Helen K. Delichatsios

Outcomes of Telephone Medical Care

AbstractOBJECTIVES: To document the outcomes of a telephone coverage system and identify patient characteristics that may predict these outcomes. DESIGN: Telephone survey. SETTING: An academic outpatient medical practice that has a physician telephone coverage service. PATIENTS: All patients (483) who called during the 3-week study period to speak to a physician were evaluated, and for the 180 patients with symptoms, attempts were made to survey them by telephone 1 week after their initial telephone call. MEASUREMENTS AND MAIN RESULTS: The mean age of the 180 patients was 41 years, 71% were female, and 56% belonged to commercial managed care plans. In the week after the initial telephone call, the following outcomes were reported: 27% of the patients had no further contact with the practice; 9% filled a prescription medication; 19% called the practice again; 48% kept an earlier appointment in the practice; 3% saw an internist elsewhere; 8% saw a specialist; 8% went to an emergency department; 4% were admitted to a hospital. Of the 180 patients who called with symptoms, 160 (89%) were successfully contacted for survey. Eighty-seven percent of these 160 patients rated their satisfaction with the care they received over the telephone as excellent, very good, or good. In multivariate analysis, patients’ own health perception identified those most likely to have symptom relief (p=.002), and symptom relief, in turn, was a strong predictor of high patient satisfaction (p=.006). Thirty-three percent of the 160 patients reported that they would have gone to an emergency department if a physician were not available by telephone. CONCLUSIONS: In the present study, younger patients, female patients, and patients in commercial managed care plans used the telephone most frequently. Also, the telephone provided a viable alternative to emergency department and walk-in visits. Overall satisfaction with telephone medicine was high, and the strongest predictors of high patient satisfaction were symptom relief and patients’ own health perception.

Nutrition attitudes and knowledge in medical students after completion of an integrated nutrition curriculum compared to a dedicated nutrition curriculum: a quasi-experimental study.

BACKGROUND Nutrition education has presented an ongoing challenge to medical educators. In the 2007-2008 academic year, Harvard Medical School replaced its dedicated Preventive Medicine and Nutrition course with an integrated curriculum. The objective of the current study was to assess the effect of the curriculum change on medical student attitudes and knowledge about nutrition. METHODS A survey was administered in a quasi-experimental design to students in the last class of the dedicated curriculum (n = 131) and the first class of the integrated curriculum (n = 135) two years after each class completed the required nutrition course. Main measures were attitude scores based on modified Nutrition in Patient care Survey and satisfaction ratings, performance on a nutrition knowledge test, and demographic variables. Two-tailed t-tests were performed. RESULTS Response rates were 50.4% and 42.2%. There were no differences between the groups in attitude scores from the Nutrition in Patient care Survey (p = 0.43) or knowledge scores (p = 0.63). Students with the integrated curriculum were less satisfied with both the quantity (p < 0.0001) and quality (p = 0.008) of their nutrition education, and were more likely to have completed optional online nutrition training modules (p = 0.0089). CONCLUSIONS Medical student attitudes and knowledge about nutrition were not affected by the model of nutrition education they receive, though students in an integrated curriculum may feel their education is inadequate and seek additional training.

BONE HISTOMORPHOMETRY IN MEN WITH SPINAL OSTEOPOROSIS

The purpose of this investigation was to determine whether there is an effect of age and the presence of predisposing risk factors on the pattern of bone resorption in men with spinal osteoporosis. We present iliac bone histomorphometric data after in vivo double tetracycline labeling in 21 men aged 34–74 with significant spinal osteoporosis as evidenced by compression spinal fracture without significant trauma. Fourteen of the 21 men (67%) had identifiable predisposing risk factors for their osteoporosis, such as ethanol abuse, hypercortisolism, hypogonadism, or underlying medical conditions. The other 7 men (33%) had no such identifiable risk factors. The conclusions of the study were that (1) there was no correlation between age of the patient and degree of bone resorption based on two parameters of resorption and (2) there was no difference in the pattern of bone resorption between the groups with and without known predisposing risk factors for osteoporosis or underlying medical conditions.

CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 14-2016. A 37-Year-Old Woman with Adult-Onset Psychosis.

Dr. Maureen M. Leonard: A 37-year-old woman was admitted to a psychiatric hospital for adult-onset psychosis. The patient had been healthy and studying for a doctoral degree when she began having symptoms of psychosis. Her first symptom was a belief that “people were talking about her” as part of a larger “conspiracy” in which family, friends, and random people were part of a “game” and acting out “scenes” for her. She had had stress associated with her schooling and had contemplated changing schools. However, she had not had other symptoms of anxiety or depression, neurovegetative symptoms, or auditory or visual hallucinations. A few months later, the patient’s apartment was burglarized and vandalized; her parents were the only other people with a key, and she believed they were involved. Because of threats she made against family members, she was admitted to an inpatient state psychiatric facility. A diagnosis of psychotic disorder, possibly paranoid schizophrenia, was rendered. An evaluation for causes of the disorder revealed evidence of marked iron-deficiency anemia, including an iron level of 18 μg per deciliter (3 μmol per liter; reference range, 45 to 182 μg per deciliter [8 to 33 μmol per liter]), a ferritin level of 6 ng per milliliter (reference range, 11 to 306), and a transferrin saturation of 3.7% (reference range, 11.0 to 50.0). The evaluation also revealed vitamin deficiencies, including a vitamin B12 level of 167 pg per milliliter (reference range, 182 to 803) and a vitamin D2 level of 10 ng per milliliter (reference value, >32). Before admission to the state psychiatric facility, the patient had had no history of psychiatric disease. She had a remote history of a left-foot fracture and had undergone a right oophorectomy at 17 years of age for torsion of the ovary. She took no medications. Her mother recalled her being a “perfectionist,” especially during her late teenage years. The patient had reported an unintentional weight loss of 9 kg over an unspecified period of time, despite self-described polyphagia and some hair thinning. She did not have diarrhea. There was no history of head injury or seizure, menopausal symptoms after the oophorectomy, or social withdrawal. Her mother had systemic lupus erythematosus, her sister had hypothyroidism From the Departments of Medicine (H.K.D.), Pediatrics (M.M.L., A.F.), and Pathology (V.N.), Massachusetts General Hospital, and the Departments of Medi‐ cine (H.K.D.), Pediatrics (M.M.L., A.F.), and Pathology (V.N.), Harvard Medical School — both in Boston.

Shared Medical Appointments: A Portal for Nutrition and Culinary Education in Primary Care—A Pilot Feasibility Project:

Introduction: Diseases linked to obesity such as cardiovascular disease, diabetes, degenerative joint disease, gastroesophageal reflux, and sleep apnea constitute a large portion of primary care visits. Patients with these conditions often lack knowledge, skills, and support needed to maintain health. Shared medical appointments (SMAs) that include culinary skills and nutrition education offer a novel, cost-effective way to address these diseases in primary care. Methods: Adult patients in a primary care practice at a large academic hospital in Boston, Massachusetts, who had at least 1 cardiovascular risk factor were invited to participate in SMAs that included cooking demonstrations and teaching about nutrition in addition to medical management of their conditions. Sessions were conducted by a physician and an assistant in a conference room of a traditional primary care practice as part of a pilot feasibility project. Results: Seventy patients, contributing a total of 156 patient visits, attended 17 nutrition-focused SMAs over a 4-year period. Patients were surveyed after each visit and indicated that they enjoyed the SMAs, would consider alternating SMAs with traditional one-on-one visits, and would recommend SMAs to others. Half would pay out of pocket or a higher copay to attend SMAs. Financially, the practice broke even compared with traditional one-on-one office visits. Conclusion: In this feasibility study, chronic disease SMAs conducted with a culinary/nutrition focus were feasible, cost-effective, and well received by patients. Follow-up studies are needed to evaluate short- and long-term outcomes of this SMA model on obesity-related diseases.

Case 14-2016

Dr. Maureen M. Leonard: A 37-year-old woman was admitted to a psychiatric hospital for adult-onset psychosis. The patient had been healthy and studying for a doctoral degree when she began having symptoms of psychosis. Her first symptom was a belief that “people were talking about her” as part of a larger “conspiracy” in which family, friends, and random people were part of a “game” and acting out “scenes” for her. She had had stress associated with her schooling and had contemplated changing schools. However, she had not had other symptoms of anxiety or depression, neurovegetative symptoms, or auditory or visual hallucinations. A few months later, the patient’s apartment was burglarized and vandalized; her parents were the only other people with a key, and she believed they were involved. Because of threats she made against family members, she was admitted to an inpatient state psychiatric facility. A diagnosis of psychotic disorder, possibly paranoid schizophrenia, was rendered. An evaluation for causes of the disorder revealed evidence of marked iron-deficiency anemia, including an iron level of 18 μg per deciliter (3 μmol per liter; reference range, 45 to 182 μg per deciliter [8 to 33 μmol per liter]), a ferritin level of 6 ng per milliliter (reference range, 11 to 306), and a transferrin saturation of 3.7% (reference range, 11.0 to 50.0). The evaluation also revealed vitamin deficiencies, including a vitamin B12 level of 167 pg per milliliter (reference range, 182 to 803) and a vitamin D2 level of 10 ng per milliliter (reference value, >32). Before admission to the state psychiatric facility, the patient had had no history of psychiatric disease. She had a remote history of a left-foot fracture and had undergone a right oophorectomy at 17 years of age for torsion of the ovary. She took no medications. Her mother recalled her being a “perfectionist,” especially during her late teenage years. The patient had reported an unintentional weight loss of 9 kg over an unspecified period of time, despite self-described polyphagia and some hair thinning. She did not have diarrhea. There was no history of head injury or seizure, menopausal symptoms after the oophorectomy, or social withdrawal. Her mother had systemic lupus erythematosus, her sister had hypothyroidism From the Departments of Medicine (H.K.D.), Pediatrics (M.M.L., A.F.), and Pathology (V.N.), Massachusetts General Hospital, and the Departments of Medi‐ cine (H.K.D.), Pediatrics (M.M.L., A.F.), and Pathology (V.N.), Harvard Medical School — both in Boston.

Case 14-2016: A Woman with a Thyroid Nodule and Psychosis.

To the Editor: In the Case Record, Delichatsios et al. (May 12 issue)1 discussed the development of abrupt adult-onset psychosis and delusional thinking in a 37-year-old woman with Hashimoto’s thyroiditis and a clinically significant weight loss. A unifying diagnosis of celiac disease was made. During a 3-month hospitalization, the patient did not eat gluten-containing foods, and her psychiatric symptoms remitted. The symptoms returned when she ate gluten-containing foods. I propose that the patient could have Hashimoto’s encephalopathy, which is a well-known cause of psychosis.2 Remissions and relapses are common. Her lapse in adhering to a gluten-free diet may have been an early consequence of a spontaneous relapse of her encephalopathy, rather than the cause of it. Immunosuppression with glucocorticoids or intravenous immune globulin is often an effective treatment for Hashimoto’s encephalopathy.2 It is also possible that the encephalopathy of celiac disease is autoimmune. Given the patient’s dire straits, it seems to me that thinking of her as having Hashimoto’s encephalopathy and treating her accordingly with appropriate immunosuppression would be a good idea. The potential benefit outweighs the risk. Gordon Worley, M.D.