Untrained Physicians Research Articles

Comparison of the AMI 9700 Aorta Scanner to Computed Tomography Imaging for Abdominal Aortic Diameter Measurement

An abdominal aortic aneurysm (AAA) is a localized dilation of the aorta to greater than 1.5 times its normal diameter. AAA is diagnosed if the diameter of the aorta is greater than 3cm, which is determined through imaging of the vessel. Elective repair before aneurysm rupture can significantly decrease mortality; thus, early detection is critical for AAA management. Despite increased point-of-care ultrasound (US) training in the medical community, the use of 2D ultrasonography is not yet ubiquitous. The AMI 9700 provides an automated way to screen for AAA at the bedside which allows for faster assessment in the emergency department (ED) compared to computed tomography (CT). This device may allow physicians to quickly detect AAA in acutely symptomatic patients, leading to decreased time to intervention and reduced mortality. Additionally, users may not need formal training in US to use the device. The primary objective of this study is to compare measurements of the abdominal aorta obtained using the AMI 9700 device with those obtained through CT imaging. A secondary objective of this study is to assess the ease of use of the AMI 9700 by comparing measurements obtained by US-trained and untrained physicians. US-trained physicians are defined as those who have completed or are currently enrolled in an US fellowship. This prospective study was conducted in the ED of North Shore University Hospital, a suburban, university-affiliated institution. A convenience sample was obtained, based on investigator availability, of patients 18 years and older undergoing an abdominal CT scan with intravenous contrast for abdominal or flank pain. Subjects received AMI 9700 scans by two user groups, US-trained and untrained physicians. The diameter of the abdominal aorta was measured at four distinct locations of the abdomen. The groups were blinded to each other's measurements, and the maximum diameter was used for comparison. The abdominal CT studies were viewed on a standard GE PACS image monitor, and the maximum diameter of the abdominal aorta was recorded. Sensitivity and specificity were calculated, along with associated 95% exact binomial confidence intervals (CI). A total of 33 subjects received both AMI 9700 and abdominal CT scans. The number of abdominal aorta diameters greater than or equal to 3cm as measured by the AMI 9700 were 9 (27.3%) and 5 (15.2%) for the US-trained and untrained groups, respectively. The number of abdominal aorta diameters less than 3cm were 24 (72.7%) and 28 (84.8%) for the US-trained and untrained groups, respectively. For the abdominal CT studies, 2 (6.1%) aorta measurements were greater than or equal to 3cm, and 31 (93.9%) were less than 3cm. Sensitivity was 100% (95% CI: 22.4-100%) and 50% (95% CI: 1.3-98.7%) for the US-trained and untrained groups, respectively. Specificity was 75.9% (95% CI: 56.5-89.7%) and 84.6% (95% CI: 65.1-95.6%) for the US-trained and untrained groups, respectively. In the hands of a clinician with US training, the AMI 9700 was highly sensitive and may be an effective screening tool for AAA in symptomatic ED patients. While specificity was high, positive results should be followed by a formal US or CT to confirm and better characterize the abdominal aorta. Enrollment will continue to improve the CI and further evaluate the role of this device as a screening tool for untrained operators.

Differences in the Determination of Cause and Manner of 127 Natural Death Cases by Postmortem Inspection and Autopsy

Medicolegal investigations in Korea depend mostly on postmortem inspection without autopsy. Both untrained physicians and experienced forensic pathologists may not be able to determine the cause and manner of death only by postmortem inspection. The aim of our study was to show the limitations of postmortem inspection by evaluating the discrepancy between the results of postmortem inspection and autopsy after natural death. The manner of death by postmortem inspection changed to unnatural death in 9.4% of the cases (12 cases/127 cases) after autopsy. The cause of death in most cases was consumption of alcohol, agricultural chemicals, and antipsychotic intoxication. The cause of death by postmortem inspection changed in 24.3% of the cases (26 cases/107 cases) among cases of confirmed natural death after autopsy. The positive predictive value of cause of death by postmortem inspection was higher for cardiovascular disease (79.0%) and lower for chronic alcoholism and/or chronic liver disease (28.6%). This study shows that forensic pathologists could make considerable errors in determining the cause and manner of death without autopsy and emphasizes the necessity to refine medico-legal investigations in Korea by introducing the limited autopsy with toxicologic study and supportive postmortem imaging.

Impact of an educational program on the management of bipolar disorder in primary care

Government agencies and industry have recently undertaken educational programs for the management of bipolar disorder in primary care, but their medical impact is not well known. Therefore, we conducted a survey among general practitioners to evaluate the impact of the Bipolact Educational Program on the diagnosis and treatment of bipolar disorder. A total of 45 general practitioners attending the Bipolact Educational Program (trained group) were compared with a control group of 50 untrained general practitioners on their ability to: (i) diagnose bipolar I and II disorders and (ii) treat bipolar disorder patients appropriately. Trained physicians, but not untrained physicians, showed a significant improvement (p < 0.0001, chi-square test) in the ability to identify patients as having bipolar I (from 10.4% to 28.8%) and bipolar II disorder (from 20.1% to 45.8%). This trend resulted in a strong decrease in nonidentified bipolar disorder patients (from 64.6% to 19.5%). Trained physicians, but not the untrained group, greatly increased the number of prescriptions for mood stabilizers for bipolar disorder patients, from 25.6% to 43.2% (p = 0.0013, chi-square test). Finally, trained physicians reduced the number of antidepressant prescriptions for bipolar disorder patients (the control group also reduced the number of antidepressant prescriptions, suggesting some bias in the survey). A well-designed education package on diagnosis and management of bipolar disorder greatly increased the likelihood of physicians correctly assigning a subtype, namely bipolar I or bipolar II disorder, to patients already perceived as having some form of bipolar illness, and to prescribing mood stabilizers instead of antidepressants to these patients.

Variability in data: The Society of Thoracic Surgeons National Adult Cardiac Surgery Database

Since 1989, data have been reported to the Society of Thoracic Surgeons National Adult Cardiac Surgery Database for quality improvement. This information is also data mined for national quality indicators, policy initiatives, and research. Such use has important limitations, because data elements cannot be verified for accuracy. We determined variability of disease etiology and operative data database elements when abstracted by untrained physician abstractors. We selected 30 patients who underwent cardiovascular surgery from January to December 2005 (10 each of coronary artery bypass grafting, mitral valve repairs, and aortic valve and associated aortic procedures). Four abstractors (2 cardiothoracic residents and 2 fellows) abstracted 28 variables. Results were compared with abstraction performed by a professional abstractor. Median percentage agreement among all cases was 89% (range, 42%-100%). Agreements were 94% (28%-100%) for mitral valve, 84% (48%-100%) for aortic valve, and 93% (35%-100%) for coronary artery bypass grafting. Among the aortic valve group, etiology of aortic valve disease had poor agreement (68%) because of cases in which multiple definitions could apply. Degree of valvular regurgitation also had poor agreement (median, 67%; range, 28%-95%). Number of internal thoracic artery grafts and absence of significant valvular disease were reported consistently. Agreements between types of aortic valve procedure and between methods of mitral valve repair (65% and 83%, respectively) were less than expected. We found variable agreement among untrained data abstractors. This has important implications regarding interpretation of database studies with de-identified data. Without good quality control and consistent standardized definitions, aggregate data in clinical databases may be suspect.

A Physician-Directed Intervention: Teaching and Measuring Better Informed Consent

To improve physician communication with parents using a physician-directed intervention (PDI), emphasizing a sequenced approach to the informed consent conference (ICC) for childhood leukemia clinical trials in which physicians discuss diagnosis, prognosis, and treatment prior to the offer of a clinical trial. Physicians and fellows at the Children's Hospital of Philadelphia and Children's National Medical Center were recruited to participate in Informed Consent Seminars and subsequent half-day booster sessions. Training was followed by a multisite study of informed consent communication. Real-life ICCs were observed and audiotaped, and parents were interviewed after the ICC to ascertain their understanding. Data from the ICC and interview were then coded and analyzed. Trained physician performances were compared with untrained physicians (controls) at two other research sites. Data were collected from 2003 to 2007 at PDI sites and control sites for comparison. A total of 102 cases were included for initial analyses, with 60 cases from the PDI sites and 42 control cases. Fifty-nine cases were included in the final analysis. Findings revealed that trained physicians followed the sequenced approach more often when compared with controls. Similarly, physicians at the PDI sites tended to elicit parental questions and understanding in an open-ended way and clarify parents' questions more frequently than physicians at the control sites. Academic physicians who are involved in the current transformation of clinical research should be trained to conduct effective ICCs. The "see one, do one, teach one" approach is no longer adequate for informed consent.

‘I WILL NOT CUT . . . ’: THE OATH THAT DEFINED UROLOGY

To explore different interpretations of the clause embedded in the Hippocratic Oath, prohibiting surgery for stones, and its relevance for urology. Various translations of the Oath, from the original Greek edition to historical revisions, were reviewed. Controversy surrounds different translations and interpretations of the Oath about the practice of lithotomy among ancient healers. The reasons Hippocratic physicians were prohibited from performing lithotomy are several, but the consensus is that untrained physicians pledged not to undertake such a complicated procedure, but to refer their patients to other healers who specialized in that practice. The Hippocratic Oath actually defined, identified and legitimized urology as the first medical speciality.

Turf Wars in Radiology: The Future of Radiology Depends on Research—And on Your Support of It!

The private practice radiology community relies on academic radiology departments to (1) do research and make advances in imaging science, (2) justify reimbursement for those advances, and (3) train new generations of radiologists. This has been largely a one-sided arrangement, with the academic departments footing the bill and the private practice community deriving the benefits and pretty much getting a free ride. But academic radiology is facing a crisis, and the research productivity of our specialty is in jeopardy. Leadership in research is a crucial element in the effort to keep out untrained and inexperienced physicians from other specialties who are largely motivated by the desire for profit. Better support from private practice radiologists is badly needed to help their academic colleagues maintain that research leadership.

The 2005 Robert D. Moreton Lecture: The Inappropriate Utilization of Imaging Through Self-Referral

Self-referral in diagnostic imaging has adverse consequences for our health care system. It inevitably leads to overutilization. If untrained physicians try to interpret images, they will make avoidable errors. Imaging facilities operated by untrained physicians are more likely to produce poor-quality examinations. These statements are backed up by abundant evidence in the medical literature. Major payers such as Medicare and the Blue Cross Blue Shield Association are aware of the problem. There are a number of possible remedies, and it remains to be seen whether they and other payers will adopt them.

Endotracheal intubation in prehospital treatment of children with craniocerebral injuries

Intubation and airway control of injured children is of vital importance, but despite its advantages is associated with meny risks when is performed outside the hospital and by the untrained physicians. Aim of this study was to determine the importance for the survival of the children with craniocerebral injuries, and also for final outcome of treatment. This study is a clinical, partly prospective, partly retrospective that includes 60 patients (two groups with 30 patients) with isolated craniocerebral injures, aged up to 17 years, and with GCS under 8, that did not require surgical treatment. The first group included patients that were endotracheal intubated, and the other group included patients that were not intubated. Theree was no statistically difference between groups regarding the sex, age and GCS. Regarding the endotracheal intubation there was a statistically significant difference, in the first group 86,7% of the patients were intubated during the prehospital treatment, while 16,7% of the patients from group II were intubated. A greater percentage of patients from group I underwent controlled (66,7%) or assisted (20%) mode of ventilation, and 13,3% of patients were on spontaneus breathing. Endotracheal intubation should be performed by an experienced physician with an adequate equipment.

Effectiveness of an intubating laryngeal mask airway (ILMA Fastrach) used by nurses during out-of-hospital cardiac arrest resuscitation

ILMA Fastrach is a good alternative to difficult endotracheal intubation even by an untrained physician but has never been studied in a out-of-hospital setting. Our aim was to evaluate the efficiency of this device used by untrained nurses in out-of-hospital cardiac arrest (OHCA).

E-25. Effective treatments for smoking: Established and experimental approaches

Treatment for tobacco smoking can be either behavioural or pharmacological. Among the behavioural methods cognitive behaviour therapy is probably the most effective procedure but also expensive and seldom available. Fortunately simpler counselling methods that can easily be applied by untrained physicians and nurses are also effective. The US practice guideline for treatment of tobacco dependence [l] has found the following approaches to be effective; simple brief advice, a dose response effect of time spent counselling with an effect from even t3 minutes time, a dose response effect of number of sessions and total time spent counselling up to 300 minutes. Content and procedures with good efficacy is general problem solving, rapid smoking (inhaling from a cigarettes approximately every 7th second until nausea or vomiting occurs) and availability of social support. Today there are programs on the internet that are believed to be effective, particularly those which are interactive. Among the pharmacological treatments nicotine replacement (NR), most commonly in the forms of gum and patch, has been on the market for 2.5 years. Its safety is excellent with hardly any contraindications for smokers. An exempt is with pregnancy. Pregnant smokers should take extra care to not use nicotine in any form but they should be recommended NR, e.g. a patch worn for 16 hours if they can not stop smoking otherwise. Nicotine per se has been implied in some in vitro studies to be a cancer promotor but that has never been proven in human in vivo studies. The absorption of nicotine is much slower from the NR products than from the cigarette that on top of higher venous nicotine concentrations also causes high arterial boli coinciding with each inhalation. The different administration forms are all equally effective with close to a doubling of success rates 1 year after quitting. Underdosing is common and therefore encouraging the patient to consume appropriate doses is important. Overdosing is virtually unheard of. One way to avoid underdosing is to use a patch and combine it with one of the more acute administration forms, e.g. gum, lozenge, oral inhaler [2]. In Sweden, where smoke free tobacco use is more common than smoking among men as many men have used smoke free tobacco to give up smoking as have used NR. Some US experience also shows that smokefree tobacco can be preferred and helpful in aiding stopping smoking [3]. A more recent pharmacological treatment is Bupropion (B) which is a reuptake inhibitor of dopamine and noradrenaline and a nicotine receptor antagonist [4]. The effects of Bupropion are also well known since before it was tested as a treatment for tobacco dependence it had been used as an antidepressant for many years. The efficacy of B is similar to that of NR. Patients considered for B have to be more carefully monitored in order to screen for some contraindications, most important susceptibility to seizures. B has been found to be effective among earlier failures on NR and even B itself. Some clinicians also combine NR and B in more dependent smokers [5]. Among the experimental treatments there are several “vaccines” in development that will create antibodies against nicotine and thus reduce the rewarding effects of nicotine in the brain. It is thought that the vaccines possibly can be used for, a. achieving abstinence, b. avoiding relapse and c. primary prevention. No efficacy trials have been reported yet [6]. The most advanced vaccines are in phase II currently. There are also new non-nicotinic substances under clinical development for treatment of tobacco dependence. The two most well known are a THC receptor antagonist (Rimonabont) and a partial nicotine agonist that both are in phase II-III development. Also new NR products with faster uptake and higher dose delivered are being developed. New uses of particularly the NR products are also to be expected like for example a. long term relapse prevention, b. temporary abstinence, and c. gradual reduction of smoking to quit. Never before has the physician had better tools available to help deal with the dependence that causes premature death in half of its life long users.

The ability of trained nurses to detect lumps in a test set of silicone breast models.

Screening for breast carcinoma is a Healthy People 2000 objective and physical examination is an important component of the screening process. However, many women do not have access to a high quality breast examination. To help address this problem for Native American women, the authors developed the Nurses Providing Annual Cancer Screening (NPACS) training program, a week-long training session conducted at the nurses' clinical site. The goal of the current study was to demonstrate that, after receiving training, the nurses can detect masses in breast models at acceptably high rates. Thirty-four nurses who had completed the NPACS training program performed examinations of a test set of six silicone breast models. True-positive and false-positive rates of lump detection were calculated. The nurses were able to detect more lumps in the simulated breasts than both untrained and trained physicians tested in previous trials using the same methodology. On the average, nurses found 76% of the 18 lumps in the 6 breast models. However, their rate of false-positive detections also was somewhat higher. Although the modal number of false-positive detections for both physicians and nurses was 0, the median number of false-positive detections was 0 for the physicians and 1.0 for the nurses. In the current study, trained nurses were able to detect masses in breast models at high rates. This observation suggests that widespread training of nurses to perform screening breast examinations might be considered as a response to the breast carcinoma screening needs of adult women.

Improving Physicians' Interviewing Skills and Reducing Patients' Emotional Distress

Despite high prevalence, emotional distress among primary care patients often goes unrecognized during routine medical encounters. To explore the effect of communication-skills training on the process and outcome of care associated with patients' emotional distress. A randomized, controlled field trial was conducted with 69 primary care physicians and 648 of their patients. Physicians were randomized to a no-training control group or one of two communication-skills training courses designed to help physicians address patients' emotional distress. The two training courses addressed communication through problem-defining skills or emotion-handling skills. All office visits of study physicians were audiotaped until five emotionally distressed and five nondistressed patients were enrolled based on patient response to the General Health Questionnaire. Physicians were also audiotaped interviewing a simulated patient to evaluate clinical proficiency. Telephone monitoring of distressed patients for utilization of medical services and General Health Questionnaire scores was conducted 2 weeks, 3 months, and 6 months after their audiotaped office visits. Audiotape analysis of actual and simulated patients showed that trained physicians used significantly more problem-defining and emotion-handling skills than did untrained physicians, without increasing the length of the visit. Trained physicians also reported more psychosocial problems, engaged in more strategies for managing emotional problems with actual patients, and scored higher in clinical proficiency with simulated patients. Patients of trained physicians reported reduction in emotional distress for as long as 6 months. Important changes in physicians' communication skills were evident after an 8-hour program. The training improved the process and outcome of care without lengthening the visits.

Does curriculum make a difference? A comparison of family physicians with and without rheumatology training during residency.

To assess the long-term effect of an extensive rheumatology curriculum on graduates of family practice residencies. Cohort analytic study using a mailed survey and a multiple-choice test based on clinical vignettes that were administered 3 to 7 years after graduation from residency training. Practicing family physicians who had graduated from a community hospital family practice residency with an extensive rheumatology curriculum (trained) were compared with graduates from a similar program without specific rheumatology training (untrained). Total test scores, results of individual test questions, practice style, and attitudes toward rheumatology training and practice. We received 39 (85%) responses from 46 potential respondents in the trained group and 25 (89%) responses from 28 potential respondents in the untrained group. Physicians in the two groups had similar backgrounds and practice styles. The trained physicians scored higher on the multiple-choice test (mean +/- SD, 25 +/- 5 vs 22 +/- 6; P < .03). The clinical significance of these differences is a matter of individual interpretation. One hundred percent of the trained physicians believed that the quality of their rheumatology training was good to excellent compared with 25% of the untrained physicians. Seventy-six percent of the untrained physicians wished that they knew more about rheumatology. No variables other than rheumatology training accounted for the differences between the two groups. The difference in rheumatology knowledge, evident during and soon after residency between trained and untrained physicians, persists for 3 to 7 years.

わが国産業医制度の現状と改善の方策

Occupational Health Physician (OHP) has been defined as a title in the Occupational Safety and Health Law since 1972 when the Law was first implemented. The Law stipulates that each manager of an establishment with 50 or more workers is requested to appoint an OHP from among qualified physicians. The small number of applicants to OHP, especially from the younger generation, has continued for more than twenty years causing the average age of OHPs in Japan to rise. The shortage of successors to OHPs in active service is also very serious. A rapid increase in the number of graduates from medical schools is expected in the near future and as a result many untrained physicians in occupational health will flow into this field. It is necessary to establish an educational and training system which is related to an OHP certification system, so that the ability of OHP can be improved and that they will be able to expand their specialty. To reach this final goal, analyses and planning on the following issues of OHP must be done comprehensively; responsibilities, specialty, educational methods and course, necessary number to be trained and its allocation, and cooperation with other specialists in the field. It is also crucial to establish an effective relationship between the occupational health service system and the community health service system. Some suggestions are made to promote these issues.

A Randomized Trial of Physician Training for Smoking Cessation

Abstract This randomized controlled trial investigated the effects of a smoking cessation workshop on physician practices and on patients' smoking behavior. Eighty-three community family physicians were randomly allocated by practice to either 1) a Usual Care condition, 2) a group in which physicians were not trained but were asked to address smoking cessation with specific patients, or 3) a condition which included physician training as well as printed resources and in which specific patients were identified as smokers. The intervention taught to the physicians through a four hour training workshop included providing advice about stopping smoking, the setting of a date for stopping, the offer of nicotine gum, take-home materials, and the offer of follow-up visits. The intervention was described, demonstrated, and the physicians practiced with simulated patients. The outcome of the intervention was assessed in terms of physician behavior and patient smoking behavior. Exit interviews with patients demonstrated that patients of trained physicians did not differ from patients of untrained physicians on how willing they were to try to stop smoking nor on their receptiveness to nicotine gum. However, there was a small but statistically significant difference favoring the patients from the trained physician group who successfully stopped smoking.

The American College of Surgeons and surgical education.

In the seventy-two years since its founding, the American College of Surgeons has changed from an organization directed toward improving the skills of a large number of poorly educated and essentially untrained physicians who were already doing surgery, to an international organization of approximately 50,000 surgeons over 95 per cent of whom have already been certified by a surgical specialty board. The College today, in addition to its numerous scientific meetings and ongoing educational programs, participates, with other organizations, in the accreditation of properly functioning hospitals, in maintaining standards of surgical training programs and in the examination and certification of candidates after the completion of the required training in approved programs. Today the College engages in a far wider range of activities than could have been envisioned by its founders and indeed, it has become an influential voice for surgery throughout the world. But its primary purpose has remained unchanged. Simply stated, it is to improve the care of the surgical patient.

Vasoplasty: flap operation.

Vasoplasty was performed in 40 cases by the flap technique; the patency rate was 79% and the pregnancy rate 34%. The method produced acceptable results almost as good as those achieved by microsurgery but without the need for expensive apparatus and long training.

Determination of the viability of muscle soon after wounding. Experimental studies using local dye for delineation of vital and nonvital muscle.

THE PRINCIPLE of local wound treatment has been wound debridement. In undebrided wounds, devitalized muscle is a bed for bacterial growth with subsequent local infection which may progress to septicemia or clostridial myositis. For the untrained and/or inexperienced surgeon, such as would likely play a role in mass casualty situations, determination of the viability of muscle soon after wounding is difficult. Only a surgeon who has had considerable experience in debriding wounds develops sufficient clinical judgment to accomplish a good debridement. The criteria used to determine dead muscle vary with the surgeon as they are based on individual experience. Primarily though, surgeons determine viability of the muscle at operation based on one or more of the following factors: contractability, consistency, color, and ability of the muscle to bleed.¹None of these criteria, either singly or in combination, is completely reliable. For the untrained or inexperienced physician, evaluation by use

The Future of the Radiologist

The term radiologist should, first of all, indicate a capable, well trained physician who has, in addition, mastered the art and science of radiology which he intelligently applies to both diagnosis and therapy to the fullest extent of its development. It is now well established that such a training is parallel with that of a surgical training, and requires a minimum of three years, to be spent with a physician or group of physicians who have a large clientele of radiologic cases. This training apparently should qualify a physician for the specialty of radiology. However, when we consider the broadness of the radiologic field and its intimate relation with all other specialties, it is reasonable to assume that such a training is only preparation for a radiologic practice. Then what of the future? How are we to maintain our position as consultants in all the specialties, as well as desirable consultants for the general practitioners? It seems to me the future presents a problem of equal importance to the preliminary training. The careful reading of all the special journals is obviously necessary if the radiologist is to keep abreast with the developments in medicine; particularly is this true of all articles which have a bearing on diseases and organs which can be examined roentgenographically and treated by roentgen therapy. This, however, is not in itself sufficient. We are still consultants in the opinion of our confrères and to maintain such a status it will be necessary to keep abreast with the developments of all the special branches of medicine if we wish to be indispensable consultants instead of radiographers with a laboratory. With such a background, no radiologist need fear the lack of referring doctors who want his opinion and who feel that the expense of such an examination is perfectly reasonable, nor need there be fear of competition from the untrained physician who buys an x-ray machine for his office. Perhaps it might appear reasonable that the specialists could best qualify themselves individually in radiology and thereby conduct their own radiologic examinations. However, this usually is not practical. First, the capable radiologist is the consultant for a number of specialties in the same field and has access to a much greater number of cases than the individual specialist. This gives him a much broader experience. Second, roentgen examination will often reveal lesions which overlap the special fields of medicine. As an example, examination of a patient with low back pain may reveal the presence of a ureteral stone, a pathologic gall bladder, a tumor in the pelvis, an aneurysm of the renal artery, a kidney tumor, a bone lesion of the lumbar spine, a tumor of the spinal canal, or many another abnormal change which may be responsible for the patient's symptoms. One or several of these conditions may be present in the same individual.