Answering family physicians' clinical questions using electronic medical databases.

OBJECTIVE: We studied the ability of electronic medical databases to provide adequate answers to the clinical questions of family physicians. STUDY DESIGN: Two family physicians attempted to answer 20 questions with each of the databases evaluated. The adequacy of the answers was determined by the 2 physician searchers, and an arbitration panel of 3 family physicians was used if there was disagreement. DATA SOURCE: We identified 38 databases through nominations from national groups of family physicians, medical informaticians, and medical librarians; 14 met predetermined eligibility criteria. OUTCOMES MEASURED: The primary outcome was the proportion of questions adequately answered by each database and by combinations of databases. We also measured mean and median times to obtain adequate answers for individual databases. RESULTS: The agreement between family physician searchers regarding the adequacy of answers was excellent (k=0.94). Five individual databases (STAT!Ref, MDConsult, DynaMed, MAXX, and MDChoice.com) answered at least half of the clinical questions. Some combinations of databases answered 75% or more. The average time to obtain an adequate answer ranged from 2.4 to 6.5 minutes. CONCLUSION: Several current electronic medical databases could answer most of a group of 20 clinical questions derived from family physicians during office practice. However, point-of-care searching is not yet fast enough to address most clinical questions identified during routine clinical practice.

A survey of general surgeons in rural Missouri: potential for rapid decrease in work force.

General surgeons have an essential role in the rural health care system. This telephone survey of 39 rural general surgeons in Missouri found that more than half were 55 or older. Most reported they practiced a broader scope of surgery than colleagues in urban areas, and half believed that current residency graduates are not prepared for surgical practice in rural areas. One-fifth had sought special training experiences to prepare them for rural practice. On balance, 70 percent of the respondents' practices was general surgery, 13 percent "specialty surgery" and 17 percent primary care. Many reported feeling professionally isolated. One-fourth had literally "returned home" to practice. The results suggest that if present trends continue, the next 10 years will see a substantial reduction in the number of general surgeons in rural Missouri.

The effect of the teaching physician rule on residency education.

BACKGROUND AND OBJECTIVES: In 1996, the Health Care Finance Administration implemented the Teaching Physician Rule (TPR) to clarify the responsibilities of attending physicians when they are supervising residents and billing Medicare for that service. We measured some of the effects of the TPR on family practice residency training. METHODS: After pilot testing, a questionnaire was mailed to the directors of all family practice residency programs in the United States. The directors were asked to provide a similar questionnaire to a senior resident. RESULTS: Of 449 residency directors, 310 (69%) responded. Eighty percent of residencies apply the TPR to at least some patient encounters. Residency directors reported that the TPR had an overall negative effect on their residency. Residents reported a more negative impression of the rule than did the directors. On average, residency directors reported that the mandated level of supervision in the outpatient setting increased faculty attending time by .24 FTE. CONCLUSIONS: The TPR was perceived by residency directors and senior residents to have some negative effect on family practice residency programs, at least in part by increasing the need for more faculty time for supervision.

Treatment of prostatitis.

The term prostatitis is applied to a series of disorders, ranging from acute bacterial infection to chronic pain syndromes, in which the prostate gland is inflamed. Patients present with a variety of symptoms, including urinary obstruction, fever, myalgias, decreased libido or impotence, painful ejaculation and low-back and perineal pain. Physical examination often fails to clarify the cause of the pain. Cultures and microscopic examination of urine and prostatic secretions before and after prostatic massage may help differentiate prostatitis caused by infection from prostatitis with other causes. Because the rate of occult infection is high, a therapeutic trial of antibiotics is often in order even when patients do not appear to have bacterial prostatitis. If the patient responds to therapy, antibiotics are continued for at least three to four weeks, although some men require treatment for several months. A patient who does not respond might be evaluated for chronic nonbacterial prostatitis, in which nonsteroidal anti-inflammatory drugs, alpha-blocking agents, anticholinergic agents or other therapies may provide symptomatic relief.

Distilling the literature: a randomized, controlled trial testing an intervention to improve selection of medical articles for reading.

PURPOSE: To test whether an academic detailing intervention would improve journal reading among residents. METHOD: In 1995-96, the authors conducted a randomized controlled trial at two family medicine residencies in Missouri. Fifty-nine family practice residents were randomized into two groups identical in baseline characteristics; 29 received individual 15-minute educational presentations, based on academic detailing, that emphasized careful selection of medical journal articles for reading. The authors measured the percentage of important journal articles of which the residents were aware, the percentage of those they had read (either abstract only or the whole article), and the percentage of correctly answered knowledge questions. RESULTS: Despite randomization, the residents in the control group indicated on the pretest that they were more likely than were the residents in the intervention group to be aware of and to have read abstracts from selected articles. However, when comparing pretest with posttest results, the intervention group recalled 18.2% (95% CI, 2.0, 34.0) more articles and correctly answered 16.6% (95% CI 3.0, 29.9) more knowledge questions than did the control group. CONCLUSION: A brief intervention increased residents' recall of important articles and knowledge of those articles' conclusions.