Influence of obstetric practice on workload and practice patterns of family physicians and obstetrician-gynecologists.

PURPOSE: Obstetric practice among family physicians has declined in recent years. This study compared the practice patterns of family physicians and obstetrician-gynecologists with and without obstetric practices to provide objective information on one potential reason for this decline--the impact of obstetrics on physician lifestyle. METHODS: In 2004, we surveyed all obstetrician-gynecologists, all rural family physicians, and a random sample of urban family physicians identified from professional association lists (N =2,564) about demographics, practice characteristics, and obstetric practices. RESULTS: A total of 1,197 physicians (46.7%) overall responded to the survey (41.5% of urban family physicians, 54.7% of rural family physicians, and 55.0% of obstetrician-gynecologists). After exclusions, 991 were included in the final data set. Twenty-seven percent of urban family physicians, 46% of rural family physicians, and 79% of obstetrician-gynecologists practiced obstetrics. The mean number of total professional hours worked per week was greater with obstetric practice than without for rural family physicians (55.4 vs 50.2, P=.005) and for obstetrician-gynecologists (58.3 vs 43.5, P = .000), but not for urban family physicians (47.8 vs 49.5, P = .27). For all 3 groups, physicians practicing obstetrics were more likely to provide inpatient care and take call than physicians not practicing obstetrics. Large proportions of family physicians, but not obstetrician-gynecologists, took their own call for obstetrics. Concerns about the litigation environment and personal issues were the most frequent reasons for stopping obstetric practice. CONCLUSIONS: Practicing obstetrics is associated with an increased workload for family physicians. Organizing practices to decrease the impact on lifestyle may support family physicians in practicing obstetrics.

Medical case teaching on the web.

BACKGROUND: Little is known about strategies for developing teaching cases and strategies for identifying design features that optimize a learner's interactions with Web-based cases. PURPOSES: We examined design features in Web cases that facilitated interactive and engaging learning. METHODS: Nine collaborators reviewed selected Web cases and documented the presence of features that facilitate interactive learning, including opportunities for information gathering, decision making, and receiving feedback. RESULTS: Eighteen Web sites offered cases. These cases mainly were narrated based on biomedical information without patient voices. The cases were organized in a linear structure from patient presentation to follow-up. Many cases presented only a single case. We found little use of features for augmenting a learner's interaction with cases. Only a handful of cases generated feedback on the basis of the learners' responses. CONCLUSION: Our study suggests ways to improve the development of Web cases. These methods contribute to future research in testing cases for educational effectiveness.

A prospective, double-blind, randomized trial of midazolam versus haloperidol versus lorazepam in the chemical restraint of violent and severely agitated patients.

OBJECTIVES: To determine if midazolam is superior to lorazepam or haloperidol in the management of violent and severely agitated patients in the emergency department. Superiority would be determined if midazolam resulted in a significantly shorter time to sedation and shorter time to arousal. METHODS: This was a randomized, prospective, double-blind study of a convenience sample of patients from an urban, county teaching emergency department. Participants included 111 violent and severely agitated patients. Patients were randomized to receive intramuscular midazolam (5 mg), lorazepam (2 mg), or haloperidol (5 mg). RESULTS: The mean (+/-SD) age was 40.7 (+/-13) years. The mean (+/-SD) time to sedation was 18.3 (+/-14) minutes for patients receiving midazolam, 28.3 (+/-25) minutes for haloperidol, and 32.2 (+/-20) minutes for lorazepam. Midazolam had a significantly shorter time to sedation than lorazepam and haloperidol (p < 0.05). The mean difference between midazolam and lorazepam was 13.0 minutes (95% confidence interval [95% CI] = 5.1 to 22.8 minutes) and that between midazolam and haloperidol was 9.9 minutes (95% CI = 0.5 to 19.3 minutes). Time to arousal was 81.9 minutes for patients receiving midazolam, 126.5 minutes for haloperidol, and 217.2 minutes for lorazepam. Time to arousal for midazolam was significantly shorter than for both haloperidol and lorazepam (p < 0.05). The mean difference in time to awakening between midazolam and lorazepam was 135.3 minutes (95% CI = 89 to 182 minutes) and that between midazolam and haloperidol was 44.6 minutes (95% CI = 9 to 80 minutes). There was no significant difference over time by repeated-measures analysis of variance between groups in regard to changes in systolic and diastolic blood pressure (p = 0.8965, p = 0.9581), heart rate (p = 0.5517), respiratory rate (p = 0.8191), and oxygen saturation (p = 0.8991). CONCLUSIONS: Midazolam has a significantly shorter time to onset of sedation and a more rapid time to arousal than lorazepam or haloperidol. The efficacies of all three drugs appear to be similar.

EMS activation in a cohort of critically ill patients.

The objective of this study was to examine Emergency Medical Services (EMS) activation in a cohort of critically ill patients and to evaluate whether factors such as perceived difficulty of access to emergency care, insurance status, and educational level are associated with EMS use. Patients admitted from the emergency department to the intensive care unit (ICU) of an urban county hospital for diagnoses other than acute cardiac conditions or stroke were interviewed about EMS use. Overall EMS use was found to be 52%. Primary reasons for not activating EMS were a belief that symptoms were not serious (36%) or that self-transport was faster (25%). The only factors significantly associated with bypassing EMS were car ownership, lack of health insurance, and self-decision to go to an emergency department. Sixty-eight percent of the sample reported little difficulty in accessing emergency care. In conclusion, because of a belief that symptoms were not serious or self-transport would be faster, nearly half of the critically ill patient sample did not activate EMS. Patient education about warning sign recognition for serious illnesses and about the potential benefits derived from EMS should be improved.