Canada produces its first MD specializing in telemedicine

Originally Dr. Rod Elford had planned to pursue a career in sports medicine. An introduction to space medicine and the possibilities inherent in telemedicine changed all that, and last year he became the first Canadian physician to complete a clinical fellowship in this emerging field. Observers think he is likely to be the first of many.     

Principles of diagnosing occupational diseases

The traditional diagnostic procedure adhered to in general medicine is too frequently neglected when a physician is confronted with a possible occupational disease. Also, the proper diagnosis in occupational medicine requires additional effort along lines of investigation not necessary in general medicine. Failure to conform to the basic steps as outlined in this paper will distort known entities or "create" false ones.     

Illicit organogenesis: Methods and substances of doping and manipulation

Doping and manipulation are undesirable companions of professional and amateur sport. Numerous adverse analytical findings as well as confessions of athletes have demonstrated the variety of doping agents and methods as well as the inventiveness of cheating sportsmen. Besides ‘conventional’ misuse of drugs such as erythropoietin and insulins, experts fear that therapeutics that are currently undergoing clinical trials might be part of current or future doping regimens, which aim for an increased functionality and performance or organs and tissues. Emerging drugs such as selective androgen receptor modulators (SARMs), hypoxia-inducible factor (HIF) complex stabilizers or modulators of muscle fiber calcium channels are considered relevant for current and future doping controls due to their high potential for misuse in sports.Key words: sport, doping, mass spectrometry, anabolics, insulin, HIF, S107     

The Link between Knowledge,Attitudes and Practices in Relation to Atmospheric Haze Pollution in Peninsular Malaysia

Transboundary haze episodes caused by seasonal forest fires have become a recurrent phenomenon in Southeast Asia, with serious environmental, economic, and public health implications. Here we present a cross-sectional survey conducted among people in Kuala Lumpur and surrounds to assess the links between knowledge, attitudes, and practices in relation to the transboundary haze episodes. Of 305 respondents, 125 were amateur athletes participating in a duathlon event and the remainder were surveyed in an inner-city shopping mall. Across the whole sample, people who possessed more factual information about the haze phenomenon showed significantly higher levels of concern. Duathletes were more knowledgeable than non-duathletes and also more concerned about the negative effects of haze, especially on health. For all people who regularly practice outdoor sports (including people interviewed at the shopping mall), higher levels of knowledge and concerned attitudes translated into a greater likelihood of engaging in protective practices, such as cancelling their outdoor training sessions, while those with greater knowledge were more likely to check the relevant air pollution index on a daily basis. Our results indicate that the provision of accurate and timely information about air quality to residents will translate into beneficial practices, at least among particularly exposed individuals, such as amateur athletes who regularly practice outdoor sports.     

Lethal injection,autonomy and the proper ends of medicine

Gerald Dworkin has argued that it is inconsistent with the proper ends of medicine for a physician to participate in an execution by lethal injection. He does this by proposing a principle by which we are to judge whether an action is consistent with the proper ends of medicine. I argue: (a) that this principle, if valid, does not show that it is inconsistent with the proper ends of medicine for a physician to participate in an execution by lethal injection; and (b) that this principle is not valid, and this is because it mistakenly views the promotion of patient autonomy as one of the proper ends of medicine. Rather, I propose, we should view respect for a patient's autonomy as a constraint on the pursuit of the proper ends of medicine, rather than as one of the proper ends itself. With this revised understanding of the proper ends of medicine, we can conclude that it is inconsistent with the proper ends of medicine for a physician to participate in an execution by lethal injection.     

Anabolic steroid usage in athletics: facts, fiction, and public relations

Anecdotal evidence suggests the widespread usage of anabolic steroids among athletes (20-90%), particularly at the professional and elite amateur levels. In contrast, scientific studies indicate that usage is rare and no higher than 6%. Conclusions from scientific studies suggest that anabolic steroid usage declines progressively from high school to college and beyond; however, anecdotal evidence claims the opposite trend. In this clash between "hard" scientific data vs. "soft" anecdotal information, it is natural that professionals would gravitate toward scientifically based conclusions. However, in the case of anabolic steroids (a stigmatized and illegal substance), should word-of-mouth testimony from individuals closest to the issues--those who have participated in and coached sports, those who have served as drug-testing overseers, and journalists who relentlessly track leads and verify sources--be set aside as irrelevant? Not if a complete picture is to emerge. In this review, hard scientific evidence is placed on the table side-by-side with soft anecdotal evidence, without weighting or bias. The purpose is to allow the opportunity for each to illuminate the other and, in so doing, potentially bring us a step closer to determining the true extent of anabolic steroid usage in athletics.     

A Large Number of Reviews on Physician Rating Websites May Reflect Reputation Management

BackgroundPhysicians with a large number of reviews and a high rating may be employing reputation management strategies. Specialists may be more likely than non-specialists to employ such strategies. This should be apparent in a study of online physician reviews on physician rating websites (PRW).MethodsUsing one physician rating website, we gathered orthopedic surgeon and family physician reviews. We measured Spearman correlations between the number of reviews and average numerical rating and used chi-squared to test threshold relationships.ResultsThere were very small negative Spear-man correlations between the number of online reviews and the average numerical rating for orthopedic surgeons (p= -0.097, p-value=<0.001) family medicine physicians (p= -0.170, p-value=<0.001; Figure 2). Physicians with more than 100 reviews had a greater average numerical rating than physicians with fewer than 50 reviews. Orthopedic surgeons are more likely than family medicine physicians to have a large number of reviews and average numerical rating greater than 3.Open in a separate windowFigure 2.Family medicine physicians average rating plotted against number of reviews.ConclusionThe small fraction of physician with a high number of reviews may be utilizing reputation management strategies, and this seems relatively specific to specialists rather than non-specialists. Level of Evidence: III     

Postmodernist theory and the physician-patient relationship

The author discusses the postmodernist claim that the "grand theories" have lost credibility, even in the field of medical science and practice. Rather than representing a shared reality among physician and patient, illness represents two quite distinct realities - the meaning of one being significantly and distinctively different from the meaning of the other. However, existential clinical narratives can function as important bridges between the world of the patient and the world of the physician. Such narratives provide important information regarding the patient's biographical situation and, particularly, the personal and cultural meanings which are a function of the biographical situation. At the same time, these narratives provide physicians with useful information for the practice of medicine.     

Physician experience and outcomes among patients admitted to general internal medicine teaching wards

Background:

Physician scores on examinations decline with time after graduation. However, whether this translates into declining quality of care is unknown. Our objective was to determine how physician experience is associated with negative outcomes for patients admitted to hospital.

Methods:

We conducted a retrospective cohort study involving all patients admitted to general internal medicine wards over a 2-year period at all 7 teaching hospitals in Alberta, Canada. We used files from the Alberta College of Physicians and Surgeons to determine the number of years since medical school graduation for each patient’s most responsible physician. Our primary outcome was the composite of in-hospital death, or readmission or death within 30 days postdischarge.

Results:

We identified 10 046 patients who were cared for by 149 physicians. Patient characteristics were similar across physician experience strata, as were primary outcome rates (17.4% for patients whose care was managed by physicians in the highest quartile of experience, compared with 18.8% in those receiving care from the least experienced physicians; adjusted odds ratio [OR] 0.88, 95% confidence interval [CI] 0.72–1.06). Outcomes were similar between experience quartiles when further stratified by physician volume, most responsible diagnosis or complexity of the patient’s condition. Although we found substantial variability in length of stay between individual physicians, there were no significant differences between physician experience quartiles (mean adjusted for patient covariates and accounting for intraphysician clustering: 7.90 [95% CI 7.39–8.42] d for most experienced quartile; 7.63 [95% CI 7.13–8.14] d for least experienced quartile).

Interpretation:

For patients admitted to general internal medicine teaching wards, we saw no negative association between physician experience and outcomes commonly used as proxies for quality of inpatient care.Many jurisdictions have instituted compulsory recertification of physicians on the assumption that quality of care declines with experience. Although a systematic review reported that 32 of 62 studies found decreasing performance with increasing physician experience, most of these studies evaluated performance on examinations or hypothetical vignettes rather than actual quality of care provided to patients, and most of the studies were done decades ago, before the widespread availability of tools to readily facilitate evidence-based medicine.¹Experience is strongly related to better outcomes in surgery and obstetrics, but studies examining the association between physician experience and quality of care for medical patients have reported mixed results.^1–8 Many of the studies reporting an inverse association between experience and quality of care have focused on the provision of “guideline recommended tests or therapies” as a proxy for quality of care. However, guideline recommendations might not be appropriate in every situation.An evaluation of broader quality metrics may be more appropriate to answer this question. For example, in-hospital mortality and readmission rates or mortality postdischarge are commonly used as markers for quality of inpatient care, are endorsed by the Centers for Medicare & Medicaid Services and are included in the Patient Protection and Affordable Care Act.^9,10 However, to our knowledge, few studies have examined the association between these broader quality metrics and physician experience, and these studies have been limited. They either focused on single diagnoses,¹¹ excluded older adult patients,² examined data from only 1 hospital⁸ or combined data⁷ for both surgeons and physicians.Patients admitted to general internal medicine services at Alberta teaching hospitals are distributed between wards purely on the basis of bed availability, and attending physicians rotate every 1–4 weeks. For these reasons, the distribution of patients between attending physicians is quasirandom. We took advantage of this natural experiment to evaluate the association between attending physician experience (years since medical school graduation) and outcomes for patients admitted to general internal medicine wards in Alberta.     

General medicine in the 'eighties.

The general physician with or without an interest is directly responsible for the initial and continuing care in most acute medicine. Specialty interests cover the whole range of medicine but in most instances are subordinate to the claims of general medicine. Consultants in district general hospitals carry a bigger caseload in acute medicine than their colleagues in teaching hospitals, and this has implications for undergraduate and postgraduate training. The management of patients in intensive care units remains very much the task of the general physician. The general physician will continue to be an essential member of the hospital service in the foreseeable future.     

中药治疗运动性贫血的研究进展

传统中医药在运动医学领域中运用越来越广泛,利用中医药防治运动性贫血的报道也有不少。本文将近年来运用中药治疗运动性贫血的文献进行整理,就其作用机制进行了综述,并对今后的发展方向提出了自己的观点。     

Do physicians have an ethical obligation to care for patients with AIDS?

This paper responds to the question: Do physicians have an ethical obligation to care for patients with acquired immunodeficiency syndrome (AIDS)? First, the social and political milieu in which this question arises is sampled. Here physicians as well as other members of the community are found declaring an unwillingness to be exposed to people with AIDS. Next, laws, regulations, ethical codes and principles, and the history of the practice of medicine are examined, and the literature as it pertains to these areas is reviewed. The obligation to care for patients with AIDS, however, cannot be located in an orientation to morality defined in rules and codes and an appeal to legalistic fairness. By turning to the orientation to morality that emerges naturally from connection and is defined in caring, the physicians'' ethical obligation to care for patients with AIDS is found. Through an exploration of the writings of modern medical ethicists, it is clear that the purpose of the practice of medicine is healing, which can only be accomplished in relationship to the patient. It is in relationship to patients that the physician has the opportunity for self-realization. In fact, the physician is physician in relationship to patients and only to the extent that he or she acts virtuously by being morally responsible for and to those patients. Not to do so diminishes the physician''s ethical ideal, a vision of the physician as good physician, which has consequences for the physician''s capacity to care and for the practice of medicine.     

Physician Care Patterns and Adherence to Postpartum Glucose Testing after Gestational Diabetes Mellitus in Oregon

Objective

This study examines obstetrician/gynecologists and family medicine physicians'' reported care patterns, attitudes and beliefs and predictors of adherence to postpartum testing in women with a history of gestational diabetes mellitus.

Research Design and Methods

In November–December 2005, a mailed survey went to a random, cross-sectional sample of 683 Oregon licensed physicians in obstetrician/gynecologists and family medicine from a population of 2171.

Results

Routine postpartum glucose tolerance testing by both family physicians (19.3%) and obstetrician/gynecologists physicians (35.3%) was reportedly low among the 285 respondents (42% response rate). Factors associated with high adherence to postpartum testing included physician stated priority (OR 4.39, 95% CI: 1.69–7.94) and physician beliefs about norms or typical testing practices (OR 3.66, 95% CI: 1.65–11.69). Specialty, sex of physician, years of practice, location, type of practice, other attitudes and beliefs were not associated with postpartum glucose tolerance testing.

Conclusions

Postpartum glucose tolerance testing following a gestational diabetes mellitus pregnancy was not routinely practiced by responders to this survey. Our findings indicate that physician knowledge, attitudes and beliefs may in part explain suboptimal postpartum testing. Although guidelines for postpartum care are established, some physicians do not prioritize these guidelines in practice and do not believe postpartum testing is the norm among their peers.     

Expert systems in treating substance abuse.

Computer programs can assist humans in solving complex problems that cannot be solved by traditional computational techniques using mathematic formulas. These programs, or "expert systems," are commonly used in finance, engineering, and computer design. Although not routinely used in medicine at present, medical expert systems have been developed to assist physicians in solving many kinds of medical problems that traditionally require consultation from a physician specialist. No expert systems are available specifically for drug abuse treatment, but at least one is under development. Where access to a physician specialist in substance abuse is not available for consultation, this expert system will extend specialized substance abuse treatment expertise to nonspecialists. Medical expert systems are a developing technologic tool that can assist physicians in practicing better medicine.     

Administrative issues in the management of a sports medicine program.

Sports medicine is a subspecialty of medicine which has recently gained prominence in this country. It is usually practiced in conjunction with a specific program of sports medicine in an institutional setting, such as a university. This article describes the integration of sports medicine and the department of athletics at Yale University. The athletic medicine department, as it is called, treats both the injuries and other medical problems of students participating in the organized athletic programs, be they intercollegiate or intramural, which are organized by the University. Problems that arise both medically, such as when to play an injured player, and administratively, such as who should supervise trainers, are discussed. Guidelines are given for choosing the director of this program, as are examples of how to deal with problems between the physicians and the coaches.     

Een carrière als specialist ouderengeneeskunde; iets voor de huidige geneeskundestudent?

Background

Due to the rise of older patients with multi-morbidity, we need more elderly care physicians. However, not all available training slots for the elderly care medicine specialty have been fully utilized in recent years. To assess medical student interest in this specialty as well as potential causes for this interest we explored the interest of medical students in the profession of elderly care physician, as well their perception of this profession, both in the ‘old curriculum’ and in a ‘new curriculum’, where the new curriculum had a mandatory elderly care medicine clerkship and more competency-related learning.

Method

At VUmc 120 final year medical students were asked to complete a questionnaire in 2014 about professional preferences and professional characteristics. The same questionnaire had been presented five years earlier, in 2009, to 150 medical students at the end of their final year.

Results

The response rates were 100% and 85% respectively. Of the students in the new curriculum 16,7% considered a career in elderly care medicine. This percentage was 9,4% for students in the old curriculum (p?=?0,087). The characteristics of the profession that appealed most to the students, but were not considered applicable to elderly care medicine were: diagnostics skills, acute complaints, visible results. The professional characteristics that students found to be very much applicable to this specialty, but less attractive for their future profession were: psychosocial, chronic and terminal conditions.

Discussion

We observe a trend that students in the new curriculum are more interested in the profession of elderly care physician, even though this interest remains limited. We recommend that the basic medical training, both in the bachelor phase and in a mandatory elderly care medicine clerkship, focus more on demonstrating that the characteristics students find appealing in the medical profession are indeed present in this speciality. Also, the basic training should concentrate more on guidance and treatment of patients with chronic and terminal conditions.

     

Illicit organogenesis

Doping and manipulation are undesirable companions of professional and amateur sport. Numerous adverse analytical findings as well as confessions of athletes have demonstrated the variety of doping agents and methods as well as the inventiveness of cheating sportsmen. Besides ‘conventional’ misuse of drugs such as erythropoietin and insulins, experts fear that therapeutics that are currently undergoing clinical trials might be part of current or future doping regimens, which aim for an increased functionality and performance or organs and tissues. Emerging drugs such as selective androgen receptor modulators (SARMs), hypoxia-inducible factor (HIF) complex stabilizers or modulators of muscle fiber calcium channels are considered relevant for current and future doping controls due to their high potential for misuse in sports.     

On the meaning of sports: Cross cultural observations of super stress

The definition of sports medicine indicates the possible therapeutic and research importance of games in the work of social scientists and clinicians. A cross-cultural comparison of super stressful competitions provides one insight into the importance of games in human societies. Fourteen such comparisons are made between Indians in Mexico who run 250-mile foot races and Americans in Alaska who conduct 1049-mile dog sled races. It is concluded that sports can help understand how a society defines itself and regulates violence. Games may be an essential human-specific need which provide entertainment, retain survival skills, ameliorate existential anxiety and promote religious and/or secular socialization. In this study, humans seem willing, if not insistent, to deploy considerable resources of time and material to sustain competitions among their own species, as well as between and with other species. A sports history is important for all individuals.     

Modulation of Motor Area Activity by the Outcome for a Player during Observation of a Baseball Game

Background

Observing competitive games such as sports is a pervasive entertainment among humans. The inclination to watch others play may be based on our social-cognitive ability to understand the internal states of others. The mirror neuron system, which is activated when a subject observes the actions of others, as well as when they perform the same action themselves, seems to play a crucial role in this process. Our previous study showed that activity of the mirror neuron system was modulated by the outcome of the subject''s favored player during observation of a simple competitive game (rock-paper-scissors). However, whether the mirror neuron system responds similarly in a more complex and naturalistic sports game has not yet been fully investigated.

Methodology/Principal Findings

In the present study, we measured the activity of motor areas when the subjects, who were amateur baseball field players (non-pitchers), watched short movie clips of scenes in professional baseball games. The subjects were instructed to support either a batter or a pitcher when observing the movie clip. The results showed that activity in the motor area exhibited a strong interaction between the subject''s supported side (batter or pitcher) and the outcome (a hit or an out). When the subject supported the batter, motor area activity was significantly higher when the batter made an out than when he made a hit. However, such modulation was not apparent when the subject supported the pitcher.

Conclusions/Significance

This result indicates that mirror neuron system activity is modulated by the outcome for a particular player in a competitive game even when observing a complex and naturalistic sports game. We suggest that our inclination to watch competitive games is facilitated by this characteristic of the mirror neuron system.     

Sex and gender medicine in physician clinical training: results of a large,single-center survey

Background

“Sex and Gender Medicine” is a novel medical discipline that takes into account the effects of sex and gender on the health of women and men. The Institute of Medicine in the USA declared in its 2001 and 2010 statements that being a woman or a man significantly impacts the course of diseases, and therefore, this fact must be considered in diagnosis and therapy. We evaluated the representation of Sex and Gender Medicine in clinical training at Cedars-Sinai Medical Center, a large, tertiary, non-profit, academic medical training center in the Western United States.

Methods

Post-graduate physician trainees (residents and fellows) in all medical and surgical departments (medicine, surgery, OB-GYN, pediatrics, anesthesiology, pathology, urology, electrophysiology, pulmonary critical care, cardiology, women’s heart, medical genetics, radiology, neurosurgery, and radiation oncology) were surveyed online; 80 (55 and 45 % female and male residents, respectively) out of 890 physicians (9 % response rate) responded to questions regarding sex and gender-based medicine.

Results

Seventy percent of post-graduate physician trainees indicated that gender medicine concepts are never or only sometimes discussed/presented in their training program. Slightly greater than 70 % of the trainees indicated that gender concepts are never or only sometimes incorporated into didactic lectures or clinical teaching. However, more than 65 % felt that gender medicine concepts are important, and 60 % agreed that gender medicine curriculum should be implemented and taught in their clinical program.

Conclusions

Current physician trainees endorse both a current lack of and need for Sex and Gender Medicine clinical training.