Paul G. Ramsey

Herpes Simplex Virus Pneumonia: Clinical, Virologic, and Pathologic Features in 20 Patients

Herpes simplex virus (herpesvirus) was isolated from autopsy lung specimens of 20 patients with clinical, roentgenographic, and histologic evidence of pneumonia. Mucocutaneous herpesvirus infection preceded the onset of pneumonia in 17. Twelve patients had focal pneumonia, 10 of whom had concomitant herpetic tracheitis, esophagitis, or both. Eight patients had diffuse interstitial pneumonia, six of whom had dissemination of herpesvirus to the other organs. Of the eight lung isolates available for typing, seven were herpesvirus-1 and one, herpesvirus-2. A high prevalence of herpesvirus antibody in serum samples obtained before pneumonia and identical restriction endonuclease patterns between mucosal and lung isolates in individual patients indicated that, in most cases, herpesvirus pneumonia was due to endogenous reactivation of virus. Focal herpesvirus pneumonia appeared to result from contiguous spread of herpesvirus to lung parenchyma, whereas diffuse interstitial pneumonia appeared to be a manifestation of hematogenous dissemination of virus.

Predictive Validity of Certification by the American Board of Internal Medicine

STUDY OBJECTIVE To determine the predictive validity of the American Board of Internal Medicine (ABIM) certification process. DESIGN Prospective measurement of the knowledge, skills, and attitudes of 185 ABIM-certified and 74 noncertified internists by a written examination; evaluation by professional associates; a patient questionnaire assessing satisfaction with care, physicians counseling role, and preventive care; and review of records of patients with common illnesses. SUBJECTS Practicing internists who completed training or received ABIM certification 5 to 10 years previously. SETTING Office-based practices in six western states. RESULTS OF DATA ANALYSIS Physicians certified by the ABIM had significantly higher scores on the written examination than the noncertified physicians, and scores on our examination correlated highly with the ABIM certification examination (r = 0.73). Ratings of clinical skills by professional associates were significantly higher for certified internists and also correlated highly with ABIM examination scores (r = 0.53 to 0.59). Regression analysis showed that ABIM certification status was the major variable affecting performance on these measures of clinical competence. Results from other measures did not show many differences between certified and noncertified physicians in the care of patients with common illnesses, but modest differences in preventive care and a few differences in outcome favored the certified physicians. CONCLUSIONS Comparison of findings from the written examination and the professional associate ratings with certification status and original ABIM certification examination scores shows predictive validity of ABIM certification. Further studies are needed to determine if certification status predicts important differences in the care of patients with complex illnesses.

Understanding Physicians' Skills at Providing End-of-Life Care

BACKGROUND: A framework for understanding and evaluating physicians’ skills at providing end-of-life care from the perspectives of patients, families, and health care workers will promote better quality of care at the end of life.OBJECTIVE: To develop a comprehensive understanding of the factors contributing to the quality of physicians’ care for dying patients.DESIGN: Qualitative study using focus groups and content analysis based on grounded theory.SETTING: Seattle, Washington.PARTICIPANTS: Eleven focus groups of patients with chronic obstructive pulmonary disease, AIDS, or cancer (79 patients); 3 groups of family members who had a loved one die of chronic disease (20 family members); 4 groups of nurses and social workers from hospice or acute care settings (27 health care workers); and 2 groups of physicians with expertise in end-of-life care (11 physicians).RESULTS: We identified 12 domains of physicians’ skills at providing end-of-life care: accessibility and continuity; team coordination and communication; communication with patients; patient education; inclusion and recognition of the family; competence; pain and symptom management; emotional support; personalization; attention to patient values; respect and humility; and support of patient decision making. Within these domains, we identified 55 specific components of physicians’ skills. Domains identified most frequently by patients and families were emotional support and communication with patients. Patients from the 3 disease groups, families, and health care workers identified all 12 domains. Investigators used transcript analyses to construct a conceptual model of physicians’ skills at providing end-of-life care that grouped domains into 5 categories.CONCLUSIONS: The 12 domains encompass the major aspects of physicians’ skills at providing high-quality end-of-life care from the perspectives of patients, their families, and health care workers, and provide a new framework for understanding, evaluating, and teaching these skills. Our findings should focus physicians, physician-educators, and researchers on communication, emotional support, and accessibility to improve the quality of end-of-life care.

Staphylococcus aureus bacteremia in patients with Hickman catheters

PURPOSE Determination of outcome and prognostic variables associated with Staphylococcus aureus bacteremia in patients with Hickman catheters. PATIENTS AND METHODS At the University of Washington Medical Center, 37 patients with Hickman catheters and S. aureus bacteremia were studied by retrospective chart review. Clinical features associated with each episode of infection were determined, and the relationships among clinical features, therapy, and outcomes were explored. RESULTS Only 18% of all Hickman catheter-associated S. aureus bacteremias and only 10% of those cases with exit site infections were cured without catheter removal. In seven of 41 episodes (17%), death or bacteremic relapse occurred. The best prognosis was found in infections with a low blood culture colony count (less than 1 colony/mL). CONCLUSION Hickman catheter-associated bacteremia due to S. aureus has a worse prognosis than other Hickman catheter-associated bacteremias. Early catheter removal should be considered except in cases with a remote, noncatheter focus of infection or in infections with no catheter-related physical signs and blood culture colony counts of less than 1/mL.

Characteristics of effective clinical teachers of ambulatory care medicine

This study identified characteristics of clinical teachers in ambulatory care settings that influenced ratings of overall teaching effectiveness and examined the impacts of selected variables of the clinic environment on teaching effectiveness ratings. A survey instrument derived from prior research and observations of ambulatory care teaching was sent to 165 senior medical students and 60 medicine residents at the University of Washington School of Medicine in 1988. A total of 122 (74%) of the seniors and 60 (71%) of the residents responded. Results indicate that the most important characteristics of the ambulatory care teachers were that they actively involved the learners, promoted learner autonomy, and demonstrated patient care skills. Environmental variables did not have a substantial influence on these ratings.

Central nervous system infections associated with hereditary hemorrhagic telangiectasia

The clinical courses of 31 episodes of brain abscess and one episode of meningitis occurring in patients with hereditary hemorrhagic telangiectasia are reviewed. Pulmonary arteriovenous malformations were demonstrable in all but two patients and presumably permitted septic microemboli to evade the normal pulmonary capillary filter and lodge in the brain. Obtundation, headache, visual disturbances, hemiplegia, and seizures were the most common presenting features. Cyanosis, clubbing, polycythemia, and hypoxemia were routinely encountered, but leukocytosis and fever were present in a minority of cases, and all blood cultures were sterile. Anaerobic and microaerophilic streptococci were the commonest pathogens found in the brain abscesses. Thirteen patients died, and patients without abscess drainage or with delayed diagnosis had a higher mortality rate. A brain abscess may develop in approximately 1 percent of patients with hereditary hemorrhagic telangiectasia, and awareness of this risk should lead to early investigation of any patient with hereditary hemorrhagic telangiectasia who has neurologic symptoms.

Dying Patients' Need for Emotional Support and Personalized Care from Physicians: Perspectives of Patients with Terminal Illness, Families, and Health Care Providers

This study addressed the emotional and personal needs of dying patients and the ways physicians help or hinder these needs. Twenty focus groups were held with 137 individuals, including patients with chronic and terminal illnesses, family members, health care workers, and physicians. Content analyses were performed based on grounded theory. Emotional support and personalization were 2 of the 12 domains identified as important in end-of-life care. Components of emotional support were compassion, responsiveness to emotional needs, maintaining hope and a positive attitude, and providing comfort through touch. Components of personalization were treating the whole person and not just the disease, making the patient feel unique and special, and considering the patients social situation. Although the levels of emotional support and personalization varied, there was a minimal level, defined by compassion and treating the whole person and not just the disease, that physicians should strive to meet in caring for all dying patients. Participants also identified intermediate and advanced levels of physician behavior that provide emotional and personal support.

Promoting fundamental clinical skills: a competency-based college approach at the University of Washington.

The focus on fundamental clinical skills in undergraduate medical education has declined over the last several decades. Dramatic growth in the number of faculty involved in teaching and increasing clinical and research commitments have contributed to depersonalization and declining individual attention to students. In contrast to the close teaching and mentoring relationship between faculty and students 50 years ago, today’s medical students may interact with hundreds of faculty members without the benefit of a focused program of teaching and evaluating clinical skills to form the core of their four-year curriculum. Bedside teaching has also declined, which may negatively affect clinical skills development. In response to these and other concerns, the University of Washington School of Medicine has created an integrated developmental curriculum that emphasizes bedside teaching and role modeling, focuses on enhancing fundamental clinical skills and professionalism, and implements these goals via a new administrative structure, the College system, which consists of a core of clinical teachers who spend substantial time teaching and mentoring medical students. Each medical student is assigned a faculty mentor within a College for the duration of his or her medical school career. Mentors continuously teach and reflect with students on clinical skills development and professionalism and, during the second year, work intensively with them at the bedside. They also provide an ongoing personal faculty contact. Competency domains and benchmarks define skill areas in which deepening, progressive attention is focused throughout medical school. This educational model places primary focus on the student.

From concept to culture: the WWAMI program at the University of Washington School of Medicine.

Shortages of primary care physicians have historically affected rural areas more severely than urban and suburban areas. In 1970, the University of Washington School of Medicine (UWSOM) administrators and faculty initiated a four-state, community-based program to increase the number of generalist physicians throughout a predominantly rural and underserved region in the U.S. Northwest. The program developed regional medical education for three neighboring states that lacked their own medical schools, and encouraged physicians in training to practice in the region. Now serving five Northwest states (Washington, Wyoming, Alaska, Montana, and Idaho), the WWAMI program has solidified and expanded throughout its 30-year history. Factors important to success include widespread participation in and ownership of the program by the participating physicians, faculty, institutions, legislatures, and associations; partnership among constituents; educational equivalency among training sites; and development of an educational continuum with recruitment and/or training at multiple levels, including K-12, undergraduate, graduate training, residency, and practice. The programs positive influences on the UWSOM have included historically early attention to primary care and community-based clinical training and development of an ethic of closely monitored innovation. The use of new information technologies promises to further expand the ability to organize and offer medical education in the WWAMI region.

Physicians' Interactions with Health Care Teams and Systems in the Care of Dying Patients: Perspectives of Dying Patients, Family Members, and Health Care Professionals

This study investigated the specific physician skills required to interact with health care systems in order to provide high quality care at the end of life. We used focus groups of patients with terminal diseases, family members, nurses and social workers from hospice or acute care settings, and physicians. We performed content analysis based on grounded theory. Groups were interviewed. Two domains were found related to physician interactions with health care systems: 1) access and continuity, and 2) team communication and coordination. Components of these domains most frequently mentioned included taking as much time as needed with the patient, accessibility, and respect shown in working with health team members. This study highlights the need for both physicians and health care systems to improve accessibility for patients and families and increase coordination of efforts between health care team members when working with dying patients and their families.