Computerized Entry into Medical Care—Its Impact on Doctor-Patient Relationships

A large proportion of cannery workers see a doctor only as a last resort, in time of crisis. The Cannery Workers Multiphasic Screening Program identified workers in need of physician evaluation, and referred each to a physician of his choice, for examination by appointment, while the worker was not acutely ill. In many instances the screening program generated the first encounters between patient and physician. It conducted a follow-up system for workers unaccustomed to methodical health care. The program financed pretesting education of the persons to be tested, multiphasic testing, physician evaluation of abnormal findings, and the follow-up reminder system.Each physician, in advance of the appointment for evaluation, was sent a computerized report calling attention to findings that exceeded limits considered normal. The report included a form facilitating the physician''s report and billing. In counties having foundations for medical care, the foundations reviewed the form for adequacy of follow-up and appropriateness of charges.The effort to bridge the gap between findings, diagnosis and therapy, for a population group newly introduced to modern medical care delivery, was made possible by the use of the computer as a tool for the attainment of specific, preanalyzed components of the total objective.     

Demonstration of a universal surface DNA computer

A fundamental concept in computer science is that of the universal Turing machine, which is an abstract definition of a general purpose computer. A general purpose (universal) computer is defined as one which can compute anything that is computable. It has been shown that any computer which is able to simulate Boolean logic circuits of any complexity is such a general purpose computer. The field of DNA computing was founded in 1994 by Adleman's solution of a 7-bit instance of the Hamiltonian path problem. This work, as well as most of the subsequent experimental and theoretical investigations in the area, focused primarily upon the solution of NP-complete problems, which are a subset of the larger universal class of problems. In the present work a surface DNA computer capable of simulating Boolean logic circuits is demonstrated. This was done by constructing NOR and OR gates and combining them into a simple logic circuit. The NOR gate is one of the universal gates in Boolean logic, meaning that any other logic gate can be built from it alone. The circuit was solved using DNA-based operations, demonstrating the universal nature of this surface DNA computing model.     

On-line integration of computer controlled diagnostic devices and medical information systems in undergraduate medical physics education for physicians

We designed and evaluated an innovative computer-aided-learning environment based on the on-line integration of computer controlled medical diagnostic devices and a medical information system for use in the preclinical medical physics education of medical students. Our learning system simulates the actual clinical environment in a hospital or primary care unit. It uses a commercial medical information system for on-line storage and processing of clinical type data acquired during physics laboratory classes. Every student adopts two roles, the role of ‘patient’ and the role of ‘physician’. As a ‘physician’ the student operates the medical devices to clinically assess ‘patient’ colleagues and records all results in an electronic ‘patient’ record. We also introduced an innovative approach to the use of supportive education materials, based on the methods of adaptive e-learning. A survey of student feedback is included and statistically evaluated.The results from the student feedback confirm the positive response of the latter to this novel implementation of medical physics and informatics in preclinical education. This approach not only significantly improves learning of medical physics and informatics skills but has the added advantage that it facilitates students’ transition from preclinical to clinical subjects.     

On the trail of Dr. Fifer.

A gift from a patient drew Hope, BC, family physician Gerd Asche irrevocably into the local medical history of the 1858 Fraser River Gold Rush. Because of his interest in Dr. Max William Fifer, Asche undertook research missions in British Columbia, England and the US, converted his computer room to a research and writing centre, and wrote a biography of his predecessor and colleague. He recounts his experience and the growing satisfaction provided by his interest in medical history.     

Acutely Suicidal Patients—Management in General Medical Practice

Suicidal crises are best understood as late stages in the progressive breakdown of adaptational behavior in emotionally exhausted patients. The premonitory symptoms of suicide include verbal communications, suicide attempts, symptomatic actions, depression, treatment failure, excessive emotional reactions to specific disease states and panic reactions.Of persons who committed suicide, 75 per cent had seen a physician within six months. To recognize and evaluate suicide danger the physician must not be afraid to question the patient directly about his suicidal plans. The average physician encounters half a dozen suicidal patients a year and will have 10 to 12 suicides in his practice during a long career.In treating suicidal patients, the physician should maintain his medical attitude. The patients need emergency medical care including appropriate drugs. Free communication between patient and physician is very important. This may take some extra time. Patients benefit from emergency psychological support and stimulation toward constructive action. Family, friends, and community agencies should be mobilized to aid the patient. For seriously suicidal patients, consultation is recommended and treatment in hospital is advisable.     

Computer based methodology for construction of orthodontic arch wire templates

This paper presents the details and logic of two Fortran computer programs. The program, BRACKET, is designed to evaluate the constant relationship among teeth and orthodontic brackets to which an arch wire is adapted. The program, WIRE, is used to initially fit brackets to teeth using the constants derived in BRACKETS, based upon a series of orthogonal transformations. Subsequently, an orthodontic arch wire is fitted through the brackets, and the results are displayed using computer graphics. It is anticipated that the system would be useful in the orthodontic clinical setting as an aid in arch wire formation. The graphics produce a template which incorporates essential points to consider in arch wire formation, namely, perimeter length, lateral widths, symmetry, and appropriate arch form for the patient.     

Computer based methodology for construction of orthodontic arch wire templates

This paper presents the details and logic of two Fortran computer programs. The program, BRACKET, is designed to evaluate the constant relationship among teeth and orthodontic brackets to which an arch wire is adapted. The program, WIRE, is used to initially fit brackets to teeth using the constants derived in BRACKETS, based upon a series of orthogonal transformations. Subsequently, an orthodontic arch wire is fitted through the brackets, and the results are displayed using computer graphics.It is anticipated that the system would be useful in the orthodontic clinical setting as an aid in arch wire formation. The graphics produce a template which incorporates essential points to consider in arch wire formation, namely, perimeter length, lateral widths, symmetry, and appropriate arch form for the patient.     

A biochemical logic gate using an enzyme and its inhibitor. Part II: The logic gate

Enzyme-Based Logic Gates (ENLOGs) are key components in bio-molecular systems for information processing. This report and the previous one in this series address the characterization of two bio-molecular switching elements, namely the alpha-chymotrypsin (alphaCT) derivative p-phenylazobenzoyl-alpha-chymotrypsin (PABalphaCT) and its inhibitor (proflavine), as well as their assembly into a logic gate.The experimental output of the proposed system is expressed in terms of enzymic activity and this was translated into logic output (i.e. "1" or "0") relative to a predetermined threshold value. We have found that an univalent link exists between the dominant isomers of PABalphaCT (cis or trans), the dominant form of either acridine (proflavine) or acridan and the logic output of the system. Thus, of all possible combinations, only the trans-PABalphaCT and the acridan lead to an enzymic activity that can be defined as logic output "1". The system operates under the rules of Boolean algebra and performs as an "AND" logic gate.     

The confederation worm token.

To an increasing degree the psychiatrist is oriented to the community and general hospital either as consultant, therapist, or collaborator in overall patient management. In these new roles, he becomes a more comprehensive physician and also conveys psychiatric insights to his colleagues.Psychological factors and the patient''s personality “style” influence the development and course of every disease, complicating diagnosis and effective treatment. It is a basic requirement that a good working alliance be established between patient and physician. This is assisted by comprehensive history taking, which clarifies the lifesetting in which the illness began, the patient''s personality and his habitual reactions of emotional regression under stress. It will also point up errors introduced by the patient, omissions, and distortions in offering the subjective data which the physician must evaluate.Seven major personality types and appropriate physician responses are outlined: the dependent demanding oral patient, the orderly controlled obsessive, the dramatic seductive hysteric, the long-suffering masochist, the querulous paranoid, the overbearing narcissist and the aloof withdrawn schizoid.The non-psychiatrist can resolve complex and puzzling medical problems if he has an increased awareness of how emotional forces complicate illness and if he can exploit comprehensive history taking to the full.     

MEDICAL HANDICAPS TO DRIVING—The Physician's Dilemma in Evaluation

The physician who examines a patient for impairment to driving must consider the welfare of the community which will be exposed to the patient''s driving in addition to the welfare of the patient himself. The medical opinion on physical and mental fitness to drive should be based upon consideration of:1. Extent and nature of driving exposure.2. Relation of organ system involved to medical requirements of the driving task.3. Duration of condition and nature of adaptability.4. Predicted speed of onset of medical crisis.5. Evaluation of the patient and his environment as a totality.An informed medical society traffic safety committee can be of great assistance to the practicing physician and to the Department of Motor Vehicles in evaluating medical hazards in driving in special cases. Most regulations concerning impairment to driving are currently based upon consensus of expert opinion since statistically valid data are not yet available.     

Hospital data management at the Graz University Ophthalmology Clinic]

In 1991, the eye hospital at the University of Graz initiated the development of a system for the documentation of patient data and services provided. The starting point of the hospital data management system was the surgical documentation system. This made it possible for the patient to be transferred to the ward accompanied by the completed and signed surgical report. In the subsequent steps we developed a complete client server system adapted to the different specific needs of all the various sections of the eye hospital. A further important feature is the fact that all the data are available for access at every part of the hospital. The current version has been in use since 1996, and will be discussed below. The main features of our hospital data management system are automated coding of medical services provided in the diagnostic, surgical and outpatient areas, and guaranteed authenticated data. Automatic generation of findings, reports, etc, allows the physician to concentrate fully on medical concerns. For a modern, service-oriented hospital, complete records of the services provided are indispensable. Complete recording of services is, however, possible only via automation. In our case, this means not only that the available data are always correct (up to date), but also that there is wide acceptance of and reliance on these data by the medical staff. Since the system is an in-house development, it is possible to react rapidly to suggestions for improvement and to eliminate possible errors immediately. The hospital data management system of the eye hospital at the University of Graz is a well-functioning example that makes it worthwhile discussing the greater use of subsystems.     

Multi-enzyme logic network architectures for assessing injuries: digital processing of biomarkers

A multi-enzyme biocatalytic cascade processing simultaneously five biomarkers characteristic of traumatic brain injury (TBI) and soft tissue injury (STI) was developed. The system operates as a digital biosensor based on concerted function of 8 Boolean AND logic gates, resulting in the decision about the physiological conditions based on the logic analysis of complex patterns of the biomarkers. The system represents the first example of a multi-step/multi-enzyme biosensor with the built-in logic for the analysis of complex combinations of biochemical inputs. The approach is based on recent advances in enzyme-based biocomputing systems and the present paper demonstrates the potential applicability of biocomputing for developing novel digital biosensor networks.     

Medical concepts related to individual risk are better explained with "plausibility" rather than "probability"

Background

The concept of risk has pervaded medical literature in the last decades and has become a familiar topic, and the concept of probability, linked to binary logic approach, is commonly applied in epidemiology and clinical medicine. The application of probability theory to groups of individuals is quite straightforward but can pose communication challenges at individual level. Few articles by the way have tried to focus the concept of "risk" at the individual subject level rather than at population level.

Discussion

The author has reviewed the conceptual framework which has led to the use of probability theory in the medical field in a time when the principal causes of death were represented by acute disease often of infective origin. In the present scenario, in which chronic degenerative disease dominate and there are smooth transitions between health and disease the use of fuzzy logic rather than binary logic would be more appropriate. The use of fuzzy logic in which more than two possible truth-value assignments are allowed overcomes the trap of probability theory when dealing with uncertain outcomes, thereby making the meaning of a certain prognostic statement easier to understand by the patient.

Summary

At individual subject level the recourse to the term plausibility, related to fuzzy logic, would help the physician to communicate to the patient more efficiently in comparison with the term probability, related to binary logic. This would represent an evident advantage for the transfer of medical evidences to individual subjects.     

Psychiatric Programs: Their Medical Integration

The basic premise that psychiatry and medicine are one and the same discipline is advanced. Patients present with symptoms: sometimes largely the result of structural change, sometimes largely the result of emotional perturbation, but most frequently a mixture of both. The physician can never do his job satisfactorily without attention to the emotional problems of his patient, which is essentially the subject matter of psychiatry. He must have adequate training during his medical school years in order to recognize and handle emotional problems. The psychiatrically oriented general practitioner and the psychiatrist, who live in the community, are most valuable mental health resources and must have treatment facilities in the general hospital. Furthermore, hospital and medical insurance plans must be devised that will not penalize either doctor or patient when mental illness is recognized and dealt with in the most appropriate manner.     

Informed Consent in California: Latent Liability Without `Negligence'

Informed consent is a legal obligation due from a physician to his patient, an obligation which may not be met by the physician''s skillful treatment of his patient. It may only be met by the treating physician obtaining from his patient knowing authorization for carrying out the intended medical procedure. The physician is required to disclose whatever would be material to his patient''s decision, including the nature and purpose of the procedure, and the risks and alternatives. The disclosures should be made by the physician to his patient, and not through use of consent forms which are not particular to individual patients. To minimize any subsequent claim by the patient that there was a lack of adequate disclosures, the physician should record in the patient''s chart the circumstances of the patient''s consent, and should not rely on the patient''s unreliable ability to recall those circumstances.     

The case against HIV antibody testing of refugees and immigrants.

Computers are now widely used in medical practice for accounting and secretarial tasks. However, it has been much more difficult to use computers in more physician-related activities of daily practice. I investigated the Desqview multitasking system on a 386 computer as a solution to this problem. Physician-directed tasks of management of patient charts, retrieval of reference information, word processing, appointment scheduling and office organization were each managed by separate programs. Desqview allowed instantaneous switching back and forth between the various programs. I compared the time and cost savings and the need for physician input between Desqview 386, a 386 computer alone and an older, XT computer. Desqview significantly simplified the use of computer programs for medical information management and minimized the necessity for physician intervention. The time saved was 15 minutes per day; the costs saved were estimated to be $5000 annually.     

PC-based system for an objective quantification of manual movement disability for clinical and scientific purposes

In clinical management and research of movement disorders exact knowledge about the extent of motor impairment is essential. This paper presents a computer program which allows for an objective measurement of manual movement disability. The program was developed for standard hardware and can easily be used in a variety of clinical and research environments. The program runs on MS-DOS computers and uses a Microsoft computer mouse as the only input device. The temporal resolution is 100 Hz, the spatial resolution 400 dots per inch. The user may choose between standard test sets or he may design sets according to his individual needs from a pool of available protocols which includes tracking tasks, ballistic tasks, complex sequential tasks, and finger tapping. All tasks are implemented in a similar way in order to keep the test environment as consistent as possible for the patient. The patient must usually carry out movements which correspond to the movements of a target symbol on the computer screen. This entails the manipulation of a follower symbol, also visible on the computer screen, via the computer mouse. The program itself and the theoretical background of the protocols are described in the paper. Additionally, preliminary results from pilot experiments are presented.     

Knowledge and Power in the Clinical Setting

In this paper we consider the three categories offered by Howard Brody for understanding power in medicine. In his book, The Healer's Power Brody separates out power in medicine into the categories of Aesculapian, Social, and Charismatic power. We examine these three categories and then apply them to a case. In this case set in an Obstetric ward, a junior member of the medical staff makes a clinical decision about a patient. This clinical decision is overruled by a senior medical staff member who then carries out his plan with disastrous consequences for the woman and her baby. This case challenges the three categories of power offered by Brody and highlights the need for a further category of Hierarchical power to be added to Brody's framework. We conclude by suggesting that there is a need to recognise the discrepancy in power not only between physician and patient but also between senior and junior staff in a clinical setting.