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Offering However cheap sildalist 120 mg on line, it is essential that such physicians have access to interactive exercises focused on the development of quality rehabilitative services cheap 120 mg sildalist with visa, appropriate accommodations cheap 120mg sildalist with visa, insight and skills, it blends many of the skills of this and reasonable opportunities to serve the public. This section section of the guide and offers practical methods to will address these themes and outline other resources that enhance the health care workplace. Many other sections cian health, information on upcoming conferences of the Physician Health Guide will be of value in your search and workshops, and additional learning resources on for information and practical ways to move forward with your physician health. Yizchak Dresner examined population • outline preventive care guidelines, quality indicators for physicians as compared to non physicians. Screening colonoscopy rates were higher Case and fecal occult blood testing rates lower among physicians. A fourth-year resident has planned a dream vacation with For complex reasons, it appears that the care physician patients their spouse to Africa. This is not always to resident keeps putting off getting vaccinations and has their advantage. Frustrated, the resident turns to a fellow in providers infectious disease and asks for help, as the resident feels All patients self-diagnose, including physician patients. Like other pa- tients, a physician patient may fail to recognize the seriousness Introduction of a symptom or to recognize non-specifc symptoms. And, Physicians receive care that is different from that obtained by like others, physician patients may avoid seeking care because other people because they are “physician patients. To expect a treating physician to provide Physician patients also have a tendency to edit out information generic medical care and ignore occupational issues specifc to that does not ft with their original self-diagnosis. A personal physician caring for medical knowledge, a high level of access to health information you, a physician patient, will consider what you know, what you and, generally, a high level of self-care. It is not known how think you know, what you would like to know, and what you physicians apply their knowledge and experience to decisions need to know in order to manage your health care. Although physicians have had extensive training, they may lack information on prevention, screening, diagnosis and treatments in certain areas. Preparing for a primary care visit: Tips for the physician patient The underuse of family physicians and preventive health • Book an appointment and advise the staff of services by physicians themselves is notable and concerning. Physician patients, even those with health problems or concerns, likely have far fewer routine visits than the average patient; thus, a periodic health examination is of great importance to this group. Do doctors look after their health as well as play in sustaining the health of fellow health professionals, their patients? Health problems and the use of health services Case resolution among physicians: A review article with particular emphasis on The fellow gently and respectfully refuses to treat the Norwegian studies. The fellow suggests that the resident see a family physician, as it has been three years since the last primary care visit. Together they review the resident’s schedule to fnd a time when the resident can slip away without compromising patient care or educational demands. During the appointment, the resident is surprised to learn that their weight has gone up by 15 pounds. The resident receives counsel- ling about weight management, agrees to complete the recommended screening tests for their age and books a follow-up appointment. Many psychiatric disorders have a • examine the importance for physicians of identifying signs detrimental effect on a person’s sense of self-effcacy and con- and symptoms of serious emotional distress in themselves fdence, and it is not a stretch to imagine why doctors would and in their colleagues. For example, a depressed physicians, beset by guilt, may be impelled to work harder and Case longer hours to make up for perceived shortcomings. Because A frst-year resident is paged to the delivery room because terms like stress, burnout and anxiety are so much a part of a patient they are following has gone into labour. This is the usual banter in the medical world, physicians may use the resident’s frst high-risk delivery and the resident is both them to gloss over warning signals such as persistent worries, excited and nervous. As the resident jogs toward the deliv- irritability, concentration problems and insomnia until those ery suite they become aware of an uncomfortable feeling symptoms become disabling. Often, physicians with mental in the back of their neck and the pit of their stomach. The health diffculties present with compensatory behaviours such resident suddenly notices that they are having diffculty as self-medication, alcohol or drug abuse. A nurse notices the resident’s diff- Risk factors for mental illness in the general population, includ- culty and takes them to the emergency department. After ing family history and previous episodes of psychiatric illness full investigation, the episode is deemed to have been an apply to medical students, residents and physicians. The resident is mortifed that this has hap- about these factors needs to occur early in a physician’s train- pened and is humiliated by what people must think. Everyone around the resident assures them Key points: physicians and mental illness that this panic occurred because of a combination of • Physicians have the same vulnerabilities to mental having been on call, not sleeping well and having missed illness as the general population. Mental health issues ranging from mild distress to severe and • Take seriously a colleague who shows signs of disabling psychiatric syndromes are among the leading causes depression. For example, the point • Suicide is a real problem, and doctors who have prevalence of major depressive disorder in the general popula- suicidal ideation need care urgently. Studies suggest that rates • Education and behavioural adjustments are of mood and anxiety disorders are slightly lower among work- necessary to improve the ability to cope with the ing physicians, but research also shows that serious emotional stresses of a medical career and to enhance distress is not rare in the physician population. Such fear can present as apprehensions about losing one’s livelihood, being rejected by colleagues and patients, the Among the factors known to contribute to physician stress possibility of regulatory sanctions, and generally diminished are their high-pressure training and practice environments, career options. Serious, recurrent mental health problems can the challenging decisions they must make every day, long change one’s professional life and affect work performance and irregular work hours, and constantly witnessing sickness and patient safety. In addition, some personality traits such as performing in complex clinical environments might eventually, perfectionism, a tendency to assume responsibility for events, for some doctors with disabling mood disorders, become a a strong work ethic and a robust desire to help others can thing of the past. By extension, physicians who do reach out for nizes a mental health assessment by a psychologist. However, resident discloses a longstanding history of anxiety that corridor consultations and collegial interventions, even with has typically been ignored or minimized. The resident the best intentions, can result in inaccurate diagnoses and sub- realizes that they are vulnerable to panic and anxiety when optimal treatment. It is essential that appropriate boundaries sleep-deprived, not eating well, socially isolated or under between the physician provider and the physician patient be signifcant academic pressure. Slowly, the symptoms wane and the Approximately 70 to 90 per cent of suicides are associated with resident enjoys much better health, self-awareness and mental illness. It is important not to downgrade the clini- depressed and burnt out residents: prospective cohort study. Arlington: Improving personal resiliency can help physicians cope with American Psychiatric Publishing. Suicide rates among regularly and taking time for friends and family are essential. Early detection, education and treatment of mental health dis- orders are crucial in this safety sensitive profession. Appropriate follow-up and monitoring of these conditions, particularly those that recur, is essential for physicians with mental illness not only as individuals but also as professionals who wish to safely and competently practise their chosen vocation. Expert assessment, including clinical history, physical • discuss the nature and prevalence of substance use disorders examination, lab and toxicology studies and collateral history, as they affect physicians, is often needed to formulate an accurate diagnosis.
Tradi- tional cohort and case–control studies are observational studies in which there is no intentional intervention sildalist 120mg visa. An example of a clinical trial is a study in which a high-soy-protein diet and a normal diet were given to middle-aged male smok- ers to determine if it reduced their risk of developing diabetes buy discount sildalist 120mg. A cohort study of the same ‘risk factor’ would look at a group of middle-aged male smokers and see which of them ate a high-soy-protein diet and then follow them for a period of time to determine their rates of developing diabetes buy sildalist 120 mg on-line. Clinical trials are characterized by the presence of a control group identical to the experimental patients in every way except for their exposure to the inter- vention being studied. Patients entering controlled clinical trials should be ran- domized, meaning that all patients signed up for the trial should have an equal chance of being placed in either the control group (also called the comparison group, placebo group, or standardized therapy group) or the experimental group, which gets the intervention being tested. Subjects and experimenters should ide- ally be blinded to the therapy and group assignment during the study, such that the experimenters and subjects are unaware if the patient is in the control or experimental group, and are thus unaware whether they are receiving the exper- imental treatment or the comparison treatment. They can show that the cause and effect are associated more than by chance alone, that the cause precedes the effect, and that altering the cause alters the effect. When properly carried out they will have fewer methodological biases than any other study design. The most common weakness of controlled clinical trials is that they are very expensive. Because of the high costs, multi- center trials that utilize cooperation between many research centers and are funded by industry or government are becoming more common. Unfortunately, the high cost of these studies has resulted in more of them being paid for by large biomedical (pharmaceutical or technology) companies and as a result, the design of these studies could favor the outcome that is desired by the sponsoring agency. This could represent a conﬂict of interest for the researcher, whose salary and research support is dependent on the largess of the company providing the money. Other factors that may compromise the research results are patient attri- tion and patient compliance. There may be ethical problems when the study involves giving potentially harmful, or withholding potentially beneﬁcial, therapy. It is still the reader’s responsibility to determine how valid a study is based upon the methodology. In addition, the fact that a study is a ran- domized controlled trial does not in itself guarantee validity, and there can still be serious methodological problems that will bias the results. Albert Einstein (1879–1955) Learning objectives In this chapter you will learn: r different types of data as basic elements of descriptive statistics r instrumentation and measurement r precision, accuracy, reliability, and validity r how researchers should optimize these factors All clinical research studies involve observations and measurements of the phe- nomena of interest. The instruments used to make them are subject to error, which may bias the results of a study. The ﬁrst thing we will discuss is the type of data that can be generated from clinical research. This chapter will then introduce concepts related to instruments and measurements. They can be classiﬁed by their function as independent or dependent variables, their nature as nominal, ordi- nal, interval, or ratio variables, and whether they are continuous, discrete, or dichotomous variables. When classifying variables by function we want to know what the variable does in the experiment. The independent variable is under the con- trol of or can be manipulated by the investigator. Generally this is the cause we 67 68 Essential Evidence-Based Medicine are interested in, such as a drug, a treatment, a risk factor, or a diagnostic test. The dependent variable changes as a result of or as an effect of the action of the independent variable. It is usually the outcome of exposure to the treatment or risk factor, or the presence of a particular diagnosis. We want to ﬁnd out if chang- ing the independent variable will produce a change in the dependent variable. The nature of each variable should be evident from the study design or there is a serious problem in the way the study was conducted. When classifying variables by their nature, we mean the hierarchy that describes the mathematical characteristics of the value generated for that vari- able. The choice of variables becomes very important in the application of statis- tical tests to the data. One can assign a number to each of these categories, but it would have no intrinsic signiﬁcance and cannot be used to compare one piece of the data set to another. Exam- ples of nominal data are classiﬁcation of physicians by specialty or of patients by the type of cancer from which they suffer. There is no relationship between the various types of specialty physicians except that they are all physicians and went to medical school. Ordinal data are nominal data for which the order of the variables has impor- tance and intrinsic meaning. Typical examples of ordinal data include certain pain scores that are measured by scales called Likert scales, severity of injury scores as reﬂected in a score such as the Trauma Score where lower numbers are pre- dictive of worse survival than higher ones, or the grading and staging of a tumor where higher number stages are worse than lower ones. Common questionnaires asking the participant to state whether they agree, are neutral, or disagree with a statement are also examples of an ordinal scale. Although there is a directional value to each of these answers, there is no numerical or mathematical relation- ship between them. Interval data are ordinal data for which the interval between each number is also a meaningful real number. However, interval data have only an arbitrary zero point and, therefore, there is no proportionality ratio relationship between two points. One example is temperature in degrees Celsius where 64◦Cis32 C hotter◦ than 32◦C but not twice as hot. This makes the results take on meaning for both absolute and relative changes in the vari- able. Examples of ratio variables are the temperature in degrees Kelvin where 100◦ Kelvin is 50◦K hotter than 50◦K and is twice as hot, age where a 10-year- old is twice as old as a 5-year-old, and common biological measurements such Instruments and measurements: precision and validity 69 as pulse, blood pressure, respiratory rate, blood chemistry measurements, and weight. This is called the number of signiﬁcant places, which is taught in high school and college, although it is often forgotten by students quickly thereafter. Height is an example of a continuous measure since a person can be 172 cm or 173 cm or 172. For exam- ple, a piano is an instrument with only discrete values in that there are only 88 keys, therefore, only 88 possible notes. Scoring systems like the Glasgow Coma Score for measuring neurological deﬁcits, the Likert scales mentioned above, and other ordinal scales contain only discrete variables and mathematically can have only integer values. We commonly use dichotomous data to describe binomial outcomes, which are those variables that can have only two possible values. Obvious examples are alive or dead, yes or no, normal or abnormal, and better or worse. This has the effect of dichotomizing the value of the serum sodium into either hypernatremic or not hypernatremic.