Although I trained in medical informatics, I consider myself a balanced psychiatrist who believes very much in providing both psychotherapy as well as medication management. Teaching resident physicians, medical students, and colleagues is also very fulfilling in addition to my various administrative roles at UCLA.
Abstract: OBJECTIVE: This article describes the process of change in an academic department of psychiatry that has led to the development of a diversity initiative in teaching, research, recruitment, and services. METHODS: The authors performed a literature review of diversity initiatives using PubMed. The authors then wrote a case study of the development of a diversity initiative at UC Davis. RESULTS: Some articles on diversity initiatives were found, but none that detailed the administrative process, funding, or sustainability of such initiatives. In 1999, the UC Davis Department of Psychiatry and Behavioral Sciences recognized the importance of issues of diversity and established the Diversity Advisory Committee, a group of department faculty and residents that explores and addresses the diversity needs of the department. In our observations, there are at least three requirements for a successful diversity initiative: a diverse patient population, a "critical mass" of interested faculty, and support of the administration. With these three factors in place, the Diversity Advisory Committee produced four Continuing Medical Education symposia focused on diversity topics, developed a 4-year cultural psychiatry curriculum and a 4-year religion and spirituality curriculum within the residency, and supported nine residents who received awards from the APA's Minority Fellowships in 8 years. Future plans include department-wide and medical school faculty-wide diversity training, educational research, and a postgraduate fellowship in cultural psychiatry. CONCLUSION: This article shows that a diversity initiative can be undertaken with interested minority and nonminority faculty, administrative support, and a diverse patient population. The authors hope this article will provide assistance to other academic departments in developing diversity initiatives.
Abstract: OBJECTIVE: This article describes the various administrative and clinical applications for PDA use in psychiatric care and review the process for implementation in an academic medical center. METHOD: The authors reviewed the psychiatric literature and tested various hardware and software products. RESULTS: The literature describes various uses of the PDA as a reference tool, in clinical care, and in training documentation. CONCLUSIONS: The PDA is capable of numerous vital roles in medical education.
Abstract: OBJECTIVE: This article provides a brief overview of important issues for educators regarding medical education and technology.METHODS: The literature describes key concepts, prototypical technology tools, and model programs. A work group of psychiatric educators was convened three times by phone conference to discuss the literature. Findings were presented to and input was received from the 2005 Summit on Medical Student Education by APA and the American Directors of Medical Student Education in Psychiatry. RESULTS: Knowledge of, skills in, and attitudes toward medical informatics are important to life-long learning and modern medical practice. A needs assessment is a starting place, since student, faculty, institution, and societal factors bear consideration. Technology needs to "fit" into a curriculum in order to facilitate learning and teaching. CONCLUSION: Learning about computers and applying computer technology to education and clinical care are key steps in computer literacy for physicians.
Abstract: OBJECTIVE: The authors describe the complexity of social processes for implementing technological change. Once a new technology is available, information about its availability and benefits must be made available to the community of users, with opportunities to try the innovations and find them worthwhile, despite organizational resistances. METHOD: The authors reviewed the literature from psychiatry, psychology, sociology, business, and technology to distill common denominators for success and failure related to implementing technology. RESULTS: Beneficial technological innovations that are simple to use and obviously save everyone time and effort are easy to inaugurate. However, innovations that primarily serve management rather than subordinates or front-line utilizers may fail, despite considerable institutional effort. This article reviews and outlines several of the more prominent theoretical models governing successful institutional change. CONCLUSIONS: Successful implementation of difficult technological changes requires visionary leadership that has carefully considered the benefits, consulted with influence leaders at all organizational levels to spot unintended consequences and sources of resistance, and developed a detailed plan and continuous quality assurance process to foster implementation over time.
Abstract: OBJECTIVE: This article provides an overview of how trainees, faculty, and institutions use technology for acquiring knowledge, skills, and attitudes for practicing modern medicine. METHOD: The authors reviewed the literature on medical education, technology, and change, and identify the key themes and make recommendations for implementing technology in medical education. RESULTS: Administrators and faculty should initially assess their own competencies with technology and then develop a variety of teaching methods that use technology to improve their curricula. Programs should decrease the general knowledge-based content of curricula and increase the use of technology for learning skills. For programs to be successful, they must address faculty development, change management, and funding. CONCLUSIONS: Willingness for change, collaboration, and leadership at all levels are essential factors for successfully implementing technology.
Abstract: Personal digital assistants (PDAs) or handheld computers have become more popular in the practice of medicine. These devices have implications for psychiatric practice, and this paper reviews various published articles describing their use. The literature demonstrates their use in document editing, patient tracking, accessing medical information and drug reference guides, prescription writing, and medical education. Security on these devices is covered, and the value and increasing implementation of PDAs in psychiatry is discussed.
Abstract: Telepsychiatry, in the form of videoconferencing and other modalities, brings enormous opportunities for clinical care, education, research and administration to the field of medicine. A comprehensive review of the literature related to telepsychiatry - specifically videoconferencing - was conducted using the MEDLINE, Embase, Science Citation Index, Social Sciences Citation Index and Telemedicine Information Exchange databases (1965 to June 2001). The keywords used were telepsychiatry, telemedicine, videoconferencing, Internet, primary care, education, personal digital assistant and handheld computers. Studies were selected for review if they discussed videoconferencing for patient care, satisfaction, outcomes, education and costs, and provided models of facilitating clinical service delivery. Literature on other technologies was also assessed and compared with telepsychiatry to provide an idea of future applications of technology. Published data indicate that telepsychiatry is successfully used for a variety of clinical services and educational initiatives. Telepsychiatry is generally feasible, offers a number of models of care and consultation, in general satisfies patients and providers, and has positive and negative effects on interpersonal behaviour. More quantitative and qualitative research is warranted with regard to the use of telepsychiatry in clinical and educational programmes and interventions.
Abstract: Factors affecting worker tolerance of respiratory personal protective devices are inadequately understood. This study evaluates whether respirator-type loads affected the switch from nasal to oral breathing. Eleven healthy subjects were studied under progressive exercise conditions, using a respirator full-face mask with inspiratory resistance (I), pressure breathing (P) (10 cm H2O end-expiratory pressure), or no load (N). A rapid-response thermistor was used to determine whether flow was predominantly oral or nasal. Both P and I increased the percentage of time that breathing was predominantly oral. The effect was most pronounced at higher exercise levels. The percentage of mouth breathing appeared to be closely related to the expiratory time. This study suggests that nasal-oral flow partitioning should be considered as a possible determinant of respirator tolerance.
Abstract: Supermarket checkers are known to be at risk of upper-extremity cumulative trauma disorders. Forty-two experienced checkers checked a standard "market basket" of items on an experimental checkstand. The counter height could be adjusted (high = 35.5, low = 31.5 inches), and the pre-scan queuing area length (between conveyor belt and laser scanner) could be set to "near" or "far" lengths. Each subject scanned under the high-near, high-far, low-near, and low-far conditions in random order. Seven ordinal symptom scales were used to describe comfort. Analysis showed that both counter height and queuing length had significant effects on symptoms. Furthermore, the height of the subject affected the degree and direction of the impact of the checkstand configuration differences. The study suggests that optimization of design may be experimentally evaluated, that modification of postural as well as frequency loading may be beneficial, and that adjustability for the individual may be advisable.
Abstract: STUDY HYPOTHESIS: Neither response to hypertonic glucose (D50W) nor presence of hypoglycemia can be reliably predicted by "typical" clinical findings (tachycardia, diaphoresis, and/or an available history of diabetes mellitus) in prehospital patients with altered mental status (AMS). POPULATION: Three hundred forty consecutive patients who received D50W for prehospital AMS as ordered by a university hospital paramedic base. METHODS: Review of prehospital records and tape recordings for all subjects to determine presence or absence of tachycardia, diaphoresis, and/or available history of diabetes mellitus at the time of field presentation, as well as response to D50W; final diagnosis was determined from emergency department charts in the 301 patients for whom they were available. RESULTS: Twenty-five patients (7.4%) had a complete response to D50W: 20 had hypoglycemia, diagnosis for one patient was unknown, and four had other causes of AMS. Three patients with an ED diagnosis of hypoglycemia had partial or equivocal responses to D50W, and five had no response. Complete responders were more likely than other patients to have diaphoresis (40% vs 13%, P less than .001) and available history of diabetes (52% vs 12.1%, P less than .001) but not tachycardia (36% vs 35.2%, P = NS). Nine complete responders, including five with hypoglycemia, had none of the three clinical signs. CONCLUSION: Although patients with hypoglycemia who respond to D50W are diaphoretic and have an available history of diabetes more often than other patients with prehospital AMS, 25% of complete responders who are hypoglycemic would not receive D50W if it were used only in patients with "typical" clinical findings. Selective use of D50W for AMS is desirable because very few patients respond, but it is only feasible with concomitant field use of a rapid test of serum glucose.
Abstract: STUDY HYPOTHESIS: Cervical-spine radiography does not need to be performed on selected blunt trauma patients who are awake, alert, nonintoxicated, do not complain of midline neck pain, and have no tenderness over the bony cervical spine. STUDY POPULATION: One thousand consecutive patients seen in the UCLA Emergency Medicine Center with a chief complaint of blunt trauma, for whom cervical-spine films were ordered and for whom prospective data questionnaires were completed. METHODS: Clinicians completed data forms for each patient before radiograph results were known. Data items included mechanism of injury, evidence of intoxication, presence of cervical-spine pain and/or tenderness, level of alertness, presence of focal neurologic deficits, and presence of other severely painful injuries unrelated to the cervical spine. Physicians were also asked to estimate likelihood of significant cervical-spine injury. RESULTS: Twenty-seven patients with cervical-spine fracture were among the 974 patients for whom data forms were completed. A number of findings were statistically more common in the group of patients with fracture than without, but no single or paired findings identified all patients with fracture. All 27 patients with fracture had at least one of the following four characteristics: midline neck tenderness, evidence of intoxication, altered level of alertness, or a severely painful injury elsewhere. Three hundred fifty-three of 947 (37.3%) patients without cervical-spine fracture had none of these findings. CONCLUSION: Cervical-spine radiology may not be necessary in patients without spinous tenderness in the neck, intoxication, altered level of alertness, or other severely painful injury. A policy to limit films in such patients would have decreased film ordering by more than one third in this series, while identifying all patients with fracture.
Abstract: The effect of alternate airflow path designs on full-face mask air-purifying respirators was assessed in 14 healthy volunteers during submaximal exercise. Respirator designs included no respirator (N), full-face mask, dual-cartridge with no nasal deflector (FN), full-face mask respirator with nasal deflector (FD), and a powered air-purifying respirator (PA). Physiologic effects were measured by using respiratory inductive plethysmography and subjective responses by two visual analog scales. There were significant effects of airflow path design upon the physiologic parameters of ventilation, tidal volume, and mean flow rate. There were no significant physiologic or subjective differences between the full-face mask respirators with and without the nasal deflector in place. The PA had less physiologic impact than the nonpowered models but did not show significant subjective benefit. The study suggests that both subjective and objective physiologic responses must be utilized in assessing respirator design.
Abstract: An artificial intelligence expert-based system for facilitating the clinical recognition of occupational and environmental factors in lung disease has been developed in a pilot fashion. It utilizes a knowledge representation scheme to capture relevant clinical knowledge into structures about specific objects (jobs, diseases, etc) and pairwise relations between objects. Quantifiers describe both the closeness of association and risk, as well as the degree of belief in the validity of a fact. An independent inference engine utilizes the knowledge, combining likelihoods and uncertainties to achieve estimates of likelihood factors for specific paths from work to illness. The system creates a series of "paths," linking work activities to disease outcomes. One path links a single period of work to a single possible disease outcome. In a preliminary trial, the number of "paths" from job to possible disease averaged 18 per subject in a general population and averaged 25 per subject in an asthmatic population. Artificial intelligence methods hold promise in the future to facilitate diagnosis in pulmonary and occupational medicine.
Abstract: The effects of pressure-biased breathing (PBB), which simulates positive pressure respirator use, were studied in 15 volunteer subjects during laboratory exercise. PBB was compared with inspiratory resistance: dead space (ID) load and a no-load (N) situation. PBB had adverse subjective effects comparable with those of ID. Physiologically, PBB led to a small decrease in inspiratory time and an increase in expiratory time as well as an increase in the intensity of ventilatory effort as measured by the mean inspiratory flow rate. It is postulated, based on these findings, that PBB has significant effects on the resting lung volume, leading to both physiologic and subjective consequences.
Abstract: STUDY OBJECTIVE: To determine whether clinical criteria (respirations of 12 or less, mitotic pupils, and circumstantial evidence of opiate abuse) could predict response to naloxone in patients with acute alteration of mental status (AMS) and to evaluate whether such criteria predict a final diagnosis of presence or absence of opiate overdose as accurately as response to naloxone. CASES AND SETTING: Seven hundred thirty patients with AMS who received naloxone for diagnostic or therapeutic purposes at the discretion of two large, urban, paramedic base teaching hospitals. METHODS: We reviewed paramedic run sheets and audiotapes on all 730 patients as well as available hospital records of all patients who demonstrated any response to naloxone to determine whether overdose was responsible for their clinical presentations. We also reviewed hospital records for a selected sample of naloxone nonresponders. MAIN RESULTS AND CONCLUSION: Only 25 patients (3.4%) demonstrated a complete response to naloxone, whereas 32 (4.4%) manifested a partial or equivocal response. Nineteen of 25 complete responders (76%), two of 26 partial responders (8%) (with known final diagnosis), and four of 195 non-responders (2%) (with known final diagnosis) were ultimately diagnosed as having overdosed. Respirations of 12 or less or the presence of any one of the three clinical findings as a group were each highly sensitive in predicting response to naloxone, and at least as sensitive as response to naloxone in predicting a diagnosis of opiate overdose. Selective administration of naloxone for AMS would have decreased the use of this drug by 75% to 90% while still administering it to virtually all naloxone responders who had a final diagnosis of opiate overdose.
Abstract: We reviewed written and audio records of paramedic-base hospital radio contact to determine whether care differed from that suggested in standard prehospital care protocols. Records of all 659 contacts for seizure, syncope, abdominal pain, or altered mental state during 1987 (28.4% of all contacts) were scored for the use of standard therapies (such as intravenous access, oxygen, naloxone hydrochloride) and unanticipated therapies (intubation, nitroglycerin). Cases that involved unanticipated treatments were reviewed to determine whether they could have been prospectively identified by simple clinical findings. Standard therapies were used in the majority of patients. Unanticipated therapies were administered to 13 patients, all of whom had abnormal vital signs, diaphoresis, respiratory distress, or a second prominent symptom. Data suggest that protocols could replace radio contact for most patients and that the few who might benefit from radio contact can be easily identified. A 90% reduction in radio contacts in Los Angeles county could save $3 million each year.
Abstract: In a series of 160 consecutive patients with pre-hospital ventricular fibrillation, outcomes were improved if base-station personnel precisely followed the initial 7 steps of standard VF algorithms. This improvement reached statistical significance regarding survival to hospital discharge (17% vs. 6%, P less than 0.05), and reflected a very strong trend with regard to initial resuscitation and admission to hospital (31% vs. 18%, 0.05 less than P less than 0.10). These measures of outcome were even more strongly related to field time, such that patients treated in the field for less than 15 min did far better than patients treated longer. While concordance with algorithms did not independently diminish field time in this study, this probably reflects the fact that paramedics had to establish base hospital contact and receive orders from base personnel in all patients; thus it is probable that allowing paramedics to treat patients in VF, using precise protocols, without prior communication with a base hospital, would diminish field time, and this might lead to even further improvement in patient outcome.
