicine faculty. Subjects rated 99 tasks across 3 domains: physical, mental, and psychological effort using a scale of 1-7 (1 = least effort, 7 = most effort). A composite effort score was calculated for each task and for each of 6 task categories: direct patient care, indirect patient care, searching for/finding things, educational/academic activities, personal/downtime activities, and other. Overall, the most difficult task was going to codes, which was also the most difficult psychological task. The most difficult physical task was placing a central line, and the most difficult mental task was transferring an unstable patient to the intensive care unit. The easiest task was using the Internet. That was also the easiest physical, mental, and psychological task. Direct patient care was more difficult than indirect patient care overall (3.58 vs 3.21; P < 0.001). We began the process of describing the workload of inpatient doctors by measuring the difficulty of the tasks they perform while admitting patients. To assess the relationship between workload and other outcomes (such as physician burnout and patient safety), it is essential that we be able to accurately measure workload.

Attitudes and Preferences Toward the Provision of Medication Abortion in an Urban Academic Internal Medicine Practice

Mifepristone offers internal medicine doctors the opportunity to greatly expand access to abortion for their patients. Almost 70% of pregnancy terminations, however, still occur in specialized clinics. No studies have examined the preferences of Internal Medicine patients specifically. Determine whether patient preference is a reason for the limited uptake of medication abortion among internal medicine physicians. Women aged 18-45 recruited from the waiting room in an urban academic internal medicine clinic. A semi-structured questionnaire was used to determine risk of unintended pregnancy and attitudes toward abortion. Support for provision of medication abortion in the internal medicine clinic was assessed with a yes/no question, followed by the open-ended question, "Why do you think this clinic should or should not offer medication abortion?" Subjects were asked whether it was very important, somewhat important, or not important for the internal medicine clinic to provide medication abortion. Of 102 women who met inclusion criteria, 90 completed the survey, yielding a response rate of 88%. Twenty-two percent were at risk of unintended pregnancy. 46.7% had had at least one lifetime abortion. Among those who would consider having an abortion, 67.7% responded yes to the question, "Do you think this clinic should offer medication abortions?" and 83.9% stated that it was "very important" or "somewhat important" to offer this service. Of women open to having an abortion, 87.1% stated that they would be interested in receiving a medication abortion from their primary care doctor. A clinically significant proportion of women in this urban internal medicine clinic were at risk of unintended pregnancy. Among those open to having an abortion, a wide majority would consider receiving it from their internal medicine doctor. The provision of medication abortion by internal medicine physicians has the potential to greatly expand abortion access for women.

Challenges of dermatology training among internal medicine resident doctors in Nigeria

Background : The scope of dermatology training varies in teaching hospitals across Nigeria. In some institutions, there is a department of dermatology while in others it is a unit in the internal medicine department. Some medical schools have clinical postings in dermatology while others do not. Although the number of dermatologists in the country has increased compared with a few years back when they were a handful, the numbers are still inadequate to train other health practitioners on skin disorders and to meet the needs of patients. The objective of the study was to determine the perceived challenges by residents with regards to dermatology training so as to provide adequate training and ultimately increase the number of dermatologist in the country Methods : This was a cross-sectional descriptive study among resident doctors in internal medicine attending the update course of the National Postgraduate Medical College in April 2012 at Lagos using a selfadministered questionnaire. Data was analysed with SPSS 16. Result : Ninety resident doctors (58 pre-part 1 and 32 post part 1) answered the questionnaire. Seventy two (80.9%) had at least one dermatologist currently in their training institution. Sixty seven (76.1%) of the respondents (35 pre-part 1 and 32 post-part 1) had undergone postings in dermatology. The length of training varied from 1- 6 months. Sixty (66.7%) of the residents had dermatology posting as undergraduates in medical school with the length of the posting ranging from 2-6 weeks (30.0% for two weeks, 23.3% for four weeks and 41.7% for more than four weeks). Residents felt they had inadequate exposure to procedural dermatology (surgery, lasers, aesthetic), dermatopathology and management of wounds. Inadequate research opportunity (55.9%), inadequate mentors (53.2%), and inadequate facilities (53.2%) were more important challenges to dermatology training perceived by more than 50% of the residents. Conclusion : Dermatology training at both undergraduate and post graduate level in Nigeria is variable in content and duration amongst training institutions in Nigeria. There is need to standardise undergraduate and postgraduate Dermatology training. Training institution should operate a standard structured dermatology posting for undergraduate training and adhere to available curriculums provided by the postgraduate colleges for postgraduate training. Adequate facilities should be provided in the training centres and were these are not in place candidates should go to other centres with adequate training facilities for their postings.

Effects of a Short Message Service Intervention on Adherence to Maximal Sterile Barrier Precautions and Catheter-Related Blood Stream Infections

Purpose: The purpose of this study was to investigate the effect of a short message service intervention on adherence to maximal barrier precautions (MBP) and catheter-related blood stream infections. Method: The data were collected from March to September, 2008, at an 826-bed university-affiliated hospital in Daejeon. The study participants were 24 physicians who were inserting central catheters and 133 patients (control group 78 and intervention group 55) with central catheter insertions. The researcher sent the message (adherence to MBP and optimal recommendations) to each internal medicine doctor using the short message service (SMS) for cellular phones. Messages were sent monthly for 3 months. Data were analyzed by chi-square test and t-test using SPSS 12.0 windows program. Result: Adherence to maximal barrier precautions was significantly increased from 44.9% to 69.1% (p=.006) after the SMS intervention. But changes in the rate of CRBSI (catheter related blood stream infection) between the intervention group (1.89) and the control group (4.45) were not significant (p=.323). Conclusions: The results indicate that the SMS intervention is effective in increasing the adherence to maximal barrier precautions and the SMS intervention can be recommended for utilization in infection control nursing practice.

Attitude and Knowledge of Physicians About Cancer Pain Management: Young Doctors of South Korea in Their Early Career

This study is aimed at evaluating the attitude and knowledge about the optimal use of opioids and finding out the barriers to cancer pain management especially for young doctors in South Korea. A survey through questionnaire form was conducted on 1204 physicians. Physicians were grouped by their medical specialties and personal characteristics. Specialties were grouped into internal medicine and family medicine doctors, surgeons, anesthesiologists, pediatricians, other board holders and general physicians. Personal characteristics were grouped by their past experiences and current surroundings. Though many doctors thought that they were fairly well educated for pain management strategy, a large population of physicians showed a negative attitude and inadequate knowledge status about cancer pain management. The degree of attitude and knowledge status was different as their specialties and personal experiences. The factors that affected doctors' attitude and knowledge were: (i) medical specialty, (ii) past history of using practical pain assessment tool, (iii) self-perception of knowledge status about pain management, (iv) experience of prescribing opioids, (v) experience of education for cancer pain management. Although many physicians had a passive attitude in prescribing opioid analgesics, they are willingly open to use opioids for cancer pain management in the future. The most important perceived barriers to optimal cancer pain management were the fear for risk of tolerance, drug addiction, side effects of opioid analgesics and knowledge deficit about opioid analgesics. From this study, we found that further education and practical training will be needed for adequate cancer pain management for young physicians in their early career.

Análisis de 2 años de actividad de Medicina Interna en los hospitales del Sistema Nacional de Salud

IntroductionWe present a summary of the results of the hospital activities of the Internal Medicine (IM) Departments of the National Health Care System during the years 2005-2006. Material and methodsThe patients hospitalized in the IM departments of Spain during 2005 and 2006 were analyzed according to the data obtained from the minimum basic data set (MBDS), in which the administrative data were collected (age, gender, personal data) and clinical data (one principal diagnosis and up to 1 secondary diagnosis and 19 clinical procedures) for all the patients hospitalized in the public and private hospitals of Spain. ResultsDuring this period, there were 7,130.85 discharges in our country, 1,099.65 of these being from IM. A total of 53.6% of the patients were male, with mean age of 70.6 years, mean stay of 10 days (standard deviation [SD] 11.7) and 9.9% deaths. A total of 9.7% of the patients were admitted through the Emergency Department. Mean weight was 1.74 (SD 1.41) according to the American classification system and 1.1 (SD 0.73) according to the National Health System data. Respiratory failure diagnostic related group (DRG-541, 88 and 101) accounted for 14% of the discharges and heart failure (DRG 17, 544 and 87) accounted for 1.4% of all the episodes. ConclusionsIn Spain, the internal medicine doctors attended one out of every 6 hospitalized patients. Admissions for more than half of the patients admitted due to cardiorespiratory disorder were unscheduled and one out of every 10 died during their stay. These data illustrate the importance of this specialty in the context of health care of our country.

The disposition of hepatitis C antibody‐positive patients in an urban hospital

Previous studies have indicated that only 26-61% of hepatitis C virus (HCV) antibody-positive patients are referred to specialists who treat HCV. However, these studies were conducted in homogeneous populations and before pegylated interferon and ribavirin became the standard of care for chronic HCV infection. The aims of this study were: (i) to determine the percentage of HCV antibody-positive patients who were referred to specialists for further management in an urban, racially diverse population, (ii) to determine the percentage of referred patients who attend specialty clinics, and (iii) to identify factors that predict referral and follow-up. All patients with a positive HCV antibody test in 2005 were identified by an inquiry of Epic, our electronic medical record system. All medical records were reviewed for demographics, location where the test was ordered (inpatient vs outpatient), specialty ordering the test, referral, clinic attendance, detectability of HCV RNA and liver function tests. Univariate and multivariate logistic regression were used to evaluate each variable's effect on referral and clinic attendance. Overall, 251 of 375 (67%) antibody positive patients were referred to HCV specialists. Of the 251 referrals, 166 (66%) attended at least one specialty clinic appointment. Patients were more likely to be referred if their HCV antibody was ordered in the outpatient setting (77% outpatient vs 38% inpatient, P < 0.001) ordered by a family practitioner (79% FP vs 64% for internal medicine doctor vs 58% for all other specialties, P = 0.01) had detectable RNA (88% detectable vs 65% not detectable vs 23% RNA status not available, P < 0.001) or elevation of alanine aminotransferase (75% elevated vs 56% not elevated, P < 0.001). Location, HCV RNA status and ALT elevation remained significant in a multivariate logistic regression model. These data confirm that up to one-third of HCV antibody-positive patients are not referred to HCV specialists, despite the availability of improved treatment regimens. Additional patients are lost to follow-up after being referred. The reasons for suboptimal referral and specialty clinic attendance rates are probably multifactorial. Institution of reflexive RNA testing for positive antibody tests and additional education of those physicians who encounter HCV-positive individuals may improve both rates.

Primary Care Physician Overestimate the Indications for Stress Ulcer Prophylaxis

Purpose: Gastric stress ulcers (SU) are acute superficial inflammatory lesions which occur due to severe physiologic stress. Despite evidence, there is widespread use of stress ulcer prophylaxis (SUP) in non-critically ill patients. Reasons for this are not clear and may involve issues other than medical attitudes or knowledge. We hypothesize that physicians overprescribe SUP due to over-estimation of the risk of SU. Methods: We developed an anonymous survey to assess physician attitudes and prescribing practices for SUP. To minimize bias, the survey contained a variety of questions and subjects were told the purpose was to assess general GI knowledge. All US internal and family medicine program directors were invited to encourage their residents and faculty to participate. The survey was also posted on 2 online physician communities. The following demographic information was collected: age, gender, date of medical school graduation, specialty, attending vs. resident, percent of time in critical care, academic practice vs. private practice, and geographic area of practice. 2 key survey items were analyzed. 1) “I place all patients in ICU on SUP”; correct answer=no. 2) “What percentage of your non-critically ill patients do you place on stress ulcer prophylaxis?”; correct answer=0-25%. Results: 581 physicians responded. 39% were attending physicians and 61% were residents. 42% were family practice physicians; 56% were internal medicine physicians. The majority of subjects spend <20% of their time in critical care settings. 75% of subjects practice in an academic setting and 25% in the private setting. Analyses used Fishers extact test with a p value of statistical significance <0.05. Comparisons were made for the following categories: attendings vs. residents, internal medicine vs. family medicine, amount of time in critical care, age in 10 year increments, academic vs. private practice. For question #1, 26% of subjects answered correctly. Internal medicine doctors answered correctly significantly more often that family medicine doctors (33% vs. 155; p=2.6 × 10−6); academic doctors answered correctly significantly more often that private practitioners (28% vs. 18%; p=0.012). For question #2, 43% of respondents answered correctly. Attending physicians answered correctly significantly more often than residents (56% vs. 35%; p=5.3 × 10−7); private practitioners answered correctly significantly more often than academicians (57% vs. 38%; p=4.7 × 10−5). Conclusion: This survey suggests that physicians overprescribe acid suppressive therapy for SUP and this may be due to overestimation of the need for SUP.

Misleading one detail: a preventable mode of diagnostic error?

Despite advances in our understanding of cognitive biases in clinical practice, little is known about correction or prevention of diagnostic errors. The presence of a single misleading detail may lead clinicians down a cognitive and actual path toward an incorrect diagnosis. In a large teaching hospital, we surveyed 51 attending doctors in internal medicine, presenting each with 10 clinical vignettes and soliciting their diagnosis of the condition leading to the presentation. Each of the 10 clinical cases included a single misleading detail. This survey elicited a wrong diagnosis in 90% of cases, which was reduced to 30% when omitting the misleading detail from the vignette. Diagnostic accuracy did not improve by warning doctors about potentially misleading information. Asking doctors to identify a leading diagnostic detail and then to formulate an alternative diagnosis after omission of the detail, significantly reduced diagnostic error rate by nearly 50%. Systematic re-examination of leading diagnostic clues may help to reduce errors in diagnosis.

Professional approaches in clinical judgements among senior and junior doctors: implications for medical education

BackgroundClinical experience has traditionally been highly valued in medical education and clinical healthcare. On account of its multi-faceted nature, clinical experience is mostly difficult to articulate, and is mainly expressed in clinical situations as professional approaches. Due to retirement, hospitals in Scandinavia will soon face a substantial decrease in the number of senior specialist doctors, and it has been discussed whether healthcare will suffer an immense loss of experienced-based knowledge when this senior group leaves the organization. Both senior specialists and junior colleagues are often involved in clinical education, but the way in which these two groups vary in professional approaches and contributions to clinical education has not been so well described. Cognitive psychology has contributed to the understanding of how experience may influence professional approaches, but such studies have not included the effect of differences in position and responsibilities that junior and senior doctors hold in clinical healthcare. In the light of the discussion above, it is essential to describe the professional approaches of senior doctors in relation to those of their junior colleagues. This study therefore aims to describe and compare the professional approaches of junior and senior doctors when making clinical judgements.MethodsCritical incident technique was used in interviews with nine senior doctors and nine junior doctors in internal medicine. The interviews were subjected to qualitative content analysis.ResultSenior and junior doctors expressed a variety of professional approaches in clinical judgement as follows: use of theoretical knowledge, use of prior experience of cases and courses of events, use of ethical and moral values, meeting and communicating with the patient, focusing on available information, relying on their own ability, getting support and guidance from others and being directed by the organization.ConclusionThe most prominent varieties of professional approaches were seen in use of knowledge and work-related experience. Senior doctors know how the organization has worked in the past and have acquired techniques with respect to long-term decisions and their consequences. Junior doctors, on the other hand, have developed techniques and expertise for making decisions based on a restricted amount of information, in relation to patients' wellbeing as well as organizational opportunities and constraints. This study contributes to medical education by elucidating the variation in professional approaches among junior and senior doctors, which can be used as a basis for discussion about clinical judgement, in both pre-clinical and clinical education. Further research is required to explain how these professional approaches are expressed and used in clinical education.

Consultation between specialists in Internal Medicine and Family Medicine improves management and prognosis of heart failure

Background and objective To evaluate if consultation between specialists in Internal Medicine and family doctors (CIMFD) improves the clinical management and prognosis of patients with heart failure (HF). Methods Design: prospective case-control study (5 years of follow-up). Setting: community-based sample within the area of a university teaching hospital. Subjects: 1857 patients (>= 14 years) diagnosed for the first time with HF (1stDxHF), in the CIMFD. Control group: 1981 patients (from health centres not covered by the CIMFD), 1stDxHF, in the external consultations of the hospital. Main outcome measures: mortality rate (MR). Admissions (HA). Emergency services visits (ESV). Delays in receiving specialist attention (DRSA), and the resolution of the process (DRP). Number (NTP) and delays in reporting (DTP) tests performed. Proportion (PRC) and delay (DRC) in resolving cases. Results We observed a reduction of: MR (by 10.8%, CI 95%, 8.6–13.0, p < 0.005); HA, per patient per year (ppy) (by 1.8, 1.3–2.3, p < 0.01); ESV, ppy (by 1.9, 1.2–2.6, p < 0.01); DRSA (by 26.5 days, 21.8–31.2, p < 0.001); DRP (by 21.0 days, 18.3–23.7, p < 0.001), and DRC (by 25.8 days, 20.3–31.4, p < 0.01). The PRC (17.2%, CI 95%, 15.5–18.9, p < 0.01) was higher for the CIMFD. Conclusion The CIMFD approach improves prognosis and efficacy in the clinical management of patients with HF because it reduces mortality and morbidity (HA and ESV), shortens the delays in receiving care and in resolving the diagnostic and therapeutic process (DRSA, DRP, DRC), and increases the proportion of diagnosed and treated patients.

El Plan Estratégico para el desarrollo de la Medicina Interna en Andalucía

The Strategic Plan for the Development of Internal Medicine in Andalusia arose from the need that the internal medicine doctors had to redefine the purpose and values of their specialty to cope with the numerous changes occurring in the health care area. The project was developed in three phases. First, the tendency of the health care system and current position of the specialty were analyzed. After, the internal and external opinions on the present-future of Internal Medicine were checked out. Finally, five strategic lines with their action plans were established. Specific objectives were defined within each line: results to be achieved, methodology according to action plan. After several years of collegial work in this initiative, very positive results have been achieved. We conclude that the Strategic Plan has been useful to better define the position of our specialty and to state which tools such as those mentioned are effective to cope with the new challenges that may occur in other groups.

Patterns of Drug Prescription for Japanese Cedar Pollinosis Using a Clinical Vignette Questionnaire

Although prescribed drugs directly affect patient outcome, the variation in physicians' attitudes towards drug therapy for cedar pollinosis has not been quantitatively assessed. This research investigated the prescription patterns of drugs for cedar pollinosis by ear, nose, and throat specialists (ENTs), general physicians (GPs) and internal medicine doctors (IMs) in Yamanashi Prefecture, Japan. A cross-sectional study was conducted by mailing questionnaires to 532 physicians in autumn 2006. The main part of the questionnaire constituted clinical vignettes of pollinosis cases with nasal and ocular symptoms ranging from mild to severe. We requested that the physicians fill out prescription medications they considered appropriate for each vignette. Responses from 172 physicians (32%) for six clinical vignettes were analyzed. The number of drugs prescribed by ENTs was significantly higher than that by GPs and IMs for vignettes representing moderate to severe cases (p < 0.004). The percentage of physicians who said they would prescribe nasal corticosteroid and eye drops was higher in the ENT group compared to the other two groups in these vignettes. In terms of second-generation antihistamines, no differences were observed between the three groups for all vignettes. Our investigation suggested that, compared to ENTs, GPs and IMs have a lower tendency to concomitantly prescribe drugs for localized treatment such as nasal corticosteroids and eye drops with oral medication. There may be differences in prescription patterns of drugs for pollinosis between ENTs and non-specialist physicians.

A Daughter’s Duty

A Daughter’s Duty