Distraction osteogenesis of the mandible for airway obstruction in children.

OBJECTIVES: Objectives of the study were to determine the effectiveness of distraction osteogenesis of the mandible to relieve airway obstruction in children with tongue-base airway obstruction and to describe the new surgical techniques developed for use in infants and young children. STUDY DESIGN: Prospective, nonrandomized study. METHODS: Analysis of 11 children with severe airway obstruction secondary to tongue-base obstruction was performed. Patients were between 2 weeks and 5.5 years of age. All patients underwent distraction osteogenesis of the mandible. RESULTS: Twelve distraction procedures in the 11 children in the study were accomplished; decannulation or extubation was successful in all children. CONCLUSION: Distraction osteogenesis of the mandible can be used to treat tongue-base airway obstruction in appropriately selected children.

The quality of psychiatric residency : the assessment of programs and options for distributing psychiatric residents in the service of health care reform.

Recent health care reform initiatives proposed training fewer medical specialists, including psychiatrists, and determining the size and location of training programs via centralized regulatory mechanisms. Facing such potential future developments, the American Association of Directors of Psychiatric Residency Training appointed a Task Force on the Quality of Residency Programs to develop informed recommendations for the field. This paper describes the Task Force's considerations and recommendations concerning how the least damaging and most effective decisions could be made regarding the distribution of residency positions, program size, and the future funding of training stipends. The recommendations emphasize voluntary decisions, feedback from local and regional stakeholders regarding perceived needs and demands for psychiatrists, and Federal or regional funding of postgraduate training stipends that are not primarily tied to providing clinical services.

USMLE (United States medical licensing examination) step 1 examination. Legal vulnerability.

Since the passage of the Civil Rights Act of 1964, the courts have ruled that sponsors of job entry assessment procedures must demonstrate the absence of discrimination against minorities. If an assessment discriminates, the courts may prohibit the use of the assessment unless the assessment is linked to a job analysis and exhibits validity. In 1994, the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME) instituted a three-step USMLE examination program as a single pathway for medical licensure. The Step 1 examination is not linked to a physician job analysis, exhibits lower scores for minority groups, and lacks construct validity. To avoid the chaos and expense of a protracted legal challenge, the FSMB and the NBME may need to revise the Step 1 examination, or discontinue it as a requirement of medical licensure.

Stability of standardized patients' performance in a study of clinical decision making.

BACKGROUND: Standardized patients (SPs) have been used extensively in teaching, but their reliability for use in research has been infrequently addressed. This study analyzes the reliability of performance of 13 SPs during 228 doctor-patient encounters in a year-long study related to the diagnosis of depression. METHODS: Patient scenarios were based on real patient cases. Four of the five cases had major depressive disorder. Two to three SPs were coached to enact each of the five case scenarios. Medical encounters were videotaped. Interview content was extracted onto a standardized checklist. Interaction between physician and patient was measured by the Interactional System for Interview Evaluation. Tests of SP performance reliability included the: 1) consistency of symptoms volunteered, 2) stability of affect and behavior, and 3) association of SP performance to detection of depression. RESULTS: The mean number of SP performances was 20.8 (SD = 5.8), with a range of 6 to 28. Problems with reliability emerged in one of the five patient cases. Results otherwise revealed high intra-performance and inter-performance reliabilities. Detection of depression was consistent across SPs and with the rates reported in the literature. CONCLUSIONS: This study provides evidence that performances, within and among SPs, remained consistent, even when intervals between performances were as long as 3 months.

Psychosocial interest, medical interviews, and the recognition of depression.

OBJECTIVES: To measure primary care physicians' attitudes toward psychosocial issues, determine their relationship to the style of the medical interview, and assess whether attitudes and interview behaviors lead to correct diagnosis in patients with depression. DESIGN: Physicians were videotaped while interviewing four patients standardized with criteria symptoms of major depression. Physicians were unaware of the mental health focus of the study. SETTING: Patient examining rooms. PARTICIPANTS: Physicians were eligible for recruitment if they were board certified or eligible in family practice or internal medicine, practiced primary care medicine, and were listed in regional directories. Standardized patients were recruited from the community. MAIN OUTCOME MEASURES: Attitudes toward psychosocial issues (measured by the Physician Belief Scale), interview content (measured by review of the videotaped encounters), interview behaviors (measured by the Interaction Analysis System for Interview Evaluation), and a listing of depression in the differential diagnosis (determined by physician debriefing interviews). RESULTS: Forty-seven community-based practitioners participated. Forty-eight percent of interviews resulted in a diagnosis of depression. Physician Belief Scale scores were not significantly correlated with patient-centered interviewing, psychosocial questions, inquiry about depression symptoms, or a depression diagnosis. Longer interviews were more likely to result in a depression diagnosis. CONCLUSIONS: High interest in psychosocial issues was not associated with patient-centered interviewing behaviors, questions about psychosocial or depression symptoms, or depression diagnoses. However, certain patient-centered interviewing behaviors, particularly those defined as "affective," did lead to the recognition of depression.

Evaluating consultation psychiatry residents.

The overall goal of this report is to provide a list of recommendations to consultation-liaison (C-L) unit chiefs for the evaluation of psychiatric residents in conjunction with the latters' assignments to the C-L service. Following a fairly extensive review of references on evaluation, the authors developed 13 recommendations: written examination materials; development of problem-solving assessment techniques; Case Presentation Inventory; and peer assessment and other nontraditional sources of performance ratings. The authors emphasize the need for direct observation of resident performance, and the problem of achieving good interrater reliability when using subjective ratings of resident performance.

Mobile mammography: the technologist's role.

This article discusses the role of the radiologic technologist in a mobile mammography screening program targeted at the economically disadvantaged in Dade County, Fla. It describes the development of process, structure and outcome standards used to guide and evaluate both the program and the radiologic technologist within this setting, highlighting the technologists' valuable contributions to the program.

Evidence of the role of psychosocial factors in diabetes mellitus: a review.

Diabetes mellitus is a very prevalent illness that produces a variety of stresses for the individual patient, but the role of psychosocial factors in this illness is frequently minimized in the teaching of physicians and the care of patients. The authors review a framework for evaluating the role of psychosocial issues in illness in general and examine the evidence that demonstrates the importance of these issues in diabetes.

Facial augmentation with Proplast and nonporous hydroxylapatite in rhesus monkeys.

Using an extra-oral approach, subperiosteal pockets were created bilaterally over zygomatic and mandibular areas in six Rhesus monkeys. One side of each anatomic site received a Proplast I implant and the contralateral a nonporous hydroxylapatite (NPHA) block. Two animals were killed postoperatively at 3, 6, and 12 months, and the implants retrieved en bloc for histologic evaluation. Clinical evaluation showed the Proplast implants more stable than NPHA implants. Histologic evaluation for Proplast implants demonstrated complete encapsulation, fibrous tissue infiltration, fragmentation of implants, and some giant cell reaction. The NPHA implants were completely encapsulated with fibrous tissues, and no giant cell response, fragmentation, biodegradation, or bone formation was observed. We concluded that the Proplast was more stable than NPHA implants, but the NPHA produced less inflammatory cell and giant cell reaction.

Interrater reliability in evaluating trainee interviewing skills.

The reliability of the evaluative judgments by psychiatric faculty of physician-trainee interviewing skills was studied. Three methods were included: global rating scales, data checklists, and a time-allotment form. Data were obtained during a training workshop for psychiatric instructors in the U.S. The authors found low interrater reliability with all three methods. The study findings were replicated at a second workshop with Canadian faculty. The authors outline some recommended modifications of observational systems that may help improve both the accuracy and reliability of ratings of trainee interviewing skills. The use of more accurate quantitative techniques is briefly reviewed.

House officer interviewing techniques: impact on data elicitation and patient perceptions.

The relationships among physicians' interviewing techniques, the amount and type of data gathered, and patients' perceptions of the interviewing process were studied. Thirty-one Internal Medicine house officers each interviewed one of three standardized patients. The house officers' thoroughness of data collection was assessed by the patients and by a trained evaluator. A videotape of each interview was analyzed at the National Board of Medical Examiners using the interaction analysis system for interview evaluation, ISIE-81, to define house officers' interviewing techniques. From the physicians' problem-solving perspective, data elicitation was positively related to the length of the interview, asking psychosocial questions, the use of narrow questions, and the amount of time the patient talked. The patients' assessments of house officers' data-gathering thoroughness were also positively influenced by interview length, the use of narrow questions, and inquiries about their psychosocial histories. The use of broad questions by the house officer was positively related to the patient's feelings about and reaction to the interaction. This study potentially explains some of the differences that appear to exist between patients' and physicians' judgments about and perceptions of the medical interviewing process.

Responding to perceived needs of the twenty-first century: a case study in curriculum design.

Mercer University School of Medicine was established in response to the shortage of primary care physicians in medically underserved Georgia. Originally patterned after the McMaster model of medical education, Mercer found it necessary to modify the three academic programs of the first 2 years of a 4-year undergraduate medical education curriculum. Since accepting students in 1982, though, it has retained many of the essential qualities of problem-based learning and those educational experiences that prepare community responsive physicians to practice in medically underserved areas.

Exercise training reduces depression and increases the performance of pleasant activities in hemodialysis patients.

This study compares the effects of a structured exercise training program to the therapeutic benefits of a 'support' group on the depressed mood and reduced performance of pleasant activities by hemodialysis patients. After 6 months of an aerobic exercise training program, the 10 exercisers showed a significant increase in maximal aerobic capacity (VO2max) and a significant decrease in dysphoric mood when compared to 7 patients attending the support group. Support group participants reported a significant decrease in pleasant activities while there was no change in the exercisers. Eighteen months after the exercise training program, the exercisers reported continued low levels of depressed mood, and were performing significantly more pleasant activities than they reported prior to the exercise program. The results of this study suggest an exercise training program may be useful in the psychosocial rehabilitation of some hemodialysis patients.

Item modelling procedure for constructing content-equivalent multiple choice questions.

Recent research on multiple choice questions has identified deficiencies of inadequate content-equivalence and item-writer bias. Systematic methods of writing multiple choice questions are being advocated as effective responses. This article describes preliminary development of a new item-writing method. Details of the procedure, called item modelling, are provided.

Competence in medicine.

During the past decade, medical educators have spent time discussing and attempting to define medical competence. There appears to be some confusion as to why definitions of competence are important and how one might describe in a logical fashion the elements of competence for physicians. Here, we try to clarify what is meant by competence, to describe how definitions of competence are of value to students, educators, institutions and the public, and to provide a conceptualization of the elements of a definition of competence in medicine.