Assuntos
Capacitação de Usuário de Computador , Currículo , Educação de Pós-Graduação/normas , Informática Médica/educação , Saúde Pública/educação , Faculdades de Saúde Pública , Educação Baseada em Competências , Sistemas de Gerenciamento de Base de Dados/estatística & dados numéricos , District of Columbia , Humanos , Armazenamento e Recuperação da Informação , Internet , Meios de Comunicação de Massa , Microcomputadores , Competência Profissional , Relações Públicas , Estados UnidosRESUMO
The authors review why the gulf between clinical medicine and public health has existed since the first schools of public health were established in 1916. They emphasize that academic health centers (AHCs) have the potential to bring together these two perspectives--as well as the health services perspective--to clarify what they offer and to find creative ways to build upon their combined strengths. The authors describe institutional approaches that can be taken to narrow the gulf, with examples from the initiatives of this type that are under way at The George Washington University Medical Center in Washington, D.C. For example, the authors state and discuss in detail that an AHC's medical, public health, and health services institutions should be physically and institutionally close; that collaboration between them requires well-structured interaction; that institutional structures are needed to ensure cooperation when internal competition is likely; and that collaboration is fostered by new opportunities and the potential for new resources. The authors conclude by stating that the future will require that the health education and prevention perspective of public health, the treatment perspective of medicine, and the financial and management perspective of health services be developed and integrated into the work of AHCs, and give examples of specific activities that would be possible with such integration.
Assuntos
Centros Médicos Acadêmicos/organização & administração , Planejamento em Saúde Comunitária/organização & administração , Pesquisa sobre Serviços de Saúde/organização & administração , Medicina , Saúde Pública , Centros Médicos Acadêmicos/tendências , Planejamento em Saúde Comunitária/tendências , Humanos , Estados UnidosAssuntos
Tomada de Decisões , Educação de Graduação em Medicina/métodos , Pacientes/psicologia , Médicos/psicologia , Preconceito , Assunção de Riscos , Estudantes de Medicina/psicologia , Atitude Frente a Morte , Cognição , Conflito Psicológico , Humanos , Relações Médico-Paciente , Probabilidade , Resultado do TratamentoRESUMO
The number needed to treat is a unique and cognitively useful summary measurement for the description of medical treatments. However, the original concept lacks the means to account for multiple benefits and harms or differences in the utilities or timings of patient outcomes. The authors describe an "adjusted" number needed to treat that allows for the inclusion of multiple harms and benefits, and also adjustments for the utilities and timings of these outcomes. The expanded version offers a richer description of medical outcomes, and may be utilized as an adjunct to traditional risk-benefit, cost-effectiveness, and decision-analytic techniques.
Assuntos
Tomada de Decisões , Resultado do Tratamento , Análise Custo-Benefício , Humanos , Métodos , Fatores de Risco , Fatores de TempoAssuntos
Métodos Epidemiológicos , Estatística como Assunto , Feminino , Humanos , Masculino , Probabilidade , Pesquisa , Fatores de RiscoRESUMO
In 1989, an expert panel appointed by the Association of Teachers of Preventive Medicine proposed minimum curricular content requirements for health promotion-disease prevention, including recommendations for timing, duration, and course sequencing during medical school. Making clinical preventive medicine an integral part of a primary care rotation is a central feature of the proposal. The panel presents recommendations for using the Guide to Clinical Preventive Services, which assesses the effectiveness of 169 types of prevention interventions, in both undergraduate and postgraduate medical education. Recommendations for incorporating the guide into the undergraduate medical school curriculum are outlined. The recommendations include options for using the guide as part of a curriculum in quantitative skills, in clinical preventive medicine, in a primary care rotation, as a health services and community dimension curriculum, and as part of continuing self-education. Recognizing that teaching methods and curriculum structures are varied in preventive medicine, the panel designed the recommendations to be adaptable to all medical schools' programs. The recommendations are aimed at achieving the goal of making preventive medicine an integral part of the education, training, and practice of physicians.
Assuntos
Currículo , Educação de Graduação em Medicina/normas , Promoção da Saúde/normas , Política Organizacional , Medicina Preventiva/educação , Sociedades Médicas/organização & administração , Ensino , Competência Clínica/normas , Educação Médica Continuada/normas , Humanos , Objetivos Organizacionais , Medicina Preventiva/normasAssuntos
Medicina de Família e Comunidade , Médicos de Família/provisão & distribuição , Atenção Primária à Saúde , Educação de Pós-Graduação em Medicina/tendências , Medicina de Família e Comunidade/educação , Feminino , Humanos , Masculino , Atenção Primária à Saúde/tendências , Estados Unidos , Recursos HumanosRESUMO
A required first-year course at George Washington University School of Medicine and Health Sciences, entitled Studying a Study: Methods for Reading the Medical Literature, was evaluated by the author to determine the students' perception of the course's effectiveness, changes in the students' perception of their competence in reading medical literature, the students' knowledge of research study design and statistics, and the effect of the course on the students' journal reading. Students who took the course were questioned before and after the course and as fourth-year students and were compared with fourth-year students in a prior class that had not been offered the course. Students rated the course as effective. The students who took the course rated themselves as more competent and had greater knowledge than did the class that did not take the course. These students' ratings and scores declined, however, from the first to the fourth year. A required preclinical course in study design and statistics can be well received and can affect students' knowledge and perceptions of their competence. Reinforcement is necessary to maintain the results.
Assuntos
Competência Clínica , Educação Médica , Publicações Periódicas como Assunto , Estudantes de Medicina , District of Columbia , LeituraRESUMO
We updated a 1978 cost-effectiveness analysis of vaccination against pneumococcal pneumonia in light of the introduction in 1983 of a 23-valent vaccine, recent medical literature, and different relative prices of medical services. Although other base-case assumptions have remained reasonable, the low estimates of 10% of pneumonia as pneumococcal and a 3-year duration of immunity now appear more likely. Vaccination of a person age 65 or older could gain a year of healthy life for about $6000 in 1983 dollars. Medicare has covered pneumococcal vaccination since 1981. With the revised assumptions, net Medicare expenditures ranged from about $5.50 to $10.50 per vaccination, or from $4400 to $8300 per year of healthy life gained. Vaccination of an elderly person would almost break even, if duration of immunity were 8 years and would be cost saving if the vaccine were administered under a public program. Current levels of vaccination appear too low considering the potential health benefits and cost-effectiveness.
Assuntos
Vacinas Bacterianas , Pneumonia Pneumocócica/economia , Vacinação/economia , Idoso , Anticorpos Antibacterianos/análise , Vacinas Bacterianas/efeitos adversos , Análise Custo-Benefício , Humanos , Medicare/economia , Vacinas Pneumocócicas , Pneumonia Pneumocócica/epidemiologia , Pneumonia Pneumocócica/prevenção & controle , Sepse/prevenção & controle , Streptococcus pneumoniae/imunologia , Fatores de Tempo , Estados UnidosRESUMO
Skills, attitudes, confidence, and behavior needed for literature reading were studied in first- versus fourth-year medical students at George Washington University in Washington, D.C. Questions on diagnostic test skills were used for comparison. Anonymous questionnaires were completed by 114 first-year and 84 fourth-year students. Fourth-year students read considerably more literature than first-year students, valued reviews over original research, and placed more value on the journal's reputation. They had greater confidence and objective knowledge than first-year students on diagnostic test skills but not greater confidence or objective knowledge on literature reading skills. Most dramatic was their "lower" willingness to admit uncertainty, even when taking into account their level of knowledge. Less willingness to admit uncertainty on the part of fourth-year medical students than first-year students may reflect medical education's emphasis on specific answers and its failure to teach students how to analyze data and draw conclusions. A need exists for specific training in literature reading skills with preevaluations and postevaluations of skills, attitudes, and behavior.
Assuntos
Estudantes de Medicina , Atitude , Comportamento , Competência Clínica , Humanos , LeituraRESUMO
The need for clinical monitoring to assure drug safety despite reliance on Food and Drug Administration testing is illustrated. The need to temper theory with clinical experience is exemplified by the recent examples of swine flu, resistant gonorrhea, and resistant pneumococcal infection. The potential for adverse effects to escape detection in animal studies and small-scale human trials is illustrated by the examples of ticrynafen, chloramphenicol, and diethylstilbestrol. The potential for unexpected side effects when established drugs are used in new ways is demonstrated by the examples of retrolental fibroplasia and vitamin D toxicity. The responsibilities of the medical profession and the individual practitioner include a healthy skepticism of newly introduced treatments, active participation in clinical monitoring, and maintenance of a system for chart retrieval when drugs are recalled or new effects reported.
Assuntos
Controle de Medicamentos e Entorpecentes , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , United States Food and Drug Administration , Cloranfenicol/efeitos adversos , Ensaios Clínicos como Assunto , Dietilestilbestrol/efeitos adversos , Avaliação de Medicamentos , Humanos , Vacinas contra Influenza/efeitos adversos , Risco , Ticrinafeno/efeitos adversos , Estados UnidosRESUMO
The physician diagnosing disease is often compared with the detective solving a crime. Eight operating principles of fictional detectives are presented and applied to diagnosis in modern medical practice. None holds up under scrutiny. In medicine, every problem does not require a diagnosis and every possibility does not have to be pursued. Time itself may be a diagnostic tool. All the facts may not be available for definitive diagnosis, or a diagnosis may not explain the patient's symptoms. Physicians, unlike fictional detectives, cannot ignore the obvious. They can and should recognize and diagnose diseases they initially failed to suspect.