Gary McCord

Discussing Spirituality With Patients: A Rational and Ethical Approach

BACKGROUND This study was undertaken to determine when patients feel that physician inquiry about spirituality or religious beliefs is appropriate, reasons why they want their physicians to know about their spiritual beliefs, and what they want physicians to do with this information. METHODS Trained research assistants administered a questionnaire to a convenience sample of consenting patients and accompanying adults in the waiting rooms of 4 family practice residency training sites and 1 private group practice in northeastern Ohio. Demographic information, the SF-12 Health Survey, and participant ratings of appropriate situations, reasons, and expectations for physician discussions of spirituality or religious beliefs were obtained. RESULTS Of 1,413 adults who were asked to respond, 921 completed questionnaires, and 492 refused (response rate = 65%). Eighty-three percent of respondents wanted physicians to ask about spiritual beliefs in at least some circumstances. The most acceptable scenarios for spiritual discussion were life-threatening illnesses (77%), serious medical conditions (74%) and loss of loved ones (70%). Among those who wanted to discuss spirituality, the most important reason for discussion was desire for physician-patient understanding (87%). Patients believed that information concerning their spiritual beliefs would affect physicians’ ability to encourage realistic hope (67%), give medical advice (66%), and change medical treatment (62%). CONCLUSIONS This study helps clarify the nature of patient preferences for spiritual discussion with physicians.

A comparison of the National Ambulatory Medical Care Survey (NAMCS) measurement approach with direct observation of outpatient visits.

BackgroundThe National Ambulatory Medical Care Survey (NAMCS) informs a wide range of important policy and clinical decisions by providing nationally representative data about outpatient practice. However, the validity of the NAMCS methods has not been compared with a reference standard. MethodsOffice visits of 549 patients visiting 30 family physicians in Northeastern Ohio were observed by trained research nurses. Visit content measured by direct observation was compared with data reported by physicians using the 1993 NAMCS form. ResultsOutpatient visit physician reports of procedures and examinations using the NAMCS method showed generally good concordance with direct observation measures, with kappas ranging from 0.39 for ordering a chest x-ray to 0.86 for performance of Pap smears. Concordance was generally lower for health behavior counseling, with kappas ranging from 0.21 for alcohol counseling to 0.60 for smoking cessation advice. The NAMCS form had high specificity (range, 0.90–0.99) but variable (range, 0.12–.84) sensitivity compared with direct observation, with the lowest sensitivities for health behavior counseling. The NAMCS physician report method overestimated visit duration in comparison with direct observation (16.5 vs. 12.8 minutes). ConclusionsCompared with direct observation of outpatient visits, the NAMCS physician report method is more accurate for procedures and examinations than for health behavior counseling. Underreporting of behavioral counseling and overreporting of visit duration should lead to caution in interpreting findings based on these variables.

Physician Activities During Time Out of the Examination Room

PURPOSE Comprehensive medical care requires direct physician-patient contact, other office-based medical activities, and medical care outside of the office. This study was a systematic investigation of family physician office-based activities outside of the examination room. METHODS In the summer of 2000, 6 medical students directly observed and recorded the office-based activities of 27 northeastern Ohio community-based family physicians during 1 practice day. A checklist was used to record physician activity every 20 seconds outside of the examination room. Observation excluded medical care provided at other sites. Physicians were also asked to estimate how they spent their time on average and on the observed day. RESULTS The average office day was 8 hours 8 minutes. On average, 20.1 patients were seen and physicians spent 17.5 minutes per patient in direct contact time. Office-based time outside of the examination room averaged 3 hours 8 minutes or 39% of the office practice day; 61% of that time was spent in activities related to medical care. Charting (32.9 minutes per day) and dictating (23.4 minutes per day) were the most common medical activities. Physicians overestimated the time they spent in direct patient care and medical activities. None of the participating practices had electronic medical records. CONCLUSIONS If office-based, medically related activities were averaged over the number of patients seen in the office that day, the average office visit time per patient would increase by 7 minutes (40%). Care delivery extends beyond direct patient contact. Models of health care delivery need to recognize this component of care.

Handheld computer use in a family medicine clerkship.

Purpose The objectives of this study were to track students’ use of medical and nonmedical personal digital assistant (PDA) software and to obtain students’ ratings of the usefulness of PDAs in a family medicine clerkship. Method During the academic year 2001–02, third-year clerkship students at the Northeastern Ohio Universities College of Medicine were loaned PDAs equipped with company-installed software, such as a date book and address book. Additional software was installed (Griffiths 5 Minute Clinical Consult®, ePocrates qRx®, ePocrates qID®, iSilo®, HanDBase®, MedCalc®, and Application Usage®). Pre- and postorientation questionnaires and a post-rotation evaluation measured students’ comfort level, the perceived usefulness, and ratings of programs on their PDA. Application Usage tracked the number of minutes and times students used each software program. Results Eighty-five students completed the study. They rated ePocrates qRx and Griffiths 5 Minute Clinical Consult the most useful medical software programs. PDAs were rated as “almost always” enhancing the clerkship experience. Students reported the PDA altered the way they accessed clinical information and that every few days it helped them understand a clinical discussion. Experience with computer technology was correlated with PDA use. Conclusions This study objectively demonstrates clerkship students’ use of PDA resources. Students’ use mirrors their assessment of the value of the software. Although PDAs and software programs can be an expense, it is a worthwhile educational resource as evaluated by the medical student.

Intra-aortic balloon pump complications: A five-year retrospective study of 283 patients

OBJECTIVE To determine the type, incidence, and risk factors for complication with the intra-aortic balloon pump. DESIGN Descriptive, chart review. SETTING Midwestern community teaching hospital. PATIENTS Two hundred eighty-three patients with 287 intra-aortic balloon pump insertions from January 1, 1990, to December 31, 1994. OUTCOME MEASURES Complications of therapy. RESULTS Seventeen percent of balloon insertions resulted in minor complications, and 14 patients had major complications. Polychotomous logistic regression was used to determine which study risk factors were predictive of the development of minor or major complications in patients. Patients with longer balloon duration had an increased risk of a major complication; whereas smokers and patients with lower body mass index had an increased probability of the development of a minor complication.

Assessing the Impact on Patient–Physician Interaction When Physicians Use Personal Digital Assistants: A Northeastern Ohio Network (NEON®) Study

Background: The effects of the use of technological devices on dimensions that affect the physician-patient relationship need to be well understood. Objectives: Determine patients’ perceptions of physicians’ personal digital assistant (PDA) use, comparing the results across 8 physician-patient dimensions important to clinical interactions. Results: Patients completed anonymous surveys about their perceptions of physician PDA use. Data were collected during 2006 and 2007 at 12 family medicine practices. Survey items included physician sex, patient demographics, if physicians explained why they were using the PDA, and Likert ratings on 8 dimensions of how a PDA can influence physician-patient interactions (surprise, confidence, feelings, comfort, communication, relationship, intelligence, and satisfaction). The survey response rate was 78%. Physicians explained to their patients what they were doing with the PDA 64% of the time. Logistic regression analyses determined that patients of male physicians, patients attending private practices and underserved sites, patients with Medicaid insurance, and patients who observed their physician using a PDA during both the index visit and at least one prior visit were more likely to receive an explanation of PDA use. Most importantly, physician-patient communication was rated significantly more positive if an explanation of PDA use was offered. Conclusion: Patients rate interactions with their physicians more positively when physicians explain their PDA use.

Incidence of Staphylococcus aureus Nasal Colonization and Soft Tissue Infection Among High School Football Players

Background: Methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infections have been documented with increasing frequency in both team and individual sports in recent years. It also seems that the level of MRSA skin and soft tissue infections in the general population has increased. Methods: One hundred ninety athletes from 6 local high school football teams were recruited for this prospective observational study to document nasal colonization and the potential role this plays in skin and soft tissue infections in football players and, in particular, MRSA infections. Athletes had nasal swabs done before their season started, and they filled out questionnaires regarding potential risk factors for skin and soft tissue infections. Those enrolled in the study were then observed over the course of the season for skin and soft tissue infections. Those infected had data about their infections collected. Results: One hundred ninety of 386 available student athletes enrolled in the study. Forty-four of the subjects had nasal colonization with methicillin-susceptible S. aureus, and none were colonized with MRSA. There were 10 skin and soft tissue infections (8 bacterial and 2 fungal) documented over the course of the season. All were treated as outpatients with oral or topical antibiotics, and none were considered serious. Survey data from the preseason questionnaire showed 21% with skin infection, 11% with methicillin-susceptible S. aureus, and none with MRSA infection during the past year. Three reported a remote history of MRSA infection. Conclusions: We documented an overall skin infection rate of 5.3% among high school football players over a single season. Our results suggest that skin and soft tissue infection may not be widespread among high school athletes in northeast Ohio.

A sexual history-taking curriculum for second year medical students

The purpose of this study is to describe the evaluation of a sexual history-taking curriculum and correlates of student performance during a Clinical Skills Assessment. Reading assignments, small group discussions, a Saturday Sex workshop and performance on a Clinical Skills Assessment were evaluated. Students most favorably rated the workshop and least favorably rated the reading assignments. Eighty-four percent of students asked at least one sexual history question on the Clinical Skills Assessment. We were unable to identify any independent predictors of sexual history-taking behavior.

Factors Related to Impaired Mental Health in Urban Elderly

Associations between self-rated, scale, and interviewer-rated measures of mental health status and a set of demographic and functional abilities variables were studied. Data on these variables were obtained from an administration of the OARS to 1139 elderly in an urban community. Findings common to at least two of the three mental health measures were that physical health showed a strong association with mental health, inability to engage in activities of daily living was associated with poorer mental health even after controlling for physical health, married men showed better mental health than those not married, social resources were strongly associated with mental health for women but less so for men, and economic resources showed a consistent association with mental health. Different models for the three measures of mental health help to explain the inconsistent associations found in previous studies.

Synthetic estimation of the distribution of mentally disabled adults for allocations to Ohio's mental health board areas

Various indirect forms of evidence are provided for the accuracy of synthetic estimation of the distribution of severely mentally disabled (SMD) adults across Ohios mental health board areas. The board areas are public mental health jurisdictions which are allocated state funds to serve the needs of SMD adults. Equitable allocation of funds to these areas depends on accurate estimation of the distribution of SMD adults across the areas. The synthetic estimation method involved two steps: (a) ECA-based prevalences of SMD adults by demographic profiles were obtained; (b) prevalences were applied to a board areas demographic mix to yield the estimated SMD count for that area. The main indirect evidence of accuracy showed that the synthetically-estimated percentages across areas agreed closely with the actual percentages of SMD adults enrolled in federal programs. Statistical characteristics of various percentage estimators indicated that reasonably accurate estimation and allocation is not difficult to attain.