J. Trig Brown

The unit of analysis error in studies about physicians' patient care behavior

Objective:To estimate the frequency with which patients are incorrectly used as the unit of analysis among statistical calculations in published studies of physicians’ patient care behavior.Design:Retrospective review of studies published during 1980–1990.Articles:54 articles retrieved by a computerized search using medical subject beadings for physicians and study characteristics. Article selection criteria included the requirement that the physician should have been the correct unit of analysis.Intervention:Presence of the error was determined by consensus using published criteria.Main results:The error was present in 38 articles (70%). The number of study physicians was reported in 35 articles (65%). The error was found in 57% of articles that reported the number of study physicians and in 95% of those that did not. The error rate was not lower among articles published more recently nor among those published in journals with higher rates of article citations in the medical literature.Conclusion:The unit of analysis error occurs frequently and can generate artificially low p values. Failure to report the number of study physicians can be a clue that this type of error has been made.

Masked depression in a combined medical-psychiatric unit

Abstract The authors describe experience with over 200 patients in a combined medical-psychiatric unit. A minority (17%) of patients carried the diagnosis of a depressive disorder on admission, but after an intensive psychiatric evaluation, over half received a depression-related diagnosis. The majority of patients had initially presented to their internists with somatic complaints. These observations reiterate previous observations that significant numbers of patients have depression that may be under-recognized because of the presence of somatic symptoms and the prominent use of denial, repression, and obsessive-compulsive defenses. Implications for the relative cost-effectiveness of treating these patients in an inpatient seuing as contrasted to outpatient and liaison models are also discussed.

Screening mammography in the elderly

This case—control study tested the hypothesis that elderly women with metastatic breast cancer were previously screened less than controls. Cases included women over 60 years old who had metastatic breast cancer; the tumor registry provided controls. Identical criteria yielded comparable groups (cases=109, controls=211) receiving primary care at this tertiary center. Radiology and medical records were examined for mammograms; these were blindly categorized “diagnostic,” “screening,” or “indeterminant.” The major, unexpected finding was that less than 6% of controls had ever had screening mammography. The associations between screening and metastatic cancer (odds ratios) suggest a beneficial effect of screening: OR/0.73 for ever screened and OR/0.71 if screened within the year of cancer diagnosis. All confidence intervals include one; however, low screening participation leaves this study with little power. The major implication is that despite the current recommendations, the elderly are not being included in screening mammography programs.This case—control study tested the hypothesis that elderly women with metastatic breast cancer were previously screened less than controls. Cases included women over 60 years old who had metastatic breast cancer; the tumor registry provided controls. Identical criteria yielded comparable groups (cases=109, controls=211) receiving primary care at this tertiary center. Radiology and medical records were examined for mammograms; these were blindly categorized “diagnostic,” “screening,” or “indeterminant.” The major, unexpected finding was that less than 6% of controls had ever had screening mammography. The associations between screening and metastatic cancer (odds ratios) suggest a beneficial effect of screening: OR/0.73 for ever screened and OR/0.71 if screened within the year of cancer diagnosis. All confidence intervals include one; however, low screening participation leaves this study with little power. The major implication is that despite the current recommendations, the elderly are not being included in screening mammography programs.

The resident leaves the clinic: the effects of changing physicians on appointment-keeping behavior.

To understand the effect that termination of an established physician-patient relationship has on patient attendance patterns in a medical clinic, appointment scheduling and patient attendance were measured for 210 patients before and after 11 senior resident physicians left the clinic. There was no significant change in appointment scheduling, although the number of unscheduled or “drop-in” visits increased (p=0.02). Likewise, patient attendance patterns did not differ between study periods. Overall the termination of an established relationship between an internist and a patient in this hospital-based general medicine clinic had no effect on appointment scheduling and patient attendance.

Psychiatric education of the internist: A teaching conference approach

Abstract Communication with the nonpsychiatric physician is of major concern to the consultation-liaison psychiatrist. Fundamental differences in the language, literature, and teaching methods of psychiatrists and of nonpsychiatric physicians frequently impede effective collaboration and, more important, interfere with excellent patient care. With this difficulty in mind, the authors redesigned a pre-existing “patient care conference” to more closely follow the format of a traditional medical teaching conference. This article discusses the new format and the problems it has uncovered, and describes references that have proven useful in the program.

Society of General Internal Medicine Symposium The Duke Minority Medical Student Summer Fellowship: One Program's Attempt to Attract Minority Residents

Despite numerous Federal and private funding programs aimed at increasing the numbers of underrepresented minorities in medicine, the participation of minority groups in the medical profession remains low and shows little sign of improvement. With the goal of improving minority representation in our primary care residency program, the Minority Medical Student Summer Fellowship started in July 1990. The programs purpose is to give minority medical students positive exposure to primary care and attract them back for residency training. In this four-week elective, students participate in seminars with our primary care residents, see patients in a variety of clinics, and complete a project. Key implementation issues include support of the medicine chairman and dean, funding, and malpractice coverage for the students. Program evaluation from the first two students rated the clinic experiences higher than the seminar sessions and the independent project. Both students stated our fellowship made them more likely to train at this medical center should they enter a primary care program. Implications for other programs are listed.

Faculty and Housestaff Priorities in Psychosocial Education: Results of a Questionnaire

The authors surveyed houseofficers in internal medicine and faculty members integrally involved in the psychosocial curriculum using a previously published questionnaire. Results indicated strong agreement in priorities between the two groups (correlation coefficient—0.85). Items identifying broad conceptual skills and those related to practical application were similarly integrated. These data tend to support the concept of providing both levels of knowledge in a training program to allow more comprehensive teaching in psychosocial areas.