Endpiece: Three different talks

ObjectivesTo characterise the information needs of family doctors by collecting the questions they asked about patient care during consultations and to classify these in ways that would be useful to developers of knowledge bases.DesignObservational study in which investigators visited doctors for two half days and collected their questions. Taxonomies were developed to characterise the clinical topic and generic type of information sought for each question.SettingEastern Iowa.ParticipantsRandom sample of 103 family doctors.ResultsParticipants asked a total of 1101 questions. Questions about drug prescribing, obstetrics and gynaecology, and adult infectious disease were most common and comprised 36% of all questions. The taxonomy of generic questions included 69 categories; the three most common types, comprising 24% of all questions, were “What is the cause of symptom X?” “What is the dose of drug X?” and “How should I manage disease or finding X?” Answers to most questions (702, 64%) were not immediately pursued, but, of those pursued, most (318, 80%) were answered. Doctors spent an average of less than 2 minutes pursuing an answer, and they used readily available print and human resources. Only two questions led to a formal literature search.ConclusionsFamily doctors in this study did not pursue answers to most of their questions. Questions about patient care can be organised into a limited number of generic types, which could help guide the efforts of knowledge base developers.

Key messages

• Questions that doctors have about the care of their patients could help guide the content of medical information sources and medical training
• In this study of US family doctors, participants frequently had questions about patient care but did not pursue answers to most questions (64%)
• On average, participants spent less than 2 minutes seeking an answer to a question
• The most common resources used to answer questions included textbooks and colleagues; formal literature searches were rarely performed
• The most common generic questions were “What is the cause of symptom X?” “What is the dose of drug X?” and “How should I manage disease or finding X?”

     

How technology is reshaping the practice of nongynecologic cytology: frontiers of cytology symposium

To pay tribute to the Founders of Acta Cytologica, this Golden Anniversary symposium on nongynecologic cytology revives the written symposium style of the 1950s. Participants from countries throughout the world were asked how new technologies are currently applied in their laboratories and whether future advances and challenges can be predicted. The specific questions and the participants' answers follow.     

Involving consumers in the development of an educational program for cystic fibrosis carrier screening.

Input from consumers of health care was sought in developing an educational program to be provided to individuals who are considering carrier testing for cystic fibrosis (CF). In addition, we assessed the ability of health professionals to predict consumers' priorities with regard to such information. A focus group of six middle school teachers formulated questions that they would ask in trying to decide whether they wanted carrier screening for CF. Then, other adults with (n = 39) and without (n = 60) a family history of CF were presented with the questions and were asked to select the questions in the order in which they would want them answered if offered the carrier test. After each question was answered, they were asked whether they would want the carrier test if it were offered to them. CF clinic staff, clinical geneticists, and genetic counselors (n = 31) were asked to select the questions in the order in which they believed that an adult from the general population would want them answered. There were no differences in the order in which adults with and without a family history of CF would want questions answered. Consumers would want to learn about the carrier test as well as their risk of being a carrier and of having a child with CF, before receiving information on reproductive options and the effect that a child with CF would have on the family. Of the 44% of consumers who changed their mind about wanting screening during the course of selecting questions, 52% did so after the first question that they selected.(ABSTRACT TRUNCATED AT 250 WORDS)     

The relevance to family physicians of core content review: evaluation of a program of continuing education.

The Core Content Review of Family Medicine was assessed for its relevance to family practice. Three sets of questionnaires were completed and assessed by 48 experienced, certificated family physicians, of whom half were faculty members from university departments of family medicine and half were in private practice. The answers to 57% of the questions were correct. In the opinion of the panelists the answers to 62% of the questions permitted discrimination between physicians providing care of good quality and those providing care that was less than adequate. The panelists rated 78% of the questions as being educationally useful. Two thirds of the questions were deemed relevant according to a composite criterion. Examples are given of the questions considered most relevant and of those considered least relevant.     

Genetic Counseling—A Health Department Service to Physicians

Questions about inheritance in all kinds of diseases and defects are commonly asked of nearly all physicians. In attempting to answer these questions, however, the physician is often hampered by lack of formal instruction in clinical genetics.Since the health department, if it is to carry out its epidemiologic function, must be as concerned over the increasing identification of genetic agents in disease as it is and has been over environmental disease agents, it should come to represent a source of assistance not now generally available to the physician. In short, as it carries out those activities by which its store of general genetic information is increased, and until other sources of genetic consultation become reasonably available, the health department can be of real service to physicians as a resource to which they may turn for help when dealing with families wanting genetic information.Such a service has been provided experimentally for the last two years by the Contra Costa County Health Department.This program calls for the taking of family pedigrees by public health nurses on families with questions of a genetic nature who are health department clients and on families who are referred by their private physicians for this service. An interpretation of each pedigree is made by the department''s physician in charge of the program and submitted to the family''s physician for his use in counseling the family. Evidence to date suggests the process can be a highly useful service to the practitioner and his patient.     

Questioning behaviour in general practice: a pragmatic study.

OBJECTIVE: To study the extent to which general practitioners'' questioning behaviour in routine practice is likely to encourage the adoption of evidence based medicine. DESIGN: Self recording of questions by doctors during consultations immediately followed by semistructured interview. SETTING: Urban Australian general practice. SUBJECTS: Random sample of 27 general practitioners followed over a half day of consultations. MAIN OUTCOME MEASURES: Rate of recording of clinical questions about patients'' care which doctors would like answered; frequency with which doctors found answers to their questions. RESULTS: Doctors asked a total of 85 clinical questions, at a rate of 2.4 for every 10 patients seen. They found satisfactory answers to 67 (79%) of these questions. Doctors who worked in small practices (of one or two doctors) had a significantly lower rate of questioning than did those in larger practices (1.6 questions per 10 patients v 3.0 patients, P = 0.049). No other factors were significantly related to rate of questioning. CONCLUSIONS: These results do not support the view that doctors routinely generate a large number of unanswered clinical questions. It may be necessary to promote questioning behaviour in routine practice if evidence based medicine and other forms of self directed learning are to be successfully introduced.     

Attitudes of medical staff towards the psychiatric label "schizophrenic patient" tested by an anti-stigma questionnaire

The aim of this research was to investigate the opinions and attitudes of medical staff towards schizophrenic patients. The research included three groups of examinees, 200 physicians of various specialties, 200 nurses and technicians working in Zagreb city hospitals, and 200 3rd and 4th year students of the School of Medicine in Zagreb. Previously validated anti-stigma questionnaire was used, consisting of 25 questions divided into three thematic groups, structured and adapted to the specific requirements of this study. The results were mutually compared and statistically analyzed by applying the chi 2-test. Significant difference (p < 0.01) between the answers of physicians and those of medical students was found in questions 2, 4, 5, 6, 11, 13, 15, 16, 18, 22, 23, 25, and between physicians and nurses/technicians in answers to questions 4, 15, 22, 23. Significant difference (p < 0.01) between the answers given by nurses/technicians and medical students was found in questions 10, 13, 22, 23. The results point to the existence of prejudices and stigmatizing attitudes in all three investigated groups. The most frequent reasons for stigmatizing attitude of students are based on fear and insufficient knowledge about mental patients and schizophrenia as a disease, while there are a high percentage of positive answers to the questions on rehabilitation and resocialization. The nurses/technicians also show a high degree of mistrust towards schizophrenic patients and mostly answer with "I don't know", thus presenting insufficiently formed attitudes about the mentioned problems. The physicians in their answers confirm fear, mistrust and stigmatizing attitudes towards schizophrenic patients found in general population in Croatia. The consequences of such attitudes are the low quality of life of schizophrenic patients, and slow, often incomplete, resocialization.     

Analysis of Free Online Physician Advice Services

Background

Online Consumer Health websites are a major source of information for patients worldwide. We focus on another modality, online physician advice. We aim to evaluate and compare the freely available online expert physicians’ advice in different countries, its scope and the type of content provided.

Setting

Using automated methods for information retrieval and analysis, we compared consumer health portals from the US, Canada, the UK and Israel (WebMD,NetDoctor,AskTheDoctor and BeOK). The evaluated content was generated between 2002 and 2011.

Results

We analyzed the different sites, looking at the distribution of questions in the various health topics, answer lengths and content type. Answers could be categorized into longer broad-educational answers versus shorter patient-specific ones, with different physicians having personal preferences as to answer type. The Israeli website BeOK, providing 10 times the number of answers than in the other three health portals, supplied answers that are shorter on average than in the other websites. Response times in these sites may be rapid with 32% of the WebMD answers and 64% of the BeOK answers provided in less than 24 hours. The voluntary contribution model used by BeOK and WebMD enables generation of large numbers of physician expert answers at low cost, providing 50,000 and 3,500 answers per year, respectively.

Conclusions

Unlike health information in online databases or advice and support in patient-forums, online physician advice provides qualified specialists’ responses directly relevant to the questions asked. Our analysis showed that high numbers of expert answers could be generated in a timely fashion using a voluntary model. The length of answers varied significantly between the internet sites. Longer answers were associated with educational content while short answers were associated with patient-specific content. Standard site-specific guidelines for expert answers will allow for more desirable content (educational content) or better throughput (patient-specific content).     

How informed is patients' consent to release of medical information to insurance companies?

A study was conducted to assess how informed the consent of patients is to the release of confidential information to insurance companies. Questionnaires were sent to 226 consecutive patients from four practices whose general practitioners had received requests to complete a personal medical attendant''s report for an insurance company. In total 195 patients returned the questionnaire, whose six questions required only a yes or no answer. More than half of the patients (102 (52%] could not recall having given their consent and 79 (40%) had one or more objections to the questions commonly asked by insurance companies. Questions about sexually transmitted diseases and AIDS led to the greatest proportion of objections (85% (67/79) and 80% (63/79) respectively). Over half (111 (57%) of the 195 respondents expected their doctor to withhold sensitive information. Of the 93 patients who gave their informed consent, 63 (68%) did not expect that their doctor would be asked to answer one or more of the common questions. In most cases the consent of patients to the release of confidential information to insurance companies is neither knowingly given nor informed.     

关于豆科植物心皮缝合线朝向的思考

当今植被和地球生态系统中多样性最高的类群是被子植物.豆科植物是被子植物中的第三大科, 因其重要的经济价值与人类的生活密切相关, 颇受植物学家的重视.百余年前植物学家已基本明确回答了豆科植物的许多形态学问题, 但仍然有一个问题不甚明确.单枚心皮是豆科植物的一个重要特征.植物学家认为该心皮缝合线朝向心皮的腹面.这种解读某种...     

Where do you know what you know? The representation of semantic knowledge in the human brain

Mr M, a patient with semantic dementia--a neurodegenerative disease that is characterized by the gradual deterioration of semantic memory--was being driven through the countryside to visit a friend and was able to remind his wife where to turn along the not-recently-travelled route. Then, pointing at the sheep in the field, he asked her "What are those things?" Prior to the onset of symptoms in his late 40s, this man had normal semantic memory. What has gone wrong in his brain to produce this dramatic and selective erosion of conceptual knowledge?     

Regeneration of canopy trees in tropical wet forests

The most diverse tree communities on earth, the tropical wet forests, to a large degree remain ecological enigmas. What accounts for the coexistence of 100 or more tree species per hectare, compared to the 15 or fewer found in most temperate forests? What are the lifespans of tropical forest trees? What factors control their populations through time and space? Do the different species have highly individual regeneration patterns, or are many in fact ecological equivalents? Although we are far from having satisfactory answers to these questions, recent studies of regeneration processes are leading toward new interpretations of these complex communities.     

Weight-specific health-related quality of life in adolescents with extreme obesity

The objectives of this multisite study were to: (i) examine differences by gender and race on generic and weight- specific health-related quality of life (HRQOL) in adolescents with extreme obesity (BMI > or = 40 kg/m(2)) and (ii) explore HRQOL differences based on treatment pursued (behavioral vs. bariatric surgery). Study participants included 145 obese adolescents (mean age = 15.3 years; 68% female; 46% black; mean BMI = 50.6) referred to pediatric weight management programs. Participants completed generic (PedsQL) and weight-specific (Impact of Weight on Quality of Life-Kids (IWQOL-Kids)) HRQOL measures. Generic and weight-specific measures indicated global (e.g., all domains) HRQOL impairment and significant differences by race. Physical, emotional, and social scores of the PedsQL (Ps < 0.01) and the physical comfort and body esteem scores of the IWQOL-Kids (Ps < 0.001) were significantly higher for black compared to white adolescents with extreme obesity. Extremely obese adolescents pursuing bariatric surgery reported similar HRQOL to adolescents pursuing behavioral treatment (n = 30 matched pairs). HRQOL did not differ for extremely obese adolescents based on type of treatment sought, but race/ethnicity should be considered when characterizing these youth. Although racial differences in adolescent body image/esteem have been reported, it is unknown why black adolescents with extreme obesity would report less impact of weight on their physical functioning. Overall, these data suggest that HRQOL is not homogenous in adolescents with extreme obesity.     

Ontogeny of odor liking during childhood and its relation to language development

One important aspect of odor hedonics is its plasticity during human development. The present study set out to probe the modulators of such olfactory change during that period by testing the hypothesis that language and semantic representations of objects are strong organizers of odor liking. To this end, 15 three-year-old children were tested in a longitudinal study. Participants were exposed to exactly the same 12 odorants once a year over a 3-year period. At each experimental session, they were asked to answer 2 questions: 1) "Do you like or dislike this odor?" and 2) "Can you tell me what it is?" The level of language production was assessed on a standardized test. The 3-year-old children were found to categorize the same number of odorants as liked and as disliked. The follow-up study, in contrast, showed that at 5 years of age they categorized more of these odors as liked and that the shift was significant only in the children with higher language production skills. Taken as a whole, these findings suggest that the 3- to 5-year age range, when children begin to master language, is a turning point in the construction of olfactory hedonic categories during childhood.     

Referral letters and replies from orthopaedic departments: opportunities missed.

OBJECTIVE--To study delays between sending referral letters and the outpatient appointment and to assess the content of referral and reply letters, their educational value, and the extent to which questions asked are answered by reply letters. DESIGN--Retrospective review of referrals to 16 consultant orthopaedic surgeons at five hospitals, comprising 288 referral letters with corresponding replies, by scoring contents of letters. SETTING--Orthopaedic teaching hospitals in Nottingham, Derby, and Mansfield. MAIN OUTCOME MEASURES--Weighted scores of contents of referral and reply letters, assessment of their educational value, and responses to questions in referral letters. RESULTS--Median outpatient delay was 23.4 weeks. There was no significant decrease in waiting time if the referral letter was marked "urgent" but a significantly greater delay (p less than 0.01) if referrals were directed to an unnamed consultant. The content score was generally unsatisfactory for both referrals and replies, and there was no correlation for the content scores of the referral letter and its reply (r = 0.13). Items of education were rare in the referral letters (8/288; 3%) and significantly more common in replies (75/288; 26%) (p much less than 0.001). Senior registrars were significantly more likely to attempt education than other writers (p less than 0.02). Education in replies was significantly related to increased length of the letter (p less than 0.05) and was more likely to occur if the referral was addressed to a named consultant (p less than 0.03). 48 (17%) Referral letters asked questions, of which 21 (44%) received a reply. No factor was found to influence the asking of or replying to questions. CONCLUSIONS--The potential for useful communication in the referral letter and in the reply from orthopaedic surgeons is being missed at a number of levels. The content is often poor, the level of mutual education is low, and the use of the referral letter to determine urgency is deficient. Most questions asked by general practitioners are not answered.     

Eight questions about invasions and ecosystem functioning

I pose eight questions central to understanding how biological invasions affect ecosystems, assess progress towards answering those questions and suggest ways in which progress might be made. The questions concern the frequency with which invasions affect ecosystems; the circumstances under which ecosystem change is most likely; the functions that are most often affected by invaders; the relationships between changes to ecosystems, communities, and populations; the long-term responses of ecosystems to invasions; interactions between biological invasions and other anthropogenic activities and the difficulty of managing undesirable impacts of non-native species. Some questions have been answered satisfactorily, others require more data and thought, and others might benefit from being reformulated or abandoned. Actions that might speed progress include careful development of trait-based approaches; strategic collection and publication of new data, including more frequent publication of negative results; replacement of expert opinion with hard data where needed; careful consideration of whether questions really need to be answered, especially in cases where answers are being provided for managers and policy-makers; explicit attention to and testing of the domains of theories; integrating invasions better into an ecosystem context; and remembering that our predictive ability is limited and will remain so for the foreseeable future.     

Multilocus enzyme electrophoresis: a valuable technique for providing answers to problems in parasite systematics

The aim of this review is to highlight the effectiveness of the technique of multilocus enzyme electrophoresis in answering questions relating to the systematics of parasites and to highlight errors in the way the technique has been used and the results interpreted. We have approached this topic by answering specific questions that we have been asked by colleagues and students not necessarily familiar with the technique, the method of data analysis and its application. Although the technique has been applied to provide answers for taxonomic and population genetics studies, it remains under-utilised, perhaps because of recent advances in newer molecular technology. Rather than not acknowledge or dismiss the value of more traditional technology, we suggest that researchers examine problems in the systematics of parasites by the comparison of data derived from morphological, biochemical and molecular techniques.     

Who owns your body? Legal issues on the ownership of bodily material

Who owns your body and parts removed from it? Can you legally sell your bodily material – or information derived from it? Can you legally prevent other people gaining access to your excised bodily material, including your blood relatives who might need your tissue or genetic information for their own genetic tests? What legal remedies are there if people take or use your bodily material without your consent? And why are the answers to these questions vitally important for scientists?